Radical Journal of Health 1998 Vol. 3, No. 1, Jan. – March
Item
- Title
- Radical Journal of Health 1998 Vol. 3, No. 1, Jan. – March
- Date
- March 1998
- Description
-
Failures of success: Tamil Nadu’s demographic experience
Technology, competition and costs of Medicare: implications for policy
No-targets for FP: how effective?
CIBA Geigy and Sandoz: some issues
Calicut declaration - extracted text
-
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,*
JANUARY MARCH
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JOURNAL OF HEALTH
■ . ••
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A SOCIALIST HEALTH REVIEW TRUST PUBLICATION
New Series VOLUME III
FAILURES OF SUCCESS: TAMIL NADU’S
DEMOGRAPHIC EXPERIENCE
TECHNOLOGY, COMPETITION AND
COSTS OF MEDICARE: IMPLICATIONS
FOR POLICY
NO-TARGETS FOR FP: HOW
EFFECTIVE?
CIBA GEIGY AND SANDOZ:
SOME ISSUES
CALICUT DECLARATION
Rs 25
Consulting Editors’.
Amar Jesani,
CEHAT, Mumbai
Binayak Sen, Raipur, MP
Dhruv Mankad,
VACHAN, Nasik
K Ekbal,
Medical College, Kottayam
Francois Sironi, Paris
Imrana Quadeer,
JNU, New Delhi
Leena Sevak,
London School of Hygiene and
Tropical Medicine, London
Manisha Gupte,
CEHAT, Pune
V R Muraleedharan,
Indian Institute of
Technology, Madras
Padmini Swaminathan,
Madras Institute of
Development Studies, Madras
Sandhya Srinivasan,
Harvard, USA
C Sathyamala, New Delhi
Thelma Narayan,
Community Health Cell,
Bangalore
Veena Shatrugna, Hyderabad
Irudaya Rajan, CDS,
Trivandrum
The Radical Journal of Health is an
interdisciplinary social sciences
quarterly on medicine, health and
related areas published by the Socialist
Health Review Trust. It features
research contributions in the fields of
sociology, anthropology, economics,
history, philosophy,psychology.
management, technology and other
emerging disciplines. Well-researched
analysis of current developments in
health care and medicine, critical
comments on topical events, debates
and policy issues will also be
published. RJH began publication as
Socialist Health Review in June 1984
and continued to be brought out until
1988. This new series of RJH begins
with the first issue of 1995.
Editor: Padma Prakash
Editorial Group: Aditi Iyer, Asha
Vadair, Ravi Duggal, Sandeep
Khanvilkar, Sushma Jhaveri,
Sunil Nandraj, Usha Sethuraman.
Production Consultant: B H Pujar
Publisher: Sunil Nandraj for
Socialist Health Review Trust.
All communications and
subscriptions may be sent to :
Radical Journal of Health,
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EMail: rjh@nrp.ilbom.ernet.in
Typsetting and page layout at the Economic and Political Weekly.
Printed at Konam Printers, Tardeo, Mumbai 400 034.
Volume III
Neu Series
Number I
January-March 1998
Editorial: Multiple Meanings, Plural
Systems Padma Prakash
A Different Ethos
3
5
The Failures of Success?: Tamil Nadu’s Recent
Demographic Experience
Padmini Swam inathan
7
Technology. Competition and Costs of Medical Care:
Some Emerging Issues and Policy imperatives
in India
V R Muraleedharan
35
Target-Free Approach: Some Missing Links
K Sasikala
55
Communications
Merger of Ciba-Geigy and Sandoz:
Some Implications
Kavaljit Singh
61*
Book Review
Documenting Research
Rqmila Bisht
Nilamvari Gokhale
64
Document
The Calicut Declaration, November 1997
t*4 •
69
Letter to Editor
Women Doctors
Thearlicleon ‘Educating Women Doctors’! Voll.4. 1996) was interesting
But I wish there had been more information on the kind of students
who apply for admission to these course at Ahfad University in Sudan
Does the university for instance, allow say. nursing graduates to take
up medical education? What social strata do students come from?
Chennai
Radhika S P
WHO Conference on WTO
The WHO has sponsored an electronic conference which began in
February to examine the possible effects of WTO rules on the produc
tion and commercialisatin of medicines in developing countries. The
conference is an interactive process aimed at providing WHO with
expert guidance on how to deal with the complex issues emerging from
the implementatin of the international agreements following the Uruguay
Round and the setting up of WTO in January 1995. The participants
are a select group of academics and experts working with NGOs. The
conference ends on April 20 1998.
A Reader
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2
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1998
Multiple Meanings, Plural Systems
The survival of medical pluralism, notwithstanding decades
oj discouragement should prompt serious introspection on the
relevance of the medical model of health care.
ILLNESS is, conventional medical sociology would have it, an
escape. The constructive approach to illness would therefore be to
push, prod and prompt the patient to move back into the everyday
world from which s/he had sought escape. However in a consumerist
society it also becomes necessary to keep an ill person from feeling
well too quickly. For, after all, the ill slate provides the impetus for
a market for medicare and its products. In many developing countries
traditional perceptions of illness and health form yet another point of
reference. In consequence perceptions of health vary sharply across
regions and communities, even as they do across gender, caste and
class. This has also meant that studies attempting to capture morbidity
in a population begin with a variety of handicaps. The assessment of
health seeking behaviour is therefore fraught with uncertainty. This
is part of the reason why morbidity studies have either relied on
hospital data or have got bogged down in rather esoteric anthro
pological inquiries.
Only recently have researchers attempted to grapple with these
problems in order to obtain an understanding and not just a quantitative
picture of disease in a community. This has required the innovative
and creative use of anthorpological and statistical methods and is
yielding rich information. A recent illustration of this is a study
sponsored by the district level administration of the malaria
programme in Gujarat which has recently sought the help of social
scientists to enquire systematically, for perhaps the first time, how
people perceive malaria. The project was originally intended to
inquire into the success of the impregnated bed nets in the malaria
control programme. But the social scientists in this quest have found
not answers but many many, questions.
The study has been yielding uncblievably rich anthropological
and ethnographic data on how people respond to the disease, how
they device the most ‘cost effective’ way of dealing with it, and also
on how modernisation in all its forms is affecting health status and
the very understanding of health in communities in fundamental
ways.
For decades, health planners have happily laboured under the
assumption that rural and even more so tribal and deprived
communities know nothing about taking care of health; that their
RJH
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1998
3
coping and caring methods and remedies are ‘unscientific’ and arc
therefore inefficacious, and if the carefully designed interventions
for disease control fail, it is because of the ignorance of the people.
and so on. This study challenges some of these assumptions.
confronting health planners with something of a dilemma. Within the
monolithic structure of the centrally defined malaria control
programme how is this new and confusing information to be
accomodated?
For instance, the study in Sural district reveals that the impregnated
bed nets are thoroughly useless and unacceptable. And this is not
because the villagers are ignorant of its purpose, but simply because
as one participant put it,” people have no beds “, nor for that matter
do the sleeping arrangements in these communities lend themselves
to the use of bed nets. The study which focussed on three typical
areas representing three ecological zones in the district, shows that
sleeping arrangements are quite complicated and depend on work
divisions within the family and also other familial and hierarchical
needs. Similarly, the study also found that the spraying of pesticides
which required that the area be left unused for several hours were not
particularly welcomed, no mailer how efficacious. Interestingly in
most communities, people use a mix of modern and local, traditional
methods to cope with disease, such as the practice of burning of wood
to keep away mosquitos, of covering the body in neem oil in the
night, etc. They also use a multiple system approach to cope with
malaria - using the PHC, the private practitioners in allopathic and
indigenous systems as well as the local folk healer or herbalist. In
short what is evident is that medical pluralism is flourishing and has
not as was once expected vanished. In fact, folk healers, since they
themselves go to PHCs and other doctors, have picked up and
incorporated modern ideas, techniques and remedies into their
practice, however haphazardly. As participants who had worked in
Tanzania pointed out, this was true also in other pans of the third
world.
Should these ‘systems’ and their practitioners be integrated into
the health system? Or, given the failure of early attempts to integrate
indigenous systems into a uniform health service,should they be
allowed continue to practice as they have done so far? Even more
troublesome arc questions of whether people should be allowed to
define their own health priorities and what if one region or village
decided that malaria was not their lop priority?
These are undoubtedly difficult and confusing limes for the health
bureaucracy, health planners and for researchers, especially those
who want to respond to the new demands and needs. Clearly rigidi
ties have little place. But on the other hand, opening the debate
4
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1998
will clearly pul lhe entire structure of current health care in jeopardy.
Old questions such as whether there should be vertical disease
control programmes at all or whether an efficient and well-funded
primary health institution can take care of all needs are being
reopened.
Perhaps the most important insight studies such as lhe Sural
one provide is that medical pluaralism has strong roots. The very fact
that systems other than the codified and acknowledged systems of
medicine have survived should prompt introspection on lhe part of
practitioners of western medicine on the limitations of lhe medical
model of health care. Further, and quite emphatically, studies such
as these show the need to imparl greater flexibility in the new health
policies and programmes to accomodate people’s voices in the
planning process.
-Padma Prakash
A Different Ethos
Existing health programmes in tribal areas fail to address
the real problems among these populations.
FOR decades the government has had on its books a separate
programme for tribal health, with the aim of providing special care
to a vulnerable population. Over a period of time the programmes
under this plan have shrunk or expanded depending on funds made
available through various agencies, which have little relation to the
needs of lhe tribal population. Not surprisingly, the programme
ostensibly aims to provide additonal support for services in lhe tribal
areas; it is not conceptually any different from health care facilities
elsewhere. Because of this they have, by and large, failed to address
the health needs of the tribal population. For one, most of the
programme is on paper and tribal areas are undrserviced. Even when
there are services, they are badly utilised. This is because often
modern medicine and its requirements are completely out of the
communties’ ken.
Significantly, lhe state of health of indigenous people everywhere
is a cause for concern - in Australia, in North and South America, for
example. There is now a growing awareness in Australia today that
their health needs have to be addressed differently. Now, after
thousands of years of European colonisation, the indigenous
population or aborigines who comprise 2 per cent of the population
are enjoying the benefits of innovative health programmes. Indigenous
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1998
5
populations it has lo be remembered are not always and altogether
clusteicd away from the mainstream ol civilisation. many have oxer
the decades moved into urban areas , and have occasionally been
assimilated into the population though the process itsell has produced
stresses. Moreover.the assimilation has often meant a low social
status in mainstream society. Often they suffer from the same
diseases as the rest of the population
In recent sears Australian health programmes loi aborigines have
become “collaborative not paternalistic” comments a note tn
The Lancet, an outlook that k being introduced into the training
programmes of medical students as well. Such a programme does not
merely expand health sen ices for tribal populations, but actually
changes it to suit the requirements of these populations in terms ol
concepts of illness and care.
In India the health indices of tribal populations tell a story ol
woeful neglect coupled with extreme poverty and exploitation II the
state health system is to address their needs, then the tribal sub-plan
needs to be reviewed and restructured quite differently from the
health programmes for the mainstream
NOTICE TO SUBSCRIBERS
Due to certain circumstances, we have not been
able to bring out any issues for 1997. All
subscription for 1997 will however be honoured
for 1998. Multiple year subscriptions will account
for loss of 1997 issues and will be extended
accordingly.
We sincerely regret the inconvenience caused
and ask you to continue to extend your
cooperation. For furtherclarificationplease write
to the editorial address.
-Editors
6
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1998
The Failures of Success?
Tamil Nadu’s Recent Demographic Experience
Padmini Swaminathan
Tamil Nadu has had an active, but cooperative family planning
programme, and if could use for this purpose a comparative good
position in terms of social achievements within India. Coercion
of the type employed in China has not been used either in Tamil
Nadu or in Kerala and both have achieved much faster declines
in fertility than China has achieved since it introduced the ‘one
child policy’ and the related measures.
As neither the economic standards nor the literacy level of Tamil
Nadu nor its employment potential for females were much higher
than most of the other states in Southern India, the comparatively
high age of marriage and easier acceptance of the concepts of
family planning has to be ascribed to a strong social awareness
programme created by a great social reformer named ‘Periyar’
Ramaswamy. Long before governments introduced thefamily planning
programme, Periyar emphasised the need ‘to liberate women from
frequent delivery by use ofcontraception ’. Also 'not to allow marriage
of a woman before she is 22', so that '3 to 4 births can be averted’
and to explain the desirability ofthe two child norm at every marriage ’,
etc. Periyar’s doctrines had a strong impact on successive political
governments in the state, as some of his disciples later became
political chiefs of the state - (TV Antony, former Chief Secretary
to Tamil Nadu Government, and member. Expert Group, Draft National
Population Policy.)
Al least iwo factors have contributed io Tamil Nadu's success, namely, strong
social and political commitment and good administrative back-up. Ashish
Bose, member, Expert Group, Draft National Population Policy.
I
THE demographic ‘success’ of Tamil Nadu as evidenced by the percep
tible decline in its fertility rales (including in the rural areas) during the
decade of the 1980s has left everyone gasping for explanations. Predict
ably, the slate government has gone overboard in attributing this ‘achieve
ment’ to the effectiveness and efficacy of its official bureaucracy in
‘successfully’ implementing a fertility regulation programme. Worse,
Tamil Nadu has become a model for the high fertility slates of the country:
the protagonists supporting direct birth control measures now argue that
RJH
(New Series)
Vol III: 1
1998
7
The Failures of Success?
Tamil Nadu’s Recent Demographic Experience
Padmini Swaminathan
Tamil Nadu has had an active, but cooperative family planning
programme, and it could use for this purpose a comparative good
position in terms of social achievements within India. Coercion
of the type employed in China has not been used either in Tamil
Nadu or in Kerala and both have achieved much faster declines
in fertility than China has achieved since it introduced the ‘one
child policy' and the related measures.
As neither the economic standards nor the literacy level of Tamil
Nadu nor its employment potential for females were much higher
than most of the other states in Southern India, the comparatively
high age of marriage and easier acceptance of the concepts of
family planning has to be ascribed to a strong social awareness
programme created by a great social reformer named 'Periyar'
Ramaswamy. Long before governments introduced thefamily planning
programme, Periyar emphasised the need ‘to liberate women from
frequent delivery by use ofcontraception ’. A Iso 'not to allow marriage
of a woman before she is 22', so that '3 to 4 births can be averted'
and to explain the desirability ofthe two child norm at every marriage',
etc. Periyar's doctrines had a strong impact on successive political
governments in the state, as some of his disciples later became
political chiefs of the state - (TV Antony, former Chief Secretary
to Tamil Nadu Government, and member, Expert Group, Draft National
Population Policy.)
Al least two factors have contributed to Tamil Nadu’s success, namely, strong
social and political commitment and good administrative back-up. Ashish
Bose, member. Expert Group, Draft National Population Policy.
I
THE demographic ‘success’ of Tamil Nadu as evidenced by the percep
tible decline in its fertility rates (including in the rural areas) during the
decade of the 1980s has left everyone gasping for explanations. Predict
ably, the slate government has gone overboard in attributing this ‘achieve
ment’ to the effectiveness and efficacy of its official bureaucracy in
successfully' implementing a fertility regulation programme. Worse,
Tamil Nadu has become a model for the high fertility slates of lhe country:
the protagonists supporting direct birth control measures now argue thal
RJH
(New Series)
Vol Hl: 1
1998
7
these slates need not wait for development to bring about fertility decline.
The fact that, Tamil Nadu, despite not enjoying the economic standards
of most other states and/or the historical advantages of Kerala, could
make commendable demographic progress is proof enough that family
planning can do the job single-handed. The contradictions of an histori
cally continuous decline in sex ratio in Tamil Nadu, the still prevalent but
relatively recent practice of female infanticide in certain pockets, and the
rising incidence of other forms of violence against women in the land of
EVR, are not the kind of issues that engage family planning officials and/
or demograhers who single-mindedly pursue a one-point fertility reduc
tion programme.
Others like A Sen have proffered a more sophisticated explanation. By
emphasising the centrality of a basic relationship between women’s well
being and their agency, Sen argues that the “reach of that agency can be
very extensive indeed and it does of course inter alia include the
possibility of reasoned decisions about fertility.’’1 Sen singles out Tamil
Nadu for its commendable performance; but it is not clear on what basis
Sen has concluded that “Tamil Nadu has had an active but cooperative
family planning programme" (emphasis ours). In our view Sen has used
the term cooperation to mean the opposite of coercion and/or
authoritarianism. The term itself is not problematised to explore whose
cooperation is being sought and on what terms. The fact that women can
be coerced into cooperation cannot be accommodated in Sen’s
presentation. Feminist researchers and activist groups are still grappling
with the phenomenon of fertility decline in Tamil Nadu and attempting
to unravel its implications for policy, but not many are prepared to buy
the'enlightened state’ or the ‘cooperative family planning’ argument. A;
one researcher very succintly summed up the present state of research on
the question: “We have yet to learn from the women concerned why they
are having fewer children while women from other parts of the country
living under similar economic and social conditions are unable or
unwilling to do so.”2
'rhe present paper is part of a larger agenda aimed al exploring the
complex interaction of various forces and factors underlying the
phenomenon of fertility decline in Tamil Nadu. Its genesis lies in the
findings of a disaggregated analysis of fertility rales within Tamil Nadu
which revealed that there exist districts like Kanyakumari on the one hand
and Periyaron the other, (representing two polar situations as it were), the
former marked by high fertility rales despite high female literacy rates,3
the latter marked by low fertility rales despite low literacy rates. Our
broad agenda includes initially a collation and analysis of available
material from secondary sources to gel a geographically disaggregated
picture of the economy and demography of Tamil Nadu. This will be
followed by intensive interviews with different sections of the population
8
RJH
(New Series)
Vol 111: 1
1998
these states need not wait for development to bring about fertility decline.
The fact that, Tamil Nadu, despite not enjoying the economic standards
of most other states and/or the historical advantages of Kerala, could
make commendable demographic progress is proof enough that family
planning can do the job single-handed. The contradictions of an histori
cally continuous decline in se,x ratio in Tamil Nadu, the still prevalent but
relatively recent practice of female infanticide in certain pockets, and the
rising incidence of other forms of violence against women in the land of
EVR, are not the kind of issues that engage family planning officials and/
or demograhers who single-mindedly pursue a one-point fertility reduc
tion programme.
Others like A Sen have proffered a more sophisticated explanation. By
emphasising the centrality of a basic relationship between women’s well
being and their agency, Sen argues that the “reach of that agency can be
very extensive indeed and it does of course inter alia include the
possibility of reasoned decisions about fertility.”1 Sen singles out Tamil
Nadu for its commendable performance; but it is not clear on what basis
Sen has concluded that “Tamil Nadu has had an active but cooperative
family planning programme" (emphasis ours). In our view Sen has used
the term cooperation to mean the opposite of coercion and/or
authoritarianism. The term itself is not problematised to explore whose
cooperation is being sought and on what terms. The fact that women can
be coerced into cooperation cannot be accommodated in Sen’s
presentation. Feminist researchers and activist groups are still grappling
with the phenomenon of fertility decline in Tamil Nadu and attempting
to unravel its implications for policy, but not many are prepared to buy
the 'enlightened state’ or the ‘cooperative family planning’ argument. At
one researcher very succinlly summed up the present stale of research on
the question: “We have yet to learn from the women concerned why they
are having fewer children while women from other parts of the country
living under similar economic and social conditions are unable or
unwilling to do so."2
The present paper is part of a larger agenda aimed at exploring the
complex interaction of various forces and factors underlying the
phenomenon of fertility decline in Tamil Nadu. Its genesis lies in the
findings of a disaggregated analysis of fertility rates within Tamil Nadu
which revealed that there exist districts like Kanyakumari on the one hand
and Periyar on the other, (representing two polar situations as it were), the
former marked by high fertility rates despite high female literacy rates,5
the latter marked by low fertility rales despite low literacy rates. Our
broad agenda includes initially a collation and analysis of available
material from secondary sources to gel a geographically disaggregated
picture of the economy and demography of Tamil Nadu. This will be
followed by intensive interviews with different sections of the population
8
RJH
(New Series)
Vol Hl: ]
jggg
^^■^ntative districts, disaggregated by sex, religion, class, employ^immunity, etc.
mportant question for examination in the course of the field work
^^’.hc concrete manner in which women’s freedom of reproductive
vis constrained by patriarchal structures, which in the context of
—-~js like Kanyakumari seem to be coercively pronatal as manifested
Taigh levels of fertility there.4 Coercive pronatalism can be the result
^^'ial and economic inequality not just between communities and
nes, but, more so, within the family, which, in turn reduces the
^aiining power of individual women, thereby making it possible for
sands to impose their own family size decisions on wives. The study
—sstricts like Periyar, in contrast, would constitute an interesting testing
-Jind to explore the much touted and oft-repealed statement that
t/lhern kinship systems bestow relatively greater autonomy on females
—m northern kinship systems. Greater or high autonomy in this context
- pplies an ability to influence and make decisions covering the full range
personal, sexual and household affairs. Thus concrete exploration of
m«e relationship between patriarchy and motherhood, should, we hope, go
^□mc way towards explaining what combinations of cultural, economic
wind political conditions interact to create a particular demographic
Slattern. More important, knowledge of the processes involved is crucial
Uo policy analysis to avoid facile linear causal connections as between,
say, female schooling and fertility, and/or between female employment
and fertility.
