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£rch seminar report
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Proceedings, of the Seminar
HEALTH FOR ALL
concept and reality
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Indian Council of Social Science Research
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Community Health Cell
Library and Documentation Unit
367, “Srinivasa Nilaya"
Jakkasandra 1st Main,
1st Block, Koramangala,
BANGALORE-560 034.
Phone : 5531518
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AMIRBANU SUMNANI
SECRETARIAL ASSISTANCE:
ELEUTERIO FERNANDES
CATHERINE FERNANDES
SUNITA VICHARE
SHASHIKANT MORE
CYCLOSTYLING:
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This document has been produced by:
The Foundation For Research In Community Health
84 «
R.G. Thadani Marg,
Worli, Bombay 400 018.
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FRCH
SEMINAR
REPORT
PROCEEDINGS OF THE SEMINAR
ON
HEALTH FOR ALL?
)
CONCEPT AND REALITY
BOMBAY s NOVEMBER 15
16, 1986
(REPORTS PREPARED BY SONYA GILL)
ORGANISED BY
FOUNDATION FOR RESEARCH IN COMMUNITY HEALTH
*
CO - SPONSORED
BY
INDIAN COUNCIL OF SOCIAL SCIENCE RESEARCH
■
4
CONTENTS,
foreword
LIST OF PARTICIPANTS
SESSION Io
Critical Evaluation of the.Health for All Strategy
1.
Extracts from Alma-Ata 1978S Primary Health
- WHO/UNICEF
d J-
2.
3.
1
12‘
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Health for Alls Concept versus Reality.
n.H. Antia & Ramesh Awasthi
13 - 26
A Critique of the Ideological & Political
27
49
Positions of the Willy Brandt Report and
the WHO Alma-Ata Declaration.
— Vincente Navarro
The Politics of Primary Health Care.
- Malcolm Segall
50
77
4.
Women: Blind Spot in Health Policy?
- Padma Prakash
78
88
5.
Discussion
89
99
6.
SESSION He
Scope & Problems in_Implementing the
Strategy in India
Indian State pursuing Capitalist Path of
Developments Main Obstacle to Health for All.
-A.R. Desai
100
112
1.
Primary Health Care Approach to Achieve
113
120
2.
as
Health for All by the year 2/000 AD.
it is understood and practised in this
country. - A Perspective.
- V.N. Rao
3.
Main Gaps & Constraints in bur Approach
121
132
Programmes for Provision of Primary Health
Care°
- N.S. Deodhar
4.
Issues in the Political Economy of Health
in India.
- Roger Jeffrey
133
157
5.
Health Policies in India: Comparisons with
the China experience.
- Lincoln Chen
HFA and NRRU by 2,000.
“ P.B. Desai
Logistic Support and Facilities for
Primary Health Care: The Crucial Role of
158
179
6.
7.
8.
Physical Accessibility.
Discussion.
180 - 199
190— 197
- Ashish Bose
198
207
SESSION III
Alternatives for Effective Implementation
1.
2.
3.
The Media, the Message, and Health for All.
- Vimal Balasubrahmanian
The Role of Curative Medicine in Health
for All.
_ Sujlt Das
Health for All - need for a people’s drug
P°licy-
208 - 216
217
225
226
237
- B. Ekbal
4.
New Public Health.
5.
Impact of Community Financing on - Health
Awareness, Community Participation, and
.. .... D. sanerji
238 - 251
252
272
273
285
Utilisation of Preventive Health Services.
- A. Dyal Chand
6.
Discussion.
v
SESSION
IV
Interaction between Government, Private Sector,
and NGOs in Implementation of HFA Strategy
286
299
Partners in Health - Governments, NGOs, and
the people.
" Bano0 Co^i
300
307
Role of the Private Practitioners in
providing Primary Health Care in Rural
- vasant Talwalkar
Area s.
Interaction between the Government, NGOs,
and the Private Sector in Implementation
- Abhay Bang
of HFA.
Health for All & the General Practioner.
- Mukund Uplekar
308
310
311
315
316
317
Health for All & the Private Medical
- G.G. Parikh
Profession.
318
325
6.
Discussion.
326
339
7.
1.
NGOs, Government & Private Sector.
- Ravi Duggal
2.
3.
4.
5o
I
FOREWORD
The ICSSR/lCMR report ’Health for All: An Alternative
Strategy* was brought out in 1979 just prior to the formula
tion of the Sixth Five Year Plan.
This critique of the exist
ing health conditions, and the recommendation for a decentra
lized, people based health care system made by this Committee,
have to a considerable extent been accepted by the Planning
Commission and the Ministry of Health.
These recommendations
are reflected in the Sixth Plan as well as the National Health
Policy Statements.
The Foundation for Research in Community Health, which
had provided the research inputs and secretariat for this
report, felt that it was necessary after a period of 6 years
since the publ? nation of the report, to review the progress in
the implementation of the health policy.
It was hoped that
such an exercise with the participation of several eminent
persons involved in the making and implementation of our
health policies and programmes (some of whom were members ;f
the Committee that produced the ICSSR/lCMR report) may help
in overviewing the successes and shortfalls in the implemen
tation of our health policies and programmes with the
possibility of indicating midterm correction/s in achieving
our national objectives.
This meeting was deliberately restricted to individuals
representing various aspects of health, so that there could
be free and frank exchange of information and views.
Back
ground papers were commissJoned and circulated prior to the
meeting in order to avoid detailed presentations, and permit
utilization of most of the time for discussion and inter
action. Many views, some conflicting, have been expressed on
several subjects and have been included in the proceedings for
. 2.
reader to make his own interpretation and judgement.
The Seminar was co-sponsered by the Indian Council for
Social Sciences Research (ICSSR). FRCH gratefully acknowled
ges the financial support extended to the seminar by the Ford
Foundation, ICSSR and the Indian Council of Medical Research
(ICMR).
We hope that the proceedings of this seminar and the
background papers will be of interest and use to policy makers
as well as those who implement the programmes in the field.
We regret the delay in bringing out the proceedings.
FRCH, BOMBAY
DR. N.H. ANTIA
APRIL
DIRECTOR
1988.
LIST OF PARTICIPANTS
1. Dr. N.H. Antia,
The Foundation for
Research in Community
Health,
8 4-A, R.G. Thadani Marg,
Worli, Bombay 400 018.
7. Dr. Lincoln Chen,
Ford Foundation,
55, Lodi Estate,
Pelhi 110 003.
-8
2. Dr. Ramesh Awasthi,
The Foundation for
Research in Community
Health,
84.-A, R.G. Thadani Marg,
Worli, Bombay 400 018.
3. Ms. Vimal Balasubrahmanyan,
605/11 Lance** Barracks,
Secunderabad 500 026.
(A<P.) .
4. Prof. D. Banerji,
Professor./
Centre of Social Medicine
& Community Health,
Jawaharlal Nehru
University,
New Maherauli Road,
New Delhi 110 067.
5. Dr. Abhay Bang,
SEARCH,
Dadchiroli 442 605,
Maharashtra.
6. Dr. Tannaz Birdi,
Foundation for Medical
Research,
84-B, R.G. Thadani Marg,
Worli Bombay 400 018.
Dr. Sujit Das,
S/3/5, Sector III,
Salt Lake,
Calcutta 700 091.
9. Dr. N.S. Deodhar,
•Suman' Saner Road,
134/1/20.
Aundh, Pune 411 007 .
10. Prof. A.R. Desai,
Professor Emeritus,
Dept, of Sociology,
Bombay University,
•jai Kutir’, Taikalwadi
Road,
Mahim, Bombay 400 016.
11. Prof. P.B. Desai,
Professor & Head,
Demographic Research Inst, of Economic Growth,
University Envlave,
New Delhi 110 007.
12. Mr. Ravi Duggal,
The Foundation for
Research in Community
Health,
84-A, R.G. Thadani Marg,
Worli, Bombay 400 018.
13. Dr. Ashok Dyal Chand,
Comprehensive Health &
Development Project,
Ashish Gram Rachna Trust,
At/Post Pachod,
Dist. Aurangabad 431 121.
19. Dr. Amar Jesani.
The Foundation for
Research in Community
Health,.
84-A, R.G. Thadani Mrag,
Worli, Bombay-400 018.
14. Dr. B. Ekbal,
Kerala Sastra Sahitya
ii Pari shad.
Dept, of Neurosurgery,
Medical College Hospital,
Calicut 673 008.
20. Dr. Saroj 8. Jha,
3A, Somerset Place,
Sonhia College Road,
Bhulabhai Desai Road,
Bombay 400 026.
15. Ms. Sonya Gill,
Rapporteur,
Foundation for Research
in Community Health,
84-A, R.G. Thadani Marg,
Worli, Bombay 400 018.
16. Ms. Manisha Gupte,
The Foundation for
Research in Community
Health,
84-A, R.G. Thadani Marg,
Worli, Bombay 400 018.
17. Dr. E.G.P. Haran,
Office of Health and
Nutrition,
USAID American Embassy,
Ghanakyapuri.
New Delhi 110 021.
18. Dr. Roger Jeffrey,
University of Edinburgh,
Dept, of Sociology,
18, Bucclench Place,
Edinburgh EH8 9LN.
1. Dr. Sanjeev Kulkarni,
C/o. Dr. Kamakshi Bhate,
95, Doctor’s Hostel (Old)
J.J. Group of Hospitals,
Bycu11a, Bombay 400 008.
22. Dr. Uma U. Ladiwala,
33, Gulistan,
Carmichael Road,
Bombay 400 026.
23. Ms. Hina Manerikar,
Foundation for Research
in Community Health,
84-A, R.G. Thadani Marg,
Worli, Bombay 400 018.
24. Dr. Dhruv Mankad,
1877, Joshi Galli,
Nipan'i,
Karnataka State.
25. Mr. Manish Mankad,
Foundation for Research
in Community Health,
84-A, R.G. Thadani Marg,
Worli, Bombay 400 018.
(
26. Dr„ Merges Mistry,
Foundation for Research
in Community Healthy
84-3, R.G. Thadani Marg,
Wor1i, 1 embay 400 018.
27. Dr. G.G. Parikh,
Ganesh Bhavan,
Slater Road,
Bombay 400 007.
28. Ms. Padma Prakash,
Asst. Editor,
S.P.W.,
19 June Blossom Society,
60-A, Pali Road,
Bandra, Bombay 400 050.
29. Dr. Ashwin J. Patel,
21, Nirman Society,
Alkapuri,
Vadodra 390 005.
*
30. Dr. V.N. Rao,
Director, Research,
K.E.M. Hospital,
S.M. Road,
Rasta Peth,
Pune 411 Oil.
31. Dr. P.V. Sathe,
Professor & Head,
Dept, of Preventive and
Social Medicine,
Grant Medical College,
Bombay 400 008.
32. Dr. V.C. Talwalkar,
Hon. Professor of
Paediatric Surgery,
B.J. Hospital for
children,
J.J. Hospital,
Bombay 400,003.
Unable to attend.
the office secretariat
1)
2)
3)
Mr. Eleuterio Fernandes.
Mr. Shashikant More,
Ms. Sunita Vichare.
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SESSION I
CRITICAL EVALUATION OF THE HEALTH FOR ALL STRATEGY
With focus on:
historical and international context in which the
strategy is placed.
*Alma Ata Declarations Alip-service to socio-economic
factors" or a genuine international strategy for
radical transformation of social, economic and health
systems.
*Social production of illness and poverty in the under
developed countries and their reflection in the
strategy.
*Social Production of sexual, racial, caste and
nationality oppression, their effect on health and the
HFA strategy.
9
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DECLARATION
OF
ALMA-ATA
The International Conference on Primary Health Care, meeting
in Alma-Ata this twelfth day od September in the year Nineteen
hundred and seventy-eight, expressing the need for urgent aotion
by all governments, all health and development workers, and the
world community to protect and promote the health of all the
people of the world, hereby makes the following Declaration :
I
The Conference stzrongly
strongly reaffirms
health, which.is a
zreaifi^nis that health
human right and that the attainment of the highest possible
level of health is a most important world-wide social goal whos
realization requires the action of many other social and econo
mic sectors in addition to the health sector.
II
The existing gross inequality in the health status of the
people particularly between developed and developing countries
as well as within countries is politically, socially and econo
mically unacceptable and is, therefore, of common concern to
all countries•
III
Economic and social development, based on a New International
Economic Order, is of basic importance to the fullest attain
ment of health for all and to the reduction of the gap between
the health status of the developing and developed countries.
The nromotion and protection of the health of the people is
essential to sustained economic and social development and
contributes to a better quality of life and to world peace.
IV
The people have the right and duty to participate individually
and collectively in the planning and implementation of their
health care•
V
Governments have a responsibility for the health of their
people which can be fulfilled only by the provision of adeA main social target of
ouate health and social measures,
governments, international organizations and the whole world
community in the coining decades should be the attainment by
all peoples of the world by the year 2000 of a level of health
that will
lead a
a socially and economically
will nermit
nermit them
them to
to lead
.. 1 .
productive life,
Primary health care is the key to attaining
this target as part of development in the spirit of social just ice •
VI
Primary health care is essential health care based on practical,
scientifically sound and socially acceptable methods and. tech
nology 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 their development in the spirit of self-reliance and
self-determination. It forms an integral part hoth of the
country’s health system, of which it is the central function
and main focus, and of the overall social and economic develop
ment of the community.
It is the first level of contact of
individuals, the family and community with the national health
system bringing health care as close as possible to where
people live and work, and constitutes the first element of a
continuing health care process.
VII
Primary health care :
1. reflects and evolves from the economic conditions and
socio-cultural and political characteristics of the country
and its communities and is based on the application of the
relevant results of social, biomedical and health services
research and public health experience;
2. addresses the main health problems in the community, provid
ing promotive, preventive, curative and rehabilitative ser
vices accordingly;
5• includes at least : education concerning prevailing health
problems and the methods of preventing and controlling them;
promotion of food supply and proper nutrition; an adequate
supply of safe water and basic sanitation; maternal .and
child health care, including family planning; immunization
against the major infectious diseases; prevention and control
of locally endemic diseases; appropriate treatment of common
diseases and injuries; and provision of essential drugs;
4. involves, in addition to the health sector, all related sec
tors and aspects of national and community development, in
particular agriculture, animal husbandry, food, industry,
education, housing, public works, communications and other
sectors; and demands the coordinated efforts of all those
sectors;
2
5• requires and promotes maximum community and individual selfreliance andparticipation in the planning, organization,
operation and control of primary health care, making fullest
use of local, national and other available resources; and to
this end develops through appropriate education the ability
of communities to participate;
6. should be sustained by.integrated , functional and mutuallysupportive referral systems, leading to the progressive
improvement of comprehensive health care for all, and giving
priority to those most in need;
7. relies, at local and referral levels, on health workers,
including physicians, nurses, midwives, auxiliaries and
community workers as applicable, as well as traditional
practitioners as needed, suitably trained socially and tech
nically to work as a health team and to respond to the expres
sed health needs of the community.
VIII
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 coordi
nation with other sectors.
To this end, it will be necessary
to exercise political will, to mobilize the country's resources
and to use available external resources rationally.
IX
All countries should cooperate in n spirit of partnership and
service to ensure primary health care for all people since the
attainment of health by people in any one country directly
concerns and benefits every other country.
In this context the
joint WHO/UNICEF report on primary health care constitutes a
solid basis for the further development .and operation of pri
mary health care throughout the world.
X
An acceptable level of health for all the people of the world
by the year 2000 can be attained through a fuller and better
use of the world’s resources, a considerable part of which is
now spent on armaments and military conflicts.
A genuine policy
of independence, peace, detente and disarmament could and should
release additional resources that could well be devoted to peace
ful aims and in particular to the acceleration of social and
economic development of which primary health care, as an essen
tial part, should be allotted its proper share.
.1-3 ..
I
The International Conference on Primary Health Caret
calls for urgent and effective national and international
action to develop and implement primary health care through
out the world and particularly in developing countries in a
spirit of technical cooperation and in keeping with a Now
International Economic Order.
It urges governments, WHO and
UNICEF, and other international organizations, as well as
multilateral and bilateral agencies, non-governmental organi
zations, funding agencies, all health workers and the whole
world community to support national and international commit
ment to primary health care and to channel increased technical
and financial support to it, particularly in developing
countries.
The Conference calls on all the aforementioned
to collaborate in introducing, developing and maintaining
primary health care in accordance with the spirit and
content of this Declaration.
*****
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RECOMMENDATIONS
1 . Interrelationships between health qnd development :
The Conference,
Recognizing that health is dependent on social and economic
development, and also contributes to it,
RECOMMENDS that governments incorporate and strengthen
primary health care within their national development plans
with special emphasis on rural and urban development programmes
and the coordination of the health-related activities of the
different sectors.
2• Community participation in primary health care:
The Conference,
Considering that national and community self-reliance and
social awareness are among the key factors in human develop
ment, and acknowledging that people have the right and duty
to participate in the process for the improvement and main
tenance of their health,
RECOMMENDS that governments encourage and ensure full commu
nity participation through the effective propagation of relecant information, increased literacy, and the development
of the necessary institutional arrangements through which
individuals, families, and communities can assume responsi
bility for their health and wellbeing.
5 • The roj-e of national administrations in primary health care:
The Conference,
Noting the importance of appropriate administrative and
financial support at all levels, for coordinated national
development, including primary health care9 and for trans
lating national policies into practice,
RECOMMENDS that governments strengthen the support of their
general administration to primary health care and related
activities through coordination among different ministries
and the delegation of appropriate responsibility and autho
rity to intermediate and community levels, with the provision
of sufficient manpower and resources to these levels.
4• Coordination of heaTth and health-related secters:
The Conference,
Recognizing that significant imr>rovement in the health of
all people requires the planned and effective coordination
of national health services and health^^elated activities of
other sectors,
., 5 ..
c.
RECOMMENDS that national health policies and plans take
full account of the inputs of other - sectors' bearing on
health; that specific and workable arrangements be made
at all levels - in particular at the intermediate and
community levels - for the coordination of health services
with all other activities contributing to health promo
tion and primary health care; and that arrangements for
coordination take into account the role of the sectors
dealing with administration and finance.
5
Content of Primary Health Care;
The Conference 9
Stressing that primary health care should focus on the
main health problems in the community9 but recognizing
that these problems and the ways of solving them will
vary from one country and community to another,
RECOMMENDS that primary health care should include at
least: education concerning prevailing health problems
and the methods of identifying, preventing, and control
ling them; promotion of food supply and proper nutrition,
an adequate supply of safe water, and basic sanitation;
maternal and child health care, including family planning;
immunization against the major infectious diseases;
prevention and control of locally endemic diseases; appro
priate treatment of common diseases and injuries; promo
tion of mental health; and provision of essential drugs.
6
Comprehensive primary health care at the local level:
The Conference,
Confirming that primary health care includes all activities
that contribute to health at the interface between the
community and the health system,
RECOMMENDS that, in order for primary health care to be
comprehensive, all development-oriented activities should
be interrelated and balanced so as to focus on problems
of the highest priority as mutually perceived by the
community and health system, and that culturally accep
table, technically appropriate, manageable, and appro
priately selected interventions should be implemented in
combinations that meet local needs.
This implies that
single-purpose programmes should bp integrated into primary
health care activities as quickly and smoothly as possible.
7•
Support of primary health care within the national health
system :
The Conference,
.• 6 . .
Considering that primary health care is the foundation of
a comprehensive national health sjrstem and that the health
system must be organized to. support primary health care and
make it effective,
RECOMMENDS that governments promote primary health care
and related development activities so as to enhance the
capacity and determination of the people to solve their own
problems.
This requires a close relationship between
the primary health care workers and the community and
that each team be responsible for a defined area.
It
also necessitates reorienting the existing system to
ensure that all levels of the health system support
primary health care by facilitating referral of patients
and consultation on health problems; by providing suppor
tive supervision and guidance, logistic support, and
supplies; and through .improved use of referral hospitals.
8.,
Special needs of vulnerable and high-risk groups:
The Conference,
Recognizing the special needs of those who are least able,
for geographical, political, social, or financial reasons,
to take the initiative in seeking health care, and expres
sing great
concern for those who are the most vulnerable
or at greatest risk,
RECOMMENDS that, as part of total coverage of populations
through primary health care, high priority be given to the
special needs of women, children, working populations at
high risk, and the under prividcged segments of society,
and that the necessary activities be maintained, reaching
out into all homes and working places to identify systema
tically those at highest risk, to provide continuing care
to them, and to eliminate factors contributing to ill health.
9.
Roles_and categories of health a*id health—related manpower
for primary health cane :
The Conference,
Recognizing that the development of primary health care
depends on the attitudes and capabilities of all health
workers and also on a health system that is designed to
support and complement the frontline workers,
RECOMMENDS that governments give high priority to the full
utilization of human resources by defining the technical
role, supportive skills, and attitudes required for each
category of health worker according to the functions that
need to be carried out to ensure effective primary health
care, and by developing teams composed of community health
workers, other developmental workers, intermediate person
nel, nurses, midwives, physicians, and, where applicable,
traditional pratitioners and traditional birth attendants.
.. 7 . .
*
1 0• Training of health and health-related manpower for primary
health care :
The Conference,
Recognizing the need for sufficient numbers of trained
personnel for the support and delivery of primary health
care,
,
RECOMMENDS that governments undertake or support reorienta
tion and training for all levels of existing personnel and
revised programmes for the training of new community health
personnel; that health workers, especially physicia-ns and
nurses, should be socially and technically trained and
motivated to serve the community;
that all training should
include field activities; that physicians and other profes
sional health workers should be urged to work in underserved
areas early in their carreer; and that due attention should
bo paid to continuing education, supportive supervision.,
the preparation of teachers of health workers, and health
training for workers from other sectors.
11, Incentives for service in remote and neglected areas?
The Conference,
Recognizing that service in primary health care focused on
the needs of the underserved requires special dedication
and motivation, but that even then there is a crucial need
to provide culturally suitable rewards and recognition for
service under difficult and rigorous conditions,
RECOMMENDS that all levels of health personnel be provided
with incentives scaled to the relative isolation and diffi
culty of the conditions under which they live and work.
These incentives should be adapted to local situations and
may take such forms as better living and working conditions
and opportunities for further training and continuing
education.
1 2• Appropriate technqlagy for health :
The Conference,
Recognizing that primary health care requires the identi
fication, development, adaptation and implementation of
appropriate technology,
RECOMMENDS ^hat governments, research and academic institu
tions, non-governmental organizations, and especially
communities, develop technologies and methods that contri
bute to health, both in the health system and in associated
services; are scientifically sound, adapted to local needs,
and acceptable to the community; and are maintained by the
people themselves, in keeping with the principle of selfreliance, with resources the community and the country can
afford,
. -8 • •
3 • Logistic support
facilities f or primary health—care,•
The Conference,
Aware that the success of primary health care depends on
adoq.uate, appropriate, and sustained logistic support in
thousands of communities in many countries, raising new
problems of great magnitude,
RECOMMENDS that governments ensure that efficient adminis
trative, delivery and maintenance services be established,
reaching out to all primary health care activities at the
community level; that suitable and sufficient supplies and
equipment be always available at all levels in the health
system, in particular to community health workers; that
careful attention be paid to the safe delivery and storage
of perishable supplies such as vaccines; that there be.
appropriate strengthening of support facilities including
hospitals, and that governments ensure that transport and
all physical facilities for primary health care be func
tionally efficient and appropriate to the social and oconomic environment•
14. Essential drugs z&nr primary health care s
The Conference,
Recognizing that primary health care requiresj a continuous
supply of essential drugs; that the provision.of drugs accounts
for a significant proportion of expenditures in the health
sector; and that the progressive extension of primary health
care to ensure eventual national coverage entails a largo
large
increase in the provision of drugs,
RECOMMENDS that governments formulate national policies
and regulations with respect to the import, local production,
sale, and distribution of drugs and biclogicals so as to
ensure that essential drugs are available at the various levels
of primary health care at the lowest feasible cost; that
•-•
specific
measuresj be taken to prevent the over utilization
of medicines; that proved traditional remedies be incorporated;
and that effective administrative and supply systems be established•
15• Administration and management for pri mary health care, :
The conference,
Considering that the translation of the principles of pri
mary health care into practice requires the strengthening of
the administrative structure and managerial processes,
RECOMMENDS that governments should develop the administrative
framework and apply at all levels appropriate managerial
processes to plan for and implement primary health care,
improve the allocation and distribution of resources, moni
tor and evaluate programmes with the help of a simple and
relevant information system, share control with the commu-
.. 9 ..
nity»
provide appropriate management training of
health workers of different categories.
16. Health services research and operational studies :
The Conference,
Emphasizing that enough is known about primary health care
for governments to initiate or expand its implementation,
but also recognizing that many long-range and complex issues
need to bo resolved, that the contribution of traditional
systems of medicine calls for further research, and that new
problems are constantly emerging as implementation proceeds,
RECOMMENDS that every national programme should set aside
a percentage of its funds for continuing health services
research; organize health services research and development
units and field areas that operate in parallel with the
general implementation process; encourage evaluation and
feedback for early identification of problems; give respon
sibility to educational and research institutions and thus
bring them into close collaboration with the health system;
encourage the involvement of field, workers and community
members; and undertake a sustained effort to train research
workers in order to promote national self-reliance.
17• Resources for primary health care :
The Conference,
Recognizing that the implementation of primary health care
requires the effective mobilization of resources bearing on
health,
RECOMMENDS that, as an expression of their political deter
mination to promote the primary health care approach, govern
ments, in progressively increasing the funds allocated for
health, should give first priority to the extension of pri
mary health care to underserved communities; encourage and
support various ways of financing primary health care, inclu
ding, where appropriate, such means as social insurance,
cooperatives, and all available resources at the local level,
through the active involvement and participation of communi
ties; and take measures to maximize the efficiency and
effectiveness of health-related activities in all sectors.
1 8. National commitment to primary health care
The Conference,
Affirming that primary health care requires strong and con
tinued political commitment at all levels of government,
based upon the full understanding and, support of the people *
RECOMMENDS that governments express their political will to
attain health for all by making a continuing commitment to
implement primary health care as an integral part of the
national health system within overall socioeconomic develop
ment, with the involvement of all sectors concerned;
.. 10
to adopt enabling legislation where necessary; and to
stimulate, mobilize, and sustain public interest.and parti
cipation in the development of primary health care.
19. National strategies for primary health care :
The Conference,
S-t^essing the need for national strategies to translate
policies for primary health care into action,
RECOMMENDS that governments elaborate without delay national
strategies withwell_(3©fined goals and develop and implement
plans of action to ensure that primary health care be made
accessible to the entire population, the highest priority
being given to underserved areas and groups, and reassess
these policies, strategies, and plans for primary health
care, in order to ensure their adaptation to evolving stages
of development.
20. Technical cooperation in primary health care :
The Conference,
Recognizing that all countries can learn from each other in
matters of health and development,
RECOMMENDS that countries share and exchange information,
experience, and expertise in the development of primary
health care as part of technical cooperation among countries,
particularly among developing countries.
21. International support for primary..health Care :
The Conference,
Realizing that in order to promote and sustain health care
and overcome obstacles to its implementation there is a
need for strong, coordinated, international solidarity and
support, and
Welcoming the offers of collaboration from United Nations
organizations as well as from other sources of cooperation,
RECOMMENDS that international organizations, multilateral
and bilateral agencies, nongovernmental organizations,
funding agencies, and other partners in international health
acting in a coordinated manner should encourage and support
national commitment to primary health care and should channel
increased technical and financial support into it, with full
respect for the coordination of these resources by the
countries themselves in a spirit of self-reliance and selfdetermination, as well as with the maximum utilization of
locally available resources.
11
22. Role of WHO and UNICEF in supporting primary health care:
The Conference9
Recognizing the need for a world plan of action for primary
health care as a cooperative effort of all countries,
RECOMMENDS that WHO and UNICEF, guided by the declaration
of Alma-Ata and the recommendations of this Conference,
should continue to encourage and support national strategies
and plans for primary health care as part of overall
development•
RECOMMENDS that WHO and UNICEF, on the basis of national
strategies and plans, formulate as soon as possible con
certed plans of action at the regional and global levels
that promote and facilitate the mutual support of coun
tries, particularly through the use
of their national
institutions, for accelerated development of primary
health care.
RECOMMENDS that WHO and UNICEF continuously promote the
mobilization of other international resources for primary
health care.
**********
• . 12 ..
HEALTH
FOR
ALL
CONCEPT
VERSUS
REALITY
Dr. N. H. Antia
Dr. Ramesh Awasthi
That every human being should hav.g the right to enjoy good
health hardly needs stating; like the fundamental right to
life, it is a basic human right.
Further, that we have to
continue to reiterate it time and again is in itself an
indictment of the inability of our society to meet this
basic need of the people.
History tells us that contrary to piou^ proclamations,
basic needs of the majority rarely gev priority over the
extravagant wants of those few who wie^_d power and influence.
The present ago is no different.
Capitalism thrives on it,
and throws a few crumbs to those who have fallen by the way
side.
Termed ^Welfare * it helps to salve its conscience
as well as prevent unrest and upheaval in the society.
Unfortunately, the vast majority of countries which gained
independence from their colonial masters have fared no
better.
Far from liberating the masses they have created
polarised society, often under the guise of democracy.
Instead of using simple and cheap available technology for
the betterment of the masses,the new rulers have opted for
expensive sophisticated technology to meet their new life
styles.
In this process, they not only culturally enslave
themselves but also pawn their country to the former im
perial powers who lose no opportunity for economic neocolonisat ion.
To justify their actions, they use the fami
liar jargon of capitalist economics which places mammon
above man, and encourage urban industrialisation which
produces consumer goods for the elite, while neglecting
agro-economics which benefits the masses in a predominantly
agricultural society.
This process of lopsided development where the benefits
have been monopolised by an upper crust at the expense of
the rest and which has further marginalised those with
small or no assets, has directly affected the health status
of the people.
To expect ’Health for .Allf in such an invi
dious set-up is sheet anachronism.
13
The broad relationship between health ana socio-economic
development has been well documented by Western authors
like McKeown (Health & Disease, Open University Press,
England, 1984, pp:105-114) in their own countries.
Almost
all the major killing and maiming diseases m countries
like ours are similar to those that existed there m the
last century andL are
are of a communicable nature. Jhej were
eradicated in
the
West long
long before
before th© advent oi modern
in the West
preventive and
curative
medical
and the decline
and curative medical technology
Sad commenced
commenced even
even before
the
cause
of
the
diseases was
before the
known. More
recent
and
much
more
dramatic
is the example
More recent and much more
5
«bloh has ao-ons-h-atoa bbat most of tto.o
which has demonsti'ated
can h«
controlled without
without vwaiting for general affluence.
be controlled
Two of -the earliest attempts to define a strategy for
Health for All were from India; the reports of the healtn
sub-committee of the National Planning Committee (1PCJ
( 1948'1 and the Health Survey and development Committee
(Shore Committee, 1946)aro worth reviewing for those who
consider HFA as a recent concept.
Though the NPC report was published m 1948, the Nationa
Planning Committee constituted by the Indian National
Congress under the chairmanship of Jawaharlal Nehru had
considered the report of its sub-committee on national
health as early as 1940, even before the Shore Committee
was constituted.
The report indicated positive approac
to primary health care - the major recommendations being.
a)
b)
c)
a)
India should adopt a form of health organization, in
which both curative and preventive functions are suitably integrated
*
... preservation and maintenance of the health of the
people should be the responsibility of the state.
As an immediate step, in order to meet special condi
tions prevailing in India, we recommend the training
These health wor—
of large number of healtb workers•,
training
in practical,
kers should bo given elementary
first-aid
and simple
community and personal hygiene9
medical treatment, s.tress being laid on the sccj^al
and implications of medical and public_health
aspects
work.
thousand
There should be one health worker for every
population .••
(Source : NPC 1948:224-25, emphasis added)
14
The report of the Shore Committee was also a declaration
of Health for All accompanied with elaborate discussion
of different aspects of public health delivery systems.
The main principles being :
i) No individual should fail to secure adequate medical
care because of inability to pay for it•
ii) The health programme must, from the beginning, lay
special emphasis on preventive work.
iii) The health services should be placed as close to the
people as possible.•
iv) It is essential to secure the active co_o^Gration
the people in the development of the health programmes.
the
The idea must be inculcated that, ultimately, the
health of the individual is his own responsibility...
(Report of the Health survey and Development Committee
1946 Vol.IV Summary p(v))»
The Alma-Ata Declaration (1978) of World Health Organiza
tion and the ICSSR/lCMR report ’Health For All J An Alter
native Strategy’ (1980) voice the same ideas with minor
modifications.
It is not surprising, for common sense
dictates, that if there is a desire that health services
should reach out to all in a country with a large population spread over a vast terrain, it is necessary :
a) to decentralise services to the extent possible,
b) to place emphasis on preventive measures and basic
health services, and
c ) to involve the people in their own health care.
India, like most other member countries of the WHO,
was a signatory to the Alma-Ata declaration.
Though the
conference believed that, in adopting the ’Declaration of
Alma-Ata’, governments had made a historic collective
expression of political—will in the spirit of social equity
aimed at improving health for all their peoples’ (WHOUNICEJ? 1978: p.19), this fabled political-will however
does not seem to have shown itself anywhere (beside a
couple of exceptions) in terms of realising the implica
tions of HFA which calls for a radical strategy towards
social equity and at least a total reorientation of the
health care system.
It makes one wonder whether the
signatory governments really believed in HFA or did they
adopt it just to improve their international image?
15
Another possibility is that they found in HFA an attrac
tive slogan to fool their people.
Either of these, or a
mix of these, is more likely to be the motive for adopt
ing Alma-Ata declaration as part of the National Health
Policy (1985) iu India.
China took to reorganising its medical and health services
with the founding of New China in 1949 and the four car
dinal principles outlined by Chairman Mao for the reorien
tation of health services were no different from the spirit
of Alma-Ata.
The principles were :
i) health work to be geared to the needs of the
workers, peasants and soldiers,
ii) putting prevention first,
iii) uniting doctors of both traditional and western
medicine, and
iv) combining health work with mass movement.
(China Handbook Series: Sports and Public Health, Beijing
1983, p:129).
In fact, as the following table would show, China had
exceeded in 1978, the targets that we in India have set
forth for 2000 AD, as part of our commitment to the HFA
declaration
(l978).
INDICATOR
CHINA
(1978)
I MR
Avg. life span
Crude death, rate
Crude birth, rate
56
64
6.3
18.3
INDIAN HFA TARGET
(FOR 2000 AD)
60
64
9.0
21 .0
(Source : China's Population: Problems & Prospects; China
Studies Series New World Press, China 1981.
: National Health Policy, Govt, of India,
New Delhi, 1983).
16
China’s accomplishments in health with a large population
and without reaching a level of general affluence have
long been recognised and the driving spirit of this sort
of accomplishment has come to be called ’national political
will’ in the vocabulary that has grown up around the pri
mary health care movement (Primary health care: The Chinese
Experiences; Report of an Inter-regional Seminar, WHO,
G-eneva 1983, p.10).
Vie in India, like most other developing countries, have
been paying mere lip-service to the social, cultural and
economic and albeit rarely to the political factors while
all strategies including those of our Planning Commission
and the Ministry of Health have looked upon health as al
most entirely a function of medical technology and profes
sional skills.
The medical profession which claims to be
the guardian of people’s health has, by and large, equated
health with illness for its own benefits.
The result has
been that entire inputs in the private sector as well as
a major part of those in the public and voluntary sector
have been in curative medicine, while the more important
preventive and promotive aspects have been relegated to
the background.
The medical profession, which had been
given the pride of place by the Bhore Committee for plan
ning as well as implementation of health care of our nation,
have not only failed to perceive health in its wider per
spective but also in providing the necessary leadership
and direction to the health care services.
Health care
has by and large been converted into a lucrative business.
The exponential proliferation of the medical profession
and the pharmaceutical and instrument industry has inevit
ably led to the growth of malpractice, and exploitation
of peoples' sufferings on a scale which would make those
who had placed their faith in the medical profession to
turn in their grave.
It is understandable why the medical profession with their
blinkered education and their personal monetary interest
in curative medicine have chosen this path.
It is even
easier to understand why the pharmaceutical industry wants
to produce an excess of unnecessary and often harmful drugs,
and why the medical instrument industry tries its best
to promote the most expensive inappropriate technology, for
their sole interest is profit.
But the question remains
as to why the elected representatives of the people con
tinue to support these interests with policies that work
against those very people whom they purport to represent.
17
Tho answer was aptly given by a villager;” 1 our * people
become ’their1 people once elected and sent to the capi
tal” .
That this process of co-option has been a contin
uous one (for 40 years) indicates that those who gain
power are willingly bought by the business interests or
get co-opted to the ranks of those who make business by
exploiting the masses.
Although many of the elected representatives who come
from the grass-roots are aware of the problems of the
common man, the majority of the elite whether politicians,
bureaucrats, professionals and intellectuals who have the
major share in power to influence decision making are
largely unaware of the life and problems of those who dwell
in the urban slums, leave aside the villages.
Their total
ignorance of grass-root issues is clearly demonstrated by
their naive deductions and facile conclusions on many
subjects including health. A mixture of ignorance and
self-interest governs the thinking of these elite groups.
Given the task of planning, even with good intentions they
can plan nothing but a delivery system for the people who
are supposed to offer only passive co-operation at the
receiving end.
Due to inherent contradictions when their
implementation fails to achieve results, they can only
indulge in victim blaming,
To them the poor are lazy and,
being illiterate, unintelligent.
They have large families
because they know nothing better
They are incapable of
solving their own problems and ever and above do not even
participate in programmes for their welfare,
They must,
hewever, remain the targets of our plans since 9 only we
are capable of planning and implementing for their welfare.
That these plans often fail is due to their inability to
appreciate the efforts and extend the necessary co.operat i on.
Lot us now examine the performance of our health services
the private sector, quasi-public sector and the public
sector functioning in the narrow context of illness-care 9
professional, super-specialisations and medical technology«
The private sector is by far the largest sector and is
responsible for three-quarter of all medical care whether
rural or urban.
Yet we have virtually no information about
the operation of this sector and the extent and nature of
health expenditure incurred in the private sector.
Atleast
three-quarters, if not more, of all doctors whether allo
pathic or non-allopathic are trained chiefly at government
expenses but they earn their living through private
practise.
V-
As general practitioners, consultants, or running their
own diagnostic clinics and nursing homes, they are mainly
concerned with curative medicine and maximising earnings.
There is an increasing number of private hospitals in
-the larger cities which offer expensive modern medical
and surgical care.
The lucrative nature of this sector
is revealed by the extent of pressures exerted for admis
sion to medical colleges and by the rush of corporate
sector in opening S-stat* super-speciality medicare centres
investing several hundred crores of rupees in each such
centre.
Inspitej of all the talk of reorientation of medical educacalled the ’ROME1 strategy in cur five
t i on, fancifully
:
year plans, the training that the medical students receive
at public expenses is most suited to private practice of.
curative medicine and least suited to their role as public
health doctors.
In the virtual absence of any supervision
or self-regulating mechanism by the profession itself,
the private sector medicare system, like its ancillaries
i.e. pharmaceutical and instrumentation industry, has
become very much a part of the market economy imbibing all
its culture, ethics (or lack of it) and rules of the game.
Still 80^ of our population lives in rural India whereas
80^ of the doctors work in urban centres where the purchas
ing power is concentrated. With over-production of doctors,
those who cannot succeed in urban areas migrate to the
villages where they have to practise without the most
elementary pathological and other facilities.
The contin
ued over-production of doctors and drugs has invariably
resulted in malpractises like giving of unnecessary.and
dangerous injections to all and sundry who seek medical
aid.
The people, and especially the poor,have -also been
hocked on to such irrational therapy. Medicine has conse
quently been converted to a trade in human suffering.
This applies not only to the lowly general practitioner
in rural areas or slums but equally to the ultra—sophis
ticated private hospitals in the larger cities which often
set the pace.
Many of them gain tax relief under the guise
of research centres.
Besides the private sector, there are quasi—government
health services in the form of Employees State Insurance
S chemes or dispensaries and hospitals run by the industry
This sector however is quite small and caters to
itself.
employees of private as well as public sector industries.
The idea of health insurance for general public is still
a far cry•
19
The public sector is the most well-known sector for we
have some data, however unreliable, about manpower employed,
expenditure incurred and its targets and achievements in
terms of various health indicators.
In a dual economy the
aim of the public sector is to ensure basic health services
tc those who need it and especially who cannot afford
expensive private services, as also to undertake preventive
measures chiefly for the control of communicable diseases.
Inspite of these being the obvious aims of the public
sector a major portion of its budget is diverted.into high
technology instruments and medicines especially in running
expensive medical colleges and their hospitals which pro
duce a surfeit of doctors who cannot be absorbed in the
public sector and are gifted to the private sector.
Consequently, the public health sector, responsible for
primary health care and for running of the district and
taluka hospitals in the rural areas, suffers not only from
lack of funds but also fails to attract the most talented
of the medical graduates.
This together with low priority
tc the teaching of preventive and social medicine and of
communicable diseases as well as a complete absence of pra
ctical training of working conditions in the field (the
rural training being only symbolic) ensures that the key
personnel of the rural health programme are incapable of
providing the leadership or direction to the vast para
medical manpower working under their supervision.
The
chief interest of the medical officers manning the primary
health centres, the keystone of our public sector services,
remains curative medi:cine at the Static Health Centre
and that too of a very poor nature due to insufficient
supply of essential medicines and lack of elementary,
laboratory facilities and total absence of contact with
recent advances in medicine.
Many use these postings as
The leader
a stepping stone to start private practice.
less paramedical staff harassed from above by impossible
family planning targets and pressurised by the demands
of local politicians find little joy in their work.
They
carry out their duties perfunctorily and there is almost
delitotal lack of accountability to the people who are3 deli
berately kept uninformed of the health services designed
for them.
Consequent to continued failure of this system to meet
the health requirements of the people and the targets o*
the bureaucracy, an attempt was made to clutch tc a new
straw viz. the 1 community health worker’ (CHW).
This
worker was supposed to be a functionary of the people
responsible to her own community with the Primary Health
Centre only providing train^ing and support.
A good scheme seeking the much talked about peoples *
participation was once again derailed by political and
bureaucratic manoeuvering and bunglings.
1,25,000 (92$ male) CHWs were appointed, post haste,
by a Health Minister who saw in it a populist vote-catch
ing measure, and a bureaucracy which perceived it as a
further extension of its own empire.
Large scale evalua
tion was undertaken within nine months of the commence
ment of the programme which showed it to be eminently
successful•
Better sense prevailed only after several years with the
realisation that it was not possible for a male in our
culture to look after the health problems which predomin
antly affect women and children, they being more vulner
able even among the poor.
Changing the name to Community
Health Volunteers and then to Health Guides, without
increasing the 'honorarium' of those who are supposed to
bear the burden of most basic health problems of the
community, has had little effect.
It must be realised
that .another good scheme has gone astray because the
community was kept unaware of its worker and her role and
moreover, she has now been co-opted into the lowest ring
of the bureaucratic system.
What are the prospects of HFA being achieved in our country in the next 14 years? If experience so far shows any
trend it is that we have been going from one solution to
the other as if trying to clutch at the last straw.
In
the process we have multiplied the manpower manifold ver
tically as well as horizontally, increased the drug com
panies and drug production, introduced 5 star health care
industry with the expensive sophistication that only a
privileged few can have access to, and to cap it. all we
have produced bountiful reports.
In the name of HFA we have been doing everything that is
inimical to HFA. All the time talking of HFA more or
less as a slogan, we have moved farther away from the
spirit and approach of HFA.
Rather than tackling social,
economic, and political issues involved in ensuring health
for all,we have converted it into a question of managerial
skills - taking it away from the people, and medical tech
nology - making it inaccessible to the people.
We have
used HFA slogan for further exploitation of the people.
HFA in reality is the collective will of the people to be
supportec. by the national political will. China accompli
shed it without talking of HFA because it had the poli
tical as well as the collective peoples' will.
21
[
\
1 it when it had closed itself from the out—
China achieved
Economic conditions and the level of tech
side world•
nology were much worse than what we have today•
The under
lying approach was of self-reliance at the national as
well as the people’s level.
Selfrreliance is probably
more important than high technology.
We,in India to-day, have enough resources and technology
to achieve health for all. What we lack is peoples’ will,
the national political will and the spirit of self-reliance,
and for these we do not require international intervention
or collaboration.
International agencies cannot play any
role in achieving HFA.
They can only give packages of
advice or experiences which are taken up by the governments
only in their phraseology which is used to divert the
issues.
On the other hand, international collaboration
takes away the will to follow the. path of self-reliance.
The policy makers and the intellectuals keep looking for
policy packages from these agencies to comment upon, or
to adopt in their writings.
International collaboration,
coming as it does as a package deal in all spheres, results
in cultural enslavement.
Moreover, it takes away a few
good people from the apex of national public bodies
for
international assignments on attractive salaries.
As..
result of this, the top people in decision making positions
keep their eyes on the next international assignment rather
International
than locking into the problems if the people,,
country
to
multinational
collaboration also opens up the <-----of supplying modern techexploitation under the pretext
_
International
collaboration,
nology, instruments and drugs.
therefore,can only play a negative role in the achievement
of HFA and there can be no substitute to national effort,
For our own failings, we probably do not wish to face the
causes and therefore, call for international collaboration;
the elites,of course, stand to gain from such collabora
te, the international agencies
tion.
And for the failures
blaming
the people who are the
j oin the local elites in —
victims•
In order to off-load some of the burden of its failures,
the government is looking towards voluntary agonciesas
intermediaries to reach out
cut to the people.
Or probably
it is on effort of co-opting the voluntary sector which
has been its strongest critic in the recent years.
The
Indian government has been professing a policy of collabo
ration with the voluntary sector even to the extent of
handing over primary health centres to the voluntary groups.
22
Handing over services is running away from its own respon
sibility but the question remains whether the voluntary
sector can deliver what the government has failed to do.
In the voluntary sector there are a variety of voluntary
agencies.
Inspite of considerable expansion in the last
decade, they are still a miniscule part of the health
system. Most of them, even with good intentions, are,in
practice, dependence creating.
They run hospitals, organ
ise diagnostic, clinical or surgical camps and distribute
free sampleq/medicines and at the most, in some small
areas, they are doing what the public health department
should have been doing in its normal run.
There is a very
small section of voluntary agencies which wants to create
self-reliance.
Under the limitations of its size, resour
ces and coverage, it cannot have but a limited impact on
the national scene.
It can only devise experimental
models, enhance understanding and formulate alternative
models and in this respect the voluntary sector has played
a commendable role*
One of such experiments at Mandwa (Alibagh, Maharashtra)
demonstrated that semi-literate and even illiterate but
motivated village women, properly trained and with a
little support, could use existing knowledge and technology
and achieve remarkable results (in 1982) not far from the
MFA targets set for the end of the century.
This was
possible because, for majority of health problems in the
country to~day» there exists simple knowledge and tech
nology.
For putting this to use, what is required is a
high cultural affinity of the health worker with the
people and her accountability to the village community.
The table below shows the achievements of 50 women CHWs,
over a period of 5 years, covering a population of
50,000.
23
TABLE
T
Mandwa Achievements'” & HFA Targets
Mandwa
fiesultL.
National
figures
1982
1981
HFA
Target
1 .
Birth rate
15
33
21
2.
Crude death rate
8
1 2C5
9
3.
Infant Mortality
74
12?
Below 60
4.
Immunisation
Triple antigen
92
28
"00
Polio
67
32
100
Tetanus
78
NA
100
*
(Source: Mandwa Story
BRCH, Bombay 9 1985)
This was achieved without any inputs in nutrition, water
supply or environmental improvement and despite opposition
from the public and private health sector as well as (at
a later stage) from the local politicians*
Projects like Mandwa have demonstrated that it is possible
to improve the health of the people, even under the pre
vailing socio-economic conu.itions, if the community is
encouraged to undertake the health functions which are
within their -st mbit and adequate supportive services are
provided to them,
It should, however, not be misunderstood
that we are talking of field level changes without any
change in the system.
Minor adaptations within the
system are bound to get adopted by the system like the
CHW scheme which was supposedly based upon the experiences
of four such community based projects.
The answer lies
not merely in the CHWs nor in their training, motivation
or skills.
It lies in the will for equal opportunities
of life- to all, and basic faith in the people.
24
Left to themselves, free from local exploiters and oppres
sive power structure, the people can do remarkable things
themselves. The village of ’Ralegan Shindi‘ (Tai. Parner,
Dist. A-imednagar) located aoout 75 km North-East of Pune,
is an example. People of this village, motivated by a
local resident Anna Hazare, have been able to achieve
remarkable all round development in a short period of ten
years. The leadership of Anna Hazare and the local tarun
mandal were successful in rooting out local exploiters
and in warding the oppressive power structure and bureau
cracy at the taluka and district level. What followed is.
to be seen to be believed i.e. profound social and economic
progress, and as a result, without any special health in
puts, the health status of the people has improved tremen
dously. An impoverished liquor brewing village in a
drought prone area now presents a model of relative general
affluence and that too by utilising the public resources
available to all other villages.
In all our national programmes, we virtually look down
upon the ’peoples’ sector’ since we do not.have faith in
tne people and in their capabilities. Having tried every
thing at the top i.e. producing more doctors, more drugs,
multiplying paramedics, everything to ’deliver’ health
care to the people, we have now finally come down to
peoples’ participation, since nothing has succeeded so
far. The usual perception of peoples’ participation is
in terms of ’their’ participation in ’our' programmes.
The government and its bureaucracy taik of peoples' parti
cipation without having faith in the intelligence and.
the ability of the people. All talk of peoples’ partici
pation without having faith in the people is bound to fail,
reducing itself to a farce ^f nominated health committees
with only the local vested interests and political power
groups being represented on these committees. With
little respect for our poor, even health education has
been reduced to bombarding the people with.messages of
do’s and don’ts, without really understanding whether
it is in their interest or not.
-■
•
■
• - and the oublic sector health services
The
private
sector
have"proliferated and grown out of proportion in selected
centres of prosperity but have not succeeded in ensuring
health for all. Now at least, we should give a fair
trial to a truly peoples’ sector.
25
Health should, in fact, become a peoples’ programme with
the participation of the government, bureaucracy, medical
profession and the elites. Health education in such a
program ie should include ec ucation of the poor in their
rights and basic education for helping them to understand
their own ability. Instead of oppressing the poor, if we
only let them mobilize their own resources and help them
with simple knowledge and tools together with necessary,
supportive services, the potential of peoples1 sector will
unfold itself. This cannot happen in the health sector
alone in Isolation. The change has to come in every field
including health.
To-day, peoples1 participation is nothing but another ploy
used to achieve family planning targets. If we truly,
believe in peoples* participation, let us ask.a question when the poor demand their rights, on which side shall we
stand? Can we ensure that when their rights are being
eroded, they will be supported? If they are crused,
how can there be peoples’ participation? And, how can
there be HFA without their participation?
★★*★*★*★*
(26)
A CRITIQUE OF THE IDEOLOGICAL AND
POLITICAL POSITIONS OF THE WILLY BRANDT
ERPORT AND THE WHO ALMA ATA DECLARATION.
VICENTE NAVARRO
_
'
The Johns Hopkins
Department of Health Policy.
Universityt School of Hygiene and Public Health.
ABSTRACT-This article (1) analyses the Willy Brandt
Commission Report and the WHO Alma Ata Declaration
within the socio-economic and political context that
determined them, and (2) makes a critique of the
ideological and political assumptions that both doc
uments make. Through an assumingly a political and
technological- administrative discourse both documen
ts reproduce the major positions upheld by the hege
monic development establishments of the western
world. The article analysis (through a study of.
what is being said and not said) how those positions
appear in the documents. It is indicated that (1)
their understanding of the causes of underdevelop
ment and its major health and disease problems and
(2) their suggestions for change based on moral
calls for social justice1 and ‘enlightened self-,
interest* are faulty and insufficient. Alternative
explanations and solutions are presented.
BACKGROUND OF THE ALMA AT24
DECLARATION: WORLD HEALTH DURING
THE SIXTIES AND SEVEnTIES
Discussion of any social event has to take place within
the historical and social context explaining that event. Thus,
we cannot understand the 1978 WHO ALMA ATA Declaration |I|
without understanding the context and social forces that det
ermined it. The stated aim of the Declaration, ‘health for
all people by the year 2000, clearly establishes the intent of
its intervention. A brief analysis of the current health,
situation of the world population shows the enormous magnitude
of the proposed task. The year that the Declaration document
was published (1978), the following situation existed:
.r 800 million people in the world lived in absol(1) Over
ute poverty, with one-third of all deaths occuring in children
countries
under 5121 . Then
--- and
__ . now,
_
. in the less developed
_
approx. 11 million children under 5 years of age die every
year of hunger, malnutrition.
27
and infectious diseases |3 j- To put the number of
preventable deaths another way, the equivalent of
20 nuclear bombs explode every year in the world
of underdevelopment without making a sound.
(2) Approximately 80% of the population in
the less developed capitalist countries did not
have access to personal health services|4|, and
the situation has since worsened for many of
these and other types of services. For example,the
percentage of the population covered by sanitation
services in less developed countries (LDC) declined
from 33% in 1975 (3 years before the Declaration’s
appearance) to 2 5% in 1980 15| .
This already alarming situation has rapidly
deteriorated during the current worldwide crisis,
worsening some trends existent during the sixties
and seventies. Individual and collective consump
tion in large numbers of capitalist underdeveloped
countries, for example, declined most substantially
during these decades.
The consequences of these developments for the
health of the underdeveloped world's populations
have not yet been studied in detail. Some studies,
however, do exist. One that merits distinction is
Wood's study |6| on infant mortality in Sao Paulo.
Brazil, a study that is specifically meaningful
because it analyzes the evolution of that infant
mortality during the period of the so-called
'Brazilian economic miracle*. The period following
the 1964 military coup that deposed the constitution
ally elected Goulard government was characterized
by a large increase in economic growth, dubbed by
the World Bank, the IMF and the main academic de
partments of international health as the 'economic
miracle1. The large growth of GNP per capita that
took place in the late 60s and early 70s was put
forth as the best proof of that 'miracle'. But
what enthusiasts of the miracle did not realize or
consider was that GNP per capita is not an indicator
of individual consumption or wealth. Rather, the
GNP is an indicator of the aggregate amount.of
goods and services provided by the economy in.a
specific period of time. The GNP per capita is
obtained by dividing the GNP by the total population
of the country, assuming that everyone- gets the
same amount of goods and services-an assumption that
is obviously incorrect. It is assumed that produc
ing ’a larger pie means that everyone gets more of
2S
the pie. Again, this assumption is incorrect. The GNP
can increase in a society and the majority of the population still consumes less. Wood shows that this is
precisely what happened in Sao Paulo, Brazil, during
the so-called 'miracle'. As with many others assumed
divine interventions, that 'miracle* was based on an
overwhelming rate of exploitation of the working class
which determined a most substantial decline of the
standard of living of the majority of the population.
This exploitation took place through the following
three processes:
(1) An increase in the intensity of labour, lower
ing individual wages and lengthening the hours worked.
Workers had to work longer periods of time to buy the
same
same amount of food than before the coup. In 1975, a
worker and his family needed to work 154 hours, 18
minutes for the same amount of food (6 kg. of meat,
7.51 of milk, 4.5 kg. of rice and others for a family
of four for one month) that it took only 87 hours. 20
minutes of work to buy 10 years earlier. Moreover, in
a situation of widespread unemployment, work-even for
these low wages - was not easily available. Thus, pex
capita meat consumption declined and consumption o
less nutritive foodstuffs increased.
(2) A decline in collective consumption (i.e.state
benefits and services used by individuals). The Pe^“
centage of state health expenditures declined from 4. /o
of total state expenditures in 1969 to 2.4% in 1977) j.
ing cl^sAanddpSea:SryGandftoward! ^ourgeoilie?^"
Analysis .of income distribution between 1960 and 1970
indicates that the high annual growth rates were
associated with an increase in the concentration of
income. As Wood points out |6|.
Although estimates of the magnitude of the change
vary according to method and data, a number of studies
conclude that the Glnlcof<=iclent for Brazil, already
amona the highest in Latin America m the 1950s, rose
substantially during this period of economic expansi .
These three developments were the outcome of
political interventions that outlawed free union
strikes and repressed most brutally the working class
tnd pXSry Consequently, while the GNP grow enermosly (the 'miracle'), the standard of living for the
29
majority of the population declined markedly/ deter
mining an increase in infant mortality. A similar
situation has occured and is occurring in many other
developing capitalist countries/ although those decl
ines in the majority’s standard of living are not
always reflected in an increase in the infant morta
lity rate |8| .
These figures encapsulate a reality that is clear
for all to see: the situation for large sectors of
today’s world population is getting worse rather than
better.
THE DEVELOPMENT ESTABLISHMENTS RESPONSE
In the face of this reality/ let us ask what the
Development Establishment-that body of internationally
minded individuals who are active in major Western
and agencies or who are their champions within Western
political circles-*- has proposed*. In the sixties
and early seventies/ a great: emphasis was placed on
population control. Population growth was considered
to be either the cause .or a. major contributing cause
of world poverty. The two sides of the coin of pov
erty were too many people on the one h.an/1 and too
few resources on the other. The theoretical frame
work sustaining this position was remarkably simple.
Looking at the ;GNP rate per capita/ it seemed obvi
ous that the fewer the ’capitas’/ the more GNP for
the existing ones. The poor countries were assumed
to be poor because they did not have resources or/
at least/ not enough resources^ Thus/ the answer
was to control the size cf their populations.
*
I am aware/ of course/ that the Development
Establishment is not uniform^ Many development
establishments do exist. But they all share
the basic positions outlined here.
30
The ’Oil and other raw materials crisis’ of the
developed countries in the early seventies showed,
--- was not
however, that if those L.Cs were poor, :
Actually,
a great
because they lacked resources,
in
the
rich
countries
deal of the key materials used
.
it
could
no
longer
came from the poor ones. Thus,
were' poor because they
be said that poor <countries
---- f and in
--->
They
did have them,
did not have resources,
--- -j consumed
But
the
resources
were
consumed
large quantities. 1.
by’theYich and not by the poor countries
countries.•
The new position that the development establish
ment took (not necessarily in substitution for but
usually complementing the -population control posi
tion) was that although the poor countries have
material resources, they do not have the
resources (i.e. the know-how or technology) to
Jhlm? Technological transfer from the developed to
the less developed countries became the name of the
game. Scientific and technological, assistance b
came important instruments of interve"^°n^°rJpp^
world poverty. Variants of this position soon appe
ared. One. represented by Shumacher |9| , ^ong
others, included a concern about the type of techn logical transfer.
‘Appropriate technology was a
term frequently used to voice the claim that n°^
technological transfer was positive;.
,^6 |PPJ|
priate form was helpful. The meaning of approprla
however, varied quite considerably.
iful.
appropriate meant small (of the ’small is beautiful
variety). For others, it meant ’labor intensive .
And jo on.
Still another variant was the anti-technology
position represented by. Illich ’
*. J^iutional
appeared side by side with the a^ti-^?s^^tatrv
positions, e.g. anti-medicine and
voiced in the developed countries.) J^v o^clivld
opposed technological transfer, since they p
such transfer as .a process whereby a dePe;V^y on
that technology would be created, thereby finder g
the possibility for individual and
Sent
lopment. The alternative offered was Jhe development
of autonomous spaces outside formal
reliance
placing great emphasis on self-care and. self-reliance
— terms that were used almost interchangeably,
reliance was supposed to be for the community what
self-care was for the individual.
31
All these ideological and political positions
population control, technological transfer, self-care
and self-reliance— were elaborated by the Develop
ment Establishment not independently of but, rather/
in response to, events occurring in the underdevelo
ped countries during that period. It was during
those years that there appeared within the political
and intellectual centres of the underdeveloped capi
talist countries an increased awareness that their
poverty was an outcome not of too many people, nor
of the use of the right (or wrong) type of technology,
but, rather, of a pattern of worldwide relations in
which the few control quite a lot and the many cont
rol very little. The problem was perceived in those
centres to be structural, not conjunctural. It
required changes, not in the variables and factors
of the developmental equation, but in the equation
itself. It required and demanded a New Economic
Order with a redistribution of worldwide resources.
Moreover, an increased number of LDCs were breaking
with that old order through confrontation and re
volutionary transformation.
The Development Establishment’s response to this
new situation was to. agree that some changes needed,
to be made in the world wide distribution of resou
rces, but to insist that change should be based on
cooperation rather than confrontation. This coop
eration would be triggered by moral calls to the
worldwide community, appealing to their humanitari
anism and sense of social justice, side by side with
calls for the capitalist developed countries to be
better aware of their self-interest. Indeed, it is
assumed in this new position that it is in the
developed countries interests that poverty in the
less developed countries be eradicated. Thus, it is
proposed that developed countries share some of thei±
riches with the less developed ones. Otherwise, the
world order will collapse or edplode. Moreover, less
poverty in LDCs will mean more capacity to consume
and thus more markets for the products of the devel
oped. countries.
A typical example of those positions appears in
the Willy Brandt Commision Report (1980)) 111|
1111f, defined ?----- ■’
'
..................... 1
by Elson|* 12| as the
brainchild
of MacNamara, the
President of the World Bank, and prepared by repre
sentatives of the development establishments of
developed (referred to in the Commission as ’North
ern1) and underdeveloped (referred to as ’Southern’)
32
countries*« Characteristic of that report are the
follcwing assumptions:
(1) The World is divided, not into capitalist
and socialist systems and subsystems, J^t, ra e ,
into the North (the (haves')
^he
J Srimarily
oiic?a::TtrSie"
one assumes. »=
too 'rhetorical' and 'ideological'. These terms are
replaced by supposedly non-ideological
J^l
tical ones such as 'global solidarity , ‘mutual
mutual
interests', and the like.
(2) There is not an intrinsic conflict based on
capitalist and imperialist
is
capitalist world order. Instead, the rep
intended to provide a framework within which fu
conciltation and dialogue can take place.
(3) Change has to occur within an unchangeable
set of national and international power relations.
The Willy Brandt Report refers to the devedoPir®^
goals oZthe less developed countries, encouraging
higher growth and greater productivity, with°ut
"wishing to suggest that
in domestic policy,
must be a prior condition for reforms in the giocai
system'1 |15| (emphasis added) .
(ah At the international level, change is
supposed to take placets .a result ^f . aw arenes s^ among
SdiSte poverty6in the underdeveioped ones^ In a
remarkable twist, the intelligent realization of
one’s own interest is seen as the has
interest. ’’Mutual interest (are) rooted m the
S"S-heaSea self-interests of all countries and
*
The Commission included members from Seveioped
and less developed capitalist countries.
9
those coming from LDCs was former Chilean
President Eduardo Fret/ a main opponent or
Allende 1s government<
33
people" l|14| . Thus, the task, of the Commission is to
make both ‘haves’ and""Thave-nots1 aware of the mutu
ality of their interestsr Once these mutual interests
are recognized, “then bo ch emotional and practical
reasons will guide the powerful as well as the power
less in the direction of joint economic activity and
reform” !15l • Within this scenario,- equity, social
justice and humanitarianism appear as abstract, moral
categories: t-eir meaning in progfaromatic terms is
a better distribution of resources within a mutually
beneficial sharing process.
In summary, in this ideological and political
position, conflict, exploitation and expropriation
do not exist. Instead, cooperation, sharing and
collaboration, are- put forward''as the solutions to.
today’s world poverty, Needless to say, within this
theoretical scenario, the concepts of class and class
struggle do not appear., An alternative position,.
however, is that there is a basic conflict underlying
the current world system, a conflict that takes place
within a pattern of class power relations that expl
ain it. :It could be postulated that there is intri
nsic and structural conflict in todayls world, and
not only between the ’have* and ’have-not’ countries
but also (and primarily) between the ’haves’ and
‘have-nots’ within each country. These conflicts
are mutually dependent end reinforceable. Indeed, a
key place in that world system is the one occupied
by the capitalist class of both developed and under
developed-countries, and it is this class for whom
the_.deye 1 opment establishments speak. The capitalist
classes of the' core eapiralist.countries play a key
role in organizing the world capitalist system to
defend their own interests. The capitalist classes
of the LDCs are, for the most part, collaborator
classes.
Whose function is to organize the state and
economy in accordance with the core definitions of
the international division of labor.. The creation
of an international political economic order based
on the inequalities of nations is rooted in the exis
tence of an expanding center of capitalism and a.set
of classes within the periphery whose own expansion
and position is enhanced in the process. The inser
tion of particular social formations within the
world capitalist market and division of labor is
largely the product of classes which combine aa
’I
double role - exploitation within the society and
exchange outside the society. This dual process
leads to the expansion oi production relations and
antagonistic class relations within peripheral society
and competition
growing exchange relations, and
competition with
with the
the
core |16|”.
Thus, the real gap is not between North and
South, but between the capitalist metropoles and the
dominant classes of the capitalist periphery on the
one side and the impoverished population of the
capitalist periphery on the other. It is these class
relations and exploitation that are at ^he^root or
underdevelopment, poverty and the disease or the
thS^
majority o£
world's population.
SOME NEEDED CLARIFICATIONS
Let me clarify here some points that need to be
made. The proposed solutions,'population control
and'technological transfer' first, and a 'cooperative
and mutually beneficial new economic order after
wards - put forward by the development establishments
during the last two decades as answers to the enor
mous problems in today's world do not represent a
conspiracy by those establishments to keep the poor
poor. Nor are they lies put forward to obfuscate
the truth. We h-ve to remember that to tell a lie*
one needs to know the truth. And those establishments
do not know it. These positions respond to a vision
of reality f(or ideology) that makes sense for the
clast which holds it. In other words, in the sixties
when USAID and the Rockefeller Foundation put i°r“
ward programs for population control in Latin America
as a solution for Latin American poverty, they were
bearers of a class-based vision of reality - the U.S.
capitalist class' vision of reality -that led them
to believe that the cause of poverty is not capita
list and imperialist exploitation but, rather, popu
lation explosion. As Marx indicated, every class
has its own ideology-vision of reality - that serve
consciousl y or unconsciously, to reproduce its wown
interests J 17| . It is also characteristic of. every
dominant class to see its own specific class interest
as universal interests. This point bears repeating
in view of the overabundance of references that see
history as an sutcome not of structure but of per
sonalities, conspiracies and individual motivations.
35-
Individuals may be unconscious bearers of ideologies
and practices that serve quite different purposes
from the ones individua'1 ly and consciously desired.
The international health field is crowded with such
contradictions between intentions and effects.
WHO AND THE DEVELOPMENT ESTABLISHMENT
All these ideologies and positions put forward
by the Development Establishment have appeared in
and are being reproduced through the WHO apparatuses.
'Population control' programs, 'technological tran
sfer', 'Self-care and self-reliance' and 'cooper
ative and mutually beneficial new economic order
have been sequentially presented as the solutions
to the overwhelming problems of disease and poverty
in the ‘.underdeveloped world. Indeed, for many years,
WHO has functioned as a 'transmission belt', of
positions and ideologies generated for the most part
in those development establishments. Here, it is
important to stress several points:
’
There is a great need to question two dichoto
mies: Politics/technology and ideology/science . I
have previously argued that science and technology
are not neutral; they carry with them a set of
values and ideologies that reflect and reproduce
power relations |18| » In that respect, WHO, while
being a technical agency of the United Nations, is
also a political agency which reproduces and dis
tributes political positions through its technolo
gical discourse and practices. Thus, it is impor
tant to question the prevalent vision of WHO as
merely a technical agency committed to the eradi
cation of disease in today's world. This vision
belongs to the realm of appearance rather than
reality. Like any other international apparatus.
WHO is the synthesis of power relations (each with
its own ideology, discourse, and practice) in which
one set of relations is dominant. The dominant
powers are the dominant classes in developed capi
talist countries.
Let me stress that I am aware, of course, of
the argument that the top decision-making body of
WHO is the World Health Assembly, in which each
country has one vote. But to believe that the Ass
embly is the top decision-making body would be as
wrong as to believe that the British Parliament is
the top decision-making body in Great Britain, or
36
that the U.S. Congress rules the United States. As
Gramsei said, a vote gives the right but not the
power |19|. The power of the dominant capitalist
classes in those parliamentarian countries is
exercised not only through elective bodies but, to
a large degree, through the administrative, tech
nical and professional apparatuses as well as throu
gh their hegemony over the ideological institutions
(such as universities) that feed those apparatuses.
