FRCH NEWSLETTER VOL.5-No. 1-6-JAN -DECEMBER-1991
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- FRCH NEWSLETTER VOL.5-No. 1-6-JAN -DECEMBER-1991
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COMMUNITY T-P-:
Srinivasa Nilaye
Jakkasandra, 1 Main, 1 Block,
No: 367,
Koramangala,
BANGALORE - 560 034-
Jan-Feb, 1991
Vol V
No. 1.
Panchayat "Raj and Health Care: The Karnataka
Experience
T R Satish Chandran*
Panchayati Raj was ushered in in Karnataka three years ago
with a view to ‘take power to the people’. The preamble
to the Karnataka Zilla Parishads, Taluk Panchayat
Samithis, Mandal Panchayats and Nyaya Panchayats Act
1983 states,
“Whereas it is expedient to provide for the establish
ment in rural areas of Zilla Parishads, Taluk Panchayat
Samitis, Mandal Panchayats and Nyaya Panchayats to
assign to them local government and judicial functions
and to entrust the execution of certain works and develop
ment schemes of the State Five Year Plans to the Zilla
Parishads, Taluk Panchayat Samithis, Mandal Panchayats
and to provide for the decentralisation of powers and
functions under certain enactments to those local bodies
for the purpose of promoting the development of
democratic institutions and securing a greater measure of
participation by the people in the said plans and in local
and Governmental affairs and for purposes connected
with and incidental thereto...!’
1. The expressions in the preamble are significant. The
legislation aims at promoting democratic institutions
which are expected to function as units of Government
in their areas. These institutions are to be entrusted with
development schemes under the Five Year Plans; wider
opportunities should thereby become available for peo
ple’s participation in the execution of the Plans, as also
in the affairs of local government. There is to be a decen
tralisation of powers and functions to enable the Pan
chayat Raj institutions to discharge the responsibilities cast
on them.
2. It must be recognised right at the outset that the Kar
nataka model of Panchayat Raj is not just an ad
ministrative innovation aimed at improving the efficien
cy of programme implementation through administrative
decentralisation. Its goal lies much deeper, namely transfer
of the function of governance from the state level to the
district and lower levels. The Panchayat Raj institutions
are visualised as units of government enjoying a great deal
of autonomy; at the same time, proximity of the elected
representatives in these bodies to the electorate would en
sure greater accountability. The process of planning is ex
pected to become more effective as these institutions have
intimate knowledge of local resources. While it is the
SPECIAL ISSUE: HEALTH IN PANCHAYATI RAJ
larger political and economic goals which underlie the
concept of Panchayat Raj, secondary benefits would also
flow in terms of more efficient administration as a con
sequence of closer supervision and answerability of the
local bureaucracy to the elected bodies.
3. In the Panchayat Raj structure in Karnataka, ex
ecutive power is vested at two levels, the Zilla Parishad
at the district level and the Mandal Panchayat which
covers a cluster of villages with a population of 8000 to
12000. There are two other levels-at the bottom, there is
the Gramsabha which comprises of all the adults in the
village and is required to meet twice a year to review the
activities of the Mandal Panchayat. In between the Man
dal Panchayat and the Zilla Parishad, there is the Taluk
Panchayat Samithi, which includes the local MLA and
the chairman of all the Mandal Panchayats in the taluk.
This body is essentially a coordinating body without any
executive power. The Zilla Parishad is designed to be the
main agency for planning and development of the district.
The personnel of all the development departments (in
cluding health and family welfare) at the district level and
below are placed under the administrative control of the
Zilla Parishad, the official machinery in the district be
ing headed by a senior officer designated as Chief
Secretary. In order to enable them to discharge the plan
ning responsibility, each Zilla Parishad is provided with
a planning team which includes a statistician, agricultural
expert etc. Conceptually, the Mandal Panchayat is a
plenary body in its area as, like the Zilla Parishad, it is
also directly constituted. In reality, its area of operation
is mainly as an implementing agency. It however wields
considerable power in regard to the selection of
beneficiaries in beneficiary-oriented programmes; it also
has a decisive voice in the choice of works to be taken
up in the local area and their location. As regards finance,
the Panchayat Raj institutions in Karnataka depend
almost wholly on grants transferred by the State Govern
ment through the annual budget voted by the Legislature.
The scale of transfer however is considerable and presently
amounts to a little less than a third of the state budget.
Thus, there is a genuine attempt to transfer both powers
and functions on the one hand, and commensurate
resources on the other, to these institutions, to enable them
to truly function as units of government in their areas.
4. As stated earlier, the prime responsibility of the
developmental activities in the district has now been plac
ed on the Zilla Parishad. This includes public health.
FOR PRIVATE CIRCULATION ONLY
compounded by the fact that in the initial period when
these institutions required to be nurtured, some unforseen adverse factors cropped up. Among these, the most
important were the fluid political situation in the State
during 1988-89 and the State’s acute financial stringency
which imposed severe restrictions on the flow of resources
to the Panchayat Raj institutions, Besides, the Seventh
Five Year Plan had been frozen before the establishment
of the new bodies, leaving hardly any free resources to
them to launch new initiatives. Given these limitations,
the performance of these institutions must, on the whole,
be considered encouraging,though three years is too short
a period to pronounce final judgment.
6. The working of Zilla Parishads and Mandal Pan
chayats was reviewed by an Evaluation Committee which
submitted its report in 1989. Referring to health ad
ministration in the districts, the Committee reported
“Likewise, there has been significant progress in the area
of medical and public health facilities. Besides a big im
provement in the attendance of doctors and other medical
personnel, steps have been taken to secure the supply of
drugs and medicines more regularly and in accordance
with local requirements. Pressure from local governments
has also led the State Government to make substantial
modifications in its medical stores purchase policy, and
ZPs have been able to secure more of their supplies locally
more cheaply and promptly”. Thus, there is evidence to
indicate improvement in two directions-first in mobilis
ing local resources for strengthening the infrastructure for
health services and secondly in greater* accountability of
the doctors and paramedical workers. Also, there appears
to have been some improvement in the supply of drugs.
7. One cannot however say with confidence that im
provement in the performance of the health service is
visible all over the state as a result of Panchayat Raj. As
yet, there has been no comprehensive study and one has
to rely on case studies or impressions gathered from a
cross-section of people. The general picture is that as in
other sectors, there have been transitional difficulties in
rural health administration. Personnel management has
been a problem area; recruitment, transfers and
disciplinary control have been a source of friction bet
ween the State Government and Zilla Parishads. In
evitably, the initial complement of Panchayat Raj person
nel comprises Government officials on deputation. It is
only over a period of time that ZPs can build up their
own cadres. There are legal limitations to the extent to
which administrative control over deputed personnel can
be passed on to the borrowing authorities. This is by no
means an unsolved problem and it should be possible to
evolve working arrangements* which demarcate the roles.
of Government and Panchayat Raj institutions. But, on
account of lack of coherence and consistency in thinking
in the different segments of Government at the highest
level, there has been considerable misunderstanding and
confusion which could -have "been aovided. An am
bivalence in governmental attitude towards PR persists
.even now. Yet another, but anticipated, factor has been
the evolution of new relationships between the officials
and the elected representatives at different levels. It was
only to be expected that it would take sometime for the
vast body of officials, specially those operating close to the
Section 182 of the Karnataka Panchayat Raj Act lists the
various functions of the Zilla Parishad; among these is
the management of hospitals and dispensaries, excluding
hospitals at the district headquarters and institutions
managed by Municipal Corporations or Councils. One
of the Standing Committees of the Zilla Parishad is the
Health Committee which shall “perform the functions
relating to health services, hospitals, water supply, fami
ly welfare and other allied matters”. The Mandal Pan
chayat has also some responsibilities in areas of sanita
tion and health, but these are mostly what one may
describes as the traditional municipal functions of main
taining sanitary conditions in the local area. Every Mandal
Panchayat is required to constitute an Amenities Com
mittee to “perform functions in respect of education,
public health, public works and other functions of the
Mandal Panchyayat". It will be seen from the foregoing
account that it is the Zilla Parishad which has a crucial
role in the health administration of the district. The role
of the Mandal is somewhat undefined and indirect. The
following figures from Karnataka’s annual budget for
1990-91 give an indication in financial terms of the ex
tent of decentralisation in rural health administration.
Total Revenue budget for
"Medical and Public Health
Deduct provision for Urban Health
Services and Medical Education
Total Provision for Rural
Health Services
Of which, transfer to ZPs
Plan
Non-Plan
Total
40.69
174.93
215.62
10.86
95.45
106.31
29.83
79.48
109.31
20.71
(69.4%)
65.63
(82.6%)
86.34
(79.0%)
As the above figures show, almost-four-fifths of the
health budget meant for the rural areas are now controll
ed by the Zilla Parishads.
5. What has been the experience of the working of the
Panchayati Raj institution in Karnataka, during the last
three years administration? When radical changes are in
troduced in the politico-administrative system, it is only
natural that there is a period of transition during which
teething problems are bound to be encountered. This was
in Karnataka, there has been massive transfer of
resources to Panchayati Raj institutions. Last year, Zilla
Parishads and Mandal Panchayats spent Rs. 1,500 crore
between themselves. Besides, a finance commission to
decide devolution of funds, there is in the State high-power
committee of experts to examine various circulars issued
by the Government to eliminate the possibility of any
bureaucratic attempts to fiddle with the Panchayati Raj
institutions. Panchayats enjoy the power to levy tax and
the entire staff of all development departments of Govern
ment has been transferred to Zilla Parishads for all prac
tical purposes barring disciplinary powers which have been
kept with respective heads of department. The lists of
beneficiaries of anti-poverty programmes are approved by
panchayats. the president of Zilla Parishad enjoys the
status of a Minister of State and the vice-president that
of a deputy Minister.
Source: Indian Express, 1146/89.
(Cont on page 10^
2
Convergence of Social Development Services
Related to Women and Children
Ela Bhatt*
Preeti Bhat**
We nave yet to solve the problems of poverty, inequali
ty and improve the quality of life for the majority of our
people despite remarkable technological advancement,
economic progress, and increased food production in the
country. It is not that human resource development and
meeting basic needs of the population have not been
recognised as important objectives and priority areas for
action. On the contrary, there is wide-ranging consensus
on meeting these needs, cutting across political affiliations
and ideological differences. To tackle the major problems
of poor health, malnutrition, high population growth and
mass illiteracy, we have national programmes run by the
respective ministries with functionaries at different levels,
upto the village level. The Integrated Child Development
Scheme (ICDS) is one of the more successful program
mes in the mother and childcare services. In ICDS
areas, malnutrition has been found to be 60 per cent lower
than in the non-ICDS areas. Infant Mortality Rate (IMR)
is also approximately 20 per cent below the national
average in the ICDS areas.
However, we must admit that we have yet to achieve
the desired results with regard to universal immunisation,
reduction in birth rate, reduction in mortality of infant
and children under 5 and maternal mortality. We have yet
to eliminate widespread malnutrition, or promote
universal literacy, and community self-reliance.
It is now being increasingly recognised that health,
nutrition, environmental sanitation and education are
such closely interrelated factors that isolated delivery of
any single input will not show the desired impact at best,
or very often, could even negate the gains made by one
intervention due to the absence of other essential inputs.
The present structure of social welfare is bureaucratic, and
has a top-bottom approach. For instance, for improving
the curative health services like the hospital referrals,
availability of personnel and drugs is very essential.
However, it will not improve the health status of the com
munity if the water and sanitation facilities are very poor,
or, if the people do not have economic access to nutri
tion due to poverty. The nutritional status of children
is affected by poverty, the family’s physical and economic
access to food, intra- household distribution of food,
mother’s awareness to nutrition, and health, availability
of health care services and safe drinking water. When so
many interrelated factors affect the nutritional status, no
wonder a lone supplementary nutrition programme fails
to show positive impact.
Similarly the success of family welfare programmes at
the national level, or acceptance of family welfare
measures at the individual level, is determined by a
number of factors which affect the knowledge, attitude
and behaviour of the women. Firstly, the woman’s status
in the family and society affects her level of autonomy
or choice in such matters. Her decision for a terminal
method of contraception will be affected by the incidence
of infant mortality and morbidity. The health status of
OlQ
the woman and the quality of health care services are also
important factors. Added to this is the near absence of
social security and public assistance available to the
families, in old age. No wonder the couples wish and wait
for the birth of a male child to the detriment of the FP
programme.
Another major and very serious limitation of the pre
sent delivery of social services is the lack of community
participation at different levels. There is straight jacket
approach, i.e. programmes are designed at the centre/state
and are expected to be implemented uniformly in every
village irrespective of the local condition. Thus the com
munity needs and priorities at the local are hardly reflected
in the programmes. The community members are rarely
consulted in the design, implementation and monitoring
of the programme meant for them. The functionaries in
volved in providing these services do not feel accountable
to the community. Their concept of accountability is
restricted to reporting to the immediate supervisor of the
line department and that too mainly related to giving ac
count of the materials used (e.g. medicine or food) or
‘targets’ fulfilled.
To make these services more responsive to people’s
needs, a thorough restructuring of the existing service
delivery system is needed. But here in this Working Paper
we have dwelt on only one crucial aspect, to get the max
imum result out of the resources now being spent on these
services in a fragmented manner.
In tune with the Plan priorities, for better and more
effective delivery of the services related to women and
children, the basic approach will be tpwards:
i) convergence of social sector services related to
women and children, and
ii) active community participation in formulating and
implementing these programmes.
Needless to say that the effectiveness of the convergence
will itself depend on the active community participation
involving particularly the local women.
When once the need for convergence has been recognis
ed, it is necessary to spell out some of the specific aspects
for operationalising the concept. The issues meriting con
sideration in this context are:
i) Type of services/sectors: The approach has to be
a phased one. The minimum package of services that need
to be converged are the services of healthcare, nutrition,
childcare and creche, pre school and non-formal educa
tion, immunization, family welfare, water and sanitation
as these are related to the quality of life of women, girls and
children. As economic programmes need a totally dif
ferent, separate experience, attitude and approach it may
be undesirable to converge social and economic program
mes at this point. However, in future, the economic and
social programmes should have active, direct interaction
with each other. Income security and social security are
interdependent for every household.
ii) Level of services: For the quickest and most direct
impact, the focal point where the services are needed to be tionaries, Panchayats, Village Women’s Groups will re
brought together is the village level. The village anganwadi quire simplified, intensive, regular training in technical
can be the central place, where the women, come together, managerial and communication aspects, to provide the
otherwise the village school could provide a base. And, for' necessary information and knowledge to the community
facilitating technical assistance and inter-departmental and functionaries.
coordination, convergence should take place at the block
level. Here, the functionaries involved must work as a team Support of voluntary agencies in these areas will be
and share their concerns as a group. Above that level, i e, crucial. Their experience of working with people and in
district, state, central-the line departments will have in novative experiences will provide a new momentum and
dependent funtioning for the specialised skills and ser direction and act as facilitators to the community.
vices required for administrative efficiency. But they will
vii) Women’s Participation: Lack of women’s involve
still need better coordination and interaction.
ment in the programmes meant for them has been a ma
iii) Resources: The funds for all the programmes of jor shortcoming of most of our development program
health, nutrition, education, childcare and other services mes. As mentioned earlier, here, the convergence of ser
mentioned above, will need to be converged at the Block vices will be coupled with the decentralisation of the
level and transferred to the implementing agency, in most •design and implementation of these programmes through
cases Panchayats, in an untied manner, with broad ear Panchayats. As the bulk of the health problems at the
marking. This will enable the community to allocate the village level are related to women and children, and the
resources in the specific areas that the people perceive as functionaries are also women, village women’s participa
priority. Thus pooling together of monetary, human and tion from the beginning is most crucial. Therefore,
material resources will provide greater flexibility which women’s participation has to be built into the local,
can lead to evolving more appropriate programmes for political and administrative machinery. The proposed
the target groups.
body, say, mahila mandal, or women’s committee or
iv) Team of Functionaries: The core team of func women’s standing committee in the Panchayat, should also
tionaries will consist of Auxiliary Nurse Midwife (ANM). be able to function as a “receiving mechanism” for hither
Anganwadi worker, Community Health Worker, Dai and to atomised client groups or individuals, who has no com
preferably non-formal education workers. These func mon reference point in reaching out for demanding the
tionaries would have separate and specific functions, but services. This will be the surest way of ensuring women’s
will share common goals and work as a team. For this, access to these services.
intensive training and orientation will be necessary. In ad
Women will actively associate themselves with the pro
dition to the specific training in upgrading the technical* grammes at various levels. As the main users of these ser
tasks they perform, a common training will have to be vices, they will set priorities amongst the different pro
given to understand the basic aspects of other func grammes, be involved in information dissemination about
tionaries’ work and in areas of communication,
these programmes, leading to effective demand genera
managerial and group work. Here, we need to clarify that tion and utilisation of these services. They will also play
we are aiming at convergence through team work and not a constructive and legitimate role in monitoring and
‘integration’, in the sense that we expect one single scheme evaluation of their programmes. They will also take care
or functionary to deliver a number of inter-sectoral ser of the needs and problems of the women functionaries.
vices. This would overburden the worker, and due to
What is most desirable is that Panchayats entrust the
allocation of multiple tasks she will try to fulfil some responsibility of implementing the programmes of health
seemingly important tasks-for which there is greater care, child care, family welfare, nutrition, literacy, fair price
pressure from the top (e.g. family planning)-at the cost shop, safe drinking water to the committee of the village
of some other tasks, which may be equally important, (e.g. women with the necessary powers and resources. Com
health education).
munity participation will also serve the long-term goal of
v) Administrative Mechanism: The major departure,
empowering the community for self reliance.
under the proposed system, will be shifting of authority
viii) Monitoring and Evaluation at the National/State
and power from the bureaucratic system to the local Level: A high level autonomous, non-government expert
village Panchayat. In operational terms this would mean group for on going monitoring and evaluation will have
that the untied funds for these developmental program to be formed at the national and state level. The groups
mes will be transferred to the Panchayats. Budget at the will have a two-way information flow with organisations
State level should reflect this commitment. The village at other levels. The National/State. group will not thrust
level functionaries will be recruited by, report to and draw centrally set ‘targets’ on the block level bodies, but based
their salaries from the panchayats. This will make the ser on realistic and locally set goals,- it can provide an ag
vice delivery system much more accountable to the peo gregate picture and assist in the mobilisation of needed
ple they are meant to serve. The Panchayats may form technical, financial and managerial inputs. This expert
group will act more as a facilitator, rather than as a con
a standing committee or a separate women’s committee/organisation to work closely with and monitor the trolling body.
Finally, a word of caution is added, that no one
delivery of these services including ensuring availability
of supplies. Thus major part of monitoring will be taken “model” "or “scheme” can be prescribed for the entire
country. In fact we need to develop various models. The
over by the local people’s agency.
vi) Technical Assistance: The professionals and the convergence concept has to be operationalised in the first
government departments will need to reorient their skills instance by way of pilot experiments in regions with dif
from supervision and control to providing technical ferent background, to start with, say, selecting blocks in
assistance, training and support. The local level func
(Com. on page 13)
4
Convergence of Services and Schemes Relating to Health
Nutrition and Education and Linkages with the
Panchayat Raj
A Report
Kavita Bhatia*
Introduction
One reaction of the group was that convergence of func
tions
at village level would have long term sustenance not
The Planning Commisssion of India sponsored a twoday meeting on “Convergence of services and schemes only through government employees, but by drawing from
relating to Health, Nutrition and Education and Linkages indigenous knowledge bases and the traditional func
with the Panchayati Raj" This meeting was arranged by tionaries at the villages, who are not government
FRCH, Pune. There were 24 participants including employees. Such functionaries (like dais) should be
representatives from the voluntary health sector, resear upgraded and better trained, but without converting them
chers, academicians and government officials. The objec to government employees.
tive of the meeting was to discuss the feasibility and 1.2 Which are the services at the village level where con
desirability of convergence of government services in the
vergence is proposed?
areas of health, nutrition and education, at the village
The functions sought to be converged were in the areas
level. The meeting was chaired by Ms. Ela Bhatt.
of
Health, Integrated Child Development Scheme
The discussion is of general interest as it also throws
(ICDS),
Nutrition and Education.
light on many relevant issues in the present health system.
The following report summarises the main issues which
1.3 Convergence defined:
emerged; the areas of broad agreement; and the areas
thrown up requiring further consideration, while con
Convergence was defined as a meaningful combination
templating convergence, or any modification in the health of activities and functions, to foster coordination and bet
system.
ter effectivity, and to avoid duplication. Convergence did
1. The Concept of Convergence
1.1 Why is convergence necessary?
Convergence of services and schemes relating to
health, nutrition and education is necessary because:
not mean that a single functionary would take up all the
activities in health, nutrition and education at the village
level.
Most of the group felt that the ICDS workers and the
health workers should function as a team along with the
dai. However, a unilinear design does not take into con
sideration the informal, indigenous, traditional func
tionaries in a village. This issue needs to be examined
deeply.
Many group members felt that whatever the changes
at the village level, impact would be limited if there was
no change in the entire system.
(a) the trickle down benefits of the numerous vertical
schemes floated by the government are minimal,
compared to the huge investments in these
schemes.
(b) there is lack of accountability of the schemes and
the functionaries, towards the people.
(c) the various functions required at village level have 2. Convergence of health and nutrition services:
been fragmented into numerous programmes, and
An alternative model for the country’s health system,
then inter-sectoral and intra-sectoral links have
been recommended between these different sectors which already exists (ICMR/ICSSR report entitled Health
and programmes. This approach has limited For All: An Alternative Strategy).
This model does propose a convergence of health ser
benefits for the people at the village level.
vices.
The ICMR/ICSSR model has influenced the health
(d) there has been a dangerous trend towards over
mystification and overprofessionalisation of those policies of the country, but needless to say, serious limita
functions which can be handled much more effec tions in the access and effectivity of the nation’s health
tively locally by people equipped with some services, still remain. Some group members felt that con
knowledge and having high cultural and social af vergence, or indeed, any modification of health services,
finity, if they are equipped with appropriate train would be effective only if the health services were
(i) decentralised and (ii) accountable to the people.
ing and support.
Group members listed out the curative and non-curative
(e) One major reason is because health, nutrition, and
education are closely related and seeing them as health functions which could be handled at village level.
isolated programmes has proved to be a major hin A new classification of diseases was proposed, which
would enable a clear definition of the work loads of para
drance to the effectivity of these programmes.
(0 today there are 10 departments and 16 functionaries medical and medical workers at the village level and above.
meant for these functions at. various levels. Con The Community Health Care System was one of the
vergence will ensure that there is no duplication alternatives proposed at the discussion. (Details in
or counter-productive efforts. Large investments the article “The Community Health Care System” in this
in administration and salaries will also be avoided.
issue).
COMMUNITY HEALTH Pr,
No; 367, 'Srinivasa-Nilayg'
Jakkasandra, I Main, I BlSsk,
5
Koramangala,
BANGALORE - Snn .
3. How far can health functions be decentralised?
A village can be largely self supporting for its health,
functions. This is possible. Field experiences have also
shown that village health workers could be very effective
provided:
(a) they are backed up by adequate referral and
curative services. The credibility of this system would re
ly on the existence of an effective referral hospital whose
doctors would also give technical guidance and support
at the village level.
(b) this curative centre should not be a second or third
grade service, and a minimum level of quality should be
ensured.
(c) there needs to be a liberalization of present con
trols on the para-medical functionaries. An ANM today
can insert a loop but cannot give an intravenous injection.
(e) transportation and communication facilities are
essential.
(f) adequate resources should be available at the
village level.
(g) adequate payment of village health workers.
(h) none of the health functionaries should be
transferred.
One comment was that while there is no doubt about
the effectivity of village workers, no categorical statement
on their potential promise can be made, since this would
be dependent on educational, social and cultural factors
also..
4. Can the system be made accountable?
financial and administrative control would be vested with
Panchayat, and technical guidance with the system?
5. Training and Su pervision/Sup port For Convergence
Training of workers at the village level, to take on their
changed functions was an important aspect. There was
broad agreement on the following aspects:
(a) Initially NGOs should take over the training because
these are culturally and socially more affiliated to the peo
ple, hence their training package would be more relevant
to the needs of the people, (b) The ANM, CHV, Dai and
Anganwadi workers should be trained at one common
centre, under one system, with some common training ses
sions. Separate sessions would also be required because
these are functionaries working at different levels, (c) This
training centre should be at the PHC or nearer, not at
district level, (d) Training should be given to both new
recruits as well as existing functionaries, (e) Continuing
education and common refresher courses should be part
of training for all levels, (f) All health education and in
formation inputs at all levels, should be common so that
uniform message reach the people.
If modifications in the health services, are aimed
towards better accessibility and effectivity, convergence
is just one of the aspects to be considered. Some other
important aspects to be considered in any alternative
system were also discussed. These were:
6. Funding and devolution of funds for an alterative
system.
The Panchayat and the health system.
While it is undisputed that there should be accountabili
ty of the health system to the people, there was concern
about the body which would be the representative of the
people.
A member summed up the various suggestions of
representative bodies at the village level to which the health
system could be accountable:
(a) the Gram Panchayat (b) the Gram Panchayat with out
side support (NGO/expert/doctors); (c) the Gram Sabha;
(d) the Gram Panchayat with representation of the health
worker plus NGOs (e) the Gram Panchayat with a village
health committee (having area representative); (f) village
Mahila Mandals.
Representation of woman at this level was a. major con
cern, since most of the health and nutrition functions are
to do with women and children. It was felt that having
representative Panchayat members or women func
tionaries or even 30 Vb reservation, was not enough. Two
suggestions were:
(a) A statutory all women Panchayat; (b) A village com
mittee which will be jointly responsible with the Pan
chayat, for the health system, to consist only of women.
Can the Panchayat adequately handle the planning and
supervision of the system? It was felt that they could, with
adequate training and support. They could also seek
guidance from outsiders (NGO/experts/doctors).
Much debate was generated on who would control the
proposed system: would there be a dualcontrol, where
The group felt that (a) Cost is not a relevant factor in any
modifications for the rural health services, because to
day much of the resources are going only to urban public
health expenditure, (b) Rational use of drugs, no use of
high technology and a lower proportion of expenditure
on salaries, should be an integral part of the alternative
system, and would lead to conservation of funds, (c) Op
timum usage of existing funds, while creating a pressure
lobby for more funds was proposed, (d) Resource collec
tion and dissemination should both be at .block/district
level to ensure equatable distribution to rural areas. This
may mean a change in the tax structure.
7. How much flexibility should be with the village to
decide health expenditure?
(a) If firm guidelines are handed along with funds to the
village, then the village’s self-reliance will be non-existent.
(b) Perhaps some portion of funds should be earmarked
from the top, and the rest handed over to the village’s
discretio. All developmental funds not only health should
be handed over with only a fixed portion earmarked for
specific expenditure. (c) One suggestion was that the per
capita expenditure should be given to each Panchayat, to
spend as per its own discretion, (d) It was felt that the
district level devaluation from ZP, is not the correct body
for dissemination of funds, nor can the system be con
sidered decentralised at ZP level, because the block level
VCont on pa^ 14^
6
The Concept of Panchayat Raj in Health Services
Reactions from the Field
Rani Bang and Abhay Bang *
Pandit Jawaharlal Nehru in late fifties once expressed ple have refused to accept this. There is no alternative but
his regret to Acharya Vinoba Bhave that even though to change the decision making style of the health program
various development and welfare schemes were planned mes and to give people a more assertive role as well as
by his Government and the Planning Commission, peo responsibility.
ple did not utilize these schemes. Vinoba’s reply was very
Even within the public health services, there are serious
typical of his way of thinking. He said that he had become problems due to this centralised style of decision making
optimistic about the future of India after listening to that and top down approach. The. District hospital at Gadproblem. It proved that people did not want to be treated chiroli once received 10,000 bottles of Lomodex, from
like cattle. People wanted to decide their own needs and Directorate of Health Service at Bombay when its annual
plan for it. What is the relevance of this interpretation requirement was only 50 bottles. The entire annual drug
today? In this paper we shall discuss the need, poten budget of the hospital was exhausted by this one irrele
tial and problems of decentralisation in health vant item though the hospital did not have medicines
services.
against malaria-a disease of high incidence in the district.
Public health services in India have experienced serious Yet the Civil Surgeon did not dare to send back excess
problems in delivering goods. Programmes like malaria Lomodex or inform about it to Directorate lest he should
control, implemented vertically through military style be reprimanded for such arrogance. Gadchiroli district
operations, initially produced good results. But other had not a single reported case of Guineaworm. Yet ali the
health programmes which ultimately depend upon human health workers in the district were asked to conduct house
interaction between the health provider—who may be a to house survey of Guineworm because such were the
doctor, nurse or community health volunteer—and the orders from higher up. The District Health Officer, a
recipient need a different approach. Unfortunately the doctor usually with an additional degree in public health
truth that service to people cannot be governed by the and ten years experience had no autonomy or say in
priorities of the health department is usually lost sight deciding what were the priority health problems in his
in the large scale functioning of the public health services. district.
The results are not difficult to predict. The experience of
We are observing the public health services closely for
two programmes should suffice. When the onus of plan the last 5 years at different levels from state capital to a
ning ones own family was taken over from people by the remote village. The working culture of this system can be
health department, a massive programme of family plan described as pushing down targets and orders and only
ning was built up. In the words of Dr. Harcharan Singh, expecting the reports of completed targets. At one time,
Health Advisor to the Planning Commission. “Between a PHC health worker had to provide information in 120
1977 to 1987, the expenditure on family planning pro indicators each month. Bombay, the workers perceived,
gramme more than doubled, the claims of couple protec only wanted figures. No other form of interaction or feed
tion rate went up from 22% to 37% but birth rate remain back is welcome within the line of command. The inability
ed static at 33 per cent per 1000 population” People are to listen to subordinates or treat them with respect was
giving signals that they have their independent thinking typically exemplified when one assistant District Health
and choices which can not be bulldozed.
Officer (DHO) boasted to us after a monthly review
Taking inspiration from the ‘Barefoot Doctor1 of China meeting of a PHC, that he had never conducted a review
and successful demonstration of this concept in many meeting in a which minimum four nurses did not cry!
small scale voluntary projects in India, a centrally spon
A system with such a relationship with it’s own workers
sored Community Health Volunteer (CHV) scheme was and colleagues can not be expected to be sensitive to the
launched twelve years ago. Several evaluations of the needs and feelings of po.or illiterate masses, who in turn
scheme have been pessimistic and cancellation of this can not be expected to respond to the messages and proscheme has been on the cards. States like Gujarat have gammes of such a health care system. This counter pro
already discarded the scheme. A question can be asked ductive relationship needs to be changed. And any change
as to ‘who has failed?1 Has the very concept of village away from this centralised style will be in the true spirit
health worker failed or the health department has failed of Primary Health Care as envisaged at Alma Ata to
in properly implementing a very good and proven idea? which the world is committed. Primary Health Care was
If the later is true then who should be changed?
described as appropriate for local needs, planned and im
The lesson to be learnt from these two experiences is plemented with community participation.
that public health services are unable to be sensitive to
The approach paper of the Eight Five Year Plan speaks
people's priorities and feelings and hence have failed in strongly of people's participation in planning and im
successfully implementing many public health program plementation through Panchayat Raj. There is some inmes. The health services tend to turn every health pro terest at the level of Planning Commission in democratic
gramme in to a vertical campaign like activity. The Health decentralization of the health care by delegating village
department probably has its own compulsions. However, level health care to Gram Panchayat. Is it desirable? Is
in this style of operation, people have no say or role ex it feasible? What are the possible gains and problems?
cept to subject themselves to the programmes. And peo We conducted discussions with sarpanchs, village health
7
workers, nurses, district health officer, chief executive of
ficer of Zilla Parishad and the collector of a district.
The first reaction of some nurses was that if they were
to work under Gram Panchayat, they would seek retire
ment. Why?
Reactions of Nurses:-
“Villagers will consider us their servants. How can we
work as subordinates under illiterate villagers? We are
government servants; not the servants of the villagers”. Or
“What does a Sarpanch understand about the technical
matters of health?”
The most crucial resistance is going to be this outlook
about villagers and the notion that being a government
servant means being humiliated. Nurses were truely reflec
ting the values and attitude of the health services in general.
Nurses had some legitimate concerns,
“How can we work simultaneously under the sarpanch
and the medical officer?” “Who will decide our targets”?
“Each village has rival groups and we will be torn apart
between their pulls. The ruling group would want us to
work as its private servant while the opponent group
would frequently complain against us to higher officers”
“We may be sexually abused if villagers have power over
us”.
“A nurse has 3000 to 5000 population to be covered.
This will be spread in two to three Gram Panchayats. How
will the control be distributed? Where will we be based?”
After lot of dicussion on what arrangement was possi
ble, a voting was taken in the group of 15 nurses, 14 voted
against and only one in favour of working under
Panchayat.
Reactions of Village Leaders and Village Health
Workers
The reaction of village leaders and village health
workers was diametrically opposite.
“This will ensure that nurses, medical officers stay at
head quarters and work properly. Problems of absentiesm
will be solved in one stroke”.
“People will be able to decide what they want and get
it from the health services”.
“Cooperation of villagers to health programmes will
improve because now the village leaders will be behind
the programme”
“We will ensure that medicines for the diseases we suf
fer from will be available in necessary quantity.’
“We will support the nurses. Villagers are not goons
to rape nurses. How many such incidents have occurred
in the whole state in an year? Definitely less than rapes
in police custody."
On Our asking as to how will villagers be able to decide
about technical matters? What will happen if a
superstitious sarpanch does not believe in immunisation
or modern medicine? How will they ensure that health
needs of women, children, lower castes or people living on
the periphery will be taken care of? The suggested
remedies were as follows.
Instead of giving sarpanch or elected members of Gram
Panchayat total control over health activities, a separate
health committee should be formed with representation
of different castes, groups, genders and peripheral
hamlets. Medical officer of PHC should be an advisor
to this committee. The health workers in the area should
work under the control of this committee. The commit
tee shall decide health problems of priority, allocate
budget including that for medicines and evaluate the work
of health workers. Each member of the committee shall
be responsible to see that the people in his/her mohalla
or group understand the scope as well as limitations of
health programmes.
But what will happen if village leaders do not believe
in vaccine or treatment of TB or family planning?
“If village leaders are at such level in their understand
of diseases and health measures, no health programme
can be directly implemented successfully even under the
present system of control. Probably that is the reason why
health services are falling to achieve results. In such situa
tion, the health programme must any way begin with the
orientation of the committee or leadership”
One thinking within the health services has been that
CHVs and Dais may be put under control of villagers but
not the nurses, male multipurpose workers or PHC
doctors. Dais are not paid by government and they are
anyway working under effective social control of the
village in which they function privately. CHV scheme has
already been made defunct due to its handling by the
health department. It will be an eyewash to hand over
these workers to villagers. The mainstay of the rural health
services is multipurpose workers (nurses and male workers
one per 3000 to 5000 population) and Primary Health
Centres. If Planning Commission is serious about any
change, then these should be linked to Panchayat Raj in
stitutions and not the defunct, malinged CHV and in
dependent dai alone.
One concern which village leaders expressed was about
targets. If targets of completing fixed number of.family
planning operations, collection of malaria slides and so
on will continue and if the government shall expect
Panchayats to be responsible for fulfilling the targets,
then, in effect, Panchayats shall be forced to obey and
become the tools of health department rather than the
otherway. A solution must be thought of for this problem.
Predictably the health department will be extremely
resistant to lose power and control over it’s vast empire
of PHCs and nurses in the villages. Unless complete ad
ministrative control of these workers is handed over to
Panchayat Raj institutions especially power of appoint
ment, transfer, writing of confidential records, promotion
| and disbursement of salaries, the workers will always con
tinue to treat village leaders as insignificant. The
Gramsevak who is secretary to Grampanchayat is not
under the control of sarpanch though the secretaiy of a
department of State or Central government is under con
trol of the concerned minister. Hence gramsevak usually
controls and makes the sarpanch run according to his
wishes. A similar situation in the proposed plan of decen
tralisation of health services will ruin the purpose.
Then what shall be the role of medical officer of PHC?
He shall provide curative services at the PHC, shall res
pond to emergency call by health workers, shall advise
village Health Committee and shall supervise the technical
quality of the work of health workers but shall exercise control over health workers through the village committee or
8
appropriate Panchayat institution!*
But will there not be lot of corruption?
Probably there will be some. But since it will not be
hidden in the files and behind the walls of office buildings
under the cover of technicality or confidentiality as it hap
pens today, it will be noticed by other villagers and will
be brought out. Moreover, there is not going to be huge
amount available for swindling. If villagers do not get ser
vices, they will immediately shout; so the one who siphons
money will be soon exposed.
