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_____ SPECIAL ARTICLES

Contextualising Plague
A Reconstruction and an Analysis
Im rana Qadeer
K R Nayar
Rama V Bam
- -

Ai

of the plaKUe epidemic KlarinKly portrays the dichotomies in pnhlic health and provides lessons for

the future of its practice in this country . The classical appr'ouch, which is

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to an <—*—

of the problem which would involve evolving

a mulit-pronged strateKy firmly entrenched in the socio-economic context.

NOW that the frertzy of the plague has
there were 250deaths due to gastro-entcritis.
to this disease from 1977-88 shows a con
waned, it is time to analyse the socio
Infective hepatitis has claimed several lives
sistent rise. Diseases like malaria and kala
economic and political factors that arc
in Delhi and a few years ago an epidemic
azar arc showing a resurgence despite elabo
responsible for the epidemic and the human
of Japanese encephalitis claimed hundreds
rate national programmes for their control
suffering it caused. The recent outbreak of of lives in Tamil Nadu and West Bengal.
The data on incidence ofcholera and deaths
plague cannot be viewed independently of
Several districts in western Rajasthan are
due to it indicate that there has been little
the recurrent epidemics of communicable
under the grip of malaria. According to
change in the status of this disease since *
diseases from different pans of the country,
reports this epidemic of malaria has claimed
1986. Until 1987. the ministry provides data
claiming thousands of lives. The immediate
over 500 lives and over 6O.(XX) positive
on cholera, gastro-entcritis-and dysentery
impression that remains in one’s mind is the
cases of this disease have been detected from
(Table 2). From 1988 onwards the categories
tear and pathos of human suffering and the
this region. The worst affected districts arc
hali-heartcd response of the administrators
hall-hearted
include cholera and acute diarrhoeal diseases
Bikaner. Barmer. Jaisalmer and Jodhpur?
and from 1991 the report only includes eases
and politicians in dealing with the situation.
While some epidemics get reported, many
Wha, is fairly evidem is iha, .he
and deaths due tp cholera. Given the large
have gone unnoticed. The deaths due to
was
much
number ol cases of dysentery it could not
”
•—‘i more concerned about the
blood dysentery in Bastar district of Madhya
possibly he included in the reporting of
economic losses incurred, the poor image
Pradesh and cerebral malarial deaths in
acute diarrhoea for the years 1988-91. For
presented of India by the western media, the
Bikaner district of Raja.<thun two years back
the years 1988 and 1990. according to the
cllcet it would have on exports, the tourism
are eases in point. Thus many ofthe epidc mics
ministry reports, there were 82.60.94A eases
industry and the, possible withdrawal of
that have occurred like kala azar. cholera,
and 7.290 deaths. 95.79.7 ^8 eases and 8.633
investments by multinational corporations.
gastroenteritis* malaria and now. plague deaths due to acute diarrhoea, respectively.
Given these concerns, the government
w
------- 1 wqs
have essentially become endemic diseases.
more p. retrieving India’s
The deaths due to m’uic diarrhoea was 35
preoccupied. with
Deaths due to these epidemics often do
Innes that of cholera deaths in 1988 and 99
i mage abr<»ad and I ailed to use the principles
not get rcllcctcd in the official statistics.
of epidemiology
times the cholera deaths in 1990 The
asscss control and
This is due to inadequacy of. the health
significance of this omission is self-evident.
provide relief to alleviate human sulTering.
information system which results in undcrtu
.. paper. looks
.
This
al thercsurgcncc oi
Ol the total cholera eases reported, about
reponing and in some cases even non
epidemics over lthe 1980s and locates the
XX per cent were reported from the coastal
reporting of ccrtaindiseases. This is a serious
plague epidemic by the state* based <
states of West Bcngal.Orissa. A >dhraPra<k5h
.
------- i on ' lacuna of fhc...J
’r system. Despite these
amj Tamil Nadu. Eycn Delhi, the capital city
newspaper reports and some interviews, in
limitations, the trends in number of cases
order to explore the complexity behind its i * '
with all its amenities has been wimess to a
and deaths for certain communicable
inefficient handling. Finally, the politics of
steady increase in cholera cases and deaths
diseases, based on offictal
official statistics
ktafistics arc
Since 1983 there has been a steady increase
plague and its consequences arc explicated.
revealing. The number of reported cases and
pealing.
in the number of cases of gastro-emeritis. In
deaths due to malaria and kala a/ar has been
1988 there were 14.712 eases and 6^4 were'
1
showing a steady increase. According to the
confirmed easesol cholera with 181 reported
Resurgence of Communicable
Health InforiHuuon tiullciiii brought out by
deaths (Table 3). In the Health injonnutiun
Diseases
the ministry of health in 1992. the max .mum
uj India, 1989 how ever, the recorded deaths
number of malaria cases per year were
Over the last decade, a number ofepidemics
were reduced to eight.
reported between 1971 and I976.3 After its
have broken out in different parts of the
resurgence* deaths also started rising from
country, resulting in thousands of deaths.
II
1974 onwards. From 1977 the number of
The number of such outbreaks seem to be
Plague* 1994
malarial ease registered a decline, bui the
on dw increase and is last becoming a part
number ol deaths continued to rise till the
There has been no case ol reported plague
of the disease profile of this country. A
mid-KOs. Table I shows that though the
«n India since I9b7. A few local epidemics
number of repots have appeared in
incidence ol eases seem to have stabilised
o newspapers about the repeated outbreak of
were suspected but never officially
over the mid-KOs/the apparent control over
acknowledged.4 The dwindling resources
epidemics but these very often do not get
the number not deaths is being lost. The
for public health led to the closure of mast
rcllected in the official statistics. Outbreaks
current outbreak in Rajasthan confirms this.
of cholera and gastro-entcritis have been
reported from Jammu and Kashmir. Madhya
limited to Bihar and West Bengal, more than
Pradesh. Delhi. West Bengal and some North
Eastern states. In Jammu and Kashmir alone.
closed down its surveillance unit. The signals
-a

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Economic and Political Weekly

November 19. 1994

2981

W ^1U.
0363/

(

1
alert b) the 17th Inter-State Plague co
ordination meeting in 1993 thus went
unheeded even though they were based on
the findings that rodent positivity for plague
infection was nsmg
The earthquake in Latur became the turning
point. There were rat falls and increase in
the number of fleas in Mamla village fnom
where the first case was reported.
r
By midSeptember Beed district was reporting
bubonic plague. It
I spread to the surrounding
areas, yet all these were
—insufficient for
•«. the
authorities They did not take nature's
warning seriously. The continuous rain in
Sural and the floods in Tapti inundated
localities and killed cattle, the carcasses of
which were scattered around the town. This
could .not be
. passed off as a ‘natural disaster’
even Iby the administrators and politicians,
had
. By September 20 deaths from .plague
-----J
already become a reality. From the inundated
areas near the Tapti it spread to the rest of
the city and forced people to flee. An exodus
of about I million people out of the 2.5
million population was reported. Rifts
between Sums and non-Surtis, the moneyed
who could run away and the poor who were
trapped, the administration and its workers
were all rooted in the fear of the dreaded
disease and the sutlcring of its victims.
Two things that left an imprint on the
history ot public health in India were the
acute misery and the blind fear despite the
availability of curative as iwell
" as r
preventive
technologies Second, the total collapse of
health administration. But for those dedicated
few who stayed and suffered with their
patients, the majority of the personnel
preferred to take leave or run away: For
those who have consistently argued that the
existence of technology is reason enough for
being optimistic about the future, this should
provide some food for thought.
Many explanations .have been offered for
the calamity in Surat It is said that the fast
growth ol the city, its expanding slums (just
next to the opulent mansions of the diamond
merchants) its inadequate infrastructure and
the additional strain of lack of resources for
civiv services were at the root of the disaster.
The succumbing of Sural is thus explained
by its inadequate infrastructures manned by
an apathetic, indifferent and callous admini
stration. What is not explained is the
behaviour of the capital city. While Bombay
managed to step-up its surveillance and look
the possible precautions against plague. Delhi
Continued with its false sense of security.
Even though it was clear that the fleeing
population from Sural was headed in all
directions, the Delhi administration chose to
ignore the threat.

Delhi Epidemic
While the city administration was still
trying to get its act together, three suspected
cases were admitted to the Infectious Diseases

Hospital (IDH), I wo coming from Gujarai
and one from Bombay. Of these, two
admilicd on September 25 tested positive
and heralded the onset of the plague epidemic
in Delhi. To control its spread, apart from
the booths at rail u ay stations and other entry
points, ten zonal plague control rooms were
set-up in the city. All hospitals were directed
to refer suspected case> to IDH. A list of
dov and don’ts was published. Voluntary
groups were also called upon to educate the

ment got its first beating Police force was
mobilised to get back the absconding pa
tients. and armed police also guarded the
gates of IDH to ensure that no one left the
hospital without a formal discharge.
The government of De 1 hi invoked Sect ion
385 of the Delhi Municipal Act 1957. under
which plague has been declared a dangerous
disease. The act empowered the government
to forcibly shift persons suffering from plague
to an isolation hospital and file criminal
cases against those who, go against the
provision of the act. After this, there were
reports of not only police harassment and
patients being lifted from their homes without
attendants but also of suspecting neighbours
calling control rooms to report non-existent
cases’. The use of forte came easy to an
administration that knew no ocher way to
reach out unpeople.
By September 30 it was dear that not all
cases of plague in Delhi were from outside.
Of the 66 cases suspected till 29ih. 26 were
permanent residents of Delhi. Of them 17
had neither visited Surat nor met anyone
from there. Of the 66 cases 25 were from
Surat., three from Bombay, two from
Ahmedabad and one each from Noida.
Muzaffarpur and Chandigarh

public in addition to the various official
committees and meetings at the state and

central level.
Taken aback by the calamity, the health
secretary and the Director General of Health
Services came up with- the typically
bureaucratic response. While Mehta, thechief
minister of Gujarat, denied the diagnosis of
plague in
in Surat
Surat even
even when
i ‘
‘ were
plague
people
"
dying,
the central....
health bureaucracy loo
were reported to have made a press statement
that cases tested sputum negative could be
called plague? Some others raised the issue
of diagnosis, included WHO’s nonacceptance of the haemagglutination test as
confirmatory. Fortunately,
,, at that time the
director of the National Institute of
Communicable Diseases (NICD) clarified
that a negative sputum is possible in a partially

H.

(.essxessxi

Ollll mat irtn ta»rf
—.
____ _
glutination
test may not U.be
as sensitive
as
the fluorescent antibody test but it was
reliable. The latter wasexpensive and needed
cosily reagents. Though it was reported that
the government had ordered the required
reagent from a Colorado-based US manu
facturer through the V/ HO and il had arrived,
no information was available on its use in
actual diagnosis.
On Monday, September 26, Ram Sumer,
the first case of bubonic plague was admitted
to IDH. The laboratory confirmations of
Ram Sumer’s ailment hit headlines on
September 29. By then the total cases of
plague had risen to 35 and admissions to
IDH had started increasing at an alarming
rate. The possibility of bubonic plague only
added to this pressure. When four patients
left the hospital against medical advice on
grounds that the conditions in the hospital
were inadequate, the image of the.govern*

•

•

symptoms of bubonic plague with well
developed buboes in the groins and high
fever. Lung infection in all these cases was
minimal".* A follow-up of this report, later
confirmed by the IDH personnel, pointed
out that out of the 69 cases among the
residents of Delhi till October 11. 37 were
indigenous. Of these 37. 14 had palpable
lymph nodes. However, none were fulminant
Except for the confirmation of one case,
reports for the others are not yet available.
Clinically, the diagnosis of bubonic plague
cannot be ruled out and it is only reports
of the buboe aspirate that will confirm the
diagnosis. All these cases were serologically
positive for plague
With this scare the drive for cleaning the
city
7 was intensified, the Rajan Babu TB
Hospital located next to IDH was directed *
to make ^500 beds available to IDH for
admitting suspected plague cases. Eftorts

TA.l£l . NOT1nEDCA^<yCHOt£,A. Mauaiua. Kala Az*, and Ja.a.aese Ence^autu

Year

1986
1987
1988
1989
1990
1991
1992

Cholera

Cases

Deaths

4211
11423
8957
5044
3704
7088
na

tF"
224
215
72
87
150

Malaria
Cases

1792167
1663284
1854830
2017823
2018783
2120472

Japat^y

Kxda Azar

Deaths
"323
188
209

Cases

Deaths

14079+
19179+
22739

47+

Cases

Deaths

77+
131
497
606
869

9080
1596
16384
3304
34489
22263
351!
353 .
57742
16757
2984
421
61438
11995
2290
na
na
9051
1685*
:
ojjly fram B.tu, Ch^ Muh,,. om«. Swosd. Btawm. Patna.'.
UpUU Noven^r I9SP
Patna;
^UpdllNovemNcr
1992
Sourer: GOI. CBHI.
"d Family Welftur. Htul,h
Delhi. 1993.

2‘»82

268

Economic and Political Weekly

Ol'S
a oA
pn
OOCUMeNTM'ON J ft

\ibrarv
and

0363t

November 19. 1994

«Si Kiss*
and the Delhi states first political rulers

plants in India. If the non-functional Dutch
plant in Delhi is my indication, these
and profiteering continued and pharmasciences
(Al I MS) an autonomous institution di reel ly
technologies offer no solution to the problem
ceulicals made their profits out of the under the health ministry, ignored the state
of garbage disposal.
widespread fear of plague.
government *s directive to refer all suspected
Despite of red alert, till as late as September
Tabic 4 shows the numbers of suspected
p.
.
cases to the IDH. Only when two of the
29
a truck load of people were reported to
and diagnosed cases jin ~
—
Dclh, The largest
AllMS patients died of plague on 25th. the
have come into the city from Gujarat The
number of patients were admitted between
hospital authorities were forced t© acknowl check-posts were obviously ineffective or
September|30 and October 4. After this, a
edge (heir reservations. They arc reported
inadequate. Il was without any prior notice
significant decline in admissions indicated
to have said that they were wailing
waiting for a
or explanation that the schools were closed
that the peak was over. Till October II, a
formal letter. The hospital was then instruct
on September 30. The explanation later
total of 69 cases were diagnosed as plague.
cd by the union health ministry itself not to
offered was (hat surveillance of children was
The u 11 i mate picture of spread that emerged admit patients suspected of plague and to
difficult and they were more susceptible.
is one where except for some cluslefing
refer them to IDH. When AllMS did refer
However, no attempt was made to stop the
around one to two kilometres of IDH. the
Sushcela Devi, a patient who had tested
immunisation drive where hoards of children
rest of the cases were scattered. None of the
positive for plague on Friday, the hospital
better off or posh localities were affected.
were collected. Those in charge of the
did not provide her an ambulance and she
immunisation campaign went around
For example the scattered cases came from
never reached IDH. It was only later (hat
Mangolpuri. Madangir. Okhla. Munirka.
ad vising parents to bring in their babies even
Delhi’shealth minister thought of instructing
Mohammadpur. Nangloi and Shahadra. The
if (he child had received a dose two weeks
hospitals to ensure requisitioning of CATS
back. This might be the strategy of a ‘pulse
areas affected around IDH were
were from
from
ambulance to send patients to IDH. DoorMalkaganj. Azadpur. Jahangirpuri. Santprogramme but could this be rational under
darshan continued to show the garbage
the threat of a plague epidemic?
nagar and Mukherji Nagar. The key factors
dumps in different parts of the city as a
affecting the course of the epidemic appear
In addition to the above, the medical
visual critique of the Delhi state authorities.
to be the scare which led to early reporting
community
contributed to the confusion
It was obvious to the viewers that rubbish
and timely treatment and extensive use of
through its own lack of confidence. Not only
collected over vearsof neglect could not be
tetracycline.
did they advise different doses of antibiotics,
cleared overnight.
By October 3 plague was overshadowed
different modes of isolation and differed on
The Delhi government on its part kept on
by political violence. Media attention shifted
the most el fecti ve drug, some also considered
complaining, that their hands were tied as
to Uttarakhand and from the head-lines
it wise to raise technical issues regarding the
plague receded to the inner pagesTxl (ten sanua”onIml*? n?*’lloW Us
existence of
an epidemic, the accuracy of
into the cradle of the weekly maeazirJ h
a',on and devcloP JUS8' clusters and
tests being carried out al N1CD and its
appeared as il plague was^UonTer
U"‘'U'horiscd
A^rding to M L
acceptability to WHO. According to NICD
problem. Tbe health ministry officials wh* dKasZ’s fonh
WaS1’ahM,rir and
antibody fluorescent tests could not be
'^hcrwtseexpresstremendousconcematwMi.
right but it '^e<-'ly He.,na’'beabsolulc|y
otherwise express tremendous concern about
performed on all cases as the reagents were
ngnt hut it was surpnsmg that it took a
information education and communication
expensive and unavailable A number of
plague epidemic to make him see the
(IEC), never actually set up an independent
suspected cases coming from Surat had
obviousness of his statement. That h- had
mlormation system. The shift of media's
already taken antibiotics and that too made
not bothered to take up this issue earlier and
attention was thertore to their advantage and
was only now planning to write to the prime
• hey did not have to answer uncomfortable
Table 2: Cases or DvsrNil
anu
minister (Pioneer, October 2) reflected (he
questions. The questions however, remain.
Gastmo-Entekitk in India
degree of his interest in the welfare of 40
lakh people living in jhuggi-jhopris and
Year --- Dysynfery
Qastro-enieritis
Administrative. Professional and
unauthorised colonies.
rCa<cs
'—
~
Deaths
Deaths
Cases
Poij-nrAi. ■Response
The five-day drive for cleaning the city
1982 8995226" 1551
IOI5I75
■□ken up by the Delhi government lacked
4(176
!• was only when people from Sural
1983 8274724
2513
1095944
5796
a long-term perspective. It only meant
1984 8469834
staned trickling in. that the administration
2370
143844
6688
removing garbage frpm one locality to
1985 8742177
woke up to the possibility of a danger. A
1937
1441411
4996
another. The cent rally-located VIPareas got
1986 7658399
1583
red alert* iwas declared
j on 2_,,,
1220237
3580
September 23.
the
maximum attention while the peripheries
•987
8741081
2109 13338594
It essentially meant setting up booths
2l'»?
c
on
of the city collected more garbage The most
airports, railway
•s"“n' NIHF*- National Pro»ra„>n,c (or
. stations and
— bus stops'for n™?’! aCl°rS
and reducing the
checkups, alerting the embassies and advisirControl of Diarrhoeal Diseases
Dircoscv New
^-..."^"ccmoasaes^advisi^ quamUy of garbage’-^.01^
sprays. “
“
The
Delhr chref mrnister's bannedlromtouchingiri?
Delhi. 1988
banned f rom touching k! It was reported that
contribution to plague control was setting
*«ing they —
tend
to -spread
garbage nence
hence me
the police
polici
Table 3: Cases of G a.stbo-Emteaft is ANU
.w w
K. vou ^mge
up a committee to supervise anti-plague
was alerted, informed and told to check ragCholeka in Delhi in 1980s
activities under the chairmanshipofthechief
pickers. No <one bothered to explain how
Month/Year
secretary. The directorate of health services
Gastro
Confirmed Deaths
garbage was critical for
— the
...j spread of
enteritis
set up its own cell to monitor plague in the
Cholera
pneumonic plague‘ 01 was Dc,hi really
Cases
Cases
country. It was expected that the two would threatened by bubonic plague? Why garbage
co-operate as far as Delhi’s requirements
July
1983
8.260
piled was better than garbage recycled by
67
were concerned. IDH was spruced-up to
July 1984
9.967
the rag-pickers, and which was more
123
receive cases from all over the city and
July 1985
8.805
128
dangerous, burning pi|e
pIas“'c bags
80
pilesS of ’plastic
July 1986
NICD was to do the epidemiological
8.141
157
90
emitting carcinogens or the possibility of July 1987
monitoring and laboratory testing.
6.372
57
115
taking tetracycline
tetracyclin: in cai~of^iarae?'
case of plague?
July 1988
14.712
The events over the next tfen days as they
624
181
There was. however, news of the govern
unfolded revealed that petty political com
S(,urc^ VH Al. Civic Netted and ILL Health: A
ment exploring
mem
explon ng possibilitie<
possibilities with garbage
petition preoccupied the Central Authorities
BriefInquiry into the Cholera Epidemii
recycling foreign companies for setting up
in Delhi, New Delhi. I98K.
Economic and Political Weekly

November 19. 1994
2983

- -1

JiT
^^rhing the diagnosis dillicult In such
a^mnditions using strict technical definition

a< tuall) amounted to negating the existence
of plague
Through this chaos the central health
minister and the director general of health
services kept telling the public that there was
nocausc lor concern as they loundcvcrything
‘salislactory’ and under control’. Instead of
realising that 3() per cent ol the suspected
turned out lo be positive where there should
have been none, they chose to emphasise
that 70 per cent patients reported as sus|>ecicd

cases ol plague, proved negative. The
government, according to them, had done
its best rhe ministry olIicials were reported
to have said that ’vested interests' were
responsible lor the panic within, and overreaction outside the country While the health
minister chose to keep quiet on the issue,
his deputy. Ghalowar was given lhe task of
delending the ministry
Ghalowar made the best ol a bad job and

made a lew revealing statements. These
clearly reflect lhe anii-|x.oplc altitude of the
government. According to him. "in a country
with financial constraints like India we cannot
always adhere lo whatever lhe experts
suggested as ideal*’. He claimed that the
experts had not warned them of a ’high risk
factor It is obvious then that the findings
ol lhe PSD. the warnings ol the meeting of
Inter State Plague Coordination Unit and
NICD tell on ears that had already decided
to be deaf
The contusion created by the experts*,
lhe inadequacy of practical knowledge of
plague among most doctors and lhe fact that
there were till October I only 23 positive

cases, emboldened lhe government to
underplay the calamity. The central governmeni s representative Ghalowar was reported
to havs said that Plague, gastro-cnterilis,
cholera are not extinct cither in India or in

countries such as the US. China. Peru. African
states, etc Gastro enteritis is a natural pheno
menon arising out ol contaminated waler,
bad sanitation, so why ask us. ask the rural
development ministry, the urban develop
ment ministry - we arc doing our best to cure
lhe afflicted. Thus he did his best to make
plague look common place. Kxik no respon
sibility lor prevention hut only for cure and
pretended as 11 the failure of other ministries
was not the government’s concern!
The officials and the politician showed
greater concern lor dwindling business export
of lixxJ and garments, the "image of India
abroad".md the inflow of international capital
rather than human suf lering and deaths. The
Export and Manufacturers Association

secretary is reported to have said that the
term plague has a historical connotation for
our European partners and they panicked.
There was pressure lixi from the smaller
- business in the capital. The season ol
festivities was good for their business. *Puja

had been creeled and markets

Bombay | received double the amoum <>l

were ovcrllowing with unsold goods. Per
haps under this pressure, schools dosed on
September 30 were reopened on the October
4. This decision was taken on October 3. Il
is obvious from Table 4. chat there was no
signilicant change in the reasons given by
the directorate initially for closing schools.
To add to the disarray, private schools were
allowed lo remain closed while lhe govern
ment schools mostly located in the less
privileged and less cleaner surroundings were
ordered lo reopen!
Once the schools reopened plague
disappeared from the from pages of daily

resources in 1991 -92 as compared lo Delhi,
in ihc.ycar 1992-93 ihe actual, alltx-aii.ms

pandals

newspapers. Delhi resumed its false posture
of normalcy Thus, even though 306 new
cases were admitted as 'suspected cases* till
October 6 - bn ng the total such cases to 514

according to Delhi ’s chief minister (Pioneer.
October 6) - the health minister claimed that
the "disease has been checked”.
WHO loo came lo government of India’s

rescue. All through n reminded the press that
plague never was eradicated even in the US
and that it was curable. It offered its
'expertise' but never commented oa the need

to gear up the infrastructures through which
any ex pens were expected lo function Indian or foreign
In brief lhe lethargic reaction of health
administrators, its contradictory acts and
statements, inability of most professionals
to rise up to (he challenge, the obvious
el Ions of politicians io underplay lhe problem
became so obvious that even lhe middle
class lost its confidence and panicked.
Under pressure of this panic and the need

to retain some credibility with its international
donors, the government look soruc measures
uu.y icwarucu n
and was duly rewarded. The US and lhe
European Community look
i a lenient view
of the epidemic. Whether il was to let their
saleable gixxJs flow into the Indian market
or to build a political alliance against its
perceived ideological opponents (the Islamic
bloc) or because of superior infrastructures
which ensure strategic preventive intervention is a mailer of detail. The real issue
is that their benevolence gave the Indian
politician yet another chance lo get away
with murder.
The cinema halls reopened on September
10 to soothe lhe short memories of its
residents. For lhe final burial of the event,

an expert committee was set up. Even lhe
press has been attacked lor its exaggerated
reporting. In short. Delhi has done all ii
could, to muddle through the plague
epidemic. Its actions become unenviable
when seen against the enormous resources
that it consumes compared to lhe states of
Gujarat and Maharashtra (Tabic 5).
In 1991 -92 Delhi received 717.6 lakh more
lhan the whole of Gujarat, in the following

two years this gap became much larger.
Similarly, while Maharashtra (including

were revised. For Delhi ii rose and lor
Maharashtra ii declined tbits lunher

narrowing the gap between Delhi and
Maharashtra as a whole. Despite Delhi’s
wealth, poverty of initiative, lack of
administrative cohesion, absence of a wgllworked out strategy, public health
incompetence and the callousness ol ik
political clue arc glaring
Somi. Issues

Dk epidemic has abated but il has certainly
noi disappeared. While lhe political leader
ship will have to assess the helmsmen it
chose for public health, a few simplcradmini
strative lessons have lo be learned. For
example.
(i) Public health activities require large
but active organisations. If the system is not

geared lo go into full action when required
then it loses its public health significance
as it is overtaken by events.
di) Though il appears to be simpler and
cost-effective to centralise services, me
trouble with the strategy is that it increases
the risk ol infection, makes patients travel
long distances and is inconvenient to their
families.
(in) Burden ol care on NICD and IDH
would have been lessened il the city‘s premier
medical colleges and other specialist hos-

I

1

Table 4: Repouiw Cases oe Si>m:rtEJ)
Plague in Delhi

Oak-

September 24
September 25
September 26
September 27
September 2X
Septeiober 29
September 30
(k'tober I
(klober 2
October 3
October 4
October 5
October 6
October 7
October X
October 9
October 10
(klobcr 11
Noir.

Daily
Admis
sions
at IDH

Cumula
tive
Total
Suspev.
ted Cases

I
2

I
4
7
17
17
W)
199
,1MX
437
572
645
755
K22

- 25
3K
44
S<>
5(>

I0G3

S4

4
13
IM
119
1X9
374
IIS
91
70
62
49
22
6
12

Cumub
live

Total
Tcsied
PoMiivc 4

2

2<»
22
23

69

Cuinuhtive suspected cases from October
4, 1994 are obvious undereslimaio as
lhe daily admissions at IDH alone add

I
I

up lo more lhan the cumulative cases
reported for a day. This may he due to
non-inclusion of discharged palictMs.
Soun < 77/r 77wir< of huliu. Hindustan Times.
Slalrxnuin and IDH reports

29X4
Economic and Political Weekly

November 19. 1994

-1

pil.ils lud been mobilised Instead of simply

criticising the working off these two hospi
l.ils they could have beem used more effi
ciently .
(is) Ancflcctivcpublic imlorrnationsystem
should have been in existence. Information
of admitted and discharged patients on a
daily basis along with maps of al lectcd areas
wou I d ha ve he I ped people pracl i se preset i bed
dos and don ts bcllci.
< v) Though the media did its best to publish
information, they at times overdid it and

contributed to the scare annong the newspaper
readers They, however, cannot be blamed,
lot it was the responsibility of the
administration to provide detailed, adequate
and correct information «»n a regular basis.
(vi) Last but not the least, drug control
of market outlets could halve been effective
from the very beginning rrastead of being an
alter thought
The epidemiological issues that arise out
of the plague epidemic are crucial both for
understanding the cpidemuic and developing
a strategy lor future. The first and foremost
is the- diagnostic issue It plague in Delhi
w as bu bon i c. t hen i t has se riou s i mpl icat ions.
It means that Delhi too is carrying a mild
or moderate epidemic in its rodent
populations which needs to be identified and
handled along with their fleas. It also partially
disprove the assumption that Delhi was
allccted because of the Surat exodus.
The indications are that plague was bubonic
3i)d the pneumonic manifestations in those
cases were secondary, h could be due to the
high rainfall, relatively lower temperatures
and oth -r climatic conditions in which case
it would K with us for some more time.
To ensure the above, rat fall studies and
flea index become indispensable. NICD is

said to be conducting such studies but the
results arc still awaited.
Thcainrusion'regarditig
is verv

reliability of detection, but thr must riot be
allowed to become an excuse lor rejecting
cases in the pre ent situation.
Social dimensions of the epidemic need
to be fiKused upon. The vulnerability of the
poor, the implications that excessive fear
generated in the middle class, the politics
of suggestions such as wearing masks in the
buses, instructions to admit all cases

irrespective of the clinical picture and the
Municipal Act. 1957 arc some such issues
which lead us to examine the very seal folding
ol our mega cities.

to be increased. Second, that public health
i
services have been undermined and need to
•
be strengthened. These twin problems of
dwindling resources for health and declining

crage nor ensure regularity o(treat mem which
»s critical to the Tuberculosis Control
Programme
The Blindness Control Programme also

standards of public health arc intimately
linked with (a)structural adjustment policies.
(b) the evolution of public health in India.
(c) the patterns of urbanisation We briefly
review here, each of these areas

registered increased outlays According to
the government, the emphasis of this pro

gramme is on cataract surgery’1 and investing
in supcrspecialist services rather than treating
ophthalmic infections which arc the second

major causes of blindness, specially among
the younger age group. Between 1991 and
1992. the investments in kala azar showed
a decline of 3.4 per cent and in 1993-94 it

Sth in’hirai. Adjistmini
The liberalisation policy of the present

government has resulted in the cut-back of
investments in ccnain sub-sectors of health.
This trend began even prior to the official

was merged with malaria control There was
almost a 13 per cent increase in 1993-94
outlay for malaria but this included outlays
lor kala azar and Japanese encephalitis as
well. Even leprosy which was lobe eradica
ted as per the recommendations of ihe
Swaminathan Committee Report1 registered

acceptance of structural adjustment and
investments in health sector have since been
gradually declining. From the mid-l9K(h
onwards the government has been cutting
back on medical and public health with
increased outlays for family welfare. During
the Sixth Plan there was some effort to
increase outlays for communicable diseases
while the investments in curative services

remained stagnant. Il is during this plan
period that lor the first lime the government
acknowledged its inability to provide the
required medical services. It introduced the
idea of opening up medical services to private
and voluntary organisations in order lb
supplement government services.
The Seventh Plan not only strengthened
the policies of privatisation of medical care
but in fact raised allocations for family
planning by 9 per cent. During this period
the investments in medical care remained

stagnant and for communicable diseases, it
actually registered a decline.”*
During the early 1990s fl990-91; the
health budget was slashed by Rs 32.9 crore
and it was communicable disease^ which
rca,,y tow* the brum of (his cut-bac k. Even
T®"1',l lhcnew“o™"’icp<>|)l.y were

on health would further marginalise the poor
During 1992-93. the ouflay for health was
increased by 60 per cent over the previous
year (Tabic 5). Much of this increase was
due to a 34 per cent increase lor AIDS

control with Rs 5K crore being invested for
this disease alone. There was also a marginal
increase for tuberculosis but much of the
outlay was to be spent on importing a new

set ol drugs for its treatment. Merely
importing newer drugs without strengthening
(he infrastructure will neither improve cov-

a decline in its proportionate share ol
allocation despii a marginal increase in

actual budget
While reading these plan outlays, two
things have io be kept in mind Firstly, a
large chunk of loan from World Bank to the
health sector ha been tied to the AIDS
programme. Secondly, the over emphasis on
AIDS has undermined other commanuable
diseases control programmes What seems
to be fairly evident from the trends is that
the priorities ol I he government do not match
with the existing patterns of disease in the

country. Their concern fcr the National
Programmes lor the major comn unicable
diseases is declining while others arc gaining
priority.
Evoi.irnoN or Pvhi.w Hemth

To understand this we have to sec how
public health practice and content w us shaped
■
tn India: Why education and training of
public health could not be rejuvenated ’ And
why most diseases of poverty arc slowly
sliding down in the national agenda? A
myriad of factors influenced the content of
public health as it evolved in India (i) Like
all other professions of that time, public
health too was guided by the interests of the
British. Its concerns were safety of the army,
a select British population and the natives
wherever profits were at stake. For example:
when revenues were threatened, special
committee was set uptocxaminc the possible
connection between canal irrigation and
malaria.'1 This was followed by the first

HI

Year

Understanding Chaos
There have been two popular responses
to the disaster. First, that the cuts in the
liealth budget have brought down invest

ments in this sector from 3.3 per cent in the
first two Five-Year Plans to 1.7 per cent in
the Eighth Five-Year Plan and these need

Economic and Political Weekly

■X

I

Tabl*: 5: Annual Butx.irr Outlay

Delhi'

Gujarat
Maharashtra

(^.< lakhx)
-----------L99I.-9?_
Total
MNP

______ 1992-93
Total
MNP

4935.61

T

2936
6164

6500
(6707)

1270
4150.76

4093
8367
(6433)

Simne: Annual Plan 1993-94 (FigUfVs

November 19. 1994

____ 1993-94____
Total

MNP

7204

1650
60(XJ
(4019)

in brackets are revised outlay.)

4132
10604

1650
4741

'’I

I

!

AS

11

I
.yV
l. >*

Jl
'©■:

k

©
^rfarch' project io control malaria in Mun
muludrug therapy reduces the period of
sector Thus (he undermining ol secondary
^^iir 14 Similarly. public health measures lor
treatment and increases the possibiht) of
level support structures made achievement
large religious congregations were initialed
intercepting transmission. The working
of effective primary health care even less
despite the well knou n reluctance to increase
group headed b> M S Swaminathan knew
plausible In other words, public health in
go vern me nt c x pc nd 11 u re. bee au sc I he profi is
that the treatment ’’eflcclivencs.s as a tool for
India has suffered due Io its substance which
ol private railways companies were linked
achieving early control or eradication of the
constrained its practical success and
with promotion ol pilgrimage by the natives.1'
diseases is yet to be established”. Yet. they
undermined its essential infrastructures.
Unlike samtars movements in Bniam. the
launched an expensive programme and the
Resources do pldy an important ro’c but
socio-economic conditions and living
public health experts went along with them.
along with resources the practice and content
standards ot the peopleol India never became
Only after successive failures some
ol public health has to be emancipated
central to public health Ai best practitioners
acknowledged that the strategy was ill
were the arm) medical doctors who later
Medical Edoca-don
conceived.1’ Over time then, public health
manned the Indian Medical Services (IMS).
not only failed to build upon the foundations
The relevance of medical education in
The Hrst formally trained public health
laid by the first generation of its practitioners
snaping public health is self evident. Bhore
practitioners in India thus got their field
but it also failed to retain what little epi
Commiitce in I9463" visualised the ’basic
training under these IMS.dcx’tors who were
demiological base they had built. Inclusion
doctor as a socially sensitive medical procompetent technically but did not concern
of socio-economic dimensions into an epi
Icssional competent in providingelementary
themselves with the social dimensions of
demiological approach remained a far cry.
health care. However, ihc history of evolution
epidemiology The superstitious native’ with
After the country became independent.
of medical education in Ihc country reveals
his unfathomable peculiar traditions was
IMS was dismantled while IAS continued.
that not only have ductors been the blue
held responsible for the failures for public
As health remained a stale subject, the
eyed
boys in a health team, their education
health efforts while all successes were the
experience of public health at grass roots
and training also continued to be heavily
achievements of modern medicine and its
levels remained stale bound and the centre
influenced by western models of education.
practitioners.
depended upon medical colleges and other
There is sufficient evidence to show that
The culture ol the professionals was carried
central institutions for its public health
in early 20th century, policies of influencing
into the national programmes ol independent
leaders. A scries of director generals with
medical education in third world countries
India. They were visions of technical
backgrounds in paraclinical (anatomy,
were consciously followed by the US through
supremacy which would compensate for the
physiology, pathology) and clinical subjects
its technical and financial suppon. In China,
lack of social change. The skills needed for
such as onhopaedics brought the status of
the argument to train personnel to meet the
midway correction through competent
’professional in public health’ to a level
needs of the country was used by the
monitoring were found lacking perhaps due
where they were easily dominated by the
Rockefeller Foundation to suppon medical
to sudden reduction ol the professional
IAS ollicer''* who invariably had a broader
education that trained elite professionals
manpower after the British doctors left.
experience The bureaucratic control by itself,
essential to westernise’ the country. This
The foreign 'experts' entered the scene
however, continued io lack public health
strategy in fact replaced the foundation’s
and the glamour of technology made entry
competence. With the failure of various
previous suppon to missionaries.'1
of many vertical technocentnc disease control
health programmes, a new category of
Similar export of western professionalism
programmes easy. Malaria was to be
professionals emerged and these were the
to Asia is also recorded by Goldstein. Not
controlled through DDT. small pox through
health management expens. Unfortunately,
only was aid linked to reforms in medical
mass vaccination, leprosy through dapsonc
these shills in the professional control al the
education but also by creating elite insti
and filaria with hetrazan therapy. Except for
lop did noi contribute to any appreciable
tutions for medical education and insisting
small-pox. w hich was eradicated alter a shift
improvement in the working of the
on supporting only those, a process of
of strategy'’1 in the early 70s. all other
programmes.
weeding out al! other practitioners and
programmes proved inadequate Their
Reported failures in public health efforts
doctors from positions of power and
failures are not the result of resource
led to a shift in emphasis whereby instead
domi nance was set in This led to a general ion
constraints alone but of inadequate and
ol controlling diseases among people through
ol physicians who were conscious of their
inappropriate strategics. In the case of
a broad-based strategy, the emphasis shifted
own professional dominance and exercised
malana. it took us two decades to realise that
to controlling people themselves - in terms
it to become one with the ••international
it was wrong to create population based
of numbers.
community
of scientists
These elite
eradication units The essential factor should
The Sixth and Seventh Five-Year Plans
physicians were (rained to exercise their
have been “the terrain and the topography’’.
integrated various programmes into the
autonomy against their responsibility to the
Il was accepted that without an efficient
general health services. This integration,
society. They di J this through the ingrained
basic health services, malana control was
however, was limited to the lower echelons
’clinical mentality’ which teaches them to
not possible. It was also acknowledged that
while at the top F amily Planning remained
do what they think is best for a single case
conceptualisation of the programme as
the priority. Such an integration put the
without a thought for its implications for the
essentially a rural activity was incorrect.17
entire lower level infrastructure on a platter
society at large or even for the family.
Even then the programme continued till
and offered it to the Family Planning
In India thisconfiict started with the British
1974 when it was finally modified into a
Programme. Instead of strengthening basic
Medical Council (BMC) in the late 19th
National Malaria Control Programme with ’
services, integration actually weakened them.
century. The issues were of curriculum,
much lowered ambitions.
Peripheral institutions worked for Family
language of instruction, training in obstetrics
The other glanng example of poor strategy
Planning targets at the cost of ail other public
znd integrated education of allopathy and
building is in Leprosy. A National Control
health activities.
tradi tional systems in medical schools.2'The
Programme wasconverted intoaneradication
Along with liberalisation, medical care
medical colleges of independent India
programme m 1982 by the Swaminathan
was opened up to private and non-govemcontinued with their curriculum which were
Committee. To any student of public health
mcntal sectors. This led to stagnation and
evolved under the guidance of BMC. Here
it is obvious that the decision was political
undermining of public hospitals as they faced
too. Rockefeller Foundation made its inroads
and not based on scientific knowledge or
cuts in their budget allocations and loss of
by offering aid and technical assistance.
operational research The excuse was that
their competent manpower to the private
Indian doctors were no different from those

2986

Economic •end Political Weekly

November 19. 1994

of Thailand and China in their concerns
whereby the less successful came to PSM
Majority of the medical students came from
As a result. I wo things happen Firstly ,u hen
Only after the banning of ECFMG. an
they think of public health they visualise
landowning and professional classes'4 and
examination for screening foreign medical
only medical technology-based intervcntivc
hoped to practise clinical medicine
graduates, which restricted the possibilities
Concern for this was expressed by ar.
programmes such as immunisation and oral
lor migration did good medical students pay
rchydration Secondly, only those diseases
official committee on Health Services and
any attention to (he subject Bui that was
Medical Education in 1975 It recognised
which they experience become their
only for the purpose of leaving the country
the necessity to restructure the entire
priorities Absence ol emphasis on others
cn route the WHO to be in the same salary
docs not bother them Their logical demands
programme ol medical education and
brackets as their seniors.
are hospitals, well equipped tertiary case lor
acknowledge India’s failure to produce the
These departments failed to link their
heart diseases, blindness, cancer and other
basic doctor “who occupies a central place
teaching with that of other departments and
among the different functionanes needed lor
non-communicable
diseases Greater access
hence became islands in medical colleges
the health services”.'” It recommended a
to curative institutions and adequate supply
isolated from the rest Their inadequacy in
UGC type of body for medical education to
of drugs in the market satisfies them
developing epidemiology as a discipline in
The health administrators, policy-makers
monitor the needs of the country and assess
the Indian context made their isolation a
the required changes in medical education
and politician who largely come from these
natural event. They could strive for
Another official effort was made by Bajaj
sections of the society are no different in
recognition only by becoming the victims
Committee which produced an outline of a
their thinking They have also learnt their
of the larger malady - competition for
National Education Policy in Health Sciences
lessons from history that the diseases of lhe
international acceptance Therefore, instead
in 1989 Full of contradictions, the document
poor
cannot be tackled by technology alone
of emphasising local specificities, and
could not but concede the govemment’s
The only time they are concerned ab mt this
seeking socio-technical solutions to India’s
failure to reduce the bias in favour of elite
set of diseases is when they arc themselves
public health problems they were lhe first
medical education, its inability to tram other
threatened. The mindless disposal of garbage
to accept and propagate ’knowledge’ that
paramedical professions and initiate proper
by the plague hit capital’s admmistrators.
emerged out of the international centres of
health manpower planning.’7 It called for
the Municipal Corporation of Delhi’s
public health. The Indian experts’ thusjomed
the constitution ol a medical commission
(MCD’s) epidemmlogK-al laboratory’s full
hands with the international ’experts in
to regulate medical education but could
time involvement with moniionnv a single
propagating purely technological solutions
disease, the handling of thcCholcra epidemic
not come up with any concrete suggestions
lo all public health problems The ancient
tor shifting the emphasis in training
m 1987 arc exampes of such concern 1 he
wisdom that most of our diseases arc rooted
from specialities to basic doctors and of
rest
of the time they concentrate on
m the poverty of the people-"' was ignored
• strengthening public health training
(i) Removing slum dwellers from amongst
Lastly, the inclusion of social sciences m
As a result of this reluctance to intervene
them and creating safer spaces for sellmedical curriculum was reduced to absurdity
actively, ihe government in fact protected
protection.
under these conditions. The recom
the structures that it had evolved to be a part
(ii) Devising schemes for educating the
mendations of ICMR/ICSSR committee went
ol th • international market for professional
poor to be healthy without any baste
totally
unheeded
and
lhe
doctors
continued
skills India’s educated elite specially its
amenities.
(o be trained to think that they alohc knew
doctors continued to be more or less inte(iii) Investing more resources in their part
what was best for their patients! This
g. ated into the global economy and thereby
of the city to beautify and keep at bay the
assumption came edsy to a set who
enjoyed the benefits ol higher salaries. "The
threatening poor.
represented the social elite.
cond : ion of integration i mo this international
(iv) Convincing themselves that there is
market was the possession of internationally
National Priorities in Public Health
1‘itlc that can be done lor the increasing
negotuble qualifications” and this implies
menace ol death and disease among the poor
India’s population control programmes
lack ol relation to local needs.-’
who are blamed for their ignorance and
ary^‘10 ’nlegrated into its health services
It is not surprising then that the initial
re uctance to benefit from modem servac
and hence continue to drain it. Even within
efforts of independent India to build
Implicit m this attitude is the shift of
the health sector, priorities remam lopsided
departments of preventive and social
responsibility from the state to the people
As we have seen the diseases which have
medicine within medical education met the
At best the state make some resources
continued to kill and maim the most (such
fate that they did These departments were
available to non govci,, mental organisations
as diarrhoea, respiratory infections, malaria
required to deal with the challenge of
to run some rudimentary formol urban basic
and kala azar) arc getting less and less
highlighting local needs’ of the vast
services. Like poverty, mortality and
attention. Those which are replacing them
populations and find socio-technical
morbidity from diseases of poverty too are
---------- ------.»ccn.no
.ncimlur.'3rgel>' thC
solutions
to them.
Reasons
behind theconcern'
failure of
now seen as prices that have to be paid for
“penmenls in medical education
of India s elite^ '' deVC Oped nal,ons or
’national development’, it is not surprising
were many. Firstly, practising public health
then thai these diseases are gradually losing
The reason for this gradual shift is not
expens were few and the demonstrative
the priority they once enjoyed.
ar to see. There is no denying the fact that
capabilities of the faculty were extremely
• Protests against the present policies are
India over the past four decades has built
limned as no links were developed between
rare
for reasons already discussed. Firstly,
its infrastructures including a health care
teaching departments of medical colleges
the knowledge and practice of public health
system.
The
focus
of
the
infrastructure,
and public health practitioners in the health
itself has been undermined to an extent that
especially for waler supply, sanitation,
care system at different levels. At best these
understanding of issues at popular level is
housing, transport, electricity and public
departments could provide some exposure
Simplistic. Secondly, in a socio-economic
distnbution system is in urban areas. Even
to real lite situations of cities and villages.
milieu, where both the urban.elite and the
within
the
urban
areas
the
disparities
are
This, in absence of any demonstrative effect
middle
classes see its interests tied to the
obvious. The larger share of the total national
of the success of public health often
process ofeconomic liberalisation and global
expenditure is enjoyed by a small elite
convinced students of its futility.
integration, indiscriminate import of
*o®scI>as»c amenities are taken for granted
The absence of rany excitement and
technology is seen as a positive step towards
by them and never seen as pan of a
challenge contributed
J to a vicious cycle
development. Thus hbtech and tertiary
comprehensive public health infrastructure
institutions are welcomed and class issues

Economic and Political Weekly

November 19. 1994
2987

J

andpnm.ir) hc.ilihc.i'c.ircsevnas’primitive’
concept \
The most tragic the silence ol those who
, sutler The) remain quiet not only because
ol iheir helplessness, their negative ex
periences of raising their voices and their
over burdened li\es bui also becauseol their
perceptions The glamour ol technology and
the acceptance of living Irom one crises to
another pushes them into dreaming of that
technology. They accept hunger, shortages
and lack ol services in everyday life but in
a crisis, they aspire lor what they privileged
classes have Thus they become easy prey
to the propaganda (hat more sophisticated
hospitals mean better health care. For the
prolessional. the laci that the poor seek
technology becomes reason enough lo pro
pagate their own model ol lechixKcntnc
health care With the poor on their side they
let public health degenerate with impunity.

