CASE STUDIES IN HEALTH DEVELOPMENT

Item

Title: CASE STUDIES IN HEALTH DEVELOPMENT
extracted text: .d*

RF_COM_H_12_SUDHA

M / Zo I

The Catholic Hospital Association of India
C. B. C. I. Centre, Goldakkhana, New Delhi - 110001
Tel.

310694, 322064

CHOMAirs STORY

Choman, a tribal, had been working as a bonded labourer
with Mathan, a big landlord in Kerala,
Being a bonded
labourer he was getting very low wages.
His family
had been working with Mathan for generations•*
With the
low income, Jhe was experiencing real pain in meeting
even the bare minimum requirements of his
six2 member
—-family.
Once Choman hinted to Mathan the wages that were in
practice in that jarea and' pleaded
“
- - with the landlord that
unless he increases
i
— the
—j wages
he cannot pull along at a
time when the prices of essential goods are very high.
Mathan was surprised to hear this,
Such a response from
a tribal, and moreover his slave!
He became furious.
Upon this Choman revealed
He did not listen to Choman.
that in this circumstances he cannot continue to work
there.
Choman should be taught a lesson, he decided.
The famous
festival of the local temple was during that time.
Mathan
was sure that Choman and his family would go for the
festival.
At night Mathan’s son, with some ’goondas’, set
From the temple Choman could see
fire to Choman’s house.
rising from that part of the area where his house was
situated. He ran to the spot.
From distance he could
He rushed madly
see his house being reduced to ashes.
towards that.
But before he could approach he was cought
He was beaten up very badly.
Hearing the noise
hold of.
neighbours came to the spot.
They were given a different
version by Mathan’s son and his goondas.
Deliberately
they had brought a sack full of coffee.
The new story
was that Choman had stolen this and when they came to ask
about this he resisted and to make his position clear and
to defame Mathan he himself set fire to his own house.
None from the crowd spoke for Choman.
By this time Choman’s
They could
wife and children came back from the temple.
only cry aloud in utter helplessness and agony.
Choman had heard about Fr. Samson working among tribals«
The next day itself he went to Fr. Samson and shared with
him all that happened.
Fr. Samson gave some money to
support the family that was starving and he filed a case
The case was taken up by the advocate
in the court.
appointed by the Government for free legal aid to the
Poor.

Some other developments were going on on the other side.
The local politicians were close aides of Mathan.
With
In addition
their initiative a public meeting was held.
to this, a case was filed alleging stealing charges
This case was also taken up by the same
against Choman.
advocate.
Mathan got the cooperation^of Fr. William, the local
Parish Priest.
Mathan’s
Choman should withdraw the case.
eldest son was studying in the seminary,
Hence a pending

:2:

They suggested that i '
would give some money to
settle the issue.
But the loss
Choman.
He lost his house and all\h^J
all that
a
‘v h
_
life-time.
thing else he
i'
and thoroughly
:::
up
put down.
was beaten
a
before
thief
"
the
public.
J
if* it is a
«e.pe„s.tie„f
cX„ Xxcompensation
be given an amount
-J construct
venient house and an < ’
otner looses,
In addition to» that, Mathan should
apologise before
-e Choman.
They disagreed and went out.
On their way back they
approached
the Bishop to influenc
him to compel Fr.
e
Samson
to
withdraw
the case,
were explained to
these
All
the Bishop to save the good
Seminarian.
name of the

--

T ‘

‘X:-

Aft er f ew months Mathan faced f--some other problems too o
His ---younger son had got a job abroad
-- Ior which he
to be free{ or anX criminal case
had
Again he approached
Er. Samson,
But Fr. Samson
repeated his previous
demands•
Ma than could not
agree
with
that.the part asking him to apologise.
Especially
was
He
at Fr• Samson,
furious
very
He came out of the room.
with the case, he decided.
Continue

<3or>n / I i'i*'7—

THIRUNELLY - CASE STUDY

Thirunelly is situated in Wynad District of Kerala
St ate 5 adjacent to Karnataka boundry, with thick reserve
forests around and it has a population of .000 people. 90%
of the inhabitants are Adivasis who once enjoyed the ownership of the entire land, But later, with the invasion of
migrants from other places, the illiterate and simple Tribals
lost all their land and today they own only 10 to 1? c ents
of land and a few people have 2-to 3 acres, About 95% '^f
the people are agricultural labours, The nearest public
health centre is U km. away from this village, and the
lower primary school in the area has 86 students but cnlj
8 are Adivasis. There is a temple in Thirunelly,5 which
attracts pilgrims from all over the country.
Thirunelly comes to limelight and lublic attention
every year because of mass deaths in the beginning of mansoon,
when there is no work. People are affected by Diarrhoea
vomiting and fever and quite a number of them succumb to it.
Government named this phenomenon gastro- jnterits. In 197/>
13 people died and many groups like Lions Club, Jeycees and
other agencies including the Diocese brought in aid from
outside. Later in 1978 Diocesan Social Service launched
a conscientization piogramme in their village on a massive
scale.in 1978, 8 people and in 1979, 7 died again.

Questions.
- Why mass death in Thirunelly?
- If you. are in this situation what programmes
would you undertake?

COMMUNITY HEALTH DEPARTMENT
CHAI.

C.0^1 H I 2-- 3

The Catholic Hospital Association of India
C. B. C. I. Centre, Goldakkhana, New Delhi - 110001
*Tel. 310694, 322064
i

STORY OF VASU

Vasu', an eight year old .boy was the only child of
has parents, who were very poor. They worked as bonded
laborers under the landlord who had very little concern
for his workers.

The family found it very difficult to

meet their dialy needs.

Vasu used to help his parents by

cutting grass from the forest for the nnWin,
There was.a Government subcentre about 2 K.M.-away
from Vasu's house. The ANMs used to visit the village but
since the villagers were not co-operating with them, they
stop.d their work in that village.
As usual, one day Vasu went to the forest to cut
the grass and he had a thorn prick on his foot,-since he
had no ohappals. The parents treated him with country
medicine, and applying cow dung on the wound. As the days
went,Vasu's condition become very serious and they thought
of taking him to.the.hospital.
Since they had no money his
father borrowed Rs. 100/- from the landlord, and took him to
the PHO, Since Vasu had developed signs of tetanus by
this time, P H C, was not able to treat and adviced the
parent to take Vasu to the District Hospital, wh-i n.h was
situated very far.
Since the money they had with them was not enough,
the parents decided to return home. On the following day
Vasu died.
*• Why did. Vasu Dio?

CHD Department.

C, Cm

H

l

VALUES & VALUES (F)
Miss Sumati was from a very poor family. She lived in
a hut near the bank of a river. She was in love with Mr.Sunil,
who lived on the other side of the river, and was also from a
poor family. This love affair was known to both the families.
Ome day Sumati heard that Sunil is seriously ill. It was
monsoon time and the river was overflowing. She had to cross the
river by a country boat. But she had no money to pay the boat man.
She approached Suresh, her neighbour to borrow some money, but
he refused to give. She then met Shankar, the boat man and oxplained to him the situation, and assured him that she will pay
him the boat fare later. Shankar insisted that only if she
pays the boat fare (Rs. 2/-) he will take her to the other side
of the river. She pleaded with him and told that her lover is
seriously ill, and that she must meet him immediately* Shankar
told her that if the matter is so urgent he will take her to the
other side on the following day provided she is prepared to
sleep with him that night* When Sumati realized that arguments
were of no use she agreed to the condition.
On the following morning Sunati reached Sunil’s house, and
in the course of their heart to heart talks, she narrated the hard’
ships she had to go through inorder to meet him. Sunil got a
shock of his life when ho realized that Sumati is no more a
Virgin, and in his anger he beat her and chased her out of the
house. Sumati returned home very sad and frustrated.
When Sathish, her brother asked Sumati the reason for her
sadness she told that Sunil rejected her and she was ill treated
and beaten by him when she visited him at his sick bed. Infuriated
by this Sathish rushed to Sunil’s house, pulled him out of his
bed and killed him.

Who is the most virtuous character in this story? Why?
Who is the worst character in this story? Why?

Community Health Department
Catholic Hospital Association
17/11/1987.
t. j./l.k.
200o

of India, P.Bo 2126,

Secunderabad - 500 003.

WRITTEN INSTRUCTIONS
Name ?
1. Read everything before doing anything. but work as rapidly
as you can
2. Put your name in the upper right-hand corner
3. Eid you want to come to this course?
4. Draw a circle round the title of this paper.
5. Put your initials below your name.
6. nre you happy with your work? Underlines Yes or No.
7. Slap your neighbour on the back.
8. Do you like your post? Underlines Yes or No.
9. ^re you satisfied with the health system in the country?
Circle: Yes or No.
10. Write the name of your occupation
11. Write the name of your superior
12. Would you like to have more freedom in your work?
Write your answer
13.

you happy with your friends? Circle: Yes or No.

14. If you have come so far 9 speak out loudly your first name.
15. Raise your hands
16. If you have followed the. instruetions so far 9 please go to
the blackboard and say9 ”1 have11.
17. Say loudly, "A.B.C.D.E.E.G,15.
18. Please do not utter a word till the whole group has
finished this exercise.
19. Now that you have read the instructions carefully 9 do only
what the sentence No.1,2 and 4 tell you to do
20. Please do not give away this exercise by way of comment
or explanation. If you have come so far, go on writing
something on this paper. Let us see how many persons
followed these instructions correctly.

I M A G E S

Lazy

Conservative

Dependable
Mature

Emotional
Restless

Uncooperative
Enthusiastic
Money minded
Loyal

Impersonal
Progressive
Helpful

Frustrated

Concerned

Efficient

Immature

Insincere
Risk-taking
Oppressing

destructive
Grateful
Honest

Supportive
Obliging

Irresponsible
Humble

Impartial

Prejudiced
Stupid

Undependable
Encouraging
Ignorant
Dishonest
Hard working

Exploiting

Clever

Arrogant

Fatalistic

Revengeful

Trustworthy
Educated

Adjusting

Innocent
Proud
Kind

Submissive

Greedy

Cunning

Lovable

Cultured

Far sighted

Ungrateful

Superstitious.

**^*****

S kcl

J
imGEs
Lazy

Insecure

Impersonal

Dependable

Conservative

Progress!ve

Plat ure

Emotional

Uncommunicative

Uncooperat ive

Rest less

Helpful

Professional

Frustrat ed

Concerned

Irresponsible

Confused

Backward

Ent husiastic

Dogmat ic

Hard-working

Money-minded

Efficient

Immat ure

Loyal

Insincere

Idealistic

Undependable

Over-productive

/Apathetic

Encouraging

Risk-taking

Responsible

Supportive

gelf—cont rolled

Unprofessional

Over-sensitive'

Impulsive

/Appreciative

Superficial

Halve

Exploit ed

1.

From the list of adjectives given above, which seem to you best

to describe the urban worker?

Select as many words as you wish,

you wish to add one of yolr own.

2.

If

feel free to do so*

From the same list, which adjectives seem best to you to des—

cribe the unemployed?

3.

From the same list, which adjectives seem best to you to describe

the villager?

4.

From the same list, which adjectives seem

cribe the average student?

best to you to des-

-2-

5.

From the same list, which adjectives seem best to you to des-

cribe your parents?

6

From the same list, which adjectives seem best to you to des-

cribe yourselves?

*

<Som H

RAMAKK'S STORY

Ramakka, wife of Veerabadrappa has two children. She goes
to work in Periaswamy's field for the wage of 1 rupee a day.
Her younger son, Linga, only 11 months old, got diarrhoea
which is a common problem leading to death in the village.
With one rupee which she got as that day’s wage, she bought
50 paise worth of powder medicine from the nearby petty shop.
50 paise worth of flowers she offered in the temple for
the cure of her son. As the diarrhoea continued she approached
the local Dai Yellamma for help. She gave her some herbal
medicines. But the situation became worse and so Ramakka,
with the money her husband borrowed , took the child to the
local doctor, who has no training
■
but some knowledge received
by watching his uncle who' was a compounder. He gave an
'
injection worth Rs. 7/-. The
child got temporary relief.
When the sedation power of the injection got over, the
diarrhoea started again, The local Dia, advised Ramakka to
take the child to the district hospital 20 Kms away. She
borrowed Rs. 20/- from the money lender on the condition that
the amount with the one third of it as interest will be paid
pack in paddy, during the harvest season.
Thus they reached the hospital. She was ignorant of the
proceedures of the government hospital. She had to give Rs. 2/to the gate keeper for entry. The hospital personnel were
so busy that they could attend to the child only very late.
They scolded Ramakka for the delay in bringing the child for
medical care. She could not tell the doctor that their trip
cost her three week’s pay which she should pay back with
interest. The doctor also scolded Ramakka for not bringing the
child early, and furiously wrote a long prescription including
four I.V. fluids. The pharmacist billed her Rs. 60/-, But
Ramakka did not have that much money. She bought few tablets
and returned home. While on her way back home, the child
breathed it's last on Ramakka’s shoulder.
* * *

*

■) :

* * * * *

Clo^A H i

i-f-

VALUES & VALUES (F)
Miss Sumati was from a •very poor family. She lived in
a hut near the bank of a river.'r'
. She was in love with Mr. Sunil,
who lived on the other side of the river,, and was also from a
poor family. This love affair was known to both the families.
One day Sumati heard that Sunil is seriously ill. It was
monsoon time and the river was overflowing. She had to cross the
river by a country boat. But she had no money to pay the boat man.
She approached Suresh, her neighbour to borrow some money, but
he refused to give. She then met Shankar, the boat man and ex
plained to him the situation, and assured him that she will pay
him the boat fare later. Shankar insisted that only if she
pays the boat fare (Rs. 2/-) he will take her to the other side
the river. She pleaded with him and told that her lover is
seriously ill, and that she must meet him immediately* Shankar
told her that if the matter is so urgent he will take her to tlie
other side on the following day provided she is prepared to
sleep with him that night. When Sumati realized that arguments
were of no use she agreed to the condition.
On the following morning Sunati reached Sunil’s house, and
in the course of their heart to heart talks, she narrated the hardships she had to go through inorder to meet him. Sunil got a
shock of his life when he realized that Sumati is no more a
Virgin, and in his anger he beat her and chased her out of the
house. Sumati returned home very sad and frustrated.
When Sathish, her brother asked Sumati the reason for her
sadness she told that Sunil rejected her and she was ill treated
and beaten by him when she visited him at his sick bed. Infuriated
bythis Sathish rushed to Sunil’s house, pulled him out of his
bed and killed him.