The same occures in WHO# The power of those classes
is not diminished by changing the composition of
the personnel who represent their interests. In
the same way that the addition of some blacks and
women to the state personnel in the U.S. has not
changed the overall pattern of class dominance m
the U.S. state apparatuses, similarly, to have
individuals of LDC origin in those apparatuses does
not change the existing pattern of control in the
slightest. As Poulantzas has clearly shown, what
counts in Western democracies is not the gender,
race, class or national origin of the state peersonnel but,' rather, their class position | *-0| •, The
_
in their
class position of state personnel- appears
specifically m
in 1) what
technological discourse, sp^v-lf^cally
-- is presented, 2) what is not presented and 3) how
it is presented. And here, again, the same occurs
in WHO. Any analysis of the articles and refer
ences in PnHO publications (the Latin American
branch of WHO), for example, will show 1) a consi
stent presentation of empirical and functionalist
positions, i.e. the dominant ideologies in Western
academic circles, 2) an exclusion of alternate
e.g. Marxist, Positionsand 3) a presentation of the
former positions as merely technological and
apolitical, while the latter positions are portra
yed as political and non-technological.
This situation is not unique toPAHO.
to PAHO. It
appears in most WHO branches. In
cis
— all
-- their
course, there is a 1 depoliticization’ of political
interventions, recycling them into technological
ones. Witness, for example, the great promotion
10 years ago by WHO of the concept of ’barefoot
doctors’. This profoundly political experience
was stripped of its political significance (an
■that ^2
were
outcome of a set of political
1
s
Republic
of
China
at
that
occuring in people
wise
and
intelligent
use
as
a
—
—
-time) and presented
37
of paramedical personnel worthy of imitation in
other political environments. It soon became clear
that experiment could not work in other, settings.
The WHO reports did not seem tq have understood
that the barefoot doctor was a political event and
an outcome of specific political forces, One could
not be understood without the other, The depoliticization of that event, however, was in itself
political.
In summary, there is within WHO 1) a continuous presentation of political positions through
its technological reports with 2) a continuous
repression of alternate positions. The extreme
form of repression, of course, is the exclusion of
alternate positions from the realm of debate. Let
us now analyze how the Alma Ata Declaration fits
within this interpretation of WHO.
THE ALMA ATA DECLARATION
First we have to realize that the major reco
mmendations put forward by the Alma Ata report
were n.t new. In 1972 the Office of Health Econo
mics |21| (the intellectual center of the British
pharmaceutical industry) and in 1975, The World
Bank |22| produced reports on the state of health
and medicine in the underdeveloped world that
closely resemble the Alma Ata recommendations.
Indeed, they are part of the conventional wisdom
within the development establishments. These
recommendations include the following: 1) a change
of priorities within health care services with more
emphasis to be placed on the allocation of resou
rces to (a) primary health care services, (b) water
control and sanitation services and (c) nutrition ;
2) a transfer of medical technology, shifting
from highly sophisticated to less sophisticated
technology; 3) an emphasis on self-care and selfreliance; and 4) encouragement of community
participation in the planning and implementation
of health programs.
How are the above changes to be implemented?
The Alma Ata report stressed the message (repeated
again in the Willy Brandt report) that these cha
nges should take place through cooperation among
nations and interest groups within nations, call
ing on both their morality (the call for social
justice) and their self-interest (the mutual
38
/•
interests of 'haves and 'have-nots1 in a better economic
order)
|23|.
3ecause of the enormous importance of th'-se points, let
me further expand on what.the report does say, what it does
not say, and how it says its
(1) The report speaks of a world divided between have
and 'have-not' nations (and within each nation, of 'have' and
'have-not' individuals) (24). Nowhere do categories such as
capitalism and socialism appear. Thus, capitalist development
is redefined as 'development', a process perceived to.be so
intrinsically good that it 'undoubtedly brings about improvm°nt in health' |25| . Evidence exists, however, that.develop
ment (of the capitalist variety) may not bring about improve
ments in health. I already mentioned the negative impact of
the Brazilian economic miracle on infant mortality in_Sao
Paulo, Brazil. Many others have also shown how some forms an
dimensions cf capitalist development may indeed be more harm
ful than helpful for the improvement of the level of health of
a population | 26 | ■«
(2) The report's suggestions focus on the need to intro
duce organizational and technological change within the frame
work of current power relations. These relations are
considered as given and unchangable* For example, in speaking
about "the need for women as well as men tc enjoy the benefit
of agricultural development", the report, after indicating
that "women are engaged simultaneously in agriculture, house
hold management, and the care of infants and children |27|
recommends that "(Women)" need appropriate technology to
lighten their work load and increase their work Pr°^ct^ty*
They also require knowledge abet nutrition which they can
apply with the resources available, m particular.conee^ing
the proper feeding of children and their own nutrition during
pregnancy and . lactation” «.
in brief, the report is saying that in order to liberate
women, there is a need for more technology (appropriate
technology) and more education of women. The report does not
mention that what is needed for the liberation of women ist
redefinition of the power of women and men within the context
of a profound redefinition of all power (including class
power) relations in the society. Maxine Molyneux has
elocfucrrtly shown how, within the world .
39
of underdevelopment, an economic, political and
social revolution has been a necessary requirement
for the liberation of the majority of women and men|29| •
(3) Besides the technological changes, the report
calls for the collaboration of those who may oppose
the shift of priorities whihin the health care sector,
e.g. the medical professions and the multinational
drug industries. The report suggests that governments
make these interest groups aware of the commonality
of interest they have with the reformers. These
interest groups need to be convinced that the propo
sed changes will be to their benefit as well. For
example, the report notes that ’’physicians and other
professionals will need to be persuaded that they
medical functions but gaining
are not relinquishing medice
health responsibilities" i30|* o Similarly, the drug
and medical industries need to be made aware of the
enormous benefits that they can obtain from the
changes•
’’Opposition from the medical' industries can be
directed into positive.channels by interesting them
in the production of equipment for appropriate
technology to be used in primary health care. . Any
losses from reduced sales of limited amounts of
expensive equipment could well be more than counter
balanced by the sale to large untapped markets of
greater amounts of less expensive equipment arid
supplies for primary health care” |31| ,
In other words, there is a lot of profit to be
made from those changes. An assumption is made here,
of course, that the powerful groups and the powerless
ones (for whose benefit the reforms are supposed to
take place) can share the same interests. This sis in
essence what is being said. What is not said, of
course, is that the medical profession holds a class,
gender and professional position and reproduces anideology and practice aimed at optimizing its class
interests, which.are incconflict with the interests
of the working class and popular masses. This ex
plains why the instruments of the medical profession^
have alw’ays - from the Bolshevik Revoliition to Allende’s
Chile - opposed the socialization programes put for
ward by the working class |32, 3-3-|/ • Similar arguments
can be made about the drug ancj medical industries.
It is to their advantage to reproduce the current
relations of forces within the outside medicine.
Witness the current opposition of the multinational
pharmaceutical industries to the establishment of
National Health Services in the LCDs|34j ... Let us not
forget that the drug industry paid for the fascist
Pihocher coup in Chiles and that the Chilean Medical
Association sent the first telegram of congratulations
to Pinochet! 135| .
(4) The Alma Ata Declaration also calls for com
munity participation. By community, the report
means an aggregate of individuals having common
interests and aspirations (including Health)• Thus,
community participation is defined as "the process by
which individuals (and families) assume responsibility
for their own health and welfare and for those in
the community who develop the capacity to contribute
to their and the community's development" |36| .
Community, then, is seen as an aggregate of indivi
duals s it is more than that. A community is a set
of power relations in which individuals are grouped
into different categories, of which classes are the
key ones. And power is distributed according to
those categories.
A physician, for example, is not merely an
individual* He/she is a member of a class (as well
as a race and gender) whose power comes’ not only from
his/her medical position but also from the position
he/she occupies within the class and gender and race
relations in that society. It is primarily one's
class position that determines one's interests. The
primary commitment of the medical profession# for
example, is not the health of the people. The
primary commitment of those in the medical profession
is to the pptimization of the interests of their
class (as well as their ^ace and gender)»
These four positions are clear ideological and
political positions, and all of them appear in the
Alma Ata Declaration. These positions need to be
critized, not because they are limited (i.e. they do
not go far enough) ,but’ becausd they are wrong. But
let's continue our analysis of the WHO Alma Ata.
positions and aee what other ideologies appear in
them.
THE HEALTH CARE 2TSTEM AS THE HEALTH SYSTEM
(5) The Alma. Ata report uses the expressions
'health'health care1, 'health care sector',
'medical care1 and 'health systems' interchangeably•
On deeper analysis, Lt appears that what the report
'41
actually means by health system is basically a health
care system built upon and organized around the medical
care ystem, i«e. health Jare goods and services pro
vided to individuals and families by health profess
ions and health workers. The report’s main recomm
endation is to shift the emphasis more toward primary
care. That shift is supposed to take place within a
medical care system in which primary health care
should be at the center|37.jS
"Primary health care is the hub of the health
system. Around it are arranged the other levels of
the system whose actions converge on primary health
care in order to support it and to permit it to
provide essential health care on a continuing basis.
At the intermediate level more complex problems can
be dealt with, and more skilled and specialized care
as well as logistic support provided. At this level,
more highly trained staff provide support through
training and through guidance on practical problems
that arise in connection with all aspects of primary
health care. The central level provides planning
and managerial expertise, highly specialized care,
teaching for specialist staff, the expertise of
such institutions as central health laboratories, and
- central logistic and financial support-’ISdl .
It is clear from this quotation that the report
is basically referring to regionalized and modified
medical care system which includes primary, second
ary and tertiary care services, giving major emphasis
to primary care. Primary care is to include preven
tive as well as curative services, environmental as
w$ll as personal health services. The report is aware, ..
of course, that health cannot be attained by the health
sector alone |39| . It indicates that other interven
tions, such as anti-poverty programs,, water, sani
tation, housing and education, contribute to health.
Later on, the report refers, to these interventions
as supportive of the primary care sector” Hoj- •
Agricultural, water, housing, public works and commu
nication interventions need to be designed to support
the tasks of the primary health care sector, which is
considered to be at the center of those endeavors.
In summary, the report uses health and health
care interchangebly. Thus, when the report speaks about
health for all by the year 2000, the report is actually
promoting accessibility to health services for all by
the year 2000. Moreover, by considering the primary
42
health services as 11 the key to achieving an acceptable
level of health throughout the world”# the report
singles out health services as the most important
intervention to attain health |41|• The central role
that accessibility and availability to health services
plays in this strategy for health needs to be chall’enged. It represents an ideological and political
position that indeed# should be questioned.
I do not want to minimize the importance of a
shift of priorities within the health care sector.
Nor do I want to diminish the value of expanding the
responsibilities of the health care sector. These
are very important tasks. But to consider them as
the most important interventions to achieve health
for- all is profoundly incorrect. Most improvements.
in health have been due to changes in economic# social
and political structures rather than in the health
sector. Indeed# abundant empirical evidence exists
to show that the most important changes in the health
of the underdeveloped countries’ populations during
the last 20 years have occurredin revolutionary
socialist underdeveloped countries via changes in
their economic# political and social structures#
independently of and outside the health care sector.
It is worth mentioning that even the British pharma
ceutical industry recognizes that the major changes
in health have taken place in revolutionary socialist
countries# referred to in its report as ’command eco
nomies’ | 42 |. Those revolutionary changes have also
enables changes in the health sector t^at have
assisted in the further improvement of health, But
most of the changes have taken place because of
interventions coming from outside the health care
sector•
EMPTRICISM OR ATHEORETICAL. PRAGMATISM IN THE ALMA_
ATA DECLARATION; THE WAY OP INTERPRETING NON-HEALTHSECTOR-RELATED INTERVENTIONS
(6) The Alma Ata document recommends a series
of interventions outside the health sector# such as
food production and education plus changes in public
works and communications# housing# water etc. 143|.•
All of these changes are needed to improve the health
of the population. This listing of activities is
presented in.apolitical terms. However# this type of
presentation is itself political. It assumes that
each of these interventions has a autonomy of its own.
In sociological discourse this is called empiricism
or atheoretical pragmation# i.e. the analysis of the
43
variables without reference to their structural deter
minants. A system, society or community, however,
is defined not by the individual elements and/or
interventions that exist within it but, rather, by
the structural relationships,among these elements and
the powers they reproduce. Linear atheoretical prag
matism and empiricist thinking view interventions as
independent of the structure and the power relations
that determine them. For example, the discussion on
whether ’population control' or 'technical transfer'
or’the New Economic Order' is the solution to under
development carries with it this type of thinking.
The ways in which the questions are posed predefine
the answers. The reality (which is dialectical
rather than linear) shows, however, that to know whe
ther population size is a problem or not, we have to
understand the variable (size of the population)
within its historical and political context. In
I.. other
words, the size of the population may or rnay not be a
problem, depending on the social, economic and
political structure in which that population is art
iculated.
In summary, what defines the effectiveness of an
intervention (e.g. housing) is not that variable per
se but, rather, 1) how the different interventions
are structurally related; and 2) who and what are the
agents of change, conflict, ana resistance within
those, structures (both within and outside medicine)•
A specific intervention may be successful in Cuba but
ineffective in El Salvador. Its analysis needs to be
seen politically and historically. Empiricism and
atheoretical pragmatism fail to do this; by not re
lating the parts to the totality, the totality remains
unchanged. The Alma Ata Declaration fails in the same
way. Its assumed ’pragmatism' is only an indicator
of its ideological function.
Here, again,7..we find that the Alma Ata recommen
dations are not so much limited but, rather, incorrect.
The mere listing of different types of interventions
(both outside and within the health care system) is
misleading, since the key question (whether they are
or are not to be effective) depends on.how these
intervention? are related within a structure and a
set of power relations that give their meaning and im
portance. The avoidance of recognition ofthe§e
structures and power relations is thus the main
weakness of the report.
44
CONCLUDING REMARKS
Contrary to widely held belief, health is a pro
foundly political issue. I have tried to /show in
this part of the article how the Alma Ata Declaration
is not apolitical but rather profoundly political.
WHO, through its technological-administrative reports,
reproduces ideologies and political positions as
well. The WHO Alma Ata Declaration is not an excep
tion.
Let me quickly add that it is not my intention to
castigate but, rather, to critique that reports It
does contain, after all, a good major reconmendation,
i.e. the shifting of priorities within health care
toward primary care and away from secondary and
tertiary care« But ii:s_^.Qf—'
health problems. In tod ayLs..rposed solutions for, them.. is
X ts rec omme nd a tions reproduce, for toe most part, the point of view
of the development establishments.-, These views are
part of the problems and not of the solution^ they
represent the perspective of the dominant classes in
today’s world.
The changes in the world structures and the
power relations that explain them (greatly stimulated
by the new liberation forces that are breaking with
the Old Economic Order) will determine changes in the
United Nations and in the ’technical* agencies within
it - including WHO. A sign of that change will be for
WHO -co 1) break with the medical ideology (the
Flexnerian model) that sees health as an outcome of
medical care, however that care may be redefined and
expanded as health care and primary health cares ^nd
2) embrace the systemic view of health that explicitly
sees health in the world of underdevelopment today
as primarily an outcome of politically determined
structural economic and social changes.
This new understanding of what health and health
struggles are should lead the WHO or the future to
focus on 1) concrete assistance to the liberation,
movements in their struggles against institutionalized
violence and disease*; 2) analysis of the structural
constraints to health and the class and other forms of
resistance to basic change;
3) change of all existing
staff and consultant structures to better reflect the
huge diversity of views on health/ breaking with the
* Foot-note on next page
45
dominant medical ideology; and 4) research and stor
age of information on the international mobility of
capital and labor and its possible implications for
health, Let me add that today/ for example/ there
is no international agency that gathers information
on the flow of capital (including toxic industries),
among countries and continents, nor about the move
ment of workers (migrations) between countries and.
the health consequences of both. Similarly/ there is
no international agency which collects systematic
information about structural economic changes and
health, nor about employment (or lack of it) and
health.
These are mere examples of areas and problems
that need to be faced and that have not been faced^
because they are seen as too ’controversial' or
'political'o They are controversial because they
threaten the interests of the dominant powers that
define the acceptable items in the social agenda.
They are not more political, however, than the current
'technological' discourse that dominates WHO positions.
They do respond to different interests than the dom
inant ones, the ones that establish the permissible
boundaries of current discourse. Still, demands for
change are increasing, augmented by the largest crisis
that the world capitalist system has faced since the
1930s. New, bold and daring solutions need to be put
forward that will transcend and leave behind the Alma
Ata report. This new discourse will not be the one
of the development establishments of the Western
world, but will come from the authentic representatives
of the majorities in the underdeveloped world who
will justly proclaim their right to a place under
the sun in their magnificent lands which could, under
different system, give to all what is now denied to
most.
* Although I am aware of the structural constraints
under which WHO operates, still the reality is
that other U.N. agencies are providing such
assistance already.
46
REFSRENCES
1.
Alma Ata International Conference on Primary Health
Care. Alma Ata, U.S.S.R., 1978.
2.
Cited in Bryant J.H. WHO program of health for all
by the year 2000s a macrosystem for health policy
makings a challenge to social science research.
Soc. Sci. Med., 14A, 332, 1930.
3.
Cited in the Seventh General Programme of Work
approved by World Health Assembly. WHO Chron. 3 6,
129-176, 1932.
4.
Cited in Bryo.nt J.H. on. cit p. 332.
5.
Estimated service coverage for Sanitation in
developing countries. 1970-19..0 In Drinking .Wnter
VIay to_
to Health,
Health. p. 2...
and S an i t at ion _19jc A Way
Geneva,
1901.
World Health Organization.
6.
Wood C. H. The political economy of infant mortality
in Sao Paulo, Brazil. Int,
Hj_thSer. 12, 215, 1902.
7.
This fact and many others explaining the deterioration
of the standard of living in many less developed
countries, is kited in Navarro V. The crisis of the
international capitalist order and its implications
in the welfare state. Int. J. Hlth. Sery. 12, 1j5, 1932.
Haignere C. S. The application of the free market
economic model in Chile and the effects on the^population's health status, I nt. J. Hl th. Sery. 13,.339,
1933.
9.
Schumacher E. F. Small I
ul (Economic^ as if
Iss Beautifful
People Mattered) Harper & Row, New York, 1975.
10.
Illich I o Tools for Conviviality.
London, 1973.
11.
northed Soixth. A Program for Survival. , The Report
of "the Independent Commission on International.
Development Issues finder the Chairmanship of Willy
Brandt Cambridge, MAj 1930..^.....^
12.
Elson E. The Brandt Report, a programme for survival
Capital^ and Class, 16, 110, 1932.
13 •
Willy Brandt Commission Reoort, op. cit, p.126.
14.
Ibid., p. 77.
15.
Graf W. D. Anti-Brandt, a critique of north-western
prescriptions for world order. 3- o $ 11-5- b JR §
2, 1901.
Calder Bovars,
16.
Petras J. Critical Perspectives on Imperialism and
Social Class in the Third World, p.36. Monthly
Review Press, New York, 1978.
17.
Marx K. German Ideology. Progressive Publishers,
Chicago. 11, 1976.
18.
Navarro V. Work, ideology and science, the case of
medicine. Soc. Sci. Med., 14C, 191-205, 1930.
19.
Gramsei A. Prison Notebooks. International Publishers,
New York, 1971.
20.
Poulantzas N. State Power and Socialism•
Books, London, 1978.
21.
Medical Care in Developing Countries. Office of
Health Economics, London, 1972.
22.
Health.Sector Policy Paper. World Bank,
23.
Alma Ata report, op. cit., 11,12 and 13 also pp 44,49.
24.
Ibid. p. 7.
25.
Ibid .p. 12
26.
Navarro V. (Ed) Imperialism, Health and Medicine
Baywood Publishing Co. Farmingdale. N.Y. (98).
27.
Alma Ata report, op.cit., p.16
28%
Ibidem
29.
Molyneax M. Socialist Societies old and new; progress
towards women's emancipation. Monthly Rev. 34, 56
30.
Alma Ata, op. cit., p.ll.
31.
Ibid., p.12
32.
Deprofessionalization and democratization in the
health sector in the period 1917-1921. In social
Security and Medicine in the USSR. A Marxist Critique
(Edited by Navarro v.^, p.18. Lexington Books,
Lexington , MA. 1977.
New Left
1975.
4
I
48 •
3 3.
breaking
of
Allende’s Chile a case study in the
--1.4
underdevelopment. Medicine Under Ca-pj-taligm
(Edited by Navarro V.) , .Neal Watson. New
I-- Yd-rk, 1976.
34.
Medicines, Health and the Poor Wor]^> ?• 21. Office
of Health Economics, London, 19UZ.
35.
Navarro V.
36.
Alma Ata. op. cit., p. 20
37.
Ibid., p. 23
38.
Ibidem
39.
Ibid., P- 10
40.
Ibid.,
41.
Ibid
42.
cit
Medicines^ Health and Poor World, op*
43.
Alma Ata. Ibid•t pp 16-18.
—
-?•
Vx.-
m
Allende's Chile, op. cit.
15
p.il5
49
■4
p. 37
THE POLITICS OF PRIMARY_HEALTH^CARE*
-7.7
Malcolm Segall
When primary health care (PHC) made its some
what glittering debut on the world stage in the
1970s, it took on the ambitious role of the agency
by which a decent level of health for all peoples
would be achieved by the year 2000. Now, well in^°
the penultimate decade of the century, PHO seems to
be losing momentum and may be in danger of.going thee
way of its predecessor - basic health.services
- in starting as a good idea at the time, but be
coming one that is more spoken about than acted upon.
In this article I want to review the politics
of this situation, and try to make the case that
political factors underlie past failures and may e
the key to future successes.
To simplify the ex
position the discussion will he limited tp develop
ing countries, although many of the issues, apply.
also to the developed world.
Similarly t£e argu
ment will be couched mainly in terms of the typi
cal oneed in developing countries to imprfev| the
health of the impoverished rural majority of th
population, on the understanding that many of the
principles apply also to the urban poor.
PRIMARY HEALTH CARB; ITS RISE AND FALLo
The EHC approach may be characterised aS'embodying three basic ideas (Segall 1983a):
-
That the promotion of health depends fundamen
tally on improving socioeconomic conditions
and, in most parts of the world, on the alle
viation of poverty and underdevelopment;
That in this process the mass of the people
should be both major activists and the main
beneficiaries;
That the health care system should be restru22
tured to support priority activities at the pri■vex because these respond to the most
mary level,
urgent 1.health
----- needs of the people.
* IDS Bulletin, Vol. 14, No. 4,
October 1983> PP 27-37
36
y
i
The third of these elements is essentially
the same as the BHS strategy y although with the
knowledge of how inadequately the latter was im
plemented, there is now a greater concentration
on the need to mould the whole health system to
support the development of the primary level.
While controlling expenditures on large urban
hospitals was a recognised corollary of BHS
thinking, there was still the tendency to
treat the BHS as a separate programme,
With
PHC came more coherent statements about the
need for integrated health sector planning and
development, including even consideration of
the private sector (Djukanovic and Mach 1975:
21-2; WHO/UNICEE 1978;40).
This was an impor
tant change of emphasis.
Nevertheless, it was the addition of the
two ideas listed first above - asserting the
importance of poverty and community participa
tion - as major elements of international
thinking on health policy that constituted the
qualitative departure of PHC from BHS (Djuka
novic and Mach 1975:10-16; WHO/UNICEF 1978:
44-52) . These new elements did have their fore
runners during the BHS period, and some ver
sions of that model acknowledged more than
others the importance of poverty in disease
and of seeking community co-operation with
health service personnel (see for example King
1966:ch 1). Yet these factors were never ope
rationalised as central features of the stra
tegy, and the BHS approach was essentially
technocratic and indeed often paternalistic:
health was something to be ’delivered’ to
the population by health professionals and
their assistants.
In this sense PHC represented a break
through in official policy formulation.. In
international circles, health was now distin
guished more clearly as a separate, if related
entity from health care: the former was the
product of many factors of which health care
was only one, if an important one.
What prom
pted this ideological shift at the beginning
of the 1970s? The scientific basis for asci*it>ing importance to socio-economic factors
in health had been established for a long time.
Two main reasons for the change may be identi. .
. 51
with the assistance at
j
-nohun Roy Library To-. i htion
H FA - 1oo
R RRLP
05354^ vv' ►’40 1
A2 A1
One was the evident failure of the BHS stra
tegy to materialise. While there was much talk
of extending rural health services through health
centres, auxiliary personnel and low-cost techno
logy, practical progress was painfully slow, and
resources continued to be channelled disproportion
ately to expensive hospital and medical care for
urban minorities, especially the well-off.
Mean
while earlier improvements in life expectancy at
birth were slowing down (Gwatkin 1980), and health
and nutritional status in the developing world
remained very poor, with hi£h morbidity and mor
tality rates due to largely preventable diseases
(for a review of the situation at the time see
Office of Health Economics 1972).
There was a
growing crisis of confidence in the conventional
wisdom about health, and strategists were look
ing around for ’alternative approaches’ to sol
ving the problems.
The second main factor prompting the appearance of PHC was the recognition of the successes
Some of these
of certain practical experiences.
in
capitalist
countries,
often
involving
were
non—
government projects that were adopting pro
-government
gressive approaches, particularly with regard
to community participation. Yet it would mean
a rewriting of the history of that period not
to acknowledge that the main demonstration effect
came from the national experiences of the deve
loping socialist countries, notably China and
Cuba, and especially the former (see for exam
ple Djukanovic and Mach 1975? Newell 1975)* I*1
these countries poverty had been greatly alle
viated, access to health services had markedly
increased, and health and nutritional status
had substantially improved.
One new feature
of these experiences was the organisation of
the people through political and social struc
tures.
Though some of the account at the time
may have painted a somewhat idealised picture,
descriptions of the health movement in China
particularly after ^965 (see for example Horn
1969; Akhtar 1975? Wilenski 1979), and especi
ally the mass campaigns and the barefoot doctors,
caught the imagination of world health circles
looking for a way out of the apparent impasse.
Primary health care was born as a synthesis
As
of these negative and positive experiences,
it
a statement of the then ’state of the art
52
and PHC provided
r“-e
blems.
Some years on, however, it ws all once
again proving to be very difficult.
To quote an
international study which was a ^^^-^piukSivic
original 'Alternative Approaches
study (Djukano
and Mach 1975) that launched PHC on to the world
stage:
.... there is often a large gap between PHC
plans’and implementation: words abound, but concrt?e results are frequently.thin on the ground.
What progress there is seems often to be along
conventional basic health service Hues, Bometimes extended in a cheaper version m the for
of village-based health workers.
The scope and
depth of community involvement are often doubtful.
The co-ordication of health and development plan
ning if often poor and intersectoral healthrelfted activities are frequently rudimentary.
Vertical single disease] programmes are often no
yet integrated with PHC in ^ct^/uNICBP 1981;48)
Meanwhile the recession is slowing down, ,
«
—- c per capiba
wiping out or even reversing
capita economic
economic^
of the^Third World, especially
growth in many parts o-*- -»•— in the poorest countries, with bleak prospec s a
possibly increasing poverty in the 1980s (World
Bank 1980a).
Overall per
Overall
per capita food production
(excluding
China and the
nn Hoveloning countries (
--other Asian socialist countries) scarcely grew
during the 1970s and in many areas ^^SO • 79-SO)
Africa) actually decreased (PAO 1977•4,1980.79
J
Earlier increases in life expectancy are slowing io
down substantially, and in Some areas have
or have even been reversed. (Gwatkm 1 980) . Accord
ing to the latest WHO report on the world health
situation: 'As regards the many diseases that
plague the less developed countries, there appears
to have been little or no progress m recent year
in reducing either their incidence or their pre
valence' ; some communicable diseases appear
on the increase, and nutritional deficiencies are
widespread and serious (WHO 1QSO;46).
1Q80:46).
The reality must be faced
ment is not yet fulfilling its
health to the world's peoples,
2000, by when 'Health for AH'
that the PHC move
promise to bring
and that the year
is meant to be
achieved/
is approaching fast,
What are the obsta-
cles to better progress?
A POLITICAL OVERVIEW OF PHC
I will now review in turn the three basic PHC
themes itemised earlier in order to bring out their
political quality.
This will not be debated in
depth since it is assumed that the experienced read
er will be familiar with the issues referred to;
my purpose is only to survey the broad political
topography of the area.
THE POLITICAL ECONOMY OF HEALTH
The importance of socioeconomic conditions for
health is now well established (see for example
McKeown 1979; WHO 1980).
Many health indicators
related
to
social
class
or reflection of class
are
:e occupation, income, literacy and housing) at
all levels of development (Stewart 1971; Cochrane
et al 1978; Preston 1976, 1980:291-3; WHO 1980;
Townsend and Davidson 1982). Life expectancy at
birth, for example, correlates closely with per
capita income, . a relationship that holds bothebetween countries and within countries.
There have been suggestions that the advent of
modern health technology has weakened the relation
ship between income and life expectancy, in the sen
se that many health problems which previously had
to await socioeconomic development can now be dealt
with technically (see for example G-olladay 1980:1825a
In fact, if anything, the evidence is that mortality
reductions in lower income countries became more
responsive to rising per capita national income in
the 1960s than they had been in the 1930s (Preston
1976).
Two plausible explanations for this are that
modern health care is more effective in synergism
1 Resolution WHA 30.43 of the 30th World Health
Assembly, 1977•
The relationship is approximately logarithmic
with an upper limit to the effect of income
above which no further gain in life expectancy
is seen (Preston 1976).
54
with higher living standards,, and/or that greater
healnational wealth allows the provision of better
.
th ca-e.3 ‘ Modern health technology has simply mesn-t
that greater life expectancies are achieved now for
any given level of income, but the relationship bet
ween income and life expectancy continues to hold
strongly.
An estimate has been made that about half
the gain in life expectancy achieved by the develop
ing countries between the late 1930s and the late
1960s cannot be explained statistically by increases
in per capita income, dietary calorie availability
and literacy rates, and it is reasonable to assume
that this part of the gain is the result of specific
health measures (Preston 1980:304-13).
However,
whatever has been the empirical apportionment of
responsibility between social and technical factors
in health improvements in the past, there is no reaer.
son whatsoever to doubi that greater socioeconomic
advances would have resulted in greater health impro
vements or that they would do so m the feature. No
amount of technical advance is an argument for under
playing the importance of acting on social conditions
to improve health..
Also it is necessary to compare like with like
ancy as a result of modern health technology will
have been due, to a considerable degree, to curati
measures, es-pecially to the use o on i in
ssion
drugs.
While the latter may reduce the transmissi
of some communicable diseases, the predominant effect
of curative care is to aid recovery and Prevent dea
ths from specific disease episodes, rather than d
crease the occurrence of ill health.
? . e.
that health care is curative, its e^ect in
.
sing life expectancy do.es not have the same implic
ations for improved health status as increases m
life expectancy resulting from improved socioeconomic
3 The association of higher average per capita
national income with better health does
contradict the argument that m most countries
a more equitable distribution of income and
health care would produce better results still.
55
circumstances.
The latter constitute the ultimate
means of primary prevention and reduce the incidence
and severity of a range of important nutritional,
infective and obstetric conditions, among others.
In improved social circumstances people are altoge*
ther healthier and that is why they are not dying
prematurely•
The struggle against poverty must therefore
remain in the forefront of the EHC approach: but
what does this amount to? Poverty rarely results
mainly from an absolute lack of resources.
Its
principal causes are social structures that prevent
people from working productively, reaping the bene
fits of their labour, and raising their living
standards.
The problem is less poverty as such th^n
the structural causes of poverty.
Landless labourers represent a large proportion
of the population in many developing countries: in
India a third of the population is landless, and
several African Countries witnessed a considerable
growth of landlessness during the 1970s (WHO 1980-27).
In 1975, a third of the urban labour force
and 40 percent of the total labour force in develorping countries (excluding China and the other Asian
socialist countries) were unemployed or underemplo
yed (iLO 1976:18).
The international economic sit
uation has greatly worsened for the developing
countries.
As an illustration, the import of a
lorry to Mozambique could be covered in 1975 ("the
year of the country’s independence) by the export
of 5.5 tons of cotton, whereas the figure in 1981
was 12.9 tons; between the same two years, the
amount of sugar that had to be exported to cover
the import of a ton of ccrude oil rose from 174kg to
639Kg (Frelimo 1983:32)..
Facts like these- far
removed from those that are'usually taught in mediae
cal schools - cannot be separated from the quest
for better health.
The struggle for health may thus involve a
range of actions in the economic, social and political
field, as diverse as for example: the structure of
owndrship of productive resources; the control of
markets and prices; the stimulation of economic and
social cooperation among direct producers; the prov
ision to the latter of adequate government resources,
credit on favourable terms, and access to productive
inputs and appropriate technology; and the structure
of international economic relations. Does this mean
56
that PHC is synonymous with the whole development
process? In a way the answer must indeed be yes,
but for practical purposes it needs to have a sha
rper focus, I believe the PHC approach must involve
that (substantial) part of the development process
which relates directly to thej alleviation of (at
least the worst aspects of) poverty in the short
t erm.
Overcoming poverty implies economic growth;
yet this is now well recognised to be a necessary
In the context of
but insufficient condition,
(at least a reasonable measure of) growth, the
alleviation of poverty means in the first instance
a more
more equitable distribution of income, especially
•£-f -the latter is understood broadly to include both
cash and subsistence income and the 'social wage*
(education, health care, and other public services)•
However, income distribution — so often the focus
of attention in reforming development strategies is an insufficient characterisation of the problem,
because it does not draw enough attention to the
More fundamental is the
determinants of income,
i
distribution of the means to generate income: the
distribution of productive wealth; and1 more fundadistribution of the means to
mental still is the
•-- ------decide on the distribution of wealth and income:
the distribution of political power.
It is to cover these basic structural questions
that I use the term, ’the political economy of
health*.
It should be noted that this embraces
social issues much more far-reaching than those of
’intersectoral coordination’ (involving mainly co
operation among government extension services) that
often passes for the socioeconomic or development
component of the PHC approach.
Important as inter
sectoral coordination is, it does not begin to cope
with the fundamental questions of income, wealth
and power, which must be faced if the goal to achi
eve ’Health for All’ during the next 17 years is
taken at all seriously.
the scope for popular initiatives
Community participation has become one of the
shiboleths of PHC, which is not surprising given the
power of popular involvement in health promotion.
One of the attractions of the idea for many govern
ments - and for some international agencies - is
57
the notion that rural communities can be expected to
raise their own resources for health care.
Even in
China, it is pointed out the commune health system
is mainly financed cooperatively.
It is important
to recognise, however, the context in which that
system operates.
The economic and social situation
of the communes is such that the annual membership it
contribution to a cooperative medical scheme amounts
to only some 0.6-3 per cent of disposable personal r
income, and there are also collective welfare funds
to cover a proportion of the health expenditures,
including the payment of the barefoot doctors and
other public health workers (Teh-wei Hu 1976), Also
the central government now allocates a majority of
the national health expenditure to the rural areas
(preferentially to the poorer ones), subsidising
the commune clinics and tht) county health services
that support the commune health system.
This is
quite different from the typical Third World situa
tion where impoverished rural communities are expe
cted to raise their own health resources, while
government (and private) health funds continue to
flow disproportionately to provide sophisticated
care for the care for the city populations.
This is
a case of self-reliance and village health workers
for the rural poor, and hospitals and medical spec
ialists for the urban rich- all in the name of prim
ary health care.
It is not that, in fair circum
stances and in proper proportion,communities should
not contribute health care resources; doing so is
indeed one aspect of their assuming responsibility
in this field.
But this fact should not let govern
ments ’off the hook’ wirh regard to reshaping the
pattern of resource allrcation in the health sector
to give priority to those in greatest need.
This excessive preoccupation with raising
community resources has often displaced attention
from the central aspect of popular involvement in
health, namely, the people’s organised involvement
in planning and decision-making on health-related
activities. This may be less attractive to govern
ments because it implies a degree of devolution of
power, but it is one of the main features distingu
ishing the EHC from the BHS approach.
Before dealing with the question of power, it
should be noted first that deprivation itself exerts
a great constraint on popular initiative.
There
is often the lack of the material means to implement
plans, and insufficient education hampers planning
and management. Yet beyond these more obvious
.
58
constraints, one of the most scarce resources m
implementation of communal activities.
One may a
how, for example, women - such important agents for
health or disease in a community - carrying the
responsibilities for household management and child
rearing, and often doing much of the farming, can
become effective in the participants health develop
ment process in these circumstances.
not r.fon
to .ubjootive
relations at the individual level, but to the rel
ionships that develop within the community as a
result of the objective positions different peopl
hold in relation to the Prevailing power structur.
In official mythologies of community Participation,
communities are portrayed as harmonious
entities, existing in an unproblematicrelotionship
with governments and even sometimes ^th the^wider
economy.
But communities are divided and stratified
socially, and they exist within the social class
structure of* "th.© naAionnl society.
Tenant farmers and landless labourers on the
one hand, and landlords on the other, do not have a
ter^^meSinSuSrarSmbSrs 0?^^: communi
ty, who happen to perform different roles.
o
homesteaders may well have different community
interests from those who hold some capital, „
are very likely to have different interests from the
owners or managers of large scale ccmmercia
'
ti
or plantations.
Differential ownership of productive
resources creates different class in
^making
confers great influence in community decision
on those holding economic power.
Often overlapping
or articulating with these economic power relations
is the traditional social structure with
w* — its various
stratifications.
The 'community, is a differen
place to the mass of local inhabitants than it is to
the unelected leaders of this traditional system,
with its related social divisions on the bases of age,
on*
sex, tribe, region, caste, ethnic origin, and
59
>
■
Not unconnected with these social divisions with
in communities are the problems in the relationship
between such ’communities' and the government. These
problems are usually ascribed to the bureaucratic
nature of the government machinery and the arbitrary/
attitudes of local administrators.
These can certain
ly cause real difficulties, but they are an insuffi-r
cient characterisation of the problem area.
The local
bureaucrat or policman, respectively administering
and enforcing, for example, the laws on land tenure
and wage labour, have an objectively different relat
ionship with tenant farmers and the landless than
they do with landlords and landowners, and a“different
relationship with farm workers than they do with rural
employers.
These are social relations conditioned by
the national political structure.
The economic and
political relationships in the wider society are pres?
ent at the community level, mediated by representatives
of the dominant national classes and the political
machinery, and often articulated with local dominant
classes or strata.
Unequal economic and political power are the
bases for the divisions in the community, and they
are maintained by means of the law and the enforce
ment agencies.
But peaceful social life implies that
these coercive means are invoked as rarely as possible,
and clothing the iron fist of force is the softer
These add the
velvet glove of supportive ideologies,
and
by mysticultural dimension to the power nexus,
fying life promote a passive acceptance of the status
quo by those on the receiving end of power*
In rural
communities traditional ideologies are particularly
strong and they can exert a highly conservative in
fluence, sometimes even in the face of crude explo
itation and oppression. No better example of this
can be found than their role in the almost omnipresent
subordination of women.
In such circumstances 'community participation1
may mean little more than the government obtaining local
compliance with its own predetermined plans (including
possibly the extraction of community resources) or it
might involve allowing the community a voice which is
in fact articulated mainly by the local holders of
power, who could well be among the main beneficiaries
of participatory exercises (see for example Ahmed
1978:88).
Local leadership of an undemocratic- kind
can succeed in mobilising populations up to a point,
especially for defined projects with a limited time
60
frame (like clinic building or well digging), but it
tends to suppress the active and creative involvement
of the people in the ongoing planning and implemen
tation of health and development activities (.see for
example Segall and White 1981).
The struggle for popular narticipation is basi
cally the struggle for democratisation of decision
making and economic power.
To achieve this goal it
is usually necessary to have specific social struct—ures - new in-most parts of the world - that will
provide for the democratic debate and managemen o
community affairs, and will supply the ideological
inputs necessary to support the involvement of the
presently weaker community members.
This is an
eminently political process, involving a transfer of
power and influence from a minority to the majori y
at the community level, and it will require a national
political process to initiate and foster its development.
RESTRUCTURING- THE HEALTH CARE SECTOR
Mudh has been written already about the typical
maldistxibuticn of health care in developing countrminority urban populations - usually alles f with iuj-xawj.
ready enjoying better health as a, result of higher
living standards - benefiting from health care
resources per capita very many times greater than
, who carry a much heavier burden of
the rural poor
disease.
This maldistribution is usually chara
This
cterised in simple urban/rural terms, but it sho
be emphasised ‘that many of the health and health
care problems of the rural areas are shared kif
generally in lesser measure) by the town poor.
The urban health care takes the form mainly of
a combill.Tition
comcin.aTion ui
of government services and the private
medical sub-sector^
Health care is available
4 The discussion here of private medicine will
exclude voluntary agencies, traditional prac itiohers and household self-care.
The more
complex situation of compulsory health insurance
and social security schemes for wage earners,
wh-ich in many developing countries have some
effects similar to those of private medicine,
will also be excluded.
61
generally to the urban population, and even the
private market at its cheaper end may be patronised
by the poorer social classes. Nevertheless, the
main beneficiaries of the private sub-sector are
obviously those who — in the national context and
in simple terms - may be said to constitute the urban,
rich, and they also often have privileged access to
the best government facilities and personnel, some
times by paying (often relatively small) fees.
The
principal pressure to maintain and develop the level
of urban health care thus comes from these main
beneficiaries, who also wield the greatest political
clout.
One mechanism for achieving their goal is
political influence on the allocation of government
resources; another is pressure in favour of private
medicine•
The 'nriv.a'te medical sub-sector may be subs"triiit*•’
lai in developing countries, in expenditure terms
being often as large as, or larger than the govern
ment health services (World Bank 1980b; Preston
1980:340).
The private sub-sector is inherently
maldistributive , in that it directs health care res
ources to those who can pay rather than to those with
the greatest need.
Nevertheless, a defence commonly
put'forward by'the protagonists of private medicine
is that it takes a middle-class load off the govern
ment health services, which can then concetrate
their efforts on the poor.
This argument overlooks,
however, the extent to which the private an(^ Public
sub-sectors intermesh to the detriment of the latter
(Segall 1983a).
To itemise some of the effects, the
private sub-sector: absorbs scarce government-trained
health personnel; practises excessive and expensive
curative care, inflating medical costs;and drawing
on the country’s limited foreign exchange for phar
maceuticals and equipment; reinforces the technocra
tic clinical bias in medical education and influences
students’ attitudes towards profit-making private
practice, thus undermining attempts to orientate
health workers towards the PHC- approach; and consti
tutes the independent economic base from which the
conservative fraction of the medical profession can
oppose structural reforms in the health sector.
In
addition, the private sub-sector is often not comple
tely financed privately, but receives substantial
direct and indirect public subsidies, ranging from
the use of health service facilities and personnel
at no or below cost, to tax concessions on private
health insurance contributions.
62
The reshaping of the health sector in the
ion.
On the consumer side these comprise, as ment
ioned, the urban rich, who benefit from superior
health care both as individuals and as employers
wanting to provide private medical insurance schemes
for their workforce.55 On the producer side are the
health care professionals, especially the doctors,
and private capital in the for* of the pharmaceu
tical and medical equipment industries, and those
private hospitals and health insurance companies
This is a formidable
that are profit-making,
enough, alliance.
Reshaping the health sector for PHC rarely
takes the form of the actual redistribution of
existing health care resources from urban to rural
-reas.
Even where this would be appropriate and.
there is a legitimate case for rationalisations m
urban care, it is usually resisted vigorously
and openly, and the political Bcope/for reductions
in existing levels of urban service is strictly
limited.
Reshaping the sector's resource pattern
is achieved usually by allocating the bulk of new
expenditures to the expansion of rural health car ,
and here the opposition manifests itself indirect y.
Primary health care is never.opposed aS such, m
these days of its orthodoxy is must indeed b
supported in theory- and there is no reason why
-Ho supported
sn-nncrrted in
theory.
fhe practical
,
cannot be
in theory.
u ciise
■
’
-"
’
Icing
of
the
limited
str'‘'-ggl© is over "the s.
omuetitive
of new rescu7?ces«
-it :-s the making of c
1urgent
---•■.y’ces
demands on 'these re
sou:
— to meet other
typically of a high
needs 11 in
in the
the urban
urban areas,
areas
common form
technology character, that is
in
the
health
sector.
of opposition to PHC reform
-‘
>
these
denfands,
Unless there is adequate resistance to
5
that
PHC
is
a national situation easily develops ■—
urban
high
technology
care
promoted in words, while u*-is sunnorted in deeds.
This contradiction is great
ly facilitated by thej common
common absence of an account- ..
ing and planning’ system that surveys and.organises
the health sector as a whole.
If the priva
1,
and
the
different
levels of care
public sub-sectors,
essentially separately - as . is etill
are treated case - the proportional divisions of the
usually the
;;;;i health resource ’Cake’ are ^eve^m^®^P^ent ’
and the contradiction between words and deeds can
k.
5 There are often tax concessions on employers'
insurance contributions, which may also be passed
on to the general public in higher prices.
63
continue with relative ease (Segall 1983a)•
Thisz. is
surely the story in most countries today, as it was
in the days of the BHS strategy.
The success of EHC requires the strictest contr
ol on resource allocations both within the health
service and — for the reasons given — in any private
medical sub-oector as well.
With regard to the
latter, at least all direct and indirect public sub
sidies should be removed, and strict limitations will
also need to be nlaced on the sub-sector's growth;
indeed some countries have opted for its contraction
or abolition.
Ownership and control in the health
care sector^
ire thus vital political issues for
PHC implementation.
Control, however, is not merely
a question of public versus private ownership though it begins with this.
A highly bureaucratised
government service may be almost as antithetical to
PHC as private medicine itself. The issue of control
involves also the question of democratisation of
decision-making: within the health service generally;
between the professionals (especially the doctors)
and the so-called subprofessionals (ie the health
team approach); and between health service workers
and communities and patients.
This democratisation
will entail struggles against both bureaucracy and
elite professionalism.
It will also often be nece
ssary to increase the obligations of health workers
to government service and to institute major reforms
in medical education. No less than in the areas of
political economy and popular involvement, health
sector reform for PHC is fraught with a wide variety
of conflicting social interests — the stuff of poli
tics »
THE NATURE OF PHC POLITICS
From the beginning official international docume
nts identified PHC as a, political issue, that requir
ed to be backed by political ’will* or 'commitment'
(Djukanovic and Mach 1975:96; WHO/UNICEF 1978:59 42i
The related pharmaceutical sector is dealt with
in other articles in this Bulletin.
64
This entailed a
a far
far more
more explicit political stance
ttei
e«r the
th. case
ease «ith the BBS
in the discussion of health problems and in the
^ — 1-- J used for their
choice of the national experience
International political
demonstration effect.
politica 1^
formulations have been in effec ex
.
a„encies
eov.m..nts to pursue BBC,P»l«-s.
The^PHG p
like WHO are international
subject to the collective
organisations
of the constituent national governments
decisions
through their respective governing bodies
t
World Health Assembly^ Hence UN statemen
lti_
must be directed towards governments and must ulti
mately be acceptable to them.
The UN secretariats, however, do have considerable scope for initiative, and they used it to
Howgood effect in launching the
'-- PHO■ movement.
q", formulations
*
ever, what were progressive political
i still emerging and struin the 1970s when PHC was t---Intentional
eeceptnnoe, .»»
yX«“onnl
ggling for international acceptance,
may
in the 1980s when it is now part of■ the
The present
wisdom of the international community,t
' » formal; support of
task in hand is to convert the
into
actual deeds, and to
the Alma Ata Declaration
and that
show results before the end of the century: screw•
of the political
may require a further turn
Primary health care is basically a
policy. Not surprisingly, the de^?lopxngp^Cia^is
countries have a good record in this ^pect
This
is e-pecially so with re-ard to the alleviation ox
poverty (which has been achieved mainly by changes
?n Ownership structure that created ^-tunitie^
for gainful employment) and to improving
*
health services.? 7 They have ^So^°ta^u^CaeciIion
in mobilising populations for health,
making has often remained too centralised and burea
ucratised (while being nevertheless usually a lot
1» th. bistorloully prucdfus
•~T
that health systems in sociaThis does not mean
list countries are without their problems (see
for example Segall 1983b), but the social system
is clearly a major determinant of health system
development•
65
/
/
9
situations).
At the other extreme, there are some
countries with right-wing regimes that will almost
certainly block significant progress in.a PHC dire
ction. However, there'are also non-sociolist coun
tries in which more distributive policies are pursued
and in which PHC progress may be possible; but in
many of them this will depend greatly on the outcome
of the contention of social forces for and against•<
Primary health care is thus not a painless
precess, but one that requires persistent pressure
This
to overcome the inevitable opposition forces,
because
the
problfact should now be made explicit
ems will not go away 1by
,v pretending they do not exist,
It is no longer sufficient to limit political Por
mulaticns to appeals to governments to have a voluntaristic change of heart, as though -• even if this
Th© more that
happened — it is all that is needed.
the necessity for continuing political action against
opposition becomes common currency, the more will the
struggles of those, both inside and outside govern
ments, who are promoting PHC be legitimated and
supported•
SIX AREAS FOR POLITICAL ACTION
It is impossible to generalise about who arej
or may come to be, among the main protagonists of
PHC in a given situation.
This will vary enormously
according to political circumstances.
They.may be
the national political leadership, groups within the
government, opposition political parties or groups,
trade unions, peasants’ associations, women’s organ-,
isations, other non-government organisations, academ.e
ics, UN agencies, or whoever.
The following are some
possible lines of action that these protagonists may
individually or severally nursue.
The selection is a
not intended to be exhaustive but is only indicative,
and priority actions are likely to change over time.
8 On some PHC issues this principle may apply also
to socialist countries.
66
1 .
AND PRACTICE OF SOCIAL
DEVELOP THE SCIENCE
■
EPIDEMIOLOGY
The key issue here is the demonstration and
quantification of social inequalities in health and
health care.
l^&y concerns the population aspects of
Epidemiology
its point of departure is a
ill health.
<Classically
---problem
(like tuberculosis or
disease or health
or
infant
mortality).
The
coronary heart disease
are
then
to
analyse
its
tasks of epidemiology
in the population, to identiquency and distribution
c—
factors
(biological,
environmental,
fy associated
other)
that
may
be
important
in the causa
social or <
view
to
discovering
means
of
control,
tion with a
impact
of
interventions
on the
and to evaluate the
Epidemiology
is
the
basic
rates of occurrence,
ILL, yet in this most common
science of public health
classical form it is (necessary
---- - but) insufficient
,
for PHQ purposes.
it- does with the
Starting as i.
individual condition, it does not identify adequately
how a range of different health problems may be con
centrated in certain social classes or
j individual
epidemiological studiThough collectively
---social
clustering
of disease, they
es may point to a £----clustering
or
the full range
do not characterise the
the
different
problems
systemati
of links between
cally.
This
is
the
role
of
social
epidemiology,
cally. of departure is not the disease but the social
point
group.
It establishes the group’s broad health
experiences and analyses their association.with
various facets of social experience, thus identifying
the problems in a way that calls for social in
tions.
Social epidemiology is thus the basic science
to underpin the distributive goals of the PHC appro
ach.
Classical epidemiology remains the science of
the individual PHC component programmes (like
for communicable disease control), but social epide
miology provides the data base for the structural
PHC reforms that will create the conditions for
o
programmes to be implemented•
The basic task of Social epidemiology .is to de
monstrate and quantify social inqualities m health.
This is now an established procedure in some develop
ed countries (see for example WHO 1980:47-50).
*n
Britain, for example, it has been shown that mortality
experience generally deteriorates with falling social
class ranking, and that such a class 'gradient
can be
observed for the majority of causes of.death; morbidi
ty tends to show a similar class distribution,
especially with chronic illnesses (Townsend and
Davidson 1982:ch 2).
67
Very few quantified data of .this kind are avai
lable for developing countries, and there is a pres
sing need to close this information gap.
One problem
naturally lies in the generally deficient health
information systems, but possibly more critical are
the simple lack of awareness of the social epidemio
logical approach and its uses, and the consequent
lack of familiarity with its methods and data needs.
In fact the inequalities in health in developing
countries are very great, and this allows the broad
picture to be painted with relative ease.
For
practical purposes it may be that, at least in the
first instance> only three main, social groupings are
required: the urban rich, the urban poor, and the
rural poor, and there are often enough data (or they
can be compiled without an impossible effort) to
characterise the health experiences of these groups
(or proxies for them) with reasonable accuracy (see
for example Segall 1985a).
Epidemiology can also be
applied to health services, and social epidemiology
is the basic method to demonstrate and quantify the
social maldistribution of health care, showing also
how this often compounds the social inequalities in
health.
Social epidemiology can be powerful instrument
in support both of political action for PHC and of
the technical planning and programming necessary to
implement the distributional aspects of the approach
(see 2 and 5 below).
The science and practice of
social epidemiology shoved be greatly expanded in
developing countries.
I"c should be adapted to their
conditions and resource constraints, and health
information systems should be developed to serve its
data needs.
2.
POPULARISE SOCIAL EPIDEMIOLOGICAL FINDINGS
AND THE PHC APPROACH
Continuing political support for PHC implies
that knowledge of the relevant issues should not
remain the elite preserve of government officials,
academics and UH representatives'; behind closed
doors opposition forces are likely to wield more
persuasive influence and to prevail*
The more the
facts about the inequalities in health and health
care, and the principles of PHC, are shared with the
mass of the people who stand to benefit — the more
the issues become part of the popular consciousness the easier it will be to build up the head of politi
cal pressure to see the policy through.
Every effort
68
should be made to propagate PHC facts and issues in
a simple form, and to use all the means of mass
communication (for the literate and illiterate) to
mount a sustained campaign of popular education.
The quantified findings (crude as they may be)
of social epidemiological studies will be valuable in
this context. For example/ to know for your country
the incomes of the urban rich and the rural poor
(which might work out to be in a ratio of/
^0 t0
1)z their respective child mortality rates (which
could be in a ratio of, say, 1 tc 40),.and the per
capita health care expenditure from which the two
groups benefit (which might again be in a ratio of
40 to 1), has much more impact than general statements
such as that poverty is a cause of disease and
the rich get better health care than the poor observations made by most people®
A special education campaign should be mounted
for health workers, especially for the professionals/
ar.d most especially for the doctors. A classical
medical education
(perhaps with a few more token,
hours of ’community medicine’) is still the norm in
most countries. This type of training, together with
the reality that curative practice is what most
health personnel presently do most of the time, tends
to narrow the vision of health workers to the
traditional clinical relationship, and this can make it
more difficult for them to open their minds to the
broader aspects of the PHC approach, notably to the
question of community and patient involvement in
decision making. It is true that many professionals
cannot’understand’ PHC because.(at whatever level
of their consciousness may be involved) they do not
want to understand. Their present bread and.butter
with not a little jam - depends on the existing
medical system. These are the fraction of the.health
professionals who constitute part of the opposition.
However, there are also a growing number of professionals
especially among the younger generations, who are coming
to see the relevance of PHC to the social value of their
work, and who are prepared to respond to the career
consequences of the approach. It is important.to provide
these professionals, and all health workers, with the .
information they need for the development of their socia
consciousness and for their own work in the propagation
of PHC ideas. The battle for a PHC consciousness should
be carried into the ranks of the health professions;
their voice carries political weight and their co-operation
is needed for the technical implementation of PHC.
^9
5.
FEED PHC POLICY INTO THE ORGANISATION OF THE
COMMON' PEOPLE
Popular consciousness is one thing, and politi
cal clout is another.
It is important that organi
sations representing the interests of the mass of
ordinary people - be these political parties (in
power or i-n opposition), trade unions, peasants’
associations, women’s organisations, or religious
groups - should take up the cause of PHC.
The
spontaneous popular demands about health are usually
for more doctors and hospitals, and this is normally
reflected in the political demands of mass-based
organisations.
While these demands for better
medical care are likely to be quite justified, they
should be located in the broader context of the PHC
approach.
The leadership of mass organisations
should be convinced about the correctness of the
approach, so they can use their influence to get
this message across to their members and constitu
encies, and use the weight of their organisations
in the political arena to support struggles for PHC.
They are likely to be particularly supportive of
the PHC elements relating to the alleviation of
poverty and to the deme eratisation of decision-making•
As this point is illustrated so well in the article
by Macedo and Vieira on Brazil included in this
Bulletin, no further discussion need be undertakne
here;
4.
LEGISLATE WHEREVER POSSIBLE
Political pressure for change is one thing,
and the force of law is another.
As and when a
government is persuaded to undertake a particular
PHC reform, it is good practice to get it on the
statute book wherever possible.
A law is not
automatically implemented, and it can always be
revoked.
It is not therefore a substitute for con
tinuing pressure to turn PHC policy into reality,
but it does strengthen the base from which such
pressure is a^^lied.
In addition, the opposition
may lose some support o^ee the apparent fait aocompii
of legislation is effected.
Thus legislative meas
ures are among the means by which political PHC
gains can be given an element of stability.
Without prejudging at this point how tough any
particular law may be, the following are seme areas
where PHC-related legislation may be called for:
70
-
Economic and fiscal reform relating to the dis
tribution of Wealth and income;
-
establishment of social structures and processes
for the democratisatirn of decision-making ;
establishment of a national health service;
-
definition of the scope of any private medical
sub-sector(s);
educational definitions of health professionals,
bonding of graduates to government service, and
criteria for career advancement;
-
pharmaceuticals and medical equipment.
5.
ESTABLISH HEALTH PLANNING MEANS TO
-
SERVE DISTRIBUTIONAL ENDS
The key issue here is planning on the criterion
of social equity.
Health planning procedures should support the
distributional aims of PHC.
Given the inertia of
entrenched planning methodologies, the establishment
of appropriate methods may itself be a political
task.
While the distributional principles apply to
all the health-related sectors, the discussion will
be limited here to the health care sector itself.
The conventional public health planning preva
lent in developing countries is based on the tradi
tional medical approach of classical epidemiology.
It identifies individual or grouped health problems
and designs specific health care programmes to re
solve them, like those for communicable disease
control, immunisation, or mother and child health.
While this is a perfectly necessary activity it is
insufficient for PHC purposes; it is health care
programming, which should not be confused with PHC
T>fanning in the strategic sense.
Where health care programming is the predomi
nant planning methodology, it tends to ’verticalise
health care activities into distinct national progr
ammes which can become complex and unwieldy.
Despite
being nominally PHC components, these programmes
tend to develop a life of their own and reproduce
many of the problems of the vertical campaigns that
characterised the period before the BHS strategy.
Integration of component programmes into a coherent
PHC structure is a continuing problem in many
countries.
This is one symptom of the general
71
problem that health care programming does not deal
adequately with the restructuring of the health
sector necessary for PHC and therefore for the. su
ccess of the health care programmes themselves.
Without that restructuring and the concomitant allo*
cation of resources to priority areas, the programm
es -will remain chronically short of funds - the comm
on situation at present.
Health care programming
does not relate to a high enough level of decision
making, and does not service the political process
with the information and proposals necessary for
strategic PHC policy formation; indeed it does not
have the planning ’Vocabulary’ to do so.
Primary health care requires a planning.method
that has - like social epidemiology - its point of
departure in deprived social classes; it can then
have ’horizontal1 distributional goals built into it
as an inherent characteristic.
The key task is to
restructure the health sector so that resources are
channelled preferentially to those with the greatest
need, that is, according to the principle of social
equity; and the key instrument to achieve this is
therefore the control and planning of resource allo
cation.
Resource planning must be the leading
planning method for PHC reform in the health secuor•
For the reasons discussed earlier, it should treat
the sector holistically, looking not merely at the
primary level itself, but at the higher levels of
the government service and. at any. private medical
sub-sector(s) as well.
Starting from the existing inequalities in health
care and health status identified through social
epidemiological studies, the prime task is to plan
their systematic reduction through the differential
allocation of resources, particularly by geographi
cal area ■ (notably with an urban/irural breakdown) and
by level of care.
Strengthening the structures and
increasing the resource availability in rural distri
cts create the conditions for the bulk of health care
programming to be done on a decentralised basis, by
people in contact with the local circumstances.. This
decentralised ’horizontalT
approach also facilit®*
at.es local intersectoral cooperation, and political
and. popular involvement.
Increasingly national pro
gramming can consist of the supervision and coordi
nation of local health care programmes, while the
central planning role remains the promotion of social
equity through resource allocations.
72
The resource approach to PHC plannigg represen
ts a considerable methodological departure from the
common practice in level, ping countries, and even
from that of WHO, whose 'Managerial process for
national health development' (WHO 1981) - itself
derived from the earlier procedure of country health
programming - is basically a systematic variant of
health care programming and has not yet absorbed the
full planning implications of the PHO approach.
This
subject, as well as how PHO resource planning should
articulate with health care programming, has been
discussed in detail elsewhere (Segall 1985a); only
this brief outline of principle is given here.
6.
PRESS FOR INTERNATIONA! ECONOMIC ACTION
The necessity for national actions to alleviate
poverty - part of the PHC approach itself -r cannot
be separated from the need for economic change
internationally, especially in this period of rece
ssion.
Economic recession is not a natural pheno
menon (as it is often portrayed), but arises out of
a specific economic system and is conditioned by
specific economic policies.
It is hypocritical for
the Western industrialised countries to claim.to
support the PHC approach in developing countries
when, in the context of providing relatively small
amounts of health sector aid, amounting from all
sources to about 3 per cent of the total health
expenditures by developing countries (Preston 1980:
315-) , their economic policies are wiping out deve
lopment efforts in many ;arts of the Third World,
with the consequent perpetuation or exacerbation o
poverty and ill h-ealih.
A vigorous campaign affirming the deterious
effects of poverty on health and stating unequivocal
ly how they radically undermine the PHC approach,
should be carried into the international fora where
the world economy is debated.
This campaign should
be prosecuted, not merely by the developing countries
themselves, but especially by the UN '^©ncies most
closely associated with PHC, namely, WHO and UNIC
The PHC movement should not be allowed to provide a
smokescreen for the grave effects of the present
economic situation on world health.
International
agencies should staunchly support the calls for a
reordering of the world economy, and for. measures
to counteract the recession and its effects on the
THird World.
73
SUMMARY AND CONCLUSIONS
All three main elements of the PHC approach the alleviation of poverty, popular involvement,
and health sector reform - are fraught with issues
of conflicting social interests, which explain the
present slow pace of progress in most countries.
The political character of PHC should now be made
more explicit to legitimate and support the struggle
of PHC protagonists to see official words transla
ted into actual deeds. The year 2000 is approaching
Six lines of action are discussed; there
fast •
will be others.
74
\
REFERENCES
Ahmed, M., 1978, 'Community Participation , the heart
of primary health care', Assignment Children,
Vol 42, pp 80-99.
Akhtar, S• 1975, -Health Care in the People's Republic
of Ch -j yia , a bibliography with abstracts, IBRC-058e,
International Development Research Centre, Ottawa.
Cochrane, A.L., A.S.St.Leger and F.Moore, 1978,
'Health service "input” and mortality "output” in
developed countries’, Journal of Epidemiology and
Community Health, Vol '52, pp 200-5
Djukanovic, V. and E.P. Mach (eds), 1975, Alternative
Approaches to Meeting Basic Health Needs in Devel-pping Countries, a joint UNICEF/WHO
study,,WHO
Geneva.•
UNICEF/WHOstudy
WHOGeneva
FAO, 1977, Fourth World Food Survey, FAO statistics
series no 11, FAO food and nutrition series no 10,
FAO, Rome-1981, 1980 FAO Production Yearbook,
Vol 54, FAO statistics series no 54? FAO, Rome.
Frelimo, 1985, ’Directivas economicas © sociais',
published in Tempo, no 662, Maputo, pp 29-56.
Golladay, F., 1980, ’Health problems and policies in
the developing countries', Staff.Working Parer no
412, World Bank, Washington DC.
Gwatkin, D.R., 1980, 'Indications of Change in
developing country mortality trends: the end of an
era?',-Population and Development, Vol 6 no 4,
pp 615-44.
Horn, J.S., 1969, Away with All Pests, Paul Hamlyn,
London.
ILO, 1976, Employment, Growth- and Bnsnc Npeda! a
One-World Problem, Praeger Publishers, New York/
London.
King.
(ed), 1966, Medical Care in Develnpi.ng
Countries, Oxford University Press, Nairobi.
McKeown, T., 1979
well, Oxford.
The Role of Medicine, Basil Black--
N ewell, K• W• ( ed) , 1 975■> HeaXth- by the ?pnp~l
Geneva•
, WHO,
Office of Health Economics, 1972, Med-i an 1 a.n-v-l-n.
Developing Countries, OHE paper no 44, London.
Preston, S.H.,1976, Mortality Patterns in National
populations, Academic•Press, New York, Ch 4
- 1980,’Causes and consequences of mortality declin
es in less developed countries during the twenti
eth century’ in R.A. Easterlin (ed), Population
and Economic Change in Developin/? Countries,
National Bureau of Economic Research, University
of Chicago Press, Chicago and London.
Segall, M.M. , 1983a, ’^jjmming and politics of res
ource allocation for primary health care: promotion
of meaningful national policy’, Social Science and
i aino , Vol 17 no 24, 1947-60 -- ------ 1983b, 'On the concept of a socialist health
system’ 9 Ixiternationai Journal of Health Services,
Vol 13 no 2 , pp 221-5
- and A. White , 1981,‘Research on Primary health
care: a multidisciplinary project in Ghana’,
World Health Porum, Vol 2 no 3, pp 341-6
Stewart, C.T.,1971, ’Allocation of resources to
health ’ , The Jnurm.1 nf Human PpRnnmpRj Vol VX
no 1, pp 103-22
Teh-wei Hu, 19?6,,The financing and the economic
efficiency of rural health services in the People’s
Republic of China ’ , TTiternati nnal
r»f. FTaqI th
Services, Vol 6 no 2, pp 239-49
Townsend, P. and N. Davidson (eds), 1982, XneqjjaLi.t
j.~
T
.as in
th r Bl -azik -■R o.p o r.i , Penguin Books,
Harmondswortji, Middlesex, England •
WHO, 1980, Sixth . Hppnrl: nu thp Wr>T»"ld Health Sitiia^jon
Part I, WHO, Geneva, ch 2 and 3
- 1981, Managerial,Process for National Health
Development, WHO, Geneva.
WHO/UNICEF, 1978, Primary Health Care, report of the
international conference at Alma Ata, WHO, Geneva
- 1981, National Decision-making for Primary Health
Care, a study by the tlNICEP/WHO joint committee
on health policy, WHO, Geneva
76
Wilemki, P<, 1979, The X 3livery of gbcilth Services
in the People's Republic of China, IPRC-056e,
International Development Research Centre, Ottawa.
WorId Bank, 1980a, World Development Report* 1989,
World Bank, Washington DC
1980b, Health Sector Policy Paper, World Bank,
Washington DC, annex 7.
1
77.
.<
I
WOMEN
BLIND SPOT IN HEALTH POLICY?
by
Padma Prakash
It is a curious fact that almost every national
health policy document all but ignores nearly half the
population in the country. The ideology, perspective and
the programmes in health documents are such that women
cease to exist, except that is, as mothers and potential
mothers.
This paper attempts to make
points for discussions
the following
1. The Alma Ata Declaration fails to reflect any
new understanding or awareness of women's health. The
Declaration came only three years after the Women's
Conference of the International Women's Year and in the
Women's Decade and evolve! in the atmosphere of the new
awareness among developing countries which gave rise to
the Mew International Economic Order. That it does not
show any new perspective on women's health, is a serious
lapse.
2o The neglect of women’s health in policy and
programmes is not new. Women's health has always been
considered as being synonymous with maternal health. This
has in turn served to constrict the concept of maternal
health and severely restricted the programmes which have
evolved under MCH. While MCH programmes in the conventional
format may have served a useful purpose at one time, they
have long reached the limit; of their effectiveness. Today
they are merely a means to an end - population control.
3O This blinkered vision of women's health has
had drastic consequences for women's health status. Firstly
social, economic and medical factors which influence women's
health but are not associated with pregnancy or childbirth
have generally received little attention. Secondly, this
invisibility of women in health policy automatically
introduces a bias into the knowledge base which is reflected
in the lack of information about women's health which in
turn, appears to support the ’neglect' of women.
In 1975 the World Conference of the International
Women's Year made a plea to governments and peoples of the
world: to 1 recognise the particular health needs of women
in all ages and in all situations - the needs og women with
many children few or more, those past child be/ring age
and those before... and further to" and to "introduce
78
effective measures for the prevention of all forms of
discrimination and cruelty against the well-being of
w^en'which^keep them from participating actively in
the political and social development of their community
and which violate their human rights"
Quite obviously the International Conference
Alma Ata in September 1978
on Primary Health Care at
had not heard the plea or if it had the resolution was
distances in time and space to
ignoredo Such are the
■-- --be bridged in bringing issues of women s health to the
attention of the health policy makers I
It was at the women’s conference that for
probably the first uime, a collective and comprehensive
analvsis of the situation of women all over the world
emerged. The Conference recognised and identified
th<=ir low health status relative to men (in most
.
countries but especially more marked in poor countries)
as a crucial factor in determining the disadvantage
and discrimination they suffer. Women's low nealth
status, it was acknowledged contributes and perpetuates
their exploited and oppressed status. The Alma Ata
Declaration nowhere reflects an awareness of this
understanding of the roots of women's low social
status. The Alma Ata Declaration defined primary
health care in the context of the New International
Economic Order, which ostensibly was directed Pt
reducing disparities between nation and nation, it
considered that while people had the right and,duty
to participate in the planning and implementation ot
their health care, governments had a responsibility
towards providing health care.