The modest objective of this paper is to provide a framework to situate
the larger study outlined above. We begin with a brief discussion of the
current demographic debate in India generated largely by the Draft
National Population Policy Report of an expert group set up by the
government of India.5 This discussion on the Draft National Population
is important in order to contextualize our study of Tamil Nadu. In the light
of Tamil Nadu’s experience the view being highlighted by demographers
(and which viewpoint dominates the draft policy) is that fertility can be
made to decline at different levels of economic and social development
through organised and effectively administered family planning pro
grammes. By and large, the feminist response to this draft, at one level,
is reminiscent of the classic discourse on, whether high population is a
malady or symptom;6 at another level it reveals the different dimensions
of the violence on women of a direct fertility reduction programme. Using
Kanyakumari and Periyar as illustrative cases we hope to underscore two
main points:
(a) The theoretical approach to population policy as such needs to
move away from the perspectives of demographers who define policy in
a very restrictive way. In the ‘general linear reality’ assumption of much
of dcmographically driven policy, the same variables must have the same
RJH
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1998
9
effects irrespective of context. Such policy does not recognize and
therefore does not provide the space to explore the differential impact of
the same policy on diverse socio-economic subpopulations across nation
states and/or territorial subunits within nations.7
(b) The concept of increased women's agency through variables such
as increased female literacy and increased female labour force participation
has been conflated to indicate increased female autonomy in decisions
relating to fertility. This, to us. is highly problematic, since, among other
things, the whole issue of fertility is linked to sexuality There is.
therefore, need to document even for a demographic understanding of
fertility, the elements of sexual choice, sexual health and sexual enjoy
ment from a gender perspective. This would capture, at one level, how
vulnerable or otherwise, couples in general and women in particular are,
to pressures emanating from the wider needs of the caste/communily to
which they belong. At another level it would also indicate the degree to
which women (within these caste/kinship structures) are able to influence
decisions on questions such as the number of children, the use of
contraception and of particular contraceptive methods, termination of
pregnancy - in short, the whole question of the quality of partnership
between man and woman.
II
The tabling of the Draft National Population Policy (henceforth, the
draft) marks in some sense a watershed as far as the politics and praxis
of demography (in this country) is concerned. The basic premise of the
Draft is that population stabilisation is vital for safeguarding the liveli
hood security of the poor and the ecological security of the nation
Thereafter there is a complete disjuncture between the analysis of the
‘population problem’, the socio-demographic goals nought to be achieved
by the year 2010 and the structures and measures designed for implemen
tation.
The analysis al once, very cleverly combines what has come to be
knowm in the literature on population as the ‘political discourse’ and the
‘development discourse’? Very briefly, the ‘political discourse’ chal
lenges the traditional models of development. “Il does not treat popula
tion growth as an exogenous factor, but secs it directly linked with the
institutional structure of society.'? The development discourse on the
other hand, considers that “population is basically an independent phe
nomenon linked to the introduction of modern medicine in traditional
communities: that low fertility rates arc a characteristic of development
and therefore something desirable in itself: that people in the South will
desire less children if they arc provided safe modern contraceptives,
better health services and education.
10
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IW#
’’The political discourse part of the Draft, very correctly identifies those
responsible lor the environmental crisis. To quote (he draft:
The unsustainable life styles of both wealthy nations and wealthy people
everywhere are posing a threat to climate, particularly precipitation and are
contributing to a potential rise in sea levels and ultra-violet B radiation. Under
such circumstances, the loss of every gene or species limits our capacity to
adapt to new situations It is high time the limits to the human carrying capacity
of the supporting eco-systems are recognised.
However, the above statement is immediately followed by the asser
tion (hat:
Population, poverty and environmental degradation have close linkages, and
quest lor food, education, health and work for all will remain illusory unless
success is achieved in limiting the growth of population (emphasis added).
In one swift action, from one paragraph to another, the Expert Group
has been able io traverse what look the US nearly 60 years of demographic
research."
The draft claims, to have ushered in a ‘new paradigm of population
stabilisation based on “environmental stabilisation, economic replicability
and social equity”. This paradigm shift is, according to the draft, essential
lor achieving the following national socio demographic goals for the
year 2010.
i) Implementation in totality of the Minimum Needs Programme, and
in particular, universalisation of primary education and reduction in the
drop-out rates of primary and secondary school students, both boys and
girls, abolition of child labour and priority to primary health care.
ii) Reduction in the incidence of marriage of girls below the age of I 8
years to zero.
iii) Increase in the percentage of deliveries conducted by trained
personnel to one hundred per cent.
iv) Reduction in maternal mortality rale to less than 100 per 100.000
live births.
v) Universal immunisation of children against tuberculosis, polio.
diptheria, whooping cough, tetanus and measles and reduction in the
incidence of diarrhoea and acute respiratory infections.
vi) Infant Mortality Rate (IMR) of 30 per 1000 live births, and a sharp
reduction in child mortality rale (1-4 years); also, a sharp reduction in lhe
incidence of low birlh weight babies (below 2.5 kg)
vii) All individuals io have access to information on birlh limitation
methods, so lhal they have lhe fullest choice in planning lheir families.
viii) Universal access to quality contraceptive services in order
to lower lhe Total Fertility Rate (TFR) from 3.6 in 1991 to 2.1 by the
year 2010.
ix) Containment of AIDS and sexually transmitted diseases.
x) Full coverage of registration ol births, deaths and marriages.
Predictably lhe ‘paradigm shift’ is articulated more in terms of demo
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graphic goals; here again the target population consists of women and
children precisely because the responsibility for limiting birth is deemed
to be a women's responsibility. Between analysis of the problem and the
specification of the goals, the draft has managed a neat transition involv
ing a shift from (a) identifying the consumption and living standards of
the north plus the elites of the south as (historically and currently)
responsible for environmental degradation, to (b) postulating that
stabilising world population is the more realistic way to move towards
sustainability, and further towards (c) suggesting the creation of such an
‘enabling environment' that ultimately makes fertility reduction the key
to the whole problem.
The structures and measures suggested by the group to achieve a total
fertility rate of 2.1 by the year 2010 are explicitly based on the assumption
that “people who have large families should change their behaviour
because the ones who created the problem in the first place cannot do
so.”12 As part of its structures for implementation the Draft envisages a
major role for panchayat raj institutions in the implementation of the
proposed population control programme. What makes this laudable
objective at once both anti-poor and anti-women stems from the Draft’s
poor conception of these institutions as well as the punitive clauses that
make participation in these institutions conditional.13
Responses to the draft, particularly from a large section of women’s
groups all over the country, in many ways questioned and reversed the
terms of the problematique as posed by the Expert Group. Women not
only held India’s development model adopted since independence
responsible for its economic crises, but going further, argued that, in a
scenario, where the ‘ever teeming millions’ constitute an expanding
constituency of the poor, the malnourished, the diseased and the deprived.
population growth in fact very often becomes a solution, particularly at
the local level.
The apporoach to matters of population policy clearly revealed funda
mental differences in perception between the Expert .Group and the
women’s groups in particular. While women implicitly seemed to stress
the importance of motivation over means, the Expert Group (which had
an overdose of demographers) - invoking the supposed urgency of the
problem it was solving - articulated its policy in terms of the attainment
of certain specified aggregate demographic targets. To demographers, as
Demeny, has ably put it, “the problem of motivation seemed and was
inherently difficult: systemic and structural. The problem of means in
contrast, was potentially soluble by suitable application of money:
packageable as a program embodying specific and tangible resources.”14
The draft itself was a culmination of a series of observations and
studies undertaken by the members of the group as well as other pro
population policy researchers. Despite strident criticism of the draft from
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various quarters, the members of the group upheld the right of the state to
intervene directly in birth control; at public forums they were however
careful in bulteressing their arguments with a lot of pro-women stances
using feminist vocabulary. An important member of the Expert Group
and also the architect of Tamil Nadu’s family planning programme,
is T V Antony. Since, demographically speaking, the decade of the 1980s
belongs to T V Antony and to Tamil Nadu (in that order) it is to a
consideration of Tamil Nadu’s fertility reduction record that we will
now turn.
Ill
Antony’s impatience with the critics of family planning programmes
and his frustration with those who do not share his characterisation of
population as the problem is discernible from the following outburst:
What is most frustrating is that despite the disastrous implications of this
explosive population growth for every sector of the economy and in particular
to the environment, (here does not appear to be much public support for the
family planning programme. Whereas inflation, natural calamities,
environmental degradation, etc. are all among the many topics which capture
media and public attention today, family planning rarely gets any mention.
What is forgotten is that these problems which are now being highlighted
represent only the external manifestation of our primal malady, namely, a
rapidly growing population’15
Even while listing ‘other important factors which influence fertility’,
Antony’s preocupation with birth control as the ultimate goal comes out
very starkly.
“In preaching a way of life involving later marriage, lower 1MR, higher birth
weights for children, spacing and stopping the child birth cycle early, contra
ception has an important role to play. If in Tamil Nadu, the CBR has fallen
drastically to about 20/1000 in recent years, I believe it wa*caused not so much
by its female literacy level (which is not remarkable) nor by ns health
standards, nor by its age of marriage levels, or its couple protection rates, but
by a combination of all these, plus above all the conviction (hat has now been
implanted in the minds of practically every couple, that a small family is ideal,
that children need not die etc. This has been done through the dedicated
services of the over two hundred thousand Mid day meal employees, and the
several thousand health and social workers in allied nutrition and health
programmes both in government and in the very effective voluntary
organisations under the. overall umbrella of a supportive political system.”16
Antony's euphoria over what he considers to be a successful govern
ment intervention in the field of fertility reduction finds its echo in the
international arena as well. In his analysis of the Asian fertility reduction,
Caldwell argues that the considerations that needed to be addressed with
regard to the historical European fertility transition are wholly inadequate
for addressing contemporary third world fertility transition, especially in
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Asia.17 Any comprehensive demographic transition theory now has to
consider, in addition, according to Caldwell, such matters as the follow
ing: “Are women or couples more likely to limit family size if free or
cheap contraception is readily available and if its availability is made
widely known? Are they more likely to employ such contraception if it is
made respectable and the morally appropriate thing to do because of the
urging of national leaders, local bureaucrats, family planning workers,
and the media? Are they likely still to employ contraception if there are
elements of community pressure or even governmental duress?” And
Caldwell himself provides the answer by stating that: “The evidence from
that part of Asia that lies in an arc from South Korea to India is that the
answer to all these questions is ‘yes’.”18
Fertility Decline in Tamil Nadu: Other Perspectives
The discussion in this section dwells on those studies that go beyond
narrow demographic details to encompass broader issues of social and
economic development including dimensions of patriarchy, gender
inequality and women's agency.
Sunita Kishor's study of fertility decline in Tamil Nadu is part of a
series of publications stimulated by the preparations for the UN 1994
Conference on Population and Development.19 The objective of this
study, in the author’s words, is to “evaluate the pace and liming of decline
in fertility in Tamil Nadu and to identify the socio-economic, cultural, and
institutional factors responsible for it.”
In her analysis of the political and social background of Tamil Nadu,
it is unfortunate that the author has uncritically accepted the propaganda
unleashed by M/s Antony and Co, regarding Periyar’s positive influence
on various retrograde social practices and beliefs linked largely to the
caste system. To admire Pcriyar for then having zeaslously advocated
pro-women reforms is one thing; but from there to jump to the conclusion
that His [i e Periyaf s] ideas have undoubtedly had a far-reaching impact
on social and political developments in the Slate”, and that the political
parties subsequently at the helm of affairs in Tamil nadu are “symbolic
of Dravidian culture”, is neither methodologically tenable, theoretically
sound or even empirically founded.
In attempting to establish the linkage between fertility and the level of
economic and social development, the author notes that, “the challenge
in explaining fertility decline in Tamil nadu arises not from denying the
link between development in Tamil nadu and fertility there, but from
recognising that a large majority of the population was excluded from the
benefits of economic development and remained in poverty even as it
continued to benefit from the social developmental changes” (emphasis
as in the original). A specific combination of continuing absolute depri
vation, but an increasing sense of relative deprivation and rising but
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unfulfilled aspirations, according to the author, has led to reductions in
fertility in Tamil Nadu even among the majority whose economic welfare
was not significantly improved by development.
In the discussion on the official family planning programme, the
author, while acknowledging that the programme has been critical to the
spread of contraception, however finds that the most common method of
family limitation has been sterilization. Among sterilisations, the share of
tubectomics has increased substantially with younger women with fewer
children. Simultaneously the author finds that female dependent
contraception, though still very limited is increasing.
Despite the above findings the author contends, that, “these statistics
undoubtedly reveal the continuing success of the family planning pro
gram in Tamil Nadu’’ (emphasis added). She does, however, realize that
the statistics raise important questions concerning the changing role of
women in the family planning programme, namely, “are there pressures
forcing women to undergo tubectomies at a relatively young age, or are
they accepting sterilisation of their own free will? Can there be ‘free will’
in the acceptance of sterilisation if there are no alternatives to choose
from? These and associated questions raise fundamental issues about the
long term reproductive health and reproductive freedom of men and
women in a family planning environment involving limited choice and
even coercion.’’
It is intriguing, how, despite an elaborate discussion which attempts to
forge a link between fertility, women’s status and kinship structures, the
author is not able to problematise and/or weave in her adverse empirical
findings (for women) on the family planning front to the existing notions
of ‘high cultural status of women’ in Tamil Nadu.
Following Dyson and Moore,20 it has become almost axiomatic to argue
that the observed north-south dichotomy in fertility patterns in India has
a lot to do with the dichotomy in kinship patterns between the north and
south, which in turn bestow different degrees and levels of autonomy on
women. It is argued that the kinship structure in Tamil Nadu -characterised
by general village endogamy, cross-cousin marriages generally, where
affinity is as important as descent in social, political and economic
cooperation, where women sometimes inherit property - is conducive to
greater autonomy for women and therefore lower fertility rales.21 “Au
tonomy’’ according to Dyson and Moore, “indicates the ability - technical,
social and psychological - to obtain information and to use it as the basis
for making decisions about one’s private concerns and those of one’s
intimates. - [Thus] equality of autonomy between the sexes in the present
sense implies' equal decision making ability with regard to personal
affairs.’’22
If we start with the assumption that improvements in status do not
necessarily lead to increase in autonomy in the sense in which Dyson and
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Moore define it above, then, understanding of the power relations
between men and women is essential if women’s capability to participate
in decisions affecting reproduction is to be enhanced. Further, reproduc
tive decision-making while very much a personal concern of the couple
concerned, is also significantly influenced by the social location of the
women in particular, her access to independent information and support
structures and the degree of physical mobility that she can enjoy/claim.
Beyond a point, the impact of education and work on reproduction, as also
the specific relationship between patriarchy and fertility need to be
empirically tested. This is imperative if we have to go beyond an
instrumental treatment of women’s education and employment to really
substantiate the concepts of women’s autonomy and empowerment and
how these impact on reproduction.
IV
In much of the literature discussed above, there is hardly any space to
locate and analyse the differentiated fertility patterns obtaining among
diverse socio-economic subpopulations making up the state of Tamil
Nadu. This, in our view, has a lot to do with (he nature of concerns
engaging much of social science, particularly, demographic research;
these tend to concentrate more on the search for context-free general laws,
very often expressed in the form of mathematical functions that can then
be applied universally. Such an approach cannot capture micro-level
paradoxical outcomes of policies enacted at the macro level. Johansson
refers to the need to look for the role of ‘implicit’ policy in such a context,
where ‘implicit’ policy includes the role played by all forms of slate
activity whether or not such activity was intended by the government to
change fertility patterns, let alone bring about a specific form of change.23
The importance of such an approach lies in the fact that it can capture the
reactions of sets of individuals belonging to various subpopulations in
‘specifically contextualised terms’. To quote Johansson,
In a contextualised analysis, the same determinant (for example, stale policy X)
can be very influential among the subpopulation of couples in context A, while
having no effect whatsoev eron the subpopulation in context B. or even the opposite
effect on the subpopulation in context C. The differential impact of policy in
various contexts can occur even when all three subpopulations supposedly share
the same geographical space (a country or town) and time period (for example, the
late nineteenth century). Therefore measuring and statistically comparing the
effects of the same policy across a large number of subpopulations, which by
definition do not live in the same context (even if they live in the same nation.
province, country, town or parish), is not a meaningful empirical activity. On the
other hand, similar contexts (which foster the same interpretation of. and response
to policy for decision making purposes among the members ol a subpopulation)
can occur among subpopulations that are widely separated in space and time.24
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We hope to (ultimately) contextualise in Johanssonian terms the
paradoxical (fertility) outcomes discernible within Tamil Nadu. A larger
question raised by this exercise (the examination of which however
lies outside the scope of (his paper) is, what should constitute the unit
of analysis. For demographers the overriding success indicator of popula
tion policy is its impact on the level of fertility whatever be the character
istics and nature of the area/people on whom the policy is administered.
Cinder such circumstances the unit of analysis becomes a matter of
convenience and not an issue for discussion or debate. The application of
the Johanssonian framework, however, necessitates identification and
isolation of subpopulations within a geographical space even to begin the
process of understanding why a particular policy creates different re
sponses among subpopulations even within the same geographical space.
However methodologically incorrect the use of administrative demar
cations (in this case, district) as a unit of analysis may be, we have
persisted in their use for our discussion for the following main reason: the
demographic argument of causal relationship between certain con ventional
indicators (like female literacy and female labour force participation) and
fertility stands discredited even on its own terms. For Tamil Nadu, using
largely the 1981 Census data, we have studied the two districts of Periyar
and Kanyakumari as illustrative of two polar cases to raise certain
questions relating to the notion of women’s autonomy in decision making
on fertility related issues. Even if it is argued that the picutrc presented by
the 1991 census data is/could be substantially different from that revealed
by the 1981 census data, the questions of
(a) why this has taken place, and
(b) whether this change has to do with the autonomous status of
women to effect a change, still remains relevant.
Our exercise begins with a set of data that posits the demographic
picture of Periyar and Kannyakumari vis-a-vis the rest of the state. (The
patterns that the data produce and the questions that they raise will form
the foci for the field investigations to be carried out in the course of
implementation of the larger project).