Who is the most virtuous character in this story? Why?
Who is the worst character in this story? Why?

17/11/1987.
t. j o /I. k.
200o C:o

Community Health Department
Catholic Hospital Association
of India, P.B.2126,
Secunderabad - 500 003.

on H—I 2-

LINKAGES IN PUBLIC HEALTH ACTION

R. SRINIVASAN

MADRAS
25TH FEBRUARY,

IC

1989

deem

I

it

a

privilege to

Voluntary Health Services,
on

in

linkages

inst i tut i on

public

Madras,
heal th

itself

VHS

action-

the

as

an

leadership and

Sanj ivi, happily with us,
f or

rural

For any voluntary organisation, to define
a clear role and to sustain that

over three

by

to present my views

exploring the scope for practical action

health caref or

invited

is a tribute to the vision,

sense of purpose shown by Dr.
in

be

decades is a notable event

note

f or

signifying

the

prescience and mututally reinforcing vigour shown at all
1 eve 1s

within the team.

In a vast country like

such examples,

even if successful,

become

fully

replicable elsewhere but the

spirit

that

pervade such an experiment

often

i deali sm

echoes and fructifies elsewhere.
the

dedi cated

meaning
sure

may not immediately

Sanj i vi’s

of

team at VMS continued success

you

will join me

continued

and
finds

May I start by wishing

and purpose in the years ahead?

al 1

ours ,

and

Again,

mo re
I

am

that

Dr.

leadership should be available

to

in

w i s h i ng

the VHS for several year s to come -

I have chosen to share my thoughts on linkages
pub lie

health action-

the entire gamut

By publie health action I

in
mean

of preventive promotinal curative

1

and

r ehab i1i tat ive

this

between

the

in emphasis

the major disease

primary health care system,
and

o ur

of

purpose I shall rapidly review the status

emerging

F o r-

circumstances•

as needed by local

tasks

various

the

such changes

with

communi ty,

tasks to ensure good health in

1 eve 1

p re s ent

health

of

prevent i on

programmes

personnel

and

linkages

that should assist public health action to

connected

with medical education

their adequacy-

useful

I see the more

and

be

the

leadership;

role of women, voluntary agencies and hope for community
the

and

part i c ipat i on;

linkages

to

related

health

sectors espcially water supply, hygiene and nutrition-

Let me start with the rural health infrastrueturesome

Today,

years

40

has

India

after- I n d e p e n d e n c e ,

some measure of success in setting up a

rural

the

Bh o re

on the precepts of commun i ty

health

care

with particular emphasis on preventive and

promo-

t i ve

measures,

ach i eved

infrastructure

health

Commi 11ee•

Based

the

first envisioned

by

India

rural health system in

to answer a c omprehensive need starting from the

s o ugh t

community level and working upwards towards a system
referral

spite
through

has

of

hospitals

at district and state

tremendous efforts and

the years,

numerous

1 eve 1s-

In

commi ss i ons

it would not be untrue to
2

of

c on c 1 ude

that the functioning of this system is yet to reach

the

expectations set out by that visionary Committee.

Again

the r e

four

have

decades

re so 1 ute

been

to combat major communicable

pox in particular.
borne

these

smal 1

How do we stand in regard to vector-

the prospects ahead and

are

last

di seases-

,especially those afecting

di seases

What

attempts in the

how

the

young?

are

integrated

programmes with the primary health care

system?

subs tant ial

health

F urthermore,

we

have

developed

manpowers are their roles clear and mutually supportive?

Are

their

them

training and orientation capable

of

relevant and functionally adequate to their

In

ahead?

part i cular,

mak ing

tasks

considering the large areas

of

ignorance about health issues in our population,

is the

aware of the role they have to play in

h e a 11 h

manpower

education and public informati on?
cing linkages should they

What sort of re inf or—

look for if the health system

were to seek also to realise the potential for self help
wi thin

the

c ommun i ty?

For- it is on 1 y

by

activating

such linkages that it will be possible for the nation to

shoulder the enormous burden of ensuring health (and not
merely health care) to the community-

Primary Health Care approach which supplanted the

3

earlier basic health services approach,

seeks to provide

universal comprehensive health care services relevant to
actual

the

communi ty

at

Even though ambitious,

it

and priorities of the

n e e ds

costs which people can affordremains a justifiably normative

a

c on s c i o u s

urban

medical

to field -oriented rural health care-The

creation

policy

too

shift

in

care
of

seeks to bring this about

important

theref ore

an

instrument to reach the goald of

Heal th

f or

ie

c urati ve

an d

health i n f r a s t ru c t u re

the year 2000 AD

by

by

emphasis from hospital-based

primary

All

aim-Our national h e a 11 h

health services,

p reven t i ve

and child services,

is,

to provide

i n c1u d i n g s pe c i a11y mother

within easy access to people living

in villagespurpose

we h a d

c ommun i t y-bas e d

village

Health Guide (average of

p o p u 1 a t i o n') :

ru ral

v i 11 a g e

a trained birth attendant

c en t re

e i t h e r-

d i s p e n s a r- i e s
30,000

at

mult ipurpose

with a m a 1 e a r i d f e m a 1 e

every 5,000 r u r a 1 p o p u 1 a t i o n ) :

< f or

to

or

by

c onve rs i on

each
a

wo rk e r

a primary h e a 11 h
exi sting

r ura 1

( f o r-

every

and a Community Health

Cen t re

b y e s t ab 1 i s h i n g n e w un i t s

r ura 1 p o p u 1 a t i o n )

eve ry

of

a

1000

through training indigenous practising da i s ;

sub-c entre

for

p1 anne d

p r- o v i d e

this

F or

o n e 1 a k hi p o p u 1 a t i o n b y p r o v i d i n g

add i t i ona 1

inputs to one of the exist!ng

primary health centre

or

by conversion of di strict/tehsi1/taiuk referral hospital

already functioning below the district level-

As we end the Seventh Plan,

close

to

lakh

sub-centres,

establishing

say by 1990,

the targeted net work

reach

curative,

services to groups (at bottom)

more

than 1000 families each

less

n umb e r,

farthest

heal th
not

in difficult areas

even

we envisaged that lowermost

within

1 yi ng

up

consisting of

sq.

an area of 5 to 6

vi1lages
and

the

I nsp i te

of

miles;

village may be as far as 15 kms•

woul d

reach

contiguous set of half a dozen to 10

a

1 - 40

I n o rd e r

preventive and promotional

care

cover

of

23,095 phcs and may roughtly set

half the targeted 2312 CommunityHealth Centresto

we seem

liberal C e n t ra1 f un d i n g,

the expected manpower availab-

the

one

male

Multi

has

bee n

on 1 y

by 1990 wile female workers

would

ility

at

rate of one female and

Worker

Purpose

f or

partially fulfilled;

SubCentre

each

be

more or less fully in position,

to

50%

reflect
wh i ch

male worders would not be

of

di fferent

roughly between 30%

states -

As

to some extent

be

may

in

expected

position
the

in

r e s u 11 s

the funding arrangements

under

female workers are re crui t ed and t r a i ned at

f ul 1

Central cost,

while male workers are meant to be

5

pos i -

*

t i o fi e d

and trained as part of the State’s

bugdet-

It

has been noticed often that in the priorities set within
the

States

own outlay,

social services in

par t i cular

rural health do not rank high, especially when resources
are short•

I'

J

The position then is that more ANNS would be

availab 1e than male workers as we end this plan (parado
xically

more male supervisors propotionate1y than

workers >-

mal e

The predictable result would be that the load

of work on primary health care will fall largely on
female

worker,

the

which may affect her ability to perform

intensive

mother

and child health and

c o n s e 11 i n g

work -

The plan also intended to provide

fami 1y

we 1 fare
a

kit

of simple medicines at each Sub-Centre and PHC

and

also

enab 1e some laboratory

even

testing

facilities!

though these have encountered poor management, the admin i strat ive
In

most States,

availab 1e
and

and logistic hurdles are largely sorted out-

fami 1y

a doctor (often more than one) is

now

at each PHC engaged largely on curat ive

work-

welfare work-

Withal,

some

emphas i s

health care of mother and child as as adjuct to
t i on

planning is visible at PHC level-

now some States
the PHC set

on

popu1a-

There are even

and some areas in most States

where

up is incomplete or incoherent; the availa

bility of the doctor (doctors),

6

in particular, presents

I

I-

a

problem

a myriad of reasons,

for

some to

with

do

infrastructure and others to difficult living conditions
and yet others due to poor supervision and management
wherever

availability

medicines etchas

of

f or

such

It

that

idle

capac i ty

persists,

time -

is clear though

especially in States

where

It

organs of the local community*

has

brought out by various studies that the

vi1lage

and

villages falling within a

receive

the

bulk of the attention and the

service

deteri orates

as

Community Health Centres
system

health

are not subject to any check

responsibilities

effective

adho c

personnel,

been better reflectingn undoubted demand

over

been

regularity

has improved, patient attendance at PHCs

faci1ities

care

and

we move to

also

sub centre
radi us

limited

quali ty

remote

which had replaced the earlier

of referal to PHCs have now

brought

the
block

with the provision of specialists at each CHC,

coverage

of

of

vi 1lages-

establishment of 30 bedded hospital nearer to the
and

by

hospital care at CD block

1 eve 1

will

the
be

complete early in the next plan*

A significant innovation in the PHC System was the
Village Health Guide Scheme,

which was re-launched as a

fully Centrally funded scheme from 1980- There can be no
two

opinions about the validity of the VHG approach
7

at

the same time; such a scheme will materially turn on the
selection
among

of proper persons - an experience that varies

States ■

Government

After a review of its working

deci ded

to replace the Male VHG,

in

1985,

by

women

guides, but this was found to be difficult and could not
be implemented in many States due to various stay orders
obtained by male incumbents-

As such the scheme

stands

frozen to an extent with only continuing liabilities are
met

being

while awaiting disposal of cases before

the

Court- Nearly 4 lakh Village Health Guides (largely men)
have been trained since inception to date and each guide
an

gets

honorarium of

Rs-50/- p-m-

f or

a

growingly

the

current

differences

between

shrinking role in community health work-

What
status

does

all this imply in sum to

PHC System?

of

States in performance.

There are

But, broadly speaking, in almost

all

States

and

about half of the Community Health

have

been

the physical framework of Sub

the

Centres

would

set up and be reasonably operational by

end of the Seventh Plan;
coherent

Centres/PHCs

the first stage of a

somewhat

referral system would emerge by the middle

Sth Plan,

both no mean achievement in

Through the decade of the eighties,

8

the

of

themselves -

we would have spent

a

of

total

of India’s population-

up,

setting

Clearly,

in the remaining years
for

there will certainly be not much leeway

upto 2000,

onerous

in funding must go instead to

Priority

task

into

outlay

cap i tai

addi t i onal

massive

infrastructure•
the

the

and manning rural health care to serve 75%

provisioning

any

over

crores

Rs-1600

the

of consolidating

by

framework

making it operational, responsive and cost-effectiveLet me now turn to the major natioal programmes to
control or eradicate diseases leading to large number of
pox

We have a splended success story in small

deaths•

eradication as part of a global effort at cost effective
action;

prat i cal

the

success

to

owes a good deal

helped

monitoring system capable of quick response that
containment

also

We have

effective eradication-

and

a

been reasonably successful in regard to leprosy control,
which has been a particularly good joint effort

Consider the

and about 150 voluntary agencies -

State

between

fact taht every third leprosy patient in the world is an
Indi an

and

pat i ents-

there is a child among
There

an

exists

five

every

even

chance

eradicating leprosy by 2000 AD by operating
our

estab 1i shed

rehabi1itat ion -

system

of

detection,

Indian
now

of

intensively

treatment

and

For the first time in 1987/88 new cases

9

detected

are

less

than old

balance

seems

at

last to have swung

network

is large :

thousand

urban

difficult

275

centres,

h o sp i ta 1

a

and

45

c on t i nu i n g

becoming

more

there is not enough replacement for

the

older committed leprosy worker- But,

the r e are two major

the multi drug therapy is effective

signs of hope too

in several case s o v e r a 3 year dosage and s e c o n d 1 y
are

but steadily moving towards an

slowly

Our

un its,

wards

is

the

favour•

There are o f course

: case ho 1 di ng

problems
and

in

over 700 leprosy control

training establishmentsoperat i ona1

discharged

cases

we

ant i 1 eprosy

vac c ine, as field trials are getting into later stages-

experien ce

The

with

di seases

vector-

borne

equally

h e a r-1 e n i n g •

ne i ther

especially

t ub e r c u 1 o s i s

nor

has

bee n

Ma1ar i a

The earlier ICMR estimate put 1-5%

of t h e p o p u 1 a t i o n as suffering from active T-B-;

re cent

es t imate

eve r

put s

40%

of

the

a more

p opu1 at i on

infected with t u b e r c u 1 o s i s b a c i 1 1 i even though remaining
apparent ly

healthy.

