ISSUES OF ACCESSIBILITY IN PRIMARY HEALTH CARE: ISSUES OF ACCESSIBILITY IN PRIMARY HEALTH CARE:
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ISSUES OF ACCESSIBILITY IN PRIMARY
HEALTH CARE: ISSUES OF ACCESSIBILITY IN PRIMARY
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ISSUES OF ACCESSIBILITY IN PRIMARY
HEALTH CARE:
STUDY OF A RURAL HEALTH CENTRE IN PATANCHERU (A.P.)
A Thesis submitted to the University of Hyderabad
for the Degree of Master of Philosophy
in the School of Social Sciences
))tD|
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n
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BY
Madhumita Biswal
Department of Sociology
School of Social Sciences
University of Hyderabad
HYDERABAD - 500 046, INDIA.
2002
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CERTIFICATE
This is to certify that Ms Madhumita Biswal worked under my supervision for the
degree of master of philosophy in Sociology. Her dissertation entitled Issues of
Accessibility in Primary Health Care: Study of A Rural Health Center in Patancheru
(A.P) is her own work at.the University of Hyderabad, and has not been submitted for a
degree or diploma elsewhere.
N Purendra Prasad
Thesis Supervisor
Lecturer in Sociology
University of Hyderabad
Hyderabad -500046
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Head, Department of Sociology,
University of Hyderabad
•r’E ‘3
r - -?
CG'
0
Dean
School of Social science
University of Hyderabad.
Date:
DECLARATION
I hereby declare that the dissertation entitled Issues of Accessibility in
PrimaryHealth Care: Study of A Rural Health Centre in Patancheru, is supervised by
Dr.N Purendra Prasad, is my original work in the Department of Sociology, University of
Hyderabad, and has not been submitted for a degree or diploma or for publication
elsewhere.
(MADHUMITA BISWAL)
Date:
Place:
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ACKNOWLEDGEMENT
I am grateful to Dr Purendra Prasad, my research supervisor for his help, guidance and
moral support throughout my dissertation.
I am thankful to all the teachers and office staff of Department of Sociology for their
help.
I thank all my respondents for sharing their experiences with me.
I thank the staff of Rural Health Centre, Patancheru and Ghanpur sub centre for their
timely help.
I thank staff of NIRD library, IHS and CESS library for allowing me access to their
library.
I am thankful to Saswati and Smriti for patiently proofreading my thesis.
I am thankful to all my friends whose constant help enabled me to complete my work.
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CONTENTS
CHAPTERS
PAGE No.
1. INTRODUCTION
1-8
2. HEALTH AS A DEVELOPMENT AGENDA
9-20
3. COMPREHENSIVE Vs SELECTIVE
PRIMARY HEALTH CARE
21-58
4. A RURAL HEALTH CENTRE IN PATANCHERU:
STUDY FINDINGS
59-89
5. SUMMARY AND CONCLUSION
90-96
REFERENCES
LIST OF TABLES
97-102
LIST OF TABLES
Table No
Page No
1 - Age-sex composition of the respondents (medical personnel)
62
2 - Age-sex composition of the respondents (paramedical personnel)
62
3 - Age-sex composition of the respondents (community)
63
4- Caste and disease wise distribution of the respondents who
consulted RHC
81
Introduction
Social well-being of individuals and communities is the central
concern of one and all.
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At the World Health Assembly in 1977, it was
unanimously decided that the main social target of member governments and
the World Health Organization (WHO) in the succeeding decades should be
“the attainment by all citizens of the world by the year 2000 of a level of
health that will permit them to lead a socially and economically productive
life” (Basch, 1990). This is clearly enunciated in the goal of “health for all by
the year 2000AD
Alma Ata Declaration of 1978 stated that the key to
attaining health for all by 2000 is primary health care. India was a signatory to
Alma Ata declaration and it pledged its implementation and committed to
achieve health for all by the year 2000 AD. The National health policy of
1983 also accepted primary health care as main instrument to achieve health
for all by 2000 AD”. A network of health institutions were set up supposedly
to ensure that health services are accessible to the people, available on a
continual basis, socially and culturally acceptable and affordable by most of
the communities.
Although the year 2000 has already been crossed, health for all has not
been achieved. It has remained a utopian vision for India, as well as for most
of the developing world. Even though the primary health care concept was
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established in India thirty y<'ears before the Alma Ata declaration, health for all
remains still an unfinished agenda. Despite the fact that India’s national health
policy of 1983 was based on primary health care approach, the grand ideas of
Alma Ata never became a reality. Though statistics show that the life
expectancy at birth has increased all over the world, and particularly in India it
has increased from 38.7 years in 1950-55 to 60.5
majority people, however lack the basic health
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years in 1990-95, the
services as well as the basic
necessities
’ 1998 human development report (cit in
uccessmes of
or life.
tire. UNDP
UNDP iin its
Frambrose, 1999) says that 840 million people in the Third world suffer from
malnutrition; 43% people in the world are living below poverty line; this
means 400 million people cannot afford two square meals a day. As Garret
(2002) points out that in 1997, more than 200 million Indians went to bed
hungry every night, officially malnourished, including half of the country’s
children. So it remains the fact that longevity without quality is a priceless
gift. Then the question arises, those people who cannot even afford two decent
meals a day, can we expect them to spend on health
care services? Is the state
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obliged to spend on the health care of the poor?
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India’s first ever-national health policy of 1983 was based on primary
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health care approach of Ata. Ata, however teetao-centric approaches
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dominated the scene. After India's acceptance of World Bank imposed
structural adjustment programmes (SAP), investment in the social sector has
been drasticaHy curtailed, of which health sector has had an immediate effect.
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And the effect of SAP on the poor is direct and subtle. The international
agencies, by dictating the policies of the government, have imposed the
vertical programmes. But these vertical programmes which treat the diseases
as single units, are not going to address the problem as long as the root cause
of diseases i.e. poverty has not been taken into consideration. Frambrose
(1999) has rightly pointed out:
“The Directorate General of Health Services has devised a
strategy to monitor, dictate and treat malaria. Monitoring is the
function of medical officers of primary health centres. But there is
hardly any medical officer in health functionaries in states like Bihar,
Rajasthan and Orissa. So the government has initiated a new scheme
called the enhanced malaria control project with assistance from
World Bank. Under this scheme it is proposed to supply biocides,
synthetic pyrethroides and medicated bed net. In these areas the
population that does not have enough to eat and drink, are required to
use bed nets. Then the question arises what happens when they are
outside the bed? The history of malaria in India has consistently
revealed the relationship between nutritional status and malaria
deaths.”
As is evident, vertical programmes are intended to treat only the
diseases and not persons. It is quite possible that people who might have
benefited from certain vertical programmes would fall prey to other diseases
due to the poor environmental condition in which they are forced to live.
Even if a particular disease is controlled for the time being, one can not rule
out that some other diseases owing to poor nutrition will not occur,
considering the fact that poverty gives rise to a chain of diseases. It is
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certainly a ‘no-end’ task to treat the diseases one by one. It appears that the
WHO World Health Report 1995 has acknowledged this fact, which saw the
inclusion of a new category of disease called Z.59.5 in the international
classification of diseases. Z.59.5 stands for “extreme poverty”. By its own
estimate, 170 million children in the world are suffering from malnutrition. It
implies that by immunization alone, it is not possible for children to be free
from diseases until and unless they are free from poverty. It is necessary to
address the causes of disease rather than only the disease.
Various studies (NSS,1996, Duggal and Amin, 1989, George et al,
1992, Kannan et al, 1991) show that private health sector accounts for over 70
percent of all primary care treatment in India. This is not a healthy sign for a
country where over two thirds of population live either at or below subsistence
level. This fact provokes one to ask series of questions: while the poor does
not have enough material resources to survive, why is he/she spending on
private treatment for primary health care? Why does the government
sponsored health service become inaccessible for the poor? And what are the
factors responsible for this inaccessibility of health service?
At this point of time it is necessary to reexamine the primary health
care approach and its applicability in the third world context where the
diseases are assuming more prominence than the persons and their well being,
also where holistic approach has given way to fragmented and selective
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approaches. By taking the above factors into consideration, following
objectives have been formulated.
Objectives of Study:
•
To understand the concept of health, more particularly primary health
care in its changing context and assess it within the framework of
development.
•
To analyse the issues of accessibility in primary health care for the
rural communities.
Following methodology has been adopted in conducting the study to
meet the specific objectives.
Methodology:
In order to assess the issues of accessibility in primary health care for
the rural poor, more particularly in an empirical situation, I focused on one
institutional setting, i.e. a Rural health centre which is supposed to be
catering to the needs of rural communities. I chose an institutional setting
because it provided an opportunity for me to observe the delivery of health
care services where health care providers and receivers directly interact.
Also the fact that institutional setting is supposed to cater to the health
needs of community irrespective of their caste, class, gender and region.
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Keeping this in mind I chose a Rural health centre (one of the model
health centres in India), which is situated in Patancheru, about 30
kilometers from Hyderabad city. There are three sub centres under this
Rural health centre i.e. Ismail Khanpet, Ghanpur and Chitkul. The study
was conducted during one-month period, October to November 2002.
Data was collected from the main Rural health centre and two of its sub
centres, i.e. Ghanpur and Chitkul. For the study of Rural health centre and
Ghanpur sub centre data was collected through both primary as well as
secondary sources, while for the study of Chitkul sub centre data was
collected only through secondary sources.
Techniques of data collection include: Unstructured Interviews,
Observation, and Informal Group Discussion. Interviews were conducted
randomly with 15 health personnel belonging to the main Rural health
centre and Ghanpur sub centre. Interviews were also conducted randomly
with 27 people who came to Rural health centre for treatment. Data on
Rural health centre and its sub centres were also collected through
secondary sources such as official documents.
Limitations of the Study:
One of the shortcomings in my study was limited interaction with the
communities as well as medical and paramedical staff, to be able to probe into
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several issues related to delivery of primary health care services.
I did not
know Telugu, hence communication with the communities was also not
elaborate as desired. Time factor was also a limiting factor in my study.
Within a very short period it was not possible for me to deal with some of the
pertinent aspects including caste which would have thrown deeper insights.
Chapterization:
In the second chapter I made an attempt to delineate the concept of
‘health’ and ‘health care’ through available literature. Then by addressing
health as a basic right, I tried to examine how it is an obligation of the state to
provide health care, particularly in the third world context. By situating health
within the framework of development, I argued that health cannot be achieved
only through economic development, but social factors play an important role
for over all development of health. Hence an effort was made to find whether
a comprehensive approach to development has been addressed in primary
health care approach or not in this chapter.
In the third chapter I looked at the primary health care concept,
particularly the social and economic background in which the concept
emerged. Then how the primary health care concept did not make inroads into
the lives of the poor and subsequently how selective primary health care
approach was introduced has been analysed. Also how in 80s due to global
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economic recession and structural adjustment programme, the social sector
investment shrunk which made it difficult for, the primary health care
approach to sustain, was examined.
Then how the primary health care
approach was translated into Indian context, how far it has been implemented,
and if it is not implemented successfully, what are the contributing factors of
its failure has been dealt with.
Fourth chapter deals with the case study of a Rural health centre and
two of its sub centres. Through the study I tried to understand, why the public
health service is not accessible to the rural poor. Several both medical and
non-medical factors that contribute to make the health service inaccessible to
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the rural poor has been looked into.
