SOCIAL AND CULTURAL FOUNDATIONS OF THE HEALTH SERVICES SYSTEMS OF INDIA

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Title
SOCIAL AND CULTURAL FOUNDATIONS OF
THE HEALTH SERVICES SYSTEMS OF INDIA
extracted text
SOCIAL AND CULTURAL FOUNDATIONS OF
THE HEALTH SERVICES SYSTEMS OF INDIA

D. BANERJ1

CENTRE OF SOCIAL MEDICINE AND COMMUNITY HEALTH

JAWAHARLAL

NEHRU

UNIVERSITY

NEW DELHI-57.

CHAPTER

I

HEALTH PRACTICES BEFORE THE BRITISH RULE

Every community has a health culture of its own—its own cul­
tural meaning of its health problems, its health practices and its corps
of practitioners. As a component of its overall culture, the health
culture of a community is shaped by the interplay of a number
of social, political, cultural and economic forces
The history of the
health services system in India provides an account of the influence of
such forces in giving shape to it. Henry Seigerist 2 has drawn attention
to this important aspect by contrasting the manifestly high stan­
dards of environmental sanitation of the Indus Valley period with the
level of sanitation that exists in India today.

Describing the five thousand year old planned city of Mohenjo
Daro, Marshall 3 has remarked that the public health facilities of the
city was superior to all other communities of the ancient Orient.
Almost all households had bathrooms, latrines, often water closets and
carefully built wells. The elaborate nature of the Indus Valley public
health organisation provides an indication of the extent of health
consciousness among the ancient Indian people. It is difficult to con­
jecture the nature of the health problems of those days, but the great
emphasis on the preventive aspects of disease indicates a fairly mature
attitude of the society towards the health problems that might have
been prevailing at that time.

The Vedic medicine that developed after the advent of the Aryans
to the Indus Valley (? during the second millennium B.C.) had begun
to show a tendency to develop rational methods of approaching health
problems at quite an early stage ”■ 162. Even in the Vedic Samhitas, purely religious books, are found reflection of anatomical, physio­
logical and pathological views which are neither magical nor religious
and there are references to treatments which are impressively rational.
Furthermore, there exists the famous decree of Emperor Ashok
Maurya (279-236 B.C.) in his second Rock Edict (257-236 B. C.)
“celebrating the organisation of social medicine shaped by the Emperor
along with the lines of Budhist thought and kindred ethics {dharma)"
i, »■ ss The works of the famous Charaka of the first century A. D.
1

and of Susruta of the fourth century A. D. laid the foundation of the
highly developed science of medicine which flourished in the tenth century
after Christ—a period of all round social and economic progress often
called the age of Indian Renaissance. There are also epigraphical evi­
dences indicating that social medicine was practised in medieval South
India 41 v' 87.
During the subsequent centuries, a series of political, social,
and economic changes profoundly disrupted the ecological balance in
Indian society. Perhaps the lowest point of this ecological crisis was
reached during the decline of the Moughal Empire, a situation which
set the stage for the British conquest of India. Even during this period
the system of Indian medicine had retained some fragments of
its past heritage ; for example, the surgeons of the British
East India Company learnt the art of rhinoplasty from Indian expo­
nents of surgery 5. It is noteworthy that during the early period of
British rule in India, the western system of medicine, which was still
dominated by such procedures as purging, leeching, scarification and
blood letting, could not be considered to be any superior to the pre­
vailing methods of the Indian systems of medicine.

2

CHAPTER II

HEALTH PRACTICES DURING THE BRITISH RULE

The social, cultural, economic and political changes that followed
the introduction of the British rule in India dealt an almost a fatal
blow to the practice of the Indian systems of medicine. With the impo­
sition of the British rule, almost every facet of Indian life, including
medical and public health services, was subordinated to the commer­
cial, political and administrative interests of the Imperial Government
in London. In developing health services for certain limited purposes
(for example, for the army), the patronage was shifted from
the Indian systems of medicine to
the western
system.
The decision to make this shift appears to be amply vindicated by the
spectacular advances in the different branches of western medicine during
the nineteenth and twentieth centuries. As a result of these changes
the already stagnant Indian systems of medicine got caught in a
whirlpool of a vicious circle : its very neglect accelerated its further
decline and the decline, in turn, made it increasingly difficult for it to
compete with the highly favoured and rapidly flourishing western system
in capturing the imagination of the educated population of India. In
the long run, therefore, not only did the professions of the Indian
systems of medicine get infilterated by various kinds of quacks, but the
very basis of the sciences got considerably eroded by forces of super­
stition and of beliefs in supernatural powers and dieties

The British had introduced western medicine in India in the latter
half of the eighteenth century principally to serve their colonial aims and
objectives. Medical services were needed to support the British army
and British civilian personnel living in India. Later on, medical
services were made available to a very tiny selected segment of the
native population. At the time of Independence, only the affluent
and the ruling classes could get adequate medical services. Of the rest,
constituting more than 90 per cent of the population, only a small
fraction could get some form of medical care from hospitals and dispensa­
ries run by government agencies, missionaries, philanthropic institutions
and private practitioners ’•
35-“. Similarly, public health services
consisted of some form of environmental sanitation in a few big cities. For
the rest some public health services were provided only when there was an
3

outbreak of massive epidemics of diseases as plague, cholera, and small­
pox
”• ■*’. Because of these conditions, in spite of the availability
of knowledge from the western system of medicine, there was wide­
spread prevalence of such easily preventable diseases as malaria, tuber­
culosis, leprosy, smallpox, cholera, gastro-intestinal infections and
infestations, trachoma and filariasis ; India was among the countries of
the world with the highest infant and maternal morbidity and morta­
lity and gross death rates. In addition, there was the enormous prob­
lem of undernutrition and malnutrition. India was among the lowest
per capita calorie consuming countries in the world 7, pp' B8-14«.
At the time of Independence, British India (population 300 million)
had 17,654 medical graduates, 29,870 licenciates, 7,000 nurses, 750
health visitors, 5,000 midwives, 75 pharmacists and about 1,000
dentists ’• ”■ 13 ■”‘,i 3S.
The colonial character of the health services had also profoundly
influenced almost all aspects of medical education in India—in shaping
the institutions, in developing the course content and, perhaps
most important of all, in shaping the value system and the social out­
look of the Indian physicians. The first medical college in India was
established way back in 1835. It was quite natural that British teachers
should have nurtured such institutions in their infancy. However, along
with the “scientific core” of medical sciences (which was a most wel­
come diffusion of a cultural innovation from the western world), there
came certain political, social and cultural overcoatings which were
definitely against the wider interests of the country ’.