What

is c 1 ear is that every

there are two to t hre e mi11i1i on new case s;
an

average district w i t h 1-5

chances

million

year

typically in

p op u 1 a t i on ,

are that 20 thousand active cases may exist

the
of

whom 5000 cases may be infectious. The programme f or
control

of

TB is run by 371 district TB

10

Cent re s

<and

backed

by over 300 clinics),

each TB centre connecting

with the PHC for case finding and domiciliary treatment

In

complete treatment remains a

ma j or

prob 1em,

emphasi ses

the cardinal point that in case of

requiring

sustained treatment for effective

avaliability

of health personnel

is a prerequisitereverting

which

di seases
cur e,

the

n umb e r s

in sufficient

The answer- does not of c o u r- s e

in

to a vertical system but would lie in augmen

ting community based health personnel

as a supplement to

health staff at health centres•

As for- Malaria,

our- early successes were reversed

by the re-emergence of the disease due to both technolo

gical (resistant vectors)and operational
r-amme

merged into PHC) reasons -

plan

of

Our-

present

modified

action has met with a number- of constraints

absence of any new operationa1 strategy

of

(vertical prog-

spray,

ineffect iveness

inadequate funds and lack of

ac countab i1i ty

for- grass roots performance- Wi th better- and mor-e power

ful

drugs,

fatalities have come down but

incompletely

cured cases vulnerable to replace have in erasedsur-ve i 1 lance

reason

as a system has not

stabilised,

Active
a

maj er

for- which is the feeling that denial of vertical

status to the programme has made

11

i t less effective • This

J

argument

should

substance

of the Kartar- Singh Committee recommendations

in

not be given

much

credence,

favour- of the multi purpose worker at PHC

basically

sound and should not be retracted

as

the

1 eve 1

is

from -

The

vector-borne diseases programme may get a new emphasis if

the present experiements at bio environmental
Gujarat

tive.

contro 1

in

and UP succeed and are proved to be cost effec
The

time

has come to

responsibi 1 i t i es

should

local

communi ty,

at

that

degree

re cogni se

that

be fully accountable

s p ray i n g
to

the

which level alone supervision

at

of the smalls seems possible

r out i ne

but

vital preventive tasks.

I nsp i te

of the great importance attached

in

last

two plans to safe drinking water supply,

rural

and urban community continues to be at risk

the

both t h e
from

water borne diseases. Apart from disturbing instances of
gas trcenteri ti s

and even cholera in major urban centrs,

hepatitis has become a major hazard- Rainy season i 11 n e such as these are still being countered by

sses

t i onal

pub lie

health measures :

on 1 y a

ma j or

tradibreak-

through in rural water supply in rural areas at the
of

the

current

technology mission and a

effort at urban sanitation,
t i on ,

are required.

end

much

1 ar ge r

especially ex eretai

pollu-

While the former seems achievable,
12

the

latter will most certainly meet with finacial

straints,

con

in spite of various low cost sanitation e x p e -

It

r iment s -

mi ght

be

better to await action

of

the

National Urban Commission’s Report- What cannot wait too
1 ong

is prevention of death from the

ora 1

dehydrati on

during infantile diarrhoea episodes at present asssessed

at over 200,000 per yea r- A feasible method may well

lie

in

localised frontal attacks on combating infant deaths

and

attempted

in specific regional pockets

with

high

IMR-

Four conclusions that seem to emerge from detailed
review

magn i tude
these

the selected programs appear

of

scale

and

to

of the effort required

be

the

to

mount

national disease c on t ro1 p ro gramme s would

deman d

greater-

epidemiological data for selective

action

and

determinat i on

to reallocate resources in favour of

the

rural

two

PHCs ;

the entrustment of

pub lie

health

action tasks to the MPW is sound policy and, notwi thstand i ng

teething

prob1ems shou1d not be

abandoned

and

three

constant

1 ook

for

commun i ty

based resources to handle separable tasks

in

efforts should be made to

programmes so that they can be community managed
the

f o ur

integrated responsibility at PHC level would get

13

fulfilled

only with far greater and continous

t ra i n i n g

of personnel and leadership of the doctor.

now

I

turn to issues conne c ted

with

fun ct i onal

adequacy of different levels of health personnel.
some facts may be set outf or

1971

First,

The Bhore Committee set

(at an estimated population of

370

out

mi 11 i on)

18500

doctors <1

75000

Health

Visitors (somewhat like a

pub lie

health

nurs e )

and

92500 dentists and midwives

each-

By

:

6300),

75000 nurses (1

43000) 9

the

middle of the eighties with a p o p u 1 a t i o n o f close to 800
m i 11 i o n

we

al 1o p a t h s,

had a health manpower stock of
2-83

1 ak h s

ISM prac t i t i one rs ,

Homeopaths and less than 10000 dentists.

we

had

a little less than 2
Care

lakhs-

2 - 97

1 akhs

1 -23

1 ak hs

As for nurses

In

addi t ion

the

to

in

Primary

Health

position

a little over 1-00 lakh SNMs and a little over-

80000 male workers.

standards,

system had been able

put

If one were to apply any appropriate

the shortage of nurses would run into nearly

a million and the ANMs would atleat have to be doubled Consider again the bed strength in hospitals- There were
a total bed strength of 5-87 1 a k h s in Jan
one

lakh were in rural areas.

1988 of which

The skewed character

of

health personnel availability is further illustrated

by

the fact that in Soviet Russia for a population of about

14

m i 11 i o n ,

200

there are 2-8 million health workers,

of

which about 40% were doctors-

Apart from the manpower being out of balance

are

the other implications?

Firstly,

there is for the

time the beginning of female of health

first

what

p e rs onn e 1

availability in mid areas capable of responding to

mot-

h e r and c h i1d needs,

even if family planning remains the

main preoccupation-

This is a gain not to be underesti-

In

mated -

f act,

increased equally,

had

the male workers’ strength

been

the gain would be even more visible,

especially in family planning counselling to men as well

as

in disease control programme

a gross underestimation and

is

there

activities-

Se condly,

undermanning

at

1 eve Is of nurses and paramedicos,a critical prerequisite
f or

any

Third 1 y,

quality improvement in health

care

servi ces-

the available ISM/Homeopaths contribute a

si-

zeab1e

f o rm

whose optimal utilisation deserves

a 11 e n -

t i on ,

especially as they in effect contribute a

second

1ine of health care
there
doctors

often on a paying basis-

is considerably large availability of

Finally 9
allo p at hie

with a substantial number of them either

urban

based or attached to the hospitals system which is again
most urban-

15

The medical education and training structure erecsubstantial

and

many medical colleges which have striven

to

standards though there is criticism about

the

in the last four decades has been

ted

there

are

maintain

Medical

degree of rigour in practical training -

in

doctors

that

reas ons

of

the c ommuni ty-

However,

the proportion

of

p r e p o n d e rman 11y

large rural population-

with

concern

national needs or any of us) are not interested

structure -

Apart from lack of minimum living conditions

some areas,

lack of medicines,

enjoyab1e

books ,

poor review and
about

their reluctance does not help in reducing the sense
frustrat i on -

It

seems

tak en

into

also

not

s u f f i c i e n 11 y

to

better-

The

always

been

exp lore

feasible solution that might work

most

spectacular result in my view,
16

of

have

true that they

c on f i den c e

of

pract ice

A steady negative public image

gui dan ce •

s en i or

absence

they are frustrated by the

preconditions that makes professional

minimum

in

health

a more active part in the emerging rural

taking

a

There are very

reasons why doctors (endowed with as much

good

less

remains

serves PHCs and newer CHCs

15 to 20% of the total stock in a c o un t ry

than

in

f or

consideration as well as

economic

esteem

f or

both

remains expensive but fulfills a real demand

t i on

on

educa-

has been a

steady

decline

in the leadership role of the medical

doctor in

rural areas-

overri ding

The

importance

given

control activities, even if justified,

to

pop ill at i on

has led to target

and mechanical attitudes in a context that

oriented

in

fact calls for an extraordinary degree of innovation and
daring-

In fact,

a whole range of public health action

stands at risk due to the absence of a team buildup with
the doctor- in total command

in

emerged

similar to teams that have

agr i c u 11 u r e an d r ura 1

It

deve1opment-

is

indeed interesting to note that wherever health has been

in terms broader than mere treatment of

viewed

disease

and as part of a larger developmental effort the results
rewarding even in t h e

have

been

The

place to start is to restate,

p re s en t

c o n s t ra i n t s -

restore and

p romo t e

the concept of the natural

leadership role of the doctor

in

of

p ublie

health

team

sho u 1 d

no

whole

the

realm

cohere n c e

of

his

leadership responsibilities-

nat i onal

res o urc e s

consider

the

more
health

importantly,
scene -

doubt

match

his

But it would be a waste of

to look elsewhere

social

The

action-

f or

costs in making him a

his direct relevance to

1eadership

doctor
the

and

pub lie

F or it is well known that health as such

17

is

not a priority for- the majority of
p r- i o r i t y

true

for- them is

poor .

The

especially

that

the

sickness,

sickness that denies them the day’s wage -

early,

half cured may be,

even

large costs.

To get cured

he is willing to in cur-

To such a clientele, nothing but curative
would carry

inter-vent i on

al 1

credibility;

health messages can only follow;

persuasive

and none else than the

can make that curative intervention.

doctor

soon

But,

eno u g h, he has to have the sensitivity to go beyond cure
and to go into larger

to "overcome” as it were,

of hygiene,

issues

san i tat i on or

heal th

n u t r i t i o n or

indeed

self help for good health-

The linkage to education, training and orientation

of

all

1 eve 1s

of medical and

para-medical

pe rs onn e 1

stands self-evident. Sadly, schools of public health < o r
as renamed departments of community medicine

the

name

diffuse the focus if you are off-guard)

have

tends

to

be come

a declining class,

t i on s

with holistic con cerns.

re c onvey
still

the

present

student

leaving indeed few

Latter-day

attempts

to

community character of the health

system

a

medical

poor- career-

cho i ce

to

the

surely he will not be attracted by that which

is so non-c1 ini cal and also so non-remunerative ;
surprising

i n s t i t u-

either.

Ue

can restart
IS

the

not so

tradi t i on

of

ft

schools

of

up with trans-disciplinary focus

to

I

first

few

*

a few

with

prestigious

holistic

concern

pub lie

health set

wh i ch

the

year’s

understanding of perceived public

young

PHC doctor can carry his

tasks

health

and acquire ’problem solving skills- ’ How relevant would
such

ori entat i on

an

merely

(not

social

may will be clear

from

the

of

the

A- I -

diploma in public health

the

that

o ur

to

ep i demi o1ogi cal

clinical)
fact

be

and

Health

Cal cut ta

Hygiene

Institute

of

Public

carrying

such

prestige over decades is not yet

re cog-

by MCI.

Infact the critique on the ROME

Scheme

n i sed
has

is

the

as well as the content of the orientation

that

brought forth repeatedly the point that it

context

change -

requires

I

conditions

I

does even a sensitive doctor become ready to grow beyond
his d i s c i p1i n e- Re f r e s h e r course could be meaningful and
indeed mandatory for certain levels of responsibility in
pub lie

cons c i ous

i n deed a

health system;

status

restorat i on

for selected public health positions within

government

is a p r i o r i t y n e e d •

large

resource

pract i t i oner
health

i

What was understressed is the percep-

t i o n that only after some exposure to ground

the

I

of

should

personnel wit h

In

qualified

this

i nd i geno us

not be forgotten
competence -

19

context,

we

the

system
need

al 1

They should be given

t

the relevant roles in public health, wherever- they carry
credibility,

but

nor

the basic position

confuse

system

this step should neither stray
that

each

from,

recogni sed

of medicine offers curative care within its

own

ground rules.

The
be

role of other para-health personnel may

covered in the next essential

status

linkage

viz-

women’s

vis public health action.

Not

on 1 y

in

planning context but in the entire range

of

vis

a

populat i on

well

issues o n the costs and benefits in health-giving

goods

and

mute ,

servi ces,

ava i1ed

women

consistently

and children have remained
less than their

ent i 11ement

and

this distributive inequality stands sanctified by custom
and social

codes. Thus the most needy do not ever become

( or al 1 owed

to become) a community

cons c i ous

of

and

articulating their right to health—giving goods e.g.
no

"effective

universally

demand"

has

emerged

in

spite

of

noticed prevalence of anaemia in women

and

mainutr-i t i on in children . Redressa 1 of th i s s i tuat i on is

often

sought

in female 1i t erarcy,

share to assets etcestablished

access

to

income,

and the so-called "political will"

as the deus ex machina.

