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Donated by Dr. C M Francis in Feb. 2010
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August 2001
Changing the Indian Health System
Current Issues, Future Directions
)
APPENDICES
Rajiv Misra
Indrani Gupta and Arup Mitra
Rachel Chatterjee
Ram Harsh Singh
V. Vijaychandran
INDIAN COUNCIL FOR RESEARCH ON INTERNATIONAL ECONOMIC RELATIONS
Core-6A, 4th Floor, India Habitat Centre,. Lodi Road, New Delhi-110 003
.1-
Contents
Appendix 1. Restructuring the Ministry of Health and Family Welfare
Rajiv M:sra
1
Appendix 2. Economic Growth, Health and Poverty : An Exporatory Study on India...
Indrani Gupta and Arup Mitra
39
Appendix 3. Evolution of Health Policy in India
Rachel Chatterjee
60
Appendix 4. Basic Principles of Ayurvedicd Medicine and its materia Medica
Ram Harsh Singh
72
Appendix 5. Health Systems in Andhra Pradesh
Rachel Chatterjee
93
Appendix 6. Health Empowerment of the People : The Kerala Experience
V. Vijaychandran
153
ii
u
APPENDIX 1
Restructuring the Ministry of Health and Family Welfare (MHFW) *
Rajiv Misra
Introduction:
At the outset, the inclusion of this paper as a separate appendix to the
Report needs an explanation. The Report deals with issues at a macro
level. On the other hand, restructuring of the MHFW could legitimately be
considered a matter of detail, which may appear to be outside the scope
of the Report. The inclusion of this paper is based on the conviction, that
the wide ranging reforms suggested in the Report would require very
strong leadership from MHFW, which may not be possible without a
thorough restructuring. Even so, keeping in view the mandate of the
Report, the treatment of the subject has been limited to only the broad
framework of reorganisation. Also, the paper has been includedI as an
appendix and not made an integral part of the Report.
The paper is primarily based on the two studies by the Administrative
Staff College, Hyderabad (ASCI) 1986, and the Centre for Policy
Research, Delhi (CPR) 1999 with important inputs from the Expert
committee on Public Health systems 1996 (Bajaj Committee). However,
the personal experience of the author in the MHFW has also contributed
to the paper, which could result in some bias. Although every possible
care has been taken to maintain objectivity, yet the possibility of this bias
has also persuaded us to keep this paper separate from the main Report.
The views expressed herein are entirely to be attributed to the author.
Existing Structure :
A minister of cabinet rank, or alternatively, a minister of state with
independent change, heads the Ministry. In the case of the former, there
is usually a minister of state to assist the cabinet minister. The Ministry
has three independent departments, viz. The Department of Health (DH),
the Department of Family Welfare (DFW), and the Department of Indian
Systems of Medicine and Homeopathy (DISMH), each headed by a
secretary (See Figure 1). The Ministry thus, has 3 Secretaries, 2
Additional Secretaries (both in DH), 8 Joint Secretaries and 30 officers of
the rank of Director excluding technical advisers.1 The cost of
administration at headquarters is Rs. 14 crores a year.
It currently
commands a budget of Rs. 6,000 crores of which Rs. 3,400 crores goes
1 CPR - 1999 and MHFW
* The paper is authored by Rajiv Misra, who held the position of Secretary,
Department of Health, MHFW from 1.1.91 to 31.1.94.
1
h
into the maintenance of institutions and existing levels of services and
Rs. 1,600 crores on the expansion of national programmes and centrally
sponsored schemes.2
The division of responsibility between DH, DFW and DISMH is given in the
Allocation of Business Rules (Annex I) DH broadly deals with public
health, medical services, medical education, food and drug standards,
professional councils, international aid to health and health research.
Although, not specifically mentioned in the Rules, health policy has been
traditionally dealt with in DH. The DFW is primarily responsible for family
planning and maternal and child health. Again, though not specifically
mentioned in the Rules, it has been made responsible for rural health
infrastructure. The DISMH, as the name suggests, deals with all matters
relating to Ayurveda, Siddha, Unani, Homeopathy, Naturopathy and Yoga.
As the CPR report observes “there is today no Ministry as such, only
three independent Departments”.
MHFW has an attached office; the Directorate General of Health Services
(DGHS), which is the apex technical institution for health matters in the
Government. It is headed by the Director General (DG), who is equivalent
in salary and status to a Secretary. The DGHS has an organisation larger
than the DH with a budget of Rs. 13 crores as against Rs. 8.9 crores for
the latter.3 The DG is assisted by Additional DG’s, Deputy DG’s and
Assistant DG’s and a host of other technical and non-technical staff.
MHFW has 3 and the DGHS 101 subordinate offices (Annex 2 and 3).4 In
addition, there are 31 autonomous / statutory bodies under MHFW,5
although only 25 are listed in the CPR Report (Annex 4). The Ministry
has 3 Public Sector undertakings (Annex 5). MHFW either directly or
through the DGHS / autonomous bodies is involved in the day to day
management of a host of institutions ranging from medical colleges,
hospitals, laboratories, production units of condoms, Ayurvedic medicines
and vaccines, research and training institutions and health care schemes
for Central Government Servants (CGHS). The situation is made more
difficult as the autonomous bodies, are autonomous only in name, with the
Minister / Secretary chairing the governing bodies and the Ministry
representatives dominating their functioning. The affairs of institutions
like the All India Institute of Medical Services, which also provide tertiary
2 ibid.
3 ibid.
4 ibid.
5 Annual Report 2000-2001, MHFW.
health care facilities to VIPs, always command disproportionate attention
of the Minister and senior officials.
The DGHS and its subordinate offices are primarily manned by the Central
Health Service (CHS) which is composed of four sub cadres as follows6 :
Name of sub-cadre
Approved Strength
(i)
General Duty Medical
Officers (GDMO)
3123
(H)
Teaching Specialists
623
(iii)
Non-Teaching Specialists
769
(iv)
Public Health Specialists
78
In addition there are 13 posts in the Higher Administrative Grade common
to all the four subcadres.77 The dominance of GDMO’s and the relatively
poor representation of public health specialists seriously affects the
professional and technical competence at senior levels, as all cadres are
eligible for the senior positions including that of the DG.
It is impossible to capture in a few paragraphs, the diversity of institutions
being managed by the MHFW and the DGHS. Most of them have highly
unionised cadres leading to frequent agitations and strikes. It would not
be an exaggeration to say that the main preoccupation of the Ministry
is managing itself rather than providing stewardship to the national
health system. The situation has got further aggravated by the recent
trend of judicial activism which imposes a heavy burden on the officers
who keep rushing from one court to another.
The organisation of DGHS is particularly weak, loaded as it is with
GDMO’s having experienced only clinical practice in CGHS dispensaries.
They have experienced neither public health nor administration. They
head organisations like the Bureau of Planning, Central Bureau of Health
Information, Central Bureau of Health Education, where they can rarely
provide effective leadership. The DG is also saddled with duties of VIP
health care which claims disproportionate time and energy. In the recent
past, all DGs have been from clinical backgrounds with no formal training
or experience in public health. This has been a serious limitation on their
technical contribution, although admittedly some gifted individuals have
6 ibid.
7 ibid.
3
overcome this deficiency by their diligence and learning capabilities. A
majority of senior technical experts in the DGHS, have never had
exposure to the rural health services where three fourth’s of the
population lives and where most public health programmes are targetted.
As a result, DGHS has not been able to provide the expected technical
leadership, which has encouraged the Ministry to directly assume more
and more responsibility and functions.
The so called autonomous institutions are worse off.
Since most
governing bodies are chaired by the Minister himself, the more important
ones, like the All India Institute of Medical Sciences (AllMS) get a lot of
attention and in the process get highly politicised. On the other hand, the
less important ones cannot even get the Minister’s attention and time for
scheduling the meetings of the governing bodies and completing the
statutory formalities of passing the budget, annual accounts etc.8 Even a
research organisation like the Indian Council of Medical Research (ICMR)
has statutorily provided for the Minister to be the chairman and the
secretary to be the vice chairman. The inevitable consequence of this
arrangement is that the Ministry is heavily burdened by routine
administrative issues relating to these autonomous bodies. This has been
further aggravated by the Finance Ministry directives in the wake of fiscal
constraints to dilute the financial powers of these bodies.
Since all
creation of posts, upgradations etc. even within the sanctioned budget
require specific approval of the Finance Ministry, the matter has
necessarily to be processed in the Ministry, even after the competent
body of the autonomous institution has approved the proposal. The
Government, thus, exercises excessive control over autonomous
institutions, which is totally counterproductive. The only explanation for
the continuance of this unhappy arrangement is, that it provides
opportunities for exercising power and patronage both to the political
heads and the bureaucracy.
The proliferation of sub-standard medical and dental educational
institutions and their unbridled expansion without requisite facilities led
Government to amend the Medical and Dental Council legislations to
provide for specific prior approval before starting, expanding or upgrading
an institution.
Earlier these approvals were given by the relevant
Councils and only their formal notifications were issued by the
Government. They were not effective in exercising control, partly due to
the weakness in the law, and partly because of their own vulnerability to
political and other pressures. This was sought to be remedied by the
amendment in the statutes, but an unintended result was the transfer of
decision making powers from the Councils to the Ministry. This had not
8 ASCI Report 1986
4
only generated substantial additional work for the Ministry but thrown up
new opportunities for corruption and influence peddling.
The parliamentary work has also increased over the years. The Standing
Committees of Parliament constituted to scrutinise the budget and
programmes of each Ministry, function round the year generating a lot of
additional paper work. Then, there are natural calamities and epidemics
in different parts of the country to keep the officials on the run.
Cumulatively, this has led to the Ministry usually lurching from one crisis
to another and the officials finding it difficult to cope with even routine
work, let alone the time and opportunity to reflect, introspect and develop
a long term vision for the health of the nation.
The quality of leadership also suffers on two counts : the low profile of the
Ministry and the high turnover of ministers and secretaries. The former
results in the portfolio being assigned to political light weights who cannot
assert effectively the viewpoint of the health sector in inter-ministerial
consultations. Till recently (27.5.2000), the minister in charge did not
even enjoy cabinet status. Similarly, MHFW is not considered an
important position in the bureaucracy, and has often been used as a
dumping ground for civil servants proving inconvenient elsewhere, which
undermines their morale and motivation. The problem gets compounded
by very high turnover both at the political and bureaucratic levels. In the
last five years, both the current Minister for Health and Family Welfare
and the Secretary Health are fifth occupants of their respective positions.
The management of the Indian health system is a most challenging
assignment in any circumstances. It naturally takes time for a minister or
a civil servant to grasp the complexity and the enormity of the problems to
be addressed.
Even before the learning process is complete, the
incumbent is replaced.
If systemic reform in the health sector is to
succeed, the Government would need to assign to this Ministry the most
capable political and bureaucratic leadership and assure them a
reasonably stable tenure.
Role of the Ministry :
The role of the State in health and the respective jurisdictions of the
Centre and the States have been discussed in Chapter 3 of this Report.
The role of the Central Government has been suggested as follows :
1.
Stewardship :
• Formulating health policy, defining vision and direction;
• Regulation, framing laws, setting standards and arranging their
enforcement;
5
•
•
•
•
•
Monitoring the health and demographic indicators, including their
main determinants, and evaluating the impact and performance of
health related interventions;
Collecting and using health intelligence for epidemiological
surveillance and policy formulation;
Promoting inter-sectoral coordination for achieving health goals;
Guiding and overseeing the health system to meet the objectives
of universal access, equity, quality and consumer satisfaction.
Mobilising public opinion and support of all stake-holders and
promoting active people's participation for public health activities.
2.
Health Finance :
• Mobilising resources and facilitating the establishment of a health
financing framework which ensures fairness and financial risk
protection;
• Mobilising external aid and channeling it to priority areas.
3.
Manpower Development :
• Planning and encouraging the development of human resources
for health and developing an appropriate incentive system to
attract, retain and motivate health workers to work in priority
areas.
4.
Health Research :
• Promoting and supporting health research in relevant areas in
both public and private sectors;
• Establishing institutional mechanisms for analyses of research
inputs and their utilisation for health policy and programmes.
5.
Public Goods :
• Promoting and supporting health education, sanitation, safe
drinking water, improvement of environment, control of risk
factors like tobacco, alcohol and unhealthy life styles.
6.
Merit Goods :
• Planning and
supporting
delivery of merit
goods,
like
immunisations, control of communicable diseases, population
control and nutrition.
7.
Public Health :
• Arranging technical
programmes.
expertise
to
guide
and
oversee
state
6
u
8.
9.
Drugs and Pharmaceuticals :
• Developing the policy framework to ensure availability
essential drugs at affordable costs;
• Standardisation, quality control and their enforcement;
• Encouraging rational drug use.
of
Food Standards :
• Laying down standards and regulations and overseeing their
enforcement.
While some of these functions are presently outside the purview of
MHFW, the main responsibility for discharging these responsibilities lies
with this Ministry. Although many of these functions are being performed
by the Ministry in one way or another, the outcomes are well below
expectations due to structural weaknesses that have been discussed
above.
Recommendations of the Studies/Committees ;
ASCI Report :
The first independent assessment of the role and structure of MHFW was
done by the Administrative Staff College of India, Hyderabad (ASCI) in
1986. This is a well researched and detailed report which, unfortunately,
never received due consideration. The report was generally regarded as
too academic and theoretical and of little practical value, and it was
quietly buried as the DGHS could not be persuaded to examine and offer
comments. The DG, at that time, was a controversial but a politically
influential figure, who blocked consideration of the report, which
recommended complete integration of the Ministry and DGHS. Above all,
no one had the time and inclination to read a bulky report and develop an
appropriate action plan to follow it up. The report got buried so deep that
when the next exercise on the same subject was undertaken more than a
decade later by the Centre for Policy Research, they were not even aware
that such a report existed.
The specific objectives of MHFW suggested in the ASCI report are :
• To monitor the epidemiology of disease, prioritise among them
and develop programmes to control or eradicate them;
• To supplement the States in providing high technology or
specialised medical care;
• To set and maintain standards of medical and related education
and to project manpower need;
• To set and maintain standards of food and drugs;
• To determine intermediate and long term research needs;
ii
•
•
•
To exercise health relatec control at international borders;
To provide contraceptive services for family planning; and
To guide and influence policy formulation.
In order to achieve the above objectives, the main recommendations of
the ASCI report were :
• MHFW and DGHS be combined and regrouped into six
programme divisions and two functional divisions. This implied
total integration of the then existing two departments of Health
and Family Welfare as well as DGHS. This was sought to be done
to “strike a judicious balance between technical soundness and
implementation feasibility.’9
• A Policy Advisory Committee be set up with a separate
secretariat to advise the Ministry on policy issues.
• The Central Government Health Scheme (CGHS) be converted
into an autonomous board to relieve the Ministry and DGHS of
day to day management responsibilities
• The Ministry expends considerable time and energy on the
hospitals under its charge for seemingly trivial and routine
maters. These routine functions be delegated to a hospital
management committee and the intervention of MHFW confined
only to policy and the larger issues.
• The publicity and promotion functions to be decentralised to
programme divisions and externalised to specialised agencies.
(This would make existing organisations like the Central Health
Education Bureau in the DGHS and the Media Division in DFW
redundant).
• A separate organisation be set up to deal with non-contraceptive
issues related to population. (The setting up of the National
Population Commission with its secretariat in the Planning
Commission may have met this need).
• The Minister / Secretary should not chair the governing bodies of
the autonomous organisations. The chairperson should be a non
official with a reasonable term of office. The Ministry may be
represented by one, or at the most two persons on the governing
body.
• The offices of the Regional Directors of Health be abolished.
• The manning of technical posts, particularly senior positions,
from state government cadres be considered.
9 ibid
8
u
CPR Report :
Almost a decade later a study on the same subject was entrusted to the
Centre of Policy Research by the Department of Administrative Reforms
and Public Grievances, Government of India as a follow up of the
recommendations of the Fifth pay Commission. The core functions of
MHFW were defined in this study to comprise the following :
• Setting national goals for the health status of all citizens, for
delivery of health services to them, and for moving towards a
zero growth population in different regions, in definite time frame;
• Monitoring progress towards these goals;
• Formulating national policies, strategies and investment priorities
to achieve these goals;
• Developing national systems of control of major communicable
and non-communicable diseases;
• Developing national programmes of medical education, training,
and research, including the establishment and control of some
institutions of national importance.
The report also stated a general proposition : “A Central Ministry should
be concerned essentially with planning, evolving policies and programmes
for the implementation of the plan objectives; and the allocation of funds
to the State, and the executive agencies and autonomous organisations,
institutions, etc. The implementation of policies, execution of programmes
and management of institutions are essentially responsibilities to be
undertaken by State Governments, executive agencies and autonomous
organisations.”
The main directions of the reforms were summarised in the CPR report as
under:
“Decentralisation of planning and investment programming in the
(i)
health sector substantially to the States, who were in any case
responsible for implementation. MHFW would be responsible for
setting national targets, formulating policies, extending advice
and assistance through technical experts, and monitoring health
indicators, demographic indices and service norms in the States.
(ii)
The executive functions that today eat up considerable time of
senior MHFW officials should be drastically reduced, This can be
done by transferring some institutions to the States and
entrusting ancillary activities like CGHS and drugs control to
independent agencies.
(iii) Large existing institutions funded wholly or partly by MHFW
should be made fully autonomous, without indirect control of
MHFW through representations on their Boards.”10
10
CPR Report
9
u
The main structural changes suggested in the CPR study are :
• Integration of the three Departments, viz. Health, Family Welfare
and Indian Systems of Medicine and Homeopathy.
• Converting the Central Government Health Scheme into a fully
autonomous organisation managed by its own board.
• Setting up an autonomous Medical Store Purchase organisation
or even a corporation to handle procurement in place of the
present organisation under the DGHS.
• All medical colleges and hospitals in Delhi be transferred to the
Delhi government along with their budgets with the sole exception
of Dr. R.M.L Hospital which may work under the new autonomous
organisation for CGHS.
• The Central and Centrally Sponsored Schemes run by the
Minsitry be generally made a part of the State’s block Cental Plan
assistance with a few exceptions like AIDS, drug resistant TB and
Malaria.
• MHFW should have no administrative responsibilities for day to
day management of hospitals, medical colieges research
institutions; instead it should concentrate on its basic tasks of
national health planning and policy making;
• All governing bodies of autonomous institutions should be
manned by expert professionals identified through search
committees. The Ministry should not have any representation on
these bodies.
• The Drug control functions be transferred to an independent
National Drug Authority as envisaged in the Drug Policy of 1994.
• An independent commission be established on the lines of
University Grants Commission to deal with all matters relating to
medical education.
Bajaj Committee :
The Expert Committee on Public Health System (Bajaj committee) 1996
had a much wider mandate but it made some very important
recommendations on the restructuring of the MHFW :
• A health impact assessment cell should be established to
evaluate development projects and schemes with regard to their
health consequences.
• An All India Service for Medical and Health be constituted on the
lines of the Indian Administrative Service, the Indian Police
Service and the Indian Forest Service, to facilitate interchange of
specialists between centre and the states.
• The three departments in MHFW should be merged.
10
•
•
•
An institutional mechanism should be devised to address inter
sectoral coordination among all health related activities, viz.
education, sanitation, drinking water, environment, nutrition, rural
and urban development etc.
Even an overarching Ministry of
Human Welfare be considered for this purpose.
Establishment of a health manpower planning division in the
DGHS.
The National Institute of Communicable Disease (NICD) be
upgraded into a centre of excellence on the lines of the Centre
for Disease Control (CDC).
Atlanta in USA, to oversee and
monitor both communicable and non-communicable diseases and
to provide state of the art technical expertise.
Broad Direction of Reform :
The above analysis conclusively establishes the need for wide-ranging
reform as well as its broad directions. The first and foremost is the
obvious need for MHFW to shed most of its executive functions and to
focus on its policy making, planning and monitoring role. Constitutionally,
‘health’ is a state subject and thus there is no justification for the Central
Ministry to involve itself in implementation of programmes or in day to day
management of medical institutions. Unless and until, MHFW can shed
the excess baggage it has accumulated historically, it would never be able
to devote time and attention to core issues. Even a cursory examination
of the list of institutions being managed by the MHFW and DGHS
(Annexes 2,3, and 4), would reveal that many of them are unrelated to its
legitimate responsibilities and have been established without sufficient
scrutiny. Many of them are the result of individual fancies and pet ideas
of Ministers and senior bureaucrats. It is obvious that MHFW has not
grown according to any vision or a plan but purely on adhoc basis. And in
Government, unfortunately, once an institution gets established, it is near
impossible to close it down, even when its redundancy is patent.
This brings us to the next point. What we need is an end to adhocism and
growth and development according to a well thought out plan.
This
requires strategic thinking and in depth analyses which could contribute to
an improvement to the quality of decision making. The core ministries of
the Government, like Home, Defence, Finance have in built capabilities
for analysis but the so called developmental ministries, which saw rapid
growth after independence, are particularly deficient. It is often argued
that the time spent on research, study and analysis is a waste as the
decision makers would anyway decide in accordance with their
preconceived notions.
There is no empirical evidence to support this
view. In any case, even if a decision is to be taken to disregard the
evidence and the analysis, it should be a conscious one mindful of its
11
implications. There is an urgent need to develop capabilities for policy
planning and analysis to contain adhocism and to encourage evidence
based and well informed decision making.
The temptation to run the health system of the country setting in Nirman
Bhawan11 arises from a desire to exercise power and influence. As we
have seen, this is neither constitutionally mandated nor is it feasible in a
country of India’s size and diversity. But the same power and influence
can be exercised much more productively in a different way, by the sheer
weight of knowledge and expertise. MHFW should then become a
repository of the highest professional and technical expertise in areas like
public health, epidemiology, health economics and finance and health
care management - something the states can never do at their level. The
states would then be voluntarily seeking the Ministry’s advice and
guidance, giving it power and influence without in any way appearing
interventionist. The centre can then use its traditional stature and
financial clout to steer the country’s health system towards rapid and
sustained improvement. Basically, MHFW and DGHS need to be
restructured to become store houses of knowledge, expertise, and
analytical capacity - more of a think tank than an organisation for day to
day management.
It would be impractical to suggest a complete shedding of executive
responsibilities. There are constitutional, statutory and parliamentary
functions assigned to MHFW which would involve management of some
institutions and organisations and performing essential staff functions.
Even in such cases, as a general rule, the attempt should be to distance
the Ministry from day to day management to the extent possible, by grant
of autonomous status and delegation of powers, and limiting the Ministry’s
role to laying down policy, approving financial allocations and monitoring
performance. This alone would keep the focus on the core policy making
role.
Another beneficial consequence of the shedding of executive functions
would be that the officers of MHFW and DGHS would not be tied down to
their desks and would be able to travel to the states, where the real action
lies. The unfamiliarity with the reality on the ground which develops as a
result of the officials' preoccupation with routine administrative work in
Delhi, greatly limits their ability to contribute to policies and programmes.
The more the officials are able to see things for themselves and interact
with health workers at the cutting edge, the better would be their
contribution to the programmes.
11
The building in New Delhi which houses MHFW.
12
Specific Recommendations :
The broad approach to restructuring would follow from the above
discussion. Once the goals are clear, the specific steps to be taken to
achieve them can be identified after considering the feasibility and
implications of various options suggested in the three reports.
It is
neither possible nor desirable in this brief paper to debate the merits and
demerits of each suggestion.
However, some recommendations, which
appear eminently sound and feasible, are commended for consideration.
However, it may again be clarified, that the specific measures suggested
are not important in themselves, as long as there is movement towards
the stated goals.
Integration of the three Departments (DH, DFW, DISMH) :
All the three reports are unanimous on this recommendation. In fact,
disease control, immunisations,
maternal and child
health and
contraceptive services are inseparable as they are to be delivered on the
ground by the same health infrastructure. It is also essential, that not
only is there complete coordination between the three departments, but
that there is someone to take a comprehensive and holistic view of the
entire health scene. It is however, recognised that a separate department
for ISMH has given long overdue attention and visibility to a hitherto
neglected but high potential area.
The ideal position would be to
completely integrate the three Departments, with activities like ISMH and
family planning, requiring senior level stewardship, being looked after by
special secretaries or additional secretaries.
However, if this is
considered infeasible for any reason, there are two easier alternatives for
achieving the goal of coordination :
(i)
(ii)
The existing structure with some modifications to avoid
duplication be retained with the Health Secretary being raised
to the level of Principal Secretary and given the coordinating
role.
The above suggestion, can also be implemented with the
senior most secretary being given the coordinating role, like in
the Ministry of Finance.
We may hasten to add that with the proposed reduction in executive
responsibilities, the existence of the three separate departments may not
be justified on the basis of workload alone.
Giving up executive functions :
13
The recommendations of both ASCI and CPR Reports in this regard need
to be implemented.
Regarding the autonomous bodies, both are
unanimous that MHFW should not be chairing governing bodies of these
institutions. The CPR, however, suggests that there be no representation
of MHFW, while ASCI agrees to one or two representatives on the
governing bodies.
MHFW is answerable to Parliament for these
orgainsations as they are discharging important functions on behalf of the
Government. Hence the ASCI suggestion appears more acceptable as
long as the spirit of the reform is respected. In respect of subordinate
offices of DGHS, a very rigorous scrutiny would be needed to see whether
their continuance is still justified.
Some important institutions like
Jawahar Lal Nehru Institute of Medical Education and Research,
Pondicherry (JIPMER) and All India Institute of Hygiene and Public
Health, Kolkata (AIHPH), need to be converted into fully autonomous
institutions. Further, the institutions in Delhi, viz. Safdarjung Hospital,
Lady Hardinge Medical College and nursing institutions should be
transferred to Delhi Government along with their budgets. Likewise the
Chittaranjan Cancer Institute, Kolkata and the Institute of Psychiatry,
Ranchi should go to the respective State Governments.
Reorganisation of DGHS :
If the DGHS is to effectively play the role of the apex technical and
professional organisation in public health, it would need to separate the
medical services functions from public health. For this purpose, the
present DGHS be divided into a Directorate General of Public Health and
a Directorate General of Medical Services. The public health cadre would
be substantially expanded by induction at senior levels from State
Directorates of Health. While the ideal would be to create an All India
Service as suggested by the Bajaj Committee, in the present political
climate, creation of a new All India Service may not be acceptable to
State Governments. Hence arrangements for two way deputation may be
worked out with 50% of all posts of DDG and above earmarked for state
officials. Directorate General of Medical Services would then become the
apex institution for curative care and medical education. It would lay down
standards, quality assurance norms, prescribe medical audits, suggest
rational drug use, develop accreditation mechanisms and deal with
professional bodies like the medical council, besides looking after
residual clinical care responsibilities.
The procurement of medical stores should be entrusted to an autonomous
corporate body as suggested by CPR following the successful model of
Tamil Nadu. This would further reduce the administrative burden on the
DGHS.
14
In order to make it a highly professional organisation, career progressions
in DGHS would need to be dependent on professional attainments rather
than on seniority and merit (as judged from Confidential Rolls). The entire
culture and ethos of the organisation would need to be transformed with
emphasis on specialisation, training and professional advancement.
GDMO’s would have very limited role in this organisation.
Central Government Health Scheme :
As suggested by both CPR and ASCI, CGHS should be converted into an
autonomous organisation separate from DGHS. The organisation would
also include Dr. R.M.L. Hospital which would serve as the institution for
specialist care for CGHS patients. Eventually, as suggested by CPR, the
entire scheme could be replaced by appropriate insurance cover.
Food and Drug Control Organisations :
The drug control functions need to be separated from DGHS with the
creation of an independent National Drug Authority as envisaged in the
Drug Policy of 1994. Better still, a combined national Food and Drug
Authority can be established on the lines of the FDA in USA. This is an
area which is relatively weak and deserves to be substantially
strengthened. The codification and enforcement of food standards has
become particularly, important with the lifting of quantitative restrictions
on imports.
Inter Sectoral Coordination :
The Bajaj Committee has rightly emphasized the need for coordination
with sectors having a major influence on health outcomes. A Ministry for
Human Welfare may become unwieldy and may not be feasible,
feasible. But as an
immediate step two committees, one at the Cabinet Secretary's level and
another at Cabinet level nebd to be set up to periodically review
coordination and strive for convergence at grass root level. These two
Committees may be :
Cabinet Committee on Health, and
(i)
Committee of Secretaries chaired by Cabinet Secretary
(ii)
comprising
all
departments
concerned
with
activities
influencing health outcomes,
like education, sanitation
drinking water, environment, nutrition, etc.
The latter may meet at least once a month and the former once a quarter.
Strengthening Planning and Analytical Capabilities :
15
The existing Bureau of Planning in DGHS would need to be replaced by a
strong, professional multidisciplinary team of epidemiologists, public
health specialists, experts in health economics and finance and
statisticians located in the MHFW itself with close linkages with research
institutions. A Policy Advisory Committee, as suggested by ASCI would
be a step in the right direction. There should be an earmarked budget for
health policy and systems research (WHO Country budget could also be
utilised for this purpose) and a mechanism for regular interaction between
policy makers and researchers for setting the research agenda and
utilisation of research inputs.
J
Health Education Commission :
The recommendation of CPR for the setting up of an autonomous Health
Education Commission on the lines of the University Grants Commission
would yield many benefits. It would enable undivided attention to medical
education and the take over of the functions being exercised by the
Government after the 1992 amendments in the statutes. Also it would act
as the focal point for manpower planning which has been rightly
emphasized by the Bajaj Committee.
Health Impact Assessment Cull :
The recommendation of the Bajaj Committee needs to be implemented to
set up a specialised unit, for in the DGHS for health impact assessment of
various development programmes which could be causing new health
hazards. In fact a health impact audit of all major development schemes
needs to be made mandatory.
Upgradation of National Institute of Communicable Diseases (NICD) :
The suggestion of the Bajaj Committee to upgrade the NICD into an
institute of excellence on the lines of the CDC Atlanta (USA) deserves
support. The existing infrastructure is totally inadequate as we have seen
in case of the epidemics. Also with the epidemiological transition, the
Non-Communicable Diseases and their risk factors would require
increasing attention. The upgraded NICD could take over from the DGHS,
the important task of epidemiological surveillance. This would again be
converted into an autonomous institution in accordance with the policy
enumerated earlier.
16
■’SS-
Indian Council of Medical Research :
The restructuring of ICMR is a subject that deserves a separate paper and
cannot be dealt with adequately here. Suffice here to say that statutory
changes would need to be made to replace the Minister and Secretary as
Chair and Vice Chair of the governing body. Also, it may be desirable to
change its nomenclature to Indian Council of Health Research in
recognition of the role of health policy and systems research, which must
be an integral part of ICMR’s mandate. It should play an active role in
promoting research in health policy sciences extra-murally and also
develop adequate in house capacity in these disciplines. Another reform,
deserving immediate attention is, developing institutional mechanisms for
close interaction between disease control programmes and research, and
more active participation of programme managers in setting the research
agenda.
Health Education :
Health education and creaing awareness about risk factors would need to
be an integral part of the new strategy. The Central Bureau of Health
Education in DGHS, as it is presently structured, would be quite unequal
to the task. As suggested by ASCI, the actual publicity would need to be
externalised to professional agencies. But internally, we would need
capacity for identifying the main messages, the best ways of
disseminating them and the ability to select the right professional agency
for each task. An integrated media division in the Ministry working in
close collaboration with programme divisions and DGHS would be the best
way to address this important requirement.
Monitoring and Evaluation :
One of the main responsibilities of MHFW would be monitoring of health
parameters and evaluating the impact of various State interventions. It
should develop strong institutional capabilities, with increasing use of
information technology, to keep a close watch on all developments related
to health in different parts of the country. It should develop capacities to
respond quickly to feedback from the states with policy and programmatic
changes.
Regulatory Framework for Health Insurance :
With the opening up of the insurance sector, there are likely to be many
players in the field of private health insurance, which would require the
establishment of a strong and independent regulatory mechanism to avoid
the well known market failures of the health insurance system. In addition,
17
there would need to be major expansion of employer-based, and social
health insurance to provide mucn needed risk pooling and financial risk
protection. All this would require a vigilant and strong regulatory
framework to be established by MHFW.
Regulation of Private Sector :
The regulation of private sector would primarily be the responsibility of
the states. However, MHFW would need to play’ a major role in developing
appropriate legislation, establishing and laying downi standards and
quality assurance norms, evolving mechanisms for public private
partnerships and accreditation and playing the role of the apex body for
interface and dialogue between the public and private sector.
In the
changing scenario, a separate division dealing with health insurance and
private sector would be required in the Ministry.
Conclusion :
The above suggestions should not be considered prescriptive. The
proposals have been made in all humility, based on the reports of expert
studies and committees, fully recognising that there may be other ways of
achieving the same objectives. The paper also brings out the deficiencies
of the existing system rather candidly, for any attempt to sweep them
under the carpet, would have defeated its very objective. However, this
must not be misunderstood as criticism of the performance of the Ministry.
The fact that the Ministry is able to discharge its constitutional and
stewardship role, albeit inadequately, despite grave systemic deficiencies,
is a tribute to the quality and commitment of the officers and other staff of
the Ministry. They are, indeed prisoners of the system, which does not
allow them to rise to their true potential.
The author is fully conscious of the obstacles likely to be encountered in
pursuing these reform proposals. However, these stem from the deep
conviction that to carry forward and lead the reform process for the health
system of the country, the MHFW must first address its own inadequacies
and equip itself for the challenges ahead. The suggestions made herein
are, thus, in the spirit of ‘physician heal thyself’.
is
References
1.
Reorganisation
Ministry of Health and Family Welfare, L. H. David,
G.R.S. Rao, A. Upadhyay, U. Pandey, 1986, Administrative Staff College of
India, Bella Vista, Hyderabad - 500049
2.
Report of the Expert Committee on Public Health System, chaired by
I
Prof. J.S. Bajaj, 1996, Government of India, Ministry of Health and Family
Welfare.
3.
Report on the Restructuring The Ministry of Health and Family Welfare, 1999,
Centre for Policy Research, Dharma Marg, Chanakyapuri, New Delhi - 1 10021. ’
4.
Annual Report 1999-2000, Ministry of Health and Family Welfare, Government
of India.
5.
Annual Report 2000-2001, Ministry of Health and Family Welfare, Government
of India.
I9
Figure 1.1
Organogram Showing Structure of the Ministry of Health and Family Welfare
Minister
J
MOS
DFW
<
>
<
DH
>
DISMH
FTSO
AO
(13
PSI
DG
PSI
r-n
PSI
SO (101
MOS
DH
DFW
DISMH
DGHS
AO
PSU
AO
(12
SO
Minister of State
Department of Health
Department of Family Welfare
Department of Indian Systems of Medicine and Homeopathy
Directorate General of Health Services
Autonomous Institutions
Public Sector Undertaking
20
Annex 1.1
Ministry of Health and Family Welfare
(Swasthya Aur Parivar Kalyan Mantralaya)
A.
Department of Health (Swasthya Vibhag)
I
Union Business
Union agencies and institutes for research or for the promotion of special
studies in medicine and nutrition including all matters relating to the .
Central Research Institute.
(i)
All India Institute of Hygiene and Public Health.
(ii)
National Institute of Communicable Diseases.
(iii)
Central Drugs Laboratory.
(iv)
Rajkumari Amrit Kaur College of Nursing.
(v)
Lady Reading Health School.
(vi)
Central Institute of Psychiatry.
(vii)
(viii) Dr. Ram Manohar Lohia Hospital & Nursing Home.
Safdarjang Hospital.
(ix)
Medical Stores Organisation.
(x)
BCG Vaccine Laboratory.
'
(xi)
Jawaharlal Institute of Post-Graduate Medical Education and Research.
(xii)
Smt Suchete Kripalani Medical College and Hospital and Kalawati Saran
(xiii)
Children's Hospital in India and abroad in medical and related fields.
1.
2.
International aid for Health Programmes.
3.
National Programme for Control of Blindness.
4.
National Leprosy Eradication Programme.
5.
National Tuberculosis Control Programme.
6.
National Malaria Eradication Programme.
7.
All National Programme relating to control and eradication of communicable
diseases.
8.
Bilateral Cultural
components.
9.
Fellowships for training in India and abroad in various medical and health
subjects.
10.
Exchange
Programmes-lmplementation
of
health
related
Matters relating to epidemics:- Problems connected with supply of medicines,
effects of malnutrition and shortage of drinking water leading to various
diseases as a result of natural calamities.
II
List of Business for Legislative and Executive Purposes in Respect of
Union Territories.
11.
Public Health hospitals and dispensaries.
12.
Scientific societies and associations pertaining to subjects dealt with in the
Department.
13.
Charitable and religious endowments pertaining to subjects dealt with in the
Department.
21
Ill
List of Business with which the Central Government Deal in a Legislative
Capacity only for the Union and in both Legislative and Executive
Capacities for all Union Territories.
14.
The Medical profession and medical education.
15.
The nursing profession and nursing education.
16.
Pharmacists and pharmacy education.
17.
The dental profession and dental education.
18.
Mental Health.
19.
Drugs Standards.
20.
Advertisements relating to drugs and medicines.
21.
Prevention of the extension from one State
contagious diseases affecting human beings.
22.
PrevenJon of adulteration of foodstuffs and drugs.
IV
Miscellaneous Business
23.
The Medical Council of India.
24.
The Central Councils of Health and Family Welfare.
25.
Dental Council of India.
26.
Indian Nursing Council.
27.
Pharmacy Council of India.
28.
Indian Pharmacopoeia Committee.
29.
Concession of medical attendance and treatment for Central Government
servants other than (i) those in Railway Service (ii) those paid from Defence
Service Estimates (iii) officers governed by the All India Services (Medical
Attendance) Rules, 1954 and (iv) officers governed by the Medical Attendance
Rules, 1956.
30.
Medical Examination and Medical Boards for Central Civil Services [other than
those controlled by the Department of Railways (Rail Vibhag) and those paid
from Defence Services Estimates excepting Civilian Services].
31.
Grants to Vallabhbhai Patel Chest Institute (under Delhi University)
32.
Grants to Indian Red Cross Society.
33.
Spas and Health resorts.
34.
The Indian Council of Medical Research.
35.
National Board of Examination.
to
another of infectious
or
22
36.
Chittaranjan National Cancer Research Centre.
37.
All India Institute of Medical Sciences.
38.
Medical & Bio-medical Research.
39.
All India Institute of Speech and Hearing.
40.
Pasteur Institute of India.
41.
Physiotherapy Training Centre, Kinf Edward Memorial Hospital.
42.
National Institute of Mental Health and Neuro Sciences.
43.
Inquiries and statistics for the purpose of any of the matters in the above list.
44.
Fees in respect of any of the matters in the above list, but not in any court.
45.
Hospital Services Consultancy Corporation Limited.
B.
Department of Family Welfare (Parivar Kalyan Vibhag)
1.
Policy and organisation for Family Welfare.
2.
Maternal and Child Welfare.
3.
Organisation and direction of education, training and research in all aspects of
family welfare including higher training abroad.
4.
Production and supply of aids to Family Planning.
5.
Liasion with foreign countries and international bodies as regards matters
relating to family welfare.
6.
Inquiries and statistics relating to family welfare.
7.
International Institute of Population Sciences, Bombay.
8.
Development and production of audiovisual aids, extensional education and
information in relation to population and family welfare.
9.
Grants-in-aid for the family welfare programme to voluntary organisations and
local bodies.
10.
Hindustan Latex Limited.
11.
National Institute of Health and Family Welfare, New Delhi.
12.
Family Welfare Schemes and projects with external assistance.
C.
Department of Indian Systems of Medicine and Homoeopathy (Bhartiya
Chikitsa Paddhati Aur Homoeopathy Vibhag)
I
Union Business
1.
Formulation of policy and policy issues for development and propagation of
Ayurveda, Siddha, Unani, Homeopathy, Yoga and Naturopathy systems.
23
2.
Development and implementaticr of programmes including Central schemes
and Centrally sponsored schemes for development and propagation of
Ayurveda, Sidda, Unani, Homeopathy. Yoga and Naturopathy systems.
3.
Co-ordination and promotion of 'esearch and development including assistance
therefor in Ayurveda, Sidda, Unani, Homeopathy, Yoga and Naturopathy
systems.
4.
Setting up and maintenance of Central institutions for research and
development, education and s:andards relating to Ayurveda, Sidda, Unani,
Homeopathy, Yoga and Naturopathy systems.
5.
All issues and matters requiring action at the level of Government in regard to :
(i)
Pharmacopoeia Laboratory for Indian Medicine, Ghaziabad;
(ii)
Homeopathy Pharmacopoeia Laboratory, Ghaziabad;
(Hi)
Central Council of Indian Medicines;
(iv)
Central Council of Homeopathy;
(v)
Ayurvedic Pharmacopoeia Committee;
(vi)
Homeopathic Pharmacopoeia Committee;
(vii)
Unani Pharmacopoeia Committee;
(viii) Siddha Pharmacopoeia Committee;
(ix)
Ayurvedic, Siddha and Unani Drugs Tec hnical Advisory Board;
(x)
Central Council for Research in Ayurveda and Siddha;
(xi)
Central Council for Resea'ch in Homeopathy;
(xii)
Central Council for Research in Unani Medicine;
(xiii) Central Council for Research in Yoga and Naturopathy;
(xiv) National Institute of Ayurveda;
(xv)
National Institute of Homeopathy;
(xvi) National Institute of Naturopathy;
(xvii) National Institute of Yoga:
(xviii) National Institute of Unani Medicine;
(xix) National Institute of Siddha:
(xx)
Institute of Post-Graduate Teaching and Research, Gujarat Ayurveda
University;
(xxi) Indian Medicines and Pharmaceuticals Corpn. Ltd.;
(xxii) Rashtriya Ayurveda Vidyapeeth.
6.
Education, Training and Researcn in all aspects of Indian Systems of Medicine
including higher training abroad.
7.
Matters of cadre formation and control including formation and amendment of
recruitment rules, recruitment, promotion and all other service matters relating
to ISM&H doctors of Central Govt. Health Scheme including doctors in ISM&H
central
hospitals
requiring
action
at
Government
level.
Day-to-day
administration and management will continue to be with the Director, Central
Government Health Scheme.
8.
Liasion with foreign countries and international bodies as regards matters
relating to Indian Systems of Medicine and Homeopathy.
9.
Matters relating to scientific societies/associations and charitable and religious
endowments relating to Indian Systems of Medicine & Homeopathy.
10.
Matters relating to quality and standards for drugs in Indian Systems of
Medicine & Homeopathy to the extent such matters require action at the level of
Government.
24
11.
Consultation and coordination with State Governments, Non-Government
Organisations and institutions for review of work and programmes in Indian
Systems of Medicine & Homeopathy.
12.
Statistics relating
Homeopathy.
13.
Proposals and matters concerning Union Territoties requiring sanction and
concurrence of Government of India in regard to Indian Systems of Medicine &
Homeopathy.
14.
Legislative proposals pertaining to Indian Systems of Medicine & Homeopathy
of individual States requiring sanction and concurrence of Government of India.
to
various aspects
of
Indian
Systems
of
Medicine
&
Source : Report on the Restructuring of the Ministry of Health and Family Welfare,
Centre for Policy Research (July 1999).
Annex 1.2
Subordinate Offices of the Ministry of Health and Family Welfare
1.
Director
FWTRC, 332, S.V.P. Road
Mumbai - 400004
2.
Director
Homeopathic Pharmacopoeia Laboratory
Central Government Offices Complex No.1
Kamla Nehru Nagar
Ghaziabad - 201 002
3.
Director
Pharmacopoeia Laboratory for Indian Medicine
Central Government Offices Complex No.1
Kamla Nehru Nagar
Ghaziabad - 201 002
Source : Report on the Restructuring of the Ministry of Health and Family Welfare,
Centre for Policy Research (July 1999).
25
Annex 1.3
List of Subordinate Offices under the Directorate General of Health Services
1.
..
Port Health Officer
Port Health Organisation
Patten Swasthya Bhawan
7, Mandlik Road, Flat No.1
1st Floor, Behind Taj Mahal Hotel
Coloba, Mumbai - 400 001.
2.
Port Health Officer
Port Health Organisation
Marina House, Hastings
Calcutta - 700022
3.
Port Health Officer
Port Health Organisation
Wirlingdon Island
Cochin (Kerala) - 603 003
4.
Port Health Officer
Port Health Organisation,Rajaji Road
Madras - 600 001
5.
Port Health Officer
Port Health Organisation
P O Kandla Port
(Kutch), Kandla - 370210
6.
Port Health Officer
Port Health Organisation
Marmagao.Goa - 403803
7.
Port Health Officer
Port Health Organisation
Visakhapatnam - 530001
8.
Port Health Officer
Port Health Organisation
Mandapam Camp - 623519
9.
Airport Health Officer
Airport Health Organisation
Airport, Chennai - 600027
10.
Airport Health Officer
Airport Health Organisation
Sahar, Mumbai - 400099
11.
Airport Health Officer
Airport Health Organisation
Dum-Dum Air Port
Calcutta - 700052
12.
Airport Health Officer
Airport Health Organisation
Delhi Airport
Palam, New Delhi - 110010
I
t
I
9
■»r
26
u
13.
Health Officer
Airport & Border Quarantine
7-A, Court Road
Amritsar - 143001
14.
Airport Health Officer
Airport Health Organisation
Tiruchirapalli Airport
Tiruchirapalli - 620007
15.
Port Health Officer
P.O.G, Building
Jawahar Lal Nehru Port
Sheva, Talvaram, Dist Raigad
Mumbai.
16.
Quality Control Manager
Government Medical Store
Depot, Mumbai Central
Mumbai.
17.
ADG (MS)
Government Medical Store Depot
9 Clade rew Nastings
Calcutta - 700022
18.
ADG (MS)
Government Medical Store Depot
Post Box No. 8
Kamal
19.
ADG (MS)
Government Medical Store Depot
37, Naval Hospital Road
Madras
20.
ADG (MS)
A K Azad Road
Gopi Nagar
Guahati
21.
ADG (MS)
Government Medical Store Depot
Behind Qutab Hotel
New Delhi - 110016
22.
ADG (MS)
Government Medical Store Depot
S R Nagar, ESI Hospital Compound
Hyderabad - 500038
23.
Dy. Drug Controller (I)
GDSCO West Zone
CGHS Dispensary Building
1st Floor, Antop Hill
Mumbai - 400037
27
h
24.
Dy. Drugs Controller (I)
East Zone, CDSCI, CGI Building
Nizam Place, II Floor (West)
234/4, A.J.C. Bose road
Calcutta - 700020
25.
Asstt. Drugs Controller
New Custom House
Annexe Ballard Estate
Ford, Mumbai - 400038
26.
Asstt. Drugs Controller (I)
1 5/I, Strend Road
Custom House
Calcutta - 700001
27.
Asstt. Drugs Controller (I)
Room No. 2, 4th floor
Custom Houses
Chennai
28.
Dy. Drugs Controller (I)
GDSCO North Zone Segment Wing
‘A’ 1st Floor, Central Govt. Office Building
Kamala Nehru Nagar
(Central Govt. Enclave)
Ghaziabad
29.
Dy. Drug Controller (I)
CDSCO South Zone
Shastri Bhawan, Hadows Road
Annexe, II Floor
Chennai
30.
Technical Officer
CDSCO, Custom House
Cochin- 682009
31.
Director
Central Drugs Lab
3KYD Street
Calcutta - 700016
32.
Director
Central Indian Pham Lab
Raj Nagar
Ghaziabad
33.
Asstt. Drugs Controller (I)
Jawaharlal Nehru Port Trust
Nahva-Sava Port, Raigad
Maharashtra
34.
Asst. Drugs Controller (I)
Indira Gandhi International Airport
Air Cargo Terminal
New Delhi
li
I
•w
I
t
I
I
28
35.
Director
Central Drugs Testing Lab
ESI Hospital Bldg.
33, Wagle Industrial Estate
IVth Floor Thane
Mumbai
36.
Asstt. Drugs Controller (I)
CDSCO Sub-Zonal Officer (UP Region)
DGHS Kalimangare House
364, Chandralok 1st Floor
2- Janpath Road
Lucknow - 220020
37.
Asst. Drugs Controller (I)
Sub-Zonal Officer of CDSCO
C/O Regional Director (H&FW)
Danara House, Salimpur Ahora
Behind ADI
Patna
38.
Director, JIPMER
Dhavantri Nagar
Pondicherry-605006
39.
Principal and Medical Supt.
LHMC & S K Hospital
New Delhi - 1 1 0001
40.
Addl. Medical Supt.
Kalawati Saran Children Hospital
New Delhi - 110001
41.
Superintendent
Lady Reading Health School
Bara Hindu Rao
Delhi-110006
42.
Principal
Rajkumari Amrit Kaur College
Of Nursing, Lajpat Nagar
New Delhi - 110024
43.
Medical Supt.
Safdarjng Hospital
New Delhi
44.
Medical Supt.
Dr. RML Hospital
New Delhi
45.
Director
AIIPMR, Haji Ali Park
Mahalakshim
Mumbai - 400034
29
46.
Serologist & Chemical Exam.
Institute of Serology, 3KYD Street
Calcutta - 700010
47.
Director & Medical Supt.
Central Institute of Psychiatry
P O Kanke
Ranchi - 834006
48.
Microbiologist
Central Food Lab.
3KYD Street
Calcutta
49.
Officer In Charge
Food Research and Standard Lab
Navyug Market
Ghaziabad
50.
Director
Central Research Institute
Kasauli-1 73204
51.
Director
BCG Vaccine Lab
Guindy
Chennai-600032
52.
Director NICD
22, Sham Nath Marg
Delhi - 54
53.
Director
NMEP, 22 Sham Nath Marg
Delhi - 54
54.
Director
IIH&PH, 110 Chittaranjan Avenue
Calcutta
55.
Officer In Charge
RHTG, Najafgarh
New Delhi - 43
56.
Director
CLTRI, Chengalpattu
Tamil Nadu
57.
Director
RLTRI (Aska Babanpur)
Dist Ganjam-761110
Orissa
58.
Director
RLTRI.Lalpur
Raipur-492001
30
59.
Dy. Director
RLTRI, Gouripur
Dist. Bankura
West Bengal-722132
60.
Director
NTI, 8 Bellary Road
Bangalore-3
61.
Officer In Charge
Model Vital Health Stat
Unit Civil Corporation
Civil Lines
Nagpur-I
62.
Medical Incharge
Regional Health Stat.
Training Centre, Trg. Annexe
Primary Health Centre
SAS Nagar
Mehali
63.
Medical Record Officer
Medical Record Depot and
Training Centre
Safdarjung Hostpital
New Delhi
64.
Addl. Director
CGHS, Room No. 526
*D” Wing, Nirman Bhawan
New Delhi-11 0011
65.
Addl. Director
CGHS, United India Building
Sir Firoz Sham Mehta Road
Fort, Mumbai
66.
Dy. Director
CGHS, 102, Sati Ganj
Begum Bridge, Opp. Cantt.