Primary health care, according to the
Declaration, must evolve from local socio-economic and
political characteristics and endeavour to address t e
major problems of the community. It should include,
as a minimum, at the least these components - health
education, nutrition and food supply, water and
sanitation maternal and child health including family
planning, immunisation etc., and was to
related sectors such as agriculture, industry, education
communication etc. Primary health care required and
promoted maximum ’community and individual self reli
and participation in the planning and implementation of
health care at all levels".
Quite clearly, the Declaration envisages
health as the primary responsibility of the individual,
with the government, given that it has the political
will1, providing the infrastructure to make it possible
79
for the individual to achieve this self-reliance in health
care. That is, it assumes that individuals are in fact, in
a position to exercise their rights to health care. Further
there is no recognition of the social disabilities that
women suffer from, - those disabilities which had been muchdiscussed in another international forum just three years
before.
The Declaration is after all, a general
statement putting forth a certain philosophy and some
concepts. The fact thar it does not reflect nor even
acknowledgesa specific concern for women's health,especially
when these issues were being debated on international fora
during that period, is a serious criticism. This lack of a
perspective concerning women's health has grave consequences
because the problem is not identified and stated no
solutions are sought. In other words, since women's health,
other than what is termed maternal health, is not defined
as a problem, there can be no question of incorporating
special component in primary health care to resolve the
problems of women's health.
This neglect of women's health in health policy
is not new - at no time have women as individuals other
than as reproductive beings, been of interest or consequence.
So much so that it is unquestioningly taken for granted
that anything to be said on women will automatically be put
under maternal and child health. Why has this been the
case? Why has MCH become the only programme which caters
to women's health and what have been the consequences of
this tunnel vision?
One of the more arguments put
forward is that maternal deaths "comprise a large, even a
major proportion of the mortality among women. Reducing
maternal mortality would automatically reduce female
deaths. Moreover, morbidity associated with pregnancy and
childbirth is the main cause of women's persistent ill
health. Therefore policies directed at reducing maternal
morbidity and at bringing down the fertility of women would
improve women's health. These arguments need to be
examined in the context of health programmes before and
after the Alma Ata Declaration. In India maternal and child
health has been an early concern - the first systematic
attempt to do something in the area dates back to the late
nineteenth century. Much later the first two documents
which provided the basis for a health care system in
independent India were the National Health Committee
Report
and the Shore Report.
The Shore Committee report published in 1946,
a pioneering document in the health field, treats women's
health issues almost entirely under a chapter 'Health
80
services for mothers and children*. The report aimed
not merely at safeguarding maternity, but at providing
adequate health protection to all women so that "the
function of motherhood is undertaken under optimum
conditions of health".
Influenced no doubt by events
at home and abroad, it strongly recommended the setting
up of creches and introducing provisions of maternity
benefits for working women. It even suggested that an
adequate number of women doctors be inducted into the
proposed industrial health services. It suggested the
supply of 'home help' for expectant and lactating non
working mothers! The main emphasis was therefore, on
protecting women's health in the workplace and the
family so that they could adequately perform the socially
accepted and dual role of both reproducing and
sustaining the family as well as contribute towards
production. All programmes were evolved towards this
end. The maternity and child welfare centre was to play
a crucial role in 'national reconstruction'.
The National Committee report reiterated
these main aims and objectives of the Shore Committee
and was critical of the 'largely ineffective course' so
far pursued in relation to maternal and child healtho
It particularly drew attention of a'charging India to
consider motherhood as high and vital a function at
least as (and ofcourse really much higher than) ruling
the country or teaching or building or inventing' e
The report looked at several estimates of
maternal mortality and concluded that the commonest
causes are puerperal sepsis, anaemia, eclampsia and
other tocaemias. Two other conclusions are also drawn
from these estimates
‘ that anemia as a cause of
maternal mortality is practically non-existent in England
and Wales and
that in Calcutta and presumably other
big cities the other causes are practically the same as
in England and Wales. Keeping in mind the fact that
this latter situation may not obtain in the rural areas,
the report concludes that "the real abnormal factor in
our maternal death rate is the prevalence of anaemia'.
■
.
i
, ■
It was argued that the protection of
motherhood and childhood was important because it was
so vital to the 'economic and social reconstruction'
being enirisaged. It was with this same purpose in view
that birth control was to be promoted as part of the
'protection of motherhood' 'children are born not as a
creative evolutionary response to the vital urge, but
as brittle standardised products of a tired reproductive
machinery automatically set in -motion by ‘thesOa^l ?-c °
The reproductive system has to be kept fresh and, vita listed
to respond creatively and must not therefore be subjected
to that strain*.
81
Thus, maternal health was a concern and component of health policy and programmes because it affected
7
-• the health of a new generation
the health of children,
--- - out the tasks of social reconstruction»
Ke^prLa^.^crSf'thls
and child
child
'primary place of this Jmaternal
(maternal and
welfare; work in Indian reconstruction .
There is obviously no gainsaying the fact
that maternal mortality was one of the major, if not the
' greatest single cause' of female mortality in the country»
logical to view
Therefore, it would be
—- quite
t.--the reduction of the high maternal mortality rates> as a
policy which is
high-priority programme within a health
..
aimed at improving the health status of women and
increasing their expectation of life. Such a policy would
recognise socio-political disadvantages that women suffer.
It would also recognise the fact that matern-1 ill
■_
and mortality.is rooted in the ill-health and neglect
women throughout their life and met only at the point of
maternity; and it would accept that the mere provision of
health facilities without special measures to ensure th
these programmes reach women, makes little impact on
women»
Nowhere it there any evidence of this pers
pective in the early health documents which set the tone
of health policy in the country. In the circumstances,
maternal health programmes were bound to have at bes ,
limited impact. Even more importantly these documents
set a certain precedent about what constituted he It
oolicv and they defined the components of all tuture
health programmes, and demarcated the limits of
components...
in the process, they made women invisibl
to health planners except in the role of mothers ^ncl
potential mothers. ■ In other words health policies were
designed to enable women to play their socialiy structu
primary role in society within the predefined limits. If
the structure and nature of maternal and chila health
programmes have undergone change or if its relative
importance within health programmes has varied it is
because these limits have been changed or redefined.
Thus, while promoting birth control measures
was only a minor component of MCH programmes when it was
directed towards protecting the reproductive healt
mothers so that they may produce healthy
became .a major.component when the limiting of birth
began to be viewed as main objectives. In neither case
was the health for women a priority concern.
82
Women have continued to be invisible in
health policy even in more recent times, None of the
plans and policies have reflected an awareness of, the
real problems in addressing the problems of womens
health. Even in those documents which re-ordered
health care priorities such as, for instance, the
Shrivastav Committee Report, while maternal and child
health continues to be one of the high priority areas,
it continues to be viewed in the same conventional
narrow point of view. The stereotype of woman the
mother dominates and is reinforced constantly. For
instance, the 1977 plan for health care Services in
Rural Areas which lay great stress on the centrality
of family and community welfare to the developmental
process states: ’Indian mothers, like mothers else
where, are selfless and ready to sacrifice anything
for the welfare of their family'. In other words, the
image of woman as mother is not only consecrated but
her sacrifices for the welfare of her family applauded.
And what is the nature of her sacrifices? It hardly
needs to be enumerated - that she go hungry so as to
be able to feed her children and menfolk of the family;
that she work long hard hours to make ends meet and to
nurture the family; that she bear child after child or
accept the high levels of morbidity associated with
every available method of family planning in the
context of current health care system; that she forgo
much-needed medical care because her sons or her
husband needs it more; that she be abused, beateft,
bruised and burnt alive... all for the sake of her
family. How can we ever hope that health policy will
pay attention to women's health issues when it accepts
implicitly and explicitly, without question and as
unchanging, the very c< editions which make for women’s
low social and health status?
It is necessary here to add that the above
statement, in the 1977 health policy is, not^and cannot
be,taken in isolation. It has to be seen in the context
of the priorities, programmes and the general
perspective of the entire policy. The characteristic
neglect of women is quite clear in the very
programmes which were formulated. Unfortunately, not
only have health policies disregarded women's health
issues, but most of us who have looked at health,
these policies have also tended to overlook the
significance of this state of affairs.
83
Curiously enough it was in the post Alma Ata
health document the ICSSR-ICMR Report
that we find for
the first time a recognition of the real situation of
women's ill health. The document noted the falling health
ratio and enumerated some of the reasons - the greater
mortality among women, the __act that women are more vulne
rable to disease because of their nutritional status and
yet, availed of health services much less than men. It
also recognised that 'the public health services have
reflected social attitudes in regarding all women primarily
as mothers or potential mothers' o Unfortunately this
recognition of the real situation regarding women's health
was not reflected in the programmes suggested, which
continued to be in the conventional MCH format.
That this new awareness was an aberration of
sorts is clear from the fact that neither the Sixth Plan
nor the Report of the Working Group on Health for All
by 2000 AD
accorded it even a passing mention. The
Sixth Plan while echoing many of the recommendations of the
ICSSR-ICMR document chose to emphasise those suggestions
which had been formulated in a milder form in that document
- MCH programmes as a means to an end i.e. population
control. And the Working Group completed the turnabout
that the Sixth Plan had begun after the ICSSR-ICMR report
and health policy was back on old track. However, coming
as it did when the women's movement in the country had
already made its presence felt, it recommended, rather
blandly state aid for the setting up of women's groups
which could then be utilised for health and family welfare
'education'. Comically enough, it laments the importance
of the mother for promotion of health within the family
and through the family to the community has not received
due recognition!
Consequences for Women's Health
Let us examine the basis for the assumption
that maternal health is the single most important factor in
determining '
the status of women's health. Maternal
mortality^ it is saidzmake up the major proportion of female
mortality. How valid is this argument? Maternal mortality
certainly does account for a large proportion of the deaths
among women approximately 13 percent and 9.4 percent in the
reproductive age groups 15—24 and 25-44 respectively. But
it is not the major killer; infective and parasitic diseases
and accidents violence and poisoning account for 47 percent
and 42 percent of all deaths in the two age groups. About
30 percent of all women who die are in the reproductive
age groups; about 26 percent of all men who die are also in
this age group. (Table 1),
84
Table 1
Percent distribution of deaths by sex for selected
causes to total ddaths in each age group (1979)
Cause
Sex
Age. in years
15-24
25-44
I Infective
Parasitic
diseases
M
F
28--16
23-11
30-55
27<70
XI^Complications
of child births
pregnancy and
puerperium
. M
F
13.15
9O38
c cd dents
Pollening and
violence
M
25.18
16.94
F
23.87
14.03
100
100
XVT
All cases
Sources Health Statistics of India, 1984
Even if we accept that maternal mortality
is caused by specific easily identifiable and
preventable factors and must therefore/ be the major
target of health programmes for women, what are these
causes? For the last 40 years they have remained the
same - toxaemias/ peurperal sepsis/ haemmorrhage and
anaemia and these have been the years when MCH progra
mmes have functioned. Undoubtedly maternal mortality
rates have come down, peurperal sepsis is no longer
as much a risk of childbirth as it used to be. But
anaemia and toxaemia continue to be two primary
causes of maternal deaths. And both these are rooted
in health conditions which are beyond the purview of
the conventional MCH programmes. Slapdash measures
at the point of pregnancy have not worked. It is
thus more than likely that the limits of what may be
achieved by the conventional MCH approach even in the
limited sphere of maternal mortality has been reached.
Moreover/ there is some indication that not all
deaths which are recorded as being due to maternal
causes are in fact so. In a recent paper Karkal (1)
has quoted a study of postmortem investigations of
175 maternal deaths with clinical diagnosis. They
found that although cause of death was assigned as
haemorrhage toxaemia etc., at postmortem several other
conditions which had probably got aggravated during
pregnancy and may well have caused death were discovered
85
Maternal and child health programmes today have
become reduced to being mere channels for family planning
work, a means of reaching women» And in fact, in the
process they may be instrumental in producing additional
morbidity among women.
In the last decade, ironically enough after the
Alma Ata Declaration, the entire family planning effort
has been directed at women. All the research in family
planning being conducted is on long acting hormonal contra
ceptives for women. Every one of the methods being
offered is associated with problems. This morbidity among
women is often unrecorded unless it leads to death. And
again because women have so little access to health care
facilities because of various socio-economic reasons even
a minor health problem can become life threatening. .
In fact many of the complications arising out of
the use of contraceptives aggravate the very conditions
which MCH programmes are ostensibly designed to eradicates..
For instance, it is well known that IUDs cause blood loss
ranging from 35 percent to 146 percent and even in
developed countries it is has been shown that the preva
lence of anaemia increases by 3 to 16 percent. Although
hormonal contraceptives are supposed to decrease blood
loss, it is also known that they reduce the absorption of
Vitamin B12 and folic acid. Moreover HCs are associated
with a higher risk of pelvic inflammatory disease which
if does not lead to sterility, may well contribute to
problems of pregnancy and childbirth.
Although much has been written about the increased
mortality risk for a woman with every additional birth,
the fac~ that “a large share of maternal mortality experi
enced in the third world relates to wanted births (2) has
often escaped attention. As the AJPH
above^
points out "Provision of contraceptives services will have
little impact on the mortality risks of women whose
pregnancies are wanted".
Ironically family planning activities have been
introduced as components of MCH programmes gradually, but
quite deliberately the ICSSR-ICMR document, in fact quite
emphatically and clearly sets out to define the FP
component of MCH programmes and the need to involve women.
Later documents are even more conscious of this aspect.
86
Quite apart from the FP component, the fact
that MCH programmes are badly designed and badly
implemented is too well known to need eLaboratione After
so many years of MCH programmes, only about half the
pregnant women receive antenatal careo Thus MCH pro
grammes in their conventional format have reached the
limits of what they can achieveo Improving the
efficiency of these programmes is hardly likely to
yield better results - what is required is a rethinking
on the entire concept of MCH vis a vis other health
programmes,
This neglect of women other than as mothers
in health care programmes has led to a non-recognition
of other causes of female morbidity and mortalityo As
seen in the table, '
a large proportion of women in the
•reproductive’ age groups die because of parasitic
diseases and duetto or in violent circumstances. These
causes also account for a large proportion of male
mortality in these age groups as well. It is ofcourse
a telling comment that even after so many years of the
implementation of the Primary Health Care concepts
these diseases continue to take such a toll of human
life. It may also be conceded for the time being that
comprehensive measures may reduce both male and female
mortality (we have to keep in mind however, that women
are socially disadvantaged and that whatever are the
measures provided they will be benefited to a lesser
degree than men).
The situation is however different in the
case of deaths due to (accidents, poisoning etc. The
so-called accidents due to which women die, we know
now are hardly 'accidents’ - they are deliberate acts
of violence on women, variously termed as ‘dowry
deaths’, wife battering etc. Karkal points out that
deaths due to burns constitutes the single largest
cause of death among women in this category in rural
Maharashtra. The health system has no way of even
classifying these deaths which is itself indication
that for the 'health people' - be they doctors,
statiscians, or policy makers, such causes simply do
not exist.
This invisibility of women in health
policy has also had consequences for the nature of
information which is collected, and in the manner
in which such data are analysed. Only recently has
processed health information, say for instance
morbidity statistics, been presented sex-wise. And
87
even now, there are crucial gaps. The very manner of
data collection therefore, is biased against women, by
simply not recording vital information since there is no
place for such data in the records. This lack of
documented information is Ln turn used to suggest that the
problem does not exist!
Quite clearly, if womens health is at all a
priority then women have to be reintroduced into health
policy and health care programmes.
REFERENCES
1. Karkal Malini, ‘Health of Mother and Child Survival*
Paper presented at Congress on Perinatology,
February 1986.
2. American Journal of Public Health editorial,
February 1986.
********** ******
88
DISCUSSION
The first session critically evaluated the HEALTH FOR ALL
strategy in terms of its significant breakthroughs and major
limitations., Presenting an overview of the four background
papers. Dr. Dhruv Mankad of Medico.Friend Circle, reiterated
that the main contribution of the Alma Ata Declaration lay in
its comprehensive perspective and focus on the socio-economic
and political determinants of health.
Tnird Vvorld poverty and
the widespread mortality and morbidity resulting from preventible enviromental factors, were the historical context for
the new emphasis on non-health factors.
However, the strategy
needed to be critically examined in order to identify and
transcend the hidden lacunae and inconsistencieso
Various
terms used in the recommendations such as political will,
self-care, self reliance, technology transfer and the new
international economic order, required to be defined and
assessed for their real meanings.
Did the recommendations
truely address the needs of the poor masses, or did they
reproduce the ideological and political perspective of the
dominant classes of today's world?
The presentation concluded by highlighting areas for
further research that 'had not been covered by the papers.
V'^hile class inequalities in health and in the utilisation of
health care services had been discussed, there was little data
regarding other forms of discrimination and inequalities.
The
limitations of the strategy in dealing with women's health was
the theme of the paper by Padma Prakash. However, there were
no studies in India on racial discrimination on the lines of
the Eslack Report from UK, and except for a few micro studies
on Muslim women, there were no studies on inequalities based
on community, nor caste or nationality.
39
Key Role Of Non-Health Factors $
Initiating the discussion, Dro Do Banerji questioned the
commitment of the Indian HFA strategy to its own wider pers
pective o How far was the inciian health policy ottempting to
subordinate medical technology and socio-economic planning to
the needs of the Indian people?
The WO's recommendations
had a progressive content, in part the result of popular and
democratic pressures, which nowever, were unlikely to be
translated into people-oriented programmes oy the ruling
classes-^
The pace setters for any fundamental change were
the people themselves.
In this context, it was necessary for
concerned health workers to empower the people with manager-
ialz technological, epidemiological and socio cultural skills
for a more effective assertion of their demands.
Dr. Deodhar pointed out that HFx^ referred to a strategy
for promoting the level of health of the people, and therefore
had as its focus the environmental, nutritional and educati
onal determinants of health. This required a throughgoing
epidimeological approach, and data, to identify the promotive
and preventive factors underlying the health of the people.
Instead, at the level of implementation, HFA was being
wrongly equated with medical services. According to him,
there were two major factors contributing to ill health in
the Indian context. The most important was the chronic, long
standing deprivation of large sections of the Indian .people,
often clubbed into an economic concept like poverty, which
was sought to be projected as medical deprivation,
The
second factor was the very inadequate outreach and coverage
of the health services themselves.
Dr. A.R. Desai, elaborating on Dr. Deodhar's pointz
raised the question whether economic planning in India,
99
including its underlying assumptions and pattern of resource
allocations, was at all conducive to making health services a
minor factor in the HFA strategy? Responding to Dr. Banerji's
observation, he wondered whether the ruling classes were
actually broadening the welfare base and that too, under
pressure from the people. The emerging socio-economic order
in the Third World was in no way conducive to 'HFA', and even
progressive health delivery systems in the advanced market
economies, such as UK's National Health Scheme, were under
attack. A progressive strategy in such a context merely pro
vided a few crumbs to the people as a means to co-opting and
suppressing their participation.
Ravi Duggal also took up Dr. Banerji's observation, In
his view, there were socio-economic reasons for formulating
progressive policies. Firstly, increased welfarism in capita
list and backward capitalist countries was a method of
managing the crisis of capitalism and the social conflicts
arising out of it. Secondly, any progressive shifts in
resource allocations, such as the priority given to the rural
sector in the Sixth Plan, had to be seen in the context of
expanding rural markets and the saturation of the uroan market.
Finally, many radical policies were first advocated by peopled
organisations and were later taken over by the government.
For instance, in the late 70's Medico Friend Circle.had talked
about child survival. Today, it was a Government programme
advocating massive immunization campaigns. However, the
question that needed to be asked was, in what fashion was the
government taking up these issues, and how did its approacn
differ from that advocated by the people’s organisations.
Dr. Ashish Bose felt it was not practicable to dp a postmorten of the genesis of the toHO1s Declaration. Quoting the
central premise of the HFA strategy from Drs. Antia and
91
Awasthi's paper, namely that it was a radical policy cased on
social equity and the total re-orientation of the health care
system, he posed the question :‘How do we convert this beautiful
slogan into a reality?1’
There was no need to point out China's
achievements as there were several local experiments in
primary health care such as the Madwa project. More discussion
was required regarding their replicability and usefulness as
models for re-orienting the medical services.
Dr. Banoo Coyaji, referring to the papers by Navarro and
Seagall, asked whether the aim of the seminar was to question
the HFA strategy itself. She also questioned Dr. Banerji’s
view that pressure from below was responsible for progressive
changes, such as the shift in budgetry priorities in the 6th
and 7th Plans. In her experience food, water, money and jobs,
and not health, were the priority areas for the people.. She
asked,
‘Do you really think that people are interested in
health?
ii
Dr. P.B. Desai agreed with the point made by all the
papers that HFA was a political issue.
He pleaded however,
that it was necessary to use the verbal committments made by
the Government to concepts such as 'people’s participation’,
'decentralisation' etc., to rouse the people and presurise the
Government towards greater democratisation.
Padma Prakash felt that analysing the roots and the
evolution of policies was not an intellectual exercise alone.
The changes in health policy were determined by tensions
between people's demands on the one hand, and the needs of the
ruling class on the other. Every new policy reflected certain
dominant ideas and positions.
In order to identify other
points of view emerging from people's pressure, it was necess
ary to understand the context in which a policy evolved, as
92
well as its dominant features, The aim should be to extend
the policy so that it expressed the needs of the people.
Dr. Saroj Jha raised the issue that while the primary
health care strategy enunciated by the bHO appeared to be
sound, the entire emphasis from the bHO down to the implemen
ting governments and some NGO’s was on doctor centred
programmes. The entire composition of the WHO was one of
medical personnel, including its regional representatives.
The traditional medical sciences did not equip doctors to
deliver primary care with its three components of inter
sectoral co-ordination, appropriate technologies and community
participation.
Dr. Haran felt that it was no point blaming cither WHO
or the doner agencies.
The latter had their own priorities.
The proolem was one of Government policy, its implementation
and the management of health services.
According to Dr. Dhruv Mankad, the strategy had to be
viewed in terms of two aspects.
The first aspect was the
underlying assumptions of the strategy.
'Health for all by
2000 AD' was not an empty slogan, but a concept which projec
ted a particular view of health to be achieved within a
certain time-span. The time-span had its own dynamics which
affected the concept itself. Such underlying assumptions had
to be questioned, and to do this the evolution of the concept
needed to be understood. The second aspect referred to the
implementation of the concept, i.e. to the existing reality.
The issue of implementation included the nature of adminis
trative controls and health programmes, and the constramtsresources perspective and political - under which the HFA
strategy had to operate in India. Pointing to the primary
importance given to non-medical factors for the first time in
health policy. Dr. Mankad focused on the example of nutrition.
93
Nutrition, or the availability of food, was a question of
wages for most Indians, but in the implementation of HFA there
was no mention of increasing wages, implementing minimum wages
or land reforms.
Apart from the other implementational
problems, this aspect had to be discussed in greater detail.
Dr. Uma Ladiwala pointed out to Dr, Coyaji that for the
rural population ill-health was the priority since it affected
their capacity to work and earn a living. However, the
relation of prevention to illness and health was not clear to
them, and therefore, only in a limited way health became an
important need.
Dr. Ramesh Awasthi made a distinction between the targets*
and the spirit and content of the HFA strategy. V;hile the
targets could be achieved within the system, the spirit of HFA
was nothing less than revolutionary, and would not be
implemented. His plea however, was that a socially progress
ive legislation should be used to build people's pressure
towards releasing forces of change.
Dr. Sujit Das found it difficult to accept the view that,
without first analysing the genesis or purpose of committments
made by the Government, these should be used to build people's
pressure.
There were definite committments from the Govern
ment of India outlined in the Directive Principles of State
Policy embodied in the Constitution, but little had come out
of them.
Turning to the methodology of building people’s
pressure. Dr. Das asked whether it was as concrete and
atraightforward as putting up a banner with a list of demands,
or were there other social demands and actions which mediated
people's health needs? For instance, in demanding money, food,
water, etc. the people were actually asking for the determin
ants of health.
People had always been struggling for a
94
better standard of living, a basic determinant of health, and
■
for more and better health care. The state and the ruling
classes in present-day society, as against feudal society, had
to respond to the people's demands, but in a manner that would
ensure the latter's continued exploitation. Hence, every
health policy, state health care system and other welfare
measures that had emerged from such contradictory or contend-
ing forces, had to be approached very carefully.
Dr. N.H.Antia felt that the WHO, like every other group
in society, began with good intentions but had, inevitably,
developed vested interests inimical to its social and global
For instance, the majority of WHO's recommendations
and financial aid was concentrated on high technology, even
social
though it was
was conscious that the solution lay in more
science inputs. Today, it was more of a -Western Health Organ
isation' dominated by the western countries that funded it. A
goals.
more serious problem was that senior administrators, interes
ted in lucrative jobs with international agencies, were more
interested in following the recommendations of bodies like the
WHO than being guided by the needs of their country. The
it provided
Government had accepted the HFA Declaration as
them an excellent, high-profile slogan. The slogan was used
a potent tool for keeping people in a perpetual state of
expectancy and dependency. It was being misused to inform
people about only some aspects of the HFA strategy and keeping
them ignorant about other features. The health and education
infrastructures were being highlighted for their vote catching
potential, but not the services and inputs needed to eradicate
illitracy, or raise the health status of the people.
Ev-
ICSSR/ICMR Report which had been accepted by the Govern
was not being implemented in its true spirit. The money
marked for primary health care was benefiting the profession
als, the bureacracy-and the village level politicians.
5
Therefore, the question was, what was to be done with the HFA
slogan? The people were not questioning the slogan and even
most doctors were not aware of the HFA strategy.
Dr. Antia
felt that the most substantial contribution that professionals
could make would be to popularise the strategy and inform the
people about all aspects of HFA, the health infrastructure and
facilities available for them, as also their health rights.
Dr. Coyaji felt that the increased allocations to rural
areas in the 6th and 7th Flans indicated a definite shift in
the pattern of Government planning.
In her view the most
important problem before the seminar was the lack of implemen
tation of the ICSSR/ICMR report.
According to Dr.' Jessani, a more clear-cut perspectiveon the relationship between the Government and the people was
required.
If the participants believed that the government
was representative of.the people’s will and genuinely
interested in solving their problems, then it was possible to
talk of utilising the government's progressive commitments.
On the other hand, if it was felt that the government, with
all the resources and administrative apparatus at its command,
had failed ^he people, then utilising the strategy would not
achieve anything. The relationship between the people and
state-power, ie. the government, had to be changed and for
that the people had to be organised. It was necessary to
concentrate on the people, address their needs and develop
their consciousness, instead of merely attempting to pressur
ise the Government to make some concessions and cosmetia
changes.
Dr. Mankad pointed out that although the Alma Ata Decla
ration spoke of the rights and duty of the people to plan and
implement health care, yet its recommendations were all
96
directed at the participant governments.
People's participa
tion being viewed only for achieving targets for government
programmes.
The two major limitations with the concept of
'people's participation* were firstly/ that it did not specify
the organisations which represented the people's interests and
secondly/ that it did not define who the 'people* were.
Did
'the people' refer to a homogenous entity/ or to groups and
classes with fundamentally conflicting interests?
And by
'people's participation* did the strategy mean the partici
pation of the oppressed and exploited groups Dr. Mankad felt
that the solution did not lie in making more recommendations
to the government and bureacracy alone; very small beginnings
had been made through trade union activities/ wage struggles
of underpaid workers, women's protest against the sex determi
nation tests etc., to build people's consciousness about
health issues. In this process some elements of the strategy
could be utilised for revolutionary purposes/ although the
Alma Ata document itself was hardly revolutionary.
Dr. P.B. Desai pointed out that at the core of the HFA
slogan lay the political issue of mobilising the people for
whatever they themselves could do.
He asked whether the
participants were prepared to take a political approach and
mobilise the people.
If, however, the participants and other
concerned intellectuals could not fight to change the power
structure, then what were the alternative ways by which the
people could be approached?
According to Dr. Sanjiv Kulkarni, the discussion had iden
tified 3 sets of actors in the HFA strategy.
The first was the
state and the WHO; the second were the people and the third
were the professionals and intellectuals such as the partici
pants themselves. He felt that as long as the participants
continued to view themselves as a separate group from the
97
people, the latter would not achieve a correct perception of
people’s problems, nor evolve correct stands and solutions.
Dr. G.G. Parikh did not think that the participants and
other professionals could appropriate the right to represent
the people.
They were, in fact, a part of the ruling class,
and consequently with the government.
He differentiated
between the HFA slogan and the strategy. The latter was
truely revolutionary in spirit and could not be achieved with
in the present framework of capitalist economic policies of
the Government. Only the targets could, be achieved through
certain techno-managerial inputs. Within this framework, the
only option for professionals was to identify those parameters
of the strategy that could be implemented,and attempt t
implement them outside the government. In this way, the
people might get motivated and pressure from below would be
generated.
However, these actions and solutions had to be
based on people’s needs and not on intellectual considerations
Dr. Deodhar, addressing the question raised by Dr. Sujit
Das as to what was hidden in a slogan, pointed out the need to
clarify the term ’Health for All’. Health, according to him,
really meant ’health facilities', and the implication of the
slogan was to give health facilities to all those who did not
have them. Accordingly, two areas for further action emerged.
Firstly, beyond doctors, primary health centres, health guides
and multi-purpose workers, what were the health facilities
that people required and wanted? Secondly, was people’s
participation possible when they lacked basic facilities?
Organising the people and developing their abilities in condi
tions of deprivation required a long educational process.
However, the burden of providing health for all was on health
services, and certain specific questions had to be raised
about the history of health seivJces in India. At Independ^8
encez the objective adopted was to provide comprehensive medi
cal care to the people. It was assumed that the satisfactory
provision of curative services would give people the confi
dence to follow up preventive and promotive services.
Instead, in the past 20 years such shabby curative services
had been provided, that the people had turned Way fVom public
health care. All public healtlji centres and sub-centres
remained poorly utilised. One solution was perhaps to
separate public health services from medical services, For
instance, family welfare services had nothing to do with
health, ie. the prevention programme. In this way, some
change could be effected in the outlook and approach of
doctors and the medical profession.
99
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SESSION II
SCOPE AND PROBLEMS IN IMPLEMENTING THE STRATEGY IN INDIA
With focus ons
*Social structure and functioning of health care
services in India.
*A review of India’s efforts in the delivery of Primary
Health Cares From Shore committee to Health For All.
*Internal and international factors responsible for
India’s acceptance of Health For All strategy.
*Health Policy determinants in India.
*Gaps and constraints in health planning in India.
*Existing system and status of curative services# drugs
& pharmaceuticals, preventive services and population
control programmes - and what changes are needed.
■
■- V
*
's:
I
'
INDIAN STATE PURSUING CAPITALIST PATH OP DEVELOPMENT °»
MAIN OBSTACLE TO HEALTH FOR ALL
A.R. Desai
A
I deem it a privilege to participate in the
Seminar on ’’Health for All : Concept and Reality , organ
ised by the Foundation for Research in Community Health.
I am no specialist either in Medico-health
problems as a medical practitioner 9 or as an activist
devoted exclusively as a medico-social worker.
I am a
student attempting to understand the socio-economic
transformation that is taking place in the country since
independence •
I am studying the transformation that is
being brought about actively by the State, which emerged
gutter independence and has adopted a path of Development
which is now clearly realized as Capitalist Path of
Development.
I am attempting to grasp the impact of
various measures, economic, political, social, cultural,
educational and health, on various classes, strata,
groups in Indian society, particularly on the conditions
of toiling strata who constitute the overwhelming majority
of Indian Society.
In a country, which contained the world’s second
largest population and where overwhelming majority of
people were rottingjunder absolute and not relative
poverty, illiteracy, unemployment, underemployment,
malnutrition, verging on starvation and semi—starvation
for mar r and lack of elemei bary, but basic requirements
for health and dignified existence like food, shelter,
water, unpolluted environment,
sanitary conditions,
and almost near absence of disease preventing and disease
causing health care services for majority of Indian people
during British period, I am struggling to grasp the impact
of State measures in eliminating these conditions during
last forty years on the basis of the capitalist path of
Development pursued by the Rulers.
I have attempted to analyse economic, political,
class
and caste stratification and other aspect of
social,
the impact of State policies inl a number of my studies,
available and hence I will not elaborate
which are already
t
on the same here.
100
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•
■
• ..
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t
r.--—
V
*
■
_I
■s
1
2.
As a part of my larger study of the impact
of the State policies, I have been trying to under
stand the impact of the Government measures on the
’’Health Situation” of various strata and classes of
the Indian people.
Considerable amount of studies of highly
sophisticated nature as well as survey type researches
of Health Care System are now available.
Starting
with Shore Committee Report (if we do not take into
account the National Planning Committee Report framed
by Indian National Congress prior to independence) to
a series of Reports by special commission and commi-.
ttees including the Alma A.ta—Declaration and the Indian
State which became a signatory to implement the
programmes suggested in that Declaration, a massive
literature has emerged examining the achievements,
limitations and basic flaws still prevailant in the
policies pursued by the Government during last forty
years as well as suggestions to rectify the situation
emerging out of the policies pursued upto now.
The Government, during its various five year
plans, have made many changes in their health care
programmes and health care system and administration.
The Government has also clearly defined various
categories to be included for financing what is des
cribed as Health Care system.
These categories as formulated in Five Year
Plan allocation comprize of following:
1) P.H.C. & Rural Health (Hospitals and
dispensaries), 2)
Control of communicable diseases,
3)
Education, training and research.
4) IMS (indegenous Medical System), 5) Other.
These five categor
ies directly dealt with health care practices for
curing diseases and are described as Health Programmes
and 6)
Water supply and sanitation ?)
Family
Planning as category though important has been consi
dered as indirectly concerned with health care and
diseases.
Information about allocation of funds for
health plan outlays are|available in Five years Plan
documents.
Even data about the amount of resources
allocated including priorities of allocation and per
centage of allocation to the total plan allocations
are also available.
1C1
H F A • »o o
RQRu- C>M
'Purchased with the assistance of 0 3 3 J “i
Raja Rammohun Roy Library Foundation
e
The achievements and limitations of the State
policies and programmes launched by the government are
now analysed fairly extensively by numerous studies
conducted by various agencies, including acad.emic insti
tutions and researchers belonging to Research Institutes
or Sensitive doctors, social workers and social scientists.
The participants in this Seminar, are well acquainted with
the achievements and limitations of Health Care policies
pursued by the Government of India during last three and
half decades.
The publication ’’Health Care for all - an
Alternative strategy” a report of the study group set up
jointly by Indian Council of Social Science Research and
the Indian Council of Medical Research, and a small
pamphlet ’’Health Care in India” , a CSA publication authored
by George Joseph, John Descrochers and Mariamma Kalathil,
sum up the entire situation of the ’’Health Care in India
during post independence period.
4,
II will avoid inflicting massive data and findings
on different aspects of Health situation in India as well
as the nature of health care institutional structure that
has been evolving in the country.
I will briefly present
the over all assessment as indicated by various studies.
' The "Health for All" Report while surveying the
present health situation, makes following alarming
observations,
’’The current morbidity and mortality picture
shows one major variation from the past.
Famines no
longer take the toll they used to; smallpox has been
eradicated; cholera and malaria have been curbed; and
immunization has protected children from dangerous
childhood disease like smallpox, whooping cough, diphtheria,
tetanus and polio.
But, i:. other respects, the overall
Diseases
character of morbidity has not changed- much.
ignorance
9
malnutrition,
arising from poverty, ignc-rance, malnutrition}. bad sanitation 9 lack of safe water supply, drainage or adequate
housing 9 and lovi levels of .immunity are still the _mp.st
These include tuberculoses, gastroenteritis,
c ommon.
malaria , leprosy, filariasis, etc. (which rarely occur
in the developed, nations) and measles, tetanus, whooping
c ough. bronchitis and pneumonia, scabies, worms and fevers
(specially among children).
It appears that although the
average Indian may now live longer, his morbidity is only
marginally less than that of his forefathers and he
continues to be largely prone to the same diseases as they
were.
While children are being saved from death, the
problem of the surviving children with severe physical and
mental retardation is one ..of considerable magnitude.”
102
5.
I need not provide the statistical details
about the massive prevailence of the diseases, aris
ing from poverty, ignorance? malnutrition, bad sani
tation, lack of safe water supply, drainage or adeq
uate, housing and low levels of immunity.
They are
given in various studies conducted upto now as well
as in the information provided by Government documents.
I will only sum up the situation as it prevails today
in the words of the Report ’’Health for All” submitted
by the above mentioned study groups.
1. ”In both morbidity and mortality, there
are larger variation from State to State , .and even within
there may be variation”.
State
2. ’’The differences between urban and rural
areas are also very large, and on the whole, the
health situation in rural areas is more dismal."
5• "What is even more important, there is a
marked difference, in health status (which is found
to be closely corelated with class, caste, income),
between the upper and the-middle clas.ses.’.pn the ..one.
hand and the vast bulk of poor on the.other.
Among
the latter, frequent illness and untimely death is
still the lot of the average individual, and among
at least some sections of the poor, there is reason
to believe that morbidity has increased rather than
decreased. ’*
Before I raise some crucial issues arising
out of this situation, in the context of the capital
ist path of development pursued by the Indian State,
I would like to draw your attention to the assessment
of features of the existing model of Health Care
system as it has evolved after independence.
(i)
The present Health Care system is:urban
biased, top-down and elite oriented,
inspite of considerable expansion of
the primary health centres since
independence .
(ii)
Bulk of the expenditure on the Health
services is still incurred in urban
centres, their benefits are still largely
skewed in favour of the upper and middle
classes.
(ill)
Inspite of all the talks about programmes
of improving environmental sanitation,
and immunization against communicable
103
(iv)
diseases,
diseases, during the last thirty five years,
and some development of promotive and pre
ventive programmes, the basic thrust and
bias of financial allocation is towards
providing of curative services i.e. estab
lishment of hospitals and dispensaries and
training of doctors, nurses and other
personnel needed for them.
The system is essentially based on urbanjbased
hospitals, and consume substantial proportion
of funds available.
The nature of a typical
hospital as a large complex offering multiple
services and many specialities and vast amounts
for maintenance of its facilities and staff
and operating as a very expensive, ineffici
ency providing primary health centre for the
population in periphery is now highlighted
by many studies.
(v)
The system based on urban based hospital
model has become highly centralized and
bureaucratized, unable to handle the problem
of distance or organize good referral services.
(vi)
The Hospital based system is highly dependent
on doctors, not educated by the right kind of
training and mostly unwilling to reach out
to poor in urban areas or unwilling to go to
rural areas.
The system is highly medicalized
resulting in cultural alienation of medical
profession, and oversophistication and mysti
fication of these professicnals.
Over medicalization, has lead to heavy reliance on
drugs, injections and many a times unnece
ssary and cost '.y technical diagnostic
instruments and practices.
Smphasis on curative health services at the
cost of more important promotive, preventive
and simple curative aspects of community
health, has resulted in the over production
of drugs, production of large varieties of
unnecessary, harmful or even dangerously
defective and fraudulent drugs.
This creates
a vast network of vested interest comprizing
of drug-industries, doctors, traders and
vendors in drugs and other medical commodities.
This phenomenon has created a situation where
in the drug industry and doctors have become
not the curer of diseases, but agents interes
ted in continuance or expansion of ill health.
104
According to the Report Health care for
all, "It is not generally recognized
that we are dangerously close to the
explosive point."
(ix)
The basic feature of the Health care
system is that in this system there is
no involvement of the community.
(x)
Our health care system is comprized of
private sector, quasi-public sector and
public, sector - operating in the very
limited context, as indicated earlier,
of sickness-care , super-specialized
professionals and drug-injection-and
other medical technology.
(a) ' In this mix, the private sector constitute the
largest sector responFiible for nearly .three-quarter
of .all medical care whether rural or _urban_s- The
private sector health care system is mostly manned
by'doctors operating .individually by providing
medical services -essentially for maximising earning
and ..selling, their skills as a commodity to client
patients or by giving their services on certain
consideration for private hospitals, or health care
agencies.
They are mostly trained at government
expenses.~ The training of the medical students, at
public expense is- focused on private practice of
curative., medicine.
It is hardly appropriate for
preventive approach^.. Rather, it|inmunizes these
"professionals from training as promoters or practi
tioners of preventive illnesses.
The private sector
medicare- system, comprized of doctors, hospitals,
. dispensaries, diagnostic clinics, nursing homes and
its ancillaries i.e. pharmaceutical and instrumentat
ion industries works- on the principle of capitalist
norms of market, supply and demand in our country.
It is thus infested with the same vices as other
business, with all the implications of black, open,
rationed, corrupt and polluted, market operations.
Medicare-in a market matrix is also generating sub
standard., dangerous, harmful and fraudulent commodiSystema• ties in the form of services and medicines.
Systema
tic in-formation about ■the- extent and operation of the.
private sector, the-major sector of medicare system
is still clouded in mystery like the other businesses
in the country.
(b) ■ The, quasi-public sector comnrized of services in
the form of KSIS‘schemes or dispensaries and hospitals
run by industries, ..is very small and caters to a
. •
- 105
limited number of employees of public and private sector
industries and enterprizes. Studies of functioning of
these quasi-public sector, de not provide a rosy picture
of their operations and reveal the same undesirable
features that prevail in private sector health care
services.
The systematic information about the extent,
functioning and finances of this sector of medicare
system is not available.
(c)
The public sector of health services is relatively
more documented giving information (however incomplete)
about manpower employed, expenditure incured and about
the targets and achievements in terms of various catego
ries of health services provided as well as in terms of
health indicators.
The public sector, in health care system, is
supposed to be operating on a slightly different princiIt is claimed to aim at
pie than the private sector.
providing health services to all who need it but cannot
afford it in the market.
It is also supposed to under
take preventive measures to ensure certain basic services
to control communicable diseases os well as create certain
infrastructure for healthy living in the form of proper
sanitory and other facilities.
The studies of the functioning of the public
sector, health service system, however reveal some very
grave alarming deformaties.
(a) Major portion of its budget is allocated to high
technology instruments, and medicines and in running
expensive medical colleges and public hospitals.
(b) Out of this budget a sizeable amount isjspent on
purchasing material from private sector suppliers national and international, for salaries and honarariums,
for maintaining outfit, constructions and other amenities,
by purchasing from suppliers of services and goods belong
ing to private sector.
(c)
Manufacturing medical practitioners and their
operalized medical adjuncts, who are trained mainly for
specialized curative medical treatment, and not for
developing and operating preventive care.
(a) The expenses incurred in training these medical
personnel is basically utilized to produce medical per
sonnel operating in the private sector.
106
(e) With regard to the establishment of primary
health centres, the expenses incurred are more on
building infrastructural facilities and on payments
of salaries and wages to the staff trained into
curative medicinal approach, rather than for providing
infrastructure for preventing services and personnel
to manning these services,
Nor are they spent on
buying appropriate cheap medical services and facili
ties attempting to provide basic drugs and services.
(f)
Even here the studies revea2_ that the expenses
incurred on infrastructural facilities and drugs and
other needs only subserve basically private sector
suppliers of those commodities and services.
(g)
The limited curative facilities do not reach
the clients for which they are supposed to be meant.
(h)
Allocation of resources on Health care system
are extremely meagre compared to the allocation of
resources in other fields.
This prevents the exten
sion of even this limited primary public health care
system to majority of people.
They do not even
conform to targets laid down by the Government itself,
even within the frame work of the skewed provision
made by public authorities.
(i)
The State has, by its own policy, transformed
the public sector health care system and services as
an adjunct and active facilitator of private sector
health care system.
It thus exhibits all the charac
teristics of private sector with its overall market,
pro-rich, pro-profitering, upper and middle class
oriented costly commodity character.
The state
health care public sector, exhibits all the essent
ial features, which otiier public sector enterprises
and services exhibit in Indian economy and society,
whose major functions is to subserve and strengthen
basically private sector, and therefore, experien
cing the same maladies as suffered by other public
sector undertakings.
6.
We have described the features of health
care system as it has developed ir. India and so ably
analysed by sensitive and concerned medico-health
specialists and workers.
We have ^Iso indicated how
these able analysts have pointed out how ’’Health is
a function, not only of medical care but of the
overall integrated development of society - cultural,
economic, educational and political1’»
The sensitive
107
•activists on health front have also pointed out how ”an
attempt to eradicate ill-health will not succeed in
isolation and that it can be pursued, side by side with the
other two inter-dependent and mutually supportive objec
tives of eliminating poverty, inequality,
inequality 9 and ignorance
and against the back drop oi a socio-economic transformation which will give effective ■nolitical power to the poor
and deprived social groups".
The Report on ’’Health for Alls An Alternative
Strategy” is to my knowledge the most exhaustive and
detailed account of the pre-requisites necessary for an
’’Alternative Strategy” to make ’’Health available for
all” by 2000 A.D.
It also admits that ’’Nothing short of
a radical change is called for; and that "Health for all”
as defined by the Report and the objectives and targets,
laid down in the document, ’’cannot be achieved by linear
expansion of the existing system and by tinkering with it
through minor reforms”.
7•
A few questions arise in my mind, which I want
to place before the participants of this seminar.
(i)
Are the maladies described in the health
care system developed by the Indian Rulers after inde
pendence not the result of the Capitalist Path of Develop
ment pursued in the country?
(ii)
Are the structural features of the Health
Care system, which has emerged in the country, not a
logical and necessary consequence of the pro-rich, pr oproprietory profit and market oriented capitalist devel
opmental policies pursued consciously by the Rulers?
(iii)
Can poverty anci inequality be eliminated by
the Rulers9 who themselves consider poor as the greatest
obstacle to pursue capitalist path of Development?
(iv)
Can the State, wedded to Capitalist path of
Development, and which has assumed even in the very
constitution, the proprietory classes producing for
profit and market as the active and main agent of develop
ment, in a labour surplus backward society, allocate
sufficient resources for people without depriving the
profit-chasing proprietory classes of their sources?
(v)
Can a State, which is developing an economy
essentially based on production for market and profit by
the private owners of means of production, and which is
determined to provide facilities, incentives, concessions
108
and even resources and necessary infrastructure to
profit chasing proprietory classes, but which does,
not assure right to work, the only source of securing
purchasing power to vast majority of people, evolve
a economic-social or health care frame work which
will ensure minimum, basic essentials to these people.
Can this state create even minimum condition essential
for health for these vast mass of people?
(vi)
The developments that have taken place
during last forty years, after independence, as a
result of State pursuing Capitalist path of Development are now fairly well documented:
Unemployment and under employment are
a.
an
alarming rate.
The number of unemployed
growing at
,
’
registered
even
in
Employment
Exchange Bureaus
alone
reached
nearly
20
million
mark.
The number of
have
under employed have acquired such gigantic dimension
that they cannot be counted.
Inflation, price rise has reached intolb.
All know that inflation basically
enable magnitude.
classes
seeking profits, and
helps proprietory
increases the burden on poor and middle income groups
in a decisive manner.
Inequality is increasing, consciously
c.
engendered by the State, which systematically buttresses
the rich by various means, sojwell known by now.
The
expansion of Capitalist market and profit oriented
transactions are leading to a massive pauperization
and proletarianization in both
urban and rural
areas.
During the last forty years, as a result of
the Government policies to pursue capitalist path of
Development, in Rural "reas pauperization of small
farmers, marginal farmers and artisans is taking
place at alarming rate > The proletarization also is
taking place at such a rapid rate that nearly 35 to
40% of population dependent on agriculture are now
reduced to the status of landless labourers, desper
ately searching for work and purchasers of their
labour power even at any cost.
In urban areas,
people living below that miserable inadequate and
cunningly formulated poverty line are now reaching
alarming proportions.
d.
The health specialist and researchers on
health problems have already provided a vivid picture
of non-availability or polluted availability of basic
amenities so essential for even survival and non
diseased existence for vast mass of poor.
Can a
109
state, which is consciously pursing the path of ’’betting
on the rich” provide these basic amenities to people,
with the frame work of the socio-economic structure which
it is purposefully erecting in the country?
e.
During last two decades numerous struggles
are developing at an exponential rate by various sections
of the poor.
They are armed to counteract the adverse
impact of the path pursued by the State.
In fact Govern
ment, instead of rectifying wrongs is increasingly adopt
ing authoritarian, repressive measures to suppress these
movements.
8,
The document ’’Health for all" by A.D. 2000 admits
that ’’The major programmes which will improve the health
are thus outside the realm of health proper”.
According
to the document, ’’These were comnaratively neglected in
the last 30 years, and that is one of the major reasons
why the country has obtained such meagre results for its
large investments.
This error should not be reneatod
and during the next two decades, the three nroorammes ,_of
~{"i'j' integratsd overall development , (iil improvement .in
nutrition, environment and health education, and—( iiij—the.
provision of adequate health care
especially for the poor and under .prij/LlA&£J^J^
to be pursued, side by side”.
I would like to raise a couple of fundamental
questions for serious pondering in this seminar.
(i)
Is the Health Care system, as it has evolved
in India a product of an error, a misjudgement by the
benevolent, neutral, well-meaning, pro-poor state or a
logical product of the State which is consciously pursuing
a capitalist path of development in the country with its
basic pro-proprietory class stance as axis of its
development thrust?
(ii)
Can this State radically reTi nt its
health care policies, in the spirit of suggestions
offered by the sensitive concerned scholars and activists
on the health care area?
(iii)
Is not the State, wedded to Capitalist Hath
of Development, itself the main hurdle, as it is respon
sible for developing the pro-rich bureaucratic top down
health care system, \.which is so vividly analysed and expo
sed by the sensitive, participants and activists involved
in spreading the Health care for all.
If the State, pursuing Capitalist Path of
(iv)
Development, in India, is the architect of the present
bizzare pattern of Health care system, as well as of the
larger social contours as described earlier, should not
110
i
I
the activists/scholars and researchers instead of placing
hope,and praying the government which is itself the
main cause to remedy the error, join the struggling
poor in the country who are heroically launching move
ments under heavy odds to replace the State, which is
consciously pro-rich by a state, which will place
power in the hands of tailing poor which alone can
usher in a path of development which will ensure
right to work, and provision of essential requirements,
as minimum starting point for its development trust?
I want the seminarians to discuss the following
crucial question which I think is axial for proper
analysis for alternative strategy for Health for all.
Is the State pursuing the Capitalist ^ath of
development in India, not the main obstacle in health
care reaching out to all?
ill
References
:
1) Recent Trends in Indian Nationalism
2) India’s Path of Development.
3) Urban Pamily & Family Planning in
India.
. z A profile
.
- ‘ an Indian Slum
4)
of
(All published in Popular Prakashan)
1 .
Desai A»R.
2o
■'
5 - ’’Health Care in India”
George Joseph and others
15-17
(Centre
for
Social
Action, Bangalore 1983)
PP ' -
Ibid and Indian Council of Social Sciences and
Indian Council of Medical Research, Health for All,
An Alternative Strategy. Report of a Study Group
set up jointly by ICSSR and ICMR - Published by
Indian Institute of Education, Pune, 1981.
4
ICSSR & ICMR ’’Health for All”
5.
Ibid p.5
6
Ibid p.5
7.
Ibid p.7
8.
Ibid see part I approach for detailed description of
the situation.
9.
Ibid p.83
10.
Ibid p.224
11
Ibid p.VII
12.
loid p.VII
13.
Desai A.R. Ed. (i) Agrarian Struggles in India after
Independence(Oxford University
Press, 1985)
(ii) Violation of Democratic Rights
in India after Independence Vol.I
(Popular Prakashan, 1986).
14.
ICSSR & ICMR op/cit p.213.
112
PRIMARY HEALTH CARE APPROACH TO ACHIEVE
HEALTH FOR ALL BY THE YEAR 2000 A.D. AS IT IS UNDERSTOOD AND PRACTISED IN THE
COUNTRY - A PERSPECTIVE.
^>y
V.N. Rao
1
Concept of Health for All:
'Health for All' in its broadest sense means that
health is to be brought within reach of everyone. And by
’health1 is meant a personal well being, not just the
availability of health services - a state of health that
enables a person to lead a socially and economically produc
tive life. According to Dr.Halfdan Mahler, ’Health for All’
is a holistic concept calling for efforts in agriculture,
industry, education, housing and communications, just as
much as in medicine and public health. Medical care alone
cannot bring health to hungry people living in hovels.
Health for such people requires a whole new way of life and
frosh opportunities to provide themselves with a higher
standard of living’.
2. The Strategy for ’Health for All1 - Primary Health Care;
Primary Health care approach is considered to
be.the basis for achieving ’Health for All* especially in
developing countries. The Alma-Ata Conference described
primary health care as:
"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
and at a cost that the community and country can afford to
maintain at every state of their development in the spirit
of 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 of the over
all social and economic development of the community. It
is the first level of contact of individuals, the family
and the community with the' national health system bringing
health care as close as possible to where people live and
work, and constitutes the first element of a continuing
health care process".
113
Thus the pre-requisites of primary health care
are multisectoral approach community involvement and
appropriate technology and on this edifice that health
programmes and health infrastructure has to be built.
India is a signatory of the Alma Ata
Declaration. Having stated the concept and strategy for
achieving 'Health for All' through primary health care
approach, it needs to be examined how far the country
is following these and with what results.
3 0 National Health Policy;
Historically health services in India have
been developed on the western model. Till recently they
were mainly hospital based and disease oriented, and have
been heavily dependent on borrowed foreign technology
leading to over-sophistication and ill-suited to the needs
of the rural community.. There has been a great imbalance
in the provision of the services;most of the services
being located in urban areas, while nearly 80% of the
population resides in rural areas.
For the first time the country has adopted a
National Health Policy taking into consideration all.
existing situation and realising the need for providing
primary health care with special emphasis on the preven
tive, promotive and rehabilitative aspects»
4
Minimum Needs Programme;
The Minimum Needs Programme Concept was
introduced during the Fifth Five Year Plan. It is the
expression of the commitment of the Government for the
social and economic development of the community
particularly the under-served and under-priveleged
segments of population. Government considers investment
in health investment in human resources development and
as such Primary Health Care forms an essential and
integral component of Minimum Needs Programme. It is a
broad intersectoral Master Plan for providing the
minimum basic needs of the people. Economic.development,
anti-poverty measures, food production and distribution,
communication, drinking water supply, sanitation, housing,
environmental protection and education contribute to
Health and hence find a place in Minimum Needs Programme.
114
5. States Plans to Implement-’Health for All1
Health is a State subject. Nevertheless in
all programmes of National interest the centre has been
laying down the guidelines for implementing the health
policies decided and agreed upon by the Central Council of
Health and Family Welfare.
The Sixth Plan had laid down the following
norms 2-
(i) One village health guide for every village
for an average of 1,000 rural population.
(ii) One trained dai for every village by
training indigenous practising dai, with ultimate objective
to train all practising dais in rural areas.
(iii) One sub-centre with one female MPW
for every 5,000 rural population in general and for every
3,000 population in hilly and tribal areas.
(iv) One male and one female health assistant
for supervising the work of every four sub-centres.
(v) One Primary Health Centre either by
conversion of existing rural dispensary or establishing new
units for every 30,000 rural population in general and for
every 20,000 population in tribal and hilly areas.
(vi) One community health centre for every
one lakh population by providing additional inputs either in
one of the existing, primary health centres or in the sub
district Tehsil/Taluka/Referral Hospitals already functioning
below district level.
Targets proposed for Vllth Plan
Category
V.H.G.
Dais
Total Require
ments (lakhs)
3.5
5.0
4.5
4.5
Sub-centres
PHC' s
1.30
21,666
CHG* s
5,417
Likely in Likely to Remarks
be in p< siposition
on 31.3.85 tion on
(Icikhs)
31.3.90
(% reqd.)
80,000
11,416
(incl.SHCs).
593
115
100%
Complete
the train
ing of all
practising
Dais
100%
100%
50%
Thus, it is envisaged that by the end of the
VII th Plan the States would have built up an health
infrastructure to effectively establish a health pyramid
for the delivery of health care. The manpower development
is to run parallel to the institutional build up. The
training facilities are also to be augmented to cope up
with the envisaged rapid expansion of health services.
6o States efforts in establishing Primary Health Care
Programme s
The Community Health Guides (CHG) Scheme was
the first level of interface between the community and
the regular health infrastructure. The CHG Scheme which
was started in 1977 was adopted by all States and Union
Territories in the country, except in Jammu and Kashmir,
Kerala, Tamil Nadu and Andhra Pradesh, where an alterna
tive scheme was adopted. Even so, the CHGs Scheme has
gone through several vissicitudes. When the Scheme was
100 percent sponsored most of the States accepted it and
started implementing it. But when the pattern of central
assistance changed several States virtually dropped out
of the Scheme. Again when the Central assistance was
fully restored there was partial response. Barring a
few States, the CHGs Scheme has been virtually a non
starter. The Scheme suffered from such infirmities like
the CHGs selected were mostly males. They were selected
on the basis of political influence there was no firm
linkage with the existing health infrastructure, the
training was inadequate and unsatisfactory and above all
there was no continuing education and supportive super
vision to help them get started in their work. Thus, the
CHGs Scheme which could have been an effective tool for
implementing the Primary Health Care Programme has been
virtually smothered.
The most peripheral health workers are the
Multipurpose Workers in the health heirarchy. The male
and the female multipurpose workers have been drawn from
the erstwhile verticle programmes, They had to be retrained in the concepts and philosophy of primary health
care approach in achieving Health for All. This has not
happened. The training given to them was not adequate
and satisfactory as the training centres were not
sufficient in numbers and the trainers themselves were
not adequately equipped to impart training in PHC approach.
116
Thus, a hotch-potch group of Multipurpose Workers are now
functioning in the rural areas without a clear concept of
their newer specific tasks and roles. The MPWs numbers is
expected to increase with the reduction of population to be
served by them as per the plan targets. But this increase
is not taking place at the pace it was expected. Nor are
the training facilities for these new recruits adequate.
The LHVs/NMs/HAs, who are in the Supervisor
echelons also suffer from lack of adequate training and
supporto Also their numbers have not been increasing as per
target <>
The Medical Officers of the Primary Health Centres,
although their numbers are closer to the target, have not been
suitably oriented to primary health care approach and their
basic training does not equip them to manage the primary
health centre adequately and effectively. Consequently the
1eadership which they are expected to provide is conspicous
by its absence.
The VIIth Plan has laid down the targets for
building up infrastructural facilities like subcentres,
primary health centres/ subsidiary health centres and commu
nity health centres. Again, with the exception of Maharashtra
and a couple of other States rest of the States are lagging
behind. Even in the States where the physical targets have
been achieved, functionally they are still to go a long way
to establish Primary Health Care. The physical facilities
such as Primary Health Centre building, staff quarters,
equipment, etc. are still far from adequate, with the result
the centres are unable to work effectively.
Above all, the morale of the staff working in
the primary health centres is not upto the mark. Consequently
indiscipline and evasion of duties and responsibilities is
surfacing more and more.
Thus, the melieu in which the primary health
care programme is to be nutured and developed will need a
sea change if the avowed goal of Health for All by the Year
2000 A.D. is to be achieved.
117
7. Need for rectifying the present priorities, strategies
and approaches to realise the set~goal■
.
.
While the progress in regard to operationa
lisation of primary health cure approach throughout the
length ano breadth of the country has not been adequate
and satisfactory as seen from the earlier review, there
is certainly no need for despair. There is definitely
scope for improving the situation in the remaining period
of less than a decade and half, provided there is
political will and a determination on the part of techno
crats and bureaucrats to implement primary health care
approach in the manner envisaged, successfully.
The following are a series of steps which
implemented may lead us to the set goal in the limited
period of time.
i) Start a movement to mobilise the community
to make them realise that their health is their own res
ponsibility. The health care, in the ultimate analysis,
should be not only for the people, but also with the
people and by the people. This needs a major thrust in
community mobilisation in all developmental activities
including health care development - a long term
programme.
ii) Have a band of trained and-motivated
voluntary workers, not necessarily community health
guides, who will Joe able to, educate, enthuse and act
effectively as interface between the community and the
regular health infrastructure.
iii) Also concentrate on promoting development in health related sectors such as water supply
environmental sanitation/ food production and nutrition,
education/ communication/ etc. This requires judicious
mobilisation of existing resources.
iv) Develop appropriate technology, which
is cost-effective suited to the needs of the community.
This requires lot of experimentation in a- different
setting. 7In this
'' ‘
connection the urgency of developing
and constructing low cost buildings"can"be considered
as; an outstanding example.
\
118
v) Training of various echelons of staff in
primary health care concepts and approach is of paramount
importance and needs immediate attention. Apart from
providing adequate number of training centres for giving
basic training, orientation training, in-service training,
etc., a '.'hand of competent trainers needs to be mobilised to
ma&e training more effective and meaningful. The modus
operand! of training needs to be throughly revamped.
Practical on-the-job training needs to be given the emphasis
it deserves. Team training is yet another aspect which has
been totally ignored. Last but not least continuing education
is a must and should be adopted everywhere.
vi) Emphasis should be more on consolidation of
existing health infrastructure and mobilising all resources
to make it function effectively in providing quality services.
This will automatically ensure better utilisation.
vii) There is an urgent need for each State to
work out its own model/s of health care delivery through the
primary health care approach. In the long run funds spent on
development of such model/s by each State fzxu~a period of
3-5 years will have tremendous benefits in improving the
health care delivery before the turn of the century. Such
practical, not necessarily purely demonstration models,which
have to be replicable, should be carefully worked out, guided,
monitored and evaluated, before they can be adopted elsewhere.
viii) The development of the epidemiological
services throughout the length and breadth of the country has
been repeatedly stressed by various expert groups. Even so,
no serious attempts have been made so far by any of the
States to establish epidemiological services. The imperatives
of starting such services needs no further emphasis.
ix) Health Services Research/Health Management
Research has not been receiving adequate attention. Research
on operational aspects of health care delivery deserves urgent
attention.
The steps suggested above are by no means
complete and exhaustive. But they emphasise the urgent
need for re-thinking to mobilise the existing resources
fully to make primary health care fully operational to
achieve Health for All.
119
8. Conclusion ;
'Health for All' is a realisable goal
provided there is a political will and a firm determina
tion to achieve it. The steps that need to be taken to
achieve the set goal has to be well thought out and
consistently followed and deligently implemented. Now
is the time for firm action. There is no doubt that
India could work towards this goal and achieve it with
its available resources.
REFERENCES ;
Primary Health Care; A Joint report of the DirectorGeneral of the World Health Organisation and the Executive
Director of the United Nations Childrens Fund, Geneva New York 1978.
World Health Forum; The meaning of 'Health for all by the
year 2000'. Halfdan Mahler, 1981, Vol.2, No.l.
Health for Some or Health for All? s 1‘fhe debate goes on' Anil -Agarwal - UNICEF NEWS ; Issue 108/1981/2.
Health for All - An Alternative Strategy; Report of the
Study Group Set up jointly by the Indian Council of Social
Science Research and Indian Council of Medical Research /August 1980.
Strategies for Health for all by the year 2000o Regional
and National Strategies ; World Health Organisation,
Regional Office for South-East Asia, New Delhi, December
1980.
Health Statistics of India 1985s Central Bureau of Health
Intelligence, Directorate General of Health Services,
Ministry of Health and Family Welfare, Government of India,
New Delhio
The Making of Health Services in a Country; Postulates of
a Theoryo Debabar Banerji, Lok Prakash, New Delhio
Draft National Health Policy; Comments and Suggestions by
Indian Medical Association - IMA Document NHP-l,
April 1979o
Report of the Steering Group on Health and Family Welfare
Programmes for the Seventh Five Year Plan? Planning
Commission, Government of India, November 1984.
120
MAIN GAPS AND CONSTRAINTS IN OUR APPROACH
AND PROGRAMMES FOR PROVISION OF PRIMARY
HEALTH CARE
by
DR. N. S. DEODHAR
Pu \e
Introduc ti on s
Primary Health Care has been accepted interna
tionally as the key approach to attain the goal of
’’Health for All” by 2, 000 A.D. Declaration of Alma-Ata,
1978, defines Primary Health Care as essential health c
care based on practical, scientifically sound and socially
acceptable methods and technology made universally acces
sible to individuals and families in the community through
their full participation and at a cost that the community
and the country can afford to maintain at every stage of
their development in the spirit of self-reliance and selfdetermination.
Essential Componentsg
It is, therefore, natural that Primary Health Care
should deal with the main health problems of the people
and provide comprehensive promotive, preventive, curative
and rehabilitative services to all those who need such
services. The nature and extent of these services will
depend on the kind and magnitude of the problems, the
economic conditions, social and cultural values, scienti
fic and technological development, and above all, what
the people desire to have. But the essential components
that should be included in the health care are proper nu-.
trition; adequate and safe water; basic sanitation inclu
ding personal and food hygiene; maternal and child health,
including family planning; immunization against major com
municable diseases; prevention and control of local endemic
diseases; education concerning health and health related
matters, including the various health problems and hazards
and measures to control and prevent them; and appropriate
and timely treatment and care for common diseases and inj uries.
The Approach Vis-a-vis Epidemiologyg
Health is relative, not absolute. The fundamental
determinants of health ,apart from the genetic constitu
tion, or make-up, are nutrition, environment and life
style. The health of a society is directly linked to its
value system, philosophical and cultural traditions,
socio-economic conditions and political organisations.
121
Each of these aspects has a profound influence on
health/ which/ in its turn/ also affects all these
factors. Consequently/ health status of any com
munity cannot be raised/ nor the health for all
achieved/ unless ail the factors shown in diagram 1
are effectively provided and all health hazards are
effectively contained and countered through a pro
gramme of integrated development. Such a progra
mme connot obviously be limited to improvements in
health and medical services/ but should be direc
ted to bring about the cultural/ social/ economic
and political transformation of the society as a
whole.
Diagram 1
o
Epidemiology of Health
DETERMINANTS OF HEALTH STATUS
I
HEALTHY ENVIRONMENT
PROPER NUTRITION
HEALTHY
LIFE
STYLE
I
*SAFE AND ADEQUATE
WATER SUPPLY
^ADEQUATE FOOD
SUPPLY
*EDUCATION
*SANITARY DISPOSAL
OF EXCRETA & ALL
WASTES
*CAPACITY TO.
PURCHASE FOOD
*HEALTHY HA
BITS & TRADI
TIONS
*HOME & OCCUPATION
IN POLLUTION FREE
SURROUNDINGS
*FOOD HYGIENE
*SOCIAL AND
ECONOMIC DE• VELOPMEN.T Sc
JUSTICE
^PERSONAL
HYGIENE
*MEDICAL AND
ALLIED
SERVICES
Secondly, as health cannot be passively
received or given, people must made to decide for
themselves and helped to acquire it through tbeir
own effort. Therefore, active participation and
involvement of the local communities and programmes,
are essential in attaining self-reliance, effi
ciency and effectiveness in Primary Health Care. The
external support that a community may need include
technical knowledge and skills, training, guidance
and supervision, logistic support, supplies,
information, finance and referral facilities.
122
For success, there is no alternative to epide
miological approacho We shall have to attend tojall
the determinants of health care through an integrated
development lolan. Unless the causes of ill-health are
contained, the health status of the community cannot
be improvedo
Th^ Ggpg. «
'j_ e
The concept 03’. primary health care for all has
been aptly anb. beautifully expressed in an ancient
Sanskrit verses ’ Sarve santu nirmayaha’. Literally
T*
■’‘,- it
means. ‘Let all be free from disease <> However,
considering the colloquial meaning, the verse truly
conveys. •Let
’-- all
-- be healthy1 <, Thus, culturally our
concept of health is much broader and richer. In her
address at the 34th World Health Assembly at Geneva,
Shrimati Indira Gandhi, our Ex-Prime Minister defined
health as, 'not the absence of illness but a glowing
vitality, a feeling of wholeness with a capacity for
continous intellectual and spiritual growth1• Our
task for Health For All, therefore, becomes stupendous.
We really are not adequately serious,committed and
determined to provide basic health care facilities to
the poor;
2o
'Exclusive Domain of Health s Most of the
politicians,- bureaucrats,- doctors and the people still
believe strongly that the Primary Health Care is
entirely the concern of the so-called health services.
Primary Health Care programmes are equatted to the
modifications and improvements in the health services
in terms of coverage of population and the quality.
Belief .that appointment op the Health Guides provides
for Puimary Health Care is also a mistake. The
attainment cf Health for all is beyond thetcbmpeteece
of .medical profession, on the conventional health
system alone, to achieve. The basic characteristics
of our people are rural predominance, poverty, high
population growth and disease burden. We need,
appropriate interventions and’ for these epidemiological
approach, community participation and organisation are
inescapable.
