To my fatherwho taught me

the quintessence of government

is its human face;and my motherwho showed us

how the human spiritmeets ever y cha.llenge.

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IMPLEMENTING HEALTH POLICY

IMPLEMENTING HEALTHPOLICY

MEERA CHATTERJEE

UNnnn rsr Ausprcrs or tueCnNrns FoR PoLrcY RrssancH

Nsw DErHr

$(\\A\II t-

MANOHAR

r988

IsBN-81-85054-36-3

@ Centre for Policy ResearchNew Delhi, 1988

First Published 1988

Published by

Ramesh Jainfor Manohar PublioationsI Ansari Road, DaryaganjNew Delhi-110002

Printed by

Lohia Composing Agencyat Sunil PrintersCB-l067, 75l1, Ajay Palace

Naraina, Ring RoadNew Delhi-110028

ACKNOWLEDGEMENTS

With gratitude and affection I acknowledge the help of all those

who encouraged and inspired, shared ideas and materials' en-

gaged in discussion and correspondence, reviewed drafts and

manuscript, or otherwise contributed to the spirit and substance

of this work. In particular I should like to mention : Asok

Mitra. Ashish Bose, P.B. Desai, Banoo Coyaji, V'N' Rao'

Harcharan Singh, C. Gopalan, Alfred de Souza, D. Banerji,

Roger Jeflery, Tricia Jefery, Ravi Duggal, Hellen Ohlin, N'S'

Deodhar, Srilatha Batliwala, Ranjith Senaratne, Lincoln Chen'

Robert Chambers, Penny Czana, Karuna Ahmad, M'E' Khan'

Susan Rifkin, David Pyle, Jim Kocher and John Wyon'

My'elders' and colleagues at CPR deserve special thanks :

V.A. Pai Panandiker, Nirmal Mukharji, B'M' Bhatia, Pran

Chopra, Bhabani Sen Cupta, Ashis Banerji, Ajay Mehra, Arun

Sood and Ujjayant Chakravorty. The cooperation of the staff

of CPR was lnvaluable. My sincere appreciation to Geetha'

who typed the final manuscript with expertise and dedication'

and to Kawaljit Kumar who has seen to the production of this

book.Malay, my husband, could not have been a greater "friend'

philosopher and guide," nor have shared more equanimously

my 'double burden.'

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CONTENTS

Acknowledgements

Foreword

National Health Policy: An Introduction

Towards lmplementation of the HealthiPolicy

The Maldistribution of Health

Orsanisation for Health: Focus on Women andHouseholds 67

Community Participation in Health Care 100

The Role of the Private Voluntary Health Sector 125

SpreadinglPrimary Health Technology 163

Life Without Food? Health ?olicy Re-examined 184

Resources for Health Care 217

lTaking Stock 280ill TAnnexure

29o

References 293

Index 315

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CHAPTER I

NATIONAL HEALTH POLICY:AN INTRODUCTION

The enunciation of a National Health policy by the Govern-ment of India in 1982 raised hopes among those concernedwith India's poor health that the government is serious aboutits commitment to provide "health for all,' (GOI, l9g2a). ThePolicy Statement was the first of its kind although, over thepast 40 years, a series of committees has advised the CentralGovernment on the country's health problems and their solu-tion. Approved by Parliament towards the end of 19g3, thePolicy has since been on the anvil of implementation.

The Policy is broad in its approach to health needs andpossibilities, and arnbitjous in its goals. Besides acknowledgingnlany ofthe mistakes of the past and calling for their redress,it embodies concepts of social justice and democratisationwhich have been eclipsed in the process of health developmentto date. Sceptics may hold that, like other proposals espousingequality and social transformation, the National Health policyis a Machiavellian stroke-that the Government does not at allintend to implement it. Others may view the policy as grandioseand over-ambitious-impossible to implement. However, giventhe undeniable need for a massive and concerted attack onnational health problems-which requires a departure fromentrenched ways-the policy can act as a stimulus for healthplanners and practitioners to formulate a strategy for its imple-mentation. This work aims to identify aspects of the policy

2 Implementing Health Policy

which are crucial to national hedlth, and discuss how these canbest be implemented:

Tsn Por,rcyls CoNTENT

The Policy Statement can be diviiled into several broad sections.The first is a brief description Of the historical antecedents ofhealth policy-the Indian Constitution, the Five-Year Plans,Indian culture's medical heritage and past achievements. The.-second is the context in which the Policy was framed-thecountry's health situation, the trwenty-Point Programme, andrapid population growth. The tliird, the'meat' of the Policy,is a statement of its overall gool to provide health care to alland its strategy to restructure pri[nary health care services andmedical education, ensuring thqir coordination. The fourth isa list of specific "Problems Requflring Urgent Attention," whilethe fifth outlines necessary suppofting services, leading, finally,to a statement of targets for service inputs and health outcomes,phased over the l5 years from 1985 to 2000.

Antecedents. As introductionl, the Constitutional mandateto eliminate "poverty, ignorance and ill-health," to raise nutri-tional levels and improve public fuealth, to ensure the health ofworkers and healthy developmenf of children is recalled. Thispreamble calls attention to the frhmework provided by succes-

sive Five-Year F.lans for the deveflopment of health infrastruc-1ure, medical research and education. In proposing "anintegrated comprehensive approaNh towards the future develop-ment of medical education. re$earch and health services" tomeet the country's health needs, the Policy depatts from pastpractice and thus provides its railon d'etre.

Recalling the country's ancie4t medical heritage, the PolicyStatement cites the impact of allopathic medicine. Overallrnortality has been reduced by hdlf, and major diseases such as

smallpox, plague, cholera and fralaria have either been eradi-cated or substantially contro[ed since Independence. Anextensive netwolk of curative an{ teaching institutions has beendeveloped and a large 'stockl of health personnel exists.

Indigenous capacity for the manufacture of medical supplies andequipment has also been establisted'

National Health Policy: An Intrcduction

However, the shortcomings ofthe past are reflected in theensuing description of the prevailing health situation: rapidpopulation growth; high mortality among women, infants andchildren; extensive malnutrition; a high incidence of blindness,leprosy, tuberculosis and other infectious diseases; a lack ofaccess of rural people to potable water and basic sanitation;and inadequate trained birth attendance. The Statement lays theblame for this poor health situation on the adoption ofa"hospital-based, curative approach to health services andmanpower," which has been o'at the cost of providing compre-hensive primary health care to all," and to the neglect ofpreventive, promotive, rehabilitative and public health measures.The curative approach is deemed "inappropriate" and "irrele-vant" to the country's needs, and is blamed for enhancingdependency and weakening the community's capacity to copewith its problems "instead of improving awareness and build.ingup self-reliance." It is also held responsible for creating acultural gap between the people and personnel providing care.As a remedy, it is suggested that achieving satisfactory healthstitus calls for "involving the community in the identificationof their health needs and priorities as well as in the implement-ation and management" of programmes.

The need for health policy to take into account the Twenty-Point Programme is then suggested. The programme givespriority to family planning; universal primary health facilities;control of leprosy, TB and blindness; nutrition and welfareprogrammes for women and children; drinking water supply;.and several other health needs which are, in fact, the gist ofthePolicy's subsequent proposals.

Goals and Strategies. The overall goal of the Policy is the"universal provision of comprehensive primary health careservices," which are ''relevant," "affordable by the people" and"participatory" of community and voluntary organisations. Itaims to provide "an integrated package of services to tacklethe entire range of poor health conditions." It is envisionedthat this will require:

(a) major modifications in the existing system of medicaleducation and para-medical training;reorganisation of the health service infrastructure; and

3

(b)

4 ImPlementing Healrh PolicY

(c) integration of health pl4ns with efforts in health-relatedsectors, as well as wi{h socio-economic developmentproces6es.

On the subject of medical e{ucation and training of healthpersonnel, the Statement's majof recommendation is that man-power development should co4centrate on imparting a greater

orientation to community health and an integrated "healthteam" approach. The details are left to be worked out by aseparate "National Medical Health Education Policy"which should examine the ts of medical and Para'medicaltrainine in the context of nal needs and priorities. Thisseparate policy is to address itselfto curriculum changes forbetter relationships among and for their social

motivation, as well as to manplower requirements, particularlywith a view to correetins re imbalances.

Reorganisation of health serivices is the major thrust of thePolicy. The proposed "restrufturing" is focused on decentra-lisation. The guiding principle is that the most-treeded services

should be closest to the co ity in order to ensure timelyavaitability of medical attentiod. Various levels of expertise are

to be deployed so that they cFn be optimally utilised, with a

referral system providing u linkages to increasinglYspecialised facilities, This strdtegy calls for "individual self-

reliance" and active "communiiy participation," and envisions

an "extension approach" utilisidg community health volunteers'paramedical multipurpose workers and non-governmentalorganisations.

Priority Problems and Actionb. The next section of the PolicyStatement is devoted to eight problem areas to which priorityattention is urged: nutrition, food and drug adulteration, watersupply and sanitation, environnjental protection, immunisation,.

maternal and child health, sbhool health, and occupationalhealth services. Little elaboratidn is provided though they are

considered "some of the more important inputs required forimproved health care." The highest priority is given toMaternal and Child Health because of the "vicious relationshipbetween high birth rates and high infant mortality."

Supporting Activities, The poncluding portion of the State-

ment proposes several supportinp activities: health education,

National Heakh Policy: An Introduction 5

information systems, essential drug and equipment production,

insurance schemes, health legislation and biomedical research.

Education is seen as t}lre sine qua non of health action.The Policy Statement proposes the integration of health

with overall socio'economic development. It advocates the

formation of committees at the Centre and in the States to help

the Health department coordinate its work with the depart'ments of Food and Agriculture, Water Supply and Sewerage,

Housing, Education and Welfare, and Rural Development. Atthe community level an "integrated programme of ruraldevelopment" including health care is favoured.

Targets. The Statement concludes by proposing that progress

be monitored in relation to a number of demographic andhealth service coverage targets set for 1985, 1990 and 2000.Commendably, it has broken away from 'conventional' inputindicators and targets of 'health facilities..to be established' or'services delivered,' and proposed more meaningful ones, suchas reductions in mortality in the general population and amonginfants, pre-school children and mothers, and in the incidenceof blindness, and increases in antenatal and delivery care,immunisation, and treatment rates for leprosy and tuberculosis.Four indicators focus specifically on fertility control-the birthrate, net reproductive rate, and famiiy size are to be loweredthrough increased "efective couple protection." These indicesare also to be addressed by a separate (new) National Popula-tion Policv.

Pmr NoNlcntBvEMBNTs

As a statement of intent, the National Health Policy is wide-ranging, almost comprehensive. To assess its future, however,one must measure it first against history. How does it comparewith past prescriptions? What factors have stood in the wayof fulfilment of past promises, and how does the current Policypropose to overcome these?

The Policy Statement clearly derives inspiration from someprevious attempts to call attention to the health needs of the

6 Implementing Health policy

country,* as well as from tfre worldwide ,Health for All'movement. Perhaps most sigfificant was the Report of theBhore Committee (Health Survly and Development Committee)established in 1943 (GOI, 19460. Its mandate was to .,survey,'

health conditions and organiqations and make recommenda-tions for their development. Arflong its more important sugges-lions were :

-that no individual shorlld lack access to medical carebecause of inability to paly for it;

-that medical relief and prpventive health care should beurgently provided to ruraI people;

-that special emphasis s[rould be placed on preventivemethodsi

-that health services shoul{ be as "close to the people aspossible in order to en$ure the maximum benefit to thecommunity to be served;'i

-that the active coopera{ion of people in the healthprogramme should be sought;

-that health units should tfe established according to a setpattefn;

-that physicians should ieceive three months training insocial and preventive medicine; and

-that all facilities for di{gnosis and treatment should beavailable in the health service system when it is fullydeveloped.

As these recommendationshave all been reiterated inment!

In fact, the call, "healthby the National Planning Coits Sub-committee on Health.

been achieved, theyHealth Policy State-

ve hardlyNational

was made even earlierThe Interim Report ofin 1940, called attention

to the need to have a stabalanced curative and

olled, free health system whichve care (National Planning

Committee, 1940). The heal of the people was seen as the

*Tbere have been several incisive of these earlier documents:see Banerji, 1980a; Boso, 1982;1984.

and Desai, 1983; and Ramasubban,

Natibnal Health Policy: An Introduction 7

responsibility of the state, Promoting health as the right ofevery individual, the National Planning Committee's goal was

"an organised public service discharging a common obligation

of society towards its members. " The Bhore Committee added

to this the stipulation that health services should be within

easy reach of people, and the unit of health administration "as

small as is compatible with practical considerations"'The Bhore Committee, in fact, laid down norms for a rural

health infrastructure with short- (l0-year) and long-term(20-40 year) goals. In the long-term, a Primary Health Unit(PHU) with 75 beds and a stafr of six medical officers, six

Public Health N1urses, and six Auxiliary Nurse Midwives was

to serve ten to twenty thousand people. One Secondary Health

Unit with 650 beds for every 600,000 people (or 15-25 PHUs)'

and a District Hospital with 2500 beds for l-3 million people

(or 3-5 SHUs) was proposed' The building of this infrastructure

was intended to commence from the smallest unit, the PHU'

with a 30-bed SHU for every 2 PHUS, and a district health

organisation (consisting of 25 PHUs and 2 SHUs) being

completed in the short-term.The construction of Primary Health Centres (PHCs) was

begun in the early 1950s in accordance with the Bhore Com'

mittee's recommendations, although some of the norms were

changed. The pattern adopted envisioned one PHC for every

Community Development Block which at that time had apopulation of 60,000 on an average. By the 1970s, this ratio

(one PHC per block) had been achieved but' significantly, the

average population of a block had incieased by then to 100'000'

It cuirently stands at over 120'000. While there were to be

three sub-health centres per block initially, this ratio was later

increased to one sub-centre per 10,000 people' The pattern

proposed now is one sub-centre per 5,00C people. There is stilla long way to go to achieve this ratio, leave alone the Bhore

Committee's recommendations for this level.

The National Planning Committee also advised a rapid

increase in the number of medical personnel through expansion

of training centres and absorption of traditional practitioners

into "scientific medicine.t' It recommended that a ratio of one

worker with "elcmentary training" in practical community

health per 1000 people be achieved within five years and that

Implementing Health policy

- In addition, a system of Stat{tory Boards was to percolatedown to the district level, wh{re the people were to haveelected r_epresentation, and whdre autonomy to design healthservices (in accordance with geperal State norms) was to bevested. Councils of ,.experts',

Were to be appointed at theState and district levels to advise on technical issues. However,such a system which would have decentralised health decision-making and planning down to the district level has not beeni mplemented.

Similarly, some other recorf mendations of the BhoreCommittee to '.democratise', hFalth care have also beenignored. For example, the Cotnmittee recommended thatvillage health committees of flve to seven volunteers be formedto promote health activities ang people's cooperation. Thisrecommendation was not implemQnted ea rlier, peihaps due toa lack of 'political will,' yet simil4r proposals are made in the1982 National Health policy Stateinent.

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within l0 years there should be 4 qualified medical practitionerfor every 3,000 people, and a hoqpital bed for every iJ00.

. Generally speaking, neither the National pianning Com_mittee nor the Bhore Commitlee, nor any of their successorcommittees saw rural health nleds as incompatible with thoseof specialised, urban-based medicine. While rural health wasconsistently projected as the most .,urgent need," sophisticatedmedical facilities (including supef-quality institutions such asthe .{ll-India Institute of Medical Sciences) were also viewedas necessary. By and large, a tog-down approach to buildinghealth facilities was nrdqinar{health facilities was ordained.

The Bhore Committee also made recsmmendations in thesphere of health ad-ministration, trnany of which were adopted.It recommended State eo,rr:_:,. . ^ _, vernrqent autonomy in health, withMinistries at rhe Central and State f"u.f..' afoofide thebureaucratic cadre of health officfals, a technocraticl"adre_theDirectorate of Health Services, usder a ni.""tor-C"n.ral_wasalso suggested. The Committee also advised the establishmentof a statutory board of Heailth Ministers, one of whosefunctions would be to recommpnd grants_in_aid to the States.Accordingly, the Central Council of Health was established in1952.

f

ttrational Health Policy: An Introduction

Certain other features of the Health Policy are based onrecommendations of committees which followed the BhoreCommittee. The most important of these were the MudaliarCommittee which surVeyed progress over the first decade andregommended the strengthening of primary health centres(GOI, 1961); the Kartar Singh Committee which recommendedthe retraining of unipurpose workers as "MultipurposeWorkers" (GOI, 1973); the Shrivastav Committee on MedicalEducation and Support Manpower which reiterated the needfor community health workers (GOI, 1975); and the ICSSR-ICMR (or Ramalingaswami) Committee (ICSSR-ICMR, l98l),which gave shape to the Alma Ata "Health for All"Declaration (WHO-UNICEF, 1978).

Despite attention to "soft" issues (such as the orientationof personnel) right from the inception of health policy-making,the emphasis over the decades has been on the "hardware"-the construction of health facilities, their equipment andstaffing, and research and development for technology-basedmedicine. Much of this is now deemed "inappropriate" and"irrelevant" by the National Health Policy. However, thereare no plans to scrap it, and efforts to bring about significantchange have yet to start. As Banerji has often pointed out(e.g. Banerji, 1977,1978), while the "existing model" of healthservices is frequently decried and "alternatives" sought toimprove rural health in particular, there has been a failure todate to modify health plans and allocations (see Chapter 9).Even the ICSSR-ICMR Committee report, which called for"radical change" and devised an "alternative" model of healthservices, simply built on the existing health system, Certainly,the approach adopted thus far has acquired an historicalsanctity, which will be extremely difficult to repudiate in theimplementation of the National Health Poiicy.

.r Ossrecrgs ro IMPLEMENTATToN

Against this backdrop, the Policy Statement's proposals ale con-cerned largely with change. The universalisation of health carerequires changes in the health sector to extend its services wide-ly, to involve people in them, and to collaborate with other sec'tors. Change is called for in both bureaucratic and professional

impedes development programthes of all kinds, there are alsomore 'tangible' obstacles to the implementation of NationalHealth Policv.

First, while the universal provision of primary health careis based on the notion that health is the right of everyindividual, the Indian Constit{rtion does not grant this rightto citizens. Rather, it "'directs the state" to provide certainamenities to its people, a mdndate that is handed down toState governments, who obserire it with varying degrees ofsincerity. Thus, the second obstacle is the lack of politicalwill, particularly the States' illadequate commitment to actindividually on policy that has blen framed Centrally. The needfor further decentralisation of authority in health decision-making and management, which is so crucial to the implementa-tion of primary health care, rais$s the spectre of a third set ofpolitical obstacles-vested-intere$t groups, such as professionals,and bureaucratic and political elltes.

Fourth, primary health care gervices are difficult to design,organise and manage, throwing $p "organisational" obstacles.Included in this category are cert[in 'scientific' hurdles, such asinadequate knowledge ofthe cau]ses ofa particular disease orof its treatment, inapplicabilit$ of available knowledge or.technology, or'fmulti-causation,'? which requires simultaneousattacks on many fronts.

Finally, a lack of resourceF for peripheral health services.has been a serious constraint to {he implementation of previousproposals for rural health improvement. While this may bebrought about in part by the competing demands made bysophisticated (urban) medicine and iflterests vested in the"disease market," it is also a syrirptom ofthe second obstacle,the lack of political commitmgnt to solving India's healthproblems. Economic pressures, i{grained attitudes, class biases,and inadequate expression of 'l.demand', on the part of thepoor (who are most in need bf health services and are thetarget of primary health care, but lack political power) resultin health being.accorded a .loW priority by Central.and State

National Health Policy: An Introduction

-Governments. Whether the National Health Policy is imple-

mgnted will depend largely on how these major obstacles

(discussed in greater detail in Chapter 2) are overcome'

CRITICAL IssuEs

From the foregoing discussion, one can identify a series ofissues which are critical to the implementation of the National.Health Policy. These are briefly outlined below and taken up

for detailed discussion in subsequent chapters'

Planning according to Need. ,Between 'the framing of health

policy and its transaction lie planning, financing and

implementation. In the past, health planning followed a

conventional approach to assessing health needs which focused

on specific health problems and provided for target numbers ofpatients or services. The resulting vertical disease programmes

suffered from several inadequacies. They focused narrowly on

.treatment of a disease and did not address the factors under-

lying susceptibility to it, such as malnutrition, or poor hygiene

and sanitation, even though these factors were simultaneously

responsible for several major diseases. They tended to address

o"iy on" link in the causative chain of a particular disease,

and interventions were designed around 'episodic' campaigns,

rather than as concerted and coritinuous attacks at all levels'

This vertical thrust diverted energies from the development of a

horizontally-integrated health system geared to those most inneed, and able to address underlying causes of ill-health'

However, the Health Policy now calls for an approach to

health planning that is focused on the reduction of inequalities

in health. Accordingly, to assist in translating the Policy intopractice, Chapter 3 examines it from a 'biomedical' point ofview, discussing health needs in terms of redressing the three

D's-death, disease and disability-and also, importantly' interms of eliminating differentials in the health of differentpopulation subgroups in the country'

Organisation for [Jniversalisatioz. No consideration of thepolitics of health or of the biological basis of health policy is

complete without an examination of the society involved, and

of social norms and behaviour which govern health and healthcare d€livery (cf. Banerji, 1973, 1974; Zntbrigg,19.84). To date,

1'l

12 Implementing Health Policy

the health sector has concentrated on the production of man-power and construction of physica.]l facilities with little attentionto this sccial context. Although a sizeable health infrastructureis now available, "under-utilisatign" and .,limited coveraqe,'are simullaneously serio us problems. To overcome th-eseproblems and be effective in rgducing differentials, healthservices must be "accessible" {nd .,acceptable" to people.Among organisational requiremehts for the universalisationof health services, the Health pdlicy Statement calls for the"reorientation" of health manpower. This will entail impartingknowledge of the socio-cultural dnd economic dimensions ofhealth to personnel, anC enhanQing their communication atrdmanagement skills. Its prime purpise is the creation of a broadinterface with "the people.', Ctlapter 4 focuses on the keyelements of this interface-wbmen-and discusses theappropriate unit of health-care delivery-the household.

Demand Creation. Discussions gf the health sector tend toconcentrate on supply-side issues, to the neglect of demand-side considerations. However, the underutilisation of healthservices points also to the possibility that a lack of .,demand',

for primary health care couldbe a major factor constraining itsspread. The Health Policy calls foi ..community participation"as a means of creating demand. However, far from beinghomogeneous, communities are stdatified and divided and maynot have the commonality of intefest required to act in concertfor health improvement. Within thbm, the people with socialstanding and economic power gpnerally take or influencedecisions as they have greater 4ccess to political srrucrurcsoutside the village. Thus, social inequalities affecting heallh arereinforced. These and other.factdrs are brought to bear on anassessment ofl the policy's advocacj, of .,comriunity participa-lion" in Chapter 5.

" Priyatisation." The Health pollcy Statement makes frequentreference to ttre need to involve thq private medical world (bothindividual practitioners and volunt{rry agencies) closely with thegovernment health effort. On the s.Upply side, the assistance ofthe non-governmental sector is spught in the setting up ofspeciality facilities and in the extehsion ofprimary health care.However, the Policy does not specify how the government willcoordinate with the private sectori. For effective collaboration;

National Health Policy: An Intro&tction 13

the separate responsibilities of private individuals, agencies, andthe public system will need to be specified in a way thatduplication of effort is avoided, friction minimised, and achieve-ment enhanced. The goal of "health for all" can be a "collectiveresponsibility" only if the actions of each partner are clearlydefined and well-coordinated.

Other constraints face the prospect ofprivate voluntary orga-nisations being involved in the creation of demand. For exam-ple, in many instances these organisations remain "outside" tbevillage social structures that are so important to health'behaviour.' They are usually (out of necessity) aligned withvillage elites, and often themselves face difficulties reaching themost needy. As Chapter 6 discusses, these are among manyreasons why private health programmes cannot be considered"models" for the govemment primary health effort, althoughsome lessons learned by them could be useful.

Simple Technology. The legacy of planned government healthservices which has emphasised the building of a hierarchical,cure-oriented infrastructure has engendered demand for.high-technology' medicine. Even among the poor and 'remote' thereis a predilection for pills, injections, X-rays and surgicaloperations and contempt for prophylactic measures, preventiveor dietary advice (see, for example, Djurfeldt and Lindberg,re76).

However, for primary health care, besides the distributionof infrastructure and manpower, simple health technologiesmust be widely disseminated. As simple technologies areavailable to address tbe major health problems, technology isnot generally viewed as a limiting factor. However, its potentialis largely determined by social and organisational requirements.These contexts are discussed in Chapter 7.

Intersectoral Action. Besid,es the transformation of socialstructures, the 'political economy' of health focuses attention onthe need to improve living conditions. The country's currenthealth situation is clearly related to inequality, poverty, hunger,unemployment, illiteracy, lack of sanitation, and the low stalusof women in society. Poverty denies people access to health'knowledge,' and to food, water, sanitation, and other goodsthat are the means to maintain health.

t4

Thus, in addition to or

Imp le menting Healt h Pol icy

ng itself for health servicedelivery, the health sector must responsible for stimulatingthose departments whose efforts related to the prevention ofdisease and to health improve The Health Policy flrmlyesnouses the need for "intersectoorganisational framework for su

developed, and specific activitieextra-health sectors need tobe given to the nutrition and supply sectors whichhave the most profound effects o health, as illustrated by thecase of Kerala, presented in Cha R

th for all" is a radicallyare grossly maldistributed

Resource Allocation. While "hegalitarian concept, health reso

in the country between rural and areas and on a regionalbasis. The remotest, poorest of rural India-with. the

most deprived. Chapter 9greatest health needs-are relatidiscusses the major gap between wand other differentials in healthfinancial resources to and wi

coordination." However, anh coordination needs to be

related to health goals indelineated. Priority must

is needed to reduce theseand present allocations ofthe health sector. Resource

allocations to primary health careand 'rate' at which the Health

ill determine the extent tolicy's proposed targets are

met. As they are primarily a functi n of 'political will,' the intimate relationship between the po , biological, social, and€conomic contexts of Healththe concluding chapter viewsan integral fashion.

CHAPTER 2

TOWARDS IMPLEMENTATIONOF THE HEALTH POLICY

As the major thrust of the National Health Policy is on

"primary health care," it would be well to examine the content

of this mandate, and the political obstacles to its achievement.

Primary health care is both a "philosophy" and a "strategy"(Cole-King, I 981). Its philosophical merit is derived from the

principles it espouses, while its strategy consists of broad-based

activities within and beyond the health sector aimed at the

improvement of health.The philosophy of primary health care holds that health is

a basic human right . Thus, the main objective of a policy

espousing primary health care would be to provide as-yet-

unreached groups with at least basic health services throughredistribution of financial resources, manpower and materials.

Primary health care also aims to improve the basis of health,

implying the distribution of tesources to maintain health' such

as food, water, income and so on. This distributive aspect

makes the provision of primary health care a profoundlypolitical issue. The requirement for 'political will' has be en

explicitly stated (Djukanovic and Mach, 197 5; WHO-UNICEF,I9 78). Furthermore, primary health care incorporatescertain 'democratic' principles, such as "community involve-ment," individual and collective responsibility for heaith, and

'kelf-reliance" (Seeall, 1983a). These imply that the implement'ation of Health Policy cannot be left entirely to the machina-

tions of the state to formulate programmes (see Jefrery,

t6 Implementing Heal th Policy

The Strategy of Primary H Care, The context in which

1978). While the level of politic4l commitment will be reflectedin resource allocations, in the bnactment and enforcement ofnecessary legislation, and so on, it will mostly be judged by theinstitution of mechanisms to shafe .health power.'

*prevention and control qf local endemic diseases,including immunisation against tfie major infectious diseases;

-provision of clean water supply and sanitation facilities,along with hygiene education;

-maternal and child health services, including antenatalcare of mothers, trained birth attendance, and family planning(when desired):

ment in primary health care delivdry are sought in the beliefthathealth is related to people's behar,liour more than to any otherfactor. Community i nvolvement js desired in the assessment ofneed and in the design and g of services. People are alsoto be involved in "mass actions,,' such as the improvement ofwater supplies and drainage. , these tasks cannot bedone by the community alo assistance of appropriatgservice agencies is required. In this *.y, g"".i"r,i* i,i"i;i

Towards Implementation of Heatth Poticy lV

services are expected to interdigitate with the commuuity's rolein implementing primary health care.

While a fundamental contradiction may be perccivedbetween state provision of services and the concept of "self-reliance," the issue is resolved by clarifying where one ends andthe other begins. The role of the health system is to assist inorganising "communities" to change the conditions thatperpetuate ill-health. A balance between government healthservices and community responsibility is the essence ofdecentralisation in health care, A point that bears emphasis isthat this balance and other aspects of primary health care willdiffer according to the specific characteristics-econo my,society, history-of a given setting.

Some Denials. An understanding of primary health care canbe further strengthened by reviewing what it is rrot intended tobe. First, it is not a vertical programme, aimed at eradicatinga disease or having a separate organisational structure. Itssuccess will depend on the concerted delivery of its vitalcomponents and integration within and beyond.the health Caresystem. Second, it is not "primitive" health care, despite itsidentification with poor countries and with rhe poor within bcountry. Although, it is antonymous with "urban," "rich,""sophisticated," "medical" care, it is basic health care forboth rich and poor. Its preventive and promotive tasks areapplicable equally to all sections of the population. Onlybecause the rich already have the means-better nutrition,water supply and sanitation, and health "knowledge"-toprotect themselves from the health problems that commonlyaffect the poor is the effort directed mainly at the poor.Primary health care must not be perceived as a "welfareprogramme"-but rather as a means to development of thenation as a whole.

Third, primary health care is not only aprogramme to be run by unskilled people. The

para-medicaleffective per-

formance of health tasks by village-level workers rests oD lheiassumption that professional assistance will be readily availableat referral poirtts. Hence, the medical profession has animpoitant .o1s 1s.. play in the organisation and delivery ofprimary health services and in functionally integrat.ing them'with . h'igher-level healih servioes. iurthermore, rbspbnsibility

18 [mp lemeyting Heal t h P olicy

extends beyond the medical profession to professionals in othersectors, so that the basic requireSents for health are met.

Fourth, while primary heflth care may be "low-cost"relative to the price of sophistic4ted medicine, it is not rntendedto be "cheap" health care fop the poor. While governments

may subscribe to primary health care because it is consid-

ered a "least cost" solution to widespread ill-health, theprovision of universal health services will require sizeable

financial allocations. Although primary health care can make

efficient use of available resdurces as various "adaptive"strategies, such as the use of briefly-trained auxiliaries and

"appropriate" technologies, arb an integral part of it, itsimplementation will most likely pequire increased budgets lorthe health sector.

Porr cll Ossreclns ro FRIMARY Hnlrrn Cene

India's assignation of the Wqrld Health Assembly's "Healthfor all" Declaration at Alma Ata (WHO-UNICEF' 1978), and

its subsequent adoption of prirfrary health care through thc

framing of the National Heallth Policy must be considered

evidence of intent. However, to convert this aim into deed,

serious consideration will first hpve to be given to surmounting

existing political constraints.

Health is Not a Legal RigbtContrary to the philosophy bf primary health care, health

is not a basic human right under the Indian Constitution.Instead, the subject is dealt wlth in the Directive Principles ofState Policy, the'conscience' of lthe Constitution (Central LawAgency, 1981). In Article 39, the State is directed to make

policy to ensure health, while Anticle 47 provides that improve-

ment of nutrition and health shquld be among the "primary. duties" of the State. The State is obliged tg implement the

Directive Principles through legislated policies. The framing ofthe National Health Policy is a step toward the discharge ofthis responsibility. The Consltitution fqrther provides (in

Article 3lC) that no legislative fieasure that conflicts lvith a

Directive Principle can be allowpd and that any.law enacted by

the State towards securing al Principlc (or giving effect to

Towards Implementation of Health Policy t9

related policy) will be valid as long as it does not conflict witha Fundamental Right.

This positive requirement and provision has received lessattention from health policy analysts than the negative condi-tion, in Article 37, that the Directive Principles, unlike theFundamental Rights, cannot be enforced by legal process. Thefact that there is no recourse to judicial process if policies arenot legislated or implemented allows the government to delaylegislation and implementation. Although there has been agood deal of social legislation enacted in accordance withseveral Directive Principles, little of it has been aimed atproviding health and nutrition to all Indian citizens. To furtherthe implementation of National Health policy, however, theDirective Principles could provide a guide to action throughlegislation, provided the various 'actors'on the national sceneown up to their individual responsibilities.

.Responsibility for Health is DifruseThe Seventh Schedule of the Constitution identifies

separatcly the subjects on which the Central and State govern-ments are empowered to make laws. Matters pertaining tohealth are variously listed under ',Union," .,State,' and"Concurrent" categories.* This segregation of responsibilityin health matters could engender confusion (or ditrusion) inthe process of health pclicy-making, legislation asd

*The Union list includes: Centrally-financed scientific and technicalinstitutions declared by Parliament to be institutions of nationalimportance; standards in institutions of higher education or researchand scientific and technical institutions; port quarantins and hospitals,and inter-state quarantine; and excise duties on medical preparations.In the State list are: public health and sanitation; hospitals anddispensaries; water supplies and drainage; relief of the disabled,production of intoxicating liquors and excise duties on alcohol. Finally,the Concurrent list deals with economic and social planning (includingh€alth planning, development and expansion); education, includingtechnical and medical education and universities (subject to provisionsunder the Union list); medical professions; prevention of the extensionfrom one State to another of iofectious or contagious diseases or pests;mental health; food adulteration; drugs and poisons; welfare of labour,includiog maternity benefits; population control and family planning;and vital statistics, including registration of births and deaths.

20

implementation ofand concensus has been achi

the recommendations of the B

"Model Public Health Act"

the Act was never Passedobjecled to the large exPendi

Iuplementing Health PolicY

certain degree of cohesionin this respect through the

A

1952 under a Constitutionall provision and the Central

Family Planning Council, established in 1965. These

Councils, composed of the lrealth ministers of the State

and Central governments, recommend policy directions

relating to all aspects of {realth and propose legislative

measures for medical and pub[ic health activities. The Centra]

Council of Health is empowere$ to coordinate and to establish

organisations to promote cooperation between Central and

State health departments. It rbcommends the distribution ofgrants-in-aid to States for health purposes. The annual meetings

of the Council since its incdption have covered almost every

significant topic in the field of health, specifying the pattern

of health services to be adopfed throughout the country and

reviewing progress towards thelr establishment' Since 1974, thetwo Councils have been mebting together and discussions

have also included the Family Planning Programme.

mechanism of the Central Corlncil of Health, established in

concerned with drug vital events registration, anil

municipal regulation of public health existed prior to Indepen-

dence (Goel, 1981). After 194|, legislation has been enacted toregulate food and drug qualiti and the medical professions,

and to establish national institutes and associations-

Other significant legislation includes the Maternity Benelit

Act (1961) and the Medical fermination of Pregnancy Act(1e71).

An early ( I953) proposal the Central Councils, followingore Committee, was to enact a

which would have subjected the

orsanisation and administra of public health to enforce-

ment under an Act of Par nt (Rath, 1978). UnfortunatelY,some State governments

which would be required toimplement the Provisions o the Act, and also, apparently,

because the task of conso relevant Central and State

Toioards Implementation of Health Policy 2l

health infr.astructures, mitigating the regional imbalances whichare so striking today and which are a major concern oftheNational Health Policy. As it is, the government's failure toenact this useful legislation clearly indicates the lack of politicalcommitment to public health in the past-which could yet be

rectified.The inclusion of a number of subjects in the "Concurrent

List" provides scope for the Central Government to operate inthe field of health services, especially for health planning andresearch, and in the regulation of standards aflecting profes-

sional training and food and dlugs. Legirlative action was

taken in the last of these areas by the enactment of the

Prevention of Food Adulteration Act (1954) and various

subsequent amendments, and in the area of professional

training by the passing of the Indian Medical Council Act(1956), which provides for the establishment of a council to

regulate standards for medical qualification. The Central

Governmart has also played a pivotal role in the areas ofCommunicable Diseases and Family Planning by setting upCentral organisations to deal with a number of importanthealth problems. Since the early 1950s, national programmes

to control malaria (1953), filaria (1955), smallpox (1962),

cholera (MYP), leprosy (I FYP), tuberculosis (I FYP)'trachoma (1963), and population growth (III FYP) have been

launched.Unfortunately, no similar initiatives have bebn undertaken

in the vital areas of Maternal and Child Health, Nutrition,Water Supply and Sanitation, or Rural Health Services.Legislation in these key sectors, crucial for the implementationof National Health Policy, is left entirely to the States. TheCentral Government can only advise-not enforce. The vastdivergence between States has reduced the Central Girvern-ment's role to establishing 'least common dominatars.'Consequently, although uniform national health services havebeen sought since the Bhore Committec Report (which alsoadvocated a more active role for the Central Government), thepatterns adopted by different States, and the extent of theirimplementation vary widely, Although , Maternal and ChildHealth Services arc linked to Family Planning, a, Centralsubject, and Water, Supply andS anitation came under ' , a

22 Implementing Health Policy

National Programme up to the Fourth Plan period,* the StateGovernments draw up priorities; allocate funds, and implementschemes in these areas. For the future, comprehensive nationallegislation on these important s1bjects is a must and additionallaws in areas such as medica[ education and service, privatemedical practice and medical industry are required.

Centre-State Interactions. HSwever, even when the CentralGovernment lays down policy t0 be followed by the States, itmust leave budgeting and implementation to the StateHealth departments. This has engendered the vastly differinghealth conditions which are clearly demonstrated by the healthindices of different States (ChApter 3). Generally, states withgreater health needs have lower per capita health expenditures(Chapter 9). The system of Central financial aid to the States isintended to ameliorate such difibrences. In the health sector, theCentral Government assists tl;e States in a number of ways.Certain health programmes meriit 100 per cent aid, while othersreceive partial grants-in-aid or loans. Some schemes receive freematerial aid-generally that provided by foreign assistance. Forexample, over the years, DDT and malathion, vehicles andother equipment have been rdceived from bilateral or multi-lateral agencies and provided to the States for malaria control.The Central Government meets 100 per cent ofthe non-recurringexpenditures of some national plogrammes and shares recurring€xpenditure on a sliding scalq. Grants-in-aid are frequentlygiven for training institutions; and a number of 100 per centCentrally-funded institutions have been established. However,States with low allocations to health also perhaps have lower"commitment" to the ideals of $ocial justice and equity, whichmay be reinforced by "doles" frbm the Centre (or, through theCentre, from international a$encies). This issue of commit-ment is linked to other 'political obstacles' which are examinedbelow.

Vested fnterestsAmong other obstacles to the implementation of National

*It should be notecl also that Watef Supply and Sanitation were dealt. with by the Union Ministry of Hdalth until 1913, but transferred to, the Miniptry of Wor.ks and Houbin$ in that year.

Towards Implementation of Health Policy 23

Health Policy are vested-interest groups who are antagonistic

or at best apethetic to the universalisation of health care, such

as medical professionals and "elites." "Doctors and politics"have been cited as major deterrents to the provision of primaryhealth (Werner, 1980). The health field is strongly domin-ated by professionals because a considerable proportion ofhealth-related knowledge is esoteric. Functional specialisationand high technology perpetuate the "mystification" ofhealth(lllich, 1975). Professionals lacking a "social-orientation" wieldthis'knowledge power' over those who have greatest need ofit-the poor and the illiterd.te. This is in stark contrast with the

objective of primary health care to simplify and disseminate

basic health knowledge as widely as possible. To achieve this

sharing of power the legitimate authority of those with medical

knowledge must be freed of power derived from "mystifi-cation." To achieve the "reorientation" of medical personnel

towards selfless service goals, which is called for by the HealthPolicy, there is a need to chalk out clearly where professional

know-how is required and where simpler systems of knowledge

will suffice.As described earlier, changes in the "orientations" of

physicians have been sought since the First Plan, in keeping

with the Bhore Committee's suggestions. The establishment ofPreventive and Social Medicine departments in medical colleges

was intended to tilt the balance towards socially-oriented

training and practice. The issue of doctors serving in ruralareas has received attention particularly since the Fourth Plan.However. various mechanisms instituted have had little positive

impact, and may even have diverted attention from othermanpower policies that could have benefited rural healthmore, such as the training of paraprofessionals. With the adventof the "populist model" in health manpower policies (Maru,1976a & b), commitment to changing professional orientationshas been diluted further by the belief that the poor can be

setved by basic health workers alone. Although the priinaryhealth worker is the cornerstone of the National Health Policy,the emphasis on upward linkages through a referral system is

signi6cant.Clearly, the implementation of primary health care will

require several changes to be brought about in the value-

24 | Implementing Heatth poticy

orientations of .health care delivbrers. There must be change infocus from individuals to groups within the wider physicaland social environments which arb the source of disease and ofpoor health practices. There rriust also be a change fromemphasis on diagnosis and therapf to prevention, especially ofcommunicable diseases. These cfianged orientations must beexpressed by reordering of resour<ie allocations so that personneland materials are available where they are most needed.

'Elites'who have to date benbfited most from the extanthighly-sophisticated medical ser1ices also stand in the way ofuniversal health care. While speci{lised medicine is regarded asessential for their health, it is no! considered feasible .,for all..',On the other hand, those who haVe access to it, will not nowaccept any 'less-developed' servides. They include the rich whohave adequate income to purctechnology, and people who have

a high level of health

care, lsuch as governmentplaoners and bureaucrats

yees. Thus, policy-makers,

lves may be reluctant toactually implement the National Health policy! Significantly,the Health Policy has not attempted to eliminate thisduality. Rather, it continues to qupport this double-standardof health care: specialist facilities for the urban elite and basichealth care for.the rural poor.

The vested. interests of Drof nals and elites are insePar'at the "familiar" critique ofable. Jeffery (1980) has suggested

the health system, which blames ing inequalities in accessto health care on the inappropersonnel and their reluctance to

ate training of medicalin rural areas, misses the

essential point that doctors' wil ess and ability to do so isdetermined by the relationshipsaspects of Indian politics and

sets of relationships-through fordignin the case of the former, and by

'insured' access to health

aid and the l'brain drain"the control of institutions

between medicine and other. He has argued that

proposals to reform the health livery system will be vitiatedby continued "medical lency." Post-IndePendence

to international-Indian and"dependency theory" relates bothcentre-periphery (urban-rural) rebban, 1982). Urban, technological

ships (see also Ramasu'biases have persisted in both

and suppression of local autonomy in the case of the latter.

Towards Implementation of Health Policy 25

Despite significant differences in the overall health situations

of developed and developing economies, health sector policies

and practices in the latter countries mimic those in the

industrialised world (see Golladay, 1980)' for example, by

the adoption of "medical technology from devcloped countries(Chatterjee, l9B5). Such teohnologies have limited and most

unevenly-distributed benefits, and impose "a sevete stiain on

the health service resources of even the most prosperous

nation" (Piachaud, 1979).

The'brain drain'in medical personnel from the developingto the developed world has the multiple effects of loss of invest'ment in medical education (which becomes purposively orientedtowards "foreign recognition" and, hence, emigration), and ofcontinuing 'duality' in the poor countries' health systems (Gish'

1976; Jeffery, 1979). The return of (even a few) highly-skilledprofessionals, and 'joint ventures' with non-resident doctors add

to prevailing inequalities in health care' These doctors formpart of the powerful lobby controlling allocations within the

health sector. Trained in super'sophisticated medicine' they

accord low priority to public health work. ,

In the context of these and other strong international forces

in the health sector, such as foreign-aided health programmes

and transnational drug manufacturers, it is legitimate to ask

whether significant change can be wrought in the healthsituation in.the absence of changes is dependency relationships(Jeffery, 1982; see also Banerji, 1983a, b). Without doubt'implementation of the National Health Policy will requirechanges in attitudes and structures entailing strong political'commitment. Yet, "few things could be further from the truth(than that) governments are universally committed to improving '

tlre.health of their populations and that the health planner

operates simply as a technical expert within such a context of'commitment" (England, 1978). In the past, government haS'

allocated resources di sproportionately to sophisticated urbanfacilities becaus.e political support has emanated from the users

and. managers of such facilities ("elites," urban workers and the

me{ical establishment). Although tho subject of rural healthhas.lnot been used as a popular political platform, it is'conceivable ihat the provision of universal health care and

26

attentionhare the

Implementing Heahh policy

to diseases that affect lthe majority of the populationpotential to enlist malss political support.

Duality in Health System OrganisationA tendency to believe that significant improvements in

health can only be brought about by"radical, political and socio-economic changes has meant that policy proposals focus onfunctional rather than structudal modifications of the healtb,system, such as .'reorientatibn," and ..reorganisation,,'

"decentialisation" and ..integr[tion." The policv invokesreorganisation of the existing sy$tem as many facilities requiredfor primary health service deiivery already exist, includingvillage-level workers. Howeverl the rural health system isknown to be poor in content, coverage and effectiveness andthus requires considerable strengthening besides reorganisation.As Banerji (1983b) has noted; the National Health policyStatement does not even specify [row the government proposesto bring about changes in the s)!stem. Although a Statement ofPolicy is admittedly not a plan, when major changes areenvisioned, a sound strategy for their implementation wouldseem to be essential. In the absence otthis, it may be impossibleto get implementing agencies td deviate from past practices.Furthermore, as the policy Stdtement avers, tle planning ofinlrastructure and manpower for health are intimaiely tinked.Thus, the Health Policy remains incomplete without a blueprintfor health manpower.

Indeed, the only structural innovation suggested by thePolicy Statement, is the introdr{ction of epideiiotogical field-stations. close to the primary levdl. This suggests happily thatan epidemiological approach nlay be taken to thc pianning ofhealth care in the future. HoWever, such an approach willrequire flexibility at the local lbvel in order to be effective, aswell as a high degree of trainin$ and organisation. Consider_able planning and administratiVe skill and decision_makingpower will need to be vested i4 the proposed epidemiologicaiunits. In this way, even ,.decentrilisation,,

entails a major rolefor the scientific medical estaUdnmcniaJ;ll ;;'il;;be equ-ivalent to leaving ..thd people's health in people,shands."

Towards Implene ation of Health Policy 27

Such 'duality' is also germane to the issue of technology forprimary health care, While the development of such technology

involves the research infrastructure, the capacity to adapt and

apply it rests with the organisational structures delivering

health care, in particular, the village base. The development ofsuch a complex delivery system, needing an effective interface

with people as well as appropriate technical, planning, admini'strative and managerial skills at all levels, hes eluded health

planners in the Past.Resources are Scarce,In fact, a major impediment to the

development of effective rural health care has been lowresource allocations. Plan allocations to health have been 2-3

per cent of total outlays. Non-plan funds, rvhich generally

account for about two'thirds of annual health expenditures, are

similarly only a few per bent of the total budget (see Chapter 9).

These figures contrast with the Bhore Committee recommen-

dation that 15 per cent of the government budget go toward

health services (GOI, 1946), and the more recent tecommenda-

tion by the Ramalingaswami Committee of 8 per cent (ICSSR-

rcMR, l9B1).As "health is a state subject," the bulk of funds for health

programmes are allocated by the States. For example, in the

Sixth Plan, Central funds accounted for less than one-third ofthe total outlay to the health sector (GOI, 1980a)' The Centre

contributed only one-fourth of the outlay for rural health

under the Minimum Needs Programme, and this contributionwas earmarked specifically for two Centrally-sponsored

schemes, the Community Health]Volunteers' (Health Guides')

Scheme and the Reorientation of Medical Education (ROME)

Scheme. Given frequent shortfalls in disbursements on the part

of State Governments-arid existing imbalances between States-the issue of Central or State funding for primary health care

is an important one. Ultimately, where does the responsibilityfor financing the implementation of the National Health Policy

lie?Besides government funding, there is the possibility-

considered in some detail by the Mudaliar Committee (GOI'196l) and repeated in the current National Policy-of raisingrevenues from "the people." Private expenditure on healthcare is substantial; but to tap this with 'Robin Hood' intentions

28

requires considerable administrati

Imp lementi ng Healt h- p ol i cv

-,1$,rwo v.,r.orusraulc aomlnlstraltlve and managerial .skill, asthe sxperience of voluntary ofganisatioDs has shown (seeChapter 6). Even thoush th

'"^r ,:..,, _. . ey ar$ close to the people, they havehad little success in raising fina]ncer. c""r"I*.["i#il;

what villagers can provide (especfally tt " p""."ri *no- u." _or,in need of services) most v0luntary 'health

organisationscontinue to depend to a large e)dtent on funds raised ersewhere.Can government health services frope to Ao ott "r*lr.f

-^^.y:1h:t the chan_nel is piivate or public, the ;rru" of n"utttsector aid is mooted. Currently, aSout ien per .roiof?" gou"ro_

T,:"1-t,h*l.hludget is derivedfdom fo.rigo gruoi, uoO tounr.yllle l'e?tth has enjoyed a low Sriority ii "iA ""g"ti"tions in

]h.. nas1, interest among foreign $overnm"ot, lo ,u"pporting thissector has been increasing. As increasea uuo.uiiii. to tt"health sector are called for] will tge Government seek iore rio_internatioral _agencies?

This is no[ unlikely ir -, ujOJto oon",::t:.:::^i1-T."r* .(and ramillr plannine), the--compeungdemaads for internal resources wfrich ,.t"gui" h."lth ;;;"i;;priority. "Commitment" and .|sustainudiii*;; 11-o' becomemajor issues.

--,1r_,t::r::r".al allocations of health resources have posed a

I lj::, l- ol:- i n the past. s"phffi;;;;;;;;;, ;;,":facilities will continui to a"ru'[J u--i;.;;;iT;i;;ili,lu:g;^y:: is left over.for pr[mary r."iir,

"u."n'ly u. u.rvIittle unless lhe manner in w::1.:,::"1";""FH;il",.:lTi.iT::,fi #',#filTi";It U:u_*-" needed for primary he4lth care, in particular, and forl:: b:atth sysrem ar large. Health may be rr.o u, u productiveinvestment ratherthan a,.li"i. arJm

-ii,n"?i.uy,,or,n,,expenditure compare favourably lwith the immediate and long-term economic 'costs' of ill-healif to the nation.

CHAPTER 3

THE MALDISTRIBUTION OFHEALTH

Health policy is aimed against the 'three d's,' death, disease

and disability. Its assessment must therefore start from an

examination of the dimensions of the country's ill-health' itsdistributional characteristics, and its underlying causes. This

can help to pin-point the priority areas for action in the

sphere of health planning and programmes and the targets tbatcan be set for health imProvement.

TnE PRoBLEMS

Measurerr.ent of llealthThe reduction of high levels of mortality (death), morbi-

dity (disease) and disability (the residual effects of disease) isthe prime purpose of health policy. 'fhe WHO has recom-mended that four mortality indices be used to measure the

level of health of a country: the crude death rate, infantmortality rate, life expectation at birth, and proportionatcmortality over 50 years of age (WHO, 1978c). While the crudedeath rate measures mortality across a population as a whole,

the infant mortality rate points to 'untimely' deaths. Health,nutrition and sanitation conditions are reflected most vividly inthe magnitude of deaths among infants and young children'The availability and utilisation of child health services are

.particularly germane to this iridex. The infant mortality rate

?nImp lemewing H eal th pol i cy

can be broken down into neonatal and postneonatal deathrates which serve as indicatbrs of the luality of prenatal.intranatal care and nutrition-environmental l.utin, rerp."tiu"ly.High

-infant and young child mortality couriOe.ady reducesboth life expectation at birth dnd the proportionate mortality

over 50 years of age' so that [mprovement of these latterindices is related to declines iE early mortality. However,these indices also take into account deaths at other ages.

Mortality statistics are usua y collected continuously and- can therefore also indicate trends over time, which are usefulto evaluate the effectiveness ofhealth policy. Changes broughtabout by health programmes, dpvelopmeni or oiher factorscan be measured. Furthermore, mortality statistics can bereadily related to age, sexJ socip-economic status, location, orother characteristics of a population, and, dffirentiats betweengroups can be demonstrated. When mortality data are so dis_aggregated, they can be used tq plan and design appropriatehealth interventions. For example, geographical

-clisaggregatron

enables the selection of priority areas for health programmeswhose measures can then be related to local healthconditions.

- Often mortality differentials al]so suggest the factors that maydetermine mortality. Such deterrfrinuot, ur" usuaiy social andenvironmental. Epidemiological studies done in irorp.", o,retrospect can test the association of mortality wiith variousfactors, such as those iu the eniironment, suggesiing under_lying c6nrlilisns that may need 1o b" ,.-ou"j-o. rectified inorder to improve health.

Knowledge of ..causes of de6th,, is jmportant to specifynecessary health interventions. ..Causes,, are biological innature and, although the data afe notoriously deficient, causeof death information can delineafe the urgenry oi a particularproblem.

In sum, an understanding of the dimensions and course,differentials, determinants and causes of mortalityis necessaryto formulate or assess appropriate health policy, anJuttimatelyto estimate administrative reqqirements in public healthProgrammes,

Mortality rates are used mos{ frequently as indicators bfhealth because they are easier tci oUtain than o,hJr-or.urur6

The Maldistribution of Health 3l

such as morbidity or malnutrition rates. They are mote 'accu-rate' because of the finality of death in contrast with illness

whose enumetation can be influenced by subjective criteria.Nevertheless, health policy must address itself to illness as

well as death. Policy directed only at human survival withoutincreasing subsequent good health is short'sighted. Whilestrategies targeted at preventing deaths may improve mortalityindices, they do not necessarily improve health conditions.

Therefore, besides mortality rates' other indicators such as

morbidity rates, disability statistics, rates of malnutrition, access

to health services, and so on, are pertinent to health policy and

planning.Levels of fertility are also of concern' But it is increasingly

accepted that mortality and fertility are intimately linked and

that a lasting impact on fertility may require prior attentionto mortality. It is Dot unreasonable to assume that efforts at'death control' and 'disease control' will encompass an ability todeliver birth control services as well.

Finally, besides the reduction of death, disease and disabi-

lity, 'development'-in its human or biological sense-formsa fourth dimension of health policy, though one that is farmore difficult to measure.

Mortality TrendsAs the National Health Policy Statement does, it is cus-

tomary to cite the dramatic decline that has taken place in the

country's death rate during this century in vindication of past

health policy (Padmanabha, 1981, 1982). The year 1921 isusually regarded as the 'turning point,'as mortality was extre-

mely high before this-almost 5 per cent of the populationdying annually in the l9ll-20 decade. Since 1921, the crudedeath rate has declined progressively, reaching a level of 12.5

deaths per 1000 people in 1981. This level is about one-fourththe averago death rate of the 1911-20 decade, and one-thirdthat of l92t-30 decade. The mortality tiecline is also reflected

in the increased. life expectancy at birth-from 20.1 years in\9n-2A to 45.6 years in 196l-70, and to over 50years by

1976-77.In the period between l9l0 and the 1970s, infant mortality

declinpd from about 220 deaths per 1000 livc births per year

q,)

'to 130 per 1000 per year. Thisthan that of the overall dcapared with 68 per cent overthat have reduced mortalitychildren. The decline in thebe proceeding faster than themortality is an importanthence its reduction is vitaiillustration, one can cite Rbution to increased life editrerent age groups between 1

fant and child mortality contri

Implementing Healti eo{tcy

was a somewhat slower deilinerate-about 40 per ceDt com-60 years, suggesting that factorsive benefited adults more thanerall death rate still appeais tocline in infant mortality. Infant

ent of life expectancy andincreased expectation of life. Inl's ( l9B4) analysis of the contri-

of reduced mortality inI and 1970. Reductions in in-ted around 40 per centofthe

child mor-the poten-not being

increase in life expectancy (or 6 years), while declines in 5-14year and 15-44 .vear mortalitycent (or 2 and 4 years) to

ntributed about 14 and 27 perincrease in life expectancy,

respectively. The remainder of the increase (about 20 per cent,or 3 years) was due to reductiage. Thus, the slower declinetality compared with overall

in mortality over 45 years bff infant and youngortality means that

tial for increasing the coun s life expectancy ismet.

The decline in overall mo in the country during theregarded as rapid relativemiddle of this century is gen

to commensurate mortality d lines in now.developed coun-ed years. It is usually attribu-'tries, which took over a h

ted to the control of major ep[demic "killer" diseases such asplague, cholera, smallpox and malaria, and also, in part, roimprovements in living conditicins, including the availability offood and curative health serviceb. ffowever, the rate of morta-lity decline has allegedly slouled <iown in the recent past(Cassen, 1978; Gwatkin, 1980N Padmanabha, 1982). Ruzicka(1984) has shown that mortalily rates fell rapidly in the first20 years after Independence bul that the decline has been slowand erratic in the past 15-17 years in most States and patti-cularly in rural areas.curafly rn rural areas.

While the broad pardmeters of this trend may be accepted,the details are somewbat confu$ing. If data from the RegistrarGeneral's Office are used to eiamine the trend in life expec-tancy at birth, the annual gainl in the 195l-60 decade appearsto be 0.94 years for males, . an[]'0.89 years for ,females. In

The Maldistribution of Health

Mortality Levels

JJ

contrast, during the 196l-70 decade, the annual gain in lifeexpectancy was considerably less, 0.45 and 0.41 years formales and females, respectively (UN-WHO, 1982). However,Visaria (1969) and Adlakha and Kirk (1974) have contradictedthis analysis. According to their calculations, the trends arereversed, giving annual increments in life expectancy of 0,45and 0.42 years for males and females, respectively, between1951-60, and 0.87 and 0.75 years between 196I-70. In corro-boration with the latter authors, Ambannavar (1975) had esti-mated mortality declines of i2 and 2l per cent in the t95l-61and 1961-71 decades, respectively.

Whatever be the direction, clearly there have been signifi-cant changes in the trends of mortality decline in the countryin the recent past. These changes in trends suggest that causalfactors need to be identified which explain mortality declinesand can provide clues for formulating policy to achieve furtherimprovements. If life expectancy increased more rapidly inthe 1960s (rather than the 1950s), as Visaria and others haveconcluded, it is likely that public health programmes anddisease control measures had a major impact on mortality.

Although the conflicting claims make it difficult to establishconclusively whether mortality declines accelerated or decele_rated between the 1950s and the 1960s, there is little doubtthat.the 1970s have witnessed a marked slowing down of mort-ality decline in Iindia. Although life expectanJy values for thel97l-80 decades have not yet been computed from lggl censusdata, available estimates show a lower annual, gain in life ex_pectation during the 1970s-about O..3f years'}or Uott ,.*.r,(Ruzicka, 1984). Even though a slowing in the rate of morta-lity. decline can be expected at lower levels of mortality, thisindisputabld deceleration in the 1970s is of great concernbecause of the high level at which mortality pirsists in thecountry.

India's crude {eath rate is almost twice that of any devel_oped country andrthus, in a global sense, is far from satis-3".t"r{. Accordinp to a world-wide srudy-(UN-WHO, l9S2),India fell among high mortality countries iecause its life expect-ancy at birth was below 50 years of age betwee n lgTO-72, It

34 Imp lementing Health policy

Besides global points of , India's high aggregatemortality rate can be contrasted as well with what has beenachieved in certain resions the country. By 1983, areassuch as Kerala, Goa, N Manipur, Tripura, Jammuand Kashrnir, Haryana and ' e union territories of Delhi,

the Andaman and Nicobardeath rates to below 9 per

Chandigarh, Pondicherry andIslands had brought down th

ranked below other developing countries such as the philip-pinis, Thailand, Burma, Malay$ia, Iran and Turkey (as well asthose well known for their low mortality such as Sri Lanka.Korea, Singapore and China). By the mid-1970s, lndia hadcrossed into the 50.60 year lifd expectancy bracket and wasclassified as a "moderately high mortality" country, along withBurma, Indonesia, Papua Ne* Guinea and others (ESCAP,1982).

The estimated life expectanc$ at birth in India for 1980-85is 52.5 year (UN-DIESA, 1984)l This level of life expectancyis about twenty years less thari that of most developed coun-tries. Although ahead of other hations in the subcontinent-Bangladesh, Nepal and Pakistari-it is still behind the develop-ing countries mentioned earlier.

1000 (CBHI, 1983) which is theNational Health Policy to bewhole by the year 2000.

In an absolute sense, a death

an independent estimate (Sun

deaths occur annually. Overrnillion-are of children in thetbird-3 million-are deaths of

Mortality DiflerentialsThe achievements ofa few

level proposed by thefor the country as a

Iarget

of 12.5 per 1000 means vastnumbers of deaths in our po tion of 758 million (which thecountry would have exctrcded 1985 according to the Regis-trar General's projections (1984 or by mid-1984 according to

a death in the country every seconds. A young child diesevery six seconds, and an infant every nine seconds in theyear! It is these alarming freq ies of death, and the condi-tions that cause them thatpolicy.

to be addressed by health

, 1984). About 9.4 millionof these deaths- around 5

0-5 year age group, and one-nfants alone. This amounts to

demonstrate that aggregate

The Maldistribution of Health

mortality rates can disguise marked differentials in mortalityin the country. Mortality differentials point to what has beenachieved in health in one area or group, but denied another.The persistence of differentials-or even their widening-overtime, despite general mortality declines, makes them important'indicators' of health. They point to inequalities not removed-or even created and perpetuated-by past and present healthpolicies. Their resolution is, therefore, of particular concern inthe formulation and implementation of health policy.

The Rural-Urban Dichotomy in death rates is well-known.Between 1970 and 1981, the rural death rate was between two-thirds and three-quarters higher than the urban rate. Forexample, in 1978, the aggregate death rate of 14.2 per 1000population consisted of a rural mortality rate of 15.3 and anurban rate of 9.4 (Table 3.1), a difference of 63 per cent-thelowest rural-urban differential in the 70s decade. Rural-urbandifferentials persist throughout the states and union territories,ranging from over 100 per cent higher in rural Rajasthan andHimachal Pradesh compared with the urban areas of thosestates, to a difference of only 25 per cent in Kerala (1981).

The rural-urban dichotomy is easily explained by betterliving conditions (including the availability of health services)in urban areas. However, what is frequently regarded as ageographical differential is, in fact, more a socio-economic oneas vast differences exist in mortality levels of different groups inboth rural and urban areas.

The Gender Diferential. Similarly, in 1978, the country-wide death rate for females (14.5) was significantly higher thanthat for males (13.8) (Table 3.1). In urban areas, males had aslightly higher death rate than females (9.6 compared with 9.1)while in rural areas, where the bulk of the population isconcentrated, the reverse was true-14.9 for males and 15.8 forfemales.*

Higher female mortality is reflected in lower female life€xpectancy at birth. An examination of time-series data on life

*At the State level, female mortality is lower than male mortality inth€ urban areas ofseven states (Andhra Pradesh, Karnataka, Kerala,Madhya Pradesh, Mabarashtra, Punjab and Tamil Nadu) but Keralais the only State where rural female Dortality is lower than male.