General Hospital
Meerut
67.
Addl. Director
CGHS 117/617
Pandu Nagar
Kanpur - 208005
68.
Addl. Director
CGHS Q.No. 1
Type III, Double Storey
CPWD, Central Government Colony
Civil Lines
Nagpur - 440001
31
69.
Dy. Director
CGHS, 7, Laddie Road
Allahabad - 211 007
70.
Addl. Director
CGHS, IV Floor
8, Esplanade East
Calcutta - 700069
71.
Addl. Director
CGHS, E-ll C
Rajaji Bhawan, CGO Complex
Besant Nagar
Chennai-600098
72.
Dy. Director
CGHS, Indu Bhawan
Gandhi Nagar
Boring Road
Patna-800001
73.
Dy. Director
CGHS, Kendra Sadan
(Near Airport) Begumpet
Hyderabad - 500016
74.
Dy. Director
CGHS, Z-Wing Hird Floor
Kendria Sadan Keramngala
Bangalore
75.
Addl. Director
CGHS
Hotel Radha Krishna
Old Post Office Road
Near Railway Station
Jaipur
76.
Dy. Director
CGHS, Swasthya Sadan
Mukund Nagar
llnd Floor
Pune - 410007
77.
Dt. Director
CGHS Shalimar Co-op. Housing Society
Ashram Road, Embassy Market
Ahmedabad
78.
Dy. Director
CGHS, 328, Near Russel Chowk
(Behind Jabal Garden Hotel)
Jabalpur
79.
Dy. Director
CGHS, 9-A, Rana Pratap Marg
Lucknow
3
■»
32
80.
Dy. Director
CGHS, Office of the Accountant General
P O Hannu
Ranchi
81.
Dy. Director
CGHS, A.G. Colony, Unit-4
Bhubaneswar
82.
Addl. Director
CGHS Anand Kutir Path
Zoo Narangitenale
R G Barwa Road
Guwahati
83.
Senior Regional Director
Regional Office for H&FW
49, 12-B, Hindustan Park
Calcutta
84.
Regional Director
Regional Office for H&FW
Banara House, Salimpur
Ahra (Behind RBI)
Patna - 500003
85.
Regional Director
Reg. Office for H&FW
C-2, B-80, Mahanagar
Lucknow 226006
86.
Regional Director
Kendria Sadan
4lh Floor, Block-C
Sector-9, Chandigarh
87.
Regional Director
Reg. Office for H&FW
Kendriya Sadan
Sultan Bazar
Hyderabad - 500195
88.
Regional Director
Reg. Office for H&FW
Anand Estate
Industrial Estate Corner
Babunagar
Ahmedabad
Regional Director
Reg. Office for H&FW
A-2A, Rajaji Bhawan
CGO Complex, Besant Nagar
Chennai - 600090
89.
90.
Regional Director
Reg.Office for H&FW
Din Dayal Upadyay Hospital Compound
Shimla 171001
33
91.
Regional Director
Regional Office for H&FW
Din Dayal Upadyay Hospital
Neelam Chowk
Srinagar - 190069
Sub-Office
F-711, Prem Nagar
New Plot
Jammu Tawi
92.
93.
3
Regional Director
Reg. Office for H&FW
BJ-25, BJR Nagar
Bhubaneswar - 751014
’I
Regional Director
Reg. Office for H&FW
84/2, Parvati Darpan Bldg.
1st Floor, Sahakar Nagar-ll
Pune - 411086
94.
Regional Director
Reg. Office for H&FW
Statue Road, Chirapuram Lane
T rivandrum-695001
95.
Regional Director
Reg. Office for H&FW,Sangrilla
Uripek Road.lmphal
96.
Regional Director
Reg. Office for H& FW
131/16, Maharan Pratap Nagar
Bhopal
97.
Regional Director
Reg. Office H&FW, llnd Floor
“F” Wingh, Kendriya Sadan
Karmangala,Bangalore - 560034
98.
Sr. Regional Director
Reg. Office for H&FW
K-10 Durga Das Path
Malviya Marg, ‘C’ Scheme
Jaipur - 302001
99.
Regional Director
Reg. Office for H&FW
Dhankheti
Shillong-794003
100.
Addl. Director
CGHS, S E Public School
Engg. Deptt. Ananda Kutir Path
Zoo Narangi Tindl. RG Barua Road
Guawahati 781003
3
34
101.
Dy. Director
CGHS, CGO Complex
Vallyam, P.O. Poonkulam
Trivandurm - 695002
Source : Report on the Restructuring of the Ministry of Health and Family Welfare,
Centre for Policy Research (July 1999).
Annex 1.4
List of Autonomous Bodies under the Ministry of Health and Family Welfare
1.
The Director
All India Institute of Medical Sciences
Anasar Nagar (Ring Road)
New Delhi
2.
The Director
All India Institute of Speech and Hearing
Manasagangothri
Mysore-6
3.
The Secretary
Centre Council of Indian Medicine
Jawahar Lal Nehru Bharatiya Chikitsa-Avam
Homeopathy Anusandhan Bhavan
Institutional Area, Janakpuri
New Delhi
4.
The Director
Ayurveda and Siddha
Jawahar Lal Nehru Bharatiya Chikitsa-Avam
Homeopathy Anusandhan Bhavan
Institutional Area, Janakpuri
New Delhi
5.
The Director
Central Council for Research in Yoga & Naturopathy
Jawahar Lal Nehru Bharatiya Chikitsa-Avam
Homeopathy Anusandhan Bhavan
Institutional Area, Janakpuri
New Delhi
6.
The Director
Central Council for Research in Unani Medicine
Jawahar Lal Nehru Bharatiya Chikitsa-Avam
Homeopathy Anusandhan Bhavan
Institutional Area, Janakpuri
New Delhi
7.
The Director
Central Council for Research in Homeopathy
Jawahar Lal Nehru Bharatiya Chikitsa-Avam
Homeopathy Anusandhan Bhavan
Institutional Area, Janakpuri
New Delhi
35
8.
The Secretary-cum-Registrar
Central Council for Research in Homeopathy
Jawahar Lal Nehru Bharatiya Chikitsa-Avam
Homeopathy Anusandhan Bhavan
Institutional Area, Janakpuri
New Delhi
9.
The Director
Chittaranjan National Cancer Research Centre
37, S P Mookherjee Road
Calcutta- 700026
10.
The Secretary
Dental Council of India
Temple Lane, Kotla Road
New Delhi-1 10002
11.
The Director General
Indian Council of Medical Research
Ansari Nagar (Ring Road)
Post Bo- 4508
New Delhi
12.
The Secretary
Indian Nursing Council
Temple Lane, Kotla Road
New Delhi
13.
The Director
National Institute of Health & F.W.
New Mehrauli Road, Munirka
New Delhi-1 10067
14.
The Secretary
Natoinal Board of Examinations
Mahatma Gandhi Marg
Ansari Marg
New Delhi-1 10029
15.
The Secretary
Medical Council of India
Aiwan-E-Galib Marg
Kotla Road
New Delhi-1 10002
16.
The Director
National Institute of Mental Health & Neuro-Sciences
(Deemed University), Post Box No. 2900
Bangalore-560029
17.
The Director
North-Eastern Indira Gandhi Regional Institute
of Health & Medical Sciences
‘New Lands’ Boyce Road
(Near Shillong College)
Shillong-793003
36
11
18.
The Director
National Institute of Ayurveda
Madhav Vilas Palace, Amer Road
Jaipur-302002
19.
The Director
Pasteur Institute of India
Coonoor-643103, Nilgiris
Tamil Naru
20.
The Secretary
Pharmacy Council of India
Temple Lane, Kotla Road
New Delhi-1 10002
21.
The Director
Post-Graduate Institute of Medical Education and Research
Chandigarh
22.
The Director
Rashtriya Ayurveda Vidyapeeth
Dhanwantri Bhavan, Road No. 66
Punjabi Bagh
New Delhi- 1 10026
23.
The Director
National Institute of Unani Medicine
Dhanwantri Road
Bangalore- 560009
24.
The Director
Morarji Desai Nztional Institute for Yoga
68, Ashok Road
New Delhi- 1 10001
25.
The Director
National Institute of Homeopathy
Block-GE, Sector-Ill
Salt Lake
Calcutta
Source : Report on the Restructuring of the Ministry of Health and Family Welfare,
Centre for Policy Research (July 1999).
37
Annex 1.5
List of Public Sector Undertakings under Ministry of Health & Family Welfare
1.
The Chairman and Managing Director
Hospital Services Consultancy Corporation (I) Ltd.
E-6(A), Sector I
NOIDA (UP) - 201301
2.
The Chairman & Managing Director
Hindusthan Latex Limited
Latex Bhavan, Poojappura
Triruvananthapuram - 695012
3.
The Managing Director
Indian Medicines Pharmaceutical Corporation Ltd.
Mohan, Via Ramour, District Almora
Uttar Pradesh
Source : Report on the Restructuring of the Ministry of Heaith and Family Welfare,
Centre for Policy Research (July 1999).
38
APPENDIX 2
Economic Growth, Health and Poverty: An Exploratory Study on India
Indrani Gupta and Arup Mitra
Introduction
The nexus between poverty and health is an area that has attracted
considerable attention of social scientists and economists. A series of
research output based on the World Bank’s Living Standard Measurement
Surveys have indicated the close links between economic status on the
one hand and a host of well-being indicators on the other, including
education and health (LSMS Working Paper Series, World Bank). The
links between economic growth and health however, have received
relatively less attention, partly because of the difficulty in separating
cause and effect, and partly because such analyses require longer term
time series data that are not easily available.
However, health
economists study the links between health and poverty, and poverty and
growth from the links between the microeconomic and macroeconomic
views of health. Below, we present a theoretical framework of these links
based on standard health economics (Zweifel and Breyer 1997).
At the individual level, there is a complex relationship between "health"
(H), other non-health consumption (C), consumption goods (X) and
amount spent on medical care (M). The relationship between H and C is
like that of any two economic goods, with a certain marginal rate of
substitution of one for the other; here the individual weighs health against
all other aims. Secondly, total income Y (i.e. budget) can be spent on
either X or M, but unlike in the case of other goods, Y itself depends on
health, H. This is because the ability to earn income is a function of how
healthy an individual is. Finally, H itself is a function of amount devoted
to health care, M. The final outcome or the equilibrium C*, H* and M*
would depend on the optimization results, but the important point to note
is the interdependence of these variables in the optimization process.
The same variables, if aggregated, will lead to macroeconomic results.
The problem is that one does not observe H and C, only X and M. Thus, it
is difficult to estimate the equilibrium levels of health expenditure and
consumption expenditure (values of aggregate M and X) spent out of GNP
(aggregate Y) that would maximize an underlying social welfare function.
However, there has been some discussion around the optimal level of
health expenditure in a country; for developed countries the concern is
cost containment, whereas for developing countries the issue is much
more related to gains in health and well-being.
The three issues of importance in a developing country context are the
following: (a) do increases in health expenditure necessarily result in
39
improvements in health indicators? (b) what effects will improvements in
health indicators have on investment and therefore on growth? And (c)
what are the links between poverty on the one hand and growth and
health status on the other.
To take the last question first: where does poverty fit into all this? There
is enough evidence now that indicates that poor standards of living go
hand in hand with poor health indicators in general. As the 1993 World
Development Report indicated, the magnitude of poverty is an especially
important reason for differences in health status World Bank 1993).
Thus for example, poorer regions or households would show higher infant
mortality rates, lower life expectancy as well higher morbidity rates. To
compensate for high infant and child mortality rates fertility rates go up,
reducing investment per child in terms of education and health, which
results in poor human capital formation and deepening of the vicious
cycle of ill health and poverty.
Secondly, will improvements in health indicators make a significant
difference to growth rates at the macro level?
Finally, will improved
health emanate from greater investment on health goods (higher health
expenditures) and therefore less to other goods or will it in fact free up
resources so that savings and investment will actually increase?
The paper examines each of these issues using state-level data for India,
and attempts to bring out the key factors that explain the nexus between
health, poverty and growth. Panel data for 15 major and smaller states
are used for the period 1970-71 through 1995. The organisation of the
paper is as follows.
In Section 2 we present different arguments
explaining the links among these variables. Section 3 presents results
from cross-sectional and time series (state-wise) analysis of trends in
growth, health indicators and poverty.
In Section 4 we present
econometric analysis explaining these observed trends and offer plausible
explanations for these. Finally, Section 5 summaries the major findings
and their policy implications.
Growth, Poverty And Health: A Framework
As the preceding discussion indicated, the links between these three
variables are many and often circuitous. In explaining the links between
the health sector and the rest of the economy, Over (1991) argues that
poor health outcomes manifested in high fertility, mortality and morbidity
rates result in poor quality and lower quantity of labour and a reduction in
the number of hours worked, which affect national income adversely.
Taking this argument further, such ill health of the population - if
sustained over time - is bound to affect the rate of growth of national
income. Poor growth on the other hand, squeezes the resources in the
hands of the Government thus reducing government expenditure on
40
I
u
education, health, food and other developmental fronts. This further
excarcebates the vicious circle of ill health and lower well-being.
It is generally understood that countries with better means and resources
provide more and higher-quality health and health-related services. But
as Stark (1995) points out, causality can run in exactly the opposite
direction, i.e. longer life expectancy translates into higher per capita
income. His contention is that longer life expectancy encourages larger
investments in human capital, which in turn accelerates the per capita
income. The explanation of larger investments on human capital due to
longer life expectancy is offered by Stark (1995) in terms of intergenerational transfer of assets.
Earlier, Becker, Murphy and Tamura
(1990) had argued that higher fertility behaviour raises the rate of
discount in the inter-temporal utility function thereby discouraging
investment in human capital.
Stark (1995) however, offers a slightly
different argument, saying that holding fertility behaviour constant,
changes in life expectancy account for changes in human capital
investment.
If life expectancy is high, children have to wait a longer
period of time to receive familial assets, which they can use for
productive purposes. This wait necessitates greater investment in human
capital formation early in life, so that the earning potential is enhanced,
since this is the only form of insurance against possible unemployment.
Earnings are certain to be higher when assets are transferred to skilled
labour rather than to bare labour. Hence, the growth performance of the
economy is expected to improve with a rise in health status of the
population.
While the effect of income among other variables like education and
medical inputs have been observed to have positive impact on health
indicators like mortality, the effects of improved health status on growth
must necessarily be long term in nature. For example, cross-sectional
evidence from 65 countries indicated that child mortaltiy falls faster in
countries where per capita income is growing rapidly (World Bank 1993).
However, the links from improved health status to growth must
necessarily be long term and are unlikely to show up in cross-sectional
data. This is because the positive impact of improved health status that
may alter investment decisions at the household level would not be
apparent immediately. These effects would take place only over a few
generations, and would have to be sustained over a longer term for the
effects to be felt on growth rates. For instance, better health outcomes in
terms of longer life expectancy encourages entrepreneurs to make larger
investment in the production sector. With shorter life expectancy they
have a tendency to invest in financial market - which may not result in
growth, but may in fact be inflationary - as the rate of return is much
faster compared to the commodity producing sector. From an individual
point of view too, better health outcomes translate themselves into
greater risk bearing capacity, which in the job market means upward
41
u
occupational mobility of the worker over his/her life span. Also, technical
efficiency of various industries- an important source of growth - has been
found to be positively associated with social infrastructure endowment of
the states (Mitra et al 1998). None of these effects however are short
term - they are necessarily medium to long term, thus indicating that the
effects of health on growth can be gleaned only from long term data.
Cross-Sectional And Time Series Results
Before turning to an econometric analysis of the relationship between
poverty, health and growth, we attempt a look at any discernible trends
that may exist in these variables across states and over time for each
state.
The variables considered for this purpose are the percentage below
poverty line, rate of growth of national state domestic product (NSDP) and
a number of indicators of health status - infant mortality rate, life
expectancy rate, and crude death rate. We also considered crude birth
rate and percentage suffering from infectious diseases in the population.
Finally, a key policy variable - per capita health expenditure - was also
looked at. Various sources were used for the data, and a list of these
sources is given in Appendix I.
Two sets of exercises have been attempted: cross-sectional at certain
points of time, and time series in each of the states.
The years
considered are 1973-74, 1977-78, 1983-84, 1987-8, 1993-94 and 19992000. The reasons for selecting these years had to do with the availability
of poverty estimates. Each of the health indicators are plotted against
incidence of poverty, net state domestic product NSDP growth and per
capita health expenditures.
What kind of associations do we see from the cross-sectional evidence?
While there were considerable year to year fluctuations, the associations
between poverty and various health indicators seem to be in the right
direction. Table 1 based on the graphs given in the appendix, presents a
summary of the nature of relationship between several indicators. Crude
birth rate performed the worst and life expectancy (LE) did the best in
terms of its association with poverty in the right direction. Both poverty
and crude birth rate show a mild positive relationship only for the years
1983, 1987-88, and 1993-94.
On the other hand, states with higher
poverty levels reveal lower life expectancy for all the years. Morbidity rate
defined as the percentage of total population suffering from infectious
diseases, crude death rate (CDR) and infant mortality rate (IMR) all three
show only mild positive associations with the incidence of poverty. From
these cross-sectional patterns though it does not seem that poverty and
all the health indicators considered here do not always move together as
one would expect; however, one of the most important indicators of the
42
health of a population, - the IMR — does show the right association with
poverty at the cross-sectional level.
Table 1
Variation across states among pairs of variabIes
i
Pairs of variables
I 1973-74 I 1977-78
1983
1987-88
Poverty & morbity rate [
Mild +
i Poverty & IMR
Mild +
| Poverty & crude birth
I rate
! Poverty & crude death
i, rate
' Poverty & life
I expectancy
Poverty & per capita
1 health expenditure
Poverty &
manufacturing growth
i rate
Poverty & NSDP
I IMR & per capita
i health expenditure
I Morbidity rate & per
! capita health
I expenditure
I Crude birth rate & per
i capita health
i expenditure
I Crude death rate &
i per capita health
; expenditure
No
No
No
Mild
Mild +
Mild +
No
Mild +
Mild +
Mild +
Mild +
Mild +
1993-94
Mild +
Mild +
Mild +
No
Mild -
Mild -
Mild -
Mild -
Mild -
Mild -
Mild -
Mild -
Mild -
Mild -
No
Mild -
No
Mild -
No
Mild -
Mild -
Mild -
Mild -
Mild -
Mild -
Mild -
No
Mild -
Mild -
What about poverty and growth rates? Plots based on cross-sectional
data point to only a mildly negative association of poverty with the five
yearly average rate of growth per annum for some of the years like 197778, 1983 and 1993-94. As for growth rates and health indicators, not
surprisingly, mostly the various years show no associations, especially in
the middle years (1983 and 1987-88). Surprisingly, National State
Domestic Product (NSDP) growth and life expectancy do not show any
relationship except for 1977-78 when it happens to be positive. Higher
growth is associated with lower CBR, CDR, and IMR only in certain years
as can be seen from Table 1.
The relation between per capita health expenditure and growth rate is
mildly positive and that between expenditure and health indicators
ambivalent, though for certain years IMR, morbidity, CBR, and CDR seem
to decline across states with higher per capita health expenditure. The
incidence of poverty also seems to fall with a rise in per capita health
expenditure.
43
Overall, there are no strong catterns that would immediately draw
attention as far as the cross section data are concerned, though the plots
are suggestive of mild associations among growth, poverty and health
indicators in the direction that one would expect on an apriori basis.
To look at whether each state showed some trends over time in these
variables, we looked at the same variables plotted against time. These
trends gleaned from the graphs are presented in a consolidated form in
Table 2.
The overall picture that emerges based on the annual data is that while
health indicators were improving almost in every state, growth rates
revealed considerable fluctuations thus showing no distinct trend over
time. Since yearly growth rates were unlikely to have any significant
associations with these variables, we used five-yearly averages of growth
rates as well for the other variables,
The picture that emerged was
somewhat clearer but not overwhelmingly so.
Table 2
Variations across time among pairs of variables, by state
Pairs of
variables
! Poverty &
! IMR
Poverty &
crude birth
rate
Poverty &
crude death
rate
I
I
J
; Poverty &
I life
i expectancy
No
relation
Movement in the same
direction
Movement in the
opposite dierection
Andhra Pradesh, Assam,
Bihar, Gujarat. Haryana
(except 93-94)Karnataka,
Kerala , Madhya Pradesh,
Maharashtra, . Orissa, Punjab,
Tamil Nadu, Uttar Pradesh,
West Bengal
Andhra Pradesh (slight),
Assam (slight), Bihar (slight),
Gujarat, Haryana (except 9394), Karnataka, Kerala,
Maharashtra, Madhya Pradesh
(slight), Orissa (slight),
Punjab, Rajasthan, Tamil
Nadu, Uttar Pradesh, West
Bengal
Andhra Pradesh (slight),
Assam (slight), Bihar (slight),
Gujarat, Haryana (except 9394), Karnataka (slight), Kerala
, Madhya Pradesh (slight),
Maharashtra, , Orissa (slight),
Punjab, Rajasthan, Tamil
Nadu, Uttar Pradesh, West
Bengal (slight)
__________ I
I Andhra Pradesh, Assam
I (slight), Bihar (slight),
i Gujarat, Haryana (except
i 93-94), Karnataka,
44
|
Poverty &
per capita
health
expenditure
I
Growth &
IMR
Bihar
i
I
Growth &
i CBR
Bihar
Growth &
CDR
Bihar
Growth &
LE
Bihar
Growth &
Poverty
Assam,
Bihar
Kerala, Maharashtra,
Madhya Pradesh, Orissa,
Punjab, Rajasthan, Tamil
Nadu, Uttar Pradesh,
West Bengal
Andhra Pradesh, Assam,
' Bihar, Gujarat, Haryana
(except 93-94),
Karnataka, Kerala,
Maharashtra, Madhya
Pradesh, Orissa, Punjab,
Rajasthan, Tamil Nadu,
Uttar Pradesh, West
Bengal
Andhra Pradesh, Assam
(slight), Gujarat, Haryana
(except 93-94), Karnataka
(except 90s), Kerala,
Maharashtra, Madhya
Pradesh, Orissa (except
90s), Punjab (except
90s), Rajasthan (except
90s), Tamil Nadu, Uttar
Pradesh (except 90s),
West Bengal
Andhra Pradesh (slight,
except 90s), Assam
(slight), Gujarat,
Haryana (except 93-94),
Karnataka (except 90s),
Kerala, Maharashtra,
I
Madhya Pradesh, Orissa, |
Punjab, Rajasthan
(except 90s), Tamil Nadu, i
Uttar Pradesh, West
Bengal
; Andhra Pradesh (slight,
except 90s), Assam
(slight), Gujarat,
Haryana (except 93-94),
; Karnataka, Kerala,
Maharashtra, Madhya
Pradesh, Orissa, Punjab,
. ..
.
------- i Rajasthan (except 90s),
Tamil Nadu, Uttar
1 Pradesh, West Bengal
Andhra Pradesh (except 90s),
Assam, Gujarat, Haryana,
Karnataka, Kerala
Maharashtra, Madhya Pradesh,
Orissa (except 90’s), Punjab,
Rajasthan, Tamil Nadu, Uttar
Pradesh (except 9O’s),West
Bengal
j_________________________________________________
i Andhra Pradesh (slight,
i except 90s), Gujarat,
Haryana, Karnataka,
45
i
Kerala, Maharashtra,
I Madhya Pradesh, Orissa
(except 90s), Punjab,
Rajasthan, Tamil Nadu,
Uttar Pradesh, West
: Bengal
The strongest association was that between poverty and IMR, both
sloping downward in most of the states. Poverty and CBR also seem to
have moved together, though in Assam, Bihar, Haryana, Madhya Pradesh
and Orissa the association of movement in both the variables appears to
be only marginal. Similarly with a few exceptions poverty and death rates
also seem to have dropped over time in several states. Also, with
declining poverty, life expectancy improved in most of the states.
Morbidity does not appear to have followed any significant pattern in a
large number of states; exceptions being Assam, Karnataka, Kerala,
Maharashtra, Madhya Pradesh and Orissa. Against poverty, morbidity
does not show any distinct pattern of movement even in these states but
that is mainly because of the scale differences in both the indices.
Morbidity figures as defined in ou' study are so low that they hardly show
any change over time when potted along with poverty. If we take
morbidity and growth rates together, the associations are somewhat
better suggesting a decline in morbidity with improvements in growth
rates in some of the states mentioned above.
Another improvement over the cross-section picture was of growth and
health indicators, especially IMR.
With 5-year averages, more states
showed an association in the right direction, i.e. IMR was lower when
growth was higher. Other variables like CBR and CDR also by and large
tend to fall with improvements in growth, though in several staes like
Andhra Pradesh, Assam, Haryana, Orissa, Punjab, Rajasthan and Uttar
Pradesh the negative association is only moderate. It is interesting to
note that in Bihar IMR, CBR, and CDR all moved in the same direction
with growth. This is mainly because the growth rate appears to taper off
over time while the health outcomes in terms of the indicators mentioned
above improved in this state. Growth and life expectancy also does not
show any relationship in Bihar.
Growth and per capita health expenditure reveal a positive association
except in Bihar, Rajasthan, Tamil Nadu and West Bengal. Growth and
poverty seem to have moved together in the right direction - poverty
falling in many states when the rate of growth of NSDP picked up exceptions being Assam and Bihar.
On the whole, both cross-section and time series data are indicative of
certain definite relationships among growth, poverty and health indicators,
though the degree of association may vary largely from state to state or
from year to year. Our objective is to delineate these relationships in
46
'
■
« '
I
4
u
terms of a more rigorous framework, which we attempt in the next section
with econometric modelling.
Health, Poverty And Growth: Econometric Analysis
Before turning to the econometric analysis of the nexus between health,
poverty and growth, a closer look at the health variables may be useful.
As the discussion above indicates, there are a few commonly used
variables that are used to indicate the health status of the population.
These are the life expectancy rate, the infant mortality rate, the crude
death and birth rates, and morbidity rate. The morbidity rate - being the
best variable to describe the health of a population - is also the most
difficult variable in terms of comparable data over the years.
The
previous section used this variable to analyse some broad trends.
However, it is often argued (Cumber ?) that this is widely under-estimated
and not comparable either across time or across states Also, to get the
correct definition of morbidity rate, one would have to get the
denominator correct, which is the total population susceptible to a
particular disease or to all those conditions defined as morbid.
Unfortunately, this could not be done for India, and a surrogate morbidity
rate - which was those who suffered from communicable diseases in the
total population - is used. Since this is an imperfect variable, we are not
going to use it in the analysis.
Of the other four indicators of health
status, the birth and death rates are more reflective of the demographic
changes taking place in the economy, and have more to do with
population policy. The life expectancy rate and the infant mortality rates
are better indicators of the health status of the population and are
influenced by changes in health policy,
broadly defined to include
investment in health and health services.
A look at the associations
among these four health indicators is useful to confirm that these
indicators however do move together over time. Table 3 presents simple
correlations among the four variables in the data set. The numbers in the
parentheses indicate the correlations for rural and urban separately.
Indicators
Table 3
Correlations among health indieators, poverty
Crude death rate
Life
i Infant mortality
expectancy j rate
i
Life expectancy
Infant mortality
rate
Crude death rate
-.91
-.93
Crude birth rate
-.72
Poverty
-.64
0.88
(.93 - R, .25 - U)
0.79
(.81- R, .26 - U)
0.30
■ (.40 - R, -.08 - U)
0.77
( .71- R, .73 - U)
0.57
(.44 - R, .67
U)
47
H
As expected, life expectancy is negatively correlated with all the other
indicators, but the closest association is with the crude death rate, which
is expected. The next close correlation is between the IMR and the life
expectancy. Again as expected, the weakest associations of IMR and life
expectancy are with the crude birth rate. Interestingly, the IMR and crude
death rates are very weakly correlated for urban areas, but highly
correlated in the rural areas, indicating that there are more factors at
work in the urban areas that impinge on morbidity rates, separate from
death rates.
Due to the non-availability of continuous data on life
expectancy for rural and urabn areas separately, this could not be tested
for this variable in conjunction with the other three indicators.
However,
these trends indicate firstly that life expectancy, IMR and crude death
rates are the three variables that could be used for the analysis.
Secondly, if possible, there may be some justification for doing the
analysis separately for the rural and urban areas. The latter argument can
be further tested by looking at the association between poverty and health
indicators for rural and urban areas separately. Unfortunately, the life
expectancy rates are not available separately for rural and urban areas,
so this could be tested only for the IMR and the crude death rates.
The last row of Table 3 indicates the correlation of poverty with the other
health indicators. Interestingly, poverty does not seem to be closely
correlated with any of the health indicators; the least correlation seems to
be between poverty and IMR in urban India.
This above analysis indicates that there is a need to look at these
relationships in a multivariate framework, controlling for other variables.
Also, as mentioned above, it is probably more meaningful to do the
analysis separately for rural and urban areas; however, due to paucity of
data, we keep our analysis restricted to total aggregates, i.e. for rural and
urban areas combined.
Turning next to the model, it has to be stated at the outset that several
alternative models were estimated, but results from only a few that seem
the most sensible are presented here.
While the brief theoretical framework in Section I was useful as a
reference point for a general equilibrium model linking health, poverty and
economic growth, it still does not offer very good directions of testing the
various causalities out empirically. We do the analysis based on three
alternative frameworks. The first framework believes that growth, poverty
and health all interact with each other and other variables, and should be
therefore estimated in a simultaneous framework. The other alternative is
to test a model where growth is essentially being determined by a set of
exogenous variables, excluding health status and poverty, which is the
common approach taken by macro economists. Poverty however, is a
function of growth among other variables, and finally health status is a
48
H
function of poverty and other variables. In the third variant of the model
growth and health are taken to influence each other and poverty is taken
to be a function of growth and health.
All these models are estimated using the pooled data. It is also assumed
that the variations in these three variables are affected by state-specific
unobservable fixed effects, an assumption which is meaningful, because
there are other cultural, political and social factors that are at work that
cannot be measured easily, and make states differ from one another. The
standard issue of whether the model should be estimated using a fixed or
a random effect estimator is resolved to some extent by doing the
Hausman test.
Variant I
In the first variant of the model the five yearly average growth of net state
domestic product (GROW) is taken to be a function of value added in the
base year (taken in the form of log of state domestic product, INSDP),
incidence of poverty (POV), health status measured in terms of infant
mortality rate (IMR), level of urbanisation (URBN), literacy rate (LIT),
industrialisation (IND) measured in terms of the share of manufacturing in
total net state domestic product, and infrastructure (INF) taken in terms of
the share of transport, storage and communication in total net state
domestic product. POV on the other hand is taken to be a function of IMR,
GROW, population density (DENS), URB, government expenditure on
anti-poverty programmes (EXPPOV), percentage of scheduled caste and
tribe population in the state (SCST), LIT, IND, total (primary plus
subsidiary status) employment of males in the rural and urban areas as a
percentage of total male population (EMPR and EMPU respectively). In
the equation for health (IMR), the explanatory variables are POV, GROW,
DENS, LIT, SCST, per capita health expenditure (PCHE). All the three
equations are identified both on the basis of exclusion principle and rank
condition. They are estimated by replacing the endogenous variables from
the right hand side by their predicted values generated from the reduced
form versions (see Table 4). Table 5 reports the point elasticity of the
endogenous variables with respect to exogenous variables, estimated at
the mean values of the variables using the reduced form coefficient
matrix.
From the structural form of the model it is evident that
(a) neither growth nor heath status influence poverty significantly,
(b) poverty does not affect health status,
(c) higher growth generates better health outcomes,
(d) poverty does not affect growth significantly,
(e) better health outcomes improve growth.
49
h
The inter-dependence of growth and health is empirically verified. Among
the exogenous variables in the growth equation, the variable percentage
urban yields a positive and significant coefficient. The coefficient o
infrastructure turns out to be negative though one would expect grow h o
vary positively with infrastructure. But here we must note that INF is
taken as the percentage share in the total value added, not in physical
terms. With every rise in INF - even if the state domestic product is
assumed to go up by equal increments - the rate of growth would indeed
decelerate, showing almost a relationship that one would expect to hold
between the base year income and its growth rate. Industrialisation on the
other hand, improves growth.
Both URBN and EXPPOV are found to reduce poverty. While the urban
male work participation rate (EMPU) reduces poverty, EMPR is found to
raise it suggesting the dominance of low productivity activities in the
rural areas. Both literacy rate (LIT) and per capita health expenditure
(PCHE) are seen to reduce IMR significantly.
Table 4
Structural Form Equations from Variant I
POV
IMR
GROW
I Explanatory
i variables
1.64
(0.66)
GROW
POV
IMR
-0.007
(-0.14)
-0.03
0.12
(0.64)
(-1.37)***
INSDP
-0.182
(-0.38)
0.02
(1.41)***
-0.80
(-2.44)*
-0.0002
(-1.59)**1
-0.145
(-0.62)
DENS
URBN
0.15
(2.41)*
EXPPOV
LIT
INF
IND
0.005
(0.12)
-0.41
(-1.98)*
0.101
(1.33)***
EMPU
PCHE
SCST
8.49
(0.82)
-0.02
(-0.57)
-0.79
(-2.37)*
-0.19
(-0.48)
0.87
(2.59)*
-0.71
(-2.03)**
EMPR
INTER
-7.29
(-3.09)*
0.31
(0.43)
i
1
-0.052
(-0.27)
34.81
(0.90)
-0.16
(-1.69)**
-0.202
(-0.47)
160.84
(4.69)*
50
H
p2(withm)
0.45
p2(between)
0.60
Model
RE
!
Note: Figure in parentheses give t-ratios. *,**
10 and 20 per cent levels respectively.
0.77
0.73
0.17
0.66
RE
RE
* represent significance at 5,
Elasticity coefficients (Table 5) show that literacy enhances growth
and reduces both poverty and the infant mortality rate. Expenditure on
anti-poverty programmes accelerate growth and reduce poverty and IMR,
though the impact of the latter (EXPPOV) is not strong.
Table 5
Elasticities from Variant I
Exogenous
Variables
GROW
DENS
URBN
EXPPOV
LIT
INF
IND
EMPR
EMPU
PCHE
SCST
-0.06
0.46
0.06
0.18
-0.13
0.53
-1.30
0.17
0.03
0.08
'
|
I
i
POV
IMR
-0.13
-0.28
-0.03
-0.145
0.02
-0.02
0.76
-0.43
-0.01
-0.58
”0?009
-0.06
-0.07
-0.54
0.02
-0.17
0.70
-0.545
-0.08
-0.10
The net effect of industrialisation on health status is better than that
on poverty. Per capita health expenditure improves the standard of living
and health both, and also appears to raise growth, though marginally.
That employment policy alone cannot take care of both standard of living
and health condition of the population is reflected in the elasticity
measures. The net effect of urban male work participation rate on growth
is positive, and it also reduces poverty and IMR. But in response to rise in
rural employment rate, growth declines and poverty and IMR tend to
increase. So policy measures need to be framed carefully which can
serve both the objectives of poverty reduction and improvement in health
status.
Variant II
In the second variant of the model (results reported in Table 6) growth
affects poverty, which in turn impacts health status. Growth is taken to be
influenced by the base year value added (INSDP), urbanisation (URBN),
infrastructure (INF), industrialisation (IND) and literacy rate (LIT).
Empirical results show that except URBN and INF all other variables are
significant. Both industrialisation and literacy raise the growth rate of
state domestic product. The base year value added reduces the growth
rate lending support to the convergence hypothesis.
51
!
H
In the second equation, POV is taken to vary with growth and expenditure
on anti-poverty programmes. In order to estimate this equation we have
used the predicted value of growth obtained from the first equation. Both
the variables are noted to reduce poverty.
In the third equation health status (IMR) is a function of poverty and per
capita health expenditure. This is estimated by replacing the observed
poverty by its predicted value obtained from the second equation, IMR is
seen to vary positively with POV and inversely with per capita health
expenditure, PCHE.
Table 6
Structural Form Equations from Variant II
I Explanatory
j variables
j GROW
GROW
i
POV
IMR
-1.59
(-5.33)*
I POV
3.12
(11.69)*
i IMR
I INSDP
-2.32
(-1.77)*
-0.07
(-0.49)
i
I URBN
|EXPPOV
-0.0004
(-5.58)*
LIT
0.23
(3.59)*
0.11
(0.60)
0.20
(2.23)*
INF
IND
PCHE
INTER
p2(within)
48.20
(1.61)***
0.39
49.03
(17.59)*
0.57
-0.17
(-2.52)*
-32.5
(-2.62)*
0.73
0.37
0.14
0.71
FE
RE
RE
p2(between)
Model
Note : See Table 4.
Table 7
Elasticities from Variant II
Exogenous
Variables
URBN
EXPPOV
.LIT
INF
PCHE
IND
GROW
POV
IMR
-0.40
2.50
0.105
0.07
-0.07
-0.46
0.02
0.60
-0.11
0.10
-0.09
-0.63
0.03
-0.06
-0.15
The elasticity coefficients estimaied from the second variant of the model
are given in Table 7. Literacy, and industrialisation seem to reduce both
poverty and IMR, and accelerate growth more than proportionately. With
respect to per capita health expenditure IMR does not show a high
elasticity though it tends to decelerate: with every one per cent increase
in PCHE, IMR drops by only ,0c per cent. Expenditure on anti-poverty
programmes results in a fall in both poverty and IMR more or less to the
same extent (-.07 and -.09 respectively).
Variant III
In the third variant of the model, growth is believed to be a function of
IMR, INSDP, URBN, INF, IND, and LIT. On the other hand, IMR is likely to
vary with both GROW and PCHE. And finally IMR, GROW and EXPPOV
would have impact on POV. Endogenous variables on the right hand side
are replaced by their predicted values obtained from the reduced form
equations. Among the exogenous variables, urbanisation, and literacy are
seen to influence growth positively. PCHE improves health outcome, and
expenditure on anti-poverty programmes reduces poverty.
Table 8
Structural Form Equations from Variant III
Explanatory
Variables
GROW
POV
IMR
INSDP
URBN
GROW
IMR
POV
-6.59
(-5.36).
(-1.62)***
-0.145
(-1.57)”.
-15.24
(-2.38)
0.46
(1.46)**-
0.18
(3.52)*
EXPPOV
LTI
INF
IND
-0.0003
(-3.09)*
0.21
(1.89)*
0.28
(1-05)
0.04
(0.28)
PCHE
INTER
|^2(within)
p^2(between)
Model_________
-0.73
373.62
(2.26)*
0.65
0.43
FE
-2.20
(-3.74)*
185.55
(10.42)*
0.57
0.13
28.82
(4.58)*
0.76
0.03
FE
FE
Note: See Table 4
53
Exogenous
Variables
URBN
EXPPOV
LIT
INF
IND
PCHE
Table 9
Elastcities from Variant III
GROW
POV
-0.43
2.46
-0.09
0.62
0.036
0.04
-0.06
-0.83
0.03
-0.13
-0.12
IMR
-0.15
-0.065
0.09
-0.18
-0.29
As far as the endogenous variables are concerned the results are again
suggestive of a nexus between growth and health outcomes - both
improving each other. Poverty is seen to be related to both health and
growth though the t-ratio corresponding to IMR is highly significant
whereas that of growth is siginificant only at the 20 per cent level. In
other words, this variant states that the issue of poverty reduction can be
addressed more effectively by improving health status of the population
rather than accelerating growth. The elasticity given in Table 9 show that
literacy accelerates the growth rate considerably. It also reduces poverty
(e = -0.83) and improves the health status by causing a fall in IMR though
the elasticity is only -0.065. Per capita health expenditure on the other
hand shows a positive effect on the health status as IMR tends to fall by
.29 per cent with every one per cent increase in PCHE. It also reduces
poverty and fastens growth. Industrialisation is another variable which
shows a promising effect on all the three endogenous variables, growth,
IMR and poverty. Expenditure on anti-poverty programmes does not show
any strong effect on poverty (-0.06).
Conclusion :
Based on time series and cross-section pooled data for the Indian states,
the analysis has been carried out for almost three decades - seventies,
eighties and nineties. Cross-section plots were suggestive of mild
associations among growth, poverty and health indicators in the direction
that one would expect on a priori basis, i.e., higher growth coincides with
lower poverty and better health status of the population. Time series data
made the picture somewhat more clear, especially as far as the
relationship between growth and health indicators - especially IMR - was
concerned. With five yearly averages, more states showed that with
higher growth, IMR declined. Other variables like CBR and CDR also by
and large tended to decline with improvements in growth, though in
several states the negative association was only moderate. On the whole,
both cross-section and time series data tended to suggest certain definite
relationships among growth, poverty and health indicators.
These trends and associations were then tested, by controlling for other
exogenous variables that could potentially influence each of these three
variables.
Three different variants of the model were estimated
54
b
econometrically. In the first variant, each of the endogenous variables is
taken to influence the other two. The second variant demonstrates a
causal connection running from growth to poverty to health, which is
essentially a recursive system. A third variant is estimated by making
growth and health interdependent on each other and then both affecting
poverty. The results can essentially be summarised in three points. Per
capita health expenditure is unambiguously and positively related to
health status; i.e. higher per capita health expenditure is seen to improve
health status in all the three equations. While the conclusions based on
these results on the linkages between poverty, health and growth would
vary depending on which model one believes in, the results do seem to
indicate that poverty is improved by improved health status.
Finally,
growth and health status are positively linked and seems to have a twoway relationship. While in cross-sectional data, higher per capita income
is seen to result in better health status, pooled cross-section and time
series data must necessarily consider a two-way relationship of growth in
income and health. The results indicate that higher growth affects health
status on the one hand, and better health status reinforces the trends in
growth of income on the other.
What do these results imply? Over the years it has been observed in
India that though poverty has declined to some extent, health status of
the population remained considerably low. These results seem to indicate
that further reduction in poverty is probably not possible without
significant improvements in the health condition of the population.
Secondly, health conditions can be improved by improved investment in
health, among other exogenous variables. Health sector investment needs
to be made on a large scale as rise in health expenditure yields both
higher growth and better quality of life. The low values for the estimates
of elasticities probably emanate from the fact that most of the states have
actually incurred a considerably low level of per capita health
expenditure. Hence, it would be misleading not to recognise the
importance of the policy implication of increased health expenditure.
Among some of the other exogenous variables - literacy and
industrialisation seem to improve both health outcome and growth on the
one hand, and reduce poverty on the other, as is evident from the
elasticity estimates. These results are not surprising; the role of
education in improved heath status is a finding that has been time-tested.
Educated labour develops awareness to remain healthy, results in higher
growth by enhancing the technical efficiency, and at the same time
experience higher earnings due to rise in productivity thus leading a
better standard of living.
Industrialisation also accelerates growth and improves the standard of
living both by narrowing the size of population below the poverty line and
generating better health outcomes. Higher productivity and higher
55
H
earnings that are likely to result from industrialisation are possibly the
driving force behind this.
What are the policy implications from these results? The main implication
seems to be that improved health outcomes are necessary for improved
rates of growth of income, especially over time. At the same time, higher
growth enables the system to generate better health outcomes. Better
health will also lead to lower poverty.
Accompanied by improved
investment in education and growth-promoting areas like industry, an
increased investment in health might be a necessary condition for putting
countries on a path of accelerated growth.
56
u
Data sources
Reported cases due to communicable diseases include Diphtheria, Poliomyelitis,
Tetanus, Whooping Cough, Measles, Enteric Fever, Viral Hepatitis, Dog bites/Rabies,’
Syphilis, Gonococcal infection, Tuberculosis.
Figures have been taken from Health information of India for the year onward 1985,
from different yearly volumes ; for the previous years figures have been taken from
Health Statistics of India, (different yearly volumes) .
Morbidity is defined as the number of reported cases to total population (per ‘000)
population)
Infant Mortality Rate, Crude Birth Rate, Crude Death Rate, Life Expectancy Rate:
Figures have been taken from Compendium of India’s Fertility and Mortality Indicators
1971-1997.
Figures for literacy rates have been taken from Health Information of India.1994
the years and from Family Welfare Programme in India, 1992-93.
for
Employment: usual status (principal and subsidiary) workers are taken from various
rounds of NSS.
Poverty figures have been taken from The Indian Journal of Labour Economics, vol.
40(1), Jan-Mar 1997. Fori 999-2000, the figures were obtained from Times of India.
Per capita health care expenditure in Rupees (in current prices), share of health care
expenditure in total government expenditure (in current prices), share of medical &
public health expenditure in total health care expenditure (in current prices), per
capita health care expenditure in Rupees (constant prices): Figures have been taken
from Health care Expenditure by Government of India by Reddy and Selvaraju,
Density, Percentage of urban population to total population, sex ratio, schedule caste
and schedule tribe population: figures have been taken from Population Censuses
,1971, 1981 and 1991.
Figures on expenditure on poverty comprise expenditure on rural development and
poverty alleviation programmes. These are plan outlay taken from various Annual
Plans, Government of India. The list of programmes taken for various years are as
follows:
(a) 1974-75: Small Farmers Development Agencies, Tribal Development Agencies,
drought Prone Area Programme, Pilot plus Intensive Rural Employment
Projects.
(b) 1977-78:
Small Farmers Development Agencies, Drought Prone Area
Programme, Tribal Development Agencies, Hill Area Development Agencies,
Pilot Programme of Integrated Rural Development, Desert Development
Programme, Food for Work Programme, Rural Links Road Programme.
(c) 1983-84: Integrated Rural Development Programme (IRDP), Training of Rural
Youth for Self-Employment (TRYSEM), National Rural Employment Programme
(NREP), Drought Prone Area Programme, Desert Development Programme,
Community Development and Land Reforms.
(d) 1987-88: IRDP, TRYSEM, NREP, Rural Landless Employment Guarantee
Programme,
Jawahar
Rojgar
Yojana(JRY)
Drought
Prone
AreaProgramme, Development of Women and Children in Rural Areas (DWCRA),
Community Development, Land Reforms Special Employment Programmes
57
u
(e) 1993-94: IRDP, TRYSEM, DWCRA, JRY, Drought Prone Area Programme,
Desert Development Programme Land Reforms and Employment Assurance
Schemes
58
References
1. Barro, Robert J. (1991).
Economic Growth in a Cross-Section of Countries.
Quarterly Journal of Economics, Vol 106, pp
2.
Barro, Robert J and Sala-i-Martin (1992).
Economy, Vol. 100.
3.
Becker, Garym K. Murphy and R. Tamura (1990). Human Capital, Fertility and
Economic Growth. Journal of Political Economy. Vol 98, pp.
4.
Cumber, Anil and Lincoln Chen.
Measurement, Seasonality and Clustering of
Morbidity. Some Correlates from a Longitudinal Study in Rural Bangladesh.
Gujarat Institute of Development Research. Working Paper No. 77.
5.
Mitra, Arup, A.Varoudakis and M. Veganzones (1998). State Infrastructure and
Productive Performance in Indian Manufacturing. OECD, Development Centre
Technical Paper No. 139.
6.
Stark, Oded (1995). Altruism and Beyond: An Economic Analysis of Transfers and
Exchanges within Families and Groups. Cambridge University Press.
Convergence, Journal of Political
7. Over, Mead (1991). Economics for Health Sector Analysis: Concepts and Cases.
Economic Development Institute. World Bank.
8. World Bank (1993). The World Development Report.
Development Indicators.
9. World Bank.
Investing in Health: World
Living Standard Measurement Surveys. Working Papers 1- current.
lO.Zweifel, Peter and Friedrich Breyer (1997).
Press.
Health Economics.
Oxford University
59
J
APPENDIX 3
Evolution of Health Policy in India
Rachel Chatterjee
The Historical Context
Modern medicine and structured healthcare were introduced in India
during the colonial period. Prior to this, practitioners, who were inheritors
of a caste-based occupational system, provided healthcare within their
homes. Institutions that functioned as hospitals were the Indian
equivalent of western almshouses and infirmaries, providing free drugs
and care to the sick and the infirm. It is believed that the ayurvedic
system of medicine, the dominant formal Indian system of medicine
became stagnant after the 10,h century AD. Unani-Tibb, based on Greek
medical theory, received greater state patronage, and during the Mughal
period, hospitals were established, financed by the rulers as well as
wealthy persons and rich traders. Health was considered a social
responsibility and state and philanthropic intervention were highly
significant.
The first medical establishment of modern medicine was set up by the
Portugese in Goa in 1510. The English East India Company set up its first
hospital in 1664 in Madras. As the needs of the British population grew,
r-a
more organised medical establishment, the Indian Medical Service was
established, catering mainly to the armed forces. By the early 19th
century, hospitals for the general population were established. These
facilities however had a distinct racial and urban bias. Rural health care
expansion in a limited way began in India from 1920 onwards, when the
Rockefeller Foundation entered India and started preventive health
programmes in the Madras Presidency in collaboration with the
government, and gradually extended its support for similar activities in
Mysore, Travancore, United Provinces and Delhi.
The focus of the
Foundation was on developing health units for preventive care in rural
and semi-rural areas, in addition to support for malaria research and
medical education. (Bradfield, 1938)
The intervention of the Rockefeller Foundation is I
historically very
important in terms of the direction it set in the development of health) care
services in rural India. It paved the way for the ideology that rural areas
need more preventive health care or 'public health’, and less hospitals
and medical care. The result was that medical care activities of the State
were developed mainly in the urban areas, and rural areas were deprived
of medical care within their reach. The same differential treatment for
urban and rural areas has continued even after Independence.
During the colonial period, hospitals and dispensaries were mostly state
owned or state financed, with the private sector playing a minimal role.
60
I
However, in terms of individual practitioners, the private health sector
was dominant. The earliest data available for private practitioners is for
the year 1938, when an estimated 40,000 doctors were reported to be
active. Of these only 9,225 or 23% were in public service, and the rest in
private practice or private institutions (Bradfield, 1938).
This historical overview reveals the remarkable continuity in the pattern of
development of health care services from the colonial period to the
present.
Evolution of Health Policy
The evolution of health policy in India takes us back to pre-independence
days.
In 1938 the Indian National Congress established a National
Planning Committee (NPC) under Jawaharlal Nehru. The NPC constituted
a sub committees on national health, under the chairmanship of Col. S.S.
Sokhey. On the basis of an interim report of the National Health Sub
committee presented to the NPC in August 1940, the NPC resolved that:
a) India should adopt a form of health organization, in which both
curative and preventive functions are suitably integrated, and
administered through one agency.
b) Such an integrated system of health organization can be worked
only under state control. It is, therefore recommended that the
preservation and maintenance of the health of the people should
be the responsibility of the state.
c) There should be ultimately one qualified medical man or woman
for every 1000 population, and one (hospital) bed for every 600
of population. Within the next ten years the objectives aimed at
should be one medical man or woman for every 3000 of
population, and a bed for every 1500 of population, This should
include adequate provision for maternity cases.
d) The medical and health organization should be so devised and
worked as to emphasize the social implications of this service.
With this object in view the organization should be made a free
public service, manned by whole-time workers trained in the
scientific method.
e) Adequate steps be taken to make India self-sufficient as regards
the production and supply of drugs, biological products, scientific
and surgical apparatus, instruments and equipment and other
medical supplies...