3o
qverorofessionalisetion and mystification of
medical and”~health care tend to generate dependence
and lead to high and wasteful inputs, especially in
drugs and equipment. We need to promote selfreliance through effective transfer of skills and
knowledge to the people. The utility of whatever
that is available should be maximised, eg. the
traditional systems of medicine, non-governmental
organisations, etc., should be fully exploited and
harnessed. Physicians, as a rule, are difficult to
123
work with and do not always try to understand the
traditional medical practitioners in whom many
people place their trust. It must be realised that
the needs of many will ha e to take precedence over
the wants of the few. Mere expansion of physical
facilities and staff without attention to relevance
quality and effectiveness, would result in a
collosal waste of resourceso
4.
Neglect of Public Healths In spite of the
changing trends in modern medicine, growing reali
sation, and gradual shift of stress towards
preventive' and promotive health care, 'Public
Health* has not been given the required profe
ssional status and high importance it deserves.
In fact, nomenclature of discipline of Public Health
has been changed in India to terms such as
Preventive and Social Medicine, and/or Community
Medicine. In medicine these are minor subdivisions
in all respects, eg., prestige, number of persons,
finance, political influence, etc. This has
resulted not only in total elimination of earlier
understanding, but has also introduced much confu
sion as to what these subjects contribute. Both
the people and the doctors knew clearly what
Public Health stood for. The concept of Public
Health is that of a major governmental and social
activity, multidisciplinary in nature and exten
ding into almost all aspects of Society. The
key work is 'health', not 'medicine', the Universe
of concern is the health of the public, not the
discipline of medicine. Medicine is a subdivision
of public health and not he vice-versa. Public
health needs not only the doctors, but also
disciplines of epidemiology, biostatistics, health
economics, sociology, anthropology, other political
sciences, biological and physical sciences, public
health engineering, nursing, dentistry, nutrition,
health education, health administration and medical
sciences.
5.
Community and Community Participations fahat
do we mean when we talk of the people or the
community? Who and where are these? There is no
clarity. There are two broad categories, the 'Haves'
and 'Have-Nots'. When we speak of Health for All
or Primary Health Care, our target population should
be the 'Have-Nots'. These are not the individuals
people or communities which are rich or privileged
or those in power and authority or the 'yes' type.
But they are the oppressed, the poor, the
exploited and the needy. They are generally not
organised and should constitute the priority group
or our target community or 'the people'.
124
Community participation is often a myth. Giving
some contribution/ such as labour, materials or
donations cannot be considered as true participation.
This ■’s also true of util ! sation of services, co
operation and other similar actions. These people
can be said to be participating when they understand
the situation and issues by critical consciousness,
and take active part in decision making, implementa
tion and evaluation of programme, and take
.
responsibility of the work as well as share in the
benefits. Such involvement of the local populations
in the decision-makinc; of development projects or in
their implementation, is more in the nature of
identificatidn with the movement. The involvement,
indeed, is a mental process as well as a physical
one. Such involvement and participation would
provide freedom from dependence on others, use of
indigenous knowledge and expertise, and things would
be done in a right way. What is needed is to
encourage and help the ‘Have-Nots' to get themselves
organised, and to enable and strengthen them to take
initiative in development work with confidence.
5
Inter Sectoral Co-ordination is of vital
importance in the success of Primary Health Care
which we are trying to achieve through total
developmental efforts. At present, in^®r depart
mental co-ordination and co-operation at all levels
from the community to the top management, are not
effectj_ve> There is much scope to improve. Without;
personal contacts and timely follow-up actions 12-a
well co-ordinated manner, mere co-ordination meetings,
etc., may not yield anything useful. Mutual
understanding, respect and determination are.th
key words.
7
Co-ordination wi-.hin the Health Sector .is also
vitally important, but unfortunately it leaves much
to be desired. There is fragmentation in the
oroanisational set-up. Different programmes,
SroiecS departments within the Health Directorates
tend to form water-tight compartments with hardly any
communication between them. Voluntary organisations
and autonomous Institutions often rue parallel
____ Government
___ ______
such as
programmes to that
of the
. Schemes
uxiu-u_______
_
. scheme
and the Health
the Multipurpose Health Workers
- -t high degree of intra
Guides Scheme demand a very
co-ordination
and co—ope rationo Tardy
departmental
widespread
failure
of these schemes can
progress and
be attributed
i___ _
to this weakness.. Family Panning
programme is often run at the cost of other health
programmes, Community Health Workers Scheme,was
originally introduced for health promotion with better
12.5
community participation and involvement but no^j
it administered under Family Welfare Programme
and the sole purpose is to bring 'cases’. Added
to this retrograde step, the Health Workers, male
and female, have started using the Health Guides
as their substitute workers, instead of providing
guidance and support to these persons who do not
belong to health services. Both MPW and CHW
schemes have been allowed to distort, degenerate
and disintigrate because of administrative failures.
They need to be scraped in the present form and
reintroduced de nova in the original concept.
8.
Management is another gap. For imple
mentation of a timebound programme,^ith optimum,
effective and efficient use of limited sources,
proper use of modern management techniques, personnel
management, public relations, financial, and
materials management, are vitally important. But
these are largely neglected fields and are often
taken for granted.
We have to first realise the enormity
of the task before us. Gaps between our planning
and achievements are too well known. We should
be clear on what we want to achieve and hown. We,
in the health sector, have lagged behind in
establishing subcentres, primary health centres
(new), reorganising medical education, organising
continuing training of various categories of staff,
etc. We have not fully attained the desired norms
in health manpower and infrastructure facilities
needed for population of around 70 crores in 1981.
By 2000 A.D,, our population will be up by almost
30 percent, i.e. over 90 croe^eg. Thus, we would
need a substantial overall increase in all kinds
of resources-finance, manpower and supplies.
We should have the right type of persons
in management. Without adequate knowledge, skills
and motivation, the services of desired quality
and effectiveness cannot be given.
’Not infre
quently, we find a technocrat trying to become
a bureaucrat or a bureaucrat thinks that he is a
better technocrat; and above all, sometimes even the.
public representatives (politicians)think that t£ey
are better than both’. What we need are efficient
health administrators or managers. We must
identify, train and use them.
126
9 e
Lack of flexibility in our programmes and
approaches poses problems. Socio-cultural and other
diversities and local differences demand different
and varied solutions and approaches. Determinants and
nature of the problems and situations vary from place
to place, group to group, urban to rural, educated to
uneducated, rich to poor, time to time, at different
levels of development and achievements, etc. While
general guidelines and objectives are essential to give
proper direction and purpose, details of the programmes,
activities and approaches are best left at as near
local level, i.e. community level, as possible.
While it is desirable to reduce-the constraints
imposed by centralisation, situations of conflict are
inevitable. One will have to find out the most
acceptable solutions in the given cultural and social
milieu. Balance between flexibility and replicability
will have to be reached at satisfactorily. One should
also note that there could be many solutions and
approaches for achieving an objective. A single
solution or formula should not be insisted upon.
1o o
Inadequate and Ineffective Decentralisation is
another important gap. Our great exercise and
programme for democractic decentralisation or Panchayat
Raj has succeeded partially. In a few States like
Maharashtra and Gujarat, the process is more-or-less
final and the Zilla Parishads are working with fair
delegation of appropriate powers and proper resources
including finance, but in most of other States, there
is hardly any true decentralisation.
Similarly, within the administrative Departments
there
is hardly any decentralisation with
also.
delegation of appropriate powers and proper' resources.
lower
Often only responsibility is padsed on to
to the
t.
___
Fulfilment
of
local
needs,.
levels of management,
effectiveness and timeliness of activities,, job
11, and self-reliance
*u-will
----- — be
- x possible only
satisfaction,
decentralisation
and
accountability
»
after true
Passive Participation of the States in the
centrally^sponsored schemes and programmes is a great
limitation. This is evident from the* fact that
although Health is a State subject, there is almost
total dependance of the States on the Central Govern
ment. What is required is initiative and active
partnership on the. part of the States in matters of
all programmes promoting health. Such an approach
will facilitate decentralisation and adjusting of
programmes to satisfy the local needs. It would not
be wrong to state that the State Directorates of
127
Health Services have hardly any preventive or promo
tive health care programmes supported voluntarily
through the State’s own financial resources.
12.
'Provide approach' is still followed by
the health and other services. In order to reap the
full benefits, what is required for Primary Health
Care, is the 'participatory approach'. The Chinese
say that teach a man I .ow to fish rather than give him
a fish. There are obvious difficulties and substan
tial social change may be necessaryc Eventually,
Government should participate tn the people's
programme.
13.
Misconcept and Lack cf Faith arc the
important problems in the operation of Health Guide
Scheme. Many people, especially the educated, and
most of the doctors think of the Health Guides/
Community Health Volunteers, anc the Health Workers
in the field as temporary and second-best substi
tutes for doctors. This is not true. They are also
called 'auxiliary workers'. In reality, they are the
primary members of the health team. Experience
gained in several research projects seeking for
alternative approaches for delivery of health care,
such as at Jamkhed, Mandwa, Padgha and Vadu-budruk,
and also in the Health guides Scheme, proves that
many villagers with minimum or no formal education
are able to perform with remarkable competence, a
wide variety of functions embracing both curative and
preventive medicine, coperatives, community
education and mobilisatio ' „ They are willing and
work with interest in the community where the needs
are the greatest. Their jobs are more difficult
than those of an average doctor. The doctor is
oriented towards disease, treatment and individual
patient. He functions best when based at a hospital
or in an health institution. On the other hand,
these workers and volunteers are oriented towards
health and the community. They have to seek a
balance between cure and care. What would happen if
a village has only a doctor? There would be an
epidemic of gastro-enteritis, the well water would
remain untreated, people would have no knowledge of
the hazards of poor hygiene and sanitation. The
poor villagers would wait till the children are de
hydrated, and only few would have money to pay for
the treatment.
The programme would succeed to the extend
the community organisation gets strengthened and
people have fuller awareness of the health issues.
128
There should be increased accountability to the community/
peopleo Unfortunately# in the process of utter mismanage
ment# we have distorted a good scheme beyond recognition
and retrieval.
14o
Inadequate Guidance and Technical Support to the
field staff is another area of concern. Supervision on
the part of medical officer is generally lacking. Problems
of training/ transportation/ communication# logistics and
supplies require quick solutions. Relationship between
the Health workers and Health Guides has not been correc
tly conceived and developed. Health Guides are not sub
stitutes or alternatives to the Health Workers. Health
Workers are part and parcel of the formal health services
and are required to discharge their assigned duties.
They are accountable to their superiors such as the
Health Assistants and medical officers. They have no
formal control or authority for supervision over the
Health Guides. Their authority lies in their technical
knowledge or skills. Health Guides are volunteers or
social workers andaare not employees of the Government
or the local authorities. They provide a link with the
community so that utilisition of health services facili
ties are maximised/ and people co-operate. The Health
Guides major task is to help the community to get better
organised and become self-reliant in matters of health.
The Health Guides are accountable to the villagers and
speak for the people.
There is also a misconcept about the new
category of health staff# the Community Health Officer*
He is a non-medical staff provided specially to im
prove guidance and technical support for the field
staff of the Primary Health Centre (Newer Type) through
intensive supervision. He is lot a substitute to the.
medical officer so as to relieve him of his responsibi
lity of supervising the field staff under his control.
Unfortunately# this corrective intervention has not re
ceived due consideration and acceptance by the State
Governments.
15.
Identification of the Process: Entry to the
community may be through the development of health
services/ but this should not be interpreted as a way
for developing community participation. The Primary
Health Care is basically anI educational process,, How
to get at it? .A process that has high potential of
success should be tested and established. There cannot
be a programme to deliver Primary Health-Care#, it is
a development process• :Implementation of Primary Health
Care can be ensured only if one is able to foster the
129
necessary political will at various policy-making levels.
1G.
Lack of Trust on Health. Education: Knowledge and
skill are the best and most potent weapons. The present
programme of health education-as a part of the health
services programme- cannot be expected to give us the
desired impact on health and change in life-style. It
has to be integrated and made a part of our educational
system. Health should be taught as a compulsory sub
ject with examination throughout the primary and
middle schools. Ar£ the high school level it may re
main as one of the optional subjects. Schools
should provide the models of healthy environment
and the temples for health promotion. It is need-?
less to add that we have to ensure that all the
children, especially SB& girls from the targeted
communities/people attend school regularly. What
we need is a massive drive to provide Information,
Education and Communication (IEC) on all relevant
issues and areas to the people. We should mean
business.
17c
Under the International Decade Programme for
Drinking Water Supply and Sanitation/ the targets
were to provide safe water to all the cities and
villages; and basic sanitation to 25% of the vil
lages; 50% of Class II and smaller towns, and 100%
of^Class I cities by the year 1990. Our progress
is, however, slow. Further, sanitation would give
desired impact on health status, especially in re
ducing the gastro-intestinal infections, only if
it is coupled with improved personal hygiene and
food sanitation. In practice, there are instances
when we. ter is being piped <_nd supplied from sources
which are either polluted or potentially unsafe.
This further strengthens the need to co-ordinate
activities of the departments of health, education,
public works and housing.
18.•
In summary, our target groups of people,
viz., most of the rural population, and the.slum
dwellers and other under-privileged people in the
urban areas, have poor levels of health because t
they are under-nourished, suffer from infections
and infestations, are deprived of social and eco
nomic justice, live in unhygenic conditions in un
healthy environment, are ignorant of haalth and
other health related matter, are not aware of va
rious health hazards they are exposed to, fail to
utilize health and other services fully, have harm
ful habits, have large families, and generally
130
i
live in a way that is not conducive-1 to health. Further,
these people are economically poor and corrective mea
sures are far beyond their resources in many ways. The
status of women is low. It is essential to deal effec
tively and immediately with all the factors that are
responsible for the poor state of our people. We shall
have to concentrate on l,3have-Nots”, may be even at
some disadvantage to the Haves” . For this, politica
will should be very strong and the health administrators
should be highly efficient and determined.
J,! should lead to improved quality of
Better health
life. Therefore the
*— health indicators should include.
among others. Index of Physical Quality of Life (PQLI)•
This should be our Primary Health care^,
Care. Key note
should be the people, :for
with the people
— the- --people,
' •
An that we
and to the people through self-reliance,
commitment#
need is the will, the motivation and the
to do this•
i
****************
4
131
i
BIBLIOGRAPHY
1.
Bang, Abhay, People’s Participation and Economic
Self-reliance in Community Health, Medico_Friend
Circle Bulletin, 64:2, April 1981.
2.
Deodhar, N.S., Primary Health Care in India,
Journal of Public Health Policy, 3:76-99, March
1982.
Deodhar, N.S., Saving Health from Poverty and From
Affluence, Future, UNICEF, New Delhi, 2:37-40, 1982.
3.
4.
Editorial,The distinction between Public Health,
and Community/Social|Preventive Medicine, Journal
of Public Health Policy, 6s 435-439, December-T585.
5.
Government of India, Agenda Papers, Eight Joint
Conference of the Central Council of Health and the
Central Family Welfare Council, New Delhi: Ministry
of Health and * Family Welfare, August 1982.
6o
Government of India, Background Materials, Confer
ence of State Ministers, Secretaries, Chief Engin
eers and Heads of Implementing Agencies in-charge
of Water Supply and Sanitations Ministry of Works
and Housing, January 1983.
7.
Government of India, Working Group on Health for
All by 2,000 A.D., New Delhi: Ministry of Health
and Family Welfare, 1973.
8.
UNICEF/WHO, Formulating Strategies for Health
For All by the year 2,000, Report of a Joint
UNICEF/WHO Regional Meeting, New Delhi,
December 1979.
9.
Whi^e, A.T., Why Community Participation?
Assignment Children, UNICEF, 59/60?17-19, 1982.
10.
W.H.O./ Development of Indicators for Monitoring
Progress towards Health for All by the year 2000,
Geneva, 1981. .
/
.
■
'
"n’
11. W.H.O. Strategies for Health for All by the
Year 2000,
S.E.A.R.O., New Delhi,
p. 111-121.
132
ISSUES IN THE POLITICAL ECONOMY OF HEALTH IN INDIA
by
Roger Jeffery
The political economy of health care provides a
necessary backdrop to an understanding of the nature and
process of health policy-making in India, This context
provides the possibility of answering questions such as why
different numbers of different cadres of medical personnel
are trained; why some areas of health provision are wellfunded while others get little more than a pittance; why
some health facilities are under-used while others are
swamped with demand; and why some systems of health care
financing are used and not others. In this paper I intend
to discuss this context, rather than the details of out
comes, for which other sources are available (cf.Jeffery,
1985, 1986, forthcoming).
The political economy of health care is an attempt
to specify the ways in which economic interests and
political processes structure the provision of health
services. It can take many forms. At one extreme lie
economistic models, based either on neo-classical economics
or vulgar Marxism, in which the political processes are
seen to follow directly from economic determinants. At the
other extreme lie politicist models where political forces,
either national or international, are in the driving seat
(Staniland, 1985). An ex<mple of neo-classical economism
would be Mahbub-ul Haq’s argument for Pakistan that health
provisions could be left to market forces (1963); of
Marxist economism would be Djurfeldt and Lindberg1s1 Pills
Against Poverty* (1975). Lipton’s ’urban bias’ arguments
lie near the politicist end of the spectrum, with his
argument that indigenous practitioners are supported as a
way of keeping good medical services for town-dwellers
(1977); so are those accounts by doctors or administrators
which conclude that ’political will* is the answer, of focus
on corruption.
An essential element in these different
political economies is how the role of the State is under
stood. One politicist view is usually characterised as
’pluralist*, where power is exercised through alliances
forged by groups on the basis of a number of common and
competing characteristics - caste, language, religion,
education, for example, all providing bases for common
action as well as (and often over-riding) narrow economic
133
interestso State bureaucracies are seen as central to an
understanding of the chances of any policy being imple
mented (Braibanti, 1961)o In some cases the analysis
seems to assume that the bureaucracy is divorced from the
every-day political world and just ‘holds the ring’o
Failures to maintain this divorce are then castigated by
calling the result * corruption *, without posing questions
about the interests of the bureaucrats, or the social
groups favoured by these 'corrupt practices'o
The alternative view of the State draws on
Marxist traditions, more or less econom'is tic * In this
view the State reflects or is an instrument of dominant
classess debate (as, for example, between the various
Marxist parties in India) focusses on which classes arc
aligned together, and whether to collaborate with the socalled 'national bourgeoisie', seen as particularly
powerful in the Congress Party (Kurien, (edo) 1975,°
Hawthorn, 1983)o The work of Alavi (1972) raised the
level of this debate by posing the possibility that State
bureaucratic structures had some limited independence of
action, because the State in post-colonial societies in
herited bureaucratic and military institutions designed
largely with a concern to maintain order and control»
Alavi suggested that these institutions are strong
enough to be relatively autonomous of the propertied
classes within post-Colonial societies, and of their
metropolitan allies abroad. In Alavi's view, what distin
guishes the colonial State from post-Colonial one was its
'alien' character, not its institutions or primary concernso
Alavi’s formulation was criticised on several
grounds, most notably that he seemed to exaggerate the
extent of the colonial State's control over civil society
(Saul, 1974; Bayly, 1979; Washbrook, 1978; Moore, 1981)»
The British recognised the limits to the control which
their State apparatus could wield, though of-course, the
Indian Army (with the British Army in India), the Indian
Police, and the Indian Civil Service, could still together
forge an instrument of domination more efficient and
flexible than any previously seen on the sub-continent.
But since Alavi's case seemed to be based on the ability
to manage everyday politics and bureaucratic matters
without reliance on landed classes, the objections
have considerable validity.
134
Secondly, Alave seemed to assume that the Imperial
State was fairly directly a tool of the 'Metro-politan bour
geoisie’ . However, the extent of control from London was
restricted by distance and lack of knowledge. The interests
of the 'Metropolitan bourgeoisie’ were rarely clear, unam
biguous or unchanging, and by the 1920s the overall struc
tural constraints of Imperial interests gave few guidelines
to Indian bureaucrats attempting to copp with world recession
and Japanese competition (Charlesworth, 1982). Further,
little can be gained from Alavi's formulation if we wish to
understand not only the pressure on the State to provide for
the needs of 'capital* but also social policy, such as the
British suppression of sati and female infanticide, or
programmes of general education, particularly female educa
tion and in the field of health. Here, elements of imperial
ideology (and variations in the form this took between impe
rialists and at different times in different places) have to
be considered seriously.
A third difficulty with Alavi's formulation is
how the State changed at Independence. The Indian Congress
Party wanted the levers of power but had confused and cont
radictory ideas of what to do with them (unlike the Chinese
Communist Party) (Maddison 1970). By taking over the
existing bureaucracy Congress could cope with the immediate
problems of maintaining an administration in desperate times.
but they were also constrained in the policy^innovations^they
jjever developed ways of
were then able to take. Congress
Conor
•tia nor provided an alternative
overcoming bureaucratic inert!
argued that this was because the
structure of power. Alavi
\
bureaucracy had developed ways of by-passing political
leaders. Wood(1980) suggests that its main technique was
to increase the complexity of bureaucratic routine as a way
of blunting political pressures.
Alavi was, ofcourse, talking specifically about
Pakistan and Bangladesh, though Wood.extends the argument
to India. However, ministerial office in the Indian States
seems to offer several controls over the bureaucracy - for
example, in the transfer and promotion of State (rather
than all-lndian) civil servants, and the awarding of
contracts (Wade, 1984), 'Policy* presumably emerges from
processes of negotiation between politicians and
bureaucrats, rather than a one-sided dictation. How do
we understand the direction taken by such policies in
Ministries like Health or Social Welfare?
135
Alavi provides some answers to these issues in
a recent article (1982), which perhaps offers a way of
avoiding the polar weaknesses of politicist and economistic approaches. He iistinguishes four levels of
analysis of the State. The first draws on the so-called
'capital-logic' school and focuses on the role of the
State in creating and reproducing a social order which
permits capitalism to flourish - in Alavi's terms, India
is a 'peripheral capitalist' economy, so the minimal role
the State must fulfil is to make it possible for capita
lists to make a profit, to benefit personally, and to
continue to invest. The second level relates to the
questions Alavi raised in 1972, on the classes and groups
who can be said to control the States at this level"
issues of the actions of the State in specific spheres
have to be considered. The third level is the analysis
of the bureaucracy, its social origins and interests, and
the extent of its autonomy, while the fourth level is
that of the State as an arena for competing interests party and pressure group politics. This approach does
not solve all the issues it raises - in particular,
there remain problems of specifying how the different
levels relate to each other, and a lurking suspicion
that it is a catch-all for very different approaches
which mean very different things when they refer to the
State. Nonetheless, I intend to explore the issue of
health policy in its terms as far as it can go.
Alavi argues that State action (at the second
level) takes place within the context of a 'structural
imperative', set by the first level. The basic notions
of profitability, calcu ation, and capital accumulation
affect the consequences of State action but do not
determine those actions in advance. Rather, aspects of
the other two levels (the bureaucracy and the 'political')
may cause deviations from what might be considered the
strict logical requirements of capitalist enterprises or
capital in general. In this model of political and
social life, strict logic never applies but politics and
society tend in this direction in the long run.
Alavi’s recent position/ then allows the
possibility that 'mistakes' can be made, and that not
everything done by the State meets the needs of dominant
classes, or results from class conflict or class
formation. In addition, it provides a space for socio
logical analysis of the ideas and interests of
bureaucratic and other groups without making them seem
136
dissembling about the realeither hypocrites - consciously unaware of the benefits
reasons for policy - or idiots
i allows for both
to particular classeso Alavi’s position
the
development
of
economic and political elements in '---similarities
it shares^ many
health policy» In this respect relations
between three
with Bardhan’s
uS'In
strict Marxian
Marxian
(not in a strict
dominant ’proprietary
1'ndu‘strial capitalists, rich farmers, and the
sense). sector Ptofesslonal tureauerats
public
basically concerned with inaustri
arowth. He argues
the cause of the siow-down in
‘ it"is a way of managing
that the public sector grows because it is offythe
conflicts between the,^,
to undermine the
prospector "productive investment and economic development.
deterbinasts of health service development
Health services respond to the demands of some
=VSh-^rqwn£iloM Jhathot^
of the ruled.
disease spectrums
4
Therefore,
even if health services were to
differentlyo direct manner to the effective demands made
respond in a
on Sem.
'--- - they
.««J
disease pattern. h~-•
a
health,services! Thecate^h.s
The State nas ^ernsts^n^er^n^
interests
controlo -------labour, have theories
enelr own
as well as views on their
In a colonial
~ iT i situation, such
sue as
considerablys and many
genous andcontinues in the postwould argue that this mism
colonialism. However,
maepenaence woril
medlcal occupation, cannot
State interests, and thos. or
identified as
de assumed once a particular^ountry^^^
, ?«Sea from country to country, and they
have changed through time.
.reaucratio context must
An historical and a bu Health services in India
therefore be takeni into account,
3 by the legacy of
today are conditioned in Wortant ways
established under British rule.
health services ie, a manor feature even of change m
’incrementalism’ context as Lampton's painstaking accounts
’ revolutionary*
?n post-Liberation China make clear
of medical
policy
Workers at all levels of a bureaucratic
(1977). V—--137
hierarchy have interests in restricting changes which may
mean they lose their jobs, or have them radically re
defined, or require retraining and uncertainty; those
near the top have scarce skills (socially defined) which
givt them power to limi proposals which might reduce or
change their positions» But in addition, the different
elements which go into the State are often inconsistent,
and policy rarely proceeds in any one direction without
calling forth entrenched opposition. For example. Imperial
medicine in India cannot be understood solely in terms of
either social control or humanitarian concern for an
ignorant and diseased populace. While social control and
Imperial economic rationality set limits on possible
health provisions, ideas of the civilising mission of
Imperialism and the proper concerns of charity gave
medical services a particular form. Medical services were
chosen as part of the symbolic justification for Imperial
rule, and as long as they never threatened Imperial
stability, they could take a variety of forms, A
successful rural health service, after all, could have
contributed far more to social order than the inadequate,
almost non-existent, rural health structure which was
provided.
The Imperial impact on health in India was thus
contradictory. On the one hand, changes in famine policy
and food distribution helped to reduce mortality;
increasing numbers of men (and later, women) were trained
in medicine to the international standards of the time;
hospitals and dispensaries attracted considerable numbers
of patients; and issues of disease prevention and public
health provision were addressed as never before. On the
other hand, many of there measures were restricted in
their impact to a relatively small sector of the
population, firstly the European civil and military
servants and their families, latex those with access to
urban facilities; if 19th century medical services were
'beneficial’, then the mass of the Indian population .could
not have benefited. The preventive campaigns were never
pushed fully through, and their impact was limited. Both
vaccination and, more powerfully, plague control, demon
strated the failure of British health policy to come to
terms with local society. Health measures per se
probably had little marked influence on mortality and
morbidity; but they established a framework (of personnel,
ideas, institutions) which permitted more substantial
post-independence provisions, whose impact is more
noticeable,
138
Ramasubban argues that this pattern can Fe defined
’
colonial
mode of health care’, characterised by segre
as a
gation, and by provisions for the enclave sector which kept
pace with ’metropolitan* developments.
The rest of the pop
ulation ’missed going through the period of sanitary reform
which swept through most of Europe in the nineteenth and
early twentieth centurees’ (l98
(198 r:107).
:10?).
This picture
seriously over-estimates a number of elements in the story,
Firstly, the stress on segregation was moderated by reaXisation that it could never be complete, and the interests
of colonialists were linked with those of the Indians who
surrounded them.
Thus the most substantial urban improve
ments (in water supply and drainage) were designed to
improve the living conditions of Indians.
Secondly, pro
visions (in terms of hospitals and dispensaries, cr places
in medical schools and colleges) soon out-rar the needs of
the Army and the European civil population, and this was
regarded with satisfaction, not alarm.
Thirdly., the most
effective elements of European sanitary reform were also
largely urban phenomena: many rural areas in Europe are
still without centralised water supply, drainage or refuse
disposal, for example.
To blame the colonial government
for not transferring urban solutions to a largely rural
India is to under-estimate the extent of the problems
involved.
And fourthly, the role of public health itself
in Europe is overstated by this view, since rising living
standards and changes in personal hygiene were largely in
dependent contributors to the changes in the level and kind
of morbidity and mortality experienced by the European
population.
The failure of the colonial Government to make
a substantial impact on morbidity and mortality in India,
then depended on factors outside their control as well as
the constraints imposed by the nature of that Government.
We should not dismiss these arguments as self-interested
excuses merely because they were made by the Imperialists
themselves.
Most prominent amongst the problems faced by
health policy-makers was the poverty of the Indian population
(not all caused either by the depredations of British conquest
in the eighteenth century,
or by commercialisation and the
sustenance of landlordism in the nineteenth).
Not only did
this mean that the diseases which they suffered were (and
are) difficult to cure, and (with the technology of the
time) difficult to prevent.
In addition, the tax base for
raising revenue to implement public solutions was also
limited.
The Imperialist Government did not, ofcourse,place
sanitory reform or medical services high on its list of
priorities 5 but in some ways they were higher in India than
in Britain.
In Britain, the Government was inclined to
leave medical provision to charitable or voluntary hospitals;
medical education to independent medical schools; and
sanitary reform to urban councils.
All these in India were
seen as the proper concern of the Imperial Government.
139
A further•problem was provided by the radical
differences in understanding the causes of disease and
the consequendes of some aspects of the environment,
held by the rulers and the ruled. This was most marked
in the case of plague, but was also true for issues of
'controversy*, or water supply, or antisepsis. Some,
or even all the views on these issues put forward in the
nineteenth century may now appear to us to be wrong,
and they might have made little difference if they had
been widely followed. But one of the causes of slow
implementation was the gap between th9 medical models
of the rulers and the ruled. In addition, the proposed
solutions encountered real technical problems (e.g.for
water closets, or water purification). The commitment
to implement such policies may have been weak; and the
constraints (financial, political, or administrative)
set on health policies were undoubtedly considerable;
but it remains an open question how much difference
would have been made by any conceivable alternative
structures or commitments, given the extent of the
changes in living and thinking patterns which were .
necessary.
Therefore, even colonialism was not totally
integrated. The context (the reproduction economically
and politically of the Imperial order) did not totally
define political precesses within the State, ^ther
pressures with an impact on medical policy were the
perceptions of medical bureaucrats, the requirements of
meeting some of the political demands made by the
rising political classes, demands in the market for
medical services and education and the need to defend
the State from accusations of exploitation - quite apart
from the brute facts of poverty and the environment.
THE IMPACT OF INDEPENDENCE
At Independence,, the 'alien* rulers were
replaced by Indian ones, albeit ones often rebuked as
no less alien in thought, speech ana action than many
extension of liberal democratic
of the British. The
r---- --institutions, and changes in the nature of the inter
national environment, had consequences for State
structure. But the impact of Independence in 1947 was
much less substantial than the political rhetoric
suggested, and do not need to be rehearsed for an
Indian audience.
140
I want to draw attention to only a few features
of the political situation since Independence. Firstly,
at the same time as the State has become more centralised,
it has had to come to terms with an increasingly clientelistic local political structure. These potentially
opposing trends provide a tension which underlies many
apparent discrepancies in policy proposal and implementa
tion. Policy-making has progressed with an eye less to
ideological coherence or overall rationality than to a
desire to meet interest group demands, often through an
expansion in the role of the public sector. Myrdal
(1968:895-900) called this a ’soft' State - one which
places few demands on the mass of its citizenry, and
attempts to offer services, employment and other benefits
without, for example, establishing a tax system or a
political structure which can systematically call upon
individual resources. Another way of describing this
pattern would be to say that Alavi’s levels of the State
in India are less tightly constrained than in many other
countries. None of the policies envisaged by ’Gharibi
hatao'or by the ’20-point programme’involved a, direct
attack on class privileges or mobilised individual resour
ces .
Secondly, in the field of health policy. Congress
took over the planning framework mapped out by the Shore
Committee, established by the British as part of a campaign
to win the hearts and minds of Indians during the War,
rather than their own National Planning Committee’s public
health proposals (Jeffery, 1976). By comparison with the
Shore Report, the N.P.C. report on Public Health (N.P.C.
1946) was shorter> less well argued and costed, and drew
on far-less detailed analysis of the existing situation.
In many areas the two reports overlapped. Both
looked towards a socialised system of health services,
dominated by the public sphere, with no financial barrier
to equal access to all, and the eventual elimination of
private medical practice. Both supported the development
of insurance-based services for industrial workers, but
accepted that this was impractical for the mass of the
Indian population in the foreseeable future. Both reports
pointed to nutrition and general living standards as the
major determinants of health, and gave preventive measures
highest priority. Both saw the integration of preventive
and curative services, provided by a full-time salaried
cadre of workers, as the way to achieve this, and they
also called for Government doctors to lose their rights
to private practice.
141
The crucial position of rural provision was
also common grounds in Shore's words, ‘’’it is the tiller of
the soil on whom the economic structure of the country
■eventually rests" (0.0.1., 1946s4),and health servicesshould be as close to tne people as possible. Both drew
on the models for health provision developed between the
World Wars by the League of Nations Health Organisation,
and implemented in Zdgc.,lavia and parts of Nationalist
China (Lucas, 1983). These involved health centres in
nodal villages, linked to larger units at district level.
The Shore report specified in much more detail not just
desirable staffing levels over a 30-40 year period, but
also suggested a strategy for the first 10 years. Both
reports called for a substantial increase in the amount
of public money allocated to health matters, .-but stressed
that a shortage of trained personnel would be a major
constraint. Finally, both reports saw the need for
health education - to change the habits of mind and ways
of life of the mass of the population - and the need to
engage the co-operation of the villagers in the work which
was needed. The Shore report cited an article by Henry
Sigerist on Soviet health committees, and suggested that
pioneer work at Singux, in Bengal, vzas proof that they
could work in India.
The difference appear in three main ways.
Firstly, Shore urged the establishment of special campaigns
against specified diseases, in particular malaria, tuber
culosis, V.D. and leprosy, whereas the N.P.C. report was
silent on this issue. Secondly, clear difference emerged
over the priority categories of personnel for training,
and the proper role of semi-trained villagers and
indigenous medical practitioners. Although Shore was
willing to float the idea of 'health assistants' to
relieve medical men (sic) of some of their curative and
preventive duties, he saw no role for part-time health
workers, who were the 'cornerstone' of the N.P.C. propo
sals. The third difference was the N.P.C.'s willingness
to include indigenous practitioners in a reformed health
service, whereas Shore excluded them.
In sum, both reports went well beyond a
'medical' model of health services. In Rifkin’s terms,
these are examples of ’health planning’; but the N.P.C.
Report included elements of 'community health', missing
from the Shore Report (Rifkin, 1985). However, without
the support :.f a secretariat, or any political powerbase
within the Congress Party, the N.P.C. Public Health
report disappeared with very few traces, and the Shore
report provided the framework for most .health decision142
making. Perhaps the most important point to note about
both these reports, however, is that they legitimised in a
powerful way the views of those who espoused a 'health
planning' view of India's public health needs. But the
new health policy had to be implemented by a health system
still dominated by a 'medical' model.
In the rest of this paper I will analyse the out
comes of health policy since 1947 in terms of the ‘levels’
which Alavi distinguished in his 1982 article.
THE STRUCTURAL CONTEXT
How far has India's position as a peripheral
capitalist economy determined the course of her health
policy? It is not possible to do more than suggest a few
possible themes here. In the first place, health policy
could not undermine principles of private property,
personal profit, or the reliability of contractual agree
ments; but this does not take us very far. Secondly, in
the post-War period, India has never been seen as short of
people, so pressure to reduce the death rate has been small;
India’s slow but now evident success in doing so accounts
in part for the alternative pressure (much stronger) to
reduce the birth rate. Thirdly, issues of population
quality have almost all focussed on education, not nutrition
or good health. Although industrial workers have been
provided.with subsidised medical services much better than
those of the rest of the population, no concern has been
shown to improve environmental factors in urban areas nor
to implement Factory Acts to reduce industrial pollution,
diseases and accidents. Most of the. industrial labour
force has been easily replaceable. Finally, in the main
tenance of a docile.labour force, factory doctors or the
employees’ health service generally have played a minor role.
All these points are even more true for the
agricultural sector. Labour productivity in agriculture
is low, and the agricultural sector remains largely out
side the direct control of corporations. On plantations,
a surplus labour force is maintained through concessional
(granting of small plots of land for self-cultivation, and
by the relative isolation of planatation populations,
geographically and socially. Health services provided by
plantations companies do little more than meet the letter
of the law. Improved health services are not demanded by
trade unions nor are they offered by management.
143
i
i
It is, then, difficult to make the case that
good health is needed for the reproduction of India’s
economy; the alternative argument - that bad health is
necessary instead - seems to underplay the significance
of -he malaria control programmes in dramatically
improving the state of health after the War. Ofcourse
illness can weaken organised movements of the downtro
dden, just as do illiteracy and the fanning of ethnic
and caste divisions, but I do not think this adds up to
a sustained case.
The limits set by the structural context
relate mostly to the financial limits on investment in
health. Establishing and maintaining a healthy environ
ment, adequate disease control programmes and promotive
health measures, and a medical service accessible to all
would be enormously expensive. In this sense, the
preferred policy would be 'indifference', keeping the
cost of the social wage as low as possible. At current
levels of economic surplus, the Indian economy cannot
seriously contemplate more than palliative measures,
whatever the long-run economic benefits that might accrue
CLASS INTERESTS IN HEALTH POLICY
Narrow class interests have a clear impact on
several aspects of health policy. The urban professio
nal, bureaucratic and commercial classes have a direct
interest in the expansion of medical education in order
to provide career paths for their sons (and to a lesser
extent, daughters). Medical college places were
expanded through the 1950s and 1960s, mostly by Govern
ment but latterly by the growth of private medical
colleges, run as combined political and commercial ven
tures in a number of States (Kothari, 1986). The same
groups have supported doctors in campaigns to ease the
import of high technology medical equipment (so as to
avoid the 'need' to go abroad for advanced treatment),
and to permit the establishment of specialist hospitals
in the major cities. These urban classes also expect
basic sanitary arrangements for their parts of the
c ities o
Quite different interests activate the rural
’proprietary' classes. For their own medical care they
share the demands for private medical facilities in the
towns - none of the proprietary classes would use
Government hospitals except in emergency, or if (as
with some urban teaching hospitals) they have facilities
unavailable elsewhere. Some of them may also have
144
interests in the growth of medical education. But their
direct political concerns focus on the expansion of the
Governmental rural infrastructure. Their political stockin-trade is the allocation of resources and the influencing
of appointments to jobs 01 access to Government facilities.
On occasion their concerns may even extend to the proper
carrying out of official duties, and ensuring that disease
epidemics or notorious causes of illness are dealt with.
Thus they are interested in the provision of clean water
supply through handpumps (though not in ensuring that all
villages get them or that the programme functions properly
everywhere) as well as in the supply of insecticides for
malaria control - in fact anything which is regarded by
villagers as an asset. They also are interested in
services which are unofficial, or break the law in some
respects, such as unregistered medical practice; suci\
people require a patron in order to avoid trouble with the
police.
Finally, the proprietary classes perceivei an
Family
interest in population control of 'them', the
'---- masses.
...
one
or
size amongst the urban classes is already small,
The spectre
of untramme. .
two child families being common. L..
growth
destroying
urban
cohesion,
denying
lied population
employment •to
— their children, and undermining their own
euuxxuy, is a potent force affecting
long-term economic security
These
fears" “
may
after
Government policy,
----, be unjustified;
r •
Hip
all the growth in white-collar employment in much of the
public sector is based on growing demand from a growing
population rather than growing wealth. Nonetheless, in
large measure, the family planning programme dominates th
public image of the main task of the health services.
^2 the^State,? therefore,
At this second level of
straightforward
drive for
class interests do not produce a j
the application of a 'medical model' to health services
development. However, they support tendencies
mine the application of health planning models
the growth of private sector medicine which is ever
sophisticated and expensive, and which sets the s n_a
fOr the public sector to aspire to; the creation
a
bureaucratic ethos which differentiates sharply betwe n
the treatment of those with 'puli’ and those without
it; and a pressure for-increasingly coercive measures
of population control which further alienates most
people from the idea of involvement m community health
activities.
145
GOVERNMENTAL STRUCTURE AND HEALTH POLICY-MAKING
Under the 1950 constitution the primary res
ponsibility for health matters was given to the States.
The Centre kept control over international aspects quarantine etc. - and over a limited range of all
India matters, including the regulation of standards
of medical education (to permit medical personnel to
practise throughout the country) and the control of
communicable diseases.
The abolition of the I.M.S. deprived the
Central Government of a cadre of medical bureaucrats
whose careers it could control and who had played a
major role in influencing and co-ordinating health
policy throughout the country. Since 1950 co
ordination of health policy has largely been handled
through the financial incentives offered by Plan
funding, and by persuasion through informal channels
and through annual meetings of the Central Council of
Health (C.C.H.). These have established that the
conclusions or motions passed by the C.C.H. were only
advisory and the states would not regard them as
binding. This exposure of the weakness of Central
control has led to calls for an All-India cadre of
medical administrators to replace the I.M.S. (G.O.I.
1962:46-7 & 463-476, but without success.
The Planning Commission has provided the Central
Government with a powerful agency for affecting health
(and other) policy because it has controlled the most
substantial part of uncommitted funds. In addition,
the Planning Commission has provided a counter-weight
to the Ministry of Health in health policy-making.
Economists and administrators have dominated the
Planning Commission. If the Ministry of Health has
been vulnerable to takeover by doctors1 interests, the
Planning Commission has had a powerful veto on their
proposals (Jeffery, 1986).
Most discussions of the planning process in
India have focussed on the overall context/ and on the
dramatised by the crises of planning (see, for example/
Streeten & Lipton/ 1968; Bhagwati & Desai, 1970;
Cassen, 1978; Frankel, 1982). The catalogue of
criticisms is almost endless. One with specific rele
vance to health sector planning is that prior to the
Fifth Plan the distributional aspects of development
were ignored. This assumption has come under
increasing attack (eg. Chenery et al, 1974), and
146
alternative planning strategies have been proposed. Of
these, a concerted attack through land reform on those
institutions which generate poverty in rural India has
not been seriously considered. Instead, the response has
been a 'basic needs' strategy; that is, to emphasise
programmes to provide basic services to the mass of the
population. The so-called Minimum Needs Programme raised
the importance of 'social expenditures (health, education,
social welfare etc.) in contrast to the earlier Plans when
the 'core' sectors were always heavy industry, power and
minerals o
In this setting, several policies have been
introduced and implemented, apparently within the frame
work established by the Shore committee. Prior to 1970
these were particularly the disease control programmes,
most notably that against malaria and smallpox; the
creation of a health centre network covering the whole
country; establishing a public-sector basic drug produc
tion capability; and the training of paramedical personnel
in large numbers. S^ince 1970 the emphasis has shifted to
integrating specialist paramedical cadres into categories
with multiple functions; creating sub-centre clinics for
every 8-10 villages; introducing village level health
volunteers and training traditional birth attendants; and
trying to- provide protected water supplies to the majority
of India's villages. None of these achievements are un
problematic, but here I want to focus on the fact that
they have been introduced at all. By comparison with
many other 'peripheral capitalist' countries, these
policies were outstandingly successful. The numerical
balance of health personnel has shifted steadily away
from tae doctors, the balance of health expenditures have
favoured primary care and the public sector health faci
lities have retained a dominant position (Jeffery,1986
and forthcoming).
Three factors help to explain this success, as
well as many of the weaknesses. The first is the position
of the Planning Commission, providing a base for the
'health planning' perspective largely immune to doctors’
pressures. The second is the presence in the Indian
medical elite of highly trained medical scientists open
to the international development of ideas of appropriate
health care. The third is the support of foreign aid,
unusually willing to fund the technical aspects of
several major policies (Jeffery, 1985). The weaknesses
of these policies derive from the same sources. The
Planning Commission had no mechanisms to ensure that
the policies were implemented in spirit as well as in
147
forme Elite medical scientists never worked in
primary health centres, district hospitals, or in
State Ministries of Health, and so they could ignore
the realities of those situations• Foreign donors'
? nfluence ended when their funding ran out, and much
of their effort (willingly or not) has been amenable
to transfer to use for family planning of an increa
singly coercive kindo
THE 'NEW’ HEALTH POLICIES
How far has this picture been modified by
the health policies which have been introduced since
1977? Key features of the new approach are its
concern with ’people’s participation', ’integration',
and the use of auxiliary heal th workers
The ‘people’ were supposed to 'participate'
in developing the work of primary health centres under
the Community Development Programme of the 1950's and
1960‘s,but the new thinking.was more sophisticatedo
However, Government programmes a:ssurne that nonGovernmental personnel can only participate in imp
lementing a programme, with no say in raising the
resources for it nor in deciding what it should be.
In addition, no changes have been made to the Govern
ment structures themselves, which in many States work
to maintain the existing inequalities, and are closely
aligned with conservative political forces. In fact,
participation receives no more than a-cursory mention.
Participation in the selection of village health
workers rarely gained any meaning in practice.
Farther proposals fot village health committees to
oversee the work of the C.H.V. and to carry out
environmental improvements are part of the received
orthodoxy, but examples of their successful intro
duction through Government schemes are lacking.
Villagers perceive a health committee as part of
normal political activity, in which leadership is
arrogated as of right by dominant factions; or as a
means of increasing the assistance the village might
receive from Government services. Village political
processes are rarely able to deliver village-level
resources (labour, in kind, or cash) for health
improvements. No plausible proposals exist to
generate such support for major improvements such as
environmental sanitation or collective rural
insurance.
148
Neither Congress nor the regional parties
make great claims for trying to change local social
structures; and practice is even less reformist.^ The
Congress Party is closely tied into local structures of
power, economic and social, and tends to draw in the
institutions of Government (the police, the civil service)
to support local partymen. Where Congress dominates, the
political orientation is at best reformist, but more
usually conservative; if Congress politicians control
health committees, ’participation’ is unlikely to progress
very far®
’Integration’ has also been a key word in
discussions of health policy. The discussions in the
1950s and the 1960s related to the integration of curative
and preventive care, at the level of the doctors, or the
administrative structure; in the 1970s the integration of
the different preventive health campaigns with separate
cadres of. paramedical workers was a central issue. In
both cases, however, integration was restricted to health
workers. In the 1950‘s health work was made part of
rural development but little was carried out, perhaps
because most people do not place health high on their
lists of priorities (Taylor et al, 1965). The new
voluntary sector health projects are much more adven
turous in attempting to integrate with non-health develop
ment as an opening into the village by addressing the
* felt needs’ of its members or on the grounds that water
supply or poverty are the main causes of ill-health
(Antia, 1985).
Government health services are only integra
ted within the health sector.
rfealth Assistants and Health Workers are now expected to
turn their hands to whatever vzork, curative or preventive,
which is required of them, though the Multi-purpose
programme is still not fully implemented in all States®
In some measure, integration can be seen as a way to bring
more workers (especially men) into family planning work,
and family planning is the only programme regarded as
sufficiently important that the health services can
require support or involvement from other Government
agencies - revenue-, rural development or police. Can
this really be regarded as ’integration’? During the
Emergency, and to a lesser extent since 1981, it has
been perceived by the public at large as using coer
cive agencies to meet sterilisation targets (Vicziany,
1983). At the level of day-to-day dovetailing of
programmes so that they reinforce one another,
14^
integration is conspicuous by its absence, E
Even in the
I.C.D.S., where the resources are available and both~
Health and Education Ministries have overt health
goals in common, integration is at best partial and
inadequate. Integration of plans in New Delhi or at
the State Capital is so oiluted by the time it reaches
the District or the Block that integration wherej it
really counts - where, services are delivered - is
almost indiscernibleo
The expanded use of auxiliary health workers
is a final element. In general, village level workers
are drawn from the villages where they work. But
projects have varied according to the minimum education
they demanded, from none at all to several years of
schooling. Ideological differences occur between
using untrained personnel as a way of demystifying
medicine, or accepting auxiliaries only in the context
of shortages of trained personnel.
The experience of Governmental approaches to
participation, integration and the use of auxiliary
workers support the argument that these innovations
cannot be applied as if they were techniques, divorced
from a social, economic and political context. The
two lessons of local flexibility and committed
leaders cannot be transferred to a Government struc
ture which allows initiative to be exercised only by
those at the top, and in which communications are
transferred down the hierarchy but almost never up.
CONCLUSION
It would be easy to conclude that health
' policy in India is so <closely dominated by national
and international class interests
--- that
---- little
------- scope
remains for major change. However, this analysis
would be too simplistico In the first place,
place. it
ignores the very real achievements of Indian health
policyo Health planning has shifted resources towards
preventive medicine, rural areas and paramedical
workerso Substantial preventive campaigns have been
waged against malaria and smallpox0 Large numbers
of P.H.C.s and subcentres have been'built and
equipped, and staff have been appointedo In some
parts of the country, admittedly areas relatively
favoured on other counts, many workers are conscientious,
150
and beneficiaries' have not been restricted to the higher
classes and castes. Paramedical staff may be trained and
employed on the cheap, but their numbers have continued
to rise, and they are sufficient to supply most of the
pcpulacion with something approaching a reasonable health
service. Some of these services probably have helped to
support the decline in levels of mortality, halting and
uncertain though this has been.
Secondly, amongst the various legs which
support class domination, health policies, health sector
assistance, and even the operations of pharmaceuticals
companies., do not have high priorities. More radical
health sector proposals (like the nationalisation of dtug
production) are ofcourse fought hard by those whose
interests would be directly affected. ^Further, changes
in the local distribution of resources which might be
needed if inequalities in health are to be overcome, or
diseases of poverty are to be significantly reduced, will
also be fiercely resisted. But very few health proposals
come at all close to such radical ideas. The more notable
features of Indian health policy are the extent to which
it ha$ shifted towards more appropriate models; and the
role of factors internal to the Government and political
party structure which have limited the implementation of
even these relatively modest proposals.
Further, the Indian Government has been
relatively successful in what it has achieved, measured
against .its near neighbour, Pakistan, with which it shared
its historical legacy (Jeffery, 1974; A.D.B., 1981;
Sheppordson, 1981). As always, the frame of reference is
crucials compared to .Pakistan, In^ia1s achievements are
considerable; compared to the ideals of the planners and
proponents of’the ’new perspectives’, India comes off
much less well. The explanations for these patterns
derives from features of the social organisation which are
well captured by Alavi’s discussion of levels of the
State and the degree of their integration. ’Tight*
States have consistencies among the different levels of
the State, and integration is close. In these States,
whether conservative (Iran, perhaps) or radical (China)
the class interests which dominate the State are closely
in accordance with the structural constraints in which
they are set, and have a bureaucratic and political party
system which responds to those interests, ‘Loose* States
are those where integration is much less clear, and
contrasting pressures are able to operate with some
effect.
151
Hfa - i o p.- ;rHEAX
with the assists
Library
J/"I
)
-
*
s
In India, the tightness of relationships
between the levels is less than in many other countries.
This results from the nature of the Indian nationalist
movement, from decisions made by the Indian political
elite soon after Independence - the creation of power
ful Planning mechanisms, the retention of State
control over aspects of the economy, the elimination
of zamindari - and from features of Indian class
structure, such as the greater size and sophistica
tion of the Indian capitalist class, and the more
secure base of the Indian civil service
This has
made.possible a political party structure more demo
cratic in its -organisation than many others, with a
diversity of parties and competition for local
political resources.
Thus, Indian decision-making has been centra
lised in the hands of a bureaucratic and political elite
vzhich has given rural provisions a priority, based
firstly on socialist and Gandhian perspectives and
latterly on a populist strategy,, The shift from 'topdown' socialism, to a populist, potentially authori
tarian regime, emerges between 1965 and 1975. In
health policy terms, the Planning Commission has lost
much of its centrality, and control over key aspects
of policy (such as the numbers and 'quality1 of medical
colleges) has become much more difficult to assert.
The socialism remained 'top-down' because it involved
no party structure at the village or ward level which
could either transmit its demands up the political or
bureaucratic structure, or act as the channel for
ensuring that higher-level decisions were taken. Some
have derided this as 'Fabian', on the grounds that it
was largely a matter of the intellectual classes, with
no popular roots. The absence of these roots made it
vulnerable to the populist takeover, which lies most
clearly behind the final implementation of the C.H.V.
scheme. But the new populism also has no strong
village roots, which limits its potential for improving
health almost as much (Jobert, 1985).
The thread which links these levels of the
State is a clientelist political structure. The
State has what coherence it receives from the flows
of resources (usually called 'black' money) which
move between capitalists, landlords and their
dependents^ political parties (especially Congress)
and members of the Government machinery♦ These
152
flows are essential for the maintenance of the party
structure, but they are also the flows which ensure the
protection of propertied classes. The C.H.V. who gains
his job through patronage has to repay that patronage;
the paramedical worker who wishes to get a favourable
transfer must please local elites and accumulate financial
resources which will eventually end up recycled through
the political machinery; and the creation of rural
resources is part of the currency of local politics, not
the implementation of clear-sighted solutions to under
lying problems.
The balance of these forces varies throughout
the countryo The contrasts between Bihar, where the
levels seem most tightly linked, West Bengal and Kerala,
where most separation is discernible, or Punjab and
baryana, where the situation seems most fluid, have been
noted (eg. by Nag, 1983). Kerala and West Bengal have
the makings of a localised party structure, based on
ideological party commitments and drawing support from
the poor and landless as well as the landed, though
the effect on health services organisation and achieve
ments is more marked in Kerala than in Bengalo Local
niches can be exploited by voluntary sector organisations,
and occasionally by mass-based political movements, but
the wider structure will not disappear.
No-one can be very optimistic about the
health of Indians and the prospects for the implementation
of community health services. Conversely, however, noone
should write off the possibility of improvement. The
grounds for hope in the Iiudian experience lie with those
who are building on local social forces to employ the
health resources which are finally arriving at village
1evel.
***************
153
REFERENCES
Alavi, H. (1972) 'The State in post-colonial societies’
New Left Review, 74.
Alavi,
(1982) ‘State and Class under peripheral
c apitalism* in H.Alavi and T.Shanin (eds.) Introduction
to the Sociology of 'Developing Societies', Macmillan,
London.
Antia, N.H. (1985) 'An Alternative strategy for health
care?: the Mandwa Project' E.P.W. XX, 51-2, 2257-60.
A.D.B. (1981) .Appraisal of the Health and Population
Project in Pakistan’, mimeo, Asian Development Bank,
Manila.
Bannerji D. (1978) 'Health as a lever for another
deve1opment' Development Dialogue, 1, 19-25
Bannerji D. (1983) ’National Health Policy and its
implementation’, E.P.W.
Bardhan, P. (1984) The Political Economy of Indian Dev1 opment Blackwells, Oxford.
Bay1y, C.A. (1979) Reappraisals in Overseas History,
Hingham, Mass.
Bhagwati, J.N. & Desai, po
Industrialisation,London„
(1972) India; Planning for
Braibanti, R. (1961) Tradition, Values and Socio-Economic
Development, Durham.
Cassen, R. (1978) India: Population, Economy, Society
Macmillan, London.
“
Charlesworth, N. (1982) British Rule and the Indian
Economy, 1800-1914 Macmillan, London.
154
Chenery, H
London o
et al o
(edso)
(1972) Redistribution with growth
Djurfeldt, G. and Lindberg, S.
Curzon, London.
(1975) Pills Against Poverty,
Frykenberg, R.EO (1965) Guntur District,
University Press, Londonv
1788-1848 Oxford
G o0.1. (1946) Report of the Health Survey and Development
Committee (Chairman, Sir J.Shore) New Delhi; IV vols.
of the Health Survey and Planning Committee
((1962)Report
_______________________
(Chairman, A.L. Mudaliar) New Delhi.
G , 0.1 o
Haq, M-u (1963) The Strategy of Economic Planning O.U.P./
Karachi.
Hawthorn, G.P. (1982) 'Caste and Politics in India since
1947' in D.P.McGillivray (ed.) Caste ideology and interaction
Cambridge U.P., Cambridge.
Jeffery, R. (1974) 'Health plans and health policies? the
case of Pakistan' in J.Cook et al. (eds.) appropriate Tech
nology and Economic Development, Edinburgh.
J effery, R. (1976)
nothing' E.P.W.
'Medical Policy? sound and fury signifying
J effery, R. (1985)
India? I.J.H.S*
'New patterns in health sector aid to
Jeffery, R. (1986) 'Health Planning in India, 1951-79? the
contribution of the Planning Commission' Health Policy and
P1anning, 1, 2 o
Jeffery, R. (forthcoming) The Politics of Health in India
California University Press, Berkeley.
Jesani, A., Gupte,M. and Duggal R. (1986) NGOs in Rural
Health Care Foundation for Research in Community Health,Bombay.
Jobert, B. (1985) 'Populism and health policy? the case of
Community Health Volunteers in India' Soc.Sci.Med.20, 1, 128.
155
Kothari, V..N... (1986) 'Private unaided engineering and
medical colleges' E.P.W. 21, 14, 593-6.
Kurien, M. (ed.)
L ongman, Madras.
(1975) India; State and Societyz Orient
Lampton, D. .(.1977) The Politics of Medicine in China,
William Dawson, Kent.
Lipton, M.--(1977) Why Poor Pc,-pic Stay Po?.-r, Temple Smith,
London.
'
Lucas, xa.E. (1982) Chinese Medical Modernisation?Comparative
policy Continuities, 1930s-1950s Praeger, New York.
Maddisonr. A. .-(1971) Gloss Structure and Sccncmic Growth,
George Allen and Unwin, London.
Moore, M.P. (1980) 'Public bureaucracy in the post
Colonial State; some questions on 'autonomy' and
'dominance' in South Asia' Dev. & Change, 11, 137-48.
Myrdal, G#
(1968) Asian Drama, London (3 volsj.
N.P.C. (9146) Report of the sub-committee on public health
National Planning Committee of the Congress Party, Bombay.
Nag, M. (1984) 'Fertility differential in Kerala and West
B enga1' E.P.W. XIX, 33-14.
Ramasubban, R. (1982) 'public health and medical research
in Indias their origins under the impact of British
colonial, policy' SAREC Report No. 4, Swedish zdgency for
Research Cooperation with Developing Countries, Stockholm
Ramasubban, R. (1984) in T. Dyson and N. Crook (eds.)
India's Demography, New Delhi.
Saul, J.S. (1974) 'The State in post-colonial societies;
Tanzania' Socialist Register.
Shepperdson, M. (1981) 'Health policies and planning in
Pakistan' mimeo, Centre for Development Studies, Swansea.
Stahiland, M. (1985) What is Political Economy Yale
U.P., London.
156
Streeten, P. and Lipton, Me {eds .) (1968) The Crisis c-f
Indian Planning London,
Taylor, C.C. et al. (1965; India's Roots of Democracy
Orient Longman, Bombay,
Vicziany, M. (1983) 'Coercion, in a s ft-states the
family planning programme of India* Pacific Affairs 55,
3, 373-402 and 55, 4, 557-92,
Wade, Ro (1984) 'Irrigation reform in conditions of
populist anarchy' J.Dev.Econ. 14, 3, 285-303,
Washbrook, D.A. (1978) The Emergence of Provincial Politics,
the Madras Presidency, 1870-1920, New Delhi,
Wood, G. (1978) 'Bureaucracy and the post-colonial State
in South Asia' Dev, & Change 11, 149-56 o
157
v
HEALTH POLICIES IN INDIA
COMPARISONS WITH THE CHINA EXPERIENCE
by
Lincoln CoChen
INTRODUCTION
A close professional colleague once confided to
me that he would have very much enjoyed undertaking a
comparison of health in India and China, two of the world’s
most populous countrieso Despite his firsthand experi
ence and academic expertise on the topic, he had never
pursued the study because, as he said, “India’s health
situation would come out so poorly in comparison that I
might lose my Indian friends’”
I am an expert on neither India nor China,
although I was born in the latter and have had the unique
privilege of living and working in the former for the past
five years. Moreover, I certainly value the many close
relationships that I have formed with Indian friends and
colleagues over the recent past. Nevertheless, I have
consistently felt that a comparison of the India and China
health experiences would be enormously stimulating - not
so much for the answers that would be generated, but for
the many questions that would be provoked.
It is thus with considerable anticipation and
trepidation that I undertook the analysis presented in
this papero I began with admittedly imperfect statistics
describing the health situations in these two societies
at the beginning of the 1980s. Moving from this empirical
comparison, I developed a conceptual framework describing
how various socioeconomic and health care system factors
could be hypothesized to impact upon the health of the
Indian and Chinese populations. The paper then under
scores a set of policy issues relevant to the theme of
this conference, ’’Health for All: Concept and Reality” »
The gaps between concept and reality are illustrated in
two health policy arenas - vertical campaigns and village
level worker performance. The paper concludes with a
discussion of the political economy of health in India
and China.
158
INDIA AND CHINA
The 1982 populations of India (733 million)
and China (1,019 million) combined constitute nearly
40 percent of the world's population or 75 percent of
people residing in low-income countries with per
capita annual incomes below US $400 (37,38). In
addition to their demographic size, these two Asian
societies share other features. Both are ancient
cultures which attained their current political govern
ance structures about four decades ago. Both have low
per capita income, modest levels of urbanisation, and
a predominance of agriculture in the economy.
Table 1
Selected Development Indicators;India
and China (1983)
India
D emographic
733
Population (millions)
24
Urbanisation (%)
a
71
Labor force in agriculture (%)
Economic
GNP per capita (US$)
Absolute poverty (million)
Cereal availability per capita
(gms/day)
S ocial
d
Adult literacy (%)
e
(%)
Enrollment primary school
a.
b.
c.
d.
e.
China
1,019
21
74
260
300
300
100
414b
533
34
79
77
100+
c
1981
1982
1979
1977
1982
Source: D.T.Jamison, 1985; World Development Report
1985; Co Gopalan, 1985.
Differences between these two giants,how
ever, are also noteworthy. Politically, China is a
centrally-controlled communist state, while India
is a federated democracy operating a mixed economy.
159
While the Chinese people are relatively homogeneous
ethnically (93 percent Han)/ India’s people are highly
diverse with multiple languages, many religions, and
diverse caste, tribal, and cultural affiliations. The
Chinese have achieved nearly universal literacy within a
reasoncbly egalitarian social structure. By contrast,the
majority of India's people remain illiterate and deeply
imbedded in rigid social stratifications. Interestingly,
both India and China may be classified as "superior health
achievers" since their national mortality levels are
lower than would be predicted by their respective national
incomes (6,18).
Data in Table 2 show that India and China
experience markedly different health situations. India has
moderately high fertility and mortality/ while China's
births and deaths are very close to those of economicallyadvanced countries. China has been able to achieve these
dramatic health advances over the past three decades
(Figure 1) (8„22).* In India, reasonably steady health
improvements have been abserved throughout most of this
century/ but India's contemporary health situation
continues to remain relatively inferior (15/35).
Table 2
Health Indicatorsx India and China(1983)
India
China
Crude Rates (per 1/000 population)
Births
Deaths
Natural increase
34
13
21
19
7
12
Fertility Rates
Total fertility (per woman)
4.8
2O3
93
11
38
2
56
54
65
69
Mortality Rates
Infant(per 1/000 livebirths)
Child 1-4 yrs (per 1/000 population)
Life expectancy (years)
Male
F ema1e
Source? World Development Report/ 1985
*Because these data are 5 or 10 year averages/ the
dramatic mortality peaks of the Great Bengal Famine(1943)
in India and the Great Leap Forward (1959-61) in China
are not depicted.
160
V
A most interesting comparison between India
and China is health disparities within societies.
Desoite high overall life expectancy, China experiences
health differentials that are primarily geographic in
character (23). Infant mortality in rural China is 70
percent higher than urban levels, and the rate in
backward Yangsu County is nearly threefold that of more
advanced Shanghai County (39). Mortality
$he
minority regions of China involving nearly 100 million
people may be considerably worse than generally reported.
In India, health differentials are also marked, and
the disparities are evident not only geographically
but across many socioeconomic characteristics (Table 3)
(15,21,35).
Indian rural infant mortality is nearly
twice that of the level in urban areas, and the like
lihood of infant death in the backward state of Uttar
Prqdesh is five-fold that of socially-advanced Kerala
State (14). Differentials are also pronounced between
religious, caste, and class groups, and socioeconomic
characteristics such as literacy and mother’s education (4,21,35). India is one of the few societies in
the world where female life expectancy is briefer than
male (7,10).
Table 3
Infant Mortality Rate (per 1,000 livebirthsj—in
India According to Selected States, Literacy,
Religion, and Child Sex (1979) ~
Rural
Urban
All
All India
136
71
,126
States
Jttar Pradesh
184
168
Kerala
45
29
172
42
Literacy
Illiterate
Literate
145
90
88
50
140
55
138
126
70
76
132
104
131
129
71
73
121
119
Religion
Hindu
Muslim
Sex Child
Female
Male
Sources Registrar-General of India, Survey on Infant
and Child Mortality, 1979.
161
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Much has been written about China's remarkable
success in improving the health of its people,* The
advances are attributable to China's health system as well
as socioeconomic gains in the provision of basic needs water, sanitation, and food (11,13,23,32), China's health
system prior to the 1980s has been marked by several
innovations. Among the more significant have been mass
mobilisation of the people for preventive health efforts,
including campaigns against the 'four pests’ (rats, flies,
mosquitos, and bed bugs), sexually-transmitted diseases,
mass vaccination, and control of the vectors responsible
for the transmission of malaria and schistosomiasis.
Another noteworthy feature has been the deprofessionalisation of health care providers through the development of
a mass cadre of barefoot doctors at the grass roots level.
The mass application of paraprofessionals through a threetier health care delivery system has helped extend the
availability of basic services into remote regions, China
also invests a relatively larger proportion of its national
resources in the health sector (23,31), These investments
have been both monetary, as well as human through contri
butions of unpaid labour. Perhaps most importantly, it is
China's capacity to implement health care and other
programmes at the grass roots level that has been the most
outstanding feature of its success (33). Few countries can
claim similar implementation capacity, including economicallyadvanced countries.
These favorable characteristics in China are
only partially shared in India, which presents a far more
complex picture. As a federated democracy, Indian cons
titution assigns health and other social sectors to India’s
2 2 states. The centre may '-'lan and fund health care systems,
but the ultimate responsibility for implementation rests
with diverse state governneats (12),
* Major policy changes in rhe Chinese political economy
were introduced in the early 1980s, These have exerted
profound influences on the Chinese health care system.
This section primarily describes the system prior to
these recent policy changes. In a later section,
recent changes of the Chinese health care system are
discussed.
163
The health departments at the state level
mirrors the bifurcation of health and family planning
at the center. The health department is responsible
for health services, medical education, hospitals and
ver ical disease control programmes. The family wel
fare department is primarily responsible for family
planning, and secondarily for maternal-child health
services. Other health-related fields are assigned to
other ministriess nutrition to social welfare; water
and sanitation- to housing and public works; and phar
maceuticals to industries and chemicals. Urban health
services are provided through a network of state or
municipal hospitals and dispensaries. The overwhelming
bulk of India’s people are in 576,000 rural villages,
covered by a three-tier primary health care system. At
the district level (population about 1 million) are
medical and family planning officers responsible for
the entire district, including dispensaries and hos
pitals. At the block level (population about 100,000)
are primary health centres. These, in turn, supervise
and back-up the work of subcenters, which optimally
cover about 10,000 people through multipurpose workers.
The bulk of basic services are provided by part-time
community health workers based at the village level.
The density of health personnel in India
and China are, at senior levels, rather similar(15,22).
Table 4
Health Personnel & Facilities in India & China
India
China
Per :
.Ndj
Per
No.
(000*s) 100000 (000‘s) 100000
pop.
____ pop.
P ERSONNEL
S enior
Doctors(western)
Doctors(traditional)
Pharmacist (all)
Middle
Assist doc/Med pract.
Nurses
Midwives
Primary
Aides/Workers
Village Workers
FACILITIES
Hospitals(all)
Beds (all)
Beds (Rural)
271.6
382.5
155.6
37
52
23
516.5
289.5
162.7
52
29
16
250.0
160.9
247.4
44
22
34
436.2
525.3
70.9
44
53
7
140.8
313.2
19
42
769.5
1839.6
78
185
7.2
500.6
93.5
1
7
65.9
67
2017.0 203
1097.1 138
16
Source: ChinasThe Health Sector, World Bank,1984.
Health Statistics of India,Ministry Health Family
Welfare,1984.
164
Both have large numbers of western-trained allopathic
doctors, and both have nurtured and subsidized traditional
health practitioners.* At the middle - and primary-levels,
differences become noteworthy. The density of Chinese
assistant doctors is similar to India's rural medical prac
titioners. There is considerable difference, however,
between Chinese para-professionals trained and supervised
as assistant doctors in comparison to unqualified, unregi
stered, commercially-motivated rural medical practitioners
in India. At the grassroots level, China's health aides
and barefoot doctors are four-fold more dense than India's
village aides and community health workers. Moreover, indepth observational studies in India have demonstrated high
rates of absenteeism, diversion into private practice, and
low work output among Indian health personnel (2,4) .