1) While the decline in fertility rales in Tamil Nadu has led to all kinds
of suppositions being made about greater female autonomy (ostensibly
because of higher female literacy rales, greater female work participation
rales, female-friendly kinship structures, etc.), the other side of the coin,
namely the declining female-male ratio has not been simultaneously
posited alongside and analysed. In fact the sex ratio has been continuously
declining in Tamil Nadu since the beginning of the century. From 1044
in 1901, it has come down to 974 in 1991.25 Dreze and Sen's decompo
sition analysis of the female-male ratios between 1901 and 1991 show
that the largest absolute declines in the ratios have taken place in Bihar,
Orissa, Tamil Nadu, Madhya Pradesh, Maharashtra and Uttar Pradesh.26
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2) Within Tamil Nadu, the district of Periyar shows a steep decline in
female-male ratio between 1901 and 1991; Kanyakumari, which at no
time had a favourable female-male ratio, neverthless, only shows a
marginal decline. Interestingly, while for the state as a whole as well as
for Periyar, the urban female-male ratios are much worse than for rural
areas, in Kanyakumari, on the other hand, the urban areas seem to be more
favourable to women. In fact, the 1991 urban female-male ratio for
Kanyakumari stands at 100I.27 (Table 1)
3) Table 2 provides the unadjusted fertility rates by districts for Tamil
Table 1: Female-Male Ratio: By Location
(Tamil Nadu, Periyar, Kanyakumari)
1981
1991
Rural
Urban
Rural
Urban
987
'960
983
956
941
995
981
969
989
960
952
1001
Tamilnadu
Periyar
Kanyakumari
Source: Computed from Census of India, 1991, Series-23, Tamil nadu. Primary
Census abstract for General Population, Part II - B (i), Director of Census
Operations, Tamil Nadu.
Table 2: Unadjusted Fertility Rates by Districts in Tamil Nadu
I ndia/State/District
_______________ Unadjusted_______________
CBR
TFR
TMFR
GFR
GMFR
India
Tamil Nadu
Madras
Chengalpattu
North Arcot
South Arcot
Dharmapuri
Salem
Periyar
Coimbatore
Nilgiris
Madurai
Tiruchirapalli
Thanjavur
Pudukottai
Ramanathapuram
Tirunelveli
Kanyakumari
25.67
24.37
22.75
26.11
27.74
26.73
27.95
20.71
18.85
19.77
22.79
22.67
22.16
23.46
27.87
27.11
27.38
25.57
3.6
3.0
2.5
3.2
3.6
3.4
3.7
2.4
2.2
2.3
2.5
2.8
2.7
2.9
3.6
3.5
3.6
3.3
4.3
4.2
3.8
4.4
4.6
4.3
4.6
3.4
3.2
3.5
3.9
4.0
3.8
4.0
4.9
4.8
5.1
5.4
112
94
85
103
112
116
1 16
79
70
74
84
88
84
89
109
104
105
98
139
129
121
138
146
136
145
103
93
104
124
122
1 15
122
149
146
154
163
Source: Census ofIndia, 1981, Occasional Paper No. 13 of 1988. Fertility in India
An Analysis od 1981 Census data. Office of the Registrar General, India.
New Delhi, p.l 18.
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Nadu; Periyar shows the lowest rates be it the CBR, TFR, TMFR, GFR,
or GMFR. On the other hand, while Kanyakumari is on the high side for
almost all the ratios, those which are particularly striking are the TMFR
and the GMFR.
4) Table 3 gives age and location-wise data on the different fertility
measurements for Periyar, Kanyakumari and the state as a whole. We find
that:
a) Fertility ratios for Kanyakumari are above those for the state in both
rural and urban areas but in the same direction, with rural ratios exceeding
the urban ones.
Table 3: Fertility Rates: By Age and Location
(Tamil Nadu, Kanyakumari and Periyar)
Total (R + U)
KK PER
. TN
CBR
GFR
TFR
GMFR
Age
Group
15-19
20-24
25-29
30-34
35-39
40-44
45-59
15-19
20-24
25-29
30-34
35-39
40-44
45-59
15-19
20-24
25-29
30-34
35-39
40-44
45-59
TN
Rural
KK
PER
TN
24.18 25.38 18.73 24.57 25.73 17.59 23.37
94.25 98.68 70.12 96.47 100.77 65.86 89.83
3.14
3.00
3.29
2.18
3.37
2.10
2.71
128.98 163.12 94.01 129.75 167.08 88.18 127.38
Percenta ge of currently married femal es
Urban
KK PER
23.67 22.74
89.06 85.23
2.94
2.92
145.16 114.80
5.88 24.08
22.81
4.92 20.54 24.59 4.71 19.44 20.24
75.49 44.61 76.44 78.91 44.39 76.11 69.58 45.62 77.42
92.19 83.31 92.96 93.24 83.35 92.87 90.25 83.12 93.27
92.92 92.08 92.64 92.91 91 93 92.39 92.93 92.76 93.54
90.89 91.15 91.15 90.61 90.91 90.99 91.52 92.24 91.80
83.96 86.55 86.03 83.70 86.29 86.07 84.58 87.68 85.83
77.22 81.76 81.48 77.19 81.68 82.36 77.30 82.11 77.60
Age-specific Fertility Rates (ASFR)
10.94 43.16
42.22
9.35 33.05 43.79
9.01 29.91 39.33
184.63 133.06 171.53 190.36 132.58 162.80 174.71 135.24 197.05
175.37 226.72 130.16 180.64 232.15 125 70 165.69 201.02 144.32
109.68 151.01 60.85 116.96 156.33 60.75 94.77 126.76 61.21
74.93 25.95
59.44 94.85 25.78 64.56 99.16 25.74 47.91
6.22
9.74 24.35 35.77 10.52 14.99 31.05
21.56 34.89
7.30
4.94
7.84
8.45
5.06
5.26
7.02
5.00
8.25
Age-specific Marital Fertility Rates (ASMFR)
185.13 190.12 160.93 180.99 191.24 153.88 194.29 185.96 179.26
244.57 298.27 224.39 241.24 298.67 213.91 251 09 296.48 254.53
190.23 272.14 140.01 193.73 278.51 135.36 183.59 241.85 154.74
118 03 164 00 65.69 125.88 170.06 65.76 101.98 136.66 65.43
65.39 104.06 28.28 71.25 109 07 28.29 52.35 81.24 28.26
7.25
25 67 40.32 11 32 29.09 41.45 12.22 17.72 35.41
6.55- • 8.89
6.00
6.78
6.13 10.15 10.35
9.09 10.08
Source: Computed from : Census of India, 1981, Series-20, Tamil Nadu, Fertility
Tables, Part VI A-B, Director of Census Operations, Tamil Nadu.
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b) In Periyar, on the other hand, all the ratios are far below the average
for the state, and their direction is different: the rural ratios are far below
the urban ones.
c) The data on percentage of currently married females reveal an
interesting pattern: in Kanyakumari less than 5 per cent of the females
in the age-group 15-19 are married as compared to 22 per cent for the
slate and 20 per cent for Periyar. In fact, it is only from the age-group
25-29 onwards that one finds a substantial percentage of females
married in Kanyakumari. Again the percentage of married females in
each of the age-groups is almost the same for rural and urban areas in
Kanyakumari.
d) For the state as a whole, the percentage of currently married
females in rural areas exceeds that in the urban areas only upto the
age group 30-34; thereafter the urban percentage exceeds the rural
percentage. In Periyar on the contrary, the percentage of currently
married females in rural areas is less than the urban figure upto the
Table 4: Districts Arranged in Descending Order of their Female Work
Participation Rate, 1991
Rank
District
in 1991
Female Work Participation Rate Rank
1991
1981
in 1981
TAMIL NADU
1 Kamarajar
2 Tirunelveli-Kattabomman
3 Periyar
4 Dindigul-Anna
5 Pasumpon Muthuramalinga Thevar
6 Dharmapuri
7 Salem
8 Ramanathapuram
9 Tiruvannamalai-Sambuvarayar
10 Tiruchirapalli
11 Pudukottai
12 South Arcot
13 Madurai
14 Chidambaranar
15 Nilgiri
16 Coimbatore
17 North Arcot-Ambedkar
18 Thanjavur
19 Chengalpattu -MGR
20 Kanniyakumari
21 Madras
29.89
42.18
40.22
38.66
38.32
37.66
37.39
36.69
35.87
35.82
34.81
33.00
31.81
31.77
30.05
29.75
26.91
26.09
24.87
21.77
11.03
8.44
26.52
41.69
33.91
36.51
34.44
25.10
29.20
33.34
28.66
33.34
29.41
26.49
26.75
28.85
28.08
26.81
28.19
23.06
21.63
20.68
9.34
6.80
1
4
2
3
16
8
5
10
5
7
15
14
9
12
13
11
17
18
19
20
21
Source: Census of India, 1991, Series-23, Tamil Nadu. Primary Census Abstract
for General Population, Part II - B (i). Directorate of Census Operations.
Tamil Nadu, August 1993, p 44
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age-group 35-59 - a complete reversal of the direction obtaining for the
state as a whole.
e) There is a drastic fall in ASFR and ASMFR for Periyar and for the
Stale as a whole after the age group 25-59; for Kanyakumari on the other
hand it remains very high almost upto the age-group 35-59. For Periyar,
in addition, the rural ASFR and ASMFR are far below the urban rates.
5) The figures for (overall) work participation rates show that in
Periyar almost 37 per cent of women are ‘workers’ in the census sense as
compared to only 1 1 percent for Kanyakumari. (Table 4) An occupational
category-cum-age classi-fication of these data however tell an interesting
tale.(Table 5,6,7) Even though overall work participation rates for women
are far below the rates for men. an analysis of even (his small component
of women workers reveals the following pattern:
a) For Kanyakumari, the proportion of female workers in the agegroups 0-14, 15-19 and 20-24 is significantly higher than the proportion of
male workers in these same age-groups. Thereafter, that is from the age
group 25-29 onwards, the proportion of male workers exceeds women
workers in all subsequent age-groups. This is true for both the urban and
rural areas.
b) Using census industrial categories we note that in Kanyakumari,
unlike in the rest of the state or even in Periyar, women workers are visibly
concentrated in large numbers in the category ‘Manufacturing, Process
ing, Servicing and Repairs’. The Census breaks this category further into
two parts, namely, the ‘Household Industry’, and ihe‘Olher than House
hold Industry’. Here again, in contrast to the generally observed phenom
enon elsewhere, women workers in Kanyakumari are proportionately
more in the ‘Other than Household Industry’ category than in the
‘Household Industry’ category. This is true for both urban and rural
Kanyakumari.
c) What is also very striking is that in Kanniyakumari, the peak
employment age for this category of ‘Manufacturing, Processing, Servic
ing and Repairs' happens to be the age group 15-19. There is a slight fall
in the level of employment in the age group 20-24 but it is still quite
substantial. There occurs a dramatic fall in the proportions employed in
the age group 25-29, and in the subsequent age groups the numbers of
women workers in this industrial category do not reach their earlier
proportions.
d) While causality still needs to be empirically established, juxtaposing
the above data with that relating to the percentage of currently married
women in the different age-groups for Kanyakumari will caution those
who read loo much progress into the phenomenon of rising age at
marriage for females. In Kanyakumari we saw that, less than 5 per cent
of the females in the age group 15-19 are married, and that, it is only from
the age-group 25-29 onwards that one finds a substantial percentage of
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females married. Whether the nature of available employment and/or
marriage practices pressurises families to send young adolescent girls for
such work before gelling them married needs to be concretely established.
c) In Periyar district the rural and urban data on female workers by age
and employment category show different patterns. In the rural areas the
two dominant census categories of work employing large numbers of
women are ‘agricultural labour’ and ‘cultivator’. The proportions of
women employed in these two categories in the age-groups 0-14, 15-19
are higher than the proportions of male workers in the same age groups
in the same categories; however, while in the subsequent age groups men
are proportionately more in numbes than women, the fluctuations in
proportions among women workers between the age-groups 20-24 to 4049 are only marginal.
Table 5: Distribution of Female Workers by Census Occupational
Category: Descending Order
Occupational
Category
Rural
Total Percent- Occupational
Workers age
Category
Workers
Urban
Total PercentWorkers
age
Workers
Periyar
Total (all categories) 330581
Total (all categories) 38526
Agricultural labourers 202941 61.39 Manf Proc Ser & Reps 12921,
Cultivators
80319 24.30 Agricultural Labourers 10665
Manf Proc Ser & Reps 30056 9.09 Other Services
6367
Other Services
3940
7323 2.22 Trade and Commerce
Trade and Commerce
4373 1.32 Construction
2128
Construction
1339
3256 0.98 Cultivators
Livestock
853
2163 0.65 Transport
Transport
145 0.04 Livestock
313
Mining
0
0 0.00 Mining
33.54
27.68
16.53
10.23
5.52
3.48
2.21
0.81
0.00
Kanyakumari
13522
Total (all categories) 52475
Total (all categories)
Manf, Proc, Ser, & Reps. 7201
Agricultural Labourers 18582 35.41
4481
Manf Proc Ser & Reps 18344 34.96 Other Services
829
Trade and Commerce
Other Services
8756 16.69
705
Cultivators
2836 5.40 Agricultural Labourers
137
Trade and Commerce
2364 4.51’ Transport
111
Cultivators
Livestock
1124 2.14
30
Transport
176 0.34 Construction
29
Mining
147 0.28 Livestock
0
Mining
Construction
137 0.26
53.26
33.14
6.13
5.21
1.01
0.82
0.22
0.21
0.00
Source’. Computed from Census of India, 1981, Series - 20, Tamil nadu General
Economic Tables. Part III-A and B (i), Tables B-3, and B-7.
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f) In urban Periyar, the domiant activity categories for women workers
are ‘Manufacturing, Processing, Service and Repairs and ‘Agricultural
Labour’. Within the ‘Manufacturing...’ category, those employed under
the head ‘Other than Household Industry’ are more than those under the
head ‘Household Industry’. Besides, the former show the same
Table 6: Location-cum-Agewise Classification of Important Industry
Group for Females
Kanyakumari
Age
Group
Manufg, Procs, Services and Repair
Total
Agricultural
Household Other than House- Other
Workers
Labourers
Industry
hold Industry
Services
Male Female Male Female Male Female Male Female Male Female
Total 347327 65997 134675
0-14
1.53 4.64
2.06
15-19
8.42 17 39 11.18
20-24 12.25 14.83 14.03
25-29 13.81 12.07 13.98
30-34 11.90 10.77 10.66
35-39 12.04 11.32 10.83
40-49 19.26 15.99 17.52
50-59 12.62 8.39 11.87
60 +
8.16 4.60 7.61
Rural
Total 288252 52475 130467
0-14
1 51 4 82 2.03
15-19
8.62 17.81 11.18
20-24 12.43 14.89 14.05
25-29 13.88 12.16 14.04
30-34 11.70 10.46 10.67
35-39 11.91 11.17 10.80
40-49 18.93 15.46 17.52
50-59 12.51 8.43 11.82
60 +
8.50 4.80 7.58
Urban
Total 59075 13522 4208
0-14
1.64 3.95
2.83
9.60
15-19
7.45 15.77
20-24 1 1.34 14.60 13.28
25-29 13.45 11.73 12.19
30-34 12.89 11.95 10.50
35-39 12.66 11.89 11.86
40-49 20.87 18.04 17.68
50 59 13.14 8.23 13.45
60 +
6.54 3.83 14.33
19287
3.51
12.21
12.46
12.35
9.21
12.37
18.64
11.64
7.62
8834 12669 24283 12875 32403 13237
3.05 10.79 0.44
1.90 5.81
1.01
7.38 27.66 10.46 35.95
1.85
3.22
10.45 18.72 14.01 21.86 5.65 10.95
9.99 15.29 3.44 11.68 17.52
11.33
11.66 7.88 11.82 5.78 16.49 20.28
10.09 9.27 12.33 5.20 18.45 18.40
19.65 12.31 17.02 7.12 28.48 20.11
16.06 5.58 10.57
3.60 13.08 6.81
11.46 2.82 5.46
1.24 3.87
1.71
18582 6968
3.57 2.25
12.29 7.75
12.58 10.98
12.61 11.67
9.44 11.88
12.52 10.02
18.04 18.84
11.59 15.69
7.37 10.88
9286 14040 9058 22208 8756
6.83
2.93 12.10 0.32 0.34
29.44
9.74 39.55
1.85
2.66
19.53 14.29. 22.49
5.44 11.09
9.89 16.23
8.05 12.37 18.81
*7.43 12.24 4.10 16.95 21.90
8.25 12.93
4.44 18.51 18.99
11.26 17.21
5.14 27.65 18.88
4.63
9.55
3.00 12.68
6.16
2.75 4.88
1.10 4.20
1.28
705 1865 3384 10243 3817 10196 4481
1.99 0.59 3.01
3.20 7.68 0.71
2.32
9.93 6.01 22.72 11.43 27.43
1.86 4.31
9.36 8.47 16.49 13.65 20.38
6.09 10.64
5.53 10.08 10.25 13.99 9.41 10.17 15.00
3.26 10.83 . 9.07 11.25
9.77 15.50 17.32
8.23 10.35 12.06 11.51
6.97 18.31 17.25
34.61 22.63 15.19 16.75 11.82 30.28 22.54
•13.05 17.48
8.19 11.97 5.00 13.94
8.08
14.33 13.62 3.00 6.26
1.57
3.16 2.57
Source: Same as Table 5.
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Periyar
T able 7: L ocation-cum-A gewise C lassification of Important I ndustry G roup for F emales
(Contd)
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25
Periyar
T able 7: L ocation-cum-A gewise C lassification of I mportant I ndustry G roup for Females
characteristics as we saw in the case of Kanyakumari, namely there arc
substantial proportions of women working upto the age-group 25-29.
thereafter there is a drastic fall in members in subsequent age-groups.
While under the category 'Household Industry' the peak employment
age-group for women is 15-19. the decline in numbers is not as dramatic
as in the ‘other than Household' category. In the case of Periyar. the lack
of clarity regarding the existence and direction of the relationship
between women's work and demographic behaviour may be due “not
only to the nature of the employment and women's broadercircumslances.
but also to methodological inconsistency and simplistic analytic
approaches. Available evidence is insufficient to determine whether
women who enter the labour force bear fewer children than others or
whether women with fewer children lend to have higher levels of labour
force participation.”2’'
6) Kanyakumari not only has the highest percentage of literate females
in the state among rural as well as urban population, it also has the least
percentage of child workers among its total child population unlike
Periyar and the rest of the state. (Tables 8. 9. 10) Further, the educational
level of the women in Kanyakumari is also above that obtaining for the
rest of the stale and way above what one finds for Periyar. For those
interested in establishing connections between literacy and fertility.
Periyar is an interesting conundrum; the rural areas of Periyar where
female literacy levels are far below the urban literacy rales are precisely
the areas where fertility rales are below those for urban areas.
What can one conclude about the demographic behaviour of Periyai
and Kanyakumari from the above sets of data, particularly as regards
the impacts of literacy levels and female work participation rates on
reproductive outcomes? Several empirical investigations (even for India.
as Sen puls it) have observed and confirmed the statistical relations
between women’s education and women's opportunity to earn an outside
income on the one hand, and lower fertility rales on (he other. Referring
to a forthcoming statistical contribution using extensive district level
data,29 Sen points out that the only variables that have a statistically
significant effect on fertility are female literacy and female labour-force
participation. He therefore concludes that “the importance of women's
agency emerges forcefully from this analysis, especially in comparison
with the weaker effects of variables relating to general economic
progress.”30
To posit the paradoxical findings fo’r Periyar and Kanyakumari against
studies that provide evidence of a strong correlation between women's
educational level and work participation rales, and fertility, is definitely
not intended to question the role of school education or increasig outside
employmentlor females as a force for social change.31 On the contrary
it is aimed al stressing the need to avoid arriving at instant policy
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conclusions from mere statistical contributions however significant they
may be. A statistical correlation is only a first step; without a substantive
ihdeplh examination to determine exactly how and to what extent vari
ables such as education, employment, kinship structures, marriage prac
tices, properly rights etc. influence women’s autonomy (as defined by
Dyson and Moore) and/or fertility rates, one could have any number of
policy enactments (including those to ‘enhance’ women’s status) with the
ground level reality responding more to Johansson’s ‘implicit’ policy
changes rather (han to the government’s explicit fertility reduction
programmes.