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HEALTH AS A DEVELOPMENT AGENDA
Tn 1946 WHO defined “health as a state of complete physical, mental
and social well-being and not merely absence of disease or infirmity”. This
implies complex interaction between humans and their environments, more
particularly between social and economic factors, physical environments and
biological environments. Inspired by the WHO definition similar attempts
have been made to clarify the meaning of health. Linda Ewles and Inna
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Simmel have added further dimensions to WHO definition of health. They
suggested that there are emotional, spiritual and societal aspects of health that
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needs to be considered (cit in Aggieton, 1990). These kinds of definitions
encourage one to think of health more holistically, relocating wide range of
human capacities and qualities. It makes clear that the concept of health
cannot be equated with physical well-being or absence of diseases. This
broader definition of health implies, as Ravichandran (2001) says “health is
truly part and parcel of societies, cultures and epochs, it makes comparison
between and within societal context across time, and, perceive value of health
amongst both those demanding better health and those providing it, is called
health care”. So 'Health care’ is not a monolithic concept, it is a
heterogeneous product consisting of a variety of services provided by health
personnel, hospitals, and public health programmes etc.
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Broadly health care can be classified into two categories, such as
public health services and personal health services. Public health services
include services like clean water supply, safe disposal of sewage, cleaning
central sources of infection etc. and confer their might benefits without any
discrimination to all inhabitants of an area. Personal health services consist of
services provided by hospitals, health personnel etc. directly to specific
individuals (Kethineni, 1991). Health is not only a medical issue to be left
entirely to medical professionals and health workers. It has more to do with
civil society and state and it is a political task depending on the political will
of the state. Hence the concept “health care” deals mostly with public health
perspective, refuting the idea of hospital as a health-building factory.
Health is classified as one of the social services provided by the state
as one of the basic needs. Health status of the people determines the quality
and longevity of life. So health is not merely a need, it is a right. It is the most
fundamental of all rights, i.e. right to life. In this context the Universal
Declaration of Human Rights, adopted by the United Nations, states that every
one has the ‘right to a standard of living adequate for health and well-being of
his family including medical care’. Also the WHO has resolved that ‘the right
to health is a fundamental right’ (Guhan, 2001). So WHO definition of heath
as physical, psychological and social well-being can also be taken as a basis
for advocating right to health.
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For the justification of claiming a right to health care, one has to
situate it within the framework of distributive justice, which can answer, what
a right to health care might include. If health care is a right, it is because of the
kind of social good health care and the kind of needs it meets. Economists
unanimously agree that health care, like school education has all
characteristics of public good. This calls for public provision of health rather
than leaving it to private sector (Report of the independent commission on
health in India, 1997). For any claim of right to health care and to situate it
within the framework of distributive justice, one has to discuss health care
needs. For this one has to concentrate on objective criterion rather than
subjective criterion in assessing well-being. Subjective criterion uses the
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individual’s own assessment of how well off she\he is with and without the
claimed benefit to determine the importance of her\his preference claim. An
objective criterion invokes a measure of importance independent of an
individual’s own assessment, i.e. independent of individual’s preference for
the benefit. In the context of distributive justice an appeal is made to objective
criterion of well-being, where needs are given importance rather than mere
desire (Daniels, 1985).
Proponents of right to health care are more concerned with social,
economic and political arrangements that sustain the condition for health
security. The right to health is an obligation of the state to fulfill; it is a “social
security”. The idea of social security is of using social means to prevent
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deprivation and vulnerability (Sen, 1981). There are two different aspects
of social security, viz. protection and promotion. The former is concerned
with the task of preventing a decline in living standards; the latter refers to the
enhancement of general living standards and the expansion of basic
capabilities of population and will have to be seen primarily as a long run
challenge. As per International Forum for Defense of People (2002), health is
an essential human right, and it is a prime right of citizenship and public good.
Hence this forum says that health is the duty of the state, and state should
provide and protect health. While providing service to the masses, the state
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also has the responsibility to maintain equity. Equity is an ethical concept.
Inequality refers not to all inequalities, but to those inequalities that are
considered unfair and avoidable. Equity has to do with fairness and justice.
As pointed out by Gish, health is an invaluable asset for the human
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well-being of individuals and nations. Therefore some of the key indicators
for the measure of development have been health-related. Access to
appropriate food, shelter, education and a productive social, cultural and
spiritual life have remained the pillars of health and well-being (cit in
Bruycker, 2001).
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Health is a part of social and economic development
process. Seers (1969) sees development as necessarily increasing aspects of
human dignity, which means access to basic needs: foods, shelter, job and also
political freedom. Development is therefore generally understood as the
process of improving the quality of all aspects of human life. There exists a
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complex relationship between health and development. According to
Narayana (1997), “development implies improved nutrition, hygienic living
and working conditions, greater awareness of health problems and wider
accessibility to health care services which have favorable effect on the health
status of the people”. There exist a great relationship between social
surrounding and health status of the population; Though ill health appears at a
biological level, it has social origin.
The development of such a social approach to health can be found in
the work of Engels. He did a pioneering work in the tracing social origin of
illness. In his work he addresses how different casual factors such as
occupational hazards in the form of exposure to dust, chemicals etc,
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environmental pollution, bad housing conditions and malnutrition were held
responsible for the wide spread disability and early death of English workers
in 19th century. The origin of ill health was traced to be the capitalist
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production process where primary consideration was profit, not safety of the
workers. Rudolf Virchow in his theory of multifactorial etiology, emphasized
on poverty, unemployment, malnutrition, illiteracy and inadequate medical
facilities as main sources of ill health among the working class population.
These theorists tried to show that although the causes of disease appear to be
at biological level, their social determination is easily discerned at a collective
level (Narayana, 1997).
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There exists a reciprocal relationship between health and
development. To explain the importance of health in overall development,
Amartya Sen narrates a conversation, drawn from the very old Sanskrit text
“Brihadaranyaka Upanishad” between Maitreyee and her husband Yanjavalka.
The conversation focused on the ways and means of becoming wealthier and
how far wealth serves to achieve what they want. Maitreyee wonders whether
she could achieve immortality through wealth, on which Yajnavalka clarifies
that there is no hope of immortality by wealth. Upon this Maitreyee remarks
“what should I do with that, which doesn’t make me immortal”. This concerns
the relation between income and achievements, between commodities and
capabilities, between economic wealth and our ability to live, as we like (Sen,
1999). The ultimate goal of development is to improve and enhance human
well-being and the quality of life of all people. The gap between two
perspectives, i.e. between an exclusive concentration and economic wealth
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and a broader focus on quality of life is a major issue of conceptualization of
development. It is important to recognize the crucial role of wealth on living
conditions and quality of life, but one has to look beyond economic growth.
For development, economic growth is not an end in itself. Development has to
be primarily concerned with enhancing the lives we lead and freedom we
enjoy. The most important freedom is freedom from avoidable ill health and
escape from mortality (ibid). From this discussion it becomes evident that
health is an integral part of development and for a proper conceptualization of
development, health and economic growth has to be conflated.
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Economic growth is a necessary condition but not a sufficient
condition for achieving good health. There is a considerable evidence to show
that income enhancement per se doesn’t lead to better health outcomes. For
example in both India and Pakistan, GNP per capita grew at an annual average
rate of 3.1 per cent between 1980 - 92. The annual rate of reduction in
mortality rate under the age of 5 years over this period was 0.7 per cent in
Pakistan and 2.9 per cent in India. Where as GNP per capita in Costa Rica
grew at an annual rate of only 0.8 percent between 1980- 92, its annual rate of
reduction under the age of 5 years mortality was 4.5 per cent over the period.
Within India itself, Punjab with a percapita income, that is twice the Kerala’s
level, reports infant mortality rate of 55 deaths per 1000 live births, more than
four times higher than Kerala’s infant mortality rate of 13 per 1000 live births.
Income is channeled by the state for provisioning of better health services and
also used by individuals to acquire better health care. Also health outcomes
are influenced by a number of other factors, such as freedom that women
enjoy, the levels of environmental cleanliness, extent of political support, the
efficiency of government administration, dietry and child caring practices etc.
(Shiva Kumar 1994).
Though poverty has to be addressed as a condition of economic
backwardness, it is important to point out that poverty cannot be seen in
isolation only as an economic condition independent of social dimensions.
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Amartya Sen (1981) in his book ^poverty and famines" says, the
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measurement of poverty can be split into two distinct operations, viz. the
identification of the poor, and the aggregation of their poverty characteristics
into an overall measure. The identification exercise is clearly prior to
aggregation. The most common route to identification is through specifying a
set of “basic or minimum” needs and regarding the inability to fulfill these
needs as the test of poverty. ’’Basic” or “minimum” needs are often specified
in terms of hybrid vector- e.g. amounts of calories, proteins, housing, schools,
hospital beds etc. The poor generally lack a number of elements, such as
education, access to land, health and longevity, justice, family and community
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support, credit and other productive resources, a voice in institutions and
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access to opportunity.
So poverty is not one-dimensional phenomena, it has many
dimensions, and health is one among them. At the same time while defining
health, the physical aspect of well-being cannot be over emphasized. There
should be equal footing to social and psychological aspects of health. The
connections between different types of deprivation are not biological (e.g.
between illness and under nutrition) but also economic and social (e.g.
unemployment and illness), (Sen, 1981). Health is a complex expression of
economic and social determination of life conditions. Health is not an
independent fact in itself; it is an aggregation of facts. As Dreze and Sen
(1993) wrote, a person’s capacity to avoid undernourishment may depend not
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merely on his/her intake of food, but also on the person’s access to
facilities like health care, medical facilities, elementary education, drinking
water and sanitation. For example, suppose the success in the rapid reduction
of mortality takes place through “support led” process. This “support led”
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process does not operate through first economic growth, but through a
programme of skillful social support of health care, education, and other
relevant social arrangements. This process is well exemplified by the
experiences of economies of pre-reform China, Costa Rica, Srilanka-, and
Kerala in India, which have had very rapid reductions in mortality rates and
enhancement of living conditions without economic growth. “Support led”
process works through priority being given to provide services (particularly
health and education) that reduces mortality and enhances life quality. Despite
their very low levels of income, the people of Kerla, China, or Srilanka enjoy
higher level of life expectancy than much richer population of Brazil or South
Africa.
Another study on British civilian life expectancy trends across the
decades of two world wars showed an unprecedented rise of seven years. This
was, inspite of tremendous increase in urban crowding (greater exposure to
air-borne infections) during the wars and reduction in medical services (half
of all doctors and nurses in Britain during world war I being recruited into
military service). These were periods marked by dramatic increase in many
forms of government support, including public employment, food price
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control, and food rationing, which ensured access to basic food
(Zurbrigg, 2001).
It is historically evident that the quality of life and acquisition of good
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health for population was not solely due to medical technology. The holistic
approach of health was addressed in the Chadwickian view of public health.
This view encompassed the full range of social and economic factors affecting
human survival: living and working conditions, unemployment, poverty, and
hunger. Since the beginning of the 18th century a crucial factor in the mortality
decline in Europe was improvement in supply of food and diet. While the
improvement in food supply and diet played main role in the earliest mortality
declme, sanitary reforms and public health movements made significant
contribution to further decline in the mortality rates after the middle of 19th
century. The modem concern of public policy with the public health
measures
was an outcome of the sanitary reform movement, which came as a reaction to
the evils of the industrial revolution in 19th
century England (Briscoe et al.,
1986, Narayana, 1997, Shah, 1997).
From the above discussion it becomes clear that, health is not only
biological well-being, it is social as well as psychological well-being. It is a
means to achieve the quality of life. It is one of the basic needs of the
individual. It is also one of the basic rights, which becomes the obligation of
the state to fulfill. The state is required to give social security against
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deprivation. In the Indian constitution, this obligation is placed on the
state in a number of articles, which deals with ‘Directive principles of state
policy’. Article 47 stipulates that ‘the state shall regard the raising level of
nutrition and the standard of living of its people and improvement of public
health as among primary duties’. Article 39 calls on the state to protect the
health and strength of workers, men and women, and to prevent the abuse of
the ‘tender age children’. Article 41 and 42 calls upon the state to make
effective provision for public assistance in case of old age, sickness and
disability, and for maternity relief (Guhan, 2001). Though these obligations
are not enforceable by law, the state takes up the responsibility of providing
basic health services to people.