No individual or firm, Indian or foreign,
should be allowed to hold patent rights for the preparation of any
substances useful in human or veterinary medicine (NPC, 1948).
61
18 October 1948 marks a wate'shed in health policy formulation when
the Health Survey and Development Committee was constituted under the
chairmanship of Sir Joseph Shore. This Committee, which endorsed the
NPC resolve, prepared a detailed plan for a National Health Service for
the country. The Plan proposed providing universal coverage to the entire
population, free of charge^ through a comprehensive state-run salaried
health service. The Bhore Committee Report remains, to the present, the
most comprehensive health policy and plan document ever prepared in
India. In formulating its plan for a National Health Service the Bhore
Committee set itself the following objectives;
1) The services should make adequate provision for the medical
care of the individual in the curative and preventive fields and for
the active promotion of positive health;
2) These services should be placed as close to the people as
possible, in order to ensure their maximum use by the community
which they are meant to serve;
3) The health organization should provide for the widest possible
basis of cooperation between the health personnel and the
people;
4) In order to promote the development of the health programme on
sound lines, the support of the medical and auxiliary professions,
such as those of dentists, pharmacists and nurses, is essential;
provision should, therefore,
be
made for enabling the
representatives of these professions to influence the health
policy of the country.
5) In view of the complexity of modern medical practice, from the
standpoint of diagnosis and treatment, consultant, laboratory and
institutional facilities of a varied character, which together
constitute “group” practice, should be made available.
6) Special provision will be required for certain sections of the
population, e.g. mothers, children, the mentally deficient etc.
7) No individual should fail to secure adequate medical care,
curative and preventive, because of inability to pay for it.
8) The creation and maintenance of as healthy an environment as
possible in the homes of the people as well as in all places
where they congregate for work, amusement recreation are
essential.
The Bhore Committee’s District Health Scheme, also called the Three
Million (representing an average district’s population) Plan, was to be
organized in a 3-tier system “in an ascending scale of efficiency from the
point of view of staffing and equipment.■ /'
'
At the
periphery would be the
primary unit, the smallest of these three types,. A certain number of these
primary units would be brought under a secondary unit, which would
perform the dual function of providing a more efficient type of healthservice at its headquarters and of supervising the work of these primary
units.
The headquarters of the district would be provided with an
organization which would include, within its scope, all the facilities that
62
are necessary for modern med::= practice as well as the supervisory
staff who will be responsible for re health administration of the district in
its various specialized types of se'vice.”
The minimum requirement recomrended by the Bhore Committee was:
• 567 hospital beds per 10C 000 population, as against the existing
24
• 62.3 doctors per 100,000 peculation, as against the existing 15.87
• 150.8 nurses per 100,000 population, as against the existing 2.32
The organizational structure of the National Health Scheme, as proposed
by the Bhore Committee, included a primary unit for every 10,000 to
20,000 population with a 75 bedded hospital served by six medical
officers including medical, surgical and obstetric and gynecology
specialists, and supportive paramedical staff. This primary unit should
have adequate ambulatory support to link it to the secondary unit when
the need arises for secondary level care. Each province should have the
autonomy to organize its primary units in the way it deemed most suitable
for its population but there was to be no compromise on quality and
accessibility. The deciding factor should be easy access for that unit of
population.
Secondary Unit:
About 30 primary units or less should be under a
secondary unit. The secondary unit should be a 650 bed hospital having
all the major specialities: medical, surgical, obstetrics and gynaecology,
paediatrics, infectious diseases, malaria and tuberculosis, with a staff of
140 doctors and supporting para medical and other staff.
District Hospital: Every district centre should have a 2500 beds hospital
providing tertiary care with 269 doctors, and supporting para medical and
other staff. The hospital should have 300 medical beds, 350 surgical
beds, 300 Ob. & Gy. Beds, 540 tuberculosis beds, 250 pediatric beds, 300
leprosy beds, 40 infectious diseases beds, 20 malaria beds and 400 beds
for mental diseases. This distribution was based on the epidemiological
profile the Committee had constructed based on their enquiry. A large
number of these district hospitals would have medical colleges attached
to them, However, each of the 3 levels should have functions related to
medical education, and training, including internship and refresher
courses.
In addition, certain diseases were singled out for special inputs that
would be needed to control and / or eradicate them. They were singled
out because they constituted a major problem then. And most of them,
54 years later, continue to constitute a major problem in the country.
These diseases were malaria, tuberculosis, small pox, cholera, plague,
leprosy, venereal diseases, hookworm disease, filariasis, guinea-worm
disease, cancer, mental diseases blindness and diseases of the eye.
A
detailed plan to deal with them was outlined.
This plan was to be
executed as a part and parcel of the general health services.
63
II
The Committee also made specie recommendation for the constitution of
a State Health Service. It recommended that all services provided by the
health organization should be free to the population without distinction
and it should be financed througn tax revenues. It further recommended
that the health service should oe a salaried service with whole-time
doctors who should be prohibited from private practice.
In the early years after independence, the Indian State was engrossed in
supporting the process of accumulation of capital in the private sector
through large scale investments in capital goods industry, infrastructure
and financial services. Industrial growth was the keyword. Social sectors
like health and education were low priority areas. Economic services,
from the first plan to the ninth plan, were allocated over four fifths of the
resources, and social sectors such as health, education, water supply and
housing have continued to receive only residual resources.
''
It was not until 1983 that India enunciated a formal National Health
Policy.
Prior to this policy, health planing was through the Five-Year
Plans and based on recommendations of various Committees. During the
first two Five-Year Plans, the basic structural framework of public health
care delivery system remained unchanged. Urban areas continued to get
over three-fourths of medical care resources, whereas rural areas
received
"special attention” under the Community Development
Programme (CDP). Within CDP the social sectors received very scant
attention.
In fact CDP, for all practical purposes, meant agricultural
development.
Health sector organization under CDP was a diluted form of the Shore
Committee recommendations. It proposed a primary health unit per
development Block (in the fifties this was about 70,000 population spread
over 100 villages) supported by a secondary health unit (hospital with a
mobile dispensary) for every three such primary health units. The aim of
this health organization was “the improvement of environmental hygiene,
including provision and protection of water supply; proper disposal of
human and animal wastes; control of epidemic diseases such as malaria,
cholera, small pox, TB etc.; provision of medical
aid along with
appropriate preventive measures, and education of the
population in
hygienic living and in improved nutrition."
It is clear from the above statement of objectives of the health
organization under CDP that medical care was given the least priority. In
contrast, in the urban areas, which developed independent of CDP,
hospitals and dispensaries, which provided mainly curative services
(medical care), proliferated. Thus at the start of the third Five Year Plan,
there was only one Primary Health Unit per 140,000 rural population (14'
times, less than what the Shore Committee recommended) in addition to
one hospital per 320,000 rural population. In sharp contrast, urban areas
had one hospital per 36,000 urban population and one hospital bed per
64
440 urban residents (rural areas had 1
population.
hospital bed per 7000 rural
The Mudaliar Committee was set up in 1959 to evaluate the progress
made in the first 2 Five-Year Plans, and to make recommendation for the
future development of health services.
The report of the Committee
recorded that disease control programmes had substantial achievements
in controlling certain virulent epidemic diseases. Malaria was considered
to be under control. Deaths due to malaria, cholera, smallpox etc. were
halved or sharply reduced and the overall morbidity and mortality rates
had declined. The death rate had fallen to 21.6% for the period 1956-61.
The expectation of life at birth had risen to 42 years.
However, the
tuberculosis programme had failed to control its spread. The report also
pointed out that for a million and half estimated open cases of
tuberculosis, there were not more than 30,000 beds available.
The
Mudaliar Committee further admitted that basic health facilities had not
reached at least half the nation. It observed that the PHC programme
was not given the importance it should have been given, and that there
were on'y 2800 PHCs existing by the end of 1961.
instead of the
“irreducible minimum in staff recommended by the Bhore Committee, most
of the PHCs were understaffed, large numbers of them were being run by
ANM’s or public health nurses in charge’. The Committee suggested
measures to improve the service condition of doctors and other personnel
in order to attract them to rural areas. The Committee also recommended
that instead of expansion of PHCs consolidation should take place, and
then a phased upgrading and equipping of the district hospitals with
mobile clinics for the treatment of non-PHC population. The Committee
insisted that medical education should get a large share of public health
resources in the belief that improvement in the technical excellence of
medical care and substantial addition to medical manpower would
ultimately change the country's health status. In the next two plan
periods,, ;allocations for training of doctors, especially specialties,
increased.
This was reflected in a large increase in medical college
seats. However,, Ithe outturn of nurses and other auxiliary personnel
continued to stagnate. During this period, urban health infrastructure
continued to increase to meet the growing demands for medical care,
funded mostly by state governments. The Centre was investing in
preventive and promotive programmes, whereas state governments
focused their attention on curative care - some sort of an informal
division of tasks had taken place, which continues even to the present.
The Third Five Year Plan, launched in 1961, addressed the deficiencies
affecting PHCs, and directed attention to the shortage of health
personnel, delays in the construction of PHCs, buildings and staff
quarters and inadequate training facilities for the different categories of
staff required in the rural areas. The Third Five-Year Plan highlighted
inadequacy of health care institutions, doctors and other personnel in
rural areas as being the major shortcomings at the end of the second
Five-Year Plan. It suggested a realistic solution to the problem of
65
insufficient doctors for rural areas: “a new short term course for the
training of medical assistants should be instituted and after these
assistants had worked for 5years at a PHC, they could complete their
education to become full fledged doctors and continue in public service”.
The Medical Council, however, opposed this recommendation and hence
it was not pursued. Urban health structure continued to expand and
proposed outlays for new Medical Colleges, establishment of preventive
and social medic-ine and psychiatric departments, completion of the All
India Institute of Medical Sciences and schemes for upgrading
departments in Medical Colleges for post graduate training and research,
continued to be high.
Faced with a rising birth rate and a falling death rate, the Third Plan
stated that “the objective of stabilizing the growth of population over a
reasonable period must therefore be at the very center of planned
development". It was during this period that Government agencies began
to actively participate in pushing population control. This was also the
time when family planning became an independent department in the
Ministry of Health. In 1963, the Chadha Committee recommended the
integration of health and family planning services and its delivery through
one male and one female multipurpose worker per 10,000 population. In
1966, the Mukherjee Committee, set up to review the staffing pattern
and financial provision for the family planning programme, recommended
introduction of targets, payments for motivation and incentives to
acceptors.
It suggested reorganization of the FP programme into a
vertical programme like malaria, and recommended addition of one more
health visitor per PHC, to supervise the ANMs for targets under this
programme.
The Fourth Five-Year Plan, which began in 1969 with a 3-year plan
holiday, continued on the same lines as the Third Plan. It recognized
again the need to strengthen the PHC programme. It pleaded for the
establishment of effective machinery for speedy construction of buildings
and improvement of the performance of PHCs by providing them with
staff, equipment and other facilities. For the first time, PHCs were given a
separate allocation.
It was reiterated that the PHC base would be
strengthened along with, sub divisional and district hospitals, which would
be referral centers for the PHCs. The importance of PHCs was stressed
in terms of the communicable diseases programme. This emphasis was
due to the spurt in the incidence of malaria, which rose from 100,000
cases annually between 1963-65, to 149,102 cases. Family Planning
continued to get an even greater emphasis with 42% of health sector plan
allocation going to it. It was during this period that water supply and
sanitation were separated and allocations made separately for these
sectors under Housing and Regional Development.
It was in the Fifth Plan that the government acknowledged that despite
advances in terms of reduction in infant mortality rates and increase in
life expectancy, health infrastructure and manpower were still inadequate
66
u
in the rural areas. The objectives of the Fifth Five-Year Plan focussed on
addressing these deficiencies:
1) Increasing the accessibility of health services to rural areas through
the Minimum Needs Programme (MNP) and correcting the regional
imbalances.
2) Developing referral services by removing deficiencies in district and
sub-division hospitals, and by providing specialist attention to
common diseases in rural areas.
3) Intensifying efforts for the control and eradication of communicable
diseases.
4) Effecting quality improvement in the education and training of health
personnel.
The methods by which these goals were to be achieved were
through the Minimum Needs Programme, the Multi-Purpose Workers
Training Scheme, and priority treatment for backward and tribal
areas.
The Kartar Singh Committee in 1 97 3 recommended the conversion of
uni-purpose workers, including ANMs, into multi-purpose male and female
health workers. It recommended that each pair of such workers should
serve a population of 10,000 to 12,000. Thus the multi-purpose health
worker’s (MPHW) scheme was launched, with the objective of integrating
various vertical programmes into the primary health care package for
rural areas.
The Shrivastava Committee was constituted in 1975 to look into medical
education and supportive manpower. In respect of medical education, the
Committee called for a halt to the opening of new medical colleges. The
Committee emphasized that there was no point in assuming that by
increasing the pool of doctors, they would go to rural areas, as there were
complex socio-economic dimensions governing this issue.
The main
recommendation of the Committee was to have part-time health personnel
selected by the community from within the community.
They would act
as a link between the MPHW at the sub-centers and the community. Thus
their option for rural areas was the Community Health Worker scheme.
Earlier in 1967, the Jain Committee report on Medical Care Services had
made an attempt to devolve medical care to rural areas by recommending
strengthening of such care at the PHC and block / taluka level, as well as
further strengthening district hospital facilities. The Jain Committee also
suggested integration of medical and health services at the district level
with both responsibilities
being vested in the Civil Surgeon / Chief
Medical Officer. But recommendations of this Committee, which is the
only Committee since Independence that focussed on medical care in
rural areas, were not considered seriously.
In the middle of the Fifth Plan, a state of National Emergency was
proclaimed and during this period (1975-77) population control activities
67
were stepped up, which unfortunately included forced sterilisations. With
the end of the Emergency, however, this policy was abandoned. In the
Fifth Plan, water supply and sanitation received greater emphasis. One of
the important objectives in the MNP’ was to provide drinking water to all
villages suffering from. chronic scarcity
of water.
The outlay
during this
plan period for water supply was Rs. 10,220 millions, almost equal to the
amount allocated to the health sector
The Sixth Plan was greatly influenced by the Alma Ata declaration of
Health for All by 2000 AD
(WHO), and the ICSSR - ICMR Report
,1980. The plan conceded that “ there is a serious dissatisfaction with
the existing model of medical and health services with its emphasis on
hospitals, specialization and super specialisation, and highly trained
doctors, which is availed of mostly by the well to do classes. It is also
realized that it is this model which is depriving the rural areas and the
poor people of the benefits of good health and medical services”. The
plan emphasized the development of a community-based health system.
The strategies advocated were:
a) Provision of health services to the rural areas on a priority basis.
b) The training of a large cadre of first level health workers,
selected from the community and supervised by MPHWs and
medical officers of the PHCs.
c) No further linear expansion of curative facilities in urban areas;
this would be permitted only in exceptional cases, dictated by felt
need.
The Plan emphasized that horizontal and vertical linkages had to be
established among all the interrelated programmes, like water supply,
environmental sanitation, hygiene, nutrition, education, family planning
and MCH. The objective of achieving a net reproduction rate of 1 by 1995
was reiterated.
The Sixth and Seventh plans are different from the earlier ones in that
they emphasised efficiency and quality through increasing privatisation.
The Sixth and Seventh Five Year Plans state: ‘ the success of the Plan
depends
crucially
on
the
efficiency,
quality
and
texture
of
implementation... a greater emphasis in the direction of competitive
ability, reduced cost and greater mobility and flexibility in the
development of investible resources in the private sector (by adapting)
flexible policies to revive investor interest in the capital markets’.
The National Health Policy (NHP) of 1983 was announced during the
Sixth plan period. The Policy recommended “universal, comprehensive
primary health care services which are relevant to the actual needs and
priorities of the community at a cost which people can afford”. The salient
features of the 1983 Health Policy are:
68
a) It emphasized a preventive, promotive and rehabilitative primary
health care approach.
b) It recommended a decentralized system of health care, the key
volunteers and paramedics), and community participation.
c) It called for an expansion of the private curative sector, which
would help reduce the government’s burden.
d) It recommended the establishment of a nationwide network of
epidemiological stations that would facilitate the integration of
various health interventions.
e) It set up targets for achievement that were primarily demographic
in nature.
During the decade following the 1983 NHP, rural health care received
special attention and a massive program of expansion of primary health
care facilities was undertaken in the 6th and 7th Five Year Plans to
achieve the target of one PHC per 30,000 population and one sub centre
per 5000 population. This target has more or less been achieved, though
a few states are still deficient. Various studies analysing rural primary
health care have observed that, though the infrastructure is in place in
most areas, primary level services are grossly underutilized because of
poor facilities, inadequate supplies, insufficient effective person-hours,
poor managerial skills of doctors, faulty planning of the mix of health
programs and lack of proper monitoring and evaluatory mechanisms.
Further, the system being based on the health team concept, has failed to
work because of the mismatch between training and the work allocated to
health workers, inadequate transport facilities, non-availability of
appropriate accommodation for the health team and an imbalanced
distribution of work-time for various activities. In fact, many studies have
observed that family planning, and more recently immunization, get a
disproportionately large share of the health workers' effective work-time.
With regard to the private health sector the NHP clearly favours
privatization of curative care, It talks of a cost that “people can afford",
thereby implying that health care services will not be free.
The
development of health care services post-NHP provide evidence that
privatization and private sector expansion in the health sector has
occurred rapidly, that in the name of primary health care, the state has
still kept the periphery without adequate curative services (while the
states support to curative services in urban areas continues to remain
strong) and that the state health sector's priority program still continues
to be population control.
India’s health policy too has been moving increasingly in the direction of
selective health care. From a commitment to comprehensive health care
on the eve of Independence, and its reiteration in the 1983 Health Policy,
there has been a narrowing down of concern for family planning;
immunization and control of selected diseases.
In keeping with the
selective health care approach, the Eighth Plan adopted a new slogan instead of ‘Health for All by 2000 AD’, it chose to emphasize ‘Health for
69
the Underprivileged’. Simultaneously, it continued the support to
privatization. During the Eighth Plan period, an Expert Committee on
Public Health Systems to review public health was set up. The
recommendations of this Committee have formed the basis for the Ninth
Plan health sector strategy to revitalize the public health system in the
country to respond to health care needs in changed times.
The 9th Five-Year Plan by contrast to earlier Plans, provides a good
review of earlier policies and interventions, analysing earlier experience
in order to plan future strategies. There are a number of innovative ideas
in the Ninth Plan. It is refreshing to note that reference is once again
made to the Bhore Committee Report and to contextualise the current
scenario within the recommendations the Bhore Committee. In its analysis
of health infrastructure and human resources, the Ninth Plan says that
consolidation of PHCs and SCs, and assuring that the requirements for
their proper functioning are made, is an important goal under the Basic
Minimum Services Programme. Thus, given the fact that it is difficult to
find physicians to work in PHCs and CHCs, the Plan suggests creating
part-time positions, which can be offered to local qualified private
practitioners, and / or offering the PHC and CHC premises for after-office
hour's practice against a rent. It also suggests putting in place
mechanisms to strengthen referral services. The Plan has proposed
horizontal integration of all vertical programmes at district level to
increase their effectiveness as also to facilitate allocative efficiencies.
Another welcome suggestion is evolving state-specific strategies,
recognising the fact that states are at different levels of development and
have different health care needs. The Ninth Plan also shows concern for
urban health care, especially the absence of primary health care for the
urban poor, and the complete reliance on secondary and tertiary services
even for minor ailments. It recommends for provision of primary health
care services, especially in slums, and providing referral linkages at
higher levels.
The Ninth Plan also reviews the 1983 National Health Policy in the
context of its objectives and goals and concludes that a reappraisal and
reformulation of the NHP is necessary, so that a reliable and relevant
policy framework is available, not only for improving health care, but also
for monitoring health care delivery systems and measuring the health
status of the population in the next two decades. In this context, it is
critical of the poor quality of data management and recommends drastic
changes to develop district level databases so that more relevant
planning is possible. . The Ministry of Health ’ and Family Welfare is
presently working on a new Health Policy document. A draft version
which came out in June 1999 was found wanting and is being reworked
presently.
The Ninth Plan reviewing the population policy and the family planning
programme, refers to the Bhore Committee Report, and asserts that the
70
core of this programme is maternal and child health services. The
National Population Policy has been announced in the middle of 2000,
in which demographic goals, are placed in a larger social context. The
Ninth Plan laments that in all the years since independence, allocations
to the health sector have not reached even two percent of plan resources.
Despite this pronouncement, the same inadequate resource allocations
for the health sector continue.
Conclusion
The neglect of the public health sector is an issue larger than health
policy making. The demand on public resources from the productive
sectors of the economy (which directly benefit capital accumulation) is
considered more urgent than the social sectors, and therefore the latter
gets only residual attention from the State. Unfortunately, health is seen
by both central and state governments as a consumption good, and not as
an investment good. It is not yet the thinking in finance ministries that
expenditures on healthcare, leading to improvements in health status, can
in turn promote economic growth. The solution for satisfying the health
needs of the people, lies not merely in health policies and plans, but in
changing mind-sets of governments, and effecting structural changes in
the political economy that will facilitate adequate allocations to the social
sectors and implementation of progressive health policies.
71
APPENDIX 4
Basic Principles of Ayurvedic Medicine
And Its Materia Medica
Ram Harsh Singh
Ayurveda is one of the most ancient medical sciences of the world. It is
considered as the Upaveda of Atharvaveda and thus has its origin from
Vedas, the oldest recorded wisdom on earth. It has survived through two
sets of original authentic texts each consisting of three books viz., (1)
Vrhattrayi i.e. the three big books namely Caraka Samhita (600 B.C.),
Susruta Samhita (500 B.C.) and the Samhitas of Vagbhata (600 A.D.); (2)
Laghutrayi i.e. the three small books namely Madhava Nidana (900 A.D.),
Sarngadhara Samhita (1300 A.D.) and Bhava Prakasa (1600 A.D.). All
these texts were originally written in Sanskrit and were in the form of an
encyclopedia dealing with all aspects of life, health, disease and
treatment. The approach is essentially philosophic, holistic and
humanistic. Ayurveda is a more life and health oriented system than
disease and treatment oriented one. It presents a total life science and
visualises the total health of the total human-being in a holistic way.
Ayurveda advocates a complete promotive, preventive and curative
system of medicine and appears to have been practised in ancient times
in the form of eight major clinical specialities of medicine namely (1)
Kayachikitsa (internal medicine), (2) Salya Tantra (surgery), (3) Salakya
(diseases of eye, ear, nose, throat), (4) Kaumarabhrtya (paediatrics,
obstetrics and gynaecology, (5) Bhutavidya (psychiatry), (6) Agada Tantra
(toxicology), (7) Rasayana Tantra (nutrition, rejuvenation and geriatrics),
(8) Vajikarana (sexology). Thus it indicates that Ayurveda was already a
well developed system of medicine in ancient times.
The Approach
The extensive knowledge and wisdom about all aspects of medicine
available in the Ayurvedic texts is very rich. It is really intriguing to think
about the approaches, methods and tools which were used to discover
such an advanced form of knowledge. Certainly these were not the crude
physical experimental methods.
The methodology would have been
definitely intuitive, experiential and perceptual. Ayurveda like all other
systems of ancient Indian learning made discoveries through the most
subtle sources namely the Paramanas, viz., (1) Pratyaksa (direct
perception), (2) Anumana (logical inference), (3) Aptopadesa (verbal and
authentic documentary testimony), (4) Yukti (experimental evidence) etc.'
In view of the above nature of the Ayurvedic knowledge, it is suggested
that all studies and investigations, directed towards revival of this great
ancient science in present times should follow three main methodological
72
parameters viz. (1) Historicity. (2) Linguistics and (3) Comparative
evaluation with contemporary sc ences like western medical science.
If we examine the Ayurvedic cancepts in proper historical perspectives
with correct linguistic interpretations viewing the same in the light of
comparable contemporary knowledge, it may not be difficult to reach the
genuine meaning. While undertaking the comparative studies one has to
appreciate that Ayurveda and the contemporary western modern medical
sciences have very different approaches.
If comparisons are made
without taking into account the distinct approaches there is always a
chance of being mislead. The obvious distinctions between Ayurveda and
western medicine are that (1) Ayurveda is essentially an experiential
science in contrast to western modern medicine which is an experimental
science, (2) Ayurveda has a holistic and totalistic approach in contrast to
western modern medicine which is analytical and reductive in its
approach, (3) Ayurveda is a function (physiological) oriented science in
contrast to modern medicine which is structure or organ oriented, in other
words the latter does not believe in a function unless it is identified as
related to a structure, while Ayurveda looks at the whole organism as a
total indivisible being which has to function as a whole, to exist as a
whole.
The Fundamental Principles
The Macrocosm-Microcosm Continuum
Ayurveda is based on the laws of Nature. The theory of Lokapurusasamya (macrocosm-microcosm continuum) is the most important principle
of Ayurveda. The individual human being is the miniature replica of the
universe.
The individual and the universe both are essentially
Pancabhautika, i.e., made up of five basic physical factors or elements
namely akasa (ether/space), vayu (air/motion), teja (fire/radiant energy),
jala (water/cohesive factor) and prthvi (earth/mass).
The individual
(purusa) and the universe (loka) remain in constant interaction with each
other and also derive and draw materials from each other in order to
maintain their normalcy and homeostasis. This exchange follows the law
of samanya and visesa (homologous vs. heterologous) on the simple
principle that a similar/homologous matter increases the similar, while a
dissimilar/heterologous matter decreases or depletes the same in the
body. The interaction and exchange between loka and purusa continues
in a natural way as the man breaths air, drinks water and consumes food
articles available in the nature. So long this interaction is wholesome and
optimum; the man is in optimum health. When this harmonious interaction
breaks, a state of disease, starts. Hence the main principle of treatment
of a disease is nothing but to restore harmony between the loka and the
purusa and to restore normal balance of pancamahabhutas in the body
and mind with due homeostasis.
73
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The Ayu And Panca Mahabhuta Theory
Ayurveda conceives life (ayu) as a four dimensional entity comprising of
sarira (physical body), indriya (senses), sattva (psyche) and the soul or
atma, i.e., the conscious element.
Thus the individual being is a
comprehensive psychophysico-spiritual unit which is highly dynamic and
is in constant interplay with the cosmos.
As stated earlier the gross
human body is pancabhautika, i.e., it consists of a proportionate
combination of five mahabhutas. The panca mahabhuta theory is
essentially a theory of physics. The panca mahabhuta represent the five
essential aspects of the matter namely
(1) The mass as earth or prthivi,
(2) The cohesion as water or jala,
(3) The motion as air or vayu,
(4) The radiant energy as fire or teja,
(5) The space as the ether or akasa.
The Theory Of Tridosa
The five physical attributes of pancamahabhuta constitute three major
biological components of the living body called tridosa, i.e., the three
dosas viz. vata, pitta and kapha. The entire body’s function is explained
in terms of these dosas. They are called dosa because of their inherent
tendency to get vitiated and to vitiate each other. Vata is the biological
product attribute of predominance of air and space; Pitta is the product
attribute of predominance of fire while Kapha is the product attribute of
earth and water factors of the pancamahabhuta. Thus the tridosa theory
of Ayurveda is essentially a biological application of the panca mahabhuta
theory of Hindu physics. Sometimes the three dosas are understood as
the three conceptual constructs developed by the propounders of
Ayurveda to explain the human physiology in an unique holistic way.
Apparently the total human body consists of a mass of solid substratum
added over it with an intensive interplay of chemical activity and an
energy pool of motion and movement. All these three aspects coexist in a
genetically predetermined proportion and function in a manner
complementary to each other in the interest of the overall function of the
total organism inspite of their opposite properties and functions. Out of
the above, the solid substratum of the body is represented by Kapha, the
chemical moieties by the Pitta and the motional energy component by the
Vata. The existence of the three dosas can be felt in the gross body as a
whole and can also be traced at the molecular level. Each cell of the
body consists of a mass substratum, a chemistry and an operative
energy. They are the kapha, pitta and vata aspects of the cell organelle
respectively. The proportion of the three has to remain in an appropriate
range of normalcy. This range of proportion varies from organ to organ,
tissue to tissue, cell to cell. For example a nerve cell i.e. a neuron in the
’4
h
brain may have higher value of vata activity than the other two dosas,
while a cell of an endocrine gland-like the cells of the thyroid has more of
pitta, and the relatively inert cells of the bone tissue like the osteocytes
or muscle cells may have more of kapha function than others.
The Dosa Prakrti, i.e., Constitution
The relative proportion of the three dosas is very important.
The
genetically determined relative proportion of the three dosas within the
normal range is called dosa prakrti. Depending upon a variety of prenatal
factors there develops a particular pattern of relative preponderance of
one or the other of the three dosas in an individual’s constitution and this
genetically determined
normal preponderance
is
responsible for
determining the total personality makeup representing the sum total of his
physique, physiology and psyche. Thus the dosa prakrit is an important
consideration in the understanding of human life, health, disease, disease
susceptibility, preventive and promotive health care and treatment
requirements of a patient. The Ayurvedic texts describe in detail the
physical, physiological and behavioural features of the persons of
different prakrtis.
Ordinarily the texts describe seven types of dosa
prakrtis.
The Trigunas, i.e., Qualities Of Mind
The pancamahabhutas are represented in the psyche of an individual in
terms of the three gunas of the manas or mind i.e. triguna viz. sattva, raja
and tama. The akasa tattva is represented in sattvaguna. Vayu and teja
are represented in rajoguna while prthivi and jala are represented in
tamoguna. The tamoguna represents mass and inertia while the rajoguna
represents dynamicity and activity. The sattva is the state of complete
balance.
Depending
upon the genetically
determined
relative
preponderance of one or the other of the three gunas the psychic makeup
of an individual varies.
This variation is categorised as three major
manasa prakrtis further subdivided into sixteen subtypes or traits.
In
principles an average normal individual is the total combination of all the
16 traits. However one of the traits may predominate giving characteristic
features to him and that becomes his mental type or manasa prakrti.
Svabhavoparamavada And Self Healing
Ayurveda propounds an important theory of natural self-cure and
spontaneous healing through the doctrine of ‘svabhavoparamavada ’.
According to Ayurveda the human body is inherently endowed with an
unique power of self defense and spontaneous healing against injury and
disease. The body heals itself and a natural cure follows after every
injury and insult. The role of medicine is only to assist the Nature.
75
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Basic Causes Of Disease
Inspite of the rich resource of natural resistance and immunity of the body
technically termed as vyadhiksamatva, people do suffer from a variety of
mental and physical disorders warranting medicinal interventions. Hence,
it is necessary to write a few lines about the causes of disease as
conceived in Ayurveda. Ayurveda propounds that the primary cause of all
diseases is the failure of harmony between the man and his environment
i.e. the interaction of the microcosm with the macrocosm referred to in
Ayurveda as the purusa and the loka. Fundamentally the loka-purusa
interaction takes place at the level of three factors i.e. (1) Kala or time
factor and its chronobiological influences, (2) Buddhi or intellect of man
as the major source of thought information and (3) Indriyarth or the
objects of the five sense organs as the source of stressful information
from the macrocosm to the microcosm. The normal functions of Kala,
Buddhi and Indriyartha are the important attributes of the life process'
But their unwanted malfunctions classically termed as ayoga, atiyoga and
mithyayoga are considered as the primary cause of disease.
___ The ayoga,
atiyoga and mithyayoga of kala, buddhi and indriyartha are termedI as
kalaparinama,
prajnaparadha
and
asatmyendriyartha
,samyoga
------respectively and are considered the primary cause of all diseases,. All
other causes of ill health known and described in different schools of
medicine are secondary to these primary factors which are essentially
environmental factors.
Thus the cause of the disease according to
Ayurveda lies in the environment and so also the cure is to be found in
the Nature.
Evolution Of A Disease And Dosika Rhythm
When an individual is indisposed through the above mentioned etiological
factors, the disease process ensues in the form of tridosika arrhythmia
and vitiation of dosas which may lead to irreversible diathesis giving rise
to a full fledged disease. Susruta Samhita a leading Ayurvedic classic
describes six stages of the evolution of a disease depicting them as the
specific
opportune
stages
for
applying
appropriate
therapeutic
interventions.
These stages are appropriately termed as satkriyakala,
viz., (1) Sancaya (stage of accumulation of dosas), (2) Prakopa (stage of
vitiation), (3) Prasara (spread), (4) Sthana-samsraya (localisation) (5)
Vyakti (stage of manifestation) and (6) Bheda (stage of chronicity and
complications).
The precision adopted in describing these stages of
disease process in relevance to the needed therapeutic intervention is a
unique concept and exhibits the intensity and purpose of an observation.
The basic philosophy behind the concept of kriyakala is to emphasize the
need of early detection of a disease and an appropriate timely therapeutic
intervention so that the disease process may be reversed towards
normalcy without waiting for cure of an end stage disease to manifest. An
Ayurvedist will be likely to detect the defect right at the moment when the
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seed of the disease is just sown. As a matter of fact the stage of sancaya
is the seed stage of the disease.
The Agni And Ama
In the above context it is often questioned, why the Dosas start getting
accumulated.
Rather what is the main triggering factor which is
responsible to precipitate the kriyakala. Among many factors Agni the
digestive and metabolic fire of the body is considered the most important
factor.
There are thirteen types of Agnis in the body which are
responsible for digestion of food and metabolism at different levels.
When the Agni becomes weak, a number of unwanted unripe by-products
of digestion and metabolism start forming and accumulating in the body at
different levels from gross to the molecular level, from local GIT level to
the systemic level over tissues and cells. Such products are called Ama
and those act as toxic and antigenic materials. The presence of Ama
renders an Ama state in the body which is characterised by increasing
impermeability and sluggishness of the body channels named srotas.
Such a state of the body allows Sancaya of Dosas which is the first
kriyakala and the subsequent sequence of events follow as a compulsive
phenomenon.
It is in view of this fact that Ayurveda categorically
emphasises that all disease are the product of weak Agni and in turn the
main principle of treatment of all diseases in Ayurveda is to restore and to
strengthen the Agni, i.e., the digestion and metabolism.
The Ayurvedic Diagnostics
The diagnosis in Ayurvedic medicine is not always in terms of the name of
a disease, but is in the form of a description of the disease process
depicting the pattern of vitiation of dosas and dushyas, the seat of
morbidity, i.e., the organ or srotas involved and the quality of life, health
and personality of the patient. All this demands a very extensive
interrogation and examination of the patient. Ayurveda makes a two-fold
approach to diagnostics viz., (1) Examination of the patient i.e. Rogipariksa; (2) Examination of the disease, i.e., Roga-pariksa. Rogi-pariksa
is essentially concerned with ascertaining the constitution of the
individual and status of his health and vitality. It is not meant for the
diagnosis of the disease.
The
emphasis
on
ascertaining
the
constitutional background and evaluation of the status of health in a
diseased person is an unique concept of Ayurveda. Ayurveda advocates
to undertake this part of clinical examination keeping in view the fact that
such informations about the patient are always of great help in presuming
the diagnosis in prognostication and in deciding the overall line of
management and treatment of the patient. Caraka, the foremost authority
on Ayurveda describes a tenfold methodology for this part of clinical
examination which consists of (1) Prakrti (constitution), (2) Vikrti (disease
susceptibility), (3) Sara (quality of tissues), (4) Samhanana (compactness
of the body), (5) Pramana (anthropometry), (6) Satmya (adaptability), (7)
77
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Sattva (mental
stamina),
(8) Aharasakti (digestive
power),
(9)
Vyayamasakti (physical strength), and (10) Vaya (age and rate of aging).
The Roga-pariksa or pathological examination is carried out with the view
to diagnose the present disease. This is usually done in three parts viz.
(1) Interrogation for main complaints and history, (2) General examination
by popular eight-fold examination including pulse, urine, stool, tongue,
skin etc. and (3) Systemic examination of the whole body including the
thirteen gross channels, the srotamsi spread over the sadangas or the six
major parts of the body viz., head-neck, chest, abdomen and the
extremities.
The pulse reading is considered as one of the most
important aspects of clinical examination.
Having acquired necessary
experience and expertise an Ayurvedic physician is supposed to know a
lot about the health and disease of his patient through pulse reading.
Many physicians claim to depend entirely on pulse reading for making a
diagnosis although classical Ayurveda does not make any such claim.
Promotive And Preventive Health Care
Ayurvedic medicine is essentially promotive and preventive in approach.
However, it also provides a comprehensive system of curative medicine
for the treatment of the sick adapting a holistic approach. In accordance
with the four dimensional concept of Ayu or life, Ayurveda conceives a
four dimensional definition of ‘health’. Susruta, one of the classic authors
on Ayurveda defines health as ‘svasthya’, i.e., a state when an individual
is in a state of 'samya' or balance of the three Dosas, the thirteen Agnis,
the seven Dhatus and the Maias, i.e., he is in the state of total biological
equilibrium besides being in the state of sensorial, mental and emotional
and spiritual well-being (Prasanna). Thus Ayurveda presents the most
complete definition of health for the first time.
The Ayurvedic texts
describe a comprehensive schedule of health regimen for preservation of
health as a code of health conduct popularly known as ‘svasthavrtta’.
This includes the daily code of health conduct (Dincarya), conduct for the
night (Ratricarya), conduct in relation to various seasons (Rtucarya) etc.
Details about life style, diet, exercise, personal and social hygiene
(Sadvrtta) have been described. Extensive information is available on
nutrition and dietetics.
Ayurveda also describes in detail the role of
periodical
biological purificatory measures i.e.
Pancakarma and
consumption of restorative remedies called Rasayana for promotion of
health, longevity and immunity i.e. Vyadhiksamatva or resistance against
disease.
The Cure And Its Approach
The object of curative treatment in Ayurveda is to restore balance of
Dosas (Dhatusamya) because according to Ayurveda a disease is nothing
but a state of imbalance of Dosas or in other words loss of equilibrium or
the homeostasis. The therapeutic attempt to restore balance is done by
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(1) Augmenting the weakened Dosas, (2) Decreasing the increased Dosas
and (3) Preserving the normal ones. This is done by utilising appropriate
diets, drugs and activities drawn from the Nature on the principle of
Samanya and Visesa (homologous vs heterologous). According to the
classical doctrine of Samanya and Visesa a similar or homologous
material received from outsides enriches the similars in the body and a
dissimilar or heterologous material depletes its counterpart in the body.
This is the concept of samanya and visesa in Ayurveda and is considered
the fundamental basis of all actions, natural or artificial in Ayurveda. This
is the law of Nature and the same is adapted by a physician in the
treatment.
The Three Streams Of Therapy
Ayurveda describes three main streams of therapeutic intervention which
may be complementary to each other but most often are used specifically
for certain specific categories of ailments.
The three classical
therapeutic streams are : (1) Daivavyapasraya cikitsa (divine therapy), (2)
Yuktivyapasraya cikitsa (rational therapy),
and
(3) Sattvavajaya
(psychotherapy).
The divine therapy is specially indicated in karmika
diseases i.e. the diseases caused by actions of the past life and where no
definite acquired cause is traceable and where no rational therapy is
effective. The divine therapy is often practised in tune with astrology.
Stars, stones, mantra, japa, oblations, prayers etc. are the usual
therapies for this purpose. This is a kind of astrotherapy. It is neither a
psychotherapy nor a therapy of biological significance,
Ayurveda
describes psychotherapy separately as Sattvavajaya and biological
therapy as yuktivyapasraya cikitsa. The yuktivyapasraya cikitsa is the
rationally planned therapy taking into account the doctrine of
Pancamahabhuta, Tridosa, Agni, Ama etc. following the principle of
Samanya and Visesa (homologous vs heterologous). This is essentially a
rational biological therapy aiming at restoration of balance or homeostasis
(Dhatusamya).
The Rational Ayurvedic Therapy
The rational Ayurvedic treatment is carried out in two parts viz. (1)
Samsodhana or purificatory therapy and (2) Samsamana or curative
treatment.
The Samsodhana therapy also popularly known as
Pancakarma therapy aims to purify the body from gross to subtle levels
and to clean the channels of the body to enable free flow of nutrients,
medicaments and metabolites.
The living human body consists of
innumerable channels called Srotas.
Due to ill-health, wear and tear
these channels, get blocked and sluggished. Ayurveda advocates that
these channels should be cleaned by Samsodhana measures in order to
enable the organism to heal itself by spontaneous recovery and also to
enable the medicaments to reach the .target sites more easily.
Thus
Samsodhana is considered a prerequisite for all kinds of medications and
79
therapeutic interventions.
A number of procedures are described for
Samsodhana karma. From practical point of view it is practised in two
forms : (1) External purification by way of oleation, fomentation and
massage where a therapist uses oil bath, heat and physical pressure of
massage as the tools of the treatment to soften and mobilise the Maias or
impurities. External purification measures liquefy the impurities and push
them to kosthas i.e. gross channels (excretory system) from where they
get easily excreted or are expelled with the help of major internal
purificatory procedures of Samsodhana karma. Thus these external
purificatory measures like oleation, fomentation and massage are
considered as preparatory measures for the major internal purificatory
therapies. (2) Internal purification is the major intervention and consists
of Vamana (emesis), Virecana (purgation), Anuvasana vasti (oleos
enema), Asthapana (non-oleos enema) and Sirovirecana (snuffing).
These are popularly known as Pancakarma or five-fold therapy.
In principles the Samsodhana karma is followed by specific Samsamana
or curative treatment which consists of rationally planned diet, drug and
life style.
While formulating a scheme of Samsamana treatment the
physician keeps in view the Prakrti or nature of the patient and
components of his Vikrti or morbidity namely the pattern of vitiation of
Dosas, Dhatus and the Agni etc. He takes the help of Pancabhautika
composition of drugs and diets including their Rasa, Guna, Virya, Vipaka
and Prabhava and follows the law of Samanya and Visesa (homologous vs
heterologous).
The Ayurvedic Materia Medica
The antiquity of Indian Materia Medica goes back to the period of Vedas
when certain Vedic Samhitas mention the use of many herbs. Rigveda
the oldest literary document presents the knowledge of medicinal herbs in
Osadhi-sukta (RV. 10: 47, 1-23).
More elaborate descriptions are
available in Atharvaveda.
However, inspite of the descriptions about
these materials one does not find any precise concept of pharmacology in
Vedas.
The materia medica in true sense with description of the
properties of drugs and their therapeutic usage and pharmacology seems
to have emerged only through the Ayurvedic classics like Caraka, Susruta
and Vagbhatta Samhitas, the former two being historically pre-Buddhist.
Caraka Samhita the foremost Ayurvedic classic text devotes the first
twelve chapters on Ayurvedic materia medica arranging the drugs in fifty
groups according to their action on different functions of the body or on
different symptoms of diseases. Susruta Samhita too describes drugs
and their botanical categories in detail. Further details are available in
subsequent treatises like Astanga Samgraha, Astanga Hrdaya and
medieval texts like Bhava Prakasa and several Nighantus i.e. special
texts dealing with drugs. The rich literature and lively traditional use of
Ayurvedic drugs in popular practice in India attracted the attention of
many western scholars and studies on these drugs began in early
80
nineteenth century.
The contemporary literature is worth reference.
Ayurveda considers all substances as medicine if used for specific
indications and with appropriate formulation, i.e., yukti. Caraka proclaims
that there is nothing on this earth which is not a medicine:
‘Nanausadhibhuta jagati kincit' (CS. Su 1:69).
Accordingly Caraka
categorises all the substances in three groups: (1) Animal products viz.
honey, secretions, bile, fat, marrow, blood, flesh, excreta, urine, skin,
semen, bones, tendons, horns, nails etc.; (2) Mineral products, i.e. the
materia medica obtained from earth viz. the metals like Mercury, Gold,
Silver, Copper, Lead, Tin, sand lime and Arsenic, Gems, salt, red chalk,
Antimony etc. and (3) Vegetable products.
The parts of vegetable
products used for medicinal purpose are the roots, leaves, bark, pith,
exudation, stalk, juice, sprout, cinders, latex, buds, flowers, fruits, oils,
ashes, thorns etc. In another context Caraka has described four kinds of
principal oils, five kinds of milk and six kinds of plants for medicinal use.
e !
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It may be mentioned that the vegetable and animal products cannot be
stored for a long period. The vegetable drugs usually become inert after
a year.
Thus the Ayurvedic medicine utilises a wide range of materia medica
mostly natural products viz., herbs, minerals, animal products and marine
originates. They are used for indications in different conditions of health
and disease in order to restore the state of balance of milieu interior or
Dhatu-samya on the basis of their Pancabhautika composition on the
principle of Samanya and Visesa, i.e., homology-heterology. The
Pancabhautika composition of the materials is adjudged in terms of Rasa
(taste), Guna (physical property), Virya (biological property and drug
potency), Vipaka (pharmacodynamics of drug metabolites) etc. Some of
these may possess specific action in the body of pharmacologic nature
irrespective of their Pancabhautika composition probably because of the
presence of certain pharmacologically active constituents. This is called
Prabhava.
Ayurvedic texts describe elaborate methods of formulation of the natural
products including their collection and taxonomy, purification, extraction,
combination development and posology.
The materia medica of the plant origin is the richest source of medication
in Ayurveda. The Ayurvedic physicians use vegetations of all range like
trees, shrubs, herbs, aquatic vegetations as well as plants submerged
under water.
The Ayurvedic texts give specific indications for the
selection of the parts of medicinal value in a particular plant such as
roots, stems, bark, leaves, flowers, fruits, seeds etc.
It is considered that all parts of a plant are not equally effective.
Medicinal activity remains concentrated in a specific part of the plant and
hence the same should be chosen for medicinal use.
Similarly there
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seems to be a profound seasoral variation in the medicinal activity of
different herbs and plants. Hence they should be collected for medicinal
use in an appropriate season. For example it has been observed that
Sankhapuspi (Convolvulus pluricaulis) has maximum medicinal activity in
its leaves and flowers as compared to its other parts. The activity is
maximum in samples collected during the spring season i.e. late winters
while its activity goes down to minimum during the rainy season (Udupa
and Singh, 1991).
Besides the above considerations a drug collector should always be
careful in choosing a plant which should be apparently healthy, mature
and free from pollution. The Ayurvedic texts also advocate collecting
medicinal material in an auspicious way with all respect to the source and
cleanliness. After collection from nature or cultivated resource the raw
plants should be dried in shade and suitably cleaned before sending the
same for manufacturing final products.
The Pharmacodynamics
Ordinarily the Ayurvedic materia medica is not pharmacologic in the real
sense. Most of the materials used as medicine in Ayurveda act more in
terms of nutrition dynamics than through drug dynamics. Ayurvedic drugs
are soft medications and are more near to food.
The action is
proportionate to the Pancabhautika composition which in turn is
responsible for the Rasa (taste), Guna (physical property), Virya
(biological property) and Vipaka (attributes of drug metabolism) of the
respective material. Depending upon the above factors a drug affords to
produce its effect on the Dosas, the Vata, Pitta and Kapha. A drug and/or
a food possessing the Pancabhautika properties i.e. Rasa, guna, virya,
vipaka etc. similar (Samanya/homologous) to the nature of a particular
Dosa/Dusya, increases the same in the system and those with opposite
property (y/sesa/heterologous) deplete the same.
However, there are certain Ayurvedic drugs which are said to produce
specific pharmacological action in the body irrespective of their gross
Pancabhautika composition and Samanya-Visesa consideration.
This
category of drug action is called Prabhava and is possibly attributable to
the presence of some specifically active principle/chemical constituent in
that drug.
The Ayurvedic Pharmacology
The basic foundation of the Ayurvedic pharmacology was laid down by the
theory of Pancamahabhuta which is considered the physicochemical basis
of the human body as well as the diet and the drugs.
The actual
pharmacotherapeutics in Ayurveda appears to have been based on the
doctrine of Tridosa which was developed to explain the biological
82
functions of the body and the attributes of health and disease in terms of
their equilibrium and disequilibrium respectively.
Restoration and
respectively,
preservation of equilibrium of Dosas is the prime objective of
pharmacotherapeutics in Ayurveda which is achieved through the
principle of homology and heterology {samanya and visesa) of
Pancamahabhutas and in consequence of Tridosas.
As also stated
earlier, in general the Ayurvedic drugs act as molecular nutrients for
different organs and tissues and their action is explained more on
nutrition dynamics than on actual pharmacodynamics. Such a holistic
concept of drug action is to be considered in terms of the composition,
metabolism and action of a medicinal material. In this context Ayurveda
further
evolves certain unique concepts on which the Ayurvedic
f_.evolves
pharmacology in based. They are called Dravya Guna Samgraha i.e.
seven Padarthas of Dravyaguna i.e. seven limbic pharmacodynamics as
mentioned below :
1. Dravya (drug or substance)
2. Guna (physical properties)
3. Rasa (taste)
4. Vipaka (drug metabolism)
5. Virya (potency, biological)
6. Prabhava (specific action/potency)
7. Karma (drug action)
Dravya is the material which is used as diet or drug. All other attributes
mentioned above are to be considered as the qualities of the Dravya.
Rasa (the taste) is significant as it is directly perceivable and represents
symbolically the Pancabhautika composition of a particular Dravya or the
medicinal material but also as an indicator of its Pancabhautika
composition because the Rasa i.e., taste of a material is constituted by
the predominance of one or more of the five Mahabhutas in a material.
Thus the action of a drug is determined in certain cases by the Rasa
alone or in co-consideration of certain other attributes. However, it may
be mentioned that Rasa is not a stable attribute. It ceases to exist after
loosing contact with the Rasanendriya i.e. tongue. Rasa operates only
during the period falling between the original contact of the drug with the
tongue till the start of its digestion. A drug when administered orally has
to undergo digestion before its assimilation. All this brings about major
transformation of the material. The final transformation is called Vipaka.
Vipaka, which refers to drug metabolism, is responsible for the drug
action such as the action of a drug on Dosas etc.
Although Caraka
describes Vipaka to be of three types using words signifying taste viz.
Madhura (sweet), Amla (sour) and Katu (pungent) but it is necessary to
emphasise that vipaka is not perceived like Rasa (taste) but is inferred
from its action on the three Dosas, Dhatus and Maias. The Madhura,
Amla and Katu Vipakas promote kapha, Pitta and Vata Dosas
respectively. This is why Susruta prefers to categorise Vipakas in two
groups naming them (1) Guru or heavy and (2) Laghu or light because of
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the respective Pancabhautika composition. In this reference it has to be
noted that the Bhutas too are of two categories viz. (1) Guru: Prthivi and
Jala- (2) Laghu: Teja, Vayu and Akasa. However their Tridosika attributes
too can be visualised accordingly. The Madhura Vipaka is essentially
Guru while Amla and katu Vipakas are Laghu.
