FRCH NEWSLETTER VOL.6-No. 1-6-JAN -DECEMBER-1992.pdf
Media
- extracted text
-
COMAUNITY HEALTH CEL
326, V Main, 1 block
Vol VI No.1.
Jan.- Feb. 1992
FAMILY PLANNING
An Alternative Strategy
N.H.Antia
The present Family Welfare programme has little to do with the
welfare of the families to whom it is targetted. It is an imposition of
the will of the rich on the poor, whose increasing numbers is looked
upon not only as dilution of the gains of 'development' but also an
eventual threat to their life style and very survival. This perception,
seldom expressed openly, has been the determining factor in policy.
making, funding and implementation of the programme at both the
national as well as international level. This is revealed by the type
of extensive propaganda and pressures, based on the perceptions
and needs of the affluent classes and nations, having little impact
on the poor who have entirely different needs, perceptions and
thinking on this subject. Though seldom articulated, a large family
people but also On all personnel in the public and, to an extent, in
the private sector. The adverse effect this has had on the personnel
and programmes in fields such as education and revenue, resulted
in easing of these pressures on these agencies. Pressures were
then accentuated on the health services and personnel, who now
bear the major burden of this thorny cross thrust on their already
reluctant shoulders.
Despite this despicable programme, which further harasses
and terrorizes the helpless female, already exploited by traditional
social customs and the country's economic policies, the population
growth rate has hardly decreased, hovering near the factor of two
for the past three decades. The increase in ‘target’ pressure has
and earing that is available to them in the inhospitable and uncaring
world in which they have to survive or die. Many of the age old
only resulted in an increase in the Couple Protection Rate without
equivalent decrease in the Birth Rate, indicating a mere increase in
false reporting. The plateauing of the graph during the past three
decades, after an initial steep rise, only demonstrates that the
practices like the 'son complex' have very likely evolved on such a
basis, even though they may not fit into contemporary circumstances.
methods which achieved initial gains can achieve no further decrease
in the growth rate, though it may avert a certain number of births.
is not only considered an economic asset by the poor but also the
only security in old age or illness, besides being the only form of love
This, by itself, is insufficient to control the rate of increase of our
Target Pressures : the backlash
Increasing consternation due to an almost uncontrollable
increase in population since independence Led to the use of overt
force against the poor during the national Emergency. Having
resulted in the overthrow of the Government, the pressure is now
exerted in the form of, though not much less harsh, covert force not against the male who rebelled, but against the helpless woman.
Not only half the Plan budget on Health, but even the entire public
health services have been diverted to population control under the
euphemism -Family Welfare*.
The chief reliance has been an
female sterilization conducted through the 'camp' approach. Not
having achieved the desired result, it has led to the increased
advocacy of non-terminal methods such as Infra Uterine Device
(IUD), condom and the oral pill. Since no political group, either in
population, which now poses a threat not only to the upper classes
but also to the economy and ecology of the entire country.
Distorted Commitments
And yet the response of the policy makers as well as of the
bureaucracy is 'more of the same', using a variety of technological,
administrative and managerial techniques as well as the introduction
of new programmes like Maternal and Child Health and Universal
Immunization to reduce maternal and child mortality. While laudable
by themselves., none of these programmes have been able to
achieve their desired results. This is because of the basic insincerity underlying these programmes, often initiated at the behest
of international agencies. Their real intention is not the welfare of
the people but as an aid to achieving the FP targets. This neither
power or in the opposition, has the necessary courage to discuss
population control after the Emergency debacle, the method has
fools those who are asked to implement them nor the people whom
been to provide ad lib funds, which are readily available from both
national as well as international sources, in order to exert extreme
'target* pressures through all available means, short of overt force.
The incentive / disincentive measures are not only exerted on the
The FP ’target* pressures have so distracted and demoralized
the health personnel and alienated them from the people, that they
are unable to achieve their sole target objectives. This apart, it also
prevents them from delivering those programmes such as
immunization and curative services, which the people actually
ft N.H.Antia is the Director, Foundation for Research in
desire, It is not that the people are averse to Family Planning but
Community Health, Bombay and Pune.
they will do so only when it suits their own needs, not those of the
they profess to cater to.
FOR PRIVATE CIRCULATION ONLY
sterilizations, which are achieved only after an average of 3.8 births,
the family. It is time this term is abolished. Good health care must
be the approach to Family Welfare and notvice versa, as is the case
would have been achieved without any need for motivation. More
at present.
government, international agencies or the elite.
Many of the
would be achieved ifthe programme was carried out more humanely
and personal attention and caring than through the present "camp"
approach and where "cases are bought and sold'. Family planning
on the adivasi population, because they are readily amenable to
pressures during drought, is immoral because they seldom show
Other Measures
Such changes will have to be associated simultaneously with
several other measures which not only impinge on health and FP
but have much wider social and economic implications of their ov/n.
any natural increase in their numbers. It can, and often has, led to
genocide of these communities. The problem of condoms in rural
areas is their disposal and with that of IUD is the problem of utilizing
a method where the vast majority of women already have chronic
economic activity which affects the age of marriage as well as the
size of the family. It will also be a potent means for improving her
gynaecological problems. "Norplants" and the possible availability
of the injectable contraceptives raise serious questions of medical
own as well as her children's and family's health. It will ensure better
nutrition with the available resources, better sanitation in the home
ethics and wide ranging moral implications of their widespread
Female education is probably the most significant of these measures.
This will not only increase the status of the female but also in her
programme.
and surroundings, higher rate of immunization and pre and ante
natal care, as well as better utilization of available health care
services and facilities. There is no better example of this than
Kerala, where the birth rate is 19.8 per thousand as compared to
The Alternatives
30.5 per thousand in India as a whole.
While there is a need to increase the overall allocation to the
misuse by the elite and other groups who wield power over the vast
majority of our people, as demonstrated by the present FP
It is abundantly clear that without the use of overt force (with
bitter results) there is little hope of any further, significant progress
in limiting the size of our population by utilizing the present methods.
The future therefore lies in seeking the voluntary acceptance of
non-terminal methods by the younger age group, both male as well
as female. This can be achieved only if the antagonism and mistrust
between the people and their health workers, (especially the
Auxiliary Nurse Midwife, who is closest to them) is overcome and
Public Health Sector, much improvement can be achieved even
today by better reallocation of existing health resources and
expenditure between rural and urban areas of the country. There
is an equal, if not a more urgent, need for reallocation and increase
in inputs into education, with special emphasis on the female.
These measures will not only affect the population growth but are
essential for the welfare of the masses, besides being laudable in
their own right and for the development of the nation as a whole.
rapport reestablished. This cannot be achieved unless the present
target approach of the FP programme is removed. It does not mean
a total scrapping of this present method of accounting in the health
services, which, unfortunately, seems to work only on the "target"
basis. Rather, the targets can be moved to better and more useful
functional parameters such as accounting for individual maternal
The direct relationship of the limitation of family size to economic
status is not only observed in affluent countries but is also observed
in our own middle class which now accounts for about 10 to 15
percent of our population. Forty percent of our population growth
is accounted by the four BIMARU states of Bihar, Madhya Pradesh,
and child deaths from readily preventable and curable diseases like
female literacy. This can be improved only through a major change
of the nation's policy from the present polarized approach to a more
gastroenteritis, acute respiratory infections, tetanus and tuberculosis
and of new cases of poliomyelitis, malaria, etc.
Simultaneously, measures will have to be instituted for bringing
accountability of the Primary Health Centre and their staff to the
people whom they are paid to serve and not permitting the provision
of excuses and blame for their failure to a more distant authority.
This can be achieved forthwith even without waiting for the Panchayati
Raj. Such a shift of targets will automatically shift priority towards the
programmes of MCH, immunization, health education and help re
establish the lost human relationship between the younger age
group and their paramedical workers. Such request for priority
medical help must inevitably lead to request for advice and help for
family planning as and when they feel the need.
Another major change for re-establishing rapport must be the
improvement of the curative aspect of the Basic Health Services,
especially maternity and emergency services. This is essential in
order to rehabilitate the lost image of the Primary Health Centre
Rajasthan and U.P. which are the poorest states, with the lowest
egalitarian form of development.
No Short-Cuts
Four decades have provided sufficient evidence that there are
no short-cuts to development or population control, certainly not
within a democratic system. Gimmicks like social marketing and
change in the name of the programme from Family Planning to
Family Welfare fool no-one except those who look to the West for
solutions to our entirely different problems. The decision for
determining the family size is an intensely personal choice and
cannot be dictated or enforced. Economic and social conditions
must be created which enable and encourage the poor to control
their family size. The present policy of population control for the sake
of economic and social development is placing the cart before the
™
horse.
(PHC). The triad of Public Information on Health and Health
Services, the Preventive aspects of health and Curative services
cannot be achieved under the existing counter-productive FP
approach. A Family Welfare programme in its true spirit must be
integrated into the mainstream of the Health Service and the
dichotomous arid overbearing FP programme merged in its entirety
at all levels from the Ministry of Health, to the PHC, into the general
health services of the country. Only thus can the counter-productive
effect of the present FP programme on population control as well
as on Health Care be neutralized. The term Family Welfare is
ERRATA
Line 3, para 2, of the second column on page 1 (Alex
George's article) in the last issue (FRCH Newsletter
Vol.V, No.6, Nov.-Dec.91) should read "of India Act of
1919" instead of 1819, as printed. The error is regretted
Editor.
redundant, for health care cannot exist without care and welfare of
FRCH NEWSLETTER. VOL.VI, NO. 1, JAN.- FEB 92
2
HEALTH CARE IN CHINA
A Model in Transition
Ravi Duggal, Sonya Gill
This is the 3rd article in the series, “Health Financing and Costs: Comparative
Perspectives" (No. 1 - Japan, No. 2 - Zambia).
China is the largest agrarian and poverty ridden country, with
a past of colonial exploitation, which has achieved rapid improvement
in the health status and social conditions of its people. In sharp
contrast to the pattern of development characterized by large and
increasing inequalities witnessed in India - another vast, agrarian
and post-colonial country - the Chinese path of development
emphasised the conscious, redistribution of resources from urban
to rural areas and in favour of the poor workers and farmers on a big
scale. The impact of this pattern of socio-economic development
has probably been greatest for, and most visible in, the health
education, housing and jobs, as well as public health campaigns
and universal primary care have been at the core of the remarkable
improvements in health conditions.
While the mortality profile has changed, the widespread
morbidity due to infectious diseases such as dysentery, influenza,
viral hepatitis, tuberculosis and schistosomiasis demand continued
attention and resources for universal preventive and curative
services. Chronic conditions related to old age among the growing
number of people over the age of 60 and those arising out of
occupational hazards and cigarette consumption, have also put
pressure on health resources in the '80s and given new impetus to
the development of traditional medicine.
Health Services: universalization of the public system
Roemer has summed up the acclaim for China's
In 1949, the backward state of health infrastructure and services
achievements in the health field --"Nothing was more impressive
than the central principle on which China’s health service (like so
many other sectors) was built: 'serve the people. This meant many
was reflected in the fact that there was one Western allopathic doctor
per 15,000 population, mostly concentrated in the few large cities
along the coastline. The vast rural majority faced a dire shortage of
doctors and medicine, except for those who had access to the
traditional practitioners of a 2,500 years old system of Chinese
sector.
things, but in contrast to policies in most of the Western world, it
meant that health care was not a commodity to be bought and sold
in the market......Health was not a matter for private profit”.
This country report briefly reviews the pre - 1980 system of
universal provision of public health and primary care services that
medicine. The bulk of medical care was provided by the 276,000
traditional practitioners, approximately one per 2,015 population.
The health infrastructure expanded rapidly as the new health
underlay the achievements in the health status and the direction of
health systems of reforms after 1980.
policy committed itself to providing universal coverage to the
people. The existing fee-for-service system was converted into a
semi-universal public system based on differing modes of financing
Health Status
of services. The first National Health Conference held in 1950 laid
down the guidelines for development of the health system: Serve
the workers, farmers and soldiers; priority to be given to prevention;
After the establishment of the Socialist State, the People’s
Republic of China, the period between 1950 -1986 witnessed the
doubling of life expectancy (from 35 years in 1949 to 69 years in
1986) and the rapid reduction in infant mortality (from the very high
level of250 per 1000 live births to 34/1000) . In contrast, the average
I MR for the developing countries is currently 92/1000 live births.
Maternal mortality has declined to 44 per 100,000 live births as
against the prevailing rate of 250 - 400 per 100,000 in India or 400/
develop both western and traditional medicine; and unite health
work with mass movements.
TABLE 1: HEALTH SERVICES
Physicians
Year
Total
100,000 in Indonesia.
In 1949, poverty, malnutrition and a high incidence of infectious
Nurses
-—per.................. 100,000...,...........
diseases such as typhoid, cholera, and tuberculosis were responsible
for a death rate-of 40 per 1000 population. By 1987, the mortality
rate had declined to 7 per 1000 population and the disease pattern
had begun to resemble that of developed countries- The leading
Barefoot
Beds
Doctors
Allopaths
...population---------
1949
67
-
6
..
1960
90
12
26
--
1985
131
57
59
121
14
106 (65)
213
causes of death today are cerebro - vascular diseases- heart
diseases arid malignant tumors, followed by respiratory diseases,
rather than infectious diseases and malnutrition as in most poor
countries. Despite one of the lowest per capita incomes for any poor
country (US $ 310 in 1986), the availability of adequate food,
Sources: Statistical Yearbook of China 1983, China :A Statistics Survey in 1965
In the early 1950's there was mass mobilisation and active
participation of people and communities in improving environmental
sanitation for the prevention of communicable diseases. The public
The authors are both researchers at FRCH, Bombay, who
have been involved in various studies concerning health
expenditure, costs and financing.
3
medical services also expanded rapidly, so that as early as 1965
"every one of China's 2,000 or so counties had a fairly wellequipped and competently staffed general hospital. Most of these
FRCH NEWSLETTER, VOL.VI, NO, 1, JAN.- FEB 92
county hospitals have about 100 beds and larger ones have from
Health Financing and Delivery: current issues
200to 300 beds". Underlying this expansion was a policy framework
that ensured that physicians and medical graduates were assigned
The Chinese health system has undergone major changes,
specifically in rural areas, since 1980. Some of the key changes and
to work in the public health institutions. However, the distribution
of the rapidly expanding services tended to favour the urban areas,
while the rural majority had much less access to health care. To
challenges are:
1)
Increased rural-urban inequalities in access to services and
resources: The general economic reforms of 1980 replaced
meet the health needs of the vast, dispersed rural population, the
insurance based cooperative medical system (CMS) was, from the
collective agriculture with the incentive based household
responsibility system, thereby raising productivity and rural
mid-60's, universalized to cover the whole country.
The decentralized co-operative medical system was closely
linked to the co-operative organization of agricultural production
per capita incomes. No organizational measures were however
taken to save the system of health stations and barefoot doctor
based on production teams (each having a 100 to 200 peasant
Health services coverage declined from 90% of all villages in
services based on co-operative finances and administration.
population corresponding to one or more villages), and work brigades
(averaging 16,000 people each). The brigades were directly
responsible for providing health care to their members, and for
1978to just25% in 1983-84. Since then co-operative insurance
coverage has increased to about 50% of the villages. These
are mainly the richer areas which can afford higher premiums
and co-payments. The poorerareas bearthe increased financial
constructing, equipping and managing the health stations. Both
primary curative care (combining traditional and allopathic medicine)
burden of a fee- for-service system. As Victor Sidel writes,
and preventive services (immunization, health education, family
“Government workers still have insurance to cover health
costs, but all others have to pay for care. Private health
planning, communicable disease reporting) were provided by the
“barefoot doctors" who were selected by the brigade members and
given six months training in public health and primary care. These,
and other part-time, para-medical workers, worked mostly in the
brigade health station and also participated in agricultural production.
insurance is being introduced. Although health statistics are
not available, it appears that these policies have reduced the
government’s ability to provide immunization and access to
medical care, especially for people in poor areas. There are
no statistics to evaluate changes in health conditions, but the
infrastructure is clearly deteriorating, particularly in rural areas.
Higher referral units, such as the commune health centres, manned
by assistant medical practitioners and county hospitals provided the
secondary-level support for the activities of the 'barefoot doctors
This 3-tier rural health services network made effective and
technologically simple services available to even the poorest
agricultural communities. Not only did it solve the problem of
New technologies are being introduced almost exclusively
into urban areas, further reducing resources available to rural
2)
inadequate health and medical personnel in a relatively short time
and provide a substitute delivery system to the expensive hospitalbased care, it also developed an insurance system to cover primary
care for the agricultural population. Rural primary health care was
financed by an insurance fund created jointly through monthly
payments by each peasant member of the brigade and the welfare
budget of the commune derived from the proceeds and profits of its
productive activities. This insurance fund paid for the brigade health
sibility of hospital management, charges have been raised and
additional co-payments imposed on patients. The reforms in
hospital insurance appear to have improved utilization and
brought down waiting lists, as also created barriers to over
utilization and lack of proper referrals However, these reforms
have yet to become popular as they shift the financial burden
station and cost of drugs used by barefoot doctors and paid a portion
of the peasants' medical expenses at commune health centres and
county hospitals. The barefoot doctors, like the peasants who
worked on the land, were paid by the brigade according to the work
points they received each day.
Although a similar 3-tier, decentralized system based on red
medical workers, street and neighbourhood health stations and
district hospitals existed in the urban areas, the fact that most of the
urban work-force was employed in government or state enterprises
has given them access to the free medical care provided by
employers th rough factory health stations or relatively better equipped
urban hospitals and health centres. Thus, even in the 60s and 70s,
the government and the enterprises fully funded the health insurance
fortheir employees and for college students, while the rural population
had to partly meet the cost of insurance premiums and some of the
cost of higher level care. The Central government finances have
mainly financed secondary and tertiary level care paying for capital
in construction of hospitals and commune health centres, salaries
for the staff and any deficits, such as unpaid bills.
The impressive improvements in health status since 1949 and
the creation of, perhaps, the world's largest network of health care
instituti ns and work-force, resulted in the advocacy of the 3-tier
model of primary health care based on village health guides and
para-medical health workers for the poorer countries, by the WHO
However, this model, transplanted to very different socio-economic
and political settings, has remained non-functional and ineffective.
areas."
Cost escalation in hospital care: Rising incomes have increased
the demand for higher quality, hospital-based care and reduced
the utilization of rural primary and preventive services. To raise
additional resources under the new schemes of self respon
3)
to the patient.
Encouragement to private practitioners: Various experiments
in financing methods have been initiated at the village and
township levels to raise local resources and avoid investment
by the state. To ensure the availability of services, an estimated
133,000 practitioners have been approved since 1980 to set
up practice. Many have contracts with authorities to carry out
immunization and operate the health stations. A large variety
of contractual arrangements and reimbursement options are
currently being tried out. However, all of them involve some
combination of fee-for-service and subsidies.
With changes in the financing pattern, private expenditures
have increased substantially. Directprivate expenditure represented
27.5% of the total estimated health expenditures of Yuan 14,791
million in 1981. This, along with the premium paid by the individuals
towards co-operative insurance, amount to nearly 32% of total
health finances. The current move to replace free care for the urban
employed with insurance will further increase the share of private
expenditure.
Conclusion
These are only some of the issues facing China after 10 years
of experimentation in health reforms. Prior to 1980, it had nearly
achieved a system of universal basic health care coverage. At
Continued on page 12
FHCH NEWSLETTER, VOL.VI, NO. 1, JAN.- FEB 92
4
IN THE LAST FIVE YEARS......
Usha Sethuraman
With this issue, FRCH Newsletter enters the sixth year of its
publication. Below, we give a compiled list of articles that have been
carried over the years, categorized subject-wise. Apart from these,
the Newsletter has regularly carried information about books and
reprint articles contained in our library and documentation unit. It
has also carried bibliographies on selected subjects, book reviews
and readers views, from time to time. Xeroxed reprints of any
article(s) can be obtained at the cost of Re. 1.00 per page plus
postage. Please quote details regarding title and issue when
sending requests for reprints.
Public Health
Health for All: concept and reality; N.H.Antia - Vol.1 (2), Jan -
Feb, 1987.
Interaction between the Government, NGO’s and the Private
Sector in Implementation of HFA, Abhay Bang - Vol.1 (5),
July - Aug, 1987.
Some Directions; Sujatha Gothoskar, Vol. 1 (6), Sept-Oct, 1987
Towards Computerised Medicare ; M.Uplekar, N.H.Antia &
P.S.Dhumale - Vol. II (2), Mar - Apr, 1988.
In Search of Cure; Vol.II (2) March - April 1988
Better Use of Medical Care; M.Uplekar-Vol. Il(3), May - June,
1988.
Target Orientation in Health Care ; AmarJesani- Vol. H(3),
May-June, 1988.
Helping Doctor Help Yourself; M.Uplekar- Vol. Il(3),
May - June, 1988.
Medicine, Science and Humanism ; P.K.Sethi- Vol. 111(1),
Jan - Feb, 1989.
Chronology of Health Committees 1940 -1981 ; Manish
Mankad Vol IV(1-2), Jan - Apr, 1990.
Compliance in Health Care ; M.Uplekar - Vol. IV(2), May June, 1990.
Private Health Sector: regulation and control; Ravi DuggalVol. V(4), July - Aug, 1991.
Medical Technology
High Technology in Medicine; N.H.Antia - Vol. Il(5), Sept - Dec,
1988.
Privatisation and New Medical Technology -I ⅈ RaviDuggal
- Vol. Il(5), Sept -Dec, 1988; Vol. 111(1), Jan - Feb 1989.
Humane Technology Needed; P.K. SethiVol 11(5), Sept-Dec,
1988.
Technology in the Service of Indian Patients; M.S.Valiatham,
Vol II (5), Sept-Dec, 1988.
X-rays: more harm than good ? S.H. KabraVot ll(5), Sept - Dec,
1988.
Tragedy in Transplantation ; Nerges Mistry - Vol II (5), Sept Dec, 1988.
Opportunity Costs of High - tech Medical Diagnostic Equipment;
Ramesh Awasthi - Vol II (5), Sept - Dec, 1988.
Occupational Health
Occupational Health: some issues; Vijay Kanhere - Vol l(5),
July - Aug, 1987.
Industrial Accidents: whose life, whose responsibility ? Sujatha
Usha Sethuraman is the Librarian at FRCH, Bombay.
5
Gothoskar - Vol l (5), July - Aug 1987.
Agriculture & Firewood collection; Vol. 1(6), Sept-Oct. 1987.
Panchayati Raj
Panchayat Raj and Health Care: the Karnataka experience;
T.R. Satish Chandran -Vol V (1), Jan - Feb, 1991.
Convergence of Social Development Services Related to
Women and Children; Ela Bhatt & Preeti Bhat - Vol V (1),
Jan - Feb 1991.
Convergence of Services and Schemes Relating to Health ,
Nutrition and Education and Linkages with the Panchayat Raj:
a report; Kavita Bhatia - Vol V (1), Jan - Feb, 1991.
The Concept of Panchayat Raj and Health Services: reactions
from the field; Rani Bang and Abhay Bang - Vol. V(1), Jan Feb. 1991.
The Community Health Care System : a model for health services in Panchayat Raj; N.H. Antia and Kavita Bhatia - Vol
V (1), Jan - Feb, 1991.
Environmental Health
Killer Waters of Chitali; Vol III (2), Mar - Apr, 1989.
Pesticide Poisoning ; Amar Jesani - Vol (5), July - Aug, 1987.
Cooking fuel; Vol l (6), Sept - Oct, 1987.
Immunization
Vaccines: fact, fancy and fallacy; N.H. Antia - Vol. 11(1),
Jan - Feb, 1988.
From Holism to Eradication and Beyond; Nerges Mistry -Vol.
11(1), Jan-Feb. 1988.
Need for Alternative Approaches in Vaccine Development;
Tannaz Birdi - Vol. 11(1), Jan - Feb. 1988.
It can be Done, says UNICEF; Saroj Iyer-Vol 11(1), Jan - Feb,
1988.
Panacea or Palliative ? Amar Jesani and Ravi Duggal - Vol II
(1), Jan-Feb, 1988.
Designing Field Trials; M Uplekar-Vo\ 11(1), Jan - Feb, 1988.Lessons from BCG; Nerges Mistry-Vol ll(4), July - Aug,1988.
Diseases
Tuberculosis
The National Tuberculosis Programme and its Implementation
Debabar Banerji-\/o\ II (4), July - Aug, 1988.
Tuberculosis Control in India: a bird's eye view; M.Uplekar Vol II (4), July-Aug 1988.
Study of Tuberculosis Cases; Sheela Rangan - Vol IV (4),
July - Aug, 1990.
Malaria
Systems Approach to NMEP ; Col. P.K.Dutta - Vol III (2),
Mar - Apr, 1989.
Leprosy
Leprosy Control by a People's Programme: new concept in
technology transfer; N.H.Antia - Vol 1 (4), May - June, 1987.
AIDS
AIDS: if slogans were vaccines; Nerges Mistry - Vol 1 (2),
Jan - Feb, 1987.
Health Expenditure/Financing
Health Expenditure in India; Ravi Duggal -Vol 1 (1), Nov - Dec,
1986.
FRCH NEWSLETTER, VOL.VI, NO. 1, JAN.- FEB 92
Health Expenditure in an Indian District; Ravi Duggal Vol 111(3-5), May-Sept, 1989.
State Health Insurance Expenditure; Ila Shah - Vol IV (2),
May - June, 1990.
Health Financing in the Developing Countries ; Shirish
Kavadi- Vol IV (4), July - Aug, 1990.
Corporatisation of Health Care in India; Saraswathy
Anantharam - Vol IV (4), July - Aug, 1990.
Health Financing and Costs: a profile of Japan; Sonya GillVol. V(3), May - June, 1991.
Health Financing in Zambia; Shirish Kavadi - Vol. V(5),
Sept-Oct. 1991
Health Statistics
Health and Related Statistics: compilation & critique; Ravi
Duggal, Saraswathy Anantharam and Sunil Nandaraj Vol. Ill(6), Oct - Dec, 1989.
Health Policy/Planning
Medical Ethics
Unrelated Living Donor Kidney Transplantation; B.N.
Colabawala - Vol. Il(5), Sept -Dec, 1988.
Health Professional as an Abuser or Victim; Amar Jesani-Vol.
111(1), Jan - Feb, 1989.
Misuse of Medicine ; N.H.Antia - Vol. V(4), July - Aug,1991.
Irrational and Unethical Medical Practices; Mohan Deshpande
- Vol. V(4), July - Aug, 1991.
Medical Malpractice and the Law; Compiled article - Vol. V(4),
July - Aug, 1991.
Medical Education
Medical Education ; N.H.Antia - Vol. IV (3), May-June, 1990.
Community Health and Medical Graduates; Sheela Rangan
and M. Uplekar- Vol. V(5), Sept - Oct, 1991.
Indigenous Medicine
Ayurveda: during freedom movement and after; Alex George
Planning : for whose development? Ravi Duggal -Vol. Ill(6),
Vol.V(6), Nov-Dec. 1991.
Understanding Traditional Medicine : the meeting ground;
Oct - Dec., 1989.
The Shore Committee: an overview; N.H. Antia - Vol. IV(1 -2),
Darshan Shankar - Vol. V(6), Nov - Dec, 1991.
An Introduction to Holistic Medicine; Vol. V(6), Nov - Dec,
Jan - Apr., 1990.
A Review of the Shore Committee -1946 and its Relevance,
1990 ; Ravi Duggal - Vol. IV (1-2), Jan-Apr, 1990.
1991.
African Traditional Medicine: concept practice and policy;
Resolution of the National Planning Committee on the Report
of the Sub-Committee on National Health : Vol. IV(1-2),
Jan - Apr. 1990.
Health Policy Content in Manifestos : an analysis; Alex
George - Vol. V(3), May - June, 1991.
Health Policy in the Five Year Plans: a critical overview; Sunil
Nandraj - Vol. V(3), May - June, 1991.
Health Education
Pages from a Diary; Amirbanu Sumnani - Vol 1 (2),
Shirish Kavadi - Vol. V(6), Nov - Dec, 1991.
Medical Pluralism: some theoretical problems; DhruvMankad
-Vol.V(6),Nov-Dec, 1991.
Drugs and Drug Policy
Action on the Drug Front; Padma Prakash - Vol. I (3), Mar - Apr,
1987.
Drugs which Boomerang; AnilPilgaonkar- Vol. 1(3), Mar - Apr,
1987.
Physician, Heal Thyself; A. S. Deshpande -Vol. 1 (3), Mar-Apr,
Il(3), May-June, 1988.
1987.
Analgesic and Essential Drug Production in India; Y. KAmdekar
and Arun Bal - Vol. 1 (3), Mar - Apr, 1987.
Misinformation - at what cost ? Sujatha Gothoskar - Vol. 1 (3),
Health Education: blaming the victims ; Mohan Deshpande Vol. Il(4), July - Aug, 1988.
Training of Local Health Educators at Arogya Shikshan Kendra,
Vol. 111(1), Jan - Feb, 1989.
Mar-Apr, 1987.
Aren’t we being Dangerously Overdrugged ? M.Uplekar
and Madhu Rokle - Vol. 1 (4), May - June, 1987.
After Bangladesh, the Philippines Show the Way: Amar Jesani
Our Experience in Teaching Methods of Health Education;
Vaishali Vaidya - Vol. V(2), Mar - Apr, 1991.
-Vol. Ill(2), Mar-Apr, 1989.
Lokseva Aushadhalay, Malshiras : a rational drug counter
managed by people; Manisha Gupte - Vol. V(2), Mar-Apr 1991.
Jan-Feb,1987.
School Health: which way to go ? Mohan Deshpande - Vol.
Health Personnel
Health Personnel in India; Ravi Duggal - Vol 1 (4), July - Aug,
1988.
Sanjeevani; Rupashree Sinha - Vol. II (4), May - June, 1987.
Degraded Breadwinner and Harassed Health Worker:
socio-economic background and problems of the auxiliary
nurse midwife; Amar Jesani- Vol. lll(3-5),May - Sept, 1989.
The Unknown Health Worker; Audrey Fernandes - Vol. V(2),
Mar - Apr, 1991.
A Matter of Survival: how Auxiliary Nurse Midwives cope
within the system; Aditi Iyer - Vol. V(5), Sept - Oct, 1991.
Medicine
Practice of Medicine: private practitioners' awareness about
HFA; M.Uplekar-\/o\. 1(1) Nov - Dec 1986.
Practice of Medicine: toxicity of vitamin overdose; M.Uptekar
-Vol. 1(2) Jan-Feb 1987.
Indian Surgery: which way to go? TehemtonE. Udwadia-Vol
Ill(2), Mar-Apr 1989.
In Defence of Cheaper Neurosurgery; C. Vidya Sagar - Vol.
V(2), Mar -Apr, 1991.
FRCH NEWSLETTER, VOL.VI, NO. 1, JAN.- FEB 92
Dangerous Drugs: supreme court ruling a setback; Vimal
Balsubrahmanyan - Vol. 1 (3), Mar - Apr, 1987.
Ban EP Drugs: an appeal to SC; Ravi Duggal - Vol. 1 (5),
July - Aug, 1987.
The New Drug Policy: what does it have in store for the people;
Anil Pilgaonkar-Vol 1(2) Jan - Feb, 1987.
Drug Policy Internationally; Compiled by Sujata Gothoskar-
Vol. 1(3), Mar-Apr, 1987.
Consumer Representation in the Formulation of Drug Policy
N.H.Antia - Vol. 1 (3), Mar- Apr, 1987.
The New Drug Policy in Nigeria; Amar Jesani - Vol. 1 (4).
May - June 1987.
Women and Health
Battling Sex Determination; Manisha Gupte - Vol. 1 (1) Nov -
Dec, 1986.
Amniocentesis Update; SanjeevKulkarni-Vo\. 1 (2) Jan-Feb.1987
Recent Trends in the Family Planning Campaign; Manisha
Gupte - Vol. 1 (4), May - June, 1987.
Health of Half the Humanity Neglected; Sujatha Gothoskar -
Vol1 (6), Sept-Oct, 1987.
6
Women Workers in the Service Sector; Sujatha Gothoskar Vol1 (6). Sept-Oct, 1987.
May - June, 1987.
Miscellaneous
Psychological Aspects of Health ; Sujatha Gothoskar -Vol 1
(6), Sept-Oct, 1987.
India and China - a comparison; Ramesh Awasthi-Vol 1 (1),
Home-based Workers ; Sujatha Gothoskar -Vol 1 (6), Sept Oct, 1987.
Women Workers in Heavy Manual Work; Sujatha Gothoskar
-Vol 1(6), Sept-Oct, 1987.
a major threat to health ? * Antibiotics in Anti-diarrhoeals;
Health for All: for women's empowerment or further
subjugation? Amar Jesani -Vol III (1), 1989.
Nov - Dec, 1986.
Notes from medical journals: * Is our pursuit of a healthy body
M Uplekar-\/o\ 1 (5),July - Aug, 1991.
Public Information ? No selective dissemination ; Ramesh
Awasthi & Sarita Pungaliya - Vol III (3-5), May - Sept, 1989.
Defence at what Cost ? Sunil Nandrajand Sahana Shetty -Vol
Poverty v
IV (4), July-Aug, 1990.
Overpopulation and Poverty; Ramesh Awasthi - Vol 1 (2),
Jan - Feb, 1987.
Poverty Alleviation or Doling out Illusions ? Ramesh Awasthi
Synopses of FRCH projects / reports
Women's Work, Fertility and Access to Health Care: a socio
economic study of two villages in Pune district; Vol II (2).
Vol III (2), Mar-Apr, 1989.
Planning for Poverty in India; Ramesh Awasthi -Vol V (2),
Mar - Apr, 1988.
Study of Primary Health Centres in Maharashtra ; Vol II (2),
Mar - Apr, 1991.
Nutrition
Are Vitamin Supplements Necessary ? Saroj /yer-Vol II (2)
Mar - Apr, 1988.
Children
Mar - Apr, 1988.
Health in People's Hand; Vol II (3), May - June, 1988.
Social Aspects of Leprosy; Vol II (3), May - June, 1988.
Arogya Shikshan Kendra; Vol II (5), Sept - Dec, 1988.
Kasare project; Vol II (5), Sept - Dec, 1988.
Child Labour and Child Health; Sujatha Gothoskar-Vol 1 (4),
Update on FRCH projects; Vol V (2), Mar - Apr, 1991.
Preparatory symposium for T.B. Project; Vol V (6), Nov - Dec,
1991.
•
DELHI DECLARATION
On the safety of the vulnerable road users
An International Conference on Traffic Safety was held in New
Pedestrians
Delhi in January, 1991. This is the first time such a conference has
Motorists require special training as to the importance of low
been held in any developing country. The sponsoring associations
and their participants passed the Delhi Declaration on road safety.
speeds for improving pedestrian safety. Children under 7-8 years
Road traffic crashes have become a major cause of ill health;
accompanied by adults.
Use of conspicuous clothing and retro-reflective devices should
be encouraged especially for children and the elderly.
each year at least 500,000 people are killed and millions are injured.
The majority of those people are vulnerable road users (VRUs);
pedestrians, bicyclists and motorized two wheeler riders. This
worldwide epidemic of VRU injuries, disabilities and deaths can be
controlled only by policies which change priorities in funding,
remedial actions and research in favour of the VRUs, in recognition
of the real world situation.
Improving the safety of the VRUs requires a political
commitment at the highest level and a recognition by the community
of the needs of the VRU. The safety of the majority of the users of
the transport system must not be subordinated to economic interests,
nor to the requirements of only one class of road users.
should not be expected to cope with traffic and should be
When pedestrian paths are not provided, pedestrians should
be instructed to walk facing traffic.
Two Wheelers
Conspicuity is vital and all riders should wear appropriate
clothing. Fluorescent and retro-reflective surfaces on both clothing
and vehicles should be encouraged. Front and rear lighting on all
two wheelers is essential. Daylight use of the lights should be
encouraged, particularly on motorized two wheelers.
Correct bicycle size is important for adequate control by the
rider. Bicycle manufacturers should provide greater choice in frame
and wheel sizes.
Helmet use by all two wheeled riders should be made universal
Specific Recommendations
through education and regulation.
Road and Vehicle Designs
Provision of bicycle lanes and pedestrian pathways separated
from motorized traffic is one of the most effective methods of
reducing VRU injuries.
Improving the urban environment by traffic calming techniques,
pedestrianization and car-free zones, pioneered in Europe, have
great applicability in less motorized countries if cultural and social
factors are taken into account.
Traffic control methods should recognise the special needs
Alcohol
High blood alcohol levels in drivers and riders is a major cause
of crashes involving VRUs. Alcohol testing after all crashes should
be required by law. Programmes to reduce drinking and driving
should be implemented with appropriate legal procedures including
random breath testing techniques.
The consequences of medicines and other drugs, including
alcohol, on all road users must be made clear. The use of drugs by
and characteristics of the VRUs.
Motor vehicles should have turn indicators, brake lights and
long distance, commercial vehicle drivers needs to be controlled.
headlights which accommodate the specific needs of the VRUs.
effects of prescribed medicines.
Physicians and pharmacists should inform patients about the
COMMUNITY HEai ru
326. V Moin. ,a
Korambngala
Bangalore-560034
Leat
ERCH newsletter,volvi,no, 1, JAN.-FEB 92
CELL
POPULATION CONTROL AND WOMEN’S HEALTH.