Health is not an independent fact by itself, it is an aggregation of
facts; it is a complex expression of social and economic life conditions, so
treating health in isolation is not going to help in achieving good health, as is
shown by the past experiences. For achieving good health it is necessary to
fulfill the basic social and economic conditions of life. Such a holistic
approach to health is advocated in a comprehensive way by primary health
care approach. This approach addresses the health needs of people through
basic needs approach. It advocates for an intersectoral approach for the
development of health, which needs coordination of health sector with other
social and economic sectors. The approach addresses the root cause of ill
health, i.e. poverty. It takes up the WHO definition of health as a measure to
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assess health. It is concerned with active health promotion and
development activities. The primary health care approach addresses health as
an issue of social justice, so calls for a right to health, which the state is
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required to fulfill. The responsibility of achieving lies in the hand of the state;
it is an obligation of the state.
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COMPREHENSIVE vs SELECTIVE
PRIMARY HEALTH CARE
The concept primary health care was defined for the first time in Alma
Ata conference in 1978. The conference defined primary health care as
“essential health care based on scientifically sound and socially acceptable
methods and technology made accessible to individuals and families in the
community, through their full participation at a low cost that the community
and country can afford to maintain at every stage of their development in a
spirit of self reliance and self determination” (Alma Ata, 1978). The Alma Ata
conference was jointly organized and sponsored by WHO and UNICEF,
which was held in Alma Ata, the capital of Kazakh socialist republic. The
primary health care approach made it clear that the attainment of health is not
only an individual human aspiration but also a social goal. The conference
affirmed that primary health care approach is an integral part of social
development in the spirit of social justice. The conference also stressed that
health is a fundamental human right.
Taking into consideration the unacceptability of health status of
millions of people the conference called for an integration of all systems of
medicine, and an integration of other social and economic sectors with health
sector through primary health care approach. It was argued that health service
delivery need to be considered as a part of whole Social and economic
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development of a nation and any improvement in services need to take
account of whole question of national structures, priorities and goals. It called
for decentralization of the activities of health sector through community
participation. It calls for a comprehensive approach to health care. The
conference fixed the goal for attainment of health for all by the year 2000.
The translation of primary health care principles into action was required to be
made through certain activities, which were considered as the main elements
of primary health care approach. These activities include education
concerning prevailing health problems and methods of identifying, preventing
and controlling them, promotion of food supply and proper nutrition, adequate
supply of safe water and basic sanitation, maternal and child health care
including family planning, immunization against the major infectious
diseases, appropriate treatment of common diseases and injuries, promotion of
maternal health and provision of essential drugs (ibid.). The Alma Ata
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declaration made it clear that the governments have the responsibility for the
health of their people. This was no less than a redefinition of the norms and
the expectation of the state role with regard to health. This was particularly
important for the newly created states, which were challenged to provide
health care for their population after the collapse of the colonial system
(Kickbush, 2000)
Every social event takes place within the historical and social context.
And to have a thorough understanding of the event it is necessary to address
22
the historical and social forces that determined that particular event. So Alma
Ata declaration cannot be seen independent of the social forces that
determined it. The health situation of the developing countries and the
economic and political context of that particular period had a major bearing
upon Alma Ata declaration.
Health situation:
The conceptual background of Alma Ata can be understood from the
time of World War II. People of the world in the decade following World War
II from mid 1940’s - 50’s were war weary and disease ridden. They were
suffering from life threatening diseases. Most of the disease producing
conditions were rooted in adverse environmental conditions and associated
with poor hygiene and sanitation, the manifestations of poverty and illiteracy.
Many developing countries looked up to the newly formed WHO to fight the
e
diseases. The burdens of tropical diseases were addressed through medical
and scientific intervention. In 1970’s efforts were made to eradicate small pox
and it is claimed to be eradicated. According to official reports the last human
being that fell victim to small pox was identified in Somalia on October 26th
1977. With the success of small pox eradication campaigning, other
programmes were introduced which came to be identified as “vertical
programmes” attacking disease problems as single units. Vertical programmes
like malaria, schistosomiasis, African sleeping sickness, and leprosy were
23
i
started. With the same euphoria in 1974 the extended programme of
immunization to vaccinate children under the age one was started in
developing countries.
Despite enormous efforts made by national and international agencies
to improve people’s health, it was realized by mid 1970’s, that nearly 1 billion
people were trapped into vicious circle of poverty, malnutrition and disease
(Partow and Bekele, 1989) One third of all deaths was occurring to children
under 5 years old. In the developing countries approximately 11 million
children less than 5 years of age were dying every year out of hunger,
malnutrition and infectious diseases. Infant mortality rate at this period was so
high that Michanek in 1975 used the term “the passing generation” to
emphasize the scale of death among young children in developing countries
(Macpherson, 1986). In these countries mortality rate of children aged 1- 5
I
I
L
years were twelve to fifteen times more than children bom in developed
countries. Morbidity rate was high; there was widespread suffering from neo
fatal diseases. There were wide regional differences in life expectancy at birth.
While it was about 70 years in developed countries, it was 50 years or less
than that in developing countries. Infant mortality rate was 10 -20 per
thousand live births in developed countries against the range of 70 -300 per
1000 in developing countries (Bekele & Partow, 1989). These disparities
could be observed between countries, within countries, between city and
country, between rich and poor and between male and female.
24
It has long been recognized that the diseases of developing countries
are diseases of poverty, poor environment conditions, lack of clean water,
inadequate nutrition, and population growth. Malnutrition was identified as
the biggest single contributor to child mortality in developing countries by
Food and Agriculture organization in 1970. It was accepted that despite
considerable variation within and between developing countries both in
patterns of disease and levels of ill health, the conditions of the poor in
developing countries are basically similar everywhere in the world. Diseases
were brought under control in most areas by 1950s, but since the 1960s it
again became a serious problem. There was success in malaria eradication
during the 1960s, but it increased dramatically i.e., the number of cases
increased by over 230 percent between 1972 and 1976 (Macpherson, 1986).
This has cast doubt on the ability of vertical disease control programmes.
Then the question raised, why vertical programmes weren’t able to solve the
health problems? It was realized that disease is not the production of single
causal factor, but multiple factors, the social, economic and the environmental
conditions have equal bearing on diseases. But the vertical programmes were
!
based on the techno centric view of health, which believes that medical
interventions have the ability to solve the disease problem (Phillips, 1990), so
i
it treated diseases as single units. It was realized during this period that areas
dominated by poverty and malnutrition are not likely to respond to the narrow
vertical programmes, because most of the diseases of the third world are
25
manifestations of poverty. As long as the root cause of disease is not
addressed, the disease is not going to disappear. But vertical programmes
were fragmented and competitive, it was only addressing the disease problem,
instead of addressing the cause of it. There was a need for paradigm shift in
the treatment of diseases, i.e. a shift from bio-medical model which believes
that disease is a production of single cause, to a holistic model, which focuses
on the relationship between human health and the total socio-economic and
environmental conditions.
It was also necessary to redress the imbalance between rural and urban
health care coverage. Most of the time the health care system was biased
against rural areas. Health care system of most of the developing countries
was a continuity of the colonial health system. In the 1960s there was a rush
for independence particularly in Africa. Health services in the developing
countries, the majority of which were former colonial territories, have grown
out of colonial medical care systems. The patterns of underdevelopment have
their roots in colonialism. The pattern of medical care during colonial era had
three major components: urban hospital, the rural dispensary, and public
health or hygiene. While hospitals were initially to meet the needs of the
Europeans, the rural dispensaries were essentially curative institutions,
i
dispensing drugs to outpatients. In terms of public health, the essential
objective of colonial policy was to provide safe environment for the
Europeans. The legacy of colonialism was irrelevant to the needs of the
26
majority. Political independence made little difference to health policies in
most of the developing countries. Most newly independent states tried to
expand their health care system, but in the form it developed under
colonialism. The health care provision was almost in urban areas, which
widened the gap between rural and urban population (ibid.)
In such a discouraging situation it was noticed that significant progress
in health was achieved by China, Philippines, Kerala in India and many small
initiatives were taken up in different parts of world by employing community
based health care mixed with basic needs approach. With this experience,
community-based health care approaches were widely recognized by 1970s.
However, the global economic situation in the post 70s influenced different
set of priorities for the developing countries.
Economic situation:
The 1940’s and 50’s spelled the end of colonial period and European
political and economic domination of the developing world. Post war re
construction was dominated by economic concepts with scarce resources
allocated primarily to increasing productivity in industry and agriculture. The
development planners maintained that though initially the wealth would be
concentrated with a small section of population, gradually it would trickle
down to the poor. This sector required a relatively high degree of skill
formation on the part of the work force. A great emphasis was given to
27
population control and food production. Population growth was considered as
the major contributing cause of poverty. There was dissatisfaction with the
employment creation and distributional record of the growth strategy.
Research findings also revealed that many preconditions for this strategy were
lacking. These factors resulted in looking for alternative strategies. First
reaction to this was employment strategy, it emphasized on programmes to
increase employment in the modem sector but it was soon realized that the
size of modem sector is too small and it doesn’t include urban informal
sectors and rural sectors. Because the concept of employment is not clearly
defined in these sectors, so attention was shifted from employment strategy to
anti poverty strategy. This strategy was required to incorporate programmes
for small-scale rural households, redistribution of lands, and programmes for
rural infrastructural works. The disadvantage of the anti poverty strategy was
that attention was prominently given to income, which often resulted in over
emphasis on the demand side as compared to the supply side. A major lacunae
of the anti poverty strategy was that some essential elements of ‘well being’ of
5
a household were not included (Hoven, 1988). It was pointed out by a few
r
studies (Wood, 1982) that infant mortality rate had grown drastically during
I
the period of Brazilian economic miracle. The largest growth in GNP per
capita took place in late 60s and early 70s in Brazil. But it was realized that
GNP per capita is not an indicator of individual consumption. The miracle
was based on an overwhelming exploitation of the working class, which
28
determined a substantial decline of standard of living of the majority of
population (Navarro, 1984).
The oil and raw materials crisis in the developed countries in early 70s
showed that, if less developed countries are poor; it was not because they
lacked resources. It was during this period, it appeared within the political and
intellectual centers of developing countries that their poverty was an outcome
of the pattern of world wide relations in which the few control quite a lot and
the many control very few. The problem was perceived to be structural (ibid.).
So out of energy crisis of seventies and the inability of the developing
countries to maintain a level of ‘quality of life’. a type of global
interdependency was felt. Research was undertaken into issues of
unemployment and underemployment by International Labour Office (ILO) in
early 70s to conceptualize and measure the social needs of the third world.
Various ILO studies concluded that the employment problems of the
developing countries were not consequence of ineffective labour utilization
but a manifestation of poverty. Due to poverty their basic necessities of life is
not fulfilled and this gives rise to further problems, like disease and ill health.
So in 1976, at the world employment conference the “basic needs approach”
was introduced (Macpheron & Midgley, 1987). It linked the concept of need
I
£
I
directly to the provision of public services. And this approach became
dominant in health policies, more particularly in developing countries. Here it
29
was to replace the state sector in public services or to reduce its role to a
minimum. Structural adjustment policies have involved sharp cuts in public
spending on health, education and other social services, phased removal of
subsidies on basic commodities, shift from production of food and goods for
domestic consumption to production for export, liberalization of trade
policies, privatization of public services and state enterprises, devaluation of
local currency (Sen Kasturi, 2001).