Virya is the power or potency responsible for the action of the drug. It is
essentially the biological property which needs to be protected and
preserved in a drug because if the Virya is destroyed or decayed, there
may not be any action. This is why Ayurveda always asserts the proper
collection, preservation and formulation or manufacturing of a drug in
proper season, proper age of the plant and its proper part for medicinal
use. Prof. P.V. Sharma considers virya as the power of a drug which
resides in the active principle or active fraction or active chemical
constituent of the drug. He further admits that virya of a drug can be
isolated from a drug and its action can be tasted on Tridosika attributes
and Sadupakramika therapeutics considering virya to be of six types, two
for each Dosa, one to increase and the other to decrease as per following
scheme.
Sat Virya
Guru
Laghu
Usna
Sita
Snigdha
Ruksa
Sadupakrama
Brmhana
Langhana
Svedana
Stambhana
Snehana
Ruksana
Vata
Decrease
Increase
Pitta
Kapha
Increase
Decrease
Increase
Decrease
The Prabhava is specific potency while Virya is the potency in general.
Virya is responsible for Dosapratyanika activity while Prabhava is
responsible for specific Vyadhipratyanika effect. The Prabhava refers to
the drug specificity in terms of specific tissues and disease-entities where
Dosa and Dusya both are involved in a particular organ or tissue for
which a particular drug is specifically responsive because of the presence
of a particular constituent. If one views the concept from this angle, the
Virya and the Prabhava appear to be overlapping concepts. As a matter
of fact Susruta does incorporate Prabhava in Virya itself.
However
Caraka provides prominence to the concept of Prabhava according to
which the Prabhava is the specific drug action irrespective of Gunas or
gross constituents of a drug while Virya is always explainable in relation
to the Gunas or the gross material properties of the drug. This is why the
following expressions are used : (1) Prabhava is Dravya Prabhava i.e.
specific action of the drug; (2) Virya is the Guna prabhava i.e. action of
the properties (Sharma, P.V.).
As a matter of fact the virya is nothing but the nonspecific biological
potency of the drug which is needed for the Pancabhautika action of the
drug in terms of its Gunas on the principle of samanya and visesa. This
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kind of action is fundamentally not different from the action expected
through Rasa, Guna and Vipaka. Such an action is a holistic drug action
more of a nature of molecular nutrient not really of the nature of a
specific pharmacological activity.
Whereas Prabhava is the specific
action of a drug which can be described as its pharmacological response
referable to an active principle (Singh, RH, 1998).
Gunas are the physical properties of a drug or material. The action of a
drug or diet or a life style in general is broadly determined by these
Gunas. Ayurvedic materia medica conceives 20 Gunas described in ten
pairs of opposites to be utilised to maintain balance in the body and in the
‘Nature’ on the principle of samanya and visesa as mentioned below.
Guru (heavy)
Sita (cold)
Snigdha (unctuous)
Manda (dull)
Sthira (immobile)
Mrdu (soft)
Visada (non-slimy)
Slaksna (smooth)
Suksma (fine)
Sandra (solid)
Laghu (light)
Usna (hot)
Ruksa (rough)
Tiksna (sharp)
Sara (mobile)
Kathina (hard)
Picchila (slimy)
Khara (rough)
Sthula (gross)
Drava (liquid)
The Mineral Materia Medica
Ayurveda uses extensively minerals and ashed metals as medicine
because in contrary to herbal products the mineral products are long
lasting and more efficacious. It is also claimed that such preparations
become therapeutically more safe and effective when they become old.
These mineral products, when processed with Bhavana dravyas, adopt
their medicinal properties. These minerals are subjected to various
systematic processes of Sodhana or purification, Marana or oxidation etc.
before their induction as medicine. The final products, which are in the
form of ashes or Bhasmas and/or organometallic compounds, are claimed
to be more effective than the herbal drugs and are prescribed in much
smaller doses.
The mineral materia medica of Ayurveda is classified into Rasa,
Maharasa, Uparasa, Sadharana Rasa, Loha or Dhatu (metals), and Ratna
(gems and precious stones). The term ‘Rasa’ in this context is ordinarily
reserved for Mercury though it also covers any mineral or metal in the
generic sense. This is why the entire subject dealing with mineral materia
medica is called Rasa-Sastra and all the drugs of this category are called
Rasausadhis. However, Parada or Mercury is the principal Rasa. The
popular medieval text on Rasa-Sastra called Rasa Ranta Samuccaya
classifies the mineral materia medica of Ayurveda as below :
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(1) Rasa
(2) Maharasa
(3) Uparasa
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
(4) Sadharana Rasa
: 18.
19.
20.
21.
22.
23.
24.
25.
(5) Lauha (metals)
Siddha Lauha
Puti Lauha
Misra Lauha
(6) Ratna (gems)
Parada (mercury)
Abhraka (mica)
Vaikranta (turmaline)
Maksika (pyrites)
Vimala (marcasite pyrite)
Silajatu (bitumen)
Tuttha (copper sulphate)
Capala (bismuth ore)
Kharpara (calamite/smithsonite)
Gandhaka (sulphur)
Gairika (hematite/red ironoxide)
Kasisa (ferrous sulphate)
Sphatika (alum)
Haratal (orpiment)
Manahsila (arsenic disulphide)
Anjana (collyrium)
Souviranjana (stibnite)
Rasanjana (yellow mercury oxide)
Sroto-anjana (antimony sulphide)
Puspanjana (zinc oxide)
Nilanjana (lead sulphide)
Kankustha
Kampillaka
Samkhiya (arsenic)
Navasadara (ammonium chloride)
Karpada
Vahnijara
Sindura (red oxide of lead)
Hingula (red sulphide of mercury)
Mrddarasrnga (plumbi oxidam)
26. Svarna (gold)
27. Rajata (silver)
28. Lauha (iron)
29. Tamra (copper)
30 Naga (lead)
31. Vanga (tin)
32. Pittala (brass)
33. Kamsya (kansa)
34. Varta lauha
35. Vaikranta (flour spar)
36. Suryakanta (sun stone)
37. Hiraka (diamond)
38. Chandrakanta (moon stone)
39. Mukta (pearl)
40. Mani (red gem)
41. Rajavarta (lapis lazuli)
42. Panna (emerald)
86
u
43. Pukharaja (topaz)
44. Gomeda (onyx)
45. Padmaraja (ruby)
46. Pravala (coral)
47. Vaidurya (cats eye)
48. Nilama (sapphire)
Mineral-Metal Processing Procedures
Sodhana (purification and Marana (oxidation) are the basic procedures
described for processing the minerals for medicinal use. Minerals contain
many impurities which may prove harmful to the human body if used
alongwith the therapeutically useful material.
Different methods are
described to purify the metals/minerals. The generic procedure consists
of making thin pieces of the material and heating the same to red hot and
then dipping the same in a series of liquids one after another several
times, each time heated and quenched in sweet oil, butter milk, cow
urine, sour gruel and kulattha, a kind of vetch. This processing purifies
the metal from its common impurities. This is called sodhana. After this
processing, what remains is only the pure metal required for further
processing/ashing.
Some relatively soft minerals can be used directly after sodhana or
purification. But the majority of minerals like metals and gems are
subjected to the process of marana or ashing or oxidation to make a
Bhasma.
It is the Bhasma form (ashed organometallic) of the
metal/mineral which is used for medicinal purpose.
The marana
procedure ordinarily consists of combining the chosen pure metal with
another breaking mineral triturating the same with selected vegetable
juices etc. then making into a bolus closed in a crucible and burnt under
high temperature several times till it gets calcined and becomes easily
powderable Bhasma.
More and more triturated and burnt better and
better is the Bhasma as it becomes fine particled and ash like free from
active metal in metal form. One may continue to burn the metal hundred
to thousand times to make the finest bhasma which may float on water
when subjected to the tarana test i.e. to test the lightness and fineness of
the bhasma when floated on water.
Such a bhasma ordinarily does not contain active metal. The metal is
converted into an ash or oxide and is usually in the form of an
organometallic compound formed with a number of organic materials used
for trituration as bhavana dravya. As such if properly prepared a bhasma
should not have the toxic effects of the original metal. However there is
always a need to analyse such products to assess the chemical
composition and toxicity level and the dose should be accordingly
determined.
87
The Pharmaceutics
Ayurveda describes five fundamental methods of use of fresh vegetable
drugs i.e. Bhaisajya-kalpana. The five basic methods are : (1) Kalka
(paste), (2) Svarasa (fresh expressed juice), (3) Curna (powder), (4)
Phanta (hot infusion or light decoction) and Hima (cold infusion), (5)
Kvatha (decoction). The fresh green and or dry plant drugs are processed
in the above mentioned five basic formulations for direct prescription on
daily basis as per need and suitability of the material and feasibility.
These five forms of preparations are collectively called panca kasaya
kalpana. Ayurveda also prescribes many drugs in the form of milk extract
or ksirapaka viz., Rasona ksirapaka, Arjuna ksirapaka, Bhallataka
ksirapaka etc. Probably this procedure is adopted in case of drugs which
contain milk soluble or fat soluble active constituents.
For long term use and storage other formulations are advocated viz.
Ghanasattva (concentration), Putapaka (roasting), Avaleha (malt), Vati
(pills), Asava and Arista (fermented extracts) etc. Ghanasattva is the dry
concentrated material made by drying the decoction in order to make it in
the form of pills of suitable size and dosage.
Avaleha is a malt
preparation of natural drugs made by concentrating decoctions added with
other necessary remedies, preservatives and flavours for lickable
administration. Certain medicines are prepared in the form of Khanda i.e.
drug sweet formulations. The Asavas are the cold percolation extracts of
herbs and fruits with minimal self generated alcoholic content after
fermentation.
Similarly the Aristas are the similar natural alcoholic
preparations of herbs and fruits which are essentially prepared by
fermenting the decoctions.
Ayurveda advocates the local and oral use of a number of drugs in the
form of medicated oils and Ghrtas for which elaborate pharmaceutical
methods of Taila and Ghrtapaka are described in Rasa-Sastra texts. This
kind of formulation is used in case where oil/fat is needed as a vehicle or
for oleation effect such as for massage etc. or in case of drugs which
possess active principles soluble in fat.
Single And Compound Formulations
As stated earlier Ayurveda always adopts a holistic approach in
medication. It uses whole crude plant drug, which is supposed to be the
mixture of many constituents some of which are pharmacologically active,
some may be nutrients while some others may be the antidotes to take
care of the potential side effects.
The whole thing is a natural
combination which has had allowed the life of the plant. Thus even a
single drug used in Ayurveda is a mixture. But in practice it would be
seen that Ayurveda uses not only single plant drugs but also the complex
compounds of many herbs and plants mixed together. There seems to be
in existence comprehensive principles for combining different herbs in a
88
formulation. Some of the constituent herbs are put-in for synergistic
action, some as antidotes, some to help assimilation of the main drug
while some are added for additional therapeutic effect needed in the
indication of the proposed compound.
Many times Ayurveda advocates herbomineral compounds too, where
several herbs are mixed with certain metals and minerals.
Common
examples are Arogyavardhini, Navayasa lauha, Sutasekhara rasa etc.
Addition of metals and minerals in herbal formulations have many
advantages.
The metals and minerals increase the potency of the
compound, act as trace elements to allow the reach of the drug at target
sites and to act as preservative for the overall compound.
Besides the classical formulations described in Ayurvedic classics and
medieval texts, in modern times many neoformulations are being
developed by physicians and pharmaceutical industries to produce more
safe, effective and convenient medicaments. The present Ayurvedic drug
market is full of such formulction products. They are becoming popular
because they are available in acceptable form, shape and presentation on
the line of modern drug presentations. Such tablets, capsules, syrups,
malts, granules, creams, ointments etc. are being produced in growing
number. While formulating such products, the producers are utilising the
practical experience of certain successful practitioners and the results of
some current scientific researches in the field of Ayurvedic medicine.
However, there is need for careful planning of dosage concentration of
neoformulations.
T
)
8Q
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92
d
APPENDIX 5
Health Systems in Andhra Pradesh
Rachel Chatterjee
Situation Analysis
With a land area of 2.75 lakh square kilometers, Andhra Pradesh is the
fifth largest State in India. It is also the fifth most populous state in the
country. Its estimated population is 76 million in mid-2000, which
accounts for 7.6 per cent of the country’s population. The estimated
growth rate of population in 1999 is 1.35 per cent per annum, which is the
third lowest among the major states of India after Tamil Nadu (1.13 per
cent) and Kerala (1.15 per cent). At this rate of increase, the population^of
Andhra Pradesh is projected to touch 100 million mark by the year 2020.
However, if the demographic goals set in the State Population Policy of
1997, are achieved within the time frame, the population of the State is
expected to touch 88 million by 2020. About 30 per cent of the people of
the State live in urban areas.
The State is divided into 23 districts distributed in
in three
three regions, i.e.,
Coastal Andhra, Telengana and Rayalseema.
There
There are significant
differences among and within these regionsi
in
socio-economic
in
development, cultural beliefs and practices. Annexure I (attached)
presents the population size, its growth rate, density, percentage of urban
population and percentage of scheduled castes and scheduled tribes in
different districts of Andhra Pradesh according to the 1991 census.
The more prosperous coastal region of the state, housing its rice-bowl,
has a higher density of population, a lower growth rate and better
demographic, health and socioeconomic indicators than the other reoions
(Table 1).
Table 1
Region / State
CBR
in
1996*
COR
In
1996*
Female literacy|
Per capita
Infrastructure
Census 1991 I Agricultural valuei Development Indexi
(%)
in 1995 (Rs.)**
1 995**
Coastal Andhra
20.6 I 2.12
36.6
23.9 ' 2.75
Rayalseema
30.7
i Telangana_____
24.7
2.89
29.2
Andhra Pradesh______
22.8 _______
2.54
32.7
Source: * Balasubramanyam (1999), IIHFW
•’Centre for Monitoring Indian Economy (2000)
3043
2363
1 566
2234
108.0
■
'
i
91.1
93.7
W4
~
’
"
Socio-economic indicators and health status
The percentage of scheduled castes and scheduled tribes constitute
nearly 22 per cent of the total population. There is, however, considerable
variation in the percentage of SCs and STs in different districts, with
Khammam showing a high of 42 per cent, and Hyderabad a low of 10 per
cent. In the Indian context, poverty has social' and cultural dimensions,
and economically weaker sections normally belong to the lowest caste
group. The poorer health outcomes among SCs and STs in the state also
u
reflect the relationship between heath and socio-economic status (Table
2).
TABLE 2
Literacy and Child Mortality by Caste, 1998-99
Caste / Tribe
Percent illiterate
Infant
among ever married
mortality
i
women age 15-49
rate
SC
_________76.0_________
95.4
ST_________________________
________ 88.6_________ (103.6)
Other backward classes
________ 70.1__________ 69.7
Other
47,1
________ 43.3_________
All_________________________
63.8
70.8
Source: NFHS - 2
Under - 5
mortality
;
i
122.4
(115.9)
89.5
64.7
91.3
Poverty and III Health
The relationship between poverty and health status is complex and
constitutes a vicious circle.
There is enough evidence to reveal that
poverty and health have an inverse relationship. The converse is also
true: ill health leads to poverty.
In many families due to expenses
incurred for treatment and loss of wages on account of ill health, families
have been reduced to impoverishment. Breaking this vicious circle will
largely depend upon both reduction of poverty and improvement of health
status. A study estimating incidence of illness by per capita expenditure
group in Andhra Pradesh indicates that, in general, there is an inverse
relationship between incidence of illness and per capita expenditure
affirming the relationship between ill health and poverty (Figure 1).
Figure 1
Morbidity by Per capita Expenditure, Andhra Pradesh, 1986-87
80
o
o
o
Rural
60
c
o .2
Urban
40
ca
□
20
5 o
42 CL
O
—H 23.7
2 1.4
- 13.X
0
0-20
20-40
40-60
60-80
NO-100
Per capita Expenditure
Source: P. Satya Sekhar, 1997, Economic & Political Weekly, Vol.32, No 12, March 1997
Health Status
Life expectancy is an indicator of the health status and socio-economic
development of a given population. In Andhra Pradesh it is estimated at
60.3 for males and 62.8 for females in 1991-951. This is slightly higher
than the national average of 59.7 for males and 60.9 for females, but is
Registrar General of India 1997
^4
1L
ower Xian life expectancy in the .
: -igure 2).
e
southern states and Maharashtra
Figure 2
Life Expectancy in Andhrs Pradesh and select States
80
75
70
S 65
"60
55
50
Llnook 11 E a
□ Females
□ Male
■'T
S
d
co
CO
in
KE
TN
MH
AP
KA
IN
CTJ
<D
m
OR
ID
LO
3
MP
Source: Registrar General, Census of India. 1997
Other major mortality and fertility indicators are indicated in Table 3 below:
Table 3
Demographic and Health Indicators of Andhra Pradesh
I
1971-73
1991-93
1981-83
CBR
”
24.9
34.1
31.2
TFR__________
4.5
3.9
2.8
CDR__________
15.8
^0.7
9.2
IMR___________
109.0
S'.O
69.0
Nepnatal
65.0
56.3
48.8
Post-neonatal
44.0
24.5
20.3
Peri-natal
66.1
50.8
53.1
Note: *’Average
‘
of 1995 and 1996 only
Source- :
SRS, various years, Registrar General. Census of India
I
1995-97
23.2
2.6*
8.4
65.0
49.1
15.9
49.5
While the birth rate is steadily declining in the state, mortality rates are a
major cause of concern. The adult mortality rate is one of the highest in
the country, and is stagnating in the 90s2. The situation with the infant
mortality rate is worse, with the neo-natal component showing no decline
at all in the nineties.
A comparison of the performance of Andhra Pradesh in respect of health
outcomes with other States reveals that it is the poorest performer
amongst the four Southern States, but is a middle performer in relation to
the other States (Annexure - II).
Table 4 below compares the state's
performance with southern states.
Table 4
Health Outcomes in Andhra Pradesh and Select States
IMR
CMR
TFR
% of children | % of women
with anaemia I with anaemia
I
(6-35 months) I (15-49 years)
India_______
~ 94,4
'
2.9
67,6
74.3
I
51.8
A.P,_______
Ii
65.8
85.5
2.3
72.3
I
49.8
Kerala_____
16.3
I
18.8 7i
2.0
43.9
I
22,7
Tamil Nadu
48.2
I
63.3
i
2.2
69.0
'
56.5
Karnataka
__________51.5
I
69.8
i_2.1
70.6
42.4
Source: SRS, Registrar General of India, & NFHS - 2, UPS and ORC Macro. 2000
T
’ James 1997
95
h
Infant Mortality and Maternal Mortality
Infant mortality and maternal mentality are recognised as sensitive
measures to assess the health status of a population. There is no reliable
data at all-lndia and State-level on Maternal Mortality Ratio (MMR). NFHS
2 estimates MMR at the all- India level to be 540 per 100,000 live births,
but has not estimated state-level MMRs in view of the inadequate sample
size. Sample Registration Survey (SRS) figures estimate MMR for A.P. in
1998 to be 159 per 100,000 live births, which is considered a gross
underestimate. A study sponsored by WHO in Anantapur District in 199495 estimated maternal mortality to be as high as 830 deaths for 100,000
live births3. Studies in 5 districts of Andhra Pradesh in 19974 have
estimated the MMR to be 712 deaths per 100,000 live births. However,
since data was limited to three PHCs in each district only, it is inadequate
to assess the maternal mortality ratio. It appears reasonable to put the
estimate of maternal mortality in the state at around 450 per 100.000 live
births. This is unacceptably high.
While there has been a decline in infant mortality in the State from around
the mid 70s, this decline plateaued off during the mid 80s, picked up
again during the period 1989 to 1993 and thereafter, piateaued again
around 65 per thousand live births. This is relatively high when compared
to the Southern States as also West Bengal and Maharashtra. Infant
mortality can be decomposed into two components: neonatal (first 28
days) and post-neonatal mortality (29 days to one year).
Neonatal
mortality results from endogenous factors relating to the mother and to
delivery practices. Post-neonatal mortality, on the contrary, occurs due to
exogenous components of the larger environment5. The decline in postneonatal mortality has been quite consistent in Andhra Pradesh over the
last 25 years. It continues to decline and its present level of 21 per
thousand live births is lower than all India average of 27. This reduction is
primarily due to the control of vaccine-preventable diseases and improved
management of diarrhoeal diseases and acute respiratory infections. The
decline in neonatal mortality, however, has been sluggish since the
1980s, and currently constitutes nearly 70 per cent of total infant mortality
in the State, and at 46 per thousand live births is almost equal to the alllndia level of 46.1 per thousand live births (Figure 3). The high levels of
neonatal mortality are a reflection of the poor socio-economic and health
status of mothers in the State.
■' Bhatia 1985
4 I1HFW, 1997
' James et al. 2000
•id
11
Figure 3
Neo-natal, Post-neonatal and Infant Mortality Decline in Andhra Pradesh
140
120
100
80
—«— PMR
60
XMR
IMR
40
20
0
r-
x
<-
-?
z -
Source: SRS, various years; NFHS 2
Gender differentials and its impact on Mortality
An important dimension of health status is gender differentials, The sex
ratio in the State which has always been unfavourable to women, has
been declining steadily since 1951. Other parameters also work to their
disadvantage (Table 5).
Table 5
------------------ Ger>der Differentials in Selected Indicators, Andhra Pradesh
lndicator
Sex Ratio (No.of women per 1000 men)________________ i
Literacy rate (%)
_________ i
■ School attendance (%)
6-1 0 years_______
_______
11-14 years________________________
Child mortality rate (1 to 4 years)
j Percentage of children
________________
i Under weight (weight-for-age)
.' Stunted (height - for - age)
: Wasted (weight-for - height)
____
i Children breastfed (in months)_____________________
; Not immunized____________
Percentage of sick children taken to hospital for
Diarrhoea
___ ARI
Source : NFHS - 2, UPS and ORC Macro (2300).
j
Female
Male
984
46
1000
83
55
28
88
67
71
17
40
40
9
35
37
9
28
4
23
5
64
66
i
73
I
72
Gender differentials have serious generational consequences. Low
literacy amongst women (the State is on par with Bihar in terms of female
literacy), coupled with low nutrition levels explain the endogenous factors
that have resulted in high levels, of neonatal mortality.
The high
incidence of malnutrition amongst women in the State is a cause of great
concern. As per NFHS II, 49.8 per cent of women suffer from anaemia,
and more than 37 per cent of married women have a body mass index
(BMI) less than 18.5 per cent, indicating a very high prevalence of
nutritional deficiency. Nutrition status of children also remains a serious
problem with 38 per cent of children under three being under-weight, 39
per cent being stunted and 9 per cent being wasted. 72.3 per cent of
children between 6 and 35 months are anaemic0. The low nutritional
status contributes to substantial morbidities and mortality among children.
Fertility Transition in the State
Fertility continues to decline in Andhra Pradesh against all odds. Analysis
of time series data indicates that fertility in Andhra Pradesh seems to
have remained more or less stable at around a total fertility rate (TFR) of
5.5 per woman during the 50s and early 60s. From 1966 fertility decline
accelerated, with an estimated TFR of 5.2 in 1971-76 (the period before
and during Emergency) and 4.5 in 1976-81. Fertility again remained
almost constant at around a TFR of 3.9 for four years from 1981 to 1984
(perhaps a carry-over of the Emergency family planning programme
backlash), and then it declined steadily in the next few years to reach 2.5
in 19987. NFHS 2 carried out in 1998-99 has revealed that, on an average,
women in Andhra Pradesh now give birth to only 2.3 children. While urban
fertility has reached replacement level (2.07), fertility in rural areas is
about 10 percent above the replacement (2.32)8.
Rapid fertility decline has occurred in the state mainly due to a significant
increase in contraceptive prevalence. NFHS 2 reveals that about 60
percent of married women are currently using some modern method of
contraception, a substantial increase from 47 percent at the time of NFHS
1 in 1992-93. Female sterilization and male sterilization (4 percent)
together account for 96 percent of overall contraceptive prevalence.
During the last few years, Andhra Pradesh has consistently stood first
among all the states of India, in terms of sterilisation performance.
In assessing the fertility impact of contraception, age and parity of
acceptors of family planning methods are important determinants. NFHS 2
showed that among all the states of India, the lowest median age of 23.6
years for women at the time of sterilization has been recorded in Andhra
Pradesh. The survey also revealed that about 40 percent of married
women began using contraception when they had 3 or fewer living
children. This pattern of first acceptance of contraception at low parities
means that family planning has a larger demographic impact than it would
if contraceptive use were initiated later. The growing number of couples
accepting sterilization at younger ages and at lower parities has made a
significant impact in reducing the fertility level9.
With a female literacy rate of 33%, a median female age at marriage of
15.3 years and a high infant mortality rate, the State is no better than the
BIMARU states on these counts. However, its performance in terms of
” \FHS2
' SRS
s\FHS 2
’ James ci al. 2000
9S
)
H
fertility reduction
defies the predominant argument that social
development is the key to fertility decline. The state proves that neither a
high level of female literacy nor a low infant mortality rate is a necessary
condition for the onset of a rapid decline in fertility. This is also evidenced
by district level fertility rates (Annexure - III). Comparatively low levels
of fertility are recorded in the north coastal districts of Srikakulam and
Vizianagaram where the female literacy levels are only around 23% and
IMR is as high as 77 and 99 per thousand live births respectively.
respectively, No
particular geographical pattern can be derived from the data. All the
districts in coastal Andhra and Rayalseema have fertility below four by
1991. Many districts in Telengana region, considered to be the backward
region of Andhra Pradesh, have also achieved this level by 1991 census
year °.
Two broad explanations have been postulated for the decline in fertility in
the State. The first is that fertility decline in the State has occurred based
on the diffusion hypothesis. The essence of the diffusion of theory is that
information or behaviour of one person can have spillover effects on the
motivation of another, which could be either positive or negative11. This
spill- over effect has both geographic and social dimensions. Geographic
diffusion is the locational spillover effect. Social diffusion can occur
through different means,
for example,
education,
mass media,
Government IEC programmes and so on. An attempt to analyse fertility
decline in Andhra Pradesh through the diffusion theory does not explain
fertility decline fully. For example, while the decline primarily emerged in
the coastal region of the State, it did not follow a diffusion process in the
neighbouring districts, but begin to occur across all the districts of Andhra
Pradesh, simultaneously.
The second argument is that the fertility decline in Andhra Pradesh has
occurred due to the family welfare and pro-poor programmes implemented
by the Government since the’ early 1980s12. Pro-poor policies have
included the implementation of the Rs 2 per kg rice scheme through a
vigorous public distribution system, large allocations for pro-poor
schemes and the strong promotion of group-lending schemes for women.
There are currently 3.66 lakh women's groups in the state, covering 50
lakh rural women, who have mobilized a phenomenal corpus fund of
Rs.810 crores by 2000. Group-based lending programmes for women have
been established to have had significant impact on reproductive behaviour
even in Bangladesh13. Other factors that have been quoted as having an
impact on fertility is the percentage of women working outside the home
and exposure to mass media. Andhra Pradesh has the largest percentage
of working women amongst the states of India. An analysis14 of factors
that could have contributed to fertility decline from NFHS I data, in
respect of three states - AP, Tamilnadu and UP - has concluded that
Ibid
'' Montogomey and Casterline, 1998
l_ James et al, 2000
'• Pitt et all 1999.
4 UPS. Bombay, 1997
effective delivery of mother and icniid
" ' healthcare
'
services, exposure to
mass media and working outside the home
------- ! appear to be factors strongly
linked to fertility decline.
Figure 4
Factors influencing Fertility Decline
Tamilnadu 3 Andhra Pradesh
Uttar Pradesh
100
90
80
70
60
50
40
30
20
10
0
My
h
lid
0
I
I
i
=t
ei
ip
Source: UPS, Bombay, 1997.
Amongst all these factors, it is likely that the effective delivery of
the
family welfare programme and better governance in the implementation of
pro-poor programmes, have had a major impact on fertility reduction. The
The
which has delivered good immunisation and ante-natal
services, has provided subsidised food, has
implemented pro-poor
programmes, has also promoted the small family
, norm. Since trust has
been built iup between the provider and the community, the family
planning message, conveyed through thei same system, has been quite
readily accepted. Family planning performance in the late 1990s clearly
evidences the impact of specific policies and strategies of the government
on contraceptive acceptance. The state government in 1997 announced a
Population Policy with specific strategies to implement the programme
more effectively. Decentralization was the key strategy for more effective
management. District population stabilization societies were formed and
authority and funds devolved to local levels. District Collectors were made
he Execufve Chairmen of the district-level societies and held responsible
or the effective implementation of the programme. The programme thus
fT0VR$*0U? °f t?e confines of the Medical and Health Department with
flexibility to implement the programme as per local need. Service Centers
tor sterilization were increased and re-furbished. Simultaneously, a
massive training programme for surgeons in more convenient surgical
techniques double-puncture laparascopy and no-scalpel vasectomy-were
undertaken. In order to address the insecurity relating to survival of
c i dren, a Health Insurance Scheme was implemented through New
Assurance India Ltd, wherein a cover of Rs. 20.000 towards hospitilisation
charges for a period of five years was assured for the acceptor of
sterilisation and his/her two children, subject to a maximum of Rs 4000
per year. Institutional deliveries were promoted through the “Sukhibhava”
scheme, through which Rs.300/- was given to every woman who came to a
i U)
u
public health institution for delivery. Rs.15 crores was allocated from the
State budget for interventions under the State Population Policy.
Additionally, Rs. 35 crores was allocated from State funds towards
enhanced compensation for loss of wages for the acceptor of sterilization
(increased from Rs.300 to Rs.500 per acceptor). Most importantly, the
programme had the backing of the political leadership. The Chief Minister
has made family planning central to the development process of the state.
It is the favoured topic in all grama sabhas during the Janmabhoomi
programme, with the Chief Minister taking the lead in these discussions.
(Appendix I gives the details of State Policy, interventions and strategies
and a more detailed analysis of the! causes for fertility decline in the
state). The state has achieved a record 8 lakh sterilisations during the
year 2000-2001. The dramatic impact of these measures is clearly
revealed in the figure below:
</>
05
C
9
8
7
6
5
7.33
7.9
8
1 999-2000
2000-01
6.3
5.2
5.13
1 995-96
1 996-97
4
3
2
1
0
1 997-98
1 998-99
Year
Source: Commissionerate of Family Welfare
So far, empirical evidence linking fertility decline to state policies and
interventions is not available. An attempt has been made!15 in recent times
to link fertility with village level welfare programmes and family planning
activities
The
A ~ using data from the national family health survey.
regression analysis demonstrates that village specific factors such as IEC
meetings on family planning at village level, which basically measure the
Government's role in family planning, have a significant impact on
contraceptive use in the State. This suggests that there is an alternative
to the Kerala model, that social and economic development need not be a
precedent for major social change, and that an effective government,
through its policies and able management, can enable fertility reduction.
Morbidity and burden of Disease
Andhra Pradesh has made progress in the reduction of morbidities prevalence of leprosy has been reduced from 124 per 10,000 population
in 1983 to 5.6 by 2000, no cases of guinea worm disease have been
reported since 1997, and no fresh polio cases have been reported in
2000. However, the state is plagued with increased incidence of TB,
malaria and ARI, and HIV / AIDS has reached alarming prevalence levels.
15 Towards a Demographic Transition. KS James & SV Subramanian. CESS. 2000
pH
I X-o q
101
1i
There is, simultaneously, a marked increase in the incidence of noncommunicable diseases.
No reliable estimates of morbidity rates are available at the state level in
India. An ASCI study on the burden of disease in the state in 1995
estimates that communicable diseases account for 54 per cent, noncommunicable diseases 30 per cent, and injuries account for 16 per cent
of the percentage of DALYs lost due to the disease burden. Amongst
communicable diseases, respiratory infections and perinatal conditions
account for 10.3% and 10.1% respectively. Other major causes for DALYs
lost include TB(7.8%),
diarrhoeal diseases(6.8%) and childhood
i 11 n es s es (4.6 %). In the non-communicable category, cardiovascular
conditions account for 10.5% and injuries for 13.2%16. Table 6 shows a
comparative burden of disease estimate for Andhra Pradesh and four
major States. The pattern is similar across States.
Table 6
Burden of Disease - India and States
1 Category
India*
Andhra
Karnataka I Punjab
West
Uttar
Pradesh
Bengal
Pradesh i
% DALY) Category 1
56.4
54.0
56.5
53.5 I
56.0
62.0
Lost
Category 2
29.0 i
29.0
30.0
28.0
28.0
26.0
Category 3_____________
____
14.6
16.0
15.5
17.5 |
16.0
12.0
Category 1: Communicable diseases
Category 2: Non-communicable diseases
Category 3: Trauma and Injuries
Source
New Directions in Health Sector Development at the State Level. World Bank,
1997
NFHS 1 and 2 have given prevalence rates for diseases covered under
national disease control programme.
Table 7 indicates the estimated
prevalence in Andhra Pradesh.
Table 7
Number of Persons per 1000 Suffering from Select Disease, Andhra Pradesh
i
1992-93
1998-99*______
i
Rural I Urban ; Total
i________________________________________
Rural
Urban I Total
j Partial Blindness
56.0
39.0
1 51.4
Complete Blindness
8.4
7.0
12.3
I
I
I
I Tuberculosis___________________
4.3
4.1
4.56
3.3
6.95 i 5.92
j Leprosy________________________
1.0
I. 8
1.2
I Malaria during last three mont_________________________________________
26.13 I 48.51~i
22.5
II. 1
19.4
56.33
Source : NFHS 1 and 2. UPS Bombay and ORC Macro, 1995 and 2000
Note : NFHS 2 replaced blindness and leprosy with asthma and jaundice
T
The prevalence of TB and Malaria has increased significantly during this
period. While the prevalence of TB is higher in urban areas, the
prevalence of malaria in rural areas is almost doublethat in urban areas.
(A detailed analysis of the state’s performance in respect of diseases
covered under National Disease Control Programmes is in Appendix - II).
!' ASCI 1995
HIV/AIDS in Andhra Pradesh
Given the high prevalence levels, strategies to contain the spread of
HIV/AIDS demand special mention. The State has the dubious distinction
of having the second highest prevalence rates in the country, the first
being in Maharastra. The first case of HIV was detected in the State of
Andhra Pradesh in 1986. The gravity of the problem became apparent,
however, only in April 1998, through the Sentinel Surveillance System
established in 4 regions of the state to assess the prevalence levels in the
category of STD and ANC clinic attendees. The shocking figures of
22.53% and 1.53% for STD and ANC clinic attendees respectively,
disbelieved initially, were confirmed during the second round in August
1998, with prevalence rates showing 22% and 2.15% respectively for
these two groups. The 3rd round of surveillance conducted in August 1999
was even more worrying. It recorded a big increase of 7.05% in one year
in the category of STD clinic attendees and 0.28% in the ANC category.
The third round indicated that both prevalence levels and spread were
high.
The state government has, since 1998, intensified efforts to contain the
prevalence and spread of HIV/AIDS. Some of the steps taken by the AP
State AIDS Control Society are:
108 targetted interventions have been started for high-risk groups
(truck drivers, street children, sex workers, men having sex with
men, slum population, and prison inmates), with the objective of
containing the spread at the starting point. Implemented through
106 NGOs, interventions address issues relating to STD cure and
behavioural change. AP's work in the areas of sex workers, prison
inmates and street children are considered as “best practices"
• 28 STD Clinics in the State have been fully equipped with
adequate drugs, supplies and trained personnel, through which
1.27 lakh STD cases have been treated.
• Family Health Awareness Campaigns are conducted twice a year
to identify and cure STDs in every village in the state
• Blood safety is promoted by supporting and monitoring 142 blood
banks and ensured that only safe blood is available for
transfusion
• A massive and sustained IEC campaign is under way utilising all
forms of media (electronic, print, visual, folk art) and ,
to
enhance general awareness on HIV/AIDS. Political leadership,
elected representatives, religious leaders and celebrities have
been roped in for the general awareness campaign.
The
awareness level in urban areas is currently 88%17 and in rural
areas is estimated to be 55.3%18.
• “Convergent Community Action” (CCA) has been launched,
involving all self help groups, to generate awareness and to
•
i7TNSM. 1998
ls NFHS 2
•
•
•
•
sensitise the community to issues relating to HIV / AIDS patients.
HIV/AIDS has become a central theme in the Janmabhoomi
Programme. Industrial houses have been involved in workplace
interventions, and support mobilised through the Cll
4 care and support centres and 23 Voluntary Counselling and
Testing Centres have been established. Telecounselling, an
interactive voice response system, with a common toll-free
number throughout the state, has been established through which
around 17000 persons have been counseled so far
Student specific approaches have been formalised with the
introduction of the subject
in the syllabus of 10lh class and
above, and through the NSS in all universities of the state
A massive training programme has been launched. Apart from the
training of public sector medical officers and paramedics, RMPs
and PMPs are also trained to identify and refer RTl/STD cases.
620 NGOs working in other sectors have been trained for general
awareness, counselling and referrals. In all, around 9500
personnel are trained so far
The programme has the full backing of the political leadership
with the Chief Minister “breaking the silence” on AIDS, talking
about prevention and control in various fora, including a full fledged discussion in every session of the State Assembly.
The above efforts appear to have had a positive impact. The 4lh Round of
Sentinel Surveillance (August to October 2000) reveals that the
prevalence rates of HIV among STD clinic attendees has just started
plateauing at 28.25% and among the ANC clinic attendees has dipped to
2.00% (Figure 6). The state needs to intensify and sustain these efforts.
Figure 6
Bar-Chart on STD/ANC prevalence rates from 1998 to 2000
_________________________ 29.05
28.25
gyp
2.43
30.
25
20'
15
IO-
o
2.15
11.11
1st Round
Apr 1998
2nd round
Aug 1998
3rd round
Aug 1999
4th Round
Aug 2000
2
I-
1.58
HI
TaL
ANC
----
g
$
0
1st Round
Apr 1998
2nd round
Aug 1998
3rd round
Aug 1999
4th Round
Aug 2000
Non Communicable Diseases
Non-communicable diseases already account for a huge share of the
burden of disease. The cause of death statistics published by the
Registrar General of India for rural areas also gives the percentage
distribution of deaths under different disease categories. The estimated
i
1
)
)
death rate and percentage of death or a few non-communicable diseases
are presented in Table 8.
Table 8
Death Rate and percentage of death for a few non-communicable diseases,
Andhra Pradesh, Rural 1993
Death Rate per 1 000
Percentage of
________ Population
Deaths
Heart attack and other heart diseasi _________ 86.6__________
8.9
Cancer
_________ 36.3_
’
3.7
Diabetes______________
4
_ .5_
'
0.5
Accidents
and Injuries
__________________
i_______ 97.0________ |
10.0
Source: Estimated from Cause of Death Stat:stics (Rural), Registrar General Census
of India, 1 993
Diseases
By 2020 it is estimated that non-communicable diseases will account for
57% of the DALYs lost. An under-financed and over-burdened public
health system will find it difficult to deal with this epidemiological
transition with its high-cost-per-episode disease profile.
Public Health Infrastructure and Access
Access to healthcare includes physical, economic and social access. The
geographic location of health facilities is of prime importance to physical
access and has a bearing on costs of healthcare. No doubt, the
government has built up substantial health infrastructure in the state.
Primary health care is delivered through a network of 1428 primary health
centres and 10568 sub-centres, secondary care through 175 community
health centres, 56 area hospitals and 21 district hospitals and tertiary
care through 31 teaching hospitals. However, as per population norms,
the State is still short of 1317 sub-centres, 573 primary health centres
and 254 community health centres (Table 10).
Table 9
Primary and Secondary Health Care
Norms
Current Requirement Shortfall *
Type of Facilit
Sub Centres
PHCs
CHCs
1
1
1
1
1
per 5,000 population in plains are 10,568
per 3,000 in tribal and hills areas
per 30.000 population in plains ar 1,386 **
per 20,000 in tribal and hill areas
per 100.000 population
218
11.885
1.317
1.889
503
472
254
Government
no norms
144
Hospitals
(upto 30 beds)
Project Hospit^no norms
6
‘ as p
----------------per
norms and1 1991 census population figures
includes 20 Government Dispensaries and 48 Local Fund Dispensaries
Source: Department of Health & Family Welfare. Government of Andhra Pradesh, 2001
Unfortunately, the distribution of the these facilities is extremely uneven,
and there are regions in the state, particularly in the tribal belt, where
access to public health facilities is extremely difficult, given the distances,
terrain and poor communication facilities. A comparison of the population
and the maximum radial distance cc.ered by a PHC in Andhra Pradesh as
compared to Southern States shoves that the state is at a disadvantage
Table 10).
Table -10_________________________________
Population
Radial Distance (km)
Covered by a PHC i covered by a PHC
1.
India______
_______ 27,364
_______ 6.58_______
2.
A.P._______
_______ 29,719
_______ 7.25_______
3.
Kerala_____
_______ 22,311
_______ 3.43_______
4.
Tamil Nadu
_______ 25,614
_______ 5.24_______
5. j Karnataka_________________________ 18.537
5.96
Source: Rural Health Statistics,MHFW.GOI. 1999
SI. No
Urban-rural differentials in terms of hospitals and beds are significant
(Figure 7).
Figure 7
Urban Rural Location of Public Hospitals and Beds in Andhra Pradesh
«r.
60000*1
U
□
s
3
z
2500 '
2000 '
1500 ’
1000 -
50000*
K
O
i> 1E
2
o
z
500 ■
40000*
30000*
i
20000*
10000*
0 -
0
Rural
Urban
n
Rural
Urban
Beds
Hospitals
Source: CBHI, 1 998
There has also been a consistent decline in the per capita number of
public hospitals, dispensaries and beds dispensaries in the 1990s (Table
11)Table 11
Distribution of Hospital and Dispensaries, Beds and Doctors Per Lakh
_______________ Population at Different Levels of Hospital_____________
Type of Hospit
Beds
Hospitals &
Doctors
Dispensaries
1990-91 1997-98 1990-91 1997-98 1990-91 1997-98
Primary
2.54
2.17
14.26
12.3
4.31
3.96
Secondary
0.21
0.22
12.92
12.87
1.61
1.58
T ertiary
0.06
0.05
18.16
16.11
3.34
3.97
Note : Year 1997-98 year data is provisional
Source : Computed from Statistical Abstract of Andhra Pradesh for different periods.
Impact and Expenditure Review, Health Sector, Mark Pearson et al, DFID
Health Systems Resource Centre, 2001
Thus there are serious problems of physical access to public healthcare in
many regions of the state and the situation is not improving. Coverage of
outreach services provided through public health facilities also suffers. An
ANM, who is required to walk distances up to 10 kms (and this is quite
I Ob
common in the tribal belts of the state), is less likely to provide outreach
services in such villages/habitations.
Compounding the problem of physical access to facilities itself, is the
problem of absenteeism, especially of doctors in PHCs and sub-district
hospitals. It is unofficial knowledge in the state that around 80% of
doctors do not live at the PHC headquarters. Though the figure is better
for ANMs, the problem persists with this cadre also (around 40%). The
result is that PHCs remain under-utilised and there is an over-crowding of
secondary / tertiary level hospitals. The lack of an effective referral
system further aggravates this situation. It also results in higher treatment
costs for ailments that could have been dealt with at a lower cost at the
primary level.
Performance Review
The NFHS has recorded coverage under key preventive health services
delivered by the public sector. A comparison between States reveals that
Andhra Pradesh is amongst the best performing states in terms of
contraceptive use and women receiving antenatal care. In respect of
children receiving full vaccinations, which is put at 59 per cent, it is in the
middle-performing group of States (Annexure - IV). Table 12 below
compares the state's performance with southern states.
Table - 12
Coverage under Key services
%
% of
% of
% of
% of
%of
%
%
Children
Pregnant Pregnant Pregnant
Children
Married
Instit
Births
Women
Women
Women Deliverie Attended Receiving
Recei vine
Women Sterili
All
Using any sation Receiving! Receiving Receiving
by
at least 11
Health
Vitamin A
at least 2 Folic Acid
Vaccina Contrac
at
Profession Suppiemen
Tetanus
tions
eptive
leasti
Toxid
Methord
Ante Nata
Check i Injections
Up
All India
42
48.2
36
65.4
66.8
57.6
33.6
42.3
i
29.7
A.P.
58.7
59.6
57
92.7
81.5
81.2
49.8 !
65.2 I
24.8
'Kerala
79.7
63.7
51
98.8
86.4
95.2
93
94
43.6
Tamil Nadu
88.8
52.1
46
98.5
95.4
93.2
79.3
83.8
16.2
Karnataka
60
58.3
52.1
86.3
74.9
78
51.1
59.1
48.4
Source : NFHS 2.
UPS and ORC Macro, 2000
Organisation of the Department
The Department of Health, Medical and Family Welfare is one of the
largest Departments in terms of human resources with around 85,000
employees. On any given day, over 1.5 lakh persons are attended to in
health facilities across the state. And this figure includes only allopathic
systems and the major directorates. Appendix III gives details of the
organization of the Department.
I
Public Health Financing
Public expenditure on health is lew at 1% per cent of the Net State
Domestic Product, This compares poorly with an already poor all-lndia
average of 1.4%. However, private expenditure levels in the State are
very high with the result that overall spending on health at 7.4% is above
the national average of 5.5%19. Per capita government health expenditure
in Kerala is Rs.111, in Tamilnadu Rs.100, in Karnataka Rs.93 and in
Andhra Pradesh Rs.66. The poor allocations to the public health sector
could be the major cause for AP ranking the lowest among the southern
states in terms of morbidity and mortality. The only states which have a
lesser per capita expenditure are Bihar (Rs.51), Uttar Pradesh (Rs.55)
and Madhya Pradesh (Rs.63) (Table 13).
State
i
!
Table - 13
Health Spending for Major States in India, 1993_______________
Per Capital Annual
Government
i Household iTotal Health I
Health Exp, _____
Health
(Health Exp. |
Exp. As
i
Expenditure as I As % of i
% of
Govt. Household Total % of NSDP / NNP I Household iNSDP / NNPl
Income
—
111
482
593
1.8
1 1.9
9.5
209
370
3.2
6.7
579
8.9
Kerala_______
Himachal
Pradesh_____
Bihar________
51
274 |
223
1.4
Orissa_______
74
276
350 |
1.6
Andhra Prad
66
421
487
1.0
Karnataka
93
360"
i 453
1.3
Rajasthan
83
196
I 279
1.6
Uttar Pradest
55
175
! 230
1.2
Gujarat______
78
259
I 337 I
1.0
Madhya Prad'
63
168
| 231 I
1.2
I
Tamil Nadu
100
202
i 302 I
1.4
West Bengal
j 227 i
73
154
1.2
Haryana
83
267
T
i 350 j
0.8
| 392 I
Punjab_____
110
282
4.5
T
Maharashtra
85
i 344 I
259
0.8
Assam______
66
96
i 162 I
1.1
All - India
84
250
I 334 I
1.4
NSDP : Net State Domestic Product; NNP : Net National Product
Source: Shariff et al.(1 995-96)
i
J
6.1
8.2
7.8
8.8
4,2
4.5
4.7
6.9
6.5
3.4
4.1
6.2
5.4
2.4
6.0
7.5
7.4
7.4
6.5
5.4
49
4 4
4.3
4,2
3.8
3.4
3.2
3.2
2.8
5.5
Though public expenditure has been increasing in both real terms (Rs
11.14 billion in 1998-99) and per capita terms (Rs.149 in 1998-99) at
current prices, this is largely due to investment in the secondary hospital
sector through the World Bank-aided First Referral Health Systems
Project. While plan expenditure has grown rapidly because of externally
aided projects, the share of plan expenditure devoted to primary
healthcare has reduced from over 90% of expenditure in 1994-95 to 67.7%
in 1998-99. The share of non-plan resources for primary healthcare has
fluctuated between 35% to 40%, and real per capita non-plan expenditure
' Shariff el al. 1995-96
11
for the health sector has actually declined between 1994 and 1 998.20
Thus, a large share of public expenditure is devoted to the secondary and
tertiary sectors. This situation is now sought to be rectified through the
World Bank-aided primary health component of the AP Economic
Restructuring Project which commenced in 1998, (Rs.350 crores) and the
proposed DFID’s sector-wide aid. commencing in 2002.
Despite
increased allocations to the health sector, the percentage share of the
health budget to the total budget is declining (Figure 8).
Figure - 8
Percentage share of Health Budget to Total Budget
4.42
■
51
4'
3
2
1
4-33
Lil
3.91
3.78
1997-98
1998-99
3.68
o-k=i
1994-95
1995-96
1996-97
1999-2000
Source: Department of Health ano Family Welfare
In terms of financing sources, non-plan expenditure is financed almost
exclusively by the Government of Andhra Pradesh, while plan expenditure
is financed by Government of A.P., Government of India and donors. A
large portion of both plan and non-plan funds are spent on establishment
costs, with too little remaining for non-salary essentials such as drugs,
consummables, maintenance of equipments/buildings, sanitation and so
on. An analysis of 1998-99 and 1999 - 2000 accounts indicates that with
the implementation of State PRC recommendations, non-salary grants
have been drastically reduced, in particulars for the primary health sector
(Figure 9). While the secondary hospitals have not felt the pinch because
of project funds, the primary health centres have faced the brunt,
reflected perhaps in the low utilisation patterns in the state.
Impact and Expenditure Review. Health Sector. Mark Pearson et al. DFID I lealth Systems Resource
Centre. 2001
•
•
It 19
Figure - 9
Director of Medical Education
Rs. In Crores
Salary Grant
Non-Salary Grant *
139
150
41.38
□ □
50
104
100
50
0
0
1998-99
33.18
1999-2000
1998-99
1999-2000
Year
Year
Director of Health
Rs. In Crores
Non-salary grants *
Salary Grants
300
200
100
0
221.91
130.08
1998-99
40
20
0
23.14
6.35
1998-99
1999-2000
Year
1999-2011' •
Year
" Excluding budget for drugs
Source: Directorate of Health & Medical Education
Equity
21
A studyzl assessing the impact of public health expenditure on the poor
based on the National Sample Survey, 52nd Round, reveals that the major
portion of public expenditure is not benefiting the poor.
Except for
immunization services, the rich are the main users of public sector
facilities, with the top quintile accounting for almost 40 per cent of
impatient days in public hospitals and the bottom quintile accounting for
just over 10 per cent. An exception is childbirth, where the poorer groups
make for greater use of public facilities accounting for almost 5 times
more in patient days than the top quintile. The table below indicates the
distribution of public subsidies by quintile.
Table 14
Distribution of Net Public Subsidies by Level of Care by Quintile (Rural and Urban)
Short
Hospitalisation
Quintile 1
Quintile 2
Quintile 3
Quintile 4
Quintile 5
T ota I
Subsidy
18.1
(11-1)
17.0
(14.3)
16.6
(20.6)
30.5
(26.4)
17.8
(27.6)
49.6%
(57.1%)
‘ Who benefits from public health spending in India. Ajay Mahal et al. MCA ER. 2000
I io
(Hospitalisation
14.8
(8.4)
14.4
(13.0)
"5.0
(18.2)
PHC and others
“20.5
(20.3)
“21.6
(20.7)
33.5
(21.7)
Immunisations
“29.3
(23.7)
“23.0
(22.2)
T otal
16.3
(10.2)
15.7
(14.1)
25.5
(26.9)
30.4 ‘ T 83.0% i
(33.5 J
(86.1 °j
i
"”15.2
’
~9?2
(20.3)
(17.0)
lT.6%“
(9.1%)
“21.5
(22.0)
’ 1 7.9~
(19.6)
“8?4
(12.5)
“6?4%*
(4.8%)
17.4
(18.7)
"23?0
(26.0)
26.7
(31.0)
100%
: All India Figures in Brackets.
