NATIONAL HEALTH POLICY
Item
- Title
- NATIONAL HEALTH POLICY
- extracted text
-
Hp i■i
RF_HP_1_SUDHA
Health
Policy
L
L
1
Health policies
affect us all very
much and we, too,
should have a role
in helping to
policy can be defined as a broad statement of goals, objectives and means that
creates
the framework for activity. Policies often take the form of explicit
evolve them,
written documents, but they may also be implicit or unwritten.
argues Dr. Thelma
National Health Policies are guiding principles for efforts by the health sector of the
State or Government
Narayan of
Independent India evolved health policies and plans with inputs by expert Commit
Community Health tees, the Planning Commission, the Central Council of Health and Family Welfare and
the Ministries of Health and Family Welfare at the centre and states.
Cell, Bangalore.
Bhore Committee and others
Whether
The Bhore Committee (1946) and others initiated this phase. It gives detailed find
ings and conclusions of a process that lasted two years.
recognised or not,
The working of the Health Survey and Development Committee, appointed by the
health and related Government of India in 1943 stressed the importance of preventive health work “if the
nation’s health is to be built”.
policies greatly
It gave a call to medical education to prepare “social physicians” for the future.
It set forth a bold vision of a country-wide system of primary health centres, sec
affect health work. ondary
hospitals and district hospitals. However, almost fifty years later, we have yet
to
achieve
the recommendations of this Committee.
They affect nurses,
Since this landmark report, other expert committees too submitted reports. They
multi-purpose
deal with different aspects of the development of health services in India. The main re
highlighted in Box 1
workers, doctors portsAsarea result,
several national health programmes were developed to address special
and all allied health problems like different communicable diseases, nutritional problems,, mental health
etc. The concept of Primary Health Centres with sub-centres covering a defined popu
professionals
lation, as part of the Community Development Programme, was accepted. The first
Health Centre was started in 1952. Taluk and district-level hospitals were de
working in rural Primary
veloped; so also specialist and medical college hospitals.
The year 1977 saw the launching of the Rural Health Scheme. This included:
nd urban, health
♦ training of community health workers;
centres and
♦ re-orientation of medical education to meet the needs of the majority, underserved
rural population; and
hospitals.
♦ the reorientation of multi-purpose workers.
Health Policy Is
Our Concern Too!
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The common thread throughout has been the expressed need to make health a real
More importantly, ity for the entire population of the country.
This was to fulfill Article 23 of the Constitution of India, which “aims at the elimi
they affect patients nation
of poverty, ignorance and ill-health and directs the State to regard the raising ot
and the population the level of nutrition, the standard of living of its people and the improvement of pubin general. This
lie health as among its primary duties, securing the health and strength of the workers,
men and women, especially ensuring that children are given opportunities and facili-
COUId bC fOr bettor ^es t0 ^eve*°P ‘n a
manner”.
This Constitutional statement could be taken as the overall goal of national health
effort
or for worse.
Ata (1978): Health For All
Therefore, health Alma
India is a signatory, along with all other nation states, to the now-famous Alma Ata
policies concern all Declaration of the World Health Organisation.
The stated goal has since been Health for All by 2000 AD with Primary Health Care
of usl.
as its main strategy.
12
Health Action • June 1994
Het
1
*
Equity in the health status of people,
globally or within countries, was accept
ed as being vitally important
Primary Health Care was defined by
the Alma Ata Conference as “essential
health care made universally accessible
to individuals and acceptable to them,
through their full participation, at a cost
the community and country can afford .
Essential principles of Primary Health
Care:
♦ equitable distribution of health services/equitable access to health services;
♦ community participation;
♦ Inter-sectoral coordination; and
♦ use of appropriate technology.
A working group of the Indian Coun
cil for Medical Research and the Indian
Council for Social Science Research, in
1981, brought out an important docu
ment, “Health for All : An Alternative
Strategy”. It stressed the need for a peo
ple-based health care system.
It also recognized that poverty is a
major cause of ill health in India. The ur
gent need for social justice in health and
health care was reinforced.
This document was used in formulat
ing the Sixth Five Year Plan.
National Health Policy
The National Health Policy was
brought out by the Government in 1982
and passed by Parliament in 1983. It re
viewed progress made thus far, analysed
the prevailing health situation and identi
fied key areas for health efforts in the fu
ture. It emphasised ♦ the preventive, promotive, public
health and rehabilitative aspects of health
BOX 1 -
work and the need for country-wide com
prehensive primary health care services,
♦ the need for a decentralized system of
health care; and
♦ maximum community and individual
self-reliance and participation.
A time framework, for the achieve
ment of specific goals was laid down
(see box 2)
The Sixth Five-Year-Plan and the 20Point-Programme gave shape to ways by
which the National Health Policy and its
goals could be achieved.
The Eighth Plan (1992-97)
Coming to the present and the future,
it is useful to look at the Eighth-Fiveyear-Plan covering the period 1992-97.
Expert Committees to Government of India on Health
- Health Survey and Planning
Committee
Maintenance phase of National
Chadha Committee, 1963
Malaria Eradication Programme;
Basic Health Workers.
Review of Strategy of Family
Mukerji Committee, 1965
Planning Programme
Details of Basic Health Services
Mukerji Committee, 1966
-I
ntegration of Health Services
Jungalwalla Committee, 1967
Karta" Singh Committee, 1973 - Multipurpose Workers under Health
and Family Planning.
On Medical Education and Support
Srivastav Committee, 1975
Mudaliar Committee, 1962
Health
Policy
The Plan states that “the most significant
goals for the plan” are:
♦ improvement in the level of living,
♦ health and education of people,
♦ full employment,
♦ elimination of poverty, and
♦ a planned growth in population.
This include
♦ the building up and strengthening of
peoples’ participatory institutions;
♦ the provision of safe drinking water,
and
♦ primary health facilities to all
Health, here, forms part of the total
development effort. Health and popula
tion control are listed as two of the six
priority objectives of this Plan. Special I
note should be made that in the Eighth
Plan Document “Health for the Under
privileged” is to be “promoted con
sciously and consistently”, through com
munity-based health systems. This is
seen as the key strategy for Health for
All.
The Plan document states; “The struc
tural framework for the delivery of
health programmes must undergo a
meaningful reorientation in a way that
the underprivileged themselves become
the subjects of the process and not mere
ly its objects. This can only be done
through emphasising community-based
systems. Such systems must provide the
base and basis of health planning. The
ethos and culture of the communities
13
Health Action • June 1994
Health
Policy
I - '
■
♦ the recognition and support given to
indigenous systems of medicine.
■
1^5A "5
I
F
I
If
I
must provide the scaffolding for such
community-based systems”.
A major role is envisaged for practi
tioners of Indian systems of medicine.
There is an intention to move more
strongly from curative medical care to
wards building positive health. Preven
tive and promotive methods and prac
tices would get greater emphasis. This
include meditation, yoga and other tradi
tional practices.
Need for further analysis
This quick review covers the major
explicit policies. However, a deeper
analysis of several factors is necessary to
assess how effectively the policies are
followed up and implemented. We could
look for instance at
♦ the total budget allocation, its trend
over time and its rural-urban distribu
tion;
♦ the availability and quality of gov
ernment health services, geographical
and social accessibility and the utilization
of services;
♦ the quality and relevance of training in
health sciences, the distribution of health
personnel; and
BOX 2 - National Health Policy Goals For Health And Family Welfare
SI.
01.
02.
03.
04.
05.
06.
07.
08.
09.
10.
11.
12.
Goals
Indicator
Infant Mortality Rate
Perinatal Mortality Rate
Crude Death Rate
1-5 year Mortality Rate
Maternal Mortality Rate
Low Birth Weight Babies (% < 2,500 gms)
Life Expectancy : Female
Crude Birth Rate
Annual Growth Rate
Family Size
% mothers receiving AN care
% deliveries by trained attendants
1990
2000
87
60
30-35
9
10
<2
10.0
64.0
21.0
1.20
2.3
100.00
100.00
10.4
15.2
2.3
18.0
57.1
27.0
1.66
3.88
60-75
80.00
Source: National Health Policy Document, 1983.
14
Ground realities
We find continued disparities and in
equalities.
The total health budget allocation has
been decreasing over the decades in
terms of percentage of total budget (from
5.9% in the First Plan to 3.7% in the Sev
enth Plan).
There is a major urban-rural differ
ence in budget allocation. This is reflect
ed in the services.
In Kerala (KSSP Study, 1991) 75% of
hospital beds and 66.6% of doctors were
urban-based. Only 5% of the budget is
allocated to the Indian Systems of
Medicine and Homeopathy though a
large proportion (approx 50%) of trained
medical personnel are in this sector.
The utilization of Government health
services is relatively poor e.g., 5.6% in
rural Maharashtra (Malshiras Study,
FRCH, 1993) and 15-20% in rural Kar
nataka (1992-93).
Inadequate coverage of the urban
poor by basic Mother and Child Health
care has been recently reported from
Delhi.
Performance of national health pro
grammes are also below par as shown by
evaluations, e.g., of the Family Welfare
Programme (stagnant birth rates) and the
National TB Control Programme (ICORCI, 1987).
There continues to be a disproportion
in the type of health personnel trained.
Smaller numbers of nurses are trained, as
compared to doctors. There are inade
quate numbers of dentists, pharmacists,
physiotherapists and other allied health
professionals. The urban rural disparity
also persists here.
Questions of relevance of training to
community needs and community health
problems are being raised: e.g., CHC
medical education study.
The mushrooming of the ‘private sec
tor’ in the training of health professionals
is also taking place with insufficient so
cial and professional accountability.
These realities could be said to reflect >
implicit, unstated policies that also gov
ern the actual functioning of health serv ices. They are not a negation of the sev- I
Health Action • June 1994
Health
Policy
eral real achievements in this field made
by the country so far.
They, however, are important point
ers to the need to understand ground real
ities and their underlying forces more
deeply.
While the present system could and
should be improved, much could be
leamt from alternative approaches, that
have been tried at various levels by vol
untary health organisations. A construc
tive and critical spirit can support the fur
ther evolution of health policies and
services, so that health for the underpriv
ileged becomes a reality.
Could policies be more date-based in
the future?
Data from the decadal census, the Na
tional Sample Survey, the Sample Regis
tration Scheme and from various re
search organizations provide us with
indicators of the health status of the pop
ulation. While there is an overall im
provement occurring, disparities be
tween states and districts in a state are
very evident This is indicated in Box 3.
Differences by social class are also in
creasingly being studied. These data
have to be used more effectively and
translated through policies and plans into
There are no ready-to-use packages or
easy solutions to these questions.
Micro-level experiments and projects
by voluntary groups, using participatory
methods, have been effective in evolving
policies and strategies that not only pro
vide low-cost health care responsive to
peoples’ needs, but also improve health
status.
Larger level planning at the state, dis
trict and national level, is also necessary.
Decentralisation - a possible future
Here, a possibility is to use an optimum
scenario
mix.
The current debate on the recent PanThis would include time-tested meth
chayat Raj Bill raises important issues.
ods:
The need for decision-making power and
for greater social and financial control at — ♦ an epidemiological approach;
♦ provision of vision and broad direc
the village/mandal level over develop
tions;
ment, health and education is being ex
♦ allowing much flexibility;
pressed.
♦ promoting and strengthening local
How will this intermesh with the
initiative and capacities in the manage
more centralised, bureaucratic system
ment of health problems and issues;
that has developed in the health sector?
♦ progressive equitable improvement in
How can the interests of the less power
health and quality of life, and account
ful and less articulate sections of society
ability and social justice in health care
be safeguarded and promoted? How will
would be indicators of effective policies.
conflicts of interest between professional
groups, powerful groups and the emerg
Can we contribute?
ing peoples’ consciousness through the
At the level of individuals and groups
process of decentralisation be resolved?
of hospitals, health centres and health/deAnd what are the actual steps that need to
velopment projects, there are policies
be taken?
that determine the direction of work.
strategies for action. Information, in an
understandable form, also needs to be
made more available to the public. To re
spond meaningfully to diverse health
problems and needs, and equally impor
tantly, as a crucial democratic step to
wards putting people’s health into peo
ple’s hands, the planning process needs
to be decentralised.
BOX 3 - Health Indicators In Different States
Life
Total
Expectancy Fertility
in females
Rate
(1985)
(1986-91)
Birth
Rate
Death
Rate
(1990)
(1990)
Infant
Mortafity
Rate
(1990)
Andhra Pradesh
Bihar
Gujarat
Harayana
Karnataka
Kerala
Madhya Pradesh
Maharashtra
Orissa
Punjab
Rajasthan
Tamil Nadu
Uttar Pradesh
West Bengal
25.60
32.90
29.50
31.80
27.80
19.00
36.90
27.50
29.90
27.60
33.10
22.40
35.70
27.30_
8.70
10.60
8.90
8.50
8.10
5.90
12.50
7.30
11.60
7.80
9.40
8.70
12.00
8.10
70
75
72
69
71
17
111
58.
123
55
83
67
98
63
INDIA
4.30
9.60______ 80_______ 59.10
29.90
. . Source: Eighth Five Year Plan (1992-97), Vol. I.
--------- ——.—————
State
Health Action • June 1994
62.23
57.00
61.49
61.97
63.31
73.80
54.71
64.30
55.15
65.30
58.69
60.80
49.64
59.53
3.70
5.40
3.70
4.60
3.60
2.40
4.60
3.50
3.80
3.50
5.50
2.80
5.60
3.70
Staff members could collectively review
the policies at regular intervals. Are pri
ority disease problems/health issues
being addressed? What are our criteria
for deciding what is considered “priori
ty”? Can the national health policy be
discussed? Are there specific
regional/local problems that need to be
addressed? Do we interact adequately
with the governmental health system?
Can people be involved more in the pro
cess of decision-making? The process
goes on.
Of course the most crucial part of a
policy is its implementation. Could we
be sentinels regarding the implementa
tion of national health policies which are
essentially our health policies? Could we
create greater awareness among people
about the various policies and pro
grammes? Could we also help the health
system to be more functional? Health
Policy then is certainly our concern,
too!. ■
15
■7T ■
Hf IHealth Care Peliey and Delivery Methode*
by
Major General B MAHADEVAN PVSM AVPM
Director of Rural Health Services
and Training Programmes
St John’s Medical College, Bangalore 560034
Introduction
Public Health in British India mainly concentrated on
legislation and measures for the prevention of epidemics in the
civil population to safeguard the health of the British Army. In
1943? a rapid stride was however made by the British India Government
in the wake of the constitution of the famous Beveridge Committee •
in Great Britain, by the appointment of ’The Health Survey and
Development oommittee (Shore Committee)’ to survey the existing
position in regard to health conditions and health organisations in
the country and to make recommendations for the future development.
The Bhore Committee Report, as it is popularly known, came out in
1946, which recommended a short term and long term programme Tor”
the attainment of reasonable health services based on the concept
of modem health practice.
India became independent in 1947democratic regime
was set up with its economy geared to a new concept, the establishment
of a ’’Welfare State”. The burden of improving the health of the
people and widening the scope of health measures fell upon the
National Government.
The Constitution of India came into force in 1950 and
India became a Republic in the Commonwealth. Article >246 of the
Constitution covers all the health subjects and these have been
enumerated in the Seventh. Schedule under three lists - Union List,
Concurrent List and State List., z Ar tide 47 of the Constitution
under the Directive Principles of State Policy states ’’that the
State shall regard the raising of the level of nutrition and
stand xrd of living of its people and the improvement of public
health as among its primary duties*. The Planning Commission was
set up in the same year by the Government of India which sot to
work immediately for drafting the First Five Year Plan and subsequent
plans. Paradoxically, the policy frame for health services of Independent
India was to be the blue print of health services drawn up by the
Shore Committee for post war British India.
The Shore Conunittee formulated its recommendations on
the basis of certain remarkably progressive guiding principles listed
below;
1.
Medical Services should be free to all without distinction
2.
The Health programme must from the very beginning lay special
emphasis on preventive work
5.
4.
Suitable housing, sanitary surroundings and a safe drinking
water supply and adequate nutrition are pre-requisites of
a health life
Health services should ba placed as close as possible o
5.
Health education should be provided on a wide basis
6.
Doctor of the future should bo a social physician
*Paper read at the Plantation Medical Officers’ Conference
organized by BPASI during 21—22 December 1978 at Coonoor.
• ...2
:2:
7.
The training of the basic doctor should be designed to equip
him for playing an effective role as a social physician
It is significant that even at such an early period
when the country was still under colonial domination and the
members of the Committee were British and native health administrators
and public men of that period, they could develop such profound
insights into the issues involved in the formulation of a national
health policy*
The Shore Committee had categorically stated that it
is ’’fundamental that development of the future health programme
should be entrusted to Ministries of Health at Centre and in the
Provinces which will be responsible for the people and sensitive
to public opinion. The need for developing the programme in the
closest possible cooperation with the people has already been
stressed". The Committee had also emphasised that in drawing
up a health plan, certain primary conditions essential for healthful
living must in the first place, bo ensured. Suitable housing, sanitary
surroundings and safe drinking water supply are pre-requisites
of a healthy life. The Committee enjoined that "the provision of
adequate protection to all, covering both its curative and preventive
aspects, irrespective of their ability to pay for it, the improvement
of nutritional standards qualitatively and quantitatively, the
elimination of unemployment, the provision of a living wage for
all workers and improvement in agricultural and industrial production
and in means of communication, particularly in the rural areas,
are all- facts of a single problem and call for urgent attention.
Nor can a man live by bread alone. A vigorous and heilthy community
life in its many aspects must be suitably catered for. Recreation,
mentxl md physical, plays an important part in building,up the
conditions favourable to sound individual and community health
and must receive serious consideration. Further, no lasting
improvement of the public health can be achieved without arousing
the living interest and enlisting the public cooperation of the
people themselves.
The Prime Minister Jawaharlal Nehru in enunciating
the health policy of Independent India to the first Conference of
the provincial Health Ministers held in 1946, endorsed the views
expressed by the Shore Committee and stated that in the past,
little attention was paid to health which was ’’the foundation of
all things”. He asserted that economy in this sphere might mean
greater expense, in the long run and that ’’the health of the
villagers required special attention as the country derived its
vitality from th it and hence benefits of health must be extended
to the whole country side”. The aim according to Shri Nehru was
to develop a ’’National Hexlth Scheme which would supply free
treatment and advice to .all those who require it”.
Five Year Plains and the Health St?.tus of the Indian People
Although policy decisions have been taken from time
to time to evolve a sound National Health Policy over the last
28 ’planned’ years, we seem to have drifted further and further
away from the goal of ’’total he .1th for all” envisaged by the
Shore Committee. Every five year Plan document contains a brilliant
rhetoric for expanding health programmes for more and better
equipped Primary Health Centres and for better implementation of
programmes. The recommendations of the Chadha Committee and Kartar
Singh Committee were aimed towards this end. Even more recently
in 1975, the Shrivastav Committee, brought out a blue print for
major policy changes giving a social orientation to the entire
system of medical education and in rural health programmes of India.
....3
:3:
As stated by the Shrivastava Committee on development
° a Rational programme of health services for the country based
effort B?°r'3 ^Omittae Wort-"During the last 30 years, sustained
ciforts have been made to implement its recommendations as well
Wort-ant Committees in this field. In spite of
substantial investments made and the impressive results obtained
particularly m the production of medical manpower, the health
status oi the Indian people is far from satisfactory. The sheer
■agni i,u e oi the tasks that still remain is so great and the additional
r8.o„ro» mUabio r„ tto pnrpo„
t0 b' m
almost despairs of meeting our health needs or realising our
aspirations on the basis of the broad modelss we seem to have accepted.
A time has, therefore, come when the entire ■progrWie of providing
a nation wide net work of efficient and effective health services"
str teS of rVTed
nOT° With a ViSW t0 evolvinS ™ alternative
pogngaJSX0”1 ““ S“ltab1’ r»
limitation.
There is no doubt that all the while manpower, material
and economic resources drained inexorably away from the country's
real, needs. They flowed towards establishing a sophisticated,
individualistic, expensive, illness service for the privileged
rather than towards a simple community based and inexpensive primary
■ wTn1CeB
th? d"PriVed Wh° f°m thG Wk of the Population.PThe
7.H.O. Regional Director, Dr 'V T H Gunaratne has termed as ’’Disease
^veCin"Tn5G prQ?enIday hospitals. According
to him, what we now
have in India -md other developing countries is in incredibly
expensive health -industry' not for the promotion of health but
SctJi ; "ei-Sy'’p‘,11“tl°”of "ais°“e
to th»
,
• -,He fur'thQ:1:’ adds ‘that consequence of the present hie-h
technological pitch of therapeutics is that the very treatment of
one illness may produce another, either through side effects or
iatrogenesis. He goes on to say that "this distortion of health
work is self-perpetuating. The whole un-healthy system- finds its
moot grandiose expression in buildings, in disease palaces, with
nedi'c- 10V°rgr0W12g noed 1-0r staff and sophisticated equipment. In
?
t0°’ th9 main thrust is towards pursuits of disease
oriented establishment. Sven in the lens developed countries probably
solutioan r hOf>,the ras03I’ch now S°ing on concerns problems, the
solution of which would benefit less than 10% of their populations".
which envisaged integration, at the immunity level, of all the
elements required to make an impact on peoples’ health. This concept
was explained by him thus ’It is an expression of what a person
fXlsd d° ln Order nOt t0 fal1 111 and What he shouid do when ho
■1 ril lb
111.
ARevised National Health Pol i cy and^^-Q^ri^
wmnrq
i ple'BhorG Committee had visualised that health services
st oi„s Lns
of percolating to the peripherals. In tho new national health
policy of our government, this trend is sought to be tvlSed and
this trend is sought to be
a deliberate decision taken to
spend 75
7g per
per cen
centt of
of the planned
to spend
allocation forTTealth in the rural areas. ------- ~-------------- planned
4
: 4;
I find that in your plantations (a primary rural industry)
too, the trend of expenditure has a similar pattern. With the
introduction of the Plantation Labour Act, the Government placed the
responsibility of providing medical care in the Planters while
stipulating the minimum requiremontsi This was based on the concept
of the Western model. Garden Hospitals and dispensaries with personnel
were proscribed on the basis of the labour force. On some estates
these hospitals developed to provide sophisticated medical care.
In an analysis of the morbidity and mortality undertaken by
Dr (Mrs) V Rahmathullah, Medical Adviser, UPASI, we find that
only 3% of out-patient require admission into the Garden Hospital.
The- estate budget runs to about Rs.75/- per worker per annum and
85% of this budget is spent on the Garden Hospital which looks after
only 3% of the out patients. This lopsided expenditure and inadequacy
of health care system in plantations need to be given serious conside
ration. In conformity with the national health policy, it is desirable
that 75% of budget is allocated for expenditure on peripheral health
services ie., a shift in favour of the primary health concept is
necessary. The change is imperative.
If the Infant Mortality Rate is accepted as a good index
of the socio-economic progress of a country, then we have one of the
highest rates in the world as far as rural areas are concerned,
ranging from 90 to 138 per thousand. In some rural areas 80^ of the
children are undernourished and-^nly 3^ have normal" body~weight. Fifty
per ccnt~bf the^deaths in our country are of children under four.
Nearly 60^ of our people who live below the poverty line,
lack the purchasing power to secure health services. They constitute
about 378 million people whose health care is being neglected. Let
us consider this matter in terms of ’health economics’ ie., the loss
to the national economy due to the ill health' of the poorer rural
and urban people. If 40% is taken roughly as the number of able
bo
died
____
_= people in our-population, then the lowest bO per cent .of our
population (approximately 378'511lions) provide a work force of 151.2
million. If even 10 per cent of-them are ill at a time, then 15.12
millions are away from work every day for the whole year. At the
current per capita incme__rate of Rs.J.400/- ( I am quoting the lowest
rate Two are losing at least Rs.~2006 crores a year in Gross National
Product alone due to ill health. If there are epidemics of any sort,
we lose much more. This huge national loss occurs because we do not
have ,a clear cut .and firm national policy.
A major shift in the emphasis in the heilth services was
necessary from a' curative to a curative-preventive approach, from
urban to rural population, from the privileged to the under-privileged
and from vertical mass campaigns to a system of_integrated health
services forming a component of overall socialand economic
development. Health had to be given a high priority in the Government’s
general development programme.
Health services are only one factor contributing to the
health of the people. Economic and social, development activities
often have a positive influence on a community's health status.
Sanitation, housing, nutrition, education and communications are all
important factors contributing to good health by improving the
quality of life. In other absence, the gains obtainable with the
disease-centred machinery of health services cannot go beyond a
certain point. Two kinds of integration are, therefore, necessary.
The first is the integration of various aspects of health policy
into economic and social development. The second is the welding
of the different parts of the health services into a national whole.
A firm national policy of providing total health care
for all will involve a virtual revolution in the health care
delivery system. It will bring about changes in the distribution
5
I
: 5:
e reap-.usability of overcoming the present inertia as well as
the well entrenched vested interests. Though the framing of health
policy belongs to thj domain of politicians, the medical profession
as a responsibility that goes beyond protecting its own interests
of tbhe ^nitSr'3st of lndividual patients, to protecting the health
of the whole community. Plantations will no doubt have to adopt
(Kbo^^
P°lacy °f health care delivery. In a captive population
an e-nn
pl:intJ'tlons’ greater advances are possible^ with
an enlightened man igement and an effective medical service
Managements must accept this new philosophy and make greater
vestments towards providing comprehensive medical care to its
labour force, with a sound peripheral health delivery system. Through
yZn
Pb
Lab0Ur ”fclfar° and Link Work2rs Schemes, some
advances have been made but a great deal is still to be done.
Ths ftew rui,il health programme launched in October last
year y
ie present Government, has in my view provided the
forXXthl-0Ugh- "Instead of waiting and waiting indefinitely
r th, health services to percolate down from the teaching
V
hospitals and district hospitals and getting obstructed and lost
somewhere on „he way, it is a bold attempt to build from the
bottom upwards using the village itself as the base", as stated hv
the Health Secretary to the Government of India.
the b ,si Jet itrad hQllth and development programmes launched on
end St
+ t
Or° ?omittce ReP°rt und subsequent Community
■ ■ r , hnyiti Raj Development Programmes, may not have made the
impact expected of them to bring about an all round development of
he rural areas, but the necessary infrastructure has been built
up. There are now 5400 Primary Health Centres (with an equivalent
number of Blocks) and 38,115 sub-centres with i large.number of
para medical staff (now Multipurpose Workers) trained in the
delivery of the different components of the package of services
required.
thG l3nd of
sixth plan, there would be
one sub-centre
for a population of 5000 compared to one for 10,000
now. Each
sub-centro would have one male and one female Multipurpose Worker
bvC+Hay t0 d'Y health care at the village level will be provided
Work5sn?cHX°w?ry of Co“ity Health WorkerS/village Level
0rStlonaiSnfetOtthe in:ratiOn giVGn by the
Wion (Bangladesh;
Maldives) have adopted this scheme.
of CHWs tlT'h^^ :ny.°thsr part of this scheme, it is the deployment
of CHWs that has met with opposition from the nodical profession
embXd^upon thi
^7°^ qUackery* Before the Government ’
embarked upon this on a national scale, several projects were
n ertaken by hospitals and voluntary bodies. The ICMR and Trqqn
reviewed these projects and the consensus was thZt 2 action
to the existing health infrastructure,' front line health tv
6
: 6;
ICMR
xurm and
ano. important
iLiporranr Health
neaitn and
and. Management Institutions in the country.
There^has been in general, massive support for the scheme from all
sections of respondents - Community Leaders9 Block Development Officers,
Zilla Parishads etc.
The Government of Karnataka has now accepted the
Community Health Workers Scheme.
Health Delivery through Auxilliaryhealth Personnel
Our Government hopes that in due course of time, when
recommendations of theyshrivastava Oonrri ttp-e on Health Services and
Medical Education are fully implemented and internship training in
rural areas is increased to two years, adequate number of doctors may
be available for deployment in rural areas on the bisis of one doctor
per 10|000 population. There is a great reluctance on the part of
doctors to serve in rural areas. For many years Governments and Health
Administrators have been attempting to coerce, induce, persuade or
even compel young doctors to go to the rur.il areas and we are
astonished that they evince signs of reluctance. May be we should,
instead, be astonished that we succeed in getting any physicians
to go to these areas. One school of thought is that we are training
a person in the science of Clinical Medicine and the academic pursuit
of knowledge to attain excellence and then attempt to place him in
a position where his whole education is negated. In short, we are
attempting to place the physician, an_elegantly trained professional
in a somewhat inelegant position. The obvious end is dissatisfaction
and fr^tration of the young doctor. To a large extent this nay be
due to^efects in our medical educ :tion system or more correctly,
lack of implementation of accepted educational policies by Medical
Colleges, to produce the type of Social Physicians, envisaged by the
Bhore Committee.
All countries want a physician-manned health service
and this no doubt will ultimately bo achieved in the under-privileged
areas. Under-developed countries cannot immediately attain this
objective, for they cannot afford to pay for a health service that
gives satisfaction to its personnel, which means providing the
buildings, equipment, operational funds, and supporting staff that
comprise the physician’s working environment. There is also a need
to provide such as educational facilities for the .physician's- children,
adequate remuneration and housing, and means to overcome intellectual *
isolation. AH these are very expensive, which an under-developed
country can ill afford.
But perhaps a physician is not needed to the extent
that wg_am^gine_in ruril areas and many of his functions can be
undertaken by the lesser trained and much less costly personnel. What
we need to do is to apply the concepts of big business-market
research, job analysis or the breakdown of the job into components
that require a lesser degree of skill than demanded for the whole,
and organisation and management. It is partly the image of medicine
is wrong. The emphasis has boon .all along on clinical aspects and
not thj managenent, to-day medicine demands competent nanugemprit
and this applies particularly-"to Plantation Medicine/
. Better health is desired, as stated by me earlier from
the combination of many factors - not merely curative medicine and
connunity health progranmes, but also higher incomes, more education,
ThereUisUthor.r?n°rm’
husbandry» and improved sanitation.
There is therefore a need to approach health from a broad ecological
view point. Change can only bo accepted at a certain rate. Further
more, health services must have a total outreach to all the people
and not merely to a.small privileged urban minority, if they are to
have a substantial impact on progress.
7
<
I
*
Underdeveloped countries have several common factors.
These are limited economic resources, a paucity of educuUd man power,
rapidly expanding populations, conservative traditional cultures>
a prevalence of communicable diseases and undernutrition. The use of
auxiliary health workers offers a means of achieving a balanced
programme of curative, preventive and promotional medicine.
Three essential distinctions have to be borne in mind
in the delivery of health services.
First is the distinction between human medical wants and
scientific health needs. Human medical wants are very simple. They
are for relief when hurt, care when sick, and reassurance and help
during maternity. The.majority of people in the underprivileged
countries have not yet reached the stage of interest in health as
such, but only want an absence of sickness. The scientific health
needs are equally clear. They are control of tne common cummunicable
diseases including those of childhood, the parasitic diseases, and
the vector borne diseases; the need for planned fertility patterns,
for, as Bnke said, ’’the equivalent sum used to reduce births can
be 100 times more effective in raising per capita incomes in
underdeveloped countries.than if invested in traditional development
projects”,and the relief of protein calorie malnutrition, which
could be furthered by the marriage of agriculture and medicine.
. The second distinction in the delivery of health services
is that between the minor and major ills with the implication of minor
and major solutions. I classify diseases into five categories for
the purpose of distinguishing between minor and major ills. The
symptomatic illnesses are the headaches, sore throats, bronchitis,
flatulences, dyspepsias, colds, neuralgias, rheumatisms, aches and
diarrhoeas. A second classification is the visible ailments, including
wounds, snakebites, tropical ulcers, scabies, eczemas, impetigos, burns,
conjunctivitis, caries, and goitres. A third group are those commonly
known to the local population, the local entity diseases tapeworm,
roundworm, anemia, maliria, and gonorrhea. A fourth group are the
infant and toddler diseases, such as marasmus, kwashiorkor, whooping
cough, measles, and chickenpox. The final group are the suspect and
referral diseases—those which must be referred to more highly triined
persons for diagnosis and treatment.
The third essential distinction in delivering health
services is in the training and use of auxiliaries in the assistant
role, when they are working directly subordinate to a more highly
tained person and in the substitute role with supervision remote
at best and completely absent at worst.
There are broadly speaking, two methods of delivering rural
he ilth services and achieving total outreach. One is to develop
an absolute standard for medical and health personnel. As time goes by,
the number of persons meeting these standards increases j.nd their
reach spreads from the center to the periphery, to cover the whole
population. The other is to commence at the economic and educational
level which the country can afford, train personnel on a less rigid
standard, begin with total outreach, and over a period of time raise
the standard of education until professional quality is reached.
At a distant end point, both those methods will achieve the same
result of quality care to all the people all the time. It is what
happens to the people during the interim until this objective is
reached that matters.
... 8
>-
:8:
A combination of these two methods offers much better prospects
for this interim period. Experience dictates that the demand for physicians
and other high level manpower always exceeds supply. The use of
auxiliaries, working through a few dedicated physicians and para-medical
personnel, offers a much greater prospect for improving the health of
the populations in the underprivileged territories, than either of the
two alternative methods.
►
’Primary Health Care * and ’Health by the People*
He .al th for all by the__year 2000 l.D. This is the call, given
by Dr. Halfd.eJT’Mahler, Director General of* the World Health Organization
at the World Health Assembly in May 1977.Dr Mahler has advocated resort
to ’Unorthodex way like increased use of auxiliary health personnel to
correct the situation even through this might be disagreeable to some
policy makers”. Both the developed and developing countries have
expressed dissatisfaction ibout their»heilth service. This was highlighted
by W.H.O. as e irly as 1975* The Director General had frankly admitted that
the most signal failure of W.H.O. and its Member States has been the
inability to promote development of basic health services and to improve
their coverage and utilisation.
>
In January 197^, the 7.H.O. Executive Board underlined the
plight of rural populations and recommended priority attention to
'’primary Health Care” at the community level.
^2 Over 700 delegates from all over the world met for a week in
September at a.lma Ata, the capital of Soviet Kozhakhstan, to discuss ways
and means of providing health care for all peoples in the world. There
was an exchange of experience .among member countries on the development
of ’’Primary Health Care” as part of the National Health Services. India
was one.of the nine countries ■whose experience with community involvement
in the health sector had triggered international action in favour of the
’Primary Health Care’ approach. Besides India, the other countries whose
experience has been drawn upon by W.H.O. in advocating ’’health by the
people”, were China, Cuba, Guatemala, Indonesia, Iran, Niger, Tanzania
and Venezulai^. Based on the experience of these countries, W.H.O. brought
out a book in^April 1975^.’’Health by the People” and following that, the
Executive Boards of UNICEF and WtH.O. adopted a novj health policy which
underscored the need for combined curitive, preventive, educational and
social approach and for simplified technology.
As India has iccepted in principle the ’primary health care’
approach as a national policy, it is worthwhile cle irly defining this
approach.
According to the WHO, the seven basic principles of
’primary health care’ arc;
a ) it should be shaped around the life patterns of the population it
is to serve and should meet the needs of the community;
b) it should be an integral part of the national he ilth system, ind
other echelons of service should be designed to support it;
c) it should bo fully integrated with the activities of the other
sectors involved in community development (agriculture, education,
public works, housing and communications)
d) the local population should be actively involved in the formulation
and implementation. Decisions as to the community’s needs should
be based on a continuing dialogue between people and the services;
9
!
:9s
e
cnmmth-+arG off'r 'd should place maximum relimce on availablo
e
een
ose services should vary according to community needs;
and
g) the ]
°f
intel,vontions should be undertaken at the
most■ peripheral level possible, by suitably trmed woXers-"
XXXX
" XXX ?"Jth
In
^opn„t OI tw
community at large.
i the
rural development,i^oomu^itTdeX^en^ctiSties
mW
at thc conoer„ of thj
iTXS to
local circumstances. These
---- health
and
balanced nutrition,
elementary medical diignosis, therapeutics,
"
environmentil s.mitation,
dental health, mental health,
community development, health management
etc.
In the ■?frequently presented diagram <
of the pyramid of health
services, the organisation
_ti-----of
: Primary Health Caree can be organised
through a three tier system H'-Pilth Worker
t-h k
^lth Centre, Sub-Centre and Community
’th'w “*pl“ b“‘ “
xx
a
sub-centre level we the two Multipurpose Workers
(male, and female) looking ifter a Community of 5000, who^ro more
Gf)arii°rCed ;ind haVe hlfl S0Und training in maternity, child ho,ilth
1 WQ UI Pro®rimmes, national health programmes and other aspects
Th. X 5 «B;(“Pr°’°
°ir °kills “a
‘»ar octlvltlo,.
wnX
o f MultlPurP°SQ Workers will bo supervised by the Multipurpose
Worker supervisors from the Primary Health Centre.
the £x s-xt rs rpXxsxxxt
xxhxxxwxox: S’S xs xxx
CW looking after i population of 1000. The staffing p ittern .and functions
a Primary Heilth Centre are well known to you. Three medical officers
will now be available at each Primary Health Centre for preventive promotive and curative work. From the Primaiy Heath Centro, referrals
will go to the Tiluq or District Hospitals.
10
:10:
It will bo obsevod the pr. sent concept of Primary He 1th Care
delivery System is ilmost the same as advocated by thj Shore Committee
in 1946. Let us hope th it now with the strong backing of WHO, UNICEF
and National Governments, 'the c ill of Dr Mahler, Director General,
VHO, ’’Health for all by theJ year 2000 A.D.” will cone true and no-t
sound to many as m utopian dream or wishful thinking.
In your own plantitions with dispersal of labour, distance and
thr3G tiOr SyStGm °f
he.ilth care could bo organised
through Garden Hospitils, Dispensaries (Mini Heilth Centre) and Link '
:lde3ult’31y supervised by medical officers. I know that
L •+e.dlR1 AdviSGI- 1G 'ilr'':'idy planning on the basis of one Garden
Hospital |-or 10,000 population with four mini heilth centres, each
aftTpolol 5? Population and Link Workers (each Link Worker looking
aiv.?r 2U-4O f imlies)
55
10 point Pool ?ir iti on on Health (T7HO/WCEF)
■ u]-<i llk° t0 conclude with the 10-point "declaration on heilth
tileon at the Aina At> Conference of ’®C, which calls for urgent
and effective international and national action to develop and
implunont primary health cire, throughout the world and n'rticularly
m developing countries.
" y
(1) ^•tK’-WhiCh/S a Stato Of 6onPl^e physical, mont.nl and social
-11 b Jing and not merely the absence of disease or infirmity !«•
a
fundamental humin right.
y’
(2) The existing gross'
inequality in
status of the people
gross' inequality
in the
the health
hoilth status
pirticularly between devolopod and developing countries is
economically unacceptable and is
is, therefore, of common concern to
-ill countries.
bU
(3) Economic and social development, based on a new international
ol he d?h°forr’n“ °d
iF,p0rtfinCO t0 th0 fU110St ^tainment
h--?°
° rcduction °f thc gup.between the
h., .1th status of the developing and developed countries. ■
(4) The people have the right ond duty to participate individually
cSreC°
V'31y ln th0 planning ■'md inplemenfation of their ho-ilth
economically productive life4
•
socially and
integr.il part
(6) Iciontihc th C3K' 18 0SS0Tltial health care based on
made th
h80
socillly acceptable methods . ■ practical,
and • to 4.1
chnology
nude universally accessible to
to individuils
individuals md
3 ; fArHi-i
community through their full participation and
.nd
ln the
the community md countrv r participation
-rr+
• nd lt
cost
afford
maintain
Of their development in the m
spirit
of toself
1" h*
eVOry sta^e
spirit 1 of self-reliance
determination. It forms -an int-R
seif-reliance and selfintegral
part both t
of the C0Untry-S
health system, of which R hth
t Tr
.nd of the ovh all Jocih —
central function -d
and main
1 ’ .focut,
development of the
comnunity.
11
slls
(7) Primiry Health Care reflects and evolves from the economic conditions
and socio-cultural and political char icteristics of the country and
includes at least education concerning previiling health problems
and the methods of preventing and controlling then
(8) All Governnants should fomulato national policies, strategies
and pl ms of action to launch and sustain prinaiy health C'ire as
part of a comprehensive national health system in coordination
with 0the r sectors
(9) All countries should cooperate in a spirit of partnership and
service to ensure primary health care for all people, since the
attainment of he ilth by people in any one country directly
concerns and benefits every other country.
d.n accept ible level of health can be attained for all the
peoples of the i^orld by 2000 Ah through a fuller and hotter
use of world’s resources, a considerable part of which are spent
on armaments and military conflicts.
/////////////
piU
D R A F
o■
FrfY/<f’, %
T
WIPRAL HEALTH FOLICT
GOVERNMENT OF Il'DIA
MIIJISTRY of HEALTH & FAMILY WELFARE
NEW DELHI
ereamele
Si°^’n2oiy0to”0oS^
Of
genetic notentiR H i+i °P 1:113 u®nbal arid physical faculties to their full
S2s and noSS: nr J CT2 be ’ieWed
^tion i.rc::: the overall
improvement in the living^coMitilnsYY"*3 *
implies' progressive
and shared by its members and th
+Y q^al:Lty of I1 ® en3 °yod by the society
Thus, health is bn+b
- and+thf central focus of such development is W.
end-produ.t oZdeveloF-ie^Y
Pithway to development as well as a desirable
JSS SSi“
;
^-po aooeoolU. to thi nation in SSSeol!
Y-™-s°^
level of honT+h CaY health services. A community achieves the highest I
intervention and^ YliYiYY°f d£aSt dependoncc on Wofessionaly
oncion ana maximun reliance on its own resources and action.
to cure
teith Of the Inaihaoals a8
Jg’XSvT"
“
glMARY HEALTH CARE
for at-taining thJ^oaTYf ^HealtYFoY/Al?
J is ?■ sine 0^ non
on Primary Health Qare held Yaih ?+ Y * R 'fche International Conference
world have gYen unio thentSo^
n “+ SePteabcr '’^0, the Nations of the
level of hefltwYYl tY
1 t°YeCtlVe °f attaining an acceptable
tory to the SlXXSratZ Yh
V0?Y+by?he
2000. L a sign,-
we have to take active stone +h
? Y.a sp:Lr:it of service to cur own peoplo.
objective.
a
VG StGpS tllrouSh
^alth Care to attain this'
’
universally accessible S^ndivid^lq^1^^^^011essential care
acceptable and AfYorrinKi
'
anc^ •^ar-11^-1GS in the ^orxinity in an
satloYaYsS-rSSe
“ “entr-ld.
of Priory HeaY^YSYarc
°f thiS aPP^ch* The gcals ’
increasingly greater resnonsnbs1•+ Y s°e1?1 ueans such as acceptance•of
and their active particion^ntfY ^ealY by ‘'or.Tnunities and individuals
scale transfer of sinpLe still s -'nd kn YY 1 + T118 approach involves large
■
■
-.'.IYYi. Y13 Yd ^wledge to people sleeted b- the cc .._j.onCG
WIXLzny to ' ‘OWr’ i4- <>- '
-
: 2 :
compassion and spirit oi^rvice. The translation of much of
*
health knowledge into practical action involves use of swple pd inejgno
inventions which can be readily inpLenented b ■ ordinary people with imnina
training leading to the greatest benefit to the society.
2.3.
Trirarv
Health Care
can only succeed if the organised health services
Frimry
Health
Careprofessional
can
po^ide full
logistic
and
supports the voluntary workers resid
ing within the cornunity. Such a g/stem would resultin op i^
c .
of the knowledge and expertise at higher levels and in the.lone ™
A
be expected to relieve the overburdened curative services in e
^,Vq+r- >
semi-urban areas. The development of an effective primry health core systc..
both for rural and urbcji areas would ensure would ensure the tollQwrng.i. A greater awareness among the community and pcpiilation ofthe
health problems and ways to tackle them at their own levels;
ii. Intervention at the lowest practicable levels by a worker more
suitably trained;
iii. Optimal utilisation of khowledge and expertise by. higher level .
technical experts, be they health workers, physicians or specia
iv. .Increasingly less dependence on hospitals and thus optimal
utilisation bf such -facilities for cases, where they arc actually
■,j needed.
FR.EVET1TVE AMD FUBLIC HEALTH SERVICES
,
....
3 .1 .
The, emphasis on public health services has slowly decreased in the
last 30 years, yielding its own rightful place to curative/ services , ihe .
trend has to be arrested to reversed. The coverage of public.health
and provision of preventive services are now spatially very limbted. uni pal and local authorities responsible for such services generally suf or ’ m .
a lack of will and resources to implement them effectively. It is rational
and economical to deal with’ a cluster of causes for poor health conditions
on a broad front in the form of integrated package of services which are
more than a mer^ collection of health interventions. There is, therefore,
an urgent need to set up a chain of sanitary*-cum-epidemiological stations
throughout the length and breadth of the country, panned by suitably tiainec ~
and equipped staff. Such stations can conveniently take care of environnenta.
health problems, detection and control of e pidemics, handle checks on-quality
of food, ■ water, etc. Investments on such stations now will have a rela ivc 1
high pay-off in the long run.
The pattern of diseases in developed countries has .changed radically
3.2.
in the last 50 years. Thoirngo of ■vaccines, sera, etc., is ever increasing
Our aim on the preventive firont should be achieve 100$ coverage of the to al
population by the year 2000 in terms of inoculation,, vaccine.tion, etc.
ho
• wherewithal is within our technical competence.
WATER SUPPLY AMD SANITATION
3«3*
Provision of safe water supply to the population and improvement in
sanitation is basic for improving the health status of the people.
s no.
to.be done at a cost and with a technology which the nation can afforc . ,0
should, therefore, aim at providing Safe drinking water and improved sani <.
tion to all ^bpulation within a given time-frame.
FROMOTIVE SERVICES
4.
For a neaningfvl involvement of the community in the health care
system, education about the advantages both immediate and long-term are
necessary. It is, therfore, in ■foe interest of the. health system 1 se_
to take on the responsibility for explaining, advising and provi xng c. ca
information about the favourable and adverse consequences of in /Given ions
available or proposed as well as their relative cost. As par o^ .promo
rl ---•viceo, it world be nebeSsary to erlr.coto people d?out to d naorrs,
: 3 :
nutrition, breast-feeding, etc., which are thenselves not costly if
properly adopted and which could Head to substantial savings in terns
of hunan nisery. In view of the large-scale widely prevalent malnutrition,
the question of proper nutrition assumes special importance and requires
concerted action. There wuld also be a difficult but pressing need to
overcome religious and social taboos which often-times prevent people from
adopting healthy habits.
FAMILY WELFARE AMD fORJLAIION FOLICY
5>
A reducticni.in birth rate is part of the National Family Welfare
Policy, a Statement on which was adopted in June 1977» Health and family
welfare are; so intimately intertwined that, without an active and vigorous
implementation of the Family Welfare Policy, the National Policy on Health
or, for that matter, any policy of national development, cannot even be
conceived of •;
WERKAL AMD CHILD HEALTH SERVICES
6.1
The future of.any nation is the future of its children. If the
limited rcso rces in the health s ector are to be preferentially applied to any
segment of population, it should logically flow to children and mothers.
Infant mortality, child mortality and maternal mortality in this country
are stark figures signifying our inability to achieve a break-threugh in this
field. Bold attempts need to be made to ensure 100% health coverage in the no
next 10, to 15 years for all children in the age group 0-5 and by the year
2000 of all children up to the age of 15 •
",
6^
Maternal services arc sparsely distributed. Our dependence on
professional birth attendants will continue for a long time. While there
may be an addition in the institutional facilities for deliveries - particul
arly to provide for complicated cases - we should ensure that all deliveries
are handled by competently trained persons. This would reduce signficantly
the maternal mortality and morbidity.,
6.3
Along with vigorous steps needed to a chieve deduction in the birth
rate, we need to improve the facilities availabeltto mothers and children to
assure the families of the safety of their progeny. This, by itself, will
have a psychological impact and would over the period favour a reduction in
the birth rate.
CURSIVE SERVICES A13D HOSPITALS
7»1
We have inherited a system df health services and medical education
from the colonial days which has a large emphasis on treatment in hospitals
and cure of diseases. With increasing sophistication, we arc now devoting
80% financial and manpower resovrees in the health sector to this segment of
health services which is more or less concentrated in urban areas. With the
public sec-'tbaj private sector and voluntary sector operating jointoly and
sometimes at cross-pirposes, there is avoidable disorganisation in the pro
vision of' curative services • Even the general hosj^itals run by Government do
not provide equality of access to the poor. There is oftenvtimes duplicato
and triplicate utilisation of facilities in an effort to get second and thirl
medical opinions. A method should be developed to avoid this wastage of
scarce resoiirces. The urge of the common ran to get quick and effective
medical treatment, particularly when he is at the physical and psychologt cal
nadir is understandable. The pfeco of investment in hospitals and curative
services has to be slowed down, linking it rationally to a national policy on
rirbanisation. One can, however, hope that extensive provision of preventive
promotivo, public health services would go a long way to relievo the burden
curative health system to a largo extent.
-
.
«?-
-
■
: 4 :
7.2.
Even so, there would be a need to provide an increasing number of
hospital beds'; firstly to take care of some of the under.served) semi-urban
and rural population and secondly, as part of the referral ^stem. Construc
tion of hospitals on traditional methods is a costly proposition, most,of
the money going into brick, mortar and equipment • We need to explore ideas
on new type of hospitals in which modern construction is restricted only to
essential areas such as theatres, wards, etc.; the rest being of simple
structures using local materials with provision for members of the family to
stay and provide basic nursing services.
7.3 •
We have, in addition to themodern system of medicine, indigenous
systems like ayurveds, unani, siddha, naturopathy and homoeopathy in wide
use. .There has so far been no coordination among all t^ese systems, either
in terms of education or in terms of services, not to speak tf integration.
We should now begin an attempt on a co-ordination of the services offered
by all these systems so as to obtain Optimal economic utilisation.
7»4.
The trend is towards increased application of sophisticated modern
technology/-, bo it auto-analysers, linear accelerators^ EMI scanners or inten
sive care equipment a.nd the like. Very often these provide a cultural shock xc:
for the average Indian. In any case, they tend to increase competition amongst
orofessionals to acquire more of these sophisticated techniques at great
cost and thereby increase the distance between the patient and the doctor
be must learn to use increasingly appropriate health technology replicable
with scientific, technical, and managerial resources available within the
country.
MEDICAL EDUCATION AID HEAITH lANPOWi
8.1 .
Medical Education has suffered as a result of cultural dichotomy
coupled with parallel development • The modern medical s ystem has kept pace
with developments in the rest of the world but the type of education imparted
particularly at the undor-gradupto level is heavily hospital-oriented with
little relevance to Indian situations. This makes a fresh graduate unsuitable
to handly situations in the community and unable to appreciate the problems and
dilemmas of the conrunity. The indiegenous (traditional) systems of medicine
have, after years of neglect, started coming into their own. The earlier
attempts to integrate the modern medicine with the traditional systems have
failed. While no attempt to forcibly integrate any system of medicine should
be made, all the systems should realise, in the Indian conditions, tbo limits
and potentials of other systems and draw inspiration from them and should
support each other mutually/
This can to done only tor a concern for other
systems and understanding of their functioning.
8.2.
The training of agents of health care in sufficient numbers
nunbors at appro
appro-
priate levels, with right attitudes, cutlooks and functioning in an orchaestrated manner, holds the key to success of any health system. The hierarchical
structure of the preset day health r.anpower and the roles allocated to each
level in the hierarchy are the outcome of a historical process. A dynamic
process of.change and innovation is needed. The concept of health team is
important in this context. The national medic al education policy aims at
qpalitabive and quantitative development of adequately trained health personnel
of all. categories in a reorganised structure keeping in view the training of a
composite health team. To help in innovative development of medical education
al processes and ensure a continuous input of properly trained manpower, it
would bo necessary to set up a Medical and Health Education Commission embrac
ing all systems of medicine and all categories of medical and para-medical
personnel •
HEALTH PLANNING ALP .HEALTKE INFORMATION SYSTEM
Th6 need for an effective infcrnation system in the Health field at
all levels providing for collection, processing, storage, and retrieval as a
-■ocl aCTdvely actively aiding appropriate decision naJking and pro-^ramn'e planr
.'lold c- ' • v-x is
h-—
-
: 5 :
□et up a dynanic informtion system to support the Health Hanning and
decision-making machinery •
MENTAL HEALTH
10.
Mental well-being is an essential component of the state of good
health. With 'increasing industrialisation and greater strains in the
community, mental health problems are on the irarease. Here again, a primary
health care approach would enable isolation of the problem at an early stage.
and handling of the sane in an appropriate manner. Traditional Indian practice
such as yoga, sadhana, etc., need to be strengthened and made universally
- available to attempt non-medical methods of handling mental health problems.
REHAEILimmi J
11.
Reha.bn Id tatn. on forms the fourth side of the health square, the other
sides being prevention, promotion and cure. Medical rehabilitation services
are not fully available to those in need of the same. Here again appropriate
technology should be increasingly used. Medical rehabilitation also needs
to be coupled with social rehabilitation in certain circumstances like Tburnt
out leprosy cases1, etc.BIO-WICAL ENGINEERING
Developments in this field are occurring every day and at a rapid
However, particularly due to miniaturisation occurring in electronics
it should be possible to take advantage of the electronic industry in the
country to make available such advances to a multitude of istitutions. This
T-branch of medical science has so far not been adequately attended to. The
industrial capability of this country is of a high order and it should be
possible, with some attention, to keep pace with developments in this field
and transfer them in an appropriate manner to Indian conditions.
12.
pace.
PHARMACEUTICAia
It would not be far wrong to say that the pharmaceuticals industry
dominates the health s ector and the doctors are deeply influenced by the drug
industry! Instead of being able to dictate to tho drug in&ustry, the medical
profession is in fact dependent on the drug industry of whatever continuing
education it receives in the form of literature. Over-utilisation of drugs
so as to increase the profits of the drug industry, has become the end and
hospital and the medical profession are used as a means towards this dnd.
This problem has been deliberated upon by various committees, essentially
to ensure that ^he drug industry plays a subordinate and not a dominant role,
without, however, minimsing the plenitude of good that it brings to millions
of people. The medical profession should have a greater say in determining
the direction of growth of the drug industry.
13.1
13.2
Reliance on synthetic chemicals and. antibiotics is a growing world
wide phenomenon. Greater utilisation of drugs tends to increase the cost of
tho health system. (Dn the other hand, vaccines and sera w liicb are used in
preventive medicine need to be encouraged and new vaccines need to bo deve
loped .
13.3
In so far as the medicines belonging to the traditional systems
are concerned, the age-old practices of local preparation of such drugs have
slowly vanished’leading to greater commercial preparation cf such such drugs*
It might be worthwhile and necessary to encourage local manufacture of such
durgs in small con. unities wherever .such treatments arc in vogue. Further
use of herbs and neicinal plants, particularly for common ailments wherocvcr practicable, needs to bo encouraged. It is expected that the local
growing of such herbs and plants, harvesting, storing and preparation of
medicines out of the,, at the community level, would go a long way towards
self-reliance•
Cont.d/6/-
-----■.
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... if.-*’'
«
:6:
,
13.4.
In keeping with the concept of community participation and selfreliance it is also neecssar^o to reduce dependonco of tho populc.tioh on tho
formalised medical system for tho use of medicines. While on tho one hand
it would be necessary to guide the population in the use of medicines particularly those which are toxic or have reactions, it is also necessary to d epend
on tho people themselves for Imowlcdgo of their own conditions and use of
appropriate remedies. Thus, consistent with our concern for overuse of drugs
and professional supervision on tho use of drugs having toxic or side-effects,
we should liberalise the idea of self-medication. Tliis will imply strict
control on the quality of medicines available in the market.
RESE/lRCH
No nation can afford to neglect the support of fundamental and basic
research, for without it there can be no proper teaching of science and no
national capability for solving unresolved problems, • meeting changing situa
tions and for adopting, in certain instances, known technology to suit local
conditions • And yet, highest priority should bo given to applied research, in
particular health services research, if the technological achievements of
medicine are to be placed within the reach of those who need them most. Health
services research is holistic, multi-disciplinary in character involving the
the joint participation of bio-medical sciences and social sciences. Such
research should be carried out within tho health service system and research
priorities determined as a result of joint discussion between researchers,
administrative decision—makers and the public. The whole ethos of such re
search should be based on discovery of simple, low cost, appropriate health
technology, the results of which are replicable under routinised settings. Wo
also need to devote ourselves to basic research, particularly with a view to
developing solutions to problems plaguing our country. W®. are yet to develop
efioctivo cures or vaccines, for such diseases as malaria, leprosy, etc.
likewise, there is immense scope for research in matters relating to Human
tepreduction. Research in the field of medicine should be relevant to the .
needs of the community.
LEGISL/_TIO1^
insurance and coordination
15.
r
“• being a Stnte subject, tho approaches to legislation in the
Heelth
health field would
--- 1 necessarily var; fron State to State. A variety of logislation s already on tho statute bock, bo it on tho national level or State
level. It would be necessary to review these items of legislation and work
towards a single comprehensive legislation applicable to the health field.
The
Provnid-e^ by government are generally free. This loads to a
situation where there
~ appreciation that the services do cost
---- is
-j not enough
money to the nation and, therefore, should be utilised only whore it is essen™avo^ablc• A realisation of the utility of such services can be
roug a cut by educating people as also by levying nominal charges for all
ervicos.
ho possibility of introducing some form of national health insuranCG^ a J oast in the future, to provide for guaranteed health s ervices to all
segmen s of population needs to be pursued. In the present system since there
anrf e^x^tonco of the private sector, voluntary sector as also tho public
13 GSgGn*^aI bo coordinate the services by these sectors. The
pcssi
1
of setting up coordination committees to regulate the services
ailable in each of these sectors needs tobe explored. Secondly, in tho
United extent in tho
the voluntary sector, sometimes
sonetines
.
5GG Sc? cr
a lulled
arc rathor high.► While this drawback will continue as long
as tho private sector exists, an atonpt’ needs to be nado to ascertain whether
thciJo can be any self-regulation. As part of this exorcise bold attempts
need to be made to end the system of private practice by doctors in Government
service and in Medical College^
I_NPUTS_IN HEALTH-RELATED FIELDS
IpL.D?vopJplcnt's
teaTth cone .not nerely as a result of inputs and
^health field, but also due to develcpnents in health related
as agriculture, water supply and drainage, communicatimi etc.
: 7 :
At the commnity level, all health activities nust be coordinated with and in
fact, form part of, total rural d cvolopnont* To the extent decentralisation
of resources, planning and implementation can be achieved^ there will bo
greater efforts and dcvelopaont in all field and thus in health alsoi Such
decentralisation should, therefor , be actively pursued and supportedI Even
at State and national levels, he gith activities and inputs shouM benefit
from investments in health—related fields and to thc..t extent, coordination with
other sectors of development have tote volunatrily sought for and achieved.
CONCLUSION
The following should, therefore, be the short-tern and long-term
17.
goals of the national health policy
17.1 •
Short-tort-i f^oals
i* to eradicate/control communicable diseases in the country;
ii. to provide adequate infrastructure for primaigr health care
in the rurrl areas and in urban slums;
iii. to utilise all availabrlmethods for health education and
spread the me-ssagc of Health and Family Welfare;
iv. to utlise knoledge from different systems of medicine. for
pr ofiding quick and safe relief from sickness and debility
at the cheapest possible cost;
v. to reorient ncdica.1 education to be in tune with the needs
of the corxiunityi
vi» to provide -increasing mternal and child health coverage.
17.2.
Lonr;-taM goals
i. to improve public health services by setting up a chain of
sanitary-cum-epidcniological stations;
ii. to ensure 100% coverage of all segments of population with
preventive services;
iii. to create a self-sustaining system of health security so that
earnings of the individual are not affected adversely during
periods of illness;
iv. to impart medical education in a medium which is an integral
pirt of cur culture and life-style and thus remove the foreign
concepts associated with foreign languages which are major
factors inhibiting people from understanding the true and
proper role which medidne plays in the development of a healthy
community;
v. to utilise available knowledge from the ancient and modern
systems of medicine in an effort to develop of co mpcsitc system
of medicine, tlrus obliterating the caste system prevailing in
the field of medicine;
vi. to inciilcatc a sense of self-reliance and discipline in all
segments of population so that all four sides of the health
square, namely, prevention, promotion, cure and rehabilitation
are effectively handled at the local level consistent with
the developments in the field of medicine.
# -shs-
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/ •
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17
MW;
In Quest of a
WIOl'IAL HEALTH POLICY
Our health services need a major shift-from
curative to curative-preventive, from urban
to rural popu3.atior; from the privileged to
the underpr-1-^11^ged. The health , i icy has
to be an integral part of the plaurlng for
e c ono’:'.i c developmont •
Over the last 26 "planned^ years, we have drifted further and
further away from the goal of "total health for all”. Every
Plan, document contained brilliant rhetoric for expanding health
programmes for more, and bettur-equipped Fri: ary Health Centres
and for better implementation of programmes. But all the while
the development and allocation of medical care resources, viz,
manpower, material and economic resoi rces drained inexorably
away from the country's real needs. They flowed towards esto. -is mg .. sophisticated, individualistic, expensive, 11 Inaaw
service for the privileged, rather than towards a simple community-oased and inexpensive .primary service for the deprived
who form uhe bulk of tho population •
i
yearly 60 -er cent, of our people, who live below the poverty
line, Inez the purchasing power to secure health services.
They constitute about 378 mil'’ion people whose healt’ caro is
being neglected. It is necessary to consider the .loss to the
national economy due to ill health of the poorer rural and
urban people, if <c .per cent is taken rougdy as the number of
able-bodied people in our population, then the lowest 60 per
epnt - 378 millions - provide a wrrk force of 151.2 riIlion.
If even 10 per cent of thorn arc ill at a !-no, then 15.12 million
are away from work every dy for the whole j^oar. At the current
Fr
lrC°nC r‘tG of
L400, we are losing at least
Ks. 2,006 crores a year m-GiiP alone duo to ill health. If
ere o.re cpidetiics of any irt of any area, we lose much more.
This huge national loss occurs because we do not have a clear
national health policy. VJhat is thorfore urgently needed is
a national health policy based on health priorities. The
Government of Inida has not so far evolved . such a policy incor
porating primary health care for all citizens-nor’ has it felt
the necessity to consider it as a, part of total planning. A
national plan, with health goals .to moot the mass needs, -the
required personnel, tho~ r training and allocation of functions,
development of necessary institutional base and establishment
of objectives, strategics an^ priorities anon' competing demands
for health services should be identified for pl oinrn ng; proper
health services to the people.
An effective health approach requires the co-ordinated efforts
of all those sectors that can contribute directly or indirectly
to the promotion of people’s well-being. This is net only at
the central level but also at the intermediate and above a~!1
the peripheral level, whore policies should have their roots.
Moreover, health should be considered an integral part of develop
ment with clearly defined goals, policies and plans.
FRAGMEMTARy EFFORTS
The efforts made now are fragmentary, not necessarily related to
those of other sectors and not directed towards .upporting national
growth on a broad, scale bjr fostering human well-being and resources.
- 'Cont;V^--
•f
J
/2/
Health activities often becone stagnant and health development
projects collapse for lack of proper budgetary support. Clear,
concise and logical priorities within the health care system
are not laid down. Realistic criteria for the dovelopmont of
priorities a.re not formulated.
For example, scant attention is given to the balance between
curative, preventive and promotional activities ar", the divis
ion of resources among them- Frier otios between primary care
and hospital ser\ ’ cos arc not defined. A balance is not always
established on objective grounds between personal health services,
cnvironr.ontal heelth services .and commun'ety-oricntcd activities.
Again, not enough is done to assess alternative methods of com
bating communicable diseases, while tho use of measures not
directly related to but generally affectin' health is frequently
neglected.
The shortage of hu an material and f nancial resources is often
complicated by faulty utilisation and maldistribution of resources •
Tho shortage of financial resources affects the larger, needier rural
population more than tho urban dwellers. Tho health sector is
often hospital-based, relies on relatively sophisticated tech
nology and places emphasis on specialised medicine. The national
health needs should bo defined to plan the manpower development
of various categories.
The training of health personnel is frequently irrelevant to or falls
short of local health needs and aspirations. Our medical graduates
have a"trained in-capacity1’ to mc..t the pressing hcalt' needs of
the people and arc more inclir.dd to remain in the protective hospital
setting in which they have received their training. To products
of such a system, the problems of preventive, pronotivc and re
habilitative health care arc fields which arc fit only for the
auxiliaries to practise. Changes in the curricula, intensive
field training, problcm-oricntcd instruction, an emphasis on the
acquisition of nccos.sary skills and above all training in organisa
tion and leadership in health care have been rightly identified
as stops required to be taken♦
Equally the training of auxiliaries usually leaves much to be
desired. Seldom is it planned according to priorities and the
job to be done. The auxiliaries with li ited basic education
and brief preparation require continuing on the spot trainingThe development of primary health workers raises a new set of
problems related to their selection, training and administrationCritical importance is attached to the technical aspects of the
activities of j^rimary health workers, who form tho entry point
to the health system for the majority of tho population. If
they give improper or wrong treatment and do not refer patients
when they should, the system will be r failure9 Consequently
their tasks must be clearly defined and the training programmes
must be efficient.
That the basic health workers of the now Janata health schci.o
will not bo equal to the task and rosponsibil-itios is obvious
from the basic qualification and tho short duration of training
in allojzathy, ayurveda, homoeopathy, naturopathy, unani, family
planning, child Pate} ’ Zodornfhygicnoy etc.- The responsibilities of
those workers are heavy and. varied as they -a-ro ocpoctod to deliver
a package of health services - preventive, promotivo, curative
and educational at the doer-stop of the villagers. The future
of the scheme depends on the quality of the workers enlisted.
/3/
_____ _jhhe-i y-^duoA ti an? ah-i U
nobility, •cacrctency, attitude
and skill. If it doos not succeed, it v;:J.l bo one rail
lion quacks lot loose on the rural connunity and nearly
Rs. 300 crores going down the drain.
The probion of health care cannot be solved by a coub-i nation
of different systens of icdicinc- Qualified an' registered practi
tioners of indigenous systens of nodicino should bo utilised
through separate schonos within nedlcy of different systems
should be discouraged. Indigenous nodicino is certainly in
groat favour ar ong the rural population. Bint its practi
tioners should bo compelled to confine thonsclves to their
own systpn and not dabble in modern allopathic treatment.
The Government policy should bo clear in this regard. It
is necessary to study the role of practitioners of different
systens of ncdiciuo and their contribution to the health care
of the cpmnunity. There should be need-based research to
provide pheaper nodieel care to the pcopLo.