Reactions of the Sarpanchs
“What about the experiences of Jawahar Rojgar
Yojana?” Sarpanchs felt that Government officers forced
them to take up schemes of their choice by framing rules
and controlling funds but the villagers blamed Sar
panchs* for not" doing what people wanted. “We do not
want to become instruments in the hands of Government
officers and be accused by our own people. Hence if
health activities are to be given in the hands of Panchayat
Institutions,.it should be given with much more autonomy”
Reactions of IAS Officers and District Health Officers
IAS officers and District Health Officer had some con
structive suggestions.
“Instead of the current pattern of one Anganwadi worker
for 1000 population, one CHV for 1000 population and
2 MPWs for 5000 population, only one female worker per
1000 population based in the village should be trained for
health and child development activities. All the present
nurses in villages and anganwadi workers should be first
absorbed in this rule, retrained and made accountable to
Gram Panchayat!* “One such female health worker, and
a budget for medicines, vaccines and water purification
should be provided to each Gram Panchayat by Zilla
Parishad.”
“Village health committee should be made accountable
to Gram Sabha. People do not attend Gram Sabha
meetings" today because it has no power or influence. If
it is given teeth people would like to attend and assert!*
“Targets and performance on National Programmes
will suffer initially. Except for minimum grant, additional
money as reward should be linked to the performance of
previous year**.
“Information and reports will suffer because village
committees will not be much interested or be particular
about it**. But with planning and monitoring becoming
decentralized, there may not be much need for volumes
of data flowing up most of which is the superflous and
is never used!*
“If health workers shall be accountable to health com
mittee and village leaders, there must be some mechanism
of making village leaders accountable, otherwise they may
use workers and funds arbitrary for personal gains!*
“If even a village Panchayat is to be given autonomy
in planning and implementing it’s health activities, then
similar autonomy must be given at district level!*
Some Reflections on Panchayat Raj in Health
Services:
Mandal Panchayat in Karnataka since 1987. Recently the
Karnataka experience was discussed in a workshop
organised by the National Institute of Advanced Studies,
Bangalore. The main conclusions are:
- Health workers have become accountable to people
- A large number of village leaders have got interested and
involved in health programmes. This has a great poten
tial to improve the health activities.
- Utilization of medicines has improved.
- Improvement in the fulfilment of targets of National
Programmes is not yet visible (Is it an objective?)*
- There is a lack of clarity about administrative matters
and line of command.
- Reports and data have suffered.
What emerges from these discussions?
- If health services are to be run to fulfil the aspirations
and needs of people and not according to the needs
perceived by the health department, Panchayat Raj in
health can be a welcome initiative.
- Village population arid leaders will need lot of educa
tion on health matters as well as on planning and ad
ministration to be able to assert the rights as well as to
carry out responsibilities. The orientation activity should
involve voluntary organizations.
- Health department and workers will need even more
education to change their attitudes towards village people
and to be able to work with and under them. This is going
to be the toughest and the most crucial aspect which will
decide success or failure of the concept.
- It should be ensured that health departments support
this idea rather than sabotaged it and then sits in the chair
of judgement to pronounce it dead as it had happened in
the case of the CHV scheme. Serious stakes must be
created for the department in the fate of this proposal.
- Instead of targets, education of village leaders should
be used for maintaining harmony between the local needs
and the national priorities.
- The transfer of power, if done half heartedly, will
certainly fail.
- There may be some small size corruption and mis
management at local level. While trying to the utmost to
avoid and correct it, we should be prepared to accept it
to some extent as a part of the percolation of democratic
process.
- The idea must be tried on pilot basis in different states
before making it a National Policy.
-If village leadership once experiences this power and
responsibility, it will build up it's own political pressure
through the political parties for more role and respon
sibility. Then the ‘decentralization* will not be at the mercy
of Planning Commission or Health Department, but will
become a major political demand.
The concept of Panchayat Raj in health services has
potential of actualising Health By the People. But in the
ultimate analysis any such transfer of power involves
struggle. Are people aware and activated enough to wrest
this power from an organised bureaucratic system with
deep interest in retaining its present control?
* Dr. Rani Bang & Dr. Abhay Bang, Directors SEARCH, Gadchiroli,
Maharashtra.
The health activities were made the responsibility of
9
(Com. Jrom poge 2)
ground, to appreciate the rationale for Panchayat Raj and
to adjust themselves to the new working environment. In
the interim, for lack of a proper understanding of their
respective responsibilities on the part of both officials and
the elected representatives, strains have developed and pro
gramme implementation has suffered in some areas. Yet
another sensitive issue has been the nature of relation
ships between Head of departments and regional officers
and their counterparts in the districts in regard to technical
control and supervision. How does one reconcile the ad
ministrative autonomy of the ZP administration with need
for continuing technical support? A system with multi
ple lines of control is difficult to operate. But there is no
simple and neat solution. What it calls for is an apprecia
tion of the total perspective on the part of officials at the
middle and higher levels.
8. As mentioned earlier, one cannot hazard the state
ment that with the ushering in of Panchayat Raj, there
has been a perceptible improvement in the level of per
formance of the rural health services. Indeed this reflects
the overall situation. While some of the ZPs settled down
to work quickly and the results have been commendable,
several ZPs still display an excessive concern with pro
cedural on petty issues which use up a considerable part
of their time or with transfers and postings. There is also,
understandably, more interest in and enthusiasm for brick
and mortar programmes of high visibility than on the
relatively unexciting task of maintaining in proper order
institutions and activities already on the ground. The
classification of public expenditure as ‘Non-Plan‘ and
Tian’ seems to give the impression that the former is
unimportant. There is inadequate recognition of the fact
that the bulk of expenditure incurred by the Panchayat
Raj bodies is on the maintenance and upkeep of institu
tions, services and programmes which are already in
operation and that expansion of an existing service or in
troduction of a new activity under ‘Plan’ can only be in
cremental in character. One hopes that, with the passage
of time, the elected representatives in the Panchayat Raj
institutions will have a better appreciation of their role
and functions.
9. A specific point pertaining to the Karnataka set up
which may be briefly referred to is the imbalance between
the two executive tiers, the district and the mandal. With
its small converage in terms of area, limited resources
(financial and manpower) the Mandal has hardly any
direct,role in rural health administration, as in many
others areas. Unless this structural imbalance is corrected,
the process of decentralisation will get frozen at the
district level. This has major implications from the point
of view of both the larger goals of Panchayat Raj and of
ensuring greater responsiveness on the part of the local
administration.
10. Alleviation of poverty and ill-health has been a
major goal of the success Five Year Plans. The National
Health Policy was enunciated a few years ago to give a
direction to an integrated development of medical and
health services in the coming years so as to meet the health
needs and priorities of the country. It visualises, among
other things, the establishment ofa network of com
prehensive primary health services which take into account
the fact that a large majority of health functions can be
effectively handled by the people themselves. It also lays
emphasis on voluntary action. Decentralisation of
political and administration power through Panchayat Raj
institutions can facilitate this process. But one must take
note of certain basic inherent factors, within the health
system and out side, which must be reckoned with before
we can expect any spectacular improvement. These are well
known but bear repetition. First, inspite of policy
statements to the contrary, the thrust of medical educa
tion as well as of programmes in action is still towards
curative urban-based services; preventive aspects still do
not receive requisite attention. Secondly, even though
decentralisation of power is the underlying concept of
Panchayat Raj, it does not automatically follow that the
power passes into the hand of those who have concern
for the poor and the underpriviledged. Studies on the
caste composition and economic background of the
elected representatives of ZPs and MPs in Karnataka do
not evidence a loosening of the hold of the dominant
landed sections of the rural community. It will take time
before the power equations shift in favour of those who
have traditionally remained out of the mainstream. This
is of importance if health services which have the vast
masses of the rural poor as their clientele are to receive
adequate attention. Lastly the system of planning followed
so far in the country has led to rigidities at the national
and the state levels, leaving little scope for local initiative
and innovation. If Panchayat Raj is to achieve its full im
pact, the planning procedures will themselves require
decentralisation, particularly in regard to social and com
munity services.
* T. R. Satish Chandran. Director, Institute for Social and Economic
Change, Bangalore.
(This paper was presented by the author at the workshop entitled “Towards
a Decentralised Health Care: A Fresh Look at the National Health
Policy" held on 20-23 September 1990 organised by the National Institute
for Advanced Studies, Bangalore].
Village Panchayats in West Bengal have been given
specific powers in epidemic control, removal of water
pollution, and maintenance of public pathways. Many
panchayats have converted wastelands to revenue yielding
social forestry plantations. Apart from relief works dur
ing natural calamities, rural housing programme and rural
water supply are the major fields of operation of Pan
chayats. The rural water supply has proceeded so well that
all problem villages have been covered in the decade en
ding 1988. Implementation of social forestry works, iden
tification of beneficiaries for sponsorship of credit link
ed schemes to assist SC and ST beneficiaries and im
plementation of infrastructural programme for them are
also taken up by Panchayats. The average funds available
to a Gram Panchayat during 1987-88 were Rs. 1,87,000,
which included Rs. 9,300 as taxes raised and Rs. 10,000
on account of assigned programmes.
Source: Indian Express, 11/6/89.
10
The Community Health Care System
A Model for Health Services in Panchayat Raj
Dr. N.H. Antia* and Kavita Bhatia**
people can understand. Apart from the large scale exam
ple of China we haye several voluntary health organiza
tions working in our own country, which have clearly
demostrated that a people based health care model is en
tirely feasible and far more effective in meeting the health
needs of people and hence of the country.
A modification of the original ICMR/ICSSR model
named the Community Health Care System (CH Care
system) is presented in able 1.
Background
The ICMR/1CSSR report “Health for All: An Alter
native Strategy” had recommended a model in which the
majority of preventive, promotive and curative health ser
vices could be decentralised and function within the
100,000 population level. This is not only technically,
logistically, economically as well as culturally feasible but
most desirable. Only thus can we ensure that adequate
services would be readily available to the people. In the
present top-down system people are seen only as ‘targets’
to whom services are to be ‘delivered’. The ICMR/1CSSR
report proposed an alternative model rooted within the
community, compatible with the people’s perceptions and
needs and hence ensured their involvement in their own
health.
As a result of the ICMR/ICSSR model being accepted
by the government there has been a considerable increase
in the rural health infrastructure in terms of buildings and
personnel. Unfortunately there has been no commensurate
improvement in the health services nor the health of the
people. A*number of factors have been responsible for
this situation. Instead of the bottom-up type of services
starting at the village level where the people are intimate
ly involved in their own health care, the service has re
mained a top-down bureaucratic exercise divorced from
and without accountability to the people. The obsession
with Family Planning (FP) targets and the coercive
measures employed has not only failed to achieve the FP
goals but has also demolished the routine health services
and alienated the health personnel from the people. There
is not only a gross disparity in the allocation of public
health resources to the rural population but even these
very limited resources are grossly maldistributed within
the rural areas with 85Vo being spent on salaries leaving
hardly anything for medicines, transport and other
services.
There are no easy solutions to this situation. The in
dividual, the community and the health professionals,
each have a distinctive and definite role to play in improv
ing the health of our nation. Unfortunately, the roles of
the individual and the community have been sidelined.
This has largely hampered, if not actively dissuaded the
people, from being involved in their own health and its
care but also in utilizing and demanding the health.ser
vices operated for their welfare. The top-down delivery
approach has also inculcated a feeling of dependency on
the government and despondency as a result of its failure.
It has sapped the will to self-help.
Community Based Health Care Model
Health Unit
Population level
5 million (city)
1 million (district)
Percentage care
Tertiary Care Hospital
District Hospital
0.25
1.75
COMMUNITY HEALTH CARE SYSTEM
(Panchayat samiti)
COMMUNITY HEALTH CENTRE
Preventive
I PSM doctor
4 Health Assistants
1 Statistician
20,000
(98)
Senior Medical Officer (PSM)
I lakh (Block)
Curative.
Rural Hospital
60-100 beds + dharmashala
with 4 basic specialists
PRIMARY HEALTH CENTRE
13
2 doctors
2 nurses
10 beds
2,500
VILLAGE HEALTH UNIT
(Gram Panchayat) _ 1 Multipurpose Worker (F)
500
1 Village Health Worker (F)
500
! DaL(F)
80
The Community Health Care System in Panchayat
Raj
The essence of the ICMR/ICSSR model was that the
people must not only be actively involved in their own health
care but that the entire health services at the 100,000 popula
tion (Block/Panchayat Samiti) level should be under their ad
ministrative as well as financial control. For this the people
should be provided adequate funds at their disposal. Only
this can ensure peoples participation and active involve
ment as well as ensure accountability of the health ser
vices to them. Without this precondition no model can
hope to succeed.
Panchayat Raj if implemented in its true spirit of
democratic decentralization of financial and admini
strative responsibility to the people will provide this basic
requirement as well as the frame-work for the implemen
tation of health care at the community level which will
deal with about 98% of all health problems of our peo
ple. At each level the people will be provided the resources
and power as well as lattitude to modify the model 10 suit
their local requirements eg. use a mix of the indigenous
and allopathic systems, and in the purchase of medicines
and supplies. No targets (such as FP) will be imposed on
them but technical information and broad guide lines will
be provided.
The Community Health Care System
in actual fact the majority of the preventive and promotive as well as curative services are best undertaken by
the people themselves with the support of the health ser
vices not in reverse as is at present. The role of the medical
professionals lies in the imparting of relevant informa
tion and knowledge in a simple and practical way, which
11
The operation of such a Community Health Care
System at each level will be vested in the people and their
Panchayati Raj institutions. The Panchayat bodies,
especially at the Gram Panchayat level, will be supported
by Peoples’ Committees. These bodies will be free to con
sult outsiders to facilitate decision making and function
ing. The health functionaries will report at each level to
the Panchayat body and the financial and technical plan
ning of the Community Health Care System will be done
by the Panchayats in consultation with the available
technical personnel at the Primary Health Centre (PHC)
and Community Health Centre (CHC). The disbursement
of salaries to other expenditure, will be through the
Panchayats and the ratio of salaries to supplies at all levels
of this system will be in a minimum ratio of 60:40 and
not 85:15 as at present. Absolute power will not be vested
in the elected Panchayat bodies alone. A stratified,
representative Peoples’ Committee will function with the
health workers and the Gram Panchayats. Any decision
or function of the Gram Panchayat will have to be ratified
by this committee. The majority of the members of the
Peoples’ committees should be women, as will be the
health workers of this village based System.
Levels of Health Care in the Community Health Care
System
The Community Health Care model does not propose
rigid guidelines but gives broad directives. The ratio of
population to personnel is flexible at each level and can
be modified to local needs. However, there will be no
transfers of staff so inimical to continuity in operation
and for purposes of accountability. Inefficient staff may
be warned/dismissed by the Panchayat bodies, but not im
posed on another Panchayat village.
Since the majority of the population consists of women
and children and most of the health problems affect them,
all health workers at the village level must be women who
will live and work as an integral part of the community
which will pay their salary and to whom alone they will
be accountable. They will work towards a common pur
poseful goal collaborating not only between themselves
but also with the Anganwadi (ICDS) worker and the
teachers of the village school. They will receive support
from the PHC and CHC both of which will also be under
the control of the community through the Gram Pan
chayat and Panchayat Samiti, and the People’s
Committees.
1. Village Health Unit:
Village Health Unit (VHU) comprising of one Female
Multi Purpose Worker, five Community or Village Health
Workers and five Dais, will function as an integrated health
team for approximately 2500 unit of population. This
population may consist of one village or more. Each
village will have its basic unit of one health worker and
dai. It will have its Gram Panchayat and a Peoples’ Com
mittee involved with its health worker and also at the
Village Health Unit. The VHU team will not only inform
the community about problems concerning their health
but also activate and support them for action concern
ing health related issues like water management, sanita
tion and environment. They will also alert the communi
ty to the threat of epidemics and help in the control by
mobilizing local resources as well as from the PHC and
the CHC. This team of local health workers will also look
after the majority of curative problems, not only those
of a minor nature such as coughs and colds, but also of
disease like scabies, diarrhoea and worms which are a
major source of community morbidity. More important
they will play a crucial role in the control of most of the
major killing and maiming diseases like gastroenteritis,
acute respiratory infections, tuberculosis, malaria, leprosy,
measles and poliomyelitis. The knowledge and technology
for the diagnosis, treatment and control of these disease
is simple, safe, cheap and effective. Village Health Workers
supported by adequately trained and motivated
paramedical workers have repeatedly demonstrated their
ability to* assimilate and use this knowledge and
technology provided it is given to them in a simplified
manner which they can understand; also given encourage
ment and support by the health system for confirmation
of the diagnosis and prescribing the regimen of treatment
which they can then carry out themselves. This is because
the control of these diseases while requiring a low level
of technology nevertheless requires a high level of cultural
affinity and constant availability and accountability to the
community. For example, these village functionaries can
take finger prick smears for malaria, give immunization
injections as well as injections of streptomycin for tuber
culosis. More importantly, they can identity, follow-up and
keep track of a malaria or TB patient, or a child requir
ing immunisation.
The increased rapport between the female staff and the
younger women of the village will also enable better
Maternity and Child Health Care and in reduction of the
birth rate by the voluntary acceptance of non-terminal
methods by the younger women which alone can improve
the present dismal situation. This can only be possible
if the counter productive FP targets and pressures of ver
tical programmes are removed.
The successful implementation of health care at this
village unit will depend to a considerable extent on the
appropriate payment, training and support provided to
the staff. All training including that of the Panchayat
members, will be the responsibility of the medical and
paramedics and within the CHC system. Initially, however,
an NGO rather than the health department, may be en
trusted with this task.
2. Primary Health Centre:
In this new set up the PHC will be upgraded to a well
equipped 10 bedded referral centre which will coordinate
and support the functioning of the 8 village health units
of the 20,000 population it serves. It will have close
association with the CHC (Rural Hospital) and no more
function in isolation but as an integral part of the entire
CH Care System.
The PHC will be well stocked and equipped to handle
most of the curative load referred from the villages, in
cluding X-ray and Pathology services. Besides two doc
tors, the PHC will also have two nurses. There will be two
health assistants (Senior MPWs) to guide the preventive
and promotive aspects in the 8 village units served by the
PHC. There will also be an aggregation of statistics of
the village units at this level, to help planning by the Pan12
chayats and Peoples Health Committee. Only those
curative cases which cannot be handled at the PHC level
will be referred to the CHC. The PHC will be responsi
ble to a body consisting of the Gram Panchayat/Committees from the VHUs and the Panchayat Samiti. This
body will meet at the PHC itself.
ty Health Care System would be around Rs.90/- per capita
per annum. The public health expenditure was Rs. 60.37
per capita per annum on Health and Family Welfare in
1986-87 as per Health Information of India; 1989. We
estimate that the expenditure on the private sector must
be about double this figure. As in the case of aggregate
health statistics, this aggregate per capita expen
diture also conceals its heavy urban bias. Besides the
urban population also has other sources like the
Municipality, the ESIS and the corporate sector spending
for its health. It is proposed that public health expenditure
on the rural areas be increased, possibly by a realloca
tion of resources between urban and rural areas.
3. Community Health Centre:
P
l
I
The CHC at the 100,000 level, will no more function
as a purely curative mini district hospital but serve as the
hub of the CH Care System with emphasis on the preven
tive and promotive aspects. For this it will function under
the guidance of a senior doctor with postgraduate train
ing in Community Health or Preventive and Social
Medicine as its leader. The curative aspects will consist
of a well equipped 60 bedded hospital further extended
by a dharmashala. It will have the four basic specialities
of general medicine, general surgery, midwifery/
gynaecology and paediatrics. It will also have the suppor
ting services and staff such as an Operation theatre, Xray unit and Pathology laboratory. It will also provide
referral services to the PHCs for all problems needing such
care. This would leave only a very few conditions for fur
ther-referral to the district hospital whose specialists will
visit the CHC at regular intervals. This CHC will be
responsible to the Panchayat Samiti and representatives
from all the PHCs in its jurisdiction.
Table 2: Cost for Community Health Care System
Vper capita per annum)
Population Level
2,500
"20,000
1,00,000
r
p
Health Care Unit
Per Capital Per
Annum Expenditure
Village Health Centre
Primary Health Centres
Community Health Centres
36
27
23
Total C.H.C System
86
The establishment of a good curative service within the
community will also be the most effective way of con
trolling the proliferating private sector which is a major
source of medical malpractices and which is increasingly
diverting the limited resources of the poor from nutritiqn
and other essential needs to unnecessary drugs and
treatment.
Medical Professionals in the Community Health Care
System:
Health Education and Health Information:
1
1
1
f
8
Besides the inadequacy of the present medical educa
tion, a major problem of the medical profession working
in rural areas is the cultural, academic and intellectual
isolation which also affects their families. The CH Care
System attempts to overcome this by maintaining close
contacts and a rotating posting for the medical staff who
will work and live together at the CHC and its attached
PHC. (One PHC will be attached to the CHC so that the
CHC does not get utilized as a PHC for the local popula
tion). There will be regular visits of specialists from the
district hospitals. In turn CHC staff will visit the four re
maining PHCs. This will ensure that the system works as
a single integral unit. The PHC doctors and staff can in
annual rotation be posted to the PHC attached to the
CHC in order to obtain refresher training with the senior
colleagues and maintain contact with them. The fear of
professionals working under the Panchayat is unfounded
for it will be in the interest of the people to respect and
support those who are genuinely concerned and who look
after their health. Without the imposed targets such as
Family Planning and Immunization, the staff will be free to
organize the local health system in conjunction with the
community based on the actual problems. Statistics will
be chiefly for local use and not merely for forwarding to
a distant authority for compilation. Health will become
a meaningful exercise involving people and not mere treat
ment of ‘cases’.
Cost:
Lack of information and mystification of health anc
illness are the barriers which have prevented the people
from taking their rightful place in the health services.
Decentralization of health functions and services, must
be complemented with the imparting of health education
and health information including information about the
health services. This will also ensure accountability of the
health personnel and services. The dissemination of health
education and information will be built in, in the CH
Care System, as far as possible. This will also reduce the
possibilities of corruption and misuse of powers and
resources.
* Dr. N.H. Antia, Director, Foundation for Research in Community
Health.
** Kavita Bhatia, Researcher, Foundation for Research in Community
Health.
: (Contd. from page 4)
hilly areas (eg: Assam), North- East, where good pan‘chayat bodies are in-place (eg. Karnataka, West Bengal),
where there are a large number of active voluntary agen
cies (eg. Gujarat), where the general atmosphere may not
be conducive and where the administration is more
responsive.
[This is an edited version of the article by the authors, published in “Con
vergence of Social Development Services related to Women and
Children’’, Planning Commission, New Delhi. November 1990].
• * Ela Bhatt is ex-member of. Planning Commission of India, and
Founder Member of Self Employed Womens’ Association. (SEWA),
Ahmedabad.
It is estimated that the cost of such a rural Communi
Priti Bhat is personal assistant to Ela Bhatt.
13
A Select Bibliography
1. Thakur D & Singh S N, ‘District Planning and Panchayati Raj*, New Delhi; Deep & Deep Publications
1991, p. 472.
2. Gurumurthy, V, ‘Panchayati Raj and the Weaker Sec
tions*, New Delhi: Ashish .Publishing House, 1987, p.
211.
3. Mishra S N, ‘Panchayati Raj, Bureaucracy and rural
development; New Delhi: Indian Institute of Public
Administration, 1986.
4. Bhargava B S & Mehta A, ‘Panchayati Raj Institu
tions and analysis of issues, problems and recommen
dations of Ashoka Mehta Committee*, New Delhi:
Ashish Publishing House, 1979, p. 79.
5. Desai, V, ‘Panchayat Raj—power to the people*
Bombay: Himalaya Publishing House, 1990, p. 516.
6. Bhargava B S, ‘Panchayati Raj,system and political
paties*; New Delhi: Ashish Publishing House, i979,
p. 536.
7. Brahme Sulabha, ‘Regional Planning: a case study of
Marathwada Region*, Poona: Gokhale Institute of
Politics and Economics, 1975, p. 187.
8. GOI, ‘Report of the committee on Panchayati Raj In
stitutions*, New.Delhi: GOI, 1978, p. 301.
9. Naik Committee Report, ‘Report of the committee
on democratic decentralisation*, Bombay: GOM,
1961, p. 298.
10. Mehta, B G, Report of the team for the study of com
munity projects and national extension services, Vol
III, New Delhi: GOI, 1957.'
VConi. from page 6)
is the one where the people feel actually in control and
have access to the system.
How much proportion of expenditure the village
decides for itself, will be the litmus test of any proposal
for decentralization.
8. Should targets be maintained in the health system?
The rationale behind targets is to maintain accountabili
ty of the health programme, and it is an easy measure of
achievements, but even with the target system, no spec
tacular achievements can be seen. On the contrary, in the
process, the general health care is also neglected. Targets,
even in selected areas are non productive. Targets can also
be a tool for control. Targets should be totally abolished.
9. Should there be a Family Planning programme?
There was unanimous consensus that today Family
Planning is eating up most of the resources and time of
the health functionaries, at the cost of every other health
programme. Every other programme has become a means
to population control. Due to Family Planning targets,
the people have lost faith and are afraid to approach the
health functionaries. Yet the Family Planning programme
has not been too successful. The answer is not more of
the same. Family Planning targets should be abolished.
The new health system should concentrate on enhancing
the health status and ensuring the survival of the child
and the mother. This should be coupled with contracep
tive guidance only. No convergence/decentralization will
be effective if Family Planning target pressures remain on
the functionaries, and the people Even partial removal
of targets would be helpful.
Statement of Objects and Reasons
Though Local Authorities, namely, Panchayati Raj In
stitutions and urban local bodies have been in existence
in the country for a long time, it has been observed that
these institutions have not been able to acquire the status
and dignity of viable and responsive people’s bodies due
to a variety of reasons including absence of regular elec
tions, prolonged supersessions, inadequate representation
of weaker sections like the Scheduled Castes and the
Scheduled Tribes and women, insufficient devolution of
powers and lack of financial resources.
2. Article 40 of the Constitution, which enshrines one
of the Directive Principles of State Policy, lays down that
the State shall take steps to organise village Panchayats
and endow them with such powers and authority as may
be necessary to enable them to function as units of selfgovernment. While this Directive Principle applies to
village Panchayats, it is felt that urban local bodies should
also be organised and endowed with such powers and
authority as are necessary to enable them to function as
units of self-government.
3. In the light of the experience in the last forty years
and in view of the shortcomings which have been polic
ed, it has been recognised that there is a need to'enshrine
in the Constitution certain basic and essential features of
the Local Authorities to impart certainty, continuity and
strength to them.
(Excerpt from the Constitution (Seventy-Fourth Amendment) Bill 1990.
AN APOLOGY
The publication of the FRCH Newsletter had to be
temporarily suspended between August and
December because of frequent change of staff. For
the same reason, this issue has also been delayed.
We now have a full time publications officer also
who would henceforth ensure the regularity of this
newsletter. Inconvenience to our readers is regretted.
* Kavita Bhatia, Researcher, Foundation For Research in Community
Health.
(This is a summary of the report published in “Convergence of Social
Development Services Related to Women and Children”, Planning Com
mission, New Delhi, November 1990)
Co-ordinated by Usha Sethuraman and Kavita Bhatia, Produced by the Foundation for Research in Community Health, 84-A, Thadani Marg;
Worli, Bombay-400 018. Registered under the Bombay Public Trust Act. Typeset by Economic and Political Weekly. Primed by Modern Arts
and Industries, A-Z Industrial Estate, Lower Parel, Bombay.
14
Our Experience in Teaching Methods of Health
*
Education
Vaishali Vaidya *
The ignorance about one’s own body and its functions
and needs is all pervasive. The need to dispel ignorance
and to meaningfully reach out to the goal of “Health for
All” through scientific tempering of young minds comes
in a most interesting way in the school health education
project. This project, sanctioned by the Ministry of
Human Resource Development (Dept, of Education), New
Delhi, began in September, 1988. The main objectives of
this project are:
1. To give accurate information about health and health
care and several physical disorders to teachers and through
them to students and to develop simple teaching methods,
experiments, demonstrations through visual media, while
imparting information.
2. To remove the fear complex regarding health and
illness.
3. To create constructive interest regarding personal
health as well as that of the community.
4. To introduce people to the available medical services
and simultaneously to dissuade them from over-use of
medicines and injections.
The following forms a record of our experience during
the pilot phase of this project, carried out with the
students and science teachers of class V - C of Nandadeep
Vidyalaya, Bombay. There were definite reasons to select
this particular class. We felt that the students from class
I to IV were too young for our project. There was no point
in disturbing students from class VIII to X as they are
normally burdened with a good deal of academic studies
and they also have to struggle a lot for the competition
created by our education system. Besides, we felt that
students of class V are more curious, receptive and im
pressionable; hence they would respond better to our pro
ject. lC division of class V was selected as the teacherin-charge felt that students in this class are more in need
of health-education as they belong to the lower strata of
society and also to the economically weaker section.
3. Different types of illnesses and disorders.
4. Personal hygiene, cleanliness and medical check-up.
Imparting Knowledge: Methodology
“I hear and I forget,
I see and I remember
I do and I understand”
The main characteristics of effective teaching are
developing the subject in a manner and at a pace consis
tent with the children’s calibre and effective utilisation of
available educational aids. Simulation of real life ex
periences with class-room teaching adds to dynamism in
learning. We therefore tried to give stimulation of three
basic levels at experience, namely cognitive, affective and
connotative by dividing each lesson in three parts:
a) lesson imparting knowledge and stimulating thinking
power,
b) appreciation lesson and,
c) Skill lesson.
Looking critically at the present traditional teaching
methods we found that lessons were aimed at informa
tion mainly at the cognitive senses. While use of aids and
experienced teachers give a notion of skillful teaching, it
prevents a dialogue between the teacher and the taught
and blocks spontaneous expression. The usual apology
is that a definite syllabus is to be ‘covered’, that too for
examinations, so the methodology must be oriented
towards that goal. To overcome these barriers of formali
ty, we have minimised the lecture method and followed
something closer to “group teaching”, involving group
discussions and seminars.
While introducing a topic we encourage them to narrate
their real life experience in their own way. Our premise
was that as personal a subject as health education should
be developed from the children’s own experience. Indeed
they vied with one another in telling of common ailments
Planning the Curriculum
The curriculum evolved through discussions with
knowledgeable' persons and observations regarding
students’ interest. It covered the following:
1. Evolution of the human species.
2. Human anatomy and physiology.
%
* Vaishali Vaidya is on the research staff of FRCH. She is a teacher
deputed to this project. Other members of. the team in the School Health
Education Project are, Mohan Deshpande, a medical doctor and Prabha
Salgaonkar, having a background in literature and journalism.
* This is the cited version of the original Marathi article translated by
Sudha Naraune.
FOR PRIVATE CIRCULAIION ONLY
to be very alert in thinking about particular kinds of ques
tions with the specific condition. Even those children who
were supposedly not bright and were generally
disinterested got involved in such activity and started ask
ing questions. At times their questions were incorrect and
irrelevant but what was important was the fact of their
participation.
We also learnt a good deal while teaching. Firstly, we
learnt that teaching is possible without bringing pressure,
coercion or beating. We also realised that what children
say is never entirely wrong. We tried to remove their doubts
while orienting them to action.
like colds, fever, typhoid eta It men became easier to
orientate the children towards a scientific way of looking
at them. We extended their experience by adding selected
bits of information. We feel that children are not totally
ignorant. They imbibe many things outside the school cur
riculum by their observation, conscious or otherwise and
by intuition. They also sub-consciously analyse their ex
perience. This is an abstract process which we felt should
be concretised in order to make learning more meaningful.
Further, it seemed that this way the children understood
their experience better and got more interested in learning.
Another aspect which required sensitivity was the use
of terminology. We tried our best to use simple, common
words and explained in detail difficult words.
Audio and visual aids such as pictures, charts, slides,
films were used in a limited way as adjuncts to discus
sions. Often we would call for a volunteer whose body
was used as a teaching aid. For example, while discussing
blood circulation, we persuaded a small boy to come for
ward and to remove his shirt. We drew a diagram of the
heart on his chest with a sketch pen. Our goal was to have
the children identify their own- bodies with the body
discussed in the text book, and also to remove any feel
ing of shame regarding one’s body. Most people consider
audio-visual aids to be necessarily expensive. We have tried
to make a small dent in this assumption by using our own
body as the best educational aid in health education.
Experimentation formed another important aspect of
our methodology. For example, while explaining blood cir
culation we asked each child to hear and count the heart
beats of his/her neighbour by means of a stethoscope
which they found fascinating. This naturally created quite
a flutter in the class. It was no more an orderly ‘dead’
class; there was a good deal of activity which included
listening to the heart-beats, counting them, helping one
another to find the correct place to monitor them eta
Demonstration and Experience
We should be able to utilise to some extent in our daily
life whatever we learn and the information we collect in
health education. It was felt that we can inculcate some
good habits and attitudes through group activity. Hence
we organised a demonstration of nutritious diet. We
prepared a mixed dish of sprouts in the school itself with
the help of the children. At home they normally do not.
relish sprouts in raw form. But this dish was a great suc-)
cess possibly because they all participated in its prepara
tion; also it was very tasty due to ingredients that were
mixed together. They also enjoyed eating together. Later
they prepared the same dish at home and gave us the feed
back on the reactions of their elders. In our actionoriented projects we did not miss out a single opportunity
to peep into children’s minds. They wrote short notes on
the above mentioned mixed dish and through that they
also gave vent to their complaints about parents.
Creative Outlets
Children have a mind of their own. They have their
views and opinions on different events and issues which
need serious consideration and an outlet for expression.
This gave us an idea to start a periodical “Dhashtapushta”,
meaning robust. Teachers were not too enthusiastic about
this venture because of their diffidence regarding their
students’ creative abilities. Yet, we went ahead and found
the response from children encouraging. We did not im-@)
pose middle class values in assessing the quality of writing, 7
which was sometimes grammatically incorrect, shabbily
written. We looked beyond, at the thoughts conveyed and
praised the specially good articles in the classrooms. We
tried to see, why, despite such creativity they fell short of
expectations in classroom assignments — Marathi teachers
commonly complained that children did not write good
compositions. Students gave very coherent and revealing
reasons:
- topics for essays are uninteresting
- there was a compulsion to adhere to specific
topics
- since teachers focussed on grammatical errors
rather than on understahding their thought pro
cesses the pages were covered with red marks
which are very discouraging
- a candid, objective assessment of their own
laziness.
Thus, while creating an atmosphere whereby children
could express themselves freely and also to look at
The Enquiry Training Model
It is an accepted fact that schools today are nothing
less than factories. Bound by rules and regulations and
taught to cram uncritically towards achievement in an
exam-oriented system the desire to ask questions is simp
ly obliterated. Being trained to uncritically abide by rules
and accept only what is offered, the child grows up
passively accepting atrocities and injustice even in later
life.
This thinking prompted us to create a model whereby
children could be motivated to think, ask questions and
act on their own. In the enquiry training model for
mulated by us, a subject was put to the children in a story
form. On the basis of this problem children were told to
ask questions to the teacher and get the solution. A con
dition was that only such questions should be asked whose
answers would be either yes or no. Surprisingly, these
students who were supposed to be of average intelligence
were able to ask twenty questions one after another in
a particular direction. Eventually they found the correct
answer with the help of rational, logical thinking. The
lesson which was about malaria was a sort of model lesson
for both teachers and children on how to learn by ques
tion and answer method. Besides, the practical advantage
to the teacher was that s/he did not have to do much ex
cept to reply ‘yes’ or ‘no’. On the other hand children had
(Contd on page 4)
2
In Defence of Cheaper Neurosurgery
Dr. C. Vidyasagar
*
It is generally thought that neurosurgery is expensive, circumference. An outpatient clinical examination is often
needs very sophisticated equipment and specialised sufficient to arrive at a diagnosis. If further confirma
surgical units. These statements are only partly true. It tion is necessary, one can introduce about 20-40 cc of air
is possible to treat nearly 50% of neurosurgery patients into the ventricles and the plain skull radiography to guage
at a district or rural hospital where facilities and person the ventricular size. Air is a safe contrast medium and gets
nel are available to undertake general surgical procedures. absorbed in course of time. A ventriculo pseritoneal shunt
A general surgeon who has a brief specific exposure to is the standard procedure for all these types of
neurosurgery and who has a small additional set of in hydrocephalus. Since the ventricles are dilated, introduc
struments which are locally available can effectively per tion of ventricular catheter is a very simple procedure and
form many of the neurosurgery procedures without com is very safe. Hydrocephalus secondary to intracranial
promise to the safety of the patient's life. In many situa tumours are difficult to suspect as these infants are nor
tions the patient will have a better chance for survival if mal at birth and manifest neurological features only after
he is treated at the local hospital. Many patients, in their 3-4 years of age. These children need specialised units for
attempts to reach neurosurgical units, die, due to delayed management.
medical attention.