Nagmani Rao
Casel: •
Country
Persons/sq .km. (1981)
'A', who had an IUD inserted after her first delivery wanted to
have it removed after a few months, due to excessive bleeding and
discomfort. The ANM who had handled her case, rudely sent her
away, saying 'A' was trying to spoil her record and making a fuss
too soon. Finally ‘A* bribed a nurse at the PHC to remove the IUD
Japan
311
West Germany
England
India
246
228
200
and to promise not to reveal this to the sub-centre ANM.
Case 2:
‘N’, a social worker, went to the PHC a few months after an IUD
insertion (following a MTP), complaining of a dislodged Copper-T
and suspected pregnancy. The attendant nurse removed the IUD,
advised her to take EP-Forte to test for pregnancy and later come
back for a renewed IUD insertion. Shocked, 'N*confronted her with
the dangerous facts about EP drugs. The nurse responded
sheepishly - "Oh ’ you want this pregnancy do you? How do you
know about EP drugs, are you a doctor..... ?
Case 3:
'S’, a dalit CHV, while at a meeting at the PNG, shared that a
lot ofwomen came with health complaints following sterilization and
she didn’t know what to tell them. The CMO humiliatingly censured
her, saying that imagined problems should not serve as excuses for
non-fulfillment of FP targets. The ANM, whom she turned to, in the
hope that as a woman she would understand better, advised - "don't
bother; tell the women that there is no connection (of pain) with
'operation' and, in any case, women should bear pain patiently !"
The above are illustrative of innumerable instances which hold
up a mirror to the almost single minded obsession of policy makers
and health personnel to carry out FP programmes at all costs. What
is the rationale for such blind determination ? Is the assumption that
population control serves as a panacea for all economic and social
ills afflicting the country, based on sound principles ?
Historical facts highlighting economic development of the
(former colonising) First World countries have shown how the Third
World countries served as a fertile ground for cheap labour and
other natural resources and therefore high fertility in the latter was,
in fact, an economic advantage (as opposed to the present cause
for concern) for the former.
Countries such as Canada, at their highest fertility, had a Total
Fertility Rate (TFR - the average number of children per woman) as
8, whereas the Indian TFR has never exceeded 6.
The premise ofthe relative safety of contraception vis-a-vis the
greater dangers of child bearing is increasingly open to question on
account of research results indicating morbidity and mortality risks
associated with contraception. These are further elaborated in the
following paragraphs.
The trend of targetting on women in FP efforts and contraceptive
research has been gaining in prominence. The brief period of
targetting men through vasectomies during the Emergency served
to topple a government, which then seems to have reverted to
targetting women with greater determination. IUD's, oral
contraceptives, tubectomies have all been tried out with vigour, and
when these had limited acceptance, a testing and promotional
campaign for injectable contraceptives and implants has been
embarked upon, disregarding the associated morbidity and mortality
risks.
The theory that contraception reduces the burden of child
bearing and maternal mortality and is therefore in the best interests
of women's health also does hot hold, on several grounds:
TABLE 1: SELECTED GYNAECOLOGICAL DISEASES VERSUS PASTOR
Countering Myths
PRESENT USE OF FEMALE CONTRACEPTIVE METHODS. (N = 558)
The entire approach towards population control is based on
certain myths. These include: a) the Malthus influenced view that
a galloping population will spill-over to eat up the world 's resources,
cause economic drain, aggravate poverty and should therefore be
urgently contained; b) the view that population control measures
come as a boon for women Since frequent pregnancies and childbirth
are the major cause of women's ill-health.
the first argument above can be countered by the following
facts:
While population increase in India has shown an 83% rise
between 1951 and 1981, during the same period foodgrain
production has shown a 135% increase.
The fears of the population of the Third World creating a
crowded environment with associated ecological degradation is
another myth propagated by the vested interests of the First World.
The following figures disprove a proportionate correlation between
population density and development.
Nagmani Rao looks after the publications work for FRCH.
She is based in Pune.
FRCH NEWSLETTER, VOL. VI, NO. 1, JAN.- FEB 92
Diagnostic groups
Menstrual Diseases
Sexual problems
Vaginal Infections
Cervical Disease
Pelvic Inflammatory
Contraceptive history
absent No.(%)
present No.(%)
(N=123)
92 (74.8)
16 (13.0)
120 (97.6)
102 (82.9)
59(49.0)
(N=435)
202 (46.4)
28 (6.4)
352 (80.9)
292 (67.1)
100(23.0)
Diseases
(Source: High Prevalence of Gynaecological Diseases in Rural IixHan Women, byRABangand
others (MFC Bulletin 159, Jan: 1990).
Gynaecological disease have been found to be more frequent
in women with contraceptive history. (Table 1)
Innumerable studies (including a recent WHO sponsored
study carried out by UM. Bangalore in two districts in Karnataka)
have indicated that terminal methods (tubectomies in particular) are
promoted more forcefully through the target approach. The fact that
8
mortality, which is really a problem of inaccessible primary health
programme may be otherwise used in some states to expand the
much needed and neglected maternal and child welfare services’.
The fact that the health status of Indian women has shown no
marked improvement over the last forty years despite ’improved’
care.
- The rate of morbidity arising directly from contraceptive use.
(IUCD's, tubectomies, hormonal pills) has been substantial.
MCH programmes indicates that they hardly cater to the real health
needs of women. The compressed MCH package and the slogan
of NRR-1 further reinforce the policy of negligence towards women's
women accept these only after achieving the desired family size (of
four to five children) not only makes FP efforts a self-defeating
exercise, they also hardly make a dent on the problem of maternal
health issues.
TABLE 2: COMPLICATIONS DUE TO CONTRACEPTION
Other Health Issues
Contraceptive
Morbidity
Incidence
method
No. of acceptors
No. of women
in 80-81
who would
have suffered
ill health
IUCDs
Bleeding
10-15/100 6,00,000
60,000 to
and pain
users
90,000
PID
10/100
n
60,000
users
Infertility
•
10/100
60,000
users
Ectopic
0.8 to 4%
pregnancies of method __ ___
240 -1200
failure
Tubectomy
Spon
50% of
taneous
method
Perforation
1/2500
of uterus
users
Post op.
5.1%
-__
15,000
Viewing women primarily as mothers (or potential mothers)
leaves a wide gamut of women's health problems out of the health
policy and delivery systems. The interest in women begins and ends
with FP services, with a few other half-hearted schemes added to
the package. The integration of FP into the Primary "Health Care
services has been like the proverbial camel taking overthe tent, thus
adversely affecting the utilization of an important service by the
masses of women. The ICSSR-ICMR document (1981) had
succinctly commented that the health status of women had not
shown any material change over the years, mainly due to the fact
that women are nutritionally more 'at risk', yet utilize health services
much less than men do.
Much of this is related to the social image of women (as self
sacrificing mothers who work long hours and eat less to sustain the
family) and biases that view many of women's illness as psycho
somatic, whether these are menstruation related or arising out of
sheer fatigue. The watering down of the MCH programme after it's
enhanced focus on fertility control has also adversely affected its
outreach.
While it is true that maternal mortality in India is rather high and
n
240
the section comprising pregnant and lactating women would need
special focus, there are other equally incapacitating (and potentially
fatal) health issues such as anaemia, parasitic diseases, problems
1,550,000
79,050
menorrhagia
associated with long hours of back breaking work, gynaecological
problems and yes, also violence. Neglecting these is doing injustice
to the cause of women's health.
Source:
Pelvic
12.42
infections
per 1000
u
19.251
Incidence Rate (IR) for bleeding and pain, 'Contraceptive Technology. 1986-87,
13lh Revised Edition. Irvington Publishers, p 202. as cited,in ref. 8.
- The legislation of abortion was considered a land mark in helping
women attain reproductive control and prevent deaths due to
quackery. Yet, physically, socially and financially MTP facilities still
remain inaccessible to a majority of women. GOI data for MTP over
a three year period (1978-1981) indicate that the highest percentage
of MTP's were resorted to following contraceptive failure. While
there may be more to these data than meets the eye, the fact that
MTP is resorted to as a method for FP points to the lack of
contraceptive education amongst the masses.
FP Vs Women’s Health
The primary health programme makes a pretence of concern
Contraception as Empowerment
The Conference marking the International Women’s Year,
1975, declared “the right ofwomen to decide freelyand responsibility
on the means and spacing of their children and to have access to
the information and means to enable them to exercise that right.....".
The situation for women in India is a far cry from the resolution. The
targetting of women for population control has oppressed and
harassed women - as health personnel, pressurized to achieve
targets; as guinea pigs, for (often uninformed) contraceptive testing,
as acceptors, as victims of a system where the choice on when and
how many children to have and What contraceptive method to adopt
is defined by the policy makers, health personnel, pharmaceuticals
and family members who adhere to patriarchal norms.
It is in this context that one questions the research info and
advocacy of newer contraceptive technologies. Why should it be
that research aspires to develop contraceptives for women only?
towards women’s (and children’s) health through the Maternal and
Child Health (MCH) programme. However, as the name itself
The persistence in testing and promotion of injectable contraceptives
indicates, women are catered to primarily as mothers, the programme
at taking away women's control over their own reproduction.
At the same time research into male contraceptives has hardly
actually serving as an entry point to achieve FP targets. With the
and hormonal implants seems to point to more pronounced efforts
introduction of the concept of National Reproduction Rate Unity
received any impetus. The fact remains that, at present, the ’ideal
(NRR-1) the fate of the Family Welfare Programme and the
associated MCH Programme is sealed. In fact, the first U.N.
contraceptive' which is effective, safe, cheap and easily accessible
Advisory Mission stated as far back as 1966 that ANM's should be
‘relieved from other responsibilities such as MCH and Nutrition so
While conceding the factthat contraception, if safe and effective,
has the potential of empowering women, unless the approach
as to concentrate on FP efforts’ because of 'the fear that the (FP)
contd. on page 12
and acceptable to all strata of society is simply non-existent.
FRCH NEWSLETTER, VOL.VI, NO. 1, JAN.- FEB 92
POPULATION, POVERTY AND SOCIAL CHANGE
An Alternative Paradigm
Vasant P. Pethe
Population growth is one of the most critical issues of our times.
Sharp differences of approach exist concerning the diagnosis of the
proves neo-Malthusian thought to be totally erroneous.
twin problem of population and poverty in terms of its causes and the
prescription in terms of policy interventions.
My new paradigm begins with the initial proposition that
population growth is not the cause, but rather the effect, of poverty.
I have two propositions to make. My first proposition is that our
perception of the population problem is based on the Western neo-
There are several reasons why the poor prefer to have a larger than
a smaller number of children. One is that many of the children born
Malthusian paradigm which is out of date and irrelevant to Indian
to a poor man are likely to die in infancy. If population growth is not
the cause of poverty the basic sources of the phenomenon of
conditions. This model regards the so-called over-population as the
cause of poverty. By doing this, it has brought the analysis of poverty
poverty will have to be sought somewhere else than mere population
size or growth. Here, we arrive at the most central thesis of my
to the dead-end of population; My second proposition concerns my
own approach. I have been proposing for the last many years an
alternative paradigm, which is eclectic in nature. It begins with the
argument that rapid population growth is not the cause but the effect
paradigm. This I have already stated as proposition two at the
beginning. I may restate it in a different way. The poverty for the
of poverty.
In fact, my central thesis is that the various socio
masses results from the incapacity of our defective socio-economic
system and inequitous international economic order to put into
service modern science and technology for an optimal utilisation
and distribution of this planet’s vast resources for raising the living
economic problems like unemployment, illiteracy, ill-health, etc.
including the population problem, result; (a) from poverty as their
'immediate* determinant, (b) from such evils as inequality,
consumerism military expenditure, defective planning, etc. as their
‘intermediate* determinants, and, (c) from out-moded non-egalitarian
social structures and spiritual degradation as their 'ultimate*
determinants These two propositions constitute the essence of my
philosophy and line of thinking on social problems in general and
affluent classes in India). To convert this consumerism in
population numbers, one can say that the population of the USA
is not 25 crores but 2500 crores (30 times India's population). An
the population problem in particular. While I call the Neo-Malthusian
model as the "numbers game" paradigm, my paradigm may be
styled as the "social transformation0 paradigm
American citizen consumes on an average energy resources 100
times the world average. Its population has therefore to be reckoned
as 100 times of what the census shows.
The state of the Indian polity, economy and society has been
in a bad shape indeed for a long time. On the demographic front, our
Having delineated my basic approach, the natural question is
what are the policy implications: three basic principles must underline
the government policy. First, egalitarian social transformation must
occupy the central stage and the major focus in all policies formulated
to attain our overall social progress Secondly, we should not be
population is growing unabated. Against this backdrop, the question
arises as to how and why we have failed.
So far as the problem of population vis-a-vis poverty is
concerned, we have unfortunately advocated very vigorously, what
is known as, the neo-Malthusian approach in our population
policy .This approach attributes poverty at the social level to population
explosion and poverty at the individual household level to large
number of children amongst the poor. To me, this paradigm is
entirely obsolete, irrelevant, and to use strong words, even perverse.
First, throughout human history, whatever the population size - big
or small - the under-privileged have always remained poor - the
slaves during slavery, surfs during feudalism and the vast majority
of landless labourers, tribals and slum - dwellers under the present
day capitalistic system. Secondly, empirically examine the economic
developments in India since Independence. India of today having
a population of about 85 crores is economically certainly richer and
standards of the people.
To speak in some concrete terms, take for example, the crazy
consumerism of the West (which is being aped by the emerging
crazy about the fulfillment of 'quantitative' targets. Rather, we
should care more for the ‘qualitative* transformation in human
attitudes and behavior. Thirdly, there has been an explosion of
expectations amongst the masses. However, in the context of
limited and non-renewable resources, it is just impossible to satisfy
completely all the expectations of all the people. Hence, it is
imperative to give a proper direction to these expectations. This
channelizing should be towards improvement in the quality of life,
not towards vulgar, rat-race like ostentatious style of living (as is
exhibited by the newly rich).
I am likely to be misunderstood, but I underestimate neither
family planning nor the population problem. I am also not against
Western people or culture. I am only against adoption of alien
paradigms. I contend that if we want that the people should adopt
stronger, especially in terms of defence, infrastructure and scientific
personnel, than India of 1951 when our population was as low as
family planning, it is necessary that we create conditions conducive
36 crores. Thus, we find that both historical and empirical evidence
to such motivation.
Dr. Pethe (Dashbhuja Ganesh Co-op Soc., Near Paud
Basic References:
Phata, Karve Road, Pune 38) is a former UGC Emeritus
Professor-Fellow at Pune University. The article above has
1)
been abstracted from his speech at the Indian Science
Congress, Baroda, January 7th, 1992.
FRCH NEWSLETTER, VOL.VI, NO. 1, JAN.- FEB 92
Pethe V.P., Population Policy and Compulsions in Family Planning, Continental
Prakashan, Pune, 1981.
2)
Pethe V.P., State of Knowledge and the Demographic and Social Reality: some
fundamental concerns. Popular Prakashan; Bombay 1986.
■
10
BOOK REVIEW
Shubhra Krori
Your Health and the Indoor Environment: A complete guide to
to electromagnetic radiation and even air purifiers) , their effects on
better health through control of the indoor atmosphere -
health and ways by which these mal-effects can be controlled. The
final section gives "additional tidbits that should not go unrecognized’
and looks optimistically towards a future where "man will improve
his environment because he must" and the hope that the reader ’will
never again fail to see the importance of maintaining a healthy
indoor environment".
Besides the information contained in the chapters, detailed
appendices and a glossary add to a better understanding of the
Randall E. Dunford, Nu Dawn Publication, Dallas, Texas,
1991, pp. 270.
Environmental consciousness, stimulated by the growing threat
of ecologically hazardous development processes, has been a
growing phenomenon in the last few decades. This is specially true
for the advanced, capitalist states like the U.S.A. The book under
review "would likely fit into the realm known as clinical ecology', a
controversial area, one which suffers from a lack of precise clinical
definition and scientific validation. However, the bookdraws attention
to numerous issues and aspects which are easily overlooked as
sources of toxicity and/or stress in the indoor environment.
The subject matter is organised in an understandable, lucid
style, in sections and chapters which present each issue in systematic
detail with an abundance of charts and diagrams. Part I sets the
stage for the information contained in the subsequent section, by
commenting on the fact that while the body is a wonderful selfperpetuating system, it has its limits in being able to combat
pollutants. Part II goes into detailed identification of a wide range
of substances in our indoor environment (from household artifacts
Shubhra Krori is based in Pune and is a researcher on the
FRCH project studying the operational and social aspects
of T.B. control.
(
------- -------
information.
While, without doubt, the information is interesting and helpful
in raising the awareness levels of readers regarding maintenance
of a healthy indoor environment, the practical relevance of such a
book to the conditions of the large masses, particularly to those
living under conditions of poverty in Third World countries, is
doubtful. The entire book is full of examples which bear testimony
to this. To illustrate, the author cites the example of natural gas as
being one of the greatest contributors of indoor pollution, on the
assumption of its widespread application throughout the world.
How many homes in India really use natural gas as a heating and
fuel source ? In fact, in most rural households (70% of the
population) open hearths (chullahs) using coal or wood are the
traditional devices used. How many households have adequate
ventilation (chimneys or, even windows) to let out the smoke ?
Building awareness and finding alternatives for this section would
be of far greater relevance in our context.
8
. —
1
THE U.N. CONNECTION
(abstracted from TOI, 14.5.91)
With a population of 853 million, India is the second most populous country in the world. At the current growth rate, adding
some 19 million people annually, the population is expected to cross the 1 billion mark by the year 2000.
While releasing the State of the World Population Report, 1991, the United Nations Fund for Population Activities (UNFPA)
has warned that such an increase will have very serious social, economic and environmental consequences, undermining the
progress made in development and further affecting the livelihood of the 322 million people who already live below the poverty
level.....To help the Indian government achieve its population and development objectives, the UNFPA has promised $90
million assistance over a five year period starting in January this year. The proposed programme has been designed to
complement the country 's revised Strategy for National Family Welfare and the Development Plan Document for the Eighth
Five Year Plan. A UN 'Programme Review and Strategy Development mission* (PRSD) visited India for that specific purpose
last September. The population goal of India is to achieve a net reproduction rate of one by the turn of the century and zero
population growth by the year 2050. Short-term targets set in the Eighth Five Year Plan include increasing contraceptive use
from 43.3% to 53% by 1995; reducing crude birth rate from 30.5% to 26.7% in five years; reducing crude death rate from 10.2
per thousand to 9.3; infant mortality from 91 per thousand live births to 80 per thousand live births. This is expected to drop
the population growth rate from 2.03% to 1.76% in five years....In collaboration with Hindustan Latex, the UNFPA would help
set up a plant in Trivandrum for manufacture of IUDS. The HT in Delhi would be setting up a cell to monitor the quality of the
IUDs manufactured.
Since women’s literacy development help to control population growth, the UNFPA’s programmes revolve around women.
In Madras, through the Working Women's Forum there is a proposal to create a revolving fund to help women set up income-
generating projects.
But now there is a greater effort worldwide to draw men into the population programme. In India, where the terminal method
of family planning is still prevalent, for some years now the emphasis is on tubectomy. To make vasectomy more acceptable
to men, now a ‘non-scalpel vasectomy’ is being advocated. Voluntary organisations are being encouraged to manufacture
as well as to do social marketing of condoms.....
1
j; ’ ;
5)
FRCH NEWSLETTER, VOL.VI, NO. 1, JAN.-FEB 92
LIBRARY NEWS
BOOKS
REPRINTS
1) Banaras Hindu University, ICMR Project on Operations Research in
1) Aneja, K.S., Active Case Finding in TB as a Component of PHC, Indian
Journal of Tuberculosis, 1984, pp. 65-73.
Delivery of Primary Health Care in Varanasi District, Banaras Hindu
University, IMS Varanasi, 1989, pgs. 97.
2) Bayu, Teklu, Reasons for Failure in Treatment of Pulmonary TB in
2) Government of India, Programmes and Concessions for the Disabled
Persons, GOI, New Delhi 1980, pgs. 69.
Ethiopans, Tubercle, 1984, pp. 17-21.
3) Bignail, J.R., Treating Tuberculosis in 1905: the first patients at the
3) Government of Maharashtra, Lokprakashan Paribhasha Kosh, (Marathi)
GOM, Bombay, 1987, pgs. 80,
Brompton Hospital Sanatorium, Tubercle, 1977, pp. 43-52.
4) Hershield, E.S., Drug Resistance: response to Dr. Shimao, Tubercle,
4) Government of Maharashtra, Rajyashashtra Paribhasha Kosh, (Marathi)
GOM, Bombay, 1986, pgs. 116.
1987, pp. 17-18.
5) Jagota.P., Venkatarama Gupta, E.V., The Acceptability and Efficacy of
Short Course Chemotherapy under Conditions of an Urban
5) Government of Maharashtra, Shasan Vyavahar Kosh.(Marathi) GOM,
Tuberculosis Programme, Indian Journal of Tuberculosis, Vol. 36 (18)
Bombay, 1973, pgs.614.
6) Myrdal, Jan, Report froma Chinese Village, Pantheon Books, New York,
1965, pgs. 373.
Jan. 1989, pp. 20-26.
6) Kilpatrick, G. S., Compliance in Relation to Tuberculosis, Tubercle,
1987, pp. 31-32.
7) Pethe, Vasant Prabhaker, State of Knowledge and the Demographic
and Social Reality: some fundamental concerns, Popular Prakashan,
7) Rouillon, A., Transmission of Tubercle Bacilli: the effects of
chemotherapy, Tubercle, 1976, pp. 275-299.
Bombay, 1986, pgs. 24.
8) Roy, Somnath, Community Participation in Primary Health Care.
8) Saxena, P., Treatment taken before Reporting at a TB Clinic, Indian
NIHFW, New Delhi, 1986, pgs. 192."
9) Srinivasan, K, Need for a Reorientation of Family Planning Programme
Journal of Tuberculosis, 1987, pp. 104-107.
9) Shimao, Tadao, Drug Resistance _in TB Control .Tubercle, 1987, pp.
Strategies in Developing Countries, Himalaya Publishing House,
(undated) Bombay, pgs.22.
10) World Health Organisation, Financial Planning for Health for All by the
5-15.
10) Sivaraman, V., Alternative TB Control Strategies and their Potential
Impact, Indian Journal of Tuberculosis, 1988, pp.117-122.
Year 2000 - report on an inter-country seminar, SEARO Technical
Publication No. 5, New Delhi, WHO, 1984, pgs.236.
contd from pg.9
contd from pg.4
sincerely seeks to enhance women's self - determination and
present the different local governments, entrusted with providing
health through a process of informed and free choice, the exercise
care under the reforms, are experimenting with a number of health
becomes self - defeating and adds to the burden of their oppression.
insurance and market mechanisms. There is no existing model of
Studies of the impact of FP programmes on the fertility decline
a viable health insurance for an agrarian society and, to that extent,
in 94 Third World countries (between 1960-70) were estimated
China's experiments will be watched with interest. It is hoped that,
around 3 to 20 percent. Social and economic factors accounted for
in the process, the system will remain accountable to the needs of
the rest. A policy which aims at enhancing women’s health should
the poorer sections, the backward regions and basic health care.
take such realities into account and stop being singularly obsessed
with the ideal of optimum target achievement in family planning.
Select References:
The priorities must be women’s health and empowerment; not state
1)
Mankad. D. - A Dialectical Approach to Traditional Medicine: a lesson from the
2)
Roemer. M. - National Strategies for Health Care Organization: a world overview,
3)
Sidel. V. W.& Sidel, R - Serve the People: observations on medicine in the
4)
Sidel, V. W. -"China: the barefoot doctor is no more". In Rolling Back Health Gare;
5)
Young, M. E - “Impact of the Rural Reform on Financing Health Services in
and social control over their fertility.
Select References
1)
Anant, R.S. .Population versus Resources - an apparent problem background
2)
Daswani, Mona & Britto, G.A.A. Women and Health; a critical review of available
paper, MFC XIII Annual Meet, Jan, 1987.
information in India; FRCH, 1984.
3)
Gupte, Manisha, Women and Family Planning - scope for struggle, paper
presented at the 3rd National Conference on Women's Studies, Chandigarh, 1986.
4)
Gupte, Manisha MCH services: Programming Reproduction ? RadicalJournal of
5)
Karkal. Malini, Can Family Planning solve Population Problem? Stree Uvach
Chinese experience, Socialist Health Review, 2 (3). 1985.
Health Administration Press. Ann Arbor, 1985, pp. 305 - 316.
People's Republic of China, Beacon Press, Boston, 1973.
Special Report. Links, 7 (1), Spring 1990; pp. 5-6;
China." Health Policy, 11,1987, pp; 27-42.
$
Health.MoM^. Sept. 1986.
Publication, Bombay, 1989.
6)
Nagraj, B.S.. Wages of Terminal Methods, Indian Express. Jan. 10,1992.
7)
Prakash. Padma, Women: blind spot in health policy ? Background Paper at the
8)
Sathyamala. C.. Contraceptive Choice: safety vs efficacy, Background Paper,
9)
Sathyamala, C., Sundharam. N. & Bhanot, N. - Taking Sides: the choices before
seminar, Health for All: concept and reality. FRCH - ICMR, Bombay, 1986;
MFC, XIII Annual Meet Jan, 1987.
FREE ABSTRACTING
The contents of this newsletter? may be
abstracted without prior permission. However
we would welcome acknowledgement of the
source and copies of any abstractions.
the health worker, ANITRA. Madras. 1986;
Edited by Nagmani Rao, with secretarial assistance from Vrinda and Joyeeta Sinha and produced by the Foundation for Research In Community Health,
84-A, R.G. Thadani Marg, Worli, Bombay 400 018. Registered under the Bombay Public Trust Act. Printed at Printext Offset, Pune 30.
COMMUNITY HEALTH CELL
326, V Main. 1 Block
Koramangala
Bengelor-560034
Mia
Mar - Apr 1992
Vol. VI, No. 2
SPECIAL ISSUE ON THE HANDICAPABLE
FROM THE EDITOR’S DESK
A visit to an unusual pre-primary school, Ankur Balmandir, in
Department of Social Welfare, already operating under severe budgetary
। Pune, provided the impetus for this special issue. Here was a school
constraints and catering to a wide section covering destitutes, juvenile
where one saw a very "normal" and healthy mixing of handicapped
delinquents, etc. While the government puts forth an impressive list of
children (called "special children") and other children. The nature of
concessions (in fields like education, training, employment, economic
handicap varied, from hearing impairmentto mental handicaps. Yet, over
assistance, housing, etc.) these are hardly adequate or accessible to the
four years of its existence, the school has provided a positive insight into
large number in need.
the potential for integration of handicapped persons into mainstream
The recommendations of the Kothari- Commission on
society.
Education (1964-66) for development of educational facilities with regard
Yes, the focus of this issue is on integration, on awareness
to the disabled, turned out to be an exercise in vain, (as with numerous
and, on understanding. The handicapped are also capable - they are
such well-meaning commissions) in the absence of strong political will.
"handicapable". They have their special needs and if society takes a
The accent therefore is on the voluntary sector, which, despite dedication
collective responsibility to meet these needs, the enrichment would be
and motivation, is beset with innumerable constraints.
mutual.
The government apart, society in general also exhibits
What is the general attitude towards the handicapped?
ignorance and lack of concern for the issues of the handicapped. The
People seem to see in them only that which is wrong or different (spelt
masses, living on the brink of poverty, have other immediate survival
abnormal) and not that which is right and normal.
Innumerable
concerns and therefore cannot even think in terms of meeting the special
handicapped persons experience the trauma of rejection, ridicule, pity,
needs of the disabled. Ignorance, superstition and a fatalistic attitude
over-protection - everything to reduce their self-esteem. What they look
blocks any constructive collective effort to provide the handicapped with
for is acceptance, encouragement and opportunities. A good life for them
opportunities for self-development.
means acceptance by family members, social peers and vocational and
classes, who may have the time and resources to avail of special facilities,
recreational outlets.
the tendency to over-protect the disabled is strong. The general attitude
Amongst the more privileged
therefore is one of seclusion, non-integration. The handicapped suffer
While surveys of the disabled by the National Sample Survey
for the Disabled does not seem to take into account every kind of
alienation not so much because they are disabled but because
society encages them in their isolation.
disability, researches" by some voluntary agencies indicate over fifty
million disabled in India.
Research has also established a definite
This is where the importance of integration centres comes in.
correlation between poverty and disabilities, with the lower socio
It benefits both waysa) in enhancing the sensitivity, awareness and
economic groups having a larger concentration of disabled children than
a sense of acceptance (on the part of "normal" persons) with regard to
the affluent sections. Facilities for education of the handicapped are
handicapped friend and, b) in helping the handicapped to face upto
woefully inadequate, covering a bare one percent of the fifty million. Till
the rigours of a normal life and thus gain in self-confidence.
1988, there were just over a hundred Special Education Centres for the
4 million blind, seventy special schools for 15 million deaf and hearing
impaired persons; less than a hundred schools for twenty million children
The process paves the way for the handicapped themselves
taking initiative to organise rehabilitation of their own kind.
having mental handicaps and just a handful of institutions for the
orthopaedically handicapped. ^Alur et al, 1988 )
The articles in this issue do not cover all categories of
There is still no clear-cut government policy in India, backed by
handicaps, but only the more prevalent viz. - the orthopaedically
handicapped, the deaf, the blind and the mentally handicapped. They
appropriate legislation, for the benefit of the handicapped. The education
seek to share experiences and enhance public awareness with a
and rehabilitation of the disabled comes under the purview of the
unanimous vision of an integrated world for the handicapped.
FOR PRIVATE CIRCULATION ONLY
•
INTEGRATING THE
ORTHOPAEDICALLY HANDICAPPED
the challenges
Arnie Antia
The relationship between society and the wide spectrum of its
society. It is here that they (and their parents) realize their potential and
citizens is an interesting yet complicated subject. The question under
thus build on the possiblities of a hopeful future.
The Society for the Education of the Crippled (SEC) was
discussion is, how individuals are able to contribute in a positive manner
It aims to educate
to the environment and the state in which they live. Each person has a
role to play and it is the part played by the orthopaedically handicapped
established in 1960 with such concerns in mind.
which we are considering here.
to be productive and responsible members of society. It also seeks to
handicapped children and adults by providing them with the opportunity
enhance public awareness on the issues of the physically handicapped.
A significant feature about the SEC school units is that they cater entirely
Causes of Physical Handicaps
The causes resulting in physical handicaps are numerous and
their incidence overwhelmingly high. An unhygienic living environment,
inadequate health services and poor socio-economic conditions in which
many of our children live, largely account for their being handicapped
to the lower socio-economic sections: a class most often deprived in
terms of capability for and access to special facilities such as these.
e
The following table gives information regarding the disabilities •
of the children attending the SEC School Units in Bombay and Talegaon.
Other prenatal factors include genetic and chromosomal anomalies and
other hereditary congenital defects. Muscular dystrophies cause
progressive weakness and wasting of the muscles which cause gross
crippling.
NATURE OF DISABILITY
UNITS, BOMBAY
These ultimately lead to a bed-ridden existence before a
RURAL PROJECT:
S.E.C. DAY SCHOOL
SEC CENTRE FOR INDEPENDENT
LIVING, TALEGAON
premature death. Spina Bifida (a congenital defect of the spine) may
cause paralysis of the lower limbs and the loss of control over urination
Poliomyelitis
192
39
and defecation. Arthrogryposis is another congenital abnormality, where
Cerebral Palsy
30
the muscles of various joints shrink and bend, producing loss of functions.
Hemiplegia
23
7
--
Other prenatal factors such as drugs, illness, malnutrition, etc., which
Muscular Dystrophy
16
--
Congenital Deformities
9
4
result in various physical deformities such as absence of limbs or
Spinal Anomalies
Bone Deformities
7
5
2
deformed limbs.
Amputation
8
1
Post Measles Alexia
1
-
291
53
play a damaging role, take place in the first trimester of pregnancy and
Injury and infection are important post-natal or acquired
factors causing orthopaedic handicaps. Trauma during delivery is a
common cause of cerebral palsy and may be accompanied by mental
retardation. Head injuries later in life may also cause brain damage.
Injuries to other parts of the body may result in deformities or require
Parents usually seek admission for their children into Special
amputation and the loss of a limb. However the diseases most commonly
School after having spent a vast sum of money and considerable effort in
responsible for orthopaedic deformities are poliomyelitis, encephalitis,
trying to cure their child's disability. They include whatever means have
meningitis, tuberculosis and hemiplegia.
been available to them, both medical and religious, but having little
Educating the Crippled
several other children who have similar difficulties as their child. For the
positive impact. It is a comfort for them to eventually realise that there are
When the handicap is mild and mobility not grossly impaired
well-being of these children it is essential that their particular handicap be
the child can attend a regular school. However with a severe disability,
understood and their abilities and limitations be accepted by their parents
a Special School for their all-round development, during their most
and that they be treated on par with the other siblings in the family. This
If this is not provided an
is not easy, as many parents are inclined to be emotionally involved and
formative period of growth, is essential.
opportunity is lost, that cannot be made up for at a later stage. Whereas,
may develop a sense of guilt. They tend to be over-protective and prevent
disabled children would be frustrated by their inability to compete with
the children from managing their own daily requirements or they may
“normal" children in a regular school, in a Special School they are able to
reject such children, considering them as liabilities.
have close association with other children with similar difficulties. This
Besides other considerations,
emphasis is placed on
helps them gain confidence, gives them a sense of security and
academic education at school, whereby the children are required to
encourages them to make progress despite their disability. Attending
follow the same curriculum as approved by the Department of Education,
school is the first step in the process of meaningful integration into
Bombay Municipal Corporation. However, here, teachers ensure that
each child receives individual care and attention for developing his/her
The author is the President, Society for the Education of the
Crippled (Child and Adult), Bombay.
FRCH NEWSLETTER. VOL VI, NO 2 MAR - APR 92
I
own abilities. This is achieved by having small class groups and providing
those with scholastic and adjustment difficulties with additional inputs.
Integration into a regular school generally takes place when students
complete std.IV and are academically on par with the others in their class.
requirements, vacation activities, legal aid, housing, employment
opportunities and field visits to the B.M.C., Airport and Nehru Centre.
Dialogues with personnel from agencies such as the Indian Cancer
Creating Facilities: Enhancing Mobility
Since the children are unable to use public transport, school
buses are an essential requirement. To minimise the distances children
have to travel, day school units are located in central Bombay and the
Society, Mobile Creche, Yoga Institute, and viewing audio-visuals, open
up areas of interest outside their daily routine and thus enrich their lives.
Preparedness for Regular School
eastern and western suburbs. At the rural unit at Talegaon in Maval
The process of integration into a regular school and
Taluka it has been found necessary to have a semi-residential unit, so
mainstream society starts as soon as the child enters the special school.
that handicapped children living in the surrounding villages can attend
school during the week and return to their homes for the weekend and
holidays. In this way they keep in constant touch with their family and
To be considered for admission into a regular school, children not only
need to achieve adequate competence in academic subjects, but also be
able to cope physically with architectural barriers and toilet facilities which
are not modified for their convenience. Besides, they also, need to be
community.
To ensure mobility, appliances need to be used by most
children. These need constant repair and maintenance. Conventional
psychologically ready to cope with being one of 50 in a class, and
emotionally prepared to face a new environment and new challenges.
Successful placement of handicapped children into a suitable
calipers are cumbersome, very heavy, require leather boots and are often
rejected. A research project to make light - weight, easy-to-manage
appliances is underway. This should help each child achieve a maximum
degree of functional independence at an early stage. Therapists help
with mobility training, give exercise and instruct parents on how to
normal school requires much effort and planning . This is done through
group meetings by the integration team. The social workers locate a
suitable school which is accessible, has transport facilities and if possible,
a class for the child on the ground floor. On being’ accepted by the
conduct activities to prevent contractures and deformities. Swimming is
Principal, the parents and their child are introduced to their prospective
an excellent exercise for strengthening and maintaining the muscles of
school.
Psychological and emotional readiness is created through
handicapped children. This is an essential weekly activity for the children
camps and meetings with integrated ex-students. Nevertheless, the
attending the day school units and at the rural centre. General medical
students entry into a regular school is often demanding and may prove a
services with doctors conducting routine check-ups for the children and
traumatic experience, if not handled with sensitivity.
providing advice for their parents, contributes to the children’s physical
The challenge of integrating severely handicapped children
well-being. Besides this, fruit, milk and a hot meal has proved to be of
into regular school does not end with the children leaving their special
value in sustaining the general health of the children.
school. Follow-up and supportive services are essential to facilitate
adjustment to society and to prevent them dropping out of school. Ex
students take part in regular Sunday Sessions where they meet their
The Process of Integration
In preparation for successful integration into regular schools,
children need to develop self reliance as well as social and emotional
growth. Children with a handicap are often not exposed to recreational
activities in their home environment.
It is therefore essential that
maximum exposure be provided, with extra-curricular activities as part of
the school program. These include outings for the very young and camps
extending from a weekend to ten days for the older students. Annual
days to be celebrated include sports, which provide an opportunity for all
children to participate and compete in an event appropriate to their age
and disability. The Prize Distribution Day is also an important event,
when the current children and ex-students perform with confidence, to be
witnessed by an appreciative audience including parents, proud of their
children's abilities and talents in drama and dancing. Other activities
include indoor and outdoor games, art and music.
Much of the success in rehabilitation depends on the positive
acceptance by the children and their families of their own condition.
Social workers provide counselling, make home visits and maintain
community contacts. In our rural project they conduct surveys in the
friends and have discussions which cover topics like smoking and
alcoholism. They participate in activities like street plays, community
singing, music sessions, picnics and visits to different industries. These
meetings also provide opportunities for socialising, recreation, structured
and unstructured learning sessions.