China’s health facilities situation is also
superior o China's hospital to population density is seven
fold that of India's, and it has four-fold the density of
beds per population (15.22). China’-s bed availability for
rural people, furthermore, is eight-fold more than India's.
Much of India's primary health care infrastructure is still
in the planning stage and not yet functional. In 1984,
less than 30 percent of primary health centres were actually
operational, and less than half of the subcenters were
staffed with trained multipurpose workers (2).
Although their 1982 per capita GNPs are roughly
similar (China US $ 265, and India US $ 229), the share of
national income invested in health differs (49). I esti
mated that India's per capita health investment is $ 2.7
or 1.2 percent of GNP (2,9,15,17,25,31). This level is
only one-third that estimated for China's at $ 8.8 per
capita or 3.3 percent of GNP (22,37,38). **
*
The Chinese traditional medical systems are Han/Mongol,
Tibetan, Udyour, and others. The Indian traditional
systems include Ayurveda, Unani, Homeopathy, Siddha,
Tibetan and others.
Indian resource investments in nutrition, water, and
sanitation, are excluded from these financial analyses.
165
Health sector resource mobilisation patterns
in India and China are compared in Figure 2O* Private
sources constitute two-thirds of-India’s health finances;
one-quarter is from government; and only 8 percent from
insurance schemes. Chir.a, by contrast/ has tripartite
financing structure with about equal shares coming
from state; private and rural cooperative insurance
sources.
Resource flows through various health care
delivery systems follow the pattern of financing.In
India/ two-thirds of the flow goes through the private
commercial systems. Only one-quarter goes through
government health services. Very small portions flow
through private non-profit voluntary organisations and
enterprise-related health systems. In China/ the flow
through rural collective systems predominates (40
percent)t with smaller portions through government and
enterprise systems.
Interesting is the similarity of Chinese and
Indian resource allocations in health. In both cases/
half or more of the resources are invested in phar
maceuticals/ and nearly all of these expenditures are
for modern/ not traditional/ drugs. About a quarter
is allocated for personnel salaries. China’s invest
ment in hospitals is proportionately half that of
India’s.
* Health financing and resource allocation data for
China were obtained from the World Sank (22/ 23) <»
Data for India are extraordinarily difficult to
compile and analyse. Considerable information was
obtained from many disparate sources (2/3/4/9/12/17/
19/25/31). Government expenditure patterns are
complex because Five Year Plan allocations relate
only to central government allocations; yet
approximately two-thirds of public health sector
expenditures are from the diverse recurring budgets
of state governments. Moreover, the available data
are often broadly categorised/ precluding detailed
analysis. The most difficult estimate relates to the
size and pattern of India’s vast and complex private
sector. Isolated health care expenditure surveys
are available/ but these show expenditure patterns
ranging from Rs. 3 to Rs. 108 per capita annually.
Crude averages were estimated through validation of
these scattered estimates with more reliable finan
cial data on turnovers in the pharmaceutical
industry. (3).
166
R’gurc' 2
Health Resource Mobilization and Allocation: India and China
China
India
SOURCE OF FINANCE
30%
A. State
26%
32%
B. Private
66%
31%
C. Insurance
8%
0% 0. Rural Cooperatives 7%
:-n i
I
DE LI VERY ..SYSTEMS
.b
32%
A. Government
24%
62% B. Pr vate (market) 0%
4% C. Private (non-profit) 0%
25%
D. Enterprise
10%
0% E. Rural Collectives 40%
■■■
D - 'I
C
/
RESOURCE INVESTMENTS
■■
.'Ci
50% A. Pharmaceuticals
B. Salaries
21%
C. Hospitals
21%
0. Others
8%
Source: Chwa data (27)
India data compiled by another.
167
58?;
24%
13%
5%
A
■
■
CONCEPTUAL FRAMEWORK
The comparison between China and India
provides an empirical base for formulating a conceptual
framework for health police analysis« Such an approach
begins with a focus on the health status of populations
A systematic approach to factors that determine the
health of populations introduces considerations related
to both the productivity of health care systems as well
as the health impact of social, economic, political, and
environmental factors (6,18,30)•
Figure 3 presents a schematic conceptual
framework on the determinants of the health status of
populations. In this approach, non-medical factors include
the quality of the physical environment, economic or
material well-being, nutritional status, reproductive
patterns, and women/household capacity variables (30).
These non-medical factors are the primary determinants of
disease risk; they also condition preventive and thera
peutic health responses. The quality of the environment
(housing, water, sanitation, workplace) is a primary
determinant of the risk of disease exposure and trans
mission. Nutritional status (agriculture, food) determi
nes the biological capacity of the host to withstand
disease onslaught, and thus the severity and case
fatality of illness. Material well-being (income,
employment) determines the capacity of families to pur
chase an adequate environment and nutritional status.
Economics also may shape client behavior, particularly
the pattern of health service utilisation (24,26).
Patterns of reproduction (age, parity, spacing of births)
determine the biosocial health risks of mothers and
children.
Many studies have shown that even if environ
mental and economic variable arc controlled, some
families are consistently better and others poorer,health
achievers (6). Inadequately understood but powerfully
significant is the capacity of families, particularly
mothers, to manage health-related investments and
behavior within households. One measurable indicator
reflective of this capacity is maternal education
(5,36). But the health capacity of a household probably
relates to a host of additional, pooriy-measured
factors such as motivation, enterprise, and behavior(36).
These household-capacity factors probably exert their
effects through both health care and non-medical factors
- such as disease prevention, improved nutrition and
more timely and effective prevention and management of
illness.
168
j
Figure 3
HEALTH STATUS
OF POPULATIONS
1--NON-MEDICAL FACTORS
HEALTH CARE SYSTEMS
GOVERNMENT
Organization
Management
PRIVATE
Environment
Profit
housing
Reproductive
Patterns__
age
allopathic
water
parity
sanitation
spacing
Traditional
<-—>
<—>
workplace
Personnel
Women/Household
Capacity
Facilities
Non-Profit
Economic
Finance
Enterprise
income
education
Resource
Al location
Non; governmental
4
employment
motivation
4
Nutrition
1
i
agriculture
I
food
I
I
165
entrepreneurship
behavior
The other major determinant of the health
status of a population is the health system. One
useful classification for health systems is public
versus private* Such a dichotomy usefully classifies
systems that are different in virtually all respects objectives, organisation, structure, personnel,
financing, and client role* Usually in developing
countries, the better understood system is the public
system. Subsidised by government budgets and usually
directly operated by public extension bureaucracies,
public sector health systems operate within reasonably
well-defined policy parameters.
The private systems are much more varied
and difficult to mapo Often multiple schools of
health, modern western (allopathic) and traditional,
are involved., The commercially-driven, for-profit
private systems operate through fee-for-service pay
ments, and health service providers may range from
highly-trained physicians, to traditional practitio
ners, to untrained providers including pharmacists □
In some countries, non-profit voluntary systems may
also be significant, especially in societies with a
history of religious or charitable movements.
Third-party health insurance systems for
employees in the formal labour sector could be either
private, public, or some combination thereof* In
most cases, these have multiple sources of funds employee contributions, company funds, and public
subsidy* Sometimes entirely separate health facili
ties have been established to service clients of
third-party or enterprise systems. The most common
beneficiaries of these systems are government employees,
industrial workers, social security and pensioners*
These systems are growing in rapidly modernising
societies, but may be virtually absent in lowestincome countries.
Overall, it should be noted that while
the health system and non-medical factors are depicted
separately in Figure 3, they are in reality highly
interactive and interdependent. In other words, non
medical factors can influence the shape and perfor
mance of health systems^fcan influence non-medical
factors* The reduction of debilitating disease could
facilitate the exploitation of previously inaccessible
agricultural lands and a reduction of malnutrition
and morbidity could improve work performance* There
* and conversely, the performance of health systems
170
may also be interactive processes between governmental
and private sectors within the health system - such as
the private production of pharmaceuticals for distribution
in public systems or the part-time private practice of
full-time government-employed doctors. Thus, processes
and outouts of health syst ms (public and private) and
non-medical factors are highly dynamic, interactive and
interdependent»
CONCEPT VERSUS REALITY
At least on the surface, there are conceptual
similarities between the Chinese and Indian health systems
- in organisation, management, facilities, personnel, and
technology policy. Both China and India have three-tier
horizontal health care systems with outreach to the village
level. These countries have invested heavily in modern
hospitals and doctors, while simultaneously subsidising
the traditional health systems. At the grassroots level,
both have para-professionals providing basic services to
the population. In both countries, about half of all
health expenditures are for drugs. Hospitals and perso
nnel salaries command most of the remaining resources.
Deeper analyses demonstrate critical differences,
however. One reality is the organisational controversy
regarding the relative merits of vertical versus integra
ted programme structures end the relative emphasis between
preventive versus curative services. Curiously, in both
countries, prevention receives less than 10 percent of
health resources (22), Disease prevention in China,
however, has achieved outstanding results through mass
mobilisation of peasants for health campaigns. These
preventive health actions id not overtax the health budget
in a poor society since monetary resources were supple
mented by compulsory mobilisation of surplus labor during
slack agricultural seasons (30, 32"; 33) . China’s success
with vertical programmes, however, is probably unique to
the sociopolitical conditions of the society (33).
Effective implementation depended upon China's strong
political-administrative capacities at the grassroots
1evel.
India, by contrast, has experienced mixed results
with vertical programmes. In the past 40 years, India
has introduced many preventive campaigns - in family
planning, malaria, filariasis, leprosy,, blindness, goitre,
smallpox, tuberculosis, kala azar, Japanese encephalitis,
and more recently an expanded programme in immunisations
171
(EPI) and oral rehydration.therapy (ORT) (2). Of these
health problems, only smallpox- has been eradicated. The
remaining have persisted, and in some instances resurged
(such as malaria). India's health system is increas
ingly burdened-by budgetary obligations and staff from
defunct vertical programmes in which permanently
employed field staff have been left behind as priorities
have shifted (2,4).* India’s vertical campaigns also
depended entirely on a full-time extension bureaucracy,
not voluntary labor, and pressures from the top could
not generate indefinitely high productivity in the
health sector.
A similar contrast of reality is noteworthy
in personnel and facilities policies• China's barefoot
doctors were a creation of and their functioning depen
ded upon the Chinese political-administrative system
at the commune and brigade levels. In other.words, the
barefoot doctor fitted into the local organisational
structures of rural China (33). The community health
worker in India operates in an administrative vacuum.
The community development movement in India, begun in
the 1950s, is based upon an extension model orginally
transplanted from the United States. Parallel sectoral
extension workers function within traditional village
power configurations, which are hierarchical and
socially stratified. India's extension approach has
yet to overcome weaknesses in motivation, supervision,
and training.**
*
Foreign donor resources often play stimulate the
establishment of vertical programmes in India.High
priority problems are identified. Five Year Plan
resources are targetted (usually involving foreign
aid), and specialised vertical programmes are
launched. The cost of these special programmes,
after the start-up phase, must be absorbed by the
recurring regular budgets of state governments.
Functional time allocation studies in India have
found that community health workers spend 44
percent of their work time on family planning and
less than 25 percent on health or maternal-child
health services., (3)o
172
In neither China nor India has there been
broad recognition and concern over the health consequences
of drug use patterns and the proportion of health resources
invested in modern pharmaceuticals.
In China, drug produc
tion is by a state corporation. There appears to be largescale aL use of modern pharmaceuticals.
In Ind-ua, only
recently have there been public efforts made to promote
rationalisation of drug production and consumption which
are predominately in the private sector (3). The problem
in India is grossly complicated by the fact that pharma
ceuticals are not considered primarily within tne domain
of health. Rather, drug production and marketing are under
the purview of the Ministry of Industries and Chemicals
(2, 3).
POLITICAL ECONOMY OF HEAl TH
Nhile understanding of health policy concepts
and reality can be advanced through any specific.lens (eg.
organisation, technology, finances), such comparisons are
only useful to the extent that they are geoculturally
specific and incorporate considerations of the broader
context of the political economy shaping health care and
non-health care factors.
Historical, political, and
economic forces operate both directly on the healty system,
as well as non-medical factors.
Health systems do not exist in a time vacuum..
Rather, they have histories which shape their present and
constrain their future□*
For China, the communist
revolution may be identified as a central determinant of
China’s performance in health. A newly-formed government
without a colonial past, Ch'na was able to introduce a
health care structure integrating local financing and
implementation to its own unique political-administrative
*
Abel-Smith noted that Bismark developed the German
employee/employer health*.insurance fund (2) o While risk
sharing was introduced, physician fees were determined
by the market beyond government control. The cost
structure of the German health system ever since has
been locked into a high cost trajectory. The German
system, moreover, was transferred to Austria, Belgium,
Italy, and Japan. Japan, furthermore;, transplanted the
system into Korea during Korea’s colonial period. All
of these systems today are plagued by problems of high
physician costs. In contrast, Scandanavia earlier
selected a system to pay physicians from government,
budgets, which today accounts in part for Scandanvia’s
relatively lower-cost health care system.
173
structures. In India, British colonialism introduced
western medicine and medical structures well before the
time of the peaceful transition to independence. The
famous Indian Bhore Committee in 1946 recommended a
national health strategy that contained all of the
elements of what we today call primary health care(13)
A more recent report by the Indian Medical Research
Council and the Indian Council for Social Science
Research reaffirmed the Bhore recommendations (19).
Neither, however, hove been able to overcome historical
momentum nor constraints imposed by the political
economy.
In both China and India, the broader
political context of health is important, China's
communist government has consistently ranked health .a
high ideological, and thus budgetary, priority, China’s
repressive political system, however, has also generated
health problems. Political opposition is not tolerated
and public debate is non-existent. Thus, 16*20 million
Chinese died quietly of famine during the G at Leap
Forward in 1959-61 (1). India, by contrast, is a
socially-stratified democracy with an open political
process and a relatively free press. Food selfsufficiency has been recently achieved, but 10 percent
of Indians continue to be deprived of an adequate diet.
Lack of response by the Indian Government to an acute
famine would trigger public outcry and could perhaps
bring down a government. But the Indian elite and
political system, nevertheless, are able to diffuse
criticism of persistent mass hunger among nearly half
of its people (34).
The linkage between politics and the health
system is well illustrated by recent developments. The
now Chinese'household responsibility system* has rein
troduced the poncept of economic incentives accordina
to individual; productivity (32). Peasants and workers
are now encouraged to produce privately for individual
reward. This fundamental political change has had
dramatic, perhaps unintentional, consequences for the
Chinese health care system. With a population in
pursuit of private gains, decision-making has shifted
from groups to families, previous operating structures
have weakened, and health motivation can no longer be
mandated but must be achieved through mass education.
174
The network of barefoot doctors has nearly collapsed,
rural health care coverage has declined, county hospitals
and rural clinics are in financial distress, and private
medical practice has re-emerged, faell-to-do clients are
now bypassing lower paramedical staff to present them
selves directly at more-ad\anced facilities (20, 32), In
India, interestingly, recently policies liberalising the
economy may generate a similar trend towards capping of
the public sector and stimulation of private enterprise.
History and politics are important, but econo
mics also counts. Health policy thus inevitably confronts
the fundamental questions how binding are economic cons
traints on health? Here we are not dealing with fiscal
issues in the health sector, but the significance of
economics as one of the non-medical factors determining
the health of populations. At the simplest level, the
relationship between per capita national product and life
expectancy of populations is tight - more wealth, better
health (14,18,38). The role of socioeconomic development
(versus medical technologies) in the historical decline of
mortality in the now industrialised countries has never
gained full scientific consensus (6,16,29). Moreover,
there are many contemporary exceptions to the direct
income-health relationship. Some countries (such as
China, India, Sri Lanka, and Costa Rica) are clearly
superior health achievers as predicted by their income
levels, while others (such as Saudi Arabia, Iran, Libya,
Iraq, and Algeria) are clearly inferior health achiervers
(6,18). The explanation for these cases of positive and
negative deviance from economic prediction is not entirely
clear. *
Economic binds are also imperfect at the
household level. Some poor families are able to bear and
rear healthy children, and conversely some well-to-do
households cope poorly. Indepth field investigations have
delineated some of the factors responsible, including
* Caldwell noted that common features among the superior
health achieving countries were religion (Hinduism or
Buddhism), history of British colonialism, women's
autonomy and education, higher relative investments
in health, education, and social services, and a
political environment fostering egalitarianism and
social justice (6).
175
female education, family entrepreneurship, and health
behavior. Female education appears to be a powerful
indicator of improved family health, even when income
levels are controlled (5,36). Many hypotheses have
been advanced to explain the power of women-related
or household capacity factors. Some have argued that
education imparts knowledge regarding the scientific
basis of disease transmission (germ theory), while
others have proposed that educated women are more
likely to utilise effectively preventive and curative
health services (6). Others argue that it is not the
knowledge imparted by education, but the socialisation
which promotes adoption of an entire set of modern
values and practices. Enhanced status of women in the
family, some propose, shifts the distribution of power
in the family and thus the distribution of intra
household resources towards women and children, the
subgroups at highest health risk (36),
The significant conclusion here is that the
family is the central production unit for health.
Economic constraints may be important, but they are
not insurmountable^ Education
behavioral,
entrepreneurial, and other factors clearly play
critical roles in the production of health. In a
recent review, Caldwell boldly concluded that 'good
health is within the reach of all’ rich and poor
nations alike (6). He concluded that necessary was
high levels of government investments in the health
sector, * broad societal consensus that health is a
high political priority, and enhanced status, education,
and autonomy of women. The issues were less technical
or bureaucratic and more ideological and cultural in
which people perceived health and social equality as
fundamental rights.
*
There is often substantial co-variation in
government expenditures for health and other social
services. Commonly, high levels of investments in
the health sector is accompanied by high levels of
investments in education, nutrition services, and
other social welfare activities.
176
REFERENCES
"Population studies and population policy in China,"
Population and Development Review 8:277-278, 1982.
1.
■’
Aircl,
JS.
2.
Sanerji, D. Health and Family Planning Services in India: An
Epidemiological, Socfo"cuTCural, and P^oTitical Analysis, and a
PerspectTveLoOak'sh"'1 ?ti5H~shers, Ne^TTelFFTTSSST^
3.
Bhagat, M.
Shagat,
M Aspects of Drug Industry in Ind-ia, Centre for Education
and Documentation, Bombay, T5S2T~
4.
Bose, A and PB Desai. Studies in Social Dynamics of Primary
Health Care, Hindustan"FuBBshing Corpora^4on,~DFlKi , 1983.
5.
*
‘Z.
Caldwell,
JC.
6.
Caldwell, JC. "The conditions of unusually low mortality: Optimum
paths
’to health for all,"
I
. memeo,. Department of Demography,
Australia National University, Canberra, March 1986.
7.
Chen, LC. "Where have the women gone? Insights from Bangladesh on
the low sex ratio of India's population," Economic and Political
Weekly, Vol.XVII:364-372, 1982.
8.
China Health Yearbook 1983, People's Health Publishers, Beijing, 1983.
9.
Col, N and M Roberts. "Allocating health resources in Gujarat
State, India,” memeo, Pew Curriculum Development Center, Harvard
School of Public Health, Boston, 1984.
10.
Dyson, T and M Moore. "On kinship stricture, female autonomy, and
demographic behavior in India," Population and Development Review
9:35-60, 1983.
11.
Gopalan, C. "Food production and nutrition trends in India and China,"
Bulletin of the Nutrition Foundation of India, Vo1.6, No.3,
New Delhi, July 1985.
12.
Government of India, Sixth Five Year Plai 1980-85, Planning Commission,
New Delhi, 1980.
13.
Government of India, Health Survey and Development Committee Report
(Shore Comm’’ttee),~Ranager of PuTRcaf ■ ons, New DeTni19457“
14.
Government of India, Survey of Infant and Child Mortality, Office of
Registrar-General of India, New~beThi, 1979.
"Education as a factor in mortality decline: An
examination of Nigerian data,” Popelation Studies 33:395-413,
1979.
.177
15.
Government of Inaia: Health Statistics of India 1984, Central
Bureau of Health InfeTn^nce, directorate General of Health
Services, Ministry of Health and Family Welfare, New Delhi, 1984.
16.
Grey, RH. 'The decline of mortality in Ceylon and the demographic
effects of malaria control.'1 Population Studies 28:205-229, 1974.
17.
Gupta, JP. "Current position, trends and policy issues in health and
financing in India," memeo, National Institute of Health and Family
Welfare, New Delhi, 1984.
18.
Halstead, SB, JA Walsh and KS Warren (eds.) Good Health at Low Cost,
Rockefeller Foundation, New York, 1985.
19.
Health for All; An Alternative Strategy. Report of the Joint
Study Group ICSSR-lCMR, Indian Instittute of Education, Pune, 1981.
20.
Hsiao, WC. "Transformation
million," memeo.
Transformation of health care for 800 million.
Institute for Health Research, Harvard School of Public Health.
Boston, 1983.
21.
Jain, AK. "Determinants of regional variations in infant mortality
in rural India," Population Studies 39:407-424, 1985.
22.
Jamison, DT, J Evans, T King, I Porter, N Prescott and A Prost.
Chinas The Health Sector, World Bank, Washington D.C., 1984.
23.
Jamison, DT. "China's health care system; Policies, organization,
inputs, and finance," paper in Good Health at Low Cost,
Rockefeller Foundation, New York, 1985.
24.
Khan, ME and CVS Prasad. "A study of health seeking behavior in
Himachal Pradesh," Monograph, Operations Research Group, Baroda.
1984.
25.
Khan, ME and CVS Prasad. 'IL.
Health financing in India: A case study
of Gujarat and Maharashtra, Monograph, Operations Research
Group, Baroda, 1985.
26.
Khan,
and CVS Prasad. "Utilization of health services in rural
India - A comparative study of Bihar, Gujarat, and Kerala,"
Monograph, Operations Research Group, Baroda, 1983.
27.
Krishnan, TN. "Demographic transition in Kerala: Facts and factors,"
Economic and Political Weekly, 11:1203-1224, 1976.
17-8
28.
Marshall, JL, S Nardones and IL Marshall. "IMF conditionality: The
experiences of Argentina, Brazil, and Chile," in Williamson, J (ed.)
IMF Conditionality, Institute for International Economics,
Washington D.C., 1983.
29.
McKeown, T and RG Record. "Reasons for the decline.of mortality in
England and Wales during the nineteenth century," Population Studies
16:94-122, 1962.
30.
Mosley, WH and LC Chen (eds.) Child Survival; Strategies for Research,
Cambridge University Press, Cambridge, 1984.
31.
Pai Panandikar, VA, RL' Bishnoi and OP Sharma. Organizational Policy
for Family Planning, Uppal Publishing House, New Delhi j "1983’. ‘
32.
Panikar, PGK. "Financing health care in China; Implications of some
recent developments," Economic and Political Weekly, Vol.XXI,
No.16, pp.706-710, April 1986.
33.
Perkins, D and and S Yusef. Rural Development jn China,
Johns Hopkins University Press, Baltimore, 1984.
34.
Sen, AK. "How Is India Doing?" New York Monthly Review of Books,
New York, 1983.
35.
Vasaria, P and L Vasaria. "Indian population scene after 1981
census: A perspective," Economic Political Weekly, Vol.XVI,
No.44, 45, 46, pp.1727-1710
", 1981.
36.
Ware, H. "Effects of maternal education, women's roles, and child care
on child mortality," in Mosley, WH and LC Chen (eds.). Child
Survival: Strategies for Research, Cambridge Universityi*ress,
Cambridge, 1984.
37.
World Development Report 1984.
World Bank, Washington D.C ., 1984.
38.
World Development Report. 1985.
World Benk, Washington D.C., 1985.
39.
Yu Su-En, " Health statistics of the People's Republic of China," in
Halstead, SB, JA Walsh and KS Warren (eds.), Good Health at Low
Cost, Rockefeller Foundation, New York, 1985.
179
HFA AND NRRU BY 2000
by
PeB. Desai
It has been a long and as yet unmitigated
travail from 1940 resolution of the National Planning
Committee of the Indian National Congress on the report of
its sub-committee on health to the 1982 adoption of the
National Health Policy statement by the Parliament, In
this, the fourtieth year of political independence, the
evidence has accumulated to show that the dependence of
our people remains to be liquidated. This is true of the
different sectors of national life to a varying degree. It
has been truer in the fields of health and population. What
we have accomplished in the course of the period of
independence is a long string of prescriptions by a
succession of commissions, committees, working groups and
the like official bodies. These august bodies often chose
to produce prescriptions without any aid from adequate
diagnosis. The definitions, concepts, models and the like
constructs emanating from the affluent west remains unabated
to grip the minds of those who wield the destiny of the
second largest population in the world, which grew from
around 300 million to more than 700 million in the course
-of these 40 years. The alienation of the power base from
the evolving reqlities has been the dismal cause of the
nation's poor performance in health and population control.
It is possible that the failure to control population has
compounded the health situation. Yet, the admission of
close interaction between health and population growth,
that is between mortality and morbidity on the one hand and
fertility and mortality on the other, has not been reflected
in social action which the government has chosen to operate.
2. The recognition of the mutuality of
mortality and fertility trends has been of long standing.
It was more pointedly enunciated by the Planning
Commission’s working Group on Population Policy in their
report in 1980. .The ICSSR-ICMR Report too had drawn
attention to these relationships and the 1982 National
Health Policy statement has put it on record. The thrust
of the contention has been that the two goals of ’health
for all' (HFA) and 'net reproduction rate of unity'(NRRU)
to be achieved by 2000 are entirely synergetic. The
implied synergism can, however, be seen as limited to the
common target date adopted for the simultaneous
achievement of the two goals. Beyond that, it is
difficult to see if a common strategy has been evolved to
maximise the operational interphase between the deterl&O
.*
minants of mortality and morbidity and those of
fertility and family planning.
3. Indeed, HFA and NRRU belong to different
conceptual categories. Health for all, whatever its
contents may be, is easy to grasp. It symbolises
universal aspiration and the causes of its absence are.
easily identified. NRRU is a fiction in so far as the
common man is concerned. It is a variable which has
caused enough mischief in formal or technical demography.
It can be grasped by statisticians, demographers and
other social scientists specialising in quantitative
analysis. But it fails to impart clarity even to wellinformed planners and policy makers. They, therefore,
cling to it as a catch-word or a slogan without being
able to spell out its implications as a goal. The
variable is synthetic in the sense that it rests on
specious assumptions about the continuation of a set
of fertility and mortality patterns. It can, however
be translated into a much simpler notion of a couple
leaving behind them no more than another couple. If
If we
we
do so, it involves an assumption that it would be
possible to pursuade as many as over 150 million couples
of the year 2000 to have not more than 2 children each.
While we do not contest the veracity of those who
desire to define the national goal.in this manner, we
are concerned about confused thinking that it may
generate among policy makers and ultimately amongst
the people who must abide by the implied prescription
on family size. We are inclined to the view that the
close interrelationships between positive health.and
individual behaviour pattern including reproductive
behaviour should make it unnecessary to complicate.the
straightforward goal setting in terms of progress in
the health field without invoking the so-called
synergism between mortality and fertility trends.
4. It is now universally recognised that
health is conditioned by social, economic, cultural,
environmental, genetic, biological and physiological
factors. Progress in health is, in the ultimate
analysis, a function of the social organisation which in
varied ways deals with these factors. Fertility and
family size too are conditioned by the same .set of
factors that determine the health and mortality situation.
But in operational terms there is a basic difference.
181
Individual behaviour patterns, as conditioned by these
varied factors, play a role in the determination of health.
But their role is partial and it often gets overwhelmed by
the broader social setting. Fertility is again a product
of the social setting. But here individual behaviour
patterns appear to play a major role. Changes in the
social setting often appear too distant and take conside
rable time to enter into the perceptions of individual
couples so forcefully as to make them change their repro
ductive behaviour.
5. In 'respect of mortality, manipulation of
social setting is undertaken to reduce mortality levels
over a comparatively much shorter time horizons. Improved
mortality patterns then become a part of the social setting
conditioning reproductive behaviour of individuals. -This
is precisely the reason why in the course of demographic
transition there has been a time lag between mortality
decline and the subsequent fertility decline. It is
possible’ that the common social setting carries a cultural
load that facilitates mortality decline but delays
fertility decline. The imputed synergism between mortality
and fertility goal is tenuous; to claim any synergism
between the strategies for reaching the two goals is
entirely unfounded. This does not, however, invalidate
the thesis that health improvement is a necessary pre
condition for fertility decline. It is, however not a
sufficient condition and many more changes in the social
setting are needed to strengthen the negative impact of
reduced mortality on fertility. We can go on deploring
high fertility, but if we do not wish to impose fertility
reduction on couples, it is imperative that we carry
forward the process of establishing a new social order
within which the people begin to cherish this quality human
life at the expense of its quantity. Against this back
ground we may reflect a little more on what we have
achieved in the fields of health and population control
keeping in view that we have in this country surrendered
the entire responsibility to the same ministry.
60 With regard to health, the tortuous
development of approaches to the problem of the critical
health situation in the country has never been informed in
the past by the concept of positive health. The major
concern throughout has been with the construction of a
nation-wide infrastructure for the provision of medical
care. Health care, as distinguished from medical care,
has received only lip service and it continues to do so. A
.
limited approach by way of mounting a separate vertical
programme for each of the major communicable diseases has
yielded success for which the government does not fail
182
to take credit„ Death rate has come down.substantially o
Correspondingly, expectation of life at birth has
increased. But reduction in infant mortality has been
entirely modest. Even maternal mortality.has made un
satisfactory progress. We have little evidence about
the prevailing morbidity levels. But an overview of
the current situation suggests that reduction in the
mortality has not been accompanied by a corresponding
reduction in morbidity. It is in fact possible that we
have bargained reduced mortality for increased morbidity.
If a comparative view of the health standards of our
people is taken, it is one of the lowest in.the.world.
Another glaring aspect of the health situation is that
it is characterised by wide disparities between income
classes, between rural and urban populations and between
different regions of the country. Health for all is a
concept based on equity of opportunities for the attain
ment of reasonable health standards by all people. That
That
equity has remained jeopardised and is in fact tending
to be increasingly compromised.
7. The proliferation of the so-called
health
services
health services in
in the country drew inspiration from
the oft-cited Shore Committee Report of 1946. But the
inconsistencies and the contradictions between the
principles enunciated in the report and its more
elaborate operative recommendations have never been
taken into account. Health is a state subject, but the
central government has from the beginning assumed the
leadership role. This role had been performed by
health officials under the circumstances, the bureau
crats often assumed a professional stance and the
professionals aspired to exercise power that the
bureaucrats enjoyed. Both were, in principle, subject
to the control of the politicians. Unfortunately, as
it almost invariably happens in our parliamentary
democracy, alienation of the politicians in power from
the masses in need of health services, exercised an
overriding influence on the course of development in
this field as in most other fields of national endeavour.
In the result, ad-hocism, trial and error, and piece
meal palliatives have been the characteristic £e^tu^s
of this process. These were further compounded by t e
gross inadequacies of the financial outlays that were
made available for the health sector. It is not
surprising, therefore, that we readily accept the den
unciation of the health services aspredominated by
bureaucratic approaches and professional dominance
leading to their urban orientation and over emphasis
on technocratic, hospital-based, superspeciality^
clinical medical care aspects, In the process the
people have been treated only as beneficiaries/ even
when most of the Ibenefits
‘
1 bypassed most of the people,,
183
8. In the course of this period, the health
establishment has claimed credit for several milestones
including, to begin with, the success of vertical programmes,
the creation of national infrastructure comprising primary
health entres and sub-centres, impressive enlargement of
the complement of para professionals, the introduction of
the multi-purpose workers’ scheme in the middle of 1970s
and the Rural Health Scheme in the late 1970s. They may
also take credit for internalising into the system the
family welfare programme. We may admit that these have
occurred. Yet the cost it has involved in terms of the
lag in the improvement in people’s health remains a matter
of speculation though it has apparently been tremendous.
For those who explore this development strategy, it will
not be difficult to realise that the so-called family wel
fare component has been more of an obstacle than of help
in the progress of healta. The situation has remained sc
complex that it is no more possible to expect the opera
tionalisation of its replacement by an alternative model
of the kind suggested by the ICSSR-IQ4R study group. We
may denounce this course of development as a neo-cclonial
aberration, but this is not at all helpful for a viable
constructive approach. To drastically change the situation
in favour of people's health is nowhere in the offing.
9O The HF/A through primary health care has
been implanted in this situation.. Besides equity, it calls
for inter-sectoral collaboration, decentralisation and
community participation» These concepts are easy to
advocate, but they are difficult to operationalise in a
social situation in which the forces of polarisation
between the rich and the poor or between the rulers and
the ruled are forcing the pace of nation’s progress or
regress_ono There has been a tendency on the part of the
scholars exploring this field of primary health care to
draw pointed attention to the political nature of the
whole undertaking. Politics indeed is in-built into this
concept of HF£i through primary health care. Equity,
decentralisation and community participation are
essentially concepts resting- squarely in the political
field of social action. They are as much necessary in
other vital fields of social action like education,
welfare, productive utilisation of human potential as in
health. The only significance we can attach to their
articulation in the field of health is that the concern
for health is the most universally shared concern and we
may have a chance, therefore, to develop political
approaches of the kind needed in this field.
184
10o Yet, it must be clearly understood
that pursuit of primary health care is to initiate a
rather holistic process of social transformation which
cannot remain confined to this particular field, but
will certainly overflow into most other fields of
developmento At the moment, the odds are against this
approach, despite the verbal commitment of the power
base to operationalise it. That base may view it with
concern our poor performance in the Seoul, Asiad, but
it is difficult to say how the vested interests in the
centralisation of political, economic and social
decision making powers will entertain any percolation
of that power down the line to the people at the grass
roots levelo For those outside the governmentwho arc
committed to the primary health care approach is to
take up the challenge to organise at the grass root
level the poor and the deprived and the underprivileged,
in order to not to teach them health, but to promote
political consciousness and social awareness among themo
There is no other alternative than this to enable the
people to give themselves essential health care which
is so comprehensive as to include promotive, preventive,
curative and rehabilitative services c People have
been left always to rely on themselves in enduring the
difficult health conditionso That passive self
into active self help
reliance has to be transformed
'------for the attainment of positive health.,
11o We have already commented the inad
visability of formulating the goal in the field of.
population in terms of a technical jargon» There is
no question in our mind that it would have been better
for economic progress of our country if the population
had not grown as fast as it has since independence®
Unfortunately, it continues to grow at the same rapid
rate® A hind sight conveys the message that the
reasons why we have not been able to temper the growth
of population are the same as those that prevent us
from securing adequate improvement in the health,
condition of our people® As far back.as the beginning
of the first plan the government had introduced a .
population policy limited exclusively to the official
propagation of family planning® It was a techno
cratic approach of canvassing modern contraception to
influence socially conditioned, but intensely
personal, individual behavioural patterns® Adhocism,
trial and error, and piece meal measures have always
kept the programme of family planning in a disarry®
185
It is quite clear that the I Plan's saner enunciation of
the approach to family planning was abandoned too soon
after it was pronouncedo This change can be traced to the
advice, perhaps well meaning, we received from external
western sources to the effect that sooner we reduce
fertility, more success we v^ould achieve in raising per
capital incomeo This source of advice had hammered on the
minds of our planners only the adverse consequences of our
failure to match reduction in fertility with that in
mortality. Neither they nor our planners had any notion
of the great variety of socio-cultural settings which
conditioned fertility patterns in a population which had
millennia of civilisation behind them.
12. Since then the family planning programme
has witnessed a sequence of changes in strategy without
ever compromising its basic thurst centered on modern
contraception. In the first plan we experimented with the
Rhythm method. In the second, we started constructing
family planning clinics and in the third we added extension
education. Then we pined our hopes or the IUD, reverted
to vasectomy and launched a strategy of time bound
sterilisation targets; experimented with the so-called
camp approach and put the programme on a war-footing during
the Emergency. There followed a back lash which is being
countered by large scale campaign of laparoscoplic tubal1 igations.
13. A national population policy was adopted
in 1976 which threatened resort to legal compulsion, but
it also focused attention on some measures 'beyond family
planning' including female age at marriage. In the days
of the backlash the Planning Commission's working group on
population policy laboured the need to operationalise the
linkages of fertility with social and economic development.
From this thinking, there seems to have emerged the notion
that the success of family planning would depend on female
education, female work participation outside home and
women's development in general. These notions remain to be
translated into policy packages. Meanwhile, in its utter
helplessness the family planning delivery proceeds in its
old ways of recruiting, by hock or crook, cases mainly for
women's acceptance of terminal methods, MCH is said to
form an integral part of the family welfare.delivery
system. But it seems to suffer neglect in the bureaucratic
zeal to exceed targets set for family planning performance.
186
14. Implied in the fixation of NRR' of unity
as a goal for 2000 is the reduction of the birth rate
of its present level' of around 3 3 to 21 per thousand
population over the next 14 years. This is apparently
a difficult task unless we strike upon an alternative
strategy of transforming family planning into people's
movement which the government has been unsuccessfully
trying to do for the last nearly a decade. At the
moment no such favourable prospect is in sight.
15. There has been a constant criticism
of our population policy that it does not form an
integral part of the planning process. This criticism,
valid as it may sound, misreads the social situation
in the country. It neglects to take into account the
indifferent performance of the planning process itself.
Planning may be said to have succeeded in developing
certain necessary economic overheads like power,
irrigation, transport etc. It has succeeded in creating
a viable and deversified industrial base as well as
creating a net work of national institutions for the
promotion of rapid advance in science and technology,
but it has remained ineffective in securing full
employment, reducing regional economic and social
disparities and in alleviating poverty. It has been a
process of implanting economic progress on to a per
vasive situation of economic want and social backward
ness and led therefore to a polarisation between the
small upper crust of population as the main beneficiary
of development and the vast majority of the masses
competing for the crumbs that may percolate down from
the commanding heights of the economy. This nature of
the planning process has not been able to bring about
meaningful changes in the universe of fertility deter
mination, within which individual couples carry on
family building activities in the overall context of
the age-old traditional milieu.
17. A special feature of the Indian
planning profession is to rearticulate the inexceptionable
goals, that any planning may have, every five years.
The latest seventh plan accordingly emphasises social
justice and employment generation together with the
increase in national income. It goes on, however, to
spell out an apparently new element under the rubric
of ’human resources development*. In fact a Human
Resources Development ministry has replaced the
Ministry of Education and Social Welfare. It is not as
yet clear of what is the operational content of Human
Resources Development Ministry. As of today it is in
charge of a high ranking cabinet minister who carries
187
the responsibility also of the Ministry of Health & Family
Welfare. The government is thus in a position to operate
an integrated programme dealing with all the different
aspects directly related to the development of vast human
potential. The new health nolicy has been followed up by
the announcement of a new education policy, which can be
coordinated with the existing child development and youth
policies and a prospective policy of the women's develop
ment. Primary health care, women's education, maternal
mortality, integrated child development programmes, universalisation of primary and secondary education, female
education, women's participation in economic activity and
improvement of the status of women in society are some of
the more important elements of social development that have
a crucial bearing on the fertility decline. If this arti
culation can be transformed into practice, we will need no
family planning propagation, but only an assured access of
all people to family planning information, advice and
services. This is in the realm of hope, however fondly one
may cherish it.
18. The concept of primary health care has
taken care to cover family planning services as well. But
the intrusion of family planning as one element in the
whole gamut of services to be provided at the grass roots
level is not very helpful. It is possible to argue that
given the existing and adversely changing political and
social situation, family planning may overshadow the more
important elements of health care that deserve priority
attention. The question is not so much to create clinical
services for facilitating adoption of contraception, but
of bringing to surface the latent demand for family
planning services or generate new demand for it. This
imperative imposes the need of invoking manipulation of
social and economic conditions such that the couples find
reduction in family size beneficial to themselves.
19o Here again it is a question of trans
forming social organisation which conditions the living
and life styles of the individual members of the societyo
It is a question of creating an atmosphere that leads to
the generalisation of human motivations for limiting births
with orrwithout artificial means of contraceptions. If the
motivations are created, marriages will be delayed and
within marriage abstinence, the Rhythm method and coitus
interruption, that were the most effective means that
reduced the European fertility levels in the late 19th
century, will surely be used widely. In a society which
puts some store on the spiritual aspects of human
existence, resort to technological innovations in
188
contraception may not make that much of a differenceo
In the ultimate analysis, the strategy to be developed
for the achievement of NRRU will rest more on ‘non
medical, non health care' aspects of social change
which has not hitherto been attempted by the planning
process in this country„
20o Yet conceptually, the notion of
positive health retains its captivating quality» Posi
tive health defined as a state of physical, mental and
social well being necessarily implies a development of
a rational approach on the part of couples towards their
fertility behaviour. But the achievement of positive
health invokes equity, intersectoral collaboration,
decentralisation and community participation. That
cannot be realised without fundamental social transfor
mation in its broadest sense. We admit the primacy of
social transformation and therefore the primacy of
positive health. But social transformation is a
political process, apparently easy to achieve through
revolution than through evolution. Since the possibility
of a revolution, social or political is remote, at the
moment, we are left with the only alternative to continue
our endeavour to secure a viable health care system and
social changes of the kind that promote motivations •
favouring smaller families. We must simultaneously
continue to work actively for democratisation ?f health
services that would necessarily involve its .debureaucratisation, deprofessionalisation and depoliticisation.
That means we must put complete faith on the people at
the grass roots level and help them to take care of
their own health themselves. Unfortunately, there are
few in the vastness of people to take up this
challenge.
★ * * * It * < A ***** W * ■;< * * ★
189
LOGISTIC SUPPORT AND FACILITIES FOR PRIx4ARY HEALTH
CAREs THE CRUCIAL ROLE OF PHYSICAL ACCESSIBILITY
by
Ashish Bose
In the rhetorical discussions on the Alma Ata Declaration
of Health For All By 2000, not enough attention has been paid
to the crucial role of physical accessibility.
The Alma Ata
Declaration (1978) does show awareness of the fact that "the
success of primary health care depends on adequate, appropria
te and sustained logistic support...” and recommends that.,
“government ensures that efficient administrative delivery^ and
maintenance services be establj shed reaching out to all
primary health care activities at the community level... That
the government ensures that transport and physical facilities
for primary health care be functionally efficient...”
"The global strategy for health for all by 2000” adopted
by the World Health Assembly in 1979 indicates that “the main
thrusts of the strategy are the development of the health
system infrastructure starting with primary health care for
the delivery of countrywide programmes that reach the whole
population”
(WHO, 1981: '12).
The object of this paper-is to draw attention to the
impact of the human settlement pattern on physical accessibi
lity and consequently, on" the delivery of primary health care
services at the local level.
We shall present here very
briefly the preliminary results of the statistical exercise
which we have done on the basis of 1981 Census and 1977
Economic Census data.*
* The computational work in connection with this project was
done at the Computer Unit of the Institute of Economic Growth.
..Cent.
190
In the international literature much is made of the
Kerala model. Several sophisticated statistical exercises
have also been made on the impart of literacy, education,
status of women, higher age at marriage and related factors on
the fertility pattern. However, there is no evidence that
these exercises have taken a.dequate note of the human settle
ment pattern and the access to health and education which the
state of Kerala has, by virtue of its unique settlement '
pattern where one can hardly distinquish a rural area from an
urban area. This is partly a function of density of popula
tion. But a number of historical, geographical, political,
economic and other considerations have influenced the settle
ment pattern of Kerala. For example, according to the 1981
Census, in Kerala, 90.3 per cent of the rural population was
enumerated in villages with population of 10,000 and over.
The comparable figure for Bihar was 4.2 per cent; Madhya Pra
desh 0.1 per cent; Rajasthan 0.9 per cent; and U.P. 0.7 per
cent. The terms of the number of villages (in Kerala) 74.3
per cent of the total number of rural settlements belong to
villages with population of 10,000 and over. The comparable
figure for Bihar is 0.3 per cent; madhya Pradesh negligible;
Rajasthan 0.1 per cent and U.P. 0.1 per cent. These figures
bring out the sharp contrast between Kerala pn the one hand
and large states like, Bihar, Madhya Pradesh, Rajasthan and
U.P. (which will be referred to subsequently as BIMARU states)
on the other.
As is well-known, in our strategy for primary health
care, we have more or less adopted a blanket approach through-
I acknowledge the assistance given to me by Mr. K. Lal,
Programmer, and Mrs. Jatinder Bajaj, Senior Research Analyst,
Population Research Centre.
191
out the country (though there are some minor modifications in
tribal and hill areas) by laying down norms for the establish
ment of primary health•centres, sub-centres, etc.
Inherent in
our primary health policy is the weightage given to population
In other words, if the majority of the villages in Kerala have
a population of over 5,000, it is obvious that there will be
sub-centres located in these villages and the access <5f the
people to primary health care will be greater in Kerala than
in U.P. because of the combined effect of the settlement
pattern and the weightage given to population in our health
policy. Mhen we consider the physical accessibility on the
basis of data on transportation, the contrasts are even
sharper.
For example, in Kerala, for every 100 sq kms, the
length of roads was 275 kms.
The comparable figure for Bihar
is 48; for Madhya Pradesh 24; for Rajasthan 21; and for U.P.
52.
Another index of road transportation is the length of
roads per one lakh population. In Kerala, for every one lakh
population, the length of roads is 421 kms. The comparable
figure for Bihar is 120; for Madhya Pradesh 205; for Rajasthan
213; and for U.P. 129.
Another question one may ark in the context of physical
accessibility iss how many villages are linked with roads? The
road statistics give such data for only_two categories of
villages; namely (a) villages with population 1000-1500 and
(b) villages with population 1500 and above.
In Kerala, 100
per cent of the villages are linked with roads in category
(a) The comparable figure for Bihar is 39 per cent; for Madhya
Pradesh 40 per cent; for Rajasthan 40 per cent; and for U.P.
25 per cent.
For category (b) villages, the figures are as
follows: Kerala 100 per cent; Bihar 52 per cent; Madhya Pr
Pradesh 65 per cent; Rajasthan 56 per cent and U.P. 52 per
cent.
Thus, the human settlement pattern, the size of
villages, the distribution of villages, and the road transpor192
tation system all favour Kerala in terms of the delivery of
health services,
What is true of health is also true of
education.
According to the 1977 Economic Census, in Kerala 96.3 per
cent of the villages had a primary school right in the village
The comparable figure for Bihar was 60.0 per cent; for Madhya
Pradesh 65.5 per cent; for Rajasthan 55.8 per cent; and for
U.P. 45.5 per cent.
In the case of middle schools/ the position was as
follows: in Kerala 92.3 per cent of the villages had a middle
school located in the village. The comparable figure for
Bihar was 14.5 per cent; for Madhya Pradesh 10.5 per cent; for
Rajasthan 14.6 per cent and for U.P. 9.3 per cent.
Next we come to high/higher secondary schools. In Kerala,
the figure was 76.5 per cent while in Bihar it was 4.8 per
cent; in Madhya Pradesh 1.8 per cent; in Rajasthan 3.6 per
cent and in U.P. 3.5 per cent.
These figures speak for themselves,
Both in terms of
health and education, the settlement pattern favours Kerala.
If the literacy rate is high for Kerala, one could ask why is
it high?
It is obvious that the settlement pattern in Kerala
make access to schools and primary health centres easy,
compared to the situation in BIMARU states. Before we look
into the so-called cultural and other factors while explaining
the diversity in India, we feel that we should have a good
look at the human settlement pattern, transport linkages, and
the communication network.
The 1981 Census (and also earlier censuses) classified
rural settlement into the following seven categories;
193
Category
Population
I
Less than 200
II
..00-499
III
500-999
IV
1000-1999
V
2000-4999
VI
5000-9999
VII
10,000 and above
In our statistical exercise, we have worked out the
settlement pattern with reference to villages as well as popu
lation in all the districts of all the states in India,
Vie
have defined a small village as a village with population of
less than 1000. Our hypothesis is that these small settle
ments, barring a few exceptions, are by and large, inaccessi
ble.
We have calculated two indices:
(1) ' Population Accessibility Index (PAI)
(2) Village Accessibility Index (VAI)
If,
in a district, the population of villages in catego
ries I to III (i.e. less than 1000) is more than 50 per cent
of the tota_ population of the district, the district will be
designated as a low population accessibility district.
Similarly, if in a district more than 50 per cent of the
villages are in the categories I to III (i.e. less than 1000
population) then the district will be designated as a low
village accessibility district.
We shall present a few figures here. In India as a whole
our Population Accessibility Index (PAI) was 60. In Kerala it
was 98; in Bihar 59; in Madhya Pradesh 47; in Rajasthan 55;
and in U.P. 55.
194
As regards the village accessibility index (VAI), the
figure was 38 for India. It was 95 for Kerala, 38 for Bihar,
34 for Madhya Pradesh, 37 for Rajasthan, and 38 for U.P.
The average size of a village in India in 1981 was 911«
It was 16,967 in Kerala; 966 in Bihar; 583 in Madhya Pradesh,
774, in Rajasthan; and 808 in Uttar Pradesh. In India as 'a
whole, 29.8 per cent of the population was in LAP districts
(i.e. low accessibility in terms of population). In Kerala,
the figure for LAP districts was 0; in Bihar 19.4; in Madhya
Pradesh 80.0; in Rajasthan 23.1; and in U.P. 16.1.
In terms of the low accessibility districts in terms of
villages, (LAV districts) the overall position was as follows:
In India, 75.3 per cent of the districts were LAV districts.
The figure for Bihar was 74,2 per cent; for Madhya Pradesh 100
per cent; for Rajasthan 92.3 per cent; and for U.P. 91.1 per
cent. In Kerala, the value was zero.
Before we conclude, we would like to mention that in our
initial exercise, we had assumed that the size of-the settle
ment had a direct relationship with the accessibility to
health services. In other words, smaller the village, lower
the accessibility and vice-versa. Subsequently, we found
enough support for our assumption in the District Census Hand
books. Unfortunately, all the 1981 District Census Handbooks
are yet to be published. However, we shall quote the data
from the Jhunjhunun District of Rajasthan in support of our
contention (Census of India 1981, Series 18, DCH Jhunjhunun:
Ixiv).
195
percentage of Villages with
some medical facilities avail
able in the village, 1931
Population Range
7.5
28.3
82.2
90.9
Upto 499
5001999
2000-4999
5000 and above
All rural settlements
34.1
We hope to do this analysis for all the districts of India, as
and when all the district census handbooks are available.
We shall conclude by point:.ng out that our preliminary
analysis shows that our primary h-.altl. care policy has mt
■taken note of problems of physical accessibility and j.dgist.i.c
support which are absolutely crucial for any strategy for
health tor all by the year 2000. We would recommend that the
status should be asked to prepare district health plans on the
basis of available data and each state should have the flexi-il
bility to devise alternative strategies to meet the local and
sub-regional requirements, keeping in mind physical accessibi
lity as a crucial factor.
In f^ct, our analysis raises
serious doubts about the strategy of multiplying sub-centres
only on the basis of population size, as spelt cut in all our
five year plans.
It is unlikely that this strategy would
succeed in delivering health care services to rural people,
particularly in the small villages of the large states of
Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh.
Alterna
tive models based on increasing mobility rather than~niultiply-
ing subrcentres should be seriously considered, along with
other criteria for logistic support and facilities for primary
healthccare
196
Paradoxically enough/ a large population has helped and
not hindered individual rural settlements in having access to
health services because our hea? th policy has an inbuilt bias
in favour of population size* Our plea is for the fullest
consideration of physical accessibility as an important factor
in planning for primary health care. This is an obvious
point. Nevertheless, cur planners have innocently ignored it..
197
•
••
•
I'l
i
'* v’l ,
t
1
DISCUSSION
Ravi Duggal began his presentation of the background
papers by identifying the twin questions that defined the
scope of Session II.
Firstly/ why had health programmes
failed? Secondly, was the present strategy capable of
providing health for all? He divided the papers into two
categories on the basis of the explanation and insights
offered on these questions. The first category of papers (by
Dr. A.R. Desai, Dr. Lincoln Chen and Dr. Roger Jeffrey) empha
sised structural constraints to the implementation of the
strategy.
The social structure itself, i.e. class relation
within the society, inhibited or set limits to radical
policies. The structural factors highlighted were the capita
list path of development, the political economy and the
private medical sector. The other category of papers (by Dr.
N.S. Deodhar, Dr. V.N. Rao, Dr. P.B. Desai and Dr. Ashish
Bose) highlighted the problems with the functioning and
delivery of health care serviqes.
Factors such as health
management, epidemiology, community participation, health
education, the wrong priorities of high technology, urban bias
and emphasis on family planning and the physical accessibility
of health services were the man'y functional problems that
could not be ignored until such time that the structure was
transformed.
The presentation also sought to point out further areas
for research not covered by the papers. One such area was
centre-state relations in the field of health. Whereas policy
making was vested in the Centre, the responsibility for imple
menting the programmes lay with the states. As a consequence
many important schemes suffered. Even the community health
workers scheme was not being implemented in some states such
as Tamil Nadu and Kashmir.
Another problem area was the over198
whelming urban-rural disparities in the availability of health
care facilities and delivery of services. Data gathered by
FRCH had shown that the hospitalisation facilities in urban
areas were 21 times more than in rural areas.
The role of
foreign funding agencies also needed to be reassessed.
Although foreign aid constituted a low 2 per cent of the
entire health sector outlay, the significance of foreign agen
cies lay in their ability to influence and focus national
These agencies were often linked up with foreign
multinational corporations. For instance, the importance
policy.
accorded to measles in the immunization campaign was partly
due to‘ the fact that India, which did not manufacture the
vaccine, was a potential market for the multinational drug
companies.
Finally, there was the whole question of decentra
lisation in the context of the local power structure and
politics of the community.
In conclusion, Ravi Duggal pointed out the need to expose
the myth that health sector plans and programmes were free of
problems, whereas the whole issue was one of negligent and
inadequate implementation by the lower level bureaucracy. He
questioned the policy framework that formulated concepts such
as 'participation1 , 'self - reliance', 'political will ,
'people taking care of their own health', etc., in isolation
from the social and political structures.
Dr. A.R. Desai initiated the.discussion with a short
summary of his paper, He asked whether the government
policies addressed the pressures from below, or were they mere
crumbs to the people. Also, there was a need for greater
clarity about the term 'people', Did it cover both the beneficiary and the oppressed classes?’ Given the capitalist
framework of development being followed by the Government,
Dr. Desai pointed out that the main question was what position
199
should the medicos take?
Even if the ICSSR/1CMR HFA document was implemented ooth
in spirit and content. Dr. Ashish Bose wondered whether health
for all could be achieved.
According to Dr. Antia, the operational word in the
strategy was 'radical'. In the process of interacting with
the Government, the Study Group had to some extent influenced
the 6th and 7th Plans. But in implementation, only those
elements were being given priority that suited the Government.
Infrastructure was being developed, but there was no devolu
tion of financial and administrative power to the people. he
did not think that radical change was possible in the present
political economy.
Dr. Coyaji agreed with Dr. Bose that there were many dis
crepancies in the recommendations of the Study Group of which
its authors were aware, and which meant that some elements of
the strategy would not succeed even if it was implemented
faithfully. She felt that though there had been a change
since 1978 in the accessibility and availability of health
services in rural areas, yet the primary level staff had not
become oriented to the primary health care approach, They
still believed in taking health care to the people.
Dr. V.N. Rao, while agreeing with Dr. Coyaji that the
adequacy and accessibility of health services had improved,
pointed out that only 40% of the available public health
facilities were being utilised. Poor utilisation was a major
failure in implementation. He attributed this problem to the
lack of community awareness about their own health needs and
about the available health services.
200
Padma Prakash/ who along with Dr. Amar Jesani was a
research staff for the ICSSR/lCMR Study Group, pointed out
that the members of the Group were well aware that all reports
and recommendations , including the Shore Committee report, had
been implemented selectively. She wondered why, inspite of
this history of policy recommendations, the Group had expected
its recommendations to be implemented faithfully.
Dr. Rao felt that the Government had accepted the Group's
report and was implementing the infrastructural aspect of it.
It was, however, failing in its task of mobilising the people
to utilise the- services and facilities. Dr. Coyaji added that
other Governmental schemes for rural areas and poverty alliovation, such as the Integrated Rural Development Programme
(IRDP), were also not reaching the people. The implementational problem lay in people's lack of awareness of thexisting facilities available to them, and it suited the
bureaucracy to keep information from the people.
According to Dr. Amar Jesani, the minutes of the initial
meetings showed that the members well aware that their recom
mendations would not be implemented, wished to formulate a
radical plan that would be useful in a new society, ^t a
later stage this perspective was modified and something in
between was proposed. Consequently, the Group's recommenda
tions were neither a plan for a new society, nor suited to the
present one. Another problem was posed by the 'pillars of
health*. The report had categorically asserted that these
were absolutely important to achieve health for all. Yet
Government policy was only addressing the health sector and
certain social services, without transforming and focussing
the planning process and the Industrial policy towards achiev
ing these determinants or 'pillars’ of health.
201
Vimal Balasubrahmanyam raised the question as to whether
the committee members had made efforts towards putting
pressure on the Government to implement their recommendations.
She cited the pressure exerted by the intellectual community
on the Bangladesh Government to implement a rational drug
policy, and wondered whether the Indian professional community
felt it was their duty to also adopt such action.
Dr. Antia pointed out that the Study Group was not a
Government body, but was set up by concerned professionals and
academics. Its achievement was in getting the Government to
consider its report, endorse the strong indictment of previous
health policy, debate it in Parliament and incorporate
elements of the recommendations in the National Health Policy.
Now that it was Government policy, and not just a private
report, the recommendations could be further used to question
and expose. Public health policy and programmes, and thereby
raise the people’s consciousness about failures in the health
sector. He hoped that Session III would throw light on the
ways and means of communicating with, and mobilising, the
people.
Dr. Jeffrey explained that his paper took for granted
Dr. A.R. Desai’s framework of constraints for Indian health
policy. His aim was to show the scope for changes within the
health planning model adopted ay India for providing health
services. Since no radical change was possible in a bureau
cratic system, the question was whether it was possible to
push/ even slightly/ the existing system in the desired
direction. What were the small scale-programmes that needed
to be pursued within the existing Government structure? One
of the drawbacks of the Ramalingaswamy Committee (ICSSR/ICMR
Study Group) report was that it did not provide assertive,
tangible, potentially achievable short-term goals and
202
programmes for the government/ as for instance with regard to
a rational drug policy'. He also felt that Seagall’s proposal
about social epidemiology was a starting point for giving
people information about health issues in their own enviroment
Dr. A. Bose/ referring to the paragraph on page 16 of
Dr Jeffrey’s paper, asked for information regarding the agencies that had run out of funds and withdrawn from India,
According to him, foreign were always ready to provide funds
for the family planning programme and, historically, had been
responsible for intr<oducing the coercive element in family
planning.
Dr. Jeffrey clarified that his reference was to the fact
that all foreign aided projects had a limited time span and a
limited budget, and in the long run, the local Government was
expected to take them over.
He also felt that foreign aid co
India had been directed towards public health measures, rather
than towards high technology medicine and hospitals. Dr. Bose
was, however, of the opinion that foreign aid and agencies had
been responsible for the coercive family planning programme,
and no agency was withdrawing its fund from the family planning sector in India.
Dr. Haran felt that the recipient Governments often
failed to take firm policy decisions regarding the relevance
of ideas and priorities put forward by the donor agencies.
There was also a time lag in the priorities of donors and
Governments. In recent times the donors were giving priority
to low technology, community based programmes, such as home
based ORS (oral rehydration syrup) and community based cold
chain.
The Government/ however, was shill empl*as..ing the
expansion of infrastructure.
203
Manisha Gupte asked Dr. Haran how the perceptions and
priorities of donor agencies had changed from a high technolo
gy to a low technology, people oriented approach?
Was it a
recognition of the failure of earlier approches? She felt
that in the absence of basic facilities such as clean drinking
water and sanitation, the emphasis on home-based ORS relieved
the Government of its task of meeting basic needs, and put the
entire responsibility of child survival on the people them
selves .
Dr. Haran agreed that donors perceptions changed as new
themes and ideas became fashionable in their own countries.
However, foreign aid, including that of the World Bank,
constituted a mere two per cent of India’s budget, and there
fore, the Indian Government was in a position to formulate its
own priorities and policies.
Dr. Ashish Bose intervened to point out that two per cent
of money was accompanied by 98 per cent of the ideas*
The
bureaucracy was influenced by these ideas emanating from such
respectable sources as the World Bank, USAID,UNFPA etc. How
ever, the projects that were formulated on the basis of these
ideas, could not stand scrutiny in terms of either their
conceptual framework, or their implementation approach.
Dr. Jesani pointed out the need to assess the impact of
foreign agencies on Government policy-making as a whole. At a
time when the Government was going in for large-scale techno
logical and financial collaboration in the field of industry
and agriculture, the health bureaucracy could not be expected
to have a different policy.
Dr. Dhruv Mankad emphasised the need to focus on nontraditional health inputs, such as food, water supply, sanita204
tion and nutrition, in implementing the Health for All
Strategy.
The implementation of the strategy was dependent
not just on bureaucratic - legislative (i.e. Governmental)
action, but would be determined by the nature of the state as
a whole, including the media and the politically vocal
intellectuals.
Dr. V.N. Rao explained that the failures in implementing
the strategy were due to the neglect of 3 important factors.
These were the neglect of community participation, appropriate
technology and intersectoral co-operation and co-ordination.
He cited the example of the small health project with which he
was associated. The project had been successful in adapting
technology to the local situation, mobilising the existing
resources and providing information to the people about their
health needs.
It had, however, reached a plateau as it was >
unable to arouse the community to self-care, and to achieve
co-operation between all health-related sectors such as water
supply, housing, nutrition etc.
These needed to be brought
within the health services sector for better implementation.
Another major problem with the Indian health services,
according to Dr. Rao, was the l_ck of proper training and
orientation of the multi-purpose workers (MPWs) and community
health volunteers (CHVs).
These Schemes were conceptually
good, but their implementation was very poor.
Finally, the
development of the epidemiological services was absolutely
necessary to understand the nature of health problems in India.
He suggested that several experimental health care delivery
models be developed in different regions of the country, which
could be replicated widely in order to improve the health
services.
Next Dr. Deodhar read out the main points in his paper
205
r egarding the problems of implementation.
Dr. P.B. Desai pointed out that the family planning
programme was leading to the coercion of para-medical workers
and the neglect of primary health care services. The improve
ment of health conditions was a pre-condition for family
planning acceptance, whereas the Indian Health for all
strategy was attempting to achieve the precondition and the
outcome simultaneously.
■ .r-
Padma Prakash pointed out the fundamental biases in the
The latter were only
National Health Policy regarding women,
viewed as reproducers, and pre-determined solutions had been
put forward.
According to Dr. Ashok Dyal Chand, the voluntary sector
had been primarily responsible for formulating the white
paper on HFA (i.e. the ICMR/ICSSR Study Group’s report).
' ■ defined concepts and
However/ in the absence of clearly
the HFA slogan into a
operational guidelines, it had turned
--
: of community health workers, he
Taking the example
benefit analysis had been done, and
pointed cut that no cost—
had been hidden from the
the unstate I costs of the sche? 3
rendered unimplementable.
policy makers. ' The scheme had been
had been taken to operationalise concepts
...Similarly no steps
community participation’. He
. such as •health, for all’ and
undertake to operationalise
suggested that the participants
the HFA concept by clearly stating-wno wa,a to implement it,
myth.
carried out.
what needed to be done and how it was to be
1
Dr. Amar jesani, responding to Dr. Dyal Chand/ felt that
the non-operational character of
< •the HFA concept was its real
strength. It could be used to. mobilise and educate the
in his opinion/ were not responsible
people. Intellectuals,
206
for merely formulating acceptable prescriptions but had a duty
towards raising fundamental issues.
He asked how was it
possible to mobilise the people in order to fight the system.
Dr. Sujit Das asked, "What constitutes participation?”
One way of defining participation was in terms of the utilisation of health services, However, real participation meant
control and that. in turn, was based on power. Since power
was rarely given, participation in this sense could not be
implemented. Even the term 'empowering' was inadequate as it
required an agent to delegate power, but not relinguish it.
Dr. Antia pointed out that the non-functioning of primary
health centres was mainly due to the emphasis on expanding
infrastructure without developing the services,
sector, too, had its problems,
The voluntary
Many excellent projects were
non-replicable,
These projects were dependency creating and
did not activate the people, In this context the role of
professionals was to create awareness and give graded informa
Professional
s
had to be the catalysts in making the people question the
tion and knowledge about the available services.
basis of their unequal and discriminated situation.
201
SESSION III
ALTERNATIVES FOR EFFECTIVE IMPLEMENTATION
With focus on:
*Relevance of people*s participation.
■^Management & people’s participation: Are they mutually
exclusive.
★People’s participation growing over to people's
control.
*Relevance of high technology in our needs.
★Appropriate technology for implementing strategy -
machines, equipments, drugs etc.
*Prevention of diseases a techno-managerial solution.
♦Communication strategy for "chieving Health For All.
♦Role of education in people's participation.
I
1
•.i
•. -i
I
THE MEDIA, THE MESSAGE AND HEALTH FOR ALL
by
Vimal Bala ubrahmanyan
"Communications" is such a fashionable word today
in the Rajiv Gandhi era, that there is no.need for me
to elaborate on the importance of using different
forms of media for conveying information on health issues
to the public. However, this paper will not cover the
use of audio-visual and print media by health educators
to convey specific messages to specific targets e.g.
slide-and-tape shows, flip charts, pamphlets etc on topics
such as immunisation, birth control, ORT and the like.
The object of this paper is to examine how the general
mass 'media can be used by the rational health movement
to influence people's attitude understanding and oehaviour on health matters.
A. brief account of my involvement in health action
may be relevant here. As a freelance journalist some of
the topics I have written about since 1981 ares drug
■trials being conducted on disadvantaged sections of the
population; campaigns against various harmful drugs,
promotion of ORT; the baby food issue; misuse of
anabolic steroids and irrational antidiarrhoeals;.the
politics of family planning; occupational health issues;
the health aspects of the nuclear industry; the
medicalisation of pregnancy and childbirth; and the
campaign for a rational drugs policy.
In the course of my search for information and
data, I have become closely associated with health action
groups and have gained access to a whole body of research
and analysis which has not only given me facts on the
specific topics I have written about but also insights
into the larger politics of health and the social, eco
nomic and cultural roots of ill-health.
3
If the public at large is to begin to understand
these deeper and broader aspects, then the public too
must have exposure to all this information which has
so far been confined within the •’alternative’ media of
the health activist and progressive social scientists,
and has remained circulating among the already—converted^
I am not referring here to specific information ,
on, say, the side-effects of clioquinol and oxyphenbutazone.
These have been figuring fairly prominently in the
general media (though I have doubts whether the adverse
208
.1
publicity has had any impact on the prescription and
over-the-counter sale of .hese drugs). What I mean
is, even though there have been media exposures on
various health issues, there has not been much basic
education of the public on issues like environmental
health, preventive medicine etc. which are integral
to the Health-For-All concept. The public still
equates ‘Health For All* with ‘Medical Care For All'.
And not just medical care, but the most sophisticated
medical care possible in terms of costly equipment/
diagnostics facilities and surgical procedures* For
example, the inauguration of a nuclear medicine unit
in a postgraduate institute of medicine is seen by
the public, the media, (and also described as such
by the Health ministry) as one more step towards
achieving Health-For-All—without anyone pausing to
wonder why, despite all this technological advancement
our people continue to suffer from, and die of, the
ordinary communicable diseases which have long ago
been eradicated in the developed countries even before
the modern medical discoveries were made. In the
public mind, athe low health status of the people is
seen as the result of inadequate medical facilities
and hence the clamour for more doctors, more hospitals
and CAT-Scan units.
Thus one finds that despite fairly intensive
coverage in the media during recent years on specific
health issues, this has not been accompanied by
fundamental enlightenment of the public on what
health really means, how lealth-For-All can be
achieved, what people must do to change their own
outlook and lifestyle, and what kind of economic and
social measures the government should introduce as
part of its health policy.
A lot of writing and analysis on these basic
aspects of the politics of health does appear
constantly in the serious, progressive journals, but
these have a limited readership and do not reach the
general public. So, the question facing the health
movement is; Can a sustained consciousness-raising
health education campaign be directed towards the lay
public through the mass media?
One must begin by acknowledging that this kind
of health education must necessarily explode a lot
of myths and this will inevitably mean that powerful
vested interests are not going to like it one bit.
For the sake of credibility and in order to convince
the public/ this task should not therefore be left
to journalists along—for two reasons;
209
a) General articles on health issues (as opposed
to reportage on, say, harmful drugs which have both
news-value and sensation value) carry greater
conviction when the information and advice comes from
qualified health personnel. Readers are far more
receptive to health advice from columns where the
by-line is a 'Dr Somebody'.