Also, opportunities for medical education in these institutions
were made available to the very privileged upper class of the society.
Additionally, the Medical Council of India accepted the British
norms of medical education in order to gain recognition of the
Indian medical degrees from the British Medical Council. This enabled
some of the physicians, who were “the select among the select”, to go
to Great Britain to get higher medical education. Acquiring Fellow­
ships or Memberships of the various Royal Colleges was generally
considered to be the pinnacle of achievement in their respective fields.
These four considerations —colonial value system of the British
rulers, class orientation of Indian physicians, their enculturation in
British modelled Indian medical colleges and a more thorough and more
extensive indoctrination of future key leaders of the Indian medical
professions in the Royal Colleges—provided a very congenial setting
for the creation of what Lord Macaulay had visualised as “Brown
4

Englishmen” 8. These Brown Englishmen acquired dominant leader­
ship positions in all the facets of the health services in India. This
arrangement proved convenient to both the parties. To the Indian
physicians it ensured power, prestige, status and money at home. Their
montors from foreign countries retained considerable influence on
the entire health service system of the country by ensuring that the top
leadership of the medical profession in India remained heavily dependent
on them.

5

CHAPTER HI

EVOLUTION OF THE EXISTING HEALTH SERVICES SYSTEMS
OF INDIA :

A Profile of the Policy Formulators and Health Administrators :

After Independence, the health services system of the country
was shaped by the two key political decisions of the new leadership.
Following the political commitments made during the struggle for In­
dependence, provision of health services to the vast masses of the
people—particulary for those living in rural areas—was made an
important plank of the Directive Principles for the State Policy of the
Indian Constitution 9. The other political commitment, which
turned out to be an even more sacred and of over-riding importance,
was to bring about the desired changes in the health services system
without making any basic changes in the then existing machinery of
the government.
The personnel of the Indian Medical Service of the British days
and the “Brown Englishmen” were called upon by the Indian leader­
ship to provide the initiative in shaping the proposed new health services
system for India. These personnel, who, like those of the Indian
Civil Service, belonged to elite class of administrators. They
were former officers of the British Indian Armed Forces who had opted
for civilian work. They were also trained in the traditions of the
western countries. Political independence brought to the fore two
additional issues which profoundly affected the cadre of the Indian
Medical Service. Firstly, the withdrawal by the British officers after
Independence caused a sudden vacuum in their ranks. This came as a
windfall to a number of not so competent officers, who were catapulated into positions of key importance simply because they happened
to become senior in the cadre because of the very large number of va­
cancies caused by the departure of the British. Secondly, by adher­
ing strictly to the seniority rules, when the health services were expand­
ed very rapidly to meet the requirements of the newly formulated
health programmes, the administration drew more and more from the
6

relatively small group of people who had entered the services in, say,
1930-35, 1935-40 or 1940-45 to meet the very rapidly increasing
manpower needs for key posts. As a result, a large number of the key
posts in the health services got filled by persons, who, even from the
colonial standards, were not considered to be bright.

Such a massive domination of the organisation by men who
were trained in the colonial traditions and whose claim to a number of
vital posts in development administration was based merely on their
being senior in the cadre, led to a virtual glorification of mediocrity, with
all its consequences 10- rp' 55-57. What was even worse, such a
setting was inimical to the growth and development of the younger
generation of workers. Often these young men had to pay heavy penelties if they happened to show, on their own, enterprise, initiative and
imagination in their work. Conformism often earned good rewards.
This ensured perpetuation of mediocrity within the organisation.
Because of their being inadequate for the job, these Brown
Englishmen went out of the way to appeal to foreign experts for help
and the latter have generously responded to such entreaties. A large
number of foreign experts were invited to play a dominant role in
almost every facet of the health services system of the country ".
Medical Colleges, Teaching Hospitals and other Medical Care Facilities
In Urban Areas

Two divergent forces in the country—availability of relatively
very much larger amounts of resources for the health sector and
perpetutation by the technocrats, the bureaucrats and the political
leadership of the old privileged class, western value system of the
colonial days gave shape to a health service system which had a strong
urban and curative bias and which favoured the rich and the
privileged.
It is significant that when the country had only about 18,000
graduate physicians and about 30,000 licenciate physicians
’• 35,
one of the first major decisions of the popular government of India in
the field of health was to abolish the three year post matriculation
licenciate course in medicine1'-’1”313. While recognising “the great
lack of doctors”, the very large majority of the members of the Health
Survey and Development Committe (Bhore Committee), probably
7

“strongly influenced by the recommendations of the Goodenough Com­
mittee in the United Kingdom’’ 131 ”• 31°. asserted that resources
may be concentrated “on the production of only one and that the most
highly trained doctor” 13 pp- 33’-3J9_
The Committee had made
elaborate recommendations concerning the training of what it termed
as the “basic doctor” and stressed that such training should include
“as an inseparable component, education in community and preventive
aspects of medicine” 131 pp' 333-33’.
The Medical Council of India, a direct descendent of the Medical
Council of Great Britain, which is the statutory guardian of stand­
ards of medical education in India, has issued repeated warnings
against reviving the licentiate course. The Health Survey and Planning
Committee of 1961 (Mudaliar Committee; *- has also emphatically
rejected the idea of reviving such a short-term course because they were
“convinced that the proper development ol the country in the field of
health must be on the lines ol what we consider as the minimum
qualification lor a basic doctor” (p. 34b). it went on to state : “India
is no longer isolated and is participating in all problems of international
health. The WHO has laid down certain minimum standards of
qualifications, in view of India being an active member, participating
in all public health measures on an international basis, we think it will
be unfortunate if at this stage once more the revival of a short term
medical course is to be accepted” (p. 349).