35

JO Implementing Heal th Policy

Tasi.r 3.1

Morfality Rates, All-India, 1978 (SRS) Showing Differencesbetween Rural and Urban Areas, Males and Females,

and 5-year Age Groups.

Age-Group Rural UrbanFersons Persons

Combined

Males Females Persons

o-4

5-9

l0-14

l5-19

20-24

25-29

30-34

35-39

4A-44

45-49

50-54

55-59

60-64

65-69

70+

s3.z

4.8

2.2

)2

3.6

4.0

4.2

5.2

7.6

9.6

15.6

24.1

38.3

53.8

108.4

zo.5

I.5

1.0

1.6

2.5

2.7

3.9

LO

9.4

14.7

21.1

34,2

106.2

44.7

z.o

t1

2.7

3.4

3.8

5.2

7.4

11.4

17.5

26.9

42.7

56.5

110.2

52.1

4.7

2.O

3.0

4.1

4.1

3.9

4.7

7.6

13.0

19.9

'a) L

47.1

106.0

48.3

4)

2.O

2.5

3.9

4.9

7.1

9.5

15.4

23.6

37 .5

51.7

108.8

Source: Office of the Registrar Genreral (1983b).

expectancy at birth reveals that females lived longer than malesup to the 1911-20 decade bult that the situation was reversedbeginning with the l92l-30 dechde, with males enjoying higherincreases in life expectancy tthan females in every succeedingdecade until the end of tbe 196ps. The gap between male andfemale life expectancy at birt$ grew from 0.3 yoars in l92l-30to 1.34 years in 1951-60, to 1.7 years in 1961-?0,.and to 2.96

The Maldistribution of Health 3'1

years in 1970-72. In was higher in some parts ofthe country.*The trend data thus show that men have benefited more fromthe mortality declines over this century than women, while thedata on female lile eKpectancy at different ages demonstratethat young females are at a particular disadvantage comparedwith their male counterparts.

The statistic of life expectation at birth is heavily weightedby mortality in infancy and early childhood (i.e. 0-4 mortality)because 15 per cent of the population is in this age group andhalf of all deaths occur before the age of5 years. The shotterlile expectation at birth of females compared with males isexplained to a large degree by much higher female mortality inthe 0-4 and 15-29 year age groups (see Table 3.1). The all.India infant mortality rates were 131 and 120, respectively, forfemales and males in 1978, with a greater disproportion in ruralareas (Office of the Registrar General, 1980). The sex

differential was generally most pronounced in rural areas ofstates exhibiting the highest infant mortality. In a study ofrural U.P, (which has the higbest infant mortality rate in thecountry), attention was drawn to the higher mortality of maleinfants until the 1960s (Simmons et al., 1979). However, in the1970s, even though almost 60 per cent of infant deaths occurredwithin the first month of life (when males are more vulnerablebiologically) the female infant mortality rate was 223 comparedwith 170 for males. The authors suggested that the status ofthe female child was declining due to changes in culturalpractices in the face of worsening smio-economic conditions-i.e. increasing poverty, Generally, in Northern India, the highervalue placed on male children is reflected in their higher

overall survival rates during infancy and early childhood.Female age-speciflc death rates exceed male death rates

up to 35 years of age in urban areas, despite the improvementsin status that one might expect to result from urbanisation. Infact, it would appear that the imbalance is greater in urban

*Life.expectancy at the ages of 5 and 15 years was similarly lower forfemales than for males, with gaps of 1.63 and l.50years beingestimated respectively in L970-72. However, at 45 ycars of age, lifoexpectancy values we:e reversed, with females living 0.6 years morethan males (197U72).

38 Implementing Eealth policy

than rural areas in thc age grbups between 5 and 19 years(Padmanabha, 1982), In urban slumso poor social and economicconditions further aggravate thb low status of females as femaledeath rates are found to bej extremely high compared withmales (Karkal, undated).

Time-series analyses show that the gap in survival betweenmales and females among tlre young has been increasing.Ruzicka (1984) has calculated ihat, while the probabiliry of amale infant dying declined by 83 per cent between l94l-50 and1,976-'77, for females it decfined only by 23 per cent. ltcurrently stands about 10 per cient higher than tbat for males,Although montality risk amdng l-5 year olds declined some-what faster for rtmales than mdles betweea 1941-50, it is stillhigher for females.

One outcotre of the bigher mortality among females hasbeen the country's adverse a{rd declining sex ratio. Until the1971-80 decade, the population sex ratio had declined at a rareof 6 females per 1000 maleg per decade during the century.While at the beginning of this centnry, the four southern Statesat least had sbx ratios favourable to women. the last censusshowed this only for Kerala (where there has also been asteady decline, a fact little kn0wn or appreciated). The all-India sex ratio of 935 females per 1000 males obtained by the1981 census may suggest a staliilisation of rhis trend, But itmay, alternatively, represent a 'data quirk' or point todeficiencies in the 1971 enumerdtion. In anv case the sex ratioremains at a markedly di Ievel.

The Age Dlferential. The death rate tends to maskvariations in morta,lity populations with different agestructures. These are reflected better in age-specific mortalityrates. Age-specific death rates based on five-year age-groupsare available and show differences at different ages. Int978,48.3

the 0 to 4 year age grouf had an overall mortality rate ofper 1000 (Table 3.1). Thi]s dropped to 4.2itthe 5.9 year

group and remained below this figure for all age groups up tothe 45-49 year age group. A rate comparable to the youngchild rate is again reached only by the 65-69 year group.Diferences between males and females and between rural andurban residents porsist through hll age groups.

The Maldistributlon of Health

Ruzicka's (1984) disaggregation of recenr mortality trendsby age groups points to the particularly disadvantageousposition ofyoung children. He calculated that the probabilityof dying between 15 and 30 years of age was reduced by almost50 per cent between 1941-50 and 1961-70 among both malesand females. A somewhat smaller improvement occurred in the

35-55 year age groups. Consistent with generally slow mortalitydeclines in the 1970s, there appears not to have been muchimprovement in adult mortality during this decade. Anexamination of mortality among younger groups shows thatthe 0-4, 5-9 and 10-14 year death rates have changed little inrural areas in recent times, although there would seem to have

been a slight but steady decline in these rates in urban areas.

The differences betw€en these age groups have not decreased.

A comparison ofdeath rates in the 0-4, 5'9 and 10'14 year age

groups for two single years in the 1970s (1972 and l'978)(Table 3.2) reveals a greater decrease in female death rates in

Tlsrn 3.2

Age Specific Death Rates (19'12 and 1978) among Children(Male/Female) in Rural/Urban Areas

39

0-4 Years 5-9 Years 10-14 Years

197 2 1978 1972 1978 1972 1978

Rural Male 58.5

Female 67.2

Persons 62.7

Urban Male 29.1

Female 35.7

P€rsons 32,2

Combined Male 53.2

Female 61.7

Persons 57,3

48.9

57.9

53.2

25.5

27 .2

26.3

44.7

52.1

48.3

5.6

6.2

5.9

2.5

2.7

2.6

5.0

5.6

5.3

).f,

4.8

1.)

1.5

1.5

2.!2.2

2.2

2.1

2.9

2.5

2.O

2.4

2.O

A.l

1.0 0.9

r.4 l. r

1.2 1.0

1.9

)6

2.2

Sources: Office of the Registrar General (1983a & b).

40 Implementing Heatth policy

both rural and urban areas, resulting in a reduction of thedifferential between males and fomales (particularly in the twoolder groups). However, there has not been aclosingof therural-urban gap in death rates in any age group, and thedifference remairls particularly ldrge in the 0_4 year age group.

The age-specific death rate fQr the 0-4 year age group rn1978 rvas more than three timeb the death rate foi the popula-tion as a whole. This high child mortality rate, coupled withthe high proportion of the population in the 0-4 year age group(15 per cent), results in the farge percentage oftotal deathsoccurring in this age group. A significantly higher per cent ofdeaths in rural areas occurs in this age group (4g.6) than in.urban areas (36.0) and more fenlales (4g.g per cent) than males(45.3 per cent) die by the age of 5 years.

While deaths of children in tlre 0-5 year age group accounrfor over halfofall deaths, infanis (0-l year olds) alone accountfor one-third. The high risk of dying during infancy does notoccur again at any age. This special vulnerability of infantsmakes their mortality rate one o[ the most sensitive indicatorsof health conditions, and trends and differentials in infantmortality are particularly instructive.

The long-term decline in infant mortality has been describedearlier. The high risk of dying during infancy declined consi-derably in the first halfofthig century, continuing for about20 years after Independence. In the past 15 or so years, declinehas been slow, and was almost degligible in the 1970s.

Actuariai reports based on the decennial censuses show thatthe aggregate infant mortality rate averaged 146 per 1000 live .

births in the 195l-61 decade irnd 129 in the 196l-71 decade.Although the computation for l gfl- l9g 1 is not yet available, therates calculated by the Sample Registration Scheme suggestthat a largely static situation Obtained throughont the 1970s.The S-year moving average ofl SRS rates up to 1979 (e.g.l97O-74, 197 2-76 and so on) pUt infant mortality consistentlyabove 129. This was the rate in ihe 196l-71 decade. The SRShas reported a somewhat lower r4te of 114 in l9g0 and lggl butthe consistency of this rate has yet to be confirmed. In anyevent, this is still a high level of infant mortality, cqmparedboth with that in developed couritries (between l0 and 20 per1000) and with Kerala's achievegents (37 per 1000 in l9S3).

The Maldistribution of Health 4l

Death rates for male and female infants separately havealso remained constant over the decade of the 1970s. thosefor females being higher (Table 3.3). Rural infantssu ccumb ata rate of about 60 more per 1000 live births than do urbaninfants-a startling diferential. While the difference betweenmale and female infant mortality in urban areas is small, thelatter may be as much as 15 per cent higher in rural areas.

Tesls 3.3

Infant Mortality Rates (1972 and 1978)

Infanl Mortalit j Rates

1978

Rural Male

Female

Persons

Urban Male

Female

Persons

t4r161

150

85

85

85

t30

142

tJo

69

7l70

Sources: Offi:e of the Registrar Gereral (1983a & b).

There is, however, some inconsistency between childmortality rates calculated from the two main sources of datawhich confounds recent trend estimates (Preston and Bhat,1984). While early rounds of the National Sample Survey(1965-66 and, 1972) seem to agree with the SRS rates aroundthose years, there is a contradiction between the 1979 Surveyof Infant and Child Morrality (Office of rhe Registrar General,1980) and the SRS rates in the l97l-81 decade. While theformer survey suggests a death rate of 39.2 between the age of0-4 and an infant mortality r?te of ll2, the SRS recorded meanrates of 49.7 and 126 respectively in the 1971-80 decade.Although a former Registrar General estimated that SRS dataare 97 per cent complete (Padmanabha, 1981), Preston andBhat (1984) suggested that the SRS may overestimate childhoodmortality. They favoured the conclusion that under-two

42 Implementing Health pol icy

mortality declined by over 3d per cent between 1961 and the

month of life and in the refnaining I I months of the firstyear. This distinction is impo t because the major causesof deaths vary in lhese twocongenital problems, birth

s. In the neonatal period,uries and tetanus are maior

killers, while in the period, infectious diseasesand malnutrition combinebelieved that deaths in the

cause much mortality. It isperiod are easier to control,

so that strategies con g on postneonatal problemscan yield large dividends in thd reduction of infant mortality.This would result in a change in the distribution of infantdeaths between the two period$ so that as infant mortalitv.declines a higher proportion bf infant deaths would occur in'the neonatal period.

In India, 55-60 per cent o infant deaths are neonataland Sweden the proportionswhile in Japan, the United

rise to 66,75 and 80 per centpointed out that in India

ly. Visaria (1985) has

occurring in the neonatalper cent of infant deaths

remains relatively constantwhether one considers ur and rural areas separately,or diferent states with theirrates, or changes over time.control of factors affecting posneonatal mortality.

Regional Variations. Therc

y differing infant mortalityThus, she concluded that the

natal mortality also benefits

also significant differencesin mortality rates in different regions of the country. Theoverall death rate in 1981 w4s as different as 6.9 per 1000populatidn in Kerala and 16.3 fer 1000 in U.p. (ORG, 1982c).In each State, rural areas have slbstantially higher death ratesthan uiban areas, For example, the rurai infant mortality rate

The Maldistribution of Heahh 43

was 85 per cent higher than the urban for the country as

a whole in 1978, and in the State of Rajasthan, the ruralIMR exceeded the urban by 132 per cent. The range ofmortality rates amoDg the States is also greater for ruralthan urban areas. For example, the average crude death ratefrom 1979 to 1981 was two and a half times higher in ruralU.P. than in rural Kerala but only 0.6 tin:es higher in urbanU.P. compared with urban Kerala.

Differences in mortality among States are also generallygreater for females than males. For example, Dyson (1979)

estimated a difference of 17 years in male life expectancybetween the State with the lowest and highest mortality rates,

and a difference of 23 years in femaie life expectancy. Suchvariations between States have persisted during the periodof mortality decline in the country as a whole.

Attempts have been made to analyse mortality rates at a

"zonal" level and provide socio-cultural explanations.Generally speaking, the central zone, comprising the Statesof Rajasthan, U.P., M.P. and Bihar, has the highest deathrates, while the northern zone (Haryana, Himachal Pradesh,Jammu and Kashmir, Punjab) and southern zone (Kerala,Karnataka, Tamil Nadu) have the lowest. The western(Maharashtra and Gujarat) and eastern zones (Orissa, WestBengal, Assam) have rates in between. However, suchanalysis is obfuscated by the wide variation in death ratesbetween States in the same zone and by the lack of a mean-ingful "explanatory hypothesis." In a later section (pp.60-61),a different grouping of states is proposed according to asimple index which suggests the priority that must be accordedto diferent states in terms of health policy and action.

Tns ClusEs ht{o Dnrnn},rrttl}lrs

Information on causes of death is uselul to determinepriority interventions in health care. Unfortunately, cause ofdeath data are grossly deficient. Despite mandatory registra-tion of births and deaths, a very small percentage ofregistered deaths are medically certified. For example, in1977, according to Padmanabha (1981), only about seven

44

per cent of registereddeath."

f

Implementing Health Policy

deaths *ere certified as to "cause of

Major DiseasesHowever, cause of death d[ta are also collected through

a retrospective lay-reporting system by primary HealthCentres. One in every fve p$ICs-a total of 9g2 cenffes_participates in this scheme, known as the ..Continuous

Survey of Causes of Death." Paramedical field workers visithouseholds in which deaths have reportedly occurred andenquire about the symptoms leading to death. Causes aretabulated by age and sex fcjr eleven major cause groups:(l) Accidents and Injuries, (2) Childbirth, (3) Fevers,(4) Digestive dlsorders, (5) Respiratory disorders, (6) Centralnervous system disorders, (7) Circutatory disorders, (g) Otherclear symptoms, (9) Causes peouliar to infancy, (10) Senility,and (11) Other.

In the five most recent yeais for which data are available(1976-1980), around 20 per cent of deaths were classified asdue to Respiratory diseases, apother ten per cent each dueto Gastroinlestinal disorders, Circulatory problems and"Fevers." 'oCauses peculiar to Jnfancy,' and deaths in Child_birth or pregnancy accounted fo4 almost l5 per cent. ,,Senility,,(i.e. old age) was recorded in l$ss than 20 per cent ofdeaths,a low percentage because of the large proportion of"premature" deaths. The remaiiring deaths were dirtribot.damong the other cause groups. The major diseases that areinvolved in the significant grbups are: tuberculosis andbronchopneumonias, diarrhoeas, anemia (or general malnutri-tion), malaria and tetanus.

There are some variations irl the distribution of deathsamong the cause groups if one looks separately at differentage groups, sexes and states. Howbver, it is impossible to discernclear patterns due to small and v4riable sample sizes in the datasets. The problem ofdeficient d4ta on causes of death is espe-cially acute when one turns to yoirnger age groups-which havethe highest death rates. Deaths in the frrst month of life areparticularly under-reported. HQwever from the Survey ofInfant and Child Mortality conducted in 1979, a few causesof death emerge as the most significant (Oftce of

The Maldistribution of Health

the Registrar General, 1981). Among infants, neonatal tetanusaccounted for the highest percentage of deaths in rural areas(15%). "Prematurity" accounted for a further 8 per cent andwas the second most important problem, with preumonia close

on its heels. Other important causes of infant deaths werediarrhoeal diseases, influenzas and malaria. ln children l-4years of age, gastrointestinal infections and bronchopneumo-nias (possibly the aftermath of measles) were the most impor-tant causes of death. Together with "fevers" they accountedfor 80 per cent of 1-4 year deaths, (in contrast with 35 percent of infant deaths). Diarrhoeas are particularly significantduring this age because it coincides with the weaning period,alrhough Puffer (1981) has noted that in absolute terms diar-rhoeal rates are much higher in infancy than in the second year

of life.The various causes of infant and child deaths point to

the factors underlying excess mortality at these ages. 'Prema-turity' is the result of inadequate nutrition and prenatalcare for mothers which predisposes their infants to low birthweights. Neonatal tetanus arises from the lack of properaseptic facilities for delivery in the absence of maternalimmunisation against tetanus. Poor obstetric care alsocauses a significant number of birth injuries. Gastro-

intestinal and respiratory infections in children are manifesta-tions of the malnutrition-infection syndrome rvhich resultsfrom poor hygiene and inadequate feeding. These underlyingfactors point to 'priority areas for action' to reduce childmortality in particular, and overall mortalily in the country.

Social and Econornic Factors Underlying MortalityDifferentials

Mortality data disaggregated by socio-economic levels arenot available at the national and state levels despite the"conventional wisdom" relating death rates to levels ofliving. lt is generally believed that "States with the highestestimated levels of mortality are also those where, by andlarge, other indicators of development and condilions of lifealso tend to be below the national average" (Ruzicka, 1984,p. 24). However, there have been some attempts to identifythe socio-economic determinants of regional variations in

45

\

46

mortality. An early study by

Implementing Health pol icy

(1981) sought to draw adistinction between social and economic factors underlyingmortality differentials. Nag co the states of Keralaand West Bengal in order tomortality diferences. West

tify factors explaining their

at least 60 per cent highergal's crude death rate isKerala's and its infant and

child mortality rates are roughly double.In the search for determiilants of this differential, Nag

found that the "standard of livlng,, did not explain Kerala,smore favourable demographic picture. Neither absolute levels'of income or food, nor more e$alitarian distribution exolainKerala's lower mortality, contrbry to an earlier hypothesis(Ratcliffe, I977), However, Kera]la's higher level of .,social,,developmenl as compared to West Bengal, notably bettersocial services such as educatifn, health and transport. andsome favourable environmental conditions were consideredby Nag to be instrumental in rdducing mortality in Kerala,Greater use of health facilitiqs (paiticularly maternal andchild health services) attributablb to Kerala's higher literacycnuo nealrh serutces) attributablb to Kerala's higher literacyrate, particularly that among women, and greater demandbeing voiced for health care whlch has been ;et in turn bymore effective supply, are other factors that may serve toexplain Kerala's better performan]ce in reducing ,ortutity.

The importance of .,female autonomy"lyebich clearlyunderlies women's access to edrfication ani health facilities_has been brought out further by Dyson and Moore (19g3).They compared north Indian states with those in the southand east and hypothesized that differences in kinshipstructures*narriage, inheritance And cooperation rules_createlower female autonomy in the nfrth, u.iiog u, constraints onwomen's ability to make decisibns that lower mortality andfertility.

However, as Jain (1984) has $ointed out, there are consid_erable differences among the st4tes in Dyson and Moore,sregional groupings, and much ovlprlap between the regions'state-level infant mortality ratesi For example, punjab andHaryana have a typically north Ibdian kinship structure butrelatively low mortality rares. On ihe other hani, Bihar belongsin the high mortality belt. along wi[h Rajasthan, U.p. and M.p.,but the authors include it amon$ the low mo ality eastern

The Maldistribution of Health 47

States. While "female autonomy" is undoubtedly an importantfactor underlying differentials in infant mortality rates, presentrates suggest a somewhat different grouping of states thanthat arrived at by Dyson and Moore. Indeed, a combinationof their 'cultural' factors, the 'social' factors proposed by Nag(1981), and economic variables must be responsible for state-level differences in mortality rates since no factor alone issufficiently explanatory, as Table 3.4 shows.

IlsrB 3.4

Infant Mortality Rates and other Characteristics of DifferentStates (1978)

IMR level Slatesand range

Range of Rangeper capita of FemaleState Literacy

Domestic (Percent)Product

(77-78prices) (Rs,)

Raxge ofCrudeBirthRate

HIGHI l8-167

Uttar Pradesh 740-1471BiharOrissaRajasthanMadhya PradeshAssamGujarat

rr.3-32.3 30.8-40.4

MEDIUM97-lr2

HimachalPradesh1043-2014 20.5-34.1 29.+33,5HaryaDaAndhra PradeshPunjabTamil Nadu

LOW39-75

Karnataka 994-1886Jammu & KashmirMaharashtraGoa, Daman & Diu

27 .8-64.5 21.0-31.8(cxcluding)J&K)

Saurce: Office of the Registrar General (1983b).

Nation-wide Survey. The nation-wideg Survcy of Inf'ant andChild Mortality (Office of the Registrar Ceneral, l98l) related

Ii

i

48 Implementing Health policy

mortality data collected in lB states to several social andeconomic parameters (beside[ age, sex and rural_urbanresidence) within each State and at the all.India level.The Survey also linked mortalitll rates with various health carefactors and collected informaticin on causes of death. Thus, thedata from this Survey may be used to explain state_leveldifferences in mortality rates and assess the relaiive contributionof different factors.

Jain (1984) has provided an analysis which groups thefactors influencing infant mortality into those operating af theindividual, household and villagF levels. Two factors includedin the Survey operate at the .,individual,,

level: trained medicalattendance at births, and the lgvel of immunisation. The firstofthese ranged from 6 per cent iq U.p. to 62 per cent in Kerala".wbile immunisation coverage vaiied from l3 per cent in Assamand Orissa to over 80 per cent in Karnataka, Tamil Nadu andGujarat. Jain found that trained medical attendance at birthshad a strong positive influence ofi infant survival. .As one wouldexpect, it was particularly effective in lowering neonatalmortality (deaths in the first moqth of life) rather than post-neonatal mortality (deaths bet.*leen 1 month and I year oflife). On the other hand, although a higber level of immunisa-tion coverage lowered mortality, the influence of this factor wasquite weak, in part because only a small percentage of childrenwere immunised at all.

The Survey found that 60 pqr cent of infant deaths in thecountry as a whole occurred ih the neonatal period, butthepercentage varied considerabty frbm state to state. The positiveeffect that trained attendance at lirths could have on thii large.proportion of infant deaths suggests that the relative contn.butions of neonatal and postnejrnatal mortality to inter-statedifferences in infant mortality sliould be assessed. Jain foundthat both components were equally important. This suggests inturn that strategies aimed at reducing neonatal and post-neonatal deaths are equally irnportant for the reduction ofinfant mortality, Decisions to em$hasise the reduction of onecomponent over the other woul{ therefore arise from consid-erations otirer than the contribution of each comDonenr rooverall itrfant mortality.

The Maldistribution of Health 49

A second group of factors studied by the Survey act atthe "household" level, such as female education, the source ofldrinking water, and the economic status of the household.Female education has a strong inverse relationship with infantmortality. For India as a whole, illiterate mothers experienced145 infant deaths per 1000 live births while those with someeducation had an infant mortality rate of 101, and those withprimary education had 71 infant deaths per 1000 live births. Inrural areas, infants of illiterate women had a mortality ratemore than double that of infants whose mothers had primaryschool education (132 and 64, respectively). The difference wasreduced in urban areas to about two-thirds higher amongilliterate women (8I) compared with primary-schooled women(49) suggesting that oiher urban lactors can partially overcome

' the detrimental effects of illiteracy on mortality.* At the Statelevel, female literacy varied from 11 per cent in Rajasthan to89 per cent in Kerala, and the infant mortality rate decreasedwith increased female education in all States (except Assam andAndhra Pradesh).

Although Jain did not include mothers' age at marriage inhis analysis of the Survey, this parameter is also known toinfluenqe inflant mortality. The mortality rates of infants born towomen who married beforel 8 years of age were two-thirds higher(in both rural and urban areas) than those of infants born towomen who married after the age of 2I years. As women's age

at marriage is related to their educational status, their effectson infant survival are interrelated.

Some other household factors also bore relationships toinfant mortality levels. Lower mortality was found in house-holds obtaining drinking water from a tap or a hand pump. Theafluence of the household (its economic level, judged by useof electricity and per capita expenditure) also affected infantmortality-the higher the economic level, the lower the mortalityrate.

'Ilowever, tbe relationship of child mortality to the educational level ofthe mother is confounded by the observation that children of motherswith higher education (matriculates and above) have a higher mortality(in both rural and urban areas) than mothers with primary cducation,though this may, onc€ again, be the result of small numbers,

50 Implementing Health Polity

The effects of "general devefupment" at the village level-the presence of a high schooll the availability of a medicalfacility, and overall trained birt$ attendance were also foundto be positive, resulting in lowpr infant mortality, particularlyneonatal mortality. While neolnatal mortality was especiallyinfluenced by trained birth attendance, postneonatal morta-lity was lowered by the availability of a medical facility.

All these factorS were also considered together in a modelby Jain. The level of generall development considerablyinfluenced the household variables, economic level and femaleliteracy. The household econo@ic level was also related tofemale literacy. Trained birth attendance was affected by threefactors : general development, the availability of a medicalfacility, and female literacy. Twd sets of factors-the householdeconomic level and trained birtbl attendance-were significant inreducing neonatal mortality. [he household economic levelinfluenced neonatal mortality diiectly (which may occur throughnutrition, for example), while rhedical facilities exerted theirinfluence on neonatal mortality lhrough both female literacy andbirth attendance. (The effect bf female education is elertedthrough trained birth attendafce). On the other hand, theavailabili.ty of medical facilities Bxerted a direct effect, indepen-dent of female literacy and household economic level, onpostneonatal mortality, presutlably through the treatment ofill ness.

When the three major fadtors, trained birth attendance,female education and econdmic level, were considered

together, an ioteresting picture emerged. The latter two factors

explained 54 per cent of the v{riation among States iri infantmortality. Economic level aff{cted mortality directly (and notthrough medical attention at birlths), but contrary to what one

would expect, had a greater bffect on neonatal than on post-

neonatal mortal ity.The availability of village-le1vel facilities such as protected

water supplies, medical centr$s, schools, and transport and

communication was found to bd associated with lower mortality,particuiarly among infants, aftA in rural areas more thanurban areas. Among the 4l $er cent of villages which had a

medica{ facility within 2 kilomefres, thc infant mortality rate

The Maldistribution of Health 51

was 117 per 1000 live births, compared with 141 in the othervillages.

From these findings, one can conclude that trained birthattendance, household economic level, and medical facilitieswere important determinants of regional variations in infantmortality-the first two particularly of neonatal mortality, and

the third of postneonatal mortality. On the other hand, theavailability of a school or of protected water supply did notsignificantly explain state-level differences in mortality. Theremaining factors were significant, but interrelated.

A factor that emerges as important for mortality reductionin both Nag's two-state comparison and Jain's analysis of thenation-wide survey is female education. The positive influenceof mother's education on infant survival has been shown else-

where. In a study of Nigerian data, Caldwell (1979) showedthat mothers' education was the most important determinant ofchild mortality even when other factors (such as fathers'education, occupation, mothers' age, etc,) were controlled.Caldwell and McDonald (1981) have suggested that mothers'

educ.ation may be more important than income and access tohealth facilities combined, Cochrane (1980) reviewed a numberof studies in different parts of the world and showed thatinfant and young child mortality invariably decreased as

mothers' education incrcased. From Bangladesh we have theinformation that mortality rates among 1-3 year olds withmothers having no education were five times higher than amongthose whose mothers had seven or more years of schooling(D'Souza and Bhuiya, 1982). This result has been generalised toother developing countries by the findings of the World FertilitySurvey (1983) although the differential may not be as pro-nounced elsewhere. Four to sevetr or eight years of schooling formothers appears to make a critical difference to child mortality.

Mosley's (1983) analysis of mortality trends and differenti-als in Kenya supports the importance of maternal education toimproved child survival, but he considered a family's economicresources also to be an important determinant. He proposedthat these factors have had a greater impact on child survivalthan the formal medical system. Nevertheless, he admitted thatcertain modern medical technologies (such as anti-malarialtreatment) have also helped to reduce mortality.

52 Implementing Health Policy

There may appear to be a qontradiction between Mosley'smicro.level study which finds family income important, andNag's macro-level comparisori of Kerala and West Bengal,which concludes that economic levels do not explain mortalitydifferentials iu these two States. This is symptomatic of thedisagreement that exists on the question of the'mortality effectof income.' A partial answer to this anomaly is provided byKrishnaji's "death rate paradoxi" (1984). In rural areas, deathrates and infant mortality ratesi in particular, are found surpri-singly to be positively correlated with per capita expenditure (i.e.death rates rise as per capita diture increases). In explan-

capita expenditure is not andiferentials in mortality (or

ation, Krishnaji asserts that

y size variations.issal of economic factors as

explanations for the between Kerala and WestBengal, there is evidence for a strong relationship betweeninfant mortality and income d on. For example, Rodgers(1979) found that life expectancy was between 5 and l0 years

lower in relatively "inegalitaribn" countries than in moreegalitarian ones. Flegg (1982) also found income distributionto be an important determinarit of infant mortality. Incomeis important for the reductiorir of child mortality because

of its effects on nutrition, housing, sanitation, clothing'and access to health care. It lrlas been suggested that women'sincomes may have a greater impact on child health thanhousehold income in general as a greater proportion of a

mother's income may be spent on cbild nutrition and care'than of family income. Howeve4, mothers who are earning may

have greater "autonomy," and so the effect on child survivalmay take place through better child care practices, includingthe use of health services. Particularly when it comes to childnutrition, mother's knowledge inay be more important thanincome per se, as suggested by Bairagi (1980) for Bangladesh.

Bairagi (1980) studied the relationship of child nutritionalstatus to several variables sudh as family income, maternalcducation and birth order. He found that income was not theonly constraint on the nutritiogral status of children, even inthe lowest income group. Materhal education had a significant

appropriate index for analfertility) because it conceals

Notwithstanding Nag's

The Malilistribution of Health 53

influence on nutritional status, as did the child's sex and birth

order, A literate mother utilised scarce resources better for her

child's welfare than did an illiterate mother with higher income'

A general conclusion arising from these findings may be that

a minimum level of income is necessary to ensure child nutritionand health but that income alone is not sumcient to guatantee

child survival.While age differentials may be thought of as largely bio-

logically determined (although culture also attacbes different

vaiues to the survival of differently-aged persons), social factors

primarily explain mortality diflerences between the sexes'

Studies in Bangladesh have elucidated some of the 'mechanisms'

involvecl. In Bangladesh, female mortality is lower than male

mortality in the neonatal period, but higher from the post-

neonatal period onward through childhood, adolescence and the

reproductive years' as in India. The greatest differences occur inthe l-4 year age group, when female mortality is found to

be 50 per cent higher than male mortality (D'Souza and Chen,

1980). This pattern emerges as a result of "sex-biased health

and nutrition'related behaviour." In a study of intrafamilialfood distribution (Chen et al., l98l), it was found that the

nutrient intake of boys in the 0-4 year age group was higher

than that of girls (even when adjusted for body weight), and

male children under 5 were brought to health centres more

frequently than female children (although females had higher

morbidity rates). These practices reflect the cultural preference

for sons, which similarly exists in most communities in India'and persists in the form of social discrimination against women

at all ages.

In summary, a variety of socio-economic factors have

important influences on mortality, and there is no simple frame-

work for their selection and analysis. While education and liter-acy, occupation and income are all highly correlated with the

standard of living, they are also related to the awareness and use

of health services, better nutritional and hygiene practices and

so on, The behaviour of individuals. families and communities

.egarding'consumption' and'investment' decisions affecting

health is influenced by development in its widest sense, and by&chnology and delivery in the health field' Both health services

and 'development' are of paramount importance to survival.

54 Implementing Health policy

This points to the need for tlealth policy to adopt mortalityreduction strategies that provlide a proper 'mix' betweendevelopment and health carei It is not a case of "either.or"between health services and so(io-economic improvements: aconcerted attack on both the inimediate and underlying causesof mortality is required. Heflth services can approach theformer, as well as a part of the fatter. However, before turningto their role, a review of thN arguments relating mortalityreduction to development would be useful,

Poucy OprroNs

Developrnent as a Means of edacing MortilityThe differentials in ty and their underlying causes

suggest that mortality rates are tially responsive to changesin economic and enviro conditions brought about bydevelopment policies, The ionship between mortality-orhealth-and development hasand has engendered muchthe relative importance ofimproved access to medical

analysed in various ways,

lic health programmes andon the one hand. and of

te. The debate has centred on

economic improvements which affect nutrition, education,housing, water supply and salitation, on the other. Someautbors consi<trer modern med[cine the chief cause of themortality declines in different parts of the world during thiscentury, while others claim that health programmes have hadonly limited impact and that edonomic development and socialchange are more important reasbns for the decline,

Between the first and fifth dqcades of this century the infantmortality rate in the U.K. wad reduced from levels over 200to 25 per 1000, or l0 per cent of the starting level, within 40years. McKeown (1976) has arglred that the decline in mortalityin Britain after the eighteentf century owed more to animproved standard of living, including nutrition, hygiene,sanitation and housing, than to ftealth services, eilher preven-tive or curative. He also extdlled the role of behaviouralchange-particularly that resullting in smaller family size. Inparticular, deaths due to resp[ratory diseases such as tuber-

The Maldistribution of Health

countries such as India), fell rapidly in the nineteenth and earlytwentieth centuries-before specific medical measures against

them were available. Sanitation led to a rapid decline in deaths

due to diarrhoeai diseases in the early twentieth century, again

before other means of "prevention" or treatment became

available. The advent of immunisation and modern medical

treatments therefore contributed less to reduced mortality from

such infectious diseases, than did the better health status

engendered by improved nutrition and lower exposure toinfection brought about by public health measures' A similar

thesis was put forward by McDermott (1978) to explain the

decline in the death rate of New York City between 1896 and

l(,31.On the other hand, looking at infant mortality declines

experienced by developing countries, Stolnitz (1965) considered

socio-economic factors of lesser importance than public healthmeasures and health facitities. . This was based in part on the

observation that such declines had occurred in countries at

different levels of development and with different rates ofeconomic growth. Amplifying this further, Preston (1975, 197 6)

found that while mortality was a function of per capita income

levels, other factors such as public health measures controllingdiseases such as malaria, smallpox and tuberculosis were also

responsible for the declines in mortality in the developing

world, and increasinglv so over the period from 1900 to 1960.

However, declines in certain other diseases such as respiratory

infections which also brought about some mortality reduction

were not due as much to specific health measures as to improve-

ments in environmental conditions (including nutrition, water

supply, housing and sanitation), associaled with economic

development.Another approach to understanding mortality and develop-

ment interrelationships is the study of dffitentials between orwithin countries. In a cross'sectional study of 120 developed

and developing countries in 1970, Preston (1980) found that

literacy was a significant factor in lowering mortality and

suggested that it may be an intermediate variable responsible

for the relationship between life expectancy and per capita

GDP. Others (e.g. Grosse, 1980) have studied the effects offactors such as nutrition and sanitation on mortality, and found

55

56

that nutritionalconsumption),important.

byhealth services, water and

per capita caloriesanitation were also

health expenditure or services these may have accounted forSimilarly, Krishnan (1975)some of the unexplained

found literacy an importanr iable for explaining interstatedifferences in mortaiity rates in I states of the country. Heexamined their overall deathhopital-, and bed-populatiurbanisation, and state per

in terms of literacy, doctor-,

and health services. Again, he found literacy to be themost significant factor, the service ratios also had some

hand, health expenditure wasexplanatory power. On the onot a particularly significant factor.

Further, Krishnan ( 1976) Nair (1910) showed that theinfant mortality rates of diff regions in Kerala were posr-

of the "catchment arbas" oftively correlated with the sihealth centres, Studying infant rates between 1971

tions largely to differences in lccess to heahh facilities in thedifferent regions, the "highlands" being areas of difrcultterrain and, thus, low access, which rcsulted in high infant

ratios, per capita incomes,pita expenditures on medical

mortality.

ir

The Maldistribution of Health 57

Despite considerable ambiguity iir these conclusions, boththe 'trend' and 'differential' approaches to studying the relation-ship of mortality and development have led to the propositionthat economic development is the means to reduce mortplity andimprove health, with the implicit-and often explicit-contentionthat resources spent on health measures are wasted resources andthat they should, instead, be channelled into "development,"from which health will automatically ensue. However, theexperience of many countries which have seen rapid growth inGNP shows that this is not necessarily the case, and thatdirect social development, rather than expeitations that benefitswill "trickle down" to the poor, must come to be consideredrnore important for the improvement of health.

This stand has been supported particularly by proponentsof athird approach to studying mortality and developmentinterrelationships. This is the examination of micro-levelhealth projects that in a short space of time brought about

significant mortality, morbidity and fertility declines in their

' target populations. This approach was used by Gwatkin' Wilcoxand Wray (1980) in their study often field projects in differentparts of the world which had specific health and nutritionobjectives. In most of the projects the 'experimental' areas

experienced more rapid mortality declines than the 'control'areas. Although direct cause and effect may be questioned, the

important role of various project components, such as village-level health workers, was established. The authors concludedthat health interventions did "make a diference." However,going on to contrast project experience with national healthand nutrition programmes, the authors pointed to the vastunrealised potential of the latter. While the ten projects reviewedwere able to reduce infant and child mortality, wider-scalehealth programmes have generally lacked this impact,

ChoicesHow do the findings of these three types of studies have a

bearing on the choice between health services and devclopmentfor the reduction of mortality and its differentials? While theprevalent view of the 1960s and 1970s was that mortalityreductions could be achieved by implementing public healthmeasures, there appears to have been a volte face on this issue

58 Impleme:nting Heatth Policy

in connection with the primarly health care movement. Forexairple, a recent UN docurfent states that "primary healthcare services can be expected td contain some of the endemiccauses pf child death, but itl is doubtful that public healthmeasures in themselves can sust[in the momentum of mortalitydecline ... in the absence df broad social and economicprogress" (UN, 1983).

By far the most pervasithis argument in both dev6lobeen that of Illich whose may be seen in a continuumwith that of McKeown (197 . The ecological view held by

physical bnd socio'economicMcKeown proposes that manenvironment is largely responsi for his health and that changesin this environment through brms in employment, housing,sanitation and so on have a far ter impact than the Provision of medical care. Add to is the view that man's 'healthbehaviour' is also a product of ciety, culture and economics,and contributes to disease. you get the Illichian maxim

responsibility for their ownis at the heart of the primary

that individuals musthealth (Illich, 1975). This maxihealth care approach and,policy in India.

While McKeown assertedcare is quite limited in this sc

tly, of current health

the effectiveness of medical

in his critique of modernof things, Illich went furtherand proposed tbat not only

is its positive contribution ndgligible, but that it has hadconsiderable negative impact on health. A perusal of contempo-rary Indian health documentsl reveals that lllich's argumentshave been freely applied to our {ontext. For example, the Rama-lingaswami Committee report (ICSSR-ICMR, lggl) pays muchattention to his view, perhaps w]ithout adequate cognisance thatthe context in which Illich spokd was primarily that of industri-alized societies where life had become 'medicalised' and muchdisease was iatrogenic. (Significbntly, Illich simultaneously alsoadvocated curbs on industrial glrowth in these countries). Whitehis analysis and his conclusion that individuals must beresponsible for their own hialt! may be relevant to the affluentsection'of our 'dual' health pconomy, its application to thepoor in a country like India

i"ut O" facile and misplaced if

influence on the proponents ofg and developed countries has

The Maldistribution of Health 59

this application suppresses the delivery of health care in favourof "anticipated development."

Such a choice could not be made if it were recognised thatthe argument that health services contribute little to healthimprovement is based largely on retrospective analysis of the

experience of developed countries, as discussed in the previous

section. Both 'project experience' and intra-country investiga'tions in today's developing world suggest tbat the role of health

care (both preventive and curative) is extremely important as

discussed above. Another case in point is that, although the

experiences of China and Cuba are used to suggest that socio-economic improvements are important for the betterment ofhealth status, in both cases access to health services was used

as a strategy to alleviate poverty, and the improvement ofnutrition also constituted a major thrust of development policies

in those countries.Historical analyses also have limited applicability because

of advances in health knowledge and technology. While there

was little recourse in health care for many of the healthproblems that existed while thc West was industrialising' the

situation is quite different in India today. India's health infra-structure is far more highly developed than that of eighteenthand nineteenth century Europe or America. Medical science

and the technology of health care are at vastly different stages

of development than they were during that historic period.Health interventions based on technology and/or "organisation"(of health services) are available which can be applied even atlow levels of socio-economic development. If made accessible

to the poor, these would improve their health status and even

their "standard of living." For example, immunisation was

not available until the 1940s and so it did not play a majorrole in bringing about changes in the health status ofdevelopedcountries, in contrast to the role of improved standards ofliving.Other examples are advances in antenatal and obstetric care

and oral rehydration therapy which can tackle major extanthealth problems. Ignoring the potential of these effectivemedical technologies and advocating only socio-economicimprovcments which could take a long time to comc about,would constitute a policy of "triage." While economic develop-ment and social change are undoubtedly essential for overall

60 Implementing Health policy

health improvement, one shoulfi not downplay the role of thehealth sector both in providifig necessary and useful health-"producing" services, as well as in inducing social change byimproving health-related practicies. There is no exclusive choicebetween health and developmenf. Both are necessary.

PARAMETERs FoR Polrcy AND Pr-ANNrNc

Target GroupsFrom the foregoing analysjis of mortality in the country it

is clear that a major objectil,e ofhealth policy should be toreduce dffirences in health cdnditions which result in thedifferentials in mortality betwden age groups, the sexes, indifferent states, and locations. fhe disaggregation of mortalitydata by these criteria permits identification of priority targetgroups and areas requiring sppcial attention in health pro-grammes. A prime target of health activities must be the 0-5year age group, and within this, infants, As children underfive constitute about 15 per cenf of the population and theirdeaths account for nearly halflof all deaths, a crucial elementin the implementation of hea[th policy is the reduction ofinfant and child mortality. Any improvement in child mortalitywould considerably reduce the gpneral death rate. Furthermore,females in this age group as vi'ell as those in the reproductiveyears require special attention.

Priority AreasHealth improvements are $articularly necessary in rural

areas throughout the country and more urgently in those ofthe States of the "Hindi belt." Using an index constructedfrom the crude death rate, the rural infant mortality rate, andthe size of the rural population, one can separate the country's17 major States into different prfority groups as follows:

First priorityt Uttar pradcsh

BiharMadhya PradeshRajasthan

West BengalAndhra PradcshTarnil NaduGujaratOrissa

$econd priority;

The Maldistribution of Health

Third priority : Assam

MaharashtraKarnatakPunjabHaryana

6t

Fourth priority : HimachalPradesh

KeralaJammu and

Kashmir

If the sex ratio is also considered in such an index, the Stateof West Bengal would enter the first priority category, theStates in the second and third categories would be roughlyequivalent in priority except for Karnatak which would standon par with the three states in the fourlh priority group.

While the National Health Policy has set aggregate nationaltargets for mortality reduction, it has ignored regional differ-ences. Instead, it should set a minimum target for each State,especially for those that currently have the highest death rates.Although this is done at the State level, given the widevariation among States-and the fact that the worst-of statesaccount for large proportions of the country's population, aphased apd differential system of target-setting for mortalityreduction is essential for the improvement of the aggregatenational rates.

Nurnbers InvolvedThe National Health Policy Statement set targets for the

crude death rate and other mortality indicators. The death rateis to be brought down to a level of 10.4 by 1990 and 9.0 bythe year 2000 (i.e. by 17 and 28 per cent of the l98l level bythese years, respectively). Using population projection data,one can estimate the total number of deaths that will take placeannually at the 'target' rates. If the Registrar General's mediumpopulation projections (Office of the Registra-r General, 1984)are the base, 8.7 million deaths would occur in the country in1991 and over 8.9 million in 2001. On the other hand, if"alternative" (more realistic?) population projections are used(Sundaram, 1984), the number of deaths even at the targetedlower mortality rates would be almost 9.0 and 9.5 million in1991 and 2001, respectively. Thus, although the overallmortality rates are to be reduced, the larger populationdenominators result in the number of deaths per annum re-maining almost the same over the 198l-2001 period. Therefore,

62 Implementing Health Policy

the National Health Policy ta{gets seem to aim only at a'stabilisation' of mortality in terms of total deaths or 'deathsper second' in the country. Ifealth programmes would be'running to stay iu place.' Inste4d, an objective of health policyshould be the reduction of absoltute numbers of deaths in thecountry.

Even at these standstill levels, these figures point to theenormity of the challenge to hea[th policy and programmes aswell as to development efforts. A 17 per cent reduction in themortnlity rate by 1990 means th&t 1.5-1.8 million deaths willneed to be averted every year u$ till then from current levels,and a 28 per cent reduclion by 200 | means almost 3.5 millionfewer deaths should occur then tban at the current rate.

Significantly, the death rate largets set by the health policyrecognise that a reduction in the proportion of total deathsoccurring during infancy (and cllildhood) is necessary for thereduction of overall mortality. prom the current proportion ofone-third, infant deaths are to cdnstitute only 23 and 14 percent of total deaths in 1991 an{ 2001, respectively. More thanhalf the gains in mortality lppear to be sought from areduction of infant deaths alone. For example, were there tobe no reduction in the infarlt mortality rate by 1991, thecountry's overall death rate wolrld decline from the curreDt12.5 to only 11.6 instead of the proposed 10.4.

StrategiesFor the implementation of h{alth policy, one must approach

the designing of health programfies from the point of view ofthe differentials in health stat[s among different age and scx

groups, paying heed to the causds, both proximate and under-lying, of these mortality differdntials. Hence, to reduce excess

mortality of the disadvantaged groups broadbased action iscalled for, including maternal and child health programmes,nutrition improvement, and the provision of sanitation andsafe water supply. Health edu{ation may aid the implementa-tion of health pfogrammes by inpreasing awareness of factorscausing illness, of preventive lealth measures, and of healthservices but is inadequate in itself unless other constraints tobetter health are also removed.

The Maldistribution of Health 63

Reducing Child Mortality. The majority of deaths occur inthe 0-5 year age group. While it is by no means implied thathealth services alone can reduce this vast differential, there isevidence to believe that simple health interventions can prevent50 to 60 per cent of infant and child deaths, even without"economic development" in the developing world (Rohde,1982). The number of conditions causing the majority ofchild deaths is small-diarrhoeas, pneumonias and infectiousdiseases (pertussis, tetanus and measles) with associatedmalnutrition. These "killers" are amenable to technologiesrvhich are available and withiu the capability of many develop-ing countries. There are antibiotics to curb respiratoryinfections, toxoid against tetanus, and immunisation for measlesand pertussis as well as tuberculosis, which could cut downthe number of cases and eliminate all deaths from thesediseases.

Beginning with the .infant, one can identify low birthweight, neonatal tetanus, and birth difficulties as major causesof mortality in the first month of life. These neonatal deaths,which account for over half of infant deaths, are related to thelack of maternal care during pregnancy and childbirth. Thus,increasing mother's access to food during pregnancy and toknowledge of their nutritional needs, to immunisation andprenatal check-ups, and to trained birth attendance, can havesignificant influences on infant mortality.

Some findings of the Survey of Infant and Child Moitality(Office of the Registrar General, l98l) point to the gaps thatneed to be bridged. The Survey found that 25 per cent ofbirths were of "low birth weight." Thus, a high proportion ofmothers received inadequate nutrition, were in poor generalhealth during pregnancy, or had no access to prenatal care.Three-quarters of births in rural areas and one-third of thosein urban areas were not attended by a trained midwife ormedical practitioner, demonstrating the absence ofadequateintra-natal services.'

In the postneonatal period, infections and parasitic diseasbsare important causes of morbidity. Malnutrition acts synergis-tically with these infections to cause high mortality in this agegroup and through the remaining preschool years. However,deaths from these diseases can be prevented for the conditions

64

T

Implementing Health Policy

can be rectified with simple r$easures: immunisation againstchildhood infections such as measles and pertussis, anti-parasitic treatment, antibioticg against respiratory ailments,and oral rehydration therapy f$r diarrhoeal diseases. Greateraccess of children to proper nutrition can be ensured byincreasing mother's awareness but the means to improve nutri-tion must also be provided. ,\ccording to the 1979 Survey,only 42 per cont of children who died in infancy in rural areasand 65 per cent of those in urban areas were treated by atrained medical practitioner. Ih the 1-4 year age group thepercentages were 57 and 77 respectively, Thus, there is consi-derable need to increase the accbss ofrural women and child-ren to appropfiate medical care.

Reducing Female MortalitJr. Attention to children and towomen is generally subsumed under "maternal and child healthservices." However, these do nbt pay particular attention tothe female child who is at a cultural disadvantage, nor do theyattend to 'non-maternal' aspectb of women's health. Even theirpotential to lower mortality due to "maternal" causes amongwomen is not being met. The ambit of MCH programmesmust be extended to include all women, regardless of theirreproductive status and to address the general health problemswhich underlie the high mor{ality rates among females of allages. Chapter 4 is devoted to a consideration of this subject.

Reducing General Mortality. Clearly,nutrition improvementnbetter sanitation, and the provision and protection of watcrsupply are crucial measures whiph would benefit young childrenas weil as other population groups. In addition, the widercontrol of infectious diseases thfough environmental measures,and early diagnosis and treatmdnt, is essential to reduce deathsdue to the major diseases. Diseases such as tuberculosis andmalaria, which account for a considerable proportion ofmorbidity and mortality, are dinectly amenable to preventivehealth activities and to health service interventions. Malnutri-tion can also be reduced by effective control or early treatmentof these diseases, besides requirfng attention to food availabilityand consumption.

Linking Health and Population PolicyThere is considerable evidenlce for a two:way relationship

' The Maldistribution of Healtlx

'between mobtalitir-particularly inlant and child mortality-'and fertility, which has special significance for health policy,High mortality among infants and young children is both theresult'and a cause of frequent births. population groups orareas, such as the states of U.P., Bihar, Rajasthan and Gujarat,'with high mortality rates also have high fertility rates.

Mortality, differentials between males and females parti-cularly in the first year of life may result in part from highunwanted fertility. A child of high birth order has a higherrisk of death than his or her older siblings, The Survey ofInfant and Child Mortality found that 2O-25 per cent oflive births had a birth order of five or more. The highinfant mortality rate (especially in rural areas) reflected thehigh risk of this large proportion of infants. (Infants ofmultiple births also have a higher risk of death). Infantmortality is also high among children of very young mothersand those over 39 years of age. Finally, short birth intervalsalso greatly increase the risk of infant death. For example,Das (1975) found that the infant mortality rate among childrenborn between 1.5 and 2.4 years of a previous birth was almost

" half that of children born within a 1.5 year interval. Withlonger birth intervals, the infant mortality rate decreasedfurther. His analysis also pointed to another factor importantto the survival of infants-the mother's previous child lossexperience. Mortality was considerably higher among infantsof mothers who had lost a previous child.

There is also evidence that children born in nuclear familiesamong the poor have lower chances of survival than those ofjoint families (Simmons et al., 1982). However, this is perhapsofgreater social than demographic significance, as it suggeststhat sttpport to the mother by family and conrmunity is animportant determinant of child survival.

These relationships suggest that contraception-particularly,birth spacing-is a measure that could reduce child deaths. Ithas been estimated (Princeton, 1983) that maintaining a two-year spacing between births could reduce infant mortality by10 per cent, and child mortality by 16 per cenf, In canalsoreduce maternal deaths because repeated pregnancies at shortintervals rssult in the nutritional depletion which renderswomen particularly susceptible to disease and death.

65

.66 Implementing Health Policy

However, ag is now well-knofun, people-rich or poor-ar€reluctant to litrit their fertjlitry unless they are assured of thesurvival of their children. Therffore, although family planning

seivices have in the past almost submerged Maternal and ChildHealth Care, there is clearly al need to rectify this situationso that child mortality reduc{ion assumes the first priority.Thus, population policy must take off from heaith policy.The links between health and population go beyond theexigencies of service delivery to common underlying social andeconomic phenomena.

CHAPTER 4

ORGANISATION FORHEALTH: FOCUS ON WOMEN

AND HOUSEHOLDS

The examination of India's health situation undertaken in theprevious chapter points unequivocally to two large. populationgroups who are especially 'vulnerable'to disease and death-'.'females" and children. The health of these two groups is in-extricablylinked-both biologically and sociologically. Fromthe moment of conception to the time of weaning the child isphysically dependent on his or her mother; and many aspectsof a woman's health, her nutrition and infection starus,directly affect the health of the child. Besides biological effects,women also determine their children's health through practicesrelating to feeding, health care, children's work, and so on. Inturrn, the survival and health of children and their numberhave profound effects on the physical and psycbological healthof women. Accordingly, if progress is to be made toward im-proving the health of these two groups, .attention must be paidspecifically to women's health status, and to their health-related behaviour, including the social and economic conditionsthat underlie these. Thii chapter thus sets out to examine thehealth status of women and its sociological underpinnings. Itaims to draw the parameters within which health policy, plan,4ing, programmes and service providers must operate. in orderto address women's particular health needs, to aisess the extent

68 Implementing Health Policy

to which these parameters arri currently being heeded and topoint to future directions in this regard.

WoMEN's Fnrerru Sra'rus

Differences in health status between the sexes emerge clearly inseveral mortality indicators ,r,r.ihjch have been discussed in theprevious chapter. In addition, p direct measure of the healtbstatus of women between 15 ald, 44 years of age is the maternal,mortality rate. At around 500 per 100,000 live births (Ministryof Health and Family Welfarei 1981) the all-India rate is about50 times that of a developed coUntry and of the well-to-do witbinIndia. However, since poor rurhl Indian women have an averageof five or six live births compated with one or two among theirbetter-off counterparts, their actual risk of dying of a mater-nity-related cause is 150 to 300 times greater. (The reason forcomparing the poor rural l4dian woman with the well-to-dowithin India or in the West is, of course, that there is no com-parable statistic for men!). Besldes anemia or general malnutri-tion, the commonest causes of maternal deaths are toxemia andsepticemia-reflections of the lnadequate health care availableto women in the ante-natal, inXra-natal and post-natal periods.

In general, during the cgurse of this century, while lifeexpectancy has increased for both males and females, in rela-tive terms women have fallen $ehind in their ability to survive.The adverse and declining population sex ratio that hasresulted from the higher mortality of females is widely used asevidence of the disadvantageoqs position of women in Indiansociety. The current level of 9b5 females per 1000 males in thecountry is a yawning gap (office of the Registrar General,1982a b). Although it is presuded that this decline has abatedwith the slight upturn seen in l98l census data, it is too earlyto say whether this is so. The [98] level may simply be a data'quirk,' or the l97l level may fave been an underestimate as a'smootheuing' of the curve wolrld suggest. There has also beena steady decline in sex ratios dt the State level. While at thebeginning of this century the fdur southern states had sex ratiosfavourable to women, the last oensus showed this only for the

Organisation for Health

State of Kerala, where also there is evidence of women'sdeteriorating status (see Chapter 8).

ln addition to these demographic indicators, health indicessuch as morbidity rates, nutritional status measurements andfood consumption data, indicate women's inferior status.Indeed, the proximate causes of higher female mortality arehigher rates of disease and malnutrition which, while inadequ-ately documented by macro-level data, .are usually clearlybrought out by small-scale surveys and studies (Jesudason andChatterjee, 1979; CBHI 1976b,1977,1978b; Khan et a1.,1983b,Kynch & Sen, 1983; Kamath et al., 1969).

Micro-level nutrition surveys generally find higher rates ofmalnutrition among women and girls compared with men andboys. Within the household, food is distributed more in accord-ance with the status and position of an individual than withnutritional requirements. While women get a smaller share ofthe family food, they may expend a greater proportion of itsenergy, as demonstrated by a study of energy expenditure inrural households (Batliwala, 1982). The food intake of preg-nant women, far frgm being increased in accordance with theneeds of pregnancy, may be further restricted because of cul-tural taboos.

Some biological reasons for the poor health of women suchas "repeated pregnancies" are well known. There are also otherproblems unique to womell which, although believed to bewidely prevalent, conspicuously lack the support of quantita-tive data. For example, amenorrhoea and infertility are prob-lems of grave significance to the individual woman who issubject to Indian societal norms (which place a premium onfertility) but their prevalence is difficult to ascertain. In anothercategory-but also inadequately quantified-are crimes againstwomen which rebound on their health, for instance, rape,burning, and physical assault. There are also female-specific

"iatrogenic" problems, such as those related to the use ofcontraception (IUDs, pills) or resulting from sterilisation orabortion. Although it may not be possible to assess the impor-tance of these on a scale of health issues, they nevertheless arepart of the subject of women's health. That they add up to aconsiderable disadvantage to women is demonstrated by thesimple statistic that while 8.4 per cent of male deaths occur

69

70

between the ages of 15 anddeaths are in this age group

WoMEN's Urrr,rsa

From the foregoingmorbidity are fragmented.ture to health centres. clinirepositories of, such informatiof utilisation'cif healthbetween males and females.females, more treatment is so

of ailing men than womention of services are orovided tPrimary Health Centres ining medical treatment forKhan et al. (1982)studied, only in 9 per cent osought from the nearby PHCThe vast majority of women

In a survey in Madhyaof all current, seiious(Jesudason and Chatterjee, Isought for about halfof allhad approhched governmentprivate allopathic or traditiwomen respondents knewcentre (staffed by an ANM)of the nearest Primary Healing timings of these facilitiesof the women had aptuallyand less than 20 per cent theqentres or PHCs forand Chatterjee, 1979; see1982 and 1983a).

Thus, available information

. the utilisation of health r

,.femgleq al tlrge particular s

reason is that few women ven:and hospitals which are theAvailable data on the extent

definitely indicate differenceshigher morbidity among

t for males, higher percentagestreatment, and a higher propor-men (Coyaji, 1980). A study of

jasthan, revealed five men seek-every woman (Murthy, 1982).that in the U,P. villages theyfemale illnesses was treatmentor government health facility.imply used traditional remedies.desh, it was found that over half

reported affected females). While treatment had been

only l5 per cent ofpatientses, the remainder seeking

ral care. Only one-third of thelocation of the nearest sub-

about 40 per cent the locationCentre. Knowledge of the work-

even poorer. Only a quartervisited the local sub'centre,

trIC. Nor did women attend sub-care or for delivery (JesudasonJfffery et al., 1984; Khan et.a1.,

WolrrN's LrrT AND HEALTH

mortality and morbidity and onces point to disadvantages toof the life-cycle: between the

Organisation for Health '71

ages of 0 and 5, 5 and 15, and in the "reproductive" period

between 15 and 45 years. This poor 'health cycle' is related

clearly to women's low status, great responsibilities and work

burdens. A female child is eminently dispensable because her

mother's status depends on the bearing of sons. First-bornfemale children, those born after a succession of births (i'e

of high birth order), or after one or two other female children

are "unwanted." The care and feeding of preschool girl child-

ren are less satisfactory than that of boys. A higher incidence

of malnutrition among female children is found ubiquitously

by surveys and micro-level studies, and their lower receipt ofhealth care has been discussed earlier.

School-age and pubertal females (5-15 year olds) continue

to suffer from inadequate nutrition and a lack of medical

attention. By the age of five, young girls are most likely

already participating in the 'domestic work force.' The wide

variety of tasks they undertake are energy'demanding, and yet,

according to the National Nutrition Monitoring Bureau

(1981), only half of all children between 5 and l5 years receive

adequate nutrition.Young girls' participation in domestic work also has unfa-

vourable repercussions on schooling. In 1981' only 32 per cent

of 5-9 year-old and 38 per cent of 10-14 year-old girls were

attending school (Office of the Registrar General, 1982a & b)'

In the past, only 30 per cent of those who have entered Class

I have completed Class V' with the largest group "droppingout" between Classes I and II. A national-level survey in 1978

showed that the percentage of girls attending school increases

with each year between the ages of 5 to 9 years-but then

drops rapidly by age 14, so that only a quarter of girls between

12 ind 1'4 are in schools (NCE,RT, 1980)' The low enrolment ofgirls in schools also deprives them of the school meals, school

health programmes, and hygiene education that are vital totheir health.

The 1978 survey found that while 63 per cent of boys inthe .5-14 year age group were literate, only 44 per cent ofgirlswere. Gender differences in literacy are more pronounced inrural than in urban areas. While rural areas of all States had

higher than 40 per cent literacy among boys of this age

groupr eight major States showed females to be less literate

72 Implementing Heatth pol.icy

than this {all-India) average level: Rajasthan, Madhya pradesh,Jammu and. Kashmir, Uttar pra[esh, Andhra pr"j.rfr, Sitr".,Orissa and Haryana. These State]s together account for wellover half of India's female popul4tiou.

During the secondary school y{ars, many girls are betrothednot even having achieved minimAl literacy. yet the evidencethat schooling is one of the l[ost important ..correlales', of'successful' motherhood is comjrelling. The Survey of Infantard Child Mortality (Office of the Registrar General, 19gl)showed that literate mothers sqffered four out of ten fewerdeaths among their infants than dfld illiterate mothers in ruralareas.

The education of girls coulil also lead to their greateremployment in adulthood. Woqen's employment may exert a.positive effect on the health and survival of children as.discussed in Chapter 3.

Education and employment albo raise the age at marriage ofwomen, another factor associated with better infant survival.The Survey of Infant and Child Mortality found thar womenwho- married after the age of 2l years experienced only two_thirds the rate ofinfant deaths cor|pared with those who marriedbetween 18 and ?0 years, and half the infant deattr rate of thosewho were married before l g years of age (Offce of theRegistrar Generat, 1981).

