• working through voluntary hospitals which are not ready and willing to move beyond their walls into the wider socio-economic and, political front.
• socio political change on the part of other power structures in the system like professional elites, bureaucracy, etc. The latter tend to support the medical elite and its privileges or at least involved in power conflicts for reallocation or privileges.
• change in the deep-rooed beliefs of people regarding their ability to challenge opressive, inhibiting fiorces.

We discuss these points furher below.

1. Hospitals have all kinds of resources concentrated in them. When such accumulationof resources occurs at one point, people who control the resources, tend to accumulate more scarce resources. It also leads to bureaucracy, and a culture which tends to exclude weak people, poor people and people who do not have access to knowledge and money.
2. The hospital based system also becomes hierarchial with doctors at the top of the hierarchy. Doctors are part of of the modern medical system - a system which is self perpetuating, in that other elites and privileged people in the system also tend to benefit fom this to the exclusion of the poor.

Even health for all and primary health care are increasingly being seen as areas of extensions for hospitals and specialised medical knowledge. The medical profession itself has historically proved to be one of the most resistant to change-change towards increasing openness, team work and demystification. Even if individual doctors change, the medical system is resistant to change because of enormous vested interests in terms of money, power and status. For OD to be successful, it requires trust, openness and ability to feel equal on the part of all members of the medical health system. Often we hve found this only in isolated individuals in the medial system, who do not by themselves have the power to overcome the enormous forces of resistance offered by the medical profession.

The medical model of health care either through hospitals or through the PHCs, has inbuilt aspects that tend to inspire a feeling of powerlessness and dependency on the part of the patient. In a poor society,people have other exploitative forceslike dominance bythe haves, and dominance related to male chauvinism, higher castes, etc. The medicl model tends to reinforce these oppressive feelings of poor people. OD techniques at their present level of sophisticationare probably not equipped to question these other oppresive forces, and traditional belief systems. The roots of people’s beliefs are inertwind with people’s world-views and existing socio-economic realities. To some extent it can be said the OD model has its basis in an implicit faith of people willing to change by defreezing procedures. The defreezing would come about by group processes like TA, T-group, gestalt, process consultation, or role analysis, survey feedback, etc. Basically these tend to be effective, in our experience , in individuals and groups who belong to an organisation broadly susbscribing to the same broad paradigam of economics, politics, have-have not and male-female dynamics. In issues involving participator health a d social change, world views of various groups are quite different and complicated and it is doubtful whether they can be changed through short term and medium term group dynamic processes per se.

OD (and probably much of current management theory) tedns to under emphasize thatpeople and situations are political in content and context and especially the fact that management of health care change is inextrically interwined with the politics of poverty and underdevelopment. Dealing with these forces explicitly tends to threaten the survival and mainenance of hospitals, PHC systems as well as most orgaisations which are either well-established or have their roots in the establishment.

We have observed that the techniques of OD, as known in OD lierature, tend to be most compatible ( and therefore has a higher degre of success/effectiveness)with persons/group of Type A as contrasted to those of Type B. In Table 5 we indentify some descriptors and characteristic world views of both typologies. For easier indentification, we’allcallthem organisation persons (Type A) and movement persons (TypeB).

Both types and the respective world views are somewhat idealised myths. Real life events pose to the respective world view holders several contradictory instances of these respective world views. Actual work process for both types of individuals is an attempt to resolve (or supress, in some cases) the tension between the desired myths and beliefs (M) and the real life contradition (R). In Table 5 we outline both aspects (M and R).

It should be also noted that in development work, tension often arises because of presence of Type A and Type B persons in the same work setting.

In Table 5, we have described ‘R’ as a set of posers, doubts, which individuals belonging to the resepctive typologies face. The list is only illustrative and not exhaustive.