One of the saddest ironies of the medical education system in
India is that resources of the community are utilised to train doctors
who are not suitable for providing services in rural areas where the
vast majority of the people live and where the need is so desparate.
By identifying itself with the highly expensive and urban and curative
oriented system of medicine of the west, the Indian system actively
encourages the doctors to look down on the facilities that are available
within the country, particularly in the rural areas, and they look for
jobs abroad and thus cause the so-called brain drain. As if that is not
enough, till recently these foreign trained doctors have been pressuris­
ing the community to spend even much more resources to attract
some of these people back to the country by offering them high salaried
prestigious positions and making available to them very expensive
super sophisticated medical gadgets. These foreign trained Indian
specialists, in turn, actively promote the creation of new doctors who
8

also aspire to “go to the States” to earn large sums of money and to
specialise. Emphasis on specialisation, incidentally, causes considerable
distortion of the country’s health priorities thus causing further polari­
sation between the haves and the havenots.
Those who are unable to go abroad, they try to settle down in
private practice in urban areas, often linking their practice with
honorary or fullfledged jobs in urban health institutions run by the
government. Only some government jobs are non-practicing. As a
result of such considerations, a desparately poor country like India
finds itself in a paradoxical position in relation to the distrbution of the
doctors in the country : the urban population, which forms 20 per cent
of the total, accounts for 80 per cent of the doctors.
To be sure, pretending to follow the recommendations of the
Bhore Committee, soon after Independence upgraded departments of
preventive and social medicine were created in medical colleges, at the
instance of the government and of the Medical Council of India, to
act as spear-heads to bring about social orientation of medical educa­
tion in India. However, as in the case of so many other ambitious and
morally lofty government programmes, concurrently it was also ensured
that the very spirit of this programme is stifled, if not totally destroyed,
by actively discouraging in various ways its actual implementation.
For instance, instead of mobilising the finest brains in the profession to
bring about social orientation, most of the positions in the departments
of preventive and social medicine were filled by the discards, who were
often found intellectually inadequate to get into the highly competetive and prestigious clinical disciplines, or even the paraclinical disci­
plines. This gave enough opportunities to the threatened foreign trained
super specialists to ridicule the entire discipline of preventive and
social medicine and bring it down almost to the bottom of the prestige
heirarchy of disciplines in a medical college 15. Significantly, the
political leadership—the ministers and legislators, who are beholden
to these super specialists for their personel needs of various kinds,
winked at this systematic desecration of the philosphy of social orienta­
tion of medical education in the country 10.

Along with the very rapid proliferation of very expensive teaching
hospitals for medical colleges, each having a number of specialities and
super specialities, a number of general hospitals were established in
urban areas. The number of hospital beds shot upfront 113,000 in
9

1946 12t ’2.
to the present figure of 330.000 "■ p' ”. There has
also been a rapid increase in the number of dispensaries for providing
curtive services to urban populations. There were over 1807 urban
dispensaries in 1966 17, p' 12°. The development of medical colleges,
teaching hospitals and other hospitals and medical care facilities has
accounted for a large chunk of the investment for health services in
the country’s Five Year Plans 12' 7S- M> r' ls. Ther recurring cost
for these institutions accounts for over three fourths of the annual
health budget of a State 181 p 3.
Mass Campaigns against some major Health Hazards :

The fact that despite their obvious over-riding importance,
preventive services have received a much lower priority in the develop­
ment of the health service system of India provides an insight into the
value system of the colonels of the Indian Medical Service, the British
trained bureaucrats of the Indian Civil Service and, above all, the
value system of the political leadership of free India. The colonels did
not appear to relish the prospects of dirtying their hands—getting
involved in problems which required mobilisation of vast masses of
people living in rural areas. The rural population raised in the minds
of these decision makers the spectre of difficult accessibility, dust and
dirt and superstitious, ignornt. ill-manered and illiterate people. There­
fore, when they were impelled to do some preventive work in rural
areas, characteristically, they chose to launch military style campaigns
against some specific health problems.

Undoubtedly, because of the enormous devastation caused by
malaria till the early fifties, this disease deserved a very high priority.
But the programme became a special favourite of the colonels not only
because it required relatively much less community mobilisation, but
it also provided them with an opportunity to build up an administrative
frame work to launch an all out assault on the disease in a military
style—in developing preparatory attack, consolidation and maintenance
phases, in having “unity of command”, and surprise checks and insp­
ections and in having authority to “hire and fire”. Significantly, some
of the followers of the colonels went so far as to compare the malaria
campaign with a military campaign ”. Another enthusiast for military
methods has written an entire book 20 with a preface from the late
Prime Minister Jawaharlal Nehru describing the saga of the growth
of the health services in independent India as if he is describing a
military campaign.
10