However, the majority of qvomen are married early andexperience. early motherhood, entering the ..reproductive

agegroup." Sixteen of a woman's 30 reproductive years may bespent in pregnancy and lactation (Ghosh, l9g4). Early, repeat-

:d ..uod prolonged childbearing coupled with inadequate

reeorng and heavy work results iir severe nutritional depletion."Pregnancy wastage" is high Fnd there is a high risk ofobstetric complications for botll mother and chiid. sesidesthese physical burdens, the health problems of women at thisstage of the life-cycle also encompass emotional and psycholo_gical stresses. Women are socialiqed to downplay theii illnessesand social taboos bar contact with outside health careproviders.

Women's life expectancies at diferent ages reflect this cycle.At birth, females have a life e4pectancy;f 44.7 years, about1.7 years less than males. By age fO, their life expictancy lras

Organisation for Heal th

risen to 57.7 years but remains l-1.5 years behind males untilthe age of40. After this they begin to have a life expectationequal to or greater than that of men. Although women'shealth needs emanate from biology and ecology, and areexacerbated by unfortunate social values, coupled with econo-mic adversity, there is ample evidence e.g. from the experienceof Kerala that female morbidity can be reduced by improvingtheir access to health services (see Chapter 8). Furthermore, ahigh pioportion of child deaths are brought about by problemswhich can be traced to mnternal health, nutritional status,fparity, and obstetric care. Other causes of child deaths areamenable to simple health service interventions, or could beaverted by pioper preventive health care. The linkagesbetween child health and women's access to health care aremanifold (see Chatterjee, 1983) and thus for health improve-ments to be effected in both "vulnerable" groups-women andchildren- women's access to health services must be substan-tially increased.

WoMEN's AccEss ro HEALTS SERvrcEs: A CoNcEpruALFneuewonr

The issue of women's access to health care is a complex, multi-dimensional one. On the one hand, ir is an "indeperdent" or"explanatory" variable, a determinant ofthe health status ofwomen and o{ family members in their charge (paiticularlychildren, but including husbands and the aged). Although thelatter groups may be independent users of health services, theyare dependent on the woman of the household for theirimmediate health needs. Thus, ultimately, a woman's access

to health care could determine the economic viability of afamily. On the other hand, access to health care is also theoutcome of womdn's status in society, including societi'sresponse to the health'needs ofwomen. Thus, it.js a 'depend-ent' variable, Ieaning on women's social standing, theirintra-familial status, their economic level, as well as on theavailability of health services. It is virtually impossible toseparate these several dimensions. Instead, one can group theminto four broad arenas which together determine women'saccess to and utilisation of health services: need, permissiont

IJ

74

interact to

Health Policy

produce tJe

Frc. l. Factors Determifiing use of Health Services.

Need is the extent of fill-heatth among women (andamong family members), and] is a measure of the extent towhich women must seek health care. It is determined largelyby economic and environrlental factors, as well as humanbiology. In Indian society, where women are conditioned totolerate suffering, actual n(ed (i.e., medically-defined need)is mitigated by perceptionsi and is thereby reduced to"perceived" or "felt" need (dhown in the fgure as a subsetof need, by a hatched line).

Permission refers to the f4milial, communal, and societalnorms that dictate whether a woman can or cannot seekhealth servicss. Often these dorms are explicit-in the formof social taboos (such .as .tho$e pertaining .to menstruating orpost-partum women), a mothtr-in-law's mandate, etc; or theymay be implicit in women's conditioning to bear suffering,to fear ridicule on admitting illness, or to anticipate chastise-m€nt if she were to express h desire for medical treatment.Permission is thus very mucti a function of women's socialstatps..

l

Organisation for Health 75

Ability is the extent to wbich women can approach health

services, depending mostly on their economic status' With their

"double burden" of employment and household chores, there

are serious 'tradeoffs' between women's economic and domestic

responsibilities, and the time, energy and expense ofseeking

health care. The compromise achieved would be determined

by the economie status of tbe family ?rs a whole-the availabi-

lity of alternative wage'earners, childminders, etc. Social

norms also operate to determine ability, and so women who

are able to seek health care are a sub-set of those who are

'permitted.' As before, some of these may not have actual

need. To use an economic term loosely, the processes of'permission' and 'ability' act together with 'felt' need to

result in demand for certain health services, some of which may

be 'unnecessary' or 'spurious' demand.

The availability of health services in general and specifl-

cally for women is the main 'exogenous' factor determining

women's access to health care. The location, nature' and

quality of services and associated factors such as the behavi'

our and attitudes of service providers are of major importance'

Services available may not be totally consistent with existing

health problems or need. Where ability to seek health care

and availability of services (i.e' supply) overlap, use of healllservices or "effective demand" occurs.

The preceding sections describe need in terms of women's

mortality and morbidity and of child health problems, using

macro-level data and information from micro-level studies'

.Based on clinic attendance and household-level surveys' use

has been shown to be far short of need. The issue of improvingwosen's agcess to health care is precisely to make their use

of bcalth services commensurate with need. The circles of

Frception, permission and ability must be enlarged tocoincide with need, and availability must be totally congruent

with it, While the major responsibility of the health sector

lies in the arena of availability, it can also be instrumentalin .bringing about some of the societal changes which are

required to modify the arenas of ability, permission and need'

Although broader changes lie outside the realm of healthprogrammes, they are nevertheless important aspects ofhealthpolicy.

./o Implementing Heatth potiiv

Avarr,lerrrry oF HrALitrr Senvrcrs FoR WoMEN

isolated efforts to improve the 4vailability of women's servicesin rural areas.

Post-Independence entsRural health services devel in the post-Independence

period following the ations of the National

Past TraditionsThe situation of women'sheallth services prior to the adventof 'modern' health policy-makidg has been described in detail

elsewhere (Chatterjee, l9g4). The traditional Indian systems ofmedicine were male-oriented, an{ male-dominated and largelyignored "women's diseases" (feffery e; al,, lggj). The onlvtraditional medicine available to women was itr the hands oidais who dealt mainly with obstptric events.

The spread of modern mediqine in the colonial period wasconfined largely to towns, and hence had little impact onwomen's health at large. The esfablishment of fuhds, nurses,training schools, and a few dai training programmes inconnection with the women's movement or as missionarvwork in the early part of this cenltury increased .the availabilitvof female health personnel plactising modern techniques.However, the expansion of wQmen's medical facilities waslimited by a paucity of women doctors, and there were onlv

the Second Five Year Plan, MCH services became an integralpart of overall health services ifi rural areas. The Third planfocused on the improvement o[ services at the pHC level,and at district and sub-divisipnal hospitals. This plan alsosaw a considerable increase id the financial allocations to

Organisation for Health , 17

family planning activities, which gathered momentum withthe introduction of time-bound targets in 1966. Since then,official policy has greatly favoured family planning over MCHservices, to the latter's detriment.

However, as it has become clear that the high fertility ofIndian women is related to the high mortality oftheir infbntsand children, attempts have been made since the Fifth Plan tore-integrate family planning with Maternal and Child Health(MCH) services. Significantly, however, in this effort MCH wastransferred to the Departmcnt of Family Planning, instead ofthe reverse! Thus, former MCH workers became responsible forfamily planning targets and began to view contraceptivemotivation and performance of female sterilisation operationsas their main duties. With their respon sibilities to meet targets,and in the absence of concurrent (or, prelerably precedent)'MCH targets,' they have largely neglected MCH work.

More recently, the realisation on the part of governmentplanners and policy-makers that the established centralisedsystem of health service provision is not reaching most ofthecountry's needy has led to the introduction of schemes toincrease community-based health care. Conprehensivc healthcare was intended to replace the vertical disease control pro-grammes and family planning drives of the 1960s and early 70s.Decentralised health care began in 19'17 with the CommunityHealth Workers' (later Health Guides') Scheme, and, the Daitraining programme was another outreach scheme initialedspecifically to provide better domiciliary maternity serv.ices.

Current StatusAlthough there are women-specific health services, including .

Maternal and Child Health care, Medical Termination of Pregn-,ancy (MTP), the Postpartum Programme, and so ott, which areenumerated in reports of the Ministry of Health and FamilyWelfare, the availability of health services for women cannot beinferred from the'usual statistics ofhealth facilities and man-power. Data on allocations to or expenditures on women's healthservices are not available nor deducible. Tabulations of numbersof services delivered or percentages of targets m€t almostalways lack "denominators" which would allow calculations ofcoverage or effectiveness.. !'qrtherqOre,. thcfQ bave. been.no

78 Implementing Health Policy

attempts to evaluate the irirpacton women's health. For these

f available services specificallyreasons and in view of the

foregoing discussion on low of health facilities by women,it is perhaps more appropriate to examine some qualitative

women.parameters of health services fiMaternal aud Child Health at the Primary Health

Centre include : antenatal, deliding diet supplementation of

and postnatal care, inclu-and lactating women.

mothercraft and hygiene, s

immunisation and health ed

are far below requirement.Tracing the development of

ce of children under five,in addition to obstetric,

services through the five

gynaecologic and pediatric The staff involved in MCHactivities at each PHC consists o[ one or two Medical Offcers.up to two Public Health N and/or Lady Health Visitors,and four to ten Auxiliary N Midwives (ANMs). EachANM, along with a trained manages one peripheral sub-centre, at which basic MCH are to be orovided andfrom where "difficult" cases are io be referred to the pHC.

The general health problems of women have been subsumedinto disease categories which tackled by 'general' health

sub-centre can effectively cover target populations. To givejust one example of this lack of coverage, only a few per centof deliveries are attended by I trained person. Institution-based medical care remains ble to the majority ofwomen and children and in preventive and pro-motive health, even in the area o[ maternal and child services.

stafl at health centres, or addressed by the vertical diseaseprogrammes. The extension worlders connected with the nationalprogrammes against malaria, smf llpox, tuberculosis, and so on,were formerly unipurpose workfrs, but more recently havebeen renamed "Multipurpose Wbrkers" (MpWs). This includesANMs who are now "Female MpWs,,' expected to cater towomen's health needs by dint of being women themselves.

Despite the investment made bver the past 30 years in thehealth infrastructure, neither the pHC staff nor the ANM at the

Organisation for Health 79

the country's low output of nurses. There are currently 200,000

nurses (with various levels oftraining) in the country, 60 percent of which are concentrated in urban areas, There are twodoctors for every nurse, a peculiar reversal of rational healthlnanpower policies-particularly in view of the need for healthservices to cater to women and children in rural areas. Toobtain the desired ratio ofone nurse per thousand population,the country ndeds almost four times the current number ofnurses. The low status, poor working conditions, and low wages

of nurses, coupled with inadequate training to deal with theproblems of women in rural areas, severely constrain proper

devplopment of the nursing profession which is vital to women'shealth care. ANMs posted at sub-centres usually come fromoutside the village and face problems of 'accommodation,' ofsafety, and of job satisfactibn which hamper their liaison role.At the PHC level, the availability of basic amenities canovercome some of these problems, but women doctors are stillin short supply in rural areas. By and large, the need is toensure proper infrastructural and " psychological support forwomen health workers. This in turn raises the need for theparticipation of women in overall health service planning,decision-making and policy formulation,

One reason for the lack of coverage by government healthfacilities is that little effort has been expended to overcomethe constraints of 'permission' and'ability,' and encourage use

of the facilities. Household surveys of people's awareness ofgovernmental health services paint images of PHCs as "dis-pensaries with facilities for sterilisation or difficult deliveries"(Jesudason and Chatterjee, 1979). Few people are aware of thepreventive and promotive services being offered, even ofimmunisation or of antenatal care. The acceptability ofinstitutionalised health care is certainly hampered by a conflictbetween traditional community values and those of modernisedextra-familial institutions. Besides, few women have the time,mobility, travel facility, money and child care alternative requir'ed to travel to a PHC or hospital several miles away. Thus,when those who do are led to complain of long waits or unplea-sant behaviour of staff, other potential clients are lost. Frequ''ently services available at the PHC are considered inadequate(e.g. nedicines in short supply) and there are often reports of

80 Imp I ementin g He att h pol icy

of access to health care largel5i ignored. Thus, the health systemhas failed to perform the twb main roles outlined for'ii.in iheforegoing di inistiing the constraints of ,permission'

and 'ability,' and making avaifability congruent with need.In order to do so, female nnel concerned with women's

health must be deployed effqctively both at health centres andin the field, and trained to be nsible for "holistic" health,

pilot schemes, . the ofrcial pr,irgrammes have been rife withproblems.

involved in'the critical task o midwifery (Kakar," 1980). Theri:is' a rich anthiopological li on their roles and functions

. Dai Training Programmimportant health asset beca

which demonstrates great vsettings. R.ecently, a detailedchildbearing in some U.p. villet al., 1984).In this fietdhome atteMed by anno contact betweendelivery. Although womenany life-threatening situation,and few had any previousroles were largely confined to

Dais are perceived as anthey are village-based and

ations in different culturalaccount of the role of dais it

has been provided (Jefferyalmost all women gave birth at

dai. However, there was little ort woman and the dai before

the dai to diagnoseconsidered experts

ded on

or apprenticeship, Theiring the "dirty work" durin!

were not

Organisation for He alth 8l

and immediately after the delivery. In this situation, the daishad virtually no role as community healers bccause they lackedspecialised knowledge and had only very short contact with thepregnant woman. Twenty per cent of the dais observed by theJefferies deviated from this stereotype-they were intelligent,trained, well-reputed, practised some form of "medicine" (e.g.gave injections) and had busy, lucrative practices. However,they too had limited 'outreach' and did not educate their clientsin health matters. Nevertheless, this more positive view of daisobtains in certain other locations (e.g. in the Punjab, accordingto Kakar, and in Tamil Nadu, according to Mathews, 1979).

It is believed that there is at least one traditional dai inevery village in India, so that the total number would be over ahalf million in the country. Although the eoncept of trainingthem in better techniques goes back more than a century, theofficial programme to utilise dars to provide "modern"village-based maternal and child health and family planningservices was launched during the Second Five Year Plan(1957-62) and sustained through the Sixth Plan. However, thenumbers trained have been consistently about 40 per cent shortofthe targets set in each Plan. At this juncture to reach theproposed ratio ofone traited dai per 500 people seems a mostunlikely feat as over 1.2 million dais would have yet to betrained.

Qualitatively, as well, the programme has f allen far short ofits objectives (see e.g. Mani, 1980; Bhatia, 1982a, b). There havebeen grave difficulties in recruiting suitable dars into theprogramme. Typically a supply rather than demand-orientedprogramme, no felt need has been created either for the trainingor for trained midwives. Nor was the programme designed tocater to perceived need. For example, although a demand forcertain services such as post-partum care exists, it has not beenconsidered in programme design. More attention to practicalaspects of pregnancy, deliverya nd infant care than to text-book reproductive physiology in the training syllabi would havemade the programme more responsive to the needs of women.

Administrative lapses result in a scarcity oftrainers, teachingaids and equipment which in turn have led to training ofpoor quality. Midwives frequently find the courses too technicaland too long. They drop-out because training centres are

82

distant, or bEcause they lose

Implementing Heal th Policy

income which is not made upeither by'incentives during training programme or byincreases in income after . Indeed, villagers often assumethat following training the have become governmentpersonnel who should rendercourse. does not suit the dais w

their services free-and this, of

necessity.

Finally, follow-up of trai is virtuallv non-existent.Midwifery kits are not repleni ed. There is a lack of rapportbetween the dais and themaintaining contact. They

who are responsible forive each other as competitors.

Alternatively, dais shy awzy m a relationship with theirlocal ANM because villa mav distrust them in fear ofbeing recruited for sterilisa The combination of poortraining and inadequate follo up often leads to recidivism totraditional approaches and

At a practical level, theref the Dai Training Program-

o do the work out of economic

women even in the limiteddequate domiciliary midwifery

me does not meet the needs omatter of childbirth, and ansystem remains a major lacuna,

Village Health Guiiles' S . While the village HealthGuides' Scheme had the tial to overcome some of the

'ability,' making health careconstraints of 'permission' aneasily available to womeR, scheme faced numerousproblcms which limited its . Initially, the vast majority

were men. Restricted fromof Community Health Wapproaching and dealing with women, these workers confinedtheir efforts to treating minor ailments and to chlorinatingwells. However, following the fecommendations of the CentralCouncils of Health and Fafnily Welfare in 1981, moreemphasis was placed on the itment of female workers.

Female health guides are potentially effective 'women'shealth workers' because of their access to the relevant targetgroup, their 'knowledge' of heplth culture, personal qualitieswhich make them harC workersl and their "apolitical" nature.However, they are rarely accQrded the status they require tofunction effectively. Although al great deal of responsibility canbe vested in them, there is also a need for support frommore skilled personnel and fop linkages to the formal healthinfrastructure. From their subtcentres, Female MPWs (ANMs)

Organisation for Health 83

are supposed to liaise with village health workers to providehealth care to women. Onield visits, ANMs are charged withresponsibility for providing basic health care, and preventive andpromotive tasks, including immunisation. However, almostubiquitously, their family planning responsibilities take over theirefforts, and their targets are inevitably handed down to theirvillage-level 'subordinates,' so that the wider task of (women's)health care is ignored by all. As has been alleged, these out-reach efforts descend to merely bringing about a "surfacechange designed to improve the relationship" between medicalpersonnel and rural women (Jeffery et al., 1983), so thatfamily planning work can be given a much-needed boost.Whether or not this is intended, it is true that in practice thehigh priority accorded to contraceptive motivation work, andthe shortage of female health personnel has severely restrictedany effort "beyond family planning." "Antenatal" care hassuccumbed, as it were, to "antinatal" policies!

FuruRE SrnArrcy

Taking Cognisance of Health BehaviourThroughout health policy-making in India, health has been

ryiewed as an "individual responsibility," so that the focus ofhealth care delivery has been the individual. A health systembased on a network of curative centres presumes that individ-uals will present themselves for diagnosis and treatment whenill. Although it is clear that the health system has failed to makean impact on the health needs of women, this is ascribed to theintransigence of society rather than to any systemic inade-quacies. However, the vcry intervention of factors such as'permission' and 'ability' between women's needs and their useof health services points out that women (and, obviously,children) are not able to demonstrate the individual behaviourwhich the current health service pattern requires, and thatthis philosophy on the part of health planners is thereforeinadequate.

Recent attempts to combine the 'centripetal' system withschemes that reach out to the periphery have devolvedresponsibility for health onto the village ',community." How-ever, several difficulties encountered by schemes such as the

village as the unit of health care delivery may once again proveinadequate to deal with the country's health problems.

Admittedly, the strategy fof community health includes afocus on "vulnerable groups"*children under 6 and pregnant/lactating women. Although it it useful from a medical point ofview to constitute groups of people with common needs usingphysiological criteria, these groups have little in commonbeyond their physical descriptidn, and the objective of creatingan identity among them is defeated by divisive social, economicand culrural forces. Thus, in practice, when such criteria areused, the individual rather ttian any .,homogeneous" grouponbe again becomes the unit of health care delivery. It istherefore more appropriate for fhe purposes of health improve-ment for these individuals to be viewed within the context ofthe grouping that has the gfeatest influence on their healthstatus: the family or household.l* Indeed, the concept of the"vulnerability" of these indiliduals is derived from theirrelative nbglect within the horrsehold. This neglect is oftenexplained in terms of the family's primary concern for survivalas an economic unit, which hps important implications forhcalth.

To illustrate the importarice of the household, one canconsider the problems that most frequently affect children ofpreschool age : malnutrition, gastro-intestinal infections, andrespiratory diseases. Although ilt is the individual child who isaffiicted, the causes of his or her condition lie in his/herimmediate surroundings, the home; and beyond that, to the

*Although awarc of the debate onchangeably to mean a group oflive within the same dwelling unit,

,I use these terms inter-Ie (related by blood or not) who

health-related resources. andtake decisions that affect theof tho group as a whole.

otindividuals witbin the group or

Organisation for Health g5

village (or urban) environment. The approach to the child'sillness and treatment must take these environments intoaccount. Another example is the pregnant woman who is thedesired subject of antenatal examinations and advice on diet,hygiene and physical precautions to observe during pregnancy.If she were to practice this advice it would be in the context ofher home, within which food is acquired, cooked and eaten,cleanliness observed or labour divided. Unless these are takeninto account, the advice would be infructuous.

Thus, most conditions affecting health, health practices anddecisions concerning health care lie within the province of thehousehold rather than at the "community" level (with someimportant exceptions such as drinking water supplies, wastedisposal, or vector-control operations). The amount of foodavailable and eaten, the treatment of sick persons, the nunberof children conceived, born or nurtured, are determined by thefamily or household acting within its particular socio-culturalcontext. Therefore, it is this unit that would constitute thomost effective unit of health care delivery. Although a recogni-tion of this is still far.removed from an ability to designeffective health programmes, an understanding of the manydimensions within the household that affect health can providea basis for health planning.

THs HoussHoLD AND HEALTH

Anthropologists describe the household variously as the unit ofproduction, consumption, residence, reproduction, socialisationor a combination of these. When considering health andnutrition, one finds that all these facets of ,.householdl' aregermaiie(Chatterjee, 1984). Household production dictateshealth because the resources gathered determine the capacity ofits members to acquire 'health goods and services.' Householdconsumption and, particularly, the intra-household distributionof lconsumables' such as food, water and clothing determinethe nutrition ald health status of the individuals that comprisethe household unit. Nutrition and health status are also theresult of the balance between energy expended in productionand that obtained through consumption, and so the aggregate

a

86

household 'energy levef ishealth of its members,

As a residential orimmediate health en

common water source,

Implementing Health Policy

an important determinant of thc

group, the household is theof its members who "share" afacilities, breathing space, a

hearth, and other facilities. has important implicationsfor the acquisition, prevention and treatment of

the household determines thedisease. As a reproductivenumber ofcbildren to be born in it. Child-bearing directlyaffects the health of women, and indirectly the

health and survival of other Ultimately, the size ofthe household determines per capita availabilitY of

of all its members. Finally,reiources-and thereby theas a socialising unit, the usehold is responsible for the

acquisition, transmission and of health-reiated knowledge.

Mental development and tal health are also importantthat takes olace within theoutcomes of the

household.Health and nutrition depend both on the com-

on its organization. AnYposition ofl the householdinhabitant ofa household has dn effect on its health status and

implications for its health care bccause all individuals (a) have

a health profile themselves, (b) can be agents who transmitdisease or prevent it, and (c) could (in theory, at least) be

responsible for providing care within the household oracquiring it from outside.

At this point, a caveat is in order. Although the householdis itself a complex system of ccioperation, it is in turn linked toother households and institu ions around it. Certainly, anyexamination of its health btatus must pay heed to theenvironment-*-physical, soci{|, economic and political-inwhich it functions. Of particullar concern are the agents andagencies from which it derives its food (nutrition), its water, itshygiene, and its knowledge, Shich are all important deter-minants of health, and the health care institutions with whichit interacts,

WounN As GUARDIANIS or HousEIloLD HSILTH

Health status data and the doncept of "vulnerable groups"

Organisation for Health 87

demonstrate that even within the household there is'differentiation'-by gender, age, role and so on. This hetero-geneity has important implications for health because it isusually associated with different sets of standards for differentpeople. For example, external health care may be sought moref,or males than for females, or for adults more than children.It is this differentiation within the household that focusesattention on women-in terms of their health problems andneeds, as we have already discussed, but also with regard totheir roles and responsibilities in the sphere of health(Chatterjee, 1984).

Within the household, women assuure a number of responsi-bilities beyond their familial roles. Besides being daughters,wives, mothers or mothers-in-law, they are also labourers,producers, cooks, cleaners, child-minders, nurses and so on.

Traditionally, intra-household tasks related to health andnutrition have been almost exclusively the preserve of women.The provision of nourishment and maintenance of hygiene arewomen's responsibilities. Women also undertake the personal

care of family members, care and supervision of young

children, and of the sick-whatever their age or gender. Thisvariety of roles makes them the 'guardians of health.'

Because of these multiple responsibilities, one might assume

that women make the health.related decisions within thehousehold. However, little is known about the process of healthdecision-making within the poor rural Indian household. Theoft-made assumption that household decision-making takesplace as an apparent and concensual process (Anker, 1978) is

not easily acceptable in the Indian context. Instead, processes

of decision-making vis-a-vis health and nutrition are mostlikely tradition- or rule-bound rather than 'active' or'informed.' Thus, the nature of health decisions made bywomen in the household are probably a function of their statuswithin the household and society. We know that this in turn isrelated to women's educational levels and employment status.

ltlornenos Education and llousehold HealthThere is substantial evidence that women's education plays

a major role in determining health (see Chapter 3). At themacro-level, cross-national studies show high correlations

88 Implementing Health Policy

between female literacy and l]ife expectancy at birth, higherthan any other factor (UN, 1983). Caldwell and others haveanalysed micro-leval data on edrJrcation and child mortality andfound that mother's educatlon influenced child mortalityregardless of her age, socio-economic background, or currentstatus (Caldwell, 1975, 1979). The mortality differentials bymaternal education could not be ascribed to the better socio-economic situation ofeducated tnothers. Furthermore, place ofresidence, access to health facilities. and father's education didnot have much significance, and Caldwell concluded that "interms of child mortality, wornan's education is a good dealmore important than even her inost immediate environment."Similarly, data from Bangladesh show that, although allhousehold educational levels (the highest, that ofthe head ofhousehold, and of the mother) Liear an inverse relationship withchild mortality, the effect of nfother's education is the strong-est (D'Souza and Bhuiya, l9B2). The mechanisms wherebywomen's education results in loiver child mortality are still thesubject of speculation. Child hgalth and survival are enhancedby better hygiene, improved nuffition and feeding practices (ofthe child as well as of the mdther), and timely medical inter_venlion, whether in the home of at a health centre. Educatedwomen may be more aware pf how to treat children duringillness, more knowledgeable abciut health facilities, or more ableto take decisions that enhance their children's health status andchances of survival. While the 4ssumption that mothers are themain decision-makers and ..marlagers" of their children nay befar from accurate in many contexts, women,s education may re-sult in significant changes in family relationships such that child-ren (and the women themselves) fet a larger share of the family'sresources. Levine (1980) has prQposed that schooling is a formof "assertiveness training" which enables women to form theirown opinions and act on them, believe in the efficacy of theiractioDs, and not be intimidated !y others. An educated womanthus takes greater responsibility fior her children's health andis permitted to pursue approprialte strategies by other householdmembers. There is also the likelihood that educated womenmay "choose" or acquire better educated husbands who sharevalues inherent in taking bettter care of children, or that theymay influence their husbands and mothers-in-law more in

Organisation for Health

this regard, In support of this, an indepth investigation oftherelationship between female education and lower childmdrtality in Bangladesh (D'Souza and Bhuiya, 1982; Chen,1984) showed that intrafamilial decision-making processes doindeed change with the education of women.

Another way in which education improves child health-andthat of women themselves-is through its impact on child-bear-ing behaviour. Decisions to delay child-bearing, space childrenfurther apart, or bear fewer children enhance child health andsurvival. Cochrane (1979) reviewed several studies in develop-ing countries and found a strong inverse relationship betweenwomen's education and fertility.

lVornen's Employrnent and flousehold HealthIncreased female employment--which may result from incre-

ased education-also leads to lower mortality and fertility.Schultz (1979) analysed data from Colombia and concludedthat mothers' education acted through increases in income todecrease child mortality in urban areas. However, he foundthat in rural areas women's wages were less strongly associatedwith child mortality, than with their education (although thiswas qualified because only a small proportion of women in thesample were in wage-earning occupations). This relationshipassumes that wom.'n are the decision-makers regarding thedisposal of their incomes and that their wages are used to"purchase health goods and services." In the Indian context,both assumptions are questionable.

While no negative effects of higher education on healthhave been brought to light, there is some cause for concernregarding women's employment. For exanrple, the RegistrarGeheral's Survey ( I 98 1) found higher mortality rates amonginfants of working women (whether 'agricultural' or 'blue collar'workers) than among infants of non-workers. The differencewas particularly large in urban areas, and persisted even in thestate of Kerala. Unfortunately, these data were not controlledfor economic status and so may reflect the fact that femaleworkers were of lower economic status. The explanation forthe negative effect of employment may lie in the 'competition'that often occurs between women's paid work and domesticresponsibilities. Among employed women less time may be

89

90 Implementing H ealth P olicy

spent on health-related tasks, and this may have unfortunatenegative eflects on child bealth. When getting medical attentionmeans a time-consuming trip to a health facility and wagesare jeopardized, health care is not likely to be sought. Insituations where the economif survival of the family dependson the womanos work, she is u{likely to leave her work to carefor a sick child, These negative effects may not be adequatelyoffset by the increased quantity of food or the better standardof living which the woman's inNome purchases for the house-hold.

The finding that 'agriculturall workers fared better than 'bluecollar' workers pointed to thq lack of child care facilities forwomen in the organised labour force. The scenario of womenhaving to lock their infants and young 'children up in theirhomes to go to work is not an uncommon one. These factsdrive home the need for womenls employment strategies to beaccompanied by efforts to enhance household access to childand health care facilities.

Another caveat. Within the frousehold, child care-in healthor sickness-may be delegateil to a member other than themother-with potential negafive consequences. Often, thesubstitute child-minder is a Cibling, barely six or seven yearsold herself, ignorant and incap{ble of looking after a well orsick child, or an aged person ugable to spend the energy neces:sary to feed, clean, or comfort d young child.

While women's double burden of domestic and productivework is immensely relevant to health within the household, yetanother aspect of the sexual division of labour relates to theiraccess to external health caie. The paradox of traditionalsocieties is that while women are responsible for 'primary'health care within the houseSold, they are not 'permitted' tocarry this responsibility to its lcigical next step, seeking profes-sional help from external health care providers. This'discontinuity' in women's roleq in health care provision hasimportant implications for healtb policy and planning.

FOR POLICY

The foregoing discussion can summarised as follows : womenand children afd severely disad taged in health matters, for

Organisation for Health 9l

which the household has first level responsibility. Within thehousehold, women are the main health care providers, but theyare limited in their access to external health care institutions.Women's education and employment status affect both thequality of health care provided within the home and the degree

to which outside help is sought and utilised, reflecting on theirown health and that of other household members. Given thepoor health status of women and children, policies must be

oriented to providing them the necessary health care in anaccessible manner. And given women's responsibility for healthmaintenance and sick-treatment, policies must also aim tobuild women's competence in these areas.* While it is clear

that policies in many sectors-health, nutrition, familyplanning, education, employment and others-are relevant, thehealth sector bears major responsibility for providing care andbuilding competence, so I shall focus particularly on its role'

Adopt the household as the unit of health care delivery.Despite the strength of association bctween 'household' and'heallh,' a focus on the household has eluded health plannersand practitioners, However, given the inadequacies of the"individual-oriented" and "community" approaches, healthplanners would do well to follow anthropological practice andadopt the household as the primary unit of health care.

A household-oriented approach would focus on the specifichealth problems that impair the functioning of the householdas a unit and its (short- and long-term) economic viability. Itwould be concerned with the intra-household distribution ofhealth resources and the members who are most disadvantaged,investigate factors that determine bealth such as hygiene,availability cf food, knowledge about health and child care,and access to external health services and seek to improve thcse.Thus an operational view of the household as the main pointof delivery for health care would be considerably different fromthe concept of target groups for health programmes andfrom the "community as the entry point" for health. As a keyhealth resource, womcn's roles in health care provision would

*The use of the word 'competencc' is not at all intended to imply thatwom€n are "incompetent" in matters of health but rather to sigDal theneed for policics to deal with factors underlying health.

92 Implementing Health Policy

be acknowledged, and emphagis placed on aiding women tofulfill this role for the bettetrment of the health of thehousehold.

Focus on women as "providerf" and "beneficiaries" of healthcare. A primary, preventive and commuoity-health approachmust necessariLy focus on wotnen as the providers of flrst-level health care within the hodsehold. However, tbe NationalHealth Policy Statement is silbnt on the specific issues ofreaching women in order to improve the health status ofthepopulation and of employing wymen in the health sector tocater to the needs ' of other women at all levels of the healthsystem. These issues are central to the Policy's proposed three-pronged strategy for achieving rlniversal health. In the absenceof specific suggestions for innovhtion, one is led to believe thatthe policy will be implemeqted through the only extantprogrammes which are intended to provide health care at thehousehold level-the Dai Trainifg Programme and the VillageHealth Guides' Scheme. In view of the lack of evidence todale that these schemes have hald any positive impact on the

need to be corrected if policy ogjectives are to be met.A household focus would re a reorientation of these

community health personnel.workers must be the home

modus operandi of fieldon which they can examine

household health in its totality, iinfluence its dynamics throughdealings with the 'decision- ' and main actors. andprovide the necessary hnkages tp 'health goods and services.'Some examples of this a already exist in the country

Services Scheme has made aThe Integrated Childbeginning by focusing the effi of a primary level worker onwomen and children (see below). Some private voluntarysector health programmes in different parts of the country havedeveloped techniques and (e.9. the "family folder")which have shown success and hre worthv of emulation. Withproper reorientation, basic female health workers couldeffectively provide household health care.

Given the gross 'underutilisation' of health services bywomen-alternatively, their "latck of access" to them-it isincumbent on the healrh systesl to increase the availability ofservices (i.e. their supply) and t0 improve awareness of them

93Organisation for Health

(i.e. demand). To do the latter the health system must itselfbecome more aware of the factors that constrain ,ability' and'permission,' as well as of those that limit perception of need.Although removing these factors completely may be a long-term development issue, the health sector can take steps to aidand accelerate the process by providing information andeducating the people. In this process (as well as in the planningofsupply), there is a need to ,consult'women as consumers ofhealth services. Existing womeu's organisations (e.g, MahilaMandals) could be used more effectively both for communica:tion and consultation. These organisations must be spurred onto provide a supportive forum for women to overcome theirinhibitions towards obtaining health services.

Improving demand, however, is purposeless in the absenceof improved supply for which several steps need to be taken.Health centres must be located where need is greatest andwhere women can approach them-and not based on .political'decisions. Attention must be paid to regional differences inthe adequacy of services, training of higher level personnel, andthe deployment of women at all levels including in decision-making positions. While the provision of an adequate referralinfrastructure 'is important, the supply and staffing of"primary-level" institutions is paramount. Female healthfunctionaries (particularly extension workers) must be mademore effective. There is a need for larger numbers, bettertraining, better support systems, improved sfatus, and greatermotivation. There is scope for better management. Women'sneeds and "demand" must be met by women because'permission' is limited by the fear of contact with malepersonnel. In addition to improved expertise, the attitudes ofpersonnel towards catering to women must change. They mustgo out and identify women needing health care. A change intheir attitudes could in turn change societal perceptions ofwomen's health care as a "waste."

In order to plan health services for women a complete andaccurate picture of the health problems of women based oncommunity-wide morbidity surueys rnust be obtained. Suchsurveys are virtually non-existent and it is not adequate to inferneeds at the local level from macro-demographic data.

94 ImPlementing Health PolicY

Inherent in this requiremfnt is the need to include all

women in the household i{ health development efforts'

Although the terms 'mother' or 'maternal' are sometimes

applieJto all women in the regroductive age group (15 1o ?5

y.urs), tn.t" are major reasons why the ambit of -health

prog.urn.., concerned with repucing female and child mor'

tiaiy uoa mortality should be pxtended to a// women including

young girls and 'grandmothers' who are important members of

iheir current or future houfehold. Besides physiological

functions, psychological preparltion for family-building occurs

in the pre-iubertal period dnd decisions about education'

marriage, first conception take $lace. Grandmothersi mothers'in-

taw wio' are excluded from MCH programmes because they

fruu" ..ur.a reproduction, exbrt powerful influences on child

care practices and decision-maliing within homes'

Furthermore, as we havO seen, it is not adequate for

health services to consider onfy the reproductive and maternal

health of women even if the Srime concern is with childrcn'

..- Gott.rnood" is intricaibly' linked to other aspects of

women's health. Thus there i$ a need to gather information

t"y*a *ornun's reproductinb histoti"t - to include general

freatth proUtems, other womenlspecific health problems' health.-- --.:r:^^+:^- --,1 i-fnrmdtinn ahorrf women's attitudesservice utilisation and inform4tion about women's attltudes

to health problems and services' Data gathered must be put

into the context of womenfs "status," including place of

residence, type of household, education levels, .employmentand so on' Knowledge of the interrelationships between

women's health, nutritional st[tus, family formatioo patterns'

and socio'economic factors can help achieve a comprehensive

understanding of their needs abd evaluate how the services are

meeting women's needs.

Pui Family P lanning in its place. The evidence of conflict

between tradltional norm, un{ practices and state policies is

most obvious in the arena bf family planning' For at least

the past two decades, steri]lisation has been the premler

methoO of contraception prpmoted in the National Family

Planning Programme. A "oneitime" method such as sterilisa-

tion is deemed appropriate b{cause of the problems ofaccess

to women in rural areas, theif illiteracy, theil lack of time

to travel frequently to heafth centres, and their lack of

Organisation for Health 95

privacy within joint or crowded housEholds. However, a storyof the repercussions of a tubectomy operation on a familyby Pettigrew (1984), poignantly illustrates the failure of policyto take into account realities facing rural women.

Women who have undergone tubectomies frequentlvexperience post-operative pain, but this is not accepted eitherby society or the medical profession as a legitimate complaint.Consequently, women must continue to perform their laborious.tasks following tubectomy although they may need and wantto rest. Pefiigrew has described the nature of these tasks,collecting fodder and firewood, making dung cakes, caring foranimals, collecting and preparing food, doing agriculturalwork and so on ad infinitum and the amount ofbending andstretching and exertion involved in them. In the incident, awoman labourer who had undergone a tubectomy was insevere pain but was forced to work in the fields at harvesttime, and to collect firewood and fodder as usual. Therewere apparently no other members in the household to takeover her work. Under the circumstances she expected hereldest child, a l3-year old daughter, ro help; but the child-already engaged in paid work herself-was apparently"playful." This enraged her mother who kicked and beat her,causing her accidental death.

The effect on the household-and on its health andnutrition-was proflound. The mother had lost her main helper.She had one son and other female children who were too smallto labour. She could have no more children because of hertubectomy. After the death ofher eldest daughter, she beganto foster her only male child by giving him the milk whichshould rightly have gone to the youngest-a female child whowas suffering from third degree malnutrition.

This episode illustrates how family planning policy over-looks the social context, pointing out how concepts underlyingpolicy may be inappropriate. The application of the .,small

family norm" to the poor rural household where there is ahigh risk of child death on the one hand and a high demandf,or children on the other is clearly erroneous. Thus, familyplanning policy disregards health realities, the vital economicroles children play in the household, and the social demandson.worqen.

96 Implementing Health PolicY.

Second, the manner in which policy is implemented may

be wrong for given tho type of work rural women must

perfogm the promotion of tubpctomy may be inappropriate'

Pettigrew contends that the emphasis on tubectomy has resulted

because "doctors" (health $lanners and policy-makers) are

out of touch with the needs a4d circumstances of rura'l women

and do not consult them. Thd priority given to sterilisation

reflects the preference of state health cadres and medical

professionals, and not of women' From a woman's point ofview, the goals of family plairning policy should be to ensure

the healthy upbringing of chilldren and tbe health of mothers'

eliminating unwanted pregnarfcies by substituting'contracep-tion' for abortion.

Third, Pettigrew points io the lack of linkages between

family planning and health dare services-a failure of bothpolicy and implementation. $he alludes to the unhygienic

clinical conditions in which stdilisatiotrs are performed' There

is no post-operative follow-up and care although healing is along process made more difrcult by women's work' The

generally negligent attitude tqwards women's health on the

part of health service provid$rs can generate intra'householdconflicts and the kind of tragedy described here. In the past'

women have been viewed solely in terms of their "links"' Afocus on mother-child and husband-wife links led to the narrowpursuit of family planning o jectives with maternal and child

health services in adjuncttake a "task-o.i.nt.d-' ui.t

nutritional impact has notgovernment intervention in

the future, health Policy must

f women-PaYing attention tohouseholds and societY, Parti-

been assessed. Besides these'

the sohere of nutrition consists

the roles they perform wicularly to their roles as care providers.

Integate Nutrition Careanother priority problem me

Heatth. While nutrition is

tioned in the National Health

Policy, there is no compre policy for the imProvement

of nutrition at the househo level. Although the sYstem offood distribution through F Price Shops and the Food-For-

ntee Schemes aim to increaseWork and Employmentthe quantities of food a e to poor households, their

of supplementarY feeding and the Integrated

Child DeveloPment Services (ICDS) Scheme, an integrated

Organisation for Health gj

health and nutrition programme. These are targeted atindividuals- young children of pre-school age, those in school,and pregnant/lactatin g women.

A common problem the latter programmes have faced hasbeen their- failure to induce women to attend, once againbecause of social strictures against women congregating oreating in a public place, or because of their lack of time.Programme designers or workers sometimes attempt to over-come this difficulty by giving the food supplements as ,,take-home" rations or delivering them to homis. The rations arethen often shared among household members_particularlyin poor households-and so the programmes' impact on thetarget group is'diluted.' Target members are also often facedwith "substitution"-they are denied their normal share of thehousehold pot because they receive the external food supplement.As additions to thc total household food supply, the rationsgiven are small-usually around 300 calories p"iJuy fo, u yooogchild and 500 for a pregnant or nursing molher comparedwith an average daily household requirement ofover 10,000calories. Thus, one could conclude that supplementary feedingschemes largely ignore the household *ot""t, failing to seea mother or a child as a member of a largei unit or groupof kin.

The ICDS Scheme combines supplementary feeding ofchildren and mothers with health che"k-upr, ilmunisation,pre-school education, health education of mothers and referrals.A village-based anganwadi worker is responsible for enrollingevery pre-school child and pregnant women in her village in theprogramrne, for monitoring their health, for providing theabove inputs, and for referring those in need of special care tothe ANM. Although the locus of activity is the anganwadi(day care centre), some workers are motiv;ted to visit homes to"investigate" ard "follow-up" their clients. In the house-holds, the workers are able to demonstrate tasic leattn tech-niques, such as the use of oral rehydration during diarrhoea, toidentify households in dire need of food o. oih.. inporr, tomotivate women to seek health care, and to link inem to ahealth para-professional when necessary. Although not withoutits shortcomings" the ICDS Scheme holds out

"r"rn. Ir"p."*

necessary health care.

Portctes tN ExrnelHeelru Secrons

To meet the health needs of wonien and households, policy must

bxtend beyond the health sectorJ. Demographic literature has

arnply illustrated the liriks betw{6n women's education, occu-

pation and lfertility, and we ave shown that malnutrition'

high morbidity and mortality arb also related to women's low

stitus. lack of education and dmployment opportunities' (Of

€ourse, these in turn arc related ito broader issues such as child

Iabour, women's political parficipation, technology, and so

on, which must be left to be deallt with "lsewhere).

Thus, there

are health implications for in in other areas such as

women's education and employImprove lYomen's Education

rural areas cannot assert theirWomen, especiallY those in

ight to or need for health care

if thelr ls6k even elementarY ed

by personnel in contact wiimportant, many health proand practices which maY notledge alone. Thus, policies to woman's formal and non-

formal education arc of immedi te relevance and concern:

Provide women emPloymenton the household as the unit o

sidering its econornic viability.

th support services. A focus

health naturallY entails con-

this context, the Provision ofemployment (income) for the nomically needY is a necessary

health input. Given the positive effects of women?s

emploYment on health, women ould be a target of such efforts

household). In view of the(especially when theY head

trend of declining female in the labour force,

spocial efforts must be made to increase women's access toskills, and io the "means ofwage work, to the necessary

on. While health educationwomen and households is

are rooted in beliefs, attitudes

influenced bY health know-

Organisation for Health gg

programmes to provide institutionalised child care (e.g. ICDSand Balwadi schemes) are important. Thus, attention must bepaid to providing "support services" such as creches, childcare centres, maternity benefits, nutritional support, familyhealth check-ups, and so on, along with employment schemes,to avoid the possible adverse consequeuces (on child health) ofwomen's employment.

There is also a need to ensure ,compatibility' between

policies which affect women and health. For example, bolhwomen's participation in the labour force and iprolongedbreastfeeding are promoted for their contraceptive effects.Prolonged lactation is a traditional method of child spacing,while female employment discourages child-bearing. Eachstrategy also has its independent benefits-greater women'sautonomy and status in ths case of increased female employ_ment, and better child health in the latter case. However, thesestrategies may also conflict with one another : it is difficult fora- woman to avail of employment opportunities outside thehome as well as breastfeed her baby full-time. .Compatibility, inthis may be ensured by providing maternity leave a-nd benifits,and creche facilities.

The "possible adverse consequences,' arise not only from thefact that women are employed outside the home, but also fromthe conditions under which women work. For example, ifwomen lose their wages or Job security' when absent, they willrefrain from using health services. On the other hand. if accessto day care facilities is provided, women could better feed andcare for childien without straining the economic situation ofthe household. Linking. health jnsurance schemes to employ-ment programmes will increasc demand for health services andimprove health. It must be recognised that health is a majorfaclor affecting productivity-including women,s_and poten-tially alleviating the poverty of households.

In new prescriptions for natioiral health, community participa-

tion in health care is regarded as a basic and essential ingredient(GOI, 1982a; ICSSR-ICMR, 1981). The diagnosis that calls for itis clear. After three-and-a-h4lf decades of building the physical

infrastructure for health servides, training and deploying man-

power of various cadres, and generating the know-how and

iechnology for health care, thp government health system is stillnot reaching a large proportiqn of the sick, the needy, the 're-

mote' and the 'vulnerable.' Tle country's high levels of mortalityand morbidity are evidence that the rnajority ofpeople possess

neither the 'goods' for health fraintenance (adequate food, clean

and abundant water, a hygieniic environment, and knowledge),

nor have access to the services that could decrease the severity

and improve the outcomes df illness. This lack of access is

due in part to the centralisdd nature of health care facilities-only towns and major villages are effectively served by the

public health infrastructure, and in part to social and economic

constraints to the utilisatiod of these facilities. More oftenthan not, the poor woman or child in need of medical assistance

is physically isolated from, edonomically unable to, and socially

prevented from using such hedlth facilities as do exist. "Corn-

munity participation" is seen as the way to get arouod these

problems, besides being a 'good' in itself. By vesting certain

health functions in the comnunity, the reach of health services

Community Participation in Health Care

is extended, atrd the links established thereby beiween com-munities and health service providers can increase awarenessof and engender rational and efective use of higher-levelservices.

The slogan "peoplo's health in people's hands" thus has adual meaning : people must assert thefu right to (i.e. demand)better health, as well as undertake theft responsibilit), to assistthe process of improving the supply of services. Their parti-cipation in the planning, implementation and evaluation ofhealth programmes will allow them to exercise both thesecomplementary roles.

Tun Omcrns

Historically, thought and action in the health sector havederived their inspiration from the prevailing development ethos.During the 1950s, when the country was concerned primarilywith the establishment of infrastructure and with technologicaldevelopment, the agenda in the health field consisted mainlyof building hospitals, establishing medical-scientific capacity,and training doctors. The 1960s emphasised the "ditrusion ofinnovations," leading to the spread of health centres to ruralareas and mass campaigns against specific diseases such ascholera, malaria and smallpox, and for immunisation andfamily planning. The "basic needs" approach of the 1970s sawthe expansion of outreach schemes : increased numbers of trainedpara-professionals, orientation of doctors to rural health, mobileclinics, and the like. This trend in primary health services ledto the search for "alternative" rural health programmes in the1980s. Current development ideology is flush with terms suchas'community-based,''village-level,''appropriate technology,''self.reliance,"integrated development' and contemporarydpproaches to rural health are peppered with the same notions.

Although the concept of community participation may haveroots in ancient history and philosophy, it owes its currentwidespread use in the health sector largely to the Declaration ofthe World Health Assembly held at Alma Ata, USSR, in l9?8(WHO-UNICER 1978). At that conference, primary healthcare was promoted as the way to achieve a more equitabledistribution of health resources and attain a better levol of

l0l

health for all, It was defined as care which.is "universallyaccessible to individuals and fa{nilies in the community throughtheir full participation and at a cost that the community and

102 Implement itrg Health Policy

country can aford to maintain at every stage of their develop-ment in the spirit of self-reliancp and self-determination" (italicsadded). However, as the 's promotion of communityparticipation has been greatlywith community-based health

bythe Chinese experienceone must go back a little

farther (Djukanovic and 1975). Immediately after 1949,China gmphasised mass mobi[isation for many developmeittasks to which her political aud social revolution was commit-ted. In health, people particip{ted in campaigns to eliminate

improving the country's he major diseases and $eatlyFollowine the Cultural Revo-

lution in 1965, tho "barefoothealth workers were trained

or" was fostered, part-timefinanced to provide basic

health services for individual prpduction brigades and communehealth centres $/ere strensthen

statements, plans, and or interpretative analyses, The

disease-carrying vectors andhygiene, thereby eradicating

report of the Ramalingaswamidescribed an alternative m

sanitation facilities and

ee on "Health for All"of health care which "is

cnange.As a result of this and othgr examples of community-based

health care from different parts of the world, the focus of worldhealth planning has shifted f4om the individual to the com-munity. Echoes of Alma Ata albound in Indian health poliqy

strongly rooted in the ty" (ICSSR-ICMR, l98l). TheRevised Twenty-Point Prograon a voluntary basis "as a peo

called for family planning's movement" (GOI, 1982b),

.reflecting the reco iQns of the Working Group ,onPopulation Policy (GOI, 1 ). The 1982 National Health.Policy states that "the ul goal of aohieving a.satisfactory'health status for all our secured without

'Communtty Participation in Health Care 103

involving the community in the identification of their healthneeds and priorities as well as in the implementation andmanagement of the various health and related programmes"(GOI, 1982a). It bolds that the success of primary health caiewill depend on the "building up ofindividual self-reliance andeffective community participation."'

Wnv Colruuury PARTrcrpATroN?

Clearly, it is the desire to universalise access to health care thathas made communitli participation an 'ideal' in the health field.fn order to be accessible, health services must be spatially andculturally close to people. Indeed, primary health care is, bythe WHO's definition. health care delivered in homes. schoolsand places of work (WHO-UNICEF, lg78). Tbe obvious wayto do this is to train health workers who have ready access tothese places. For universal health care to be "at a cost that thecommunity and country can afford" reliance on low leveltechnology and labour-intensive strategies is advocated for lessdeveloped countries. Hence, health services will be "community-based," staffed by village peopte.

Certain other attributes of primary health care also makecommunity participation in it desirable. It focuses specialattention on vnlnerable groups whose identification is madeeasier by familiarity with a community. It stresses pteventivehealth strategies which can be enhanced through mass mobilisa-tion and mass education. While community-based healthworkers can deliver curative services and impart some healtheducation, many preventive health activities call for concertedcommunity action. To ensure effective primary health servicedelivery, the formal health system is supposed to be responsiveto the needs of consumers, to be culturallv acceDtable. and toassociate with tradiiional forms of health

'care,' all oi which

require an intimate understanding of, and communicationwith, "the people." This is translated into an explicit call foithe involvement of people in the design, implementation andmanagement of health care. Primary health services are alsosupposed to be integrated with other "community development"services, such as agriculture, education, public works and hous-ing, and communications, A final explicit principle of pr.imary

104

- -f

Irnplementing Health Policy

health care is reliance on available community resources, humatrand material,

Although ourrent policy an{ plans espouse these conceprs,there is little clarity about thp requisite nature of communityparticipation in health, how it can be brought about, and whatspecific outcomes can be expected. It remains an elusive,perhaps even illusory, goal to the vast majority of those con-cerned with providing health selvices and to "the people" them-selves. Even where rationale dnd purpose can be elucidated,'feasibility' and 'necessity' may 4eed to be examined,

Accordingly, we should olarify what is expected to beachieved through community pafticipation in health. For thisit is necessary to define what is rireant by "community participa-tion:" In what ways can peofle partioipate in health care?For what objectives? One must then examine the strategies pro-posed to bring about community participation in health : Whatis to be done by whom? It is useful to recall previous experience,drawing lessons from earlier attempts at eliciting people'sinvolvement, Jo assess the 'feasibility' of bringing about parti-cipation one can ask: Can the expectations we have ofthepeople be met within existing social, economic and politicalconditions? One can identify spme basic problems facing com-munity participation and, perhaps, isolate factors that facilitate,as well as those that mitigate 4gainst it. Finally, one shouldpose the question about neceqsity. Although it is dpfinitelynecessary to improve health in village homes, is "cor{munityparticipation" in its formal seasp a necessary condition fpr this?Are there more fundamental pyeconditions to bringind aboutbetter health which will inmaking it a natural outcome of improved access to healthservices? In fact, are these nqt preconditions forparticipation itself? In thecommunity participation so

be left ultimatelv with anas the limits of communityIndian society and its healthdistinct from what is ideal buf may not be feasible, or what issimply expedient,

Community Participation in Health Care

Nerunp or Colruuntrv PaRtrcrrerroN

The spectrum of participative possibilities in health care is wide,albeit discontinuous. At one end, people m'ay simply be passiverecipients of information and services which are conceived,designed, delivered and controlled by others. They are, how-ever" "participating" to the extent that they make an effort toavail of these services (i.e. they are exercising their right tothem). In some instances, they may contribute to the services.in cash or kind, as fees or in the form of insurance premia.Besides deferring the costs of the Services, such contributionsprovide an incentive to the service personnel or act as a'guarantee' that seruices will be available,

Another form of participation is the involvement of certaia"representatives" of the people in the planning of.or decision-making for the health programme which, however, is stillimplemented by outsiders. Village-level committees may simplybe forums for stating opinions and preferences, an advisoryboard which lets the health service providers know what servicesare desired by the people, where the health clinic should belocated, and so on,

The people may be requested to identify their health pro-blems, needs and priorities so that the health programme ismade "relevant" to them and takes into account any constraintsfaced by its intended beneficiaries. Instead of arising out of thepredilections of health planners and professionals, ifa healthprogramme is based on local "felt need," it is believed it willbe more acceptab'le, used more effectively and be more satisfy-ing to the people.

Participation can end with such consultation or it canprogress toward community action. Services move from being"community-oriented" (i.e. directed at the people) to being"community-based" when the people are "conscientised" andorganised to participate in their delivery. However, eveninvolvement in implementation may take a variety of forms.The community (or its limited representation) can select anddeploy health workers, identify specific beneficiaries, raisecontributions towards the health programme, perform specifichealft tasks, etc. Towards the most'active'end ofthe spectrumof com,munity participation are efforts which require initiative

t05

106 Implementing Heahh Policy

on the part of .the comm in the design, implementation,management, and evaluation f the health programme. The

community has full control-ultimate is rbached whenfinancial and the health prograinme and isresponsible for its main

Thus, community partici n in health care can progressfrom, 'receiving' to contri ing, advising, decision-inaking,initiating, implementing, lling and supporting health pro-grammes. It is clear that this is spectrum of increasing respon-sibility placed on thb people fo health care provision. Calls forcommunity participation incommunity to be involved iu

th most often intend the entireplanning, implementation, and

control of health care. This includes decision-makin s aboutprogramme objectives and pri dties, activities and methods :

what is to be done, to whatdegisions; contributing in cash

and how; implementing the

gramme; sharing in itsr kind or labour to the pro-and monitoring and evaluating

it. It is taken for granted thatincrease with their increasingwhether such involvement is

the benefits to people's health

ssible, wethese benefits are expected to a

BsNsprrs or C NIry PenrrcplttoN

Community participation is pected to bring about betterhealth in a number of ways. e's health consciousness and.knowledge are expected to and result in better healthpractices among individuals, ilies and communities, in placeof existing harmful or ineffecti ones. Demand for basic healthis expected to ensue and access health care improve at thesame time through the promunity-level workers "at the

ion of basic health aid by com-oorstep." Stress on preventive

measures undertaken at the ividual and community leVels isexpected to reduc€ the need fi curative care while increasedawareness of higher{evelconsidered use. In this wav

encourages their timely and

of health facilities is tackledprobleni of "underutilisation"

d the distribution of health care"improved."' Community ipation is also expected,tobring about improvements in

volvement. Before determiningshall examine hdw

community level health 'infra-and sanitation, through mass'structure,', sucft as: \ryater

Community Participation in Health Care

action. It will also indirectly improve the distribution ofavailable resources .through increased awareness of basic needs.

While there is no doubt that each of the above exoectations-increased awareness, demand for health care, improved access.to services, public health improvements, more equitable distri-'bution of resources, and participation in development-lie onthe path to better health, they cannot be easily equated withspecific.health outcomes. In the absence of ways to fteasure thdhealth benefits of participation, it is difficult to 'evaluate' theeffectiveness of community parlicipation as a strategy for health.The strategy has, however, gained credibility from experiencein the non-governmental sector. Many voluntary health agencieswhich have succeeded in reducing mortality, morbidity andfertility consider people's participation a key to their success(see, for example, ICMR 1980). In order to assess the viabilityof the strategy of people's participation in governmeht healthprogrammes, therefore, it would be well to look at theseexperiences, examining, especially, who participates.

Wno PeRrtclparrs?

Efforts to elicit community participation in health care havebeen widespread in the ongovernmental health sector,although each is admittedly on a small scale.x A commonapproach begins with a meeting of project personnel (almostalways outsiders) and village leaders (usually panchayatmembers) to solicit support for the proposed health work. parti-cipation in the dialogue may be enlarged to include leaders ofvillage social organisations, such as mahila mandals, yuvakmandals, and krishak mandals, and key village-level func-tionaries, such as school teachers and post-masters, Almos[by definition, these people represent the "ruling elite" of thevillage. Althciugh the voluntary health group may itself beoriented towaids the poor, direct approaches to them are con-sidered risky if not impossible whilc contact with village leaders

' *A fulle! examination of'the voluntary health sector is present€d in' Chapter 6, Tbe discussion that foilows here is .based .9n the sa$c' nritiirials and sources. See also Bang (1983), Chbudfiury (1982), FRCH

(1981), Jajoo (1984) and Ramprasad (1979).

r07

108 Implementing Eealth policy

is seen as a necessary step t$ establishing credibility. Thevillage health committee which rhay subsequently be forrned isinevitably dominated by high castes, the economically better-off, and males, to the exclusiorl of those rvho are most i.n needof health care,

Frequently, attempts to widpn participation follow. Villagemeetings may be called (even on a regular basis) at which

,people are asked to identify t[eir problems and make sugges-tions. In the presence of the dotninant minority which demandssophisticated facilities, a or the latest technolosicaladvance, the poor majority may refrain from expressing theirparticular needs or pressing demands. Ultimately decisionstaken by the health service providers generally reflect theopinions and needs of theupon to accept certain

ff, The latter may be pievailedsuch as street-paving and

drainage; but mobilising their to bring these improve-

munity to support the worker a4d defray other health care costs(eg. that of drugs). A village fiealth fund may be established,with villagers contributing accoiding to income, land-holding orother assets. A not-uncommon procedure is to deny free healthcare to those who do not levying fees on theminstead. Thus, those who afford regular contributions,

the services; if they cannot

ments to the poorer sections ofthe village more often than notproves an uphill task. Being higher caste, they are generally notsupportive of common latrines; and only the more philanthropicwill contribute toward 'commorf goods,' such as feeding pro-grammes. Neither the rich nor the poor are really interested inhealth education, the former deeming it a waste of time on thepart of health service providers, while the latter cannot utilise

i.c. the poorest, are not entitled

Community Participatton in Health Care 109

afford the fees levied for the services or drugs at the healthclinic in emergencies, they do not utilise them. The presence

of trained health personnel in the vicinity relegates CHWs tosecond-class status and even the poor may be reluctant to availof their help.

As the health group begins to focus more attention on thepoor and intensifies personal contact with poorer households,the interest of the village elite begins to \ryane, Because they arebetter-otr, they have fewer health needs, but they begin to resentthe higher contributions they make to the health fund, or thehigher fees they pay for services.

Thus, over time, their contributions decline. When thebetter-off back out of supporting the health programme, it oftenfails. A.lternatively, as Bang (1983) has suggested, in order toforestall such an eventuality, the heaith programme increasinglyfocuses its attetrtion on the rich to the detriment ofthe poor.

There are, of course, examples of health projects which haveovercome these problems by expanding representation to includelower castes, tribals, women and so on, by cajoling or pressuris-ing the elite group to pay more heed to the needs ofthe poorand thus sharing health benefits more widely (Prem, I980; Roy,1985). Usually however, voluntary organisaiions choose tomaintain a profile below the level of reckoning with the villagepoiver structure, by limiting their objectives to service delivery.Conflict with the power structure is exacerbated if the healthgroup attempts to attack some of the underlying causes of illhealth among its clients, such as unemployment and poverty,by undertaking other development activities. and by "conscienti-sation." Such efforts are viewed by the elite as a direct threatto their economic and political positions. Most often suchconflicts are 'resolved' by appeals to higher,bodies (for example,a recalcitrant panchayat may be set right. by a Zilla Parishad towhich thg project leader has access), and rarely by grassrootsmanoeuvrqs (Sethi, 1984).

, Perhaps a major lesson to be learried from the btperience oftl_ro voluntary sector is that universalising .laealth, by. goirtg.'beyond service delivery tg "awakening people's consoiousness"aboui,health .pnd its determinants is a process fraught withconflicts. Th,g rgsolutiqn lof suoh. conflicts: requires intense '

personal efforts and charisma, an abilily:. td . foous, on orucial ;

BnrNcrNc Asour Panrrcrferrox : pAsr ExpERTENcB

From the foregoing discussion of what constitutes participationand who participates, one oan bee that tho nature and extent ofcommunity participation are det{rmined to a great deal by theagency charged with stimulating it, and the processes used to doso. A basic assumption of the cal[ for community participation inhealth by the government is that cooperation from uod u-oogthe members of a village community . to solve health problemscan be stimulated by agents of ttie governmental health^ system.Tbis is somewhat reminiscent of the Community DevelopmentProgramme of the 1950s anb 60s in which governmentfunctionaries were sent out to promote a better standard ofliving among rural people by aw[kening their .,natural,,

tend_ency to self-help, cooperative deciision-making and action (Dey,1970; Gaikwad, 1981; Madan, 1933).

Despite the decades that havp intervened, there are markedqimilarities between the primary Eealth Care and CommunitvDevelopment Programmes, perhaps attesting to the cyclicalnature of development "fads." For exampli, both purport toencourage local initiative rathef than impose outside plans,including local determination of $riorities, cooperative planningald decision-making between go\t€mment and people, contribu-tions of labour and ojher resourceb, and local paiticipation in theexecution of decisions. The strategy of having community leaderscarry out the programme, with orily technical guidance and gen-ergl coordination provided by ouisiders, is also common to bothprogrammes. Another poiat of sjmilarity is the requirement forcoordinition between multiple golvernment agencies (e.g. health,agriculture and education). att$ougtr prim-ary haalti care isentrusted to a single sector inl the main, its frulti-sectciralobjectives require coordination bdtween sectors, just as did the .