Brain abscesses secondary to chronic ear infection oc
Trauma accounts for nearly 30% of neurosurgical ad cur frequently (5-10 Vo). They are generally located either
missions. Head injuries following road traffic accidents in the cerebellar hemisphere or in the temporal lobe - on
seldom occur in the vicinity of the major hospitals located the side of the ear discharge. Patients are often very ill and
in the cities. Taluka and district hospitals are far more ac die unless the abscess is drained fast. Blind exploration
cessible for the serious multiple organ trauma which oc with burr-holes on the side of the ear discharge have sav
curs on our highways.
ed many lives. Attempts to send these patient's to CT scans
Contrary to the general opinion, only 2% of all head at great distances have often resulted in avoidable tragedy
injuries develop extradural haematoma, while compound (the author has personally evacuated" a temporal lobe
depressed fractures occur in about 10% of such injuries. abscess in a child in a cardiac ICU on clinical evalua
CT scan is not necessary to the diagnosis of an extradural tion alone. CT scan could not be done due to non
.haematoma. Deteriorating level of sensorium and drop availability of an ambulance and breakdown of the CT
in the pulse rate are the most consistent parameters in scanner!).
suspecting an extradural haematoma. Similar findings also
Intracranial tumours are difficult to recognise without
frequently occur when oedema is developing in the injured the help of sophisticated radiography. Now-a-days it
brain. A few burr-holes (2 on each side) will quickly solve would be simpler to get a CT scan than attempt
the problem. While burr-holes are life saving procedures angiography under difficult conditions of distinct
in the former, they do not cause any adverse effects in hospitals. Once the nature of the tumour is established
the presence of cerebral oedema. A couple of plain x- rays further management will have to be decided by the physi
of the skull (AP and lateral) taken with a 60MA machine cian and the patient.
if available, can be very informative. If there is a linear
A large malignant tumour often needs a burr-hole
fracture and if such a patient develops extradural
biopsy to establish the diagnosis followed by radio
haematoma it is mostly likely to be under the fracture.
therapy. Extensive excisions of malignant lesions in the
1 Plain x-rays will also indicate the presence of compound
brain have not, on the whole, produced correspondingly
depressed fractures. Thus both the common surgical com good results in keeping with the effort and cost involved.
plications of head injuries can be effectively diagnosed TUberculomas which comprise 10-15 Vo of all tumours can
by clinical observation and by the help of simple
be effectively treated by modern anti-tuberculosis
radiography alone. Closed depressed fractures do not
chemotheraphy under proper supervision without surgery.
generally need correction.
A district surgeon can manage these patients if he has a
Use of the CT scan to identify contusions for diagnosis
close contact with a neurosurgical unit.
of acute intracerebral haematomas, respirators, in
Back pain is common in the rural population. In a
tracranial'pressure monitors and other similar expensive
study conducted by the author (sponsored by Karnataka
methods have not produced sufficiently improved results
Council for Medical Research) it was found that the causes
to justify their cost and efforts.
of backache in the rural population were similar to those
Spinal injuries are best managed non-operatively. The
of the urban population. Psychosomatic problems and
process of shifting patients to a specialized center for bet
pelvic infections were the common causes in the rural pa
ter treatment often aggravates the problem. Decompres
tients. These can be adequately treated at the district
sion of the spinal cord and fixation of spinal fractures
hospital level. In the above study of 100 patients only two
have not produced encouraging results even in specialis
had evidence of disc prolapse indicating that “not all
ed centres.
backaches are due to prolapsed discs”. Diagnosis of lum
About 15% of all neurosurgical operations are perform
bar disc prolapse does not necessarily require CT scan or
ed for hydrocephalus. Tuberculous meningitis and con
genital aqueduct stenosis with or without myelomen
* Dr. C. Vidyasagar is a Neurosurgeon, formerly Professor of
ingocele are responsbile for nearly 90% of infants (before
Neurosurgery at National Institute of Mental Health and Neurosciences
the age of three years) who present with an enlarging head
and at St. Johns Hospital arid Medical College, Bangalore.
3
myelography. In a study of 135 patients, the diagnosis of
disc prolapse and the level of the lesion were arrived at
by clinical examination and plain radiography (except in
one case). The pre-operative diagnosis including the level
of disc prolapse was found to be correct in all these pa
tients at surgery. The surgical skill for the procedure can
be acquired by a general surgeon. The author has a young
general surgeon associated with his team who is now con
fident to do disc surgery after a brief exposure to the
surgical procedures (six .operations).
ing a more sophisticated pneumatic tool, he turned round
and said, “What is wrong with this? It is safe and does
the job well”. The author once (1979) trained a group of
district surgeons for a period of six weeks in the manage
ment of head injuries. Within a period of one year there
were at least six instances where these district surgeons
were able to save patients who would have lost their
lives if they had been transferred to a distant neurosurgical
centre.
While it would be ideal to treat all neurosurgical pa
tients by neurosurgeons in specialised centres, we are very
far from these ideal conditions. Adequate and safe ser
vices closer to their homes will certainly benefit the ma
jority of our people, especially those living in rural India,
who are either late or never reach specialised urban
centres.
Let me end by quoting Dr. T.E. Udwadia in his presiden
tial address to the Association of Surgeons of India “By
all means we must have advanced and'prestigious institu
tions on par with the best in the world, but let us not
measure our surgical prowess or progress only by the
number of CT scans we have’.’ o
Tuberculosis of the spine forms a third of all com
pressive lesions of the spinal cord. Adequate clinical
evaluation and a plain x-ray are sufficient to establish the
diagnosis. Postero-lateral costotransversectomy achieves
spinal decompression by draining off the pus. The surgical
procedure is often made simple by the tissue destruction
which guides the surgeon to the area of compression.
All the above procedures can be performed in a general
surgery operating room. The total cost of additional
equipment required is about Rs. 6000-7000 and it would
need about three months training to equip the general
surgeon with the necessary skills to undertake the above
procedures. Many young neurosurgical trainees feel that
unless very expensive equipments are available effective
surgery cannot be performed. On a recent visit to the
world famous Montreal Institute of Neurosurgery, the
author was amused to see the senior neurosurgeon using
the old fashioned Hudson’s burr to perform a cranotomy.
When the author asked the surgeon why he was not us
“The cost of one CT scanner could absorb the total
health budget of some small countries. CT is not an
immediate need in many parts of the world; it should
not even be considered except where there is already
very good health care throughout the country”.
[Source: WHO Scientific Group, No 22 Dec 6, 1987].
(Conid. from page 2)
it on the spot.
themselves critically and honestly without fear of judge
ment, we tried to establish rapport with them.
(ii) Since we were outside teachers we could not get
the required number of periods in the school. Each time
due to some programmes in the school, periods could not
be allotted to us. When we revisited the school after a few
weeks revision took a lot of our time and delayed our pro
ceeding further.
We feel that we have achived quite a lot through these exer
cises. At the same time we are aware that much more could
have been done.
(i)
(iii) It is necessary to divide the whole curriculum in
to small parts in order to study and to make use of various
teaching methods. As this was not done, we were unable
to discuss teaching methods with experts in this field.
More demonstrations should have been organised.
(ii) Systematic notes should have been obtained from
children and some more information should have been
offered to them.
The lessons learnt from the pilot phase in Nandadeep
Vidyalaya equipped us effectively to conduct the teachers
training programme for health education. This formed
the second phase which began in August 1990 and con
tinued uninterrupted over one year. Thirty-four teachers,
both from rural as well as urban schools have completed
training and started health education activities in their
respective schools. This project has covered 34 schools,
20 of which are located in Shahapur taluka (Dist. Thana),
some in rather remote villages in the Sahaydari ranges.
(iii) Complete medical check-up of all children should
have been done during the three year period.
(iv) Deeper study of various teaching methods should
have been undertaken.
(v) So far only one meeting with parents could be
organised. More such meetings should have been held.
Also personal contact with more parents should have been
established. Home visits could be conducted with only
10-15 families.
Looking Ahead
Our shortcomings were inevitable because of certain
reasons:
The project has now reached its third and final phase
which mainly consists of detailed follow-up studies and
evaluation. This phase will continue for two years and end
with the publishing of manuals for teachers and students,
for imparting health education. •
(i) The curriculum was not pre-planned in detail. It
was taking a definite shape through discussions in the
classroom, but it was not possible to plan and implement
4
Lokseva Aushadhalay, Malshiras
(A Rational Drug Counter Managed by People)
Manisha Gupte ♦
y. We would not assume that people cannot understand
complicated and technical aspects of science. Thus we
would teach fundamental concepts of biochemistry and
pharmacy even if that meant long months of study.
vi. Ultimately, the drugstore would become a con
sumers’ cooperative, without external financial aid.
With this idealistic blueprint, the actual academic train
ing started around October 1988. Seven persons, including
the author of this article, attended the sessions. The idea
was to train actual functionaries in the drugstore. Even
tually, a few of our trained personnel would even appear
for the D.Pharm examinations, so that the drugstore
would be truly run by the local people themselves.
Each extended session of training (which spanned over
two to three days) comprised broadly of the following:
“Lokseva Aushadhalay” was inaugrated on March Sth
(International Women’s Day), this year, by Dr. N.H. Antia,
Director , FRCH. Dr. Vishwas Rane of Ratnagiri
Chemicals who is actively involved with the rational drug
therapeutics movement presided over the function.
Dr. Anant Phadke of Lok Vidnyan Sanghathana (People’s
"Science Movement) and Dr. Anil Pilgaokar, National Con
venor of Medico Friend Circle, also actively involved with
ACASH, Bombay. were the chief guests. Dr Nerges
Mistry of the FMR, Bombay, Ms. Soonoo Engineer from
a peace group in Canada and seventeen women from a
Mahila Mandal organised by TDSS, Pune also attended
this inaugural function.
For several reasons this tiny drugstore is interesting and
is therefore worth reporting upon.
• 1. The Idea: Some researchers of the FRCH are engaged
A. The Academic Aspect: For two months, inspite of the
excitement of waiting to start a local drugstore, when the
students realised that they were to learn microbiology,
biochemistry, genetics, (infact most of them had heard
these names for the first time), they feared that they would
get so confused that they would probably poison the
clients.
Painstakingly, both for tutor and students, the first few
sessions crawled at a snail’s speed. Often, the entire ses
sion would have to be repeated not once, but thrice. Fin
ding the Marathi equivalents for technical jargon was a
tough job. Simplifying cell biology in the abstract was a
daunting task. Confusion at various levels was being gent
ly clarified: why did one have to learn cell wall synthesis
to understand the action of penicillin? Aren’t micro
organisms smarter than us? Are all bacteria dangerous?
Are enzymes living organisms? Confusion was giving way
to alert curiosity. For the fist time in the learning career
of the participants, one could ask any questions however
silly they sounded. Everyone was learning to respect drugs;
such small tablets, aren’t they really .clever?
Sessions of role play were being introduced. How would
the micro-organism invade? How would the human be
ing respond? How would the micro-organism retaliate?
How would drugs intervene? Could drugs “disguise”
themselves? Lessons were full of analogy-the enzyme was
our spanner that did work more efficiently, protein syn
thesis was taught as a series of rolling wheels of different
sizes. One of the participants who is also our vehicle driver
was ecstatic. The following week he pointed out to a car’s
number plate that read “DNA”. When the cell “wall” was
being built and penicillin disguised itself and entered it
to eventually destroy this almost finished wall, a love-hate
relationship with drugs was growing. In great enthusiasm
we debated as to whether we should use the “strongest”
antibiotics (broad spectrum) to successfully treat a disease.
The moral that emerged: you don’t hire a lion to frighten
full time in an action research project which imparts
health education in 18 villages of the drought-prone
Purandar tehsil of Pune district, 60 kms. away from Pune
city. Since the Government Community Health Guides
no longer have their basic medicinal kit, some of us
thought that it would be a good idea to keep such simple
medicines with local people. The majority of peoples’ dayto-day ailments would then be taken care of. However,
on official enquiry we found that no medicines can be
stored or sold without acquiring a license from the Drug
Commissioner.
Disheartened, in June 1988, we presented our dilem
ma in the Medico Friend Circle Core group meet at Wardha. The enthusiastic response from the friends gathered
there was overwhelming. We were urged not to give up
the idea of starting this rational drug counter because at
that time there was no such experiment wherein the ra
tional drug movement retailed drugs to the consumer
directly. (In July 1989, SEWA Ahmedabad started a ra‘ tional drug counter in Ahmedabad city); Besides, this
counter was to be based in a remote hilly village and would
be handled by trained rural colleagues. The dynamics of
its genesis and working would be of interest to the health
movement, too. Anil Pilgaokar immediately offered to
train us to start such a venture. Accordingly, from
September 1988 he started coming to Malshiras. During
the first six months he came thrice and taught us for 2-3
days each time. As the enthusiasm and interest grew, from
April 1989 he started coming once every month. The train
ing was declared as "enough" by him and the group in
October 1990.
11. The Training: Anil laid down certain ground rules
before the training commenced.
L The counter would sell only rational drugs.
it The drugs would be sold under generic names only.
iii. We would not charge more than 8-12% on any of
the drugs.
iv. The drugstore would be run on participatory
principles.
• Manisha Gupte is on the research staff of FRCH. She has been a
member of the core team of the Health Education Project, at Malshiras;
since its inception.
5
a pesty mouse because the lion may eat you up for din which would allow us to keep a simple array of drugs,
ointments and liniments. Fortunately, the Drug Commis
ner, as well.
All said and done, the completed course graduated from sioner in Pune was supportive of our venture and after
the digestive system to the endocrine system. This is not four months of applying, we got our license in August
1990. By then, to our great delight, T. Krishna (who was
to say that all of us remember everything that we learnt.
Neither does it mean that each one understood every con earlier coordinating LOCOST activities) had decided to
cept that was put across. However, each one has lengthy join the Malshiras team; infact he joined us in November,
1990. Krishna holds a B.Pharm degree and we could easily
notes that can refresh one’s memory from time to time.
Our homework included the preparation of ready reckoner have taken advantage of this fact to get a full fledged
charts which listed out the names (generic and brand), license. The group however decided to set a precedent and
indications, dosage, contraindications, interactions and to acquire a restricted license, arguing that every small
side effects of each drug that we studied. The total number group wanting to start such a counter may not: get
of drugs covered were around 35.
D.Pharm or B. Pharm colleagues.
B. Management: This section included the day to day
handling of the forthcoming drugstore. How to order IV. The Space: At Malshiras, the researchers of FRCH
drugs, where to order them from. Readers are probably have started Mahila Sarvangeen Utkarsh Mandal
aware that there are very few drug companies that (MASUM), which trains women from oppressed castes
manufacture rational drugs under generic names. and from economically deprived backgrounds to attain
LOCOST pharmaceuticals in Baroda is one such unique self-employment. MASUM then lent to Lokseva a large
group. Managed by socially conscious individuals they room on its own premises in the village at a nominal rent
market drugs in wholesale only to voluntary agencies for of Rs. 25 per month. Eventually, in repetition of the story
whom profit is not the main motive. Ratnagiri Chemicals, of the camel and the Arab, Lokseva plans to expand on
a private concern, is another example. Naturally, we decid these premises to start a full fledged pathology laboratory
ed that the main bulk of our purchase would be from these (the training by Dr. Nerges Mistry has already started;
groups.
again the participants of Lokseva enrol for another
Training in management also included billing, accoun academic course!) and a women’s health centre.
ting, receipting. How much money was required to start
Lokseva Aushadhalay, in official terms is now one
Lokseva? (We started with Rs. 5000/-). How many drugs month old. Like the multitude of Indian children it may
to order and how to decide on quantities required? What die before it reaches its first or fifth birthday. Surviving
is SWOT analysis. How to determine break-even points? as a drugstore that doesn’t make huge profits (for eg. an
What non-drug items should we sell so as to support the Aspirin tablet costs 10 paise in Lokseva as compared to
drugstore financially? What product mix was necessary? brand name aspirins that cost 50 paise per tablet outside)
These and other questions were raised, discussed and -is not easy. Ethics and ideals may not contribute to finan
debated upon. The name “Lokseva Aushadhalay” was cial security. Fortunately, it is the spirit of Lokseva that
democratically elected from among 40 proposed names. is more important than the registered shop itself. What
C. Ethics: It is this section that really determined the one has gained in terms of experience and values will
“spirit” of the drugstore. Why should we not sell irrational hopefully outlive the physical structure of Lokseva
drugs, unnecessary combinations, tonics and cough mix Aushadhalay. o
tures? Why should we uphold the movement for rational
drug therapeutics? If Dr. Arun Bal is victimised in
Bombay, does it concern us in Malshiras? Should Analgin
be’banned? These formed the broader politics and ethics
of the drug movement. At the same time smaller perti
nent issues were also raised. Why should we use simple
and cheap packaging? Should we create an artificial de
mand for drugs? Why not sell banned or “bannable”
drugs for example, analgin? Should we make profit on
people’s illness? How much profit is ethical? How to pay
‘decent wages’ to our worker(s)?
To avoid the domination of any one participant over
the drugstore, an upper limit for donations/fund raising
was put. No single person could raise or contribute more
than Rs. 200. To avoid domination of local caste/class
groups, no local villager was allowed to pay more than
Re. I as a membership to the Lokseva fund. These funds
would help to buy drugs. (LOCOST gave us excellent
credit facilities). The dream is to start local vending units
at weekly village bazaars. Alas, the problem of acquiring
such a license, once more!
Ill The License: We found out that if we wished to run
a full fledged medical store, we needed to have a full-time
D.Pharm trained person. No such individual was available
in the village. So we decided to obtain a restricted licence,
6
Planning for Poverty in India
Ramesh Awasthi *
Over three decades of development planning have hard
ly had any far-reaching impact on poverty in India. It
would be interesting to review the change in the govern
ment’s approach to poverty over the last seven Five-Year
Plans.
Poverty and the-Five Year Plans
The removal of poverty was not a specified objective
of planning in India in the first three Five-Year Plans of
the Nehru era, although a fifteen year prospective
(1961-75) to secure minimum living standards was worked
out by the Perspective Planning Division of the Planning
Commission.
The First Plan (1951-56) was based on community
development and rural extension as the method with em
phasis both on intensified agricultural production and
provision of basic amenities.
In the Second Plan (1956-61) cooperative farming for
agrarian reorganization was the focus and the problem
of local participation came to the fore as a result of Balwant Rai Mehta Committee’s evaluation of the Communi
ty Development Programme.
The Third Plan (1961-66) proposed a 3-tier model of
democratic decentralisation at the levels of village, block
and the district with corresponding layers' of
administration.
The basic premise or the explicit dream of development
planning in that era was development along socialist lines
to secure rapid economic growth with reduction in
disparities of income and wealth. The emphasis therefore
was on prevention of concentration of wealth and crea
tion of values of a free and equal society.
After three years of Plan holiday, when the Fourth Plan
(1969-74) document was prepared, the conflict between
growth and redistributive justice was very much in the
forefront. It was being debated the world over that the
‘Midas touch’ of growth is not all pervasive and that
‘trickle down effect’ was a myth.
By that time however the urban elite and the Indian
capitalists had developed strong vested interests in the sec
tarian character of ‘growth’ benefitting only the upper
strata of the society. Probably that is why the growth
model was not questioned. Instead, aggravating poverty
was given window- dressing through a talk of ‘emphasis
on the common man, the weaker sections and the less
privileged’.
Anti-poverty programmes became a part of planning
in India when ‘Garibi Hatao’ became a central political
slogan for electoral battles in the country in 1971. Exag
gerated concern for the poor by politicians, planners and
academicians dominated the scene in the 1970s and it con
tinues to be so even in the 90s.
The Fourth Plan, for the first time, introduced a
beneficiary oriented programme like the SFDA (Small
Farmers Development Agency) which later included
MFAL (Marginal Farmers and Agricultural Labour) so
as to assist them to benefit from the green revolution. In
1971-72 a crash scheme for rural employment was in
troduced for creating employment for 1000 persons per
year in each district. This continued in 1972-73. The
Fifth Plan (1974-79) quantified the conc.ern for the poor
into neat numerical targets and promised to raise the
average monthly per capita consumption of the poorest
30% of the rural population by 60% (in real terms) in
five years from 1973-74 to 1978-79.
The Fifth Plan had a bad run. Political exigency over
took the planning process. The drought of 1972-73,
massive inflation of 1973-74, 20 point programme of the
Garibi-Hatao creed and the new anti-poverty schemes of
the emergency period shattered the plan and the change
of power in 1977 brought it to an abortive end. However,
the Fifth Plan had called for integration of all develop
ment and employment generation programmes and in
troduced the concept of Basic Minimum Needs
Programme.
The Sixth Plan (1980-85) document admitted that “so
far, it has not been possible to make a major dent on
poverty on account of the inadequate rate of growth of
the economy, uneven distribution of income and con
sumption as well as high rate of growth of population.
The reduction in poverty should, therefore, receive the
highest priority in our development” (p. 21)
A programme of target group-oriented, household bas
ed, anti-poverty packages superimposed on the same
growth model has constituted the government approach
to fight poverty since the launching of the Sixth Plan and
the same approach was continued in the formulation of
the Seventh Plan.
The development strategy of the Seventh Plan aims at
the direct attack on the problems of poverty and un
employment with an admission that the programmes
for poverty alleviation should be regarded as supplemen
ting the basic plan for overall economic growth, in terms
of generating productive assets and skills as well as in
comes for the poor.
The problem of poverty at the level of target groups
comprising of marginal farmers, landless labourers and
artisans is attributed to lack of enough income generating
assets, lack of skills necessary for gainful employment or
for self-employment and lack of wage employment op
portunities, (unskilled manual wage labour) for those who
have neither assets nor these skills.
This micro-level analysis of the causes of poverty has
formed the basis on which most anti-poverty have been
designed notwithstanding various adhoc populist pro
grammes introduced from time to time.
Poverty in India
The main features of the poverty problem in India are 1. Poverty and inequality are linked issues and an ef
fective instrument to eradicate poverty should therefore
• The author is on the research staff of FRCH. The above article is based
on a study carried out by him titled, Understanding Poverty: The
Touchstone of New Economics, the report of which was documented
in 1986.
COMMUNITY HEALTH CELL
326. V Main, I Block
Koramangala
have teeth to tackle both poverty and inequality
simultaneously.
2. Although the initial conditions presented to us (by
semi- feudal and colonial exploitation) to start with plann
ed development were characteristic of a high degree of
social and economic disparities, poverty in the form as
it exists today is definitely an essential product of the
development model that we have adopted after
independence.
3. Poverty situation has surely been aggravated by slow
overall growth but a faster growth rate would not
automatically bring about better life for the poor because
of discriminatory distribution built into the system.
4. Poverty is not an issue of growing numbers. A pro
gramme of strict enforcement of population control
measures among the poor is not an answer to poverty.
Rather poverty is a major constraint in implementing the
population control programme.
5. While the mainstream growth process is throwing out
the poor (of whatever little entitlements they were holding)
on to the periphery of the economic system, poverty can
not be eliminated by a National Malaria Eradication type
programme through a spray of anti-poverty programmes.
tion in terms of assets, skills and wage incomes for a large
section of our population, this micro-analysis reduces to
victim-blaming that the poor are poor because they have
obsolete or no assets and no relevant skills. i.e., the cause
is rooted in them and not in the system.
(C
) The Minimum Needs Programmes (MNP) in
troduced in the Fifth Plan is also based on implicit ac
ceptance that the large number of people who have poor
incomes also have poor access to the basic needs and ser
vices for an accepted minimum level of living and
therefore their minimum needs have to be taken care of
through special efforts by the State.
The Limitations
Since these programmes ignore the basic mechanism
through which the poor have been driven to the state of
absolute deprivation the following consequences are
unavoidable: ■
(1) The acute symptoms may be pacified here and there
for a short ‘while but the problem cannot be solved unless
the causes are tackled.
(ii) The programmes will continue to be ad hoc in
Schemes for Poverty Alleviation
nature and continued expenditure would be needed to
maintain the poor in a state of being lifted above the
A) The Integrated Rural Development Programme poverty line.
(IRDP) is basically an asset endowment programme aimed
(iii) The forces (of the mainstream growth process)
at creating income generating assets in the hands of the which have caused asset and skill alienation among the
poor so as to develop self- employment in a variety of poor continue to operate on the life of the poor. Therefore
activities in primary as well as secondary and tertiary these programmes either fail to reach the poor or whatever
sectors.
reaches them, in the absence of backward and forward
The IRDP, contrary to what the name implies, does not linkages, does not yield the desired results, i.e., a sustain
involve any plan or conception of overall/integrated
ed income enough to maintain the family above the pover
development of the block/village neither does it integrate ty line. These consequences are evident from the numerous
the poor (target beneficiaries) with the overall develop evaluations conducted of the anti-poverty programmes,
ment process/plans.
by various government and non-government agencies.
It does integrate some other anti-poverty programmes
G. Parthasarathy (EPW Vol. XX (48), Nov. 30, 1985
like the Training of Rural Youth for Self-Employment
pp. 2125- 2128), while stressing that rural poverty is rooted
(TRYSEM) which aims at skills improvement and the in the system in which the poor are deprived of assets and
Development of Women and Children in Rural Areas incomes rightly points out that “poverty alleviation is a
(DWCRA), in the sense that funds for these programmes political process involving use of resources and of
come from the IRDP allocation.
technology for the benefit of the poor and there is need
B) The National Rural Employment Programme. for the poor to gain control over the institutions vested
(NREP) launched in October 1980 became a regular Plan
with decision making at the local level for such use”.
programme from April 1981 with the aim of generating
Zilla Parishads and other Panchayat bodies created
wage labour mainly during the seasonal gaps between the under Community Development Programmes have
crops season. Another wage employment scheme,
become the hotbed of politics and factional intrigues.
especially for the rural landless called, the Rural Landless These bodies, as of today, are the vehicles of rural elitism
Employment Guarantee Programme (RLEGP) was in with anti-poor bias..Handing over or linking up of the
troduced from 15th August, 1983. Though the guarantee
implementation of anti-poverty programmes to these in
component of the programme has not been introduced
stitutions, even with some representation of beneficiaries
even to a limited section of the target group and in prac
on these bodies, is not going to change the situation even
tice therefore, it in no way differs from the NREP, it con
marginally.
tinues as a separate programme chiefly because it was anThe irony is that all the poverty alleviation program
nounced by the late Prime Minister from the historic Lal
mes go on in the name of welfare. In the welfare approach
Quila in her Independence Day address to the nation in
there is a tacit admission that:
1983.
The very basis of these programmes is founded on the
- the society will continue to be divided in two sectors, the
tacit admission that a large number of people are left out • growth sector and the poverty sector.
of the normal run of the development process but it does
- in the normal run of the system the growth will bypass
not accept that the poor are deprived of their means of the poverty sector.
- for the growth sector all laws of capitalist growth con
existence by the mainstream growth process itself. Without
tinue to hold good.
going into the causes that have created a state of depriva
8
0)
g
V
- Some surpluses from the growth sector will be spent on
the welfare programmes for the poverty sector.
Welfare itself has become a big business with politicians,
officials and the rural elite pocketing most of the benefits.
Continuing lack of commitment to the anti-poverty
programmes is evident from the poor resource backing
that these programmes have received. Total expenditure
in the Sixth Plan for the poverty alleviation programmes
was Rs. 4,004.95 crores (against an outlay of Rs. 3,900
crores) which amounts to a meagre 4.1% of the total
public sector outlay of Rs. 97,500 crores. In the Seventh
Plan, inspite of so much noise about ‘sharper focus’ on
poverty alleviation, the outlay was maintained more or
less at the same level of 4.28% of total government sec
tor outlay of Rs. 1,80,000 crores which comes to Rs.
7,705.24 crores (details given in table below).
TABLE Anti-Poverty Allocations
(Rs. in erpres)
Vlth Plan
Centre
Total
VHth Plan
Total
Centre
1. IRDP & related
programme
1661.17
788.39
1864.38
2. NREP
1843.78
1250.81
3. RLEGP
500.00
500.00
1743.78
Total
4004.95
As percent of total
4.1%
Govt, sector Plan Outlay
(of 97,5000)
(of
8478.99
2487.47
1743.78
7705.24
4.28%
1,80,000)
(Source: VHth Plan document.)
Note: Sixth Plan figures represent actual expenditure whereas
for the Seventh Plan allocation figures are mentioned.
Even for this expenditure the planners had to offer an
apology, probably to the industrial vested interests. Page
22, para 14.2 Sixth Plan (1980-85) reads - “the provision
of free or subsidised services through public agencies is
expected to improve the consumption levels of those liv
ing below the poverty line... This integration ofsocial con
sumption programmes is necessary to accelerate growth
and- to ensure achievement of Plan objectives”
tThe planners were more explicit in the Sixth Plan
1978-83 document, Vol. Ill, p. 141, para 4.21 reads - “the
broad Strategy (of 7 Vo big increase in investment) that is
proposed in employment intensive activities like
agriculture and allied activities, irrigation and infrastruclure like power and roads and minimum needs like water
supply, health, primary education and housing will
stimulate the demand for a wide range of mass consumer,
intermediate and capital goods”
Therefore, in the overall strategy of planned develop
ment the expenditure on poverty alleviation or Minimum
Needs Programme is seen as a public welfare expenditure
which would generate temporary wage employment and
increase the demand for consumption goods and hence,
to an extent, relax the demand on industrial expansion.
tion programmes is a total hoax being played in the name
of the poor. It only amounts to doling out an illusion to
sections of the poor that if not they, some others in similar
conditions are being helped and that they should keep
waiting for their turn or eventually curse their own fate
if they fail to take benefit of the IRDP assets given to
them. Paulo Friere calls it false generosity of oppressor—
giving the oppressed too little to alter their material well
being, but enough to suggest that those in power aire tak
ing positive action on behalf of the poor.
Increasing the allocation for the anti-poverty program
mes or repeated appeals by heads of the government for
efficient and faithful implementation of these program
mes cannot tackle the problem of poverty. Poverty of such
dimension that engulfs half of the rural population can
not be eradicated by a peripheral activity that these anti
poverty programmes have come to be while the entire
economic planning is directed to the goal of high rate of
overall economic growth.
With the poor caught in the oppressive power struc
ture at the village level, corrupt and elitist bureaucracy
coming from the better off sections of the society that
despises and exploits the poor, and the economic growth
which is generating more wage labour than what in
dustrialisation can absorb, the prospects are that by the
year 2000 A.D. we will have many more marginalised poor
falling off into the dark ditch of starvation, malnutrition,
disease and death.
Our point here is not to oppose poverty alleviation or
overall economic growth but to bring to the fore the issues
of social justice: With all this overall economic growth
and in the name of welfare of the poor are we really help
ing the poor? Are we moving towards creating conditions
in which the poor will have access to skills, resources and
opportunities to satisfy their basic needs? If the poor
ever get a say in planning, will they tolerate, even
for a day, the growth model, which enriches the elite
and keeps the poor waiting for four decades without any
share in the fruits of growth? Will the planners of today
plan in the same way if they were living a life below the
poverty line? •
POVERTY IN INDIA
According to an Operations Research Group (ORG)
demographics study 61 per cent of the households
in rural india have fallen below the poverty level
against a national average of little over 50 per cent/
Of these, 27.5 oer cent have a monthly income of
less than Rs. 350, while only 3.4 per cent have a
monthly income of more than Rs. 2,500.
(Source: Economic Times 13-12-90]
Social Indicators of Development, 1989, published
by the World Bank also presents a telling situation
of poverty in India—56.5Vo of the population is
illiterate (corresponding figures for females, 71.1 Vo)
49.3 Vo children (under 5 years) suffer from malnutri
tion, the doctor: patient ratio is 1:2521.
Illusion of ‘Garibi Hatao’
After examining the situation in the country and the
government approach with regard to planning and im
plementation of the anti-poverty programmes, one comes
to the conclusion that the entire gamut of poverty allevia
(Source: Times of India, 31-1-90]
9
The Unknown Health Worker
Audrey Fernandes *
Kashibai, part time attendant, greets one with an the ANM. Though mostly illiterate, she knows the names
outstretched hand. She insists on carrying your bag, of the medicines, recognises them and often doles them
because that is what she is used to doing. Behind the Aux out too, if the ANM is absent or busy. She is also more
iliary Nurse Midwife (ANM), carrying the immunisation
adept at convincing women about undergoing a tubectomy.
kit, she is always there. She sits outside the door, while
She talks their language and they trust her has one of them
one talks to the ANM and once in a way you are reminded
in every sense - being from the same village (except in Beed
of her presence when the ANM asks her to buy poha, or district where part-timers are also transferred) she wears
the same kind of saree, talks the same coloquial language.
sugar for tea, or to clean up some vessels, etc.
One often thinks of the ANM as the final grassroot
In Wardha, many ANMs, when asked what problems
health worker. But essential to her, in terms of work and
they were facing in their jobs, replied that the salaries of
support is the part-time attendant. This is the woman who their attendants were very low. As a result attendants
occupies the lowest rung of the health worker ladder. She avoided accompanying the ANM on home visits, prefer
has often been doing the same job for years together. She ring agricultural work. Most ANMs don’t feel confident
lives in constant hope that she would be recognised as a about going alone through fields and jungle tracks.
full time government employee, that she would get the
Some ANMs, though, have a very condescending at
status and benefits that these employees enjoy. Kashibai,
titude to their part-timers and use the ‘lokseva' idiom to
from Beed district said, "I joined in 1972 at the time of extract more work from them. An illustrative
the big drought. I was sent to Mali-Chincholi, a PHC conversation:
away from my village, in Beed district itself. I worked there
Part-time Attendant (PTA): We get paid so little. It’s bet
for 8 years, after which I got transferred to Paithan. I have
ter to work as agricultural
been transferred 8 times. In each place I had to rent a
labourer.
room for Rs. 20-25.”
ANM
: Don’t talk like that! You are
She continues, “Look at us, we get Rs. 80/- only; if we
bound to get benefits in
went for agricultural work - the daily wages are Rs. 10.00.
future. See us, we also
We cannot do that as we go for home visits early in the
started with Rs. 125 per
morning and come back at 1:00 pm. Sometimes it is 2:00
month. Did we not benefit?
or 3:00 even. And what does the government pay us PTA
: When did you work for
Rs 3.00 per day! The nature of the job they are required
Rs. 125?
to do, though termed ‘part-time’, keeps them from tak
ANM
: During our training - this
ing up any other gainful employment. As a result they
was our stipend! Think this
become overly dependent on the ANM. Very often they
to be your stipend. Besides,
act as domestic servants in the ANM’s house, cooking and
you are doing service to
washing clothes, cleaning vessels and running errands for
people; is there anything
her, dependent on the meal an ANM may provide, or the
bad in that?
occasional saree.
When asked what made her take up the job, Kashibai
One ANM, when talking about how the village men related, “My husband used to constantly pick fights with
cat-call, or ask embarassing questions about FP spacing me. I thought it was better to earn some money - and leave
methods, mentioned that she never replied to any of these the village. He wanted that. He then remarried. I now have
taunts, but her attendant did. She recognised every one nobody”. What was disturbing was that a very large pro
in the village and would call them by name and give them portion of these women had been deserted by their
a fitting reply. This was by and large the rule with most husbands, or were widowed. This negative status adds to
ANMs we met, especially in Wardha district. They often their need and dependence on the job.
said they did not go for home visits without the part- time
In one PHC in Wardha the part-time attendant
attendant. Even if there was a delivery call during the night employed in the PHC, earned Rs. 80.00. Her husband had
an ANM would not step out of her house until the part- deserted her and she had three small children to look after.
time attendant came along. For most ANMs, the part-time She said she had to clean the operation theatre, sweep and
attendant is a source of strength, valued for the company swab the whole PHC, and clean the toilets. She came to
and support offered.
the PHC everyday. She hoped to be made permanent. In
To ANMs newly posted in a sub-centre the part-timer Beed, a full-time attendant at the PHC said that she had
provides information, introduces her to the village and worked for 16 years as part-time before she.was made full
helps her get sterilisation cases. She also acts as protec
time. Her mother had worked as part-time for 22 years
tor against elements in the village who might attempt to
before that.
harass a newly appointed ANM. ANMs related that
Another part-time attendant, under the mistaken no
Medical Officers often, while sending an ANM to a tion that we were government personnel, complained to
‘troublesome” sub-centre, warn the part-timer, “If
(Contd. on p.12)
anything happens to sister (meaning ANM) I’ll hold you
responsible!’ .