Experience of implcmenation of India’s National Tuberculosis
Programme brings sharply into focus the limitations of this military
approach to developing a health service system for the people of this
country. On the basis of a series of operational research studies 2l, it
was demonstrated that it is possible to offer facilities for diagnosis and
treatment to over a million and a half of sputum positive cases who are
known to be actively seeking help for their illness from over 12,000 to
15,000 health institutions in various parts of the country. But
because of failure of the programme administrators to develop a sound
health delivery system on a permanent basis for the rural populations
of the country, more than a decade after the launching of the programme,
less than one fifth of these sputum positive cases, who have an active
felt need, are being dealt with by the programme organisation21.
This provides an example as to how the militaristic urban privileged
class value system has come in the way of building a health service
system to meet even some of the very urgently felt needs of the people
of the country.
After some pilot projects, a National Malaria Control Programme
was launched with the help of the United States Technical Co-operation
Mission, the World Health Organisation and the United Nations Interna­
tiona! Children’s Emergency Fund (UNICEF) in 1953 to cover all the
malarious areas of the country, then involving a population of 165 million
20. p. in it ac[jievecj a phenoininal success; for instance, the number of
malaria cases for every 100 persons visiting hospitals or dispensaries dec­
lined from 10.2 percent in 1953-1954 to 4.0 per cent in 1958-1959 20’ ”•112.
This success emboldened the administrators to think in terms of totally
eradicating the disease from the country, onceand for all. The danger of
the mosquitos developing resistance to the main weapon for malaira
control, DDT, was given as an additional reason for embraking on the
eradication programme. Besides, pressure was also put on India by foreign
consultants from WHO and elsewhere to embark on the eradication
programme as it was to become a part of the global strategy propound­
ed by the WHO 20\
It was also stated, to give economic grounds for the decision,
that while the control programme was estimated to cost about Rs. 270m
in the second Five Year Plan (1956-1957 and 1960-1961) and Rs.
350m during the Third Plan (1961-1962 and 1966-1967) and there­
after continued to remain a heavy item of expenditure, “the cost for
the eradication programme was estimated to be Rs. 430m in the last
11

three years of the Second Plan and Rs. 580m for the entire Third Plan
with the annual expenditure becoming negligible thereafter” 20. 113. The
immediate successes of the National Malaria Eradication programme were
even more spectacular, but a disastrous snag developed in implementing
the maintenance phase of the programme 22, pp' 1-6. It turned out that
among other factors, because of preoccupation of the administrators
with specialised mass campaigns against malaria and other communi­
cable diseases, they had not paid adequate attention to building a
permanent health service system—the so-called health infrastructure—
strong enough to carry on the malaria surveillance work effectively
at the village level. This has been responsible for a series of setbacks
to the National Malaria Eradication Programme, resulting in the rever­
sion, at a very considerable cost, of large segments of the maintenance
phase population on to consoldation or attack phases. Instead of
geting rid of malaria once and for all by 1966, as it was envisaged in
the late fifties, 40 per cent of the population is still to reach the main­
tenance phase 22, p‘ “. The National Malaria Eradication Programme
thus continues to drain huge quantities of scarce resources even today
thus making it even more difficult to find resourees to develop the
health services infrastructure.

During the last four years, for instance, less than 3 per cent of
the additional population (9.4 units) has entered the maintenance
phase 221 5. Meanwhile the country is forced to set aside huge
chunks of its very scarce recources to prevent the programme from slid­
ing still further. As against the envisaged expenditure of Rs. 1,015 m,
the National Malaria Eradication Programme has thus far sucked in
over Rs, 2,500 m 23, p* 225 and 27. In addition, Rs. 967m have been
set aside for it for the next five years 22- ”■ 23-21 and even this
allocation might have to by raised still further In spite of this the
chances of eradicating malaria in the foreseable future does not appear
to be very bright. So the country will be compelled to keep on pour­
ing in resources on this programme to see that the disease does not
come back in an epidemic form as it has happened in some other coun­
tries.

Also, following the model of the NMEP, a specialised military style
campaign was launched in 1963 to a eradicatesmallpox within three years
2o, p. no Once again the campaign conspicuously failed to achieve the
result of eradication. Only recently (1973-74) yet another campaign has
12

been launched to eradicate smallpox “once and for all” 22
31-38.
A mass campaign to provide BCG vaccination to cover the entire popu­
lation of the country, and to continue to do so periodically, was the
first effort to deal with the problem of tuberculosis in India as a public
health
problem 22.
120-121.
This
programme,
unfortunately,
also failed to yield the desired results 21. Special campaigns have
also been launched against leprosy, filariasis, trachoma and cholera with
even more discouraging results 22,
61-108.
The health service system of the country had hardly recovered
from the consequences of the very costly failures of the mass campaigns
against malaria, smallpox, leprosy, filaria and trachoma, when a large
bulk of investment in health was cornered by another specialised cam­
paign—this time it was against the rapidly rising population of the
country. The Fourth Plan investment in family planning was Rs.
3,150m as against Rs. 4,500m for the rest of the health sector of
the country 10- ’•
This involved deployment of an army of
125,000 persons 10, B’ 16. A.1I of them were specially earmarked for
doing family planning work only. Significantly, once again, this pro­
gramme was also developed by officers belonging to the Indian Medical
Service—the colonels, with strong backing from foreign consultants
from various agencies. Predictably, once again, this compaign also
failed to attain the demographic objectives, with disastrous consequ­
ences, both to the programmes for socioeconomic development as well
as to the development of a sound infrastructure of health services for
the country 10- pp' 222_22i, 21

Recognising, at long last, the weaknesses of this campaign
approach, recently the Government of India has veered round the
idea of providing an integrated package of health, family planning
and nutrition services with particular emphasis on the weaker sections
of the community 25, ”■ 23‘. This package, in turn, is a part of a
bigger package of the Minimum Needs Programmes of the Fifth
Five Year Plan (1974-1979) which is meant to deal with some of the
very urgent social and economic needs of the rural populations of
the country 20, pp' 87-91.
Development of a Permanent Integrated Health Service System for
Rural Areas :