IV
Issues for Urban Health

The noteworthy feature ol urbanisation
in India is the increasing concentration of
people in mega cities industrial cities and
towns The share ol population of class I
cities in the total urban population rose
Irom 22 9 per cent in 1901 lo 60.4 per cent
in 19X1. Another conspicuous feature is the
(all in the proportion of urban population
in the small and medium towns.'"
In exclusively industrial cities like Sural,
melropoliian-cum-industrial city like
Bombay or the capital city like Delhi, a large
share ol the concentrations and additions in
(he population consist of migrants. The
characteristics ol such migrants and the
population, ol course, vanes depending on
the (jeonomy ol the city. The functional
specialisation ol cities is an important
determinant of the characteristics of the
population and quality of life in cities. The
industrial classification of migrant workers
by rural and urban residence shows a higher
proponion ol rural migrants in primary and
secondary sector activities, and urban
migrants in ichiary activities.'1 In million
plus cities, the sex ratio of migrants is in
favour of males. The problem of living space
in the metropolitan cities probably acts
against female migration. Il also gives an
indication of the type of job opportunities
in such cilies which are male-biased.
The patiem of urbanisation in India raises
several issues for a public health policy
especially in the light of the outbreak of
plague.
Find is (he issue of economic organisation
of cities in India, whereby increasingly the
emphasis is on concentration of industries
rather than dispersal which lead lo human
concentrations and the miserable conditions
under which many city people live now. The
concentration of industries in cities like Sural.

298K

L___

periphery of Delhi. Bombay. Kanpur, etc.
results in large-scale migration of people
horn other urban and rural areas. Il is possible
io sec the modern industrial city as a human
I ailurc. a monster which does not lead to any
improvement in total human welfare. “Most
modem cities arc easily perceived as dreary.
grey wastelands housing dreary, grey,
dehumanised people working as cogs in a
machine which seems lo destroy much of
what is good about life”.'-' The modern
industrial city may add lo material wealth,
and perhaps with the changing economic
scenario this is what the state needs, but it
destroys the very essence of human life. The
people in such cities live under miserable
conditions, similar lo the well-documented
stage ol industrial revolution, now con
veniently forgotten. The conditions of lilc
in such cities, the nadir of which is the
outbreak of epidemics, should enable the
planners to re-examine the pattern of
urbanisation in India.
This dixrs noi. however, mean that human
well-being is a mirage in such cities. This
leads io the second issue of quality of life
ol people in cities as against growth. This
is related to the availability of basic services
such as health, drinking water, sanitation
and other uiilities apart from housing, and
transport. There are isolated cases where
even in big cities some degree of efficiency
was introduced for maintaining al least a
minimum level of civic order. Il has to be
recognised that utter neglec t and callousness
ol the state is responsible for much ol the
urban decay.
The case of Delhi, which is the national
capital, is a classic example of such neglect
apart Irom Surat, of course. This neglect has
to be located in the dichotomous organisation
ol the city itself, the garden city for the ruling
classes and (he elite and the shanty towns
for the deprived. The growth rale of Delhi,
in line with the patiem of urbanisation in
India, is however much more startling. The
decennial growth rate between 1971 and
I9KI was 53 and between 19X1 and 1991.
50.64. Alter 1961, the growth rate continues
to remain around 50. The density of
population in Delhi, similarly, is very high.
In 1991. it was 6.319 as against thcall-lndia
average of 267. Il is estimated that by 2(M) I.
Delh’s 10 million populalionwill rise three
fold or more.
As the ruling classes rebuild the city for
themselves, erect skyscrapers and beautify
their surroundings, more and more migrant
labour is brought in to accomplish this.
However, regarding health services,
availability of basic services like waler,
sanitation, housing, etc. there is a clear
demarcation between privileged Delhi and
deprived Delhi. There are 44 resettlement
colonies with a population of throe million
and 480 or more unauthorised colonies with
more added every year." It is estimated that

al least 53 per cent of the toial Delhi popu
lation is living in subhuman condition*
While these subhuman population is needed
for \nntaining the cozy structures ol the
up;
classes, there is total lack of human
. oncem to provide the basic services lo them
Surat, similarly, has been one of the fastest
growing urban centres in Gujarat While
Gujarat's urban population growth was 3.5
per cent per annum in the X0*. Surat grew
from 9 lakh in 19X1 lo 1.49 million tn 1991
Il has now crossed two million and 2X per
cent ol these lives in slums. Unprecedented
growth of small-scale industries in the
unorganised sector has significantly
contributed lo the rise in population.'*
The civic umcnities have imh kept pace
with the rapidly expanding population ol
this town. According lo a survey about X0
per cent of (he slum households do not has c
sanitary facilities. Even before the outbreak
of plague, malaria and hepatitis have claimed
a numkr of lives in this town. Il is fairly
evident (hat in a town which is largely de
pendent on migrant labour, the municipality
can .il lord lo ignore the needs of this class
as they are not permanent residents of Surat.
The municipal government has failed lo
meet the changing needs ol the city.
The - ports of the plague epidemic in both
Sural and Delhi captured the fear and panic
that people experienced. The major toll of
this epidemic was home mostly by the poor.
In Sural, majority of the reported deaths
were from the slums in lhe low-lying areas
of the city. From various newspaper accou nts
what is fairly clear is that certain areas of
Surat were worse affected than others
although even the wealthier pockets were
not spared Mostly slums in the low-lying
areas, near the banks ol iheTapti were badly •
hit reporting a number of deaths. Vcd mad.
Katargaon. Randcr. Sanjay Nagar and Rajiv
Nagar of Udhna industrial area. Ruderpura
and Li m bayat were the worst affected.,
According to descript ions of these areas, the
people who resided here were labourers who
where employed in the export earning ,
diamond]and textile industries. Surat is
lamtius for these two major industries which
arc both export-oriented and earn crores in
foreign exchange. Majority ol the labour
force of both these industries is constituted
by young male workers from different parts
<»i he country. The diamond industry
employs craftsmen mainly from Rajasthan
and the diamond cullers and polishers belong
lo Saurashtra. These workers live in slums
like Vcd Gaon and Kalar Gaon. According
to the deputy collectof there arc two lakh
migrant labourers in Sural and some of them
did ficc from Surat to Iheir respective states
when the epidemic broke out.
In Delhi, the majority of the plague cases
were reported from resettlement colonics.
This broadly replicates the pattern observed
during the cholera epidemic in I9XX. Most

Economic and Political Weekly

November 19. 1994

”1 ihc cholera dcalhs < .

<»c< uncd in ihc
C<i\( | | muss
H'sciilcinciii colonies .,ndI B«ppijlhxnpn
..... .
Chislers m Delhi Similarly <
even during ihc
I Ik- rec.nMruch..,, ..I pl.,guc epulenuc
plague epidemic. ii is m lhesc places u here
Basic civic amcniiies •«ic lacking lhal cases
lKZZ>rnr'ly''hcdkh,,,,'''llc'l''P''h|K
' ’I""’"* W"'l> -I ........ ..
Z
■"KJ r’r"',dc' k"""' I"' <hc huu.c
*vre repined
H..", iK u l,,,,,,,.,,, Kt pth
s-.........
Evet, whet the Htlcrc ure throtcttul by
s Pr«Hiice in this enumrv li r evidcni
’ "iiinulitt u,
... ,
Hu WttH
1 i.» Ihc cl.icMt.|| .,ppr(ldv|, W|,
.
MBtlcntu., the complexity (ll the .smk-s
............
..... trutln
mill h> krt , unmetHl Mt auur, /o< lm/..... .
t'hj,, deette
not tc.thsed The tne.tMtres
Uirnl. |97(». Ml,....... "Hkalil,
••
i"e-niu>l the spreadol plague. |„r titstance
|
kZ u
l,P‘lW,‘ '^'hh;.c1.;v..
mrig .mil Urban Ikwli
-.‘•ipincni Neu Ikll.i
cttlttely hK,,sed on a ongle-ptonged
■I c ilK . ,‘S """cd-,r"n",ed'’h|ccl|tcl|,l.„
(Mudhok ( iiiniiiiiie Kvporil pp 9/. 11$
'"•'T
.......... ... "I (■•artrage rathe than
iwoblem ThS>’flen"c ""‘k-r'‘h»*hng „| ||K.
Ib Tare S Petal. Him
* ar Ilk- (hm! o| Ixprow
This would involve wohine •
iMiahsttig eptdentcs ... a result ol the
hradkaihiH bj .nni ,\l> k
ini i-pi<.iiL.tt|
hril|| Cl,|r
) d '
\i hicv able
ongoing deej) ol urban sysicms It seems
3‘h/v//< lluul Jaimary 1990
pp 14 ir>
K •-■““ “•‘non... cn.ex,. N.Hw.d,.
’he earher ouihreak ol elmleru m Dclh, |1;1S
.................................... .
■>ik mg Hk- |,(C| lh;|| |h|x W11|1| |
;i h.irUcr
ii“i provided any lessons '
l^7"VC ,n ,n,k‘ "" . .......
Apr.l t i
When iIk- Delhi adminiMraimn ined m
Zcomin 'lhhH dllr-"","h'IUll"cl>Hk-nHlc
hccoming
shoner
..ml
the
hl.ul
„!
c can up the etty o| garbage, most ol t|K.
S'"''........
sllons wcreemceitrated tn the tni.ldlc tnd
Z ™
...............
.. .,1
dPIK-t noddle ................... Ix etywtthaXm
•Uld miiMtc p,,MI|vc ;M.||
” ’“b,u-"
....... (ioHrnnknr
*vss Ik-Hi, <BIhhv (’.Him.ince kcpuri,
dlort tn the slums There wee reports „(
21 Broun |- Rnh.1,,1
health
.,1
ll»s
.........................
;|h)He
i||(
iklh "eU |!‘lrh’'"C
;"e;'S
,l,c slu,n' "•
Xlh esett a wevk alte the-ant..,unect,tent
ol s leaning drive
UH
v‘>t I 3A. pp 5X < 9S
Notes
The thtrd issue which needs to be
I We « ould 1,^.
n'm Z "Cd “ 'hC n"L',;",,ry l«'«c'nts'm the
Mcd,c ? . "
A<
S,u'h "I
SiiMkai
national emtext As uKtut.mgd earlte ,
^ ',‘7;;...... .. v"1-" iK-o.ms, ,97..
I ll«
(k.1>Ki u (((i j
ynstst ol mtgrants This adds a new

'

:X•l 7:;, ld ....

.

oms,'r*,r",n ,,r

^'•■"•“-■'-ns ■

he'Zir'A'L"
’
1*’111 io <«■|-,„dPuhhc
health Almongh
it is easier
u..,
cason lor nk. large-scale llceng ol ixtople
h->n. .mra. a, lhe Ihst inlnr,nation ,,| an
■m.break ol plague in ihc Icar ol disease it
aciually.sarelle.amnoititeall-rouud decay
.-HM.Iedw.lhtlK'p.K.rMa.eofciv.ctunemiies
'^hectly.htcprcyen,.,^^
Ihc ivople on sialc-nm -machinery
.
>■ was .he upper and noddle
classes who managed io use any means
Za*.........
,Hil *" Su™ According
><-Ihc railway ..ll.aals nearly 75.(XXi1Klels
ad been issued lor Almtedabad. Bombay

i shmZ'd
>h

S’‘U-‘I

.idmmistrut

Hk
who were making

“ /r<XXm

...

I,'".-

6W,,a M,n,Mr>

H-11”

4),.,,.........
<«>r0//Tr/,,,./r>>,1„„(w |1/7(

kuhiA:ur. IVXX.NICD.

Ik-lhi

4 1AUk,“- Ep'dc...... logy and hunk-nee ,d
I laguemtlK- Wm! t. 19SX-79.WH„
Vol 60. No 2.
— 19X2. pp |(>.S-69
5 The Ptum; ,■
• September 27. 1994
7
n,‘ne,', September 30. 1994
Otr I u,„rr,. (XluK.r i

2d
25

““',■-’•0.....

Klhi. 14/7.1

.... ... ......

Kcp,,r" Nc"

|W4

Inrnhfhr lia,friM,S' Pruple mm
tl,Hl f.riHHHH
F.t omn„,t y
m lbr Rrenlmv Ir t-lr
hrlb,

?73r
n,,,riz3M,nk
^",H-d'h-'
Mr ZT'"1-'
' '*
...

Wide Fund fur N;ilul»n India
./ ,l,e WM'-rr.
‘rr. OeioK(kiober I. Ivy

?

,Mwa,u‘

----- Strustirral Rcadji.Mmcnt
.. J he CuMiies Nathwis p|;u 'or/rv Vol I.
No 2. mt. R, IX 22 •
<HHernr^nt of |n.ha. Mmrstrv of Hv:,hh and
h-Hh Welftm-. ......... ..
k:d;,,':“d
Hinn m-ss ( omrol l',„grulllZ.
p ,'4

Ih M
lx
Mmisirj of Health
arid fainilv Weilarv S™ iXlhrtlUpiu,,,,,
niiltec Rc|>oni
2k <:i'h (bear and Ma,in,vv .A R
P—' <•< Hk- Bra.,. |>rTO1
hdcrcneem uw Med,cat
....... .. L

• > -•niccmems asking people
|Cave
m,h • b*W 'hC
-d
r.imnics home
In an enirrch ddlcicni conicxi ol mahria
ppI-H .......
V„l IU
M.dhok < ••nnn.Hcchmldrawn aiiem,on
V large ag-gregalion ol labour m
29 ^nfMaur,ce. Huucu.luae
m nsnuciim. projects which had sprung up
all over the cotitnri i.
.
snec,,
'
, ,ry. It pomted out that
oNn4- PP 196 201
a
'1X0.11 ellons should be made to ptoyjd,.
Minisiry ol Heald, and Fa,ml, WeliZ *"■
" y "" T S A C' 'C,k' ■'
- "■ l.rM,,,
adcMuateprov.s.on to. health and sanitation
I»
^.,.l.l.|,,.,l(me11Ib,ny1,un^^
a legmmate eha, e on cmsirwiimt
.... .....
’I 1‘rci,,, Mahendra K ■„ K;„, MSA ci ,| ,..a„
I mjecls • As lar as IXIh, is co.Kerncd. this
•h«d. pp los.06
4 ^-'Hcdsi.
•' an onponam lesson" whcie a larg^
14
32
fxipnlatmn ol migrant kibour is engaged m
c.insmKt.im activnies. T|,e k-ssinMnitn
T"7" . Me,h,K". Lomlon. p .,.
"
plague is that migration which forms m
■"'-habyBmmbm^^'^hsbed
’3 VHAI. lirllu
«9<M. Neu
iklhi. p IS9
........ r;‘,,urtl;"‘,encu-'1 wuhtdded
15 Ramasiilihan R-xiliij..,
'
Ihahh ,«n/
onph.isis „„ thesj- sections which produce
34 A'h-d' CihMshya,n. Economy am) C,v,c
Mi'tliiul kt \rait it ltl
*"//./ Iluii On mu
serial weahh I heir ist.la.t .n “ d
IUlJrr the Imim. 1bllll
f ubumtl /‘tt/it w
Muaramme must glvc way to an awareness
th <9Xh S,,Kkh'’,‘" S\RI< . p M
Vol 29(41). I99J
267t 7ft
‘•I their problems.
*lb Smallpox has aven MXVjt
ny., Rllu Mr p,,^^ (.^

EX,X1’“

- - "i

z;Zu.z"7V;'t's7o...

Ind^Xlsh r,,nerZiCS

-

vharac .ensne ol lk-,nr
'‘,‘k‘""*»FKal
■ u<-,k
Its ecological

Ixononik .iihl Poiiiiviil Weekly

Nagarr . .SrutuHu. 19X9. 354

V» .V<,d/„4 ropt,,. pll.3

November 19. I‘W4
29X9

°i

.............

ABSTRACT

RESURGENCE OF INFECTIOUS DISEASE
Dr. T. Sundararaman
One of the most significant achievements of developed nations have been in the control of
communicable diseases. Modern public health in India had its origins as part of the effort against
epidemics but the motives of a colonial administration imposed major constraints limiting its success.
Newly independent India undertook the 'war' against these diseases with renewed vigour and by the
mid^ixties there were significant decline in a number of major diseases. Since the seventies however,
there has been a steady resurgence of infectious diseases. Malaria, Kala azar, Cholera, Gastro enteritis,
tuberculosis, typhoid are all increasing and fast changing to more drug resistan1 forms. New infections
like Japanese encephalitis and AIDS have also become major public health problems. The present
national disease control programmes suffer from being vertical, fragmented, centrally planned,
bureaucratically administered programmes that seek narrow technical solutions to essentially social and
ecological problems. The controversy over whether it was a plague epidemic or a plague like epidemic
illustrates the concept that if a suitable ecological niche is available 'a germ will rise to the occasion.
The approach to the control of communicable diseases needs to be based upon a better general
standard of nutrition, san ■ •‘ion and education of the population. This needs to be supplemented by
integrated local level phr^ing for health backed by good epidemiological centres ano disease
surveillance, as well as w> e needed, inputs from research The active participation of the people in
planning and implementing disease control programmes is crucial to sustaining success. Panchayats
need to be made capable and transformed to facilitate participatory local level planning and

implementation of disease control measurers.

©

THE RESURGENCE OF INFECTIOUS DISEASE
A HISTORICAL INTRODUCTION:

One of the most impressive achievements of developed societies is undoubtedly the control of
communicable disease. In most developed countries mortality from infectious disease now accounts
for less than 20% of overall mortality as compared to over 60% in developing countries?1

To a large measure the development of a science baseo public health has played the central role in this

Speaking of the achievements in public health, Sir Winslow in his landmark address ,2) given in 1925
classifies the main historical process in the development of moderrv public health into 3 major periods.
First is the period from 1820 to 1860 which he calls the great sanitary awakening a period when the
link better general sanitation and health was established. In one famous study, Snowden, one of the
pioneers of this period demonstrates how in an area in London where 2 private services were supplying
drinking water drawn from the Thames, there was a much higher cholera incidence in those who had
consumed of that water brought by one of these twe services. This particular service collected its
water downstream of the sewage exit and changing the site of water collection was able to bring down
the incidence of cholera dramatically.
Second is the period from 1860 to 1900 - where beginning with the work of Pasteur and Koch there
was an explosion of knowledge about mechanisms of infection - what Winslow calls the bacteriological
era. This period saw a redoubled effort at sanitation especially in public engineering works as well as
in developing vaccines as a preventive measure. To Winslow, speaking in 1925 the third era (wh'ch
was the then current era) was where public health centered ground public education. The object of
public health had already begun shifting from infections to all diseases. The control of noncommunicable diseases by changes in life style started gaining prominence too. Other authors have
called the third era as the era of social medicine.
o
’
In the 1930s came the chemical era when drugs like sulphonamides and chemicals like DDT became
available. With these developments, morbidity started falling even further and by 1960s many sources
were now describing it as the conquest of infectious disease. w It has been repeatedly emphasized by
a number of authors that though the development of modern chemotherapy was a major step forward,
it had little to do with the control of infectious disease at the level of public health. The incidence of
infectious disease had already started coming down under the impact of better nutrition, a major
expansion of public engineering works for sanitation and better housing.(5>

PUBLIC HEALTH IN BRITISH INDIA
The situation in India has some parallels and some marked contrasts. Public health became a major
issue in India largely as a result of colonial considerations. One of the main impediments the British
faced in governing India was the very high susceptibility of the white race to the Indian germs. One
may indeed have to be thankful for this, for otherwise, (according to Crossby) like what happened in
the North America or Australia where the indigenous peoplp were relegated to becoming a few
scattered tribes living off reservations, (6)
(6) our race may also be have been similarly marginalised.

2

I

fXd.SPeCted n° ClaSS °r race barr,erS’ like the pla9ue Or srnaNpox or cholc'a or malaria were the most

As modern medicine became more successful in i
Its understanding of disease and in its ability to control
al,S0 SaW ’he diSlinCt possibil"Y ofthe use of medicine To furihe/th^
interests to legitimize their rule and to win approval for
'
it. So modern public health as it was initiated
in India had a distinctly paternalistic air about it
-------- .t an explicit attitude of 'helping the ignorant natives to
be clean and healthy'.

see the"reasons why infeet o
d
n't
'
medicine and public health tend 10 fail 10
Europe of tho Xhlnth
d
.
356
aCh'eVed epidemic Pr°P°rtions in these times both in
nl JTn f
9,h r
d Gar y n,netoenth century and in colonial India. They do not recognize or
Urbanization Xith hs I d V
Pauper'zation of the Peasantry, the frequent famines, the unplanned
mav be called I m h
oyer crowding and lack of sanitation. Most such versions project what
and ignorant
t
’ the people are unhealthY b^e they have bad habits are unclean
and 'anorant. Unless they change there is no hope. At best what we can do is education^" It mav
n i b hatlISeases iike ch°lera and Plague,are well known over history but they achieve mX
public Si h e'lXnnE> X 'n S?eC'fiC S°Cial contexts- And official reconstructions of history of
public health, especially but not only those, authored by the British, remain silent on this.

IXnd mam dCU?V in-the understanding of public health is the assumption that prior to the advent
nl lt
r
KV'Ce 3S inStitUted bY the British there was
Indigenous tradition of disease
control or treatment or that what existed was hopelessly 'unscientific' & 'primitive' A lot of even
of hat n? lteratUre ta‘ks of the eemplete absence' of western notions of sanitation and the necessity
of having to tmpose these on a reluctant public - completely failing to see what culture specie
Xm'eOnntPPdahtlCemWere
eX'Stin9' EVGn
Prevention> scholars of subaltern history have now
pot ant htwlreX X 3 W'deSpread practice of ’"“eolation to provide prevention gainst sm II

it by its prescription

’ vaccination programme had to use every means to drive off this to replace

specific^eawres thathavr d" '’''J'T
PUb"’C hea''th P°!iCy iS irnpOrtant t0 understand two
aH nuhh-r h«ifh hathavc d°9ged all subsequent practice of public health. One feature is the bias that

alwavs qn
th- pro8rarnme? s are< Is a failure to see people as active rational participants. Health is
Pen Jo f
hn9
31 needS 10 be flivCn frOm above' '^"9 a military style pattern of command
eople cannot be expected to understand and take initiatives. It has to be done on their behalf The
The sX^nd"feature is't'"- listpMic health pr°9ramme.
® P
feature is the elitist bias now seen as a focus on urban curative services and personal
se?vSsaX'S
S°C,etal 'eVel Pfeventive measures, and an universal access to basic curative

THE BHORE COMMITTEE REPORT
inllKe^^tXuTtl051

INDEPENDENT INDIA'S HEALTH CHARTER:
ChOmrO1 °f communicable diseases 'n independent India.

' J r
about the same t,me that the Bombay Plan was being written a national
commission was set up under the Chairmanship of Sir Joseph Bhore called the 'Health Survey &
lanrimark16"^^01'”66; Th'S 25 PerS°n conlmittee submitted a 4 volume report which is itself a
Heal"for'AH^by^"©^^AdI^'h
1
W3VS *
the Al™ Ata ^darX of

In one of its most powerful paragraphs it

XchZXhln °f PUbliC bealth requires
fulfillment of certain fundamental conditions,
which include the proviston of an environment conducive to healthful living, adequate nutrition,

3

9

the availability of health protection to all members of the community, irrespective of their ability
to pay for it, and the active cooperation of the people in the maintenance of their own health.
The large amount of preventible suffering and mortality in the country is mainly the result of an
inadequacy of provision in respect of these fundamental factors, environmental sanitation is
at a low level in most parts of the country, malnutrition and under nutrition reduce the vitality
and power of resistance of an appreciable section of the population and the existing health
services are altogether inadequate to meet the needs of the people while lack of general
education and health education add materially to the difficulty of overcoming the indifference
and apathy with which the people tolerate the insanitary conditions around them and the large
amount of sickness that prevails."

(Report of the Health Survey & Development Committee, Vol.IV para 6)

The Bhore Committee report was also unequivocal as to the basic philosophy on which a national health
policy should be based. To quote:

?

"12. We have indicated above certain dark shadows in the health picture of the country. If it
were possible to evaluate, with any degree of exactness, the loss India suffers annually through
avoidable waste of human material and the lowering of human efficiency through malnutrition
and preventible morbidity, the result would be so startling as to arouse the whole country and
create and enlist an awakened public opinion in support of the war against disease. According
to one authority the minimum estimate of the loss to India every year from malaria alone lies
somewhere between 147 and 187 crores of rupees. ■ A nation's health is perhaps the most
potent single factor in determining the character and extent of its development and progress
and any expenditure of money and effort on improving the national health is a gilt-edged
investment yielding immediate and steady returns in increased productive capacity.

13. In drawing up a health plan certain primary conditions essential for healthful living must in
the first place be ensured. Suitable housing, sanitary surroundings and a safe drinking watersupply are pre-requisites of a healthy life. The provision of adequate health protection of all
covering both its curative and preventive aspects, irrespective of their ability to pay for if/th?
improvement of nutritional standards qualitatively and quantitatively, the elimination of
unemployment, the provision of a living wage for all workers and improvement in agricultural
and industrial production and in means of communication, particularly in the rural areas, are all
facets of single problem and call for urgent attention. Nor can man live by bread alone. A
vigorous and healthy community life in its many aspects must be suitably catered for.
Recreation, mental and physical, plays a large part in building uo the conditions favourable to
sound individual and community health and must receive serious consideration. Further, no
lasting improvement of public health can be achieved without arousing the living interest and
enlisting the practical cooperation of the people themselves."
To achieve these goals the Shore Committee drew up specific recommendations which they classified
under the heads of a long term programme and a short term programme. The long term programme
was in essence the building of a 3 tier district level health organization with the smallest unit catering
to 10,000 to 20,000 population. The entire network was to be staffed by a cadre of full time health
professionals who would be banned from private practice.
The short term programme written for the first two five year plan periods, envisaged the immediate
setting up a skeleton of primary and secondary units and special health service for mothers and ■
children, school children, industrial workers as well as for special services for dealing with the more
important diseases prevalent in India, such as malaria, tuberculosis, venereal disease, leprosy, mental

4

a"*

°°^nmto^l3Cyab5e0^VSeeaars%Cte?TtOrernainsna\oSnV^ermnp^rQgrrTmPmOe^rarnrne

DEVELOPMENTS AFTER INDEPENDENCE:

,hep““fc

-—

In the yearS that followed the following programmes came into being.
1.
2.
3.

4.
5.
6.

8.
9.
10.
11.

12.
13.
14.
15.
16.
17.

’National BCG Vaccination Programme 1951
Family Planning Programme 1952
National Water Supply & Sanitation Programme 1954
National Leprosy Control Programme 1954
Filaria Control Programme 1955
•National Sexually Transmitted Disease Control Programme, 1955
Trachoma Control Programme 1956
National Smallpox Eradication Programme 1962
National Goitre Control Programme 1962
National Tuberculosis Control Programme 1962
(called District Tuberculosis Programme)
National Programme for Prevention of Visual Impairment & Control
of Blindness Programme 1956
’Universal Immunization Programme, 1978
National Diarrhoeal Disease Control Programme 1983
1983
National Guineaworm Eradication Programme 1983-84
National AIDS Control Programme, 1987
National Diabetes Control Programme, 1987
Child Survival & Safe Motherhood Programme
1991.

It is

3n«X” ,ta,hIhePta 7o vea!s “eTHc'.m, ’J” 'k'""’'’/ " d'd b“'
.era™ („ <rom adequmo. To a ferae
outpatient curative services and maninulaLn

‘ 'P"ch l°»»'

b“'i,s '"rc'fedfeq
crna,ned conf|ned to providing a minimal

disease health policy has always relied on the vertical VealhprogTammes^'

s^ies and early seventies - only to sj/it

ihe'S^d nS^*

Eradication Programme as it had been enthusiastically renampd'

•Modfefed Plan o, O^.lon-. The ™act oAhfe

5
■c

'h'6*’0”8

C3SeS‘ '

Nat'ona’ Malaria

2 million cases per year at which rate it has remained reasonably stable over the last 15 years (Though
with small but worrying upward trend). What is more worrying however is that the death rate from
materia has started climbing upwards from 1973 and continue to do so to this day. (Reported deaths
over 500 annually are probably only a fraction of the actual deaths). fThe major factor underlying this
is the shift in the malarial species from the more benign plasmodium vivax to the malignant ptesmodium
falciparum. Increasingly this ptesmodium falciparum i$ drug resistant as well. Today there are tribal
pockets where almost 50% of people test positive for malarial parasites. Clearly there is a crisis here
in public health but a response to this crisis situation is just not tl.? r in' 12‘131

TABLE - I Material Incidence

?

Year

Positive

1961
1965
1976
1981
1982
1983
198//
1985

49151
99667
6467215
2701141
2182302
2018605
42184446
1864380

P.
falciparum
cases

Deaths

API

.53713
589591
551057
600964
655454
607822

59
170
187
239
247
213

0.21
11.24
4.11
3.22
2.93
3.08
2.57

Let us take the case of kala-azar a severe systemic infectious disease which if untreated proves fatal.
. The infection is caused by a protozoan and spread by the vector 'sand-fly'. This disease too
disappeared in the sixties but by 1977-78 was back in epidemic form. In 1991 there was an epidemic
outbreak with an estimated 25,000 cases (official figures 77/101) and a mortality rate of 5-lOper cent.
It still remains widely prevalent in large parts of Bihar & West Bengal and the worst news is this - th$
protozoan is increasingly turning resistant to all drugs. Even as of today the cost of treatment is about
about Rs. 1,500 (five courses of a'drug at Rs.250 per course of 20 injections). Some forms of kal^-azar
require so many course that it may cost over Rs. 15,000 per patient. The newer drugs needed are likely
to be even costlier.
..
The experience with filariasis, another mosquito-borne infection is similar - with the difference that
incidence of infection never came down at all. It continued io rise despite the national filariasis control
programme all through the post-independence decades.
.
'

r'.'

6

TABLE H

ESTIMATED POPULATION (IN MILLIONS) RESIDING IN ENDEMIC AREAS THE MF CARRIERS ANH
CHRONIC FILARIASIS CASES AT DIFFERENT POINTS OF TIME.

Year

Population Residing in Endemic areas
Total
Rural
Urban

M.F.
carriers

Chronic
filariasis
cases

1963
1962
1970
1976
1981
1989

25.00
Data incomplete
64.24 ^0.16 24.08
136.30 84.91 51.39
236.14 174.53 61.16
304.10 221.92 82.18

5.30
11.30
18.00
21.74

4.40
8.00

374.00

25.00

14.00
15.84
19.00

Another classic example of this pattern is what is happening with cholera. C.J
Cholera was one of.' the
largest kiLcrs of the last century and remained so in ’he early part of this century tod. C.
Despite
considerable efforts no successful vaccine has been pc ible, partly because the strain of causative
bacteria changes so often. Nevertheless with greater public awareness cholera epidemics have become
much less common and the overall incidence of cholera and mortality from it has also significantly
declined over the first three decades since independence.

it is oifficult, due to the absence of comparable data to talk of what is the situation in the last two
decaces. However one notes that mass epidemics of acute gastroenteritis not due to the cholera germ'
but due to a number of other germs - enteropathogenic, E-coli, entero virus, etc now occur. Some of
these epidemics are associated with considerable mortality also. Witness for instance the 1976
epidemic of gastroenteritis^n West Bengal that affected over 2 lakh people and is estimated to have
caused over 3000 deaths
Such epidemics of gastroenteritis are a common feature every summer
and during the onset of monsoons in most parts of the country. To make matters worse cholera itself
is back. In October 1 992, an uncommon strain of cholera designated 0139 Bengal broke out in Madras
and in neighbouring districts and by December 1992 it accounted for 95 per cent of cholera cases in
Calcutta
This strain has subsequently spread world wide, and especially in South and Central
America where the disease has been absent for decades, epidemics took pl ice recently. Even ’oday
the incidence of the disease remains high. Dr. Jacob John of CMC Vellore calls this the 'eighth
pandemic of cholera.'
*
Alongside these epidemics of cholera and gastroenteritis are an endemic prevalence of other infectious
disease - all of which are spread by the feco-oral route (also known as water-borne diseases). All of
these diseases spread by feces of an infected person gaining access to new individuals mainly through
contamination of drinking water but also due to lack of personal or social hygiene. Amongst these
diseases worms account for a great part of the morbidity. Hepatitis (jaundice) and typhoid n9). also
account for major part of water-borne disease.
Reliable epidemiological data on these diseases are hard to come by but estimates put prevalence of
worm infestation at about 70% of the population. For typhoid the lowest estimates would put it at three
lakh cases per year. Again the important thing to note about typhoid is this - the typhoid bacillus has
increasingly become resistant to most drugs so far used against it. Whereas it would earlier respond

7

to a course of chloramphenicol at a cost ol Rs.25 or so per course now the main drug used is
ciprofloxacin which is almost Rs.200 per course. And if the typhoid bacillus turns resistant to
ciprofloxacin as is likely and indeed perhaps already happening the cost of^veatment may go upto overRs.2000 with the next generation of antibiotics.
The outbreak of plague and the curious controversy, as to wtiethe’ it vvas plague or not that shook
Surat, has a similarly interesting moral. It does not, in the eventual ana1, sis, really matter whether it
was the plague bacillus itself or not. If it spread like plague, if it killed like plague if it responded to
treatment like plague it ought to be quarantined and managed like plague ! Indeed the possibility that
it was not the plague bacillus at all is much more interesting. Could it be that one can propose a theory
that in infections, given a suitable environment an organism could rise to fill the gap ? This principle
of the 'ecological niche' is well established in pest management in agriculture, but we need to see how
far it is true to the behaviour of infectious d^eases. Simply put all living organisms whether micro or
macro are inter-linked by an intricate series of interactions, especially the food chains. Various
organisms compete for available resources in any niche in this web and this determines their numbers.
Now if one organism is eliminated, another organism grow to fill this niche. In a situation of a total
failure of sanitation and overcrowding and unchecked rodent population the rise of a plague-like disease
is only to be expected.

The most outstanding success of medical science in this century is undoubtedly the eradication of
smallpox. We must at one level understand that this eradication was made possible by a number of
unique factors. One small-pox is a very contagious disease with a short incubation period, a very visible
disease phase and with relatively little sub clinical infection and has no a' nal reservoirs. The strategy
of surveillance and containment with well planned use of vaccination against all potential secondary
exposures to a detected case could thus yield dramatic results. It will be difficult to find other such
convenient diseases. And even in the poxes or exanthematous fevers like smallpox, chichekn-pox,
measles, etc. One does not know whe.ther in the long run these diseases will stay eradicated. Or will
other similar exanthemus become public health problems.
Though such a statement is quite
speculative, we must remember that history has seen many epidemics of pox fevers which from
accounts of their clinical presentation do not fit in with the currently known poxes.
Thus we can see that the control of cholera does not mean the control of acute gastroenteritis. And
the drug resistant form of malaria, kala-azar and tuberculosis a'so demonstrate the limitation of curative
treatment as a strategy of public health.

It is in the background of these questions that one must also look at the rise of new infectious diseases.
Take Japanese encephaletitis for instance. Before 1960s it was almost unknown in India in the mid
seventies the first major epidemics took place. Now a number of epidemics have taken place and the
annual spike in incidence during the onset of the monsoons and its steady annual death and disability
contribution no longer causes much comment (20). Why did this occur? We know that all the elements
of the disease transmission chain - mosquitoes, herons, pigs, man were all available before but why an
epidemic only now? Could it be that changes in the pattern of chemical use led to changes in insect
predator patterns that favoured multiplication of these mosquitoes ? Is there a relationship between
Japanese encephalitis spread and the bringing of new areas under paddy cultivation in the
Or take for instance Kyasnoor forest disease (in Shimoga district of Karnataka) (21). Clearing of forests
clearly led to a disturbance of ecological balance that shifted the tick from its usual mammalian hosts
(monkeys) to man.

Of course by far the most dangerous epidemic now catching or is the AIDS epidemic.

Everyday an
Everyday an
estimated 6000 people world wide get infected. By mid 1994 over 4 million cases of AIDS are reported

8

to have occurred and over 2 million are dead. By 2000 AD this figure is likely to reach 8 million dead
and 30 to 40 million infected. Some sources put the world figure at 100 million. Sexually transmitted
disease was never really controlled though it could be cured effectively. Now a form has arisen where
cure is difficult to achieve 1
And with the spread of AIDS another disease that we have never been very successful against has
taken on a much more dangerous form - tuberculosis.