Such policies

may

have

their own justification but,

taking the short r un

and

realm

greater

of practi ca1

action,
20

face-to-face

!

s i gnals,

contact with female health workers may send up
of

needs effectively-

health

revo1ut i onary

To expect

changes in women’s status to improve their health shares
would only postpone any immediate succour
in greatest need are already clear :

and

with

starting

Third trimester of

ado 1es cent

girls

and

child

mother

30 months of a

critical

those

Two segments

Ue

pregnancy•

are

really

looking at the need to reach to about 200 to 250

million

women (about a third in our cities and

generate

and re convey upwards their demand

community volunteers,
and

quant i ty,

happening to VHGs,

including

must match this demamd in quality

which will

dep 1oyed•

currently

not

f Gr health

Paramedical female field personnel,

services-

towns),

call for ten times the number

F u rthe r,

unlike what has

started

the force should remain proactive and

bureaucracy -

be merely the lowest rung of the

How

can such an augmentation take place soon enough?

possible way would be to consider linking

One

proto-health functionaries at

existing
namely

the

anganwadi

woman

worker

teacher at primary

school

- together adding upto at

more women in an ANN’S jurisdiction-

of

the

Indeed,

up

grassroots
and

the

1 east

ten

the skills

a village health guide or an anganwadi worker can be

21

■

i

imparted

in

Or,

indeed

the

training

can be available through a mobile

system

for-

all

falling

women

curriculam-

school

the

within

laid

down

criteria,

thus

augmenting

the reach of health information channels

least cost.

The school, the anganwadi and the sub centre
f or

grow into a defence system

together

shou1 d

at

women

their health entitlement and getting their

art i culat ing

due shares, which will bring in immeasureably liberating
gains•

social

The decisive element is to

the

empower

woman to make her own decisions, (howsoever subrosa) and

effective

create

demands on the health system for

her

linkages to health action

a

and the child

Vo 1untary
venerab1e
the

1 oad

i n t o1e rab1e

sector

and proud history in this country
on

the

pub lie

o t h e rw i s e -

system

would

have
in

fact,

have

b e en

The range and points of concern

in the linkage with the voluntary sector are too diverse
to comment briefly s

b u t it has remained a constructive

linkage sometimes in quiet experimental action,
dispensing

services alongwith the

pub lie

often in

system,

and

more often in public interest articulation and advocacy.
May

I explore quickly two specific aspects,
flow

the

first

of

government

financial assistance to voluntary agencies :

the record

concerns

the

arrangements

f or

is

mixed

marked

by poverty of

imagination

in

aid

by

unreasomable

interpretations

of

as

schemes

inter

Nor has

autonomy -

voluntarist

and the

record

in

assistance is enveloped in

b outs

of

of

a

a signal success,

networking

been

availing

foreign

mistrust•

What

vo1untari st

emerges

clearly

is the absence

the

mediating mechanism carrying trust from both sides,
devolution

of hard headed criteria to

agenc i es

assess

and projects complemented by fending government off from
intrusive curiosity-

Neither the UGC nor social welfare

boards nor the statutory boards to support small capital
activities
Perhaps

re cords -

inspire much hope with their track

like

CAPART

areas

(in its relatively new

of

operation) an institution can be founded as a non-profit

to

totally

profess i onally

staffed

and

managed

body

assess

apprise,

f un d,

mon i tor-

and

where

necessary ,

penalise or encourage voluntarist activity in the health
sector-

A public debate on developing such a body would

be

timely and may help clarify several aspects

the

voluntari st

sector- in health has

because

acqui red

eno ugh

maturity and self confidence to play a larger role-

The second aspect concerns the issue of
parti c i p a t i o n

in

both

global and

23

voluntary

communi ty
systems -

merit in the criticism of lip

is

There

service

being

paid but bureaucracy managing to prevail : at one end it
concerns the larger issue of the quality of democracy

gap

"cultural

that

exists

between

the

the

peop 1 e

and

enlarged -

personnel providing health care ii has

Present

is not encouraging but dramatic changes cammot

evidence
be

expected either.

f or

all

But no satisfactory health

peop1e can be achieved without

if

oversee,

not managed their health
means

which

community,

the

communi ty

commun i ty

can

programmes -

individuals

to
The

thereof

has to be helped to do so

especially the weaker ones
a

the

status

their own health needs and then allowed

i dent i fying

and

if

it is necessary to see

the other end,

at

but

be empowered

only

the

when

and that is a function

individuals do get so empowered;

of practical access to knowledge and information-

The r e

of

a

re covenant ing

of

the

const i tut i ona1

arrangements

in

the near future.

Such

a

is

talk

denouenment

would be fruitful only if the local community is seen to
decide

on

priority needs and enable to oversee implementation.

No

’’own"

the

health

personnel

empowered

to

current

socio

political realities and deny equity and access to

those

doubt,

the

structures

may

reflect

who do not count in the decision making process. To them
indeed,

we

should

erect

supplementary face
2d

to

face

/i * *

%

and

prevai1•

That

provides

the

best

rati onale

f or

and

part

female health personnel full time

augmenting
wage

time,

emerge

channels of contact for their needs to

informal

emp1oyed

and community

derived,

formally

and informally skilled-

t ra i n e d

In

a

country

with vast disparities

crossing levels of deprivation,
access

to

criss-

questions of equity

about coverage and expansion.

deve1 oping

effective

1ikages

in

critical to the health system-

is

That

several

why

dimenss i one

Side by

side,

directions:

there

has to be a relentless thrust in two

push

down resources to reach the community and

them

to

the ir

own interest-

empower

the utmost extent to decide for themselves
This demands faith

too -

25

of

urgent

health care tend to get lost in more

arguments

becomes

and

and

in

optimi sm

Go

H - 1 X-

VISIT TO AGRICULTURE DEVELOPMENT AND TRAINING SOCIETY
(ADATS) ON 29th AUGUST AND 13™ SEPTEMBER 2002
XG
Agriculture Development and Training Society a non-governmental dc\elopmcni
organization works towards impro\ ing the socio, economic and health slaliiN ol the land lc-of Kolar districts.
districts, \w/
i/ Bagcpalh.
laborers in 800 villages in the following 5 taluks ot
( bikbalapur. chintamani Sidhalaghatta and Gudibanda.

i

In each of the \ illage where ADATS is working, they have started a Coolie Sangha I mt
(CSC); each CSl consists of 20 30 families. One member from each of these familicN i>
represented in the ('SC One field worker (ADATS staff) for every 30 village s functions as
a link between CSUs and ADATS. Every villageJias trained heajth_wprkei

I. PROBLEMS AND HEALH NEEDS OF THE PEOPLE ACCORDINC; TO ADA I s
STAFF.
I'here was a discussion with the project assistant and 5 field workers
needs as perceived by them are furnished below.

I'he problems and

Specific health problems
Poor environmental and food hygiene is due lack of health awareness. Gynaecological
problems of women particularly white discharge are common among women. They said
recently they had conducted a health camp through which they had screened about 250 ?oo
women with the problem of white discharge. This is identified in the local dialect as
({hclkahattciY
General Health Problems

The following problems were tgld as the other common health problems prevailing m the
villages; fever, cold, lack of awareness on nutrition and headache were told as common
problem among the people.
Problems of women
♦

Problems related to menstruation.

♦

'I'here could be women with HIV possibilities (This they said the doctors from St. Johns
Medical college who conducted the camp for the cancer of cervix told them)

♦

I'here are other gynecological problems including infertility.

♦

They said they also found out a few women with childlessness

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Problems of ( hildren

Ihey said that they conducted a health camp for children. 9 children ideniiHed with some
problem were referred to hospitals in Chickakbalapur and Bangalore. 1 hc\ said the\ also
identified 4 children with impaired vision and referred them to hospitals nearlw
I obacco & Alcohol abuse
l he\ said that use of tobacco and alcohol is common among both men and woilidl. Il w;is
reported that elderly women use tobacco to avoid thirst while working in (he held, I here is ,i
practice of gi\ ing tobacco to lactating mothers before they first begin lactation I lie) >aid
people start with chewing beetle leaves and areca nut and later switch to tobacco. It was
reported that alcohol consumption is common among both men and women I hex said more
people among the scheduled caste group consume alcohol.

2. CLSl'TER MEETING HELD AT WARVUNSHATTIHALLI
I'here was meeting held with the people in the village mentioned above to discuss then health
problems and needs. About 20 men and women came for the meeting. Representative from >
villages attended the meeting. From each village 2 male members. 2 female members and the
VHW attended the cluster meeting. Following information was provided about the health
problems and needs.
Tuberculosis

Hie people said that Tuberculosis is prevalent among both men and women but women arc
more affected.

Epilepsy
4 children were reported to be suffering from epilepsy. {Local treatment for this was reported
as giving a bunch of keys in the hands of the person suffering from epilepsy) They also said
that there are traditional healers who give some herb for treatment of epilepsy. In one village
it was reported that one child, and two adults, a man and a woman in their thirties are
suffering from fits. The child is being consulted at NIMHANS and the lady who got Ills soon
after childbirth went to a traditional healer and she is reported to be improving. They said the
person who practices mantra is taking advantage of some of the problems ol people by
promising to cure them. They shared the experience of the VHWs. Once when she was
suffering from stomach pain she went to this healer. He tied a chicken to her stomach, the
chicken died after few minutes and her pain subsided. They said though they have questions
about its reliability, they are helpless but to seek the help of such people when some problem
arises at midnight. They said they take them in the morning to a hospital. One child was
identified with water collection at his side, wheezing is also reported to be common among
the population.

Adats-assesment-fmal / support to NGOs d/chander/540

Problems of Women
The women said that white discharge is common among them and when lhey have this ihe\
arc unable lo work. They said that the treatment provided at the recent camp conducted b\
\I)A1S has helped in improving this situation. Two women said lhc\ alwavs feel tired and
lhey are not interested doing any work. One woman said whenever she cals she would ha\c
diarrhoea and vomiting. When she went to the doctor, he told her that she has no blood m her
body (nut]- be anemia}. When she went to traditional healer, he gave her some medicine
there was a relief for a short while and the problem started again, fhicc more women >aid
dial lhey also are interested in doing any work and they always feel tired.
Problems of Men
It was reported that a few men suffer from Pain while urinating, emission of blood was also
noticed and they are unable to work when this happens.
Mental Illness
They said that there were two men suffering from mental illness (mental, thikkulu} One man
suffering from this illness says that he wants three wives. People said it is a problem known
as mohini (female evil spirit); they said if such people were married they would be all righi
l hey said that the son of the VHW who is suffering from mental illness always experiences
mood swing. He experiences more particularly during full moon day.
Govt. Health Services
About Govt. Health services, they said; "The sister comes to the village once a month to give
immunization, she visits houses and asks if anybody is ill. Ifpeople said yes she would collei /
the blood and go away"

Anganwadi
There is a centre with a teacher. The center is open between 10 am and 3 pm. There arc 30
children in the centre. They said food given there is nice. They said the teacher weighs the
children. The people said anganwadi is helpful in getting the habit of going to school foi
small children. They said the purpose of giving food to children in the centre is to improve
their health status.
School
There is a middle school in which 90 children are studying. They said the school has
improved during the last 3 years. The teacher teaches well. Previously it was not good so the
children went to other schools. The people said in one village the teacher was not leaching
properly. She would come at any time she liked and go away as she wished. 'The villagers
said, “ we would gently ask the teacher to improve and he/she improves fine, if they don 7. //
necessary we would give them a slap ”.

Adats-assesmenl-final / support io NGOs d/chander/540

3. INTERVEIW WITH THE BLOCK HEALTH EDUCATOR
I he following information was elicited from the interview held with block health educator
I here arc 9 Primary Health Centres (PHC) in Sidhalaghatta taluk, under each PHC there arc 2
> sub centers. He said asthma and TB are common among half of the population who are
predominantly SCSI' with whom ADATS works. He said the position of taluk medical
officer was filled and the positions for physician and pediatrician are still vacant for main
\ears. There arc other specialists like orthopedician, gynecologist, medical officer, general
surgeon's posts arc filled and they are functioning. He said earlier n was a 3()-beddcd
hospital, later n was upgraded to 50 beds.
I he block health educator said, “People do not understand the problems of stall'. "H7/c// ih
st/i no medicine, people still demand, they don 7 understand that the government doesn 7
supply us. sometimes they even heat the staff. That is why some oj the positions arc vacant
and staff does not want to be posted here. " He said that the hospital gets only 40"(. of drug
supply. 'TTe get the paracetamol and a few other drugs, no antibiotics and the doctor has to
prescribe. People don-'t understand this; they question him. "
He said patients registered on a normal day with the outpatient unit are about 300. [’here arc
50 beds, 20 for females, 20 for male and 10 for children. There is a special room for which
the patients have to pay Rs .15.00 per day.
He said they see more people with TB and malaria recently. Every month 5 to 6 new case <4
I B is reported. 500 people were treated for leprosy during 2000- 2002 and al present there
are 43 patients under treatment. He said malaria cases are increasing and there are no malaria
workers. Of the 20 positions only six are filled, of the 3 senior health inspectors positions
only one is filled.
4. VISIT TO PRIMARY HEALTH CENTER
We visited the PHC at Bussetty halli. Doctor had gone to Bangalore. We met the ANM and
the male health assistant; they said TB and malaria cases have increased. At present there arc
1 1 TB patients under treatment and no new cases reported during the past 3 months. 4
leprosy patients are under treatment.

Problem of women
The ANM said that the white discharge problem that is common is due to poor personal
hygiene and poor nutrition intake. She said people perceive the problem is due to tubectomy.
They said they give health education on importance of hygiene during menstruation.

Problem of Children
They said diarrhoea, cough, fever and worm infestation are common among children and
about 30% children suffer from anemia. They said school children are given IT at schools.