The Health Survey and Development Committee13, which
was set up by the British Indian Government in 1943 to draw a
13

blueprint of health services for the post-war British India, had shown
exceptional vision and courage to make some very bold recommen­
dations. These included development of an elaborate health service
system for the country, giving key importance to preventive aspects
with the “countryside as the focal point” 131 ”•
To forestall any
criticism of the recommendations on grounds of practicability, point­
ing out the achievements in health in the Soviet Union within a span
of 28 years (1913-1941), it asserted that its recommendations are
quite practical, in fact relatively very modest, provided there was
the will to develop the health services of the country 13, ’’ 10.
Unfortunately, however, the leaders who took over from the British
did not show this will. They had quoted, often out of context, the
recommendations of the Bhore Committee to justify abolition of the
licenciate course and to establish a very large number of medical
colleges with sophisticated teaching hospitals in urban areas. They
also invoked the Bhore Committee to justify to setting up an even
more sophisticated All India Institute of Medical Sciences in New
Delhi on the model of the Johns Hopkins Medical Center of the
U. S. A. 121 v' 322. A number of other postgraduate centres for
medical education were also set up in due course. It, however, took
them over seven years even to start opening primary health centres
to provide integrated curative and preventive services to rural
populations of the country 2S. These primary health centres were a
very far cry from what was suggested by the Bhore Committee : they
did not have even a fourth of “the irreducible minimum requirements”
of staff recommended by the Bhore Committee for a given population
(and that too only as a short term measure) 13, u. Furthermore,
it took more than 10 years to cover the rural populations in the
country even with this manifestly rudimentary and grossly inadequate
type of primary health centres.
The entry of the National Malaria Eradication Programme
into the maintenance phase and concurrent development of an
extension approach to family planning provided a transient impetus
to providing integrated health and family planning services through
multipurpose male and female workers 2’. But the clash of interests
of the malaria and the family planning programmes again led to the
formation of unipurpose workers for malaria and family planning 30What was even worse, application of very intensive pressure on various
workers of primary health centres to attain certain family planning
14

targets led to the neglect of whatever health services which were
earlier being provided by the PHCs, thus causing a series of further
setbacks to different health programmes 101 p- '10.
Maternal and
child health services, malaria and smallpox eradication, environmental
sanitation and control of other communicable diseases, such as
tuberculosis, leprosy and trachoma, are examples of the services which
suffered as a result of preoccupation of health workers with achieving
the prescribed family planning targets.
Very recently, following the recognition of the fact that a unipur­
pose, high pressure milit ary type campaign approach which does not
ensure a concurrent growth and development of other segments of health
and nutrition services (and, growth and development in other socio­
economic fields) will not be able to yield the desired results, as
pointed out above, decisions have already been taken to integrate
malaria, family planning, maternal and child health, smallpox and
some other programmes and thus provide an entire package of health,
family planning and nutrition services to the community through
male and female multipurpose health workers 2S. 26.
The Indian Systems of Medical Services in India

There are three major indigenous systems of medicine in India :
Aurveda—the Hindu medical system ; Unani—the Greek system of
medicine which was brought to India from West Asia by the Muslim
rulers of India ; and the Siddha system, which can be considered
to be a specialised branch of Aurveda. After Independence, these
systems were subjected to two contradictory pulls : their being firmly
rooted in the culture of the people of the country for centuries and
their rich heritage invoked considerable admiration and even certain
degree of emotional attachment from a large section of the population
of the country. And, at the same time, long neglect of these systems
of medicine led to a very sharp deterioration in the body of knowledge,
in their institutions for training and research, in their pharmacopia
and drug industry and in their corps of practitioners. Therefore,
while the leaders of independent India built almost the entire health
services on the lines of western system, they have, from the very
beginning, shown sympathy for the Indian systems of medicine and
have made available some grants for conducting research in these
systems, for supporting educational institutions and for providing some
services to the community31.
15

CHAPTER IV

THE PRESENT STATE OF THE HEALTH SERVICES
IN INDIA

Considering the size of the population and the staggering nature
of its health problems, the existing health services are grossly inade­
quate. Furthermore, the bulk of the expenditure is earmarked for
curative services and these services are predominantly situated in
urban areas and they are more accessible to the more privileged
sections of the society. The privileged population has the additional
advantage of being able to pay to avail of private nursing home
services and services of private practitioners who are located almost
entirely in urban areas. 53 per cent of the doctors in India are in
private practice ; another 7 per cent are employeed in the private
sector 32- ”■ 71-72 ; the community spends about Rs. 100,000 for the
training of one doctor.
India has barely half a bed per thousand population, while the
corresponding figure is over 10 for industrialised countries 111 ”■ 60.
90 per cent of these beds are located in cities and towns where only
one fifth of the population lives. Even the 10 per cent of the beds
which are primarily meant for rural populations are ill-staffed, illequipped and ill-financed 171 ”• 27
121.
The expenditure for
curative services is about three times as much as for preventive services18.
Again, in terms of the preventive services, while over 90 per cent of
the urban population is provided with some degree of protected water,
only four per cent of villages get piped water supply ; while about
40 per cent of the urban population has a sewerage system, it is
almost non-existent for the rural population 331 ’.

Primary health centres and their sub-centres form the sheet anchor
of rural health services of India. There are over 5,195 PHCs in the
country ; there are 32,218 sub-centres attached to these PHCs 14. 36.
Each PHC and its sub-centers are expected to provide integrated
health, family planning and nutrition services to a population of about
100,000. Provision of medical care, environmental sanitation, maternal
16

and child health services, family planning services, eradication or
control of some of the communicable diseases and collection of vital
statistics are some of the functions of a PHC 28, 63. However,
both quantitatively as well as qualitatively the resources made avail­
able at a PHC are grossly inadequate for serving the population assigned
to jt 31, 35. 26. 59

There are now 103 medical colleges which have an annual admis­
sion capacity of over 13,000 I1> v' 20. The number of doctors
available in India has now increased to 137,930 14' 20. There are
88,000 trained nurses, 32,000 sanitary inspectors and 54,000 auxiliary
nurse midwives “• ’• 20.
The government is at present financing about 9,000 dispensaries
and 195 hospitals which offer the services according to the Indian
systems of medicine. There are 44,460 institutionally qualified and
111,371 non-institutionally qualified Aurvedic registered practitioners in
the country ; the corresponding figures for the Unani and the Siddha
systems are 6,013 and 18,507 and 625 and 14,785 respectively 31. The
government runs two postgraduate colleges in Aurveda and one in
Unani; there also 91 Ayurvedic, 10 Unani and one Siddha undergraduate
colleges 31.