Tuberculosis afflicts 1.5 per cent of India's total population; (22) the patients number 12.7 million of
which 7.4 milion are infective. Every year half a million Indians die of tuberculosis and 1 million cases
are added. All this despite the fact that the quality of drucfs available to treat this disease have
dramatically improved over the last three decades. Today among serious public health thinkers there
is almost a sense of panic as multi drug resistant tuberculosis cases emerge as a public health problem.
Already in all of Europe & USA tuberculosis has risen in the city of New York for example by 150 per
cent in one year ! And most of these cases are multi-drug resistant.
In India the problem of multi drug resistance has not reach such dimensions, but by all past experience
any major epidemic contagioun of the developed world even if soon controlled in its source becomes
me developing world’s major problem. Unless we can act decisively to prevent it, one is likely to
witness a major emergence of MDR tuberculosis within India also in a major way in the coming decade.
We can sum up this discussions of trends in the incidence of infectious disease to say that
’a)

b)

c)
d)

the last few decades have witnessed dramatic decline in a few major infectious diseases as
compared to the pre-independence period e.g., malaria smallpox;
the decline in the disease was maximal in the sixties or early seventies, thereafter these disease
have made a spectacular comeback though they are still well below the pre-indep^ndence
levels.
Again, a number of diseases like fiiarjasis, diarrhoea and tuberculosis, existing vertical control
programmes have just failed to work.
A number of new infectious disease are now rapidly emerging or have already emerged as major
public health problems.

A CRITIQUE 01 VERTICAL HEALTH PROGRAMMES

Obviously we are in a far from satisfactory position. One needs to review the main philosophy of the
control strategies utilized to understand what has gone wrong. We shall discuss two illustrative case
studies to underscore our central position. Our central position is that the main reason for this
resurgence is the construction of communicable disease control programmes as vertical health
interventions. Such vertical health interventions depend on a programme of action decidea centrally
and implemented through a bureaucratic chain of command. Such a vertical health intervention
provides little room even for local adaptation and much less for community participation. Necessarily
therefore it depends on it success on a few simplistic technological solutions that can be applied
uniformly and extensively and is capable of being directed and monitored centrally. Though these
vertical health programme claim to be in the spirit of the Alma Ata declaration the central political
concept of this declaration is that primary health care is "essential health care based on practical
scientifically sound and socially acceptable methods and technology made universally accessible to
Individuals and families in the community through their full participation at a cost that the community
and country pan affojd to maintain at every stage of their development in the spirit of self-reliance and
self-determination,". The vertical health programmes nowhere envisages community participation

i

9

i

except to some exent in its administration.

In contrast to the Alma Ata declaration's approach, this the philosophy for the v^tical health
programmes is much nearer to the paternalistic approach to public health of earlier colonial times,
significant traces of which can be seen even in the Bhore committee report. ’ ne main features of a
paternalistic approach is basing one's policy on the premise that people cannot 'ook after their health
needs. It has to be done on their behalf, often without their consent by those
ho know. This
approach can be seen to manifest itself in the choice of technology and strategy that the various
vertical health programmes have taken.
Let us see the example of malaria:

The National Malaria Control Programme was launched in 1953. A central directorate was set up and
corresponding departments were created in the state and district levels and provided with staff
dedicated fully to malaria control.
’
The central strategy of the programme was, at field level - a one point strategy - spray DDT. DDT was
liberally sprayed and adequacy of spraying monitored by an elaborate programme of monitoring
activities and disease surveillance articulated in the language of the military. The results were so
encouraging that in 1958 the programme was renamed the National Malaria Eradication Programme and
further intensified. Mass treatment of all fevers with chloroquine was also instituted in an attempt to
interrupt malarial transmission further. By 1 965 and 1966 the incidence of malarial deaths had dropped
to zero and the cases of malaria were down to a few thousand. But by 1970'the incidence curve was
sharply rising. One reason given for this is that malaria eradication just lost administrative priority being
no longer a major health problem. Benign neglect and a premature satisfaction was according to this
interpretation the cause of the relapse. If the rising costs of insecticides and if the resurgent mosquito
and plasmodium was developing drug resistance - why that could not have happened if the
administrative laxity had been avoided.

It is difficult to argue on theoretical grounds that it is not so. One only notes that any programme that
has such a top-down approach inherently becomes much more vulnerable to administrative laxity and
it is almost impossible as any General knows to sustain a 'war' indefinitely.

An alternative approach could have been a much greater decentralized, locally planned participatory
initiative. Thus for example in urban south Madras where malaria is holoendemic, accounting for
roughly 40,000 of the 80,000 cases that annually occur in Tamil Nadu the approach must focus on
open wells, overhead tanks and all fresh water collections even in garbage cans or tyres in the roadside ■
shops or in tree hollows! But no government can do this. It needs a vast social mobilization.

On the other hand in tribal Orissa where one of the highest malarial incidence in the world exists the
vector breeds in the safety of the forest pools and streams. Here perhaps mass chemoprophylaxis done . c
at the same time as a spraying operation with perhaps the large scale introduction of impregnated
mosquito nets would help. Or perhaps biological methods may help. And of course every hamlet mpst
have a malaria monitoring unit run by local people I To an administrator asking for this to happen is
suggesting the impossible. He would rather place emphasis on a newer insecticide and more staff..
What one is suggesting is not that newer insecticides or better administration may not be needed but
unless one undertakes the social mobilization and the local level participatory planning that is necessary
no such technical solution can be sustained.
There is resistance to such a suggestion from not only th£ administration but some sections of the

10

I
technocracy too.
To these technical people there is a worry that such an approach underestimates
the ro!e of science and technology in the conquest of disease. The biological control of vectors is
possible they argue. The malaria! vaccine is just around the corner. What one needs is more inputs
in science and technology. Tropical disease research has iust not attracted enough attention and such
arguments as advanced in this paper may be used conveniently to scuttle research even further.
To them one has to reply that one is not talking of downscaling research. Indeed it needs much higher
investment. But one must start looking closer at the research questions being addressed. One must
examine carefully the strategies for which technology is being developed. Are these strategies capable
of sustaining their achievements ? Are they capable of democratic control ? Do they allow for local
flexibility ? Do they sufficiently respect the ecology of disease and their social nature ?

And no one need fear the downgrading of science. Social mobilization for such a purpose necessarily
means a much wider dissemination of scientific understanding, a much wider application of scientific
principles than has been hitherto possible. For example unless every school child in south Madras
knows to identify mosquito-breeding sites and destroy them the malaria epidemic here (which has
persisted over nearly a century) stands little chance of being eradicated.
If we look at most of the other vertical health programmes we can see this same reliance on
technological bullets sprayed through a bureaucratic chain of command to be at the heart of orogramme
design. Thus in filaria and kala azar control it was DDT spraying, in goitre control it is universal
iodisation of sait, Tor Vitamin A deficiency related blindness it is to give prophylaxis to all children, for
leprosy it is case identification by search teams and drugs to those identified. Of course where such
simplified technological bullets are just not available these programmes have made no impact. Thus
diarrhoea disease control programmes confine itself to stocking and distributing ORS packets which
even theoretically cannot be expected to prevent diarrhoea (though it is an essential measure to stop
deaths).

i
i

L

Even the family planning programme, India's largest and most prestigious vertical health programme
reflects this trend of exclusive reliance on technological bullets. First it was a drive for loop insertions,
and then it was a push for vasectomy. Later still, these were given up up and the stress came to be
on tubectomy, especially laproscopicsterlisation. Each time targets were at least claimed for some time
and then that particular drive just tailed. The birth rates remained high declining by less than 1 per 1000
over a a whole ten year period,

TUBERCULOSIS CONTROL

THE STORY OF A DISTRICT LEVEL INTEGRATED PROGRAMME:

Whereas programmes like malaria, kala azar, AIDS; leprosy, smallpox have all depended on a complete
bureaucratic chain of command there are notable exceptions to this strategy. The National Tuberculosis
Control Programme, known as the district tuberculosis control programme, envisages district level
pla ming and full integration with the primary health centre. The Tuberculosis control programme
envisaged that the microscopic examination of spuctum of those seeking medical help for chronic couch
and then ensuring their regular drug treatment would be the cornerstone of TB control. The District
’ Tuberculosis Centre, would organise this in some 40-60 health institutions - PHCs, dispensaries,
hospitals - fully horizontally integrated. The diarrhoeal diseases control programme and maternal and
child health programmes are also PHC based. Despite a more methodical planning the TB programme
has not done any better. The reasons for this are to do with the way a PHC is structured and
functions. Understanding this is important because with the evident failure of most vertical health
programmes, today the emphasis is on integrating the functions of the vertical health programmes with
the PHC. This in practice means that all the field level functions of these programme have to be carried

11
03651

j

out by the mutlipurpose health worker/or ANM or equivalent^. The vertical structure extends only f,om
Delhi through the state headquarters to a designated district medical officer for each oj these
programmes. Below this level it is all stated to be integrated. JBut such integration often means only
an allocation of functions on paper.
At the village level only one of these 16 vertical health programmes is currently functional and has a
significant outreach and that is the family planning programme. In Tamil Nadu and a few more states
the mother & child programme especially the immunization component also has some effectiveness.
The other programmes are accorded such low priority, that they just do not take place. Tuberculosis
for example needs a massive social effort at case-finding and an intensive participatory monitoring
effect to ensure case-holding. At present only a small percentage of cases are discovered and patient
compliance (case-holding) for a complete course is in the range of 45 per cent. Within this 45 percent
due to periodic drug shortages adequate coverage reaches even fewer people. In a sense tuberculosis
control more than any other disease control is a true reflection of the efficacy of the entire health
system of the country - both preventive and curative. And by that score card we have faller far short
of what we could have achieved.

What could turn the tide against tuberculosis. Any successful strategy against tuberculosis would
provide clues to an approach to all infectious disease. Or in other words - what should be our response
to the resurgence of infectious disease.

A STRATEGY AGAINST INFECTIOUS DISEASE

The first and most important requirement is a higher level of nutrition of the population. Resurgences
of disease, especially of a disease like tuberculosis is often only a mere indicator of the malnutrition and
dismal living and working conditions of the people. Whereas at the individual level curative care is a
must, if this is not integrated into a strategy of prevention this same curative care is only going to lead
to the emergence of MDRT (multi-drug resistant tuberculosis}.
Other than nutrition the single most important input is general sanitation with special reference to safe
drinking water and safe disposal of human excreta and other wastes. A situation of poor sanitation
provides breeding grounds for vectors and allows transmission of a wide variety of germs. Curative or
even preventive measures (e.g., cholera or typhoid vaccines) against these germs will not provide any
sustainable improvement unless the niche is made unavailable.

I

The third pre condition for health is a much higher degree of education and health awareness available
today. In the main health education means providing a much higher degree of access to information
on health - by posters, by booklets, through the electronic media, in school curriculum and so on. But
beyond mere transfer of information health education must also mean questioning existing cultural

norms or patterns of living and social mobilization to create new cultural norms or provide support for
changes in life styles.
ese three aspects - nutrition, sanitation and education (health awareness) taken together form one
cornerstone of any public health policy that hopes to improve the health status or even just to contain
infections. Improvements in all three require policy changes at various levels but policy changes alone
will not be adequate. A much more important component, especially for ensuring sanitation and
education is a well planned social mobilization effort.

The o*her cornerstone of public health policy has to be development of local level (district level, taluk
evel) health planning which is assisted by a mechanism of good epidemiological surveillance. Without
a mechanism of continuously monitoring disease incidence, infectious disease control is not possible

12

■

to sustain. The National Health Policy Document talks of setting up a chain of epidemiological cum
sanitary stations throughout the country but to the best of our knowledge nowhere has this work even
begun. Al present almost no district or PHC has epidemiological data of diseases in their area. Much
of the existing resources are therefore spread thin instead of being able to focus it where it is most
needed. When an epidemic occurs there is no capability to either trace the source or to cut off its
spread. Performance of control programmes also become impossible to monitor without such data.
And above all the local community cannot be informed nor any attempt at local level planning be made.

Such local level planning can only emerge with the development of capabilities with bodies of local self
governance to understand the nature of health problems and to plan for their control.

These are not profound original statements. This concept that local bodies need to play a role has been
with us almost since 1880s when the bodies of self-governance were first mooted by the British
primarily to control the then raging epidemics of cholera, typhoid, smallpox and later (1892) plague.
But what British administrators then and Indian ones now had in mind for local bodies was the
deconcentration of power - the handing down of certain administrative functions which v,ere impossible
to do from above. What is really needed however was the decentralization of power passing of
capabilities and the power to plan downwards too. Even this limited deconcentration of power to
panchayats never took place. For reasons of politics every time the decentralized holistic approach lost
out to the vertical.bureaucratic one. And this continues to this day. The promise of spectacular results
with a short time, the support from international organizations and western countries for programmes
that yield immediate visible results and the cultural gap between providers of health services-and the
broad mass of the people will continue to fuel this trend to depend orr purely technological solution
administered from above rather than integrated solutions planned below.

Let me conclude with a quotation from D. Banerjee, Professor emeritus of social medicine in Jawaharlal
Nehru University the most outspoken and consistent critique of the vertical programmes Over almost
halt a century.

"It is worth noting that in the history of public health in western countries virtually no vertical
programmes have been employed to combat communicable diseases. Changes in ecological
conditions brough t about by socio-economic development have been the principal factors which
led to control or eradicaticjn of communicable diseases in these countries (Mckwown 1976).
Even in the recent instance of control of poliomyelitis with the help of the vaccine, the
vaccination programme had been a part of the activities of the local health authorities. It is
interesting to examine why those who never had a vertical programme in their own countries
have been so fervent in advocating such programmes in Third World countries 'Walsh &
Warren)"

G

13
:l

I

1 :

! I ! 1

I

IS FAMILY PLANNING;
EMIOWERINC. OR COERCIVE ?

Paper Presented at the Seminar "Health For AH - Now; Organised by the All
India Peoples Science Network, Nov. Sth - 7th 1995, New Delhi,

9

Is Family Planning Empowering or Coercive?

D)oming as a menacing idea over (he last two centuries, to congeal into one of the
most powerful and abiding myths of our times, is the reproductive profligacy of the poor.
Indeed, as it went on to recommend a family planning programme for the country, the Brfure
Committee noted:

The classes which possess many of these undesirable characteristics are known to be
generally improvident and prolific. A continued high birth rate among these classes,
if accompanied by a marked fall in the rate of growth of the more energetic,
intelligent and ambitious sections of the population, which make much the largest
contribution to the prosperity of the country, may be fraught with serious
consequences to national welfare.1

The empirical fallacy of this myth, both historical!) and cross-culturallv and
contemporaneously in India, has been commented upon by Krishnaji in a'host of

publications.2 In this paper I present some findings from my study in three villages of an

average performing Primary Health Centre in the relatively prosperous ^nd agricultural!)

dynamic Mandya District of Karnataka to tangentially throw light on the question we are

discussing.
***

A family is defined, at a point in time, as a co-resident domestic group comprising

the reproductive unit of husband and wife and their offspring, either natural or adopted, who

. Government of India, Report of the Health Survey and Development Committee
Government of India Press, New Delhi, 1946.
. Including, among them, "Agrarian Structure and Family Formation: A Tentative
Hypothesis", Economic and Political Weekly, Vol.XV, No. 13, 1980; "Povert) and Family
Size", Social Scientist, Vol.9, No.4, 1980; "Poverty and Fertility: A Review of Theory and
Evidence", EPW, Vol.XVIIi, Nos. 19-21, 1983.

1

‘

ccunmonly shared the same kitchen. The study population comprised 670 such families. Table

I presents the (Lit<i on the distribution ol families by si/e in relation to elass.
Table 1. Distribution of Families by Size in Relation to. ('lass.

I Family Size

1-4

5-9

Class

10-14

Total

Primarily Exploiting Labour
Landlord

No.
%

16
2.4

31
4.6

Rich
Peasant

No.
%

117
17.5

141
21

3
0.4

261
39

37

1
0.1

78
11.6

47
7

Primarily Self Exploited

Middle
Peasant

No.
%

40
6

Small

No.
%

2.7

11
1.6

63
9.4
~66"

7.2

2
0.3

113
16r9

47
7

3
0.4

17.3

Peasant

18

5.5

4.3

Primarily Exploited

Poor
Peasant

No.
%

Landless
Labour

No.
%

Non
Peasant

No.

15
2.2

10

1

%

1.5

0.1

26
3.9

Total

No.
%

335
50

325
48.5

To"

670

9.9

48

116

1.5

100
=n

% proportion of total families
What is extnmely important to note is that 50 per cent of the families

in this

primarily agrarian population comprised up to four members alone. This goes against the
grain of most common sense assertions regarding the family size of agrarian populations. The
second most significant finding is that°it is in the primarily exploiting classes, viz. the

landlord and the rich peasant, that a larger family size of five to nine individuals was more
prevalent.

Table II presenting the proportionate distribution of families by size in each class and

2

the mean family size serves to highlight the differentials.
I able 11. Mean family Size and Propon.onate Distribution of Families by Size in Relation
to Class.
Size
Class

1 to 4

5 to 9

Landlord

37.04

65.95

Rich Peitsant

44.82

54.02

1.14

Middle

51.28

47.43

L28

Small Peasant

62.06

Poor Peasant

55.75

37.93
42.47

1.76

4.42

Landless
Labour

56.89

40.51

2?58

4.33

Non-Peasant

57.69

38.46

3.84

4.38

10 to 14

Mean
5.02

4.76
4?55

Peasant
4.66

What the data presented in this table reveals is that with declining class status, the
proportion of families with a smaller size increases. The primarily exploited classes, viz. the

poor peasants and the landless labourers, had the largest pronortion of families comprising
up to tour members. The difference in the proportion between these classes and the landlord

and rich peasants was statistically significant.

It is interesting to note that the landlord class has ’he largest mean family size. The
mean family size declines as we go down the class hierarchy; it is lowest among the landless
labourers.

I he size of a family, it is well known, is dependent upon the following factors:

selective migration, fertility and mortality. One of the most striking findings of the 1991
Census is that there is a dampening o/ rural-urban migration; indeed dependence on
agricultural employment may well have increased over the previous decade.1 This attests not

so much to the absence of push factors in the rural economy as perhaps the weakening of pull

\ Kulkarni, Sumati, "Dependence on Agricultural Employment", EPW, Vol.XIX,
Nos.5I-52, 1994.
3

factors in the urban economy. Nevertheless the import of this finding is that we may discount

selective out-migration as a factor to explain these observed differentials in family size.

A number of mechanisms have been postulated through which the comparative fertility
of the poor would be lower. These include a higher age at menarche, a larger number of
anovulatory menstrual cycles, longer post-partiim amenorrhoea due to prolonged breast
feeding, pregnancy wastage, still births and so on 4 An index of fertility that can be utilised,

albeit as a proxy for fertility rates, is the Children Ever-Born Ratio. This is given by the

following formula:

Children

No.of Children Ever-Born to Married Women in an
Age Cohort.

Ever-Born
Ratio

x 100

No. of Married Women i the Age Cohort.

Table
i the study population.
iaoie III
in presents the data on the distribution of this ratio in
fable III. Distribution of Children Ever-Born Ratio in Relation to Class Croups.

Age
Class

1 i-15yrs

16-25yrs

26-35yrs

36-45 yrs

Total

Class I

Non-Peasant
Total

72.54

201.85
184.00
206.66
144.44
192.99

395.78
420.00

Class III

61.53
66.66
93.75

556.52
625.00
503.92
533.00
548.66

333.55
322.23
315.13
296.00
324.86

Class II

375/X)
290. (X)
386.02

. Class I = Primarily Exploiting
Class II = Primarily Self-Exploited ©
Class 111= Primarily Exploited

Although the differences among the class groups are not statistically significant given
the nature of this study and the sample size, it is indeed quite arresting that women among
1970 GopaIan’ C-’ and Naidu, A.M., “Nutrition and Fertility”, The Lancet, Nov. 18th,

4

the classes primarily exploited have a lower level of fertility than the other peasant classes

as revealed by the children ever-born ratio. Indeed in the age cohor^of women 36-45 years,
towards the end of the reproductive life span, the diiierenue in the ratio between the classes

primarily self-exploited and the primarily exploited assumes statistical significance.
An index of the mortality of infants and children, again as a proxy for infant and child

mortality rales, is the Child Sun ival Ratio. This is given by the following f< rmula:

Child

Total No. of Infants and Ch Jren Ever-Born Surviving
Among Married Women in an Age Cohort

Survival

Ratio

x 100

Total No. of Married Women'in the Age Cohort
Table
IV provides
provides the
the data
data on
on the
the distribution
distribution of
this ratio
ratio in
i the study popu1 .lion.
iame iv
oi this

Table IV.Distribution of Child Survival Ratio bv Cohorts of Married Women in Relation to
Class

Age
Class

ll-15yrs

16-25yrs

26-35yrs

36-45yrs

Total

Class I

61.53

184.25

344.21

443.47

284.56

Class II

66.66

170.00

360.00

504.16

275.72

Class III

93.75

178.88

291.80

374.50

250.30

144.44

220.00

450.00

248.00

178.21

322.04

430.00

270.03

Non-Peasant

Total

72.54

Class I = Primarily Exploiting
Class II = Primarily Self-Exploited
Class III = Primarily Exploited

What this reveals is that among the peasantry as a whole, the child survival ratio

decreases with decreasing class position. The differences in the ratio between the primarily
exploiting classes and the primarily exploited in the age of women 26-35 years is statistically

significant as indeed is that between the primarily self-exploited clas and the primarily

5

1
exploited. In the age cohort of 36 -45 years also the differences between the latter classes
assumes statistical significance. In other words, the poor peasants and the landless labourers

in these age cohorts had the least chances of child survival among the peasant classes.
To sum up, the data presented here indicate that the primarily exploited classes, the

poor peasants and the landless labourers, the “poor" who constitute close to 40 per cent of

our population, had a lower family size. This is governed not only by a heavier mortality
load borne by these classes but also apparently lower fertility thus largely substantiating
Krishnaji’s hypothesis.5
*♦*

It is not as if the findings presented here are entirely novel. The truth is that data such
as these have been largely ignored in a flood of Neo-Malthusian fact and fiction.
To conclude, tamil\ -banning may well represent empowerment to pc

as in the

classes primarily exploiting labour. Assured of access to resources, employment, incomes,
educational skills, nutrition, a relatively better endowed environment, access to health
services — and thus child survival, access to family planning services would widen

reproductive choices for well being. Indeed they may empower both men and women. On
the other hand, for those primarily exploited, family planning and the question of
reproductive choice, in the absence of child survival and all it > accoutrements, may represent

not just mockery of poverty but, as policies are implemented in our country, coercion.
©

Mohan Rao
Centre of Social Medicine and Community Health
School of Social Sciences
J.N.U.

\Krishnaji, N., ’’Poverty and Family Size’’ op cif.
6

©

COST OF MEDICAL CARE
Issues of concern in the present scenario
Sunil Nandraj

This paper examines the financial aspects of various components in the health care delivery system of
the country. It attempt’s to highlight some of the major issues of concern that need to be addressed in
the present economic scenario.
The health care sector in India has come of age. There has been a tremendous amount of growth in terms of
physical size, investments, expenditures and utilisation of health care services. Unfortunately, it continues to
be maldistributed and the average quality of services, not commensurate with what it is capable of achieving.
There is an absence of a holistic approach for the provision of services which has led to a lack of
comprehensiveness. Health planners and policy makers among others have failed to take a holistic picture of
the health services in the country. They failed to take into account the role, functions, size, investments,
distribution of the private health sector which was operating and growing by leaps and bounds. Recent studies
conducted bring out that for indoor care around 50 percent and ambulatory care (out-patient) nearly 70 to 80
percent of people utilize private health facilities in the country (NSSO 1989, Duggal and Amin 1989,
Kannan ct al. 1991, NCAER 1992, George etaL 1994). Compared to state expenditure on health the private
household expenditure is nearly four to five times more than that of the slate. Today, the nation knows very
little about a sector which is consuming 80 percent of health expenditure and being utilized by majority of the
people in the country.
This has been inspite of the fact that the Bhore committee in 1946 had set out a detailed plan for ti c
development of health care services in the country. This plan was well studied, comprehensive and suited to
Indirn conditions. It recommended that the resources for hen’‘b should be increased by three times of that
< fis mg then. Health services were to be provided universally to all free of cost. It gave greater emphasis to
aral areas in correcting the wide rural-urban disparities. (Bhore Committee, 1946) If implemented fully in a
time period of twenty-five to thirty years the level of health services would have improved in a substantial
manner spread proportionately all over the country. This would have made the private health sector
dispensable. The first and second health ministers conference after independence accepted the Bhore
committee's recommendations in principle only, citing lack of resources as a major constraint. The first five
year plan made some effort on the recommendations of Bhore committee, but subsequently there was no
mention of the committees recommendations.

Components of health care services' in the country
India’s health care system is characterized by a mixed ownership pattern. To compound this plurality of
provision, there are different systems of medicine- Allopathy, Ayurveda, Unani, Siddha and Homeopathy.
There arc three major groups in the provision of health care and consumption of health resources in the
countiy . These are the public sector, private health sector and thirdly the households who utilize the health
service constitute the largest constituent who spend on health care.

The public health sector consists of the central government, state government, municipal & local level bodies.
Health is a state subject and therefore the primary responsibility of providing health services vests with the
concerned state government. However the central government does contribute in a substantial manner through
grants and centrally sponsored health programs. There are other ministries and departments of the
government such as defense, railways, police; ports, mines etc. who have their own health services/schemes
and institutions that provide care for their own personnel. For the organised sector employees (public &
private) provision for health services is through the Employee’s State Insurance Scheme (ESIS).

1

o

The private health sector consists of the 'not-for-profit' and the ‘for-profit' health sectors. The not-for-profit
health sector includes various health services provided by non government organisations (NGO’s), charitable
institutions, missions, trusts, etc. Health care in the for profit health sector is provided by various types of
practitioners and institutions. The practitioners range from General Practitioners (GPs) to the super specialists,
various types of Consultants, Nurses and Paramedics, Licentiates Registered/Rural Medical Practitioners
(RMPs) and a variety of unqualified persons (quacks). The practitioners not having any formal qualifications
constitute the 'informal' sector and it consists of tantriks, faith healers, bhagats, hakims, vaidyas and priests
who also provide health care. The institutions falling in the private health sector range from single bed nursing
homes to large corporate hospitals, and medical centres, medical colleges, training centres, dispensaries,
clinics, polyclinics, physiotherapy and diagnostic centres, blood banks, etc. In addition to these, the private
health sector includes the pharmaceutical and medical equipment industries which are predominantly
multinational.
Issues to be addressed

Privatisation and liberalization characterize the new economic policies being pu^ued in the country. It is in
this context that we have to view the various dimensions and aspects of health care costs. These are, majority
of the people living under extreme poverty conditions, non-availability of basic amenities for the majority of
the people, poor nutritional status, impoverishment due to health, poor availability of public services, presence
of a dominant and unregulated, unaccountable private health sector along with strengthening of market forces
and helplessness of the consumer against various odds.
The Finances of the Public Health Sector
The Indian constitution in it’s Directive Principles of State Policy has vested the state with responsibility for
providing free health care services to all citizens. In the present scenario the state is abdicating its role of
providing health services to the people. There was no attempt post-independence to radically restructure
health care services inspite of the recommendations of the Bhore Committee Report. On the contrary, aspects
contributing to inequality were strengthened; for instance, under funding of public health services,
concentration of medical services disproportionately in the urban areas, production of doctors for the private
sector, financial subsidies by the State for setting up private practice and private hospitals.
Under-funding
The investment by the public sector for health care has been inadequate to meet the demands, of the people.
The State has over the years committed not more than 3.5% of its resources to the health sector. The budgeted
expenditure for 1994-95 was at 2.63% of total government expenditure which is the lowest ever. As a
percentage to Gross Domestic Product (GDP) it has been around 1 percent only, woefully short of the World
Health Organisation’s (WHO) recommendation of five percent.

Further when we calculate per capita expenditure we find that the state spends a meager amount of Rs 60 per
year (1990-91) on health. At today’s market prices providing all the above services free of cost requires much
more expenditure than that is spent presently. Raising this to 5% of GDP would mean an additional
expenditure of Rs. 175 billion. This sounds like a lot of money. But given a population of 860 million it
works out to only Rs. 260 per capita. At present day prices this amount is equivalent to 35 kgs. of wheat or 40
kgs. of rice or 7 kgs. Of ordinary edible cooking oil or an ordinary rail ticket between Bombay and Calcutta at
a little less than a well known medical consultant's fees for a single consultation or 9 GP consultations or 11
days wages of an organised sector industrial worker or 15 litres of petrol. This is not a very extraordinary
demand. Given a political commitment, financing of the health sector along with other social sectors needs to
be substantially strengthened because ultimately it is these provisions that become the foundation for
improvement in the quality of life. (Duggal R, Nand raj S, Shctty S, 1992)

2

Expenditure on health has not kept pace with increase in government expenditure. Under structural
adjustment there has been further compression in Govt spending in an effort to bring down the fiscal deficit
to the desired level. Analysis of data by National Institute of Public Finance and Policy gives evidence for this
compression which has taken place over the last decade It shows the state's share in health spending has
increased from 71.6% in 1974-82 to 85.7% in 1992-93 and that of the grants from centre declined drastically
from 19.9% in 1974-82 to 3.3% in 1992-93 Further the breakdown of central assistance to states reveal that
central programmes or centrally sponsored programmes are the most severely affected. The Share of central
grants for public health declined from 27.92% in 1984-85 to 17.17% in 1992-93 and for diseases programme
from 41.47% in 1984-85 to 18.50% in 1992-93 (NIPFP, 1993>. The investment by the state in the health
sector is very small both in the overall economy as well as within the public domain.

Rural-urban disparity
It has been clearly shown time and again by various studies that the rural-urban disparities in terms of health
infrastructure is wide and should suffice to show where the state’s investment in health sector is going.
Analysis of state expenditures on health reveals that between 70 to 80 percent of the investment and
expenditure goes to 30 percent of the population in urban areas. For instance, in 1991 of all hospitals and beds
in the country only 32%, and 20% respectively were in the rural areas i.e., 0.57 hospitals and 20.2 beds per
100,000 population in rural areas as compared to 3.5 hospitals and 238 beds per 100,000 population in urban
areas. (CBHI, 1992) This is inspite of the fact that urban areas also have access to othci public and quasipublic health facilities such as municipal and other local body hospitals and dispensaries, ESIS and CGHS for
industrial and government workers and so on. Most municipal bodies spend between one-fourth to one-third
of their budget on health programs whereas rural local bodies don’t spend anything significant on this account
(NIUA 1983,1989).

There is utter neglect of rural areas in provision of medical care services. The State took up the responsibility
of preventive and promotive health services and left the curative care largely in the hands of the private health
sector The poor in the villages were given inferior health services in the - e of Primary Health Care,
National Programmes etc. For the rural population there is very little provis. .. of state funded curative care
though the major demand of the people is curative care. Studies conducted bring out the fact that PHCs are
grossly underutilized primarily because they are inadequately provided (staff, medicine, equipment, transport,
etc.) and because the entire focus of the health program through PHCs is in completing family planning
targets (ICMR 1991, Gupta JP, etal 1992, Ghosh B 1991). The loss of faith in the public health sector has
provided the private health sector an oppoftunily to thrive and make its presence felt as the sole provider of
curative care in the rural areas.
Mis-placed priorities
The state funding for health care as seen above is very meager and insufficient to meet the needs of the
population. Within this meager amount available the state’s prioritization and allocation of health
expenditures are misplaced: The major emphasis of the state health program has been on population control.
From among its various developmental efforts the population control program stands as the most priority
activity the Indian state has pursued with a zest bordering on obsession. The under development and poverty
of the country is blamed entirely on its population growth rate. Family planning is the single largest plan
health program swallowing more than half the plan resources for the health sector. Over the year's
expenditure on family welfare program has increased at a very fast pace. From an annual average expenditure
of Rs 4.40 million during the second plan (1956-61) it went upto Rs 49.80 million in the 3rd plan period
(1961-66) and further to Rs 235 million during the plan holiday (1966-69). (Duggal R, Nandraj S, Shetty S,
1992) It went on increasing at a rapid pace in the consecutive plan periods. Family planning expenditures are
spent mostly in rural areas through the PHCs and sub centres. On as average each PHC spends around Rs
200,000 to Rs 300,000 on family planning. Besides the allocation of resources it uses the entire infrastructure
and human power to meet the targets of its programme. This has resulted in a neglect of other health
programs but also the discrediting of the rural health sendees as a family planning services. This has made the
entire rural public health sendee defunct. Inspite of such large quantum of funding the FP programme has
3

becn a miserable failure. The Total Fertility Rate continues to remain around 4.5 per women and the growth
rate has remained near constant for the past three decades at around 2.2 percent per annum.
Shifting priorities
Another area of concern is the expenditure incurred by the state on diseases control program. At present there
are around 15 national diseases programs functioning in the country. These are for diseases and illness like
TB, malaria, filaria, leprosy, diarrhoea, blindness, STD, mental health, cancer, etc. The latest addition is
AIDS. These programmes were funded and sponsored by the centre. Every plan period brought out a new
national diseases program. The policies and priorities to various diseases programmes kept shifting. The
shifting priorities within the diseases program was more due to the international pressure than the diseases
profile of the country. The union government has played a far more significant role in the health sector than
demanded by the constitution. It has pushed various national programs in which the states have had very' little
say in deciding the design and components of the programs. The states have acquiesced to programming due
to the central government funding that accompanies them. The expenditure on this programme across the
various plan periods has been between 12 to 13 percent of the total health expenditure except during the 195565 period when expenditure on malaria was over one-fourth of total health expenditure. On an average «nly
Rs 7 per capita per annum is spent on diseases program. Low priority, under-funding and shifting priorities
for diseases programmes persist in spite of an increase in morbidity and mortality due to various diseases. The
share of central grants for diseases program declined from 41.47 percent in 1984-85 to 18 50 percent in 199293. The decline of expenditure on diseases program has been considerable in the states of Assam, Karnataka,
Madhya Pradesh, Punjab, Rajashtan, West Bengal, Bihar and Orissa. (State Government Budgets, Various
Years).

Health Finances to support Salaries
Though the reach of the public health services is very limited it supports a very large bureaucracy from the
union capital down to the PHC level.
support for this elaborate bureaucracy and line workers forms a
major chunk of the states health bud.,
This fiscal control by the centre and top heaviness of the health
organizational structure has made adudnistrative costs of the health ministry 's programme phenomen illy
high. For instance, as of March 1991 the rural areas the State was employing 311.455 line workers (doctors,
nurses, pharmacists, paramedics) and 293.400 support staff (clerks, wardboys, drivers, surveyors, etc). It may
be noted that these were 39% less than the stated requirement for the existing health infrastructure in place
(DGHS 199 V. The Central Ministry of Health employs over 30,000 persons. The figures for the States is not
available but it must be a whopping amount considering the fact that health services are a State-subject I.
Analysis of the expenditure on health in Maharashtra during 1990-91 shows that out of a total expenditure of
Rs 1767.13 millions on public health account, 43 40 percent was incurred on direction and administration,
this is addition to the expenditure on salaries under each program head. Diseases control programmes
accounted for 35.23% of total expenditure under public health account. Out of a total expenditure of Rs 31.56
millions on filaria control, malaria Rs 372.51 millions, cholera Rs 19.03 millions, leprosy Rs 130.17 millions
it was seen that 74%, 66.66%, 86.21% and 78.87% went into salaries respectively. (Demand for grants ,Govt
of Maharashtra, 1992). Salaries take away an exceptionally large proportion of expenditure leaving very'
little for drugs and supplies. The major expenditure on the public health sector is incurred to maintain a huge
army of personnel employed rather than on the provision health services.
State fundingfor the private health sector
The state directly or indirectly supports the growth of the private health sector at the cost of public resources.
The areas where the state support is clearly evident is production of doctors for the private health sector. The
other areas are financial assistance for setting up private practice, hospitals, diagnostic centres,
pharmaceutical manufacture etc. through soft loans, subsidies, tax and custom duty waivers, income-tax
benefits etc.

The expenditure on medical educatioii was around 11 percent of total health expenditure in 1992-93 as
compared to 5 percent in 1950-51. Nearly 16,000 doctors are being produced every year from some 140
medical colleges in the country. Until recently the role of the private sector in medical education & training of
4

this human resource was very limited At today’s prices on an average each doctor costs the state around Rs
500.000 (for a five year period) and each medical college costs about Rs 80 million per year. Though the state
spends a fairly large proportion on medical education the state services are unable to fill in the vacant
position. Between two thirds and three fourths of those qualifying from public funded medical colleges
practice in the private sector. That means for every 3 doctors the government trains for its ow n health sen ices
it also trains 7 doctors for the private sector at public cost. A further distressing fact is that out of every 100
doctors who go into the private sector 40 migrate out of the country This is a gross injustice to the poor
people in the country' who have contributed their mite in training these doctors. Thus the massive investment
made by the state from public resources is not only drained away but those who have gained from this exploit
the very people who have contributed to their acquiring skills by charging them exorbitantly, thereby making
huge profits in the bargain.

The Finances of the Private Health Sector
The private sector has grown to be the most dominant one in the health sector The share of the private health
sector is around 4 percent of the Gross Domestic Product as compared to the government spending which is
less than one percent. The share of the private health sector at today’s prices works out to between Rs. 16,000
crores and Rs. 20,000 crores per year. India probably has the largest private health sector in the world
(Duggal R, Nandraj S., 1991). This sector has expanded greatly in the post independence period, especially
in the eighties. This is because the state did not take seriously the responsibility of regulating monitoring and
making the private health sector accountable. Due to the unregulated nature of this sector the data available is
inadequate and often inaccurate.

It has become all the more important in the current context where the private scctoi is being encouraged to
actively involve itself in almost all sectors of the economy. In the new lexicography of Indian economics
privatisation and liberalization are the new panacea for ills in the economv The structural adjustment policy
which is being pushed by the World Bank and the International N j-Uary Fund (IMF) along with other
bilateral and multilateral agencies, has helped expedite this process. The World Bank team's paper on 'Health
Financing in India' and the ’World Development Report 1993’ advoc led a similar approach for the health
sector. '
The unchecked grow th of the private health care and its absolutely unregulated functioning in India has made
profiting from human misery a big business It will not be an overstatement to say that due to the
predominance of the private health sector, the Indian health care market has turned out to be a largely supplydetermined market.
There ;iic various irrational and unethical practices being followed. The major concern is how to make profit
in the shortest possible time. Health has become a healthy business. The trend in the private health sector is
towards irrational therapeutics, overcharging, subjecting patients to unnecessary tests, investigations,
surgeries, and over prescriptions for monetary reasons, their highly commercial nature among others. Only
recently attention has been focused on the serious anomalies with regard to the functioning of private health
sector. This was possible because a number of cases of medical malpractice and negligence filed in the court of
law by the victims and their relatives. It is also due to the role played by different consumer organisations in
raising awareness on the various issues related to the care being provided by the private health sector.

Irrationality of Charges
There are not enough studies conducted on this vital aspect of the charging practices. Due to the secretive
nature of the private health sector functioning there is. not enough information available. Not many of them
maintain proper books of accounts. With regard to the nursing homes and hospitals the charges are diverse and
mind boggling. The charges include consultation fees, charges for bed, nursing, operation, operation theater,
various investigations and disposables used, for medicines, etc. In many it has been observed these charges are
levied by different entities ; for instance the Doctor conducting the operation would be different from the one
5

who owns the nursing home, the anesthetists who is present his/her's charges are different. The charging
practices in the private health sector more often is purely based on a profit motive. The charges levied arc
arbitrary, irrational and without any proper basis. There arc no restrictions or guidelines for fees and amounts
charged by the practitioners, hospitals, nursing homes, diagnostic & therapeutic centres, medical centres,
corporate hospitals etc. in the country. It varies in terms of place of practice, demand in the area, years of
practice put in by the doctor, competition among them, undersunding between them, etc. It is left to the whims
and fancies of the providers in the private sector to charge as much as they like. The charges arc never
displayed openly. The consumer does not know how much s/he would be charged when visiting the providers
in the private health sector. (Nandraj S, 1994)
Earnings of the practitioners and hospitals
As there is insufficient information on the charging practices we have looked at the earnings of the doctors and
nursing homes operating in the private health sector. The earnings of the doctors have been studied only
recently. A study undertaken by FRCH in Bombay city found that a GPs net income, on an average, works out
to Rs 16,560 per month. (George A, 1991). Another study conducted in Delhi found that on an average the net
income of a GP practicing in a clinic or residence was Rs 24,290 p.m.. and a graduate gynecologists income
was found to be Rs 28,910 p in. With regard to those having post graduate qualifications in medicine, the
average income was found to be Rs 27,880 p.m., for general surgery Rs 37,870 p.m.; and for gynecology Rs
53,870 p.m. With regard to that of the ones running nursing homes with graduate (MBBS) qualifications, their
net income per month was Rs 73,650/ and the ones having post graduate degrees had earnings going upto Rs
79,960. (Kunsal S M, 1992). The high income of the doctors & nursing homes has been extracted by making
illness an industry. Many patients and their family members have been pauperized during the course of
treatment from the private health facilities.