Adats-assesment-final / support to NGOs d/chandei7540'

-4

5. DISCI SSI(» HELD AT AMMAGHARAHALLI ON 13.9. 2002.
Members of the CSU participated in the meeting; there were about 15 women and 5 men
present for the meeting. Mr.S.J.Chander and Dr.Rajan Patil facilitated the discussion fhe
health problems perceived by them are furnished below.
Health problems of women
I he women said the following problems are common among them cold, fewer, cough, while
discharge and backache. One woman said she has body pain and back ache. She said when
she lakes an injection she would feel all right for a week and the problem would start again
Kb 1 here were two women reported to be affected by goiter. Another woman said she is
1
suffering from piles, body pain and indigestion. Another woman said she is suffering from
x ItaJfcTB and she is taking treatment from Bangalore. Another woman said she feels tired and
J
body pain. She said she took an injection and the doctor told her that she had no blood:
another woman said she has backache, fatigue and white discharge. Two of the women
'
present complained of burning sensation in their stomach. Another woman said she has
' backache, feels fatigue and unable to walk. One woman was suffering from leucoderma
(w bite patches).
Problem of Children

hollowing are the problems reported to be common among children: fever, cold, cough, fits
1 Tree children are suffering from epilepsy and they are under treatment from a p\ l. doctor at
Chinthamani. One girl was reported to be suffering from diplopia. Ten children with eai
discharge and one child was suffering from umbilical hernia. They do go to both the pri\alc
doctor and government doctors. The private doctor charges 10 -1 5 rupees and gives
injection and tablets. The government doctor takes 5 rupees for each consultation.
6. ACTION INITIATED BY ADATS
Village Health Worker (VHW)

71^

Every village has a women health worker identified among the CSU members. These health
workers were trained by CSI (Church of South India) hospital at Chickabalapur. They have
undergone a 4 days training programs for 2 or 3 times. They are taught about treatment of
minor ailments, like fever, cough, cold and body ache. It was reported that they spend more
lime in empowering women and address non-health related issues.
Treatment of minor ailment

of medicines (the staff said
200 rupees worth
-'vMonthly each of the VHW are given 100 - 2w
wuiu. ui
providing medicines for common ailment help them as a strategy' in promoting CSC
7s
membership and participation.)

Ambulance Service
ADATS provides their Jeep for CSU members particularly during any emergencies to take
the person to a hospital either at Chickbalapur or Bangalore.

Adats-assesment-final i support to NGOs d/chander/540

\ la hila meeting
Mahila meeting is held once a week in every village for the women of ('SI II was rcporiol
that socio, economic and political issues are discussed in the meeting. 1'hcic is a mahila fund
created by CSU members and ADATS contributes Rs 30,000 for the entire taluk. Il i> a
revob ing credit fund. Very poor and destitute women are provided with loans up to I 200(1 io
14000 rupees to start income generation activities. 25 to 50”o of the amount is given .i>
subside.
I he VHW present said she attends Mahila meeting. She said she conducts deli\cries and
gives medicines for fever, cold, headache, injuries, stomachache and diarrhea. She also lakc^
the sick people to hospitals whom she is unable to manage.

Recommendations
I.

It was observed that most of the health problems prevailing are preventable. People
needing curative care could avail the services of the existing public health deli\cr\
system. It was observed, the health care facilities/are fairly equipped to handle the
prevailing health problems.

2.

It was also observed that the people are empowered enough to demand health as their
right. If there are gaps with the public health care delivery system it needs to be bridged
with the support of the local NGO.

1

Anemia and white discharge were frequently reported. A prevalencestudy may be helpful
in understanding the magnitude of the problem. There may be a need to address
specifically these problems. Community Health Cell and ADATS could agree upon a
feasible programme/strategy for addressing these problems after discussion.

4. The present strategy adopted by ADATS by introducing village health worker is found to
be more effective by many projects in the country. It was observed the roles currently
played by the VHWs are limited to treatment of a few minor ailments and credit
management only. Knowledge and skills of the existing Village Health Workers (VHW)
needs to be enhanced through regular training programmes for a year or so to address the
health problems and needs of the community effectively. Community Health Cell would
be interested in taking up the task.
5. The Proposed training programme would enable the VHWs to identity any other health
problems of concern to people and to seek support for equipping themselves to address
these problems/ needs effectively.

Report prepared by

S.J. Chander
7,,’ November 2002

Adats-assesment-llnal / support to NGOs d/chander/540

VA - I X _

Report on training programme at St . Joseph s Health Center Doddaballapur
Date ; 7th September 2002
As a part of regular training programme to the community health volunteers of the
center session on few major community health issues was conducted in month of
September . Topic for September session was on " Communicable Diseases" .
Objective of this training programme was to introduce few common communicable
diseases to the volunteers. Three major topics identified were, Malaria, Tuberculosis and
HIV/AIDS.
Malaria : under this topic major points covered were- causes(parasite called
plasmodium), Carrier-Vector) Female anopheles mosquito) signs and symptoms(Chills,
Fever and Sweating-in this order only) test done- Blood smearfthick and thin)
prevention) controlling water logging, chemical spraying esp. just before monsoon, using
bed nets, mosquito repellent methods etc.) treatment) 10 Choloroquin tablets only for 3
days and its given free at PHC or any other Government Hospitals) and management of
these diseases at community level. Apart from discussing these information few
common question regarding malaria were clarified and few of the misconceptions were
rectified. Some common misconceptions were - mosquito jn the gutter & unclean water
spreads malaria, malaria is a water borne disease etc.
Tuberculosis: Under this topic also major points covered were as above in the case of
Malaria Causes
( bacteria called Micro bacterium tubercle) carrierf air) signs and symptoms) fever for
more than 14 days , cough more than 14 days, loss of appetite, loss of weight , blood in
the sputum), test done- (sputum, and x-ray prevention- maintenance of cleanliness in
and around the house, BCG vaccination, proper nutrition , and follow healthy and
hygienic practices) , treatment) long term , but it is free in government hospital, but
they were told that apart from taking medicine patients should also take very nutritious
food)
and how to manage these diseases at the community level was also told to them. Apart
from discussing these few major misconceptions were also clarifies. Few misconceptions
were- TB spreads if healthy person stamp on the sputum of the patient etc.
HIV/AIDS: Under this topic also major points covered include causesfhuman immune
virus), carrier
( person's body fluid like semen, blood, vaginal discharge) ways of spreading - sexual
contact, blood transfusion, mother to child, and through usage of pricking instrument)
,signs and symptoms - fever more than for a month, diarrhea for more than a month
Joss of body weight to the extent of 10% of body weight, test done- blood, vaginal
discharge and semen analysis, prevention- abstinencefif not yet married) being faithful
to partnerfif married) , get blood checked if anyone is taking blood from unknown
source etc. treatment- as of now there is no drug for the cure of the disease therefore
prevention is the only option to keep away from this dreaded disease. Apart from these
discussions few major misconceptions were also clarified, few major misconceptions
were - AIDS can spread though saliva and urine of the infected person, can it spread
though usage of same plate, sharing the food with infected person etc.
In the post lunch session participated saw the cassette on these three problems and
was summoned back to discuss about the issues highlighted in the cassette. This
procedure helped in addressing the various important questions they had and there
fore could clarify the queries they had and endorsed the views expressed by the
trainers.

H
$
Report on visit to Hakki Pikki Colony and Iruliga camp
Date: 16th September 2002
Visit to Hakki Pikki and Iruliga colony was made with Vimochana team on the basis of
their request. Team consisted of 3 members from Vimochana (Ms. Madhu, Mr.
Amararesh, and Mr. Shivamurthy) , a member from FRLHT (Ms. Shree) and Mr. Prahlad
from CHC. This colony is located 7 kms beyond Bannerughatta National Park on
kaggalipura main road. This is approximately 30 kms away from Bangalore city. Hakki
Pikki is the tribe originally from Gujarat and Iruliga from Karnataka. They have
rehabilitated in this area in 1962 during Jawaharlal Nehru government. Even now
administratively this area comes under Tribal Development Board, but geographically
belonging to Anekal taluk, Bannerughatta panchayat.

Objectives of the visit ’"is:
• To get first hand information on health and social conditions prevailing in the camp.
• To understand local health practice, services available to the residents of the
colony.
This camp consists of approximately 120 households with more than 800 persons.
Female outnumber male numerically (is this because male members usually migrate in
search of jobs). These hundred and twenty households are almost equally divided
among Hakki Pikki and Iruliga tribes.

Basic facilities:
Water: One hand pump and bore well is serving the population for their need of water.
Bore well is connected to Mini Water Tank through which they have to collect water.
Drainage and toilets: Though open gutters have been constructed, they have not been
maintained properly leading to stagnation of water and cesspools could be seen all over
the living area. This is very unhygienic and can also lead to mosquito breeding
School: primary school up to 5th standard is available in the camp itself. For further
studies they have to go to Bannerughatta or Kaggalipura. Right now 30 children from
different age groups go this school, while two are pursuing higher studies in
Bannerughatta. There is no gender discrimination in sending children to school.

Anganawadi/Balawadi: there is balawadi run by panchayat. 30 children avail the
services of Balawadi here. However for; last few months they do not have any teacher.
Only helper is managing the center by giving the supplementary food.
Social situation: Iruliga (literally meaning - night beings) tribe feels they are socially
superior to Hakki Pikki tribe. Iruliga are the priest community, therefore they enjoy
better status in tribal community. Hakki Pikki is lower in the tribal hierarchy. Socially
women are more vocal in the both tribes. They still have the practice of groom's family
giving money to girl s family during the marriage (Rs. 5,500- Rs. 6,000 is given or it
may any amount fixed by priest depending on the economic condition of groom's family.
Four deities are worshipped among these two tribes. Two deities are said to be superior
clan to which Iruliga belong while two other deities are said to be inferior-tribe to which
Hakki Pikki belongs. But what was very sad was concept of caste; superior-inferior is
slowly but, steadily creeping into their lives. Women enjoy equal status with men.
Occupation and Economic Condition: Both the tribes living are given 3 acres of land
per household by Govt of Karnataka. But the area around is rocky therefore land

available for cultivation for each of the family is very less. Iruligas follow cultivation and
grow Ragi, vegetables and depending on the rains they grow little paddy also. Hakki
Pikki tribes mostly go for agriculture and construction labour. Hakki Pikkis live very
easygoing type of life. They would sometimes even carryout begging for their livelihood.
But staff from Vimochana said that they never carry out flesh trade for the sake of
livelihood in spite of their difficult living conditions. They have peculiar way of
protecting themselves. (Women when they come out from their camp, maintain
themselves very shabbily so that they wont attract men around.). Economic condition is
very pathetic for both the tribes, as they both do not have sustained livelihood.

Health problems: Major health problem in the area is Water borne diseases such as
(Vomiting, Diarrhea, jaundice is common among general population. Apart from these
they even complain mostly of joint pains, Chest pain, Body ache (they complain of pains
and orthopedic problems only from last 3-4 year. This is period during which
community has started using hand pump water) while women complain mostly about
missed periods, white discharge, and other gynecological problems. Respiratory
problems and Diarrhea is the most common among the children. Alcohol and Tobacco
abuse is rampant in the area. There is no gender difference in this, as both men and
women were found extreme alcoholics.
Health facilities / practices: As this is located in center of Kaggalipura and
Bannerughatta they usually approach both the areas for medical help. While
Bannerughatta (7 kms from camp) has a Primary Health Center, FOSA (Friends of Sick
Association) Humanitarian hospital - initiated and managed by Kempfort and two
private clinicians, Kaggalipura - (8 kms from camp) has a Primary Health Center, and
few private clinicians. Apart from these, Mr. Sakayya from community is traditional
healer. He is more known as massage expert and bonesetter. There are no traditional
birth attendants.

General Observations:
1. Sanitation awareness among the community is very low.
2. Community started complaining of orthopedic problems, since they started
drinking water from hand pump.
3. Caste discrimination has started creeping in their lives.
4. Community is willing to have their own kitchen gardens.
5. Many youngsters were found wasting their time just hanging around in the area.
Suggestions:
1. As awareness is low among the community approach should be to create
awareness. Though community looking forward for medical support, through the
awareness and training programmes their problems could be reduced. (CHC
could help in this process)
2. Community Volunteers could be identified from the community (preferably group
of women) and they can be trained as a health volunteers. Training programme
could be planned on above-mentioned problems. This needs to be continued for
at least six months. This will reduce their problems of approaching various
hospitals and reduce the danger of getting exploited. (CHC with support of few
other groups SJMC etc could help in this process)
3. As the community is eager to have kitchen gardens, it should be initiated first to
increase the involvement of community.
4. For treatment purposes, Government Hospitals and Medical college hospitals
could be involved. KIMS, St. John’s and M.S.Ramaiah Medical Colleges and
institutions like Indira Gandhi Institute of Child Health etc could be approached

5.

6.

7.

8.

9.

for this purpose. (CHC could help in introducing Vimochana to these institutionsif necessary)
As many youngsters were found to have free time due to unemployment and
underemployment - they could be trained in community based and relevant job
oriented programmes. For this purpose SKIP house could be involved- CHC
could help to create the linkage between Vimochana and SKIP.
As the water source is suspected to have chemical contamination, water sample
could be taken to State water laboratory, Public Health instute, Sheshadri road
and tested. Vimochana could write to Dr. Kamat, State laboratory directly or can
ask Bannerughatta PHC Medical Officer to write. This helps in involving the local
governance in the Vimochana’s intervention in the camp area.
Discussions could be held with Tribal Welfare Board and Department of Women
and Child development regarding improving the Balawadi. Number of Under 5
children will indicate whether there is a need for additional balawadi. Steps to
appoint the teacher are also needed. If identified, Karnataka State Council for
Child Welfare, nandidurga Road, can train a person from the community itself.
It is important for the community leaders along with Vimochana and CHC
(Through Mr. Prahlad) to meet the doctors and staff of the two PHCs and discuss
public health progrfasmmers and referral systems. If it falls under the PHC zone
then ANM should visit this area.
A community exercise will need to be done to assess age, gender profile,
immunization status of children, Mother and Child health care, any public
health problems like TB, Malaria, STDs etc in addition to whatever expressed by
community.