* Audrey Fernandes is on the research staff of FRCH. She is involved
Often, because of the many years of experience that an
in the Study oj Auxiliary Nurse Midwives and Doctors at the PHCs
attendant has, she knows the tricks of the job better than
in Maharashtra.
10
UPDATE ON FRCH PROJECTS
1. Arogya Shikshan Kendra (ASK): A field
based health education project supported by
ICMR. It covered 18 villages in. Malshiras
(Purandar taluka, Pune district) PHC area. The
project includes a wide range of activities cover
ing health education, self-employment (for
women), public information service, and very
recently a retail drugstore for rational drugs
(detailed report on page 5).
2. Health Financing and Costs: Comparative
Perspectives: A descriptive and analytical study
of cross-national trends in the financing and
delivery of health care covering 22 countries
representing different socio-economic and
political systems, viz. the less industrialised
economies, the centrally planned industrialised
economies and the industrialised capitalist
economies.
3. Private Sector and Privatisation in the Health
Care Services: A report recording the
phenomenal growth of the private sector in
health care, the role of the state in this growth
and its implications for achievement of the
Alma Ata goal. •
4. Kasare - Self Help Development: An effort at
motivating people in five villages towards self
development following the Ralegan Shindi model.
5. School Health Education: This project enters
its final follow-up and evaluation phase. Detail
ed description of this project is contained in the
article on page 1.
6. Study of Auxiliary Nurse Midwives and
Doctors at the PHCs in Maharashtra: Covers
four districts in Maharashtra and studies six
non-tribal PHCs from each district and three
tribal PHCs in Pune district. The study focus
on socio-economic background of ANMs and
doctors, their role expectation, performance,
satisfaction/dissatisfication, and problems of
ANMs. It also assesses their training vis-a-vis
their performance.
7. Study of Household Health Expenditure in
Madhya Pradesh: After the study of household
health expenditure in Jalgaon district (Maha
rashtra) this is a study in two districts, Sagar and
Morena, in Madhya Pradesh. It aims at under
standing household health expenditure by dis
aggregating the components and analysing its
differentials based on the three geographical
seasons, socio-economic strata and on social
geography.
8. Some Issues in the Community Participation
in Health Care Services: A review paper at
tempting to analyse the meaning of community
participation and the socio-economic-political
obstacles that have stood in the way of such par
ticipation in health care services as envisaged in
the Sixth Five Year Plan Document.
9. Study of Health Expenditure in India: Spon
sored by the ICMR this study was completed
in three phases. The first covered household ex
penditure patterns for health care, the second
made an analytical documentation of State
health services in India while the final phase
made an exploratory study of the private sector
covering general practitioners as well as the
corporate sector.
10. Study of Urban T.B. Clinics: Focuses on in
depth case studies of T.B. clinics in Bombay. The
study looks at the health functionaries as well
as patients with the idea of understanding con
straints and identifying possible interventions in
the effective implementation of the T.B. control
programme.
11. The Community Health Care System: FRCH
team is in the process of evolving a detailed
model which aims at the convergence of the dif
ferent prongs and substitute with curative,
preventive, promotive health services, in the
delivery of rural health care and health educa
tion and information.
12. The development of PVC Footwear for In
sensitive feet of Leprosy Patients: A project
to devise a prototype of mass production of
footwear which would be mechanically sound
as well as aesthetically acceptable for leprosy
patients with anaesthetic feet and moderate
deformities of the feet.
The above gives a brief idea the projects of
FRCH. More detailed reports about each pro
jects are compiled in the FRCH Annual Report,
1990 available at FRCH, 84-A, R.G. Thadani
Marg, Worli, Bombay - 400 018, on request.
COMMUNITY HEALTH CELL
326. V Main, I Block
Koram-ngala
Bangalore-560034
India
. -r3
New Arrivals
Books-.
1. Klinoubol K., ‘Public health development’, New Delhi,
Deep & Deep, 1989, pp. 436.
2. Roemer M., ‘ National •Strategies for health care
organisations: a world overview’, Michigan: Health
Administrtion Press, 1985, pp. 426.
10. Battersky, Anthony, ‘Evaluation of the DANIDA assisted health care and family welfare projects, In
dia’, Copenhagen: DANIDA, 1987, pp. 63.
Reprints
1. Youmans., ‘Tuberculosis’, 1979, pp 7.
2. Naganna, K. ‘Tubercle bacilli retain pathogenicity after
_ seven weeks chemotherapy’, IJT, pp. 1-8.
3. Indian Institute of Education, ‘Baseline survey on
comprehensive project in health, family welfare and
community development’, Pune: KEM Hospital, 1989,
pp. 46.
3. Jeanes; C.W.H., ‘Perspectives and prospects in tuber
culosis control’, IJT, 1986, pp 1-4.
4. Government of India, ‘Report of the first inter-state
work shop on health manpower planning and
management’, New Delhi: GOI, 1985, pp. 116.
4. Pamra, S.P., ‘Short course chemotheraphy of
pulmonary tuberculoses—second tuberculosis
association of India trial UJ, 1984, pp. 81-88.
5. Scetha, M.A., ‘Short-course chemotherapy-rewards
and challenges’, IJT, 1988, pp. 123-27.
5. Government of India., ‘National programme for con
trol of blindness in India - a report’, New Delhi, 1985,
pp. 50.
6. Baldwin, J.A., ‘Text book of medical record linkage*,
Oxford: Oxford University Press, 1987, pp. 347.
7: Visaria, Pravin., ‘Seminar on population growth and
its links with development’, Bombay: Economic
Research & Training Foundation, 1989, pp. 31.
8. Shryock, H.S., ‘The methods and materials of
demography’ Vol. I & II, Washington: V.S. Dept, of
Commerce, 1971, pp. 369. & pp. 888.
9. National Institute of Urban Affairs., 'Upgrading
municipal services: norms and financial implications’
- Vols 1 & 2, New Delhi: GOI, pp. 135 & pp. 200.
Corud. from pg 10)
us that we were only paying attention to the problems of
the ANMs and neglecting the part-time attendants. In her
own words: “Nobody thinks of us. If we went for wage
labour we would get Rs. 12.00. per day. What we get is
not enough for even the ST. fare to the PHC. What can
one buy in Rs. 80.00? And, the ANM I work with does
not pay for bus fares when I travel with her. When my
husband fell sick with paralysis, she gave me medicines
and then asked me for the money.
The DHO office in Wardha informed us that part-time
attendants are employed under two heads. Those under
the MCH programme were paid Rs. 80.00, and those
under the FP programme Rs. 50.00. But when asked many
attendants were not aware of this differentiation. They
said that they had got Rs. 80.00 for 5-6 months. After
that they were getting Rs. 50.00. In a few cases we heard
that after their salary was reduced to Rs. 50.00, they ac
tually got Rs. 40.00 for the earlier mistake, as Rs. 10.00
was being cut every month, as arrears!
6. Fox, Wallace., ‘The current status of short course
chemotheraphy’ Tubercle, 1979, pp. 177-90.
7. Cohen John M., ‘Participation’s place in rural develop
ment: seeking clarity through specificity,’ 1980,
pp. 213-235.
8. Rasmussen, N.K., ‘Use of indicators for Health For
All’ strategies: experience of Denmark, WHO 1986,
pp. 311-19.
9. Yellowlees, H., ‘Use of indicators for ‘Health For All’
strategies: experience from the WHO European
region’, WHSQ, 1986, pp. 320-21.
10. Government of Maharashtra, ‘The Maharashtra Nur
sing Council Rules, 197P, 1976, pp. 63.
In Wardha, there had been an attempt to unionise part- •)
time attendants. Some attendants went for the meeting,
escorted by their ANMs. Some said the ANMs had given
them the money for the ticket to Wardha and back. Also
for the union membership fee of Rs. 11.00. Other atten
dants when asked whether they had attended the meeting
replied angrily. “What union are you talking about? How
do we go? Do you think we can afford bus-fare to and
fro? And Rs. 11.00 for membership? What will be left
from Rs. 50.00?
And so, they continue to wprk. Like bullocks pulling
a cart. Carrying the immunisation kit, the ANMs
hand-bag, cooking for her, looking after patients after a
tubectomy, looking after the ANM when she is alone, pro
tecting her when she is on home visits.
the slogan, “Health for All” sounds glorious. But
unless the lowest rungs in the hierarchy of the health
delivery system are empowered and their vital link in the
achievement of this goal recognised, the slogan may well fall
by the wayside on its bumpy ride in the health wagon. •
Edited by Nagmani Rao, produced by the Foundation for Research in Community Health, 84-A, R.G. Thadani.Marg, Worli, Bombay-400 018,
Registered under the Bombay Public Trust Act. Typeset by Economic and Political Weekly. Printed by Modern Arts and Industries, A-Z Industrial
Estate, Lower Parel, Bombay.
Vol V No. 3
May - Jun 1991
HEALTH FINANCING AND COSTS
A Profile of Japan
Sonya Gill
FRCH Newsletter, July -August, 1990, had carried an article, Health Financing
in the Developing Countries' by Shirish Kavadi, which gave an introduction to the
study, ‘Health Financing and Costs: comparative perspectives with special
reference to India', which was sponsored by the WHO. Beginning with this issue,
five non-thematic issues will each carry one profile based on the country reports
prepared for this study.
pollution, overcrowding and shortage of housing and inadequate
sewage and garbage disposal systems. The rise in coronary heart
diseases, cancers, suicides and accidents reflect these
environmental conditions.
TABLE 1: HEALTH STATUS - JAPAN
Crude
Crude
Birth
Death
Infant
Maternal
Expectancy
Rate
Rate
per 1000
per 100,000
At Birth
(per 1000 pop.)
births
births
(years)
1960
17.2
7.6
30.7
49.0(1980)
68
1986
11.4
6.2
5.2
15.0
78
Year
Japan has a statutory health system that ensures universal
coverage and good quality care at reasonable costs. Since 1961,
when universal coverage (as against the earlier voluntary
schemes) was implemented, there has been a progressive
expansionof medical benefits and greater equity in the distribution
of health care resources. This country report briefly reviews the
universal health care system in Japan, that has been one of the
major factors underlyingthe rapid improvement in health status.
Health Status
Japan, with a population of 122.2 million (1987), has achieved
remarkable improvements in the health status of its people over
the past three decades (Tablel). By 1986 life expectancy of the
average Japanese (75.2 years for men and 80.9 years for women)
was the highest in the world. Total mortality is considerably
lower (6/1000population) than in other countries, while its infant
mortality rate of 5.2 deaths was the lowest in the world.
In the 1920s and 30s and immediately after the war, the
health conditions in Japan were characterized by a high incidence
of communicable diseases, particularly tuberculosis and
gastroenteritis and high maternal mortality (160-180/100,000
births). Between 1955 and 1980, all these health indices improved
rapidly, i.e. within a period ofjust 25 years andby 1986, mortality
in all age groups and due to all categories had shown a significant
decline. However, rapid industrialization and urbanization since
the 1960s have given rise to environmental problems such as
Sonya Gill is on the research staff of the Foundation for
Research in Community Health , Bombay. She has been
coordinating the study, from which the above article has been
drawn.
Mortality Rate
Life
SourceJapan Statistical Year Bock, 1988.
Universal Health Insurance
Pre-World War II Japan had established limited compulsory
health coverage for the industrial work force in 1927 and voluntary
health insurance for the self-employed rural and coastal
population by 1938. These limited social security provisions for
medical care were modified and made compulsorily applicable for
every Japanese by 1961. The scope of medical benefits was also
established by law and includes all ambulatory and in-patient
care, diagnostic services, drugs (specified in a list approved by the
Ministry of Health and Welfare), dental care (including most
dentures), all appliances except eye-glasses and transportation.
However, preventive examinations, screenings and normal child
delivery are not covered but appear as benefits in some of the
better-off employment based insurance schemes.
Thus, while health insurance is universal and covers the
cost of a wide range of needed medical services, the Japanese
system is neither uniform nor equitable. This system, in fact,
consists of two altogether different programs. The first is the
Employee Health Insurance (EHI) scheme covering 62.4% of the
total insured population (1985). It has 7 separate plans for
different categories of the employed population, e.g.. employees
oflarge corporate firms, seamen, employers in medium and small
enterprises, civil servants and government employees, school
FOR PRIVATE CIRCULATION ONLY
which is under greater pressure to curtail demand and find
alternatives to public subsidies. The mainpolicy measure adopted
has been to impose and increase user charges. This raises a
fundamental question about social policy objectives in the
capitalist welfare states: does not the less well-off and medically
more needy population (the 37% covered by the NHI) have the
right to more public funds in one of the world's most affluent
economies? User charges, it must be noted, meet less than 10% of
the total health cost hi these countries, with the exception of the
USA. In the latter, direct household spending accounts for 25%
of health expenditure as it is the only OECD country lacking a
universal health care system and extensive public coverage. The
level at which user charges have been imposed in Japan will
hardly modify medical needs or raise substantial funds. It may
however prevent the lower income groups from taking adequate
health care. A more thorough-going solution will be to have a
single health insurance program for the country as a whole; but
those enjoying higher standards under the better-off EHI scheme,
have opposed the pooling of resources.
teachers etc., and is financed through contributions by both the
employer and the employee. However, the contribution rate and
its division vary from scheme to scheme. The EHI uniformly
meets 90% of the medical costs for the beneficiaries and 70% for
the dependents.
The second program, the National Health Insurance (NHI),
covers 37.6% of the population and consists of regionally based
insurance plans, administered by local governments and
municipalities in cities, towns and villages, for the non-employee
population (agricultural workers, the selfemployed, construction
workers, doctors, employees at small-scale places of work, farmers
etc.). The NHI provides a lower coverage of 70% of health care
costs imposing 30% cost sharing on its members. It is financed in
equal proportion by a special NHI tax on the insured households
(levied and collected by local governments) and central government
subsidies. The difference in insurance arrangements and the
larger user charges in the NHI means that a greater burden ofthe
costs is borne by the self - employed and the rural population as
compared to the urban and organized employment sector. The
EHI scheme is at a considerable advantage as regards the
amount of income available to both employers and employees to
finance a health insurance scheme. Moreover, the health
standards of employees in the larger industrial enterprises tend
to be better than in rural occupations which again places the EHI
at a financial advantage over the NHI scheme.
Japan also created a separate financing system for the
retired elderly in 1982, so that the NHI would not be burdened by
the rapidly rising aged (above 65 years) population constituting
10.6% in 1986 and estimated to rise to 23.6% by the year2020. The
employment based schemes have been made responsible for
partly financing the growing demand for geriatric care. Small
user charges have been imposed, overturning the 100% free
coverage provided since 1973.
Health Expenditures and Cost Containment
With growing demand for medical care, Japan, like other
industrialized affluent countries, is faced with rising medical
care costs. While Japan has been a lower spender on health care,
(Table 2) whether measured in terms of the GDP share of 6.7% in
1986, (lower than the OECD - Organisation of Economic
Cooperation and Development - average of 7.3%) or interms ofper
capita health spending of US $831 (significantly less than that of
USA: $ 1,926, Canada: $ 1,370, Sweden: $ 1,195, and W.Germany:
$ 1,031.), it lias, nevertheless, had one of the highest growth rates
of health expenditures from 1960 to the present. These trends
partly reflect the rapid growth and affluence of its economy.
Health Care Services
Medical care is largely provided by private practitioners in
fami ly owned clinics and hospitals. Investor owned health facilities
are prohibited and the larger hospitals are public institutions. In
.1986, there were 9,699 hospitals and 79,369medical clinics. The
ratio of 1,492 beds per 100,000 population (Table 3) is one of the
highest among industrialized countries. Since 1985, the
Prefectural (state) governments are required by law to develop
regional and local healthplans inorder to contain excess hospital
bed capacity and achieve balanced distribution ofservices. While
in overall quantitative terms, Japan's medical care system has
attained a highstandard, problems ofmaldistribution characterise
the remote mountainous areas and rapidly urbanizing regions.
TABLE 2: NATIONAL HEALTH EXPENDITURE 1960-1986
Year
Total
Billion Yen
Per
Public Expense.
Total Expense
Capita
to Total expense
toG.D.P.
U.S.S
%
%
TABLE 3: HEALTH DELIVERY
Physicians
1960
1970
1980
1986
409.5
2496.2
11980.5
17020.0
66.85
451.38
830.09
60.4
69.8
70.8
72.9
Nurses
Dentists
Beds
Per 100,000 1 population
3.1
8
Year
6.0
6.7
1960
117
1970
134
79
10
1266
1980
231
335
11
1374
1986
339
381
15
1493
Source: Sawamura, H,Recent developments in medcal care delvery systems in the region, National expenditure of
912
Japan,1969 OECD, Health Care systems in Transition. 1990
Sources: Japan Statistical Yearbook, 1962 and 1986. '
Rising expenditure has reopened the question of how to
finance health insurance and raise additional resources. The
policy debates have however, given less thought to modifying
medical services and practice patterns, such as regulating the
duplication and excessive utilization of high cost medical
technology or separating medical and pharmaceutical services to
curb doctors from over prescribing and dispensing expensive
drugs to increase their profits, than to achieving fiscal stability.
In a multiple insurance system, it is the tax funded scheme (NHI)
The health insurance system, while ensuring, universal
coverage, also provides a framework for regulating the: price of
medical services. Japanese physicians are paid on a fee for
service basis which, in turn, is based on a uniform fee schedule
for the entire country. The fees established through negotiations
between the government, the medical profession, and the
insurance associations are for a particular service or procedure,
(Continued on Page 8)
(2)
HEALTH POLICY CONTENT IN MANIFESTOS
An Analysis
Alex George
family planning knowledge and services, as a part of a social
movement linked to their broader approach to equity and basic
developmental needs and to aim at a higher quality ofpopulation.
The Communist Party of India (CPI)
The CPI is for an extensive free health program and for
increasing the budget allocation for health. The party also offers
to improve" health services in all district and primary health
centres with linkage to the district centres.
Though elections are generally contested on the basis ofonly
one or two issues, they compel the political parties to come out
with their manifestos, setting forth their positions on a wide
range of aspects which have a bearing on the nation's development.
Thus, of late, apart from education which used to- occupy a
position of importance in manifestos, other social sectors like
health, environment, women and child development, are also
beginning to catch the attention of those who prepare the
manifestos. But a mere gaze from the political quarter is hardly
sufficient for these important sectors.
The Communist Party of India, Marxist (CPI-M)
The CPI-M promises improved primary health services in
the rural areas with the adequate supply of medicines. The party
also offers to implement a people oriented national drug policy.
The following article presents the health component in the
current manifestos followed by some observations. The manifestos
discussed here are those ofthe main political parties and alliances,
viz. the Samajwadi Janata Party (SJP), the National Front (NF),
the CPI, the CPI-M, the Indian National Congress(I) and the
Bharatiya Janata Party (BJP).
The Indian National Congress (I)
in its 'first 100 days in power', the Congress(I) promises to
extend drinking water supply by exempting from taxation the
profits invested in the same. 'In the first 365 days' as the party
puts it, they intend to hand over the primary health centres to
panchayat bodies at taluka samiti levels and'provide funds
directly to them. It also aims at building 1000 Sulobk
Skcuickalayus every year. The party’s target for the 'first 730
days' is to set up in every state capital either in the private orjoint
sector, a multi-disciplinary high quality institute of medical
sciences with a hospital. Another target which the party promises
to fulfill in the first twoyears is to establish and enforce standards
of noise pollution.
The Samajwadi Janata Party (SJP)
The SJP pledges to correct what it calls the "distortions
in the nation’s investment priorities" and to work towards provid
ing the basic necessities, in which it includes health and educa
tion along with food, clothing and housing. In addition the party
promises to supply drinking water in each village of the country
by the end of the VIIIth Plan. The SJP also puts forward "a new
approach to population growth by clubbing together awareness
campaign, health facilities, nutrition and family planning."
The National Front (NF)
The Front believes that preventive, promotive and curative
health care need an inter-sectoral approach and that the existing
imbalance in public spending should therefore be corrected by:
a) enhancing the community's own preventive / promo
tive capacity by imparting knowledge related to nutrition, health and hygiene,
b) strengthening the health care infrastructure to reach
remote rural and tribal areas and urban slums,
c) taking health services to the people through commu
nity level networks linking health workers and facilities to other service systems,
d) giving first Service priority to mother and child health
considering their vulnerability during pregnancy and
early childhood, and,
e) promoting, on a priority basis, those health services
which address the most common causes of illness and
death.
The Front also Commits itself to removing the basic causes
of the high rate of population growth and in particular, to
eliminating rural poverty which it regards as the main obstacle
to regulating family size. It intends to take urgent steps to expand
The Bharatiya Janata Party (BJP)
The BJP aims at introducing an integrated system of
medicine by bringing together Ayurveda, Siddha, Unani,
Homeopathy, Chromopathy, Naturopathy and Allopathy.
Compiling and publishing ancient wisdom on health care, and
encouragingYogasana inschools, follow in the order ofprominence.
The party promises to give an annual health check-up to all
students and to set up in every village a health care centre with
emphasis on mother and child care. Increased production of milk
and proteinous foods are also planned. The party promises to
take adequate measures to "promote the production of poor man's
grains like jowar, bajra, and ragi." It also intends to replace the
60,000 brand name dings by 250 generic formulations and ban
amnioceritesis.
Sri the population front, the BJP intends to adopt a National
Population Policy (NPP), if necessary even through legislative
measures. This will make family planning information and
facilities available to the people and will involve voluntary
organisations in creating awareness. Another component of the
proposed NPP is to integrate family welfare programs with other
community welfare programs. All the same, the party does state
clearly that it plans to introduce both incentives as well as
disincentives to promote the 'voluntary adoption1 ofthe 'two child'
norm.
Alex George is on the research staff of FRCH, Bombay. He
has a background in Sociology. At present, he is involved in
an FRCH study on household health expenditure.
(3)
Some Observations
That the SJ P lists health as one of the five basic necessities
is commendable. So also is their new approach to family planning,
combining awareness building, health facilities and nutrition.
Yet, it has to be pointed out that the party does not carry a
comprehensive health policy anywhere in its manifesto.
production of milk and proteinous foods is to be welcomed. But
the point however is, how will this enhanced production of milk
and proteinous food stuffs be made available to the public,
especially the poor, at affordable prices? There is no mention of
introducing a price policy which will bring them within the reach
of the poor.
The National Front’s emphasis to improve the "preventive/
promotive capacity of the community" demonstrates an
acceptance of the people’s own ability to take care of their health
to a considerable extent. This marks a change from the
conventional development thinking where people are seen merely
as ignorant recipients of developmental information. Yet it has to
be pointed out that the curative capability of the people, which
was demonstrated in experiments such as the Mandwa health
project, has not been given.-any attention. This means that the
curative part is left entirely to the medical profession. The
Front’s attempt to link health workers and facilities with other
service systems indicates a holistic approach to health care
within the framework of developmental services in general. The
Front also makes a welcome shift- from mere population control
to expanding family planning knowledge and services as part of
a social movement within the broader framework oftheir approach
to equity. Yet one must hasten to add that the National Front also
does not contemplate any structural change if the above
commitments are to be implemented.
While the BJP plans to increase the production of "poorman's
grains like jowar, bajra, and ragi", it is hoped that the poor will
also be provided with adequate quantities ofwheat and rice. The
party's promise to introduce generic names instead of brand
names is laudable, but the question remains as to how the BJP
plans to bringdown 60,000brand names straightaway to just 250
•generic names as promised by them. How do they intend to tackle
the formidable lobby of the pharmaceutical industry? Their
.claim to ban amniocentesis is very radical, but it would be
interesting to see how the party goes about implementing it in the
BJP ruled states of Madhya Pradesh and Rajasthan, where
amniocentesis and female foeticide are emerging as growing
.phenomena. The BJP's statement that it intends to introduce
disincentives to promote the voluntary adoption of the "two child"
norm is likely to lead to coercion. Other components of its
.population policy such as involving voluntary organisations in
creating family welfare awareness and integrating family
planning with other community welfare programmes are not
altogether new.
Both the Communist Parties do not have much to say on
health. Though the CPI calls for a free health programme and
increased budget allocation for health and the CPI-M calls for a
people oriented national drug policy and improvement of rural
primary health care, both the parties apparently reflect a lack of
grasp of the finer aspects of health policy formulation.
Conclusion
On the whole, it may be pointed out that an important social
sector such as health is not on the priority list of most of the
political parties. But what is more striking about all manifestos
is that, none of them mention anything about structural reforms
of the health sector, such as universal health care, regulating the
growth of private sector in-the field and bringing accountability
into the public sector. Most manifestos suggest only peripheral
reforms within the existing framework of the health sector, a
.framework which lias clearly failed to provide health to the vast
majority of our people, especially to the poor in rural areas.
-Though the Congress® promises to introduce popular
measures such as extending drinking water facility and
constructing 1000 Sulabh Shouchalayas eveiy year, the party
still gives prominence to the high profile sophisticated medical
technology, as indicated by its plan to establish a multi
disciplinary high quality centre ofmedical services attached with
a hospital in every state capital. Since these centres are to be set
up in the private or joint sectors, it will also amount to further
privatisation. Moreover, since we already have several such
centres in the country, should not the provision ofprimary health
care to remote rural areas be the first priority? The party's
intention to hand over the primary health centres to the
panchayats is laudable. But, the attempt to fund them directly
from the centre nullifies the idea of such decentralisation.
BRANDED AND GENERICS
It has been estimated that generic prescribing could save the
NHS 30-50 million Pound sterling a year straigh latter being introduced,
and 100-150 million Pound sterling, after 4 or 5 years.
The logic of generics is compelling: 95% of the drugs on the
WHO Selection of Essential Drugs can be bought as generics - because
their patents have expired; Research and development spending on the
drugs the Third World poor need has mostly been recouped.
The drug industry allocated only 1% of research and develop
The major thrust of the health component of the BJP
manifesto is to revive the Indian systems ofmedicine, particularly
Ayurveda, and to integrate them with Allopathy. However,
modalities of this integration have not been indicated. The
schemes to give an annual medical check up to all students and
to start a health care centre in every village with focus on mother
and child health is commendable, but again, no thought seems to
have been given to make such village centres more functional
than at present.
ment spending to poor world diseases in 1980 - i.e. about half as much as
it costs to develop just one new drug.
Current research mostly ignores Third World needs: Out of
87 diseases specific to poor countries; there are vaccinations for 10,
satisfactory drug treatment for 23, but no drugs at all to treat 32 disease
and the remaining 22 can only be treated with very unsatisfactory drugs
that have serious toxic side effects.
Source: Prescription for Change - Virginia Beardshaw, The Hague,
1983,as carried in Health Action I nternational’s Guide to Rational I Icalth
The intention to increase milk production seems to be
related to the party’splan to ban cow slaughter which is mentioned
elsewhere in its manifesto. In itself, the idea to increase the
Projects. pg.73
(4)
HEALTH POLICY IN THE FIVE YEAR PLANS
A Critical Overview
Sunil Nandraj
Health infrastructure development in India clearly shows
that the pattern ofgrowth ofthe health sector has only contributed
to its underdevelopment. Thethree high growth areas ofmedical
education, pharmaceuticals and private practice, coupled with
the backwardness of the health care services specifically and the
overburdened economy in general, has only added to this misery.
The beneficiaries of such a development have been the enclave
sector - the metropolis urban-entrepreneurial economy. In
contrast, the health care services in the periphery, like all other
sectors of the economy, remain backward; what little exists is
both of difficult access and poor quality.
It was not until 1983, that India adopted a formal or official
National Health Policy. Prior to this, health activities ofthe state
were formulated through the Five Year Plans and the
recommendations of various Committees. In the Five Year Plans
the health sector was broken into schemes which had targets to
be fulfilled. Each plan had a number of schemes and every
subsequent plan added more or dropped a few.
In the fifties and the sixties, the entire focus of the health
sector in India was to manage epidemics. Mass campaigns were
started to eradicate various diseases. These separate countrywide campaigns with a techno-centric approach were launched.
against malaria, smallpox, tuberculosis, leprosy, filaria,trachoma
and cholera. Cadres of workers were trained in each of the
vertical programmes. The National Malaria Eradication
Programmes (NMEP) alone required the training of 150,000
workers spread over in 400 units in the prevention and curative
aspects of Malaria control. (1)
The policy ofgoing in for mass campaigns was in continuation
of the policy of colonialists who subscribed to the precept of
modern medicine that health could be looked after if the germs
which were causing it were removed, thus ignoring the socio
economic dimensions ofvarious diseases viz. poverty, inadequate
nutrition, clothing and housing and the lack of a proper
environment. National programmes were launched to eradicate
diseases. The NMEP was started in 1953, with the aid of the
technical cooperation mission of the U.S.A, and technical advice
from the World Health Organisation (WHO}. Malaria, at that
time, was considered an international threat. One of the most
important activities of the. programme was DDT spraying;
operations. The tuberculosis programme involved vaccination
Sunil Nandraj is on the research staff of FRCH, Bombay. He
has been involved in the study of health expenditure in India.
The article above is based on a part of the report; 'State
Health Services and Expenditure in India 1 to be published
shortly. This article has been reviewed by Ravi Duggal
(5)
with BCG, clinics, domiciliary services and after care. The
emphasis however was on prevention through BCG. These
programmes depended on international agencies like UNICEF
and WHO for supplies of the necessary chemicals and vaccines.
The policy with regard to communicable diseases was dictated by
the imperialist.power's as in other sectors of the economy. Along
with financial aid came political and ideological influence. The
entire policy framework, programme design and financial
commitments etc. were decided by the experts of various
international agencies.
The Mudaliar Committee report in 1961, recorded that the
disease control programmes had some substantial achievements
in controlling certain virulent epidemic diseases. Malaria was
considered to be under control. Deaths due to malaria, cholera,
smallpox, etc. were halved or sharply reduced and the overall
morbidity and mortality rates had declined. The death rate had
fallen to 21.6 per 1000 population for the period 1956-61. The
expectation of life at birth had risen to 42 years. However, the
tuberculosis programme had lagged behind. The report also
stated, that, for a million and half estimated open.cases of
tuberculosis, there were not more than 30, 000 beds available (2).
The Mudaliar Committee further admitted that the basic health
facilities had not reached at least half the nation. The Primary
Health Centre (PHC) was not given the importance it should have
received, right from the start. Most ofthe PHCs were understaffed,
a large number of them were being run by Auxiliary Nurse
Midwives (ANMs) or the public health nurses in charge. The fact
appears that doctors were going into private practice after training
at public expense. The communicable disease programme was
given top priority in the first two plans. But the primary health
centres, through which the gains of this programme could be
maintained were given only tepid support. In the process; the
rural areas had little or no access to them. The condition of the
secondary district hospitals was the same as the PHCs. The
report showed that the majority of the beds and other facilities
were located in the urban areas.
The committee, with regard to medical human power,
suggested measures to improve the service conditions of doctors
and other personnel in order to attract them to the rural areas.
The committee makes a mention that except for a substantial
increase in the number of doctors, the number of other categories
of health personnel was still woefully short of the requirement.
The committee insisted that medical education should get a
greater amount of the financial allocation from the central
government. Tins was in clear contradiction to its findingthatthe
doctors were not willing to go to rural areas. In what way,
therefore, would a greater number of doctors being trained mean
more access for the people?
The IIIrd Plan launched in 1961 discussed the problems of divisional and district hospitals who could be referral centres for
the provision of the PHCs and directed attention to the shortage the PHCs. The importance ofthe PHCs was stressed to consolidate
of health personnel, delays in the construction of the PHC the maintenance phase of the communicable diseases
buildings and staff quarters and inadequate training facilities programmes. This acknowledgement was due to the fact that the
for the different categories ofstaffrequired in the rural areas. The entire epidemiological trend was reversed in the incidence of
'doctor' syndrome loomed large in the minds of the planners and malaria cases, which rose from an annual incidence of 100,000
increase in the supply of human power in health meant more cases between 1963-65, to 149,102 cases in 1966 (7). This was
doctors and not other health personnel. By the end of the IIIrd admitted by the Planning Commission. Family planning
Plan it was felt that the doctors were not going to the rural areas continued to get an even greater emphasis with 42% of the health
or serving in the government primary health centers. While the sector plan allocation going to it.
IIIrd Plan gave serious consideration to the need for more
auxiliary personnel, no mention was made of any specific steps
It was in the Vth Plan, that the government ruefully
to reach this goal (4). Only lip sendee was paid to the need of acknowledged that despite advances in terms of the infant
increasing auxiliary personnel, but in the actual training and mortality rate going down, life expectancy going up, the number
establishment of institutions for these personnel, inadequate of medical institutions, functionaries, beds, health facilities, etc.,
funding became the constant obstacle. On the other hand, the were still inadequate in the rural areas. This shows that the
proposed outlays for new medical colleges, establishment of government acknowledged that the urban health sector had
preventive and social medicine and psychiatric departments, the expanded at the cost of the rural sector. This awareness is clearly
completion of the All India Institute of Medical Sciences and reflected in the objectives of the Vth Five Year Plan which were
schemes for upgrading thedepartments forpost graduate training as follows:
and research in existing medical colleges, continued to be high
(3) . The urban health structure continued to grow and its 1. Increasing the accessability of the health services to the
sophisticated services and specialities continued to multiply.
rural areas through the Minimum Needs Program (MNP),
and correcting regional imbalances.
The Hird Plan gave serious consideration to suggesting a 2. Referral services to be developed further by removing
realistic solution to the problem of insufficient doctors for rural
deficiencies in the district and sub-division level hospitals,
areas; stating "that a new short term course for the training of 3. Intensification of the control and eradication of
medical assistants should be instituted at an early date;"
communicable diseases.
undertaking health education as a serious national programme 4. Affecting quality improvement in the education and training
of health personnel.
was stressed (5). In this plan, a rapid increase in the numbers of
PHCs was witnessed but their condition was the same as the 5. Development of referral services by providing specialised
attention to common diseases in rural areas.(6).
Mudaliar Committee had found at the end of the IInd Plan
period. Due to the vertical nature of the disease control
The method by which these goals were to be achieved were
programmes, we find a huge army of workers. The delivery of
services continued to be done by special uni-purpose health the MNP, the Multi Purpose Worker (MPW) training scheme and
workers. Therefore we find that in the same geographical areas, priority treatment to backward and tribal areas. Major innovations
there was overlapping and duplication of work.
took place with regard to the health policy and method ofdelivery
of health care services. This was envisaged through the MNP. It
The health programme that shot into the limelight during was an integrated package approach to the rural areas. The plan
the IIIrd Five Year Plan was Family Planning (FP) and Population further envisaged that the delivery of health care services would
Control. India is the first country in the world to adopt, in 1951, be through a new category of health personnel to be specially
a policy of reducing population growth through a government trained as multi-purpose health assistants.
sponsored family planningprogramme. In the first two Plans the
The multi purpose worker scheme was launched with the
family planning programme was mainly through voluntary
organizations under the aegis ofthe Family Planning Association objective of retraining the existing cadre of vertical programme
OfIndia (FPAI). Faced with a rising birth rate and a falling death workers. The various vertical programmes were to be fully
rate, the Hird Plan stated that "the objective of stabilising the integrated with the the other health care programmes. Further,
growth of population over a reasonable period must therefore be in 1977, a major innovation in health strategy was launched- a
at the very centres ofplanned development" (5). It was during this programme for training village based health auxiliaries called
period that the camp approach was tried out and government the Community Health Volunteers (CHV) scheme. These were
agencies began to actively participate in pushing population part time workers selected by the village, trained for 3 months in
control. There was a fundamental change in India's health policy. simple promotive and curative skills both in allopathy and the
This policy change, though it had its own inner compulsions, was indigenous systems of medicine. They were to be supervised by
the MPWs. This step was taken on the recomendations of the
more due to the influence of foreign agencies.
Shrivastava Committee (Study Group on Medical Education and
The IVth Plan, which began in 1969, after a 3 year plan Support Manpower), in 1975. The main recommendations of the
committee concerned having part-time health personnel selected
holiday, continued on the same line as the IIIrd Plan. It lamented
on the poor progress made in the PHC programme and recognised by the community from within the community. They would act as
again the need to strengthen it. It pleaded for the establishment a link between the MPW at the sub-centre and the community.
of an effective machinery for the speedy construction ofbuildings With regard to medical education the committee cried for a halt
and improvements in the .performance ofthe PHCs by providing to the opening of new medical colleges.
them with staff, equipment and other facilities. It was reiterated
This was also the period of the ’Emergency* and the peak of
that the PHCs base would be strengthened along with sub(6)
the population control programme. Family planning which started
with an insignificant outlay in the 1st Plan, was now taking away
50% of the outlay of the health programmes.