Community Development progrdmmq ;whioh was conceived of ,

as an inter-sectoral effgrt.

Community ?articipation in Health Care !! t

A key assumption.in both programmes is that the bureauc-racy and community leaders will share power, responsibilityaqd benefits widely with the people. Htweve.r, one of, themost significant lessons of the Community nevefofment erawas that this does not happen automatically. Witnio th"bureaucracy, inter-departmenialrivalries stymiJmulti_sectoralaction.- A lack of cooperation between tle bureaucracy andpeople's institutions slowed vertical flows. At the village level,local leaders, reluctant to share benefits, pr.u.o,.J efectiveimplementation. Thus, the government efort to mobilise peoplefor community development (which included health and nutri.tion components) was largely a failure.

Since the Community Development era, rural India hasexperiencsd considerable infrastructural development, includingthe growth of Panchayati Raj institutions

^and cooperative

organisations. These were created to act as links between thepeople and higher level government departments. Numerousdevelopment prograrnmes have been channelled through them.The current call for people's participation in health could restwith the participation of such institutionsin th" de[;;i;iIiealth se_rvices. However, a major question *oufJ-u.irc out ofsuch a formula : in the matter ofhealth care, will puo.nuyutr,mahila mandals, and so on represent and cater to the mass ofpeople (the poor and the needy) orjust to the dominant elites?The experience of the voluntary sector, as well as of otherdevelopment programmes, would seem to show that linksbetween such institutions and,.the people,, are weak ;. ;;;;missing. If they do not cater to the poor, chanelting health carlthrough them fuould be pointless becausi the majoi reason forpeople's participation in health is aniverial o""rrr,'. In contrast to the Community Development programme,sconcentiation on economic matteis and maierial imprJvements,

lg.-u.1tity particip_ation in health is aimed against social injus-

tlce as the cause of underdevelopment. The objective is largelyto increase the demand for social goods and produce equality inT:ess t: health. However, in vi=ew of rura^i ,.utiiirr]r.o"r"ali:.11r_r-ii l"""ple's

participation musr clearly be accompaniedoy a search lbr new ways to bring it about.

r12 Implementing Health PolicY

Cunnrxr Srnerrctes

A strategy recently developed to bring about communityparticipation in health is the and deployment of village-

level health workers. Mode on the Chinese barefoot doctorvoluntary health agencies, thebut tried and tested by

Community Health Workerh 1977 (GoI, 1977). The

introduced on a national scale

me itself is participatorY and is

also intended to bring t wider participation in healthealth Worker is a member of theactivities. The Community

community, selected by the co unity to provide basic healthservices "at the doorstep." an accountable to them. The CHWinteracts with the formal th svstem on behalf of the

community and is paid a monment. The worker is also

y honorarium by the govern-responsible for motivating the

community to identify its c health problems, organising itto deal with them, and gen

in health activities.There are some between "iommunity develop-

mgnt workers" and " health workers" which make

the latter scheme novel, In tlte Community Development Pro-gramme, the workers came from outside the village and were

g the participation of peoPle

considered government func{ionaries. Their mandate was todemonstrate techniques and instruct villagers to change theirways in accordance with cdntralised decisions. Communityhealth workers, on the other hand, come from within the village'

and thbir main role is conceivdd as one which draws upon indi-genous stores of knowledge, lalbour and resources.' However. there have been beveral evaluations-at the micro-

and macro-levels-of the CHW Scheme which point out prob-

lems with its participator! intentions (Bose er al', 1978;

Dandekar aird Bhate, 1978; Saksena, 1978; Ghosal and

Bhandari, 1979; Maru, 1980f Bose and Desai, 1983; NIHFW'1978, 1979, 1984). First, althcr]ugh the CHWS are indeed resi-

dents of the i'illages in which tbey work, the communities at

large rarely seleci them (Vohrd et al., 1978;Bhatt et at., IgSlJ.Insiead, selection is carried Qut by.village leaders (members ofthe panchayat) who view th€ scheme as dnother opportunity for

Community Participation in Health Care 113

nepotism or to hand out political patronage.* Despite theinvolvement of the health centre doctoi, the sti-pulation thaf theCHW.must be acceptable to all membeis of the community isoften iguored. Thus, frequently, CHWs belong to a particularfactionof the village and cater solely or primaiity to it, often tothe.neglect ofthe poor and the needy. Also, in the past, themajority of CHWs have been men, and, as is culturally pres-cribed, women and children have largely beeo excluded fromtheir ambit.**

Second, the CHWs are trained by ..outsiders,, who have a

different value system regarding heaith practices aoj the.efor"attach importance to converting the ways of village peoplerather than

.building on indigenous knowiedge ana ways. fh"qemonstratton approach" is very much a part ofthe functionof CHWs. Much is, therefore, imposed from the outside ratherthan locally generated.*** There may be essentiar differences be-tween what is considered desirable.by the programme,s designers

l^11,,r,r"f .: and^ "the people,' (e.g. smail famities vs. large

lamrltes). Even if there is agreement on priority needs, theremay be divergences of opinion on the means- to aclieve certaingoals. For example, villagers may not see community latrines asan appropr,iate means to bring about improved healih althoughth€se- are usually well regarded by heaith planners: Thus, tieCHWs are caught between two fair$ disparate ,.is of .*p."t_ations.

.,, Third, although the scheme is frequently welcomed byvillage people who have heretofore tett letptess in dealing withtheir health problems, their interest focus-es on the curative.care which CHWs are trainecl to provids. tlnAeeO, oiteo,

*Only rarely are there instances of other village organisations (e.g.mahila mandals) being involved in the selecti-on .f"CHk or in anyother aspect of the Scheme.*"To r-ectify this problem, the Iggl Joint Councils of Health and FamilyWelfare recommended tbat all future CHWs seteJO Ue women, sothat the pressing tasks of maternal and child t

"uftfr- ,,'uy

-U" ,""r, ,o(GOl, I98la)

***Inj31d, to the extent that. participation io health is rarely perceived asa high priority, even rhe CHW Scheme is ," ,1rnp..;ii"'". ilnd rherearg instances of friction between CHWs unO ioO'ig;oo. pru"tltion".swho perceive each other as competitors.

Although the curativo"entry point" into theparticipation in health

1,14

people proPose that the worker

Implementing Health PolicY

a fully qualified doctor!).is intended to be the CHWs

to enhance community

, in fact he rarely progresses

beyond it. This is in part dud to the fact that the demand for,curative care out-strips the (two or three hours a day) the

vention of various diseases an about practices that promoteparticipation in specific Publicgood health, to encourage

heaith tasks, and to refer them to the next level of health service

(the MultipurPose Worker) in of need, However, the CHWunicating with, organising, oris not trained for his role in

mobilising the communitY' Th tbe preventive and promotive

tasks which are the crux ot health care and require

collective action remain save a few discrete ones such

as wel.l-chlorination or organising children to receive immunisa-

tions. The intention to Pro people's participation in health

through the community health worker therefore is still-born'

Fourth, the CHW is not rted by the community but

comtactio

is paid a small stipend by government. This immediately

makes him beholden to the bureaucratic apparatus which pro-

cesses his paYments' F re, to acquire the drugs and

supplies to carry out his curati]ve function, the CHW must align

himself to health sYstem In practice, therefore,t functionaries than likeCHWs behave more like

communitY members. . the name of the Scheme was

changed in 1980 to Co Health Volunteers' Scheme and

again in 1982 to the "Health Guides' Scheme." They are. only

beholden to their co ieb in the sense that theY maintain

rworker devotes to health work' (The CHWs are only part-time

workers who have other econoniic and/or domestic responsibi-

lities). It is also due to. the fact that the overwhelming emphasis

in their training is on diseasb identification and treatment.

A perusal of the CHW Manual (MOHFW, 1977) indicates

thai the CHW is required to dducate the people about tle pre-

Community Participation in Eealth Care 115

to better paid jobs, iust as Community Development workers.did beforo them.To overcome some of these inadequacies, it was proposed

to set up v rage health committees as paft of the revised HealthGuides' Scheme in the Sixth plan period (COl, iSirul. fneintention is to elicit greater community involvement, includingthat of lower castes and women, and io clarify the relationshipbetween health worker aod community. It is, of course, tooearly to pronounce judgement on this additional strategy,although some possible problems have been alluded to earlier.

FUNDAMENTAL pnosrsr4s

From the three sets of experience described in the previoussections-that of non-governmental health agencies, the Com-rnunity Development programme, and the -ommunity HealthWorkers' Scheme-one discerns a gap between the view fromthe-top that community participetion is desirable and necessaryand grassroot realities in operationalising it. To close this gapone nust take cognisance of some fundamental problems thatface community participation in health care.

Village Cornmunities are IfeterogeneousTo participate effectively.in the planning, implementation

and evaluation of health services, a community *ort b. a groupwith a. collective capacity to make decisions, to mobilise human,material and financial resources, and to share responsibility foraction. However, in national development plannirg, the term'tommunity" is applied to a group of peoile contiinea within.a. circumscribed geographic area, such u,

" oittug" or an urban

slum. This bureaucratic rendering diverges frori socio_culturalreality, It is well known that these grouf. ur" extremeiy hetero_geneglxs, being divided by religioh, casd, class and clan. Suchstratification inhibits their ability to identify commonproUtems,interests and goals, and to work together as cohesiveirnits. Asdiscussed in the section on 'who participates,' in stratified villagesocieties, the rich are reluctant to share responsibility and bene-fits with fhe poor lest they tbreaten the power struJture. Con_versely, the poor are reluctant to join hands with the better-offas they feel the latter will corner the benefits (not withorlt

116 Implementing He al t h P ol i cY

historical justification). The commitment of both grouPs

is to family rather than to an rphous "communitY." Unless

unity concensus, communitYwavs are found to achieve co

action for health will remain a d issue.

This problem may be co dered semantic and the criterionuse of the term "PeoPles' Partici-of homogeneity avoided bY the

pation," implying that the

achieved through widesPreadal of improved health can be

vidual participation. However'

we must recall that the objective of people's Participa-tion in health care is to access of the most dePrived

{the poor, the landless, women

is their particiPation that isand children) to bealth care. Itsought above all; but the verY

factors that have denied access in the past to health-likely to prevent their Partici-producing goods and services

pation in the futwe, unless factors are temoved.

Health is a Low PrioritYAnother problem facing n in health care is the

low priority generally accorded to health concerns. The poor

family, whose resources (of labour. cash or kind) are

mostiy used up in the tasks of survival, prefer to "participate"

in what seem to them more Vital areas of economic life' Their

participation in programmes cpn be expected only if these are

seen to alleviate poverty. Unfortunately, health programmes are

women of the householdgrammes is constrained bY

their lack of information on

not viewed in this light ( they have not been Projected as

such). In tho normal course, y health care is left to theparticipation in health Pro-

onal-social norms. bY theirose

double burden of and domestic work, and bY

benefits of particiPating (see

Chapter 4). Only those

preventive health. Health beqomes a paramoxnt . concern only

when disaster strikes a famil]y in the form of major illness (pri-

marily that of the main wage ]earner). Although the poor heve

limited financial resources to ipend on private, curative treat-

ment, the concept of insurJance' against ill-health does not

exist, and indebtedness is a frfquent consequence of illness'

Even if the better-off can "afford" to participate in health

care, they are less in need of primary health services because

Conthunity Participation in Health Care fi7they have greater access to health-producing goods, to the ser_vices of local private practitioners, or to uriai hospitals in timeof.need. They too prefer to participate in progiammes thatbring economic gains and."un b, induced io -purli"iput"

iohealth care only if gains in power and prestige'are associatedwith the programme. Thus, they also accord"primary nealthcare a low priority.

Self-reliance is Difrcult-If not fnlpossibleThe terms "self-reliance" and .,self cire,, refei to tne abilityof individuals or communities to establish ancl sustain a systemwiich ensures health, relying on their own resources (Wirner,

1,977). They have emerged as a reaction against people,, d.p.o_cenc€ on centralised and professionalised health services whichare rnaccessible, unreliable and culturally unacceptable.

However, there are both historical unA pog-uti" impedi_ments to their achievement. For the maintenance and improve_m€nt of health, village people need access to four broad kindso_I resources : knowledge, technology, manpower and finances.However, traditional knowledge i,

"oi fuly

"qoipped to dealwith th€ prevailing disease pattern, as the persisLnce of high

morbidity and mortality in th- country attest;. It mav not beequipped at all to deal with the new dlseases_such asihe wide_spread chronic malnutrition which has replaced the acute starva_tion of famine, but is frequently not recognised as a preventable

.and treatable condition. With the adveni of modern medicineand other forms of 'modernisation,, rural people,s access totraditionat practices and practitioners has itself ieclined. For"Y1Ot., changes in family structures have often cut mothers:tI llom grandmotherly sources of advice.on child health care.As the competitive cash economy has replaced the cooperativejajmani system and enveloped traditional medicine men, accessof the poor to them has diminished. Among the poo, *no huu"scarce- resources, the gap between knowledge and practice maybe wide. Furthermore, a psychological .fir"'ut" nuJ.uo

"r."r.dover the years of public health service expansion (even in remotevillages) which places value on what eliies have and use_theparaphernalia of curative allopathic medicine (drugs, diagnosticequipment, injections). In the face of this dema-nd, ,trutrgir.

which emphasise indigenous kdowledge and technology alono

will not be readily accePted.

The mandate to utilise avdilable community resources ofmanpower and finance arises fri'om the belie[ that free or charity

services provided by 'outsideis' have increased dependency'

The Alma Ata Declaration call$ for services to be provided "ata cost the community can aifford" (WHO-UNICEF, 1978)'

However, poor communities lrave severely limited resources

which are inberently maldistributed. Although it is desirable topromote people's participation to enhance the cost-effectiveness

of health progtammes by ensu{ing their relevance, acceptability'

118 Imple ment ng He al t h P ol ic Y

utilisation and continuity, it is clearly unrealistic to expect poor

communiti€s to manage care (however low'cost) entirelY"myth of self-sufficiencY" has

-by the voluntary health sectorbeen explored-and(see Chapter 6). There are reasons why 'external' assis-

tance is needed for health effofts at the village-level' For one,

if people's knowledge and ths effectiveness of traditional prac-

tices are limited, as discussed there is need for at least

with their own resources. Thi

in water-supply, sanitation {nd nutrition need to be under-

taken. These call for both external manpower and finance.

Professional Comrnitmenf is LackingA reason often given for the inadequate functioning of the

CHW Scheme is the lack of commitmen[-even opposition-tothe Scheme by the medical profession. As illustration, tlre

scheme was called "a package of absurdity" and "a cruel joke"

by the Indian Medical Associ{tion, and the CHWs referred toas "quacks let loose on unsuspecting masses." In the field,

doctors are disillusioned with ithe Scheme and want the CHWs,

including their selection an{ its criteria (such as educational

level), to be trnder their techflical and adminjstrative control(see, f6r example, Maru, 1E80). This problem of professional

Commwity Participation in Health Care l19

antipathy beleaguers community participation in general. In asystem that has become professionally "mystified" and rigidlyhierarchical, the idea of decentralising function is anathema.Medical personnel do not perceive a useful role for people'sparticipation in the provision ofhealth care and, indeed, see acontradiction between community participation and their ownrole in providing health services. Para-professionals, too, feelthreatened by the CHW Scheme, as do local traditional or allo-pathic practitioners. By opposing it, these groups succeed inundermining the people's confidence in it.

A Double Standard PrevailsThis antipathy to community participation is part of the

Iarger Iack of professional commitment to rural health care.Because trained health professionals do not wish to serve inrural areas, "acceptable," "community-oriented" persons, whocan be trained to handle 80 to 90 per cent of health problems,are sought to fill the gap in health services at the village level.These semi-literate village people are expected to performservice, education and motivation tasks that even the mostdedicated professionals would find difficult. Thus. orofessionaland bureaucratic responsibilities are devolved'oir powerlessand poverty-stricken individuals under the guise of peoples,participation.

Again, although CHWs' services are not supposed to besecond class, the Scheme is aiclaimed as the low-cost solutionto rural health care. CHWs are expected to perform their tasksvirtually free, although it is important and essential work. A"service motivation" is considered paramount for them, whiletheir role-models, doctors, are better remunerated to provideremote, curative services. More women are expected to under-take this low-paid work at the same tirne as "women's status', issought to be enhanced! The assumption that participation inhealth work confers prestige and status on the communityhealth worker is highly questionablb in our socio-economicand political context.

Thus, while community participation is intended to encour-age people to recognise and realise their own potential tomaintain and improve health, there may be a fine line betweenurging people to take an interest in their health and perform

120' Implement ing Heal th Policy

basic health tasks, and viewing people's responsibility" as ameans of obviating the necessi for action on the part of thegovernment machinery. The co llary to individual or com-

is individual or communitymunity responsibility forblame for illness. In the contextinequalities, and their profound

f existine social and economrcuence on health, this is both

moraliv indefensible and. in the long run, disastrous for thenation. Under these the Door health conditionsofrural areas will persist, andhands" will becanre an alibi forperformance.

tion, and sugge$t that a greateris required for the former (Paiprevailing socio-economic and

"people's health in people'sthe system's continued non'

of societal developmentdlker et a/., 1983). Under

litical-bureaucratic conditions

NrBos on NDTTIONS'

From the foregoing discussion conceptual and pragmaticproblems facing community oation in health care. onecan identify at least three majorful and effective achievement.

ditions' for its meaning-otle, too, cautioned that

although productive partici in the affairs of state en-

hances the quality of life in a society, it depends on the priorexistence of certain conditions it. Sociologists currentlydistinguish between "aut " and "rnobilised" participa-

in India, it is unhkely that pation in health care will occurnaturally (i.e. autonomously). ough community mobilisa-tion and initiative may be so y interdigitated that it is some-

times difficult to discern where e ends and the other begins, inthe near term, community tion in health will need to be

mobilised-through better co unity organisation, mass healtheducation, and improved health delivery.

The first need is to create "tions of individuals with widely

unity" identities in popula-bring status, aspirations and

requirements.'Points of con must exist throueh whichcommon health goals can be iated and promoted. The non-governmental sector has frequen used village social organisa-tions to do this. first pressure otr them to widen

ust see the health of all asrepresentation. The communityinter-related and view health for as their joint concern. Thps,

Commwtity Participation in Health Care t2l

comftunity organisations which can enhance participation parti.:cularly of the poor in health care need to be fostered. Ruraldevelopment bodies which promote upliftment of the poor mustbe encouraged. For this, national commitment to people's parti-cipation must extend to fields other than health, and a generalcliftate of widespread local involvement in development pro-grammes be created. A comprehensive policy for people's parti-cipation in development as a whole would be more conduciveto participation in health programmes.

The second need is to increase public awareness of healthproblems and possibilities. While it is expected that communityparticipation will lead to greater access among people to know-ledge, a great deal of information has to be imparted to com-munities in order to bring about participation in health. Mobi-lisation for health action will not occur until people cease toequate health only with drugs and hospitals, and until thepsychological dependence on curative services is lessened by therealisation that individuals, famiiies and communities car pre-yent illness. To instill a readiness to change existing healthperceptions, practices and conditions, mass health education iscafled for. Such education must be aimed at a people and atpromoting major health goals.

To illustrate the point, one important reason for the ineffec-tiveness of the Community Health Workers' Scheme has beenthe lack of public health education about it. Although theinitial specr'fication-selection of a worker by the community-is interpreted as participation, this is "mobilised" by out-siders (health system personnel). Further involvement, whichis supposed to occur "autonomously," has not been achiev-ed; and .the objectives of the Scheme have been hamperedby. the lack of wider participation in it. Although the CHWsrole in educating the people and mobilising their support forhealth activites is of paramount importance, people's accept-ance of the workers and use of the services provided by themshould have been encouraged independently at the outset. Forthis, other 'health education' mechanisms, such as the massmedia, including radio, television, films, posters, which havethus far remained underutilised, could have been employed.Community organisations and village meetings at which differeot

t22 Implementing Health Policy

groups ofthe village are represlented could also be utilised. Forthe longer term, health educatiqn in schools should be orientedto primary health concerns.

At the present time, the fiealth system has a.major role inexpanding public health educatflon, including information aboutavailable health services. Whilo the ultimate soal of both healtheducation and of community organisation may be to enablecommunities to plan and de$ign services to meet their needs,and to impler4ent those plans rlsing their own workers and sucfiresources as can be mobilised , the more immediate needis to get people to perceive and articulate their health problemsand priorities, and to demand both primary care and referralhealth services. Unless stinulated by the spread of in-formation about bealth proble{rs and services, this demand side,which has remained dormant dtue to social, economic, politicaland bureaucratic constraints, will remain underdeveloped.

Of course, demand and Nupply are iinked in a two-wayfashion: if denrand is created, dealth services must be in a posi-tion to meet it; and if the srfpply of health services addresses

and utilise them. Thus. health ion must be accompaniedby appropriate healtir services to enhance public credibility inthe health system, including the CHW Scheme, and to be effec-tive in improving health.

The third major 'precondition' for meaningful people'sparticipation in health care, is the efficient delivery of thehealth services that people need and want (and will demand moreofwhen they begin to 'participbte'). It is not enough to encour-age communities to provide bagic health services for themselvesand to create demand for highdr-level services. It is essential tohave a supply line that meets dlemand at the appropriate level,ensuring that it is not frustrated. The institutions charged with

' delivering health services thus have a responsibility to re-organise in accordance with actual health needs and prioritiesand reorient themselves to a participatory form ofhealth care.The disjunction between peoplg's demand for curative servicesand primary health care's odintation to preventive health willonly be resolved when curatiie care is ensured for those inneed.

Indeed, the quest for pepple's participation in health has

Community Participation in Health Care

emanated from a desire to make health services more relevantand acceptable to people by addressing their "felt needs."Thus, the health structure must be able to gauge tbese needsand respond to them. This ability has been one of the majorstrengths of non-governmental agencies. The governmentalsystem must similarly f nd ways of formulating its programmecontent according to local rreeds and priorities. Better know-ledge and undcrstanding of local-level problems is required.Information must flow from periphery to centre, while resources

flow in the opposite direction. To implement appropriate healthservices at every level, decentralised planning is required.Organisation and managerial skills are essential for independentdecision-making and evaluation at lower levels of the healthsystem (e,g. the block level). In addition, certain mechanismswhich have become integral parts of centripetal health pro-grammes need to be reassessed and changed, if decessary. Forexamplo, inflexible worker-to-service population ratios andtargets deny the flexibility that is required to 'fit' a health pro-gramme to a community, and in turn may kill communityinitiative.

To bring about these changes, a much greater level ofbureaucratic and professional commitment to primary healthcare is the most import?nt requirement. Both "debureaucratisa-tion" and "deprofessionalisation" will be involved. For thedelivery of basic health care at the village level, the healthsystem must "demystify" basic health functions. Doctors mustshare their knowledge by properly training village healthworkers to serve a population in accordance with its needs.Community health workers need quality training in prevention,diagnosis, treatment and follow-up (and not just the pastichetraining that is currently imparted). In addition to creating awelFtrained cadre of Community Health Workers, the perform-ance of the health system in terms of providing CHWs withsupplies, supportive supervision, and refresher training needs

improvement. The question of appropriale remuneration forCHWs-whether by government or community-needs to befaced squarely.

In summary, before community participation in health canbe brought about, there is a need to increase people's awareness,

to train workers, to ensure logistic support and information

t23

\24 ' Implementing Health Policy

to the workers and to the c{mmunity, to train people fordecision-making and managem$nt of participatory organisa-tions, to reorient bureaucratic and procedures, and soon. Thus, bringing about comgnunity participation will taketime and effort and require money. Although communityparticipation may lead to low-cqst health care in the long-run,in the short term it entails anl increase in the buduet for ruralhealth. Rural health has consisfenly captured only i very smallpercentage ofthe national health budget, the major portiongoing to sophis1isa1s4 and spbcialist facilities in urban areas(see Chapter 9). A premature sdarch for low-cost solutions toill-health in rural areas, while "gragmatic," will only perperuare

-rather than rectify-this skdwed distribution of resources.The purpose of involving people in their own health care is notsimply to legitimise past policies and practices, or to curb dis-satisfaction with the health systepr,s failure to meet expectatiotrsbut to actually improve their he{lth.

CHAPTER 6

THE ROLE OF THE PRIVATEVOLUNTARY HEALTH

SECTOR

New jargon frequently creeps into the parlance of policy-makingat critical junctures, and is apt to confuse. "Privatisation',is one such expression in the health sector today. What ismeant by it? What are the aims of such a strategy? Whom andwhat does it involve? How is it to be set about? What criteriamay be used to judge whether it has been 'operationalised'or results achieved? Although the National Health policyStatement (GOI, 1982a) invokes the private sector on severalcounts, there are no readily available answers to these questions,In this chapter, therefore, I intend to review the basis of sucha strategy and ask, simply, what is desirable in connection withnational health objectives, and what is possible?

Tne Srnltrcv or "pnrv,q,Trse.rroN"

The Policy Statement, it will be recalled, espouses a decentralis-ed, participatory mode ofhealth development. Besides callingfor the "orgdnised invcilvement and participation of the comlmunity" (see Chapter 5), the planning and implementation cfprimary health care is seen.to depend on paramedical extensionworkers reachrng out from health centres, linking up wjth agentsin and efforts at the peripbery. Among these effortS are includ-ed the large number of private voluntary organisations working

t26 Impl ementin g H e al t h P ol icy

in the field of health throughorit the country. The Policy State-ment suggests that the servicej being rendered by these privatevoluntary health agencies sholuld be adequately "utilised"by the government in the provision of universal primary healthcare. In addition, the government is to encourage new voluntary€fforts in the cause of health fot rural and urban slum areas.It is envisioned that voluntary agencies' o'services and supportwould require to be utilised and intermeshed with the govern-mental efforts, in an integrated manner." Analogously, theservices of private indigenous Sractitioners are also to be "inte-grated" in the overall health delivery system for "preventive,promotive and public health objectives," but those of privateallopathic practitioners have bepn excluded from this intention.

Besides joining hands with the pdvate sector for primaryhealth care, the government also wishes to increase invesrmentby private agencies in curative hedical centres, particularly in"speciality" and "super-specialfty" facilities, to ensure that theyare adequately available within the country. The avowedintention here is to reduce gDvernment spending on these, sothat more monies become availfble for basic health services andexisting government curative fiacilities are eventually used totreat the needy. To achieve thi$, it is proposed that the govern-ment ofer logistic, financial and technical support to the privatemedical sector.

Thus, in a spirit of "privatisation," the government isdevolving on the private sectror some responsibilities whichhave been its purview to date. lThe several modalities enunciat-ed pay due heed to the plur{lity ofthe private health sector:the private voluntary sector is tb participate in the extension ofprimary health care while pdvate commercial interests investin curative and speciality facilities. In this way, a more focusedrole seems to be envisioned for the government in the provisionof health services. If the health sector is viewed as a conven-tional pyramidal structure, services would belimited to the intermediate while private agencies occupythe top and bottom of the Their situation impliesthat both community-based ary agencies and sophisticat-

will have 'interfaces' with thoed urban medicalgovernment hcalth system. the nature of theso interfaces-

The Role of the Private Volantary Health Sector 127

"private-public" or "government-NGo" collaboration_that isof immediate interest in the strategy ..privatisation,"

Tse Pnrverr He lrrn Srcron

1t 'd1al health economy'-both private and public investment

in the health sector-already existed in pre-Independence Indiawhere the colonial government provided health facilities inmilitary and European civilian "enclaves" (Ramasubban, 19g2),while the rest of the population depended on private practi-tioners for its health care. However, the scope ofgovernmenthealth services expanded greatly after 1952, so that todaygovernment agencies provide a large proportion of availablehealth services. While private practitioners and facilities haveincreased in number, their importance is largely confined tourban areas, the public system tending to predominate in termsof allopathic health care in rural areas. Government healthstatistics show that in 1983, 43.g per cent (or 3022\ of the 6901hospitals in the country wero owned. by private agencies, while

l^0:1,p"t cent (3500) were government-owned and 5.5 per cent(379) ra,s1g owned by local bodies (CBHI, l9S3). The proportionof hospital beds owned by the private sector was evei lower at27.6 per cent ofthe total, while the government owned 67.7 percent. The rural-urban distribution of these facilities is highlvskewed with only 26.9 per cent of hospitals and 13.5 per cenrof beds being in rural areas. .While breakdowns by private andpublic ownership are not available separately ioi rural andurban facilities, one can look at the ownership of dispensaries,which are mostly (68.7 per cenr ofthe tottl) locatei in ruralareas : the private sector runs only 14.4 pet cent of the dis-pensaries in the country. Furthermore, while governmentfacilities are distributed widely throughout the corintry, thereapp3ar to be many areas in which private health organisationsdo not function, or function only in a limited way. Althoughone. should perhaps accept these government figures withcaution-also because the collation of information ofihis natureis fraught with difrculty-they confirm the lesser role of thepriyate s€ctor-in rural allopathic health care. However, althoughthe number of rural hospitals and dispensaries owned Ly privateagencies may be small, thore are also a large number oi

-..other

128

institutions" insuggesting that itsof its activity.

ledgement of the need tgovernmental health servicesapproaches to health care."to attract attention becausebringing about'micro-demoareas. ln 1976, a symposium

of voluntary health projectsand Miraj in Maharashtra1980).

Thus, even thoughprogrammes have hadtics, the succ€ss

policy-niaking.

t

Implementing Health Policy

the volunt{ry health sector (VHAf, l98l),strength mpy be not in size but in the nature

S INTEREST

Despite the histor5' of priva sector involvement in health,health organisations is of recentgovernmental interest in pri

origin. In the mid-1970s understandings of the inter-ity and fertility and acknow-relationship of morbidity,

improve the performance ofto the search for "alternativefew private health efforts beganappeared to be succeeding inphic transitions' in their target

held under the joint auspicesof the Indian Council of edical Research (ICMR) and theIndian Council of Social Scic Research (ICSSR) to reviewsome significant on-going jects (ICMR-ICSSR, 1977). By1980, when the ICMR hosted ther conference-this time toreview "evaluation" strategi s for Primary Health Care, thenumber of "sisnificant" vo sector projects was doubled(ICMR, 1980). These events gnalled a change in governmentalperceptions of voluntary orgato participants in the nationalhealth care.

isations as strictly private entitiesealth effort to provide universal

Indeed, by this time, thesomething of the efforts of

vernment had alreadv imbibed

the Community Health Workvoluntary sector by introducing

Scheme at the national levelin 1977 . Although reco for a cadre of villaee-basedhealth workers go back to Bhore Committee (GOI, 1946)and were reiterated by the vastava Committee (GOI, 1975),the implementation of the owes much to the exoerience

THE

such as those at Kasa, Jamkhed,(ICMR-ICSSR, 1977; ICMR,

ively, private voluntary healthpact on aggtegate health statis-

of 'their

on-demonstrations" has affected

coll,little

policyHealth vis-d-vis the private sector \as

, The.Role of thd Private Voluntary Health Sector . 129

r evolved rapidly in the past decade from advocating the incltnionof some specific modalities such as Community HealthWorkers, to the more general strategy of "privatisation.', This

, strategy is a turn-about from the I 940 resolution of the NationalPlanning Committee which called for an integrated (curatiyeand preventive) system of health organisation which ,,can

beworked only under state control." In its Interim Report(which foreshadowed the Bhore Committee,s). the Sub-committeeon Health of the NPC recommended that ,,the preseryation andmaintenance ofthe health ofthe people sbould ie the responsi-bility of the state" (NPC, 1940). Instead, the National HealthPolicy advocates "rehabilitating the role and importance of

. voluntary health actions at all levels and voluntaiy organisa-tions vis-d-vis the government's role and responsibjlitv in thisarea. The policy envisages a very constructive and supportiverelationsbip between the public and private sectors in the area

, of health by providing a corrective to re-establish the positionof the private health sector,' (Ministry of Health and FamilyWelfare, 1985).

. However, the proposal for "privatisation" can be viewed ina number of ways. At its most straightforward, it can signify

' the government's desire to expand private enterprise in allspheres of health in order to increase people,s u""is to h"ulth

. care. By tbe absorption of private agencies and personnel instate policy and programmes, the Joint, health sector mav

. receive a fillip so that it becomes bigger, more varied. and mor-eeffective. The jnclusion ofindigenous practitioners in the strategysuggests that no 'systems, are barred in the effort to expandhealth

.coverage, although the exclusion of private allopathicpractitioners is puzzling in this regard. In any case, the scenario

. is o.ne of "a hundred flowers blooming,,' albeit at the peripheryof governmental health services

At this level, "privatisation,' may be part of a strategy for. decentralisation, necessary to achieve better results in health,just as. in other development sectors such as agriculture oreducation. Within the standard governmental approach ofpolicy-making and planning at the Centre and servici delivervat the 'grassroots,' with privatisation the implementation o"fprogrammes at the local-level would simply be entrusted tovoluntary organisations. This may help to iircumvent a maior

130 Impl mtcnting H e al t h Policy

, ptoblem encountered in gove- the reluctance of State-level

efforts to decontralise :

to devolve power on the' district, block and village The locus of conflict is shiftedfrom Centre-State or State' ct, etc. to voluntary agency-stale relations.

In this view of "privatisatidn," the desire of government toinvolve volqntary agencies in rrational health development canbe seen to stem from its admitted inability to meet policy andplanning objectives and and to implement programmeswith the desired characteristics (e.g. community participation) orcoverage (e.g. in remote areas where government doctors willnot go). The decentralised and socially-committed nature ofthevoluntary sector, and its sulprior ability to organise people

compared with bureaucratic stfuctures are given as teasons forprivatisation. Beyond such elpedience, the States' desire to€ncourage wider democratic participation for social progress

may be cited. In this context, the government perhaps views

itself as providing'legal sanctioh' and'back up' to the voluntarysector to fulfil its mandate to spearhead social change.

A second less-favourable interpretation of privatisation,which finds currency in radicafl analyses of the government'scourtship of voluntary agencies (e.g. Sethi, 1984), is that privat-isation is a strategy to coopt thle voluntary sector in order toquell shouts about bureaucratic inefficiency, corruption, and

. so on, and to dilute threats to existing power structures. In

. this view, thg provision of fuqds and/or technical assistance tovoluntary agetcies, the placement of private sector leaders ongovernmental committees or giving consultancies to them, are

considered tactics ofdefusion. Although the govemment appears

to be "decentralising," the cooptation view holds that the devo-lution of responsibility on the Voluntary sector'is nominal ratherthan real.

It becomes real in a thitd possible interpretation of 'privat-isation'in which the term is taken to be akin to 'denationalisa-

tion.' Although devolution may be gradual, the government

may hope eventually to turn ovbr the provision' of health care

'entirely to the private sector] This aspiration may stem from' the realisation. that, despite the immense resources the State has

sunk into health services ovef the past 35 years, it still fails to

'r€ach the majority of people. Ih oontrastn the "successl' of the

The Role of the Private Yoluntary Health Sector I3l

privato sector is invoked, The corollary of 'denationalisation,is greater "privatisation of the state," that is, increasing reserva-tion of government health services for 'the few,' so thatultimately public services are made private. Which of theseinterpretations of the strategy of privatisation is 'desirable'?What is possible? To resolve these questions, the nature of thevoluntary health sector, its activities, strengths and weaknessesrnust be examined.

VoruNreRy HelLrH AceNcres : GrNssrs lr,tn Bnmc*

'Charity,' 'development' and 'empowerment' largely sum up themotivation of voluntary agencies in general, and are the basisof their classification into three distinct types : (a) disaster-reliefor charity ones, (b) the development-oriented organisations,and (c) political-activist groups (Sethi, 1978). The first groupis viewed as "ameliorative" and "altruistic," while the secondis seen as having a more "technical" or "professional" approachto improving the productivity of the poor. The third aims tobring about structural change by "conscientising', poor peopleto fight against exploitation, organising and mobilising them.

The majority of voluntary health organisations fall intothe first or second of these categories, few of them having.entered the third arena. Examples of those in the charity-.oriented group are Arya Samaj dispensaries, Christian Missionhospitals and relief agencies, and the like. T'he second category,though smaller, is varied, consisting of efforts emanating fromboth religious and secular institutions, including hospitals aadmedical colleges, business houses, and so on. Because of the''professionalised' nature of health care the distinction between

*The observations and judgem€nts made here and in subsequcnt sectionsare based on personal field visits to numerous voluntary healthagencies in the country (and a.few in other developing countri€s), ondiscussions held with agencies' staff and othcrs interested in thovoluntary health sector, on material ilresented at several conferences.and workshops on the subjcct of voluntary health actioD and itsinterface with government, and on extensivo reading of availabler€ports, descriptions and studies of voluntary health agencies, besidesreferenced articles, A list of agencies isgiven in Annexure A along, with the major modes of study adopted for each agency,

t32

the two groups may be unc

Implement ing Health Policy

The former group may be

laken to consist of agencies concerned with supplyinghealth services though not as 'charity' or free services,

while the latter encompasses that also undertake other'development' activities for tbe improvement of conditionsunderlying health. These latler agencies exemplily the "newhealth praxis" in the health sector.

out to deliver health servicesFew agencies whichindulge directly in political activism, although some may

organise people specifically for health and development work.The reason for this may tie paFtty in the reluctance of medicalprofessionals to "meddle" in politics. The third category, then,consists more commonly of radical groups who began withpolitical organisation (for exahple, of ribals, harijans, workers,or women), but came to a realisation that health was an impor-tant concertr of their tarCet group and so started healthactivities.

It is however important to recognise the chameleon-likecharacter of voluntary health [ction. Many organisations undei-

It is however important to recognlse the chameleon-llKe

character of voluntary health [ction. Many organisations undei-take a mix of activities which hake them hybirds of the three"types." For example, whild the 'normal' work of an agency

may be developmental, in the bvent of a disaster it may turninto a relief organisation. At qome otherjuncture it may under-

take political activity, for expmple mobilising public opinionor protest against a Bill or Act under consideration. A certain

. amount of 'non-threatening' political action may be part of thenormal activity of 'health

example, these groups oftendevelopment' agencies. For

to pressurise local governmcntbodies to act in favour of clients, and at the same timsactivate the latter to d services from the State. A flew

groups function as " to ensure that the government

fulfils its commitment to provide certain services and to protect

the rights of citizens to thsse

The 'typology' of vo asencies is of interest because

the question, 'What type ofl agency does the government envi-

1.

The Role of the Private Vol4ntary Health Sector IJJ

of collaborative measures. Collaboration may not be possiblewith all types of voluntary agencies, or may need to take ondifferent forms with the different types. The heterogeneity ofvoluntary health agencies is even greater when one begins toconsider other 'modes of difrerentiation' among them, besides

the typology based on orientation (or ideology?), discussed

above. Vast differences exist among voluntary agencies' objec-tives, approaches, programmes, services, methods of operation,'styles,' leadership, coverage, resources and so on (Table 5,1),which are important determinants of their potential to contri'bute to national health.

J.

TlsrB 5. I

Modes of Differentiation of Voluntary Health Agencies

By objectivcsi

(a) provide services only.(b) reduce recidivism and attendance at clinics.(c) reduce morbidity/mortality/fertility etc.(d, research and/or training,(e) "evolve a model" for any of the above.

By "target" groups:

(a) clinic-attendersonly.(b) poor and vulnerable groups e.g. women and children.(c) specific disease sufferers.(d) whole communities, etc.

By mode of health-service delivery:

(a) clinic-based only.(b) clinic plus mobile teams.(c) central facility plus sub-centres or community-level workers,(d) centre, sub-centres and community-based workers*services "at

the doorstep."

By " linkages:' '

(a) whouy private services (hospital with or without outreach, orcommunity health agency),

(b) linked with other private or public facility as referral point, VOprovides "extension" services.

(c) train, utilise or manage govcrnment pcrsonnel and facilities.

t34 Implementing Health Policy

(d) to other service institutionsi(e) to other similar VOs.

5. By services provided :

(a) specific services e.g. specifib disease detection, trcalment andprevehtion; immunisationl nutritioDal supplementation oreducation.

{b) MCH and/or family plannlng.(c) chilO care and developmen!, "under-fives'clinics."(d) comprehensive health progtammes.(O hcalth and development actlvities.

6. By funding source(s)

(a) fees-for-service (graduated, partial, etc.)(b) local contributions and otbEr indigenous .donations.'(c) government grants-in-aid (Central or State),(d) foreign donors (governmedtal, non-governmental including reli-

gious and individual donalipn).(e) support from multiple sourpes.

HErrnocrnnry oF VoLUNTARy Hnelrn Acrncns

Voluntary health organisatidns tend to exist in the 'gaps'creat€d between the need for health care and a lack of it. Theyare usually started by "outsidb agents," often a committed andcharismatic individual or groujp of persons. They are character-ised by a concentration on a defined area and population,sometimes by a concern for a specific health problem (e.g.leprosy, blindness, etc.) or problems, and or a focus on thepoor.

Difrerentiation by Objectives and Target Groups, However, they have differing objectives. The most

usual statement of itrtent. icularly of hospital-based pro-grammes, is "to provide ' beneficial to the target group.Where outreach schemes from a hospital into itstatchrrent areas'-the o may be to reduce loads on outpatient departments, to cut wn recidivism rates, to follow-up

or to increase numbers of specifcpatients, to controlservices rendered (such as ions or sterilisations). Thus,such programmes may preventive measures and healtheducation. health programmes state their

The Role of the Private Voluntary Health Sector 135

objectives as the reduction of morbidity (or of a specificdisease), of mortality (often, specifically, infant, chilC atdmaternal mortality), and of fcrtility. While an occasional projectreport gives precisely-worded, target-oriented statements ofthese ultimate objectives (e,g. "reduction of infant mortalityby 50 per cent (or "to 60 per 1000") by the year 1990," etc.),more common are global statements without time-bound goals.

Where preventive and promotivo measures are employed th6irobjectives are generally stated as "to bring about change in thecommunity's attitude to health and nutrition" or "to imptovehealth practices and behaviour." Projects which include socio'economic development ivork aim "to increase the per capitaincome of the codmunity"-without usually stating by howmuch or by when-or simply "to improve the quality of Iife ofthe community."

Obviously., different objectives imply different target groups.These range from 'clinic-presenters only' to 'whole commiini-ties,' with intermediate conformations such as 'women andchildren,''poor and vulnerable groups,'or those affiicted with aspecific disease.

Some voluntary health projects, especially those begun bymedical colleges, have training and research objectives presidingover their service functions. Usually, the purpose is to providefield training for medical students, post-graduates, nurses orparamedics and research opportunities for post-graduate staff.Almost always sbrvice, training and research activities remainindependent of one another. Such porgrammes are labelled"action-demonstrations." Experimentation and innovation arepart of their ambit, and the evolution of a "model" (healthserv.ice delivery) programme is an occasionally-stated objective.

Difierentiation by Organisation and 'LinkagesDifferent forms of organisation evolve among voluntary

agencies in response to their concern with effective health servicedelivery. Beyond the clinic-based mode, extension work may beundertaken through mobile teams, sub-centres or personnel de-ployed in the field. Community-based health programmes maydeliver services at central points in villages or in an area or "atthe doorstep." A common feature emanating from practicaland resource consirlerations has been the use of persons resideat ,

136 r Implementing Health Policy

in villages (who are not health $rofessionals) to deliver services.The 'gap' that voluntary agencils attempt to fill is perceived asboth a cultural and an inlrastruptural one and so the training oflocal people for health care is agpropriate. Usually, CommunityHealth Workers are required to deliver services to each house-hold. In this way, attendance at a sub-centre or clinic locatedat a central point, where parampdics or doctors are deployed, isrequired of clients only for 'masB-services' such as immunisationor nutritional feeding, and procpdures requiring clinical exper-tise (such as IUD insertions).

The Community Health W{rkers usually operate autono-mously, without day to day sup$rvision, although the modalitiesadopted by ditrerent agencies (iffer considerably. Among themost difficult tasks admittedly Fncountered by voluntary healthprogrammes are the recruitment and training of village workers,the provision of supervision, and coordination with other healthworkers. Insuftcient attention to these issues has often limitedthe impact of a community health programme, despite theincreased coverage that is eftpcted through the modalitv of avillage-based worker.

Differences in the intern{l organisation of a voluntaryhealth programme also depend 0n and determine the agency'slinkages with other institutionts. Many organisations remainwholly independent, leaving it up to clients to connect withother service bodies if needbei Other agencies running'basic'health programmes may link up with more sophisticated medicalinstitutions-private or public-Jto obtain speciality services orfor referral purposes. In some the voluntary organisa-tion is the 'extension' agency, oftaining and channelling servicesto the target population, ortraining or research for the

specific tasks such ast institution. The presence or

absence of such linkages may a critical factor to an agency'spotential to collaborate with thA government.

Difrerentiation by Service edClearly, the mode of o adopted by an agency and

its linkages are related to the ices it provides. However, acommon Dattefn of is encountered among com-munity health efforts, the details being defined largely by

all voluntary health agenciesthe resources available. Alm

The Role of the Private Voluntarr Heahh Sector

endeavour first to provide low-cost (or free) curative care includ-ing'emergency cale and treatment of diseases prevalent in thoarea. (Cases requiring sophisticated medical attention are usu-.ally referred to a 'link' institution). Beyond this, they turn topreventive and promotive health care, providing immunisation,nutritional screening and (often) supplementation, maternal andchild care and family planning, health education, and environ-mental sanitation measures.

In addition to health services, 'health and development'groups undertake some of a variety of development activities.They may begin with kitchen-gardening as a strategy forimproving nutrition, but go beyond this to agricultural extensionwork, animal husbanilry schemes, or eyen land, water andenergy development. Another range of activities includes non-formal adult education (particularly for women), vocationaltraining, and'cottage-based' (non-farm) income-generatingschemes. Associated with these efforts' may be the developmentof community organisations (such as Mahila Mandals, YouthClubs or Farmers' Clubs), the institution of facilities such ascreches, and schemes for loans, marketing and the acquisition ofcommercial skills.

These modes of ditrerentiation are by no means exhaustive.They are simply intended to illustrate the heterogeneity ofagencies at the 'base' of the health service pyramid. A verywide range of voluntary health action exists in the country. Beg-inning with different 'entry points,' a wide focus emerges in thework of voluntary health agencies. Each agency is today makingits own particular contribution to national bealth. Any strategyof privatisation, therefore, would require a variety of 'means

of interfacing' with government.

INGREDTENTS oF SuccEss, rN THE VoLUNTARI Hslrru Sncron

The potential for 'privatisation' or for collaboration between thegovernment and voluntaty sectors will be delimited by thestrengths and weaknesses of both, Voluntary health agencies areconsidered to have succeeded where government structures havefailed. What have been the ingredients of this "success"? Whathave been the 'stress points'?

137

t

I38 In,plementing Health Policy

flexibility ard DynarnisrnThe "flexibility" of voluntafy health organisations is mani'

fest in their varying programrhe strategies. Less encumberedby structural hierarchy and probedural webs than the govern-mental health system, their actlvity mixes can be changed tosuit local conditions or emerging crises, and to eliminate out-moded techniques and methods. Their ability to respond tochanging situations-"dynamigm"-is demonstrated by theirchameleon-like nature, Thus, [he voluntary sector can indeedbe a vehiele of change-among its clients as well as within thecootext of national health care,iprovided it rises to the challengesinherent in 'flexible' aotion such as clear vision, prioritisation,"management by objectives" and a comriensurate enlargementof organisational capability.

'Local adaptability'is also part of the ethos of volrtntaryagencies. The physical positicin of voluntary agencies 'close

to the 'grassroots' permits thenn to respond to people's desirefor change. However, while hpalth agencies may view them-selves as co-partners in an indigenous process of chatrgeand wish to promote strategies rwhich are based on specific localdimensions ofa problem, they have not done this unequivocally.For example, most have imposed external values by 'importing'and propagating allopathic rnedicine, rather than workingtbrough or with indigenous pr4ctitioners. In fact, few projectsinvolve traditional practitioners at all, except for dais-andeven the approach to these is one of 'conversion' to modernmedicine.

Dedicated LoadershipBecause dedicated programfne managers arc the sine qlua non

of private voluntary health projects, the foremost explanatorytheory of their success is the "dynamic leader theory." In thehealth sector, leaders are ahnost invariably middle-class, medicalprofessionals guided by their concern for people who do not'have access to the formal medidal system.

. The committed leadershi! factor may, however, poseproblems in the search for the'added significance' of voluntaryagencies to the national health bffort. The problems relate bothto current management of volqntary agencies. and to the issueof "succession."

The Role of the Private Voluntarv Health Sector

The majority of voluntary health project leaders tend toassume responsibility for all programme decisions rarely delega-

ting authority within their organisations, leave alone availing ofexpertise beyond their agencies. While continuity of directionmay be ensured as long as the committed leader is around,continuity of leadership is far more difficult. The centralisationof power invariably means that projects fold up when the

individual moves on, as has happened in a number of voluntaryhealth pfforts. To date, the issue ofsecond-line leadership remainsa critical problem facing (but rarely faced by) voluntary healthagencies almost without exception. If privatisation or collabo-ration is envisioned between a voluntary agency and the govern-ment it would be essential to ensure that the committed leaderbegets committed and competent followgrs.

"Professionalisrn"'Although the terms 'voluntary' and 'professional' may appear

contradictory, in the health.sector voluntary efforts have Iongutilised trained professionals, such as doctors and nurses. The"trend to profesiionalisation" in the voluntary health sectortoday thus refers to the use of expertise in 'allied' areas such as

maoagement,communications, social sciences, rural develop-ment, marketing, and so on. Voluntary efforts are increasinglybeing "systematised," in part out of necessity (because ofshortages of funds) and in part out of concern for the long-termsurvival of projects. Sustained development is equated with aprofessional approach.

This trend also arises from the increase in numbers ofprofessionals seeking "alternative forms of employment in re-action against hierarchioal, inefficient, or corrupt structures.Urban living and institutional careers are no longer regarded asirrecusable. Although young professionals in the voluntarysector may work at rates below their'market value,' ' voluntary'no longer means l'unpaid." Most draw salaries and receiveother perquisites such as housing, school fees, medical costs,travel allowances, and/or are able to write off various expensdsagainst project funds. Many admit that the 'quality of life' intheir project 'enclaves' and the satisfaction they get from theirwork far outweigh any hardships they may suffer.

However, voluntary agencies have a great deal of difrculty

139

l4O. Implementing Health Policy

keeping effective persirnnel in pldce and consequent high turn-overs of statr Although this f s sometimes ascribed to thepersonality or ideological conflidts that arise among members ofvoluntary groups (particularly wlhen authority is centralised asdescribed above) it may also from a basic contradictionbetween the need for bssional people in voluntaryaction and the fact that "flexi programmes require flexiblestaff. Frustration often sets in aDrong professionals because jobdescriptions are vague or and upward mobility non-existent, Thus, the major q facing voluntary agencies inthis regard is whether 'professioilalism' and social commitmentcan be combined in an adequate number of cases.

fntensive Management"Intensive management" is another factor that has appa-

rently contributed to voluntary success. After surveyingseven irealth agencies in Pyle (1981) identifiedseveral managgment strategies employed by them. They were

" rather than acredited with having a ":procedures dourination' (Ko 1980), emanating from clearly-

goals and targets. They had adefined obiectives and"target-group focus," and "prio " the needs of their tarsetcommunities. Programme components were introduced to meetthese needs in a phased fasllion. "Flexibility" and "localadaptation," "community participation," "decentralisation" and"local involvement" were also aspects of their nanagementstrategies.

There is little doubt that a nlrmber of health agencies utilisethese tactics and owe to them a gireat deal of their effectiveness.However, the extent in which surih strategies have been 'syste-matised' may be doubted. Rettrospective investigations intovoluntary agency functioning palnt the process as organised andsomewhat linear in its evolution because any stray paths travelledcan be downplayed. Prospective inquiries do not reveal thesame degree of managerial visioir, and day-to-day happeningsappear more 'ad hoc' than "inte+sive management" implies. Infact; if 'flexibility' is a strength gf voluntary action, clearly laidout managemeflt strategies would seem to be somewhat antitheti-cal. Further, the absence of datal bases, discussed belou wouldmake 'management by objectiveqf impossible.

The Role of the Private Voluntary Health Sector

" A workshop convened to identify specific managementproblems faced by voluntary health organisations identifiedseveral (Maru et al., 1,983). Among "strategic issues" were the"preservation of uniqueness," expansion, succession of leader-ship, and development of interlinkages between agencies.

Resource-related issues included manpower planning and devel-opment (including in-service training),'team-work' management,financial systems, and cost-effectiveness measurement. Opera-tionalisation of certain values such as participation and evalua-rion of health projects were the 'project-related' issues discussed.Ilowever, a conllict was perceived by voluntary sector partici-pants to exist between "project nanagement" and "the project'swork." The former was seen as potentially taking away fromthe latter: "If VO's continue to run projects (i.e. rather thanwithdraw), project management rather than promotional/educational work will dominate." Thus, the formalisation ofwhat is now an informal managerial process in voluntary agencies

is questionable but without it, "collaboration" with the govern-ment may be a moot issue.

People's Participation. . The emphasis on people's paiticipation represented the

voluntary health sector's first major diversion in 'style' from'the normal patriarchal pattern of service delivery. Although itis a cornerstone of voluntary health action, many voluntary

'leaders admit that the extent of community .involvement in theirlrrojects is "insufficient." Some are unclear as to what they wish'to achieve through it. Others demonstrate contradictory stances,

for example, calling for participation in programme planning,decision-making and implementation but at the same time forbetter project 'supervision' of community level workers. Thislack of clarity regarding objectives has meant a paucity of ideasabout mechanisms to foster community participation. Fewprojects have even established proper communication channelsbetween project staff, village residents and workers, althorigh.this would secm a fundamental pre-requisite to decentralisation.Even though voluntary agencies are believed to have their 'earsto the ground,'there is rarely awareness of villagers' reactionsto their programmes. While they often build up and tdp com-munity organisations, the extent of health activity that these

t4l

142 [mplementing llealth Policy

have undertaken has remained small. The alternative device ofvillage health committees has also played a limited role (seo

Chapter 5). The functioning of both sets of institutions' hasbeen poor in rnost locations and it is widely acknowledged thatbetter strategies forevolved,

ity participation need to be

Although the "creation ofparticipation, few-if any-vo

is a major objective ofagencies have built up the

necessary self-confi dence to the capacity of their clientsto be effective in their in with the government health

on the government to deliver on its health schemes. Related tothese inadequacies is the failure of most voluntary health pro-grammes to develop local leadeiship among their target groups(ostensibly because of a lack qf capability). Although this isperceived as necessary for a programme's long-term viability andultimate indepqpdence from 'external' project managers, fewvoluntary agencies can envision a world without themselves.

WslrNEssrs on VoruNtany OnclNtsettoNs

Besides the weak points of volqntary organisations . that havealready surfaced in the precedin! discussion, a few others needto be pointed out as potentidl obstacles to voluntary agencycollaboration with government.

'Isolationism': A troublin$ aspect of voluntary healthaction to date has been its fdilure to reinforce itself throughinteractions or networks among individual groups. Voluntaryagencies tend to work in isolation so that their individual suc-cesses and failures remain largely unknown. This is due inpart to their spatial spread, ideological diversity and programmeheterogeneity, but not the least to notions of "uniqueness" andegotism among project leaders. ilhe few "apex organisations"that eiist, suoh as the Yoluntflry Heatth Association of India(VHAI) or the Christian Medicdl Association of Iridia (CMAI),focus more on providing inputs [o individual programmes thanon the creation of forums for thb sharing of experiences, whichcould lead to better programmgs. An exception, the MedicoFriends' Circle, has remained tmall, though purposive, A dia-logue between groups with oomfton objectives could enhance

The Role of the Private Voluntary Health Sector 143

the learning procesb through which most organisations struggle,and make for more effective utilisation of scarce resouroes.Links with other institutions, such as training, management orresearch centres, could also strengthen the quality of voluntaryeffort.

There is a parallel sense of isolation between voluntaryagencies and the government. Despite attempts by governmentinstitutions (such as the ICMR and more recently the Ministryand National Institute of Health and Family Welfare) to bringleaders from the voluntary health sector together with bureau-crats and technocrats, there has been no systematic collation ofexperience, or building on the knowledge gained from thedialogue.

Another outcome of the isolation of voluntary agencies is aduplication of efort. Despite the 'criterion' that voluntaryaction occupies 'gaps' created by the lack of public infrastruc-ture, they often operate in areas where public services alreadyexist, labelling these "underdeveloped" and "ineffective." Thisoften has the efect of further deterioration in the governmenthealth facility, so that ultimately the private servic.- replaces thepublic one. It is this trend which (although still fledgling today)is tantamount to "privatisation as denationalisation" in healthseryices.

Voluntary agencies occasionally even overlap with othervoluntary agencies, creating a sense of competition which fur-ther isolates the groups from one another. In terms of thenational health effort, all this duplication is wasteful. Finally,the absence of concerted 'spokesmanship' within the voluntaryhealth sector has engendered a situation where the wood isbeing missed for the trees.' Expansion and replication dfficult. A major reason for soft-pedalling the National Health Policy's approach to the volun-tary sector is a welFknown weakness of voluntary health pro-grammes-the difficulty of expanding or replicating them.Recognising the 'particularities' of their projects, many volun-tary agency leaders abdicate a desire for replication-and there-by, perhaps also, responsibility to relevance. This attitude hasled to accusations of voluntary projects being "little pockets of'excellence (which) do not carry much significance." A few volun-tary healtlr agencies have sought to enlarge their programmes

144 Implementtug Health Poliiy

through processes of expansio[ or replication. Experience hasshown that success at the frricro-level does not ensure larger-

. scale achievements even in thd same location and with the samestaff. Although the process ofl expansion may be gradual, pro-ject leaders are often unable t$ 'keep tabs' on the villages orworkers subsumed into the programme and 'quality con-trof is lost. If the pro becomes too large they begin toface problems similar to afficting the government infra-structure. The'endogenous t' that took place at thevillage level instigated by thp 'outside'agency is difficult toaclrieve at the 'project level' (lilirschman, 1,967; Lele, 1975).

Pyle (1981) has explored the problems experienced with'replication.' The usual assu{ption on which replication efforts

, proceed is that the 'materials {nd methods' used in the small-scale effort can simply be "sdaled up." What is ignored is thatthe original project consisted of a set of inputs which wereimplemented in an iterative manner. "Process" is forgotten,and the'time frame' sought to be compressed, The consequentdilution of effort makes for an ineffective Iarge-scale programmeand disillusionment with the otriginal project ensues.

A combination of n and replication occurs when avoluntary agency itself to greatly enlarge the ambit ofits activities, for example,tem. A significant aspect

the government health sys-f this'collaborative replication'

. process is the need to adherb to the governmetrt pattern ofhealth services and to its e$tablished budgetary norms. Thevoluntary agency may be giver[ 'technical' but oot 'administra-tive' control of the gover

.activities of the sovernmentinfrastructure. It directs the

and provides additionalstaff to the health services.. Several problems surface this kind of arrangement. For,example, government person.counterparts in the agency,

insubordination. Its inabilitv

el may be paid less than theirleadiug to resentment and even

'hire and fire' may hamper the.agency's effectiveness in the structure. Anotherprob-lem is that vested interest ps; such as private practitioners,nay perceive a greater threat m the collaborative effort thanthey did frorn the voluntary and the government sepa-.rately.. Constrained to f the government:s. budget, , therprivatc.ag€nc"y may. have to ' ise' as. thg.: availability of

The Role of the Private yoluntary Health Sector 145

funds per caput will be considerably less than in the originalproject.

In short, while 'coilaborative' replication may be desirableto improve the quality of government health services, it isextremely difficult.

Limited transferability of learning. Voluntary agencieshave been called "learning laboratories" (Korten, 1979) becausethe flexibility that characterises their programmes has permitted'experimentation' with different strategies and methods. As aresult, some have evolved effective modes of primary healthservice delivery which deserve close scrutiny in the context ofthe national proposal to deliver health to all. 'National learning'may be possible with regard to the design of specific interven-tion strategies and perhaps in the areas of health personnel andtheir management. Management specialists tend to view'management' "at the core of the process of replication"(Subramanian, 1982). While admitting that small-scale projectsfunction well because oftheir adaptability to local situations,they contend that a "model" or a specific package can be evolv-ed which can be used in ditrerent locations.

In this context, it bears mentioning. however, that mostvoluntary agency health projects were started as efforts to pro-vide services, to train or do research, and even their individualcomponents were not designed as'models'or 'packages.' Thusrather than the individual experience of 'successful' voluntaryhealth programmes, it is the cumulative experience'that mightpoint to technologies, methods, and modes of organisationthat have worked in a variety of locations and situations, andtherefore have wider applicability.

The other side of the coin is that the government is in factdependent on the non-goverDmental sector for innovation. Theuniform pattern of health services across the country and thepressures under which government programmes are implementeddo not permit the kind of experimentation that is needed todevelop primary health care strategies.

Problems with diversifcation. \ oluntaty health programmesare often extolled for their "integrated approach" which, inaddition to providing health services, addresses the underlyingcauses of ill-health. Although there is little doubt that thepromotion of social and economic development activities catr

t46 hnptle mdnt ing Health po t icy

assist the health effort, many qroblems arise in the course ofcombining health and development activities, or .diversifying.,

Some atteotpts at integrating health ivork with efforts inother seotors are rendered ineffective because the health agencycannot provide the specialised sbrvices required for each activity.Jntersectoral aotion often engeqders a confusion of staf roles,vagueness about responsibility (even infighting) and lack ofooordination. As projects grorw horizontally, there is also thedanger that vertical linkages mdy become weak", usually leavinggr4ssroots workers in the lurch., -' Although there are examples of successfu.l .health

andde.velopment' agencie!, greater guccess in integrating health anddeveloprnent action mal perhaps be. achieved if health organ_isations didn't attempt to provide the developmental services(herqselves; butjoined instead with otber ugencie, working onthe provision of food, water, education, social justice, etc; in4ddition to prossurising local government bodies to deliver theservices for which they are rqsponsible. However, as alreadynoted, the isolation of voluntarj agencies from each other andfrom the government is a major deterrent to this strategy.