Standardization of charges
There is no standardization of fees charged. In a study conducted by Medico Friend Circle (MFC), for the
question regarding standardization of fees charged by the doctor, it was found that 65% of them felt ’’at
should be some form of standardization of fees charged by the doctors. The study also found iLt neo
/6%
oi the doctors did not give a receipt for the payments made, only 24% of them gave receipts after being asked
for it. (Medico Friend Circle Bombay Group, 1993, Draft Report). Despite having one of the largest
private health sector in the world, providing 70 percent of care in India, the fact that it should function
practically unregulated is a matter of grave concern. There is no rationale behind the level of fees charged by
them and the law of market operates. Majority of the people utilize the services of the private health sector but
have, little or no control on the quality or pricing of the private health services.
Unethical practices
The rising costs of health care are also due to the irrational and unethical practices resorted to by the private
health sector. One of the major reasons of irrational practices among doctors is due to the fact that they are
supplier induced demands.
The use of unnecessary injections is quite well known due to the strong financial incentive. In a stud,
conducted in Madhya Pradesh it was found that out of 884 illness episodes which received medicines along
wi^h injections, 86.09% of them received it from the private health facility. (George, A, Shah, I. Nandraj, S.,

Cut Practice/Kickbacks
Referrals are often made to specialists and laboratories for a kickback. Over production and competition
among doctors in the private health sector has led to harmful competition among them and has made them
create unnecessary demand for their services amongst the people. For specialized treatment like
hospitalization and investigations, the GP would refer the patient elsewhere. For referrals made, a part of the
fee charged to the patient is given to the referring doctor. A GP/consultant gets a cut if s/he refers a patient to
a consultant, hospital/nursing home, laboratory, diagnostic center etc. In Bombay, the cut-ratio is as high as
6

30 to 40 percent of the fees charged. In some towns of Maharashtra informal associations of doctors have
standardized the ratios of cuts to be given. Cut-practices inevitably leads to unethical and unnecessary
investigations, referrals, hospitalization, high costs, etc Those doctors who want to practice ethically and
rationally cannot survive in this atmosphere

Unnecessary surgeries and investigations
Private hospitals tend to perform unnecessary investigations, tests, consultations and surgeries. Due to the fact
that surgeries are profitable many of them conduct them rampantly without any regard for the patients well
being. The KSSP study revealed that 31 percent of deliveries were by cesarean section. More significantly 70
percent of the hospitals where cesareans were routine were privately owned. (Kannan eLal) The Mangudkar
committee in Maharashtra found that the average rate of cesarean childbirth in private hospital was 30
percent as compared to government w hich was only 5 percent. The prix ate hospitals on an average in Bombay
charge anywhere between 10.000 to 20,000 for a cesarean delivery. Ultrasound investigations, amniocentesis,
epidural anesthesia etc. are done unnecessarily more often since the facility is there and there has been an
investment made on it.

There are other forms of unethical and irrational practices carried out by the private health sector for
economic reasons. In many hospitals there is pressure on the doctors to ensure that the beds are occupied all
the time and the equipment in the hospital aic utilized fully. Many hospitals fix the amount of business’ a
physician/surgeon has to bring. Many of the private hospitals refuse admission to patients unless a certain
deposit is not paid before hand. This is inspite of the fact that the patient may be serious or an accident victim.
It is also well known that there is demand for more money especially when the patient is vulnerable
(operation). Many big hospitals in the private health sector use the facade of registering themselves as trust
hospitals. This is done with a view to get various benefits from the state and escape the provision of various
taxes.

The business of health
A rather new feature in the health care delivery system is the entry of corporate hospitals. These hospitals
cater to only the rich class of people. The cost of treatment in these hospitals is beyond the reach of common
person. During the last one and half decades the growth of corporate hospitals has been at very fast pace. In
1983, the first corporate hospital in India was set up in Madras. It was established by Apollo Hospitals
Enterprise Ltd. (AHEL), which recorded a turnover of Rs 11.48 crores and a net profit of Rs 1.66 crores in
1988. Many corporate houses and non-resident Indians have recently joined this enterprise. Several large
business houses in addition to their regular business have diversified into the field of health. Some of those
who have entered are the Hindujas, Escorts jgroup, Standard Organic group, Surlux Diagnostic Centers.
United Breweries group, Goenkas, Birlas and the Modis. This is due to the realization that health could also
be transformed into an industry with such desirable features as: a large and available market of illness, access
to a ready qualified and trained labour, and the new miraculous state of the art medical technology. They also
boast of the latest diagnostic and therapeutic facilities, in a span of two years 1984 to 1986, over 60 diagnostic
centers have entered the market with an investment of over Rs 200 crores in sophisticated equipment. Today
Bombay has 13 body scanners Delhi has 11, Madras has 8, Calcutta has 3, Hyderabad has 2, Pune has 3 and
Ahmcdabad has 3. (Jesani. A & Ananthraman S. 1993, P 82). Surlux Diagnostics Ltd. with five centers in
India had declared a dividend of 19% during 1988. The United Group owns over 32 body scanners and 14
brain scanners in the country (Indian Express, May 18th, 1989). Suffice to say that with the rise of the
corporate sector, the cycle in health care does not start with a trained medical person and a sick person in
search of each other, but with an investor in the share market in search of profitable investment : the
availability of newer medical technology and a market in medical care being merely an attractive form of
investment (Phadke A, 1993).

7

Health finances of the Households
The households constitute a major component in terms of expenditure and utilisation of the health services.
The various studies conducted have brought out the fact that the households spend a substantial amount on
health care and the poorer class spends more on health care in terms of their proportion to consumption
expenditure and income. The criteria used for defining classes in these studies differ, but then no comparisons
are possible if we insists on academic sophistry. A study conducted in two backward districts of Madhya
Pradesh, in 1991 showed that the per capita expenditure incurred by the household on health worked out to
Rs.299.16 per year with 73.85% of the expenditure going into doctors fees and medicines. The percentage of
consumption expenditure works out to 8.44%. The upper class spends only 3.91% of their consumption
expenditure, while the lowest and lower middle classes spend as much as 7.91% and 9.9% respectively on
health. (George, A, Shah, L Nandraj, S., 1993). Kerala Shastra Sahitya Parishad (KSSP) which undertook a
study in rural Kerala in 1987 found that the per capita cost per year incurred by the house .old on health was
Rs. 178.33. The percentage of the reported income spent on health was found to be around seven percent.
Comparing it across class it found that the lowest class spends as high as 14.36% of their income on health as
compared to the highest class which spent only 4.36% of their high incomes. (Kannan, K.P., Thankappan K
R, Roman Kutty V, and Aravindan K P, 1991). A study conducted in Jalgaon district of Maharashtra
brought out that the per capita expenditure on health was found to be Rs. 182.49 per capita per year, 7.64% of
total consumption expenditure and 9.78% of reported income were spent by the household on health care Out
of this total per capita expenditure, 68.50% of the expenditure goc^ into practitioners fees and medk nes.
(Du"gal, R., Amin, S., 1989). National Council of Applied Economic Research (NCAER) conducted an all
India study in 1990 brought out that the average household expenditure for treatment worked out to Rs. 142.60
per illness episode in urban areas and Rs. 151.81 per episodes in rural areas. (NCAER, 1992).

The findings make it evident that a substantial financial burden of the household is borne for meeting health
care needs. Households spend between 4 to 7 times of what the state spends on health care sen ices. This
certainly is not a happy state of affairs, since such expenditure on health care would mean cutting down on the
food consumption of the households. This gains sigikj...^ance when vc realize that nearly half of the countn s
population docs not have enough resources to meet their food requirements, and worse still the capacity to
earn it the patient happens to be the sole earning member. Given this socio economic situation in the country
the purchasing power becomes a crucial factor. As we know the accessibility of the public health service is
poor especially in rural areas of the country. The private health sector becomes unaffordable for the vast
majority of the poor in the country. There is impoverishment of the lower class or middle class due to illness
w'hich could be of a chronic nature or that involving hospitalization or surgery. The high cost of health care
makes the poor more marginalised. There is a need to question the commodification of health care, the
dominant role of the private health sector and as a result spending a enormous amount of money on health
care.
Conclusions

The broadest possible platforms should be created for bringing in some amount of change in the health sector
The states allocation need to be questioned. The underfunding of medical services is matter of serious concern.
The need for more resources and greater decentralisation has to be taken up on a priority basis. The priorities
within the health sector need to be changed drastically. More funds need to be made available for the rural
areas, especially with regard to curative services. Increasing support for population control needs to be
questioned. There should be additional resources especially for non-salary expenditures, reducing wastage and
improving efficiency by better management practices and setting up of proper referral systems. There is a need
to use the existing resources more efficently and effectively.

There is hardly any regulatory intervention or interference of the government in the private sector and on the
health care market. Even the few existing laws and regulations are either toothless or not implemented at all.
People's dissatisfaction with the private sector and their disillusionment with the medical establishment is

,,

8

- - -—- •v-rr*’

quite high. There is an urgent need for regulation and monitoring of the private health sector. Through
licensing and other means the proper geographical distribution should be done. Legislation should be enacted
where there is no legislation.There should be regular prescription and medical audits and the renewal of
licence should be dependent on it. The findings of the various studies on earnings of the medical profession
show s that it is one of the best paid professions. Large sections of the population have become pauperized due
to the large sums of money spent on private health care. With regard to charges and fees there should be
standardization of fees charged by the practitioners and fixation of reasonable charges by hospitals and
nursing homes, diagnostic centres, investigations for the services provided These should be displayed
prominently in a conspicuous place.
There is a trend of favouring user charges/fee-for services for public health services. This should be counted as
in the present socio economic conditions the poor would be hit the hardest. Additional revenues specifically
for the health sector could be generated through additional tax on degrading health products such as
cigarettes, liquor, pan masala etc. Those with a capacity to pay especially in the organised sector, middle and
rich peasantry' and other self-employed should be made to contribute for health care services. This could be
through insurance and other pre-payment programs. In India no single system can work. What we would
need is a combination of social insurance, employment related insurance for the organised sector employees,
voluntary insurance for other categories who can afford to pay and of course tax and related revenues.

There should not be any kind of payments done at the point of provision of care since they are unfavourable to
patients. Payments should be made to providers by a monopoly buyer of health services who can also
command certain standard practices and maintain a minimum quality of care - payments could be made in a
variety’ ways such as capitation or fixed charges for a standard regiment of services, fee-for-service as per
standardised rates, etc. The move towards monopoly purchase of healtn services through insurance or other,
means and payment to providers through this single channel is a logical and growing global trend. To achieve
universal access to health care and relative equity this is perhaps the only alternative available at present, but
this of necessity implies the setting up of an organised system and for this the Slaie has to play the lead role
and involve the large private sector within this etaversal health care paradigm if it must be successful.
(Duggal R, 1995).
Sunil Nandraj works as a Research ojjicer at the Centre for Enquiry into Health & Allied Themes, (CEHAT)
Bombay.

References:

Bhorc, Joseph, Report of the Health Services and Development Committee, Vol. i- IV, Government of India,
New Delhi, 1946.
Detailed Demand for Grants 1992-93, respective States: 1990-91 Actuals, 1991-92 Revised Estimate , 1992-93
Budget Estimates

©

Duggal R, Nandraj S. 1991, Regulating the Private Health Sector, Medico Friend Circle Bulletin No 173174, July/August, Nasik.
Duggal, R., Amin, S. 1989, Cost of Health Care, Surveyor an Indian District, FRCH, Bombay.

Duggal,R., Nandraj,S., Shetty,S., 1992, State Sector Health Expenditures : A Database, All India and the
States, FRCH, Bombay.

Duggal Ravi and Nandraj Sunil, Vadair Asha, Special Statistics on Health Expenditure Across States.
Economic & Political Weekly, Bombay Vol XXX No 15 & 16 April 15th and 22nd, 1995.
9

Duggal. R, A note on issues in health financing, 1995 (unpublished).

George A, 1991, Earnings in Private General Practice, An Exploratory' Study in Bombay, Medico Friend
Circle Bulletin 173/174, July/August 1991
George, A. Shah. I. Nandraj, S., 1993, A Study of Household Health Expenditure in Madhya Pradesh.
FRCH,
Ghosh B., 1991, Time Utilisation and Productivity of Health Humanpower, A case study of a Karnataka
P.H.C, IIM, Bangalore.

Government of Maharashtra, Department of Finance, civil Budget Estimates 1992-93, Major Head-cum-Dept
Summary of Expenditure and Public Accounts, Bombay, 1992.
Gupta, J.P., Gupta R.S., Mehara P., et.al, 1992, Evaluation of the functioning of Area development project in
Health sector in India for improving the health care system, NIHFW, New Delhi.
Health Information of India, CBHI, GOI, 1991.

ICMR, 1991, Evaluation of Quality of Family Welfare Services of Primary Health Centre Level Neu Delhi
Jesani. A, Ananthraman S, 1993, Private Sector and Privatization in the Health Care Services, FRCH.
Bombay.

Kannan, K.P., Thankappan K R, Raman Kutty V, and Aravindan K P, 1991, Health and Development in
Rural Kerala, K.S.S.P, Thiruvananthapuram.
Kansal S M, 1992. Contribution of ’Other Services Sector’ io Gross
Evaluation, EPW, Sept 19.

Domestic Product in India, An

Medico Friend Circle, (Bombay Group), 1993, Patient-Provider Interface : A Public Survey, MFC Bon bay.
Draft Report.
Nandraj S. 1994, Beyond the Law and the Lord : Quality of Private Health Care, 1994, Economic and
Polictical Weekly, Vol XXIX, No 27, July 2, Bombay.
National Council of App..cd Economic Research, 1992, Household Survey of Medical Care, NCAER, Nev.
Delhi.
National Institute of Public Finance and Policy (NIPFP), (Draft report) 1993 April, Structural Adjustment
Programme- its impact on the Health Sector, Nev. Delhi.

©

National Institute of Urban Affairs (NIUA), 1983, A Study of Financial Resources of Urban Local bodies in
India and level of Services provided. New Delhi.

National Institute of Urban Affairs (NTUA), 1989, Upgrading Municipal Services, Norms and Financial
Implications, Recent studies, Series Number 38, New Delhi.
National Sample Survey Organization (NSSO), Morbidity and Utilization of Medical Services, 42nd Round.
July 1986-June 1987, Report No 364, Dept of Statistics, GOI, New Delhi.

Phadke A, 1993, Private Health Sector, FRCH, Bombay.
10

DRUG

PRICING , IS

IT

JUSTIFIED ?

. Dr W.v.Rane

Under the X 1995 DPCO, drug units are entitled for 18
per cent post tax return on net worth if bulk drugs are
manufactured from the basic stages, as against 16 per cent

in the 1987 DPCO. This rise the drug manufacturers can claim
justifiably. The bulk drug units making 6-APA and 7-ADCA
intermediates for synthetic penicilline will now have to
r>~nioill in a from local manufacturers to the extent
of 70 per cent of their requirement. This government policy
shows a clear shift in favour of domestic penicillin G
manufacturers. An inevitable outcome of the tilt towards

domestic manufacturers of Penicillin G will be likely price
increase of semysyntheti penicillins like ampicillin,
amoxycillin and cephalexin.

The drug industry and trade had come to an agreement to

increase t.ie trade margins for decontrolled drugs in phases,
starting from July 1. The government has decontrolled a total
of 67 bulk drugs and their formulations under DPCO 1995 and

the chemists are entitled for a higher margin for : hesy
•products. The agreenient provides for a 2 per cent increase
in tr<.
margins at 18 per cent to retailers l: kXd July 1 for
all formulations of drugs which are ortside the price control
under. DPCO 1995 . The wholesale trade will get a margin of 9

.
A firrther 2 per cent increase in the retail tr.tde m.irgin
and a 3 per cent tdkt* in wholesale margin will be effected
from January 1996 in the second phase. With these increases’
the retail margin will be 20 per cent, and wholesalers' margin

■will be 10 per cent for -all decontrolled drugs. This makes
a total of 30 per cent for drug retailing and who! eseiling.

Express Pharma Pulse (June 29, 1995) says ” A 30 to 40
per. cent rise in the prices of most of the decontrolled drugs ‘
is expected from July 1995, with the agreement between the
drug industry associations and pharmaceutical trade to hike
trade margins taking effect. A further 60 per cent increase
in prices of these drugs is likely from next year. An estimated
Rs. 25 crore is expected to be collected by AIOCD (All- Indi a
Organisations of Chemists and Druggists) from the drug Units" .
In short the drug industry and the trade decide amongst
themselves how much should be extracted from the consumers
and the government takes a position of silent spectator.

2

Normally 10 per cent -.ree scheme is bfferred by many drug
companies throughout the
but from Table—1 you. can find

the additional per cent free schemes that are offerred*

Table - i
Free Schemes
Manufacturer

Brand 'name

Scheme

Amazon

Coldin Tab
Dolgin Tab
Ibunova Tab

10 + 6
10+5
10+6
10 + S

Brown & Burk
Micro Labs

Plethico
Mac Labs

Eldopar Cap "
Renitab 150
Microflox 250/500
Microdine Oint
Gentamycin 10 ml
Geninan 2 ml

Per cent fr<
60
‘ 50

60
50

10 + 4 ■
10 + 4 .
10 + 5

40
40
50

7 t 5
10 + 5-

71U3

.

St .

-

From Table 2 we find that nearly 20 per cent of the product
and 28 per cent of the ■roducts and paehs have increased the
prices. The break-up of the price rise shows that 11.17 per
cent have shown a rise of less tl-m 1 per cent, 5.32 per cent
a rise of 10 to 20 per cent, 3.83 per c^nt a rise of 20 to
30 per cent, 2.30 per cent a rise of 30 to 40 per cent and
i.oo ptaa Citii: a. >ri.se. tp
cent. But Staangaiy
enough 3.80 per cent show a rise of over 50 per cent. Some of
this rise may be of' bigger packings. This has been the usual
Practice of the drug companiie to increase the prices of
different packings of products at different times.

41 products show a rise of over 100 per cent and 11 of rk
these are ophthalmic products of Bell Pharma. The top
position is taken by Gesicalne, a local anesthetic of S.G.Pham
with a rise of 221 per cent and followed by
Glucagon- hypoglycemic attack-Toprent-200 per cent
Hematrine- Iron preparation
Daktacor t-Antifurgal
Epsolin- Anticonvulsant

Depsonil-Antidepressant
Septopal- Antibiotic
Nutrisan- Nutritional

-Sandoz -148 per cent
-Etlinor -14 7 per cent
-Cadila -145 per cent
-.G.Ph -144 per cent

-Merck -139 per cent

-Sandoz -121 per cent
-Wyeth -114 per cent
Myembut<. 1- antituberculous-Cyanamide - 114 Oer cent
Corex - Crmcrh niixnir®
— Cf’ioriT*
JAQ r>a^ acn4c
Testanol-25 -Hormone
-xnfar —108 per,cent
Lanoxin - Cardiac .
B# Wellcome -105 per cent
Alludrox Gel- Antiaeid

Dilantin- Anticc '’.vulsant—Perke Davis —105 ■per cent
Endrine- Nasal ’decongestant

-Wyeth
-Wye til

-104 per cent

- 3
10 products show a rice botuceji 90
to 105 percehc, 7
products between 80 to 90 per cent, 17
products between 70
to 30 per cent, 10 products between 60 to 70
per centz end
33 products between 50 to 60 per cent, m this
group the

X “ra”'y ““—— —!r »..a products
«»—«, I«U.1-3ntialler,
, z,et- co„qh mixture, rrnnatal-w.h-U^at, coraau . ..l£
cmvulsant, sodium .ntimny glu.0..*._ Kala a
U.3IU.M
ran Bclm, X^ccanc „eathetlc. rteodicn^r

‘

naoniae- cough mixture, hroat-vltemlu etc. Pflc«r h„ ’

-XT th" Pri“ “

50^ geuetlc.

L
””
increased the DrirA bv qn »
sh„™ it.
P
T
; ’

“= =>»-P-t eutl-ce^leect
cent- The
“htroller has
the chalets to stock and

sell this most commonly used anticonvulsant.
Table -

Category-Sys tern

No.•
0-103

Alimentary

28

C.irdiovascul ar

-27

Central Nervous

Kvsculo-ykulet.'l.

products 'showing r~~
a per cent pricerie
10-20
20-30
30-40
10
40-50 Over 50

4

1

2

9 '>

2

12

10

3

49

9

3 Ci

1 1

13

4

17

20

5

7

4

Hormone:-,

6

3

31

13

13

Ceriitb .urinary

4

2

13

9

9

6

1

Infections

2

110

3

22

22

12

Nutrition

5

65

17

29

39

Respiratory

12

7

20

18

12

9

•5

I

Bar-Nose-T?iroat

9

1

5

2

2

2

10

6

6

4

3

5

4

17

2

4

Skin

3

27

4

1.2

2

15

Others

11

1

2

14

11

10

2

2

11

403

192

11.17

5.32

138
3293

Eye
Allergic

Total ( 360 7)
Per centage

83
46
137
2.30
1.28
__________
3.80
in June 1593. thg frioes Wer. ^r3^al3. de^es^i, tui~ihc
in^scd /rom Decainber 1993 onwards and were
maximum by
Ha comparative
• •
y June
e 1995 t
The
figures presented he-

are fro. MXMS

1993 to Sep^ter 1995/5.32 per cen\

e products have shown marginal decline in prices and the
decline is from, norfloxacin, ciprofloxacin, famotidine
cmeprazol, rifampicin dtc. The real price rise began from
June. 1995 and., hecneforth more ‘end more products.,will rise the
prices.

- 4- In September 1994, the <----government of India , Ministry
of chemicals and FertilizerS/ Department
of Chemicals and
Petrochemicals announed r
modifications in ^rug Policy 1986.
Under clause 22.7,2(±v) :sPan
- ~Control: it says
says uu Government
will keep a close watch on the orices
of medicines which are
taken out of price control. In '
case, the prices of these
medicines rise unreasonably, the
Government would take
appropriate measures.. including
‘ -eclamping of price control."
Now that 67 drugs have been P
-—i decontrolled, it becomes the
responsibility „£ TOlmt,ry orgar,lsations
to keep a track of
price rise and force the government to take
appropriate
art inn

Under clause 22.7.3:Ceilijg Prices: it

ssys nn ceiling
standard pack
sizes of price-contrcP Led formulations
and it would be
prices would be fixed for commonly marketed

£“/n' lncluai“’

to £011o„

tne price so fixed.% Now in this category we will trv
andXpirin^Th3
Paracetamol

Of T
'
3 Celllng Pric*3 fixed and notified by Governmer
of India undor nnco 1997 ,hd <onttntta fa, fae in operaiC ' ^ef
UPCO 1995 are as foj . ows:(Order No. 672(E) 14-9-Z2)
Paracetamol 500 mg per tab.
strip 10 T @ R„, 2.74
125 mg per 5 ml. Syp 60, ml @ RS.. 7.04
150 i-g per ml drops
15 ml © Rs. 6.58
Thr actual prices as prevalent
today are:
Calpol (B.Wellcome)500 mg tab
10 T
Rs. 4.12 + 50 .36%
125 mg per 5 ml
60 ml
Rs.11,67 +65.77%
Crocin (Duphar)
500
500 mg'
mg' tab
tab
10 T
Rs. 3.98 +45.26% .
12 Sing per 5 m 1 c**ru
- 60 ml
syrup
Rs.
10.78 +53.13%
150 mg per ml drbps
15 ml
Rs. 7.34 +11.55%
Metacln (Themis)
500 mg tab
lo T
Rs. 3.13 +14.23%
125 mg per 5 ^r.l
-1 syrup 60 ml
Rs. 8.21 ^16.62%
150 mg per ml drops
15 ml
Rs. 7.42 +12.77
(Metacin prices are not increased.
but they may increase the
same, soon) .

From these prices we can

see that the popular brands of
paracetamol prices are 65.77 to 11.55
per cent more than the
ceiling price fixed by the
government. The Calpol tablet price
has been increased by 40 per cent and
syrup, by 56 per cent
and Crocin tablet has been increased :
by 35 per cent and syrup
by 31 per cent. This price rise does
I
not seem justifiable.

Another way of cercumventing the rules and regulations
is to make drug combinations. One such example is Fortagesic
of Bin-Medicare. It contains Paracetamol 50C mg and Pentazocin
15 mg per tablet. Fortwin 25 mg pentazocin costs Rs. 2.73 per

tablet and Crocin 500 mq pfirfic.tfinin1
co^s K£ 0
So 500 mg paracetamol and 25 mg pentazocin can cost Rs.3.13

Bur Fortagesic with
costs Rs. 4.95

,
q P^ntazocin and 500 mg paracetamol
Per tablet. Win-Medicare has another

combination product of
Paracetamol 450 rp~ ,
, 3
mg + chlormezanone 100
mg costing Rs. 2.50
Per taolet.

the ceiling price of aspirin
o. 12(E) of 4-1-1988 is as follows; formulation (per order

Aspirin 300 mg per tablet sfcriD Qf
Tabs

Actual prices are as follows..

Apidin (IDPL) Aspiring

Colsprin (Reckits)
Disprin (Reckits)

Miaropyrin (Nich.

Rs. 0.64

10 T

Rs. 2.42

10 T

Rs. 1.92

10 T

Ra. 2.00

Aspirin 325 mg
350 mg -r+-r

1°^) 350 mg

10 T

RS. 2.37
"insprin (win-Mc— ••c-dicare) 324 mg
10 T
Rs. 3.73
The brand
Prices are more than the
ceiling
prices
from 482.31%
to 200 Per cent. Beside
none of these products confirm to
the standard-f-.nnulation of
300 mg aspirin. This shows the
Gflien--nt worivihc of
FDA-s in allot -.ng irrational formulary.,
How car. these inc
•-■aseG P^'c-s d- justified ?
’

And to top this all

-

C- UO COmnxrH^e. u_____
.
^aaAl dose aspirin as anti ... cornP^nies have marketted
-co.igulaHts for profphy* • .8
cases of increased risks
’f blood clotting.
Rovernmen .-ailing price
or 100 mg aspirinlO T is Rs.
J .6^ASA 50 (rt.;-ridn Remedies)
50 mg aspirin P^r tab 10T
6.'^0
Aspicot (Cc-icept) 80
aspir- i n1 • :r tab
1(J
T
2
.2Q
10 T
How .an the r--government allow 9. 3’^ tines (938%) the ceiling
the
price to ASA 50
-J and that \qq
r;rir,- rise o£
a<
.00
of a 4 .00
If we can compare all the
ceiling prices and find wide
di-ocrepancies that can be
reported to the government.
_

H

ail'

L-

Most -if the expectorants (benadryl

Bro-zedex,
Cineryl,
Corex, Jeecos, Lupihist, Mif s Unctus' Pent
'
Soothex, Sovental
.
l-nctus' Protussa pluS/
Solvin,

lna' Zed“ “d

■ 1—.ed e.a X, Z

have
• •
P
' rang-Ln^ rrora 20 per ce-t to
Like-Wise vitaraiQ fMations
J
“ 220 Per cect.
Arcvit, Becosules, Eeetrion, 3epl(^
to

Citravite, Cobadex forte, H-xavit

Peaie, Polybion,

/ •

B1V1Iial forfce'

--^^-^-berin,

; minerals .(Calcium-sandcz, citS1
Ci/ei’Slectrobiob, Pilibon, «acal,it
iron preparations ( Dexorange plus7^X1

ltne'^On etc-’
^lyte, Electral, .
etc) '

Hcpntogiobin, x:il£ewn, ^nospromin Ton"- '
lte' Kera=trine,
nutritiona! products ( Bayerfcs ’ t/i
p
Livogen, Neogadine elixir etc) r-z C' ‘e^PhOS' Klnet°ne,
ncve increased the rates.

In the o n ti tube r cu 1 ou
S products, exiutraarty ethamfautol,
and Pyrazinamide prices
have increased. IR t.be antibiotic/

- 6 tetracycline and chloramphenicol rates have gone up. Hormones
hace always increased the rates and this time Aquaviron fcxxxk
(without B12) , by 41.36 per cent, Lynoral by 56 per cent,
Orgalutin by 47 per cent ^nd Testancn by 108 per cent have
increased the rates. Most of the anticonvulsants like
Dilantin, Eb/ilex> tpsolin, Eptoin, Garoin, Mysolin, Valparan
•
•
’
f!; •
1
"
•
alkalets , and gardinal have raised the rates. Sedatives and
antidepressants have never stopped hiking the rates.

>'
1

Some of the newer entrants of drug manufacturers have
become intelligent enough to market only tablets - so that.'* .
capital investment iS' less or one can get the tablets
compounded on loon liceuiusse, for vague indications— where
doctors cannot complain that there are no results, .and at a
very high price so that there is no need to ask fot*. increase
is Sordid uEa has introduced
in ratesc. One such
. •

*•

■

.

following products.

Convdrsyl
Daflon-500

- antihypertensive
cardiac

Diamicron
Flavedon-20
Isomeride
Natrilix

antidiabetic
cardiac
antiobesity
antihypertensive
antiobesity
antidepressant
antl-parkinson

10 T © Rs.201.47
158*64
10 T
90 .40
10 T
90.40
in t
88.81
10 c
37.10
10 T

lod
1 bd

1 bd
ILds
1 bd
1 Od

10 C
77.22 1 od
Ponderax
10 T
119,96 Ibd
Survector
10 T
141.55 1-4
Trivastal LA
For such products and for such high introductory rates the

i

i

question of justification does not arise.
>

Dr. W.V.Rane
Arogya Dakshata Mandal
2117 Sadashiv
PUNE 411 030
i

Tel: 0212-442329

Pune dt-3 Nov 1995

•i. ’

I

J*

:

? r ••••(•: J-’ '

I

I •

I
«
4

1
An over view of Current Drug Policy and
Implication of Recent Policy Changes

Amitava Guha
Need of a Drug Policy:
Necessacity of a drug policy for nations was felt not very long ago. It was the industry
who used to determine production,price and availability of drugs in a country. For the
purpose of health care many national governments had been spending considerably
from their scanty available funds. Accountability of such expenditure arose in view of
the deteriorating health situations. Many countries expressed that unless of an
appropriate policy,nation’s fund goes into wests while the health of the industry grows.
It was also found that the pharmaceutical business had become international and large
Multinational Corporations (MNCs) dominated global production of drugs. Many
developing countries felt helpless in developing proper policy under the pressure of
Drug MNCs. In the developed countries, the government and the insurance companies
had to develop some strategies to minimise expenditure on health for which guidelines
were developed. Though not comprehensive, but the guidelines rendered certain
restrictions on the drug production and its use.
In the WHO forum, various questions like appropriate use of drugs,large influence of
industry and availability of drugs were raised. It was felt that in absence of a national
drug policy with certain definite minimum necessary decisions, health care facilities
can not serve real purpose. WHO had developed a guideline of drug policy for the
developing nations. Nirobi conference of WHO held in 1985 end 39th World Health
Assembly held in 1986 decided to prepare a guideline for es .r.eTshing national drug
policy. A group of experts finalised the guidelines in 1988.

Parameters of Drug Policy:
While introducing the guidelines, the Expert Committee expressed that : ”A vital
requirement is that governments should exert the political will necessary to
formulate and implement a drug policy. Lack of political will, even more than lack
of resources, has been a decisive factor in the failure of some countries to ensure
adequate provision of drugs and vaccines.”

The guideline provides us a balanced frame work of social, economical and
therapeutically acceptable measures those are required for majority of the developing
countries. The essential parameters described in the policy guidelines are briefly as
follows:

1. Components of a drug policy
2. Specific legal issues
3. Information and promotion
4. Appropriate drug use
5. Self medication

6. Health education
7. Monitoring and evaluation
8. Financial resources
9. Research and development
10.Technical cooperation between countries

The guidelines emphasised the need of a legal framework to ta^e into account not only
the policy objective but also administrative, social, and health infrastructure, the available

2
manpower, and other resources. The legislation must also spvcTy the sanctions that
will apply in the event of failure to conform with any provision of the act Sanctions must
be enforced if the policy is to functIOn effectively. There should be regulatory control in
several urgent areas. The drug control administration should not confine to licensing
quality control, manufacturing standards, etc which are very much concerned to
production, but it should be responsible to control information dissemination and sales
promotion also. A registration authority must be developed by establishing increasing
levels of control in the areas of collection and evaluation of informations available on
all drugs for their registration or granting licenses for production and marketing in the
country. There should be regulatory control for cost and pricing for drugs for the benefit
of the consumers. Based on the codes to be developed in prescribing, professionals
and health workers can meet the gaps in manpower need and availability of drugs.

Considering safety, quality, efficacy and cost, the guideline suggests that due importance
be gwen in choice of drugs. There should be limited and adequate number or of drugs
in the list based on the criteria of selection of essential drugs. The list may also contain
traditional drugs available in the country. A country should always attempt to build up
step by step a viable pharmaceutical industry for production of all the listed drugs with
the aim of achieving self reliance.
y
There shall be eff.cient system for quality assurance of drugs for monitoring the entire
process from the acquisition of a pharmaceutical raw material to its conversion mlo a
imshed product. The policy should be equipped with suitable legislation and effective
SySft6m' TeTniCal systems for ^forcing good manufacturing practices
establishing of required quality control laboratories and drug testing laboratories is

-or r^o^roXZZoboS

Re9U'a,0,y

Sh°U,d be de“e“^d

o envisage appropriate use of drugs, the policy must provide suitable measures in the
areas of training and refreshing the knowledge of practitioners and para-medical stuff
ys em of health education will enable proper implementation of the policy Health
educa ion a the level of schools and at home would include basic concepts of drug use
nd information of specific therapy. “Openness and effective communication are basic
o the success of a drug policy. Public participation in the design and implementation of
such a policy will foster the effective use and control of drugs.” (Guidelines fo
developing national drug policies-WHO)
'aennes for
As an ongoing process, the policy should provide the scope of monitoring and evaluation
of all tne drugs marketed. Review of therapeutic value, quality and prices at least every
five years are necessary. A mechanism for post marketing surveillance and monitoring
of adverse drug reactions can determine the rationale of a drug and can avoid large
disaster. Information on drug utilisation pattern are also required for deciding the
production pattern and providing steps of inappropriate use of drugs.

3
Health problems vary in countries. Research and development of drugs are essential
features of national strategies to meet the challenges of health probiem. Research
may involve fundamental research in molecular biology and chemistry, immunology
and biotechnology, industrial research to convert scientific knowledge into technology,
pharmacological and toxicological studies, clinical and field trial of drugs and vaccines.
It is not necessary to start research in all areas at a time. Consumer groups can be
encouraged to study peoples’ attitude to prescribed drugs and self medication.
Analysing the policy situations in the 104 countries, WHO presented a dismal situation.
Only 25 countries have somewhat policies but no country has a comprehensive drug
policy. Among the ten parameters defined in the guideline, India has the credit of well
established drug production system but did nit feature in any of the other parameters.
It is evidently clear that India has given prime importance to industry and the drug
policy in India had always oriented around the interest of the industry.

Drug Policies in India:
Two decades ago and eight years before WHO, the Committee on Drugs and Chemicals
(Hathi Committee) defined almost all the criteria described in the guidelines of
developing drug policy prepared by WHO. Interestingly, none of the drug policies in
India could follow the recommendations of the Hathi Committee in totality. Contrarily,
whatever good recommendations were taken up in the past policies, there have been
systematic removal of them at the instance of industry. First drug policy was developed
in 1978 which was basically formulated on some selected recommendations of Hathi
Committee. Previous to this, we have a strait jacket formula on pricing provided by
Drug Price Control Order (DPCO),1970.
Drug Policy, 1978
Distinctive features of the Drug Policy, 1978 was that it had pronounced that the policy
would consider development of indigenous pharmaceutical industry with main emphasis
to public sector and national sector drug industry. The policy considered the following
areas mainly: production, pricing, quality control, research & development, developing
of drug authority. Main criticism against the policy was that while preparing the policy,
the government had ignored the recommendations of Hathi Committee in respect of
the health aspects. The policy had not considered the following:

1.
2.
3.

4.
5.
6.
7.
8.
9.

10.

Nationalisation of the multinational corporations in drug industry.
Taking measures provided for dilution of the foreign equity of the multinational
corporations to 26 percent.
Taking over the diluted foreign equity by the financial institutions of the government.
Measures for weeding out the hazardous and irrational drugs.
Preparing the list of essential drugs for the country.
Specific measures for encouraging the small scale sector.
Reducing the prices of essential drugs.
Use of all essential drugs in generic names.
Curbing the unethical marketing practices.
50% of the bulk drugs produced be supplied to non associated formulators.

Drug Policy, 1978 had certain favourable consequences to the national sector drug
industries with the help of which companies in this sector had developed to the extent

4

that they have been successful in competing the MNCs. Even today, Indian companies
rank equally with the MNCs in sales turnover.
The Government never implemented a large number of decisions declared in the drug
policy either due to pressure from the industry or due to lack of political will. Some of
them are as follows:

1.
2.
3.

4.
5.
6.
7.

Each manufacturer should produce essential drugs 20 per cent
of their total turn over.
Diluted equity of the MNCs be purchased by the public finance institutions.
All manufacturers of drugs from intermediates and penultimates shall commence
manufacturing from basic stages within two years.
Enforcement of ratio parameters of bulk drugs and formulations.
Measures to remove court injunctions on price control mechanism.
Obligatory research expenditure for MNCs having turn over of more than Rs. 5
Crores per annum to the extent of 20 per cent of their net block.
Establishing a high level committee on drugs and pharmaceuticals.

Drug Policy, 1986:

There was significant failure of the government even in implementing the drug policy
resulting into lack of availability of essential drugs and vaccines, rise of prices, spurt of
number of irrational drugs, proliferation of substandard drugs, etc. This policy diluted
many regulatory controls provided in the .78 policy. Number of drugs exclusively
preserved for Public and Indian sector companies was slashed by delicensing of 94
bulk drugs and by waiving of licenses from another 90 bulk drugs under the guise of
broadbanding. Role of public sector was clearly diminished and the objective describee
it as -important role' which was considered as 'leading role' in 78 policy. The objective
of developing self-reliance in drug production has given up Ratio parameter for bulk
drug to formulation was tapered down according to turn over.

Conceding to the demands of the industry, the government marginalised the price control
span on drugs. It not only reduced the number of drugs to be put under price control
list, but increased the profit margin also. The system of compensating loss due to
import of bulk drugs through Drug Price Equalization Accounts was abolished. The
only good decision taken through this policy was to discontinue Loan License system
though it remained non implemented till now. The drug policy'86 was known to be a
move toward a retrograde direction from that declared in 78 policy.
Drug Policy 1994:

The government introduced a bill in August, 1992 titled as Modifications in Drug
Policy,1986. Without waiting for the conclusion of the debate which generated much
heat in the Parliament, the Government through a cabinet decision declared new drug
policy on 14th September, 1994. This decision virtually declared end of our national
drug policy. It was stated that over all changes in the old policy was required to suit the
liberalisation policy of the government and new perspective generated in signing the
World Trade Organisation (WTO) agreement. Except three, out of fourteen decisions
announced in the policy, all are concerned exclusively to the industry. It is agein
established that the drug policy had never been policy for the people but a policy for
the drug industry.

5

*

f

As far as the implementiation of policy guideline of WHO is concerned, it is obvious
that India do not qualify in most of the parameters. Despite, the offficial stand of India in
WHO is different. The government representative in the World Health Assembly held
in May’94 drclared that India has implemented allthe policy guidelines of WHO. Smae
year, in seminer co-sponsored by WHO at Delhi, the Drug Controller of India announced
that except implementation of ‘Criteria for Ethical Marketing Practices, all the policy
guidelines are implemented.
Implication of the Recent Drug Policy:
Production controI:
The government decided to abolish industrial licensing system from almost all the bulk
drugs^The market size of pharmaceuticalshad increased to a very large extent. There
is a very little need of import of any formulations as most of the bulk drugs required are
available . The trend that have manifested in the recent years shows that production of
bulk drugs in the country is less than import. Production data of the recent years are in Rs. Crores

Bulk Drug
Formulations
Export
Import

1991-92

1992-93

1993-94

900
4,800
1,231.30
807.30

1,150
6,000
1,410.30
1,100.00

1,320
6,900
1,781.40
1,440.00

(Source: Financial Express:31st August, 1995)

From one |policy to the other, it is observed that production control has been gradually
weathered. The role of MNCs in production of essential drugs have been minimal.
Table -1 shows that bulk of the sales of MNCs in India has been generated from sales
of irrational formulations. A study of the monitored 58 bulk drug production shows that
the tendency of the MNCs in bulk drug production has been substantially reduced (See
Table-*).

The government have reduced the duties and levies in imported bulk drugs ignoring
the fact that it would adversely affect the Indian bulk drug producers. In the last two
years, a number of bulk drug manufacturers have stopped production due to proliferation
ofcheap bulk drugs in our country. The MNCs have neither upgraded their technology”
nor introduced new technology. Most of theirplants are old, though production capacities
have been increased but they have failed to compete cheaper bulk drugs produced
abroad. The other factor precipitating to this situation is that due to relaxation of
production control and import control, bulk drugs are dumped in the country in artificial
cut prices. Prices of the imported bulk-drugs were raised after the indigenous
manufacturers were compelled to close down their production plant. Country’s self
reliance in drug production is being converted to import dependency.
Research and Development:

o

In all the drug policy declarations, it was stated that due stress shall be given in R & D
sector. So far, the government have failed to tal^e any effective steps for obligatory
o

6
investment in R & D. In reality, several MNCs have closed their R & D establishments
here. Ciba Geigy, Boots, Hoechst, Rohne Poulenc are such examples. Investment in
R& D in this industry is now less than 2 percent of sales turn over and R & D department
in the Plants of the MNCs are the smallest among all other departments. Future
development of production of new drugs would be through biotechnology route. Even
though there is no dearth of expertise and infra structure, Indian R & D houses are
afraid of the terms of WTO agreement which has clamped stringent clauses in genetic
science research. Indian research houses have been successful in developing process
technology of almost all essential drugs. With the enforcement of product patent system,
scope of future development of process technology will also be stopped ’ •
Price Control
The pricing structure provided in the drug policies have been a severe eye sore for the
industries whowanted total decontrol of prices. The span of price control has been
narrowed down very sharply form one policy to the other. The details are as follows.