Table 8: Districts Arranged in Order of Literacy Rankingjn 1991 Census
and Comparison with 1981 Census
Literacy Stale/District
Rank
in 1991
(2)
(1)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
Literacy Literacy
Increase
Rate 1991 Rate 1981 of Literacy
Rate 1981-91
(4)
(3)
(5)
Tamil Nadu
Kanniyakumari
Madras
Chidambaranar
Nilgiri
Madurai
Chengalpallu-MGR
Coimbatore
Thanjavur
Tirunelveli - Kattabomman
Pasumpon Muthuramalinga Thcvar
Kamarajar
Ramanathapuram
Tiruchirapalli
North Arcot - Ambedkar
Pudukottai
Dindigul-Anna
Pcriyar
Salem
Tiruvannamalai-Sambuvarayar
South Arcot
Dharmapuri
62.66
82.06
81.60
73.02
71.70
66.41
66.38
66.35
66.02
65.58
63.04
62.91
61.59
61.22
60.87
57.63
56.68
53.80
53.31
53.07
52.86
46.02
54.39
73.80
78.21
NA
65.22
NA
56.14
59.97
58.33
NA
NA
NA
NA
52.68
NA
46.02
NA
44.86
44.67
NA
43.85
34.43
8.27
8.26
3.39
6.48
10.24
6.38
7.69
8.54
11.61
8.94
8.64
11.59
Not available.
Literacy Rales have been Calculated on the Population aged seven
years and above
Source: Census of India, 1991, Series-23, Tamil Nadu, Primary Census Abstract
for General Population, Part 11 - B (i), Directorate of Census Operations,
Tamil Nadu, August 1993, p 14.
NA:
Note:
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V
Putting together the scattered bits of oral information that we have
been able to collect on Periyar, we find that Periyar is part of a region
which is not only agriculturally prosperous, but, one which in the last
few decades has seen the emergence of some of the fastest growing
towns in the state catering to the export market. There is severe
competition for labour from both the towns and the villages; the towns
in addition attract quite a large number of young female labour force.
The fast changing nature of the economy and employment pattern of
the region has led to changes in the agrarian structure of the region,
including in the relationships that previously obtained between the
landholding classes and the tenant farmers. How these changes have
combined to create conditions for increasing female work partici
pation rates but not literacy levels is as intriguing as the questions
Table 1 1: Marital Status : Kerala. Tamil Nadu vis-a-vis India
Total/
Rural/Urban Never Married
Male
Female
Martial Status
Married
Widowed
Male Female Male Female
Divorced/
Separated
Male Female
as % of as % of as Vc ofas % of as % of as % of as % of as % of
total
total
total
total
total
total
total
total
male female
male female male female
male female
popn
popn
popn
popn
popn
popn
popn
popn
India
(Rural +
Urban)
55.26
(Rural)
54.73
56.90
(Urban)
Kerala
(Rural +
Urban)
61.55
(Rural)
61.34
(Urban)
62.44
Tamil Nadu
(Rural +
Urban)
55.71
Rural
54.77
All ages
Urban
57.59
All ages
45.75
44.87
48.70
42.05
42.27
41.35
45.79
46.45
43 55
2.43
2.71
1.56
8.01
8.20
7.40
0.23
0.26
0.13
0.42
0.45
0.32
50.85
50.77
51.19
35.86
37.15
36.33
38.65
38.86
37.71
1.14
1.18
0.97
9.08
8.86
10.04
0.29
0.31
0.22
1.39
1.49
1.01
45.51
41.76
43.80
2.26
10.00
0.24
0.67
44.58
42.33
44.30
2.58
10.35
0.30
0.76
47.45
40.63
42.76
1.63
9.28
0.13
0.49
Source: Computed from Table C-l, Part IV-A, Census of India, 1981, Senes I,
India. Social and Cultural Tables. Office of the Registrar General, India,
New Delhi.
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raised by (he Kanyakumari data, namely, contrary to expectations,
why do widespread female literacy and delayed marriage, not result in
increasing work participation levels for women? (As of now we have
very little information on the overall nature of the economy of
Kanyakumari). Additionally, we need to have some idea of the
(changing) community composition, kinship structures, marriage
practices, inheritance patterns, role of religion, in both the districts to
Table 9: Literacy Rates (for population aged 7 and above) in 1991
Tamil Nadu, Periyar, Kanniyakumari
Among the Total
Among the Rural
Among the Urban
Population_____ _____ Population_____
Population
Persons Males Females Persons Males Females Persons Males Females
Tamil
Nadu
62.66 73.75
Periyar 53.80 65.54
Kanniya
kumari 82.06 85.70
51.33 54.59 67.18
41.58 47.56 60.00
41.84 77.99 86.06
34 65 73.06 82.57
69.61
63.08
78.39 80.76 84.56
76.93
85.44
88.36 91.29
Source: Census of India, 1991, Series-23, Tamil Nadu. Primary Census Abstract for
General Population, Part Il-B(i), Statement 5, Director of Census Operations.
Tamil Nadu , p. 12.
Table 10: School Attendance of Children
(Age 5-14 years)
Tamil Nadu
Males Females
Periyar
Males Females
Kanyakumari
Males Females
% of children attending school
(R+U)
64.69
49.65
57.62
42.33
77.48
Rural
59.75
41.20
53.77
36.39
76.63
62.04
Urban
74.83
67.02
70.35
81.74
% of children not attending school
57.67
35.31
50.35
42.38
22.52
(R+U)
58.80
46.23
63.61
23.37
Rural
40.25
25.17
32.98
29.65
37.96
18.26
Urban
% of child workers to total child population
14.04
8.87
7.99
14.25
3.10
(R+U)
16.47
15.93
3.05
10.78
10.40
Rural
5.95
3.36
3.03
8.68
4.96
Urban
% of Non-workers not attending school to total child population
44.00
19.00
42.00
28.00
27.00
(R+U)
30.00
47.00
20.00
48.00
Rural
30.00
32.00
15.00
21.00
30.00
Urban
20.00
73.39
72.28
78.77
26.61
27.72
21.23
1.84
1.83
1.89
25.00
26.00
19.00
Source: Census of India, 1981 Series 20, Tamil Nadu. Social and Cultural Tables.
Part IV-A, Table C-4, Director of Census Operations, Tamil Nadu.
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be able to assess how all these simultaneously impact in bringing
about high fertility rates in the one and low fertility rates in the other
district.
The assertion that women in Tamil Nadu have relatively more au
tonomy and are not subject to coercive family planning programmes (and
therefore the fertility rates in Tamil Nadu are as low as they are) is highly
problematic. Whether it is the autonomy of Periyar women that is
responsible for their low rates (and vice versa for Kanyakumari) is
difficult to ascertain from the secondary data presented here. While high
fertility rates resulting from lack of autonomy is understandable and
plausible, low fertility rales need not necessarily imply presence of
autonomy for women.
The fact of more autonomy for women in the southern stales,
including Tamil Nadu, is generally based on data pertaining to female
literacy levels, work participation rales, age at marriage, contraceptive
prevalance rates, female-friendly kinship structures etc. Another set of
data that is not simultaneously looked into is the marital status of the
population. A quick look al the census data on this clearly show that the
model slates of Kerala and Tamil Nadu have relatively more percentage
of women who are widowed, and, divorced/separated.(Table 11) In
addition, according to the NSS data,32 these slates have more number of
female headed households, when compared to the female-unfriendly
stales of the north. Whether divorce/separation constitutes enhanced
autonomy for women (in that it enables them to opt out of oppressive
manage structures) again needs to be concretely established. Further,
when the data on female-headed households is viewed in the context of
the growing incidence of ‘feminisalion of poverty’ in the country as a
whole, it does raise questions about the circumstances and the conditions
that ultimately make a couple arrive at the decision - either to have or not
to have a child.
The issue of coercion needs to be dealt with at various levels. The
fact that Tamil Nadu has not seen Emergency type coercive practices
where groups of people particularly in the rural areas were herded
into family planning camps and sterilised (largely vasectomised),
cannot be the sole reason to come to the opposite conclusion that
cooperation is the hallmark of the ‘success’ of the family planning
programmes in Tamil nadu. Family planning programmes are based
on assumptions about sexuality and gender that must be identified and
challenged.33
In the first place we need to document very systematically what
goes on in governemnl hospitals, and what is done by governemnt
and govt-recognised private doctors, in the name of family planning.
Our very limited interaction with NGOs active in this field in
Tamil Nadu reveals that a large number of abortions take place
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outside the formal system since very often the state through its family
planning outlets tries to impose its own morality on women seeking
abortions.
While the north has seen a change-over from vasectomy to tubectomy
in the post Emergency period, in Tamil Nadu this change over has taken
place without the state having experienced the Emergency-type of ex
plicit organized violence on the family planning front. The much touted
‘success’ of the family planning programme of Tamil Nadu is anchored
largely on the increasing number of lubeclomies performed as part of the
family planning programme. This, to us, constitutes a form of state
violence on women.
In a field-based study of factors contributing to fertility transition in
Tamil Nadu, Sundari Ravindran has collected very telling information on
the ‘successful’ family planning programme of Tamil Nadu. To quote
Ravindran:
Forthe majority, family planning is synonymous with ‘femalesterilisation’.
Information on how any of the methods work is practically unknown even
among those who have adopted a method. And most important of all, the
family planning programme’s pre-occupation with promoting female
sterilisation (and more recently, other female methods of contraception)
may have only further reinforced and even considerably strengthened the
notion that fertility control is exclusively a ‘female concern’... Because
women do not adopt spacing for fear of negative side effects, it is assumed
that there is no option but for women to resort to abortion in order not to
have an unwanted birth. Practice of contraception by men, either the
condom or periodic abstinence - features nowhere in their realm of
options’54
Unravelling the processes by which a couple arrives at answers to the
following questions would itself reveal whether women feel coerced or
not to behave and act in particular ways: whether or not to have a child
and, if so, when; whether to terminate a pregnancy because it is unwanted
or because the foetus belongs to a particular sex; what form of contra
ception to practice, etc. Thus, coercion defined broadly, would capture
the interpersonal power relations that affect sexual and reproductive
outcomes.
Notes
[This is a revised version of the paper presented at a Conference on ‘Gender
Perspectives in Population, Health and Development in India’, sponsored by
the Macarthur Foundation and organised by the National Council of Applied
Economic Research, New Delhi, between January 12-14, 1996. I am grateful
to all the participants at the Seminar for their comments and suggestions. I am
equally grateful to my colleagues, Janaki Nair, K Nagaraj, Manabi Majumdar
and M S S Pandian, for their comments on an earlier draft of this paper; to
P Anbazhagan and Millie Nihila for their assistance with the data, to T
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Maheswari and R Dharmaperumal for their painstaking effort in bringing out
this paper. Needless to add. the usual disclaimers apply.]
1 Sen A ’Population Policy: Authoritarianism Versus Cooperation’, The
John and Ca'herine T MacArthur Foundation Lecture Series On Popula
tion Issues. August 17, 1995, New Delhi, (mimeo).
2 Ravindran, Sundari, T K ‘Women and the Politics of Population and
Development in India’, Legal Perspectives, Documentation File No 31
Madras, p 7.
3 Savitri, R ‘Fertility Rate Decline in Tamil Nadu: Some Issues’.
Economic and Political Weekly, Vol XXIX, No 29, July 16, 1994.
pp 1850-1852.
4 In this context it needs to be stated that it is largely the rise of feminist
scholarship that has given a new life and vitality to demographic research
besides forcing'a reconsideration of the role of state policy in fertility
change. For a useful disucssion on fertility change from a gender per
spective, see, Nancy Folbre, “Of Patriarchy Born” Feminist Studies,
Vol 9, No 2, Summer 1983, pp 261-284.
5 The Ministry of Health and Family Welfare set up (by an order dated 19th
July 1993) an Expert Group chaired by M S Swaminathan for preparing
a draft National Policy on Population. The Expert Group submitted its
draft to the above Ministry on May 21, 1994.
6 See in this context the following references:
(a) Demeny, Paul, ‘Social Science and Population Policy,’ Population
and Development Review, Vol 14, No 3, September 1988, pp 451-79.
(b) Hodgson, Dennis, ’Orthodoxy: and Revisionism in American
Demography,’ Population and Development Review, Vol 14, No 4,
December 1988, pp 541-69.
(c) Amalric, Franck and Banuri, Tariq, ‘Population: Malady or Symp
tom’, Third World Quarterly, Vol 15, No 4, 1994, pp 691-705.
7 For an elaborate discussion on approaches to population policy, see
S Ryan Johansson ‘Implicit Policy and Fertility During Development'.
Population and Development Review’ Vol 17, No 3, September 1991.
pp 377-441.
8 For an elaboration, see, Almaric, Franck and Banuri, Tariq, ‘Population;
Malady or Symptom’, op cit.
9 Ibid, p 701.
10 Ibid, p 701-702.
11 Refer in this context, Dennis Hodgson, ‘Demography as Social Science
and Policy’, Population and Development Review, Vol 9, No 1, March
1983. pp 1 -34. and the references cited in note (9) above.
12 Almaric, Franck and Banuri, Tariq, op cit, p 701.
13 This point and the paragraph immediately following below have been
taken from V.Geeta and Padmini Swaminathan, “The Politics of
Population and Development in India”, Economic and Political Weekly,
September 17, 1994.
14 Demeny, Paul. ‘Social Science and Population Policy’, op cit, p 18.
15 Antony, T V ‘The Family Planning Programme - Lessons from Tamil
Nadu’, op cit, p 320.
32
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Antony, T V ‘Wanted - for the Family Planning Programme - A Positive
Image’, Note dated March 15, 1994, Madras (mimeo).
17 Caldwell, John C, ‘The Asian Fertility Revolution: Its Implications for
Transition Theories’, in Richard Leete and Iqbal Alam (ed): The Revolu
tion in Asian Fertility: Dimensions, Causes and Implications, Clarendon
Press, Oxford, 1993, pp 299-316.
18 Ibid, p 315.
19 Kishor, Sunita ‘Fertility Decline in Tamil Nadu, India’, in Bertil Egero
and Mikael Hammarskjold (ed): Understanding Reproductive Change:
Kenya, Tamil nadu, Punjab, Costa Rica, PROP, Lund University Press,
Sweden, 1994, pp 65-100.
20 Dyson, T and Moore, M ‘On Kinship Structure, Female Autonomy, and
Demographic Behaviour in India’, Population and Development Review,
Vol 9, Number 1, March 1983, pp 35-60.
21 Apart from Sunita Kishor, the ‘female-friendly southern kinship’
arguments finds its echo in the following article, among others, namely,
John Caldwell and Pat Caldwell, “Patriarchy, Gender and Family
Discrimination, and the Role of'Women”, in Lincoln C Chen, Arthur
Kleinman and Norma C Ware (eds) Health and Social Change in Inter
national Respective, Harvard Series on Population and International
Health, Boston, Massachusetts, 1994, p 357.
22 Dyson, T and Moore. M ‘On Kinship Structure,’ op cit, pp 45-46.
23 Johansson, Ryan, S ‘Implicit Policy and Fertilty During Development’,
Population and Development Review, Vol 17, No 3, September 1991,
pp 377-414.
24 Ibid, p 381.
25 See Census of India, 1991, Series-23, Tamil Nadu, Primary Census
Abstrct for General Population, Part II-B(i), Statement - 4, p 11, Director
of Census Operations, Tamil Nadu.
26 Dreze, J and Sen, A: India: Economic Development and Social Opportu
nity, OUP, Delhi 1995, p 150.
27 Computed from data provided in Census of India, 1991, Series-23, Tamil
Nadu, op cit.
28 Mahmud, S, and Johnston, Anne M ‘Women’s Status, Empowerment and
Reproductive Outcomes’, in Gita Sen et al, (ed) Population Policies
Reconsidered: Health, Empowerment and Rights, Harvard Seies on Popu
lation and International Health, Distributed by Harvard University Press,
Boston, Massachuseltes, 1994, p 154.
29 Dreze J, et al, ‘Demographic Outcomes, Economic Development and
Women's Agency’, Discussion Paper, Centre for Development Eco
nomics, Delhi School of Economics, 1995; to be published in Population
and Development Review.
30 Sen, A ‘Population Policy: Authoritarianism Versus Co-operation’, op cit,
p 18.
31 Ibid, Sen is critical of those, who have disputed the observed links
between education and outside employment (for women) on fertility.
32 See Sarvekshana, Special Number, September 1990. Results of the
Fourth Quinquennial Survey on Employment and Unemployment
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(All India), NSS 43rd Round, (July 1987- June 1988), NSSO, Depl of
Statistics, Govt of India, Statement 3, pp 18-19.
33 A very useful article in this context is Ruth Dixon-Mueller, ‘The Sexual
ity Connection in Reproductive Health’, Studies in Family Planning Vol
24, No 5, Sept/Oct 1993, pp 269-282.
34 TK Sundari Ravindran, ’Factors Contributing to Fertility Transition inTamil
Nadu: A Qualitative Investigation’ Paper presented al the Silver Jubilee
Seminar of the Madras Institute of Development Studies, Madras, April 2-4,
1996, p 251.
Medico Friend Circle
Publications
In Search of Diagnosis edited by Ashwin Patel, pp 175,1977
(reprinted 1985), Rs 12. (Currently out of stock)
Health Care: Which Way to Go? Examination of Issues
and Alternatives edited by Abhay Bang and Ashwin Patel,
pp 256, 1982 (reprinted 1985), Rs 15. (Currently out of
stock)
Under the Lens: Health and Medicine edited by
Kamala Jayarao and Ashwin Patel, pp 326, 1986, Rs 15
(Currently out of stock)
Medical Education Re-Examined edited by Dhruv Mankad,
pp 214, paperback Rs 35, hardcover Rs 100.
Bhopal Disaster Aftermath: An Epidemiological and
Socio-medical Study, pp 76, 1985.
Distorted Lives: Women’s Reproductive Health and Bhopal
Disaster, October 1990, Rs 10.
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subscription: Rs 30.
For enquiries
Ravi Duggal, Convenor, Medico Friend Circle,
Building 4, Flat 408, Wahatuk Nagar, Amboli, Andheri (W),
Bombay 400 058. Phone/Fax: 621 0145.
34
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Technology, Competition and Costs
of Medical Care
Some Emerging Issues and Policy
Imperatives in India
V R Muraleedharan
The private sector plays a significant role in meeting the health
care needs of the people of India. With increasing international
drivefor privatisation, scholars and policy-makers have been debating
the efficacy of market forces in financing and delivering health
care in developing countries. Containing costs of care has been
an important concern in devising appropriate health care policy
all over the world.
This speculative essay, is a summary' of a body of evidence
(drawn from the US) that addresses the question whether competition
will contain costs of medical care, and improve access and outcome
(Section II). It raises certain issues and questions that need to
be examined empirically alongside issues that require explicit
value judgment on the part of those involved in the production,
distribution and consumption of health care. In Section III, is
presented an argument for technology management and health
promotion as two essential public policy measures, whether or
not one believes in the efficacy of market mechanisms, to contain
costs of care.
I
THE private sector plays a significant role in meeting the health care
needs of the people of India.1 With increasing international drive for
privatisation, particularly since the publication of the 1993 World
Development Report on health, scholars and policy-makers have been
debating the efficacy of ‘market forces’ in delivering health care in
developing economies. In India, the government is yet to explore the
relative efficacy and costs of regulation and competition with specific
reference to health care. To determine the appropriate mix of private and
public sectors in financing and delivery of health care, we must address
the following two questions:
1 Is there evidence in support of the argument that a competitive
environment would force (or even encourage) for-profit health care
providers to reduce the costs of care without compromising quality?;
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2 Do we have evidence on the efficiency of the public sector and other
not-for-pro fit health care institutions in India, and how do they compare
with for-profit private health care organisations?
Ideally, answers to these two questions should provide a basis lor the
policy-makers in designing an appropriate health care policy. The
debate on privatisation of health care market depends crucially on
answers to these two quetions. There is no known study as yet in the
Indian context to throw any light on the above issue. Given this fact, this
essay seeks to answer the following question: Can we anticipate the
likely impacts of policies that promote for-profit corporate hospitals on
costs, quality and outcome of medical care, and thus be able to devise
mechanisms to contain possible adverse effects of privatisation in India?