Lack of impact eyaiuation. Paradoxically, while voluntaryhealth projects are credited with favourable impacts on thedemographics of their target pppulations, their .tonitoring"and "evaluation" components afe weak-or non-existent, Visitsto voluntary health agencies almlost invariably reveal poor datacollection and recording systetns. A few projects conductsurveys to learn about the heplth problems of their areas butbaseline surveys at the. inception ofa programme are extremelyrare. Some projects "map" their target populations andestablish household{evel inform{tion dossiers. Rarely are recordsdesigned and deployed in such a way as to give continuousfeedback on the programme.

ln view of the voluntary sector's reputation of being sensi-tive io local needs and probld:ms, the absence of systematicdiagnoses of health conditions apd ofthe effectiveness of theirservices through monitoring relnains a major scientific lacuna.Gwatkin, Wilcox and Wray (1980) reviewed ten voluntaryhealth projects from around the ivorld which had "incorporatedthe concept of the scientific mdthod." Two of these were inIl{r.g. l1 .Jamkhed aad Naran$wal. The latter was a research

The Role of tlte Private Voluntary Health Sector

programme designed specifically to study the effectiveness ofdifferent health interventions, and so collected adequate data.In the early years of the Jamkhed project, ooresults"

wereextrapolated from a comparison of estimated vital rates at theproject's initiation and later measurements. Comparisons withcontrol areas were not tested for significance. The authorsboncluded "the efficacy of the Comprehensive Rural HealthProject in Jamkhed in lowering mortality must be assessed withcaution." Jamkhed is cited as one of the most impressive/,successful health projects in the country. While there may beother criteria of success besides improvements in health indices(such as "community participation"), it is difficult to select,.leave alone 'measure,' these and they are insufficient to provehealth effects.

Costs uncertain Voluntary health programmes are alsoregarded as "successful" because their efectiveness is believed tobe accompanied by low costs. However, estimating the costs ofvoluntary health programmes is uncertain(even tr€acherous) ter-ritory. For example, cost data rarely, if ever, compute the valueof donated goods (which may include medicines, vaccines, food,buildings, vehicles and other expensive items) or of'free' labour,and so it is difficult to arrive at correct total cost or evencapital investment figures, or estimate the proportion of costs'contributed.' Efforts to compare different projects or to con-trast private and public health expenditures are thwarted bythe problem of appropriate denominators. The latter compari-son may be made on the basis ofper capita costs obtained bydividing the total cost of a project by the size ofits targetpopulation. However, the extents to which target populations4re actually served differ, limiting the usefulness of this methodof cost compafison (Pyle, 1979; Pyle and Choudhury, 1980).

It is unclear whether economies of scale exist in primaryhealth projects. While Pyle's estimates (1979) of per capitacosts for the Maharashtra projects seem to be inversely relatedto the size of the project, this did not emerge in five Bangladeshiprojects studied (Pyle and Choudhury, 1980). However projectcosts per caput may decrease with time, as capital investnrentsdecline, as treatment 'backlogs' are covered, and when aprogramme has positive effects on the health ofd population.Clearly, however, costs also depend on the type of services being

tc7

148 Implementing Heahh Policy

delivered, besides the extent oll coverage. Primary health pro-jects may keep costs down irnless they add secondary andtertiary level services, a danger that Sen Gupta (1983) has point-vgl,Ug \r /vJ?'

ed out. In the case of projects which provide health servicesas uell as other development Services, it is extremely dificult toestimate the costs of the health component as manv facilitiesstafl vehicles, buil<iings, etc. are shared among different acti-vities. Indeed, some projects qndertake 'development' activitiesto raise funds to support work in a quest for "self-sufficiency."

" Self-sfficieniy"? While the goal of "self-sufrciency"(ACHAN, 1983) represents aspiration of some voluntaryagencies to provide healthfrom a practical problem

at low 'cost,' it emanatesmany agencies-shortages of

ices, they will place greater

funds to meet their dis ts. Many modalities are usedof which the most relevanr the context of national health

ns from target communities.policy is the raising ofcontriSeveral reasons for attempts at local resource

generation. First,tions contributevalue on health

that by making target popula-toward

areit is

and health and that this, in turn, williesult in health improvemen Second, it is felt that people

from contributing because theybenefit in psychologicalare then not receiving charity. Third, resources mobilised frorncommunities (whether mo materials or manpower) are

of "felt need" and demonstra-perceived as tangible expressrotions of acceptance by the of the service organisa-

it is believed, will bringtion. Fourth, community fiabout'accountability' among e service providers and thereby

provided. Thus, the strategy ofimprove the quality of servrcommunity fnancing can beand'consumer organisation,'social upliftment.

ught of as 'demand creation'with psychological and

However, there are also ' reasons why voluntaryagencies seek to become " :sufficient." Many communityhealth programmes are ini with financial assistance fromforeign donor agencies, who prefer to provide assistance tocreate infrastluctures or innovations, but not to meet

the donor agency and therccuffrng programme costs.project holders hope that dependence on external funds

The Role of the Private Voluntary Health Sector

will diminish with time. ln fact, "self-sufficieocy" is a criterionoften used by donor agencies to evaluate the programmes theysupport, and by project leaders to gauge their own "success."

Ofcourse, besides foreign donors there are other sources ofsuppoft for voluntary health programmes, including localphilanthropies and government grants-in-aid. Although theissue of self-sufficiency has been looked at primarily with regardto foreign donations, it is also relevant to receipts from these

other sources.

The main mechanism which voluntary health agencies haveused to raise contributions are service fees, "insurance" premia,and income-generating schemes either for the service organisationitself or for clients who then contribute a portion of the incomeearned to the service providers. Clearly, a major assumptionunderlying the pursuit of solf-suftciency is that resources arereadily available in the community and that it is just a questionrf mobilising them-a task which the health service organisationtakes upon itself. This strategy is seen as necessary to reducethe "maa-baap" mentality and dependency.

However, the resources raised remain small. In the sevenprojects surveyed by Pyle (1979) in Maharashtra small amountswere charged for medicines and in one case two per cent ofproject costs were realised from such sales. In another,60 percent ofthe honoraria paid to village health workers were met bygram panchayats but no other contributions were made. Amongthe five projects studied in Bangladesh (Pyle and Choudhury,1980), less than 5 per cent of costs were recovered from thetarget populations through fees, salo of medicines, and otherincome-generatirg schemes. One project which reached a

figure of l0 per cent cost recovery did so by charging fornutrition rehabilitation in cash and kind-which would seem amost unethical practice given that children requiring nutritionalrehabilitation usually come from the poorest families!

A common technique voluntary agencies use to raise fundsfrom their clients has come to be known as the "Robin Hoodmethod." However, this method is not without its pitfalls, asBang (1983) has pointed out. Rich patients who pay more tendnot to be satisfied with simplo (low-cost) health interventions,and begin to demand "sophisticated" medicine. The health

149

t50

programme is then forced tospecialist care.

Implementing Health Policy

in expeusive equipment and

Although even this scenarirf may be justified on the groundsthat dependency among rich patients will guarantee their contri-butions to the health programme, Bang has warned that suchprogrammes may become morb dependent on well-to-do clientsihan vice versa. Inevitably, the cosis ofthe health programmewill rise, and there may be molves to increase the charges leviedon the poor. This, in turn, willl result in the exclusion of thosewho are unable to pay, anld "utilisation" will be skewedtowards the rich.

One may conclude that if the primary concern is to gethealth care to the poor, self-srlfficiency is an unattainable goil.The process of raising community contributions may conflictwith the goal of social justioe-in particular, with the goal tomake health care available to those who have not had anv inthe past.

Colrenonarrorq BETwEEN GovrdulrrNr AND VoLUNTARy SEcroRs

The issue of privatisation or colllaboratiolr between aovernmentand the voluntary health sector must be viewed inlhe lght ofthe common features, differences, problems and possibilities ofvoluntary health agencies <tespr.ibed above, bui it is useful tofirst review current thought on the subject.

PerceptionsAs already discussed, the National Healrh policy Statement

suggests that government interest in coilaborating with thevoluntary sector in the field of health has as its immediatecau_se, the inability ofthe public health system to deal effectivelywith national health problems, A partnership between gou..o_ment and voluntary sectors is etpected to overcome some of thestructural weaknesses of the rlpacro health system and to result(in the 'immediate term') in tdtter utilisation of the eovern-ment's tesources.

However, close scrutiny df some other government docu_ments reveals a somewhat corlfused view of the relationshipbetween government and voluhtary qectors. A recent publica-tion of the Ministry of Health (MOHFW, 1985) stresses the

The Role of the Private Yolantary Health Sector

steps that government has taken to date to support the voluntarysector and refers repeatedly to the fact'that non-governmentalagencies "supplement" government efforts. This view is expand-ed somewhat in the following statement of the National Instituteof Health and Family Welfare (1977) :

These agencies are mainly engaged to supplement the workof official organisations, to explore ways and means ofdoing new things, such as the spearheading of family plann-ilg movemeut in lndia and putting up demonstration andexperimental projects . . . (p,, 11).

Recently, the Approach Paper to the VII Plan (1984) translated,the recommendations of the National Health Policy to involvevoluntary organisations into a broad action strategy. It identi-fied the areas of family planning, health education, and curativemedicine as important, and suggested five ways in which volun-tary agencies can participate-in planning, education, serviceprovision, resource supplementation, and innovation.

Thus, the government view of collaboration with the volun-tary sector is largely one of encouraging the latter to fill thecracks between govenlment health programmes, to undertakeexperimentation, and to provide resources. This is accompaniedby the belief that government support and reinforcement (e.g.

wider-scale application of private innovations) will serve togive the voluntary sector the additional momentuln it requires.

A sonewhat complementary attitude exists in some quartersofthe voluntary sector. For example, an editorial in a news-letter of the Asian Community Health Action Network, whichincludes some Indian voluntary health groups, proclaims :

. . . cooperation between governments and NGOs is un-likely to be very effective unless a significant portion oftheinitiative and the creativity in this relationship comes fromthe government (ACHAN, 1982).

Another instance of this perception is provided by anational networking agency. At a seminar convened by theVoluntary Health Association of India to discuss the NationalHealth Policy Statement, the main objectives set were the

Is1

152 Imp lenrenting Health Policy

of health and developmentsee a roli for itself as a

), it does not seem to

adopt favourable strategies, nogroup on the government toor policies in this regard.

Thus, it appears that are perceived both by them-selves and the government as playing a supportive and not alead or 'forceful' role. Not can they not "push or instructgovernment" (ACHAN, 1982); but their creative instincts haveapparently to give way to ones. Alone these linesan extreme suggestion has provided by Roy (1985) who

sector is "demoralised andstates that because the volunsplintered" and suspicious of i[s fellow members on account of"irregularities" and politi n within it, the government is"the only agency capable of ing factions together."

There are other. more com ex, perceptions of the proposedcollaboration. One emanates from the gap that is discernedbetween the government's recognition that voluntaryorganisations should be involived in the national health effortand its positive action in thisof government believe that

n. While higher echelonsearlier attitude of government

as 'patron' and voluntary o as 'clients' has changedinto one of equal (MOHFW, 1985), voluntaryagencies allege that this change has not permeated lower levelsof government with which they deal more frequently (Roy, 1983).This attitude arises in part m governmental perceptions ofnoi-governmextalorganisationg as'competitors' or as redundantentities. It belies the of collaborative relationshiosand nullifies the reason why collaboration was sought in the firstplace.

Government Assistance to Voluntary HealthAgencies

According to the Ministry 0f Health (MOHFW, 1985), thegovernment has taken several steps to date to "collaborate,'with voluntary health organisatlons. ln the 1950s, a Board of

"dissemination of tbe policy antd identification of modalities forcollaboration with the Government in its implementation atevery level." Although the Association has recently been con-cerned with issues relating to the demedicalisation of health care(such as low cost drugs, health education, and the integration

The Role of the Private Voluntary Health Sector 153

Inspection (sic) was established by the Ministry to visit volun-tari medical organisations and encourage them to "supplemant"government efforts. The Board was instrumental in recom-rnending financial assistance to these agencies, and, indeedthe grant of funds has been the premier mode of "collabora-tion" between the government and voluntary sectors, Upto1983-84 such assistance had been provided to 854 organisationsnrnder two governmental schemes, one initiated in 1954-55, theother in 197*76. Either full (100%) or matching (50%) grantswere given to organisations for the control of TB, leprosy andcancer, the control of blindness and treatment ofeye diseases,and for the establishment of occupational thorapy facilities.Assistance is given for non-recurring expenditures such as thepurcbase of "costly essential equipment" including Xrays andoperation theatre equipment, and for the construction of hospitalfacilities, including operation theatres, laboratories, and wardsfor the poor. Another scheme provides NGOs with partial fundsto establish upto 30-bed hospitals and dispensaries in ruralareas where facilities are inadequate. In addition NGOs areassisted specifically to promote voluntary blood donation,organise eye camps, and promote family planning.

How does the voluntary sector view this modality? The issueof taking funds from government has perhaps been divisive. Onthe one hand, there is the feeling that government funds arepublic funds and so the government should make more avail-able to the organisations who are in touch with the people(Roy, 1983). In turn, some NGOs feel that taking governmentfunds ensures credibility with the government and the people,and accountability to them.

However, it is felt that bureaucratic procedures to obtain oraccount for these funds should be minimal and that thev shouldnot have "strings attached." Many agencies are daunted by the"red tape." Agencies outside Delhi complain that they lack themoney and time required to pursue assistance from the Centralgovernment. Their experiences with state governments may besimilarly problematic.

While reporting that his experience with government fundinghas been encouraging, Roy (1983) laments that a voluntaryagency becomes committed to "a straight, tangibly-oriented

r54. Implementing Health Policy

programme that has no room for improvisation or intiative'? ifit takes funds from government. In general, Roy perceives the"dttitudes and approaches" of government officials towardsNGOs may cause problems for yoluntary groups, driving themto seek their funding elsewhere I

A foreign donor agency oomes with a human face; thegovernment in many cases {hink they are doing us a favour.The former comes as an equal and is prepared to considerthe agency effcient unless proved otherwise; the latter doesnot believe in equal partnerEhip and in 80 per cent of thecases considers NGOs guilty of corruption, of irregularities, ,

of inefrciency . . . (Roy, t9B3).

However, while "alternatipe', sources of funding wereimportant in the past, they har,1e recently become more difficultto tap because of some legal chpnges. The amendment of theForeign Contributions Act (1985) now requires organisationsreceiving foreign donations to obtain prior clearance from theHome Ministry. The removal in 1983 of the tax exemptionearlier given to business houses for their donations to develop-ment work has led this source offunds to dry up considerably.Thus, voluntary organisations will need to tur[increasingly tothe public exchequer for funds.

However, NGOs sometirnes feel (and the feeling js mirroredamong government officials) thalt accepting funds from govern-

lenl may destroy their "voludrtary nature.,' They are wary ofbeing dictated to by bureaucrats or politicians. In contrast toexpectations of credibility, they are sometimes accused ofcorruption and inefficient use of public funds. Despite thecontractual nature of funding agreements,'.misunderstand-ing"-either genuine or 'engineeped'-can lead to the applicationof ad hoc decisions. These fears lead many to stay away fromgovernment grants which perhalps explains why funds meantfor private programmes often go unutilised. The .,communica-

tion and credibility gap" thus lemains a major constraint togovernment-NGO collaboration.

The Role of the Private Vohtntary Health Sector 155

CoNcr,usroxs

It seems clear that the criticality ofthe voluntary health sectorto national health lies not in its size-which is small in terms ofits coverage ofthe nation's population, but in the nature of itsexperience with primary health care, which however has beenonly faintly "evaluated." The "ingredients of success,' ofvoluntary health action are by and large not multiplioable. Theinnovations which voluntary agencies make arise largely fromspecific local needs, and only a handful of projects can becredited with "model" developments. Despite the government,sdependence on private sector experimentation, the lessons ofvoluntary agency experience have had a limited applicability tothe macro health system, as efforts at "expansion', and ..repli-

cation" have demonstrated. Tbis constrained realitv conrrasrsmarkedly with the policy prescription for .'privatisation,'

whichimplies large scale deference on the part ofthe public healthsystem to the private health sector.

Another attribute ofthe voluntary health sector that putspay to the possibility of "privatisation,' is its considerableheterogeneity. "Charity-oriented," "developmental,, and,,politi-cal-activist" agencies make different contributions and wouldrequire different approaches on the part of government. It isunlikely that 'formul'ae' can be evolved to deal with the manydifferent types of agencies. Inthe absence of a standard buteffective approach, the government may find its interacttonswith the voluntary health sector too costly. Indeed, despite thechanged orientation of voluntary action from ,.social welfare"to "development," a look at its interactions with sovetnmentreveals no new modalities

Thus, any official attempt to decentralise health servicesthrough the voluntary sector ('usilg mjcro-level projects todeliver macro programmes') would be severely limited by itssmall size and heterogeneity. The government,s hope to increasepeople's access to primary health care through the

-private sector

therefore, will have to take .the form either of increasing thesize of the voluntary health sector several-fold, or of markedlyimproving the capacity ofgovernment health services to ,absorb'

its significant lessons. The first of these options clearly haslimited potential, given the very special needs (besides finances

156 Implementing Health Policy

and technical know-how) of votuntary health action (e.g., dedi-cated leaders, community rapflort) which cannot be'produced'on demand by the government or anyone else. The second

the government and voluntary rs is to have any meaningto the national health effort.

Although this logical on of thousht leads to theconclusioo that the voluntary sbctor must help the government togain 'know-how' with regard to delivering primary health careand to imorove the of its health services, therebyenhancing its efforts andresources, the tendency to

the effectiveness of itshas been to concentrate on how

lhe government must help the voluntary sector. Hence the debatesabout funding, cooptation, aqd so on. Instead, the focus ofattention should be on how lhe significant learning of thevoluntary health sector can bq inculcated by the macro healthsystem.

A major conclusion that arises is that the government woulddo best to view voluntary healtti efforts as "alternative develop-ments," nurseries of a new health praxis, rather than as"conduits" for government schemes. In lieu of "privatisation"in the health sector, therefore, a more fruitful approach wouldbe the sustenance of an independent, voluntary sector for health.This does not rule out certail limited modes of collaborationbetween the government and prlvate voluntary agencies, but itdoes argue against any major interlocking ofthe two systems.Specifically, the following actiVities can be envisioned whichwould be useful and not dettimental to the national healtheffort :

(1) Continued "experimentation" by voluntary agencies todevelop approaches and methods relevant to thomacro-health system in the country (along with theirother service and 11a111pg objectives).

(2) Pressure from the vlluntary health sector on thegovernment (a) to impfove its services so that morepeople enjoy access to them and (b) to develop struc-tures capable of "replicating" proven approaches on alarger scala

The Role of the Private Voluntary Health Sector lS7

(3) Funds from the government to voluntary agencies forspecific project inputs and relevant research,

(a) The collection and dissemination of information onboth private and public health programmes, and net-working of 'actors' in both fields, undertaken by bothpublic and private institutions.

(5) Interaction between the two sets of actors to foster agreater effort to educate the public, particularly bygovernment institutions and large "national,' NGOs.

A few more details on each of the above activities are in order.

Experirnertation by Voluntarey AgenciesThe emphasis here should be on 'relevance.' Voluntary agen-

cies must'become more accountable of their own accord to thenational health effort by undertaking only those programmesand research projects that are relevant to the health needs ofthe country. For example, useful 'action-research, is necessaryin the area of simple health technologies (see Chapter 7), onlow-cost but effective health care, on defining personnel roles,and so on,

The voluntary sector is well aware of the deficiencies of thegovernment. health system at the ground level as well as at thetop. Yet few projects have developed specific health strategieskeeping these in mind. If there is a prevailing sense that goyern-ment structures must change, the major questions are: whatchanges must be made and how can they be brought about?Thought clearly needs to be given to evolving 'methodologies forreplication.' The corollary is that voluntary projects must beevaluated with respect to their relevance to the developmentof an appropriate health care system in the country.

Voluntary Agency Pressure on GovernrnentThis must occur at all levels. The voluntary sector's 'ground-

level'potential to mobilise people has more far-reaching oonse-quences than its circumscribed service-provision role. Besides"equipping the poor to care for themsilves" e.g, by trainingvillage-level workers, voluntary agencies can organise peopleto demand better government health services and use them. Thecreation of duplicate infrastructures must be avoided. At the

macro-level, greater cohesion within the voluntary sector couldwork to pressurize government to improve its policies, planning,programmes and implementatiol, and to develop receptivity tonew ideas and methods. An approach which accepts principlesand fosters the evolution of local strategies would be mostuseful.

Clearly, before the governmbnt can avail of the knowledsegenerated by voluntary sector 'expcriments' for improved healihcare, certain fundamental changes must take place within it.Current attitudes must give rvay to less wary views of privatehealth agencies at all levels of the bureaucracy. There is a need,particularly, to apprise lower-level ofrcials ofthe role, potential,and needs of voluntary agenciesf-it is not adequate for hopes ofcollaboration to be voiced at the Central of even State level

158 Implement ing Health Policy

alone. It may be useful to have $tate or district-level committeesor consultative groups, voluntary leaders, to evolvelocal strategies for collaboratiorl. Ultimately, even the limitedrelationship between and non-governmental agen-cies which is being advocated

collectively bygovernment at all levels.

conducive to finding solutions td national health problems.

Governrnent Funding for Voluntary SectorDespite the government's cbll to the voluntary sector

provide its resources for schemes, it remains moreimportant for the government share its financial resourceswith voluntary agencies. The blems of raising local resourcesand the shrinkage in other sources of funds make this

that voluntary health efforts,necessary. It must befar from being "low-cost" pro have sizeable financialrequirements, although the expended are perhaps used

'The Role of the Private Voluntary Health Sector 159

m.ore effectively. Both private and public health programmeswill require greater financial outlays for their improiement, butthero is also room for better financial accounting and morecost-effective spen ding,

The issue of "self-sufficiency" in health care at tho locallevel has been a red-herring, Although the multiplicity of fund_ing sources may have encouraged lax financiai accountabilityamong voluntary agencies, the need to provide free healthservices to the poor and to undertake preventive and promotivehbalth activities means that it is not entirely possible ti .balancehealth books.' There is clearly a need for more flexibility andsmoother working in the government's current grant-in-aidsystem so that, at the least, funds are not released in the lastday of the financial year!

Networking of Governrnent and Non_GovernrnentalInstitutions

A means of coordination between government and noa_governmental agencies would be useful to enable the threeactivities suggested above. The ctrrent ad hoc approach on thepart of government is inadequate and potentially quite destruc-tive to the relationship. Government must assess its capabilityto render "help" to voluntary agencies and endow suitableiirstitutions with the mandate to wo;k with voluntary agencies.

In addition, government technical organisations such asmedical colleges, research institutes, 6nd administrative/manage_ment institutions could be encouraged to work more withvoluntary agencies for a two-way exchange:to meet agencyneeds as well as to strengthen their own t.uioiog and researchprogrammes. Such collaboration would be useful only if an'equal partnership mentality' prevails.

It is clear that collaboration between government and non_govemmental agencies-whether defined by funding agreementsor teohnical exchanges-must have clear guidlfin'es, Bothgovernment and voluntary sector must be clear on why they arecollllborating and what are the nature and limits of tileir colla-boration. To achieve this the government must perhaps firstdecide what kind of agency it wishes to work with, io fund or toassist: Given the hetdrogeneous and changing nature of volun:tary agencies these definitions may be difficuli to arrive at.

160 Implementing Health PolicY

The voluntary sector must institute internal coordinat-

ing mechanisms which will en its hands vis'rit'vis lhegovernment. The lack ofresponsible for its limited

coordination has largely been

to date, Besides serving theirown members, apex organi ns should take on the largerrole of working as pressure

to acquire such cohesion,on the government. In order, voluntary agencies must

'network' themselves rather depend on 'outside' institu-tions (e.g., donor agencies, ic institutions, or govern-

ment organisations) to do for tbem. Although links tooutside institutions are i t to overcome the isolation ofindividual islands in the 'vo archipelago,' the strengthening

luntary organisations is Para'of horizontal linkages among

mount. Voluntary agencies m st learn from each other. Ex-out 'growth and develoPment'provide "added significance" to

changes could helP them sortproblems whr'ch, in turn, mighvoluntary health action.

Public EducationThis is a vast field of endbavour which could usefully be

strengthened by government-iNGO collaboration. Onemoda-lity-tbat of mobilising people to 'use' government health ser-

vices has already been mentioried. Another is the use of mass

media to promote health objpctives, A combination of volun-tary agency knowledge of rural peoples' health behaviour and

government technology would be useful.Finally, some modalities rth at are rejected by this analysis

should be mentioned. First, the attraction of private sector

resources into public (except through health insu-

rance schemes in the or sector) would seem to be bark'ing up the wrong tree. Secondl, the establishment of any 'todeof conduct" (Roy, 1985) by for the voluntary sector

is likely to restrict voluntary n, and may become an instru-ment of repression, as Baxi has argued (1985). If government's

obiective is to foster vo action then anY administrativeor legal procedure which cen authority is a fundamentalcontradiction. Forms of already exist; the institutionof more may lower the '

national healthof voluntary health activitY to

T'he Role of the Private Voluntary Health Sector r6l

and voluntary sectors must concentrate on creating space forvoluntary health action, rather than circumscribine it.

Third, the creation of a "semi-autonomous- governmetrtdepartment for social service" (suggested by Chandra, l9g5)would make voluntary organisations extensions of the govern_ment machinery.and destroy their dynamism. The governmentshould not aim to 'bureaucratise' the voluntary sector. Whilefavourable macro'level policies can reinforce voluntary healthaction, government "planning" for the voluntary sector wouldbe quite antithetical to it. Instead, the government should con_centrate on planning for its own health service system to takeinto account the lessons ofthe private sector.

Fourth, while government should encourage the privatevoluntary sector, 'denationalisation' would work asainst theinterests of national health. Although bids may be mide by theprivate sector to take over government programmes, there aremany reasons why health care cannot be left to the private sec_tor alone, whether one considers 'conimercial' or .voluntary'organisations, together or separately. The private sector cannotspread widely and densely enough over the country to adequate_ly meet rural health needs. It lacks the steady resource base andwidespread inlrastructure that the government has. Its volun_tary component depends on funds from external asencies andother uncertain sources. Its profit-making segmen-t will notperform well in rural areas, even given Robin Hood methods.Nor will it provide the public health, preventive and promotiveservices required, as these are perceived to take awiy from itslivelihood.

Many people in need of health care, need free servicesbecause they cannot afford even highly-subsidised ones. In thisrespect, health care rernains a social and community service,and cannot become a fully commercial enterprise (Basu, 19g3).The inadequacies ofthe private sector are clearly demonstratedby the situation in urban areas where, despite a glut of privatepractitioners, clinics and hospitals, the poor flock to governmenthospitals and charitable clinics, The heavy demanJ on thesefacilities may suggest that ttrey should be expanded; but, per_haps more important, is the need to reserve these free publicservices for those who need them most, keeping out the affuentwho can well afford to patronise the private se-tor.

162

Whatever be the allegationq of inefrciency or corruptionlevelled against the government health system, and even if pri-vate sector efforts are better nlanaged, the govemment cannotabdicate its responsibility for health care. At most, the privatesector can contribute to the national health effort by providingspecial services, generating kno*ledge, mobilising people, andexerting pressure on government to fulfil its responsibility.

Such, then, are the limits to "privatisation."

Implementing Health Policy

CHAPTER 7

SPREADING PRIMARYHEALTH TECHNOLOGY

While inadequate knowledge of health conditions and theirunderlying causes as well as poor organisation of services areconsidered obstacles to the implementation of primary healthcare, the availability of technology is not in this category. Thisis largely because primary health care is designed aroundexisting technologies, For example, it is believed that the'unnecessary' mortality of 0 to 5 year olds can be tackledwith a relatively simple "package,, of interventions_antenatalcheck-ups for pregnant women, along with tetanus toxoidadministration and nutritional supplementation; immunisationof infants against six infectious diseases (diphtheria, pertussis,tetanus, tuberculosis, poliomyelitis and measles); treatment ofdiarrhoeal diseases with oral rehydration salts, and ofrespiratory infections with antibioXics; and growth monitoringto prevent and 'treat' malnutrition (Rohde, l9g2).

Indeed, an objective of primary health care is precisely tospread these and a few other technologies. Lewis Thomas (1979)has termed them "real high" technologies because thev areaddressed to significant problems, are effective; inexpensive andinconspicuous, in contrast with ,,halfway,'

technologres, suchas cancer therapy or organ transplants, which are isimultan.,,eously highly sophisticated and profoundly primitive,,i Themajor difference beiween these two types of technologies is,

164

perhaps, the level of

Implementing Health Policy

on which their disseminationdepends. Sophisticated medithe purview of a few-while

technologies are 'mystified -health technologies arebased on knowledge that can transferred to a population at

and management to reach its clientele. The technology itselfmust be acceptable to clients. r{hich may call for its'adaotation'to local conditions; and, bre, the delivery system mustalso be capable of adapting it. Organisation of clients may benecessary in order for them to benefit from the technology,Many primary health techno are oriented to behaviouralchange among service providegs as well as beneficiaries, forwhich well-worked-out strategies may be required.Thus, it is not possible tofrom those of the delivery

e the attributes of a technologyhandling it or from the social

milieu of its target population.Accordingly, this chapter eiplores some of the intricacies of

primary health technologies, arid identifies some conditions andrequirements that must be fulfillled for their spread. A case studyapproach is used in which one health tool-the growthchart-serves as the for primary health technologies-

the spread of this technologyThe problems encountered inthrough the health care system are discussed and some limita-tions pointed out. This case s(udy has been presented in muchgreater detail in the context of a review of global experiencewith growth charts (Gopalan apd Chatterjee, 1985).

Although growth monitorinf is not currently being under-taken widely in the health service svstem. it isone of the focal activities of the national Inteerated ChildDevelopment Services (ICDS) Scheme which involves healthdepartment personnel at all The Scheme seeks to deliverintegrated basic health, nutrition and education services tochildren in the 0-6 year age group and to reproductive-agewomen. At the end of the Sixth PIan it covered a thousandadministrative blocks throughout the country, and will beextended to serve another thoutand in the Seventh Plan period.

Spreading P rimary Health Technology 165

Thus, in terms of the dissemination of a 'simple healthtechnology,' growth monitoring in ICDS provides experimentalevidence of considerable proportion. For the case study, sixblocks in the States of Rajasthan and Haryana in which theICDS programme had been in operation for at least threeyears were selected.+ Primary{evel field woikers, theirsupervisors, and medical personnel associated with the pro-granme were interviewed, information and views being solicitedon all aspects of growth monitoring. A small sample of clients,in this case, mothers of children participating in the schemeor those enrolled themselves, were also included. In addition,available records were reviewed. To verify these field observa-tions, other studies of growth monitoring have been examined.Several non-governmental health projects in the countryundertake growth monitoring and reports of their experiencehave been drawn upon.

Tns TBcHNorocy or Gnowtg MoNrronwo

Conceptual Basr.r. The technology of growth monitoring isbased on the scientific observation that growth is a sensitiveindicator of nutritional status (Jelliffe, 1966). Because of theintimate relationship between nutrition and health, particularlyin the child under five or six years of age, growth monitoringalso permits assessrnent of overall child health (WHO, 1978a).In the early years of childhood, growth is rapid and anydeviation from "normal" can be detected. Growth falteringcalls for attention both to nutrition and to the possibility ofinfections.

It is believed that health workers can learn to identifychildren in whom grorvth is faltering using growth monitoringtechniques, to provide them with the necessary care, and evento transfer this knowledge to mothers (Morley, 1973). It isthis belief that has led to the inclusion of growth monitoring

rThis study was undertaken in collaboration with Dr. C. Gopalan,Nutrition Foundation of India, and has been published as a SpecialReport of the Foundation (see Gopalan and Chatterjee, 1985).

t66 Implementing Health policy

among primary health techndlogies. Its spread is advocatedto enable the diagnosis of ill-hpalth in young children and theprovision of integrated nutrifion and health services to them.In fact, it has come to be considered a crucial component ofchild health programmes. Fof example, it occupied pride ofplace in "GOBI" (Growth monitoring, Oral rehydration,Breastfeeding, Immunisation), UNICEF's world-wide strategyfor improved "child survival a4d development" (Grant, l9g3).

Application. Although a variety of anthropometric measures,such as weight, arm-circumfergnce, and so on, can. be used toassess child growth; weight is regarded as the most sensitiveand practical parameter (Jelliffe, 1966). A child,s weisht canbe plotted at regular intervals against his or her age, giving a"weight-for-age" graph. Whilc a single weight measurenrent isdifficult to interpret, serial can demonstrate asteady-state, an increase or p decline in a child's weieht.Thus, the most common application of the concept of growthmonitoring is found in the "gbowth chart," a tool predicatedon the principle of regular monthly weighing of subjectsand permitting visual on of the growth pattern ofan individual child (Morley, 1973; Morley and Woodland,t979).

Weight measurements canpopulation of children, and

lso be 'standardised' for a given' growth curves evolved.

Comparing an individual c 's growth trajectory with thatone to determine whether theHealth" (Morley, 1973). Thus,

of a healthy populationchild is following the "Road tthe growth chart can bc used f r timely attention to illness orimproper feeding underlying wth faltering.

The growth chart is incorporated in a "ChildHealth Card" whicb records information on the child

-his/her health "risk" fact such as family socio-economicstatus, birth order, etc., of illness, immunisation, andeven feeding history. The usethe growth records permits

f this information along withsystematic and comprehensive

approach to the diagnosis,health.

or recovery of child

While growth charts are individual records theycan be used to assess the and severity of malnutrition in a

Spreading P rimary Health Technology 167

population. Thus, growth charts can be used to target health-nutrition programmes, and to evaluate the effectiveness ofinterventions (WHO, 1978a).

Because of its wide-ranging applications, growth monitoringmay be unique among primary health care technologies. It isuseful for preventive, diagnostic and curative health work. Itis regarded as an'objective tool'to select children for nutritionaland medical interventions, such as supplementary feeding,immunisation, deworming or nutritional prophylaxis, and toassess the impact of the interventions on child health. At tbemacro-level, growth charts can be used to prepare 'nutri-tional profiles' of populations and thereby as the bases for theformulation of health-nutrition programmes and policies. The,growth chart also serves as a tool to educate health workers-from pediatricians to village{evel personnel-and mo!hers aboutchild health and.nutrition, and to motivate them to improvethe conditions and practices that effect these states.

Process. For its multiple potential, growth monitoring iswell worth "spreading." However, the fulfilment of this potentialdepends to a great extent on whether the health system compre-hends its principles thoroughly, and institutes adequatemechanisms to follow through the process involved in its use.

Besides requiring appropriate "hardware," (e.g. weighing scales

and charts), there are several operational steps on which theutility of the technology depends. For example, scales need tobe checked for accuracy and handled impeccably at the time ofweighing. Weight readings must be taken carefully. A child'sage must be correctly assessed, and his weight-for-age plottedaccurately at every weighing. A sufficient number of weightpoints must be obtained on each child in order for his "curve"to be visualised and interpreted. Interpretation must be.

thorough, and appropriate "follow-up" action must be takento render this a useful tool. Thus, although growth monitoring,appears simple, it calls for considerable skill and care. Workers.must be appropriately trained and supervised to ensure reliabledata and its proper use for health action.

r68

RequtnnlreNts

Implementing Health Pol icy

EFFBcrrvE UsB

A system capable of the m activities involved inthe implementation of grorvth oring is clearly its sine quanon. The various requirements and attributes of a system to

FOR

spread such a primary healthform of propositions. While

Iogy are presented in theare substantiated here bv

specific reference to growth mo g, most or all of thesepropositions apply also to other imary health technologies,

Adequate supply and pr maintenance logistics : arrasr. Although this may so obvious as not to deservemuch consideration,of equipment mayhealth technologiesillustration.

inadequateso severely

plies and poor maintenancehamper the use of primary

that the of possibilities bears

In growth monitoring, the s[pply and maintenance of twoitems-weighing scales and charts-are critical. Yet

reported in both govern-shortages of both are ubimental and non-governmental wth monitoring programmesin India (Nutrition Foundation, 984) and other countries (eg.Solon, 1983; Fajans and Sudirpan, 19g3), Besides increasingthe burden on workers, suchresults. Frequently, children

logistics make for sloppyin need of growth monitoring

may not have charts and bre are excluded from thebenefits of the technology. A loc'substitute' Droceduresdiminish the utility of the rec gy. Shortages of hardwareinevitably mean that the use olthe technology is disrupted,and it is consequently devalued by workers and clients alike.

Several types of scales are a Ie for weighing children,differing in accuracy, suitability (t6 workers, working conditionsor clients), durability and price. lThe scale of choice in mostgrowth monitoring programmes [s a ,,hanging" type on whichchildren are "suspended" for weighing. These scalesreadily portable but require uent checking for accu-racy. Observing growth operations in the field,

the scales as they hadone found that workers did notnot been trained in this relatively simple procedure, and had

Spreading P mary Health Technology 169

Clearly, therefore, the use of this technology requires not.only proper arrangements for procuring and distfibutingweighing scales and gfowth charts in adequate numbers, but.also maintaining and repairing or replacing the former in the

event of breakdown, and constantly replenishing supplies

of the latter. Analogously, other primary health technologies

{such as immunisation or oral rehydration salts) depend on

equipment and supplies for which the delivery and maintenance

lines are crucial.Manpower must be appropriately trained and deployed.

Growth monitoring technology was originally developed for use

by doctors and nurses at health clinics, Commonly, paramedi-cal personnel who visited villages and homes referred childrento health centres for weighing, which was then carried outunder the supervision of medical staff. Under these circum-.stances, Iittle doubt was cast on whether the skill-level oftheperson using the technology was suited to it, and results wereassumed to be of high quality.

However, with its inclusion among primary health techno-logies, growth monitoring must be spread at the village-level.At currently-conceived health personnel:population ratios, itwould require very high levels of organisation for paramedics

such as Auxiliary Nurse Midwives (ANMs) to monitor allchildren in their target populations. For example, Cowan has

described a procedure by which ANMs in the project area ofrhc Christian Medical College-Ludhiana monitor their targetpopulation of children in a selective, highly ordered manner,;under the constant supervision of medical staff (NutritionFoundation, 1984). Alternative techniques are used and muchdiscretion is vested in the paramedical staff. Although theeffective deptoyment of trained manpower has permitted thespread of growth monitoring in this instance, replication ofthis system on a larger scale would not be possible. Instead,the objective of universal icoverage of young children withgrowth-monitoring is usually sought to be met by entrustingthis technology to village-level health workers, such as commu-nity health volunteers, dals or child-care workers,

Although growth monitoring and the type of care possiblewith the Child Health Card were not included in the job des-

criptions of governmental community Health Guides, the

170 Implementing Health polici

Anganwadi Workers of the ICDS programme are .public,village-level personnel. On hpr visits to ICDS centres, theauthor observed that Anganwqzli Workers who had eight to tenyears of schooling understood and performed the tasks ofgrowth monitoring well (though not without errors). However.work_ers with fewer years of education had difficutty plottingweight data because they did not understand the sraphicalnature and 'time dimension'of the growth chart, and * on. a,a result, this was a time-con$uming rather than a time savingtool and €rrors were frequent.. Recording weight data is indeed a sophisticated procedure,

and not the simple one it is assumed to be. Even medicalscientjsts are often confused (Baitey, 19g4)l Anandalakshmyand-Sindhu (1984) have pointed out that the conceptual basisof the growth chart requires high-level abstract reasoning to beunderstood. Educational level is important to attain such under_standing, and hence the use of semi-literate village level per_sonnel to spread growth monit6ring is called into question.. The interpretation of gro[.vth charts is also a subtle and

complex business. A health worker requires a fairly sophistica_ted knowledge of growth dynamics, and of the interrela-tionships of .growth, feeding and health, to comprehend theinformation provided by a child's growth curve. Experiencein the field has shown that .cQmplete' interpretation is diflicultto achieve. In the ICDS blocks studied, workers focused on a.child's "grade" of malnutrition (i.e. his weight-for-age at a singlcpoint in time), paying little or no attention to his growth curve.A decline in weight was considered significant only when achild became severely malnoufished. In the ICDS programme,severely malnourished children qualify for a double ration ofthe food supplement, and so the growth monitoring technologywas being used only to identify such cases. Although the pro_gramme includes other strategids for children exhibiting .,earlywarning signs" of malnutritidn, they were not being pursuedbecause health workers'failed !o interpret growth curves pro-perly. As a result the use of ihe technology was limited to itscurative function, and its prime objective-early detection ofgrowth falteritr g and preventlpn of severe malnutrition_wasnot being achieved.

Sp pe ading P rimar y He al th Techno I ogy t7l

These points illustrate the inrportance of training for theeffective use of growth monitoring techniques: weighing proce-dures, recording, even matters seemingly as simple as determin-ing a child's age. Workers need rigourous training in how tointerpret growth data, and how to diagnose and treat theunderlying causes of any adverse findings. The complete use ofthe technology requires that they also be taught how to instructmothers on child feeding, illness prevention, and care. Healthworkers must be skiiled in the entire range of tasks associatedwith its use if a technology is to meet its potential.

In addition to a system that can impart good initial training,continuous practical training and supervision are essential. Theprovision of "feedback" to workers on their performance isnecessary to produce good results. These requirements implythat training in the use of the technology must be given to alllevels of personnel, including pbysicians, paramedics and otherswho are 'trainers.' A lack of awareness among higher'levelstaff of the intricacies of growth .monitoring or a lack ofappreciation of field problems can be a serious constraint to itsdissemination.

If the use of a technology such as growth monitoring isadded on to the tasks ofworkers who have multiple responsi-bilities, it is likely to be less than optimal. While a "verticdl"approach may overcome this problem, it is not desirable forprimary care. Rather, there is a need for effective functionallinkages with other services in order for the technology to 'payoff.' For example, anganwadi workers must link up with healthpersonnel in order to provide "follow-up" to growth monitor-ing. The "deployment" of all these persons is thus critical tothe effective use of basic health technology. The size of thepopulation a worker serves i.e. access to clients as well as to'trainers' and supervisots, and other responsibilities are alsoimportant factors.

The issueS of workers' skills and deployment are also relatedto the problems of supply and maintenance discussed above.While paramedic workers may have the capacity to obtain andutilise growth information well, time and distance constraintheir access to target populations. On the other hand, village-level workers have easier access to clients, but they are far awayfrom the headquarteis supplying charts, scales, repairs, etc. To

172 Implementing Heolth Policy

overcome these handicaps, ad{itional demands are inevitablyplaced on the service delivery sjrstem. The spread of primaryhealth technologies may ultimat$ly mean that 'quality' is tradedoff to quantity.

Technology must be user-appropriate to be practicable. Thecorollary of using appropr.iatelyltrained manpower for dissemi-nation is that the technology itsdlf must be tailored to the skillsofthe workers involved. In othdr words, a "fit" between tooland user is essential. For exarirple, in growth monitoring, thegrowth chart must be designed qo as to be comprehensible to

feinnotogy must be user-apyopriate to be practicable. Thecorollary of using appropr.iatelyltrained manpower for dissemi-nation is that the technology itsdlf must be tailored to the skillsofthe workers involved. In othdr words, a "fit" between tooland user is essential. For exarirple, in growth monitoring, thegrowth chart must be designed qo as to be comprehensible toand useable by village health workers. On the contrary, it isoften the case that the spaces provided on growth charts forplotting weights are unsuited to the large hand-writing of semi-Iiterate workers, and they codsequently have difficulty usingthem. This and other findings iddicats that growth monitoringtechnology has yet to be ad4pted for use at the villagelevel.

The issue of 'appropriateness' [s confounded when the 'user' isinadequately specified, or when there is more than one intendeduser, as is the case with growth charts which are aimed at bothvillage health workers and mothers. Experience has shown that'cultural appropriateness' is an important requirement ofprimary health technologies ( et al., 1975).

Technology must be targercd but not exclusiye. In addi-tion to specified 'users' healtli technologies must. also havean ident ified target group. Qrowth monitoring is usuallyapplied to children under six of age. However, its utilityto this large group may be at th cost of 'efficiency.' A growinggroup of professionals feels t it shouid be targeted only atchildren under three (N on Foundation, 1984). Theyargue that this would the load on workers andallow them to concentrate on who are most at risk ofmalnutrition, thereby in the efficacy of the technology.

for children over three.Alternatives have been suHowever, the application of fechnology may also err on the

side of 'exclusivity,' which wbuld diminish its utility. Fieldenquiry in the ICDS blocks in Rajasthan and Haryana revealedthat, at most sites, only 30-40 per cent of children registered inthe programme were actually being weighed: fewer childrenunder three than those between three and six years; more boys

Spreading Primary Health Technology 173

than girls; few children who lived t-ar away from the angann adi;and very few from the poorest families. Thus, many ofthe childrel 'excluded,' were precisely tllose who were most inneed of growth monitoring. Clearly, while primary healthtechnologies must be targeted for effectiveness, they must alsobe used in a way that does not exclude the needv.

Programme organisation is a key ,equirement for fficiency.From the above discussion it is clear that the usefulness ofgrowth monitoring technology is determined in large part bywho is weighed, which in turn depends on whether prosrammesspecify a target group within the universe ofchildren under six,whether they are "centre-based" or reach into homes, the extentto which they motivate mothers and children to participate,and so on. These are all aspects of programme design andorganisation from which a technology cannot be separated.

Efficacy depends 'on integration with other service compo-nents. An effective growth monitoring system links .growthcharting' to the provision of appropriate health services. At theleast, a growth-monitoring programme must aim to detect anddeal with the common childhood infections, because growthfaltering can be due to infectious illness. The value of growthmonitoring clearly increases as the requisite health services areincluded within a programme. The most common servicedelivered with growth-monitoring is supplementary nutrition.Other services that may be provided are immunisation, anti-parasitic treatment, oral rehydration therapy, health andnutrition education and family planning. While the integrationof these services with growth monitoring often also rmprovestheir coverage, their'supply' is as critical to the success ofgrowth monitoring as the supply of inputs for growth monitoringitself!

In the ICDS scheme, village-level anganwadi workers areentrusted with simple prophylactic treatments such as VitaminA, iron-folic acid, deworming tablets and oral rehydration saltsto back up their growth monitoring activities. Besides givingout these and the food supplements that are central to theprogramme, workers are expected to counsel mothers on childcare and refer children in need to the next_level paramedicalworker, the ANM. In practice, however, workers tend to linkgrowth monitoring pr.imarily to the provision of food

174 Implementing Health PolicY

supplements. Although they ocgasionally trace weight loss toillness and 'follow-up' by in:itructing mothers in appropriate

care and/or not.ifying the para4edic to examine a child, these

attempts are usually haif-heaited, and so the effectiveness ofthis multifaceted technology is diminished.

Other extant growth-monitoring programmes do not have

built-in arrangements for follonv-up health activities-or even

down-play the need for them. For example, the Tamil Nadu

Integrated Nutrition Programme, tecommends a search forinfection only. if a child failq to thrive after three months ofnutritional supplementation (Government of Tamil Nadu'

1979). The possible role of heallth interventions is de-emphasis-

ed because the programme is primarily a nutrition supple'

mentation scheme. While grbwth-monitoring technology is

intended as a basis for health care, in 'vertical' programmes

such as this one obvious linkagos are neglected.

In sum, while growth monitoring must be integrated

horizontally and vertically with other health services to be

truly useful, the implementation of health interventions is

stymied by a lack of adequaf e training of workers, their time

constraints, improper programrhe design, or other factors. Aview of technology as an 'end' father than a 'means' may be the ,

basic cause of this problem (see Gopalan and Chatterjee'

198 s).

Technology must be evaluated to iletermine effectiveness. The

number and complexity of requtirements described suggest thatthe likelihood of proper conditions obtaining for the dissemina-

tion of technology is small. Thls highlights the need to evaluate

the performance of technologieF \ryithin a given context, and

to identify factors that may pe constraining their ptoper use.

The likelihood of evaluation results being used to improve a

technology or a programme of khich it is part is enhanced by

built-in monitoring. Thus, evaluation must be part and parcel

of efforts to spread a technologN rather than an after-thought-for scientific, social and politic4l reasons.

An important aspect of eval]uation relates to the "tradeoffs"a health system makes to use a particular technology, and itsrelative cost-effectiveness. As ppimary health technologies are

usually relegated to basic hehlth workers whose time is not

costed by the official health system, they are often not seen in

Spreading Primary Eealth Technology l7Sthis light; Where a health system has to attend to a wide

' spectrum of significant hearth probrems with severe constraintsof manpower and monetary and material resources, a technologymust be able to provide direct benefits to health which justifyany financial and manpower resources used.

One approach to evaluating a technology is to askwhether what is achieved by it could be achieveO withoutit. In the case of growth monitoring, achievements dependon growth measurements being taken at regular intervals on aIarge proportion ofchildren. However, examination of recordskept by anganwadi workers in the ICDS blocks visitedshowed low coverage of their target populations, despite a highproportion of workers'time spent either on weighing childrenor motivating mothers to bring children to wei;hin; sessions.Little time.was actually spent on follow-up and, consequently,"coverage" of the target population with successive steps inthe application ofthe technology decreased, so that, eventually,little was achieved by it. Had this time been spent by workerson the education of mothers about child feeding and health,comparable results may have been achieved, calling intoquestion the benefits of mechanically-applied technology.

Meeting objectives necessitates social organisation. Thespread of primary health technologies depends on .quantitative'and 'qualitative' interactions between .providers' and .bene_

ficiaries.' While quantity refers to coverage, quality concernsthe ability of providers to imbue in clients a desire for thetechnology concerned, Both these dimensions are related to the"social organisation" of clients-so that ultimately, the successof a technology comes to depend on this complex factor.

For example, the effcacy of growth monitoring is relatedto the participation of mothers in a weighing programme (the'quantity' of interactions) and to their 'education' in its use andutility ('qualitative' interaction). Experience has shown that,besides being constrained by competing demands on their time,mothers' involvement in growth monitoring programmes ishampered by the lack of 'demand.' One approach to overcom-ing this has been to offer incentives (such as food supplements)to mothers to bring their children for weighing and otherhealth services. .Some programmes have been successful in

176 ImPlementing Health PolicY

overcoming the lack of partici[ation by using social organisa-

tions such as Women's Chibs and Farmer's Clubs for thedelivery of services including growth-monitoring (Arole, 1984).

'Demand creation' is also sought to be achieved throughindividual education and m0tivati of clients. It is believed

that if mothers observe or participate in the processes ofweighing and plotting, they can be made aware of the impor-tance of weight gain and be {ncouraged to improve their child's

weight by following advice by the health worker (Rohde

et al., 1975). However, it observed in the ICDS centres

were not interested in weighingthat the majority of mtheir children because they oould not comprehend the relation-ship of weight to their child'd health. Thus, the technology was

not 'accessible' to the majoritiy of clients, and efforts to spread

it would have to concentralte on breaking the cycle of 'noknowledge, low demand.'

In summary, the dissemin[tion of primary health techno-logies has both supply- and demand-side requirements. Thechief ones that have emerged firom a study of one technology'growth monitoring, have been described-supply and mainte-nance logistics, manpower draining and deployment, appro-priateness and targeting ofthe technology, programme organis-ation, service integration, and social organisationfclient education. These n most likely apply to other basichealth technologies. In there may be other require-ments that are more technol

ATTRIBUI'ES OF v llrlrTlr TrcnNotoclrs

Primary health technol also appear to have certain

not easy

Spreading Primary Health Technology 177

communities lacking birth records, and so the technology is'inherently limited.' It may, however, be possible to overcomesome limitations of a technology by ingenious programmeplanning and design.

Adaptation and substitution are possible. The need to adapta technology to specific local situations is fortunately accompa-nied by a potential to do so. However, adaptation or evensubstitution, where it is possible, is often difficult. An exampleis provided by the use of indigenous' equipment in growthmonitoring.

Village-based growth monitoring programmes call for aweighing scale to be available in every village, but the costs ofthis are often prohibitive. To overcome this, some investigatorshave experimented with the use of local market balances(Nutrition Foundation, 1984). However, inappropriate ..substi-

tution" may also.occur such as platform scales, use of registersinstead of growth charts for recording weights, and so on.Thus, although programme guidelines which allow flexibilityat the local level are desirable, they must be broached withcaution.

Available alternatives. Thus far the discussion of growthmonitoring has been limited to growth charts based on weight-for-age measurements. However, the limitations of age dataand other problems suggest that alternative "age-independent"methods of monitoring growth would be desirable.

However, although such measures as arm circumference andweight-for-height are available (Shakir, 1978; Nabarro andMcNab, 1980), they too have 'inherent' and operational limita-tions! At the current time, there does not appear to be a growthmonitoring technology which adequately fulfills "reliability,feasibility, utility and sensitivity criteria,' set by the AmericanPublic Health Association (APHA, 1981), a situation whichunder-scores the need for technologies to be used with fullappreciation of their limitations,

Application involves ethical choices. The 'selectivity' that maybe an inherent feature ofa technology and 'exclusivity, that mayemanate from programme design, both point to a fundamentalattribute of technologies-their ethical underpinnings. Theimportance of the characteristic will be underscored by providing

178

examples of ethical choicesrnonitoring.

Implementing Health Po licy

application of growth

As described earlier, there i wide variation in the "normal"n and so siatistical proceduresanthropometry of any populati

are used to demarcate levels of malnourishment. These demar-cations are arbitrary, involhave particular physiological

value judgements, and do notor "infallible progno-

stic value" (Gopalan, 1984).

to select beneficiaries forinstances benefits beins made

et, growth monitoring is used

specific interventionso in most

tion of children.For example, in the

ih the

Proiect nutritionalchildren who are found to

ble only to a small propor-

Nadu Integrated Nutritionare provided only to thoseseverely malnourished. While

this application of growththe desire of programme

oring technology arises out ofto imorove the cost-benefit

ratio of the nutritional s scheme and is based

children are at muchon the finding that severelygreater risk of mortality thaned children (Chen et al., I

oderately or mildly malnourish-

), it loses sight of the arbitrarynature ofthe procedures used to grade children into differentdcgrees of malnutrition.

Furthermore, the neglect of children who are moderatelyand mildly nralnourished is a self-defeating strategy whichGopalan (1983a) has termed a "nutritional policy of brink-manship."

Political itnplications. Tbat even "simple" health technologies

are not free of political implications can be illustrated bygrowth monitoring. To evaluate nutritional status, a child'sgrowth curve is usually compafed with that of a "reference"population. The most extensively-used reference standards arederived from data on Western populations (Stuart and

Stevenson, 1959; Tanner et al., 1966; WHo, 1978b) but theirappropriateness has been qubstioned. Some scientists argue

that the use of standards based on "developed" populations,

or even on the well-nourished in developing countries, sets

unachievable goals for less welfl-off communities, and unneces-

sarily inflates the malnutriti<fn problem (Eusebio and Nube,

1981). Others maintain that subh standards are useful as growthpotential is more strongly infl$enced by environmental factors,

Spreading Primary Health Techno logy

such as nutrition; than by ethnicity (Habicht et al., 1974;Stephenson et al., 1983). Thus, the deliberate adoption of alower "standard" would defeat the purpose of comparing achild's growth with his actual potential. It may amounr ro a'political strategy' to keep less-developed populations at lowlevels of growth achievement. Similarly, since the manner inwhich "grades" of malnutrition are demarcated determines theextent of malnutrition in a population, "cut-off" points can bechosen so as to exaggerate or downplay the extent of malnutri-tion in a population. This is often done, for example, toreduce the numbers of undernourished children to proportions"manageable" within programme resources, " wiping out"malnutrition by a "redefinition of parameters" (Mitra, n.d.) !

Cost constraints. Besides such distortion of technology tofall in with "practical resource constraints," there are, however,"real" cost constraints to the spread of technology. Forexample, the cost of growth monitoring may be so high as toprohibit its adoption by the health system at the national level.In illustration, one can examine just the cost of the weighingscales necessary. It has been estimated,that a capital outlay ofRs. 3 lakhs and an annual recurring expeuditure of Rs. 60,000would be required to provide a single district of one millionpopulation with scales (Kumar, 1984). At the national level,an initial expenditure of Rs. 20 crores and an annual recurring€xpenditure of Rs. 4 crores would be required for the scalesalone! Stipends for village level-workers conducting the growthmonitoring would amount to Rs. 55 crores per annum. Inaddition, the costs of growth charts, of training and supervisoryinputs would need to be added. These expenditures wouldbe infructuous unless other related services are provided.Thuso' growth monitoring alone could conspme a considerableproportion of the national health budget (see Chapter 9)!Although equipment may be 'donated' initially if programmesare envisioned on a national scale, external assistance may be.counterproductive because 'adaptation' to local needs may bedelayed oi avoided altogether. Thus, the cost of manufacturingeQuipment and supplies locally is an important considerationfor the long-run dissemination of a technology. In the shortterm, although a technology may be desirable, the. resources it

t79

180.

requiresmartial.

Implementing He alth Policy

to be usefully opefationalised may be impossible to

CoNcLusroNs

To assess the capability of the health system to implementprimary health care, field e*perience with a single primaryhealth technologyo growth mobitoring, has been discussed.. Although a technology inay itself be 'simple' (growthmonitoring is based only ofr a paper chart and a weighingsoale!). a number of basic irements must be fulfilled lbr atechnology's potential to bs met. Among these are: adequatelogistics for the supply an maintenance of "hardware."appropriate training, depl and supervision of manpower,

including integration with, cultural acceptability, socialother services, targeted de

organisation of clients, and eValuation. Clearly, with this list ofrequirements anydifficulties.

could face severe ooerational

because the spread of simple technologies must be at thesame time "low-cost" and hidhly "cost-effective."

I{owever, the "low-cost" bf primary health technologies hasnot been adequately established. Considerations of cost mustencompass organisational, {ranpower, Iogistics and'hidden'costs besides the direct of equipment arrd supplies. Inview of all these costs,primary health technologies

' in the application ofbe as important as equity. Inconsiderations might be more

proper programme o

fact, beyond a point 'qu

Spreading Primary Health Technology lglimportant than 'quantity.'As we have seen in the case ofgrowth monitoring, large-scale applications of a technology mayresult in a mechanistic and ineffectual approach, while targetingthe technology and ensuring additional inputs (e.g. follow-up)may be far more "cost effective."

A given technology will be 'cost-effective' only in particularcircumstances, e.g. at a specific level of development of thehealth service system, for it requires adequate development inorder for results to be commensurate with the time, energy andfinancial resources expended.

This argument contrasts somewhat with that put forward byadvocates of the "selective primary health care" approach(Walsh and Warren, 1980). A selective approach to theimplementation of primary health care has been suggested onthe premise that resources are limited, and hence that..total"primary health care is unattainable. This would mean that alarge number of people would continue to be exbluded fromhealth care unless the 'prescriptions' are reduced to feasibleproportions, Although growth monitoring is not included amongthe 'selective' primary health care interventions advocated,immunisation, treatment of acute conditions (eg. malaria), oralrehydration, the encouragement of breastfeeding, and otherMCH, family planning and health education measures arelisted. These interventions are largely aimed at young childrenand women in the childbearing years-the same target groupthdt is the focus of growth monitoring operations. It has beenproposed that these services can be provided sporadically (onceevery 4-6 months) through mobile health units. The cost ,,per

patient contact" of such a strategy has been estimated as aboutone-fourth the cost of "total PIIC" per caput.

However, this proposal overlooks several field realities thatobtain in India (and most probably in other developingcountries) from the'mundane' (eg. the inaccessibility of manyvillages by road transport but the existence (at least in theory)of village-level health personnel) to the profound-the attitudesofhealth service providers and the need for constant interactionsbetween providers and clients. Even the implementation of'selective' primary health technologies will require healthseryices to be substantially upgraded. This will necessitatelarge resources.

182

Social fssues

Implementing Health P olicy

The 'economic' issue of the cost of health technologies is

inextricably linked to the soqial issue of their 'acceptability.'Primary heallh technologies are 'demand-oriented' and so

clients' perceptions, attitude$ and practices determine theiracceptance, use and effectiveriess. 'Culturat appropriateness' is

of prime importance to the spread of a health technology.Unless appropriate, the techriology will not be sought after by

clients, it will only be perceived as having high opportunitycosts. Even strenuous efforts by health workers will then be

infructuous, and the technologiy will become 'costly.'One aspect of 'cultural 4ppropriateness' is the fit between

the technology and the delivery system. Like pieces of a jigsaw

puzzle, both these must intQrlock with the social milieu. It isthe system delivering the technlology that must adapt it to localconditions, and itself be anenable to changing in tune withlocal requirements. Although poncern is often expressed about

the extent to which commutities can absorb a technology'it is more important to ask whether a given technology and

the health infrastructure prompting it can adapt to communityneeds and constraints.

Political IssuesFinally, one can examinb a few 'political' issues, not

unrelated to tbe economic and social ones discussed above.The most important is the issue of 'control' over technologies.Even thougb primary health technologies are intended to be

spread to the population at la{ge, the medical profession stillexercises technical control oJvcr them, and the bureagcracycontrols their administrationi There have been few attemptsat 'decontrol,' For example, ulhile mothers are urged to bringtheir children to growth mqnitoring programmes, they arerarely taught how to conduct the weighing and chartingthemselves, much less to apply the findings to benefit theirchildren. For that matter, even basic health workers are irottaught the latter properly.

A related issue is the possibility that the aims of a tech-

nology rnay be subverted. [nstead of "early detection" ofchild illness, growth monitciring can be used simply to select

Spreading Primary Health Technology 183

beneficiaries for feeding, or to collect information on mothersand children for family planning purposes. ..Evaluation,' of atechnology implies assessing whether it is being used to achievestated objectives. lt is perhaps equally important to assesswhether it is essential for doing so.

A third 'political' issue arises from the question: for whomis the technology intended? It is necessary to examine whethera technology really benefits the target group-or some othergroup, eg. programme designers and administrators. Healthtechaelot1., are not necessarily egalitarian in their consequences .

and so, if reducing differentials in health is an obiective ofpolicy, their application must be directed to benefit tirose mosrin need.

It is crucial to remember that health technologies do notfunction independently of the social, economic and politicalsystems of which they are part.

CHAPtrER 8

LIFE WITH UT FOOD?-,'POLICY

While public policies over the past two centuries haveprovided the ingredients for Kerala's impressive mortality andfertility declines, they have failqd to improve nutritional status

in that state, Policies enactpd with equity considerations

brought about the spread of education and health services,

social integration, improvemehts in the status of women,political participation and other factors that have contributedto the low birth, death and irlfant mortality rates and highlife expectancy of Kerala. But iirattention to growth has resultedin inadequate food production, low incomes and markedseasonality of employment which operate to perpetuate poornutrition levels. While the major paradox has been seen as

one of 'high social develop[nent despite economic back-wardness,' there is also, clearly, a paradox within the microcosmof health. Mortality and fertility rates are low, but malnutritionand morbidity are high. One mi[ht well ask: How can there be

"life without food"? Given cufrent population pressures andeconomic uncertainty, declinitg trends in nutrition may be

expected. There may also be indications that Kerala's healthstatus, judged by indicators othpr than mortality rates, may beworsening. What then is the fufure of Kerala's "health"? Whatare the lessons for health policyJ elsewhere?