High norbidity and high mortality, particularly anong infants
and children, are an index not only of a connunity's low
health p.ovol but also of inadequate health education. A large
number of diseases could be prevented with little or no.nodical intervention if people are adequately informed and if they
are encouraged to take the necessary precautions in time.
Health education is particularly needed where the network of
services is weak,- whore peojiLc must learn to protect them
selves from disease and to seek help only when needed.
It is therefore necessary to plan and guide hoal':h informtion activities to suit the., health culture and. psychology of
the rashes. There .is an imbalance between onvirnomontafL
sanitation should aim at safe drinking water, sanitary collection
and disposal of human wastes, control of pollution, unconta
minated, food and a decent place to live in. A major problem
is thpCLack of a competent service infrastructure to carry
out / comprehensive range of functions effectively.
Many statistical services fail to provide public health .
authorities with the information they need for sound decision
makihg. The collection of data of doubtful validity and utility
so/ves neither the decision-makers nor the community. Informa
tion services should bo recast according to the priorities.of
health system and should bo aimed strictly a t problem-solving.
J The objectives of a n^'tional hoaltrh policy should therefore
’ 1 bo :
/
\
1. To create the infrastructure for integrated and ccnprehonsivo health services2. To integrate the family planning and health ptrogrammes at
the grass-roots level.
3. To provide well-organised health care prograwne for infants,
children and mothers, with a view to reducing infant and
maternal mortality.
L. To ensure effective prevention and control of communicable
diseases and to organise epidemic-logical, services supported
by well-equipped public health laboratories.
To establish well-organised industrial health serv cos for
/ 5 . workers^
to provide protection.against industrial health
I
hazards, to create a healthy environment to places of work
and to provide workers and uheix families with medical care.
"j'r-
• -j •'
"• .r
;•
/ 4/
6. To provide hospital facilities in iriraJ. areas by
hr-viiig 25 beds at each primry health centre.
7. To create adoqurto under graduate and postgraduate
teaching and training facilities for . edical and auxiliary
personnel and to c nsi^r- proper service conditions
enabling the staff to bo used to the optiinun extent.
8. To ensure the availability of all essential and life
saving drugs at reasonable cost and of imunising
agents for the prevention and control of coricunicable
diseases.
9- To oneuro intersectoral co-operatoon and co-ordination
in inproving onvironncntal sanitation, housing, po
table water supply, etc., at hone and at places of
work.
10. To plan and guide health education activities.
Overall health policy requires a. policy requires a political
will to provide the resources necessary and an effective ex
ecutive structure to implement the decisions. The machinery
for national health planning is lacking with the result the
plans that arc formulated are unrealistic and not presertod
in terms attractive enough to appeal to the cost-benefit and
cost-effectiveness minded planners. This is a serious short
coming and loads to neglect, relatively, of social sections
and health in particular.
The outlay for health sboul.d be considerably increased, The
annual per capita expenditure is loss than Rs. 10 and the total
is about one per cent of GFP as compared to about six per cent
in developed countries like the U »K., the U *S., and Canada.
Investment in health is investment in liuman capital and this
realisation is yet to dawn on our planners. Health care de
livery systems - public and private, curative and preventive,
peripheral, intermediate and. central must be considered as a
whole •
HI
i
I
1
I
■
■
J
In
I
I
BANE OF QWu-CEWALISATION:
In a health service, ovorcentraiLisation of authority and executive
responsibility nay prevent effective and adequate delivery at the
periphery - It tends to maldistribution of resources. Any plan
or progra i c is first planned, then put in operation, then evaluated.
A strict and impartial assosnent of the utilisation of the services
rendered should be made to know if the aims have been achieved*
The evaluation results would enable the necessary adjustments to
bo made in the progra.' re. In our planning, we encounter many
shortcomings. Operation is the only continuous area of nest pro
grammes. ELanning is often sporadic. Evaluation is relatively
rare. So the cycle is not operating in a continuous manner in
many programmes.
A major shift in the emphasis in he health services is necessary
- from a curative to a curative-preventive approach, from urban
to rural population, from the privileged to the underprivileged
and from vertical mass campaigns to a system of integrated health
services forming a component of overall social and economic deve
lopment. Health has to be given a high priority in the Government’ s
general development programme.
Health services arc only one factor ccntributiry to the health of
the poea'le..’ EconorAc and scci-’J. dovelopmcn't ao
■ .■ (
hWQ
f
I
!
1
housing, nutrition, education and communications are all
important factors contributing to good health by improv
ing the quality of life. In their absence., the gains ob
tainable with the disease-centred machinery of health
services cannot go beyond a certain point.
Two kinds of integration are, therefore, necessary. The
first is the integration of various aspects of health
policy into economic and soc?al development. The second
is the welding of the different parts of the. health ser
vices into a national whole •
A firn national policy of preadding total health care for
all will involve a virtual revolution in tne health care
delivery system. It will bring about changes in the dis
tribution of power, in the pattern of political decision
making, in the attitude and colt ituent of the health profession
als and adirdnistraders and in people’s awareness of what
they are entitled to.
To achieve such far reaching changes, political loaders
w-m have to shoulder the responsibility of over-coming
tho inertia as well as the well entrenched vested interests.
Though the framing of health policy belongs to the domain
of politicians, the medical profession has a responsibility
that goes beyond protecting its own interests and the interest
of individual patients to protecting the health of the comm
unity.
The needs of our people warrant a clear national health
policy. In this, there arc two important factors: 1. Health
planning should be an integral part of socmo-economic plann
ing; 2. Most health work is carried out at the State level.
Under those circumstances, it is essential that there should
he co-ordination and co—opera.tion between tho fantral and
State Ministries oi* Health if planning is to be successful.
X
Dr': T .JI. Kumara swfcM ; i; $
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STATEMENT
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600flI
■ 560
Qqj
-
NATIONAL HEALTH POLICY
GOVERNMENT OF INDIA
MINISTRY OF HEALTH 8 FAMILY WELFARE
NEW DELHI
1982
I
Introductory
1. The Constitution of India envisages the establishment of a
new social order based on equality, freedom, justice and the
dignity of the individual. It aims at the elimination of poverty,
ignorance and illhealth and directs the State to regard the
raising of the level of nutrition and the standard of living o^ its
people and the improvement of public health as among its
primary duties, securing the health and strength of workers,
men and women, specially ensuring that children are given
opportunities and*facilities to development in a healthy manner.
1.2 Since the inception of the planning process in the
country, the successive Five Year Plans have been providing
the frame work within which the States may develop their
health services infrastructure, facilities for medical education,
research etc.. Similar guidance has sought to be provided
through the discussions and conclusions arrived at in the Joint
Conferences of the Central Councils of Health and Family
Welfare and the National Development Council. Besides,
Central legislation has been enacted to regulate standards of
medical education, prevention of food adulteration, main
tenance of standards in the manufacture and sale of certified
drugs, etc.
1
1.3
While the broad approaches contained in the successive
Plan documents and discussions in the forums referred to in
para 1.2 may have generally served the needs of the situation
in the past, it is felt that an integrated, comprehensive
approach towards the future development of medical education
research and health services requires to be established to serve
the actual health needs and priorities of the country, it is in
this context that the need has been felt to evolve a National
Health Policy.
Our heritage
2. India has a rich, centuries-old heritage of medical and
health sciences. The philosophy of Ayurveda and the surgical
skills enunciated by Charaka and Shusharuta bear testimony to
our ancient tradition in the scientific health care of our people.
The approach of our ancient medical systems was of a holistic
nature, which took into account all aspects of human health
and disease.
influences
Over the centuries, with the intrusion of foreign
and mingling of cultures, various
systems
of
medicine evolved and have continued to be practised widely.
However, the allopathic system of medicine has, in a relatively
short period of time, made a major impact on the entire
approach to health care and pattern of development of the
health services infrastructure in the country.
Progress
achieved
3.
During the last three decades and more, since the attain
ment of Independence, considerable progress has been achieved
in the promotion of the health status of our people.
Smallpox
has been eliminated; plague is no longer a problem; mortality
from cholera and related diseases has decreased and malaria
brought under control to a considerable extent.
The mortality
rate per thousand of population has been reduced from 27.4 to
14.8 and the life expectancy at birth has increased from 32.7
to over 52. A fairly extensive network of dispensaries, hos
pitals and institutions providing specialized curative care has
developed and a large stock of medical and health personnel
of various levels, has become available. Significant indigenous
capacity has been established for the production of drugs and
pharmaceuticals, vaccines, sera, nospital equipments, etc.
2
The existing
picture
4. In spite of such impressive progress, the demographic and
health picture of the country still constitutes a cause for
serious and urgent concern. The high rate of population
growth continues to have an adverse effect on the health of
our people and the quality of their lives. The mortality rates
for women and children are still distressingly high; almost one
third of the total deaths occur among children below the age
of 5 years; infant mortality is around 129 per thousand live
births. Efforts at raising the nutritional levels of our people have
still to bear fruit and the extent and severity of malnutrition
continues to be exceptionally high. Communicable and noncommunicable diseases have still to be brought under effective
control and eradicated. Blindness, Leprosy and T.B. continue to
have a high incidence. Only 31% of the rural population has
access to potable water supply and|0.5%enjoys basic sanitation.
4.1 High incidence of diarrhoeal diseases and other preventive
and infectious diseases, specially amongst infants and children,
lack of safe drinking water and poor environmental sanitation,
poverty and ignorance are among the major contributory
causes of the high incidence of disease and mortality.
4.2 The existing situation has been largely engendered by the
almost wholesale adoption of health manpower development
policies and the establishment of curative centres based on
the Western models, which are inappropriate and irrelevant to
the real needs of our people and the socio-economic conditions
obtaining in the country. The hospital-based disease, and
cure-oriented approach towards the establishment of medical
services has provided benefits to the upper crusts of society,
specially those residing in the urban areas. The proliferation
of this approach has been at the cost of providing compre
hensive primary health care services to the entire population,
whether residing in the urban or the rural areas. Furthermore,
the continued high emphasis on the curative approach has led
to the neglect of the preventive, promotive, public health and
rehabilitative aspects of the health care. The existing approach
instead of improving awareness and building up self-reliance,
has tended to enhance dependency and weaken the community's
capacity to cope with its problems. The prevailing policies
in regard to the education and training of medical and health
personnel, at various levels, has resulted in the development
of a cultural gap between the people and the personnel provi
ding care. The various health programmes have, by and large,
failed to involve the individuals and families in establishing a
3
self-reliant community. Also, over the years, the planning
process has L**come largely oblivious of the fact that the
ultimate goal of achieving a satisfactory health status for all
our people cannot be secured without involving the commu
nity in the identification of their health needs and oriorities as
well as in the implementation and management of the various
health and related programmes.
Need for
evolving a
health policy
—the revised
20-point
programme
5. India is committed to attaining the goal of "Health for all
by the year 2000 A.D." through the universal provision of com
prehensive primary health care services. The attainment of
this goal requires a thorough overhaul of the existing approa
ches to the education and training of medical and health
personnel and the reorganisation of the health services infras
tructure. Furthermore, considering the large variety of inputs
into health, it is necessary to secure the complete integration
of all plans for health and human development with the overall
national socio-economic development process, and specially in
the more closely health related sectors, e g. drugs and pharma
ceuticals, agriculture and food production, rural development,
education and social welfare, housing, water supply and sani
tation, prevention of food adulteration, maintenance of pres
cribed standards in the manufacture and sale of drugs and the
conservation of the environment. In sum, the contours of the
National Health Policy have to be evolved within a fully inte
grated planning framework which seeks to provide universal
comprehensive primary health care services, relevant to the
actual needs and priorities of the community at a cost which
the people can afford, ensuring that the planning and imple
mentation of the various health programmes is through the
organised involvement and participation of the community,
adequately utilising the services being rendered by private
voluntary organisations active in the health sector.
5. 1 It is also necessary to ensure that the pattern of develop
ment of the health services infrastructure in the future fully
takes into account the revised 20-point programme. The said
programme attributes very high priority to the promotion of
family planning as a people's programme, on a voluntary basis,
substantial augmentation and provision of primary health
facilities on a universal basis; control of leprosy, T.B. and
Blindness; acceleration of welfare programmes for women and
children; nutrition programmes for pregnant women, nursing
mothers and children, especially in the tribal, hill and back
ward areas. The programme also places high emphasis on the
supply of drinking water to all problem villages, improvements
4
in the housing and environments of the weaker section of
society; increased production of essential food items; integ
rated rural developments; spread of universal elementary educ
ation, expansion of the public distribution systems, etc.
Population
stabilisation
6. Irrespective of the changes, no matter how fundamental,
that may be brought about in the over-all approach to health
care and the restructuring of the health services, not much
headway is likely to be achieved in improving the health status
of the people unless success is achieved in securing the small
family norm, through voluntary efforts, and moving towards
the goal of population stabilisation. In view of the vital
importance of securing the balanced growth of the population
it is necessary to enunciate, separately, a National Population
Policy.
Medical and
health
education
7. It is also necessary to appreciate that the effective delivery
of health care services would depend very largely on the nature
of education, training and appropriate orientation towards
community health of all categories of medical and health
personnel and their capacity to function as an integrated team,
each of its members performing given tasks within a coordi
nated action programme. It is therefore, of crucial importance
that the entire basis and approach towards medical and health
education, at all levels, is reviewed in terms of national needa
and priorities and the curricular and training programmes res
tructured to produce personnel of various grades of skill and
competence, who are professionally equipped and socialy
motivated to effectively deal with day-to-day problems, within
the existing constraints. Towards this end, it is necessary to
formulate, separately, a National Medical and Health Education
Policy which (i) sets out the changes required to be brought
about in the curricular contents and training programme of
medical and health personnel, at various levels of functioning;
(ii) takes into account the need for establishing the extremely
essential inter-relations between functionaries of various grades
(iii) provides guidelines for the production of health personnel
on the basis of realistically assessed manpower requirments;
(iv) seeks to resolve the existing sharp regional imbalances in
their availability; and (v) ensures that personnel at all levels
are socially motivated towards the rendering of community
health services.
5
Need for
providing
primary
health care
with special
emphasis on
the preventive,
promotive
and
rehabilitative
aspects:
8. Presently, despite the constraint of resources, there is
disproportionate emphasis on the establishment of curative
centres-dispensaries, hospitals, institutions for specialist treat
ment—the large majority of which are located in the urban
areas of the country.
The vast majority of those seeking medical relief have to travel
long distance to the nearest curative centre, seeking relief for
ailments which could have been readily and effectively handled
at the community level. Also for want of a well established
referral system, those seeking curative care have the tendency
to visit various specialist centres, thus further contributing to
congestions, duplication of efforts and consequential waste
of resources. To put an end to the existing all-round unsatis
factory situation, it is urgently necessary to restructure the
health services within the following broad approach :
(1)
To provide within a phased, time-bound programme a
well dispersed network of comprehensive primary health
care services, integrally linked with the extension and
health education approach which takes into account
the fact that a large majority of health functions can be
effectively handled and resolved by the people them
selves, with the organised support of volunteers, auxilliaries, para-medics and adequately trained multi-purpose
workers of various grades of skill and competence, of
both sexes. There are a large number of private, volun
tary organisations active in the health field all over
the country. Their services and support would require
to be utilised and intermeshed with the governmental
efforts, in an integrated manner.
(2)
To be effective, the establishment of the primary health
care approach would involve large scale transfer of
knowledge,, simple skills and technologies to health
volunteers, selected by the communities and enjoying
their confidence. The functioning of the front line of
workers, selected by the community would require to be
related to definitive action plans for the translation of
medical and health knowledge into practical action,
involving the use of simple and inexpensive interventions
which can be readily implemented by persons who have
undergone short periods of training. The quality of
training of these health guides/workers would be of
crucial importance to the success of this approach.
6
(3)
The success of the decentralised primary haalth care sys
tem would depend vitally on the organised building up of
individual self-reliance and effective community partici
pation; on the provision of organised, back-up support
of the secondary and tertiary levels of the health care
services, providing adequate logistical and technical
assistance.
(4)
The decentralisation of services would require the estab
lishment of a well worked out referral system to provide
adequate expertise at the various levels of the organisa
tional set-up nearest to the community, depending upon
the actual needsand problems of the area, and thus ensure
against the continuation of the existing rush towards the
curative centres in the urban areas. The effective esta
blishment of the referral system would also ensure the
optimal utilisation of expertise at the higher levels of the
hierarchical structure. This approach would not only lead
to the progressive improvement of comprehensive health
care services at the primary level but also provide for
timely attention being available to those in need of
urgent specialist care, whether they live in the rural or
the urban areas.
(5)
To ensure that the approach to health care does not
merely constitute a collection of disparate health interv
entions but consists of an integrated package of services
seeking to tackle the entire range of poor health condi
tions, on a broad front, it is necessary to establish a na
tion-wide chain of sanitary-cum-epidemiological stations.
The location and functioning of these stations may be
between the primary and secondary levels of the hierar
chical structure, depending upon the local situations
and other relevent considerations. Each such station
would require to have suitably trained staff equipped to
identify, plan and provide preventive, promotive and
mental health care services. It would be beneficial,
depending upon the local situations, to establish such
stations at the Primary Health Centres. The district
health organisation should have, as an integral part ot
its set-up, a well organised epidemiological unit to
coordinate and superintend the functioning of the field
7
stations. These stations would participate in the inte
grated action plans to eradicate and control diseases,
besides tackling specific local environmental health
problems. In the urban agglomerations, the municipal
and local authorities should be equipped to perform
similar functions, being supported with adquate resour
ces and expertise, to effectively deal with the local
preventable public health problems. The aforesaid
approach should be implemented and extended through
community participation and contributions, in whatever
form possible, to achieve meaningful results within a
time-bound programme.
(6
The location of curative centres should be related to
the populations they serve, keeping in view the densi
ties of population, distances, topography, transport
connections. These centres should function within
the recommended referral system, the gamut of the
general specialities required to deal with the local
disease patterns being provided as near to the comm
unity as possible, of the secondary level of the hierar
chical organisation. The.concept of domiciliary care
and the field-camps approach should be utilised to
the fullest extent, to reduce the pressures on these
centres, specially in efforts relating to the control and
eradication of Blindness. Tuberculosis, Leprosy, etc.
To maximise the. utilisation of available resources, new
and additional curative centres should bo established
only in exceptional cases, the basic attempt being
towards the upgradation of existing facilities, at
selected locations, the guiding principle being to
provide specialist services as near to the beneficiaries
as may be possible, within a well-planned network.
Expenditure should be reduced through the fullest
possible useof cheap locally available building mater
ials, resort to appropriate architectural designs and
engineering concepts and by economical investment
in the purchase of machineries and equipments,
ensuring against avoidable duplication of such acqui
sitions, It is also necessary to devise effective mech
anisms for the repair, maintenance and proper upkeep
of all bio-medical equipments to secure their maximum
utilisation.
8
(7)
With a view to reducing governmental expenditure and
fully utilising untapped resources, planned programmes
may be devised, related to the local requirments and
potentials, to encourage the establishment of practice
by private medical professional, increased investment
by non-governmental agencies in establishing curative
centres and by offering organised logistical, financial
and technical support to voluntary agencies active in
the health field.
(8)
While the major focus of attention in restructuring the
existing governmental health organisations would relate
to establising comprehensive primary health care and
public health services, within an integrated referral
system, planned attention would also require to be
devoted to the establishment of centres equipped to
provide speciality and super-speciality services, through
a well dispersed net work of centres, to ensure that the
present and future requirements of specialist treatment
are adequately available within the country. To teduce
governmental expenditures involved in the establish
ment of such centres, planned efforts should be made
to encourage private investments in such fields so that
the majority of such centres, within the governmental
set up, can provide adequate care and treatment to
those entitled to free care, the affluent sectors being
looked after by paying clinics. Care would also require
to be taken to ensure the appropriate dispersal of such
centres, to remove the existing regional imbalances
and to provide services within the reach of all, whether
residing in the rural or the urban areas.
(9)
Special, well coordinated programmes should be laun
ched to provide mental health care as well as medical
care and the physical and social rehabilitation of those
who are mentally retarded, deaf, dumb, blind, physically
disabled, infirm and the aged. Also, suitably organised
programmes would require to be launched to ensure
against the prevention of various disabilities.
(10)
In the establishment of the re-organised services, the
first priority should be accorded to provide services, to
those residing in the tribal, hill and backwaro areas as
well as to endemic disease affected populations and the
vulnerable sections of the society.
9
(11)
In the re-organised health services scheme, efforts
should be made to ensure adequate mobility of personnel
at all levels of functioning.
(12)
In the various approaches, set out in (i) to (11) above
organised efforts would require to be made to fully
utilise and assist in the enlargement of the services
being provided by private voluntary organisations active
in the health field. In this context, planning encoura
gement and support would also require to be afforded
to fresh voluntary efforts, specially those which seek
to serve the needs of the rural areas and the urban
slums.
Re orientation
of the
existing
health
personnel
9. A dynamic process of change and innovation is required
to be brought in the entire approach to health manpower
development, ensuring the emergence of fully integrated
Private
practice by
governmental
functionaries
10. |t is desirable for the States to take steps to phase out
the system of private practice by medical personnel in govern
bands of workers functioning within the
approach.
"Health Team"
ment service, providing at the same time for payment of
appropriate compensatory nonpractising allowance. The State
would require to carefully review the existing situation, with
special reference to the availability and dispersal of private
practitioners, and take timely decisions in regard to this vital
issue.
Practitioners
of indigenous
and other
systems of
medicine and
their role in
health care
11.
The country has a large stock of health manpower comp
rising of private practitioners in various systems, for example.
Ayurvedic, Unani, Sidha, Homoeopathy, Yoga, Naturopathy
etc. This resource has not so far been adequately utilised. The
practitioners of these various systems enjoy high local accep
tance and respect and consequently exert considerable influ
ence on health beliefs and practices. It is, therefore, neces
sary to initiate organised measures to enable each of these
various systems of medicine and health care to develop in
accordance with its genius. Simultaneously, planned efforts
should be made to dovetail the functioning of the practitioners
of these various systems and integrate their services, at the
appropriate levels, within specified areas of responsibility
and functioning, in the over-all health care delivery system,
10
specially in regard to the preventive, promotive and public
health objectives. Well considered steps would also require to
be launched to move towards a meaningful phased integration
of the indigenous and the modern systems.
Problems re
quiring urgent
attention
12. Besides the recommended restructuring of the health
services infrastructure, reorientation of the medical and health
manpower, community involvement and exploitation of the
services of private medical practitioners, specially those of
the traditional and other systems, involvement and utilisation
of the services of the voluntary agencies active in the health
field, etc., it would be necessary to devote planned, time
bound attention to some of the more important inputs requi
red for improved health care. Of these, priority attention
would require to be devoted to:
(i)
Nutrition: National and regional strategies should be
evolved and implemented, on a time-bound basis, to
ensure adequate nutrition for all segments of the popu
lation through a well developed distribution system,
specially in the rural areas and urban slums. Food of
acceptable quality must be available to every person in
accordance with his physical needs. Low cost, proce
ssed and ready-to-eat foods should be produced and
made readily available. The over-all strategy would
necessarily involve organised efforts of improving the
purchasing power of the poorer sections of the society.
Schemes like employment guarantee scheme, to which
the government is committed could yield optimal results
if these are suitably linked to the objective of
providing adequate nutrition and health cover to the
rural and the urban poor. The achievement of this
objective is dependent on integrated socio-economic
development leading to the generation of productive
employment for all those constituting the labour force.
Employment guarantee scheme and similar efforts
would require to be specially enforced to provide soci
al security for identified vulnerable sections of the
/
society. Measures aimed at Improving eating habits,
inculcation of desirable nutritional practices, improved
and scientific utilisation of available food materials and
11
the effective popularisation of improved cooking practi
ces would require to be implemented.
Besides, a
nation-wide programme to promote breast feeding of
infants and eradication of various social taboos detri
mental to the promotion of health would need to be
initiated. Simultaneously, the problems of communi
ties afflicted by chronic nutritional disorders should be
tackled through special schemes including the organi
sation of supplementary feeding programmes directed
to the vulnerable sections of the population. The force
and effect of such programmes should be ensured by
delivering them within the setting of fully integrated
health care activities, to ensure the inculcation of the
educational aspects, in the over-all strategy.
(li)
Prevention of food adulteration and maintenance
of the quality of drugs: Stringent measures are
required to be taken to check and prevent the adulter
ation and contamination of foods at the various stages
of their production, processing, storage, transport,
distribution, etc. To ensure uniformity of approach
the existing laws would require to be reviewed and
effective legislation enacted by the Centre. Similarly
the most urgent measures require to be taken to ensure
against the manufacture and sale of spurious and sub
standard drugs.
(iii) Water supply and sanitation : The provision of safe
drinking water and the sanitary disposal of waste waters,
human and animal wastes, both in urban and rural
areas, must constitute an integrated package. The
enormous backlog in the provision of these services
to the rural population and in the urban agglomerations
must be made up on the most urgent basis. The provi
sion of water supply and basic sanitation facilities
would not automatically improve health. The availa
bility of such facilities should be accompanied by
intensive health education campaigns for the improve
ment of personal hygiene, the economical use of
water and the sanitary disposal of waste in a manner
that will improve individual and community health.
All water-supply schemes must be fully integrated with
12
efforts at proper water management, including the
drainage arid disposal of waste waters. To reduce
expenditures and for achieving a quick headway it
would be necessary to devise appropriate technologies
in the planning and management of the delivery
systems. Besides, the involvement of the community
in the implementation and management of the systems
would be of crucial importance, both for reducing
costs as well as to see that the beneficiaries value and
protect the services provided to them.
(iv) Environmental protection: While preventive, pro*
motive, public health services are established and the
curative services re-organised to prevent, control and
treat diseases, it would be equally necessary to ensure
against the haphazard exploitation of resources which
cause ecological disturbances leading to fresh health
hazards. It is, therefore, necessary that economic
developmeat plans, in the various sectors, are devised
in adequate consultation with the Central and the State
Health authorities. It is also vitally essential to ensure
that the present and future industrial and urban develo
pment plans are centrally reviewed to ensure against
congestions, the unchecked release of noxious emiss
ions and the pollution of air and water, in this
context, it is vital to ensure that the siting and
location of all manufacturing units is strictly regulated,
through legal measures, if necessary. Central and
State Health authorities must necessarily be consulted
in establishing locational policies for industrial
development and urbanisation programmes. Environ
mental appraisal procedures must be developed and
strictly applied in according to the clearance to the
various developmental projects.
(v)
Immunisation programme : It is necessary to launch
an organised, nationwide immunisation programme^
aimed at cent percent coverage of targetted population
groups with vaccines against preventable and communi*
cable diseases. Such an approach would not only
prevent and reduce disease and disability but also bring
down the existing high infant and child mortality rate.
13
(vi) Maternal and child health service:
A vicious
relationship exists between high birth rates and high
infant mortality, contributing to the desire for more
children. The highest priority would, therefore, require
to be devoted to efforts at launching special progra
mmes for the improvement of maternal and child health,
with a special focus on the less privileged sections
of society.
Such programmes would require to
be decentralised to the maximum possible extent,
their delivery being at the primary level, nearest to the
doorsteps of the beneficiaries. While efforts should
continue at providing refresher training and orientation
to the traditional birth attendants, schemes and progra
mmes shoul.d be launched to ensure that progressively
all deliveries are conducted by competently trained
persons so that complicated cases receive timely and
expert attention, within a comprehensive programme
providing ante-natal, intra-natal and postnatal care.
(Vii)
School health programme : Organised school health
services, integrally linked with the general, preventive
and curative services, would require to be established
within timelimited programmes.
(viii)
Occupational health service : There is urgent need
for launching well-considered schemes to prevent and
treat diseases and injuries arising from occupational
hazards, not only in the various industries but also in
the comparatively un-organised sectors like agriculture.
For this purpose, the coverage of the Employees State
Insurance Act, 1948, may be suitably extended ensu
ring adequate coordination of efforts with the general
helth services. In their respective spheres of responsi
bility, the Centre and the States must introduce
organised occupational health services to reduce
morbidity, disabilities and mortality and thus promote
better health and increased welfare and productivity on
all fronts.
Health
education
13. The recommended efforts, on various fronts, would bear
' * > health education
only marginal results unless nation-wide
programmes,
backed
by
appropriate
communication
strategies
programmes, I-----...
are launched to provide health information in easily under
standable form, to motivate the development of an attitude
14
for healthy living. The public health education programme
should be supplemented by health, nutrition and population
education programmes
in all educational
institutions,
at
various levels. Simultaneously, efforts would require to be
made to promote universal education, specially adult and
family education, without which the various efforts to organise
preventive and promotive health activities, family planning
and improved maternal and child health cannot bear fruit.
Management
information
system
14. Appropriate decision making and programme planning in
the health and related fields is not possible without establi
shing an effective health information system. A nation-wide
organisational set-up should be established to procure essent
ial health information. Such information is required not only
foF assisting in planning and decision making but to also
provide timely warnings about emerging health problems and
for reviewing, monitoring and evaluating the various on-going
health programmes. The building up of a well conceived
health information system is also necessary for assessing
medical and health manpower requirements and taking timely
decisions, on a continuing basis, regarding the manpower
requirements irf the future
Medical
industry
15.
The country has built up sound technological and manu
facturingcapability in thq field of drugs, vaccines, bio-medical
equipments, etc. The available know-how requires to be
adequately exploited to increase the production of essential
and life saving drugs and vaccines of proven quality to fully
meet the national requirement, specially in regard to the
national programmes to combat Malaria, TB, Leprosy,
Blindness, Diarrhoeal diseases, etc. The production of the
essential, life saving drugs under their generic names and the
adoption of economical packaging practices would considerably
reduce the unit cost of medicines bringing them within the
reach of the poorer sections of society, besides significantly
reducing the expenditures being incurred by the govern
mental organisation on the purchase of drugs. In view of the
low cost of indigenous and herbal medicines, organised
efforts may be launched to establish herbal gardens, producing
drugs of certified quality and making them easily available.
15. 1 The practitioners of the modern medical system rely
heavily on diagnostic aids involving extensive use of costly,
sophisticated biomedical equipment.
Effective mechanisms
15
should be established to identify essential equipments
required for extensive use and to promote and enlarge their
indigenous manufacture, for such devices being readHy avai
lable, at reasonable prices, for use of the health care centres.
Health
insurance
16. Besides mobilising the community resources, through its
active participation in the implementation and management of
national health and related programmes, it would be necessary
to device well considered health insurance schemes, on a
State-wise basis, for mobilising additional resources for
health promotion and ensuring that the community shares the
cost of lhe services, in keeping with its paying capacity.
Health
legislation
17. It is necessary to urgently review all existing legislation
and work towards a unified, comprehensive legislation in the
health field, enforceable all over the country
Medical
research
18. The frontiers of the medical sciences are expanding at a
phenomenal pace. ,To maintain the country's lead in this field
as well as to ensure self-sufficiency and generation of the
requisite competence in the future, it is necessary to haye an
organised programme for the building up and extension of
fundamental and basic research in the field of bio-medical and
allied sciences. Priority attention would require to be devoted
to the resolution of problems relating to the containment and
eradication of the existing, widely prevalent diseases as well
as to deal with emerging health problems. The basic objective
of medical research and the ultimate test of its utility would
involve the translation of available know-how into simple,
low-cost, easily applicable appropriate technologies, devices
and interventions suiting local conditions, thus placing the
latest technological achievements, within the reach of health
personnel, and to the front line health workers, in the remotest
corners of the country. Therefore, besides devotion* to basic,
fundamental research, high priority should be accorded to
applied, operational research including action research for
continuously improving the cost effective delivery of health
services. Priorities would require to be identified and laid
down in collaboration with social scientists, planners and
decision makers and the public. Basic research efforts should
devote high priority to the discovery and development of more
effective treatment and preventive procedures in regard to
communicable and tropical diseases—Blindness, Leprosy, T.B.,
etc. Very high priority would also have to be dtvoted to
contraception research, to urgently improve the effectiveness
16
and acceptability of existing methods as well as to discover
more effective and acceptable devices. Equally high attention
would require to be devoted to nutrition research, to improve
the health status of the community. The overall effort should
aim at tha balanced development of basic, clinical problemoriented operational research.
Inter-sectoral
cooperation
1&. All health and human development must ultimately
constitute an integral component of the overall socio-economic
developmental process in the country. It is thus of vital
importance to ensure effective coordination between the health
and its more intimately related sectors. It is, therefore, neces
sary to set up standing mechanisms, at the Centre and in the
States, for securing inter-sectoral coordination of the various
efforts in the fields of health and family planning, medical
education and research, drugs and pharmaceuticals, agriculture
and food, water supply and drainage, housing, education and
social welfare and rural development. The coordination and
review, committees to be set up, should review progress,
resolve bottlenecks and bring about such shifts in the contents
and priorities of programmes as may appear necessary to
achieve the overall objectives. At the community level, it
would be desirable to devise arrangements for health and all
other developmental activities being coordinated under an
integrated programme of rural development.
Monitoring
and review
of progress
20. It would be of crucial importance to monitor and period*
ically review, the success of the efforts made and the results
achieved. For this purpose, it is necessary to urgently identify
the base line situation and to evolve a phased programme for
the achievement of short and long term objectives in the
various sectors of activity. Towards this end, the current level
of achievement as well as the broad indicators for the achiev
ement of certain basic health and family welfare goals are set
out in the annexed tabular statement. These goals, as well as
other allied objectives, would require to be further worked
upon and specific targets for achievement established by the
Central and the State governments in regard to the various
areas of functioning.
17
GOALS FOR HEALTH AND FAMILY
WELFARE PROGRAMMES
GOALS
SI.
No
Indicator
1.
Infant mortality rate
Current level
1985 1990 2000
Perinatal mortality
Rural 136 (1978)
Urban 70(1978)
Total 125 (1978)
67 (1976)
122
60
106 87 below 60
30-35
2.
Crude death rate
Around 14
12
3.
Pre-school child
10.4
9.0
20-24 15-20
10
(1-5 yrs) mortality
24 (1976-77)
4.
Maternal mortality rate
4-5 (1976)
5.
Life expectancy at
Male 52.6 (1976-81) 55.1 57.6
Famale 15.6 (1976-81) 54.3 57.1
64
64
birth (yrs)
6.
3-4 2-3 below 2
Babies with birth
weight below
2500 gms (Percentage)
30
25
18
IQ
7.
Crude birth rate
Around 35
31
27.0
21.0
8.
Effective couple
Protection (Percentage)
23.6 (March 82)
37.0
42.0
60.0
1.48 (1981)
1.34
1.17
1.00
1.66
1.20
9.
Net Reproduction Rate
(NRR)
10.
Growth rate (annual)
2.24(1971-81)
1.90
11.
Family size
4.4 (1975)
3.8
12.
Pregnant mothers
receiving ante-natal (%)
40-50
13.
2.3
50-60 60-75 JOO
Deliveries by trained
attendents (%)
30-35
18
50
80
100
14.
Immunisation status
(%) coverage
TT for pregnant women
20
TT for school children
10 years
16 years
20
DPT (children below 3 yrs) 25
15.
100
100
100
85
70
80
100
Polio (infants)
BCG (infants)
5
65
DT (new school entrants
5-6 years)
20
80
85
85
Typhoid (new school
entrants 5-6 years)
2
70
85
85
20
40
60
80
50
60
75
90
1.4
1
0.7
0.3
too
85
85
85
Leprosy - percentage of
TB - percentage of
disease arrested cases
out of those detected
17.
100
40
60
70
50
70
arrested cases out of
those detected
16.
60
Blindness Incidence
of (%)
19
\
I
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Reprinted and circulated as a discussion document by
Voluntary Health Association of India
40, Institutional Area
South of l.l.T.
New Delhi-110 016.
Phones : 668071, 668072, 665018.
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h p i (,
COMMUNITY HEALTH CELL
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POSITION PAPER ON NATIONAL
HEALTH POLICY
Amla Rama Rao
Voluntary Health Association of India
© 1987
Voluntary Health Association of India
40, Institutional Area, South of I.I.T., New Delhi-1 10 016
Printed by
Joginder Sain & Bros. (Printing Division)
A 30/1, Naraina Ind. Area, Phase I, New Delhi-110028.
POSITION PAPER ON NATIONAL
HEALTH POLICY
The National Health Policy as planned may remain only a policy document unless
all of us make a commitment to it, and try to implement it at all levels. Each of us
must carefully analyse the health problems, keeping in mind the country’s capacity
to deal with them. The goals and priorities will be fixed accordingly. Strategies to
achieve them need to be based on social justice and equity, intrasectoral linkage and
self-reliance as far as possible.
The ill-conceived and inadequate health services currently provided to the vast
majority of the population has created a feeling of social injustice and given many
voluntary organisations the impetus to act as natural leaders of their communities.
They have the responsibility to lead movements for the change. For this they need to
identify the strategies to develop their full leadership potential. They should look
beyond the traditional system of health care and develop a deeper understanding of
the philosophy of primary health care and a commitment to achieve health for all
by 2000 A.D.
1.
PROVISION OF HEALTH SERVICES TO ALL
For those who live in remote areas and belong to the lower income groups, health
care can be provided only through a system which creates a broad base of
functionaries and provides health care to the maximum number of people. The
training of new community health workers at the village level has only duplicated
the existing system and has not proved very helpful in the long run. Wherever the
traditional health functionaries have been involved, the infrastructure has become
stronger. The health care system may continue to be lopsided, unless efforts are
made to improve the training and supervision of CHW’s and Dais.
2.
REFERRAL SYSTEM AND PRIMARY HEALTH CARE :
A STRATEGY
The bottlenecks that exist between the village and a health sub-centre are again a
matter of concern. The health assistant is no better equipped with the skills and will
to deal with certain health problems than a CHW. So unless there is a way to reach
Primary Health Centres very little can be done at these levels.
3
Another important point is that the referral system does not allow for any planned
way to go from one to another. There is no geographical or political boundary
which one cannot cross. Unless the screening is done at all levels, the political and
the social linkage is established between a specialist hospital to a Primary Health
Centre of the block, from there to the village sub-centre and back from village to the
specialist hospital; the congestion, duplication and the parallel system will
continue to exist. The suggested change of effective links between primary health
centres and medical colleges and hospitals in order to harness and provide
specialised skills is no doubt progressive thinking for re-orientation of medical
education and better health service, but its implementation has been held up due to
many administrative difficulties. As a result, neither are the Block Administrators
taking responsibility for the better functioning of these Primary Health Centres nor
have the medical college hospitals established a proper linkage with them. Very few
specialists from these hospitals like to go out to the Primary Health Centres. In fact
the person who goes there is only a junior or senior resident working in those
specialised units. Most of the time they treat these trips as holiday excursions. There
is no continuity of ties nor any feedback from such hospitals to the Primary Health
Centre doctor.
3.
INFORMATION SUPPORT
To estalish a proper information support, there must be a well-defined referral
system. General practitioners, indigenous practitioners and all others who are
involved in any way with the health care system should become a part of the
information support. The Epidemiological Cell in each State may not be essential
but it should have a computerised system for collecting and processing information
from different units. Without information, support evaluation and monitoring of
any programme is not possible.
4.
RE-ORIENTATION OF HEALTH PERSONNEL
To equip health personnel with appropriate and scientific techniques we must
provide a system of continuous education. Inservice training programmes are
essential to develop the skill to do the job better. Certain managerial skills which are
never imparted to medical professionals in their undergraduate courses must
become a part of the orientation training programmes. All courses could be so
planned that NGO/Govt. officials attend the courses together and can interact with
each other.
The voluntary organisations have a greater sense of dedication and commitment to
social causes and are more open to change. This gives them an enormous advantage
in the field. They provide care at all levels in all kinds of settings to the poorer
section. They frequently act as links between the individuals, community and the
rest of the health care system.
4
5.
INTERSECTORAL COORDINATION
That various sectors have influence on health is well understood, but intra or
intersectoral coordination remains most of the time only in the minds of people or
as words on paper. Actual coordination at various levels is possible only if the
planning of the two sectors are done at one place, and from bottom to top. The
possibility of removing the bottlenecks is maximised if two sectors, well connected
like water and sanitation, nutrition and education, are planned together. Again,
regarding the educational status of woman and her acceptance of family planning,
both must be worked out together, and receive the same importance. The
administrative blocks also need attention. There is a need to define the job
responsibility of various people at different levels, as well as a policy of delegation
of authority at each level. If decision making is confined to the planners’ level, the
implementing functionaries find it very difficult to carry out their day-to-day
duties.
6.
ALTERNATIVE SYSTEMS OF MEDICINE
There is a need for integrating the training programmes of different personnel in
different systems. The policy has recommended the use of indigenous systems of
medicine like Ayurveda, Unani, Sidha and Homeopathy. It also emphasises
introducing Yoga and Naturopathy into the overall Health Care Programme. But
when it comes to putting this into practice, none of the Primary Health Centres or
the dispensaries is equipped to give advice on any of the traditional systems of
medicine.
Traditional systems of medicine have always had a place in our culture. They are
both less expensive than modern medicine and more easily accessible to the
majority of our population. To allow them to stagnate will only increase existing
inequalities in the health care system. Therefore, ways of integrating the modern
with traditional system of medicine must be thought of.
7.
REGIONAL IMBALANCES OF THE HEALTH CARE SYSTEM
It is of vital importance to correct the regional imbalances that exist in health care
systems today. The policy cannot be successfully implemented unless sustained
political, social and administrative support is obtained from everyone concerned.
Here the local communities play a very important role and it is our duty to make
them aware of the facilities they are entitled to, so that they demand the care they
need. The concept of preventive and promotive services is still lacking all through
8.
MEDICAL EDUCATION
We need not go into the details of formal medical education as we all know that it is
not tailored to meet the requirements of the type of medical practitioners who work
5
in Primary Health Centres. If more clear and effective strategies could be specified,
the wasted resources could be harnessed. The re-orientation of medical education
has been talked about for the last several years but very little has been done to make
education community-oriented and problem-based. Most of a medical graduate’s
time is spent in hospitals. The type of knowledge and skills that he/she acquires are
the ones from the hospital itself, when almost 80% of the ailments are preventable
and can be cured by simple remedies. But these cases never reach the hospital for
their attention.
The National Health Policy is aimed at taking services to the doorstep of the people
ensuring fuller participation of the community and improvement in the quality of
their life. It is intended to restructure the health care services on the preventive,
promotive and rehabilitative aspect rather than on cure only. Therefore to provide
trained personnel with the right attitude and outlook is more important for proper
functioning of the services talked of in the policy document.
9.
MEDICAL RESEARCH
It is the opinion of various experts that today there is a lot of money being wasted on
basic research which could be well’shared by the developed world. The technical
know-how can be easily obtained from them.
Special research on health care system, problem based medical education and need
based para-medical education at various levels, require a lot more attention than is
being given in this country. In my opinion “behaviour problem” of the recipients
of health services should form the priority for the research grant in India. There is
also a need for a constant feedback on the new findings and advances in medical
research and their application to health services. The dissemination of this
information to the proper levels both upward and downward are equally
important. Unless we keep informing our workers at the grassroots level of what is
happening at the central level, the implementation of the programmes become
difficult.
10.
THE TARGETS
The National Health Policy paper gives the targets to be achieved according to the
time frame. These targets are not comprehensive nor have they been worked out on
any realistic terms. The exercise only tells what future achievements can be expected
provided the base is known. No doubt it is better to work on some frame, to measure
the milestone and progress being made but the baseline information is of crucial
importance.
The target sets are based on certain information that was available at one point of
time: perhaps as far as 1975 or 1976. Unless the relevant data is available from
different states it is of no use setting up targets to reduce the incidence. A few studies
6
carried out by big institutions like the All India Institute of Medical Sciences or PGI
Chandigarh tell us very little about the overall health statusof our country. Lack of
vigilance in reporting and collecting of information will hinder us from reaching
our targets.
11.
ROLE OF NGO’s
The role of voluntary agencies has been very well spelt out by the Alma Ata
Declaration. It includes:
1. Identification of the needs and problems of the people.
2. Development and innovative programmes for Primary Health Care, in the
context of comprehensive human development.
3. Promotion of full participation by individuals and communities in the
planning, implementation and control of these programmes.
4. Training of health workers, supervisors, administrators, planners and various
agricultural and development workers, along with training schemes, build on
the skills of traditional healers and midwives.
5. Creation of new and effective methods of health education.
6. Recognition of the essential role of women in health promotion and in the full
range of community development concerns.
7. Contribution to the search for greater social justice.
8. Development of locally appropriate health technologies and use of resources.
r
Most of the voluntary organisations are working for both health and development.
The standards of health cannot be improved unless there is an improvement in the
general quality of life. The NGO’s are more willing to go to the most difficult areas
where nothing exists as far as the health system is concerned. Still they find it
difficult to be recognised and get little or no help from the government system. It is
time we all realised that to achieve health for all by 2000 AD, the involvement of the
voluntary sector is essential.
THE DILEMMA—NATIONAL HEALTH PROGRAMME
Most of the time the doctor faces a very big dilemma in his day-to-day functioning.
He is unable to find what to do and how to get started with diverse programmes like
TB, Leprosy, Prevention of Blindness, Malaria control, Family Planning,
Immunization, School Health, Nutrition and MCH, as well as to keep evaluating
the programmes from time to time. Only if the planning process, information
system, resources, supervision, coordination and training is adequate can the
7
doctor use his energy as a team leader to build up the team, organise the community,
keep proper records, monitor the programmes and do a follow up review, as well as
initiate certain changes in the programme when the need arises.
The bring about any change is a very complex task. The people who are striving to
reach the goal of health for all must have a clear understanding of the National
Health Policy, the critical issue required for its implementation and the broad
principles involved in it.
In these three days let us together work out an action plan for our own areas keeping
all the elements of the National Health Policy in mind and evolve our own
strategies to reach the goal of health for all by 2000 AD.
*************
>
8
GOMMENTARY
Simplistic Approach to Health
Policy Analysis
World Bank Team on Indian Health Sector
Debabar Banrrji
A World Bank report on the health sector has set out to offer an
alternative policy framework to cushion the impact of structural
adjustment programmes on health services. But by choosing
health financing as a tool for policy analysis it has arrived at
highly questionable conclusions.
THE secretive World Bank Report: India:
Health Sector Financing, has been widely
commented upon in the national press. A
World Bank team paid a five-week visit
in March-April last and claimed that the
analysis and the policy outcomes were
generally endorsed by senior health sector
personnel in India (p 3). Indeed, based on
a ‘vigorous’ discussion at a meeting of
“India’s most eminent health policy
researchers, chaired by the Secretary of
Health”, the team claims that the report
in many ways is a joint statement of the
two sides (p 3). It is worthy of note that
a substantial majority of those who at
tended the meeting were not even ac
quainted with some of the basic literature
concerning growth and development of
public health practice in India, not to
sepak of health policy research with its
political, administrative, technological,
epidemiological and sociological dimen
sions. That might be the reason why the
distinguished participants of the meeting
failed to note that health financing is a
part of the wider academic field of health
economics, which in turn forms only one
component of health systems research for
developing effective public health prac
tices under given conditions. Health
economics has interest, among others, in
the complex questions of identifying more
effective uses of given resources. A health
service system is a complex entity, where
a large number of variables, derived from
a large number of disciplines, are in com
plex interaction with one another. The in
teraction determines the output of the
system. This output needs to be optimis
ed, using the methodologies of opera
tional research and systems analysis. In
this sense, research in health economics
becomes a component of the even larger
field of health systems research. Optimisa
tion of complex systems in order to get
the maximum returns from a given quan-
Economic and Political Weekly
turn of resources thus becomes the corner
stone of research in public health practice
and health policy research [Banerji 1985:
362-64). For instance, in considering a
programme for containment of malaria in
India, it is important to ensure that ade
quate inter-disciplinary research has been
carried out to have the optimal solution
of the problem. The question of financ
ing comes after the problem of optimisa
tion of the system is attended to. There
is, indeed, a likelihood that the current ap
proach adopted for malaria control is not
cost-effective [Banerji 1985: 142-44]. In
such an eventuality, clamour for a mere
increase in the funding of the malaria pro
gramme may result in increase of waste
of resources. Health human-power develop
ment, National AIDS Control Pro
gramme, the health service system, as a
whole or in the form of its components
(e g, hospitals, medical colleges or PHCsX
are other examples of systems that need
optimisation, before the question of
financing is considered. The heading on
page 13 of the report, ‘Enhancement of
Efficiency through Redirection of Funds’
is a good example of the narrow and ob
viously distorted approach adopted in the
report: as if lack of redirection of funds
is the only cause of inefficiency. The focus
on health Financing, to the exclusion of
the wider issues of optimisation has
sharply distorted the problem analyses
and the solution suggested by the World
Bank team. It has put the issues upside
down.
The team is expectedly simplistic in
making policy analysis. The report makes
a sharp contrast with the National Health
Policy of India (NHP) of 1982 [GOI
1982]. It did not occur to the team to iden
tify the factors which have come in the
way of implementing the NHP over the
past decade and more. In addition, apart
from the numerous gaping holes in the
June 12, 1993
analysis of epidemiologicai, technological
and organisational and management issues
that need to be considered for policy
analysis, the team is deafeningly silent on
the political and sociological dimensions
of the analysis. Is it because the team itself
is a creature of international politics of
the World Bank and the affluent countries
that dominate it? How could the team ig
nore the wealth of literature available on
politics of family planning, immunisation,
health systems research and of course, the
World Bank’s own National AIDS Con
trol Programme [see, for example, Banerji
1990a; 1992a; 1993]? There is moreover
the politics of capitation fees in medical
colleges which has led to the recent over
throw of the governments in Karnataka
and Andhra Pradesh. The savage 42 per
cent cut in the malaria programme in the
1992-93 budget by the finance minister,
and/its restoration apparently at the in
sistence of the World Bank in 1993-94,
provides yet another chilling instance of
the way politics literally decides issues of
life and death of a large number of peo
ple of this country.
Th» Report
The main purpose ot the report is to
initiate dialogue between the government
of India and the World Bank to clarify
issues of direction and policy in the face
of structural adjustment, which will in
fluence the pattern of co-operation in the
health sector for the next few years (p 3).
The purpose is to ensure that budgetary
constraints do not reduce the scale, equity,
and quality of health services by encoura
ging health administrators to take difficult
decisions. The major concern ought to be
to make reallocation of expenditures to
achieve greater effectiveness in solving na
tional health problems, specially for the
poor, who suffer disproportionately from
poor health and high mortality.
The most significant aspect of the
health services is that it has undergone
rapid expansion while it was receiving
slowly declining share of public budgets
for health in the 1970s, with a precipitous
decline occurring in the 1980s. The plan
expenditure has steadily declined from
0.08 per cent of GDP to a low of 0.04 per
cent in the revised 1991-92 budget. This
has caused, what the report says ‘a double
squeeze*. The infrastructure stretches the
existing budget very thin. This has caus
ed marked inefficiencies, which has made
it almost ineffective. Over and above came
a sledgehammer approach to the budget
cut to bring about structural adjustment.
The central health budget was slashed by
1207
— I
ires as an integral component of the
disparities and increase efficiency. It offers
broader community development pro
a massive 20 per cent in 1992-93, without
<
a chance for the health sector to emerge gramme. At around the same time, a
even accounting for inflation from
from the period of financial stringency massive health manpower development
Rs 302 crore in 1991-92 to Rs 244 crore in
stronger, more effective and better
drive was launched, which also included
1992-93. There was also a massive 30 per
targeted. The current budget shows that
social orientation of education and training
cent cut for rural drinking waler and 40
the central government has missed the op
of physicians and other categories of
per cent cut in rural sanitation. An acros
portunity to raise spending on health and
the board of cut of 20 per cent in all ex
health workers In 1977. there was the pro
family welfare during adjustment as a pan
gramme to entrust ‘people’s health in pcopenditure heads will obviously be a laceraL
of the safety net (p 12). The report urgent
ing way of making the reduction. How
pie’s hands’. Later, there was the pro
ly calls for evolution of a positive policy
gramme of rapid expansion of the infra
ever, apparently to placate the rich,
before fiscally driven cuts, with little
structure with PHCs and its sub-centres
already privileged urban classes, there was
regard for the efficient functioning of the
and CHCs [Banerji 1990b: 37-42). Data
indeed an increase of 13 per cent in the
health service system, effect severe damage
have been colkcted by the team to demonst
allocation for hospitals and dispensaries
to the quality and equity of services that
rate^vidly how this rich heritage has been
and, correspondingly, the malaria pro
can be delivered. The report has presented
frittered away due to unpardonable acts
gramme which caters to (he large masses
an alternative policy framework (p vin):
of omissions and commissions of the
of the population of the country received
(a) expand spending on primary care and
political leadership and the bureaucracy
a savage 42 per cent cut. In effect, there
communicable disease programme; (b)
of the country. Nevertheless, it should be
is some rise in expenditure towards pro
redirect public resources to health acti realised that the health services is a live,
grammes with what thc report terms as
vities with broad benefits to the nation as
organic entity, despite its many serious
‘relatively few externalities’ at the expense
a whole; (c) improve efficiency and effec
problems. The remedy does not lie in the
of programmes with larger externalities
tiveness of service delivery primarily
vivisection of this organic entity. The
and benefits to the poor.
through adequate blend of inputs; and
‘hospitals’ (from above CHC level right
The selected neglect of the health ser
(d) redouble efforts to address inter- and
up to the super-sophisticated ones and the
vices which were of greater relevance to
intra-state equity problems through the
medical colleges) are integral parts of this
the poor has precipitated a serious crisis.
redistribution and targeting of public ex
organic structure. Hypothetically, even if
The report quotes an NCAER survey of
penditure to raise the primary health care
they are dissected away from the main
1990 (p 9) to state that the poorest 40 pa
services to an acceptable minimum stan
body and are conceived as autonomous
cent of rural households spend, on an
dard. It makes the interesting suggestion
bodies, making 20 per cent cost recovery,
average, Rs 157 per illness episode, when
of making poverty levels as a basis for
it will also mean laceration of the entire
receiving care from government doctors
distribution of grants to states, rather than
health service workforce. Further, where
and Rs 131 when purchasing care from
using the general population-based
private doctors. The richer 60 per cent of
will the poor, who form the overwhelming
formula.
majority of the patients, go? What about
the population paid less for government
The team has defined some specific
doctors, Rs 137, and more for private doc
the urban poor? What will happen to
short-term health policy responses to the
community health activities of the
tors, Rs 215. A similar pattern was observ
structural adjustment (pp xiii-xv): (a) En
hospitals-family planning, referral sup
ed in the 42nd round of the NSS, com
hancement of efficiency through redistri
pleted in 1987. Thus, those who are least
port to PHCs, immunisation, social
bution of funds; (b) Restoring cuts to the
paediatrics, education and training of
able to pay are bearing the heaviest burden
malaria and tuberculosis programmes;
when they go to a government doctor. The
health workers, and so forth?
(c) Increased spending on communicable
poignancy of this finding is underlined by
The tcam
team jiss similarly vague and equidisease control; (d) Increase selective spenThc
another finding of the survey, which indh
ding on non-salary inputs for what the
abou( strengthening of what it calls
cated that medical care cost is next only
report calls ‘primary health care services’;
primary care’ institutions and communito dowry as a cause of rural indebtedness.
(e) Develop a health economics unit in the
diseases programmes. This is retThis is a shocking situation in itself.
department of health; and (f) Begin policy ^ed indirectly in the team’s confusion
However, more shocking is the utter
development for increasing cost recovery
the usc of the term ‘primary care with
callousness of the political leadership,
in hospitals and medical education.
thc COncept of primary health care of the
Joth at the centre and in the stated, which
Precisely because the team has provided Aima-Ata Declaration [WHO 1978) and
has created the present state of affairs.
primary health centre of the Bhore Com
quite a convincing argument for a reThe draconian cuts in the budget is only
mittee. Besides, what will happen to the
evaluation
of
the
health
services,
for
the
one such episode in the long story of
reasons mentioned earlier, the recommen World Bank’s own National AIDS Control
almost criminal neglect of the health serProgramme on the UNICEF’s Universal
dations come as an anti-climax. They
rfees by the political leadership.
Programme of Immunisation and the
amount to a prescription for a vivisection
The report notes that public health
Polio Plus Programme, which -have al
of the health services so painstakingly
financing in India is characterised by an
been shown to be not cost-effective
built and nurtured over more than six
emphasis on ‘hospitals’ (all institutions
[Banerji 1990a; Gupta and Murali 1989]'
decades.
.
above community health centres (CHC)),
India’s health policy is rooted m the Then, over and above, is the critical ques
rather than ‘primary care’ (all services
lion of optimisation of other programme
vision of a new India during the antifrom CHCs down); urban rather than
colonial freedom movement [Banerji
and institutions.
rural populations; medical officers rather
1985: 13-24]. It was articulated m the
than paramedics (again with an urban
Other Conceptual Gaps
report of the National Health Sub
bias); services that have larger private
committee of the National Planning
The team had done commendable wor
rather than social return; and family plan
Committee (1948) and the Bhore Commit in mobilising data on different aspects c
ning and child health to the exclusion of
tee [GOI 1946). Despite severe resource
health financing and develop insights cor
wider aspects of female health (p vi). The
constraints and colossal dimensions of the
cerning the three important areas of eff
report maintains that structural adjust
health problems, after independence the
ciency, equity and disparity. However,
ment can facilitate flexible, imaginative
country launched the very ambitious pro
number of :ssues concerning the study c
strategies and operational changes that
gramme of setting up primary health cenwill redirect public spending to ameliorate
Economic and Political Weekly
1208
June 12, 19*
h
e
d
1ic
ol
al
le
ill
ve
I?
!Sies
)rk
of
onffi’> a
■of
1993
empowenng
the panchayati raj institu were bterally not fit lor the job. They lack
health policy through analysis of health
<
ed the public health competence needed
tions. This opens up exciting possibilities <
financing have been raised earlier which
1
for policy research, because as generalist
of
bringing
the
health
services
nearer
to
call into question the basic policy recotn<
administrators, their posting in a health
the people by making suitable policy
mendations made by the team. It is con
ministry is a mere episode in their long
changes.
However,
the
team
finds
itself
in
tended that such an analysis of health
<
career span, which takes them to many
the opposite camp. Throughout the report,
financing ought to have been associated
other ministries. So. they cannot be held
its
recommendations
lean
heavily
on
a
with wider analyses of the health service
accountable either. The team does not
strong centre which can serve as a conduit
system and its numerous sub-systems, subseem to be aware that some 15 years back
for
bringing
about
the
changes
desired
by
sub-systems. and so on. This required a
India had a competent cadre of public
it (see, for example, p xvii of the report).
much wider inter-disciplinary scholastic
health physicians, with long experience in
There
then
is
a
clear
political
issue:
should
base for optimising systems of different
policy formulation and pub he health prac
the World Bank’s interest in strengthening
sizes and complexities. Due to excessive
tice. This heritage is now lost. Along with
the leverage capacity of the centre receive
preoccupation with aspects of financing,
the domination of the generalist administ
precedence over the dictates of the na
the team has missed discussion of some
rators, there are many key public health
tional parliament and of the Constitution?
of the key variables within the health ser
(3) Regional Variation: The team is seiz positions at the centre and in the states
vice system, which have profound policy
ed
of the serious nature of regional varia which are filled by physicians who do not
implications. Some of these are briefly
tion in health service development. It also have the needed qualifications and train
ing [Banerji 1990b: 91-99). One reason for
mentioned below:
advocates allocation of support on the
(1) Social Dimensions of Health ana
the present crisis among the physician
basis of poverty, an issue which has also
Health Services- India has been a pioneer
administrators is the nature of the cadre
been discussed in the National Develop
ing country in promoting social science
ment Council. However, one misses a structure, which does not have a clear-cut
studies in health fields as an integral com
more detailed policy frame for reducing career plan for the making of physicians
ponent of inter-disciplinary efforts for
who have the managerial, epidemiological,
the disparity, based on actions already
health service development [Banerji 1993).
sociological and political competence
initiated.
That is why it is all the more striking that
(4) Inadequate Public Health Inputs' (managerial physicians) to effectively deal
the team should have ignored this very
As a result of the preoccupation of the with questions of health policies and pro
critical input in health policy research.
grammes. Besides, the relatively inferior
team with financial aspects, it has almost
The Alma-Ata Declaration on primary
positions given to even top technical per
totally omitted some key considerations
health care is also anchored on social
related to public health practice. Interest sons in comparison with the generalist ad
science considerations: increasing com
ingly, if the team had used an epidemio ministrators of corresponding seniority
munity self-reliance through increasing
logical approach to community diagnosis has its deleterious impact on the morale
their own coping capacity in health field,
and solution to a community health pro of the health workers [Banerji 1990b:
social orientation of technology and inter
143-50).
blem, the concept of natural history of a
sectoral action in health. The concept of
The responsibility for the present state
community-felt need, developed on the disease in an individual would have almost
of affairs rests squarely on the political
logically
led
it
to
the
identification
of
the
basis of imparting sociological dimen
leadership, because all the decisions which
strategic points in the natural history
sions to the epidemiological parameters
have precipitated the present crisis wcr^
where
intervention
in
the
form
of
an
op
of health problems, is yet another impor
taken with their active consent [Banerji
timised package of programmes would
tant area of interest for study of health
1990b: 143-50). The macabre slashing of
have yielded the maximum returns from
policy [Banerji 1993].
funds
in the 1992-93 budget is an example
There is, moreover, the important con a given investment. This would have been
Here the finance minister acts even holier
particularly
relevant
because
of
the
team
’
s
cept of interaction of health behaviour
deep concern about communicable dis than the pope. The donor agencies asked
With access of services of various kinds
for a pound of flesh as a price for their
and of cultural meaning and perception eases and about women’s health.
‘help’; the finance minister insisted on
(5) The National Health Policy of 1982: giving them two pounds of flesh? While
of health problems in a community. These
ideas are of particular importance as the This important document has received vir pampering the rich by making massive
team has laid so much of stress on equity tually no attention in the report. This is
reductions in excise and customs duties,
and disparity. Indeed, the team has paid surprising, because an analysis of the the finance minister did not show any
factors which came in the way of its im
attention to the NCAER and NSS studies,
mercy for the poor. He allowed them a
showing how tragic it is for those who are plementation would have provided valua free fall, steadfastly refusing the offer of
ble leads to the team. The NHP strongly
poor to pay higher amounts for the same
a safety net by the kind-hearted donors
endorsed the principles embodied in the
services in government institutions than
,
Alma-Ata Declaration, including the key (p xii)!
the rich and how often the loans taken for
[
(7) Impact of the Family Planning Proissues of community self-reliance and
meeting such catastrophies become a
! gramme: The team has not done justice
decentralisation
of
health
administration
major burden on them in the form of
to the analysis of the damage done to the
to promote it. An interesting point stress
debts incurred. Social analysis of India’s
infrastructure of the health services as a
ed
in
the
document
was
to
“
bridge
the
experiences of the community health
result of according the highest priority to
worker scheme ought to have raised im cultural gap that exists between the pro the target-oriented, time-bound family
viders of the health services and the
portant issues concerning rural power
planning programme. Ironically, the
community”.
structure [Banerji 1985: 306-16].
damage was maximum in the regions
(6)
Management
of
Health
Services
(2) Centralisation and Decentralisation:
where the infrastructure was weak.
This is by far the most critical, because
Closely connected with the social science
(8) Consequences of Imposition of
the managers and their political leaders
dimensions, including the issue of com
Internationally Sponsored Health Pro
are key elements in policy formulation and
munity participation and the nature of
grammes-. The Universal Immunisation
its implementation. Even though the
power structure in rural populations, is the
Programme sponsored bv the UNICEF,
desirability or otherwise of decentralisa team’s Indian contacts were predominant
the WHO and other international and
ly secretaries, commissioners and joint
tion in administration of health serivces.
bilateral agencies was brought in as
i
secretaries
at
the
centre
and
in
the
states,
This acquires even greater significance in
another target-oriented, high priority proit
did
not
strike
them
that
most
of
them
view of the recent constitutional change
1209
Economic and Political Weekly June 12, 1993
---- F
a Perspective, Lok Paksh, New Delhi.
_ (1990aj Politics of Immunisation,
EconomK and Milical Wetkly. Vol XXV.
of
research
PP 715-18, ...
f
basc<J on inter-disciphnary
— (1990b): A Socio-Cultural, Political and
ministraiive Analysis of Health Mictes and
Op,imise the highly complex
Programmes m India in the
t
m Qr Us smaller COn>
Critical Appraisal. Ink Paksh. New Delhi.
"eTOs-^.de down'study has !ed
— (1992a): Combating AIDS as Public Hetf/rA
die team to advocate a lacerating vivisec
Problem in India. Voluntary Health
when a review [Gupta and Murali 1989)
tion of a live organisation which has been
Association
of India and Nucleus for
showed conclusively that it had miserably
so painstakingly nurtured and build up
Health Policies and Programmes. New
failed in attaining the objectives set for i ,
over more than six decades^An
Delhi
.
the
programme
was pursued
— (1992b) Family Planning in the Nmetics.
and-cla'ims
continued
to be made about
"^siSon ‘ the1’ powerful
H
'...—J to be made about
More of the Same?’ Economic and Political
its remarkable• ‘achievements ’ [Baherji
(Banerji ‘ical ^d socio-economic forces which
Weekly. Vol XXVli. pp 833-36.
1992a]. The National AIDS Control
critical for conducting a policy
_ (1993): *A Social Science Approach to
Strengthening India’s National Tuberculosis
Programme promoted by the World Bank
analysis Other critical inputs for healt
Programme’, Indian Journal of Tuber
also suffers from a number of infirmities
developments, such as social
(Banerji 1992a], It is still bemg pushed Science inputs, epidemiological analyst
culosis, Vol 40. pp 61-82.
Government
of India (1946): Report. Health
nevertheless. These are glaring mstances
public health competence of the Key
Survey and Development Committee (Bhore
of how international politics worksi in a decision-makers in India, the damage
Committee). Vol IV. Manager of Publica
country like India. Is the current World
caused to the health services by impos tions, Delhi
Bank team a harbinger of yet another in
lion of vertical programmes like the rarget_
(1982)
Statement on National Health Policy,
ternational initiative? The loan-intox.orienied time-bound family planning pro
Ministry of Health and Family Welfare,
cated finance minister has again welcom gramme and Universal Programme of Im
New Delhi.
munisation, are missing. The teatr> ca.Ils
ed such an initiative with open arms. This
Gupta, J P and Murali. 1 (1989): Nattonal
is another facade to obscure the plight of
for still greater centralisation of health
Review of Immunisation Programme in
slices at a t.me when the country has
the wretched poor.
India, NIHFW. New Delhi.
National Planning Committee, Sub-Comnuttet
Taking’into account the crisis
opted forr a major programme of decenby structural adjustment, the World Bank
ualised administration. This is not a
on National Health (Sokhcy Committee
policy alternative the country can look
(1948): Report, K J Shah (ed), Vora
ream has set out to offer an alternative
Bombay.
policy frame to cushion its impact on the
forward to.