We begin with a universal fact that the costs of medical care have been
going up rather rapidly during the recent past - as mentioned above.
there is no empincal estimate of the increases costs of care in India, but
we have no basis on which to question this either. In fact, it is difficult
to contest this common impression. Besides, there is a large body 01
evidence (as we shall see later in this essay) that under certain market
conditions such as those found in India, costs of care is likely to increase
due to intense non-price competition amongst providers. Given this
common observation, we face two interrelated questions: (a) what arc
the causes for the increasing costs or care, and (b) what can we do to
contain costs of care?
There is a general consensus among scholars that technological
change substantially contributes to the increasing costs of medical care.2
What is not so readily agreed upon is the extent to which new medical
technologies in a competitive market environment have influenced
physicians behaviour and the interests of their patients, and how far this
has resulted in higher costs of care. The general debate on whether and
to what extent we should rely on market forces in delivering medical
care is bound to contihue, perhaps more intensely so in future. In the
meanwhile, corrporalisation of the health care industry and joint
venture facilities have begun to attract the attention of the policy-makers
and providers of health care in India as the most ‘efficient’ mode of
delivering health care, while investor-owned (for-profit) hospitals are
increasing to numbers, physicians are also increasingly becoming the
owners of health care facilities (we have no official figures on how many
of the private hospitals are owned by physicians in India, but it is safe
to say that the number is substantial). Thus, on the one hand, questions
have been raised from various quarters that cast doubts on the physicians'
role in increasing costs of care, while on the other hand it has become
more and more difficult to evaluate medical technologies.
In this essay I present a survey of studies that question the belief that
competition will contain costs of medical care as well as improve access
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and outcome (Section 11). The survey covers only the experience in the
US. where much empirical work on this issue has been carried out in the
recent past. I then raise certain issues and questions that need to be
examined empirically alongside issues that require explicit value
judgement on the part of all those involved in the production, distribution
and consumption of health care. Many recent empirical studies support
the view that technologies under certain competitive market conditions
because of the inherent difficulties in assessing their benefits and costs,
provide scope for physicians to over-use medical procedures and thus
contribute to increases in the costs of medical care. While it is
cxlremeiy important but difficult to come to a definite conclusion on
‘issue, we should ask ourselves as to what we can possibiy do in order
to contain costs of medical care from the point of view of the individuals
issue various providers, and policy makers. In Section III, I argue for
technology management and health promotion as two essential public
policy measures, whether or not one believes in the efficacy of market
mechanisms, to contain costs of care.
II
An important question that economists in general and policy makers
in India in particular, should address themselves to is: what is the
economic behavior of investor-owned (for-profit) hospitals in India?
More specitically, we can pose the following questions: How do
investor-owned and not-for-profit public sector hospitals compare in
terms of costs of care per admission? How do they compare in their use
of the medical procedures? To what extent are their use of various
medical procedure influenced by financial incentives? Does ownership
have any direct effect on the costs of care obtained? Are there differences
in quality of care obtained? In essence we are asking, can we account
for the differences in costs, quality and outcomes of medical care
obtained in various types of hospitals in India? With the existing data
base on health care in India, it is not possible to answer with any
reasonable certainty any of the above mentioned complex questions.
However, a number of empirical studies conducted in the US in the
recent past provide a basis for us to speculate on what we may expect in
the Indian medical market. Our response to the above questions is
therefore tentative, and should be considered as hypotheses for further
research for scholars concerned with designing better health care system
for India.
Recent studies on the behaviour of for-profit hospitals add to
the growing body of evidence that ‘self-referrals’lead to overuse of
services and excessive cost. “Self-referral is the term used to describe a
physician’s referral of patients to an outside facility in which he or she
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has a financial interest but no professional responsibility.”3 Mitchell
and Sunshine, based on their comparative study of joint-ventures with
other facilities providing radiation-therapy services in Florida in the
US, report that 40 per cent of all practising physicians are involved in
some kind of self-referral.4 They observed that self-refferal in radiation
therapy was associated with increased use and costs. Swedlow et al's
study on workers in California also found that self-referral increased
the rate of use and cost per case of physiotherapy and increased the cost
of psychiatric evaluation.' Further, they observed that inappropriate
use of magnetic resonance imaging was more frequent among the
patients cared for by self-referring physicians, although there was no
difference in the cost per case. Hillman et al’s study on differences in
physicians' practices with respect to diagnostic imaging compared the
frequency and cost of imaging examinations as performed by primary
physicians who used imaging equipment in their offices (self-referring).
and as ordered by physicians who always referred patients to
radiologists ("radiologist- referring”).6 Their study also led to the
conclusion that for all clinical representations “the self-referring
physicians obtained imaging examinations 4.0 to 4.5 times more often
than the radiologist-referring physicians.” Further, they observed
that self-referring physicians charged significantly more than the
radiologist for imaging examinations of similar complexity. The
combination of more frequent imaging and higher charges resulted in
mean imaging charges per episode of care that were 4.4 to 7.5 times
higher for the self-referring physicians. Pattison and Katz in their
attempt to explain the rapid growth of investor-owned hospitals found
that (a) both costs and charges were higher in for-profit than in not-forprofit hospitals; and (b) the for-profit hospitals have used “aggressive
marketing and pricing strategies” to generate high rates of profitability
and growth.7 To put it differently, the for-profit hospitals have been
success in generating higher net income for their owners, not by
operating less expensively but by virtue of charging more per admission.
Similar conclusions were reached by Walt et al based on a comparative
study of the economic performance of 80 matched pairs of investorowned chain and not-for-profit hospitals in eight different slates in the
US, during 1978 and 1980/
None of lhe studies cited above can claim to be comprehensive or
definitive, but taken together they seem to provide a coherent and
persuasive description of the average economic behavior of investorowned vis-a-vis not-for-profit hospitals and the consequences of
physicians’ ownership of health facilities. As a result, they also form a
reasonable basis for questioning the claim that investor-owned/joint
ventures hospitals would improve access to care and also would lead to
greater economic efficiency.9
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It is interesting to know how the American Medical Association
reacted to this mounting evidence of excessive costs and rates of use in
jointly-owned for-profit facilities. In tracing briefly the response of the
AMA, I believe, there is a lesson fbr the counterpart institutions in India.
In December 1991 at its annual meeting, the AMA officially ackowledgcd
the negative consequences of physician practice of self-referrals to
facilities in which they have financial interests. The AMA as a result
strongly advised physicians to avoid self-referrals, “except wnen there
is a demonstrated need in the community for the facility and alternative
financing is not available’’. The following words of the Council on
Ethical and Judicial Affairs of AMA, reflect their stand in this regard.
At the heart of the Council’s view of this issue is its conviction that, however
others may see the profession, physicians are not simply business people
with high standards. Physicians are engaged in the special calling of healing,
and in that calling, they are the fiduciaries of their patients. They have
different and higher duties than even the most ethical business person...
There arc some activities involving their patients that physicans should
avoid whether or not there is evidence of abuse."’
But within the next six months by the middle of 1992, the AMA
operating under different pressure groups passed a new resolution
declaring self-referral to be ethical as long as the patient is fully
inforrmed about the physicians financial interest in the facility.11 The
AMA justified its change of stand by saying that a policy that prohibits
self-referrals would limit access for many patients to necessary health
services. The proponents of the new resolution also claimed that “the
great majority of self-referring physicians, who do not abuse their
patients’ trust, were being penalised because of concern over the few
who did.”12 The foliowrig comments of Reiman on the adoption of the
new resolution by the AMA, reflect the growing dissatisfaction over the
prevailing practices within the medical community’ in the US, a large
section of which strongly believes in the efficacy of the free-market
approach to delivering health care:
As for distinguishing between physicians who abuse self-referral and those
who do not, there would be no way to do that without prohibitively expensive
and intrusive surveillance of the private practices of all physicians who
practice self-referral. Besides, the argument that self-referring physicians
should be trusted unless they can be proved to have abused that trust misses
an essential point about juduciary responsibility: people in important positions
of trust should not put themselves in situations that inevitably raise questions
about their motives and priorities, regardless of whether they actually
behave to accordance with that trust.”
In fact, in addition to self-referrals, there is also a need to have a close
look at the ‘deals’ between physicians and the manutacturers or medical
devices, and a wide variery of other kinds or joint ventures between
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physicians and the facilities in which they treat their patients. It is
common knowledge in India, particularly in metropolitan cities, lhai
private (small and large) hospitals give a pan of their fees collected from
the patients to the physicians who refer them to their facilities. It is
difficult to establish the extent to which it is being practiced, but an esti
mate of n would certainly be useful to the policy makers in judging more
accurately the nature of measures required to regulate the private sector.
The subject of industrial marketing and medical ethics has always
worried health policy makers. It is said that the relationship between
medicine and industry is a “marriage of convenience and necessity”. As
marketing is an essential part of the industrial process, physicians
(because they determine the use of medical products in the care of
patients) thus become the direct marketing target of medical-service
companies which are competing actively to sell their products. While
medical-service companies may have their own ethical guidelines, they
often tend to go beyond the ethical boundaries of physicians. As Reiman
puts it, “physicians have an obligation to preserve their patients' trust.
It is an obligation quite different from, and often incompatible with, the
relation between sellers and buyers in a commercial market.”14
But the practice of ‘kick-backs’ and active involvement of the
medical profession in promotional exercises of the products of the
industries wil continue, and perhaps become common in the future. The
enticements and bonuses offered to the medical profession by the
competing companies can no longer be said to be free of any motives.
They in the long run add to the costs that are passed on to the consumers,
namely the patients. As Rawlins noted in 1984:
Few doctors would accept that they themselves have been corrupted. Most
doctors believe that the are quite untouched by the seductive ways of the
industry’s marketing men; that they are uninfluenced by the promotional
propaganda they receive; that they can enioy a company’s “generosity’ in the
form or gifts and hospitality without prescribing its products. The degree to
which the profession mainly composed of honorable and decent people, can
practice such self deceit is quite extraordinary. No drug company gives away
its shareholders’ money to an act of disinterested generosity.15
Several factors have been identified as being responsible for the
tendency among physicians to offer medical care more intensely than
warranted. These are plausible explanations. In the Indian context each
requires an empirical verification of the extent of their influence. Let us
consider some of them briefly.
(a) It is a generally observed phenomenon that the fear of malpractice
tends to increase the intensity of medical care offered by the physicians.
In fact, in economies where patients have easy access to consumer fora
and courts, the physicians have learned to practice expensive defensive
medicine fearing law suits. As yet this has not become a major problem
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in India. Bui with consumer protection groups increasingly playing an
active role in protecting the interest of the consumers and the prospects
of private insurance companies protecting the providers from malpractice
claims, defensive practice could to become common in India. Increases
in malpractice claims are also likely to increase the costs of malpractice
insurance.16 This in turn lends to push costs of medical care. Thus while
malpractice claims on the one hand may at least partially compensate
patients’ loss of life or well-being caused by inappropriate medical
interventions, they are on the other hand likely to escalate costs of care
and bring about certain undesirable systemic changes in the provision
and financing of medical care. This is very much a likely scenario to be
witnessed in India too, if corporate, for-profit hospitals continue to grow
unregulated as they are now.
(b) Another important contributor to the increasing costs of medical
care has been the agressive medical culture itself. This refers to the
narrow, mechanistic, technologically and biomedically defined version
of medical science. Several scholars have written extensively on this
subject. This has led to signifeant behavioural changes among the
physicians to such an extent that, as Kassirer puts it,
physcians no longer tolerate uncertainty and thus pursue diagnostic certainty
beyond clinical usefulness. Some tests do provide some what different data,
and certainly not all duplicate testing is redundant but many tests are carried
out merely to confirm a diagnosis that is virtually certain. Because of this,
duolicate testing has been described as “bell and suspenders” approach namely, one in wnich both are worn at the same time.17
(c) Finally, in cxcplaning the increasing costs of medical care, we
come to consider an issue wrich is perhaps the mest controversial. This
relates to the role of specialists, and the extent to which their services
could effectively be offered by primary care physicians. It is worthwhile
mentioining here some of the important studies that ought to be considered
by policy makers, particularly during a period when we are passing
through an era of severe budgetary constraints. Manu and Schwartz,and
Garg, Mulligani, Gliebe and Parekh,19 among many others, have observed
that primary care physicians lend to deliver less intense care for specific
conditions than specialists. Franks. Clancy and Nulling in their review of
studies comparing primary care physicians with specialists in the US
observed no difference in quality of care or outcome.20 The literature on
the effects of physicians’ practice style on the outcomes of care is limited.
Il is extremely difficult to conduct studies large enough to detect small
but clinically important differences in outcomes or to control adequately
for the confounding factors. But the available studies seem to sup port the
view that “the primary care physician are more likely than specialists to
provide continuity and comprehensiveness”, resulting in imoroved
outcome in patients at all ages.
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The improved outcome include higher birth weight in newborns; more
preventive care a reduced risk of hospitalisation and reduced morbidity in
diiihsi; a reduced ride of h^italisarrn in the eHeri/.21
While Lurie el al’s study suggests that patients who lost access to
primary care physicians had measurable declines in their health22, other
studies suggest that the quality of care provided by specialists outside
their specialities declines.2' Il is estimated that in the US nearly 20 per
cent of primary' care is delivered by specialists. It is likely to be higher
in India. The moot point is whether specialists tend to offer care more
intensely than necessary, as compared to primary care physicians. Some
results suggest that the ‘primary care physicians may centiry alienls wno
are not appropriate candidates for a procedure more effectivejy than the
specialists, who performs the procedure.”24 The implication of these
studies is again obvious: that the increasing number of specialists, if left
uncontrolled, would tend to raise the costs of care more than necessary,
and that it is therefore necessary to increase the number and role of
primary care physicians in order to contain costs of care. To pul il
differently, existing studies suggest that more specialists in the medical
market would lead to the risk of overtreatmenl. Paradoxically, as Frank,
Clancy and Nulling observe, “the poor, whose access to care is limited,
may have more to gain from health than others”, since it is the rich who
have greater access to medical care. The rich are more likely to receive
the more intensive care offered by specialists, and are therefore more
likely to undergo invasive procedures!25 Some scholars, in fact, have
found a direct correlation between income and rales of surgical procedures
in the US medical market.26 While higher income may improve access
to care, il may also increase the risk of receving excessive care.
How do investors in health care industry in India make decisions
about how much to invest, on what to invest and when to invest? In the
light of the findings of the above mentioned studies on the consequences
of investor-owned hospitals on the costs and (questionable) utility of
certain medical procedures, one wonders what must be happening in
countries like India where corporate enterprises have slowly begun to
play a significant role in the medical care industry. This issue assumes
greater importance, given the fact that private (both corporate and non
corporate) hospitals are practically unregulated in India.27
There is a vast literature on the decision-making process in hospitals,
highlighting the role of both financial and non-financial fators in
determining the level of investment. Essentially, they point out that both
the changes taking place al the macroeconomic level as well as within
the health care system determine the investment behaviour of hospitals.2”
Sukanya’s study on the investment behaviour of private (corporate and
non-corporate) hospitals in the city of of Madras reveals that investment
on medical equipment alone constitutes about 50 to 60 percent of their
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total investment on various fixed assets.29 She observes that while there
is a certain uniformity in the capital investment pattern of many
hospitals (in the sense that they allocate a major portion of their
resources to medical equipment), there are differences in the distribution
of resources allocated to various medical equipment. This is explained
by the size, competitive strength and ownership pattern of hospitals (i e,
whether it is a sole proprietor, or partnership or corporate hospital).
Sukanya’s study also reveals an interesting pattern of investment
behavior over lime of private hospitals in Madras city: “all non
corporate hosoitals start with investing in surgical equipment. As they
grow, they begin to invest in laboratory equipment or imaging equipment
and later invest in intensive care and therapy investment.’’™
While the investors may explain variously why the invested as much
as they did in different medical equipment and its sequencing, what is
of importance to policy makers, as already noted, is to assess and
account for the extent to which the cost of care varies across regions and
types of providers. In explaining the variations, we may hopcfliliy be
able to identify the ‘culprits’ for the inappropriate and excessive use of
facilities and medical procedures.
For many people, to question the increasing role of technology in
medical care is blasphemy. The popularity of medical innovations is so
immense, as Russell observes, “that in the emotionally charged
atmosophere of medical care, the momentum of a new technology often
puts the burden of proof on those who question the evidence for it, rather
than on those who propose it.””
What I would like to argue here is that it is not as important to estimate
accurately the extent or overtreatment or excess use of medical procedures,
as it is to realise the existence of such phenomena under certain economic
environments, in order to regulatory mechanisms to curb such practices.
To control the increasing costs of medical care delivered to the people
(and therefore contain expensed incurred by the state in the long run), I
>hall outline two important public policy measures that have become part
jf the health policy making process in many developed and developing
countries. They relate to (1) making technology evaluation an integral
part of the health policy making process, and (2) according a high priority
for health education programmes as a strategy for promoting good
health.
Ill
(1) Assessing medical technologies poses a number of difficulties,
particularly at a time when costs of medical care have become the most
serious concern of the policy makers in the government. In a competitive
market economy, where insurance companies and employers are likely
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to pay increasingly for costs of medical care, technologies are being
evaluated for the extent to which they can restore the functional ability
of patients.
Il should be noted ai the outset that medical technology assessment
does not slop with performing oniy a randomised controlled clinical
trial. The range of outcomes of interventions has been expanded to
include, apart from safely and efficacy, the functional status, emotional
health, social interaction, cognitive function, degree or disability, elc.
To put it differently, technology assessment now encompasses the
measurement or effectiveness, consideration of quality of life and
patients preferences, and especially the evaluation of costs and benefits.”32
The randomised controlled trials have not provided information on all
of the above aspects of medical care. It is also not clear whether it can
potentially handle such diverse range or dimensions of medical care
evaluation. Evaluating health technology in a broader framework as
mentioned above poses a number of difficult methodological problems.
Perhaps, the most difficult one is imputing value to various outcome
status.
As Fuchs and Garber put it,
even a well executed assessment may not resolve whether a form of
technology is worth using, because they stop short of assessing what a
change in health is worth in dollar terms.
From a payer’s point of view, an intervention must be cost effective.
meaning that its health benefits are commensurate with the benefits from
interventions of equal or lower cost.
Although technology assessment often includes an analysis of costeffectiveness, it cannot tell us how much we should be willing to pay for a
given health effect. That would require explicit value judgments, which are
eschewed in both the old type of technology assessment and much of the
new.”
Another demanding aspect of the technology assessment process has
been the need to incorporate patients’ preferences as well into medical
decisions. Over the recent past there has been a tendency among the
policy makers to develop standardised and codified guidelines for
making clinical decisions. It is well known that different patients view
outcomes differently. Also, their preferences change over time and they
do not always behave ‘rationally’. Some scholars view that, even though
it is difficult to capture the true state of patients’ attitudes toward
outcomes “a policy that explicitly considered how patients viewed
outcomes would probably be belter than one based on the implicit
assumptions of a consensus panel.”34 Because medical decsions have to
be often individualised, ‘it is essential to identify’ decisions in which it
is especially important to consider patients’ values and to protect such
decisions from intrusive external decision making.35 Assessing patients’
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preferences and also identifying which decisions require the most
patients’ preferences acquire importance in the light of increasing costs
or care.
This essay is not a commentary on the methodologies for assessing
technology The above brief comments are made only to underscore the
fact that technology assessment in medicine has and will become more
complex and more demanding as a result of several socio-economic
factors, including the increasing expectations of the people on what
medical science can and should accomplish. Also, from policy makers’
point of view it is essential to keep in mind the significant changes in the
ways in which health technologies arc being evaluated. Such an awareness
of new developments will hopefully guard them from offering
inappropriate policy prescriptions for containing costs and for improving
access to care. While malpractice and other socio-economic factors may
make it difficult for the policy makers to contain costs of care, it can be
argued that through a regulatory body (an Office of Health Technology
Assessment), it is possible to exert influence at the point of introduction
of technologies. It is useful to make acleardistinction between controlling
acquisition of new technologies and controlling their use. They require
rathcr different approaches. In this essay, my purpose is to highlight only
some of the fuzzy areas in medical technology management that should
be of concern to health policy makers. It is naive to assume that the
rational diffusion of new norms of technology will be easier to achieve
under a monolithic state health care system. A study of medical
technology management in Canada led Linton and Naylor to conclude
that.