The ‘enforced’ application of the standard economic reform strategies
of International Monetary Fund \ World Bank has become the routine in many
developing countries. This structural adjustment programme had a severe
impact on the essential public goods such
as health and education, the way
they were handled. Privatization, liberalization, and free market
became
dominant slogans from which the already weakened health sector could not
escape (Bruycker, 2001). Several studies highlighted reduction in the
consumption of nutritional staple foods as a result of these changes, especially
among vulnerable groups, such as children and elderly people. This has
occurred in the early adjusting countries of Africa and Latin America, such as
Mexico and Brazil (Watson, 1994, Werner & Sanders 1997). By early nineties
a clear correlation had been established between the introduction of user fees
for health care and a marked fall in women’s attendance at antenatal clinics in
Zimbabwe, one of the first African country to experience reforms. Adverse
health trends were beginning to emerge in
infant mortality and maternal
44
I
mortality levels at Harare General Hospital. Here mortality rate among
children due to mothers who did not attend antenatal clinics was almost five
times greater than that of registered counterparts (Sen, 2001). Many
developing countries implemented adjustment policies since 1980s. As a
result of the adjustment policies, many developing countries had drastically
reduced resource allocation in public sector. UNICEF echoed the danger
signals from these countries. UNICEF report of 1990 and 1992 on “the state
of the world’s children” describes that “for the first time in the modem era, a
subcontinent is sliding back into poverty. The number of families in SubSaharan Africa who are unable to meet their basic needs have doubled in a
decade. The proportion of children who are malnourished has risen”. It further
blames such conditions on the debt burdens imposed by world bank’s policies
on these countries, noting that “the total inhumanity of what is now happening
is reflected in the single fact that even small proportion of interest which does
manage to pay is absorbing a quarter of all its export earnings and costing the
continent, each year, more than its total spending on health and education of
its people” (ibid).
UNICEF report further comments “great change is in as the 1990s
begin. And great change is needed if a country of unprecedented progress is
not to end in decade of decline and despair for half the nations in the world. In
many countries poverty, child malnutrition and ill health are advancing again
after decades of steady retreat. And although the reasons are many and
45
complex, over shadowing all is the fact that the governments of the
developing world as a whole have now reached the point of devoting half of
their total annual expenditure to the maintenance of the military and servicing
of debt (Sengupta, 1994).
By eighties, the International Monetary Fund and World Bank were
freely using the debt trap of third world countries to compel them to accept a
set of new economic deals, of which health sector was a part. By early 90s,
South Asian countries were made to agree to plans which were convinced for
them, but not necessarily by them. They adopted bank driven, narrow, techno
centric interventive strategies in the area of population control, reproductive
child health, and treatment of communicable diseases. They opened up
medical care to private sector and introduced a slow dismantling public sector,
first by depriving it of funds and second by taking advantage of people’s
dissatisfaction with it (Qadeer, 2001).
The world development report, 1993: Investing in Health is designed
to keep state support to health to a bare minimum. It advocates the policy of
further promoting vertical programmes, which destroyed the entire primary
health care concept. Since the world development report 1993, the debate on
public health, or on public interest considerations has been becoming
dominated by economic aspects, with a focus on specific disease and risk
factors, leading to a fragmented picture of health (Bruycker, 2001). The report
46
has a series of recommendations designed to operate the withdrawal of the
state, like reduction in support to medical education, research activities and
tertiary care. In order to keep the state support to health at a minimum, the
report compartmentalizes health into a series of ‘nuggets’ to which it assigns
scores with a novel computing system called “DALY”(Disability Adjusted
Life Years). The whole exercise is to reduce health to a series of mathematical
calculations to determine which intervention ‘optimizes’ returns. The
fragmentation of health into discrete components facilitates the calculation of
DALY. This reinforces a model of health care that has its roots in
technological determinism, which is based on the belief that technological
solutions can be applied to all health problems of a community, in the name of
cost effective analysis. The issue of cost has been pushed to the center stage,
but the questions regarding the nature of development and cost to whom are
sidelined. DALY is a composite index quantitatively representing “burden of
disease”, incorporating into one figure morbidity, disability, and mortality,
expressed in terms of estimated years of human life affected. Each disease is
quantified in terms of number of deaths caused and age of death converted
into standard numbers of years of human life lost “prematurely” and weighted
for value of human life at different ages. The value choices made by the
proponents of DALY include considerations of only those social variables
“that-are general to all communities and households, namely age and sex”.
Other variables such as occupation, income, educational attainment, religion,
and ethnicity have been excluded. Equality as a value is catered to by making
47
no difference in quantifying death or disability of individuals, except age and
sex. For example, the premature death of 40-year-old woman should
contribute equally to estimates of the global burden of disease irrespective of
whether she lives in slum or wealthy suburb (Ritu Priya, 2001).
Due to structural adjustment policy the public sector investment is
shrinking, and this condition is not a favorable condition for PHC approach to
survive. So the survival of PHC approach is questioned, at the same time
SPEC approach is further supported and promoted. As a result of which it is
seen that in 1980s, a disturbing trend emerged, while child mortality rates
dropped, malnutrition and morbidity rates rose. In the late 1980s and early
1990s, the decline in child mortality rates slowed or halted and in many
countries, especially in Africa, the child mortality rate is rising (Kelly, online).
The SPEC approach does not give importance to individual disease problems;
it clusters individuals into certain age and sex groups and tries to treat their
disease problem in isolation of their social context. Because of all these
factors along with selective elimination of PHC approach “health for all by
2000" became an unrealized dream.
The failure in achieving “health for all by 2000" in an international
scenario leads us to ask the question, whether “health for all by 2000" has
been achieved by India? So an attempt is made in the following pages to
understand the Primary Health Care situation in India.
48
Primary Health Care in India:
During colonial period Indian medical science declined rapidly.
Ayurveda along with Unnani, Siddha and all kinds of indigenous medicines
suffered. Indian medical service was established mainly to cater to the needs
of British population and armed forces. The medical facilities had a distinct
racial and urban bias. Government of India Act of 1919 and 1935 led to some
rural health care expansion in a limited way (Duggal, 2000, Banerjee, 1991).
The British who formed health boards and built up sewage, and piped water
supply and medical facilities in England during 19th century, did not take a
similar step as rulers of India. Indians were blamed for their resistance to
sanitary programmes. It was forgotten that the attitude of British people
towards sanitation in the last century had been in no way different from that of
Indians. H. A. D. Phillips wrote in 1880s that “those who know anything of
the progress of sanitary reforms in England are aware that sanitation was to a
great extent forced on the people. Even at the present day there are villages in
England where sanitary arrangements shock the tourists, and sanitary
education is no more advanced than in a Bengal village . Indifference to
sanitary conditions in British society in the 19th century, as noted by John
Bristowe, produces in many persons state of ill health, which makes life
irksome, but do not necessarily end in death. In India, neither the State nor the
elite social reformers launched sanitation campaigning before Independence
(Shah, 1997).
49
Indian national movement compelled the British Government to set up
committees on health situations. The Health Survey Development Committee,
well known as Bhore committee, was appointed by the Government of India
and it submitted its report in 1946. The committee found that the state of
public
health was
very poor,
environmental sanitation extremely
unsatisfactory, inadequate nutrition, protected water supply and drainage
reached to a very small section of population. The gap between the ratio
between people and health personnel was very wide. The majority of the
health personnel served the urban population. There was shortage of women
doctors. Very little attention was given to the general health problems of
women. Bhore committee plan was biased in favour of rural areas with the
intention of correcting the wide rural-urban disparity in the shortest possible
time. It emphasized on an equal footing to the preventive, promotive and
curative services. So, the presence of primary health care approach can be
seen in India 30 years before the recommendations of the ‘ health for air was
accepted in 1978. And independent India had the fortune of having well
studied health policy document and national health plan in the Bhore
committee report. After independence, the Bhore committee report provided a
framework for the development of health services in India. The constitution of
India in its directive principles of state policy provided in the article 47 states
that the “state shall regard the rising of the level of nutrition and standard of
living of its people and the improvement of public health as among its primary
duties”(cit Guhan, 2001).
50
-
1
While the first health ministers’ conference in 1948 accepted in
■
T
principle the recommendations of the Bhore committee, the subsequent
conferences and committees, conferences and Five-year plans picked up only
pieces of the recommendations of Bhore committee recommendation (Duggal,
2001).
In the First and Second Five-Year Plans, priority was given to
building infrastructure, water supply, and sanitation, maternity and child
health. Health sector planning was visualized as a technical and managerial
exercise. The central problem of poverty was left for the economic planners
after recognizing the link between poverty and disease. This separation led to
a disjunction between nutritional planning, agricultural policies, sanitation.
control of communicable and occupational diseases and welfare sector
planning (Quadeer, 2001). The percentage of funds allocated in the Five-Year
Plans for health have been inadequate and nowhere commensurate to the
recommendations of Bhore committee. Third Five-Year Plan onwards greater
focus was on the urban based curative infrastructure like, medical colleges,
hospitals and the training of doctors even though the rural primary health
centers suffered due to the unwillingness of the urban trained doctors to serve
the rural areas. There was massive increase in manpower, infrastructure and
financial inputs in the field of curative medicines. During this period, the
health planning indirectly supported private sectors by diverting attention
from the holistic approach of preventive, promotive and curative aspect and
people’s participation as recommended by Bhore Committee especially for
51
09058
rural areas. Private sector not only grew at fast pace, it also received
■^1
government subsidies. During this period health policy was guided by
planning commission and few committees on specific issues, this process
I
diluted the comprehensive character of health policy. All these factors resulted
in primary health center concept being relegated to a centralized health
bureaucracy to help achieve the national targets of a variety of vertical
programmes such as family planning, devised by international experts. Force
and coercion became the hallmarks of family planning programmes. The
height of arrogance was reached during the Emergency when officially
inflicted atrocities became the main reason for the downfall of the Congress
Government in 1977 (Antia et al, 2000, Qadeer, 2001).
India was a signatory to primary health care declaration of Alma Ata
in 1978. But Sixth Five-Year plan did not find a mention about it. The
programmes of immunization and later the child survival strategies were
promoted, and selective primary health care became a part of health sector
planning. Later in 1982, the Government of India came out with a document
sharply criticizing the pattern of health service development since the country
attained Independence. Within the over all framework of the Alma Ata
declaration, India had accepted primary health care as the basis of planning
for its health services. In 1983 a comprehensive, all embracing national health
policy was formulated. India’s national health policy was mainly influenced
by the preamble of the constitution of India, envisaging the establishment of
6^
new social order based on equity, freedom, justice and dignity of the
individual. The primary objective of the national health policy was to attain
R
H
the goal of health for all by 2000 AD. But the implementation of
comprehensive primary health care continued to be weak. Despite the
!
advantage of having started the programme earlier, Indian government has
chosen to put on a number of independent programmes and call them as its
PHC strategy, while the PHC strategy should have been more comprehensive.
The acceptance of primary health care policy and formulation of national
health policy was in fact a political move by the government of India to regain
its democratic image that had sullied by the emergency and it’s excess
(Qadeer, 2001).
Though the PHC strategy advocated for decentralization of health
services, in India, the health care service continues to be centralized in its
form. Health care system in India is operationalized on a three-tire system, the
central, the state and the district. Though constitutionally the responsibility of
health lies with the government of each state, health policies are defined by
central government, which allocates grants from the plan budget. So the
responsibility of the central level of administration consists mainly of policy
making and planning, guiding, assisting, evaluating and coordinating the work
of state health ministries. And the primary health centers are the principal
institutions for providing integrated service to the rural population. Planning is
made at the central level, which needs to be implemented in the grass root
I
1
I
I
level. In other words, while there has been a great deal of macro planning at
the secretariat armchair level, there has been very little of micro planning at
field level. Programme related information, guidelines, technology and
resources have to pass through a series of steps before they reach the people.