World Health Organisation (1978): Pnmar
health services. By making it more effi
Health Care: Report of the Internationa
References
cient and equitous, the team attempts to
Conference on Primary Health Care. Alm
convert the crisis into an opportunity.
Banerji D (1985): Health and Family Plann
Ata. USSR, September 6-12, 1978. Worl
However, by choosing health financmg as
ing Services in India: An Epidemiological,
Health Organisation, Geneva.
a tool for policy analysis, it has arrived
Socio-Cultural and Political Analysis and
al highly questionable conclusions. Health
As in the case of UnW plan
ning, it furthe r pushed down other rura
health programmes in the order of pnony
[Banerji 1990a]. Tragically, the pro,
gramme was very poorly designed, but t
...
were m no
i
director for bird
,MCT.Tirn= OF RURAL DEVELOPMENT (BIRD). Lucknow, a Society
BANKERS’ INSTITUTE OF RURAL UL
candidate for
registered under the Societies
the post of Director (Head o 1e ns4
National Bank tor
js
g
level institutei wholly funded by
ment fof conducting training, research
an<J development The post is to- a fixed tenure
management disciplines besides teaching and administrative experience and in the age
group of 45 to 55 years would be preferred.
The application together with curriculum vitae, for consideration of the Search
Committee constituted for the purpose, may be sent to Shn S D_Ralhan“n‘;en“g
Manager. National Bank for Agriculture and Rural Development Sterling Centre. P B
No 6552 Dr A B Hoad. Worli. Bombay 400 018. latest by 31 July..1993
Economic and Political Weekly
1210
June 12,
Hp I 3
TNVHA NEWS LETTER
-^ROUq.
>
\
&
V.
I
/J
SUPPLEMENT JULY 1990
31, MANDABAM ROAD, KILPAUK, MADRAS 600 010
For Private Circulation only
AN APPRAISAL OF THE
IMPACT OF
EIGHTYEARS OF
NATIONAL HEALTH POLICY
By
Dr. K. Venkateswara Rao
MBBS, DCH, Ph.D.
Additional Director
Voluntary Health Service
MAC Institute of Community Health
Adyar, Madras 600 013
* Paper presented at the National Health Policy Follow up Workshop at Madras organised by
TNVHA-VHAI on May 17- 18, 1990.
/f
AN APPRAISAL OF THE IMPACT OF EIGHT
YEARS OF NATIONAL HEALTH POLICY
Dr. K. Venkateswara Rao,
MBBS, DCH, Ph.D.
Introduction
Based upon the framework indicated by the Bhore Committee, the government of India,
over the last four decades have embarked upon the process of development of health infrastruc
ture, so that Primary Health Care services are made available as near the people as is possible.
Though the initial emphasis was on the development of basic health services, several
individual disease oriented programmes have been given importance in view of the higher preva
lence resulting in high morbidity and mortality among large sections of population. In the long
run, this strategy of simultaneous encouragement to vertical health programmes has contrib
uted to the non-development of health infrastructure for the delivery of comprehensive and
integrated basic health services. This strategy also has taken away the much needed resources
- men, material and money, from the health services.
Several Committees like the Health Survey and PlanningCommittee, the Chadha Com
mittee, the Mukherjee Committee, thejangalwalla Committee, the Kartar Singh Committee,
and the Srivastav Committee have emphasised the role of Primary Health Care and suggested
various mechanisms for achieving the same. It was not until the eighties that any concerted at
tention was paid to the meaningful development of infrastructure. The AlmaAta declaration, the
ICMR/ICSSRCommitte report, the WorkingGroup of Ministry of Health and Family Welfare,
the successive Twenty-point programme have all focussed attention on the need for develop
ment of comprehensive and meaningful health services nearer the door steps of the households
In this back-ground, the National Health Policy of 1982 can be regarded as the first con
scious effort of the Government for laying down a policy frame for achievement of a reasonable
level of health service in thecommunity. The National Health Policy while reiteratingthe ma
jor issues highlighted in the twenty-point programme and major recommendations of the Work
ingGroup of Ministry of Health has laid down certain specific guide-lines.
A policy is not static and does not stand still. It is dynamic and is prone to constant change.
The policy is formulated in the context of changing goals, shifting environments and varying
situations. Seckler-Hudson regards it as a 'moment in a process'. Policy formulation is a continu
ous oblication and the re-formulation of policy in the light of experience is as important as its for
mulation., In the words of Gladden, four different levels in the policy making may be distin
guished: "(1) Political or general policy framed by the parliament, (2) executive policy framed
by the Cabinet, (3) administrative policy, that is, the form in which the administrator carries out
2
the will of the government, and (4) technical policy, that is, theday-to-day policy adopted by
officials in the working out of the administrative policy."
A policy is only a guideline. Its efficiency and success will depend upon the speed and
energy with which it is implemented. It will also depend upon understanding of the same at
various levels of political, administrative and technical hierarchy. The constitution, the legisla
ture, the Cabinet, have to a certain extent, done job in giving a policy direction. The advisory role
of planning commission, advisory committees, working groups, task forces, pressure groups,
political parties, professional association and the press will have to play a vital role in focussing
attention on specific issues in policy and should point out the lacunae, if any, and help in remodellingthe policy if needed.
The technical and the bureaucratic wings should understand the spirit and content of the
policy and help in wide dissemination of the content. They should also set an example by imple
menting the policy in right earnest and taking it to a logical conclusion to enable the benefits reach
largest section of the populations in the quickest possible time.
Professional bodies and associations like Indian Medical Council, Indian Medical Asso
ciation and the Voluntary Health Assodation of India have an important role to play by dissemi
nating the information and acting as an interface between the Government and the community
as well as by playingthe role of advocacy etc.
The present conference would have played a more than a useful role if it can focus atten
tion on some of the key issues in the implementation of National Health Policy.
I now propose to examine some spedfic issues in terms of their impact and current status.
FOLLOW-UP OF NATIONAL HEALTH POLICY
1. Development of Health Infrastructure
The Health Policy envisages a phased time-bound programme of well dispersed compre
hensive Primary Health Care services giving priority to tribal and hilly areas as well as to vulner
able sections of society. I mprovement of health status for facilitating the achievement of rea
sonable level of health; knowledge and simple skills and technology are to be transferred to
health volunteers. The existing health personnel are to be re-oriented forthe integrated deliv
ery of primary health care. The siting of the curative centres is to be related to the population they
serve. For higher levels of medical care the health policy wanted a good referal system to be built
up.
Now let us take a look at the development of health infrastructure in the country.
a. Hospitalsand Dispensaries
Government
Hospital
Dispensary
Total
4042
10845
14887
3
Local Bodies
Pvt. and voluntary
Total
Hospital population ratio
3363
3071
13579
27495
37326
Dispensary
beds
Total
beds
409539
22892
175117
18987
2672
2187
585889
23846
292
5497
9831
.. 1:1351
19076
b. Hospital and Dispensary beds
Hospital
Government
Local Bodies
Pvt. and voluntary
Total
Bed population ratio
beds
390552
20220
177304
609735
.. India - 1:1426
1:127
UK
USA
1:171
c. Doctor population ratio
India - 1:2600
UK
1:711
USA
1:750
d. Nurse population ratio
India - 1:4564
UK
1:207
USA
1:190
e. Rural infrastructure
Required
by 2000 AD
Community Health Centres (1,00,000 pop.)
Primary Health Centres (20,000-30,000 pop.)
SubCentres (5000 pop.)
Village Services
1253
14609
102674
387472
7650
25500
255000
765000
f. Tribal health infrastructure
Required
Primary Health Centres
Sub Centres
3322
21948
In
position
% short
1792
12610
53.94
fall
57.45
This is a priority item as stated in the Health Policy. Roughly a decade after the policy we still
have only 50% coverage in this item.
It is very obvious that we have taken a quantum jump in the matter of laying down the health
4
infrastructure. This lead is not supported by improvement in quality of the services provided.
Though comprehensive job descriptions have been laid down for various levels of health func
tionaries, due to operational inefficiency, the quality of care at their hands is continuously suf
fering. The chief problems contributingto the poor quality are inadequate pre-service and in
service training, bad and ineffective supervision, inadequate direction from the higher-ups, lack
of managerial capability of medical officers, political interference, lack of resources, rigid admin
istrative control, red tapism etc.
Eventhough every committee from the Master Plan onwards have talked ofthe need for
building up of a referal system, not much has been achieved in this sphere. Inadequate planning,
aided by poor communication and transportation facilities at times of need, non development
of health records, and non-attachment of the families to an identified institution for first contact
and building up of referal chain from that point onwards are the chief problems that have to be
tackled in this arena.
It appears that greater attention should have been paid to location planning and site selec
tion of health facilities that have been and are being established.
2. Control of Communicable Diseases
The Health Policy envisages establishment of nationwide chain of sanitary cum epidemi
ological stations and an organised programme for building up fundamental and basic research
in problems like blindness, leprosy and tuberculosis.
The current status ofthe various communicable diseases are as under:
Tuberculosis - currently 9 lakhs cases
(Prevalence 15 to 25/1000 pop.)
Leprosy
- currently 40 lakhs cases
(prevalence 13 to 19/1000 pop.)
Whooping cough
Tetanus
Cases/lakh
CFR
21.12
0.02
12.32
0.34
4.28
Measles
191.05
2.72
2.14
2.2(1987)
API-2.2%
3.0 million
(342 M population are at risk)
Guineaworm
1.10
0.08
Diarrhoeal diseases
1281.95
0.09
STD
117.83
Rabies
13.30
0.69
As regards tuberculosis there is poor case identification consequent to the policy of case
detection by sputum microscopy. Even if 10OX) efficacy is ensured in exhausting all the available
sputa in the community only 25% of the prevalence can be detected. The remaining 75% are in
Polio
Malaria
Filaria estimated
5
the early stages before tissue breakdown could occur.
As regards leprosy, I feel it is too pre-mature to claim reduction in the case load and attrib
ute the success to the multi drug therapy programme in a mileu where the portal of exit, the portal
of entry, the incubation period, the immunological deficit and the assured efficacy of the regi
men followed are not very well understood.
Elsewhere I have made a plea, on the need atleast now, to build a base-line so that we can
compare the effect of the Universal Immunisation Programme on the six-killer diseases. It is not
late even now, to embark upon a systamatic survey using the existing health infrastructure to
gathervital information regardingtheincidenceof these diseases.
The current tempo of educational activities is expected to have some impact on the preven
tion and cure of the diarrhoeal diseases. With the possible continuance of the same socio
economic conditions and the state of environmental sanitation any appreciable reduction in
these diseases may be too much to expect.
The prevalence and incidence of non communicable diseases like mental disorders, dia
betes, hypertension, heart attacks and cancer instead of showing any decline is showing upward
trend not only because of increase in exciting factors but also because of increased tempo in case
detection and better awareness among the massess. The gap between anticipation and achieve
ments which is very likely to be more in the coming decades will certainly contribute to the oc
currence of these diseases in greater numbers. It is alarming to note that these diseases are
occuring in young individuals as against comparatively older individuals in other countries.
3. Maternal and Child Health
palpation and auscultation. To my knowl
edge, identification of high risk mothers and
providing them needed services at time of de
livery by proper communications and trans
portation to higher level care will go a long
way in preventing maternal morbidity and
mortality. The supervisory staff seem to be
wasting time in counting the number of ante
natal visits which are not made. Certain pro
grammes for MCH care contemplated in the
health policy like growing and distribution of
lowcost nutritious food can be expected to
have a good impact if proper supervisory
control in equitable distribution to really vul
nerable women and children is ensured.
The Maternal and Child Health pro
grammes are being delivered from the sub
centres through multipurpose workers
(female) mainly and to a certain extent by
multipurpose workers(male). Even today
80% of the deliveries are being conducted by
the traditional birth attendants. Though fig
ures are being furnished in the matter of Dais
trained it is not very clear as to how many of
the traditional birth attendants who are practisingthe profession have been trained.
Scientific data is lacking as regards the
impact of the type of antenatal care that is
being provided, the so called registration,
6
social welfare and rural development for
greater impact of health programmes.
4. School Health
Though the Policy envisages organised
school health services, school health exami
nations are not conducted in the spirit with
which the programmes have been organised.
A lot of improvement in both the quality and
in follow-up is required, for early diagnosis
and taking remedial action.
Most of the problems of present ine
qualities arise from factors outside the scope
of health service system. Social and eco
nomic factors like income, work, environ
ment, education, housing, transport, and
what are today called'life-styles' all affect
health and all favour better off and yet these
have largely remained outside the national
health policy.
5. Health Information
There is a greater need for intrasectoral
co-ordination before we talk of co-ordination
at the inter-sectoral level. There is so much of
duplication and lack of information within the
health sector.
The Health policy contemplates a na
tionwide set-up for procuring essential health
information. We are singularly lacking in
health information as there is no uniform data
collection system. Even when information is
available, expertise is lacking on the manage
ment of the available information.
Co-ordination is required not only in
over-all planning but also at the practical level
at health centres. Needless to say that health
programmes are only a part of the over-all
social and economic development.
6. Health Eduction
The Policy says that health education
programmes must be backed by communica
tion strategiesand adult education and non
formal education. To my mind even today this
is the most neglected sector. Drawbacks
seem to be identification of good and accept
able messages; testing their usefulness;
modifying them identifying the means for the
delivery; training in the process of delivery;
and follow-up of the impact. Though adult
and non formal education are useful pro
grammes for health education inadequately
trained animators can easily be a source of
disinformation.
8. Role of voluntary organisations
Even in the past top level politicians and
administrators realising the magnitude of the
health problems, vastness of the area and
inadequacies of the official effort, have called
for voluntary participation in the matter of
provision of health services to supplement
the governmental efforts.
The National Health Policy has envis
aged a key role to voluntary organisations in
the two most vital components of health and
family welfare programme i.e. population
stabilisation and Primary health Care.
7. Intersectoral Co-ordination
The Policy lays down thedevelopment
of intersectoral co-ordination between
health, family planning, medical education
and research, drugs, agriculture, food, water
supply and drainage, housing, education,
8.1 What the VII Plan expects of
voluntary sector
7
The Seventh Five Year Plan has given a
pride of place to voluntary organisations. It
says, 'There has been inadequate recogni
tion of the role of voluntary organisations in
accelerating the process of social and eco
nomic development. These agencies have
been known to play an important role by
providing a basis for innovation with new
models and approaches, ensuring feedback
and securing the involvement of families liv
ing below the poverty line. Therefore, during
the Seventh Plan, serious effortswill be made
to involve voluntary agencies in various de
velopment programmes, particularly in the
planning and implementation of program
mes of rural development. Voluntary agen
cies have developed expertise and compe
tence in many non-traditional areas to plan
their own schemes instead of expecting the
Government to do so".
as possible.
vii. To show how village and indigen
ous resources could be used, how
human resources, rural skillsand
local knowledge, grossly rural skills
and local knowledge, grossly under
utilized at present, could be used
fortheirown development.
Al
f
viii. To demystify technology and bring
it in a simpler form to the rural poor.
ix. To train a cadre of grassroots work
ers who believe in professionalising
voluntarism.
x. To mobilise financial resources from
within the community with a view
to making communities stand on
their own feet.
xi. To mobilise and organise the poor
and generate awareness to demand
quality services and impose a comm
unity system of accountability on
the performance of village level gove
rnment functionaries.
The Seventh Plan suggests the following
as the possible roles for voluntary organisa
tion:
i. To supplement government efforts
so as to offer the rural poor choices
and alternatives.
It urges the voluntary organisations to
extend their programmes to rural hilly and
backward areas. Their role in health educa
tion and for spreading rural sanitation was
emphasised.
ii. To be the eyes and ears of the people
at the village level.
iii. Tosetan example. It should be pos
sible for the voluntary agency to adopt
simple, innovative, flexible and inex
pensive means with its limited reso
urces to reach a larger number with
less overheads and with greater community participation.
8.2The Positive lead of
Tamil Nadu Government
It must be mentioned that successive
Tamil Nadu Governments have been quite
progressive in realising the value of the NGOs
and in supporting the voluntary organisations
involved in several health and welfare activi
ties. They have shown a lead in supporting
the voluntary organisations without waiting
for approval or a matching grant from the
Central Government. They are supporting the
mini health centre programme evolved by the
Voluntary Health Services. This programme
iv. To achieve the delivery system and
to make it effective at the village level
respond to the felt needs of the
poorest of the poor.
v. To disseminate information.
vi. To make communities as self-reliant
8
*
The author was invited to be a member
of the Regional review committee regarding
implementation of Primary Health Care for
Southern States and Union Territories held at
Bangalore on February 22-23, 1990. This
meeting was convened by the Directorate
General of Health Services, Ministry of
Health, Government of India and World
Health Organization.
is not being run by several voluntary organisa
tions throughoutTamil Nadu.
4
The voluntary agencies depend on
government and official agencies for funds,
equipment, supplies such as drugs, vaccines,
sera and health education materials.
InTamil Nadu voluntary organisations
receive two thirds share promised by the
Government under the scheme of financial
assistance to organisations running mini
health centres. It is distressing to note that
due to procedural and administrative bottle
necks several organisations including the
Gandhigram Institute of Rural Health were
forced to close down their centres and give up
the idea of running such programmes, espe
cially when moreand more agencies should
have come forward to run mini health
centres.
The following unanimous recommen
dations were made at the meeting:
i.
"Committed and reputed Voluntary
Organisations (VOs) may be involved
in the development of primary health
care system by handing over certain
proportion of infrastructure facilities
namely, sub centre or Primary Health
Centrealongwith buildings, funds
and staff with relatively more mana
gement freedom to VOs/NGOs dep
ending upon their capability of funds,
staff eta after ascertaining their credi
bility.
Constraints to voluntary work
■
i
4
1
ii. Willing VOs may be involved and
encouraged to take up the primary
health care work in backward areas.
The bulk of the limited financial support
available to the NGO sector is locked into
patterns of assistance that are centrally de
signed. The funding constraints kill the initia
tive and innovative spirit that are the hall
marks of the most successful NGO efforts.
The need for NGOs to secure clearances/recommendations for undertaking programmes
and projects from the governmental machin
ery, most often is a tedious and frustrating
process stemming from the lack of under
standing and due to adherence to established
rules by the lower levels in the administrative
ladder.
iii. Community must be involved to
choose the site of primary health
centre(PHC) & sub centres (SC) by
involving local youth in particular, in
constructive activities. In this direct
ion, Government as an institution
should take leading part in involving
the VOs and NGOs in primary health
care work and not vice-versa.
iv. 2.5% of total health outlay amount
be allowed to flowthrough VOs
after assessing their credibility. This
percentage may gradually be in
creased.
8.3 Most recent developments
v. Voluntary sector may be encoura
ged especially in areas where the
A. Regional review committee meeting
9
need is high.
management
computers
social marketing
finance
i. Lobbying/applyingpolitical
pressure locally
j. Site visitation coordination
vi. Village level VOs must be involved
in infrastructural organization.
vii. Health planning maybe decentral
ised to States and Districts with due
involvement of VOs and NGOs.
viii. Lessons must be learnt from suc
cessful VOs/NGOs for evaluation.
*
II. Future Role
ix. VOs/NGOs may also be involved in
such training programmes by mak
ing use of training materialsand jour
nals produced by them."
1. Professionalism and human resource
requirements
2. Support services
3. Expanding role of action research
education, documentation
B. Workshop organised by the Ford Foun
dation.
4. Placeofvoluntarism
I had the privilege of attending a work
shop organised by the Ford Foundation a
week ago, which was attended by the Union
Health Secretary, Advisorto PlanningCommission, representatives of the Central Gov
ernment and voluntary organisations. This
workshop has agreed on the following as the
roles of voluntary sector:
8.4. Some issues in policy towards
voluntary organisations
It is realised that consequent to the Na
tional Health Policy the governments are
establishing sub centres one each for a popu
lation of 4000 to 5000 Primary Health
Centres for 30,000 population and Commu
nity Health Centres for 1,00,000 population.
I. Networking
The following questions crop up on the
role of voluntary organisations in the chang
ingscenario:
1. Interface with Government
a. National level
b. State/Regional level
i.
2. Linkagewith other institutions
3. Roles of intermediary organisations
Should the existing voluntary agen
cies wind up their innovative experi
mentsand service programmes?
ii. Should no new voluntary effort be
made?
a. Networking among NGOs
b. Clearinghouse (collection / disse
mination of NGO experiences)
and newsletter
c. Legal advice
d. Budgeting/accounting
e. Proposal development
f. Fund-raising
g. Information on sources of funding
iii. Should voluntary organisations re
frain from doing any service pro
grammes and concentrates only on
community arousal byway of edu
cation and motivation?
iv. Should voluntary organisations be
only theoreticians taking part in work
shops, seminars, symposia, work
ing groups, task forces etc?
h. Technical assistance
- research
v. Will the government restrain from
10
t
k
opening sub-centres and primary
health centres in areas already under
the care of voluntary organisations?
v. Net-working along with thevoluntary organisations and professional
bodies.
vi. Will the Government by suitable
orders handover subcentres and pri
mary health centres to accredited
voluntary organisations to continue
their service programmes and inno
vative activities? There are prece
dents in this area.
vi. Creation of a watch-dog mecha
nism for over-seeing the implemen
tation of the policy at State and Dis
trict levels. This mechanism should
have an equal share of official and
non-official members.
b. Accessibility of the services
vii. Will the National Front Government
and the DMK Government in Tamil
Nadu showthe way fora meaning
ful dialogue at the Central and State
levels which should form the basis
of the discussion in the Eighth Plan?
Attention will have to be paid to locate
the health infrastructure so as to be accessible
to all the sections of the community. Today
the sub centres and other health facilities are
not ideally located. Most of the buildings have
been constructed with lack of basic facilities
including water supply with the result, the
female worker does not find it convenient and
safe to live there, so as to be accessible to the
community during their hour of need. It is no
wonder under such circumstances that 80%
of the deliveries are being conducted by the
traditional birth attendants most of whom are
untrained.
viii. Will the new PlanningCommission
examine the model presented here
with particular reference to the four
essential requisites for primary health
care and resource mobilisation from
community?
9. Some key areas for strengthening for a
better impact of National Health Policy:
c. Optimisation of work potential of staff
Consequent to the bureaucratic system
of functioning and target oriented time bound
approach and inadequacies of the supervi
sory mechanism, a number of records have
been prescribed. Several studies have re
vealed that most of the time of the MPWs is
consumed for maintenance of records and in
travel. Consequently very little time is avail
able for actual services. They are unfortu
nately subjected to pressures from both
within the community and from outside by
the official hierarchy. That is largely due to the
gap between the training they receive, which
is heavily hospital oriented, and actual job
description and job experience at the field
level. This disorientation has contributed to
the poor quality of work in terms of maternal
a. Awareness and implementation of Policy.
i.
I
Increased awareness of National
Health Policy and its goals down the
health hierarchy.
ii. An increased awareness among legislatorson thehealth policyandin
health financing as they are the ulti
mate controllers of the purse strings:
iii. Creation of a committed band of in
dividuals as health administrators,
who are wedded to the profession of
public health, at various levels.
iv. Introduction of scientific tools in
health care management.
11
and child health care and other prescribed
activities.
lated to the real function in a particular coun
try rather than copy the traditional duties
carried out elsewhere in the world. The tech
nical knowledge of trainees must be up
graded constantly by refresher courses and
information flow.
If health care programmes have to have
the desired impact, the optimisation of work
potential by suitable studies to analyse the
work load and simplification of record system
will become absolutely essential.
The present training of doctors is exami
nation-oriented, clinical and curative in
emphasis. While social aspects of diseases
are recognised, students are not given expe
rience in community interaction nor a role or
responsible leadership of a health team, nor
managerial competence; medical colleges
have often interpreted community health
services as their own outreach operation,
rather than as a supportive of the responsibil
ity for the health of a defined population
group. This must be immediately rectified.
d. Supervisory Support
Today the supervisory cadre is thor
oughly inefficient in carrying out the pre
scribed duties. The machinery that is existing
today for enforcing better quality care does
not seem to move and for any programme to
succeed supervision of good quality is a must.
Somebody remarked that in our country even
God requires supervision. The supervisors of
the Primary Health Care programme are not
oriented to practical supervision. The whole
exercise of supervision at various levels is
confined to perusal and rather inadequate
scrutiny of reports submitted and records
maintained without any scope for field verifi
cation. Supportive guidance of the staff is
lacking consequent to the value orientation,
cultural differences pressures of long distance
travel, coupled with plurality of programmes
and inadequate direction from their own
supervisors. This explains the ills of this cadre.
Separate training and retraining modules will
have to be thought of to correct this unfortu
nate system.
The same factors operate in the matter
of training of paramedical workers. The trainingis more weighted towards hospital nurs
ing. Only one semester is devoted to commu
nity health and two semesters to hospital
work in the curriculum of MPW(F). Even
during this semester there is no guided pro
gramme of community health care. There is a
serious shortage of qualified and committed
training manpower.
As scientific knowledge is increasing
every day it is necessary to keep all the staff
engaged in the programme upto date with in
formation. The creation of a machinery is
absolutely essential to give orientation train
ing in a systematic manner to every staff
member so that each of them receives an
orientation atleast once in two or three years.
e. Trainingand retraining
As already stated the training program
mes in the country today at both medical and
para-medical levels are not tuned to commu
nity health work. Though certain statutory
provisions have been made for compulsory
services in rural areas, they have indeed failed
to generate the necessary enthusiasm. The
training is not need based and flexible. The
training programmes have to be directly re-
f. Financing of Health Care
While the Bhore Committee in 1946
recommended an out-lay to the tune of 15%
of the total expenditure; the Central Council
of Health in 1952 favoured 10% the same
12
i
rural areas a mere 13 paise is available per
person.
Council in the year 1989 recommended 7%;
the financial allocation for the health sector in
our country as a percentage of over all public
sector out-lay has been between 2.9 to 3.9%
in the successive Five Year Plans.
Break-down of Health Rupee
A perusal of the expenditure pattern
indicates that more than 85% of the expendi
ture goes to maintenance of staff and only
14% goes to drugs The question that crops up
is-how much of this expenditure really results
in accrual of benefit and of what kind to the
ultimate recipients of the services for whom
the entire health hierarchy exists.
It is understood that the working group
on "Health Financing and Management" set
up by the Government of India for the formu
lation of eighth plan has recommended a
minimal raise of allocation for the health
sector to 5%.
It might be of interest to note that in
United States it is 10.81% of their much
higher income; in Australia it is 9.99% Even in
Kenya and Mauritius it is more than 7% and in
Burma it is 6.96%.
Is it possible for the benefits to be quan
tified in economic terms?
Will a mere increase in the allocation of
rupees and consequent increase in the per
capita health expenditure result in tangible
benefits in terms of reduction of morbidity
and mortality? If yes for how long?
Per Capita expenditure
Calculatingthe per capita expenditure
on health by simple arithmetic is obviously a
misleading information. According to Plan
ning Commission the per capita expenditure
on health has been 46.23 and on Family
Welfare 7.19. As 80% of the health services
are in the urban areas, 80% of the expenditure
naturally goes to urban areas and a greater
proportion of this goes to the maintenance of
multimillion, chromium plated, ivory tower
institutions.
The determining factors seem to be
minor ailments which keep on recurring,
higher threshold for suffering; Low priority to
health. What would be the proportional cost
ing of health rupee? Salaries Vs Services/
Benefits, Preventive Care Vs Curative Care.
I am sure that NGOs and Government
will rise to the occasion in a spirit of under
standing, co-operation, mutual support for
the furtherance of the common goal of mak
ing health services meaningful to the commu
nity especially to the underprivileged in rural
areasand urban slums.
The following table highlights the percapita expenditure of Maharashtra State:
Total - Rs.156miHion
3 cities: Bombay - Rs. 14.6
Poona - Rs. 12.1780.0%
Nagpur - Rs. 6.09
District towns
Other miscellaneous centres
Villages
The Voluntary Health Services M.A.Chidambaram Institute of Community
Health will be happy to network with any
agency in developing an action programme.
6.2%
9.3%
4.5%
A perusal of the table reveals that in the
13
INDIA SELECTED HEALTH AND
SOCIO-ECONOMIC INDICATORS
SI.
No.
Item
Year of
reference
Particulars
1
2
3
4
1.
2.
Population (000) as on 1st March, 1981
Census:—
(i) Total
.......
(ii) Male
.......
(iii) Female
.......
Decennial Growth Rate (%)
....
6,85,185
3,54,398
3,30,787
25.0
1971-81
3.
Sex-ratio (No. of females to 1000 Males)
1981 Census
933
4.
Area in Sq. Kms. (000)
1981 Census
3,287.3
5.
Density of Population per Sq. Km.
.....
....
1981 Census
216
6.
Proportion of Urban Population to total population
1981 Census
23.31
7.
Number of Districts
1981 Census
412
8.
Number of towns*
1981 Census
3,949
9.
Number of Developments Blocks
....
1980-81 Census
5,011
10.
Number of Villages (inhabited)
....
1981 Census
11.
Broad Age distribution of population (Percentage to total
population) & Age Groups:
1981
1981
39.6
53.9
6.5
1987
32.0
1987
10.8
.....
1987
21.2
....
1987
95
1981
0-14
15-59
60+
12.
Crude Birth Rate (SRS)
13.
Crude Death Rate (SRS)
14.
Natural Growth rate (SRS)
.....
15.
Infant Mortality rate (SRS) .
16.
Expectation of life at birth—
Persons
Male
Female
........
17.
No. of Medical Colleges
18.
No. of Hospitals and beds
(i) Govt
(ii) Private
(iii) Total
5,57,137
.....
19.
Area Served per hospital (sq. Kms.)
20.
Population served per hospital
....
58.1
59.1
1987-88
125**
1-1-1989
Do.
Do.
Do.
4,504/4,21,025
5,641/177,034
10,145/5,98,059
1-1-1989 (Range) •
Do.
14
58.6
(1986-91)
•
(19-491)
(14,236-1,27,000)
21.
Population served per bed.
22.
Hospital beds per 1000 population
23.
.
.
.
.
.
Do.
(775-2,540)
.
.
.
.
1-1-1989
0.74
No. ofPHCs
31-12-1988
16,756
24.
Number of Sub-Centres
31-12-1988
1,12,004
25.
Number of Community Health Centre
31-12-1988
1,468
26.
Number of Doctors (registered with Medical Council
of India) .
1988
3,31,630
Number of Registered Nurses (with Nursing Council
of India) .
1987
2,19,299
.
1988-89
3,168.42
29.
Per capita expenditure on Health and Family Welfare (Rs.) .
1986-87
53.06/7.31
30.
Proportion of Scheduled Castes & Scheduled Tribes
population to total population
.
.
.
.
.
(i) Scheduled Castes
......
(ii) Scheduled Tribes
27.
28.
.....
Plan outlay on Health Family Welfare
and Water Supply etc. (Rs in crores) .
.
.
.
1981 Census
15.75%
7.76%
Source: Health Information 1989
**Included 19 unrecognised Medical colleges.
CBHI, DGHS New Delhi
♦Excluding Assam.
@Quick Estimation.
GOALS FOR HEALTH AND FAMILY WELFARE
PROGRAMMES IN TERMS OF
'HEALTH FOR ALL' BY 2000 AD
SI.
No.
1
Goals
Current Level
Indicator
2
3
1985
1990
4
5
2000
6
1. I nfant Mortality Rate
Rural
. 104(1987)
122
Urban
. 61 (1987)
60
Combined
. 95 (1987)
106
87
10.4
9.0
2. Perinatal mortality
Below 60
30-35
. 53.8 (1985)
2.(a) Crude Death Rate
. 10.8(1987)
12
3. Pre-school child (1-5 yrs) mortality
. 24(1976-77)
20-24
15-20
10
4. Maternal mortality rate
. 4-5(1976)
3-4
2-3
below 2
5. Life expectancy at birth (yrs)
15
Male
Female
.....
55.1
57.6
64
. 59.1 (1986-91)
54.3
57.1
64
25
18
10
30
6. Babies with birth weight below
2500 gms (percentage)
7. Crude birth rate
. 58.1 (1986-91)
....
31
27.0
21.0
8. Effective couple protection (Percentage)
. 39.9 (March, 88)
37.0
2.0
60.0
9. Net Reproduction Rate (NRR)
. 1.48(1981)
1.34
1.17
1.00
10. Growth Rate (annual)
. 2.12(1987)
1.90
1.66
1.20
11. Family size
12. Pregnant mothers receiving
ante-natal care (%) .
’. 4.4(1975)
3.8
. 60(1988)
50-60
60-75
100
. 40-50 (1988)
50
80
100
. 86.3 (1987-88)
60
100
100
. 88.7 (1987-88)
40
100
100
16 Years
. 86.45(1987-88)
60
100
100
DPT (children below 3 years)
. 96.0 (1987)—88)
70
85
85
. 83.5(1987-88)
50
70
85
. 94.3 (1987-88)
70
80
85
. 87.5 (1987-88)
80
85
85
Typhoid (New school entrants 5-6 years) . 62.6 (1987-88)
70
85
85
.
13. Deliveries by trained birth
attendants (%)
14. Immunizations Status (%) cover-,
age TT (for pregnant women)
TT (for School children)
10 Years
Polio (infants)
....
BCC (infants)
DT (new School entrants 5-6years)
.
. 32.0(1987)
2.3
15. Leprosy-percentage of disease
arrested cases out of those detected*
. 20(1988-89)
40
60
80
16. TB percentage of disease arrested
cases out of those detected
. 62(1987-88)
60
75
90
17. Blindness-Incidence of (%)
. 1.4 (1987-88)
1
0.7
0.3
Note: Cases cured after 1983, out of the 4 million estimated Leprosy cases
Source: National Health Policy-1983
PRINTED AT SICA
16
y •
1
Original Article on Health Policy and Underdevelopment
THE MANDWA PROJECT:
AN EXPERIMENT IN COMMUNITY PARTICIPATION
Noshir H. Antia
The project at Mandwa was designed to study the problems of health in rural
India and the delivery of health care by the existing public and private health sys
tems. The results demonstrate the important role of socioeconomic and political
factors not only in vital areas such as nutrition, water supply, sanitation, and housing,
but also in the delivery of health services. The private sector showed a predominantly
curative and monetary orientation, while the public sector demonstrated a lack of
accountability to the people it was designed to serve. Under these conditions, an
attempt was made to test the possibility of training local women in self-help with a
minimal supportive service. The results reveal that adequate knowledge and tech
nology exist for most of the prevalent problems of health and illness in developing
countries, and that semiliterate villagers have the capacity to use these effectively if
they are provided in a simple manner. This experiment also demonstrates the opposi
tion trom local vested interests to any change of the status quo, even in the rela
tively noncontroversial field of health.
INTRODUCTION
In 1947, a newly emergent independent India resolved that the benefits of develop
ment, inclusive of health, henceforth would reach all our people and not be restricted
to a select few. In their enthusiasm for rapid advancement and modernization during
the prevalent postwar euphoria of science and technology, it was not unnatural that
our leaders, many of whom had received their education in the Western tradition,
opted for the ad hoc adoption of the Western model for the country’s development.
To them, modern science and technology provided the necessary means to leap from
the bullock cart to the jet age.
Unfortunately, unlike Gandhi, distanced from the masses the leaders failed to
appreciate the socioeconomic and above all the cultural problems that this would
involve. If any shortcuts were to be tried, the regimented discipline and hardships of a
closed society would have to be borne by the leaders as well as by the people. Instead,
while adopting the planned approach of the socialist countries, they sought to achieve
their goals through a “mixed economy” with ample room for the free play of market
forces. This “free” or what may be more aptly termed “free for all’’ approach has
resulted in a patchwork type of development that has chiefly benefited the upper two
deciles while 50 percent of the population continues to remain below the poverty line.
This work was supported by funds from the Pirojsha Godrej Trust.
International Journal of Health Services, Volume 18, Number 1, 1988
© 1988, Baywood Publishing Co., Inc.
153
154 / Antia
Table 1
Health status: India and China0
China
India
1960
1983
1960
260
Per capita GNP (USS, 1981)
1983
300
41
67
165
39b
Infant mortality rate
' (per 1000 live births)
165
55
110h
Child mortality rate
(per 1000 population aged 1-4 years)
26
11
26
2
Crude birth rate (per 1000 population)
44
34
39
19
Crude death rate (per 1000 population)
22
13
24
7
43
69
Life expectancy at birth (years)
Adult literacy rate (percent, 1980)c
43
28
36
aSource (except as noted below): World Development Report 1985, World Bank.
^From UNICEF, State of the World’s ChUdren 1982-83.
cFrom World Development Report 1983, World Bank.
This is the result of a lack of accountability and remarkably poor performance by the
public sector and a highly exploitative private sector devoid of the trusteeship concept
of Gandhi. The performance of the health sector can only be appreciated in the
context of the overall political economy of the country. Unfortunately, the medical
profession working in splendid isolation has failed to perceive health in its wider
perspective and hence been unable to diagnose what ails the people as well as itself.
India has always had a rich tradition of its own indigenous systems of medicine
which has been a part of the health culture of its people. But it is the allopathic system
that has dominated the health scene since independence. This was partly because it
was a legacy of the British Raj and as such had been adopted by the local elite, and
also because of its inherent superiority in the relief of acute illness, the treatment of
communicable disease, and the use of surgery.
In 1947, India had 15 allopathic medical colleges and 47,500 doctors trained in the
Western system of medicine. It was also fortunate in having in the Bhore Committee’s
report (1) a document of unrivaled clarity which analyzed in great detail the problems
of delivery of health services to the common person in a country with a large and
predominantly rural population and with limited financial resources. The report
contains the original concept of primary health care, of which we hear so much today,
with a clear advocacy of a decentralized service based within the local community and
involving the people in their own health care.
Considering all the facts, it is not surprising that the founding fathers of our nation
placed the responsibility for the planning as well as the operation of our health services
entirely on the shoulders of the allopathic medical profession.
Four decades later, we realize that though theri has been considerable improvement
in the health status of our people as measured by the increase in life span and fall in
The Mandwa Project / 155
Table 2
Comparison of Punjab and Keralafl
India
Punjab
Kerala
Target for
2000 AJD.
Birth rate (per 1000)
33.9
30.3
26.0
21.0
Death rate (per 1000)
12.5
9.4
6.9
9.0
Infant mortality (per 1000, 1980)
114
89
40
Per capita income at current prices (Rs.)
1758
3164
1447
Female literacy (percent)
24.7
34.1
<60
64.5
^Source: Government of India. Health Statistics of India. Ministry of Health and Family
Welfare, New Delhi, 1984.
0
infant mortality (IMR) and crude death rates, statistics have also shown (Table 1) that
our achievements have fallen far short of our expectation. This is especially true when
we compare India with China, a country that gained independence in about the same
period and has similar and probably much greater problems to overcome.
Even in our own country, the differences between the poorest state of Kerala
(before the Gulf boom) and the richest state of Punjab are remarkable, as shown in
Table 2. Even though Kerala received the same health services as the other states of
India, the health of its population has already reached the targets set for the rest of the
country for the year 2000 AD.
It is evident from the above figures that the health of the people does not merely
depend on the income level of the people or medical services; the Punjab per capita
income is 2.4 times that of Kerala. John Ratcliffe (2) has attributed the success of
Kerala on the health front to mass education and political will. Education, especially
of women, is probably the most important factor in improving the health of the family
and community. The causes for the inadequacies of the health services have been
examined in detail in the 1980 joint report of the Indian Council of Medical Research
(ICMR) and the Indian Council of Social Science Research (ICSSR) (3). These causes
have also been remarkably well summarized in the government’s own statement of its
National Health Policy of 1983:
The demographic and health picture of the country still constitutes a cause for
serious and urgent concern. The mortality rates for women and children are still
distressingly high; almost one third of the total deaths occur among children below
the age of 5 years; infant mortality is around 129 per thousand live births. . . . The
existing situation has been largely engendered by the almost wholesale adoption of
health manpower development policies and the establishment of curative centres
based on the Western models, which are inappropriate and irrelevant to the real needs
of our people and the socio-economic conditions obtaining in the country. The
hospital-based disease, and cure-oriented approach towards the establishment of
medical services has provided benefits to the upper crusts of society, specially those
residing in the urban areas. The proliferation of this approach has been at the cost
of providing comprehensive primary health care services to the entire population,
whether residing in the urban or the rural areas. Furthermore, the continued
high emphasis on the curative approach has led to the neglect of the preventive,
156 I Antia
promotive, public health and rehabilitative aspects of health care. The existing ap
proach instead of improving awareness and building up self-reliance has tended to
enhance dependency and weaken the community’s capacity to cope with its prob
lems. The prevailing policies in regard to the education and training ol medical and
health personnel of various levels, has resulted in the development of a cultural gap
between the people and the personnel providing care. The various health programmes
have, by and large, failed to involve individuals and families in establishing a selfreliant community. Also, over the years, the planning process has become largely
oblivious of the fact that the ultimate goal of achieving a satisfactory health status
for all our people cannot be secured without involving the community in the identi
fication of their health needs and priorities as well as the implementation and man
agement of the various health and related programmes.
It is evident that the failure to deliver health care, especially to the rural poor who
form the majority of the population, is the result of a lack of professional and political
will to look after the underprivileged and share the benefits of development; this is no
different from the other fields. Despite protestations to the contrary, the chief beneficiaries of such a system are those who are supposed to deliver the goods. Welfare,
including health care, has become another large and profitable business.
Two decades in the public as well as the private sector were more than adequate to
convince the author that the medical profession had neither the desire nor the training
and capability to deliver health care to our people. Even the sophisticated urban
services, which were chiefly monopolized by the elite, left much to be desired, for in
the absence of a generalized scientific culture and with an archaic administrative infra
structure they generally ended up as poor imitations of their Western role model and
often only a caricature. Even worse, I was convinced that those of us educated in
urban medical colleges were totally unaware of the actual problems of health and
disease of the common person in our own country, even in the urban slums let alone
the villages. What we saw and learned in big hospitals was only the tip of the ice-berg,
as represented by the few “interesting” cases of advanced pathology that reached us,
often in extremis. The emphasis of medical training was almost entirely on cure and
not prevention.
PLANNING OF THE MANDWA PROJECT
Being an observer as well as a part of this scene, I made a decision in the early
1970s to try to understand the actual problems of the health of our people and, if
feasible, to explore new avenues whereby the benefits of modern medical science
could reach the common person. Since 80 percent of the population of the country
is rural, a community comprised of 30,000 population distributed in 30 villages across
the harbor of Bombay was chosen for the study, now popularly known as the Mandwa
project. Though only 15 kilometers by sea from the great metropolis with all its
sophisticated medical services, Mandwa represented a typical undeveloped rural com
munity along the coastal belt of Western India with hardly any worthwhile medical
services.
The first two years were spent in trying to understand the problems of health and
disease of the people by meeting, observing, and discussing these problems with
the people and their leaders in the villages. Also, we observed the functioning of the
,
V
The Mandwa Project / 157
Primary Health Centre,1 which was located 40 kilometers away, and of the District
Hospital with 250 beds, which was at a distance of only 20 kilometers. The findings
of this exploratory phase can be summed up as follows:
1. The village is as much a stratified community as is the city. The interface
between the village and the external world is a few “leaders” who exert financial as
well as political control and are the self-appointed trustees of the silent majority,
which is virtually unapproachable without going through this local power structure.
2. Health, and especially the preventive aspects, is of little significance to the vast
majority whose main preoccupation is to provide the next family meal. Even illness
and pain are not adequate reasons to seek medical aid unless they interfere with
earning the daily bread. Early detection of disease and regularity of treatment, let
alone prevention, were a luxury the villagers could ill afford. What they sought was
quick temporary relief, which was provided by the doctor in the form of an injection
of a broad spectrum antibiotic and analgesic, a bottle of tonic, and injection of
vitamin B complex to which they were now hooked.
3. The commonest problem was malnutrition, which together with the lack of
water supply and hygiene and the tensions of survival took an extraordinarily heavy
toll on the health of the population. Yet the extensive load of chronic ill health was
considered only as the norm.
4. Despite their poverty, villagers incurred considerable expenditure in emergencies
such as obstructed labor, accidents, or terminal stages of dehydration, often by resort
ing to the moneylender.
5. The Government Primary Health Care service was virtually nonexistent despite
the two subcenters and a dispensary with 10 beds in the area covered by this project.
The doctors and nurses, when available, were concerned only with curative services
which chiefly favoured the leaders. They often charged the poor for services despite
drawing a nonpracticing allowance. Family planning was the only program that was
implemented with any regularity in order to reach the stipulated government targets;
the coercive measures employed were generally resented by the population, who asso
ciated the Primary Health Care services solely with population control.
6. The services of the not too distant district hospital were of limited use because
of lack of adequate transport and the cost of travel.
Despite this dismal picture, there were some hopeful signs that provided a silver
lining to an otherwise depressing scene. First, though illiterate and oppressed, the
people showed remarkable practical ability and intelligence in making the best use of
the meager resources available to them. Second, the prevalent diseases were chiefly of
a communicable nature, their diagnosis required elementary medical knowledge and
skills, and appropriate medical technology was readily available. Besides being remark
ably simple, the technology was also cheap and highly effective as well as safe, both
for prevention and cure.
1A Primary Health Centre (PHC) is the basic unit of the government for primary health care
as well as for the National Disease Control programs. The present PHC caters to about 30,000
population and has two doctors, two multipurpose paramedical workers, and one Health Guide
(HG) for every 1,000 population.
158 / Antia
We realized that instead of employing the usual anatomical and pathological classi
fication, if the diseases were graded according to the knowledge, skills, and technology
required for their diagnosis, prevention, and treatment, it provided a very practical
and an entirely new approach to their management. Broadly speaking, the problems
fell under the following four categories:
Minor illness and minor injuries that have traditionally been looked after
adequately by the people themselves with local folk remedies.
Group II. Diseases that are responsible for a great deal of morbidity but do not
endanger life, e.g., scabies, worms, minor gastric upsets, and simple
diarrhea.
Group III. The major killing and maiming diseases of the developing world such as
tuberculosis, tetanus, dehydration due to severe diarrhea, dysentery,
measles, acute respiratory infections, poliomyelitis, and leprosy.
Group IV. Conditions such as cancer, heart disease, stroke, major trauma, and those
requiring surgical assistance.
Group I.
The problems in any one group, especially if not treated in time, could escalate to
the next in a few instances, but as a rule, groups I to III required simple skills for
diagnosis or suspicion of the disease, and the majority of diseases could be prevented
by simple measures, often by the community’s own action. Cheap, simple, safe, and
effective treatments were also available for all of these diseases.
In view of this and the fact that there was no hope of delivering the available tech
nology provided by modern medical science under the existing system, we thought it
reasonable to explore whether the villagers themselves could be taught the simple
medical skills and how to make use of the equally simple available tools to look after
their own health problems to the extent possible. We also thought it reasonable to
teach them how to use the available medical services and demand what was their due.
In the absence of any precedent, the evolution of the Mandwa project was through
a series of trials and errors. This experiment in self-help was explained to the local
village leaders (sarpanchd) who were presuaded to help select a woman from each
village for training. Experience reveals that motivation should be the single most
important criterion in selection of such part-time health workers and that every
village can identify a few such individuals. Since most were semiliterate, training was
conducted in an informal manner in the form of weekly discussion groups in the
villages themselves.
The training was of an entirely practical nature and under conditions in which the
health workers would eventually work. Hardly any teaching aids were employed. The
village well, the pregnant woman, and the people who were ill in the village provided
adequate material for practical demonstration. The germ theory was taught using the
magnifying glass and simple school microscope to examine water from the local well,
smears from lepromatous patients, and sputum of those suffering from tuberculosis.
The major problem was finding teachers among the professionals who could convert
complex theoretical knowledge into simple and practical knowhow, and above all,
could overcome their cultural barriers and learn to differentiate between intelligence
and education and to respect the highly practical approach of simple village folk as
i
The Mandwa Project / 159
*
opposed to their own impractical theoretical education. It was also difficult for the
urbanized doctor to adjust to the slower pace of the village.
Despite the payment of a salary equivalent to and even higher than that of the
doctor of the government Primary Health Centre, it was virtually impossible to attract
a suitable candidate. Most doctors did not believe that a village woman could possibly
acquire knowledge on health when it takes two to five years to train a paramedic or
a doctor. At best it was considered dangerous practice, and at worse an attempt at
institutionalizing quackery. The arduous task of spending most of the day on a motor
cycle visiting villages rather than running a traditional static outpatient service, com
bined with absence of payment from the patient, was a further disincentive. The only
doctor who was prepared to work continuously was a young ayurvedic physician, the
son of a local fisherman. Though poor in medical skills, he was acceptable to the
people for he belonged to their community.
Finding suitable nurses and even Auxiliary Nurse Midwives (ANMs) posed a similar
problem with a high turnover.
The staff of the project consisted of a doctor trained in ayurvedic medicine, an
administrator trained in social science with three helpers (to maintain accounts and
records and to undertake statistical analysis and the purchase and distribution of
medicines to the subcenters), five ANMs, and 27 Village Health Workers (VHWs).
Except for the senior administrator, all were local personnel. A small health center was
established with 10 beds (used chiefly for maternity cases and for tubectomy opera
tions). The cost of such a service (not accounting for the research inputs) was approxi
mately Rs.6/- (rupees) per capita per annum in 1980 compared to the all-India average
of Rs.30/- (4). Of this sum, the cost of medicines could be recouped from the
patients.
RESULTS OF THE MANDWA EXPERIMENT
Let us now examine what semiliterate women could achieve in their community
with such simple instructions and a very elementary referral and support system
without an associated program of economic development or inputs into nutrition,
watersupply, sanitation, and improvement of environment. It took about three years
to establish the project and for the VHWs to gain the necessary confidence. The
effective period of the project was from 1977 to mid-1983 which was followed by a
period of turmoil until its closure in January 1984. It was interesting to note that with
increasing experience, many of the VHWs surpassed the ANMs in their effective role
in the village and they replaced all the ANMs at the subcenters during the last three
years of the project. The VHWs also undertook the giving of injections for immuniza
tion as well as streptomycin to patients suffering from tuberculosis.
A preliminary survey of the area was undertaken by the Tata Institute of Social
Sciences, which revealed that the health and economic situation of this area was no
different from that of the country as a whole and hence the national statistics have
been used as the baseline. Table 3 shows some of the figures for Mandwa compared
to the national figures.
It should be noted that all activities were carried out through individual VHWs
on a routine daily or weekly basis, including immunization of children and pregnant
160 / Antia
Table 3
Achievements of Mandwa
Mandwa project
1982
National figures
1982
Birth rate (per 1000)
15
33.3°
Crude death rate (per 1000)
8
11.7«
Infant mortality rate (per 1000)
74
114 (1980)°
Immunization (percent)
Triple antigen
Polio
Tetanus toxoid
92
67
^8
256
5*
206
Source: Government of India. Health Statistics of India. Ministry of Health and Family Welfare,
New Delhi, 1984.
^Source: Government of India. National Health Policy. Ministry of Health and Family Welfare,
New Delhi, 1983.
mothers, family planning operations, and detection of leprosy. No camp or mass
approach was used.
Immunization. The high rate of immunization was achieved only after ANMs
were replaced by the VHWs, for this assured regularity and undivided responsibility.
This, with improved hygiene at delivery, resulted in the absence of even a single
death from tetanus (the second largest cause of death in India) during the entire
period of the project.
Leprosy. The number of cases detected by the full-time government leprosy
technicians in 12 years prior to the project was 63. The number of cases at the end of
the project was 161 and the detection rate of the VHWs was similar to that of the
two-year-trained leprosy technician. Moreover, all the cases detected by VHWs were at
the early stages of the disease, and with the much improved regularity of treatment
there was not a single new case that developed deformity. Since the VHWs visited
leprosy and tuberculosis patients in their homes, there was a virtual abolition of stigma
and the old deformed patients were reaccepted by their family and community.
Tuberculosis. The rate of early detection was high, and since the patients were
given their streptomycin injection at home, the regularity of treatment was ensured,
especially because the importance of treatment in preventing family transmission of
the disease was explained. Preventive measures such as disposal of sputum were also
ensured. It must be stated that the role of the VHWs was to detect suspected new cases
and to carry out the treatment as recommended by the doctor after confirmation of
diagnosis.
*
The Mandwa Project / 161
Gastroenteritis. Deaths from dehydration were virtually eliminated by oral
rehydration therapy using home-made salt and sugar solutions. More important,
preventive action such as cleaning and chlorination of wells and boiling of water pre
vented the spread to epidemic proportions.
Malaria. Blood smears of fever cases were taken by the VHWs, followed by chloro
quine administration. Definitive treatment was provided for positive smear cases and
the local community often undertook the spraying of insecticide.
The question naturally arises as to why such a cheap and effective people-based
health service, which is in keeping with the recommendations of the country’s own
Bhore (1) and the ICMR/ICSSR (3) Committees as well as with the National Health
Policy (5), fails to get implemented on a nation-wide scale. The answer to this has also
been indicated by the Mandwa project.
At an early stage of the experiment, the then Director of Medical Services of the
State requested that the project take over the functions of a Primary Health Unit2
(PHU). The staff sanctioned for a PHU was placed at the disposal of the project
administration. This was done with the hope that this experiment would provide a
prototype for the development of a similar service on a state-wide basis. Unfor
tunately, both the district medical personnel as well as the paramedical staff con
sidered this a threat to their comfortable existence, for the community was now made
aware of their presence as well as their duties. Not only did they refuse to perform
their alloted duties but they took every opportunity to undermine the working of the
project. Yet they had no hesitation in claiming credit for the tasks performed by the
VHWs, such as detection of cases of malaria, tuberculosis, and leprosy, pre- and post
natal care, immunization of children and pregnant women, and above all, motivation
for family planning.
The nine nonallopathic private doctors in the area posed less of a problem, although
one doctor who operated a private nursing home prevented the appointment of a
VHW from his area. Patients, especially those who could afford it, continued to
patronize these doctors for injections, for these were not provided by our service,
except for immunizations and tuberculosis. Most of these injections given by other
doctors consisted of unnecessary and often dangerous antibiotics such as Chloro
mycetin, analgesics, and vitamin B complex, even for diseases such as the common
cold. Interestingly, injections of penicillin or streptomycin or for immunization were
seldom employed.
The local leaders, who welcomed us initially, lost interest when they realized that
the project was not going to provide a hospital with doctors, nurses, X-ray and
pathology facilities, and an ambulance, which in actual fact was their priority. Our
repeated pleas to them to form a health committee for the area received little
response. The effectiveness of the VHWs varied from village to village. Besides their
It is a “mini” Primary Health Centre with one doctor and other staff set up in areas that do
not have easy access to the Primary Health Centre services catering to 30,000 population. The
Primary Health Unit (PHU) was a subunit of the old PHC which looked after about 100,000
population.
162 / Antia
own ability and motivation, an important factor was the extent of support they
received from their village leaders.
Several of the leaders resented the fact that the project succeeded in reaching the
poor in their villages while bypassing them, thus arousing fear of an alternative power
structure and an attitude of self-reliance developing among the poor. The health
professionals were quick to seize this opportunity to drive a further wedge between
the project staff and the local leadership.
Despite the fact that the poor and even some of the leaders accepted the project
services, the local power structure dominated by the richer and more powerful leaders
joined hands with the government health personnel in open hostility and demanded
that the project leave the area, handing its assets to them. Their object was achieved
after threats and a show of open violence to the project staff.
The question arises as to why the beneficiaries, namely the poor, who formed the
majority of the population did not actively oppose this threat. The answer lies in their
abject poverty and dependency on the local power structure for their survival. Health
is not a priority in their daily life.
Summary
The findings from the Mandwa experiment may be summarized as follows:
1. Modern medical science and technology have provided us with the knowledge as
well as the tools for the prevention and treatment of the vast majority of the diseases
that affect the people of the developing world.
2. This knowledge and technology is remarkably effective though simple, cheap,
and safe.
3. Semiliterate and even illiterate village women have the capacity to absorb this
knowledge and use the technology if this is made available to them in a simple and
acceptable manner.
4. The role of the professionals is to impart such knowledge, encourage self-help,
and provide graded supportive services for problems requiring greater skills and/or
facilities. It is not their role to appropriate functions that the people themselves can
undertake.
5. Health at this level, at which almost 80 percent of all problems can be tackled
by the people themselves, requires low technology but high cultural affinity with the
people.
6. The local village women are therefore more suitable for tackling these problems
than more highly trained professionals.
7. The average professional fails to discriminate between education and intelli
gence. He or she looks down upon the illiterate as being unintelligent.
8. The interest of the professional often does not coincide with the interest of the
people; hence the appropriation of peoples’ health by a process of secrecy and
mystification.
9. Health professionals generally perceive a well trained VHW as a hindrance or
threat rather than a help. This is because the VHWs often demonstrate results superior
to those of the professionals, demystify health, arid reduce peoples’ dependency. This
results in loss of practice in the private sector, creates surveillance, and hence brings
accountability in a normally unaccountable public sector.
The Mandwa Project / 163
10. Semiliterate village women have demonstrated that in five years they could
almost reach many of the targets set for 2000 A.D.—this without any inputs in
nutrition, water supply, sanitation, and improvement in environment. They achieved
this despite limited supportive services, and opposition from the private as well as
public health sector and latterly from their local politicians. Table 3 gives some of
their achievements, and all this at the cost of Rs.6/- per capita per annum.
CONCLUSIONS
Mandwa and similar projects merely demonstrate that the ICSSR/ICMR report’s
recommendations for health at the village level, where the majority of the people live
and where the problems lie and should be solved, is not merely fanciful hypothesis.
Why is it then that the experiences of Mandwa and similar projects have remained
isolated and have had little impact on the health service of the country as a whole?
To the casual observer this is particularly difficult to comprehend when the national
policy continues to harp on “Health for All” through primary health care and com
munity participation. Surely it is not lack of finances because these projects are highly
cost effective, nor is it due to lack of manpower. Even though part-time VHWs, now
known as Health Guides, have been appointed by the government in the majority of
our half-million villages with the same objectives and a similar complement of
supporting staff and services as at Mandwa, it has had little impact on the general
health of our people.
The answer to these questions has also been provided by Mandwa. The extent
of opposition to even such a small project from both the health and the local political
structures demonstrates the emptiness of slogans such as “Health for All” or “Rural
Development.” It reveals the true intentions of the power structure and its vested
interest in maintaining the status quo, in which a few individuals can dominate the
rest of the community. In a democracy, all programs and activities are carried out in
the name of the people and especially of the underprivileged. The fact that almost
all benefits of development gravitate to the elite reveals the extent of the dichotomy
between preaching and practice, and this applies equally to the field of health in both
the public and private sector. While there is dissention within the health system and
between it and the bureaucracy and politicians, these forces will close ranks if the
existing system is threatened by any external agency that may disturb the balance
between them and the silent majority on whose presence they thrive.
Only thus can be explained why, almost four decades after Independence, half the
population remains below the poverty line, 100 out of every 1000 children die within
the first year of diseases such as gasteroenteritis, and diseases for which we have
effective measures of prevention and control continue to take their unrelenting toll.
Even here, aggregate statistics hide the true reality because improvement in the upper
two or three deciles conceals the infinitely higher mortality and morbidity figures in
the lowest two or three. Despite a school in every village, about 60 percent of the
population and 75 percent of women remain illiterate, when the nexus between female
literacy and health is clearly demonstrated by the statistics of Bihar and Uttar
Pradesh—IMR > 250—versus those of Kerala—IMR < 50.
■ .
164 / Antia
It is unfortunate that even the well intentioned members of the medical profession
see health as a medical rather than a social, cultural, economic, and political problem.
Even with the best of intentions, most of the voluntary agencies with their purely
humane approach often help to create an even greater dependency among those whom
they serve.
Mandwa can either be seen as a failure of a community health project or as an
experiment that demonstrates how knowledge can help people to overcome their
fears and encourage self-reliance. Whether this knowledge and technology can be
spread through an organized movement or in a nonformal manner or a combination of
both remains to be seen. Whether the impact will be only in health or will also, by
demystifying the most mystified subject, create the awareness to overcome the sense
of abject helplessness and start a process of questioning of the existing order—this also
remains to be seen.
Acknowledgment — The author thanks the Directorate of Health and Services of
Maharashtra for cooperation with this project.
REFERENCES
1. Government of India. Report of the Health Survey and Development Committee. Govern
ment of India Press, Simla, 1946.
2. Ratcliffe, J. Social justice and the demographic transition: Lessons from India’s Kerala State.
In Practising Health for All, edited by D. Morley et al., pp. 64-82. Oxford University Press,
London, 1983.
3. Indian Council of Social Science Research, and the Indian Council of Medical Research. Health
for All: An Alternative Strategy. Indian Institute of Education, Pune, 1981.
4. Centre for Monitoring Indian Economy. Standard of Living of the Indian People. Bombay,
1984.
5. Government of India. National Health Policy. Ministry of Health and Family Welfare, Delhi,
1983.
Direct reprint requests to:
Dr. Noshir H. Antia
Director, The Foundation for Research in
Community Health
84-A, R.G. Thadani Marg, Worli
Bombay 400 018
India
Original Article on Health Policy and Underdevelopment
THE MANDWA PROJECT:
AN EXPERIMENT IN COMMUNITY PARTICIPATION
Noshir H. Antia
The project at Mandwa was designed to study the problems of health in rural
India and the delivery of health care by the existing public and private health sys
tems. The results demonstrate the important role of socioeconomic and political
factors not only in vital areas such as nutrition, water supply, sanitation, and housing,
but also in the delivery of health services. The private sector showed a predominantly
curative and monetary orientation, while the public sector demonstrated a lack of
accountability to the people it was designed to serve. Under these conditions, an
attempt was made to test the possibility of training local women in self-help with a
minimal supportive service. The results reveal that adequate knowledge and tech
nology exist for most of the prevalent problems of health and illness in developing
countries, and that semiliterate villagers have the capacity to use these effectively if
they are provided in a simple manner. This experiment also demonstrates the opposi
tion from local vested interests to any change of the status quo, even in the rela
tively noncontroversial field of health.
INTRODUCTION
In 1947, a newly emergent independent India resolved that the benefits of develop
ment, inclusive of health, henceforth would reach all our people and not be restricted
to a select few. In their enthusiasm for rapid advancement and modernization during
the prevalent postwar euphoria of science and technology, it was not unnatural that
our leaders, many of whom had received their education in the Western tradition,
opted for the ad hoc adoption of the Western model for the country’s development.
To them, modern science and technology provided the necessary means to leap from
the bullock cart to the jet age.
Unfortunately, unlike Gandhi, distanced from the masses the leaders failed to
appreciate the socioeconomic and above all the cultural problems that this would
involve. If any shortcuts were to be tried, the regimented discipline and hardships of a
closed society would have to be borne by the leaders as well as by the people. Instead,
while adopting the planned approach of the socialist countries, they sought to achieve
their goals through a “mixed economy” with ample room for the free play of market
forces. This “free” or what may be more aptly termed “free for all” approach has
resulted in a patchwork type of development that has chiefly benefited the upper two
deciles while 50 percent of the population continues to remain below the poverty line.
This work was supported by funds from the Pirojsha Godrej Trust.
International Journal of Health Services, Volume 18, Number 1, 1988
© 1988, Baywood Publishing Co., Inc.
153
154 / Antia
Table 1
Health status: India and China0
China
India
1960
1983
1960
300
260
Per capita GNP (USS, 1981)
1983
165
67
39b
41
Infant mortality rate
' (per 1000 live births)
165
55
110^
Child mortality rate
(per 1000 population aged 1-4 years)
26
11
26
2
Crude birth rate (per 1000 population)
44
34
39
Crude death rate (per 1000 population)
22
13
24
19
7
Adult literacy rate (percent, 1980)c
28
36
43
69
Life expectancy at birth (years)
43
^Source (except as noted below): World Development Report 1985, World Bank.
^From UNICEF, State of the World’s Children 1982-83.
cFrom World Development Report 1983, World Bank.
This is the result of a lack of accountability and remarkably poor performance by the
public sector and a highly exploitative private sector devoid of the trusteeship concept
of Gandhi. The performance of the health sector can only be appreciated in the
context of the overall political economy of the country. Unfortunately, the medical
profession working in splendid isolation has failed to perceive health in its wider
perspective and hence been unable to diagnose what ails the people as well as itself.
India has always had a rich tradition of its own indigenous systems of medicine
which has been a part of the health culture of its people. But it is the allopathic system
that has dominated the health scene since independence. This was partly because it
was a legacy of the British Raj and as such had been adopted by the local elite, and
also because of its inherent superiority in the relief of acute illness, the treatment of
communicable disease, and the use of surgery.
In 1947, India had 15 allopathic medical colleges and 47,500 doctors trained in the
Western system of medicine. It was also fortunate in having in the Bhore Committee’s
report (1) a document of unrivaled clarity which analyzed in great detail the problems
of delivery of health services to the common person in a country with a large and
predominantly rural population and with limited financial resources. The report
contains the original concept of primary health care, of which we hear so much today,
with a clear advocacy of a decentralized service based within the local community and
involving the people in their own health care.
Considering all the facts, it is not surprising that the founding fathers of our nation
placed the responsibility for the planning as well as the operation of our health services
entirely on the shoulders of the allopathic medical profession.
Four decades later, we realize that though there has been considerable improvement
in the health status of our people as measured by the increase in life span and fall in
The Mandwa Project / 155
Table 2
Comparison of Punjab and Keralafl
India
Birth rate (per 1000)
33.9
Punjab
Kerala
30.3
26.0
Death rate (per 1000)
12.5
9.4
6.9
Infant mortality (per 1000, 1980)
114
89
40
Per capita income at current prices (Rs.)
1758
3164
1447
Female literacy (percent)
24.7
34.1
Target for
2000 A J>.
21.0
9.0
<60
64.5
^Source: Government of India. Health Statistics of India. Ministry of Health and Family
Welfare, New Delhi, 1984.
infant mortality (IMR) and crude death rates, statistics have also shown (Table 1) that
our achievements have fallen far short of our expectation. This is especially true when
we compare India with China, a country that gained independence in about the same
period and has similar and probably much greater problems to overcome.
Even in our own country, the differences between the poorest state of Kerala
(before the Gulf boom) and the richest state of Punjab are remarkable, as shown in
Table 2. Even though Kerala received the same health services as the other states of
India, the health of its population has already reached the targets set for the rest of the
country for the year 2000 AD.