Source: Impact and Expenditure Review, Health Sector, Mark Pearson et al. DFID Health
Systems Resource Centre, 2001
The study also reveals that the top quintile is hospitalised over 7 times
more frequently than the lowest, and almost 10 times imore often in rural
areas.
In terms of outpatient visits, the top quintile made 65%
. .□ more
outpatient visits than the bottom quintile
in urban areas and
125%
i
.wi*_<//omorein
rural areas. In terms of immunization, a child in the top quintile has on
average 4.6 immunization shots, whilst a child from the lowest quintile has
3.8.
The top quintile account for 27% of all in-patient days associated
with childbirth, despite the fact that they only account for 10 9% of
children aged under one.
The poor make relatively more use of the public sector. For the poorest
quintile, 61.9% of inpatient days were spent in public facilities compared
to 28.5% for the top quintile. However, it must be borne in mind that the
poor still make significant use of the private sector22.
Cost of Healthcare :
A comparison of NSS data (42nd & 52nd Rounds) reveals that the costs of
healthcare have grown much faster in the state than the country as a
whole, and the rise was much greater for inpatient care than for outpatient
care. For inpatient care, costs grew at 93% for rural and 58% for urban
population, as compared to 31% and 26% at the all-lndia level. For
outpatient care, the increase was 16.3% and 19.2% in the State as
compared to 15% ano 15.5% at the all-lndia level23. This increase is a
cause of great concern and needs to be analysed and addressed.
Private Sector
Data on the private sector in Andhra Pradesh, as is the case with the rest
of India, is weak.
—
The available data relates to the year 1994. There has
been significant growth, in recent times,, especially in the number of
nursing homes. Of the estimated 79000 beds in the state in 1994, it was
estimated that around 59 per cent were in the private sector, 35 per cent
in the public sector and six per cent in the voluntary sector24. There are
" Ibid
,bid
“’’Impact and Expenditure Review. Health sector. Mark Pearson et al. DFID.2001
!1I
h
significant regional differences with :ne developed coastal region having
many more private hospitals. Most of these hospitals are small (87 per
cent have less than 30 beds). Almost all these hospitals provide obstretic
services and less than half of them provide a broader range of services
covering medical, surgical, obstetric and other specialties. The region
wise size and location is shown in Table 16 below.
Table 15
Private Hospitals by Size and Location
1 to 9
10 to 19
20 to 29
30 to 99
100 to 249 I
beds
beds
beds
beds
beds
|
250 +
beds
No.
Beds
No.
Beds
No.
No. Beds
No.
Beds | No. Beds|
Coastal Andh 529
2751
623
7698
237 | 5128 129 5583
19
2737
1
296 |
421
744'9
"eT
T
Ts
“420“
0
~Tj
716T
3
862 I
Rayalseema
“82~
Telengana
260
768
Beds
"28~ ! 614
‘24~
922
3T3 3947 T8 8 | 4169 763 662’3
Source: Institute of Health Systems, Andhra Pradesh, 1996
Ths share of the private sector in delivery of hospital services is the
highest of all states in the country. The private secto.* accounts for 72 per
cent of total hospitalisations and over 85 per cent of outpatient services25.
These figures indicate that the public sector plays a somewhat marginal
role in the delivery of curative services in the state. Annexure - V gives
details of utilization rates of public and private facilities, state - wise.
A study in Mahaboobnagar district26 found that:
even low income households spent large amounts on minor and
major illness in the private sector
that PHCs have a minor role in the treatment of minor illnesses
and a negligible role in the treatment of major illnesses: Sub
centres play a negligible role in the treatment of minor illnesses,
and no role at all in the treatment of major disorders
PHCs and SCs are primarily used for preventive MCH services
such as ante natal check ups and immunisation, but rarely used
for deliveries, despite the low cost. PHCs are also used for
tubectomies.
People prefer to go to a qualified private practitioners when
available especially so for major disorders
The main reasons for using a particular facility were its close
proximity and lack of alternatives - over 80% - for both minor and
major illness
Ibid
IIHFW. 1997
Relaiive efficiency of the Private Sector
No comprehensive studies of the relative efficiency of the public and
private sectors exist. In terms of unit costs, there is some relevant data.
A comparison of unit costs in 3 secondary public health facilities in
Khammam District (Khammam District Hospital, Bhadrachalam Area
Hospital Penuballi Community Health Centre) and a well-respected NGO
facility (Peoples Polyclinic, Nellore) has been made27. Costs per unit of
output seem to be highest in the district hospital (Rs.86,204 per bed),
followed by the NGO facility (Rs.69,905 per bed), whilst the unit costs in
the smaller area hospital and community health centre are somewhat
lower. There are significant differences in how resources are spent and in
the degree of cost recovery achieved. The Peoples Polyclinic spends a
far higher proportion of its resources on non-salary costs (4 times more
than the larger and busier district hospital - and almost 10 times per unit
of output). In addition, whilst cost recovery in the APVVP facilities was
less than 3%, the Polyclinic was able to more than cover all costs. While
APVVP facilities receive greater financial support than the NGO facility,
they are also far busier.
Quality of Care: Private versus Public
In terms of quality of care, NFHS II has attempted to present select
quality indicators for both public and private health care in the State.
Table 16 below indicates that while the private sector scores higher than
the public sector on several indicators (cleanliness and attitude of staff),
surprisingly, there is not much difference between the two in terms of
waiting time.
_______________________________ __________TABLE 16_______________
' Quality of care Indicators for Visit to a Health Facility Within the Last 12 months
Public / Private Source
in Andhra Pradesh, 1998-99
Quality Indicator
Visit to a Health Facil
Public
Sector
Private
Sector / NGOI
Total
Percentage who received service they went for
98.1
99.6
99.4
Median waiting time (minutes)
29.6
29.3
29.4
Average waiting time (minutes)
54.2
4 2.7
44.6
Percentage who said the staff spent enough time w
her_______________________
Percentage who said staff talked to her
93.2
98.0
97.2
Nicely
57.6
71.6
69.2
Somewhat nicely
37.6
27.8
29.5
|Not nicely
4.8
0.6
1.3
Percentage who received services they went for
Impact and Expenditure Review. Health Sector. Mark Pearson et al. DFID Health Systems Resource
Centre. 2001
113
I
Percentage who said staff respected her neec for
privacy__________________
Percentage who rated facility as
80.1
Very clean
.51.8
I
71.6
68.2
Somewhat clean
44.6
I
27.4
30.3
Not clean
3.6
1.0
1.4
Number visiting a health facility
469
2296
2765
84.5
Source : NFHS (1999)
KEY FINDINGS
The key findings from the above review are as under:
• Andhra Pradesh is fast approaching a replacement level of fertility
and has proved that fertility reduction is possible even within the
context of poor performing social and economic variables
• Health indicators in Andhra Pradesh, although better than national
averages, still lag behind those of other southern states
• Coverage of key preventive services is also generally better than
the national average, but is somewhat below that of the Southern
states.
•
In terms of curative services, the public sector plays a very minor
role in the delivery of services. In terms of in-patient services,
utilisation of the private sector is the highest of any state in India,
and is well above the national average of 49.7 per cent.
The
utilisation of public in-patient facilities exceeds only that of Bihar
and is comparable with that of Uttar Pradesh.
• There are significant differences in access to public health
infrastructure, health indicators and service coverage both between
and within districts, pointing to the need for a need-based planning
and implementation strategy
• The state has a huge and double burden of disease, which an
under-financed public health system is ill equipped to handle.
Additionally, HIV/AIDS has assumed alarming proportions
• Andhra Pradesh spends more, in aggregate, on its health care than
other states in India, but has worse health indicators. In terms of life
expectancy at 61.8 years in 1991/5 AP ranks 8th out of the 15 major
states28. A major cause for this dichotomy could be the fact that only
around 13.6% of total expenditure is public expenditure, a large
portion of which goes to secondary and tertiary care, whereas the
state carries a large disease burden with huge externalities,
requiring a preventive and promotive focus
• In terms of allocative efficiency, too much of non-salary grants is
spent on the secondary and tertiary sector, given that the most cost
effective health interventions for its disease burden are at the
primary level
• Technical efficiency is low as too high a proportion of resources is
spent on establishment costs with too little remaining for non-salary
\P Economy in Brief. 1998
I 14
•
*
costs. Absenteeism of key staff, in particular, PHC doctors, is a
major problem, leading to uncer-utilisation of PHC services The lack
of adequate referral systems means that primary health services are
bypassed, resulting in unnecessarily expensive treatment at higher
levels and relatively low utilisation at primary levels
The rich not only utilise health services more than the poor, but are
the main users of public sector facilities, except for institutional
deliveries, antenatal care and immunisations
The poor make relatively more use of the public sector but still make
significant use of the private sector
KEY HEALTH SECTOR POLICIES
There is no overarching state policy for the health sector as there is for
population stabilization. Policies for the health sector are
are set out in
different documents. Vision 2020 enunciates the goals, targets and
approaches within which health policy is framed:
Goals
I
Indicator________
;a)Natural Growth Rate (Per 1000
! population)
1998
13.5*
jb) Crude Birth Rate (per 1000
22.3*
i population)
!c) Crude Death Rate (per 1000
.
8.8*
I population)
____________ ;
;d) Infant Mortality Rate (per 1000 I
66.0*
j births)
e) Maternal Mortality Rate (per 10’
3.8**
I live births)______
f) Couple Protection Rate (Percen
59.6#
:9) Total Fertility Rate (per women]
2.25#
|
2.25#
Sources: * SRS 1998,
” NFHS - I (1992-93);
2000
12.0
2010
8.0
2020
7.0
20.0
15.0
13.0
8.0
7.0
6.0
55.0
30.0
15.0
2.5
1.2
0.5
60-0
,
70.0
75.0
2.1
:
1.5
!
1,5
# NFHS - II (1998-99)
Targets
• reduced maternal and infant mortality rates
• reduced communicable disease burden
• spread of AIDS contained
• increased life expectancy
• families small and better spaced
Key Approaches
• women to have safe and successful pregnancies and child survival
to be ensured
• effective prevention of communicable diseases, especially gastroenteritis, malaria, TB, ARI
• delivering quality services for non-communicable disease esp. injury
and trauma
• ensuring safety net for poor and disadvantaged groups
•
•
•
•
increased technical and allocs: ve efficiency of resource use and
improved targeting of public subsidies for the poor through user
charges for the better-off and "surance schemes
improved quality of care/consumer satisfaction
enhancing the role of the private sector
enhancing consumer awareness and health - seeking behaviour
through an effective information and education campaign
Policies and strategies for the health sector are also set out in a
Statement on Health Policy laid on the Table of the House, the Report of
an Expert Committee on Health Sector Reforms and on Administrative
Reforms in the Department, and in tne Cabinet Sub-Committee Report on
Health and Population. Key strategies and activities, which will have a
major role in achieving Vision 2020 goals, are discussed in a subsequent
section.
Major Current Initiatives
The Government has initiated steps to improve public service delivery and
performance through innovative programmes and strategies to specifically
address issues relating to efficiency and effectiveness of public sector
performance. The initiatives are:
• Performance Monitoring
• Human Resource Management
• Reform of drugs procurement and distribution systems
• User charges
• Decentralisation
• Initiatives for Disease Control
• Private Sector initiatives
Performance Monitoring
In order to improve performance in public health service delivery and to
motivate public health personnel, a transparent system for performance
assessment has been instituted in the Department for all directorates
functioning under it.
Output based performance indicators have been
finalised and reporting frequency also fixed. Each institution is graded as
A, B and C category based on the output measures. Performance criteria
have been fixed with the consensus of health personnel. The data is
collected regularly in secondary hospitals, where reporting is almost
100%, and a report is compiled, grading performance, and re-circulated to
all concerned. In an attempt to involve stakeholders, the report is sent
separately to the Chairperson of the society/committee of the facility. The
same system is followed for PHCs, though the percentage of reporting is
much lower. It is not started yet in tertiary institutions. The framework of
performance monitoring for facilities at all the three levels of care is
indicated below:
u
Level
APVVP
(Secondary
Hospitals)
Performance Monitoring Framework
Objectives
Output/Performance Indicators
Provision of
a) Output Measures
hospital
1. General Services : outpatient,
services according inpatient, bee occupancy
to guidelines on
2. Emergency Services : emergency
range of
OP, Emergency IP, emergency major
services and
and minor oeerations
level of services
3. Clinical Services : major/minor
operations , t-oectomies and deliveries
4. Diagnostic Services : X rays ,
ECG , lab tests . USG
(b) Quality
Performance
Against
Indicators
monthly reporting
against indicators
with grading
system
results of quality
satisfaction survey
Tertiary
hospitals
Same as for
secondary
level
Output measures same as for
secondary hosoitals, but speciality-wise Output indicators
agreed, but noncompliance from
hospitals to date
Medical
Education
Provision of
medical education
as per norms and
standards fixed by
Medical Council of
India
Indicators agreed for asst., associate
and professors: no. of classes per
month,
CME
hours
per
month,
national/international papers published
per month
PHC
Primary
Provision of
preventive and
limited curative
services and
effective
implementation of
vertical
programmes.
a)Output measures relate to general
services (OP).diagnostic services (lab
control
tests), national
programmes
(sterilisation.
deliveries,
ANC
registration,
full
immunisations )and
specific
communicable
diseases
(GE/malaria deaths)
monthly reporting
against criteria
with grading
system
b) Quality
quality surveys
under
consideration_______
Source: Adapted from Impact and Expenditure Review Health sector. Mark Pearson et al.
DFID Health Systems Resource Centre, 2001
An attempt has been made to link performance to individual career
advancement through the issue of government orders that the
performance grade of facilities will be attached to the confidential rolls of
doctors. There is also a move to reward good performance through the
allocation of additional resources, so that busier hospitals get their due
share.
Human Resource Management
Expenditures on health salaries represent around 75% of health
expenditure. The extent to which doctors and paramedics man posts and
work productively can have a major impact on quality and coverage of
services. Government have felt that one of the most effective tools to
motivate improved performance is a transparent transfer policy based on
merit, and have initiated steps in this direction.
u
The impact of the functioning of the public health sector is best
exemplified by the way PHCs are functioning. It is at this level that there
is the highest level of absenteeism, leading to underutilisation and
wastage of resources. Government has been of the view that a
transparent transfer policy, which provides for rotation of doctors on a
regular and impartial basis, will mitigate this problem to some extent.
Accordingly draft rules, prescribing a transfer every three years, and
allowing doctors to choose their places of posting from the locations
notified, in order of merit, based on the grading given through the
performance monitoring system, have been finalised. The draft rules have
been referred to the Cabinet Sub Committee on Health for approval. The
procedure, termed as ‘counselling’, is also transparent, with the list of
doctors and grades, and the available locations to be publicly displayed.
Each doctor will be called in order of merit, and the transfer order handed
over to him on the spot, as per his choice, by a Committee comprising of
the Director of Health, the Commissioner APVVP and the Director of
Medical Education. Incidentally, all recruitments in the department for
both medical and para-medical staff, have been undertaken through this
procedure for the last 3 years, with MBBS marks being the criteria for
doctors, and written examination marks being the criteria for para-medics.
The merit list of candidates and list of vacant locations is publicly
displayed, and each candidate is called in order of merit and the
appointment order, with the place of posting as per his choice handed
over to him on the spot by the Committee. The government has recruited
more than 8000 doctors and para-medics in the last 3 years, without a
single complaint from candidates or the media.
In order to address the problem of vacancies in tribal areas. Government
has constituted a separate Tribal Health Service, and recruited doctors
separately to these 300 and odd posts. The recruits sign a bond to work in
the tribal areas for 5 years, after which they can opt to join the
mainstream. Three years of tribal service is considered equivalent to five
years of rural service, which is the eligibility criterion for in-service
candidates for PG courses. They are also given an incentive amount of
Rs. 1500 per month for working in difficult areas. There has been an
improvement in the availability of doctors in tribal areas after the
constitution of this service.
A Committee constituted by the government,
including doctors'
association representatives and finance and health departments, to
address the issue of manpower shortages in the State has recommended
in its report submitted in January 2001, that government may consider
taking the services of doctors on contract or even on a part-time basis for
chronic vacancies.
In Andhra Pradesh, doctors are neither permitted private practice, nor
given a non-practising allowance which is seen as a strong disincentive,
especially when it comes to recruiting and retaining specialists.
Additionally, it could encourage malpractice at all levels — primary,
)
h
secondary and tertiary. The Committee referred :o above has
recommended that private practice continue to be banned, but that
doctors be paid decent salaries, with 25% of basic pay as non-practising
allowance, The Committee’s report is under the consideration of the
government.
Simultaneously, government has taken up a special drive to identify cases
of prolonged unauthorised absence and have issued orders terminating
the services of more than 500 doctors in the last 3 years. An impartial and
transparent disciplinary policy is also sought to be instituted with one
increment cut with cumulative effect for every year of unauthorised
absence in pending cases. These initiatives have the support of the
Doctors’ Association.
In a bid to improve management skills, the state has launched a
comprehensive training programme through the state level Human
Resource Development Institute for continuing education of all levels of
staff in the Department. A massive exercise has been undertaken for
preparation of Departmental Manuals, clearly prescribing the duties and
responsibilities of each category of functionary in each Directorate. These
Manuals, which took a year in preparation, have been published in 2000
and distributed. Training modules for management of services of primary
and secondary levels have been prepared and are under implementation.
While a beginning has been made for effective management of human
resources, certain systemic issues remain unresolved. These need to be
addressed on priority:
• low levels of remuneration
• promotion based on seniority not on merit
• some cadres (particularly supervisory) considered unproductive
• failure to supervise and monitor field performance effectively
• failure to enforce disciplinary action when poor performance is
evident
• inability to reward good performance
• inability to retain staff in remote areas
In terms of manpower development for the health sector, the government
has constituted an Expert Committee, with the Vice Chancellor of the
University of Health Sciences as the Chairman to assess the manpower
needs in the health sector, both medical and paramedical, and to make
recommendations. Based on a preliminary assessment, the government
has notified locations in rural areas for setting up private medical and
dental colleges in each of the districts, as well as over 3000 paramedical
institutions in various disciplines. This initiative is expected to address
shortages of manpower needs to some extent.
! !'>
u
Reform of Drugs procurement and Distribution Systems
)
Several surveys on consumer perceptions of public health services reveal
two major lacunae non- availability of doctors and non- supply of drugs, in
order to enhance drugs supply, a centralised. Drugs Procurement and
Distribution System has been put in place on the lines of the Tamilnaau
model.
Drugs are procured centrally through the AP Medical
Infrastructure Corporation, following strict procedures for contracting and
quality checks. All drugs are strip-packed and are only procured from
manufacturing forms with GMP certificates. These drugs are distributed
through 22 district warehouses. 53 drugs are eligible for purchase by
PHCs and 290 drugs for tertiary level hospitals. A pass book system is in
operation, giving the head of the facility the flexibility to lift the drugs
he/she requires from the district stores. 10% of untied funds are released
to PHCs and secondary hospitals, and 20% to tertiary hospitals to be
utilized for emergent needs. While the system has resulted in certain
improvements over the previous situation, there are yet concerns that
need to be addressed29:
• the budget of Rs 60 crores, even if fully released, (only Rs.35
crores released in 1999-2000) amounts to around Rs. 8 per head
of population. At the PHC level based on budget allocations, it
amounts to only Rs.3.50. There is need to increase the budget
based on an exercise estimating ideal drug requirement at a
standard PHC
• the corporation is able to meet only around 70% of requirements,
mostly due to a lack of timely releases
• quality monitoring needs to be strengthened
• the current list of eligible drugs needs to be reviewed. There has
been a gradual upward creep in the length of the list
• there is need to train doctors on the rational use of drugs, and
to adhere to standard protocols and guidelines
• there is need to evaluate performance after institution of the
central procurement system in terms of availability, quality and
costs of drugs
• there is need to expand this system to cover supplies and
consumables also
User Fees
User fees are currently levied in the State in district, area and tertiary
level hospitals.
Below poverty line users are exempted from such
payments. PHCs and Community Health Centres provide free services.
While initially the Government had issued an order from the state level
fixing user fee charges for secondary level hospitals, this ran into trouble
with political parties organizing major demonstrations against user fees.
Subsequently, Government constituted hospital committees to manage
and monitor hospital services at the local level. A decision was taken to
Impact and Expenditure Review. Health Sector. Mark Pearson etal. DFID.Health Systems Resource
' 2>J
)
*
□
delegate the authority to levy user fees to these committees and to permit
them to charge at rates that were considered locally acceptable.
Currently 76 hospitals in the secondary sector, and 22 out of 42 tertiary
level hospitals are collecting user charges for OP, IP (bed charges) and
diagnostic services.
The rationale behind this levy is three. The first is to ensure that public
subsidies are better targeted for the poor who are exempted from payment
of user fees.
The second is to raise revenues for improving the
functioning of the hospital. The third is to improve efficiency and
accountability. An analysis of user fees collected in APVVP institutions
reveals that collections are increasing every year, and currently account
for 2.5% of non-salary expenditure. It is also seen that the number of
users of these hospitals have not decreased since the institution of these
charges (Table 17)
______ Table 17
Year
;1996-97
I 1997-98
'1998-99
I 1999-2000_____________ _
Amount
Rs. In lakhs I
No fees
24.29
31.74
55.53
Source: Commissioner, APVVP, 2001
Numbers (in lakhs)
OP
IP
80.5
5.2
88.8
5.7
99.6
296.0
6_1_
7.5
In view of the political overtones, user fee policy has not been formalised.
The issues to be now addressed are as detailed below:
• Hospital committees have been informally authorised to collect user
fees, set rates and decide exemptions. Some hospitals, both secondary
and tertiary are not charging user fees yet. Users may not be able to
distinguish between official and unofficial fees, due to the lack of
transparency. A clear government position is therefore required
• if an effective referral system is to be promoted, user charges should
be graded, with higher charges for similar services, at the tertiary
level. This only underlines the need for a clear government stand
• rates
and exemption procedures should be widely publicised, and
display boards put up in prominent locations in the facility
• the exemption policy for the poor must be clearly enunciated at
government level, and
should not be left to the discretion of
Committees. In addition to BPL cards, self-declaration appears to be a
reasonable and practical procedure
• user fees should not be used as a replacement of regular budgets. The
Finance Department of Andhra Pradesh has opened a separate budget
head for user fees. If it is only for monitoring collections, this is
desirable. However, if user fees are used as a replacement of regular
budgets, the very objective gets defeated. International experience
shows that not more than 20 per cent of running cost can be met
through user fees. Even this level will not be reached, if user fees are
used to make good budgetary gaps. The flexibility to gradually shift
operating cost budgets from hospitals, which generate funds through
such fees, to the primary level should be left with the departments of
health
•
user fees should be evaluated to obtain quick feedback regarding its
impact on efficiency and equity objectives, and in particular, its impact
on utilisation patterns by the poor and disadvantaged groups
Decentralization
In terms of the 73rd amendment, no component of the health sector has
been handed over to panchayat raj institutions in the State. However, the
state has undertaken other initiatives to decentralise healthcare
administration and management. They are:
• constitution of Andhra Pradesh Vaidya Vidhana Parishad
(APVVP) as an autonomous body, under an act of legislation, to
be responsible for management of secondary hospitals
• constitution of Advisory Committees for PHCs,
Hospital
Development Committees for secondary hospitals and Hospital
Development Societies for tertiary hospitals, to monitor and
supervise delivery of services in these facilities
• constitution of district societies for implementation of specific
programmes
APVVP was constituted in 1986 with the express objective of granting full
autonomy, financial and administrative, to the secondary level of
hospitals, in order to improve the efficiency and effectiveness of service
delivery. In practice, however, such autonomy does not exist. The
Governing Council of the APVVP has not been constituted for years and
the Commissioner, APVVP, the Chairman of the Council, acts as another
Head of Department. In administrative terms, since the staff of APVVP are
on deputation from the department, they are subject to the same pulls and
pressures in terms, of transfers/administrative matters as regular
department staff. It is necessary that these lacunae be addressed
urgently. However, the initiative is not without advantages20:
• Financing procedures have been simplified with block grants for
APVVP instead of budgetary allocations to individual hospitals.
However, release of block grants at the State-level are subjected
to the same procedural complexities and delays
• independent
decision-making
relating
to
maintenance
of
buildings/equipment and sanitation through contracting has
resulted in improved performance
• the decision to improve resource mobilisation through user fees
has been facilitated by its autonomous character
• there is evidence that a performance management culture is
developing, much more so than in the regular directorates
In 1998, the State Government has constituted hospital development
societies for tertiary hospitals and committees for district hospitals
chaired by the District Collectors, hospital development committees for
area and community hospitals chaired by the local MLA, and Advisory
Impact ana Expenditure Review, Health sector, Mark Pearson et al. DFID Health Svstems Resource
Centre. .2001
122
Committees for primary health centres chaired by the local body
president. All these bodies have elected and community representatives,
ihese bodies have been given specific responsibilities and authority
detailed in printed manuals. Funds are also released to these
societies/committees for maintenance of the facility and for sanitation.
Building maintenance grants, earlier with the Public Works Department,
have been withdrawn and released to these societies/committees. The
societies/committees have been allowed to charge user fees and retain
the same with them for improvement of the facilities. The State has also
prescribed charges for (i) internship transfer from private colleges to
government institutions and (ii) clinical attachment of private dental
colleges and para-medical institutions to government institutions (hitherto
free) and permitted retention at the facility level.
The Societies /
Committees have been authorized to rent out facilities in the premises
such as Pharmacies, canteen, cycle stands etc., and retain
retain these
revenues. While it is as yet too early to assess the impact of these
initiatives, the general perception is that there has been improvement in
the maintenance of the facility as well as in its performance. Two tertiary
level hospitals, one in Guntur and the other in Kakinada, are held up as
models by the Chief Minister, as the societies were able to mobilise
substantial donations, and the appearance of these hospitals are now are
on par with private sector corporate hospitals.
District Societies exist for population stabilisation, for blindness, AIDS,
TB and malaria control. These societies have been constituted primarily to
circumvent the funds flow problem, which is seen by the Department as a
necessity, given the fiscal problems faced by the State. The state is now
considering merging these societies for better coordination. While in
theory, the District Health Officer has overall responsibility for the various
disease control programmes, he is reluctant to take on this role, which
results in compartmentalisation of programmes. Merging societies can
mitigate compartmentalisation to some extent. However, since every
programme has separate budget lines, which have to be accounted for
separately, the advantage of merging appears to be limited. Financial
management and accounting procedures need to be streamlined and
strengthened.
Initiatives for Disease Control Programmes
Access to safe water, sanitation and a clean environment are significant
factors in the prevention of communicable diseases, underscoring the
need for inter- secotral co-ordination in the fight against disease.
Initiatives for cross-sectoral co-ordination in the control of diarrhoeal
diseases, malaria and Japanese Encephalitis in the state merit mention.
The effort has been spearheaded by the Chief Minister himself with
monthly video conferences weekly during high incidence seasons with the
district collectors and the departments of health, water supply and
sanitation, panchayat raj and municipal administration, District level
teams comprising representatives of each department, inspect and
maintain water supply sources and distribution systems, and ensure the
123
I
areas around them are kept clear’ for the prevention and control of
diarrhoeal diseases. The teams also arrange to clear drains, stagnant
water pools, clear shrub growth and garbage around habitations for
mosquito source reduction. A massive campaign is launched ahead of the
high incidence season for each of these diseases, spearheaded by the
district collector, to educate the community on actions to prevent the
onset of these diseases. The result of this co-ordination is seen in the
figures of incidence. The incidence of G.E. shows an appreciable decline,
while malaria appears to be contained.
G.E.Incidence
(U
60 “
a 50 a 40 ■
| 30-
g 20 "
-
10 ■
0)
tn
0
</>
Q
o
’1995
'1996
’1997
’1998
'1999
’2000
Malaria incidence
Annual Parasite Index — Annual Falciparum Index
0
c0
0
o
Q.
O
O
50 |
40 I
30 | -
I 20 |—
.E
0
<u
0
nj
O
10 i0 v(O
(0
o
T-
0)
(D
O
0)
to
O)
K
O)
n V) N
r* bo> o
bO)
v
y
CJ)
T-
H
O>
CO
CD
Iff
N
o
r-
co co co co a>
a> a>
o o
co
O)
in
o
N
0)
O
O)
V
Source: Directorate of Health, Andhra Pradesh, 2001
The government needs to take this initiative forward by:
• institutionalising
co-ordination
arangements
through
the
establishment of inter-departmental committees at state and
district-level with clear mandates and authority to take action
• ultimately devolving powers and functions to panchayat raj
institutions for activities related to water supply, drainage, solid
waste management and source reduction for mosquito breeding.
This will address the current problem of compartmentalisation at
the implementation level
124
•
constituting similar inter departmental committees for non
communicable diseases - in particular, to address traffic
accidents and tobacco-rela:ed diseases
Surveillance
Surveillance has been a weak point in the control of communicable
diseases in the state. An initiative to use the GIS31 platform to highlight
specific villages, where malaria, Jaoanese Encaphilitis and GE incidence
tends to be high, merits mention. Malaria and JE are focal diseases, the
spread of which is essentially based on breeding sources in the area.
Advance information on where the ‘hotspots’ are helps enormously in
planning and implementing a prevention and control strategy. For malaria,
two types of mapping on the GIS platform have been done:
(i) an annual profile, based on 8 years data, shows the distribution of
villages in 3 categories
• those where annual SPR has been greater than 3 in at least 7 out
of 8 years
• those where annual SPR is greater than 3 in 4-6 years out of 8
years
• those where annual SPR is greater than 3 in less than 4 out of 8
years
(ii) since the incidence of malaria varies from month to month, a
monthly |profile based on 4 years data is also prepared. This is
available for all malaria-prone districts for all 12 months
For JE too, village-wise incidence of JE between 1996 and 1999 have
been mapped. Separate maps showing villages where JE has occurred for
2/3/4 consecutive years is also prepared. For GE, mandal-wise incidence
in the previous 10 years has been mapped, but shows no particular
pattern.
These maps clearly indicate the areas of high concentration and assist in
focussing attention for prevention and control activities, Staff .vacancies
are also made good in the mapped areas through re-deployment /
recruitment.
Vertical Versus Integrated
One of the issues constantly under debate relating to disease control
programmes are vertical versus integrated programmes. Verticality ends
at the level of the district programme officer in terms of all vertical
programmes in Andhra Pradesh, except leprosy. Thereafter, human
resources at the district level, are integrated. Even in the case of leprosy,
staff are now carrying out HIV/AIDS control activities. The resurgence of
malaria in the state is blamed largely on integration. The underlying
problem, however, is less one of integration and more one of lack of
skilled human resources at the peripheral level. Upon integration, malaria
1 Geographical Information Systems
surveillance staff were dropped and their responsibilities passed on to
multi-purpose health workers. The oroblem was that these workers were
either not in place, as the state had a large number of vacancies (male
health workers), or were unable to take on this additional workload
(ANMs). As a result, prevention and control measures, and treatment of
malaria cases suffered a setback. The lesson learnt is that precipitous
integration, without alternate human resources and systems in place, is
dangerous.
The state has attempted to address this problem by
appointing one trained community health worker in each habitation in the
malaria endemic habitations at an Honorarium of Rs. 300 per month, and
by filling up male workers posts in tne mapped high-incidence areas either
by fresh recruitment or by re-deployment. For the TB control programme,
the state proposes to use leprosy staff also for the DOTS strategy, as
there are synergies in the administration of these two programmes.
Expecting the multi-purpose worker to deliver the DOTS strategy appears
unrealistic, as 50% of male workers posts remain vacant and ANMs are
overburdened with their regular work.
Private Sector Initiatives
80% of care in Andhra Pradesh is p'ovided by the private sector and it is
essential that government oversee me private sector to address concerns
relating to quality, access, efficiency and equity. The state has drafted
legislation on standards to ensure improvement in the quality of care
provided by the private sector. Special mention needs to be made of the
procedure adopted by the government in framing the rules that fix the
standards. A Committee, representing the interests of all stakeholders,
has been constituted with the responsibility of laying down the standards
for each type of medical establishment and formulating the rules. The
Committee is chaired by a medical professional of standing and repute,
with the Vice Chancellor of the University of Health Sciences, and
representatives of the state medical council, the state branch of the IMA,
the nursing homes association, the forum for super-speciality hospitals,
the diagnostic clinics and laboratories associations and the government
as members. Contentious issues, such as inclusion of provisions relating
to cost-containment, social obligations, and the composition of the
authority which will implement the legislation have been resolved
amicably. There is consensus that costs of treatment and surgeries,
room/bed rates, nursing charges and diagnostic test costs will be
prominently displayed; that private medical establishments will discharge
their social obligation and participate in public health programmes, and
that an Appropriate Authority, chaired by a medical doctor of repute, and
with representatives of all stakeholders will implement the legislation. The
draft rules are currently under the consideration of the government. The
government is understood to be considering enlarging the provision
relating to the Chairman to include a retired judge or administrator of
standing and repute.
In order to improve access to tertiary care, the state has permitted the
setting up of 14 medical and 18 dental colleges only in identified
126
>
u
backward locations. This policy has paid dividends, with the private sector
investing hugely in rural locations, taking specialist care closer to the
people. Similarly it has permitted the setting up of 1301 para-medical
institutions, based on need, in identified locations of the state.
A variety of public-private partnerships have been initiated in the state. In
order to address the problem of maternal and infant mortality and to
promote institutional deliveries and newborn care, a pilot is being
implemented in Anantpur district, where 42 private nursing homes have
been approved for undertaking deliveries for women below the poverty
line. An amount of Rs. 300 will be paid to the nursing home per case.
Since many women do not avail of private nursing home services because
of the lack of transparency relating to rates, a mother and child health
package, to promote ante-natal care, institutional deliveries and
immunisation, has been negotiated with private nursing homes through
the AP Private Nursing Homes Association and the state branch of the
Indian Medical Association. Reasonable rates for different areas of the
state have been agreed upon, and nursing homes that participate will
have a board displaying details of the package and costs. This could be
the precursor of an accreditation network.
In order to improve access to primary health and family welfare services,
the government has contracted out the management of 192 urban health
posts in 73 municipalities to NGO’s. It has issued notification for handing
over management of PHCs in the remote tribal areas of the state to
NGOs. It is also partnering with a private trust hospital in Hyderabad for
delivery of the DOTS programme in a given 5-lakh population. It has
initiated a sucessful link volunteer scheme in the urban slums of
Hyderabad, where a volunteer, selected by a group of 20 families is
trained in basic healthcare, and acts as the link between the community
and the urban health post. This scheme involving 5581 link volunteers is
implemented through 22 NGOs. It proposes similarly to train DWCRA
group representatives as Village Health Workers/link volunteers in
identified remote villages to improve access to basic health and family
welfare services.
While the state has taken steps to better partner with the private sector,
these interventions need to be co-ordinated within a coherent, articulated
policy framework to meet stated objectives.
Future Direction
A Cabinet Sub Committee on Health and Family Welfare has been
constituted to make specific recommendations to operationalise Vision
2020 and to achieve stated goals. Accordingly, the Committee has made
recommendations with specific actions for the next five years. Details are
in Appendix IV. Some key issues/activities that will have a major role in
achieving Vision 2020 goals are mentioned below:
•
Developing a financing strategy
I2~
> to increase the share of state budget to health from the current 4%
to 10% and allocate a greater share of resources to primary and
secondary health care
> to increase non-salary expenditure to 50% of total
> user fees in secondary and tertiary hospitals to cover a minimum
of 1 0%-15% of costs
> to implement insurance for all public sector employees
> to ensure a safety net for poor through (i) piloting health insurance
schemes for women’s groups (3.66 lakh groups covering 50 lakh
poor rural women)and (ii) creating a Sickness Fund for the Poor to
address serious illnesses
• Prioritising funding and programme focus to reduce high maternal and
infant mortality and the huge communicable disease burden in the state
• Strengthening surveillance systems
• Strengthening managerial and technical capacity and accountability at
all levels through effective training programme and transparent
performance assessment systems
• Equipping health institutions at primary and sub-district levels to
diagnose serious non-communicable ailments for timely referral.
Simultaneously developing simple and cost effective interventions to
treat non-communicable diseases and equipping primary and sub
district level facilities to deliver these services
• Expanding public health infrastructure in areas of need, particularly
tribal regions and urban slums
• Introducing the integrated base-hospital approach -since hospitals act
as “islands”, and referral networks are poorly developed,
to make
referral hospitals administratively responsible for overseeing and
managing lower level units within its catchment area
• Promoting convergence between family welfare, health and ICDS:
institutionalising co-ordination mechanism with other departments for
integrated disease control
• Addressing issues of supply, demand, and development of human
resources
for the
health
sector by quickly acting
on
the
recommendations of the Expert Committee.
• Articulating and implementing a coherent policy in relation to the
private sector, both formal and informal
• Strengthening the surveillance, monitoring and evaluation process for
improved performance and informed policy and decision making
• Increasing decentralisation and community participation through
streamlining hospital advisory committees, the establishment of village
health committees, and devolving powers to local bodies for water
supply, sanitation, public hygiene and pollution control
• Enhancing advocacy and community education, for increasing
consumer awareness and promoting health-seeking behaviour
• Enhancing advocacy for political commitment to the health sector
h
Annexure I
The size of Population and other social and demographic
variables across
distict in Andhra Pradesh, 1991
Distircts
Total
Population
(000)
Coastal Andhra
Srikakulam
2321
Vizianagaram
2111
Visakhapatnam
3285
East Godavari
4541
West Godavari
3518
Krishna________
3699
Guntur________
4107
Prakasam______
2759
Nellore________
2392
Rayalaseema
Chitoor _______
3261
Cuddapah______
2268
Anantapur______
3184
Kurnool________
2973
Telengana_____
Mahaboobnagar
3077
Rangareddy
2552
Medak_________
2270
Nizamabad_____
2038
Adilabad________
2082
Karimnagar_____
3037
Warangal_______
2819
Khammam______
2216
Nalgonda_______
2852
Hyderabad______
3146
Andhra Pradesh
66508
Source : Census of India (1991)
Annual
Exp.
GR
Density
Per Sq.
Km.
%
Urban
%
%
SC
ST
1.69
1.57
2.43
2.05
2.02
1.93
1.79
1.69
1.72
398
323
294
420
454
424
361
157
183
12.5
17.2
39.8
23.8
20.7
35.8
28.9
16.4
23.8
9.3
10.4
7,8
18.2
17.9
16.6
14.0
20.0
21.9
5.8
9.0
14.3
3.9
2.4
2.5
4,4
3.6
8.9
1.75
1.61
2.22
2.11
215
148
166
168
19.8
24.0
23.5
25.8
18.4
14.9
14.2
17.4
3.2
2.1
3.5
1.9
2.30
4.72
2.28
1.93
2.39
2,21
2.03
2.35
2.24
3.35
2.17
167
341
234
256
129
257
219
138
200
14497
242
11.1
17.6
17,2
17.9
7.4
47,2
14,5
20.3
23.1
20,5
19.4
20.2
11.9
100.0
24.2
15.1
18.5
18.6
17.2
16.3
17,7
8.9
15.9
4.3
4.2
5.9
17.0
2.7
13.7
25.2
9.7
0.9
6.3
!29
u
Annexure - II
Comparative Health Outcome Indicators
Infant
Child
Total | % of Children
% of everMortality
Mortality
Fertility with Anaemia (6- married Women
Rate
Rate
Rate
35 months)
with Anaemia (15(CMR)
49 years)
(SRS)
(SRS)
(SRS)
All India
72
94.4
3.2
74.3
51.8
70
76.8
3.3
83.9
47.0
Himachal Pradesh
64
42.4
2.4
69.9
40.5
Punjab
54
72.1
2.6
80.0
41.4
Rajasthan
83
114.9
4.1
82.3
48.5
Madhya Pradesh
98
137.6
3.9
75.0
54.3
Uttar Pradesh
85
122.5
46
73.9
48.7
Bihar
67
105.1
4.3
81.3
63.4
Orissa
98
104.4
2.9
72.3
63.0
West Bengal
53
67.6
2.4
78.3
62.7
Gujarat
64
85.1
3.0
74.5
46.3
Maharashtra
49
58.1
2.7
76.0
48.5
Andhra Pradesh
66
85.5
2.5
72.3
49.8
Karnataka
58
69.8
2.5
70.6
42.4
Kerala
16
18.8
1.8
43.9
22.7
Tamil Nadu
53
63.3
2.0
69.0
56.5
North
Haryana
Central
East
West
South
Source :___________
SRS 1998, NFHS2_________________________________
For major states, SRS estimates refer to 1998___________
For smaller states, the estimates refer to the period 1995-97
i
I
130
H
Annexture III
District-wise fertility estimates for 1981 and 1991 census years, and IMR and Female
______________________
literacy rates for 1991
District
CBR
1981
Srikakulam
I Vizianagaram
Visakhapatnam
East Godavari
West Godavari
Krishna______
- Guntur_______
Prakasam
,! Nellore_______
' Chittoor______
! Cudddapah
Anantapur
Kurnool______
Mahabubnagar
Ranga Reddy
Hyderabad
Medak_______
Nizamabad
Adilabad______
Karimnagar
Warangal_____
Khammam____
Nalgonda_____
CBR
TFR
IMR
Female Literacy
Source
1991 I 1981
TFR
1991
i 3.39
31.1 27.1 4.10
30.3 27.5 - 4.00
3.41
31,9 29.0 4.00
i 3.41
29.5 29.0 j 3.80
I 3.42
31.8 26.1 3.90 | 3.00
34.3 28.1 I 4.30
3.29
32.7 26.8 I 4.10
3.16
34,3 28.3
4.60
3.53
32.0 26.6
3.90
3.10
31.5 26.6
4.00
3.14
34.8 26.9
4.50
3.35
35.5 30.4 I 4.90
3.88
36.8 32.9 I 5.00
4.28
35.3 | 33.5 | 4.90
4.49
36.0 | 31.1 I 4,80
3.87
34.7 33.9 I 4,20
4,13
33.6 31.3 iI 4.60
4.17
32.3 27.5
4,10
3.31
35.3 30.2
4.60
3.84
30.6 28.1
4,10
3.43
34.0 31.6 I 4.60
4.08
34.6 30.4 !I 4.70
3.68
33.7 32.9 I 4.50
4.32
j IMR
1991
Female
Literacy
1991
77
23.5
99 I 22.5
73 I
34.6
54 I 42.3
65 I 47.0
30 I 45.5
38
35.9
46 I 27.1
46 ' 37.0
60 l 36.4
44 I 32.4
70 I 27.6
68 I 26.0
77__ 18.0
56
36.9
22
63.6
52
19.2
41_ _ 21.3
51_ _ 20.6
35 i 23.4
59 I 26.1
£7
30.5
58
24.9
Crude Birth rate per 1000 populationTotal Fertility rate per woman
Infant mortality rate (number of infant deaths per
1000 live births)
Percentage female literacy in the population aged 7+
Registrar General, India (1997). District Level
Estimates of Fertility and Child Mortality for 1991 and their
Interrelations with other variables, Occasional paper No.1
of 1997 Census of India, New Delhi
i .'I
H
Annexure - IV
Comparative Health Service Indicators
%of
Children
Receiving
All Vaccina
tions
All India
42
% Mamed
Women
Using any
Contrace
ptive
Methord
48.2
%of
Pregnant
Women
Sterilisation
Receiving
at leastl
Ante Natal
Check Up
36
65.4
%of
Pregnant
%
Women
% of Births % of Children
PregnantW
Receiving
% Instil. Attended by Receiving at
omen
at least 2
Delivenes
Health
least 1 Vitamin
Receiving
Tetanus
Professional A Supplement
Folic Acid
Toxid
injections
66.8
57.6
33.6
42.3
29.7
North
Delhi
69.8
63.8
28.6
83.5
84.9
77.8
59.1
65.9
32.7
Haryana
62.7
62.4
40.8
58.1
79.7
67
22.4
42
45.2
Himachal Pradesh
83.4
67.7
52.4
86.8
66.2
85.6
28.9
40.2
71.1
Jammu & Kashmir
56.7
49.1
30.7
83.2
77.7
70.8
35.6
42.4
36
Punjab
72.1
66.7
30.8
74
89.9
79.6
37.5
62.6
56.5
Rajasthan
17.3
40.3
32.3
47.5
52.1
39.3
21.5
35.8
17.6
Madhya Pradesh
22.4
44 3
38
61
55
48.9
20.1
29.7
24.4
Uttar Pradesh
21.2
23 1
15.6
34.6
51 4
32.4
15.5
22 4
13 9
Central
East
Bihar
11
24 5
20.2
36.3
57.8
24.1
14 6
23.4
10.2
Orissa
43.7
46 8
35.6
79.5
74 3
67 6
22.6
33.4
42
West Bengal
43.8
66.6
33.8
90
82.4
71.6
40 1
44.2
43 4
20.9
Northeast
Arunachal Pradesh
20.5
35 4
20.7
61.6
45.6
56.3
31.2
31 9
Assam
17
43 3
16.6
60.1
51 7
55
17 6
21 4
154
Manipur
42.3
38.7
15.5
80.2
64.2
50
34.5
53.9
38 4
Meghalaya
14.3
202
6.5
53.6
30.8
49 5
17.3
20 6
24 7
Mizoram
59.6
57 7
454
91.8
37.8
72.7
57.7
67 5
70.6
Nagaland
14.1
30.3
12.2
60.4
50.9
42.5
12.1
32.8
68
Sikkim
47.4
53 8
24.8
69.9
52.7
62.4
31.5
35 1
45.8
Goa
82.6
47 5
28.2
99
86.1
94.7
90.8
90 8
78
Gujarat
53
59
45.2
86.4
72.7
78
46.3
53.5
51 9
Maharashtra
78.4
60.9
52.2
90.4
74.9
84.8
52.6
59 4
64 7
Andhra Pradesh
58.7
59.6
57
92.7
81.5
81.2
49.8
65.2
24 8
Karnataka
60
58.3
52.1
86.3
74.9
78
51.1
59.1
48 4
Kerala
79.7
63.7
51
98.8
86.4
95.2
93
94
43 6
Tamil Nadu
88.8
52.1
46
98.5
95.4
93.2
79.3
83.8
16 2
West
Siouth
Sources : NFHS 2 .1999
)
H
Annexure - V
Inpatient Services - Utilisation Rates and Type of Provider
State
Andhra Pradesh
Bihar
Gujrat
Haryana
Himachel Pradesh
Karnataka
Kerala
Madhya Pradesh
Maharastra
North East
Orissa
Punjab
Rajastan
Tamil Nadu
Uttar Pradesh
West Bengal
Unweighted Average
Utilisation (per 100 000 polpulation)
Public
Private
444
198
540
905
2,335
683
2,944
579
791
1,169
1,163
530
669
848
440
1,088
958
1,161
516
1,176
1,948
290
1,030
4,537
445
1,726
222
158
1,093
336
1.290
566
353
1,053
T otal
1,605
714
1,716
2,854
2,624
1,713
7,481
1,023
2,518
1,391
1,321
1,623
1,006
2,138
1,006
1,442
2,011
Share_______
Public(%) Private(%)
27.6
27.7
31.5
31.7
89
39.9
39.4
56.5
31.4
84
88
32.7
66.6
39.7
43.8
75.5
50.3
72.4
72.3
68.5
68.3
11
60.1
60.6
43.5
68.6
16
12
67.3
33.4
60.3
56.2
24.5
49.7
Outpatient Services - Utilisation Rates and Type of Provider
State
Andhra Pradesh
Bihar
Gujrat
Haryana
Himachel Pradesh
Karnataka
Kerala
Madhya Pradesh
Maharastra
North East
Orissa
Punjab
Rajastan
Tamil Nadu
Uttar Pradesh
West Bengal
Unweighted Average
Source :
Utilisation (per 100,000 polpulation) ________ Share
Public
775
229
877
1,012
3,760
872
3,390
1,026
667
1,887
2,006
693
1,171
1,456
367
826
1,313
Private
4.543
2,600
3,089
6,129
6.010
3.028
7.594
3,112
4.477
2,581
2,827
8.084
1,647
3,446
5.804
5,248
4.389
NSS 52 nd Round.
T otal
5,318
2,829
3,965
7,142
9,770
3,900
10,984
4,138
5,144
4,468
4,833
8,778
2,819
4,902
6,172
6,074
5,702
Public(%) Private(%)
14.6
8.1
22.1
14.2
38.5
22.4
30.9
24.8
13
42.2
41.5
7.9
41.6
29.7
6
13.6
23
85.4
91.9
77.9
85.8
61.5
77.6
69.1
75.2
87
57.8
58.5
92.1
58.4
70.3
94
86.4
77
u
Appenc;x 1
Positive Trends In Demographic and Service Indicators of
Andhra Pradesh as Per National Family Health Survey - I & II
SI.
No
Indicators
1.
NFHS-I
(1992-93)
NFHS - II
(1998-99)
Crude Birth Rate (CBR)
24.1
22.3 (SRS 98)
2.
Higher Order Births
41.0
31.2
3.
Couple Protection Rate (CPR)
45.3
59.6
4.
Total Fertility Rate (TFR)
2.6
2.25
5.
ANC receiving women
86.6
92.7
6.
Safe Deliveries
49.3
65.2
7.
Infant Mortality Rate (IMR)
70.4
65.8
8.
Full Immunisation
45.0
58.7
2. Low TFR despite poor social indicators
High levels of school drop-out
AP 78%
High incidence of child labour
AP 14-19%
Low female literacy
AP 33.7%
High Percentage of women married below 18
AP 64.3%
Should have led to
High CBR
In AP, the
High TFR
has been a
Drop in TFR
From 2.6% to 2.25%
)
CAUSE
IMPROVED HEALTH SEEKING BEHAVIOUR
!34
I
3. Causes for declining TFR in Andhra Pradesh
A. AP Population Stabilisation Policy, 1997-98
• AP was the first state in India to announce a comprehensive population
policy with the following demogrsjhic goals to be achieved by 2020:
SI No ____________ Indicator
Goal
•
•
•
1.
Natural Growth Ra:e (NGR)
8/1000
2.
Crude Birth Rate (CBR)
15/1000
3.
Crude Death Rate >CDR)
7/1000
4.
Infant Mortality Ra:e (IMR)
15/1000
5.
Maternal Mortality Rate (MMR
0.5/1000
6.
Couple Protection Rate (CPR)
75%
7.