Large parts of potential of the given medical technology is lost in multistage
transfer process. The bureaucratic set up is highly centralized organization.
The highest level of organization is far removed from the ground level
situation (Shiva Raju, 1991, Srinivasan, 1987, Cruz and Bharat, 2001,
Kochar,1991)
Though Alma Ata accepted community participation as central to
primary health care approach, but while translating the ideology into action
India systematically ignored it. A vast gap can be noticed between programme
and implementation. The national health policy is against ‘vertical’
programmes and advocates that existing vertical programmes like the national
malaria eradication programme, family welfare etc. be merged into the general
health services. But in practice new vertical programmes such as AIDS and
separate organizations, like national AIDS control organizations were formed
outside the ministry of health (Report of the independent commission on
health in India, 1997). During the Ninth Five-Year Plan India had already
received the World Bank policies for structural adjustment. The entry of
international agencies like World Bank has meant an attempt to dictate the
development policies, plans and programmes of the country. After India
accepted the conditionality laid down by the World Bank/IMF, there was a 20
percent reduction in the allocation for the health services compared to its
previous year. The World Bank seems to be promoting vertical programmes,
which destroys the concept of primary health care. The World Bank package
on communicable diseases focuses primarily on AIDS, malaria, tuberculosis
and blindness. Between 1990 and 1993, World Bank funding for AIDS went
up, while there was a cut for programmes, which is critical to the poor. There
was 40 percent cut in the malaria programme and 20 percent cut in the
eradication of tuberculosis (Report of the independent commission on health
in India, 1997, Banerjee, 2001,Cruz and Bharat, 2001). The key to successful
implementation
lies
in
cultural
affinity,
constant
availability
and
accountability to the people of whom they are a part. This is a social than a
medical function which vertical programmes formulated by World Bank can
never hope to achieve. Since our own bureaucracy in Delhi and state capitals
cannot understand this problem due to their physical and cultural distance
from the people, it is less likely for those orgamzations that dictate policy
from the opposite side of the globe (Antia, 1994).
Much emphasis is given to vertical disease oriented programmes rather
than comprehensive programmes. Again the public spending on health
remains low in priority in most of the developing countries, including India,
which makes it difficult to carry out comprehensive programmes. Only 1.7%
of India’s total public expenditure is devoted to health care, in sharp contrast
with 16.9% in US or 14% in UK. It is even lower than that in some less
55
r
R!
i
developed countries like Brazil (5.9%), Malaysia and Kenya 5.6% (World
Development Report, 1997). Debabar Banerjee (2001) also highlights that in
Europe and Japan the percentage of public expenditure on health is over 80%,
;
■
while in India it is only 23%. Even in USA it is over 50%. And after India
submitted to the conditionalities laid down by World Bank there is further 20
percent reduction in the allocation for health services. The fund allocation on
health care is very less out of which a large amount goes on the payment of
staff.
Due to this poor central government expenditure on health, health
service system is affected. A keen observation on India’s health situation was
made by Amartya Sen, he states “illness is, obviously enough, one of the most
widespread cause of human deprivation and economic insecurity in India. It
affects not only the actual patients and those who depend on them for their
subsistence, but also the other members of the society, in so far as the threat of
disease arising from morbidity reduces the quality of life. A well developed
public health system is an essential contribution to the fulfillment of social
security object!ves”(Dreze and Sen, 1995). The public investment on health in
India has been miniscule compared to the demand for health care in the
country. So the quality of health care suffers.
For the low quality health care provision by primary health centers,
primary health care becomes inaccessible to the masses. Jayaram (1977) and
Madan (1980) in their studies made it prominent that the inequality becomes
manifest whenever any disease acquires epidemic or massive proportions. In
all these cases it is the poor who get hit hardest as they have the least access to
information, doctors, hospital care, transport, life support systems.
From the above discussion it becomes clear that, Alma Ata declaration
represented the liberation of people through the promotion of self-reliance and
democratization of health services. Though the primary health care approach
was advocated enthusiastically by the world community in 19/8, the grand
ideas were not translated into practice. The SPHC approach has been accepted
by the international agencies as a better alternative. And the SPHC approach
is further promoted through structural adjustment programme, while primary
health care strategy is suffering a natural death due to cut down in public
spending. In Indian context the primary health care approach has not been
implemented successfully. Though India signed Alma Ata declaration in
1978, it only tried to implement the programme in 1983, by that time the
global economic recession had already started. So the climate did not favor
the primary health care approach, which needed large amount of social sector
spending. And India’s acceptance to structural adjustment policy further made
it difficult for the primary health care approach to sustain successfully.
Though the selective primary health care approach has been adopted by the
state, the past experiences with vertical programmes have already shown that
such programmes do not have an impact because it tries to treat the disease
57
independent of its social surrounding. In such a situation the question always
remains, how far the state will be able to solve the disease problem of its
population. Given this scenario, to what extent the existing institutional health
care delivery is approachable, accessible and affordable to the rural poor is
examined in the next chapter.
A RURAL HEALTH CENTRE IN PATANCHERU:
STUDY FINDINGS
The primary health eare approach of 1978 was not new for India.
rS
1
Presence of the approach could be felt since the 1946 Bhore committee report,
■J
1
i
Again the primary
health care approach was redirected in the first ever
■
t
■
national health policy of 1983. The primary
objective of national health policy
was to attain health for all by the year 2000
”. But the implementation of
continued to be weak. The selective
primary health care programme
took over the primary health care approach, Selective
programmes
programmes were promoted through the health care system, which was meant
for implementing primary health car. approach. The selective disease oriented
programmes do not treat peopie as a whole; rather it dusters people into
certain age or sex groups and
and tries
tries to
to treat
treat only the problem of disease
independent of their social surrounding. This approach is in exact opposition
to the primary health care approach. So it diluted the pnmary
healthcare
programme by being implemented through same organizational structure.
After India’s acceptance to structural adjustment progmmme, there is a
reduction in the public spending on health. Again this makes it difficult for the
primary health
care approach to sustain. The World Bank through structural
adjustment policy further stresses
on vertical disease control programmes. So
in the Indian context the primary
health care approach has never been
implemented Mly, though Indi, had the potential to implement this primary
59
health care programme successfully. In such a situation, the question arises
formulated and
that the existing primary health care model that was
implemented from time to time, to what extent, health services are available,
accessible and affordable to the rural communities? Although the aim of
primary health care is to bring health care as
close as possible to where people
live and work, it leads one to ask how accessible are health care services to
communities and what are the constraints in accessing health services for the
rural poor?
In order to assess some of these issues, I conducted a study on a Rural
health centre (RHC), located in Patancheru, and two of is sub centres. This
study was expected to give clues about the health care system in India and
how far the health care
centres are able to meet the health needs of rural
communities. The health centre is located on a national highway, about 30
kilometers from Hyderabad city. It is a model health centre for field training
unit of social and preventive medicine department of Osmania medical
college. The main objective of the health centre is to give hands-on training to
house surgeons and paramedical students regarding comprehensive health
services and make the services available to the community.
60
Organizational structure of Rural health centre and it’s sub centres:
!
The rural health centre is under the administrative control of the
Principal, Osmania Medical College, but the health targets are fixed by district
level administration and hence, a kind of dual administration operates at the
health centre. The rural health centre covers 42 villages consisting of about
one lakh twenty thousand population. There are three sub centres under this
rural health centre, i.e. Ismail khanpet, Ghanpur and Chitkul. Ismail khanpet
sub centre exists at a distance of 17 kilometers on the western side of
Patancheru, the sub centre covers 7500-8000 population. Ghanpur sub centre
is located in the southern side, about 7 kilometers away from Patancheru and
covers 4000-5000 population. And Chitkul sub centre exists 7 kilometers
away in the western side of Patancheru and covers 4000-5000 population.
In the Rural health centre, health officer is the supervisor of the health
team, under him two medical officers, one assistant woman surgeon and one
assistant dental surgeon and other paramedical personnel work. In the sub
centres the medical officer is the leader of the health team, along with other
paramedical personnel. For the purpose of study data was collected randomly
from 15 medical, paramedical personnel and house surgeons who came for
training. The age-sex com]iposition of the respondents is given below.
61
1’
Table -1: Age-sex composition of the respondents (Medical Personnel)
Age group
Male
Female
Total
21-30
4
1
5
31-40
0
0
0
41-50
1
1
2
51-60
1
0
1
Total
6
2
8
In the age group of 21-30, 4 out of 5 respondents are house surgeons who
were appointed in rural health centre for training, and one lady health officer
belongs to this age group. In the 41-50 age group the respondents were one
health officer of Ghanpur sub centre and one assistant woman surgeon of
RHC. And in the age group 51-60, the respondent was the health officer of
RHC.
Table -2: Age-sex composition of respondents (Paramedical Personnel)
Age group
Male
Female
Total
21-30
0
1
1
31-40
1
1
2
41-50
0
1
1
51-60
2
1
3
Total
3
4
7
62
■'
In the 21-30 age group the respondent was a multipurpose health assistant, in
the 31-40 age group the
respondents were pharmacist and dresser. In the 41-
50 age group the respondent was a pharmacist and in the 51-60 age group one
public health nurse and one health supervisor of RHC and one health
supervisor from Ghanpur sub centre were the respondents.
Socio-economic profile of the community respondents:
Data was also collected randomly from 27 respondents who came to
access health service from the Rural health centre. Their socio-economic
profile is given below.
Table-3: Age-sex composition of the respondents (community)
Age group
Male
Female
Total
17-45
10
15
25
46-60
0
1
1
61 and above
1
0
1
16
27
Total
L_
Among the community respondents, 16 of them are females and 11 are males.
Majority of them belong to 17-45 age group. However the age profile of the
randomly selected respondents in this study does not reflect the actual profile
of different communities accessing the health services at RHC, Patancheru.
63
The findings of my study are presented along with other studtes m
order to compare as well as analyze the issues of accessibility in health care in
a more comprehensive manner. Although several factors limit people’s access
to health care, in this study, it is found that most of the people am not given
proper attention by the health personnel, and there is a clear bias in favor of
educated and economically well-off people and known people of health
personnel. Casual approach of dispensing medicine was noticed in the dresser
of RHC. Although some particular medicines were prescribed, due to
of medicines, whatever medicine was
available was being dispensed to
people. Some unhygienic way of dispensing medicines to the poor and
uneducated people was also found. For example- two bottles of me
were kept on a table in the comer of the dispensary, which were kept open all
the time. And a stick to which cotton was tied on one end kept in each bottle
of medicine.
When people (especially poor and uneducated) come for
dressing, the medicine from the bottle is applied, without
wound, even though the cotton touches the person
even cleaning the
’s wound every time while
applying the medicine. And this stick is kept back inside the bottle.
Sometimes when three to four persons are in a queue, the medicine is applied
at a stretch without even adding more medicine into it But differential
treatment is found when
educated, rich and known people come and approach
for dressing. The dresser used to take out medicines from new stock to apply
medicine to these people.
64
'll
1
It was revealed by one of the paramedical personnel that when penicillin
injection is not available in the health centre poor are dispensed with vitamin
‘B’ complex injection, though they are prescribed for the former one. It was
also revealed that with the shortage of government supply of disposable
syringe and needles, the recycled ones are required to be sterilized for a
particular time period, but because of over flow of patients, and their attitude
towards poor clients, they are not sterilized as required. Most of the time
people are asked to buy needles from outside, with some exception to the aged
patients from buying the needles. In this study it is observed that while
dispensing injection to the poor, the same syringe is used to dispense different
kinds of injections, without even sterilizing or cleaning it with water. Similar
kind of finding is also drawn in Rai and Bhaduri ‘s study (2001). In their study
it was found that most of the people feel that there is a clear bias in favor of
high caste, educated and powerful (socially, economically and politically)
people. The rural poor felt that the PHC doctor often maintains distance; the
doctor does not encourage dialogue. So this kind of bias against the rural poor
limits their access to health care.