	Type A: Organization Person		Type B: Movement Person
1.M	Most goals related to socio- economic change in large systems can be achieved through formal organisations consisting of proactive key individuals	1.M	Most goals related to socio-economic change in large systems can be achieved through mass movements for the same.
1.R	How do we affect the political system, corruption, inter class exploitation and domination and yet keep our formal organisation alive and sustaining? How important is it to preserve the organisation?	1.R	How do we meet the short term needs and sufferings of poor people? How long should they wait for radical changes? Should we in the short term help create formal organisations for supply of goods(drugs) and services (medical care) and other programme oriented activities?
2.M	Organisations are efficient ways of achieving above objectives by using material and human resources economically and effectively.	2.M	Organisation are dysfunctional for the above objectives. Efficiency may have to be sacrificed for democracy and participation.
2.R	Are organisations really effective and efficient in the long term? Of what use is creating small models of social change? How can we trigger system wide replication and transformation?	2.R	Are we practising true democracy or ‘guided’ democracy? Why can not we be more openly directive and speed up the process of consciousness raising? Aren’t formal organisations useful?
3.M	Professionalisation of tasks is an end in itself and as a means it is highly desirable for achieving agreed objectives	3.M	Professionalisation is contrary to movement building. It tends to put off the weak and oppressed from the movement.
3.R	Professionals are more interested in the task and their skills. How do we make them less task oriented and more aware of the broader perspective of why we do what we do? How do we prevent technocracy creeping in? Can the professional ever enter into the skin of the oppressed?	3.R	Professional competence is often necessary for real accomplishments How does one coopt the professional for the movement, without being coopted by élites, and without appearing to alienate the poor and the weak?
4.M	Bureaucracy can be contained and even avoided by appropriate MIS (management information system), creative operations research, team building, etc.	4.M	Bureaucracy stifles people oriented movements and at best it is a necessary evil to kept tightly under control. Cadre based self discipline and obedience can lead to humans systems as an alternative to bureaucracy.
4.R	A great deal of formalisation (and with it concomitantly, bureaucracy) seems to be unavoidable as organisations grow. Professionals seem to hate this, but may be able to accept it as necessary for organisational discipline. Some succumb and become more passive.	4.R	The worst type of bureaucracy which movement persons face is the inner core group bureaucracy, resulting from the needs of the core group to hold on to position power. Should they condemn it or tolerate it for the sake of the movement? One result of emphasis on the nonformal, non-bureaucratic ideal is that there are no formal systems of accountability and evaluation of members who undertake responsibility. Even the concept of accountability for routine tasks tends to get viewed as bureaucratic.
5.M	Decision making should be ideally participative (or according to progressive management theories) but pragmatic considerations can dictate otherwise. Participation can vary with competence and maturity of followers (employees) for the ‘good’ of the organisation.	5.M	Participation in decision making is a desirable end in itself.
5.R	With emphasis on professionalisation and goal achievement, decision making can become directive if not authoritarian. At the best of times participation is limited to formal parliamentarism (after Braverman) - election of coordinators, taking decisions by ballot, etc. This happens without change in world view of class-relationships or without the acquiring of genuine skills/expertise by the weak.	5.R	In person-centred movements, followers are ‘persuaded’ by force of personality, recourse to ‘self-evident’ statements, historical necessity, etc. Here followers feel the illusion of participation at some level or the other.
6.M	Work is an important reference point for individuals for selfworth, peer esteem	6.M	Work is only a part contribution to the movement building ethos status, etc.
6.R	Alienating nature of work becomes a difficult issue to explain away as also the inherent inequalities which competence related work generates.	6.R	How does one encourage competence in work and work-related self-esteem without appearing to focus the individual more than the movement? - - or otherwise accentuating inequalities ?
7.M	Team work is great but individual talent and genius should also be allowed to blossom.	7.M	Individual talent can blossom but not at the expense of the team culture.
7.R	Great amount of hidden organisational and psychic energy is spent in balancing individual’s (especially professional’s) need for creative space, team culture needs and organisational needs.	7.R	Often tense situations result wherein the team tries to assert itself. Individual self-actualisation contrary to team ethos is discouraged How humane then is the movement to individuals?
8.M	The organisation may at least publicly have humanitarian philosophy and one may critically question inequitable power structure	8.M	Confrontation of basic questions of inequality and injustice, especially as related to the goals of the movement, take priority over all other tasks and issues.
8.R	Often such questioning is not allowed if it results in rocking the organisational boat too severely The Church, for some inexplicable reason, becomes more important than the witness of the Christ.	8.R	The above often results in the austere, severe movement person type, who tends to discount the importance of feelings as also other basic issues in life, art, science, technology, etc. The ugly movement person?
9.M	Hygiene factors (social needs, safety and security needs, recognition, physical needs) have to be satisfied before motivators (like self- worth, esteem, self-actualisation, etc.) can operate.	9.M	Motivators and hygiene needs are both important
9.R	The leader/core group on their motivator trip forget hygiene needs of the lesser mortals. Often seen as, for instance, in salary disparities between top and bottom, or other denial of basic justice, in organisations fighting for social change.	9.R	In practice, members in the movement who draw energy from and operate on ideals, goals of the movement, and other such motivators seem to get peer esteem much to the discomfort of hygiene hungry members. (See also point 12 below)
10.M	Knowledge and data base are acquired to achieve organisational goals and objectives more effectively. There are large areas of knowledge and data which are relatively politics-free. Knowledge for knowledge’s sake may be encouraged.	10.M	Knowledge and data base generally relate to critical questions of political economy. Knowledge for knowledge’s sake (as may happen in R & D1 wings of organizations) is not encouraged. Large areas of knowledge and data base are part of the politics of the issues.
10.R	The above seems to result in spurious objectivity in social issues, and blurring of wider social implications of organizational goals.	10.R	May result in over labelling of all professionals and professional knowledge as a vested interest and therefore ill-equipped to use that knowledge to liberate people. May also result in romanticisation of people’s traditions, beliefs, traditional medicines, etc.
11.M	Work and family life can have large areas of separate identity. Ideally, they are sought to be ‘integrated’	11.M	Work and family life (and for some love life) are aspects of the movement ethos. (There is no such thing as separate work life)
11.R	Often the integration is symbolic (viz: departmental picnics) and scratch the surface. This is because the organisation as such can get overwhelmed by agendas of oppression within families and communities. Dealing with these threatens to dilute the ‘original’ purpose of the organisation.	11.R	In practice, the above view can alienate members from the movement without them being aware of it. Tends to result in uniformity of world view with a possible low tolerance of variety and lack of interest in cultivating versatility.
12.M	People will with good management ‘own’ organisations and feel loyal to it.	12.M	Questions of maturity and success of movement and related goals and activities of the individual need to be constantly examined for vitality and authenticity of movement.
12.R	In practice, individual agenda like salary, career, status tend to dominate personal conversation - especially now after the entry of professional, career oriented development workers. So ‘success’ of the organisation is a preoccupation of a few key individuals only. Nevertheless there are exceptional individuals who appear to be working out of pure commitment	12.R	Material/hygiene needs of the self are either suppressed or seen as of little significance to the maturity of the movement. Questions of career pattern and life plan of individual in movement tend to be viewed as inappropriate and irrelevant or at best viewed uncomfortably.