Total Fertility Rate (TFR)
1.5/ woman
Key strategy followed
• Improved RCH Approach
• People-centred approach
Collaboration with other departments for:
• Enhancing literacy
• Reducing child labour
• Reducing malnutrition among mothers and children
• Increasing age at marriage
• Socio-economic and political empowerment of women
Translating goal into activities
B. Value- added service delivery
• De-centralised structures to implement SPP with PHC Advisory
Committees and District Population Stabilisation Societies positioned.
• Freedom with funds at grass-root to manage population control
activities.
• Enhancing the quality of services rendered
• Strengthening the physical infrastructure
• 160 FRUs and 626 PHCs built.
• 477 PHCs renovated
• Recruitment done frequently to reduce vacancies to a minimum
• Streamlining drug supplies through centralised stores.
• Positioning equipment required for mother and child care at
service delivery points.
• Innovative techniques like single/double puncture laprascopy
non-scalpel vasectomy and Murthy technique introduced.
• Extensive
Inter Personal Communication
by village
level
functionaries like ANMs, VAOs, VDOs, AWWs, teachers etc.
• Effective community mobilisation using community-based formal
andjnformal groups and through local bodies
C. Innovative services
1. Maternal and child health care
• Doctors of PHCs visit villages twice a week particularly for FW
services
• 215 Round the Clock PHCs functional to provide services for
normal delivery
• Providing specialist services of gynaecologist and paediatrician
once a week at the PHC for detecting/treating high-risk cases.
• Providing specialist services of gynaecologist and paediatrician
once a week at the FRU for referral and emergency cases.
• Weekly clinics at village level for STI/RTI care.
• Pulse polio campaigns
• ORT and ARI Campaigns
2. Family Planning services
• Effective logistics management by systematic program implementation
• Increase in PHCs from 1100 to 1390 in 1999
• Doubled the quantity of drugs, materials and consumables at PHCs.
• Skill training for 286 surgeons in DPL and NSV
• Raise in compensation for loss of wage for sterilisation from Rs.120 to
Rs.500.
• 'Aarogyaraksha’ medical insurance scheme for FP acceptors and their
children extended to 2 lakh families per anum
• Awards for best performing MOs, para-medical staff and eligible
couples from districts.
• Expanding MTP services to avert unplanned child birth
• Expanding sustainable use of Condoms & Pills by undertaking social
marketing
D. Bureaucratic Commitment
• Very strong bureaucratic commitment at all levels in the State
particularly at the district level for Family Welfare Programmes
• Support by bureaucracy results in :
• Effective delivery of Family Planing Services
• Motivation, awareness generation to accept small family norms
• Mobilising community participation
• Tailored Family Welfare Programme to suit local needs
• Deployment of machinery (money, people & infrastructure) at
their disposal to support and plug the gaps in Family Welfare
Programme.
E. Political Commitment
• Exemplary leadership of the Hon ble Chief Minister of Andhra Pradesh
in adopting SPP & allotting an annual budget of Rs.15 crore.
• Personal interest shown by the Hon’ble Chief Minister in reviewing the
Family Welfare Programme.
• Placing Family Welfare high on agenda in the Janmabhoomi
Programme, which is the vehicle for social development. Under this
.'O
u
•
programme, the health teams have visited every habitation 12 times in
the past 3 years.
Apart from general health camps, the health teams have undertaken
the following activities as part of Janmabhoomi Programme.
SI.No. ___________ Particulars
1.
ORT / ARI Campaign____
2.
AIDS Campaign_________
3.
Camps on Gynaecological
problems_____________
4.
RTI / STI camps_________
5.
ANC / PNC camps_______
6.
Immunisation
•
•
Frequency per annum
_________ Once_____
_________ Thrice
Four times
Twice
Twice
T wice
Mobilising support from other departments to support Family Welfare
Programme.
Involving public representatives at various levels inculcating a sense of
ownership & competition.
F. Total Literacy Campaign
• Initiated in all districts of Andhra Pradesh in 1991 with differing levels
of success.
• Programme comprised :
• 6 months environment build-up / ground work
• 6 months learning
• The literacy primer carried health care messages
• Outcomes of TLC in terms of what it did to women learners.’
• Key health messages in primer received
• Laid foundation for community mobilisation
• Women gained a 'social identity’ , which made them more
'powerful’ and hence capable of executing their key health
decisions
• The TLC gains consolidated in the PLC Phase and the CEC
Phase.
G. Women’s Empowerment
£mation of thrift and credit groups: An incredible number of 3.95 lakh
DWCRA groups with 50 lakh women currently exist in the state withi a total
private savings of Rs.600 Crores.
H
2. Improved health seeking behaviour through empowerment:
Increased Social Presence & Space
Community Mobilisation
Social Identity
THRIFT & CREDIT GROUPS / COMMUNITY BASED
ORGANISATIONS
Knowledge Of Development
Programs
Enhanced Awareness
Economic Empowerment
♦
Decision Making Powers &
Resources Available
IMPROVED HEALTH SEEKING BEHAVIOUR
2. Formation of other community-based groups; leading to better health
seeking behaviour. Other self-help groups that are involved for health
programs are as follows;
• Watershed Groups
• Vana Samrakshana Samitis
• CMEY Groups.
• Mother’s Committees
• School Committees
All these groups are given health messages regularly as part of their
training program.
i.'S
>
i1
Appendix 2
1. Tuberculosis
The NFHS included questions for the head of household to find out
existence
of any
of the
identified major
morbidity
conditions.
Tuberculosis was included in both the surveys.
Prevalence of
tuberculosis in Andhra Pradesh appears; to have slightly increased
between the two surveys. The question about medically
r_______ , treated
tuberculosis would give a more accurate estimate. Since the NFHS-1 did
not have such a question, we cannot compare between the two surveys
using this parameter. However, the prevalence of medically treated
tuberculosis at the time NFHS-2 was similar to the prevalence of perceived
tuberculosis at the time of NFHS- -1. That would mean that the real
prevalence of tuberculosis has definitely. gone
up.i slightly between 1992-93
_
and 1998-99 (Figure 1).
Figure 1
NFHS- I (1992-93)
NFHS- 2 (1998-99)
NFHS - 2 Medically treated TB
O
t
IW)
2x00
=
w 7(M)
"MX)
»*
3 400
3 .'oo
i.'oo
h nx)
o
OR
Source : NFHS-1 data from UPS (1995)
2.
Leprosy
Andhra Pradesh is a known endemic area of leprosy. Prevalence of leprosy
has been brought down from 133 per 10,000 in 1961 to in 1983, 56/10,000
in 2000.
Figure 2
Incidence
Prevalence
§
g | 95
90
« 65
S O 80
ns *- 75
j 3 70
S 55
I 60
1v> g. 85
-1 £ 65
1995 1996
1997
1998
1999 2000
o 50
° 45
(/)S 40
o
1995
1996
1997
1998
1999
2000
Figure 2 shows recent trends in incidence and prevalence of leprosy in the
state. There has been a slight spurt in leprosy cases during the year 1998
and 1999 consequent to the house to house search conducted in a national
H
campaign. The incidence has reverted to its low position thereafter. The
close similarity of prevalence and incidence figures suggest that the
programme for treatment of leprosy is quite effective, resulting in a quick
cure. As a result, the duration of suffering from leprosy by those who get
the infection, appears to be low.
Figure 3
o
o
o
250
o
C\J
200
CM
<D
?</) d- 150
nj
O S. ioo
5*
50
o
Q.
□□□□□
CO
0
TN
KE
CD
CO
CO
AP
KA
MH
MP
O
OR
IN
Source: NFHS - 1 data from UPS (1995) Table - 8.2 p205
The NFHS.1 included a question on leprosy, which was dropped in NFHS-2
. to accommodate questions on other conditions. Figure-3 shows prevalance
in AP and its neighbouring states. Overall the performance of the Leprosy
Control Programme in the state appears to have been very good.
3. Blindness
The NFHS- 1 asked a question about blindness. Figure 4 shows that
prevalence of both partial and complete blindness is higher in AP and
Karnataka compared to other neighbouring states. There is a need
for greater focus on the National Blindness Control Programme to
reduce the prevalence of blindness.
Figure 4
Blindness Cases in A.P. and other States, 1992-93
□ Pa rlia I B Im d ne s s
=
V)
0)
o
</v>>
c
■U
60 00
s
</CJ»
"U
w
o
oComplete Blindness
5000
I
4 000
2000
mi
’
3000
2
3
&
10 0 0
0
K E
TN
K A
A P
MH
MP
OR
iN
Source : NFHS - 1 data from UPS (1995)
4. Acute Respiratory Infections (ARI)
ARI is a significant childhood morbidity. Figure 5 based on NF-^S 2 reveals that point
prevalence of ARI in AP was lower compared to Kerala, Madhya Pradesh and Orissa.
Other neighbouring states like Tamil Nadu, Karnataka and Maharashtra had lower point
prevalence of ARI.
140
H
Figure 5
E
£
1
o
CD
<0
5
c
®
§
3 5
3 0
2 5
2 0
1 5
1 0
5
0
00
CM
CM
0
K E
a
n
o>
T N
K A
A P
M H
M P
0
O R
IN
Source : NFHS - 2 data from UPS (2000)
5. Diarhoea
Diarrhoea incidence and case fatality remained more or less constant
between 1995-97. In 1998 there was a slight spurt of diarrhoea cases,
There is a decline in diarrhoea incidence and related case fatality in the
last two years.
Figure 6
Incidence
Case Fatality
Q « 60
o
g * 50
<n
O O 40
3
2.5
2
o 1 20
h° 1.5
IS □ 10
M Q
C 30
°I 0
1995 1996 1997 1998 1999 2000
1
0.5
0
Q
1995
1996 1997
1998 1999 2000
6. Malaria
Figure 7 shows the long-term trend of malaria cases in the state since
1961. During the 1970s malaria incidence in the state had significantly,
was brought under control in the 80’s and upto the mid 90’s.
Thereafter there has been a gradual increase in the incidence of
malaria. Recent increase in incidence appears to have been contributed
by the increase of both Vivax and Falciparum Malaria:
Figure 7
Annual Falciparum Index
Annual P aras ite Index
50
40
30
20
10
0
-
■
oource : Government of AP, Directorate of Health - Malaria Division
141
Ii
The two NFHS provide a comparative picture of malaria among AP and
its neighbouring states and also give us an independent estimate of time
trend during the 1990s. This also corroborates the rise of malaria in the
1990s. Incidence of malaria in the state of AP is similar to the incidence
in Madhya Pradesh. Malaria incidence in Tamil Nadu, Karnataka and
Kerala is considerably lower (Figure 8).
Figure 8
Recent Trends of Malaria in AP and Other Indian States
s
5
£o
1 2000
£
1 0000
I
6000
8000
□
4000
c
2000
5
0
o
I 5
*
K E
.2
§
?
TN
KA
NFHS 11(1 998-99)
3
I I I I
5
AP
M H
MP
OR
IN
■ NFHS ’1 (1 992-93)
Source : NFHS data from UPS (1995)
7. Japanese Encephalitis
Japanese encephalitis (JE) is caused by a virus. JE incidence in the
state has been erratic, swinging up and down, The state has made
significant efforts in building up professional capacity for management of
JE cases. That appears to have contributed to the significant reduction
in case fatality over the last two years.
Figure 9
Recent trend of Japanese Encephalitis incidence and case Fertility
Incidence
Case Fatality
o .2
wo arc 40
in £2
ra q, 30
o Ji 16
o_ £ 1.4
o O 1.2
Q.
(_) a,
1
0.8
§5 20
£ 10
£TO co2
I? 3 0.6
° o 0.4
Q.
2
3
4
5
<D
Q
Q.
TO
o
1996
1997
1998
1999
2000
Extracted from the White Paper on
Health and Family If’elfare.
Govt, of Andhra Pradesh, 2001.
•I i
Appendix 3
The organisation of the Department of Health and Family Welfare is
summarised in the following Chart -
Organogram of the Department
At the district level, the District Medical and Health Officers are in charge
of primary health care and the District Coordinator of hospital services are
in charge of secondary health care. At the sub-district level are the area
hospitals, community health centres and the primary health centres. Each
area/community hospital has a civil surgeon and deputy civil surgeon in
charge respectively.
Deputy District and Medical Health Officers look
after primary health centres for a specified geographical area. The
Directorate of Health is responsible for all primary health services
including preventive and basic curative services, and the Department of
Family Welfare is responsible for the family welfare services. The Andhra
Pradesh Vaidya Vidhan Parishad, an autonomous body set up under state
legislation, is responsible for secondary care. The Directorate of Medical
Education is responsible for tertiary care.
ORGANOGRAM OF DEPARTMENT OF HEALTH,
MEDICAL AND FAMILY WELFARE
|
Chief Mianter
|
|
| Minister (IIM&EW) |
I
"
| Spl. Chief Secretary [
Secretary
(Health)
!
Dir. IPM
[■ -J
|<ominHM&H)p-|
Dll
( omm. ,\P\ VP
IG(I)CA)
|
Dir. IMS
PI). /XPFRHSP
&APERP
DME
EOS & ( omm |
1 I I umilv Welfare I
EOS & Ml). |
PI). \PS\( S I
(APIIMIIIIH ) | [
IPM
: Institute of Preventive Medicine
IG/DCA
: Inspector General, Drug Control Administration
Comm./ISM&H
: Commissioner, Indian System of Medicine and Homeopathy
Dir,IMS
: Director, Insurance Medical Services
DH
: Director of Health (Primary Health Care)
Comm.APWP
: Commissioner Andhra Pradesh Vaidya Vidhan Parishad
PD.APFRHSP & APERP : Project Director, AP First Referral Health Systems Project
& AP Economic Re-structuring Project (Secondary Health Care)
DME
: Director, Medical Education (Tertiary Health Care)
EOS
: Ex - Officio - Secretary
MD,APHMHIDC
: Managing Director, Andhra Pradesh Health & Medical Infrastructure
Development Corporation
PD.APSACS
: Project Director, Andhra Pradesh Statae AIDS Control Society
11
ORGANOGRAM OF DIRECTOR OF HEALTH AND
COMMISSIONARATE OF FAMILY WELFARE
DIRECTOR OF HEALTH
COMMISSIONER
family welfare
i
| ADDITIONAL DIRECTORS (sT
I
I
ADDITIONAL COAAAA.(B&F)
|
'
JOINT DXRECrroUS (6)
JOirsIT DIRECTORS (-4)
REGIONAL DIRECTORS (<S)
DEPUT/ DIRECTORS fT-)
|
1
|
F
-T
~
DEPUTY DIRECTORS (6)
1
DAA A FKSs (22)
|
Addl
OAA A HiOs (26)
|
PROGRAMME OFFICERS (92)
P«r- OaTr-icT-
| t>y.
I
OAA A HO» («) |
PRIMARY HEALTH
CENTRES (1386)
i
CHCl -si
(
UPHCi-53
[ fcovT, MoepiTgli
Slrtgle Doctor ~F»ro Doctor - M5
•4
|
Thr«« Doctor
Foor Doctor -
4
Five Doctor -
1
ORGANOGRAM OF
DIRECTOR OF MEDICAL EDUCATION
DIRECTOR
ADDITIONAL DIRECTOR-1
JOINT DIRECTORS (2)
DEPUTY DIRECTORS (2)
TEACHING INSTITUTIONS (10)
OTHER INSTITUTIONS (21)
5
1
:44
Ii
ORGANOGRAM APVVP & APFRHSP
iSOV'Fi’vilNG COUNCIL
COMMISSIONER
PROJECT DIRECTOR
(APFRHSP)
I
j JOINT COMMISSIONERS (3) |
SECY (QA)
|
7
i
SUPPORTING STAFF (5)
DISTRICT CO-ORDINATORS I
OF HOSPITAL SERVICES-(23) j
DISTRICT
HOSPITALS (20)
DY COMMISSIONER
(RAT)
; r
| [
I
ASST COMMISSIONER
_________________________I I
MEDICAL OFFICERS
(2242)
PARAMEDICS
(1655)
I
AREA HOSPITALS - 56
NURSING
(5534)
COMMUNITY HEALTH
CENTRES - 76
, SPECIALITY HOSPITAL
6CIVIL DISPENSARY - 33
(>
ORGANOGRAM OF
INDIAN MEDICINES &HOMOEOPATHY DEPT.
(_____ I
j Addl. Director
(Ayur)
Research
Officers
Inspecting M.O
Drug Inspectors
I____ _____
I
J
Colleges-3
Hospitals-7
Pharmacies-1
COMMISSIONER
I
I
1
I
Addl. Director
(Unani)
Addl.Director
(Homoeo)
Research
Officer
Drug Inspectors
■
I
Regional
Dy. Directors
Dy. Director
(Admn)
Research
' Dispensaries
Officer
viiivsi
1 uiaiimraiu
Grant-in-aid
Drug Inspectors : Dispensaries
Admn. Officer
Accounts Officer
Inspector
S.I.M
1
Colleges-1
Hospitals-5
Pharmacies-1
I
Cclleges-4
j
Hosoitals-6
i
j
145
11
Organogram of Drug Control Administration
Inspector Genera: i DC A) I
I
'
Director (DCA)
I
______________ i
Enforcement Wing
I
r
I________
Laboratory Wing
I
|
J.D.(l)
J.D. (Lab) (1)
D.Ds(2)
Sr. Scientist Officers (2)
A.Ds (8)
Jr. Scientist Officers (6)
A.Ds (NT) (2)
Jr. Analysts (25)
| Drugs Inspectors (55)
4
ORGANOGRAM OF STATE AIDS CONTROL SOCIET
GOVERNING BODY
PROJECT DIRECTOR
ADDITIONAL DIRECTOR
I
ACCOUNTS OFFICER
JOINT DIRECTORS (2)
1
N G.O. ADVISOR
I
; ASST. ACCOUNTS OFFICER (3)
DEPUTY DIRECTORS (2)
PROJECT ASSOCIATES (4)
! SUPPORTING STAFF (11)
3
’.46
u
Appendix 4
Action Plan Approved By Cabinet Sub-Committee For
Family Welfare
Demographic Goals for the Next 5 Years:
SI.
No,
1.
2.
3.
4.
5.
6.
7.
Indicator
Natural Growth Rate (%)
Crude Birth Rate / 1000 Pop.
Crude Death Rate/1000 Pop,
Infant Mortality Rate/1000 Lbs
Maternal Mortality Rate_____
Couple Protection Rate (%)
Total Fertility Rate/Woman
2000-01
2002-03
2004-05
1.2
20.0
8.0
55
2.5
60
2.1
1.05
18.0
7.5
50
1.8
63
1.9
0.98
17.0
7.2
45
1.6
65
1.8
j
i
Action Plan
Strategy
1. Decentralised
Organisationa
I Structure
, 2. Quality
Services
! 3. Safe
Motherhood
_________ Activity__________
Establishment of Population
Stabilization Societies at Dist.
Mandal and Gram Panchayat
Level._____________________
Strengthening Infrastructure
Streamlining
Drug
supplies
(changes in procedures)______
RCH
Training
for
Health
Personnel_________
Ante-natal coverage
Sukhibhava
to
increase
Institutional Deliveries
Establishment of Round the
Clock PHCs (Nos.)___________
VNM Scheme (Villages to be
covered)___________________
Conduct of Antenatal camps at
village level_________________
Provision for Maternity, RTI/ STI
clinics on fixed days at PHCs
Establishment of Referral &
Emergency Services for Mother
and Child___________________
Establishment
of
RTI/STI
Clinics in Referral Units
integration with ICDS to reduce
malnutrition in pregnant women
& lactating mothers__________
Campaigns for Adolescent Girl
(Number)__________________
Specific Schemes for Age at
Marriage_______
2000-01
Ail
Dists.
2001-02
150
FRUs
600
PHCs
All
FURs
25% of
doctors
65%
5.2 lakhs
Balance
buldmgs
100 Subcentres
All
PHCs
25% of
doctors
80%
7 lakhs
300
20002-03
2003-04
2004-05
wo
sub
centres
100
sub
centres
100
sub
centres
25% of
doctors
>95%
9 lakhs
25% of
doctors
>95%
9 lakhs
25% of
doctors
>95%
9 lakhs
494
494
494
494
2000
2000
2000
2000
2000
All
PHCs
All
PHCs
In 75
referral
units
In 75
referral
units
in 2
Dists.
All
PHCs
All
PHCs
In 125
referral
units
In 125
referral
units
in 5
Dists.
All
PHCs
All
PHCs
In 175
referral
units
In 175
referral
units
in all
Dists.
All
PHCs
All
PHCs
In 200
referral
units
In 200
referral
units
in all
Dists.
All
PHCs
All
PHCs
In 200
referral
units
In 200
referral
units
in all
Dists.
2
2
2
2
2
✓
✓
✓
7
iI
I
Strategy
i 4. Child Survival
i____________ Activity_____________
| Universal Immunisation
j Pulse Polio Immunisation________
Campaigns for ORT & ARI
_
Provision for special neonatal |
care in referral hospitals
i
Integration
with
ICDS
to
improve nutrition practices to
reduce low birth-weight babies
5. Increasing
contraceptive
prevalence
6. Strengthening
Family
Planning
Social marketing of condoms &
pills______
Incentives
for
community
individuals
and
service
providers
Welfare benefits for acceptors
and
motivators
of
Family
Planning ____________________
7. Incentives
8. Filling
gaps in
system
No. Of Sterilisations___________
Percentage of Male Sterili sation
(of total sterilisations)__________
Delay in First Pregnancy by 2-3
years (% of cases)_____________
Increase in Birth Intervals of 1st
& 2nd Child by 3-5 years (% of
cases)_______
Research
studies
to
test
acceptability
for
alternative
spacing methods
Insurance coverage for FW
acceptors_____
Skill
Training
for
Medical
Officers
(OPL/NSV/Conventional)
Expand MTP services
up
the
9. IEC Activities
10. Improve
Monitoring
and
Evaluation
System
11. Active
Participation
of Community
& N.G.Os
Pilot
work
for Optimum
Utilisation of Manpower and
Infrastructure__________________
Urban Health Centres
Messages on Female Literacy, |
Age at marriage, Institutional I
deliveries
Low
birth-weight,
Spacing & Male Sterilisation______
Introduce Computensation upto
PHC level
Introduce concurrent evaluation
by independent agencies for
validation of data______________
Introduce Sample Registration
System (SRS) for Districts
Public
participation
through
Janmabhoomi
Thrust
on
environmental
sanitation in Janmabhoomi.
Involvement
of
public
representatives and Self-Help
Groups
2000-01
65%
' 00%
20002-03
23
-PUs
in 2
Dists.
2001-02
80%
100%
1
50
FRUs
in 5
Dists.
70
FRUs
in all
Dists.
2003-04 I 2004-05
> 95% I > 95%
100%
100%
1
1
70
70
FRUs
FRUs
in all
in all
Dists.
Dists.
8 lakns
10%
8 lakhs
15%
8 lakhs
20%
8 lakhs
25%
8 lakhs
30%
15%
20%
25%
40%
50%
15%
20%
25%
40%
50%
2 lakhs
4 lakhs
4 lakhs
25% of
doctors
25% of
doctors
in 75
Insts
m all
Dists.
in 125
Insts
in all
Dists.
> 95%
100%
1
in Pilot
Dists.
■I-------------------
4 lakhs
4 lakhs
25% of
doctors
25% of
doctors
25% of
doctors
in 175
Insts
in all
Dists.
in 200
Insts
in all
Dists.
in 200
Insts
in all
Dists.
✓
✓
✓
✓
/
2
Dists.
5
Dists.
All
Dists.
73 Muni
cipalities
addl.
44 Municipalities
All
Dists.
All
Dists.
All
Dists.
All
Dists.
All
Dists.
All
Pilot
Dist.
Hqs.
All
Dists.
All
3
Dists.
All
PHCs
All
PHCs
All
PHCs
All
Dists.
All
Dists.
All
Dists.
All
Dists.
3 pilot
Dists.
All
Dists.
All
Dists.
All
Dists.
All
Dists.
All
Dists.
All
Dists.
All
Dists.
All
Dists.
All
Dists.
All
Dists.
All
Dists.
All
Dists.
All
Dists.
All
Dists.
All
Dists.
All
Dists.
All
Dists.
All
Dists.
All
Dists.
- Dept, of Family Welfare, Govt, of Andhra Pradesh
I4S
i i
Action Plan Approved By Cabinet Sub-Committee For Health
Year
2000-2001
% share of health
6
budget to total
budget
% share of health
80
budget to primary
and secondary
_____ care_____
Increase
Streamline
community
functioning of
particioation
hospital advisory
committees
2001-2002
7
2002-2003 I 2003-2004
j
82.5
8
85
i
9
2004-2005
’
io
87.5
90
|
I
Increase role of
j
Extend
mandal panchayats I village health |
in functioning of
i committees i
PHC's
to rest of the i
Set up village health
state
committees in
villages with high
risk of GE.JE and
_____ malaria._____
Strengthen
Institute systems
Prepare and
Extend
Extend
Localised
surveillance
for reporting from
implement localised implementati
implementati j plan based
system for vaccine
health institutions
p;ans based on
on of
on of
on disease
preventable and
including private | disease incidence in localised plan
localised
incidence !
communicable
sector.
100 PHC's on a pilot
to additional i
extended to |
plan to
diseases
basis.
400 mandal j additional
i
all PHC’s
PHC’s
500 PHC's
Integration of
Initiate training of |
Extend duties to
Review and I
Extend
Indian system of
all non-allopathic
cover preventive
modify
duties to
Medicine and
doctors in
asoects of malaria
functioning of
cover
Homeopathy
preventive aspects
and GE .
ISM&H
preventive ;
of national
Set up mechanism
dispensaries
action for all I
programs.
for reviewing
in relation to
national
Allocate duties
functioning of
national
programs
relating to
ISM&H units at
programs.
immunisation to all
C!Strict level.
ISM&H
dispensaries
Strengthen
Complete
Upgrade additional
Expand on I Expand on ; Set up fully i
secondary health
implementation of
124 units as first
line hospital ! line hospital I integrated
care sector.
all non-recurrent
referral units under
monitoring | monitoring |
system
components of
4PFRHSP.
system to
computer I
I system to all I
APFRHSP
Exoand on line
additional
i first referral I
network
including civil
hosoital monitoring
100 units.
units.
system for i
works and
system to additional
Integrate with j
Integrate
both mandal j
procurement of
50
mandal
' with mandal I
and first
j
equipment.
Units.
i computer
referral level. |
computer
Implement
Integrate with .
network for I network for i
hospital
mandal computer
50 additional
100
monitoring system
network for 20 units
units.
additional j
in 150 hospitals.
on pilot basis.
units.
Commence on
line hospital
, monitoring system
! for 20 district level
hospitals
149
i 1
Year
2000-2001
2001-2002
Strengthening of
tertiary care in
existing
government
hospitals
Identify source of
funding and prepare
self-financing
upgradation scheme
in 2 teaching
hospitals
Implement plan for
upgradation in 2
teaching hospitals
2003-2004 I 2004-2005
2002-2003
■
Review
' implementati I
on of
scheme and I
j . modify.
Study
impact of
scheme
and plan
for 2
i
additional i
units
I
based on
experience I
Extend plan
to cover 4
additional
units
I
Encourage
private sector
investment in
the health sector
Establish 5 medical
and 5 dental colleges
in the private sector.
Institute transparent
mecahnism for
establishment of
institutions for
paramedical courses
in the private sector.
Introduce bill for
setting up regulatory
authority for
monitoring the quality
of treatment in the
private sector.
Establish additional I
Establish
5 medical and5
additional 5
dental colleges in
medical and5
the private sector.
dental
colleges in
Frame rules for
I t; ie private
functioning of
sector.
regulatory authority |
and establish
authority
Establish
additional 5
medical
and5 dental
colleges in
the private
sector.
Developing
health
information
systems
Utilise APSWAN for
processing district
level data on-line for
22 districts
Systematise data
collection on mandal
level disease patterns
including private
sector institutions
also.
Strengthen district | Link mandal
level data
level centres
processing and
to districts
initiate direct
and
mandal level data
undertake
processing on pilot
on-line
processing of
basis in 100
mandals.
mandal level
Set up interactive
in additional
web-site.
500 mandals.
Strengthen I
Integrate
mandal level I systems with I
on line data i
nnv/oto
private
processing ; institutions I
and cover
network.
i
remaining
Introduce |
500
telemedicine. I
mandals.
i Streamlining of
drug
procurement
l
processes and
quality control
Strengthening of
warehousing facilities
in 23 districts.
Computerisation and
on line transaction of
drug procurement.
Set up drug data
base.
Establishment of
additional godowns in 9 ITDA
areas.
Extend activities to
cover surgical
consumables also.
Set up interactive
web-site.
Extend
‘
Fully
activities to I
integrate
cover all I
computer
consumables.! network with
! private sector
network.
Improve
quality
control at go
down level
and obtain
quality
certification.
. Extend
computer
network to
cover mandal
level.
I
Establish
| additional
' medical and
I
dental
| colleges to
|
ensure at
least one
! medical and
one dental
college in the
' private sector
in all districts.
•
I
!
u
i
_____ Year
Strengthening
referral system
Human resource
development
2000-2001
2001-2002
Integrate national
Strengthening of
programs including I
referral system
'
D
!—J
RCH
into the
through base
secondary referral
hospital approach
system.
based on lessons
Introduce systematic
learnt from the pilot
referral protocols and
study, in 5
treatment schedules.
additional districts.
Introduction of pilot
Introduce system of
scheme in 3 districts
incentives for
for adopting the base
encouraging
hospital approach
referrals.
with a stronger
component of mobile
healthcare.
2002-2003 j1 2003-2004
2004-2005 1
Introduce
Int.'ocuce
.... ..........
I
Introduce
i
base hospital I
base
base hospital I
approach in Ij
hospital
approach in
additional 5 ! approach in i additional 4
districts.
' additional 5 I
districts.
Upgrade all I
districts.
taluk level
hospitals into I
first referral j
units.
Continue training of
Strengthen
Continue !
Continue
all medical personnel
Extend quality
hospital
training
training
with special reference circles in additional
management
Extend
Extend
to nursing staff and
5 districts.
capability.
quality circles I
quality
lab technicians.
Set up
Continue
circles to 1 to additional
Introduce quality
computerised
training
additional 5 I 5 districts.
circles at different
hospital
Extend
I
districts.
I
levels on pilot basis
management
quality circles |
in all health
systems.
i to additional
*
institutions in 3
| Introduce system of I 5 districts.
districts.
hospital
I
i
Institute performance
management staff.
i
based system of
transfers.
I
I
Strengthening
IEC activity and
health education
Strengthen traditional
forms of public health
education with focus
on providing area
specific information.
Set up systems to
review impact of IEC
activity.
Introduce strong
element of health
education in school
curriculum including
personal hygiene
public hygiene and
healthy habits.
Introduce AIDS
awareness programs
at high school and
college level
Set up interactive
web-site for public
information.
Review impact of
IEC activity and
make necessary
modifications
Expand use
of multimedia
for public
health
education
through
satellite
commumcati
on.
Review
impact of IEC
activity and
make
necessary
modifications
Review
Review
impact of
impact of IEC
IEC activity | activity and
and make I
make
necessary
necessary
modificati
modificatio
ons
ns
- Medical, Health and Family Welfare Dept., Govt of Andhra Pradesh
I T-O'l t
u
References
1.
Bhatia, Dr.J.C., (1988), A Study or. Maternal Mortality in Anantpur district.
Andhra Pradesh, Indian Institute of Management, Bangalore.
2.
James, K.S. and.Subramaniam, S.V, (2001). Towards a Demographic Transition. Centre
for Economic and Social Studies (CESS), Hyderabad.
3.
Mahal, A, et al, (December 2000), Who Benefits from Public Health Spending in
India, NCAER, New Delhi
4.
Pearson, Mark; Gupta, DB; Cumber, Anil: Purohit Brijesh; Rao Venkat; George Alex.
(March 2001), Impact and Expenditure Review, Health Sector, DFID Health Systems
Resource Centre, Presented to the Government of Andhra Pradesh, Hyderabad.
5.
Department of Medical, Health and Family Welfare, Government of Andhra Pradesh,
(1998), Report of the Expert Committee on Reform of the Health Sector in Andhra
Pradesh, Secretariat, Hyderabad.
6.
Department of Medical, Health and Family Welfare, Government of Andhra Pradesh.
(1997), Report of the Expert Committee on Administrative Reforms in the Health. Medical
and Family Welfare Department. Secretariat. Hyderabad.
7.
Department of Medical, Health and Family Welfare, Government of Andhra Pradesh.
(2000), Draft Report of the Cabinet Sub-Committee on Health and Family Welfare.
Secretariat, Hyderabad.
8.
Department of Medical, Health and Family Welfare, Government of Andhra Pradesh.
(2001), Strategy Paper on Health and Family Welfare in Andhra Pradesh. Secretariat.
Hyderabad.
9.
Government of Andhra
Secretariat, Hyderabad.
Pradesh,
(2000), Vision
2020:
Swarna
Andhra
Pradesh.
10. Sample Registration Survey (SRS), (various years. Registrar General. Census of India.
Government of India. New Delhi.
i1
APPENDIX 6
Health Empowerment of the People: the Kerala experience
V. Vijaychandran
Introduction
Kerala is a small state in the southwestern corner of India occupying 1.1
per cent of the country’s geographical area and supporting about 3 per
cent of its population. It is known for its high social development like high
levels of education and life expectancy and low rates of infant mortality,
birth, fertility etc. A curious thing about the state is that this level of social
development has been achieved without any high levels of income. The
coexistence of relative poverty and better health has drawn the attention
of various academics to Kerala. This paper will draw a picture of the
health status of its people in comoarison with the other states of India and
some other countries. It will also attempt to explain the process of
achieving that status and try to draw lessons from it. Section 2 will
introduce the state with some cr.aracteristics that make it stand out from
the rest of the country and compare it with some other countries of Asia.
Section 3 will put forward some explanation of the process that has led to
this development, emphasising, among other things, the role of education.
Section 4 will trace the history of health care development in the state
and describe the health systems and its strengths and weaknesses. The
next section will speak of the role of the private sector. Section 6 will
touch upon the recent phenomenon of migration from the state in search
of employment and how it brings in extra income. Section 7 will describe
the epidemiological transition from communicable to non-communicable
diseases while still carrying the burden of the former. Section 8 will list
the main problems in health care, the initiatives taken and the lessons
that can be drawn from the Kerala experience. The concluding session will
summarise the arguments.
The Characteristics of the State
The state was formed in 1956, when the states of India were reorganised
along linguistic lines. Three regions speaking the common language of
Malayalam were unified into one state, reviving the old name of Kerala.
These regions were Travancore and Cochin in the southern part under the
princely rulers before independence and Malabar in the northern part
ruled by the British Government directly as part of Madras Presidency.
They had a common cultural, social and historical past at the time the
British established their supremacy over the territory in 1793, but were
destined to traverse different socio-political routes during the next century
and a half. This diverse development of the three regions led to different
levels of development in them. But we shall go into this later.
1
u,
The state has a coastal line of about 600 kilometres stretching from South
to North. The eastern boundary of the state is the Western Ghats. The
average distance from this to the Arabian Sea on the West is about 65
Kilometres. This stretch of land nas four major physiogeographic zones.
The area of the Western Ghats is the highlands where plantation crops
like tea, coffee and cardamom are grown. The midland region, which
varies from an altitude of 300 to 600 meters, has rich laterite soil and the
major crops are rubber, and coconut. Coconut is the major crop of the
state, stretching to the low lands where rice is also grown. In the sands of
the coastal plain coconut is virtually the only crop. Fishing is the mam
activity in that region. The state has relatively heavy monsoon ram and
not much difference in temperature at any time of the year. There are
more than 40 rivers that originate from the Western Ghats and flow into
the Arabian Sea forming backwaters and rivulets in some of the low lands.
The first thing that strikes a casual visitor to the state is the settlement
pattern of its people. Unlike in the rest of the country, where people live
in clusters, leaving vast areas for cultivation, the people of Kerala live in
small
homesteads
surrounded
by
coconut
palms,
sharing
the
neighbourhood with members of other religions. The mixture of religions
in the state is the highest among the major states of the country. Only 57
per cent of the population are Hindus against 82 per cent in the country.
Muslims are 21 per cent (all India 12) and Christians 20 (all India 2), the
others constituting 2 per cent (Census 1991). The provisional figures of
the 2001 Census show that 819 persons live in a square kilometre, which
is one of the highest densities in India.
This settlement pattern, no doubt, necessitated by the high density of
population and facilitated by the cropping pattern, has led to the
obliteration of the rural-urban differences in the state. The state looks like
one huge settlement, with names of the administrative divisions changing
from village to town and to city with the increase in the number of houses.
In fact these divisions are only in the maps and have only rarely any
demarcation visible on the ground. The whole state has been described
as a rural-urban continuum. The huge development-gap between rural and
urban areas that we find in the rest of the country is virtually non-existent
in Kerala. 85.3 per cent of Kerala villages are well connected by good
roads. In the rest of the country only 36.85 are so connected. 94.7 per
cent have a bus stop within 5 kilometres and a post office within 2. The
percentage of villages with a telephone within 2 kilometres is 80. Only
26.7 per cent of the villages of Kerala have to depend on unprotected
water, while more than half the villages in India have to do so. (See Table
1- Percentage of Villages and Availability of Different Facilities by
States). According to the first Economic Census conducted in 1977, 99.7
per cent of villages in Kerala had a primary or junior basic school within 2
kilometres, 98.6 per cent had a middle school within 2 kms and 96.7 per
cent, a high or higher secondary school within 5 kms as against an all
India average of 90.1 per cent, 43.8 per cent and 20.9 per cent,
respectively. (Kannan 1988).
1?4
)
H
Another feature of the state is a v.ell-developed public distribution system
of food grains. A large part of tne cultivable area of the State is under
commercial crop. The State does not produce enough food grains to feed
its people and this has been ceclining as more and more areas get
converted from food grain production to commercial cropping and for
construction of houses as the population expanded. The State produced
63 kilograms of food grains per annum per capita in 1970-73, which
declined to 37 kgs in 1990-93, when at the all India level the Green
Revolution was making it steadily rise. But from the 1960s the state has
been distributing through its fair price shops a reasonable quantity of food
grains for its people. Against 22.2 kg at all India level in 1992, Kerala
distributed 70.4 kg of food grains per capita. (Srinivasan and Shariff
1997) It had 92 per cent of its people covered under the PDS system in
1991. The 42nd round of National Sample Survey (NSS) (1986-7) showed
that 37 per cent of the people in the rural areas in the State depended
solely on public distribution system and 30 per cent on PDS and other
sources. In the urban areas 83 per cent dependent on PDS and other
sources. (Nair 2000) The beneficial impact of PDS on nutrition has been
well documented. (For example, George 1979)
Though the infrastructure is well developed, the economy of the state
does not perform as well as an average state in the country. The per
capita net state domestic product of the state has always lagged behind
the average of the country. At 1980-81 prices it is Rs.2349 in 1996-97, the
8th lowest among the states. (See Table 2 - Per Capita Net Domestic
Product). Figure 1 below illustrates this point.
Figure 1
Per Capita Net Domestic Product - India and Kerala 80-81 prices
3000
2500
g 2000
o. 1500
1000
500
0
o
IlllilH
CO TZ
O co
(N
CO CO
CT) CO
4
CT) °0
CD
co co
n n n
n
GO
OD O)
CT) 00
o
CN
O>
o> &
□ India
□ Kerala
4
S
£
CT) CD
Years
Source: see table 2.
The state government estimates that the Per Capita Income at current
prices in 1999-2000 was Rs. 19,461/- which works out to about USS 423
at the current exchange rate (Government of Kerala 2000). This poor
u
economy has also been growing much slower than the rest of the country.
While the NDP of India grew at 1.39 per cent in the seventies, that of
Kerala grew at 0.06 per cent only. Tne situation was not much different in
the eighties when the growth rate was 3.25 for the country and 1.45 for
the state. Only in the nineties it has overstepped the average. (See Table
3 - Compound Annual Rates of Growth of Per-capita Net Domestic
Product in Kerala and India, 1970-1 to 1991-2). The poverty of the state
becomes more apparent when we look at the head count ratio of poverty.
According to official estimates Kerala had 48.4 per cent of its people
below the poverty line in 1977-78'. (Table 4 - Percentage of Population
Below Poverty Line-India and States.) Though the situation has improved
over the years, 32 per cent of the people were still below the poverty line
in 1987-88 according to the estimates of the expert Group.
Along with poverty unemployment is also high in the state. According to
the 43rd round of the National Sample Survey (1987-8) 14.1 per cent of
males in the urban areas and 12.5 per cent in the rural areas were
"usually unemployed" (unemployed for more than 183days). The
percentages of females were 33.8 and 25 in the urban and rural areas.
This was the highest in the country The picture is more striking when you
come to the unemployment level among the educated. According to the
NSS, the level of unemployment among the educated males in Kerala was
18 per cent and among females 42 per cent in 1986-7, while the figures
for all India were 6 and 22 peer cent. The average waiting period for the
first job for a job-seeker with a school leaving certificate was 48 months
for a permanent job and 35 months for a temporary job (Oommen 1992).
But in this state ridden with relative poverty, unemployment and poor
economic growth, the people are highly literate. The provisional results of
Census 2001 show that 90.92 per cent of the people are literate against
an all India percentage of 65.38. This is not a recent phenomenon. Nearly
all the census showed that Kerala had a much higher level of literacy than
the rest of the country. The literacy level among females has also been
the highest. In 2001 it is 87.86 per cent against the all India figure of
54.16. (See Table 5 Crude Literacy Rate - India and States). The female
to male ratio was 93.1 per cent in 1991. Even the Schedule Caste2 women
of the state are more literate (74 per cent) than the adult general
population of many states (see Table 6 Kerala: Educational Record).
Though there is no law making primary education compulsory, sending
children to school is the norm even in poor households. Only 0.4 per cent
of the male children between 12 and 14 years and 1.8 per cent of the
female children had never been enrolled in school in 1986-87. It is not
only that they enrol in Class I, but all of them go to Class V. In fact, the
drop out rate from Class I for IV is negative for both the sexes in 1993-94.
1 This is defined as enough income for consuming 2250 calories in rural areas and meeting the other basic
needs. There are different estimates of the Head Count Ratio of Poverty.
■ Scheduled Castes and Scheduled Tribes are very backward communities recognized in the Constitution of
India for whom many measures of positive discrimination like reservation in Government jobs and tn
educational institutions are in place.
156
4
h
What is more interesting is that less number of females drop out from
Class I to X, their percentage being 24.51 against 33.43 for males. But in
the country as a whole 74.74 per cent of females and 68.41 of males drop
out of school before reaching class X. No wonder, the reading habit is
wide spread in the state. More than half the adult male population read a
newspaper and about 46 per cent of the agricultural labourers also read
some publication. Compare this with 23.6 per cent and 3.1 per cent
respectively for India. This makes the people politically quite aware and
demanding. We shall see later how literacy spread in the state and how it
influenced the demographic and health situation. But before that, we have
to have a peep into the health status of the people.
Kerala has often been compared with the developed countries for its
health indicators. Kannan (1999) has made some comparison of various
indicators like Human Poverty Index, Life Expectancy and GDP Per Capita
in Purchase Parity Dollars with some Asian countries. (Table 7 Selected
Indicators of Development - Kerala and some Asian Countries) has been
extracted from his various tables. It can be seen from this table that with
less than a fifth of the income of Malaysia, Kerala has achieved about the
same levels of life expectancy (71.7) and infant mortality (13). In fact, in
total fertility rate (1.8) and female literacy rate (86.3), Kerala is much
ahead. The Human Poverty Index constructed by UNDP taking survival
deprivation beyond 40 and other deprivations of education and economic
provisioning shows that only 15 per cent of the people of Kerala suffer
from poverty. Only Thailand has a better figure among the countries for
which data is available. Although most Asian countries in this table have
made a remarkable progress in reducing the rate of population growth, the
policy regimes under which such population programmes have been
enforced showed wide variations. The strict policy of mandatory limitation
of family size in China is well known. Indonesia’s programmes were
enforced with a heavy hand by the government until recently. It is without
any of this that the fertility rate has been brought down below the
replacement level in Kerala, Sri Lanka and Thailand. But Kerala has only
about half the income of Sri Lanka and less than a fourth of the income of
Thailand. In fact, Kerala achieved tremendous fall in birth rate, fertility
rate and population growth rate in the 1970’s and 80’s when its economy
was growing only at 2.5 per cent and per capita income at less than 1 per
cent. Curiously enough, this was the time when the economy of the
country was for the first time growing at 5 per cent. (Kannan 1999). The
provisional figures of Census 2001 shows that The annual compound
growth rate of population has been brought down to 0.89 per cent in 19912001. The rise and fall in population growth rate is summarised in Box 1.
15"
H
Box 1
Annual Population Growth Rate 1901-2001 Kerala And India (Per Cent)
i
I Period
Kerala
India
1.11
1 .44
1.79
2.33
1.55
0.89
0.56
0.51
1.30
i_____________________________________________________________________________ _ ______________________________________________
1901-11
1911-31
1931-51
1951-71
1971-91
1991-2001 (provisional)
2.12
2.17
1.96
Source:Census reports
A high life expectancy and literacy has made the state known for it high
physical quality of life, in spite of its low income. A comparison of the
Human Development Index of the state with other states brings out the
picture very strikingly. Srinivasan and Shariff (1997) have constructed an
HDI slightly different from that of UNDP. They put the HDI for Kerala at
62.79, which is 20 notches above that for India. (See Table 8 - Human
Development Index - India and Major States). Even for China and Egypt,
two countries known for their high physical quality of life, the figures are
only 60.9 and 61.1 respectively, according to them. A rich state like
Punjab, which has nearly double the income of Kerala, has an HDI of only
54.86 as they do not do as well as Kerala in life expectancy, literacy and
middle school enrolment, the other indices for which weightages have
been given.
Figure 2
Human Development fridex inpia ano large states 1993
70
60
50
40
30
20
10
0
1111111 111111 III
/
/
/
/
/
J
£
/
/
/
/
/
/
<■
CP
/
/
Source : See Table 8
The Process
How did Kerala achieve a high status of health and other social
development without a strong economic base? This is a question that has
plagued many academics and planners.
Many explanations have been
attempted for the ‘Kerala phenomenon’ which sometimes has been called
the 'Kerala model of development’. People like Amartya Sen have cited
15K
Kerala as an example of what can be achieved without much income. The
following can be identified as the main causes for the high health status
of Kerala's people:
• Spread of literacy and education
• Mass movement for uplifting the backward classes
• Political awakening
• Agrarian reforms
• Prevalence of indigenous systems of medicine
• A well developed health infrastructure in public and
private sectors
• Migration.
The scope of this paper does not permit a detailed examination of all
these factors. We will touch upon the first five and dwell at some length
on the last two.
The spread of literacy, education
and reading habit is the result of
decades of action by the people. The importance of literacy appears to
have been felt by the upper castes even in the sixteenth century.
Tharakan (1984) describes sixteenth to eighteenth centuries as a period
of growth of literacy in Travancore, when it spread beyond the reach of
Brahmins and came within the reach of almost all the socially and
economically privileged sections of society. A Royal Rescript by the
Queen of Travancore in 1817.
________________ Box 2_____________
Royal Rescript by the Maharani of
T ravancore, 1817
“The State shall defray the entire cost of the
education of its people in order that there may be
no backwardness in the spread of enlightenment
among them, that, by diffusion of education, they
become better subjects and public servants.”
Source: Nair (1 974)
This was a remarkable declaration in 1817 when no other Government in
British India thought of universal education. It was 55 years before
Japan's Meiji Educational Law of 1872 was enacted making education
universal. It not only declared education to be universal, but also
proclaimed the intention of the state to bear the expenses.
However,
starting primary schools did not follow this immediately. Travancore had
to wait till the second half of the 19lh century for expansion of education.
The Christian missionaries established modern schools in Travancore and
later in the other two parts of the state. In this they got liberal support
from the colonial power. Christianity in Kerala is much older than the
advent of colonialism. The traditional Christian population of Travancore
■ For a detailed analysis of these factors except the fifth and the seventh, see Ramachandran (1996).
159
k
U-
and Cochin (Syrian Christians) were also a supportive factor for the
missionaries. Cochin soon followed the example of Travancore in starting
schools. Malabar was slow in this, as in many other aspects, and had to
wait till the 20th century for the spread of education.
Initially, schooling was for the upper castes. But social reform movements
that started as a protest against the institutionalisation of social exclusion
practised by the upper caste Hindus, began demanding education for the
backward communities. Kerala had several forms of oppression of the
lower castes like untouchability and distance pollution. This was the main
hurdle in the spread of literacy among the masses. A movement started by
Sree Narayana Guru in the early part of the twentieth century was mainly
responsible for a series of social changes that facilitated the removal of
caste pollutions and made literacy spread to the oppressed castes. The
change in the political message spread to all castes and religions more
significantly to the Scheduled Castes. Later, in Malabar the emerging
proletarian nature of the labour force provided a good breeding ground for
the growth of the secular forces. This led to a radical political movement,
which first emerged as a leftist group within the Indian National Congress.
This group quickly turned itself into communists and was quite successful
in mobilising the labour power. Working underground and fired by an
ideology of liberation, they influenced the poor in the nook and corner of
Kerala. Their method of organisation was critically dependent on
education. Political study classes, publication of radical literature and
work among the intelligentsia to influence art and literature were some of
the means by which they sought to effectively communicate with the
masses. Even after the formation of the State of Kerala and the ushering
in of the first elected communist Government, the relevance of these
various forms of social movements did not fade away. From the point of
basic education capabilities, one of the institutional legacies of this half a
century of mobilisation was the establishment of what are called village
libraries throughout the length and breadth of Kerala. These libraries
established in the mid 1930s became a popular rallying ground and
meeting place for the local youth. After the formation of the State, the
Government recognised them for their contribution to non-formal
education and initiated a system of grant-in-aid for their maintenance.
(Kannan 1 999)
The demand for education is reflected in the government’s spending on
education. In 1980-81 when all the states together were spending Rs. 47/per capita from their budget on education Kerala was spending Rs. 85/-.