It was also observed that people while seeking health service most of the
time prefer to consult doctors belonging to their own social group. In my
study it was found that in OPD (out patient department) though two to three
house surgeons are there, but when a Muslim house surgeon is available
65
(identified by his beard, dress and looks) the Muslim patients consulted him,
though there used to be less crowd near other house surgeons. So cultural
sensitivity is as important as any other medical intervention for the successful
primary health care approach in India.
The vacancy of staff in the health centre also makes the health service
inaccessible to the rural poor. Urban orientation and private practice
orientation of the medical personnel results in lack of staff in the health
centers situated in rural areas. In my study it is found that, in one of the sub
centres, Chitkul, the medical officer post is vacant for four months, so doctors
from RHC Patancheru go for health check up and immunization only once in
a week. It implies that this sub centre is being run by para-medical staff except
occasional visits by the doctors from RHC. In another sub centre, Ghanpur,
though the post is filled, the doctor goes to the sub- centre once or twice in a
week depending on his convenience. That too for the purpose of
immunization, the doctor goes to the sub- centre regularly on every
Wednesday. Here it is important to point out that the immunization programme
and other vertical programmes are given much importance by the health
professionals, and there is a clear negligence towards delivering other curative
services, which is the felt need of people.
From the study on these two sub
centres, it is clear that the filling up of the post of medical officers or the
vacancy of post does not make much difference. Even though the post is
filled, most of the time the doctor is not available in the health centre, because
66
the doctor is not willing to stay in the rural area. The reluctance to stay with
the rural communities is justified with the targets that need to be fulfilled as
part of vertical health programmes. The ‘vacancy’ in health centres is often
i
pointed out for inordinate delay and work pressure on part of the medical
officers, m not discharging health services to the people. However, it is the
5
target-oriented approach that is mainly responsible for not attending to people
with sickness, although insufficient staff issue cannot be brushed aside,
In
both the sub centres, in the absence of doctors the paramedical staff try to run
the OPD. But in the absence of doctors, people are reluctant to visit sub
centres, because they think that the paramedical personnel are not trained
enough to prescribe medicines. People’s expectation from the doctors may not
match with the presence of only paramedical personnel at sub-centre. Hence
most of the time they come directly to RHC for treatment. Similar finding is
also drawn by Rai and Bhaduri (2001). They point out that in the absence of
doctors, the number of patients visiting the PHC is appealingly low.
From the study conducted by Ray and Bhaduri (2001) it is prominent
that the shortage of doctors severely limits the extent of curative health
services that can be offered by primary health care network. In UP, where
doctors posted in primary health centre are never present there, in West
Bengal, the government health services fail to attract
new doctors and
therefore posts of medical officers at primary health centre remain vacant. In
primary health centres some doctors deliberately neglect OPD patients,
67
thereby indirectly compelling them to visit their private clinics. They often use
local ‘quacks’ and agents of different modes of transport (like rickshaw
pullers) and other middlemen as commission agents to lure patients to their
clinics. It is often found that the medical officer of the PHC is demotivated
and somebody who is more interested in illegal curative medical practice, can
hardly serve as a role model for rest of the team. In the absence of supportive
leadership, the lower cadre staff are required to carry out their responsibilities.
Selective concentration of health care providers, such as urban
concentration and preference for private practice becomes a major concern in
making the health service inaccessible to the rural poor. As per 1981 census,
59 percent of the country’s medical practitioners are located in cities out of
which 73% of the allopathic practitioners are located in cities, and especially
metropolitan ones. For instance, of all allopathic medical graduates in
Maharashtra 60% are located in Bombay city alone which has onlyl 1% of the
state’s population (Duggal, 2000). In the Ahmednagar study conducted by
Foundation for Research in Community Health (FRCH) in 1992, it was found
that 77% of allopaths were in urban areas and 23% in rural areas. Not only is
there an urban bias, but also most of the health professionals are interested in
private practice. In 1996 it was found that 68% of the hospitals were private
hospitals where as 31.9% were public. And in 1986 while there were 73.4%
private allopathic doctors, only 26.6% were in public services. In 1997-98 it
68
was found that while 77.1% of all allopathic doctors were in private sector,
only 22.9% of them were in government sector (Duggal, 2000).
From the above studies it is found that most of the medical professionals
are urban oriented and private practice oriented. All these factors limit access
to health service to the rural people and particularly the rural poor. The urban
orientation and the preference of private practice among the medical
professionals gives rise to shortage of doctors in public sector in general and
the rural area health centres in particular. For this factor the rural poor, who
cannot afford to spend on traveling and private treatment, has the least access
to health service. As Banerjee (1983) points out that the policy with regard to
the education and training of medical professionals at various levels has
resulted in the cultural gap between the people and personnel providing health
care. Studies show that the urban educated health personnel are unwilling to
stay in rural area and serve the rural communities. This results in urban
concentration of doctors and shortage of doctors in rural areas.
Health service becomes inaccessible to rural masses not only due to
the urban orientation of the medical personnel, but the gap between macro
level planning and micro level implementation of health services also makes
the service equally inaccessible to the people. Health planning is made at the
central government level, which is required to be implemented at grass root
level. Rural community’s health needs and their culture of acceptance or
69
5
rejection of particular health behaviour is not taken into consideration in the
health programme, although it is intended for the people. For example: in my
study it is found that certain food taboos are practiced by women during and
*
■'W-
after pregnancy. After pregnancy women are restricted to take certain foods
like potato, brinjal, fish etc., though they are advised by the health personnel
to eat all kinds of food. It is not accepted by the rural people, because they see
the health personnel as someone who does not know about their customs,
practices and values. The traditional folk cultures of village, their pattern of
behaviour and perceptions, may not always match with the assumptions of
modem health technology. So there is some tension and misfit between the
assumptions of medical technology and rural life style. The plans for
providing health service are drawn at macro level, which has little
understanding of rural people’s attitude of acceptance and rejection towards
particular health behaviour. So as long as the health programmes are not made
with the people, and it is only made for the people, the problems are not going
to be addressed. The involvement of the community is required to implement
health policy successfully. The community has to be made aware of every
health activity. So the process of implementation of health programme
deserves closer attention, i.e. the manner in which the health workers carry out
specific programme interventions and activities, the manner in which the rural
communities and individuals interact with or respond to the health worker and
how they act in relation to the information and tasks entrusted to them.
70
The highly centralized administration with vertical programmes as
their strategy is unable to address the felt health care needs of the rural
masses. This is one of the major limiting factors in terms of accessibility to
health services. Out of 27 respondents who came to seek health service from
Rural health centre, 15 of them said that the health workers don’t visit their
>
houses, and 10 respondents said that they visit their houses either for survey,
immunization or for the purpose of persuading people to accept family
planning. Though at the planning level they are required to carry other
activities like health education, most of the health workers do not see it as
their primary duty. They only give importance in meeting the health targets.
Several studies have observed that family planning and immunization
programmes get a disproportionately large share of the health workers’
effective work-time (NIRD, 1989, Duggal and Amin, 1989, Duggal, 2000).
An overriding priority is given to the family planning. While the plan
allocation for it was Rs 6.5 million in the first plan (1950-55), it increased
10,000 fold and became Rs 65000 million in the eighth plan (1991-1995). But
the plan allocation for other programmes did not rise on par with the family
planning allocation (Banerjee, 2001). The family planning targets are fixed at
the central level and each level of bureaucracy is required to fulfill the
assigned target. Entry of target achievement in service records of the health
bureaucrats is the motive behind this kind of action (Banerjee, 1992).
71
In case of RHC patancheru, the target of family planning is fixed by
District level authority. The target for family planning for the year 2000-2001
was 1280, and it is 1300 for the year 2001-2002. Auxiliary nurse midwives
and their field supervisors and lady health supervisors are required to generate
a prescribed number of family planning cases. If they fail to meet required
number of targets their fixed tour allowance and increment are stopped by the
authorities. As it is pointed out in Jairam’s study (1977) that a majority of
ANMs and basic health workers are from lower middle class background and
so when their increment or allowance is stopped they are hit hard. For this
reason they desperately want to meet the family planning target. Because of
this sometimes they try to convince the poor widows and people who have
crossed the reproductive age through offering government sponsored entice.
In my study, one of the respondent who is a widow belonging to Lambda
tribe, had come for tubectomy operation said that the health worker convinced
her to go for tubectomy operation, because of Rs. 500 incentive being offered.
While action is taken against the health workers for not fulfilling certain
targets for family planning, similar kind of action is not taken against them for
not delivering some of the most essential health services, like health
education. Hence health workers give top priority for fulfilling the targets of
family planning and immunization, where as the other health care activities
are given least importance.
72
In the monthly health centre meetings, most of the time is devoted to
review
f
;•
case motivations by individual staff members. Auxiliary nurse
midwives, the field supervisors and lady health visitors are required to
generate a prescribed number of family planning cases from scheduled areas.
Mark Nichter (1986) in his study focuses on how this target for health workers
introduces organizational conflict and provokes tension and competition
between the cadres. This affects the health service delivery.
It was found in my study that when the family planning programme is
resisted by a particular community, different types of coercive and pressure
techniques are used, which is antithetical to the primary health care ideology.
It was revealed by one of the paramedical staff that when people in a
particular village don’t accept family planning, pressure is built on the
community through Mandal office, by which it stops giving loans to the rural
poor for buying seeds. So the family planning targets not only makes health
service inaccessible to the poor, but the rural poor’s non-cooperation in
achieving the targets affects them badly, by making other services
inaccessible to them.
It has been observed in various studies that family planning and more
recently immunization gets a disproportionately large share of health worker’s
effective work time. In my study it is also found that the other services in the
health centre gets affected badly because of the over emphasis on family
73
planning. In the RHC most of the health centre staff are engaged in family
planning programme for which other programmes suffer, The two medical
officers and the woman assistant surgeon concentrate on the operation theatre,
where only family planning operations are done, although one of the medical
officers is supposed to look after OPD and the health officer is in charge of
the inpatient ward. But a greater importance is given to meet the family
planning target; so the two medical officers spend their effective time in doing
family planning operations, while OPD is left to the house surgeons who are
on training. By implication, patients at OPD suffer as the house surgeons run
OPD, instead of any experienced medical officers.
A batch of 20-30 house surgeons is posted for one month in RHC for
training. They are required to work under the supervision of medical officers
and health officer. The batch is divided into four groups. Each group is posted
in OPD for a week and they work on rotation basis. So everyday two to three
house surgeons are on OPD duty. In the absence of medical officer and with
frequent change of house surgeons, the laypersons face a lot of problems,
They complain that when one house surgeon prescribes certain medicine and
asks the person to revisit for follow-up, the same house surgeon is not found.
And in the absence of that particular house surgeon, no attention is given to
the prescription written by her/ him, by the other house surgeons. Hence the
diagnosis for follow-up cases starts from the beginning again. The rural clients
complain that most of the time in the nearest sub centres, the doctors are not
74
i
I1 ;
available. When these people are in dire need of health service and cannot
afford to pay private practioners, they come to approach this RHC to fulfill
their health needs, but here also they don’t get satisfactory treatment.