Inspite ofthe realisation on the part of the planners and the
policy makers that most of the investment being made in the
health sector was going to the urban areas, human power,
medical facilities, water supply and sanitation facilities, etc.
continued to grow in the urban areas, where only 30% of the
population was residing. Even within the urban areas a
disproportionately large chunk was being appropriated by the
privileged classes, as is evident from the social consumption
patterns.
Ata declaration of 'Health for All by 2000 AD' and the ICSSRICMR report. The Plan conceded that "there is a serious
dissatisfaction with the existing model of medical and health
services with its emphasis on hospitals, specialisation and super
specialisation and highly trained doctors which are availed of
mostly by the well-to-do classes. It is also realised that it is this
model which is depriving the rural areas and the poor people of
the benefits of good health and medical services" (9).
The Plan emphasised the development of a community
based health system. The strategies advocated were:
a.
provision of health services to the rural areas on a priority
basis.
the training of a large cadre of first level health workers
selected from the community and supervised by the MPWs
and medical officers of the PHCs.
no further linear expansion of curative facilities in urban
areas; this would be permitted only in exceptional cases
dictated by real felt need or priority.
In the Vth Plan, water supply and sanitation got a greater b.
emphasis. It was one of the important objectives of the MNP to
provide drinking water to all villages suffering from chronic
scarcity of water. The outlay for water supply during this plan c.
period was Rs. 10,220 million, i.e. nearly as much as health and
family planning taken together(6). The provision of safe water.
supply and basic sanitation. are either absent, or grossly
The Plan emphasised that horizontal and vertical linkages
inadequate for the vast majority of the population of both, the
urban and rural areas of India. The major diseases which affect had to be established among all inter-related programmes like
the Indian population, such as diahorrea, amoebic dysentery, water supply, environment, sanitation, hygiene, nutrition,
cholera, typhoid and jaundice, are water borne. These diseases education, family planning and Maternal Child Health (MCH).
are also carried and spread due to the lack of basic sanitation. To The objective of attaining a net reproduction rate of 1 by 1995 was
alleviate this problem, the National Water Supply and Sanitation reiterated.
Committee, (Simon Committee) was formed in 1960, to review the
This Plan and the Vllth Plan too, appear to be radical
progress made under the national programmes in the first two
Plans. The report came out with the finding that the states departures from their predecessors. But the story is the same themselves lacked data and information regardingthe magnitude progressive thinking and inadequate action. Whatever new
and nature of the problem. It stressed the need for immediate schemes are introduced, the core of the existing framework and
survey and investigation to obtain correct data on the existing ideology remain untouched. The underprivileged get worse and
conditions in both the. urban and rural areas on which future the privileged get a better deal. The status quo of the political
planning and implementation could be based. It strongly economy is maintained. In fact, the VIth and Vllth Plans have
recommended that by the end ofthe Hird Plan, minimum drinking provided a fillip for strengthening the existing status quo, with
water must be provided to all villages in the country(8). This did a focus on privatisation.
not happen even till the end of the Vllth Five Year Plan.
The National Health Policy (1983) was announced during
The VIth Plan was, to a great extent, influenced by the Alma the VIth Plan period. It was in no way an original document. It
accepted inprinciple the ICSSR-ICMR report's recommendations,
as is evidenced from the paragraphs which are common to both
UNEQUAL DISTRIBUTION OF HEALTH RESOURCES
documents. But beyond stating the policy there was no effort to
change the health situation for the better.
The World Health Organization estimates that in many Third
World countries 70% of the population has no access to organized health
services or to supplies of essential medicines, dispensed by trained
healthworkers.
All the money spent on public health services i n 67 of the poorest
developing countries (excluding China) adds up to less than the rich countries
spend on tranquilizers alone.
To provide the entire rural population of India with clean water
by the year 2000 would cost an estimated 277 million Pound sterling a year
(excluding time consuming and costly technological and maintenance prob
A new dimension added in the Vllth Five Year Plan is to give
special priority to new medical technology, especially
biotechnology and electronics and "development of specialities
and super-specialities pursued with proper attention to regional
distribution"(10). The special attention that AIDS, cancer, and
coronary heart diseases are receiving and the current boom ofthe
diagnostic industry and corporate hospitals, is a clear indication
of where the health sector priorities are.
lems to be overcome). This sum is not far from the 250 million Pound sterling
calculated to have been invested in the Indian drug industry in 1977. Invest
ment in drug production brings immediate financial return: unlike clean water
for poor communities.
Source: Prescription for Change - Virginia Beardshaw, The Hague, 1983, as
carried in Health Action International's Guide to Rational Health Projects.
Page 74
Right through the Seven Five Year Plans, the planners and
policy makers have never discussed the private health sector
which provides two-thirds of the health care in the country.
Hence plans and policies are bound to be limited in their impact.
The influence of international agencies in policy making
and programme design, both within and outside the plans, is very
evident. Right since the 1st Plan, one can see the presence of
international aid agencies, who, with a small quantum of money,
international aid agencies, who, with a small quantum of money,
. - able to inject large doses of ideology. It cannot be a coincidence
that almost every health programme that the Indian Government
has taken up since the 1st Plan, has been anticipated by some
international donor agency.
In conclusion, it can be said that the neglect of the public
health sector is an issue larger than the government policy
making. The latter is the function of the overall political economy.
Under capitalism only a well developed welfare state can meet
the basic needs of its population. Given the backwardness of
India, the demand of public resources for the productive sectors
of the economy (which directly benefit capital acccumulation) is
more urgent from the business perspective than the social sectors;
hence the latter get only a residual attention of the state. The
solution for satisfying the health needs of the people therefore,
does not lie in the health policies and plans alone. Rather, it is a
question of structural changes in the political economy that can
facilitate implementation of progressive health policies.
NEW ARRIVALS
BOOKS
1.
2.
3.
Ballentine Rudolph, ‘Diet and Nutrition: A Holistic Approach', Honesdale,
Himalayan International Institute, 1978,pp.634
Desai N., Patel V, ‘Critical Review of Researches in Women's Studies', 197588.Bombay.SNDT University, 1988, pp.76
Dighe S.D., ’Shetkaryansathi Karjamaficha Kayada', Bombay, Manovikas
7.
Prakashan, 1989, pp. 102
G.H.L.F., leprosy in India: A Statistical Compendium.', Wardha, Gandhi Memo
rial Leprosy Foundation, 1989, pp. 153
Government of India, ‘An Indian Personality for Television', Vol.l & II, New Delhi,
Ministry of Information And Broadcasting, 1985. pp. 220
Krishnaraj Maitreyi, 'Gender and Household Domain: Social and Cultural Dimen
sions,', New Delhi, sage Publications, 1989, pp. 264
Patil P.S., 'Mahatma Jyotirao Phule: Charitra, Bombay, Manovikas Prakashan,
8.
1989, pp. 184
Raffel M.W., ‘Comparative Health Systems: A Descriptive Health Analysis of
9.
Fourteen National Health Systems',Pennsylvania; 1984, pp. 600
Soman A, ’Timirbhed: Maharashtratil Andhashraddha Nirmulan Karyacha
4.
5.
6.
Magova', Bombay, Manovikas Prakashan, 1989, pp. 113
10. Worldwatch Institute, 'State of the World, 1990',New York, W.W.Norton & Co.,
1990, pp. 253
REPRINTS
1. Bharti Indu, ‘Decay of Gram Panchayats in Bihar’, EPW, 1989, pp. 18-19
1.Banerjee,D., Health and Family Planning Services in India, Lok Prakashan, 1985. pp
2. Economic Journal, ‘Distribution of Tax Burden', 1976
3. Government of India, 'Product oriented programmes in the department of
24-25
Biotechnology’, 1989, pp. 58
2
.Report of the Health Survey and Planning Committee, (Mudaliar Committee Report,
4. Jain Anrudh, importance of female primary education for fertility reduction in
Vol.1), Manager Of Publications, GOI1961. pp 173
India', 1986, pp. 1602-1608
3
.Batljwala, Srilatha,The Historical Development of Health Services in India, FRCH, 5. Nag Mani, ‘Alternative routes of fertility and mortality decline: a study of Kerala
and Punjab', 1989, pp. 143-147
1978. pg. 17
6. Riddel, RogerC., ‘Zimbabwe:the economyfouryears afterindependence’, 1984,
4
.Gill, Sonya, Health Status of the Indian People, FRCH, 1987. pg. 11
pp. 463-476
5
.Planning Commission, Third Five Year Plan, 1961-66, GOI, 1961.
7. Talwar, G.P., 'Recent Developments in immunocontraception', 1987, pp. 1075-
References:
6
.Planning Commission, Draft Fifth Five Year Plan, 1974-79, GOI, 1974.
^Directorate General of Health Services, Pocketbook of Health Statistics,
CBHI,
601,1981, pg.115
8
.Simon Committee Report, 1960, as quoted in Gill, Sonya, op. ciL pg 185.
9
.Planning Commission, Sixth Five Year Plan, 1980-85, GOI, 1981. pg. 367
10
.Planning Commission, Seventh Five Year Plan, 1985-90, GOI, 1985. pg.273
(Continued from page 2)
including cost of materials such as drugs, laboratory tests and
injections and do not vary with the skill of the physicians or the
prestige ofthe hospital. As every Japanese is covered compulsorily,
the majority of practitioners are registered (by the prefectural
government) as insurance doctors and dentists. Privately
purchased care and private insurance are an insignificant feature
of health care in Japan.
In recent times the government has attempted to influence
clinical practice (primarily as a cost containment measure) by
revising the fee schedule in the direction of giving preference for
out-patient care and home care rather than costly hospitalization.
It has also attempted to develop a referral system and curb the
extensive use of laboratory tests. Since the delivery system is
private and characterized by independent physician
entrepreneurs, the competition between clinics and hospitals to
attract patients is intense, as clinic based physicians do not have
hospital admitting privileges. Without any organized referral
system, clinics and hospitals often offersimilar services, duplicate
equipment and maintain excess capacity. While the Ministry of
Health and Welfare is encouraging the cooperative use of
technology such as CT scans, this is totally voluntary and no
certificate-of-need procedure to regulate technology purchases
has been developed. The Japanese delivery system is today on the
threshold of developing new modes of provision based on home
8.
9.
1078
TISS, ‘Workshopon curriculum development inhealthcare management’, 1989
WHO, 'Research in human reproduction, Biennial report (1986-87)', 1988, pp.
177-197
10. WHO,'Health for all by 2000', 1990
care, domiciliary care, visiting nurse services and chronic illness
treatment in order to adequately meet the demand for geriatric
care and to keep its costs under control.
The Japanese system of social insurance has become a
model for the provision of universal health care coverage for
many of the middle income capitalist societies of East Asia, most
notably South Korea. The latter is in the process of establishing
separate insurance programs for different sections of population,
employees in large corporations,public sector employees, self
employed rural communities,etc. in order to achieve compulsory
coverage for every citizen. A pluralistic insurance system based
on separate funds is most strongly supported by the affluent
sections whose employment in large enterprises entitles them to
higher employer contributions and higher level ofbenefits. Such
a system is also favoured by the medical profession as it allows
them to retain a strong hold on the private delivery system.
However, for populous, agriculture based societies such as
India, Indonesia, etc., where the majority of the population is
self-employed or in the unorganized sector and large numbers are
below the poverty line, the question is whether an insurance
model would provide an effective and equitable access to health
care. Perhaps a tax based (either central or local government
revenue) national healthservice, along with proper planning and
distribution of resources and services, would be a surer road to
universal coverage for these societies.
Edited by Nagmani Rao, with secretarial assistance from Sunita Kesavan and produced by the Foundation for Research in Community Health, 84-A.
R.G. Thadani Marg, Worli. Bombay 400 018. Registered under the Bombay Public Trust Act. Printed at Printext Offset, Tilak Road, Pune.
July - Aug 1991
SPECIAL ISSUE ON MEDICAL MALPRACTICE
Vol V No. 4.
MISUSE OF MEDICINE
N.H.Antia
There is no field of human endeavour where misuse of
privileges, authority and funds can be entirely eliminated.
Hence society devises methods for limiting such misuse in the
form of rules, regulations and legal measures even though
enlightened self monitoring and self restraints are ideal. What
differentiates professions from trades is that the former not only
possess special knowledge and skills but also evolve a code of
conduct and ethics to monitor their own members. This is in
order to ensure not only the level of technical competence but
also the obligation to the society which has entrusted them with
responsibility and has placed its trust in them. The medical
profession has enjoyed a uniquely privileged position because of
their technical skill as well as the intensely personal relationship
which develops between a doctor and his patient, whereby the
latter puts his/her entire faith in the doctor who not only cures
but also cares and consoles the patient as well as the family. The
epithet ‘noble’ is symbolic of the love and respect that this
profession has enjoyed over the ages, which is somewhat akin to
that of the priest.
It is unfortunate that there is now a rapid deterioration of
this happy relationship between the profession and society at
large and a degree of suspicion and mistrust pervades this
relationship today. Before we blame the profession as a whole,
let us not forget that there still exists the same relationship
between the family physician and his clientele; only that this
breed is rapidly diminishing as a result of the new, impersonal
and materialistic trends which affect not only this profession but
also the rest of society of which they are an integral part,
The wholesale adoption of the western model by our policy
and decision makers after independence, based on an alien
culture and its science and technology has shaken the entire
social and economic fabric of our society and distorted age old
values associated with our civilization and its culture. It has
polarized our society with a small, wealthy, elite group
marginalising the vast majority whose life is being increasingly
degraded, as clearly observed by the burgeoning urban slums.
While this western science and technology has given the
knowledge and technology to provide for. the basic needs of
everyone on this planet, yet, because of its very materialistic
nature and lack of a human and moral basis, it is used chiefly as
a tool for aggrandizement and exploitation. Such misuse is not
Dr. N.H.Antia is an eminent plastic surgeon and honorary
Director of both the Foundation for Medical Research and
the Foundation for Research in Community Health.
only restricted to the western nations where it has originated,
but is also rampant in the poor countries, in the hands of those
who have been able to obtain access to this technology. The gross
misuse ofsuch knowledge and technology in the field of medicine
is demonstrated by the fact that the most simple, cheap and
efficient aspects of the cure and control ofcommunicable diseases
(which still remain the major health problem for the vast
majority of our people, especially the poor) are neglected and
undue emphasis is paid to the most expensive, complex and cost
ineffective diseases like cancer, heart-stroke which affect the
small, affluent sections of our society .This clearly demonstrates
that the dominant consideration in the import and use of such
science and technology is dictated by the requirements of the
rich and that of the medical profession rather than the needs of
the vast majority. In the process, medicine is being converted
from a profession to a lucrative trade in human suffering; an area
where consumer resistance is at its lowest.
The gross overproduction ofdoctors, drags and sophisticated
medical instruments and that too of the wrong type has ensured
that malpractice has been built into our present health system.
Unfortunately, over the years, this has become an accepted form
of medical practice by both the medical profession as well as the
public. This is further compounded by the absence of any
regulatory measures like public information and education on
health and suing for malpractice, as exist in the USA and many
other western nations.
In the case of the urban rich this is demonstrated by the
unnecessary, excessive and even dangerous investigations and
medications, inclusive of surgery, and the pressures to impose
the latest and most expensive glamour technology imported
from the West regardless Ofits appropriateness. Also, the patient
or the public is seldom informed of the attendant dangers which
are reported in Western journals, leave aside the far greater
shortcomings in our own limited experience. Due to availability
of easy money, the rich are unwittingly at the greatest peril of
iatrogenic (doctor made) diseases, as is demonstrated by the
mushrooming ‘five star’ urban hospitals with the latest
specialities, the latest scanners and the latest drugs and
operations. Intensive care units are indiscriminately used, even
for terminal care patients; who now have to end their life in stark
aseptic conditions monitored by the latest gadgets, rather than
in an ordinary hospital bed or preferably in the home, surrounded
in their last moments by loving and caring relatives and friends.
Each one of these facilities have their specific limited use, but
when unintelligently or deliberately pushed to their limits by
FOR PRIVATE CIRCULATION ONLY
those trained as technical robots or for satisfying their monetary
greed, these “wonders” of modern science prove to be counter
productive, if not actually harmful.
Illness:
A Lucrative Business
The growing middle class has now been caught in the cleft
stick between providing the latest medical care like renal dialysis,
kidney transplant and coronary bypass surgery for their loved
ones and being pauperized in the bargain. Many search for a
good, old fashioned family doctor, who is now in short supply, or
turn to other cheaper and more acceptable alternative systems
such as Ayurveda and Homeopathy. Without insurance and
adequate financial resources, the thought of illness has become
a source of anxiety and neurosis for this rapidly enlarging
section of our society.
common publicopinion is that patients trust their
physicians technically and personally but not
economically,^.. The harshest judgment comes from
some medical economists who bluntly state that the
ethical ideals of the Hippocratic Oath are out-moded
and mythical...... The doctor-patient relationship is a
commercial transaction that should be regulated by the
rules of the marketplace,..... normal business activities
such as aggressive advertising, paying in advance, and
undertakingprofit-makingenterprisesthatare unrelated
to direct provision of physicians services are all clearly
legal and good business practice. But, are they ethical?
Are they primarily in the spirit of what is best for the
patient?"
For the vast majority of the poor who live in villages and
urban slums, this poses an entirely different problem. While the
middle class are their role model they can hardly conceive of
using the private hospital with its specialists or even the nursing
home for their medical needs. And yet they too have been hooked
by the medical profession, albeit by those in the lowest rungs, to
the universal injection as a panacea for all ills. The ‘blunderbuss’
therapy of Rs. 20 or more for a so-called ‘cocktail’ injection
consisting of an antibiotic, corticosteroid, vitamin B, antihistaminic and analgesic is now familiar even to most villagers,
leave aside the older ‘heat’ producing injection of calcium
gluconate. The public hospital, whose mal-functioning was so
starkly revealed by Justice Lentin, remains their last resort.
Fear of these institutions now drives them to small, unhygienic
private nursing homes, often after a preliminary visit to the
moneylender. The government Primary Health Centre, which
was designed to serve the preventive, promotive and basic
curative health needs of the 70% of our population that lives in
rural India, has ceased to undertake any of these functions as a
result of its almost total devotion to Family Planning and its
accessories like Immunization and MCH. Shrouded in secrecy,
the PHC is unaccountable to the people for whom it is meant.
Excerpted from the presidential address by FrankC. Spencer, (M.D., FACS,
New York), to the American College of Surgeons, as carried in the ACS
Bulletin, November, 1990.
for Western science, the continuation of the use of this model,
that too in its worst aspects, despite ample experience to the
contrary, can only be ascribed to the selfish and exploitative
nature of those who continue to promote and operate this form
of development.
It is regrettable that this type of medical practice now poses
a threat to the health of our people. The public health colleges
produce doctors who are mostly trained for, and work in, the
private sector. It is inconceivable that any sane politician honestly
believes that private medical colleges, which levy a capitation
fee of several lakhs in declared and undeclared monies, are for
the benefit of the rural masses. The mad rush for securing the
highest marks for admission to government medical colleges, or
paying high capitation fees by the rich, for then* children who
cannot get into the former colleges, does not demonstrate love for
the health ofthe people but a clear indication ofthe extent ofsafe
monetary returns that this profession ensures them. The type of
medical education and even worse, the values inculcated in them
are directly opposed to the health needs ofour people. Permission
to produce 60,000 drugs and formulations (costing Rs.3,600
crores), whenthe WHO lists only 258, is surely not for the benefit
of the people but that of the pharmaceutical industry and those
who give them licenses on the basis of kickbacks. The
multinationals who control the major drug companies and
increasingly, the medical instrumentation industry, do not come
to India for the health of our people.
What is it that has lead to this lack of accountability of the
public sector and the exploitative nature of the private one? The
answer lies clearly in the inappropriate Western model that has
been chosen for the development of this country. While we may
forgive Nehru for being enchanted with the post-war euphoria
OheshipporraticOath
-.3 will prescribe regimen for the good of my patients according to m
abdlit and m jubgmen arid nber bo harm to anpont. To please no on toil
3 presotir a beably brug nor gie abbur which may tause his beath---____ 3( 3 tap this oath tatfjtuUr, may 3 orlop mp lite and practice n art,
respected by all men anb (n all times; but i $ sette from it of blolate tt,
The medical profession and the associated health industry
have the unique opportunity to trade in an area where consumer
resistance is at its lowest, as a result of fear and ignorance.
Public ignorance and absence of consumer resistance is
demonstrated by the fact that malpractice insurance premium
of doctors in India is Rs. 100 per annum, while that in the UK
it is over 1200 Pounds sterling, and for certain specialities in the
USA over $ 60,000 per annum. This is not to advocate legal action
as the optimal way for improving the health services, but under
the prevailing conditions of increasing material values and
human greed, public awareness and threat of legal action remain
map the ttbott temp lot,
Excerpt, as contained in “Medical Negligence”, S.Raghavan, The Free
Press Journal, Apr. 13,1980.
2
IRRATIONAL AND UNETHICAL MEDICAL PRACTICES
Mohan Deshpande
in recent years the press has been abundantly covering
hitherto unreported and under reported cases of malpractice in
the medical field. Undoubtedly, these and many more unreported
cases will have to be fought in the legal courts, which in turn, will
hopefully have a deterrent effect on the medical profession. This
will also make people at large aware of their health rights to
some extent.
Much goes under these press reports of overt malpractice
and negligence. This consists of a bulk of irrational medical
practices which are invisible and seldom brought to light owing
largely to ignorance of people and a smart combination of tactics
and the skills the profession possesses collectively. Moreover, to
locate and to identify irrational practices needs quite a good
knowledge of medicine and its practice. Since the effects ofthese
irrationalities are neither immediate nor severe enough on the
patients, they are rarely complained about. Even if a patient
suspects an irrationality, he/she usually refrains from asking for
clarification. He/she is simply a stupefied victim of so-called
‘faith’.
Usually medical doctors, even those rational in their own
practice, do not come forward to report such irrationalities even
though in private they would express their dissatisfaction about
the increasing commercialization in their profession. Some even
try to protect fellow professionals under the pretext ofprotecting
the medical fraternity. There is also a false notion prevailing
amongst doctors that it is ‘unethical’ to divulge information on
such matters to the ‘lay' public. There are attempts even to
justify the wide-scale unscientific and irrational practices on
grounds such as, it is beingunfair to isolate the medical profession
to blame leaving untouched the general social atmosphere of
rampant corruption at every level. Some tend to blame the
professional (or business ?) competition or the dog-eat-dog
health bazaar (too many doctors ?) as if these are entirely
extraneous to their profession and thereby justify the so-called
‘survival instinct’.
Irrational practices can be grouped in the following
categories:
-
life saving purposes and intractable diseases) for
simpler ailments, for quick relief. The doctor also
provides a (false) sense of well-being to the patients.
This attracts more patients to him.
3) Irrational use of antibiotics notwithstanding their
longterm severe effects like tolerance cross-resistance
etc.
4) Using banned or bannable drugs: the profession
cannot absolve itself from its responsibility to update
knowledge of recent research and government/legal
decisions.
5) Usingsub-standard drugs for dispensing: These drugs
are usually available in local markets inbulk quantities
produced by various ill-known companies.
6) Prescribing tonics, milk powders, protein powders.
- 7) Injecting B complex for a variety of ailments where
injectable vitamins have no role to play.
8) Using intravenous (1. V.) fluids when not indicated.
Using l.V. calcium gluconate for various non-specific
indications.
9) Use ofanabolic steroids (even injectables) for growth/
gaining height etc.
10) Using drugs (especially from other ‘pathies) without
proper knowledge of their pharmacology. This applies
not only to heteropathic practice but also to allopaths
using allopathic drugs which are banned or bannable.
The newer drugs and their information reach doctors
sometimes through unethical and un-scientific
literature from the drug industry with reports of
contrived trials. There are also wide ranging
empiricisms (e.g. ‘no side effects’) in the use of brand
prescriptions from the Ayurvedic industry.
11) Unnecessary investigations, both invasive and noninvasive.This is not a ‘defensive’ practice. The sole aim
is profit.
12) Unnecessary admissions/surgery.
13) Refusing to treat seriously ill/dying/leprosy/HIV
positive patients/accident victims.
While diagnosing ailments
Usually the following diagnoses are thrown to patients:Weakness, low blood pressure, backache, white discharge
due to weakness, deficiencies, psychosomatic illness etc.
Creating cardiac neurosis: patient is not a heart patient in
reality but is made to believe she/he is.
A) While actually treating/investigating patients,
B) While diagnosing the ailment,
C) Concerning the relationship with the drug industry,
D) Concerning other doctors,
E) Miscellaneous.
Concerning drug industry
While actually treating/investigating patients
1)
1)
2)
7njeclioiV practice: irrational or over use of this
mode of drug administration, for profits.
‘Steroid’ practice: using steroids (reserved for
2)
Mohan Deshpande is a medical practitioner who is also a
researcher with FRCH, Bombay. The above is a slightly
modified version of the paper presented in the
workshop. ‘Medical Malpractice; what it is and how to fight it"
organised by Medico Friend Circle (Bombay Group) in 1991.
3)
Acceptingsamples and gifts from drug industry causing
both overt and unconscious obligation to prescribe.
Accepting and not verifying information coming from
drug industry. One such example is the use of high
potency combination BlB6B12fora variety ofillnesses
ranging from weakness to serious nerve-brain
disorders.
Engaging oneself in false, fabricated research for drug
industry.
Continued on page 8
3
EDUCATIONAL INTERVENTION IN MEDICAL MALPRACTICE
Amar Jesani.
The term Medical Malpractice (MM) encompasses a very
broad (perhaps entire) area of inappropriate medical practices.
The Bombay Group of Medico Friend Circle tentatively proposed
a working definition (1990) of MM for its workshop on this topic
as, ‘a variation from the normally acceptable, scientific and
average standard of medical practice at a given point of time’.
There may be many shortcomings in this definition (readers are
invited to suggest their alternatives) but, for the time being it
will serve our purpose, because the subject of this article is to
discuss the strengths and weaknesses ofeducational intervention
intended to bring about appropriate changes in the doctors
medical practice so that it becomes acceptable, rational, scientific
of minimum average standard, ethical and free from possible
negligence.
it is obvious that the prescribing doctors have grossly inadequate
scientific information on what they prescribe. Lastly, the problem
of doctors’ incompetency is a universal one. Even in countries
where the profession is better organized, internally regulated,
and has strong emphasis on continuous education, a significantly
high proportion of doctors are found to be incompetent. For
instance, in the UK, 10% to 15% of independently practicing
doctors are estimated to be incompetent (Smith, 1989). A
Canadian study in 1988, found that in their sample, 15% of
family practitioners and 2% ofspecialists, had serious deficiencies
in medical records or care (Smith, 1989). In our country, at least
3/4th, of all practising doctors are independent practitioners
having no regular continuous medical education. Only a fraction
ofthemsubscribe to standard scientificjournals. The prevalence
of incompetency among them is,- of course, anybody’s guess.
Why educational intervention?
We believe that there is a strong case for advocating
continuous, scientific education of all practicing doctors. How
can one object, in principle, that all doctors must be continuously
educated so that the quality of medical care provided by them
can be of optimum standard? In fact this is a truism universally
accepted as an essential ingredient of medical ethics.
Unfortunately in our country this component of medical ethics
is violated by the profession as it has hardly any effective
mechanism to provide systematic continuous education. As a
result doctors’ reading habits are found to be abysmally
inadequate to do justice to their role in medical care.
There is another compelling reason for advocating
educational intervention. Although there is no systematic study
available on the medical ‘competence’ of Indian doctors, certain
indirect indications show that 'incompetency' among Indian
doctors is shockingly high. For instance, in two studies of
prescription practices ofprivate general practitioners in Bombay
city by Uplekar (1989a, 1989b), for the FRCH, it was found that
a majority of them had grossly inadequate knowledge of ding
treatment for two highly prevalent diseases; leprosy and
tuberculosis.
The structure and practices of the medical profession raise
further doubts. In 1986 we had 7,63,437 qualified doctors of all
systems of medicine. Of them about 42% were allopathic and
58% were non-allopathic. While in the developed countries,
scientific criteria to assess competency of allopathic doctors are
well developed, we have nothing to go by tojudge the competency
of non-allopathic doctors. In fact, we are almost sure that there
will be divergent views about the methodology used to assess the
competency of non-allopathic doctors. Secondly, cross system
therapeutic practices are highly prevalent. It is generally accepted
that a majority of non-allopathic doctors regularly use al lopathic
drugs and devices. With the ayurvedic drug industry coming of
age; the use of ayurvedic drugs by allopathic doctors has also
substantially increased. In this use of cross system therapeutics,
Amar Jesani is a researcher at FRCH, Bombay. He is also
a non-practising medico, actively involved in the Medico
Friend Circle.
4
Inshort, inspite of non-availability of hard data, the doctor’s
ignorance/lack of information on the scientific therapeutics need
no further elaboration. The socially conscious doctors and others
have therefore strongly argued that this ignorance or gap in
information is greatly responsible for many irrational practices
or malpractices by doctors. Due to lack of information, doctors
also fail to critically evaluate information provided by
commercially vested interests like pharmaceutical companies.
As a result, many have suggested that malpractices be classified
under two broad categories; intentional and unintentional. The
former is deliberate MM indulged in with a motive, such as
augmenting one’s income. The latter is supposedly due to
ignorance. A typical argument for the latter is, why should a
private doctor prescribe wrong medicine for tuberculosis when
it is not going to help him to hold the case. That is why
educational intervention is considered useful, particularly to
remedy unintentional MM.
Another strong argument advanced for educational
intervention is that individuals in the profession have inflated
egos and are very sensitive to criticism. Positive educational
intervention would help some sensitive and ethical individuals
to see reason and thus to change their behaviour. Also, since
such intervention would not generate extreme negative reaction,
it would help win over some to the cause of rational practice.
After this is accomplished, it is believed that tactics can be used
against those who refuse to ‘shed their ignorance’.
Undisputedly, these arguments are highly logical, clear,
and straightforward. However, these arguments are clinically
too precise to explain the actual reality. It is indeed tempting to
put high prevalence of MM and lack of continuous education into
a one-to-one, direct relationship. But this relationship is highly
complex with many other variables more crucial in determining
the prevalence of MM. The need for continuous education is not
only because the MMs are highly prevalent but that even if it
fails to make a significant dent in the prevalence of MMs it is still
badly needed for many other reasons. The point being emphasized
here is that though educational intervention is necessary, its
mere presence is not a sufficient condition to bring about a
lasting change in the behaviour of doctors.
(c) some may be very costly such as providing one-to-one
education by a visiting physician, and so on.
Limits of educational intervention.
In our country some voluntary efforts have been made to
change doctors’ behaviour through education. Most of such
efforts are in the field of drugs and pharmaceuticals. “Dear
Doctor” letters, along with educational material on the rational
use ofdrugs, information about hazardous, banned and bannable
drugs, appeals against the use of drugs such as high dose
estrogen-progesterone (EP), fixed dose combinations and so on
have been circulated amongst doctors. In addition, certain
categories of drugs (anti-diarrhoeals, tonics) have been studied
for their rationality and reports have been compiled and
circulated amongst doctors. These are highly commendable
voluntary efforts and we have been participating in them in
various ways.
On scanning through some ofthe study reports we find that
the method of providing doctors with mailed, printed material is
the least effective method whereas the one-to-one education of
the physician by a visiting physician is the most effective
method. Perhaps this is the chiefreason why the pharmaceutical
industry uses an army of medical representatives who can
change the doctor’s prescription behaviour through one-to-one
education. In any case, it will be the height of irrationality to
create another army ofvisiting physicians for providing rational
drug education.
Those who propagate the idea of rational prescribing most
often depend on the method of providing doctors with print
material. Studies of this method however, show disappointing
results. At the same time it is found that the provision of printed
material could create a necessary condition for trying other
methods out. Further, studies using a patient care protocol to
guide doctors at the time of examining and treating patients,
show that the protocol makes a great difference in the behaviour
of those doctors who participate in formulating such a protocol.
That is, a participatory exercise in creating educational material
is more important than in the use of the same educational
material for other doctors.
However, to what extent do they make a dent in the MMs?
Unfortunately, none of these efforts were adopted for
experimental research by institutes. Most of these reports were
by activists, done with the full conviction that such things ought
to be done, irrespective of the extent of the immediate impact
that they would make. Further, some important attempts were
part of a wider campaign to get a particular drug banned, as the
campaign against the high dose EP drugs. It was not a simple
educational campaign but a definitive campaign to get the drugs
banned on the ground that these are irrational and hazardous.
Thus, there was no scope to wait for the results of the educational
intervention. The ultimate ban on EP drugs was, in fact, brought
about despite the lack of support from the profession!
What influences prescribing behaviour?
When we talk about alternative rational drug information,
it is necessary for us to understand the role of such information,
on the prescribing behaviour of doctors. A rational enquiry into
the prescribing behaviour ofdoctors would reveal a very dominant
phenomenon called ‘the non-pharmacological basis of
therapeutics’, (Avorn et al, 1982). It is this phenomenon which
makes educational intervention, which is chiefly centred around
rational pharmacological information, less effective. Avorn et al
(1982) argue that “irrational ding choices are made frequently,
despite the availability of ample empirical evidence counseling
otherwise”. In a study of doctors they found that “although a vast
majority of practitioners perceived themselves as paying little
attention to ding advertisements and ‘detail men’ (commonly
used t erm for medical representatives) as compared with papers
in the scientific literature, their beliefs about the effectiveness
of index dings revealed quite the opposite pattern ofinfluence in
large segments of the sample”.
Most systematic research on improving prescription
practices through educational intervention is done in the
developed countries, particularly in the USA, as the vagaries of
the market in health care has made that country cost-conscious.
But all experimental researches carried out there, on this
subject, are also not scientifically rigorous. In a review of such
services, Soumerai, McLaughlin and Avorn (1989) found that
almost one third of them were inadequately controlled studies.
They found that 85% of the inadequately controlled studies
reported positive findings as compared to 55%, of well controlled
studies. They also found that in several studies, the control
groups showed positive improvement due to the effects of other
factors. (Note: in the control groups there was no educational
intervention).
There are seven categories of educational approaches used
in various studies reviewed by them. They are:
1) Dissemination of printed educational material,
2) Reports ofpatient-specific lists ofprescribed medicines,
3) Group education including conferences, lectures,
seminars, tutorials,
4) Feed back of physician specific prescribing patterns,
5) Reminders at the time of prescribing,
6) One-to-one education,
7) On going clinical pharmacy services.
Thus, in actuality, what a doctor normally does in treating
patients is customary behaviour that is routinised, habitual and
automatic. Such customary behaviour is formed with the influence
of history, locality, peer groups and above all, environment and
the system within which medicine is practised.
When sufficient weightage is given to the factors which
actually condition prescribing behaviour of doctors, we find that
the role of simple information dissemination or education is
grossly limited. Henhouse and Jacoby (1988), in an article
reviewing the subject. argue that the 'customary behaviour* of
doctors is likely to change only in the presence of a motivating
trigger. Such information has a useful role only in conditions
which are introduced to change the environment in which
medicine is practised.
Going through the above list we realize that:
(a) some of them are clearly suitable in the hospital set up and
very difficult to implement in the case of independent
private practitioners,
(b) some are very cumbersome, forinstance, providing reminder
at the time of prescribing may need a highly computerized
set-up,
Continued on page 8
5
PRIVATE HEALTH SECTOR
Regulation and Control
Ravi Duggal
Prevailing Situation.
Auditing of prescriptions of the doctors in relation to the
diagnosis.
v
Determining a fixed tariff of charges that patients pay to
doctors.
vi Providing continuing medical education to all those who
practice medicine. For instance, a 'summer' refresher
course every three to five years should be compulsory for all
practitioners and their license renewal should be dependent
on this.
vii Regulation ofgeographical distribution ofsettingup practice
to correct the urban-rural disparities. (We feel that as of
present there is adequate medical humanpower in the
country and it only needs redistribution.)
viii Annual return of patients treated; some minimum data to
be maintained and filed with an appropriate authority.
iv
The private healthsector consisting of general practitioners,
nursing homes and hospitals, employs two thirds ofthe medical
manpower and is responsible for two thirds of the total
expenditure on health in this country. Despite this there is
hardly any regulation of the practice in this sector of health.