Powerful interest groups legitimately promote the continuing diffusion of
new procedures and programmes, and tension increasingly develops between
the competing imperatives of controlling costs and providing high-quality
health care. Incomplete data, the absence of clearly defined objectives for
philosophical differences within the medical profession all contribute to the
difficulties of technology management.
In this arena medical organisations that participate in decision making run
the risk of generating division in the profession; in particular, academic
physicians in subspeciallies may feel both offended and threatened by the
issuance of guidelines for medical practice?6
Many studies have also shown that transfer of technologies from the
developed to developing countries have often yielded disappointing
results, largely due to failure on the part of the decision makers to
recognise unfavourable factors or other deficiencies in advance.'7 In fact
many recent studies (some of which we referred to in Section II) have
questioned the usefulness of many medical procedures/technologies
developed in the west, even after they have been tested for their safety
and efficacy. This is largely explained by the increasing concern for
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costs containment. [It is also not uncommon in the western countries to
hear about medical procedures of unproven effectiveness being practiced
widely]. In most developed countries, as a part of cost-containment
strategies, there is already in place or efforts arc being made to establish
a body for technology assessment and to regulate use of expensive
medical equipment (in public and private sector).,x In India as in many
other poor countries, due to lack of any regulatory mechanism to assess
health tecl»..blogies, policx makers have no means to assess their
contribution to overall increase in costs of care and also their utility and
cost-effectiveness. As a result of the liberalisation policy in India we
may soon sec an increase in the import of modern high cost medical
technologies. There is thus a prima facie case for health technology
assessment in India.
The broad aim of health techology assessment is to indicate the
conditions under which a technology can be purchased, used and
maintamed. As Perry and Marx argue “in order to decide whether a
health technology is suitable tor introduction into a developing country
it is first necessary to assess "both it and the infraslrucrural conditions
in which it would have to function”.'*4 But merely assessing technologies
alone will not do, “the major challege is to develop a policy structure that
can controi technology”.40 Il is a well known fact that often technologies
are acquired without giving much thought to operating and maintenance
costs. In many of the government hospitals in India, it is not uncommon
to see medical equipment lying out of order or unutilised due to lack of
proper maintenance, or used in unexpected ways. K P Mathur’s (1988)
report on three governmnent hospitals in Delhi is replete with examples
in support of the above observation.41 Due to difficulties in maintaining
medical equipment in public hospitals, the government of Tamil Nadu
has allowed the Electronic Corporation of Tamil Nadu to operate and
maintain certain modern diagnostic facilities in five hospitals in the
state.42
Several kinds of uncertainties are associated with evaluating medical
technologies, particularly the new ones, as they are introduced into the
marketplace. They relate to production process, performance
characteristics, estimated rates of change in component technologies,
clinical effects for specific conditions, costs and size of market, etc.45
Ultimately they determine “the size and composition of current and
potential market and thus about the expected rale of market penetration
and the probable return on investment.44 These factors in turn influence
pricing policies.
Of late there has been a growing recognition of the need to conduct
economic evaluation alongside potentially influential trials or new
procedure or a new medicine at the premarketing stage. This is due to
the fact that often new' technologies diffuse widely through the health
46
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care system before systematic evidence on costs and benefits r available.
As a result, it becomes more difficult to devise effective measures for a
more rational diffusion and use of health technology.45
In fact as Bryan Jennet foresees, technology assessment itself may
soon come to be considered a competitor for restricted resources
available for health services.46 This is so because of the fact that they are
very cosily to carry out. Longitudinal clinical trials are costly to conduct.
Economic evaluations which go beyond clinical evaluations therefore
cost a lot more. But they are essential. To pul it in Bryan Jennet’s words.
Someone, somewhere has to face up to comparing hernias with hips and
kidneys with hearts, to making value judgments that cannot be undertaken
by computers or bureaucratic machinery. There is no other way to judge the
wisdom of a value judgment than by awaiting the outcome of decisions based
on it and then making a value judgment about this.47
Il is thus suggested that a periodic evaluation of health technologies
in terms of safely, efficacy, effectiveness, and cost-effectiveness should
be ol value to policy makers to make decisions on the allocation of
resources, and also to understand the capacities and needs of their health
care system. The health policy of India (1983) does refer to the need for
developing appropriate health technologies, but it does not spell out how
such an objective can be achieved. All over the world there is now a
growing concern for developing methodologies for evaluating medical
technologies, in order to help public policy makers in allocating scarce
resources among competing medical care interventions. Indicators such
as Disability Adjusted Life Years (DALY) and Quality Adjusted Life
Years (QALY) arc two examples of the recent developments in evaluating
the relative cost cltectiveness of various health care technologies and
intervention strategics.41*
(2) It has been observed by many scholars that the bulk of the burden
of illness and the associated costs is accounted for by preventable illness.
In a developed country like the US preventable illness accounts for about
70 per cent of the total burden of lliness and costs of care.49 Even if one
were to assume a corresponding figure of only 50 per cent for India, the
costs averted would still be enormous. There is hence a prima facie case
or advocating health promotion programmes.50
A large number of studies have recored positive effects or advocating
health promotion progrmmes. It is a well recognised fact that lifetime
medical costs arc cioseiy linked to health habits. For example, studies
have shown a slalslically significant assocalion between smoking habits
and overall morbidity; the overall morbidity was higher by 60 per cent
among the smokers.5' Wennberg’s study strongly supports health
promotion programmes that help educate consumers in making informed
decisions.52 He says when patients are given information and alternatives
they have shown on average, to select less invasive (and less expensive)
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strategies than their physicians. In an earlier study he observed that
admission rates in hospitals correlate with the number of hospital beds
per capita rather than the incidence of illness.5' Such observations
should not surprise us. given the fact that investor-owned hospitals, and
the consequent practice of self-referral are not regulated adequately
Health education programmes have been shown by many«sludies to
reduce the cost of care to the patients and other payers of health care
Through such programmes self-management can be encouraged to a
certain extent, which in turn can reduce use of (rather dependence on)
health services, thus resulting in some savings.54
More particularly, there is a growing literature on the benefits of well
formulated health-promotion programmes in terms of reducing health
care costs in the workplace. The effects are seen in the substantial
reduction in the number of sick days, outpatient costs, hospitalisation
costs, etc.''' Some of these studies have used randomised control groups
in similar plants or facilities for soundness of the experimental design
The savings made through such programmes are confirmed through an
analysis of claims data. There are also other ways of reducing costs ofcarc
to the society as whole, and for the individuals as well. What the existing
studies clearly show is the potential of the health-promotion programmes
to improve both physical and financial health. The central goal of these
programmes is the improvement in health habits. Of course, widespread
dissemination of such programs will cost money, but in the long run these
costs will not be as large as what we would end up spending ultimately
for many curative services. Available data seem to suggest a lag of two
to three years between improvement in health habits and signs of better
health and reduced costs.56 As with any other programme, the costs ol
such programmes should be borne by those who benefit through savings
What is required, as Fries et al. put it:
is a widespread conviction that appropriately designed programs directed al
reducing need and demand can actually save money. (But] advocates ol
health promotion have themselves caused delays, first by not making cost
reduction a primary goal and second by neglecting rigorous economic
evaluation... [Also] it can be argued that academic conservatism has held
preventive policy to a more stringent standard of proof than that generally
applied in other areas of health policy.57
The ICMR-ICSSR joint report in 1981 also emphasised that many ol
the health problems of the poor can be solved to a large extent through
health education.5'' They relate to messages on sanitary disposal of
excreta and waste waler, control of vectors, use of protected waler.
encouragement of breast feeding, maintenance of good personal hygiene
etc. The report argues that people can be taught to manage man
debilitating infections such as tuberculosis, hookvorm, malaria, filariasis
leprosy, etc. The report thus observes:
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Simple health messages communicated effeclivcy can produce excellent
results in all such cases, and on the basis of cost-benefit considerations,
health education can be a very effective input to raise their health status.59
In India Stale Health Education Bureaux have been established with
the responsibility of educating people on a number of health promoting
activities. Besides, every national programme concerned with control or
eradication of communicanblc diseases and with family planning, has an
education component as well. But despite this enormous input and
impressive administrative set up for health education, health altitude of
the people have hardly changed and the programme has hardly made any
impact on the situation.60
Health education can no longer be justified purely on humanitarian
grounds. They play a complementary role in the delivery of health
services, be it curative or preventive. Il is a pari of preventive as well
as promolive strategy. Il is true lhat preventive medicine is not always
cost-effective from the point of view of cither lhe society as a whole or
the individual. But, in many instances, as some of lhe studies noted
above show preventive medicine is cost effective and more attractive in
terms of its net benefits than many forms of rescue medicine.61
Concluding Remarks
We began with an observation of lhe universal phenomenon that lhe
costs of medical care have been going up rapidly over lhe last few
decades. We thus are faced wiih two importanl questions: (a) what are
lhe causes for lhe increasing costs of care? and (b) what can we do to
contain them? Many scholars have analysed lhe question of “why
various cost-conlrol strategies in markel economies have not been
successfully in the past”,62 Some of lhe reasons are to be found in the
nature of lhe markel system that encouraged the transformation of
physicians into aclass of manager-physician-entrepreneurs. Some others
have blamed the unholy alliance between the government and the
medical profession in encouraging peoples’ dependence on private
medical services.63 Some scholars suggest why blending market mecha
nisms with regulations is necessary in containing costs of care.64 While
studies in future will throw further details of physicians’ behavior under
different market conditions, it is necessary to reflect on the implications
of what we are beginning to observe and how we may have to institute
different mechanisms to develop a better health care system. I have
attempted in this essay (a) to pul together evidence lhat throws some
light on the behaviour of this new class of entrepreneurs, and how as a
result we are facing certain basic issues primarily ethical in nature, that
restrict access to appropriate care; and (b) to indicate certain policy
measures by which costs of medical care could be better contained.
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Il is important to mention here two widely prevalent ‘myths'
(particularly among the policy makers): one is that greater access to
better medical care and containing cost of care do not go together. To pul
it differently, if you are to have the finest medical care system, be
prepared for high costs. The second myth (some would call it ‘public
expectation’) recognised by many scholars, is that high technology i*
essential for improved health and longevity. There arc several examples
(of community-based health care projects in India as well as other pans
of the w odd) w hxh explode these m yths.65
Policy lessons emerge and can be learnt not only from our own past
mistakes and achievements, but from the experiences of developed
economies as well. The recent developments in the medical care market
in the US have a clear lesson for the health policy makers in India. While
there are forces that seem to be pushing up the costs of medical care
beyond our control, there are also ways and means that arc well within
our reach and control that can be used effectively to reduce costs or care
and thus effect some savings for the society.
Notes
[This essay was revised during my stay at Harvard School of Public Health as
a Takemi Fellow in International Health during 1995-96, supported by a Ford
Foundation fellowship. I have benefited immensely from many people. I wish
to thank Peter Berman. Michael R Reich. Anne Mills, Barbara Harriss-Whitc.
S Subramaniam, S Ambirajan and D Veeraraghavan for their helpful critical
comments on earlier drafts. I however am responsible for the views expressed
here and any errors that may be found in this essay.J
1
For a general review of studies on the utilisation of private health care
facilities, see Ramesh Bhat ‘The Private Health Care Sector in India’, in
Peter Berman and M E Khan (eds) Paying for India’s Health Care (Sage
Publications. New Delhi, 1993. For a recent report (based on the 42nd round
of the National Sample Survey, 1986-86) on the utilisation of the private
and public health care facilities across states in India’, Economic and
Political Weekiy, April 30, 1994:1071-1080. For a more recent and complete
survey of evidence and issues, see Berman P (1995). India: Policy arid
Finance Strategies for Strengthening Primary Health Care Services, World
Bank. Washington DC.
2 For a reviiew of various positions on this issue, see J D Branzino, V M Smith
and M L Wade, Medical Technology and Society (MIT Press, 1990).
3 For a brief and critical commentary on this issue see, Arnold S Reimari,
‘Self-Referrals What is at Stale’, .Vew England Journal of Medicine,
(hereafter, N Engl J Med) 1992; 327:1522-24.
4 J M Mitchell and J H Sunshine, ‘Consequences of Physicians’ Ownership
of Health Care Facilities - Joint Ventures in Radiation Therapy’, N Engl J
Med, 1992: 327:1497-501.
5 A Sweldow, C Johnson, N Smithline and A Milstein, ‘Increased Costs
50
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and Rates of Use in the California Workers’ Compensation System as a
Result of Self-Referral by Physicians’, N Engl J Med, 1992; 327:1502-06.
6 B J Hillman el al, ‘Frequency and Costs of Diagnostic Imaging in Office
Practice - A Comparison of Self-Referring and Radiologist Referring
Physicians’, N Engl J Med 1990; 323:1604-8.
7 R V Pattison and K M K Katz ‘Investor-owned not not-for-profit hospitals’.
N Ena! J Med 1983; 309:347-53.
8 J M Watt et al, ‘The Comparative Economic Performance of Investorowned Chain and Nol-for-Profit Hospitals’, N En J Med, 1986; 3 14:89-96.
9 For a general review of literature on this issue, see references 2-6 cited
above. Also. Geraldine Dallek. Hospital care for profit’, Society July/
August 1986:54-9.
10 Council on Ethical and Judicial Affairs American Medical Association,
‘Conflicts on Interest Physician Ownership of Medical facilities’, Journal
of American Medical Association (hereafter, JAMA) 1992; 267:2366-9.
' I Reiman (1992), ref 3 above.
2 However, in the states of Illinois, Florida, and New York, bans on
physicians’ joint-ventures, covering various types of services, were enacted
in 1992. But for such law to be effective, Mitchell and Sunshine argue that
“they must include a requirement for the reasonably prompt divestiture or
dissolution of existing joint ventures.’’ Mitchell and Sunshine (1992), ref 4
above.
13 Reiman (1992), ref 3 above.
HAS Reiman ‘Practicing Medicine in the New Business Climate’, N End J
Med 198; 316:1150-1.
15 M D Rawlins, ‘Doctors and the Drug Makers’, Lancet 1984\ 2:276-8.
16 Many Critics of the American health care system have commented on these
developments, see for example. Keith\Leiler, Health Care Policy in the
United States or America (Nebraska University Press, 1993).
17 J P Kassirer, ‘Our Stubborn Quest for Diagnostic Certainty’, N Engl Med,
1989; 320:1489-91.
18 P Manu and S E Schwartz ‘Patterns of Diagnostic Testing in the
Academic Setting: the Influence of Medical Attendings’ Subspecialty
Training, Social Science and Medicine (hereafter, Soc Sci Med) 1983;
17:1339-42.
19 M L Garg, J L Mulligan, W A Gliebe and R R Parek Physician specialty’
Quality and Cost of Inpatient Care’, Soc Sci Med 1979; 13C: 187-90.
20 P Franks. C M Clancy; and P A Nutting ‘Gatekeeping revisited - Protecting
Patients from Ovenreatmcni, N En J Med 1992; 327:424-9.
21 Ibid, p 426.
22 N Lurie et al, ‘Termination of Medical Benefits: A Follow-up Study One
Year Later’, N End J Med 1986; 314:266-8.
23 For details of these studies, see Franks. Clancy and Nutting (1992), ref 20
above.
24 Ibid, p 426.
25 Ibid, p 425. See for example, M B Wennekar, J S Weissman and A M
Epstein, ‘The Association of Payer with Utilisation of Cardiac Procedures
in Massachusetts’ JAMA 1990; 264:1255-60.
26 C Bombardier et al. “Socioeconomic Factors Affecting the Utilization of
Surgical Operation’. N End J Med 1977: 297:699-705?
27 This is not to say (hat public hospitals are better monitored and regulated.
For a succinct summary of the state of public hospitals in India, refei
Medico Friend Circle (Bomba} Group). Background papers for Seminar on
Improving Public Hospitals in Bombay (Bombay. June 1994).
28 For a review of relevant literature, see S Sukanya. ‘A Study on Capital
Investment Decisions in Private Hospitals in Madras City’ (M S dissertation,
Indian Institute of Technology, 1994). chapter 3 24.
29 Ibid.
30 Ibid, p 86.
31 L B Russell. Technology in Hospitals: Medical Advances and Their
Diffusion (Washington. DC. Brookings institution, 1979), quoted in
Lawrence D Brown. Health policy in the United States: Issues and Options
(Ford Foundation. New York, NY, 1988), p 9.
32 Victor R Fuchs and Alan M Garber, ‘The New Technology Assessment,
N Eng J Med 1990: 323:673-7.
33 Ibid, p 676.
34 Jerome P Kassirer ‘Incorporating Patients’ Preferences into Medical
Decisions’ N Engl J Med 1994: 330:1895-6.
35 Ibid, p 1896.
36 Adam L Linton and C David Naylor, ‘Organised Medicine and the
Assessment of Tchnology, N Engl J Med 1990: 323:1463.
37 For a brief review of related issues, see Seymour Perry and Eric S Marx
‘What technolocies for health are in developing countries’, World Health
Forum 1992, 13:3S6-62.
38 Brian Abel-Smith and Elias Mossialos, ‘Cost containment and health care
reform a study of the European Union', Health Policy, 28 (1994). 89-132
39 Perry' and Marx, p 356. ref 37 above. For a more detailed discussion of related
issues, see Perry Seymour’s earlier essay ‘Selecting medical technologies in
developing countries' in David B Bell and Michael R Reich (eds) Health
Nutrition and Economic Crisis: Approaches to Policy’ in the Third Word
(Auburn House Publishing Company. Dover, Massachusetts, 1988), 379-400.
40 H D, Banta, Medical Technology and Developing Countries: The Case of
Brazil’, International JI of Health Services, 1986; 16:363-73.
41 Report of the Inquiry' Committee Regarding Three Central Government
Hospitals (K P Mathur, chairman, one-man inquiry committee, Government
of India, Ministry' of Health and Family Welfare, 1988).
42 The Hindu, October 8, 1994, p 3.
43 Richard A Rettig, ‘Medical Technology in a Changing Health Care
Environment, in J A Meyer and M E Lewin (eds) Charting the Future of
Health Care Policy, Politics and Public Health (American Enterprise
Institute for Public PoUcy Research, Washington DC, 1987), 98-117.
44 Ibid, pl 09.
45 Fora detailed description of the methodological issues involved in conducting
economic evaluation, see M F Drummond and L Davis, ‘Economic Analysis
Alongside Clinical Trials’, International Journal of Technology Assessment
in Health Care 1991; 7:561-73.
52
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46 Bryan Jennctt High Technology Medicine- Benefits and Burdens (Oxford
University Press, Oxford 19S6), chapter 1 I.
47 Ibid, p 257.
4 s- For a general overview of the concept of DALY and its usefulness, see
World Development Report 1993: Investing in Health Washington DC.
World Bank 1993). Several scholars have critiqued the concept of DALY.
For a more recent one from equity-perspective, see Sudihir Anand and Kara
Hanson, ‘Disability-Adjusted Life Years: A Critical Review’ (Harvard
(’enter for Population and Development Studies, Working Paper Scries
No 95.06, September 1995). On QALY, refer to Claire Gudex and Paul
Kind, The “QALY TOOLKIT” (Centre tor Health Economics, University
of York, 1988) for a very lucid introduction to the notion and calculation of
QALY. For a general critique of QALY, see Roy A Carr-Hill, Asumptions
of the QALY procedure’, Soc Sci Med 1989; 29:469-477.
49 James F Fries, el al ‘Reducing Health Care Costs by Reducing the Need and
Demand for medical services’, N Engl J Med 1993; 329:321-25.
1 F.lscwr I ere I have argued that there are certain aspects of health care which
are indispensable lor promoting equality of access to health care, even
though we may differ in defining basic health care needs of a society. These
are things that we can and should promote, irrespective of our belief in the
efficacy of a compelilve market economy in achieving equal access to
health care. They arc: (1) Prevention of illness, through health education;
(2) Caring for the sick; and (3) Regulations to protect the interests of the
patients as well as the providers. For details, see V R Muraleedharan,
‘When is Access to Health Care Equal?: Some Public Policy Issues’,
Economic arid Political Weekly June 19, 1993:1291-96.