Policy

Number of Drugs
under control

DPCO.1970
DPCO.1978
DPCO,1986
DPCO.1994

All Drugs
378
164
73

Only argument so far furnished by the policy formulators as to selection of drugs under
DPCO is that they want market forces to control the prices of drugs. Unlike any other
commodities, drugs do not depend on the choice of the users. It has been admitted by
the Chairman of Glaxo India Labs.,Mr.G. Thomas that - “What people do not realise is
the cost of manufacturing a drug is hardly twenty percent of price you pay. It is very
low part of the cost of the drug. Thw main cost of the drug, cost of research which can
be upto fifteen percent and the major cost is sales and distribution.” (From the text of
the speech at the meeting of CH,March, 1992)
As against the claim of the industry that they earn only 3 recent profit, it is surprising
that the share value and mobility of shares of the industry has remained always high.

Growth of Profits of Top Drug Companies
COMPANY

Ranbaxy
Glaxo
Hoechst
Sandoz
Alembic
Cipla
Pfizer
Dr.Reddy’s
Boots
Parke Davis

Industry

SALES
’92

‘94

177
276

688
551
351
290
262
244
214
175
154
137

118
97
89
73
65
60
51

51

GROWTH0/©
’92
’94

2004

33
22
2

24
3
14
13
80
27
10

22
28
23
1
65
24
25
31
18
7
24

PROFIT
’92
*94

12
11
6
4
3
9
4
11
6
3

79
32
32
22
5
24
20
33
16
17

115

,GROWTH%
DIVIDEND
'92
’94
’92
*94

61
■ -19

57
65
33
27
8
331
9
-17

71
49
136
3
1
21
86
23
23
13
48

25
18
20
16
16
30
10
35
34
20

40
27 ,
25
25

32
30
30
38
35

'

I
7
Big pharmaceutical companies were detected to earn profit flouting the DPCO and
even the order of the Supreme Court. Though they have agreed before the Supreme
Court that they would pay to the government the excess profit earned by over charging,
but it was not kept and the companies for years together, continued flouting court or
der. Not only this, the government had allowed these companies to increase the prices
of the drugs which were over charged. Example of some of the cases are given in
Table - 3

Government’s statement in this respect is that “The liability of 67 cases amounting to
Rs. 245.38 crores has been worked out and has been communicated; the details of
which are given in Annexure-I. Out of this, Rs. 18.27 crores had already been recovered.
11 cases have already been finally resolved so far." The cases referred so far are those
upto 1989 after which, the over charging had not stopped and the excess profit
accumulated are there very high. The companies had not paid this excess amount but
took the liberty of showing them in their balance sheet for tax exemption. “ Only M/s.
Glaxo Labs Ltd. has shown in their balance sheet their liability towards Drug Price
Egualisation Account. No income tax has been shown to have been paid on this amount
by the company." (Lok Sabha question No.3807 12th August,1986). There is a large
sum of money to be available from the drug companies which shall be enough to met
the expenses for setting well net drug control machinery. Instead, the government has
decided that to set up National Drug Authority estimated amount of Rs. 130 crores will
be required which sill b realised by imposing cess of 1 percent on the drug industry’s
turn over. (Business Standard; 30/8/95)This amount be certainly realised by the industry
from the consumers.
The feeble element of price control will be gradually given up by the government in
course of time. Within one year the government has decided to drop two drugs doxycicline and pentazocine from the list. Moreover, there will be no scope of enforcing
any price control on the newly introduced drugs any more.

Impact of Patents Act Change:

The Government had introduced Patents Amcndmeik bill, 1995in March, 1995. This is
a step towards changing the existing Indian Patents Act, 1970. Aiming to please the
U.S. drug multinationals who have been threatening India for retaliation under the
U.S.Trade Act, the bill provides uniimitso to: ilifies for MNCs than sought for in th WTO
Agreement. The bill proposed granting of :xcl>,sive Marketing Rights (EMR) to the
patent holder for a period of five years on marketing and distribution of drugs. This is
worse than the product patent. There will be no need to take separate patent if any
drug is patented in any member countries of 'WTO. This will allow dumping of irrational
and hazardous drugs in the country. No national company will be able to manufacture
or import any new drugs. It will be slowly under the mercy of MNCs who will, according
to their desire bring new drugs and price them at their own like.
r

o

The MNCs in India had not invested much in the past and had shown a passive response
to the government's liberal policy. A number of them had either sold their plants or
reduced manufacturing activities. In recent times no new drugs are manufactured by
them in their plants but are fully importing formulations from the parent countries. The
price of these drugs are to be paid in dollar terms. A vial of Acychlovir or anti hepatities
vaccine costs Rs. 1,400 now.
OJ Hi
LIBRARY
36 31
library

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AND
DOCUMENTATION
documentation
■ i MIT

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8
Due to the long patent protection time, 20 years of product patent and 20 years of
process patent, there will be no scope of manufacturing them in the country as most of
the drugs become obsolete much before when are replaced by new drugs. India will
have to depend on import completely for new drugs. No lav/, like DPCO or any of the
provisions of the Drug Policy would be applicable on the import. On the contrary the
government will be compelled to further relax/ withdraw whatever restrictions are still
applicable.
Conclusion:

There are many more areas where the recent policies turned blind eyes to act Some
of them are issues like banning of drugs, rampant misuse of loan license system, use
of generic names for essential drugs, monitoring of production of bulk drugs, reduction
of taxes on essential drugs,etc. The steps taken by the government in the past in these
areas have been very helpful to the industry. Government is determined to intensify
these kind of action.
The task of organisations involved in the health/ drug action has therefore become
more difficult. This meeting can decide to evolve a real drug policy aiming restoration
of self reliance in the production and research of drugs of different systems. A campaign
programme based on the alternative policy be launched throughout the country.

TABLE - 1

PRODUCTION PATTERN OF
MULTI NATIONAL CORPORATIONS
TOTAL
MARKE

SHARE

BRANDS

VITAMINS

3458234

1910011

SYS. & TOP. STEROID

2123464

NUTRIENTS &
MINERALS

1636445

COUGH & COLD &
ANTI ALLERGIC

THERAPEUTIC
GROUP

MNC

%

14

1845100

96.60

1020635

7

945745

92.66

595471

6

524347

88.0().

3773211

1606917

15

1291994

80.40

ANTI-INFLAM./ANALG.
ANTISPASMODIC

4134327

2265906

17

1499601

u6.18

..BS& BALMS

480169

409675 :

4

266145

64.96

ANTACID etc.

2599181

1431440

12

845101

59 0-.

ANTI ANAEMIC

1454285

615755

5

289610

47.03

DIABETES, CVS.,
EPILEPSY, etc..

4226096

1348542

14

563277

41.77

ANTI ASTHMATIC

1235405

275871

3

110959

40.22

ANTIBACTERIALS

12541714

7618188

52

2249402

29.53

ANTI PARASITIC/DIAR.

2368640

675649

7

173699

2S 71

AN'I’l T.B.

1776963

1045456

186550

17 84

—

Q

Q

I

TABLE -2
SECTORAL PRODUCTION OF BULK DRUGS(1989-90)
(figures as percentage of total prodn.)

DRUG
ANTIBIOTICS
Penicillin
Cloramphenicol
Palmitate
Tetracycline
Ampicillin

Erythromycin
Amoxycillin
Gentamycin
Cioxacillin
Phenoxymethyl
Penicillin
Cephalexin

SULPHA DRUGS
Sulphamethoxazole
Sulphadimidine
Sulphacetamide
Sulphaguanidine

VITAMINS
Vitamin A
Vitamin Bl
Vitamin B2
Vitamin B12
Vitamin C
Vitamin E
Folic Acid

MNC

INDIAN
TOP 2 0

PUBLIC
SECTOR •

OTHER
INDIAN

34.6
38.7
26.7
(Production mainly in Small Scale Sector)
15.5

42.5
42 0
6.5
56.9
36.6
(significant production also in Small Sector)
25.9
66.0
8.. 1
81.6
0.7
17.7
100
100
100
99.6

0.4

(over 50% production in Small Scale Sector)
0.1
99.9
76.9
23.1

86.5

13.5
100
100

100
36.1

63.9

100
100

ANALGESZCS/ANTIPYRETICS
Aspirin
100
Paracetamol
(Production mainly in Small Scale Sector)
Ibuprofen
75.8
24.2
Baralgan
100
ANTI T.B
Streptomycin
PAS & its Salts
Thiocetazone
INH
Rifampicin
Ethambutol
Pyrazinamide

46.5
53.5
(over 50% production in Small Scale Sector)
100
(Production mainly in Small Scale Sector)
(over 50% production in Small Scale Sector)
90.4
9.6
(Production mainly in Small Scale Sector)

4

SECTORAL PRODUCTION OF BULK DRUGS(1989-90)
(figures as percentage of total prodn.)
DRUG

MNC

ANTI PARASITIC
Chloroquine
Metronidazole
Tinidazole
Dilaxonide
Furoate
Furazolidone

34.2
7.1
17.6
41.1
(over 50% production in Small Scale Sector)
(over 50% production in Small Scale Sector)
22.3
77.7

INDIAN
TOP 2 0

PUBLIC
SECTOR

OTHER
INDIAN

(Production mainly in Small Scale Sector)

ANTI DIABETIC
Chlorpropamide
Tolbutamide
Glibencamide
Insulin

42.5
17.2
100
100

57.5
82.8

ANTI ASTHMATIC
Fphedri ne
Salbutamol
Terbutaline
Theophyllin
Aminophyllin

100
82.2
100
59.5
100

11.8
40.5

CARDIOVASCULAR ..RUGS

Propanolol
Digoxin
Methyl Dopa
Frusemide

(Main production in Small Scale Sector)
100
9.1
90.9
100

ANTI HELMINTHIC
Piperazine
Mebendazole
Pyrental Palmoatc

(over 50% production in Small Scale Sector)
(over 50% production in Small Scale Sector)
49.4
'•7.1
50.6

TRANQUILISER/ANTI-CONVULSANT

Phenobarbitone
Diazepam

100
(over 50% production in Small Scale Sector)

VACCINES
Triple Vaccine
Tetanus Antitoxin
Dip. Antitoxin
ource:

14.9
28.1

Amit Sen Gupta,
New Drug Policy:
Not
Prescription; Economic Times:24/9/04

o

85.1
71.9
100

the

Right

TABLE - • 9
EXCESS AMOUNT PAYABLE TO GOVT. ON ACCOUNT OF DPEA

COMPANY

EXCESS PROFIT

AMOUNT RECEIVED

Supreme Court Case Companies:

1.
2.
3.
4.
5.
6.
7.
8.
9.
10 .

Cyanamid
1320.52
Hoechest
7780.80
John Wyeth
506.q2
Merind
2391.72
Pf izer
87.61
Franco India
14.42
Tamilnadu Dhada
37.97
Anil Starch
12.77
S.G Pharmaceuticals 205.36
Ethnor
10.19

100
312.10
45.00
43.80
1.42

10.19

Other Companies:

11.
12.
13 .
14 .
15.
16.
17.
18.
19.
20.
21.
22.
23.
24 .
25.
26.
27.
28.

Glaxo India Ltd.
Sarabahi
Sandoz
Pfizer
Parke Davis
Abbott
Burroughs Welcome
Lyka Labs.
Warner Uindusthan
Boehringer Knoll
Carews
IDPL
Krupa Traders
IDPL
A.P.Chemicals
Maladi Drugs
Lupin Labs.
Bayer India

Total

Source:

7178.00
20.00
74.68
179.83
1466.15
182.38
191.15
678.73
106.36
97.74
710.24
336.45
20.48
37.30
25.43
116.30
21.03
107.37

23019.90

819.00
20.00
37.34
49.00

91.19

5 5.49

?

1584.54

Rajya Sabha; Unstarred Question No.4331 dt:25/08/93

n

Prescribing practice of Doctors and Unethical marketing practice.
A paper presented at the AIPSN seminar, New Delhi. Nov.5-7, 1995
by- Dr.K.R.Sethuraman.MD. , Professor of Medicine, J I P M E R.,
Pondicherry. 605 006.
"I would like to know what type of patient has a disease *'
than what type of disease the patient has." (Hippoctates).

Introduction.
Modern medicine is a miracle indeed! The advances made in
the past 50 years in diagnostic tests,
"designer drugs" and in
surgical
and other interventional procedures are mind boggling.
Take the case of coronary artery disease as an example. John Hun
ter, the famous anatomist of 19th century had said "My life is in
the hands of a scoundrel who chooses to raise my temper!". He had
coronary artery disease and it was he who coined the term angina
pectoris to describe the symptom; however, there was no effective
remedy and true to his words, he died suddenly during an alterca
tion. Dut now you can pinpoint the blocks in the arteries and
correct them by plastic or suraical procedures. With such great
advances in operative and anesthetic skills,
it is even possible
to do any life saving surgery on a growing baby in its mother's
womb.
Killer infections like small pox have .r.-.en eliminated from
this planet and manv others have been rendered nreventable. The
advances in antimicrobials have made it possible to save people
from certain death.
Advances in reha bi 1 i tat i or. have made’ lives
of thousands of disabled person more digniiied and acceptable.
Advances in understanding the mechanisms of chronic diseases and
in. designing specific drugs tor them have revolutionised the
management of high blood pressure,
peptic ulcer, diabetes,
asthma,
epilepsy etc.
In fact, the greatest discovery of 20th
century in terms of simplicity; effectiveness and millions of
lives saved is not CT Scan or Bypass Surgery, but sal!-sugar
solution (oral rehydration therapy) for treatment of diarrhea.

Public Dissatisfaction- a paradox ?

—

—
.—
_—
—
--------------------------------------------------------------------- ■

The painful fact is,
as medicine became more and more ad
vanced,
so did public dissatisfaction with it! This seems
paradoxical until one«realises that it is not scientific advance
ment but humanistic medicine .that results in a satisfactory
doctor-patient interaction <and a harmonious health provider
client relationship.
This is mainly bee mse of the dehumanising effect of pursuit
of scientific medicine at the expense of humanism.
GPEP report
(1984) of USA has strongly recommended that its medical colleges
should train its future doctors in humanistic medicine also
About 90% of health problems in the community are minor and self
0

1

from the West, Often considers anything ancient as quite rational
and sound,
and resists or belittles attempts at scientific in
quiry into the traditional practices.
If we have to usher in a new system of health care that is
just,
equitable, optimum and non-exploitative,
then all the
players have to necessarily change in the right direction.

THE ROLE OF HEALTH ACTIVISTS
Health activism is necessary to bring the pl ay ers
for the common cause of providing rational health care.

together

The activists should realise that

1.
Health care seeker (patient) is not a consumer hut a coprovider of health for self.
2. Health care is a co-operativ^ venture and not a commodity
transaction.
3.
Care-seeker should be empowered with questions to ask a
care provider before consenting for treatment.
4. Campaign for 'health needs' as against 'health wants 1, a
campaign to promote primary health care and family practice and a
campaign to know the common health problems targeted at the
public will pave way for inexpensive and non-exploitative health
care.
5.
Campaign for a well irounded
' ' medical education including
humanistic medicine and family practice is an urgent need of' the
hour.
The health activists should-

6.
Organise a multi-disciplinary group of scientists to
develop evaluation instruments to assess the influence
of
placebo, Hawthorne and factor-x effects on health and healing and
to put together training modules on these her ting processes for
medical curricula to render them scientifically acceptable ra
tional practices.

7.
Promote critical <and’ unbiased
’ ’
media output that truly
empowers the people with relevant knowledge;: ccounter any media
efforts to the contrary by effective monitorinqj and follow up act ion.
8.
Follow the example of consumer groups of the West in
publishing
unbiased Guidelines- on products and services including
,
diagnostic tests and treatment procedures
prOCed“res.- •Th”e
9.
Monitor the health care findustry
' ’
including hospital
services and campaign for Quality Assurance.
10.
C
Campaign for banning of hazardous drugs
(like foetal
_1 sex testing).

and

practices
4

Selected Bibliography & Annotations
1.

K.L.White (ed). The Task of Medicine- dialogue at Wicken
burg.
1988. Menlo Park, California.
Cali forn i a.
The Henry J. Kaiser
Family Foundation.'

2.

C.E.Odegaard. Dear Doctor-a personal letter to a physician.
1986.
Menlo Park, California. The Henry J. Kaiser Family
Foundation.’

3.

J.H.Burnum. Medical practice a la mode. NEJM 1987; 317:1220
("It is shameful taat like lemmings, we physicians push with
blind enthusiasm, certain treatments because every one else
is doing the same”)

'

J

4.

T.E.Lankester. Health for the people or cash for the clever.
BMJ. 1986; 293: 324.
("mercenary doctors and the drug industry have distorted the
perception of the people 1 -adinq to a clamour for vitamins,
injections and iv fluids. Correcting this betrayal of tru^.t
is a main task in order to achieve -Health For All)

5.

Editorial.
Inequalities in health care delivery.
Lancet
1986(2);116.
(..we need..correction of interlocking features of depriva
tion, unemployment, decayed housing, substandard education &
poor provision of medicine that collude to make poor people
powerless to obtain essential minima for a decent life.)

6.

W.A.Si 1 verman. Therapeutic nonsense (placebo). Perspect Med
'
■'
Biol 1995; 38:480-495.
(Complex interventions and high-tech medicare prolongs lives
with smoldering or altered diseases and disabilities,
these
are examples of failures of successes. The pursuit of cure
at all costs may restrict the supply of care.)

7.

Editorial. Where to draw the line? Lancet,1986( 2):H49 .
(A useful ethical self test before accepting anything from
the Industry:
"would I like to have these arrangements be
known to my patients or my peers?" If the answer is nega
tive, then it is unethical to accept it.)

8.

Muthaiyan. P & Sethuraman K.R., A survey of retail drug sale
in Pondicherry.
(The total purchase of medicines from five retail shops
during the' entire month „of October 1993 amounted
to
Rs.10,32,360 .
Of this, 45% (by value) was purchased based
on doctors' valid prescriptions,
34% based on doctor s old
prescriptions (without revalidation), 11% by patients self
order and 10% by the drug store sales person's recommenda
tion. The overall figure shows that about 21% was purchased
without doctor's prescription. The extent of direct purchase
of medicines is a cause for concern.)

I

I
1o

2-

5

9

initiated by IOCU,
t ion.

Penang are examples of efforts in this direc-

Fourthly,
consumerr education and people empowerment to expect and get access to irational and quality health service as a
be the most effective socio-political
matter of right. This
T-- will
..
the
most
difficult
and daunting one too.
strategy but 1-- ----- —

JIPMER strategy

iiiedfcal colleges.
£-- -----------—
At JIPMER, Pondicherry one of the premier
we have an ERDU network of
c motivated faculty from clinical dis"Catch them young, but catch them
ciplines and pharmacology,
anyway" is our philosophy.
’ ‘
:: During the first clinical year, the
Undergraduate training
-- pharmacology
conducts two seminars - one on how to
department of
]
analyse promotional literature and ethics of piomotiona.1 gifts,
The second is on "Adverse Drug Reaction (ADR)
(ADR)" monitoring
pAnitnrfnn .
a multi-disciplinary
During internship orientation course,
On
medical promotion, .
team conducts a workshop for three days,
________
"
(source:
IOCU) showing
we show a video "push, promote or educate
drug
representative
to influence
the manipulative behaviour of a
on
■
,
The -interns then comment
the skit,
a general practitioner.
list of ethical promotion' as a guide for1 focused
using the *'WHO
..
They also view the video ‘IN THE NAME OF MEDICINE'
discuss ion.
On day
(source: 1VHAI/IMA) and get quite powerfully motivated.
and
ADR
3,
the whole session covers rational drug therapy
monitoring in the form of group exercises.
We have found that the immediate impact on interns is quite
This reduces to
high - about 90% to 99% show positive changes,
is
obviously
a need
about 60% by the end of internship.*
There
for reinforcing these topics repeatedly,.

CME for GPs: Our ERDU team has similar CME modules varying from
90 minutes to 4 days covering various issues on rational drug
use. For small groups, the workshop methodology works well. For
large groups, we use "panel discussion forum" for a better impact
than lecture or symposium. We have conducted programmes on ra
tional use of antibiotics, analgesics and anti-hypertensives.
Patient/consumer
empowerment:
In
these days *of corpora te
exploitation of gullible patients is a major scandal.
medicare,
We have therefore formed an NGO to link np with various consumer
groups to promote the cause of citizens' right to health care.

[I

CONCLUSION:

"In the race for quality,
there is no finish line".
It is
true of our efforts as an ERDU team.
We welcome further col
laboration and alliances with like minded groups to promote the
cause of rationality.

2

I

Presentation
frew* Rational
Drug
Campaign
Caapaign
Anniversary of the f«iore Committee Report with
and “Critical and constructive appraisal
How"
Poli cy".

By Dr .
>

Al.
. 1 .

Chairman, Rational

C™
Committee,
on
the
50th
the
----- 1 slogans "Health for
All
of the Indian Public
Heal th

Maresh Banerjee.
Drug Campaign Committee.

Introduction s

I thank the All

India Peoples' Science Network and the Delhi
Science
For urn
for
taking up this right opportunity to organ! ze and
to
host
the
conferonce
for health professionals and activists, on
he occasion of
the
50th Anniversary of the Bhore Committee Report (published in 1946).

1.2.
On
behalf of the Peoples' Relief Committee and The
Bengal
Medi cal
Relief
Coordination Committee with the assistance of late Dr.
B.C.Roy,
I
had
the privelege to be a member of the team to submit memdrandum
to
the
Bhore
Committee
in the year 1945 at the height of the great
post
Fa.ni n?
mass scale epidemics in Bengal. At that time, people had very little
access
to
rud ment ry outdoor health care facilities. Acutely ill
patient
could
not, be
admitted in the Govt, hospitals rxs 507: of the hospital
bt?d<=;
u.'er e
kept reserved > or the victims of Air raid and war emer gency.
•9

1.3;
> t=:
During
the great: Bengal famine and post famine
epi demic.
v_J
About
lakhs
of
people died of starvation and about 30
akhs of people, died
epi demies (as estimated by Prof. P.C.Mohalanobis & Prof.
K.P.Chattapadhya)
of
malaria, cholera
cholera, small po.< , tuberculosis,
bronchnpneumoni a,
tetanus ,
di phtheri a,
measles etc. All those
f
were due to shortage of
< ood,
potablt
water,
poor
sani tation, lack of treatment
preventive
heal th
care and medicines.

2.

Background Note

2.1.
"The Bhore Committee Report of 1946" and "Health for All by 2000
AD"
o; W.H.O. ~ UNICEF in 1978, all these did not come out overnight
overnight, they have
go.t a long history ®f development of health care system.
o

2.2.
From
the very begining of the primitive human
society
man
evolved
var ious
methods
of health care to take care of their health in .cases
of
illness, injury, natural calamity and child birth.

2-3Procedures adopted and progress made in the struggle
f or
ex i stence,
better
existence
and
better
way
of
life ■ through" human
labour
and
intelligence brought about by the productive forces with soci al
evaluat i on
with
changing production rel at i on /Jpr i mi t i velc 1 an society,
slave
society,
feudal
society,
capitalist
society
with
phases
of
capital!sm
to
imperialism.

1
€>

2.4.
Similarly in the field of medicine from wrath of
supernaturc
power, various types oF magic remedies, superstitions of magic craft, wi tc
craft, animal/human slaughter to treat acute illr,_i>ses were practiced.
Hot
& Cold therapy, herbal remedies were considered as remodi cal measures,
ar
gradually developed a discipline of social science, from an individual
ar
to social art For remedies.

2.5.
Science has advanced much more rapidly in comparison to the sic
development of social progress with varying degrees in various parts of tl..r
world to keep pace with the development of
latest
remedial
measures,
diagnostic and therapeutic medicines, tools and gadgets.
2.6.
- Social, economic, administrative and political conditions have set
up barriers to make available to the common people latest
advancement i
various fields of medicine and surgery due to their inability to pay for i >
reli gi ous, cultural and tribal taboos and prejudices ana
or due to social, religious,
lack of health consciousness.
•?

A. 3. Glorious her-itagn of Indian Medicine

*
3. 1.
Since the onset of Indian Medicine overcoming the past
legacies
an
assi mi 1 at i ngl the positi ve features, about 3000 years B.C. i.e. about
50 0
years ago, the Indian medicine developed wi t h'*fiel p < nd guidance of
Ri shi
Indra, Sankaracharya, Dhanwantri, Charaka, Sushruta, Jiboka etc. till
160'’
A.D.
& this had been the golden chapter of the Indian medicine,and
dur i n
this time were published
famous treaties
- Charaka. Samhita,
Sushrutci
Samhi ta. The Indus valley civilization with excellent development
of health
care <system and the Ankarbhat templesoF Kampuchea are examples of
golde
days of Indian Health care system (Rahul Sankirtanya).
3.2.
Subsequently,
due to repeated foreign
invasion,
gradual
foreig
domination in various parts of the country, with mixing up of various type
of
socio-economic,
religious, cultural and political set up,
all
these
up,
? creatc-d multifaceted social, economic, religious, cultural
and
political
and
contradictions. All these adversely affected the projress of Indian
Indi an syste
of medicine, which suffered from contradictions, stagnation and decay.

3.3.
As an
inevitable outcome’of
all t those constraints,
the
India;
Medi ci nes along with Ayurveda, Siddha, Unani System of Medicine Failed ti
keep pace with the developing
ientific capitalist system of medicine from
the .womb of ■'feudal system in keeping with the progress!ive development or
scientiFic systemi as an outcome oF industrial revolution,,
3.4.
From 2nd half of 17th century till 2nd half
of
19th century the
sci enti Fi c
system of medicine was gradually dominated Ly the British ii
major parts of India except in a few places by the? French, Portuguese ant
Indian system oF medi c i ne.
’ r hl h' .

3.5.
In the first part of 19th century the English peopl e Started < ‘
setti nc
up oF medical schools. These doctors were posted in the health centres, the
subdi visi ons and district. Head Quarters Army ar i Fol i :e. barracks,
i ndi go
pl enters,
to serve the colonial interest of health care
For
the Army
Pol ice,
Administrators,
Merchants and Native Agents supervised by the
British Surgeons,
ignoring the health care of the common people o F
our
country,
Who were the major victims of illnesses and
epidemics.
The sc
>

T .

•

■

called
modern
system
of medicine was intreduced
str ongthen i ng foreign domination in our c ountry.

•f or

Perpet uati ng

and

Efforts before* achieving Indian independence
4.1.
In
1938 about a decade before India achieved
Neta ji
Freedom,
when
Subhash
Chandra
Bose - President, Indian National Congress did set
up
a
Nat i onal
Planning Committee with Jawaharlal Nehru as Chairman, and
a
sub
committee
for
formulating
national Health
Policy
was
constituted
f or
improvement
of
the
Health
Service
in
the
country,
b=-?
which
should
preventive oriented and rural oriented as the people of the rural areas are
under served and under privileged.
I n the Health sub committee of the National Planning Commi tee persons
4.2. In
Dr .
1 i ke
B. C.Ro/ ,
Dr . A.R.Ansar i , Dr
Sokhay ,
Dr .
Jivraj
Dr.. Santak Si ngh
Dr .
Mehta,
Dr.
N. N.Joysooria,
Dr.
Khan
Saheb
Hakim. A.mal
Khan,,
Col.
Khan
i
J . K-. .Kripalani,
Dr .
J.C. Roy , Col -. S. Hodur Reh aman , Dr .
G.V.Deshmukh
were
included. The subcommittee submitted its interim report on 31st August 1940
highlighting
13 points concerning health care of our
ountry,
summary of
which are noted below
4.7.1.
To
improve the health condition of the people priority
□ i ven
to
raise nutritional standard by improving the balanced
at 1 past
2400
calories for an adult and it should be increased
doing hard labour as suggested by the League of Nations.

snould
be
F ood
wi th
f or
those

4..’.. .2.
India
should
adopt
a health
are
system
with
integration
preventive and curative health care under single administration.

rf

4.2.o. Such integrated health care system, preservation and maintenance
such health care should be under state control and responsibility.

of

4.2.4. For proper functioning.of such health organ!sac ■ on importance should
be
laid on research in the fields
ejrent i on, diagnosis,
treatment
of
n-'Ti genous system of medicine.
diseases and also for development of

4.2.5.
In
view
of pancity of qualified medical men
and
women
countr /
to set up large number of training centres to incr-ease the
of qualified doctors rapidly.

in
the
number

4.2.6. Along with the above to set up large number of training centres
f or
large
number of health workers, they should be trained in elementary
care
to
tackle
the
practical health problems in
the communi.ty,
first
ai d
personal and community .hygiene. There should be one community health worker
per 1000 population to be attained within 5 years period.

4.2.7.
Within next 10 years there should bo one medical man or
woman
for
..every 3000 people and 1 bed for 1500 people. Ultimately there should be one
qualified
male or Female doctor per 1000 people anc one bed For every
60®
people with adequate provisions for maternity cases.
4.2.8.
Medical
and Health organisation should be•so devised
with
social
obligation
and
proper organ!sations set up to offer free service to
the
people by whole time medical officers. In each medical teaching institution
a
chair
should be set up for social training of the medical
students
in

3

o

a

©

I

modi ci np? and national

h--?al th .

su-t r i c i en t
in
sei f
4.2.9.
Adequa I: e
st ep s sh ou 1 d L < • t a k en to make Indi a
surgical
and
aiagnosti<
production
of
drugs,
biological
products,
instruments and apparatuses and other medical suppl ier .
up
Indian
" Q._
dr aw
formed
should becommi ttee
4.2.10
A
p harm ac opea1
rt
phytochemicals
that
and
in
j
rugs
.
Pharmacopea.
To
organise r esc?ar ch
our
country.
being commonly used in

n the market not
di sc 1osi ng
4.2.11.
All
secre?t remedies propagated
compositions and contents shall not be alleged to be marketed.

t ht

mould be allowed to
hoi r*
4.2.12. No individual or firm, Indian or foreign
patent rights For any substance useful in human and ve4- er i nary medi cine.
4.2.13.
Attempts
should be made to absorb practitioners in
Ayurveda
and
t her
Unani system of medicine into the state Health organisation by giving
further training in modern scientific, medicines. Medical training in
ever'
field should be based on scientific methods.

Regard!ng
essent ial
aspects.

Naturopathy
systems of medicine i.e. Homeopathy,
it
ot her
is
j. n mod .-rn sc i ent i fie med i c ines i n
al 1 'its
to
undergo training in

Cone1udi ng Note : -

It
is very
ver y
significant that such people
oriented,
preventive
orientec
integrated with curative and promotive health care system with
integratioi
of various system of medicine with scientific up dating. Training of
1 ar ge
number
of
medical and paramedical people did set up ar ideal
before
th-doctors,
and health workers. Some of the points re ...ommended by the
Heal th
sub committee were incorporated in the Bhore Committee and i n the
Nat i onai
Health Plan's but not. implemented as yet.
B. 1 .

Shore Committee Report

1.1.
The “Health Survey and Development Committee"
British Govt, in 1943, completed its report in 1946.

was set

up

by

the
V*O'TfU

1.2. During 1943 at the height of Indian National movement f or f reedom
the British Col on i a1 rule. This committee had the advantage
f getting som>
guidelines
f r om the National Health sub committee, welfare state
movement
of the Beveridge
committee
in
.
..
U.
K.
,
and
devel
opments
soci
al
heal
th
servi ce
G
USSR\,
the BYggest partner of the antifascist war, Dr. Henry
in
Si ger i si
of John Hopkins Institute of U.S.A..
COilU.

1.3.

iii .
i v.
v.
vi .

So

The Health Survey and Development. committee members we as foilOW5
A

Si r Joseph Bhore
Dr. R.A.Amesur
Dr. A.C.Banerj ee
Dr. A.H„Butt
Dr. K. V. (J h a n d r a c h u d
Dr . (Nr s) D.J.R.Dadabhoy

Z|.

Chai rman

Dr . J. B.Grant
Dr. M.A.Hameed
Gen . Sir Bennet
Sir. Honry Hol 1 and
Sir Fr edr i ck J ames
ii .
N.M.J osh i
i i i . Lt.Co1 (Mi ss)H.M.Lazarus
i v.
Pandit L.K.Maitra
xv,
Dr. Lakhanaswami Mudaliar
x vi .
Dr. LJ.B. Narayan Rao
x vi i . Dr. Vishanath
■ viii .Maj.Gen. W.C.Raton
iX .
Dr . B.C.Roy
Mr . P.N.Sapru
'xi .
Col . B.Z.Shah
.: x 1 1 . Dr. B.Shiva Rao
• x i i i . Mr s. K. .Sufi Tayabji
• • x i v. Dr. H.R.Wadhwan i .
Dr. K. C.K E Raja
Secretar-y
vi i .
■i i i .

■ oi nt Secretar i es
xxvi, Dr. M.Ahmed
xxvii.Capt. A.Banerjee
xx vi i i.Dr. K.T.Jungalwala
x i x . Mr. Man Mohan
Dr. S.Rama Krishnan

r. 4. Summary of the guiding principles of the Ehore Committee were
a.
No individual should fail
his inability to pay for it.

to secure adequate medical care

because

of

D.

Modern medicine demands progressive development
development of
of medical
medical
science
both short term and long term with development: of
of various
various types
types of
of
medical
diagnostic
and
therapeutic, (gadgets and also for prevention
diseases
of
should be made available to- all,, with special emphasis for the rural people
who
are
mostly
under served. They suffer
from
various
calamities
and
epidemics.
We are highly indebted to the vast rural peasants who provides our food and
commercial
(crops^they should be given due priority in the field of
health
care, to these
_ sections
---------- of people who suffer from various diseases.
o

4.
— Health care with integrated—preventions, promotive and curative
care
to ensure maximum benefits to infants, children and mothers. They should be
provided
with
adequate food pure water to maintain
heal, th
and
prevent
epidemics.
er

- People should be taught general education alongwith "health
educati on
on®
personal
hygiene,
breast feeding of new born
babies.' These
people
should undergo training i n domestic and environmental sanitations
disposal
of waste, alongwith potabl e water supply.

6.

- Health service must be placed

tr

G

very near rather close to the people

to

ensure maxi mum b e n e f- it w i t h suitable flexibility of med cal and paramedical
ni e i c i n e s and
man
power 7
equipments. The
extention o5
care
shall
A health
i nc]ude
pr i mar i1y
delivery of mothers by .rained
midwife
with sanitatyju
measures.
7.
Med i c:: a 1 educations should be extended upgrade
alongwith
nurses
and
paramed i cs
f or'
providing progressing health care coverage
upto
Furthest
per iphery
of
human habitation. One
medic-1 college for 5
One? medic"!
to
10
mi 1 lion
peop1e.

8.
Centraly,
Al 1
India Institute of
Medical
Sc i c •ice
Scicice
with
all
t h -a
d i sc i p1i nes
medi cal
oF
science
should be set
up
with
development
oF
research
f aci1it i es
f or
training research cadres, for
training
of
f or
the
medi cal
teachers. Si mi 1 ar set up can be started in ;.he
h •• var ous states,
to
keep pace with the 1atest advancement of medical science.
w

9.
Medical
e d u c a t i on . sh □ u 1 (J b e social
oriented.
Need
For
fullest
cooperat i on
and
understandi i ,g is very vital for the.
thr success of
th^
both
prevent i ve
and
- -•.re
curative
health
r?re
alongwith
propagation
of
heal th
educat i on.

10.
The
Health
set up should
be
democr at i sea ,
decentr al i secwith
i nvolvement
oF
local peoples organisations
and
repre.entives
i nc1udi ng
women
to
generate self help among the local people
ail ongwi.th
survey
of
illness, to identify the causes and sources'of infection, and local methods
to
do away with
t
>and to involve in Family planning and
child
i mmuni sat ion
and suitable■ measures for disposal of waste.

1 1 . - Suggested to introduce gradation of Health Care delivery units
based
on population coverage and administration set up
within two decades>
with
5
yearly
d eve1 op men t plans,
state/di strict/sub
divisi on(taium),
Ib1oc k ,
pr i mary
h e a 11 h
c en t r es ,
s u b s i c.: i a r y
Heal th
Centres
etc..
with
spec ial
emphasi s
for
malaria, s. t. d . , tuberculosi s, cholera,
1eprosy,
ka l aaz ar ,
tetanus,
diphtheria, small pox, F i1 ar i a etc . The nearest
medical
v_ol lege
should serve as super referal hospital.
n

12.
- Set up for p r i m a r y h e a 11 h centres have been laid down as Follows
Bhor e Comm i 11 ee -■ (no single medical of f icer unit was
i
suggested)

Medical 0
Officers
F f i cers
- 2
Public Healt
Health
h Nurse
Nur se
•- 4
Nurse
- 1
Midwives
- 4
Trained Dais
)
- 4
Public Health Inspector-- 2
Health Assistants
- 2
Pharmacist
- 1
Clerks
- 2
Servant, s
Infer ion Servants
— 2
13.

Detai 1s have been worked out i n following chapters

I .
II.
III.

I nt roduc ■. :i on
Moder r i t ren d s in or gani sat i on of health servi c.e
Long t r" m h e a 11 h service For the people

6

by

IV.
V.
VI .
VI I .
V III.
IX.
X.
XI .

Short term Health service For the people
Nutrition of the people
Health Education.
Physical Education.
Health services for the mothers and children
Health services for the school chi 1 dren
Occupational Health including Industrial Health.
Health services for certain important diseases - malaria, tuber
culosis, small pox, cholera, plague, leprosy, veneral di seases,
hook worm, filariasis, guinea worm, mental diseases and mental
deficiency, disease of the eyes and blindness prevention.
XII.
Environmental Hygiene.
XIII.
Housing - Rural and Urban
XIV.
Public Health Engineering ~ including water supply, general
sanitation, control of insects - mosquitoes, rodents, river:; ponds
flood water pollution.
XV.
Quarantine — seggregation .
XVI .
Vital statistics.
XVII.
Organisation and Administration.
XVIII. Professional Education -<nedical,
general and post graduate, nursi ng,
pharmacists, various grades of paramedical educat i on , denta'! educat i on
ec t.
XIX.
Medital research - training and institutes should be set up.
XX.
All India Institute of Medical Sciences.
XXI.
Drugs equipments and other requisite manufacture and supply
XXII.
Indigenous system cf medicine to be developed
XXIII. Regulation of the responsibilities of the medical profession
to
serve the community.
XXIV,
Employment of demobilised Medical Men.
XXV.
Establishment
of ’ committee jto •’ maintain
standards
of
medical
education, both undergraduate and post graduate.
XXVI.. Population problem
1'/ Welfare
Programme,
XXVII. Alcohol in relation to health,.
XXVIII.Instituti on for medical 1i brary servi ce
XXIX.
Medical Legislation
'
XXX.
Pinancia1 Implecation of health programme
XXXI.
Employment of persons who have reached super annuation.

C.

1.

Present Day Health Probleas of India -

1.1.
Incia is the 2nd largest populated country of the world after
China,
with
population
of
91 crores in July 1975. Grow-th
rate
is
about
16.8
mill!on
people per annum, almost equal to the population of/Australia
and
New
Zealand taken together
Birth rate is 29 per 1000, death rate
is 8.5
per 1000. (jssaj

©

I.X..
-There is 16.57. of the global population inhabitating on only 2.67.
of
global land area in India with a burden of 227. of global morbidity (various
types of illnesses), 317. of global illiteracy with 2.S7. .of the global
druo
f'rD°"ytl°n ’ OLlt Pf which 1.67. drugs are irrational and hazardous, about 157.
to xlW/. of the diseases are drug induced in our country.
1.3. In India, about 507. of the people are below poverty Line,
1.6
mi 11i on
di e
within
a
year
of their birth, mainly
due
to
lack
of
prevent!ve
medi ci nes
and sanitation. 607. children are born under weight due
to
poor

7
©

*

live
in
status
of the mothers. 747. of the people
vi 11ag t- S •
nutritional
mortality rate is as high as*per 1000. Literacy rate is
about
607.
In Fant
male 387. amongst female, 94 women- —“■ 1000 male. Only
457. of
the
amongst
oF India failed comply with Marpeople have access to potable water
de Plata resolution on ^ater decade^ending in
i n 1990. About 257. to 3077 people
have
got
access to modern drugs in 1993 that also partially. Due
to jiew
Policy^’ and
Industrial
and
finance policy alongwith modification of Drug
Patent *0?
of 1970,
1970, the drug prices are going up sharply, The new DPCO
reduced
p r i c e control
span of price
c ontr ol on 73 drugs only and raised the NAPE to 1007 on those
drugs
under
control, rest including most essential drugs
are
not
under
restriction
on
production,
price control, and export3import
On
pr
l./uuu u j> u*11 ,
control
are
"mZ <*'rip IU4" 'rty «a
sharply going beyond the reach of common people^ cAorriv'newest
'Thrso mo p>o

•

1.4. Though gti peopIp 1i ve i n villages, 2^7. people are in cities and urban
areas
but
707.
of the health care resources are spent
For
urban
areas,
inspite of the fact that rural people are major victims of various diseases
and
epidemics. There are very Few doctors/nurses to man the r rural
health
centres with scanty supply of medicines and other facilities.
Socio Econoaic detie?r-ioration and lack of political

will

1.5.
With
inflation
and
price Ihike
in
essential
commodi t ies,
risi ng
unemployment , high rise in Foreign loan, about 407. of the to-’-al budget
are
being
spent
for
debt
servi ces. Not
taking
steps
against
corruption,
dehoarding oF mi 11i ons of crores oF black money, devaluation oF rupees etc..
have
placed India in 134th pos111on out of 178 nations of the wor1d, as. a
r esul t
heal th
budget oF both central and state govts.
have
been
pruned
al ong<a‘<l ack
of social and rural oriented motivation ,
amongst
the
heal th
workers and 1 a c k: oF determined political will'on the part of the Govt.
for
betterment o
• f Health care of the people.