Some questions tha can be posed at this stage are : Do the strengths of OD theory and practice have relevance for mass movement persons, especially with regard to health care? What alternatives in terms of social action does one have for mass movement related to health care?

Let us take the former question. The answer, from our experience, seems to be that the strengths of OD are certainly relevant to movement persons. Activists groups in India, for instance, who can be identified with movement person collectives, have many a time split because of insufficient appreciation of intra-personal and inter/intra group feeling level processes 1. In some activist groups awareness of such processes has not led to the logical goal of team -building or movement, because of absence of concrete processs skills which OD practitioners in contrast tend to have. There are also some austere activists, who consider such feeling level process interventions a luxury for the movement. Probably we are historically too close to the post 1970 phenomena of voluntary work/activist work to understand the various forces at play in activist work. But it does seem a paradox that persons who believe and work for the strengthening of people’s unitr, cannot themselves be united. This is the challenge to the assumption and values of OD theory and practice.

Choice Before the Activists

What we then experience from the above discussion, as also that of Table 5, is that when we talk of OD, health care nd social change--at the same time --the theatre of action is vast. The issues to be dealt with are numerous. Do we aspire for change in health care delivery patterns through existing health oganizaion or do we set up radical alternativces? Do we--if we believe that health is related to poverty that is related to development patterns, which in turn is related to opressive power structures-do we, then work for social change and social action (the movement person’s preferences’) or just restirct to OD and change through ‘organizations’ (in one conventional sense of a geographically and physically confined and limited organization)?

The answer is difficult at the individual, personal level, for the choices seemingly obvious, are not in fact so. Even at the system level, there is a need for institutional frameworks which can guarantee a people oriented health care delivery sysem- a need hat probably cannot wait for a total systems change, revolution of sorts of the Chinese or Cuban kind.

However then as social activists and health care activists, dowe not focus on the ‘movement’ issues: generation of amass action programme that involves a considerable change in people’s consciousness and perceptions about their own needs and desires? The answer again is not obvious, though seemingly so. The case of Chinnamma Mathew, in Appendix 1, amply illustrates the dilemmas, choices and the world line of a development /health care activist as he /she progresses through life and encounters several different contexts and realities.

Even if one is involved ‘normal’ or normative OD, the values and atitudes that inspirlarge scale social action would be highly useful in shaping the meaning of day-to-day organizational work processes. Internally, I would appear that social activists need to have sub-personalities operating --the organisation person and the movement person -- with a facile facility to switch from one to the other.

Activists who have been involved purely in agitational issue oriented political action have often reported the need to take up ‘constructive programmes’ involving a move towards institution building and organization formation even if only to prevent the increasing disinterest of the ordinary people in the agitational programme. Those involved in such a move may well ponder over appendix 2. ‘Conditions for Failure and Success in OD Efforts’. They have been derived from the experiences of the authors as OD facilitators in health care and especially hospital settings, and have a lesson or tow for wider organisational contexts.

In table 5 we discussed the myths that the organizational person/movement person tries to actualize and the real life tensions and contradictions encountered in the processs. Notwithstanding, the one or the other, tensionsand contraditions, seem built-in--whether as a social change activist or as an OD practitioner.

Where this logically leads to is not clear, but one path seems to be the politics of nonviolent action. We discuss the strategies of nonviolent action in a move towards a holistic society in Chapter 10.