5 I Cited in Fries el al, (1993), ref 49 above.
5? J E Wennberg, Outcome Research, Cost Containment and the Fear of
Health Care Rationing’, N Engl J Med 1990; 323:1202-4.
5' J E Wennberg et al, ‘Hospital Use and Mortality Amon Medicare
Beneficiaries in Boston and New Heaven’, N Engl J Med 1989; 321:116873.
54 D M Vickery et al, ‘Effects of a Self-Care Education Program on Medical
Visits’, JAMA 1983; 250:2952-6.
55 Fries et al. (1993), ref 49 above.
56 Ibid, p 323.
*7 Ibid.
5x Health for AU: An Alternative Strategy, report of a study group set up jointly
by ICSSR and ICMR, New Delhi, 1980.
59 Ibid, p 52.
60 Ibid, p 54.
61 J D Branzino, V M Smith and B J Wade (1990), ref 2 above, p 561.
62 For a comprehensive review of related issues in the context of developing
countries, see (a) Jonathan Broomberg, Health Care Markets for Export?
Lessonsfor Developing Countriesfrom European and American Experience
(Department of Public Health and Policy Publication No 12, London School
of Hygiene and Tropical Medicine, 1994); and (b) Sara Bennet, ‘Promoting
I he Private Sector: A Review of Developing Country Trends’, Health
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Policy and Planning, 7(2) 1992, 97-110.
James C Hurowitz, ‘Toward a Social Policy for Health’, N Engl J Med,
1993; 329:130-33
64 Stanley S Wallack. Kathleen Carley Skwara and John Cai, ‘Redefining
Rate Regulation in a Competitive Environment’. Journal of Health Politics.
Policy and Law . 21(3) 1996. 4S9-510.
65 For an impressive collection of ‘success stories' of various community
based health and developmental projects and the role of NGOs, refer to
N H Antia and Kavita Bhatia (eds) People's Health in People's Hand: A
Model for Panchayati Raj; (Foundation for Research in Community Health,
Bombay 1993).
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Target-Free Approach: Some
Missing Links
K Sasikala
However sincere the government's intentions to do away with
the target-free approach, the manual published for that purpose
exhibits lacunae which are probably a result of inadequate
comprehension of the new thinking.
FOR nearly three decades population policies and family planning
programmes in India have been making women their objects without
considering the role of ‘sexuality’ and ‘gender’ issues. Posl-ICPD period
represented a conceptual shift from the concerns of ‘population growth’
to one of reproductive health'. Shifting the emphasis from target
orientation to individual needs, the Platform for Action has emphasised
the life span approach for women.
In response tothecommitmentsmadeatCairoand Beijing conferences,
after nearly one year, the Government of India has come out with the
Targel-free approach’. Reproductive health care has been equated with
the targel-free approach. From April 1996, the family welfare programme
is supposed to be implemented all over India on the basis of this
approach. In keeping with the changeover to the target-free approach,
the ministry of health and family welfare, in consultation with the family
welfare secretaries and directors of the states as well as management
experts and experts from the family welfare department, has prepared a
manual to highlight this approach. The objective of this manual is to
provide guidance on decentralised planning to the ground level staff and
enable them provide quality care as per the requirements of the
community. Regional consultations have taken place with NGOs and
other interested sectors in different parts of the country under the
auspices of Chctna and Health Watch. A critical review of this manual
vis-a-vis the intended objectives is made in this article and an attempt
is made to focus on vital links that need to be borne in mind for policy
/ programme implementation.
The contents of the manual on target-free approach are truly not
reflective of its title Decentralised Participator)' Planning in Family
Welfare Programme. A predominant part of the manual focusses only on
the performance evaluation of the para-medical team, particularly the
ANM, in a structured format. The staled objective of the manual, namely
providing guidance on decentralised planning at the level of the PHC
and improving the quality of health care re not adequately fulfilled. So
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55
is the case with the adopted meaning of decentralised planning which is
to be. “close association of the community and its leading lights and
opinion leaders in the formulation of the PH C-bascd family welfare and
health care plan”. The document is conspicuously silent on the actual
strategies or means of operationalisation of decentralised planning ol
health care.
The venture appears to be ’old wine in new bottle’. Not only has
the document failed to emphasise change from a segregated approach
of family planning (FP) and maternal and child services (MCH) to an
integrated approach of reproductive and child health (RCH) services.
but it also seems to have taken a narrow view of the concept ol
integrated health. Even though the issues of STDs and RTIs are
discussed, the emphasis has not shifted from FP and MCH areas.
Critical health care needs have not been addressed. For instance.
tuberculosis (TB). one of the major causes of deaths in India, is also
a serious health hazard for women. Ideally the integrated approach
should encompass ’comprehensive primary health care’ needs of all
men. women and children covering the preventive, promotive and
curative aspects. To recall, the rationale behind the integrated
programme of health and family welfare, introduced during the
1980s, was that health and family planning are mutually inter
dependent and reinforcing. One cannot lose sight of the linkage of the
basic needs such as safe drinking waler, environmental sanitation
and prevention and control of communicable diseases (eg, malaria
and TB) with the health care of women and children.
While the needs of urban health sector are missing in the document,
a few other lapses of the manual also need a mention. Attention has not
been paid, even while dealing with reproductive health, to other
gynaecological problems such as menstrual disorders, adolescent
reproductive health problems, etc. Only a passing mention has been
made about the problems of breast cancer and infertility. Again, under
‘contraceptive services’, indigenous or traditional methods of family
planning are just nominally mentioned without relating them to the
aspects of decentralised planning, quality of care and performance of
PHC staff. Similarly, in the sections on Requirement of the Area vs. Fell
Need of the Population - Sub Centre Action Plan’ and ‘Reducing Unmet
Need’, neither the concept nor the methodology indicated for assessing
the fell needs reflects comprehensive health care. On the contrary, the
discussion appears to provide a lilt towards a status quo in FP and MCH
areas.
In a decentralised system, with emphasis on quality ofcarc. provision
of comprehensive, integrated primary health care (inclusive of RCH)
calls for major steps like budgetary re-allocation for health sector -particularly at the ground level. This in turn means certain changes in the
56
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structure as well as control of resources through panchayat raj bodies. In
this context, involvement of women members of the panchayat raj in the
planning of health care for women as well as monitoring of female staff
could be more effective. The manual does provide a positive signal in
this direction with the mention of “participatory approach with the
Panchayat Raj leaders al PHC level”. However, what is needed is to
concretise and expand the scope of involvement of the local bodies in the
primary health care.
The focus of the new National Family Welfare Programme is
staled to move from target-based activity to “client-centred, demanddriven quality services programme’’. However, the translation of
such a rhetoric into action requires political and bureaucratic will
and commitment. Ensuring ‘quality of care’ in a decentralised
framework necessitates, among other things, provision of better
infrastructure al the service delivery point and improving the service
conditions of the health staff as a minimum A number of studies
reported that PHCs lack even simple accessories like cotton, spirit,
spirit lamps, sputum cups and facilities like examination tables and
pucca buildings for housing the sub-centres. In several regions, lack
of spirit and sputum cups which are used for collecting samples to
diagnose T B have forced the staff to remain inactive and to do only
referral services. Basic equipment, supplies of high quality medicines
and transport facilities and availability of medical personnel particularly lady doctors and ANMs - are lacking. Il is well known
that the posts of female doctors and ANMs remain vacant in several
villages all over India. Rural health services failed to attract these
medical personnel for the obvious reason that these areas arc without
the basic infrastructure. It is also closely linked with the service
conditions of the rural staff. For instance, lack of promotional avenues
leads to the stagnation and monotony in service, particularly for the
ANMs. In a PHC set-up, after a few specified years of services, the
ANM can at lhe mosl rise up lo the level of a supervisor i e, LHV
or female mulii-purpose supervisor. Even after 30 lo 35 years of
service, she continues to slay in the PHC set-up, may be in a different
area but essentially doing lhe same work and more or less in lhe same
environment.
Research studies, including this author's, pointed oul lhai rural health
siaff often do not live in lhe areas of their posting but commute from a
nearby town or city. Study of the reasons indicates that personal needs
like children's education, spouse’s employment and inability to gel a
belter house in the village arc major reasons for these staff staying
outside lhe area of their operation. While making the human resource
planning for lhe health staff, these factors should be kept in mind. While
improving the infrastructure in rural areas e g, schools and transport
RJH
(New Series)
Vol Hl: 1
1998
57
system would be ideal. it will also help lo link the promotional channel
ot the PHC employees, particularly ANMs. lo the urban health
infrastructure based on merit. To give an example, an ANM initially
p 'sled in a PHC could be posted lo a semi-urban public health set-up
alter serving a minimum, stipulated number of years and prov ing herself
to be responsible and meritorious. When there is a scope for opportunities
of growth. ANM feels motivated in her work
The manual places a lot of emphasis on monitoring and supervision
by the respective higher cadres as a means lo achieve quality of care.
However, provision of better transport system for all the cadres of the
health centre is a necessary' pre-condition for better supervision. A
simple statistic - but often not recognised and appreciated - is the
number of records to be maintained by the supervisor and the number of
trips she or he has to make and the distance to be travelled without proper
means of transport.
Interlinked with the aspect of better quality of care is the need lo
improve the basic training and the in-service refresher courses for the
grassroots level staff. An issue that merits mention here is that of the
skills related to administration of contraceptive services particularly
those related to lubeclomy by the doctors, and IUDs by the LHVs and/
or ANMs. Empirical studies have reported that many mishandled
lubectomies and lack of post-operative care resulted in serious
complications, ultimately leading to hysterectomy. Since the PHCs are
not equipped lo conduct major surgeries, the women go lo private
nursing homes spending a lot of money. Even with regard to IUD
administration, the female health staff are found to lack the technical
skills, giving rise to complications and failures. There is a strong need
for effective training and good follow-up services with adequate stocks
of medicines lo cope with situations of this sort and to serve the segments
with ‘felt-need’ for contraceptive services. Il must be recognised that
apart from the need lo provide the service lo the community in a proper
way. there is a need to regain the confidence of the people and credibility
of the PHC.
The manual gives rather superficial and rudimentary treatment to the
very important social aspects like ‘gender-sensitive services’, ‘male
participation’ and ‘responsible sexual behaviour’. While these are
talked about in the context of improving quality of care, none of these
‘gender’ issues figures in the strategiesof implementation or performance
Back Volumes of Radical Journal of Health and Socialist Health
Review are available al Rs 150 per volume
58
RJH
(New Series)
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1998
assessment formats ol the field staff. This creates an impression that
there is a lack of seriousness and reveals a ‘formalistic’ altitude of (he
proponents of target-free approach. Besides, any serious approach
towards implementation would and should initiate a fresh rex ision of the
training capsule. As a minimum, the training curriculum needs to
include all gender-related issues, male involvement and the role change
for the staff in a decentralised set-up in addition to the technical aspects
of primary health care.
Once again, when one talks of gender sensitisation, the role of the
male staff- particularly male health worker-assumes a lol of importance
in sensitising the men about responsible sex behaviour, use of condoms,
reproductive problems of women, proper nutrition for women, and so
on. The manual however ascribes only a limited role for the male worker
and projects as though the responsibility of implementing targel-free
approach lies on the shoulders of the ANM alone. In other words, there
is an overload of work for the ANM. Considering the extent of ground
she has to cover in providing the services, interacting with ihe clientele
and above all, the amount of record work she is expected to maintain, it
is hard to believe she can cope up.
To highlight some of the other important aspects of the manual, a lol
of effort has seemingly gone into highly structuring the various formats
of evaluation, forms of reporting and technical assessment charts of
various cadres of health staff. However, what is essential is that these
forms need to be user-friendly with some guidelines and instructions
provided (missing in the manual). Further, the manual missed out on
certain important qualitative indicators of performance assessment in
crucial areas of health care provision. The paramedical staff not only
need orientation in using these, but the forms themselves need to be
provided in a prepared, printed fashion. One should learn from the past
experiences when ANMs had to maintain the records: observations from
field revealed that there was no stationery (such as registers I books)
available to them. Therefore, the ANMs had to prepare the records using
plain sheets of paper, spending their own money and investing a*Iot of
time and energy. This obviously hampered the other important work
they were to actually carry out.
As for the structured forms or activity reports and other related
documents, provision of a check list of associated symptoms for
different ailments should also be made since the ANMs are entrusted
with new activities (not done earlier) such as breast cancer, STDs,
gynaecological ailments. This would not only help them handle their
new tasks in a proper way but also aid the technical assessment of ANMs
by the supervisory staff.
In addition to the changes contemplated and projected in the
manual, some reforms in line with the experimental models of Tamil
RJH
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1998
59
Nadu and Kerala may go a long way in implementing the target-free
approach. For instance, in the North Arcot Experiment.2 novel step*
like integrating literacy campaign with the health and family welfare
programme, developing a model for co-ordinating the efforts of the
revenue, rural development and health department staff have helped
the planners in fertility reduction. Similarly, employing literacy
volunteers, introduction of state population policy, special macro
progrunes for women and child welfare by the Jayalalitha government
have also helped in good measure. Other positive steps to he
emulated are: performance boosters like measuring individual ANMs
performance by matching the acceptors addresses with (he jurisdic
tion of (he ANMs. involving the ANMs and other staff in target setting process, supportive supervision and treating the ANM as
a ‘colleague’ by the higher-ups in the medical cadre, and not as a
subordinate.
Notes
I K Sasikala, Human Organization at Work - A Case Study of Primary Health
Centres in Andhra Pradesh’. Doctoral Thesis, 1SEC, Bangalore 1993.
2 S Ramasundaram, End of Target Era - Family Planning Programme in
Tamil Nadu.
Women Studies Research Centre
Faculty of Home Science Campus
M S University
Baroda 390 002.
'
Note to Contributors
We invite contributions to the RJH. Original research
articles, perspectives, field experiences, critiques of policies
and programmes in health care, medicine and allied areas
are welcome. Please send manuscripts, preferably typed in
doublespace. If the material is on a word processor, please
send us a hard copy along with the matter on a diskette
preferably in WS4. Address all communications to the
editor at the address on the inside front cover.
60
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1998
Communications
Merger of Ciba-Geigy and Sandoz
Some Implications
The ongoing process of mergers of TNCs in chemicals and
pharaceuficals not only gives them an edge over the Indian companies
hut also poses a serious threat to government policies.
ON March 6, 1996, (he two major Swiss TNCs - Ciba Geigy and Sandoz
- announced worldwide merger (o form a new company ‘Novartis’. The
worldwide merger of Ciba Geigy and Sandoz has certain implications for
(he home country (Switzerland) and host countries (including India).
This merger has added new dimensions to the growing debate on the role
ol TNCs in Indian economy.
In India, the new company is to be called Novartis (India) and will be
among the lop five pharmaceutical giants in India. The two companies
had a combined net sales of Rs 785 crore which include Rs 467 crore for
Hindustan Ciba Geigy (HCG) and Rs 318 crore for Sandoz India. If the
sales of the recently demerged chemical business of Sandoz and the
Ciba’s 100 per cent subsidiary company is taken into account, the com
bined sales will be much higher. In India, both these companies were
competitors before merger. Both TNCs are present in agro-chemicals and
pharmaceutical business in India. Certain products of both companies
overlap in the Indian markets. This merger is expected to drastically
change the face of Indian pharmaceutical industry. According to V S
Sohoni, managing director of HCG, “This (merger) would mean a Rs 200
crore pharma business between the two of us, a Rs 200 crore pesticide
agro-chemical business. Hence, this would mean greater financial strength,
greater marketing muscle...”. In the Indian context, this would mean that
now these companies will no longer be competitors. Besides the market
shares in many products of the new company will increase automatically,
without any new efforts on research and development, efficient marketing
and distribution. From HCG’s 14th rank and Sandoz India's 34th rank in
the pharmaceutical industry, the posi-merger company’s rank will jump
to 8th position. In the agrochemical sector, the combined business of
HCG and Sandoz India will rank second, after Rallis. Thus, the Novartis
India will be in a better position to face other competitors in Indian drugs
and agro-chemical industries. Besides, the power of new company to lobby
with the Indian government for concessions has also increased after (he
merger. Thus, such merger of TNCs should not only seen in the context
of dealing with other competitors but also in the context of gaining more
power to lobby with governments of home and host countries.
RJH
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61
The merger is basically a result of international phenomenon where a
large number of TNCs aa undergoing a process ol mergers and alliances.
Last year, the merger ol Gla\<»and Wellcome look place With the merger
the Novartis', overnight becomes the second largest pharma TNCs in the
world. alter Glaxo Wellcome with 4.4 per cent ol the woild market and
also the global leader in the life sciences as aw hole 1'hc Get man TNC
- Hoechst - which enjoys the ntimbei two position, now has been
displaced by the mergei In the coming days, we will be witnessing an
oligopolistic trend in the pharmaceutical industry as there is a possibility
of three Gei man TNCs Hoechst. Bay erand BASI -- collaborating a joint
strategy to increase their market share in the drug industry Thus, the
power ol drug TNCs yy ill be further consolidated the world over.
This merger also reinforces the argument that major decision within
the TNCs arc taken by the parent companies, leay ing very little space for
decision making with the affiliates in the host countries. In the case ol
Sandoz India and H^G. a large part of equity toy er 40 per cent) is still in
Table I: Post-Merger Bai wce-Siiei i
| Year ended March I995J
(in Rs crore I
Total Sales
Pharmaceuticals
Chemicals
Agro-chemicals
Consumer healthcare
Sandoz
HCG
Merged Company
318.37
91.91
125.48
, 79.16
-
467.21
128.88
185.43
122.50
30.30
785.58
220.79
—
201.66
-
Sonne: Business Today. April 6. 1996.
Table 2: Post-Merger Marketshares
Pharmaceuticals
Company
Percentage
Company
Agro-Chemicals
Percentage
13.0
Rallis
HCG
7.0
Sandoz.
4.0
8.5
Excel Indust
Bayer
7.3
Hoechst
7.0
6.8
D E Noci I
United Phosphorus
6.0
Lupin Agrochemicals
6.0
Others
34.4
Strengths: leaders in pesticides
and strong in seeds
Glaxo-Wellcome
Ranbaxy
Cipla
Hoechst-Roussel
Pfizer
Alembic
Knoll
HCG
Sandoz
7.2
5.4
3.9
3.5
2.7
2.5
2.5
1.6
0.9
Others
69.8
Sirent'tln. nervous system.
gynaecology and neurology
Sonn e. Business Today. April 6. 1996
62
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/9y.\
the hands ol Indian public As (his mergei has certain implications (both
negative and p<»>ime) for Indian shareholders of these companies, (hey
were neithei consulted nor informed about the merger plan. This clearly
exposed the my ih ol i 01 porate democrat y and transparency as propagated
by these companies where leave alone workers and employees, even
Indian shareholders u ho own a large equity in both these companies were not consulted.
Culling organisational costs is one ol the major factor which influences
lhe mergers In the case of merger of Sandoz and Ciba Geigy, reduction
ol combined workforce of these two companies is a major agenda for
culling organisational costs. According to lhe companies’ estimate, the
merger would reduce lhe combined workforce by approximately 10 per
cent or around I 3,000 in numbers. As n is well known about Swiss TNCs
thal their strategies arc rarely decided by the factors in lhe Switzerland
but largely in the host countries (including India), this reduction of
combined workforce is likely to be higher in lhe host countries Even in
total numbers, the conjoined workforce of these two companies in the
host countries is much higher than in the Switzerland. Thus, it indicates
a process ol layoffs and retrenchment of workers in lhe various plants in
India and other host countries will be launched soon. This also indicates
that a similar process of layoffs of workers will also be undertaken in
Switzerland. Thus, instead of creating more jobs, the merger would
reduce workforce in Switzerland as well as in other countries where these
iwo companies are operating. On the whole, workforce will be a major
loser in this merger.