(See for example the
popularity of the weekly medical column published
in the Sunday magazine section of the Hindu.)
B) The medical profession is itself hostile when
a non-medical person exposes malpractices by the
health-care profession.
(e.g. Padma Prakash’s cctonn
Medisense which appears once a month in the Express
Sunday section. The most vocal opponents to Padma s
plain-speaking on overprescription of drugs and
Health columns which
vitamins have been doctors.)
on
the politics of health
seek to enlighten the public
tread
on
Establishment
toes. And when
will necessary ----__
such articles are attacked by 'qualified'' medical
personnel, the public doesn't know whom
— to believe-the doctor or the journalist.
It is worth mentioning here that health
education of a radical kind is also bound to^ offend
the drug industry, especially when specific orand—
names are mentioned. Journalists as well as doctors
writing on harmful drugs face different kinds of
pressure——subtle as well as blatant— and since the
media controllers are anxious not to lose the support of
their advertisers, this is a major problem and we have
to get together to think of appropriate strategies to
fight this phenomenon.
On the basis of some of my experiences while
writing on health issues, I would like to offer some
suggestions on how the health action movement Can
more actively use the media as an instrument to
further its own cause.
1) Health activists, especially those with
medical degrees and designations, must acquire media
skills, establish contact with editors, and introduce
regular health columns in the print media. The help
and guidence of sympathetic media people can be enlisted
to ensure that these columns are written in appropriate
language and style. The column on 'Harmful Drugs’ by
Dr P.K. Sarkar in the Telegraph and the Education
Service started by LOCOST (published in the,Express
Magazine) are good examples of the kind of initiative
needed.
210
2) Constant and tactical use of the Letters-toEditor columns should be m de tos initiate debates;
get across information on crucial issues; refute
distorted information planted in the media by vested
interests.
(The example of ORT which I shall describe
later illustrates this point.)
3) Qualified medical people, especially those
in high positions who may not be 'activists' but who
are progressive in outlook, should come out in vocal
support of any health action campaign launched by the
activist groups. This could be in the form of a
press release, a formal statement or even a letter-tothe editor. Such endorsement greatly enhances the
credibility of the activists. For example, media
coverage of the rational drug policy campaign has
helped in getting the government's pro-industry
proposals stalled. However, it has not occurred to
the 'eminent' members of various government-appointed
committees, who have in the past called for an
essential drugs policy, to issue statements supporting
the demands of the All India Drug Action Network*.
4) Health activists must feed information more
effectively to committed journalists so that timely
coverage of important issues is ensured.. Often it is
necessary not only to brief the media on the pertinent
facts but also to explain the perspective lucidly so
that the emphasis is on the right aspects and the
message is not distorted^ The health movement should
actively seek out and identify sympathetic media
people and keep up a steady flow of information to
these contacts so that consistent media coverage on
health matters is maintained.
(This is something
that the KSSP has been successful in doing in Kerala)
5) It is sometimes more useful to feed infor
mation to a news agency rather than to a freelancer or
a staffer whose report will appear in only one paper
or journal. An agency repDrt is likely to be carried
by newspapers all over the country. For example, when
the Medico Friend Circle published a critique of
painkillers on the market, I realised that any article
I might write would only appear in one of the weekly
journals I contribute to, I therefore passed it on to
a friend in PTI, persuaded him to do a short news item
on it and this subsequently appeared in many newspapers
in different parts of the country.
6) Specific health actions should be appropriatelyplanned with an eye to factors like 'news value' and
211
'topicality1—two holy criteria for the media people.
For" example, if a letter is written to the Drug
Controller calling for a ban on a certain in class of
drugs, the news is more likely to be printed if released
to the Press simultaneously rather than two weeks
later--as often happens.
7) If an issue needs coverage in the press, a
suitable and timely write-up should be released to the
media which is short, and which straight-away mentions
the highlights in the first two paragraphs. A long
research-type report, often polemical in language,
may be all right for publishing in the alternative
media but very"difficult for use by the general media.
Most media people won’t even have the patience to go
through the stream of words and sift out othe relevant
•newsworthy’ facts. It is my impression that health
activists do not realise the nature of this problem
and feel disappointed by what they see as the media’s
indifference, when reports they send to newspapers
don’t get published.
In this matter, much can be learnt from the
UNICEF style of preparing a well-designed ‘Press Kit’
every year, consisting of terse and snappy pieces
summarising its longer and more verbose yearly report
on the State of the World’s Children. Most of this
material gets published in the newspapers mainly
because it comes in the ’predigested‘ and ‘instant’
form which readily appeals to the hardpressed newspaper
staff•
8) If you turn media-watcher for a whiles you
will notice how cleverly vested interests use the
media for their own purpose. The PR departments of
the drug firms work overtime to present a favourable.
picture of some of the worst culprits—and the public
swallows it all. When a drug gets a great deal of
adverse publicity/ the industry manages to get
spokesmen from the medical profession to defend its
product and these statements are reported prominently
with big headings. This has happened repeatedly in
the case of the E.P. Forte drugs, clioquinol, anabolic
steroids and injectable contraceptives. Unless these
statements are challenged and refuted by the progressives,
the public will continue to receive only distorted
information. The media has to be used by the health
action people in as dynamic a manner as it is currently
being used by the Establishment.
21 2
9) The potential of radio and television in
serving the cause of the health movement remains almost
totally untapped. Recent programmes bn health issues
^■n Janyani, Panorama, Sach ki Parchayen and Focus
Indicate the immense possibilities that exist. We
have become so obsessed with the notion that radio
and television, being government-controlled media,
are not ’free' that we have ’ overlooked the fact that
it is precisely because these media are governmentcontrolled that they can be harnessed even better to
serve the Health-For-All purpose. The government
claims to be committed to achieving Health For All
and so the most logical thing would be for the
government to agree to use the media under its control
for this purpose. Talks, interviews, feature,
programmes, even serials, could be planned as
vehicles for getting across health education messages
to the public, using the most potent of audio-visual
media. And this could be extended to the area of the
UGC television programmes as an excellent way of
getting basic health information to the student
community. Since the initiative to do all this won11
come from the government, its upto the health
movement to 'persuade* the controllers of government
media to act.
The fact is that the different forms of media
have been generally thought of as areas of expertise
beyond the purview of those not specifically trained
to handle them. It is time that all of us, working
for various progressive movements and causes,
realised that the media are only tobls for getting
messages across and if we have something important
and worthwhile to say, all we need to do is to
collaborate with those trained in the media and
disseminate our ideas effectively. But to do this,
we have to go to the media instead of writing in the
media people to come to us«
The ORT Examples Some of the points I have raised
in this paper may be illustrated by a specific
instance.
Thanks to UNICEF’s consistent PR work on ORT,
there has been a steady media focus since 1983 on
the salt-and-sugar remedy for diabrhoea. The image
which has been built up in the process is that ORT
is a miracle solution for preventing Third World
diarrhoeal deaths. Inevitably, the word ORT has
become associated with ’children1 and with ‘poverty*.
213
Nowhere does the ORT message in the.mass clarify that
this is a therapy for all peoplez rich and poor,
adults as well as children«
(Nor does the media
image of ORT acknowledge tnat ORT may prevent
dehydration deaths but it doesn't prevent repeated
diarrhoeal attacks and that the ultimate solution lies
in sanitation, hygiene and safe drinking water. This
however is a separate and important aspect which I
won't go into just now for lack of space.)
Going back to the media coverage on ORT, a
crucial omission is a statement to the effect that
ORT is the only therapy needed for the common Viral
diarrhoeas and that most of the antidiarrhoeals
prescribed or soldover-the-counter are unnecessary and
that some are positively harmful. Besides this,
evaluation of ORT promotion has repealed that a.major
obstacle to ORT acceptance is the fact that senior
health personnel are themselves unconvinced and continue
to recommend drugs rather than ORT. In the eyes of the
literate middle-class public, even today, three years
after a veritable media blitz on the ORT miracle, the
salt-and-sugar remedy is seen as something meant for
the very poor—those who cannot afford to buy antidiarrhoeal drugs.
This critique of the ORT issue is something I
have written about in serious progressive forums, but
I felt that this aspect needs to be focussed also
in a typical Establishment paper, whose readership is
unlikely £o have been exposed to such an understanding
of the issue. I have already mentioned that both
readers and editors are suspicious of health infor
mation coming from non-medical writers. So, instead
of an 'opinion and advice* piece, I did a short 'news'
report quoting the information compiled by Health
Action International in their Diarrhoea File and
released last December for use by the health movement.
This I sent to the Open Page of the Hindu which I
felt was an appropriate choice as a conservative
newspaper and mouthpiece of the Establishment. The
Open Page is a weekly forum for the expression of
diverse views but the Hindu declined to use my item
on this page (probably because I am not a doctor and
therefore not competent to write on matters medical),
and placed it instead in the Letters-to-the-Editor
column. Anyway, my purpose was served.
My piece specifically mentioned that many doctors
themselves do not promote ORT but prescribe irrational
drugs. Not surprisingly/ there was an immediate
response from a Madras doctor asserting that "doctors
214
know best and also defending some of the commonly consumed
irrational preparations (which one assumes he was in the
habit of prescribing). This was immediately followed by a
letter frc m an ’eminent' Madr s doctor, one who is well-known
to the readers of the Hindu, defending the statement of his
younger colleague, and condemning the misinformed sensation
alism indulged in by "journalists and politicians’.
I nowT stood thoroughly discredited in the eyes , of the
Hindu readership and all because 1 tried to share with them
the’Tnformation I had been regularly receiving from the health
groups and from no less a journal than the WHO supported
Diarrhoea Dialogue published from London.
I realised that in addition to my own rejoinder, it was
necessary (for carrying conviction) to get doctors to support
my stand. I therefore sent photocopies of my original letter
and the two responses to doctors in health groups all over the
country (members of AIDAN)f and requested them to send their
respo9.es to the newspaper. Of about 16 letters sent by these
health activists, the Hindu published about eight, all
deploring the attitude of the Madras doctors, welcoming the
kind of critique I had offered, and endorsing the statement
regarding irrational antidiarrhoeals. Some of the letters
also used this as an occasion to explain why a rational drugs
policy is an essential component of health policy and that
this alcne will prevent the misuse and overconsumption of
harmful and unnecessary drugs. There was no response to any
of these letters from the Madras doctors and one assumes that
as far as the Hindu readership at least was concerned, the
point about ORT was adequately made.
This little episode shovthat: 1) It is not easy to get
radical health information into the Establishment media.
2) Even when one ’smuggles’ it in there is opposition from
the medical profession itself.
3) When a doctor contradicts
a journalist on a health issue, it is the former’s words
which carry weight regardless of how well-informed, factual
and scientifically sound the latter’s argument may be. 4)
In
spite of these handicaps it is still possible to save the
situation if the movement as a whole mounts an orchestrated
attack on the views being propagated by the vested interests,
5)
In such a strategy the role of ‘qualified’ people with
medical degrees is crucial.
215
6) The letters pages of the Establishment papers are
an ideal forum to introduce information which may not
readily be accepted in the news columns or feature
pages. This fact should be exploited more consistently
and these columns used for raising consciousness and
for creating an informed public.
All of us in the health movement must be vigilant
media-watchers and media-critics if we are to become
effective media-users. And every time an opportunity
presents itself, however trival it may seen nt the
moment, a 'counter-message' should immediately be
sent out to point out the distortion. For example,
when a sophisticated diagnostic service meant for the
elite displays a full-page ad<. using the slogan
'Health For All' and announces that the Health
minister will inaugurate the building, a strong
letter-to-the-editor from activist doctors should
set right the picture in public eyess that Health-For-All
does not mean costly medical services for the affluent
and that it is scandalous for the Health minister to
be a party to this perpetuation of falsehood.
However, this type of alert action has so far
not come naturally to the health movement because
they haven't really thought about it seriously.
Taking the ORT issue for instance, many progressives
who read the Hindu may have silently criticised the
Madras doctors' statements but did not realise that
in public interest they should sit down and write
rejoinders. The activists who did write had to be
contacted and briefed, and their subsequent use of
the media to put across the viewpoint of the movement
was part of an organised strategy. For, this issue
of using the media more actively was something we
had discussed earlier during a conference last December
on 'Pharmaceuticals and the Poor',
and when the Hindu
incident cropped up, everyone was conscious of the
need to "swing into action".
What we need therefore is to draw up a sort of
'media strategy1 by which activists in the health move
ment in different parts of the country agree upon a
regular programme for using the different forms of media,
in different ways to suit different occasions and subjects,
consistently and imaginatively—from features, columns,
articles and news reports to sponsored programmes, cartoon
films and even public-interest advertising.
I put it to the participants in this seminar that
they should see this as an important component of the
action programme for achieving 'Health For All' and
for stimulating the 'Peopled participation' which is
crucial to the achievement of this goal.
216
I
ROLE OF CURATIVE MEDICINE IN HEALTH FOR ALL
Dr. Sujit Das
The social practice of arranging for medical care
is as archaic as any other social activity. Individuals,
community, religious & voluntary institutions, and the
State - all play their party« Modern societies, however,
enriched by advanced scientific knowledge, have turned
their attention to basic health care which determines
the health status of a community. Socio-economic-cultural
roots of ill health have been identified and the deter
minant role of food-water-sanitation, economic security,
education, women's liberation etc. has been emphasized.
Accordingly, in the strategy of Health For All, priority
is given to universal availability of the provisions
non-medical health care and the prevailing dominance of
curative medicine in the practice of health care has
frequently been decried.
Concerned people betray an ambivalent attitude
towards medical care or for that matter, curative
medicine. Since the Shore Committee’s (1946) observation,
“If the nation's health is to be built, the health
programme should be developed on a foundation of preventive
health Work", to the latest proclamation of national
health policy (1982) , the Government of India persistently
emphasized the necessity of prioritisation of non-medical
health care, but the Government practice of steadily
expanding medical care service to its highest sophisti
cation xias never been decelerated. For some considerable
period lately, medical education has been according due
importance to the tra: ning in preventive and social
medicine, but medical practice continues to deal with
curative medicine almost to its entirety. Political
and sociological commentators have incessantly been
talking about socio-economic roots of ill health but
political activists demand only medicare for the people.
People on their part, consistently seek curative medicine
which is not only the urgently felt need but often held
synonymous with health care.
Concept and Realitys
Role of curative medicine though underplayed in
policy-making* is not ignored in practice. This apparent
paradox is resolved if the relationship between concept
and reality is reviewed. Healers are venerated and ;
honoured since the infancy of the human society for the
2 17
essential vital function they perform both at the
individual and social levels; they respond to human
distress. Most of the minor illnesses heal themselves;
man learns to tackle a good number of every day phyoical
distress himself; when he seeks a healer, it is more
than the mere physical but includes added factors of
aporehension, fear and helplessness which compound the
distresso The healer offers an explanation of the
causation of the ailment (however weird), takeo charge
of the battle, relieves the patient of helplessness,
applies his technology (however primitive and absurdly
ritualistic) of diagnostication and therapy and emerges
triumphant when the self-healing ailment heals itself.
The entire episode restores confidence and balance to
the sufferer and his kinfolk, enabling them to again
face the adverse world with renewed courage - the
unknown enemy is now known and conguered, and the
weapon to tackle the enemy, the healer, is there. Even
when the healer fails, he allays distress, offers
comfort and finally legitimises death. This is one of
the most vital psycho-social function to the mankind to adjust to environmental adversity in the strive for
survival and progress. Modern doctors.also perform
the same psycho-social function, only immensely more
successful owing to remarkable development of potent,
life-saving, preventing, curing, relief-producing
technology of medical science.
Curative medicine has long been an integral
element of tradition and culture/ while preventive
medicine/ a recent concept born out of recent knowledge/
is yet to attain such position. Even preventive.medical
intervention e.g. vaccination which also saves lives,
took a long time to gain acceptance from a section of
the people. Various efforts in health education have
so far failed to make any positive impact in people s
concept wherein the determinant
(---------- role of non-medical
health care is yet to gain entry, Protection of
health, it is believed, is
i_ essentially dependant on
curative medicine.
In health care, the dominance of the felt need
of medical care is as strong asi ever. The agony of
and
relief in the removal of
the body in distress a
—---that distress or for that matter, the dramatic episode
emotive
of life-saving carries such an overwhelming
c
force that it transcends all cold reasons and arguments.
This reality explains the emergence of certain apparently
irrational but culturally compatible practices. In Indiaz
218
we have created a large.number of institutions where
a citizen, dying from a physical ailment, may legiti
mately claim free life-saving high cost medical aid.
But there is no such institution to provide life-saving
food to a citizen dying from starvation or for that
matter, cloth-shelter etc. to the similarly deprived.
Neither is there any demand on the State from any
corner for such provisions. In fact/ it is still
conceptually repugnant to the present society that
there should be some provision for the routine free
supply of food etc a to the deprived, though it is
not disputed that without food there cannot be any
health.
It is not suggested that this ambivalence has
no objective basis. The parent of a child dying
from diarrhoeal dehydra bion cannot be expected to be
interested in safe water supply; his/her instant
need is medical care to save the child. The need of
curative medicine is so enormous in India that in
popular concept/ no health care service is worth its
name if it does not offer curative medicine. On the
other hand/ it would perhaps be unwise to hold that
people have no conception about the determinant role
of the provisions of non-medical health care. Social
and political workers/ providers of medical care,
the ailing people - all are quite aware that persons
with higher living standard suffer less from ill
health and the linkage between affluence and health
is there for all to see and draw conclusions. And
it is also known that peonle all over the world have been
struggling for food-cloth-shelter long before their
determinant role on health has been formally theorised.
Medical Care s The Key approach
The contradiction between the concept and reality
of HrF.A. needs to be reviewed in this perspective.
It is apparent that the W.H.O. slogan of H.F.A. has
not so far been able to obtain a significant place
in people’s struggles. Primary health care has been
prescribed to be the key to attain H.F.A. Elements
of primary health care were not unknown earlier and
the health centres established in post-independence
India were supposed to provide almost all of these
elements. But eventually, the health centres have
been turned into agencies to provide medical care
and even this cannot be adequately provided. It is
quite clear that conventional health institutions are
not suitable to provide for non-medical health care.
219
Food-water-sanitation-employment-education cannot be
achiev d by the people in ainimum necessary measure
without establishing political control over the State,
Social wealth and Means of production. Primary health
care approach may be sound in concept but is not
implementable in practice in the present Indian socio
economic reality. People’s participation is sound in
concept but in real life, only those participate who
wield power and exercise control. That is why in the
prevailing health care service only the providers
participate, not the recipients. People’s participation
is a myth if delinked from authority and control. In
this context, it is suggested that medical care could
be a key approach to attain the goals of H.F.A.
Present situations
Medicare service is catered to the people through
three broad systemss-
(a) Free medicare; through State health care
service and non-governmental voluntary & philanthropic
agencies.
(b) Indirectly purchased medicare: through various
schemes e.go E.S.I<(M.B.) Scheme, institutional schemes
of Government and non-government employees/ rudimentary
insurance schemes etc.
(c) Commodity medicare: through the large market
of private practitioners, nursing homes, laboratories
etc. Private practitioners include those belonging to
various systems of medicine as also quacks.
State authorities never tire of proclaiming for
umpteen times that the State service is free and is meant
for the poor. In reality, both the principle and practice
are far from true. In principle - legal, constitutional and
otherwise - State medicare is not meant for the poor
only. By policy, the access is universal. State
service is available to the residents of the province millionaire and pauper alike; to the visitors from other
provinces; to the visitors from other countries; to the
people who enjoy guaranteed indirectly purchased medicare
e.g. C.G.H.S., E.S.I. etc.; one and all. Needless to.
say, the state service is not equipped - neither it is
so expected - to cater to such large clientele. Expectedly
the service is far short of need. The demand for free
State medicare has been fast increasing mainly for three
reasons - steady development of more and better technology;
220
steady price escalation of commodity medicare; and
concentration of up-to-date intervention technology
and better skilled medical personnel in the State
institutions. For emergency patients, the universal
trend is towards State hospitals. Affluent people,
who in the earlier days., used to shun Government
hospitals, now increasingly invade them and corner the
better and costlier part of the State Care employing
economic, social and political power they enjoy. The
topographic distribution pattern is also stacked
against the poor. Both quantitatively and qualitatively.
State service is overwhelmingly concentrated in the
urban areas while the poor mostly reside in the
villages. The eventual result is that the poor is
deprived of its only available source while the affluent
enjoys the option to choose from all sources. Then
again, the State service is far from free for the poor.
Conceptually, the State service is still run on the
old philanthropic principle - as a matter of charity
or welfare. While the recipients approach the State
institution as if seeking alms and feel obliged for
whatever they receive, the providers, i.e. the doctors
and hospital workers are imbibed with reciprocal concept they hand out doles. Such basis has expectedly given
rise to all sorts of corrupt practices similar to what
are found in the relief programmes. The practice of
some form of payment as premium to the doctor or
hospital workers for the privilege of admission in a
free bed is still rampant in most of the provinces.
Quite frequently such premiums are obligatory for
investigative, surgical and similar services. In the
urban and semi-urban hospital wards, it is now
customary to engage an additional care-taker at the
patient’s own cost in order to obtain minimum necessary
caring services. It should however be kept in mind
that the affluent can avoid paying these premiums on
account of higher social status and when pays, the
service is far too cheaper than the- market commodity.
Rational Medical Care- Scheme:
A rational medicare service is expected to be
based on social justice and provide for essential
need of all people regardless of their ability to pay.
Under the existing socio-economic reality a drastic
restructuring of the medicare service is therefore
called for.
(a) State free medicare should be exclusively
reserved for the larger section of the people living
below a predetermined level of income.
221
(b) Rest of the population be divided into two
broad categories, again on the basis of income and
wealth. The upper richer section should be left.to
fend for themselves - to build up their own medicare
service in the private market.
(c) Medicare for the remaining middle group be
organised through insurance system* Among them,
sections of people belonging to ’indirectly purchased
medicare schemes * should be kept confined within their
respective schemes.
A host of problems will come up in the way of
implementation of this scheme. It has been arjued
that such a scheme is discriminatory, is not^feasible
and works against humanitarian principles» .Surely it
is discriminatory but it is a reverse discrimination
in favour of the poor aimed at abolishing the present
discrimination and introducing eguitable distribution.
As regards feasibility, the problem does not appear
to be insurmountable. The scheme envisages a compart
mentalised medicare service and already a few such
schemes are being operated in the country e.g.E.S.I.,
Railway, Armed Forces etc.; it is only a question of
extension and coverage of the entire population.
Division of the population into economic categories
already exists in some form or other - the food
rationing system in Andhra Pradesh being an example.
There may occur some interpolation and that could be
ignored. The humanitarian argues that it is cruel
to bar the hospital door to a dying perdon just
because he is rich. This argument hardly holds water
as under the oresent system the hospital doors are
virtually closed to the poor millions. Closing the
door to a few and opening the door to many actually
reduces cruelty and the rich has means to gain entry
to his own category of medicare institution. In any
case, in extreme cases emergency services may be
rendered in the State hospitals to the unentitled
but at a price, not free.
Implementation of the above scheme will require
restructuring and rationalisation of various related
enterprises. For example. State financing of medical
education, uniformity in the standard 6f medicare,
decentralisation of and accountability in local
administration etc. There will be.many other related
issues demanding attention e.g. private investment in
commodity medicare. State policy on preventive and
rehabilitative health intervention, Centre-State
222
relationship etc. But these are issues that can be
and should be tackled only after the adoption of the
scheme is decided upon.
Implicationss
It is not suggested that the above scheme will be
readily implemented by the authorities/ if only its
rationality and feasibility are established. The
State, in an exploitative society, does not undertake
social welfare for innocent benevolent purposes.
Social welfare measures e.g. education, health care,
and public distribution system are actually outcome
of class struggle. The State is obliged to concede
these and at the same time, uses these to project a .
benevolent, friend-of-the-underprivileged image for
itself. Such a process perforce has a limitation
within the constraints of the exploitative system.
Financial allocation to social welfare cannot be
allowed to climb to such proportionsas to make a
substantial dent in profit rate of the economy. This
unwritten law is causing a crisis in the State medicare
service. Demand for modern curative medicine has been
increasing steadily and the state, under the restraint
of the unwritten law, finds it difficult to provide
such costly service universally. But it is imperative
to maintain the benevolent image in order to contain
social unrest and legitimise and sustain the existing
social order. Hence, sprouted a number of prescriptions
as the way out. Barefoot doctors, glorious indigenous
medicine, people’s healtl. in people's hands, healthy
life style etc. are being propagated in order to explain,
justify and perpetuate denial of effective medicare to
the underprivileged. It is noteworthy that the propo
nents of all these alternative remedies never propose
dismantling of sophisticated modern medicare system
serving the affluent. Theaffluent will be allowed to
enjoy alien western curative medicine. Alternative
prescriptions are meant only for the poor.
The proposed scheme under discussion will not
only expose the deprivation of the paor in the current
discriminatory medicare service practised under cover
of universal eligibility/ but at the same time disturb
the legitimization process. The deprived people will
now have a concrete slogan to counterpose against the
apparently benign slogan of H.F.A. The slogan of
exclusive guaranteed medicare service carries no amount
of mystification around it. The effects of medicare on
health, life and limbs are obvious, pointed and clear
223
to them. They now have a clear circumscribed demand
to struggle for and organise. They may leave no
avenues unexplored to achieve an exclusive right for
themselves and if achieved/ will be equally zealous
to guard it. If achieved., they are apt to exercise
control over it through their own democratic means
in order to see that it functions effectively for them.
The.demand is culturally compatible, emotionally
moving and meets urgently felt need.
__ this scheme be realised? Will the State
Will
concede this demand to the deprived and exploited
________ The prudent answer is No. Indian reality,
classes?
enjoins that social justice and equitable disttibution
cannot be expected to materialise in an exploitative
class divided society. A few sporadic benefits may
be realised from time to time-through class struggle
to produce some palliative effect. But a scheme of
exclusive control by the lower echelon of the
society is apt to face strong opposition and,resistance.
The present beneficiaries of the State service will
oppose it as they are to loose an existing privilege.
The controllers of the State exchequer will oppose
it as it not only entails increased allocation to the
poor but setting ip a framework for accountability
of the providers to the recipients. Such opposition
will instantly expose real beneficiaries and utter
inadequancy of the present system; will pierce through
the humanitarian camouflage undermining the benevolent
friend-of-rthe-poor image of the State; and make a
dent in the legitimacy of the present social order.
It will breed conflict and facilitate polarisation
of the contending forces. It may act as a nidus for
class struggle.
There is, on the other hand, the question of
legitimacy of the scheme itself. The illusion that
the deprived people may obtain effective primary
health care for themselves through the good-will
& philanthropy of well-meaning liberals and humanitarian
international community should be abandoned once and
for all. India has a long tradition of voluntary
welfare activity in the field of medical care
producing, so far, little result. The illusion that
technological (alternative medicine etc.) and managerial
(H.F.A. s an alternative strategy - I.C.S.S.R./l.C.M.R.)
innovations may do the trick, should also be seen through.
The deprived will have to demand for their legitimate due
and struggle for control. But then the demand itself
224
should not only be legitimate but should also be
rational and conform to political reality, The
labouring masses should not act only as> a pressure
themselves but
group :for
---- ------------------------ should emerge as the future
■*
They will
leaders of the ensuing just social order.
have to take the need of entire people into consi
deration in order to earn legitimacy for the scheme
The scheme therefore provides for feasible effective
medicare for the other strata of the society.
If the control over the medicare service is
ever achieved it will soon be apparent that without
overall political and economic control neither
effective medicare could be sustained nor the basic
health care provisions e.g. food - water etc. could
be obtained. The fundamental problem is political and
economic. This situation is not peculiar to health.
State allocation on education/ housing/ relief etc.
does not reach the poor but is substantially appro
priated by the socially dominant classes» Only
successful struggle and eventual assumption of control
over the State by the overwhelming majority of the
organised labouring people could reverse the trend.
It may begin in the field of medical care.
225
HEALTH FOR ALL NEED FOR A PEOPLE’S DRUG POLICY
by
B
Ekbal
India has become one of the few developing
countries whose pharmaceutical manufacture has reached a high
level of-self-sufficiency, oriented towards full integration
at least for the main sectors of the economy. For example,
India produces 45 thousand formulations in .different forms
like tablets, liquids, injcctaoles using about 400 bulk
drugs being manufactured in the country. In its classification
of pharmaceutical industries of less developed countries,UNIDO
placed India in group 5, representing the most advanced stage.
Some of the characteristics of this stage as defined by UNIDO
are near self-sufficiency in raw-materials for the production
of drugs from basic stages, a wide variety of therapeutic
groups of drugs produced etc.
The total investment in the pharmaceutical sector
expanded from *>.24 crores in 1952 to Rs. 200 crores in 1972 and
further to 600 crores by 1983. The value of output which was
only Is. 10 crores in 1948 rose to 300 crores in 1971-72 . BY
1974, the value of production of drugs and pharmaceutical
products reached the level of Rs. 377 crores and further
Rs.1870 by 1982-83.
Table I
India’s Pharmaceutical Growth 1952-53 to 1982-83
81.No.
I tern
1952-53
1643
5
Number of units
Investment
Bulk drug
production
Formulation
Imports
6
Exports
0.08 crores
1
2
3
4
24 crores
1982-83
% Increase
6631
300
600 crore 2400
27 crores
(64-65)
325 crore 1800
35 crores
16 crores
1545 crore 4300
141 crore 780
111 crore 13700
Sources Charpure Y.H. 'Drugs for MassesEastern Pharmacist,
26 Feb.1985 pp. 35-38.
226
The evidence presented above on the growth of
pharmaceuticals industry in India suggests an impressive
picture. But a closer look, however, reveals a somewhat
different picture of extremely disquieting features.
Though the total number of licensed drug units of nearly
5200 are among the highest in the world the share of
Indian pharmaceutical industry in the world production is
as low as 1.2 percent. Per capita drug consumption is
one of the lowest in the worl*d, embracing only 20% of the
total population.
Since independence, the government of India
permitted the Multinational Corporations to set up units
in India so that India may get access to new discoveries
of the West. The liberal approach to foreign collabora
tion in the pharmaceutical industry was highly detrimental
to the development of initiatives already taken by the
then existing research institutes in India. The 'Pro
foreign' attitudes of government of India enabled Multi
national with ready access to the sophisticated technical
knowhow as well as modern managerial talent, to establish
production facilities. A closer look on the history of
the development of this industry will instruct us about
the weak chemical base over which it is erected. While,
the pharmaceutical sector in developed countries came to
be established as a result of diversification of basic
chemicals, the growth precess in India was characterised
by a 'reverse process* of backward integration which has
the adverse effect of making the industry dependent on
Multinational Corporations for the supply of raw materials
and other inputs. The liberalisation of major instruments
of ctntrols like licensing, foreign collaboration guide
lines etc. facilitated the growth of foreign companies.
At present there are 48 firms in the foreign
sector of which 35 firms are those in which foreign share
holding is 40 percent and above. The number of foreign
companies operating in India will only show the outward
manifestations of foreign control. Foreign control
defined in terms of control of output is of staggering
proportions. Foreign companies control about 78% of
total sales turnover of drugs in the country while the
shares of Indian private and Public sector are 16% and
6% respectively.
A study of the market shares of foreign com
panies in India vis-a-vis their shares in a few developed
and developing countries yielded interesting insights into
the concentrations of Multinational Corporations in the
Indian Pharmaceutical industry. The concentration is
found highest in the case of Indian pharmaceutical industry
than in both developed and developing countries.
227
The proportion of bulk drugs produced by Multi
national Corporations have been coming down over the years.
If it was 36.17% in 1974-75, it declined to 21.8% in 1980-81.
Whereas the share of Indian sector including public sector
increased from 62.82% in 1974-75 to 68.2% in 1980-?81. The
thrust of Multinational Corporations continue to be,as Hathi
Committee has observed long back, 'towards capitalising over
drug formulations and nondrug items like cosmetics and
luxury goods where technology and capital inputs are much
lower and which permits promotion and aggressive salesman
ship and brings in much higher returns on investment'.
What is more tragic has been the breach by the Multinational
Corporations of the important National Drug Policy directive
stipulating that the ratio of bulk drug to formulations
production by them must not be lower than Is 5 but atleast
statistics indicate that they are nowhere near the official
guidelines.
Table II
Ratio of Bulk Drugs to Formulations
Sectors
1 Foreign Sector
II Indian Sector
HI Public sector
Ratio as on
1974-75
Ratio as on
1980-1981
1:12.53
1: 2.6
Is 1.26
1:6
ls8
1 s 0.8
Ratio as on
1982-83
Is 12
Is 3.44
10 1.12
Sources Ministry of Petroleum and Chemicals, various reports
quoted by Mohanan Pillai in paper presented in KSSP
Seminar ‘A Decade lifter Hathi Committee' Nov.24-27
at Trivandrum.
Instances of over pricing through transfer pricing
Librium was introduced into
in India have been reported
the Indian market at more than Rs. 5,555 per kg. While 1 )cal
firms could import it for Rs. 312 per kg. A foreign subsidiary was charging Rs.60,000 for a kg. of dexanethasone
reduced
on threats and pressures by
which was l
,----- to_ Rs.- 16,000
r
the controller of imports. The international price of a
particular bulk drug^used in the treatment of heart.
disease, is approximately 530 per kilogram., A multi
multi-
national was producing it in India in the early 1970s by
importing the basic raw materials from its parent company
and price paid for this import was $ 871 per kilogram.
Such examples can be multiplied. (Table III)
228
Table III
Over-pricing of Imports of selected bulk drugs by
the TNCs in India
Name of the
bulk drugs
Unit
The price
at which
the TNCs
imported
in India
Inter
national
market
price (Rs)
Over
pricing
1680,4
(Rs)
Chlordiazepo
xide
Kg
5555
312
Vitamin B 12
Gram
Kg,
230
3400
90-100
Prenylamine
lactate
Kg,
1900
470
844.4
304.2
Erythromycin
Kg,
1200
780
53.8
Fursam ide
Kg.
1650
520
217.3
Indomethacin
Sources
360
130-155,5
Towards a Rational Drug Policy
All India Drug Action Network 20 March 1986.
A recent systematic study on the incidence
of transfer pricing by multinational subsidiaries revealed
that outflow of resources on this account alone amounts
to ks. 550 lakh an year. According to Kafauver Committee
of U.S.A, drug prices in India were the highest in the
world and were in inverse proportion to the per capita
income (Table IV). Drug price indices in developed
countries have been falling when static groups of drug
price index calculated on the basic prices of eight
age old static drugs showed a rise by 41.9% during
1961 and 1970.
Table IV
Some common
.drugs
Price at
which
bought
(per kg.)
Doxycycline
Ethambutol
Frusemide
G entamycin
Vitamin B 12
Ampicillin
L ibrium
5,890
620
1,426
35,670
494
1,392
5, 555
International Percentage
price(per kg.) of profit
1, 377
320
450
3, 500
132
743
312
340.5
93.8
216.9
919.1
274.3
87.3
1680.4
SourcesQuoted from paper presented by Dr.Naresh Bannerjee
in KSSP organised Drugs Seminar,Trivandrum,Nov.24,
Also see Sudip Chaudhuri's Making Drugs without
TNCJs EPW Annual Number 1984.
229
In India, pharmaceutical industry controlled by
Multinational Corporations is notorious for its use of high
pressure sales techniques. When new products which are
only 'molecular manipulations' (with no therapeutic gains
and is by-product of marketing oriented research than
genuinely innovational research) are introduced in the
market, they are bc^cked up with a barrage of high-powered
promotion. The success depends much on branding them and
impressing the doctors of the virtue of particular brandnames.
The 'merit' of brands are proved to be of a dubious kind.
They promote a product differentiation under which the same
basic drug is marketed under different brandnames. There are
around 40 to 45 thousand brand names circulating in India for
some 700 basic drug. The amount of promotion expenditures on
brand names is just stupendous, around 23 percent of the
Some
value of sales in the case of some foreign companies
companies like Pfizer spend even more, No'- wonder than that
as many as 406, 308, 155 and 115 formulations under different
names are marketed for vitamin B complex, Multi-vitamin
tablets, chlorophenical, Vitamin B12 respectively. What is
more disturbing in this context is that Multinational Corpo
rations market in India,
drugs which are not authorised for
sale in the country of origin. The U.S. food and drug
administration has circulated among federal agencies a
comprehensive list of 369 drug products that it considers
either ineffective or unduly hazardous. It is not precisely
known how many of these are being currently sold in India.
Table V
Drugs marketed by MNCs in India but not in their home countries
Name of the Drug
Company
Country of
origin
xAvil Expectorant Hoechst
F.R.G.
Soventol Expecto- Boehirnger
F.R.G.
rant
Knoll
Piriton Expecto G1 axo
ll.K.
rant
Periactin
Merind(MSD)
U.S.A.
Os tocalcium 812 Glaxo
U.K.
Amebiotic
Pfizer
U.S.A.
Nova1gin
Hoechst
F.R.G.
Baralgan
H Dechst
F.R.Go
Suganril
S.G.Chemical SWISS
(CIBA Giegy)
Indications for
which the drugs
are promoted
Cough Expectorant
-do-
- do
Appetite Stimulant
Growth Tonic
Anti Diarrhoeal
Pain Killer
Anti Spasmodic
Anti inflamatory
containing phenyl
or oxyphenylebutazone.
Sources Towards a rational drug policy.
All India Drug /Action Network, 20th March, 1986.
230
Is the higher levels of production in the
pharmaceutical industry in confirmity with the pattern
of prevalent diseases? The industry is bestowed with the
responsibility of protecting the health of the nation by
orienting its product structure to the prevailing disease
pattern. All studies done so far indicate the inappro
priateness of the drugs produced in India for catering
to the needs of the people. Infections and parastic
disease (e.g. dysentry. Malaria and Cholera) and respi
ratory diseases (general respiratory illness and tuber
culosis) are the major classes of illness prevalent in
India. Drugs for these major illness should be available
in India for indigenous production but paradoxically most
of the required drugs are not produced and if at all
produced, it is in such a small quantity that requirements
have to be met by imports.
(Table VI). Whereas sales of
vitamins, cough and cold preparations tonics and health
restorators which are used for no ailment in particular,
constitute 22% of the total sales of pharmaceuticals in
the country and essential medicines such as anti-tuber
culous drugs are always under produced. (Table VII).
Table VI
Decreasing Production of Essential Drugs
Drugs(in tonnes)
1980
Apr.to Sept,
46.41
1981
Apr.to Sept.
36.16
PAS (For tuberculosis)
INH (For tuberculosis)
215.16
69.1'8
122.22
Piperazine (for worms)
6.30
4.20
Dapsone (For Leprosy)
10.28
10.58
10.17
8.42
Chloramphenicol
D.E.C.Citrate(for
filariasis)
Sources Issues involved in Drug Policy
Chermai Books, Madvas 1986
231
53.70
Table VII
Sale of vitamins formulations and tonics
Product
Company
Sales
1979
Sales
1984
Growth
%
Santevini
Neogadin
Bayer’s tonic
Waterbury’s
8OG.Phos
Sandoz
Raptakos
Bayer
Warner
Merind
(MSD)
Sarabhai
1.83
1.46
1.45
1.40
1.40
3<>05
3,05
2O54
2O15
2.06
66.O'7
108.90
74.17
53.57
47.14
lo19
2,00
680O6
Phosphomin
Sources Amitava Guha ’Cycle of Profit’ paper presented in
Seminar ’Drugging of Asia’ Madras 6 to 9th
December 1985.
One of the dynamic effects postulated with regard
to the activities of Multinational Corporations is that their
operations in developing countries like India will lead to
research-intensive technological advancement. But the
pharmaceutical industry dominated by Multinational corpora
tions showed an extremely poor record of research and devel
opment. The R & D expenditure of all Indian companies as
percentage to sales is calculated to be around 1.5 whereas
in advanced countries it is as high as 10 to 11 percent of
total sales. Studies in the past indicated that there is
no serious attempt on the part of foreign companies to adopt
and assimilate imported technology and to make further
process on it. In particular they have shown no interest in
tropical drug research, such as antimalarialst anti
tuberculosis etc. With 40 to 50 years existence they have
yet to come out with a drug the knowhow of which has been
developed entirely in India. What research and development
studies are undertaken is generally confined to and relevant
for the parent companies’ research efforts. Instances have
been quoted in the case of few companies where, in the name
of experimentation, human trials were carried out first in
India even before trials were carried out in the West. It
is also alleged that some subsidiaries of Multinationals do
research on processes which is forbidden for experimentation
in advanced countries. May be India is a preferred area for
multinationals because of the absence of any strict rules of
safety against genetic engineering research. Such examples
of Multinational companies doing irrelevant research in the
Indian context can be multiplied. In areas of essential
drug research the Indian companies had made rapid success.
But such successful efforts could not be carried forward
due to the opposition from drug multinationals and also due
to the charry attitudes of government of India.
232
The official statistics is replete with
evidences that shows higher profitability of foreign
firms vis-a-vis Indian companies. In particular, the
profitability of foreign firms in sectors such as perfumes
and cosmetics, medical and pharmaceutical products and
beverages, are the highest. The data for 72-73, 73-74
showed that when the average profitability of all foreign
subsidiaries operating in India was only 9.5, 9.3 percent
respectively that of foreign subsidiaries in pharma
ceuticals were to the order of 15.6 and 15.1 percent. It
is to be remembered in this connection that this represents
profits on book values and does not include the remitt
ance through other channels such as, transfer pricing etc.
The banning of irrational and dangerous drugs
in India or even their control is a tedious and often
impossible task because of the plethora of control
measures. Some of the drugs that have been banned with a
great deal of procrastination over the years is still
furtively ^available in the market as are some drugs
banned or rigorously controlled abroad. Recently the
Drugs Consultative Committee recommended the weeding out
of 22 drug formulations. The firms were asked to stop
production by September 1982 and marketing and sales by
March 1983. The Government's procrastination in stopping
the sales of drugs obviously to help the manufacturers to
clear the stocks, has come in for severe criticism in a
recent judgement on drug issue by the Hon’ble High Court
of Kerala (Annexure 1).
But the banning of 22 formulations itself
was so much diluted. For example, hydroxyquinoline
groups of drugs are permitted to be administered for
diarrhoeal disease. The drugs have been known to cause
SMON (Sub Acute Myelo Optic Neuropathy) in 28 countries
of which Japan reported 10,000 cases. They suffer
numbness and weakness in the legs and eye damage. zA
large number became blind. One firm had to pay out
millions of dollars as compensation and the drug was
subsequently banned in U.S.A, and U.K.
The absence of a national stability forum
like the British Safety Committee of medicine in U.K.
or FDA in U.S.A. z is one of the reasons for this sorry
state of affairs. Only three out of twentytwo States
in India(Maharashtra, Gujarat and West Bengal) have
machinery to regulate the manufacture, distribution and
sale of pharmaceuticals. A lot of drug analysis is
done at private laboratories barely equipped for the
job.
233
a
Some vital measures like the introduction of
essential, drugs in mass scale as advocated by the Hathi
Committee and WHO, centralised bulk purchasing of these
essential drugs by national agencies, introduction of
generic names in preference to brand names, cheap standard
ised packaging of a limited but sufficient number of
products need to be implemented rigourously in poor countries
in order to provide essential drugs at low prices to a much
larger proportion of their people. But in almost all
countries the large pharmaceutical firms have consistently
opposed such policies. It is a measure of the enormous
power and influence they weild that they have generally '? io i
successful in getting rid of all progressive measures takjn
by some third world countries like Sri Lanka and Bangladesh,
The use of drugs has in any case to be put in
its proper perspective. In the developing countries like
India,ill health is mostly caused by a vicious combination
of malnutrition and infectious diseases. Drugs cannot help
unless the very sources of diseases, nutritional and
environmental conditions are improved. Latrines to carry
away excreta, improved housing, draining stagnant water and
pipes for clean water are much a part of a programme to
bring health to people as drugs and hospitals. A People's
Drug Policy linked to health strategy which meet the real
health needs of the people should be formulated.
It becomes an urgent need therefore to have a
people oriented drug policy, which is based on sound
scientific principles and not on the drug industry's profit
motiveso The Government of India has already in principle
accepted the need for formulating such a People's Drug
Policyo In the Fifth Non-Aligned Summit Conference held
in August 1976 in Colombo a resolution (resolution No.25)
was unanimously passed by the Heads of States present,
asking for the preparation, with assistance of UN agencies,
of a detailed drug policy and programme suitable for these
countries. Accordingly in 1978 with the help of 4 UN
agencies (UNAPEC, UNCTAD, UNIDO and WHO) a Joint Task Force
was set up which after detailed discussion with governments
and the industry submitted its report titled ''Pharmaceuti
cals for the Third World* Policy for Health, Trade and
Production' c This report, which contains a detailed
description of an integral national drug policy was accepted
unanimously by the Sixth Non-Aligned Summit conference
held in Havana in September 1979 (Resolution No.8).
234
The Kerala Sastra Sahithya Parishad has
already initiated a big campaign exposing the anti-people
and exploitative tactic s of the multi-national drug
companies. The questions of essential versus nonessential and dangerous irugs, the inadequacy of the drug
safety control measures, the rising prices of life saving
drugs, the non-implementation of the Hathi Committee
recommendations. (Annexure II) are being highlighted
during the campaign. The aims of the campaign will be to
sensitise the medical profession on these issues and to
launch a people's Movement for the formulation of a
People's Drug Policy. KSSP is organising seminars, street
meetings, exhibitions, signature campaigns, slide shows,
art items, publication of pamphlets, books etc. during
the campaign period. The campaign was launched on
April 7th, 1984, the World Health Day. KSSP along with
other voluntary groups in India has already formed the
'All India Drug /Action Network' to take the campaign to
the all India level.
* * * A- ************ *
ANNEXURES
Zinnexure - I
"As between the lives of the citizens of this country on
the one hand and the loss that may result to the manu
facturers and traders by the immediate ban on the
manufacture and sale on the other. Government has chosen
to view the latter as -^f more concern".
Justice Subramanian Potti,
Chief Justice,
Kerala High Court,
Judgement on the ban of
Harmful Drugs,
May, 1983o
Annexure - II
The Main Recommendations of the Hath! Committee were;
1 , Nationalisation of multinational drug companies <>
2 . Establishment of a National Drug Authorityo
3. Priority production of 116 essential drugs.
4. Abolition of brand names and introduction of
generic names.
5. Revision and updating of the Indian National
formulary.
6. Strengthening of quality control.
7 . Elimination of irrational drug combinations.
235
REFERENCES
1. Dr.Halfden Mahler (1981), Health for all by the year
2000, World Health - arum, Vol.2 No.l WHO Geneva.
2. UNCTAD(1977), Case studies in the Transfer of Technology
the Pharmaceutical Industry in India, United Nations.
3. Report of the committee on Drugs and Pharmaceuticals
Industry (1975), The Hathi Committee, Ministry of
petroleum and chemicals. Govt.of India.
4. Mukarram Bhagat (1982), Aspects of Drug Industry in
India, Centre for Education and Documentation, Bombay.
5o The drug situation in India (1982), Voluntary Health
xAssociation of India, New Delhi.
6. Lail Sanjay (1974), International Pharmaceutical
Industry and less developed countries, EPW Vol.IX,
No.47, Nov.23.
7. Medawar Charles (1979), Insult or Injury Social Audit,
London.,
8. Essential drug list (1979), WHO Technical Report
Series 641.
9. Agarwall Avil (1978), Drugs and Third World. Earthscan,
London.
10.Patel Aswin (ed.)
Gujarat.
(1977), In search of diagnostic MFC.,
11.Diana Melrose (1982), Better Pills, Oxfans.
12.Richard Blum (1981), Pharmaceuticals and Health Pclicy
Health Action International, Penang.
13.Virginia Beardshaw (1983), Prescription for change,
Health Action International.
14.Milton Silverman and Philip Lee (1982), Prescription
for Death, University of California, Berkley.
IS.Dr.Tom Heller (1977), Poor Health Rich Profits,
Spokesman Books, Nottingham.
16.Milton Silverman (1976), The Drugging of the
Americas, University of California, Berkley,
Los Angeles.
236
17. UNIDO (1978), The Growth of Pharmaceutical Industry
in Developing countries? Problems and prospects.
18. Report of the Pharr^.ceuti’cal Enquiry Committee, 1852.
19 „ Indian Drug Statistics, Ministry of Petrolium, 1978.
20. United Nations Centre of Transnational Corporation
(1979), Transnational Corporations and the Pharma
ceutical Industry, New York.
21. UNCTAD (1980), Major Issues in Indian Pharmaceutical
Industry, Geneva.
22 . UNCTAD (1980), Technology Problems in the Pharma
ceutical Industry, Geneva.
23. Central Drug Research Institute (1976), Country
Status Paper of India.
24. P.Mohanan Pilai (1984), Multinationals and their
Impact on Pharmaceutical Industry in India,(1985)
KSSP.
25. Towards a Rational Drug Policy (1986), AIDAN.
26. KSSP, DSF, and FMRAI Seminar Papers on Drug Industry.
***************
237
new public health
Conceptual Basisi
at present two major trends^in public
There are
One trend is to move away from the .
health practice,
1 ataoet all-CTbrscinS definition of public
very wide and t—
health
C.EoA.
often been neplnood b the
rightly pointed out in
CO“?iSiZ (?98?) 1
K
fl Pubiio Health
?olilil “S Un® CtcnunitZi-Sioin. i.
« “e’oL
line its subordinate poeition to '""^aTy
of
h„, even alapanart »lth
oubai^lpltn^
”E uxsh? Ub!irbUKb”UUu:orau:e:a”itb
modlcil adhoola.
technology <>
The emphasis is on teoHnoloey
The other trend is to make a fundamental departure
pioneers by shiftever from
from rne
the concepts developed by the from technology
ing the focus of public health practice
to the people.
It is this trend of
c_ starting from the
which has formed the
people, rather than from technology,
foundations for concepts and methods for a new approach
New Public Health.
This
to public health practice +
. in its
approach situates the health of a
Actions in
social, economical and ecological setting,
are considered
social and economic fields, m their urn,
political
as parts of a political process.
Again,
socio-cultural n.spira—
process is an articulation of the
tions of the people, which emerge from the existing modes
Going further
of production and production relations,
their
roots in the
still, socio-cultural aspirations have
of human ecology.
Correspondhistory and in the dynamics c- -->
the
fact
that
the
ingly, this approach also underlines
which determine the
very social and political forces, x..also determine the growth
health status of a population,
Thus9 developand development of its health services,
health
service
system.
ments both in health and.. in a 1-components of socio
should be basically considered as
In effect, it leads
cultural and political processes, Virchow had advocated
to the rediscovery of what Rudoli
. that medicine
in the middle of the nineteenth century (Rosen 1958*86).
is essentially a social science I
health service system 9
In terms of formulation of: a
P-ublic
—- Health
parameters, of New
these social and political
and epidemiological perspective|t;o
impart a sociological ?.-technological processes in public health
the managerial and
J
In
words 9 health problems are considered
practice.
1- other
--
23B
not only in terms of the factors determining the
dynamics of their prevalence and incidence in the
entire population, but also in terms of the response
of the people involved to these problems.
It places
emphasis on social meaning of epidemiological para
meters of a health problem (Banerji 1986 a:95-105).
These epidemiological and sociological data are then
used to determine the choice of technology and type
of the administrative system needed to make the
chosen technology accessible to the people.
As
against the conventional approach of subordinating
people to a predetermined package of technology,
here it is the technology which is subordinated to
meet the needs of the people; the approach of New
Public Health requires a social orientation of
technology.
These basic postulates of practice of
New Public Health have been included in the Alma Ata
Declaration (World Health Organization 1978);
inter sectoral action for health; promotion of commu
nity self-reliance by strengthening people's capacity
to cope with their health problems; social control
over health services; use of technology which is
appropriate to the prevailing social, cultural and
economic conditions; integration of promotive,
preventive, curative and rehabilitative services;
and ensuring coverage of the entire population.
The body of knowledge of New Public Health has
thus been generated at two different planes.
One
plane concerns analysis of the wider ecological,
historical, socio-cultural and political forces which
determine the status of health and health services of
a population.
This plane of knowledge includes what
is now called nolitica”1 economy of health and health
services (Mckinlay 1984).
In a sociological frame
work, this would bo called sociology of health and
health services (Banerji 1986a:1l).
it is significant
that studies at this plane have led to the crucial
understanding of the elements which form the founda
tion of the superstructure which is seen as health
and health services of a copulation (Banerji 1985a).
The modes of production and production relations,
social and ecomomic structure, ecological and epide
miological conditions and health culture arc examples
of the major elements which form the foundation,
The
foundation places a constraint on the architecture of
the edifice that can be built on it o
In that sense,
it is deterministic in nature
Any grafted health
programme, which is not aligned to the foundational
structure, is not allowed to thrive.
239
The foundation thus sets limits for health service
development.
The challenge, then, is to build, a sound
edifice within the limits set by the foundational struc
ture. Meeting of this challenge forms the other plane
of generation of knowledge for New Public Health s how,
within the existing constraints, a health service system
can be formed which most effectively deals with the health
problems confronted by the people? It may, however, be
noted that neither the foundational structure nor the more
effective ways of dealing with health problems are static
entities.
They undergo changes as a result of changes in
th , objective conditions.
Therefore, the body of know
ledge also undergoes changes in both the planes.
Iww Public health in the South : The Case of India:
Under real life conditions, practice of Now Public
Health should be seen as a nrocess of shift of focus from
technology to the people.
In this sense, history and
political economy of conventional public health and of
community medicine with its high degree of technocentric
orientation form integral ccmnonents of the political «
economy of New Public Health.
The case of India is taken
here for analysis to elaborate on these and other aspects
of practice of New Public Health.
Even a very brief historical analysis provides
some critical insights into the political economy of
contemporary health service system of India.
Western
Medicine was introduced in India in the wake of the
British colonial conquest of the country in the eighteenth
century.
This led to further decay and degeneration of
the pre-existing health practices.
Concurrently, colonial
exploitation led to further deterioration of the ecological
setting, leading to further increase in disease load on
the masses of the people.
Furthermore, access to Western
Medicine was limited to those who formed the oppressing
class, namely the British rulers and a small section of
the rich natives who sided with the British.
Thus,
advent of Western Medicine along with colonial conquest
led to further strengthening of the oppressors and
further weakening of the oppressed masses of people Access
to Western Medicine was thus used as a weapon for oppression
Predictably, education and practice of Western
Medicine was developed in the imago of the Western or,
rather, the British Model.
The attempt was to produce
British trained Indian physicians who conformed to
Lord Macaulay’s vision of a Brown Englishman.
This pri
vileged class orientation and heavy dependence of the
240
health, services on foreign models was actively promoted
by the new ruling class which came to power after India
attained independence in 1947 (Myrdal 1968:291)♦
Technocentricism continued to dominate.
Availability of
what had then been described as ’magic’ or ’silver’
bullets against widely prevailing diseases like
malaria, tuberculosis, leprosy and trachoma whinped
up considerable enthusiasm in WHO and among other
foreign donor agencies.
India undertook to launch
a number of huge, technocentric mass campaigns against
suchdiseases (Banerji 1985b:95-131).
A still more
massive programme on similar lines was built up to
deal with the population nroblem.
Following a Malthu
sian approach, people became ’targets' of an elaborate
programme of coercion, victim,/blaming, motivational
manipulation and social marketing to make them accept
the contraceptive technology that is handed down to
them (Banerji 1985:186-209). Here, too, there was
a massive participation of foreign donor agencies of
various kinds (Banerji 1985b:243).
A parallel movement for health and health
service development as a component of the wider
anti-colonial freedom struggle has been a remarkable
feature.
Rediscovery of the lost scientific and
empirical elements of the indegenous systems of
medicine, particularly the Ayurvedic and Unani Systems
(Government of India 1948), active involvement of the
medical profession in the freedom struggle (Roy 1982)
and enhancing the capacity of the masses to cope with
their health problems through the training of locally
elected community workers (National Planning Committee
1948), are instances of the issues that had formed a
part of the health movement.
While attainment of
independence saw considerable mellowing of the past
rhetoric and there was a major swing in favour of the
technocentric Western Model, the emerging forces of
democratisation, impelled the political leadership,
despite their class bias, to undertake major steps
tojbring the health services nearer to the people.
Apart from rapidly increasing the number of facilities
for education and training of the needed manpower, a
major decision was taken to give a social orientation
to that education and training (Barter ji 1 985b ; 73-91 ) .
An elaborate nation-wide network of rural health
centres has been developed and now there is a provision
for a sub—centre with a male and a female health worker
to provide integrated, comprehensive health services
to every 5000 people in rural areas (B.anerji 1985b: 255).
241
The decision in 1977 to entrust ’peoples’ health in peoples’
hands’ through training of a health worker for every 1000
population chosen by people themselves, was a still more
important milestone (Government of India 1978).
The
National Health Policy of 1982 (Government of India 1982)
incorporated the philosophy of entrusting people’s health
in people’s hands, with a commitment to ensure that the
entire health service system to be geared to support the
people by responding to their needs.
By asserting that
the contours of the health services are to bo evolved
'within a fully integrated planning framework which seeks
to provide universal, comprehensive primary health care
services relevant to the actual needs and priorities of
the community at a cost which people can afford, ensuring
that planning and implementation of various health progra
mmes is through organised involvement and the participation
of the community*, the policy document provides important
directions for growth and development of knowledge for
New Public Health in India.
As eo,rly n,s in 1959? historical and socio-cultural
conditions had generated propitious political conditions
in India for making systematic efforts to generate a body
of knowledge for the practice of Nev? Public Health.
Showing their concern over the data which showed that more
than nine-tenths of the (then prevalence of over six
million) cases of pulmonary tuberculosis had no access to
the very notent tocls for diagnosis and treatment, the
political leadership got together an interdisciplinary
team of workers at the National Tuberculosis Institute
at Bangalore (NTl) with the specific mandate for develop
ing a nationally applicabley socially acceptable and
epidemiologically effective National Tuberculosis Programme
(NT?) for India (Chakratory 1978), (Sanerji 1985:106-16).
The instinctive response of a group of workers in NTI was
technocentric - let thousands of mass radiography units
filter the huge population of the country to ’catch' the
tuberculosis patients for treatment with chemotherapy
and let there be a Mass BCG- Campaign. However, the NTI
sociologists shifted the focus from the technology to the
people: how do people respond to the problem of tuberculosis?
(Banerji and Andersen 1963)By going to the people, they
learnt that almost all the patients in a community are
’aware* of the disease and that, motivated by the suffering
caused by the disease, more than half of them had sought
treatment in rural health institutions, whore most of the
cases were dismissed with a bottle of cough mixture.
Sociological data were also used for developing a peopleoriented technology for diagnosis and treatment of the
cases under the prevailing constraints and to draw up an
242
/
organisational and management system to embody the
people-oriented technology (Banerji 1971).
Iu subse
quent studies, the sociologists questioned the then
prevailing technocentric definition of a defaulter
and offered a people-based alternative: a defaulter
is one whose actions cause suffering to himself or
others, presently or in the future.
It was shown that
by far the greatest ’defaulters’ are those responsible
for organisation and management of the NTP (Banerji 1970).
There were also major lapses in the definition of a
’case’.
Thus, by giving a technocentric twist to the
definition the victims were blamed, while the main
defaulters got away scot free.
Apart from making the substantial contributions
in the form of providing a framework for formulating
people-oriented national programme in a country like
India, the approach developed in the NTI was also used
for developing new approaches to such extensive areas
as health education (Banerji 1985b:592-93)9 use of
social sciences in health fields (Banerji 1986), inter
disciplinary research in public health (Banerji 1972)
and hospital administration (Banerji 1981).
Thus, NTI
has been one of the pioneering institutions for genera
tion of knowledge for a new approach to public health
practice, where the focus is on the people.
Development of people-oriented approaches for
dealing with community health problems also brought
into focus the powerful role of political and social
forces in determining the degree of implementation of
health services in the country.
In a study on intro
duction of Western Medicine in the village Thaiyur in
Tamil Nadu, conducted in 1969-70, Djurfeldt and
Lindberg (1975:216) concluded that as ’the health
situation in the village is a consequence of the
prevailing economic and political order, both western
and indigenous systems of medicine are equally impotent
in dealing with the health situation; and only a pro
found transformation in the social and economic struct
ure can give people of Thaiyur the means
to improve
their health*. Noting that making programmes for
alleviation of suffering due to health problems access
ible to the oppressed sections of a community can,
atleast to some degree, (a) blunt the use of access to
health services as a weapon of oppression, (b) can
increase their fighting capacity, and (c) offer an entry
point for wider social and political action, Banerji
(1986a:129) has pointed out significant political
243
potential of health service development based on meeting
the felt-needs of the oppressed people.
There are many
other contributions which deal with political economy of
hc-alth and health services (for example, Mckinlay 1984,
Navarro 1976),
Work has also been done on political
economy of specific areas, such as nutrition (Banerji 1978a),
malaria control (Clever 197b), rural health services
(Banerji 1978b)- (Zurbrigg 1984) and family planning
(Banerji 1980).
%
Because of its Malthusian overtones , technocentric
orientation and active efforts to make people accept cont
raception, understandably, the family planning programme
has been an important area of concern among those involved
in giving primacy to people in programme formulation and
development.
In his book, Birth Control and Borc-iyn Policy,
Nicholas Demerath Sr.(l976) has given a vivid account of
the very povjerful foreign agencies in the USA which have
been lending support to a Malthusian approach to family
planning. How ever, from a very early stage there have
also been a number of scholars who had underlined the need
to their socio-economic
to shift the focus to the people
They maintained that poverty was at the root
development.
of ranid population growth and not the result, as expounded
Gunnar Myrdal
by the exponents of the Malthusian school
Asoke Mitra (1969), Ashish Bose(l974)9
(1968:2156-57), P.B. Desai (1983) , are among those who had thrown their
weight on the side of the people.
In their book, Popular
tion and Poverty, Lars Bondestam and Staffen Bergstrom
7*1980) have brought together ideas of a number of scholars
to underline this point.
In a separate paper, Staffen
Bergstrom (1982) had pointed to the pronounced Malthusian
overtones in the Model Plan, which had formed the frame
work for channelling fore:in assistance in the fields of
health and family planning.
Subsequent evaluation of
these programmes has strongly vindicated his assertions
and premonitions (Banerji 1985b:318-20).
In the wake of
the powerful backlash from the intensified family planning
drive during the National Emergency of 1975-77? a policy
decision was made to shift the focus to the people :
motivation for a small family norm was to be generated by
action in social and economic fields, such as health,
nutrition, water supply and sanitation, education, employ
ment and status of women (Government of India 1980).
With a perspective of political economy of family planning,
it is not surprising to find that some basic social struc
tural constraints are coming in the way of implementation
of the new policy (Banerji 1 985b: 237-4 5 ) «>
■»
244
Considerable amount of work has been done at the
Centre of Social Medicine and Community Health of
,Jawaharlal Nehru University (1985) to develop a body of
knowledge for health service development in Indie, with
a focus on the people, particularly the unserved and
the underserved.
The knowledge had become substantial
enough in 1972 to launch an 18-month doctoral level
course work for producing 'Managerial Physicians’ for
implementing concepts based on New Public Health.
Additional work done in the past fourteen years have
further strengthened this academic programme.
Some
concepts of New Public Health also find place in the
curricula for training in other public health insti
tutions in the country.
Considering the political and social implications
of shifting the focus from technology to th., poaplc-, it
is not surprising that doubts should have been raised
about the concepts of primary health care from some
influential quarters in industrialised countries0
They
raised the issues of ’Selective Primary Health Care'
(Walsh and Warren 1979) because they contented that the
goals of primary health care, though highly desirable,
are unrealistic.
They glossed over the fact that
primary health care is basically a philosophy for
health service development, applicable to all the
countries of the world.
The suggested selective
approach is the very antithesis of some of the basic
postulates of primary health care: for example, commu
nity self-reliance, social control over technology and
community involvement in policy formulation, planning
and implementing of health services.
The fact that
certain countries, along with international agencies
like UNICEF, could show such an utter disregard for
the undoubtly weighty arguments against the selective
approach (institute of Tropical Medicine Antwerp 1985)
and could impose a technocentric, dependence producing,
vertical Universal Child Immunisation Programme (G-rant
1985)p provides a manifestation of the awesome power
they command to be able to impose their will on others.
This also explains why the Bhopal Disaster occured and
why those responsible got away so lightly (Banerji1985c).
Struggle for New Public Health has thus to be political
struggle of the masses to wrest their democratic rights
from the ruling classes and their very powerful foreign
supporters ? it has also to be a struggle in the 'field
of public health research and practice, involving use
of a sociological and epidemiological perspective to
develop a managerial and technological system which
ensures subordination of technology to the needs of the
uneorved and the underserved masses.
245
Now Public Health in the North;
Countries of the North have attained remarkably low
infant mortality rates and the expectation of life at birth
is very high.
The ’Medica - Industrial Complex’ has become
so confident about its capacity to handle community health
problems that even the much watered down departments of
community medicine are being dispensed with.
Winslow’s
comprehensive definition of public-health has become as
archival curiosity.
It was Ivan IHich (1977) who dared to
question the role of the medical establishments in the
North as a threat to health of the people, because they
cause iatrogenesis, they medicalise life and they promote
dependence.
He called medical technology addictive and
disabling.
The 1977 Dag Hammarskjold Seminar on Another
Development in Health (Editorial 1978) had underlined
these infirmities in the health services of countries of
the North,
There are additional moral and ethical dimen
sions when it is noted that the Medical/Military Industrial
Complexes are nurtured by the sweat, blood and lives of
numerous human beings of South, because North is able to
extract from them unequal terms of trade, including trade
with perpetrators of appartheid and including comtomptuous
disregard for safety for hundreds of thousand of human
lives, as manifested by the Bhopal Disaster.
It is not
surprising that the North should idolise Bob G-eldofs for
their missionary zeal in carrying out ’charitable ’ work
for Africa and the South.
Ironically, a life of conspicuous consumption in
the North has generated its own pattern of health problems;
alcoholism, drug addiction, mental problems, for example.
Then there are also problems of the poor, of the ethnic
minori'ies, of the elderly and the rapidly rising number
of the unemployed.
Even after cornering the bulk of the
natural resources of the planet through the use of brute
force, different classes in most countries in the North
are widely different in health status and in access to
health resources.
This certainly is not a profile of
throbbing, healthy societies.
There is a great deal that
is sickening.
The task of shifting the focus from technology to
the people in the North is even more daunting? it requires
taming of the Medical/Military Industrial Complex, so that
it is possible to develop healthy public policies, includThis
ing policies concerning the medical establishment,
The North
will require bearding the lion in its own den.
has to go a long way in terms of social and political
Hafdan Mahler
mobilisation to fulfil this important task.
(1986), the Director-G-eneral of WHO, has recently pleaded
246
for New Public Health to move into positive and active
advocacy for health, to enable individuals and commu
nities to develop their health potential.
Illona
Kickbush(1986), his colleague from the European Office
of WHO, contends that New Public Health lies within
three spheres - political, social and public health.
Somehow, both of them seem to avoid confronting the
principal problem of North : the depradations of the
Military/Medical Industrial Complex.
The Universal
Child Immunization is but one manifestation of its
capacity to impose its will on the South.
Even if it
turns out to be crass romanticism, exponents of New
Public Health can be
forgiven if they dream of a
situation where the oppressed people in the South and
the North get together to ncrform the onerous task
of taming this monster!
Summary °.
New Public Health embodies knowledge generated
With
on the basis of according primacy to the people,
their roots in the dynamics of human ecology and
history, health and health service development in a
community is regarded as a socio-cultural process, a
political process and a managerial and technological
process with an epimemiological and sociological
perspective.
Elements such as modes of production and
production relations, social and economic structure
and epidemiological situation go into the formation of
the foundation, which determines the architecture of
the edifice of health service system.
Practice of
New Public Health involves development of a health
service system which, within the existing constraints,
most effectively deals with the health problems
confronted by the people.
Considerable progress has been made in generating
knowledge for New Public Health in countries of the
South.
The case of India is discussed.
Colonial
conquest and formation of the colonial pattern of
health services, which continued to be perpetuated by
the leadership of the post-cclonial period and a
parallel development of concepts and practices for
people oriented health services, which culminated in
the decision to entrust ’peoples’ health in peoples'
hands’ provide a historical backdrop.
Work at the
National Tuberculosis Institute at Bangalore provided
a framework for developing nationally applicable,
socially acceptable and epidemi©logically effective
247
health programmes of the country.
Study of political
economy of population control has led to a strong advocacy
for generating motivation for small family norm through
socio-economic development.
It has been possible to
generate enough knowledge to launch academic programmes
based on New Public Health.