■>
The over emphasis on family planning leads to neglect of other
patients in various ways. In RHC, for instance tubectomy cases are given
more importance compared to delivery cases by the health centre staff. When
more number of tubectomy operation patients get admitted in the health
centre, the delivered women are asked to shift from the ward to the corridor.
The delivered women complain that enough care is not provided by doctors
and nurses. Dayas only help with deliveries, but they feel that dayas in the
health centre are less skilled than doctors and nurses. Even after the delivery
the patients are not attended by doctors. This is another evidence of health
personnel attending to those cases that meets their targets at the cost of other
serious cases. Cruz and Bharat (2001), also point out that pregnant women are
treated badly in addition to being pressurized for contraception. As a result
only 13 percent pregnant women register for antenatal care and 8-10 percent
deliveries are attended by government personnel.
The family planning programme itself is discriminated and
programmed against women. The ground level health workers who are
employed to meet the targets are also women. So they always feel comfortable
to convince women. In state health policy, the family planning programme is
75
formulated in such a way that, it only attracts women to accept it. The entice,
given by the government for receivers of family planning is more in case of
women. A family gets more monetary benefit, in case of a woman recipient
than a male recipient. So there is pressure on woman to go for it. At the same
time the health personnel get more monetary benefit for convincing women,
than a man, so they pressurize women.
The programme acts as a kind of
oppressive mechanism against women. Due to this programme women are
pressurized by the health workers and the family members to go for the
tubectomy operation. Women are subjected to emotional harassment and
forced to go for the tubectomy operation. One of my woman respondents told
how her husband insisted her to go for tubectomy operation, instead of him
going for vasectomy operation. And gave the justification that she should go
for operation, because he is the wage earner and if he goes for the operation he
will be weak, which will affect his work. At the same time, the domestic
work, that she is engaged does not get counted as work. Though the woman
also felt that she will be very weak after the operation and was as scared of the
operation, she was forced to go for it. So the target oriented family planning
programme not only affects the health service delivery in the health centres,
but it also pushes women into further subordination.
It is not only the family planning programme that discriminates against
women, the primary health care approach also does not address the needs of
women as a marginalized category, who has least access to health care in the
76
1
society. Women’s health needs are given less importance in the society as
well as in the family because, most of the time they don’t contribute directly
I
I
I
to the economy of the family. So in a family where there is lack of resources
the health needs of a male member is given much importance because of his
direct economic contribution. There is reluctance to invest money on women s
health. Primary health care approach views women only in terms of their
childbearing roles. So for the women who fall outside the category of
motherhood, their health needs are not addressed. These factors reinforce
discrimination against women and
further worsen their health status. Cruz
and Bharat (2001) point out that, in the Indian context while only two percent
of national health budget is spent on women through MCH programme,
family planning programme gets a respectable share, which is targeted against
women. In Indian the context women and adolescent girls face various social
and cultural constraints in acquiring health services and expressing their
health needs. One of my woman respondents who is a Muslim said “there are
many restrictions on our movement, we don’t come to the health centre until
and unless the illness is unbearable”. So there are lots of restrictions on the
movement of women. Due to social norms women as a category have the least
access to health services. So when the sickness becomes unbearable and
affects their work, they come to approach the health centre.
There is an urgent need to structure the health services to respond to
gynecological and obstetric conditions that women experience, and to take
77
into consideration the social, cultural and the economic constraints that
women face in expressing them. In my study, most of the women respondents
I
said that they don’t feel comfortable to tell their gynecological problems to a
I
only male house surgeons are available, in the absence of any lady doctor,
doctor, who is a male, due to social distance. Though in OPD most of the time
they are compelled to consult male doctors, but they feel that there is always a
cultural constraint in expressing their problems.
One of the women
respondent said that a woman doctor gives better treatment for gynecological
problems, because she experiences these. There is also a need to address
factors underlying infertility. Women’s poor health and nutritional status,
which can lead to, repeated miscaniage and foetal wastage. Infertility can
have serious consequences for female well-being in a culture like ours, which
prizes reproduction. It leads to various kinds of emotional harassment or
marital disharmony. Adolescent girls, most of whom are out of school,
constitute a sizeable proportion of female population. They are particularly
vulnerable and neglected, coming under the purview of government
programme only once they are pregnant. . The majority are out of school and
are neither served by educational or school health programmes nor by child
health nutritional services. While poor quality of health care can inhibit
women from seeking health care, women’s lack of autonomy in decision
making or freedom of movement and time can restrict visits to health centres
even where a health problem has been recognized. Health workers themselves
are poorly informed about reproductive morbidity and can be insensitive in
78
probing and recognizing symptoms (Jejeebhoy, 1997). The present health care
system focuses largely on women sterilization rather than women s health in
general, which limits women’s accessibility to health service. To cater
women’s health needs there is a need for health service, which can be
available to them at their doorstep.
Health programmes are aimed at providing some services to the
people, thereby expecting them to accept, collaborate and comply. The
expectations from health programmes can be described in terms of appropriate
patterns of participation, acceptance and compliance by the target population.
All health programmes to be effective require people to do certain things in a
particular manner, which is different from the customary behaviour. This
means health programmes are in effect the programmes of social change
(Kochar, 1991). So to bring change in the health behaviour, the community
cannot be seen as passive receivers of service; for making it successful, active
participation of the community is required. In India, while translating the
primary health care approach, the community participation was selectively
ignored. So health service is more centralized, instead of being decentralized.
A particular community’s felt needs for specific health behaviour is not given
importance in the centralized planning. And health-seeking behaviour differs
from community to community, so a universally applicable health programme
is not going to solve the problem. As Imrana Qadeer (1985) defines health as
a social concept, which is determined by the perceptions of a group or
79
community and therefore differs from community to community. So to
identify different community’s health needs, it is important to understand the
social and cultural context of people’s lives to identify their health needs. A
comprehensive concept of health should have an inbuilt social dimension,
reflecting upon the available knowledge and consciousness of people and
culture and power relations within the society. The health programmes are
drawn at the central level, and the rural people don’t necessarily share the
perceptions of health planners and their priority of health needs.
As the
perceptions about the health behaviour differs, the acceptance of a particular
health programme becomes difficult.
Based on the field data and observation, it can be said that the poorer
sections of population, i.e. Muslims, migrants and S.Ts are the ones who
predominantly access health services at RHC, Patancheru (see table- 4). This
is because all of them with their meager income could not afford private
practitioners and hence consulted RHC. In the West Bengal case study Ray
and Bhaduri (2001), found that the hospital OPD is used either by the very
poor who have no access to credit to make an immediate payment for private
medical care or by the rich and politically influential who can extract
preferential treatment from the OPD services
S
80
Table - 4: Caste and disease wise distribution of the respondents who
consulted RHC
Minor ailments
Skin disease
Febrile
Gynecological
problems
Caste
Male
Female Male
1
2
Muslims
1
Female Male
1
1
Female Female
2
1
S.Ts
S.Cs
1
B.Cs
1
1
5
13
1
2
1
2
1
3
1
1
U.Cs
Others
3
Total
Total
1
3
1
4
5
3
3
2
1
6
7
27
ST-Lambadas, S.C-Madiga, B.C.-Munuru kapu, Padmasa i, Mudiraj, U.C- Reddy
Others- include migrants from Maharashtra, Bihar, Nepal, so their castes were difficult to be
classified.
In my study it was found that in five cases while women came to the
government health centre for treatment, the male members of the house went
for private treatment. It was also found in another case that while the earning
member of the house went for private treatment, the non-earning members of
the house visited government health care, and in most cases where there is
frequent recurrence of disease, the government doctor was consulted. The rich
and educated people come to RHC for health care when they knew the doctor
81
Bl
personally and for simple BP check up, other simple checkups and to get
■^1
f'
I
I
I
'1
specific medicines from the health centre which were not available outside.
It was found that most of the time the patients were not satisfied with
the interaction they had with the doctors. Often it is found that the duration of
consultancy is very less, and no physical examination was being done by the
doctors at RHC. The rural people have their own perception of doctor and
expect the doctor to do physical examination by pulse check-up, examination
by stethoscope etc. But when their expectation is not met, they become
suspicious about the effectiveness of the treatment and it restrains them from
repeated consultation of RHC. When the poor villagers expectations from the
health centre is not met, they simply don’t want to access the health centre at
the cost of losing wage and spending on transport. Rhode and Viswanathan
(1995) in their study point out that rural people prefer private practitioner
because the duration of consultancy is more and in case of government clinics
the consultancy period appear to be small and waiting time prior to
consultancy is longer. And the private practitioners give much importance to
physical examinations. Often primary health centre is seen as a poor man’s
place. When all other options of getting health care are closed, they seek the
government health care.
The OPD timing is also one of the important factors in terms of
accessibility to health services. It is found that the OPD timing does not match
82
with the poor wage earners timing. In RHC though the OPD timing is from 9
am to 1 pm, it is actually open from 10 to 12. As this is the time people
engage in wage labour, they have to lose one day’s wage if they decide to
consult RHC. Hence when the disease becomes unbearable to the extent that it
affects their work and also in most cases as they cannot afford private
practitioners, they come for health service at RHC. And they also expect quick
relief, so that they can get back to work soon. Hence there is always a great
demand for injections, which is to save their wage earning. In their study
Rhode and Viswanathan (1995) point out that average rural persons prefer to
go to private practitioners for medical care because of their preoccupation
with quick care. Because an average rural person loses wages if daily work is
interrupted. So they cannot afford the luxury of prolonged cure and periods of
rest. For the relatively poor wage earner and tillers, the treatment at the OPD
often proves to be quite costly in terms of lost working days and wages since
it involves regular visits and long delays every time. Often the OPD patients
have to pay for diagnostics and medication due to lack of adequate supplies.
Thus effectively the cost of private care is not perceived to be significantly
higher. So the poor comes and approaches the government health centre when
the option for accessing the private care is closed due to lack of money. But
here also the poor does not find the health service to be accessible.
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Non-availability of drugs further curtails people’s accessibility to
health services. This assumes much importance because the people who come
to government health centres are needy and all the other options of accessing
health care are closed. It is found that there is shortage of drugs in RHC, for
which the poorer sections of the society and women are affected badly.
Women are affected because there is reluctance for spending on the health
care of women in the family. So most of the time the women members of the
house come to access health service from government health centre while the
other members of the house exercise the option of consulting private
treatment. In the RHC, knowing well the shortage of drugs and institutional
lacunae,
employees of RHC took advantage in establishing their
entrepreneurial activity. For example one pharmacist’s husband has
established his medical store right in front of RHC, while no other medical
stores exist in the near vicinity. The discussion with pharmacist, other
paramedical personnel and community persons revealed that some important
medicines like penicillin also does not get utilized (subsequently may also get
expired) in RHC, while people were asked to buy those injections from
outside to be administered in the dispensary. So most of the time people will
have to buy the injections from outside medical shop and come to the
dispensary to take it. On the other hand, medical personnel take advantage of
institutional weaknesses and make profits; while on the other hand; rural
communities have to make hard choice even in consulting government health
centres as they have to buy injections and certain medicines.
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Due to the casual approach of the doctors and paramedical staff, and
lack of satisfaction and the interaction with the health personnel, people are
often suspicious about the quality of medicines given in RHC. Most of the
people complain that the same medicine is dispensed for different kinds of
diseases (perceived by the size and colour of the medicine). And they feel that
though medicines are available in the health centre not all of them are
dispensed to people. One woman respondent showed two sets of medicines
and told “see, my child and myself are given the same medicine for different
diseases, and the doctor has asked to give the full dosage to the child. How
can a child and an elderly person have same medicine with the same dosage,
either the medicine won’t be effective for the elderly person, or it will be
harmful for the child”. Similar findings have been drawn by Rai and Bhaduri
(2001) in their study, where they discuss that some people complain about
ineffectiveness of PHC medicines, when it is available. The same medicine is
dispensed to all patients irrespective of the ailment. They suspect that good
quality medicines are given to ‘known’ and ‘privileged’ patients.