This is indeed surprising, because such activity cannot be
carried out without registration. The medical professional has to
be registered with the Medical Council, which is a statutory body
that last set the standards of medical practice—‘discipline’ the
professionals, monitor their activities and check any
malpractices. The doctors who decide to set up their own clinics
as well as hospitals, nursing homes, polyclinics etc. have to
register with the respective local body.
b) . Nursing homes and hospitals:
Similar to the practitioner, regulations need to made for
setting-up and running of hospitals and nursing homes. Minimum
quality standard, nurse:doctor ratio, patientmurse ratio, proper
location ofpremises, geographical distribution, fixed reasonable
tariff charges, proper medical records, maintenance, filing of
minimum data returns, properly qualified and adequately trained
personnel for jobs assigned, prescription auditing, medical
auditing etc.
The problem with the above is that the controlling bodies
are virtually non-functional. The reason for this is not only lack
of interest but also weak provisions in the various acts. They are
also heavily influenced by the private health sector.
Another agent in the private health sector which needs to
be regulated further is the pharmaceutical industry. As a chemical
industry, this agent is regulated to some extent but as a
participant in the health sector, it operates virtually unregulated.
c) . Pharmaceutical industry:
The pharmaceutical industry must be allowed to manu
facture only rational drugs in required amounts with clear
priorities in favour of essential drugs. All irrational and
non-essential and dangerous drugs must be banned.
ii Branding of drugs must be prohibited.
iii There is every reason for a progressive nationalization of
the pharmaceutical industry.
iv The regulatory body for the pharmaceutical industry must
be the Health Ministry and not the Ministry of Chemicals.
v The practice of canvassing drugs through pharmaceutical
(medical) representatives should be banned.
vi A National Formulary should be evolved with generic drug
names becoming the basis of prescription writing.
vii Continuing pharmacological education of doctors should
be through the Medical Council or other such statutory
body.
i
In view of the existing health situation and practices,
regulation of those who provide the nation’s health care is an
urgent neccessity. Regulation exists in other sectors, so why not
in health? This is especially needed as consumer resistance is at
its lowest in this field and therefore lends easily to malpractice.
How to regulate
a) . Medical practitioners:
Each medical practitioner is registered with the respective
state Medical Council. Presently, beyond this registration the
Medical Council does not concern itself with the practitioner,
unless some complaint is made and a prima-facie case is
established. The Medical Council and other related bodies, in
consultation with the health ministry, must regulate the following
areas of health practice: (This is only a selective list).
i
ii
hi
Monitoring that only registered practitioners practice
medicine.
Assuring that clinics have minimum standards of
quality by setting standards for the same. (This should
include X-ray, CT scan and pathology laboratories.)
Making maintenance of patient records compulsory and
accessible to patients.
d)
. General regulations:
i
To prevent unnecessary concentration in urban
especially metropolitan areas, state subsidies, soft
loans, must not be given to those wanting to set up
practice, or hospitals and nursing homes in these
areas. Such loans should be restricted to rural
areas and taluka towns.
A tax on private medical practice and private hospitals
and nursing homes must be levied. This tax should be the
highest in metropolitan areas and the lowest in rural areas.
Private hospitals should not be allowed to be operated as
ii
Ravi Duggal is a researcher at FRCH, Bombay. The above
formed a part of a larger note on the private health sector,
presented by FRCH to the Planning Commission in April,'90.
Continued on page 8
6
MEDICAL MALPRACTICE AND THE LAW *
The issue of medical malpractice is dealt with by the rules
governing medical negligence, which forms a sub-branch of the
law of negligence. These come under the Law of Torts which
offers civil redressal in the form of compensation. “A person is
said to be negligent when s/he acts without due care in regard to
the harmful consequences ofher/his action”. A physician surgeon
or other member ofthe medical profession, if he has not exercised
reasonable care in the treating of a patient, may be liable to a
negligence suit. While the degree of care to be exercised depends
on the facts of each case, it is generally presumed that the test
is the standard of the ordinary skilled person, exercising and
professing to have that special skill.
Hospital/nursing home liability
Private as well as public hospitals (including charitable
hospitals) are liable for the negligence of their employees. In a
landmark American case, (Darling vs Charleston Community
Hospital, 1966), the judges held:
“...The present day hospitals, as their manner of operation
plainly demonstrates,do far more than furnish facilities for
treatment. They regularly employ, on a salary basis, a large staff
of physicians, nurses and interns, as well as administrative and
manual workers....certainly the person who avails himselfofthe
hospital facilities expects that the hospitals will act on their own
responsibility”.
Duty of care
Pleadings
Once a doctor accepts a patient, the principle of exercising
reasonable care becomes applicable, whether the doctor accepts
fees or not, and whether the doctor is a private practitioner or
public servant, general practitioner or specialist. A person who
offers medical advice and treatment, impliedly undertakes that
he/she has the requisite skill and knowledge. Such a person owes
to the patient certain duties., ofwhich the following are important:
Duty of care in deciding whether to take in a case.
Duty of care in deciding what treatment to give and in
diagnosis.
c) Duty of care in administering the treatment.
d) Duty of care in answering a question put to him by a
patient when he knows that the patient intends to rely
on his answer.
A breach of any of these duties will support a suit by the patient.
a)
b)
Forms of medical negligence
Medical negligence may assume a variety of forms. These
include:
a) negligent diagnosis,
b) negligence in operation,
c) failure to listen to a patient's complaint,
d) negligent administration of a wrong drug,
e) negligent exposure of the patient to risk of infection,
0 negligence in advice about the risk of an operation or
negligent failure to warn the patient of such risks',
g) negligence in post-operative care,
h) inadequate supervision or inadequate staff in the
nursing home.
In any suit claiming compensation for negligence, the
plaintiff must plead and prove three things:
i)
ii
ii
The defendant owed a duty of care to the plaintiff.
(Exact situation must be mentioned).
) The defendant had committed a breach of that duty.
(How such breach was committed must be clearly
stated)
i) The breach of duty resulted in an injury. (The cause
effect relationship must be definitely brought out.)
As in the above, while the onus to prove guilt lies with the
patient, in some cases, due to a number of reasons ( such as
incomplete information given by a doctor etc.) it becomes diffcult
for the patient to provide sufficient proof. In certain of these
cases, when circumstances make it quite obvious that negligence,
in fact, has been the cause, the doctrine ofRes Ipsa. biquUa (the
thing speaks for itself) is applied. This doctrine has been
extensively used in "swab cases" where after an operation, an
instrument is left inside the patient’s body.
Damages
Damages are classified as special andgeneral. Special
damages include pain and suffering, loss of expectation of life,
loss of amenities and the injury itself. General damages refer to
pecuniary loss, such as loss of earnings, legal expenses, loss of
pension rights, loss of marriage prospects, and loss of
opportunities for gainful employment.
Conclusion
At present, litigation in case of medical malpractice is not
widely prevalent. But the trend is catching on, especially in
urban areas. While litigation in itself, may not serve to wipe out
malpractice, the threat of legal recourse can certainly create
conditions compelling accountability on the part of the medical
profession. Needless to say, the extent of utilization of legal
recourse would be pre-determined by its accessibility as well as
the extent to which demystified information reaches the masses.
*The article above has been compiled from the following:
-Mathew, P.D., Bakshi P.M., "Medical Negligence", Legal
education series, No. 21, Indian Social Institute, New Delhi,
1986.
--Desai, Mihir, "Medical Malpractice and Law", in the Radical
Journal of Health Vol.II, No. 4, March 1986.
[Editor]
7
NEW ARRIVALS
REPRINTS
BOOKS
1
.
Government of lndia,"Diamonds Fox Grants of Central Govt. 1988-89",
1
Kerala Shastra Sahitya Parishad (K.S.S.P.), .“Need for a peoples drug",
2
Anderson Roy M., “Modern Vaccines: Immunization and Herd Immunity",
3
Hall A.J., “Modern Vaccines: practice in developing countries”, Lancet,
4
Bannerji D., “Crisis in the medical profession in India”, EPW, 1989, pp.
5
Medico Friend Circle (MFC), "Effect of Bhopal gas leak in women's
6
ShivakumarM.S., "Voluntary agencies and planned development”, 1985,
7
Lancet, “Potential value of serology for diagnosis of extra-pulmonary
pp.8.
GOI, New Delhi, 1989, pp. 153.
2
All India Drug Action Network, “A Rational Drug Policy: Problems, Per
Lancet. 1990, pp. 641-645.
spective, Recommendations", VHAI, New Delhi, 1986, pp. 157.
3
Baker Selwyn J. (Dr.), “Design and Analysis of Iron Supplementation
4
Demaeyer E M, “Preventing and controlling Iron Deficiency Anemia
1990, pp. 774-777.
Trials", Nutrition Foundation, USA, 1984, pp. 34.
1091-2215.
through Primary Health Care, A Guide", WHO, Geneva, 1989, pp. 58.
5
Nofziger Margaret, “The Fertility Question", The Book Publishing Com
reproductive health”, pp. 6.
pany, Summertown, 1982, pp. 104.
6
Burton J.L., “Aids to Postgraduate Medicine", 1st edition, Churchill
pp. 31-32.
Livingstone, New York, 1988, pp. 263.
7
Nath Uma Ram, “Smoking Third World Alert", Oxford University Press,
8
Society for Participatory Research in Asia, “The Takeover", SPRA, Nev/
tuberculosis”, 1990, pp. 641 -644.
New Delhi, 1986, pp. 292.
8
9
Panchamukhi, "Economics of health and nutrition; A review of policy
oriented thinking....”, 1989, pp. 1-89.
Delhi, pp.32.
British Pharmacopoeia, "Vitamin A”, 1988, pp. 596-598.
Rubenson Brigitta, “What is AIDS? Manual for Health Workers", Christian
9
Medical Commission, Switzerland, 1989, pp.28.
10 KSSP, "Mortality, morbidity, and disability in Kerala; Results from a rural
health survey”, 1987, pp. 1-4,
10 Wilson Sir John, “Disability Prevention: The Global Challenge", Oxford
University Press, Oxford, 1983, pp. 107.
Continued from page 3
Continued from page 5
Concerning other doctors
Accepting / offering ‘cuts’ (percentages) for referring /
treating / investigating patients.
In conclusion one can say that MMs exist not simply
because there is a dearth ofeasily available rational and scientific
literature but often inspite of it.The fight against MMs therefore,
cannot be just an educational effort but must address to more
fundamental factors which decisively shape the environment in
which medicine is practised.
Miscellaneous
1) Giving false certificates,falsification of reports e.g.
pathology, post mortem etc.
2) Advertising
3) Not preparing case papers records, not making them
available to the patients.
4) Overcharging: There is no standard/prescribed price
for medical care nor are there stipulated rules and
regulations for monitoring. There are no grades given
to dispensaries/nursing homes.The price of health
care is guided by such factors as professional
competition, crowding ofdoctors in a locality, patient's
income and living standard, needs and greeds of
doctors etc.
References:
1
Avom Jerry, Chen Milton, Hartley Robert: "Scientific vs commercial sources of influence on
the prescribing behaviour of physicians’ in The American Journal of Medicine, Vo.73, July
1982, pp. 3 10 8.
2
Kenhouse David E., Jacoby Itzhak,. "When does information change practitioner's behaviour*
in InternationalJournal of TechnologyAssessment in Health Care. Vd.4,No.1,1988, pp. 27-33.
3
Medico Friend Circle (Bombay Group): "Medical Malpractice; what it is and how to fight it'.
4
Smith Richard, Profile of the GMC: Dealing with sickness andincompetence; successes and
5
Soumerai Stephen, McLaughlin Thomas, Avan Jerry, ‘Improving drug prescribing in private
Repat of a workshop in Medico Friend Circle Bulletin, May-June 1991.
failures.* in the British Medical Journal, 298,1695-8 (24 June, 1989).
care; a critical analysis of the experimental literature' in The Milbank Quarterly, Vd. 67, No.2.
1989, pp. 268-317.
6
Uplekar Mukund (1989 a), ‘Prescribing behaviour of private G.P's of Bombay in treatment of
7
Uplekar Mukund, (1989 b), ‘Private doctors and public health: the care of leprosy in Bombay*,
pulmonary tuberculosis', Bombay, FRCH, (unpublished).
There is a minuscule section of doctors who are guided by
ethics and rationale against the dominant market forces which
usually control the attitude of doctors. It is necessary today to
widen this circle of conscious,ethically motivated doctor's and
thus reverse the tide which threatens to wash away the noble
principles on which this profession is supposed to be based. •
The British Connection
About two-thirds of the world drug sa les are controlled
by big trans-national drug companies in West Germany
(Hoechst,Bayer),Switzerland (Hoffman, La Roche,CibaGeigy, Sandoz), and USA (Merck, Pfizer, etc), all with
subsidiaries in the U.K.
Source: Prescription for Change, Virginia Beardshaw, as carried in HAI’s
Guide to Rational Health Projects, pg.74
Bombay, FRCH, (unpublished).
Continued from page 6
iii
iv
v
trusts or societies which give them cover for tax relief. They
should be treated as corporate bodies;. Hospitals operating
■research centers’ must be audited and their tax reliefs
questioned.
A social audit of the health sector must be an ongoing
activity of a statutory body which should be created for this
purpose.
A tax on the international migration of doctors.
Embargo on private practice ofthose receivingstate financed
medical education by part training at civil/rural hospitals
or PHCs. This should be combined with a long term change
of relocating medical colleges at the district centers.
Edited by Nagmani Rao, with secretarial assistance from Sunita Kesavan and produced by the Foundation for Research in Community Health.
84-A. R.G. Thadani Marg. Worli, Bombay 400 018. Registered under the Bombay Public Trust Act. Printed at Printext Offset. Pune 30.
COMMUNITY HEALTH CELL
No: 367, 'Srinivasa Nilaya'
Jakkasandra, I Main, I Block,
Koramangala,
BANGALORE - 560 034.
Sept. - Oct. 1991
Vol V No. 5.
HEALTH FINANCING
ZAMBIA
IN
Shirish Kavadi
TABLE 1: HEALTH STATUS -ZAMBIA
This article is second in the series from the study: "Health Financing and Costs:
Comparative Perspectives" (No. 1 Japan).
In 1972 President Kenneth Kaunda declared that “by the
end of the decade, health care will be free to allpeople and health
institutions will be within easy reach of every Zambian”.Two
decades later Zambia has yet to attain the goal of universal and
quality health care. Inequity in the health care delivery system
persists. The reasons are two-fold:
Year
Crude
Crude
Child (1-4yrs)
Infant
Birth
Death
Death
Mortality
Expectancy
Rate.
Rate
Rate
per 1000
average for
live births
both sexes
(per 1000 population.)
Life
1970
49.6
20.1
25.2
125.6
44.6
1987
50.
13
15(1985)
80
53
Source: World Tables, Vol. 2,1983, UNESCO Statistical Digest 1987, World Health Statistics Annual
(1) the proclivity ofpolicy makers towards hospital care, modern
medical technology and urban medical services;
(2) structural constraints imposed by a dependent economy.
An important factor influencing the satisfaction of basic
needs in Zambia is the country’s high level of dependence on the
outside world. Fluctuations in the international market get
reflected insimilar vicissitudes in the Zambian economy, affecting
the government’s capacity to spend on public programmes and
services.
Health Status
The apparent improvement in certain basic health indicators
such as crude birth rate, crude death rate, infant mortality rate,
child death rate and life expectancy (see Table 1) in the post independence years, mainly due to national programmes of
immunization, does not describe the complete picture of the
health situation in Zambia. Since the mid-1980's health
conditions have, in fact, deteriorated somewhat with the general
decline in the economy. There has been a fall in health and
nutritional status leading to a significant increase in morbidity
and mortality in both urban and rural areas. UNICEF has
estimated that the share ofchild deaths (under fives) attributable
to malnutrition in Zambia rose from 29% in 1977 to 43% in 1983.
Mortality caused by malnutrition for 1-14 age constituted more
than 62% of the total mortality in 1984.
Another major cause of high child morbidity and mortality
are gastro-intestinal diseases which have increased recently
Shirish Kavadi is a researcher at FRCH, Bombay.
Presently
he is involved in a study of "Health Expen
diture and Investment in Ahmednagar District".
1985, World Development Reports 1983,1987,1988,1989, Sixth report on World Health Situation, 1980.
due to the drought conditions affecting large parts ofZambia and
rapid growth of squatters' settlement near pre-urban areas.
They made up 19% of the total outpatient care and 10% of
mortality in children, in 1982.
Health problems in Zambia, as in other developing countries,
are mainly related to the problem of poverty and insufficient
social development. Rapid inflation, population increase, a
forced migration to urban areas and drought conditions have
affected large areas of the country. Large sections of the
population continue to live in poor conditions and without basic
amenities such as a protected water supply or a proper refuse
collection and disposal system . The epidemiological pattern
reveals that a high proportion of death and illness is due to
common environment related diseases such as diarrhoea,
malaria, malnutrition and measles.
Health Services: distributional
imbalances
The colonial health services were oriented towards curative
medical care, had a heavy urban bias, used sophisticated medical
technology, depended on expatriate health personnel and were
racially discriminatory, emphasising European healthcare alone.
Policy makers in independent Zambia have inherited this
propensity for an urban based hospital and elite oriented health
care system. In 1964, Zambia attained independence and
Kenneth Kaunda, leader of the United National Independence
Party (UNIP), took over the reins of the government. The
government’s official ideology of Humanism - a mix of socialist
tenets and Gandhian ideals- committed it to a socially just and
egalitarian society,
FOR PRIVATE CIRCULATION ONLY
To fulfill its objective, the government gave a major thrust
to provision of primary health care in the rural and under-served
areas. Basic health services were decentralised and efforts were
made to coordinate the preventive and curative health sectors.
Certain other measures, such as the passing of legislation to
regulate private medical services and the integration of mission
hospitals and health centres into the national health services
were also undertaken.
is quite pronounced, both amongst doctors and auxiliary health
workers. Around 76% of the doctors are located in the developed
cities and provincial capitals in the Central, Copperbelt South
Provinces or in Lusaka, the nation's capital. Unequal distribution
of doctors is also evident from the wide variation in the doctor/
patient ratio which ranges from 1:500 in the Copperbelt Province,
to 1:25,000 in the province of Luapala. The urban bias common
amongthe paramedical personnel is exemplified by the presence
of 80% of the nurses in the large towns and cities.
To ensure availibility of free health care, the government
embarked upon a programme of rapid expansion of rural health
centres and district hospitals, which was greatly facilitated by
a fast developing economy with Zambia enjoying one of the
highest GDPs in Africa. Between 1972 and 1976 in particular,
there was a substantial increase in the number of health care
units, with five new hospitals and 62 health centres/clinics
coming up, thereby increasing bed capacity by 2,340.
The government has attempted to encourage rural staffing.
For instance, nurses under training are required to sign an
agreement to work for a certain period in a rural area. However,
on the whole, there has been great difficulty in finding modern
health personnel to go to the rural areas for the reasons stated
above.
The Problems Of Health Finance
Despite the significant gains made in the setting up of new
health units, geographical maldistribution of health facilities
remains and the problem of unavailability of and inaccessibility
to health care persists. This may be attributed to the bias in the
apportionment of facilities bythe government. Certain provinces
such as the Copperbelt, Southern and Western provinces (areas
where copper mines are situated) received preference in the
location of facilities whereas the Northern Province (the most
backward) showed the lowest increase in the number of health
care units.
Zambia today faces a conflict between the equity objectives
of a humanist - socialist political programme and the crisis of its
economy. External assistance has increased, merely reinforcing
its existing dependence on the external world. The aid has
entailed certain policy reforms within Zambia, which are not
consistent with the overall ideology ofhumanism. The implication
ofthe increasing external funds is that the programme, directions
and policy decisions are being influenced by external priorities,
targets and objectives.
Tins urban bias is further revealed in the financial allocation
to the health facilities. An examination of the allocation in the
Recurrent Budget 1980-82 shows that disproportionately large
shares went to the headquarters, training and research at the
University Teaching Hospital (UTH), Lusaka. The Copperbelt
Provinces and Lusaka shared 41 percent of the recurrent
allocation while UTH alone used 40 percent.
In the 1970’s three external but inter-related events
contributed to the deterioration of Zambia’s economy: the fall in
the international price of copper; the simultaneous rise in oil
prices and the world economic recession. Drought and the
consequent reduced agricultural output worsened the situation
in the eighties. The combined result: a low level of production
and export earnings, adverse terms of trade, a foreign exchange
crisis and shrinking government revenue. Zambia was forced to
turn to borrowings from the International Monetary Fund and
the World Bank to finance budget deficits and maintain public
services.
To reduce dependence on expatriate personnel, the training
of health personnel was given priority by the UNIP government.
A medical school and some nursing schools were established to
train Zambians. The situation began to gradually improve after
independence so that, by 1987, there were 880 doctors in all.
More and more nurses, midwives and other middle - level
technical health personnel, such as medical assistants and
health assistants, received training.
The IMF prescribed stringent economic reforms to bring
about structural adjustments hi the economy. The various
austerity measures included devaluation of the currency, (1980
- 1 Kwacha = USS 1.27, April-May 1987- 1 Kwacha = US$ 0.125)
wage freezes, price decontrol, the abolition of government
subsidies to essential commodities, and the curtailment of
expenditure on public services. These austerity measures brought
no relief. Instead they lead to a high rate of inflation.
TABLE 2: MEDICAL PERSONNEL
Year
Physicians
Nurses
Dentists
In Zambia, the sources ofhealthcare finance are the central
government, the mining companies, missions, foreign donors,
and the private sector; The government’s commitment to provide
free health care was demonstrated when it abolished user fees
in both government and mission facilities in 1969, although, in
the private sector these user charges continued. The government
has an extensive subsidy programme to ensure health care to the
under-privileged and the deprived segments of the population.
The mission and mine managements function within a grant-inaid system, under which the government provides a substantial
portion of their operating costs. More than 60% of the total cost
of mission services is met from government aid. In 1980-81 the
government provided missions with 6.6 million Kwacha, more
------- Per 100,000 population ■
1975
7
10
21
51
1980
12
16
1970
0.84
0.57
0.61
Sources: World Health Statistics Annual 1977 & 1983, T ables 1 & 3, pp. 16 & 19,
Tables 17418, Pp.482- 490.
However, the increase in health personnel, as seen in
Table 2, has not kept pace with the increase in population. The
tendency to take upjobs or set up practice only in the urban areas
2
than halftheir expenditure on health care. In the same year, the*
government paid mining companies 80,000 Kwacha, as
reimbursement for health care services to indigents; this was
approximately 2.5% of the total health expenditure incurred by
the companies.
The economic crisis and the devaluation of the Kwacha,
have also adversely affected the employment of physicians.
Salaries and wages declined, having failed to keep pace with
inflation, leading to large scale resignation of doctors from
government services and, in some cases, migration. Although
the majority ofdoctors who left were expatriates, there were also
a few Zambians who resigned to set up private practice. In
comparison with the number of doctors who resigned, a smaller
number was recruited. For instance, in 1984, 140 physicians
resigned from government service while only 115 were recruited.
Since 1981, over 400 physicians resigned, reducing the available
staff in 1985 to 520, some 291 less than the 811 posts available.
It was estimated that by the end of 1987, Zambia fell short of
some 549 doctors.
International financial assistance in health care increased
overtime since 1979.In 1983 more than 24% of total expenditure
incurred by the Ministry of Health came from external donors.
In view of the extremely tight economic and financial conditions
prevailing in the country, it appeal’s that Zambia’s need for
international support will continue and increase, with the
corollary that foreign funding agencies will attempt to influence
Zambia’s health policy. To illustrate, as a condition to the IMF
aid in 1988, the government introduced a user fee scheme under
which all expatriates must pay fees for health care, while for
Zambian nationals, fees are restricted to services categorised as
"non lifesaving".
On the whole, health sector financing has been seriously
affected by the crisis in the Zambian economy. Even though total
annual Ministry of Health expenditure increased, it was only in
nominal terms, for when measured in real terms it actually
declined. When measured using a deflated price index for gross
domestic expenditure and adjusting for Kwacha devaluation.
the health expenditure declined by 17% bet ween 1970 and 1981.
The real government per capita health expenditure fell from
21.9 % in 1970 to 8% in 1985, the decline being ofsome 37%. It has
been estimated that the real value of Zambia’s health budget of
1986 was only a quarter of the 1983 level.
Under the IMF programme, the share of the health sector
in the government budget has declined. There has been a
curtailment in the total funds allotted to the health sector. These
cuts brought down the recurrent health expenditure from K. 85.8
million in 1976 to K. 72.6 million in 1981, while the reduction in
capital health expenditure in just one year, was 88%, from K.
11.1 million (1982) to K. 1.3 million (1983). Capital projects have
come to a virtual halt. Indeed, no new hospital has been put up
since 1974 owing to a lack of funds. However, between 1978 and
1985, a total of 162 health centres were built with Swedish
International Development Agency (SIDA) and European
Economic Community (ECC) assistance, attesting to an
increasing reliance on external sources to set up health care
units.
The proportion of the health budget expended on essential
drugs, primary health care and maintenance of health facilities
also witnessed a marked decrease. An evaluation of PHCs
carried out in 1984 showed that the sendees at rural facilities
were quite poor. Almost 24 ofthe 32 health centres covered by the
survey had no anti-malarial drug available for treatment.
Supplies of other essential drugs were also noted to be in
adequate throughout the country.
Summing Up
The health care situation in Zambia is typical ofa developing
county. While it is a fact that structural limitations have
hampered the development of the health delivery system thus
making universal health care a distant goal, the need is to look
beyond these limitations to understand the true nature of the
problem.
The government’s inability to attain its goals with regard to
health care arises out of a general lack ofpolitical will. Although
publicly committing itself to creating a fair and just society, the
government has not demonstrated the political will required to
bring about such a society and to overcome existing biases and
prejudices. This is reflected in the State’s continued pursuance
of the colonial pattern of development, when it should have
jettisoned the colonial model in favour ofone that was compatible
with its “humanistic” concerns.
Internal finances for health care are unavailable or
inadequate and therefore the development of health services in
the last decade has been largely dependent on foreign funding
agencies. Aid received from external sources has been both
conditional and specific. Solutions induced from abroad,
(especially from international aid agencies ) to ameliorate the
health care system have, in fact, had the reverse effect. Introducing
user charges when the patient’s purchasing power is low has
only meant making health care inaccessible to the people.
Succumbing to the pressure of external agencies is once again a
manifestation ofthe government’s inability to assert its political
will. As long as the path of health care development is dictated
by priorities of the local elite and those of foreign agencies,
Zambia has little hope of achieving equity in health care.
Select References:
1
Akhtar, R. & Izhar, N.: The Spatial Distribution of Health Resources Within Countries and
Communities - Examples from India and Zambia; Social Science and Medicine. 22 (11). 1986,
pp. 1115-1129.
2
3.
Clark, John, with Alision, Caroline - Zambia: Debt and Poverty. Oxfarm Oxford; 1989.
Freund, P. : Health Care in a Declining Economy • The Case of Zambia. Social Science and
Medicine, 23(9) 1986. p.p. 889-897.
There was inadequate distribution of fuel and funds for
vehicle maintenance. In 1982, only 26% of the total 550 vehicles
were in working condition and only a few of these could be used
due to a lack of fuel. Conditions in the rural health centres have
steadily deteriorated. Though urban-based hospitals also
experienced shortages of drugs or personnel, they received
priority attention, especially the central hospital and U.T.H.
and concerted efforts were made to maintain their services.
4.
Hoeven, R V.: Zambia's Economic Dependence and the Satisfaction of Basic Needs.
5.
Kalumba. K & Freund, P.: The Eclipse of Idealism: Health Planning in Zambia. Health Policy
6.
WHO: Sixth Report on World Health Situation, WHO. 1980.
7.
WHO: Seventh Report on World Health Situation; WHO. 1987;
8.
World Bank. Financing Health Services in Developing Countries - A World Bank Policy.
International Labour Review, 121 (2), March- April, 1982, pp. 217-230.
and Planning. 4 (3), September 1989, pp. 219- 228.
Study IBRDM.B Washington1987.
•
COMMUNITY " “
3
No: 367, ‘Srlnivesa 1*"
Jakkasandra, 1 Moln,
" ‘
Koramangalo,
,
BANGALORE-5C003
A MATTER OF SURVIVAL
How Auxiliary Nurse Midwives (ANMs)
Cope Within The System.
Aditi Iyer.
Sister Renu*, a Rajput woman, was deserted after 14 years
of marriage. Her husband, a taxi driver in Bombay and 18 years
older than herself, had an affair with another woman. Sister
Renu’s life, which had previously revolved exclusively around
conjugal and domestic duties, now began to change dramatically.
In the past, when she wanted to teach in a primary school, the
choice had been denied to her by her pregnancy and her husband’s
refusal to grant her permission. Now after 14 years and 4
children,with nothing but a 10th standard education and no
experience in working outside the home, she was compelled to
find ways to support herself and her children. This was in the
mid 80s when the “Health For All” slogan resulted in an
expansion in the health infrastructure. She heard of the Auxil iary
Nurse Midwives’ (ANM) course and though she knew nothing of
what the job involved, she recognised the potential of being
economically self-sufficient. This was a regular job, something
she needed very badly.
Sister Sulochana*, an independent minded and spirited
Gond woman, took to nursing to protect herself from some of the
uncertainties that surrounded her unhappy marriage. Of the
two options available to her, with her 10th std. education, the
ANM course was more accessible: there were no fees to be given
and the low grades did not disqualify an applicant. Besides,
there was a demand for women in the health services at that
time. Sister Sulochana applied for the course and got in. She
decided to hand over almost her entire salary7 to the family at
Nagpur, so that the economic benefits of herjob would pre-empt
opposition from her husband.The job meant a lot to her and she
was prepared to do anything to keep it from slipping away from
her.
When ANMs like Sister Renu and Sister Sulochana are
pushed into the labour market, their social and economic positions
are guided precisely by these forces. Their jobs support the
futures of the others in the family but have a veiy conservative
role to play in any change oftheir status within it. Further, given
their administrative and functional status within the health
services, a new set of limits are set on the lives and work
situation of these lower level functionaries. This article strings
together the experiences of a few ANMs as they try to cope with
a system which supports them on the one hand while creating a
new set of contradictions on the other.
Varying Expectations
ANMs are supposed to look after the health needs of the
people in their sub-centre villages. Sister Shanta*, who works in
Beed district, had every intention of living in her sub-centre
village when she was transferred there. However, she had to
abruptly reverse her decision even before she could move in with
her belongings. Almost immediately after her first visit, a
member of the Panchayat propositioned her. “If you do as I tell
you to”, he said, “I’ll see that you do not face problems in
completing family planning work”. Sister Shanta realised what
was on his mind and quickly decided that staying in the village
was not only improbable but also impossible. Ever since, she has
lived alone in a neighbouring village and takes care to keep her
divorce a secret from all but a few people. She has also come to
believe that women have a reputation like glass: fragile and
easily broken.
Adding to some of the problems that ANMs face in the
community, is the task of doing family planning work - a
programme that has been increasingly strengthened over the
years . The bureaucracy places a high premium on the completion
of FP targets. This is often at variance with what people expect
from health services and ANMs. Given the distances that need
to be negotiated in order to reach a dispensary, people look
towards their ANMs for their supply of medicines. However,
stocks of basic medicines are, most often, insufficient and ANMs
are not adequately trained to deal with slightly more complex
illnesses. While then* jobs depend on fulfilling FP targets, they
also need to build up some credibility in the community in order
to protect their reputation and themselves from the village
leadership, which could use FP targets as an excuse for
harassment.
Economic Participation and Status
The relationship between participation of women in the
labour force and a qualitative improvement in their status is not
a direct one. The capacity of women to enter and compete in the
labour market is constrained by social relations within which
they are embedded, namely,
1. prevailing social norms relating to the suitability of wage
labour vis-a-vis domestic responsibilities,
2. the structure of familial relationships that do not always
accommodate their changing economic role,
3. current norms about what constitute “appropriate”
occupations for women, and
4. the structure of their roles and status positions within
occupations.
The target approach has set up the practice of depersonalised involvement. Of the four districts that we visited;
- Pune, Beed, Wardha and Ratnagiri, - this was particularly
evident in Wardha and Ratnagiri.
Aditi Iyer is a researcher at FROM, Bombay. She has been
involved in the study of ANMs and Doctors at the PHCs in
Maharashtra.
* The names of the ANMs have been
changed to protect their identities.
Sister Lata*, who works at Wardha, is just one person
among several others vying for “cases”. The teacher, talutlu,
4
(village revenue official), gixun-seuak, (the village official for
overseeing development activities), the second medical officer,
and the compounder, are under the same compulsions to fulfill
targets. This sets up a market situation at the village level where
the price for an operation is set according to the competition
prevailing at the moment. For ANMs this works out to Rs. 200
per case as her personal contribution, in addition to the official
rate of Es. 130. Further, this practice is fully endorsed by the
authorities at the PHC who are more interested in seeing that
targets are completed while turning a blind eye to the mechanisms
that are set up in the process.
Sister Lata, however, is lucky. She pays an average of
Rs. 100 per case. She ensures this by looking after every need
of those who live in her sub-centre. In order to ration stocks, she
gives her patients less than the prescribed dosage - 2 tablets
instead of 4, - often having tojuggle between the few alternatives
that she has. She conducts every delivery, and personally sees to
it that women come for ANC (ante-natal care) and PNC (post
natal care) clinics. She is thus looked upon as being a person who
can be trusted for the provision of health care. While nobody goes
back empty-handed after approaching her, she establishes her
position in the community and makes her family planning work
an easier and cheaper task to handle.
Some ANMs like Sister Lata tend to draw the link between
family planning and other duties, so that they perceive their
involvement in deliveries, immunization, ANC / PNC as
pre-conditioning factors for motivation.
Further, in the target approach, women - especially mothers
or those potentially capable ofbecoming mothers, - are of special
interest. By emphasizing the family planningand MCH (Maternal
and Child Health) programmes the bureaucracy employs its
women health workers to circumscribe the scope of motherhood
within those definitions that are approved by the state. This
distorts the relationship between the health worker and her
community and creates problems for her.
Sister Renu, who had a difficult time adjusting to the life of
a working woman in Pune district, was faced with some truisms
when she set out to explain the need for sterilization to some
tribal women. They confronted her - "You do not want us to have
2-3 sons. Alright, give us your's then”. Sister Renu’s son, who
was just getting over the turmoil in the family following his
father’s departure, was upset on hearing this. Later she had a
hard time assuring him that she did not intend to send him away.
On the same issue Sister Shanta takes a moderate view as
she looks at problems within the system. She says, "if targets are
removed, some ANMs will work, others won't. Targets are
needed but the authorities should be less rigid about them than
they are now. The way targets are enforced, the pressures they
create, make ANMs do kkola kaam (perpetuate falsehoods).
Instead of spending so much money on Copper-Ts, all of which
may never be used, the government should supply adequate
medicines and injections to us”.
On the other hand, based on her experiences, Sister Renu
questions the system within which she is being made to function.
She states categorically," Til tell you the truth. Where I work)
people have no demands from us. They work so hard that they
have no time to think, let alone ask for health care. They have no
5
time to be sick. What they need is a release from poverty, not
family planning!” Sister Renu accepts the tribal way of life and
is accepted as being one of them.
For Sister Sulochana, however, FP has threatened her
career for ever so long. When she joined the services as a
temporary member of the staff, her tryst with the programme
had onlyjust begun. After working for 15 months and completing
one case, she was asked to leave. For Sister Sulochana, this
meant a loss to her new found freedom. She did not have a union
to go to for redressal and so she fought her battles alone. With the
help of her neighbours who were lawyers, she successfully filed
a case in the high court. Yet, while the proceedings implicated
her “non-performance” and “begged” for reinstatement, they did
nothing to question the target approach to health work.
Since her reinstatement, Sister Sulochana concentrates
her energies on surviving within the system, having been a
victim of it once. She concentrates on family planning to the
virtual exclusion ofall other activities. As part ofher motivational
strategy, she promises and conducts follow up services which
take the form of weekly injections of B-Complex (which she
administers with her own syringes without always taking care
to sterilize the needles after each prick).
Sister Sulochana has maintained a satisfactory record of
cases but is still issued 6 monthly orders. Having completed only
1 year of the one and a half year Step Ladder Course, she is
ineligible for permanency in service. What is more, she seriously
doubts the probability of being deputed to the training school for
the remainder of the course due to her past experiences with an
affronted bureaucracy.