That the present health services system of India needs consider­
able improvement is dramatically brought home by the fact that in
the year 1974 India happens to be one of the few countries in the world
which has not yet succeeded in eradicating smallpox. Much remains to
be done before it will be possible to control such apparently easily
controllable diseases as tuberculosis, leprosy, trachoma and filariasis
23. t>- 22i The fact that the National Malaria Eradication Programme
continues to be a very heavy drain on the very limited resources even
today, instead of being eradicated by 1966, also provides an indication
of the serious weaknesses in the system.

17

CHAPTER V

THE COMMUNITY AND THE HEALTH SERVICES SYSTEMS
IN INDIA

Health administrtors sought to secure some degree of social legiti­
macy for their actions by getting some not very well defined or even
relevent social, cultural and psychological considerations raised by
social scientists and health educators. Their appeal was particularly
directed towards the then dominant group of social scientists which
was engaged in generating social science knowledge to legitimise the
existing social structure and social relations 37. 3S. The response
was generous. Eminent social scientists from the west, such as McKim
Marriot3’, Morris Carastairs10, Morris Opler11, H.A. Gould13 and Elvin
Wood13 came out to draw attention to certain basic cultural and
social factors which mitigate against acceptance of modern medical
practices in the mostly tradition bound, caste ridden, rigidly heirarchical, illiterate and superstitious rural communities of India. Their
Indian disciples dutifully carried on the refrain by drawing similar
conclusions on the basis of their own “studies”. Studies of Hasan(44)
Dhillon 1B, Khare 40, Kakar 47 and Prasad 48
offer examples of
such Indian workers.
The report on the Conference on Social and Cultural Factors
in Environmental Sanitation4’ represents an instance of the collective
wisdom on this subject of a group of eminent Indian social scientists
which was brought together by the Ford Foundation. Ignoring
the vital necessity of “distinguishing between true clinical core of
scientific medicine and the surrounding folklore, magic, custom, and
faddism that are included in our institution of medicine” 50, they went
on to find ways of overcoming the cultural resistance of villagers to
installation of sanitary latrines. They overlooked some basic epidemio­
logical, clinical, social, economic and even cultural issues which ought to
have called into question the very rationale of selling such latrines to
rural populations6,50. Their deep seated bias, which perhaps contri­
buted to their inability to have a holistic view of the social, cultural
and technological interaction in the sanitation programme, made them
behave more like salesmen, than like scientists who possess the compe­
tence to use conceptual and methodological rigor of their discipline to
make an objective analysis of the situation51.
18

The profession of health education also came very handy to
health administrators in giving a facade of legitimacy to the health
service system built by them. As practioners of social science know­
ledge which was generated by scholars like Marriot, Carstairs, Hasan
and Khare, the administrators found it convenient to assign to them the
task of “educating” the community to pave the way for acceptance
the western system of medicine. When the administrators in India,
with strong backing from consultants from abroad, launched a
country-wide family planning programme which required acceptance
of family planning practices in a poverty stricken population, with
very poor health services, extensive unemployment and social injustice
10, pv- 31.35, (hey once again found it quite convenient to call upon
the health educators to sell this brand of family planning to the masses.
It is significant that the leaders of the health education profession,
both in India as well as from other countries, willingly allowed
themselves to be identified with a programme which involved motivat­
ing individuals to accept family planning practices by using persuasion,
administrative coercion and monetary enticements21.
A carefully conducted sociological study of tuberculosis patients
in a rural district in South India sl,21 revealed that more than half
of the these cases visited a government institutions of modern medicine,
where they were almost invariably dismissed with a bottle of cough
mixture. These findings were diametrically opposed to what was fore­
cast by social scientists like Marriot and Carstairs. Again, a number
of studies of treatment default among tuberculosis patients getting
domiciliary treatment revealed that by far the most important causes
of default are attributed to limitations at the technical level and in the
field of administration of the services, rather than to the patients’ own
behaviour 53131,65.
Yet, despite these very clear-cut findings,
health educators and community health workers have kept harping on
the need for “educating” the public about tuberculosis 5e’ 67. They
could not think of “educating” the programme administrators to take
into account the community health behavior and accordingly formulate
suitable services. They have written numerous accounts as to how
the villagers in India refused smallpox vaccination because of their
superstitious faith in the goddess “Sitala", but they could not take note
of the very glaring fact that a much larger number of persons remain
unvaccinated because nobody even cared to offer facilities of vaccina­
tion to them35.
19

CHAPTER VI

A RECENT STUDY OF HEALTH BEHAVIOUR OF RURAL
POPULATIONS IN INDIA

Taking note of the limitations in social science studies in health
fields in India, an attempt was made by the author to narrow this gap
by considering the activities of primary health centre as a purposive
intervention to change for the better some aspects of the pre-existing
health culture of the community served by it. A research study was
designed to examine the current status and the nature of this inter­
action between the health services that are interoduced through the
PHCs and the pre-existing culture of rural populations in India. A
report on this study has been published elsewhere 30. Only the broad
outline of the study design and the principal findings are being sum­
marised here to draw attention to some aspects of the health behaviour
of rural populations of India which appear to be of significance in
shaping the future pattern of the health services system of the country.
In order to get data on health behaviour of rural populations
under relatively more favourable conditions, a deliberate effort was
made to select, in the first instance, PHCs and villages which are much
above the average. The study has been completed in 16 villages, 10 of
which also serve as the headquarter village of a PHC. These PHC are
from seven states of the country, belonging to seven regions. Considera­
ble attention was paid to developing a methodological approach that is
specially tailored for studying the health behaviour of villagers (includ­
ing their behaviour in relation to the PHC services) against the back­
ground of the total village culture. Research investigators lived in
these villages for three to five months. Apart from making special
efforts to get themselves accepted by all the segments of the village
community and collecting data through village informants, the investi­
gators identified informants and some “ordinary” members from each
segment of the village community and made observations and conduct­
ed depth interviews to understand the health cnlture of each segment
of the village against the background of its total culture. They also
prepared case reports to provide a deeper insight into the response of
the different segments to health problems in the fields of medical care
20