Counselling is available for school matters, career selection,
employment and issues related to adjustment in life. Thus they are able
to solve problems related to their studies and other difficulties. Many ex
students apply for assistance. Educational aid, Mobility grants and Merit
Scholarships
are sanctioned
each
year.
Eventually successful
integration results in finding suitable and gainful employment and
accepting the fact that it is the individual's mental attitude, perseverance
and hard work that counts.
Building Public Awareness
Public Awareness Programmes are helpful in bringing about
greater understanding of the disabled. They can be undertaken through
workshops, integrated programmes, the press and other media publicity.
villages to identify the handicapped, arrange for assessment camps and
It is a sad reflection of-our society that funds are more easily obtained
hold meetings with the Sarpanch, along with the parents. They also
while projecting a "pitiable" condition rather than a happy situation. This
provide vocational counselling and assistance for improving the
attitude is most damaging and prevents the handicapped from feeling like
occupational skills of disabled youth.
"persons” and erodes their self-respect. It takes a greater effort to
provide for the true requirements of the handicapped, as felt by them,
Parents' participation and involvement in their children's
overall development helps them know of their child's progress and to
rather than to dole out what the giver gains satisfaction from giving.
recognise his/her abilities. With the teacher they can successfully draw
The effort, time and thought spent on integrating the
However parents have varied
handicapped into mainstream society can only be successful when they
requirements of their own, which need to be met. An "awareness"
are accepted by society as people with the same rights and obligations as
programme of monthly meetings related to their everyday life has a
any other citizen. Finally, it is the attitude of society which determines, to
out the best in their own children;
positive contribution to make.
3
Topics covered include health
a large extent, the successful integration of a handicapped person
•
FRCH NEWSLETTER, VOL VI, NO. 2 MAR - APR 92
HEARING IMPAIRMENT
The Invisible Handicap
Yeshashree Gurjar
“My child is 4 years old but still does not utter a word". It is
Degree
Loss in dB (range)
typically with complaints like this that most parents of Hearing Impaired
(HI) children approach doctors. Very rarely do they realise that their child
Normal
0-20
is unable to speak because s/he has a hearing impairment or is a 'deaf
Mild
25-40
child. Most people label their children 'deaf and dumb' or 'deaf and mute'.
Moderate
45-60
Contrary to the belief that deaf people are also dumb or mute, these
Severe
65-80
children are born with normal vocal apparatus. Parents are surprised .
Profound
85 and above
when they are told that their child cannot speak because s/he cannot hear
what is being spoken by people around.
Language has aptly been
described as the finest form of imitation and what one cannot hear one
cannot imitate. Thus the process of language acquisition, which normal
children acquire with ease, remains stagnant in deaf children. Hearing
Impaired at birth but might become so due to illness or accident. If this
impaired children have to be taught to understand and speak the
happens after they have acquired some amount of language ability,
language of their community. This procedure is long and labourious, but
their
can definitely make these children vocal enough not to be labelled ‘dumb*
rehabilitation measures are not
or 'mute*.
language abilities can occur.
Initial Identification Difficult
g
•
Needless to say that language of children with severe to
profound loss is affected the most. Some children might not be Hearing
rehabilitation
procedure becomes slightly easier,
but
if
immediate, regression in existing
Importance of Early Identification
Hearing Impairment has been described as the invisible
It is imperative that a H.l. child has a proper hearing aid. In a
handicap mainly due to the difficulty in identifying it. In fact, it is never
sense they are the ears s/he does not have. These hearing aids are
easy to identify a H.l. person from a normal hearing person in a crowd,
prescribed by an audiologist and are available in various powers. A
since persons with this difficulty do not have any external signs of having
hearing aid picked up at random cannot suit any child. It has to be brought
a handicap. It is only through their unintelligible speech that they are
keeping in mind his hearing loss.
identified. This handicap thus goes unnoticed in the early years and is
A H.l. child must begin his/her language training as early as
often detected at about 2 years of age or later. A H.l. child can be
possible with a special teacher or a language therapist. Research has
identified much before this since a normal child responds to sounds,
proved that children who begin training in the first three years of their lives
especially loud sounds, by the time s/he is two months old.
show better academic achievement .since language forms the basis of
Since the effects of hearing impairment are seen on the
any curriculum. Sometimes a hearing impairment is overlooked at an
capacity. A normal hearing child begins the language learning process
early age because it is not severe enough to affect responses to sound
during infancy. The problem arises when the child starts going to school ())
and is unable to cope with academics and keep pace with peers. The "
right from birth, hence it is never too early to start teaching language to a
child is labelled as 'dull', 'inattentive' etc. The H.l. which has always been
deaf child.
there is the actual cause.
Varying Degrees
who are identified when the effect of this disability manifests itself.
language development of the child, if the rehabilitation process is started
early, s/he can be helped to achieve near-normal, if not normal, vocal
In India, especially in rural areas, there are very few children
Hearing Impairment, like any other disability, has varying
degrees of severity and no person can be classified as 'totally deaf or
what is known as, 'stone deaf. The degree of hearing loss present in a
child determines the extent to which his language abilities can develop
without intervention. The following chart gives various degrees of
Hearing Loss as measured in decibels (dB). These are meant to be
guidelines and are not rigid parameters.
Sometimes the lack of speech and language is also overlooked with the
hope that the child might start talking late. This view is encouraged by
well meaning relatives, neighbours and friends.
We are also faced with the problem of children becoming deaf
in their childhood due to constant and untreated ear infections. Illiteracy
and ignorance about ear hygiene leads the parents to taking these
problems very lightly, little realising that it can lead to permanent damage
to the ear. This type of hearing loss can be prevented with public
awareness about ear care. To cite a few examples:
The author has studied linguistics and has specialised in
education for the hearing impaired, for her B.Ed. studies. Her
doctoral research has been to study the language development
of hearing impaired children. At present she is co-ordinating
Any ear discharge should be referred to a specialist for examination
and treatment.
Ears should never be cleaned by any sharp or wide edged instruments
(ie. hairpins, toothpicks, safety-pins, small, sticks, etc.)
the forum, "Action for the Rights of the Child", in Pune.
FRCH NEWSLETTER VOL VI, NO, 2, MAR - APR 92
4
COMMUNITY HEALT
326. V Main, I Block
Korameng“la
,
pongalore-560034
programme and partly due to teachers in normal schools, parents and
SPECIAL EDUCATION
The term 'special education' refers to all special
provisions made enabling orallowing disabled children
to get education. Special education requires services of
experts, adapted equipments, and specially trained
teachers.
Special education would include all the disabled
i.e. the blind, the deaf, the spastics, the polio affected
and the mentally retarded.
In the developed countries and even in some of the
developing countries, 'special education' is the
responsibility of the Ministry of Education. In India, it
still comes under Ministry of Welfare, which is wrong, as
disabled children sitting for public examinations do not
need welfare or custodial care but technical experts and
modified equipment and environment.
Source : A Critical Review of Services for the Disabled in India with Special Reference
to Education*. Mithu Alur el al. Research Dept.. Spastics Society of India, Bombay.
1988.
school administrators being apprehensive about the H.I. child's ability to
cope with the normal school environment and course work.
The successful implementation of IEP in about six schools in
Pune has proved beyond doubt that not only do H.I. children cope but
they excel in certain areas of study. The IEP makes provision for a
resource teacher for H.I. children for additional inputs. Although exact
statistics are not available, the dropout rate in these programmes is very
low and most children pass their 10th standard examination with atleast
a second class.
Other Aspects of Rehabilitation
The problems of rehabilitation do not end by providing them
with equal educational opportunities. Rehabilitation aims at making H.I.
people a part of the society without the stigma of the word 'handicapped'
being attached to them.
Unfortunately they are sometimes denied
college admissions and equal job opportunities, not because they do not
have requisite qualifications, but because people are skeptical about their
intellectual and physical capabilities. This results in a lot of frustration in
Children suffering from constant coughs and colds should have a
routine check-up after each period of illness to monitor ear blocks or
the minds of young H.I. persons, who, despite remarkable capabilities,
are uncertain about their future.
H.I. persons strive all their lives to see that their disability does
damage. Such a check-up can be carried out even by a qualified
general practitioner.
The practice of putting oil inside the ear creates condition favouring
fungal infections and should therefore be discouraged.
not handicap them in any way. Yet they are faced with the grim reality of
having to constantly convince people around that they can do anything
that others do - except hear.
•
The ears of infants and younger children prone to ear infections should
be protected by not allowing any water to enter the ears, particularly
THE U.N. CONVENTION ON
while bathing.
THE RIGHTS OF THE CHILD. - ARTICLE 23.
When a child (sometimes or always) does not respond to calls, parents
often dismiss it as his/her “moodiness". However if this is a recurrent
phenomenon it should immediately call for examination for possible
onset of deafness.
1. States Parties recognize that a mentally or physically
disabled child should enjoy a full and decent life, in conditions
which ensure dignity, promote self-reliance, and facilitate
the child’s active participation in the community.
2. States Parties recognize the right of the disabled child to
special care and shall encourage and ensure the extension,
subject to available resources, to the eligible child and those
responsible for his or her care, of assistance for which
application is made and which is appropriate to the child’s
condition and to the circumstances of the parents or other
caring for the child.
Limited Facilities
Even if a child is identified early, there are very few schools in
India which offer pre-school programmes for deaf infants. Most schools
only take in children at the age of four and above.
According to the 1981 census there were about 3 million H.I.
people in India. These figures do not take into account children below 3
W)
years of age. Most of the population is concentrated in rural areas. In
3. Recognizing the special needs of a disabled child, assistance
extended in accordance with paragraph 2 shall be provided
free of charge, whenever possible, taking into account the
financial resources of the parents or others caring for the
child, and shall be designed to ensure that the disabled child
has effective access to and receives education, training,
health care services, rehabilitation services, preparation for
employment and recreation opportunities in a manner
conducive to the child’s achieving the fullest possible social
integration and individual development, including his or her
cultural and spiritual development.
contrast to this there are only 365 special schools for deaf children and
these are mostly in urban areas. The facilities available for H.I. people in
India are very few, considering the enormity of the problem.
Most experts in the field agree that a special school
environment is best suited for a H.I. child, especially in the initial years of
his life. However setting up new schools in every rural area is not possible
in a country like India where the problem far exceeds the resources
available.
4. States Parties shall promote in the spirit of international
co-operation the exchange of appropriate information in the
field of preventive health care and of medical, psychological
and functional treatment of disabled children, including
dissemination of and access to information concerning
methods of rehabilitation education and vocational services,
with the aim of enabling States Parties to improve their
capabilities and skills and to widen their experience in these
areas. In this regard, particular account shall be taken of the
needs of developing countries.
Integration: The IEP
"The Integrated Education Programme (IEP), a government
sponsored programme, aims to provide the H.I. child with equal
educational opportunities, that is, a right to seek admission and study in
schools meant for normal children. Integrating the H.I. child ensures
educational opportunities to the child living in remote areas with no
special school facility.
The child can socialise with his hearing
counterparts and hence feels a part of the mainstream. Though the IEP
has a lot of advantages it has yet to be successfully implemented in areas
l
Source: UNICEF, Nov. 1989.
where its need is the greatest. This is partly due to ignorance about this
5
ERCH NEWSLETTER, VOL VI. NO, 2. MAR - APR 92
SETTING SIGHTS HIGH
K. Ramakrishna
Dhritharashtra, the legitimate heir to the throne of Hastinapur,
stenographers, telephone operators, factory workers etc. We also have
was denied his rightful due, only on the pretextthat he was born blind, the
a large number of blind persons who are self-employed through vending
result being ambitions nipped at the bud, frustrations carried through life,
stalls, public call offices or in small business activities. Not only have they
hatred of the very near and dear ones, finally culminating in a fratricidal
thus blended with the productive labour force in this country, but some
war, the like of which history has seldom seen. The blind man may have
have achieved heights in their respective professions, - Dr. R.T.Vyas of
proved himself incapable of managing the affairs of the mighty empire,
the National Association for the Blind who pioneered the Blind Welfare
but what is regretted is that his incapacity was taken for granted. The
Movement, the late Dr. Wadegaonkar, ex-principal of Government Law
negative traits that this character so vividly displayed, more towards the
College, Bombay, Deepak Motiwala, Solicitor, Ravindra Jain, renowned
latter part of his life, may well be attributed to denied opportunities than
lyricist and music director, Dr. Kalyanraman, an officer in the Economic
Research Department of RBI, to name a few. It is heartening to see that
inherent human frailty.
There are yet others like Surdas, Swami Virajananda, (whose
the younger generation is not far behind; - Raman who specialised in
disciple was the well known social reformer, Swami Dayanand
Computer Science from I IT Powai and is presently pursuing doctoral
Saraswati), Louis Braille, John Milton and Helen Keller who have shown
studies in the U.S.A., Sam Taraporewala, lecturer in Sociology in St.
outstanding ability to conquer disabilities.
Xavier's College Bombay, and many others.
Welfare of the Blind
Succeeding Against Odds
- *atf
" 6 squs i
S414: 364: n
Te: as 36n: H
Notwithstanding persons who have excelled in different walks
of life and scores of other individuals pursuing lucrative and respectable
occupations, there are instances of even well-informed persons
expressing apprehensions about the abilities of blind persons who have
a sound academic track record.
I wish to share some personal
(There cannot be a syllable which finds no place in a word, no
experiences which reflect this. I was initially denied permission to avail
plant without medicinal properties, no human being without abilities,
the services of a writer during the entrance exam to the post graduate
however, what is rare is a good planner who harnesses the qualities in
degree course in management studies, by the authorities of a reputed
people and brings the best out of them)
management institute in Bombay.
The authorities seemed to be
The government, as also the voluntary agencies, have
convinced that let alone going through the course, a visually disabled
mobilised men, money and materials to promote the socio-economic
person would never be able to tackle the quantitative analytical problems
rehabilitation of the visually handicapped in India. Blind welfare has been
of which the entrance test comprised of. My interest was humoured as
in existence for over a century now. Over this period the approach has
over-enthusiasm. It required considerable persuasive effort on my part
to convince them to give me a chance, which they condescended to. If
evolved from one of relief to rehabilitation, which is evident from a variety
of programmes and projects currently undertaken by the government and
I may be excused for sounding a little immodest, I cleared the entrance
the voluntary sector.
test, joined another institute and completed the entire course, standing
The past few decades have witnessed appreciable work in the
areas of prevention and cure of blindness, and education, training and
second.
In sharp contrast, when I recently took the GMAT examination
The activities include eye camps, cornea
conducted by the Education Testing Service of U.S.A., upon my request,
transplants, cataract operations, production and distribution of Braille
the authorities not only permitted me to avail the services of a reader but
and recorded literature, scholarships, special schools for the blind and
also allotted extra time, if required. The question paper was set in large
employment of the blind.
g
• '
integrated educational programmes, vocational training centres, self
print braille, as also audio cassette, though none of these were requested
employment and placement services, etc. National Association for the
for. This aptly brings out the fact that blind persons are well capable of
Blind, (NAB), is the main organisation carrying out these functions. The
competing with others, when given the necessary infrastructural support
whole effort is directed towards a single objective - the economic
and a positive approach from society showing confidence in their abilities.
resettlement of the blind. When this objective is not achieved, the entire
Such challenges apart, the government, the voluntary agencies,
gamut of services becomes somewhat redundant. Years of well directed
educational institutions and people at large have played a determinant
work have certainly yielded desired results facilitating blind persons to be
role in shaping my academic and professional career.
gainfully employed as lecturers, solicitors, teachers, social workers,
Congenital cataract at birth and subsequent deterioration of
vision, compelled me to discontinue my school education for five years.
The author, a post graduate in Economics as well as Management
Studies, is presently the Deputy Manager, Project Finance
Ms. Rahmad Fazelbhoy, a social worker attached to NAB, paid home
visits and convinced my parents, the school authorities, and me that I
Department, IDBI, Bombay.
FRCH NEWSLETTER. VOL VI, NO 2 MAR - APR 92
6
()
—
spreading the services to the rural sector and funding community based
rehabilitation programmes. It will be desirable to educate, train and
More Disabled in Rural Areas
rehabilitate the blind in the general environment, thus integrating them
into society, rather than subjecting them to a special environment in the
There are more handicapped persons in rural
Maharashtra than in urban areas and those with locomotor
disablity top the list of disabled persons, according to a survey.
Statistics compiled by the National Sample Survey Organisation
after a survey of disabled persons during July - Dec. 1991,
indicated that the estimated proportion of such persons in the
state was 15.74 per 1000 population.
Of these 17.17 per
thousand were in rural areas while 13.42 were in urban centres.
form of special schools, sheltered workshops etc. which, unfortunately,
isolate them and make them apprehensive in interaction.
Economic rehabilitation of the blind will become increasingly
difficult if we do not change the methods of imparting education and
vocational training.
We may have to view this activity of economic
rehabilitation in the background of general unemployment, resulting in
severe competition and changing job requirements due to increased
mechanization, automation, and computerisation, both in production and
service sectors. This calls for a transition in our vocational training. More
Source Indian Express. March 20th 1992.
emphasis should be placed on our exploring newer avenues for selfemployment, as also re-orienting educational methods to include training
could continue my education. She assured us of infrastructural support.
in the areas of computers, electronics and communication skills.
I completed my graduation in Economics and Statistics from St. Xavier's
College, Bombay, with the support given by the college and friends with
Society can play a much more constructive role in the
rehabilitation of the blind rather than merely providing funds. There is
whom I could establish a relationship of ‘mutual benefit*.
need to engender awareness in the society that collective welfare can be
After completing post-graduation I joined a friend
in his
optimised by complementing strengths and combatting weaknesses
electronics business, primarily as in-charge of the marketing and finance
through appropriate technologies and facilities. This awareness should
functions. Though initially the customers had apprehensions in dealing
translate itself into the needs of all segments of society, impaired or
with me, my professional approach in delivering quality products on time,
otherwise, and creation of appropriate facilities to fulfill these needs, not
my effective communicative skills coupled with perseverance, removed
out of a sense of sympathy, but in the spirit of service. We, as a society,
all such doubts in their minds, over time.
must recognise that disabilities can be of various kinds and dimensions,
Management education is characterised by heavy course
physical, mental, social, so on and so forth. We can collectively optimise
load, pressure on time management, data crunching and heavy
only by being sensitive to each others1 distinct needs and pursue steps by
numerical analysis. The faculty in these institutes, largely consisting of
providing appropriate support systems to fulfil these needs in a spirit of
professionals from the industry, had reservations about my ability to cope
co-operation . This approach of society could play a crucial role in the
with such a programme and even if successfully completed, whether I
transition from dependence to self-reliance, darkness to light, mediocrity
would be able to get placed in the industry. It is however largely, sheer
hard work and goal orientation, aided by the very positive approach of my
to excellence.
In the current competitive environment, the blind cannot
co-students, and the encouragement from the faculty, that I out
depend solely on external help, but rather, have to rely on initiative and
performed all expectations and earned recognition . There was some
self help. They have to equip themselves to be equally efficient, perhaps
initial resistance in my getting a placement in the industry. I received
more, as compared to the sighted, and have to rely more on merit rather
offers from a few private sector companies; however the amount of
than reservation in the competitive job market.
options available to me were much more limited as compared to my co
conscious effort to come out of their shells of isolation and integrate
students. The Central Government, at this stage, and on a request from
themselves with the mainstream. In keeping with the trend of self help,
me, forwarded my bio-data to many public sector units who interviewed
organizations for the blind are giving way to organisations by and of the
me and offered me placement commensurate with my qualification. I
blind. Tonameafew, Blind Men's Association, National Federation of the
He has to make a
joined Industrial Development Bank of India as an Officer. The nature of
Blind, Blind Graduates, Forum of India, National Sports Club of the Blind,
my job here is-appraisal of industrial projects. Appraisal techniques are
subject to continuous upgradation and are increasingly more computer
and a few industrial Co-operative Societies.
The success of these efforts will assert the fact that, where
oriented. My success on the job is due to my ability to continuously adapt
there is a will, there is a way.
•_
to the job requirements. The support on the job given by the organisation
in the form of PC availability linked to speech synthesizer and a full-time
assistant has contributed much to my productivity. The approach of my
seniors and colleagues has been one of co-operation rather than
RALEGANSHINDI: ek sakhol abhyas
sympathy.
In an endeavour to continuously evolve professionally, I have
associated myself with teaching in some of the leading management
(Marathi)
by D. Panmand and ft Awasthi
institutes in the area of finance. I did not restrict my achievements to
professional success only. I am also a performing artist in vocal music,
The second (updated) edition is now ready. Copies can be
rendering devotional songs in many languages, in several parts of the
ordered from FRCH at the following contributory rates :
country.
Individual - Rs. 40/- (Plus postage)
Need for a Changed Focus
The ultimate welfare for the blind may be ensured only through
Bulk Order Concessions - 35% less (excluding postage)
a well-planned and co-ordinated approach by all the interested parties.
Government and voluntary agencies should place more accent on
7
FRCH NEWSLETTER, VOL VI, NO 2, MAR - APR 92
From Isolation to Integration
THE MENTALLY HANDICAPPED
Nagmani Rao
The mentally handicapped, perhaps, are the most deprived
section amongst all the handicapped.
While the generally popular
feelings so openly against a committment of confidentiality. The parents
and others interviewed come from educated, upper-middle class
They, therefore do not
represent
a generalised
attitude towards the handicapped is not a positive one, in the case of the
backgrounds.
mentally handicapped this is even more pronounced. It is no cause for
experience. Yet, even amongst these privileged classes, not everybody
wonder then that family members often choose to tuck the fact of a
makes an all out effort to get over the trauma of having a mentally
mentally handicapped person within the family away from public glare.
handicapped child and to seek opportunities for his/her integration.
While the intent may be to protect, this attitude amounts to further
Amit's mother, Vaishali, was so disillusioned that her first child
punishing a person already deprived on account of a disability.
was mentally handicapped that she was least concerned about the way
Institutional care (if accessible) may offer opportunities for training upto
he dressed or looked when he went to the play school.
a point. But the seclusion in institutions will neither take care of meeting
Deshpande, who runs an integrated play school for normal and special
all needs, nor will it gear the person to face up to mainstream life. The
children, questioned Vaishali on this and got the reply - " Why bother?
Madhuri
question raised is, do we advocate institutional care for the mentally
Who knows how long he'll live ? This is just a time-pass............... "
handicapped for their betterment, or is to protect ourselves from taking a
had to use a combination of sternness and persuasiveness to help
more responsible and sensitive role in their real development ?
Vaishali come out of her apathy regarding Amit.
Social Stigma and the Family
Experiments at Integration
She
The author, several years ago, had occasion to be associated
In fact, Madhuri, has several anecdotes to reveal the process
with a residential centre for the mentally handicapped, in Madhya
of transformation of attitudes of parents having mentally handicapped
Pradesh. This was a premier institution, offering excellent care and
children. A post-graduate in Child Development, Madhuri's inspiration
facilities from a dedicated staff. The Head of the institution once painfully
for an integrated play school for pre-primary children came from her own
remarked, “Most of the children here are from well-to-do (professional or
experience with Ameeta, a case of Down's syndrome, and the daughter
big business class) families who don’t have the time or patience to cope
of a friend. The child was unable to adjust in any of the regular nursery
with the situation of these special children. Somewhere, there are also
schools. Around the same time (Jan. 1988) Madhuri started a small play
elements of shame and guilt. We however stipulate that the children
group at home, with 4-5 children, including her son, Anoop. Ameeta
spend at least then long holidays with their families. Since the children
joined this group. Over the years she found remarkable progress in
come from as far away as Delhi and Bombay, it is not possible for us to
Ameeta and also noticed the positive impact of a normal, healthy
have the parents' on-going participation in their ward’s rehabilitation.
friendship between Anoop, Ameeta and the other children. This
However, we do keep them regularly informed through detailed reports
encouraged the idea of expanding on the experience. Since then, there
and correspondence and give them elaborate guidelines when the
has been no looking back.
children go home for holidays. Yet, in most cases, the parents find it
The parents who have sent their children to this school also
difficult to manage and when the children return we are dismayed to see
express great satisfaction, although, as admitted both ways, it has been
that our year’s labour has almost been washed away in just two months
no cake-walk. The parents of the handicapped children are often quite
and we have to begin again!"
broken down, more so when they have gone through a series of
The experience related above sharply brings to the fore the
(misguided) experiences, as happened with Sonali's or Rahul's parents.
limits of exclusive institutional care and makes a strong case for family
Sonali was not born with any apparent handicap. The second of two
and social responsibility in the rehabilitation of the handicapped. It also
daughters, the first signs of a problem were noticed when she did not
emphasises the need for integrated efforts between professionals and
communicate verbally till two years of age, despite there being no hearing
concerned lay persons to ensure the ultimate well-being of the
impairment. When she was a little over two years, in the absence of full
handicapped.
time home care support and both with full-time jobs, her parents had to
But then, the example cited refers to an experience 15 years
put her in a creche. They had faced no problem with their elder daughter,
ago. There are signs that today, situations and attitudes are changing -
who was six years older. But Sonali felt totally traumatised; she stopped
-if not radically, at least perceptibly enough to indicate hope.
The
eating and sleeping and exhibited other signs of emotional insecurity.
contents of this article are drawn from the experiences of parents of
The resulting severe dehydration compelled hospitalisation and the
mentally handicapped children; their reactions, their struggles, their
beginning of a series of long term treatments, not always rational.
hopes. The names of the parents and children have been deliberately
Subsequently her non-adjustment in a regular nursery school in a big
changed to protect the identities of those who shared their thoughts and
institution brought her to this play school, where, with special attention to
her and guidance to the parents, she now shows definite signs of
The author looks .after the publications work at FRCH.
FRCH NEWSLETTER. VOL VI NO. 2, MAR - APR 92
progress, in speech, as well as peer group interaction.
8
Rahul was a case of delayed delivery, a breech case, who
seemed stiff-limbed, there was no immediate indication of a major
As the handicap became obvious, Asmita, who held a
created initial panic because he did not breathe immediately.
handicap.
Considering that he had exceptionally tall parents, at 18 inches he did
graduate diploma in fine-arts, submerged all her interests to taking care
seem small. Yet, the doctors certified him as a normal baby. The first
of her son who is now over seven years. It also involved a good amount
signs of a problem began when he had severe convulsions at about 6
of persuasion on her part to convince her husband, Vineet, that a second,
months of age. Various tests revealed a diagnosis of "febrile convulsions"
normal child was possible and necessary. Their daughter, Sheetal, is
•which recurred frequently till he was nearly two years old. During this
now a two-year old.
duration he had had 20 convulsions. When he was six months old, his
Another striking aspect in our conversations was the varying
mother, Romi, closely monitoring his development, felt and expressed
degrees of isolation experienced by many of the mothers. Many of them
that he was showing signs of delayed milestones. But others (family
and more so the professionally trained women, while apparently coping
members) dismissed these thoughts and preferred to adopt a “wait and
in a rather stoic manner, definitely felt that if alternative structures did
watch" policy, although various treatment regimens for the convulsions
exist and if there was greater sharing of responsibility by their husbands,
continued. The persistence of Romi however, led them to a senior
they could have pursued other creative pre-occupations. Some of them,
paediatric neurosurgeon, through whom an I.Q. test was carried out
like Shamlee, are biding their time till the handicapped child becomes
when Rahul was 2 years old. His mental age was revealed to be 14
sufficiently trained, such that dependence on the mother is not so total.
months and he was recommended for occupational, speech and physio
therapies. He is now four years old, happily adjusted in his play school,
shows signs of a good memory and spontaneous expressions of
Siblings and Others
emotions. In the past 2 years he has also not suffered a single
All, except one couple interviewed, had at least one other child
convulsions attack, despite high fever. All these signs make the parents
hope that perhaps he is a border-line case. As Romi says," a normal
(older or younger) who is not handicapped. Tackling the delicate issue of
the relationship between normal and special siblings has posed its own
person uses only one-tenth of his potential and still functions well; then,
challenges. Sonali's parents were, in fact, the only ones to claim that this
with the scale of advancement in medical knowledge and a good deal of
was the least of their problems. Perhaps the fact that the older daughter,
effort to create a stimulating environment for my handicapped child, I
Meenal, was a good six years older and therefore relatively independent
believe his normal functioning, to a very large extent, is possible."
when the special child demanded attention was an advantage. And, as
Shashank, now 26, was also a breech case. Asphyxiation and
the parents candidly admitted, “Sonali is a good looking child and both of
a delayed supply of oxygen following birth damaged a part of his brain.
us worked together closely to involve Meenal in giving Sonali the special
But he has managed to complete high school, (he wentto a normal school
attention she needed. Meenal's friends accepting a “different" little sister
till the ninth standard and was tutored at home for the public
went a long way in her accepting responsibility for the little one
examinations), has picked up several other skills such as music, bicycling
others, it has not been easy. Shamlee's younger child, Anjali (3 years)
and so on and is able to share a few responsibilities with his parents. A
has been handicapped since birth. Her elder son, Ajay (5 years), is
large measure of his progress can be credited to the attitude of his
unaware of his sister's handicap. The explanation, "she is small" seems
parents and grand-parents, as well as the special efforts made, specially
to satisfy him. Yet Shamlee wonders anxiously what the situation will be
by his mother Sulabha , who was closely involved in each detail of his
like as the children grow older and comparisons are drawn. Asmita felt
treatment and rehabilitation, which began since he was two years old.
particularly emotional while talking about Sheetal, who, she feels, is
Sulabha and Vikram also consciously decided to delay their second child,
being denied a normal childhood because she is being inculcated with a
to enable a longer period of attention towards Shashank.
sense of responsibility towards her older brother. Parents shared their
Bringing up a child is no easy task.
For
When the child is
feelings of hurt when normal siblings (specially in their adolescence)
handicapped, the difficulties are further multiplied. How do parents of
exhibited embarrassment or resentment and impatience towards their
mentally handicapped children cope ? What are the support structures
handicapped brother/sister.
they can fall back on ?
differences and enhance the sensitivity of their normal siblings. This, they
How does one integrate normal siblings in the
They felt responsible to explain the
process of
rehabilitation of a handicapped child ?
hurdles ?
Given existing conditions how could the process of
In the process of wider integration, apart from family members
rehabilitation be further facilitated ? The parents interviewed came out
outside the nuclear family unit, are the circle of friends, neighbours and
with a wealth of insights on these matters.
eventually, those the child comes face to face with in school. As Romi
What are the
felt, is crucial in the wider social integration of their handicapped child.
said, "to a large extent, society's reactions are tempered by the way the
The Focus on Mothers
In most cases the mother seems to take on the greater
responsibility in the rehabilitation of the handicapped child, though, in
family members relate to a handicapped child. The more normal and
open our behaviour, the more accepting are the reactions of friends and
neighbours
many cases, the father and other family members do take on a supportive
role. At least three of the mothers interviewed expressed an initial feeling
Inadequate Facilities
of deep guilt on the discovery of a handicapped child. They wondered if
At the same time all parents expressed unanimous dismay at
their strenuous schedule during pregnancy, or other factors caused by
unwitting negligence could have caused the handicap; In Asmita’s case,
the dearth of “rational and human" professional guidance in dealing with
this was reinforced by her in-laws who were apparently misled by their
family doctor into believing that She was to blame for her son, Sumit's
retarded growth, because she had not rested enough during pregnancy.
Sumit, the older of two children, was born a full-term but underweight
a handicapped child. Facilities are few and inaccessible to most people,
more so for those living in small towns or rural areas. Even in the cities,
the distances and the costs involved make most facilities beyond the
reach of those families who need them the most - i.e. the toiling classes.
Many parents were also critical about the almost mechanical, clinical
baby and although he was kept in isolation for two and a half months and
9
FRCH NEWSLETTER VOL VI, NO. 2. MAR - APR 92
AIDAN - VHAI MEET
Members of the All India Drug Action Network (AIDAN) and
though it is well known that self generated alcohol in Ayurveda cannot
the Voluntary Health Association of India (VHAI) met in New Delhi, on
exceed 11 -12%, recent Sura tragedy has brought into focus, 'Ayurveda*
27th-28th of February '92. to discuss the forthcoming 'New Drug Policy*.
products with 70% alcohol base.
(Dr. Unnikrishnan).
Audrey Fernandes, FRCH researcher presently involved in the study on
On the other hand, the Government's preoccupation with
Use and Cost of Drugs and Pharmaceuticals in Government Health
family planning, has meant using uninformed Indian women as guinea
Care Centres', attended the meet. Below are some of the major issues
pigs for testing of contraceptives. Not only is the method of research
unethical, the clandestine testing of Norplant and Neten has cast doubts
put forth by the members.
Hopes were first belied in 1988 when the then New Drug
about the safety of the drug itself (Dr. Sathyamala).
One of the main features of the Dunkel Draft Proposals
Policy, turned out to be only a price control for some essential drugs. This
involving Intellectual Property Rights, demands a change in the model
resulted in a decline in production of those drugs under price-control.
The Indian Drug Industry while whining about the unfair and
Indian Patents Act, 1970. Accepting these would mean succumbing to
unfriendly environment has expanded from 1643 units in 1952 to about
the chauvinistic economic interests of the developed nations. It would
20,000 units today, and has similarly grown in sales from Rs 34.68 crores
also mean a 30-fold increase in today's drug prices. The implications for
to about 4000 crores (Anil Pilgaonkar),. The drugs they manufacture
agriculture, scientific research, Indian industry and the economy are far
have no real links with giving rational therapeutics at reasonable rates
worse. It would virtually amount to surrendering economic and political
(Dr. Wishwas Rane). Yet, they have been lobbying for a change in the
sovereignty. This discussion was facilitated by Mira Shiva, Dinesh
1988 policy, reports of which have been trickling in. The consequences
Abrol, and Narendra Mehrotra.
on the anvil are:
1. Slashing down of the number of drugs under price control,
2. An across the board increase in mark-up (profits);
3. Increase in returns allowed for bulk drug manufacturers;
4. Freedom to companies to automatically revise formulations and
The Hathi Committee Report in 1977, decried the role of the
foreign sector because of its reluctance to produce bulk drugs and its non
performance in producing essential drugs. Their interest
was in
producing non-essential drugs with low technological inputs. Yet, this is
precisely what liberalisation is inviting.
prices without prior Government approval upto.70% of CPI
The government now totally belies the rights of more than half
(Cost Price Index) increase;
5. Allowing Foreign Equity Participation upto 51%, automatically, with
a case by case study for higher foreign equity component,
6. Exemption of all formulations from licensing (except I.V. Fluids);
7. Ratio Parameters for Bulk Drug to Formulation production
the country's population, for whom public sector health facilities are the
only feasible means to health, by attempting to introduce service ‘at cost1.
This would reduce actual welfare expenditure (as is seen in the present
budget) and introduce a drug policy which would only lead to price rise
and in no way increase the accessibility of essential and life saving drugs.
abolished.
Is the Government of the people, by the people, keen to work against the
(Dr. Amit Sengupta)
people ?
besides irrational
The meet ended with a call to oppose the Dunkel Draft Text
combinations and formulations, some firms have been trying to pass old
and as part of the proposed campaign, called on all concerned citizens to
allopathic products as Ayurvedic products, to bypass excise duty. Again,
send postcards to the Prime Minister, conveying dissent about the same.
Profit making
being the sole aim,
approach in professional institutions. They feel that while institutions
s
THE NEED FOR FULL INTEGRATION
have a role to play, in terms of giving specialised guidance and therapy,
total segregation in such institutions isolates the handicapped and blocks
It must be remembered that opportunities for a
their integration in society. The general public also remains isolated from,
close, loving relationship are only one aspect of leading a
and therefore insensitive to, the issues of the handicapped.
full, accepted and participating life in the community.
Some parents also expressed that if neighbourhood facilities
for recreational opportunities were organised and multiplied, it would help
in inter-mixing between handicapped and other children. It could also
pave the way for a forum where parents of handicapped children could
The more that can be done to bring about greater
integration and participation of disabled persons in the
meet, share experiences and put their minds and resources together to
life of the community, the more everyone will learn to look
advance the rehabilitation process of handicapped children.
beyond a disability and see the person. When it happens,
For all of them, living and taking each day as it comes, utilising
one’s time and creativity for the best possible development for their
special child is the most pragmatic way of coping with the situation. Their
attitude is summed-up in the motto, “Do your best, step-bystep. The
future can be faced, as and when
FRCH NEWSLETTER VOL VI. NO. 2 MAR - APR 92
it opens tip many new possibilities.
: Source: Disabled Village Children. David Werner, The Hesperian Foundation. 2nd edition;
1 1988.Ghp.52.pg.494.
e
10
SEGREGATION
the other side of the coin
When parental concern about a handicapped child goes
beyond the confines of one’s own home, the effort can help transform
This forms the history of
the lives of many handicapped children.
them to study at their own pace."
Vidya Jyoti, as a special centre, keeps the teacher-student
ratio at an optimum of 1:10. Innovative methods of teaching and an
Dr. Poornima Pandit and Ms.
adaptive curriculum, with varying proportions of academic and
Rita Makhija, both parents of slow learners and Fr. Alfred Barretto,
vocational courses (to keep with the levels of progress of each child,
former Principal of Vidya Bhavan School, Pune, discussed the
irrespective of age) help each student "attain a level of self reliance"
problems and decided to put their collective ideas into action. The
and become “a useful member of society".