It is evident from the above figures that the health of the people does not merely
depend on the income level of the people or medical services; the Punjab per capita
income is 2.4 times that of Kerala. John Ratcliffe (2) has attributed the success of
Kerala on the health front to mass education and political will. Education, especially
of women, is probably the most important factor in improving the health of the family
and community. The causes for the inadequacies of the health services have been
examined in detail in the 1980 joint report of the Indian Council of Medical Research
(ICMR) and the Indian Council of Social Science Research (ICSSR) (3). These causes
have also been remarkably well summarized in the government’s own statement of its
National Health Policy of 1983:
The demographic and health picture of the country still constitutes a cause for
serious and urgent concern. The mortality rates for women and children are still
distressingly high; almost one third of the total deaths occur among children below
the age of 5 years; infant mortality is around 129 per thousand live births. . . . The
existing situation has been largely engendered by the almost wholesale adoption of
health manpower development policies and the establishment of curative centres
based on the Western models, which are inappropriate and irrelevant to the real needs
of our people and the socio-economic conditions obtaining in the country. The
hospital-based disease, and cure-oriented approach towards the establishment of
medical services has provided benefits to the upper crusts of society, specially those
residing in the urban areas. The proliferation of this approach has been at the cost
of providing comprehensive primary health care services to the entire population,
whether residing in the urban or the rural areas. Furthermore, the continued
high emphasis on the curative approach has led to the neglect of the preventive,
156 I Antia
rpromotive,
; public
••• 'health and rehabilitative aspects
, ' j of health care. The existing ap
proach instead of improving awareness and building up self-reliance has tended to
enhance dependency and weaken the community’s capacity to cope with its prob
lems. The prevailing policies in regard to the education and training of
ot medical and
health personnel of various levels, has resulted in the development of a cultural gap
between the people and the personnel providing care. The various health programmes
have, by and large, failed to involve individuals and families in establishing a selfreliant community. Also, over the years, the planning process has become largely
oblivious of the fact that the ultimate goal of achieving a satisfactory health status
for all our people cannot be secured without involving the community in the identification of their health needs and priorities as well as the implementation and’ management of the various health and related programmes.
•
~
’•
’
)
It is evident that the failure to deliver health care, especially to the rural poor who
form the majority of the population, is the result of a lack of professional and political
will to look after the underprivileged and share the benefits of development; this is no
different from the other fields. Despite protestations to the contrary, the chief bene
ficiaries of such a system are those who are supposed to deliver the goods. Welfare,
including health care, has become another large and profitable business.
Two decades in the public as well as the private sector were more than adequate to
convince the author that the medical profession had neither the desire nor the training
and capability to deliver health care to our people. Even the sophisticated urban
services, which were chiefly monopolized by the elite, left much to be desired, for in
the absence of a generalized scientific culture and with an archaic administrative infra
structure they generally ended up as poor imitations of their Western role model and
often only a caricature. Even worse, I was convinced that those of us educated in
urban medical colleges were totally unaware of the actual problems of health and
disease of the common person in our own country, even in the urban slums let alone
the villages. What we saw and learned in big hospitals was only the tip of the ice-berg,
as represented by the few “interesting” cases of advanced pathology that reached us,
often in extremis. The emphasis of medical training was almost entirely on cure and
not prevention.
PLANNING OF THE MANDWA PROJECT
Being an observer as well as a part of this scene, I made a decision in the early
1970s to try to understand the actual problems of the health of our people and, if
feasible, to explore new avenues whereby the benefits of modern medical science
could reach the common person. Since 80 percent of the population of the country
is rural, a community comprised of 30,000 population distributed in 30 villages across
the harbor of Bombay was chosen for the study, now popularly known as the Mandwa
project. Though only 15 kilometers by sea from the great metropolis with all its
sophisticated medical services, Mandwa represented a typical undeveloped rural com
munity along the coastal belt of Western India with hardly any worthwhile medical
services.
The first two years were spent in trying to understand the problems of health and
disease of the people by meeting, observing, and discussing these problems with
the people and their leaders in the villages. Also, we observed the functioning of the
The Mandwa Project / 157
Primary Health Centre,1 which was located 40 kilometers away, and of the District
Hospital with 250 beds, which was at a distance of only 20 kilometers. The findings
of this exploratory phase can be summed up as follows:
1. The village is as much a stratified community as is the city. The interface
between the village and the external world is a few “leaders” who exert financial as
well as political control and are the self-appointed trustees of the silent majority,
which is virtually unapproachable without going through this local power structure.
2. Health, and especially the preventive aspects, is of little significance to the vast
majority whose main preoccupation is to provide the next family meal. Even illness
and pain are not adequate reasons to seek medical aid unless they interfere with
earning the daily bread. Early detection of disease and regularity of treatment, let
alone prevention, were a luxury the villagers could ill afford. What they sought was
quick temporary relief, which was provided by the doctor in the form of an injection
of a broad spectrum antibiotic and analgesic, a bottle of tonic, and injection of
vitamin B complex to which they were now hooked.
3. The commonest problem was malnutrition, which together with the lack of
water supply and hygiene and the tensions of survival took an extraordinarily heavy
toll on the health of the population. Yet the extensive load of chronic ill health was
considered only as the norm.
4. Despite their poverty, villagers incurred considerable expenditure in emergencies
such as obstructed labor, accidents, or terminal stages of dehydration, often by resort
ing to the moneylender.
5. The Government Primary Health Care service was virtually nonexistent despite
the two subcenters and a dispensary with 10 beds in the area covered by this project.
The doctors and nurses, when available, were concerned only with curative services
which chiefly favoured the leaders. They often charged the poor for services despite
drawing a nonpracticing allowance. Family planning was the only program that was
implemented with any regularity in order to reach the stipulated government targets;
the coercive measures employed were generally resented by the population, who asso
ciated the Primary Health Care services solely with population control.
6. The services of the not too distant district hospital were of limited use because
of lack of adequate transport and the cost of travel.
Despite this dismal picture, there were some hopeful signs that provided a silver
lining to an otherwise depressing scene. First, though illiterate and oppressed, the
people showed remarkable practical ability and intelligence in making the best use of
the meager resources available to them. Second, the prevalent diseases were chiefly of
a communicable nature, their diagnosis required elementary medical knowledge and
skills, and appropriate medical technology was readily available. Besides being remark
ably simple, the technology was also cheap and highly effective as well as safe, both
for prevention and cure.
1A Primary Health Centre (PHC) is the basic unit of the government for primary health care
as well as for the National Disease Control programs. The present PHC caters to about 30,000
population and has two doctors, two multipurpose paramedical workers, and one Health Guide
(HG) for every 1,000 population.
158 / Antia
We realized that instead of employing the usual anatomical and pathological classi
fication, if the diseases were graded according to the knowledge, skills, and technology
required for their diagnosis, prevention, and treatment, it provided a very practical
and an entirely new approach to their management. Broadly speaking, the problems
fell under the following four categories:
Minor illness and minor injuries that have traditionally been looked after
adequately by the people themselves with local folk remedies.
Group II. Diseases that are responsible for a great deal of morbidity but do not
endanger life, e.g., scabies, worms, minor gastric upsets, and simple
diarrhea.
Group III. The major killing and maiming diseases of the developing world such as
tuberculosis, tetanus, dehydration due to severe diarrhea, dysentery,
measles, acute respiratory infections, poliomyelitis, and leprosy.
Group IV. Conditions such as cancer, heart disease, stroke, major trauma, and those
requiring surgical assistance.
Group I.
The problems in any one group, especially if not treated in time, could escalate to
the next in a few instances, but as a rule, groups I to III required simple skills for
diagnosis or suspicion of the disease, and the majority of diseases could be prevented
by simple measures, often by the community’s own action. Cheap, simple, safe, and
effective treatments were also available for all of these diseases.
In view of this and the fact that there was no hope of delivering the available tech
nology provided by modern medical science under the existing system, we thought it
reasonable to explore whether the villagers themselves could be taught the simple
medical skills and how to make use of the equally simple available tools to look after
their own health problems to the extent possible. We also thought it reasonable to
teach them how to use the available medical services and demand what was their due.
In the absence of any precedent, the evolution of the Mandwa project was through
a series of trials and errors. This experiment in self-help was explained to the local
village leaders (sarpanchd) who were presuaded to help select a woman from each
village for training. Experience reveals that motivation should be the single most
important criterion in selection of such part-time health workers and that every
village can identify a few such individuals. Since most were semiliterate, training was
conducted in an informal manner in the form of weekly discussion groups in the
villages themselves.
The training was of an entirely practical nature and under conditions in which the
health workers would eventually work. Hardly any teaching aids were employed. The
village well, the pregnant woman, and the people who were ill in the village provided
adequate material for practical demonstration. The germ theory was taught using the
magnifying glass and simple school microscope to examine water from the local well,
smears from lepromatous patients, and sputum of those suffering from tuberculosis.
The major problem was finding teachers among the professionals who could convert
complex theoretical knowledge into simple and practical knowhow, and above all,
could overcome their cultural barriers and learn to differentiate between intelligence
and education and to respect the highly practical approach of simple village folk as
The Mandwa Project / 159
opposed to their own impractical theoretical education. It was also difficult for the
urbanized doctor to adjust to the slower pace of the village.
Despite the payment of a salary equivalent to and even higher than that of the
doctor of the government Primary Health Centre, it was virtually impossible to attract
a suitable candidate. Most doctors did not believe that a village woman could possibly
acquire knowledge on health when it takes two to five years to train a paramedic or
a doctor. At best it was considered dangerous practice, and at worse an attempt at
institutionalizing quackery. The arduous task of spending most of the day on a motor
cycle visiting villages rather than running a traditional static outpatient service, com
bined with absence of payment from the patient, was a further disincentive. The only
doctor who was prepared to work continuously was a young ayurvedic physician, the
son of a local fisherman. Though poor in medical skills, he was acceptable to the
people for he belonged to their community.
Finding suitable nurses and even Auxiliary Nurse Midwives (ANMs) posed a similar
problem with a high turnover.
The staff of the project consisted of a doctor trained in ayurvedic medicine, an
administrator trained in social science with three helpers (to maintain accounts and
records and to undertake statistical analysis and the purchase and distribution of
medicines to the subcenters), five ANMs, and 27 Village Health Workers (VHWs).
Except for the senior administrator, all were local personnel. A small health center was
established with 10 beds (used chiefly for maternity cases and for tubectomy opera
tions). The cost of such a service (not accounting for the research inputs) was approxi
mately Rs.6/- (rupees) per capita per annum in 1980 compared to the all-India average
of Rs.30/- (4). Of this sum, the cost of medicines could be recouped from the
patients.
RESULTS OF THE MANDWA EXPERIMENT
Let us now examine what semiliterate women could achieve in their community
with such simple instructions and a very elementary referral and support system
without an associated program of economic development or inputs into nutrition,
watersupply, sanitation, and improvement of environment. It took about three years
to establish the project and for the VHWs to gain the necessary confidence. The
effective period of the project was from 1977 to mid-1983 which was followed by a
period of turmoil until its closure in January 1984. It was interesting to note that with
increasing experience, many of the VHWs surpassed the ANMs in their effective role
in the village and they replaced all the ANMs at the subcenters during the last three
years of the project. The VHWs also undertook the giving of injections for immuniza
tion as well as streptomycin to patients suffering from tuberculosis.
A preliminary survey of the area was undertaken by the Tata Institute of Social
Sciences, which revealed that the health and economic situation of this area was no
different from that of the country as a whole and hence the national statistics have
been used as the baseline. Table 3 shows some of the figures for Mandwa compared
to the national figures.
It should be noted that all activities were carried out through individual VHWs
on a routine daily or weekly basis, including immunization of children and pregnant
160 / Antia
Table 3
Achievements of Mandwa
Mandwa project
1982
National figures
1982
Birth rate (per 1000)
15
33.3C
Crude death rate (per 1000)
8
11.7*
Infant mortality rate (per 1000)
Immunization (percent)
Triple antigen
Polio
Tetanus toxoid
74
114 (1980/
92
67
78
25*
5*
20*
^Source: Government of India. Health Statistics of India. Ministry of Health and Family Welfare,
New Delhi, 1984.
^Source: Government of India. National Health Policy. Ministry of Health and Family Welfare,
New Delhi, 1983.
mothers, family planning operations, and detection of leprosy. No camp or mass
approach was used.
Immunization. The high rate of immunization was achieved only after ANMs
were replaced by the VHWs, for this assured regularity and undivided responsibility.
This, with improved hygiene at delivery, resulted in the absence of even a single
death from tetanus (the second largest cause of death in India) during the entire
period of the project.
Leprosy. The number of cases detected by the full-time government leprosy
technicians in 12 years prior to the project was 63. The number of cases at the end of
the project was 161 and the detection rate of the VHWs was similar to that of the
two-year-trained leprosy technician. Moreover, all the cases detected by VHWs were at
the early stages of the disease, and with the much improved regularity of treatment
there was not a single new case that developed deformity. Since the VHWs visited
leprosy and tuberculosis patients in their homes, there was a virtual abolition of stigma
and the old deformed patients were reaccepted by their family and community.
Tuberculosis. The rate of early detection was high, and since the patients were
given their streptomycin injection at home, the regularity of treatment was ensured,
especially because the importance of treatment in preventing family transmission of
the disease was explained. Preventive measures such as disposal of sputum were also
ensured. It must be stated that the role of the VHWs was to detect suspected new cases
and to carry out the treatment as recommended by the doctor after confirmation of
diagnosis.
The Mandwa Project / 161
Gastroenteritis. Deaths from dehydration were virtually eliminated by oral
rehydration therapy using home-made salt and sugar solutions. More important,
preventive action such as cleaning and chlorination of wells and boiling of water pre
vented the spread to epidemic proportions.
Malaria. Blood smears of fever cases were taken by the VHWs, followed by chloro
quine administration. Definitive treatment was provided for positive smear cases and
the local community often undertook the spraying of insecticide.
The question naturally arises as to why such a cheap and effective people-based
health service, which is in keeping with the recommendations of the country’s own
Bhore (1) and the ICMR/ICSSR (3) Committees as well as with the National Health
Policy (5), fails to get implemented on a nation-wide scale. The answer to this has also
been indicated by the Mandwa project.
At an early stage of the experiment, the then Director of Medical Services of the
State requested that the project take over the functions of a Primary Health Unit2
(PHU). The staff sanctioned for a PHU was placed at the disposal of the project
administration. This was done with the hope that this experiment would provide a
prototype for the development of a similar service on a state-wide basis. Unfor
tunately, both the district medical personnel as well as the paramedical staff con
sidered this a threat to their comfortable existence, for the community was now made
aware of their presence as well as their duties. Not only did they refuse to perform
their alloted duties but they took every opportunity to undermine the working of the
project. Yet they had no hesitation in claiming credit for the tasks performed by the
VHWs, such as detection of cases of malaria, tuberculosis, and leprosy, pre- and post
natal care, immunization of children and pregnant women, and above all, motivation
for family planning.
The nine nonallopathic private doctors in the area posed less of a problem, although
one doctor who operated a private nursing home prevented the appointment of a
VHW from his area. Patients, especially those who could afford it, continued to
patronize these doctors for injections, for these were not provided by our service,
except for immunizations and tuberculosis. Most of these injections given by other
doctors consisted of unnecessary and often dangerous antibiotics such as Chloro
mycetin, analgesics, and vitamin B complex, even for diseases such as the common
cold. Interestingly, injections of penicillin or streptomycin or for immunization were
seldom employed.
The local leaders, who welcomed us initially, lost interest when they realized that
the project was not going to provide a hospital with doctors, nurses, X-ray and
pathology facilities, and an ambulance, which in actual fact was their priority. Our
repeated pleas to them to form a health committee for the area received little
response. The effectiveness of the VHWs varied from village to village. Besides their
2 It is a “mini” Primary Health Centre with one doctor and other staff set up in areas that do
not have easy access to the Primary Health Centre services catering to 30,000 population. The
Primary Health Unit (PHU) was a subunit of the old PHC which looked after about 100,000
population.
162 / Antia
own ability and motivation, an important factor was the extent of support they
received from their village leaders.
Several of the leaders resented the fact that the project succeeded in reaching the
poor in their villages while bypassing them, thus arousing fear of an alternative power
structure and an attitude of self-reliance developing among the poor. The health
professionals were quick to seize this opportunity to drive a further wedge between
the project staff and the local leadership.
Despite the fact that the poor and even some of the leaders accepted the project
services, the local power structure dominated by the richer and more powerful leaders
joined hands with the government health personnel in open hostility and demanded
that the project leave the area, handing its assets to them. Their object was achieved
after threats and a show of open violence to the project staff.
The question arises as to why the beneficiaries, namely the poor, who formed the
majority of the population did not actively oppose this threat. The answer lies in their
abject poverty and dependency on the local power structure for their survival. Health
is not a priority in their daily life.
Summary
The findings from the Mandwa experiment may be summarized as follows:
1. Modern medical science and technology have provided us with the knowledge as
well as the tools for the prevention and treatment of the vast majority of the diseases
that affect the people of the developing world.
2. This knowledge and technology is remarkably effective though simple, cheap,
and safe.
3. Semiliterate and even illiterate village women have the capacity to absorb this
knowledge and use the technology if this is made available to them in a simple and
acceptable manner.
4. The role of the professionals is to impart such knowledge, encourage self-help,
and provide graded supportive services for problems requiring greater skills and/or
facilities. It is not their role to appropriate functions that the people themselves can
undertake.
5. Health at this level, at which almost 80 percent of all problems can be tackled
by the people themselves, requires low technology but high cultural affinity with the
people.
6. The local village women are therefore more suitable for tackling these problems
than more highly trained professionals.
7. The average professional fails to discriminate between education and intelli
gence. He or she looks down upon the illiterate as being unintelligent.
8. The interest of the professional often does not coincide with the interest of the
people; hence the appropriation of peoples’ health by a process of secrecy and
mystification.
9. Health professionals generally perceive a well trained VHW as a hindrance or
threat rather than a help. This is because the VHWs often demonstrate results superior
to those of the professionals, demystify health, and reduce peoples’ dependency. This
results in loss of practice in the private sector, creates surveillance, and hence brings
accountability in a normally unaccountable public sector.
The Mandwa Project / 163
10. Semiliterate village women have demonstrated that in five years they could
almost reach many of the targets set for 2000 A.D.—this without any inputs in
nutrition, water supply, sanitation, and improvement in environment. They achieved
this despite limited supportive services, and opposition from the private as well as
public health sector and latterly from their local politicians. Table 3 gives some of
their achievements, and all this at the cost of Rs.6/- per capita per annum.
CONCLUSIONS
Mandwa and similar projects merely demonstrate that the ICSSR/ICMR report’s
recommendations for health at the village level, where the majority of the people live
and where the problems lie and should be solved, is not merely fanciful hypothesis.
Why is it then that the experiences of Mandwa and similar projects have remained
isolated and have had little impact on the health service of the country as a whole?
To the casual observer this is particularly difficult to comprehend when the national
policy continues to harp on “Health for All” through primary health care and com
munity participation. Surely it is not lack of finances because these projects are highly
cost effective, nor is it due to lack of manpower. Even though part-time VHWs, now
known as Health Guides, have been appointed by the government in the majority of
our half-million villages with the same objectives and a similar complement of
supporting staff and services as at Mandwa, it has had little impact on the general
health of our people.
The answer to these questions has also been provided by Mandwa. The extent
of opposition to even such a small project from both the health and the local political
structures demonstrates the emptiness of slogans such as “Health for All” or “Rural
Development.” It reveals the true intentions of the power structure and its vested
interest in maintaining the status quo, in which a few individuals can dominate the
rest of the community. In a democracy, all programs and activities are carried out in
the name of the people and especially of the underprivileged. The fact that almost
all benefits of development gravitate to the elite reveals the extent of the dichotomy
between preaching and practice, and this applies equally to the field of health in both
the public and private sector. While there is dissention within the health system and
between it and the bureaucracy and politicians, these forces will close ranks if the
existing system is threatened by any external agency that may disturb the balance
between them and the silent majority on whose presence they thrive.
Only thus can be explained why, almost four decades after Independence, half the
population remains below the poverty line, 100 out of every 1000 children die within
the first year of diseases such as gasteroenteritis, and diseases for which we have
effective measures of prevention and control continue to take their unrelenting toll.
Even here, aggregate statistics hide the true reality because improvement in the upper
two or three deciles conceals the infinitely higher mortality and morbidity figures in
the lowest two or three. Despite a school in every village, about 60 percent of the
population and 75 percent of women remain illiterate, when the nexus between female
literacy and health is clearly demonstrated by the statistics of Bihar and Uttar
Pradesh-IMR > 250—versus those of Kerala-IMR < 50.
k
*
164 / Antia
It is unfortunate that even the well intentioned members of the medical profession
see health as a medical rather than a social, cultural, economic, and political problem.
Even with the best of intentions, most of the voluntary agencies with their purely
humane approach often help to create an even greater dependency among those whom
they serve.
Mandwa can either be seen as a failure of a community health project or as an
experiment that demonstrates how knowledge can help people to overcome their
fears and encourage self-reliance. Whether this knowledge and technology can be
spread through an organized movement or in a nonformal manner or a combination of
both remains to be seen. Whether the impact will be only in health or will also, by
demystifying the most mystified subject, create the awareness to overcome the sense
of abject helplessness and start a process of questioning of the existing order—this also
remains to be seen.
Acknowledgment — The author thanks the Directorate of Health and Services of
Maharashtra for cooperation with this project.
REFERENCES
1. Government of India. Report of the Health Survey and Development Committee. Govern
ment of India Press, Simla, 1946.
2. Ratcliffe, J. Social justice and the demographic transition: Lessons from India’s Kerala State.
In Practising Health for All, edited by D. Morley et al., pp. 64-82. Oxford University Press,
London, 1983.
3. Indian Council of Social Science Research, and the Indian Council of Medical Research. Health
for All: An Alternative Strategy. Indian Institute of Education, Pune, 1981.
4. Centre for Monitoring Indian Economy. Standard of Living of the Indian People. Bombay,
1984.
5. Government of India. National Health Policy. Ministry of Health and Family Welfare, Delhi,
1983.
Direct reprint requests to:
Dr. Noshir H. Antia
Director, The Foundation for Research in
Community Health
84-A, R.G. Thadani Marg, Worli
Bombay 400 018
India
I-IO
VII / PT
personnel, specially those directly in public
contact at village level —the Village Health
‘ Worker (VHW), the Multi-Purpose Worker
(male, i e, (he MPW) and the Auxiliary
Nurse-Midwife (ANM)—are all busy
meeting family planning txrgeis Immunisa
Ritu Triya
tion targets have also got added on to the
family welfare programme in the name of
•child survival’ and therefore hgve become
While the basic orientation of the Eighth Plan approach paper
important. Thirdly, the malaria surveillance
towards decentralisation and employment generation can prove to
and treatment work continues to some ex
be a major step for the improvement of health status, there is
tent. No other work worth its name is being
done by the rural health services.
little recognition of how developments in other sectors have an
These are the only activities the super
impact on health. Jn making health care a component of a social
visors check—the middle rung supervisors
service package there is every danger of it being neglected.
or the PHC doctor or the district medical
officer—either during supervision visits or
trying to raise is also not of preventive vs
THE approach paper to the Eaghih Five-Year
at monthly meetings. No one bothers about
curative
services.
Nor
is
it
of
two
separate
Plan prepared by the Planning Commission
how man) tuberculosis cases have been
cadres for preventive and curative work The
after the National Front government took
delected, how many arc being treated or
question
is
of
the
side-lining
of
curative
care
over starts by stating that the health delivery
whether anti-tubercular medicines arc being
in the name of preventive measures on the
systems in rural areas are ‘inadequate and
adequately supplied Treatment given in
one
hand
and
the
side-lining
of
basic
inputs
defective’. Five lines of action have been sug
minor ailments, an officially assigned task
for health status in the name of special
gested to correct the defects
of the local level workers, is never given a
preventive measures on the other The point
(1) To make the health delivery system “pan
thought to No one checks the level of
is only that both must be given their nghtful
of a package programme tn which other
knowledge of the workers, their prescribing
place—(i) Curative cart in the health care
social services such as education and
practices, etc.
system
and
(ii)
promotion
of
health
and
women’s programmes arc also brought
On the other hand a major section of the
prevention of ill-health in national
in”.
VHWs. ANMs and MPWs art providing full
developmental
activity.
Let
me
explain
(2) Special suppon to national programmes
medical care as ‘doctor sahebs’. As their
myself in some detail
such as for control of leprosy, malaria
official dutj thr> do family planning and
Thus understanding of the health care
and *kala-azar’.
immunisation work As their private prac
system arises out of observations and
(3) Decentralise planning of details and im
tice they give curative care. Along with the
research in various pans of rural north India
plementation of programmes to state
minimal training in medical care officially
and among Delhi's urban poor The
and local levels keeping some areas such
given them, they pick up bus and pieces of
arguments art based on two ground*.—(i) the
as manpower training, research and
information and start practising it.
present condition of the health cart system.
health information collection with the
These gosrrnment health personnel are
40 years after planned services have been in
central government.
partly meeting the demand for medical care
troduced into it based on this integrated ap
(4) The medical education system must be
unofficially and without adequate training.
proach. and (2) perceptions of the majority
‘structurally modified’.
The rest of the demand is met to some extent
sections
of
our
citizens
about
health
and
(5) The health care system needs to be
by other ‘informally trained' persons and by
health care.
ennehed by using simple inexpensive
those trained in other systems of medicine
Health
workers
of
the
public
rural
health
methods and remedies derived from
(specially those with a BAMS degree), all
care system are, in addition to being insuf
traditional systems.
three in the category of what arc called
ficient in number and therefore having large
The overall direction indicated by the first
‘quacks’.
populations to cover, loaded with in
point and supported by the second one is
Only a very insignificant section of the
numerable tasks, emphasis being on those
highly problematic and is the one issue 1 will
population comes to the subcentre .or
largely
‘
preventive
’
in
nature.
As
one
of
their
focus on in the first pan of this report. The
primary health centre for medical treatment.
minor tasks they preside medical treatment
second pan shall deal with some concrete
The government health services art generally
‘
also
’
.
What
has
this
meant
at
ground
level?
steps which can initiate a process of change
not perceived as institutions for ‘care’ but
in direction and onentation of the health
People want a doctor’s medical care when
as something antagonistic, something meant
care delivery system and its personnel.
they art ill. What do they do? Most often
to impose family planning, etc, on people,
go to a ‘private practitioner’ in the area
not to cater to their needs
I
whom they often kno^ is not really qualified
The prescription practices of these
but will at least give them some injection and
•quacks’ are probably causing all kinds of
Planning special programmes for discrete
some tablets to relieve them of their ailment
unknown havoc in the bodies of the urban
interventions and then integrating’ them in
They have nowhere else to go. The earlier
poor and rural populations E g. excessive
to packages is ho^ the health services have
folk remedies which enabled them io deal
use without reason of steroids is a wrll
developed over the last 40 years. Practice of
with a: least the everydas ailments have
known hazard caused by ‘quacks’. Of course
the concept of integrated preventive, pro
largelj been delcguimised and wiped out of
the misuse of medicines is picked up from
motive and curator services in this manner
practice and memory The ‘doctor’ and his
the malpractice of trained ‘doctors’. However
has been one of the major causes for failure
medicine base been glorified out of propor
as the larges: body of personnel providing
of the health care system. The packaging of
tion and have become almost the onh firs:
medical care to the deprived sections the
health care with other social services is only
resort
impact of me quacks’ wrong practices is
a further extension of th: same logic.
more direc:
1 he public health care svsten.. * hue it ha^
Carrying on this direction of integrated’ set
1 his is th: state in terms of treatment of
helped generate this demand, docs no: real
sices for health r hardh lu-r^ to improve
illness, i e, ’.he curative care Coming to the
|\ preside medical care. It is supposed to be
the health care system
preventive ana promotivc aspect—the direct
providing integrated preventive, prompnve
While i: i' essential io hfc'r ar. integral
inputs arc nutnuor.. watt:, sanitation, etc.
and curative service^ Is it though” 1 he
notion of prrvcmiu;. and care for sound
Employment, women’s status and education
whole rural primary health care system is
health care the concept of integration is
are also acknowledged determinants of
geared toward’, faniih planning w-ork Al!
being used sujserficjalls T he question 1 am
Dubious Package Deal
Health Care in Eighth Plan
1820
Economic and Politico’ Weekly
August 18, 1990
’ VII / PT2
(contd.)
measures
more eastl). The following are
to serve the purpose of by-passing sustainr
health status. These are all basically ’non
some suggestions for what is possible with
able
longterm
solutions
with
medical
s
health’ inputs for health But the jargon of
the existing infrastructure and personnel.
technological solutions. One cannot be a
t
integrated services has been carried to the
replacment for the other
'Instead of continuing with the distoned em
extent of including all these in ‘health pro
phasis
on family planning the health services
What is needed is to give a significant
|
grammes' or in ‘social services'. Emplov
should
provide good, efficient and safe con
place to health in the planning of sectors !
ment. water supply and sanitation all
traceptive services on demand. The demand
other than the health services. All develop
become ‘social services
for contraception exists specially among
ment activity —from employment generation
Until recently it was the lamily planning,
AiDmen; even poor women of both rural and
strategies to agricultural policy; land and
the immunisation and the malaria program
urban areas. However the aggressive pushing
water management and animal husbandry
mes which hijacked the health services. The
of family planning by government person
to promotion of the food processing
latest trend in the health sector currently
nel and the experience with various con
industry; development of human settlements
being pushed by WHO. UNICEF, the volun
traceptive methods as provided by the
and housing — must be planned taking into
tary agencies, etc, is to include all sectors
government service discourages the use of
account
their
impact
on
health
of
the
people.
affecting health of a population in health
familv planning services. In addition to the
Uptil now even our drug policy has been
programmes.
non-health
inputs talked about in the ap
determined by the dictates of the industry
Health services mainiv for the poorer
proach paper (raising women’s status, in
alone
and
not
by
the
health
needs
of
our
sections are now to loo*, alter not onlv
come levels, etc) provision of contraceptive
people. This is not a factor considered even
medical care, detection ol cases and their
services with dignity and in the safest man
while formulating policies even in areas with
treatment, etc, but also involve themselves
ner possible (not 300 to 1000 sterilisations
most direct impact, e g, the agricultural
with these other ‘social services! The Eighth
done in one camp in a day; not haphazard
policy
does
not
keep
the
link
between
Plan approach paper is echoing this ap
insertion ol Cu-T but insertion with all asep
agriculture, food and nutrition in sight (even
proach when it talks of the health delivery
tic precautions so that chances of P1D and
in this approach paper).
system as pan of a package along with other
other complications are minimised, etc)
To cue an example, with the pushing of
‘social services!
coupled with improved efficiency of the
high-yielding w heat and rice in the last few
Of course these inputs are vital for heajth.
medical care system including the treatment
decades, the production of coarse grain,
But giving them the garb of a health pro
of children s ailments, will go a long way in
pulses and oilseeds lost out. Until a couple
gramme or including them in a package of
encouraging birth control. The undue effort
of
decades
ago
coarse
grains
and
pulses'
social services is not an effective way of
and emphasis on family planning is unnecesblack
gram
plus
milk
products
were
the
basic
providing for these needs; rather, only an
sarv. Instead health personnel can concen
diet of large parts of the rural population,
effective way of seeming to provide for them.
trate on providing basic medical care which
in north and central India at least Todas it
In the process long-term measures are
includes treatment in illness, immunisation,
is reduced to ‘rotis’ of wheat with salt or
avoided and only ad hoc solutions tned out.
contraceptive services, etc.
chillies
or
a
little
vegetable.
Small-scale
For instance—provision of water as part
The Village Health Worker Scheme needs
animal husbandry has declined and the little
of integrated health programmes means, say.
to
be re-established with modifications so
milk available is sold to the towns so that
putting in hand-pumps. This is done and it
that (a) the VH Ws have better clinical skills
intake of milk products has declined among
is taken for granted that safe water has been
and a better understanding of preventive
manv sections of the rural population The
provided for. But this is really simplifying
health aspects, (b) the VHWs actually ac
nutritional quality of peoples diet has
the issue of water supply It has actually to
quire the role of a people’s representative for
deteriorated with these changes. And then,
be tackled as an overall problem of water
the health sector rather than as the lowest
instead
of
dealing
with
these,
we
have
to
management. For example, in Delhi, the real
rung in the hierarchy for implementation of
develop new ‘low-cost nutritional sup
issue is how to provide the city’s enure
government programmes. With the overall
plements'
and devise special programmes
population with adequate and ‘safe water,
thrust of the approach paper towards decen
What in fact does this jargon of integrated
not that this jbuggi-jhonpn cluster or that
tralisation, revitalising of the panchayati raj
preventive-promotive-curative services
one of even these 50 clusters have got hand
institutions, etc, one area must be the
achieve? On the one hand it is not allowing
pumps. Because the rest of the 600 will have
autonomy of the VHWs from the health ser
us to work on long-term, sustainable
nothing by way of an assured, sustained
vices His, her accountability must be to the
measures for provision of basic needs, allow
water supply. Even in those clusters which
people rather than to the public health
ing them to be postponed, a waue in both
do get hand-pumps, their numbers, are
services, (c) The VHW must have some
financial
and
human
terms
On
the
other
generally inadequate to meet the total needs
credible role, having a legitimate standing on
hand innovative thinking and creativity in
of the residents. In Dcihi a mix of sources
health-related matters with the local
,
the field of health is today being concen
must be tapped for water. Suitable sources
authorities and in panchayat bodies for the
trated on how to deliver this integrated
and appropriate systems need to be identi
villagers to begin taking them seriously.
•package
to
the
‘
community
’
(besides,
o.
fied area-wise, installed accordingly not only
To improve the situation of medical treatcourse, on high technology super-specialist
for the slum areas but for all sections of
ment wc should vtait with the ground reality.
research) There is no space for innovation
Delhi 1 his the health service or the I than
To begin with the role ol the MPW and
and creativity in applying medical know
Basic Services Programme (a UNICE!ANM as providers of medical care should
ledge appropriately, or in establishing effisponsored integrated programme being run
,
be officially recognised so that they arc then
aent medical management of common
by the Delhi administration besides being
I
given adequate training, their activity superclinical problems according to our nerds and
.
vised and their clinical knowledge and skills
adopted by other io*n and city civic
conditions
The
lack
of
such medical care
administrations) cannot do. And because the
>
constantly checked and upgraded. Improv
is being acutely felt by the common
hand-pumps have bcm provided the pressure
ing the quality of medical care and
person —rural and urban, rich and poor.
on the Municipal Corporation or the Delhi
knowledge supplied by the ANM/MPW to
Development Authority to do something for
the ccmmuniiy should in the long run have
II
overall water management is eased. Then,
the effect of upgrading quality of caic pro
uith the lack of safe *a:er exacerbating
vided by other so-called ’quacks as well.
Coming back to the question of irr.['ro,>health problems such
diarrhoea, choleraJ
It car. be argued that ‘training will not
’
s
—
shouldn
’
t
mg the health services themselves
rcallv help in improving the quality of
and polio the health system‘’ has
- to’ provide
the fin: tasl be to gear the pubbe health ser
more preventive services in the form of pre
medical care What about the poor quality
vices to meet the demand for curative care’’
ventive medical technology— immunisation
of care provided bv our trained doctors. Il
This will provide better qualit) medical care
md promotion of ORS packets In this *ay
is a valid argument for poor practice is not
and also help in the acceptance of preventive
the prtvenlive-promoiive jargon has come
1821
Economic and Political V>eckly
A gust 18. 1990
vii
1!
/ pt2 (contd.)
The adoption of a drug policy along the
only because of lack of knowledge but
because of the contrary pulls of commercial lines recommended by the Hathi Committee
gain and rational practice. Tackling the lat would also go a long way in changing the
ter problem needs a change in the socio scene of curative care.
There is an urgent need to take concrete
political climate and is a mauer of vision
and will of the social and political leader steps for revitalising traditional health prac
ship. However any change in practice can tices so that at least everyday ailments can
not be expected in the absence of correct in be effectively dealt with at the home and
formation. We could make a beginning by community level itself. Approaches for this
giving relevant practical knowledge and skills have been worked out very concretely and
in great detail, e g, by the Lok Swasthya
to local level workers.
In order to equip the MPW/ANM ade Parampara Samvardhan Samiti. These must
quately through short-term training, in be seriously examined and given a significant
novative modules for management of com place in the health policy.
The approach paper emphasises the
mon medical problems .need to be worked
out. These would be useful not only for importance of traditional systems in reorien
those with lesser medical knowledge but for ting the health system. However it talks only
doctors as well. Medical colleges should be of “enriching the health system by using sim
involved in working out these modules and ple inexpensive methods and remedies of the
operational research done to test effec traditional systems’’. This line only promotes
tiveness of various approaches to medical the Zandus and Daburs, not self-reliant
management under ‘field’ conditions. In decentralised medical care. The real need is
volvement in such efforts would re-orient not to just incorporate some remedies from
some medical college doctors as well, the ‘traditional’ into the ‘modern’ system but
making them deal creatively with field con to revitalise those systems themselves and
ditions and its challenges rather than find allow them the space to give society of their
excitement in copying foreign research; they best.
A change in the attitude of health profes
will deal with everyday ailments rather than
sionals is of course essential. “The health
exotic diseases and syndromes.
This suggestion must not be read to mean care system in the country cannot be made
that the role of ANMs/MPWs should be effective unless the medical education system
only curative and a separate cadre is is structurally modified" rightly says the
necessary for preventive work. A redefining approach paper. However it gives no clue as
of their role is needed so that they are to how this is to be done. We’ve had attempts
actually able to integrate both preventive and in the pat (the Bhore Committee recommen
dations, the ROME programme) but with
curative services.
The primary health care system must be little success. How will the effort be different
backed up by a good referral system from this time?
subcentre to PHC to district hospital to
The approach of the Sokhey Committee
medical college, etc. Improving efficiency of (the sub-committee on Health of the
hospitals must be a priority. Privatisation of National Congress Planning Committee,
this so-called ‘tertiary sector’ in answer to
1946) with regard to health humanpower
the problem of inefficiency in the public development was radically different from
system is a lure which must be resisted. In that of the Bhore Committee. However, it
the present social situation we cannot stop has never received any serious consideration.
them but at least no government support It started humanpower development from
should be given to this sector. The corporate the base of the pyramid and moved gradual
sector is a purely commercial venture— ly upwards. If the Sokhey Committee ap
Apollo Hospitals could be Oberoi Hotels— proach can be implemented even in part and
and should be treated as such. They should suitably modified according to the present
not be given any subsidies on land, no sub situation, it can lead to a process of ‘struc
sidies on import of equipment, etc. They tural changes’ in the health care system. For
cannot provide the poor man a solution to instance one step could be to encourage the
his problem of medical care. On the other MPW/ANMs to upgrade their skills and
hand they will blur the perception of need after a certain number of years in service,
for improving the public hospital system.
the best among them could be taken up for
The approach paper also talks of a strong training as doctors. A certain percentage of
case both on grounds of revenue and equi seats could be reserved for them in admis
ty, for the better-offs to pay for health
sion to medical colleges. There they should
services utilised by them in the public sector.
be treated as ‘senior’ students not as ‘lesser’
This does not seem like a sound proposition students as can possibly happen. Their
because the mechanism for differential pay
socio-economic background, their maturity
ment will not work. Or, if a workable
and their work experience in the field could
mechanism is evolved then the health care
slowly
change the character of the medical
provided will not remain equitable; those
graduate, of the training and of the doctor
who pay will get better services. Making the produced at the end. But this kind of ‘struc
better-offs pay in the form of taxes and the
tural change' needs a lot of political will
health service remain free for all seems to
behind it for it to be implemented.
be a more equitable system which, at least
The attitude of the doctor to be produced
theoretically, provides services according to
need and not according to the ability to pay. is basically a function of the overall health
system and the socio-political conditions and
prevailing dominant values. From the
1822
mechanism of recruitment for training, to
the way training is given, to the final work
for which they are to be produced, all
influence the quality and attitudes of the
medical student. The medical student
already has a set of values and aspirations
when he/she comes to medical college. Only
very effective training and education can
change these to any significant extent. It is
only when larger societal values are positive
that the doctors too will have positive
attitudes.
Similarly, they will take the preventive
aspects of health care more seriously and at
tempt to integrate them with their clinical
practice when ‘health’ is overtly part of
larger societal concerns. Emphasising
‘health’ as a goal in national development
policy and planning will help create a general
environment in which health becomes a ma
jor concern. This is an area for the Planning
Commission. But more than that it is a
political question. The Planning Commis
sion can raise issues, prepare plans accor
dingly and start a debate on them. But for
implementation, how far is the present
government ready to go?
The Planning Commission approach
paper makes a promising beginning with a
very positive shift from only economic plan
ning to social goals as well. The basic orien
tation towards decentralisation and employ
ment generation can prove to be a major step
for improvement of health status and for
promoting family planning. However, even
in this approach paper, improvement in
health services is not seen per se as a factor
for improving the life of our people. Its need
is felt on two grounds only—of increasing
productivity of the labour force and of pro
moting family planning. This is
disappointing.
H P4JI
INDEPENDENT COMMISSION
ON HEALTH IN INDIA
People’s
Initiative to
appraise the
current
problems of
the health
system—to
make health a
reality for the
people of
India.
4
1CHI Secretariat, Tong Swasthya Bhawan, 40 Institutional Area, South of IIT, New Delhi-110016 INDIA
Phones: 668071,665018,6965871,6962953 Fax: 011-6853708
Background and scope
In spite of the Parliament adopting the National Health Policy in 1983 the health situation in
the country today is a cause for deep concern.
There is considerable consternation in the minds of health and development experts as well
as NGOs and other organizations involved in the promotion of health care at the grass roots
level. The present day “EPIDEMIC OF EPIDEMICS” is a reflection of the extreme
deterioration of health services resulting in the failure to provide effective preventive and
curative measures. The recent episodes of Plague and Malaria and the defunct health care
delivery system in half of the country causing immeasurable hardships to millions of people
in the country have ominous portents. The Voluntary Health Association of India (VHAI), which
links over 3500 grass-root level health and development non-government organisations
across the country, along with its co-travellers, associates and friends, felt the need to
facilitate the setting up of an INDEPENDENT COMMISSION ON HEALTH IN INDIA, which
would have an in-depth look into the maladies affecting the health care system. Based on its
assessment of the ground realities at the micro and macro levels, the Commission will come
up with pragmatic, people-oriented solutions for decisive action. It is hoped that this will form
a foundation for future health planning of the nation.
The report of the Commission will be completed by January 1996, well in time before the
process of the 9th Five Year Plan begins. Copies of this report will be presented to the
President of India, the Prime Minister, Union Health Minister, Chief Ministers and Health
Ministers of all States, Administrators of Union Territories and Members of the Parliament.
The Independent Commission will do a comprehensive study using scientific socio-economic
data covering the entire nation. The major areas of concern which the Independent Commis
sion intents to thoroughly understand and analyse will be:
1. Vulnerable regions and people : The Commission will be involved in a meaningful
exercise that will use the available data, both quantitative and qualitative, to identify
vulnerable and deprived regions and people in terms of health and development. Visits to
selected regions, interactions with people and functionaries at various levels including local
and Panchayat bodies by members of the Commission will supplement the analytical work.
2. Epidemic of Epidemics : Vector-borne diseases such as Malaria and Kala-Azar; Water
borne diseases such as Cholera and Gastroenteritis; and other diseases such as STDs/AIDS
and Tuberculosis would be looked into in great detail besides the existing National Health
Programmes. The aim of this exercise is to determine the reasons why these diseases are
still prevalent and what the gaps are that need to be filled in the public health system in the
country.
3. Public Health Institutions : The Commission will specifically be looking at All India
Institute of Public Health & Hygiene (AIIPH), National Institute of Communicable Diseases
(NICD), Indian Councilfor Medical Research (ICMR), National Instituteof Health & Family
Welfare (NIHFW) and other such premier Institutions in terms of their functional relevance
today with regard to their mandate. The aim is to discern whether their programmes and
activities are tuned to the health needs of the people and current realities. This would also
help identify progressive public health initiatives in different states of India which have the
potential to improve the health status of the people.
4. Family Planning Impasse :ln this area the Commission will investigate how we are dealing
with the population problem. Though India was the first country in the world to initiate Family
Planning programme 40 years ago, the impact has been far from impressive. The Commission
will closely look into the relationship between population and the state of health and
development in the country.
Mr. Alok Mukhopadhyay, Executive Directorof Voluntary Health Association of India will
be the Convenor and Dr. Almas All, the Member-Secretary of this un-affiliated Commission.
The other renowned experts on the Commission will be:
Mr. R. Srinivasan, Dr. Balu Shankaran, Dr. Harcharan Singh,
Prof. Ashish Bose, Dr. D. Banerji, Dr. Raj Arole, Dr. Shanti Ghosh,
Dr. N.S. Deodhar, Dr. Darshan Shankar, Dr. H. Sudarshan,
and Dr. Bhaskar Ray Chaudhri.
I HCALTH IS NOT €V€RVTHING i
I BUT CVCRVTHING IS NOTHING I
I
WITHOUT HCRLTH
I
L
J
Members of the independent Commission on Health in India
Mr. Alok Mukhopadhyay (Convenor): Executive Director, Voluntary Health Association of India.
Former Country Director OXFAM. He has made a significant contribution towards promoting voluntary
action in the South Asian Region.
Mr. R. Srinivasan: Former Secretary, Ministry of Health and Family Welfare, Government of India and
former Chairman of the Board, World Health Organization, Geneva.
Dr. Balu Shankaran: Famous Orthopedic Surgeon and former Director General, Health Services,
Government of India and Consultant to the World Health Organization.
Dr. Harcharan Singh: Former Health Advisor, Planning Commission, Government of India and
Consultant to World Health Organization in Nepal. Presently Consultant to various national and
international health projects.
Prof.Ashish Bose: Honorary Professoratthe Institute of Economic Growth and formerly Jawaharlal
Nehru Fellow. Former member of National Commission on Urbanization and Advisory Council
monitoring the 20 point programme.
Dr. D. Banerjee: Professor (Emeritus), Centre for Social Medicine and Community Health, Jawaharlal
Nehru University. Eminent Public Health Scientistand author of numerous well-known books. Known
for his life-time contribution to Social medicine, particularly in the field of Tuberculosis and Family
Planning.
Dr. Raj Arole: Magsasay award winner, known for his outstanding contribution to rural health through the
Comprehensive Rural Health Project, Jamkhed in Maharashtra.
Dr. Shanti Ghosh: Eminent Pediatrician and former Professor of Paediatrics at Safdarjung Hospital,
Delhi. Advisorand Consultant to World Health Organization and other international agencies.
Dr. N.S. Deodhar: Former Director, All India of Public Health and Hygiene, Calcutta and Addl. Director
General, Health Services, Government of India. Currently Consultant to various national and interna
tional health projects.
Dr. Darshan Shankar: Director of the Academy of Development Sciences at Karjat and is one of the
founders of Lok Swasthya Parampara Samvardhan Samiti and Foundation for Revitalization of Local
Health Traditions. Known for his contributions for the revitalization of traditional health systems of India.
Dr.H.Sudarshan: Vice-President, Voluntary Health Association of India and recipient of the 'Right
Livelihood Award’ for his outstanding work in the tribal regions of Karnataka.
Prof. Bhaskar Ray Chaudhry: Noted Neuro Surgeon; former President, Indian Medical Association and
former Vice-Chancellor, Calcutta University.
Dr. Almas Ali (Member Secretary): Has been involved for almost two decades in social research on
health issues, particularly those issues pertaining to the tribals and weaker sections of society.
Associated with a number of developmental projects and organisations throughoutthe country.
Associates
Community Health Cell, Bangalore
Gramin Vikas Vigyan Samiti, Jodhpur
Centre for Enquiry into Health and Allied Themes,
Bombay
Lok Jagriti Kendra, Bihar
Self-Employed Women’s Association, Ahmedabad
Medico Friends Circle, Bombay
Center For Development Studies, Trivandrum
Foundation for the Revitalisation of Local Health
Traditions, Bangalore
Jagruti, Orissa
VHAI (Delhi and North East Offfices)
State VHAs: Uttar Pradesh, Himachal Pradesh,
Tripura, Assam, Orissa, Bihar, Madhya
Pradesh, Delhi, Karnataka and Other State
VHAs.
Vivekananda Gramin Kalyan Kendra, Mysore
Dr. S. P.Tare
Dr. N.K. Sinha
Dr. Hamza Thayyil
Dr. Srinivas Murthy
Dr. Saramma Thomas Mathai
Dr. Sanjay Ghose
Dr. Bharat Jhunjhunwala
Mr. Thomas Mathai
Dr. P.V.Unnikrishnan
Mr. N. M. Mathew
Dr. AliBaquer
Dr. Mira Shiva
Mr. TaposhRoy
Ms. Manila Jose
Ms. Christina de Sa
Mr. Indu Prakash Singh
Ms. Nilina Mitra
Ms. Bhavna Banati
Ms. Chandra Kannipiram
Dr. Sanjay Kapur
Dr. P.N.Sehgal
Ms. Asheena Khalak-Dina
and many others
H p iJ
EDUCATION POLICY FOR HEALTH SCIENCES
A statement of shared concern and evolving collectivity
COMMUNITY HEALTH TRAINERS DIALOGUE
OCTOBER 1991
Preamble
We,, the. pa^ttctpant^
the, Comm'j.ntty He,atth Tfiatne.n.6
VtatoQue, sie.p'ie.Ae.nttng Commiintty He.atth and Pe.veZopne.nt
t^iatne.^, ne.tu)o^h6 and coosidtnattng age.ncte.6 avid fac-LLtty
meinbe,^
medtcat eoUe.ge.6 tn the. votantaiy he.atth ~6 e.atok
havtng n.e.^te.cte.d on the, he,y compone.nt-6 o^ the, Nattonat
He.a£th Pottoy, the. >ie,po>it6 ofc the, van.tou.6 aommttte.e.6
tnctadtng the. Nattonat Edacatton Pottcy fcon. He.atth
Sct.e.nce.6 a6 fcoand tn the. Eajaj Pe,pon.t (7 989) ;
havtng eon6tde.n.e,d the, ne,e,d fcon. change, tn Edacatton
fcoK He,a£th tn vtew ofc oua goatt and tn the. conte.x.t
ofc he.at.th and commantty de.vet.opnie.nt; he.atth and cuttuAe.;
human poweA de.vetopme.nt; t^iatntng 6t^ate.gte.6; e,dacatton
ofc t^iatne.^ and the. app^oache,* to adopt at att>o the,
me.chant6m6 ofc tmpteme.ntatton ;
have. <wiZve.d at ZAe. ^oZZocuZng concZitdZoni aZ ZAe. me.e.ZZng
hzZd on October 3-5, 199 7 aZ BangccZo^e,,
NEED FOR CHANGE
The socio-economic, political
and
cultural
situation
in
our country has resulted in the declining health of the
majority of our people who are poor and marginalised,
especially the women and children among them.
Various factors including the increasing commercialisation of the health care system,
with the tendency to transfer governmental responsi
bility to privatised, profit-oriented sector ;
increasing use of inappropriate capital intensive
sophisticated technology and high cost services ;
2
limited, available resources for health care ;
the disregard of priorities ;
the use of English to the exclusion of local languages as medium
of training and instruction, with a consequent shortage of
competent health workers ;
lopsided health human power development policy in production,
distribution and utilisation in the health sector, not linked
to need ;
the destructive impact of modernisation on culture and health;
the orientation of health care more in terms of disease than
of health ;
the dominant influence of
and values in health care ;
Western
and
consumerist
practices
and the lack of a holistic approach ;
indicate an urgent need
for change in our policy for education for
health.
GOALS
Considering the goal of Health for All the policy for Education for
Health must
see health as a constituent part of human development and as
an integral instrument of building a just and equitable society;
aim at building up and sustaining a health system that
is people oriented,
problems in health;
helping the people to cope with their
*
is available and accessible preferentially to the
sector;
*
strives to enable and empower them to participate in their
own health care by sharing in decision making, control,f: inaneing
and evaluation with regard to their choice of health system;
*
is in consonance with the culture and traditional practices,
when these are constructive and beneficial;
*
uses the resources better,
serves the people.
poorest
with appropriate technology which
3
HEALTH AND COMMUNITY DEVELOPMENT
The increasing recognition of the interaction between health and
community development should be reflected in proportionately adequate
budgetary allocation for health. Given the resource crunch, the
priority needs of the majority of our people must be focussed on.
While we see a gradual shift already taking place from hospital and
dispensary to the community, we need to go still further in our
progress from curative to promotive and community health, through
awareness
building and participation in decision making by the
members of the community.
All health and development workers together with
work as a team.
the
people
must
In this sharing process, care must be taken not to put too much of
a load on the primary community level workers.
HEALTH SYSTEMS AND PRACTICES
There is a plurality of health systems and practices in our country,
many of which have their roots in our ancient past, These systems
are to be recognised for their specific strengths and limitations,
and to be nurtured as a valuable and effective heritage,
A greater
and more sustained effort must be made to study and understand these
systems and their specific relation to the various needs of the people.
There is also a complexity of health service systems in operation
viz. governmental, private and voluntary. These systems must be
decentralised to the extent possible with greater accountability
to the people.
HEALTH HUMANPOWER DEVELOPMENT
The present context of education and training needs to be reviewed.
What is useful should be retained and what is inappropriate should
be removed. The contents of all levels should also include the study
of ethics and values, behavioural and social sciences, management,
economics of health and ecology.
There is need for the creation of a body of knowledge and skills
that are locally relevant and for the building of proper attitude.
4
The capacity of people to cope with, and the
take for their health is to be recognised.
responsibility
they
Health Personnel
Different grades of workers are needed at different levels of health
care and they must include
a.
the group of people at the community level, including
voluntary, quasi-governmental governmental health workers,
teachers and others; and
b.
the doctors, nurses, dental surgeons, allied health professionals
technicians and others of similar category.
the
the
There is need for an optimum mix of the different categories, both
quantitative and qualitative, with priority for the health workers
at the community level.
Health teams
The training should be such as to enable the members to work as a
team for the health of the people.
Continuing Education
Continuing education should enable even the most remotely situated
worker to benefit from it.
This may be achieved by distance and
other methods of learning.
The focus must mainly be on social goals,
knowledge, skills and attitudes.
in
addition
to
needed
TRAINING STRATEGIES
Education for health should be community-oriented and people-based
so that the health professional/worker is able to equip and enable
the people to cope with their health problems.
Competence based learning
The health personnel at differentlevels should be trained with appro
priate
skills attitudes and knowledge to function effectively in
the area of work, encouraging competence based learning.
Opportunities should be provided for learning outside the training
institution or organisation in the health care delivery system at
various levels. One way of achieving this objectives will be through
the greater use of electives in the community with government and
voluntary health and development projects.
5
Value orientation
The training programmes at all levels should lay emphasis on values
and ethics including conduct and relationships at the personal level
and right to health and distributive justice at the social level.
Health and Culture
All training programmes should take into consideration the way of
life of the people and their practices, learn from it and build on
it. Both trainers and trainees must approach
this area with an
attitude of learning.
Governmental and non-governmental programmes
It is the primary responsibility of the government to provide health
care services, while the voluntary (NGO) sector also has its increasing
role.
To achieve the optimum mix, with respect to numbers, types
and qualities of health
workers and effective training programmes,
all efforts should be made to have interaction between governmental
and non-governmental sectors, learning from and supportive of each
others' efforts.
Systems of Health Care and Medicine
All training programmes must take into consideration peoples'
culture.
health
Whatever be the focus of the system of health care .and medicine,
in a training programme, there is need for generating awareness of
the plurality of health systems and traditions in the country and
encourage a healthy respect for all systems.
Evaluation
All training programmes should be evaluated for their effectiveness
to achieve their goals, including their cost
effectiveness.
The
process of evaluation should encourage
evaluation by the trainees
and the people themselves.
Training of trainers
There is need for improving training of trainers for community based,
people-oriented health care.
The trainers should be role models
for the trainees. For all formal courses, the trainers should devote
their full-time for the training.
Methodologies of training
Different methodologies of learning and training, appropriate to
the situation should be used. To the extent possible, all training
should be more experimental.
6
Innovative Programmes
To meet the requirements of Health for All innovative training
programmes should be encouraged and supported, whether in the governmental or voluntary sectors. National institutes set up to function
as torch bearers of innovation should be accountable to the people
in this role.
Networking of individuals/institutions involved in promoting relevant
Innovations in training should be encouraged and strengthened.
TAZi statement
&h.aM.d conc^n and an QAJoZvZng aoJULzatlvi-ty amongst
at Zb aZAo the. begtnntng ofi a p^oce.66 ofi wosdztng toge.th.eA towa^dA
the. e.votatton
Auch an e.dacattonat pottcy tn he.atth AQte.nc.e.6 tceApon6tve. to the. ne.e.dA ofa the. ta/ige. majoitty o^ oua pe.opte. - the. pool
and maigtnatt^e.d. We. at^o le.-botoe. that battdtng on oai own tndtvtdaat/
pioje.Q.t/piogiamme./tn6tttu.ttonat e.xpe.ite.nce.6 we. 6hatt woik toge.the.1,
tobbytng ^oi the,Ae. change.* and new dtie.ctt.on* tn tiatntng ofi hcatth
hamanpowe.1 tn the coantiy.
Rajaratnam Abel
Dara S. Amar
D.Banerj i
Pramesh Bhatnagar
Sara Bhattacharji
V.Benjamin
P.G.Vijaya Sherry Chand
Darleena David
Sujatha de Magry
Desmond A.D’Abreo
Margaret D’Abreo
C.M.Francis
Ulhas Jajoo
George Joseph
Mani Kalliath
Daleep S.Mukarji
Dhruv Mankad
Jose Melettukochyil
Thelma Narayan
Ravi Narayan
K.Pappu
P.Ramachandran
Amla Rama Rao
Sukant Singh
Sathish Samuel
Shirdi Prasad Tekur
Reynold Washington
P. Zachariah
*** **
H f>- I.
AGENDA ITEM No. 1
DRAFT HEALTH POLICY
1999
r
i
?
I
g
V
p
5i
GOVERNMENT OF INDIA
MINISTRY OF HEALTH & FAMILY WELFARE
NEW DELHI
—.. H, i
Auaatf•»,Aattfjx
’1*^1___
DRAFT HEALTH POLICY
COiNTENTS
Subject
1.
INTRODUCTION
2.
HEALTH CARE INFRASTRUCTURE
Rural Health Services
Organizational Structure of the Health Services
Urban Health
3.
ENVIRONMENTAL HEALTH AND SANITATION
Health Risk Assessments and Public Health Institutions
Hospital Waste Management
Nutrition
4.
CONTROL AND PREVENTION OF NON-COMMUNICABLE
DISEASES AND EMHASIS ON OCCUPATIONAL HEALTH
Control of Blindness and Restoration of Vision
National Cancer Control Programme (NCD)
Special problems of Person-; with Disabilities
6.
DRUG POLICY AND PRESCRIPTION PRACTICE
Vaccines
7.
8.
9.
1
-D
4
4
5
5
COMMUNICABLE DISEASES
Tuberculosis
Leprosy
AIDS Control Policy (In Summary)
Draft National Blood Policy (In Summary)
Malaria
Filariasis
Dengue
o.
Page No.
PREVENTION OF FOOD ADULTERATION
trauma and emergency services
INTERSECTORAL coordination
6
7
7
7
S
S
8
8
9
9
10
10
11
health cake fok special groups
11
Healih of Women
Health Care of Children
Elderly persons
Mental Health
Dental Health
11
11
12
12
12
SYSTEMS SUPPORT FOR HEALTH SERVICES
12
Voluntary Sector in Health Care
Hcal’.h Finance
Relevant Technology
Health Management Information Systems
12
13
13
13
PRIVATE HEALTH SECTOR
14
Regulatory measures for Private Nursing Homes and Hospitals
Social responsibility of Industry
14
15
MEDICAL EDUCATION
15
Policy Objectives
Assessment of availability and need of medical manpower
Increasing availability of medical manpower in rural areas
Restructuring of the Professional Councils
Manpower Planning for Dentists and Para-Prof°ssionais
Human Resource Development
Fees and Resource Mobilisation
15
15
15
15
16
16
16
14.
HEALTH INSURANCE
17
15.
MEDICAL INDUSTRY :
17
16.
MEDICAL RESEARCH
17
17.
PRIORITIES FOR HEALTH PROMOTION
IN THE 21ST CENTURY
18
POLICY ON INDIAN SYSTEMS OF MEDICINE
AND HOMOEOPATHY
18
SHORT AND MEDIUM TERM GOALS UNDER
THE HEALTH POLICY 1999
20
10.
IL
12.
13.
18.
19.
draft health policy
1.
INTRODUCTION
1.1
Health is one of the core elements that determines human development and progress. To c.ve a long and
healthy life is among the most critical options that human development offers to people Health is an
indicator of well-being that has direct implications not only for quality of life but also indirect implications
for productivity and economic gain. It is for this reason that every country has considered :he promotion
of good health among its people a cherished goal.
1.2
While on the one hand the country has the capability to perform the most sophisticated medical procedures,
morbidities requiiing simple, low cost interventions have daunted health planners. Experience in some other
countries has shown that even without a significant increase in per capita income, it is possicie to raise the
health status by pursuing appropriate policies.
1.3
Liberalisation of the economy and reduction in trade barriers have widened the possibilities for investment
in health. While the private sector has been able to take advantage of these developments, the public health
system has to grapple with increasing pressure from growing numbers and high expectations. Against this
background the Health Policy has to aim to create not only structures that ensure basic health needs but also
to see that there are a range of alternatives available to ensure that limited resources are targeted effectively.
1.4
The National Health Policy 1983. reflected the Nation’s commitment to provide universal access to primary
health care services. It stressed the need to link health services with health related activities such as nutrition,
drinking water and sanitation. The active involvement of voluntary organisations in the health sector was
sought to be encouraged. The regular supply of essential drugs and vaccines, delivery of good quality health
and family planning services and establishment of training and medical research facilities were accorded
priority. After a period of consolidation of the infrastructure, India embarked on several disease control
programmes for AIDS, Leprosy, TB, Blindness and Malaria and also began availing of external assistance
through the World Bank and bilateral agencies. The experience in implementing these projects and relying
largely on the infrastructure established earlier has been varied.
1.5
The impact of the Health Policy can be viewed with some satisfaction.
1.6
The crude birth rate (CBR) has declined from 33.7 in 1983 to 27.2 in 1997 which amounts to an annual
decline of 0.43 per year. The infant mortality rate has come down from a level of 105 in 1983 to 71 in 1997.
The crude death rate has declined from 11.9 in 1983 to 8.9 in 1997. Life expectancy at birth for men has
gone up from 55.6 years in 1981-86 to 62.8 in 1996; for women from 56.4 in 1981-86 to 64.2 in 1996. The
total fertility rate (TFR) has declined from 4.5 in 1983 to 3.5 in 1995 (desired level of TFR is 2.1 in 2010).
1.7
The success on the Immunization front has been another notable achievement. 96% coverage has been
achieved in respect of BCG. The level of Measles immunization which was only 4% in 1985-86 has
increased to 83% in 1997-98. The DPT coverage which was 41% in 1985-86 has gone upto 90% in 199798 and TT for pregnant women from 40% in 1985-86 to 80% in 1997-98. The most outstanding achievement
which has been acknowledged world wide has been the pulse polio programme through which zero incidence
is expected to be achieved in 2000. A wide network of primary health centres and sub-centres has been
established throughout the country. The incidence of leprosy was brought down from 57 to 5 per 10,000,
with eradication achieved in three States. The rest of the country is set to meet eradication status in the next
three years. I hc_ transmission of guincaworm infestation has been successfully interrupted in endemic
villages and certification has been sought from WHO’s International Commission confirming eradication of
I
the disease. The j
programme :or control of Cataract blindness has made an effective dent cn the prevalence
and incidence of senile cataract which
---- 1 was a huge problem in (he country.
1.8
***
,nh7 hoid ... .. .
-
or mob*, ouce rtarrb, ,o |„..e tee7e„d“*d md',’r ‘'""“S'"" °f dis“ likt l’l"S“- *"SU(
reflxintt of priorities and formulation of
’
i "n
Pat'tlS and AIDS aavc necessitatec
production water supply aXainkation moTT ' i'
SUbstantial illves“-’ts
4 area of fooc
deficiencies, contaminated w/-.r d Z
, 7
morta '^v continue to be exacerbated by nutritional
increase in life expectancy andlha^inXU M'7
^“h'31 POl,Uti°n- At the same linK
communicable diseases like cncer^l 7
>
' C°atrlbuted tOwards the Srowing Xence of nonmst.tut.onal care
' d,abCteS’ Cardl°-vascular ad™nts, generating a massive demand for
1.9
““'7,"" ln
““ ““ 'W ^-opumal
number of boepi.als a„d beds bo„, in lhe
'S
appropriate manpower dia^nosrir nnd
p
stcior, sonic or them lack
at places with the states wh *‘ JoX Z ZTi
T Inter'State
haVe widened
burden of disease caused bv e vZ
, T'
'^’H2 1116 WeakeSt illfrast™^- The emerging
responsibility so far targeted mainly to coXtt
T0?16™
accentuated tlle border ’
teiologica advances manv o he e ha2 b S
Altl’0Ugh
haVe beei’ ■Several
awarene; amon. the Zp e a a oZno
t
n’0St °f
POpUial,°n dUC t0 lack of resol'rc^
=
people as also ignorance about services that they can rightfully claim.
.10
not only to fulfil the Constitutional nro ' ' Z partlCIPatl0n of the PeoPle- Decentralization is required ■
and responsive to the needs of the loca 'co'
Xr
‘’““b
SCrViCCS 'l10re efficient
secondary and tertiary levels of hmltl
muni Yeferral systems and linkages between primary,
extended to entitled patients to receive
^’eaZev'
1.11
Xounu'TVT Z'10 T r°f na,TowinS 'Wr-state disparities-and differentials in health indices acre
flexibility in the planning procXso ZXoor^d
Success will lie in the abilfty tZestructure th e ,
2.
Sub-districts wiIi n«d
recillil'c"’c”‘s
view.
HEALTH CARE INFRASTRUCTURE
Rural Health Services
2.1
aad PrimaD health centres are fully operational
anrttlX'aXvZTpoor clientele1?
i > .
D 3 p00r cl,LnteIe due to locational disadvantage closed down The
nr rho
community health centre level wifi need to be filled by re-structuring the existing block level PHCs. Taluk
7
cc
and Sub-divisional hospitals by utilizing the funds earmarked under the Basic Minimum Services nackaae
The current approach of allocating more funds to constnict buildings for primary health centres and sub
centres, and expanding the requirements of health workers, will need to be supplemented with a system that
improves access to health for the unreached sections of the population. This would include making adequate
provision for essential equipment, drugs and consumables relative to the level of facility, addressing the
problem of absenteeism of staff, poor maintenance and ineficiency caused by poor supervision. This Stalls
for a restructuring of the primary' health care system with adequate autonomy, funds and authority to
discharge essential medical and public health functions.
w
e
d
d
:1
r
Organizational Structure of the Health Services
2.2
The integration of vertical programmes including family planning, reproductive and child health and disease
control into a viable synthesis will be promoted so that the infrastruemre can be used to optimal advantage.