Facing the Situation
The work situation of ANMs, rife with contradictions, has
evoked varied reactions from them. Mainly, it is a question of
survival. Sister Sulochana and Sister Renu have reflected upon
their role as health workers and experience some alienation. The
reasons for this, however, are very different. Whereas Sister
Sulochana sees no benefit in doing work, apart from family
planning, as it holds no personal rewards, Sister Renu senses
that her role is both irrelevant and unbeneficial to the people
whose welfare is dear to her. Unfortunately, her reflections,
invaluable as they are, have to be subsumed to the more routine
preoccupation of distributing oral pills and condoms to a
population that is caught up in the more crucial battle of
survival.
Sister Lata and Sister Shanta, on the other hand, have
channelised some of their anger into practical avenues. Both of
them take an active interest in their union and have won a few
small battles through them. Workers unions in Beed and
Ratnagiri have provided some solidarity but have not looked
beyond the confines drawn up for nursing within medicine.
Given these limitations and the mammoth task of building up
communication links with ANMs who are separated from each
other geographically) their victories are transient and their
battles are never quite finished Perhaps this may change once
ANMs begin to look beyond the hurdles that lie immediately
before them and question the assumptions that underline all
that they do in the village community.
•
COMMUNITY HEALTH AND MEDICAL GRADUATES
Sheela Rangan,
M. Uplekar
The interns' estimates of the population of India varied
from 1 million to 200,000 million. About 30% of the interns were
not even aware of this basic piece of information, though 77% of
them knew the urbanrural population ratio. More than 70%
could not give the correct definition of maternal mortality rate
(MMR) but about 49% could guess the correct figure of MMR for
India as 4-5/1000 live births. Eighty seven percent of the interns
did not know the number of registered doctors in India, the non
response to this question being to the tune of 50%. Sixty percent
of them, however, could correctly guess the approximate
distribution of doctors in urban and rural areas.
Internship is a very crucial period in the training and
development of a doctor - this is the period when knowledge
gained during the 4 1/2 years of medical education is enriched
through the addition ofskills acquired by the practical application
of this knowledge.
Over the years, however, this crucial learning phase has
regressed from vital compulsory training into a compulsory
ritual. Consequently, practical skills are learnt by those who are
genuinely interested, while a majority treat this period as a year
long holiday. Since no definite curriculum exists, various
departments continue to use the interns for clerical purposes
and as general all-round workers.
Expectedly, about 70% of them were veiy clear about thenpreference to practice/work in urban areas. Turning a blind eye
to the fact that doctors ultimately prefer to set up practice in
urban areas regardless of where they are trained, the government
continues to open more medical colleges, supposedly to satisfy
the health needs of the rural population.
This insidious trend needs to be arrested, and hopefully
reversed, in order to make the internship training period more
productive in the preparation of well trained doctors who should
be competent to function in the community and should also have
some knowledge of managing either a Primary Health Centre or
general practice.
About 75% of the interns also indicated that they would be
registering for a postgraduate degree. Surgery, medicine and
gynaecology were mentioned as common preferences, while
there were a few interested in specializing in subjects like
biomedical engineering, genetic engineering, aviation medicine,
nuclear medicine and oncology. This demonstrates how far
removed are the students’ specialty preference from the health
needs of the Indian population. A crucial subject like Community
Medicine, which was indicated as a specialty preference,
surprisingly by nine interns, is generally looked down upon, in
the first place, by the faculty of the college and consequently by
the students too. In fact, the staffof the departments of Community
Medicine themselves lack the conviction that their subject is as
important, if not more, than the clinical subjects.
The Study of Interns
Against the background of the much discussed and well
recognized need for reorientation of medical education, to make
it more responsive to the health needs of the community, we
conducted a study of fresh medical graduates commencing their
internship trainingin one government and two municipal medical
colleges in Bombay. The objective was to assess a fresh intern’s
knowledge about some essential aspects of community health
care, which is supposed to be covered in the undergraduate
medical curriculum. A questionnaire was administered to probe
into their knowledge of basic health information, their
understanding of some public health problems and primary
health care, essential drugs and rational drug use.
Forty-five percent of the interns knew that infectious
diseases continue to account for a major chunk of illnesses in our
country and 60% mentioned diarrhoeal diseases as top killers
among children. Forty-nine percent mentioned tuberculosis as
top killer among adults while 25% and 26% mentioned
cardiovascular diseases and cancer respectively, which actually
rank second and third in the list of killers.
The questionnaire was administered by us in two of the
colleges at the time of an orientation programme on internship.
In the third college, the department of Preventive and Social
Medicine (PSM) undertook to administer the questionnaire on
our behalf. At the outset, the interns were explained that the
purpose of the questionnaire was to get a collective idea about
their understanding of community health with a view to identify
areas for strengthening the undergraduate curriculum.
National Programmes - What goes wrong
Answers to the questions on the poor performance of the
national tuberculosis programme and the reasons for tetanus
continuing to be a major public health problem, reflected the
usual attitude of the medical profession of placing the entire
blame on the patients and attributing the problems to illiteracy,
ignorance, carelessness etc. Only 9% mentioned about the
availability and accessibility of the health care services, problems
with its delivery and with those of health care personnel .When
asked what advice in their private practice would they give to
poor TB patients who defaulted, only 51% suggested referring
them to municipal or government clinics/ hospitals or PHCs
Ill-defined knowledge - Misplaced Priorities
An analysis of the responses of 340 interns from all the
three medical colleges revealed the following findings:
Sheela Rangan and M. Uplekar, both doctors, are on the
research staff of FRCH, Bombay. They are involved in
various studies, including one looking at the social and
operational aspects of tuberculosis control in the urban and
rural areas.
6
where they could avail of free treatment facilities - interestingly
more interns from the government medical college knew this as
compared to those from municipal colleges .The rest of the
interns gave solutions like offering financial aid, free drugs and
referring them to social workers. This reflects the lack ofinterns’
knowledge about the public health departments and their
functioning. While the staff and students may be theoretically
aware of the services available under various national
programmes, in actual practice, they may not know where and
what type of services are available and how they can be utilised.
Every third leprosy patient in the world is an Indian and
the prevalence ofleprosy in Bombay is as high as 13 per lOOO.The
National Leprosy Eradication Programme has been in operation
for over three decades and there are clear cut guidelines available
for treatment for leprosy,which are simple enough to be followed
by paramedical workers . Inspite ofthis, when asked to prescribe
treatment in the case of an adult leprosy patient, 86% of the
interns could not do so correctly.
As to the question of how often, hi their clinical years, had
they actually witnessed Oral Rehydration Solution being
administered, it was revealing to learn that 19% had never seen
it while 36% had seen it less than 5 times, after having spent 1
month each with the Pediatrics department and the Preventive
and Social Medicine department. This is despite the fact that
Oral Rehydration Therapy, which is recognized as an important
tool in reducing child mortality, has been receiving a lot ofinputs
towards popularisation from various national and international
organisations. In fact, nowadays, there is even a move towards
having Oral Rehydrating Centres attached to the Pediatric
Outpatient Departments of some major hospitals.
A Question of Orientation
More than 82% of the interns did not know the true import
.of "Health For All by 2000 AD” and did not even mention
availability of basic health care or “primary healthcare”. To the
majority it meant achievingtargets like universal immunization
and reduction of birth rate and a larger number answered this
question by giving the WHO definition of health, which is a
narrow concept, more applicable to an individual than to the
community at large. But one wonders whether it is fair to
apportion blame to students for failing to understand what
Health For All really means , when it is actually pressure from
the government for attainment of targets, especially family
planning and immunization, upon the medical teachers, which
gets conveyed to the students and remains on top of their minds.
The concepts of Health For All and primary health care, in fact,
tend to get dismissed by most ofthe medical colleges, apart from,
perhaps, the staff of the department of community medicine.
This is because they do not visualise any role for themselves in
primary health care, believing it to be the sole responsibility of
the department ofCommunity Medicine. This was also one ofthe
main reasons for the failure of the Reorientation Of Medical
Education (ROME) programme which was aimed at bringing the
specialists to the community setting, be it urban slums or rural
areas.
The concepts of essential drugs and rational druguse do not
appear to receive much importance in the medical curriculum,
if the interns' responses to the questions about these are any
indication. While 65% of the interns did not know the number of
drugs on the WHO list of essential drugs, 24% did not know that
branded drugs cost substantially more than generic drugs.
When asked to write a prescription for an adult male suffering
from symptoms of ‘flu’, 37% prescribed unnecessary oral
antibiotics, 37% suggested oral anti- inflammatory drugs, 27%
recommended injections of analgesic/antibiotics and 36%
favoured vitamins/tonics. Forty-one percent df the interns
prescribed 3 or more drugs. This practice of prescribing drugs in
great abundance reflects the blanket treatment approach of our
doctors. No doubt, this type of doctor and the health care model
also contribute in supporting the drug industry which takes
great efforts to keep in contact with these young doctors-in-themaking, right through their clinical years.
The Social Costs
Coming to the question on health economics, only 54% knew
the per capita government spending on health, while their
estimates of government expenditure on each medical graduate
varied from nil spending to Rs. 30 lakhs, 95% being unable to
guess the correct figure of Rs. 4 and 5 lakhs which is the actual
social cost of producing a doctor. One wonders whether this cost
is justified, especially in the light of the fact that 75% of these
doctors educated at public expenditure prefer to enter the
private sector, and more than 5000 doctors migrate every year to
developed countries, thereby subsidising these countries by
saving them the expense of producing their own doctors.
After the questionnaire had been answered, interns in two
ofthe colleges where we administered the questionnaire ourselves,
were addressed by the heads of the departments ofPSM, surgery,
pediatrics and gynaecology. They were given an idea about their
postings, the administrative procedures like getting their
completion certificates etc. A disproportionate amount of time
was then spent on explaining about the amount of casual leave
the interns were entitled to and how they could avail of it; in fact,
this was the only part of the entire talk that was heard out by the
interns without any interruptions. The addresses given by most
of the professors were in the same vein - they implored the
interns to abide by the rules and regulations and not create
problems for themselves and for the respective departments, to
enjoy the one year fully and to learn as much as possible in that
order. If such are the priorities set by the teachers themselves,
is it fair to expect anything different from the students ?
This was followed by addresses from representatives of
three pharmaceutical companies who were sponsoring the gettogether and providing refreshments in one of the colleges.
These representatives congratulated the interns on their
performance in the examinations and exhorted them to bear
their products in mind while writing prescriptions. They also
assured of continuous support from their respective
pharmaceutical companies as far as providing the latest
information regarding drugs was concerned. In the absence of
organised Continuous Medical Education (CME) programmes
for doctors today, information given by these drug companies
remains the only way to get updates; which more often than not,
is heavily biased. The representatives then doled out drug
information literature, free drugsamples and several other giveaways to the interns. The final act of incongruity was the
distribution of the Hippocratic Oath printed by one of the
companies which the interns were made to read out in unison.
Continued on page 8
r'OMMUNIir ... - B,
7
g Ri "Srinivasd"N,. ■
—kkasandro, i Main, । EiJ-k,
Koramangala,
NEW ARRIVALS
REPRINTS
BOOKS
1
. Botang W. Sports and Public Health - China hand book series 1983,
1
American Thoracic Society, Control of Tuberculosis, pp. 336 -342
pp.176.
2
Fox W., The current status of short course chemo therapy, 1979,
pp. 177-190
2
Campbell C.D., Financing Social Security, 1979, pp. 352.
3
Desai R., Social Background of Indian Nationalism, 1948, pp.46.
3
Gothi G.D., Epidemiology of T.B. in India, pp. 134-146.
Hurley, R., The Love of the Self: The History of Sexuality, 1986, pp.
4
Krishna Swami K.V., Intermittent short course chemotherapy of
5
Mankodi K., Socio-cultural content of T.B. treatment: A case study
6
Nagpaul D.R., Planning and management of National Tuberculosis
7
Nagpaul D.R., Why integrated Tuberculosis programmes have not
4
Pulmonary Tuberculosis., pp. 40 47
278.
5
Indian Market Research Bureau, Diarrhoea in Rural India; A Nationwide
study of Mothers and Practitioners, West Zone, 1990, pp. 268
6
Lawand, T A., Solar Water Disinfection; proceedings of the workshop
of Southern Gujarat, pp. 87 - 92.
held at Brace Research Institute, Montreal, Canada, 15-17 Aug.,
1988, pp. 239
Programme pp. 18-24.
succeeded as per expectations in many countries - A collection of
7
Parish, P., Medicines: A guide for everybody, 6th ed., 1987, p.. 660.
8
Prabhu, V., Arogya; Samaj ani gairsamaj
9
Vishwanathan H., Diarrhoea in Rural India, All India summary, 1990,
8
Rao K.N., Outlook of T.B. control, 2000 A.D., 1984, pp. 47 - 52.
pp.192
9
Shimao T., Review of Tuberculosis Control programme in the
observations pp. 149-152.
(Marathi), 1989, pp. 181
10 Weekes, V.W., Women in Development; at the right place for the
right reasons,1980, pp. 1980
PRINTERS DEVIL
In the July - Aug., issue, the following may please be
corrected:
pg. 2
last line of the article ends with...:"the only
means for people to guard their health."
pg 8
under Books, title no. 1 to read as “Demands
for Grants of Central Govt. 1988-89"
The errors are regretted.
Editor
Continued from page 7
Reorientation - Where do we start ?
After this experience one wonders where the correction
process in the present medical education system needs to be
started - is it with the student community that we need to
interact in order to change value systems, or is it the teachers
themselves who need to be given a better social orientation ?
The need today is to introduce subjects like sociology,
anthropology and health economics fairly early in the course of
medical education, to help students to identify the health
problems of our society, understand the influence of culture on
health and disease behaviour and chart out priorities in health
care. Here again, raising the age ofentry ofstudents into medical
colleges and introducing a couple of years of appropriate
premedical training and compulsory work experience may also
help. This may result in having older and more mature students
who do not look only at the glamour ofthe medical profession, but
are really motivated to practice the profession as it should be.
Another area which ought to receive special emphasis in
the medical curriculum is general practice and its responsibilities
and challenges, taught preferably by a general practitioner. This
eastern region of IUAT, 1986, pp. 108 -116..
10 Sivaraman S. T.B. in India, - the prospect pp. 71 - 86.
would help prepare students better to perform the duties of a
family physician and possibly reduce the massive number of
students who today flock to register for postgraduate studies.
Apart from the cu rriculum changes, another very important
need is to make the internship training programme more
meaningful. In order to do this, it is necessary to identify definite
skills to be imparted by individual departments to the interns - basicskills which any doctor starting general practice or taking
charge of a primary health centre should have. It must be made
mandatory for each intern to acquire these skills before getting
a certificate ofcompletion from the respective departments after
undergoing a practical test at the end of this period.
Unless such steps are considered towards reorientation of
our present undergraduate medical education system, our
medical colleges will continue to churn out academically bright
but immature doctors lackingsocial orientation and unprepared
to do justice to the practical challenges which lie ahead of them.
References
1.
D ugg al Ravi: Medical Education in India: Who pays ? Radical Journal of
Health, VoLIII, No.4,1989.
$
FREE ABSTRACTING
The contents of this newsletter may be
abstracted without prior permission. However
we would welcome acknowledgement of the
source and copies of any abstractions.
Edited by Nagmani Rao. with assistance from Sunita Kesavan and Vrinda Sinha and produced by the Foundation for Research in Community Health,
84-A.
R.G. Thadani Marg. Worli. Bombay 400 018. Registered under the Bombay Public Trust Act. Printed at Printext Offset, Pune 30.
Nov. - Dec. 1991
SPECIAL ISSUE ON INDIGENOUS MEDICINE
Vol V No. 6.
AYURVEDA
During Freedom Movement and After
Alex George
The present state of decadence of the Ayurvedic system of
medicine in India is not just due to the relatively higher efficacy
of allopathic treatment. Though Ayurveda was stagnating even
before the British period its current decadence is as much due
to the colonial policy7 of subjugation of the indigenous systems of
medicine as also the cultural choices of the Indian elite which set
the terms of medical discourse of independent India in favour of
western medicine. While colonial subjugation of Indian science
was aimed at depriving the nation of its possible sources of
cultural pride, both the policy of colonial subjugation ofAyurveda
and its marginalisation during the post independence phase
were based on certain presumptions which,
in fact, was characteristic of 19th century
European thought. Positivism never accepts
the existence of anything which is not verified
through empirical observation. The
ideological aura of western science built
around empirical verifiability was something
against which Ayurveda stood to loose
tremendously. Since too little research had
been done to translate the treatment
techniques of Ayurveda into the academic
language of discourse of modern western sciences and it was
practically not feasible to subject an entire system of medicine to
the rules ofverifiability of western science, it became far too easy
to brush aside Ayurveda as queer. Seeing itself as rational,
scientific and universalistic, western medicine defined itself in
opposition to the presumed irrationality and superstition of
indigenous medicine.
were offered in all medical schools and doctors trained in
western medicine were required to take the training. By 1979
about 4 la kh hectares of land were brought under the cultivation
of medicinal plants.
Nationalists’ Efforts During Freedom Movement
Indian attempts at revival ofAyurveda and other indigenous
systems during the colonial period started with the Government
ofIndia Act of 1819 which gave the power oflocal selfgovernment
to the provinces and with the Nagpur session of the Indian
National Congress in 1920, which resolved
that “earnest and definite efforts should be
made by the people ofthis country to popularise
schools, colleges and hospitals for instruction
and treatment in accordance with indigenous
systems of medicine”. This was followed by the
establishment of committees by the
governments of various provinces and
principalities for revitalizing the indigenous
systems. Earliest among these were the
committees set up in 1921 by the Governments
of Madras and Bengal provinces and by the United Provinces in
1925. They were followed by the Central Provinces and Berar
and also by the Punjab in 1937, the Mysore principality in 1942,
Utkal in 1946 and the Bombay province in 1947.
WISH YOU
A
VERY HAPPY
1 992
India’s post independence experience is in stark contrast
with that of China where traditional medicine has been
incorporated as an integral part of health services. By the end
of 1965, there were already over 2,80,000 doctors of Chinese
medicine working in medical institutions owned either by the
whole people or by collectives and their social status had been
considerably raised. Developed courses in traditional medicine
Alex George is on the research staff of FRCH, Bombay.
He has been involved in studies related to health
expenditure and is presently contemplating a study
regarding indigenous medicine.
In the midst of these developments, the National Planning
Committee established by the Indian National Congress in 1938
resolved to absorb the practitioners of Ayurveda and Unani
systems into the state health organisation ofindependent India.
However the Health Survey and Development Committee
(Bhore Committee) Report 1946, which was to become the
blueprint for the organisation of health services in free India, did
not visualise a significant role for the indigenous systems. The
Committee observed that it was “not in a position to assess the
real value of these systems” and that on account of the paucity
of time and opportunities at their disposal "it could not conduct
an investigation into the problem as would justify clear-cut
recommendation in respect of the part to be assigned to the
indigenous systems of medicine in the organised state medical
relief of the country”. This omission led to criticism at the XIII
FOR PRIVATE CIRCULATION ONLY
session of All India Medical Conference held at Madurai in 1946
and later the same year at the All India Provincial Health
Ministers’ Conference held at Delhi. As a consequence, the
Health Ministers’ Conference resolved that adequate provisions
be made in the Centre and the Provinces for:
approach, Ayurveda was relegated to the level of a fringe
phenomenon. The mystifying ideological halo within which
modern medicine operates in the health market ofan increasingly
commercialising economy also further ensured the decline of
Ayurveda in post-colonial India.
(a) research in, and the application of scientific method for
the investigation of indigenous systems like Ayurveda and
Unani with reference to the maintenance of health and
. prevention and cure of diseases,
However there were some government committees which
went into the status of Ayurveda after independence. The
Pandit Committee (1949) and the Dave Committee (1955) also
recommended the concurrent teaching ofAyurveda and modern
medicine. The Udupa Committee appointed in 1957-58, made
several recommendations relating to the professional education,
medical care, research and drugs. It recommended the
establishment of a Council of Indian Medicine and a Council for
Ayurvedic Research. The Mudaliar Committee (1961) took the
view that concurrent teaching ofAyurveda and modern medicine
should be stopped and only Shuddha Ayurveda was to be
taught. It felt that the extraordinary growth and range of utility
of modern medicine are due to the contributions it has received
from the phenomenal growth of physical and biological sciences
in recent times. Therefore a synthesis of Ayurveda and modern
medicine should be through the incorporation in modern medicine
of all that can be tested scientifically and proved to be useful in
the Ayurvedic system. The Committee’s approach was mainly
(b) starting colleges and schools for training in Diploma and
Degree courses in indigenous systems of medicine and,
(c) offering post-graduate courses in indigenous systems of
medicine to graduates in Western medicine.
It also reiterated the resolution of the National Planning
Committee to absorb practitioners of Ayurveda and Unani into
the State Health Organisation by giving them further scientific
training wherever necessary. In order to suggest ways and
means of attainingthe above objectives, the Conference appointed
a Committee under the Chairmanship of Col. R.N. Chopra
which submitted its report in 1948.
one of engrafting Ayurveda onto thebasic foundation of knowledge
Post Colonial Period
The Chopra Committee Report suggested a synthesis of
Indian and Western systems, for which it felt attempts were to
be made in the field of medical education. Accordingly the
Committee recommended a three stage integrated training and
research programme in Indian and Western systems. In the
first stage of this programme papers in Ayurveda and Western
medicine were to be taught side by side with some amount of
comparison, but maintaining the distinctiveness of the two
systems. Some of the papers suggested included;
(1) PadarIha Vlguqna in Ayurveda which was to have its
parallel in basic sciences in Western medicine,
(2) Sharira in Ayurveda with its counterpart of anatomy in
Western medicine,
(3) Dravya Guaa Vigaana Rasashastra an d. Aushudha
Nirmana with their parallel of MaieriaMedica in Western
medicine etc.
In the second stage each of these pairs of subjects were to
be taught by the same teacher instead of by two previously,
wherein he was expected to give a unified view of Indian and
Western medicine. The final stage would result from the work
in research institutes where eminent experts of Western and
Indian systems would work side by side, discussing, testing,
checking and verifying hypotheses and theories with a view to
either rejecting or harmonising them. There could also be
parallel hypotheses, which is not too uncommon in science.
The equality of status of Ayurveda vis-a-vis Western
medicine, as envisaged by the Chopra Committee, was not quite
granted to it in the post-independence health policy. The
overbearing concern for the post-colonial Indian elite was of
being left behind in the onward march toward modernisation, in
which the West was perceived as the model. In tune with this
FRCH NF VSLETTER. VOL.V. NO. 6, NOV.- DEC. 91
in modern medicine by starting post - graduate courses in
Ayurveda for those trained in modern medicine, instituting
chairs in Indian medicine in modern medical colleges etc.
From the Chopra Committee (1948) which recommended a
somewhat harmonious synthesis of Ayurveda and modern
medicine on equal terms to the Mudaliar Committee (1961)
which recommended the engrafting of the tested out portions of
Ayurveda within the modern system of medicine, itself speaks
for the marginalisation of ayurveda in post-colonial medical
discourse. That the so-called integrated schemes of medical
education never succeeded in a synthesis of Ayurveda and
Western medicine as envisaged by the Chopra committee has to
be admitted. But this again was due to the market pressures
Plan Allocations
for Traditional Indian Systems
of Medicine and Homeopathy,
First Plan
0.40 crores
Second Plan
4.00 crores
Third Plan
9.80 crores
Fourth Plan
15.83 crores
Fifth Plan
25.07 crores
Sixth Plan
85.39 crores
Seventh Plan
129.05 crores
Source: Indian Systems of Medicine and Homeopathy, Min. of Health and
Family Welfare, GOI, N.Delhi, 1988, pg. 18.
2
from the modern medical system which was encouraged to hold
sway indiscriminately, in the name of modernisation. It must be
borne in mind that the Chopra Committee report had a holistic
approach towards health care in the country, which it sought to
root in the scientific bases of our own cultural traditions and
from there to build up linkages with the Western medicine.
However the post-independence policy, took a different turn and
led to the marginalisation of the indigenous system.
In a welcome departure from the predominant policy
postures on Ayurveda, the ICSSR-ICMR report 1981 had
recommended the introduction of a national orientation to our
health care system by the incorporation ofculture and traditions
of the people in an unchauvinistic and rational manner.
Accordingly it suggested that each indigenous system should be
allowed to retain its identity and grow in its own genius, but an
effort should be made to ultimately develop a national system of
health care in which all different systems can make theirunique
contribution. The National Health Policy (NHP) which was
announced in 1983 also understood the need for planned efforts
to dovetail the functioning of the practitioners ofthe indigenous
systems and to integrate their services at the appropriate levels
within the overall health care delivery system, specially in
regard to the preventive, promotive and public health objectives.
Conclusion
The situation calls for studies in the receptivity ofAyurveda
in the various cultural regions of the country, to get a full picture
of the utilisation of Ayurvedic health care. In addition, such
studies will also provide us with success stories of effective
utilisation of Ayurveda in certain regions. The emerging trend
of putting emphasis on the supply side of Ayurvedic health care,
by financing nurseries/gardens of medicinal plants has in fact to
be balanced with studies on the actually existing demand for
Ayurvedic health care, backed by educational inputs wherever
required. The burden of colonial-scientistic hangover is far too
heavy, such that people are happy with any injection, even of
distilled water, compared to some of the effective Ayurvedic
medicines
Select References:
1
Arnold David (ed.) Imperial Medicine and Indigenous Societies Oxford University
2
Sanerji D. • Place of Indigenous and Western Systems of Medicine in the Health
Press, London. 1989
Services of India. Paper presented at IX World Congress of Sociology, Uppsala,
1978.
3
China Handbook Editorial Committee,Sports and Public Health, China Handbook
4
China Health Care Study Group, Health Care in China: An Introduction Christian
5
Government of India, Ministry of Health, Report of the Committee on Indigenous
6
Government of India, Ministry of Health, Report of the Committee to Assess and
Series Foreign Language Publishing House, Beijing, 1983.
Medical Commission, Geneva. 1974.
System of Medicine Vol.1 GOI, New Delhi, 1948.
In spite of such policy pronouncements, in recent years the
central plan outlay for Indigenous Systems and Homeopathy
has never been even a full 5 % of the allocation for health. In fact
in the VII Plan it was only 1.27 %. The IV Plan (1969-74)
allocation of 4.72% was the highest. This vividly illustrates the
near total marginalisation to which the indigenous systems
have been subjected to in the post-colonial India. Due to the
neglect of and poor investment in the indigenous systems both
before and after independence the utilisation of Ayurveda and
the number of Ayurvedic practitioners are on the decline.
Evaluate the Present Status of Ayurvedic System of Medicine New Delhi.
1959-60.
7
Hughes John, The Philosophy of Social Research, Longman, London, 1980.
8
JaggiO. P.. Ayurveda: Indian System of Medicine, Alma Ram and Sons, New Delhi,
9
Kragh Helge, On Science and Underdevelopment Roskilde Universitetsforlag,
1981.
Roskilde 1980.
10 RoseH. and Rose S., TheProblematicInheritanceofMarxandEngelsontheNaUiral
Sciences in Rose H. and Rose S (Ed) Political Economy of Science, MacMillan,
g
London, 1976.
PREPARATORY SYMPOSIUM FOR T.B. PROJECT
A preparatory symposium for the FRCH research
project on "Social and Operational Constraints in T.B.
Control" was organised at Pune on 2nd and 3rd
November, 1991.
The purpose o f the symposium was to present the
Research Plan in the preparatory phase of the project
before the experts and have their comments and
suggestions. As policy planners, they are the real
consumers of the research study. Tills will enhance the
relevance of the study, which will be useful for policy
formulation.
On the first day, afterthe welcome address by Dr.
N.H.Antia and an introduction to FRCH by Dr. Ramesh
Awasthi, Dr. Sheela Rangan gave a brief overview of
research in T.B. control, which was followed by Dr.
M.W. Uplekar’s talk on the research and intervention
needs in Tuberculosis Control. Later in the day the T.B.
project team presented the progress made in the above
project during the last few months by presenting a
resume of the work done , sampling strategies and
various research instruments prepared. In this the
interview schedules, Interview guides, the formats of
the case study and observations to be made were
presented and discussed.
On the second day the invited expertsga ve critical
comments and suggestions on the Research Plan. This
was followed by an open discussion with them, by the
research team, which was very fruitful. The invited
experts who participated in this symposium included,
Dr. S.P. Tripathy, Director General, ICMR, New Delhi;
Dr. D.R.Nagpaul, Retired DirectorNationalTuberculosls
Institute, Bangalore, and presently Hon. Technical
Advisor to T.B. Association of India, New Delhi; Dr.D.
Banerji, Head, Centre o f Soc ia I & Community Medicine,
JNU, New Delhi; and Dr. R. Prabhakar, Director
Tuberculosis Research Center, Madras.
COMMUNITY
HEALTH CELL•
FRCH NEWSLETTER, VOLV. NO. 8. NOV.- DEC. 91
326. V Main, I Block
Koramengala
Bangalore-660034
Indie
UNDERSTANDING TRADITIONAL MEDICINE
The Meeting Ground.
Darshan Shanker
The revitalisation of traditional medical wisdom, which
still caters to the health needs of a major section of our society,
can play a major role in realising the ideal of self reliance in
primary health care. Instead of re-educating the people with
exclusively Western concepts, the healthy elements ofthe people’s
own health traditions should be strengthened and the distortions
removed.
Sensible Strategy
Despite the creation of an impressive modern medicine
infrastructure for health delivery services in rural areas which
includes District Level Hospitals, Block Level Hospitals (for
1,00,000pop.), Primary Health Centres (for 20,000 pop.), Primary
Health Units (for 3,000 pop.) Village Health Guides (for 1,000
pop.) the percentage of the rural population actually covered by
the state health sendees is reported to be 30% at the maximum
and in certain difficult areas, as low as 3%. Bearing in mind the
limitations of governmental machinery, even with additional
inputs to improve the efficiency ofthe system, the coverage is not
expected to rise substantially. In the light of such ground
realities, it has become necessary to critically review the strategy
that should be adopted in India in order to achieve the goal of
‘Health for All’.
My thesis is that in a country of India's size, the state will
never be able to provide basic health services to all, through its
official machinery. The state should therefore revise its strategy
for achieving this goal by ‘enabling’ communities and individuals
to engage in ‘self-help’ for provision of‘primary’ health care and
should complement the community’s own efforts by way of
providing critical referral support. The basic instrument forpromoting this ‘enabling’ role and self-help of rural communities
should be a culturally sensitive programme of“health education”.
A realistic goal to aspire for by the year 2000 AD should be a
provision for an enabling scheme of ‘health education to all’
rather than the present goal of ‘health services to all’.
In the above context it will be discovered that traditional
health culture has a tremendous role to play, as India has
perhaps one of the richest ethno-medical traditions in the world.
They are based on widespread local knowledge and resources.
mostly plants, but also animals and minerals. Self reliance in
primary health care is possible if it builds up on this heritage of
the people of India.
Traditional Medical Wisdom : two streams
Traditional Medical Wisdom expresses itselfin two streams,
the empirical stream at the folk level and the codified stream at
the shastric level. The former is of the nature of traditional
Darshan Shankar is the Director, Academy of Development
Science, Kashele, Dist. Raigad. He has made pioneering
efforts in the promotion of indigenous medicine, specially
herbal medicine
FRCH NEWSLETTER, VOL.V, NO. 6, NOV,- DEC. 91
beliefs, norms and practices based on experience and passed
down via an oral tradition. It is located in the villages of India.
It may be called the lI/)k Swuslkya Purantparci (LSP) or ‘Peoples'
Health Culture’. The LSPs are spread across the length and
breadth of the country in all our rural communities. The carriers
of the LSPs are millions of housewives with practical knowledge
of home remedies, food and nutrition, lakhs of traditional birth
attendants, thousands of bone setters, practitioners skilled in
acupressure (uannan), eye diseases (neb a ckikUsa.), dental care
(danl vuidyas), poisons brisk uuldyas), veterinary care (pasku
vuidyas) and village level herbal medicine healers, especially in
tribal communities, who treat a variety of common and chronic
ailments.
The second stream of the traditional health system is the
scientific (or 'skaslriya*) level. This consists of codified and
organised indigenous medical sciences like Ayurveda, Siddha,
Unani and Tibetan medicine. These indigenous systems of
medicine (ISMs) have sophisticated theoretical foundations
expressed in thousands of manuscripts covering treatises on all
branches of medicine and surgery.
Both exist in a symbiotic relationship. It is the codified
stream that can assess the folk stream based on its understanding
of principles of drug action, etiology, etc. and remove distortions
from it. In fact, the rationale of many folk practices has been
better understood within the theoretical framework oftheskasbie
stream. The skastrie stream can, in turn, learn from the
empirical knowledge of the folk stream.
Resource base of Traditional Medicine
Medicinal plants form the major resource base of the
indigenous systems of medicine since over 80% of the remedies
are plant based. Nature has provided every micro-region with
the plant species required for its local health needs. Some
examples may serve to illustrate this. The plant Epkedra
gerardiana (a Himalayan specie) from which the broncho
dilator ephedrine is derived, is typically found only in high
altitude regions and the local people make frequent use of the
whole of the plant to make a special tea consumed several times
daily to help them breathe conveniently. There are also plant
species like Acorns calamus (sweet flag) which have wide
distribution across tropical and the temperate regions. It has
important medicinal use in nervous and respiratory disorders,
which occur in a variety of bio-climates. Given their tremendous
potential it is imperative to implement suitable strategies for
conservation of dwindling medicinal plant resources.
Different Foundations: Different Knowledge
and Structure:
The Modern and Traditional sciences rest on two wholly
different foundations and cannot therefore be easily compared.
Indiscriminate comparisons, however, form the order ofthe day.
To gain an understanding of indigenous health sciences like
4
Ayurveda which is a ‘holistic science’, it is necessary to be
familiar with the indigenous scientific tradition which is
foundationally distinct from the western scientific tradition.
Foundational differences couldbe better understood ifthere was
healthy debate on alternatives in science in the Indian scientific
community.
A major problem that non-western societies have to contend
with in any serious evaluation oftheir indigenous sciences is the
common claim of all western scientists and philosophers that
‘after all, science is one, universal and uniquely expressed
(western) paradigm'. Thus, while it may be possible to conceive
of alternative methodologies, theories and practices in other
domains such as music, linguistics, logic, art and politics, there
is no such possibility with regard to science. Such claims smack
of a dogmatism borne out of western ethno-centric world view.
Beginning with such an epistemological position, it is impossible
to initiate a debate on ‘alternatives in science’ for the very idea
is dismissed as an absurdity. Given the continuing domination
of the West, non-western societies are left with no option but to
accept modern science and technology as the universal wellestablished system and to derive legitimacy for their own
traditional system by demonstrating how well the latter conforms
to the methodology, theory and practise of the former. There is
however, an urgent need to evolve a new approach to the
question of alternatives in science by first examining the Indian
epistemological position on the issue. This would indeed be
possible if scientists, philosophers and scholars of the various
Indian skaslras interested inexaminingthisquestionseriously
are given sufficient encouragement.
Different foundations in medical sciences
naturally give rise to different structures of
knowledge
The foundational theories, principles, concepts and
categories upon which indigenous health science is based are
indeed different from Western medical science. While indigenous
science is built up on the holistic perspective of the punckur
nralwbkootiia sicIdhanUu the western foundational theory is
atomistic; while the former rests on such philosophical
foundations as samkhya, vaishesika andyog, the latter rests on
various schools of positivistic foundations necessarily differ in
form, structure, categories and concepts. This foundational
difference is reflected in differences in the formulation of theories
pertaining to causation of diseases, pharmacology and drug
action, dietetrics and nutrition, physiology, diagnostics, etc.
For instance, in indigenous pharmacology, better known as
drauya guna shaslra^ the whole plant or its parts - the leaves,
stem, seeds; root, bark, fruit, flowers - is studied in terms of its
inuivo effects on such parameters as ras, veerya7 uipak and
prabkau and is used as an active substance. Modern
pharmacology, on the other hand', isolates the active chemical
entity from the plant (or its parts) and studies its invilro and
inviuo effects on different parameters. Both approaches
undoubtedly have their uses. The difference lies primarily in the
fact that in indigenous knowledge systems, that category of
knowledge known as chemistry is absent. What exists is a
holistic category called drauya guna skastru. If we believe the
absence of chemistry to be a serious lacuna in indigenous
sciences, we would have to concede that the absence of drauya
guna skastra in modern science is as serious a lacuna. The point,
however, is not one oflacunae in the scientificity ofeither system,
5
but the fact that these differences arise from fundamental
foundational differences which make unintelligible any simple
comparison ofthe form, structure and categories ofboth systems.
Terminologies and Comparisons not easily reconciled
In any comparative study of two sciences it is imperative to
have the appropriate terminology and language for a dialogue.