Vidya Jyoti School for slow learners.
germination of the idea for such a school came from the experience
While, on the one hand one talks about integration, what is
that regular educational institutions are compelled to instill a
competitive curriculum and slow learners cannot cope with this,
the role such institutions can play ? Dr. Pandit, whose own daughter
particularly as they advance to higher levels.
the sixth standard, admits,
(now 17 years) came into this school after being in a regular school till
Started in Pune in 1986, Vidya Jyoti is perhaps the first
"My
daughter
certainly
from
benefitted
initial
her
such institution in Maharashtra. Dr. Pandit, who is also a Paediatrician
experiences in regular schools. But today regular schools are
and Family Physician and Founder President of this school, pointed
increasingly rigid in their policy of not accepting handicapped children.
out, "Slow learners are certainly not mentally retarded.
They are
children having below average intelligence (I.Q. range 70)85) and
Hence, while a process of segregation (and therefore non-integration)
is not desirable, social attitudes make these efforts inevitable
suffer from repeated failures in school because the sheer crowd and
And so, it comes to pass, that while initally Vidya Jyoti
course load does not allow for individualised attention to those who
admitted older children finding difficulties in regular schools as they
Repeated failures also frustrates these children and
went to higher classes, today children are taken in from the primary
need them.
reduces their self esteem. What is needed is an institution that allows
school level itself.
STATEWISE RURAL/URBAN DISTRIBUTION OF
DISABLED POPULATION
STATEWISE DISTRIBUTION OF VARIOUS
AGENCIES/INSTITUTIONS
FOR THE HANDICAPPED IN INDIA - 1986
STATE
RURAL
URBAN
ALL
(RURAL +URBAN)
STATE I
MENTALLY
ORTHO-
VISUAL
DEAF
UNION TER.
RETARDED
PAEDICALLY
HANDICAP
MUTE
Andhra Pradesh
12
Assam
--
10
--
Bihar
Gujarat
1
20 *
2
|
Haryana
•
Himachal Pradesh
1
Jammu & Kashmir
Karnataka
Kerala
TOTAL
16
10
48
2
2
4
19
77
2,683.416
274.841
14,270,051*
1,504,573
147,655
13,777
1.370,235
139,733
161.432
1,509.968
India
11,586,635
Andhra Pradesh
1,229,732
Assam
Bihar
Gujarat
411,266
140,159
Haryana
246,826
74,043
511,385
320.869
9
7
25
28
4
--
2
--
2
--
8
Himachal Pradesh
Jammu & Kashmir
86,512
85,868
4.085
10,224
90,597
1
-
1 •
1
2
4
Karnataka
623.812
177,949
801,761
17
10
6
9
Kerala
420,434
96.747
11
12
17
44
7
45
Madhya Pradesh
688.806
138,942
517,181
827,748
37
144
Maharashtra
807.189
311,248
1,118,437
Manipur
9,814
2.041
11,855
4
Meghalaya
18.313
1.541
19,854
22
Nagaland
--
==
20
Orissa
53.587
478
662,978
.
96;092
Madhya Pradesh
3
7
10
17
Maharashtra
43
30
53
Orissa
-
16
--
2
Punjab
Rajasthan
2
2
4
5
5
10
2
11
|
Tamil Nadu
Uttar Pradesh
18
5
17
4
19
34
88
Punjab
609.391
360.033
29
47
Rajastan
650.554
88,331
140,416
448t364
9
West Bengal
7
1
13
27
48
Tamil Nadu
946.582
397.174
1,243.756
Delhi
20
8
39.737
4,158
43,895
1
11
--
Tripura
1
10
--
49
Goa
2
Uttar Pradesh
2,074,504
352,693
2.427.197
169,514
91,735
984,229
2
West Bengal
814.715
2
6
U.T. (all)
44,697
1
-
1
187
269
Chandigarh
-
1
1
Pondicherry
-
2
'• 2
Sikkim
-
-
162
102
790,970
136,432
Note: Computed using data from National Sample Survey prevalence rates and
720*
•Includes institutions run by the Govt.. either Geniial/State or LocalMuncipal Administrations.
which is approximately, 10% of the total. Therefore only 72 are run by Govt, and 648 by
voluntary organisations ( underestimated in any case). Source . A Critical Review of
Services for the Disabled in India with Special Reference to Education", Mithu Alur et al. Dept.
of Research. Spastics Society of India, Bombay. 1988.
11
1981 population Census of India.
Source: KushnaswamyS. The Demography ofthe Disabled and the Handicapped in India.
The Indian Journal of Social Work. Vol.XLVIII. LAptil 87.. as cited in Mithu Alur et al.
Spastics Society of India Bombay
* According to this estimate there are 14 million handicapped in India. However, a survey
done by the Spastics Societyestimates a population size of50 million who are handicapped
- in India.
_____
FRCH NEWSLETTER, VOL VL NO. 2 MAR - APR 92
LIBRARY NEWS
Reprints
Books
1)
Aglietta, Michel, A Theory of Capitalist Regulation: the U.S.
2)
experience, Verso, London, 1979, pp. 390.
Bose, Ashish, Demographic Diversity of India -1991 census, B.R.
1)
Badgley, Robin F., Social and Economic Disparities under
Canadian Health Care, International Journal of Health Services
(IJHS), Vol. 21 (4), 1991, pp. 659.
2)
Banerji, D., Miracles through Technologies?, Health for the Millions,
Vol. XVII (5), Dec. 1991, pp. 16-18.
3)
Bhatia, Jagdish C., Light on Maternal Mortality in India, World
3)
Publishing Corpn, Nev/ Delhi, 1991, pp. 463.
Chakravarti, R, Recolonization, GATT, the Uruguay Round and
the Third World, Third World Network, Malaysia, 1990, pp. 319.
4)
Chaudhary, C.M., Research Methodology, RBSA Publishers, Jaipur,
4)
5)
1991, pp. 234.
Coontz, Stephanie, The Social Origins of Private Life, Verso,
Brown, Lawrence D., Politics and Equity in Policy - making for the
Medically Uninsured, IJHS, Vol. 21 (4), 1991, pp. 653-57.
London, 1988, pp. 365.
ESCAP, Asia Pacific, POPIN Directory: database, services,
5)
6)
Navarro, Vincente, Production and the Welfare State: the political
context of reforms, IJHS, Vol. 21 (4), 1991, pp. 585-614.
products and institutions, United Nations, New York, 1990, pp. 234.
6)
Radhakrishan, R., Ravi, C., Does Inflation Hurt the Poor More?,
7)
Mills, Anne, Health Systems Decentralization : concepts, issues
and country experience, World Health Organisation, Geneva, 1990,
7)
Richardson, R., Joseph Rogers and the Reform of Work House
8)
pp. 151.
Paul, M.S , The Theory of Capitalist Development, K.P. Bagchi and
8)
9)
Co., New Delhi, 1991, pp. 398.
Ray, Nandita, Papers on Development and Rural Poverty, Young
9)
Saltman, Richard B., Emerging Trends in the Swedish Health
System, IJHS, Vol. 21 (4), 1991, pp. 615-23.
Wadhwa, K., Housing Programmes for Urban Poor: shifting
India Project, Andhra Pradesh, 1988, pp. 156.
10)
Singh, S.P., Poverty, Food and Nutrition in India : implications,
problems and prospects, Chugh Publications, India, 1991, pp. 543.
Health Forum (WHF), Vol. 11 (2), 1990, pp. 188-91.
EPW, Vol XXVII (4), Jan. 25,1992, pp. 59.
Medicine, BMJ, 1989, pp 1507-10.
priorities, EPW, Vol. XXVIII (34), Aug. 20,1988, pp. 1762-67.
10) Wallack, Lawrence, Two Approaches to Health Promotion in the
Mass Media, WHF, Vol. 11 (2), 1990, pp. 143-64.
BOOKS IN BRIEF
Usha Sethuraman
Programmes and Concessions for the Disabled Persons, GOI,
Disability Prevention : the global challenge, Sir John Wilson (Ed.)
Ministry of Social Welfare, New Delhi, pp.70.
Oxford University Press, Oxford 1983, pp. 107.
. This document lists programmes and concessions provided
Towards the close of the International Year of the Disabled an
for the disabled under various heads - Education and Training,
international group was convened by the British Department of Health
Employment, Economic Assistance, Medical and Health, Welfare and
and Social Security, at Leeds Castle. It was a group of scientists, doctors,
Rehabilitation, Housing and Travel and Communications - by the
health administrators and politicians, who met to consider practical
different agencies, at various levels. 'These agencies are, for example,
measures to prevent disablement. This book contains papers presented
'public sector banks' for economic assistance, ‘Welfare and rehabilitation
at the seminar.
While examining the principle causes of the problem, some
institutions* for medical and health, etc. Every agency lists out each
scheme with rules concerning eligibility, duration, etc.
papers discuss factors like vaccines, prenatal neglect, malnutrition and
There is also a section on measures undertaken by the
mental handicap, as important in the development of disabilities. Acute
Defence Ministry for the rehabilitation of the war disabled and the
conditions like blindness, deafness, injury and occupational accidents
dependents of those killed in action. There are ten annexxures listing
form another set of causes. Chronic conditions like leprosy, tuberculosis,
notifications issued by the ministry of Home Affairs like 'Grant of priority
stroke and hypertension, coronary heart disease and old age are dealt
to the physically handicapped persons’, 'Award of scholarships for the
with as the third set of causes. The book, through detailed examination,
physically handicapped’ etc. Ten more annexures list notifications like
shows that most of the world’s disabilities are preventable and that many.
income tax concessions’, ‘Grant of conveyance allowance to blind and
of them are curable.
orthopaedically handicapped’ and so on.
NEWSLETTER BACK ISSUES.
We have frequently received queries regarding availability of back
FREE ABSTRACTING
issues. We can make these available, either in original or as
xeroxes (where the original stock has been exhausted ). Each
issue would cost Rs. 5/- plus 0.50 p. for postage. Requests for
back issues may be addressed to:
.
FRCH Newsletter, Editorial: Office,
64/5, Anand Park,
The contents of this newsletter may be abstracted
without prior permission. However, we would
welcome acknowledgement of the source and
copies of any abstractions.
.
Aundh, Pune 411 007.
Edited by Nagmini Rao, with secretarial assistance from Vrinda and Joyeeta Sinha, and produced by the Foundation for Research in Community Health,
84 - A, R.G. Thadani Marg, Worli, Bombay 400018.Registered under the Bombay Public Trusts Act. Printed at Printext Offset, Pune 30.
COMMUNITY HEALTH CELS
326, V Main, 1 Block
Koramangala
Bangalore-560034
India
Vol. VI, No. 3
May - June 1992
ESIS AND WORKERS’ HEALTH
need for action
Vijay Kanhere
1956 with the idea of providing comprehensive health care to workers in
Comparison with money spent on benefits from employees shows
how little is actually spent on benefits. If it is assumed that ESIC spends
the organised sector. Taking a part contribution from employees as well
Rs. 100 for employees' benefits, then its own figures show that Rs. 40 to
The Employees State Insurance Scheme (ESIS) was started in
as employers and subsidised by state governments, this scheme is
Rs. 50 are with the employers as arrears and its reserves are more than
supposed to cater to treatment of illness as well as occupational
four-fold and are rising at a faster rate than the expenses on benefits.
disabilities and accidents involving workers and their families. In reality
For every Rs.100 spent on Benefits
87-88
88-89
Arrears from employers
Rs. 43
Rs.50
Total Reserves of ESIC
Rs. 438
Rs. 483
this is not so.
“When you are suffering with 'stomach upset’, ESI hospital gives
you. same tablets which they will give for ‘flu* or for ‘sore throat.
Generally they have two-three types of tablets, one or two types of
syrups; with this kind ofmedicine they claim to treat any type of disease",
says a worker from a textile mill in Kanpur.
Yet ESIC is still trying to reduce expenses on benefits. After
reserving money for construction fund and contingencies, (an amount
around 20 crores) it had net excess income over expenditure.
Is this a body established as a profit making corporation? We do
not say it should go in a loss. Without going in loss it can spend more
ESIC: Financial Position
money on hospitals, by making the doctors permanent, employing more
The ESIC (Employees State Insurance Corporation) needs to
doctors and paramedical staff, obtain better drugs and equipments. For
improve its functioning. Many
every 100 rupees spent on benefits, its net excess income was around
Total Reserves of ESIC
committees have given suggestions
Rs. 54. Add this to the arrears from employers and you have good
(in crores)
for improvement but they are not
being implemented. ESIC cannot
resources to use in a much better way than is being done today.
complain about lack of funds for not
activist from Delhi. He explained: "Employers can keep the workplace
31-3-89
31-3-8
1119.10
944.42
"ESIS is insuring the employers not the workers", said one legal
improving its services. Figures in the
unsafe; if number of accidents are more, the ESIC takes care of the
adjacent box establish this fact. Part
injured workers. Employers can keep the work-place as unhealthy as
of these reserves are earmarked for particular purposes. ESIC still has
they want; if workers get affected due to diseases, ESIC is there to treat
large non-earmarked funds at its disposal. These reserves are invested
the workers". This is very true. The employers can get away even by
in nationalised banks (Rs. 933 crores) and with the Central Government
not paying contributions by employees, cut from wages, to ESIC. ESIC
(Rs 184 crores).
is very soft • towards employers.
It coolly states that arrears from
These funds are just deposited and are idle. They are generated
employers are 116 crore rupees. Employees suffer, as benefits stop if
because ESIC does not spend sufficient money on the necessary
ESIC does not get money from employers. " The panel doctor is not
services. Apart from these reserves, its arrears from employers stood
interested in proper treatment. So we go to other private doctors, pay
at 116 crore rupees in 1989.
from our own pockets. The ESI doctor is useful for certificates", said a
worker. ESIS needs to become a scheme for employees in its true
sense and all its resources need to be directed towards this goal.
The author has been working in the area of occupational health
with some of the unions in Bombay. He is also associated with
Participatory Research in Asia,
PRIA, New Delhi. He is a
member of Occupational Health and Safety Centre, Bombay.
This article is based on ESIC Annual Reports, Lawyers'
Collective, Bombay, issues and field work of the PRIA, Delhi.
Broad Areas of Complaints
1)
Panel doctors and doctors in hospitals are not interested in patients.
2)
Supply of medicines is irregular. Medicines need to be bought by
workers and reimbursement takes undue time.
FOR PRIVATE CIRCULATION ONLY
3)
4)
Staff in ESIC offices and hospitals do not treat workers humanely.
around 12.5 percent. If, in any state, the expenditure rises above the
Workers contribute to ESIC, but the atmosphere is such as to make
national average, then ESIC claims these amounts from the state
the workers feel that some favour is being done to them. "We
governments. In 1987-88 ESIC received around 2 crore in this manner.
contribute; ESIC runs on our funds, but we have no control over it"*,
Secondly, there are ceilings decided by ESIC. Expenditure upto the
said a worker.
ceiling is shared as given above. Expenditure above the ceiling is borne
There is a shortage of medical shops supplying ESIC prescribed
by the state governments. In 1988 ESIC increased ceilings and they
drugs. At places such as Anand (Gujarat), workers have to travel
are as follows:
long distances to reach the medical shop attached to ESIC. Other
wise workers spend from their own pockets.
5)
6)
7)
8)
Necessary forms are not available with ESIC offices.
Diagnostic instruments are not available with ESIC doctors and
Full medical care per insured person
Rs. 190
Expanded medical care per insured family
Rs. 085
Restricted medical care per insured family
Rs. 070
Expenses on drugs per insured family
Rs. 070
Building hospitals and running them is costly. This increases the
hospitals.
contribution by the state government.
Medical boards decide percentage of disability of injured workers.
crore are to be spent to build a hospital in a particular year, in that year
For example, suppose Rs. 5
But medical boards do not meet frequently. “They are more con
expenses will go above the national average and the state government
cerned in reducing percentage of disability and compensation
will have to contribute heavily. It is in the interest of the state
paid to us ", said workers in an asbestos factory.
governments that the above expense is spread out over as many years
The most notable complaint is lack of hospitals. ESIC has set itself
a norm of 4 beds per one thousand insured persons. The shortage
was around 2000 beds in 1988. This norm of 4 beds for one thou
sand persons itself falls short of the need. Hospitalisation is needed
for:
as possible, such that, for every year their contribution is within limits.
Because of these constraints, hospitals are built slowly by Government
departments. Built hospitals are not commissioned fast so as to delay
and spread over costs of running hospitals. As a result workers are
denied proper medical care.
The contribution by the state governments is just 12.5%. We saw
i)
Accidental injuries resulting in temporary disablement
earlier that the net excess of income over expenditure of ESIC was
ii)
Accidental injuries resulting in permanent, partial or total disablement
around Rs. 54 for every Rs. 100 spent on benefits. We estimated
iii)
Employees affected by occupational diseases.
contribution by state governments as one seventh of ESIC expenditure
iv)
Employees and family members needing hospitalisation for causes
on benefits and extra contribution was added to it. (i.e. contribution for
not directly related with employment.
crossing ceilings).
ESIC records themselves show that injuries resulting in permanent
87-88
88-89
(in crores)
(in crores)
disability were 23,414 in 1987-88 and 23,196 in 1988-89. It turns out
that, in concerned employments, injuries resulting in permanent
Contribution by State Govts.
32.77
36.40
disability were 3.8 per thousand employees. Accidents resulting in
Arrears from employers
92.84
116.64
permanent disability are serious accidents; their proportion is nearly 4
Net excess
117.80
124.05
per thousand. These require hospitalisation. Hospital beds are needed
(of income over expenditure, of ESIC)
for others as well, as noted above. ESIC has thus set itself a norm
which is not satisfactory. The Review Committee Reports need to be
taken seriously by ESIC and employees' representatives in ESIC.
These figures are self-explanatory.
Even if ESIC bears all the
expenditure on benefits, it will still be left with net excess over income of
around 85 crore rupees per year.
Tying up with the state governments increases red-tapism.
All
Causes of Problems
proposals go through two channels — ESIC and the respective state
A. Staffing
government. The ties with state governments need to be restructured.
One report had pointed out the following things:-
1)
concerned government. Then ESIC can run its schemes as it wants.
governments and reluctantly join the scheme. They are therefore
uninterested. Service conditions of doctors also need to be
Ties with state government have now become a dead weight. The idea
improved.
2)
ESIC can fix a definite amount for each state to be contributed by the
Medical officers are drawn from general health cadre of the state
Many doctors remain temporary for many years. One
of national average expenditure is a disincentive for state governments
to develop new hospitals, plan new schemes. Even if ESIC plans
MARD (Maharashtra Association of Residential Doctors) activist
anything,-the threat of increased contribution will compel state
said, “lot of corruption is involved in getting a good posting, becom
governments to slow down the development. The union representatives
ing permanent and for promotions of doctors. A doctor who is at
on the apex body of ESIC need to go into the question of ties with state
the mercy of corrupt superiors won't be interested in patients or in
governments and give a proposal for fixed contribution (linked with
rational medical practice".
price index)
At all levels, there is under-staffing. The Review Committee had
better services.
from state governments and should free ESIC to give
also said that there is a shortage of drugs, drugs may be sub
standard, there is a shortage of ambulances.
C. Medical Boards
Medical Boards are constituted to decide percentage of disability of
B. Linkage with the State Governments
ESI Scheme is tied with the state governments. ESIC and state
injured workers. The injury may be due to accidents at work-place, or
governments share expenses on benefits in the ratio seven is to one
The pension/compensation paid to workers depends on the percentage
(7:1). That is, ESIC spends around 87.5 percent and state governments
of disability. The medical boards are constituted by doctors who may
FRCH NEWSLETTER, VOL VI. NO. 1 MAY- JUNE 92
during the course of employment, or, due to occupational diseases.
2
not be residing in one city. Meetings of Medical Boards become less
4) At one end ESIC denies beds, hospitals, diagnostic equipment,
frequent due to lack of time on the part of specialists, the problem of
drugs to poor workers and allows employers to keep dues at the
bringing them at one place and the expenses involved. An injured
other end. Action by ESIC is needed on this front also to establish
worker has to wait for months before the Medical Board calls him for
its bonafides. Only pressure by unions, workers/employees will
checkups. A worker affected due to asbestosis said, " The doctor saw
ensure improvement. If there is enough pressure, well-intentioned
my X-ray. There was not enough light in the room. He said 23%
representatives of people, doctors, officials will help in improving ESIC.
disability. KEM doctors told us correctly that we are affected due to
asbestosis. The percentage (of disability) given by KEM was higher
B. Work on Occupational Health
than the one given by the Medical BoardThe procedure to challenge
1) Trained doctors in Occupational Health Institutes such as NIOH
percentage given by Medical Boards is lengthy and tedious. Workers
Ahmedabad, CLI Bombay, ITRC Lucknow, may help ESIC in
organising the training of their own doctors.
affected due to silicosis (in Baroda) had to battle in courts to get proper
compensation from ESIC. A worker already affected by disease, or due
2) Develop Occupational Health and Safety Centres all over India - at
to accidental injury, has to wait and also has to face humiliation. This is
least one in each district, more in industrial cities such as Bombay.
inhuman.
These centres should be well equipped and have specialists and
should cater to the employees of ESIC hospitals as well.
Medical Boards should meet six times a year, in each district, or
more frequently. A worker should not be forced to wait for more than 2
3) All panel doctors, doctors in ESIS hospitals, should start recording
months to get the opinion of the Medical Board. Medical Boards should
occupation of employees. This should include nature of work,
record reasons of deciding on a particular percentage of disability. The
exposure to high noise levels, heat, chemicals (particulars) and
necessary information for diagnosis of occupational diseases.
criteria for this must be put forward clearly.
Procedures to challenge Medical Board decisions should be simple
4) A Superintendent of an ESIS hospital said 'We should treat emp
and fast. We saw that the number of workers involved in accidents,
loyees even after retirement. Proper medical records should be
resulting in permanent disabilities, was around 23 thousand every year.
preserved until expiry of an insured person. Proper forms for
This shows the necessity of fast, proper functioning of Medical Boards.
medical records need to be preparedHis suggestion needs to be
implemented. In case of cancer due to asbestos, it may affect a
worker many years after exposure. Many diseases have long,
D. Lack of Attention to Occupational Health and Safety
latent periods. This makes us emphasize the need for proper
Doctors in ESIS seem to be unaware of the branch of medicine
concerning Occupational Health. This is shocking, because ESIS is
medical records.
meant for industrial workers also.Thousands of textile workers are
5) Section 69 of ESI Act gives a right to ESIC to recover excessive
affected due to byssinosis - a disabling disease caused by cotton dust.
sickness benefit given to employees due to unsanitary working
Similarly silica dust, coal dust, asbestos fibres take the toll of human life.
conditions or unsanitary residential facility provided by the
employer. Has ESIC used this section against any employer ?
There are many carcinogenic substances used abundantly in Indian
industries - asbestos, benzene, chromium, nickel, vinyl chloride,
6)
In case of higher rates of accidents, ESIC should inform the Factory
auramine and many others may cause cancer to exposed workers.
Inspectorate to check up unsafe working conditions. The inspectors
Lung diseases, skin diseases, nervous system disorders may also be
of ESIC should inspect work-places and should not stop at just
occupational diseases. The Factories Act (1948 ) has given a list of
occupational diseases which are to be notified to factory inspectors. Do
inspecting records.
7)
ESI doctors notify factory inspectors when they treat a worker affected
Compensation Rates - The disability rate should be linked to the
index. Suppose a worker is awarded Rs. 15 per day as disability
by occupational dermatitis (or any such occupational diseases)? Most
benefit -- this amount should change every year, depending upon
are unaware of their duty under the Factories Act. They are also not
the average price index of that year. The prices are rising and
trained to diagnose occupational diseases. They do not have enough
disability compensation for loss of earning capacity should be linked
equipment needed for proper diagnosis. Secondly, ESI Act has
with the price index.
Schedule III which lists occupational diseases for which employees can
8)
claim compensation from ESIC. ESIC has neither informed the workers
and the doctors about Schedule III, nor the workers about how they
Procedure for collection of disability benefit, dependents* benefit,
must be made easy.
9) Sickness benefit, other benefit rates amounts for drugs, need to be
may know if they are affected by any occupational disease in Schedule
linked with price index and revised every year. They should not
III. It has not acted responsibly in this important area.
depend on arbitrary desire of ESIC heads. The present rates need
to be raised and ESIC does have the necessary finances to do so.
What Needs to be Done
ESIC needs to be made to do the following things :-
C. Simplification of Procedures and information Dissemination
A Recovery from Employers
1)
There are more than 900 employers in India who owe ESIC more
i]
than Rs. 1 lakh each. Total dues, we have seen, stand at 116 crore
booklets should explain :-
ESIC
should produce booklets in regional languages.
These
rupees.
2) When worker’s/employees’ contribution is cut from wages but not
a)
Procedures involved in getting benefits.
paid to ESIC by the employer, this should be treated as a criminal
b)
All the benefits available to employees. This should include
information about compensation in case of occupational
breach of trust and ESIC should not stop at recovery of fines or
diseases (Schedule III).
writing off dues as bad debts.
3)
It is heard that there is a lot of corruption involved in procedures of
c)
All the proformas of forms required by ESIC.
inspection, recovery of dues from employers etc. Stringent pro
d)
Grievance procedure - where, arid how to complain, etc.
cedures must be evolved to overcome this.
3
FRCH NEWSLETTER, VOL VI, NO, 3, MAY - JUNE 92
OBJECTIVITY, HEALTH AND POLICY
Amartya Sen
Health is perhaps the most crucial aspect of human well-being.
is corroborated by a study by Lincoln Chen and Christopher Murray, who
"Health transition” refers to the transformation of a society with high
apply similar criteria of self-perceived morbidity to the U.S. population. In
morbidity and mortality rates, into one in which people standardly live
disease by disease comparison, they find that while Kerala has much
long, disease-free lives. Health transition has to be a central feature of
higher morbidity rates than the rest of India, the US population has even
significant social progress. Many countries have achieved such a health
higher rates for the same illnesses. If we go by self-reported morbidity,
transition, and the list includes poor as well as rich countries. India,
we would have to conclude that the USA is the least healthy in this
despite some considerable achievements, is still quite far away from such
comparison, followed by Kerala, then the rest of India, with the states
a health transition. It is in this context that the issue of objectivity of health
most backward in education and public health services - such as Bihar
assessment assumes crucial importance. The need for objectivity in
health assessment is significant in two distinct exercises: (i) in crucially
and Uttar Pradesh - enjoying the highest levels of health !
appraising the health status of the people, and
(as argued already) to take the relative rates of self-perceived
We clearly do need a different approach. But what? It is a mistake
(ii) in scrutinizing policy issues in promoting good health.
morbidity as reflections of actual rates of illness and ill health, but it would
The demands of objectivity are quite exacting in both the exercises.
also be a mistake to ignore the information on self-perceived morbidity
Consider the first problem - that of objectivity in appraising health status.
This appraisal can run into problems with the subjectivity of perceptions.
rates as worthless and irrelevant. For example, it is not irrelevant to the
persistence of high mortality rates in Bihar and Uttar Pradesh, that there
The difficulty is not related only to individual variations, such as
is such a deficiency of self-perceived morbidity there. The educational,
hypochondria, on the one hand, and health bravado, on the other. There
medical and social backwardness of these states links the low levels of
are systematic social variations as well. For example, the state of Kerala
reported morbidity rates to the high levels of actual mortality rates. The
has had great achievements in longevity (the average Keralite life
biased positional view of the truth is important to understand the truth and
expectancy at birth appears to be now over 70 years), but that state also
its persistence. In my Storrs lectures at the Yale Law School (on
‘'Objectivity*1, given in September 1990), I have tried to discuss the
reports the highest incidence of self-perceived illness in the country. The
lowest reports of morbidity come, oddly enough, from states with the
lowest life expectancy levels (i.e.,Bihar, Uttar Pradesh).
precise role of "positional" observation in objective assessment. (The
lectures will be published later - supplemented by some empirical
studies-
but some of the main themes are discussed in my paper
“Objectivity and Position : Assessment of Health and Well-being,"
Self - perception and Health
These contrasts may appear to be puzzling, and there have been
Working Paper No. 1, Harvard Centre for Population and Development
some attempts to explain how a high incidence of illness may go hand in
Studies. )
hand with low mortality. But is the picture of reported morbidity rates (i.e.,
high in Kerala, low in Bihar) a good reflection of the objective situation in
Gender Inequality and Perception
In making inter-personal or inter-regional
To illustrate the same issue with a different example, nowhere is the
comparisons, is self perception of health a good indicator of one’s actual
importance of positional views as crucial as it is in understanding gender
different parts of India?
inequality. The questionnaire method of obtaining the views of rural
health status?
A more literate
women on their own perception of gender inequality has often failed to
population tends to have a greater understanding of illness, whereas an
find any strong recognition of disparity or inequality: This has sometimes
illiterate and ignorant population may have little appreciation of its health
been interpreted as a proof of the absence of any “real" gender inequality
in rural India. It has even led to the suggestion that raising the question
of gender inequality in this setting amounts to planting an alien notion in
There are good reasons to think that it is not.
predicament. Also, greater availability of health services and medical
facilities, which make it easier for people to seek medical attention, may
time, it also increases the perception and understanding of illness. Non
an illegitimate way into the classical harmony of Indian rural living. And
yet; in terms of various directly observed criteria of mortality rates, literacy
availability and non-use of health facilities can go with non-recognition of
rates, nuttition-related diseases, use of hospital and medical services,
morbidity; Thus, a greater subjective perception of suffering from illness
etc., women emerge as being systematically underprivileged vis-a-vis
may be a concomitant feature - and a necessary condition - of achieving
men in rural India
reduce death rates (and improve health conditions), but, at the same
Perception of morbidity is a
if the analysis I am trying to present is correct, then the perception
precondition of its solution.
This interpretation of the picture of reported morbidity rates in India
of harmony and the absence of a perceived sense of gender inequality
better health and few death rates.
are quite central to understanding the nature and persistence of gender
inequality in rural India. These perceptual features contribute to the
The author is in the Department of Economics, Littaner Centre,
Harvard University, Cambridge, U.S.A. The above article has
casual influences sustaining the inferior position of women, rather than
been printed here with his permission.
distorted as it is - is far from irrelevant. We have to see it as an important
FRCH NEWSLETTER, VOL VI, NO. 3, MAY - JUNE 92
contradicting the existence of gender inequality. The positional view -
4
part of the objective picture of women's deprivation - a crucial casual
respectively, through economic growth and through public support, can
influence that has to be reckoned with to understand the durability of that
work independently of each other. Indeed, some countries (such as
deprivation.
Objectivity of health assessment is a complex task. It requires the
China, Sri Lanka, Cuba, Jamaica, Costa Rica) have achieved remarkable
rejection of subjectivism, but it also demands that serious attention be
and despite the fact that they have remained quite poor in terms of gross
paid to positional perspectives
improvements in health conditions even without much economic growth,
- limited and distorted as they are.
national product (GNP) per head. However, there is evidence also, that,
Observational generalizations that would amount to crude subjectivism
given other things, economic growth and the consequent rise of per
if they were seen as reflections of the simple truth (eg., low reported
capita GNPcan contribute significantly to health achievements, especially
morbidity rates in Bihar or Uttar Pradesh, the absence of perceived
when the growth process takes an employment-oriented participatory.
gender inequalities in much of rural India) are, in fact, important parts of
form.
the
objective truth seen as crucial casual influences (i.e., in the
continuation of generally high mortality rates and of gender disparities).
Objectivity has many dimensions and the objectivity of health assessment
is no exception.
Growth Mediation Versus Unaimed Opulence
But the two distinct processes - based respectively on economic
growth and public
support - can also supplement each other very
substantially, as Jean Dreze and I found in our joint study, assessing
Positional Views and Social Philosophy
The question we are discussing here links with many classical issues
comparative international
experiences
[Hunger and Public Action,
Oxford University Press, 1989). Countries such as South Korea, Hong
in social and political philosophy. For example, the systematic distortions
Kong, Singapore and Kuwait have not only achieved fast economic
present in "positional views" can be seen as undermining the reach of
growth (yielding high average incomes), but have also ploughed back
utilitarian philosophy, at least some versions of it. The fundamental
substantial parts of the resources generated by economic growth into
information on which utilitarian evaluation relies is the psychological
public provisioning of health, education and social security.
self-perception of each person's well-being - various utilitarian building
countries have brought about major transformations of health conditions
blocks such as "pleasure", "desire", "satisfaction", all share this feature.
in a way that has not happened in, say, Brazil or Oman, which have
While these psychological features have importance of their own, they
experienced comparably fast economic growth without the generated
These
are quite limited as guides to individual well-being in objective social
resources being particularly used for improving public health, or public
assessment. The illiterate villagers in Bihar and Uttar Pradesh may be
education, or social security. The "unaimed opulence" of Brazil or Oman
"happier" with their health conditions than are the probing Keralites
contrasts quite sharply with the "growth-mediated process" of health
fussing about their health, but are they really better off for that reason?
improvement in Hong Kong or South Korea. What differentiates the two
Happiness, however fragile or misguided, should not, of course, be
categories of experiences is not really the vigour of markets, or the
scoffed at altogether, but nor should it be taken as a terrifically good
contribution of private economic enterprise in generating economic
indicator of a person's overall well-being. Utilitarian calculations stand in
growth - they share these features (though there has been much more
some danger of concentrating or rather limited - and often somewhat
state planning of industrial direction in South Korea than in Brazil). But
deeper and more fundamental
the Brazilian neglect of public support of health, education and social
aspects of one's health, well-being and the capability to live fulfilling lives.
welfare contrasts sharply with the emphasis placed on it in Hong Kong,
These issues also link with other classical problems in social
Singapore or South Korea, and these latter countries have reaped as
superficial achievements,
ignoring
on
"pro-market*
versus
philosophy, such as Adam Smith's investigation of deprivation and
they have sown. The
necessities, John Stuart Mill's discussions of women’s subjugation, and,
government" policies may have to be redefined to take note of empirical
of course, the large area of social research opened up by Karl Marx's
regularities, particularly those that emerge irresistibly from trying to
debates
“pro
The
analysis of “false consciousness" (a concept that draws particularly on
understand and assess comparative international experiences.
the positional distortions from the perspectives of deprived groups).
central issue is not one of “supporting" the market mechanism or
“opposing" it, nor of being either "pro-government" or "anti-government".
Policy Divisions and Objective Assessment
The real challenges are much more complex than that.
I turn now, briefly, to the second issue - that of objectivity in assessing
alternative policies. This is a particularly important question at this time
Positional Views and Integration
in India, since the traditional governmental policies are now undergoing
In this short presentation I have tried to discuss two rather distinct
major reforms. It is clear that official policies will tend to be much more
aspects of the need for objectivity in assessing health status and policy.
"pro-market" now than they have been in the past. These changes have
First, as far as health conditions are concerned, self-perception proves to
divided the professional economists and political commentators into
be a rather unreliable guide to the prevalence of illness and ill health, but,
different camps. The divisions, to a great extent, have followed traditional
at the same time, provides important clues to the persistence of these
dichotomies (e.g., "left" versus "right", "pro-business" versus “pro-
deprivations. The positional views - distorted as they often are - have a
government"). This is, obviously, not the occasion to discuss these
general social divisions and their important political role. But the need for
crucial role to play in the continuation of prevailing inequalities. Objectivity
has much to do with understanding both the relevance and the limitations
objective assessment of the cause-effect relations on health and well
of positional perspectives, and the need to construct a more integrated
being cannot be over-emphasized. There are essentially two different
picture.
ways in which health conditions improve for the more deprived section of
Second, on the question of policy assessment, it is important to go
First, economic growth and employment in gainful
beyond simple "pro” and “anti" attitudes about the respective roles of
activities can bring the means of health care and nutrition within the reach
markets and of government actions. Empirical studies of international
of the deprived groups. Second, public support of food consumption,
experiences suggest that the causal influences on health transition have
community health, medical care, basic education, etc., can transform
to be understood in less fragmented, more integrated terms. Objectivity
general health conditions. To some extent, these two processes working,
can offer rich rewards in this vital field - as in others.
5
COMMUNITY HEALTH CTLEEWSLETTER, VOL VI, NO, 3 MAY - JUNE 92
328, V Main, I Block
Koramsngala
the population.
Bangaloro-56002e
•
THE DUNKEL PROPOSALS AND INDIAN INTERESTS
Audrey Fernandes
The Indian media have focussed many articles on the negotiations
as the Dunkel Draft text (DDT) which seeks to break the impasse at
under Super 301, GATT (General Agreement for Trade and Tariff),
Brussels and widen the scope of GATT. It includes seven broad areas:
DDT (Dunkel Draft Text). All these have many serious implications to
(1) Market Access (2) Agriculture (3) Textiles (4) GATT rules including
health status, drug availability and use and the concept of essential
TRIMS (5) TRIPS (6) Trade in Services (7) Institutional matters.
drugs. Especially, the frontal attack being made on the Indian Patent
Act (IPA) 1970, if relented to, would turn the clock back, and make
essential drugs out of reach for the common person and perhaps, not
s
The Indian Patent Act
What is it, in the Indian context, that the US and other developed
available at all. Some of the important features of these negotiations
countries find so objectionable about our Patent Law?
are presented below.
Indian Patent Act (IPA), 1970, came into being after a long debate on —
Briefly, the
.
Industrial Policy and the recommendations of the Tekchand Committee 9)
Special 301 and GATT
1948 and the Ayyangar Committee 1957. Both Committees suggested
The US has, under its Omnibus Trade and Competitiveness Act of
that:
1988, a special, Super 301 clause. It is under this clause that the US
argues that, unless India offers 'adequate' protection in the area of
(1) A Patent should not be granted to enable patentees to enjoy a
intellectual property rights it would impose sanctions against its exports
monopoly to export the patented product to exploit the poorer
to our country. Access to the US market is used as a leverage against
nation; rather patents should help the development of industries
erring countries so as to be able to enter their markets. The clause
and protect them from aggression of foreign capital.
empowers the US President to employ coercion to attain greater
(2) Patents should be granted to encourage inventions and to put them
compliance from its trading partners. This includes compelling changes
into operation in India on a commercial scale.