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Susan Rifkin is a lecturer in International Affairs at the University
of Sussex and is affiliated to the Science Policy Research Unit at
the University. Raphael Kaplinsky is a Research Officer at the
Institute of Development Studies in Sussex shd was formerly b
Research Fellow at the Science Policy Research Unit. The authors
gratefully acknowledge the assistance and advice given by Oscar Gish,
j 2r“;ans» Dr Robert Worth, Dr Maurice King, Dr Tom Robinson
and the Developing Countries Group of the Science Policy Research

Q *
O ^-

S

w

: 2 :

C~ 14

In fcjction I of this paper we present art analytical paradigm by which to
evaluate health and medical care services in under developed countries.
In Section II, we apply this framework to an analysis of the health policies of
one developing country, China. In Section HI, we evaluate the Chinese health
and medical care policies within the framework of a'.cost:-benefit analysis
and argue that these policies are appropriate to China's factor proportions
andheaith needs. Finally, in Section IV, we raise a number of questions
to be considered .'in any more detiiiledvstudies dri the transferrin? of the
Chinese services to other developing countries.
•

I

analysis

: of delivery

of health

services

Only recently have developmental economists begun to consider health ser
vices as an important area of overall development strategy. Despite Myrdal'u
emphasis (Myrdal, 1968, pp. 1533-1619), the literature on the relationship of
health policy to economic development is still sparse, and few develops nt
plans explicitly recognise the need for integrating the health system into the
strategies for development. Some professional health administrators and
doctors continue to argue the need for integrated health and economic
policies (Bryant, 1969; King, 1966; Worth and Shah, 1969; Gish, 1971), but
mZii1rflT<-leeded th4e Cal1* nP18 Study’ by focussirig on Chinese health and
medical care services, will emphasis the need for Such integration.
Figure I presents our basic paradigm of the-relationship of health and
medical care services in the socio-political-economic system. Three
factors affect the provision. :of these services to the consumers The
major factor is the structure of Effective Demand , which reflects the
ability of the powerful groups in society td'a'ftgct the allocation of resources
to produce certain types of goods and services to meet their nteeds. The
second factor is the nature of these services, that is the Health Programme,
5ih2S con?posed of a mix of Preventive and curative techniques7 T?e —
iS the techni(lue °f distributing the goods and services of the
w
iS the ^e£y Sy?£JP ’ this is determined by
the capital, labour mix m three spheres - construction techniques tn
S
tyPe and level 01 traininS of manpower (medical auxiliaries
the manpower and equipment used in providing traditional
-nd
i^?ern medical services. The Health ProgramnA and the
D^liv^ Sj^ten^ together comprise what wenia^allecF the ^althJSystem.

The primary factors conditioning the nature of the Health System are the
structure of effective demand (which is conditionedTotfi"6y tfielevel of
per capita income and by the interplay of socio-political forces) and the
endowment of factors of production. The highly curative and capital
intensive Heakh_System which exist at present in the developed countries
generaily_were predated by more preventive, labour intensive systems.
As their GNPs grew (with a consequent increase in the capital: labour ratio)
and as preventive infrastructure^ were developed, new resources were
channelled into more curative programmes distributed by more capital
intensive Delivery Systems.

: 3 :

C -14

Underdeveloped countries with low levels of per capita income generally
do not possess these well-developed preventive infrastructures, and labour
is plentiful relative to capital. It is to be expected (given that there is a
limit to investment in the Health_System_ and assuming that health and
medical care services are to be widerpread) that their Health Systems
would stress prevention rather than cure and would useTalxjiif rattier ~
than capital-intensive techniques. However, this is not the case.

FIGURE I
PARADIGM OF HEALTH AND MEDICAL CARE SERVICES
Health System

De livery-SyStem
Preventive Curative

Labour Capital
intensive- intensive—

elite

urban
population

rural population

In Figure II we use the paradigm to elucidate what we believe to be the

• • •

C -14

It represents the situation in countries where the distribution of goods and
services favours the relatively rich and relatively skilled.urban minority
at the expense of the relatively poor and unskilled rural majority? Their
have stressed cure rather than prevention, and the
Delivery Systems-fiiave been of such a type that construction techniques
have been capital-intensive and highly skilled doctors have been trained
rather than medical auxiliaries. In addition, "Western" medicine (dis
pensed by doctors in private practice-rather than public serviced) has been
stressed to the exclusion of traditional medicine.
FIGURE H

HEALTH AND MEDICAL CARE SERVICES IN A TYPICAL
~ UN5FRT)EVF7L5W_Cb'0NTRY-----------------------------Health System.

Health Programmes

Delivery System
,------------ - ----------------

Preventive

Labour
intensh

I

i
4

----------- i

e litre

rural popular

1

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: 5:

The reasons why these countr es developed these largely inappropriate
HealtlL^^ST^PlP1®8 an^ Deli ver y_Systems_ are varied and complex.-As
has been previously mentioned, the system has partially been a con
sequence of the structure of effective demand and its related factors.
Where policies have been made and implemented, these decisions have
been a result of both the nexus of decision-making commonly-referred
to as the "demonstration-effect" and the historical ties of ex-colonies
to the mother country. In addition, the elites, because of their high
incomes and general good health, have had a lesser demand for the
basic preventive services than the low income masses.

a* *

The Chinese Heakh Systejn (see Figure HI) on the other hand differs
from the paracTigm ThTTgure II. This is largely related to a socio
political structure which affects the allocation of resources to provide
a more preventive programme to a larger-part of the population with
a more labour intensive (and less import-intensive), Delivery System^
This market structure, combined with a high level of political"consciousness of (appropriately trained) manpower, has led to the develop
ment of a unique Heakh System. Thus publicly supported medical pro
grammes have beenTargely preventive, public works construction
techniques have been labour intensive, medical auxiliaries have partly
been substituted for highly skilled doctors, and use has been made of
traditional medicine as a complement to "Western" medicine.

FIGURE III
PARADIGM OF HEALTH ANL MEDICAL CARE SERVICES IN THE
T’Et^E^lTEPUBLKTOF'cniWA
Health System
Health Programmes

Delivery System

rative

a pit al

P

elite
Qn

luiation

sive

i

C -14

: 6 :

n
DELIVERY OF HEALTH SERVICES IN CHINA
In this section we argue that the Chinese health and medical services are
not only a reflection of a restructuring of the pattern of effective demand
but also of the development strategy. Before describing the Chinese health
services, it is necessary further to define and qualify the nature of our
case study. It must be noted that we are confined in our analysis by the
necessity to limit our evaluation to ex post reports by the Chinese and to
data provided by the occasional visitor. We base our study on what the
Chinese have stated as their goals and the It mited information available
on how these objectives have been pursued. We believe ewgh tfate and
analytical statistical information is available to present a broad descrip
tion of the development of health and medical services and to indicate
certain areas of policy decisions which have aided in the creation of the
Chinese Health_System.
For background information we present in this paragraph a synopsis of
the growth of health and medical services in China. In the first three
years after the founding of the People's Republic in n49, the Health
Systen^ in support of policies of economic reconstruction, focused"bn
the re-establishment of basic health organizations, the creation of health
teams (which depended upon auxiliary workers) and on the development
of mass mobilization for both disease eradication and political ends.
During the following period of the First Five Year Plan (n53-57), pro
grammes emphasised benefits for the urban, industrial workers, which
r!f1nCCIed the devel°Pment strategy of rapid industrialization. Policies
of 1956 and the subsequent period of the Great Leap (1958) stressed a
return to "taking agriculture as the base" and the rapid development
of extensive rural health services, through the establishment of rural
health centres and the incorporation of traditional practitioners, the
transfer of urban personnel to the countryside and the training of parttime auxiliary workers. The withdrawal of Soviet aid in 1960 marked
the beginning of the strategy of "self-reliance" which stressed agricul
ture and decentralization and culminated in rhe period known as the
Cultural Revolution. In the areas of health services, this era was marked
by an assault on health problems in the rural areas manifested in
increased transfer of urban medical teams to the countryside, the
emergence of the "barefoot doctors" and the widespread formation of
cooperative medical systems for the countryside. The present-day
medical system continues to stress rural medical programmes but
with heavy reliance on the People's Liberation Army (PLA) for the
direction of these services.
Effective Demand
With the rise to power of the Chinese Communists on the Mainland, the
patterns of resources allocations were radically altered (Donnithome,
l^o7). -As the revolution was based on the support of the small and
middle-peasants, one small way of maintaining this support was to
alter the distribution of welfare benefits so that the majority of people,
35% of whom lived in the country side, had an opportunity to share in
the fruits of production. To spread the limited resources in the health

c-i4
:7:

The growth and distribution of health and medical care services in China
have followed the various stages pi economic development (Sakka, JPRS
4485). The period from 1950-52 was one of economic rehabilitation which
was reflected in the health sphere by the concern of the leadership in
nealth end medical care and in the
providing the basic organisation
rapid eradication of epidemic diseases. The government established theMinistry of Public Health in 1949, strengthened the already existing hosp-_
itals and research centres and also took measures to utilize trained medi
cal personnel. Private practice v/as strongly discouraged and medical
schools expanded to train more personnel for public service (Cheng, C.Y
1965, pp 50-52).

To disperse medical care from its heavily concentrated urban bais and to.
get the Health S_ystem to China's rural population (Sze, W^), other mea
sures were taTcen? ~v7bst important was the establishment of health teams.
The early work of the teams focused-on anti-epidemic activities which
included staffing and multiplying anti-epidemic stations, establishing
maternal and child care services, training locals to carry out preventive
work, including health education and vaccination inoculations, and esta
blishing health services in the isolated rural districts (Wei-Sheng
Hsuan-Chuan Kung Tsu, JPRS 96).
The period of the First Five Year Plan, 1753-57, emphasised the develop
ment of heavy industry rather than agriculture and accordingly health
policies focused on programmes to benefit urban workers (NCNA 1954).
Preventive Programmes continued to hold an important place in health
plans as did the training of new personnel, but little concern focused on
rural health organizations. Then sy 1956, economic planners realized the
necessity of placing more emphasis on agiicuhure and the development of
the rural areas and began to formulate plans which have marked the direct
ion of both economic development ana health care services until the
present time.
By 1958, the communes^ had emerged as the cornerstone for the implementat-ion of the economic infrastructure of the Great Leap Forward. The decentral
isation which permeated organizations throughout the country resulted in
the field of health work in the formation of the rural health centre or hsien
hospital 7 (see Figure IV), which became responsible for all health act
ivities of the commune and adjacent areas which were unable to support
their own centre. Their major tasks included responsibility for outpatient
and regional health work; the direction of mass campaigns; the investi
gation and control of contagious diseases; the inspection of public mess
halls, nurseries, kindergartens and maternity hospitals; the delivery of
medical care; and the responsibility for all preventive work (Jen Min Pao
Chien (People's Health) December 1959). By 1965 all of China’s 2000
counties had at lease one health centre or hospital (CMJ, June 1965).

The economic decentralization which began in 1965 and accelerated in the
Great Leap period met with obstacles in 1959. Due to, among other things,
a much too rapid attempt to develop the institutional structure to carry out
these policies, a series of natural disasters in the years 1959-61 and the
withdrawal of Societ technical assistance and technicians in I960, the years immediately following the Great Leap were ones of economic re
trenchment and consolidation. "Self-reliance" began to emerge as a major

c -14

: 8 :

(1969-65) has been characterized as that of dominance by the technocrats
and bureaucrats and development of urban areas rather than the countryside.
In the field of health and medical care, it is an era described as one in
which the drive for excellence in medical research and training diverted scarce
resources from the establishment of health services for the masses^.

Although.the policies of this period await clarification, it appears that the
leadership continued to advance agriculture as the basis of economic growth
and took steps to protect the health of the rural agrarian manpower. Faci
lities were greatly expanded but at a reduced rate. 9 Training of medical
auxiliaries and diffusion of skilled medical doctors to rural areas remained
policy goals. Medical colleges were established in many of the provinces
and students were taught to combine scientific research with production
objectives (Kuang Min Jih Pao (Enlightenment Daily) May 21, 1965, JPRS 30758).
In the months immediately prior to the onset of the Cultural Revolution in
1966, concern for rural health services reached a new high. In 1965 Mao
issued his famous "June 26” directive stating "In health work put stress on
the rural areas (Chen, J., 1970). In response to this appeal, the number of
urban personnel travelling to the countryside rapidly increased. In the five
months following issuance of this command, over 1, 600 additional mobile
medical teams comprising 20, 000 urban medical professionals were-sent
to the rural areas. Led by prominent figures such as Dr Huang Chia-ssu,
President of the Chinese Academy of Medicine, these teams were organised
on a large scale involving large numbers of health and medical people on all
levels (CMJ, March 1966).

The transfer of-personnel through mobile medical teams has become a
permanent long-range goal, and one-third of all urban doctors have been
transferred to the rural areas since 1965.

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:9:

FIGURE IV
SYSTEM OF BASIC-LEVEL HEALTH ORGANISATIONS AT THE YUNG-LO

’

People 's Commune *
^Central hospital
*

Central maternity f
hospital
|

Production brigade]

♦

^Branch hospital |

nputpatient I

! {depart me nt f
^Production team -----

a,

-------------______

r-

ealth office

*
4

~~ ~

1

Public health
worker

.