family planning, maternal and child health, communicable diseases,
environmental sanitation, etc. Documents have been prepered to en­
able all the investigators to cover uniformly all the major areas in
relation to these problems Their stay in the village also enabled them
to make direct observations, followed by depth interviews, of the actual
behaviour of the villagers when they encoutered certain specific health
problems. They could also study the interaction between the PHC
personnel and the villagers, both when the former visited the village
and when the villagers visited the PHC. Apart from these efforts to
ensure that in-depth qualitative data are obtained from all the segments
of the entire village community according to well defined work proce­
dures and check lists and they were, as far as possible, checked
and cross-checked, a quantitative dimension was given to the main
qualitative data by framing an unstructured interview schedule on
the basis of these data and administering it to a twenty per cent strati­
fied random sample of the village households.
As an additional safeguard, after completion of the field work in
the villages of a PHC, some of the data concerning the health behaviour
of the community were cross-checked with personnel at the level of
the corresponding seven State Directorates of Health Services. An addi­
tional three States were added to the original seven to examine how
far the findings from these seven were applicable to the others. These ten
States covered 77.8 per cent of the population of the country. Recogni­
sing that the complex nature of the problem for this study calls for
a new and rather exacting methodological approach, special safeguards
were adopted to ensure that the data collected by all the investigators
are of a minimum acceptable quality.

Taking into account the social and economic status of the people,
the epidemiology of health problems and the nature of the health ser­
vices available, it is not surprising that problems of medical care should
be by far the most urgent concern among the health problems in rural
populations. But the sutprising finding is that the response to the
major medical care problems is very much in favour of western (allo­
pathic) system of medicine, irrespective of social, economic, occupational
considerations. Availability of such services and capacity of patients
to meet the expenses are the two major constraining factors. On
the whole, the dispensary of the PHC projects a very unflattering image.
Because of this and because of its limited capacity it is unable to
satisfy a very substantial proportion of the demand of the villagers for

medical care services. This enormous unmet felt need for medical care
services is the main motive force in the creation of a very large number
of the so-called Registered Medical Practitioners (RMPs) or “quacks”.
The RMPs are thus in effect created as a result of the inablity of the
PHC dispensary or other qualified practitioners of western medicine
to meet the demands for medical care services in the villages. It
is worth noting that all these RMPs use allopathic medicines rather
than aurvedic or unani medicines. When these RMPs prove ineffetive, depending on the economic status of the individual and the
gravity of his illness, villagers actively seek help from government and
private medical agencies in the adjoining (or distant) town and cities.
There are, however, numerous instances of adoption of healing prac­
tices from qualified or non-qualified practitioners of the different Indian
systems of medicine and homeopathy and from other non-professional
healers. But among those who suffer from major illnesses, only a very
tiny fraction preferentially adopted these practices, by positively rejecting
facilities of the western system of medicine which are more efficacious
and which are easily available and accessible to them. Usually these
practices and home remedies are adopted : (i) side by side with wes­
tern medicine ; (ii) after western medicine fails to give benefit ; (iii)
when western medical services are not available or accessible to them
due to various reasons ; and, (iv) most frequently, when the illness is
is of minor nature.

Another very significant finding of this study is that the family
planning programme has ended up in projecting an image which is
just the opposite of what was actually intended. The image of the
family planning workers in rural areas is that of persons who use coer­
cion and other kinds of pressure tactics and who offer bribes to entice
people into accepting vasectomy or tubectomy. Because of the failure
of family planning workers to develop a rapport with the villagers,
sometime the villagers are unable to meet their needs for family plann­
ing services. There are several instances of mothers who, failing to get
suitable family planning services from the PHC, took recourse to
induced abortions to get rid of unwanted pregnancieas. This not
only points to the failure of the programme to meet their needs
for the services but it also draws attention to the failure of the pro­
gramme to offer suitable abortion services to mothers with unwanted
pregnancies, despite the passage of the abortion bill.
22

Another significant finding of this study is that there is codsidcrable unmet felt need for services of the Auxiliary Nurse Mid-wife
(ANM) at the time of chidbirth. Villagers are keen to have the ANM's
services because they consider her to be more skilled than the
traditional dai. Wherever the ANM’s have provided the services, the
dai's role has become less significant. The overall image of the
ANM in villages, particularly in North India, is that of a
person who is distant from them—meant only for special people
or for those who can pay for her services. She is not for the poor.
She can be called only when there are complications and then
also she should be paid. Because of the inaccessibility of the ANMs,
the majority of the deliveries even in the villages where the PHC
is located are conducted by dais and relatives and neighbours. In
villages with no PHC, their sway is almost complete. As in the case
of the Registered Medical Practitioners, confinement by relatives and
friends and by indigenous dais is popular among the villagers not because
of their intrinsic superiority but in the absence of suitable services
from the ANM/Lady Doctor, they are compelled to settle for some­
thing which they consider to be inferior but which is all that is available
and accessible to them. They actively seek more specialised services
either from the PHC or from the towns and cities when the dais are
unable to tackle complicated cases.
The only two programmes which can be stated to have reached
the grass-roots level in the villages are those concerning malaria and
smallpox. Despite several complaints regarding the sincerity of these
workers, there is almost a universal agreement among the villagers
that these workers do visit the community. A significant finding is
that these workers do not encounter any major obstacle in getting parti­
cipation of the community in these programmes. Except when there are
understandable compulsions, such as the prospect of a poverty stricken
mother losing wages for 4-5 days at the peak agricultural season due
to the child's vaccination reactions and some cases of orthodoxy, there
is genera] acceptance of smallpox vaccination in village communities.
The number of children who are left unvaccinated due to lapses of the
parents appear to be a very small fraction of those who remain unvaccinatcd due to lapses of the vaccinators and their supervisors.