(3) India should not become a member of the Paris Convention. (The
in their respective trade and investment policies. During May 1990, the
US began investigations against India for its ‘unfair trade practices'.
Paris Convention on Patents which dates back to 1883, was
Later, action was deferred. The breathing space India got was aimed at
established to restrict industrialisation of former colonies.) As a
bringing stronger pressure at the GATT negotiations at Brussels, in
result, an act which served as a model to developing countries
December, 1990.
This was
an extension of the Uruguay round,
came into being. The important features of the IPA, 1970, were:
-
T
launched in September 1986. At Brussels, an impression was created
(i)
National interests held priority over patentee interests.
that governments, including India, were destroying multinationalism in
(ii)
Product patenting was not allowed in chemicals, drugs and
pharmaceutical products.
Only process patenting was allowed, permitting the manufacture
I
particular, accused India of blocking progress in the negotiations,
of the product through any different processing. In pharma--
|
particularly because of the latter's stand on Intellectual Property Rights.
ceuticals it was lowerthan forother in ventions .five years fromg
the date of grant, or seven years from the date of application "
trade. The warning of a choice between a collapse of the system and
triggering of a depression was made.
Germany, and the US, in
(iii)
Why was this so? In the earlier seven rounds of GATT negotiations,
for patent, whichever was shorter: This allowed for research
and development in drugs and pharmaceuticals, suiting Indian
international trade was sought to be liberalised mainly through cuts in
tariffs and selective lowering of non-tariff barriers. But now, for the first
time in the Uruguay round, the reorganisation of the international
economy was being sought, through proposals
covering trade,
conditions.
(iv)
investment and technology. Multinationals are being favoured and the
Third World would be required to change the regulations regarding
foreign investment and intellectual property rights. Three new themes
proposed by the US were introduced.
1)
Trade related investment measures (TRI MS)
2)
Trade related intellectual property (TRIPS)
3)
Trade in services (GATS)
Compulsory licensing for process patenting in medicine after
the expiry; of the three years from the date of granting the
—
|
patent, meant that the government could revoke the patent if it
I
found that it had not met the requirements of the public, or was
available at unreasonable prices. Such licensing ensured that
the patentee worked the patent in the country.
Er
(v)
The patentee was not allowed to import the patented product at
(vi)
his/her own price.
The burden of proof of violation of the patent was on the
patentee.
Arthur Dunkel, Director General of GATT, has introduced what is known
This had a positive impact on the drug and pharmaceutical industry.
where, from 1975 onwards, the production of bulk drugs increased 5
times, the production of formulations 6 times, the rise in exports of
The author is a researcher at FRCH, involved in the study,
drugs pharmaceuticals 10.5 times. The time-lag for introduction of new
Drugs Utilisation and Costs in Government Hospitals.
drugs, which was 10-15 years before the IPA 1970, now got reduced to
FRCH NEWSLETTER, VOL VI. NO. 3 MAY - JUNE 92
p
■ IT
|
The failure of the EEC and the US to reach an agreement on
Agriculture at Brussels, resulted in the talks being suspended. Now,
■
6
4 to 6 years, and the production of 100 bulk drugs was introduced with
Under TRIMS too, industrialised countries such as US, EEC,
Japan, have identified 14 such measures.
indigenous technology.
They cite a number of
regulatory performance requirements which have ‘distorting and
inhibiting' effects on trade. These requirements, introduced by Third
DDT, TRIPS and TRIMS
Interestingly the Dunkel proposals seek a reversal of the above
salient features. Where, even today, multinationals control about 78%
of the drug production in India, the private sector 16% and the public
sector only 6%, most life-saving and essential bulk drugs are produced
in the public sector and small scale units. A reversal of the IPA would
mean a worsening of the present situation, where already 80% of the
over 60,000 formulations sold in the country, are, according to WHO,
non-essential and irrational.
World countries in accordance with their development needs and
priorities,
include requirements for local manufacturing, technology
transfer and local equity. Through these they have tried to make sure
that net outflows by way of profit remittances or payments for goods and
services etc. do not cause strains on the balance of payment; also that
the business practices of the multinationals are kept under control and
their adverse effects on economies are reduced.
Alongside,
DDT proposals under TRIMS would also knock our
agricultural economy askew,
Again, the Indian Patent Law does not allow the patenting of living
organisms, as in the American Patent Law (which we would be required
to accept under TRIPS). Bio-technology is set to be the technology of
days to come. It governs the manufacture of products derived from
living organisms, like foodstuffs, vaccines, medicines and even certain
categories of chemicals which are manufactured by fermentation
technology based on micro-organisms.
Acceptance of TRIPS would mean overturning of conventions which
regard genetic resources as the common heritage of humanity. These
resources, now available in limitless quantities, would restrict the full
use of biological potential only to what is patentable, and will erect
barriers to entry in certain branches of production. Monopolies thus
created would be detrimental to the poor and needy of the Third World.
It will become increasingly expensive for the Third World to build local
technological capability, the thrust of research will change, human
needs would take a back seat and research for profit to multinational
It would prevent any practical price
support to farmers, whether to promote self-reliance, or food security, or
to promote export. In developing countries, input subsidies would be
allowed only to very restricted groups of farmers. The Public Distribution
System would be limited only to nutrition as a criteria. The freedom the
government now enjoys to protect farmers from imports of agricultural
commodities by introducing safe-guards such as non-tariff barriers etc.
will be taken away.
Liberalisation: the GATS way
Under GATT negotiations many issues regarding increasing
participation of Third World countries in world trade and expansion of
their service exports are subject to application of the provisions of
agreements relating to progressive liberalisation, market access and
commercial establishment or presence.
'definition of services', 'definition
Whereas issues like the
of commercial presence* or 'the
application of the most favoured nation principle* remain unresolved.
corporations will determine priority.
The fact is that, most plant genetic resources have been
concentrated in areas of genetic diversity located in tropical and semi-
tropical areas. Also, germ-plasm collected from the Third World is the
result of sustained efforts of farmers who have carefully selected and
observed varieties for generations together. (Bolivian farmers were first
While discussions have covered the content of proposed annexes for
tele-communications, construction, professional services, financial
services and labour mobility, there is no general obligation imposed on
the need to provide access to foreign service enterprises or for granting
them national treatment, i.e. same treatment as to national enterprises.
to create disease resistant potatoes, and rice, as we know it, was
These are subject to negotiations on a request and offer basis. The
created by farmers in India). Under TRIPS these would become the
sectors where India has made an offer include engineering services,
computer related services, research and development, hospital
monopoly of multinational corporations.
The DDT also introduces new proposals under TRIPS. Firstly, it
takes away the sovereign right of developing countries to exclude
certain subject matters from patentability for national interests. It treats
'import of the patent to be working of the patent in the country.
Obligations on patent-holders, such as compulsory licensing for non
working of the patent, are to be completely abolished. Instead, the
burden of proof is on the defendant, in case of violation of intellectual
property rights. This would, in practice, mean an almost non-existent
check of such violations. Next, the draft rejects any kind of special and
differential treatment for developing countries in view of their low level of
technological development.
Instead, it
provides for a time bound
mechanism for allowing governments to bring their national laws into
conformity with the proposed TRIPS draft.
The bilateral Super 301 has led to objections to India's ’unfair'
trading regulations regarding foreign investment covering:
(a) 40% ceiling on foreign ownership of Indian companies
services, and the construction of road and bridges. Since the agreement
on services deals not merely with trade in services between countries,
but also affects 'domestic services', it goes against national interest.
Any attempt at supporting any service sector in the interest of the public
would be seen as interfering with the agreement of liberalisation of trade
in services. The DDT fails to take note of the distortions that would be
caused in, for example, health care or education. For instance, if health
care is opened to foreign commercial interest, would it take care of basic
health services dr public health services? Chances are they wil l not. To
imagine that justice could be obtained if disputes arise when the
interests of our people clash with the commercial interest of powerful
transnational corporations is a delusion.
With GATT as a super -
national body, the Third World is being forced to open out sector's which
Were kept
for national
enterprises.
Therefore globalisation and
liberalisation of trade in services cannot be looked at without the existing
Social context.
(b) the phased manufacturing programme, which requires that at least
25% of the value of production should consist of local inputs within 5
years
(c) requirement to export a certain percentage of production if foreign
ownership exceeds 40%
(d) exclusion of foreign companies from the Indian insurance market.
7
Finding our own alternatives
The whole thrust to globalisation and the supremity of multinational
companies does countries like India, no good. We see this from past
experience. Before the introduction of the IRA in 1970, multinationals
with patents only imported drugs into the country, at 5-6 times the cost.
FRCH NEWSLETTER, VOL VI, NO, 3, MAY- JUNE 92
LIBRARY NEWS
Reprints
Books
Antia, F.P., Should Our Population be Allowed to Explode? Forum
1)
of Free Enterprises, Bombay, 1989, pgs. 23.
Combe, S., Voluntary Agencies and Development in Rural India a selected bibliography, 1991, pgs. 83.
Heer, D.M., Society and Population, Prentice - Hall of India, Pvt. i
Ltd, New Delhi, 1987, pgs. 155.
!
Anyinam, Charles A., Transboundary Movements of Hazardous
Wastes : the case of toxic waste dumping in Africa.International
Journal of Health Services (UHS), Vol. 21 (4), 1991, pp.759-77.
2)
Das, Sujit K., Rapeseed Oil Tragedy: cause for concern, Economic
4)
Kahn - Hut, R., Women and Work: problems and perspectives, I
3)
5)
Oxford University Press, New York, 1982, pgs. 327.
Lucas, R.E.B., Papanek, G.F., The Indian Economy: recent
development and future prospects, (Centre for Asian Dev. Studies,
4)
1)
2)
3)
6)
7)
8)
9)
10)
and Political Weekly (EPW), Vol. XXIII (34), Aug. 20,1988, pp.1736-
Boston Univ.), Oxford Univ. Press, Delhi, 1988, pgs. 374.
Nandy, A., Science, Hegemony and Violence: a requiem for
5)
modernity, Oxford University Press, Delhi, 1990, pgs. 137.
6)
Ranade, S, Rural Banking Adrift, Jaico Publicity House, Bombay,
1984, pgs. 126.
Rudolph, L, Rudolph, S.H., In Pursuit of Lakshmi: the political
economy of the Indian state, Orient Longman Ltd., Bombay, 1987,
pgs. 529.
World Health Organisation, Drugs Used in Parasitic Diseases, B.R.
Publishing Corporation,, Delhi, 1990, pgs. 126.
Young, R.H., Addressing the Human Dimensions : in nutrition
sciences, agro-industries, and international agricultural research,
IDRC, Canada, 1991, pgs. 48.
7)
8)
9)
10)
1737.
Ganguli, Indrani, Sans the Language for Communication, Health
for the Millions Vol XVII (5), Dec. 1991, pp. 34-36.
Iyer, Ramaswamy R, Privatisation Debate : an alternative
framework, EPW , Vol. XXV (27), July 7,1990, pp. 1491-92.
Nakajima, Hiroshi, Breaking the Fatal Cycle of Transmission,
World Health, Sept. - Oct. 1991, pp. 2-3.
Qadeer, Imrana, Integrally Women, Health for the Millions, Vol.
XVII (5), Dec. 1991, pp. 11-13.
Rice, Dorothy P., Ethics and Equity in U.S. Health Care: the data,
UHS, Vol. 21 (4), 1991, pp. 637-51.
Sen, Ilina, Class and Gender in Work Time Allocation, EPW, Vol.
XXIII (33), Aug. 13,1988, pp. 1702-06.
Thrupp, Lori Ann, Sterilisation of Workers from Pesticide Exposure
the causes and consequences of DBCP induced damage in Costa
Rica and beyond, UHS, Vol. 21 (4), 1991, pp. 731-57.
Zi, Werlian, Financial Inducement for Improving the Efficiency
of Immunisation, World Health Forum, Vol. 11(2), 1990, pp.173-78.
contd, from page 3
Due to unavoidable circumstances, the fourth country profile
in the series, "Health Financing & Costs: comparative
ii] Industrialists are now having facilities of one window clearances.
perspectives" could not be carried in this issue.
Employees should get one window clearance of their dues from ESIC.
The profile of Brazil will now appear in the July-Aug
issue of the Newsletter. Inconvenience to readers
regretted.
They should not be made to run around to get forms, to queue up at
is
various offices and windows. Simple procedures in consultation with
- Ed.
employees need to be developed.
contd. from page 7
ill] Local committees should publish reports of their meetings. Local
Their stress then, and even now, continues to be largely irrational
combinations. At present too, foreign drug manufacturers sell drugs in
committees need to have some powers. Employees need to have
avenues to reach decision making bodies and disciplinary bodies and
India, which are banned in their own countries, also charge exorbitant
get errant officials and lengthy procedures straightened.
prices for life saving combinations patented by them and marketed
through high power advertising campaigns. What the situation will be
There are employees' representatives (union representatives) on
like, if the DDT proposals are accepted, perhaps, cannot be imagined, If
ESIC bodies at national as well as local levels. Still, workers' complaints
we are to reject the GATT and DDT proposals, the fear is that the
are not heard. The unions need to take more active interest in ESIC
developed countries will use their economic strength to throttle us. On
the other hand, if we relent, we will be co-opted into a system which will
affairs. Now the wage limit has gone to Rs. 3000 per month, so more
employees are coming under ESIC. The need to pay more attention to
benefit only the rich and powerful. It is perhaps time to question what
make ESIC a more vibrant and effective agency to provide health care
this "development’, "globalisation", "liberalisation" and the sole aim of
for the working class has therefore now become all the more imperative.
"industrialisation", at all costs are all about. India is a country which
launched a large resistance movement to drive away the British, who
plundered the land for self-interests.
Will it allow the same kind of
robbery, though at a very magnified scale; to occur again? Or will we
Associations of Doctors;, health activists, such as industrial
hygienists, need to work to develop criteria for deciding disabilities and
also to improve ESIC functioning.
find our own alternatives to "development", to benefit the large majority
of our citizens ? It is, perhaps, time we did.
Selected References.
FREE ABSTRACTING
1)
Abrol Dinesh, GATTastrophe a close look, (a report on Uruguay round of
2)
negotiations) National Working Group on Patent Laws, New Delhi, 1991.
Bidwai, Prafui, Ms Hill Delivers a Message: sense and nonsense on IPR, Times of India
3)
4)
5)
Oct. 9,1991.
Chimai, B.S , Ambiguous Arena, Economic Times, Feb. 3,1992.
Ghosh, Arun, Insidious Assault on India’s Rights, Maharashtra Herald, Dec. 13, 1991.
Lok Vidnyan Sanghathana, Defend the Indian Patent Act, 1 970 (Pamphlet) Pune, 1992
6)
• Sahai, Suman. Planting a Patent Problem. Economic Times, Feb. 3,1992.
Ite contents of this newsletter may be abstracted
without prior permission. However, we would
welcome acknowledgement of the source and
copies of any abstractions.
E
Edited by Nagmani Rao, with secretarial assistance from Vrinda and Joyeeta Sinha, and produced by the Foundation for Research in Community Health,
84. A, R.G. Thadani Marg, Worli, Bombay 400018. Registered under the Bombay Public Trusts Act. Printed at Printext Offset, Pune 30.
•
GOMMUNITY IP
No: 367, ‘Srinivasa i sju
Jakkasandra, I Main, J Block,
Koramangala,
BANGALORE - 560 024
NEWSLETTER
Vol. VI, No. 4
July - Aug 1992
BRAZIL
A Profile in Contradictions
Shirish Kavadi
This^the4th article in the series, "Health Financing and Costs:
comparative perspectives". (No.l- Japan, No.2- Zambia, No.3China.)
TABLE 1: HEALTH STATUS.
Infant
Child
Mortality Death
Life
Expectancy
Year Crude
Birth
Rate
Crude
Rate
Rate
Rate
1
2
3
4
5
6
1970
35.0
10.3
98.6
12.5
58.9
developed' nations, facilitating far greater availability of health care
1985
29.0
8.0
67.0
5.0
64.5
resources than exist in most of the developing world. Health care is
Sources: World Tables, Vol 2, 1983. and World Development Reports, 1987,1989.
The Brazilian health system combines in itself features of both the
developed and developing countries. The two dominant features of the
Death
health system are public funding and private production of services.
One of the most developed of the developing countries, Brazil spends
as much on health (4% of the GDP in 1981) as the industrialized
Brazil's largest social security programme, receiving in 1982,90% of the
total health budget.
Brazil has a disease pattern that is a combination of communicable
Yet, about one-third of the population lacks regular access to basic
diseases common in developing countries and illnesses afflicting the
health care, resulting in high morbidity and mortality rates amongst the
developed world. Nutritional deficiencies affected half the population. In
poorer communities. The enormous expansion of curative medicine in
1975,46.8% of the children in the age group of 0-5 suffered from some
the social security system on account of government policies has
degree of malnutrition. Brazil, in the 1980's, was said to be a 'sick
resulted in excessive costs, unnecessary surgery, overly sophisticated
country', with Chagas'
care and all the distortions of modern, hospital-oriented medicine.
taking very high tolls.
disease, tuberculosis, malaria, and tetanus
This then represents the paradox in Brazilian health care system.
Doctors in Brazil have neglected preventive services in favour of
The Brazilian policy-makers are thus, on the one hand, faced with the
curative services. Various measures undertaken by the government,
task of containing rapidly increasing medical costs and on the other,
such as mass immunizations, mobile vaccination teams, mobilization of
reducing the disparity in the quality and quantity of health care available
national health teams and national publicity campaigns, failed to
to different sections of the population, owing to chronic under-funding of
effectively curb or eliminate the most common communicable diseases,
the public health sector.
except for short periods. It is significant, however, that incidence of
Health Status
0.1 per 1,00,000 persons since 1981.
poliomyelitis fell from 2.1 per 1,00,000 persons between 1975-1980 to
Brazil, in 1985, had a population of 134.6 million. Health indicators
Slow population growth over the years and increased life
have shown a reasonable improvement over the years (see Table 1).
expectancy has led to the aging of the existing population, which has, in
However, there are regional variations. For example, the infant mortality
turn, contributed to the growing rate of chronic and degenerative
rate in 1990 was 68/1000 nationally, but in the north-east region it was
diseases. Mental disorders are common and deaths due to accidents
200/1000.
and violence are increasing in frequency.
The author was formerly co-researcher in a WHO sponsored
Organisation of the Health Sector
FRCH study, from which the above article has been drawn. At
present he is involved in the study, "Health Expenditure and
Investment in a District".
Administrative and Legislative Framework: Brazil
is a federation with a three-tier governmental structure. Formulation of
FOR PRIVATE CIRCULATION ONLY
health policy and its implementation is the responsibility of governments
at all the three levels.
Planning at the national and state levels is
confined to developing standards in disease control programmes and
staffing of hospitals.
Consequently, the more basic concerns of an
equitable health system have received little attention.
practitioners with their own clinics cover the health care needs of the
economically well-off sections of the population.
This covers about
20% of the population, either on a fee-for-service basis or through
contractual arrangements with social security agencies.
However, in recent years, private medical practice is becoming a
peripheral activity. Only 7.5% of the total number of physicians are
Health Care Development: The first attempt at national
purely private practitioners. The rest are primarily salaried employees
organization of health and welfare by the Brazilian government in 1887,
dependent on the State. Of these, 45% are reported to have private
was guided by considerations of controlling epidemics which threatened
practices, though on a small scale, spending less than 12 hours a week
the urban population.
Growing industrialization prompted increased
attending to private patients.
governmental intervention in the social sector in the form of various
Seven autonomous social security institutions operate their own
welfare measures. Improvement in the health of the working class was
facilities. They also have contractual arrangements with private health
essential for increasing industrial production.
providers. The social security agencies cover medical care for different
However no coherent policies were ever formulated and the social
categories of private and public employees in urban and rural areas.
security system that evolved was essentially discriminatory in nature.
The largest of these is the National Institute for Medical Assistance and
Social security was first introduced in 1923 to cover railway employees
Social Insurance (INAMPS).
but gradually expanded its coverage to include the organised working
consisted of 41 hospitals, all with out-patient units.
sector, such as maritime and dock labour and other politically powerful
health centres, which constituted the bulk of its own ambulatory care
groups. However, it left out the marginal urban groups and the poor
resources.
In 1980, INAMPS hospital network
It also had 487
rural masses. In 1971 this drawback was somewhat corrected when
The Government of Brazil made every attempt to increase health
social security was extended to rural workers under the programme of
care resources over the last three decades, but this has not necessarily
assistance for rural workers.
resulted in the extension of health care coverage. Since the 1960s the
World War II gave further impetus to public health endeavors.
number of persons trained in medicine has increased five-fold (Table 2).
These were a part of the war effort undertaken with US cooperation.
The doctor to population ratio is considered high. The number of para
The focus was on rural health programmes, especially malaria control,
medical staff has also gone up, but the ratio of nurses to population
and training of public health personnel. US cooperation came to an end
remained below the standard set by the Ministries of Health of the
in 1960.
Americas.
From 1964-1984, Brazil was under a military regime.
This
TABLE 2 : HEALTH RESOURCES
government too had no well-defined health policy. Committed to a
modernization programme, it pursued economic and social policies
which subserved public health needs to curative medicine. With the
Beds
Year
emphasis on hospital based technology and specialist-oriented, curative
Physician
DENTISTS
Nurses -
(per 100,000 population)
medical care, preventive and promotive health care were neglected, to
the detriment of the health of urban and rural poor.
1970
370
48
2
6
1985
410*
143
12
19
for
Latin America
A new civilian administration took office in March, 1985. As a part of
the various steps undertaken to address the problems faced by the
people, the government outlined a new health sector strategy. This
strategy focussed on integrated health services delivery; financial
Source : U.N. Statistical Yearbook
and Pie Caribbean. 1988.
•Figures are for 1984
control; expansion of state municipal services; and finally, increasing
efficiency of the delivery structure through decentralization and de
emphasizing specialized and professionalized health care.
Health Care System: services and resources
Brazil has a pluralistic health system wherein health care is
Yet most public hospitals in the late 1980s faced a serious shortage
of staff. Brazil faced no real shortage of physicians, and had many
under-employed and unemployed physicians. The non-availability of
doctors to large sections of the population was due to geographical
maldis-tribution.
The geographical distribution of doctors tended to
delivered through both public and private sectors. Facilities in the form
of polyclinics, health centres and posts run by the national and state
•follow the level of economic development of a region and the location
governments and municipal bodies provide ambulatory and primary
majority existed in the Rio de Janeiro - Sao Paulo belt, which falls in the
medical care to about 20% of the population, mainly the poor and the
economically developed and high income Southeast region. This region
children.
had 65.6 percent of the physicians against 16.3 percent situated in the
pattern of medical schools and hospitals. Out of 76 medical schools the
This section of the population also receives primary health services
northeast. Of the total doctors in the state of Rio de Janeiro in 1980,
from non-government organisations. Although there were about 6000
78.56 percent were reportedly in the capital alone. Adding neighboring
groups spread throughout the country in 1990, the importance of
municipalities, the concentration in the Rio metropolitan area reached
voluntary bodies in recent years has generally been declining.
89.6 percent.
Industry-run network of ‘consultaries' and polyclinics in the main
The inadequate supply of health staff, along with under-funding,
cities provide medical care to the employees and their dependents.
mismanagement and shortage of supplies affected the working of the
Private profit-seeking groups, similar to health maintenance
public hospitals. In 1987, some 1500 of the 3500 public hospital beds in
organisations (HMO) in the United States, have prospered in areas like
Rio de Janeiro were taken out of service. This created the ‘deadly
Sao Paulo, where the governmental health infra-structure is weak and
problem' of overcrowding in the public sector hospitals throughout
In addition, privately owned hospitals and private
Brazil. However space is always available in private institutions. Out of
inadequate.
FRCH NEWSLETTER, VOL. VI. NO. 4. JULY - AUG 92
2
the total hospital beds, 75% (1990) were in the private sector. However,
Excessive surgery has also been a common phenomenon.
since government social insurance for the poor pays around 60 to 70
1980, one third of the deliveries compensated by INAMPS were
In
percent less than private insurance programmes, the private hospitals
caesarean. The caesarean rate in Brazil is perhaps the highest in the
show little interest in treating this section of the population. The Brazilian
world and higher than normally accepted. There were 400,000 surgical
bed to population ratio (Table 2) is better than the Latin American
deliveries in 1981.
average of 2.5/1000 but is lower than the WHO standard of 5/1000.
Another distortion in Brazil's health care system is the highly
technological orientation of medical services. In 1981 INAMPS paid
Cr$ 22 billion or 6% of its budget to just 10,000 patients who had
Financing of Health Care
There are both public and private sources of health financing in
Brazil. The private sources include individual households for personal
health care (16.5%), employers' schemes (6.3%), private insurance
(2.9%), trade unions (2.1%) and voluntary agencies (0.7%).
It has
already been pointed out that most of the medical care delivery is
organised through the private sector but financed dominantly by public
sector agencies. 72% of overall health expenditure in 1982 came from
public funds. Public sources include the Federal government (primarily
Ministry of Health), state and municipal governments.
In 1982 the
contribution of each of these in the total public health budget was 6.8%,
received kidney dialysis, coronary bypass surgery, or intensive care. It
has been pointed out that these patients cost more than the Cr$ 19
billion spent the same year on all public health services and disease
control for a target population of 40 million people.
Most of the
specialised services have thus been directed at a small elite population.
The expansion of social security medical care and increased
privatization of services caused a relative reduction and progressive
marginalization of the public health budget.
Thus, the share of the
Ministry of Health in the federal budget went down from 5.87% in 1960
to 1.31% in 1980. Besides, it was the public health sector which was
most affected during the economic crisis of the 1970s and early 1980s.
20.4% and 7.3% respectively.
This inverse relationship between private provision of medical care
and public funding has been responsible for various distortions in the
The government health sector had to curb most of its capital
expenditure.
But not so the INAMPS. Robert Woodward points out that during
system. The culprit is largely seen to be the social security services.
Says James Horn, "Social Security policies and expenditures have
been the major factor increasing the privatization of medicine and the
this period of recession and international debt problems, Brazil was able
to effectively maintain the funding of its health services. The real gain
expansion of a' medico-industrial complex' whose growth threatens to
however, was of the INAMPS. By 1982, INAMPS medical budget was
increase the gap between those covered by sophisticated technologies
eight times higher than that of the Ministry of Health.
and those lacking even basic services".
Around 37% of the total health sector funds came from the INAMPS,
Is Social Insurance the Answer ?
the social security agency for medical care. This was the single largest
The government made attempts at reforming the system.
source of finance. Some 80% of the total Federal government funds
example, in 1988, the government launched the National Programme of
went into the social security system.
For
Basic Health Services (PREVSAUDE) which unfortunately died a quiet
The INAMPS subsidizes services partially funded by the
and early death. No amount of reorganisation and reorientation of the
government, the employers' schemes and trade unions. Government
health services appear to have rectified the distortions and drawbacks
agencies have increasingly turned to this institution as a source of
of the Brazilian health system. Part of the problem lay in the overall
socio-economic policies which ignored and neglected the impact these
financial help, on account of a chronic shortage of funds.
Unable to meet the demand for increasing coverage through its
would have on health conditions and health care delivery.
own resources, the INAMPS progressively turned to the private sector.
The Brazilian case is a good example of how the mere existence of
A very large proportion of its funds were allocated to the purchase of
social insurance and large government funding do not necessarily lead
medical care from private providers.
to good and universal health care.
In 1981, 71% of the INAMPS
The availability of funds and
budget was spent on paying private providers for medical services and,
resources alone do not determine the quality of health care. But, the
as such, the thrust of this institution was towards curative care. (The
priorities and concerns of the government, as reflected in its policies, do.
rest of the funds went to INAMPS health units for services provided -
Policies should foremost reflect concern for proper management and
mainly to out-patients - and to federal, state and municipal hospitals and
equitable distribution of resources. Commitment to equity in health care
health centres).
arises out of a commitment to justice and fairness in the social and
The INAMPS reliance on private practitioners, hospitals and
medical enterprises nourished a lucrative private sector.
Doctors and
hospitals determined need and duration of hospitalization, surgery,
economic sphere. The true test of a government's political will lies in its
ability to go beyond mere rhetoric to an uncompromised exercise of its
commitment to the common good.
tests and treatment. The reason is found in the mode of payment made
under the scheme to private providers through their contractual
arrangement with the institution. The INAMPS reimbursed a doctor a
low flat fee for office calls, and a schedule of fees per unit of service, for
tests and procedures. For example, in 1984 the consultation fee was
Select References
1)
Guest Charles, Public Health, Welfare and the New Constitution in Brazil, Medical
2)
Journal of Australia. Vol. 145, Dec. 1/15,1986.
Horn James J, Brazil: the health care model of the military modernizers and
3)
4)
Lancet. Vol. 336, Dec. 1.1990.
De Macedo C.G. and De B. Vieira C.A., The Fate of Primary Health Care In Brazil, IDS
5)
6)
Newsweek, June 18,1990.
Seventh Report of the World Health Situation, Vol 3. WHO, 1987.
7)
Woodward R.S. Brazilian Health Care Delivery During a Recession. BullelinofthePAHO.
even less than $ 1 (Cr$ 2100) per office call. This low remuneration for
office calls encouraged physicians to order more tests on
hospitalizations in order to enhance the amount of their own payment.
Given the deficiencies of public hospitals, the private hospitals gained.
In 1982, INAMPS thus financed about half of the out-patient care, two
thirds of the laboratory tests, X-rays, specialized treatments and 90% of
technocrats, International Journal of Health Services. Vol. 15, No. 1,1985.
Bulletin. Vol 14, No. 4,1983.
Vol 18, No. 4,1984.
the hospital care provided by the private sector.
3
•
FRCH NEWSLETTER, VOL, VI, NO, 4, JULY-
AUG
92
SPREADING INFORMATION
Some Preliminary Results
Vasudha Joshi
In the literature on development one discerns a tendency to first
Different methods of communication were made use of to judge their
look towards structural factors in terms of lack of resources, followed by
social network, and then, individual/psychological explanations (such as
relative effectiveness. To ensure credibility and acceptability, the
pamphlets were circulated with the signatures of Padma Bhushan Shri
presence or absence of innovativeness or fatalism) for identifying
Anna Hazare, the famous leader of Ralegan Siddhi, and Dr. R.C.
obstacles to development. There is also an inclination to attach prime
Awasthi of FRCH.
importance to structural factors in the Third World setting and to discuss
considered specially significant as the success of the Ralegan Siddhi
Hazare's association with this project was
the social network and individual problems primarily in the context of the
experiment stemmed from the same basic premise of becoming aware
First World. The issue of access to information has accordingly been
of one's rights first and then asserting them collectively.
discussed more in the First World context.
IRDP is the top-most development programme started by the
government in 1980. It enables the poor to obtain, through bank loans,
The Perspective
To identify information as a factor that inhibits development is to
assume that current behavior is poorly adapted to the prevailing
environment. People do not know, so they do not act optimally. People
do not know because information, which they can understand and act
upon, has not reached them. Ensuring access to information should
productive assets for generating a continuous flow of income in future.
EGS is a well-known wage employment programme of Maharashtra
It guarantees employment to the rural poor and has been in
State.
operation since 1974. Government health services provide facilities, in
the form of health centres and health staff, for improving individual and
community health.
underprivileged. This is an issue which has become very relevant to the
IRDP and EGS entitle the poor to immediate monetary benefits
while health services are designed for a more long-term impact. In the
Third World societies today.
rural areas health is not a priority with people but illness is, specially
hence serve as the first step towards conscientising the poor and the
This perspective forms a useful backdrop for evaluating the
effectiveness of the various development and poverty removal
programmes that have been launched in the country since the late '60s.
The problem of 'leakage', which is acknowledged to bedevil all of them
alike, may primarily be due to the lack of information among the potential
beneficiaries about their entitlements and the modalities of these
when it interferes with their wage earning capacity.
Even then, our
experience is that no more than 4% to 8% of the illness cases come to
the public health services. This is due to the poor opinion people
universally have about their functioning. A more positive response to
IRDP, EGS pamphlets was hence expected by us. Giving information
about health services was thought to be more of an awareness-building
exercise.
programmes.
Dissemination of information regarding these programmes has
mostly taken place, so far, through the government machinery.
Bureaucracies are not known for sensitivity to the problems of the
disadvantaged.
The secretive fashion of bureaucratic functioning
Implementation
Results from a pilot study that was first undertaken in 1990 in
Purandar taluka (Pune district) were very encouraging.
The study
results in mystification, while vested interests bring about systematic
disinformation. This prevents community participation, which is essential
showed that people appreciated the information so much that they were
for the effective implementation of these programmes and also for
money for giving the pamphlets to them. Villagers also applied for IRDP
creating accountability in the implementing machinery.
willing to pay for it. Gram Panchayat officials unscupulously collected
loans in such large numbers that the officials could not cope with the
work-load and advised us to go easy.
The Project
FRCH decided to undertake a Public Information Project with the
objective of gaining first-hand understanding of the effects of making
information about government and other programes, facilities etc.
available to the rural poor. Printed leaflets, in Marathi, regarding the
Integrated Rural Development Programme (IRDP), Employment
Apart from indicating a good deal of enthusiasm and receptivity
among the villagers, the pilot study also threw light on the myriad
difficulties they faced when they decided to act on the information and to
get benefits to which they were entitled. A full-fledged project was then
undertaken to give a better understanding of these difficulties and their
impact on the villagers’ behavior.
Guarantee Scheme (EGS) and the government health services were
In this expanded study covering selected areas in Ahemdnagar and
distributed in twenty villages in Pune and Ahmednagar districts.
Pune districts, it was decided to distribute detailed printed pamphlets
The author is a lecturer at Wadia College, Pune. She is also
Assistant Editor of "Baiza", a Marathi magazine, writing on
women's issues. Her association with the Public Information
Project comes from her wider social interests.
FRCH NEWSLETTER, VOL VI, NO, 4, JULY - AUG 92
among the villagers. Pamphlets were prepared on the basis of
information obtained in the concerned government offices. Rough
drafts were shown to the officials for comments and correction. The
emphasis was on simplicity and specificity.
Specimen application/
request forms were included in the IRDP and EGS pamphlets.
4
Field workers visited the villages several times and decided about
Tehsildar, who was contacted for submitting the application forms,
the appropriate method of information dissemination. They went back
cynically maintained that people who applied for work rarely turned up
to the villages after a gap of a month or two, to check the progress and
regularly, once it started. He hence advised the field workers to make
observe the villagers' response.
efforts to ensure regular attendance at work-sites. In spite of the large
Communication Methods and Impact
officials, this year no work was started in the twenty villages till mid-May,
number of application forms and also letters written to the concerned
1)
House to house distribution, so that pamphlets would reach the
villagers without getting 'lost' in transit, and also to enable them to get
their doubts clarified immediately.
2) Gram Sevak or Gram Panchayat attendant: Wherever they were
found to take interest and initiative in the development programme they
were requested to pass on the pamphlets to the villagers.
3)
by which time the worst was somehow over.
People also applied in large numbers for loans under IRDP. They
had to contact the Gram Sevak or Talathi for this purpose and
encountered many difficulties in doing so. In many villages the Gram
Sevaks were mostly unavailable, as their visits were highly irregular.
So, in Purandar taluka, complaints were made to the Sarpanch and
through him the Gram Sevak was asked to be regular. In one village
By post: In small villages the pamphlets were merely posted to
where the information was sent by post, prospective beneficiaries
each beneficiary to see the effectiveness of impersonal modes of
pressurised the Sarpanch and accompanied him to the Panchayat
communication.
Samiti office to get a Gram Sevak appointed for the village, in order to
4) Group meetings followed by pamphlet distribution: It was thought
process their loan applications. Being forced to visit these functionaries
that discussions in the meetings would make the villagers receptive to
again and again for follow-up and paying “on-money" were the other
the information in the pamphlets. Help from local youth clubs, Mahila
obstacles mentioned by the villagers.
Mandals was also taken for this purpose.
Some Gram Sevaks were openly dismayed by the increased work
Posters, notice boards, wall writings: These were used to highlight
load following the spate of applications. Bank officers, and in one case,
selective information about the programmes. Posters and notice boards
even the Block Development Officer, advised the villagers to make
were placed at strategic points in the villages, including the ration shop,
fewer applications so that they could cope with the processing work.
5)
hotel, community hall (chavdi), etc.
There was a noticeable lack of enthusiasm among the villagers
6) Through contact with school teachers, students of Sth and 9th
about the pamphlet on public health services.
standards were addressed on the government health services.
preferred information that promised some monetary benefit to them.
They, on the whole,
Pamphlets were then distributed and the students were requested to
Inquiries with health visitors and attendants revealed that almost nobody
read them out to their parents and elders in the family.
came to them after reading the pamphlets. This also reflects the mood
of disenchantment and cynicism that the villagers widely share about
Distribution through post was quite effective in reaching the
public health services.
However group meetings followed by
The government nurse in one village in Purandar taluka requested
discussions had the greatest impact in initiating people to act. This
the field worker not to distribute the pamphlets in the sub-centre village
underscores the importance of interpersonal media in introducing
where she was posted, as she feared that the villagers would insist on
Distribution through gram panchayat functionaries was
her staying in the sub-centre village - a proposition highly inconvenient
probably the least effective method, as in most of the cases, they were
to her. At the same time, in another village, the CHV, after reading the
reluctant to pass on the information.
pamphlet, successfully pressurised the government doctor to pay a
monthly visit to the sub-centre. In one village, a written complaint was
information to the villages.
change.