For instance vaatka is often equated with the nervous system or
nerve force and pillka with the digestive system, enzymes,
hormones and the heat regulating mechanism. While such
equating may work at one level, it often breaks down at other
levels. For example in indigenous practice, intellection is a
function of pittka, representing a preponderance otsalwaguna.
In Western philosophy, however, intellection would fall in the
domain of the nervous system (cerebrospinal) which is equated
with uaulka in the indigenous science.
The untenability of such an equation arises from the fact
that the principles of classification belong to radically different
orders. Western physiology speaks of the nervous tissue,
muscular tissue, epithetical tissue, etc. The principle of
classification is anatomical, based on the structure of the
component parts. In the triadic classification of uaatka, pittka
and kapka, the basis is biological, based on the function correlated
to the three gunas.
Departure from the experimental method of
Western science
The essence of the modern laboratory method is to isolate
any problem from its environment, to eliminate its interlinkage
with other diverse factors in nature and reduce it to the minimum
possible number of controllable parameters. These parameters
are then varied (usually one at a time) and their effects on the
system studied.
s
In contrast, the traditional approach attempts to solve
problems by taking them in their entirety together with their
inter-linkages and complexities. This method ofsolving problems
in their natural settingseems to be efficient in providing balanced
solutions. Indian systems seek to systematize common sense
and to make it rigorous rather than destroy its essential unity in
its multi - facetedness. Thus, according to Charaka, science is
dependent phenomena brought into existence by the coming
together of a multiplicity of causes of winch the phenomena are
constituted. Again, having perceived the multiplicity of causes
it uses yuktki
to bring together appropriate actions and
materials at the appropriate time and place. The traditional
system thus, even in its theoretical formulation, seeks to find
means of healthy living rather than dissecting it or bringing
about major changes. It appears then, that while traditional
sciences are indeed built upon a stupendous amount of detailed
ad minute observations ‘experiment* (in the modern laboratory
sense of the term) perhaps does not have a clear counterpart in
this tradition.
Measurement and Quantification differences in approach
Although measurement and quantification are an important
part of indigenous systems of medicine, they differ in form from
the modern systems. Most measurement in the traditional
Continued on page 11
FRCH NEWSLETTER, VOL.V, NO. 6, NOV.- DEC, 91
AN INTRODUCTION TO HOLISTIC MEDICINE
(Compiled Article)
Medical centres around the world are coming to understand
that the human mind is not walled off from the supposedly
involuntary activities of the autonomic nervous system. Medical
scientists are dealing with evidence that the brain is a force in
our healingprocess, producing or ordering the endocrine system
to produce the changes in the body’s chemistry. In this way the
mind can govern the ability of the body notjust to overcome pain,
but to regulate such functions as respiration, digestion, circulation
and even cell reproduction.
What is Holistic Health ?
These findings are what make the basis of holistic health
care. While there are many definitions, the most accepted one
comes from the Berkeley Holistic Health center, Claifornia
“Holistic Health (H.H.) is the state in which an Individual is
integrated in all levels of being: body. mind, spirit and emotion."
All modalities of treatment may be used in holistic health surgery, medicine, chemotherapy, radiation, hypnosis,
acupuncture, acupressure and yoga to name a few. The key is to
use them appropriately and responsibly. Assuming responsibility
for one’s health is really the ultimate goal of holistic health. It
holds that the human being is a fully coherent and integrated
life support system with built-in mechanisms of balance and
control. The mind is regarded notjust as a biological switchboard
but a centre for total management. Therefore, the mind must not
be bypassed or underestimated in any healing effort.
roles in underminingour quality of life - poverty, unemployment,
malnutrition, mortality, crime, divorce, human unhappiness,
stress: especially stress, for that causes a multitude ofpathological
conditions. H.H. is more ecological in orientation than allopathic
medicine. It acknowledges the inf nite resources available to the
individual and seeks to decrease dependency on sophisticated
biomedical technology.
Harmony and Balance in Medicine
The rise of allopathic medicine with its scientific approach
became the dominant paradigm in the 20th century, particularly
in the Western world. It viewed the world as a sort of giant
mechanical machine governed strictly by rigid laws of nature.
Tills left out the spirit both in man and in nature. It neglected,
for the most part, the interrelationship between mind and body,
psycho-social and biochemical aspects of the diseases. It led to
various assumptions:
i)
Disease was conceptualized as an outside organic entry that invaded
the body and attacked a particular part.
li)
The appropriate treatment for an illness is a biochemical agent that
will counter-attack the causal agent and neutralize it. So the
physician’s role was seen mainly as selecting a pharmaceutical or
surgical intervention aiming at the afflicted part.
iii)
Since bodies are considered to be essentially the same (like machines)
personal consciousness was not considered to be a significant
variable. So the same intervention was applied to different patients
as long as the organic symptoms were the same.
Why Holistic Health ?
People have become aware that modern drugs can be
healing, but are also powerfully dangerous. Antibiotics can be
miracledrugs and also make bacteria resistant to any treatment.
Each drug has a side effect which is sometimes greater than the
benefits. Growing public awareness through newspaper and
magazine articles and consumer consciousness groups has
resulted in a growing distrust of modern dings.
The distinct features which characterise H.H. have further
popularised it amongst the conscious sections in society. H.H. is
person oriented rather than disease oriented. It recognises that
the patient is an active committed partner in the healing process
rather than a passive recipient of treatment. It respects the valid
contribution of current medical science and practice and seeks
for their responsible integration with traditional and alternative
healing and health programmes. Whenever appropriate it
recommends use of gentle, natural forms of healing. While
recognising the value of the rational, scientific approach as a tool
for discovery, understanding and evaluation, it also accepts
non-scientific " approaches in some situations, especially when
this results in a noticeably healthier person. There are many
factors outside the province of medicine that play significant
This article has been compiled verbatim from the following:
i) Huss,Carol (Ed) The Banyan Tree : A Textbook for Holistic
Health Practitioners,Vol1, Pune Medical Mission Sisters, 1989.
ii)Payapilly, Celine (Director, Holistic Health Centre, Pune)
Holistic Health (unpub), 1991.
FRCH N A/SLETTER, VOLV, NO. 6, NOV,- DEC. 91
iv)
Knowledge regarding treatment is complex and known only to the
specialist and therefore the patient is seen as a passive recipient of
the intervention, preferably without interference or resistance since
the doctor knows best.
The theme central to the holistic approach is individual
responsibility for one’s health. In the words of a patient who was
healed through treatment by the H.H process :
"I made myselfsick and I removed it myself. I knew why I was
sick - the main cause was stress and I know now how to manage
stress in a better way. I was not able to digest my food. After many
investigations, I was told that my pancreatic enzyme was not being
produced. I was told that nothing can be done for it and I ha ve to live
with it and keep a strict diet and continue pancreatine tablets until
I die. Then I attended the Holistic Health Centre and was helped to
see the real problem. Side by side with foot reflexology, diet with
sprouts and stress management, within two months my pancreas
started to function normally. I stopped all the medicines and started
on normal diet. By taking responsibility for finding the cause, I
achieved a permanent cure.”
The concept of holistic approach to health is not a new one.
In fact it is as old as medicine itself. Hippocrates was
quintessentially holistic when he insisted that it is natural for
the human body to heal itself, and that this process can generally
take place even without the intervention of a doctor. Holistic
medicine merely reconnects to roots and goes forward with
people taking responsibility for their own health and also that
of the environment in which they live.
e
6
AFRICAN TRADITIONAL MEDICINE:
Concept, Practice and Policy
Shirish Kavadi
A movement in support of traditional medicine has grown
gradually over the last one decade in Africa. The growing
interest is part of the search by the WHO and governments for
alternative sources for delivering primary health care to the
underserved rural communities in non-industrial countries.
Governments in Africa, urged on and supported by the WHO, are
attempting to develop the indigenous systems of medicine
through research, standardization and regulation of traditional
healing practices. These steps are being undertaken with a view
to greater utilization of traditional medicine in national health
systems.
The Spiritualist or Diviner: Spiritualists practice divination
and also diagnosis through dreams and trances. They specialize
in metaphysical treatment and do not normally give patients
any physical examination. Spiritualists first identify the social
and psychological symptoms and signs of the ailment. Later the
patient is given herbal medicine.
Faith Healer's: Faith healers investigate the social rather than
the physical cause of the disease. They subject their patients to
intensive interviewing and use social analysis to get to the root
cause of the patient’s illness. Apart from interview, faith healers
rely on mediation, dreams and prayers for diagnosis.
The indigenous approach
The African approach to health is holistic, incorporating
the personal, social, physical and spiritual aspects of a human
being’s life. The concept of illness and disease is inseparable
from their religion or philosophy of life - a reflection of the
African world view. Africans perceive the world as one moral
universe in which humans, spirits or God(s) interact: as one in
which human beings maintain a harmonious relationship with
their material, social and spiritual environment: and one in
which the spirits of forefathers or God(s) are guardians of the
social order.
Illness results from breach of the universal moral laws.
When an individual transgresses the universal moral laws he/
she disturbs the natural equilibrium between him /her and the
social, physical or spiritual environment. Illness is a physical
manifestation of this lack of harmony between the individual
and the environment. It is also retribution from God(s) or spirits
who, as guardians of the social order, can take punitive action
against those who infringe the moral order of a society. Sickness
may also be induced by a sorcerer or the will of malevolent enemy
or because a spirit has not been propitiated.
It is clear that indigenous medical system views moral
health and hygiene for the immortal soul as its most important
concern as against Western medicine which emphasizes physical
health and body hygiene. The latter specializes in prescribing
medicines, injections, or surgery. Traditional medicine differs
in stressing health in its totality thus including within its ambit
health problems related to the physical body, the mind-soul, the
social and spiritual environment. Several types of traditional
practitioners are found in Africa. However, reference is being
made only to the more commonly known.
Shirish Kavadi is a researcher at FRCH Bombay. He has
recently completed a study making a comparative analysis
of health systems and financing of various countries.
Presently he is involved in the study of "Health Expenditure
and Investment in a District".
7
The Herbalists : The herbalists, besides prescribing herbs,
also assume the roles of counsellor, pharmacist and social
worker helping in the rehabilitation of patients.
All the three above mentioned healers, particularly faith
healers and spiritualists, treat psychosomatic diseases. They
also diagnose and treat epilepsy, impotency, insanity, chest
asthma, and spirit possession, bewitchment, sterility and
infertility. Spiritualists and herbalists in addition diagnose and
give medicine for such ailments as marital discord, rheumatism,
venereal diseases, love problems. Overweight, high blood
pressure, problems of unemployment, delirium, forgetfulness
oedema and prevention of disasters are the other ailments
which spiritualists treat. Besides those mentioned above,
herbalists have cures for cough, persistent headaches, prolonged
menstrual periods, abdominal pain, charms for good luck,
diarrhoea, vomitting lumps, worms and child delinquency.
Apart from the practitioners referred to above, there are the
traditional paediatricians and mid-wives who deal with
pregnancy related illnessess and health problems of mother and
children. These two, along with the herbalist, are concerned
more .with health problems of the human body and the physical
world, than with spiritual disturbances.
Revived Interest
The WHO and African governments have acknowledged
the failure of modern health services to meet basic health needs
of the African people and are therefore prompting traditional
medicine. Health services are characterized by inequity,
inefficiency, shortagesand geographical maldistribution of health
resources. Large hospitals and other well-equipped healthunits
are mainly located in the urban centres. The majority of
qualified health staff - and the number is absurdly low in most
countries - are similarly based. Rural areas, where 80 percent
ofthe population resides, are underserved or without any primary
health sendee. Existing health care units suffer from inadequate
supplies, staffshortages and lack maintenance funds. Expansion
and extension of health care services to the rural communities
COMAUNITY "HLNLHICELL
326, V Main, I Block
Koramongala
Bangalore-560034
India
is rendered difficult by the lack of necessary finances. Modern
health services are also particularly subject to competingdemands
for the available but limited resources. Since health is not a
priority concern of the governments in developing countries it
receives less allocation than requirement. The economic crisis
of the last decade lias only aggravated the problem. But illhealth is more prevalent in rural areas than urban. The rural
masses are most vulnerable to illness being exposed to (the inter
linked factors of ) a hostile environment, poverty, under
nourishment and malnutrition. They are also ignorant of the
objective causes of ill-health and of the appropriate protective
measures.
One way of rectifying the situation would be to have more
hospitals, dispensaries, health centres and a proper distribution
of essential drugs. However, these modern health systems
require sophisticated technology, specialized personnel,
considerable financial investment and are hence expensive.
Moreover such type of sendees may be inappropriate to the
situation. It is common knowledge amongst medical practitioners
that many diseases can be easily treated by suitably trained
paramedical staff through simple methods and do not need the
attention ofdoctors or specialists. Theauxiliary health personnel
only need to be accessible. This has been an important
consideration in the promotion of traditional medicine.
Since 1970 there has been a growing realization that socio
economic development required a healthy labour force. A
precondition to economic development was improvement in the
health of the people and hence primary health care became the
focal point of health care development in the non-industrial
countries. But primary health care objectives could not be
attained with the various inadequacies prevalent in existing
national health systems.
Against this background the WHO began searching for
alternative forms ofhealth care delivery system (apart from the
Western system of medicine), with African governments. WHO
and UNICEF have concluded that curative medicine is
inadequate and that hospital treatment, as it exists in industrial
countries, is both expensive and unsuitable for the situation in
the developing countries. In addition, the Western approach to
health and illness and its treatment is incompatible with the
African concepts of health and illness.
It is argued that
historical, cultural and sociological factors have identified
traditional healing systems as this alternative source.
Traditional medicine, it is observed, is readily available and
accessible in every rural community besides being culturally
acceptable. A very large section of the population, already seek
treatment from indigenous healers.
After evaluating this situation, WHO lias formulated a
strategy which aims at using Africa’s own resources, including
indigenous medicine as it is currently practised. Traditional
healers can offer low cost and simple treatment. Moreover being
an integral part of the local culture they know the community in
which they live. They can make themselves acceptable to the
people. The WHO programme expects African countries to
identify and exploit those aspects of traditional medicine that
provide safe and effective remedies or practices particularly for
use in primary health care. The scope for utilising the skills of
traditional healers to achieve the minimum acceptable WHO
standard of health personnel to population ratio are therefore
FRCH NEWSLETTER, VOL.V, NO. 6, NOV.- DEC. 91
being explored. The cooperation of indigenous practitioners is
also being sought in the hope of improving and extending basic
health care services to the underserved rural communities and
to operationalize primary health care objectives.
Government Policy
The WHO has a coordinated programme for utilising local
traditional herbal medicines and tapping the skills and
knowledge of indigenous healers. Most governments in Africa,
having adopted the programme, are formulating policies to
operationalize it. Research projects drawing upon Africa’s
accumulated knowledge of traditional medicine are underway.
They seek to identify the active ingredients of various plant
extracts and mixes used in folk medicine. Aiming at producing
a pharmacopoeia of the medicinal plants of Africa, it is expected
that local import substitutes in pharmaceutical production
would be obtained and the local pharmaceutical industry would
be developed. Thus the governments would be able to curtail
imports and save scarce foreign exchange. This would further
help to reduce health care costs and it is felt the ultimate
beneficiaries would be the people. The focus is on rational study
of medicinal plants because that is an area which is directly
accessible to scientific research. Governments, along with the
WHO are fostering research into botanical, phytochemical and
pharmacology aspects of traditional medicinal herbs and plants.
Toxicity levels ofcommonly used herbs are also being investigated
to determine then* positive and harmful qualities. Some of the
WHO supported research institutes have already made some
progress in regard to making an inventory ofplants, plant health
control and utilization of medicinal plants.
The Medical Research Institute, Nairobi (alongwith the
WHO), the Department of Chemistry, University of Malawi,
(supported by the International Foundation for Science, Sweden),
the Traditional Medicine Research Unit at the University of
Dar-es-Salaam and the University of Zimbabwe are involved in
such research programmes.
This research has helped to a certain extent on reducing the
drug expenditure in some countries. Senegal has saved an
estimated $ 631,000 a year in foreign exchange by developing
READER'S COMMENT
I regularly receive the FRCH bulletin. I find the articles
i nteresti ng a nd useful, but would a ppreciate the bulletin
more if you publish articles/comments/news items in
the field of community health - in short, happennings
even outside FRCH. The bulletin should reflect and
respond to contemporary events, - Drug policy in the
offing, safety of Ayurvedic preparations (ref; Sura),
patients* rights (context; M ARD strike), etc.
Ravindm R.P, Bombay.
The suggestionsare welltaken. Inthiscontext, weinviteour
readers to write for FRCH newsletter. Ifpotential authors
indicate their interests, specific articles could be
commisioned.-- Editor.
8
and producing two low cost drugs: one a cough syrup and the
other a laxative. The former is derived from an indigenous plant
called gueira and is considered as effective as codeine based
drugs manufactured in Europe, while the latter is based on the
lam plant.
Mental health is another area in which research is conducted
to determine the contribution traditional healers can make to
the care of the mentally ill. It is felt that although Western
medicine is un-su rpassed in the rel iefofphysical health problems,
traditional medicine, well-versed in local psychology, is better
placed to deal with some of the mental health problems of the
local people. Such research programmes are being carried out in
Senegal and Zimbabwe. In the former, the programme also
includes several experiments in cooperation between psychiatric
hospitals and indigenous healers who specialize in treating
mental disorder.
Training is being imparted to some types of traditional
health staffsuch as traditional birth attendants (TBAs), perhaps
because in most African countries more than 60 per cent deliveries
are conducted by TBAs. The TBA is perceived to be not just a
mid-wife but a social worker and a herbalist specializing in
diseases of women and children. The government of Zimbabwe
has embarked upon a training programme for the traditional
mid-wives in every province, conducted by the District and Rural
Health Centre Staff operating at the grassroot level. Zambia has
provided additional training to TBAs through UNICEF and
WHO assistance. In Malawi, the Ministry of Health has
undertaken training programmes for TBAs in all the 24 districts
of the country hoping to provide primary health care through
them to the whole population. In the Gonda region of Ethiopia
it has been observed that the standard of care available to
mothers and babies significantly improved after traditional
birth attendants had been given a two - week training course.
Policies to facilitate a better and greater utilization of
traditional healing are being worked out and planning is being
done to incorporate the services of indigenous healers into
national health systems. Government plans include legal
recognition and organization of these practitioners to submit
them to standardization and regulation. Issuing licences is one
way of conferring legal recognition. It is also the most preferred
legalisation method in Ghana and Nigeria where individual
licenses are issued to the practitioners while in Botswana, the
government has authorized the Traditional Healer Society “to
regulate the practice of traditional healing, issuing licences to
those whom its officers,judge to be competent.” Supervision and
control over practice is essential to ban or eradicate the negative
aspects of indigenous healing practice.
National associations are being encouraged to act as
supervisory and regulating bodies. For this reason governments
are encouraging the setting up of such associations. In Zimbabwe
the Traditional Medical Practitioners’ Act No. 38 of 1981 which
gave legal recognition to the healers also established the
Traditional Medical Practitioners' Council, with responsibility
for supervising and controllingtraditional healingpractitioners.
In Zambia indigenous healers were asked by the government
to form an association to standardize and control their practice.
The Traditional Medical Associations in Nigeria lay down some
guidelines for the practice by their members and are responsible
9
for disciplining of erring members. Zambia and Zimbabwe have
instituted registration for traditional healers, making it an
offence to practice without registration. The Government of
Zambia has introduced regulation to eliminate and ban
indigenous healing and medicinal practices perceived to be
negative or deemed inimical. The Witchcraft Act 1967 provides
for penalties for the practice of witchcraft. But the government
also encourages legitimate healers to institutionalize their forms
of healing and thus supports the growth and development of
indigenous medicine. In Nigeria, while the Federal Government
is itself a long way from legalizing and utilizing traditional
healers in the country’s health delivery team, the governments
of Lagos and Oyo states have already acted upon it. Governments
are making various efforts to integrate traditional medicine into
the national modern health systems. The governments of
Guinea, Mali and Zaire view integration as a part of a total
reform of the medical system from a public health perspective.
Efforts are directed towards establishing new public systems
into which traditional healers will gradually be integrated and
play a defined role in the provisions of both primary and
specialized health care.
Concluding remarks
There appears to be a fair degree of ambiguity with regard
to traditional medicine in most countries. By and large traditional
practice has been left un-regulated, it has generally not been
made illegaland in countries where licensing ofsuch practitioners
does exist the effect, has been minimal.
An argument made in favour of traditional medicine is its
cultural acceptability. The WHO approach however does not
take into consideration the essentially holistic approach of this
system because it concerns itself merely with the physical and
biological aspects which form the basis of modern medicine.
Besides, modern and traditional health systems are viewed as
being complementary to one another. Yet this complementarity
does not appeal’ to develop into effective cooperation. The two
have still to be integrated into a structure which acknowledges
the fundamental legitimacy of both systems.
Wherever academic and research interest exists in
traditional healing methods, specific healers are referred to or
are consulted by modern practitioners and researchers, only on
an adhoc basis. The problem with indigenous healers is their
reluctance or refusal to part with their knowledge which is
regarded as absolute secret. Being a gift from the spirits it
cannot be transmitted. They do show a willingness to cooperate
or have no objection to exchanging patients or information but
are unwilling to working together.
An additional problem has been lack of funds. The WHO
collaborative research institutes and programmes have financial
and other resources. But this research is being carried out
mainly by persons trained in modern medical science. On the
other hand, associations of traditional healers who may wish to
carry out research are constrained by the lack of resources. The
Zimbabwe National Traditional Healers Association (ZINATHA),
despite having both a research department and trai ning centre,
has been unable to cany out either task due to lack of funds. The
WHO committee of experts on traditional medicine has
maintained that the main reason for traditional medicine in
some developing countries not making substantial progress as
Continued on page 12
FRCH NEWSLETTER, VOL.V, NO. 6, NOV,- DEC, 91
MEDICAL PLURALISM
Some Theoretical Problems
Dhruv
Mankad
Anthropological investigations of health care practices
have demonstrated that medical pluralism is the rule and not
the exception the world over. Medically plu ra listic societies offer
a variety of alternatives ofhealingtechniques. These alternatives
not only represent different medical systems : allopathy,
homeopathy or Ayurveda, they represent different ideologies,
each having a separate historical and philosophical base and
each providing a different theory of treatment.
traditional experiences can be analysed on their own terms, they
are no more or less progressive than other experiences. For
example, it is argued that it is only when we consider mastering
nature as an ideal for a scientific endeavour that “western”'
medical science is progressive. On the other hand, it further
argues, if we consider harmony between man and nature as a
predominant value then the achievements ofAyurveda or Chinese
medicine stand out as more advanced.
While it has been argued by some that medical system itself
is a cultural artifact and therefore an ideology also, it is the
ideological aspect of a medical system, that presents complex
theoretical problems in understanding and analyzing what is
conventionally called Traditional Medicine. These problems can
be broadly classified into the following categories:
However, such a view is not without its critics. While
sympathising with those wanting to do justice to the
achievements of non-western or pre-modern cultures, the critics
of ethnocentrism warn of dangers of falling into relativism and
of denying the fundamental continuity and universality of all
science. By considering the science of different cultures as
totally separate, immiscible thought patterns, irreconcilable
and unconnected, such a view may be used as a cloak for some
historical racist doctrine
1.
The relationship between medical system and culture.
2.
The legitimacy of pluralistic analytical concepts in
medicine.
3.
The problems of integration.
It has been argued that each medical system is a product of
its historico-cultural condition. It is true that all organised
medical systems derive their overall philosophical, ideological
orientations from the surrounding culture. Thus, Ayurveda is
rooted in Nyaya Viseshu and Sanikkya. The modern medicine,
allopathy, derives its philosophical framework from positivism.
It is also argued that each major transformation in the dominant
framework ofunderstanding human diseases and their treatment
was a cultural transformation.
The problem that such a view throws up is that if each
system is defined in its own cultural terms, can we legitimately
talk of progress in scientific thought in any real sense ? Can we
consider modern medical theories and methods as an advance
over the traditional ones ? If we indeed do so, medical systems
like acupuncture, which are practised widely and effectively and
do not find a place in the modern medical thought, will have to
be rejected as being not a part of this march of modern science.
The other problem that such a view leads to is the
ethnocentric view of the cultural artifact that a medical system
is. An ethnocentric view of medical system maintains that each
system can be understood and analysed on its own terms. It also
maintains that a traditional medical system is a part ofa culture,
a way of life and thus cannot be grafted on an alien culture. Thus
it considers attempts to analyse factors leading to progress hi
scientific thought as being futile because it considers that if
Dhruv Mankad is a medical doctor and is presently
Director, Voluntary Association for Community Health and
Nurture, Nasik, Maharashtra.
FRCH NEWSLETTER, VOLV, NO. 6, NOV.- DEC. 91
If we accept the pluralistic view implied in the criticism of
the ethnocentrist / progressivist views outlined above, we have
to grapple with a further theoretical problem. Can there be more
than one scientifically valid but distinct conceptual analytical
framework for diagnosis and treatment of a single disease
entity? Can there be more than one valid causal explanation of
an event, forming the basis of the medical intervention as
evinced by two different but presumably effective modes of
interventions ?
Such a view is alien to the existing medical scientific
thought, though not entirely so to physical sciences where
multiple explanations of a physical phenomenon have been
found to be acceptable but after a philosophical debate. An
alternative to the plural view is an integrative view ofall medical
systems. Such a view argues that modern medical science has
not replaced traditional medicine after carefully screening of
traditional theories, practices. Ayurveda thus, for example, has
just passed out of fashion as a result of forces other than those
generated by internal developments.
Such a reevaluation forms the basis of integration of all
valid theories / practices into the body of medical knowledge and
would involve:
a)
Interpreting a disease in modern terms and evaluating
a traditonal drug like any other modern drug.
b)
Diagnosing a disease using traditional conceptual
framework and testing a drug clinically by the same
method. This would not only-test, using modern
evaluating techniques including the statistical ones,
the efficacy of a drug but also the theoretical validity
of the diagnostic principles involved.
10
However, the critics of this view point to certain theoretical
problems inherent in such a reevaluation.
traditional medical systems like Ayurveda, by this definition,
can qualify as sciences proper, neither pseudo- nor proto- sciences.
(a)
Thus, at its most fundamental level, the problematic of
traditional medicines is the problematic of the philosophy of
science.
(b)
It presupposes the superiority of the testingtechniques
ofthe modern medicine over the ones used by traditional
medicine, a presumption which, in itself, is
questionable.
This reduces traditional medical system, which is
holistic, encompassing a healthy way of life and not
just a therapeutic technique, into a technique within
the terms set by a modern medical framework.
Select References
1.
Alvares, Claude. Homo Faber Technology and Culture in India, China and
the West 1500-1972. Allied Publishers (P) Ltd., New Delhi, 1979.
2
Chattopadhyaya, D. Science and Society in Ancient India. Research India
3.
Elzinga, Aant and Jamison, Andrew Cultural Components in the Scientific Attitude
Publications, Calcutta, 1977.
Finally the most fundamental theoretical problem, the
question of traditional medicine throws up is regarding the
definition of science itself. If science is defined (content wise) as
a body of knowledge obtained by a systematic observation of
events, phenomena, tilings and (method wise) as the process of
knowing and explaining the dynamic interrelationship between
events, phenomena and things in materialistic terms, based on
such systematic observations, then the special status awarded
to allopathy vanishes. There is nothing in this definition that
precludes the possibility of referring back to the insights gained
in the past or in other cultures in order to further the
approximation to reality which it attempts to obtain. Organised
contd from pg.5
science are made usingunits ‘normalised' to an individual. That
is, while assessing a person’s height or the length of his or her
limbs, the measurement is expressed in units of anguli the
dimension of a finger of the concerned individual rather than an
arbitrary standard external to the individual - the international
metre. Such normalised units exist not only for measurement of
length but also for volume and time. In Yoga Cluidainani, for
instance, a maal.ru of time has been defined as the time taken
by a sleeping individual to complete one cycle of breathing - one
inhalation and exhalation. Although measurement and
quantification have their place in indigenous systems ofmedicine
their importance is somewhat limited as compared to modern
systems. In India it is not the geometry of Euclid but the
astkadkaayi of Panini that is considered to be the supreme
example ofthe construction of theory. Indian sciences are based
on the understanding that number’s and symbols are essential
to achieve scientific rigour rather than the "technical use of
natural language. Sanskrit, for instance has sufficed in highly
abstract and technical topics like logic, mathematics and Vedanta.
Recent research has indicated that this method of using natural
language to achieve rigour has powerful applications in computer
sciences as well.
The need for legitimising serious cross cultural medical research
Such differences should come as no surprise to those medical
professionals aware of the plurality of cultures and their varied
scientific expressions. Difficulties in correlating principles,
categories, concepts are only to be expected in any cross cultural
11
to Nature: Eastern and Western Modes? Research Policy Studies Discussion
Paper I46oi Research Policy Institute, Lund University, Sweden, May, 1981.
4.
Foucault, Michel. The Birth of the Clinic: Tavistock Publishers. London, 1976.
5.
Leslie, C.: Introduction in Asian Medical Systems (Ed.) University of California
6.
Mankad, Dhruv. A Dialectical Approach to Traditional Medicine - a case of
Press. Berkeley 1976.
traditional Chinese medicine in Socialist Health Review Vol. 2 No. 4 Bombay 1986
7.
Mankad, Dhruv and Narayan, Ravi: Medical Pluralism: a caseforcritical attention.
Medico Friend Circle Bulletin No.155-156. Wardha. 1989.
8. ■ Prigorgine, Iliya. Chaos out of order, Fontana Paperbacks, London, 1989.
9.
Rose, H. and Rose.S : Science and Society Penguin Paperbacks, London, 1970
B
endeavour. They have to be faced and resolved by serious
comparative research workers. Schools for comparative medical
research need to be established in the country. In these schools
a creative dialogue must be initiated by the medical professionals,
starting from the fundamental issues related to the epistemology
and philosophy of science. A comparative framework needs to be
constructed to serve as a bridge to cross from one side" to the
other. Only then will we be able to resolve the differences in the
knowledge structures ofthe two systems. In such schools will the
meetingground for‘understanding’traditional medical sciences
be found.
Glossary of terms
Although exact English equivalents are not possible, we
give a brief explanation of the Sanskrit terms not explained in
the text, to help the lay reader understand.
1) Shastras
Panchama habhoota Sidhaanta
3) Dravya
Guna Shastra
4) Ras
5) Veeiya
6) Vipak
6) Prabhav
8) Vaatha
9) Pittha
10) Kapha
11) Satwa Guna
12) Yukthi
2)
Text based on principles and general
and specific rules.
Principle of five states of nature.
(Earth, water, fire, air, & sky.)
Pharmacology - indigenous
Taste
Potency
Metabolised taste
Overall invivo effect.
Physiological function.
Physiological function.
Physiological function.
Harmonising property.
Method of solving a problem in-situ /
using multi-variables.
FRCH NEWSLETTER, VOL.V, NO, 6, NOV.. DEC. 91
LIBRARY NEWS
Books
12. Vithoulkas, George Homeopathy - medicine of the new man, B.Jain
Publishers Pvt. Ltd., N. Delhi, 1985, pgs. 160.
1. Balasubramanian, A.V.,Vaidya, R.M. Local Health Traditions: An
Introduction, (LSPSS Monograph No. 1) Lok Swasthya Parampara
13. Voluntary Health Association of India Rational Use of Medicines, VHAI,
N.Delhi, 1988, pgs. 40.
Samwardhan Samithi, Madras, 1989, pgs. 95.
2. Britto, G.AA. Indian Systems of Medicine and Homeopathy, FRCH,
Bombay, 1984, pgs. 52.
3. Dash, Bhagwan (Dr.) A Handbook of Ayurveda, Hind Pocket Books (P)
Reprints
1. Arya VaidyanRama, Comprehensive Rural Health Project, International
Ltd., Delhi, 1977, pgs. 161.
4. Djurfeldt, G,Lindberg, S. Pills Against Poverty: A study of the
Institute of Ayurveda,Coimbatore, 1983, pgs. 25.
2. Cheng, T.S. Medical Education and Practise in People’s Republic of
introduction of western medicine, Oxford, N.Delhi, 1976, pgs. 232.
China. Annals of Internal Medicine, Vol. 5 (83), 1975, pp. 716-24.
5. Government of India A Handbook of Common Remedies in Siddha
3. Frankenberg, R, Allopathic Medicine Profession and Capitalist
System of Medicine, GDI, N. Delhi, 1975, pgs. 83.
6. Khan, S.H. Islamic Medicine, Routledge and Kegan Paul, London, 1986,
Ideology in India 1978, pgs. 36.
4. Narayanswami, V. Social Medicine: concept of Ayurveda, Ancient
pgs.108.
7. Kurup, P.N.V. Bird’s-eye-view on Indigenous Systems of Medicine
Science of Life, 1982, pp. 35-40.
5. Oyeney, O.Y. Mobilising indigenous resource for primary health
in India, Min. of Health and Family Welfare, N. Delhi, 1977, pgs. 38.
care in Nigeria: a note on the place of... Social Science
8. Lele, R.D. (Dr.) Ayurveda and Modern Medicine, Bharatiya Vidya
Bhavan, Bombay, 1986, pgs. 539.
and Medicine Vol. 20 (1), 1985,pp. 67-69.
6. Reilly, D.T. Is homeopathy a placebo response ? Controlled trial
9. Moose, N.S. Ayurveda Flora Medica, Vaidyasarathy Press (P.) Ltd.
Kottayam, 1978, pgs. 184.
10. Mukhopadhyaya.G. History of Indian Medicine, University of Calcutta,
of homeopathic potency with pollen in hay fever as model, The
Lancet, 1986, pp. 881-886.
7. Udupa, K.N. Studies on promotion of health by ayurveda and yoga.
Calcutta, 1923, pgs. 210.
(Pandit Shiv Sharma Oration), pp. 1 -3.
11. Randi, J. The Faith Healers, Prometheus Books, New York, 1987, pgs.
•
314.
FOUNDATION FOR REVITALIZATION OF
LOCAL HEALTH TRADITIONS.
The FRLHT has its history in the coming together of
many individuals and organizations under the banner
of the Lok Swasthya Parampara Samwardhan Samiti.
The Foundation is expected to play a strategic role
towards creating a supportive environment for the
revitalization of the indigenous health culture of India.
It brings out a quarterly bulletin which intends to forge
information linkages as well as generate healthy
interaction and dialogue with all those connected with
the revitalization of traditional systems of medicine and
related areas such as logic, mathematics, linguistics,
plant sciences, etc.
For Further details contact: Darshan Shanker, P.O.
would such commercial exploitation through modern technology
necessarily and always lead to curtailingpharmaceutical costs?
Medicines may not necessarily be available at affordable prices
to the general population. It would, perhaps, be more relevant
and pragmatic to have traditional healers continue to prescribe
herbal medicine while at the same time devising such policies
and programmes as would ensure availability of medicinal
herbs and plants to traditional healers.
Select References
1)
Akerele. 0. Medicinal Plants and Primary Health Care: an agenda for action, Part
2)
Dunlop. D.W. Alternatives to “Modern*’ Health Delivery Systems in Africa: public
I & II Essential Drugs Monitor No 10,1990.
policy issues of traditional health systems. Social Science and Medicine Vol 9,
. 1975 pp. 581-586.
3)
Kikhela.N. etal. Africa's Two Medical systems: option for planners. World Health
4)
Land. Thomas Going back to traditional cures. The Hindu, July 14 1991.
5)
Last. Murray and G.L. Chavunduka (eds)' The Professionalization of African
6)
Onwuanibe, K.C.
Forum 2(1): 96-99(1981).
Medicine, Manchester Univ Press. Manchester -1986.
Kashele, Tal. Karjat, Dist. Raigad, Maharashtra.
The Philosophy of African Medical Practice: Issue: A
quarterly journal of Africanist opinion.
contd. from page 7
7)
Yangni Angate. A. Understanding Traditional Medicine: Worid Health Forum 2(2)
compared to Western medicine is because the former has not
exploited the rapid discoveries of science and technology as
effectively . It of course follows that such exploitation would also
lead to its commercial exploitation. WHO recognizes the potential
economic value of medicinal plants. Referring to research into
African medicinal plants and herbs, Prof. Norman R. Farnsworth,
Director of the WHO collaborative research programme said,
“Such research programmes can lead to industrial development
in any country where diseoueries are made". The question is,
8)
WHO:
The promotion and development of traditional medicine. WHO, Geneva.
1978.
•
240-244 (1981).
FREE ABSTRACTING
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