1.6.
o F basic guidelines enunciated by the tex-c
Inspite
oF
National
IHealth sub committee, fundamental
f undament al basic guidelines enunciated
by
the
Bhore
Committee.
Later
on
World
Health
Organizations
Alma
Ata
dec1 arat i on of'Health for all by 2000*in 1973 with 10 points programme
f or
i mplementat ions,
With major emphasis on implementation of
pr i mary■
health
carp a key to the solution (of' the problem. The Govt. of India has
«accepted
to
abide by the directive oF' Heal th For Al 1 by 2000 AD,.’inspite which
the
Govt.
of
India has failed to implement any of the 10 conditions
till
to
day.
1.7.
Under the existing conditions of our country it is not. possible f or
the Govt. of India to implement "
"Health
Heal tn For All by the 2000 AD " mainly
due
to
its lack of political will with positive determination and
ant i-peco1e
soci o
economic policy alongwith negative move for privatisation of
Heal th
Carp gradually, rather commercialization of Health Care.

D. 1. The way out

D.1.1.

The key slogan of the seminar

“Health Tor All

Now”

It has to be realised that without a determined political will o F the Govt.
alongwi tt
in power backed by the socio-economic and other logistic support
►
campaign
active
involvement of the people with organised broad b sed mass
as
Such slogan could not be implemented or realised, rather it will iremain

8

V

x'<r

a

gimmick,

to

hoodwink

asspssflient

Cr i til cal

of

our

people.

National

Health Policy

of

Indi a

D. 1.2 . On healthy mandays labour output oF our people working i n the ..-Fields
factories economy of the country alongwith its social
edifice
and
main1y
But
the
health
care
of
these
people
are
being
neglected
depends .
i n the mailn.

D. 1.3.
total

does

"Health"

physical 7

mean mere absence of disease and
economical and social wellbeing.

not

mental,

infCrmit y

but

D.1.4.
The broad outlines of the national health policy
the people
of
our
country
should
be to implement a system
of
comprehensive t posit i ve
health
care system with provision for promotion of health
prevention
of
disease, prompt diagnosis and treatment in case of illnesspr injury
a 1 on
with
facilities
for
estoration of health, and rehabilitation
i ri
ncrmai
means
of•1ivelihood. Such 'health care should cover all secionE of
peop1e
in
all
stages and facets of life from mothers woumb to
tojb.
It
chou1d
cover every individual without any discrimination of his =oca}?
cconomic,
religious
status, political affiliation, caste, creed, colour Df the
skin
and "other constraints.

D.1.5.
Formulation
of such comprehensive National health pol^y
and
its
implementation
has been criminally neglected during the last 4
yeai
of
our
national independence by our national planners and
politi^j
1 ead er s
governing our countr
b pite oF the Fact, that even af^ur r^c^ving clear
cut
guide
1 nes
fro,;, the National Flan
Health
Sub-c nmittee i n
1941/;
extensive health pl’n formulation suggesting positive prsumatic ^ps
0&a>
implementation
b/
the Fhore Committee in 1946 and
WHQ--NICER
1 nr
Ata
declaration of '^Health For All by 2000 AD“ in 1978 with i tIGO poi.!- 2 g u i fl e
si gn aty-y
i s
lines
for
implementation,
to which Govt, of India
f or
implementation in our country, by 200(3 AD.
the
i gnored
The
dr afters
of
our Indian
Constitution
PLples '
health .■are,
proper
right
to enjoy good health and to receive
which should have been incorporated into the fundamental rights chapte
of
dirr-c.lV;?
oh 1i gatory
of
instead
oF placing-it under
non
our
c on st i t ut i on

D.'l., 6.

inherent

princi p1es

of

the

states

D.1,7.
The
Govt. cH Incia did set up several commissions and
committe
a
F t. er
only
to
shelve
their recommendations For good
after
each
election \
noodwink the easily gullible people of our country and at the same time di
doctors-,
not
Fail
to
point the. accusing fingers to the doctors,
paramedics
anc
people for their non-cooperatioh.
D.l-8.
Our National planners and political leaders of tho
National
Plan
Committee
have ignored the importance of Peoples' Health Care
improvement
as a positive measure for the economic growth of the country by the way
of
the man day loss due to sickness and maximising the economic growth through
the output of healthy man d“ays labour, and have failed to incorporate flight
. to health care," in the fundamental rights chapter of our constitution.
D.1.9. The doctors, nurses and the paramedical staff have failed to realise
the importance of their service to the society by playing an effective role
as a leader in the health care movement team To fight out the anomalies and

9

G

.o

constrai nts created by the socio-economic anu bureaucratic constraints ir
social
and pr o F^essi onal obligations to the people : at
at. large,
di schargi ng
af f l i lent wes • ern
Rather a section of profession is still under the spell of af-Flnent
—
countries ou 11ook o F commercialisation of health care, Ibuilding
up persona.'
creating increasing gap betweeni th«
economic and service carrier thereby
and the.people, often exploiting the people unde, the garb o F
proFessi on
health care.

E.

I cap 1 pcps -t at- co a-f Heal th Pol i cy

o

E.l.
Implementation of comprehensive Health Policy cannot be taken up
ir
isolation. It isvitally integrated and inseparably linked with, the various
facets of
the socio-economic system of our country. This is dependent on
provision oF adequate Food, potable water supply, suitable clothing, proper
housing with nyderate degree of sanitation along with disposal
of
waste,
basic educati(h with health education, viable employment,
adoption of
measures again>t environmental
pollution,
preventive
measures
against
communicable diseases etc.

E.2.
Succe^- of
Implementation depends on total
integration with the
National devAopmnnt programmes starting From^euSal back log with radical
land reform,
^od to do away with colonial
legacie .,
development of
agricultura production and animal husbandry augmentation. At the same time
massive dev?1 opment of industrial production with improvement of industrial
relation, trash programme to ensure potable water supply. To ensure basxc
education°ngwith health education, with development of hygienic habits.
Improvemproads and communication, social ser'dce and other
essential
infrastrttureE.3. Coptraints in the way of implementation should be removed. Within the
present socio-economic,
political and legal. Fabric it will be an uphill
task t overcome all these constraints within a short tome unless and until
all
actions of people are properly organised and unit d^ with determined
politcal
to remove the constraints. To begin with to start
changing
the -rection such as proper utilisation of existing ’resources, to “develop
worl culture, decentralisation of power, democratisation with
involvement
of ne people through their respective mass organisations, 1ocal panchayets
anf civic bodies to do away with the lopsided pl -nning and half
hearted
I flementation,
maladmin;sti ation,
bureaucratic
corruption,
bureaurratic bunqling;
t/f t , indiscipline etc.

ne present direction and orientation of the health policy should also be
-hanged From urban to rural oriented, from individual to community, from
major emphasis on curative to preventive, with due priorities for emergency
babies, pregnant and nursing mothers, old, invalid-handicappedI etc.
cases, babies,
The health administration should be controlled by the medical
men Ihavi nq
in
training
administration
and not by the non-technical
bureaucr“ts,’
part i ci pation of
inviting partici
the
local
people for
local
planning
and
i mp1 emen t at i~
on
“.
E.4.
At the same time proper allocation for Health Budget is very vital..
Bhore Committee and WHO suggested allocation pF 107. of
he National Vbudget
should be earmarked for health sector. But Govt, of
India is gradually
reducing Financial allocation For Health.

10

i

Economic

and Political

YEAF<

HEALTH EXPENDITURE
PER CAPITA IN RUPEES

weekly of

3rd June,

199b reports

EXPENDITURE IN HEALTH
‘IN MILLIONS OF RUPEL^

EXPENDITURE ON
PREVENTIVE HEALTH
CARE IN MILLIONS
OF RUPEES

1989-90

120

103

103

1990-91

127

100

98

1991-92

1 19

95

87

1092-93

118

94

83

This is causing very serious set back in development
of health care in
the
face of increased i nf1 at1 on 1 increasing incidence of di
sea. es like ma 1 -aria,
tuberculosi s,
diarrhoeal
di seases,
diseases,
gastro-enterit is,
kalaazar,
viral
di seases, aids, cancer, infant and maternal mortality
under weight” babies,
1
i ncreasing
incidence of■accidental injuries on roads 1 r di 1 ways -and
other
tra nsports
and
various
types of industrial acci dents,
anti
social
and
terrorist activities 7 natural calamities, etc.
E.5.
To meet all these Health problems it is essent" <1 to set up
suitable
health
inFrastructure
starting
from remote ru; ^1 areas
to
urban
areas
includ.. , ig big. cities. ■ All these are manned by inadequate number of staff
doctors,
nurses, pharmacists, midwives, other group of
paramedi cal
staff
and
shortage
of
Medicines. There are no doct-rs 'in
many
remote
many
areas,
doctor
population
ratio is 1 doctor (qual i F i ed) ForSd&oto
6000
people
i rf
For ad&o to
rural
areas,
where
as 1 doctor for 500
people
m
urban
areas.
500 to
to 700
people
Medical paramedical
manpower picture
picture is
is upside
upside down.
down. Dr. K,N.Rap .reported
that there should be atleast 2> paramedics
per
doctors,
---- -3 per doctors, but the^p-ar
ni 1 ib
paramedics
per doctor. Moreover 707. of the health care
arp
care expenses
expenses
don/?
for
urban area to cater to the needs of 2B7^ of the people
e living in
urban
areas and only 307. of the health budget is spent F ir 727. rural people, most
of
them are poor, under nourished and are major victims of
11 It.bssbs
and
epidemics with scanty supply oF potable water, So reallocation
of
heal tt
budgets
needs urgent revision to make it people orie ited
r ur al
or iented
1
and needbased.

F.

Medical Education

F.l.
The national health policy document published by the Govt, of
India
in
1985 states in the chapter "Medical and Health Education", it has
been
menti oned that’ effective delivery of Heal th Care services wquld depend very
largely
on the nature of education, training and
appropriate
or i entation
towards community health of all categories of medical and health
personnel
and their capacity to function as an integrated team . . ,
. . . " is
reviewed
in terms of national needs and priorities and curriculum and the
training programmes should be restructured to produce personnel of
vari ous
grades of skill- and competence who are professionally equipped and soci ally
motivated
to
deal
with
effectively the problems
within
the
exi sti ng
con str ai nt,s.
Towards
this end it is necessary to formulate
separately
a
"National Medical and Health education policy" which s—
o

11

€>

sets out changes required to be brought in the curri'• ular contexts
ant
training
programme
of medical and- health personnel of various
levels or
functioning.
,

ii.
takes into account the need for establishing the extremely
interrelations between functioning of various grades,

iii. provides guidelines for producuion of I ..?alth personnel
the realistical 1y assessed manpower requirement and,
iv.
ensures
that
personnel
cf^levels
rendering community health services.

are

soci u.l 1 y

ess-ent i a:

oh the basis oi

moti vated

toward?

Even
after
one decade since 1985 nothing has been done by
the
Govt.
India
to formulate a separate Medical and Health Educe?, ion Policy’
or
i mpl ement at i on .

o^
i t<

F.2. uojectives
trair
Objectives ot
of me
the medical education of our country
country should be
be to
to
up
adequate
number
of
basic
doctors
suitable
to
tackle
devitality,
morbidity, mortality due to communicable and endemic
diseases prevailing in
endemi
our
country alongwith promotive, preventive,
and
rehabi1itati /prevent i ve, curative
health
care with maximum care for the poor and underserved section of
the
community.
Their training should be patient oriented
and
:rectl>
Field
practice oriented with adequate flexibility and adaptability to satisfy the
health
care
needs
of the people in rural and
urban
areas,
fields
anc
factories, sites of production, construction and human habitation.
F.3. We need large number of basic doctors with adequate clinical acuman
to diagnose and treat common diseases prevailing amongst people without the
help of sophisticated diagnostiic and therapeutic gadgets. They should
also
be
trained
in those gadgets
whenever available.
fhe* doctors
alongwitb
other sections of paramedics and local pec pie and panchayets shall have tc.
play
the role of a leader in the field'of health c »-e. Thene teams
should
involve
and
educate the local people how to safeguard their
own
hoalth,
domestic
health, community health , environmental health,9 immunization
and
Family welfare programme etc.

F-4.
During the last 47 years the Govt. of India has failed
to
introduce
such type of basic doctors, iinspite of ^recommendations of Shore
Committee',
Adarkar
Commi ttee, Mudaliar Commi ttee’^ Kotharil Committee, Gani
Committee,
Sri vastava
Commi ttee,
Sokhey
Committee,
Duraiswami
Commi ttee,
K.N.Rac
Commi ttee,
Hathi
Committee
etc.
most
of
the
recommendati cns
of
the
committees were not taken up For consideration.

F.5.

IPresent
day
medical educations are curative
b i a ... ed ,
urban
Ibased,
uiicruu nr u j.
J. ,
theoretical
disease oriented than patient or i en ed v isolatedI
from
the
people
and their health problems, and society at large.
The
pr esent
soci o-economic
conditions prevailing in our country is mainly
responsib 1 *=
•for
creating half baked doctors, specialists and
superspecialist
di ploma
and
degree
oriented,>
without any field practic.1
training
as
hospi t
housestaff,
rural
oriented
in rural
health
centres,
directly
getting
admitted
into
postgr aduat i on im.nediately after internship, to
make
then
qualified
*medi cal quacks. They are motivated to convert health
care
as
a
trade with too much dependence on medveal
gadgets and
fl ouri shing
nursing
homes
charging high fees. They are fit far atflqent
sections, of
mOBtly'

12

about
a dozen metropolitan cities of India or for export to
the
aff1uent
Forei gn
countries.
Moreover
there
is no
system
of
ongoing
medi c a1
educati on to update their knowledge, nor there are any facilities for b a s i c
research in various disciplines of medicine.

F.6.
The
undergraduate
medical course should be
of
5
years
duration
Followed by one years internship to get temporary registration, followed by
one year residential house staffship in a teaching hospital, followed by
2
yrs.
compulsory
rural
service to get permanent
registration
to
secure
permanent jobs, independent private practice, or to go for post
graduat ion
and super speciality.

a week o-f selection by the P.S.C the doctors
F.7.
Within
have
shal 1
to
undergo
one
year
training concerning various
admi n i strati ve
and
other
aspects
of health service like I.P.S., I.m.P.
There should be
an
I . M. S.
service cadres with equal Facilities like other services.

F.8. Special arrangements should be made to update the!
regi strati on
after every 5 yrs. till the age oF 65 yrs.
compulsory refresher courses as per schedule.

knowledge and
re
aster
undergoing

F.9.
Medical teachers should be a separate stream. Besides
postgraduation
they shall have to undergo medical teachers training in various disciplines
alongwith
research
project
training
in
various
disciplines
and modern medical training methods. They
shal ]
have to accompany students during Field practical training. They should
be
provided with incampus residence and other essential facilities..

Paraa&dical Education

t
G

.
There

•
are great shortage of, various grades

4

of
paramedics,
nurses,
pharmacists,
dentists , radio technicians, laboratory technvcians,
medical
computer,
physiotherapists,
multipurpose
heal t hw c.* r workers,
health
k er s ,
opthalmic
technicians, dental technicians , O.T. nursing, mental health nurse, medical
instrument^ technicians etc.; So large number institutions shall have to
be
set for training various groups of paramedical technicians with
facilities
for updating their training.

G.2.
These Paramedical Training Institutions could be set up
attached
to
medical colleges, or technical colleges, or district or upgraded hospitals.

G.3,
There should be compulsory first aid training for the
6,D.A.,
■other
hospital
staff,
ambulance
van driver. Training should
be
arrangedI
for
hospivtal
cooks with food values in diet, proper storage,
preservation
of
'’Food , serving the food to the patients without outside contaminations.

H.

Drugs & Pharaiaceiiticals

H.l. Drugs are one of the most essential part for tpe treatment of patients
and also for prevention oF diseases. The Hathi Committee in 1975 gave clear
cut
guidelines
regarding Drug Policy and
development
of
P h armaceutical
industry,
identified 117 essential drugs needed for India and
restriction"
of Fera equity not more than 407. etc.

13
G

' I

i *!

The Indian Patent Act of 1970 is a definite landmark in development of Drug
Industry,
to make our country self
sufFicient
in drug technological
development, introduced product patent not process patent, patent period 5
to 7'years only.

H.2. In 1979-80 it was assessed that to fulfill drug needs as an essenti al
component of Health for All by 2000 AD, India will require about Rs. 16,000
crores wArth of essential drugs at the price level of 1979-80. But due to
in Fl atiortSjj!..deficit Financing, devaluation of Indian Rupees 7 heavy drainage
of
funds due to Debt Services, adoption of inew economi c
and
industrial
policy,
Fera equity participation of 517. or above, modi f i cat i on of
1986
Drug Policy and adoption new DPCO 1994, amendment <of Indi an patent act,
’
the,World Trade Organization by the Govt.
oF
Indi a. Indi a
shall have 'tcj ^manufacture essential drugs to the tune
‘___ of Rs. 40,000 crores
by 2000 AD to meet health need of the people besides> export.
H.3. Growth of production of Bulk Drugs
Di ngs and formulation in India
last
5 years!3Sourco - Annual Report of the Dept. oF Chemicals
Chemicals' - 1994-95 s
YEAR

■ BULK DRUG RS.

1990-91

IN CRORES

FORMULATIONS RS.

during the
and Petro

IN CRORES

730.00

3840.00

4

1991- 92
*
1992- 93

900.00

4800.00

1150.00

6000.00

1993-794

■ 1320.00

6900.00

1994-95
(Estimated) 4

'I'

1518.00

7935.00 C,/-3S'0.oe)
31

cXv

The figures
f i gures refd.
above shows that it will not be possi b1e to produce
40,000 crores .of Rupees in worth of drug by 2000 AD. Moreover Rs.
1781.40
crores worth of Drugs were exported in 1993-94 including Bulk
Drugs
and
Formulati on.
H.4. In India there are over 70,000 drug formulations in the market, hardly
10,000 of these are rational. The World Health Organization has identified
about 250 td 300^drugs with which 95% of the common diseases prevailing in
country could be treated. The Govt, of India should set up due priority
our country-could
to manufacture these drugs. In this respect key role should be played by
the public sector, and national sector, small, medium and big shall have to
he
— involved.. All drugs should be in generi c names. Over Rs. 400 crores are
being spent annually in creating brand names^
k-c-x nn^
ZAjl

■J

VIA e_4-vw<2
A

■v-

.w

r

14

ZL-Q.

cJ yr,

H, 5. Research ajnd Development
This is very vital
Y’ E A R

b ut. most neg1ect ed. R e s e a r c h E >: p e n s e s o n urugs :
RUPEES IN CRORES

1991-92

80

1992-93

95

1993-94

125

Research is very vital in the sphere of Drugs, more so due to emergence of
new diseases and flare up of old endemic and epidemic diseases. Due to new
economic and industrial policy indigenous researches will be crippled.
The Govt, shall have to put major emphasis on research. Part 1 cul ar 1 y
Indi a
should be proud to posses over 1600 plant species of medicinal
val ue
and
250 species posses aromatic value. So greater importance should be giveni on
pnytochemical
research as was .suggested
by
oSLiggee+’ed
by
Acharya
P.C.Roy
and
1Dr.
R.N.Chopra.
Research in genetic Engineering,
biotechnology
has
assumed
greater importance.

H.6.
Drug prices are going high day by day due economic and industrial
policy-, modification of 1986 Drug Policy, New D.P.C.U, Amendment of
Patent
Act
Bill, joining World Trade Organization and unconditionally accepting
Intellectual Property Rights, genei al agreement in Trade and Tari-ff ,
Trade
related investment measures. All those have led to price r i se i r- essent i al
drugs crom 257. to 250%. The drug coverage has already down from 357. to 157.
of ti >e peopl e.

\H.7.
Indigenous development of therapeutic and diagnostic machinery and
various other instrument, for scientific research equipment s has assumed
greater importance alongwith training of personnel to man those equipments
and. also to >epair those when out of order. Over Rs., 1000 crores worth of
sophisticated machines lying out of order.
H.8. Drug Induced Diseases
Over 207. of diseases in cur country are drug induced due to hazardous drugs
and
irrational
prescribing habits. So all the hazardous drugs should be
banned.
There should be special training course in the undergraduate
education on clinical and applied pharmacology and adverse drug reactions
centres should be set up in various parts of the country.

After graduation ongoing education ori latest advancement in drugs with
its
bioavailability,
pharmacokinetic and pharmacodynamic properties alongwith
adverse drug reactions study.
In a recent survey made in China published in "Owen*Hui Ban'
Bau”1 on 28/8/95
from Sanghai7 quoting Public Health Dept, figures - "For
"For- the last few years
due to intake of wrong medicine about one lakh ninety thousand people
die
peopl
annually...... "Every year on an average twenty lakhs of people are
being
are
admitted into hospitals for taking wrong medicines, without knowing adverse
15

G

G

£

drug reactions,

lethal doses or stopping the medicines before recovery...."

Of
late Govt, of India has suggested setting up of adverse drug reaction
study centres in 5 places excluding eastern India. These centres have not
been started as yet, no protocol have been Fixed till now.
?

I.

Concluding Suggestions

I. 1.
Policy decision of the Govt, of India with determined political
will
wi th constitutional obligation for incorpcration in the fundamental rights.

I.?.

To incorporate and integrate health sector
With the
nat i onal
development
plan with increased Financial and other logistic support
with
involvement of people and peoples' organisation at e/ery level of
dec i si on
making oF planning and implementation.
1.3.
Medical
and paramedical manpower development in various
varl o
di scipline
with due social motivation to man the health delivery units -New< PHCj PHC,
Block Health Centres, Rural General .Hospitals, Subdi vi sj. onal and cii str i ct
Hospital,
Medical College Hospitals,. Super specialist. Hospitals 7
Hospital
for
Children,
Maternity,
Tuberculosis,
Mental
diseases,
Leprosy,
Cardiology, Traumatology, Cancer, InFectious disease etc.

Integrated preventive health care wi?th child
1.4.
i mmuni sati on,
y
water suppl
supply.,
provision
For adequate nutrition,
disposal
of
sanitation domestic and environmental and ecological.

potable
waste,

1.5. Mass education drive alongwith elementary heal'-.h education for all.
Education regarding promoting of health and precautionary measures agai nst
di seases.
preventable diseases.
Education regarding food values and food habi ts
alongwi th f ood pr eser vat i on and protection from contamination.
1.6.
All essential drugs both preventive and therapeutic be made
those who will be in need,
of
avai1able to all
good quality
a^FordabLe price, with provision For free supply to the indigent.
To ensure viable employment for all
1.7.
wi th abolition oF child 1abour.

i n var i us me. ns

of

f r ee1y
■t

an

1 i vel i'hooci

Spec i al
measures to be adopted for
industrial
health ano
1.8.
other
occupational diseases andI accidents with regular health check up For them.
1.9, The tenpoint Alma-Ata declaration are as follows :

It realizes’that health, which is a state oF complete physical, mental
social wellbeing, and not‘merely the absence of disease or
infirmity,
and
a
fundamental
human
right
and
that
the
attainment
of
the
highest
is
level
of
health
is
a
most
important
world-wide
social
goal
whose
possi ble
reali z ati on requires the action of many other social and economic sectors
$I
■
■
• i
in addition to the health sector.

the
gross inequality in the health status of
ii.
The existing
particularly betweeni developed and developing countries i s of
concern to al 1 countri es.

16

peop1e
common

iii.
Economic and social development is of basic importance to the fullest
attainment of health for all. The promotion and protection of the health of
the
people is essential to su s t a i n ed ec o n om i c an d s oc i a1
de ve1o pment
and
contributes to a better quality of life and to world peace.

iv.
The
people have the right and duty to participate
individual 1y
collectively in the planning and implementation of their health care.-

and

A m a i n social t a r g c:-1 o f g v e r n m e n t s , i nt ar n •<!., ; on al
i1 e wor 1 d c cm mu." ■
'.■? coming decade
td
7
AD" . Hr!
.
i s 11) e I-.:
: .
p ar t o F d eve1 op men t i n the spirit of soc i a J. j u /;i c e.

and

or gan i z at i on s
“He ;5 1 th f or
th i s

vi.
Primary
health
c ...ire is essential heal th care
based
on
p r a c 11 z a 1 ,
scien11 fical 1y
■ot md
and
sc-c i al 1 y
accept an 1
.net hods and
technd ogy
accessi b 1 e to :i n d i vi d u a.s and {' a .Ti i 1 i e
i n t h e c c , / ■ > i u n 1.1. y t h r o u g h t hi e i r
t u1 1
p ar t i c i p at i on
a n d at
. cost that tt’r
commun.
md country can
afford
to
mai n t a i n . at
e / er y s ■
g e c:; f t ti e i r d e v e 1 c< p m e r 11 ..
It for s an
integral
part
P
both
of- the country's health system, o F-whi ch it; is the
central
f unct ion
and
main focus, and of the overall social and economic development of
the
commoni ty.
vi i .

Primary Health Care :

Addresse

the

/ent i ve ,

ma i n

11 e a 11F;

curative ai 1

p 5- o h 1 e m s

rehabili

in the communit
providing
’vti ve .ser vi c s a.. . or d i n g 1 y-;

promot:ve,

at least : education cl ncerninc, pr
■ il i>
health pre
met: .ods
c
prevent i ng •■?.nd control ] i ng them; promo . i on of Fcod
■ i per
nut r i t i on ; an auequat e s upp*X y of sb' e w -■> t er and . . u a s i c
"••eternal
and
child
ealth cace, including Family
p"anning;

In: . udes

agai ns4"
endemi c
and

1ems and the
supply and
sani tati on;
i mmuni c it i on
the major infectious diseases; prevention
nd control
of
1ocaliy
diseases; appropriate treatment of common d i seases" . and
i n j ur i es;

provision

of

essential

Should
be
sustained
referr a1 systems.

drugs;

by integrated,

iunctional

and

mutual 1 y-supporr.i ve

Relies,
at
local
<
and
referral
levels,
on
■ iea 1 th
w o r k e r s,
i n c J ud i n g
phyc c 1 an-.,
nurses,
m i d wi ves,
auxi1i a ri es
and
community
workers
as
applicable,
as
wcl1
as traditional
p r ac 111 i on er s
as needc d,
su i t ab1y
trained socially and technically to work as a heal th team and to respond to
the expressed health needs of the community.
©

viii.
All governments should formulate national poli cies, strategi es>
and
plans of
action to launch and sustain primary health care as
part
of
a
comprehensive
national
health’
system
and
in
coordinati on
with
other
sectors.
ix.
All countries should cooperate in a spirit of partnership and
service
to
ensure
primary health care For”all people. In this context
the
joint
WHO/UNICEF report on primary health care constitutes a solid
sol i d basis for
the
Further
development
and operation of primary health care
throughout
the
world.

17
G

a

o

An acceptable level of health for all tlie people of worId by tne
yeap
can
be
a11 a in ed
through a fuller and better
use of
the world's
a considerable part of which is now spent on armaments and
.resources,
military conflicts.

x.

2000

1.10.
All
these as suggested above cannot be i mpl emen t eci
resolution, holding professional or selective convention.

in,

adopting

?

— We shal1 have to launch country
<
wide broad based mass movement unitedly
with al 1 sec t i ons of peop 1 e>7 profe< sional and mass organisations,
N.G.O's,
peoples Represent at i ves in Parlia-.-e. t. Assemblies and F*ahcha/ets for a
prolonged period to winover the demands: of peoples health care as suggested
above.

*

r'

4

18

ACTIVITIES OF COMMUNITY DEVELOPMENT MEDICINAL UNIT

Activities :

Community Development Medicinal Unit (CDMU) is engaged in promoting
Rational Use of Drugs (R.U.D.) and ethical prescribing and therapeutics.
The major way of achieving this,
is through regularly organizing
seminars, trainings, orientation courses, involving active participation
from various
professionals like doctors,
paramedicals pharmacists,
nurses, universities, drug activists, non governmental organizations and
institutes. This activity is taken up through C.D.M.U. Documentation
Centre. The hallmark of CDMU Documentation Centre is collection and
dissemination of unbiased drug information to people from all walks of
life,
and
it has attained national
importance and is enjoying an
international accolade, by being in active networking and collaboration
with
similar
organizations,
through
exchange
of
drug
bulletins,
newsletters, journals and other relevant information.
Currently, CDMU Documentation Centre is focussed on,
on, and has iniriated
a series of Training Programmes on ’’Rational Use of Drugs”.
The
programmes encompass different topics, relevant to the main theme like
- (a) Diarrhoea and role of O.R.T., and R.U.D. in diarrhoea, (b) Mother
8 Child Health, Safe Motherhood, Immunization and relevant R.U.D., (c)
Malaria - its cause, preventive aspects, rational therapy for malaria,
(d) Rational use of Antibiotics, (e) R.U.D. in Acute Respiratory Tract
Infections.
For training purposes, CDMU has a good collection of audiovisual aids,
on topics relevant to our training. Training programmes have been, and
are being successfully conducted in different parts of West Bengal. In
November and December, a series of programmes have been fixed up in
Tea Gardens of North Bengal. CDMU Documentation Centre has slowly
updated and expanded its journal and book sections, facilitating the
catering of information to different scientific streams. CDMU also has a
prized collection of Press Clippings of all health-care related topics,
from all leading newspapers published in India. CDMU Documentation
Centre provides access to information on request, regarding Adverse Drug
reactions,
Iatrogenic
diseases,
doubtful
drug
combinations,
drug
regimens and a variety of medical topics. Reknowned experts from
faculties of different medical colleges provide their help at all times.
W.H.O. has published in its ’’Essential Drug Monitor” - a news journal,
the name of CDMU’s ’’Rational Drug Bulletin” as an internationally
recognized source for information relating to R.U.D.

CDMU Documentation Centre has plans of diversification,
prescription audit services, and a regular Adverse
monitoring centre.

by introducing
drug reaction

IJ

: 2 :
Its membership is open to all individuals/institutions interested in this
field.

Contact Persons
1.

Mr. M. Sarkar
Associate Secretary
Community Development Medicinal Unit
86C Dr. Suresh Sarkar Road
Entally, Calcutta
700 014
Phone: (033) 245 2363

2.

Dr. (Mrs.) Moitrayee Mandal
Coordinator
C.D.M.U. Documentation Centre
47/1B Garcha Road
Calcutta
700 019
Phone: (033) 748553

3.

Dr. Amitava Sen
Coordinator
(Address as above)

1

Structural Adjustment Programmes and the
Pressures by International Agencies on Health Policies
(Dr.) Amit Sen Gupta

The World Development Report 1993 is the
most comprehensive document of the World
Bank regarding the Health Sector as a
whole, and in that sense embodies the basic
understanding of the Bank towards this
sector. In this paper I shall try to critically
analyse the essential formulations being
made in this document, as well as attempt to
project the implications of these
formulations on the future development of
health infrastructure in developing
countries.

9

Before embarking on this task, however, it
would be useful, first, to take a look at the
specific juncture at which the World Bank
has chosen to make its views on the Health
Infrastructure public, in such gi ent detail.
Structural Adjustment Pol:cies, now being
enforced in the country have been in force in
many Third World Countries (mainly m
.Africa and South America), for a fairly long
period - in many cases ove r a decade. Such
policies, thus need to be viewed in a global
context, specifically in the context of the
attempt by developed market economy
countries to gain access to the growing
markets of Third World Countries. These
policies attempt to encapsulate the ‘free
market* ideology as a guiding principle, and
are designed to place the ‘market’ in a
central position of dominance, where It
would act as the principal, if not sole,
arbitrator of all processes. At a global level
such a position is extended to encompass
the concept of‘free trade’ - a„concept that
has been captured in its full essence by the
GATT treaty of 1994.

What Lies Behind the Safety Net

The World Bank has obviously has had time
to analyse the effect of its Adjustment
Policies in the couijtries which started on
Adjustment policies around 1980. One fact

o

that obviously must have leapt to the eye
was the ‘rolling back’ of many gains of the
previous decades, however insubstantial
they may have been, in the areas of Health
and Education. As a result of the adjustment
Policies, at the behest of the Bank, many of
these countries had drastically reduced
resource allocation in these areas. The
‘danger signals’ from these countries were,
for example, echoed by the UNICEF in the
following manner : “For the first time in the
modem era, a subcontinent is sliding back
into poverty. The number of families in subSaharan Africa who aie unable to meet their
most basic needs have doubled in a decade.
The proportion of children who are
malnourished has risen " (l; The UNICEF
went further in squarely blaming such
condition? on the debt burden imposed by
the Bank’s Policies on these countries,
noting : “The total inhumanity of what is
now happening is reflected in the single fact
that even the small proportion of interest
which Africa does mandge to pay is
absorbing a quarter of all its export earnings
and costing the continent, each year, more
than its total spending on the health and
education of its people.” (2) and further,
“Great change is in the air as the 1990s
begin. .

And great change is needed if a century of
unprecedented progress is not to end in a
decade of decline and despair for half the
nations of the world. In many countries
poverty, child malnutrition and ill-health are
advancing again after decades of steady
retreat. And although the reasons are many
and complex, overshadowing all is the fact
that the governments of the developing
world as a whole have now reached the
point of devoting half of their total annual
expenditures to the maintenance of the
military and the servicing of debt.(3)
c

The report essentially accepts its complicity
in the process of this slide back when it
says, “Because cuts in government spending
are usually central to an adjustment
program, health spending is likely to be
reduced. In many countries early cuts were
indiscriminate and failed to preserve those
elements of the health system with the
strongest long term benefits for
health.’’(emphasis added)(4) Having
accepted that its Adjustment Policies were
responsible for rather unpleasant fallouts in
many countries, the Bank found it necessary
to suggest certain remedial measures. These
measures, had to be of the kind which did
not fundamentally endanger the Bank’s
Adjustment policies in these countries, but
which at the same time could initiate some
sort of'disaster management’. The Bank
hence starts talking of a 'safety net’ for the
poorest, who are feeling the brunt of the
Adjustment policies most acutely. The term
used is in itself interesting, implying as it
does the hazards associated with the
Adjustment Policies, thereby requiring the
use of a safety net. The WDR 1993 is
essentially a prescription for setting in
motion the erection of this safety net.
The nature of the safety net the Bank wants
in position is not determined by any
altruistic concerns for the victims of its
Adjustment Policies in developing countries.
Rather, they are an extension of the very
same concerns which led the Bank to push
for the Adjustment policies in the first place.
In the seventies, the capitalist world was
going through a crisis of its own leading to
a sharpening of inter-imperialist
contradictions and thereby a greater urgency
was felt for carving out Third World
markets. The precise mechanisms tailored to
efficiently carve out the ‘global cake’ was

pushed through in the recently concluded
GATT agreement. But much earlier, the
World Bank, working as the ‘battering ram’
of the capitalist world, had moved to initiate
policies - called Structural Adjustment
Programmes - that, it hoped, would make
markets-pf the Third World freely accessible

on one hand, and at the same time would
bring an element of stability in these markets
for long term exploitation.
Let us see how, in more concrete terms, the
kind of thrust these policies would like to
have in a country like India. In the schema
of seeking out markets in the Third World,
India occupies an almost unique position.
The ‘middle class’ consumer market in the
country is estimated to cater to a population
of around 100 million - i.e. larger or
comparable to the total market in the largest
countries in Europe and about 40% the size
of the entire domestic market of the United
States. There is thus a special interest in
‘prising’ open the Indian market for various
global players to exploit. In order to nurture
this market it is also necessary to increase
extraction of surplus value from the 800
million who do not constitute a part of this
potential market. This is precisely what is
sought to be achieved through Structural
Adjustment Policies that have been initiated
in the country - by way of fiscal austerity
measures designed to cut Govt, spending
and subsidies in social sectors, reduction in
direct taxes, increase in administered prices,
deregulation of the labour market, etc. In
other words, policies designed, on the one
hand, to increase the paying capacity of the
target population in the potential market
and, on the other hand, to keep the rest of
the populace at a level of mere subsistence.
However, as noted earlier, the signals
emanating from the countries that had taken
up Structural Adjustment Programs in the
early phase, were disturbing for the Bank.
Disturbing not because of its actual effects,
but because the effects threatened to totally
disrupt the stability of these countries, and
thereby of their markets. Markets in SubSaharan Africa and in some countries of
South America almost ceased to exist due to
widespread dislocation of local economies.
The safety net formula was hence required
to bring back a semblance of stability in
these countries, and had to be extended to
■ countries now going in for Structural

3
Adjustments, so as not to repeat the past
experience.
The safety net formula can thus be also seen
as a partial strategic retreat of the earlier
World Bank prescription of total withdrawal
of the State from all social and
infrastructure sectors. While the Bank
continues to pursue its policies geared
towards private takeover of other
infrastructure sectors like Power,
Telecommunications etc., in the area of
Health and Education it has had to do make
certain concessions to the logic of state
support. However such concessions are
grudgingly advanced, and in fact are
responsible for the large variety of
inconsistencies contained in the Report. The
attempt is still to formulate a package which
involves minimum state involvement, as the
intent is not to make provisions for
comprehensive health care that required, in
the words of the Alma Ata Declaration of
1978, “All governments should formulate
national policies, strategies and plans of
action to launch and sustain primary health
care as part of a .comprehensive national
health system and in co ordination wjth
other sectors. To this end, it will be
necessary to exercise political will, to
mobilise the country’s resources and to use
available external resources rationally.”(5)
The WDR 1993, in sharp contrast, believes
in the necessity for a political will to restrict
health care access when it says, “As
policymakers try to reach compromises,
they must deal with powerful interest
groups...... and strong political
constituencies, including urban dwellers and
industrial workers.”(6)

Thus essentially the report is an attempt to
formulate a package of interventions, and
push for a policy that can sustain the
overwhelming number of people in a
developing country at a level of mere
subsistence. Anything beyond this is
anathema, and is strongly disapproved of in
the Report. For, after all, the Report is
designed to keep state support at a

minimum and not to provide health care.
This is stated in so many words, “Adoption
of the main policy recommendations of this
Report by developing country governments
would.... and also help to control health
care spending. Millions of lives and
billions of dollars could be saved.
(emphasis added)(7) But even to make
provisions for such a package requires State
support, and this is where the Report goes
into a series of convoluted reasonings to
work out a comprehensive set of rules for
state intervention. In order to do so the
report also goes through the exercise of
compartmentalising health into a series of
'nuggets’, to which it assigns scores with a
novel computing system called DALYs
(Disability Adjusted Life Years). The whole
exercise is to reduce health to a series of
mathematical calculations to determine
which interventions 'optimise’ returns. To
this end the report states, “When
governments become directly involved in
the health sector -.... policymakers face
difficult decisions concerning the allocation
of public resources. For any given amount
of total spending, taxpayers and, in some
countries, donors want to see maximum
health gain for the money spent. An
important source of guidance for achieving
value for money in health spending is a
measure of the ccsx-effectiveness of
different health interventions and medical
procedures - that is, the ratio of costs to
health benefits (DALYs gained) (R) It is
interesting to note here the Bank’s concern
for the taxpayers, as ultimately this is the
constituency, or in other words the market,
that the Bank wishes to address and nurture

Cost-effectiveness is important for the
World Rank as it candidly admits, “Using
cost-effectiveness to select health
interventions for public financing does not
necessarily mean spending the most
resources where the burden of disease is
greatest. Instead, it means concentrating; oh'~ “
the interventions that offer the greatest
' possible gain in health per public dollar
spent.” (emphasis added)k9) It is such an

approach that impels the report to exhort
the use of iodised salt for endemic goitre but
abhor 'government action in nutrition’. The
report clarifies this - “There is a strong case
for government intervention to improve
health by improving nutrition, but not for
interfering generally in food markets, except
in extraordinary conditions such as famine.
Government action in nutrition has often
been wasteful because it has duplicated
what private markets do and has paid too
little attention to the causes of poverty and
to cost-effective measures that improve
families’ knowledge and capacity to feed
themselves adequately.” (,0) The calculations
to justify this is simple if one understands
the World Bank’s logic. Salt iodisation
requires little resource inputs, and the costs
can easily be passed on to the consumers
But actual intervention to raise nutrition
levels would interfere with the market - a
cardinal sin as far as the World Bank is
concerned. So a hands-off policy is
recommended, except in times of famine.
Under more 'normal’ conditions
governments can limit their intervention to
telling (and not providing) people what they
should eat. Intervention in nutrition would
attract the World Bank’s ire as it is not costeffective and 'distorts’ the market,
irrespective of the fact that protein-energy
malnutrition affects an estimated 28% of
children and iodine deficiency goitre affects
7% (an overestimation by some accounts).

The fragmentation of health into discrete
components, to facilitate calculation of
DALYs, reinforces a model of health care
that has its roots in technological
determinism. It follows from the belief that
technological solutions can be applied
piecemeal to health problems of a
community, to the virtual exclusion of social
and economic determinants. Thus the belief,
for example, that governments can fulfill
their objective of controlling diarrhoeal
diseases by efficiently distributing Oral
Rehydration salts, without intervening in
provision of safe drinking water. While not
discussing more details of such an approach,

already in vogue in many countries including
India, it would probably suffice to point cut
that this approach is a necessity as far as the
World Bank’s compulsions are concerned,
rather than a logical need.