In a couple of villages however, newly elected sarpanches, in their
filed with the District Health Officer for holding Immunization Camps
initial enthusiasm, showed some interest in the project.
regularly in their hamlets. In another, the health services pamphlet was
distributed among women at an Immunization Camp. They sat together
Progress and Findings
and jointly read it out.
The villagers unanimously opined that the pamphlets contained
comprehensive, useful information that was hitherto not available. They
knew about all the three programmes but were uninformed about some
In a subsequent camp, when the PHC
functionaries tried to take money for the drugs supplied, these women
refused to pay, saying that public health services were supposed to be
free.
vital operational details which prevented them from taking full advantage
of them.
For example, many did not know whether their names were included
in the list of households below poverty line, in order to avail of the
benefits of IRDP. It was also generally not known that under IRDP one
Potential for Action
All the villagers were well aware of the importance of information.
They also understood that information would not reach them easily.
contd. on page 8
was entitled to a second or third “dose" of loan, provided the subsidy
limit of Rs. 4000 had not been crossed by previous loans. As for EGS,
most of them did not know that they could demand work as a matter of
right and that the government was obliged to give them work.
The
application forms in the pamphlet were therefore highly appreciated.
FRCH PUBLICATION
STATE HEALTH EXPENDITURE: A Database
All India and the States (1951-1985)
Authors: Ravi Duggal, Sunil Nandraj, Sahana Shetty.
Information about where and for what reason complaints could be
lodged was appreciated particularly in the case of health services.
The EGS pamphlets were, particularly welcome as most of the
villages were reeling under severe drought and the people badly needed
employment. In Parner taluka, many villagers filled in the application
forms but were skeptical about the possibility of really getting work. The
5
Postage - free copies can be ordered from
the FRCH at the following contributory rates:
In India:
Overseas
Institutions; Rs. 500/-
$ 50/-
________ Individuals; Rs. 250/-
POMMUNL
, -
e
Jakkasandre, I Main, I BiX&k,
Koramangala
PARIAs.
-
not qualify as an illness. The book argues that sociology serves the
function of re-establishing the boundaries between healthy and sick,
between normal and deviant. Structural-functionalist medical sociology
was engaged in understanding Nazi prejudices as a disease. It has
been criticized for sympathizing with the fascists, by way of medicalising
the act of mass-murders.
Illness as Professional Construction
With the symbolic-interactionism, the hierarchies between the
patients and the doctors, between the oppressed and the oppressors,
become unclear. Uta Gerhardt remarks that interactionists relentlessly
Ideas about Illness: an intellectual and political history of
medical sociology - Uta Gerhardt, Macmillan Education Ltd.,
take sides with the oppressed classes to resist processes of exclusion in
London, 1989, pp. 425.
pathology altogether. Sociology, rather, becomes an 'ally of the welfare
the society, and consequently fail to discuss the problem of social
state', pushing the deviant into the mainstream.
The emergence of modern medicine and our growing obsession
with health, higher life expectancy, etc., are simultaneous events. Our
personal suffering invariably finds expression in medical discourse, to
get qualified as illness, which consequently acquires asocial dimension.
Medical sociology becomes privileged in theorising the idea of illness.
Sociologists are engaged in locating the origins of illness in the doctor
patient dialogue or in social welfare politics, rather than in the immediate
experience of pain. Medicine, with its claims to political neutrality and
self-righteousness, becomes the first rate institution of social control,
It takes a political
stance on the side of patients, who succumb to the professional politics
of medical and welfare service agencies, to acquire 'illness' and
'disability* labels. A person with a poor vision, when pronounced as
blind by the ophthalmologist, suffers no longer from medical but social-
psychological problems of adjusting to the new identity. For the
harmfulness of such diagnosis, patients* right to challenge or negotiate
0
the diagnosis and course of treatment becomes all important. The book
argues that negotiability of diagnosis does not make medical knowledge
a lesser truth.
which clandestinely expands to other areas hitherto defined by religious
or legal discourses. Uta Gerhardt traces the changing configurations of
'illness', generated and monopolized by medicine, through the range of
sociological traditions. The tremendous documentary work brings out
the evolution of sociological thought in relation to medical science and
medical practice.
Illness as Intersubjectively Constructed Reality
The doctor's responsibility for the patient's well-being explains the
former's apparent dominance in medical encounter. Since illness
becomes obvious only when help is sought, it seems no further appeals
can be made. Even suicide is a matter of interpretation of the dead
person's presumed behaviour. The sociologist, a stranger to the world
Illness as Social Role and Motivated Deviance
of clinical reasoning, is obliged to assume perspective of a patient.
Truly speaking, health, rather than illness, plays a decisive role in
A phenomenologist cannot distinguish between a sick person and a
Health indicates the basic
criminal. The amount of responsibility attributed to the behaviour of the
condition for participating in the competitive world. Harmony, equality
victim/convict (medical or judical) and available freedom are debated at
and democracy are symbolized alike, by the health-quality shared by
length. The author suggests that criminology shoud be re-established
the 'structural-functionalist paradigm'.
the majority
phenomenon.
citizens.
Illness is regarded as a minor, accidental
individual's social conformity, are considered only as secondary
defenses.
The view that both the body and the society are organic in nature
and that the doctor-patient relationship is an exact replica of the social
system in minature, leaves a simpler task for the sociologists. They
legitimize doctors, who in turn favour interests of the capitalists.
Doctors' obligations to follow the highest possible standards of technical
and scientific competence interfere with their loyalty to patients' welfare.
The idea of a patient in this context includes an adult male worker in an
organized sector, who has benefits of earned sick leave, insurance
policies etc.
outside the scope of medical sociology.
Corrective interventions of medicine, propagating
In a reciprocal but hierarchial relationship between the
Illness as failure of resources and ideological
construction
g
Y
Medicine, as an instrument of social reform, has been expanding
into areas of life beyond curative purposes (plastic surgery) and taboo
areas (alcoholism, pregnancy) etc.
Through unequal distribution of
services it also serves an exclusionary function. It discourages people
to enter into a sick role and encourages them to maintain work or family
responsibilities, regardless of their personal sufferings.
State
interventions concerning health are said to serve the bourgeois'
purposes.
doctor and the patient, illness is supposed to be generated from patient's
Despite the virtually epidemic advancement in medicine, a vast
anticipatory consent or from his unconscious motivation. Cure means
amount of illness remains untreated. This has motivated the sociologists
annihilation of patients' disease consciousness, so that the patient
to focus on health rather than on medicine.
resumes a role in a competitive society.
terrorism of doctors and of sociologists, and the mundane patient
In this approach, illness becomes sociologically relevant only if the
ill people enter into a sick-role. Anti-semitism in a fascist society does
After all professional
politics, the sociological thought has come across a lay conception of
treatment. Self-help movement,
deprofessionalisation and
demedicalisation of health care are the results.
Illness, now, refers indirectly to social inequality, exploitation etc.
The reviewer above is involved in the FRCH study, "Health
Expenditure and Investment in a District".
FRCH NEWSLETTER, VOL, VI, NO, 4, JULY - AUG 92
and directly to pollution, toxic wastes, unsafe goods and dangerous
Contd. on pageB
6
LIBRARY AUTOMATION
Its in-house applications
Usha Sethuraman
Library automation is no more a new concept. Libraries have been
assigned to each field. The nature of the field - numeric, alpha-numeric
using computers to carry out different functions like accessioning,
or alphabetical -is defined, along with the length of the field. The FDT
cataloguing, issuing and various aspects of documentation, to mention
should be created keeping in mind the indexing fields and the added
a few. Every library is a growing organism where innovation leads to
entries.
It is not only the size which indicates growth, but also the
The next step is to create the field select table(FST). In this table
documentation techniques and extent of dissemination. Our library and
selected fields are assigned indexing techniques which will enable
documentation unit has introduced changes and always adapted to
sorting and retrieval of records accordingly.
them.
different formats are prepared to suit different outputs. For example,
change.
This article shares our experiences in introducing the method of
The work-sheets and
there is one format defined to print author cards. There are also subject
I continuous cataloguing using CDS/ISIS in the Library and
cards and title cards prepared for both books and reprints. To take care
Documentation unit at FRCH. Here we describe only the advantages
of added entries the concerned field is sorted in the print work-sheet and
The print menu of the ISIS
and preliminary techniques for such automation. Subsequent articles
printed through the author format.
would share other aspects concerning use of CDS/ISIS in libraries.
programme provides a worksheet and by choosing it with the
combination of formats earlier defined, these cards are printed. The
lines per page should number 18 so that the information fits into the 5" x
The Advantages of Automation
3U card. To edit before printing the catalogue cards, the output can be
We started the creation of a database in 1989 using CDS/ISIS.
Since then we have been learning this software package and have now
introduced it for cataloguing also.
There are
various reasons for
changing from a manual system to an automated system. The labour-
intensive original cataloguing is eliminated. It reduces the chances of
error or inconsistency and thereby produces standardized records. Of
course, last, but not the least, it saves time and costs and takes care of
staffing constraints. Using library automation enhances the in-house
applications by improving library services and management.
For
example, it is a time consuming activity to prepare a bibliography from
read through the DOS editor and changes can be carried out. We run
the save file through a 'C* programme to eliminate the page break put by
the ISIS programme.
While printing author cards, the author field is sorted alphabetically,
followed by the titles. The subject cards and the title cards are similarly
sorted. The task of filing thus becomes very easy, since the print-out is
already sorted according to the filing order. User orientation is a very
important factor because this will help optimise efficient use of an
automated library system. This kind of library automation looks forward
to networking, remote access and maximum utility.
•
the manual system, as the librarian has to copy all the references over
again from the catalogue cards. On the other hand, in a computerised
system, the details of all entries which are on record are made only once
and different outputs like an accession register, a bibliography, a
FOR READERS' ATTENTION
catalogue card, a search, etc., can be printed out from such a master
record.
Planning, Orientation and Adaptation
At the pre-planning stage of automating the cataloguing routine of
the library, the assessing of the existing system is important. The fields
like author, title, subject and the part statement are written over and
again in the accession register, in a minimum of three catalogue cards:
in the worksheet to enter in the database, in the book card, and finally in
readers' issue books. Acclimatising and evaluating the library staff is an
equally important aspect. New machinery requires fresh orientation.
The staff should posses the capability of grasping the new technology
and adapt to the resultant changes in their routine work.
At the planning stage the major task is to create the database. A
field definition table (FDT) is where the fields are defined and a tag is
The author is in charge of the Library and Documentation Unit
Readers would be aware that FRCH operates on
limited, time-bound grants. Therefore, to help make this
newslettera self-sustaining, long-term venture we request
you to share in the production and postage costs.
Those of you who have made no contribution formore
than a year, please fill the attached 'Friend of FRCH'form
and send it to us, along with yourcontribution. If, however,
you have made a contribution in the recent past, please
pass on theform to others who may be interested in sharing
information on health related issues.
Please also inform any change ofaddress promptly and
completely, to ensure regular and correct delivery of the
newsletter. All editorial and subscription enquiries maybe
addressed tor
FRCH Newsletter,
64/5, Anand Park, Aundh,
Pune 411007.
at FRCH.
7
FRCH NEWSLETTER, VOL, VI, N0.4, JULY- AUG 92
LIBRARY NEWS
Books
1)
Reprints
Ahmed E., Dreze J., Hills J., Sen A., Social Security in Developing
Countries, Clarendon Press, Oxford, 1991, pgs. 477.
1)
Alanagh Raikes, Gender and the Production of Health Care
2)
Chatterjee H., Indian Women: their health and economic
2)
3)
productivity, World Bank, Washington, 1990, pgs. 130.
Jeffery R., The Politics of Health in India, University of California
Services: Issues for womens' roles in health care development,
IDS Bulletin, Vol. 23 (1), 1992, pp. 19-28.
Bal Arun, Dangers of Drug Price Decontrol, ACASHNews, Jan-Mar
3)
1992, pp.11-14.
Bhende M.J., EGS and the Poor: evidence from longitudinal
4)
Press, Berkeley, 1988, pgs. 348.
Kannan K.P., ThankappanK.R., Raman Kutty V., Aravindan K.P.,
Health and Development in Rural Kerala: a study of the
linkages between socio-economic status and health status, KSSP,
Trivandrum, 1991, pgs. 218.
4)
Goldsmith Edward, The Seductive Language of Development
5)
Education and Development, (37), Sept. 1991, pp. 214-215.
Haragopal, Health Care as if People didn't Matter, Health Action,'
5)
village studies, EPW, Vol. XXVII (13), Mar. 28,1992, pp. 623-625.
Kohli A., The State and Poverty in India : the politics of reform,
Cambridge University Press, Cambridge, 1987, pgs. 262.
6)
Patnaik P., Economics and Egalitarianism, Oxford University Press,
7)
Delhi, 1991, pgs. 42.
Sainath P., Patentfolly: behind the jargon on intellectual property
8)
9)
rights, The Indian School of Social Sciences, Bombay, 1992, pgs. 28.
Sen A., On Economic Inequality, Oxford University Press, Delhi,
1985, pgs. 118.
Society for Participatory Research in Asia (SPRIA), Non
governmental Organisations In India : a critical study, SPRIA,
7)
8)
9)
10)
New Delhi, 1991, pgs. 139.
10)
6)
Vol. 5 (5), May, 1992, pp.11-16.
Jesus Balhen A., Notes on Literacy Efforts for 1990-criticism and
reflections, Adult Education and Development (37), Sept. 1991,
pp.194-201.
Kakwani N., Subbarao K., Rural Poverty and its Alleviation in India,
EPW, Vol. XXVII (18), May 2,1992, pp. 971-72.
Matson Jim, Selden Mark, Poverty and Inequality In China and
India, EPW, Vol. XXVII (14), Apr. 4,1992, pp. 701-715.
Sen S.R., Drought, Starvation, Unemployment: some corrective
measures, EPW, Vol. XXVII (19), May 9,1992, pp. 989-991.
Rahmathulla Laxmi, Vitamin 'A' and Childhood Mortality, EPW, Vol.
XXVII (3), March 1992, pp. 666-668.
World Bank, Gender and Poverty in India, the World Bank,
Washington, pgs. 373.
contd. from page 5
The library and documentation unitofFRCHbringsout
comprehensive mon thly updates ofnew addilions to the library.
It lists new books and reprints along with references indexed
from selected journals and newspaper cuttings. Those inter
ested in availing of this facility may please contact:
One villager quipped,u being informed is as good as holding power. So
why should one who has information part with it?"
The villagers were quick in seizing the opportunities that information
opened before them. Even in those cases where they decided not to
make use of these opportunities, their behavior appeared to be rational.
For instance, a villager did not want to file an application under I RDF as
The Librarian, FRCH,
84-A, RG. Thadani Marg,
Worli, Bombay 400 018.
he felt that he would actually be better off without a loan, considering the
cost of the time that would be required to chase the application.
It would appear that village communities do recognise information
as an important resource. Just like other resources it is something to be
acquired and guarded. Therefore persons with some authority are not .
willing to share their information with others. ‘
•
contd. from page 6
Information is the first step towards the objective of empowering the
services, rather than to individual's presumed behavior or confession.
disadvantaged. Information is necessary, but may not be sufficient for
The dividing line between pathology and normality finally breaks down
activating them. The structural barriers around the underprivileged are
in a society where practically everyone is sick owing to the degenerated
so strong that a substantial breakthrough may require collective action
living conditions. The celebrated 'healing* powers of medicine then boil
with a firm ideological direction and leadership. In spite of this over
down to a 'cure* dogma.
riding limitation the positive implications and potential of taking the first
At this point Uta Gerhardt warns the medical sociologists against
step of information dissemination were judged to be significant in
the temptation of seeing themselves as better healers than medicine
themselves. The pamphlets planned for the near future include those
itself.
She asserts that medical sociology should never attempt to
concerning Panchayati raj system and laws related to women.
•
overcome or replace medical practice. The author is doing exactly what
she thinks sociologists should do;
that is
to keep the disciplinary
boundaries of society or those of social sciences intact.
The
FREE ABSTRACTING
conventional history of medical sociology anticipates a drastic change in
its scenario.
The future focus would be the imminent world-wide
epidemic of behavior-induced incurable diseases'.
The bibliography included in this scholarly work is very resourceful.
It gives exhaustive references useful for research in critical theory,
sociology, psychoanalysis, pathology and medical sociology.
The contents of this newsletter may be abstracted
without prior permission. However, we would
welcome acknowledgement of the source and
copies of any abstractions.
•
Edited by Nagmani Rao, with secretarial assistance from Joyeeta and Vrinda Sinha, and produced by the Foundation for Research in Community Health,
84 - A, R.G. Thadani Marg, Worli, Bombay 400018. Registered under the Bombay Public Trusts Act. Printed at Printext Offset, Pune 30.
COMMUNITY HEALTH CEU
326, V Main, I Block
Koramengala
Bangalore-560034
Sept. - Oct. 1992
Vol. VI, No. 5
SPECIAL ISSUE ON CHILDREN
CHILD LABOUR IN INDIA
Promises to Keep
Ingrid Mendonca
The Constitution of India, through various articles such as Article
India has legalised child labour. The Actalso places the responsibility of
45, Article 24, Article 39F, as well as the National Policy of Children,
education and recreation on the owner, which is equivalent to asking the
pledges a commitment to the welfare and protection of children against
thief to guard the house.
exploitation and harm. At the international level India has ratified 6 of
culmination of the legislations relating to the employment of children
the ILO conventions concerning the employment of children and young
since the pre-independence days. Many legislations since the 1930's
This enactment has to be seen as a
persons and is now in the process of ratifying the U.N. Convention on
banned the employment of children in certain industries.
the Rights of the Child. One of the main obstacles to this process is that
were neither enforced nor was any regulation laid down regarding the
the U.N. Convention specifies that the minimum age for a child to start
working conditions and wages of children in the industries where their
work is 18. Yet, the reality starkly belies these pledges. Many promises
employment was not prohibited. The 1986 Act bans the employment of
are yet to be kept....
children (those below 14 years) in specified 'hazardous* occupations
In India, many children start work at a very young age.
Even
But these
and processes. Significantly, only a few industries where children are
children of a pre-primary school age can be seen working in cottage
employed in a large way are notified under the Act as 'hazardous*. This
Children sometimes work to pay debts incurred by their
Act further tries to regulate conditions of work of children and lays down
families, even those related to marriage of other children. While parents
enhanced penalties for their employment in violation of the provisions of
gain from children's employment, at home or outside, it remains unclear
the Act.
how much worse off the family would be if these children were in school.
Schedule of 'banned industries'.
Children are universally recognised as the most important asset of any
uniformity in the definition of 'child* in the related legislations.
industries.
nation.
It lays down a procedure to decide modifications to the
This Act also tries to arrive at a
The Employment of Children Act, 1938, already prohibited the
In developing countries like ours the problem of child labour in both
employment of children in certain occupations which are considered
urban and rural areas is principally one of poverty and unemployment,
hazardous and injurious to health. Prior to this, the Children (pledging
land and production
of labour) Act, 1933, prohibited a parent or a guardian from making an
assets and low levels of development Nearly half of India's population
agreement to pledge the labour of a child. The Factories Act, 1948,
subsists below poverty line. The distribution of land is most iniquitous
prohibits the employment of children below the age of 14 in factories
and economic compulsions weigh heavily on the consciousness of
and lays down certain conditions for the employment of children
poor parents. They would thus not mind colluding with their children's
between 15 and 18 years. The Contract Regulation and Prohibition Act,
themselves a result of unequal distribution of
employers in violating the law and putting their children under risks of
1970, lays down the permissible age for contract labour as 18 and
inhuman exploitation.
above. Bidi and Cigar Workers (conditions of employment) Act, 1966,
prohibits the employment of children in any industrial premises. The Act
is however silent on the employment of children at their own houses. At
Child Labour Laws : an overview
the same time the Minimum Wages Act, 1948 provides that the minimum
There has been a long history of legislation in order to regulate the
employment of child labour.
The Child Labour Regulation and
Prohibition Act, 1986, is often criticised because the government of
wages applicable to adolescents is three-fourth of the adult pay and to
children two-thirds of it.
These rates are decided by the State
Governments and the above stipulations are applicable to Maharashtra
only. The Bombay Shops and Establishments Act of 1948 prohibits
The author is Regional Coordinator, Central Region, with TDHGermany (India Programme). She also represents TDH in
children below the age of 12 years in any of those establishments
Action for the Rights of the Child (ARC), a federation of NGO's
children in motor-transport undertaking is banned, by the Motor
and government agencies working for children.
Transport Workers Act, 1961. Then there is the Apprentices Act of
covered under the Act - eg. hotels,'dhabas', juice bars. Employment of
FOR PRIVATE CIRCULATION ONLY
TABLE 2
AREAS WHERE CHILD LABOUR IS MOST INTENSE
1961 which stipulates that a person shall not be qualified for being
engaged as an apprentice in any designated trade unless he has
completed 14 years of age. Employment of children has thus been a
Name of the
Project Area
Name of the
Estimated No.
Industry
of CHILD WORKERS
Sivakasi
Match &
40-50,000
2.
Jaipur
Fireworks
Gem polishing
15,000
employment. But the National Sample Survey of 1983 shows that the
3.
4.
Mirzapur
Carpet
50-60,000
Ferozabad
Glass
4500
number of children in employment had increased to 17.6 million. As
5.
Markapur
Slate
2000
against these official figures, independent research organisations like
6.
7.
Moradabad
Brass
7500
Mandsaur
Slate
SCO
Lock
500
topic of concern in various labour welfare Acts. Yet, millions of children
continue to work in extremely oppressive conditions.
Sr.
No.
1.
Extent and Forms of Child Labour
India's 1981 Census Report shows that 13.6 million children were in
Operations Research Group, Baroda and the Balai Data Bank of Manila
claim that, the number of working children is 44 million and 100 million
. Aligarh
8.
respectively. India has the largest number of child labour in the world.
Source: Reportof The Task Force on the Implementation of the 1986Act. Constituted by The
Central Advisory Board on Child Labour. Dec. 1989.
TABLE 1
STATES WITH THE LARGEST NUMBER OF CHILD
LABOURERS : (1981 CENSUS)
It is significant to note that while in the carpet industry, lock making
industry and tanning, more boys are employed, more girls are found in
the match factories. The bidi industry is another employer of a large
Name of the State
Figures in 000s
Andhra Pradesh
1754
employer of children in South India. The furnaces used by the glass
Madhya Pradesh
1372
industry in Firozabad generate a heat between 700 degrees and 800
Maharashtra
1263
Uttar Pradesh
1246
glass stuck onto iron rods. Cottage industries like wood carving are no
Karnataka
966
exception for employing children. In the agricultural sector children are
Bihar
893
Tamilnadu
871
Brick kilns, stone crushers are other sectors where children are
Rajasthan
589
employed, in the rural areas. And in the urban centres children are
number of children, mostly girls. Many of these girls work from their
houses and share the family labour. Silk weaving is another major
degrees centigrade in the pot variety.
Children work around these
furnaces and even carry balls of blazing glass and burning loams of
found working as part of family labour and also as wage labour. Even
instances of bonded child labour are often reported from different states.
found employed in market places as headload workers, helpers,
vendors, etc. Rag picking and other odd jobs like shoe shining, cleaning
Source: The Lawyers. Aug. 1988. p. 13.
of cars, scooters, vending of newspapers are other jobs which children
Though poverty is definitely the major cause of child labour, other
countries like Bangladesh, Pakistan, Sri Lanka, Afghanistan, also having
a similar socio-economic background,
do not have such a large
percentage of child workers. In India too the extended school system in
high literacy states like Kerala, has helped to control, if not eradicate,
do.
TABLE 3
PARTICIPATION OF CHILDREN IN THE WORK-FORCE
BY SEX
the extent of child labour. The child work participation rate in Kerala
Total
was 1.9 percent as against the all India figure of 7.1 percent in the year
1981.
pop.
The National Council of Educational Research and Training
(5-14 YRS J
Main
Workers
Main &
Marginal
Workers
i
Child Work
Participation Rate%
Marginal
Main
reported in a 1975 Survey that 82 percent of all children who entered
primary school in Kerala completed the fifth grade as compared with 26
RURAL (Total)
percent for India.
Males
72993
6681
7339
4.9
11.3
21.3
Females
66671
3506
5211
8.9
9.6
2.1
5.0
732
757
1.8
5.9
246
281
4.6
4.6
Despite this, neither the Indian State nor the parents seem
committed to children's education. Part of the reason for this is that
education does not provide the skills or assurance for employment and
a better future.
Employers preference for child workers as they
5.8
URBAN (Total)
Males
Females
20446
18942
constitute a cheap, productive and obedient labour force without the
demands of adult unions is also another cause for the persistence of
child labour.
Child Labour Intensive Industries
Source: Report and tables based on 5 per cent Sample Data. Series 1, India. Part II. Special.
Census of India, 1981. New Delhi. Registrar General and Census Commissioner. 1983.
Note: Figures in thousands.
Many of these jobs are gender specific, with different ramifications
While large numbers of children ar employed in specific industries,
for girls and boys. While boys largely work in hotels and tea stalls, girls
the agricultural sector stands out as the biggest single employer of child
constitute 70 percent of child workers in the weaving industry and 63
labour in India. There are several other specific industries where child
percent in the match making industry. Other major areas in which girl
labour is prevalent
child labourers out-number boys are agriculture, rag picking, bidi
FRCH NEWSLETTER, VOL VI, NO. 5, SEPT, - OCT. 92
2
making and construction sites. Cultural protection of girls, however,
Child and the State in India'. However many groups argue that banning
restricts their mobility, thus limiting their choice of work. This makes
of child labour is not practical, nor is it going to solve the problem. They
them vulnerable to underpayment, as compared to boys, for the same
predict that, children who are actually working will then be thrown out of
kind of work. While age-wise, girls enter the work-force earlier than
their jobs with no other viable alternative. The socio-economic situation
boys, there is gross under-enumeration as the former's vast contribution
of their families will deteriorate because the earnings of the children,
to domestic labour is rarely accounted for.
though meagre, are an important economic support to the families.
Occupational Health Hazards
need of the industries which cause the employment of the children.
It appears however, that more than the need of the children, is the
Occupational hazards may originate in the poor working
Considering their meagre earnings, no substantial change occurs in the
socio-economic status of the family if children are taken out of em
ployment. On the contrary, the only significant change would be a fall in
environment or the vulnerability of children.
TABLE 4
HEALTH HAZARDS IN CHILD LABOUR INTENSIVE
INDUSTRIES
the profit margin of certain industries. Also, because the children are
employed, adults remain unemployed. According to Dingwaney and
others, there exists a link between child labour and adult unemployment.
The all India average of unemployed persons is 9.21 million and that of
child labour is 12.55 million. Similarly there also exists a link between
S.No.
Occupation
Type of health hazard
1.
Bidi Industry
Chronic bronchitis & tuberculosis
Children cannot be allowed to wait for structural adjustments in the
2.
Glass Industry
Asthma, bronchitis, tuberculosis,
industry and the socio-economic milieu, nor can child labour be
eye defects
legislated away.
3.
4.
Handloom Industry
Asthma, tuberculosis
Zari & Embroidery
Eye defects
5.
Gem cutting and
Eye defects
child labour and people below poverty line.
Children need to be assisted to protect their own
interests, by banning child labour or by ameliorating the conditions of
the working child. The final goal of eradication of child labour has to be
the focus of even rehabilitation and regulation programmes for working
Diamond cutting
6.
Construction
Stunts the growth of the child
7.
Rag Picking
Tetanus and skin diseases.
8.
Pottery
Asthma, bronchitis, tuberculosis.
9.
Stone Quarries
Silicosis
children. The process of development has to be designed to overcome
unemployment and destitution. As child labour is embedded in poverty
and unequal distribution, it is only through a sustained increase in
standards of living that it will be abolished. Meanwhile, children are still
Slate Quarries
working in extremely oppressive conditions, following the dictum 'all
work and no play'. The promises of protecting the Rights of the Child
Source . Dingwaney et al.. Children of Darkness. p13
made to her/him remain to be kept, yet.
From the description above, it is obvious that works which are
hazardous to any worker are certainly much more hazardous to
Select References:
1)
2)
vulnerable children.
Vishwapriya Iyengar, in her study on the match industry at Sivakasi
writes that, “children mixing chemicals in the boiler get lungsful of toxic
child labour in India, Rural Labour Cell (A Project of Academy of Gandhian Studies,
3)
lumes, suffer high degrees of intense heat and run the risk of being
badly injured in fire accidents. Children who stamp frames on the metal
sheets also suffer heat, toxic fumes and excessive strain on the arms
4)
5)
and shoulders which have to remove and place the heavy frames with
The Status Report on Child Labour, prepared by the National
Hyderabad), New Delhi, November, 1988.
Gupta M. Voll K., Child Labour in India: young hands at work, Atma Ram & Sons,
Delhi, 1987.
Krishnaswamy P., Not Child's Play, Indian Express Sunday Magazine, October 13,1991.
Report of the Task Force on the Implementation of the Child Labour Prohibition and
Regulation Act 1986and the Legal Action Plan contained in the National Child Labou r Policy.
Constituted by the Central Advisory Board on Child Labour, Ministry of Labour; New Delhi,
6)
Dec. 1989.
Singh AN Child Labour in India - a socio-economic perspective, Shipra Publications,
7)
New Delhi, 1990.
Weiner M., The Child and the State in India, Oxford University Press, Delhi, 1991.
great rapidity. Delay of a second can cause the entire frame to go up in
roaring flames, causing instant death."
Burra Neera. Child Labour Health Hazards, Seminar Publications, New Delhi, 1988.
Dingwaney M.S. DograS., VidyasagarR., Gupta R., Children of Darkness; a manual on
is
Institute of Occupational Health (NIOH), Ahmedabad, has this to say
regarding the glass industry - "In this industry there is a serious risk of
physical injury, burn hazards, and exposure to silica containing dust."
According to an NIOH study report there was a prevalence of 4.76%
silicosis cases among 84 child workers studied in the batch house of a
glass sheet factory.
Convention on the Rights of the Child.
Article 32.
The above are only a few illustrations amongst many. Sometimes
the effect of risks exposed to are seen only much later and take a heavy
toll on the child. Many succumb, while others suffer from a variety of
diseases. Yet, hardly any attention is paid to the issue of occupational
diseases.
States parties recognize the right of the child to be
protected from economic exploitation and performing any
work that is likely to be hazardous or to interfere with the
child's education or to be harmful to the child's health or
physical, mental, spiritual, moral or social development.
Positions Concerning Child Labour
There are different positions regarding child labour.
child labour
Banning of
Source: The State olthe World's Children. 1991. UNICEF. OUP1991.
and enforcement of free and compulsory education is
proposed by Myron Weiner to be an approach to the problem in The
3
FRCH NEWSLETTER, VOL VI, NO. 5, SEPT, - OCT, 92
STREET SURVIVORS
Poomima Chikarmane
FREEDOM, IS BEING ABLE TO TAKE THE NEXT TRAIN TO
SOMEWHERE : ENTERTAINMENT, IS THE PREMIER SHOW AT
families with whom they maintain irregular contact. They seek shelter,
food and companionship on the street.
ALANKAR: WORK, IS DOING ANYTHING THAT WILL PUT MONEY
Abandoned children are part of the above group; but these have
IN THEIR POCKETS : JOY, IS GIGGLING AT DISNEY CARTOONS
severed all ties with their biological families and are therefore the most
SHOWN ON THE PLATFORM TELEVISION : FEAR IS THE
vulnerable. Children on the street are those who spend long hours
POLICEMAN FROWNING IN THEIR DIRECTION : TRAGEDY, IS
working on the street but return to their families every night. These,
BEING CONFINED IN THE REMAND HOME : FRIENDSHIP, IS
who are primarily working children, comprise the largest group.
SHARING FOOD WITH EACH OTHER : CARING, IS BUYING
CROCIN FOR A SICK FRIEND ....... HUMILIATION, IS BEING
SHOOED AWAY BY THE LIKES OF US.
Extent and Living Conditions
It is estimated that there are between 50,000 and 1,00,000 street
children in every metropolitan city. In Bombay alone there are said to be
THE TRANSIENT SHADOWS
The above encapsulates the life of what are called the Children of
over a lakh of them. Global estimates by UNICEF about six years ago
placed the figure at 6 million, most of them in the countries of the South.
Street children are, more than anything else, little labourers, part of
the Street.
the mass of the unorganised informal sector which supports the urban
economy.
The Phenomenon
Street children are a growing phenomenon in most countries of the
world.
They are seen at railway stations, bus stands, in public
parks, engaged in* polishing shoes, sweeping, petty vending and rag
In countries of the developing world such as Brazil, the
Phillipines, Pakistan, Bangladesh and India, an interplay of complex
structural factors account for the increasing numbers.
picking. Their work is invisible, underpaid and unrecognised.
.
Situational analyses of street children in six major Indian cities were
commissioned by UNICEF. They revealed significant aspects of the life
styles of the children. The average age ranged between 8 to 16 years.
Various theories have been propounded to explain the existence of
Boys outnumbered girls, probably because the street life is more harsh
street children. Uhprecedented industrialisation and urbanisation have
on girls. About three-fourths of the street children in Bombay city were
led to widespread migration from rural to urban areas.
found to be working; over half of them were self-employed. Thirty eight
The layman's perception of migration in terms of the lure of the city's
glamour has little substance. The role of the 'pull factor* is limited and
street children reported a 10-12 hour working day.
percent of them earned less than Rs. 400 per month. Most working
proves inadequate for explaining the phenomenon. Recent studies on
Contrary to popular belief, the UNICEF studies also revealed that
employment trends have shown increasing rates of underemployment
among poor urban dwellers. Consequently, galloping inflation pushes
most street children (74 percent in Bombay) have regular contact with
their families. Fifty four percent of those interviewed had never been
children and women to seek low skilled, low wage employment.
enrolled in school.
Economic reasons apart, large numbers of children take to the
Lack of access to adequate recreational facilities makes street
streets on account of family disintegration and violence. They feel ill-
children avid film-goers. Gambling and reading pornographic and pulp
equipped to cope with desertion or harassment and the street provides
literature are some of their other pastimes. This leads them into various
the only means of escape.The problem of street children cannot be
forms of sexual experimentation, including homosexuality and visiting
explained merely in socio-cultural terms either. It is neither aimlessness
nor delinquency but primarily existential in nature. For the street child,
prostitutes.
the street is, above all, a means of survival.
Characterised by qualitatively and quantitatively inadequate food intake,
Determining the exclusivity of street children has proven difficult.
Yet, it is acknowledged that they are a distinct group with specific
distinguishing features and special needs. For operational purposes,
UNICEF has attempted to classify them on the basis of the nature of
shelter and extent of family contact.
Children of the street, live and work on the street.
They have
Street children are especially vulnerable when they fall ill.
their health and nutrition status is poor. Inadequate access to medical
care compounds the problem.
Public perception of street children is that they are thieves and
indulge in delinquent behaviour. That there is little substance in this has
been shown by a study in Madras, where only 12 out of a sample of
1662 children had committed offences such as drug peddling, robbery
and theft. The biggest threat, as perceived by street children, comes
from the police. Bound by the framework of the law, the police regularly
The author is the Project Officer, Dept of Continuing & Adult
round up children from public places. Beating, collecting caution money,
Education, SNDT College, Pune. This department is also part
getting them to do petty jobs under duress and using them as informers
are other forms of harassment.
of the ARC network.
FRCH NEWSLETTER, VQL- VI, NO, 5, SEPT. - OCT.
92
4
The Law and Other Institutions
Street children are governed by the Juvenile Justice Act of 1986 (JJ
Act), which states that ‘the state shall provide for institutional care for
neglected, destitute, delinquent and vagrant juveniles*. The word
‘juvenile* itself is interpreted differently by different Acts. While the term
implies a boy under the age of 16 years and a girl under the age of 18
years under the JJ Act, the Child Labour Restraint and Regulation Act
mentions 14 years as the cut-off point. This means that large numbers
of street children aged between 14 and 16 years have to exist in
specially designed for street and working children. It is scheduled to be
implemented, in phases, in the Eighth Five Year Plan. The first phase
covers six major Indian cities. The scheme provides for non-institutional
programmes for street children.
Radical Initiatives Needed
Notwithstanding the individual and collective efforts of NGOs, the
fact remains that they will make only a marginal difference to the
existence of street children. Substantive change will occur only if the
ambiguity.
NGOs are able to promote organisations of street children themselves,
Further, institutionalisation as the sole option for street children,
needs to be reviewed in the light of emerging evidence. Only very
young street children and those who have been on the streets for short
periods of time take kindly to Remand I Observation homes. Most
to collectively seek fulfillment of their rights as children. Experiences of
such organisations in Brazil and the Phillipines have shown that 'a shout
street children do not like the strict regimentation, lack-lustre existence
and the harassment by institution staff. Identifying a means of escape
slice of the cake.
becomes their pet preoccupation.
Select References:
According to the law. the Remand Home authorities have to trace
the parents within six months. However, this rarely happens and
children are known to languish in the Home for periods ranging from 2-3
1)
DLima Hazel and Gosalia Rima, Street Children of Bombay : a situational analysis,
2)
UNICEF, New Delhi, 1992
Mishra Shashi, Street Children: a strategy for an institution-pl us programme, paper
in the mountains has been known to cause an avalanche* - politically
and socially aware, street children have demanded and got a greater
presented at the National Workshop on Street Children, New Delhi, 29-30 August, 1988.
years.