Life l4/ithout Food? r85

THE ,MAJoR' plnnoox

The people of Kerala apparently enjoy good health despitetheir poverty. The state's health status is usually judged by itsfavourable demographic indices. Its overall death rate andinfant mortality rate are the lowest in country at 7.0 per 1000people and 43 per 1000 live births, respectively (CBHI, l9g3).At over 65 years, its average life expectancy lat birth iscomparable to that of Europe or North America, and exceedsthat of most countries in Afiica or Asia. Within Itrdia, it isthe State with the highest sex ratio (1032 females per 1000rnales)-indeed, the only one where there are more femalesthan males; the highest female literacy level (65.7 per cent), andthe lowest birth rate (26.8 births per 1000 population), excludingsome of the Union Territories. On the other hand, the percapita income of Kerala is much lower than the nationalaverage (Rs. 1448 compared with Rs. 1750 in .l9gl-82), whichindicates the overall poverty of the state.

Prevailing Explanatory TheoriesThere are several explanatory hypotheses for this anomalous

situation. Nair (1974) first suggested that the extension ofprimary health centres and public health measures in the statdled to declines in infant and child mortality rates in the i950sand subsequently to fertility declines in the 1960s. On theother hand, Panikar (1975) pointed out that mortality rateshad already declined substantially prior to the 1950s andproposed that public health measures, such as sanitation,inttoduced by the rulers of Travancore and Cochin in the 19thand 20th centuries, were the key to reduced mortality. Heargued that the relative contribution of 'modern' health facilitieswas small. An 'all-encompassing' hypothesis was provided byRatcliffe (1977) who saw cbange in Kerala's demography asthe result of broader socio-economic and political developmenrs.First, he pointed out that the State's pursuit ofland reformenabled it to achieve more equitable distribution despite lowaverage income, in contrast to the rest oflndia. In addition,he proposed that the availability of wage employment andhigh *age rates helped .landless agricultural labourers as will

186

as workers in thebetter terms and

Implementing Health Policy

industrial service sectors. Better wages,

available. In sum, a greaof work, and wel fare wereproportion of the labour forceuctivelv in the economv-andparticipated actively and

therefore shared in the overall istribution of income, despitereported high rates of un oyment. (The latter situation,explained Ratcliffe. obtained there was less disguised

t in Kerala than elsewhereunemployment and underemplin India.)

Second, Ratcliffe extolled 's education policies, whichand made allocations olemphasised primary

educational expenditures inresult, primary educationwidespread. Kerala had

ce with this prioritv. As aalmost universal and literacy

this universal educationdespite its shortage of reso , debunking the commonassumption that the two are patible. Education of womenand of lower castes was a ftey factor enhancing their statusand social mobility. Educatlon increased participation ineconomic activity and thus cdntributed to income distribution.The education ofwomen vlas aflso associated with a higher ageat marriage &mong women in Kerala compared with the restof India. Third, Ratcliffe clted the high tevel ofl politicalconsciousness in the state as ar! important factor. He attributedthe political awareness to tlle inffuence of the CPI during the1950s. (However, as we shall sbe below, organisation of lowercastes and pressure for legislative changes which had an impacton health, began long before tlie CPI came to power, althoughthey undoubtedly continued to flourish under CPI rule andinfluence.)

Discussing the role ofthe health services, Ratcliffe assertedthat education .and political participation had engenderedknowledge of individual rights, including the right to healthservices. This, in turn, created a popular climate of "demand"within Kerala, and both the and the vote were used bythe people "to force the to be responsive to their

led health resources to be

fashion. and the resultant

demands." Widerdistributed in a moreservices were better utilised.. This happened despite loweroverall per capita expenditure bn health in the State. Ratcliffeconsidered unlikely the hypo put forward by Nair (1974)

Life Without Food? 187

that Kerala's fertility declined in response to mortality declinesand health service usage: He contended that both mortalityand fertility in Kerala declined in response to improvedkvels of social development (though fertility decline may haveIagged slightly behind mortality).

.In fact, Ratcliffe went on to assert that more equitable distri-butions of political power, resources, goods and services, wereresponsible for mortality and fertility declines. He associatedhigh labour force participation and more equitable distributionof wealth with Kerala's reduced fertility, and suggested thatother forms of social welfare and security in Kerala, as well asthe enforcement of child labour laws, reduced the "desire forchildren," thus also contributing to decreased fertility.

Ratcliffe also claimed that higher incomes and productivityand education meant improved nutritional intakes. He suggest-ed that although average per capita calorie intake may be low,the distribution of calories had been conducive to betternutritional status. In sum, he saw the factors of income andresource distribution, political participation and education asacting synergistically to enable Kerala to overcome its handicapsof high population density and a low resource base, and provideits population a better standard of living.

HrsroRy on Hrnr"ru DevnropurNr

However, Ratcliffe's analysis was largely confined to the post-1950 period; it thereby ignored historical developments in thevarious fields discussed, particularly those in the health services.The historical context is important because the healtheffects ofearlier social and political developments in Keralawere most profound. Yechouron (1980) has provided a descrip-tion of the development of public health in Kerala in thecontext of social and political change. She has suggested thatsocial change brought about "from below" was instrumentalin modilying the demographic picture. In the -nineteenth andearly twentieth centuries, the caste system in Travancore andCochin was already breaking down under the influence ofChristian missionaries who fostered the lower castes andimproved their conditions through education and organisation.The breakdown of the caste system went hand in hand with the

188 Imp lemeiting Heal th Policy

spread of education. The access pf lower castes to governmentschools, which included health ekaminations and health educa-tion, helped to improve their hedlth status. Enhanced politicalparticipation on the part of lowpr castes also led to govern-mental response to public he{lth and medical needs. By thesecond half of the nineteenth century, the Rajas of Cochin andTravancore began to build hqspitals and dispensaries whichwere accessible to all, and they dxtended public works, includingsanitation.

Thus, a favourable situation lwith regard to health facilitiesobtained by the mid-nineteenth fentury with the widespread andrapid construction of both publiQ and private (largely missionary)health centres. The latter conoentrated on providing servicesto tbe poor and to lower castes, and on training local midwivesand nurses to cater to these co@munities. Free from the certifi-cation requirements instituted by the British in other parts ofIndia, suoh training provided aq important personnel base.

In the face of public government commitment tothe provision of health fa<

ture considerable. While thewas also strong and expendi-pment of medical facilities

elsewhere in the country was largely confined to urban areas,in Kerala they were spatially uted throughout the ruralareas,of the

ensuring an access which is unparalleled in any other partcountry. "Mobile clinicsl' became an earlv feature of

medical services because of road networks.These public hospitals and hfalth centres wete well-equipped

and also fostered the training arid deployment of women healthworkbrs at all levels. F a "grant-in-aid" systemoffered by the government uraged the development ofprivate institutions and of indieenous medical institutions.Utusually, there was ion between private medicalinstitutions and the governmentfs public heallh department inthe areas, for example, of trainihg and vaccination.

In view of this early and spread of medical facilities,Panikar's (1975) assertion that they played a minor role inbringing about demographic cannot be totally accepted.Yechouron's ( 1980) historical s

inent of medical institutions took place from the 1880s

onwards, ccinourrent with an emphasis on prevention andemphasised improiedpriblic health. Many medical

Life Without Food?

midwifery techniques. Dai training hadCochin and Travancore. These factors arecontributed to an early drop in infant andrates in the region,

189

begun early in bothquite likely to have

maternal mortality

Political commitment to health was also exemplified by thesupport given to vaccination programmes by the Rajas ofTravancore from the 1860s onward. By the end of the lgg0s,vaccination had become a major programme and sanitation workhad begun in both urban and rural areas. A cholera epidemicin the 1890s instigated the establishment ofa Sanitation Depart_ment and epidemic control measures were installed. Theimprovement of water supplies, through the digging and cleaningof wells, was a first step.

A Public Health Department was created in 1933 andconcerned itself with other endemic diseases such as hookwormand filaria. Research in transmission and treatment beganand control measures instituted. public health educationwas emphasised, including the prevention of endemic diseases.In 1934, a state-wide vaccination campaign began whichrapidly covered over 70 per cent of the state,s population.Efforts to improve water supply and provide drainage continuedto spread through larger towns and v.illages. The importanceof clean water was recognised and both governmental andpopr:lar comm itment to it were strong. The government waswilling to spend large amounts of money and the people werewilling to contribute both finances and labour for theseprogrammes. It is most significant that vaccination and sanita-tion and water supply were the first major public healthprogrammes instituted in the area and that thesd were accom-panied by increasing education, school health, and politicalparticipation.

Around this time, a ruial health unit was established withassistance from the Rockefeller Foundation to develop a rural.health service model. Here, maternal and child health werestressed. The unit was a training ground for physicians, publichealth nurses and other health personnel. Witbin ten yearsinfant mortality in the health unit area was.reduced to g3 per1000, in contrast with the prevailing (1938) all-India figure. of,207, and the Travancore-Cochin-Malabar rate of lZ3. (How-ever, whether this lower rate is attributable solelv to the health

190 Imp I ementing H eal t h Poli cy

programme remains an uncertain conclusion.) Although therural health model programme was intended to be extendedthrough the state, this was not possible because the effort was

expensive, and there was both a shortage of funds and oftrained medical personnel. It ls interesting that Kerala intro-duced such a "model" exporime4t as early as 1928, and thatthis failed then for much the sarhe reasons as model efforts failtodayl Nevertheless in 1936, a didespread Maternal and ChildHealth programme was establlshed in Travancore, and taluk-level health units were started to provide basic health services.The MCH centres provided intta- and post-natal care, domici-liary visits, hygiene and child care education, and even

supplementary feeding.The impact of people' awarefless, organisation, participation

and contributions, brought aboult by education and democrati-sation. must not be underestimated in the situations of bothTranvancore and Cochin, whehe there was a parallel develop-ment in health. As Ratcliffe notod (1978) the people of Keralaare aware of their rights and Use demonstrations, newspapersand elections to "force the slstem to be responsive to theirdemands." As a result, the health system has a relationship withits clients that is favourable to |realth objectives. The process

of "health awakening" has, however, taken place over more thana century! The major participdnts in this process have been

women who exercised influence dn the health and welfare oftheir families and succeeded ih bringing about 'amrmativeaction' in the sphere of public h$alth institutions.

THe RoLr oF EDUcATIoN AND WoMEN's STATUS

Besides the 'spin-off' benefits bf higher literacy for health,

education was also used effectively to directly further healthand hygiene. The Travancore Health Code of 1909 required

that all school students be vaccirfated before entrance and every

five years thereafter, aod that all schools be inspected by the

Medical and Sanitary and Public Works Departments. Itallowed domestic science and hygiene to be taken by women inplace of geography and history, and provided for teachers to be

trained in hygiene, which was lafer included in all government

Life Witllout Food? 191

school textbooks. (Since 1945, hygiene has been taughtas a separate required course in all primary and secondarvschools). Although initially girls and boys studied in the sameschools, the number of girls' schools was increased and domesticscience and nursing became compulsory subjects. This could befollowed by prdctical nursing at local hospitals. The crucialpoint is that education of women in general terms as well asspecifically in health care went hand in hand, At the sametime, women's relatively higher position within their homesensured that they could utilise their school learnins,

In faot, the favourable demographic situation olKerala owesmuch to the high status of women, which emanates from thematrilineality of Kerala society (Krishn a lyer, 1970). Under thepredominant marumakkathaya system in Kerala (Gulati, 1976)women enjoy the right to inheritance and residence, and theright to divorce and remarry if widowed. Because of theirinfluence and position of power within the family, they weroeducated,. Thus, they became aware of influences on health, andeven took up professions connected with health; working asdoctors, nurses and dars in hospitals. They were also inductedinto other health cadres, such as vaccinators, and in all theseroles ventured into communities which had little or no accessto institutionalised health services. The influence of Christianmissionaries on the provision and propagation of femaleeducation, as well as on the

"ntry of fernul.s into the health

professions was undoubtedly strong.The high status of women in Kerala is borne out by the

ielatively more favourable female demographic indices (Govern_ment of Kerala, 1984). The mean age at first marriage hasalways been higher in Kerala than elsewhere in India (Gulati,t976). For example, in the l90l-10 decade, the mean age inK,erala was 17.1 years while the corresponding all-India age was13.2 years. In 1981, the ages for Keraia and India were Zl.gand 18.7 years, respectively. In addition, the proportion ofwomen remaining unmarried in Kerala is much higher than therest oflndia. Although these nuptial trends are due in parr rovery different interpretations of religious and social norms thanthose enjoined elsewhere in the country, higher rates of femaleeducation and participation in the labour force obviously alsoplay major roles. All these factors also exert influences on the

t92

t

Implementing H ealth Policy

ed largely unimplemented, in pontrast to the concrete activitiesof the rulers of Travancore and Cochin. Education and social

organisation (eg, of lower groups) remained underdevelop-. The status of women was alsoed in the Madras

inferior in the Malabar area with Southern Kerala(Gulati, 1976). Malabar had (and still has) a higher proportionof Muslims, whose wom.en tremained in purdah, were noteducated, and were married e{rly. To this day, the districts thatcomprise the region of Malabdr remain behind those of the rest

of Kerala in terms of female llteracy.

DtsAccREcATrNG SocIAL, EcoNorr.ttc AND PoLITICAL FAcroRs

The role of social factors ln Kerala's mortality and fertilitydeclines is highlighted in Nag's comparisons of that State withWest Bengal (1981, 1983). Celsus data show that infant morta-lity rates and birth rates wpre higher in Kerala than in West

Bengal until the 1941-50 dec[de. Nag's comparative analysis

focuses on post-I950 develo$ments. Since the 1950s and parti-cularly in the 1970s Kerala hds fared better than West Bengatr

on these indices. To explain the more rapid declines in fertilityand mortality in Kerala than ln West Bengal during this periodNag examined various socio-dconomic parameters, as well aseducation and health factors.

First, he showed that West Bengal's per capita income ishigher than Kerala's and that there is also greater inequalityin the distribution of rurat household incomes in Kerala.Although rural Keralite hbuseholds apparently had larger

mortality rates of Kerala, re{ucing the differentials between

male and female mortality dnd decreasing infant and childmortality rates. Female life exlectancy is higher than male lifeexpectancy in the state, a situation that results in a sex ratiofavouring women.

The importance of the sbcial and political climate thatprevailed in Travancore-Cochif to the development of health iseasily recognised when that region is compared with the areaof Malabar, which was under British rule as part of the Madras

Presidency. (The two areas weire merged to form the state ofKerala only in 1956.) Although the British had codified publichealth norms for areas under {heir rule, these proposals remain-

Life lVithout Food? 193

average total assets than rural households in West Bengal,these were apparently also inequitably distributed. Citing astudy by Ahluwalia, Nag showed that the inequality of ruralper capita consumption expenditure was greater in Kerala thanWest Bengal. Using data from the National Institute of Nutri_tion and the National Sample Survey Organisation he pointedto the higher nutrition levels of West Bengal compared withKerala. Low income groups in Kerala had the loweit per capitacalorie and protein intakes among 9 States surveyed in 1972_74.while high income groups in Kerala had the highest per capitaintakes, suggesting markedly skewed distribution oifood con_sumption. Looking beyond rural areas, Nag showed thaturbanisation and industrialisation were higher in West Bengalthan in Kerala, and so did not explain the latter States .better,demography. Thus, Nag contended that neither the economic"standard of living" nor equitable distribution of food, explain_ed Kerala's more favourable demographic picture, in contrastwith Ratcliffe's (1978) earlier claim. Despite land reform andminimum wages, the situation of poorer groups in Keralawas worse than of those in West Bengal.

Nag then compared health and educational facilities in thetwo States. At first look, medical and public health facilitiesappeared to be'balanced.' West Bengal had a higher doctor:population ratio, while Kerala had a higher nurse: populationratio. However, West Bengal,s doctors *r., .on.*t.ated inurban areas, while Kerala had more primary health centres inrural areas (163 centres in 144 blocks in Kerala jn 1977_7g.compared with 316 centres in 335 blocks in .West

Bengal).By 1973, Kerala's pHCs had their full complement of doctors,but there was a "10 per cent vacancy', in West Bengal, Further-more, in Kerala in 1977, there were ll subcentres for eachPHC, compared with 6.2 in West Bengal. The catchment areasof subcentres in Kerala were smaller and good roads andtransportation facilities made them more accessible. Thus,Kerala had a higher proportion of institutionalised births anddeaths in rural areas than did West Bengal. The governmentalper capita expenditure on health in Kerala was slightly higherthan that in West Bengal.

Nag also drew attention to the early introduction of public

lg4 Implementing Health PolicY

health measures, including satritation and immunisation, inTravancore-Cochin during the 4ineteenth century, and to the

absence of such measures in West Bengal. Although the

increasing differential in mortality between the two states since

the early 1970s could be explalned by different causes of death

(because Cause of Death datd are deficient in both states-indeed, all over India), Nag prlrposed some environmental and

hygiene factors that may be "r{rore favourable to health" inKerala. According to him, the people of Kerala have a "tradition of cleanliness" and boil tiheir drinking water, while West

Bengal's water tanks -are ill-maintained and unhygienic. Thus,

Nag asserted that better undErlying conditions and greater

utilisation of preventive and curative health facilities may bemajor determinants of the mof tality differential between thetwo States. He also suggeste{ that the greater availability offamily planning services in Kerbla had been responsible for itsreduced fertility.

Education also played a sigiiificant role in Kerala's better

status compared with West Berrgal. Kerala's history of wide-

spread basic education in the vernacular, contrasted withBengali education which wa$ elitist and oriented towards

secondary English-medium education' There was less primary

education in West Bengal and less interest in the education ofwomen. Kerala had higner turrent educational expenditures

than West Bengal, particularly on primary education. Kerala'shigh literacy rate, and particul{rly the higher literacy of females

compared with West Bengal, fbvoured reduced mortality and

fertility in the former State. Hlgher literacy increased awareness

of health facilities, and conqequently their use. In particular,

Maternal and Child Health serfices were widely used by women.

Higher literacy also favoured political participation, especially ofthe poor, and demand for health care' Demand for health

services was at a far lower level in West Bengal, refleoting lowerpolitical awareness and participation (despite the Left move-ment in this state as in Kerala), Thus, political processes, too,seem to have favoured dembgraphic change in Kerala more

than in West Bengal.On the whole, Nag conoluded that 'equity' in health and

education facilities had been a greater influence on the decline

of mortality and fertility ratep in Kerala than had income and

Life llilhout Food? 195

asset (e.g. land) distribution. In keeping with this, he suggestedthat elsewhere in India, mortality and fertility declines could bebrought about through greater equity in health and educationservices (which is politically easier to achieve) and need notawait the redistribution of income or land reform (which willbe politically resisted).

While both Ratcliffe's (1977,l97S) rtnd Nag's (l9Sl, 1983)analyses cover the gamut of factors possibly indicted inKerala's demographic transition, they are significantly diver-gent from one another. Ratcliffe stresses the equitable distri-bution of economic resources as the major cause ofthe state'sdemographic change, while Nag emphasizes the .distribution,ofsocial services, negating the role of economic factors. How-ever, underlying both sets of factors would seem to be .politicalprocesses.'

Poverty RecapitulatedAlthough Ratcliffe maintained that Kerala,s redistributive

policies increased incomes which were most important for the de-mographic transition, Zacbaiah and Kurup (19g4) have suggest-ed that a degree of economic deprivation resultedfrom land reformwhich was at least partially responsible for inducing the fertilitydecline. The process of land redistribution changed .,the cost ofchildren relative to the family's income." Those who lost land,lost income, and so began to place emphasis on having fewer"higher quality" children. On the other hand, those who gainedland did not gain enough to desire more children. Simultaneo-usly, higher wages brought about by minimum wage legislationresulted in more unemployment. This decreased the potentialof child labour and enforcement of child labour laws eliminatedchildren's economic contributions. Minimum wage legislationalso increased the earnings of women, s.o that the ,.opportunitycost" of child-bearing rose. And so, while Ratclifle (197g) andNair (i974) had earlier postulated thar fertility decline inKerala had little to do with the family planning programme,Zachariah and Kurup (1984) and others (Kurup and Cecil,1976) held that the programme was most important for thereduction of the birth rate. That is, tbe availability of familyplanning services made it possible for the..desire', to control

196

family size to be turned into"unmet demand" for famil(Zachariah, 1981).

Zachariah and Kurupresult of "a systematic eros

the inherited characteristics o

etc.) and the simultaneoussignificance of personal

Education was perceived as

mobility, and thus aeducation ensued. A similarforward by Panikar (1984a).

Zachariah (1981) hadpolicy interventions design

smaller families are healthsuggested that other states

measures to reduce infantfemale education. He stipby providing the means towages) to 'purchase' betterbe brought about by reducingcare to the poor i.e. maeffcient delivery of .familyabout fertility declines elsew

Again in contrast topoverty, Mencher (1980, 1982

among Kerala's agriculturalgreater poverty. Mencber,situation of agricultural Ia

rheir life conditions had ipolitical economy (1980).

over one-third of all rural wproportion of workers inabout twice as many a

Mencher exDlored their hliteracy, employment situaand land.

With regard to fertility, Mmuch of the decline in Kerala

Implementing Health Policy

reality, (althoughplanning services

the decline in fertility as theof the economic significance ofa person (religion, caste, family,enhancement of the economicbutes (education, healthi etc.). "ensuring social and economicdesire to 'invest' in children's

is has recently also been put

concluded that "The princiPalto encourage couples to desire

education," and like Nae (1981)

in India should take similarchild mortality and increase

ed that while this could be donehigher incomes (eg. minimum

and education. it could also

'cost' of education and healththese more accessible. More

services could also bring

tcliffe's theory of 'diminished'considered the decline in fertilitylabourers a reflection of their

anthropologist, examined theto determine to what extent

roved with chanses in Kerala'sultural labourers constituted

in Kerala, and a higherareas she studied. There were

tural labourers as cultivators.nutrition, fertility, education,

access to other public facilities,

supported the

there is stiilin Kerala

view thatdecreasedis accounted for by the

Life Witltout Food'! 197

fertility of this group, but she argued that the main reason forfewer children among agricultural labourers was that it was nolonger advantageous to have more, due to pressu{es. onemployment. Employment opportunities had decreased becauseof an-increase in the population oflandless labourers, depressionin industry, technological displacement of workers from industryand other occupations (such as forests), and a decreased demandfor labour on the part of landowners. More children wouldrnean more household. expenditure, which may not be offset bytheir future earnings because of high unemployment. Thus, thelabourers chose to have fewer children. Mencher pointed outthat, in any case, labourer households traditionally had fewerchildren than landowning ones, perhaps because of the higherprevalence ofjoint families in the former group. Because ofthe lack of employment, children ,... noir.quired much fordomestic labour and so they were sent to school. ..Sending achild to school need not be an indication of lessening poverty.,,In fact, because there was less employment for children andparental incomes were limited, parents preferred to send childrento school where they got a midday meal at least. Accordingto Mencher (1982), although education was readily available ithad not meant better employment for agricultural labourers.In the face of declining work opportunities, the minimum wagemay have helped to prevent the poor from slipping to lowerlevels of poverty, but it has been insufficient to iaiseihem abovethe poverty line. There has been little or no improvement inthe quality of their lives.

Discussing medical care, Mencher stated that while it was,indeed, available and helped to avert many deaths, it was"insufficient to eliminate poverty." Although chances ofchildren surviving were indeed higher than eailjer, there wasstill a higher incidence of child death among the poorer groupsthan among landowners, .,The reason wny peopte are livinglonger and why child deaths have declined ,.lui.r'u. much topoliticisation ofthe people as to public policy . . . .There is noquestion that politicisation of people in Kerala has played amajor part in affecting (improving) people,s health. . . . InKerala, if a PHC was unmanned for

-a few days, there wouldbe a massive demonstration at the nearest collectorate led by

local leftists, who would demand to be given what they knew

198 Implementing Health Policy

they were entitled to. This hds had the effect of making health

care much more readily availhble for the poor in Kerala."Mencher noted that (in 1970-71) doctors in Kerala preferred

working at Primary Health Centres to engaging in private

practice. They did not regard a PHC as a "dead-end job," and

were usually to be found hard at work with people waiting inqueues for treatment.

In sum, Mencher stipulatbd that Kerala's high levels ofliieracy, and low levels of mortality and fertility are notnecessarily indicative of a reduction in poverty or improvement

in the quality of life. This facille association is usually drawnbecause of Western experience with declines in mortality and

fertility, which ensued from improvements in the economic

standard of living. While ecodomic improvements may, indeed'

have led to lower rnortality and fertility in the West, this can

be disputed by inter-State analyses in India (such as Nag's, l98land 1983, or Gopalan's, l9S3b). ,A,nd further, the converse ofthis proposition-that improved mortality and fertility rates

are the result of better living cbnditions-seems definitely untrue

in the case of Kerala.Having thus explored the major paradox of 'demographic

transition despite economic bactwardness,' the stage is set foran examination of the internal inconsistency or 'minor' paradox:

"Iife" (i.e,low mortality, high life expectancy) without "food"(low nutrition). The rosy picture of health development painted

for Kerala with demographic brushes is confused by details ofthe State's health and nutrition status. But mortality is

inevitably a reflection of morbidity, and so health factors and

trends are important for long'term prospects.

Hrlrtu AND NurRlrIoN STATUS

Analysts of Kerala's demcigraphic transition have largely

focused on fertility and, in a few instances, on mortality as the

'dependent variables.' While nutrition has been considered interms of food consumptibn as a measure of economic

development (i.a. an indepe4dent variable), nutritional status(the outcode or dependent rlariable) has rarely been examined'

Nor have other indicatols of morbidity been used. The

Life Without Food? 199

exception to this is the work of Panikar and his colleagueswhich, fortunately, sheds proper light on the health andnutrition status of Kerala. A few observations bv Mencher arealso useful.

Initially, Panikar (1979) had also confined his examinationof Kerala's health status to indicators such as the overall deathrate, age-specjfic death rates, including the infant mortality rate,and life expectancy, and pointed out the state's advantageousposition compared with other states. He also showed that rural-urban d.ifferentials in Kerala were less than in other parts ofthe country (e.g. 1.2 points in the death rate per 1000 popula-tion compared with an all-India difference of 7.5 per 1000 in1978). Kerala had successfully lowered the death rate ofherrural population and of children in the vulnerable yearsbetween 0 and 5.

However, using Cause of Death data, Panikar (1979)pointed out that the major causes of fdisease and death weremalnutrition, poor water supply, and lack of environmentalsanitation, although "the success of Kerala seems to lie to alarge extent in having given equal emphasis to preventive andpromotive measures as to curative medicine." The spatialdistribution of health facilities allowed preventive health careto be delivered to the population. Immunisation, clean water,sanitation, nutrition, and health education were amongthose measures. Immunisation coverage rvas high, and contri-buted to lower mortality. Better health awareness due tohigher education levels led to better utilisation of healthfacilities and higher 'institutionalisation' of birrhs, resulting inlower infant and maternal mortality. However, despite Kerala'slong history of work in sanitation, water supply, diseasecontrol, and public education, Panikar pointed out that in1978 "the proportion of the population covered by protectedwater supply and sewage in the rural parts of Kerala remainsrather low."

MorbidityMore recently, Panikar and Soman (1984) have provided a

detailed account of the health situation of Kerala and of thehealth service system. Besides low levels of overall mortality

200 Implementing Health Policy

and infant mortality, rural-urbafl and male-female differences inthese rates are small, and life exf,ectation at birth is higher forfemales. than males, a unique I situation arnorg.rth€ States'ofIndia. However, the authors havb characterised the morbidityprofile as "a rnixture of the disqases of poverty and diseases ofafiuence." Among the latter are included 'diseases of aging,'which are manifestly importanf because Kerala's populationhas a somewhat 'older' pyramid{l structure than the country atlarge because of its lower birth r[te and higher life expectancy.

These separate disease profiles are of some interest. Atrural primary health centres, fespiratory infections predomi-nate. They particularly affect overcrowded coastal villagepopulations living in the hot and humid tropical climate.Diarrhoeal diseases are the next lmportant cause of morbiditydue to the lack of sanitation facilities and scarcity of drinkingwater. They were, again, more prevalent in coastal villages,and also exhibited seasonal ions. Skin inlections werecommon because of poor hy Other data showed thatintestinal parasitism was ram 90 per cent ofthe populationbeing affected by one form or (or multiple parasites).

Ilospital data on child o Datients from an urban area(Trivandrum) revealed the irflportance of communicablediseases such as diphtheria, ing cough, measles andtuberculosis, in addition to othei respiratory and gastrointesti-

y occurred during the 1970s,due in part to the success of tion programmes and inpart to thb availability of th facilities, respiratory andgastroenteric infections and pbliomyelitis maintained highlevels. The first two groups of were also seen frequently

urban hospital. Thus,among adults admitted to andiseases related to poor envi nments-lack of sanitation,impure drinking water and -were most significant

nal infections. Whilecommunicable diseases a

among the people of Kerala.significantly over the period I

a degline r'n the prevalence of

Malaria had also increased63-68 to 1973-76, suggesting a

decline in vector-controlAmong "diseases of the t," gastrointestinal problems

and cancers were prominent cardiovascular disease and'accidents and poisoning' were olife-styles among the urban

the rise, reflecting 'modern'sections of Kerala's

Life Withaut Food? 201

population. Some differences in the pattern of diseases emergedfrom a comparison ofthe records ofa free public hospital and.a paying private. hospital. .Ilowewr, as both werer'urbatr,hospital-based data sets, they were not representative of theprevalence of such diseases among the population at large. The"diseases of poverty" (infections, including TB and leprosy,infestations and deficiency diseases) clearly emerged as the mostsignificant class, especially in rural areas. Panikar and Somanconcluded that the high rate of utilisation of medical facilitiesin the state reflected existing high morbidity rates superimpos-ed by a consciousness of medical care. One can extrapolatethat'health awareness'even in Kerala relates more to seekingcure than to preventing disease. The prevalence of poorenvironmental conditions favours the spread of infectious diseaseso that morbidity is high. Deaths can, however, be avertedbecause medical care is close at hand,

Nutritional StatusPanikar and Soman ( 1984) have also collated information on

nutritional status, judged by the growth achievements of Keralitechildren, and the prevalence of nutritional deficiency diseases.Growth measurements dating back to 1936 are reported andshow considerable stunting and underweight among Keraliteschool children in both the Travancore and Malabar regions.Later studies between 1943 and 1976 substantiated theprevalence of growth retardation among children. On theother hand, periodic studies of birth weights carried outbetween 1940 and 1978 show remarkable consistency over timeand acceptable average values.

More recent growth information is avai.lable from theannual survey reports of the National Nutrition MonitoringBureau (NNMB, 1976, 1977 , 1978, 1979, 1981). Berween 1975and 1979, about 38 per cent of children in the pre-school agegroup were found to be moderately or severely malnourished inKerala. Although other states surveyed had higher levels ofundernourishment, this proportion is already large. Significantly,percentages of "normally" nourished children were no differentin Kerala than, say, in U.P. The prevalence of nutritionaldeficiency diseases such as anaemia was also exceedingly highamong children, particularly those of coastal villages.

202 Implementing Health Policy

A plethora of data is avallable on food consumption inKerala, beginning with the 1940s (Panikar and Soman, 1984;Soman, 1982; Panikar, 1978, 1980; Kumar, 1979; UN, 1975).Without exception, they show that Kerala's populationconsumed substantially less on an average than the "recom-mended" per capita -intake of calories. Among the poorestgroups the shortfall was morg than 50 per cent in some years,and it was as much as 30 per cent among middle to better-offgroups. Time-series data between 1950 and 1970 for foodconsumption in rural areas suggest energy deficits of l5 to 25per cent. A decline during thp 1960s is also evident. A surveyin 1971 showed a deflcit in avelage calorie intake of about 20per cent in both urban and rural areas (with very liftledifference between them). While the poor consumed roughly25 per cent less than "recommdnded," even the rich consumed5-10 per cent less.

In the I960s and 70s the National Sample Surveyconsistently showed that the average per capita calorie intakein Kerala was the lowest in the country, considerably belowthe national average. Por exanlple, in the 197l-72 (26th) Roundof the NSS (1975), the daily calorie intake per consumer unitwas lowest in Kerala at 2023 itt rural areas and 2103 in urbanareas compared with the highest levels in rural punjab (37tI)and urban Rajasthan (3006), respectively, and the recommendeddaily intake of 2400 calories. In Kerala over 18 per cent of"consumer units" in rural areas and 27 per cent in urban areashad a daily per capita intake below 1500 calories, One mayrecall that in their classic st[rdy of poverty in India based onNSS data, Dandekar and Rath (1971) found that Kerala hadthe highest percentage of peoplp below the poverty line.

The NSS collects monthly expenditure and consumptiondata on a sample of households over the course ofayear.Unfortunately, the variance in a household's mean caloricintake is not reported. Thug, the tabulated data iron outseasonal fluctuations. While low average intakes over longperiods of time already have seiious implications for nutritionalstatus, seasonal fluctuations dan be even more detrimental.Given that among the poor in Kerala the average intake isalready very low, in the absepce of data disaggregated over

Lift ltithout Food? 203

the course of the year, one can surmise that during lean periods,

the shortfalls in calorie intake are exceedingly drastic.As NSS food consumption estimates are based on consumer

expenditure data, it has been suggested that they grossly

underestimate caloric intake because food items such as tapiocaand coconut, which are grown in Keralite "kitchen gardens,"

are not accounted (UN, 1975). However, one should note thatthe levels measured by the NSS are very similar to calorieconsumption data obtained by actual diet surveys, which collect

data on food consumed and not just food purchased, and so

would include these homegrown foods. For example, theNational Institute of Nutrition (1973) obtained a per capita

calorie consumption figure of 1842 based on diet surveys

between 1960 and 1969, which is in consonance with theaverage figure of 1620 calories obtained by the NSS in 1967'62'Data gathered by the National Nutrition Monitoring Bureauduring the 1970s also show Kerala as having the lowest average

caloric intakes among ten states surveyed (1983 calories per

capita in rural areas) and the highest proportion of householdswith inadequate food available-between 54 and 81 per cent inthe years 1976tot979, and 53 per cent in 1980 (the most recentyear available). At the individual level, one out of every fourpersons was deficient in both calorie and protein intake, withhigher proportions among vulnerable groups (e.g. 63 per centamong lactating females, 36 per cent among 1-4 year oldchildren).

In her study of agricultural labourers' households, Mencher(1980, 1982) also investigated food consumption. By comparing

villages, she showed that less work meant less to eat. She foundthat the majority of households had an inadequate diet. Theircalorie deficits were not made up by eating tapioca' Mencherreported seeing no tapioca growing in the compounds ofagricultural labourers homes in the areas she studied. (The

growing of tapioca is regionalised and much is being used tomanufacture starch). Dietary preference for rice remained high,and this food accounted for most ofthe calories consumed, incontrast to the notion hetd by Gwatkin (1979) that Keralitediets 'are "balanced." With the spread of refrigeration and

demand from outside the state for fish, vegetables and fruit,these items are fast disappearing from the poor man's diet.

204

Agricultural labourers"seasonality" and M€ncherthinner between Aprit and

Implementing Health poticy

particularly susceptible toibes ''seeing" F,eople getting-June. The use of fair price

shops by these poor households was also seasonal. Thev didnot get credit from the fair shops and so when cash wasIow, they were forced to buy fro local shopkeepers whose off-

public distribution system

Mencher's observations are

rners, salaried workers in theidents (cf. Kumar, 1979).

by those ol Banerji(1982). In an in.deprh srudy of I villages in different parts of

season prices are higher. Thus,caters primarily to regular wagelower middle classes and urban

the country, Banerji includedof Kerala. He found that 70village reported hunger for 3 toother village almost 40 perand a further 20 per cent for o

villages in Balghat districtcent of the people of one

months in the year. In thewent bungry for 3-6 months

situation" of all those he

6 months in the year. Thesetwo villages had the worst ,,hun

studied in the country.While it is generally acknow ged that nutrition and health

are closely related, it has usuallv been assumed that if data onnutrition (r:.e. food intake) an health (i.e. mortality) are

poor quality of nutrition dataincompatible, the fault lies inor the "inappropriateness" of n nal yardsticks (Sukhatme,1982). The tendency has been either to show that the foodintake data are gross as was done by the Centrefor Development Studies in their pioneering work on poverty inKerala (UN, 1975), or to consi the prevailing calorie intakes'adequate' (as does Ratcliffe. 1 , 1978 and the proponents ofthe "small but healthy,' h e.g Seckler, 1982). A thirdtendency has been to gloss over te nutrition, consider-ing it unimportant for .demosra transition.' For example,even Nag (1981), who argued there is little data to supportRatcliffe's hypothesis that foodas a result of land reforms."effective" public distribution

s more equitably distributedminimum wage legislation,

ough fair price shops andschool feeding programmes. d fnot consider nutrition aconfounding factor in his .,belief that "social develoom

al development" theory. Thecan be achieved without

t has obscured the adverseconcurrent economic develo

Life lltithout Food? 205

consequences of low economic deveropment on actuar levers ofliving, nutrition and health.The assumption that low mortality implies low morbidity

and an absence of malnutrition is however belied by the nutri-tion and,morbidity surveys and anthropological investigationsdiscussed above which point out that lowfood intakes are indeedprevalent in Kerala and that these are reflected in poor nutri_tional status and in the high incidence of disease. Althoughmorbidity data are, admittedly, deficient, their improvementcould only reveal higher levels of illness

The lack of 'correlation' tetween morbidity and mortalityin Kerala is largely explained by the high ut.ilisation of curativehealth services in the state which help to avert deaths. This,in turn, suggests that the spread of health services has been akey factor in Kerala's mortality decline, and that explanationsthat gloss over this fact are inadequate. Factors undeilying thehigh utilisation have already been discussed. The t.act thatmortality has been rowered by curative medical interyentionswithout change in nutritional status and morbidity demonstra_tes that preventive health care has been less successful. This isclearly manifest in the pattern of morbidity. panikar and hiscolleagues (e.g. Panikar and Soman, 19g4) have consistentlymentioned the poor environmental conditions (.lack of sanita-tion and clean drinking water, poor hygiene, and overcrowding)that predispose the population to infectious diseases. Thus, thefocus on Kerala's low mortality and its equation wlth a high"physical quality of life,, (Morris and McAlpin, l9g2) nas evenobscured widely acknowledged undernutriiion-infectron rela-tionships (Scrimshaw et al., 196g).

, Given this 'minor' paradox in the health situation, it wouldbe useful to examine the current status and likely future trendsof factors underlying morbidity and nutrilional status whichmay, in turn, affect mortality Ievels in Kerala. In this conrext,it is most significant that Kerala's demographic u"hiu"_.o,.are credited to synergism among a host of factors. Althoughhistorical explanations are important, trends are oo, irr.n"._sible. If the processes that have brought about demographicchange lose momentum or are overtaken by other factors, anew situation may obtain with regard to -orLidity, mortalityor fertility. 'Ihus, a discussion of factors that may

"-ootribut, to

246

worsening trends can

and action.suggest aroas

Imp lementing He alth P ol icy

for public policy attention

TnrNos rN Rsi.areo FAcroRs

Population GrowthSince the 1910s Kerala's crude death rate has been lower

than the all-India a\etage, and the lowest of all Indian states

since the 1940s (Bhattacharjee bnd Shastri, 1976;Mitra,1978).Declines irr the 1970s have beerl most remarkable. As already

mentioned. rural-urban differelntials are lower for Keraia thanany other state and females acttally outlive males, an altoge-ther unique situation (CBHI, 1983).

On the other hand, Kerala's birth rate declined very slowly(at about the same level as the all-India rate) until the 196l-70decade (Nag, 1983). From l92l:30 to 1961-71it declined by 8

births per 1000 (or 20 per cent) and by a further 10 births per

1000 between 1971-81. Thus. tlhe total decline since 1921-30

has been around 45 per cent, though especially sharp over thepast 20 years. In the same peripd, the all India birth rate hasdeclined by 30 per cent. Sidce 1971, Kerala's birth rate has

been the lowest among Indian $tates.However, because Keral4's mortality declines occurred

earlier and more steeply than its fertility declines, its popula-tion growth rate increased ellery decade until 1961-71 (Kurupand Shamala Devi, 1982; RayaSpa and Prabhakara, 1983). Itsdecadal growth rate was hig[er than the country's average

until 1971, particularly in the 1921-31 and 1941-51 decades.(Interestingly, unlike other pads of the country, Kerala's popu-

lation did not decrease during {he great pandemic between 191Iand 1921). Most recently, bec4use the decline in Kerala's birthrate has caught up with the fall in mortality, the decadalgrowth rate has fallen for the first time-from 26.3 per cent inthe 1961-71 period to 79.2 per cent in 1971-81.

During this century, Keralal's population growth rate has

been doubl6 that of the countfy as whole. While India's popu-lation has trebled since the turn of the century, Kerala's hasincreased four-fold (from 6.3 rgillion in 1901 to 25.5 millionin 1981), doubling between 19!l and 1971 alone. Consequently,

Life Without Food? 207

Kerala is the most densely populated state in the country, withthree times the number of persons per square [kilometre thanIndia as a whole. This high density has important implicationsfor the provision of curative and preventive health services andfor the environmental and economic factors affecting health.For example if the 'equitable distribution' ofhealth and edu_cation services has been among the factors ensuring Kerala,slower mortality, will the favourable situation continue in theface of population pressure? Will much-needed water andsanitation improvements be possible with the attendant over_crowding? And so on.

Declining Sex RatioWhile the decline in the country,s sex ratio during the course

of this century is well noted, Kerala is usually cited as anexception because its sex ratio favours females (Mitra, 1979).The fact that Kerala's sex ratio has also been declining hasavoided notice. In the 1981 Census the sex ratio was 1032females per 1000 males in Kerala (Government of Kerala,1984). Ifoneadds to the male and female populations thenumber of male and female emigrants estimated at the ttme ofthe census, the sex ratio of the total population emerges as1018. This figure is consistent with the declining trend in thesex ratio of the overall population which has been occurringsince 1951, when it was 1028.

This decline is fuither substantiated by the low sex ratio inthe 0-14 year population group (971 females per 1000 males)and is borne out by analysis of the sex ratios of single decadalcohorts i.e. the 0-9, 10-19 and 20-29 year age groups. The sexratios of these groups are 967, 1000 and 1120 respectively. Onewould indeed expect the sex ratio to be highei among adultpopulations because of the higher out-migration of males, and infact the ratio in the 15-34 age group is 10g4. However, not allofthe difference could be so accounted, especially since in themost recent decade the number of female out_migrants has alsorisen and amounts to about three-quarters of the number ofmale emigrants (Gulati, l9S3). If one accepts, as Gulati hassuggested, that almost 80 per cent of emigranis are under 35years of age (and presumably over l5 years), one can cdlculate

208 Impl ementing Health Policy

the sex ratio of the populatiorl including these men and women.

It works out to 1051 . A comfarison of the ratio in this twenty-year cohort with that of the cphort under l5 (971) again shows

a considerable decline in the siex ratio over time.

The 1981 Census ranked Kerala's districts by their sex ratio(Government of Kerala, 1984). One finds, not surprisingly, thatthose districts that had the hi$hest sex ratio had provided the

largest numbers of males to the out-migration phenomenon as

shown by Gulati's (1983) ran$ing of districts. Thus, male out-migration is currently ible for a good part of the"favourable" sex ratio in Were it to cease the situationwould be different. One misex ratio) that the statusfavourable as it used to be

conclude (from these data onwomen in Kerala is no longer as

that it may be declining at anturn signal changes in the healtha'larming rate. This may in

situation if (socially or eco ) women are increasinglyprevented from utilising hknowledge.

th services or obtaining health

Changing Fanrily and Horlsehold StructureIn fact, emigration may alfo have other effects on the ferti-

lity and mortality levels of ttie state. Although out-migrationfrom Kerala is not just a recdnt phenomenon, the recent wave

of emigration is in large part a response to the high unemploy-

ment levels of the state. It appears to have several distinctcharacteristios (Gulati, 1983). First, a large proportion of the

emigrants are from districts (in the Malabar region) which

have a higher percentage of Muslims in their populations than

the state average. These distribts also have the lowest per capitadomestic production levels in the state. The possible repercus-

sions of this on women's stafus and consequently on health

have already been alluded to. It should be noted, however, thatalthough emigration among the Muslims of Kerala is high' itis by no means limited to ihem, Hindus and Christians also

out-migrating in significant numbers. Second, the emigrants

are mostly young men. Althofgh as many as half the emigrat-

ing man may be unmarried, the others leave behind wives and

children. The majority of milrant households are low-income

households: Gulati has repor(ed the effects of this migration

on the family. She hypothe$ized an increased interdependence

Life Without Food? 2Og

among family members of emigrants. This includes the re-estab-lishment of joint or extended families in place of nuclearfamilies. In the 1973-74 National Sample Survey, Kerala rankedthird in terms of household size in rural areas among 17 Statessurveyed (exceeded only by punjab and Haryana) (NSS, 1976).It had an average of 5J2 persons per household, comparedwith an all-India average of5.3l persons. Of these, 1.79 personswere adult women (or almost one out ofevery 3 persons). Thiswas by far the highest number ofadult women per householdof any State. On the other hand, Kerala had fewer children perhousehoid than most other States, and ranked sixteenth out ofthe l7 States (the exception being Tamil Nadu) in terms of theratio of children to adult women in these households.

As a result of the male-biased emigration, the emigre house-holds have an even higher proportion of females (and evenvillage-level sex ratios are often highly skewed). On the positiveside, these women appear more independent, especially in themanagement of household and family affairs, and in the school-ing of children. They are also becoming more active jn outsideeconomic transactions (Gulati, 1983). However, they are alsoapparently subject to greater pressures and tensions, and mentalhealth problems are on the increase (Anon, l9g2). Familybreakdowns are not uncommon. Migration can also be expect-ed to have an impact on fertility and a study cited by Gulatinoted the low proportion of children among emr'gre households.Health awareness and behaviour may well change in thiscOntext.

A third feature of the out-migration is that remittances fromthese emigrants now make up a sizeable proportion (17 percent) of the State's domestic product. Gulati has estimated thatthey added 30 per cent to the income of the average ruralhousehold in 1980-81 (considering both migrant and non-mig-rant households). In the case of migrant households, the contri-bution is obvr'ously a larger percentage, and many depend onthe remittances for their living expenses. Housing has been oneofthe chief investments. Although standards of living arebelieved to have improved in these households, in the absenceof specific information about their access to clean water antlsanitation, this cannot be assumed to be high. Thus, the impact

2lO ImPlementing Health PolicY

of emigration on the health stftus of those remaining behind

iray not necessarilY be Positivb.

Econornic Situation-- K.rula'* per capita income has been lower than the all-India

uu"*g" at least since the 1960s and this gap may be widening

further. The State's per capita annual income is Rs' 1100

"ornp"r.O with Rs. 2300 in Punjab' Per capita consumption

""p."Ji,"t" levels in both rurdl and urban areas of the state

il;; ;;; been consistentlv lpw, the average expenditure being

"t"t, aS per cent of the all-fndia average figure during the

;;;0; ;r; 1970s. Kerala's iconomjc growth rate has barelv

;;;;G with its populatiot growth fl" ul: " '1111:i1t'on are still below the poverty line'proportion of its populati - - . .. --- ^--r ^..^rilir;d;;; t* cent^of ttre state's labour force were unemploved

uoi n fottn.t 36 per cent had iess than 120 days employment

l.r 1fr" v.ur. Although the minimum wage of the agricultural

i"t".*i and wages of semi a4d unskilled workers -are higher

i.- f.*f" than in other Stales' they (along with other factors)

have led to the shrinkage of tlie job market'*';;;; population dlnsitv and successful land distribltion

r.urrri., have engendered 4 situation whereby the average

iunarroraiog in Kerala is aboqt half a hectare. Ninety. per cent

;if;;.*r;t Kerala have holdings below one hectare (oofPareg

;;,h-id d cent in Punjab). This situation must bejuxtaposed

*iin in.'higb average houqehold size in Kerala mentioned

p*"i"r.fv' iurg, fa-ili"t, $omprised mostly of . adults' are

l.p.oa*i on small acreagd for food, which may have serious

nutritional imPlications..'- io fu"t, Kerala is a food deficit State' While the staple diet

.f lt. p."pf" is rice, it does n{t produce enough 1o feed them'

;.;;Liit; the agricultural situation in the State' Panikar

iis3iuip.t"*a orit that there fT p:e-n " .1,..111: l^11.'-.:::1::ffJt""'#;i,*"i'"" ir"* :-sl4-1s' while- riceaccounts for

iO p.. ".",

of the total cropped area, its 'yield rate'.. was static

"".1-in. decade of the lg70s and per capita production actually

i"rii"ra during the decade' The staple has been 'imported'

from other States to. supporf the public distribution sYstem'

O.tpl " this system, the oliren market price of. rice has been

frig-t.rittut thai in the rest of the country' Tapioca (another

Life Without Food? 2llimportant source of calories, but modestly occupying onlyl0percentof the total cropped area) also declined in yield(by about 30 per cent) during the 1970s, One can estimate thefood value of tapioca grown on the minimal landholding ofa Keralite family (one tenth of an acre), given a yield rate of18 tons per hectare on an average and processing losses ofabout one-third. It works out to about 350 calories per caputper day for 350 days in the year. This is about 15 per cent ofthe "recommended daily allowance', of calories and thereforea mere supplement to a family's food.

Thus, although the production of cash and export crops'such as rubber, coffee and tea has increased, the major foodcrops have declined. This deteriorating trend has serious impli-cations for Kerala's already precarious nutritional situation.Krishnan had in fact predicted in 1976 that ,.the averageconsumption and level of nutrition in agricultural labourerhouseholds will decline" and possibly that the decline innutritional intake would raise mortality levels.

Health ServicesAs discussed, Kerala's health services are widely creditted

with having successfully brought down mortality levels. Severalfactors have enabled this situation. For one, the services (andtheir associated resources, financial and human) have beenspatially well-distributed. Kerala consists mostly of contiguousvillages with homes dispersed in such a way and com-munications so developed that most people are within reachofa health facility. This contrasts with the 'cluster' villagesettlements of most of the rest oflndia where lack of accessto health centres located in some villages remains a majorcause of the underutilisation ofhealth facilities, and the poorcoverage of people with health care., Besides facilitating access to health care, this spatialdistribution ofhouses in. Kerala. may also have been instru-mental in containing disease-again, in contrast to otherparts ofthe country where housing situated check-by-jowl abetscross-contamination arnong inhabitants of a village. However,.if this spatial isolation of homes in Kerala reduced thetransmission of disease, increased population densities (,.over-

2t2 Implementing Health Policy

crowding") may nullify tfris achievement and exacerbatepersisting high levels of infectious disease in the state.

The most important contributors, however, to the prevalence

of infections are inadequate sanitation facilities and impuredrinking water supplies (Panikar and Soman, 1984). In partthe result ofpopulation denqity, this situation also emanatesfrom a lack of awareness anlong the people of pret,entive healthmeasures. Despite the early development of preventive andpublic health measures under the Rajas of Travancore andCochin, they have clearly hot kept pace with the State'sdevelopment more recently. Although some infectious diseases

have been reduced, malaria, filaria, hookworm, and otherparasitic problems remain serlious health hazards. Environmentalimprovements are sorely ngeded to reduce morbidity-andensure that mortality trends &re not reversed.

Another factor that enabled the health system to reduce

mortality was the availability of qualified women doctors, nurses

and other female health worlkers. Their presence meant thatwomen could venture to pub[ic and private hospitals, facilitatedby their higher status. Howtever, the recent wave of emigrationmay have consequences both for the staffing of health facilitieswith women (large numbers of Keralite nurses have been

emigrating to other parts ofthe country and out of it) and forwomen's use of these facilitibs, as previously noted.

In Kerala, in earlier year$, both public and private allopathicand indigenous practitionefs and facilities were widespreadand were used interchangeably by patients who chose accordingto the disease and treatrinent prescribed. However, moterecently, the expansion of facilities for traditional systems ofmedicine has been considerdbly slower and 'consumers' mayhave a reduced choice in thd future.

During the 1960s and 70b Kerala had the highest proportionof State government expendLiture on health of all the States(13-14 per cent) (see Chapter 9). Between 1957 and 1980'expenditure on health incfeased faster than total governmentexpenditure and State domebtic product. Despite this, Keralahas one of the lowest p{r capita health expenditures of allStates in the country. Pu]blic expenditure on health may notrise further because of the peneral economic situation in the

State. As poverty has lowered the ratio of private to public

Life Without Food? 213

health expenditure over time in Kerala, diminished publicexpenditures may occur at a time when people are mostdependent on the governmental health svstem.' Also of significance are existing inter-regional differences inhealth facilities. Panikar and Soman (19g4) stated that dis-parit.ies in the death rates of Travancore-Cochin and Malabar de-creased "as a result of the improvement in medical care facilitiesin the Malabar region" since the formation of Kerala in 1956.However, two lines of evidence suggest that this was not so.First, declines in mortality in Malabar actually began in the1940s when it was still part of Madras state. Second, although,as Panikar and Soman pointed out, the number of healthinstitutions in Malabar in l96l was smaller than in Travancore-Cochin, an examination of health facility: population ratiosshows that those in the former region were actually morefavourable than in the latter (only in terms of the bed:population ratio was Travancore-Cochin better off thanMalabar). In 1971 and 1981, the health facility: populationratios of districts in the Malabar region were behind thoseof the Travancore-Cochin area. In other words, the expansionof health facilities in the Malabar region has not been asfavourable as in other parts of the state. This factor, alongwith the crucial social differences in these regions alreadyreferred to, may explain persisting inter-regional health dis-parities and even increase them.

These aspects ofthe health services-the enlarged populationsize of their 'catchment' areis, the inadequacy of preventiveand public health measures, reductions in health manpower,particularly female and indigenous, in per capita publio healthexpenditures, and interregional differences-all have seriousimplications for Kerala's health.

Social TrendsIn the past, heatth and education facilities in Kerala served

the majority of people and not just a privileged few. In additionto the decline of casteism brought about by early socialreforms, the pattern of habitation increased social contactbetween members of different castes and classes. Among factorscontributing to the development of infrastructure (includingcommunicatiens and health facilities), Mencher (1980) included

214 Implementing Health Policy

the lemigration' of retired hiddle-class professionals to ruralareas from urban areas of thefstate where they exerted demandson the government to improte facilities. The spatial dispersionof socio-economic classes most likely had a 'Jones effect'-for example, schooling came to be viewed by the poorer groupsas a way to ensure that (heir children kept up with theneighbours. Such effects may plateau when economic conditionsbecome constraining,

Besides the declining seN ratio and changes in familystructure noted earlier there is also other evidence of changingwomen's status which may hafue repercussions on health. Forexample, dowry which was earlier unknown in Kerala has

increasingly crept into the $ocial system. While Kerala was

earlier sequestered from thp brahmanical and patriarchalcustoms of tbe rest of the country, since Independence pan-

national forces of materialism, Hinduism and "Hindi filmculture" are eroding its tra.lditional social development. Aswomen are being educated, more quaiified grooms are sought

from whom dowry deman{s are-peryersely-high. If thesocial environment was imporltant to the reduction of mortalitythen such changes in the social situation of the State are likelyto be critical to the future heailth status of its population.

Political DevelopmentsKerala's experience dem tes that social development is

compatible with a broadly ocratic framework and that, infact, social changes derive entum from a participatoryatmosphere. Structural oriented to equity and social

unt in bringing about healthtransformation were paramimprovements. Thus, any pocould also affect health in(1984) have drawn attentionabout by the proliferation

ical changes ofa regressive naturethe future. Panikar and Soman

the political instability broughtof parties and coalition politics in

Kerala, which does not a well for its health situation.In particular, the centralisati n of authority and bureaucratisa-tion of decision-making, wformulation and implemen

people have little say in then of social programmes, in

contra$t with the historical of popular participationmay diminish the of public health services.

Life Without Food? 2t5

CoNcLUsIoNs

From the evidence, complacency about Kerala's past mortalityand fertility declines is clearly misplaced. The sustenance

of low mortality levels will depend on the State's ability todeal effectively with morbidity-disease and malnutrition-henceforth. This will require action in several spheres.

Attention must be paid by the health system (and related

departments) to preventive measures aimed at reducing both

the spread of infections and malnutrition. Kerala's health

awareness currently relates more to seeking cure than to pre-

venting illness. To promote 'prevention,' it is not enough for

health services to be 'conveniently situated,'they must reach

into homes to provide individual health education and motiva-

tion. More important, facilities must be provided to the one-

half to two-thirds of all households in urban and rural areas

who do not have access to protected water and even lack

rudimentary sanitary facilities (Panikar and Soman, 1984)'

These requirements clearly stand out as priorities for tho

public health system in place of "sophisticated medical faciliiies" which are absorbing large proportions of the State's

health budget (Panikar and Soman, 1984). Unless equity

considerations continue to prevail in the allocation ofresources,

the "diseases of poverty" may well reverse Kerala's demogra-

phic achievements especially in view of increasing poverty'

The cause and effect relationship between malnutrition and

ill-health has thus far been ignored. Undernutrition is clearly

linked to poverty. The failure to deal with these problems has

resulted in Kerala's present anomalous health situation' Since

there is an association between per capita consumption expendi-

ture and caloric intake (at least at low expenditure levels),

raising economic leveld in the State is the only way to reduce

the prevalence of malnutrition. "Nutrition" policy must be

an integral part of Kerala's future "health" policy.The significance of Kerala's poverty has been bypassed

because demographio declines of the magnitude it has experien-

ced are believed notto be normally associated with widespread

poverty. Kerala is promoted as a "cheap model of develop-

ment" which has occurred in the absence of radical structuraltransformation, at low levels of economic investment and

viewed-and to view itself-in relation to other States incountry and not in terms of the living standards of its ownpopulation. It is frequently poi[ted out that Kerala has alreadyachieved national health targFts (e.g. Kerala State FamilyWelfare Bureau, 1984). While the nation aims to achieve adeath rate of 9, an infant moftality rate of 60 and a birth rateof2l bytheyear 2000, Keral4's rates in l9g3 were already7, 43 and 25 respectively. One hight just as well point out thatwhile Kerala's vital rates arq low compared with the rest ofIndia and many other developing countries, they are nowherenear the level of developed cou$tries and so much remains inthe 'art of the possible.' Tho nation must also note thatKerala's population amounts to less than 4 per cent of the

country's total so that there is ,[ittle' consolation to be derivedfrom her achievements. Fur{hermore, the approach thatpromotes Kerala as a model for other States in India (andother developing countries) does not pay adequate attentionto what is not duplicable abOut Kerala-which is not iust itsstructure, but its history, For example, while the study by

for other states,"practically limited.

CHAPTER 9

RESOURCES FOR HEALT.HCARE

Besides "poor" knowledge, a iack of organisation or inappro-priate technology, inadequate flnance could be a seriousconstraint to the implementation of the National Health policy.To assess whether this is likely, one can extrapolate from anexamination ofpast expenditure on public health care, assessingit against future needs. Thus, this chapter documents andanalyses financing and expenditure in the governmental healthsector to date. Although a complete picture of resources forhealth care would include private health finance and expenditureas well, one is daunted from dealing with that aspect by itscomplex nature and by the inadequacy of data on the subject.Both these problems affiict the subject of governmental healthfinance as well, though to a lesser degree. Nevertheless, an effortis made here to use available information to address, in parti-cular, the following questions : (l) What has been the patternof investment in health services in post-Independence India?Sources of finance, proportionate expenditures on health, timetrends and regional variations will be examined. (2) How havegovernment resources been allocated within the health Sector?Attention will be focused on allocations to rural health care.(3) What are future funding needs in the health field and whatare the implications of past health financing and expenditurepatterns to these needs? (4) Are there 'options'in regard toraising the resources necessary for future health care? From

218 Implementing Health PolicY

this analysis, crucial requirenients with regard to ensuringresources for the implementatioh of National Health Policy willbe pointed out and discussed.

FrNeNcrNc

In tbe aggregate, governmentfl health expenditure consists of(a) that proportion of the Fifance Commission's allocationsto a State which is sDent in the Medical and Public Healthsub-sector, the Family Welfare iub-sector, and the Water Supplyand Sanitation sub-sector; (b) any grants-in-aid made by theFinance Commission to the States for use in this sector; (c)

Plan assistance for health. is decided durins the formF

States need to implement th,p Five-Year (and Annual) Plans.It estimates resource availabilitles and allocates funds amongthe different sectors. s to the health sector atemade after consideration of all sectors in a competitive manner.Exoenditure on health is deci through an iterative process

between the Planning ons and the Health Ministriesat the Central and State levels n the one hand. and the State

and Central Planning Com on the other. Adiustmentsin outlays are common both d g the period of Plan formula-tion as well aB during the life 0f the Plan.

Although health is a State $ubject, the States are actuallydependent on the Centre foh financing both Plan and Non-plan schemes because their totfl expenditures generally exceed

their own revenues, Overall 30 per cent of Plan financecomes from the States'

. from domestic boriowing,resources, another 30 Per'cent

a further 25-30 per cent fromthe Centre (including forejgn-aided project disbursements)(Wallich, 1982). Theremainin! 10-15 perceflt is made up by

Resources for Ilealth Carc 2t9

funds for Central or Centrally-sponsored schemes. Theseschemes are initiated and formulated by the Central Ministrieson "issues of national importance," and funded directly by theCentral Government. They may be 100 per cent funded by theCentre or have "matching requirements" ofthe States. Althoughthey are implemented by the States, the Centre maintains afoothold in a given sector through this mechanism. (Besides thelast two categories of Central assistance to the States, there arealso certain banking mechanisms such as advances and over-drafts which supplement State resources (Lakdawala, 1967). Asthese are not of much significance in the health sector, theyshall not be discussed in any detail). However, as funds forCentrally-sponsored schemes come from the Centre's totalfinancial 'pie,' such schemes tend to be few in number. Else,the total availability to be allocated by the Finance Commissionwould be smaller. If a Centrally-sponsored scheme favours aparticular State, the others lose out because of the manner inwbich the remaining resources are allocated. The mechanism ofgrants-in-aid, however, enables poorer States to fulfil theirPlan targets with additional Central assistance,

Allocations to Non-plan expenditure are made by theFiaance Commission in accordance with the Gadgil formula,which distributes available resources among the States accord-ing to their 1971 populations, per capita incomes, and otherfactors. While Constitutional requirements, political considera-tions, regional problems, and administrative realities all playa role in the Centre's deciiions regardir:g financial allocationsto the States, this approach limits Central control over Statebudgets (Chelliah et al., 1978).