The process of integration will be addressed from the Ministry of Health & Family Welfare at the Centre
through the States with a view to enhancing the output and cost-effectiveness of programmes. At the village
level, the duties and functions or all health staff implementing the health programmes would be made
available to Panchayats and villagers, to enable them to demand services and draw attention to the o-aps
which exist at each facility. Encouragement would be given to handing over the management'and
administrative control of the primary health centres to Zilla Parishads where they exist and of the sub-centres
to the panchayats.
2.3
The adoption of a decentralised recruitment policy for filling vacancies of doctors in rural areas and the
introduction of an element of limited compulsory rural service appears to be warranted by the current trend
of doctors seeking to work only in urban and peri-urban settings. The local recruitment of doctors, if
necessary on a pan-time basis, will be permitted. The possibility of sub-centres, PHCs and district hosoitals
being run in an autonomous fashion with the involvement of industrial establishments, cooperatives, religious
and charitable institutions will be explored. Local practitioners will be permitted to pay rent and practice
in the PHCs after OPD hours. In order to encourage in-service doctors to function in rural areas, a
percentage of the post-graduate seats would need to be reserved for in-service medical officers and the
eligibility condition for joining post-graduate courses for in-service doctors linked with completion of rural
postings. In the States where there is a serious and continuous shortage of doctors in rural institutions, the
possibility of posting upgraded paramedics will be given serious consideration. This strategy has improved
health outcomes in other countnes and can be tried selectively depending on situational requirements.
n4
TlhLn^d f°r establtshlnS a senlor focal Point at the district level for health, family welfare and women and
child development schemes has been recognized. The States would be encouraged to set up a district based
hierarchy for overseeing the implementation of national programmes and public health functions.
2.5
Health, physiology and hygiene would be introduced as compulsory subjects at the primary, secondary and
-h^h school levels with students being used actively to disseminate messages on preventive measures and
ealth promotion. This offers immense possibilities for information dissemination, which undertaken in a
coherent and coordinated manner, could bring about changes in behaviour patterns and help inculcate a health
seeking attitude.
Ikban Health
2.6
Unlike the rural health services, there have not been any structured efforts to provide primary, secondary
an tertiary care services in geographically delineated areas in the urban sector. As a result, either
insubstantial utilisation of urban health centres has taken place or there has been a overcrowding at the
secon ary and tertiary care hospitals. As a direct result of urbanization, there has been a spread of urban
s urns w ic axe inadequate access to basic health facilities. The possibility of mobilizing resources from
3
!
l
i
mdustrial enterprises, private health care institutions and voluntary organizations would be explored and <’iven
a lair Ir.aL fhe essent.a! serv.ces wouhl need to include medical and surgical services inc|uSC eve
EN1 car , obs etric care ana new-born care and child health; counselling for reproductive htZ a d
contraception; dental serv.ces; emergency and trauma care; and prevention and contro of ccmmunica
a d
non-commumcable diseases Wherever feasible, instead of setting up new infrastructure, eZ wo d e
I
!
Z cZy
'bTr and V°,Untary SeCt°rS '0
baS‘C —
particu arly necessary in the case of urban slums which have become a cause for overwhelming COncem
where the people for lack of timely primary health care eventually become a burden on the city hospitals.
i
3.
ENVIRONMENTAL HEALTH AND SANITATION
3.1
Environmental factors (in panicular, drinking water and sanitation) play a crucial role i
in influencing
morbidity and mortality, apart from nutrition and'the income level of the people.
3.2
The need to advocate the improvement of drainage, sullage and solid waste management would be made a
i
^bSblefor th^hi^h JX of'Z
dZZSZ
l
i
related and water-borne diseases in ninl nrAnc nnd
f• c
, 6 P^-aience or soili urban
in rural areas and the spread of infection in
and peri-urban areas.
(
3.3
Altta,Sl, .1.0 availabilily of drinking „.er has ineroased sabs.aa.ially and the
f„r dorining
dis.ancc
W r n I?
W 7 S0UrCe nave been reV1Sed’ people continue t0 obtain water from uns^ water sources
» ataS
r“k »f
gi,e"
“”d
to alert the community about the consequence of drinking unsafe water.
3.4
The population at large would be given practical knowledge about personal hygiene, health hazards and the
met od of promotmg and maintaining good health in all aspects. The traditional pillars of health care
gu ar habits, health education, yoga, dietary practices, food safety, civic values, home treatment for minor
ailments and injuries etc. would be reinforced.
3.5
The notification and early reporting of designated communicable, occupational and other diseases will be
made mandatory and suppression of data made punishable.
Health Risk Assessments and Public Health Institutions
3.6
Given ll.e accelemed pace of indostrialisauon, environmental hazards would need to be addressed at th
P u„„.„g stage ttself. Before the eons,ruction of new factories, railway lines, power plants dams min s or
one quarries .s taken up. a health impact assessment study would be mar.dmed to be calrmd o« and
ends tor addressing the emerging heakh risks provided for during rhe formulu.ion of rhe proiem ro co e
the .mplememurion and mamtenance phases. There is an immediate need io substantially smeoeihen hexisting public health institutions and regional and Slate laboratories. Essential public health'funciio’ns which
address prevent™ health care, immunization, establishing a rapid public health response sysrum Xe« ve
P" " f Tk' “'’“'V “ "nderat' laboratory analysis ar the district level, the availability of reagents and
heakh i-untao: ”* ™“’S
b'
essX^We
3.7
Die epidemiological and entomological capacity at the district level would be strengthened-by covering the
V 10 e coun ry t iroug a disease surveillance programme aimed at proper networking of'public health
ins itutions laboratories and trained health personnel so that a syndromic approach to disease outbreaks can
be adopted. Without the involvement of the private sector, the basis for epidemiological inteZence and
surveillance .nay remam undependable and unrepresentative. The best practices available globally would
4
be accessed and a model suitable tor Indian conditions introt need in order to build a reliable epidemiological
base to plan public health initiatives.
jjos;pital Waste Management
3.8
All hospitals in the country whether in the Government or Private Sector are now required by law to initiate
an appropriate hospital waste management system. Each h jspital would have an infection Control and Waste
Management Committee to devise policies and segregation of waste and infection control. The provision of
incinerators/appropriate method of waste disposal to be installed in hospitals having more than 50 beds would
be monitored. The establishment of common incineration facilities would be encouraged. The enforcement
of the law would be undertaken by involving the public in o^ .rseeing compliance and reporting shortcomings.
Nutrition
3.9
Food and nutrition security for the vulnerable section of the society would be viewed not only as issues
concerning the science of nutririon but would be rela ed to the right to work, the right to health, the right
to education and the right to information, all of whic i are dependent on a healthy state of mind and body.
Within the overall ambit of the National Nutrition Policy, priority has to be assigned to the equitable
distribution of food to all including women and girl. Pregnant women and nursing mothers constitute one
of the most important target groups particularly as investment in their health and nutrition directly affects
the birth weight of new bom children and their development. Ti e need to start complementary' feeding at
six months and for tackling mainourishment in the under 5 age gr up are two more interventions which need
to be augmented where critical gaps continue to persist.
3.10 The lack of iron and iodine intake also need to be given reinformed attention. Micronutrient malnutrition
is not confined to India but is accepted as a global problem. Investment in assessing the magnitude of iron.
Vit-A and iodine deficiency with sustained intervention strategies to improve dietary intake of micronutrients
will be provided for within sectoral allocations.
3.11
People’s.own responsibility for their health at the level of the individual and the family would be given
appropriate focus. Imparting health nutrition education in terms of knowledge as well as practice will be
given a major thrust to help people overcome the aggressive marketing of consumer goods and sendees often
injurious to health.
COMMUNIC/VBLE DISEASES
4.1
The health status of a people is determined among other things by the availability of safe drinking water,
sanitary disposal of human waste and other wastes, adequate nutrition, literacy levels, educational attainment
and the status of women. Health outcomes are mostly the result of activities and policies that fall outside
the health sector: agricultural output and food production, poverty alleviation programmes in the area of rural
employment, education and social welfare, housing, water supply and sanitation etc. Health outcomes are
also dependent upon non programmatic initiatives such as governance and the capacity or the regulatory
systems to enforce the rule of law related to food adulterate -n, maintenance of prescribed standards in the
manufacture and sale of drugs. An integrated and multisc c:oral approach is essential for implementing
health programmes which would have a direct impact on the disease profile.
■ Tuberculosis
. 4.2
Tuberculosis remains one of India’s most serious health problems and has been identified as one of the
hot-spots for multi-drug resistance. It is estimated that there are 5,00,000 deaths per year trom tuberculosis
5
in the country - more than 1,000 every day, 1 every minute. The Revised National Tuberculosis Control
Programme (RNICP) is being expanded in a phased manner across the country. In the next 10 years, the
challenge lor prevention and control of tuberculosis will be to implement RNTCP throng ■'.out the country
while ensuring high quality or service delivery. For this to happen, the capability of uncertaking quality 1
diagnosis will be upgraded through the provision of essential equipment. Increased access to quality
microscopy services, uninterrupted drug supply,’directly observed treatment at a place ernvenient to the
patient, and the introduction of new reporting system will be implemented countrywide. In addition, •
HIV-associated tuberculosis is likely to increase in the coming years and could greatly increase the burden
of tuberculosis in the country. Therefore, new strategies will be introduced to reduce the burden of
HIV-associated tuberculosis. ‘
j
Leprosy
4.3
With a significant decline in the number of leprosy patients due to effective cure with muiti-drtig therapy,
it is expected that leprosy will be eliminated in most of the States/UTs by end of year 20CC: the remaining
States may take up to year 200?. The present trategy of detecting hidden cases and treating them with MDT
will continue. Efforts would be made for pi >per integration of leprosy services with general health care
paiticuiaily for ulcer care and attention to the problems of disabilities. The need for socio-economic
rehabilitation of leprosy cured persons having disability beyond grade 11 will be given priority.
AIDS Control Policy (In Summary)
4.4
The problem of AIDS is a public health challenge and will continue to be treated as a matter of great
urgency calling for commitment, effective implementation of the programme, provision of7 accurate
information and education to make people aware of the need to protect themselves from HIX’ infection. The
State will introduce a helpful and supportive social environment so that people who suspect themselves to
be infected can come forward for voluntary testing and for seeking help so that they can live peacefully with
other members of the society. Special efforts would be made to remove fear psychosis from the minds of
people and prevent discrimination and stigmatisation. While a separate AIDS Control Policy is under
formulation the notable elements would include:
Development of a rstrong ownership of the HIV/AIDS Prevention and Control Programme by the Centre and
Stale Governments.
Stiong advocacy and social mobilisation from the top most level in government to ensure the spread of the
message throughout the country' with full cooperation of NGOs and Community Based Organisations.
Promotion of low cost care to people living with HIV and AIDS without any discrimination and
stigmatization. This would include encouraging systematic attempts to create homes for people with AIDS
who may no longer be able to live with their families.
*
*
. Promotion of management of Sexually Transmitted Diseases (STDs) throughh a syndromic approach.
Expansion of targeted intervention s!
''-gies for high risk groups of the population.
Reduction in transmission of HI'efforts to increase voluntary bloo .
d by transfusion of blood and blood products by mobilisation of
:on and screening of blood.
*
Strengthening the effectiveness of
'ogrammc through technical, managerial and financial support.
+.
Expansion of SF1/HIV/AIDS sentinel surveillance and operational research programmes.
*
6
rol
he
Inter-sectoral and cross-sectoral collaboration with the public, private, corporate sectors t
o involve citizens
in responding to the problem of HIV/AIDS.
‘tv
ty
ty
he
n,
:n
*
A sizeable research effort would be launched to develop drugs, vaccines and testing kits in a time bound
manner.
Draft National Blood Policy (In Summary)
Jt
4.5
r
The recent Supreme Court judgement on Revamping of Blood Transfusion Services has brought into focus
the urgent need for streamlining and managing the blood transfusion services in the country. The mandatory
licensing of Blood Banks, the elimination of the professional donor system and the revision of Drugs and
Cosmetics Rules to prescribe standard practices have already been introduced. Government’s commitment
to make adequate and safe blood and blood products available will be reinforced. A separate National Blood
Policy which has been formulated would set out the guidelines and directions for better mamgement of blood
transfusion services, giving meaningful encouragement to blood donation, expansion of bleed separation and
component facilities, phased indigenisation of blood bank equipment and testing kits and emphasis on
biosafety measures as they relate to safe blood. Screening of blood would also include HCV alongwith
the existing four diseases already being screened.
Malaria
4.6
The ongoing programme with 100 percent Central assistance in the seven North-Eastern States and the tribal
districts of the country where the prevalence of P.falciparum malaria is high, will be continued. The
enhanced malaria control programme will also be implemented in all districts, cities and towns having a •
rising slide-positivity rate and in areas where there have been focal outbreaks of malaria Ln previous years.
The main components would include early diagnosis and. prompt treatment through strengthening of active
and passive surveillance; laboratory diagnosis; selective vector control by integrating various sector control
approaches; promotion of personal protection methods; prediction, early detection and effective response to
malaria outbreaks; and intensified information, education and communication campaigns. The involvement
of the community in die prevention and control of malaria will be given the strongest emhasis with the aim
of eliminating mosquito breeding through people’s participation.
Filariasis
4.7
During the Ninth Plan, the strategy for filariasis control would include single dose DEC mass therapy
to be introduced in a phased manner to eventually become a National Programme. Vector control
measures, detection and treatment of microfilaria carriers, and treatment of acute and chronic filariasis
would continue.
Dengue
4.8
For the containment of dengue, efforts will be made to establish an organised system of surveillance and
monitoring, strengthening facilities for early diagnosis and prompt treatment; and intensification of IEC
efforts to ensure that all households implement peri-domestic measures to reduce the breedLng of Aedes. The
adoption and enforcement of urban bye-laws will be pursued so that those responsible for creating breeding
Orounds for mosquitoes are made accountable for the same. A Dengue Control Programme would be
introduced to cover the high risk areas of the country.
7
I
5.
“c™?no
5.1
Life-style related diseases are at times
a concomitant outcome of increase in life expectancy as well aindustrialization, urbanization and increase in < - '
' " '
earning
capacity.
Cardiovascular
becoming major conributors to the burden of disease.The thrust
wouto be diseas
on es, cancers, diabetes art
: would
be on early prevention through
organtzed health educatton campaigns aimed at informing-----------the population
including
young
of the dangers ot rich ciets in satnntpH fnt eon j
" , .
mciuain^ caildren and /uull
v aadults
aLUU
to tobacco and alcohoi. The magnitude of the
6X0555 Calones’.absence of Physical activity and addiction
standardised surveys. National and State
f
n0,n;Ck°mmunicable diseases wccld be assessed through
prevention strategies would be developed ^Xin^'
f°r VltaI reSlstra-on- Targeted primary
interventions for both diagnosis and nrima
P = ’? min he dem0oraphic transition cost-effective
centres and rural hospitals^vill be introduced inTXsed nOn’CO^municable diseases at the primary health
aimed at creating cost-effective models suitable for rural“ionsmaJ°r
mOllnted
5.2
The health infrastructure would he
•,
• ■
,
generating data on occupational diseases and m^in'°mtOnnS|116 provis,on of occupational health care by
The tertiary and district hospitals would be expected f6
reSponsible for Prevention and treatment,
extent of morbidity caused by occupational
°f
the
0,N 0F n(w-co»imunicable diseases AND emphasis Of
i
i
!
I
i
i
5.3
products having to carrv a bold direcTwaning^f01^
j™^015 W°Uld bc introduced with all tobacco
people. The advertisement of tobacco product would b "bn
^‘7’,
inteili--ible t0 even illiterate
made a punishable offence. Tobacco education would iT ' I n I
i ’6 53,6 °f SUCh products t0 nli'iors
colleges.
LdUCat,On "°uld be "'cludad m the curricula of schools and medical
Control of Blindness and Restoration of Vision
5.4
nnplan. mgCty w„uld te smdarii2ed
5.5
„ en,p|1^?”7gl]t ”
“r"'”8
National norms would be developed for the diagnosis and
management of glaucoma at the PHC level.
National Cancer Control Programme (NCD)
5.6
point of time and approximately 0 8 million ne
~
' ■100 03563 °f cancer 10 the country at a given
Programme would
strenXeneS’ tlX h rnnZ" " reS,S,ercd
71,0 Nationa' C” Control
patients. The strategy under the prottramme
u Pr ,T’ ^Hd^ Prevention and treatment of cancer
of existing institutions and adoption of anti-tobnc/H6 U 5 103 educatlon’ early deletion, strengthening
growing incidence of cancer, special efforts would be nnTT t0
tObaCCO consumPdon. With the
—
-remely expensive^ outs^tLf
“f
Special problems of Persons \t ith Disabilities
5.7
In the new - f
1995, the seven
8
there is a loss ot sensation, or deformity causing social and physical embarrassment, hearing impairment,
locomotor disability, men ml retardation and mental illness.
5.8
With the introduction of the Prevention of Disabilities Act, 1995, centres for Rehabilitation will need to
be set up at the District Hospitals. The existing health infrastructure would be strengthened to incorporate
provisions tor the prevention of disabilities and rehabilitation of the victims. Each State and Union Territory
would ensure that PHC doctors and para-medical personnel receive training and are given orientation in the
medical aspects of rehabilitation. Strategies would need to be devised to overcome the myahs, misconceptions
and prejudices surrounding disabilities and deformities which have been a hinderar.ee in undertaking
meaningful efforts to rehabilitate the disabled and make them productive members of the community. The
recommendations of the Medical Council of India to start Physical Medicine and Rehabilitation Departments
in every medical college would be implemented.
5.9
In all poverty alleviation programmes, priority would be given to actively involve persons with disabilities.
District hospitals would be strengthened to cater to the medical rehabilitation aspects. ?HC doctors would
be sensitized to provide early and special treatment to patients with disabilities. Health and safety measures
would be promoted at the work place, home, public places and public transport.
6.
DRUG POLICY AND PRESCRIPTION PRACTICE
6.1
Within the overall framework of the Drug Policy 1994, a National Drug Authority will be established to
oversee inter-state commerce and undertake central registration of drugs.
6.2
The Proceedings of the Drugs Technical Advisory Board and its decision to withdraw hazardous drugs and
those of questionable therapeutic value will be published in relevant publications for the benefit of the
consumer. The Central Drug Control Organization would be strengthened and new Central Laboratories to
cater to Regional needs established.
6.3
The capacity to undertake drug testing would be augmented by providing additional equipment and
manpower and undertaking appropriate renovation and modernization of the laboratories. The enforcement
staff at Central and State levels would be strengthened and their capabilities enhanced through specialized
training.
(
Drug package labelling will compulsorily have to carry proper drug information and consumer warnings.
Pharmacists will be under instructions to warn consumers about side effects of drugs. The concept of Over
The Counter drugs and prescription drugs will be defined and administered through the licensing authorities.
J5.5
The essential drug list which .has already been declared for different levels of health facility will be adopted
countrywide so that there is uniformity in approach. Surveillance on patterns of drug misuse and on
monitoring of adverse drug reactions would be undertaken and reports thereof discussed at the Drug
Technical Advisory Board and published for consumer information.
6.6
The indigenous production of testing kits for Hepatitis ‘C’ and HIV/AIDS will be encouraged.
Vaccines
•6.7
The country is self-sufficient in production of all the vaccine required for National Immunization Programme
except Oral Polio and BCG Vaccines. The Polio concentrates arc imported blended, bottled and
supplied to the States. 60% requirement of BCG Vaccine is fulfilled by the indigenous production and the
rest (40%) is imported. The efforts would be continued to attain complete self-reliance in the production
of vaccines.
9
6.8
Die vaccine produc.ng Institutes in the Public Sector would be assisted to renovate and modernize theii
nri • UC I0” C‘lp‘lc,l,L> so tliat d,cy can continue to contribute in maintaining standards and containing the
Would beXoWt.zedWh o
‘'le UnivCrSal "'"’’“"‘“‘ion programme. Whenever possible, they
voutd be corporatized through joint ventures to make them function cost-effective?.-.
6.9
fhe traditional neural vaccine used in the treatment of Rabies is
very painful md at times capable of
producing neuroparalytic disorders. The indigenous production of a more
safe and receptive tissue cultureaccine wi e encou.aged and the traditional neural vaccine phased out.
6.10 Considering the threat of Yellow Fever in
the Asian Region, the production of Yellow Fever vaccine
restarted in the country will be augmented as a
precautionary measure with the surplus made available
for export.
7.
PREVENTION OF FOOD ADULTERATION
7.1
Programme boS, at the CentraJ and
Food Laboratories, training o taff
augmentation of the C-ntra! and St-£ r t
as quantitative an^ o
X
fT,1*STWOU,d -cIude establishment of new Cent ’
hn’Cnt.of
Quality Control Units at the Ports ano
“
l° Perf°rm SC”Sitive tests as
substances. The establishment of District Food Inspection Units
would be given priority.
7.2
A Naiio"a' F“d
Ito n a“C"'iOn Pn?U'arly ” and ar0“"‘i<*
2XX?
ocdvely Invoked in .be proEramn,0! M
7.3'
like
O^ations/NCOs „iU be
Q.fld"Y■??'?.uld'^explXd oJ t™'1,'"? ",r°“sl'.ll’e l"cdia “d ll" mponanee of Food Safely and
awareneas aboo, heal,!, ImaS
P
7
S,''d'"'S and NSS
• sense of
7.4
Designated courts would be established
10 see that the trial of food adulteration officers is efficacious and
swift.
8.
TRAUMA AND EMERGENCY SERVICES
8.1
The right of the citizen as <determined
’
by the Supreme Court to access emergency care in any hospital and
to receive the first line of critical
established in all hospitals runnm. a 24 h7
publ,cized- Communication and wireless links would be
running a 24 hour emergency
- be
8.2
~ ;“;heXSXe“
“Z““ Of
fc'.aid- ““
-ciden. vie,,™ ,0 ,be
high risk spots on Sonal S^waT^PlaCe’ t0
Telecommunication authorities.
8.3
a"d SP“'a,i“d M“"'
™wX^
conjunction w.th the Highway Authority of India and
dZe^Zh6 te'tia;- h?PitalS W1,iCh V°,UntCer t0 ,re:lt aCCidCnt Victi™ -
hospitals during such emergencies
"ll-ocluced to reduce the unmanageable load cast on public
10
9.
INTERSECTORAL COORDINATION
9.1
Intersectoral co-ordinatior. between relevant departments would be strengthened so that the preventive
promotive aspect of health care are integrated and propagated through the existing extension arms of the
government machinery. A close partnership between voluntary organisations, private practitioners and local
government infrastructure networks would also be developed so that the spread of health education messages
becomes a universal responsibility.
10.
HEALTH CARE FOR SPECIAL GROUPS
Health of Women
10.1
Girls start working earlier than boys, work longer and harder throughout their lives. The energy consumption
in mere survival tasks of - fetching fuel, water, fodder; care of animals; washing; cleaning which are
exclusively women’s responsibility results in a negative nutritional balance and calorie deficit. The
programmes on AIDS, STD and Family Planning would be integrated so that women can have access to all
the inputs through a single source at the primary health level. The large number of abcrtions and abortion
deaths reflect the increase in the number of inflicted, unwanted pregnancies which women have to bear. These
contribute substantially to maternal mortality. The non-availability of trained attendants for deliveries would
be corrected in a time bound manner by laying down targets for yearly achievement.
10.2 Changes in medical and nursing curriculum would be introduced to incorporate women’s health concerns.
10.3 A separate Population Policy would be announced. Hitherto, public policy has been restricted to the
reproductive health of women. There is need to broaden the framework and provide women access to other
services. This can be possible only when health care delivery is fully integrated. Health will also need to
be centred within the broader context of empowerment of women and interrelated to the overall plans and
strategies of the other related departments working for gender equity.
Health Care of Children
ir).4 The largest mortality amongst infants and children takes place under five years of age mainly on account
of low birth weight, respiratory diseases, diarrhoea, malnutrition, measles, the outcome of improper
antenatal, natal and post-natal care and premature birth.
10.5
Children are also engaged in stressful conditions in agriculture, hazardous industries, domestic jobs, etc. The
health of children has to be safeguarded through special health check-ups which will be organized in
conjunction with other activities aimed at checking child labour and uplifting the quality of life of children.
Reporting of causes of injury in the case of accidents involving children will be made mandatory so that
corrective action can be taken including the use of penal provisions where called for
10.6 The enforcement of the Child Marriage Restraints Act which will help in reducing the number of teenage
pregnancies will be given nationwide priority so that society at large is involved in preventing the illegal
marriage of girls before the age of 18.
10.7
Special attention would be given to the nutritional status of adolescent girls and pregnant women through
the Reproductive Child Health Project and the health services strengthened so that children get proper
protection and timely treatment against the common diseases of childhood.
10.8
Universal immunisation of children against vaccine preventable diseases, elimination of polio and near
e imination of Tetanus and Measles would continue to be a priority.
11
1 .1
Elderly persons
I
I
10.9
I
I
lhe concept ol geiiatric care would be introduced into hospital services al all le* els. both in urban and rur.
areas. Special ertorts would be made to address the health component of the p< iicy on aeine - particular!
introducing the p.omotion ol health giving life styles and freedom from psychosocial pioblcms as an esscnti.
component <4 care for the elderly.
Mental Health
!
I
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I
I
I
10.10 Mental illness having been included as one of the disabilities eligible lor certain benefits under the provision
on the Disability Act. 199.1. Schemes would be instituted for the rehabilitation cf the mentally ill and ilkacceptance within the community. Nervous disorders constitute the highest burden of disease and they affec
women predominantly. Anti-depressant drugs would be stocked at public sector health centres and hospital
at the sub-doisienal level and measures taken to address the social stigma attached to mental illness.
10.11 The improvement of mental hospitals and Departments of Psychiatry in general ami teachins’ hospital
in terms ol adequate stall and services will be given priority attention. Regular and adequate suppl
ol medicines required lor treatment of the mentally ill will be ensured at the district hospitals an,
health centres.
‘
10.12 The pilot community mental health programme under implementation for the primary health care level wouh
be expanded.
10.13
<u.o Existing
cx.sung niencil
menuu hospitals
nospnats would be
he selected to be npmaded
upgraded as Regional centres fur communid mental heahl
and loi standing as examples ol best practice for surrounding areas.
10.14 Departments ol Psychiatry would be created in all (he medical colleges and die menial health trainum ol
graduate medical students given fresh orientation. Mental health care would be integrated with primary healtl
care and the fetors, staff and community trained to recognize early signs of menta'l problems so that’besidetreatment and lol!ow-up of mentally ill persons are integrated with the communitv through different welfare
schemes.
10.1. The Central and State Mental Health Authorities would play an effective role in enforciiig the existing
legislations and measures would be introduced to see that every mental hospital, its wards mid inmates arc
inspected by groups of public spirited individuals who would periodically report the state of affairs to the
visitors and authorities set up under the Act.
Dental Health
10.16 Oral health would be made an integral part of the general health policy and separate Directorates established
to pursue the public health aspects ol proper dental care. Dental colleges would be asked to set aside quality
time to build student knowledge on preventive and community dentistry. The dental check tip of children
wou d be unreduced by providing linkages with dental surgeons both in the publ.c and priyate sector who
would be pmd lor services rendered on the basis of case finding.
11.
SYSTEMS SUPPORT FOR HEALTH SERVICES
1 l.l
While voluntary acencies and NCJOs have been used extensively in implementing health sector programmes
and bus would be conlinued and expanded, a forum to elicit their '.lews and to deal uh '^ei eric operational
12
problems would be established so that the interaction is meaningful and continuous and there is a formal
body to take note of ihe need for mid-term correctives. Voluntary agencies ar.d Community Based
Organisations would continue to be used for the effective implementation of National Programmes as well
as to spread health education and act as a watch dog over the provision of health services within the public
and private sectors.
Health Finance
I 1.2 The share ot public health in the expenditures of the state governments would be increased annually and
the focus would be on consolidating and improving the existing health structure and system rather than
spending on expansion of infrastructure. Facility wise list of procedures alongwith a check list of equipment,
drugs and consumables would be available at every district hospital, community centre and primary health
centre for public information. Maintenance of facilities will be separately provided for in the State and district
budgets.
11.3 There is need to have tne upper crusts of the society pay for the services. User fees or private insurance are
some of the means available for such sharing of costs. Limits will also be introduced and imposed on free
treatment facilities in Government hospitals so that citizens pay for expensive procedures and only those who
are clearly unable to pay get free or subsidised treatment. Guidelines and norms for deciding paying capacity
will be evolved limited to other economic indicators.
11.4 The need to maintain national health accounts to monitor health expenditures will be given concrete shape.
Expenditure would be reviewed activity-wise to oversee the actual returns on investment so as to introduce
timely corrective action.
. 11.5
Research and experiments would be undertaken to create financially sustainable models of free health care
for the poor in rural and urban areas.
Relevant Technology
Health Management Information Systems
11.6 Priority would be accorded to the establishment of Health Management Information Systems which are able
to identify the gaps so that resources can be assigned meaningfully. The benefits of computer technology
have so far percolated into medical colleges, research and training institutions. Small projects for data
collection at the district level, E-mail communication through the satellite and modem techniques have been
introduced on a pilot scale but their universal application is still many years away. The collection of
information in a continuous fashion to enable correctives being introduced in a timely manner will therefore
need to be achieved through the use of modem systems of data processing. While this will improve the
efficiency and effectiveness of the health care system, it will also facilitate better policy planning.
11.7 Efforts will be made for the development and testing of appropriate inexpensive technologies for
measuring weight and height to facilitate early detection of under nutrition in adults and children; in
the PHCs, self-recording instruments for measuring arterial blood pressure for use-by ANMs/male
multi-purpose workers and hand-held electronic data entry machines for ANM/MMPW will also be
introduced in a phased manner.
- 11.8
Attempts will have to be made to create a district data base on health manpower belonging to various
categories including ISM&H practitioners working for government, voluntary and private sectors so that they
can be used effectively in promoting health care through proper orientation and training.
13
12.
PRIVATE HEALTH SECTOR
12.1
miS,'teX‘l!1«nd'ta"n'S° tl“ pri“'“ SCCT ■'"d Eiv‘ 'l“'n ” 0,“-'i"S
,o deml.
eta „.ed
eT
Sn°S “
01
“ re"en,“d- Tl»" PM'"1"'
providing hi.
r„ I’
Servmg prevmus foreign exchange which would be spent in having to sei
complicated cases abroad for treatment as well as their capacity for attracting foreign client e in search
advanced med.cal care ,s recognized. None-the-less. the other side of the com repre"en d bJ t
X
of poor quality, unregulated nursing homes and clinics is also a reality
Y
Regulatory measures forPriyateNursing Homes and Hospitals
12.2
fotiliti^fo? dtff-renTfo™
f°r reg‘StratlOn Of OnIy those Private hospitals which have minimu;
t ies.tor dift.rent forms of treatment. Monitoring mechanisms would be developed to ensure that tf
>"
12.3
priv” ““ 7"““’sec"
tali'
™"Z'S a"“which ■" p°sics‘
Medical care in the private sector has so far worked in isolation without being accountable to any regulatio
or even self-regulatory mechanisms. Juxtaposed with some of the finest examples of world “ass me “
re instances ot callousness, negligence and poor quality care continue to be reported Although puuii
s itutions are beset with similar complaints, the existence of internal supervisory systems media°attentio
and parliamentary- v.g.lance, have to some extent protected the rights of L pub^c. In the absence of sue
...“tafcix':gc c:: “t’1 “c,oris a s'r“s ““,or»'»
12.4
The States will encourage the establishment of accreditation mechanisms to give a star rating to each leve
a nb
t!
'nfOirmaI,°n Wil1 bc made available d’rough Directories on medical facilities for public
the Bureau of s?
i '^i^xT m
absence of a staniJard-setting agency will sought to be filled throunl
Bureau of Standards, the Medical and Nursing Councils and the Consumer Forum workihv together°c
pro°x“
12.5
SiXS'x"without “ra'il’' pushi"s “sts op ii'r”Ih
A Council for Medical Care Standards will be established which can function as an independent regulatory
ScrbeZX
7 311 nertabl,Sh“ W1'l be required t0 fulfil the
P^!X tie
,
e cettmg clearance from the appropriate accreditation authority. Existing facilities will be -iven
m ted period-to attain such standards. The Council will grant recognition to accreditation Councils at
schmne w IMrlCt
consumer.' "
12.6
12.7
.? e1"
P0WerS t0 IeVy C'largeS f°r ^^tion and renewal. A Charter mark
being adoplcd volt"'>arily by the hospitals for the benefit and guidance of the
incentives and disincentives to make for the dispersal of medical
L neZmedical and d.! ,the';.PraCtiCe in Urban areas' They would declare a P°'icy on establishment of
eauitv The M h an^d,a°nostlc centres- —tng homes and clinics would address the concern of spatial
the ethical ■tsolctTof
'T
C°UnCilS
be enj°ined t0 play a mors effective role checking
consumers ' P
P"
P^^6 lncIudlng over Pncing and Profiteering at the cost of the ignorant
While i ’
intrnH
t,ie existing Acts and laws, an entirely new range of comprehensive regulations will be
introduced
reduced to prescribe minimum
m.mmum irequirements of qualified staff, conditions for carrying out specialized .
interventions and procedures within
‘ .
■■■•i a set of established procedures for quality assurance. Th!e maintenance
* W“
tains
14
‘’re’“Kd “ta"-™ “■’« ■
•
•
I2.S The subject of quackery would be tackled by making registration of all medical practitioners under the
relevant State laws mandatpry. Non-registered practitioners would not have a right :o practice medicine and
the judgement of the Supreme Court in respect of medical practice woulc be enforced.
Social responsibility of Industry
.
12.9 The corporate sector will be expected to respond to the challenges in the area of primary health care, as part
of community development efforts in rural and urban areas. The sector would be expected to sponsor
information and educarion programmes on health issues, using modem professional skills of advertising and
public relations, using various media as a part of this social responsibi'ity. A legislation which would seek
this mandatory service would be introduced and the funds spent on f :a th promotion included in the annual
report of each company engaging more than 100 workers.s
13.
MEDICAL EDUCATION
°olicy Objectives
13.1
Maintenance of high standards of medical education will continue to be the primary policy objective within
the overall ambit of the National Health Policy. In addition, the endeavour shall be to bridge the gap between
availability and demand for medical manpower in rural areas and to ensure that the quality of medical
education is socially relevant.
Assessment of availability and need of medical manpower
13.2 For making an assessment of the availability of medical manpower and future needs of the country it shall
be prescribed by law that all medical personnel (including dental and para-medical) shall get their registration
with the appropriate technical Council once every five years. Provision shall also be made for registration
of additional qualifications/super-specialisations in order to create a data base on manpower in various
specialities.
13.3 The existing medical and dental institutions shall be geographical! / mapped and areas of the country found
deficient in such infrastructure will be given preference for estabiis ling new facilities. Establishment of new
medical and dental colleges within the same area will be discour; ged* ad sustained availability of qualified
medical teachers made a-criteria for determining the establishment of more medical and dental colleges.
Increasing availability of medical manpower in rural areas
13.4 The recruitment of medical personnel will be decentralised and powers vested in the local bodies for making
such recruitments. Skills of para-medical personnel will be upgraded to enable them to provide basic
medicines even in the absence of a medical personnel.
Restructuring of the Professional Councils
13.5 The Councils will be restructured in order to enable them to be responsive to changing social requirements.
All States/UTs shall have Councils to represent the Medical, D mtal. Nursing and Para-medical professions
(hat are comprised of elected representatives of the concerned professional community. Efforts to weed out
unqualified medical practitioners shall be renewed. The Professional Councils would be strengthened to make
them effective in maintaining standards and encouraged to become self sufficient by raising resources through
re-registration of doctors.
15
I
13.6
While the position of the C
“«-
I
consumer groups as well
13.7
The Indian Nursin^ Council and 2
« profas,onals tm Naliora| |cvc| M.njne
~ --=
res
™l»l=ry agencies,
nurses in the absence of
13.8
There is an acute shortage '-f dt'rr H
services has largely been
\ . g aauates and post graduates.The ^rowr'-^ nf
i
preparing a cadre of dentists clXe
in high^ de'e,°P^ countrieS.P The
eld^ win ^reC0gnised by intmdtX’j^l ZoU™
13.9
Yet another r
population ratio i
r„es are req;,;x^
~
The nuluc
and technology,
to be tmparted in keeping with the growing ne ds T
theref°retraining neVd
serv.ces wtl! be given renewed attention. °
' qUal‘tat,Ve and ^“'itative expansion of nursing
T0 SSsion^ XmZr'onhl0 inf0™atl0n “^4 the pre
Councils for left-out XXo 'r
°rpresent
have stock or registered para-medical
7
gone abroad. The establishment of
deC'ara[,°n °f a
manpower production and exodus
policy for key personnel will be given'a^eetton.315
Human Resource Development
shortage of teachers.
7 — - - =— of ,„e „„c„
Special im
° en for specialisation in subjects in which there is a
AH I"d» tatac of Medical !Scie„c=s
be governed according to relevant Statutes
Research, Chandigarh would continue to’
13.13 Continuing medical education will he fnrth
be linked to attending a prescribed numbel of CMeToI
of Registration ■
shall eventually
to improve the skills of para-medical staff to enable th §ramme’ Special Programmes shall
, .
-1 be introduced
m the absence of a medical practitioner.
m Pr°V,de a basic first line of medical care even
£g£g-anOesource Mobilisation
13.14 There shall be a similar fee structure for nil
and deemed universities. The penalty for\i
, ■
lnstltlltlons ,n the private sector including univers'r'
”f MCI A« ..... .rXJ’ XSZ XZ S
16
14.
health insurance
14.1
•'1,.ere "" >« ’ S'»'™s ««d to
health insurance would largely be catering m thp
• u
J
the-less, regulatory mechamsms would S i T*^
protected. A joint forum^to formulate He^n T"
established alongwith the Insurance Regulatory Authority
14.2
rekV"t
be
Xps Td the T^would'be’ZminTd ° ThTTeTT
instead of establishing new medical centres would be considered
15.
nCl eft °Ut °f the system- While
"h0
paying CaPacit* un
°f the C°“er are
t0 C°Ver indigsnt
2
partlCUlarIy ln
areas
MEDICAL INDUSTRY
15.1
is at present »o
devices. Ws systems Xtes Zn' IT*
equipment and medical devices. There
for
• equipment and
no forum for understanding the dimension ofTuchTo^T51 iX °f
COntr°L R 3150 provides
to judge whether exemptions ouT t" h "
r P
"
the CmicaIity of lhe Praducts in order
are of life saving nature. This also
r
i,Or Spe“flC ec!ulPment, devices and consumables which
the country The0National Druo Authn
°
°f
vaccines manufactured in
seeuid “ S^X^^de^ST
—“
life-saving treatment so that
in mind
Medical devices would be brought under the purview of the Drugs
and Cosmetics Act for standard setting.
p~XT„Xe'aX“ M.J±“.”ri,S °f
•
16.
MEDICAL RESEARCH
16.1
develope^natio^toPrdeveloyn^one
_
_
*
4
------------------------ — • • «»»»
trar!Sition: As the C0untI7 moves from an under-
the developing as well as the devel
h
'"r
1 tnple bufderl of diseases which beset both
over population and lack of matemafmd chhd health1^
thS
°f nutritional disorders,
the emergent non-communicable n rf
f
nUmber °f c^ntunicable diseases, and
especiahy due" t£X^tamtmn M
^Cti°nS
and .rising demands are putting health
25
1 CaUSe °f senous concera- Spiralling costs
yet millions receive inadequate unsatisfZn
St™n’ M11I10ns are sPent °n health care annually,
ultimate test of its utility would involve the^ S?7'CeS'
e,b,a.S1C objectlve of medical research and the
applicable appropriate technolomes iev.ee and" 3 ■
S'mpk 10W-C°St'
latest technological achievements within th?
in the remotest corners ofThe XT
h'VfTu0115 SUltlng local conditions, thus placing the
“
t0 the fr°ntline heaJth Work^
16.2
16.3
r p"f" —°
Special attention would be paid
socially deprived and economically disadvantaged sections of the society
to understand their social, health and nutritional problems and making available a health care system
that is acceptable to them.
17
16.4
An atmosphere conducive for research interactiiMi is essential for holistic development. Biomedical rosea
is last becoming cost and expertise intensive with new developments taking place each day.
comprehensive research agenda would be formulated and pul into action by pooling the available nalk
resources. Promotion of international collaboration for capacity budding of the infrastructure would
encouraged to create the requisite competencies for the future. A larger funding for R&.D based
project proposals as opposed to the present practice of routinely providing lumpsumafctaHts tQ insiituti
will be introduced. This Will ensure that in the long term projects are related to capacity to deli
results.
‘
16.5
For research inputs to feed into’ planning for health, it is crucial to strengthen the research laboralb
in the country to undertake research using tools of modern biology. The overall effort would aim at
balanced development of^basic clinical and problem-oriented research.
17.
PRIORITIES FOR HEALTH PROMOTION IN THE 21ST CENTURY
17.1
Both the public and private sectors would be made responsible for the promotion of good health by pursi
policies and practices that:-’
lay emphasis on the certainty of health to complete well being.
Wkr
avoid harming the health of other individuals.
.
protect the environment and ensure sustainable use of resources.
v
restrict production and trade in inherently harmful goods and substances such as tobacco
.armaments, as well as unhealthy marketing practices.
safeguard both the citizen in the marketplace and the individual in the workplace.
J’*
\
\
‘
•••; .......
include’equity-focused health impact assessments; as. an integral part of policy development. .
f
J,-
.... ...
**
J
•I
•4
h
18.
POLICY ON INDIAN SYSTEMS OF MEDICINE AND HOMOEOPATHY
18.1
India has a rich centuries old heritage of traditional, medical and health sciences. The philosophy
Ayurveda and other systems like Siddha and Yoga are testimony to ancient tradition on which scicntil’ic he
care was extended to the people. The ancient medical systems have a holistic approach taking into accoi
all aspects of human health and disease. However, with the intermingling of cultures; these systc
relegated not only to a secondary status but they were also suppressed. Yet it is to the credit of the syst<
that they have survived and have’continued to be practised widely in the country. .
18.2
Immediately after Independence starting with the First Five Year Plan, these systems of medicine recei
a broad policy support and moderate resources. As a result, a broad infrastructural frame work has b
created for the development and promotion of these systems.
18.3
At present, the country has more than 6 lakh practitioners of the Indian Systems of Medicine
Homoeopathy and around 300 educational institutions producing about 13000 graduates every year. T1
are 21000 dispensaries and 6500 hospitals of Indian Systems of Medicines and Homeopathy. There are
about 9000 pharmacies manufacturing drugs of-ISM&H. Unfortunately, the services of these systems
under-utilised at present.
18.4 The earlier National Health Policy acknowledge the high local acceptance and the respect enjoyed by ,
Indian Systems of Medicine and Homoeopathy in the country. The policy expressed the need to init
18
1
19.
i
19.1
I
SHORT AND MEDIUM TERM GOALS UNDER THE HEALTH POLICY 1999
be “ ”""c ................... .....;"d““
19.2 The goals to be achieved in the short and medium term are
eradication of leprosy, polio, yaws, filariasis and guineaworm infestation and sustaining the achieve
through proper prevention and detection programmes;
I
reduction in infant mortality to less than 30 per thousand live births.
-
universal immunisation, reduction by half of low birth weight babies and doubling of the numb
institutional deliveries;
reduction in maternal mortality to less than 100 per one hundred thousand live births.
Reduction in annual malarial parasitic index per 1000 cases to 1.5 in 2010 and to 1 in 2015. !
Cure rate of TB to go up from the present 50% to 85% in 2015.
Prevalence of Cataract Blindness to be reduced from 1.4% to 0.80% by 2015.
i
establishment of facilities for early diagnosis
I
capacity development for treatment of mental health and disability at all district headquarters,
establishment of a broad based disease surveillance and a computerised health information netwot
tne district level..
formulation of a special policy framework for the rational development of human resources and
integration of Indian Systems of Medicine in the overall delivery of health services.
i
; .
i '
l
J
p.
20
1
I
f I
Hp '•/</'T
The Catholic Hospital Association of India
•a
C. B. C. I. Centre, Goldakkhana, New Delhi - 110001
Tel. 310694, 322064
LU LUUa. - PyU-.c
The approach oT
oar ancient medical system was of a
noilstic nature. which took into
account all the aspects of human
nealth and disease»
Nevertheles s9 due to the influence
of the
west,
■j it
-ll has
nas been reduced to
curative, an urban-biased, top-down
and an elite-oriented
approachu
This improvement's
ave to be made
to combate BLIirDNESS 9 ilALARI A s
hlzdiKHOSAL DISEASES , LBPAOSY, TB
et c •
In order that our health service are
to be effective, there
arises the need for transfer of knowledge
9 simple skills and
t echnologies to health voluntaries who
are selected by the co.,,
nities 0
1 for e over 9 primary health
care must be provided with
special emphasis <on preventive
9 promotive and rehabilitative
aspects together with other systems of indigenous
medicines ? such
as AURVBDIC , aTNANI,9 SIDHA.9 HOHEOPATHY, yoga 9
NA TdROPATHf 9 et c«
xieace the large stock of such health
manpower could be utilised
for promoting an effective health
care services in Indiao
Besides tnese.aspects9
attention to be paid in the ot.er
aspects such as a yell developed distribution
of low cast food,
of acceptable quality, available to
1 every person especially to
the rural poor, prevention cf food
adult erat ion and maintenanc e
of the quality of the dr
■-igs y safe drinking water , proper environmental sanitation, immunisation programme
y a well planned matteraal
and child health services to reduce
morbidity,9 disabilities and
mortalities so as to promote better health.
Production of liTe s aving" drug-s
under their generic names
especially for the treatment o± TB
and leprosy are to be within
the reach of the rural poor who
suffOT uostly from these diseases
The us e c low cast and no
cast indigenous and herbal medicines
are to be encouraged.,
Nevertheless , when we critically analyse this
statement 9
we see that
very little efforts have been made
in the promotion
of low cast drugs for example, nearly 4o to 60
example, nearly 4o to 60 million people
suffer from endemic GOITRE through its prevention is
sc caeap by
daung loaizea salt which .is
L^ not
not available
available to
to the
people in needo
In the same way, more
time s^d
more time
and money are spent
t o pr o du c e exp en —
sive drugs than the production of Vitamin
A9 the deffiency of
Wnich lead to blindness as 30,000 million
c.~ildren suffer from
o2. o
o
-2this today.
But at the
same time, out of the total production
1000 million (in 1976) 25% was token away by Vitamins and
tonics while 20% by anti-biotics.
Hence,
it is not
Hone o
enough to
see that drug’s
hre produced by Indians and in
abundance, but it
is even nore inportant
to see wha.t drugsi are produced and ror
■whom? e.g. the diseases
of poverty such as TB and Leprosy got
scant attention and thus DAPSON for
Leprosy and INH for TB are
constantly in short Supply.
of Rs.
Hence all health anu hunan development must
ultimately
constitute cm integral component of the
overall socio-economic
development process in the country.
It is thus of vital import.to ensure eff e’etive
co-ordination between health and other
de v e 1 o pmen t al activities in order to build healthy communities.
Re Ierence s
1 .
Statement on National
Health Policy (1982)
2. Seminar on the National Health Policy a reportu
COIil .UNITY HEALTH DEPARTMENT, CHAI
The Catholic Hospital Association of India
C. B. C. I. Centre, Goldakkhana, New Delhi - 110001
Tel.
310694, 322064
National, .health policy mb the seventh five year plm
r*following are a few suggestions submitted by the
Catholic Hospital Association of India to the
Director General of Health Services, New Delhi,
within the over all ambit of National Health Policy
Document for being considered for incorporation
in the ensuing Seventh Pive Year Plan, in response
to a request made by the Director General in his
letter dated 25th February 1984 addressed to the
Catholic Hospital Association of India. This was
prepared in consultation with other National and
Church related organisations based in Delhi?]
At the very outset we welcome the new National Health Policy
of the Government for its commitment to the rural and under
privilaged sections of the society and making an effort to
reach out to the masses through a decentralised pattern of
health care.delivery system through PHCs and sub-centres with
active participation of the people and voluntary organisations.
In a country like ours, governmental efforts alone can not
cater to the needs of the people particularly in remote
rural areas, especially in the field of health. We also felt
satisfied that the roles of voluntary agencies are recognised
by the government in this health policy.
The discussion centred around the following points:
i. Role of voluntary agencies and their relation
to the government at various levels.
ii. Community participation in health care.
iii. Nutrition and Environment factors.
iv. Low cost drugs/Low cost health care.
v. Reorganisation of health care education system.
vi. Population stabilisation.
We felt that, inspite of good policy decisions by the govern
ment from time to time and its desire to improve the lot of
the poor, the programmes do not reach the target groups.
We identified the following few factors
"
5, there could be many
more, responsible for this situation.
1 . Lack of community participation in the government
programmes.
2. Lack of proper attitudes and value orientations
of the health care personnel and thereby lack of
commitment to people.
3. Failure from the part of the government at various
levels in implementing policies.
4. Meagre budget allocation to the health sector and
particularly to the rural health programmes, for
purchase and supply of essential dri^gs and pro
viding other minimum facilities.
-.2/
* *
-2-
We have the following to suggest for resolving the above:
1. The Voluntary agencies can play an-' important role
to organise educational programmes for the poor in
matters relating to health to make them conscious of
what it means to be healthy and when to approach
health care institutions. They also can create
an awareness in the people about their rights and
responsibilities. In such programmes necessary
financial assistance should be given to the voluntary
agencies, by the government.
2. Since voluntary agencies are better equipped in
terms of commitment etc. they should be encouraged.
3. The government health care personnel should be made
aware of their accountability and commitment to
people whom they are commissioned to serve, and nece
ssary steps should be taken to ensure this.
4. Since PHCs, as it function today, are not viewed as
people's institution, to monitor and evaluate the
effective functioning of the PHCs, committees should
be set up at the PHC level, consisting of formal and
informal leaders of the area with due representation
from the people and from the voluntary agencies. This
would ensure more active participation of the people
in health care. How ever this should be preceeded by
awareness building programmes. Voluntary agencies
can play a big role in this.
Similar committees should be set up at the district 9
State and national level to perform same functions
at the respective levels. The committees should be
involved in the planning, implementation and evalu
ation levels in all the schemes.
5. Organise motivation training programmes for doctors
and other health care personnel for giving the right
orientation and proper motivation to work in the rural
areas. Here also the cooperation of the volunatry
agencies could be sought.
6. Efficiently run community health projects in the
voluntary sector could be identified and considered
for recognising as resource centres for planning,
training, evaluation etc. of programmes for the govern
ment. The rich experiences from the part of the
voluntary agencies in working with people should be
made full use in this regards.
7. Community Health Workers should be selected by and
from the community itself.
8. Community Health Workers trained by the voluntary
agencies should be employed by the government progra
mmes.
-!>-
9. Similarly the government should assist the voluntary
agencies of good standing giving financial support
for the payment of health workers etc.
For promotion of nutrition, better sanitation and healthy
environment, the following points were highlighted.
1. Nutrition, safe drinking water, healthy sanitary
facilities and healthy environment are basic to any
health programme as they are also the basic rights
of everyone. However, these come under different
departments of the government, which itself stands
on the way of an effective health programme. Hence
the existing inter-sectoral cooperation should be
enhanced to effectively implement the provisions of
these facilities.
2. Locally available low cost nutrients should be
promoted.
3. Materials used at present for nutrition education very
often do not correspond the local situation. Hence
efforts should be made to develop adequate teaching
materials based on the real situations of the rural
andurban poor. This can vary from place to place and
provision should be made for necessary adaptation.
4-w -to increasing trend is found in the consumption of
baby food. The poor also are misled by propoganda.
Advertisement and mass media have a vital role in
promoting this unhealthy trend, toe strongly propose
that something urgently needs to be done both in
regulating the production and mass media support of
baby foods. Legislative measures should be expedited
to deal with the offenders.
5. Along with the feeding programmes, health education
programmes also should be included, The feeding programmes, thus should not be an end —
in— —itself
—
y hU t
rather a means to an end.
6. tohile identifying the low purchasing power of the
poorer sections of the population, it is equally im
portant and binding on the part of the government to
spell out clear, concrete and organised efforts to
Increase their purchasing power. This is of crucial
importance to enable the masses to earn good quality
food and purchase nutrients. The effective implemen
tation, of minimum wages could be one among such
organised efforts.
7. The number of fair price shops in the country should be
increased particularly in rural areas to ensure better
availability of essential commodities.
-4-
t
Regarding the re-organisation of health care education system
we have the following to suggest:
1 . The existing health care education system should be
t0 giVe
commuili'ty orientation and releanCi.real needs of the people, engulfed bv
poverty and mal-nutrition. Hence the reo^anised ■
system should- include:
gdnisea
a. topics relating to the awareness of community
needs and analysis of the society.
b. management of community health programmes.
c. field programmes with training in teaching people
and. in relating with people. During the training
period the medical students and doctors could be
asked to work with voluntary agencies involved
m rural community health programmes.
d. orienting doctors to prescribe drugs under
generic names.
suit able particularly formrurIl1a?S?nnCoQpetenttrained
voluntary agencies should be invited to design and conduct such courses and such should be recognised bv the
government.
&
'5. The carriculum for nurses' training will also have to
reorganised to train right type
would^o ^■'ifit wIuldPSlIboratrPle”
with voluntary agencies
in ----this
~
—
J field.
4. While formulating the r_,"
y
new medical
education policy,
TOlmtary
agencies
involved
in
health
I---■’
' —
■Association of India
India etc. should be consulted.
consult.
9
Of
5. Efforts should be made to promote
■
other systems of
^^L+1+eS’ esPecially indigeneous
ones, by uorganising
— ———cjonesj
short term courses by them recognised by the governe^big role6 a'gain ^ile voluntary agencies could play
Two general suggestions regarding the drug policy:
1. Government health care institutions should promote
and treat with essential drugs with generic names.
Correspondingly discourage the use of brand name drugs.
2. Due publicity be given to essential drugs, by the
government.
..5/
-5-
Regarding p.p^u.l_ation stabilization, concept of small family
should be promoted not by force but by persuation, education
motivation and by voluntary acceptance thereby Methods used
in this regard should al so be in keeping with human dignity
and the cultural background of our people. Natural Methods
of Family Planning should be given due importance and re
cognition. Expertise available in this field, in the inter
national, national and local level should be made use of
for this purpose. However, care should be taken to give
correct and scientific knowledge in this regard. The Natural
Family Planning Association of India through its President
c/o Indian SociaJL Institute, Lodi Road, Nev/ Delhi 1 10 00J;
the FIAMO Bio-Medical Ethics Centre through its Executive
Director, c/o St. Pius College, G-oregaon East, Bombay-400063
and the Catholic Hospital Association of India through its
Executive Director, CBCI Centre, Gol*dakkhana, New Delh-1 10001 9
could be contacted for this purpose.
It is common knowledge that there is a close corelation
between nutrition and high literacy rate on the one hand and
low fertility rate on the other. The Government would do
well if more emphasis could be given to education of women
and providing better nutrition, particularly for women, and
less emphasis on the so called terminal, methods of family
planning with not so successful result. This should be kept
in mind when allocating funds to various programmes.
In conclusion we wish to re-affirm that the reason for the
ill-health of the poor is attributable not to the lack of
government policies or programmes but to the problems connected
with proper implementation, ^e once again place on record the
courageous step the government has taken in bringing out this
wonderful national health policy and requests the government
and all concerned to have the same courage to get it imple
mented. In all these, there should be a genuine collaboration
in the spirit of true partnership between the government and
bonafide voluntary agencies keeping the good of the people at
large as the prime concern. What is to be avoided by all
means is a “holier than thou” attitude both from the part of
the voluntary agencies and the government.
N ew Delhi
17.4.1984
FR. JOHN VATTAMATTOM SVD
Executive Director, CHAI
HP IHS-
The following proposal was submitted to the Government of
India and approved by the Ministry of Health and Family Welfare on March 25, 1987.
WORKSHOPS ON THE NATIONAL HEALTH POLICY
AND "HEALTH FOR ALL11 AWARENESS SEMINARS
INTRODUCTION;
The Alma Ata Declaration affirms that health is a fundamental
human right; that the attainment of the highest possible
level of health is a most important world-wide social goal
whose realisation requires the action of many other social
and economic sectors. In addition to the health sectors,
the Declaration adds. Primary Health care constitutes the
first element of continuing health care process and therefor
requires and promotes maximum community and individual selfreliance and participation in the planning, organisation,
operation and control a primary health care, making fullest
use of local, national and available resources, and to this
end develops through appropriate education the ability of
communities to participate.
i
4
The Bhore Committee 1946 report provided a revolutionary and
well reasoned blueprint for the reorganisation of health
services. Curative and preventive services were to be inte
grated. Deep thinking and wider action on the more basic
issues of reorganising role definitions within the health
team, with special attention to new relationships between
doctors and auxiliaries should have been done long ago. The
Bhore Committee report had urged the development of a wholly
new orientation. Progressively, there has been considerable
advance in providing the structure of the system, but there
are major gaps and the system has hever developed smooth
functioning inter-relationships.
In recognition of the crucial need to initiate an active and
constructive dialogue among all groups for continuing identi
fication of progress er lack of progress in this regard and
seeking participatory measures to accelerate progress, the
Voluntary Health Association of India proposes to conduct
state level residential workshops on the National Health Policy and Health for All awareness seminars at Block levels.
2
-2Voluntary Health Association of Indi a (VHAl) . is a federation
of State Voluntary Health Associations; through whom it has
linkages with more than 3000 institutions and organisations.
Besides/ VHAl has extensive reach to Government training
institutions/ universities and other centre of education
which subscribe to VHAl publications.
VHAl has a place in the recent evolution of health develop
ment and health strategy in the country considering its
unique innovative attempts to promote Health Care Administra
tion Education and a well-defined residency course in community
health for fresh medicos/ a Health Equipment maintenance couse
for fresh recruits from technical institutes providing'to the
small rural health centres a mobile team of young experts to
repair delicate machines and instruments on site at low cost.
The Nurse Anaesthesia Course recognised by the Indian
Nursing Council is a unique initiative in this country.
VHAl1s Diploma Course in Community Health Management is also
the first of its kind.
The correspondence courses in community
health and the community health team training initiated by
VHAl have contributed in a very significant way to furthering
primary health care.
VHAl publications covering a wide spectrum of health specific
and related issues are indispensable in voluntary and
Government training programmes.
t
Besides the above, the Voluntary Health Association of India
has played a key role in transferring the vision of the Alma-
Ata goal throughout the country since the year 1983. The
National seminar on the Health Policy in 1983 was followed up
by seminars in 11 states for fostering an understanding and
appreciation of the text of the policy and 'the role and
responsibility of those involved in Primary Health Care in
the voluntary sector.
A large number of health personnel from Primary Health
Centres, sub-centres and the Government Secretariat in
different states received their first copy of the National Health Policy from VHAl, which were available in Hindi,
Bengali, Tamil and English.
Since adequate number of copies
were not available with the Government, VHAl printed
3
3
30,000 copies which were soon exhausted.
The enthusiasm
generated among them led VHAI to formulate a scheme to hold
state level residential workshops in the 16 states where the
Voluntary Health Association of India has affiliated units;
specially to bring government functionaries together with
their counterparts in the voluntary health centres and other
organisations.
In this context, two workshops in Bihar and
Kerala in 1986 were held and the third one in this series is
proposed to be held from 2-4 April, 1987,
19871 in Lucknow.
VHAi1s
experience with the two earlier workshops held in Bihar and
Kerala have initiated a process of sharing, learning,
planning andcbing together that which is indispensable for
raising the health consciousness and evolving a new pattern
of health care which will meet in a more adequate way the
needs of the people; and providing a reasonable basis of
mutually strengthening linkages between all levels of the
health care system. It has paved the way for voluntary
groups to forge horizontal and vertical links with the
government system at all levels.
Monitoring and evaluation
of the workshop, together with the follow up action proposals
will be drawn up within a time frame, with the collaboration
of respective participants.
In view of the fact that the National Health Policy is based
on the Alma Ata Declaration, which promises health for all
and further that the World Health Assembly, 1985 resolution
initiated by the Government of India and accepted by all
settles categorically the imperative to promote a relation
ship of partnership between the government and voluntary
organisations/ VHAi as a major NGO, with its state units and
the vast network of organisational and associated members,
makes the proposal as follows : 1.
That the Voluntary Health Association of India will
hold 3-day state level residential workshops on the
above pattern with - Objectives
(a) improving the efficacy of existing health services at
all levels, especially support services to Primary
Health Care;
(b) enhancing role perceptions of every member of the healih
teams at all levels;
(c) enhancing community perception of their role in
health development.
4
-4-
Specific
At the end of the workshop9 the participants
should be aware of the specific health targets in their
a)
b)
area and the resources available to them;
should be aware of their role as leaders of their teams
and the expectations from the leader both to motivate,
educate, guide and support team members to fulfil their
c)
d)
role in strengthening primary health care;
should be aware of the initiatives necessary to forge
intersectoral linkages to translate policies into
actions;
should be able effectively to facilitate 1-day H"Health
for All” awareness seminars at Block and village levels
involving grass—root community organisations like Mahila-
Mandals, Yuva Mandals, young farmers clubs, village -
leaders etc.
PARTICIPANTS:
Participants will be drawn from District Health Centres of
the government and the voluntary sectors.
The list of
government participants will be given by the respective
District Health Officers. State VHAs will elect the voluntary
participants.
In states where VHAs do not exist, suitable
steps will be taken by VHAI to identify those to be involved.
RESOURCE PERSONS:
Resource persons will be selected with great care, The
criterion will be the dedication and attainment of the
individual in activity significant to rural health develop
ment, urban slums and work with vulnerable groups. The
resource team will be balanced with 1:3 from the government
and the- voluntary organisations.
While majority of the
Resource Persons will be region specific, a few extra -
ordinary leaders, who have distinguished themselves and
have international esteem will be invited to contribute
their vision and enrich the workshop.
The panel of these esteemed health leaders is made up of
Baba Amte, Dr’s. Matelie and Rajnikant Arole, Dr .N.H.Antia,
Dr. C.Gopalan, Dr* Banu Coyaji, Drs. Rani and Abhay Bang,
5
-5-
Dr. Anil Desai, Smt. Elaben Bhatt, Dr- V. Hande, Dr. Ragini
Prem, Dr. Samir Chaudhuri, Dr. Debabar Banerji, Ms. Indu Kapoor, Ms. Mirai Chatterji and others who have integrated
in their own work the most meaningful and significant
aspects of health.
METHODOLOGYs
Several methods may be adopted to suit the soci o —r.u 1111ra 1
affinities of different state.
are common 2 -
However, the following
Panel discussion sessions. Group work. Plenary sessions.
Role plays. Study of displays and exhibitions, and Report
writing sessions, to be followed by a field visit where
possible.
Being residential workshops, sessions may extend beyond
formal timing schedule leading to meaningful group dynamics.
Group leaders and rapporteurs are selected by participants.
Gr-^up leaders conduct the session while Resource Person is
available for reference only.
Education kits will.be provided to all the participants and
resource persons.
The kit will comprise of the following 2
The text of the Policy in the regional language
A map of the state with district boundaries
An organogram highlighting the specific areas
to be taken up at state workshop
Visual charts indicating health education methodologies
Printed Case studies of programmes emerging from
exemplary inter-sectoral coordination and health
team relationships in other parts of the country.
Appropriate books and booklets serving as reference
material available from VHAI and government agencies.
SUPPLEMENTARY ADDITIONS 2
Follow up source books indicating allocation of manpower,
/
financial and technical resources available at the
level of Districts, Blocks and villages from the
government and voluntary organisations in respect of
health and development activity.
....6
-6WORKSHOP CONTENTS
I.
The core chapters from the National Health Policy on
(a) Primary Health Care and Problems requiring urgent
attention,
(b) Health Education and (c) Indigenous
systems of medioine will be taken up for reference
with the aid of an organogram.
The region specific
Resource Team would draw up the framework for
initiating discussions at panel discussion sessions
based on feedback from advance questionnaires
delivered to participants.
II.
The "Health for All" Strategy adopted by the Central
Health Council.
BUDGETS
State level residential workshops on the pattern enumerated
above will be held in Andhra Pradesh, Gujarat, Delhi,
Karnataka, Himachal Pradesh, Haryana, Jar-imu & Kashmir,
Madhya Pradesh, Maharashtra, North East Megion (Assam,
Arunachal, Manipur, Meghalaya, Mizoram, Nagaland and Tripura),
Orissa, Punjab, Tamil Nadu, Uttar Pradesh and West Bengal.
A consolidated budget based on respective sizes of states and
on the basis of two representatives per district for
participation totalling a sum of Rs.10,78,745/- is attached
See Annexure "A"o Detailed statement for UP State - see
Annexure "B".
Exhibition, Training module and kit -
see Annexure "C" .
ONE-DAY "HEALTH FOR ALL" AWARENESS SEMINARS:
The thrust of the Alma Ata Declaration goal is "that the
Government should enhance the capacity and determination
of the people to solve their own problems". The natural
corollary to this thrust would be the holding of "Health
for All" awareness seminar at Block and Village levels.
In recent years, alternative strategies to reach health have
been tried through government infrastructure and through
modest and significant initiatives of health professionals
and health workers. However, much more is to be done as
the HFA strategy calls for dramatic changes. In fact, a
social revolution in health development is needed.
7
-7-
“Health for All*' implies the removal of the obstacles to
health - that is to say, the elimination of malnutrition,
ignorance, contaminated drinking water and unhygienic housing quite as much as it means the solutions of problems such as
lack of doctors, hospital beds, drugs and vaccines.
Given the magnitude of these tasks, strong political will and
the mobilisation of public support is essential for launching
the necessary Health for All action. VHAI proposes to hold
1-day Health for All awareness seminars in 5000 blocks of
this country in collaboration with all the active socio
cultural and development groups engaged at the macro and
micro levels. The modalities of organising these seminars
will be worked out with each one of them separately.
These seminars will have clear objectives sa) to change the mentality of people to take a comprehensive
view of health, in which their total will-being is at stake,
b)
to make clear that the drive towards the goal of Health for
all by the year 2000 can only be inspired and fuelled by
concerted inter-sectoral action of all people in agriculture
education, culture, industry, food and nutrition and
c)
information,
to make clear
d)
resource allocation, national and local leaders can promote
policy-making mechanism to progressively correct the
imbalance in maldistribution of resources,
to make visible the health risks inherent in the use of
that in order to effect a national change in
certain technolgies leading to deterioration of health
e;
and nutritional status,
to understand that two-way interaction between Health and
Family Planning is a means to improve maternal and
f)
child health,
to understand that there is effect of child health and
survival on family planning motivations and that this
understanding needs to be strengthened.