Retreat of the State

The need to repeatedly emphasise that state
intervention, and thereby resource inputs,
should be kept to a minimum, has led the
report to take strangely contradictory
positions. While reiterating that publjc
funding of health care needs to be reduced,
the report is forced to contend with the fact
that in most developing countries such
funding is abysmally low. It thus grudgingly
admits, “Adoption of the package in all
developing countries would require a
quadrupling of expenditures on public
health ....There (in the poorest countries),
paying for an essential package will require
a combination of increased expenditures by
governments, donor agencies, and patients
and some reorientation of current public
spending for health.” (emphasis added)
But the crux lies in mobilising the extra
resources to quadruple spending on health.
No answers are offered, except for
references to good work being done by Non
Governmental Organisations (NGOs) and
the possible help by donor agencies. Except
in Sub-Saharan Africa, such aid accounts
for, 1.5% or less, of the total spending on
health in developing countries and even the
report does not visualise any major increase.
NGOs are dependent on either foreign
donors or government funds, or act as a part
of the private sector. The World Bank is
obviously caught in a contradictory
situation, and has no solutions to offer.
The report is on much firmer ground, in
terms of internal consistency with its other
positions, when it argues for increased
involvement of the private sector. The intent
is at least transparent and consistent with
the need to reduce public sector
, involvement in health care. The report thus
argues for private sector takeover in most

•A

r
areas not covered by the Bank’s minimum
package. This, it is posited, would increase
‘efficiency’ and ‘consumer satisfaction’.
There is a clever piece of argumentation
which shows that public funding is already
low in most developing countries, and a
formal role for the private sector, with the
state acting as a regulator of the market for
health care, will only work towards making
the present system more efficient. The
report argues in this vein, “People often pay
dearly for supposedly ‘free’ health care.
Recent household surveys in India,
Indonesia and Vietnam indicate that each
visit to a government health centre actually
costs patients two to three times the amount
of the low official fees. Bribes aside, the
indirect costs such as transport and the
opportunity cost of time spent seeking care
are substantial. Since patients are already
paying for supposedly free or low-cost
health-care, new user fees, when
accompanied by reduction in indirect costs
and improvement of services, may increase
utilization.” (12)
The private sector is portrayed as the
paragon of efficiency. Efficiency is a term
difficult to quantify in the area of health
care. The report obviously equates
efficiency with fast turnover, easy
accessibility and possibly, consumer
satisfaction. Whether these considerations
really go towards improvement of the
quality of health care is however a debatable
issue. The report for example lauds the
performance of private practitioners
working in the slums of Bombay thus “Competition among health providers in
developing countries can improve the
quality of services as perceived by patients
and thus increase consumer satisfaction.
...... competition among private physicians
in the slums of Bombay, for example, is
intense, with private practitioners offering
convenient evening hours, short waiting
times, and readily available drugs to win
patients from other private practitioners and
from public clinics.” (,3) Contrast this with
innumerable studies on private practice in

India, which has shown that practitioners
chronically overcharge, use too many drugs
and use inappropriate medicines, not to
speak of various reports of malpraxis: One
study says, “...private physicians serving the
urban poor in the slums of Bombay have
grossly inadequate awareness about the
treatment regimen of leprosy.” and further
that, “..(they) do not consider standard drug
regimens in treating patients suffering from
pulmonary tuberculosis. The drugs which
were used were found to be three times
more expensive than the standard
regimens.” (14) The situation is probably best
summed up in the following terms : “Its (the
World Bank’s) implication continues to be
that markets can do little wrong and that all
economic growth is necessarily to the good
........ Government intervention in the
economy, on the other hand is always
regarded as guilty until proven innocent.” (,5>
Impact on Infrastructure Development

Let us now turn to what is possibly most
fundamental to the position of the World
Bank - the need for the state to withdraw
from areas of infrastructure. It has been
discussed earlier how in the area of Health
the Bank feels compelled to slightly dilute
its position, but regardless of that, this
remains an overriemg concern in the
Report. It is a posk.c.i that needs to be
addressed at a generic level, because the
Bank’s position is dictated not by concerns
of feasibility but by ideological
considerations. These ideological
considerations necessitate that the Bank
make a case for a global push in developing
countries, for the state’s withdrawal from
areas of infrastructure. Yet, it is a germane
question, whether such areas are at all
amenable to market forces, and if so at what
stage. As has been pointed out, “It is
common knowledge that savings/
investments (and labour productivity and
incomes) are low in a developing country.
There is no 'market demand’ for basic
' 'infrastructure services. This is where Adam
Smith’s famous argument in favour of the

'I

u>

State - erecting and maintaining those public
institutions and those public works, which,
though they may be in the highest degree
advantageous to a society, are however, of
such a nature that the project would never
pay the expense to any individual or small
number of individuals, and which it
therefore cannot be expected that any
individual or small number of individuals

should erect or maintain - becomes
obviously relevant.” (,6)
It would be interesting here to examine in
some detail the kind of spending that is done
by countries on health care and the
percentage of such spending that is bome by
the public sector. The following table gives
the comparative figures :

Income and Health Spending in 34 Selected Countries
(countries with population >20 million in 1991)*
COUNTRY

GDP
PER
CAPITA

% of GDP
SPENT ON
HEALTH

•/•OF
PUBLIC
SHARE

COUNTRY

GDP
% of GDP % OF
PER
SPENT ON PUBLIC
CAPITA HEALTH SHARE

TANZANIA
ETHIOPIA
BANGLADESH
ZAIRE
NIGERIA
INDIA
KENYA
PAKISTAN
SUDAN
EGYPT
INDONESIA
PHILLIPINES
MOROCCO
SYRIA
COLOMBIA
PERU
THAILAND

100
120
220
260
300
330
340
400
420
610
610
730
1030
1160
1260
12«5
1570

4.7
3.8
3.2
2.4
2.7
6.0
4.3
3.4
3.3
2.6
2.0
2.0
2.6
2.1
4.0
3.2
5.0

68.1
60.5
43.8
33.3
44.4
21.7
62.8
52.9
15.2
38.5
35.0
50.0
34.6
19.0
45.0
59.4
22.0

TURKEY
ALGERIA
IRAN
SOUTH AFRICA
VENEZUELA
ARGENTINA
BRAZIL
MEXICO
SOUTH KOREA
SPAIN
UK
ITALY
FRANCE
CANADA
UNITED STATES
GERMANY
JAPAN

1780
1980
2170
2560
2730
2790
2940
3030
6330
12450
16550
18520
20380
20440
22240
23650
26930

4.0
7.0
2.6
5.6
3.6
4.2
4.2
3.2
6.6
6.6
6.1
7.5
8.9
9.1
12.7
8.0
6.5

37.5
77.1
57.7
57.1
55.6
59.5
66.7
50.0
40.9
78.8
85.2
77.3
74.2
74.7
44.1
72.5
73 8

Source : Calculatedfrom data in librld Development Report, 1993.

An analysis of this data shows very clearly
that countries with higher income levels
spent a larger percent of Gross Domestic
Product on Health and, further, these
countries also have a significantly higher
percentage of these costs paid for by the
public sector. Thus what we have here is a
clear illustration of the fact that developed
countries have been consistent in following
the logic that development of health
infrastructure requires state funding. Yet the
Bank tells us, arguably at the behest of these
very same countries, that in order to
accelerate economic growth developing
countries must cut public spending on health
infrastructure. This is however not a novel
method of argumentation any more - we

have heard similar logic being put forward
in the pressure being put on developing
countries to change consumption patterns iin
order to reduce the threat of‘Global
Warming’ while the global North can
merrily continue its unsustainable
consumption pattern.

So the Report has a series of
recommendations designed to operationalise
the withdrawal of the state, like reduction in
support to medical education, research
activities, tertiary care etc To legitimise this
the report cleverly ‘uses’ the terms of
discourse common among public health
' professionals and social and community
health activists. Concern is expressed for

7
poor communities and women, and a case is
sought to be made for reduction in tertiary
care expenditure so that the same could be
reallocated for primary health care. The
issue which it skirts in the process is that
infrastructure development does not take
place piecemeal There are certain minimum
facilities that need to be built up,
irrespective of their level of deployment.
Thus for example, it is not feasible to have
primary health care exist in a vacuum
without tertiary facilities also being set up.
In fact the report itself contains reference of
previous infrastructure development in
developing countries having helped in
partially tiding over the disastrous
consequences of Adjustment Programmes in
many countries, when it says, “....especially
in the earliest adjustment programs,
recession and cuts in public spending slowed
improvements in health. This effect was less
than originally feared however - in part
because earlier expenditures for
improving health and education had
enduring effects.” (emphasis added)(,7) Yet
the final prescription is to cut down on
infrastructure development, if not totally
withdraw from it.
The concept of targeting is used to argue for
the narrowest possible base of beneficiaries
for the minimum package suggested by the
Bank. The principal villain, that we are told,
needs to be excluded in this exercise is the
organised working class - a section wTich
finds repeated mention as being responsible
for garnering too many benefits of
government supported programmes. One
may argue about the truth in the specific
charge made against the organised working
class, but it should be understood that the
Bank is also making a specific political
point. While a market demand does not
ordinarily exist for infrastructure
development, organised sections of the
working people can and do orchestrate such
a demand. This has been so in all developed
countries at various points in their history,
and infrastructure development in these
countries has been accelerated by such

organised demands - in addition of course to
the real needs of their ruiing classes. Thus if
the Bank today i: ceen to be harsh on these
sections, such an attitude is also designed to
stifle islands of organised demand for
infrastructure development in developing
countries.

Finally, the report also indicates how donor
agencies would and should modulate
policies of developing countries and give
them the ‘desired’ direction. A veiled threat •
is implied in the following assertion “Countries that are willing to undertake
major changes in health policy should be
strong candidates for increased aid,
including donor financing of recurrent
costs.”(18)
Future Trends in India

India’s situation in terms of spending of
Health Care is different from most
developing countries on two counts. At 6%
of GDP spent on health care, India spends
more on health care in percent terms than
most developing countries. At the same
time, at 21.7%, public spending of the total
expenditure on Health Care, India is one of
the lowest in the world, both in actual terms
as well as in percentage terms. Health
spending in India is thus already heavily
distorted in favour of the private sector.
There are signs that the distortions will
further sharpen as India embarks on a
‘corrective’ course under the tutelage of the
World Bank. On the one hand trends of
charging fees in public health facilities have
started gaining gro^r.d, and the emphasis on
‘Vertical Programmes’, i.e. programmes
designed to follow the World Bank’s
piecemeal, cost-effective return based
approach, is being strengthened. The Indian
government receives a pat on its back on
this count in the report - ‘Tn India, where
state governments account for more than
three-quarters of total public spending for
health, the central government is attempting
to act as a catalyst for more cost-effective
resource allocation by earmarking its funds

<■>

for immunization, treatment of leprosy and
tuberculosis, and AIDS control.” (,9) The
message is clear - the central government is
valiantly trying to cover up for the
‘wasteful’ state governments. In its
recruitment policies too the government is
looking for avenues to cut down on
infrastructure, a step which too the report
finds cause to comment favourably upon “In India the Ministry of Health is planning
to hire 8,000 workers for a leprosy control
project on a per diem basis rather than
engage them as civil servants with virtual
lifetime guarantees of employment.(20) (Note
: This is part of a Rs. 302 crore World Bank
project in 66 endemic districts for Leprosy
Control. It is a nice illustration of how
donor agencies, while providing only a
small part of health care costs, can
determine policy directions.)

On the other hand private medical colleges
are sprouting and there is a proliferation of
private facilities catering to the ‘high end’ of
the market, or one can argue the only actual
market that exists for health care. The
movement is towards creation of islands of
‘excellence’ in general conditions of
subsistence existence. However, how far
such islands are sustainable in the absence of
government supported infrastructure is a
moot point. It has not happened in any
country till date, to the limited exception of

the United States, though even there the
extent of public funding is as high as 44% of
total health care costs.

Conclusion

A lengthy conclusion is not being attempted
here, as the inferences are fairly simple to
draw. At the risk of repetition, it may be
mentioned that the WDR 93 is a fire
fighting measure drawn up by the World
Bank, after the feed back received about the
disastrous consequences on health care of
Adjustment Programmes in many countries.
Having set out to do so, the report appears
to have had to contend with too many
contradictory impulses. Thus, while setting
out to work out the case for a ‘safety net’
the report ends up in re-emphasising the
virtues of state sector withdrawal from
health care. In other words it only manages
to reiterate the same policies which had
compelled it to think of the necessity for a
safety net in the first place. Strangely, this is
being attempted in the background of the
fact that developed countries show little
signs of actual dismantling of health
infrastructures, which are publicly funded, in
their own countries. India, has chosen to
follow the World Bank’s logic. It is to be
seen how long such a logic, and its
attendant fallouts can be sustained.

to

•1

References :
1) State of the World's Children - 1992, p. 48, UNICEF, 1993
2) Ibid, p.51.

3) State of the World's Children - 1990, p. 1, UNICEF, 1991

4) World Development Report - 1993, Oxford University

Press, 1993, p. 45

5) Alma Ata Declaration - 1978, International Conference on Primary Health Care

6) World Development Report - 1993, Oxford University

Press, 1993, p. 45

7) Ibid, p. 13
8) Ibid, p. 5

9) Ibid. p. 65
10) Ibid, p.81

11) Ibid, p. 11

12) Ibid. p. 118
13) Ibid, p.131
14) Bhatt. Ramesh, 'The Private Health Care Sector m India ’. Health for the .Millions, p. 3-4, Feb. 1994, IHIAJ.

15) State of the World's Children - 1992. p. 34. UNICEF. 1993

16) Ghosh Arun, Infrastructure Development: The Economic Issues, paper presented at seminar on
Infrastructural Issues in the Current Context. 7th Oct. 1994, Teen Murti, New Delhi, organised by Delhi
Science Forum.
17) World Development Report - 1993, p. 165, Oxford University

Press, 1993.

18)Ibid, p. 16
19) Ibid. p. 158
20) Ibid. p. 127

21) Ibid. p. 147
22) Ibid. p. 155

(Note : This is a slightly modified version of a paper presented at a Seminar on World Development
Report 93 : Investing in Health, held at JNU on Dec.8-9 1994 and organised by the Centre for
Community Health & Social Medicine.)

<0

Towards Alternatives of Health Case

Every man aspires to be healthy. Brom time immemorial
man has been interested in trying to control diseases.

medical men,

The

priests, traditional practitioners.herbalists,

undertook in various ways

magicians and others, all

to cure man's disease and or to bring relief to the sick.

In India all the systems^from ancient era to modern time, all
are in practice in the society, simultaneously.Health care
systems of various forms starting from Governmental system,
private sector, non-Governmental Voluntary organisations,even

individual endavours are in vogue.
The practice ofAilinical medicine ^worldwide)is based on
diagnosing and treating illness as they affect individual
patient^. In India, as in other developing countries,the

majority of diseqses and major diseases are from variety of
infections or communicable diseases.This means that the
diagnosis and treatment process

fir individual patient^

is being applied to a wide range of diseases caused by micro-

organisms; which are always present in the community. In other
words they are continually,

circulating within a community.

A particular patient who suffers from a disease at one parti

cular

point of time is cured by using suitable medicines.

This implies that the process is quite effective for that

in the
particular patient. However the disease^remains
A
community level - it is not prevented or eliminated. The
community itself remains infected though the one individual

has been temporarily improved or cured. However, the envir

onment has not changed and neither have the conditions under
which the community lives. So the disease occurs against

often in the same individual who was treated and cured
earlier.
It is not difficult, therefore to understand why the

clinical medicine approach by itself has not been shown to
have had a

significant impact upon the health status

indices of populations suffering

prinicirixy ±rom communicable

diseases*

In contrast, ’’Primary health car^J’ an approach evolved
over the l$£t two ddoades, has proved somewhat effective within

these same population*
medicine

Primary health or re differs from clinical

in two fundamental ways*a^ its scope is much broader,

b) it is based on promoting a

co-operative relationship with

the community, where it is attempted for implementation* Clini

cal medicine

focuses on pathological conditions afflicting

individuals,^ primary health care broadens that focus to include
pathological conditions that persists in the communities as a

whole. Where clinical medicine actively diagnoses and treat
patients who are ’Passive

recipients”, Primary health care

involves and

collaborates with individuals and communities

as a whole in

learning to actively diagnose and treat them-

selves.
Irony is that though philosophically Primary Health care

system is accepted by the Government, little is done on this
aspect,. I^onetary allocation for health is being curtailed in

successive five year plans. Jh Planned budget is always meger
in respect of demand of the population. It’is interesting to

note that the bulk of the planned budget of health of both the
* .

union and the State Governments

is

-

expensed on constructions

and maintenance of buildings^ and-wages of employees and on curative aspects. Very little ^ua^is aciualjy utilised for preventive

and promotive healthy Institutionalised approach for advancement
of medical science and technologv is beyond the

reach of vast

majority of the population of the c mntry. As a resuit till
today only 20% of our people have access to modern mddicine and
84% of health care cost is borne privately.

The slogan ’’People’s Health ii people’s hands” has today
received universal support. The Government’s statement of Health
policy recognises this position ’vhile

years, the planning

stating ’’Also over the

precess has become largely

oblivious of

■

-3”

the Jact that the ultimate goal of

achieving1a satisfactory

health status for all our people x cannot be secured without

involving the community in the identification of their health
needs and priorities as well as in the implementation and manage-.
ment of the various health

and related programmes", unfortunately

there is a basic kx lack of clarity of the concept of community
participation. Another

misconception is to view the

rural communi

ties as homogeneous units. As a result there is no clear vision

regarding how community participation can be ensured in vast tracts
of rural India which is divided on the lines of class, caste and .
religion. The tendency is to solicit support from the village

"sarpanch" or other influencial members of the village which
is most areas means landed sections and often high caster
If the planning is done in proper way, the result is

encoura

ging. The example of Comprehensive Rural Health Project* started

in 1971 can be sited for review. Dr. Rajnikant Arole and
Dr. Mebella Arole started it in a small town

The husband and wife team initially

villagers and

found that’health

Jamkhed in Maharastra*

conducted discussion with

especially preventive health was

a relatively low priority for these marginal, subsistence farmers.
They were more interested in getting enough food, safe drinking

water, stable housing and clothing, .’roles decided to

focus first

on these "felt needs of the community". Young farmer’s groups and

Mahila Mondals (Women’s groups) were organised. These groups were
taught by Project staff. They began to spread information

and

impart training in a wide range of community development programmes*
-

These programmes included new seed

-■

■...........................................................

variety introduction, guarenteed

bank loans, promotion of cottage industry skills and sinking
tubewells.

At the same time, the project qlso started a medical cl inlr.
and later a 30 beded hospital. These facilities effered treatment

on a sliding scale fee-for service basis . They quickly became
heavily utilised by all strata from villages surrounding Jamkhed.

The experience of Sahid- Sib Sankar Seva Sanity, a Voluntary^^^l
organisation of District town Burdwan in West Bengal,is also very
glittering,

f-teaith also the Voluntary Health Workers including women

from the whole district come for training of the basic health needs
of the people. As these volunteers work in their community in the

arena of simple curative care, services for mother and child health

and family welfare^ antenatal and perinatal care, safe delivery,

immunization, nutrition by at hand available foodstuff as well as

an array of health education and community development activities

h-

are of tremendous success. It is estimated that they are able to handl
80% of the illness episodes from the villages. They also run health

clinics as a referral centre for curative aspectseThe more complica—
ted cases are referred to Burdwan Medical College»

Many similar activities are going on in different part of the
State • The experience gathered from these activities,
planning is bein^
‘ T :
'
i
made by Paschim Banga Vig^an Mancha to conduct a Planned activity in

the State. A pilot project has been conducted in Katulpur Block in
the District of Bankura. Five Blocks have been selected in Bankura Di
strict for this sort of work, Attempts are being made to conduct this
activity in atleast one block of every district, by constituting

District level and Block level co-ordinating bodyr with other organ!—
sations.
Health activist volunteers are being selected from

the

community where they reside. A sizeable section of them are women,
They ar e being trained with health and related problems under the

leadership of their team leaders, selected by them amongst themselves.
They are conducting surveys with the population. The basic objects of
survey are to identify the health and related problems of that area.
With the help of Panchayet and local youth, women, club,peasant and

other organisations and effective individuals, a local level health
action plan is formulated. Local level

interventions are yielding

prompt results. Attempts are being made to utilise the Governmental

facilities, which are ought toUavailable for these people as effect
ively as they may be. In other words demands arc being generated

and specified from the people ad pull the Governmental machinery

c

?

JI wive the prebiemfi ao far as practicable, 'we cemmunity nae t© taxe

L

I

re opens 1 bi lily in certain aspects te build up and te maintain the faci
lities required for them. People, whe are properly educated and motive^
ted t also actively participate te achieve their their health needs.

ef theta become active against addiction, superstition etc.

Seme

A large section

of people express their interest in knowing about the management of proven-

table

noncommuni cable diseases. Continuous health education progrwmne is

essential to sustain the spirit in them.

Tot si literacy,

land reforms, generation of wrk for all,

proper distribution of food and nutrition, proper housing, safe
drinking water, sanitation, maintenance of proper environment,

mental and physical recreation, fighting against superstition ,

prompt

proper and

tion etc. have a role in

ss well as the narion.

treatment of ailments, health educa

improving the situation of the community
Improvement of the conditions prevailing

now can generate self reliance* For this reason,

funding is

to be properly planned.
To. sum up, for any
cal

tangible change in the field of health, r^dj

re demarcation of priorities in the whole health care delivery

system have to be initiated . Proper scientific approach is to be

taken. Hard political decision to greatly increase spending on Pri-

mary Health care is to be taken. For the Primary Health Care system
to function adequately, it has to be made answerable to local bodies.
o

■ This

in turn

©

would require steps to democratise the functioning

pf the Panchayat system and much decentralisation of

administrative

and fiscal powers. In the absence of such measures,•Health for all
by 2000 AD1

will only be a slogan,* not a programme translated

into action

Presented by a

Dr. Kuntal Biswas,
Paschim Bangs Viggan Mancha. „
■

'^rifWnTTT 1

-UBT

Ii
Health as a Peoples Movement

Dr.Vijay Kumar & Dr M VRamanaiah AP Jan Vigyan Vedika

4

People did participate in health movements prior to the PSM or other health
activist catalysed movements. They fought with the bureaucracy and political struc
ture to provide them with a hospital and, if a hospital is already there, for more drugs
and doctors’ regular functioning. They are absolutely correct in doing so as they
believe in a concept: ‘Disease, doctor, drugs.’ This is believed in not only by the
common man but also by common doctors and other intelligentsia, the bureaucracy
and local politicians. The real concept of health which the PSM propagates is limited
to a very few.
The WHO says that health is a positive concept and depends most of the time
on issues other than drugs, doctors and diseases - such as drinking water, sanita
tion, nutrition, housing etc.--and people do demand these things as ordinary needs.
An extra flavour in understanding these needs as health related is yet to catch up to
the imagination of the masses.
90% of the people are criticizing the functioning of the existing governmental
health infrastructure and more than 90% of the people are against closing them
down and handing over to private people. 80% people are ready to pay something to
the govt, according to their income for the services which they get from the govt,
health infrastructure. The sample studies conducted by the State Institute of Health
and Family Welfare (SIHFW-AP) with the help of Jan Vigyana Vedika clearly indi
cates the above feelings of the people.
It is against this background that health is consciously included in the post
literacy activities in the name of‘Arogya Deepam' or Light of Health in Nellore Dis
trict. Nearly 21/2 lakh people are included in this in 100 villages and hamlets.
The salient features of the programme are:

1 The organization is provided by the literacy network upto grassroot level. District
level programme groups and academic groups are formed.

2. Finances are provided by the Ministry of Family Welfare, Gol through BGVS and
Dept, of Family Welfare, Govt, of AP. Equal amount is contributed by villagers as
cash apart from other help.
■3. Initial sensitization is over in all the villages in which the 110 villages covered by
IPP IV are also included and committees formed.

4. Training programme for all the organisers has taken place at various places.
5. The villagers themselves conducted the survey, consolidated it, prepared the

village health plan and conducted the health festival.

The Survey

This is one of the most important aspects of the programme.

a) the village health group (‘dalam’) takes the responsibility, divides the households
amongst itself, gets training on how to do the survey as many technical aspects are

iI
involved.

»

b) the villagers give personal information including on issues such as abortions, child
deaths etc. In one sense the entire information collected is the property of the people
and it has to be handed over to them.

c) The survey is consolidated in the presence of the dalam and also discussions are
held with village elders.

Village Health Festival
a) The plan is prepared by the dalams at the village in the presence of activists and
elders based on the survey details. The district academic group assists.
b) The plan which is unique for the particular village differs from that of other villages
in many aspects.
c) At the same time, it stimulates the plan of other villages as there are many com
mon problems.

d) the data and village health plan which belong to the villagers is put to them in a
public meeting i.e. the Village Health Festival.
e) there would be a qualitative change in the mood of the entire village when they
come to know the health scenario of their own village. They feel so much for the
infant deaths and communicable diseases. They cut a sorrowful smile when they
hear about the incidence of worm infestation. Lots of suggestions follow and the final

bTimplehe ^t'd96 'S

'S deC'ded then and there itself how the health Plan is t0

Village Health Plan
FBroadly the plan divides all the health related problems of
a particular village into three parts.
1. The issues that can be tackled by the villagers themselves without govt, help
2. the issues that require govt, help

3

3. the issues requiring long drawn out battles against the government.

The details of the plan often include:
a) immunization
b) drinking water and sanitation
c) health education
d) nutrition
e) training of village health activists
f) tackling islands of disease
Among all these issues, the last requires some explanation.
Village Health Activists

*

These are the activists, 2 per 500 population, 1 male
?

iI
and 1 female, selected by the dalams and approved by the Village Health Festival.
They are given residential training for 15 days in a hospital where obstetric work is
adequate. These two apart from giving first aid act as academic wing of Aroqya
dalam. The training costs are paid by the villagers The money is collected from each
household. This strategy is taken up consciously because at any point of time the
Govt, may withdraw its support to the programme as was done during the Anti-liquor
Struggle. There is a criticism that they may become quacks. All precautions are
taken in the training. The training material is in the process of production after ex
perimentation and field tests. This is graded material and skills required for health
activists.
Islands of disease
To our surprise, we found 100 cases of malaria in a village
of 500 people. 180 cases of leprosy in a village of 600 people....The present ap
proach of the govt, system is not noticing this problem and acting upon it. In arogya
deepam this is specifically tackled and pressure mounted on the govt, to provide
'minimum curative package'. Unless these islands are tackled the statistics remain
high or low but we speak always about the averages but not specific cases or vil
lages.

Not an alternative structure
The entire structure that is created is not an
alternative to the existing health infrastructure but an aid to that and also a pressure
group over it.
To conclude
..
It io
a, ,d bring
r. possible to create a peoples health moven
about attitudinal change where people do not think about health. It i: possible to
generate demand not only on the present health infrastructure but on various other
issues like drinking water, nutrition, land and minimurf) wages, housing etc not only
&s mere needs but as health needs also.
It is possible to generate enthusiasm amongst the village youth and involve
them in health related activities.
The only problem in this is that there is no end to the programme and the health
in scientific terms is related to various aspects of societv right from our traditions to
the present socio-economic situation. We speak about this theoretically but when it
comes to the point of 'movement' a lot of antagonism is expected from the existing
socio-political institutions.
I feel that the.peopies movement for health is going to be the alternate at tne
present tragic situation of peoples health where almost all the communicable dis
eases have started a resurgence and the others have become more virulent.
The Govt, of AR-appointed a team to stddy and evaluate the Nel lore pro
gramme so that it may be replicated in other districts of AR. But as far as Nellore is
concerned, this is only a beginning and the real task is ahead.

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I j

UNDERSI AND 1 NG IHE HEALIH Cl
WORKERS
A PUIENl1AL EUR CHANGE

I

bhe goes by many names.
In some places the ear Iiest
I test
name is sti I I in use - A.N.M. - *
y AuxiIiary nurse midwife.
And now the term r most commonly used is Multipurpose
Health Worker, f-emal
-le - . MPW(t-)
and Multipurpose
.
.
rr _ _ J Health'
Worker , Male - MPW(M).
Indeed
this
been
in use in two states Karnatakaterm and concept had
J
(Mysore)
& West .
Bengal , dll 195J but
was disbanded* as the mood in the
fifties
* sixties were all
in favour of separate
u n i p u»pose workers
tor
different
Programmes. it took
another commi t tee
(Multipurpose Workers Committee 19/j)
and a 1ui ther id years
of contusion to get back to this
name ,

I hese changes in
name and nomenclature a I so
reflect
changes in poI icy and
perceptions. One
important
— reason for
worker concept is the the reversion to multipurpose
recognition that
separate
cadre of uni purpose worUf maintaining a
for
various
vert ical heal th programmes
(ma I ar i a iworker, f 11 a r i a
worker,
!
leprosy control worker, ANMs etc.)
J was neither
11nanc i a I Iy nor functionally a sound
proposition.
However we must recognize
signi ficant Ro I icy shift
that occurred in 19//.
* b-2 village level health worker
or community health worker was introduced as
t he
centerpiece of publ ic health delivery.
(his
»
Ihis was partly
out of a realization that though the . deficit
in
trained
doctors was being overcome, the elite urban o
of the doctor would not be broken. Compulsionorientati on
i did not
help.
Doctors
resented it and both training
and
dispos 11 ion made it di ff icuit for them
to cope w i th
rural
health needs.
Mobile clinics too had
succeeded.
«lie name community health worker*
not
(CHW) was
later changed to C.H.V, ■
- community
in mi th-s was again» moditied
to heaI th volunteer, li !
> ’ the term village
health guides.
I he P"i losophy underlying the community
hea I th
idea
is
•8 uorr community, control.
iri providing worker
the
back giound of this programme when jt was
Ministry or Health and family Welfare had Iaunched ®the
stated (bovt.
erf 1 nd la 19/7a), t

and adequate efforts have
community in taking care of i tse I f
33 when such «»>»
assistancee i<£ needed
tho
to
y ,as tended • a»tol anc
become servife
provided.
|he common 11y "^outd” JecoAe
858 1 *1 anCC
Ihe
--- conscious of what
1

•y

-z/..
G

o

i

LI

it can do itself and when to call for assistance ••
that improvement cannot be brought about merely by
increasing the doctors or the output of medicine but by
making each individual realize the need tor simple steps,
in sanitation, prevention, promotion etc. • ot health
activities, some or which make remarkable changes in
morbidity and mortality pattern in our country”, t

Io achieve this goal the community health worker was to
be chosen by and from the community and provided with
the wherewithal tor handling >inor ailments,
thus
serving as a link betweeri the PHI and the community and
providing the much needed health education to the
v il I age popuI a 11 on.
lor this work the
government
committed a sum or Rs. bOO towards honorarium
and
another Rs . 600 for a medical kit.- for the whole year.
I he responsibility tor getting the best out or the CHW
• ay with the community itself - with a promise of full
support from the government. Ihis Sthem.e. never real Iy /
took o I t .
A tew states officially declined to even
attempt
it. Most or those who attempted it concluded
that it was not a workable idea. At present the schene
is all but giveo up.
It
is in the background of these discussions :'on
*on the
basic
philosophy ol
the health worker
that
the
muItipurpose health worker force began to be built up
t t om the mid eighties,
lhe multipurpose workers were to
rep I ace the multiplicity of field level unipurpose
workers or various ditterent schemes - malaria worker,
s m a I I p o x vaccinator, ANN, leprocy worker etc. I o d a y i t
i s estimated that there are about 2 lakh mu It ipurpose
workers,
Ihough this force is clearly seen as part of
t h e government staff and distinct from the community
heal th worker or village health guide scheme,
the
concept underlying the community health worker
is
relevant to the functioning of the multi-purpose- health.
■mi .
workers.

WHO ARt IHb ANNS?

AI I
ANMs are women, Multipurpose workers
(male),
are also important but tend to be .less often recruited
.and play a lesser- role as coapared to the woaen.
in
- I a m i I n a d u tor examp Ie there are 8,UUO teaale health i
workers in about 8,001)
8,000 sub-centres catering
to about
5 . UUU populationi each,
In
in contrast there ire only about
<1, UUO male health workers and they cater
1U .000
lhe administration percieves them^foday^is
population,
unionized and unwilling to work but
pursTstent in
inc tea’s i ng demands,
the thinking is td lock t3r wSH to
abandon the male worker altogether and go tor a teaaieon I y
worktorce.
lhe remale multipurpose worker1 ••.•in

fl

O' .

2

■

*

u

contrast, is widely appreciated as hard working and to quote a
senior health official the only person doing anything in public
health. (Much of what we say for ANMs in this section applies to
them also, but we have chosen to focus on the female MPW or ANM) .
Most ANMs come, attracted by the security that the job brings - a
regular salary and other employment benefits. In rural areas,
this is one of the few well paid jobs open to women-comparable to
that of a school teacher. ANMS in most parts of the country draw
basic salary ranging from Rs.700 p.m.to Rs.1200 p.m. with a net
take home pay of between Rs. 2 000 to Rs. 3 000 p.m..

The average age of starting work for most ANMS was 22.7 according
one study done in Maharashtra.
Even though the qualification needed was a 10th standard degree
it was found that in the last decade more and more women with
college education were looking at this occupation seriously. In
the absence or other job opportunities the demand for this job
grows. The Maharashtra study showed that a smaller population of
higher caste women opt to be ANMS, whereas there is a larger
proportion of SC, STs, Christians and Muslims. Often women who
are single, widowed or separated also opt for this vocation.

This composition of the ANM workforce has its advantages for
they would be more willing to reach out to another section.
However it also does imply that a better quality of support is
needed to enable their functioning.
The functions of the ANM:

The major function of the ANM may be listed as follows:

a) Provide motivation and education for the family planning
programme. Fulfill their quota for sterilization, as well as for
oral pills and distribution of condoms.
b) Immunize all babies

c) Maintain records of all pregnant women ' and new born babies,
Maintain the growth to health card for infants and under five
children.
d) Carry out almost all aspects
distribution of iron-folic acid.

3

G

o
©

of

antenatal

care

especially

IJ

tablets. Assist at delivery And render
care.
e)

programme
Carry out the entire child health
control
of
activities especially on diarrhoea,
education,
acute respiratory infection^ nutrition
vitamin A' prophylaxis etc.,’

t)

Hea I th educat ion

9)

Disease surveillance

■ IU

i)

J)

post-natal

Conduct school health prograajes
Carry out almost all the fUhtHons of the vertical
health programmes that hied .to
to be done at the
tuberculoiU and leprosy control,
village level - tuberculoJli
blindness control, malaria control, filariasis
control and so on.
Render basic curative services.

k)

Look after local sanitatioh aspects especial Iy
distribution of bleaching ponder and d islntect
wells i overhead tanks with it.

U

I*o rm ma hi la health commit taeSj village committeSi
etc. to ensure effective health education and
community participation.

4

iI

I h i s impressive list of functions is ameliorated by two
facts,
I ike
One is that in most areas Some tunct ions
application
of bleaching powder
(often
pompously
referred to as control
of epidemics) and malarial
control
operations are seen as the male MPWs function
and the ANN is relieved of this. 1 he second important
aspect is that an ANN has only about 5UU to 1U0U
households to look after. If it Is located without too
much spreadf this is not an unmAnigeable
unmAndgeable proposition,
It would tn identifying and Attending on about 15U
pregnant WG:,::n and infants in a Hir
y<Mr and this wou I d
involve visaing 4 to 5 villages regularly In an area 0 t
about 3 Sq.
. i ume tre s .
In practice lowever most of these functions remain
paper.
in
well administered programme the first
♦unctions
fP, immunization, maintaining records
pregnant women and new born children * and provision
antenatal care may get realized, In many cases only
or not even that, gets realized.

on
4
of
of
fP

D1K1CUL IltS & BUI ILtNtCKS

‘1- ■

i /■

Why is this so?
i

I he pfiswers lie in four main areas, One reason
status within the health services.

is

■-’'■■’Wfc

I he second is her status as a wom^n, often doubly
disadvantaged by her caste,
caste. her
I ow income family
background
d her marital status
single, widowed,
divorced etc.

I he third is orublems of

I

I ogistics«

And the fourth is the structure of the health
itself .

services

S I A I US IN HtALIH SLRVICtS

Within the health services, the tau111pu rpose health
worker,
far from being the community’s organise r and
.7
voice, becomes the last rung in a hierarchy.
I he buck
stops with her. She is posted to A sub-centre
w i th
/
usua I I y no support
and no syittfri of rewards
or
recognition for services rendered and it is upto her to .J
achieve all the targets. No one fclse is accountable.
Also, often there are large vacancies and ANHs are
r-“ / /
required to hold addl charge of vacant posts, making the
task and the jurisdiction unmanageable

__ She is und■' r pressure to pertorn, especially
in- higtr^'- •
priority arras. utten cases of salaries v.
or permanent
pos11 ions be i ?kg withheld tor monthi till ster i I izatldri
o

5

IJ

targets
are met are heard.
As a result ?.NMs often pay
pay
extra out of their own salaries to motivate or transport
patients
at their own cost (in the absence of
thfc PHC
jeep; lor sterilization operations.
Iler
c oneen t r a tion on family pl annihg work
bestows
her
with
a
low standing in the community.
Her
advice
on
curative care is seldom sougfit and due to lack of drugs,
t r a i n i ng or back-up services is iildom valued.
Indeed
in
a number of ways, doctors teiid to
run down
their
curative abilities.
IHt ANN AS A WOMAN

I he ANM is a woman, quite often
or widowed.

l Single, separated

' -Si
I h e popular connotation of A filitds
'A
stigma.
And tier having to spectfi'fSBBfrlSfcihg
------------use of condoms, fitting
c o p p d P ’’
„.
y. .
target of eve-teasing and s e U airamhjht:
liJht - troM botfi
village heads and youth.
Ihe
ANM
is dependant on the coOuhlty for
stay,
lor water etc.
I here havA been cases
sarpanch has demanded the transfer of an ANM
warded of his sexual advances or Whdre local
thrown
stones on her home at night,- t h u s
her .

homi
(6
wherfe
th£
because.sh4 .
youth have
t e r r o r i z i ng

a

Cases
oI
rape
and murder of
ANNS,
espec i a I : y
wh iIe t
walking
long distances from one Village to
another
is
known.
I he
p o p u I a r image of aNms as a Ibose women, the
stigma
o r a nurse , the problem oi a transferable
tranftfcrable job,
all make
in a r r \ age
o f f e r s more difficult.
these have
Ihese
also been
souic e s of mar i ta I discord amongst Already married ANMAt
bo o I ten, the ANM l ihds herseIf al 6h8
and
vuInerab I e .
He r
t a m i I y cannot shift when shi i S ’ transferred.
Her
job
t oo
requires her
to work
a I bni t
I he
tv i II agl
community does ho t own her and tfi8 hUlth servicesj doii
hot back her,
9

' PRUbLLMS Ob LUG 15 I ICS:

w.;

• -v’

Very often the ANM finds that sh8 Slone ’‘mans' the
sub
centre.
Ihe MPW male is missiH§’ (as thi male MPW
are,
paid out ol state funds their vStincy position tends
to
higher)•
be higher).
Ihe ANMs 5UU to 1UU0 hou.i.ehQ.lds may be
-one village or even jJ or
~ .44 nearby
4 ' v •i *I •I *agfcs
*
k
• *
Vbut
t
____
often
especially in tribal areas can bA~ipfAAd out in 10 tb~lb
hamlets over
a wide area.
Ihfcn Mobility
becomes
a

6

I i

problem.
tven a monthly visit to each hamlet becomes
difficult^nd quite often she stayfe in A nearby town
and even visiting her field area takes timet
i n a population o f
low literacy, backward area, in
1n a
2UU
pregnant
women and over a
there .pay be over ZOO
5UUU ,
under
5
children.
Without
any
organized suppor t
1UUU
the
com
.1
unity
this
can
become
an
impossible task.
t rom
i mmun i za t i on
children
a<e
mobilized
to
one
place
tor
1r
by community members, or pregnant women come to meet her
during her visit to the hamlet (as is possible in an
but i r
anganwadi centre) , her task is quite feasible.
she has to persuade every case, meeting them al I
the
individual I y at their homes with no local support,
task in impossible.

One must also remember that lor a number of reasons
vacanc i es ,
improper sub centres or Plit. distribution,
isolated hamlets or lai lute to create new sub centres or
the
a considerable part of
Plies
where needed
pIanned
programme
ay be outs ide any
p o p uI a tion
Ihough this problem must be viewed in the
intet vent ioi even where there are staff they do not
context
the..
1unc11on as xpected, nevertheless uncovered hamlets are
a pro bIe m thrt heed to be attended to. Quite often these
areas are jurt assigned on paper to an MPW !

- ihl sikuciuk< or

IHt HLALIH SLRVICtS

Eliciting community support, making the heal th worker
said, but
the community’s representative, is alt well
has proven an elusive goal.
It
for one the village is not a homogenous entity*
the
health
worker
wi thout
without
community
appointing
involvement and from outside it creates problems, giving
the community a role often Means
aeans that only influential
vocal
sections make the choice based on sectional
considerations.
illthe training is provided often by
Moreover
bureaucratic •
minor
ill-’
prepared
motivated,
f unc t i onar i es of the medical fest abIi shment who are
supposed to teach the health workers how they shouId
teach the conlmunj ty .

•| h e leadership that Jthis cadre needs can seldom be
I i* 111 e
provided by a medical doctor, himself hav ing
orientation to community mobilisation, or even sympathy
tor the MPW's problems.

Goals like
I ike integration of indigenous system are stated
but neither their training nor their daily I eade rsh i p i
1 n any position to provide inputs in such areas.

7
a

o

I

LJ

A concept like decentralisation ot the health
services
so
important
to this programme have never
even been
understood by an overwhelmingly hierarchical
top-down
approach
to health care, tvery programme
envisages a
completely
mechanical
implementation
of
packages
prepared centrally - providing little room a t
al I
for
any creative contribution ot either the coMmun11 y or the
health worker.