The trend continues to today, as can be seen from Table 9 (Per Capita
Expenditure on Education - All States). In the budget estimate for 200001 the state was to spend Rs. 870/- against the average of Rs. 579/- for
all states. If we ignore the small states with populations less than 5
million, Kerala spent the highest among the states on education in the
eighties. Only in the nineties did the other states catch up. About half of
what Kerala spends is on primary education. There is one lower primary
school for 236 children and one upper primary for 329 children of the
1i
■
relevant age group in the state. (Government of Kerala 2000). All this has
spread education to virtually all the people of the state. The importance
given by government to education is also evidenced in the fact that the
government pays the salaries and maintenance grants to the schools run
by the private sector. About 40 percent of the state's budget goes for
education. ( Government of Kerala, Budget in Brief 2001-02)
The change in the structure of agrarian relations can be put forward as
the next contributory factor. This emancipated the tenants and agricultural
labourers and made them conscious of their rights, generating among
other things, a demand for education. Though there were varying nature
of agrarian relationships in the three regions of the State, by and large,
the relationship in Malabar was much more feudal than in the other two
regions. In Travancore, and to a large extent in Cochin, significant
changes had taken place in the second half of the 19th century in agrarian
structure and economic relations leading to a wider distribution of the
ownership of cultivable land, growth of a large body of peasant
cultivators, expansion of the area and diversification of cultivation,
commercialisation of agriculture and growth of employment and wage
incomes. Malabar remained, on the other hand, for the most part of 19th
and first half of 20th century, a region in which feudal land relations of an
intensively exploitative kind existed. It resulted in the majority of the
agrarian population particularly the simple tenants and the landless
agricultural labourers getting progressively impoverished. (Varghese
1970). This turned Malabar into a breeding ground for the radical political
movement, the spreading of which we have already seen. The decades of
effort in improving the lot of the landless agricultural labourers culminated
in the historic step of passing the Kerala Land Reforms Act in the mid
sixties which gave absolute ownership to the occupant of the land and
liberated him from the clutches of the land lord. This is one of the
important steps that led to the empowerment of the people and put them
in charge of their destiny.
Health Care
Before the advent of modern medicine the people were dependent on the
Indian system of medicine called ayurveda. Not much literature is
available on the role this system played in the health care of the people.
But as a centuries old system of medicine that describes in detail many of
the physiological and anatomical systems of the body and the pathology
of many ailments accurately long before it was discovered in modern
medicine, and as the only system available, it was the one resorted to by
people for their health care needs. It has not only what today is called
internal medicine, but various surgical and other therapeutic procedures
and specialities. It uses many techniques, the efficacy of which is only
slowly being understood by modern medicine. By emphasising the
preventive aspect of health care and by providing home remedies and
traditional practitioners in the villages, this system took care of the health
of the people long before modern medicine came to the scene. Its role in
161
making people take care of their own health, or the 'health empowerment'
of the people has to be studies in detail. Though it cannot deal with
epidemics and many of the acute ailments, it is cost effective, accessible
and has no side effects. Gradually many of the procedures fell to disuse
with the advent of the quick-fixing modern medicine; but they are being
revived slowly as people realise their value as a safe system. This is a
system prevalent throughout the country and used by the rural people as
the first resort. But the practice by quacks, who prescribe modern
medicine under the guise of ayurveda without a licence to do so has made
it rather unsafe system. However, in Kerala it has been better preserved
with less of a 'mixture'. The peooie of the state still resort to Ayurveda for
certain chronic diseases, degenerative disorders and for general health. It
is attracting patients from outsiae the state and country as a safe system
of alternate medicine. Here the practitioners have developed a procedure
known as 'Panchakarma'. which uses the application of various medicated
oils to the body. The popularity of ayurveda can be judged from the fact
that there are nearly 5000 institutions and 2600 beds in the private sector
in the state (Table 10 - Kerala: Institutions and Beds in Different Systems
in Public and Private). The number of institutions in the public sector is
about 800 and the number of beds about the same as in the private
sector. There is demand for starting more and more dispensaries and
hospitals in the public sector. The State Government has a programme of
covering all the villages with such institutions and has already covered
more than 700 of the 996 villages. There are 5714 institutions and 5199
beds and five medical colleges in the public and private sector put
together in ayurveda. Another system called 'Sidha', which branched off
Ayurveda and flourished as a full-fledged system in the neighbouring
state of Tamil Nadu is also popular in the southern part of Kerala. The
state government promotes both Ayurveda and Homeopathy as two
alternate systems of medicine and maintains two departments for them
with separate Directors as for modern medicine. Medical education in
these two systems is also promoted with government themselves running
medical colleges and paying the salaries of teachers and other staff of the
colleges run by the private sector. The government runs Homeopathy
dispensaries in more than half the villages, gradually increasing the
coverage and runs hospitals in the districts and 2 medial colleges. Adding
the private sector, there are 3673 institutions, 1364 beds and 4 medical
colleges in Homeopathy.
The history of modern medicine starts with it’s introduction by the colonial
power, for treating their military. The princely rulers who were quite
receptive to modern ideas started adopting this. The King of Travancore
issued a royal proclamation in 1879 making vaccination against smallpox
compulsory for public servants (Ramankutty 1999) He subjected himself
and members of his family to vaccination publicly as an example for his
subjects to follow. His 1907 proclamation (see Box 3) shows the
importance given by a monarch to the health of his subjects.
162
Box 3
Proclamation by the King of Travancore
1907
“One of the main objects of my government is to see
that good medical aid .s placed within the reach of
all classes of my subjects. It is a blessing, which is
not at present in the power of individuals generally
to secure however mucn so ever they may desire it.
It is hence the obvious duty of the state to render its
assistance in this direction."
Source: Nair (1 974)
Parasite surveys were conductec in the State of Travancore in 1928 with
the help of experts from the RooKefeller Foundation (Ramankutty 1 999).
The Public Health Department started by the Travancore government had
the preventive control of contagious diseases as their main activity. They
were successful in checking the spread of malaria, cholera and plague.
They also collected vital statistics and did propaganda work among the
people (Krishna Pillai 1941). L;xe education, health too began to be
demanded by people as they became more politically conscious. With the
introduction of modern medicine the people started realising the
advantage they will get by having health facilities within reach. The rulers
responded to these demands. The most convenient indicator of the
importance given by the rulers of Travancore and Cochin to health and
education is the share of these in their Government expenditure. The data
available from 1867 show that starting with less than 1 percent they
increased the share over time to about 6 percent on health and about 17
per cent on education. (Table 11 - Share of Education and Health
Expenditure in total Government Expenditure: Travancore and Cochin).
By the time popular governments came on the scene the demand for
education and health had reached such heights that no government could
ignore it. After the formation of the state the share of health shot up to 12.
65 per cent and fluctuated between 11.41 and 16.49 percent (Table 12 Trends in Government expenditure in medical and public health and
related variables, Kerala). The provision in the budget for 2001-2 is 11.97
per cent (Government of Kerala: Budget in Brief 2001-2). As a percentage
of State Domestic Product the public spending on health is more than one
per cent when the state was formed, exceeding 2 per cent in some years.
In 1999-2000 it came to 1.4 per cent. One has to remember that the
current level of expenditure of Government of India is about 0.8 per cent
of GDP. On a per capita basis the state's spending on health worked out
to Rs. 32 in 1980-1, increasing to Rs.198 in 2000-1 (Table 13 - Per Capita
Public Expenditure on Medical and Public Health Care - All States). This
is more than the average for all the states and one of the highest among
the large states.
163
H
This kind of importance given tc health by successive governments has
helped build up a good infrastruc:ure for health care delivery in the public
sector. The all India pattern of one Sub Centre with an Auxiliary Nurse
Midwife for 5,000 population, ore Primary Health Centre for 25.000 and
one Community Health Centre fo* 100,000 for the rural areas has virtually
dotted the landscape of Kerala w th these institutions. A woman of Kerala
has to travel typically 1.5 Kms. to reach a sub centre for antenatal care
and for immunising her child whe'eas in the rest of the country the radial
distance is 2.7 Kms. There is one sub centre for 4205 people in the state.
A typical PHC in the country covers an area of 143.08 sq. km. with a
radial distance of 6.8 kms, and ir Kerala 37 sq. kms with a radial distance
of 3.4 kms. Similar difference is there for CHCs also. In spite of the fact
that the state has only 105 CHCs against the required 300, the radial
distance to them is only 14.5 kms against 20.6 for the country
(Government of India 19,98). The shortfall of CHCs is made up by a net
work of 184 sub district hospital with better facilities. These take care of
the primary and secondary care in the rural and urban areas. For tertiary
care there are 16 District/General hospitals, 11 speciality hospitals and
six medical college hospitals which are geographically well distributed.
All put together the government runs 1317 institutions manned by 4367
doctors in the modern system with 45684 beds (Government of Kerala
2000). If the institutions and beds in the other systems are added it comes
to 2672 institutions and 48258 beds. That is about one bed for 650
persons in the public sector alone (see table 10). While for India as a
whole there are 7 hospital beds per 10,000 population practically
remaining unchanged during 1981-91, for Kerala it has gone up from 10.5
to 20.6 (See Table 14 - Beds per 10,000 Population in Public Hospitals India and States). But if you taxe the private medical institutions also
there is one hospital for every 14264 persons in 1991 against an all India
average of one for 61810 (See Table 15 - State-wise Distribution of
Population and Medical Care Institutions-1991). Even this does not
narrate the whole story as only allopathic medical institutions are
covered. If you include the bees in ayurveda, homeopathy and other
systems of medicine, there are altogether 15290 institutions and 120182
beds for a population of 31.84 million as we have seen in Table 10. This
means that there is one bed for every 265 persons in the State. Thus the
picture that emerges is quite different from the one that comes out of
various studies, which do not put together the beds in different systems of
medicine. One bed for 265 persons is something that not many developed
countries can dream of.
While a well serving network of facilities is the main strength of the Kerala
public health system, it has many weaknesses. A summary of these is
available in an article wriiten by a doctor after conducting a study of the
public health infrastructure in an average district (the district of Trissur).
The main weaknesses he found are that the doctors do not stay in the
residential accommodation provided by the government, expectant
mothers do not visit the sub centres for antenatal check up, the inpatient
facilities are not utilised by the public, the field staff do not work as a
164
u
team, buildings are in poor maintenance and that many posts of doctors
are vacant. (Jagadesan 1997). Tnese weaknesses are real and are the
refrains in the complaints about tne public health system. We will see how
bad they are and how they are tackled when we come to the problems and
initiatives. Suffice it to say here that the proof of the pudding is in the
eating. And on that score we have seen that the state is doing well. The
utilisation of public facilities appears to be better than many other states.
Analysing the 52nd round of NSS data Mahal et al (2000) found that about
half the patients use the public facilities. The distribution of inpatient days
between public and private facilities is 122.8 and 124 respectively out of a
total of246.8. Only Karnataka has a similar pattern of utilisation. While
61.3 per cent of the people of Kerala below the poverty line and 73.5 per
cent of the Scheduled Castes and Tribes used public facilities, even 41.5
per cent of the fifth income quintile used these facilities. (See Table 16
Distribution of Inpatient Days between Public and Private Facilities
Kerala) This is in spite of a wide network of private hospitals in the state.
People, especially of the higher income brackets, will not use public
hospitals unless they expect a reasonable quality of service.
Similarly, if we judge the performance of the field staff by the results of
their work, with the current indicators in demography and health no one
can say they have not been working. The field staff is to implement
various disease control programmes, meet the need for contraception,
give maternal and childcare, deal with epidemics etc. We have seen how
fast the fertility and the growth of population has been brought down. All
reports by the state and central Governments and by studies conducted
by independent agencies show that immunisation in Kerala is more than
90 per cent. (Table 17 - Performance in Immunisation - Kerala) Similar is
the story in disease control. The state has successfully interrupted the
spread of filaria through community action, nearly eradicated the polio
virus (the surveillance system has detected only one case in the last three
years), and brought down the prevalence of leprosy to the elimination
status. In the programmes like TB Control the state achieves a cure rate
above the target of 85 per cent. In blindness control the target is achieved
usually. These programmes are implemented by the field staff like Male
Worker, ANM, their supervisors and the doctors in charge, All this would
not be possible without the field staff
working in in a co-ordinated
manner.
One of the nagging worries of the health planners is whether the money
spent by the government is reaching the poor, The common charge
against the government is that the quality of the services is kept so low
that only those who cannot afford better quality services go to government
facilities. The moment there is improvement of quality, the better off rush
to the public facilities edging out the poor. This can be called the public
health conundrum. Solving this is a major challenge of the health planners
in all the states of India. We have seen that the utilisation of public in
patient facilities is more equitably distributed in Kerala than in the other
states. Taking the outpatient and other services into account Mahal et al
165
(2000) has done yeoman work ir analysing the 52nd round of NSS data
and arrived at the incidence of oubiic health subsidies among various
income groups, people below the ooverty line and Scheduled Castes and
Tribes. It will be interesting to ;ook at the incidence of subsidy in the
states that spent the highest amount per capita on health in 1995-6 when
the NSS 52nd round was done. We know from Table 13 that those who
have spent more than Rs 100 per capita among major states are Himachal
Pradesh, Jammu and Kashmir and Kerala. For J&K the benefit incidence
is not available. A comparison of Kerala with the other two high-spenders
and with all the states is made in ihe figure below.
Figure 3
Distribution of Net Public Sector Health Subsidies for Quintiles - India and Kerala
Distribution of Net Public SectorHealth Subsidies
forQuintiles-lndia and Kerala
50
40
I
£
K e ra la
30
—«5>— P u n ja b
20
—•— Himachal F
—»
10
ades•
AII S ta te s
0
I
II
III
IV
V
Per capita expenditure Quintiles
Source: Mahal et al (2000)
In Punjab and Himachal Pradesh and in all states the subsidy is
distributed regressively. 31 percent of the subsidies is cornered by the
richest quintile in all states, nearly 44 per cent in HP and 22 per cent in
Punjab. But the lowest quintile in Kerala gets 21.9 per cent of the
subsidies whereas at all India level the group gets'only 10.2 per cent.
Though the second quintile in Kerala gets 23 per cent, it comes down to
18.2 per cent for the third and 17.2 per cent for the fourth, slightly
increasing to 19.7 per cent for the last quintile. The all-states picture is
one of steady regression from 10.2 to 31 per cent. The people below the
poverty line in Kerala get 31 per cent of the subsidies, a higher proportion
than their population. Their share is only 27 per cent in all states, 7 in HP
and 3 in Punjab. (See Table 18 (Distribution of Net Public Sector Health
Subsidies for Quintiles - India and Kerala). Thus, in spite of the
weaknesses, the Kerala health system appears to be functioning
reasonably well in efficiency and equity.
The question we are grappling with is how the state could achieve a better
health status without being rich. Our discussion shows the foundation
was laid by literacy, social reforms, public action and political
commitment. But to give the entire credit to these will not be right. On the
foundation laid by these the superstructure of a well serving public
infrastructure has been built assiduously. It is doubtful whether the
current levels would have been achieved without that network manned by
li
a motivated beaurocracy. Some writers like Panikar and Soman (1981)
and Zachariah et al (1994) who have studied the issue in depth are of the
view that the public health system has contributed significantly to the
present health status. No doubt, the building of this edifice itself is
cependent on public action. It is a demanding public that points their
fingers at the drawbacks of the system in such a way that no government
can ignore them and helps maintain efficiency and equity at a level higher
than the richer states. It will not be wrong to call the development of
health in Kerala as health empowerment of the people. Some academics
gathered in Ballagio, Italy in 1985 and considered the social development
of 4 low-income regions that have achieved significant health and social
status. Their summary of factors is in Box 4.
Box 4
Characterisation of the Four Examples in Reference to Specific Indicators of the
_________ Major Social and Political Factors Contributing to Good Health_________
Four Examples
Social and Political Factors
China
Costa Rica
Kerala
Sri Lanka
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Partial
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Medium
Yes
Medium
Yes
Medium
Low
High
Low
Low
Low
Low
High
Medium
Medium
High
Medium
Medium
High
High
High
High
Medium
High
Yes
Yes
Yes
Yes
Historical Commitment
Early legislation
Early government welfare policy (grea
than 30 years)
Early medical system (centuries)
Christian missionary influences
Social Welfare
Preventive health
Food subsidies
Education
Land reform
Participatory Orientation
Universal franchise (historical)
Since 1949
Extent of decentralisatioin (program
Medium
management authority)
NGO involvement
Low
Community involvement in health proc
High
Equality of Coverage (Equity)
Health, education, nutrition status :
Women
'Minority groups
Urban / rural coverage
!
Intersectoral Linkages
Mechanisms (e.g., inter-agency
16“
u
committees)
Incentives for linkage (e.g., laws.
Yes
Yes
Yes
Yes
regulations)
Training programs (e.g . intersectoral
Yes
Yes
No
No
I n_t e_r disciplinary j
Source: Rockefeller Foundation (1985) Good Health at Low Cost: Proceedings of a conference
held at Bellagio. Italy April-May 1985.
As can be seen, most of the factors that are common to the regions are
available in Kerala. Those factors, which are medium, low or negative for
the State, are in the process of improvement, as we shall see later.
The Private Sector.
We will now look at the role played by the private sector in the health
transition of the state. We have seen that there were 67,517 beds in the
private sector in 1995 which is about one and a half times the beds in the
public sector. This was only 49,000 in 1986. Thus the growth of the
private sector in recent years has outstripped the public sector which
grew only from 36,000 to 38,000 in the same period (Ekbal 2000). The
growth of the public sector is certainly limited and will continue to be so
as it has already fulfilled the norms fixed by Government of India for rural
health infrastructure. All the panchayats (villages) are served by a facility
in modern medicine.
In a few years time all will have facilities in
ayurveda and Homeopathy. Therefore, further growth in modern medicine
is likely to be only in the private sector.
However, this has put concern in the mind of activists and made them
express the fear that Kerala has changed from a demand driven
provisioning of health care which is responsible for the present health
status to a supply-driven health care seeking. The burgeoning private
sector with no restriction on the charges levied and the establishment of
expensive investigative equipment like MRI (there are three within one sq.
km. In the states’ capital) have led to many undesirable consequences. An
example of the overuse of medical facilities is the number of caesarean
section deliveries. As a percentage of normal deliveries they have gone
up from 11.9 per cent in 1987 in rural Kerala to 21.4 per cent in 1996 in
urban Kerala (Table 19 ■ Caesarean Section Rates - A Comparison). This
table gives a comparison of caesarean section rates with some less
developed and some developed countries, though for different years.
Urban Kerala in 1996 is nearly as high as North America in 1993. One
study in Trivandrum district found that the caesarean rates in some of the
hospitals was as high as 60 per cent. (Kunhikannan and Aravindan 2000)
According to WHO, no region in the world is justified in having a
caesarean rate higher than 10-15 per cent. Some writers call it the
‘Healthflation’ of the State. Narayana (2000) analysed the utilisation of
health care facilities during the last year in Kerala and found the
probability of using private facilities to be 0.75 and public hospitals 0.38
with utilisation of public facilities coming down with education.
16S
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Two questions come up in this context. First, how does this affect the
health care burden of the poor people? Second, how are the people of
Kerala be able to support such a rapidly expanding heaithfiation? Will
entrepreneurs invest in new hospitals and super speciality centres without
a market for it either apparent or dormant? Our first concern is how this
’healthflation' is affecting the poor. The burden of health care on the poor
has certainly gone up in the last few years. Kerala Sastra Sahitya
Parishad (KSSP), a prominent NGO of Kerala who conducted a health
survey in 1987 and visited the same families in 1996, found that there has
been an increase of more than five fold in medical expenditure for all
categories of people from 1987 to 1996 and as a percentage of per capita
income it went up from 3.57 to 6.79, an increase of 90 per cent. For the
lowest socio-economic group the increase in expenditure is more than a
seven fold and as a percentage of income the increase of medical
expenditure is more than four and a half times. (See Table 20 (Annual per
capita medical expenditure by socio-economic status 1987 and 1996).
Thus it is clear that the burden of health care on the poorer segments has
increased. The role by the profiteering attitude of some private sector in
this cannot be denied.
However, there are two points about the private
sector in the state that are on the positive side. The first is that a large
number of them are run by church based organisations. Their origin is
similar to the origin of missionary activities in education. They charge low
rates from people who cannot afford and generally give good service.
Thus they are midway between the not-for-profit NGOs and the for-profit
private sector. The second is that many private sector facilities are
established in the rural areas. Many of the entrepreneur-doctors find it
more lucrative to set up small hospitals in the rural areas rather than
compete with the well served urban areas. Not all of them charge
exorbitant rates. A study of two sample private hospital in the rural areas
in the northern part of the state found them taking care of indigent
patients free of charges and setting the prices in such a way that some of
the basic services cost not more than what they cost in a government
hospital (Narayana 2000). But the private, purely for profit hospitals in the
tertiary sector tell a different story. On the whole, the private hospitals
have filled the gap of the health infrastructure in the public sector. But in
this process, it has contributed to increase in health care costs.
Migration
We shall seek an answer to the second question about the market
sustenance of the private sector by looking into a 30 year old
phenomenon in the state which would also throw some sidelight into the
inadequacy of income calculations. This is the huge migration of Keralites
to the countries of the Persian Gulf in West Asia. With a stagnant
economy and 4.18 million job seekers registered in the employment
exchanges (Government of Kerala 2000) the educated Keralite has to
seek employment outside. Already government is providing 52 per cent of
the organised employment in the state and the private sector in primary
and secondary sector is stagnant. Migration became the only solution.
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Fortunately the oil crisis caused a boom in the Middle East throwing up
employment opportunities. The Keralite grabbed the opportunity.
Educated people going for employment outside is not a new phenomenon
in the State. Migration has been tnere with Kerala for quite sometime as
petty traders going to Myanmar and Sri Lanka and ministerial job seekers
going to the rest of the country was quite common. But the boom in the
1970s has no parallel. This gave tne opportunity of a job abroad not only
for the educated but also for carpenters, masons mechanics who
constitute the bulk of this migration. Zacharia et al (2000) estimates that
1.5 million Keralites now live outside India. Together with the migrants to
other States in India and those who have returned they estimate that 3.75
million people are involved in migration. This is about 118'r‘ of the
population of the State. No reliable estimates are available of the inflow of
money in cash and kind through legal and illegal channels from the
emigrants. World Bank (2000) estimates from the national accounts of the
Central Statistical Organisation that if you take into account the net factor
income from abroad and the other current transfers disposable income is
about 2.1 per cent more than the GDP in 1997-98 at the country level.
Prakash (2000) took the total figure of workers remittance to India from all
countries provided by the World Bank in 'Global Development Finance
1999' and reduced it by two assumptions. Firstly, by 75 per cent assuming
that that is the share of the remittances from West Asia and secondly by
50 per cent assuming that that is the share of Kerala. His table is
reproduced as Table 21 (Workers Remittances to Kerala). According to
this the remittance to Kerala has varied between 10.74 per cent of the Net
Domestic Product in 1990 to 30.42 per cent in 1996. Though these figures
are based on the two assumptions, thus reducing their usefulness as
exact numbers, these assumptions are not wide off the mark and the
contribution to the economy is sizeable. Thus any study of the states
economy without taking into account this factor and coming to the
conclusion that the state is poor is misleading. Zacharia et al (2000)
estimated that in 1998, a migrant on an average sent home Rs.25.000 in a
year. If we spread it on all the population it works out to Rs.1105 per
capita. But the authors would add the value of the goods that are brought
in by the migrants and estimate the total remittance to be Rs.407171
million in 1998 which is 10.7 per cent of the State domestic product. “Ho.also estimate that 86 per cent of the households involved in mic'atmtheir remittances for living expenses. Thus the disposable incopeople is much higher than what estimates of state domes’. •. !■. .
would show.
It is a curious fact that the population growth rate and total fertility rate
started falling when migration started going up. Is the improvement in
demographic indicators influenced by the quick rise in standard of living
of the poor who constitute the majority of migrants? Do we finally prove
the dictum that ‘development is the best contraceptive', which India
preached in the World Population Conference in Bucharest in 1974
notwithstanding the fact that shortly afterwards was written the black,
though fortunately short, chapter of compulsory sterilization? These are
tempting questions. But demographers who have looked into this would
u
not agree that the remittances rom the migrants and the consequent
increase in disposable income is tne sole determinant of the demographic
transition. Some writers who have gone into this question finds that the
demographi : transition of the state started long before the migration boom
took place in the seventies (Example, Nair 1997). Demographers
generally put the sixties as the turning point when the population growth
rate started declining. However, tne influence of the improved standard of
living brought about by the remittances from abroad on accelerating
demographic changes is likely to be substantial. Zacharia et al (1994)
attribute four determinants to the fall in fertility. Universal Immunisation
Programme, Universal Literacy Drive, the World Bank Project in the
Backward D stricts of Kerala (India Population Project III) and accelerated
Gulf migration. More such in deptn studies have to be undertaken to find
the impact of migration on genera! health care and the explosion of health
care provision in the private sector. It goes without saying the latter is a
direct consequence of higher disposable income with the people.
Epidemiological Transition.
We have already seen the quick transition of demography in the state,
The second transition is in its epidemiology.
The picture of
epidemiological transition is a little more complex. We have the various
rounds of N$S, the studies carried out by the National Council of Applied
Economic Research (NCAER) and two studies carried by KSSP. All these
studies shovy the prevalence of morbidity in the State to be quite high,
NSS round cif 1974 found the morbidity rate in rural Kerala to be 71.21
against an a I India rural figure of 22.46. According to the survey carried
out by NCAER in May-June 1993. there are 168 sick persons for every
thousand people in rural areas in Kerala against an all India average of
97. Based on the survey conducted by NCAER in 1994, Shariff (1999) has
found that among the States in India, Andhra Pradesh and Kerala have
the highest prevalence rate of major morbidity at 7684 and 7319
respectively aer 100,000 population (See Table 22 - Prevalence Rates of
Major Morbidity by States). Mahal et al (2000) also found that Kerala has
the largest number of illness episodes treated at 90.3 per thousand
persons. KSSP found the morbidity in the State in 1987 to be 206.39 per
thousand. They visited the same families in 1996 and found that the
morbidity ha? come down. Box 5 gives the comparative figures of NSS
1994, KSSP ’ 987, 1996 for acute and chronic diseases :
_____________ Box 5________________
MORBIDITY RATE PER THOUSAND
POPULATION IN KERALA
Disease
NSS1974
KSSP 1987
KSSP 1996
Acute
Chronic
71.21
83.68
206.39
138.02
121.86
114.6
Source: Kunhikannan & Aravindan (2000)
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The size of these morbidity figures has often made planners and others
doubt their authenticity. How could a people with such good health
indicators and low mortality figures have such a high degree of sickness'?’
But some say that high morbidity co-existing with low mortality is not a
strange phenomenon. This appears to be common in developed countries.
Panikar (1999) quotes from Johansen S Ryan. "In general, it is not high
mortality developing countries that have high levels of morbidity and low
mortality (generally developed) countries that have low levels of
morbidity, but quite contrary". He also refers to Riley who reviewed the
morbidity trends in four countries, Japan, United States, Britain and
Hungary and found that sickness prevalence has moved in a direction
opposite to the death rate for most of the age and sex groups. Thus the
State appears to toilow
follow the pattern of development followed by the
btate
developed countries. But not all agree with this. Others argue that a
higher reportage in Kerala reflects a better health care system and higher
levels of health consciousness, as well as a greater awareness of
personal rights and of the demands that a citizen can legitimately and
successfully make of the health care system (Ramachandran 1996). The
author cites Christopher Murray and Lincoln Chen who showed that self
perceived morbidity in Kerala is substantially lower than in United States
and shows with the data on Cote d’lvore Ghana and Peru that self
perceived morbidity rises with income. This appears to be nearer to the
truth in Kerala. It is difficult to believe that the average person of Kerala
suffers more sickness than, say, the rural poor of Bihar.
But the pattern of sickness shows that Keralites suffer from life style
diseases more then the people of the other states. 1433 persons out of
100,000 suffer from hypertension, 980 from diabetes and 914 from heart
diseases which are the highest or the next highest in the country, (table
22). Cardiovascular diseases and neurological disorders constitute about
29 per cent of the cause of death in Kerala. They caused only 12.8 per
cent of the deaths in 1987 (Table 23 Some common causes of mortality in
Kerala). But the state does not appear to have got out of the burden of
communicable diseases during the transition to non-communicable
diseases. The large part of the disease burden still continues to be
communicable diseases. The official reports of the state Director of Health
services show that diarrhoeal diseases, respiratory infections and
tuberculosis continue to be major killers in the state. (See Table 24Affliction and death due to principal communicable diseases - Kerala).
Even as late as 1996 there was an outbreak of cholera killing 114 people.
New diseases like Japanese Encephalitis, Dengue fever and Leptospirosis
are emerging. It is this persistence of diseases of poverty and deprivation
side by side with the emergence of the diseases of the affluent that will be
the challenge for health planners in the State.
I
Problems, initiatives and Lessons
The question that interests health planners is what lessons can be
learned from the performance of Kerala. We have seen that it is a
r?
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combination of public action and s well serving network that helped Kerala
attain a high level of health and quality of life. Obviously the history of
Kerala has been unique and ca~not be repeated in other states. The
Kerala example shows that the route for better health is health
empowerment of the people. In th s literacy, especially of the female, has
played a pre-eminent role proving the dictum that literacy is the corner
stone of development. Development thinkers of the country cannot miss
this. But the history of 50 years of development planning of the country
shows that not enough importance has been given to literacy and primary
education. The teacher-population ratio, which was growing at 3.6 per
cent between 1950-51 and 1960-61, grew only at 2.3 per cent in the next
decade. The growth declined furiner to 0.5 per cent in the decade after
and stagnated between 1980-81 and1984-85.In the next five years the
growth rate actually declined by 0.5 per cent (Dreze and Sen 1995). In
1971, 21 years after planned development came on the scene, the literacy
level in the country was 29.5 per cent (Census Reports). In another 20
years it reached only 42.9 per cent. In the early 90's Government of India
started a campaign for literacy wrich got a great fillip by the trail blazing
experiment by a district administrator in one of the districts of Kerala. His
untiring work made the Prime Minister declare Ernakulam the first fully
literate district of the country in 1990, the world literacy year
(Rajanl 991 )4. Government of Incia adopted this model for the literacy
mission. The mission has had its impact. The provisional Census figures
of 2001 show that the level has improved to 65.4. But the female literacy
is still only 54.2 per cent. The country has still a long way to go and the
momentum does not seem to be acequate.
Is literacy the only lesson that Kerala can give to the others? To find an
answer to this we now look into some of the problems faced by the health
sector and how they have been cealt with, if at all, and what initiatives
have been taken to improve the performance of the sector. The first
problem that faces the planner comes from statistics. It comes out of the
fact the averages conceal huge differences. There are sections of the
population of the state who have not been benefited by the so-called
Kerala Model. Three such groups can be identified. The first is the
traditional fishing communities in the coastal areas. They live in very
crowded surroundings with poor sanitation and water supply. The infant
mortality rate among them was estimated to be 85 in 1981 and sex ratio
972 women per 1000 men (Kurien 1993). This is the year when the state
had an infant mortality rate of 37 and a sex ratio of 1032. The recently
completed Coastal Health Project with the help of the World Bank has not
made any dent on the situation. The second such deprived social group is
the Scheduled Tribes of Kerala's hills. They suffer from peculiar genetic
disorders like sickle cell anaemia and are poor in literacy, nutrition and
other indicators. The district of Waynad, in the north of Kerala which has
4 Some media reports showed Kottayam, another district of the state as the first fully literate district. This is
wrong. The Kottayam campaign was for making the town of Kottayam fully literate and not the entire
district. For the correct picture see New York Times International, March 16.1990: Ernakulam Journal: J
success story that all can read
a tribal population of 17 per cent (1991), tne highest among the districts,
has registered a decadal population growth of 17.04 per cent from 1991 to
2001 against the state's growth cf 9.42, (Census 2001). In the district of
Idukki, the next highest in the number of tribals (percentage 4.77) the sex
ratio of 2001 is 993 making it the only district in the state with a sex ratio
unfavourable to women. To know that this is a district of a state, which
has not only a sex ratio of 1058 (Census 2001), but also equality with men
in literacy is quite revealing. There is one village (name Vattavada) which
has a mortality rate of 59 and literacy level of 32 per cent Report in the
'Hindu' of April 15, 2001). Suer pockets of deprivation should be the
immediate concern of planners. Though the government has launched
many programmes for tribals including setting up health facilities beyond
the norms for the plains, the oroblem continues to persist. A new
programme launched with the heip of UNICEF is currently the hope for
these people. The third group is tne new class of Tamil migrant workers in
Kerala, who come in search of unskilled manual jobs. Many such workers
are homeless and live in deprived and unhygienic conditions. There is
very little information about their nealth status and little recognition that
they are part of the community of Kerala. But it is known that they are a
very deprived group (Ramachandran 1996). The existence of these
deprived groups is sometimes not even recognised in the euphoria
generated by the averages. Special efforts are required to improve their
lot.
The second problem is one of sustainability of the public health system
The people expect the state to orovide health care of all types to all
categories of people. It 1s the 'Dharma' (duty) of the ruler to look after the
health of the people and public nospitals are 'Dharma' (free) hospitals.
But the state of public finances is such that no state can ever do it.
Shortages in the system are huge. The drugs are in short supply, the
buildings are in poor maintenance, and essential manpower is lacking.
The claim from other sectors of governmental activity is so strong that the
share of health in the state budget has been coming down steadily. (Table
25 Trend in Development Expenditure 1990-91 and 1994-95 to 2001-02,
Kerala). It has declined from 15.45 per cent in 1991 to 11.97 per cent in
2001 - 02. The increase in nominal terms is only 2.9 per cent in the last
two years. The rate of inflation being much higher than this, the growth is
negative in real terms. Similar is the fate of education, which has come
down from 43.02 to 39.02 per cent. With the continued pressure on
resources, it is very unlikely that this trend will be reversed. Therefore, if
the system has to be sustained, other resources have to be mobilised
outside the budget.
The state has taken some initiative in resource mobilisation. In the early
80's the Government formed Hospital Development Committees for all the
major public hospitals. The committees consisted of reoresentatives of
political parties and other groups in the locality with a senior administrator
of the district as the chairman and the medical superintendent of the
hospital as the convenor. The idea was that they would voice the local
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needs and find solutions. They were also permitted to collect parking
fees, visitors fees etc. and to collect certain charges for some procedures.
The Government collected some cnarges for procedures like X-rays and
laboratory investigations from those who could afford, but that went into
the general revenues of the Government. The HDCs were permitted to
retain the collection and spend it on the development of the hospital as
decided by them. Gradually they were permitted to collect charges for
some other hospital services also. The revenues from the charges
collected by Government for the treasury were meagre as there was no
way of means testing and all would declare a low income. But the HDCs
employed better means testing tecnniques like questioning the patient and
the accompanying persons. In the 90's HDCs developed into a regular
system and some of them were registered as separate charitable
societies. In the major hospitals, the HDCs collected reasonably good
amounts. For example, the HDC of Medical College Hospital Trivandrum
collected an amount of Rs 30 million in 1997-98, which is nearly 10 per
cent of the total running cost of the hospital including salaries5. This HDC
runs a fair price medical shop and has established expensive equipment
with borrowed funds and is able to repay the loan with the charges levied.
Care is taken to see that the poor are exempted from the charges. Not all
HDCs are able to perform as well as this. But slowly realisation is
dawning on the public that without mobilising resources like this, the
system cannot be sustained. The collection of hospital charges by the
Government for the treasury is also not insignificant. The information
about that is available in the Government accounts, which has been
collected by the National Institute of Public Finance and Policy. The NSS
52nd round has also collected data about this. Mahal et al (2000) has
looked in to both these and found that Kerala has collected the highest
amount among the states according to both the data. The NIPFP figure
shows Kerala collected 2.22 per cent of the total expenditure of
Government on health, and Maharashtra 2.68 per cent, while the other
states ranged between 0.10 per cent (Karnataka) and 1.31 per cent
(Punjab). The NSS data reveals a completely different picture. While
Kerala collected 15.86 per cent, the other states collected between 0.92
per cent (Rajasthan) and 10.67 per cent (Punjab). (See Table 26
Collection of User Fees and Cost Recovery Ratio - Major States). The
collection of user charges formally by the Government and informally by
the HDCs for which no data is available together would constitute not an
insignificant proportion of the budgeted expenditure on health. This is one
way out of the resource crunch, provided care is taken to see that the
poor are not affected.
Another experiment that has contributed to the mobilisation of resources
is autonomisation of hospitals. Registering a hospital as a separate
society helps it to collect user fees in a more systematic manner. This is
because the society will have to manage its own resources. Though the
Government will have to continue to support it with grants, the society
5 source: Internal reports of the Superintendent of tne hospital.
1’5
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knows that the grant is a finite amount and anything extra will have to be
mobilised by it for its development. This will, of course, depend on the
degree of autonomy given to the society. Kerala has made only one
hospital an autonomous body. This is the Regional Cancer Centre
Trivandrum. Though the degree of autonomy is limited and the major
source of finance continues to be the Government, the resources it has
mobilised from other sources are considerable. From 1989-90 it has
generated between 11 and 53 per cent of its total receipts by internal
mobilisation which consisted of user fees and sale of drugs. This was
enough to meet between 19 and 65 per cent of its running cost and the
cost of drugs. (See Table 27 Receipt and Expenditure of Regional Cancer
Centre Trivandrum). This is all the while giving free treatment to the poor.
Only because it was an autonomous hospital it started thinking of deficits
and surpluses, which made it tap outside sources for its development. It
has also made it improve on customer satisfaction and research. In its
sixteen years of existence it has published more than five hundred
research papers in peer reviewed journals. The autonomy facilitated it to
stop private practice among its doctors in 1999 and start a pay clinic that
generated enough income to pay non-practising allowance to the doctors.
It is possible to introduce such autonomisation in teaching hospitals and
other big hospitals. Once the institution is made autonomous, each
department can also be given the freedom to generate its own resource
and use it for the development of the department, which will give enough
motivation for the staff to collect more. The Government can always
stipulate that the poor should be exempted from user charges. Already
Hospital Development Committee has shown the way. Autonomisation has
of course, other advantages like decentralised decision making. This is
another path of reform for Kerala and other states. But the important
■ condition is that autonomy should be real and not in paper. But such an
initiative requires advocacy and bold decision making at the political level.
Let us now turn our attention to the weaknesses pointed out by
Jagadeesan. The first one is that doctors do not stay in the residential
accommodation provided by the government. This is a kind of paradox.
While lack of residential accommodation is usually given as the reason for
the doctors being not available in the rural areas, it is also true that in
some places where accommodation is available, doctors do not use them.
This points to one of the major problems in public service of doctors. The
doctors are allowed to use their spare time to treat patients at home and
collect fees from them. Staying in the government accommodation, which
is often in the campus of the hospital, is a disincentive for the doctors to
get private practice. When the patients come to the hospital campus it is ■
expected that they will be treated in the public facility. The lure of private
practice not only makes the doctorTive outside the hospital campus but
also makes him neglect his hospital and fieldwork. Very often, complaints
are made of doctors refusing to treat a patient in the hospital who does
not meet him as a private patient and pays the fees. Such corrupt
practices also leads to other services in the hospital being dependent on
bribe. Private practice is usually supported on the argument that doctor's
176
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services should be available to the public after office hours. While this
argument may hold good in very remote areas where other doctors are not
available, this becomes a pervading evil in the urban and semi-urban
areas, which constitute the major part of the state. It becomes quite
pernicious in medical college hospitals and district/general hospitals. The
Government tried to stop this in the past, but had to withdraw immediately
on account of the political pressure put in by lobbies of doctors. Only
Regional Cancer Centre could stop it.
The second weakness pointed out by Jagadeesan is the under utilisation
of the sub centres. There are 5094 sub centres in the state. These are to
be housed in a separate building constructed according to a type design
which houses the office of the ANM in one half and the other, her
residence. But only 2986 sub centres have such buildings and the others
function in private buildings where the ANMs do not stay (Government of
India 1998). There is a qualitative difference in the service at the sub
centres functioning in government buildings where the ANM is available
day and night and those functioning in rented premises. Complaints of
ANM not being available there even during office hours are common. Only
a program for constructing buildings for sub centres can rectify this. Only
in one district such a program has been launched with the assistance of
the World Bank where a special area project is being implemented under
the Reproductive and Child Health Programme. Similar programmes are
required in the other 13 districts.
The third weakness is a similar under utilisation of the inpatient facilities
in the Primary Health Centres. There are two types of PH
in the state,
The small ones are called Mini PHCs, which are run as
inics by one
doctor and usually there are no inpatient facilities. The next are Block
PHCs which have two or three doctors, and CHCs with a minimum of four
doctors but very often more than 4. It is true that there is under utilisation
of inpatient facilities in the PHCs. We have seen in Table 16 that a total
of 122.8 inpatient days are spent in public facilities. But the data also
reveals that only 1.6 days were spent in PHCs and others, the balance
being spent in hospitals (Mahal et al
2000).
This calls for some
rethinking on the need for inpatient facilities in PHCs. In Kerala where
facilities are available at short distances the need for maintaining beds in
the PHCs without being able to provide the necessary staff and
consumables, has to be reassessed. It is better to run some facilities well
than to run all badly. But closing down the existing facilities will generate
protests from the locality and a proper campaign has to be launched for
making the people understand the price of keeping bad facilities open.
This, again, requires bold political initiative.
The next problem is the shortage of manpower. There is always a
considerable number of vacancies of doctors and other staff. It is small
comfort that these are much less than in the rest of the country. Though
most of the rural areas have essential infrastructure as we have seen, the
choice of the doctor to work in a place is very often dependent on his
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perception of the scope for private practice. Two recent initiatives have
helped in improving this. The first is the reservation of a small number of
seats for postgraduate medical courses for doctors serving in difficult
rural areas that have been carefully selected for the purpose. Many young
doctors now opt for these areas as they get a much-treasured seat in a
PG course without going through the tough entrance test. The second has
came as a part of devolving powers on the locally elected governments in
the villages which is discussed separately. The elected Presidents of the
Village Panchayats are now permitted to fill up vacancies on contract
basis. As the institution itself is under them they can no longer tell the
people that they have petitioned the Minister. It is now their responsibility
to get some doctor to work there. The State Government has even given
in some difficult areas, a remuneration higher than that paid to the
permanent doctors. Though the officially reported vacancies of doctors
continue to be 419 out of 2,500, the contract appointment has reduced it
effectively to about 80 (Government of Kerala 2001). The large number of
vacancies of Staff Nurses (187). Auxiliary Nurse Midwives (84), Male
Workers (443), Lady Health Inspectors (88), Lab technicians (76),
Hospital Attendants (522), Nursing Assistants (247) continue to be a
matter of serious concern. Permitting the Panchayats to fill uo these
vacancies also on contract will solve the problem.
Yet another problem in health manpower is a perennial one of clinicians
getting into health administration without any formal training and attitude.
There is also the problem of the specialists getting posted to the
institutions that do not need them. This is because there is no speciality
cadre and when a doctor gets promoted he gets posted to a post vacated
by a different specialist. As a solution to both these problems an attempt
is being made to break-up the cadre of doctors into a few categories. The
first will be the doctors who get into administration. Generally these will
be doctors without any specialist training. But they will be trained in
public administration and hospital management. The second will be a
cadre of public health specialists who will have the requisite qualification
and training. The third will be different cadres of specialists. Thus there
will be six or seven specialities to which the doctors will opt after a few
years of service and get their promotions in those cadres. The senior
administrative positions like Deputy Director, Additional Director and
Director of Health Services will be only from the administrative cadre.
This is a long drawn process and will take at least two years to be in
place. But a beginning was made in 2000.
The third major reform attempted in the state is in decentralisation. After
the 73rd and 74th amendment to the Constitution of India of 1993. the state
passed the necessary laws and went in a very serious way in devolving
powers, responsibility and funds to the elected local governments in the
villages (panchayats). Many sectors of the State Government have
handed over their work to these panchayats. The state government has
handed over to them all but 18 of the 1300 dispensaries, Health Centres,
sub district and district hospitals under the control of the Director of
rx
)
ii
Health Services. The state government now runs only general hospitals,
speciality hospitals and the medical college hospitals. Similarly the
majority of the institutions under ayurveda and homeopathy have also
been handed over to them. 37 per cent of the development budget of the
State has been given to the panchayats with the only stipulation that they
should use at least 40 per cent in the productive sector of the economy.
This has been in place for the last 5 years and though the impact on the
performance of the health systems is not assessed in a systematic
manner, the general impression one gets is that things are working much
better. The hospitals are getting maintained faster and the shortages of
drugs are replenished by local purchases quickly. We have already seen
how the presidents of the panchayats were able to find doctors to work on
contract in remote places where regular service doctors refused to go.
The feeling that it is the responsibility of the people to manage and run
the hospital has gained ground. The panchayats prepare detailed
development plans for their area and it is heartening to see that many of
the plans in the health sector are for improvement of sanitation, mosquito
control, garbage disposal and such other preventive measures. It is the
responsibility of the Panchayats to prepare project, raise resources,
implement them and be answerable to the public. Administration has
become a lot more transparent and though there are complaints about
corruption, the accountability to the public has improved. In the year
1999-2000, the Local Self Governments have implemented 159850
projects raising 12.20 per cent as loan from financial institutions and co
operative societies, 2.87 per cent as voluntary contribution and 9.17 as
contribution by the beneficiaries. They found 9.27 per cent from their own
funds and had to depend on government grants only to the extent of 66.49
per cent. (See Table 28 Financing Pattern of Projects implemented by
Local Self Governments Kerala 1999-2000.J 14.32 per cent of the projects
are exclusively for Scheduled Caste, 3.27 per cent for Scheduled Tribes
and 7.37 per cent for women. If we look into the nature of the project, it is
seen that 27.8 per cent are for productive purposes.
When decentralisation is discussed as a solution to many of the problems
in health and general administration, it is common to dismiss it as a
solution suitable only to states like Kerala with high levels of literacy and
awareness. It is pointed out that the previous experiments at
decentralisation conducted with a lot of fanfare in many states have failed
to yield results. Therefore, it is concluded that it will only end up in
dispensation of favours by privileged groups in the states ridden with
illiteracy, cast politics and serious deprivations for several groups of
people. However, it has to be remembered that the previous experiments
have not been done with sufficient preparation. Kerala this time, launched
a six-phase campaign. The first was one of intensive advocacy among the
people to make them realise that for the first time they had an opportunity
to decide what they want and what they can do in their Panchayat. The
Gram Sabhas, which are mandatory meetings of all the voters in the
Panchayat, were poorly attended before. The experience of the
neighboring State of Karnataka, which made a serious attempt at
1'9
u
devolution in the early eighties, had shown that only 29 per cent of the
villages had even convened their Gram Sabhas. A study made in a sample
district of that state revealed that the attendance was only 5.25 per cent
in 1987. In another panchayat the average number of persons attended
was just 29. With the kind of advocacy launched in Kerala the meetings of
Gram Sabhas proved to be a resounding success. The attendance ranged
from 8.38 to 15.32 per cent of the total electorate in most of the 996 Gram
Panchayats (Isaac and Franke 2000). The second phase consisted of
training to the elected representatives and building their capacity and
holding development seminars in the Panchayats. These seminars were
attended by local resource persons who themselves were trained in a
three tier structure. 373 Key Resource Persons were selected and trained
for seven days at the state level, who trained 1 1628 District Resource
Persons in 81 camps for three days. They, in turn, trained the Local
Resource Persons who numbered nearly 100,000. As a result of their
involvement, the quality of the deliberations in the Gram Sabhas improved
dramatically. The third phase was in forming task forces for preparing
projects, the fourth phase in formulating grass root level plans at the
Panchayats, the fifth phase for preparing higher tier plans for Blocks1 and
Districts and the sixth phase for appraisal of the plans by Voluntary
Technical Corps. This campaign lasted for about a year and a half and it
is only this that has made decentralisation a successful experiment this
time. Such advocacy and campaign are a necessary pre requisite for
giving powers to the local representatives of the people and there is no
reason why it will not succeed even in backward areas. The success of
some women’s self help groups in many states point in this direction.
The next experiment in the state is in the women's self help group. A
small programme of women from 25-45 families coming together and
organising their own schemes like thrift, tiny manufacturing, attending to
local problems etc. has grown into a movement. There is a health
volunteer in these neighbourhood groups. About 12 of them form
themselves into an Area Development Society and the ADSs in
municipality or panchayat form themselves into a registered charity called
Community Development Society. Banks are lending to them for various
productive activities and the recovery is very often 100 per cent: There is
no outside involvement in this. The State Government has spread this to
one entire district (Malappuram) and 241 Panchayats out of 996. 7537
Neighbourhood groups have been formed so far who have formed 607
ADSs and 58 CDSs. 400 of these neighbourhood groups are by tribal
women (Government of Kerala 2000). If properly nurtured, this is a
scheme like Gramin Bank of Bangladesh, which can bring in community
participation, reduce gender disparities, alleviate poverty and improve
health.
'' Blocks are a group of about 10 Panchayats formed for community development programs in the 50's.
Now the Block Panchayats are the second tier of Local Self Government, the third being District (Jilla.l
Panchayats.
—
18h
H
We have seen already seen that one of the problems the state has is the
prevalence of communicable diseases. Though the rate of prevalence is
much less than in the other states, diseases like Cholera. Malaria,
Japanese Encephalitis, Leptospirosis and Typhoid still break out
sporadically though in minor proportions. The entire machinery of the
district administration comes together as a war team and contains these
outbreaks. However, there is no system of knowing the outbreak in time. A
scheme has been put in place to detect the early warning signals and take
preventive as well as curative measures before they come to epidemic
proportions. Based on the Nadhi scheme (John 1998), Kerala started a
programme of disease surveillance in the District of Kottayam. The
scheme consists of training and sensitising the doctors and clinicians in
the private as well as public sector to report diseases. Fourteen diseases
have been carefully selected for this based on the past experience of
outbreaks. Pre-paid post-cards are given to the doctors and when they
suspect a patient to have any of the 14 diseases, they write the details of
the patient and tick the relevant disease and post the card to the District
Medical Office. They do not wait for laboratory confirmation. A software is
installed in the DMO where all these postcards are entered and at a
glance the Officer in charge of Public Health knows whether there is any
clustering of any particular disease in any location. Threshold levels are
fixed for each disease and the rapid action team moves in once the
threshold is crossed. A monthly bulletin is published reviewing the
reporting and the action taken. This bulletin is an important feedback to
the doctors and motivates them to continue the reporting. The scheme
was put to test in the district in 2000 when there was an outbreak of
cholera, which was nipped in the bud and many lives were saved. The
scheme is to be spread to three more districts in the next phase and to all
the 14 districts in the last phase.
While communicable diseases are hoped to be tackled with a good
disease surveillance mechanism and with good preventive measures in
environmental sanitation taken by the panchayats under the decentralised
set up, there is no program for screening people at risk of contracting non
communicable diseases. Only some sporadic initiatives have been taken
in this regard. Worth mentioning here is the program of screening all
women in the reproductive age group for cervical and breast cancer in the
backward four districts in the north of Kerala. Another such initiative is for
screening the entire population of a block near the capital of the state for
hypertension and cardiovascular problems. Such sporadic initiatives are
not enough for a state that has an ageing population who are at greater
risk of non-communicable diseases. According to 1991 Census 8.81 per
cent of Kerala's population are above 60 and above 74 are 1.96 per cent.