Moreover, the absorption capacity of the state Homes is much less
than the number of street children.
The cost benefit analysis of
institutionalisation also shows that it is expensive and requires an
elaborate infrastructure. In this context, Shashi Mishra, former
secretary, Social Welfare, Government of Maharashtra, has eloquently
advocated a quasi-institutional model, where children have access to
basic services on the streets.
Such creative initiatives on the part of the state are called for.
Provision of non-institutional services for street children seems to be a
promising alternative - it is need specific, caters to a wider population
and is cost-effective. NGOs have taken the lead in this regard in most
metropolitan cities.
CHILDREN
OF A
LESSER GOD
Asha Vadair
We are Children of a lesser God,
That is what the world proves today,
We have no roof, we have no floor
Work With Street Children: approaches
NGO intervention with street children covers a wide range of
approaches. The first agency to start work was Sneh Sadan (Bombay),
which promoted the idea of open institutions. The inherent limitations of
institutional care resulted in experiments with non-institutional
programmes.
Certain NGOs provide street children with shelter,
educational, health, nutritional, recreational, vocational and other
services. Others have organised street children to articulate their
demands and represent them to decision makers and urban planners.
Most use a combination of the two approaches, while varying the
emphasis. Almost all NGOs working with street children intercede with
the police, the railway authorities and the juvenile justice system on the
issues of these children;
The Coordination Committee for Vulnerable Children (CCVC), is
the Bombay based forum of NGOs working with street children. It has
made some breakthrough in coordinating city level action for street
children with active support from Ms Mishra; Geographical zoning of the
city and NGOs, establishment of contact centres for street children at
key locations and effective liaising with the police are some of the
We are alone today.
We know all about wars,
And all about crimes,
But when asked what a school is like
We have no answer at all.
We know we too can work,
We know we can be sold,
We know how it is to starve.
But we know nothing about love.
People come, ask and go,
they pity us for our state you know,
But beyond solace nothing we get,
Not even a piece of Bread -
We want to laugh,
We want to play,
We want a mother who will care Tell us, is there a mother available
Tell us if we can buy -
elements. Similar fora also exist in other metropolitan cities. The
National NGO Forum for Street and Working Children attempts to
Not with money or influence, but,
coordinate efforts nationwide.
With true love which is very rare.
These concerted attempts have been brought to fruition in the form
Tell us! Oh! Pray! Tell us!
of a recently announced central government, UNICEF aided scheme
5
FRCH NEWSLETTER, VOL, VI, NO. 5 SEPT, _ oCI.n
CHILD WELFARE SCHEMES
a critique
Audrey Ferreira
The well being of children, especially the socially and economically
home life. At present this scheme is being run by three institutions.
disadvantaged, is one of the most critical problems facing developing
These are the Family Service Centre, the Maharashtra State Womens*
countries today. In India, although there are a number of Voluntary
Council, Bombay, and the Vidarbha Maharaj Sewa Mandal, Amravati.
Agencies working in this sector the Government response is of crucial
As yet, relatively few children benefit from this scheme.
importance because of the magnitude and complexity of the problem.
This article will therefore focus on the relevant schemes of the Social
problem is to find families who are properly motivated and who have the
necessary background and skills to handle problems that may arise
Welfare Department (SWD) with special reference to Maharashtra.
because of the troubled pasts of these children.
The main
Classification of Schemes
The physical and social environment plays a pivotal role in the
development of the child.
Hence a useful criterion for classification
would be the relation to the environment in which the child is growing
up. Besides providing a comprehensive context and meaning to child
* Orphanages/Bal Sadans
The SWD has the facility to house over a thousand children in the
Institutions it runs or aids.
development, it also indicates the directions of change in the
approaches and strategies of programmes for children. Essentially this
consists in the realisation that the best environment for a child is a
healthy family situation. The most effective schemes would be those
that help the child within its own environment.
Often this implies
impacting the environment itself, either at the level of the family or of the
neighbourhood. Where this is not possible, efforts today are towards
providing "quasi-family" conditions even in an institutional setting. The
Orphanages
19
Beneficiaries
455
Bal Sadans
55
Beneficiaries
622
The Bal Sadans are an effort to minimise the negative effect of
traditional style orphanages by providing a form of living closer to that of
a family. About ten children live under the care of a foster mother in an
independent unit.
Often, however, these are centralised into a Bal
Gram consisting of 18-20 Bal Sadans. This, of course, could lead to a
loss of the intimacy that is found in the smaller operating units, yet
maybe the most practical option available today.
SWD schemes can be divided into three kinds:
1)
Replacing the Environment for vulnerable children. This
includes programmes like Foster Care, Institutions like
Orphanages, Bal Grams, Remand Homes and Certified
Helping the Child but leaving the environment as it is.
This is through Child Guidance Clinics, Balwadis, etc.
3)
Children who come under the purview of the Courts are first placed
under Observation in a Remand Home, after which they are either
Schools.
2)
* Remand Homes / Certified Schools
Changing the Child and its Environment. Often the
environment itself has to be transformed so that it becomes
conducive to the all round development of the child. This is
released or committed to a Certified School. About 15% of the boys are
hardcore criminals. Though the Juvenile Justice Act of 1986 explicitly
requires two parallel streams for such offenders and for non-offenders,
from custody to commitment, as yet there are no separate residential
institutions. The entire structure is thus geared to the presence of the
offenders, with adverse impact on the other ‘innocent* children.
the underlying premise of the Integrated Child Development
Scheme (ICDS) which, in urban areas like Pune, comes
under the purview of the SWD.
The Integrated Child Development Scheme (ICDS)
This article focusses on the first and third strategies. The first is
The ICDS was set up as a result of the 1975 National Policy for
important because it deals with the most vulnerable, who need the
Children. This scheme has been acclaimed as one of the biggest and
greatest attention. The bird strategy is the one with the greatest pay-off
most successful of its type anywhere in the developing world and, in
in the long run.
1991, was awarded the Ligouris International Technology for
Development Prize in the field of nutrition and children's health.
A Substitute Environment for Vulnerable Children
The ICDS seeks a two-fold integration:
1)
* Foster care
In conditions where it becomes necessary to remove a child from a
harmful situation for any extended period of time, this is perhaps the
best alternative, since it provides the child with the nearest substitute to
Sectoral integration of various programmes in education,
health and nutrition.
2)
Integration with local communities where people's participa
tion leads eventually to community management.
Operationally the key person is the Anganwadi Worker (AW) who
The author is the Project Coordinator, India Sponsorship
actually implements the programme elements and provides the interface
She is working in community
with the community. Initially she was a woman from the local community
Committee, Pune Project.
development projects in Yerawada region in Pune.
FRCH NEWSLETTER, VOL. VI. NO. 5, SEPT. - OCT. 92
6
and her role was that of an Extension Worker. In the original concept,
her success was to be measured by the quality of her interaction with
through Half-Way Homes, both for those who do have families
to return to and those who have to strike out on their own.
the people and her ability to motivate the community. However in the
actual implementation, the emphasis has shifted from community
Existing structures are very limited with regard to the number of
children that can be accommodated, as well as the kind of
dynamics to administrative efficiency.The AW, overburdened with paper
work, (each AW has to maintain 16-18 separate registers) has neither
services that are provided. At present only Bombay and
Kolhapur have such facilities. These cater to only a fraction of
the time nor the incentive to interact effectively with the community,
since this is not something that can be quantified in a way that meets
the total number of institutionalised children.
bureaucratic reporting requirements.The ICDS, though well
conceptualised, has been so bogged down by bureaucratic procedures,
The Social Welfare Schemes for children, despite many positive
that it does not have the flexibility to adapt to local needs and conditions.
aspects, still fall short, quantitatively as well as qualitatively. Budgetary
limitations are, of course, one of the casual actors. But this is only
This is partly a consequence of the funding linkages which require
detailed but purely quantitative monitoring procedures. It is also due to
the inherent characteristic of government functional style.
indicative of a deeper malaise-a lack of awareness of real priorities and
little political will to make hard options in the long term interests of the
people. One can only marvel at the short-sightedness of a policy which,
while reducing the welfare budget in the last allocation by 20%,
Need for a Human Face
The greatest need in the SWD Schemes is to provide a more
‘human face* to its welfare programmes. This could perhaps only be
achieved through a more effective collaboration of the SWD with
Voluntary agencies (VAs). The existing attitude is primarily one of a
paymaster, with the tendency to pull the VAs into its own bureaucratic
mould. What is needed is a strategy by which the VA's forte of genuine
increased the scope of the activities of SWD. A diversion of just 0.5%
of the defence budget would make a difference of life and death to
millions of children, who, in the last analysis, are the greatest natural
resource that the country possesses.
0
Child Malnutrition in the Developing World, 1990
involvement with the local community can be symbiotically integrated
with the SWD schemes, thus revitalising them, while maintaining the
state-wide scope of the programmes. The VAs, on the other hand, must
take on the role of catalysts to enhance peoples' participation in the
177 million malnourished children
Departmental schemes, without themselves losing
South Asia
76 million'
their specific
rationale as VAs. One important initiative in this area has been the
China
24 million
involvement of the SWD in Pune in a Network of NGOs called “Action
For The Rights of the Child" (ARC). Such, and other joint endeavours,
could result not only in improving the operational aspects of the
schemes but could also influence the entire policy in this field.
Specific Recommendations
More specifically there are certain areas of concern that need to be
tackled on a priority basis.
*
Much greater attention needs to be paid to the emotional
needs of institutionalised children. Apart from being physically
deprived, these have been often psychologically battered and
the present structures to provide them psychological help are
woefully inadequate. The Counselling and Therapy structures
need to be radically improved and integrated into the day-today functioning of the institutions. Here too non-government
resources could be effectively tapped through VAs in order to
take advantage of the vast fund of knowledge and expertise
available in the bigger cities.
*
Another area of concern is the future of these children after
they “graduate" from institutions. The trauma associated with
such a transition is well-established. But very little is known in
India about their adjustment, once they leave/ The problems
are both economic and social. They are given some kind of
technical training to put them on a sound economic footing.
The system however needs to be seriously evaluated in terms
Rest of Asia
39 million
Americas
8 million
Africa
30 million
One in three malnourished
Americas
14% I_______
China
—
21%
Africa
26% I______________
Rest of Asia
42%________________________
South Asia
47% I---------------------------------------------
0 5 10 15 20 25 30 35 40 45 50
% of malnourished children
of effectiveness and utility in securing employment, etc.
•
Institutional life can also be a great handicap to learning to
Malnourished is defined as more than two standard deviations
live a normal family life. The institutions need to prepare the
below the desired weight for age, and child malnutrition refers
children for this, during the latter stages of their stay, with
to the child population under the age of five.
special programmes The actual transition must be supported
Source. The State of the WotIds Children. 1991. UNICEF. pg. 29
/
------------- COMMUNITY HEALTH CELL-------------------
7
326. V Main, FACRNGWSKETTER, vol, v, no, s SEPT,. oct. 92
Koramangala
Bangalore-560034
I Hit
FOSTER FAMILY CARE
A Substitute Home
Vinita Phatak
Parenthood is an experience that most couples look forward to. It is
one campus, the supervision and monitoring of the programme would
however not possible for all couples to have a biological child. On the
be very convenient.
other hand, there are babies who became destitute because their
Adventist Mission was selected.
biological parents were unable to take care of them. It was for the care
included the family constellation, family atmosphere, marriage stability,
of such family-deprived babies that the Society of Friends of Sasoon
Hospital (SOFOSH) set up a Child Care Centre called “Shreevatsa",
health and hygiene of the home. A home study of each family was
conducted by the Social Workers of SOFOSH to ascertain all these
meaning Children of God. Since its inception in 1973, Shreevatsa has
points. After the selection, these families were then trained in Child
A group of foster families in the Seventh Day
The criteria defined for selection
provided a home for many babies who are victims of the unfortunate
Care - eg ; feeding, bathing of children, first aid, knowledge of drugs
circumstances in which their birth parents found themselves.
and their administration. At the moment there are a total of 20 such
Shreevatsa worked as a Remand Home for babies brought in by
families enrolled with SOFOSH. The babies put in their care are mainly
the Police, after they had been retrieved from harsh situations, babies
new born babies relinquished by their birth-parents and sometimes
relinquished by unwed mothers, as well as babies of patients admitted
babies in need of special care.
to Sasoon General Hospital, for short term crisis care. In every case the
Social Workers at SOFOSH worked for their permanent rehabilitation.
However the most immediate problem faced by the young child is the
question of survival itself.
Shreevatsa’s Child Care Centre has a
competent staff of nurses, helpers, ayahs, social workers, doctors, etc.
But, in a group care situation the child is deprived of the most important
ingredients of survival — the closeness and continuous watchful care of
its very own family.
Organising the Programme : pains and pleasures
The financial input for this programme comes from SOFOSH. Apart
from the daily allowance to the family, it includes all expenses to cover
the physical, medical and transport costs needed in caring for the baby.
Families looking after premature babies are given a special allowance
for the extra care given. Besides the financial incentives, social activities
and other schemes are devised to provide encouragement to the foster
The concept of Foster Family Care has been developed in many
countries in the world to provide a child deprived of its natural caretakers
an alternate family known as a Foster Family. Such foster parents
nurture the child within their own family unit, for a short period, till the
institution works out its permanent rehabilitation, whether by restoration
to its birth parents, or by adoption.
families.
The programme is monitored and overviewed by a trained social
worker. Under her are two supervisors who maintain the health files
and distribute supplies, medicines and clothes for the children. Over the
years each foster family has nurtured and looked after hundreds of
babies. They have watched a majority of these children going into their
very own adoptive families. Each child's departure is a bitter sweet
Adoption and Foster Care : the beginnings
experience for the foster family, as they go through the invariable
With the lodging of these destitute babies taken care of, the
question facing the Social Workers was to arrange for their
separation pangs, yet are happy to see their babies go into homes of
rehabilitation. Adoption was felt to be the ideal answer to a mutual need
witnessed with sorrow the deaths of some babies for whom the efforts
for children permanently deprived of birth families and for childless
at survival proved very difficult.
their own. Sometimes, inspite of all efforts and their love, they have
couples longing for a baby, or parents wanting to add to their families,
Among the families there are some who have, over the years,
through adoption. Thus, in 1974, the Adoption Programme was started.
displayed greater capacity to look after 'special needs children'. So
Many children and adoptive families found a new meaning to their lives
children who might be premature or have chronic and serious health *
through this programme.
problems or genetic disorders like heart problems, cleft palate, etc., are
The Foster Family Care Programme prior to adoption was started in
1979. In the early stages of the programme the foster families were
placed in such families.
geographically scattered.
and motivation.
This meant practical difficulties for
Being a foster mother is a full time job, requiring tremendous energy
Besides looking after her own children, a foster
supervision and monitoring as well as carrying out needed services.
mother’s day is full of nappy changes, boiling of bottles, washing of
After some search and discussions a Foster Family Care unit was
clothes, preparing feeds and feeding the babies. Sometimes a fester
established in the campus of the Seventh Day Adventist Mission. The
suggestion and invaluable assistance to start such a unit came from Ms
mother might have two or three babies to look after. So, as soon as she
is through With one baby's routine, she may just be starting with the
Elionar Hetke, a volunteer from the Seventh Day Adventist Mission
other. Sometimes, besides the normal chores, a sick baby may require
itself. Since a number of the foster family members would be housed on
an emergency rush to the doctor at an unseemly hour.
The author is the professional social worker handling matters
related to foster care and adoption at SOFOSH.
FRCH NEWSLETTER, VOL. VI. NO. 5, SEPT, - OCT. 92
In any foster family, it is not just the foster parents, but also their
children; who are involved very actively in looking after the babies. An
contd. on page 12
8
COMMENT :
SPECIAL ISSUE ON THE HANDICAPABLE
Ms. GladijsS. Kothavala, Trustee, AWHM, Maharashtra, writes:
W e have in the school — and in the greatest problem to parents —
the more severely handicapped who can be educated in some academic
Thank you for devoting your March-April 1992, issue to the four
major handicaps which handicap children and adults.
skills and who can be trained for social acceptance and for supervised
work. This is best done in organised workshops and special schools —
in other words, institutions. And their future living requires supervision,
I have a little experience with the institution to which Mrs. Arnie
so there is a need for adult residential facilities.
Antia refers in her article. This school not only promotes the welfare of
To place these people in an open employment requires such an
physically handicapped (orthopedically) children of an income level
expenditure of professional time and energy and financial cost, that I do
not think that it is feasible in India at this time.
which needs the most help, but also it imparts learning on a sound
. educational basis. This is the work of dedicated volunteers and
V motivated personnel.
The Association for Persons with a Mental Handicap in Maharashtra
(AWHM) is studying the effects of early intervention in its clinics
Job training and job placement — even in this group — require
(handicapped children or children-at-risk aged 0-3 years). We are not
considerable effort by social workers and these handicapped workers
sure which treatments are better or what benefits carry into the school
have to compete in the same job market as non handicapped workers.
years. But we do know that the clinics with their counseling and their
treatments are of immense moral support to mothers.
Based on my experience with the mentally handicapped, I
commend the article by Ms. N. Rao. She quite rightly states that the
blame is usually focussed on the mother and the majority of doctors
have little knowledge and offer very poor advice.
The birth of a retarded child
into a family of vocational or
educational aspirations is a disaster. One can hardly blame parents for
wishing to find an institution as far away as possible!
It is parents who must organise and rise up for the welfare of the
mentally retarded. It helps to be financially well-of and to have the
benefit of a good special school and workshop. But the most important
factor and need in the life of a retarded child is a good mother and a
good father.
If I see a mentally retarded child or adult—whatever his economic
In the rural areas, the majority of the persons of lower mental
ability can perform the tasks expected of them more satisfactorily.
level — urban or rural — who keeps busy (workshop, family circle,
business, home) and who is socially acceptable in his family circle and
Therefore the IQ factor is not so important. It is in the urban areas
in public, I know he has received good training from devoted,
intelligent, disciplined and consistent parents. Such parents are hard to
where a lower mental ability stands out
I think this is one reason that schools and training centres have
grown in numbers in those states with large urban centers.
Although the number of facilities is greater than the chart on page
11 indicates, we must ask whether the quality of the institutions has
• improved as much as the quantity! It is a fact the best schools, etc., are
' run by parents , NGO's, including religious groups, not by the
Government. We also ask about the quality of training in the teacher
training institutions.
Integration is another matter. A study, (published by TISS, Bombay)
indicated that the government’s proposal for the integration of the
handicapped into schools was possible except for MR children.
Crowded classrooms, high pupil-teacher ratio, and a marks-oriented
find. In India, discipline of children by parents is not easily practised.
These remarks merely supplement the article in your Newsletter. I
was inspired to write to you because of my pleasure in seeing your issue
on the interests and problems of handicapped people.
SB
Year 2000 goals
Child Health:
The eradication of Polio.
The elimination of neonatal tetanus (by 1995).
A 90% reduction in measles cases and a 95% reduction in
system do not benefit the mentally handicapped. Social integration is
measles deaths, compared to pre-immunization levels.
also difficult. It works to a degree at the pre-school level and among
Achievement and maintenance of at least 90% immunization
older groups but becomes a problem at the school age, teenage and
coverage of one-year-old children and universal tetanus
young adult level.
immunization for women in the childbearing years.
"Open employment" is much talked about. If we look at the cases
where this has worked to a degree, we see that the person involved was
A halving of child deaths caused by diarrhoeal diseases.
A one third reduction in child deaths caused by acute
marginally handicapped or very mildly handicapped. This is the majority
respiratory infections.
of the MR persons in this country. They do not come to our attention
The elimination of Guinea worm disease.
very often as they can be absorbed into the average social and family
situations.
9
Source: The Slate of the World's Children, 1992, UNICEF, pg. 61.
FRCH NEWSLETTER, VOL. VI. NO. 5. SEPT. - OCT. 92
There are approximately fifty pages given to research methods,
tools and tests. The need to formulate a common multicultural research
framework makes it necessary, albeit an uphill task, to combine
knowledge and research skills from various disciplines like social
paediatrics, psychiatry, physiotherapy, psychology, sociology, social
work and epidemiology. All this information leaves one quite dizzy but
also arouses interest regarding their applicability and effectivity.
The ethics and sensitivity required to do such research come out in
various chapters.
Working Paper of the 1st International Seminar Workshop on
Children in Crisis, Nov. 27 Dec. 10,1989, Protacio - Marcelino Elizabeth
(Ed.) Children's Rehabilitation Centre, 5-B - Escaler, St. Loyola Heights,
Quezon City, Phillipines, March 1991, Pgs. 257.
The annonated bibliography in Part IV reflects the thrust of
researches done so far. This includes effects of war, evacuations,
imprisonment, disappearance, violent death and exile of parents on
their children. There are new explorations in the area of battered,
maladjusted, sexually abused children, as well as Child Labour
Research in learning of new behaviours and values by affected children.
In order to cope with stress and trauma, the postulating of post-traumatic
This book is dedicated to “our children and our children's children.
May they find hope and peace in the future". A fervent prayer from sane
stress syndrome, intervention strategies and their efficiency have been
done mainly in the recent past, in a period of 45-50 years. The
reference to some pioneering research studies makes one want to rush
minded humans in a world with increasing man-made disasters like
wars, genocides, coups, foreign debt pressures, dictatorial and
repressive regimes, racism, deprivation and degradation of earth. All
these cause loss of physical and psychological damages. A world full of
such organised violence is a frightening place for children who have
faced it directly and indirectly.
The book is an attempt at focussing on the issue of human rights
violations on children. It was brought out one year after the First
International Conference on Children in Crisis and has a compilation of
its proceedings and working papers. It collates and analyses the
up to a reference library.
An important section is the one giving country reports from Third •)
World countries like Argentina, Pakistan, Phillipines and Greece and "
developed countries like Denmark, France, USA and South Africa.
These country reports try to put their studies in the context of socio
cultural, economic, political and historical realities. In developing
countries, the situation of human rights violations has not improved
inspite of newly elected and so called democratic leaderships. There
are economic and political pressures from inside and outside and lack of
researches done in a few countries. The research is aimed at
understanding the mechanism of organised violence and its impact on
political will. The support of super powers like the USA and (former)
USSR to dictatorship in Argentina, is only one glaring example of
political malaise in the present world order. The pattern of repression
children and the effect of intervention programmes. The need to
disseminate these findings in the widest possible manner and to create
an awareness of the situation of children in crisis seems uppermost in
and violence in all deprived, backward and semi-feudal societies is
more or less the same. The Phillipine study records the situation of
affected children in 1988 (Aquino regime) as :-
the minds of participants.
3,800,000 children suffering from forced displacement
The book contains six parts, out of which four are given to
1,44,000 children of political detenus
elaboration on research and action strategies. Part II consists of
attempts at building a framework for national and multi-cultural research
on the impact of human rights violations on children. It examines the
scope of ensuing problems to a shared approach on aspects such as
monitoring, assessment, diagnosis and intervention and treatment
strategies. Parts III and IV consist of pilot studies dope in the Phillipines
and Denmark, While Part V elaborates on insights gained from various
researches on children in crisis.
The pilot studies are done with a
participatory research perspective wherein the subjects - children and
parents - are involved in seeking answers and new questions in the
research process, thus making it a therapeutic and liberating process.
These studies have made use of descriptive, correlational, quasi-
4681 children exposed to massacres or summary executions
in their communities
1,38,600 children orphaned by disappearance or killing of
parents.
While, on the one hand, these societies want arid love children, the •)
insensitive social system encourages rampant infringement and neglect
of their basic rights (education, protection, health;) with impunity. The
plight of child labour, child prostitutes, homeless, abandoned, street
children, helpless victims of violence within domestic walls, need as
much redressal as children affected by armed conflict in the outside
world.
The developed country reports show work done with children of
experimental research designs. They draw out the types of exposures
to armed conflicts, the socio-cultural, economic and intellectual
dislocation of the Child and the family- the psychological and emotional
effects on the child, the expressed needs of the child, the usefulness of
political refugees and asylum seekers from eastern Europe, Asia and
South America. There is also a reference to stress factors emanating
community-based rehabilitation programmes. The Danish study takes
on two more aspects of research - (i) to evaluate the validity of the
children's racial classification affects their lives, surroundings, the level
examination methods in the context of different cultural backgrounds
of stress and the trauma of violence.
and (ii) to find suitable tools for improved diagnostics, with the aim of
One should however honestly bring out the fact that human rights
violations are prevalent even in developed countries. Amnesty
giving better treatment.
from lower socio-economic status and crumbling family structures,
violence, abuse and battering in the family. In the case of South Africa,
International had recently chastised the U.S.A. for human rights abuse
The reviewer is a researcher with the School Health
Education Project of FRCH.
FRCH NEWSLETTER. VOL VI. NO: 5. SERB - OCT. 92
in three areas Contd. on page 11
10
ON THE RHETORIC OF PLANS
Pledges and Action
Shirish Kavadi
The second SAARC conference on children (Colombo, September
Through historical and comparative analysis Weiner shows the
18-19,1992) reiterated the commitments of the First World Summit on
contribution of compulsory education to modernisation and the process
Children (1990) and the National Action Plans of the seven member
of change.
nations.
capabilities and welfare of its beneficiaries, also has a positive impact
The goals enunciated for children's welfare pertain primarily to their
According to others, education, besides raising the
on health, mortality, fertility and family life.
health, nutrition, education and social conditions. Strategies focus on
The Executive Director of UNICEF endorses the view that for
increased resource mobilization and greater community participation.
economic progress, population control and children's health and well
The working group on poverty reduction however expressed
being, a basic condition is education. In South Asia, Sri Lanka has
apprehensions that the structural adjustment process within most South
experienced the gains of such a policy.
Asian economies was likely to hinder the achievement of these goals.
"The group considered effective poverty reduction policies as imperative
literacy programme focussing on primary education. In India, the Kerala
experience has confirmed the value of education in reducing child
for speedier poverty alleviation and real improvement in children's lives.
labour.
The Colombo declaration suggested an alternative development
strategy be considered to ensure human development.
welfare would be central to this strategy.
Bangladesh has a national
Education is no longer children's right but the duty of the State. A
Children's
long accepted doctrine in developed countries, it has found acceptance
However the proposition
in several developing countries in recent years, with remarkable results.
The current shift to free market
Contrary to this world trend, India has retreated from constitutional
economies indicates acceptance of the conventional economic model of
commitment to mandatory full-time schooling, to universal education.
Simultaneously retrogressive legislation such as the Child Labour
contradicts the ground reality.
development By bowing to the dictates of multilateral funding agencies
the governments have foreclosed any option for evolving an alternative
development strategy.
(Regulation and Prohibitory) Act, 1986 has effectively legalised Child
Labour and violated Articles 24,39 and 45, which ban child labour and
It would seem that the emphasis on linking economic development
ensure compulsory education. In India the concept of 'children's work'
with child welfare attempts to legitimise inadequate state initiatives.
Professor Myron Weiner, in “The Child and the State in India" (1991).
is widely accepted as a useful skill-acquiring experience and a
explains India's failure in child welfare as based, not in economic
backwardness and mass poverty, but in the belief systems and interests
of those in power. Weiner argues for compulsory education through
legal enforcement of school attendance as the most effective method to
necessary contribution to the family income and the nation's economy,
although there is little evidence to substantiate the former and justify the
latter.
Participants at the World Summit had pledged to act at the highest
political level to ensure child welfare. The SAARC declaration stated
He observes, "Compulsory
investment in children to be a “non-negotiable" political commitment. At
education laws usually precede child labour laws, and their enforcement
their press conference the SAARC ministers echoed the sentiment,
substantially reduces or eliminates child labour".
He rejects the
“where there is a will there is a way". But, in India, where what Weiner
argument that the elimination of mass poverty and a guaranteed basic
livelihood are pre-requisites of compulsory education, as it has no basis
calls "politics of doing nothing" prevails, will the pledge to act at the
highest political level be redeemed?
$
remove children from the work-force.
in either past or current experience.
contd, from page 10
(1)
police brutality, especially with racist biases
(2)
the Haitian refugee crisis, when they sent back 14000
refugee Haitians, and
(3)
the death penalty.
A Carpet Over Bonded Child Labour
Almost
the entire carpet industry depends on children
purchased from parents in Bihar, Madhya Pradesh, and Nepal
at rates ranging from Rs. 200 to Rs. 2000 each. The Varanasi Bhadoi belt in U.P., which accounts for 80% of the carpet
The refusal of developed countries to write off debts of poor
countries, the interest of most debts being three times more than the
aid, the expenditure on arms, the amount spent on advertising of
exports from India, has, according to a U.P. government official,
83% of bonded child labourers. A survey of 858 cases in
Palaman, revealed that 48% received only food (that too
tobacco in two years being equal to the amount needed to prevent 100
inadequate ) for their labour. The maximum daily wage of a
million child deaths in 1990, are crime enough.
child was Rs. 5/-.
The book will certainly provoke, thought in academic circles, but its
real worth will be found by activists, volunteers and new entrants in this
field.
S
11
Compiled from the Times of India. 12th & 13th August. 1992
FRCH NEWSLETTER, VOL VI, NQ, 5, SEPT.-OCT. to
LIBRARY NEWS
Books
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
Reprints
Ashraf M.S., Infant Mortality in India : a diagnostic study, Giri
Institute of Development Studies, Print House (India), Lucknow, 1990,
pgs. 177.
ChhabraR., Pettersson W., The Situation of Children in India, SIDA,
Sweden, 1979, pgs. 58.
Cutting P., Children ofthe Siege, Pan Books, London, 1988, pgs.210.
Grant J.P., The State of the World's Children -1992, (UNICEF),
Oxford University Press, Oxford, 1992, pgs. 100.
Mahadevan K., Policies and Strategies for Child Survival:
experiences from Asia, B.R. Publishing Corporation, Delhi, 1990,
pgs.498.
SPARC, Waiting for Tomorrow: a study on four groups of
vulnerable migrant children In the city of Bombay, UNICEF,
Bombay, 1991, pgs. 126.
UNICEF, Child Abuse in India, UNICEF, New Delhi, 1981, pgs. 51.
Verma A., Agnihotri C., In Favour of Children : agenda for action,
Good Companions, Baroda, 1981, pgs. xiv + 184. (illust.)
WHO, A Manual on Child Mental Health and Psychosocial
Development - Part I, New Delhi, 1982, pgs. 37.
WHO, Urbanisation and its I mplications for Child Health: potential
for action, Geneva, 1988, pgs. 80.
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
Burra N., Child Labour: health hazards (Resource Centre for
People's Education and Development), Seminar (350) October, 1988,
pp. 1-17.
Childhood Injuries in India, Health for the Millions - Vol. XI, June
1985, VHAI, New Delhi.
Convention on the Rights of the Child, Population and Development
Review, Vol. 15 (4), 1989, pp. 779-783.
Hill K., Rebley A.R., Child Mortality in the Developing World,
Population and Development Review, Vol. 15 (4), 1989, pp. 657-687.
Hobbs C.J., Wynne J.M., Buggery in Childhood - a common
syndrome of child abuse, The Lancet, 4 Oct., 1986, pp. 792-796.
Joseph A., Eradication of Child Labour, Resource Centre for People’s
Education and Development, Nov. 18,1990, pp. 1-6.
Kapur M., Gariappa I., Emotional Problems amongst Children : a
guide for school teachers, NIMHANS, pp. 13.
Reddy C., Infant Government’s Anti-infant Policy, From the Lawyer's
Collective, Vol. 5 (6), 1990, pp. 28-30.
Sabn George, Rajaratnam Abel, Miller B.D., Female Infanticide in ।
Rural South India, EPWVoL XXVII (22), May 30,1992, pp. 1153-56.
Taitz L.S., Unemployment and Child Abuse, British MedicalJournal,
Vol. 294, 25th Apr. 1987, pp. 1074-1076.
contd. from page 8
older child sometimes takes on full responsibility for a baby, if there are
more than one in a family. Many a time the babies and these children
form a special bond. However, it is seen that foster children sense a
permanency when they go into their adoptive families. As such, there
have been no major transition problems when a child in foster care goes
into his/her adoptive family.
being of the child. Inspite of best efforts, years of looking after babies all
the time may sometimes lead to a brief period of low motivation. The
families, over the years, have learnt to take in their stride the invariable
separation of a child that they have cared for over a period. In case of
an older child this separation is always more difficult, but there is always
a new baby to nurture. This helps in assuaging such separation pangs.
Running a Foster Family Care Programme is not always smooth
sailing. The sheer distance between the SOFOSH office at Sassoon
General Hospital and the foster care programme at Salisbury Park
proves to be a problem where transportation and communication is
Also, cost wise, it is an expensive programme for SOFOSH as each
family is paid a daily allowance per child, besides the supplies and all
concerned. Sometimes the admissions of babies may be very high, or
A Model for Indian Conditions
the ill health of a foster family member may force the transfer of their
babies into other families and this may lead to a deterioration in the
quality of care provided. There is a constant need for vigilance to see if
the children are being given their due of medicines, food. Sometimes
families have been discontinued. Discontinuation could come from the
families side, because of retirement from the Seventh Day Adventist
Mission, or ill health of any family member. The discontinuation could
also come from the side of the institution, if the care provided by the
family was not found satisfactory and conducive to the health and well
other costs.
At any given point of time however, the merits of the programme a
largely outweigh the difficulties faced in running it. It has given babies •
handicapped by rejection by birth families, pre-maturity and other
medical problems, optimum conditions for their emotional and physical
growth and often, a new lease of life.
The Foster Care Programme of SOFOSH has successfully
completed 12 years. The main credit for this goes to the genuine love
that the foster families feel for each and every child and the care and
missionary zeal that they have shown through the years. These gains
exceed all financial price tags. The programme has thus proved a boon
for all babies who await a home of their own With their adoptive families.
FREE ABSTRACTING
The contents of this newsletter may be abstracted
without prior permission. However, we would
welcome acknowledgement of the source and
copies of any abstractions.
The adoptive families are also very appreciative of the programme.
They are happy to know that before a child found a home with them he/
she was well cared for in a foster home. This programme has given a
tremendous boost to Indian adoption, as Indian families are particular
that their adopted children have no previous emotional deprivation that
can lead to future problems. This has been possible to a large extent,
because of the successful running of the Foster Care Family
Programme at SOFOSH.
•
Edited by Nagmani Rao, with secretarial assistance from Joyeeta and Vrinda Sinha, and produced by the Foundation for Research in Community Health,
84 - A, R.G. Thadani Marg, Worii, Bombay 400018. Registered under the Bombay Public Trusts Act. Printed at Printext Offset, Pune 30.
COMMUNITY HEALTH CELS
326. V Main, I Block
Koramangala
Bangalore-560034
India
Nov. - Dec. 1992
Vol. VI, No. 6
Setting The Right Priorities
A PROFILE OF SRI LANKA
Sonya Gill
This is the5th article in the series, "Health Financingand Costs:
comparative perspectives". ( No.1 — Japan; No.2 — Zambia;
No.3 — China; No.4 — Brazil).
fluctuated sharply, as the island was swept by epidemics of malaria and
influenza. During the 1935 malaria epidemic, IMR rose to 263 per 1000
live births, and the crude death rate of 36.6 per 1000 population
overtook the birth rate (34.4/1000 population).
Sri Lanka has achieved one of the highest
Modern allopathic medical care was, upto the
levels of human well-being, not just in South Asia,
1940s, largely restricted to a network of hospitals
but among the entire range of post-colonial,
and dispensaries in the main provincial towns, and
largely agrarian and poor countries.
the tea and rubber estates. Since the late 1930s,
These
achievements are the result of the public policies
and public intervention programmes that, from the
beginning of independent development, gave high
priority to the satisfaction of basic human needs -
health, education and food.
both, the major public health campaigns to control
to all our readers
communicable diseases and the system of primary
health units providing basic curative services to the
rural population, began to be expanded. The war
Sri Lanka, and
countries as diverse as China and Cuba, have demonstrated the crucial
years were a period of acute food shortages
resulting from the curtailment of rice imports. The IMR reached another
role played by public support measures and the universal provision of
peak of 140/1000 live births in 1945. Food subsidies in the form of a
amenities, to dramatically improve living conditions even in the absence
ration scheme were introduced to provide relief during this period.
of rapid economic growth.
After 1945, the coverage by medical services expanded rapidly and
the malaria eradication programme produced dramatic improvements in
Health Status
mortality rates. Between 1946 and 1947, in a single year's span, the
ust 21 percent of the 17 million population of Sri Lanka resides in
death rate fell from 20/1000 population to 14/1000 and IMR declined
urban areas, and the annual per capita income is a low US$ 410. And
from 141 to 101 per 1000 live births. A comparable IMR for India as a
yet the health and education indicators - life expectancy, mortality rates
whole was achieved only in the 1980s.
and levels of literacy and education - have long surpassed the targets
TABLE 1
HEALTH STATUS
that India ia hoping to achieve by 2000 A.D. By 1986, the average life
expectancy had risen to 70 years, the infant mortality rate had declined
to 6 per 1000 population, and the maternal mortality rate was around 60
per 100,000 live births (Table I).
YEAR
These health indicators had begun to improve from the early 1940s
Crude
Crude
Birth
Death
Rate
Rate
(per 1000 pop.)
itself, when government intervention and health facilities expanded to
Mortality Rate
Life
Infant
Maternal Expect.
Literacy
Rate
PER 1000
PER 1 LAKH* AT BIRTH
%
BIRTHS
BIRTHS.