I oday when there are an estimated two lakh
women
in
this cadre spread across the country there is an urgent
nee d
t or a fresh look at the whole problem.
I he r e
i s a case for
lor hope.
ho p e.
Ihere are instances ot
many
ANMs who have proven
themselves as primary heaI th
workers and village communities which have
rec 1 procated
by
taking her as their own, providing her
support and
protection and honoring her.
Examples from all over the
world and from NGU groups have also reiterated
that
a
potential exists.

bI kA I tbits tuk INILkVtN I 1UN

I he
4 cornerstones on which a strategy ot
must be cons true ted . are .

intervent ion

a)

bu i Id i ng
force.

b)

u p a me ch an ism of providing
Building up
the multipurpose heaI th worker.

c )

Bui Idin g up the links of the health worker
force
with
the
community.
Ihis
implies
a
changed
understanding of the role ot the community and its
organized forms vis-a-vis the health worker's role
and
the role of the health establishment
in
the
delivery ot health care.
.. ‘ •1.

d)

Building up the capabilities ot the health
worker
force - with specific reference to the ability
to
identify local community's needs and to respond to
them .

U |)

the

morale

ot

t he

heal th

worker

support

to

H01NIb I UK AC I 1UN

Io
real iz e the above policy cornerstones we
suggest
number
o r actions from which the district officers
nay
draw
depending on
their
own preferences
and
the
si tuat ion ot his or her district. Ihere are
only
sone
possibiI 111e s based on experience from here and
there.
I he list could be much l onge r .
a)

I raining

I he r e

9

i s a major scope tor

intervention

ii

here.
Is training today didactic? Does
it talk down
to
the health worker-' Ur is it participatoryr
Does
it
build up her self confidence and seIf-esteem<
Are
the
trainers motivated' bo the trainers share
a commitment,
even a passion
tor
health care?
Do
the
trainers
understand the concept ot health worker
as empower i ng a
communi ty?
I o many NbUs who are working in the
area of
health,
these are not new concepts,
concepts.
In tact,
this
Is
t he central
axis of their work.
As NGUs
they
have
Iimitations
i n expanding their work,
but a persuasive
district
o tl i c e r ccan
‘ get their help for conducting
the
t r a i n i n g programme .
I heir helpJ is needed not only
tor
Iresh tra inees, bu I even more
important for
in-service
t r aining .
io I isten to the health worker’s
problems,
sympathise
with them and help them and
officials
evoIve concrete action points to district
overcome
their obstacl e s , NGOs can help.

1n
t he
absence o t NGUs z<°r
even
in
thei r
presence u s i n g
t hem)
one needs
3
evolve
a
we
I Ior iented»
commitied team of trainers - a
team
made
of
persons with
-h a reel tor the problems on the ground,
Hake
this
team rresponsible not only for ’
training the heaI th
workers
i n i 11a I Iy but r
in service
support
those so trained tor atproviding
to
- least
least aa year or so.
And make
them at least partly accountabIe
tor the
re su I t s
the
that
heal th workers deliver.
I
here
are
training
institutes
coming up tor health tworkers
in
many
district,
One needs to pay attention to
.j them to ensure
that Xhey can play their role.
3ut one
still need to involve NGUs in the training will
probabIy
process..

b)

buiIdihg

up

S

morale has

been

done

by

district

I

1

H

officers spending more time .with this sec 11 on o t
personnel and participating in their Functions.

hea I th

who have
rewarding health workers
schemes ol
or
targets)
good community support (not just
achieved
initiatives
will
good innovations or taken Fresh
made
exper iences
I he positive
also change their own image.
not
on I y
should
be
highlighlvd
such hea I th workers
of
a
a
whole.
amungst them but in the community as
must
med ia ,
and
managers
p u b I i c 11 y
tven
worker
heal
th
the
create a new image tor
consc io11sly
For
doctor,
instead of merely emphasizing a mystical
village
workers'
the tact that a good health
example
deaths
level interventions saves tar more suttering and
commun
i ty .
the
than
a doctors must be widely known to
curative
level
of
health
worker
as
First
coneep t
I he
intervention is one message that Will evoke conside rabIe
areas
from doctors but in many
res i s tance especially
this message is needed.

very
c)
Measures to support the health worker are
which
special
mechanism
by
One has to have a
important,
sexual
especial I y
workers
health
ot
grlevances
community
can
be
the
from
or hos11 I i t y
harassment
discreet
yet
firm
and
sympathetically
to
list ene’d
Special etForts to ensure she lias a place
act ion taken.
are
met
in the village, that her basic needs
to stay
persona I
(e.g. there i s a toilet in the house) , and her
ot
I he success
are understood ate important.
prob Ie m s
but
many NbU led CIIW programme is largely due to this .
health
the
of
do
the presept supervising structures
worker understand the need tor such support?

Support
should also extend to the concept of
her
curative
and related lunctions.
For example
when she
refers cases of acute respiratory infection does the PHI
doctoi
run down her prescriptions or praise it?
Is a
feedback provided for her to learn?

bi nee such support may not be possible 1 n
today's
prevailing work atmosphere, some reaching
out from
the
level , however symbolic will go a long way/
district level,
A
grievances day tor health worker’s perhaps f
Spec ia I
lectures
by suitable eminent persons " a
Nun doctor
activist or a bandhi an social Worker?
I he possibilities .
are many.
Once the need is recognized,
much can be
done .
-

10
...

11

Support is no t only froc the health depaitmen t
d>
How does one organise
and
the district col I ec tor.
the
support
I rom
from
the community ? How does one make
commun i ty own her?
services,
Partly
by creating a demand tor her
ot
mobilisation,
I isation, an understanding
Ihis
requites social mobi
the
and
what are the .de term inants of health and disease
Kalajathas and songs
the health worker plays.
role
But
has
a
meeting
been
organized
in
the village
yes.
medical
person
(collector?
sen
i
o
r
attended
oy
a
the
introduced
B.D.u.f) which has
officers? doctor?
to
Did
thie
village
decide
worker
and
her
role?
health
last
po l.i o
honor ,her when there were no cases of, say,
the
to
Did the collector tactfully suggest it
year i
perhaps he
(Ur
gram panchayat chairpersons to do so?
do panchayat
the idea down).
Indeed
thrust
to
had
and
the
I e a d e r s known about the health worker's role
as
oolI
_rq I e
panchayat members in supporting as well
to
taken
What are the measures
mon i to < mg her
work,
build a rapport
lapport a t least between the elected women
relationship
of
Io build a
and
the ANm f
membeis
passes
on
family
that
the
ANM
Not
partneiship!
horrors
many
them (as horror of
to
planning quotas
nature
of
to
the
- states have started doing thanks
the
that
(Avoid)) .
Nor
innovat ion
bureaucratic
and
panchaya t
members or (Iner starts making demands
of
sense
1 uiediately.
But a
complaints
1iIing
day
one
One
car;
start
with
pa
r
t
i
c
i
pa
t
o
r
y
partnership!
workshops U the snb-biock (I HL?) level (or a cluster of
of
gram panchaya ts, to be attended by the women members
these panenayats, the ANrt and the medical officer.

e)

is
a
But beyond such administrative measures’
the health worker as a community’s
conceptual one .
Not the person
a change agent!
spokesperson
who kicks tlie cat (sic - Bureaucracy is a series
cat!
last person kicks ' the
k i cks ,
the
oI
But a • a person who initiates actions
(Avo i d!).
Hie health
and plans on behalf of the community.

11

Q

o

IJ

I he community tells
pyramid is to stand inverted^
the health structure what it needs,
I he health
structure dues not deliver health in packages on
Delia I f o r t he peop I e .
In p r a c 11 c a I terms this translates t o a single
point
ot
ac t i on. building
action,
bu i I ding
the
health
worker1 $
capabilities to understanding the felt needs of peopIe > ,
going beyond it to understanding the real needs and its
relationship to needs as people pertelv'e them.
It aeah
a health worker being able to forMUlate the MOSt
appropriate strategy or local action plan including the
ability to choose trom different available technological
options,
1 s this too much ot a de■and at the present
stage? As an immediately achievable target - yes.
But
as a direction - not so. tven being able to maintain a
simple but comprehensive register of her bUU househoI ds
and their health status can be transformed from a boring
chore, that it is now,
into a tool ot planning which it
was meant to be
it this concept is understood,
Gathering
health
information exists today
as
a
delinea ted task but it never happens for there is never
any use tor such information gathered. Indeed a health
worker has in some states to till over 18 reg i stars.
but what use are these registers and torms put to?
Delhi is too distant lor any feedback. Only it it is a
part ot local planning can it make sense to col Iect so
much information.

I oday
the panchayat
panchaya t
laws after
the
/drd
const itutional amendment requires an annual village plan
t0
be submitted, May De no one is serious about it. •
Bu t can such an register lead to a village health plan?
Why not take the amended laws seriously? At least in a
few panehayats?
t

Admittedly this is a challenge ot the future,
but lor a young, commi tted district officer the building
up o I
sue fr local capabilities constitutes the
worthwhile challenge, Not the achieving of targets set
up in some back room in Delhi or worse at the World bank
HU at New York!

.. a’proposal Tur Change - REDOING THE CHW PROGRAMME
I od a y a situation exists,
Multipurpose health workers
exist as the lowest order in a hierarchy,
I hey exist
isolated from communities.
Ihey exist as obedient
servants not as creative individuals,
How does one ■
begin the changer

A concept tried out earlier was that of commurii.ty health
workers or village health guides and link volunteers or

u.

lhe
health
I he concept was of one
health volunteers.
link
volunteer
for
20
to
30
houses
and
one
volunteer or
Health
Worker)
or
VHt»
(Village
Health
CHW (Community
lhe
Guide) as she is termed tor each hamlet or village.
community
health
workers,
and
health
role ot these
volunteers was to use the catchy phrase of the 19//
document, o place People’s Health in People’s Hands’. j
tas a non-starter in many ways. tor one they
lhe scheme
soc i a I
were unpaid workers, doing this work part-time as
ot Rs. 50
service. At best they were paid a paltry sumi of
per month and provided with a very minimal medical kit
More cruc iaI , the
which hardly served the purpose,
recruitment, training and deployment and support to
these volunteers were left to the health department and
government
neither
the PHI doctor nor the other
to 90
personnel at that level had any conception of how heal
th ]
mpI
ementing
this.
Indeed
to
expect
the
about i
trackbureaucracy by itself to deliver, given its own wiihful
record and motivation at the village level was
an
thinking, binally the whole programme took place in not
where
the
local
community
were
env i roninent
viich nvw
prepared to unuerca^e
undertake thfcir
new .v.v
role and
sensitized or prepareo
the
community
health
worker
tor
this.
Schemes
utilise
based on volunteers cannot take place in the absence or
any socral mobilisation effort. One can learn a trp
lessons^tn- this, regard from the
total
liter -y
campaigns- ...... “ -z.
----- ----- ---

5>

Before the
t h e total
t o t a I Iiteracy caipaigns were launched, me
RHP pidgramme ot the adult education departments based
month
its literacy delivery on a cadre of Rs. 1UU per
paid volunteers, with careful arrangements to provide
But this
supervision and adequate logistic management*
animator' was never able to arouse much enthusiasm or
cooperation from the community. In contrast the LLCs
threw up tens ot thousands of volunteers who without any
lite to
honorarium whatsoever were able to give new
adu I t literacy work.
lhe d v1 Ie ren c e in lhe approach lay in the tact that the
recruitment and deployment or volunteers in the total
I i teracy campaign was done pot as part ot a government
Io be effective
people’s movement.
type scheme but _
asj a people*s
the volunteers had to see themselves not as part of the
government mechanism but distinct from it. they were to
not
mere I y '
be
articulating
community
concerns,
implementing a government scheme^
lhe I eadersh ip torthis force was provided by a district level organisation
created for this purpose - where both NGUs and the

o

o
a

«• .

i1

Unly in those
government part i c i p a t e d as partners.
effect i v e d i d
leadership
was
districts where the Nb u s
the programme succeed.

Similarly it
11 the health
hea I th volunteers are to be recruited,
trained and deployed by the health department there; is
little chance of
o t success. but it this could be done by
an NbU or at least a specially created leadership which
likely.
understands voluntarism, success is much more
w r - . ,.. it
..
recruitment,
Again like the total literacy7 campaigns
training and deployment ol the heafth volunteers is done
as part ot a major“ social mobilisation campaign built
around a theme ot people's empowerment, there is a much
greater chance ot success .

but
committed
U n e also needs to create a small
mon
1 t 0 r the
can
persons
who
s t r u c t u r e ot I u l I -1 1 in e
programme provide support to these cadre 0. , J he Ip them
ttiese
these J essential
enhance the community's role. All
’ a major
soc 1 a I ■
ingredients of
a ILL campaign
a
full-time
comm
11
ted
support
mobilisation campaign, and
in the
and monitoring provision need to be tried out
health context too.

I he relationship o t the MPW with this community heal th
worker in this new approach must be clearly understood.
I hey are
Heal th volunteers are not under the MPW .
channeIs through which MPW's can reach out to the
in
in tar flung areas and
community,
t spec i p I I y
high morbidity 4 mortali t y rates
backward areas with
i
such an assistance is essential for a MPW to perform
even her most basic functions ol maternal and child care
hand, one is
and family planning.
If on the other hand,
their tunc 11 ons as
serious about MPWs realising all
a
force
then without such
understood,
currently
anywhere she
assisting her ,
it is inconceivable that
her
tasks.
will
be ab I e to do justice to all
U 11 I i sa t ion of existing PNC resources requires such
channels ot interact ion with the community.
I h1s fresh approach to the community health workers “is
there are however a few pildt
necessar i ly tentative.
i

If

<"

’

,

*

which not only build

around

on in this area
programmes
concept
but also hope to use this health volunteers
this (------panchayats, especially the
to sensitise and involve the
t
gains
ot the campaign can be
—women members, so that the

sustained.
note that in a sense this i s
before we conclude we must Ihe book People's Health in
not a new concept at all.
b. Antia (published by
people’s Hands‘ edited by Ur .
io examples ’ of major heaI th
bRlK, Pune) lists over J precisely this approach with
programmes which have used,
a question ot studying these
it 1 s only
<
iesuIts.
good
how to handlte the problems
e x a m p I e s and thinking into
ot
these efforts on a wider
posed by replication
level
scalfci Besides in most ot
district level or block
quoted
in Itill book the NGUI has
the N b U s u c c e s s stores
hdiith care functions
t-"?
basical Iy taken over all primary
_____
.
primary
health
structure
tor
by providing a par a I IeI
most
HUUs
nor
the
government
Neither
i
--care in that area.
to be the main tori# or public health
would want this
the country.
Ihe
, .
the alternative approach
delivery tor
creating
a
structure only tor a
parallel
recommends cred'-"iy a If_________
.....
sensitize
the
local se 11-government
temporary period to
the
usingJ the community health
bodies and I
..- community
tor
doing
this, Subsequent 1y the
wor‘<r‘ a*, the vehicle
bodies must be eqc ped with both
I oc< . seIt-government
resources to plan lor their health
the capab 1 Iities and
suPi )rted by
the community health worker must be
and
these bodies with their structure.

IS

o

Ii

Health For All - Now: Changing Global Perceptions Since the Alma
Ata Declaration of Health For All by the Year 2000

By
Dr K Balasubramaniam
Pharmaceutical Adviser
Consumers International
Regional Office for Asia and the Pacific
PO Box 1045

10830 Penang
Malaysia
Tel: (60-4) 2291396
Fax:(60-4) 2296506

Health For All - Now
A Conference for Health Professionals and Activists
Organised by All India People's Science Network

Hosted by Delhi Science Forum
November 5-7, New Delhi, India

i i

I

Contents
A.

Introduction

B.

National Response to the Alma Ata Declaration

C.

International Response to the Alma Ata Declaration

D.

Peoples’ Health after the Alma Ata Declaration
Five years later
ii.
Ten years later
iii. Fifteen years later
iv. Before and nine years after GOBI-FF

E.

Challenge to NGOs

IJ

A.

Introduction

When wailing, poverty stricken parents were burying their new Ibom infants and young
children by the millions, they were reassured that health was their fundamental birth
right; that primary health care was the key to solve all their problems; it was low cost,
participatory and empowering. In the same breath they were told to wait for 22 years
to achieve that elusive goal of health for all. What self-conceited and presumptuous
arrogance to assume that a mother, whose young child was dying in her hands
because she had no access to a few cents worth of piperazine, should care about
what would happen in 22 years!
In September 1978, the World Health Organization (WHO) in collaboration with the
United Nations Childrens Fund (UNICEF) organised an International Conference on
Primary Health Care in Alma Ata, USSR. The participants noted with great concern
the deteriorating health status of vast sections of people and expressed the need for
urgent action by all governments, all health and development workers and the world
community to protect and promote the health of all the people. The Conference
concluded with the Declaration of "Health for All by the Year 2000". This Declaration
proclaimed that primary health care (PHC) was the key to achieve Health for .411 by the
Year 2000.

The Alma Ata Declaration of 1978 was doomed to fail the moment it was born
when the words "by the year 2000" was added. The 22 year long interval took
away in totality the urgency of the problems facing over a billion people. National
governments and international agencies became complacent. Action gave way to
rhetoric - rhetoric that began during the International Conference on Primary Health
Care in Alma Ata. It is interesting to recall what Mr J.P. Yadav, the Indian
representative to the Alma Ata Conference said. Among other things he stated,

"... It is important that health care should not mean provision of all the
sophisticated health facilities to a few and denial of even the basic essentials to
many... The health scene in most of the countries of Asia and Africa suffers
from severe distortions. It is painful to say so, but this is the truth, the harsh
truth. The city gets the best, the village the least. In India over the years we
have built magnificient hospitals. All of them are in the cities... But we are
now laying greater emphasis on primary health care in rural areas - on
narrowing the gap between the village and the city, between the health
haves" and have-nots’. The new direction which we have given to our
health programmes seeks to take basic health care to the doorsteps of the
people in the viilages!(l)”
These admirable sentiments and noble ideals were the solemn promises made bv the
official Indian Government representative to the world community in 1978 - promises
that would transform the lives of the vast sections of suffering and poor Indian children,
women and men. The promise was that the Indian Government would give a new

1i

direction to its health care services, formulate and implement a national health policy
based on PHC as outlined in Alma Ata in 1978.

What has happened to the promise of greater emphasis on primary health care in rural
areas in order to narrow the gap between the village and the city, between the health
haves" and "have nots"? What has happened to the promise of a new direction which
was supposed to be given to the Indian health programmes to take basic health care to
the doorstep of the people in the villages?

The answers to the above questions are contained in a critical analysis of empirical data
on the health situation in India in 1994. This was reported in the journal. Health for the
Millions, November-December 1994, published by the Voluntary Health Association of
India, New Delhi. The report, among other things, states:
’’The health scenario of the country is in an abysmal state,
notwithstanding the islands created by the five star private hospitals and
nursing homes. In spite of the Parliament adopting the National Health
Policy in 1983, the health situation in the country today is a cause for
deep concern. There is considerable consternation in the minds of health
and development experts as well as NGOs and other organisations
involved in the promotion of health care at the grassroots level. The
present day ’’Epidemic of Epidemics” is a reflection of the extreme
deterioration of health services resulting in the failure to provide effective
preventive and curative measures. The recent episodes of plague and
malaria and the defunct health care delivery system in half of the country
causing immeasurable hardships to millions of people in the country have
ominus portents.”
Neither India nor any other country represented at Alma Ata, has fulfilled even a part of
the promises the official representatives gave to the world community.

Since 1978, enormous numbers of documents have been published on PHC But
people had different interpretations of what PHC was although the original description
of PHC as recorded in the Alma Ata documents is quite clear and transparent as the
following paragraph shows:
"Primary health care is essential care based on practical, scientifically sound
and socially acceptable methods and technology made universallv accessible to
individuals and families in the community through their full panicipation and at
a cost that the community and country can afford to maintain at every stage of
their development in the spirit ot self-reliance and self-determination. It forms
an integral part both of the country’s health system, of which it is the central
function and main focus, and ot the overall social and economic development
of the community. It is the first level of contact of individuals, the familv and

2

i i

the community with the national health system, bringing health care as close as
possible to where people live and work.(2)

Perhaps the particular section of the above statement which made PHC a non-starter
was, ”... it forms part of the overall social and economic development of the
community.” This statement was based on the enormous amount of both historical
and contemporary evidence that major long-term improvements in health and survival
are not, to any large extent, determined by medical care or specific health interventions.
To the contrary, far-reaching improvements in health result from social, economic, and
political changes. These changes lead a community or a nation to an improved standard
of living, fairer distribution of resources, more adequate returns for the work people do,
and fuller assurance that the basic needs of all people will be met. For example,
tuberculosis was controlled and almost eradicated in Western Europe long before
specific antituberculosis drugs were introduced. However, tuberculosis continues to be
a major public health problem in developing countries even though there are potent
drugs to treat tuberculosis.
It is quite clear that PHC as it was defined in Alma Ata implied a very fundamental
social revolution. Unfortunately for some people there is only one meaning for social
revolution and that is communist take over! Therefore, there have been efforts to
undermine the implementation of PHC as agreed upon by all member states of WHO at
Alma Ata.

The Alma Ata Declaration was based on the fact that ill health and malnutrition
among the poor are biological manifestations of a socio-economic disease.
Factors such as:
foreign debt;
international and national income maldistribution;
exploitation of the primary (agricultural) sector;
the commoditization of agriculture;
oven or hidden under-employment or unemployment;
illiteracy particularly female illiteracy;
and an array of other factors are some of the macrocauses of this socio-economic
disease.

Poverty rather than any microbe or parasite is the key vector of ill health and
malnutrition.
The above list of macro-elements does not mean that there are no micro-components in
the causal chain which need correction; and they are more intimately and easily seen to
be directly related to ill health and malnutrition.

3

1i

B.

National Response to the Alma Ata Declaration

PHC as defined in the Alma Ata Declaration was never implemented in any of the
WHO Member States since the task of implementing was entrusted with the medical
establishment. The reason for non-implementation was given in an article in an issue of
the WHO journal World Health in the early eighties. The writer compared the
implementation of PHC services by the medical establishment to landlords given
the responsibility to implement land reforms.
At Alma Ata it was unanimously agreed that one of the first initiatives towards
introducing PHC would be to shift resources from the urban, hospital-based high
technology curative services to PHC services in the rural areas where majority of the
people lived - people who were in urgent need of PHC because they were the ones who
were poor and fall ill more often than the minority of affluent people in urban areas.
The concept of PHC, with people having a major role in health promotion and
taking an active role in decision making was seen as a challenge to the medical
profession who feared that PHC would demystify medicine, jeorpardize its
authority and threaten its absolute monopoly over health care.

The fact that developing countries were not implementing PHC prompted Dr Hafden
Mahler, former Director-General of WHO to issue a challenge to these countries in
1983, five years after Alma-Ata (3). "If you take a group of doctors from medical
schools throughout the developing countries and put them through an
examination on PHC, then the overwhelming majority would fail." This was
Mahler's challenge. Medical schools in developing countries took the easy way out and
ignored the challenge. He added a postcript to this challenge - "In theory you can
have PHC inspite of doctors. But in reality we, the doctors will always win if we
decide to fight PHC. Because we have developed this conviction that we are
God’s chosen representatives on earth." No one seemed to have read the
postcript.
In implementing PHC, the medical establishment gave its own definition:
Health for All became health care services for all
Health care services were then equated with primary medical care and
Primary medical care was defined as the first contact medical care

This simplistic definition and implementation has resulted in a situation where
paramedicals provide "PHC” services to the poor in the rural areas and highly
specialised consultant clinicians provide the same "PHC" services in the teaching and
tertiary hosptials to the affluent sections of the population in the cities.
Dr Mahler gave additional reasons why PHC was not introduced in any country.
”PHC as conceived in Alma Ata failed because of doctors - too many doctors and because doctors practice inappropriate medicine. Health of millions may be

4

•

ii

at risk because of doctors. Doctors may be one of the main factors holding back
progress in the health of poor countries.”

These were the startling facts presented in the World Health Organization’s "Progress
in Primary Health Care: A Situation Report", published in 1983 on the fifth
anniversary of the Alma Ata Declaration. This report brought together information
from 70 countries containing 64 percent of the world population.

The report had this to say about doctors in India, ”... In India, doctors’ inability to
understand the importance of prevention and hence their lack of interest in the
various health programmes, is to a large extent responsible for the inadequacy of
rural services.”
WHO believes that what is needed is inexpensive preventive methods rather than the
kind of drug-centred technology practised by some members of the medical profession.

c.

International Response to the Alma Ata Declaration

In retrospect it would seem that the major focus of the international response to the
Alma-Ata Declaration was the successful attempt to. completely separate the macro
causes of a social disease of which ill health and malnutrition are the biological
manifestations, from the micro-elements in the causal chain which needed
correction. It was into the micro-elements that international agencies and donors put
all their expertise and resources - vertically implementing selected components of PHC
such as growth monitoring, oral rehydration; breastfeeding and immunization, provision
of food and family planning. There v/ere referred to by the acronym GOBI-FF and
UNICEF began implementing them globally in developing countries.

Unfortunately all the interventions under GOBI-FF do not seem to have made any dent
in the global problems of ill health and malnutrition.

Therefore, again in retrospect, it is also clear that attempts to solve problems which are
caused by socio-economic factors, through purely technological interventions are
doomed to failure. And this failure will be even more certain when these technological
interventions afe top-down and people have no participation in the decision making. A
classical example is oral rehydration therapy (ORT) which has been described as
potentially the most important advance this century.(4)

Numerous studies have shown that home made cereal-based gruel is in many
circumstances the most effective therapy for children with diarrhoea. This was the
management of diarrhoea routinely used by all the cultures in the South for centuries.
Cereal water was also used as weaning food in the homes of millions of poor families
around the world. It is cheaper, more acceptable, more consistently available and more
effective in reducing dehydration, stool volume, vomiting and weight loss from diar
rhoea than is the standard WHO sugar-based formula - oral rehydration therapy (ORT).

5

Ii

Unfortunately with the introduction of modern medicine into these cultures, the
management of diarrhoea was medicalised, mystified, institutionalised and
commercialised. The production of aluminium-foil packets of the WHO formula has
grown into a multi-million dollar industry.

Initially, ORT packets were distributed by UNICEF and governments to mothers free
of charge. But as the demand grew, so did the expense, to the point where ORT
consumed too much of the countries' national health budgets. With the IMF demanding
cuts in public spending in order to maintain the servicing of foreign debt, most poor
countries could not sustain the increasing costs of ORT packets. They yielded, under
pressure from advocates of privatization, to go commercial.
As a result in many developing countries several brands of ORT packets and drinks in a
variety of flavours are being marketed. But all these are beyond the reach of the poor.
And yet the experts are asking themselves why the worldwide ORT campaign has fallen
so far short of its goals. These experts have still to learn how a potentially
empowering health technology, when introduced top-down, without adequately
considering all the socio-economic constraints can- fail and worst still, be
transformed into yet another means of exploiting the poor.

How did the separarion of the macro and micro determinants of ill- health and
malnutrition come about? It could probably be traced to a 1979 article in the New
England Journal ofMedicine by Drs. Julia Walsh and Kenneth Warren which proposed
a programme of “selective” PHC which would focus on a smaller more attainable set of
objectives.(5 ) From this was bom, much later, the concept of the UNICEF sponsored
Child Survival Revolution which focussed on four basic health interventions designed
to save the lives of millions of children each year.(6) Food and family planning FF were
added .ater to the original four-growth monitoring, oral rehydration therapy,
breastfeeding and immunisation - GOBI.

With all due respect to UNICEF, there is great concern whether GOBI-FF and the
Child Survival Revolution really address the root causes of child misery in the world.
There is also great doubt whether the goal of health for all by the year 2000 can ever be
achieved through GOBI-FF and Child Survival Revolution, which completely ignore
the operative parts of the Alma Ata Declaration - ”... PHC is essential care based on
socially acceptable methods and technology made universally accessible to
individuals and families in the community through their full participation and at
a cost that the community and country can afford to maintain at every stage of
development in the spirit of self-reliance and self-determination.”

ORT is a good example which demonstrates that GOBI-FF violates the PHC concept
Home made cereal gruel was a socially acceptable technology, easily accessible
and always available in the community’. The wheel was in place. The only thing
necessary was to help roll the wheel. Instead, enormous resources were put into
re-inventing the wheel. In the process the new wheel designed first became oval

6

11

ana men assumed a square shape ana is now stuck and refuses to move, The
experts are wondering why the ORT campaign has fallen short of its goals.
How can people living in absolute poverty take the prime responsibility for the
health of the individual and family just through GOBI-FF?
How can people in absolute poverty make choices such as:
lighter workload and more food during pregnancy;
long term commitment to breastfeeding;
adequately feeding a child during illness;
using packetted ORT;
.child spacing;
overall food availability for the family.

.All of the above are linked to a state of poverty. Decisions on lifestyles are severely
limited for the poor who lack access to minimum income. They live unhealthy lifestyles
because they are poor.

Poverty has increased in spite of 4he • decades of UN sponsored development
programmes. Table 1 shows the percentage share of the poorest 20 percent of the
world population in global opportunities expressed in terms of trade and economic
activity in 1960-70 and 1990. This group has become poorer in the intervening period.

Almost all the poor people live in the South (Table 2). Poverty in the South is due to
the fact that, among other things, the advanced industrialised countries control world
output and trade (Table 3). This table shows that about a fifth of the world's
population consumes over 75 percent of the world's resources.
Table 1: Percentage share of the poorest 20 percent of the world population in
global opportunities expressed in terms of economic activity

Global GNP
Global Trade
Domestic Savings

Percentage share of the poorest 20 percent
__________ in economic activity
1960-70
1990
2.3
1.3
1.3
0.9
3.5
0.9

Source: Human Development Report 1993. UNDP

7

Ii

Number of poor
(millions)

Region

All developing countries
South Asia
East Asia
Sub-Saharan Africa
Middle East & North Africa
Eastern Europe
Latin America & the Caribbean

1985

1990

1.051
532
182
184
60

1.133

87

108

Percentage of
population below
poverty line
1985
" 1990

562
169
216
73

30.5
51.8
13.2
47.6
30.6
7.1
22.4

29.7
49.0
11.3
47.8
33.1
7.1
24.9

Source: World Development Report 1992. World Bank.

Table 3: World output and trade

Countries

Population
(million)

G7
G23
Developing countries 138

650
1200
4100

Percentage
share
of total GDP
65.9
76.2
23.8

Percentage
share
of total exports
54.8
73.9
26.1

Source: World Bank 1990 estimates. World Bank

G7 countries: Canada, France, Germany, Italy, Japan, UK and US.
G23 countries: Advanced industrialised countries (includes G7).

GOBI-FF is a watered down version of the original .Alma Ata Declaration and depends
on effectively applying technical solutions, top-down, to outstanding health problems
but completely fails to address the social, economic and political causes of the ven'
same health problems.
UNICEF has de-politicized the Alma Ata Declaration to make it more acceptable to
iunders from the North. In doing so it has limited, from the outset, the potential to
bring about real and lasting changes to the health of poor children.
At best-GOBI-FF is an international effort to drastically reduce the number of children
under five years who die or are disabled each year from common preventable diseases.
It has ignored the tact that low cost strategies, which are culturally acceptable and

8

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affordable are already available. If these are "socially" marketed, they can be expected
to reduce morbidity and mortality

But the question which has not been raised or answered is:
saving the lives of children for how long9
and for what future?

If we fail to raise and answer these questions we will end up like the person who sees a
baby drowning in a river, jumps in and saves it, then sees another baby in the river and
then jumps in and saves it and then sees a third... That person is so busy saving babies
that he does not see or look upstream to realise that there is a man throwing babies into
the river!
As mentioned earlier, attempts to solve problems that are fundamentally
fundamentally social,
social,
economic and political in nature exclusively through technological interventions are
doomed to failure.

How does growth monitoring help a malnourished child whose parents are too poor to
buy food for the child? Causes of malnutrition are poverty and repeated episodes of
diarrhoea and infectious diseases. Do we focus on the social causes or the biological
causes or both? The former involves working towards empowerment, equity and social
change. The latter involves technical interventions such as immunization and ORT.
o Clearly both should be integrated within a comprehensive approach - the PHC concept.
But unfortunately UNICEF has opted for the purely technological top-down approach.
UNICEF estimates that for every one hundred dollars spent, one child's life is saved.
This indicator is deceptively simplistic. It does not take into account the more
important set of quality of life indicators. We do not know how these children, who
have been saved, are living; nor do we know whether these children are dying’at an
older age. Or do we need to have yet another indicator - U10MR (under ten mortality
rates) - to find out what is happening to the children saved by GOBI-FF9

Without changing the forces that give rise to and maintain poverty and an inequitable
control over most resources, health promotion efforts will be very limited in their
effectiveness. GOBI-FF and the Child Survival Revolution cannot therefore, be 'the
engines to drive PHC to the far corners in every country" as the USAID administrator
wanted us to believe (7).

There are two other aspects of GOBI-FF which need to be examined:

It has been estimated that women provide more health care than all the world's
health care services put together. Yet this easily available and abundant resource
has no role in GOBI-FF, except of course as passive recipients of contraceptive
drugs and devices.

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The role of drug multinationals and private enterprise in GOBI-FF as producers of
ORT packets, mass marketing specialists and suppliers of drugs and vaccines.

D.

People's Health after the Alma Ata Declaration

1.

Five years later

The WHO report published on the fifth anniversary of Alma Ata refers to the extent of
the tragedy measured in human suffering and death - deaths that could have been
prevented by PHC.
Half a million mothers die during childbirth each year in South-East Asia and
Africa.
One hundred and twenty-two million infants are bom each year. Of these about 10
percent or over 12 million infants will die before their first birthday. A further four
percent or approximately five million will die before their fifth birthday.
2.

Ten years later

UNICEF's State of the World's Children, 1989 stated,

"The 1980s is 'the Decade of Despair'. Both in underdeveloped countries and
in the USA the gap between rich and poor is widening. Progress towards the
international goal of Health for AU has virtually stopped and in many countries
has been reversed. For the world's poorest people, average incomes have
dropped by 10-25 percent. More than one billion people - or one out of every
five - live in a state of absolute poverty. In the 37 poorest countries, spending
on health has been reduced by 50 percent and on education by 25 percent. In
over 50 countries primary school enrollment has been falling."
An article it) an issue of WHO's World Health Forum stated, "The prospects for
achieving HFA by the year 2000 AD have seemingly dimmed in the face of
deteriorating world economic conditions" (8). An article in a later issue of the same
journal posed the question, "What is the international climate of support for HFA?"
The answer given was, "All too often it is ice-cold."(9)
3.

Fifteen years later

The World Development Report, 1993, by the World Bank states,
The poor lack access to basic health services and receive low quality care.
Government spending for health goes disproportionately to the affluent in the form

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of free or below-cost care in sophisticated public tertiary care hospitals and
subsidies to private and public insurance.
In middle income countries, the bulk of the population, especially the poor, relies
heavily on out-of-pocket payments for health care services.

Public money is spent on health interventions of low cost effectiveness while
critical and highly cost-effective interventions remain underfunded. In some
countries a single teaching hospital can absorb 20 percent or more of the budget,
even though almost all cost-effective interventions are best delivered at lower level
facilities.
Much of the money spent on health is wasted: brand-name pharmaceuticals are
purchased instead of generic drugs, health workers are badly deployed and
supervised and hospital beds are underutilized.
4.

Before and nine years after GQBI-FF

The following two excerpts, taken from UNICEF's "The State of the World's Children"
reveal the mortality and morbidity figures for children in 1982 and 1992.
(a) Every day of this last year more than 40,000 young children have died from
malnutrition and infection. And for every one who has died, six now live on in
hunger and ill-health which will be forever etched upon their lives...

... To allow 40,000 children to die like this every day is unconscionable in a world
which has mastered the means of preventing it. (The State of the World's Children,
1982-83).
(b) A quarter of a million of the world's young children are dying every week, and
millions more are surviving in the half-life of malnutrition and almost permanent ill
health.

This is not a threatened tragedy or an impending crisis. It happened today. It will
happen again tomorrow. (The State of the World's Children, 1992)
Infants and young children continue -to die in equal numbers in 1992 nine years after
GOBI-FF, as in 1982. And several millions continue to survive in utter misery in 1992
as they did in 1982.
Can any one prevent children dying in such large numbers?

PHC as defined in Alma Ata offers the only solution,
approach.

There is no second-best

E.

Challenge to NGOs

Seventeen years after Alma Ata and after the enormous resources that have gone into
the various interventions in the name of PHC we do not see any dent made in the
incidence of global poverty, ill health and malnutrition. Over one billion people live in
absolute poverty; about 2.5 billion people live without any regular access to even a few
basic essential drugs.

The tragedy is that PHC was never implemented the way it was defined in Alma-Ata.
It can be implemented, IF:

i.

We agree that what we need for PHC is not extra resources but change in
attitudes. Whatever resources are available, if they are used in the spirit of social
equity, we move towards Health for All - Now.

ii.

We accept that micro-interventions in PHC will succeed only when the macro
policies are implemented concommitantly or in advance.
These are the
interventions that tackle the socio-economic causes of ill health and malnutrition.
They include equity oriented development policies such as:

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land reform;
small farmer credit;
price incentives for food producers;
subsidization of agricultural products;
labour intensive agriculture with high priority for food crops;
equitable food distribution schemes;
female literacy.

iii.

We revise undergraduate and postgraduate medical curricula and train doctors
with the motivation and skills to provide PHC and to accept the challenge Dr
Mahler posed to our medical schools in 1983.

iv.

We encourage our universities and research institutes to change their interests in
research. In addition to developing technological solutions to combat the recurrent
biological manifestations of the social disease, our scientists and research workers
should put more effort and resources into research that will provide lasting
solutions for the economic, social and political causes of ill health and malnutrition.

How can we make all the "IFs” come true?
At national levels, there is no concern for social equity in governments' health policies.
People have lost faith in multilateral aid through international agencies or bilateral aid
with strings attached.

IX

There is therefore, an urgent need for a new approach to mobilise the interests,
commitments and resources of a broader constituency of support for the poor. It is
quite clear that the current approaches have failed. There is a need to move with
different partners, to find different sources of support and to use different mechanisms
to bring all possible pressure to bear on the problem.
A new and interesting development is taking place all over the world. Sociallyconscious people from different walks of life, disillusioned with the apathy of their
governments in tackling urgent problems, are organising at the grassroots level to plan
and implement development strategies to improve the lot of the underprivileged.
Substantial contributions to health and well-being have already been made by this non
governmental sector. Many NGOs (non-governmental organisations) in the South have
pioneered several health related development projects which meet the needs and
enhance the participation of the communities they seek to assist and which recognise
the role and needs of women in the development process. More importantly these
programmes are all sustainable. The major thrust of these is to alleviate poverty by
empowering people to improve their own lives.

Literally thousands of socially-oriented indigenous groups exist in the South. All these
groups provide some form of PHC to vast numbers of people who have no other
sources of help. These groups are waiting for additional ways and means to apply their
energies and leadership. Social and political activism is not new, but it can be put to
new use at local, national, regional and international levels. This will enable concerned
individuals and groups to bring their views and the power of the people to bear on
ineffective, misguided and exploitative officials and agencies.
The Consumers International Regional Office for Asia and the Pacific in Penang (CI
ROAP) is planning to provide an international forum for the non-governmental sector
to meet, share experiences and plan future strategies. This international forum will take
the form of a People's World Health Assembly (PWHA) tentatively scheduled for 1997.
The need for the PWHA arose because governments and inter-governmental agencies
seem to have ignored the commitment made at Alma Ata in 1978. Since then the
member states of the World Health Organization (WHO) meet each year in Geneva to
plan strategies, draw up action programmes and revise old strategies to achieve this
goal. In spite of the enormous efforts and resources that went into these World Health
Assemblies, we seem to be nowhere nearer this elusive goal. UNICEF’s GOBI-FF
programme has not touched the root causes of poverty and ill health.

It is clear that the World Health Assemblies, as a world forum of health policy makers,
have not succeeded in changing significantly health care policies that would be directed
mainly to the poor majority.
What we need is an alternative world forum for health NGOs to discuss and promote
their views for achieving more equitable health for people and for organising concerted

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action. Hence the People's World Health Assembly which will bring together com
munity leaders from around the world who have been working with people providing
relief, direct health care, education, research and policy development.

The People's World Health Assembly will provide:
a political statement to the world, that the agenda for better health lies in the hands
of people, and people's organisations and that governments have, by and large,
failed to meet peoples' needs.

opportunities for the national, regional and global NGO health communities to
analyse and evaluate the accepted and frequently pronounced health strategies.
opportunities for the national, regional and global NGO health communities
working on various aspects of health care provision to act in cohesion.

The major objectives of the Assembly are to:
a.

look at the Alma Ata Declaration on Primary Health Care and examine why the
various components of the Declaration have not been implemented in most of the
member states of WHO.

b.

on the basis of the Alma Ata Declaration, prepare a programme of action for the
NGOs.

c. ‘prepare a strategy and activities for a campaign to urge the governments in the
South to take definitive steps to implement the Alma Ata Declaration on PHC.

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References

1.

Statements by Participants at the Plenary Sessions, International Conference on
Primary Health Care organised by World Health Organization and United Nations
Children's Fund, September 6-12. 1978, Alma Ata, USSR.

2

Report of International Conference on Primary Health Care, ibid.
WHO, Progress in Primary Health Care: A Situation Report, Geneva, 1983.

4.

Lancet, August 5, 1986.

5.

Reported in Gregory Friedman. Oral Rehydration Therapy and the Children's
Revolution, working paper on the Future of Health and Health Care Institute for
Food & Development Policy, October 24, 1984.

6.

UNICEF, "The State of the World's Children", 1985.

7.

McPherson, P„ International Health News, February, 1986.

8.

World Health Forum, Vol. 8, 1987

9.

World Health Forum, Vol. 9, 1988.

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