In addition to the above factors, professional hierarchy of health centre
staff also affects the delivery of health service in health centre. In the RHC, it
was found that there is an over utilization of the services of the sub-ordinate
staff by the upper cadre. For example, while there are two pharmacists in
RHC, one is in charge of dispensing medicines and the other pharmacist takes
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care of the store. The person, who is in charge of the store, is required to take
the medicines out of the stock room only once in three to four days and rest of
the time, she was free. Though it is the duty of a pharmacist to dispense
£
injections, the multi-purpose health assistant was required to dispense
injections at the dispensary, at the same time she was required to be in the
-
operation theatre when tubectomy operation was going on, also attend the
deliveries. This additional burden and irregular shifts (day and night)
demotivates the lower cadre staff. This affects the service delivery. For
instance, in the absence of multi-purpose health assistant the dresser used to
give injections, for which job he was not skilled. Mark Nichter (1986) also
focuses on the generic difficulties in implementing primary health care
ideology at the health centre level. He argues that the ideology of the primary
health care needs to be considered from the vantage point of health centre
staff and in relation to issues involving professional status and personal
motivation. In the health centre workers are keenly aware of each other’s
status, which is in part determined by salary, specialized knowledge and
access to sources of power and symbols of authority. The professional
jealousy between the health centre staff affects the health delivery system. In
the South Karnataka health centre study, Mark Nichter found that two out of
three medical officers observed, restricted their auxiliary nurse-midwife field
staff from administering even the simplest curative medication, though they
have been trained to attend medical emergencies. The rationale of those
medical officers was that if field staff were allowed to dispense medicines,
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they would aspire to become ‘quacks’ and would pay less attention to their
preventive and promotive health duties. At the same time the doctors were
X-
engaged in private practice. The ANMs recognized that their inability to
provide even the most basic curative services reduced not only their status, but
also people’s receptivity to their promotive, preventive health advice.
From the above discussion it is clear that the rural poor has least
access to healthcare service. As Antia (2000) rightly points out poorly
functioning public health care system in rural areas has in some states reduced
to a collection of deserted and chaotic primary health centres, filthy
dispensaries and unmotivated doctors. Imbalance is also reflected in the
quality of service provided to the rural people by primary health centres which
has failed in providing an integrated service and also adequate preventive and
promotive care while neglecting curative services which is the felt need of
people. Though health service infrastructure is there in rural areas, it is of
little use for the rural poor in the absence of health professionals and adequate
services. The rural poor is worst affected, because they lack resources even to
spend on transport to access health service in urban areas. Besides, the cultural
gap between health personnel and rural masses makes the health service
inaccessible to the rural people. Women as a marginalized section have least
access to health service. Their subordinate position in society along with
social norms and restrictions on their movement makes the service
inaccessible to them. The needs of women are not addressed in the primary
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health care service. Women are only addressed in terms of their motherhood
roles, through mother and child health programme and family planning
programmes.
The family planning programme acts as an oppressive
mechanism against women. Due to target-oriented approach of family
planning, the poor in general and women in particular are worst affected. The
selective programmes, which are carried through primary health centres, are
given prime importance by the health personnel, which affects the delivery of
most essential services. As the medical personnel spend all their effective
work time on carrying out the selective programmes, the delivery of curative
health service is affected. The casual approach of the health centre staff along
with shortage of drugs and OPD timings further curtails the accessibility of
health service to the rural poor. People’s expectation in terms of physical
examination by the health personnel do not meet. In addition the casual
approach of treatment of health personnel gives rise to suspicion about the
service made available by the health centre as it forces the poor to choose the
RHC as the last option for accessing health service. Distance is also one of the
critical factors in terms of accessibility to health service. For instance, some of
my respondents who came from more than 5 kilometers, from the places like
I
Chitkul and Isnapur, to access health care from RHC said that for coming to
RHC each time they had to spend 20 rupees on traveling, so it becomes
difficult to access RHC as soon as they fall sick. Only when the sickness
!
becomes intolerable they come to consult doctors in RHC. So the availability
of medicine, long waiting time, money and time spent on traveling influences
88
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or rather hinders the accessibility to health service. It is quite evident that,
whatever health services are available to the rural poor, these services are not
even accessible to them because of the top-down and vertical programmes that
are designed and implemented without any concern for the local needs of the
communities.
89
SUMMARY AND CONCLUSION
WHO defines health as a state of physical, mental and social well
being. The health status of people determines the quality and longevity of life.
Thus health is not merely a need; it is the most fundamental of all rights that
is, the right to life. As it is a right, it is an obligation of the state to fulfill this
need. The concept of health connects well with the development thinking,
which emphasizes that the purpose of development is human well-being.
are health related.
Therefore some key indicators of development
Development does not mean only economic growth. Though economic growth
is a necessary condition for the achievement of good health, but other factors
like environment, education, status of women, dietary/health practices, culture
equally influence health.
The primary health care approach addresses health as an issue of
I
development and right of the individual. The primary health care approach
was first defined in the Alma Ata declaration. It emphasizes on a
comprehensive view of health, giving equal importance to curative, preventive
and promotive aspects of health. It addresses health in terms of three measures
such as: health as a basic human right, a social goal and necessary for
developing strong
economies. Alma Ata declaration made it clear that
ponsibility for the health of their people. This was a
governments have the res]
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redefinition of the norms and expectations of the state’s role with regard to
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health. This was particularly important for newly created states, which were
challenged to provide health care for their population after the collapse of the
colonial system.
Within a year of the introduction of the primary health care approach,
it was criticized, and an alternative to primary health care approach emerged.
Primary health care approach was ignored on the basis of the amount of
money required to be invested. As an alternative to primary health care
approach, Walsh and Warren presented selective primary health care approach
to a joint FORD/ Rockfeller foundation symposium on health services in
Bellagio, Italy, which was well received. This approach was required to
institute health care directed at preventing or treating few diseases that are
responsible for greatest morbidity and mortality. It was justified on the basis
of cost effectiveness. This approach is based on techno centric approach,
which subordinates people into technological packages.
SPEC defines health as absence of disease rather than well-being. This
definition implies that medical intervention can restore health. However, by
emphasizing a biological body-machine model, it undermines dynamic
interaction between mind and body. The interplay of three factors of mind,
body and environment, which is responsible for manifestation of disease, has
not been given importance in selective primary health care approach. Where
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as the primary health care approach gave equal importance to curative,
1.
preventive and promotive health care service, the preventive aspect of it
became the most favored approach of many developing countries and that of
international agencies. The interventions were aimed at the disease rather than
*■
its cause. By ignoring malnutrition as the mother of morbidity, health
interventions based on selective approach gradually developed independent of
its social matrix. Limitations of technology in the context of health of children
1
can be addressed if we focus on the larger issue of role of public health
technologies and emphasize that the health improvements brought about by
immunization and Oral Rehydration Therapy can only be sustained by
availability of food, water, shelter and political and economic power.
The selective primary health care approach became the most favored
approach of international agencies. Due to global economic recession, World
Bank and International Monetary Fund emerged as major funding agencies
and tried to dictate the policy
impose their economic policy
of the developing countries. They tried to
on developing countries in the name of
structural adjustment programme. Through structural adjustment programme,
1
budgets for so-called non-productive government activities such as health,
education and food subsidies were ruthlessly slashed. Here the real issue is not
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whether adjustment is necessary but the manner in which it has been put
through undermines the issue of social justice. In such
a situation the
implementation of primary health care became an impossible task. WHO in its
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“health for all in 21st century” agenda is reinventing the wheel by
emphasizing the selective primary health care approach, and supporting
■
selected disease control programmes. It pushes the commitments to equity and
social justice under the carpet. The proposed agenda of “health for all in 21st
century ” targets the year 2020 as the time frame for achieving this vision. But
as long as the solution to the disease problem is treated independent of the
social context, it may have limited impact, and health for all will remain a
distant dream.
In the Indian context the existence of primary health care approach
was felt much before India’s formal commitment to primary health care
strategy through Alma Ata, in Bhore committee Report 1946. The first ever
national health policy of India accepted primary health care as the basis of
providing health care service. But it has not been implemented successfully.
Selective primary health care approach was the preferred strategy and it was
implemented through the same health care machinery, which was meant for
implementing primary health care approach. And after India’s submission to
structural adjustment programme, the implementation of primary health care
approach became much more difficult. In such a situation, the question arises,
to what extent are the health services available, accessible and affordable to
the rural communities?
93
In order to assess some of the issues of accessibility I conducted a
study on Rural health centre, Patancheru. In the study I have made an attempt
to understand the complex set of factors that determine people’s accessibility
;•
to public health care system which
I
cater to their health needs. The
inaccessibility of government sponsored health care service can be attributed
to various reasons. It is found that most of the doctors are urban oriented and
private practice oriented. Because of this in most of the health centres situated
in rural areas, either the post of doctor is vacant or if it is filled, the doctor is a
reluctant service provider. This attitude of doctors seriously affects the
delivery of health services. Although the paramedical staff try to deliver the
service, it does not meet the expectation of, most of the times. The centralized
planning of health care service is also unable to incorporate the felt needs of
the rural communities. The vertical programmes in general and family
planning programme in particular is given much importance and it is carried
out with much sincerity at the cost of the curative and other essential services
of the health centre and because of this the curative health service becomes
inaccessible to the rural poor. The inadequate supply of drugs also affects
people’s accessibility to health service. Also the professional hierarchy and
subordination of the lower cadre staff affects the health service delivery in the
health center. Along with the several factors mentioned above, the casual
approach, attitude towards the rural clients, timing of the health centre etc
equally restricts people’s accessibility towards public health services. As the
OPD timing does not match with the poor wage labourer’s timing, the public
94
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health service often becomes expensive in terms of loss of wage. And only
when all the options of getting health care are closed, the poor often visits the
government health centre. But here also the poor do not get proper health care
service. So the rural poor in real sense is left with minimal or no option in
J
terms of health care.
As is evident, the rural communities have several factors, which affect
their utilisation of services from the public health system. On the other hand,
several studies
(NSS,1996, Duggal & Amin, 1989, George et al, 1992,
Kannan et al 1991) show that the private health sector accounts for over 70
percent of all primary health care treatment, inspite of the fact that over two
third of the population live below poverty line. But the poor goes for private
treatment not out of choice, but out of compulsion, since services are not
available from government machinery. Without understanding complex set of
factors, why most of the people access private health sector for primary health
care, Draft National health policy 2001 as well as the World Bank prescribes
that the government should focus only on preventive and promotive health
services leaving curative care for the private sector. If this happens all the
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options will be closed for the poor to get cured from sickness, and it will leave
the poor to be diseased in eternity. Again health, especially the preventive
aspects have little significance to the vast majority of people whose main
preoccupation is to provide the next day’s meal for the family. Even illness
i
and pain is not adequate reason to seek medical aid, unless it interferes with
earning their daily bread. Further from my study it is evident that there are
95
people who solely depend on the health centre for treatment and cannot even
i
afford to pay for a single needle to take injection, although the needles
provided by the dispensary are not sterilized properly and there is every
possibility of transmission of deadly diseases by taking injection with those
needles. Secondly in a society like ours where women are conditioned to cope
with and not complain about their sickness and their health needs are given
secondary importance, as also there is a reluctance to spend on their health. If
the government health sector is not going to provide curative service, women
as a marginalized category will be the worst affected category. The goals of
achieving social justice, equity, all round development etc becomes rhetoric
unless felt needs of the communities gets incorporated into primary health
care approach.
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