With lhe merger lhe possibilities of increase in inter-firm and intra
firm transactions between the two companies have also increased. Il is
well known thal many TNCs indulge in capital flight through transfer
pricing methods. According to lhe latest World Investment Report 1995
by the UNCTAD. TNCs account for two-thirds of lhe world trade in
goods and services, one-third of intrafirm transactions and lhe other onethird of inter-firm transactions. Thus, the merger of Ciba Geigy and
Sandoz provides more opportunities to the new company to indulge in the
transfer pricing, as compared to their pre-merger status.
Lastly, lhe process of world-wide merger of TNCs undermines lhe
existing legislation and policy guidelines of national governments.
Irrespective ol sound pro-competition and anti-monopolistic policies of
governments, the mergers al the global level leave lhe national policies
redundant and ineffective.
-Kavaljit Singh
Public Interest Research Group
142 Maine Apartments
Plot 28. Indra Prastha Extension
Delhi I 10 092.
RJH
(New Series)
Vol Hl: 1
1998
63
Reviews
Documenting Research
Ramiia Bisht
Nilamvari Gokhale
Health Research in India - A Review and Annotated Bibliography:
Foundation for Research in Community Health: 1994.
THE book is a significant annotation of available ‘health research’ in
India. This book is a result of a project carried out by the Foundation
for Research in Community Health (FRCH) team al the request of the
ministry of health and family welfare and the World Health Organisation
The bibliography, published as a single volume tries to examine the
available health research conducted by social science research organisation.
academic institutions and market research organisations in both
governmental and non-governmental sector. This review is particular!)
important as health research in India is of recent origin. The FRCH team
has not only documented the available research carried out between
1985 and 1992 but has also critically examined it, pointing out the gaps
in knowledge as well as the methodology of the research. The team
undertook this review in 1993. They visited many institutes, organisa
tions and agencies personally and contacted others by post. The book
covers 102 instituiions/organisations. Out of 400 documents gathered.
250 studies covering five broad topics were selected for review.
This methodology was adopted by FRCH team to review health
research has resulted in covering a large number of organisations and
receiving maximum inputs of relevance. Teh review is done under five
broad categories - (i) service delivery, (ii) epidemiological pattern,
(iii) health educations, (iv) community participation and (v) alternative
strategies.
Service Delivery'
This is the largest section of the book. It covers studies on provision,
access and utilisation of health care services along with the evaluation
of national health programmes and health facilities in the public and
private sector. The team in its review discovered that studies have
concentrated mainly on public sector instead of predominantly prevailing
private sector. 'Even in the public sector focus is more on rural public
health services, concentrating on primary health care services and
64
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1998
below, with only occasional focus on hospital and other referral facilities.
A similar trend is evident in studies on human manpower. Unfortunately
the approach here is from an operational perspective rather than social.
The review clearly points out the inadequacy of public health services
to handle the expected range of helath care responsibilities, focus being
largely on fmily planning programmes. The growing private sector is no
better. Despite increase in number, it fails to maintain even minimum
standards.
The bibliography reveals that very few research studies have been
undertaken is the area of finance. In shortlisted research studies, the
coverage is on non-governmental sector. The document correctly points
out that probably the non-availability of recorded information and
reluctance on part of private and non-governmental sector to share this
information must be barriers in undertaking studies on aspects related to
finance. Under organisational dynamics the review focuses on
management information system in public health care model. The
studies report duplication of reports and absence of standard formats. A
lot of information is generated, but it is not very relevant or reliable and
hence cannot be used for decision making or planning.
The FRCH research team found very few studies focussing exclusively
on access and utilisation of health services. The bibliography reveals
that even in rural areas there is predominant preference for private
sector. But the studies fail to elicit the magnitude of utilisation of the
private practitioners and services among various classes of society or
their distribution in rural areas. The review team in its study reached the
conclusion that the emphasis has been more on vertical programmes,
stress being on family planning activities, leading to neglect of other
impotant programmes.
The evaluations point to the diversity of health circumstances present,
which speak of importance of priority setting. Given limited resources
and the immensity of health problems facing our country, it is imperative
that priorities be set and resources be allocated efficiently, if we want to
have any impact on the health situation of the country. Several health
problem are receiving attention, but other equally important ones appear
relatively neglected.
The review makes no reference to the recent explosion of funding for
research on AIDS. There is no doubt of the enormous health significance
of AIDS, but it is critically important the research investments on AIDS
do not use funds from reserch urgently needed for other health problems
causing greater mortality and morbidity. Research on fertility and
reproductive health claims high priority because of unwanted fertility
and its relationship to population control. The need is to undertake
research on issues related to women’s health rather than just fertility or
reproductive health.
RJH
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65
Throughout the hook, the ivv lewers point to paucity ol information on
private health sector No wonder this has resulted in hardly any data being
available regarding then growth, distribution in rural and urban areas
standard of medical cure prov ided or patterns lor regulating or monitoring
them. This is a significant omission pointed out by the rev icw team as the
private health sector is an area rapidlv growing undei the umberella
liberalisation.
A gap in this hook is a review of research studies in traditional
medicines or indigenous system of medicine and practices. Health
research in Avurveda. Siddha and Unani needs to he documented One
expected the FRCH team to at least have attempt to include it in their
review of health research. Similarly no attention is paid to research in
Field of menial health and behavioural health which is a major cause ol
morbidity.
E/iidem iolog ii -a I Pa tic n r v
The review team undertook studies in this area with the objective <«i
assessing the available evidence on prevalence and incidence oi
communicable diseases and their morbidity and mortality rates
Bibliography reveals most epidemiological studies arc hospital-based
though there is a trend towards doing smaller surves which generate
health and morbidity patterns in selected geographical areas. They also
discovered that the most commonly researched diseases are ARI an J
diarrhoea.
Pointing to the gaps in research, the team rightly indicates the
need to do cultural - epidemiological studies. It points out. though
not very explicitly. the urgent need for epidmiological data to be des
egregated from palional averages. These average often hide differen
tials and variabilities in terms of geogaphical area, income, social
stratification, various social groups - minorities, tribals, immigrants and
those disadvantaged due to the process of industrialisation and
modernisation.
Critically analysing this areas of research the team intelligent!}
suggests prioritising diseases into various categories. This will help in
identifying those diseases far which an understanding of the disease load
is useful. It also points lo lhe need io utilise available data to gauge the
current disease load which they erroneously feeel is sufficient. This r
a contradiction in lhe analysis as they have already questioned ilk
quality reliability and validity of lhe available daia. Despite accepting
lhe ‘unregulated’ nature of private sector, lhe team hopes that betu
imposition lb ’compulsory notification act’ is possible and would help
in collecting reliable edpdemiological information in this sector. These
stand taken by the review team seems rather far-fetched to this
66
RJH
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199<S
commentator, as such laws and acts have existed tor long
negligible impact. The review-team seems to be unduly hopeful
with
Health Education
Though health education is a universally accepted component of all
hclalh programmes, the FRCH learn throws light on only nine studies
indicating the need for more research in the area of health education A
majority of studies reviewed are e\ aluations ol effectiveness of methods.
materials and medium use in health education activity. Imparling
information is only one part of health education. 1 he other objective is
to bring about change in health-related attitudes and behavior in
directions more conducive to good health. Studies examining the second
objective of health has also not delved in detail into the methodology
adopted by the studies in this sections, which are of relevance and should
have found a place in a study like this.
Comm unity Participation
The studies reviewed under this category cover studies on socio
cultural factors influencing use of. and access to public health services,
and evaluation of community participation in health care delivery. A
large number of studies reviewed are KAP/KABP studies which the
team reports are accompanied by in depth interviews, focal group
discussions etc in order to enhance the quality of data gathered on
people's belief, attitudes, perceptions and behavior.
As we all know community participation is of utmost importance, and
is a desired goal of all community-based health programmes both in
government and nongovernment sector. But a look at the studies
indicates that it is still an elusive goal. Despite knowing this, unfortunately
none of the studies have analysed the success or failure of efforts in
increasing community participation by any agency. Various tenets of
community participation had not been spell out in these studies, therefore
as correctly pointed out by the FRCH team further action research needs
to be encouraged and promoted.
Alternative Strategies
The annotated bibliography ends by reviewing studies (hat evaluate
alternative approaches to health care delivery in public, private and non
government sectors, especially with regards to cost-effectiveness are
few and far between.
Another important finding is that these non-governmental
organisations are able to bring about improvements in levels of awareness
RJH
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1998
67
but it is seldom seen translated into individual or collective efforts al selfcare. The team though points to the overall vulnerable financial poslion
of non-government sector because of dependence on lime bound external
funding, it does not explicitly indicates need to study this whole issue of
‘sustainability’ of these experiments
In Held of alternative strategies, the current focus is on greater
participation of private sector and alternative sources of health care
financing (Reflected in WDR 1993). The review clearly points out that
research in this area is still marginal. Studies reviewed presents a rather
hazy picture of the role of private sector in insurance-based health
delivery.
The book also reviewed few modification in health care delivery
within the prevailing public helath system. In the rural sector, the team
reviewd the area development projects - an effort towards socially
integrated approach of the bio-environmenlal sector control programs.
While in the urban areas, the team reviewed the studies on establishment
of health posts with the aim of covering the needs ol primary health care
in urabn population.
The FRCH team concludes by empasising that no clear understanding
of alternative strategies seems to be emerging from the literature under
review. There is need to look at health sector in a holistic manner,
recognising the role of the private sector. It appropriately cautions that
better regulation of private services and well-designed research of
comprehensive financing systems needs to be undertaken. This will
bring the private practitioners into an integrated referral systems and
enhance coverage rather than burdening the people with increased used
charges.
The document has to a large extent fulfilled its mandate to survey
current health research in the country, identify its strengths and weaknesses
and generate specific recommendations for further research. It is impor
tant to recognise the ‘power’ of research in accomplishing the goal of
improving health of the people - which until now have been largely
neglected.
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68
RJH
(New Series)
Vol HI: 1
1998
Document
The Calicut Declaration, November 1997
1 There is a universal and permanent need for all health care
professionals to he cognisant with the ethical basis of clinical
practice.
1.1 Health care professionals will encounter ethical dilemmas during
their practices. These must always be resolved in the best interests of the
patient.
1.2 Disadvantaged patients (eg; those infected with HIV/AIDS, the
menially ill or handicapped, the poor, the prisoner or victim of torture
demand the same high standards of health care as docs the rest of the
society. In addition, they deserve special compassion. It is unethical to
discriminate against the disadvantaged in any way.
1.3 Although we learn from our ancient heritage and contemporary
practice world-wide, it is necessary to devise Asian solutions to Asian
problems, taking into consideration social customs, national differences,
and economy ic; realities.
1.4 It is important that we use cost effective measures, drawing upon
the strengths provided by close-knit family relationships.
1.5 There is need to incorporate the teaching of medical ethics into
the undergraduate and postgraduate education of each member of the
health care team. Structured training programmes must be supplemented
by debates, discussions al the bed side and periodic consideration of
actual or hypothetical situations that are encountered in practice.
2. The doctor-relationship must be one of partnership, founded on
trust and fostered by honesty.
2.1 The inevitable inequality in the relationship necessitates an extra
effort by the doctor who must do all he can to help without patronising.
3. There is real danger of technology overpowering the dictates of
common-sense and reason. It is necessary to ensure appropriate,
relevant and cost-effective approaches in the diagnosis and treatment
of illness.
3.1 Treatment of the patients with advanced cancer demands special
qualities of both the head and the heart. It is important to recognise the
stage at which we must call a hall to tests and anti-cancer therapy. From
this stage onwards, the goal is ensuring freedom from pain and othpr
distressing symptoms.
3.2 Although life is precious, there is a lime for each of us to die. In a
terminally ill patient, preserving life at all costs with high technology
interventions is inappropriate; it is bad medical practice and therefore
unethical.
RJH
(New Series)
Vol Hl: 1
1998
69
4. There is need to ensure equitable distribution of scarce resources
so as to gain the maximal advantages for both individual patients and
society in general.
4.1 li is important to avoid the waste that is inevitable in duplication
the building of monuments io individual empires, and hie setting up ol
"mega-centres".
5. Each member of the health care team is a specialist in her or his
chosen field and deserves respect. The team must be the first among
equals.
5.1 The relation between the members of the health care team should
be such as to promote learning from one another, mutual consultations.
co-operation and efficiency - all focused on the welfare of the patient
6. Associations of doctors, nurses, other health care professionals
and voluntary agerfeies need to work in harmony with good
communication between themselves and a commitment to patients
and the general public.
6.1 Suspicion, paranoia about "turfs” and "territories”, and vested
interests have no place in ethical medical practice.
6.2 These association must inform, advise and motivate bureaucrats
and politicians so as to facilitate and bring into being facilities that
benefit public health and the care of patients.
6.3 The Associations need to work together to ensure human rights and to
eliminate abuse, especially in relation to the underprivileged, the poor, the
aged, the handicapped, the ill and those deprived of their liberty by the stale.
6.4 Steps to ensure openness in all activities in clinics, hospitals.
asylums and prisons - and periodic public scrutiny with free publication
of findings - are a necessary part of this programme.
6.5 The functioning of our Medical Councils deserves close scrutiny and
urgent corrective action. In the absence of effective statutory watchdogs.
little improvement in health care will occur.
Tiparul Jiranantanakoran RN
K B Linge Gowda
34, Marappa Garden
Benson Town Post
Bangalore 560 046. India
National cancer Institute
Rama 6 Road Rajdhavi
Bangkok, Thailand 10400
Judy Sathyan
Tri Arimanto Yuwana
Kondiyara House
Puthiyara Post
Calicut - 4. Kerala
JL. Tenggilis Timur 111/57
Surabaya 60292
Jawa Timur, Indonesia
Bishwa Raj Joshi
House No 16. Flat No K
2nd Floor, Doctor's Quarters
Sobahan Bagh. Dhaka 1207
M D Yeaqub Ali
Consultant Surgcon/Urologist
Western Regional Hospital
Pokhara, Nepal
Mary Tom Kooroth SD
Elsie George
Mundakapadam Mandiram Hospital
Manganam,
Kottayam 686 018, Kerala
70
RJH
Sisters of The Destitute
Opposite Men’s Hospital
Medical College Post
Trivandrum 695 010, India
(New Series)
Vol 111: I
1998
Aleyamma Mathew
May Phyulatt
Staff Nurse
RCC
Medical College Post
Trivandrum 695010. India
Assistant Radiotherapy Dept
General Hospital
Mandalay. Myanmar
Soe Aung
HouseNo B2, NGO Quarters
Vellimadukunnu
Calicut
Kerala. India
Consultant Medical Oncologist
Dept of Oncology
Yangon General Hospital
Yangon. Myanmar
Geetha M
Tashi Wangchuk
Holy Cross Convent
Madiwala New Ext
Bangalroc 560 068, India
Sr ENT Surgeon
Jigme Dorji Wanchuck
National Referral Hospital
Thimphu. Bhutan
Swapan Kumar Nath
E Divakaran
Registrar. Radio Therapy Dept
Chittagong Medical College
I lospital
Chittagong. Bangladesh
Kumkumam
Kanattukara post
Thrissur. Kerala 680 011
India
.Jose Mary
Ahmed Razee
Siti Annisa Nuhonni
Consultant Physician
Non Communicable Diseases Unit
IGM Hospital
Male, Maldives
Dharmais Cancer Center Hospital
JL Let Jen S Parman Kav 84-86
Jakarta, Indonesia
Hemanth Kumar V V
Kozhisseri house
Andiyoor Kunnu
Valiyaparamba Post
Malappuram, Kerala
Near Chitra Medicals
Medical College Post
Calicut
Kerala 673 008, India
Philomina Joseph
Phongkitti Thisuphakorn
National Cancer Institute
Rama 6 Road
Rajdhavi Bangkok
Thailand 10400
P M Koyakutty
Dept of Anaesthesiology
Medical College
Kottayam 686 008
Kerala, India
Kozhimala House
Puthupally Post
Kottayam
Kerala, India
S Kumari Thankam
TC 38/516. Lakshmi Nilayam
Chenlhittal
Kochar Road
Trivandrum 695 086, India
Madhavan Nair
M R Chandran
Abbas N
Nalakalh House
Kodakkad Post
Palakkad, Kerala 678 583
(New Series)
Marulhum Kalayil House
Arunooltimangalom Post
Kadulhuruthy
Kottayam 686 604
Special Correspondent
The Hindu
Calicut
Kerala, India
(Jshakumari K V
RJH
Abdulla Manima
Vol HI: 1
Professor, Forensic Medicine
Medical College
Calicut
Kerala, India
1998
71
Robert Twycross
Usha Shinde
Sir Michafi Sobell house
Churchill Hospital
Oxford. UK
Bangalore Hospice Trust
New Tippasandra
Main Road
Hal 3rd Stage
Bangalore
Karnataka. India
U Nanda Kumar
Depl of Physical Medicine
Medical College. Calicut
Kerala. India
Umeshhabu
1434 Hal 3rd Stage
10th Main. 6th Cross
Bangalore 560 008
Karnataka. India
Madhaxan Kutly N
Resident Editor
Indian Express
Trivandrum 10
Kerala. India
Jayalakshmi P
Officer in Charge. Cancer Unit
Vavuakavu Post
Karunaaappally
Koi lam 690 528
Kerala. India
Anil Kumar Paleri
Dept of Anaesthesiology
Medical College. Calicut
Kerala. India
B F.khal
Dept of Neurosurgery
Medical College
Kottayam
Kerala. India
Kasote Rajasree
Cipla Cancer and Aids Foundation
Worgec
Mumbai-Bangalore Highway
Pune 41 1 029, India
Jan Stjernsxvard
Mohanachandran
Borrinackloster
S2339K Suedala
Sweden
Dept of Psychiatry
Medical College Calicut
Kerala, India
Rajasekharan
Marina Rajanjoseph
Medical Record Officer
RCC Trivandrum
Kerala, India
Mose mm Hospital
Kolenchery
Ernakulam
Kerala, India
Sreekumar
Community Oncology
RCC Trivandrum
Kerala, India
Thomas Varghese
Moscmm Hospital
Kolenchery
Ernakulam
Kerala. India
Dvyasree
Medical Officer (Homeo)
K H H and M M T C ’
Francis Road
Calicut
Kerala. India
Assumma Beevi
Asst Professor
College of Nursing
Calicut
Kerala, India
Kishore Rao
Managing Trustee
Bangalore Hospice Trust
•New Tippasandra
Main Road
Hal 3rd Stage
Bangalore
Karnataka, India
72
Jayakumar
Chief Medical Officer
Cochin Shipyard Ltd
Kochi 682 015
Kerala, India
And many others.
RJH
(New Series)
Vol 111: 1
1998
The Reality of Foreign Investments
Kavaljit Singh
Rs. 80
Powers and Prospects
Noam Chomsky
Rs. 140
Lent and Lost
Cheryl Payer
Rs. 80
Globalisation and Third World Trade Unions
Edited by Hcnk Thomas
Rs. 140
Swiss TNCs in India
Public Interest Research Group
Rs. 50
Testing Times
The Global Stake in a Nuclear Test Ban
Praful Bidwai & Achin Vanaik
Rs. 50
TNCs and India
Jed Greer & Kavaljit Singh
Rs. 50
Economic Reforms and the People
C. T. Kurien
Rs. 30
Crisis and Response
Vinod Vyasulu
Rs. 40
Unhealthy Trends
The World Bank, Structural Adjustment and Health Sector in India
Public Interest Research Group
Rs. 15
Madhyam Books
142, Maitri Apartments, Plot No. 28, Patparganj, Delhi-110 092.
Ph : 2432054 Fax : 222433 Post Free!
“All the plagues that threaten us with doom today;
from the arsenals of horror bombs and nightmare
germs, to the pollution that is poisoning our air and
water... from the tensions of packing crowds to the
lunacies of human prejudice; all, all, all have been
treated at length and over and over from every
aspect in science fiction...
But that part of our job is done. We didn’t do it well
enough. We didn’t do it quickly enough. The task
was too great; the human poupulation was too
numerous ...too determined on its folly...too
obstinate in finding sufficient unto the day the evil
thereof.
—Yet, never mind. Too little and too late but what
we could do, we have done.”
Isaac Asimov
‘The Serious Side of Science Fiction’
in Today, Tomorrow and...
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