In the health sector to date about three-fourths of govern-mental expenditures have come from Plan or Non-plan Statebudgets. The remainder has been expended by the States fromthe Central health budget on Central Sector schemes orCentrally-sponsored schemes. These schemes have covered thesubjects of Communicable Diseases and Family Planning and,to varying degrees, progranrmes such as the Community Health\Moikers'/Volunteers'/Health Guides' Scheme.

A Stdte health budget consists of Capital and RevenueAccounts. The former includes Capital expenditure and Loansand is divided into 'rDevelopment" an<l "Non-development"

I

220 Implementing Health Policy

subheads. Development capitall expenditure is largely Planexpenditure (but includes a residual "other" category).Similarly, the States' Revenue Account has Development andNon-developnrent sub-divisions, Development Revenue expendi-ture is mostly "Recurrent plaf expenditure," while Non-development expenditure is Nolr-plan committed expenditure(Venkataraman, 1968).

Thus, the State Plan budgetor Recurrent PIan expenditures

of Capital and Revenue

ment subhead, Caoitalare under the Develop-cover construction and

equipment purchases and new -and hence constFtute the bulk of Plan while Revenue expendi-tures meet recurrent costs such ils wages and salaries, supplies,and so on. Recurrent expend of one Plan become"committed expenditures" in thg subsequent Plan period. Theyare then subsumed into the category andthe States become responsible for meeting them from FinanceCommission allocations. In while the Centre and the

Commission allocations. The success or failure of this comoetition can be assessed by g the per cent of total Plan

the proportion of total govern-outlays allocated to healtbment expenditure on health,sections. Second, while Plan

hich is done in subsequentrepresent expenditure

on new programmes and cap investment in the sector,expenditure on ongoing eff , particularly their recurrentcosts, is reflected in Non-plan expenditure data, With time,Non-plan expenditures grow. T[ey may do so at a rate differentfrom the rate of growth ofPlan pxpenditures. Thus, to examinegovernmental spending on health, both Plan and Non-plancategories must be consideredi This point, though obvious, isfrequently missed in discussions of health sector financing inIndia which teqd to concentrate on Plan outlays alone. Third,as health is a State subject, thfre are wide variations in healthsector expenditures by the Strates. This has considerable

Resources for Health Care 22I

consequences for health levels across the States and is examinedin depth below. The potential to mitigate these differences existsin the mechanism of Central funding of special Schemes andgrants-in-aid to the States but the extent to which this is donemust be examined. Fourth, the breakdown of expenditures byCapital and Revenue accounts approximates the relativeproportions of health budgets being spent on 'infrastructure'and 'services,' though the definition ofthese does not strictlyadhere to the budgetary categories.

PLAN INvesrr\4nNT lN HEALTI{

While Plan allocations to the health sector since l95l demons-trate the growth in investment in public health infrastructure,the proportion of each Plan's outlay spent in this sector showsthe decreasing importance accorded to it over time. In absoluteterms, outlays grew almost thirty-fold from the First to theSixth Five-Year Plans (at current prices), but the per cent oftotal plan outlay allocated to health declined (Table 9.1).In the First Five-Year PIan, which marked the commencementof construction of public health facilities and manpower trainingin accordance with the suggestions gf the Bhore Committee,3.3 per cent of total Plan expenditure was in the Health sub-sector, a negligible amount went to Family Planning, and 0.6per cent was spent on Water Supply and Sanitation. The percent of Plan funds to Health dropped gradually over succeedingplans to 1.9 per cent in the Sixth Plan. However, if expenditures on Family Welfare are added to Health allocations,a fluctuating picture emerges-the highest proportionate ex-penditure on these combined sub-sectors being registered inthe Fourth Plan (3.9 per cent) and the lowest in the Third andSixth Plans (2.9 per cent). An aggregate expenditure of 3.1 percent of Plan allocations on Health and Family Welfare js

obtained over the period from 1951 to 1985. From the FourthPlan onwards, Family Wetfare has accounted for over a thirdof expenditure in the combined Health and Family Welfaresub-sectors. -

Expenditure on Water Supply and Sanitation may also beconsidered investment in health and so Table 9.1 includes Planexpenditures in this sub-sector. They have increased over

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Implementing Health Policy

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Resources for Health Care 223

350-fold over the six Plans, and also gradually increased as aproportion of total outlay, from 0.5 per cent in the First Plan to4.0 per cent in the Sixth Plan.

The utilisation (i.e. expenditure) of PIan funds (outlays) bythe different health sub-sectors is of some interest because thisinfluences Finance Commission allocations in the subsequentPlan period. In the First Plan, the Health sub-sector utilisedabout three-quarters of its allotted funds while the FamilyWelfare sector utilised less than l5 per cent, and Water Supplyonly 22 per cent, giving an overall utilisation figure of justover one-half. This poor record improved during the SecondPlan which registered almost 100 per cent utilisation. In theThird Plan and during the Annual Plan years (1966-69), utilisa-tion exceeded 100 per cent in all three sub-sectors, but in theFourth Plan which sizeably increased the allocations to Healthand Family Welfare, the utilisation again declined to 82 percent. It was somewhat higher in the Water Supply and Sanita-tion area. The Fifth PIan showed rough equivalence in alloca-tions and expenditures in all sub-sectors.

The Planning Commission's Mid-term Assessment gave apicture of the utilisation of funds in the first three years of theSixth Plan (Planning Commission, 1983). Of the total Planallocation of Rs. 2831 crores to Health and Family Welfare,57 per cent had been utilised, a figure that compared favour'ably with utilisat.ion in other Social and Community Service

sectors. The details on Rural Health in the Sixth Plan are alsonoteworthy. Under the Minimum Needs Programme (MNP),the schemes to train Village Health Guides and MultipurposeWorkers are 50 per cent Centrally funded, while the Reorienta-tion of Medical Education (ROME) Scheme and theCommunicable Disease programmes for Malaria, TB' Leprosyand Blindness are 100 per cent Centrally-funded. While the

total allocation to Rural Health under the MNP was originallyRs. 601 crores, rvith the transfer of the Health Guides' Scheme

to the Family Welfare department, it was reduced to Rs. 577

crores. Between 1980 and 1983, 63 per cent of these funds hadbeen spent. A further expenditure of Rs. 140 crores was

anticipated for 1983-84. Despite these expenditures, the Mid-term Assessmentteam considered the retraining of MultipurposeWorkers unsatisfactory, and mentioned "no progress" in the

224 Implementing Health policy

scheme to train new Multipurpose Workers. It also pointed outthe need to critically re-evaluate the ROME Scheme which hadalready used its entire five-year plan allocation within the firstthree years! In any case, thb assessees considered the fundsremaining for Rural Health Insuficient for the final year ofthe Plan, and so listed an addifional demand of Rs. 100 crores.

In the area of Water Suppl$ and Sanitation, 54.5 per centof the Sixth Plan allocation to rural water supply (Rs. 2007crores) had been utilised by 1983 although only 43.3 per centofthe "problern" villages aimed to be covered by the plan hadbeen reached. A likely shortfalfl in achievement during the planperiod was therefore anticipateE by the Mid-term Assessmentteam.

Resource utilisation levels ahd rates are important because inthe past finances have been allcjcated in a somewhat 'stochastic'manner. A sector tends to be allocated resources commensuratewith its previous performancp. Thus, initial low utilisationrates and fluctuations may pfrtially explain the small propor-tion ofPlan funds habitually bllocated to the health sector.This issue is especially critical dt the state level because poorperformance is perpetuated by such a system. States whichutilise funds poorly receive small allocations. It is perhapsnecessary, instead, to break the vicious cycle by increasingallocations to these States and [nstituting measures alongside toensure their effective utilisatiou.

Utilisation is also importrant because of the mechanism.mentioned earlier, which 'convtirts' recurring plan expenditureinto "committed (Non-plan) dxpenditure,, in the subsequentPlan period, which is met from allocations made by the FinanceCommission. Aggregate Nationht and State-level health expendi-tures are the sum of Plan and Non-plan expenditures and, thus,their'growth' rates are relatdd to utilisation of plan funds.among other factors.

PnopontroN.lrr Hrnlrn Exptnorrunr rN orHER Clrsconrrs

Besides the proportion of natii:nal plan allocations given tohealth, a few other 'propoftions' are useful to assess theimportance accorded to the health sector in government finance.

Resources for Health Care 225

Among these are the proportions to health of State planbudgets, of Central and State Non-plan budgets, and of totalexpenditure at the State and Union levels. Recent data on someof these are considered berow.

Between 1974-15 and 1984-85 State governments allocatedbetween 2.1 per cent and 3.3 per cent of their plan budgets tothe Medical and Public Health sector (excluding Family Welfareand Water Supply and Sanitation). Although this is a dismallylow percentage, a slowly increasing trend during the period is afaintly hopeful sign in contrast to declines in national planallocations over the same decade.

However, Plan expenditure has usually accounted for onlyabout one-third of total expenditure in the health sector,including the sub-sectors Medical and public Health, FamilyPlanning and Water Supply and Sanitation. For example, in

. two recentyears, 1979-80 and 1980-81, plan expenditure account-ed for 34 per cent of total expenditure in the health sub_sector.Thus, since Non-plan funds make up the bulk of expenditurein the health sector, one must examine the proportion to healthoftotal (Plan and Non-plan) government expenditure to get anaccurate picture of government .,comrn itment,' to hea.lth.

Indeed, when both Plan and Non-plan expenditures areincluded, the proportion spent on health of total State govern-ment expenditures exceeds the proportion to health oftheirPlan expenditures alone. For example; in the period lg7l-g0,health accounted for 5.62 per cent of total State governmentexpenditures (Table 9.2). If the Current and Capital accountsof State governments are examined separately, health expendi-ture during this period accounted for 7.49 per cent oftheformer and 1.63 per cent of the latter.

However, when Central and State government expendituresare considered together, health accounted for only 3.22 per centbetween 1971-80. While Capital expenditure in this sector was0.88 per cent of total Capital expenditure, 4.57 per cent of totalConsumption expenditure was on health. The comparable figuresfor the Fifth Plan period (197 4-79) were 4.47 per cent ofConsumption expenditure, 0.86 per cent of Capital expenditure,and 3.0 per cent of total expenditure. The lower proportionobtained when Union and State government expenditures areconsidered together than when State government expenditures

'))( Implementing Health Policy

Slqte Central-FstateGovernment Governmenls

5.44J. t)5.235.39f,. tr,5.675.726.045.585.615.62

TestB 9.2

Expenditure on Health, F y Wel fare and Water Supplyand Sanitation as Per Cent o Total Government Exoenditure

1971-721972-731973-741974-75197 5-761976-771977-781978-791979-80i980-811971-80

CentralGovernment

1.542.O02.06I tl1.141.881.981.541.44l .31

3.2'l

3.083.0612.92 |

2.98 | 3.02.69 |3.40 j3.41-3.423.22

Includes all in Consumption and Capital catego-ries including Loans, Trapsfers, etc. As Capital expendituresare very low in the Medlical and Health Sector (and oth€rNon-Economic Services qxcept for Housing), the bulk of TotalExpenditure is Current $xpenditure which includes Consump-tion Exp€nditur€ plus Subsidies and Current Transfers.

Sources i Ministry of Finance (Various Years) Indian EconomicStatistics.

alone are examined is, of courge, due to the fact that health ex-penditure is only a very small flercentage of Central governmentexpenditure-between I and 2 pet cent in the l97l-80 decade-because "health is a State subjdct." Nevertheless, State govern-ment allocations for health rer4ain exceedingly small.

Iftlr,rn As "DavELopMENT'l AND "Socrel" ExpnNnrrunu

However, if expenditure on he{lth is examined as a proportionof total government 6'Developni'ent" €xpenditure, an interestingtrend emerges (Table 9.3). Ifthe Central government's Revenireaccount is considered alone, health expenditure accountedfor7.56 per cent in the 19811-85 period. The proportion onhealth had fallen from a peak qf around 10 per cent in 1971-75,up to which there had been pn increasing trend from 1951-55-

Resources for Health Care 227

(Development expenditure accounts in turn for about half oftotal Central government expenditures).

TABLE 9.3

Expenditure on Health as Per Cent of Total"Development" Expenditure

Central Govemment(Revenue AccountJ

Central, State and UnionTerritory Governments

(Rev enue + Capit al Accounts)

1951-55

195G601961-65

t966-70197 r-7 5

1976-80

1981-85

?s?8.209.479.729.798.287.56

6.408.148.9I9.20

10.8313.10

Notes i Column (l) is based on Rcvenue Account only ofthe CentralGovernment.

Column (2) includes Revenue and Caoital Accounts ofCentral, State and Union Territory Governments.

Excludes Family Planning and Water Supply and Sanitation,Sources: Ministry of Finance (Various Years) Indian Economic

Statistics.

Putting Central, State and Union Territory government"Development" expenditures together reveals a slightly morefavourable trend-an increase from 6.4 per cent during l95l-55to over 13 per cent in 1976-80. These figures reveal that thehealth sector enjoys some priority in terms of investment indevelopment infrastructure by the States.

For accounting purposes, government expenditures aredivided into four major 'functional' categories-General Services(including Defence), Social and Community Services, EconomicServices, and Grants-in-Aid (which may be for developmentpurposes). In the decade between 1970 and 1980, Centralgovernment Revenue disbursements were categorised as follows:

228

Gcneral Servii:esEconomic ServicesSocial and CommunityGrants-in-Aid

and Community Services"l97l and 1980 are given bel

Implement ing llealth Policy

ss.4%r63%7.0%

)l ao/

Services received a very

in each sector between

Clearly, Social andsmall portion of the Central vernment revenue 'pie' compar-ed with other Services and rants-in-Aid,

In this period, capital dis amounted to a further70 per cent of revenue . (That is, of total expendi-ture, capital disbursements ted for roughly 40 per centand revenue disbursements for 60 per cent). A much smallerproportion of capital dis (than of revenue disburse-

sectors, and particularly thements) was spent on theSocial and Communitv , sector, because the bulk ofcapital expenditure went togovernments.

Loans and Advances" to the State

Considering both Ca and Revenue accounts togetherent expenditure in the Social andCentral sovernment Develo

Community Services sect

subheads and an "others"can be disaggregated into five

ory, The proportions of "Social

s6.6%

10.7%< 10/

7.r%15.4%

Thus, one can see that thp health sector received only about

l0 per cent of total allocatfons to Social and Community

Services from the Central 6iovernment, and less than one-fifth

ofthose given to Education, fiaring slightly better than the other

three areas in this category !f services'

Fortunately, the picture ii somewhat better at the State level.

Plan expenditure in all StateE combined was almost 98 per cent

"Development expenditure" between 1975 and 1984. That is,

EducationMedical and Public Health,

Family Welfare, Water puPplyand Sanitation

Labour and EmploymentHousing and Urban Develo$mentBroadca6tingOther

Resources for Eealth Care 229

only 1.5-3.5 per cent of State Plan expenditure was used for"Non-development'o purposes. Social and Community Services

accounted for roughly 48 per cent (between 41.5 to 56.0 per

cent) of total Plan expenditure in these years, the rest going

to Economic Services. Medical and Family Welfare Services

accounted on an average for about 20 per cent of total Planexpenditures in the States' sector during this period.

Again, in the States' sector, Social and Community Services

accounted on an average for about 39 per cent of Non'planexpenditure. A much higher proportion of Non-plan expenditurethan of Plan expenditure is spent in "Non-development" areas.

"Development" accounts for only two-thirds of Non-planexpenditure in contrast with over 96 per cent of Plan expendi-ture. Although figures for Medical and Family Welfare expen-diture are not available under the Non-plan head, these can beestimated if one assumes that the proportion ofSocial andCommunity Services expenditure going to Health is roughly thesame whether under the Plan or Non-plan heads. This is notan unreasonable assumption as one would expect the Plan:Non-plan expenditure ratio to remain the same for the differentcategories under Social and Community Services, i.e. Education,Medical and Family Welfare, Housing, Water Supply andSanitation, Social Welfare, and so on. The assumption may alsohold since Capital expenditure is small compared with Consump-tion expenditure in PIan budgets, and Non-plan expenditurelargely consists of consumption expenditures.

The per cent oftotal Plan expenditure in the Medical andFamily Welfare sector remained relatively constant over the197 5-84 period. If Medical services are assumed to account onan average for 43 per cent cf expenditure in the Social andCommunity Services sector, and the latter accounted for 39 percent of Non-plan expenditure, Medical Services utilised about16.8 per cent of total Non-plan expenditure in the States' sectorbetween 1975 and 1984.

Finally, one can examine the 'growth' of government '

expenditures in the different Econouic and Functional classes'between 1971 and 1980, as shown in Table 9.4. It is inter-esting to note that the Medical and Public Health seetor fared '

well relative to all other sectors in terms of the growth ofCurrent expeoditure, but less well on Capital expenditure

230 Implementing Health Policy

Tebre 9.4

Compound Growth Ra of Expenditure in DifferentFunctional Catego , All States, I971-80

Carrent CapitalExpenditure Expenditure

TotalExpenditure

General Public ServicesDefence

Education

Medical & Public HealthSocial Services & WelfareEconomic Services

Total Expenditure

1,2.9

12.4

I5.015.7

I5.3

15.6

14.1

J.J

-1,9t2.017.0

37.1

18.3

16.8

12.4

10.9

14.9

15.8

17 .5

t7 .z

t4.9

Sonrce; Ministry of Finance (Various years) Ind.iaa EconomicStat istics.

'growth' compared with other bocial Services (excludins Educa-tion) and Economic Services. Qn the whole, alihough tie healthsector surpassed many others (lncluding Education and Defence)in the growth rate of expenditufe, the computation of the ratesis based on current prices. *ere inflation taken into account,the 'growth' rates would bb far less impressive. And, of course,population increases also aFect the 'real' sienificance ofaggiegate health expenditrr.es, io that per capita fiiures must beexamined, as is done later.

HEALTH ExprNortunt AT TnB STATE LEVEL

Aside from Central and Cen schemes, the statesexercise expenditure in the health field. Table9,5 shows the relative contri of the Central and Statesectors to Plan allocations.

Since these figures pertain to the Medical and PublicHealth sector, excluding F Planning and Water Supply and

231

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232 Implementing Health policy

Sanitation, the increased propo{tion contributed by the Centrewent towards the Communicable Disease programmes and RuralHealth_(which were 50 per ceht Centrally-funded during thisplan), The last two Plans (the F'ifth and Sixth) have seen astabilisation in the relative proiortion of plan allocations con_tributed by the Centre and the States-roughly two-thirds beingin, the States' sector, a quar{er in the Centrally-spon soredschemes, and under l0 per cent fn Central schemes.

Centrally-sponsored scheme$ were intended originally toaccount for no more than 30 per cent of the financial lssistancerouted from the Centre to the Stdtes through the planning Com_mission. Their purpose is to that all States implementpolicies and programmes of n4tional priority. While the pro_portion of Plan allocations toFourth to the Fifth and Sixth

schemes decreased from the, the number of schemes hasproliferated. Such schemes enablb the Central governmenr to

3xelcise authority and influence ih the State healti departments.It should be noted that Familv g has consistently beena 100 per cent Centrally-funded $rogramme.

Besides the issue of authority over health expendi-ture and the trend to greater centralisation of health planresources, a major consideraticin in the health sector is the

::::il:t ofequity among Stares. As described earlier, the Statesoepend on transfers from the Centre to rnake up the differencebetween their'smalt' revenues afd much larger expenditures.As we have seen, aliocations td the social sectors (including

::1ll l.: .:*."1t.- They inevilably become the vlctims ofgrowrng deficits jn the governmedt budget. Alfhough states withstrong resource positions may ha{e larger plans tilan those forwhom transfers are critical, .V.n J.ong the former, ..lowpriority" sectors such as health dbviously get small allocations.

, . Nor does the process of trdnsferring Non-plan resources

help to improve the positions of poorer sthies. Non_planr€sources are allocated by the Fihance Commission in accor_oance with sectoral needs and different States. requirementstaking into account a State's l97i ponulation and

"u.r"n, pe.

capita income. Insight into the process is provided by theSixth Finance Commission Repdrt (1973). Noting the States,"repeated complaints" about tl|e inadequacy oi provisions

Resources for Eealth Care 233

for "medicines and diet,' in hospitals and dispensaries ..and{he consequent hardship caused to poor patients,; the Commis-sion examined the basis on which allocations ior these itemswere made by State governments. They found that severalStates, including 'well-off, ones such as Kerala, Maharashtra,Punjab, Tamil Nadu, Meghalaya, Nagaland and Tripura, madetheir budgetary provisions on the basis of ..past actuals.,, In,certain cases, such as in Gujarat, arbitrary ceilings were fixed onexpenditures at different health facilities. If expenditure normsexisted, they lacked uniformity across the Statei some being onthe basis of "per patient per day,' while others were on an"actuals basis." There was also no uniformity, for example, inth_e items covered by the provision for medicines and drugs,which sometimes included hospital linen, instruments, and evenmajor equipment such as X-ray machines. Widely differingnorms had been proposed by individual States for the FifthPlan period.

Subsequently, the Commission ruled out ..number ofpatients per day" as the basis on which to allocate funds formedic,ines and diet, considering the data unreliable. The reportstates, "the only course open to us in these circumstances is,therefore, to categorise the states into certain broad groups onthe basis of the present provision for medicines and diet perhead of population, and to lay down dffirential rates oJ.increaseover the existing level of expenditure', (emphasis added).Accordingly, the States were grouped into threelhigh, averageand low-expenditure groups. The higher their expeinditure thegreater the rate of increase allowed in the medicines and dietbudget provision. Thus, rather than correcting state_levelimbal4nces, this process exacerbated differences f,etween theStates, The Commission considered equalisation of provisionsfor medicines and diet on a per capita basis impractical becauseof the constraint in States' .rrooi"", and the inadequacy ofhospitals and dispensaries-once again perpetuating the viciouscycle!

During the Fifth plan, a budgetary norm was adoptedacross the country for medicines to primary Health Centres andSub-centres in rural areas under the Minimum Needs pro-gramme, and budget allocations made in accordance with this

. standard. However, as States have differing heatlh centre:

zJ+ Implementing Health Policy

population ratios, it cannot be said that this procedure irons

out differentials either. Furtherfuore, while the Finance Com-

missions have awarded special lrants to States to equalise the

minimum level of basic servicds in areas such as Education,

Communications, and Public Administration, no such award

has yet been made in the health sector, despite vastly differing

levels in health services among the states (Finance Commission,

various years). Ultimately, con$iderable regional imbalances inhealth are perpetuated by this financial allocation system.

T.lurn 9.6

Expenditure on Health, Family Welfare and Water Supply &Sanitation as Per Cent of Tothl Revenue and Capital Expendi-

tures of Indivi States, 1979-80

Capital Revenae

Expenditure + CaPi'tal Ex'

penditure

Central GovornmentAndhra PradeshAssamBiharGujaratHaryanaHimachal PradeshJammu and KashmirKarnatakaKeralaMadhya PradeshMaharashtraOrissaPunjabRajasthanTamil NaduUttar PradeshWest BengalTotal of Unlon,

22 States and 4 UnionTerritory Governments

0.58.98.47.99.59.2

11.5

9.28.4

10.2tt.49.8

10.1

9.314.7

10.1

9.4ll.04.2

0.24.1

9.86.O

1.620.420.4

0.713.52.r3.71.82.1

15.5ta1.3

6.81.2

0.48.07.8E.4

8.8

7.3t 3.6

lz.97.O

t0.79.48.88.2

11.5

9.67.8

10.74.1

Ministry of Finance (lAccounts, 1979-80.

Combined Finance and Rerenue

Resources for Health Care

How much importance do individual States themselvesaccord the health sector? Table 9.6 lists individual Stategovemment expenditures in Revenue, Capital and Combinedaccounts for a single year, 1979-80.

During this year, the State and Union governments togetherspent 4.2 per cent of Revenue expenditure on health, 18.9per cent on all Social and Community Services, 31.4 per centon Economic Services, 32.5 per cent on General Services, and10.7 per cent on Defence. (These figures are not shown in thetable but were obtained from the same source.) Whether oneconsiders Revenue or Capital Accounts independently ortogether, there is wide variation among the States in the per centspent on health. Capital expenditure ranges from 0.7 per centin Karnataka to 20.4 per cent in Himachal pradesh and Jammuand Kashmir. (It must be remembered that as these are figuresfor a single year, they may not reflect a State's .usual'expenditure

and are being used here mainly to illustrate differentials). Revenueexpenditures on the other hand had a much smaller range,from 7.9 per cent in Bihar to I I .5 per cent in Himachal pradesh.Because Capital expenditure is a small percentage of thetotal (14.6 .per cent of all expenditures and 11.5 per cent ofhealth expenditure), the combined Revenue and Capital expen-diture range was also smaller, from 7.0 per cent in Karnatakato 13,6 per cent in Himachal pradesh. The States cluster asfollows .'

Per cent spent on Health ofTotal Revcnue Expenditure

2:35

highcst Andhra Pradesh

Low (7.0-8.0)

Karnataka

Haryana

Punjab

Uttar Pradesh

Assam

Medium (8,2- 9.6)

Orissa

Bihar

Gujarat

Maharashtra

Madhya Pradesh

Tamil Nadu

High (10.7-l j.6)

West Bengal

Kerala

Rajasthan

Jammu & Kashmir

Himacbal Pradesh

Implementing Health Policy

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242 Implementing Health policyttt.(tc.ttcttt tng ta(qt tu IUucy

To what extent do state-levell variations reflect past .,com_

mitments" or conlinuing {evelopment of health care?Table 9.? illustrates the variafions ln the States, modes offinancing health activities. In fthe single year 1974-75, planexpenditures accounted for anywhere from 20 to 55 per centof State health expenditures, the rest being Non-plan expendi-ture. Capital expenditures varied from 4 per cent to over 35per cent, mostly from PJan funds. While plan expenditures onRevenue account varied from 6 to 40 p",

""nt, Non-planRevenue expenditure met the bulk (45 to g0 per cent) ofhealthsector expenses. On an average€ gne-third of State health expen-ditures were from 'new'Plan furtds and 90 per cent were on'committed' Revenue Account.

What is the relative 'commitrhent, of the States to the threesub-health sectors? Data on the allocation of Revenue eipendi-tures during the Sixth Plan peiiod (1980-35) show thar theproportion spent on public Hdalth and Water Supply andSanitation ranges from a low of 12 per cent in Tamil Nadu toa high of 44 per cent in Rajas[han (planning Commission,1983). Family Planning receives o[lya small percentage because,as previously noted, most funds for this activity come from theCentre. Most States spend betwe{n two-thirds and three-fourthsof their health sector funds in thd Medical sub-sector alone anda quarter or so in the area of Pu$lic Health and Water Supply.

The extent to which individuhl States are currently com-mitted to improving the health of their rural populations canperhaps bejudged by their allocbtions of Sixth plan funds toRural Health under the l\,finimurn Needs programme(Table 9.8).

Several observations and conolusions can be drawn fromthese data. First, as column 2 $hows, there was very widevariation among the States durihg the Sixth Plan in per capitahealth outlays, ranging from a vefy low figure of Rs. lI.2l inOrissa to the highest, Rs. 145, in Sikkim. Thirteen Statesincluding all the major ones, werg clustered between Rs. I I andRs. 20 per caput, while the remafining nine spread up to theceiling figure. (Wide variations afe seen also in State per capitahealth expenditures based on Ptan plus Non-plan funds inTable 9.9). If the States' 'rank$' in Sixth Plan per capitahealth outlay (in column 2 of T[ble 9.8) are compared with

their 'ranks' in terms of average annual per capita health exoen-ditures between l97l and 1981 (Table 9.9), one

"ur, ,." ihut

the positions of a few States have changed. This suggests achange in priority given ito health by the State between the1971-81 period and the Sixth plan. Notably, Rajasthan whichranked 7 out of 22 in its l97l-g0 annual per capita healthexpenditure fell to a rank of 20 in its Sixth plan allocation,Kerala fell from 9 to 15 and Maharashtra from 12 to t6. Natu-rally, some States also showed an .improvement,,

Karnatakarose in rank from 20 to 12, and, Assam from 19 to 13, perhapssignallirrg that they are making greater eforts to improve theirhealth facilities (at least relative to their earlier positi,on vis-a-visother States).

Second, in most cases, States allotted between 25 and 45 percent of their Plan health outlays to Rural Health (column 4):

Third, the per capita f gures for Rural Health (column 5)are most revealing. Four States allocated over Rs. 40 per capitafor the Plan period (Manipur, Meghalaya, Nagaland andSikkim). Next in rank were Jammu ancl Kashmir, withRs. 19.21 per capita, Tripura (Rs. 1g.67), Himachal pradesh(Rs. 12.50) and Punjab (Rs. 11.38). The remaining Statesallocated between Rs. 6 and 9 per capita except for three withextremely low allocations: Kerala (Rs. 4.61), Andhra pradesh(Rs. 5.93) and Assam (Rs. 5.93).

Finally, one can examine the proportion of rural to totalper capita health outlays (column 6) as a measure of the extentto which States are serious about redistributing their healthresources in favour of rural areas. Four States had percentagesover 60: Manipur, Meghalaya, Uttar pradesh and Orissa. Threeothers allotted at least half of the amount per rural head asper average: Rajasthan, Maharashtra and Bihar. The remainingstates, however, do poorly-the worst being Haryana (23%),Jammu and Kashmir (241), Kerala and Sikkim (32 each) andHimachal (33%).

Resources .for Health Care z.l J

Prn Cepme Hrerru ExpsNorrunr

In addition to comparing States' allocations of Sixth plan funds,one can consider their total per capita health expenditures

244 Implementing Health policy

over time (at current prices.l (Table 9.9). Wide variationsare again obvious both in lhe 'level' of per capita healthexpenditure reached and in the 'paths' taken to achieve currentlevels. While the dramatic incr{ases in expenditures both amongthe States and at the national level appear to have occurredpost-1971, it is difficult to say |row much of these were nullifiedby inflation. During the 197l-ql decade, most States increasedtheir per capita health expendi{ures on the average by aboutRs. 1.2 to Rs. 2.2 per annu$. Some States have been visiblyslower at increasing their expedditures, notably Bihar and U.p.,which had low levels in 197l-72 and maintained this low profilethrough 1981-82. On the other hand, a few have increased theirexpenditures faster than most, $specially the north-eastern statesof Nagaland, Meghalaya and lyfanipur and also Jammu andKashmir, Himachal Pradesh {nd Sikkim. For purposes ofcomparison, the States are gro$ped below into four categoriesaccording to their 1981-82 e>fpenditure levels, and the annual'growth'rates of their expendi{ures between l97l and 1981.Their ranks in terms of Sixth Plan outlays to health (fromTable 9.8) are given alongside.

High level () 75)-Rapid increase (E 4) Rank in VIPlan Outlay

1. Nagaland 22. Mechalaya 53. Manipur 44. Jammu and Kashmir 35, Himachal Pradesh 76. Sikkim I

20

o15

98

13. West Bengal14. Gujarat15. Madhya Pradesh

16l4l01I

Resources for Health Care

t ow level (12-20\-Low increase (0.9'1,5)

16, Tamil Nadu17. Andhra Pradesh

18. Orissa19. Assam20. Karnataka21. Bihar22. Uttar Pradesh

245

t719

22t3t2

18

From these data, it is not difficult to assess. which States

accord health importance in their financial allocations, and

which lag far behind.At the national level, health expenditures per caput increas-

ed gradually until 197l-72, when expenditure was Rs. 6'39 per

caput. Subsequently, more rapid growth in expenditure is appa-

rent with a doubling of the 1971-72 figure by 1976'77

(Rs. 13.31), and again by 1981-82 (Rs. 27.36). Although infla-

tion has perhaps nullified a considerable proportion of these

increases, there is nevertheless hope in the increasing trend inexpenditure per caput of the 1970s.

Even then, India ranks low among developing countries in

its per capita health expenditure, despite the fact that it is

reported to have a more highly'developed and wider-spread

health infrastructuro than most other less-developed countries'

A 1978 study of 107 low and lower-middle income countries

(including the 68 poorest countries in the world, with per

capita incomes under $ 700 per annum' but excluding China)

reported public sector per capita health expenditures between

US $0.58 and $ 27.00 (WHO, 1981). In that year the per capita

health expenditure in India was about $2.10. The study foundthat allocations of public funds to the health sector generally

did not exceed I per cent of each country's gross nationalproduct. The figure for public health spending in India is

roughly 0.6 per cent of GNP. In a later section, I shall discuss

private expenditure in the health sector (which also forms part

of GNP spent on health), and contrast this with government

exoenditure.

246

Locar-Lrvel

Per Cent on Health of Total197

9.10

Expenditure of Local Bodies,77

Rural Local Bodies

l[/at er Medical lryaterSupply

& Sani:t.ttion

Andhra pradesh

AssanrBiharGujaratHaryanaHimachal pradeshJammu & KashmirKarnatakaKeralaMadhya PradeshMaharashtraManipurMeghalayaNagalandOrissaPunjabRajasthanSikkimTamil NaduTripuraUttar PradeshWest BengalAll States

10.1

0.91.2

7.5),

0.50.6

10.57,9**

3s.42.9

I 1.5

5.1

49.9

zJ.3l3.l*35.2

34.9

35.2**6.6

28.417.0

t2.o

tion

8.511 a

30.5

NA

a.J

0.6l5.g*9.4NA4.7NA

Y:-).JNA

NA1.9

NANANANA6.J2.83.5

4.51.0

12.7*

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vNA

NA8.2

16.6

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0.1

2.32.00.5

NA

t? <

12.6*r 0.3

Notes : *1975-'1.6,

** 1974-7 5.NA:Not Available.

Joarce : Computed from Finance

13.925.8*I8.7

$ommission (1978).

Resource,s for Health Care

may vary considerably at these levels but there are severe cons'

traints to collecting and analysing their data. Differences are

ultimately submerged in State{evel aggregations.

However, some data are available on the health expendi-

tures of local bodies. For example, Table 9.10 gives expen-

diture on health as a per cent of total expenditure by local

bodies, disaggregated by States and rwal/urban sectors for the

single year 1976-'77.

In both urban and tural areas, there is wide variation amongthe States irr expenditure by local bodies in both the Medicaland Water Supply and Sanitatio(l sub-sectors. The former varies

from less than one per cent of the total in urban areas of States

such as Assam, Haryana, Himachal Pradesh and Rajasthan tolevels of over 20 per cent in U.P. and Kerala. The aggregate

total for urban areas of all States is over 10 per cent; but it isone-third of this for rural areas. Water Supply generally

accounted for proportionally higher expenditures, being over

one-third oftotal expenditure in the urban areas of Assam,

Haryana, Himachal and Karnataka. In rural aleas, however,

Water Supply fared worse than Medical expenditure, accbuntingfor only 2.4 per cent of the total. Of course, besides variations

in spending, there may be considerable differonces between

States in the 'accuracy'ofdata reported and the extent to whichmonies are actually spent where they are said to be! Bothrationalisation of heelth spending across States and districtsand rnonitoring of expenditures for their 'effectiveness' wouldappear to be necessary.

INTRASBCToRAL ALLocATroNs

While discussions of health sector financing may focus, on

finances available to the sector as a whole, it is not just theavailability of funds that determines improvement in health.

Patterns of spending within the health sector are of paramount

importance. Health budgets that are heavily biased towards

sophisticated curative facilities are inappropriate in terms ofnational health objectives. They are now evefl considered so

for developed countries (WHO, 1980). The leed is for cost-

effective allocations to different levels in the health system in

Implementing Health policy

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Resources for Health Care

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250 Implementing Health policv

keeping with priority problems and the principal of universalcoverage. There is no doubt tliat larger health expenditures aredesirable but, in addition, bettgr distribution and'use of, healthresources are also required if tliere is to be a significant positiveimpact on the health of the maliority.

Accordingly the distributi{n of funds within the healthsector is examined below. T{ble 9.1 I shows the manner inwhich Plan funds have been all$cated among Health Facilities,Communicable Disease Co]ntrol programmes, MedicalEducation, Indigenous Syste$s of Medicine, Rural HealthCare, Family Planning and W4ter Supply and ianitation, sinceIndependence. In the frst threq plans, roughly one-third of thetotal health allocation went to Water Supply and Sanitation.The remaining two-thirds was almost .q* y aiula.d amonghealth infrastructures, disease control piogra..es, educationand "other" schemes in the Fir$t plan. However, in the Secondand Third Plans, the disease control programmes predominated(although some of this .reallocation' may simply te due to aredeflnition of accounting catdgories). Familyplanning beganto consume large proportions oftotal allocations in the AnnualPlan years 1966-69, so that bdth Health and Water Supplydropped in terms of proportilnate expenditure beyond thattime. While allocations in ab[olute figures increased. theproportions to health facilitie$, communicable diseases, andeducation were relatively low in] the Fourth. Fifth and SixthPlans. Although some Family planning expenditures can beconsidered 'contributions' to health services, a considerableproportion of them has gone to pay incentives to family planningacceptors which cannot strictlj be considered investment inhealth care.

The Fourth Plan saw the infeption of the Minimum NeedsProgramme for Rural Health. dhis programme accounted for12 per cent of the total healtf hllocation in the Fifth plan, butan even lower percentage subsequently. On the other hand. thepercentage to Water Supply ilrcreased considerably over theIast three Plans, while Family planning dropped from an all_time high of 36.7 per cent between 1966-69 to tS p., cent in theSixth PIan. Of the total expg{rditure oq Water Supply andSanitation from the First to the Fourth plans 65 per cent went

Resources for Health Care 251

towards urban water supply systems. In the Fifth and SixthPlans also, despite vastly increased allocations, only about one-third was to be spent in rural areas, particularly on theprovision of drinking water.

The last column of Table 9. I 1 gives the total amountsspent in the various sub-areas between 1951 and 1985. If theentire 35 year period is considered, Health and Family Planningreceived roughly half the total allocation to all three sub-sectors.Within these two sub-sectors alone. health facilities utilisedabout 20 per cent and Communicable Diseases Programmes 18pet cent of funds. Seventeen per cent went to the MinimumNeeds Programme, 6 per cent to Education and Training and35.6 per cent to Family Planning. In the health sub-sectoralone, the most substantial allocations have gone to healthinflrastructures, followed by the Communicable DiseasesProgrammes, and then Rural Health, when all six Plans areconsidered together. These breakdowns illustrate the relativeimportance accorded to different health programmes over thecourse of development of public health care in India.

One can further examine the relative importance accordedindividual programmes by the Centre and the States. Focusingon the Fifth and Sixth plans, one finds a slight increase in theStates' relative contribution to aggregate health expenditurefrom the earlier (about 5l per cent of the total) to the later(67 per cent) Plan. While the Rural Health programme wasentirely in the States' sector in the Fifth Plan, the Centreabsorbed 30 per cent of its cost in the Sixth Plan. Conversely,Communicable Disease control was largely Centrally-funded inthe earlier Plan, but the States met 45 per cent of theexpenditure on this in the Sixth Plan. In the health infra-structure and education categories, the Centre met about 20per cent of expenditure in each Plan period. While the Centreexpended about three-fourths of its total health allocation onthe Rural Health and Communicable Diseases Programmes theStates spent only 35 per cent of their Fifth PIan funds and 53 percent of their Sixth PIan funds on these programmes. Of course,Family Planning was entirely Centrally-funded in both Plans.Significantly, the Central allocation to this activity was 50 and70 per cent more than its allocation to Health in the two Plansrespectively. The division of responsibility in terms of Central

Allocations of Funds to HealthAlthough Rural Health e a separate expenditure

category with the inception of e Minimum Needs Programmein the Fourth PIan, its

252

and State allocatioosimportant implicationsdiscussed later.

more recently. As the budgetIast three Plans, it is useful

(Rs. 1220 crores) by the StatesCentre's share, about half wentProgrammes, while 28 and 24to Rural Health and to H

(19.3 per cent) to Communicabin health, therefore, around

of State to Central funding isCommunicable Diseases: 45:55:

I mpteme nt i ng Heal th po li cy

to diffe]rent health programmes hasfor fufure health financing, which are

other prograrnmes. In the Sixthexamine how it fares relative toPlan period, the total allocation

to health was Rs. 1821 crores. of PIan funds (Rs. 601crores) were allotted by the tre, the remaining two-thirds

ce has only been recognisedtion to it has grown in the

Union Territories. Of theward Communicable Diseasescent were allotted respectively

Medical Education and

Diseases. Of total Plan funds

therefore: Rurai Health: 70:30:and Hospitals, etc. 80:20.

Research. On the other the bulk of the States'sharethe last category of medical(47.3 per cent) was allocated t

infrastructure, one-third to R Health" and the remainder

per cent were allocated tohealth facilities and medical on, while around 30 percent each were in the Rural H th and Communicable Diseasecategories. Within the three of expenditure, the ratio

Given the States' overall brence for allocating monies tothe Hospitals category, it is not surprising that their contribu*tion to Rural Health is only 22 cent of the total health'pie.'

is even more dismal: 1:9 perRural Health and Communi

The Centre's share of Ruralcent of total health funds. Bothcable Diseases prograrnmes are per cent Centrally-sponsoredschemes, so that Central funds ust be matched by the States.

the two programmes which areA further point of interest isof paramount importance to Pri Health Care-and henceto national health policy-the th Guides' Scheme and theMultipurpose Workers' Scheme are Centrally-sponsored-got only 8 per cent ofthethe total health budget.

allocation and 15 per cent of

Resources for Health Care 253

To assess whether 'equity' considerations went into the

decision to allocate funds to Rural Health, one can evaluate

them on a per capita basis. Dividing the total health outlay by

the country's 1981 population, a per capita five-year plan outlay

for health of Rs. 26.58 is obtained. The comparative figure

for Rural Health is Rs. 10.98. Thus on a per capita basis

Rural Health received only about two-fifths of the per capita

funding ofthe health sector altogether!of the total Sixth Plan outlay in the states' sector, 56.1 per

cent had been expended between 1980 and 83, according to the

Mid-term Assessment report (Planning Commission, 1983).

Forty-six per cent of the States' allocation to Rural Healthwas spent in these first three years. In addition to slower

expenditure of funds for Rural Health, only 4l per cent of the

target number of Sub-centres had been established, although90 per cent of the target number of additional Primary HealthCentres had been reached. The Mid-term Assessment mentionedproblems with construction and shortages of manpower as

reasons for the failure to reach set targets.

The largest proportion of State funds in the health sector

was allocated to Food and Drug Control, School Health,Medical Education, and Hospitals and Dispensaries at the

district, sub-divisional and taluk level. According to the Mid-term Assessment, the last two categories, especially medicaleducation, research and development of super-specialities, had

received "relatively larger allocations" and had "largerexpenditures than their allocations!" As the assessees note, theStates are under !'compulsion" to allocate large resources tomedical colleges and hospitals to keep up with Medical Councilstandards. This scenario is likely to present problems to thedesired reallocation of funds to Rural Health.

LINB ITBMS rN GoVBRNMENT Hrllrg BUDGETS

A somewhat different approach to examining government healthexpenditures is presented in Table 9.12. Here, total Revenueexpenditures for a single year (1979-80) in the Medical, FamilyWelfare, Public Health and Sanitation, and Water Supply andSewerage sub-sectors are'broken down into heads of expenditure

which permit comparisons between diferent departments,modes of spending.

In the Medical sector, 62.6 plr cent ofexpenditure was onServices, while 43 per cent of d|amily Welfare expenditure wasin this category. A larger proportion of Family Wilfare monieswent towards Supplies and Eqriipment than in the other threesub-sectors. Backward and Tribal Area programmes utilised

254

Detailed Bre:ikdownHeads

Imp lementing Health policy

of Reven Expenditure on Health, byof Ex ,1979-80

Medical Family Public Waterllelfare Heahh Supply &

& Sanit- Sewer-ation age

TrN-s 9.12

Total (Rs. Crores)

ServicesEducation Research

& Training, andStatistics

Insurance & OtherHealth Schemes

Indigenous Systemsof Medicine

AdministrationSupplies &

EquipmentMaternal and Child

HealthCompensationBackward and Tribal

AreasTransportPrevention & Contiol

of DiseaseFood & Drug ControlRural Water SupplyUrban Water SupplySewerage

692.84

62.6

13.3

tJ.f,

5.72.1

2.1

'j

I18.94

43.0

9.7

t,

9.7

t)

0.9J.l

198.47

7

8.8

rls

3.0

0.90.5

67.82.4

263.29

1

2.6

;

t:

4-4.6

l9.tt.9

,Soarce : Ministry of Finance\ Accou ts,(1984) ined Ffiiance and Revenue

Resources for Health Care

under I per cent of Medical, Family Welfare and publicHealth funds, but 16 per cent of Water Supply expenditurewas in these areas. "Administration" of Family Weltare,Public Health, and Water Supply programmes consumedsubstantial proportions of their respective funds, in contrast tothe Medical sub-sector. Such comparisons permit an estimationof the extent to which funds in different sub-sectors are wellutilised (or, at least, well accounted.) It is clear that whileServices utilise the bulk of resources in each department, otheritems such as Administration, Insurance Schemes, Education,etc, are also voraciorrs 'consumption items.'

However. in this type of categorisation, the dividing lines areoften unclear so that caution must accompany inference. Forexample, it may not be strictly appropriate to considerexpenditure on Rural Health limited to that under theMinimum Needs Programmes, as I have done earlier, becauseother accounts also contribute to health care in rural areas.A major iproblem' is created by the fact that the FamilyWelfare budget pays for some inputs that are part of ruralheaith care, notably in MCH programmes. The importance ofthis contribution must be assessed, which can be done from'broken down' Family Welfare budgers (Table 9.13).

The breakdown shows that 33-38 per cent of the FamilyWelfare budget went towards Rural Family planning Services,2'3 per cent to Urban Services, 33-35 per cent to Education,Training and specific contraception schemes, about 7 per centto Administration, 13 per cent to Transport, and 10-12 percent as Compensation. Only 5-7 per cent of the Family Welfarebudgets were spent on MCH during these two years, suggestingthat the direct contribution of this department to rural healthcare is relatively small.

LoorrNc AHs.Ao

What are the prospects for health from the Seventh Planperiod which will take us up to 1990, leaving only ten years for"Health for all by the year 2000?" (Table 9.14). The Work-ing Groups set up by the Planning Commission advocated anexpenditure of almost Rs. 14,000 crores on Health and Family

€i ;

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Implementing Heal th Policy

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Resources for Health Care

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258 Impl ementing Health Pol i cy

total Plancompensa

tion to Family Planning accpptors and 48 per cent for theFamily Welfare depaltment (of which about 2 per cent of thetotal allocation was to be for MCH programmes, includingImmunisation). The remaining 25 per cent was allocated toHealth.

However. these amounts were whittled down in the'iterative' planning process-Sy almost 22 per cent at the"Steering committee" level, dopn to less than two-thirds at thestage of the Ministry of Health and Family Welfare's proposal,and to less than half the ofiginal figure at the PlanningCommission's final submission. Of the Rs. 6649 crores finallyapproved, 51 per cent is for He|lth. The States' share in thehealth budget is almost 74 per cent. Of the States'share,43per cent will go to the Mini Needs Prosramme for RuralHealth (equivalent to 31 per t of thc allocation to Healthand 16 per cent of the total H th and Familv Welfare allo-cation). The other balf of the tal allocation is in the FamilvWelfare category which is y-funded. The total amountaccounts for 3.7 per cent of the Plan outlay of Rs. 180,000crores. These figures lend hope both to the health budget andto rural health expenditure.

To assess the situation vis-d-vis Non-plan funds, one canexamine the report of the Eiglith Finance Commission (1984)which will be in effect during tljre Seventh Plan period. Takingcognisance of inter-state diffefences, the report noted: "Toimprove the standards of servicd rendered in the States markedby low expenditure levels on mddicines and diet, it was felt thatthe expenditure on medicines arld diet should be stepped upto the level of all-states averago." They then took into accountthe total expenditure incurred by the States and worked it outon a "per bed per annum" basis. However, although theCommission made provisions foF the lower-than-average Statesto receive additional funds, it rfstricted the amounts, apparentlyassuming that the norm set by tfre previous (Seventh) FinanceCommission bad been met bf all the States. This procedurewill again fail to even out exidting state-level differentials inr.-^llL -'^-*J:r,.-^health expenditure.

Resources .for Health Care 259

Thus, while slightly increased Plan allocations for Healthhold out hope for rural health care in the Seventh Plan period,no change seems to have taken place in the Finance Com-mission's approach and combined Plan and Non-plan fundsmay not effect significant improvement in health care.

Pnrverr Hrllrn ExpeNprruns

The total financial resource base for health care includes publicand private spending. However, data on the latter are difficultto obtain. Although governmental health budgets are'account-able,' there is no mechanism to aggregate private healthexpenditure. Studies by bodies such as the WHO have suggested

a ratio of l:4 for public:private health expenditure amongdeveloping and developed countries in general (WHO, 1980).

In India, private health expenditure is estimated to be aboutthree to four times government spending in this sector so thatabout 2 per cent of the country's gross national product isspent on health care in the country. For example, the 28thround of the National Sample Survey estimated that publioexpenditure on health in 1973-74 was Rs. 280 crores whileprivate expenditure was Rs. 843 crores, accounting for 25 and

75 per cent, respectively, ofthe total (NSS, 1976). (In contrast,the relative proportion of private to public spending oneducation was 79:21.)

Antia and Batliwala (1977) estimated that the nation was

spending Rs. 300 crores annually on private medical con'

sultations alone. In addition, the Pharmaceutical Producers ofIndia estimated an expenditure of Rs. 7.50 per caput per annum

on allopathic drugs i.e. a total of Rs. 450 crores, of which one-

third were individual purchases. These two estimates add uproughly to the governmental per capita health expenditure inthat year. If one added to these the costs of private hospitalcare, employee insurance premia, and so on, private healthexpenditure per caput would indeed be several times the publicfigure.

If macro-level data are deficient, micro-level studies ofpersonal or household health expenditures are few and farbetween. Available ones reveal high per capita expenditures on

260 Implementing Health Policy

health care even among poort rural families. For example,Nichter (1980) gathered data pn the health expenditure of 82poor rural families in South I{anara district, Karnataka. Hefound they spent almost 7 per cetlt of their mean annual incomeson health care, amounting to abirut Rs. 270 per family per year,

or Rs. 45 per caput if one assu.nles an average family size of 6persons. (This is almost double the per capita health ex-penditure of the government). Olver 60 per cent of family healthexpenditures went for private allopathic consultations and drugs,and a further 35 per cent ofl traditional practitioners. Inanother group of 20 families living within a five-kilometreradius ofa Primary Health Centre, the per capita expenditurewas only slightly lower at R$. 34 per annum. (About 5 percent of the expenditures ofboth groups were on "governmentdoctors.")

In a study of 25 families in each of two villages in U.P. in1980, the Operations Research Group estimated per capitaannual health expenditures of Rg. 83 and Rs. 121 in Easternand Western U.P., respectively (not including "high" amountsspent on surgical care in some igstances) (Khan et al., 1982).The government health expenditure in the State at that timewas Rs. 11.7 per caput per annutn.

Some private consumption e4penditure figures on "MedicalCare and Health" are also avallable in the National AccountsStatistics (Table 9.15). During the 1970-71 and 1980-81period, between 1.9 and 2.5 pel cent of total private consump-tion expenditure was spent in this sector. At constant prices(1970-7l), the figures were slightly higher, averaging 2.7 percent over the period.

All these data serve to illustr{te the importance of privatehealth spending, and to point oirt that government expenditurein the health sector is a small prdportion of what is spent irttoto. These are important considerations when future financialneeds in the health sector are discussed. However, beforeturning to 'future needs,' I sh$uld briefly summarise the pastand present picture of health fin{ncing and resource allocation.

Resources for Health Cqre 261

Tenr"r 9.15Private Consumption Expenditure on Medical Care and Health

(1970-71to 1980_81)

At Current Prices At 1970-71 Priccs

Rs. Crores Per aentof Total

Expendi-ture

Rs. Crores Per centof TotalExpendi-

ture

19'tO-71

1974-75197 5-76

1976.77

1977-781978-79

19 79-801980.81

6t21056

I t871369

1458

1508

1567

l7l7

612906

932951

981I0001048

1078

2.O

2.92.82.92.72.82.92.7

2.0)n)1

2.5

2.22.11.9

Source : Cenlral Statistical Organisation (19g3).

Sutr,ntlttc Up

The following points about public health care financing emsrgefrom the foregoing exposition:

Small allocations. The health sector gets a very smallproportion of the government budget whether one considersPlan allocations, total expenditure, Development or Social andCommunity Services' expenditure, consumption or capitalinvestment, or the proportion of GNp spent on health. Thisis true both at the national and state levels and refects the lowpriority given to health.

Declining trends. Although outlays may have increased inabsolute figures, the proportion of plan investment in healthcare declined through the first six plan periods, especially afterFamily Welfare expenditures came to dominate the field,beginning with the Fourth plan. To some extent the picturehas changed with the Seventh plan. Allocations to WaterSupply and Sanitation have risen dramatically but until theSixth Plan these were largely for urban areas. In any case Water

262

Supply and Sanitation is a

Implementing Health P olicY

ital-intensive sector. During the

Sixth Plan, health exPenditure declined as a per cent ofD€velopment expenditure. e the 'growth' rate ofcurrentexoenditure in the health sect has been better than that tn

some other sectors, the rate of of capital investment has

been comparatively low. declining trends are discernible

despite the difficulty of comparisons over time which istions and budgetary categories.engendered by changing de

It should also be noted, tically, that data from differentsources are often inconsistent.

developing countries.Centrc-State division of iry., As health is a State

by State governments,subject, most expenditures are

usually being Non-plan ption expenditure. OnlY one-

and very little on Capitalthird has been Plan expenditaccount. The Centre's share

in the Fourth Plan, but hasin the last two Plan oeriCentre and the States mav for poorCentrally-sponsored schemes ( as thea lack of State-level commi t to them.

health sector outlays increased

about one-third of the totalThe different 'interests' of the

implementation ofCHW Scheme) and

differing levels ofuse ofState-level inequalities.commitment on the part ofhave emerged in the perStates, in the proportion of

Neither the Planningmission's allocation procedin nature, have helped to

govemments, wide variationshealth exoenditures of the

resources committed to health,in their modes of fnance, nd particularly in their capital

erally, the States with high perinvestments in tbis sector.capita expenditure levels ha high capital investments sugges-

ting that they may still be in the jnfrastructural developmentstage in health servjce on. Relatively low consumption

for continued commitment inexpenditures do not bode wthe health sector.

ission'.s nor the Finance Com-which are largely 'stochastic'out these differentials, nor haveused to do so. As a result.grant-in-aid mechanisms

Resources for Health Care 263

certain States consistently lag pitifully behind even the national

averages-generally, the poorer and larger States of the

countiy,.perpetuating the vicious cycle of poverty-ill healthlack

of heaith-caie-high mortality and high population growth'

Inapprcpriate intrasectoral distribution' Both Central and

State joveinment allocations (but particularly the latter) tend

to favour the Medical sector over Rural Health care (although

there are, again, wide variations among the States)' Family

Planning errr.rg., as the most 'preferred' sub-sector' followed

by Hospitals and Dispensaries, Communicable Disease control'

Rural Health and then Education and Training' Even following

national 'commitment' to rural health care in the form of the

Policy Statement, Sixth Plan allocations were skewed toward

the urban sector, rural health getting less than half the per

capita outlay ofthe health sector as a whole' Proposed Seventh

Plan allocaiions while hopeful for future trends' do not rectify

this situation adequately. Howevei, some of the accounting

categories are oveilappin g or 'furzzy' and their aggregation

makis it difficult to study exactly what is spent on different

services,

Poor utilisation of funds for rural health' Compared with

the Hospitals or Medical Education sub-sectors' funds for Rural

Health or for Maternal and Child Health are slowly and not

fully utilised, resulting, in turn, in low subsequent allocations

whieh prohibit the improvements required in Rural Health

services.Targets not met. lnadeq\ate resources allocated in the

first plice, coupled with their poor utilisation results in the

lack of achievement of targets set independently ol the

financiog Process.Locil levet spending: "a pork barre!?" Even within the

resources utilised, the achievement of targets is poor' While

the data on spending by local bodies may be questionable in

quality, they tend to prefer the 'capital-intensive' sectors'

ootuUiy Water Supply (in urban areas) and Medical care' The

extent to which monies are being spent on 'viable' infrastructure

and purposeful services must be investigated.

ilrsi prh,ate spending, Private health expenditure is

at least three to four times that of the government's, reflecting

the demand for health cate. However, at the same time, govern-

264

ment services are ,underutilised' for reasons of inaccessibility,inappropriate staffing and stbff train.ing, io.m.l.o"V uoapoor logistics. Despite the widegpread p"Ufi" m*ri.ucture, ahigher proportion of health serVices are provided iyit. prtuut"

sector than by government facili{ies. There is also inaO.qrratecoverage of the population with .outreach, schemes eg.immunisation. Th.is and the .lwastage,, ttut- o""ur, .ugg.rtthat government monies and-faci]ities s[oulA U" mo.e elfectively

targeted at those whose health rieeds are not yei belng met,i.e. the poor, leaving the ric! to use private ,.rui""r r"ni"f,they can afford.

Furuns Nneos

Future needs in the health

Implementing Health policy

r involve a variety of issues.care must be estimated andor to meet this cost assessed.

must be discussed

First, the 'cost' of pr.imary healthe capability of the healthSecond, alternative financinein order to evaluate the role o public finance, Third, given arole for governmental health g, the crucial requirementsfor health resources to effectivelli caie. to t

"uiif,

-n..0, u"Opossibilities, must be pointed outi

Cost of Primary Health Care

. The term "primary Health Cbre,, generates some confusionwhen_ financial requirements for i{ are U.ing

"oo,ia"."d. On theone hand, primary health care is constered ,,low_cost,, perunit and highly cost-effective. On the other, it calls for

universal cgverage ofa populatioi, and so Iarge allocations arerequired. While health ministribs and impiementing uoCiesmay recognise it as an additional set of activiiies which requiresmore resources to be allocated, especially in vjew of existinginfrastructural deficiencies, bud]geting bodies such as theFinance Ministry or planning - Coirmission oruv ulew it:::.T:*tI as requiring no more or few additiooui ."rou."..(or even fewer in real terms), donsidering it more a questionof "organisation and management],,, which are presumed notto require any funds.

In order to assess whether av4ilable public health resourcesare adequate for the provisioh of primary heatth care

Resources for Health Care 265

throughout the country one can only resort to comparisons

between current per capita health expenditures or total health.allocations and the estimated costs per caput or in toto ofdelivering primary health care services. Unfortunately, even

such comparisons are fraught with danger because of the natureof primary health care (eg. the need for "intersectoral action")and because of the current distribution pattern of healthexpenciitures, issues to which we shall turn later.

An estimate of the cost of providing basic health care to thepoor in developing countries by the year 2000 was made by the

World Bank in 1977 (World Bank, 1980). At 1975 prices, thisworked out to US $5 per capita. It included the capital cost ofa health facility for every 8000 to 12000 people or at every ten

kilometres (whichever is greater), and the cost of training a

community health worker for every 1500to 1200 people. The

estimate excluded health workers' salaries, administrative over-heads, the costs of supplies, in-service training, training and

referral facilities, and allied needs such as transport, communica-tion etc. It excluded other items which are considered part of"total primary health care" notably, water supply and sanitationand nutrition. In contrast, the national per capita healthexpenditure in 19'15-76 was Rs. 10.63 in India, or about one-

fifth the then estimated cost of primary health care.Another estimate was made by Joseph and Russell (1980).

For low income-countries including India they estimated

"start-up" costs of $l-2 per caput per year for five years, and

additional operating costs of $l-1.5 per caput per year for 10

years, at 1978 prices. Similar figures were arrived at by Evans

et al. (1981), who estimated the cost of basic "selective" primaryhealth care as $2 per caput per year. Even if the lower figureof $1 per caput per year is taken (and not adjusted for inflation),this would mean that an outlay of Rs. 4500 crores would have

to be made for the current national population of 750 millionpeople in the forthcoming Five-year Plan for primary healthservices alone. This amounts to an additional one-third of thetotal Seventh Plan outlay for Health and over four times theallocation for Rural Health. Needless to say, even though aconsiderable amount ofthe 'infrastructure' for primary healthcare already exists in the country, and Non-plan funds wouldalso be available, the total availability for primary health

266Implement ing Health pol icy

services is likely to be far short ofthesc estimated needs. Theadditional requirements, howgver, may be well within thecountry's financial capability, [iven the current low proportionof investment in the health secror.

In fact, Antia and Battiwala (1977) worked out an estimate oFannual expenditure for a basic health infrastructure proposed by

and supplies (at Rs. 2.50

obtained. Ifl the costs of refi

:::-;":h: stru-crure co_nsisred of two CHWs;.; i006;;;;,two MPWs per 5000, and a Hehlth Assistant for every 10,00Opeople. Including their stipend$ and the cost of basic medicinesd,uu supples (at Rs. 2.50 per caput), as well as Transportand

. Administrative Costs, a total of Rs. g per capita was

uulalneo. rI Ine costs ot' ret-errd.l facilities were included, theestimated per capita cost rose to about Rs. 20 per year. Thiswas somewhat higher than the national per capita healthexpenditure in 1977-7g, which Was Rs. I 5.05 per annum.. Another way of estimating the cost of providing primaryhealth care is to examine tfie expenditures of siall-scaleprogrammes that have detivtfred such services effectively.Although this approach is not itithout its shortcomings (whichare discussed at length in Chapter 6), it is useful to aplroximatefinancial needs.

For example, the Narang*,al project cost between U.S.$1.50 and $2.00 per caput pet annum (from 196g to 1973)including both capital investrlents and recurrins costs butexcluding the research complnent) (pyle, lggl)l A similarfgure ($1.25-$1.50) was estim{ted at jamkhed around 1976.H-owever, the Comprehensive Hpalth Service project in Alibag,Maharashtra, estimated the c$st of providing basic preventiveand.curative care at the primariy level as low as Rs. 5 percapita in that year. If block-l]evel facilities were included. the

Resources for Health Care 267

per capita health expenditure figure exceeds this, the current

intra-sectoral distribution pattern would require the government

to step up its allocations to the health sector in general and tobasic services in particular.