Reacting to the political ^nd
social issues raised, there has also been a counter move
ment.
The Universal Child Immunization Programme repre
sents an effort to go back to the old approach of impos
ing on people technocentric, dependence promoting,
vertical programmes.
New Public Health is also relevant to countries of
the North. ' There is a need for social control over the
medical establishment so that it does not cause iatro
genesis,
medicalisation of life and dependence and it
does not become addictive and disabling.
Confronting
some of the newly emerging problems, providing coverage
to the unserved and the underserved and creation of more
equitous health status are still major issues.
On the
wider plane of North-South relations, there remains the
moral and ethical issue of epidemiological consequences
of unequal terms of trade and social and political
relationship.
References;
1 .
Banerji, D. (1970): Effect of Treatment Default on
Result of Treatment in a Routine Practice in India,
Proceedings of the XXth International Tuberculosis
Conference, Paris, International Union Against
Tuberculosis.
2.
Banerji, D. (1971)5 Tuberculosis as a Problem of
NIHAB Bulletin, Vol.4,
Social Planning in India,
No.1, pp.9-25.
3.
Banerji, D. (1972): Operational Research in the
field of Community Health, Qpgearch, Vol.9, Nos,3-4,
September-December, pp. 135-142.
4.
Banerji, D.(1978a): Political Issues in Health,
Population and Nutrition, Social Scientist Vol.7 y
Nos.73-74, August/September, pp.159-168,
5.
Banerji, D.(1978b): Political Dimensions of Health
and Health Services, Bqcnomic and Political Weekly,
Vol.13, No.22, pp.924-927.
248
6,
Banerji, D.(198O): Political Economy of Population
Control in India, In Bondestam, L. and Bergstrom,
S. (ed): Poverty and Population Control, London,
Academic Press, np.85-101.
7.
Banerji, D. (1981): Hospitals and Promotion of
Community Participation in Primary Health Care
In Aga Khan Foundation ( 1 981 ) ; Proceedings .of the
Conference on Role of Hcsnitals in Primary Health
Care, Karachi, Aga Khan Foundation.
8.
Banerji, D.(1985a): The Making of Health Services
in a Country: Postulates cf a Theory, New Delhi,
Lok Paksh.
9.
Banerji, D.(1985b): Health and Family Planning
Services in India: An Epidemiological, SocioCultural and Political Analysis and a rorsvectiyo.
New Delhi, Lok Paksh
10.
Banerji, D.(1985c): Bhopal Tragedy and Sarkari
Scientists, Economic and Political Weekly. Vol.20,
No.32, August 10, pp.1530.
11 .
Banerji, D. (1986a): Social Science and Health
Service Development in India: Sociology of Boraation of* an Alternative Paradigm, New Delhi,
Lok Paksh.
12.
Banerji, D. (1986b); Technocentric Approach to
Health: Western Response to Alma Ata, Economic
and Political Weekly,. Vol.21 , No.28, July 12,
pp. 1235-1 234.
15.
Banerji, D. and Andersen, S. (1965): A Socio
logical Study of the Awareness of Symptoms
Suggestive of Pulmonary Tuberculosis, Bulletin
of World Health Organization, Vol.29,No.5 ?
pp.665-683.
14.
Bergstrom, S. (1982): Family Welfare as a Health
Need in Indian Population Policy, Tropical Doctor,
Pt.1, October, pp.182-184.
15.
Bondestam, L. and Bergstrom, S. (cd) (1980)
rcverty and Population Control, London? Academic
Press.
16.
Bose, A. et al. (ed) (1974): Population in India's
Development 1947"“2OOO. D e Ih i , Vikas Publishing House
249
17.
Chakraborty, A.K. (1979): Twentieth Anniversary of
NTI - What hrs the NTI Achieved? NTI Newsletter^
Vol.16, No.4, December, pp.104-110.
18.
Cleaver, H. (1976): Political Economy of Malaria
De control i Economic ai 1 Political Weekly^ 7ol.11 ,
No. 36, pp .1463-1473.
19.
Demerath, N.J. (1976): Birth Control and Foreign
Belie//5 The Alternatiyes„jvi„,larnil Planning, New
York, Harper and Row.
20.
(1983): Health and Family Welfare In
Desai, P•B
Bose, A.
P.B ' Studies in Social Dynamics
A and Desai,, P-B.
of Primary Health Care X Delhi, Hindustan Publishing
House, pp.179-200.
21 .
Editorial (197?)S Health and Another Development,
Development DialoCT-0 Vcl.1, pp.1-3A
22.
Government of India, Committee on the Indigenous
Systems of Medicine (1948) • Re-port Vol.1, New Delhi,
Ministry of Health.
23.
Government of India (1978): Annual Report 1977“7.g_x
New Delhi, Ministry of Health and Family Welfare,
pp.i-iii.
24.
Government of India, Working Group on Population
Policy ( 1 980) 2 Report New Delhi, planning Commission.
25 •
Government of India (1982): Statement on Dgition^l
Health Policy, New Delhi, Ministry of Health and
Family Welfare.
26 .
Grant, J.P. (1985): Universal Child Immunization by
1990, Assignment Children, 69/72, pp.3-14.
27.
Illich, I. (1977)? Limits to Medicine - Medical
Nemesis 2 The Ex-prc-priotion of Health,. Penguin,
Harmondsworth.
28.
Institute of Tropical Medicine, Antwerp (l985a)_:
29-30.
Meeting on Selective Primary Health __Care November
--Belgium,
Institute
of
Tropical
1985. Proceedings, Medicine.
29.
Centre of Social Medicine and Community Health (1985):
Information Bulletin 1985, New Delhi, CSMCH, JNU.
250
50.
Kickbusch, I. (1986): Introduction to the. Journal,
Health Promotion, Vol.1, No.1, May, pp.3-4.
31
Mckinlay, J.B. (1984/» Issues in the Political
Economy of Health Care, London, Tavistock.
32 o
Mahler, H. (1986): Towards a New Public Health,
Health Promotion, Vol.1, No.1, May, pp.1.
33.
Mitra, A. (1969) s The Small 1'amily Norms and
Literacy, Family Planning* News, Vol.10, No.2, p.6.
34.
Mytdal, G-. (1968): Asian Drama :
Inquiry into
the Poverty of Nations, New York , Twentieth
Century Fund.
35.
National Planning Committee , Sub-Committee on
National Health (1948): Report (Sokhey Committee
Report), Bombay.
36.
Navarro, V. (1976): Medicine Under Capitalism.
New York, Pradist.
37.
Rosen, G-. (1958): History of Public Health,
New York, M.D. Publications.
38e
Roy, B.C. (1982): Future of the Medical Profession
In India - Reprint of Presidential Address at the
All India Medical Conference, Lahore, December 1929,
Journal of Indian Medical Association, Vo1.78,
pp. 24-30.
39.
Walsh, J.A. and Warren, K.S. (1979): Selective
Primary Health Care: An Interim Strategy for
Disease Control in Developing Countries , New
England Journal of Medicine, Vol.50,pp.964-967.
40.
Winslow, C.E.A. (1920): The Untilled Fields of
Public Health, Science, No.8, 51, pp.23-33.
41 .
World Health Organization and UNICEF (1978);
Primary Health CaresReport of the International
Conference on Primary Health Care, Alma-Ata, USSR,
Sept.6-12. 1978, Geneva, WHO (WHOHealth For All
Series No.1).
42.
Zurbrigg, S. (1984)°. Rakku1 s Story: Structures of
Ill-Health and Source of Change, New DeIhi, Voluntary Health Association of India.
251
------- ON -. HEALTH AWARENESS,
IMPACT OF COMMUNITY FINANCING
COMMUNITY PARTICIPATIONt & UTILISATION OF PREVENTIVE HEALTH
SERVICES
by
A. Dyal Chand
Primary Health Care has been defined as 'Essential
health care 000 made universally accessible ..coo at a cost
that the community and country can afford oo»
'Such health
care requires and promotes community and individual self
reliance and participation -a-e o <» □ » making fullest use of
local, national and other available resources’ <>
The P.HoCo approach may be characterised as
embodying three basic ideass
- that the promotion of health depends fundamentally on
improving socioeconomic conditions, and in most parts of
the world, on the alleviation of poverty and underdeve
lopment;
that in this process the mass of the people should be both
major activists and the main beneficiaries;
• - i should be restructed to
that the health care system
activities
at the primary level, because
support priority
the
most
urgent
health needs of the
these respond to
peopleo
(1)o
Two other complementary issues have been.
emphasised in the PHC approach. One stresses mobilisation
and effective application of underutilised national and
local resources. The other emphasises the development of
affordable and culturally appropriate delivery systems to
make health care universally accessible, Both movements
rely heavily on community participation, the first beacuse
potential organisational, labour and cash resources are
underutilised, and the second because ttw demand for health
care - the ultimate expression of affordability and
appropriateness - must come from beneficiaries rather than
from outsiders. (2).
Since 1977, the Indian Government is carrying
out an initiative, to train one TBA*and one community health
worker for each village - a total of 580,000 TBAs and the
same number of community health workers. (3) »
* Traditional Birth Attendant
252
It was decided to pay the CHWs a stipend of
Rs o 50.00 a month. As early as in 1978, however, there
were reports that CHWs were dissatisfied with their
modest honorarium of Rs. 50/- per month.
They demanded the same payment as Multi
purpose Workers (MPWs). The government responded by
emphasizing that CHWs were not government employees, but
representatives of the people and social workers. They
were paid only a small honorarium because their health
work was only part-time. Yet the CHWs continued to
agitate for higher remuneration and a recognised place
in the health service itself. There were reports from
different parts of the country of CHWs trying to form
their own unions. The Ministry of Health rose to the
occasion and in 1979 produced a curious administrative
solution. They simply renamed the programme the Community
Health Volunteers Scheme. The change of nomenclature
from 'worker' to 'volunteer' was intended to disabuse
recalcitrant CHWs of any notions that they were government
employees or that they deserved anything but a modest
honorarium for their work. (4).
The Scheme continued to limp along until
June 1981, when the government once again made a name
changes the Community Health Volunteers Scheme became
the Health Guides (HG) Scheme. The Ministry also issued
new guidelines emphasizing and clarifying the responsi
bility of HGs to the community. Village Health Committees
were to be established in order to better manage health
activities. Mindful of the row about CHWs' honorariums
and status three years earlier, the guidelines made it
absolutely clear that the HGs were not government
functionaries. (5).
'The Health Guides and the Village Health
Committees are to be treated and honoured as representa
tives of the Village community, who have come forward
to assist the Government in the implementation of the
Primary Health Care Programme. In no sense whatsoever
are they to be treated as subordinate to the Health
Organisation or subject to its commands and orders'
(Government of India 1981).
Evaluation of the programme reveals that
despite its weaknesses it has resulted in changes in
health consciousness and health status, and the
Government, in the 5-Year Plan announced in 1984, reaffirmed its resolve to continue with the
programmes. (6, 7, 8).
253
Parallel to government efforts several
voluntary organisations have been experimenting with
alternative strategies in implementing Primary Health Care.
Community financing is one of the areas of concern where
several health projects hav .• been experimenting with various
methods. Over 100 such innovative projects in 40 different
countries were reviewed' by the American Public Health
Association in 1982. (Of. the 100 projects reviewed by APHA
11 were from India.
Attipra Dispensary - Govt, programme
Io
Comprehensive Health & Development Project, Pachod,
2 o
Dist. Aurangabad.
3. Barpalli village service.
4 o Christian Rural Health Programme - Orissa.
5O Co-operative Rural Dispensaries, Kerala - Govt.programme.
6 . Howrah Contraceptive Depots, West Bengal - Govt.programme.
7 . Comprehensive Rural Health Project, Jamkhed, Dist.
Ahmednagar.
8. Kottar Social Service Society, Tamil Nadu - ICMR.
9 . Lalitpur, Uttar Pradesh - ICMR.
10. Maharashtra Arogya Mandal, Pune..
11. Mallur, St.Johns Medical;College Bangalore,
These projects are, serving populations from
5000 in Mallur to 2,600,000 in Howrah, Wiest Bengal. (9).
The various forms of community financing that
have been experimented with by various projects are listed
below:
Form of payment
Method
1. Fee for Service
2 o Drug Sales
3. Personal prepayment
•4. Production base pre
payment
5. Income generation
6o Community labour
7. Individual labour
8. Donations and adhoc
assessments
9. Festival raffles etc.
CHW compensation. Recurrent.
CHW compensation, Recurrent.
CHW compansation, sometimes
Hospitalisation, recurrent.
CHW compensation, sometimes
Hospitalisation, recurrent.
CHW compensation arid drugs,
recurrent or one time.
Facility construction,one time.
Recurrent, labour.
Facility construction, or
community project, one time.
Facility construction, one time.(10)
The summary conclusions of the APHA evaluation
...
‘
Community
financing requires great organisational
were
and managerial spade work, and its ultimate yield may be small
in relation to total primary care costs. The peoples'
ability and willingness to pay must be ascertained, both in
the aggregate and for individuals at differing sooio2 54
economic levels. The Alma Ata Declaration lists eight
elements of Primary Health Care, but individuals appe r
willing to pay only for curative., services, not for
prevention or community activities.
Curative services, though politically
essential, have little lasting effect\ on health status,
may
and expensive educational
(------------------- efforts
---- be, required to
' ' i.
The
convince communities to pay for prevention
challenge is to find a balance between government.and
community finance - to use the former for professicnally perceived priorities and the- latter for loca±ly
felt needs. (11)»
Whereas 'Community Financing is at best
v
_ly
a
partial
solution to the problem of health care
only
finance, its impact on community participation, utili
sation of health services, response to preventive health
services has not been researched.1 (12).
Studies of successful community finance
must both process and outcome.
The Comprehensive Health and Development
Project, Pachod, Dist. Aurangabad, has been researching
various methods of community financing for primary
health care since 1977.
Comprehensive Health and Development Project Pachod(CHDP)
Backgrounds
The C.H.D.P., Pachod, is based in one of the
more under-developed areas of rural Maharashtra. The
project began in 1977, and is providing Primary Health
Care to a population of 50,000 in 47 villages. The
average size of a village is 1000 population. One
traditional birth attendant and one
community
health worker have been trained in each village.
The project area is divided into 8 sub
centre-areas, each with a population of 6000o There
are 8 male multipurpose workers, one for each of
these sub-centres, and 4 female multipurpose workers
(A.N.Ms) one for 12,000 population. The female
M.P.Ws and TBAs function as a team providing maternal
and child health services and family planning. The
male M.P.Ws and CHWs function as a team and provide
child health and all other primary health care services
including family planning. Both preventive and
curative services are being financied by the community.
255
The study on community financing for preventive
services were based on the following objectives;
1. To study if resources can be mobilised, in a rural
community, for preventive health services.
2 o To study the possibilities of generating community parti
cipation for a preventive service provided at the
community level.
3O To study quantitatively the ability of community based
health workers to generate demand for preventive
services - immunisation of children under age 5.
4 „ To evaluate the effect of a quantified amount of health
education on the changes in knowledge, attitudes and
practices of a community.
The hypotheses of this study were;
1.
lo Even the underprivileged in a rural community will be
willing to pay for preventive health services if the
demand can be created through appropriate health education
2O Given the incentive of direct and immediate reimbursement
for their initiativet community health workers would
educate the community to create such a demand for
preventive services»
3. Provided with appropriate skills, community health
workers would be effective educators, not necessitating
the use of expensive educational efforts«
4. Reimbursement directly from the- community for services
rendered would make CHVJs accountable to the community
rather than the Health Systern»
Methodology;
Immunisation services were provided by the
project on a mass campaign basis. Community health workers
were utilised to register children whose parents agreed to
avail of the service. The CHWs were also instructed to
involve their communities in the registration process and in
preparing for facilities for the mass immunisation campaign.
The children that had been registered were immunised on a
single day. The immunisation team visited each village on
4 subsequent occasions at monthly intervals tc> provide the
second and third doses, including mopping up operations.
In 1979 a Knowledge, Attitude, Practice (KAP)
study was conducted to assess awareness regarding D.P.T.
immunisation. In 1980 parents of children were contacted
personally by the CHWs and given health education on DPT
education
immunisation. Following a fixed period of healh d
—
256
described in detail later a KAP survey was conducted
again to study changes in concepts of the community and
comprehension of messages in the health education. Mass
immunisation services were provided free cf cost and the
utilisation rate wqs monitored.
In 1982, three years later, a KAP study was
conducted to assess the awareness regarding Polio
immunisation. Following this parents of children under
age 5 yere contacted personally and given health education
regarding polio immunisation. The strategy of health
education used in 1979 for DPT vaccination was repeated
for polio immunisation, so that comparisons could be
made. This was followed by a KAP survey to study changes
in concepts and assess the level cf comprehension cf
health education messages. Mass polio immunisation was
provided, but this time the parents were charged a
nominal fee for this service. The method used to assess
the ability and willingness of the community to pay for
this service is discussed later in this paper.
The community health workers received the
entire fee for services paid by parents as a reimburse
ment for educating and metivoting parents and registering
children for the immunisation programmeo The response
rate for polio immunisation and payment for the services
were monitored as before. The same strategy of mass
immunisation that was used for DPT was repeated for polio
immunisation.
Health Education and Motivation cf Community Quantified
The health education campaign for both the
immunisation programmes began 3 months prior to the
actual vaccination of children. During the first month
pamphlets were distributed twice and their impact
evaluated at fornightly intervals.
During the second month the CHWs gave
informal education regarding immunisation by word of
mouth to parents of children identified as eligible
candidates for vaccination. The impact of this was
evaluated through a KAP study. Finally, just before
the vaccination the village announcer made announcements
in the village twice.
One day prior to the immunisation programme,
in each village the CHW of that village was asked to give
identification slips to parents of eligible under-fiveso
The CHWs were also asked to collect the service fee from
the parents. Even though this was not a part of the
health education strategy it was felt that it had a
considerable motivational impact on both the CHWs as
educators and on parents to utilise the immunisation
services <»
257
It was felt that the CHWs would have put in
considerable effort in educating and motivating parents
because of the obvious benefit of immediate reimbursement
for this service. Once the parents had paid the required
fees they were motivated t bring their children for
immunisation. Even though this process of education, moti
vation negotiation for the fees and actual transaction
could not be observed and evaluated, it is believed it had
an important motivational impact.
Each village was thereby exposed to the same
message 6 times by three different vehicles. Twice by a
printed pamphlet, twice verbally by the community health
worker visiting households individually, and twice by the
village announcer by means of general community contact.
This way a minimal input was required of the project
health staff. Distribution of pamphlets, health education
during household visits, arrangement for village announcer,
were all done entirely by CHWs in their own villages *
Similar procedures were adhered to during the
DPT vaccination in 1980 and subsequently during the polio
vaccination in 1982. In 1982 during the polio immunisation
the CHWs were instructed to collect Re.1.00 per dose from
each parent when they were registering children for the.
immunisation programme. They were allowed to retain thrs
as a reimbursement for their services. This was the only
difference in the strategies employed for the DPT and polio
immunisations. Response rates for the two immunisation
programmes are presented in Table II.
A fortnight after each immunisation programme
had been completed a second KAP study was conducted to
evaluate the health educat'on and immunisation strategy.
The findings of the final evaluation and KAP test are
presented in Table III.
Community Participation Defined
Community meetings were held in 1978 to
determine community response to immunisation programme.Once
the community of a village decided that they wanted the
immunisation programme, community representatives were
requested to prepare lists of under-fives in each village
and to determine the proportion immunised prior to the
immunisation programme.
258
Community representatives chosen in each
village help the CHW in registering the children for
the immunisation programme. Announcements in the village
are arranged by the village panchayat, and the community
provides the building, sterilisation facilities and
volunteers to organise the immunisation of children.
Methods used to Assess Ability and Willingness of the
Community to Pay for Preventive Serviceso
Parents of all children under five years
were told that a nominal fee would be required, and were
asked what they would be willing to pay towards this
service. The amount decided in the majority of villages
was Re.1,00 per dose of polio vaccine. This decision
was based on an informal house to house survey of land
less labour families (under-privileged) by the CHW and
upon group discussions organised by them in their
villages,
H ca1th Awareness Quantified
Awareness regarding diphteria, pertusis,
tetanus and polio, and their immunisation was quantified
as follows:
le Diseases against which immunisation was being introduced,,
2 Signs and symptoms of the disease„
3o Cause of disease,
4. Immunisation available or not for prevention.
So Dosage schedule.
If respondents answered all 5 questions
they got a score of 5 (complete positive)„ A score of
3-4 indicated partial positive response, and a score
of 0 - 2 indicated a negative response.
Cost Analysis:
It cost Rs,150/- ($ 15,00) to have 10,000
pamphlets printed. This was the only additional input.
In terms of paid personnel ho additional time was
allocated for this purpose. The cost of increased time
and effort of the community health workers has not been
analysed as yet.
^59
Willingness and ability to Pays
In 1982 when the polio immunisation service
was offered for a fee for service it was felt that some very
poor households may want to avail of the services but may
not be able to afford it. Whereas the willingness to pay
for this service had been ascertained through personal
contact with all the families belonging to the landless
labour class it was necessary to study the ability of these
families to pay this amount. Following the polio immunisa
tion a study of non-utilisers was conducted to determine how
many had not availed of the service because of monetary
reasons (Refer Table TVi. Of the households interviewed
73.7% children had received oral polio vaccine and 26.7% had
not. Of the 26.7% who had not received OPV 20% said it was
due to moneraty reasons.
From the analysis it is seen that 1079 parents
of 1800 children were' interviewed (randomly selected). Out
of 1800 children 1327 (73.7%) had received OPV and had paid
for the service. 473 children did not avail of polio
immunisation. A 50% random sample (230 parents) out of the
non-beneficiary group were interviewed, and 20% (46 out of
230) responded that they did not avail of the service for
monetary reasons.
It could be concluded that 4.8% (87 out of
1800) children could not be immunised because the families
were financially unable to pay for the service.
These families were later covered by immunisa
tion services offered at half the cost levied the first
time. (See Table IV b).
In 1978 a base line survey was done to establish
socio-economic and literacy levels, immunisation status of
children prior to starting the project and proportion of the
population in the age group 0-5.
Since this study was concerned with community
financing, impact of health education through KAP studies
and on immunisation of under-fives, the relevant tables
from the base line survey are reproduced as follows?
ao Age composition of populations
11.93% of population - age 0-5.
260
I
b . Socio-economic status s
i. Land ownership
30.59 are landless labourers21.90 own 5 or less acres of land, and are
essentially labourers
Total; 52.49%.
ii.Occupation
49% households responded that they were either
agricultural or construction labourers.
c 8 Educational status;
54.78% male and 83.70% female population were illite
rate (unable to read or write).
d
Immunisation status of children 0 - 5 in 1978;
Less than 10% for DPT and Polio.
e . Awareness regarding DPT and Polio;
Less than 12% of the population.
Baseline Survey 1978
1. Project Areas
No.of villages;
No.of hamlets;
Total;
No.of households?
No.of households?
45
33
78
- . . .7
10527
1622
12149
2. Simple Random Sampling; 1215 houses selected randomly.
Each household represented a nuclear family.
Average number of persons per household; 5.4
3o Population Characteristics
a. Z-ige Compositions
Age Group
0
1 - 4
5 - 9
10 - 14
15 - 29
30 - 44
45 - 59
60 - 64
75 - +
% of total PopIn
2.75
9.18
15.09
13.92
24.98
18.64
10.68
4.25
0.51
Total
lOOoOO
261
bo Socio-economic Status
b.i.) Land Ownership
Land in Acres
Nil
< 5
5 - 7
8;
10
11 - 15
16 - 25
26 - 35
36 - 50
50 +
% of Households
30.59
21.90
14.18
10o..55
9.04
7.98
2.93
0.98
1.84
Notes 30.59% of households are full-time agriculture or
construction labourers. Those with 10 acres or less
work as labourers for 6 months of the year or more.
b. ii) Occupation
Name of Occupation____ ‘% of Households
a}Farming
b) Agricultural labour
c) Construction & otherlabour
d) Animal husbandry
e) Plantations
f) Trade, commerce or
industry
g) Others(includes
services)
Total
262
40
42
7
2
2
4
3
TOO
c. Educational Status of the Population age 5 and above;
J Educational level__________ Male %
Female %
Total %7
54.78
a) Nil (Illiterates)
1.06
b) Literates. (Non--formal
Edi on)
9.86
c) Primary (Upto 3 years)
21.15
d) Middle (Upto 7 years)
6.83
e) Non-rijiatric (Upto 10 yrs)
3.29
f) S.S.C.(Upto 11 years)
0.40
g) Intermediate (Upto
12 years)
0.15
h) Undergraduates (Upto
14 yrs)
1.02
i) Graduates(Upto 16 years)
0.11
j) Post-graduates (upto
18 years)
0.07
k) Technically qualified
1.28
l) Others (not specified)
100.00
I
TOTAL
83.70
0.41
69.17
0.73
4.91
7.38
0.70
0.41
7.40
14.30
3.78
1.85
0.20
0.07
0.7
0.55
0.06
2O42
0.04
1.85
100.00
1007700
Literacy Rate (ages 5 and above)
45.22%
1) Male
s
16.30%
2) Female s
30.83%
Total s
d. Immunisation Status of Children Under Age 5 in 1978s
I Immunisation
Smallpox
B.C.G.
T.T.
D.P.T.
Dose .1
2
3
e) Polio
Dose 1
2
3
a)
b)
c)
d)
Infants
1-4 yrs
5-9 yrs
10-14 yrs Total for
%
Age 0-5
_______ only - %
99.62
98.00
17.15
18.14
1.10
0.11
%
%
%
93.09
7.14
0.60
96.51
20.21
1.: 3
99.78
21.52
0.86
7.74
4.76
2.98
11.78
11.78
9.94
6.42
5.67
4.50
2.64
2.41
2.41
10.84
10.15
8.23
5.36
5.36
2.38
15.47
12.30
11.07
7.17
6.64
5.14
3.87
2.64
2.53
13.17
10.70
9.05
e) Awareness regarding DPT in 1979 and polio in 1982 Response to KAP Questionnaire;
Immunisation
% Positive Response
D.P.T.(1980)
Polio (1982)
12.67
11.85
£63
Table I
Dissemination of health education messages
through the media of printed pamphlets studied by means of
comprehension tests in 1980 for DPT, and in 1982 for Polio
immunisation.
Response□ to written health education messages
Printed pamphlets without simultaneous informal verbal
health education, Comprehension test done in 13 randomly
selected villages in 1980. The same villages surveyed in
1982.
I.
(a) Houses listed by level of literacy
Year Compre
hension Test
conducted
1980
1982
I.
1980
1982
39.3%
45 o 4%
Positive
Positive
No. of
Households Response response
Interviewed to prin
ted
message
X = 71.26
71o8
1894
2639
P = <.0001
X
= 83.14
76.2
2230
2926
p== 4.OOOI
(c) Literate and Illiterate families analysed separately
Tyear Compre- No. of iltension test literate
conducted
households
interviewed
1980
1982
1036
1328
% lite
No. of
families rate
with more families
than one
literate
member
60.7%
1603
54.67o
1598
(b) Response to Printed Messages
Year Compre
hension test
conducted
I .
No. of
% illifamilies terate
with no families
literate
member
1036
1328
Positive
response
to
printed
message
557
789
264
% Posi- ,
%
No. of
positive litera- Posi- tive res
response te fami tive ponse
resp.
lies
to
inter
prin
viewed
ted
message
83.4
1337
1603
53.8
90.1
1441
1598
59.4
Table II
Utilisation rates for DPT (1980) and Polio (1982)
vaccination in 13 villages of project areq-o
Y ear
No. of
No. of
villages house
in
holds
sample
in
sample
1980
13
4312
22475
2639
52%
1982
13
4791
25943
2926
77.2%
Popula- No. of
tion in child
sample ren
villa under
ges
5 yrs.
X2 = 389.34
P =
Range
% of
child of U-5s
ren
immuni
immu sed in
nised 13
with 3 villages
doses
33.9 to
65.1%
52.6 to
90%
< .001
Note: DPT immunisation in 1980 was provided free of cost.
Polio immunisation in 1982 was provided at a fee
for service of Re.1.00 per dose. This amount went
to CHWs as reimbursement.
Table III
KAP test conducted one month after completion of both
Itnmunisation programmes. DPT (1980) # Polio (1982)
Year
No. of
villages
in
sample
No. of
house
holds
in
sample
CompletePartialNoga Total
positive positive tive
response response resp.
1980
13
981
77(7.8^‘)
1982
13
1079
177(16.4%) 600
(55.6%)
X2 = 215.8
P =
314(32%) 590
981
(60.1%)(100%)
302
1079
(27.9%)(100%)
<.0001
Note: 5 questions asked in KAP test.
Score: 1) Complete positive response = 5 correct'?
answer^
2) Partial positive response = 3-4 correct
answers
3) Negative’response
= 0-2 correct
answers
Note: Households with children under 5 years were
selected in the sample for the KAP test.
265
Table IV
a 7)
Utilisation rate for OPV
1982
No. of
house
holds
inter
viewed
No. of
children
in house
holds
that were
inter
viewed
No. of.
children
who had
received
OPV
% of
children
who had
received
OPV
1079
1809
1327
73.7
No. of
children
who had
not
received
OPV
% of
children
who had
not
received
OPV
473
26.3
Of the 473 children who had not received OPV
230 (Approx. 50%) were sampled and interviewed to determine
reasons for not taking OPV. Parents of these 230 children
were interviewed with an open ended questionnaire.
b)
' iVillage Reasons for not taking oral polio vaccine
Sr. No, Monetary
problems
1
2
3
4
5
6
7
8
9
10
11
12
13
1 Total
%
7
6
2
5
7
5
Were not
aware of
service
14
15
5
Not pre
sent in
village
at the
time
12
11
9
5
5
4
6
1
2
1
4
4
5
14
4
1
6
5
6
46
86
20
36.1
6
4
Child
sick
at time
of immu
nisation
Total
No. of
families
3
8
1
36
40
17
5
16
18
12
28
14
2
12
15
15
59
4
3:
2
6
1
5
6
3
42
230
25.6
18.3
100
2
5
Limitations of Studys
Ideally the study design could have introduced
immunisation service free of cost in one area and for a
service fee in another area.of the project, However,
since the service fee was linked to-the reimbursement
of the CHWs it was felt that differentiating between
CHWs with regard to reimbursement systems would be a
divisive force. Since the cohesion and sense of
association among these community based women is a
very important factor in establishing group norms and
expectations it was decided not to introduce different
reimbursement systems amongst them.
The decision was taken to study the effects
of community financing by holding every other factor
constant and introducing two different immunisation
programmes at 2 points of time - offering one free and
the other for a service fee. For this reason DPT
vaccination was introduced as a free of cost service
in 1980z and polio vaccination was offered for a
service fee 2 years later in 1982.
It is possible that the differences in comm
unity response to the two immunisation programmes could
have been influenced by factors other than community
financing alone.
Firstly the CHWs had two years more
experience when the polio immunisation was introduced
as compared to the DPT immunisation programme.
It is possible that the general health
consciousness had been raised because of the routine
activities of the Project and the increased response
to utilisation of polio immunisation services cannot
be entirely attributed to a greater initiative of CHWs
and the community or to the impact of community
financing. However/ the KAP survey in 1982 just
prior to the polio immunisation programme showed that
awareness regarding polio and immunisation against
polio existed only amongst 11.85% of the respondents.
It was concluded that the increase in awareness (72%)
following the immunisation programme was because of
the health education provided by the community health
workers.
261
Communication amongst a rural community is
informal and verbal, but community health workers do need
some audio-visual aids. The impact of pamphlets used as
audio-visual aids has been shown in Table Io
Impact of Health Educations
degree of dissemination of
There was a high
.
>
distribution
of printed pamphknowledge by house to house
Families
with
no
literate
member
took the
lets alone
•
*
■
•
)
have
it
read
to them.
pamphlet to literate neighbours to
families
responded
positively
when
Over 70% of the
interviewed about the message contained in the pamphleto
The message in the pamphlet was reinforced
.^^agos
by verbal messages given by the traditional village
announcero Parents
1--- - were able to associate the verbal
with
the printed pamphlet they bad received.
messages
The increase in utilisation rate in 1982
for the polio immunisation, it was concluded, was due to
. ’ by
y CHWs
and their ability
the increased awareness created
<
also"concluded
that the impeto motivate parentso It was <--- of
direct
reimbursement
tus in their initiative was because
by the beneficiaries•
The total utilisation rate increased from
52% for DPT in 1980 to 77% for polio in 1982.
The K&p study conducted after the two
immunisation programmes showed that comprehension
retention after polio health education was greater than
after DPT. Partial to complete positive response was
obtained from 70% respondents after polio as compared to
4 0% respondents after DPT. It was concluded that the Cri/Js
increased initiative in educating and motivating the
community was responsible for this.
Impact of Fee for Service Strategys
From studying the utilisation rates and
interview responses it was concluded thau 95»2% of
oarents of the children that were immunised had the abil
S Slingness to gay for the service, only
that monetary reasons were primarily responsik
children not availing of this service. This is contrary
to the popular belief that , the under-pnvileged_ in rural
areas arc incapable- or unwilling to P&y for health
services
□
services# particularly preventive l
__.-
268
y
The impact of community financing on the
performance of CHWs was measured through general
observation of their worko They showed more interest
and exhibited qualities of leadership and initiative
which were not apparent earliero
Conclusions and Policy Implications
In India CHWs are being reimbursed by the.
governmento They receive a token amount as ’honorarium’
for services they render to their communitieso This
reimbursement is linked to abstract activities which
cannot be measured such as number of health education
talks given per month, number of couples eligible for
family planning motivated etc. They are neither
accountable to their own community nor to the health
system which reimburses them.
If the reimbursement of CHWs is linked to
out-come instead cf activity, and primarily to preven
tive services they will create a demand for these
services in their communities by increasing the aware
ness of the community for the services introduced.
Direct financing by the community leads to
an increased initiative of CHWs in providing health
education and in involving the community in the
organisation of these services»
Cost Implicationso
Health education strategies which often
require expensive educational inputs or intensive
personnel involvement are not practically applicableo
By giving impetus to local community
initiative through involvement of community health
workers and encouraging community financing towards
their reimbursement, substantial resources can be
mobilised within the community, without the
necessity of increasing direct government health
spendingo
269
Why Pay?
By linking the reimbursement of CHWs to
that CHWs will take
preventive services it can be expected
<_ v
•
--;
-■a
4
x-j
health
education tor
increased initiative in providing Lresulting in subcreating a demand for these services
l---stantial changes in health awareness and behaviour (i.e.
use of immunisation services)»
Who Pays?
It would L
bej particularly inequitable if those
who can afford these services at the healtn centre can
receive them free of cost , and those who cannot are made
to
to pay
pay for
for these
these services
services albeit at their own door Suepo
If the policy of charging[ a nominal fee for services
by CHWs is considered the same consideration
pre ;vided
.
should apply to services provided at the health centre«>
Pay for What?
If community financing for services rendered
that they may . become
by CHWs is encouraged it is
— possible
K
icines for minor ailments.
ailmentSo Curative
dispensers of medicines,
services have little lasting effect on health status.
Besides with the charges that CHWs were allowed to take
only limited resources can be mobilised through curative
services, F^r preventive services where the entire
community is mobilised to pay for a service, larger
resources can be mobilised. CHWs may consider such returns
worth the increased effort they have to put for extending
such service.
Implications of Research Findings2
Community health workers have been ^ble to
mobilise Rs, 125 - 150 per month from their communities.
This level of community financing has been sustained over a
period of 4 years, 1982 to 1985, Several preventive PHC
services have been added to the list which are being
financed by the community,
1, All immunisations including measles.
2, Six monthly vitamin A supplement.
3, Growth charts for under-fives,
4, Oral contraceptives.
5, Minor ailment treatment.
2 70
The project pays workers for needs
perceived by it, such as
1.
2.
3.
4.
Neo-natal survival.
Eligible couples motivated for family planning.
Growth monitoring of children.
Environmental sanitation.
The community finances those preventive
and curative services which are high on their priority
1 ist o
Apart from the financial implication the
rapid dissemination of health awareness,
awareness. the increase
in motivation of .community health workers, and the
increase in utilisation of preventive services as a
consequence of community financing make it an attrac
scalee
tive proposition to experiment with on a larger
7
REFERENCES
1. Segall, M.M., 1983 'Planning and politics.of
resource allocation for primary health care;
promotion of meaningful national policy' ■
Social Science, and Medicine, Vol.17,No.24, 1947-60.
2. Wayne Stinson, Community Financing of Primary Health
Care.
PHC Issues series 1, No.4, APHA, 1982.
3. Ghoshal, BoG., and Bhandari, Vinod, Community_Hea1th
study. Directorate General of
Workers' Schemes a s_tudy
Health Services, New Delhi (1979).
4 . Bose, Ashish et al. Limits to medicine. Social
Dynamics of primary health-care in India.
5 o
Government of India, Ministry of Health and Family
Welfare, Guidelines ^_for_the Health .Guide^^Scheme,
New Delhi (1981)□
271
6.
7 o
Dandekar, Kumudini and Bhate,
- '
Rural Health Services Schemes
and Political Weekly, Bombay,
r,p. ' 2047-52-( 1978; .
Vaijayanti, Maharashtra
--i evaluation.
<-n
c-----• Economic
—
Vol.13, No.50,
National Institute of Health & Family Welfare, an
Health workers Scheme - a
evaluation of Community
(----collaborative study.
NIHFW Technical. Report No.4 0 New Delhi (1978).
8.
National Institute of Health & Family Welfare, Repeat
evaluation of Community Health Volunteers Scheme 1979: a collaborative study. NIHFW, New Delni (1979).
9.
Wayne Stinson, Community Financing of Primary -lealth
Care.
PHC Issues Se_ries 1, No.4, APHA 1982
10. Ibid.
11. Ibid.
12. Ibid.
*
*
272
*
*
■
•
•
■.
DISCUSSION
Manisha Gupte introduced the session on •Alternatives for
Effective Implementation*. She pointed out the relevance of
the theme in the context of the several experimental models of
health care that had been developed in India, and that had
influenced national policy making.
To what extent had these
models been able to generate alternative strategies for
effective health care? Were they replicable on a'large scale?
What were the other broad strategies that needed to be consi
dered in view of the developments in health policy since the
ICSSR/ICMR Report?
The background papers, as well as the discussions in the
preceeding sessions, had highlighted four categories of alter-
natives s
I. Techno-managerial strategies, including the bifurcation of preventive and promotive from
(i)
curative health care as suggested by Dr. Sujit Das’
(ii)
paper;
better implementation of the existing health care
services and better utilisation of health resources;
and,
(iii) the reallocation of resources within the health
sector in the context of the on-going debate regard
ing the merits of rural-based, low technology,
preventive and promotive health care as against
urban-based, high technology medical services.
II. Political decision making and governmental action in the
field of health policy. This included(1)
rethinking the emphasis on family planning as it had
over-shadowed the delivery of health care and the
utilization of health services;
273
(ii)
providing health insurance;
(iii) formulating a 3-tier health care system as suggested
by Dr. Sujit Das;
(iv)
formulating and implementing a rational drug policy,
as highlighted by Dr. Ekbal's paper.
(v)
nationalising the health services, i.e. private
practice and orivate drug industry; and,
(vi)
freezing the production of doctors and drugs.
These were all controversial issues and needed a thorough
discussion.
III. Non-health actions which included-
(i)
reforms ranging from female literacy and universal
education to increasing public awareness through
the mass media, and through more active media
participation by medicos;
(ii)
meeting basic needs such as food, water, sanitation
and an unpolluted environment;
(iii) tackling more fundamental issues such as employment
and wages;
(iv)
mobilising the people to demand health as one’s
right, as stated in the papers by Dr. Das and
Dr. Banerji.
This last point was linked to the
fourth set of strategies namely people’s
participation o
IV.
People's action:
Here the central point was, what was
meant by people’s participation?
(i)
At what levels did participation take place? As
vigilant consumers; as implementors and administra
tors; or as decision-makers. The last called for
a redefinition of the relationship between the
state and the people. Did community financing of
primary health services, as suggested by Ashok
Dyalchand constitute participation?
274
(ii) What did the phrase autonomy to the people mean in
terms of the nature of government controls and the
nature of authorities to be delegated to the people.
The.presentation pointed out the variety of viewpoints on
people’s participation in the background papers.
Dr.Sujit
Das’ paper stated that only the providers, and not the recipi
ents, were participants since the latter had no control over
other areas of their existence.
According to Dr. Banerji's
paper, there was no basis for participation within the
existing structure of global inequality where the terms of
trade were highly disadvantageous to the South.
Cn the other
hand, Dr. Dyal Chand’s paper advocated participation in terms
of community financing of village health workers. Manisha
Gupte pointed out that while the fee-for-^ervice approach gave
some autonomy to the community to plan its finances, there was
no guarantee that, within the present.unequal structure, this
would ensure better health care for the people.
It also
amounted to privatisation of health services, thereby
absolving the Government of meeting basic health care needs.
The alternative approaches suggested in Dr. Sujit Das'
paper were firstly, a 3-tier health care scheme with free
services for the poorest segment of the society.
This was
suggested as a strategy for mobilisation of the people and for
exposing the hollow liberalism of the Government as it would
never be implemented within the present structure,
The
presentation pointed out that while the 3-tier scheme had a
mobilising value/ it could not be a plan for a radically new
health and health care approach. Secondly, the paper advoca
ted that in the existing Indian conditions, the public health
sector had to ensure the delivery of good curative care to
the people.
Preventive and promotive care could be met by
other non-health programmes, and should net be confused with
275
the activities of the health sector.
Vimal Balasubramaniam's paper highlighted the role of
journalist in giving health education. Manisha Gupte commen
ted that there was a need for journalists to move out from the
medical framework of health which made them vulnerable to
contradictions and criticisms from the medical profession, and
to use concepts better suited t^ people’s need and experiences
In conclusion, Manisha Guptc returned to the question
‘'What do we mean by 1 alternatives1 ?". Did alternatives refer
to strategies to change the structure, or to better methods of
deliverying health care within the existing structure? In
this context, she raised questions with regard to the notion
of community; the limits of participation; and the knowledge
content to be imparted to the people. With regard to the term
'community' she pointed out the unequal participation in
village life due to caste discriminations. Was it possible
for Dalits to get clean water supply on an equal basis with
upper caste people? The issue of people’s participation
developing into people’s action was another grey area.
For
instance, health education activities taught people to ask
questions, and if as a result their demands went beyond
gaining access to primary health care, what attitudes should
the professionals adopt?
Finally, the presentation pointed
out that alternatives ultimately referred to a change in atti
tudes, and asked what the content of these changed attitudes
would be within the different alternative approaches. As an
example, Manisha Gupte pointed out the many contradictory
attitudes toward women. On the one hand, the population
policy and its objective of NRR-I was acutely discriminatory
towards women and had made them a target of hazardous contra
ceptives; the mother and child programme put the primary onus
of child survival on women as also the responsibility of
276
regulating the size of their families; the health services
system emphasised the importance of women village-level health
workers, out went against the spirit of the CHV scheme by
putting prassure on them to c<erce the rural women into
accepting family planning; and none of these programmes nor
the medical profession acknowledged the oppressed condition of
women and their subjection to familial and social violence.
Did the elimination of Diases also form part of the alterna'v
tive approaches?
Pej?spectivcs on People^ s Participation:
Dr. Dyal Chand explained that his paper on community
financing of health workers was concerned with ways and means
to improve the work of community health workers and their
interaction with the community, in order to increase health
awareness and utilisation of services. He was not suggesting
an alternative strategy to the Health for All strategy, but
was addressing himself to the sense of dependency on the State
which characterised rural communities. He was opposed to the
view that health was solely the State's responsibility. This
generated dependency.
Community financing was one method of
increasing the community's stakes in its health conditions,
and thereby increasing participation and utilisation.
According to Prof. Mutatkar, health managers genuinely
believed in technical solutions to health problems and.
therefore, paid only lip-service to people's participation and
health education.
They perceived health education as a means
to educating and informing the people rather than listening
and learning from' the latter.
Dr. Banerji endorsed Dr.Mutatkar 1s point that the health
education and community participation- practised in the health
sector were manipulative- of the people.
277
He felt that an
optimal solution to the health problems would be reached only
when the middle class activists and professionals went to the
people and learnt from them about their problems and health
practices. Only then would health education increase the
fighting power of the oppressed sections.
Dr. A.R. Desai analysed the concept of people's partici
pation in the context of the existing agrarian situation. He
asked as to who were the people for whom health planning was
required. Numerous studies on the rural areas had shown that
almost 40% of the rural population was without land or ha^
only marginal holdings. Another 30 to 33 per cent were small
farmers undergoing pauperisation.
Both landlessness and
pauperisation were a consistent trend due to the economic
policies of the Government.
threatened with indebtedness.
The middle peasants were
It was the rich peasants,
constituting 20 per cent of the agrarian population, who were
the major beneficiaries of the State's economic, land, taxa^ni
tion, agricultural and income policies and programmes.
This
same section was also becoming increasingly aggressive,
He
also pointed out the growth of migrant agricultural labour
which was controlled by contractors and found seasonal work in
areas of commercialised, inte. sive farming.
Citing the case
study of migrant labour from Khandesh to Gujarat, he asked,
"In this scenario, who are the people?"
On one side were the
rich farmers, government authorities, traders and contractors^
and on the other were the small and marginal farmers and the
landless agricultural population. It was the latter who were
facing suppression and needed to be aroused. He felt that
there was a need to use the health facilities to approach the
people, expose the Government policies and awaken the people
to fight the structure.
Revolution did not come overnight as
demonstrated by struggle for India’s Independence, and several
struggles and movements were required to build the momentum
278
for revolutionary change.
Dr. Sujit Das felt that alternative approaches had to aim
at changing the restrictive socio-economic structure.
He
proposed the new slogan "Free medical care for the poor as an
exclusive right". This would expose the hollow welfarism of
the State, and arouse and mobilise the people to struggle for
fundamental changes.
The slogan 'Health for All' could, not be
achieved in the absence of people's political control,
particularly control over the State. He rejected the fee-for-
service approach since it was the task of the welfare state to
provide the services.
Dr. P.B. Desai pointed out that in the Indian context
proletarianization was occuring without polarization of the
population into two major classes. Exploitation had increased
which was reflected in the fact that 40% of the population was
below the poverty line, but the poor had no alternative
avenues for organising. In this context, the intellectuals
and the medical profession had to be activists.
According to.Dr. Jesani, organising the people f_r
'
political struggles would lead to polarisation and the
development of class consciousness. Alternative strategies
for organising the people were being tried out by health
activists.. These activists were linking up with trade unions
and political struggles in order to develop a political perspective against the system, One such example was the approach
He emphasised
adopted by the Chhatisgarh Mineworkers Union,
that any attempt to suggest alternatives to the Government
would result in those very alternatives being used against the
demonstrated by the anti-women contraceptive
people. This was
technology and family planning programme, In this context,
community self-financing could become an instrument for the
279
Government to privatise health workers.
Dr. Dhruv Mankad cautioned against romanticising 'the
people1. It was felt that left to themselves the people had
the knowledge to solve their own problems, His own experience
showed that there was a felt need among the people for medical
care, as well as a common sense awareness of the determinants
of health, such as food, water, etc. However these demands
were not taken up as the people did not foresee any liklihood
of their being satisfied in the near future.
In certain areas
such as the growing popularity of non-essential and hazardous
drugs like Vicks and Anacin, there was a need to actively
educate the people.
Alternatives, in his view, would emerge
only through a process of working and interacting with the
people on all fronts.
According to Dr. Ramesh Awasthi, there were two concepts
of people's participation.
The first concept referred to
planning and implementation by the people, leading to their
eventual control of the health services.
This was possible
only in conditions of equality, as otherwise it would be taken
over and controlled by the dominant classes,
The other
concept of people's participation was guided by the freemarket ethos of consumer resistance, Health was a commodity
It was therefore
produced by some and sold to others,
necessary to provide information by way of health education to
build up consumer consciousness. It was the same market ethos
that resulted in strategies of community financing, since a
consumer was more concerned when he had to pay„ Dr. Awasthi
felt that one way to develop health consumer resistance was
through overproduction and free competition, i.e. that the
doctors should be allowed to advertise their services, and
thereby giveLthe people information about what was available
to them.
280
Dr. Antia summed up the various possible models of
These included
people’s participation under a market economy.
in order to build consumer resistance
(i) creating awareness
(ii) allo 'ing people to adver ise; and
(iii) taking recourse to legal action and suits.
Role of the Medical Professiont
Dr. Sujit Das disagreed with the suggestions made by
Drs. a.R. Desai and P.B. Desai' that the medical profession
role of social activists. He felt that the
should take on the
medical profession should limit itself to fulfilling its role
sincerely and honestly.
Dr. Antia suggested there was a need to rethink the role
Upto the 80s, the profession had
of the medical profession,
claimed public health and the promotive and preventive
first time at Manipal, during
services as its domain. For the
a discussion of the ICSSR/lCMR Report, the doctors had voiced
their .desire to do only curative work.
Dr. Deodhar cautioned against limiting the role of the
medical profession to curative services alone. The promotive
and preventive services were bsolutely necessary to reduce
context where poverty was the main
the disease burden in a
could be traced to some form
problem and most health problems
service approach suggested by
of deprivation. The fec-forin this situation
Dr. Dyal Chand would be counter-productive
could not even satisfy
of impoverishment where the people
health should be the
their henger. He felt that public
medical services would be
responsibility of the PHC, ’• and the
subject of community
one part of a total approach, On the
but the need .to..help the people to .
participation, he pointed
_
translate their own experiences and knowledge into activities
to help themselves.
In :his’experience of the many health
281
projects in India, only one project in the Sunderbaans, Bengal
had managed to achieve this.
Dr. Banerji stated that his paper was concerned with the
scientific discipline of new public health, and not with the
subject of health as a whole. The conventional understanding
of public health was technology-based, but the new public
health took the people as its starting point. The rest of the
paper attempted to give substance and content to this approach
based upon the work being carried out at the Centre for
Community Health at the Jawaharlal Nehru University.
Role of Mass Medias
Vimal Balasubramanyam pointed out the role of the print
media in providing information about drugs and other aspects
of health care. Citing the mischievous OPPI (Organisation of
Pharmaceutical Producers of India) advertisement carried the
day before in a Bombay newspaper.
(’’Are harmful medicines
banned elsewhere marketed in India” Times of India, Nov. 14,
1986). She felt that some sort of rejoinder by supporters of
AIDAN (All India Drug Action Network) was required. This
could include (i) strong rejoinders in all newspapers; (ii)
lobbying with editors about the unethicality of publishing
anti-public advertisements; and (iii) raising with the Press
Council the issue of the industry planting wrong information
in the press.
Dr. Saroj Jha felt that effective communication could
utilise more relevant forms of media, especially folk media,
besides the English press media. She elaborated on the
importance of communication, and pointed out that even the
Information, Education and Communication (IEC) approach to
health education, which had replaced the earlier KAP (Knowle
dge, Attitude, Practice) approach, was a top-down approach.
282
A recent UNICEF/WHO conferenced had changed the terminology to
'Participatory Communication in Health1
(PCH).
Nationslisation of Medical S e .cv ice s cLDCl Drug Product ion *
Ravi DuggSl pointed out two sets of Governmental action
that could be demanded from the State, The first would be to
make work or Employment, and the related factors of health and
education, fundamental or justicable rights, The second
demand, which could be met within the system, was to nations-
lise the health services and the drug industry.
Dr. Sanerji was cautious about the demand for nationslisation as it would strengthen the powers. of the medical
explained that the In1 tian
profession and the bereaucracy. He
1
Medical Association (IMA), formed
formed during the freedom struggle,
one of the standard bearers of the new health approach but
was
after independence it had come to be dominated by the emerging
a medical mafia". The latter promoted the growth of medical
education and the production of doctors, which had resulted in
the 'brain drain', rather than giving priority to the needs of
the poor.
However an internal contradiction had developed
between the increase in the number of doctors and the declin
ing avenues for employment, both abroad and at home. It was
at that juncture that the IMA recalled its 1935 policy resol
ution to nationalise the Indian health services. The medical
profession had demanded nationalisation in order to ensure
employment. The demand for nationalisation according to
Dr. Sanerji, had to keep in mind the political economy, as
well as guard against creating a "huge monstrosity of
bureaucracy" which might eat up all the resources including
the little that was going to the poor.
Ravi Duggal felt that the powers of the medical profess-
283
ion could be checked by banning private practice, and giving
doctors fixed salaries, instead of fees.
Dr. Jeffrey spoke about UK’s experience with nationalised
health services, though he stressed that the situations were
very different. According to him, a big danger of any nation
alised service was that the common people, who had in the
first place demanded it and had also gained some benefits from
it, lost a sense of control and involvement in its management.
The service turned into a bureaucratic institution, and it was
the resultant alienation among the people that had enabled
Mrs. Thatcher to privatise so much that was positive in
British life.
He felt that a system of local control, a
devolved structure, as in China, was a better alternative
since the locus of power remained closer to the people.
According to Dr. Deodhar, nationalisation in India would
mean that the people would receive the same inefficient
services at a higher cost.
Dr. V.N. Rao felt that the Government would not be able
to control private practice in a nationalised health care
system, when it did not have adequate machinery to deal with
the illegal private practice carried on by doctors attached to
rural and tribal primary health centres (PHCs).
Ravi Duggal asserted that there was a strong case fot
nationalising the private pharmaceutical industry as it was
being subsidised by the public sector. The public sector
supplied the bulk drugs, thereby incurring losses, which were
formulated by the private sector for huge profits.
Dr. Sujit Das disagreed with Dr. Sanerji's interpretation
of the demand for nationalisation of medical services. Accor-
284
(ding to Dr. Das, the concept of nationalisation stood for
’’guaranteed medical care to all”. This concept had nothing to
do with the demand made by the IMA for attachment of general
practitioners to hospitals. Qu stioning the viewpoint that
whatever was nationalised would become inefficient/ he stated
that inefficiency could not be worse than the lack of ethics
in the private drugs manufacturing sector.
As for the problem
of Governmental inefficiency in implementing nationalisation/
he felt that this reflected the Government’s lack of support
and committment to controlling private practice.
Dr. Das also
clarified that there was no contradiction in simultaneously
demanding Governmental intervention/ such as for nationali
sation, and waging struggles against the Government’s policies
and programmes. The former was necessary to gain certain
legal rights, such as universal medical services, not availa
ble in a private medical system.
Sujata Gothoskar felt that apart from the strategies
emphasising Government intervention/ alternatives about auto
nomous action also needed to be discussedo
She wondered if
there had been any experiments in health co-operatives on the
lines of production and self-employment co-operatives in
England and Spain?
Ashwin Patel pointed out the need to regulate and socia
lly control drug production in the private sector.
social
control through nationalisation was one method/ but needed
further discussion.
285
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3
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v
SESSION IV
INTERACTION BETWEEN GOVERNMENT, PRIVATE SECTOR, AND NGOS
IN IMPLEMENTATION OF HFA STRATEGY.
With focus on:
*Perspective of the government of India in the policy
for health and socio-economic development.
f
*Achievements and failures of the government.
★Problems faced by government and NGOs.
*Role of NGOs and their significance.
★Private sector in Health.
i
i
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■
*
NGOs
GOVERNMENT AND THE PRIVATE LECTOR
By
Ravi Duggal
This paper sets out to critically examine within a
historical framework, the role that the non-governmental
organizations (NGOs) have played in Indiars political
economy.
Its relationship with the private sector and
government policy making will be highlighted.
The
health sector will be used to illustrate the issues that
emerge•
WHAT ARE NGOs?
NGOs are private organizations, tut their nature makes
them somewhat different from what one generally refers
to as the private sector.
Firstly, organizations
operating as NGOs are registered either as ntrustsn or
nsocieties”. As a consequence, they are not supposed to
make profit, unlike the private sector.
Secondly, NGOs are involved in the 11 development sector” ;
that is, running programmes such as health, nutrition,
family planning, education, water supply and sanitation ,
urban renewal, housing, research, training and documen
tation, agriculture related development programmes
(IRDF etc.) and employment programmes (FEW etc.),
among others.
These constitute what one might call
service-NGOs.
Another category of groups included
under the banner of NGOs are activist groups who are
involved in conscientisation and struggle oriented
activities, but they may also undertake some services.
Organizations that are usually only production oriented
are normally not included under the NGO umbrella. How
ever, some service NGOs may undertake production acti
vities such as agriculture, household industry, etc.
And there are also funding agencies which are referred
to as NGOs.
Thirdly, NGOs are invariably dependent on external
sources of financing their activities (including most
activist groups)•
These sources could be government
agencies, local, regional, provincial, national, bi
lateral and multilateral or private agencies, NGO fund
ing agencies, private corporate foundations and trusts
and religious groups.
At this point, it may be noted
that funds given to registered trusts and societies in
India as donations are eligible tax expenditures,
2 86
therefore, for many funders. NG-Os may constitute tax
shelters•
And finally, a large number of NG-Os, especially in rural
areas, run programmes of the government on a contrac
tual basis because of their (NG-Os) supposed dedication
and flexibility.
a is is a more recent phenomena
(Fifth Plan onwards) - the government, for instance,
gives its own health centre or IRBP project to be run by
an NG-0 because the government believes that its own
structure is inefficient, bureaucratic and incapable of
reaching the beneficiaries.
HISTORICAL PERSPECTIVE
NG-Os, it appears to-day, have suddenly arrived,
The
current debate in various journals as well as at meet
ings and seminars generates
this feeling,
_
_,
But it is not
NG-Os have their own history and that too a highly
true •
s ignifleant one as regards India’s political economy.
Christian missionaries are generally considered as
pioneers in organized activity of the kind we attribute
to NG-Os to-day.
The non-christian response came fairly
late beginning with the Brahmo and Arya Samaj and Rama
Krishna Missions, among others. Much later G-andhian
and Sarvodaya groups emerged and became a dominant
force.
The common thread among all these groups was
charity and missionary zeal*
The three major areas of
involvement in the social service sector of these groups
were education, health and rural development; and an
overwhelming majority of them focussed on women and
children, many of them also working with backward castes
and classes and the handicapped.
These NG-Os laid the foundation of the social services
sector or welfare sector in India during the British
rule.
After independence many NG-0 experiments and models
bocame replicas that the government used for formulating
its own development strategy»
Thus, the Community Deve—
lopment Projects (CDP) of the government that began in
1952 were based on the experiments of Albert Meyer in
Etawah, U.P. and of the YMCA in Martandam, T.N.
The First
Five Year Plan notes :
2 87
\
”A major responsibility of organizing activities
in different fields of social welfare like the
welfare of women and children, social education,
community organization, etc® falls naturally on
private voluntary agencies.
These private agen
cies have long been working in their own humble
way and without adequate aid for the achievement
of their objectives with their own leadership,
organization and resources.
Any plan for social
and economic regeneration should take into account
the services rendered by these agencies and the
state should give them maximum co-operation in.
strengthening their efforts. Pub^ic_.cj^op^r^vtj^n
through voluntary social service^jorganizo^Vj^on^,
is capable, of yielding valuabl^^suYts^n_charineling private .efforts for the promotion of social
welfare”•
CgCI, 195 iT •
To back this up, the government in 1953 set up the Central
Social Welfare Board, to provide grant-in-aid to l\^Os.
Further, in its own development programmes,the govern
ment sought the expertise and co-operation of wellknown NGOs.
This was more so necessary when CDP was
evaluated at the end of the First Five Year Plan by the
Planning Commission : ’’Most of the time was spent in
Q^vi^S procedural/administrative wrangles making imple
mentation of programmes inefficient, inadequate
inadequate and
ano
wrongly directed’1. (GOI , 1958)
The government could not ignore the social services
sector and the private sector was unwilling to invest
in social infrastructure.
The private sector, for its
own expansion and profitability, pushed the government
into investing vast public resources in building infra
structures and heavy industry that was essential for
economic growth,
but more so to facilitate the growth
of private capital.
As a consequence, the social sectors
like health and education were totally neglected -.
health sector was mainly operated by private practitioners
and a large number of hospitals run by NG-Os, and the
education sector was mainly run by NGOs (missions, public
trusts and societies).
The NG-Os in these early years were largely concentrated
in urban areas, but many were now gradually spreading,
their tentacles into the countryside, the leaders being
G-andhian and Christian missionaries.
2 88
In the health sector the government, though in principle
had accepted the Bhore Committee recommendation, was
still undecisive - even to-day, the physical targets recom
mended by the Bhore Committee are far from realisation.
The anti—malaria and anti—smallpox campaigns were under
taken at the behest and with support of international
agencies.
It was not until the mid-sixties (Third Plan)
that the health infrastructure for rural India got serious
attention from the government.
This too for two reasons the resurgence of malaria and the government’s decision
to give family planning programmes a big boost through
the camp approach.
This was also the time when the green revolution in India
began and the countryside had suddenly come into focus
(from the perspective of mainstream economics).
The
corporate sector showed increased interest in rural India
for here was an opportunity to capture rural markets not
only with the new agricultural technology but also (due
to increased commercialisation of agriculture) with other'
goods and services.
The corporate sector, however, was unwilling to go on its
own into the rural areas.
It wanted crutches from the
government and the latter obliged by starting massive
agricultural development programmes such as IAPP and later
SPDA.
In these programmes the inputs for modern agricul
ture (equipment, fertilizers, high yielding variety seeds,
pesticides, etc.) were provided by the corporate sector
through the government agencies to the farmers.
The
government paid the corporate sector for goods and services
and marked the amount as loan and subsidies to the farmers.
Thus, the corporate sector’s profits were assured.
To
facilitate the government’s loan programmes the corporate
houses set-up NGOs who would act as middlemen between
the peasantry and the government (using the same logic government is inefficient and private sector is dedicated
and effective).
This was a new kind of association for the Indian Corporate
Sector with its periphery (earlier they only looked for raw
materials and cheap labour in the periphery) and it pro
mised, .assured returns because of the involvement and parti
cipation of the government at two levels - one as a mono
poly buyer of agri-products and the other as a concession
giver, in the form of tax-expenditure (with weighted
deductions) and tax— holidays for venturing into agri
business and moving into the countryside (for details see
Duggal, 1985).
289
These NG-Os ? floated and/^or supported by the Corporate
sector, invariably used medical programmes or drought
relief as entry points.
Though their interest was in
promoting ’now agriculture’ and expropriating surplus,
they also added social services such as medical, educa
tion, vocational training programmes, etc. to their
activities, both for legal purposes (because they- were
registered as ’trusts’ or ’societies’) as well as to
show that they were socially responsible!
However,
their approach was significantly different from that
of the existing NG-Os.
They broke away from the charity
oriented/do-gooders approach and established a new trend.
Until the late sixties, the charity-oriented legacy of
the missionaries and G-andhians constituted the dominan t
approach among various NG-Os.
Attitudes of piety and
compassion towards the ’poor, down trodden and the miser
able Hot’ motivated senior citizens to work amongst Such
people.
It was invariably an individual’s mission of
charity to do ’constructive work’ in a deprived and
underserved community.
Many Tempires’ have been built
in such pursuits.
Business houses too have indulged in charity, in fact,
even before G-andhian groups emerged.
For instance, Tatas at
-frho turn of the present century began charitable works
among the tribals in what is to-day known as Jamshedpur
and by 1907 TISCO was launched, appropriating the land of
the tribals of many villages to build the factory and
subsequently the township.
Where the government was concerned, until the Third Five
Year Elan, its official approach vis-a-vis the NG-Os was
mainly one of a grant giver.
After the Third Five Year Elan the country-went through
a prolonged and wide-spread crisis : The contradictions
of the green revolution began to emerge, the fourth plan
was delayed? there was widespread famine in the country,
the Naxalbari uprising apread into a movement and was
repressed brutally, and the Congress party split.
This
crisis ended with the naticnalisation of banks and elimi
nation of privy purses on the one hand and a new rural
development strategy in partnership with the corporate
sector on the other hand (passage of section 3b(c) of
the Income Tax Act in '96Q which provided 120$ weighted
deduction from taxable profits to the Corporate sector
for undertaking agri-business)•
290
The World Bank provided full support to this new strategy
of the government and the Indian Corporate sector.
McNamara categorically decj>ared that widespread poverty
in the countryside of the third world had to be stemmed
otherwise the ’spectre of communism’ would grip the third
world.
He suggested that NG-Os and the private sector had
an important role to play where the government had failed.
He assured the World Bank’s full assistance in funding anti
poverty projects in the third world.
This support of the World Bank and private US foundations ,
besides western government AID programmes, encouraged
the Indian private sector, to directly as well as through
their sponsored NG-Os, to move into rurai areas in a big
way :
i) to promote agri-business under the umbrellaL of
government's rural development programme ((SFDA,
MFAL, etc•)
ii) to set-up 'rural development projects* that would
provide alternative employment opportunities as
well as help in increasing agri-cultural producti
vity, which in turn would raise purchasing power
iii) to provide health care, assist in population pro
jects, local resources development, and other
social services, and
iv) in general to strengthen the base of capitalism.
Thus, the corporate sector paved the way for the dominance
of the new approach of NGO intervention, an approach that
discredited and strongly critiqued ’charity’ and talked
a great deal about ’self-reliance’.
They professionalised
the NGO sector.
In contrast to the charity approach, the
new approach (also referred to by many as the ’develop
ment’ approach) was ’not to give anything free of charge’
because i) whatever is given free is not seen by people to
have a value
it creates a ’feudal1 relationship of giver
recipient
iii) it generates a dependency among beneficiaries, and
iv) it acts as a barrier to ’peoples participation ’.
ii)
291
In the health sector, this new approach was first demon
strated in Narangwal, Punjab, by Carl Taylor and associates
but its consolidation took place only in the early seven
ties in Maharashtra with ths Jamkhed, Mandwa and Miraj
projects of different NG-Os.
A model for village based
outreach health care delivery was demonstrated 5 and by
mid-seventies this model had proliferated all over the
country, and even before Alma-Ata it was officially incor
porated by the government in its own health programmes.
By the end of the Fifth Five Year Plan, the government
had realised that successive failures of all its develop
ment programmes was due to weaknesses inherent in its own
structure: ’’Experience (CDP to IRDP)
has shown that fruits
of development have been mostly availed of by the better
endowed areas on the one hand and "ihe better off members
of the rural society on the other*. (GOT, 1980).
THE HBALTH SECTOR :
Health programmes of the government have probably been
After independence the government
more disastrous,
accepted the strategy outlined by the Bhore Committee.
However, after 39 years of independence we are—s bill—no—
where nearer in realising the recommendations —of—the—Bhore
Committee.
For instance, the Bhore Committee had sugges
ted' that for a population between 10,000 and 20,000,.
there should be a 75”bedded primary health centre which,
would provide co-ordinated preventive and curative services
through doctors, public health nurses and health assistants ?G-0I , 1946). However, even under the 7th Five Year
Plan, the target of the government still remains a 7-bedded
primary health centre for r- 30,000 population with less
than half the personnel recommended by the Bhore Committee.
The implementation of this plan was never taken seriously
because ;
a) health of the people is not considered a priority
area of development by the government whose power
base operates through Kulaks and the bourgeoisie,
b) the private health sector and the system of private
practice of medicine has prevented the government
from developing the medical and health functions
for the peoples 1 benefit*
Sops such as charitable
or ’voluntary1 hospitals providing ’concessional’
care have mushroomed to give a respectability to
private medical practice,
292
c ) the government1s planning and programming has never
taken into account what the actual requirements of
the neople are - people have always been ’given* what
the government thinks people want and even the latter
does not reach them,
d) the government's obsession, under the influence of
international agencies, in the health sector has always
been with family planning, and
e) public resources have .largely been invested outside
the social services sector, mainly benefiting the
growth of private capital.
It is clear then that the failure of the government health
and development programmes is organically linked to the
manoeuvering of the private sector. How did the private
sector achieve this?
The private health sector is probably one of the strongest
lobbies in India.
Its growth has been phenomenal after
Independence, growing each year from strength to strength.
Its biggest support is the pharmaceutical industry - from
the late fifties onwards pharmaceutical MNCs began their
entry into India and from then till to-day have monopoli
zed control over the peoples’ health.
British imperialism had cultivated a health care delivery
system that served only the British and the Indian bLasses
that owed their allegiance to them.
Rural India, compri
sing over 80% of Indians, was left to its own means. The
only contribution the British made was to leave behind a
grandiose plan - the Bhore Committee report.
After
independence, the government accepted the Plan in principle,
but since health care was not a priority area it ignored
it, providing an oppo.-tunity to the private sector to
monopolize it; and once the pharmaceutical MNCs came,
there was no looking back -away from privitization.
Thus f> government‘s indecisiveness in the social services
sector, including health, ,h msing and education, led to
the strengthening of the private sector in these areas.’
The private sector was most pleased tclVt the government
have a monopoly of infrastructure related heavy industry
and general infrastructure because they (private sector)
did not have the ability to muster resources required for
such industry.