Medical
station

t
------ !

Branch maternity ;
-hospital______

3

EZZZ

Family maternity
hospital

1
t
i
:__ J'

Midwives |
j

Source: Jen Min Pao Chien (People's Health) Vol. 1, No.6. 1959 .

The Cultural Revolution and its aftermath has seen a more explicit
development of the policy of "self-reliance". In the health field these
policies concentrate on the expansion and diffusion in the rural areas
of the mobile medical .teams. Another development has been the
growth of a cooperative medical system at the commune level. Although
such a plan had first appeared in 1958, because of the chaos and centSMiaetf trends which followed the Great Leap, it was not until this
era that it made a widespread appearance. Basically, the system calls
for both the production brigade and individual commune members to
contribute a fixed amount per annum. In return, the patient pays only
a minimal amount of money for treatment and medicines he receives.
While all these measures expanded rural health medical services, the
confusion of the Cultural Revolution made the firm establishment of the newly
By 1968 k w38 aPP^rert that the professional
medical people could not carry out their tasks as members of the
mobile medical teams and undergo political "rectification" simultaneously
In order to prevent a breakdown of the Health System the political leader-*
ship turned to the one group that had remained relatively cohesive
during this intense period of struggle - the army. By June of 1969, the
People s Liberation Army (PLA) had sent more than 4,900 medical
teams and 30, 000 men. into the countryside (NCNA, June 25, 1969)
LU m mn 3! 3“ P!riOd e”?‘"8 July 1’70 they h3<l sent 6- 700 teams
with 80, 000 members for rural health work (NCNA, July 31 1970)

C -u

: 10:

Healt h programmes:
When the First National Health Congress met in 1959 one of the principles to
emerge from the conference was that of creating services to meet the need of
the people. To translate this dictum into practice the Chinese placed priorities
on preventive activities. As a first measure, four basic health units were
’St
reconstituted (Li, T.C. 1950): 1) the epidemic prevention station had responsibi
lity for the reporting of and iaoculations against all communicable diseases.
Under the control of local authorities, they carried out public health work and
dealt with sanitation problems in their region - this provided the basis for the
early health structure. 2) Affiliated clinics were established in areas where no
other health unit existed to carry out preventive programmes. 3) The Red
Cross and Red Crescent societies which had been present in China since 1904
naw had responsibility for sanitation work through the use of environmental
inspection teams and for health education. 4) Spare time clinics were esta
blished in factories, mines, etc, to be responsible for disease detection and
inoculation.
To support the work of these units and further to promote health education
and sanitation work (the cornerstone for any preventive activities), the
Chinese relied on the mass campaign. Mass campaigns for health purposes
were called "Patriotic Health Campaigns and were first initiated in P52 to
urge the people to improve village water sanitation and to eradicate the four
pests (rats, flies, mosquitoes and bedbugs) which were the carriers of infect
ions whose widespread presence was allegedly due to the use of germ warfare
by the Americans in the Korean War 1°. Poorly organized, these initial
campaigns were soon reconstituted as "Shock Attacks", which proved
effective for an intensive effort for a short period of time, reached their zenith ’
in the Great Leap period of 1957-58 at a time when agriculture became
increasingly important in the economic development of China.
Thereafter, campaigns were institution alized as seasonal affairs aimed at the
eradication of all major communicable diseases as well as the four pests. These
campaigns had a low resource cost because they were focused on diseases whose
control could be effected by changing the ways of village life, rather than by the
provision of services of skilled people and because they were a vehicle for
health education and for the dissemination of health propaganda in both urban and
rural areas. In addition campaigns mobilized people for constructing rural
public works projects. This had two functions: it aided agricultural output
through, for example, controlling the supply of water; and it was instrumental
in preventive activities, as for example in the eradication of schistosomiasis
by destroying the disease-carrying snail.
Over the last twenty -two years, the Chinese have consistently stressed the
need to place prevention first. Although there is no consistent time series
data on monetary allocationii to preventive activities and it is, in any case,
difficult to distinguish strictly between programmes for prevention or cure,
one indication that this policy has been implemented is the rapid decline in
incidence and mortality rate of some of the most contagious diseases. For
instance, tubercultsis in the pre-1949 period infected 3-b- percent of China's
urban population. In 1956 the rate had dropped to less than 1 percent (Sakkaf
JPRS, 4435), In the marshy Yunnan province, the incidence rate of malaria
was 71 percent in 1950; in 1953 it had dropped to less than 3 per cent (CMJ
December, 1953). Other figures for the reduction of communicable diseases

c -14

11
TABLE I

Disease (per 1000)

Mortality rate

Mortality rate

IW

Measles

86.0

16.5

Dysentery

38.0

4.7

Scarlet Fever

78.0

16.8

Infant mortality —

117

34

Overall mortality

17

11,4

Source: Measles, Dysentry and Scarlet Fever from T’ung Chi Yen Chiu
(Statistical Research), May 1953, cited in Union Research
Service, vol 11; no 25; p. 369
Infant Mortality, from Journal of Medical Education, July, 1953,
p. 521; overall mortality from: Salaff,' J'.'W., "Mortality decline
in Mainland China and the United States", to be published in
Davis, .K., ed. Lssays in Comparative Demography.
Delivery Systems:

Having placed priorities on a Preventive Programme, the Chinese sought a
Delivery System to support this Pregramme . The'key to this System was
the utilization of manpower. .At its inception, the Chinese Health 'System
rejected the traditional orientation of a capital-consuming one to one
doctor-patient' relationship which stressed large investments in training
facilities and hospital-based services. Instead plans focus.ed on pro
viding medical and health care for the greatest number of people at the
least resource cost; through: 1. labour intensive construction techniques
in public health through the use of campaigns; 2. the training and use of
medical auxiliaries; and 3. the incorporation of traditional medical
practitioners into the Health System.
We have already described the mass campaigns in the section on
Preventive Programmes. It need only be explicitly stated here that one of
the values of mass campaigns is the mobilization of manpower for labour
intensive construction at low opportunity cost. In activities for health
education and disease eradication as well as support for agriculture through
irrigation projects linked with health, mass campaigns provided the man
power to carry out widespread health projects.
Auxiliary workers appeared in health work shortly after the founding of the
People s Republic. Organized into health teams, these workers, under
the direction of the mere 13, 000 - 20, 000 Western trained medical
doctors in China in 1950 (Li, T.C., 1950 p. 9), carried out a number of
health and medical measures and released the precious time and skills
of the professional physician. The auxiliary workers were divided into
four groups: 1. the specialist, educated for two years in one field of

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: 12 :

who in a one-day to three-month training period learned how to give
vaccinations and to recognise anc report endemic diseases. Auxiliaries
were taught both curative and preventive techniques, a policy which
continues today.
In the growth of the Chinese health service, a policy of massive recruit
ment of medical auxiliaries has occurred on two occasions. During the
Great Leap, the leadership launched a drive to disperse welfere services
to the countryside and created a new type of auxiliary who was educated
in the training centres that proliferated during this period. Studying
medicine in part-time or spare-time schools, these workers were trained
to carry out rudimentary treatment, and preventive and sanitation workl2.
This type of training was designed to enable the employment o£ these people 1
in health work during slack seasons and provided means of on-the-spot
treatment. It was also to create a corps of concerned local people who had
a stake in the good health of their community.
At the beginning of the Cultural Revolution, with a renewed emphasis on
rural health, the "barefoot doctor"13 appeared. These auxiliaries, like
their Great Leap predecessors, are local people trained (in both Western
and Traditional methods) during agricultural slack seasons to serve the
community in which they live. Depending on a system of referral to more
highly trained personnel, on the periodic visits from the physicians of the
mobile medical teams, on preventive medical techniques and on the high
morale of and acceptance by the people whom they treat, these medical
workers augment the ranks of available medical manpower. Their duties
include, in addition to treatment for minor ailments, the responsibility for
the organization of health progra imes. patriotic health campaigns and
general sanitation work in their locale*4, The work of the "barefoot
doctor" is not only supported by the traditional medical assistants,
nurses, midwives, labc atory technicians, and the like, but also by
thousands of public health workers who participate in the implementation
the Preventive Programme . In late P69, the family health worker,
a member of eachyebrnmune household equipped with first aid techniques
to treat minor problems and to aid actively in sanitation work and health
^campaigns, first appeared (Hung Chi (Red Flag) 1970).

Another major policy for manpower mobilization focused on the incor
poration of the Traditional doctors into the health services. These
5, 00, 000 practitioners of Chinese iredicine (Jen Min Shou T'se
People’s Handbook’; 1951) formed a resource pool which the Chinese
leadership decided to tap. As early as 1954, the Chinese Academy ofTraditional Medicine was established and in the 1956-58 period a con
centrated effort was begun to introduce both traditional doctors and medical
theory into the university classroom 15, A search for a synthesis between
these two_systems ensued and students were encouraged to study both
systems - this has been re-emphasised since the Cultural Revolution.
In addition. We stem-trained doctors were urged to study Chinese
medicine, in special courses devised for this purpose. By 1958, there
were reportedly over 13 colleges and several hundred secocdary schools
of traditional medicine, which were training 79,009 apprentices
(Peking Review, 1958). Under this new official attitude traditional
doctors in increasing numbers joined the national and municipal public
health services. They were assigned to hospitals end clinics of various

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: 13 :

increased presence provided an alternative type of treatment to ''Western"
medicine - where, as the Chinese indicate, "the traditional methods are
preferred because they are simple and effective and appropriate to the
constitution and habits of the Chinese people" (CMJ , February, 1959).
The traditional doctors staffed rural health centres, trained auxiliaries and carried out health team work. By 1956, 30,000 traditional practitio
ners had been incorporated into government public health organs (Ten Min
'
Jih Pao (People's Daily) 1957).
---------In summary, the change of effective demand and the creation of policies to
meet this demand through preventive, labour-intensive, rural-based health
and medical services, relying on medical auxiliaries and mass mobilizat
ion techniques, are the chief characteristics of the Chinese health system.

ni
EVALUATION_qF THE CHINESE HEALTH SYSTEM
As we have seen, the health and medical care services developed by the
Chinese are particularly interesting for two reasons. Firstly, they are
a function of a radically altered distribution of social and political-econo
mic power (if the demand structure had not been altered, health tech
nologies could have been readily imported from the other developed
countries), and secondly, their health policies were closely allied to
their general development strategy.
In this section we will evaluage their health and medical care services in
terms of the familiar cost-benefit framework. Before we embark on this,
however, it is necessary to be aware of two problems which are common to
cost-benefit studies in general. Firstly, it is difficult to identify all the
costs and benefits of health services, and secondly, even if all these elements
could be identified, it is difficult to impute their value.
Cost-benefit analysts frequently ignore the problem of distribution and argue
that it is mainly a normative problem concerning consumer welfare andthat it has little effect on production. However, we believe that the dis
tribution of health services affects not only the distribution of welfare,
but also the production of goods and services over time. With regard to wel
fare (that is, the consumption element in health expenditure), the Chinese
health and medical care service improves conditions for the many instead
of (and sometimes at the expense of) the few - that is although it may now be
more difficult to receive attention for care-intensive illness (e.g. brain
tumours), the majority of the population receives greater protection from
chronic diseases such as schistosomiasis and malar iaJS
With regard to production (that is, the investment element in health
expenditure), the Chinese rural-oriented services act to increase output in
the agricultural sector. Since one of the major bottlenecks to economic
development has been especially in the early 1960's, the availability
of a marketed agricultural surplus 17 this is where increased production

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: 14 :

The increased output resulting from a healthier labour force can be related

S

“ ^4ted

(a) The productivity of capital and land will increase due to lower absenlatoSm’f greaW eff0rt ’ loriger working days and better morale of the
(b) New lands can be opened up, partly as a result of the elimination of
diseases in particular areas (e.g. malarial and schistosomiasis land in
China) and, where the mantland ratio is low, partly as a result of the
increased efficiency of the labour force (Cheng, T.H., 1971).
-

,

•

■

■

•

-J

(c) Increased health has a complementary effect with other inputs such as
education and training, making investment in education and training that
much more productive by enabling a more efficient absorption of training.
(d) There are externalities in preventive health activities. For example
the digging of ditches in the elimination of schistosomiasis (to bury the

°dUCeS tl’e eXter"i" eC0"°n’y °f added lrrisal:ed
ll,8ed as a Prol»S»n<la weapon to Increase the
ale J1*3 effort of.^he working population - particularly in the Chinese
case, where the rapid increase of health services provides a concrete
example of the interest of the leadership in the welfare of the people.
■ ffiAf;!i?1.adyantage is the establishment of an auxiliary corps from the
local population, creating a body of locals who are loth to leave their
JOgether With the low P*7 differeritials between town and country
!he brban-ruralJ ^ration which is characteristic
oi most other underdeveloped countries.