---
(years)
combat major killer diseases such as malaria and tuberculosis.
Throughout the first three decades of the 20th century mortality rates
The author was formerly co-researcher in the above FRCH
1946
38.4
19.6
141
1966
32.3 -
8.3
54
1986
24.0
6.0
22
60
43
58
64
72
70
87
study. She is presently involved in revising and editing the
C
01’3
forthcoming updated volume of "Health Status of the Indian
Sources: Anand and Kanbur, 1991; Annual Health Bulletin - Sri Lanka, 1985; World
People".
Development Report. 1988.
FOR PRIVATE CIRCULATION ONLY
* Lakh = 100,000
did not grow as fast as the national income, averaging 1.5 % of the
GNP, and declining to 1.3 % in the '80s. The early and sustained
A Unique Case
The Sri Lankan experience of effective public health interventions
even under a colonial administration is probably unique and needs a
more detailed historical study. As early as 1947, and on the threshold of
Independence, Sri Lanka had made a qualitative break with the high
mortality trend, as demonstrated by a sharp fall in infant mortality and
reduction in incidence of malaria.
These improvements in health related indicators were sustained
and consolidated immediately after independence, in the 1950s and
60s itself, as public policy pledged itself to provide free universal health
services, universal compulsory education and food subsidies. The near
universality of these social programmes and their accessibility to the
rural population stood in sharp contrast to the urban concentration of
public programmes in other South Asian countries. Between 1948 and
1963, the medical care infrastructure and health investment increased
rapidly; this is the period in which the bulk of improvement has taken
commitment of resources, even at relatively low levels, to expanding
public health care coverage, is demonstrated by the rapid growth of real
per capita spending from SL Rs.8.86 per annum in 1950- 1951 to SL
Rs. 15.86 by 1960-1961. Thereafter, real per-capita spending has
ranged between SL Rs. 15 to 16 per annum.
Overall social sector spending is also linked to improvements in
health status. The real per capita expenditures on education doubled in
the 1950s and then grew slowly in the next decade. By 1982 it was SL
Rs. 33.97, but its share of the GNP declined from around 4 % to 2.9 %
in 1982.
While per capita public spending on health care and education has
remained stable in the post-liberalisation period, the budgetary support
to the universal ration scheme was withdrawn in 1978. In 1979, a
targeted food-stamp scheme was introduced to enable poor households
to buy basic foods in exchange for the stamps.
place.
Apart from the availability of services, the high utilisation of the
public health care system has been an important factor in raising the
health status. This, in turn, is linked to both the quality of health services
However, inflation
doubled the price of food within three years and halved the purchasing
power of the food stamps, with the result that the per capita calorie
consumption of the lowest income group fell from 1,335 calories to
1,181, and that of the second lowest group from 1,663 calories to
6)
•
itself, as well as the rapid expansion of educational facilities. Education,
which became free in 1946, was made compulsory after Independence.
Adult literacy rose from 58 % in 1946 to 87 % by 1986, and secondary
school enrolment had risen to 54 % of the relevant age-group by 1982.
As a result of compulsory and free education, the enrolment of women
at all three levels rose rapidly, resulting in the virtual disappearance of
male-female differentials in educational levels.
Higher educational
levels have contributed to the increasing utilisation of health services.
1,558.
The shift, towards targeted interventions in welfare policy that
accompany structural adjustment programmes, may, in principle, help
to reach the needy sections more efficiently. However, in practice, as
the experience of Sri Lanka has shown, the replacement of a universal
approach by strict targeting of beneficiaries, can worsen the position of
vulnerable groups.
The share of food subsidies in government expenditures dropped
However, the one blot on Sri Lanka's record is the condition of the
The discriminatory citizenship policies have
from 15 % in the mid - 70s to about 3 % in 1984, and its share in GNP
deprived them of the benefits of welfare programmes. Whereas prior to
dropped from 5 % to 1.3 %. At their peak, total social sector spending
Tamil estate labour.
Independence social indicators for this group appeared to be somewhat
ranged between 10 to 11 % of the GDP, but had declined to 6.5 % by
above the national average, in the Post-Independence period their
the 1980s.
general and infant death rates are almost double those of the national
TABLE 2:
HEALTH AND SOCIAL EXPENDITURES
rates.
In the 1970s, persistent poverty and related health conditions, such
as the high rates of morbidity and malnutrition, further intensified by the
economic crisis of this period, have been the main concerns. The
Year
withdrawal of food subsidies in 1978, under an economic readjustment
Total
Million
Rupees
THE/
GNP
%
PHE/
THE
Public expd. as % of GNP
Health
Educa Food TOTAL
%
Social
tion
.
and liberalisation programme, appears to have contributed to an
increase in severe malnutrition among infants and children.
Health and Social Sector Costs
In the ongoing debate on public policies in developing countries, a
•
1950
---
1963
254,000
979
1,299,000
1982
2,219,000
...
1.5
2.5
N./A
58.6
2.2
4.7
5.1
11.01
2.7
63.8
1.5
2.7
5.7
10.0
2.5
58.9
1.4
2.9
1.8
6.4
common assumption is that the latter cannot "afford" social security and
public provision of basic needs.
Reinforcing this assumption is the
controversy surrounding Sri Lanka’s social sector spending.. It is argued
that the provision of free health care, education and subsidised food had
THE = Total Health Expenditure: PHE = Public Health Expendilures:N/A = not available.
Sources: Alailima and Mohideen, 1984; Anand and Kanbur, 1991.
been “excessive" in relation to achievement, and has diverted resources
away from investment in economic growth, output and employment.
Public expenditure on health constitutes around 60 percent of the
With the change in macro-policy towards greater trade liberalisation and
private investment, there have been some cut-backs in public
total health expenditures of SL Rs. 2,219,000 (1982). Over 90 % of the
programmes and the withdrawal of food subsidies.
However, as Amartya Sen has pointed out, an examination of the
private sector is quite substantial and has been growing since 1978.
The changes in policy, permitting private practice among public sector
growth and levels of public spending on health and other social sectors
personnel and the growth of incomes in the post-liberalisation period,
indicates that "the costs have been astonishingly low".
public finances are derived from Central Government revenues. The
In the two
have probably fuelled the demand for private nursing-home care,
decades after Independence, public spending on health care ranged
diagnostic facilities and practitioner services among the urban based
between 2 to 2.5 % of GNP. From the 1970s onwards public spending
richer sections.
FRCH NEWSLETTER, VOL VI. NO. 6, NOV. - DEC. 92
2
headed by a Medical Officer, with a team of public health inspectors
Health Care Services
nurses and midwives.
The lack of access to medical care, a major problem in almost all
The preventive measures took the form of
special campaigns against major infectious diseases, particularly
developing countries, virtually does not exist in Sri Lanka. Allopathic
hookworm, malaria and tuberculosis.
medical facilities are available at an average distance of 4 Kms from any
preventive services has once again received attention in the context of
home, while ayurvedic services are even closer. An extensive network
the high prevalence of poverty related illnesses, mainly malnutrition and
of government medical facilities covers all parts of the country. A well
diarrhoea. The wide availability and good functioning of the curative
The need to strengthen
organised hierarchy of institutions, including Peripheral Health Units,
infrastructure has been crucial to the rapid improvement in the survival
Central Dispensaries, Maternity Homes and Rural Hospitals have
and longevity, but has not prevented the health of the people from
ensured basic curative services to the majority rural population. Higher
level care is provided by the District, Base and Provincial General
has also seen the resurgence of malaria, while the longer life span has
Hospitals, with the Colombo Group of Teaching Hospitals providing
resulted in the rising incidence of cardio-vascular diseases, cancer and
specialist services. The ratio of 29 beds per 100,000 population is one
of the highest in Asia, and the nurse-population ratio is almost double
that of India. Underlying the remarkable decline in infant and maternal
mortality has been the systematic provision of ante-natal care (98%
pregnant women covered) and institutionalised or attended deliveries
the diseases associated with old-age.
The organisation of health services is being restructured on a 3-tier
health center model that will integrate the curative and preventive.
services, putting emphasis, in the future, on prevention and primary
health care.
(87% of all births).
Future Trends
TABLE 3
HEALTH DELIVERY
Year
remaining vulnerable to poverty and poor living conditions. The late 70s
Physicians
(Allopaths)
Nurses
Free and widely available basic health services and high literacy
Beds
per 1lakh* pop.
12
33
302
1975
16
42
287
14
54
the Sri Lankan people.
Its distinguished record is the result of a
sustained and systematic commitment to welfare programmes, and not
1960
1985
levels have played a central role in the improvement of health status of
279
the size of financial allocations. However, even that small social sector
spending has experienced cut-backs since the change in economic
policy after 1977. Even as per capita GDP growth has accelerated,
there is evidence to show that the gap between the upper and lower
income groups has widened. The cut-backs in social expenditures may
have enhanced the vulnerability of the low income groups, among
Source: United Nations, Statistical Yearbook of Asia and the Pacific 1988. Lakh = 100,000
whom poverty - diarrhoea - malnutrition continue to form a vicious cycle.
The government sector offers mainly allopathic medical care. The
allopathic system was introduced during the British period, expanding
Select References
rapidly during the final years- of colonial rule and in the post-
1
Independence period.
'
Abmad E Dreze J • andSen A, Social Security in Developing Countries, OUP, Oxford,
Today, it accounts for 80 % of all medical
treatment Sri Lanka also has a long history of organised systems of
medicine and health care, namely the original Sinhala system, 'Deshiya
Chikista* and the Ayurveda system. The widely available Ayurvedic
services are largely provided by private practitioners, while the
2
AlalimaP. andMohideen R' Health Sectorexpenditure Flows in Sri Lanka, WorldHealth
3 Anands, Kanbur
and achievement Sri
4
and
S.M R, Puolic Policy and Basic Needs Provision: Intervention
in
Lanka, ThePo,i,ical Economy of Hunger.
J. Dreze and A.
.Sen, Clarendon Press, Oxford, 1991
^1^^*^^*
government component is limited to a few hospitals and dispensaries.
According to the 1983 data, there is one Ayurvedic practitioner per
5
t^7eadSBetal(edS)1GoodHcalth^LowC”^
1,280 population. And yet the Ayurvedic system accounts for a smaller
6.
UNDP, Human Development Report 1990, OUP, Oxlord, 1 990.
•
proportion of the total utilisation of medical care. The dominance of the
allopathic system is also reflected in expenditure patterns.. Until 1966,
private health expenditure on Ayurveda exceeded that on Western
medicine, but by 1979 allopathic care accounted for 77 % of all private
health expenditure.
The utilisation of private out-patient and diagnostic services has
accelerated in the late 1970s, when public policy was modified to enable
specialists and medical officers employed in the public health system, to
supplement their incomes through private practice. This allowance was
subsequently extended to paramedics, physiotherapists, radiographers
and lab-technicians. The post 1979 import liberalisation policies and the
pressure from multinational pharmaceutical companies eliminated the
State monopoly on drug imports and prices. This overturned Sri Lanka's
progressive drug policy as well as enhanced the scope for private
practice. The data on the private sector is, however, minimal, as there
is a virtual lack of monitoring or regulatory framework.
Sri Lanka also gave early emphasis to preventive care, which, until
recently, was organised as a separate service through health units
3
FRCH NEWSLETTER,
. NOV. - O^c. W
1 VO VI
V,| ,
,10.6,
HEALTH RESOURCES IN A DISTRICT
A Survey of Medical Practitioners in Ahmednagar
Manjiri Sule
Development of effective health services needs the mobilization of
associations of doctors and pharmacists were also tapped. By cross
adequate resources and their proper utilization. This requires sound
checking information from all these sources, a master list was compiled.
policy formulation and planning, more so in an underdeveloped country
About 3060 doctors of all systems of medicine have been identified in
like India, with low incomes and limited resources. Various studies in
the entire district. This was an arduous task, as the available information
health economics are being carried out to -generate information for
was neither updated, nor reliable.
facilitating the process of policy making and planning in India.
To validate these data a sample-check study was carried out.
Health expenditure is an important component of health economics.
Information about 127 doctors from selected villages of 4 talukas was
These places were selected randomly from the
The Central Statistical Organization report on National Accounts(1989)
physically verified.
states that the total health expenditure in India is 2.69% of GNP, which
categories of villages and talukas made on the basis of doctor /
includes 1.27% of GNP as state sector expenditure and 1.47% of GNP
population ratio. Of these 127 doctors, 72 (57%) were found actually
as private expenditure. Other studies have calculated private
working there. The rest had migrated or retired or were dead or simply
expenditure as ranging from 2 to 6 times of public expenditure (FROM
untraceable. We found 42 doctors working in the selected villages who
1987, KSSP1991, NCAER1991). These studies have shown that 78%
were not listed with us, making the total number of actual practitioners
of health care resources are in the private sector; that 77% of people
11
4,10% less than the number recorded.
prefer private services for their illness and 88% of household health
A postal survey was also carried out, covering all 3060 doctors
expenditure goes to the private health sector. Yet information about
originally listed, to get some reliable data. The results of both these
such a dominant section is neither adequate nor readily available.
exercises are being analysed. The information which follows, however,
is based completely on the compiled master list.
The Study
To get an idea about the cost of health care it is necessary to look at
the investment and expenditure done by health providers. The FRCH
study on which this article is based is being carried out in two phases a)
an extensive survey of health care resources in a district, and
b)
investment and expenditure patterns for providing health care.
Nature of Medical Practitioners
Of the 3060 doctors identified, 51% are in urban areas and 49% are
in rural areas.
Of the total doctors 92% are private practitioners -
including a very small percentage in the voluntary sector - and only 8%
are employed by State government and local self-government bodies.
According to collected information 84% of total doctors are male and
Ahmednagar, an average district in India according to CMIE index
16% are female.
of economic development, was selected for the study. Its population
The system-wise proportion of doctors is : allopaths - 31%;
(1991 census) is 33,62,359, of which 84% is rural and 16% is urban. Of
practitioners of Indian Systems - 42%; homeopaths - 6%; dentists -
13 talukas in the district 5 are relatively developed, with sugar co
1.5%; RMPs - 3.5%; practitioners of more than one system - 0.5%; and
non-qualified practitioners - 0.1%. The system of qualification of about
operatives, trade, industry and good infrastructure facilities.
The
remaining 8 underdeveloped talukas include 1 tribal taluka. The nature
and distribution of health care resources in the district correspond to its
5.4% of total doctors was not available.
It may be presumed however, that the actual percentages of cross
- therapeutics and non - qualified practitioners would be much higher
socio-economic background.
The survey of health resources covered health personnel and
than the above figures indicate. Cross-practice by non-allopaths is a
with state measures to identify non-qualified
establishments involved in providing health and medical services, from
well-known fact;
the public and private sectors. Health personnel includes qualified and
practitioners underway, such information Was also not forthcoming.
non-qualified practitioners of modern and traditional systems of
The levels of qualification are available for 2740 doctors. Of these
Health establishments include
2740 doctors, 2506 (91.5%) are general practitioners and 234 (8.5%)
dispensaries and clinics having indoor facilities, hospitals, nursing
are specialists. The specialists are gynaecologists (22%), surgeons
medicine, and paramedical workers.
homes and pharmacies. Based on the findings of the first phase survey,
(20.5%), physicians (12%), pediatricians (10%), ophthalmologists (7%),
this article focuses on medical practitioners alone.
anaesthetists (6%), dermatologists and orthopedics (5% each), ENT
The survey was carried out by first tapping available official records
like registration lists of councils of all systems of medicine and local self-
specialists (4%), psychiatrists (2%), and others, including radiologists,
pathologists, cardiologists, plastic surgeons, physiotherapists (6.5%).
government bodies. Available private lists prepared by medical
representatives' association, pathological laboratories and various
Geographic Distribution of Medical Practitioners
The geographic distribution of doctors only confirms the generally
The author is a researcher in the FRCH study, "Health
known bias in favour of urban and developed areas.
Investment and Expenditure in a District
FRCH NEWSLETTER, VOL VI, NO. 6, NOV. - DEC, 92
4
TABLE I
GEOGRAPHICAL DISTRIBUTION OF DOCTORS
In rural areas, services of ENT specialists, ophthalmologists and
orthopaedics are not available. Amongst a total of 234 specialists, 214
(91%) are working in 5 developed talukas and only 20 (9%) are in the
Urban (%)
Taluka
Rural (%)
Total
remaining 8 underdeveloped talukas.
Rural population in these 8
talukas gets the services of only 16 (7%) of total specialists.
AHMEDNAGAR Dist.
1556 (51.0)
1501
(49.0)
*3057
Ahmednagar
836 (84.07)
150
(15.03)
986
The number of recorded female practitioners is 446 (16% of total
Shrirampur
184 (52.8)
164
(47.2)
348
practitioners). Of these total female practitioners 116 (26%) work in
Kopargaon
189 (58.5)
134
(41.5)
323
rural areas.
Sangamner
193 (65.9)
100
( 34.1)
293
underdeveloped talukas. There are a total of 50 female specialists in
Rahuri
89 (40.3)
132
( 59.7)
221
Pathardi
36 (23.2)
the district. Specialist services are being provided in rural areas by 5
119
(76.8)
155
138 (100.0)
127 (100.0)
138
Newasa
--
Akole
--
Shrigonda
29 (26.6)
Parner
--
Shevgaon
-=
Karjat
--
Jamkhed
--
127
80 (73.4)
105 (100.0)
109
95 (100.0)
Only
80 (18%) women doctors are working in
(10%), and in underdeveloped talukas by 11 (22%) of them. Of the total
27 female gynaecologists in the district, only 3 (11%) are working in
rural areas and oriy 2 (7%) are in underdeveloped talukas.
105
It is obvious that a small group,of women having professional
95
qualifications hardly provides services where they are most needed. It
85 (100.0)
85
72 (100.0)
72
is generally known that the health problems of women do not get
adequate medical attention, more so in rural areas, because of other
social problems and cultural taboos.
(* Taluka and/or social geography of three doctors could not be identified)
A substantial increase in the
number of lady doctors will perhaps help women to achieve better
According to 1991 population figures in Ahmednagar district, 1099
health status.
persons are served by one doctor. The disparities within this district
average are revealed in the following persons per doctor ratios: urban -
342, rural
- 1885, developed talukas -811, and underdeveloped
talukas-1804.
Need for Planning
The number of vacant posts for doctors in the rural government
services of Ahmednagar district is 82, the highest in the state (TO/, 1st
December, 1992).
TABLE II
GEOGRAPHICAL DISTRIBUTION BY SYSTEM
With such inadequate public services and the
geographic disparity in the availability of private health care resources a
substantial proportion of the population in the underserved areas has to
travel to better served areas. This increases the cost of health care for a
Urban
Rural
Developed
Underdeveloped
(%)
(%)
Talukas (%)
Talukas (%)
Allopathy
63
37
76.5
23.5
Dentistry
91.5
8.5
98
2
population which already belongs to a lower economic strata.
The overall picture of medical manpower in Ahmednagar district is
comparable to the Indian scenario. In order to achieve WHO standards
for better health care, a proper policy is required to organize and
regulate health services. Better policy for medical and health education
and equitable distribution of health care resources would be amongst
Indian Systems
Homeopathy
48
68
52
32
39
61
71
29
38
62
65
35
the essential components of planning to attain the goals set by the Alma
0
Ata Declaration.
R M Ps & non-
qualified
This shows higher proportion of all doctors in 5 developed talukas.
Forthcoming FRCH Publication
The proportion of doctors of systems other than allopathy and dentistry
is higher in rural areas. But most of the non-allopathic practitioners are
practicing allopathy without having any institutional training. Also the
PEOPLE'S HEALTH IN PEOPLE'S HANDS:
higher proportion of RMPs and non-qualified practitioners in rural areas
Indian experiences in decentralised health care
indicates a ready market for such practitioners in regions lacking
and a model for panchayati raj
qualified services. Of 234 specialists recorded, 207 (89)% work in urban
areas and 27 (11%) work in rural areas, mainly in the developed
Eds. N.H. Antia & Kavita Bhatia.
talukas.
TABLE IN
GEOGRAPHIC DISTRIBUTION OF SPECIALISTS
Urban
Rural
General surgery
35(73%)
13(27%)
Gynaecology
44(86%)
7(14%)
Paediatrics
21(91%)
2(9%)
Dermatology
11(92%)
1(8%)
General Medicine
26(93%)
2(7%)
Anaesthesia
13(93%)
1(7%)
5
This book, expectedforreleasebyearly 1993, analyses
the development of existing health and medical serives in
India. Authoritative views of eminent personalities in
medicine, health administration, social and political
sciences are putforth, leading up to the presentation of an
alternative, decentralised people based model testable
against sound technical, economic and socio-cultural
considerations. This book is particularly significant in the
context of the forthcoming Panchayati Raj Bill.
Price: Soft Cover - Rs. 751- Hard Cover - Rs. 1751-
COMMUNITY HEALTH CEL
326
V Main
I ERCBNEWSLETTEA.VOLV.NO.C, NOV.-DEC, 92
Koramangala
Bangalore-560034
THE CONSUMER PROTECTION ACT AND DOCTORS
Some Misconceptions
Anant R.S. Phadke
There is a widespread opposition to and even resentment amongst
doctors against the Consumer Protection Act (CPA) .This opposition is
adequate justice to patients.
based, by and large, on ignorance and on an unenlightened view of the
the IMC by the Civil Court and by the Consumer Redressal Forum
current status and future of the medical profession. At the same time,
(CRF). This is unfair”.
“Doctors would be punished thrice for the same offence — by
consumers should understand that CPA is only one of the measures to
No! If a doctor is punished by the CRF he / she cannot be punished
improve the quality of medical care; that there is a need to make many
again by the Civil Court, for the same offence. The Medical Council,
profound changes in our social culture as well as in the medical
however, has a different role and its punishment is of a different nature.
profession so that honest, competent doctors do not get frustrated.
It is thus not a double punishment. Secondly, a 'single offence' is many
There are certain misunderstandings amongst doctors, about CPA,
times violative of different sections of a law and hence, many times,
which are conveniently used by them to oppose its applicability to their
draws punishments of a multiple nature.
profession. Let us, then, first deal with these.
exception. The main point is whether the punishment is out of proportion
Medical negligence is no
to the offence, and not, whether technically there are multiple
Countering Misunderstandings
punishments.
“Can CPA be applicable to the medical profession ?"
The first thing to note is that CPA is already applicable to doctors
since its enactment in 1986. The only uncertainty is about the result of a
case pending before the Supreme Court, challenging the application of
CPA to doctors. It has been argued that CPA does not apply to those
“How can a non-medical panel decide about cases of medical,
technical nature? Is it competent?”
The Civil Court also consists of non-medical persons as judges.
These have been giving judgments about medical negligence. Judges
take the help of experts whenever felt necessary. The CRF is no
rendering service and since doctors fall under this category they should
different from the Civil Court in this regard. The President of the CRF is
be exempted from its ambit. What is side-tracked here is that in the
of the rank of the District Judge — a fairly responsible and experienced
CPA, what is meant by personal service is a contract between a master
judge.
and a servant. A doctor is not a servant of his patient, in the sense of a
master-servant relationship.
Hence a division bench of the Andhra
Pradesh High Court has dismissed a batch of Writ-petitions filed by
doctors and IMA (Indian Medical Association) on this ground.
It is true that a doctor is not like a shop-keeper, but is a professional
“No doctor would take risky cases if CPA is enforced on the
medical profession."
Failure of treatment is no crime, if the doctor has taken due care
and has due expertise. If it is proved by the complainant that the doctor
was negligent, that he/she did not apply the due care and expertise,
bound by a code of ethics and answerable to its own professional body
then, and only then, is the doctor punishable.
— the Indian Medical Council (IMC).
But the point is, all other
principle in medico-legal cases is applicable to CPA also. Thus, no
professionals — lawyers, architects,, engineers — are covered under
the CPA. Doctors, hence, cannot claim exception on the grounds that
does not give him/her expected benefit. Even a mistake in diagnosis
"a doctor is not practising commerce but a profession." After all a
and treatment is to be condoned, provided the doctor had reasonable
This well-established
doctor would be punished merely if a patient dies or if the treatment
profession has its commercial aspect also and the consumer of a
knowledge and had given reasonable care. A risky case can thus very
professional service needs protection from damage due to neglect by a
well be taken up, provided the doctor is competent and conscientious.
professional.
“Doctors would do unnecessary investigations to be legally
“When doctors are answerable to and punishable by IMC why
should there be a second body to do the same ?”
safe. This would increase the cost of medical care.”
Contrary to Widespread misbelief, a number of laboratory
IMC operates through its State branches. As things stand, many of
investigations are not always necessary, even if we were to follow
them are almost defunct. They hold their proceedings in the absence of
Western textbooks. For example, Western textbooks on anaesthesia
Being an all-doctor body the
recommend no investigations at all in case of apparently healthy males
below 40 years of age, undergoing "peripheral non-blood loss surgery"
the complainant and in-camera.
consumers' views, interests, etc., are not represented in it. Above all,
Consumers have no faith in IMC because so far it has failed miserably in
like herniogrhaphy, closed reduction of fractures, piles, fissure, etc.
Secondly, what is 'reasonable care1 can be decided against local
protecting the interests of patients. By its very nature IMC cannot do
standards, which are different in London, Bombay, and ataluka-place in
IMC has no powers to order any compensation to be paid to the patient.
India. Thus, all the investigations or precautions mentioned in Western
The author is a medical professional, active in the Medico
Friend Circle and Peoples' Science Movement. He is presently
associated with FRCH on the project, "Cost and Utilisation of
Drugs and Pharmaceuticals in Government Hospitals".
FRCH NEWSLETTER, VOL VI, NO. 6, NOV, - DEC 92
textbooks are not necessarily applicable in, say, Alibag. This is a well-
recognized principle in medico-legal cases.
What is, however, necessary is that the local medical body, such as
the IMA branch in the concerned town, lays down standard treatment
6
guidelines for medical practitioners in that area to follow. Today no such
iii) There should be proper guidelines in the selection of the non
local standard guidelines are available and medical practice is quite
judicial members of the CRF and these guidelines should be strictly
anarchic. This must change. The CPA has offered a chance for socially
followed. In cases where CRF deals with medical negligence, a
conscious doctors to come forward and press for the preparation of
doctor should also be co-opted as a member of CRF.
such guidelines, to be formulated by the local professional bodies of
general practitioners, surgeons, paediatricians, etc. So long as a doctor
The first of these three modifications has already been suggested
follows these well thought-out guidelines, he / she would be legally safe.
by the working group set up on the advice of the Central Consumer
It should thus be clear that, by and large, it would not be essential to do
Protection Council, to suggest suitable amendments to the Consumer
unnecessary, costly investigation for a rational and legally safe medical
practice.
Instead of opposing the CPA on irrational grounds, IMA
should spend its energy in regulating the quality of medical care.
Protection Act, 1986, and the MRTP Act, 1969. These are likely to be
passed in the coming session of Parliament.
Medical bodies should
lobby to get the other two modifications to be accepted.
"Would not CPA lead to a loss of trust between the doctor and
the patient? Would not the CPA be misused?”
Broad Reforms Needed
There is already a certain amount of loss of trust between the doctor
Lastly, a word about the limitations of the CPA. If the irrationalities
and the patient. The CPA merely provides a more accessible and
and malpractices in the medical profession are to go, a number of
These include, a ban on
speedy legal avenue for patients — no fees, no lawyers, judgement to
reforms are needed in the medical field.
be delivered in 90 days. If doctors become more conscious about their
capitation-fee medical colleges; a ban on polypathy (a doctor using
knowledge, follow scientific, ethical principles in their practice and,
different pathies) without adequate training; compulsory continuing
above all, are more communicative to the patients, this trust- can be
medical education of doctors; ban on irrational drugs and irrational drug
regained. The consumers should also be enlightened about the
limitations of medical technology, about 'what is medical negligence',
combinations; pre-censorship of advertisements and other drug
and about the functioning of the CPA. It is not true" that the consumer
information supplied by drug companies, so that only correct and
adequate information is supplied to doctors and lay-people; strict
can obtain justice by a simple letter to the CRF. Cases are dismissed by
restriction on the promotional activities of drug-companies and corporate
CRF without a hearing, if it finds that the complaint does not have any
medical enterprises; proper health education in schools and through the
legal validity. Secondly, the onus of proving medical negligence lies
lay media; incentives and disincentives to reduce urban congestion of
with the patient. This is an extremely difficult task. The CPA cannot
doctors; standardization of doctors' fees on a rational basis.
therefore be misused for harassing and blackmailing doctors. A doctor
these and other such measures are instituted, mere use of CPA is not at
can always appeal to the State CRF if he / she is not satisfied with the
judgement of the District CRF; and later even to the National CRF
all sufficient to improve the medical profession and hence the quality of
Thus there are no summary trials or instant or irreversible judgements.
i)
medical care to the patients. Consumerism, the illusion that 'there is a
pill for every ill' should also go. Consumers should also recognize their
"Does it mean that the CPA needs no improvement ?"
role in improving the
No! The following improvements are necessary:
organizations and organizations of doctors should come together, sit
If the CRF finds a complaint to be frivolous or vexatious or
across the table and negotiate the terms of reforms to bring about such
changes. Is it too much to expect this to happen ?
O
mischievous, then the doctor should be paid the same amount of
compensation claimed by the complainant and this fact should be
widely publicized.
ii)
Unless
Cases against doctors (or for that matter anybody) should not be
reported in the lay media before the verdict has been given.
quality of medical services. Consumer
We invite readers to respond to the debate on the
above subject. Selected responses may be
published in future issues
- Editor
A PHC DOCTOR SPEAKS OUT
It is my personal opinion that if our Tuberculosis Control Programme
much political and administrative dominance on a worker's. technical
goes on in the way it is going at present, Tuberculosis will be one of the
skill and job satisfaction. Therefore, right from 'new case detection' to
leading killers in the Indian community. And let me say that this is
complete treatment, everything is hampered. The worker is bothered
destined to happen. Allow me to state in short the reasons for it.
only to collect the sputum samples as per his population. The M.O.
Right from the top to the bottom—from the apex officers to the field
relieves his headache by giving figures in the M.O.'s meeting so as to
workers — everyone is nowadays working for his pay and personal
avoid firing by the DHO. The higher officers themselves are bothered
interests outside of his job. An officer may be interested in promotion, a
only about the figures and ranking of the District. Family planning is
medical officer in practice or a MPW may not at all be interested in work,
given top priority - the District targets and state targets are completed
as is the plight of all government workers. No one is motivated morally
above 100% — but the birth rate is rapidly increasing. In a district level
to do something for the sake of humanity.
meeting it is unfortunate that important aspects
.... When I joined a PHC I felt sickened by what I saw. There is so
like Malaria and
Tuberculosis etc. are given less importance by higher officials. These
diseases also, as past experience has shown, will one day be rampant
The above has come in response to a questionnaire sent
through the FRCH project studying the 'Social and Oper
Extracts are
shared here with the writer's express permission.
ational Constraints in Tuberculosis Control'.
7
and out of control.
So the " lall" (saliva) — not sputum proper — is collected and
examined, giving a negative reading. The case detection (process) thus
COMMUNITY HEAUTU CELL
Contd.onpage 8
326, V Main. I FRCH NEWSLETTER, VOL, VI, NO, 6, NOV, - DEC, 92
Koramengala
Bangalore-560034
India
LIBRARY NEWS
Books
Reprints
Anant S., Women at Work in India: a bibliography, Sage Publications,
1)
Nev/ Delhi, 1986, pgs. 238.
Bala P., Imperialism and Medicine in Bengal: a socio-historic
perspective, Sage Publications, New Delhi, 1991, pgs. 174.
Bose A., Demography of Tribal Development, B.R. Publishing
Corporation, New Delhi, 1990, pgs. 312.
Burton J.L., Aids to Postgraduate Medicine, Churchill
Livingstone, New York, 1989, pgs. 263.
Chakrabarty C., An Interpretation of Ancient Hindu Medicine,
2)
3)
4)
5)
6)
7)
8)
9)
10)
Neeraj Publishing House, Delhi, 1983, pgs. 599.
Dreze J. and Sen A., Political Economy of Hunger-Vol 3., Clarendon
Press, Oxford, 1991, pgs. 385.
Dutta G.P., Health Care in India, P.K. Choudhari, Calcutta, 1987, pgs.
112.
Killewo J.Z.J., Behavioural and Epidemiological Aspects of AIDS:
research in Tanzania, SAREC, Sweden, 1992, pgs. 203.
Rameshwaran G., Medical and Health Administration in Rural
India, Ashish Publishing House, New Delhi, pgs. 163.
Zohr C.A., Maternal Mortality: a global factbook, WHO, Geneva,
1991, pgs. 598.
1)
Bhooshanam K. and Tirumulpad R., Frontiers of Ayurveda, Health
ActiohW: V (7), July 1992, pp. 21-23.
2)
Daniels N., HIV Uninfected Health Care Professionals : public
5)
threat or public sacrifice, Milbank Quarterly, Vol. 70 (1),'92, pp. 3-42.
Groeu Van der G., Simplified and Less Expensive Confirmatory HIV
Testing, Bulletin of the WHO, Vol. 69 (6),1991, pp. 747-52.
Hunter B., Financial Management in the National Health Service,
Management Accounting, Sept. 92, pp. 56 and 60.
Khanna R., Women's Health as Empowernment, Health for the
6)
Millions, Vol. XVIII (4), Aug. 1992, pp. 12-15.
Lewis G and others, AIDS Programmes in Transition, World Health
3)
4)
7)
8)
9)
10)
Forum, Vol. 12 (3), 1991, pp. 297-301.
Parthasarathi A. and Singh., Science in India : the first ten years,
EPW, Vol. XXVII (35), Aug. 29,1992, pp. 1852-58.
Prasad J., Dereliction of Duty: despite being shown the way, the
BMC .... Business India, Sept. 14-27,1992, pp. 149.
Statement from the WHO/UNICEF Consultation on HIV Trans
mission and Breastfeeding, June 1992, pp. 18-19.
Yugandhar B.M. and Raju B.Y., Government Delivery System for
Rural Development, EPW, Vol.XXVII (35), Aug., 1992, pp. 123-127.
contd. from page 7
suffers, the patient remains undetected and the disease spreads. We
a village, no one will offer a glass of water.
take our monthly pay passively, give anti-koch's treatment on cards
somehow continuously maintained — and fill in our target figures.
You will be surprised to know that we have to take the signatures of
the 'sarpanch' or police ‘patil’ on the family planning accounts, while
Shameful, isn't it?
submitting it to the DHO office. Such is the belief of the government in a
Talking about private practitioners — here, in this tribal area, the
Class II Gazetted Medical Officer. We are reprimanded by persons who
doctors only want money. They would advise a pregnant female to take
2 injections—one for herself and one for the baby—and would charge
are illiterate and know nothing about the medical field or PHC
administration, at Panchayat Samiti meetings. Only the paper records,
her doubly. Both the injections, unfortunately are of teramycin (bad for
and not the work, seem important.
the foetus) or B-complex — not even tetanus toxoid.
Just as we sit in a taxi and the meter is started—the private doctors
So how can Medical Officers working in such a society for years
together keep their motivation positively?
Their attitude becomes
catch a patient and put him on I.V. — no matter what he complains of —
negative and administration, laissez-faire. The Medical Officer Who has
the (I.V.) meter is on—the bill drips on, increasingly. Today, such is the
good relations with the local and other
condition of the society due to misguidance by the private doctors, that a
complaints to the higher officers is thought to be good — no matter how
patient comes smiling to me and says that he feels a little weak and asks
me to fill 2 bottles of saline — injecting a yellow injection in the saline
in treatment and follow up. Same is the story of most of the national
bottle! Now, how should I alone wipe out this belief and how should I
programmes. There is only one satisfaction — that I am serving the
morally educate people ?
If I say that a patient doesn't require an
injection or IM — he looks at me as if I am a fool — or tries to give me
money for it. It is very disgusting.
politicians and brings no
many new tuberculosis cases he has found or how regular he has been
needful.
Logically, as taught in school, one bad mango spoils all mangoes in
the basket. But one good mango in a basket of all spoilt mangoes does
Patients themselves are so illiterate that they do all "Dey- Bhagat
not purify all — that too gets spoilt. But believe me, I have not yet got
(consulting religious quacks and shamans) stuff and then come to the
PHC. It is shameful also that a field worker doesn't refer a case to the
spoilt. Firstly I am a human being—then a doctor—then a government
medical officer. I sincerely strive, as per my efficiency, to follow the rules
PHC in time. The community is not that poor but their tendency is very
in all national programmes, without hurting my superiors or the
wrong. They sell the milk in the dairy and buy biscuits (which are costly)
for their child, but won't think of feeding milk to the child.
community. It is sort of a tight-rope walking job.........
Being tribal, the community gets everything free of cost from the
FREE ABSTRACTING
government—cattle, roof tiles, wells, electric motor, bank loans — that
too under 100% subsidies. They look at the PHC as cheap, the ANMs
as public figures, the MPWs as good-for-nothings and doctors as
unsocial animals. They think that all the government people are their
servants. If a police constable or a simple Talathi I Gramsevak* visits a
O
The contents of this newsletter may be abstracted
without prior permission. However, we would
welcome acknowledgement of the source and
copies of any abstractions.
village he is welcomed warmly. But even if an ANM walks 2—3 kms to
Edited by Nagmani Rao, with secretarial assistance from Joyeeta and Vrinda Sinha, arid produced by the Foundation for Research in Community Health,
84. A, R.G. ThadanI Marg, Worli, Bombay 400018. Registered under the Bombay Public Trusts Act. Printed at Printext Offset, Pune 30.
Position: 4060 (2 views)