Both are the highest in the country. These figures are expected to go up
substantially as the population growth in shrinks further. Many of them are
going to suffer from terminal diseases like cancer. Taking care of the
terminally ill is going to be another problem. Usually these terminally ill
patients are either taken to the hospital or hospice or allowed to die at
home. But the degree of care they get at either place leave many things to
ixi
H
be desired. The people would nc'mally like to spend their last days at
home with their family. But the members of the family have to be trained
to take care of them and administer pain-relieving drugs. One such
program has been launched in the state. The program consists of enlisting
volunteers, giving them intensive training and sending them to the homes
of the terminally ill where they acminister the pain relievers, console the
patients and train the family memoers to care for them. Rules have been
liberalised to make oral morphine, which is a narcotic drug but which is
the best pain reliever, easily available to these patients. The Scheme was
started with the medical college hospital, Calicut as the hub and has been
spread to other districts. There.are now 26 satellite centres and more than
4000 patients on their roles. Hosoitals are also encouraged to take the
patients when they need it. This has been found to be better than a
hospice approach.
Conclusion
The experience of Kerala is one of health empowerment of the people.
That is the route for health for all. This paper has attempted to describe
the characteristics of the state which make it a unique case of good health
at low cost. In trying to find the reasons for such a development we saw
that literacy has played a major role. But the spreading of literacy was a
result of not only political decision by the rulers but also of public action
for upliftment of the backward classes, the demand for agrarian reforms
and political awakening. These and other characteristics like Christian
missionary influences, indigenous medical system with its emphasis on
preventive care and food subsidies are shared by Kerala with other
regions of the world that have achieved good health at low cost like Sri
Lanka, China and mostly with Costa Rica. Public action has facilitated and
was complemented by a good network of health infrastructure m the public
sector. The state is one of the best in the country on utilisation of the
public sector and the best on the incidence of public subsidies on the
poor. Recently there has been a burgeoning of the private sector. Public
and private sectors in all the systems of medicine put together have given
the state a very high bed to population ratio. With their dual characteristic
of NGO like behaviour by some and profit motive by many, the private
sector has contributed to curative care, though it has added to the cost of
health care. Migration to the Middle East in the last 30 years has brought
in extra income to the people, which supports the private sector. It has
also helped accelerate demographic changes among the population.
Though the public sector is quite equitable and, judged by its utilisation,
fairly efficient, it is plagued by shortages and inadequacies. But the sector
that requires the most immediate attention is the pockets of deprivation
people like scheduled tribes, coastal fishermen and Tamil migrant labour.
Resource crunch is the major problem faced by the public sector. The
initiatives taken by the state in resource mobilisation and cost recovery
are not insignificant. Nurtured properly, these initiatives will show the way
for sustaining the system against declining resources. On the manpower
] S2
u
side, the greatest problem is the private practice by government doctors.
It has affected the quality of service, contributing to absenteeism and
neglect of duties. There is heavy under utilisation of inpatient facilities of
PHCs. The question of continuing the inpatient facilities in Mini PHCs has
to be examined. Permitting local administration to recruit doctors on
contract basis, giving the incentive of post graduate seats to doctors
serving in difficult rural areas and breaking up the cadre of doctors into
specialists and administrators have helped in mitigating the problems of
manpower. But there is a large number of vacancies of paramedics, which
needs to be addressed.
In the last five years, the state has devolved powers on locally elected
governments and handed over, among other things, the health facilities to
them. This has been preceded by a massive campaign of advocacy and
training. Funds have also been given to them for managing the work in
each sector. This is a successful experiment and most of the problems of
the public health facility get solved at the local level. It has been a great
step forward not only in democracy but also in efficiency. The health plans
formulated by the Local Self-Governments very often empnasise
preventive care, sanitation, mosquito control, water supply etc. Though
devolution is mandated by the Constitution, many states have not taken it
seriously. It is time they did. Similar community participation has been
brought in by the Neighbourhood Groups. These women's groups have
proved to be a good experiment in self-help.
Some other recent initiatives worth noting are a simple and cost effective
mechanism for disease surveillance and the scheme for taking care of the
terminally ill. The lesson that is thrown up by the Kerala case is that
literacy, especially of the female is the prime prerequisite for health
empowerment of the people. Unfortunately, this lesson does not appear to
have been learned and put in oractice as the female literacy figures of
Census 2001 show. Literacy will result in public action and will create
demand for health care and the elected governments will have to rise up
to this demand by providing better health care.
1'.-
u
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u
APPENDIX-List of Tables
1. Percentage of Villages and Availability of Different Fadiities by States.
2. Per Capita Net Domestic Product - India and Kerala
3. Compound Annual Rates of Growth of Per-capita Net Domestic Product in Kerala and India, 1970-1 to 1991-2.
4. Percentage of Population Below Poverty Line-India and States.
5. Crude Literacy Rate - India and States.
6. Kerala: Educational Record.
7. Selected Indicators of Development - Kerala and some Asian Countries.
8. Human Development Index - India and Major States.
9. Per Capita Expenditure on Education - All States.
10. Kerala : Institutions and Beds in Different Systems in Public and Private.
11. Share of Education and Health Expenditure in Total Government Expenditure: Travancore and Cochin.
12. Trends in Government expenditure in medical and public health and related variables,Kerala
13. Per Capita Public Expenditure on Medical and Public Health Care - All States.
14. Beds per 10,000 Population in Public Hospitals - India and States.
15. State-wise Distribution of Population and Medical Care lnstitutions-1991.
16. Distribution of Inpatient Days between Public and Private Facilities Kerala
17. Performance in Immunisation - Kerala
18. Distribution of Net Public Sector Health Subsidies for Quintiles - India and Kerala
19. Caesarean Section Rates - A Comparison
20. Annual per capita medical expenditure by socio-economic status 1987 and 1996 - Kerala
21. Workers Remittances to Kerala
22. Prevalence Rates of Major Morbidity by States
23. Some common causes of mortality in Kerala, from the KSSP in 1987 & 1996.
24. Affliction and death due to principal communicable diseases - Kerala
25. Trend in Development Expenditure 1990-91 and 1994-95 to 2001-02 , Kerala
26. Collection of User Fees and Cost Recovery Ratio - Major States
27. Receipt and Expenditure of Regional Cancer Centre Trivandrum.
i
28. Financing Pattern of Projects implemented by Local Self Governments Kerala 1999-2000
)
187
u
Table 1
Percentage of Villages and Availability of Different Facilities by States
Transportation
Region/States
Communication
Bus Railway
Connected
Stop Station
with Pucca
Within Within
Road
5 km
5 km
Major Sources of Drinking Water
Post
Office
Within
2 km
Tele
phone
within
2 km
Piped
Water
Unpro
Other
Hand
tected
Protected
Pump
Sources
Water
of Water
North
Haryana
Himachal Pradesh
Punjab
61.1
23.8
81.4
76.7
61.9
68.6
25.6
4.8
21.4
77.8
68.3
78.6
55.6
54.0
65.7
32.2
61.9
34.3
12.2
0.0
48.6
13.3
1.6
0.0
42.2
36.5
17.1
Upper Central
Bihar
Uttar Pradesh
19.0
34.3
42.2
44.4
32.8
23.6
74.1
65.3
37.9
35.2
0.0
6.0
32.8
20.4
3.5
13.0
63.8
60.7
21.2
40.1
44.1
53.8
11.5
62.8
13.2
41.9
53.9
68.9
37.8
36.3
42.5
2.8
0.0
9.4
3.2
5.9
13.2
6.9
0.0
2.8
87.1
94.1
74.5
14.1
63.6
56.4
15.2
35.9
63.6
79.5
28.8
47.4
3.0
2.6
3.0
59.0
3.0
0.0
90.9
38.5
West
Gujarat
Maharashtra
54.6
45.0
85.2
81.5
27.3
15.2
79.6
64.2
68.2
60.9
47.7
24.5
5.7
6.6
33.0
35.8
13.6
33.1
South
Andhra Pradesh
Karnataka
Kerala
Tamil Nadu
All India
44.3
25.9
85.3
40.8
36.8
92.0
85.9
94.7
93.4
64.5
15.0
11.9
26.7
30.3
22.4
94.7
76.3
94.7
92.1
70.2
58.4
62.2
80.0
85.5
50.9
8.9
22.2
10.7
52.6
16.6
15.0
51.9
0.0
26.3
18.4
17.7
3.7
62.7
11.8
13.0
58.4
22.2
26.7
9.2
52.0
Lower Central
Madhya Pradesh
Orissa
Rajasthan
East
North-eastern Rg.
West Bengal
15.7
40.6
21.2
Source : Shariff. A (1999)
ISS
I i
Table 2
Per Capita Net Domestic Product - India and Kerala
at 1980 - 81 Rupees
Year
India
Kerala
1980- 81
1981- 82
1982- 83
1983- 84
1984- 85
1985- 86
1986- 87
1987- 88
1988- 89
1989- 90
1990- 91
1991- 92
1992- 93
1993- 94
1994- 95
1995- 96 (P)
1996- 97 (Q)
1625
1692
1699
1804
1827
1857
1893
1929
2099
2198
2267
2226
2298
2386
2522
2644
2793
1508
1469
1485
1406
1473
1507
1453
1482
1614
1705
1815
1826
1932
2043
2113
NA
NA
Sourse: Reserve Bank of India (1999) Hand book of statistics on Indian Economy (for India)
Government of Kerala Department of Economics and statistics -Bullettin for various years
( for Kerala)
The figures are in two series, 80-81 and 93-94. The latter has been reduced to 80-81 for
the purpose of comparrision.
P - Provisional, Q- Quick estimates
Table 3
Compound Annual Rates of Growth of Per-capita Net Domestic Product
in Kerala and India, 1970-1 to 1991-2 ( percentages)
Time Period
Kerala
India
1970-1 to 1980-1
0.06
1.39
1980-1 to 1990-1
1.4
3.25
1986-7 to 1991-2
6.16
3.79
Note: The figure represents two separate series: one for percapita domestic product
at constant 1970-1 prices for the period 1970-1 to 1986-7, and one for percapita
domestic product at constant 1980-1 prices for the period 1980-1 to 1991-2
Source: Ramachandran (1996)
I
IS9
u
Table 4
Percentage of Population below Poverty Line - India and States
Official Estimates
India / States
India
Average Annual
Change(%)
Expert Group Estimates
Average Annual
Change (%)
1977-8
1983-4
1987-8
1977-83
1983-7
1977-8
1983-4
1987-8
1977-83
1983-7
48.0
37.0
30.0
3.8
4.7
51.8
44.8
39.3
2.3
3.1
43.6
47.3
56.3
N.A.
38.9
25.2
27.0
50.8
48.4
58.9
506.0
65.1
16.4
33.6
52.8
49.7
52.2
36.4
23.5
49.5
N.A
24.3
15.6
13.5
35.0
26.8
46.2
34.9
42.8
13.8
34.3
39.6
45.3
39.2
31.7
22.8
40.8
N.A
18.4
11.7
32.1
17.0
36.7
29.2
44.7
7.2
24.4
32.8
35.1
27.6
2.8
8.4
2.0
N.A
6.3
6.3
8.3
5.2
7.4
3.6
5.2
5.7
2.6
-0.3
4.2
1.5
4.2
3.2
0.7
4.4
NA
6.1
6.3
8.0
2.1
5.1
4.1
-1.1
12.0
7.2
4.3
5.6
7.4
40.0
57.6
62.0
33.1
42.2
29.5
32.5
49.5
52.9
62.4
56.1
70.4
19.4
38.0
56.3
49.2
60.7
29.9
40.9
62.5
26.8
33.3
21.2
16.4
38.5
40.9
50.1
43.6
65.3
16.3
35.0
524
47.2
54.7
27.2
36.8
53.4
16.0
32.3
16.6
15.5
38.1
32.1
43.4
40.1
55.6
12.7
34.6
45.1
42.0
4.2
4.8
-0.1
3.2
3.5
4.7
8.3
3.7
3.8
3.3
3.7
2.3
2.5
3.6
10.1
0.8
5.4
1.4
0.3
5.4
3.3
2.0
3.7
5.5
0.3
3.5
2.8
4.9
NA
NA
NA
NA
NA
N.A
N.A
NA
N.A
NA
NA
NA
NA
N.A
N.A
NA
N.A
NA
NA
NA
NA
NA
NA
NA
NA
56.6
27.6
37.3
54.1
55.5
52.7
23.9
157
43.5
45.2
12.9
18.7
37.3
44.7
States
Andhra Praoesh
Assam
Bihar
Delhi
Gujarat
Harayana
Himachal Pradesh
Karnataka
Kerala
Madhya Pradesh
Maharashtra
Orissa
Punjab
Rajasthan
Tamil Nadu
Uttar Pradesh
West Bengal
’9.2
9.1
44.0
1.2
2.7
1 3
1.2
07
1 6
Union Terntones
Andaman & Nicobar
Chandigarh
Dadra & Nagar Havel i
Lakshadweep
Pondecherrv
51 4
1.1
2.2
9.7
3.3
3.6
11.5
-4 8
3.6
3.3
1.2
Note: The official estimate is based on the aggregate private household consumption expenditure as estimated by the National Accounts Statistic
of the Central Statistical Organisation. The expert group estimates is based on NSS Consumer Expenditure Distnbutions.
Source: Srinivasan and Shariff (1997)
N.A. = Not available
190
u
Table 5
India/States/Uts
India___________
States__________
Andhra Pradesh
Arunachal Pradesh
Assam__________
Bihar___________
Delhi____________
Goa____________
Gujarat__________
Haryana_________
Himachal Pradesh
Karnataka________
Kerala__________
Madhya Pradesh
Maharashtra
Manipur_________
Meghalaya_______
Mizoram_________
Nagaland________
Orissa___________
Punjab__________
Rajasthan________
Sikkim___________
Tamil Nadu_______
Tripura__________
Uttar Pradesh_____
West Bengal______
Jharkhand*_______
Uttaranchal*______
Chhatisgarh*______
Jammu & Kashmir**
Union Territories
Andaman & Nicobar
Chandigarh_______
.akshadeep______
Pondicherry
Crude Literacy Rate- India and States
Persons
F/M Ratio
Scheduled Castes
Persons F/M Ratio
1991
2001
1991
1991
1991
42.9
65.38
60.8
30.1
47.3
36.8
32.8
30.6
62.4
66.6
51.2
45.2
53.5
46.7
78
35.5
53.8
49.9
38.2
67
51.1
40,8
49
33.1
46.5
54.3
49.5
33.2
47.9
61
66.2
66.8
64.5
61.11
54,74
64.28
47,53
81.82
82.32
69.97
68.59
77,13
67 04
90,92
64,11
77.27
68.87
63.31
88.49
67,11
63.61
69.95
61.03
69.68
73.47
73.66
57,36
69,22
54,13
72,28
65,18
54.46
81.18
81.76
87.52
81.49
Scheduled Tribes
Persons
F/M Ratio
1991
1991
23.6
44
59.3
55.7
25.9
46.2
49.8
56.6
13.6
28.9
34.2
57
43
71,6
80.2
66.6
58.4
69.5
65.9
93.1
49.1
67,7
66.2
83.7
90.8
79.1
54,9
77
37.1
67
69.9
70
44,8
67.9
15.1
45.7
49.8
50.5
30.8
43.7
30.7
69.4
27.7
45.9
46.8
35.5
71,5
N.A.
30.2
33.4
20.6
41,2
39.5
45.5
21.1
34.3
22.7
62
68.2
60.5
45.9
63.2
52.2
88
35.6
58.9
73.1
54.7
74.7
N.A.
39.6
61.9
19.5
72
59.9
67.2
25.8
52.5
21.4
N.A.
33
29.7
N.A.
38.7
29.2
48.6
16.9
29.4
44,8
36
66.9
50
18.1
N.A.
15.3
48.4
23.4
32.3
28.4
22.4
38.2
N.A.
49.7
49.9
N.A.
49.9
49.1
81.1
33.3
48.8
71,1
87.8
91.1
81.2
29.7
N.A.
13.2
74,4
57.4
51.4
39.1
37.2
53.6
76.2
71,8
75.4
N.A.
44,6
N.A.
47.1
N.A.
64.9
N.A.
70.3
47
N.A.
65.2
N.A.
76.8
N.A.
81.3
N.A.
Note: * Jharkhand, Chhatisgarh & Uttaranchal are new states formed in 2000.
** The other figures of Jammu & Kashmir are not available.
Source: Sreenivasan & Shariff (1997) for all columns except for 2001
The figures for 2001 are from Census of India 2001 - Provisional Population Totals released by
Director of Census Operations, Kerala.
191
u
Table 6
Kerala: Educational Record.
1961
Literacy (% of population above & years of
age)
1991
1961
Literacy among Scheduled Castes (ex
untouchable communities)
Age group
6-11
Literacy among children
Age group
12-14
Class I to
IV
Dropout Rates (%)
Class I to
_________________________ X
Percentage of rural childrn aged 12-14 who
have never been enrolled in a school
Proportion of persons aged 6 and above who
have completed primary education
5-9 years
Proportion of rural children
attending school
10-14 year
Proportion of readers in the estimated adult
________ population (Any Daily)________
Proportion of readers in the estimated adult
______ population (Any publication)______
Proportion of readers among agricultural
labourers (Any publication)
I
1991
1986-87
1986-87
1993-94
1993-94
1986-87
1992-93
1987-88
1987-88
1989
M
F
M
F
M
F
M
F
M
F
M
F
M
F
M
F
M
F
M
F
M
F
M
F
M
F
1989
1989
M
F
M
F
KERALA
55
38.9
94.5
86
31.6
17.4
85.2
74,3
97.4
97.4
99.5
99.1
-5.35
-3.05
33.43
24.51
0.4
1.8
65.8
60,5
86.9
82.8
93.3
91.2
53.4
35.8
63.3
54,2
45.9
11.9
INDIA
34.3
12.9
63.9
39.4
17
3.3
49.9
23.8
64,7
48.9
75.3
54.5
35.05
38.57
68.41
74,74
26
51
48.6
28.1
52.5
40,4
66.1
41,9
23.6
11.5
26.6
15.4
3.1
0.7
Source : Kannan ( 1999)
192
u
Table 7
Selected Indicators of Development for Kerala and Some Asian Countries.
Country /
State
GDP Per
HPI
Population
Capita
value
(million)
PPSS
(%)
1994
1994
1996
Population
below
International
Poverty line
1985 (one PPS
$ /day)
Female
Literacy
Rate (%)
1994
Gross
enrolment
ratio (1995) in
Secondary
Schools
Life
Expectancy
Year 1994
Total
Fertility Rate
IMR
1994
1
2
3
4
5
6
7
8
9
10
Kerala
30.5
1618
15.0
NA
86.3
103
71.7
1.8
13*
India
918.6
1348
36.7
52.0
39.0
49
61.3
3.0
74
Sri Lanka
18.1
3277
20.7
4.0
86.9
75
72.2
1.7
16
Thailand
58.2
7104
11.7
0.1
90.7
.55
69.5
18
29
Malaysia
19.7
8865
NA
5.6
77.5
57
71.2
3.4
12
Indonesia
194.6
3740
20.8
■14.5
77.1
48
63.5
2.5
53
China
1208.8
2604
17.5
29.4
70.9
67
68.9
1.8
43
* According to National Family Health Survey for 1998-99, the IMR for Kerala is 16.3
Notes: HPI: Human Poverty Index. This takes into account (l)the survival deprivation in terms of
people not expected to to survive to age 40,(ii) a composite index of deprivation in
economic provisioning indicated by (a)population without access to safe water.
(b)population without access to health services, and ( c) underweight children under
the age of five.
Source: Kannan,1999.
)
193
Table 8
Human Development Index-lndia and Large States,1993
India/States
India___________
Andhra Pradesh
Assam__________
Bihar___________
Gujarat__________
Haryana_________
Himachal Pradesh
Karnataka_______
Kerala___________
Madhya Pradesh
Maharashtra_____
Orissa___________
Punjab__________
Rajasthan________
Tamil Nadu______
Uttar Pradesh
West Bengal
Source:
Life
Expectency
1989-93
59.3
60.5
54.9
58.5
60
63.1
63.6
61.8
71.8
54
64.2
55.5
66.3
57.9
62.4
55.8
61.5
Index of Life
Expectency Adult
Literacy
(li)
Rate,1991
57.23
59.14
49.89
55.85
58.36
63.43
64.33
61.36
78.01
48.26
65.27
50.84
68.88
54.87
62.31
51.41
60.83
48.7
40.1
49.4
38.7
56.7
49.9
50.9
52.2
86
41.8
60.3
46.4
51.8
36.1
50.6
38.4
57.1
Middle
School
Enrolment
Ratio,1993
Index of
Literacy
(l2)
Human
Per Capita Index of Development
SDR,1993 SDP (l3)
Index
59.1
56
53.4
32.9
67,7
68.6
100
67
100
55
81
50
65.6
46.2
103.4
46.6
53.1
52.16
45.38
50.72
36.76
60.38
56.12
67.27
57.12
90.85
46.19
67,39
47,6
56.41
39.48
68.19
41.14
55.75
6255
5718
5310
3084
7175
9171
5979
6443
5768
4733
9628
4097
11106
5086
6663
4273
5775
19
19.33
17.81
9.56
24.73
32.13
20.29
22.01
19.51
15.67
33.82
13.32
39.3
16.98
22.83
13.97
19.54
42.79
41,28
39.48
34,05
47,82
50.56
50.63
46.83
62.79
36.71
55.49
37.25
54.86
37,11
51.11
35.51
45.37
Srinivasan and Shariff 1997)
Notes of Authors: Index of e{ )(!!)=((( Percent males*e( > (males)+Percent females‘e(} (females))-25)/60’100
Index of education(l2)= (2* Adult literacy rate(%)+ Middle school enrolment ratio)/3*100
index of per capita income(l3) =
(i( State net domestic product / net domestic product of country)*1240)-100)/5348*100
HDI^h+^+hyS.
N4
•*
H
Tane9
Per Capita Expenditure on Education - All States
S. Na
1
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
State
2
Andhra Pradesh
Zvunachal Pradesh
Assam
Bihar
Delhi
Goa
Gujarat
Haryana
Himachal Pradesh
Jammu & Kashmir
Karnataka
Kerala
Madhya Pradesh
Maharashtra
Manipur
Meghalaya
Mzaram
Nagaland
onssa
Punjab
Rajasthan
Sikkim
Taml Nadu
Tripura
Uttar Pradesh
Wast Bengal
All States
1980-81
Edu.
3
43
54
34
53
57
105
73
47
85
33
61
143
77
163
41
83
43
133
50
81
32
45
47
1990-91
Edu
4
1994-95
Edu
5
1295-96
1996-97
Edu.
1997-98
Edu.
o
7
8
9
10
11
171
592
221
142
240
718
361
181
385
793
356
303
521
442
306
443
193
361
668
464
929
763
242
359
307
890
333
509
194
247
278
239
"92
296
212
275
1047
419
238
536
1038
450
406
697
591
391
528
262
489
960
587
1317
811
312
467
398
1246
425
633
248
325
357
307
1083
462
265
695
1277
496
456
859
663
439
569
267
556
1062
645
1243
860
346
574
423
1288
485
677
265
334
395
384
1069
535
266
819
1397
667
643
1092
669
524
625
337
599
865
739
1288
895
420
748
538
2235
645
737
351
395
477
460
1167
825
427
896
1599
707
640
1058
883
557
796
325
1042
1801
914
1794
973
496
888
583
2250
693
1036
356
635
595
541
1175
927
435
1067
1413
714
660
1187
962
692
870
320
759
1178
1012
1370
1048
484
919
617
2614
749
1160
333
469
579
653
226
202
385
293
187
269
.141
222
438
379
704
461
171
281
196
717
201
418
154
218
190
940
419
360
630
509
354
464
229
'39
34
'365
928
275
415
352
1012
374
566
267
316
1998-99 1999-00 R.E| 2000-01 B.E
Edu.
Edu.
Edu.
RE
Revised budget Estimates,
BE Budget Estimates
Source: Government of Kerala. Budget in Brief 2001-2002
195
u
7 = oie10
Kerala: Institutions and Beds in Different Systems in Private and Public
Government
(2000)
Private (1995)*
Total
1317
4568^
4288
67517
5605
113201
792
2604
3
4922
2595
2
5714
5199
5
555
970
2
3118
394
3
3673
1364
5
8
290
418
298
418
Allopathy
Institutions
Beds
Ayurveda
Institutions
Beds
Colleges
Homeopathy
Institutions
Beds__
Colleges
Other Systems
Institutions
Beds
Total__________
Institutions
Beds_______
Population(2001)
Beds/Population
Beds per 100,000
2672
-9258
12618
70924
15290
120182
31.838.619
1:265
377
Source: Government of Kerala: Economic Review2000
* Data for 1995. ( Survey undertaken by Economics & Statistics
Department of Govt, of Kerala.)
Table 11
Share of Education and Health Expenditure in Total Government
Expenditure: Travancore and Cochin
Period
1867-78 to 1869-70
1870-79
1880-89
1890-99
1900-09
1910-19
1920-29
1930-39
1940-01 to 1942-43
Share of Education
Share of health
Travancore
Cochin
Travancore
Cochin
I. 90
0.90
1.50
2.80
4.20
4.20
10.90
16.50
18.10
17.30
N/A
1.80
1.50
3.20
4.10
4.00
4.50
5.30
4.60
N/A
N/A
1.7
2.6
3.4
7.9
5.4
6.3
6.9
2.70
3.40
4.60
6.30
II. 10
18.30
19.80
16.10
Source : Ramachandran (1996)
196
h
Table 12
Trends in Government expenditure in medical and public health and related variables,Kerala
Year
Govt,
Net State
exp. on
domestic
Index
Total State Index No.
Index No.
Medicine
product
No.1957-58- Government 1957-58 1957-58 and
at
100
expenditure
100
100
Public
current
Health
prices
1957- 58
1958- 59
1959- 60
1960- 61
1961- 62
1962- 63
1963- 64
1964- 65
1965- 66
1966- 67
1967- 68
1968- 69
1969- 70
1970- 71
1971- 72
1972- 73
1973- 74
1974- 75
1975- 76
1976- 77
1977- 78
1978- 79
1979- 80
1980- 81
386
445
501
541
627
755
769
843
981
1137
1427
1581
1684
1943
2635
2813
2995
3970
4627
5240
5051
3630
6865
7879
Growth
rate %
13.04
100
115
130
140
162
196
199
218
254
295
370
410
436
503
683
729
776
1029
1199
1358
1309
940
1779
2041
Source iPanikar and Soman (1984)
3051
3572
4010
4474
5491
6076
6447
6749
7281
7951
9981
11116
12354
13700
16197
17688
20726
24070
30575
34121
37224
42725
50020
54272
12.45
100
117
131
147
180
4 99
211
221
239
261
327
364
405
449
531
580
679
789
1002
1118
1220
1400
1639
1779
36691
39367
43136
46215
49420
52000
55693
67626
16601
88667
100210
103000
114178
118336
121047
139726
174621
202944
213131
227065
240576
261832
9.81
100
107
118
126
135
142
152
184
209
242
273
281
311
323
330
381
476
553
581
619
656
714
Percent of Govt,
expenditure on
Medical & Public
____ Health
Total
State
State
Domestic
Govt.
Product
exp.
12.65
12.45
12.49
12.09
11.41
12.43
11.92
12.49
13.47
14.30
14.29
14.22
13.63
14.18
16.27
15.90
14.45
16.49
15.13
15.35
13.57
8.49
13.72
14.52
1.05
1.13
1.16
1.17
1.27
1 45
1 38
1.25
1.28
1.28
1 42
1.53
1.47
1.55
2.10
1.94
1.66
1.96
2.13
2.22
2.09
1.39
I
Table 13
Per Capita Public Expendfture on Medical and Public Health Care - All States
State
2
Andhra Pradesh
Arunachai Pradesh
Assam
Bihar
Delhi
Goa
Gujarat
Haryana
Himachal Pradesh
Jammu & Kashmir
Karnataka
Kerala
Madhya Pradesh
Maharashtra
Manipur
Meghalaya
Mzaram
Nagaland
orissa
Punjab
Rajasthan
Sikkim
Tarril Nadu
Tripura
Uttar Pradesh
West Bengal
All States
1980-81
Health
3
1990-91
Health
4
1994-95
Heath
5
1995-96
Health
6
1996-97
Health
7
1997-98
Health
8
23
52
225
51
39
79
299
80
53
149
290
94
81
211
196
97
113
63
90
143
158
335
263
64
106
98
320
106
120
61
73
83
66
288
73
36
83
384
80
42
204
374
98
85
236
245
91
124
65
103
160
206
464
385
65
121
101
466
116
144
59
85
88
93
420
88
43
240
399
117
103
268
262
115
139
68
113
165
223
436
407
70
153
111
414
130
136
74
89
99
22
14
26
31
84
84
19
32
23
27
98
120
197
22
32
33
81
23
31
14
26
24
254
61
60
145
137
62
90
49
68
111
165
171
255
59
91
62
250
66
108
40
73
59
318
88
72
195
207
84
109
53
88
151
154
324
314
56
121
85
332
99
104
52
72
75
1998-99
Health
9
199000
R.E
Health
10
200001 B
E
Health
11
110
441
76
49
273
472
160
134
354
285
138
156
96
122
177
264
434
425
92
206
134
739
160
141
65
129
117
144
582
107
77
349
514
185
131
356
404
156
204
89
156
319
280
715
414
94
278
140
678
166
166
76
152
139
155
574
116
77
443
518
164
151
372
460
168
198
87
154
214
339
518
418
115
301
147
679
176
182
77
178
146
cvemrrent of Kerala: Budget in Brief2001-2002
I9X
Table 14
Beds per 10,000 Population in Public Hospitals - India and States
’ndia/States/Uts
1981
Rura
1986
1991 I 1981
Urban
1986
1991
1.2
1.3
1.9
25.6
24.9
Assam
Bihar
Delhi
Goa
Gujarat
Haryana
Himachal Pradesh
Jammu & Kashmir
Karnataka
Kerala
Madhya Pradesh
Maharashtra
Manipur
Meghalaya
Mizoram
Nagaland
Orissa
Punjab
Rajasthan
Sikkim
Tamil Nadu
Tripura
Uttar Pradesh
West Bengal
0.8
5.7
NA
0.1
1.4
0.0
0.6
0.4
1.0
0.1
1.0
10.5
0.3
1.2
3.7
0.3
8.6
9.7
0.8
2.4
0.3
8.6
1.1
0.8
0.3
2.2
0.8
4.6
1.4
0.4
I. 7
II. 0
1.1
0.4
1.2
0.6
1.0
12.0
0.3
1.6
3.2
0.2
0.0
5.1
1.0
2.7
0.4
0.0
1.4
0.8
0.3
1.8
2.0
21.9
2.0
0.4
19.5
2.5
0.4
1.1
13.7
1.0
20.6
1.2
2.1
6.9
0.0
5.3
2.6
1.2
1.6
0.3
0.0
1.2
1.4
0.2
1.5
.23.7
107.7
NA
25.2
22.2
0.0
28.9
24.0
74.1
30.8
25.2
44.9
14.2
28.6
21.5
58.9
27.7
36.8
28.3
24.2
22.0
39.2
22.9
45.1
21.1
26.0
Union Territories
Andaman & Nicobar
Chandigarh
Dadra & Nagar Havel
Lakshadeep
Pondicherry
21.1
0.0
4.0
23.1
0.4
18.6
9.7
4.5
30.0
0.0
8.0
0.0
0.0
0.0
0.0
58.8
26.5
0.0
0.0
71.4
India
1981
Total
1986
1991
21.8
7.0
7.3
7.0
21.8
84.7
36.4
23.8
21.8
49.4
30.2
18.8
91.7
48.1
22.7
45.2
14.4
32.5
20.6
65.2
56.9
38.2
24.6
21.1
20.7
69.6
21.9
44.8
17.8
27.5
9.7
74.3
35.0
23.0
21.9
47.9
36.6
16.0
74.7
0.8
25.1
43.1
7.8
22.5
12.6
56.6
34.8
38.1
26.1
20.6
19.3
155.4
23.3
33.1
16.2
25.3
6.1
12.3
NA
3.2
20.7
0.0
9.4
5.5
6.5
6.6
8.0
16.9
3.1
10.8
8.4
10.9
13.3
13.9
4.1
8.5
4.8
13.5
8.3
5.7
4.0
8.5
6.2
11.0
5.3
3.6
20.6
24.5
10.6
4.9
8.4
11.3
7.8
18.6
3.4
13.1
8.1
13.5
16.7
11.4
4.3
8.2
5.1
13.8
8.5
5.7
3.8
11.8
4.0
28.6
5.6
3.4
19.9
31.2
14.3
4.3
7.4
10.6
8.4
26.5
2.7
10.0
8.5
10.5
18.9
8.7
4.6
7.2
4.7
14.1
8.7
6.3
3.4
8.0
61.9
22.9
0.0
0.0
61.3
55.0
8.7
59.7
24.0
50.4
31.0
24.8
3.8
12.4
37.5
30.9
22.2
4.2
16.1
35.0
20.5
7.8
5.1
13.5
32.3
States
Andhra Pradesh
Arunachal Pradesh
2.7
Source : No. of beds has been taken from Health Information of India, 1993,Directorate of Health
Services,Ministry of Health & Family Welfare ;
Population of 1981 & 1991 has been taken from Census of India 1981 & 1991.
Population of 1986 is projected population by Expert Committee.
NA = Not Available
199
Table 15
State-wise Distribution of Population and Medical Care Institutions : 1991
States
1
2
3
4
Andhra Pradesh
Assam
Bihar
Gujarat
Haryana
Jammu & Kashmir
Karnataka
Kerala
Madhya Pradesh
Maharashtra
Orissa
Punjab
Rajasthan
Tamil Nadu
Uttar Pradesh
West Bengal
All India
665.08
224.14
863.74
413.1
164.04
77.19
449.77
290.99
661.81
789.37
316.6
202.82
440.06
558.59
1391.12
680.78
8463.03
141
141
237
263
58
65
209
141
363
495
250
174
218
282
534
242
4235
2554
9687
20522
20708
4796
3062
2716
28030
18141
34261
13077
10786
20465
37935
34267
47252
365696
Source
Medical Care
Institutions (1 992)
Pvt.
No. of
Govt.
Population
Hospital
Hospitals
Beds
Hospitals Beds
5
6
1722
80
90
2031
20
2
56
1899
24237
1992
8519
33497
2232
187
9999
49169
2583
29
39
37758
1306
3782
119
159
129
9113
10366
12026
6912
210987
Total
Hospitals
Population Coverage of
Health Care Facility
Rates of Population to
Hospitals(Col. 2 to 7)
7
8
1863
268
328
2370
78
67
293
2040
363
3115
248
217
218
408
735
592
13692
35.099
83.635
2.63.337
17,430
2.11,070
1.15.204
1.53.507
14.264
1.82.317
2.53.41
1.1 1,478
93,465
2.01,862
1.36.909
1.89.268
1,73.668
61.810
Panikar (1999)
Table 16
Distribution of Inpatient Days between Public and Private Facilities
Kerala
Public Share Private Share
Percentages
Poverty Status
BPL
APL
Social Status
Non SC/ST
SC/ST
Expenditure Quintiles
I
II
III
IV
V
Total ('00,000s)
Total ('00,000s)
61.30
46.40
38.70
53.60
56.20
190.40
45.50
73.50
54.50
26.50
209.20
37.40
58.50
64.40
50.70
42.80
41.50
122.80
41.50
35.60
49.30
57.20
58.50
124.00
39.20
41.30
39.70
50.10
76.60
246.80
BPL: Below Poverty Line
APL: Above Poverty Line
Source: Mahal et al. (2000)
200
Table-17
Performance in Immunisation - Kerala
Year
BCG
DPT
Polio
Measles
TT( Preg.W)
1993- 94
1994- 95
1995- 96
1996- 97
1997- 98
1998- 99
1999- 00
108.7
114,7
109.5
107.9
116.9
116.5
111.9
99.5
106.6
101.5
101.8
108.6
108.8
105.8
99.3
108.4
104,5
103.2
109.7
110.5
106.9
88.3
96.5
90.3
91.5
95.7
102.6
100.3
91.4
94,2
87.8
87.1
89.5
90.8
94.5
X
Source : Government of Kerala, various tables.
Table 18
Distribution of Net Public Sector Health Subsidies for Quintiles - India and Kerala
States
Per capita
expendure
on health 9596
Per capita expenditure Quintiles
Social Status
I
II
III
IV
V
BPL
SC/ST
Kerala
109
21.9
23
18.2
17.2
19.7
30.9
21.1
Punjab
121
14.7
17.1
18.5
27.6
22.2
2.9
44.1
Himachal
Pradesh
195
7.5
11.4
13.4
23.9
43.8
7.2
31.5
All States
75
10.2
14.1
18.7
26
31
26.9
28.7
Source : Per Capita Expenditure on health from Government of Kerala Budget in Brief 2001-2002
All the others from Mahal et al (2000)
Note:
BPL : people below the poverty line
2')l
Table 19
Caesarean Secction Rates - A Comparison
Sample Size
% Caesarean
% Institutional
delivery
% Skilled
attendent at
delivery
Year
Egypt
Kenya
Madagascar
Malawi
Morocco
Namibia
Niger
Rwanda
Senegal
Uganda
Zimbabwe
6302
3989
2836
11454
6062
5604
4512
2235
3814
7094
5612
5581
6027
2328
1.3
1.8
1.9
6.6
5.2
1
3.4
3.5
7
0.9
1.8
2.3
2.6
6
43
45
50
33
44
45
57
37
67
16
25
47
35
69
41
45
46
46
45
57
57
40
68
15
26
47
38
69
1988-93
1992-94
1990- 95
1991- 95
1988-93
1987- 92
1988- 92
1990- 94
1987-92
1987-92
1987- 92
1988- 93
1992- 95
1991- 94
Latin America
Belize
Nordeste Brazil
Brazil
Brazil
Colombia
Dominican Republic
Ecuador
Guatemala
1490
3392
2864
4782
5050
3820
8837
9150
8.4
17.9
31.6
36.4
16.9
22
17.1
8.2
76
76
81
92
77
92
64
34
77
96
95
97
85
92
64
35
1986-91
1986-91
1981-86
1991-96
1991-95
1986-91
1989-94
1991-95
Asia
Indonesia
Phillipines
Kerala (rural)
Kerala (urban)
16983
8803
1314
103
2.5
5.9
11.9
21.4
18
28
78
97
34
53
90
99
1989-94
1988-93
1987
1996
Country
Africa
Burkina Faso
Cote d'Ivoire
Central African Republic
Europe
United Kingdom
Finland
Canada
North America
United States
____________
9
11.9
18.3
1985-90
1990-95
1989-90
22.8
1993
Source : Kunhikkannan and Arvindan (2000)
202
Table 20
Annual per capita medical expenditure by socioeconomic status 1987 and 1996 Kerala
Socioeconom
ic status
I
II
III
IV
All
Source:
Note:
Annual per capita expenditure in (Annual Expenditure as % of per
Rupees_________
capita income
1987
1996
% of increase 1987
1996 % of increase
54.99
42.11
126.33
160.8
88.92
477.26
467.26
538.27
569.49
548.86
768
1010
326
254
517
7.18
2.93
3.38
2.18
3.57
39.63
16.11
5.08
2.44
6.79
452
450
50
12
90
Kunhikannan and Aravindan (2000)
For classifying people into socioeconomic groups, income, size of the land owned,
educational attainment and housing condition, were taken into account
Table 21
Workers Remittances to Kerala
Year
Remittances
in US $ Million
Exchange
Rate
1990
1991
1992
1993
1994
1995
1996
1997
Total
728.63
1281.75
939.75
1155
1866
2401.5
3497.25
3339.75
15209.63
17.94
24.47
30.64
31.36
31.39
33.45
33.5
37.16
Total
Remittance
(Rs. Million)
Remittances
as % of NDP
of Kerala
13072
31364
28794
36221
58574
80330
124152
124105
496612
10.74
20.77
16.76
15.48
20.41
22.9
30.42
25.9
Source: Prakash (2000)
203
We 22
Prevalence Rates of Major Morbidty by States
Regons/States
Epilepsy
North______
Havana____
Punjab_____
Upper Central
Bihar________
Lttar Pradesh
Lower Central
rvtectya Pradesh
Crissa_______
Rajasthan
East________
North-eastern Ffa
Vtest Bengal
Vtest________
Gqarat_______
Maharashtra
South_______
AxtraFYadesh
Keraia_______
Tanl Nadu
All Inda
Person_______
Gender dspanty
i
Hypertension
Major Morbidty (per lakh pop.)
Diabetes
Heat
Mental
Disease
Disease
IB
Leprosy Cancer
Major
Morbidty
34
28
6,697
6,692
19
34
3,817
3,523
103
103
372
1,475
100
196
230
166
143
286
322
^0
78
120
481
221
143
158
443
231
169
120
496
370
74
369
60
366
863
64
138
116
55
160
245
84
136
99
79
686
206
303
313
31
57
74
37
4.801
5,011
3,150
50
133
732
1,049
226
207
502
795
105
151
189
636
74
22
127
32
3,076
6,168
103
147
381
241
215
130
188
151
160
84
276
282
30
65
7
62
2,551
3,487
129
81
205
1,295
1,433
1,191
545
980
377
676
914
^9
163
283
80
580
504
583
63
83
66
39
15
7,684
7,319
6.775
120
0.71
___
589
1.31
221
0.65
385
0.86
132
0.75
423
0.59
1.64
43
0.95
4578
1.00
29
27
57
Soiree: Shanff (1999)
Ta&le 23
Some CommonCauses of Mortality in Kerala, from the KSSP
Surveys in 1987 & 1996.
Cause of death
Heart attack
Cerebral Thromboj
Cancer
Accidents
Suicides
1 9 57
199 6
ra n k
%
ra n k
%
1
7
2
4
5
1 0.4
2.4
7.4
3.6
3
1
1
2
3
4
14 28
14.28
8.57
5.7
2.8
Source : Kunhikannan and Arv ~oan (2000)
204
Table 24
Affliction and death due to Principal Communicable Diseases - Kerala
Name of
Disease
a
r D
Diseases
inlcuding
Cholera
707246
21
656635
Diptheria
33
4
Measles
Acute
Respiratory
Infection
6107
1995-96
1996-97
A
D
1997-98
1998-99
A
D
1999-2000
A
D
A
PD
114
554695
34
580441
36
609936
25
4
0
7
0
18
1
4
0
1
7931
1
4930
0
6043
0
6433
2
3032563
139
3769791
164
4056142
183
7512989
507
5594351
1024
Pneumonia
21753
26
21299
26
21873
38
24590
47
23550
79
Enteric fever
(typhoid)
7749
6
5516
1
598
1
10739
1
15494
5
912
66
Leptospirosis
Japanese
Encephalitis
Menengococal
Menengitis
Pulminary
tubercolosis
105
31
61
8
co
13
133
0
29
1
98
7
65
10
39
4
69
4
244
10
42091
272
36922
243
33269
131
10419
123
36549
226
A: Affliction. D: Death
Source: Government of Kerala: various tables of Directorate of Health Services
205
Table 25
Trend in Development Expenditure 1990-1 and 1994-5 to 2001-2 , Kerala
Item
Share of Government Expenditure
g8.99 | 99.200Q | 2000-01
96-97 —
97-98
1990-91
94-95 | 95-96
Education
43.02
44.81
42.06
39.93
35.00
34.70
40.08
38.65
39.02
Health
15.45
14.31
14.61
13.22
12.60
12.32
13.37
12.29
11.97
-1.14
0.30
-1.39
-0.62
-0.28
1.05
-1.08
-0.32
Deviation points
01-02
Rs. Million
2785
4316
4986
5353
6341
6949
8704
8953
9212
Agriculture
8.75
11.49
11.40
11.73
11.44
10.91
9.89
9.78
9.84
Community
Development
16.95
13.55
13.43
17.36
24.48
25.90
20.97
23.39
21.90
Industry and
labour
4.02
4.39
4.63
4 98
4.27
3.40
3.33
3.44
3.02
Irrigation
3.57
j 3.44
3.57
2.86
| 2.21‘
2.61
2.34 J
2.10
|
2.34
Public Works
3.45
3.04
4.11
3.75
3.37
3.52
3.77
3.60 j
4.85
Forests
1.72
I 2.24
2.10
2.15
1.58
1.85
1.94
2.42
2.20
’ransport &
Communication
other than
roads)
0.39
0.35
0.33
0.32
0.30
0.29
0.31
0.34
0.34
Housing and
Urban
Development
0.91
1.25
1.24
2.92
3.27
3.36
2.96
3.03
3.57
Others
1.77
1.14
2.52
0.77
1.47
1.16
1.05
0.96
0.96
Total in Rs.
Million
18026
30154
34122
40480
50313
56420
65102
72852
76987
Index
100
167
189
225
279
313
361
404
427
|
Source : Government of Kerala Budget in Brief 2001 -02
Note:
The figures for 1990-91 and 94-95 to 99-00 are the accours of expenditure.
The figures for 2000-01 is the revised budget estimate for rat year.
The figures for 2001-02 are the budget estimates proposes for the year.
206
Table 26
Collection of User Fees and Cost Recovery Ratio - Major States
State
Total exp
Total User Fees
. NIPFP
NSS
Rs. Lakhs
Cost Recovery Ratio
NIPFP
NSS
Andhra Prade
Bihar
Gujarat
Haryana
Himachal Prat
Karnataka
Kerala
Madhya Prad(
Maharashtra
North East
Orissa
Punjab
Rajasthan
Tamil Nadu
Uttar Pradesh
West Bengal
47897.97
22304.44
33564.11
11957.45
11621.46
42614.04
31226.29
36218.31
45892.85
22695.49
19093.04
17693.15
43161.48
55983.65
84308.17
50801.52
210.62
252.15
203.70
26.11
76.24
44.71
693.06
212.88
1229.22
214.85
32.46
232.66
154.24
204.39
243.82
232.30
0.44
1.13
0.61
0.22
0.66
0.10
2.22
0.59
2.68
0.95
0.17
1.31
0.36
0.37
0.29
0.46
734.92
229.75
438.14
1136.67
78.40
1180.41
4952.00
577.91
2126.99
386.37
183.21
1888.04
397.92
1238.33
2726.22
1063.42
1.53
1.03
1.31
9.51
0.67
2.77
15.86
1.60
4.63
1.70
0.96
10.67
0.92
2.21
3.23
2.09
Source: Mahal et al (2000)
Note:
The author has taken the figures for the North East by scaling the
corresponding figures for Assam in accordance with the proportion
of population
207
Table 27
Receipt and Expenditure of Regional Cancer Centre Trivandrum
(Rupees Millions)
Year
89-90
90 91
91- 92
92- 93
93- 94
94- 95
95- 96
96- 97
97- 98
98- 99
99- 00
Receipts
State
Govt.
10.45
2067
22.35
31.05
34.22
37.50
58.61
41.32
44.89
41.04
34.60
Federal
Govt
200
14 00
3.00
6.50
7.00
7.00
7.50
9.00
7.50
8.16
7.50
Internal
Rev.
1.77
4.13
7.35
15.11
21.99
26.82
33.63
36.97
45.19
46.50
49.00
Expenditure
Research
Grant
Total
0.85
1506
1 08
39 88
I. 97
34 68
2.22
54 89
538
68.60
4.05
7537
8 17
107.92
7.26
94.55
9.13
106.70
II. 00
106.70
12.00
92.10
Running
Cost
8.12
10.11
14.04
18.38
23.70
33 99
34.71
52.76
52.48
54.62
96.25
Drug
Bldg. &
Purchase Eqpt1.12
6.41
2.97
24.38
5.06
11.31
6.20
33.15
987
33.10
17.13
2627
21.45
34.65
21.90
41.40
24.58
2380
25.50
31.50
27.00
31.43
Total
15.66
37.46
30.41
57.74
66.67
76.40
90.82
116.26
101.78
111.62
154.71
Surplus
(+)
Interna Revenue as %
Deficit (-)
-0.60
2.42
4.27
-2.85
1.93
-1.03
17.10
-21.71
4.92
-4.92
-62.61
a Total Of Running Cost
Receipts & drug purchase
11.75
19.16
10.36
31.57
21.19
38.48
27.53
61.47
32.06
65.50
35.58
52.46
31.16
59.88
39.10
49.52
42.35
58.64
43.58
58.04
53.20
39.76
Source: Regional Cancer Centre, Trivandrum. Annual reports for various years and internal documents
Note: The huge deficit in 1999-2000 is due to the introduction of pay revision and of non practising allowance to the doctors necessitated
by the stopping of private practice. The latter was made up from the income from pay clinics .
208
Tatie28
financing Pattern of Projects irrpiemented by Local Seif Governments Keraia 1999-2000 (per centages).
1
QartLoan from Loan
Benefidary
State
No of in-ad Giant Own
Centrally
Co
from Vciutary Beneficial Contribution
Spons
Others Total
Rejects carried in ad Find
Sponsered operatic Fin. Contribution Contribution
(drectfy
ered
CMBT
Inst
Inst
spent)
Item
Gam
F^nchayats
118931
14.45 36.59 1279
5.23
3.65
1.19
3.63
ao5
284
10.95
5.62
100
5^51
10.65 2291
0.00
8.55
37.43
0.48 11.96
1.68
0.20
1.49
4.63
100
Dstrid
F^nchayats
6521
14.18 2526
0.00
6.13
231
0.56 30.91
500
0.17
1.32
1217
100
Mhdpelities
9949
10.02 27.00 24.59
6.15
836
0.28 1281
222
0.84
5.71
202
100
Gerpcraticns
1784
10.96 3224 19.73
1.58
811
0.60 17.12
1.62
0.95
5.46
1.63
100
1207 30.85
9.27
6.31
10.83
0.83 11.37
297
1.60
6.72
6.18
100
131724
(8240%)
11.39 29.12 11.34
5.57
11.48
0.85 1207
287
1.82
7.35
6.14
100
22892
(14.32%)
19.13 37.54
206
7.71
824
0.72
9.16
254
0.62
4.22
7.04
100
5234
29.99 4568
262
5.51
580
0.75
274
279
0.26
1.47
238
100
11783
(7.37%)
1283 40.00
1.90
268
214
1.74 14.71
284
3.14
9.65
6.56I
100
44435
(27.80%)
55813
(34.92%)
20.40 3275
1.99
4.26
11.71
1.09
5.42
281
3.70
14.07
1.80
100
9.63 30.06 4.74
6.68
10.33
0.64 17.59
263
1.02
5.53
9.951
100
59602
(3729%)
1201 30.33 29.65
5.73
10.87
0.95
1.78
0.43
0.94
3.23
100
Sock F^nchayats
Total
t
Categories of
Rejects
General
FcrSchedded
Castes
FcrSchedded
Tribes
(227%)
FcrWTnsn
Natireof
Projects
Ftoductive Sectcr
Sendee Seder
IrfrastnxtuE
Seder
508
Sojce: GcM. Of Keraia (2000)
htfe: Gam F^ncha^s are the lowest deded int with a pepdatien cf aocut 29.000. Bock F^nhayats are the next tier and consists ocf a gxxp
cf abcut 10 gram F^nchayats Dstrid (JiIla) F^nchayats are the third ter cf deded seif gj^mmerts.
209
Position: 2658 (2 views)