As stated earlier, public health expenditure currently

amounts to about 0.6 per cent of GNP and to not more than

20 per cent of total health care consumption expenditure in

the country. One can briefly compare these levels of expenditure

rvith a spectrum ofother more developed countries. At one end

of this spectrum is Sweden where health care accounts for

7.3 per cent of GDP and is 92 per cent state funded' On the

other hand, in the U.S., private expenditure accounts for 60 per

cent of total health expenditure, which is 7.4 per cent of GDP'

In Spain, Greece and Japan, the per cent of GDP in the health

sector is around 4 (roughly double India's) and in the former

two countries, two'thirds is'public expenditure, while in Japan

almost 90 per cent is government financed. These data would

suggest that the "development" of health services in Indiawould call for health care to account for a larger percentage

of the CDP and particularly for the government to increase its

contribution to at least 2 per cent of GDP.As if in corroboration, Gwatkin, Wilcox and Wray (1980)

estimated that private voluntary projects of some efective-

ness in different parts of the world cost (per caput) about

1-2 per cent of the country's per capita GNP. This was upheld

by Pyle and Chowdhury (1930) whose study of seven voluntary

agency projects in Bangladesh revealed per capita cost levels ofabout I per cent of Per caPita GNP.

While these programmes are admittedly more expensive than

government health services, they are considered more effective

in terms of bringing about health improvements' Although

their impact data is insufficient to calculate 'cost-effectiveness,'in some instances private agencies have supplemented govern-

ment budgets to enhance the effectiveness of public services,

and such data are of sorre interest. For example, in the Inte-grated Health Project at Miraj in Maharashtra about three'fourths of the total costs were met from government funds,

while one-fourth was additionally provided (Ram' 1980).

Although 95 per cent of goYernment funds were allocated tosalaries these were supplemented by a further 26 per cent from

Imp I ement ing IIe o I t h p o t icy

thus relieving the state of its respbnsibilities in this area exceptfor some carefully selected ities." Indeed, a World Bankpublication has argued ,. health financing policies inmost developing countries need tS be substantially" reoriented.Strategies favouiing pr.rblic on of services at little orno fee to users and with littlehave been widely unsuccessful"

t of risk-sharing

268

private sources. In addition, private funds were used formedicines and supplies, transport, trpining, and so on. A .functionalanalysis' of a health centre carried out in the NarangwalProject showed that 75 per ceirt of allocated funds wenr tosalaries, 10 per cent to drugs and supplies, and the remainderto transport, etc. In contrast among private primary healthprogrammes, budget breakdowns usually. show about 50 percenl allocated to salaries, 25 pef cent to medicines and supplies,and 25 per cent to transport and other items. This informationsuggests that government fund$ must be both supplementedand_ reallocated at the primary level to provide better basichealth care.

Alternative Sources of FundbA declining interest on the pflrt of government in financing

health care clearly jeopardises ttie promise of,.health for all.,,It has been stressed that progres6 towards this goal will requireincreased resources to the health sector as well as reallocations.However, there has been a cl]imate of questioning whethergovernments should finance publlic health systems entirely fromti-reir budgets dr seek .alternadive' financing mechanisms. Itmay, therefore, be useful to consider other sources of funds forprimary health care, such as.,community contributions,, andexternal assistance. The crucial issue is whether funds obtainedfrom these sources could mitilate the currcnt picture ofinadequate finance for rural health care.

Community financing of health care. The goal of raisinglocal resources is often seen as a way of relievjng governmentfrom certain expenditures borne at the grassroois, and ulti-mately even of responsibility fdr health care at this level. Forexample, according to Gish (l9g j) ,,. . . by implication, if notexplicitly, health care is expected to remain or become anessentially private transaction betiveen providers and consumers,

(de Ferranti, 1985). Thus,

Resources for Health Care 269

discussions of community financing of health services have con-

centrated on the recovery from irsers of the costs of health care

either through fees-for-service and/or health insurance schemes'

Several arguments are used to support such cost-recovely

strategies. The "efficiency" argument maintains that the 'wast-

age' irt public health systems will be minimised by the greater

accountability ofa paying system through better management

and better allocations. The "equity" argument holds that the

current maldistribution of health resources favouring tho better

off is reinforced by a totally public financial system'

However, experience at the micro-level in India (described in

Chapters 5 and 6) has shown that levying fees-for-service

ultimately excludes those who are most in need of health care'

A curious anomaly might arise in that the poor who are ill most

frequently would bave to pay the most in fees if they no longer

had the option of free services! In practice community "contri-

butions" tend to reflect the capacity of contributors to influence

decision-making and benefit from the health services, rather

than increase participation as is desired. Further, even if the

nature of demand is affected, it is not clear that supply would

improve in quantity, quality or efficiency' Inevitably, only a

veiy small proportion of the costs of supplying services are

raised by health insurance schemes, user fees, or both' Contri-

butions are episodic in nature. There are costs associated with

collecting them, so that neither equity nor efficiency may be

achieved. Although seeking community finance may generate

'externalities,' such as greater interest on the part ofthe public

in the services provided, the extent to which these would be of

real benefit to health status is unknown'

Raising local resources also has implications for the mix of

health activities. While fees can be charged for curative care'

they are difficult to levy on preventive services' And yet the

latter are necessary and require sizeable allocations of funds'

As described in Chapter 6 on the Role of Private Voluntary

Agencies, under these circumstances, curative care begins to

"o-orunla the lion's share of resources generated, and overtakes

preventive care in terms of the importance accorded it by

providers and consumers a'like'

However, one suggestion has been that users should bear a

larger share of health care costs with discrimination among

270 Implementing Health poli cy

types of services. De Ferrantf (19g5) admits that preventiveservices should remain t's purview, but he states thatcurative services can be indi financed and regulated bygovernment, ratber than provided. Accordingly, he hasproposed the institution of ,. ncy pricing" for curativeservices. However, besideswho also, especially, need

ting against the poor-

still require government tocare, this approach would

considerable resources tocurative care for, while costs (e.9. of drugs) may be

etc. would have to bemet, capital expenditures,'guaranteed.' Thus, a strateg5,i to raise local resources may besomewhat opposed to the need {o reallocate government lundsin accordance with primary hcation of funds within the

care objectives. The misallo-sector to date causes. to a

greater degree, the lack of success of government healthprogrammes than does its failurp to raise funds from users.

In sum, discussions of the .$otential' for communitv financ_

tly have no constitutionally-defipred power to raise resources(even if they have the comptence}. This would present a problemif health care is singled out to be financed and managed bylocal bodies. Thus far, the flow pf financial resources has beendownward-local bodies have rei:eived financial assistance lromstare governments, analogous fo Centre_State flows. In theabsence of a comprehensive revfew of this system, it is difficult

ing of primary health care seem to ignore the fact that thepeople most in need of heallh carc are the poorest, and thatpreventive care iS also importanf. Given that the poor make up40 to 50 per cent of the countryis population and that currenthealth care allocations would be hard pressed to meet eventheir needs, community financing would seem to be a i,allaciousconcept.

A final salient point is that lfcal-level organisat.ions curren_

Resources for llealth Care 271

agencies (Central Law Agency, 1981), foreign aid from bilateraland multilateral donors is provided to the Central government

to be passed on to the States for use in specific sectors or -

projects. Such funds are subject to the usual procedures govern-ing financial flows between the Centre and the States. Theforeign aid received by the Centre for a project is added tototal Central resources and disbursed according to the Gadgiltbrmula to all States. The project State receives 70 per cent ofthe foreign aid allocated to the project (Wallich' 1982). Inaddition, the Central government gives the States "matchingassistance" for such projects as a means of providing incentives

to them to undertake foreign-aided projects, Therefore, theparticipating State ultimately gets an amount slightly largerthan the original project budget. Project selection and planning

are undertaken jointly and even implementation may depend

on the specific fiscal arrangements.Thus, generally, in the sectors where the Centre normally

plays a less regulatory role (including health) external assis-

tance permits it to exercise 'control' over the States. While the

funds may 'increase' State health expenditures, they do notrepresent a State's greater commitment to health and so mayhave an opposite effect"on a State's responsibility. In particular,the "jncentive" to undertake foreign-aided projects as well as

the relaxed expenditure norms that come with such schemes

may serve to reduce State accountability in health.The same may hold true at the national level particularly

since external aid perrnits fungibility in government finances.

Thus, the major questions that need to be examined aboutexternal assistance to the health sector are : (1) Are the fundsused in areas which are in keeping with national health goals,

objectives, priorities and norms? (2) Does the receipt of aiddecrease internal 'commitment' to these areas or does it permitlarger allocations than would otherwise occur? i.e. Does

external aid increase spending in the health sector? (3) Does

aid increase the 'dependency' ofthe national health sector onforeign funds or institutions or improve the performance and

viability of our own? There are no simple answers to these

questions, but a brief examination of past and current aid tothe health sector may provide some clues.

In the past, external aid to the health sector has primarily

272 Implementing Heatth policy

supported the Communicable Disease (particularly malaria) Con-trol and Family planning progr[mmes. Upto t9i9, the periodof greatest assistance was 1965-69, tha hey-day of malariaeradication and of Family pldnning infrastructural expansron.The U.S. Government was the lnajor donor, being responsiblefor almost 75 per cent of aid td the health sector between 1950,and 1974. It channelled over g0 per cent of its .technical

assis-tance' (and half of pl,-4g0 rupep funds) in the health sector intothe malaria programme (JeffOry, l9g2). The proportions toFamily Planning are somewha-{ more difficult to compute, inpart because of the overlap between the Health and FamilyPlanning sub-sectors but also bicause of the inadequate specif,_cation of budgeting categorie{ in donors u".ouitr. Only 6per cent of U.S. government tcichnical assistance between l95Oand 1974 would appear to have been spent on famiiy nanning.The other major donors duri4g thai period we.e UNICEFand WHO (whose assistance Was not broken down separatelyinto a_Family Planning categorJrl) and the Ford and RoctefelerFolndations which together cdntributed only about US g tO.Zmillion between 1950 and 19?4, amounting to' l;;s ?an + p".".ol

oj _p.tll aid (excluding pL-480) to th! health sector in thatperiod. (This does not include aid from otherforeign noo_gou..n-

mental donors who do not channel ttreir assiiance throughgovemment but deal directly with private organisations theyfund). While it is true rhat the majority of fu-nOs sfent in ttrehealth sector by the Ford Foundation went toward populationassistance, the total amounted td just over I per cent ofexternalassistance to the health sector. {he UNFPA intered the FamilyPlanning aid arena in l97l and $rovided about US $ 47 millionbetween l97l-79. Besides contra<ieptive and sterilisation schemesand population education, these funds also supported ANM,/ai and MPW training. Its assisnance in those years amountedto about 22.5 per cent of total hdalth sector aid.

Besides malaria and Family Flanning" other CommunicableDisease programmes (such as tB and smallpox) received asizeable chunk of foreign assistadce eg. about on"+t i.C of WHO

cent of total aid.

funds between 1,947 and tSZSj Water Supply and Sanitatior...captured 3.3 per cent. Finally, Medical Eaocuiioo, BiomedicalResearch and Health facilities directly ,"""iurJ

"UJut f.S p.",

Resour ces for Health Care 273

These data suggest that health aid between 1947 and 1979supported those areas that were deemed important bothnationally and internationally at the time. Admittedly, inter-national thinkilg backed up by aid funds may have influencednational priorities to the detriment of internal health develop-ment. It is well known that the external aid was used primarilyto purchase'hardware'-buildings, equipment, supplies, vehiclesand so on. In fact, the lack of attention to 'software' (with theexception of training of professionals in some fields) is con-sidered the major reason why both the Family Planning andCommunicable Disease programmes failed to achieve adequateimpact despite sizeable allocations. However, as Jeffery (1982)has suggested, the predilection for technical aid may have beenas much that of national decision makers as of foreign aidagencies, for 'hardware' is generally considered less "threatening,'and more desirable. In sum, while external health aid hassupported 'national priorities,' it has perhaps been inadequatelytuned to the national context.

Because of the manner in which aid funds are received anddisbursed by the Central government, it is difficult to saywhether the allocations to the health sector were ,,additionali-

ties" or whether they simply substituted local government fundsthat would have in any case gone to those programmes. Healthaid from 1947 to 1974 aclr:ally accounted for only about l0per cent of health Plan expenditures (and only 3-4 per cent oftotal external assistance to the country) (Jeffery, l9g2). Theimpact of this aid on the size of allocations cannot be con-sidered significant and the fungibility brought about by it isalso unlikely to have had much effect on other sub-sectors. AsJeffery has pointed out, its size was not to the scale of extantproblems so it was limited in what it could achieve.

More recently however, there have been a few changes inthe aid arena which could modify some of the above con-clusions, There are many more donors to the health sectortoday than there were up to the mid-70s. This has meant a largeincrease in the amount of aid, and a diversification in activitiesand programmes funded. Foi example, between 1973 and l9g3l5 per cent ofPlan expenditure in the Family planning sub-sector

274 Implement ing I) ea I th Po I it y

came from external assistance r$ceived from 10 major donors(Ministry of Health and Family Welfare, 1983).

A signal qualitative change ifr external health aid has been

the funding of "Integrated Rlural Health and Population"projects in place of earlier concentration on vertical disease

control and Family Planning Srogrammes. It has been allegedtbat this is simply "old wine in new bottles" (Banerji, 1983a).

Indeed, the bulk ofover $250 million that was contributed by

five donors to such projects bet\lveen 1980 and 85 went towardsinfrastructure, although, somer{'hat greater attention was paid

to 'software'than previously. Flowever, given the small totalallocations to tural health, sileable external assistance in thiscategory may not be an entirely happy trend. National and

particularly state{evel involv{ment in implementation may

suffer from all the problems attelndant on foreign aided projects

and "model" schemes.

Besides these "area projicts," Communicable Disease

programmes, contraceptive delivery, prevention of blindness,

health research, planning and administration and child health

and nutrition also receive aNsistance from foreign donor

agencies,Some other new trends ln thd area of health sector aid must

also be mentioned. This has resulted largely from greater

pressures on donor agencies id their countries of origin to

Resources for Health Care 275

lateral donors was traditionally directed at the public sector.More recently, sorne aid agencies set aside funds for the privatehealth sector (although these may be channelled through govern-ment). Accordingly, a large number of non-governmentalagencies have come under their umbrellas and it can perhaps besaid that the proliferation of 'packets of aid' has led to aproliferation of voluntary agencies! Many ofthese have become'visible' in part because they have attracted foreign funds; manywould have difficulty surviving if it were not for such funds.While these consideralions have been discussed in Chapter 6.it

is pertinent to note here that this practice is part of theoverall trend to "privatisation," which may have significant-negative-impact on government health spending in the longrun. In the short run, it is perhaps more closely linked to theissue of "dependency" which has been explored in Chapter 2.

In sum, qualitative considerations are perhaps more importantthan quantitative ones in the matter of health sector aid, andone might conclude that neither community financing norexternal assistance could contribute substantially to the financialrequirements for primary health care. The only "alternative',then is to pay greater attention to the major problems thatafiict government financing of the health sector. First, there isthe scarcity of funds. The financial resources currently availablecannot provide universal primary health coverage in the country.Second, the distribution of funds is inappropriate considering€xtant health problems and inequalities. Third, available fundsare being utilised poorly because of overlaps between pro-grammes, budgeting categories, "pork-barrels," and so on. Whilethe first problem requires the health sector to be viewed morefavourably by institutions such as the Finance and planningCommissions, the second and third issues require financing andexpenditure within the health sector to be reorganised. The twoaienas are of cotrrse interrelated because rational use of resourceswithin the health sector may be a condition for increasingallocations to it. These requirements are considered below.

Requirernents. Larger allocations. The . implementation of primary health

care clearly leqilires. the allocation of. additional financial

lto Implementing Health PoIicY

resources to the rural health spctor' and particularly to com-

munity-level health activitiesl. Despite the priority given toRural Health and Primary Health Care in recent policy state-

ments, the Sixth and Seventh Plan outlays do not reflect an

adequate cornmitment. The [llocations to Maternal and ChildHealth remain meagre in sbite of the importance of thisprogramme.

Not only are policy priorities not reflected in allocations,but there may also not be adequate correspondence between

sectoral targets set by the Plans and allocations of financialresources for them. While the latter are subject to the 'itera-tive' planning process, the former are laid down by nationalpolicy. While the Policy S{atement refers to the need forreorganisation, it makes no niention of the need to increasethe quantum of finance to tbe health sector. If this is erroneo-usly construed as permission to financing bodies to 'freeze'allocations until "reorganisaltion" occurs, little headway islikely to be made towards policy objectives. Persistent incong-ruity between targets and resources will lead to a situation inwhich the health sector becomes demoralised and targets are

simply 'met on paper,'Currently different governrpent departments "compete" with

one another for budget allooations. While bealth pojicy recog-nises the need for coordinatioh between Health, Family Plan-ning, Water Supply and S&nitation, Education, Food andAgriculture, and other sectors, they fail to coordinate andcollaborate to optimise use of their funds, manpower andphysical facilities. Since hedlth improvement also requiressocio-economic development, tresources in related sectors mustbe assessed and allocated to areas which are identified as pro-ducing health benefits. While socio-economic development maybe necessary to generate the resources to improve health, a

healthier population will also contribute to nationaldevelopment.

Reallocation of resources, The planning process has also

failed to ensure the "best" usti of available resources. Withinthe health sector, the majorit! of funds go toward medical/curative care. Family Plannlng outlays are mostly for services

and incentives. Only 3 per cent of the total Sixth Plan alloca-tion to Health, Family W{lfare and Water Supply and

Resources for Health Care 277

Sanitation went to MCH programmes. Although paramedical

training is an acknowledged need for the expansion of primaryhealth services, only 0.1 per cent of the total allocation in the

Sixth PIan went towards training ANMs and dais. In their studyof Maharashtra and Gujarat, Khan and Prasad (1984) has shown

that these areas do not receive much priority at the state leveleither.

The need to redistribute funds pertains, of course, to allhealth sector accounts. Although one would argue that fundsmust be diverted from the urban hospital sector to rural health

services, this possibility is severely limited by "political consid'erations." The reduction of urban health services is neitherfeasible nor strictly advisable, given the demand for them bythe poor, besides thd rich. Thus, the 'redistribution' of healthresources is a longer-term goal which can be achieved by theallocation of new resources to the rural health sector. In parti-cular, monies have to be ensured to cover the increasing recur-ring costs of programmes because these, rather than develop-ment costs which are "one-time" expenditures, are likely to be

most limiting in the expansion and sustenance of qualityprimary health care.

Monitoring spending. Because line-item budgets and accountsare aggregated for the entire heaith sector, and heads ofexpenditure overlap, it is difficult to discern *hat is actuallyspent on specific services. Budgeting categories do not permitthe kind of investigations into intra-sectoral allocations thatare really necessary, such as comparisons between hospitalcare and primary care, preventive and curative care, etc. In anycase it is admittedly difficult to decide exactly what the appro-priate allocations to different health services should be, sincethe relationship between the quantum of health expenditure indifferent areas and health outcomes is unclear and, most likely,affected by a host of other intermediate factorsi,"Cost-effective-ness" and !'cost.benefit" are difficult to determine becausemajor health goals (such as mortality reduction) require long-term investments, while intermediate achievements (eg. reduc-tion of low birth weight) are difficult to measure with accuracy.Theunit costs of different interventions have not been workedout and, just as details on the distribution of public funds oreven priv4te monies between different health strategies are

218' Implementing Health policy

unavailable, their effectivenfss in meeting health goals isunknown. Nevertheless, experi{nces at the local level. such asthat at Miraj, indicate how gorlernment budgets require supple-mentation and reorganisation i! accordance with primary healthservice needs. Por example, thQ need to channel more resourcesinto areas such as paramedical training and staffing are clearlyind icated.

In this connection. 'wise' nding is as important as 'more'even a 'guesstimate'spending. While it is difficult t arrive at

of the proportion of funds away in the health sector(because of ths lack of infi on ffowing upwards from theblock-level on the actual utilis4tion and achievements of healthmonies), health expendi lend themselves to leakages.

that one-third to one-half .ofK.N. Raj (1985) has estiall development expenditures at the block-level is going intothe "pockets of intermediarigs. " Although this may be aninevitable result of a situation in which resources are planned

care is distributed in acco with demand. The inequalitieshealth care will bave to be

ocation of resources to priorityidentified in bealth statussystematically reduced by the'areas' (rural locations, backcare, vulnerable target grou

States, the primary level of

To begin with, there is aand major health problems),

need to eoualise state-leveldifferentials in health which were discussed atIength earlier. One approach y be to equalise the per cent ofStates' GDPs spent on health, which currently range from 0.7to 2.0 (Shah, 1980).

The reduction of s in health is essentially a politi-cal decision-the benefits of , better distributed, and more'effective' alloc ations to pri health care can be weighed

Although hard data are few, itagainst the 'costs' of ill-healis widely accepted t&at the try's high morbidity and dis-

Resources for Health Care 279

ability rates are at least partially responsible for low skills,low productivity in agriculture and industry, and absenteeism

among workers. Ill-health among children decreases school-

attendance and learning ability and so results in 'wastages' inthe education sector. High mortality is clearly a loss to thenation, given the value to society of an individual's futureearnings ("human capital"), and also because of its effect on

fertility. Thus, the economic costs of low health expenditures

are considerable. There are also social and psychological costs-disintegration of lamilies on account of illness. perpetuation ofinequalities, and impoverishment due to indebtedness onaccount of illness. Thus expenditure on primary health care can

achieve investment, redistributive and welfare goals. Thebroader political economy of health involves the social distri-bution of income, wealth and power, and so equity in resource

allocation is an issue for all sectors.

TAKIN STOCK

Current health policy in India prfoclaims "health for all" (GOI,1982a). While providing hope to those concerned with thecountry's poor health situation, it poses a series of dilemmas.Any analysis of health policy rhust confront these dilemmasand delineate the choices for the[r resolution.

HEALTH Polrrrcs

While the heaith policy Statemeht notes the many developmentsthat have taken place in the health sector since Independence,it does not take adequate account of the .'political economy"of health in the country (Chaptsr 1). It has turned a blind eyeto the political obstacles which have left unimplemented manyof the proposals of the piongering Bhore Committee - andmerely reiterated these prescriptlons. Unless these inadequaciesare redressed norv, the Health Policy too will remainunimplemented. For example, the State must pursue more fullyits obligation to legislate and implement actions favouringthe principle of "ensuring health for all" which has not beenadequately observed in the pa$t (Chapter 2). In the future,certain articles of the Constitution should be utilised topromote health more widely pnd lo a greater degree. Forexample, Article 15, the Right to Equaliry, which prohibitsdiscrimination by sex and other attributes and provides that theState can make special provi$ions for women and children,

Taking Stock 281

could be used to establish better facilities for these groupswhich are, indeed, discriminated against in terms of health.

While the framing of a National Health Policy Statement:suggests that the ideat of "health for all" is espoused at the

national level, the commitment of the States to implementingthis Policy may vary widely as it has in the past, Therefore,mechanisms need to be instituted to ensure that a// States

implement the basic health care envisioned by the Policy' The

Central Councils must be strehgthened so that both 'carrots'

and 'sticks' are applied to their recommendations, insofar as

these favour the goal of universal health care.Despite the Constitutional provision for States' autonomy in

matters of health, the extant system of planning and financinggives the Central Government some authority over the States'

which could be used in the crucial area of primary health careito remove current wide disparities among States' In addition'the "residuary" power of Parliament to legislate on any

subject not listed in the Seventh Schedule could be invoked for"primary health care." There are also a number of articles inthe Constitution which enable Parliament to legislate on subjects

included in the State List (notably Articles 249 and 252)' and

others that give the Centre power to direct the States toformulate policy [eg. Articles 256, 257 , 339 (2), 350A, 353 (a)'

360 (3)1. Existing legislation provides health benefits to the

organised, urban sector, to the neglect ofthe rural populace'

A collation and review of existing legislation, and new enact-

ments to further the goals of the National Health Policy are

clearly indicated. In sum, while 'decentralisation' is a key

element for the implementation of primary health care, the

'Centre' caunot abdicate its responsibility to cooperate with the

States, to assist them fully, and to goad them rvhere necessary.

Most significant among other political obstacles to the imple-mentation of a primary health care policy is the powerfulinterest group of medical professionals in both public and

private, traditional and modern health sectors, and their relatedlanoillary' groups, such as the drug industry. For widespreadbasic health care to become available, the current system in

which doctors influence political decision-making, resource

allocations and implem:ntation in favour of "high technology"health care, must give way to one in which consumers' needs

,i

I

and concerns are given pdmart importanca. .paths of influence,lwhich currently flow as in (A), must change to (B).

A B 3=3ffiffi::i:"./a\ D: Doctors(9 , 6) p=potiticians

t i !7'(

282

Besides requiringof all involved, manythe health sector.

Implementing Health Policy

,frt',e

F= f,OtrttCtans

-*}Major influence

----tMi!lor rnfluencel'.. -..iEpisodic influenbe

Ie attitudinal change on the parttional changes are called for in

OnclNtslnou FoR HEALTFT

task of "redistributing" health, but political exigencies dictatethat the levels of health of the upper strata cannot be reduced,and so prevent 'taking from lthe rich and giving to the poor.'Thus, a "duality" ensues in he{lth policy-it talks of providing'minimal health care to alll while still maintainingand furthering

Taking Stock 283

the development of "five-star" hospitals and sophisticated

medicine. Such multi-level health development has profound

implications for health service organisation (including the role

oflactors' outside the governmental health sector), for man-

powe4, technology and research, for health finance, and so on'

The existing health infrastructure reaches down to the

village level from Primary Health Centres through Multipurpose

Workers and community-based Health Guides' While prescrib-

ing the strategies to reach the goai of "universal provision ofcomprehensive primary health care services" (reorientation,

reorganisation, integration), the Policy stops short of developing

the riecessary interface between health services and clients' Most

health functions are vested in the family or household unit'

and the role of women in household health is crucial' In the

presence of stratifying social structures, while women provide

health care inside the home, they have limited access to health

services outsiile. Thts, health workers must be selected, trained

and organised to develop a systematic interface with women by

visiting homes on a regular and frequent basis.' Their tasks on

these visits should be focused on health and not on family

planning as in the past (except where this service is being

demanded by the client herself). Primary workers must be

deployed in sufficient numbers to cover all households at least

once a month, as well as to be available at specific times at a

given location for 'emergency' and 'group' care activities such as

immunisation. Support and referral structures must be similarly

strbamlined. The creation of cadres without specification oftheir tasks and linkages is counterproductive. Both horizontal

integration ofhealth personnel with people in nced of health

care, and vertical integration with those who are more highly

trained is needed.

A major paradox in the rural health sector is that while

there is considerable "unmet need," utilisation of existing

health services is inadequate. Thus, policy for rural health has

the dual task of improving health services as well as raising

demand for 'health.'Given that social and economic phenomena regulate demand,

policy must aim to amend these to favour better health' Forexample, social constraints to the utilisation of health services,

summed up in the lack of "permisson" (Chapter 4), must be

mitigated and eventually removed. Over the short run the appro-ach must be to provide health se{vices in such a way that theyare accessible to those in need. Ol,er the long term, ,.education,'

must reduce social barriers-bducation of all members ofsociety, particularly those that .nlake the rules'and those thatmust exercise their rights! While the Health policv Statementrecognises the especially poor health situation of women andchildren, during its implementgtion greater attention mustbe paid to relaxing the social strt]ctures that deny them accessto health care.

In this context, demand for h4alth services is most often notindividually-motivated, but rather is the result of intra-household dynamics. Thus, the creation of demand alsorequires attention to households.

284 Implementing Healrh policy

DECENTRALISATIoN

In contrast with this suggestion, [he Health policy Statementconcentrates on "community" p{rticipation as the means toincrease demand for health and to decentralise (Chapter 5),Wf ile such participation may be desirable, it is difficult toachieve in the context of heterogeneous village communities.Community participation ofterl amounts simplv to localcompliance with plans and programmes designej externally(eg. by government), decision-m4king by locai power-holders(who in turn benefit most frpm the programme), or the'mobilised' participation of labpur and resources by localleaders. In most instances, it [s a far-crv from the creativejnvolvement of people in health aitivities thai is desired.

The involvement of commudities is also sousht bv theHealth Policy because of the potential of their ;"oitribuiio.rr'to health care. Resources raised directly from the people incash or kind would lower the cost of health care to the publicexchequer. Community health rlorkers paid ,honoraria' areamong such resources. However, pxperience in the non-govern_mental sector (Chapter 6) has shbwn that impover.ished ruralcommunities cannot raise other significant contributions.Reliance on community contribu{ions only sets up a double-standard: village-level workers for the rural poor, but continuedhospital and specialist facilities for the urLan and rural rich.

Taking Stock 285

Ultimately, also, the concern with raising community resources

diverts attention from other more fundamental aspects ofparticipation in health-eg. in planning and decision-making,These are difficult to bring about because they entail a devolu-tion of power. In view of this and of socio-economicconstraints to "autonomous" participation of the poor in healthservices, interactions between service providers and people atthe household level must take precedence over "community"pafiicipation per se.

In addition to community participation, the Health PolicyStatement advocates decentral isation also through the privatevoluntary health sector. Privatisation is proposed in both therural health extension effort, and in the development ofspeciality and super-speciality services. However, the limitedcoverage of voluntary health sector programmes makes themless useful to improving national health than is proposed. Theirmajor contribution will continue to be in the area of experi-mentation with and demonstration of "alternative" approaches.As "collaboration" between the governmental and non-govern-mental sectors is limited in scope, the government would bestreserve its energies to improve its own health efforts and whereuseful to inculcate the lessons learned privately.

DTSSEMTNATING TEcHNoLoclEs

Besides the three abproaches to reorganisation-'epidemio-logical planning,' community participation and "privatisation, "the Health Policy emphasises the "preventive and promotive"aspects of primary health care. This raises the issue oftech-nological needs for implementation of health policy. While theStatement refers to the need to provide laboratory tecbniquesfor diagnosis and monitoring in the field, it is silent on thesubject of disseminating 'simple' technologies, which are theplanks of primary health care. Such technologies have special

characteristics and requirements for their spread (Chapter 7).Firstly, a technology is only as good as the system chargedwith using or delivering it. Primary health technologies willonly "make a difference" when requirements and mechanismsfor supply, logistics, training and management of workers are

286 Implementing Health Policy

well-worked out. Secondly, a Iogy is only as 'efficacious'as the social milieu receiving its permits. This in turn.implies that the system g the technology must becapable of adapting ir to the nstraints and advantaies of"clients," as well as of g the 'social ground' fordissemination. Thus, the health livery system, social organisa-tion, and technologies are inmertation of primary health

linked-and so the imple-is by no means "simple."

AND HEALTH

"Technology" is sometimesdevelopment"-for example,health tecbnologies weaken

aeainst "socio-economic

economic levels and health,t with now and do not need to

(Golladay, 1980). However,the effects of technology and can also be seen as

synergistic. Segall (1983b) has

in developing countries resPon

inted out that mortality ratesmore favourably to rising

socio-economic levels after advent of modern health tech-

nologies (i.e. from the 1960s o ), than they had earlier.are better able to avail of

tion' and a good delivery sYstem

of technology. If--and only

the argument that modernrelationship between socio-

that manv of the healthproblems of the poor can be

await socio-economic improv

The converse is also true.technologies when their living standards are improved; andthe capacity of a health system deliver better care improveswith better conditions and national'wealth.' These

relationships demonstrate that 'social organisa-are crucial for the effectiveness

-they are appropriate andcapable, will a health technolbgy improve health at a given

level of living.That ultimate achievements i[ health are bound up with

wider social, economic and p{litical developments is clearlyillustrated by the case of Kerala {Chapter 8). The relationshipof, health and development i+ demonstrated by Kerala'shistorical and current contexts. llhe early devplopment of healthsbrvices went hand in hand wit$ social ard political cha4ges

which enhanced their effectivenes!. Moie recently, the abating ofpositive soeial, (and political) tre?gds and..the. limitations imposed

Taking Stock 281

by,a stagnant economy have prevented further achievements.

While Kerala's mortality and fertility rates are the lowest inthe c.ountry, morbidity and malnutrition remain severe problems

in the State. While the synergism between health care, edu-,cation and women's status is clearly positive, the segregation olthe heaith and nutrition sectors demonstrates the inadequacy.of pubtic policy for'health.' By extrapolation, a regression inKerata's health status may occur if attention is not paid toimportant factors such as nutrition and sanitation.

. This issue has major implications for the nation as a

whole, but has remained largely unaddressed by the Health

Policy even though the "integration of health and otherdevelopment sectors" is the Policy's third and final strategy tomeet its goal of universal health care. In simply suggestingi'coordinating committees" at ministerial levels, xhe healthpolicy has failed to secure this plank. More direct linkages

between key health inputs such as nutrition and water supplyand health services are necessary for r'mprovements in health.

Unless the relevant sectors have health objectives and measure

their achievements by health parameters, little improvernent is

likely to occur in the health of the nation at large.

The health system also has a role linked to efforts in othersectors. Just as it is responsible for creating demand for itsown services, it must also create demand for 'preventive'

measures including 'health producing goods' such as food,water, housing, sanitation, and education. If the poor are

erroneously led to demand ing only health services, there willraot be much change in their overall health situation, as neither

the factors predisposing them to disease nor those constrainingtheir access to health care would have been removed'

RrolsrntsurlNc HEALTH REsouRcEs

A maj_or obstacle to implementation of health policy isinbdequate resources. The problem is shown clearly by thedeclining trend in health sector outlays (Chapter 9). Thehealth sector fails to compete Successfully with other develop-ment sectors and so accounts for only a small percentage offovernment spdnding. While it is difficult to cstimate the

288 Implementing Health Policy

quantum of financial reso to implement theavailable on the

the per copitocost of primary health care fap exceeds the current allocationin tlie public sector. Besided the finances to purchase the'hardware' of health services-buildings, equipment, transport,drugs and supplies, and health Sersonnel, considerable resourceswill be required to provide the I'soft' inputs for primary healthcare programmes (training, f{edback systems, etc.). Althoughhealth policy must of course be inrplemented ..at a cost whichthe country can afford" (WHO-IJNICEF, l97g), the provision ofuniversal health services will pot be inexpensive. There areproblems inherent in 'reducinp' the costs of health care bydesigning low-cost programmeq and by mobilising communityresources (Chapters 5 and 6). Neither a double-standard inhealth care nof exclusion of the needy would serve the intentiongof the Healrh policy.

The distribution of funds within the health sector has todate discriminated against rl:ral health care and favoured"sophisticated" urban health facilities and family planning.Despite its call for primary qare, the policy has done little todecrease the emphasis on tedhnologic sophjstication at thesecondary and tertiary levels.

If'there is little or no politicpl scope for the reduction ofallocations to urban health f[cilities, then in order to makemore resources available for prfmary health services in ruralareas the size of the 'health pie' needs to be increased, andnewly-mobilised resources prefelentially allocated to the primaryrural sector. The critical issue of regional imbalances needs tobe addressed by bringing on pat at least the per capita ruralhealth expenditures of the States. There are several relatedneeds. For one, an accounting qystem that examines the healthsector as a whole (including public and private componentsand all levels) would be useful fbr allocating health resources.For another, strjct controls o! resource allocations within thehealth sector are required.

potrrrcAr. Drvrornos

A plea for larger allocatiofrs to the health sector (and

Taking Stock 289

'health-producing' sectors) is based on the stipulation thatinvestments in health while generally considered 'consumptioninvestments,' are clearly also 'production investments.' Betterhealth can improve national productivity, reduce populationgrowth, improve "equity and social justice," and reducesuffering and 'wastage' of national resources through a reductionin untimely mortality. Attention to major health problemsaffecting the labour force (particularly women) and 'futurelabourers' (children) will result in a more productive popula-tion. Such achievements can, in turn, engender increas€dpolitical returns. Just as sophisticated curative medical facilitieshave been developed in response to urban-elite 'demand' andhave paid political dividends, so, too, will primary health careelicit political support from its special target groups. Theirlarge numbers could amount to considerable political clout.Recent experience in Tamil Nadu and Andhra Pradesh, wherenutrition schemes have been instrumental in capturing (inparticular, women's) votes, has demonstrated the nexus betweenpolitics and social programmes. The provision of health carecould also be viewed as an effective political strategy.

On the other hand, ambiguity in political will can generateoffi cial indiffer.ence-even hostility-towards the implementationofthe health policy, hampel the mobilisation of resources, andstymie the reorientation of the health system. By the verynature of jts Utopianism, the slogan and the strategy of primaryhealth care can be interpreted in many ways, sometimes quiteequivocally, by the government and other concerned agencies.Will the National Health Policy remain "an artificial facadebehind which particular interests are continually promoted?"(Guhan, 1982). One must espouse hope rather than cynicism;and continuously judge the government's intentions vis-d-visthe Policy by the manner and extent of its implementation,

Projects

I.1.2.3.

)-

o.7.

8.

9.

16.

'(1)(2)( J.l

(4)

List of Voluntary H' Programmes Studiedand Mode of Study*

(r) (2) (3) (4)

"Grassroot' Health and Deve Agencies

Arpana Trust, Karnal, HarYana

xBanwasi Seva Ashram,Chetna-Vikas, Wardha,

XxXChild in Need Institute'

Deenabandhu Rural LifeA.P,Gram Nirman Mandal,Comprehensive Rural Deve

Project, Jamkhed, MKishore Bharati, Hoshangabad' M.P.

Kottar Social Service SocietY, gercoil,

XXXChittoor,

Bihar x X x

Tamil Nadu10. Lokshiksha Parishad, N

Calcutta11. Maharogi Sewa Samiti, W

Maharashtra

X

XXlz.

13.Mahiti-Utthan, Dhanduka Gujarat

Marianad CommunitYProject, Trivandrum Distt,Comprehensive Health and

Project, Paahod, Maharashtra

PRAYAS, Chittorgarh'Sewa Mandir, Udaipur Distt,

Conference or SeminarProject person

XXX

x X

Annexurc

I7. SEWA-Ruraf , Zagadiya, Gujarat18. Social Work and Research Centre,

Tilonia, Rajasthan19. Tribhuvandas Foundation, Kaira Distt.,

Gujarat20. Apnalaya, Bombay21. Indo-Dutch project for Child Welfare.

Hyderabad22. Mobile Cr€ches, Delhi23. Streehitkarini, Bombay24. VIKAS, Ahmedabad

Itr. Hospital Community Itealth Outreach Schemes

25. Health for One Million project, St. John,sHospital, Trivandrum Distt., Kerala

26, Holy Family Hospital, Bombay27. i0"dftaj Medical Centre. Maharashtra28. Naujhil Integrated Rural project for

Health and Development, Mathura, U.p.29. Padhar Hospitals, Community Health and

Development Project, Betul District, M.p.30. Vadu-Budruk Health project and KEM

Rural Health Project, pune

III. Special Service or Hospital-Based projects

31. Govel Trust Aravind Eye Hospital,Madurai

32. Government Erskine/Rajaji Hospital,Madras

33. Kabliji Hospiral, Haryana34. Sanjivini Mental Health Society, Delhi

IV. Medical College or Research Institute FieldArea or Project

35. All India Institute of Medical Scienccs,New Delhi (Ballabhgarh C€ntr€)

36. B,J. Medical College, puns (Sirur Taluk)37. Christian Medical College, Ludhiana

(Sanewal block)38. Grant Medical College, Bombay : palghar-

Kasa Integrated Maternal-Child HealthNutrition Project (Thane district)

39. Mahatma candhi Institute of MedicalSciences, Sewagram, Maharashtra

xX

XxX

xX

xX

291

x

xXXX

xX

XXX

XX

X

XX

x

X

xXXx

XX

X

Xx

292

tlO. Mandwa-Uran Rural Health +rojects,Foundation for Research in QommunityHealth, Bombay

41. Medical College, Rohtak (Ber[, Kathuraand Chiri blocks)

42. Post-Graduate Institue of MedicalEducation and Research, Chandigarh

' (Raipur Rani block)43. Rural Unit for Health and Sqcial Affairs,

Christian Medical Collcge, Vdllore, TamilNadu

V. Employee or Cooperative Schefutes

44. Comprehensive Labour Welfaie Scheme,Unitcd Planters Association df South India.Coonoor

45. Mallur Health Cooperative, Bangalore46. Self Employed Women's AssopiatioD,

Ahmedabad47. Voluntary Heallh Services, Madras48. Working Women's Forum, Mbdras

yI. Alternative Government Models

49. Cooperative Rural Dispensarigs, Kerala50. Rehbar-i-Sehat Scheme, Jamntu & Kashmir

VII. Heahh Service Research Proibcts andInstitutes

51. Gandbigram Institute of Rural Health andFamily Welfare, Tamil Nadu

52, Khanna Study, Punjab53. Narangwal Project, Punjab54. Project Poshak, Madhya Pradesh

Implementing Health Policy

xX

x,X

XX X

X

X

X

XXXX

XXXX

x

X

VIIL Projects in other Developing Countries

55. Bangladesh Rural AdvancerdentCommittee x

56. Gonoshastha Kendra, Bangla{esh x57. Savar People's Health Centre, Bangladesh x58. BKKBN-Surabaya Project, Iddonesia X59, Yayasan Indonesia Sehajtera, Indonesia x60. Sarvodaya Shramdana Mov€rnent,

Sri Lanka x

Total i 59 Projects' literature revfiewed3l Proj€cts visited43 Project leaders/staff di$cussions35 Projects' conference p{esentations heard.

XXXXXXXXX

5.

References

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2. Ambannavar, J.P. (1975) Population, Second India Series (New

6.

Delhi, Macmillan and Co.).American Public Health Association (1981) crowth Monitoring(Washington D.C., American Public Health Association).Anandalakshmy, S. and N. Sindhu (1984) "Growth Charts: Percep-tions of Women from Diferent Educational and OccupationalLevels" (New Delhi, Lady Irwin College) Mimeo.Anker, R. (1978) "D;mographic Change and the Role of Women :A research programmc in developing countries," Population andEmployment Working Faper No. 69 (Geneva, InternatioDal LabourOrganisation).Anonymous (1982) "The Mental Gulf," India Today, 15 September7982.Antia, N.H. and S. Batliwala (1977) Health Care in India, FRClllICSSR Workshop on Health Care (Bombay, Foundation forResearch in Community Health) Mimeo.Arole, R. (1984) "Monitoring of Child Nutrition Through WeightCards, ' cited in Gopalan and Chatterjeo (1985).

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Banerji, D. (1983b) ,.Narional

tion," Economic and politicalPolicy and its Implementa-

eekly XVIII, 105-108.Bang, Abhay (1983) SelI-sufficiency in CommunityHealth Programmes," paper ed at rhe ACHAN Workshop onSelf-sufficiency in CommunityJanuary 1983.

Health Programmes, Bangalore,

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Scarcity and Under-Nutrition :

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21,

t{

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27. Bhatia, J.C. (1982b) ,.Eva of Traditional Birth(Dais) Training Scheme iD th€ State of Maharashtra,"

Mimeo,Indian Institute of28. Bhatt, A., R. Maru and A.S.

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234. Ninan, K.N. (1981), " tural Labourers and Poverty,"

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ImpJementing Health Policy

1940), Report of the Sub-CommitteeGovernment of India).(1948), National Health (Bombay,

230. National Sample Survey (1975) 26th Round (July 1971-June 1972)

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231. National Sample Survey (1976)) 28th Round ofthe National SampleSurvey, 1973-74 (New Delhi, G4vernment of India),

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308 Implementing Health policy

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INDEX

Adlakha, A., 33Alibag project,

cost per capita,266Allopathic drugs,

per capita expenditure on, 259Allopathic medicine, 2, 70Alma Ata declaration, 9, 18, l0l-2,

lt8Ambanravar, J., 33Amenorrhoea, 69Anandalakshmy, S., I70Anganwadi, 97

worker, 97, 170-1

Antia, N,H., 259, 266Aristotle, 120Auxiliary Nurse Midwives (ANMs),

7,'70, 76,'18-9, 82-3, 169

Bairagi, R., 52

Balwadi schemes, 99Banerji,D.,9,26Bang, Abhay, 109, 149

Bangladesh,female mortality, 53

infant and child mortality,female cducation and, 5l-1,

88-9

voluntary projects,costs of, 149

Batliwala, S., 259Baxi, Upendra, 160

Bhore Committee of I943,recommendations of, 6-8, 20-I,

27,76, r28,280

rural health infrastructurc,norms laid down for, 7

Brain drain,effects of, 24-5

Budget,state plan, 219-20see also Expenditure, Financing,

Resource allocationBureaucracy, 8-10, 24, 111

Caldwell, J.C., 51, 88

Causes of death, 30, 42-54, 61

Continuous SurveY of, 44

Central Council of Health' 8' 20, 82

Central Family Planning Council,20

Centralisation, 139

Child care,factors infl uencing, 88-90

Child hea!th see Primary health care

Child mortality see Infant and childmortality

China,community-based health,care,

102health expenditure per capita, 245

health policy of, 59

Chowdhury, S.A., 267

Christian Medical Association ofIndia (CMAI), 142

Cochrane, S.H,, 51, 89Colombia,

women's employment,infant mortality and, 89

316

Communicable diseases, 200Community Development program-

me, 110-12Community financing, 268-?0Community Health workersT

Volunteers' Scheme, 27, ?7, 80,82-84, 92, 108-9, 112-15, 128_9,136(also Health Guides' Scheme),

expenditure on, 222ineffectiveness of,

reason for, 121professional commitment,

Iack of, 118-9selection of workers, 112-3

Community particjpation, 12, 17,284-5in health care,

benefits of, 106-2forms of, 105fundamental problems of,

115_20

importance of, 100-1meaning of, 104nature of, 105-6

ne€d for, 103-4origins of, 101-3padticipants, 107-10past experience, I10.11preconditions, 120-4present strategies, l l2-|5

Constituf.iou of India, 2, lO,lg_ZZ,280-ISeventh Schedule, 9

Cowan, B., 169

Crude death rate, 29, 33-4see also Mortality rates

Cuba,

health services and,59

Dais,92role of, 80-ltraining programme, 8O-2

Dandekar, V.M., 202Das, N., 65de Ferranti, David, 270Death rate,

Implementing Health Policy

r€e Mortality ratesDecentralisation, 26, 129-31Demand,

lack of, 12

Dependency theory, 24-5Developing countries,

life expectancy in, 34mortality decline in,

causes,55Development,

health services and, 137 , 286-87mortality reduction and, 5+6

Development services,voluntary health agencies and,

146Diarrhoeas,45Directive Principles of State Policy,

18-9

Disease control, 44-5

foreign aid for, 272"3plan funds for,

allocation of, 248,249t, 25\in rural areas,

funds for, 252

Donof agencies, 274-75

'Dynamic leader' theory, [38

Dyson, T., 43, 46-7

Education and training,plan expenditures on, 249t,251

Elites,24Endemic diseases, 189

Epidemic diseases,32

Expenditure,allocation of,

methods,2l8to non-plan, 2i9

capital,coverage,220statewise,234t

on development, 226-7Central Government's, 228

State plan, 228-9on Family Welfare, 253t,254-5,

z56tin Five Year Plans,221-3, 225tgovernment,

fuDctional categories, 227

Index

growth rates of,category-wise, 230t

on health sectot, 221'2, 224, 226t,

227 , 253t,254capital,224,235Central Government's share'

228criticism of, 261-4decline,261-2funds distribution, 247-9,

250t,251-2head-wise detail, 253tby local bodies, 246-7

per capita in Karnataka, 260per capita at national leYel,

74sper capita Statewise, 236,

241-3,244t,245per capita in U.P., 256

per cent-wise, 2271

private consumption, 260,

261tas per cent of revenue, 235

at State level, 23O-l, 232t,233-6, 237-8t, 239-40t,24r

State-wise percentage, 234tvariation among States, 236,

239-40tintrasectoral distribution,

inappropriate. 263

monitoring of,277-8on Primary Health Centres,

per capita, 260in private health sector, 259-61,

zo5-+public health, 267

revenue,220catcgory-wise, 235

State-wise,234on Rural Healtb,252-4

Plan-wise, 248, 249t, 251-2,254

on Social and CommunityServices,Central Government, 228

Non-plan, 229

317

State-wise percentage, 237.38t. on Wat€r Supply, 2531, 255

see also Budg€t, Financing'Resource allocation

Family folder, 92

Family planning, 77

foreign aid for, 272'4

health care services and, 94-6

plan funds for 248. 25ot, 251

UNFPA's aid for,272U.S. aid for, 272

Family Welfare,allocation in Seventh Plan, 257'

258t,258expenditure on, 253tt 254'5 , 2561

plan expenditure on, 221-2, 225t'26t

Feeding schemes,drawback in, 97

Female,autonomy, 46-?death rare, 35, 36t, 37-8education,

infant mortality and, 49, 5lmortality,

age specific, 391, 40

causes of, 69-70

reduction of, 64F€rtility,65-6

levels,31Finance CommissioD, 219-2Q, 231,

233-4,257Financial resources,

alternaiive, 268-75

redistribution of, 287-8

Financing,allocation system, 233-4

Center-State relaticns, 22

community, 268-70

€xternal assistance' 270'5

of health plans,intra-sectoral allocations,

247 -9 , 250t, 251-2mechanisms, 218'21

see also Budget, ExPenditure'Resource allocation

3r8

Five Year Plansdcrs training ancl, 8lexpenditure on health, Z2l_3, ZZst

intra-sectoral allocation,247 _9,250t, 251-2

rural health services and, 26-7funds allocated for, 248,

249t, 251-2Five lear plan, Sixth,

per capita health outlays,variation among States, 236,

239-40.rural h€alth,

allocation fot, 236, 239-40tFlegg, A.T., 52Ford FouDdation,

aid to health sector, ZTZForeign aid, 271-5Foreign donations, I54

Gish, Oscar, 268Gopalan, C., 178Growth charts, 166-9, 172

interpretation of, 170Growth monitoring, t 64-5

aims of, 173

cost constraints of, 179-90tecbnology of, 165-8

alternatives, 177ethical choices, 177-8evaluating, 174-5integration, l?3-4requirements for, l6g-76substitutions in, lZ7us€r-appropriateness, 172

Gulati, Leela, 207-9Gwatkin, D., 57, 146, ZO3, 267

Health,household and, 85-6low priority to, 116-7population policy and,

linkage between, 64-6Health behaviour, 83-5Health care,

community participation in,ree Community participation

Implementing Heal th p olicy

universalisation of, ll- lzsce also primary health car€

Hcalth centres, 77location of, 93

Health education, 121-zHealth environment, 84-5"Health for all" declaration, 6,

101-2, t 18Health Guides' Scheme

see under Community HealthWorkers'/Volunteers' Schemc

Health indices, 69Health infrastructure,

per capita cost of, 266Health legislation cxisting, 20-2Health levels

m€asurement of, 29-31Flealth manpower, l2Flealth Policy Starement,

aims of, 29contents of, 2-5decentralisation and, 284-5duality in,282features of, 5-9financial resources,

redistribution of, 287-8goals and strategies, 3-4hcalth and development,

relationship between, 286-7health integration in, 5

health services,reorganisation of, 4

implementation of, 15-28

critical issues, 11-4obstacles to, 9-11, 18-28

on medical education, 4priority problems,4rural health,

financial allocation and 275-5

scope of, Itargets, 5, 6l-2technology dissemination, 285-5voluntary health sector and,

12s-6, r50-rIf,ealth services,

delivery of, 122

Index

expenditure on, 253t, 254capital,223private consumption, 260,

26ttState-wise, 221-2, 224, Z26t

in Kerala,2ll-3mortality and,56-7suggestions for, 91-8

target groups, 60women's access to,

conceDtual framework, 73-83

factors determining, 74-5women's employment in, 92women-specific, 77women's utilisation of, 70

Health system,duality in, 26-8organisation, 282-4

Health Technology, 13, 27, 59attributes of, 176-80

cost-effective, 181

cultural appropriateness, 182

dissemination of, 285-6equity vs. efficiency, 180-81evaluation of, I74-5

approach, 175

of growth monitoring, 164-76

requirements for, 168-7 5

implementation of,requirements, 168-76

preconditions and requirements,164

target group, 172-3types of, 163-4user-appropriate, 172

Hospitals,Plan funds for, 249t

rural areas, 252,254priv^te, 127

Household health, 85-6, 9l-2differentiation in, 87

women's role in, 86-90

Illich, Ivan.,58Immunisation, 199

Indian Council of Medical Research(rcMR), 143

319

Indian Medical Council Act (1956),21

Infant and Child Mortality, 32, 37,39t, 40-2all-India rate, 37birth spacing and, 65causes of high, 65health services and, 56-7influencing factors, 48-54, 88-90mother's education,

influence of, 88-89Nation-wide Survey, 47-54neonatal, 42

causes of, 50iates,29-30

region-wise differentials,42-3

statewise characteristics, 46-7 ,4'7 t

reducing strategies, 54-60, 63-64,163

Integrated Child DevelopmentServices (ICDS) Scheme 92,96-8, 164-5, 1'70, 172-3,1',75

Jain, Anrudh N., 45, 48-51Jamkbed project, l47Jeffery, Roger, 24, 81, 27 3

Joseph, S., 265

Kartar Singh Committee, 9

Kerala,agricultural labourers,

fertiJity decline 196-7

nutrition status of, 204

agricultural situation, 210-lbirlh rate,

decline in, 205calorie intake, 211

deficit in, 202

calorie and protein,per capita intakes, 193

death rate in,42cause of, 199

diseases spread in, 200-1

economic situation of, 210-l Ieducation policy of, 186, 194

emigration, 208-10family planning, 195-7

family structure,changes in, 208-9

female literacy levels, 49, 185

female mortality in, 38fertility reduction, 187

cause of, 195-7food consumption data, 203-4health expenditure in, 212-13health services in, 193, 211-3,

286-7education's role, 190-1history of, 187-90

inter-regional differences,

role of, 186-7health status of, 199

household size, 209cl'ranges in, 209-i0

infant mortalily rates in, 40,189-90cause of, 46factors affecting, 56

land reforms,efects of, 185-6

mean age at marriage in, 191

medical institutions,developrnent of, 188-9

morbidity in, 199-201morbidity-mortality correlations,

204-5

mortality rates in, 185

mortality and fertility,factors inducing decline of,

192-5,211-13nutritional status of, 198-9,

20t-6per capita income, 185, 210political awareness in, 186political developments in, 214population growlh in, 206-7poverty in, 195-8private medical centres,

grant-in-aid system to, 188public health measures in, 209rural health unit,

establishment of, 189-90

Implementing Health Policy

sex ratio in, I85decline in, 207-8

social trends,2l3-4unemployment in,210women status in, 68-9, 191-2

change in, 214Kerala Public Health Department,

189

Kirk, D., 33

Krishnaji, N., 52

Krishnan, P., 56(rishnan, T.N.,211Kurup, R.S., 195-6

[,egislative powers,of Central and State Govern-

ments, 19-22

[-evine, R.A., 88

Life expectancy, 32-4

at birth, 33-4

of females, 35-7,72-3at birth,35-6

of males, 36-7

I.iteracy,mortality and, 55-6

Local bodies,health expenditure of,

state-wise, 246t,247

Madhya Pradesh,health services

women's utilisaiion, 70

Maharashtra,voluntary health agencies,

per capita costs for, 147

$ahila Mandals, 93

[4alaria control,f orcign aid for, 272

[4alnutrition, 63-4, 170

among women, 69

[4ateroal and Child Health Services,76-8see also Primary Health Care

Maternal education, 52-3

Maternal mortality,causes of, 68rate,68

trndex

McDermott, W., 55lvlcKeown, T., 54, 58

Medical edueation,policy statement on, 4

Medical knowledge, 23

Medical professionals, 23

antipathy, 113-9

orientations, 23.4Medicines and diet,

budget allocations, 233

Medico Friends' Circle, 142Mencher, Joan, 196-8, 203-4, 213Midwifery see DalsMinimum Needs Programme, 27

see also F.aral Health ProgrammeMobile clinics, 188

Model Public Health Act, 20-21

Moore, M., 46-7

Morbidity,causes of, 200rates, 31

Mortality,causes and determinants, 43_-54

differentials,34-43age-wise,38-42gender,35-38

regional variations, 42-43rural-urban,35socio-economic, 45-54

fertility andrelationship, 64-66

infant,37,39tIevels,33-4literacy and, 55-6

measurement of, 29-3O

rates,30-3aggregate,34-5decline in, 34

maternal, 68projections,6l-2targets,61-2zone-wise,43

reduction strategies, 54-64statistics,30trends,3l-33

Mosley, W,H., 51-2

Mudaliar Committee, 9, 27

321

Multipurpose Workers' Scheme,22-3,'78,82-3

Nag Moni, 46-7, 5l-2, 192-6Nair, P.R.G., 56, 185-6, 195

Narangwal project,expenditures of, 268per capita cost of, 266

National Planning Committee, 1940

resolution of, 129

recommendations of , 7-8, 76Sub-Committee on Health,

interim report of. 6-7, 129

National Nutrition MonitoringBureau,20l

Nichter, M., 260Non-governmenlal organisations see

Voluntary health agenciesNon-plan resources,

allocation, norms, 231, 233

Nurses, see Auxiliary Nurse Mid-wives (ANMs)

Nutrition, 165-7

Nutrition care, 96-8

Nutrition programmes,political nexus, 289

Nutritional defi ciency diseases, 201

Nutritional status, 178-9

assessing measures, 176

Panikar, P.G.K., 185, 188, 196, 199,2ol-2, 205, 2lO, 212-5

People's participation,in voluntary organisations, 141-2see also Community participation

Pettigrew, Joyce, 95-6

Plan funds,allocation sectoral-wise, 247-8,

249-50t,251-2Planning, 11,93

parameters for, 60-6Planning Commission, 218, 222

Mid-term Assessment report of,254

Political will, 10

Politics,280-2Population W owth, 246-7Population policy,

health and, 64-66

322

Prcvention of Food AdulterationAct (1954),2l

Preventive and Social MedicineDepartments, 23

Primary health care, lI0-11aims of, !6attributes of, I03cost estimation, 264-8cost per capita, 266-7definition of, 103expenditure,

monitoring, 277-8financial allocation,

inequalities in, 278-9requirements for, 27 5-9

financial resources,community resources, 268-70external aid, 270-5

objectives of, 16-7, 23, 163obstacles to, 10-11, 18-28philosophy of, 15strategy of, 16-17technologies, 163-5

attributes, 176-80economic issues and, 180-lgrowth monitoring, 165-8political issues and, 182-3requirements for, 168-7 6social issues and, 182

UN document on, 58Primary Healrh Cenlrcs (pHCs.), 7,

44, 18-9Primary Health Unit, 7Private h€alth sector, 127-8

expendilures on, 259-61governmenl's interest in, 128-31,!"e a/.ro Voluntary health agen-

clesPrivate medical consultations,

expenditure on, 259Privatisation, 12-13, 125

interpretations of, 129-31strategy of, 125-7

Professionalism, 139-40Pyle, D., 140, 144, 14'7, 149,267

Ramalingaswami Committee, 9, 27,58

Implementing Heatth policy

recommendations of, 102Ratcliffe, J. I85-7, 190, 193, 195-6,

204Reorientation of Medical Education

(ROME) Scheme, 27Resource allocatio a, 14, 27-8Revenue distribution,

Central Government's,catfgory-wise, 228

Right to health, 10, 18-9Rural areas,

death rates, 35health services and, 60-1

infant mortality rates, 42-3Rural dispensaries, 127

Rural health services, 8

Bhore Committee's report on, 7development, 76-7

expenditure on,per capila, 241per utilisation,263

funds allocation to, 252-4Plan-wise, 248, 249t, 251-2,

254

requirements tor, 2'7 5-6Sixr h Plan a)location for,

236,239-40tStatewise, 239-40tsee also Primary tlealtb Care

Ruzicka, L. 32, 38-9

Sanitation,2l-2Self-reliance, 117-18

Sex ratio, 68-9decline in, 207-8

Shrivastav Committee, 9recommendations of, 128

Social and community services,

revenue expenditure on, 235

Soman, C.R. 199, 2O1, 213Standard of living, 46$tatutory Boards, 8

Tamil Nadu Integrated NutritionProgramme, 174, 178

Thomas, Lewis, 163

Tratning,23-4importance of , 169-'ll

Index

Sixth Plan funds for, 2?7Travancore and Cochin,

casle-system,

breakdown of, 187-ggsec also Kerala

Travancore Health Code of 1909,190

Tubectomy operation, 95-6Twenty-point programme, 3

Urban areas,infant mortality rates jn, 43

Village community,heterogeneity, I I5-l6

Village health committees, I08Visaria, P. 33, 42Voluntary health agencies,

Board of InspectioD for, 152-3bureaucratisation of, 161categories of, 13 t -33ditrerentiation, 133-4

by objectives and targetgroups, 134-5

by organisation andlinkages, 135-6

by services provided, 136-7dynamism in, 138€thos of, 138flexibility of, 138fund.raising methods, 148-50gen€sis of, I3l-4government aid to, 152-4, 158-9government interest in

collaboration, 150-4heterogeneity of, 134-7impact evaluation,

lack of, l4G7ingredients of success, 137-42iotensive management and, 140-

41

leadership and, 138-9management problems of, 140-1objectives of, 134-5peopf e's participation, l4l-2pressure oo government by,

156-7

7)?

professionalism, 139-40public education and, 160-62replication and, 144-5resource generatlon,

difficulties, 149-5CscieDtific method concept, I46-7wcakoesses of,142-50

diversification problems,145-6

expansion and replication,143-5

isolationism, 142-3lack of impact evaluation,

146-7

learning transferability, 145

self-sufficiency, 148-50, 159uncertain costs, 147-8

Voluntary Health Association ofIDdia (VHAI), 142, l5l-2

Water supply programme, 2l-2expenditures on, 253t, 255pf an expenditure on, 221-23,

225t-26t, ?48,250tWeighing scales, 166, 168-9

cost of, 179

Weight data,recording of, 70

Women,education, 7l-72,98

household health and, 87-9

in Kerala, 190-1

employment, 72, 98-9

household health and' 89-90health cycle of, 7l-3health services and,

conceptual framework, 73-83

factors determining use of,74-s

future strategy, 83-5

utilisation, 70

health status of, 68-70

household health and, 86-90life expectancies, 72-73

malnutrition among, 69responsibilities of, 8?

role of, 283

JZ+

Women's organisations,role of, 93

Working Group on PopulationPolicy, 102

World Health Assembly,declaration of, 101-2, 118

Implementing Health Policy

World Health Organisation,recomm€ndations of,

on health measurem€nt, 29

Yechouron, A, 187-8

Zachariah, R. 195-6, 216