PARTICIPANTS:
1.
The participants in these 1-day “Health for AllI!” seminars
will be organisers and members of groups at the village
level, responsible leaders from the Block and District
Panchayats.
8
-8-
These may be non-health groups involved in socio-economic,
cutural or religious activities like young farmers clubs,
mahila manuals, traun mandals, school teachers, panchayat and
panchayat committee members, members of agricultural and
land cooperatives, societies/village banking institutions.
2.
All village health workers
(There will be separate seminars for homogenous
groups to make necessary impact).
PROGRAMMEs
(will be divided into a morning session general and afternoon sessions- subjects)
The seminars will be action-oriented.
Resource persons will
be drawn from different states to expose their practical
experiences in primary health care, (see attached Resource-
Persons list.)
Knowledge of resources available at the village^ taluk and
District levels to fulfil the targets of PHC at individual
and community level will be brought home to them*
The role expectations from doctors and the role expectations
from teams of auxiliaries to reach large populations will be
discussed in group meetings and at plenaries.
The role of village health workers and the supportive
mechanism for them at the community and referral level
will be discussed.
Social and Scientific inputs to work out the dynamics of
changing mass need of all - to standardise the motivational
approaches that will convince families to practice planned
parenthood will be attempted.
The role of administration leaders in realising the goals of
HFA will be discussed.
An afternoon session will be devoted to two or more of the
following topics? since 1-day health awareness programmes may
:
draw large
participation, these will be taken up in groups
and summaries shared at the plenaries s
. . .9
9
1)
Sources of water and simple water purification
methods to achieve Health for All (HFA)
2)
Promotion of village sanitation and personal
hygiene to promote HFA
3)
Use of foods for health and prevention and
cure of diseases to achieve HFA
Use and economy of solar and biomass energy to promote HFA
5)
The cause effects and approaches to speedy treatment
6)
of communicable diseases to ensure HFA
Symptoms and home treatment of common diseases
Using low cost and rational medicines to ensure HFA
7)
8)
9)
Application of Herbal and Home remedies to aid HFA
Role of practinners of traditional medicines to
reach the goal of HFA
Who will conduct 1-day "Health for All" Awareness Seminars ?
( RESOURCE PERSONS )
1.
Since these seminars are to be organised at the village
and taluk levels, a panel of experienced local personnel
identified by VHAI and State VHAs in consultation with
the active local groups and the health department will
form the core Resource pool.
2.
Committed and exceptional individuals, who have shown the
way in neighbouring districts and blocks, even from
other states.
The role of these individuals in generating a powerful
impulse towards a resurgence and faith in community and
family care about health cannot be minimised.
3.
Members of the health team attached to
Primary and Subsidiary Health Centres.
4.
Local government leaders and members of Parliament of
the area, who have distinguished themselves by concern
for their constituencies.
( See Budget annexure D )
ANNEXURE A
CONSOLIDATED STATEMENT
OF EXPECTED EXPENSES ON
NATIONAL HEALTH POLICY
WORKSHOPS IN STATES
STATES/UNION
TERRITORIES
NO. OF
DISTRICTS
AMOUNT
RUPEES
Andhra Pradesh
23
64,400.00
Gujarat
Haryana
19
12
Himachal Pradesh
12
61,560.00
55,400.00
55,400.00
Jammu & Kashmir
Karnataka
14
19
57,160.00
61,560.00
Kerala
12
55,400;00
Madhya Pradesh
Maharashtra
Orissa
45
26
19
84,440.00
67,720.00
Punjab
12
55,400.00
Rajasthan
Tamil Nadu
26
16
67,720.00
58,920.00
Uttar Pradesh
57
95,000.00
West Bengal
North East Region
16
58,920.00
37
61,025.00
365
Tot^l Amount: Rs. 10;78, 745.00
Total No.Districts
56,280.00
* Follow-up
For follow-up action towards Travel and Documentation,
a supplementary budget will be prepared in consultation
with participants in due course.
ANNEXURE B
state level workshop on national health policy in u.p
Estimate of Expenses
3-day residential workshop for
District Health personnel .from Government and Voluntary
sectors from 57 U.P. Districts.
The budget estimates given under the various heads of
accounts are adjustable within the overall amount for
the project.
Rs o
T.A. for 114 participants
@ Rs.200/-
Rs. 22,800.00
D.A. for 114 outside participants
@ Rs.75/- per day for 3 days
Rs. 25,650.00
D.A. for 8 local participants
@ Rs. 20/- per £ay for 3 days
Rs.
D.A. for 8 outstation experts
@ Rs.150/- per day for 3 days
Rs. 3,600.00
T.A. for 8 outstation experts
@ Rs.200/- each
Rs. 1,600.00
D.A. for 8 local experts
@ Rs.50/- per day for 3 days
Rs. 1,200.00
Secretarial assistance
@ Rs.2000/- p.m. for 1 month
Rs. 2,000.00
8)
Stationery and postage etc.
Rs.15,000.00
9)
Tea/Coffee for 130 persons twice
daily @ Rs.5/- per person for
three days
Rs. 1,950.00
Compilation and printing of
a Report on the Workshop
Rs.10,000.00
Follow-up expenses on
travels, etc. for 1987
Rs.10, 720.00
1)
2)
3)
4)
5)
6)
7)
10)
11)
GRAND TOTAL:
480.00
Rs.95,000.00
ANNEXURE C
STATE LEVEL WORKSHOP ON THE NATIONAL HEALTH POLICY
RS.
500 sets of portable exhibits in regional
languages on Primary Health Care, Symptoms
and prevention of communicable diseases.
Sanitation and Personal Hygiene, Water
Management, Mother and Child Health,
Nutrition, Family Planning, Disability
Prevention, Environment, Agricultural Technology, low cost housing, Sulabh souchalayas, smokeless chulhas, bio-gas,
appropriate technology.
Rs.5,00,000.00
500 sets of charts on organisational.,
managerial and financial resources of
Primary Health Care
Rs.1,00,000.00
3.
1000 Education Kits ( for participants
and Resource persons )
Rs.1,00,000.00
4.
Expenses for preparatory work
for the workshop
Rs.1,50,000.00
5.
Contingencies
Rs.
1.
2.
TOTAL
*
A set will be available to all 365 Districts
to be covered by State level Workshops.
NOTEs
A set will also be presented to all Districts
in Bihar, and Kerala, where VHAI has already
held State level workshops in 1986.
50,000.00
Rs.9,00,000.00
>*
t
ANNEXURE D
BUDGET FOR VILLAGE/TALUK LEVEL 1-DAY ’HEALTH FOxR ALL'
AWARENESS SEMINARS
Expenses for One Seminar
Rs.
4
Conveyance for 50% of the participants
coming from an average distance of 8 kms
@ Rs.5/- per person x 50
Rs.
250.00
Educational Kit to be distributed
to 100 persons @ Rs.50/- per kit
Rs.5/000.00
Cost of Lungar for 100 participants
and 10 organisers = 110 persons x
Rs.15/- eqch person
Rs.1/650.00
Travelling expenses of the personnel
conducting seminar 2 x Rs.200/- each
Rs.
400.00
personnel conducting seminar
2 x Rs.100/- each
Rs.
200.00
Miscelleneous expenses
Rs.
500.00
Boarding & lodging expenses of the
TOTAL
Rs.8/000.00
Rs.40000/000.00
8000 x 5000 Blocks
VHAl’s overhead expenses for
coordinating the programme through
State VHAs and other Volags at
12^%......
GRAND TOTAL:
5000,000.00
Rs.4,50,00,000.00
TRUE COPY
No.M.11014/10/87-IH
GOVERNMENT OF INDIA
Ministry of Health & Family Welfare
New Delhi, dt« the IDth Marcrh, W7.
v
To
The WHO Representative,
WHO, Nirman Bhavan,
New Delhi.
Subjects- WHO Assistance for organising Workshop on
National Health Policy & Health for All by
the year.2000.
I am directed to convey the approval of Government
of India for the organising of State Level Workshops on
National Health Policy and "Health for All" Awareness
Seminars in all the States by the Voluntary Health Association
of India and to forward the proposal of VHAI, for funding by
WHO • The entire expenditure as indicated by the VHAI in
their project proposals may be incurred from the WHO country
programme IND MPN-002 under which such activities have been
provided for. A copy of the proposal from VHAI is enclosed.
Yours faithfully.
(Dr. K.S. GANESHAN)
Under Secretary to the Government of India
copy to
Voluntary Health Association of India, New Delhi,
40 Institutional Area (Near Kutab Hotel)
South of I.I.T., New Delhi 110016.
Sd/(Dr. K.S. GANESHAN)
Under Secretary to the Government of India.
Copy to
A.D-G-(IH)
POSITION PAPER ON NATIONAL
HEALTH POLICY
.. /''library
>.
r
AND
’ r-)j
mA documentation )
u
Amla Rama Rao
Voluntary Health Association of India
A
1
© 1987
Voluntary Health Association of India
40, Institutional Area, South of I.I.T., New Delhi-110 016
Printed by
Joginder Sain & Bros. (Printing Division)
A 30 1, Naraina Ind. Area, Phase I, New Delhi-110028.
POSITION PAPER ON NATIONAL
HEALTH POLICY
The National Health Policy as planned may remain only a policy document unless
all of us make a commitment to it, and try to implement it at all levels. Each of us
must carefully analyse the health problems, keeping in mind the country’s capacity
to deal with them. The goals and priorities will be fixed accordingly. Strategies to
achieve them need to be based on social justice and equity, intrasectoral linkage and
self-reliance as far as possible.
The ill-conceived and inadequate health services currently provided to the vast
majority of the population has created a feeling of social injustice and given many
voluntary organisations the impetus to act as natural leaders of their communities.
They have the responsibility to lead movements for the change. For this they need to
identify the strategies to develop (heir full leadership potential. They should look
beyond the traditional system of health care and develop a deeper understanding of
the philosophy of primary health care and a commitment to achieve health for all
by 2000 A.D.
1.
PROVISION OF HEALTH SERVICES TO ALL
For those who live in remote areas and belong to the lower income groups, health
care can be provided only through a system which creates a broad base of
functionaries and provides health care to the maximum number of people. The
training of new community health workers at the village level has only duplicated
the existing system and has not proved very helpful in the long run. Wherever the
traditional health functionaries have been involved, the infrastructure has become
stronger. The health care system may continue to be lopsided, unless efforts are
made to improve the training and supervision of CHW’s and Dais.
2.
REFERRAL SYSTEM AND PRIMARY HEALTH CARE :
A STRATEGY
The bottlenecks that exist between the village and a health sub-centre are again a
matter of concern. The health assistant is no better equipped with the skills and will
to deal with certain health problems than a CHW. So unless there is a way to reach
Primary Health Centres very little can be done at these levels.
3
Another important point is that the referral system does not allow for any planned
way to go from one to another. There is no geographical or political boundary
which one cannot cross. Unless the screening is done at all levels, the political and
the social linkage is established between a specialist hospital to a Primary Health
Centre of the block, from there to the village sub-centre and back from village to the
specialist hospital; the congestion, duplication and the parallel system will
continue to exist. The suggested change of effective links between primary health
centres and medical colleges and hospitals in order to harness and provide
specialised skills is no doubt progressive thinking for re-orientation of medical
education and better health service, but its implementation has been held up due to
many administrative difficulties. As a result, neither are the Block Administrators
taking responsibility for the better functioning of these Primary Health Centres nor
have the medical college hospitals established a proper linkage with them. Very few
specialists from these hospitals like to go out to the Primary Health Centres. In fact
the person who goes there is only a junior or senior resident working in those
specialised units. Most of the time they treat these trips as holiday excursions. There
is no continuity of ties nor any feedback from such hospitals to the Primary Health
Centre doctor.
3.
INFORMATION SUPPORT
To estalish a proper information support, there must be a well-defined referral
system. General practitioners, indigenous practitioners and all others who are
involved in any way with the health care system should become a part of the
information support. The Epidemiological Cell in each State may not be essential
but it should have a computerised system for collecting and processing information
from different units. Without information, support evaluation and monitoring of
any programme is not possible.
4.
RE-ORIENTATION OF HEALTH PERSONNEL
To equip health personnel with appropriate and scientific techniques we must
provide a system of continuous education. Inservice training programmes are
essential to develop the skill to do the job better. Certain managerial skills which are
never imparted to medical professionals in their undergraduate courses must
become a part of the orientation training programmes. All courses could be so
planned that NGO/Govt. officials attend the courses together and can interact with
each other.
The voluntary organisations have a greater sense of dedication and commitment to
social causes and are more open to change. This gives them an enormous advantage
in the field. They provide care at all levels in all kinds of settings to the poorer
section. They frequently act as links between the individuals, community and the
rest of the health care system.
4
5.
INTERSECTORAL COORDINATION
That various sectors have influence on health is well understood, but intra or
intersectoral coordination remains most of the time only in the minds of people or
as words on paper. Actual coordination at various levels is possible only if the
planning of the two sectors are done at one place, and from bottom to top. The
possibility of removing the bottlenecks is maximised if two sectors, well connected
like water and sanitation, nutrition and education, are planned together. Again,
regarding the educational status of woman and her acceptance of family planning,
both must be worked out together, and receive the same importance. The
administrative blocks also need attention. There is a need to define the job
responsibility of various people at different levels, as well as a policy of delegation
of authority at each level. If decision making is confined to the planners’ level, the
implementing functionaries find it very difficult to carry out their day-to-day
duties.
6.
ALTERNATIVE SYSTEMS OF MEDICINE
There is a need for integrating the training programmes of different personnel in
different systems. The policy has recommended the use of indigenous systems of
medicine like Ayurveda, Unani, Sidha and Homeopathy. It also emphasises
introducing Yoga and Naturopathy into the overall Health Care Programme. But
when it comes to putting this into practice, none of the Primary Health Centres or
the dispensaries is equipped to give advice on any of the traditional systems of
medicine.
Traditional systems of medicine have always had a place in our culture. They are
both less expensive than modern medicine and more easily accessible to the
majority of our population. To allow them to stagnate will only increase existing
inequalities in the health care system. Therefore, ways of integrating the modern
with traditional svstem of medicine must be thought of.
7.
REGIONAL IMBALANCES OF THE HEALTH CARE SYSTEM
It is of vital importance to correct the regional imbalances that exist in health care
systems today. The policy cannot be successfully implemented unless sustained
political, social and administrative support is obtained from everyone concerned.
Here the local communities play a very important role and it is our duty to make
them aware of the facilities they are entitled to, so that they demand the care they
need. The concept of preventive and promotive services is still lacking all through
8.
MEDICAL EDUCATION
We need not go into the details of formal medical education as we all know that it is
not tailored to meet the requirements of the type of medical practitioners who work
5
in Primary Health Centres. If more clear and effective strategies could be specified,
the wasted resources could be harnessed. The re-orientation of medical education
has been talked about for the last several years but very little has been done to make
education community-oriented and problem-based. Most of a medical graduate’s
time is spent in hospitals. The type of knowledge and skills that he/she acquires are
the ones from the hospital itself, when almost 80% of the ailments are preventable
and can be cured by simple remedies. But these cases never reach the hospital for
their attention.
The National Health Policy is aimed at taking services to the doorstep of the people
ensuring fuller participation of the community and improvement in the quality of
their life. It is intended to restructure the health care services on the preventive,
promotive and rehabilitative aspect rather than on cure only. Therefore to provide
trained personnel with the right attitude and outlook is more important for proper
functioning of the services talked oj in the policy document.
9.
MEDICAL RESEARCH
It is the opinion of various experts that today there is a lot of money being wasted on
basic research which could be well shared by the developed world. The technical
know-how can be easily obtained from them.
Special research on health care system, problem based medical education and need
based para-medical education at various levels, require a lot more attention than is
being given in this country. In my opinion “behaviour problem” of the recipients
of health services should form the priority for the research grant in India. There is
also a need for a constant feedback on the new findings and advances in medical
research and their application to health services. The dissemination of this
information to the proper levels both upward and downward are equally
important. Unless we keep informing our workers at the grassroots level of what is
happening at the central level, the implementation of the programmes become
difficult.
10.
THE TARGETS
The National Health Policy paper gives the targets to be achieved according to the
time frame. These targets are not comprehensive nor have they been worked out on
any realistic terms. The exercise only tells what future achievements can be expected
provided the base is known. No doubt it is better to work on some frame, to measure
the milestone and progress being made but the baseline information is of crucial
importance.
The target sets are based on certain information that was available at one point of
time: perhaps as far as 1975 or 1976. Unless the relevant data is available from
different states it is of no use setting up targets to reduce the incidence. A few studies
6
carried out by big institutions like the All India Institute of Medical Sciences or PGI
Chandigarh tell us very little about the overall health status of our country. Lack of
vigilance in reporting and collecting of information will hinder us from reaching
our targets.
11.
ROLE OF NGO’s
The role of voluntary agencies has been very well spelt out by the Alma Ata
Declaration. It includes:
1. Identification of the needs and problems of the people.
2. Development and innovative programmes for Primary Health Care, in the
context of comprehensive human development.
3. Promotion of full participation by individuals and communities in the
planning, implementation and control of these programmes.
4. Training of health workers, supervisors, administrators, planners and various
agricultural and development workers, along with training schemes, build on
the skills of traditional healers and midwives.
5. Creation of new and effective methods of health education.
6. Recognition of the essential role of women in health promotion and in the full
range of community development concerns.
7. Contribution to the search for greater social justice.
8. Development of locally appropriate health technologies and use of resources.
Most of the voluntary organisations are working for both health and development.
The standards of health cannot be improved unless there is an improvement in the
general quality of life. The NGO’s are more willing to go to the most difficult areas
where nothing exists as far as the health system is concerned. Still they find it
difficult to be recognised and get little or no help from the government system. It is
time we all realised that to achieve health for all by 2000 AD, the involvement of the
voluntary sector is essential.
THE DILEMMA—NATIONAL HEALTH PROGRAMME
Most of the time the doctor faces a very big dilemma in his day-to-day functioning.
He is unable to find what to do and how to get started with diverse programmes like
TB, Leprosy, Prevention of Blindness, Malaria control, Family Planning,
Immunization, School Health, Nutrition and MCH, as well as to keep evaluating
the programmes from time to time. Only if the planning process, information
system, resources, supervision, coordination and training is adequate can the
7
doctor use his energy as a team leader to build up the team, organise the community,
keep proper records, monitor the programmes and do a follow up review, as well as
initiate certain changes in the programme when the need arises.
The bring about any change is a very complex task. The people who are striving to
reach the goal of health for all must have a clear understanding of the National
Health Policy, the critical issue required for its implementation and the broad
principles involved in it.
In these three days let us together work out an action plan for our own areas keeping
all the elements of the National Health Policy in mind and evolve our own
strategies to reach the goal of health for all by 2000 AD.
#############
8
HP" I
DECENTRALISATION OF HEALTH CARE:
HOW
DOES
HEALTH
POLICY 'FIT’?
— Meera Chatterjee, Ph.D.
Paper prepared for the Workshop on
"Towards
a
Decentralised
Health
Care:
A Fresh Look at the National Health Policy"
at the National Institute of Advanced Studies,
Bangalore, 20-23 September 1990.
I. The National Health Policy’s View of Decentralisation
Rationale. The Statement of National Health Policy provides its own
raison d’etre
as /he need to establish "an integrated, comprehens've
approach towards the future development of medical education, research and
health service^. Not only are 'integration’ and 'comprehensiveness ’ intended
to be departures from the past, but each of the three major components
(education, research and services) ha^ to break from the patterns established
over three - now four - decades./The policy statement avers that "ohe
hospital-based disease and cure-oriented approach" which has "proviced
benefits to the upper crusts of society" has to give way to "comprehens've
primary health care services to the entire population," incluc'ng
"preventive, promotive, public health and rehabilitative aspects of hea’th
care.'/
^/fhe statement goesTon to diagnose the problems caused by the "exist'ng
approach." It "tended to enhance dependency and weaken the community’s
capacity to cope with its problems." Existing patterns of education and
training of medical and health personnel resulted in the "development o~ a
cultural gap between the people and the personnel providing care." Hea’th
programmes "failed to mvolve individuals and families in establishing a
self-reliant communit'A/The planning process has been oblivious of the need
to/involve "the community in the identification of their health needs and
priorities as well as in the implementation and management of the various
health and related programme^/
Aims. Thus, the policy aims to move toward:
—universal, comprehensive primary health care, which is culture*ly
acceptable;
—people’s involvement in planning, implementing and managing hea’th
care;
—community self-reliance in health matters;
— integration- of health and human development with soc’o-econc.-.i c
development
Structure and Functions, i he basis of universal health care is interred
to be/a "well-dispersed network" of service^/as it is believed that tne
2
//majority of health functions can be effectively handled at the community
level - by the people themselves with the organised support of volunteers and
paramedics/ Health volunteers are to be selected by, to enjoy the confidence
of, and be accountable- to their communities. However, their actions are to
be part of definitive action plans prepare^ at higher levels (see below)
which are based on simple and inexpensive interventions.
The policy states:
-/’The success of the decentralised primary health care system
would depend vitally on the organised building up of individual
self-reliance and effective community participation; on the
provision of organised, back-up support of the secondary and
tertiary levels of the health care services, providing adequate
logistical and technical assistance."
and^f^Trther that:
^(5
I
°
V^^The decentralisation of services would require the establishment
a well-worked out referral system to provide adequate
expertise at-th^Tvarious levels of~ the organisational 'set-up
nearest to the community... (and to) ensure the optimal utlisation
V
of expertise. at the higher levels of the hierarchical'
structure..."
Specialist services are to be provided as near to beneficiaries as possible.
In order to provide the integrated package of services addressed to the
entire range of poor health conditions, a nation-wide chain of sanitary-cumepidemiologica l stations is proposed to be”established. These stations, based
aT~Frimar.y Health Centfres, would have suitably trained staff to identify,
plan and provide services. In addition, the District Health Org'anisatwn is
16“ have a ^we’l 1-organised epidemiological unit t5~~Goordi~nate and^superintend
functwhing of the field stations. In urban areas,, municipal and local
a uthorities would be equipped to p e r f o rm similar functions. A health
i 1fomiation—system is to*1 be establ ished, and ~ monitoring conductecT with
respect to indicators and targets which have been set by the policy. It is
in these connections that the integrated approach to medical education,
research and health services is germane. Further, the policy states that
these approaches should be implemented and extended through community
participation and contributions.
Foci, Certain other intentions of the policy are also closely related
to, if not subsumed in, a decentralised approach. These are:
its focus on vulnerable groups, particularly the call for MCH
services to be provided "at the doorstep," to involve traditional
birth attendants, etc.
— its concern with correction of rural/urban and regional imbalances,
eg. in speciality centres; the location of curative centres Is
to be in keeping with population densities, topography, transport
connections, etc. "——
' CoLx
r*
3
— the priority it ascribes to service provisionjfor tribal, hill and
backward areas and endemic-disease affected popuT^Tohsi ---
Resources. The policy further stipulates that health care should be
provided at_a cost which the people can afford." Besides community manpower,
it also advocates maximal utilisation of available resources - eg. the use
of local building materials and local mechanisms for repair, maintenance,
etc. of equipment; the upgrading of existing facilities rather than
establishment of new ones. Private medical practitioners, including
indigenous practitioners are to be integratecTihto the overalJLhealth effort,
and their availability is to determine the phasing out of private practice
by government doctors. Non-governmental organisations are also to be
encouraged"tKrough provision of technical support and financial assistance
by the government to enlarge jib^ic services and increase their numbers. Thgir
investment in curative centres is sought. While government investment^ in*
speciality and super-speciality services is also expected to continue, the
policy proposes that "the majority of government speciality centres can
provide adequate care to those entitled to free care-, the affluent sectors
being looked after by paying clinics." It is also advocated that health
insurance schemes be devised to mobilise additional resources to ensure thatT
ai "^he community "shares the. cost of services, in keeping*-with its paying
11 capacity."
—-Intersectoral Action. Finally, the integration of _several other healthrelated activities which are also discussed by the policy is a function of
decentralisation, such as:
—nutrition - specifically, improving the purchasing power of the poor,
generating productive employment through employment guarantee
schemes combined with a ’’’nutrition and health cover;"
supplementary feeding programmes; and nutrition education; and
— water supply and sanitation (which are al so> expected to involve
_
For these, intersectoral coordinating committees are advocated at the state,
district and block leveTs, while at the community level they are expected to
form part of an "integrated programme of rural development."
Clearly, the National Health Policy views decentralisat ion as a key to
its rationale and aims, to its vision of the structure and functioning o~f~the
health system, to its foci, to its approaches to resource~jeneration and
uti 1 i sat ion, and to the intersectoral actions ft-advocates. The "question
before us, then, is not "What changes are required in the health policy to
bring it in consonance with the philosophy of decentralisation and to
increase people’s participation?" (as expressed in the tentative Workshop
Programme). Rather, we must askz/^'Is the Policy’s view of decentralisation
consonant with current approaches to decentralisation in the country?" and
"How can the implementation of decentralised health care proceed in the
context of the current health and pol itico-bureaucratic systems^XThus, the
emainder of this paper will examine the 'fit’ between three pieces of the
decentralisation of health care" puzzle - health policy, the health system,
<r
4
and current models of decentralisation.
II. Representation for Universal Access
The policy’s main thrust is "universal access" to health care. While
decentralisation is purported to bring this about, we must examine whether
this has yet occurred, or is occurring in India. If so, how has it been done;
and if not, what have been the impediments to it, and what~Ts the potential?
Clearly, none of the states which have had decentralised governments
over a substantial peHod~~of~time - &ujarat, Maharashtra, and test Bengal71
nor Karnataka, whose experiment though newer is bolder and has the benefit
of earlier experience, have achieved "universal access." Is it just a matter
of time? Probably not. RatherT”there are fundamental problems which must be
tackled if "decentralisation" is to bring about universal access to health
care. Alternatively, we may need to admit that the problems are so
fundamental that universalisation is impossible to achieve through
decentralisation,-and all we can hope for is somewhat better distribution of
health care, or, simply, better health care as has been achieved to some
extent in Maharashtra. (We should note, however, that Tamil Nadu has fared
oven bfittpr than Maharashtra without decentralisation," and neitherGuj a rat
nor West Bengal have improved health beyond what might be expected in their
socio-economic - rather than politico-bureaucratic - contexts).
The first problem is inherent in the nature of the institutions that
embody "democratic decentralisation" - they are unrepresentative. Universal
access means— skewing health care avail ability in favour of previously
neglected groups, caterwg to their specific health needs anTT^yerconrmg
their particular constraints. But these groups (eg. the poor, womenyahd
chi 1 dren) are unUeT-r^p'resented in Panchayati Raj bodies and^Tack the power
to influence reorientation and Fedistribution. (In the case of women and
children, social norms also reduce attention to them, though more effective
women’s participation in local government could conceivably overcome this to
some extent.)
Can a redressal of current imbalances be effected by the
oligarchies who dominate panchayats, zill-a pari shads, etc.? They could,
indeed, make decisions in favour of the excluded groups either if they are
imbued with an especially philanthrophic spirit, of if they perceive such
decisions to be in self-interest. Unfortunately, phi 1anthrophy can hardly be
a "model;"
and the process of enhancing "enlightened self-interest and
creating a vision of health care as a common good has yet to begin. Rather,
the current reality fs that health care is viewed as a zero-sum game
more
for the-poor means less for the rich - because of severe shortages of hea'Tth
resources. Thus, the first need, if decentralisation is to fit with health
policy, is expanded meaningful representation on PRIs of neglected groups.
This must be accompanied by a * process of enligh€enmep t’ of the~Traditional
elites, and also by increases in^tesources (discussed below). In the absence
of any of these desirable changes, universal access and equitable
distribution are unlikely to be achieved.
*
5
III. Resource Generation and Allocation
From where should these resources come? The health policy talks of
generating them locally, and panchayati raj, too, once spoke of the same, but
neither effort has approached this possibility (the latter with concern for
the health sector) with the seriousness it deserves. Thg_current system of
resource generation by panchayats and zilla oarishads i^~inadequate to one
tasTT OnTy a few percent of the taxes and fees collecteo by them are
retained, while most are funnelled upward _to the, .state government. Their
incqm§_jfrom other sources (enterprises^-inveLStments and public contributions)
is mj_nimal. Even urban municipalities have had troublesome experiences their tax_Jiase is also small and inelastic. Where efforts have teen mace,
contributions directly for health purposes have been virtually negligi_b1e.
Ultimately, both rural and urban bodies have depended on state_cpverhrnenV~
assistance by way__of assigned revenues and grants. Although these are
devolved to Tower levels on the basis of equity considerations (pcpulaticn,
fecgwardness, heddy groups, etc.), the system is ;inefficient; as‘the costs
/^of collection and devolution.-are—high. Ultimately, there is never enough
finance~~to~~~meet the considerable expenditures entailed by the multitude of
functions ajid__duties of local bodies, among which health service provision
is’-re 1 atively low priority.
Thus, the second problem impeding effective decentralisation ’or heath
is the current system of financing health care. It is excessive:y centralised
and completely normative, leaving little room for local cecis'on-mak:ng
regarding allocation. Ultimately, most of the finances for health care haye^
come either from the state governments or the ^entre, in the form of block
grants tied to specific programmes, schemes or expenditure norms. ^TFiug,
neither are Fesources generated—lo^a 11 y_^_ nor . -are.Iythey allocated ;vor
'allocable’) irT^accordance with local needs. This is as true in the four
"model" states as it Ts elsewhere. An additional stumbling block is thac,
even where local decision-making is exercised over block grants, say by tne
zilla pari shads, decisions mayjiot be made in.favour of lieal th oecause^of one
competing claims of roads, schools, etc. which are given higher priority. '
i
If
--------------------- -
---------- ---------------- ----------------------------------------------- --------------------------------------
Problem One confounds Problem Two in the following *ays. First.'/,
inadequateattention to the needs and constraints of the poor, ^omen and
children, etc. results in the scarce health resources being spent on hospital
care rather than primary health activitJes, in_complete negation of hea^th
policy. Secondly, although the needs of these groups are critical, their
capacity to contribute to resource generation ^Ts limited. Thus^ PrcoTems une
and Two aTready call for a complex remedy: Tocal bodies must generate
resources from wealthier sources, but spend them on the neglected._?roups. mow
can this be ensured? Invoking "higher authorities" would seem to be qu'te
contrary to the spirit of decentralisation, but the activ'ties of local
bodies can perhaps be brought in line with policy imperatives by a so
shifting the weight of state and Central government expenditures in favour
of primary health care so that both "carrots and sticks" operate down tne
line.
Therefore, it would seem that if decentralisation is to meaningfu :y
6
A
bring about universal access to health care, specific revenues must be
generated, foe health which can be used locally, aTlocated in accordance with^
local needs and numbers by democratic decision-making processes. Vi 11 ages
must gain access to resources for health care. Given Constitutional and
'traditional’ treatment of tax revenues,’ resource generation should perhaps
take the form of a Human Resource Development Fund, based on fixed
contributions from families and institutions according to status and thedfoe*
and utilised spec, i fTcaT-ly-fxir^ heal th and education^ although water supply,
sanitation and other social services are conceivably also candidates. A bold
step may be to vest the management of this fund with women’s organisations,
such as broad-based mahi1 a mandals. The HRD Fund should be additional to the
9rADts received from_t_b-e. state goyernment] which invariably arF earmarked',
have to be spentjDn specific schemes or according to specific norms, and in
any case are' insufficientd Tn short, the implementation of health'policy and
of decentralisation are probably not likely to progress very far until people
b^gjii-J^..fiJnd___ser^ices for themselves, as the state and Central governments
are already only funding., what they can and want to.
-----Alternatively (or additionally?) a fee-for-service approach can be
utilised, graduated according to., paying ^capacity. In effect, urrTeSs local
bodies can generate enough resources to provide the entire gamut of health
services from primary to tertiary, they will need to concentrate on low-cost
health care. In conditions of scarcity, government health services could be
" reseryedl_for^ the poor, even though the re i s~~wi desp’read feeTf n^,' based~^
trends in thepTfTvate sector, that the poor (who are extremely dependent on
good,health fQ.r_.surviYg 1) are wi 11 ing^to pay for health services 'if these are
good quality. Under any circumstances, improving the quality of services is
a definite requirement if health care ~is to be effect!v~e~~an'd universal.
Certain public health services will continue to need complete under^wrlTTrTg
by the state (eg. malaria spraying, surveillance and case detection, etc.)
It is these that could remain under “central" fiscal control, effecting a
division of responsibility between iocal bodies and the Central and state
governments. There is also no getting away from central control of medical
education, research, the drug industry, health legislation, and so on.
IV. Health Planning and Service Provision
The current top-down mode of health planning and resource provision is,
in-JLa£t_^_the_major impediment to decentralised heaTtTr~cafeT~The~^Ts~e~nce~of
I.decentralis at ion is planning according"to Tocal needs, aTlseating 7esourges
^n_keppiiig^rith_jthese needs, and local management of services so that, with
appropriate monitoring, changes can be made within short time-frames to
enhance effectiveness. Currently., while planning and resource allocatforT
involve iterative processes between the administrative secretariats and
f technical directorates at the higher levels of the health—system, health
servi_ce_management, at the district level and below is almost entirely the
responsibility of medical "personnel. While District Collectors have some
powers to oversee the District Health Organisation, the "technical" nature
of health services by and large preserves their independence. Even in the
panchayati ra.j states, secretarial power has not devolved to the district
*
7
level in the health system, so that there is considerable 'misfit’ between
the politico-bureaucratic structure and the ’’technical" (implementing) health
system.
This misfit is often expressed in terms of conflict. "The people" or
their leaders are considered to be "ignorant" of health care by the medical
hierarchy. Dqctors resent the "interference" of politicians, bureaucrats or
other lay people. Leaders are accused of misusing their powers, of needing
"guidelines." Health workers are unclear .which of their "two masters" (the.
doctor or theZZboTTtician/bureaucrat) is to be given greater obeisance.
Reporting horizontally is perceived to c6nTTTcT~witfi reporting vertically.
Under decentralisation, "technical
supervision of health workers will
continue to rest with their niorB qualified superiors^ while admin1stnative
control will be exercised by_panchayats. It is a moot point whether these
parallel, separate and disjointed systems can be made one, though this would
seem to be a major pre-requisite for effective decentralisation.
V
Furthermore, despite the effusive rhetoric of the National Health
Policy, there is little evidence to date of decentralisation within the
health system^ In fact, if one examines health care trends since th^~NHP~was-~
]|adopted in~ 1983, one must conclude that the health system has gone in the
other direction - toward greater central control and direction. There has
been an increasing tendency over time for high priority health issues to be
dealt with through national programmes," planned and funded (50 'to~TOO per
centJ by the Central Goverrltnent. More and more of the basic ^TieaTth
infrastructure in the states has been established under Central Plan schemes,
notably thea Family Welfare Programme. While the states have had some autonomy
in decisions about rural health services under the Minimum Needs Programme,
this has been reflected more in their inadequate health expenditures and the
slow pace of implementation, than in the development of independent
initiatives. There is even 1ess devolution of creative responsibility from
t|je state to the district level. Despite the size~of~TFie district health
infrastructure, and the large and motley populations for which they are
res pons i b 1 e, di strict heal thorgani sations mostly implement plans handed down
to them from-~above-r-A4t.-hough health plans are to be formulated at the
district level, and -district health officials have drawing and disbursing
« powers, the essence of decentralisation - working out local approaches to
1 ocal problems is seldom oractised. There wiTl be increasing neecT for this
if universalisation of health care is to come about. Both the Centre and the
states will need to be more flexible in permitting local aproaches and
responses to local developments, rather than enforcing standardised packages
and procedures.
The health policy itself does not go far enough on the issue of health
planning. This responsibility is vested primarily in the epidemiological
field stations at block and district levels, although community involvement
is suggested. Under decentralisation, the health organisation must play the
role of information-giver and_educator of people’s 'organisations which can
then plan~Tn accordance withneed and demand. This relationship is quite the
opposite of the prevailing situation in which the people are subservient to
health institutions for thed-r health care needs rather than suoervising~~tRenn—
4
8
It is argued (not without justification) that health needs are largely
the same everywhere, that we know what they are, and that in the context of
severe resource constraints, it is more efficient to simply divide the pie
and distribute it in accordance with norms. It is significant that while
primary health care calls for a form of decentralisation which involves
"bottom-up planning" and horizontal integration, decentralisation in India
is more akin to top-down devolution of responsibility where vertical links
are strongly maintained, rather than horizontal harmonisation established.
Plans are simply handed down from Centre to states to districts to blocks and
I to villager in which manpower, materials and~money“are allocated- on a
' pop_ujati.on_basis. Even the relatively simple matter of indenting ^for drugs'
according to local needs does not function in a decentralised mode because’
the bulk of drug budgets is expended on the standard drugs which are
centrally-procured and distributed. The remainder of the budget which is
subject to district-1evel decision making is usually used to procure more
* expensiv_e non-essential drugs, because these are what are demanded by those’
who influence the DHO’s decisions! While this normative approach to health
manpower and service provision and to budgetting ensures-that^resources are
u spread__egjjally across populations by the Centre and the states, it is quite
I Kfitithetical to-decentralisation.
Another manifestation of the "centralist tendency" of the health system
is the Technology Mission approach." This approach not only imposed an
additional structure at the top of the health pyramid from which decisions
emanated, but also favoured centralisation through the adoption of
technological approaches whose diffusion depended on central control and
management. The techno-bureaucratic approach which has
adopted
— been
--- --r--- for
's more in keeping with "selective PHC" than with
universal immunisation is
care,
hoiistic primary health ca
re, which is the essence of the health polfcy.
Besides Be"!ng considered more ^feasible, in contrast with primary health care
which is considered ’idealistic" because of the actions required beyond the
health system in the spheres of social justice, etc., selective PHC is deemed
efficient and effective. In the case of immunisation,^ it is also considered
equitable because hjjjh coverage fs an implicit condition for effectiveness.
j l J However, with _other_Jn.tervent ions such as oral rehyd rat ion~and"~vi tarn i n~ A
(11 prophy1 axi s,—achieving the equity objective is 1ess cert.ai n. These
interventions depend more ^n household knowledge, deci si on-ma-ki ng processes
or act.ip.ns.j_._which in "~turh are' infTuenceT^Ty sociaT ancT “economic
dharacteristics (such as education, incomeK With diminished coverage'~arTd—
effectiveness, equity will also diminisFil Few existing health technologies
lend themselves to wide distribution and local application which is
independent of underlying socio-economic .conditions. In general, the
technological approach does not " involyel__pepple - thpy are me re 1 y_rec_i p i ent s
(Targets) of a service, centrally planned. Nor does it adress underlying
cohditions^such as unsanitary environments or practices which expose peopTT"
To—disease. While some technology-based health interventions such as
immunisation may reduce specific morbidities and mortality, few others have
this capacity. Such approaches do little to invert the top-heavy health
pyramid or even broaden its base.
Indeed, programme management within the health system is similarly topdown as targets set by the Central or state governments have been the driving
9
force. While the use of targets in family planning is notorious, the approach
covejis^ several other national programmes - immunisation, malaria, etcT’
Concerned^ w^ith meeting targets (though the actual numbers may have no
relevance at the local level) tha district and block level health
organisations have little scope for utTTisi_ng healtEjj^
to address local problems. Only_during epidemics does this machinery appear
M to gear itseTT up for ""fire-fighting" which entails rapid appraisal, on-thespot decision-making and emergency shifts in the deployment of resources.
The exigencies of resource constraints, people’s participation and
provision of primary health'care ~at~~the doorstep would seem to dictate that
the disreputed community health workers’ (Health Guides’) scheme must be
revived. We have learned enough lessons over the past two decades to
encourage PRIs to reintroduce this scheme so that its earlier pitfalls are
avoided and it is implemented in a meaningful way. The National Health
Policy, decentralisation and health system all converge on this modality of
implementing health care which still bas the potential for equity and
effectiveness^. Further, there is little doubt that for ^"effective
decentralisation another key requirement will be strong links between primary
and secondary and tertiary health services through a working referral system.
It should be noted that the trends in the health system which were
discussed above also do not fit either with the policy thrust or with the
approach to decentralisation ^that is intended to tackle the underlying
conditions of disease. The health sector in India has done little to further
i_ntersectoral action, everT~in the closely related areas of nutrition, and
water supply and sanitation. It is especially critical to mesh heaTth
pTanning with education~planning as the synergism between these sectors is
increasingly recognised. (The HRD Fund proposed above would go some way
toward linking these services.)
V. A Caveat to Decentralisation?
>
Besides equitable distribution at the micro-level (which we have
discussed above), universal access also implies equitable distribution of
health resources across regions, rural and urban areas, etc. The health
policy is especially concerned about/rectifying regional imbalances, and with
If special attention to "tribal, hill and backward area^X^ Because of the
I "macro" nature of these areas, such corrections will require the attention
of the Centre and of state governments, perhaps more than of district-level
government. Can decentralisation accomodate this "affirmative action"
approach? Or, as in the case of micro-level units such as villages, will
those who already have get more? The divergence between "need" and "demand"
(or effective demand) is therefore a serious constraint to the implementation
dT~~HeaJ_th policy within the context of decentralisation. The poor (whether
p’erson or state) need, while the rich demand, and the latter largely control
the processes of resource allocation nationally as well as the panchayati
raj institutions locally. In effect, perhaps equity - across regions, social
groups, age groups, and gender - can only be ensured from 'outside’ and
'upstairs.’
10
In this context, the lack of equality in the resource mobilisation
capabilities of the states and districts is also critical. Experience has
shown that better off areas can raise more finances and therefore implement
better quality care (For example, in Gujarat, Baroda and Khera districts have
usually raised more family planning incentive money by tapping industry).
This will exacerbate already large differentials in quantities and quality
cf health services.
VI
Summing Up
Both the National Health Policy and the philosophy of decentralisation
have equity at the core of their being, and so are in essence 'on the same
wavelength.’ However, several critical problems have been identified that
stand in the way of their being implemented meaningfully. Firstly, panchayati
raj institutions have not overcome the problems of social heterogeneity in
the villages and the control of PRIs by better-off elites reduces their
potential for implementing health care for the poor. Secondly, the inadequate
resource base of PRIs makes it difficult to implement locally relevant health
care, particularly as grants received from the Centre and state governments
are tied to preset norms and expenditure patterns. Decentralisation is
meaningless without local resource generation. Third, PRIs must have the
capacity to plan according to local needs and demand, and to raise and
allocate resources in keeping with their plans. Need-based/demand-oriented
planning is quite different from the norm-based methods now in use which are
based on limited resource availabilities and equal sharing principles.
Fourth, the combination of oligarchical control and limited resources results
in the traditional skewedness of health spending - on sophisticated medical
care for the few rather than on basic primary health care for all. Fifth, if
the resource base of local bodies is to be increased in a meaningful way,
attention must be paid to implementing systems which provide good quality
health care to the poor despite their lower paying capacity. Sixth, the
implementation of health policy, ie. of primary health care, requires the
health system to change in keeping with the philosophy of decentralisation.
In particular, the relationship between the technical and politicobureaucratic cadres needs to be clearly defined so that planning and
management controls are exercised in accordance with democratic principles
and professional interests are subordinated to people’s concerns. Seventh,
health plans, in terms of the activities to be undertaken by service
providers and the resources allocated to them, must emanate from below and,
hence, the "national programme," "technological" and "target-based"
approaches which currently dictate programme management from above must give
way to locally decided and suited strategies.
* * * * *
. HEALTH POLICY AND PLANNING; 9(4): 353-370
© Oxford University Press 1994
Hp~L
Review article
Reforming the health sector in developing countries:
the central role of policy analysis
GILL WALT'AND LUCY GILSON1’2
'Health Policy Unit, London School of Hygiene and Tropical Medicine, UK, and department of Social
Policy and Administration, London School of Economics and Political Science, UK
Policy analysis is an established discipline in the industrialized world, yet its application to developing
countries has been limited. The health sector in particular appears to have been neglected. This is surpris
ing because there is a well recognized crisis in health systems, and prescriptions abound of what health
policy reforms countries should introduce. However, little attention has been paid to how countries should
carry out reforms, much less who is likely to favour or resist such policies.
This paper argues that much health policy wrongly focuses attention on the content of reform, and
neglects the actors involved in policy reform (at the international, national and sub-national levels), the
processes contingent on developing and implementing change and the context within which policy is
developed. Focus on policy content diverts attention from understanding the processes which explain
why desired policy outcomes fail to emerge. The paper is organized in 4 sections. The first sets the scene,
demonstrating how the shift from consensus to conflict in health policy established the need for a greater
emphasis on policy analysis. The second section explores what is meant by policy analysis. The third in
vestigates what other disciplines have written that help to develop a framework of analysis. And the final
section suggests how policy analysis can be used not only to analyze the policy process, but also to plan.
Introduction
Policy analysis is an established research and
academic discipline in the industrialized world,
zt its application to developing countries has
been limited, and the health sector in particular
appears to have been neglected.
This is all the more surprising because of the
growing crisis in health systems. The initial
optimism of the Primary Health Care (PHC)
revolution of the late 1970s has been challenged
by a number of trends: escalating costs but lower
public health budgets because of economic reces
sion; the emergence of AIDS; the increase in the
number of large-scale and complex disasters; the
prevalence of chronic diseases side by side with
persisting communicable diseases; worsening in
equities in access to services; demoralized health
staff; emerging drug resistance to some diseases.
In the face of severe economic constraints and
shifts towards neo-liberal values, many countries
have introduced structural adjustment program
mes which have led to cuts in public health ser
vices, introduction of, or increased, charges for
health care, and liberalization of the health sec
tor to promote private sector development. The
effects of such economic reform programmes
have been harsh. Zimbabweans dubbed their
Economic Structural Adjustment Programme
(ESAP) the Extreme Suffering of the African
People (Woodroffe 1993). Gains in health status
achieved up to the 1970s are being eroded, and
evidence is growing of the negative effects of
health reforms on health status, especially on
the vulnerable (Kanji and Jazdowska 1993;
Messkoub 1992; Pinstrup-Anderson 1993).1
Gill Walt and l^ucy Gilson
This crisis in health is well recognized and
prescriptions of what countries should do
abound (for example in the World Bank’s World
Development Report 1993: Investing in Health).
However, there is very little attention to how
countries should carry out reforms, much less
who is likely to favour or resist such poli
cies. Just as the primary health care approach
foundered by concentrating on content (the
introduction of voluntary community health
worker programmes) rather than process (how
communities would be encouraged to support
such workers), so recent health reforms are likely
to fail because it is expected that policies will be
implemented as planned without taking into con
sideration factors that affect implementation.
This paper argues that much health policy
wrongly focuses attention on the content of
reform, and neglects the actors involved in policy
reform (at the international, national and sub
national levels), the processes contingent on
developing and implementing change and the
context within which policy is developed (Figure
1). Focus on policy content diverts attention
from understanding the processes which explain
why desired policy outcomes fail to emerge. As
Reich (1994a) has argued, policy reform is a pro
foundly political process, affecting the origins,
formulation and implementation of policy.
Policy-makers, whether politicians or bureau
crats, are acutely aware that reforms are often
unpopular and can cause significant social in
stability. They may be reluctant to push through
reforms, even when part of loan agreements. The
World Bank admits that only 55% of conditions
in structural adjustment loan agreements have
been fully implemented when the final tranche ol
funds is released (Clapp 1994; 307).
New paradigms of thinking urgently need to be
applied to the health sector, to understand the
factors influencing the effectiveness of policy
change. This approach has already been ad
vocated for the fields of development and
economic policy, by scholars questioning con
ventional and received wisdom about the role of
the state (Mackintosh 1992), and the role of ex
ternal donors (White 1990). Manor (1991; 6) has
argued the need for ‘thick description’ rather
than ‘parsimonious models’. We argue that the
same challenge exists for health, because the con
text within which health policy is formulated And
implemented has changed. From a policy de an
characterized primarily by consensus, health
policy is increasingly subject td) conflict and
uncertainty, and this change'calls'for alternative
ways of thinking about policy. Wc argue that
• policy analysis offers a more comprehensive
framework for thinking about health reform
than approaches which concentrate on the
technical features of the content of reform;
• literature from political economy and other
disciplines offers insights to the way policy
analysis could be applied in the Ijealth sector;
• by using a simple analytical model (Figure 1)
which incorporates the concepts of context, pro
cess, and actors as well as content, policy-m 'rs
and researchers will be able to understand better
the process of health policy reform, and to plan
for more effective implementation. The model
CONTEXT
ACTORS
* as individuals
* as members of groups
CONTENT
PROCESS
Figure 1. A model for health policy analysis
Policy analysis in health sector reform
can thus be used both retrospectively and
prospectively.
This is a highly simplified model of an extremely
complex set of interrelationships, and gives the
impression that each can be considered separa
tely. In reality actors are influenced (as in
dividuals and as members of interest groups or
professional associations) by the context within
which they live and work, at both the macro
government level and the micro-institutional
level. Context is affected by many factors such as
instability or uncertainty created by changes in
political regime or war; by neo-liberal or socialist
ideology; by historical experience and culture.2
The process of policy-making (how issues get on
to the policy agenda, how they fare once there) in
turn is affected by actors, their position in power
structures, their own values and expectations.
And the content of policy will reflect some or all
T the above dimensions. In other words, we
argue that the traditional focus on the content of
policy neglects the other dimensions of process,
actors and context which can make the difference
between effective and ineffective policy choice
and implementation.
355
mechanisms as being inadequate in developing
countries (Chowdhury and Kirkpatrick 1994; 1),
legitimizing governments’ role in intervening io
correct market imperfections through public sec
tor investment. It also fitted well with the in
terests of political rulers allowing them to
establish or consolidate loyalty through extend
ing state enterprises or bureaucracies. And in this
period international aid expanded to support the
state.
The return to classical economic theory - the neoliberalism of the 1980s - was a reaction partly
to positive economic growth and development in
Asia (where many governments had promoted
neo-liberal policies); partly to the growth of what
came to be seen as over-extended and weak
public sectors in some developing countries; and
partly to the recognition that government
preferences expressed through policies did not
unambiguously promote the interests of their
populations. Indebtedness, instability and,
above all, inefficiency were perceived as failures
in economic policy.
A changing development context
The scope and scale of political and economic
change in the late 1980s and 1990s has been
dramatic, and has led to significant political and
economic policy reforms which have also in
fluenced sectors such as health.
From the 1980s many actors played a part in ex
pressing dissatisfaction with the state. From
many different disciplines and positions writers
complained of the ‘self-deceiving state’
(Chambers 1992) or ‘the unequal state’ (Bayart
1993). In central and eastern Europe people took
to the streets to overturn the state in 1989. And
the international financial institutions, such as
the World Bank and IMF, became impatient
with what were perceived to be authoritarian
developing country governments. Given their
central role in debt rescheduling and new loan
agreements, these agencies were able to introduce
significant conditions in the form of structural
adjustment programmes which demanded
political reforms (e.g. retraction of the civil ser
vice, introduction of multi-party elections) as
well as economic reforms (e.g. trade liberaliza
tion, removal of subsidies). Economic adjust
ment programmes affected the health sector
through cuts in budgets, promotion of the
private sector, and the introduction of user
charges for health services.
In the 1950s and 1960s state directed develop
ment was part of the intellectual environment of
the time (Sen 1983). It was justified through
economic analysis that • identified market
The tendency of those advocating policy reforms
was to perceive them as technical: international
experts negotiated reform programmes with
national policy-makers. Although many agreed
This paper is organized in 4 sections. The first
sets the scene, demonstrating how the shift from
consensus to conflict in health policy established
the need for a greater emphasis on policy
analysis. The second section explores what is
meant by policy analysis. The third investigates
what other disciplines have written that help to
develop a framework of analysis. And the final
section suggests how policy analysis can be used
not only to analyze the policy process, but also to
olan.
The shift from consensus to conflict in
health policy
356
Gill Walt and LJucy Gilson
that some reform was necessary (despite fierce
debates about scope, timing and conditions), the
focus on the content of reform neglected impor
tant factors such as varying political cultures and
institutions, the influence of ideologies or
schools of thought, and historical traditions.3
From the late 1980s economists and political
scientists argued that complex economic reforms
which had immediate and major distributional
(and often drastic) effects on populations, and
where benefits were long term (and major doubts
existed on the extent of benefit), could not be
treated as technical policies that would be
automatically implemented. National policy
makers and scholars increasingly criticized
technocratic approaches. Lindenberg (1989; 359)
quotes an anonymous policy-maker saying
‘Often these people who come here from in
ternational organizations to preach the gospel
of stabilization and structural adjustment
know as much about the political and
economic consequences of what they are pro
posing as the medicine men who used to
prescribe leeches to correct imbalances in the
four humours of their patients.’
Herbst (1990) argued that structural adjustment
programmes that demanded major curtailment
of public enterprises in Africa did not recognize
that such enterprises had been an important
source of reward and patronage to African
leaders for decades. Reducing their activities
threatened important constituencies and could
lead to weak implementation or make the state
much less flexible in dealing with crises. In
similar vein, Haggard and Webb (1993) observed
that structural adjustment programmes were
undermined by their tendency to ignore the in
stitutional characteristics of the political system,
the internal and external economy, and the
design of reform programmes.
A changing health context
The changing political economy had repercus
sions for health policy and facilitated the idea of
reforming the health sector. During the period
when the state played a strong central develop
ment role, health policy had been decided largely
on consensual grounds, partly because it was
controlled by a medical elite. During this period
health policies were largely uncontroversial,
received broad (if passive) support from the
population, and appeared as ‘low politics’issues on the political agenda. They were almost
entirely concerned with the content of policy
(e.g. how to improve access and coverage, how
to increase efficiency in the use of hospital bed.s)j
and reforms were largely limited to organiza
tional questions regarding health systems (e.g.
the relationship between different levels of health
service - tertiary, secondary and primary).
In the 1980s, however, as neo-liberal ideas began
to dominate, health policies moved into a policy
arena in which previously accepted values were
challenged (e.g. by calls for ‘cost sharing’ and
the promotion of private health chre provid ;).
A context in which market values dominate
leaves little room for morality, values and feel
ings, and may undermine and destroy previously
accepted, socially constructed concepts of public
purpose, public morality and public accoun
tability (Wuyts et al. 1992). Debates about health
policy were increasingly characterized by con
flict, making them, relative to previous decades,
‘high politics’ agenda items. This conflict
inevitably generated considerable uncertainty
around appropriate policy choice.
How did the change from consensus to conflict
occur? The period of consensus was largely
derived from a relatively restricted policy field
dominated by medicine. From the 1940s to
the mid 1970s health policy was fuelled by
tremendous confidence in medical sci
e.
Sulphonamides, penicillin and broad spectrum
antibiotics provided the tools to challenge
disease. The synthesis of DDT and its application
to control malaria, vaccines against infectious
diseases, the advent of the oral contraceptive, all
strengthened professional monopoly and lay
beliefs that medicine had the answers: health
policy-makers had merely to decide how to
manage and organize health services to make
them accessible, available, acceptable and
affordable.
The domination of health policy by medical pro
fessionals was repeated in international circles.
From the 1950s international and bilateral agen
cies became more involved in health, and
established their credibility by conquering yaws,
eradicating smallpox and (more controversially)
helping to control malaria. They provided
Policy analysis in health sector reform
357
technical expertise and funds for various progiammvs in health, including family planning.
grammes or expansion of rural health infrastruc
tures (Walt 1990).
However, by the late 1960s the medical paradigm
was increasingly challenged from both within
and outside the profession. Past policy which
had emphasized disease treatment in centres of
excellence was questioned by historians,
epidemiologists and economists, who showed
that much illness was poverty related (AbelSmith and Leiserson 1978), that drugs which had
appeared to be ‘magic bullets’ had many
unintended consequences (Illich 1975), and that
teaching hospitals served a small proportion of
the population but swallowed large proportions
of the health budget (King 1966). Social scientists
increasingly encroached on the policy domain of
medical professionals, raising questions about
the effects of culture on health behaviour and the
elative costs of different health care activities
among other things.
Neo-liberal policies introduced new tensions into
the health policy domain. In the industrialized
world there was increasing emphasis on cost con
tainment and efficiency improvement, leading to
concepts of the internal market and separation
between providers and purchasers, and a con
troversial emphasis on the virtues of competi
tion. Managers and economists increasingly
intervened in areas previously controlled by pro
fessionals. In the developing world donors and
financial institutions laid down neo-liberal con
ditions for debt servicing and loan agreements:
these included a reduced role for the public sec
tor, the introduction, or raising, of fees for con
sultations, drugs and admission to hospital, and
reductions in the regulation of the private sector.
1 he launching of the primary health care ap
proach in 1978 reflected the thinking of these dif
ferent groups, and expanded the health policy
arena to include many other groups than medical
professionals. The loss of professional monopoly
opened the way for conflict in policy debates.
This was manifest in global level debates about
comprehensive versus selective care (Rifkin and
Walt 1988), in the battle to get an international
code on breastmilk substitutes and over
establishing an essential drugs programme (Walt
However, even though the notion of ‘political
ill’ introduced in the Alma Ata policy docu
ment on Primary Health Care acknowledged the
role of politics and conflict in health policy, it
was never conceptually developed (with a few
recent exceptions such as Reich 1994b;
Whitehead 1990), and had little effect on donorsupported health policies implemented in many
low income countries. These continued to be
largely technical, vertically-organized programmes such as immunization against 6
childhood infectious diseases and control of diar
rhoeal disease. Even national primary health care
policies were often interpreted narrowly and ex
pediently as vertical programmes within
ministries of health (Decosas 1990), or as
synonomous with community health worker pro
The shift from consensus to conflict in health
policy served to heighten awareness about the
failure of past policies. For example, by the late
1980s many aid agencies were admitting that
years of experience in primary health care had
shown that technical solutions, while often
necessary, were not sufficient to sustain policy
outcomes, especially in poorer countries. While
infant mortality rates had decreased and
coverage of immunization had increased in many
countries, those gains came at the same time
as growing social inequalities, poor quality of
care, and worsening living conditions. It had
become clear that the effectiveness of pro
grammes was influenced by values and culture
(both national and international), accounta
bility, morale, and communication, among other
things, but that such factors had been neglected
in the belief that better techniques or
technologies could by themselves tackle the
causes of ill-health (Cutts 1994; Nabarro and
Chinnock 1988; Heggenhougen and Clements
1987).
Looking for new policy solutions, donors
promoted decentralization policies to remove
control from central, distant state authorities;
service delivery through non-government organi
zations which were perceived to be closer to local
communities and which might instil a greater
sense of democracy; and ‘good governance’
which included reform within smaller bureau
cracies (performance related pay, greater flexi-
358
Gill Walt and Lucy Gilson
bility in recruitment and dismissal) and greater
accountability.
In so doing, however, two issues were raised.
One related to sovereignty, accountability and
unequal power relations. Put baldly, national
governments wanted loans or grants from inter
national organizations, but received them only if
they agreed to impose economic reforms. For
some this reflected conditionality without
responsibility (Cliff 1993). However, interna
tional agencies were themselves accountable to
their own constituencies, and have been affected
in some countries by scepticism expressed about
the role of aid and the value of technical
assistance and cooperation (Bauer 1981; Han
cock 1989). Also international agencies are
themselves actors of great variation; multilateral,
bilateral and non-government organizations are
fuelled by different goals and values. Bollini and
Reich (1994), for example, differentiate between
‘internationally minded’ and ‘nationally minded’
agencies.
The other issue related to a lack of understanding
of the policy process: there were huge gaps in
knowledge about how bureaucracies worked or
how policy-makers responded to pressure. While
concerns with ‘good government’ demanded
understanding about bureaucratic culture and
decision-making processes, this knowledge was
fragmented and partial. It was unclear how far
implementation of reforms would be influenced
by domestic policy processes given the lack of in
formation about institutional development and
how organizational and administrative systems
worked. For example, while there was force
behind the arguments for greater effectiveness
and efficiency, there was little understanding
about how this would occur in a contracting
rather than an expanding economy. As Cumper
(1993) argued, health planning had always been
based on assumed growth, and the knowledge
and techniques for originating and implementing
change in contracting health systems was miss
ing. Introducing competition, whether through
internal markets, as in the UK, or through
non-governmental organizations in developing
countries, raised major questions about the con
ditions for success for which there were no
answers (Broomberg 1994).
In this policy environment ideological certainty
expressed through policy documents such as the
World Development Report 1993: Investing in
Health appears a great deal more robust than it is
(Reich 1994a). And because of this there is a nas
cent acceptance that new analytic approaches are
needed which offer a better understanding and
more complete explanation of the policy environ
ment. We argue that our framework for policy
analysis offers such an approach.
What is policy analysis?
Policy analysis draws on concepts from a
number of disciplines: economics, political
science, sociology, public administration id
history, and emerged as a subdiscipline in the late
1960s, mainly in the United States. It is variously
defined by different scholars, comes in many
guises, and offers a confusing heterogeneity of
different theories ranging from highly prescrip
tive to descriptive (Heclo 1972).
Most policy analysis focuses on the policy pro
cess. Dror (1993; 4), for example, defines policy
analysis as ‘approaches, methods, methodologies
and techniques for improving discrete policy
decisions’. Similarly, Paul et al. (1989; 1) define
policy analysis as ‘the task of analyzing and
evaluating public policy options in the context of
given goals for choice by policymakers or other
relevant actors’. The implication in these defini
tions of policy analysis is that policy-makers are
concerned largely with the content of policy re
intendedly rational, and need to have particular
skills to make proper choices among well-defined
policy alternatives in the furtherance of complex
but compatible goals.
These approaches are similar to those
characterized by the incrementalist or rational
schools of policy-making. The classical propo
nent of the first approach is Lindblom (1959),
who is concerned with analyzing what happens in
organizations or what happened in a particular
decision. His is a descriptive approach which
argues in favour of incrementalism and
acknowledges a process of bargaining between
different interest groups in the process of policymaking. The rational approach is more abstract,
and deals with values and how policy-making
should be undertaken. It offers a prescriptive
and ‘ideal model’ of how policy-making ought to
be undertaken, providing a way of improving the
Policy analysis in health sector reform
35g
effectiveness of policy-making by explicitly iden
resources and partly because it deals with
tifying values and goals before making policy
measurable
eifects, economics has increasingly
choices and. selecting the best policy options
been seen to offer valuable techniques for policybased on comprehensive information about the
making (Sharpe 1977).
costs and consequences of each (Simon 1957).
These approaches centre their analysis on policymaking, although Lindblom emphasizes the role
of actors as partisans in the policy process. Our
approach to policy analysis goes further because,
while it is concerned with the processes of policymaking, it is also centrally concerned with the
behaviour of actors in formulating and im
plementing policy and the context within which
policies are promulgated (Figure 1). It offers a
much broader framework for thinking about
health policy. In adopting this model we argue
that policy is not simply about prescription or
description, and nor does it develop in a social
vacuum; it is the outcome of complex social,
political and economic interactions.
Our model of policy analysis is thus nearer to
political economy approaches, which also draw
on the concepts of several disciplines but have
been dominated by economics and politics. Re
cent political economy theorizing has been driven
largely by a concern to explain the processes
related to formulation and implementation of
structural adjustment programmes in low income
countries. The richest analyses have been pro
vided by development theorists, economists and
political scientists. What have these approaches
to offer health policy analysis?
What can be learned from other
disciplines?
Economics has made a major contribution to
health policy over the past two decades. From
the late 1960s policy-makers increasingly turned
to economists for analysis of health care costs
and health service financing options. Within a
decade growing numbers of health economists
were to be found in academic institutions, inter
national organizations, ministries of health; they
dominated health services research and health
policy discussions. Economics plays an impor
tant part in appraising options in policy-making,
helping policy-makers to make choices on the
basis of efficiency and equity. Partly because of
its central concern with the allocation of scarce
However, while few would deny the usefulness of
economics as one of the tools for policy choice,
like any^discipline, it has its limitations. Green
(1990; 274) has argued for example, that there is
a danger that economists may be seen as ‘neutral
technocrats, harbingers of rationality and con
veyors of objectivity’, although they are, as any
other actors, fuelled by particular values which
may or may not be articulated (or even recognized) explicitly. Fuchs (1993) gives three
examples that illustrate the limitations of
economics in health policy. The first is that
economics is a general method or way of think
ing, but does not necessarily offer solutions for
health policy-makers because of the peculiarities
of the health care market. For example, in most
industries where there is excess capacity prices
fall sharply and some firms are forced out of
business. But in the health care markets of the
USA there are excess supplies of hospital beds,
high technology and certain surgical and medical
specialists, while charges and fees remain high.
Fuch s second example is in the social and
political domain: while economics helps to
understand how health care costs are higher in
the USA than in Canada or Germany, economics
does not explain ‘Canada’s superior political
capacity to enact and administer universal health
insurance’ or the greater willingness of Germans
to obey centrally established rules for health ex
penditure. And finally, Fuchs’s third limit relates
to the importance of values in health policy.
Conflicts over values are particularly stark in the
health policy arena: for example, should ad
vanced medical technologies be made available
to all, in spite of cost, or should funds be spent
on public health and the prevention of disease?
Economics cannot provide guidance on which
value system to favour in policy-making.
Economists themselves have increasingly
recognized the need to enrich their focus and
methods of enquiry with conceptual tools from
other disciplines, and it is to policy and political
analysis they have turned (Healey and Robinson
1992; Meier 1993).
I
360
Gill Walt and Lucy Gilson
‘Economists are trained in the study of the
operation of economic forces within political,
social and moral constraints. This approach
has to be supplemented (and in some cases
replaced) by the study of the operation and
manipulation of political, social and
psychological forces within economic limits.
More fundamentally, the distinction between
economic and noneconomic variables may not
be tenable if the aim is to understand society.’
(Streeten 1993; 1286)
Development theorists have similarly re
appraised old relationships between economic
growth and development, highlighting the need
for different modes of analysis (Manor 1991;
Chambers 1992).
Thus economists have joined with political scien
tists, sociologists and anthropologists to provide
a better understanding of the political environ
ment within which policies are decided and ex
ecuted. Much of the impetus for this resurrection
of the tenets of political economy was stimulated
by the introduction of economic reforms through
structural adjustment programmes. Initial
debates revolved around the benefits and
disbenefits of economic adjustment, and were
concerned with timing, scale, and debates about
short and long term effectiveness (Cornia et
al. 1987; Mosley et al. 1991; Parfitt 1993;
Stewart 1991). In other words, they were con
cerned with the content of structural adjustment
programmes.