The choice of an alternative health and medical service is not only a consi?i2 ie w116^8 " theSe ^Hefit8 must be related to the costs which
are entailed. We believe that the-Chinese Health System has a lower
thaLa
caPital-intensive, curative urban-based system.
This is for a number of reasons:
y
mlvlhnTi”106!?
is worth a P°und of cure" is a statement not
nly about welfare but also about total costs. A system which prevents
mtuitively (and is_, if it is not absurdly costly) preferable
to that which has repeatedly to treat a chronic ailment^O. Preventive health
™TXnhiVOOd
°f thiS maxim is weH"illustrated in the case of

in tte

tha’’ ,he rePeaKd CUr,nS °'the dlSeaSe

pe/illn^'^-pe^T^ol^!"8 e"™6
,
Health Centre ,
District Hospital

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Shillings
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With regard to capital costs, a Health Centre is estimated to cost
E 10, 000, whereas the construction of a minimum size district hospital
(with 60-100 beds) costs between E 250, 000 and E 500,000 (King, P66).
An additional advantage of this system is that the relatively small sum
of capital required to establish a Health Centre is well within the reach
of small, poor communities. A hospital, on the other hand, is not,
because it requires large and lumpy sums of capital and thus necessitats finance from hard-pressed central development funds (Gish, 1971).
(c) The Chinese Delivery System is more labour-intensive than any
existing alternative curative system 22, in China the opportunity cost of
this labour is low, mass mobilization techniques have been used, and the
period used for training and for public works construction has been pre
dominantly in the agricultural off-season (Orleans, 1969, p. 33)
(d) The import cost of the Chinese Health System has been much lower than
that of a capital-intensive curative system. Partly it is because of the
closed nature of the economy (which has been a result of both relatively
autarchic development policy and the size of the market) and partly because
of the labour-intensive nature of preventive services. It has also been
related to the frequent use of local herbs and medicines as a substitute
for "Western" treatment 23,
(e) With regard tp manpower a preventive rural-based Health System
of the sort used by the Chinese requires a lower level of skills than that
demanded by the established curative system 24. This is important
because for a given health expenditure, more manpower can be trained.
An additional advantage of this policy of intermediate level manpower
is that the wastage resulting from this system has been lower than that
which would arise from a curative one. Firstly, in an open economic
system where labour is mobile, emigration from underdeveloped to . developed countries and regions is likely to be lower, as the health ser
vice is comprised basically of medical auxiliaries who will not be ableto prectise as doctors in the developed countries. Secondly, an under
staffed curative system is likely to waste the scarce skills of its highly
trained manpower due to "excess demand” 25.
(f)Another cost advantage in the manpower sphere arises from the use of
traditional medical practitioners. While it is unclear what the precise
value of traditional cures (e.g. acupuncture) is, there is no doubt that
some are relatively effective and relatively uncostly. 26 In addition, a
large element of medical help is of the emotional-support type and the
relatively long time spent with patients by traditional doctors, together
with the confidence with which they are viewed by the population, make thenx
an important, effective and relatively cheap supplement to modem practices .
(g) It has been argued that there are additional costs which are invobved
in the Chinese Health System . Specifically, these are that:
(i)

the Chinese Health System requires a high degree of political
commitment and makes arbitrary demands for the re. location
of the urban doctors to the rural areas, running the risk of

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(ii) the stress on rural health has removed the highly skilled doctor from
his urban research facilities to the primitive rural health centre where
his talents are wasted.
(iii) the sacrifice of high medical standards in urban areas due to the
reformed education system and the transfer of urban personnel to
rural areas have failed to raise rural medical standards.

(iv) the incorporation of traditional medicine and practitioners and the
growth of the medical auxiliary corps have been at the cost of quality.
(v) the elimination of the division of labour between agriculture aryl
health work has led to a decline in productivity in both sectors'12 .
It is our general feeling that the lack of hard information makes m^ingful
comment difficult. However, it is our impression (which we believe is
substantiated by much of the developmental literature on China) that these
criticisms, although net devoid of validity, are not of an order of signi
ficance which negates the positive aspects of Chinese health and medical
care policies. Perhaps future studies in China (which have access to de
tailed information) will show the opposite - if so, we shall stand
corrected.
IV
PROBLEMS IN TRANSFERRING THE CHINESE HEALTH SYSTEM TO OTHER
T® VE LOSING WObrTRTES
We have argued in this paper that, as a result both of the changed structure
of effective demt nd and a health policy which was integrated into the general
development strategy, the Chinese produced a unique Health System which
was well-suited to its fector endowment and supply bottlenecks. This
Health System contrasts error.gly wVb'f'e more inapprop. ate" system^ wHich
exist in1 most other wVrmeve’opcd -s’:-:'./
.

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.....

..

As these underdeveloped countries face similar supply bottlenecks and
have similar factor endowments, it would seem a priori that elements-of
the Chinese Health System could usefully be transferred to these coun
tries. However, there are a number of reasons which suggest that this
transfer might not be as easy or appropriate as it seems. Detailed
consideration of these problems is not possible at this stage, due to our
relative ignorance of the Chinese Health System and because much of
the basic theoretical and empirical wcrE in the transfer of technology
field is yet to be done. However, at a more general level these consi
derations are:
(a)Development does not occur in a vacuum. It acts in favour of some groups in society and at the-expense of others. The predominantly urban-based, curative and capital - intensive systems which exist in many under
developed countries largely act to consolidate and reflect the power of the
ruling classes. The room to manoeuvre with regard to the implementation
of a radically new Health System which reflects and consolidates the power
of different groups in society is therefore limited. We hesitate to take an

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and in few countries is the leadership in a position to make
these demands upon the population - a fact which mlist inevitably have a
lar^ bearing on the transferability of the Chinese Health System to
other underdeveloped countries.
---------- ------

Jnitour'scarce economy nor for a labour-surplus economy where the

mrttelpttion
tor ,,K ft*11countries
of the
not aUow
labour force (i.e. the positiond?es
today).
in most
underdeveloped
(d) The fact that China is not an open economy obviously affects the
structure and functioning of the Health System. Not only does it affect
and ^ernaI mlgratfon of health personnel, and the costs and
Kh services inveStment fh heakh’ but also the structure of demand for
(e) Related to the closed nature of the Chinese economy is the problem of
with the attendant problems
of lumpy cost and external economies* is partly a function of the size of
*^«/I^er’;fOre thf alternaHves °Pen to a country with 800 million
SlO'^ y mu thf S^ne aS those open to * COUntry with 5 million
Snip
Iteople (er even 50 million). The problem for future research therefore
lies in lliumlnating the precise effect of this scale problem on the Hea»
□ysrem.
-*■ i— i
(f) Historical factors also inevitably affect the composition of the health
serves* A long history of relatively "scientific" traditional medicine
has made the integration of old and new much easier in China than in most
other underdeveloped countries. Cultural factors also have a significant
tiff Pessibilities of transfer - for instance, mass mobilization
has been effective partly due to its roots in the clan system of social
organisation in the dynastic period of China (Levy, 1949; Yang, 1945).
Conclusion:
Our study suggests a mode of analysis for evaluating health and medical
and factor endowments, by analysing Chinese health and medical care
services tn these terms, and evaluating them within a cost-benefit frame
work. Although it would a priori appear that the Chinese Health System
could profitably be transferred to underdeveloped countries, we have-----suggested a number of factors which must be considered in this transfer.
1lG Wkhin the comPass of existing political structures,
the most important is the argument for integrating these policies into the
deveJ°Pment Plans. Specific aspects of the Chinese policies mi^ht
then be considered, e.g. great stress on prevention, the use of health °
teams and auxiliaries, the decentralization of services. However, a more

9

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Notes:
1.

By this we mean the relative labour intensity of techniques of (physical)
construction used in the digging of sanitation ditches, the building of
hospitals, etc.

2.

It is necessary to note that while curative health services need not nece
ssarily be urban-oriented, this is almost invariably the case. For example,
in India 30 percent of the doctors practise in urban areas where only 20
percent of the population reside (Lipton, M. 1963). While "in Kenya in
1963, the population;doctor ratio was 10,000 for the country as a whole,
672 for the capital city of Nairobi and 20,000 for the country outside of
Nairobi. But 93 percent of the population lives tn truly rural areas where
the ratio was 50, 000" (Bryant, J.H., 1969b).

3.

For more details concerning the consequences of this pattern, see
Takulia, 1967, Gish, 1971.

4.

The reasons why this political structure has provided a Health Programme
a greater proportion of the population than in other underdeveloped
countries are open to dispute and are not the subject of this paper.

5.

These-policies were promulgated at the First National Health Congress
(Li Te-chuan, 1950).

6.

The average size of a commune in 1959 was 24, 000 households.

7.

In China, the difference between these two institutions is mainly in size
and not in function.

■ .1

This period has been discussed in the Red Guard literature and has been
a subject for ongoing research. For a description of the politics of health
at this period see Current Scene, May 1, 1963; June 15, 1969; and
Dec. 15, 1969.
——
9.

601Q00«

10.

For a report of the International Commission which investigated these
charges, see CMJ , September^December, 1952. Robert Worth points
but that "these Patri^’c Health Gaimpaigns' represent a masterful
utilization of war psychology to effect basic cultural changes with
regard to environmental sanitation. The specific charges of ’germ warfare*
tevelled' against the Amei-icans were focused ’ very skilfully on certain
diseases most likely to spread through water supplies (cholera), to be
carried by flies from exposed faeces (cholera) or to be carried by rats
(plague -"(Personal correspondence, 20 Sept 1971).

11.

One estimate of expenditure on-health and welfare activities is as follows:
(billion yuan in current prices - 1 yuan = 4/-)

1952

0.06

1,775 rUri210O000y health centreS; in 1957 there w61'6

1953

unro

1954

TTO

1955

TTn

1956

07TT

1957

TO

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12. For a description of all levels of medical education and an indication of
the relative numbers of people involved, see Leo Orleans, 1969.
13. An estimated total number of barefoot doctors to date is 750,000. This
figure has been supplied by Leo Orleans in personal correspondence, 15
September, 1971.
14. For details of training of these auxiliaries see Horn, 1960. Horn is a
British surgeon who spent fifteen years in the Chinese medical service.
15. Traditional medicine includes the practices of acupuncture (treatment by
inserting long silver needles into the body at specified points); moxibustion (treatment by applying a heated container with the moxi herb
inside to the body); and herbal remedies based on medicines from indi
genous Chinese plants. A complete history of this subject has been
written by Huard and Ming Wong, 1968. For a discussion of the politics
of integrating the western and traditional medical systems, see Crozier.
16.For instance the imperative rural service for urban doctors not only give#
increased health care to. rural residents, but also exposes city doctors t»
disease problems in the countryside in order to focus future research onthese issues.. For a detailed account of the change in Chinese health ser.
vices due to a transfer of urban medical personnel to the rural areas,
see Horn, P69.
17.lt is increasingly recognised that a major element in low agricultural
productivity can be attributed to the prevalence of debilitating diseases
in the rural population. Of course improved health will only increase
agricultural production, if the rural population is actually employed
(Oyens, D., "Investment in Human Capiaal", in Streeten and Lipton,
op.cit p. 240). However, for a dissenting minority viewpoint see the
results of the Universities of Nottingham and Zambia Agricultural Labour
" Productivity Investigation, Some Determinants of Agricultural Labour
—
LU? Zambia, Report Ro.“3”.
~
18. That the Chinese have recognised this feet can be seen from repots in
Hunan Hsin Pao (Hunan News) 1975 in SCMP 1639, p. 32. It is also
valuable to note in this context the study of Richman, Industrial Society
ln Communist China 1969 p. 554, which compares Chinese labour pro
ductivity with that of India.

19. The concept of ’Investment in human capttal" stems from this point
(Myrdal, G. 1968, Chapter 29).
20. Thus Ovens (op. cit, p. 237) argues ..." The cost per person prevented
from contracting any disease is likely to be much less than the cost per
person cured of that disease after he has caught it".
21. However, malaria control is also a good example of the need to look at
secondary costs and benefits, for it is increasingly argued (although
wrongly, we believe) that the environmental costs of using DDT in

V

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22Although it is possible to develop a more labour-intensive curative tech
nology than that which exists, it would have to be done ab initio,-and the
nature of the process of cure will always make it a more skill - and
capital-intensive activity than that of prevention. However, health
expenditure in general is neither capital-nor import-intensive. In India
for example, less than 40 per cent of health costs are capital costs and
•
the foreign exchange content is less than 7 percent, whereas in the
Fourth Five Year Plan the coefficient was 36 percent, v. Overtb, op. -cit
p., 93. This extimate of import cost is prdbably too low though, as "it only
takes into account the import cost of rural consumption.
23Faced by severe balance of payments constraints, this aspect of the Chinese
system is of obvious interest to many developing countries. For a dis
cuss ton^Df the difficulties entailed in the adoption of this process, see
24J\ U.N. report thus argues "With today’fe drugs, an intelligent villager,
trained to recognise the two or three ailments most commonly found in
a given area, may be able to do more to save lives and end sickness than
t ,tqe best doctor in the world could have done 25 yfears ago". See Science’
.and Technology for Development, U.N. New York D63 (Wtlenski,~'D7i).
25. Jn one Indian Health Centre, for example, highly trained doctors spent
between 1 and 3 minutes with a third of their patients, and between 39
and 60 seconds with another third (ibid, p. 61)
26. The Chinese support for this statement might have been seen in such
articles as the on by Li, T.Y. 1969. However, recent visitors have also
been impressed by their experiences with traditional practitioners, and, the
plying of this trade. Notably, one such person was James Reston of the New
New York Times, who discussed his appendectomy operation with the use
' . 7:
of acupuncture needles in a Times article of 27 August, 1971.
27. For an excellent discussion of the role of the traditional doctor as a link
in the transfer of a modern science to rural areas, see Worth, 1962.
28. These criticisms have been documented in the work of Allen, 1965.
29.i.e. 'the walking on two legs policy" existing in China, which means
the simultaneous utilization of traditional techniques and modern capital
and skill-intensive methods.
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