Patients suffering from tuberculosis, leprosy and trachoma get
very little services from the corresponding national programme. It is
remarkable that despite this, they actively seek help from elsewhere—
23

from the nearby towns or even big cities. Such help is not only
much more expensive and bothersome but it is also much less efficaci­
ous, both clinically as well as epidemiologically. Other preventive
measures, of course, are almost non-existent.
Extensive prevalence of abject poverty, as a result of which more
than half of the population is unable to meet even the minimum
dietetic calorie needs and appalling conditions of sanitation, water
supply, housing and education present an ecological setting which
is conducive to widespread prevalence of various types of health
problems in the community. These health problems form only a
small component of the overall gloomy picture of the way of life in
Indian villages.
Ignorance, superstition, suspicion, apathy and
fatalism should thrive in such a milieu. It is, therefore, a tribute to
the strength of the culture of the rural populations in India, that,
despite these overwhelming odds, their health behaviour has retained
so much of rationality.
Because of their urban orientation, workers of rural health and
other developmental agencies generally have a strong distaste for
rural life. This distaste is for the entire way of life and not simply
for the very poor facilities available there. Health workers tend to
keep a distance from the rural population as a whole. However, as
they are required to work for rural populations, they take advantage
of the village power structure and confine themselves, as far as
possible, to satisfying the privileged gentry of the village. In doing
so they : (a) win approbations and rewards from the so-called commu­
nity leaders who have the ear of their superior officers and of the
political leaders at the higher scales ; (b) deal with the least disagree­
able segment of the village community ; and (c) get a free hand to
“tackle’’ the rest of the community.

The findings of this study bring out some of key issues which
are of far reaching significance for the future development of the
health services system of the country :

1.

It brings out clearly that there is no significant cultural
resistance to acceptance of modern medicine as long as they
are efficacious and they are available and accessible to them.
This finding, therefore, seriously calls into question the
belief of a very significant section of health administrators,
24

social scientists and health educators that there is consider­
able cultural resistance to the acceptance of modern
medical practices in rural populations in India ;

2.

That the existing health services are working at a grossly
low level of efficiency, which has led to considerable under­
utilisation. Priority should, therefore, be given to ensuring
that this problem is overcome 69 ;

3.

There is also considerable scope for bringing about quali­
tative improvements in the existing health services system
in rural areas by bringing it more in tune with the social
and cultural setting of the village communities ; and,

4.

Finally, after ensuring a reasonable utilisation of the existing
capacities quantitatively and after bringing about qualitative
changes, there is a strong case for making quantitative expan­
sion of the health services to meet the requirements of rural
populations. This will imply rectification of the existing
imbalance in allocation of resources : this will imply a shift
in investment from urban to the rural, from curative to the
preventive and bringing about a shift in providing services
from the privileged to the underprivileged.

25

CHAPTER VII

SUMMARY

There has been a cumulative increase in the knowledge of the
medical sciences which had at times grown almost at an exponential
rate. However, the actual application of this knowledge to societies
is determined by a number of political, social, cultural, economic
and technological factors. In ancient India, when these factors were
favourable, despite the very rudimentary nature of the available
knowledge, the people enjoyed a much higher level of health services
than what is available at present. In fact these favourable conditions
created a setting which enabled the society to make significant contri­
butions to the body of medical knowledge—through Charaka and
Susruta, for instance. Decline of the society in the subsequent
centuries saw a decline in the health service system. Colonisation of
the country by the British, when every facet of its activities was
subordinated to the interest of the Imperial Government in London,
dealt almost a fatal blow to the still active Indian systems of medicine.
The entire health service system of the country was purposely develop­
ed to provide the western system of medical services to a small
privileged group—the armed forces, the British civilians and the Indian
gentry. Medical colleges were opened to prepare Brown Englishmen,
medical institutions were established to serve the gentry living in
urban areas and officers of the armed forces medical services
were brought in to administer the health services.
With the advent of Independence, the new leadership readily com­
mitted themselves to providing good health services to the vast
masses of people of the country, but for this they did not consider
it necessary to bring about basic changes in the system. The colonels
of the Indian Medical Service, by then greatly depleted by the with­
drawal of the British, and the Brown Englishmen were assigned the
very much more challenging task of building the new health services
system for India.
Medical colleges grew very rapidly and these
colleges poured in a large number of physicians who are mostly aliena­
ted from the masses of the people. A number of hospitals were opened
in urban areas. Out of the limited resources that were made available
for providing preventive services for rural areas, the colonels, with
strong “persuasion” from foreign consultants, set aside big chunks for
26

running mass campaigns against specific diseases—malaria, population
growth, smallpox, leprosy, trachoma and filariasis. Not only have
these campaigns hindered the development of a permanent health
services system in rulral areas but almost invariably they have also failed
to achieve the set goals. The country was persuaded in the late fifties
to invest about Rs. 1010m to eradicate malaria by 1966, but, even
after an investment of over Rs. 3500m, the prospect of doing so even
by 1979 do not appear to be particularly bright. The campaign against
populations growth turned to be a similar costly blunder.

Social scientists and health educators from abroad helped the
colonels to divert attention from the basic malady of the system by
raising the bogey of resistance of the villagers to acceptance of the
western system of medicine. Following that reference model 6S, their
counterparts in India dutifully echoed their findings and a large number
of positions were created to accommodate such professional health edu­
cators and social scientists within the system. Findings of a carefully
conducted emperical study of health behaviour of rural populations of
India have been presented to underscore the fact that already there is
considerable active interest among villagers in acquiring both curative
and preventive services. Mostly it is the services which have let them
rather down, than the reverse. Not only are the rural health services
very much below what the Bhore Committee’s short-term programme
had called in 1946 the “irreducibly minimum requirements” and much
below the actual demands of the people, but even these very limited
services are working at an alarmingly low level of efficiency—one of the
main causes for this being the alienation of the health workers and of
the institutions for education and training of such workers from the
masses of the people of the country.

27

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