By the end of the 1980s, however, a number of
writers were pointing to the poverty of this ap
proach. Elliott (1988) argued that the prescrip
tions of structural adjustment programmes in
Africa assumed that reforms would be accepted
and implemented through a process of policy
dialogue and that this was naive. Policy
reformers did not sufficiently consider the
political culture of African countries and it was
the political culture that would ensure that
reforms failed. Nelson (1990) and Haggard and
Kaufman (1992) also argued that economic
analyses world-wide had neglected the political
dimensions, and without an understanding of the
process of policy (and, for example, the risks
political leaders were being asked to take), policy
failure was likely. An analysis of economic
development experience in Africa demonstrated
that the continent's comparatively poor perfor
mance could have been predicted had analysis
taken more account of political science concepts
of the state, personal rule, history and social
structure (OD1 1992).
The argument that politics and economics could
not be separated in analyzing economic policy
reform was captured in Lindenberg’s description
of ‘two-legged’ governments:
‘One leg is economic, consisting of all the
national economic strategies designed to im
prove the well being of the population. The
other leg is political, because econo*':c
strategies rarely endure unless (hey are u..,o
politically feasible. Problems with either leg
can cause a government to stumble. Poorly
conceived economic strategy can result in
undue national hardship. Popular reaction
to ill conceived policies i$ sometimes
strong enough to bring governments down.
Similarly, politically expedient policies can
keep rulers in power in the short term at the
expense of national bankruptcy, increased
human misery and eventual public outrage.’
(1989; 359)
The implication of the thinking of all these
scholars was that had policy reformers perceived
governments as two-legged when they introduced
structural adjustment policies, the much criti
cized prescriptive manner of introducing anc
forcing reforms might have been avoided, and
implementation tailored more to the needs of
individual countries.
Many writing in the political economy field take
a dynamic approach to policy analysis, believing
that if policy analysis precedes policy choice,
the chances of more effective implementation
are greater. ‘Policy analysis matters because it
helps us to act effectively’ (Wuyts 1992; 285).
This position is arrived at through the develop
ment of explanatory frameworks of relationships
between state and society, political actors such as
governments, foreign donors and interest
groups, which draw on historical, cultural and
sociological concepts to add depth to explana
tion. While all start with the premise that
political factors are a feature of all policy
analysis, they offer a wide variety of approaches
and frameworks. Some however, focus more on
Policy analysis in health sector reform
the macro-political context of policy-making,
and others on the actors involved in policymaking, although inevitably there is a great deal
of overlap.
Foeusing on context
Many policy analysts are concerned to make
explicit the macro, contextual factors that in
fluence policy. Their central concern is with the
state and its role in economic policy reform.
However they write from different perspectives.
One of the dominant questions has been about
the rightful role of the state. This debate
underlies all policy analysis, viewing the state
either as having a central role in policy-making,
or as having an increasingly marginal role.
Mackintosh (1992) reviews the political and theo
retical critiques of the state. The ‘public interest’
view of the state, which underpinned early
development theory, was challenged by two
critiques:"the Marxist critics who saw the state as
ruled by class and power relations (suggesting the
state was not a disinterested institution pro
moting the public interest, but one exercising
power in favour of dominant classes); and the
‘private interest’ (or public choice) theorists, who
argued that the state was made up of selfinterested bureaucrats and politicians who, in
their search for power, would be forced to
respond to majority views. This view of the
state provided the rationale for reductions in the
role of government and increased competition
between state structures.
Mackintosh’s clear analysis shows that whilst
Marxist and ‘private interest’ analyses have some
similarities, they cannot necessarily be reconciled
with the ‘public interest’ view of the state.
‘Reform of the state on a market model conflicts
with reform which seeks to strengthen the state
as a vehicle of social solidarity’ (Mackintosh
1992; 89). Others have also criticized the ‘pri
vate interest’ or public choice theorists. Toye
(1993; 135-6), for example, accuses them of
displaying a ‘profoundly cynical view of the state
in developing countries’, suggesting that ‘to at
tribute individual self-interest as their exclusive
motive to politicians in developing countries is to
deny their sincerity, their merit and, ultimately,
their legitimate right to govern’.
While many policy analysts accept the need for
reform of the state, most perceive that the state
361
must continue to have a central role in policymaking. Streeten (1993) emphasizes the role of
state intervention in assisting markets to work
better, not simply favouring the already power
ful groups. Perkins and Roemer (1991) also
observe that the state cannot be treated simply as
an impediment to the proper functioning of free
markets - the real debate is not so much whether
the state should be involved but how state in
tervention should be handled. Klitgaard (1991b)
argues that policy analysts need to go beyond the
‘state versus market’ arguments, challenging
them to make both the market and the state work
better.
Others have characterized the state as weak or
strong, and looked for factors which helped to
provide political explanations for patterns of
policy. Whitehead (1990), for example, surveys 8
overlapping factors which provide explanations
for differences in macroeconomic management
of change in developing countries. He suggests
that it should be possible to synthesize these 8
factors, identify whether states are strong or
weak, and then analyze what this would mean
for the speed, flexibility and likely effectiveness
of various policy options. The factors Whitehead
identifies as important to consider in policy
analysis are: historical traditions (colonialism,
independence, experience of war); sociostructural determinants (social class, ethnic and
religious divisions); the self-interest of politically
powerful sectors (the position of ruling elites);
entrenched characteristics of the political system
(democratic experience); formal properties of the
political institutions (regulation of state power,
authority and accountability); the influence of
particular economic ideologies or schools of
thought (neo-liberalism); the logic of particular
sequential processes of the ‘vicious circle’ (grow
ing inflation leads to speculation, high interest
rates, hoarding) against the ‘virtuous circle’
(price stability causes prices to fall, wages to
stabilize, confidence to return); and a variety of
ad hoc or conjunctural considerations (such as
accidents of good or bad timing).
Migdal (1988) also attempts to characterize states
as weak or strong, but juxtaposes them against
‘society’, arguing that many low income coun
tries have weak states and strong societies, which
explains the partial or failed implementation of
many policies. According to this view, the state
362
Gill Walt and Lucy Gilson
this century has had a tenuous hold on society
which is why it often falls back on the military.
Other institutions - religious, caste, tribe or
family - have kept these societies together.
Consequently, the capacity of the state to inter
vene effectively has always been weak. Hinnebusch (1993) has used the notion of strong and
weak state and society to explain the politics of
economic reform in Egypt, suggesting that the
balance of power between state and society af
fects the policy process. For example, when there
is a strong state and a strong society, he suggests
there is likely to be a balance of power between
the two, and therefore considerable consensus on
reform. With a weak state and weak society there
is little strength to reform, and unresolved prob
lems increase the state’s vulnerability to external
forces, so that reform is imposed.
Writers concerned with the context of policymaking do not only focus on the state. Some are
concerned with culture, and the extent to which
cultural factors pervade the policy environment.
Hyden (1983), for example, has argued that
cultural factors are an important part of the
policy context, influencing political behaviour.
His description of an African ‘economy of affec
tion’ explores traditional obligations at all levels
of society, and illustrates how these lead to con
tradictory expectations of those in all levels of
public office (obligations to family versus the
promotion of national interest, for example).
Liddle (1992; 797) argues that in Indonesian
political culture the pervasive notion of keTimuran or ‘Eastern-ness’ must be taken into
account in considering the policy environment:
‘Ke-Timuran has to do with the attitudes
necessary to the maintenance of a harmonious
society. It contains such ideas as respect for
the views of others in general, deference to
elders and to authority in particular, a notion
that differences of opinion should be ex
pressed privately and nonconfrontationally.’
Focusing on actors
For many writers concerned with policy analysis,
the key determinant of policy change is the group
of actors involved, and the focus is often on
government. Lindenberg (1989), for example,
reviews how the governments of Panama, Costa
Rica and Guatemala managed support and op
position to their stabilization and structural ad
justment policies in the mid-1980s. He concludes
his analysis with a set of initial lessons which
could help other governments manage the ‘win
ners and losers during the process o'f economic
change’, although he points out these are not
blueprints given each country’s unique history
and policy environment. In his analysis of ad
justment policies in three African countries Toye
(1992) concludes that the World Bank did not
sufficiently take into consideration the vested in
terests of government leaders and rich farmers in
the agricultural sector, and as a result, efforts to
reform the economy faltered.
Attempting to answer the question ‘Who makes
Economic policy in Africa?’, Gulhatt (1990) sug
gests national policy-makers are influenced by
four political variables: political trends in the
country, and especially the character of the ruler
(he divides rulers into ‘princes’, autocrats, pro
phets and tyrants); social stratification (class,
ethnic and regional loyalties); foreign donors and
investors; and the size and quality of the civil ser
vice. These variables (some of which overlap
with Whitehead’s) focus on the actors within
each category, and attempt to provide an over
view of the political culture of the country.
Gulhati goes on to identify points of intervention
in the resulting policy environment if reforms arc
to be successful.
In reviewing Whitehead and Gulhati’s papers,
Bery (1990) suggests that both frameworks, while
not that useful for national policy-makers, offer
outsiders, such as donors, a way of assessing the
probability of success of a particular reform
effort. Perhaps because he is focusing on Africa,
and Whitehead’s examples are more from Latin
America, Gulhati accords donors far greater in
fluence in shaping national decisions; he also
shows more concern than Whitehead for the
extent to which the civil service affects the
execution of policies.
Attention on the civil service is argued to be im
portant because of the strategic roles bureaucrats
play in the implementation of reforms. Some
have sought to understand the influence of actors
by focusing on the relationship between politi
cians and bureaucrats. Brown (1989), Mukan-
Policy analysis in health sector reform
dala (1992) and Panday (1989) for example,
argue that in Liberia, Tanzania and Nepal
respectively bureaucrats have played a relatively
insignificant role in the policy process, largely
because of the dominance of politicians (and in
Nepal the Royal Palace).5 In contrast, Koehn
(1983) has argued that Nigeria has seen so many
changes of mainly military government that civil
servants have controlled policy-making through
their greater expertise and continuity. Charlton
(1991) likewise suggests that in comparison with
politicians, civil servants in Botswana played a
particularly important role at independence,
although the balance of power between politi
cians and bureaucrats changed over time.
Gulhati (1991) observes that the failure to build
consensus between officials and politicians on
the need for reform in Zambia (and the fact that
the reform measures were largely developed out
side Zambia by the IMF, World Bank and
foreign consultants) was one of the reasons for
that country’s economic impasse during the
1980s.
A few writers are concerned with societal actors,
rather than policy elites within government (Ghai
1992). Tironi and Lagos (1991), for example,
argue that structural adjustment policies in Latin
America are bringing about profound changes in
the social structure of those countries implement
ing them. They suggest a number of factors (the
strength of the government and its administra
tion, the dependence on multilateral financial
agencies, the will and capacity of social actors to
resist) will determine whether structural adjust
ment policies are implemented by shock
measures or more gradually. They place par
ticular emphasis on the roles of trade unions and
the business community, and on marginal social
groups as well as political parties and the
state, exploring their relative influence on the
constellation of factors that influence policy.
In his review of development policy as a process,
Wuyts (1992; 283) argues that the public cannot
be separated from the state: ‘State institutions
are influenced by public action, and in turn, pro
vide the means through which this action is sus
tained or modified.’ He argues that public action
is not simply an additional factor in analyzing
the state’s role in the policy process, but is an in
tegral part. Hyden and Karlstrom (1993; 1402)
also emphasize the complexity of policy en
363
vironments and interaction of actors within
them:
‘a narrow focus on the inherent values of
specific policy instruments or on the presumed
interests of various policy actors at a certain
time is not enough. What needs to be added is
a longitudinal dimension that helps us under
stand how various actors interact with each
other on specific issues and with what out
comes.’
Liddle (1992) writes from the development
(rather than economic) perspective, arguing that
theories of the causes of development in the
Third World have paid too little attention to
policy, and are too concerned with generaliza
tion. The tendency to formulate global assess
ments and prescriptions in development is taken
up by Uphoff (1992) who proposes an approach
which ‘particularizes’ and disaggregates. Long
and Van der Ploeg (1989) also criticize develop
ment theories for espousing rather general,
mechanical models of the relationship between
policy, implementation and outcomes. They take
an actor perspective that starts with individuals
and their households rather than with political
elites in government, and argue in favour of
deconstructing the process of policy implementa
tion, looking more closely at how interventions
‘enter the life worlds of the individuals and
groups affected and thus come to form part of
the resources and ' constraints of the social
strategies they develop’ (1989; 228).
To sum up, the papers reviewed above represent
a number of publications which have appeared
over the past few years which are concerned with
the effects of policy. Basic to their argument is
the fact that policy outcomes can only be
understood within a historical context, and by
identifying the different actors who may have in
fluenced policy. However, few scholars look ex
plicitly at the process of policy-making, Grindle
and Thomas (1991) being the most important ex
ception to this observation. Partly this is because
each analyst comes from a different perspective
or central concern, ranging from macro-political
views of the state and state-societal relations, to
micro-political views of how policies affect and
are influenced by individuals and households.
The literature is therefore diffuse and rich in its
diversity and complexity, but lacks consistency
and rigor.
364
Gill Walt and Lucy Gilson
Focus on processes
Very few of the papers described above do more
than touch on the processes of policy-making:
they are more concerned with explaining contex
tual factors or the behaviour of actors. What
Grindle and Thomas (1991) provide is an
analytical framework which incorporates pro
cesses to help understand how public policy is
made, and who influences it. Their approach is
mostly derived from economic policy reform,
although they give one example of health sector
reform in Mali. They focus on actors (policy
elites who are largely perceived as key politicians
and bureaucrats) and processes of agenda set
ting, decision making and implementing reform.
While principally analytic, they try to map out a
process and identify critical factors that affect
the policy outcomes of reform initiatives, believ
ing that this approach can help to influence the
process of reform as well as to understand
it. They compare the policy process in cir
cumstances of crisis as well as routine or
politics-as-usual’, take into consideration the
likely responses to particular policies (support
and resistance, where it arises, and its relative
strengths), the resources needed for implementa
tion, and include judgements about enabling or
constraining contexts.
Their analysis focuses on the overlapping boun
daries of state and society, and although they
somewhat neglect the role of vested interests and
interest groups, the framework they offer is
unusual because they integrate explicitly context,
actors and processes of policy-making.
Health policy analysis
As has been shown, economic reform led to a
spate of papers arguing that more attention
should be focused on the policy environment.
The result has been a valuable outgrowth of
approaches, rich in diversity and explanation.
However, it has hardly touched the health sector*
Although health reform has paralleled economic
reform in many developing countries (not to
mention the industrialized world), little interest
has been shown in the policy environment. In the
mid-1980s Abel-Smith, for example, drew atten
tion to the world economic crisis and its reper
cussions on health, demonstrating the drastic
effects of recession. Structural adjustment pro
grammes were alluded to (in terms of govern-
ment cut-backs in the health sector), but th'.,
focus was on economics and not politics (AbelSmith 1986). A few exceptions to this focus stand
out. Analysis of health sector reforms in Chad
and in Niger explored some of the political and
economic factors that explained partial or slow
implementation of reforms (Foltz 1994; Foltz
and Foltz 1991). Bennett and Tangcharoensathien (1994) analyzed the context and processes
of policy change encouraging the growth oi
private health care in Thailand, drawing on
Grindle and Thomas' analytical framework.
Dahlgren (1990) and Mwabu (1993) evaluate the
process of introducing charges into the Kenyan
health sector; Reich explored pharmaceutical
policies in a number of countries using a pol al
economy perspective (1994a).
These papers suggest that health Reform is not
easy, is subject to considerable external in
fluences (external to the health sector as well as
to the country) and is often resisted. A review of
health sector reforms in 4 countries in Africa
supported by non-project aid from the US
Agency for International Development, con
cludes that evaluation of a number of experiences
suggests that
‘the completion of health sector reforms is
more difficult than that of reform in other
sectors.’ (Donaldson 1993; 13)
Some of the reasons why the health sector • >y
differ from the economic sector may lie in s^h
factors as the peculiarities of the health care
market, the status of health professionals, con
flicts over values about coverage, access to high
technology, and control over the quality of life.
While there is a lack of policy analysis on health
reform in developing countries (as described
above), there is a sparse literature which is con
cerned with actors and their roles in health
policy-making, and with political economy ap
proaches to health.
Ugalde (1978) focused on policy-making in the
health sector in Colombia and Iran, showing that
not only did medical professionals and their
values dominate the policy process, but that
policy-making was limited to a tight circle of top
elites, especially in Iran but also in Colombia.
Ugalde suggests that international donors
Policy analysis in health sector reform
perpetuated this under-developed system of de
mand articulation in spite of rhetoric about com
munity participation. The strong position of a
small elite of health professionals in influencing
health policy was also apparent in Mozambique
after independence (Walt and Cliff 1986) and the
authors suggest that exogenous factors such as
war and structural adjustment agreements
(negotiations with the IMF and World Bank
began in 1985) combined to change the thrust of
health policy.
Many of those writing about health policy in
developing countries have been concerned about
the extent to which national health policy making
has been undermined since the 1980s by
dependence on donors. In some countries in
Africa between 60-70% of the government
health budget is provided from external sources.
A few case studies have explored directly how far
donors are influencing health policy in particular
countries (Okuonzi and Macrae 1994; Cliff 1993;
Cliff et al. 1986; Linsenmeyer 1989), and others
have looked at donor influence as part of the
health policy arena both within less developed
countries (Justice 1986) and from inside the
agencies (Gerein 1986). Emerging global inter
dependence is also a major concern in the
analysis of the increase in violence and complex,
large-scale disasters (Duffield 1994). The impact
of political violence on health and health services
has been described as a public health issue by Zwi
and Ugalde (1991) and its lasting impact on
‘post’-conflict societies is illustrated by Macrae,
Zwi and Birungi (1994). Duffield (1994) suggests
that aid agencies have often depoliticized policy
by reducing it to a technical matter of organiza
tion or good practice, and argues strongly that
policy must be premised on the centrality of in
digenous political relations and not imposed
from outside.
There are a few political economy approaches to
analyzing health policy. One of the earliest
historical overviews of how political and
economic systems affected the development of
health care is Doyal’s Political Economy of
Health (1979). Turshen (1984) used a similar
analytical approach to describe how disease ex
periences changed with colonial history in Tan
zania, and how politics has affected public health
issues (Turshen 1989). A more recent and use
ful review on the political economy of health
365
transitions is provided by Reich (1994b), who
distinguishes between two approaches: the
government intervention school, which sees a
place for public sector control over the free
market, and the neo-liberal or market forces
school, which rejects government intervention
and looks to the private sector for advances in
health policy. Morgan (1993) also takes a
political economy approach in looking at com
munity participation in health in Costa Rica.
Stock and Anyinam (1992) conclude that health
services have not been greatly influenced by
ideology in Africa, but as neo-liberal reforms
begin to bite this conclusion may be challenged.
Kalumba and Freund (1989) suggest that revela
tions of social discrepancies within and between
regions led to the eclipse of idealism in Zambia in
the late 1980s.
The growth of global interdependence has
highlighted the role of international and bilateral
agencies in health, and their relationships with
national policy-making. A critique of WHO’s
Health for All advocacy by Navarro (1984) ex
plored the relationship between global political
rhetoric and power. A number of international
relations scholars have examined policy-making
in international agencies: Sikkink (1986) looked
at the agenda setting role of UNICEF and WHO
in relation to the International Code on
Breastmilk Substitutes; Taylor (1991) examined
several international agencies, one of which was
WHO, to explore the consequences of financial
pressures in the UN system. One of the issues on
changes in financing within WHO raises ques
tions of where power lies within the organization
(Walt 1993). Several authors have explored the
role of international agencies in the development
of pharmaceutical policy (Kanji et al. 1992;
Chetley 1990; Reich 1987).
Although many of the above papers use a policy
analysis approach, it is often implicit. In con
trast, Leichter’s comparative framework of 4
health policies in 4 industrialized countries offers
a useful and explicit overview for policy analysis,
and can be adapted to different situations. He
draws on 4 contextual categories of factors which
affect the policy process: situational, structural,
cultural and environmental, which offer a
scheme for analyzing public policy (Leichter
1979; 41).
366
Gill Walt and Lucy Gilson
The dearth of literature that addresses the way in
which health policies are made and implemented
in the developing world emphasises the need for
more detailed and comprehensive health policy
analysis.
Building policy analysis into health
studies
We have argued that historically much health
policy has been simply concerned with the
technical features of policy content, rather than
with the processes of putting policy into effect.
As a result policy changes have often been im
plemented ineffectively and expected policy out
comes have not been achieved. Policy analysis
cannot continue to ignore the how of policy
reform.
While the policy environment in health was
relatively consensual, the technical orientation of
health policy raised few objections. However,
the current policy environment is more uncertain
and more conflictual, and policy debates raise
fundamental questions about the values and
group interests being furthered by policy change.
Given that policy reforms often depend on
political compromise and not on rational debate,
a particular influence on their impact is the
power structure within which they operate. In the
health sector there are important and influential
policy networks of managers and professionals
and, at least in the UK, the hostility and dif
ferences between these two groups are legion
(Salter 1994). In many low income countries
there are large gaps between top and lower level
bureaucrats, between nurses and doctors, bet
ween policy elites and managers. In such coun
tries power is further complicated because it rests
not only on internal relationships, but
significantly, on external relationships with ad
visers, experts, aid donors and financial institu
tions. Policy analysis cannot continue to ignore
the influence of values and group interests - the
who of policy reform - on policy choice and im
plementation practices.
Our simple analytical model (Figure 1) em
phasizes the critical role of these actors in the
policy process, influencing the values inherent in
policy and the specific policies chosen through
that process, and influenced by the policy con
text (historical, political, economic and soclo-
cultural). Decisions over policy content are not
simply technical, but reflect what is politically
feasible at the time of policy choice. Seeing
policy as a dynamic process is also key to this
analysis: the policy environment is continuously
shifting, transforming relations between groups
and between institutions. Indeed Warwick (1979)
refers to ‘transactional analysis’ rather than
policy analysis to stress the complexity of social,
economic and political interactions which in
clude value systems.
In promoting this view of policy analysis we are
aware of the arguments that are marshalled
against policy analysis: that all policy is decided
for political reasons, and is therefore unique .
time and place; that because it is so complex, the
social sciences cannot offer sufficiently specific
tools to be precise about outcomes; that access to
information is difficult and can be delicate; that
it may become quickly outdated especially in
unstable political situations; that policy analysis
is based on Western concepts, which are not ap
plicable in less developed countries. The conclu
sion from such points is that there is little point
in doing policy analysis, apart from intrinsic
understanding, because it is never generalizable
and cannot lead to change.
We strongly disagree with these arguments. In
deed, one of the reasons for policy analysis is
precisely to influence policy outcomes. As
Grindle and Thomas (1991; 141) put it
‘We have proposed that decision makers and
policy managers can analyze their environ
ment, in the context of a political economy
framework, to see if the conditions and
capacity exist for successfully implementing a
reform.’
Reich (1993) has developed a method of political
mapping to assist in the analysis of policy en
vironments. As a tool, political mapping can be
used for both research (retrospective analysis)
and for planning (prospective analysis). For ex
ample, it offers several different ways for in
vestigating which actors might be affected by a
particular policy, and assessing their relative
strengths and weaknesses. If such an exercise is
undertaken before a policy is put into effect, it
should be possible to assess which groups are
likely to be resistant and to plan strategies to
overcome opposition.
Policy analysis in health sector reform
Others have similarly used policy analysis in
helping national policy-makers think through the
implications of particular health policies
(Gilson 1993). Klitgaard describes his attempts
to build analytical capacity among government
oiiicials in Equatorial Guinea (1991 a) and in
Bolivia (1991b).
We emphasize the critical importance of sen
sitivity and caution in this approach to policy
analysis, recognizing the potential influence of
the analyst’s own values and perspectives over
the analysis and even the decisions made. We
also accept that policies are formulated and im
plemented within specific historical contexts, and
outcomes are dependent on time and place.
However, this does not mean that nothing can be
done to change policy. We suggest that the cur
rent crisis in health demands rigorous and com
prehensive analysis of the policy process and its
influence on policy effectiveness, as input into
future policy making.
Endnotes
1 Long-term evidence for the negative effects on health of
econonmc reforms is still difficult to interpret however and
open io dispute (World Bank 1994).
Leichter (1979) refers to these as situational, structural
cultural and environmental factors.
It must be acknowledged that policy-makers in interna
tional organizations are aware of their own limitations in
national settings, and are not insensitive to intervening or
being seen to be intervening, in issues of sovereignty and
domestic politics. Offering technical advice and assistance on
tne^other hand, is perceived as legitimate.
The terms ‘high’ and ‘low’ politics are borrowed from
the international relations literature, and compare major
contentious policy issues (often crisis engendered), with
rouhne, polilics-as-usual policies (Walt 1994; 42).
It is relevant to note here that one of the criticisms of
policy analysis is that it is subject to continuing change: these
three countries have been subject to major political changes
■since these papers were published, rendering these particular
conclusions useful largely in historical terms.
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370
Gill Walt and Lucy Gilson
Biographies
Gill Walt is a Senior Lecturer in Health Policy, and heads the
International Health Policy Programme in the Health Policy
Unit at the London School of Hygiene and Tropical
Medicine. She has worked largely in southern Africa, and re
cent research has focused on international organizations in
volved in health. Her book, Health Policy: an introduction to
process and power was published by Zed Books earlier this
year.
Lucy Gilson is a lecturer within the ODA-funded Health
Economics and Financing Programme of the London School
of Hygiene and Tropical Medicine and the Department of
Spcial Policy and Administration of the London School of
Economics and Political Science. She has worked primarily
in Africa, particularly Swaziland and Tanzania, and is in
terested in issues of health financing, health care management, political economy and policy analysis approaches to
health.
Correspondence: Dr Gill Walt, Health Policy Unit, London
School of Hygiene and Tropical Medicine, Keppel Street,
London, WC1E 7HT, UK.
--
'.•4.
, »i<».ns iiicilicinc uill remain of interest
n anlhn>poiogiU|| pO|(1|
View
•I provision of health services will
(nd multiple sources of care will con
ic hy Mile lihhgenoiis practitioners
<’ this phenomenon by modifying
ind adding selected modern pro■ cations to their repertoires.
tries will reduce social welfare sector
ight or will not increase them fast
nsale lor inflation and population
ghcr priority is given to military
e will come when pressure by the
countries to reduce armaments in
which improve the quality of life,
the managers of the health sector
“P clhcicntly the full potential of
I resources. As part of this process
II recognize that indigenous medio be completely displaced, linkage
I the traditional will be given less
•serves.
REFERENCES
of the World Health Organization.
i'th lor All /.) the Year
World
ion. Geneva. 1979.
J Anderson B. G. Medical Anthro* York. 1978.
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c Institute of Medicine. London.
medicine and medical science Med
1978
•f World Health Organization and
•r of United Nations Childrens's
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2. 59 70. 1978.
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cd by Knowles J H ). W. W. Nor-
d. Role of the indigenous medicine
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7 149 |9‘’|.
' of resort in the use of therapy
igmticance for health planning in
2. 29 58. 1978.
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Report of the Conimiitee Io A ^ess
>ent Status of -liuriedie Sysrcm of
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The (raining of traditional birth
I xpcricnce of the Danfa Rural
beoiirl Med 29. 197 203. 1977.
|l9x(>famil'V plann‘ng
Rep.
ie Traditional Birth Attendant in
-alth and family planning World
Geneva. 1974
Ao. A.l Mid Vol |6. pp IK24 to INM 19X2
Pimicd HI (iicMl Hiilum All nglu, rcMcivc.l
0277.9516 a: 2llX25-l(lJ(l.UMIO
< opynghl C 19X2 I’crgamon Pros I U
POLICY AND EVALUATION PERSPECTIVES ON
TRADITIONAL HEALTH PRACTITIONERS IN
NATIONAL HEALTH CARE SYSTEMS*
Barbara L. K. Pillsbury
Depanmcn. of Amhropology. Un,vers,,y of Clifornia-Lo. Angeles. Los Angeles. CA 90024. U.S.A.
{
Abstract—After much resistance by physicians i................
?Iai'.t.h;??.n_n"S !° ,rad',ional Practitioners, internauonal policy has recently shifted to support their inclusion in modwn-wcW heaHh
i care programs.
-------- — •- family planning
resist incorporating traditional healers into the
national health care system. Bureaucratic and sociological rca^...
f’
reasons for this are discussed and recommendaltons are made for more balanced evaluation of the traditional
practitioner components that have
en developed in national and other health care systems.
The late 1970s were a major turning point in the long
history of the uncomfortable if not antagonistic re nous practitioners—reasons having to do with socio
lationship between ‘modern’ and 'traditional' healing cultural distance, professional bias, and so on—for
these are already well documented [I], Rather, we
systems. Rather than being a disparaged subject in
focus here on some of the major but less often dis
most medical circles, the possibility of utilizing tra
cussed
structural reasons why national health systems
ditional. or indigenous, practitioners in 'modern' Weshave done so little in utilizing indigenous prac
^rn-type health care systems has now received the
official stamp of WHO approval and become part of titioners even when policies have been adopted that
would seem to pave the way.
the formal policy of that organization as well as of
many national governments and international donor
INTERNATIONAL POLICY: WHERE
agencies alike. A survey of national health systems
APPROPRIATE’
established throughout the less developed nations of
Africa. Asia, and Latin America reveals, however, that
In 1977. the Thirtieth World Health Assembly of
little progress has been made in actually utilizing indi
the World Health Organization passed a resolution
genous health practitioners, especially healers, in
these national systems. It appears in fact that in the promoting development of training and research in
traditional systems of medicine. In the following year.
entire developing world there are only one or two
1978. the international Conference on Primary
countries in which traditional healers have actually Health Care held in Alma-Ata under WHO and UNI
been incorporated, as traditional healers, in the CEF sponsorship passed additional resolutions sup
national health care system.
porting the utilization of indigenous practitioners in
If the policy is there, why then is it so little imple
government-sponsored health care systems. Shortly
mented and how should outcomes be evaluated when thereafter other international •donor' organizations
it is’ These are questions this essay seeks to answer
also adopted similar policies stating that it is now
Part of the answer to the first question lies in the way acceptable for their grants and loans to be used to
policies giving formal approval to utilizing indigenous finance health programs utilizing traditional prac
practitioners were formulated and adopted in the first titioners.
place—with qualification. Part of it lies equally in the
Policies of international agencies concerned with
general, generic difficulties that all developing country health are important in two major ways. Those of the
governments are experiencing in extending public World Health Organization in particular even
health care services into the rural areas. The answer thou«h not direulV enforceable on a country-hyto the second question, that regarding evaluation
coun 1 basis. are preeminentlysi«nificaTf in th;, t In.
relates closely to these difficulties. The present essay
dividuaTmember nations commit themselves
to th; em
irmr.wi
focuses not on the now familiar reasons for the long
ir> priilCiple through~the approval given them by those
standing reluctance or refusal of Western-oriented
natjofis' delegates Policies of various other donor or
medical professionals to accept and work with indigeganizations (such as United Nations agencies, the
World Bank, and bilateral donors such as the U.S
Agency for International Development) are likewise
Paper prepared for symposium. Traditional Health Prac
important in that ihey~provide a great portion of the
titioners in National Health Care Systems. Society for
Applied Anthropology 41st Annual Meeting. Edinburgh
financial resources that presently PcrrniTcleveloping
Scotland. 12 17 April I9SI The author is grateful to
couffny governments to extend national health s^rDr David Dunlop of Dartmouth Medical School for
vicesintoTtiral towns and villages. Thus together the
his insights and thoughtful critique of an earlier version
policies of WHO and the other donor organizations
of this paper.
are of great consequence in giving both sanction and
1825
[
/ V
1826
Barbara L. K. Pillsbi ry
financial means to national governments for the de
velopment and expansion of health systems—systems
that could draw upon the services of traditional prac
titioners. Absence of supportive international policy
in any given sensitive or controversial area docs not
mean that a country will not move ahead on its own.
as did China, but for most countries the existence of
supportive international policy is a major facilitator
in moving ahead. The significant point here, however,
is that while supportive international policy facilitates
adoption of a particular strategy, in this case utiliz
ation of traditional practitioners, it by no means auto
matically assures it will happen.
Looking more closely al the above-mentioned
policy resolutions, we see that they are cautious and
qualified. The 1977 WHO resolution, for example,
after lengthy debate in and out of committee, was
finally formulated as follows (emphasis added):
The Thirtieth World Health Assembly ...
1. Records with appreciation the efforts of WHO to in
itiate studies on the use of traditional systems of medicine
in conjunction with modern medicine;
2. L ryes inrerested yorernnients to give adequate import
ance to the utilization of their traditional systems of medi
cine with appropriate reyulalions. us suited to their national
health systems;
3. Requests the [WHO] Director-General to assist
Member States in organizing educational and research ac
tivities and to award fellowships for training in research
techniques for studies of health care systems and for inves
tigating the technological procedures related to traditional
indigenous systems of medicine; and
4. Further requests the Director-General and rhe Reyional
Directors to yive high priority to technical cooperation for
these activities and to consider appropriate financing of
these activities [2].
The 1978 “Declaration of Alma-Ata**, while simi
larly conferring international sanction and a highlevel go-ahead on the previously contended subject,
was also similarly cautious in stating (emphasis again
added):
Primary health care:...
7. relies, at local and referral levels, on health workers,
including physicians, nurses, midwives, auxiliaries and
community workers as applicable, as well as traditional
practitioners as needed, suitably trained socially and tech
nically to work as a health team and to respond to the
expressed health needs of the community ....
and, under discussion of “technical and operational
aspects’*,
... High priority should be given to the development of
adequate manpower in health and related sectors, suitably
trained for and attuned to primary health care, including
traditional workers and traditional birth attendants, where
appropriate....
and finally, under discussion of community health
workers.
Traditional medical practitioners and birth attendants are
found in most societies. They are often part of the local
community, culture and traditions, and continue to have
high social standing in many places, exerting considerable
influence on local health practices. With the support of the
formal health system, these indigenous practitioners can
become important allies in organizing efforts to improve
the health of the community. Some communities may
select them as community health workers. It is therefore
well wort/i while exploring the [wssihilities nJ ethjaiiuiii them
in primary health care and of training them accordingly
[3]
Finally, the health policy paper of a major bilateral
funder of developing country health programs also
gave cautious sanction to the idea but likewise im
plied reservation in its endorsement, stating:
...Traditional practitioners are already widely utilized
in their communities and may provide effective care in
many circumstances. Specific types of traditional prac
titioners who may be encouruyed to participate in primary
health care programs include midwives (“traditional birth
attendants"), herbalists, and religious and secular leaders
and counselors who already provide information and as
sistance on fertility regulation and maternal and child
health. Traditional medicines also deserve further study as a
readily available and inexpensive resource for combatting
certain prevalent health problems [4].
In all the above policy statements, and in related
documents of the respective agencies, two facts are
noteworthy. First, they all are concensus documents,
arrived at after considerable debate and difference of
opinion; thus the choice of gentle wording and use of
qualifiers such as ’where appropriate' and ’as needed*
was necessary in order to bring divergent minds into
agreement while leaving wide latitude for interpreta
tion. Second, these documents generally say more,
and do so more positively, about indigenous mid
wives ('traditional birth attendants') than about indi
genous healers. The policies say it is permissible, and
perhaps even recommended, to utilize indigenous
midwives and healers, but they leave it up to others to
determine when the time is appropriate. In reality,
then, as these policies are implemented (i.e. as rep
resentatives of these agencies sit down among them
selves. or with health planners in the developing
countries, and reach decisions as to what particular
activities their funds will be used to finance) indige
nous practitioners, and especially indigenous healers,
are often simply forgotten unless the developing
country personnel themselves decide that the time
and place are appropriate. Relative to their active
promotion of other health improvement strategies, in
ternational agencies do not take particularly active
initiative in facilitating or even encouraging the utiliz
ation of traditional practitioners. Where they do. the
initiative far more often concerns indigenous mid
wives than indigenous healers.
Policies of the international agencies thus leave the
developing country health planners with essentially
the same set of policy options that they had before
with regard to utilizing traditional practitioners. A
typology of six such policy options can be easily
identified:
(a) Illegalization or otherwise severe restriction of
traditional practitioners (an option that, in countries
where adopted, has nowhere yet proven possible to
fully implement).
(b) Ignoring traditional practitioners, at least offi
cially.
(c) Nonformal recognition of and occasional co
operation with traditional practitioners.
Policy and evaluation perspectives on traditional health practitioners
(d) Formal recognition of traditional practitioners
and their various institutions.
(e) Recruitment and twining practitioners for incor
poration or utilization in a modern-sector primary
health care program. (This is actually two policy
options—one being the ’upgrading' strategy in which
traditional practitioners are given training to improve
the way they carry out their traditional repertoire of
tasks and the second being the strategy in which tra
ditional practitioners are recruited to a newly insti
tuted cadre of community, or village, health workers
and then trained in a new repertoire of tasks.)
(f) Licensing or registration of traditional prac
titioners. which may or may not be combined with (d)
or (e) above (licensing, like illegalization. also being
difficult if not impossible to implement throughout
rural districts).
(g) Actual integration of traditional and modern
systems with referral and similar cooperation pro
ceeding in both directions (also extremely difficult to
implement) [5].
IMPLEMEXTATIOV CRl CIAL DISTISCTIONS
IN TTILIZAT1OV
To understand what has and has not been ac
complished by way of actual efforts to ‘incorporate’ or
‘utilize* indigenous practitioners in national health
care programs, three crucial distinctions must be
made concerning the type of practitioner and the type
of traditional-modern relationship. These arc: (I)
between government pobH-f nf
incorporation
vs simple coexistence: (2) between traditional mid;
wives and traditional healers -and (3) between■ pilot
projects and national programs-—•
Regarding the first of these distinctions, where
governments have officially accepted the existence
and institutions of traditional practitioners, most are
still more likely to let the traditional practitioners
simply coexist in a pluralism of health systems rather
than to incorporate the traditional practitioners as
paid workers in the national (official) health care sys
tem. A case in point is India where the national
government permits Ayurvedic. Yunani, and other
traditional practitioners to pursue flourishing prac
tices and in 1972 even announced a plan in which
they would become core workers in a nationwide
rural health care system. The plan was abandoned
shortly thereafter, however, following the replacement
of the health minister under whom the plan was for
mulated. Instead the Indian government has subsequenTTy" created, as the mainstay of its national
primaPy health cure system, a new cadre of health
care providers called communitY health workers'.
mosFof-whinii tradTittle if any prior health care ^xperience and very few of whom had ever Mantraditional practitioners [6]. A similar sequence of
events lias occurred in numerous other countries.
As for the second distinction, projects and pro
grams that have incorporated indigenous midwives
('traditional birth attendants') are far more numerous
than those incorporating traditional healers (at per
haps a ratio of al least 20 to 1, although nowhere is
this definitively quantified). A major reason for this is
the fact that traditional midwives, while performing a
wide range of diverse functions, are concerned pri-
1827
marily with the technical processes of childbirth
where their interventions are not particularly alien to _
modern-sector
professionals—even though
the latter may express dismay over the lack ofstcnle*
procedure arid sanitary environment characterizing
traditional midwife's practice Traditional healers, in
contrast, have a practice frequently premised on
'
supernatural and other belief systems that are dis
tinctly alien to and not easily comprehended by
modern-sector practitioners,Tradnional midwives have been given formal traini
ing (’upgrading') and utilized as service providers in
projects in al least forty-four countrjesj-jhe Asian
countries of Afghanistan^Bangladesh. l^Jr-kidonc- '
sia. Malaysia. Nepal. Pakistan, the
and
Thailand; Bolivia. Brazil. ColombiirCiSsta Rica.
Dominican Republic. Ecuador. El Salvador. Guate
mala. Haiti. Honduras. Mexico. Nicaragua. Panama.
Paraguay and Peru in Latin America: Camerogn,
Central AJpohi Republic. Chad. Ethiopia. Qfjaryl
Kejmi. L^beryZ Mali. Niger. Nigeria. Senegal.iSwjp?
tn). Sudan. Tanzania. Upper Volta, and Zamblain
Al t£a; and. in the Near East. Egypt. Iran. Syria, and
Yemen [7], While there has been much discussion by
governments and funding agencies of possibilities for
incorporating traditional healers as service providers
in modern-sector projects and programs, instances of
this actually occurring are significantly fewer:
Although literature describing the actual attempts is
also much less abundant, the list of countries in which
• such projects and programs have been undertaken
appears to include: Bangladesh. China. India. Nepal,
the Philippines, and Sri Lanka in Asia; Bolivia. Bra
zil. and Haiti in Latin America; and Botswana,
Ghana. Kenya. Liberia. Niger. Nigeria, and Zim
babwe in Africa (with governments in the Near East
being quite staunchly resistant to efforts to support or
encourage indigenous healers). This list totals sixteen
countries in contrast to the forty-four in which
projects have incorporated traditional midwives [8].
It is also worth noting in this context that most of
the projects and programs utilizing traditional healers
have tended to single out herbalists and related
specialists (e.g. compounders) rather than religious,
shamanistic, or other spiritual healers. Again this is in
large part because the procedures and substances of
the herbal-type practitioners are relatively less alien,
and alienating, to modern-sector professionals than
are those of the religious-type practitioner [9], A clear
illustration of this principle is provided by China
where the vigorous promotion of traditional medicine
by the Maoist government meant that it supported
and encouraged herbalists and research and develop
ment of herbal medicine but has sought persistently
to eliminate the large numbers of spiritists and
diviners that flourished before 1949. A minority of
China's ‘barefoot doctors* were originally herbalists,
and all barefoot doctors have been encouraged to use
herbal as well as 'Western' medicines, but few if any
spiritists or diviners have ever become barefoot doc
tors [10].
A result of the greater number of efforts to utilize
traditional midwives is that protocols and standards
for their training, performance, and supervision are
far more numerous and well-developed than for tra
ditional healers, thus making it easier to initiate ad-
L1
- -
'
'
(
5
'
./
■
1828
I
1
Barbara L K. Pillsbury
Policy and evaluation perspectives <on traditional health practitioners
1829
ditional |programs involving
‘
‘traditional midwives,
togetheewith a relatively unfavorable ratio of healthenforced. Thus a policy calling for involvement of tra
.—i- —
j standards
j.
car£_^rkerslo~the~populaiiOn served, makes the
especially difficult tn achieve given the romplrv ennDozens ifr not hundreds of protocols
and
ditional practitioners may be adopted on paper in a
strajntslhat impinge on rural health prngnm
for traditional midwives have been developed, refined,
more intensive and more effective hands-on approach
capital city butjinless persons with conviction and
tiv^nessr-and perhaps equally iLaoi more difficult in 1
and exchanged by and among a large number of the exception rather than the rule. Frequently, even in
clout are in andTimportanth. remain in a position tn
national governments, charitable and other non-gov
*----measutr-eveiMUchifve
d OnJhe mher hand nrnorerc
countries where such pilot projects have been rela
IQ^eejhcnQljicy throu^j^g_actii-r-r
1 ' -------- r
' -'
~
ernmental organizations, and various WHO offices
tively successful, national programs have not adopted
h<^ary. j^onne^and timX^llocations)at the cenffal
[11] . In contrast, projects and protocols for tra
provej access In and improved quality nf health yrthe indigenous practitioner model established by the
anTregiofrarieycls.Jittlc wilTmngeout in the rural
ditional healers probably number only a few dozen at
vices_EBmd££k-is easier to achieve and measure Yet,
pilot project. A case in point is provided by Thailand
communities where the majority of the population
even here the record is not good [24],
- -----most and tend to involve significantly smaller
where nearly three hundred traditional birth attend
livej^Ortetl m dcsdvpIHg countries rapid and sucnumbers of practitioners. The Primary Health Train
ants were trained to deliver services as part of the
cessive shifts of regimes and consequent ministerial «
ing for Indigenous Healers Program in Ghana's
government-sponsored Lampang Health Develop
reshufflings preclude such follow-through despite an 4.
( StrrrM of traditional practitioner component li.'^7
Techiman District provides an unusual example of a
ment Project, which was implemented from 1974 to
dependent on effectiveness of overall program
original intent (as was illustrated bv the abandonment
project centering specifically on traditional healers
1981 as a single-province demonstration project with
noted above of India’s 1972 traditional practitioner "- The status—and success or lack thereof—of the
[12] . In other projects involving traditional healers
expectations
of nation-wide
replication
[16].
national program overall directly influences the status
plan folloing the change of health ministers).
the latter tend to be only a minor element of the
Although the traditional birth attendant component
and success of the component thereof seeking to util
of the Lampang pTqject was regarded as fairly suc
project. For example, the C1MDER project in
2. Paucity of evaluarire findings regarding ejfectirenes* ize traditional practitioners. By way of example, we
_ Z7 0/VColombia, which has emphasized the use of tra
cessful. when the Thai government expanded its
of traditional practitioners
can take health personnel at the district level who are
ditional midwives and healers had. as of 1979. incor
primary health care efforts to a twenty-province pro-~
responsible for .the fo||pw-Up. support, and super- "
There now exists a fairly voluminous literature that
porated seven folk healers (curanderos) but depended
gram in 1978 the new strategy as implemented did not
V-S—n ■■Or_V-!a.ge~leVel hCa!th workers—be they tra, describes indigenous health practitioners in various
include ~~ahy traditional practitioners, even though
for the bulk of its activities on fifteen vaccinators,
ditidrral practitioners or others; if these personnel are
parts of the world and advocates their incorporation
thirty-four health promoters, twelve sanitary inspec
early planning documents indicated that this was to
dissatTsficd over jheir pay and are wi?hout adequate
— modern
a
, 4./ into
healthcarc program^ StH| (hef.c
tors. and eleven multipurpose workers in addition to
happen [17],
/^)
been little systematic
.„
Ume^Ftransportatio-nTo carry ou7 assigned supervievaIuation—either qualitative or
the usual range of nurses and phy sicians [13].
soryj^onsihihljes. then the performance pf tra
AU«nt«tat»vc—of their performance. Neitherr ,.
o,v
have
This brings us to the final distinction noted above,
ditional juactilionrrs as p
art
v
//there been many evaluations of (a) the efficacy of the
REASONS FOR LACK OF GREATER
pa
rt of
of the
the general
general svstem
namely that between pilot projects and national pro/ var*^^ practices of indigenous practitioners nor of (b)
automatically suffers.
PROGRESS EVEN IN POSITIVE
grams^cre is is important to recognize that most
7 the^Tfficacyol utilizing indigenous nractitipners in
NATIONAL POLICY CONTEXT
5- ^anticipated high recurrent costs of national health
attempts to involve traditional practitioners in
^mSdffK:seCtOr Pfog™ms This lack of evaluative rvicare jj.i.i.j„.1
modern-sector health-care activities have occurred in
Excluding from consideration countries whose
defied serves as fuel for the arguments of health planrelatively small pilot or <other
‘
localized' projects in
policies make illegal or otherwise severly restrict tra."Tapas’ couple of years have seen rapidlv mount
- ners and providers who do not want to work with
•
t__ J
i_______
j:.:___ -t
ii
T
which the traditional practitioners
involved have
ditional practitioners, why have countries that have
indigenous practitioners and hinders those who ing awareness that developing country governments
often numbered no more than a dozen or so (for adopted policies favorable to traditional medicine
would like to do so in making a case for doing so or cannot afford the national primary health care pro
example, the CIMDER project noted above). This is
made so little progress—relative to the hopes and
grams that they have set forth in their various fivein knowing exactly how best to proceed [21],
true for both midwife and healer efforts, but especially
promise that advocates have set out—in utilizing tra
year and other development plans. In part the infla
for healers. According to one recent synopsis, of the ditional practitioners in their national health care sys
3. Poor performance of national primary health care tion caused by the post-1974 oil crisis Was been devas
forty-four countries listed above in which pilot or
programs
tems? A number of related observations from the
tating (e.g. a cost increase in Nepal's national health
other small-scale projects have trained and utilized
fields of policy analysis and valuation help clarify this
care sy stem of about 30°o beyond normal, budgetedAt the same time, there now exists a substantial
traditional midwives, only seventeen countries have, question. These observations are not necessarily new.
for inflation). In part the problem is also due tn thr
body of evaluations that have been carried out on
at some time during the past two decades, incorporand may even seem extremely obvious, to medical
fact that as.sumnlions mad*-™ iha pi.-mn,np
national primary health care programs, and these
/iZated traditional midwives into the national health
and development anthropologists familiar with the
unrealistic Io begin with and han proven themselves
point to two general conclusions that are important
'7'
oare system or Janulyplanning program. Thesefljx:
work of anthropologists such as
H
.<ivuuoncr
sincejfoMnstanrr that village health workcu wHl
------to bear in mmd with
regard
to traditional
practitioner
;
Afghanistan. ^angla^esTl^Injjia. Indonesia, Malaysia.
But in general discussions of the effectiveness of tra
evaluation. First is that the performance of national
** content to conlmue working as unpaid volunteers
fi
.
Pakistan, and urr^hilipping in Asia; Colombia.
ditional practitioners—discussions in which phys
: demonstrably
:
----------------------------health care programs in
improving~the" or that distnct-phvsicians would be willing io
Costa_j^£A^LtommicalEciradorr-Haiti. icians. health planners, and other non-social scientists
hedftli of rural Populations has generally been poor.' new supervisory responsibilities without commensnrtf {
Hondura^frteaiccu^and Nicaragua in Latin Ameffca; dominate—the linkage is not often made between the
a,c 'ff^SaSfiSJlLpay). With some exceptions. tHe most*^
Secpnd is the (act thai.litlip conclusive evirlenrr* exists
kpcf*
anj
SlW?lFfsa5y m Atrir-a F14]. OPthe
narrower issues^ concerning traditional practitionersnotable being China, most national health systems in /
thaj proves or establishes the efficacy of other catesixteerbefnmtrteshotec|_above in which pilot or other ahsHt afid the much broader bureaucratic, pro•hc £22£er £Qunliie.s_j2LM77~As,a. and Latin (
gories of rural health care~providers in reducing the
I
small-scale projects have incorporated traditional
fesstuiul. anH policy issues constraining, or al Ic^st
America are financed to a great extent bv foreign \
morbidity and mortality nf rural nonnlatinns The
healers, it appears that only in two. Zimbabwe and cuticti'lhng. entire programs. If is for this reason, and
sorry truth is that it simply cannot be shown—in the donors with the consequence that those countries’ /
possibly Nigeria, are traditional healers being utilized, ih view of the great amount o’f energy that many anth
governments would not be able to mFam the'£F6- (
majority if not all cases of national programs—that
in their traditional healing roles, as service providers ropologists and others still continue to invest in pro
leLft °n-ihcil-own [2.1]- Recent evaluations
health status has improved and. in fact, in some
in the national health-care system. Elsewhere, notably moting the utilization of indigenous practitioners in
instances the incidence of infectious diseases has been
nignTignt the seriousness of this problem in United
in China and Bangladesh, traditional healers have modern-sector programs, while overlooking the ob
States-supported health programs in Senegal and the
found to be on the increase. In Nepal, for example,
also been recruited into the national health care sys stacles to doing so. that the following observations
Philippines, for example, but the problem is widethe incidence of malaria actually became greater in
tem but only as members of a newly-created corps of are presented [19],
spread
[26]. In an environment of such great financial
/
districts where the new national Integrated Com
village health workers (i.e. ‘barefoot doctors' or ‘vil
munity Health Program was first implemented—this
’’ *S. no1 surPr's'ng that program com7
1.
Even
national
policy
is
not
always
implemented
nor
lage medics' respectively) rather than as traditional
in contrast to neighboring districts which experienced
P°nen,s other than traditional practitioners become
always binding
healers per se [15].
higher
priority
in
the
allocation
of
scarce
resources.
/
no such increase [22],
It should also be noted that a large proportion of
It is a well-known fact among policy analysts that
It is not intended here to condemn national health
the pilot projects are ssponsored‘ 'by non-governmental policy performance usually falls short of policy
r •• Priorities of key decision-makers and implementors
care programs or to imply that the rural or primary
p..... .
organizations (both local and foreign) and that they
promise—that the go^ls and targets of th? formula—
health care approach is a failure, as some harsher
take precedence over improving rural health
are implemented in a typically ‘hands-on’ manner tors _of policy______________
htromr iiluted. deferred and even ebb
critics
insist
is
the
case
[23].
Rather
what
is
intended
made__possible by a relatively favorable ratio nf- away
as implementors
Underlying the first observation above is the fact
_ _____
,' - ------- take
—1-. Qver_.[20]. Any muional
is to highlight the need to distinguish among different
healrh-care workers to the population servedthat the political and personal priorities of kev decipolicy may aclLgo ignored unless ft-particulai indi
levels of evaluative criteria according to which pro
. .
sion-makers and program implementors (all up and
NaTional programs, in contrast, are the products of vidual. interest group, or regulatory body of siiffigress is measured. On the, one h-mti. i.;~....
national governments and are thus typically tmple- ciently high administrative authority and capability
lUtimate indj^ down the line but especially, perhaps, at the topi take
ca,ors of-Program firress -Are rriincrd levels (Tmnrmentetfin a top-down bureaucratic manner which .actively pushes to have the pnlirv implemented and
levek of m«r. precedence over more general goals of improving the
hidijy. mortality, and fer’’1 ’ ■ this is u here progress is
------- j hves-mduding the health-of poor, largely illiterate
J"
1830
aid to Pakistan, discussions likewise began about
resuming support to the national basic health services
scheme that had earlier been set back when U.S. stra
tegic priorities overrode developmental priorities.
Clearly such disturbances in a health system's develgovernments seek to develop support from the rural
areas of their countries by the actual provision of
of opment guarantee poor progress for a scheme to utiltraditional practitioners in that system.
health and other services through rural ““outreach" op/^zd
<
juverridinti personal priorities related to personal and
extension programs. Many regimes moreover, ar
V newly established ones in particular, actually use su<ich yimily situations. Frequently persons in charge of im;nv-^plementing health programs at the district and
outreach programs as a form of political dientelism^
subdistrict levels where the program attempts to link
That is. they also seek to develop and consolidate
up with tradition.il practitioners are phyviri-mr nr tidrural support bases bv handing nut inhs and related
ministrators_wJin -are considerably more f.tgrr iofringrTSenefits (such~as~vehicles. buildings, and overadvance their ow n cajxeiS-or their families' socioccnn. ,
seas Training) not just- or even primarily, on the basis
of tecKmcaiqualilications but to persons judged most' omic'positions than engage in the public service, work
with which they argjchiicggd. In virtually every devel-"
likely—nrfender political support. Ihis is true not so
oping country, government physicians are regularly
mucTT perhaps at the-tillage level where personnel are
busy if not preoccupied with a private practice and
most frequently recruited as volunteer workers but at
frequently striving to be transferred back to the capi
the rural township level and above where health
tal: other civil service administrators are often pulling ■
worker positions are more often salaried and fre
hard too at various efforts to augment their modest
quently have civil service status, thus providing a fair
salaries in order to be able to afford to send their
assurance of relative long-term security as well as. in
children to a university in the capital or furnish their
many instances, a base from which to earn additional
home with,modern conveniences. Thus, in the face
income. An example of this sort of political clientelism is pmvjded. by Ranghirlevh'c -rnrps _nf maternal
competing demands for limited time, the great ma|OTity of such individuals are not likely to spend their (
and chiUTicahh workers, a large proportion of
evenings"worrying about how to improve collabo'r- k
are daughters of rural political elites and show TiTtle
atioh with traditional practitioners nor even to devote
J
interest cither in public seryjcg_in_gcaera1 or in worka gTeat amount of on-the-job time, relatively sneak* /
ing toTmpfoveThe health of their..less formnate neigh/
' b°rs *n Particular. If such poorly motivated personrieT ingTto this complicated task
are then askedTiTcollaborate with traditional healers,
7. Culrwre gap from modern to traditional Sector too
the traditional healer component of the larger pro
great for officials to bridge easily
gram is automatically off to a bad start.
Primary health care, regardless of how the particu
'Turf' considerations—the desire of central-level
lar system is set up. is very difficult. Implementation
bureaucrats to retain or enlarge their spheres of control
requires organizing a large body of many different
over staff and budgets. Certainly not unique to devflcategories of workers to perform a complex range of
oping countries, control over bureaucratic ‘turf' is a
goal fieUby'a good many program managers at all" new tasks generally without adequate forethought as
to why those persons should be willing to take on the
levelsand one which, like that just mentioned, is freextra work, in many if not most cases without corre
quently at odds with increasing the effectiveness of a
sponding remuneration for the additional tasks to be
public program, health or otherwise. Thus, sav. a
performed. Given the enormous challenge of trying to
“division chief" in charge of training (including that for
implement a national primary health care scheme, let
traditional practitioners) may be aspiring to expand
alone achieve 'health for all by the year 2000". it has
his' sphere of influence by having the program’s
generally proven more difficult and thus more time
(esearch function combined with training and his own
consuming. at least in The short run, for modern-sec-position then elevated to ‘department director' for
tor personnel to work with traditional practitioners—
(research and training. If his energies arc being spent
\ in this direction (bm he is clearly.kssJlkel>-iQ direct
especially healers—than to work with villagers of the
sort that have “usually been selected in most countries
)adequate attention to ascertaining that his subordinas community or primary health workers. Character
ates in change ol traditional practitioner and -other
istically? the latter have been young people without a
z-commuflfiy-levd training are doing ap pffectiveJob
great deal of schooling—say. perhaps, only six to ten
. ] PoliticaEg'iorities of international funding agenciesyears—yet this schooling has ty pically grounded them
^yrioritieyof international donor agencies contributing
in modern-sector ideas and their relative youth and
2 major portion of the costs for a developing
lack of prior health care experience made them quite
^country's national health system may also be at odds
open to the material put forth in training programs of
with getting the system to perform effectively, or more
national primary health care systems. Traditional
effectively. In Pakistan, for example, a national sevenpractitioners, in contrast, are typically mature adults
year basic health services program being supported
with set ideas, ideas developed through and put into
by the United States government was abruptly cut
real-life everyday practice in a way that makes the
back to a three-year program when in 1979 the U.S.
traditional practitioners less likely to afiTpl.training,
L*/
government decided to cut off economic assistance to
I
material, or other instructions, unless they they are
Pakistan because of U.S. official displeasure over
clearly linked to the realities of the people and en
Pakistan's move to build nuclear reactors. When, fol
vironment that make up their world. This is true not
lowing the Soviet invasion of Afghanistan and the fall
ol the pro-American regime in Iran, the U.S. govern jusTfor training but perhaps to all aspects of performpeeled by the national primary health care
ment again began contemplating restoring economic an
people living out in the rural hinterland [27]. ^rnong
such poliUcaLpricrjlirs are the following,—
\
The^esire of a 'egime to evtend_fts influence and
\ authority jtm IhP loimffys^e. Kot only do national
i
Policy and evaluation perspectives on traditional health practitioners
Barbara L. K. Pillsbury
fwofram attempting to ‘utilize* traditional
prac-
titioners.
Ql ESTIONS FOR THE EV ALL ATION OF
PROORAM COMPONENTS LTILIZING
TRADITIONAL HEALTH PRACTITIONERS
1831
?able to them in appropriate quantities? (f) Support^ ’
rnj/f w/urvision Do the personnel designated as super
visors for the traditional practitioners have adequatetime, transportation, and ot^hgr means to provide fre
quent. supportive assistance (in contrast to~supervision that is infrequent undependable, and authoritativePjg) Slants and relationships to rest of system^
Have as many steps been taken as possible to legiti- J
The performance of traditional health practitioners
who have been brought into a modern-sector health
mize the status of the traditional practitioners and to
care system, or project, must not be evaluated in a
facilitate cooperation with other health professionals I
vacuum. Evaluators must look at not just the pep
in such a way as to maximize chances of improving^/
form.incc of the traditional practitioners but also ask
the health of the population at large?
whether the svstgm nr prn»*ct and especially its tradi;
tional-modern interaction points, was properlv con. _— , ,
. .
s •
ee.WJKj implemented io ,ivf .lie
' * WrrtwWJSMnWh><«*«■ community-level health
atteffijn~~a fair chance^ Where performance of tra-
ditional practitioners has been judged poor by pro
gram administrators and evaluators, this is frequently
attributed to reasons having solely to do with the
traditional practitioners—for example, illiteracy,
superstitiousness, being untrainable. failing lo report
m on schedule, not following instructions given dur
ing training, continuing to use unclean procedures,
unwillingness to cooperate, and so on. While these
may be characteristics of poorer than anticipated per
formance. they should not be accepted as the sole or
even most important reasons for that substandard
performance. Rather, underlying explanations should
be sought in the structure of the health care system
that has been attempting to utilize the traditional
practitioners. That is. their performance should be
viewed as an .outcome .and then the “inputs and
related components leading to that outcome also
exalfimed. It is suggested, therefore, that each evalu-*1
atifih of the traditional practitioner component of a
national healthcare system seek to answer the follow-ing key questions [28].
Performance of the traditional practitioners
What improvements in the health of the rural
population served has occurred or is occurring as a
result of bringing traditional practitioners into the
formal health care system? If it is too soon to see clear
changes, what evidence exists that such improvements
are likely to_oc£ifQn- the near-Tuture? [29]
'.easons for effective performance, or lack thereof
Under this rubric are
qrwiiens to answer
(each needing further specification of indicators as to
what constitutes “best', “most appropriate", “most
likely", and so on). These are the following, ftf) Propram dcsicin. Is the strategy for utilizing traditional
practitioners the best that could be employed given
existing local and national constraints (e.g. cultural,
economic, and infrastructural)? (b! Recruirment. Are
the selection criteria according to which traditional
practitioners have been recruited those most appro
priate for bringing in traditional practitioners most
Rikely to perform effectively'’ (c) Trainimi. Are the
i training curricula and materials as practical as poss
ible and tailored to the local culture and conditions?
(d) Rcsponsihilidfs. Arc the expectations of tasks to be
performed by the traditional practitioners appropriate
given prevailing health problems and realistic given
.local culture and conditions? (e) Supplies. Are the
equipment and drugs that the traditional practitioners
art ex
I to use and dispense consistently avail-
77^ 41/^^
Mor <T
How more or less effective are the traditional prac
titioners than other categories of health workers in
actually bringing about health improvements at the
community level? Here it is necessary to look care
fully also at the performance of both established
medical system practitioners (i.e. physicians, nurses.
and midwives) as well as newly recruited categories of
workers (i.e. community or primary health care
workers, volunteer or otherwise). Whqj clear evidence
exists_ that-these Jatter-categories, of personnel w ill
prove more cost-effective during the next decade or so
in improvTng'tKe health of the general~populace, especraTTy or that great majority of it who live in the
rural areas? [30J Finally, how should this knowledge
be'^used to improve the overt!! performance of the
health cure system?
RECOMMENDATIONS FOR SOCIAL SCIENTISTS
Time is long past for social scientists to move
beyond describing, extolling the virtues of traditional
health practitioners, and advocating their inclusion in
modern health care systems. The above observations
taken together suggest four recommendations to
which those of us who are social scientists concerned
with community-level health in Africa. Asia, and
Latin America should
ild pay greater attention in our
future work. FirstUwe.* must seek more consistently to
involve traditional practitioners at tfie earliest pncc^B
ible planning stages in all research an<
‘
id.^u
’vice
•dlSeCond.
projects with which we ourselves are engagec^
—,
there is need for us to turn more attention to the area
of nffn«ivMtinn-Al
ti is increasingly clear that
health planners in capital cities make many unrealis
tic assumptions about what village and other rural
people do and can be motivated to do. Here anthro
pological and other sociological studies can provide
information of great use in designing programs more
linfedjo reality and thus more likely to succeed.
TFiTrdT^oere is likewise great need for social scientists"
wortfng st the village level to devote more attention
to quevfions TcT.iled to the economics of health care;
Here also national-level planners have been making
many overoptimistic and similarly inaccurate assump
tions about community health financing -healthrelated expenditure patterns and the willingness of vil
lagers to engage in health work for little or no re
muneration: here also is an opportunity for social
scientists to make important contributions to improv
ing the knowledge base on which mujiimillion-dnllar
heahhjl!ll?r:|ms :«rp—hnilt—Eaur|ti<ahd finally, it is
.
1832
Barbara L. K. Pillsbury
important that we. in our writing, put forth clear rec
ommendations and conclusions that health planners
can draw upon tn improving program design and im
plementation. Many social scientists among us may
respond to this by protesting that their data do not
permit them to be so bold. To this we must urge that
social scientists be bold and press forth with rec
ommendations as far as it is possible based not just
on their data but also on their related sociological
insights and then, rather than stopping at that point,
continue by offering hypotheses that
their
obser
vations suggest. This will serve not only health plan
ners and program implementors but will also have the
merit of simultaneously serving the social scientist's
own
discipline
by contributing
ultimately
to
the
building up of a greater theoretical body of knowl
edge. In so doing we will thereby contribute not only
to knowledge about traditional practitioners but also
to the larger body of theory and practice related to
improving the health of the hundreds of millions of
rural people for whom today traditional health prac
titioners are still the primary health care workers.
REFERENCES
1. For systematic overview and analysis of the arguments
for and against working with traditional practitioners,
see Pillsbury B. L. K. Reaching the Rural Poor: Indige
nous Health Practitioners Are There Already. U.S.
Agency for International Development Program
Evaluation Discussion Paper No. I. Washington. DC.
1979. Also see Harrison I. E. and Dunlop D. W. (Eds)
Traditional Healers: Use and \on-Use in Health Care
Delivery. Michigan State University. African Studies
Center. Rural Africana No. 26. East Lansing. MI
1974-1975 and Taylor C. The place of indigenous
medical practitioners in the modernization of health
services. In -tsian Medical Systems: .4 Comparative
Study (Edited by Leslie C). pp. 285-299. University of
California Press. Berkeley 1976.
2. World Health Organization. Committee A: Pro
visional Record of the 18th Meeting. Thirtieth World
Health Assembly A30 A SR 18. 1977.
3. World Health Organization. Primary Health Care.
Report of the International Conference on Primary
Health Care. Alma-Ata. USSR. pp. 5. 19 and 63.
Geneva. 1978.
4. L S Agency for International Development. Health
Sector Policy Paper, pp. 14-15. Washington. DC 1980.
At the present time, of the (approx.) 48 national health
Systems to which AID gives support, approx. 18 are
making some effort to work with traditional midwives
but only about 6 are trying to work with indigenous
healers.
5. More detailed discussion of a similar typology of
policy options is presented in Green E. C. Roles for
African traditional healers in mental health care. Med.
Anthrop. 4(4). 489-521 1980.
6. See. for example. Jeffery R. Policies towards indigenous
healers in Independent India. Soc. Sci. Med. 16. 18351841. 1982.
7. Five extensive surveys of such projects involving tra
ditional midwives are provided by de Lourdes V. M.
and Turnbull L. M. The Traditional Birth Attendant in
Maternal and Child Health and Family Planning. W HO
Offset Publication No. 18. Geneva. 1975; World
Health Organization. Traditional Birth Attendants: A
Field Guide to Their Training. Evaluation, and Articula
tion with Health Services. WHO Offset Publication No.