The government accepted this task and
began construction of huge public sector undertakings in
the 'core' sectors from atop of which it could proclaim
socialism.
After getting the government busy on the heavy
infrastructure front, which was in reality constructed
293
by the private sector under profitable contracts from
government9 the private sector settled down with the task
of expropriating surplus from all sectors of the cccnemy
and society, including health care.
Over the years the government run programmes and projects
showed heavy losses and indicated the government’s ineffi
ciency, complacency and corruptibility.
On the other hand 3
the private sector demonstrated its efficiency, costeffectiveness and ability to execute anything successfully <.
Therefore the private sector established its credibility,
which the government was forced to recognise and the latter
began framing policies that increasingly shifted in faveur
of the private sector.
Even in provision of ’social
services’, which under the concept of the welfare state are
the concern of the state, the private sector -demonstrated,
models through its NG-Os.
In the health sector tcd.oy private practice is the most
easily accessible .and acceptable form ef mol?' cal c tre tha. b
people have come to recognise and utilise.
The public
sector’s rural health services are greatly discredited, both
because of poor services and because their primory concern
is family planning; people utilise private services^, most of
the time.
In urban areas private practice thrives because
public facilities provided by local bodies are inadequate,
inefficient and bureaucratic. . These factors, over the years,
have resulted in private practice of medicine becoming
deeply entrenched in society, acquiring a credibility, that
even the government has euologised.
Thus, the private sector ■'.ssured the failure of government's
health programmes by :
a ) monopolising and controlling pharmaceutical manufactures
suited to their profitability and not necessarily to
what the people’s needs were, forcing the government to
strain resources to acquire essential drugs through
imports;
b) demonstrating that they could administer health care
better and more effectively to the people than the
government, which recruited mostly doctors and otherhealth personnel who could net establish private
practice or find private jobs, leading to further com
placency and inefficiency of the government's health care
delivery system, and
c ) forcing the government’s health structure to push vigo
rously population control, thus o’iscrediting thegovernment’s health care delivery system,
294
NGOs
A NEW POLICY
The 1970s saw a /?ro.at mushrooming of NG-Os for various
reasons o
Firstly the government was encouraging them by
giving grants or pcrmittin them to receive foreign funds
directlyo
Secondly, the Corporate sector in partnership
with the government was encouraging and supporting NGOs,
especially in the rural areas.
Thirdly, new tax deductions
to donors for providing funds for rural development and
social services to NGOs were introduced in the Income Tax
Tkct, therefore , increasing willingness to donate funds to
NGOs.
And finally, the Professionalisation of the NGO sector
provided opportunities to committed and motivated individuals
to take up careers in ’’development” .
Further, in the fifth Plan period the government began
encouraging NGOs to take over, on a contractual basis, the
programmes of the government in the social services sector.
This was certainly a major policy shift from being earlier
only a grant-giver.
In the health sector tho government
began giving its primary health centres to the NGOs to run
them; also, certain national programmes (eg. leprosy) in a
specified area .would be given to NGOs to implement.
Under
the Sixth Five Year Plan this process was accelerated. In
addition NGO representatives were made official advisors or
nominated as experts in government committees and bodies,
including the Planning Commission, indicating that NGO
business was also official business.
During the Sixth Plan period NGO representatives lobbied
the government with all its might and its impact can be
seen in the National Health Policy Statement and the
Seventh Five Year Plan.
The Approach Papers of the Seventh Five Year Plan calling
for greater participation from NGOs states, ’voluntary
organisations will have to be associated more closely and
actively than hitherto with the programmes for reduction of
poverty and with the efforts to make the minimum needs
available to the population for improving their quality of
life.
This will be incorporated as part of the overall
strategy for augmenting such programmes meant for the poor,
as also an alternative feedback mechanism for ascertaining
whether the target groups have received the benefits meant
for them’ (GOI 1984)•
It further adds that, ’’Achieving active community parti
cipation and involvement in health and health related
programmes should also be part of the strategy.
In
particular, active community participation and involvement
295
of non-government organisations in a massive health
education effort is urgently needed . . . With _a vj-ey7_to
roducing governmental expenditure and fully utilising
untapped resources, plannod programmes_may be devised,,
related to the local requirements and potentials, to
encourage establishment of practice by private medical
professionals, increased investment by non—government
agencies
in establishing curative centres and by ofiorin^
organised logistical, financial and, technical support—tb
voluntary agencies active in the health field
(ibid)The Ministry of Health and Family Welfare (MHFW) is in full
agreement with the Planning Commission on the issue of
greater involvement of NG-Os in the field of Health Care.
In a recently published document (G-OHI 1985) it categorically
states, ’’The government has envisaged a very prominent role
of voluntary organisation/NG-Os in the implementation of
these (health, family planning and 20 point) programmes.
In October 1982, directives were issued that voluntary
agencies be involved in the implementation of anti-poverty
and minimum needs programmes which contain all the important
health programmes like MCH, family planning, communicable
diseases, health education, drinking water facilities,
immunisation, etc. and consulative groups be formed in all
the States headed, by a Senior Officer of the State ....
Voluntary organisations are doing a very creditable _ job _j.n
organising and running hospitals and_dis^ensaries—in—India.
India is only second to the USA in terms of number of
hospitals outside the government health sectors andjun by
NGOs.
If suitably encouraged in terms of liberal—financial
grants, they can contribute a great deal .in filling ihe—gaj3
of referral hospitals at taluka level, district level,and
in urban slums".
Evon the National Health Policy of 1985 recognised the need
for greater reliance on the voluntary and private sectors
for achieving the goals of ’Health for All by the year
2000 A.D. ’
’’The policy envisages a very constructive .and
supportive relationship between the public and—nrivaj;e
sectors in the area of health by providing.a corrective to.
re-establish the position of the priyate_health sector"(ibid)
The above statements make it; appeal? "that;:
a ) the government has accepted its inability to provide
adequate health care;
b) the active participation of the NG-Os is most necessary
for achieving goals of the health sector; and
c ) privatisation of the health sector will result in better
provision of health services.
296
This perspective suite both the government and the private
health sector.
The government succumbs to historical
evidence of the failure of all its anti-poverty programmes
including those of the health sector, and invites the
private sector to take charge of tho fight against poverty
and disease.
The private sector? which is mainly res
ponsible for the poverty -- poor health, nutrition, housing,
sanitation, etc. - has over the years demonstrated to the
government, through ’voluntary efforts', that it can do a
better job even ;o'f ’development ’ !
Thus, a self-fulfilling prophecy is generated that 2
a) the government is inefficient, complacent and too
bureaucratised and therefore cannot reach tho people with
its development programmes, howsoever well pl .mned; and
b) that the private sector is efficient? cost-eff ctive?
flexible and non-formal and therefore it can successfully
execute the programmes of development taking it to
population groups for whom they are really meant.
All this is clearly indicative of the close nexus between
the private sector, NG-Cs and government policy making.
The role played by the private sector in building up its
socially more acceptable image through the NG-0 sector
emerges clearly.
How the government is used by the
private sector for strengthening itself has also been
established.
Today, in the health sector, as well as in other sectors
of the economy, we see a great boom in privatisation both
independently as well as through the NG-0 sector. Diag
nostic centres, corporate hospitals, health insurance and
the like are on the uptrend, egged on by the present
government’s policies to "re-establish the private sector”.
Will all this lead towards ’’Health for All”? To answer
this we need to look at the social structure, And since
the purpose of the NG-0 is organically linked to welfarism
and directed at managing inequality under capitalism> a
brief description on the nature of welfarism would be in
order•
socia1 structure that is founded on the -principles of
inequality is time and ar-.ain forced to introduce pald.iativ-.•
measures so as to stem the rising tide of class conflict.
297
V/ elf prism in capitalist societies (developed and backward)
is ope such response.
It seems to moke blunt both the contra
dictions of capitalism as well as to provide a defense system
against the consequences of unequal social relations.
Historically, uxiclcr capitalism in its development process,
the state was delegated the responsibility to provide for
welfare from public resources.
The Capitalists, who
facilitate unequal relations did not deem welfare as their
r esponsibility - their sole objective being expropriation of
And whenever the
the greatest possible amount of surplus,
measures (as a consequence
capitalist did provide some t,welfare
......
of workers’ struggles) to workers it was only against tax
expenditures - which indirectly meant .a reduction in the
State welfare for capitalism was a doubleState revenue,
It
provided political stability which was
edged weapon.
essential for further growth of capitalism and it directed
or diverted the conflict against the State which had become
the main welfare agency.
In other words the State more than
the capitalist became the enemy of the working class. Cn the
other hand, for the working class, welfare and not the right to
employment became a legitimate and institutionalised means of
attaining a better standard of living.
Thus, the struggle
for a change in the social order got institutionalised into
a system of compromises, assuring both, a stability that
would help the advance of capitalism and at the same time
create an increasing dependancy of the working class on the
S tate.
It must be noted that welfarism got established firmly only
in the developed western bourgeois democracies, where today
it is under great strain with the State facing a fiscal
crisis.
State welfare is today caught between two opposite
f01*ces — the demands of the working classes for more welfare
and the pressures of capitalism to reduce state intervention
in economic and social relations .
And one of the responses of the private sector to this, as
discussed earlier 9 has been the establishment and streng
thening of the NG-0 sector.
In this complexity of affairs where do people stand? Can
we assure them health? The history of our development
programmes indicates that different strategies have been
„ .
There have been no
tried out hut have failed miserably
structural changes but only efforts at extenuating crises
situations that only help postpone the crises.
But for
how long?
Capitalism and inequality strive with the aid of state
patronage and repression. NG-Cs consciously
298
t
i
or unconsciously, are part of this system and are using
ever larger amounts of public resources.
The State’s
recent policies are supportive of this and channelise an
increasing amount of funds for the NGOs.
Though the NGOs have demo- strated that they can run
specific programmes limited to a specific population
efficiently, including reaching out to the underserved and
the underprivileged, there is no evidence that they have.
brought about either change or peoples’ participation which
they are never tired of talking about.
Thus, it is clear that NGOs serve the system rather than
the people, that they nres'erve the status quo instead_of
bringing
bringing about change and that they are often only another
face of the private sector.
Therefore, the question whether ’Health for All’ is possible
It is
cannot be seen independent of structural changes,
there that the answer lies.
************
References
■
'based1 on data collected for the study
This paper is partially
’NGOs in Rural Health Care’
’ by
1. Amar Jesani, Manisba Gupte and.
Ravi Duggal, FRCH,
'
. Bombay,. 1986.
1
Duggal Ravi, 1985: Tax Expenditure and Rural Development
in a Corporate Sector in Rural Development under IRDP,
University of Bombay.
2 . GOI9 1946: Health Survey and Development Coinmittee, Govt.
of India, Delhi.
5. GOI, 1951: First Five Year Plan, Planning Commission,
Govt.of India, New Delhi.
4. GOI, 1958: Fifth Evaluation Report on working of
Community Development and NES Blocks, Programme
Evaluation organisation, Planning Commission, Govt.of
India, New Delhi.
5. GOT, 1980: Manual on IRDP, Rural Reconstruction Ministry,
Govt.of India, New Delhi.
6. GOI, 1984: The Approach to the Seventh Five Year Plan^
1985-90, Planning Commission,. Govt.of India, New Delhi.
7. GOI,1985: Collaboration with NGOs in Implementing the
National Strategy for Health for All, Ministry of Health
and. Family Welfare, Govt.of India, New Delhi.
299
PARTNERS IN HEALTH - GOVERNMENT N.G.Os AND THE PEOPLE
DR. MRS. BANOO J. COYAJI
In India, voluntary agencies or N.G.Os as they
are now called, have played a vital role in health,
family planning, rural development, care of the sick,
the maimed, the blind, the old - in fact in nurturing
every significant social reform in this century. They
and their contribution have been, more or less, ignored,
if not viewed with suspicion. In the last few years
they have become respectable, and now they are being
wooed. It must mean that Government has begun to
realize that the dimensions of poverty, ill-health and
illiteracy have become so staggering that they cannot
be tackled without the people's active participation
and of the Voluntary Agencies who are close to the
people.
Let us be very clear as to what we mean by Health.
It was on September 12, 1978 at Alma Ata in the U.S.S.R.
that 134 nations of the world affirmed that health is
a state of complete physical, mental and social well
being, and not merely absence of disease, and that
people have the right and duty to participate individually
and collectively in the planning and implementation of
their own health care. The U.N. General Assembly
resolution 34/58 of November 29, 1979 declared "Health
For All by 2000 A.D.” as its goal, with the promotion
of primary health care as part of the New International
Development Strategy for the 1980s and beyond. Primary
Health Care is defined as essential health care based
on practical, scientifically sound and socially
acceptable methods, made universally accessible to
individuals and families in the community, through thier
full participation and at a cost the community and the
country can afford to maintain, at every stage of their
development, in the spirit of self reliance and self
determination.
In simple words it means that such a level of
health Will be reached by individuals and communities
by the year 2000# that it will permit them to derive
social satisfaction from being able to realize what
ever latent intellectual, cultural and spiritual
talents*they have.
"Health for All does not mean that in the year
2000 doctors and nurses will provide medical repairs
300
for everybody in the world for all their existing
ailments; nor does it mean that in the year 2000
nobody will be sick or disabled. It does mean that
health begins at home, in schools and in factories.
It is there, where people live and work that health
is made or broken. It does mean that people will
realize that they themselves have the power to shape
their lives and the lives of their families, free from
the avoidable burden of disease, aware that ill-health
is not inevitable. It docs mean that people will use
better approaches than they do now for preventing
disease and alleviating unavoidable illness and
disability, and better ways of growing up, growing
old and dying gracefully. It does mean that there
will be an even distribution among the population
of whatever health resources are available.
And it
does mean that essential health care will be accessible
to all individuals and families, in an acceptable ?_nd
affordable way, and with their full involvement1' .
(Mahler)
India is a signatory to the Alma Ata Declaration
and to the U.N. pledge of Health For All by 2000 A.D.
The Government of India has translated this into
action by enunciating the new National Health Policy
in 1983, and setting before it time bound targets.
The VIth Plan had provided resources which
are considerably enhanced in the VIIth Plan. This
underlines the fact that there is political will and
bureaucratic planning. The million dollar question
is that "Is there sincere committment to Primary
Health Care and community participation or is it
mere rhetoric"? Will the policy be implemented in the
true spirit or will it go like the best laid plans
of men and mice?
The New National Health Policy, the approach
paper to and the Seventh Plan document reveal a
gloomy picture of the health status of our people,
after more than three decades of planned development.
The National Health Policy unequivocally states that
the existing situation has been largely engendered by
the almost wholesale adoption of curative centres
based on the western models which were inappropriate
and irrelevant to our needs. It also states that
the planning process was largely oblivious of the fact
that the ultimate goal of achieving a satisfactory
health status for all our people cannot be secured
without involving the community in the identification
301
0
of their health needs and priorities/ as well as the
implementation and management of the various health
and related programme^, thus unequivocally vindicating
the finest blue print on health that any country
could have had - the Shore Committee report enunciated
in 1946 - one ye?r before Independence.
Undoubtedly, under the stimulus of Alma Ata,
there has been considerable change in the official
health policy of India. There are however many gaps,
constraints and problems. One big problem, eight
years after Alma Ata, is failure to understand the
very basic concept of Primary Health Care. Upto date,
the idea seems to be to increase the reach of the
Government programmes and to "provide" services
further & further into the rural areas. It is not
surprising that people are reluctant to utilize such
services. The main reason for this is, the failure
to understand what primary health care is all about that health services should be strongly based in the
community, so that people are involved in planning
and implementing programmes for their own health care,
that the community will no longer be the periphery,
but the hearV of the system. The implication is that
services do not "reach" the’ people but "begin" with
the people and are located in their midst. It is
from tais strong base that they rise to district and
regional levels, providing adequate supplementary
referal services. It is only if this basic premise
of primary health care is understood and implemented,
that there will be established a close ppartnetship
between the people and the health services, which will
release the tremendous capacity of the people to
solve their own health problems and specially of
those in greatest need - women and children.
The dimensions of the problem, of bringing about
Health For All are staggering. If, to this is added
the fact that only fourteen years and limited
resources are available to achieve this miracle, then
we would be well inclined to throw up our arms in
despair.
It is evident that more of the same will not do.
Creative solutions to thousands of problems are
meeded to achieve our goals. Can Government find
these solutions alone? I doubt it, if the past is any
indication. Political, bureaucratic, financial and
other constraints restrict the ability of Governments
to design and experiment with new innovative methods
302
.._L1 be needed. It is precisely because of these
which will
limitations on Government, that Voluntary agencies
exist. But can the Voluntary agencies do it alone?
Ofcourse not. They are a drop in the ocean. Can the
people do it? Yes, but not without guidance, financial
and other support and genuine democratic decentralization.
What is the solution then? We can do it together.
With a working partnership between Government, the
Voluntary Agencies and the people founded on mutual
respect, trust and shared objectives, tremendous
progress can be achieved.
Thousands of Voluntary Agencies exist. They
are of all sorts, shapes and sizes. Some are giants
and affiliates of international agencies. Others are
large and national. Socne are medium, but most are
small and struggling for a place in the sun» Most^
work in towns, but increasing numbers are working in
rural areas. The most important, from the Health
For All point of view are the struggling Mahila Mandals
(women’s groups) dotted all over the country sideestimated 70,000, albeit not equally active, with a
membership of nearly 1.75 million and the thousands of
youth and farmers and service groups. Here is an
enormous resource to be organised, helped and guided.
What are the strengths of Voluntary Agencies?
By their very nature, they are more able to design
and implement innovative and creative solutions to
Primary Health problems than Government. This is
because they are closer to their target audiencies —
the people, They are more able to be flexible and
experiment. They can quickly make midcourse
corrections, if things do not proceed in the right
direction. They are made to, and able to.work with
very limited resources. They have the ability to s
collect funds. Philantropists can be persuaded to
give them small or big donations. They must, perforce,
deliver the goods. A Voluntary organisation must
give excellent services to the people in order to
survive. People are prepared to pay, what they can,
for such services. And they are held accountable —
They must demonstrate results or cease to exist -.a
condition that Ministries and departments of public
health are not required to meet.
What are the deficiencies pf Voluntary Agencies?
Agencies.
They mostly work in splendid isolation from Government
and from each other. This results in their work being
fragmented into bits and pieces. Very many depend on
303
the presence ef a charismr‘ic leader and therefore go
under, when he disappears rom the scene. They show a
reluctance to work with Government and regard Govern
ment only as a funding agency. It is absolutely^
necessary that Voluntary Agencies show better under
standing of national plans and priorities and the
tremendous problems Government faces. They should be
willing to be junior partners of Government in the.
larger task of implementing Health For All Strategies.
They should use their natural strength of closeness
to the community to help stimulate the development
movement among the people. The Government tod^y is
interested in an indepth out reach programme to take
preventive, promotive and curative health to remote
_1
villages and urban
slums.» Atleast
Atleast in
in Maharashtra,
Maharashtra^
Government is willing to share responsibility^with
seize this opportunity to work with
N.G.Os. Let us l
Governmento
Voluntary Agencies do not even work with each
other. There is so much voluntary effort going to
waste, just because small groups to not have managerial
skills, and technical, know how, to even make proposals
for financial aid. It is for this big lacunae that
recently the Society for Service to Voluntary Agencies
"SOSVA" has been started with the blessing of the
Government of Maharashtra to identify, help ^and
are the
nurture these small but dedicated groups. What
T. — ---practical steps necessary to forge a meaningful
partnership?
Government today is willing and ready.
ready, There are
' ' ., The
procedures for registering,
however many constraints
f
release of grants and rules and regulations are
cumbersome. They must be simplified. For example the
Mahila Mandals can get a grant of Rs. 50/- p.m. if
they are registered. The hassle of getting them
registered is so great, that many prefer to work
without registration. Ofcourse monitoring, accounting,
financial checks etc., are necessary, if Government is
to give grants. But there need not be a feeling of
distrust. There should be more encouragement, supportive
supervision and genuine democratic decentralization.^
Without this there can be no ’’people's participation •
Tlge raison ddetre of the whole exercise is the
people - the "have nots", the oppressed, the exploited,
the poor and needy living in 600,000 villages and the
11 People's participation"
participation 1 is now
sprawling urban slums. "Peoiio's
304
5X
a fashionable expression in development parlance.
It is still a myth - It does not mean passive
acceptance of services ’’provided" or offered. It
does not mean carrying out orders, attending clinics,
or meetings/ or even being persuaded to give free
labour and material. The poor have been exploited
from times immemorial. They view all overtures with
suspicion. Community participation is a slow process
and evolves through various stages from acceptance,
awareness, co-operation add involvenebt to active
participation. The people’s own creative ability to
identify problems, take decisions, gain confidence
and assume control over their own lives is the
central tenet of primary health philosophy - we are
certainly far away from this goal. In order to help
people to reach this stage a massive health and
development education programme is needed - Before
formulating such a programme it is wise to spend time
to listen to what the community feels and thinks. A
quiet talk under the trees, quiet observation and
questions to know what the people’s practices are,
will give a wealth of knowledge. We rv.ust realize that
we do not know the problems, leave alone their
solution. We should forget our intellectual arrogance
and be prepared to listen and learn about their concepts,
beliefs and customs about health and disease. Some of
these are good and should be preserved, and some are
harmful and should be corrected. Patience is necessary
for changing attitudes and entrenched practices.
Respect the peoples 1 felt needs and fulfill them, The
secret to win their confidence is ” Serve first/ service
second, service last".(Taylor) In doing this, it is
necessary not to allow the people to transfer their
dependence from the juggernaut of Government tp that
of a little more caring voluntary agency. That would
be self defeating. Unrealistically high expectations
should not be placed on the people. Community parti
cipation counts on the resources of the poor i.e. their
time, energy and enthusiasm and, looked at realisticaly,
these resources are limited-r
Community participation
is not a magic solution to development and health
problems, but a very critical input. Plan as if people
matter. They are the most important part of this
partnership.
305
This brings us to the role of voluntary agencies
It is in
in the exciting voyage to ’’Health For All”
short :
(1)
To identify and articulate the unmet needs and
priorities of the people for hea.lth and development.
(2)
To stimulate Government to introduce measures to
meet these needs.
(3)
To act as a catalyst mobilizing people for
development.
(4)
To be a model builder ’experimenting and evolving
alternative approaches for health and development.
(5)
To be a representative of peoples’ aspirations.
(6)
To act as a watchdog, ensuring the interests of
the weaker sections of society, be they in urban
slums, or remote tribal villages.
(7)
and above all to be an active partner with Government and the people for preventive, promotive and
curative health and social, economic and cultural
development.
The concept of primary health care embraces the
very quality of life of the people. It is an interface
between the extension of essential services by Govern
ment and the vibrant, dynamic, upward struggle of the
people for the betterment of the quality of their life.
interface
that Voluntary agencies
It is it this vital --have their greatest role, They are the bridges between
They are rhe pace setters
the people and the Government,
innovaters and reformers.
Ofcourse they have problems and irritants in working
__
______ They They
have have
to betoovercome.
ThereThere
are are
with
Government.
be overcome.
_-_l indifferent Government officers as there
good, L--'bad and
are good, bad and indifferent voluntary agencies.
It is useless to blamej the Government for everything
that goes wrong. Let us together
u--,---- meet the formidable
.n
challenges of Health For All oy marshalling all avai..aoie
resources at all levels.
306
Health For All is a social contract between the
Governments of the member states, U.N. agencies like
W.H.O. & UNICEF., Voluntary Agencies and the peoples
of the world.
Only 14 years remain to redeem our pledge. The
answer to health problems, as in many fields of human
endeavour, does not solely lie in technology. Let us
harness the tools of technology to a powerful human
effort for the common good*
Let us be partners in health and development
to meet our tryst with destiny.
307
ROLE OF THE PRIVATE PRACTITIONERS IN PROVIDING PRIMARY
HEALTH CARE IN RURAL; AREAS
Vasant Jalwalkar
Our country has undertaken to ensure that a
minimum level of health care will be provided to every
citizen by' the year 2000. The progress achieved in
the last nine years does not give us a great deal of
hope that the level of achievement during the next
14 years will be very considerable. This paper
assumes that the strategy adopted is.correct and
suggests some tactical changes, par-ticularly with
regards to the role of private practitioners.
When this policy (PHC approach) was announced
by Government of India in 1977/ in advance of the
Alma Ata declaration of 197 8, a certain amount, of
haste was discernible in the way the then Health
Minister made his announcement□ Although both the
tne
then ruling party as well as the main opposition
party at the time had included a similar strategy in
Health care in their election manifestoes for uhe
General election of March 1977/ the clumsy attempt
of the Minister to hog the credit for that policy
meant also that he did not stop to consider the role of
private practitioners/ as represented by I.M.A./ m
implementing such policy. The President of I.M.A.
had made a suggestion to the Government about implementing
such a policy and had indicated that.I.M.A.
totally support any Government in this regards This
overture was disregarded. I have detailed all this
the
an now, because/impression has been created that/_.I .M. A.
is against the P.H.C. approach. This is entirely cue
to some historical accidents/ related more to.political
rivalries in the parties, rather than any basic or
fundamental difference of opinion between the mecical
profession as represented by the official policy of the
I.M.A. and the Government’s position on this matter.
The PeH.C. strategy involves provision of health
care to the rural population by about 100 VHWs in each
Taluka (average population of 100,000) covered by one
eccentrically placed Primary Health Centre manned by
thrle doctors. I know that this ratio is now being
reduced and the aim is to have 3 doctors of the P.H.C.
supervise only 50 VHWs, by doubling the Centres by
2000. It is worthwhile to note that even the second
centre will be eccentrically placed in the Taluka and
there is no proposal to utilise even the Government
§
308
financed doctor attached to the municipal dispensary
in the Taluka town. I would like to suggest that
private practitioners of the Taluka town should be
recruited to help in training and continued super
vision of VHWs in the Taluka to achieve the aim of
having one doctor supervise no more than 10 VHWs.
It is hoped that Primary Health Care will cover
provision ofcataract surgery to all the population
by 2000. No body quite knows the exact number of
operations needed to be done in the population every
year. At present about 100,000 operations are
being done in the State of Maharashtra (Pop. 68 million)
while 400,000 operations are being done in the entire
country (683 million - 1981 census). The population
is expected to age substantially by 2000 and by 2040
the number of people above the age of 55 is expected
to be four times the present number, necessitating a
proportional increase in the provision of services
for cataract operations. I can’t imagine that the
Government can hope to provide anything more than a
small proportion of this service through its own
doctors. Provision of spectacles for myopia and
hypermetropia (including reading glasses) is not even
in the PHC strategy, although the demand and need
for them) is enormous> The private practitioners
(surgeons as well as opticians) must be recruited for
this purpose.
Tubectomy (and Vasectomy) services are considered
essential services and are being offered in the PHO
approach by the Government. But services of a
gynaecologist are not considered essential either for
contraceptive advice or supervision of antenatal
care of ’at-risk’ pregnancies. The other glaring
omission in the PHC approach is the absence of any
practical plan to help those women (estimated at 5% - 10%)
who have difficult labour. There is no effort to
develop the provision of services of Forceps delivery/.
Caesarian Section and blood transfusion. Both these
are perhaps due to severe shortage of trained gynae
cologists/ but recruitment of the services of private
practitioners will go a long way in meeting the need.
The provision of surgical services for conditions
like hernia/ hydrocele, fistula/ etc. is not included
in PHC strategy, although the need for them is sub
stantial. Private practitioners could be persuaded
to help, if suitable arrangements are made to enable
them to do so.
3t9
The main question ir- to decide whether the
Government needs these private practitioners. If the
answer is yes, the Government must work out suitable
incentives to ensure their co-operation. I have no
doubt whatsoever that enough men and women can be
found in the Medical profession who will volunteer
for this work, without demanding excessive compensation.
I have no doubt also that the Indian Medical Association
will be a strong ally of the Government if the approach
is right.
310
Interaction Between the Government, NGOs and the Private
Sector in Implementation of HFA
by
Abhay Bang
1.
Ideological basis of cooperation? The Coopera
tion between the Government and the NGOs in the health
sector was* always on the basis of common ideology and
interests. Thus different categories of NGOs were colla
borating at different times with the then ruling govern
ments. Christian missions were actively cooperating with
the British rulers with common imperial interests. The
Gandhian constructive institutions were active in colla
boration with the Congress government with their common
roots in the freedom movement and ’Congress' ideology. The
gates were opened for the voluntary agencies with closer
links with the 'opposition' parties (When these came into
the power under the name of Janata Party) by allowing a
major role to NGOs in the National Adult Education
Programme. Now with the free market ideology of the
Rajiv Gandhi's government, private sector shall have more
role. The talk of social marketing, of delegating the
responsibility of advertisement of the national programmes
to the private agencies are the few examples.
Where do the NGOs in the health sector ideolo
gically stand today? Inspite of their tremendous diversity
and different religious or economic roots, most of them
explicitly or implicitly believe in the welfare state with
mixed economy. Obviously they don’t find any major ideo
logical problems in collaborating with the various govern
ments in India. Even those who profess to have a radical
ideology usually don't have problems in cooperating with
the government as long as they can continue to attack the
system while retaining their safe positions in the urban
universities and institutions. Many other grass root
workers or activists strive for limited reforms by
opposing the government policies; and yet in the long run
they too work with the government as their reforms are
accepted.
Thus most of the NGOs today have no major
ideological barriers for cooperating with the Governments
in Indiao
311
3
2o
Changing Role of the NGOs; Inspite of
hundreds of failures of implementation, the National
Health Policy is more progressive than most of the NGOs
At least at the conceptual level, the Primary Health
Care is oriented to prevention, outreach and use of
paramedics, while most cf the NGOs are still curative
oriented running charitable dispensaries or hospitals
or diagnostic camps. Gone are the days of Albert
Schweitzer or Father Domain when such individuals or
The
NGOs outreached where no government care reached
most important outreach agencies today are the
practitioners o rThus
government or the private practitioners
----- -in the
Gadchiroli district which is probably the most diffi
cult district in Maharashtra, there are;
NGOs in health
PHCs
GPs(including
RMPs)
3
34,with 230 subcentres
and 700 CHVs
About 300
A recent study by FRCH on the NGOs in health
in Maharashtra concluded that the NGOs are concentrated
in the developed districts rather than the backward
areas.
With tremendous expansion of the Government
health sector or the private practitioners, what new
role the NGOs can assume, especially if they want to
increase their impact by interacting with the government
which alone has the political responsibility and
resources to provide HFA?
’Following roles may be possible
1. Research and innovation
2 o Demonstration
3. Training
4o Evaluation
5o Building public opinion for change of
the Government policies»
While the last one is not a cooperation
with the Government in the narrow sense, this role is
extremely important,, The history of public health is
studed with the examples as to how this role has
greatly improved the Government policies and programmes»
The Sanitary Movement in the Great Briton in 19th
century or the work of the environmentalists today are
_____ examples
__________
the glaring
0 But the rest of the discussion
in this paper does not include this type of role.
-?
T •
312
Issues in Government - NGQ Interaction
In any working together compatibility/ on
attention.
following points is important, and
u.-d hence
---- needn
--
le Ideology and Goal
2. Objectives (specific)
3. Organisational structure and culture
4. Procedures and rules
5. Personalities
6. Finances
The ideology and the goal being similar,
these don’t pose much problem in actual working together.
But the different emphasis due to different obj ectives
may ibose a problem. Down in the field the primary health
care seems to be reduced to fulfilling targets of few
vertical programme objectives. The family planning tops
the list with immunisation and blindness control coming
next. Rest of the programmes or indicators like infant
mortality count little. The NGO may have different or
broader objectives and hence a tussle for priority may
ensue. A NGO may not be willing to go all out for the
numerical targets of FP while for the Government health
officer, it is a sacred cow.
There is a contradiction in the structure
and function of the Primary Health Care strategy. The
National Health Policy has abandoned the unipurpose
organisational structure. Now we have buildings and large
number of health workers so that an organisational basis
is created for continuum and comprehensive health care.
And yet, the health programme® are still conducted in the
form of campaigns which need a mobile structure and large
scale propoganda rather than buildings and accessible
workers•
In the relationship with the government
organisation a NGO is likely to face what may be called the
’middle level constraint’. At the top, the officers can
take broader view about cooperation. The bottom level
functionary may be happy to work with NGO because of more
humane and liberal treatment. It is at the middle levs
where the problem of rivalary and sharing.of power arises
and hence a great resistance or even hostility may start.
313
The maze of the procedures and inscru
table rules which are characteristic of the Govern
ment functioning pose two types of problemso NGOs
often understand the intricacies of these and can be
easily trapped into immobility while working with
these. On the other hand the NGOs have the advantage
of autonomy and flexibility in their own structure
and their partnership with a Government institution
or officer who is tied by the procedures may be like
a pair of inequal bullocks resulting in strain and
dissatisfaction to both.
Even in the seemingly faceless and
impersonal government system the success of the coo
peration may depend heavily on the personalities.
A single person with vision and openness for new
things can make a world of difference.
whether NGOs
find cooperative government officer or an obstruc
tive one in their path depends on their luck or on
the political maneuvering. How to match compatible
persons from two sides so that smooth working is
possible is a major issue.
be
The government money should^available to
NGOs in health if they too are working for HFA. And
yet if NGOs take money from the government, they are
either subordinated by the political decision maker
who use distribution of favours as a political weapon
or they are trapped and immobilised by the endless
restrictions and procedures which necessarily accom
pany the government grants. In both the ways,
NGO looses its qualities of autonomy and speed.
How can the government money be made
available to NGOs and yet not have these side
effects is an issue for discussion.
314
CHV Experiment ; A case of NGO-Governmcnt Interaction^
When conceived, the CHV was to be a volunteer
bringing with him/her the qualities of NGO i.eo autonomy,
motivation, community participation etc. And yet during
implementation he was converted into the lowest category
of government.worker with little financial remuneration.
He was subordinated and internalised by the government
health structure.
Except for a handful of powerful NGOs, the
most will be feeble and dependent on government once they
enter in cooperation. A fate similar to that of CHV must
be avoided by giving attention to the various aspects of
interaction discussed above. And yet, this is a new area
of organisational research and innovation. Only through
a process of trial and error, experimenting and learning
that a feasible model will emerge. Respect for each
other and openness is essential prerequisite on either
side.
'kX-icTk'k-k'ic-k-k-klc >. **
315
'HEALTH FOR ALL' AND THE GENERAL PRACTITIONER
Mukund Uplekar
How many of practising General Practitioners
'Health
for all by 2000 ADo'? If our telephonic
know about
2.
survey is any indication,, the answer is - 'most of the
Practitioners
do not know what it is all about!
G eneral 1
------- --Answering three questions put to them, 4% of
the responding General Practitioners confessed that they
are absolutely blank about it, 36% had heard something
like 'health 'for all' but knew nothing more than that, 54%
recalled to have read a little about it but refused to
c-ive any importance to it as they considered this as just
another slogan (like 'G--:ibi Hatao' according to a few).
Gnlv 6% could elaborate on the issue and were aware that
it is a WHO declaration. They knew about Alma-Ata, the
targets set for 2000 AD and also about, integrateo deve
lopment and primary health care approach etc. The
questions put were — (a) Have you heard about 'Health for
all by 2000 AD (b) could you tell us more about it (c) In
what way, you think you could help to achieve the goal. In
most of the cases, the question of answering the third
querry did not *rise at all.
It is estimated that about 70% of the health
care services are provided by the private practitioners <> It
is needless to mention that these services at present are
exclusively 'curative’ in nature taking, care of the
illnesses rather than health.
What has been the Government* s efforts to involve private
practionars? How many of General Practitioners are aware
of our national health policy? What is precisely the role
of a General Practitioner? Is it possible to- achieve health
for all without involving the General Practioners at all?
In no other country so many systems of medicine must be
practised as they are in India. How many of those trained in
indiginous systems of medicine really practice what they are
trained in? Why most of them ultimately land up in practising
•western' type of medicine in a haphazard fashion?
In achieving the goal of Health for all, must
not the first priority go to locking after the health of
health .service? and particularly of those provided by
private practitioners in whom people have much greaterfaith than they have in the Government's efforts?
********’******
3-6 •
316
PRIVATE PRACTITIONERS' AWARENESS ABOUT
“HEALTH FOR ALL BY 2000AJD."
HAVE you HEARD ABOUT " HEALTH FOR ALt "^
36 7.
\
THINK SO III
■54Z*
isocio
i \
X
improve )
WELL .-YES-4
PUBLIC (
health \
SCR.VICES/
F ECONOMIC l~x\
peyelopmentj \
ALMA)
_ ata/
I/z^InvolvFX
((primary
7/xT PRtVATfe’'^iPRACTtnONE!
7ou \
TC-nJ
/XhX
w
/ 54 7» \tl
JUSTANOM
SLOGAN LIKE-'
40% NO
WiiK z
52% ?
^^GARlBiA \/
COULD YOU TELL US MORE ABOUT IT.5J
HOW J)0 YOU THINK YOU COULD
HELP TO ACHIEVE THIS GOAL
-
r
■
■
F
HEALTH FOR ALL AND THE PRIVATE MEDICAL PROFESSION
by
GoG. Perikh
2.
---- feeling of unease while
There is always
a vague
articles and reports of discussions and
A.D. and
debates on the obiective of Health for All by 2000 ^A.D
the National Health Policy adopted in 1983^by Parliament.
Any enquiry into this feeling yields a whole gamut of
causation; the foremost being that while discussing these
. v
almost every one moves in the rarefied atmosphere of hign
theory and idealism and not on the firm ground of reality.
There is a dream like quality of the discussion.
This unease is not because the objective is
undesirable. A little reflection tells us that the
objective can be realised and the national health policy
with some modifications can be implemented. But this
cannot haopen by the due date and through the announced
policy measures as long as the current socio-economicpolitical philosophies continue to prevail. it is not
sufficiently realised that the framework of the National
Health Policy is the framework we had accepted when
Socialism was the goal and there was a commitment to
contain the market forces through state and societal.
intervention. This situation has radically changed in uhe
last three years, in fact it was not there even when the
policy resolution was being drafted, and since the date o._
■ - frame
"
its acceptance little is left of the old
6,_ It
It is
is
accepted
the
objective
and
passed
the
obvious that we have
resolution on National Health in the best Indian tradition
of aiming high while practising low.
A survey of documents from Shore committee
report (1946) to the National Health Policy Resolution
(1983) establishes fairly reasonably that ve have progres
sively refined our concept of health and learnt to
distinguish between health and health care. o we know now
that it is not enough to have so many doctors, paramedics
and beds per thousand of population, so many medical
institutions (PHC, DhC, etc J for a particular proportion
of population, a particular hierarchy of administration
from the national to the taluka level with the required
logistic support, or capacity to produce the required drugs
in the required quantities at prices that people can afford,
but we also need safe drinking water and.sanitation, equal
access to services and provision of services at doorsteps.
3-18
better nutrition/ widest possible diffusion of
knowledge about health and health related matters and
disease and their prevention/ integration of vertical
services/ holistic approach/ integration of private
voluntary effort with the state effort/ more jobs,
better housing/ and involvement of community; in short/
total economic development<» What better refinement
is possibTel As we read through chronologically these
documents we febl that a picture of Gandhian Ramrajya
or a Socialist Utopia is unfolding in front, of our
eyes» There is no dearth of ideas or high thinking in
this country and the international community comes in
with a lot of high-minded suggestions to help us
along/ and besides/ the experience of China and the
pioneering work of a few of cur own doctors were
available to build this dream picture.
It is possible to prick holes in the policy
s tatement from several directionsz but let us limit
ourselves to doing it only from just two partly
related directions»
The National Health Policy adopted in
December 1983 refers to the private medical profession
in a few paragraphs. The reference to the profession
is very scanty but mercifully it is not totally
ignored. It would be worth reproducing the paragraphs
where the private medical profession is referred to.
The Paragraph No.8(7) says:
!'Vvith a view to reducing Government expen
diture and fully utilising untapped resources/ planned
programmes may be devised related to the local
requirements and potentials/ to encourage establish
ment ’of practice by private medical professional/
increased investment by non-governmental agencies in
establishing curative centres and by offering organised
logistical/ financial and technical support to
voluntary agencies in the health field.’’
Then there is a reference in the
paragraph No.8(8)
‘‘While the major focus of attention in restructuring the existing governmental health
organisations Would relate to establishing comprehen
sive primary health care and public health services,
within an integrated referral system/ planned
attention would also require to be devoted to the
establishment of pentres equipped to provide speciality
and super-speciality services/ through a well dispersed
319
1
network of centres, to ensure that the present and future
requirements of specialist treatment are adequately available
within the country., To reduce governmental expenditure
involved in the establishment of such centres, planned efforts
should be made to encourage private investments in such
fields so that the majority of such centres, within the
governmental set-up can provide adequate care and treatment
to these entitled to free care, the affluent sectors being
looked after by the paying clinics. Care would also require
to be taken to ensure the appropriate dispersal of such
centres, to remove the existing regional imbalances and to
provide services within the reach of all, whether residing
in the rural or the urban areas/’
There is also a reference in the paragraph 12,
but it is largely in the form of a summary of the paragraph
7, which acts as an intro to certain specific measures.
It says
“Besides the recommended restructuring of the
health services infrastructure, reorientation of the medical
and health manpower, community involvement and exploitation
of the services of private medical practitioners, specially
those of the traditional and other systems, involvement and
utilisation of the services of the voluntary agencies active
in the health field, etco, it would be necessary to devote
planned, timebound attention to some of the more important
inputs required for improved health care”.
A few things are clear from the above. The
role of the private medical profession (75% of the doctors
are in private practice in this country) in the realisation
of the national objective is limited to minimising the cost
of providing curative treatment by encouraging the private
practitioners to establish themselves (perhaps in rural
areas) and providing speciality and super-speciality services
to the affluent sections of society (perhaps in urban areas).
This formulaticn of the role is an admission by
the Government that the private professional has very .
limited - actually very little - role to play in the reali
sation of the goal of Health For All .by 2000 A.D, The
Government also admits that there are going to be two types
of health services in the country; private for the rich
and public for the poor, justified on the beguiling principle
‘those who can afford should pay*.
320
Leaving aside the examination of this
principle - it would again become a theoretical
discussion, let us examine, ofcourse cursorily, what is
happening to the private medical profession and what
influence it can have, unless positively harnessed, on
the realisation of the goal via the policy perspective
and programme enumerated in the National Health Policyo
It should be kept in mind that what the
medical practitioners say and do influences the rural
community as much as it is influence the urban populationo
(1) Since the Shore Report, the situation
in the distribution of the medical practitioners
(allopaths, practitioners of Ayurved and Homeopathy most of these practice allopathy and RMP’s mostly
recognised for no other reasons except that they are
practising medicine for sometime) has changed to a
certain extent in the last fifteen years. More and
more villages are having practitioners of modern
medicine (trained or not), and many of them are earning
a reasonably comfortable income. Similarly, doctors
have discovered that the practise in the slums can be
as lucrative as in middle class areas- and therefore
almost every slum in most metropolitan areas has a
doctor - some times more than one.
(2) There is a growing bias in favour of
paid services in the country. Patients for various
reasons - a few of them certainly valid - prefer to go
to the private practitioners and are willing to pay
for services even to those Government doctors who are
not allowed to charge in the belief that they will get
better services. That some Government doctors extort
money and get away needs no emphasis.
(3) The general practitioner earns his
income by providing services and there is a fee for
each service. More service he provides more income he
earns; there is little money in giving advice excepting for the consultant. This applies not only to
general practitioners but also to consultants. There
is a general complaint that the number of unnecessary
references, investigations, and operations have
increased and this complaint is not without substance.
In such a situation a private practitioner has a vested
interest in over prescribing, giving injections etc.
321
However much the health activists talk against these, this
D^ctice will continue till either the society s mores
SSl!y change or it finds out a different way of c^penstting the doctor for his services. The experience of
Universal Health Services as in Britain or contributory
health services in other countries has not come up to
-e
expectations of their originators. In Somoay, the E.
becoming more and more unpopular daily and the f^ulnot of doctors alone.
(4) Many patients have a preference for uhC'Se
who
give
more drugs, injactions and charge more,
doctors
idealist
private practitioner discovers to his
Many an
dismay that it doos not pay to be idealistic.
(5) A doctor
doctor spends
spends a
a lot of money on .ducation
and to start his practice, 'in
In addition, there is new the
svstem of capitation foes and the sons and
daughters of
:
doctors queue up to get admissions.
The
expensive
.ducu^ion
admissionso
end the high colt of starting private practice generate a
desire to make money quickly. This is rtinf^rcec. by
general atmosphere where every young man is t.^..ii j
making a fast buck.
(6) Offering cut and extracting it from the
consultants is fast becoming a normal business practice in
many cities. It is not frowned upon as in tbc past, i^ung
specialists plead helplessness and general practitioner.,
Sgue that after all the specialists .make ^ney out of the
patients they send. Barring the periodic.critical notice^
of this practice in the lay press, there is 1 u
'
with a view to eliminating it in the prof0 percent
specialists confess that they have to part with 50 Percent
of their fees and some general practitioners b*.st -h-.t
they do not send patients unless they get SO percent.
e
are bold enough to extract pre-payment, the cut
earned
in due course. No one talks Of noble.profession th.-St
days, not even for the sake of hypocrisy.
(7) No one can say that only medical profe
is considered reprehensible. A man who makes it in ....
- g
way is not stigmatised. The smuggler, the cc.rrupt
politician or the bureaucrat, and the black marketeer are
not shunned or boycotted. In fact, we pay our respects to
322
them if they are sufficiently rich, and they all move
in high society. Actually, they form the high society.
In such a situation, it is too much to expect the
medical profession to think of the noble tradition of
service to humanity or to be motivated by the example
of the pioneering work of their peers who have blazed
a new trail of providing low cost health care through
training illiterate women, involving community etc.
They cannot be expected to decry the hospital rased,
urban oriented, pro-rich health care system that has
developed in this country and which is growing despite
all efforts to the contrary. Let us not just keep
bemoaning that doctors are not moving to the rural
areas and keep exhorting them to settle down there, Tin
a society where everyone is pragmatic, everyone is for
himself, it is foolhardy to expect doctors to make
sacrifices. An individual doctor may, but not the
class.
If what is said about the prevailing
practices is correct, there will be a rise in hospitals
giving super-speciality services, more and mjrc
colleges to produce more doctors, and certainly even
greater concentration of institutions in urban areas,
specially metropolitan areas, negating the very
strategy which has been accepted to achieve the
objective of Health for All by 2000 A.D. No sophisticated analysis of who owns the state, or how free
is the state, or whether it is a soft one is necessary
to draw these simple conclusionso
The Government will not change the resolution
It will remain as a pious objective before us, useful
to give us points to make impressive speecheso The
International Community also will not change the Alma
Ata Declarationo Only the reality on the ground will
be different and now that the country is re-discovering
virtues of the market economy, it might even be more
difficult for our state to change courseo
There are people who think in their innocence
that it is possible to build at the cost of the public
exchequer a health care service which is comparable to
the service which the rich are giving to themselves
and this public service will be free and accessible
to the poor. But even a cursory glance at the fate
of the welfare measures taken in behalf of the poor
and the needy shows that even if money is found to do
323
it on the scale required (which is; an impossible assumption)
v=' 1will benefit disproportionately more even
those who ‘have'
The
better
jyi tTiese ©
__ offs, the educated, the influential
;
-j escape clause
will preempt these services through^some
right
deception
if there is
legitim, tely or through dowo rJ g'-"
no escape clause.
This is not all. If more money is spent on
health care less will be available for drinking water,
sanitation, nutrition supplement , employment generation.
education, housing etc. And the only result of the slogan
of community involvement will be; that it will act as.a
salve to our conscience, Butz if we are sensitive, it will
not be very good salve» When someone from the rural areas
or the slums points out to.us that having given yourself
a highly sophisticated medical services and solving all
your economic problems, you arc now giving us a second
class service by making us responsible for our own health,
and advising us to take recourse to the age-old 'kadhas'
because they are cheap and wej can afford it and also because
grandmother used to prescribe them. I am sure, we wiH
t h e cJ
be very much troubled, but forgive me if i assert, that
feeling will not result in any action. It
this troubling
•_
will only produce some debate, some disdussicn, one.more
.
round of seminars and1 taking
. advantage of the infinite
biological capacity to adapt we will get over this
this feeling
feeling
in no time.
But, supposing we wish to do something,
the slogan and are
supposing we are serious about achieving
.
determined to persue the strategy laid down, is there
anything that can be done?
There is little that can be done via the
We
can petition it as many are doing, but a
Governmento
Which
is convinced of the virtues of the free
government
market economy and given the experience of
decades of mixed economy which has produced only a bigg
and more vicious class of exploiters, tnere is i^-ttle
ground for hope to do anything via that route, unlej
all decide to work for changing this government and
installing a new one. While it is a task
N-,tional
more utopian than the task assigned to us by the National
Health Policy, it is also a way of escaping our r<_^pc i
lities. To think of changing the government without
formulating a philosophical basis an^
± t
gathering the required strength to effect the change
indulge largely in day dreaming»
324
Perhapst a peoples' movement committed to
the goal and convinced of the strategy can set us on the
course of realising the dream. But this will involve
buil ling brick by brick an alternate social system
working in a different value system, something similar
to what Gandhiji did during the national movement. He
visualised the ideal social system and created an army
of trained and disciplined and practising people who
were willing to work for it. He even made it possible
for them to live in the system. We are in a very
peculiar situation. We are all beneficiaries of the
existing system, though we keep decrying it and trying
hard to dismantle it. I am afraid, all cur criticisms
end up in strengthening it and not dismantling it. More
than radical critique what is required is praxis, It
was once a revolutionary step to offer a radical
criticism of the existing society. It is no more so.
Radical critics are strewn all over the landscape and
a number of critiques are available and yet nothing is
happening. It is time we think of acting and go beyond
exploring the gap between the concept and the reality.
*
*
325
★
•k
DISCUSSION
Both the National Health Policy (1983) and the Seventh
Five Year Plan (1985-90) envisage the Active participation of
the non-government (voluntary organizations) sector and the
private sector in the delivery of health care services, as
part of the overall strategy for achieving the goals of HFA by
2000 A.D. Session IV focussed on the interaction between the
government, the private sector and the NGOs in the implemen
tation of the HFA strategy■<
There were six background papers,
three each on the private sector and the NGO1s respectively•
The Role Of The Private Sector;
Dr. Abhay Bang, presenting the three papers specifically
dealing with the private sector,
(by Dr. V.C. Talwalkar,
Dr. G.G. Parikh and Dr. M. Uplekar), pointed out that these
had limited themselves to(i) a discussion of the features of
private practice, and (ii) the potential role of private
practitioners in the government’s health care delivery organi
zation.
The role of th^ private and multinational pharma
ceutical industry in the health policy was not covered by any
of the papers. The papers pointed out, that while 60 to 70
per cent of the Indian medical manpower and resources woe
concentrated in the private sector, the latter was assigned a
marginal role in the overall HFA strategy.
During the discussion, two sets of questions were raised
about the potential role of the private sector in achieving
HFA. The first set of questions dealth with the interactional
problems between the preventive and promotive orientation of
the primary health care approach, and the largely curative
activity and profit motive of private practice.
326
Those who did not visualise a change in the curative
orientation of private practice, suggested that it be
integrated into the government health organisation at the
point of referral services.
According to Dr. Talwalkar, there
was a substantial role for private practitioners in providing
referral services in municipal dispensaries and taluka hospi
tals. These services were absolutely necessary to make a dent
in the high infant mortality rate (IMRl, as many infant deaths
were due to difficult pregnancies in need of medical attention*
Dr. Coyaji coroborated the need for referral hospitals and
logistics in order to control maternal mortality which was on
the increase between 1979-80 a The ctrative component in the
national programmes for diseases control could also involve
private practitioners.
Dr. Talwalkar felt that preventive
work should be the responsibility of the government, and its
para-medical workers and of the Primary Health Centres (PHC’sy,
and not of the medical professionals.
With rising educational
and economic status of the population the demand for profess
ff
ional services, as against para-medical services, would
increase, and this was already happening in China. The role
of private practitioners and curative services would increase
significantly in the future. A third viewpoint was provided
by Dr. Sujit Das’s paper (Session III) which argued for a
3-tier system within which private medicare would serve the
health needs of the affluent, while free public services would
be reserved for the low income groups.
Several doubts were raised regarding the above arguments
for integration:
Firstly/ it was emphasised by Dr. Antia that the reduction in
maternal and infant mortalities in China was the outcome of
preventive and promotive action in non-health areas, such as
in tackling nutritional anaemia, and not of the expansion of
referral services^
327
Secondly, the Primary Health Care (PHC) approach was a totality
of nine elements, as set out in the Alma-Ata Declaration.
According to Dr. Deodhar, the discussion of this approach
could .1O'C
.lo'c be reduced to the elements of medical care and
curative services., nor that of ‘barefoot doctors’ & Health
Guides.
Thesuggest.ions for building up the secondary level
medical and hospital services were outside the scope of the
present 'itscussj.on and reflected a lack of understanding of
the strategy is underlying philosophy•
Dr. Deodhar identified
a number of areas of PHC activity within which the role of the
private practitioners and’ the service NGO’s could be
qualitatively expanded
(?-)
Continuing education about the national diseases control
(b)
p rogrammes;
Post-treatment health care, rehabilitation and providing
information about medicines, immunization etc.
(c)
(d)
(e)
Cataract surveys;
Registration of all births and deaths;
Epidemiological information regarding morbidity and
mortality in their area of practice;
Conducting sterilizations & MTP’s
Thirdly, accordingl-to Dr, Saroj Jha, the distinction between
promotive, p. eventive and curati/e activities was confusing,
since survey and the diagnosis of illness, treatment and
rehabilitation constituted a single process. A general
practitioner who did not undertake epidemiological surveys and
public health measures in his area and was completely clinic-
oriented, could not undertake effective curative work.
Fourthly, Dr. G.G. Parikh, pointing to the experience with
honoraries, felt that any integration of private practitioneis
in the HFA strategy would only result in the expansion of
private practice. The government should (i) ensure continuing
education to the GP1s and (ii) develop measures to expose and
328
control malpractices in the private sector, before any viable
interaction was possible.
Fifth, a cautious note was struck about the. importance of
medical professionals in the HFA strategy. According to
Dr. Abhay Bang, doctors eroded the role of ANMS and grass
roots health workers, or used the latter to fulfill family
planning targets.
Unless power devolved to the lower-level
workers, major problems such as maternal mortality could not
be reduced. According to Dr. Antia, those in favour of
expanding the role of the medical professionals, were under
estimating their contribution to the excessive medicalization
of health problems, and the mystification of surgery and
medicine.
The other set of questions were concerned with the
historical trends underlying the interaction between the
private sector, the NGOs and the government in health services
delivery, and their implications for the future.
These
questions are taken up in the section on NGC-•s.
The Role of the NGQ * s.
Two broad approaches to understanding the role of the
non-governmental organizations (NGO’s) in the implementation
of the HFA strategy were adopted during the discussion. One
approach began with the assumption that the NGO sector and the
Government sector were mutually dependent,• and the issue was
one of identifying specific areas of co-operation and conflict
in their interaction. The other approach viewed this depend
ence in historical and structural terms, in order to pin-point
the political role of NGO1s and to better eveluate their
claims.
The first approach was developed in the presentation by
329
Dr. Abhay Bang. He limited himself to a discussion of the
role of “Service NGO’s” (see Duggal’s paper, p.l.), and elabo
rated on the issues set out in his own background paper.
According to Dr. Bang, main interactional problems between the
government and the NGO’s were with regard to implementation
and not ideology.
To give his argument a sharper focus, he
compared the interaction between the government Primary Health
Centre (PHC) at Bamhragarh (Maharashtra) and a pioneering
voluntary agency in the neighbourhood:
"Just a week ago I was at Bamhragarh, probably the remot
est area in Maharashtra.
It requires 70 kms journey
through forest to reach there, the area is totally without
electricity.
Some 13 years ago, a doctor-couple settled
in the area and began to provide the first medical care
services. According to their records, they have treated
37,000 patients in the last 13 years.
To my surprise I also found a government Primary
Health Centre (PHC) some 4 kms. away, staffed by a Medical
Officer (an old class-mate. Dr. Maheshwar) and II ANMS.
The two institutions-a pioneering voluntary agency and a
government PHC-are an interesting study in contrast.
Their relationship is one of mutual distrusts while the
voluntary agency ^regards the work of the PHC as an
unnecessary encroachment on its curative services,the
PHC1s view is that the voluntary agency’s only concen
trates on curative work and has no contribution to make in
©ther areas such as family planning. In actual fact, both
are only doing curative work, thereby duplicating each
others efforts. The other feature of voluntary agencies,
that they reach out medical services to the very remote
areas not served by any orfe else, no longer holds.
Probaoly the Government health servrfcces and the private
practitioners are delivering curative health care far more
330
to remote places than the voluntary agencies. I have
mentioned in my papers/ and the FRCH study on NGO1s has
also pointed it out/ that most of the voluntary agencies
in Maharashtra are concentraced in the relatively
developed areas.
If the original roles of voluntary agencies, such as
humanitarian service and taking services where non exist,
are obsolete then what are the possible new roles for
them? What are the areas in which co-operation and inter
action between the Goven ment and. the voluntary sector are
possible?
1. Research and innovations--
Voluntary agencies have
been credited with innovation, model building and
undertaking pioneering project^. This role can
probably provide the substance and quality rn the
extensive quantity of the ongoing Government programmes
As I have already pointed out, outreach is the Charact
eristic of the Government services, not of the volunt
ary sector. The former often lacks content and quality
in its programmes and probably the voluntary agencies
can, through innovative approaches, provide substance
to the structure.
2. Training and Demonstrations-
Some voluntary agencies,
especially in Maharashtra such as the Wadu and Jamkhed
projects, are already performing this role in relation
to the government health services.
3. Creating public opinion to influence and pressurise for
reforms in health policy.
This will not be perceived
as co-operation by the Government, but mobilising
public opinion for reforms in the health policy is a
very important role that the voluntary sector can play.
Many agencies are doing this with regard to, the drug
policy, the use of amniocentesis test for sex determi-
331
nation and so on.
The ideological positions of the government and the
voluntary agencies, and the question whether there could
be any ideological harmony in their interaction, has been
discussed in the papers. Although the approach to this
issue differs from, paper to paper, the conclusion is simi-
liar. Ravi Duggal has' argued that within a welfare state
framework, voluntary agencies have functioned to provide
relief and have thereby further legitimised or popularised
the Capitalist Government (State).
Dr. Coyaji has argueo
that voluntary agencies can, and should, become the
•partners of the Government, fulfilling those roles that
the latter wants to take up but is unable to carry out.
r'
t
Either position, leads to a statement of fact that the maj
ority of voluntary agencies in this country have an ideo
logy similar to the Government *s-whether this is called
capitalistic, mixed economy or welfare state—and that
there are no major ideological barriers to their working
together (interaction) . Their understanding of health and
health care being similiar, ideology is not the problem in
their interaction.
Certain advantages and strengths have been attributed
to the NGO’s. There is no doubting that they are motiva-
•
However, two other strengths claimed by the NGO's,
namely that they are closer to the people than the Govern
ted.
ment agencies and that they are more efficient and cost-
effective, need to be questioned and discussed.
The very structure of NGO1s is undemocratic and cent
ered around a single personality. As they work at the
micro—level and their culture of working stresses humane
behaviour, the □ ] lusion is created Lliatvol untary agencies
332
are closer to the people. However, NGO’s are not struct
urally accountable to the people. Whatever the deficien
cies of the present political system, the Government is at
least made accountable to the people^ directly or indirec
tly, through the electoral and political process.
With
regards to cost-effectiveness, it must be remembered that
voluntary agencies often have motivated people willing to
work at lower remuneration.
This norm is forced on the
subordinate staff as well so that the functioning of NGO’s
is cheaper.
However, what is never evaluated is the out
come or end-result of their work.
What sort of problems exist in the Government-NGO
interaction? These are not ideological but problems of
implementation.
Although the broad goal of welfare of the
people is the same, the two sectors differ sharply in
their specific objectives and priorities. Let me go back
to the Bamhragarh example. That particular area has the
highest incidence of falciparum Malaria in the whole of
India. Malaria accounts for 50 per cent of OPD attendance
and hospitalization causes in the hospital run by the
voluntary agency. Yet the doctor-couple, doing excellent
curative work, have never stopped outside their hospital
to locate (and eradicate) the source of the malaria
infection.
They are content to do their humanitarian,
curative workl Similarly, most NGO’s continue to run
dispensaries, hospitals, diagnostic and treatment camps,
and remain highly curative-oriented in their priorities.
The pioneering model projects like jamkhed, Vadu and some
others are simply not representive of the NGO sector.
The Bamhragarh PHO on the other hand, has concentrated
mainly on the Family Planning and immunization programmes.
Two interesting features of the population in this area.
333
highlight the problems with the PHC’s work. First, the
tribal population is declining so that family planning is
irrelevant to this area. Second, measles, diphtheria,
tetanus, chicken pox are no.i-existent in this area. It
would make an interesting epidemiological study to under
stand the reasons for the absence of these diseases.
ever, inspite of their absence,
How
the PHC Medical Officer is
vigorously irrelementing the national immunization
programme.
Thus, the main activities of the PHC are
irrelevant to the area.
Irrelevance marks the work of both the NGO and the
PHC, although for different reasons.
In the case of the
NGO this is due to 'a lack of epidemiological vision and
the lack of prioritisation.
The priorities of the NGO
doctor flow from his own desire, feelings and skills
rather than from what the people need, The irrelevance
of the Government programmes are due to over-centraliza
tion, so that whatever the national policy, it has to be
implemented in Gadhchiroli, whether relevant or irrelevant
Besides the irrelevance of their work, the problem of
differing objectives has to be overcome to enable
Governm nt NGO interaction.
There are also differences in structure, rules and
procedures, and the culture of work. We have been working
with the Government structure for the past few months.
The culture differ sharply. When I go to my office, our
driver doesn’t even care to stand up. When the Deputy
Director of Health Services comes. our District Health
Officer immediately offers him his own chair and sits.
like a schoolboy, on a chair in front of the DDHS. This
particular exchange of chairs is very, very symbolic, Its
not a mere ritual, but is mean*-, to indicate who the boss
334
is. In the Government culture it is very important to
establish repeatedly, and at every step, who the boss is!
The fact that I do not follow this culture has become a
problem in my work with the Civil Hospital. The Civil
Surgeon, the Government representative with whom I co
ordinate, is expected to follow the advise that I give
him.
When I go to his office, I sit in front of him and
He then thinks that he is the
So how are
one to advise me and tell me what I should do!
he retains his own chair.
these two cultures to be reconciled in order to achieve
interaction.
Personality problems exist, but these are
present within the NGO’s as well. However, when the two
systems come together, these problems multiply. This is
more so at the middle level. At the top of the hierarchy,
as for instance the Health Secretary or the Planning
Commission level, no one loses anything by giving a role
to the NGO’s.
At the grass-roots level, the PHC MO and
health workers do not really mind co-operating with the
NGO’s. It is at the middle level where power-sharing
oecomes necessary, that structural and personality
conflicts arise.
Most of the NGO’s in ihe field of health, unlike in
the field of education, do not depend upon the Government
for their finances.
This gives them autonomy in their
'decision-making and work.
However, if the Government is
committed to transferring resources to the people in the
context of its goal of Health for all, then NGO's should
also get a share of these resources. The problem is how
to share these resources without turning the NGO’s into
the appendages of the Government, as has been the case
with the Community Health Volunteers.
Therefore, how do
the NGO’s maintain their autonomy, the freedom to
criticise and differ with the Government, while receiving
335
K
funds from the latter?
So far -we have discussed the problems and possibili
ties of jOvernment-NGQ interaction from the NGO standpoint
What about the Government's perception of this inter- action?
Interaction has taken .place in the past too.
From time to time there is a spurt in the Government-NGO
interaction.
Recently, this interaction has gained
momentum again. Why does the Government want to co-oper
ate with the NGO1s? Is the Government admitting to its
inability to implement its tasks and programmes? Or is it
an attempt by the Government to shrug off its responsibi
lity on to other agencies? or, is it that the Government
is using the NGO's to blunt the suffering of the people,
and thereby, blunt their political struggles,as some of
our friends here have interpreted? If the Government is
willing to share responsibility, is it also reacty to be an
equal partner with the NGO's in sharing resources, roles
and power?
How is this to be implemented?"
The need to safeguard the autonomy of voluntary work was
taken up by Dr. E.G.P. Haran. The evaluation of USAID funded
NGO projects showed the increasing dependence of voluntary
agencies on the government for finances. This jeopardised
voluntarism since the government was in a position to impose
its model of health services on the NGO’s. Raising their own
funds was one way of minimising dependence, but none of the
practical schemes such as health co-operatives and health
.insurance had worked. The largely curative-orientation of NGO
activity was also due to the scarcity of resources, since the
promotive component needed additional finances. He suggested
the setting up of intermediate agencies, such as SOSVA, to
improve the collaboration between the Government and the NGO's.
336
Dr., B. Coyaji, citing the philosophy of the Vadu health
project/ did not accept the view that the government was
attempting to control the NGO’s.
In her view, the NGO‘s were
the junior partners attempting to improve the functioning of
the government through certain marginal inputs.
Dr. P.V. Sathe, was critical of the view that the NGO1s
could provide the managerial inputs for improving the function
ing of the government health organization. In his view, most
NGO*s required funds but worked with very small numbers. This
was the basis for their success in reducing birth and death
rates.
Such experiments were non-replicable.
They represented
a parallel health system which was a waste of resources o
The
government should instead depend upon the resources of the
government medical colleges.
A number of views were expressed regarding the political
significance of the role of NGO’s. Dr. G.G. Parikh, replying
to Dr. Sathe’s criticisms/ claimed that the performance of
NGO1s was superior to that of the government’s in every
development sector. He identified the NGO1s as socialist,
Marxist and Gandhian grass-roots organizations which had
internalised a definite radical critique of the system and
were fighting on behalf of the oppressed. Progressive govern
ment policies, such as the Gandhian concept of people’s
participation, were substantially moulded by NGQ’s. They had
an on-going role to play in pointing out the basic weakness in
the society which needed active intervention.
Dr. A.R. Desai, however questioned the potential of NGO1s®
as also of the government and the private sector, in reaching
out to the poor people, awakening them, and assisting them to
develop movements for the solution of their problems. He
posed the question, “How do these three groups handle the
337
three non-medical factors: food, water and shelter, which are
the basic determinants of health?" Were doctors, whether
private practitioners or those with the NGO's, aware of the
wider problems in their environment such as the proliferation
of slums and pavement- dwellers and the threat of evictions,
the lack of basic facilities such as laterines, water supply
etco?
In his view, most middle-class doctors condemned the
poor and respected those with money. They were hardly
interested in wider socia.l problems and dynamics such as the
socio-economic causes underlying female suicide rates. In
this context Padma Prakash pointed out that NGO1s had the
same limited understanding of women’s health problems as the
government.
According to Dr. Amar Jesani, the approach and basic
philosophy of the Alma-Ata Declaration, particularly its
emphasis on people’s perceptions and participation, would
distinguish between those NGO1s who aimed at implementing the
Government's development programmes, and those who sought to
empower the people in their struggle against the government.
The latter referred to trade unions and people •s organizations
and these were also a part of the NGO sector.
The trend of transferring public resources to NGO1s by
the Government was questioned. Ravi puggal sought to modify
the notion of ideological affinity between the Government and
the NGO sector by pointing out the underlying historial trends
in their interaction. NGO’-S had played a significant role in
influencing health policy and. moulding the social services
sector along western modelsA new type of NGO had emerged in
the post Green Revolution period -which was strengthening the
private sector by smoothening the process of integration of
rural areas into the market economy. Both he and Dr. Jesam
questioned this trend towards the privatisation of the public
338
health sector. The issues highlighted were whether public
money should be appropriated by the private sector, and
whether professionals should aid this trend.
Dr. Sujit Das disagreed with Dr. A.R. Desai and Dr.Jesani
about the role of the present forum.
Decisions about organi
zing people for their basic needs could not be made in a
seminar. The focus instead would have to be on.
(i) health sector allocation, and
(ii) the interaction between the private sector and the
government.
A concrete discussion on what could be done within the system f
and keeping in view the demand for social justice, was
required.
Once again the question of people's participation was
brought up.
Dr. Antia, pointed out that in discussing the
interaction between the Private, NGO and Government sector,
the People’s sector had been ignored.
There were no attempts
to learn from the people about the methods they used to cope
with their health problems.
In this context Dr. P.B. Desai
asserted that the two features of HFA highlighted by Dr.Antia /•
namely 1democratisation1 and 'd centralisationwere not
realisable within the present structure, and that HFA as a
strategy could not be achieved.
—l H ,i
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