44. Geneva. 1979; Traditional Birth Attendants: ,4n
Annotated Bibliography on Their Training. Utilization.
and Evaluation. WHO Publication HMD NLR 79.1.
Geneva, and Supplement I: Traditional Birth Atten
dants—An Annotated Bibliography on Their Training.
Utilization
and
Evaluation.
WHO
Publication
HMD NUR 81.1. 1981; and the Johns Hopkins Uni
versity Population Information Program. Traditional
midwives and family planning. Popul. Rep. Series J.
No. 22. 1980. See aiso Midwives and modernization.
Special issue of Med. Anthrop. 5(1). 1981.
8. This list includes the following project and program
efforts (some of which, however, may not have pro
gressed much beyond the planning stage); Bangla
desh's Palli Chikitsak (‘Village Medic') program.
China's use of herbalists as part of the barefoot doc
tor' corps. Nepal's Shanta Bhawan Hospital's Com
munity Health Program's use of traditional village
compounders, the Philippine Barangay Health Aide
Project's use of herbalists and spiritual healers, the use
in Sri Lanka of Ayurvedic physicians for family plan
ning. the PRHET1H program in Ghana. Nigeria's
passage of a law in 1980 to integrate herbalists and
spirit mediums into the national health service, and
Zimbabwe's incorporation of traditional healers
{ngangasi into its national health service. It is difficult
to arrive at a definitive listing since often what is
reported as 'utilization of traditional practitioners' in
an overview article or document (e.g. Traditional and
Modern Medical Systems Special Issue in Soc. Sci.
Med. 15A. 1981. or American Public Health Associ
ation. Tracking Report on AlD-Sponsored Primary
Health Care Projects. Washington DC. 1980) turns out
to mean either traditional midwives or. rather than use
of traditional healers as service providers, simply a
conference or meetings in which traditional healers
have participated. For example. Kathmandu's Shanta
Bhawan Hospital succeeded in bringing local shamans
(ihankris} together with doctors and health department
officials for an innovative seminar but did not actually
use them as service providers (Comniwnirv Health Ser
vices /V’5 Report, p. 9. Shanta Bhawan Hospital.
Kathmandu. Nepal). Likewise the Kotobabi polyclinic
project in Ghana, which has also been singled out for
working with traditional healers, includes them on
subdistrict health education committees but does not
incorporate them for health care delivery (American
Public Health Association. Kotobabi Polyclinic.
Ghana. Project Capsule Series. Washington. DC.
1979). Where errors or oversights in bringing together
and interpreting the relevant literature have crept into
this essay, the author would appreciate having it
brought to her attention.
9. See. for example. Carlson D. G. Policy and practice
implications in the integration of traditional and
modern health systems. Paper presented at National
Council for International Health Annual Meeting.
Washington. DC. 1981.
10. Contrary to common belief in the West, most Chinese
trained as ‘barefoot doctors' have not come from the
ranks of traditional healers but are young literate men
and women selected from the general peasantry on the
basis of ideological commitment and enthusiasm for
community service, rather than because of prior health
work experience. See Wilenski P. Integration of the
traditional Chinese practitioner into the medical sys
tem. In The Delivery of Health Services in the People's
Republic of China, pp 31-37. International Develop
ment Research Centre. Ottawa. 1976; and. for an ana
lytic description of Chinese spiritist-diviners. Kleinman
A. and Sung L. Why do indigenous practitioners suc
cessfully heal? Soc. Sci. Med. 13B. 7-26. 1979.
11. Eighteen illustrative protocols or questionnaires are
reproduced in World Health Organization, op. cit.. pp.
45-88.
1833
Policy and evaluation perspectives on traditional health practitioners
12. Warren D. M. et al. Ghanaian national policy towards
indigenous healers: the case of the Primary Health
Training for Indigenous Healers iPRHETIH) Program
Soc. Sci. Med. 16. 1873-1881. 1982.
13. American Public Health Association. CIMDER—
Norte del Cauca. Project Capsule Series. Washington.
DC. 1979.
14. Popul Rep. op. cit. pp. J-452-453.
15. In the case of Bangladesh, the Ministry of Health and
Population Control in 1981 set the goal that at least
50°o of villagers recruited for the new national village
medics' training and service program should come
from the ranks of traditional healers (see U.S. Agency
for International Development. Palli Chikitsak (Village
Medics) Project Paper .Vo. 388-0055. p. 50. Dacca.
losis control, leprosy control, and immunization. See
Area Auditor General Near East. Audit report on the
examination of USAID Nepal's health and family
planning program. Report No. 5-367-79-20. pp. 27-29.
Agency for International Development. Washington.
DC. 1979.
23. For example. Navarro V. (Ed.) Imperialism. Health, and
Medicine. Baywood. Farmingdale. NY. 1981. See also
Crankshaw L. C. The misunderstanding by health care
programs of the social construction of realities: the
Bolivian case. Paper presented to the Society for
Applied Anthropology. Edinburgh. 1981.
24. When compared with programs in other sectors (e g.
agriculture or rural development) health programs are
often poorer performers. For example, when a worldwidFseries ol impact~evaluations was launched in 1980
by the U.S. Agency for International Development,
1981).
16. Among the vast number of documents produced by
this project, see Lampang Health Development Project
Evaluation Board. Lampang project evaluation pro
gress Report No. I: summary baseline evaluation
results and preliminary performance data. Lampang.
Thailand. 1978: and International Council for Edu
cational Development. The Lampang health develop
ment project: Thailand's fresh approach to rural
primary health care. In Meeting the Basic S eeds of the
Rural Poor (Edited by Coombs P k pp. 103-194. Perga-
rural health fare vlfli offs '»1 hall a dozen priority
sectors identified In each of the other ketot's (Agricul
tural research. potaEle water? rural electrification, and
so on) it proved relatively easy to identify at least six
developing countries in which a program m tht! tcspectne sector was judged to have progressed
enougfflo merii'being a Iruitlul subject Idr an Irrtpaet
evaluJTTon. I'he health sector, however, lagged far
behrTTCTThe rest, for all health project managers
approached claimed it was still far too early for the
project they managed to have begun to have an im
pact; by the end of the year, only one health project
had been identified as a candidate for evaluation. This
was a project tn Senegal which itself turned out to be
flawed in many serious ways. (See Weber R. et al. Sene- ,
gal: The Sine Saloum Rumi Health Care Project. U.S.
Agency for International Development Project Impact
**
mon Press. New York. 1980.
17. See. for example. World Bank. Thailand. Appraisal of a
Population Project. Population Projects Department
Report No. 1663-TH. Washington. DC. 1978; and
Stewart M. et al. Mid-term evaluation of the Thailand
rural primary health care expansion project. Report
prepared for USAID Thailand. Bangkok. 1980.
18. Notably. Foster A. Bureaucracies as social and cultural
svstems. In Applied Anthropology, pp. 96-113. Little.
Brown. Boston. 1969; and Medical anthropology and
international health planning. Med. Anthrop. Sewsl.
7(3). 12-18. 1976 (reprinted Soc. Sci. Med. 11. 527-534.
1977).
19. In this section and elsewhere, generalizations are based
on a broad familiarity with the evaluative and related
literature on (a) traditional practitioners and their util
ization in modern-sector health care activities; (b)
primary and rural health care systems in genyal; and
(c) economic development programs fn general. This
was acquired during the course of four years of work
for the U.S. Agency for International Development as
a medical anthropologist and program evaluator with
departments of that agency responsible for overall pro
gram and policy coordination and for programs in the
Near East and Asia regions. See. for example. Pillsbury
B. L. K. op. cit.. and Traditional Health Care in the
S’eur East: Indigenous Health Practices and Prac
titioners in Egypt. .4jyhanist<in. Jordan. Syria. Tunisia,
Morocco, and Yemen. U.S. Agency for International
Development. Near East Bureau. Health and Nutrition
Divisions. Washington. DC. 1978.
20. See. for example. Dreyfus D. and Ingram H. The
national environment policy act: a view of intent and
practice. Sat. Resour. J. 16. 243-262. 1976: Bauer R
Implementation: The Neglected Aspect of Policy. Har
vard University Press. Cambridge. MA. 1972: and
Montoya-Aguilar C. Health goals and the political
will: definitions and problems of national health
policy WHO Chron. 31. 441-448. 1977.
21. On availability
availability of evaluative findings,
findings. see Pillsbury
B. L. K. op. cit.. pp. H-12. and Population Infor
mation Program, op. cit.. pp. 477-481.
22. The Integrated Community Health Program is an
attempt to bring together, by 1985. the majority of
services previously provided by six separate programs
of Nepal's ministry of health: family planning and
maternal-child health, malaria eradication, tubercu
'
Evaluation Report No. 9. Washington. DC. 1980).
Also, when compared w ith family planning programs.
the record of primary health care In having a measurable impact is also poor—in part because measuring
health impact is intnnsicnlly more elusive and in part
because much more careful attention has gone into
designing and implementing family planning programs
to produce short-term impacts.
25. Dunlop DT-W? PrimarriTealth Care: An Economic
Analysis ol the Problems Facing Implementation. World
Health Organization WHO SHS Background Docu
ment No. I. Geneva. 1982; and Gaspari K. C. The cost
of primary health care. Report prepared for U.S.
Agency
for
International
Development
(AID,
OTR-147-80-84). 1980.
26. See Weber R. et al., op. cir and U.S. General Account
ing
ing Office.
Office. Report
Report to the Congress: Management Prob
lems with AID'S Health-Care Projects Impede Success.
pp. 18-19. Washington. DC. 1981. The specific projects
criticized on this count were the Sine Saloum Rural
Health Care project in Senegal and the Panay Unified
Services for Health project in the Philippines.
27. An illustrative case study from Morocco detailing the
compromising impact on public health programs as a
result of priorities placed on political stability by the
Alawi sultans is presented in Meyers A. R Famine
relief and imperial policy in early Morocco: the politi
cal functions of public health. .4m. J. publ. Hlihl)(\\\.
1266-1273. 1981. Harsher critics contend that__the
problem is not just one of comprotnised goafs but that
the imnact bT~Westcrn.. medicine, foreign aid, and
related interventions is~~such that they actually contnbute to dillth dfifl dKda<d. See aim Navarro, op. cit. and
Foster pp 530 531.
~
28. This set of questions is phrased for purposes of the
present essay in terms of a national system. It is
equally applicable, however, to rural and primary
health care projects and programs of more limited
scope as well, in which case the word ‘project' or pro-
'6
/
/
'
5
1834
Barbara L K. Pillsbi ry
gram' should simply be substituted for ‘system'. Also to
be consulted, especially for evaluation of traditional
birth attendant components of projects, are the WHO
1979 and 1981 publications cited in Ref. [7]. See also
the work of Brigitte J. Training courses for traditional
midwives in Yucatan. Mexico, pp. 15-30. Report pre
pared for U.S. Agency for International Development
(AID PHA C-IIOOk 1979.
29. Clearly it is difficult to determine vital-events rate
changes, or other health impacts, for populations in
developing countries where reliable statistics are not
available—and even more difficult to attribute such
change to a particular intervention. Nevertheless, and
while the health evaluation community urges a
broader approach to assessing project effectiveness, the
demand of funding agencies for impact data still
renders important at least cursory attention to changes
in health status. See Dunlop D. er al. Toward a Health
Project Evaluation Framework. U.S. Agency for Inter
national Development. Evaluation Special Study No. 8,
Washington. DC. 1981. Realistic guidelines for impact
or even process evaluation of health care projects in
developing countries are few and far between but a
useful start is provided by Cole-King S. Approaches to
the Evaluation of Maternal and Child Health Care in
1 he'•CrMift.i! 7^' Primary Health Cary. WHO
ckground"Paper HSM 79.2. Geneva. 1979; and frecmao
H. et al. Evaluating Soci tl Prai<“-tr in rtevelapina ( <mptries. Development Centre of the Organisation for
Ec°rlOmic Co-operation and Development- Paris. 1979
30. Reference here to cost-effectiveness is not meant as a
recommendation" for reliance upon this approach, and
certainly not for benefit-cost analysis, both of which
have considerable shortcomings in the developing
country health context. Rather, given that cost-effectineness analysis is in any case relied upon by many
health planners and evaluators, it is meant to signal
the lact that we have little evidence at all as to the
ultimate cost-effectiveness of any category of health
worker in improving the health of a rural developing
country population. In fact, in the opinion of some
veteran analysts of the question (c.g. Bannerman R. HSynwosium enmmem4ry 1981) 'f b^n-*H oniit unul; ris
could be done it would probably show a
n
loss due to the ‘internal brain drain effect' of newlv.
traTned primary health workers thinking themselves
overqualified for the village and leaving rural health
work for larger towns and cities
&h. Sei. Med. Vol. 16. pp. 1835 to 1841, 1982
Printed in Great Britain
0277-W36,82,211835-07J03.00 0
Pergamon Press Ltd
POLICIES TOWARDS INDIGENOUS HEALERS IN
INDEPENDENT INDIA
3
Roger Jeffery
E
Department of Sociology. University of Edinburgh. 18 Buccleuch Place,
Edinburgh EH8 9LN. Scotland
Abstract—Policies towards indigenous healers in independent India show considerable continuities with
policies followed in the British period, varying according to the sex of the healer. Traditional birth
attendants (dais) have been offered short periods of training by the State since 1902. whereas until
recently male healers (raids and hakims, and later homoeopaths) have been treated with official hostility.
Current plans include the training of religious and ritual healers in psychiatric services as well as the
employment of indigenous healers in new community health schemes. These changes are assessed in the
context of a political economy of health services.
INTRODUCTION
Many discussions of the potential role of indigenous
healers in health systems ignore the historical dimen
sion. apparently assuming that the proposals are
novel and practicable. No-one should make this mis
take in India, where there is the work of Leslie and
Brass to draw attention to shifts in policy from 1820
onwards [1]. In this paper I want to elaborate on a
small part of this topic by looking at official policy
with respect to indigenous healers in the context oP
theories about the dynamics of relationships between
indigehous and cosmopolitan medicine.
There are/in essence, three views of these relation- '
ships in India. The first is the nuiww w-irnt<i»
the process i$ one in which the indigenous systems are
steadiTygiving ground to the onward march of
science, with only the areas where Western medicine
is ineffective remaining for the indigenous prac
titioners. This was the dominant view of the British
doctors in India; it remains common, though many
Indian doctors express guarded sympathy and sup
port for the relevance of indigenous medicine. The
second view is the agnostic anthropological, besT
expressed in Leslie^ phrase describing Asian medical
systems as ‘coexisting normative institutions, in
w h ich Cultural processes olchange arc not simply uni
directional (with indigenous medicine being affected
by cosmopolitan medicine but not vice versa) but
multidirectional, with no predictions of necessary
future patterns [2]. The third view is th^ political
see the systems of indigenous medicine as discrete and
discontinuous, whereas Leslie's model of healers occu
pying positions which shade into one another seems
more plausible [4]. Secondly, there is a great deal of
regional variation, not only pre-1947 when the Native
States could follow policies radically different from
those of British India, but also since Independence,
when health policies have been constitutionally the
sphere of the States.
THE BRITISH PERIOD
It is customary to see 1835 as a major turning point
in British attitudes to Indian culture. This was the
year of Macayley's Minute on educational policy,
where hc-argued that European culture-should provide Jhc-Gurriculum of schools and colleges. This
strengthened the opposition to schemes which
attempted a mixing of European and Indian cultures,
or were designed to restore Indian culture to its pre
sumed glory. In medical education it meant that the
Calcutta ‘Native Medical Institution', founded in
1822. would no longer teach aspects of Ayurveda (the
Hindu medical scriptures, especially those ot Susruta
and Caraka) nor of pigni (the medical doctrines de
rived from Greek medicine and more closely linked to
Muslim culture). While this move had obvious signifi
cance. it did not mean a total ban on such teaching,
nor on co-operative relationships between the British
Raj and indigenous practitioners as a class. As Hume
has demonstrated, for example, in Punjab the Provin
structuralist ope, in which the superrerrty-of-Western
cial Government employed hakims (Unani prac
medicinyiollows not from its RCienTifiC advances but
titioners) in the 1860s and 1870s. usually as vaccinabecause if is more closely linked to the class interests'* tors and health extension workers, and the University
of the pohtical leadership in the country [3]. I shall
of the Punjab offered courses in Ayurveda and L'nani
explore ^ome of the strengths and weaknesses of these
medicine until 1907 [5].
positions by taking a closer look at policies towards
One reason for the tolerance displayed by the State
indigenous medicine in India, tracing the links
is that its own services, and practitioners trained in its
between the British period and post-1947 policies,
medical schools and colleges, had a minimal impact
with particular focus on policy proposals made (and
before the end of the nineteenth century. The first four
medical colleges (Bombay. Madras and Lahore fol
to a lesser extent implemented) since 1971.
Two caveats should be entered here. Firstly, there
lowing Calcutta by the 1850's) produced too few
graduates to make much impact on the setting of
may be no clear relationship between official dis
practice for most indigenous healers, and were mostly
cussions of indigenous healers and the situation ‘on
the ground’. In particular, the official mind tends to
employed in the growing State bureaucracy—in the
1835
hip
*
(T 141 I.; IM
1‘rintcd tn Crreat Htiiatn •
J^,n
I
I \/
\
■
<5v\
I
THE INTERFACE OF DUAI, SYSTEMS 0^ HEALTH
CARE IN THE DEVELOPING
.TOWARD HEALTH
POLICY INITIATIVES-^ m^CA*
Charles M. Good
Department of Geography. Virginia Polytechnic Institute and State University. Blacksburg. Virginia
John M Hunter
Department of Community Health Science. Department of Geography.
African Studies Center. Michigan State University.
East Lansing. Michigan.
Selig H. Katz
Department of Anthropology . Michigan !Stale University.
East Lansing. Michigan.
and
Sydney S. Katz
Department of Anthropology. Michigan State University.
East Lansing. Michigan
I
3(
items of health care in the developing xorld. oix is traditional and
Abstract Basically, there are two sysu
atific
prcscientific; the other modern, scient
... and Western in derivation The two exist side by side, yet
d
remain functionally unrelated in any intentional sense: with the traditional, ethnic system being disre
garded by the government-supportedI modern system, although it is the dominant mode of health care
— structure of this dualism with
for over three quarters of the population of the developing world The
particular reference to Africa should be more widely recognized and used in national health care
planning.
Neither traditional nor modern medicine is adequately meeting health care needs; therefore we must
ask if. together, they can be articulated so as to produce a synergistic outcome that will maximize the use
of scarce financial resources? It is suggested that the modern system can be consciously articulated
downwards so as to increase the potential for integration with traditional medicine at the village ,level
- -1
through referral systems and training programs while traditional medicine can be supported by
bj the
litional psyc
psychiatric
modern system with the use of village heafth aides, traditional birth attendants, traditional
aides, village drug stocks, herbal medicine research and referral systems. The dualistic and dichotttomized
health care systems are ripe for change. Many governments do themselves a grave disservice by officially
ignoring traditional medicine and not considering its partial or fuller incorporation in health care
planning.
INTRODUCTION
f
4
Basically there are two systems of health care in the
developing world: one is traditional, pre-scientific and
ethnic; the other modern, scientific and Western in
derivation [1], The systems are different in terms of
availability and quality of care, techndlogy. and social
adaptability; yet ideally both aim to serve the same
pop ' 'ion in need. At the interface between the two
syt
some fusion occurs. Techniques and medica
tion^ ui modern practice are increasingly filtering
through to local healers who are not trained in
* Portions of this paper are based upon a field project on
«rban and rural cthnomedicme conducted in Kenya by Dr
Good in 1977-78 with the support of a grant from the
National Science Foundation, Washington. D.C Field
observations in traditional medicine were made by the Drs
Katz in visits to Kenya in the summers of 1974 and 1977
The paper as conjointly developed here utilizes and
expands upon a discussion paper originally prepared by Dr
Hunter for an international symposium on rural health
««re hosted by the Dartmouth Medical School. July 24- 27.
*"• IJ Jo .
modern medicine: and where feasible most ill persons
attempt to obtain the most effective therapies from
both systems, often concurrently or serially for the
same illness episode. The two systems exist side by
side, yet remain functionally unrelated in any inten
tional sense. Paradoxically the government-supported
modern system, which tends to be synonymous with a
monopolistic medical “establishment’' and a doctor
dependent. hospital-based, curative health care model,
does not with few exceptions, officially recognize,
cooperate with, or adjust to the traditional ethnic sys
tems. This stance is unrealistic because the ethnic
therapeutic systems, based on a variety of healing
strategies, arc collectively the dominant mode of
health care [2]. Furthermore, government health
ministries greatly diminish their opportunities and
responsibility for understanding and influencing the
health status of the communities they are supposed to
serve by ignoring the many positive qualities and
social utility of traditional forms of health care [1].
Traditional healers are. of course, well-aware of the
official disregard they are accorded. Many are also
141
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tional medicine, despite its unquestioned clinical and
social value. There is by no means uniform knowledge
or utilization of even the generic therapeutic methods.
For example, although psychotherapy, occult prac
tices and phytotherapy are probably well-developed
in most healing systems south of the Sahara, surgery
and orthopedics are practiced but not universally.
Difficulties of diagnosis in certain chronic and emer
gency conditions due to ignorance; lack of rigorous
dosology and drug selection; and, from an external
viewpoint, the perplexing inungiblc means and ends
of particular forms of psychosomatic therapy, and the
perpetuation of belief in witchcraft and sorcery, may
justifiably be seen as negative features [10]. To these
we might also add a caveat concerning the growing
commercialism of many traditional healers (a trait
widely shared with modern health professionals in
private practice). These factors should not. however,
obscure the evidence that, on balance, traditional
medicine (1) has been and continues, potentially, to be
a very valuable human resource system; and (2) if
restructured as part of a carefully planned strategy of
self-reliant community development, could contribute
appreciably towards meeting national primary health
care requirements in this century.
Whereas scientific medical practitioners might
readily demonstrate the inappropriateness of specific
traditional medical practices, the same has already
been shown for some “modern" therapeutic regimens
[46]. Modern medicine has its fads; practices deemed
good today may be found worthless or even harmful
tomorrow. The reality of iatrogenic mistakes should
be accepted as the consequence of lack of present
knowledge and the inadequacy of the art of medicine
rather than carelessness or deviation from accepted
practice. The thalidomide episode and the recently
recognized effects on the children of women to whom
diethyl stilbesterol (DES1 was administered during
pregnancy are only two examples.
Traditional African medicine exhibits a diverse
complement of therapeutic procedures which reflects
ingenuity, trial and error experimentation, and the
gradual accumulation of empirical wisdom over time
Techniques which have their equivalents in modern
medicine include, for example, oral, cutaneous, rectal
and respiratory administration of plant preparations;
hydrotherapy, treatment by radiant heat, counter
irritation. massage and psychiatric testing.
Midwives quite obviously perform a crucial health
care function in all societies in the region. They pro
vide prenatal care, some applying skills such as ability
to rotate the fetus; assistance during labor, delivery
and after birth: and often continuing care for new
borns and young children. Although abilities vary in
dividually. many traditional midwives are relied upon
to perform the roles of gynecologist, obstetrician, her
balist. dietician and pediatrician [8. 10].
The recent surge of scientific interest in African
pharmacopoeias highlights an important dimension
ol traditional healing the historical importance of
which cannot be overestimated [47]. Research aimed
at discovering the pharmacodynamic properties and
therapeutic potential of widely used traditional plant
medicines is now a common activity in African uni
versities and certain government-aided agencies in
West [48] and East Africa, often in cooperation with
for relatives.
healing, including healer-patient interdepen- close friends, and in some destitute cases.
foreign research centers. In Kenya, for example,
and the paraphernalia which enhance the mysresearchers have been focusing on plants such as
reliance on traditional healers
Maytenus buchananii, which yields a compound of
low toxicity known as maytansire. Initial human trials Koreo«r.gmany “medicinal" plants are belief to
or acquire, magical powers (as in the case of "S The Shortage of these services and the desue for
by the National Cancer Institute in Washington. D.C
transformed into ^ondu among ^amba m
have yielded evidence of its positive activity in reduc
Enyai.
Such plants are not conceived of as effective
ing tumor volume in childhood leukemia and ovarian
and lymph node cancers [49]. Extracts from this and KXmselves. Rather, healer and patient alike see self-styled and unscrupulous bush doctors These
Rm
at
one level as earners of, or as the material
related plants have reportedly been used in Kenya for
illegal practitioners, who unfortunately are sometimes
___ : force
that t..-.
misidentified as bona fide traditional healcri adminis
traditional treatment of venereal disease, rheumatic Kework for. the intangible supernatural
St’s" [8.10.21,60],
pains and swellings, gastrointestinal disorders, and in HI produce beneficient rc--.~
ter injections of preparations such as liquid chloro
.
function
is
to
ternal body injuries. Other medicinal plant com jbove all. the healer s most important
quine and dispense prescription-type drugs PurcJ“*£
traditional "medicine is through black market channels- often with tragic
pounds in Kenya have known or potential uses as
Enre social order, for t.-d~2"’ ■ pot
iwer or
Emd up with the concept of magical
antimicrobials, cardiac glucosides, hypotensives, and
results for entire families [62], The.r urban counter
limited to parts are the notorious “bus-stop dispensers, and
drugs which relieve inflammation, spasms, and Muence and its possible effects are. not
i.~.......
asthma [21. 50].
jhat we would regard primarily as pharmacological parts
•backstreet doctors", whose lucratit°Cjob iTto hustle antibiotic capsules, abortifacients
Continuing “discoveries" confirming the active
the more remote areas, traditional health care
pharmacological properties of traditional herbs
and other illicitly-obtained drugs to anxious clients!in
should not be ignored [51-53]. The classical example
say be the onlv source of help available. Patients wi
crowded city streets, bus depots, and markets [63.641
iaw little or no chance of access to modern medical
of malaria and quinine bark in South America is rein
Whereas these "fringe" practitioners are a factor of
Jvices Their use of traditional care will vary with
forced by the relatively recent introduction of RuuhoIgreat concern in the overall pattern of health care, we
Ik gravity of the case; the nature of the illness, the
fia. long used in Africa and India, into the Western
wish to keep them separate from our purpose in this
ane of specialist customarily sought (e.g. dinner), and
pharmacopia [54,55].
acculturation of the client; the proximity of a.pre- PafoAfrica's towns and cities the greater availability
In 1975 researchers in Ghana were informed of a
small seed which villagers in the Kwahu district ingest
■
' ...ct by an increased level of
and .ravel coat „ rickneTs and community demand for both modem
to protect themselves against an annual dry-season
right be expected; but surprising distances are tra-f and traditional medicine. In short complementarity
epidemic of abscesses. This epidemic was. in fact, "an
Wrsed for health care, especially on foot, reg^d*^s • and elasticity of demand for health services are both
infection with the ... parasitic disease dracunculiasis.
fa expense, time, and effort involved if P5°Ple^el i in effect. Western-style chmcs and hospitals of the
and the seed in question is a preventive against that
E result will be favorable. In cases where modern
disease" [10], Wangwe has identified plants which are
modern system arc intensively patromzed foci of
Edicine is also accessible to part of the rural popula urban health care; but a most interesting pheno
used by the Abasamia of Kenya to improve lactation
and prevent neonatal tetanus [56], Some plants are
tion individual decision-making tends to be pragmamenon is patients' widespread use of both systems
ITinfluenced by previous experience, concept ol
basically repellent to insects, and others are believed
interchangeably, consecutively, or even concurrently
'riology, perceived chronicity. and expectations of a
to offer protection against poisoning and contagious
for the same ailment. Moreover, these behavior pat
diseases such as chickenpox and smallpox [10], Ethcure. In rural Kilungu m Kenya, for examp e. it is
terns occur despite the paradox of the very high co
nobotanical (and vernacular) names of plants with
^nlikelv that the local Kamba women would seek
of much traditional medical treatment vs fee-free gov
treatment for infertility, edema attributed to witch ernment services [8]. Patient flow and reverse flow
reputed medicinal and ritual healing value typically
number in the hundreds for a given ethnic group
craft. or mutarnhuLo (pain in limb joints) at one of the between the parallel systems is a much understudied
[8. 55.57].
two government Health Centres, or at the fee-charg and highlv complex process about which more infor
A point of clarification is in order concerning the
ing mission hospital. On the other hand, observa ion mation and sound theory are needed. It is. of course.
ol many of these women who are mothers reveals ‘hey
function of African pharmacopia. In contrast to the
a form of integrative behavior, akin to syncretic re
have a strong (but by no means exclusive) Preference
Western tradition tn which “medicine" and "phar
macy" have remained largely distinct. African thera
for modern curative medicine, where and when it is 'Afferent research in several large African cities, in
pies show a close association of the two elements
accessible, for their “under-five children suffering cluding Nairobi. Kenya [8]; Dar es Salaam. Tanzania
with fever, acute respiratory infections, and diarrheal [65]; Ibadan. Nigeria [26]; Lusaka. Zambia [66]
Many non-African commentators, in particular, iden
tify traditional medicine, explicitly or implicitly, with
diseases [8]. Research has shown that this selecti e Kinshasha. Zaire [67]. and Kampala, Uganda [68]
acceptance of modern medicine is. at best, only
a narrow, stereotyped set of practices relating to the
. _ centers^are
—■.r.. viable and vigorous
indicate that urban
collection, preparation, and administration of “herbal
vaguely related to mothers' cognitive orientation to
traditional medicine. In Nairobi, this
remedies”, or pharmacopoeias. There is a strong ten
modern conceptions of etiology , mode of spread, pre- arenas of nt- would obtain even if the City <- ouncil
phenomenon
dency to define healing in terms of herbal “cures" or
fwmion and treatment of diseases [61].
able to provide numerous additional modern
aLL to r.-----| Economic costs of traditional med.cme m rural were
"remedies" for specific diseases. This restrictive con
dispensaries distributed uniformly
uniformly across
across the city.
cept overlooks the fact that, as in modern medicine,
areas are relatively well-adapted to local resources,
n. prefer <<->
People
universally
to have options, and
the majority of illnesses dealt with by traditional
urban
although this too is changing rapidly in many areas.
Kenvans are no exception In
....... self-help
.
healers are self-limiting and have a very substantial
I iTradilional healers typically may not directly charge "villages' such as Nairobi's Mathare Valley [69].
psychological component Herbal treatment and indi
on
a
fee-for-service
basis,
and
money
transactions
the
spacing
between
traditional
healers
<
Swal
’’11
on a
vidual or group psychotherapy are typically com
- may be entirely absent. Many practitioners accept
waaonuci) is typically less than 70 metres. In th s ex
bined. although the latter methods may be employed
payment in kind, often only after the outcome of the
tremely congested, low-income environment, sheltered
frratment .s known Levels of indebtedness may be
without recourse to herbs. A common effect is that
living space is estimated at less than two square
the patient s symptoms and feeling are improved
-> decided by the client A particular token down pay meters per person. Consequently, few
have
without necessarily changing his pathological condi
ment is usual and customary. Settlement may be post- The foxuTy of6or even see a need for. making rat.ona
1 poned through mutual agreement until the fol'owing
tion In essence, as the striking results of the "placebo
locational decisions which relate to the placemen eff
experiments" in the United States and Europe sug
I agricultural season, and can take the form of a gilt ol
their competitor's "chmcs ". Many are migran s from
I a chicken or goat, foodstuffs, or some assistance in the
gest. those who respond favorably to placebos are
rural areas of marginal agricultural potential. They
apparently "predisposed to accept and react t°
I. form of farm labor. The amount of payment varies
are strongly attracted to the city by a perceived
socially defined symbols of healing" [58. 59]. The use
I with the severity of illness and the lime required for
opportunity to realize substantial econom.c gam from
of herbal medicines is thus inseparable from the urt o
Wcccssful therapy . Children are assessed less than
Uh
IF
If! r
IM
ill
Ii
I!IIF
ml
Hh
Hl
t
i
1
I
■
0
14«
Charles M. Good et al
P^'c'ng traditional healing for profit. Income
potential becomes a function of charisma, prior repu
tation, and entrepreneurial ability [8], These Mathare
and the hundreds of others elsewhere in
• P 7 an extremc,y significant role in the life
of the etty. As described by Andrew Hake.
wn^abte L™ '?Cy “re a" cconomic factor, handling
ronant
-a' n,°ne>’ h*1*'*" ,hCni Far more ,mH y. Pr0V,dc “ uTUC‘al elemcnI ■"
"spintuaJ"
dty?TO£nnm7L°na1'
“ner lifc °f mos! of ,hc
citys popuianon. They are at once feared and ridiculed.
SakrI
aM an<J aV°Jded- Pa'd 3nd chcatedhealers and sources of anxiety, links with the past powerful
influences on the present and seers of the future" [69].
avoidance of diagnoses which require extensive riluaU
■9
Significant new efforts include the varied, innovative,
community-centered approaches to preventive and
doctors do not practice in their own coun- curative care promoted by the Institute of Child
w-te after qualifying. Reasons include lack of accep- Health of the University of Lagos. Nigeria [80].
The litany of disillusionment nevertheless con
•Ef pathways to professional development and rewspecialty certification and income base) and tinues, and most criticisms are indeed valid. However,
instability, both of which stimulate a “brain for good reasons, the demand for modern health care
is insatiable. Thus, perhaps the biggest criticism is
Bijin” producing “reverse foreign aid." Alternatively.
■Ire highly qualified professionals may abandon that there is not enough of it! For example, in quanti
tative terms only Congo. Swaziland and Zambia have
for a career al home in politics, government
enough doctors to provide a crude ratio of 1:10.000
S^usiness.
people. This relationship is by no means stable, how
Highly trained medical specialists are needed in
Sy developing country. However, the fundamental ever, since a large percentage of doctors are
is for health personnel whose qualifications and expatriates. In Kenya, only 600 of 1800 doctors arc
^siyle (especially willingness to work in rural areas) Kenyan citizens. The estimated doctor-to-population
C oriented toward provision of primary health care ratios are 1:987 and 1;70.000 for urban and rural
p( •he treatment and prevention of common dis- areas, respectively. Moreover. 70"o of all doctors are
in private practice in Kenya's towns, whereas 10",, of
ises
all physicians serve rural areas [73]. Nigeria, with 80
recent study of health services conducted for
million people and less than 3000 doctors, has a ratio
Raid's Technical Assistance Program to the
of approximately 1:25,000. Since most of these doc
tentrnmen'. of Kenya found that (p. 75)
tors live and work in the larger cities, the bulk of the
Wt training of physicians prepares them to render services population is served at a ratio of 1:50.000 to
^hospital settings, and to treat diseases (complex and
1-100,000. Rwanda's ratio is 1:625 for Kigali, the
S&iively less common) which are largely irrelevant to the capital, and 1:90.500 for the rest of the country
■cds of a rural population and. equally important, irreleto the equipment available and to the training of [3.82]. As orthodox indices of health manpower these
doctor-population ratios effectively represent nearly
jBphysician support staff' [73].
zero availability of modern health care for most of the
tamicallv. the same study (pp. 80 81) also notes that
population.
I terms of the tasks they perform onsite, clinical
Of course, statistics relating to doctors alone do not
officers who work in hospitals and rural health
accurately represent the quantity of health services
onters “appear, with three years of training, to be available to people in developing countries. However,
itertrained" and underutilized relative to their skills even when doctors, nurses, medical assistants and
asd the major categories of disease they routinely
midwives are considered as a single resource pool
anfront.
there is still wide disparity, regionally within develop
4 A related factor is the attitude of the elite in ing countries, and in comparison with the industrial
man) developing countries— in favor of transposed,
nations. Thus Burundi has approximately 8.3 health
workers. Mali 26.7 and Canada 749.5. per 100.000
ttpensive Western-style medical standards. Their
Klitical influence anil conservatism help to insure population [83]. Added to this are the problems of
that these standards are reflected in national health imbalanced, top-heavy staffing which results in too
flans, even though only a small minority will realize few auxiliaries to support the health services In some
fte benefits. Such attitudes and values also ensure African countries this takes the form of an inverted
pyramid", where the small number of doctors actually
that medical schools are designed more as national
prestige symbols than as progressive instruments for exceeds the number of auxiliary staff. 1 his problem is
ttformmg medical education in the interests of im exacerbated where the auxiliaries are not permitted to
work except under a doctor’s direct supervision [82].
proved health care for the majority
Other criticisms leveled at the modern medical care: Hence, the key issue is what kind of care can and
should be made available: "If you ask people what
model emphasize that it is crisis-oriented, particularly,
when financially restricted; treats symptomologies; iss they want, most will tell you they want hospitals and
1
doctors. But what they really mean is that they want
7 technology-dependent and resource consuming; and
to be kept well" [84], Must African health ministries
•llocates few resources and attaches little prestige to
less immediately productive preventive programs, postpone better health care for the overwhelming
even though recognizing their importance [79]. Mor- majority of the population until enough doctors are
- ley emphasizes that in developing countries "three trained and hospitals built’.’ Tanzania s national-exper
iment with medical auxiliaries offers one potentially
-quarters of the deaths are caused by conditions that
can be prevented at low cost, but three-quarter^ of the significant alternative [85].
This absolute, quantitative lack of modern health
medical budget is spent on curative services" [81]
Moreover, because health care systems have generally care, or al best the widespread insufficiency of its ser
vices.
is exacerbated by the population explosion.
undergone little structural change since independence,
Most countries in Africa are doubling their popula
the health care experience for rural Africans in many
tion
size
every 20-30 years; birth rates are in the
countries is largely the same as it was during colonial
rule [9], In some cases, outstanding colonial pro order of 40 50 per 1.000; and youth dependency
ratios are high with 40 50°„ of the population
grams such as the Ecole Africaine de Medecine in
younger than 15 years of age. Importantly, there is a
Senegal, which produced over 800 “sub-professional
S medicins africains between 1918 and 1951. have been flood of migrants io urban areas. Cities are doubling
Ej<ihe cost of preparing one medical/clinical assis-
Traditional medicine is an omnipresent reality
life for both rural and urban folk-an in^X**
resource system still serving the majority ofS
and the remainder of the Third World. Yet, desniteS
preponderant importance, it is mcredibly overl^k^
and discounted by development planning ageiSS
Interest, where n exists, is generally limited to
preparation of national inventories of medidtS
plants, and to sporad.c, uncoordinated attempt
conduct phytochemical, pharmacotechnical. pharma
^ynanuc and clinical studies with a view toX’
establishment of pharmaceutical industries. However
few African governments officially recognize trad.’
tional healers, and fewer still make anv attempt tt
^orporak their services into a national healthPplan
trad*‘ional hea!CTS ,end to be generalists
who serve a heterogeneous ethnic clientele drawn
from all classes.
-onudc of societies undergoing rapid
nu.
,and de jure nonrecognitreat are symptomatic
urbanization, commercialization, and social change.
medical establishment
rationalizes
through
its
own
_________
(In Senegal, for example, it has been observed that
r---------- ‘'"tJ cul‘ of lienee
and protessionahsm,
cannot
diminict.
;immense
____
:
“
™
o,
k
d
™
‘
n>
s
h
'he
'“d.e faao
...
—
—
•
...o..
,•>.„
uv lanuic
the peasant consults the marabout or the healer less
frequently than does the city dweller, always attracted contribution made by traditional health' care. Tradi^f
n
h!.|^?
Cine
reflCCtS
3
marsha
«ing
of
resources
for
to.the supernatural as a result of the break with his
ongtnal environment" [70].) Their clients' problems self-help by peasant and infraurban communities It
are very commonly attributed to. or suggest the need expresses the strength of African cultures to meet
for protection against, witchcraft and sorcery These human needs. Given that health care in toto. both
and modem, is extremely inadequate for
theories of causation are linked to a iwide
'' variety of traditional
the
conditions which are eventually accompanied’ by .... overwhelming majority of African populations,
the
critical
question
arises: Should post-colonial gov
frank somatic or behavioral symptoms. Typical exam
ples include psychogenic sterility, chronic general ernments continue their laissez-faire stance towards
radmonal medicme. concentrating all resources on
malaise, abdominal disorders, edemas, and many dis
turbances which reflect individual coping, adaptation the class- and residentially-segregated modern health
or acculturation difficulties such as inability to secure care sector, even where the latter fails to reach the
employment, sex or marital partners: strained or great majority of the population [19.73]?
broken km relations; alcoholism: and job failure
MODERN MEDICINE
Mental d.sturbances, ranging from mild, temporary
The modern health cor:
neurosis to chronic psychotic forms of behavior, often
care system, based on Western
head the list of illnesses traditional healers perceive !science
and„technology,
is surprisingly new in most of
,,t._
■ .....
-j -—ejthemselves as “best qualified to treat”. In addition to t'the
Third ”
World.
In Africa its introduction largely
^■'chcrafi and sorcery, disturbed spirits, the curse.
vu.se. dates from the late 19th --------century. n
It „
is aiICI1
alien UIClt
there..
excessive anxiety and drug abuse au believed to be “,nc!d,n8 »"«h colonial invasions, the rise of capitaCOHimnn
------------------------------------------- ,
common raiicottyto
causative factors roi
[8].-----------------------------------------------------li^m
lism. tnp
the penetration of r?.._
European
educational
values,
opean educational values.
Modern medicine is not presently organized to and often with Christianization ["t.
[74. 75.
75.76.77],
77], At
At
handle the rapidly growing caseload of mental and first all doctors were foreigners,
foreigners, endowed
endowed with
with "magi"maeisociopathic disorders, which approach communicable cal powers of the new ruling classes. Missionary doc
diseases in their importance. In contrast, the town tors and colonial medical officers pioneered Western
based traditional healer is generally rural-born, and is medicine, often with spectacular sucv^.,.
success. Tl.v
The introcapable of offering clientele who are
recent migrants a» duct,on of antibiotics in the mid-20thi Cv...u.
------------------------century, ffurther
lamniar cnnrv>rNftiof
____ •
.
.^n“Pk“!i.vnd b,ehavioral P°lnl °f reference ^^Cn,cdJ ,heir contributions. Immunization
in matters of health, sickness, and’ survival in the paigns. and non-medical developments such as imurban mflieu. Many of the same labels for illness
proved water supplies,
about a dramatic fall
, r---- brought
——e.... uuvui
ideas of causat.on. ritual paraphernalia and curative in death rates.
methods are already known to such clients, even
>et. in recent decades, once-euphoric expectations
though the symbolism may be recast away from par- tor the orthodox model of modern medical care in
ticulanstic-cthnic content towards a more universal Africa have subsided in the face of growing awareness
symbolic framework acceptable to a variety of ethnic of its many limitations. Medical schools are a case in
groups [17], This common ground, and the exper point. Although they have increased considerably in
ience. compassion and advice a traditional healer will Africa (as well as in Asia and Latin America) since
often share, can serve to reduce stress and facilitate mdependence.
.
f u . there is much
---------criticism of the overall
adjustment to town life. What the urban healer fre- ValuC
°c.
f ,hcir
'
- larger
’-e- ■numbers of conven•
;..v.r Fproducing
quently lacks is the support of a residential km or cult "nnal,y 'rained doctors.
------ Several interrelated argugroup to participate in the therapy process Hence menls form the case agatnst ,.
lall
maintenance
of the status
diagnosis and treatment of town-dwellers" health quo ,n med'cal education [2, 3].
are credible and
s usually means
ITrs]
1
I
-
148
4
1
1
I:
I
I
I.
I
Charles M Good et al.
Toward health policy initiatives in Africa
149
tom upward, has been recommended before [96] and
m size every 6-15 years, yet there is little economic
ȣntinn of an integration policy wherever feasible
implemented with varying success in Tanzania s I j
basis for such growth apart from the informal self to remedy the situation—given that the goal is ah■way*
improved total care, including prevention?
maa villages, the “health promoters of Guatema a.
help and client-patron arrangements which characte
in each country there is a need for several iand China [97]. The involvement of already practic
rize the transitional urban economy [69,86], This
■gfaroiects. backed by strong public support and
ing traditional healers into the overall, integrated
PROMOTING COOPERATION
expansion of the jobless and underemployed, most of
gy-ninp inputs from the national and local health ihealth planning would add a new dimension, for they
whom are physically accommodated in spontaneous
WK-tr
Minns
These
experiments
would
give
grealare a potential source of insight into a larp: number
The interface of the two systems may not be tl*
or “uncontrolled- settlements [69,87], produces a best area to begin. Dying patients transferred into or E^hasis to rural areas, but should also 'nclude
of “culture specific” illnesses, a reservoir of informa
great strain on the urban health care system. At the
health care environments in which traditional
tion about herbal medicines, and expenenad with a
out of the modem hospital do nothing to enhance
same time, the rural areas, which are still the home of
fS-ine
is
expanding
today.
Human
resources
and
confidence on either side. Doctors are frustrated bv
variety of psychiatric techniques [33J80% or more of the population, are largely neglected.
the delayed commencement of appropriate treatment fZartunities for trial programs are certainly not
Careful pre-planning of locations of pilot projects,
District and regional hospitals are few and far
and patients and patients’ families, in turn, come to W^ir". For example, data obtained systematically
comprehensive objectives and a range of PO*"'131'*
between, and they are understaffed; satellite clinics,
iSmTin-depth
interviews
of
66
traditional
healers
in
workable health care delivery models should be the
know the hospital as a place in which one dies. On
health posts and mobile services are scarce; and nurs
■S?of Nairobi, Kenya show that the great majority
the other hand, hospitals as institutions are generallv
essential first step toward intentional strengthening of
ing staff other paramedicals, and medications may be
ILc, practice referrals and report substantial interlinkages between the traditional and modern hwlth
not
organized
to
care
for
the
mental
health
and
physiin short supply or nonexistent
1
^cooperating
with
modern
medical
practitioners
cal care of terminally ill patients. One consequence is
services. Although each country will have to modify
Rising political consciousness is an important
that an in-patient may be bluntly given his prognosis Bghtunately. the decision to move toward cooperthe suggestions to conform to local conditions, repre
urban phenomenon and, among other considerations,
sentatives of all types of health personnel intended for
by the hospital doctors, discharged, and then deli
it demands that governments provide urban health
I
and
integration
will
require
extensive
and
sigvered by an anxious family (unwilling to accept the
participation in the projects, mdtgenous social scien
services even at the expense of the rural hinterlands.
i-Jcant reforms in the definition and organization of
tists. and health ministry planners and officials should
death decree) into the hands of a traditional healer,
Thus, inequitable government investments, lifestyle
ifaiff. care, regardless of the scale of change sought.
whose responsibility it now becomes to treat a patient
I Ssonnel and working relationships which character be integrated at all stages of phnnmg and renew,
aspirations, and also social and economic induce
suffering from both a grave organic illness and severe
Pilot programs should be created with a view to
ments—including opportunities for doctors to main
ise medical “skills pyramid" will be augmented
nationwide replicability Research on traditional
psychological insult resulting from the hospital’s dis
tain lucrative private practices while employed on pensation of the case [8].
Bd reordered, and local communities will be
medical systems has recently been inducted m
government service, or to receive “non-practice
ftpected to assume greater responsibility for the kind
several countries in the reg.on, includ ng Ghana,
Obviously, the net effect of cooperation and col
allowances in lieu of such activity [88]—produce con
fbealth care lhey receive. The appropriateness and
laboration between the traditional and modern sys
Nigeria. Zaire. Kenya [8], Botswana [98]. and Zamcentrations of doctors in the cities. The by-product is
Contacts and. presumably, gooa
goodjapport
■iient of specific
one country
ecinc reforms
retorms will
win vary from
uu... —
*rappry
tems. in terms of patient behavior and health levels,
Suaditlnal practitioners have already.estabspatial-segregation of medical facilities, not unlike the
t
.
.t..^h -jiou.nnrv’ fnr Incal conditions.
»another, wuu uu<— ■— - cannot be determined in advana of concerted, wellwim irauiucnixu
- —pattern of racial segregation during the colonial era
hall respects, however, the mustering of political will
fished there in specific locales. These sues would seem
planned
efforts
to
test
the
concept
in
practice.
If
the
[19], A recent study in Kenya concludes that 80"o of
commitment by national governments, hca th■ to suggest for the countries conarned. excellent locathe national health budget is consumed by residents two systems were to be consciously articulated
Khistrics and organized medicine is clearly the; lions for the initial pilot programs to promote and
together, we believe there would surely be a syncreisof Nairobi, Mombasa, and Kisumu—th.
aacial first step in promoting cooperative approaches; assess the cooperative potential of traditional and
the three largest tic outcome with positive health value—even though
cities [73]. Geographically, a map of doctor location
-•health care. However, inaction and tokenism are
this could be interpreted from certain quarters as hav
at the national scale in most developing countries is
iKtively decisions not to change the status quo Is mOA ctosTwS of traditional practitioners selected
ing the effect of “delaying” acculturation to modem
virtually a map of urban centers. Yet urban and rural
there a paradigm for cooperation and integration
medicine [89]. Both systems might be gradually
by their own communities, respected community
areas are part of the same interconnected economic
Specificallv what changes might be called lor
leaders and others knowledgeable about traditional
modified so as to be more closely interrelated. In
^frobablv the best approach would be to start with
system, and unmet health needs are a universal
medicine, health need, and disease patterns m the
creasingly. there are calls for collaboration. Authors
national problem that bears both on human welfare
K consumers: that is. the peasants and the urban
specific localities conarned should be part of the pre
such as Nchinda [90] and Conco [91] make strong
and economic growth.
joor.
This
approach
would
commence
with
indivi
planning process For innovations m the delivery of
Connected with the problem of underserved popu supporting statements but give few specific recom
duals. families and. most importantly, commiimnes of health care to be adopted, it will be crucal to gener
mendations
for
achieving
a
rapport.
A
few
tentative
lations is the need to keep new modern facilities, such
liHaeers. their perceptions, world views and hea th
ate “grass-roots” support and identification with the
steps in this direction have already been taken The
as teaching-research hospitals, at a manageable scale,
seeds. With a real, rather than a token, focus ori h
Niger.an experimental use of traditional healers in
experiment; and. ultimately, shared community re
financially and physically. Some hospital systems are
peasant with “peasantocentrism as the starting
psychiatry is well-known [92], although details of
£ planning for health care would work upwards sponsibility. Indeed, faithful integration of commum. y
believed to be growing too big. too < ’ '
development principles m all phases of p anmng w 11
Li7Ca_t'?g Procedurcs and results have never been adequately
an intolerable national burden with ballooning
and not down. Conceptually, due weight would be
be crucial to the success of each phase of the: unde reP°rIed African countries including Ghana. Nigeria
overhead costs to be absorbed by the health and Sudan, and Asian states such as Indonesia.
given to the sick farmer, ailing woman, or wasting
taking. In effect, this clearly suggests that the basic
budget; and ultimately contributing to the defeat of Malaysia, Thailand. Philippines and Pakistan recog
child, rather than to the needs of a seemingly remote
spatial units in wh.ch the new arrangements for pri
the goal of adequate health services for all citizens
providers
’
bureaucracy.
As
Martin
puts
it
P™?™™
mary health care and cross-referral occur would be
nize. tram and use the services of traditional birth
are still developed too much within high level pla
defined bv community social boundaries. These jire
attendants [93]. In Liberia (and Kenya), traditional
Il is apparent that a constellation of forces bear on
ning
cells
and
Ministry
offices,
by
people
whose
boundaries within which individuals, including herba
practitioners refer patients to the hospital if they
the issues of health care in Africa and the remainder
immunity awareness can sometimes be questioned
lists. midwives and diviners, and groups, interact and
believe lhey are unable to help. Conversely. Liberian
of the Thirld World. They include the population
reciprocate with each other on a more or less daffy
bone doctors" are encouraged to use the hospital's
[951
explosion, social upheaval, cultural change, techno
| Any alternate approach, such as the one we are
basis. Community patternmg vanes cons,der^'>
X-ray facilities before and after setting fractures [94].
logical impact changing economic and occupational
Vitcommending. will obviously have to m ermesh
Such examples are localized and limited in scope, and
across Africa m terms of socio-spatial organization
relationships, new dependencies and consumer expec
' doselv with the already existing government health
and scale. Consequently, the community boundaries
essentially represent individual adjustments to present
tations, politization and. in some countries, an emer
care
structure
To
advocate
incorporauon
of
tradi
reality rather than national policy.
used to delimit primary health servia areas may coin
gent proletariat. These forces, together with new levels
tional healers into the system does not mean to sugcide with nucleated or dispersed village and hamlets,
In 1978 the World Health Organization issued a
of awareness, as well as an increased intensity of in
gest training fewer medical ass.stants, although it
herding units, marketing areas, or other localized, mcall for the "promotion and development of tradi
formation flow, bring compounding urgency. It seems
should
necessitate
changes
in
then
trammg.
as
wdl
be
tional medicine". The report stresses the need for
terdependent household or functional groupings in
extremely improbable that modern medicine, given its
’discussed below It is. however, based upon a comwhich people have substantial face-to-faa contact
scientific planning; indicates possible obstacles to suc
typically monopolistic structuring in Africa [3], can
.
: cious effort to involve each community in the proces.
and reciprocity relationships. This approach departs
cess, such as fear of the iatrogenic effects of traditional
unilaterally provide the necessary solutions.
i
of
solving
its
own
health
problems
more
effecti
e
y
from the >dea ona proposed by W H O. that basic
medicine and resistance by “intransigent advocates of
Neither traditional nor modern medicine is adei
and on the premise that it is socially and psycho log -• conventional health servias “may serve a popuUl. n
one or another system”, and outlines areas of needed
quately meeting health care needs. Separately or
i
callv beneficial, as well as economically sensib’e. il. of 2b000 25.000 through a group of small health
research. Recognizing that traditional medicine will,
together, both fall short. There are parallel but separ- <of necessity if not also by desire, remain’ the major
individuals who supply primary health care come
posts whose number would be determined by the size
ate and inadequate systems; and national resources s
from and are an integral part of the local communn
of the area, and its geographical boundaries In fact.
source of health care for much of the world for some
are scarce. What steps, therefore, could be considered
ttime to come. W H O. recommends national impleI This approach, the attempt to develop from the bot-
7
-
•
.
'
■-
i ■
150
Charles M. Good et al.
Toward health policy initiatives in Africa
as Singer and Araneta insist, this latter approach is
oftftn quite opposite to the concept of social boun-
[iooT 80 Cen,ral 'O lhe definit‘on of a cominuni’y
■fi;
I
j;
’I
r
Igj
III
Ideally, the communities in our proposed model
would be linked to the regional government dispens
ary or health center for referrals and special services,
would establish a local supervisory health committee
and would receive regular, frequent visits by the
health center team at locations accessible to several
^Uages. such as markets, schools or trading centers.
Ihe additional on-the-job training which traditional
healers would receive to enhance their usefulness in
the community health team would also be provided
for other members of the team. This is based on the
principle reportedly pioneered by the yniwsny
I’
Centre for Health Sciences in Yaounde. Cameroon,
that “those who will work together should dc.Jup
develop
their professional relationship (and interdependence))
from the start’' [90, 101],
In regard to necessary policy changes, with conse
quences for planning activity, there is a range of pos
sible specific actions focused — —J • • care which may be ext o'
------ fcvatvM, IUVKWCU,
and evaluated. Such actions would include the follow
“O“ wo”,d ind“d‘
ing:
after learning new skills. Literate assistants might Z
be recruited from among underemployed secondarv
sutSicL"'^ ,O main,ain SirnP‘e
and S
and .trarn ,raditional bir'h attendant!
(TBA s) with a goal of perhaps providing at least one
person with basic scientific midwifery skills per com
Eai(TBA l-hO comPIetcs the Pegram could
be encouraged to take on responsibility for a youn»
apprenfoe. Training should be s.mple and emphasS
skills such as the recogmtion and prompt referral of
I
high
risk cases and wx/uipicvaii
complications, particularly hemorrhage.
infection; asepsis and proper cord
hage. toxemia and mfect.on;
care to avoid tetanus infections at delivery; and
famib planning. These and other approaches to
family
TB
a’ss are currently being developed and evaluated by
TBA
die Danfa Project m a rural area containing 60.000
people north of Accra, in Ghana [103].
Identify and
S
L30-92], among the Navaho in America [104], and
I. Establish procedures and criteria which will per ^*W*?erc are finding that traditional healers arc res
pected and heeded, and that they can play an impormit, in an atmosphere of mutual trust and respect,
rmohaIb,1‘,al,ng and re-integrating chronic
systematic evaluation of the basic knowledge of
various kinds of traditional specialists, and their diag patients [105]. It would be valuable to have such
specialists
attached as clinical associates and be
nostic skills relative to the medical assistants, nurses,
and midwives currently responsible for providing located near each health center and hospital How
ever.
psychiatric
aides should be physically separate
government health services in the local area. The lat
from health units so as not to interfere with (a) the
ter experiment would necessarily require separate
healers
engagement
of the value process; and (b)
diagnoses of the same patient-subjects The prep
expectancy (psychiatry) or "placebo" effects (medi
aration. dosology. and efficacy of traditional herbal
preparations could also be included in this phase of cine) on the outcome of therapy [I06J. The rat.onale
lor this experimentmg w.th psychiatric aides is based
the program. A major problem all participants must
be prepared to face immediately—once a decision to on the global experience of modern health specialists.
Accordmg to Dr T. A. Lambo of Nigeria. Deputy
experiment with the cooperative approach is taken
Dncctor o. the World Health Organization. 70-80' .,
—is .low to reconcile the different value systems in
herent in the traditional and modern approaches to of patients who come to doctors' offices and clinics
"O’r.S^ering from an> discernible organic dis
illness.
order [107]. Indeed, in view of the escalating
2. Identify and train one or more traditional healers
demand
lor psychiatric services in affluent Western
(e.g. herbalists) as health aides for each village, hamlet
societies, and the recent findings of field research in
or mobile pastoral community. These aides should
Tanzania
[5. 7], Kenya [8] and elsewhere, there is
normally be residents of the communities thev serve
little justification for assuming that African populanot strangers and not salaried bureaucrats. Thev
10ns will not continue to require culturally-relevant
should be selected by the community and responsfble
assistance m matters of psychological health.
to the community they serve. Some workshop-type
Supply small stocks of drugs to communities,
instruction in hygiene, sanitation, first-aid procedure
perhaps on a "cost-plus" revolving credit basis. These
asepsis, and health education could be provided in the
would
be made available to health aides and TBA's
nearest government or private dispensary or health
who have been taught and have demonstrated compe
center Traditional healers in the prograr^ would be
trained to give simple treatments at the pomt of tency m their proper use. Tablets, injections, svrups.
ointments and other materials could be strictly
first and perhaps only—contact; assist in local
limited to the principal illnesses; for example, malaria,
immunization campaigns; and to refer patients to dis
infant gaslromtestinal disorders, scabies, and tra
pensaries or rotating satellite climes held m a central
choma.
In hyperendemic disease regions, the list of
place for a cluster of communities. They could be
medwations could be modffied so as to treat particu
fairly recompensed by their communities, although
lar regional hazards such as malaria, schistosomiasis,
government remuneration should not be discounted
and onchocerciasis. The benefits to nomadic groups
as an incentive. (This point of entry to primary care
smalli'',la8cs wb'ch may be completely iso
complement's current policies of the W.H.O. which ■
lated from otherwise available health centers by sea
loucncourage commun'ty pamc.pation
sonal
weather
are obvious, and should offer a major
and self-help through the establishment of "village
incentive for cooperation by the enure community.
151
absorb some of the surplus of unemployed secondary
approaches to supplying essential drugs is
school graduates and leavers whose literacy skills
S^ifcal need in view of the chronic shortages and
could be of great value in their communities
afifeirital unavailability of drugs in rural health facili2. Substantially increasing the numbers of health
Sgduc to high product costs, inequitable distribution
professionals (auxiliaries) at intermediate and lower
the direction of hospital-based curative services.
levels and. at the same time, giving them increased
management and misappropriation [108]. The
responsibilities for medical care. They should be
concept, a decentralized system which
assigned to work in their own communities, or at
SEcportcdly been successfully introduced in Camerleast among their own ethnic group. Their training
would appear to have excellent potential and
and subsequent service should include interaction
SSfresents a model which other countries might profitwith traditional healers. This recommendation would
2 Sy emulate [109].
effect a broader delegation of duties, thereby giving
3 -6. A flexible, rudimentary referral system could be
more support to doctors, and also diminish the
Slfcouraged using the community as the basic cell for
topheaviness of the modern medical care hierarchy
ff|iinary~ care. Village health aides, midwives and
[111-113].
3 ^.:rs would need established channels for sending
3. Increasing the in-country training of doctors
■Sit refractory and complicated cases, without fear of
B mcule or denigration. Presently there are no inten- Their orientation would thus be attuned to the reali
ties of local cultural norms, and to scarce technologi
3&n3| or formalized linkages between traditional
cal resources. This proposal would call for the estab
■ kalcrs. doctors and other modern health personnel:
lishment of new medical schools, even in very small
'ibwever. as we noted earlier in this paper, given the
countries; and it would also require reforms in medi■'®portunity, people do resort to both systems.
cal education curricula, appropriate to specific local
8 Manned implementation of cross-system referrals and
needs, most especially with regard to the use of
IfSfcrdcpendency would reduce the often acephalous
limited resources. Regional medical training programs
jplation characteristic of much traditional health
would be an extension of this idea—whereby a group
'tere. especially in rural areas. Existing spontaneous
of medical schools of adjacent or nearby countries
ij&lieni flows would be guided, improved and. poswould pool their postgraduate medical training pro
jftily, optimized. Traditional medicine would thus be
grammes. Home-trained doctors would be belter
Snked to a larger national system and to technically
adapted than foreign-trained, more concerned about
•higiier levels of health care.
priorities of community health care, less frustrated
. The foregoing proposals to not radically disrupt or
with the lack of technological support less likely to
:ftrraten the traditional health care system. The pri be exportable and. hence, to be lost in the brain
mary orientation towards indigenous values is not
drain".
/Changed in fostering reforms that promote increased
4. Consonant with broadening the base of the pyra
‘jtf-reliance. It is not proposed that traditional medimid of health care providers would be the need to
dne should be regulated, but the question may be carefully integrate referral systems at each level of
'addressed: Should traditional healers be trained, cer care. Apart from members of the family, a patients
tified. and licensed to practice? Most considerations first contact for health care would be with a village
seem strongly to disfavor control, although tn the
health aide. Referrals would then proceed, if required,
minority of ethnic and community settings where tra- up the hierarchy, at perhaps five levels from: (I) vil
dhiona) healers do cooperate with one another, it lage health aide birth attendant, to (2) health agent or
might be advantageous to encourage them to form or community nurse's aide, to (3) nurse, medical assist
farther develop professional associations [8.98]. and
ant. or clinical officer, to (4) general medical doctor,
'?acarefully constructed code of ethics [21]. However, and to (5) specialist medical doctor The referral tiers
^regulatory management by government would be would also be spatially organized through linked
alien to the fabric of traditional medicine. Barriers to catchment areas, based at the lowest level on com
free access to traditional medicine would be deeply munity social boundaries. This would tend to mini
f resented, both by the clients and the healers Imple- mize aggregate
a6j.,<£
patient travel and also identify the
f mentation of a control scheme would be impossible. more remote
remot communities to be visited on regular
Wasteful of resources, and undesirable. In fact, regula- rotation. by a health team from the regional health
' tion should be avoided so as not to drive practitioners center
center. Risk
Risks of mis-diagnosis and delayed referral
7 Underground [110].
would have to be evaluated in benefit-cost terms,
S It would be much better to use incentives to recruit
against the risk of no diagnosis at all Treatment res
and train traditional healers and health aides, and to ponsibilities at lower levels would need to be categori
? give them a competitive advantage over nonpartici- cally defined in terms of access to listed drugs, and so
S pating healers. Those not encouraged by such induce on.
ments would be free to practice at will: and their
Inter-meshing with traditional healers would be
presence would give the peasant an alternative, which possible at the primary community level (village or
.? competition would be of some marginal value
hamlet); and some healers might also be employed at
| Policy options which focus more directly on the the regional health center. New categories of resident
modern health care sector must also be considered
village-level health aides might be developed The
j. Among those to be evaluated arc.
health agent who travels around an area by motor
ized bicycle treating domestic animals could also be
\
1. Substantially increasing the number of part-time
health workers (in addition to selected traditional trained to de-worm human subjects and give other
treatments. The idea is not revolutionary: it can be
t healers) in line with principles recently outlined by
turned around to recommend that health aides who
■...............................................
I
>
Toward health policy initiatives in Africa
152
I
I
II
III
If
I*
it
I
I
153
Charles M. Good et al.
treat humans should also be trained to treat animals,
since human health and animal health are closely in
terwoven in the peasant world. Traditional herbalists
often treat domestic livestock as well as humans [23].
Unstated but implicit in discussing health care, so
far, is the role of major public health programs in
preventive medicine. It is known that the capping of
wells or the introduction of piped water supplies can
reduce infant and child mortality quicker than any
free access to modern drugs; that large-scale control
programs for selected diseases such as smallpox, try
panosomiasis. or onchocerciasis will transcend local
level health-care organization. However, the involve
ment of efficient local level health care management is
indispensible to the success of capital intensive‘largescale health schemes. Individual, village-level preven
tive medicine is absolutely critical, for example, in
areas of infant weaning, nutrition, or schistosomiasis
prevention. Thus, for our present purposes no differ
entiations are drawn between public and preventive
medicine, large-scale or small-scale.
The dualistic and dichotomized health care systems
of the developing world seem ripe for modification
and mutual adjustment especially given the dire scar
city of economic resources. The health sector, per se.
must compete with agriculture, transportation, and
other sectors for very limited development funds. The
example of China with its "barefoot doctors" has been
much overworked, but nevertheless, China does suc
cessfully combine traditional and modem medical
practices, using local level health aides, both in rural
and urban settings, with a spatially integrated referral
system. The successes in community health achieved
by the Chinese during revolutionary reconstruction
have since led to a quest for quality of care and
lengthened periods of training in all categories (bare
foot doctors now study for 2 years rather than three
months) [114], How much of their experience is
transferable across cultures and polities is an open
question. The Tanzanian experiment, with its decen
tralized health services, may also be viewed in this
light. Cuba's polyclinics are primarily addressed to
urban and semiurban populations. Wherever one
looks there are health care delivery modes or models,
but caution advises against their simplistic pursuit
and adoption.
Culturally adapted local and regional solutions,
modifying the status quo ante, are recommended.
Paramount would be some integration of the tradi
tional and modern systems. This would represent a
diffusion downwards of modern care and a diffusion
upwards of traditional care. In Africa, scattered
attempts al experimenting with ideas in this vein are
currently being tried out and a synoptic review is
urgently needed to evaluate these and other novel and
experimental experiences
In summary, it is argued that countries of Africa
and the developing world in general do themselves a
disservice by officially ignoring traditional medicine,
by excluding it from the central planning process, and
by not considering its partial or fuller incorporation
as a public policy option in health care planning
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