EVOLUTIONOFHEALTHPOLICYININDIA Revised
EVOLUTIONOFHEALTHPOLICYININDIA Revised
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Health and health care development has not been a priority of the Indian
state. This is reflected in two significant facts. One, the low level of
investment and allocation of resources to the health sector over the years
– about one percent of GDP with clear declining trends over the last
decade. And second the uncontrolled very rapid development of an
unregulated private health sector, especially in the last two decades.
Post-SAP one sees a declining role of the Centre in the health sector. The
opening up of the economy has allowed state governments to directly
negotiate with agencies like World Bank and this has meant taking some
initiative on the policy front even if it is driven by the lending agency. In
this context a number of state governments have set up think tanks
and/or policy groups to facilitate policy making and planning for the
health sector.
Introduction
Structured health policy making and health planning in India is not a
post-independence phenomena. In fact, the most comprehensive health
policy and plan document ever prepared in India was on the eve of
Independence in 1946. This was the `Health Survey and Development
Committee Report' popularly referred to as the Bhore Committee. This
Committee prepared a detailed plan of a National Health Service for the
country, which would provide a universal coverage to the entire
population free of charges through a comprehensive state run salaried
health service. Such a well-studied and minutely documented plan has
not as yet been prepared in Independent India.
The English East India Company set up its first hospital in 1664 at Fort
St. George in Madras because they could not see the "English men drop
away like dogs" (especially the soldiers) because of disease (Crawford,
1914: II.401). This was followed by hospitals in Bombay and Calcutta for
the same reasons.
The IMS catered mostly to the needs of the armed forces. However, by
early 19th century hospitals for the general population were established
in chief mofussil towns, besides the Presidency headquarters (Crawford,
1914 : II.430). The expansion of medical facilities followed the devolution
of the imperial government especially after 1880 with the setting up of
Municipalities and District Boards. However, these medical facilities had
a distinct racial and urban bias. Separate provisions were made on
employment and racial grounds, though in some places non-official
Europeans were allowed access to hospitals designed for civil servants. In
General Hospitals, wards for Europeans and Eurasians were separated
from those for the rest of the population (Jeffery, 1988:87). These
facilities, atleast till the Montagu-Chelmsford Reforms of 1919, were
located in urban areas in the military and civilian enclaves of the
English.
Another aspect, which received early attention, atleast in the
cantonments, were public health measures. The continued high mortality
of British soldiers despite good access to medical services led to the
appointment of a Royal Commission to enquire into sanitary conditions
of the army in 1859. “Fevers, intermittent, remittent, and typhoid,
cholera, dysentery, smallpox, spleen disease, diarrhoea, rheumatism,
such is the account of station after station. Epidemics, the result of
imperfect civilization and removable causes prevail in India at the
present day, as epidemics used to prevail in Europe in the Middle Ages.
The work of civilization and sanitary improvement has yet to be initiated
in this great country. The prevailing causes are everywhere the same –
filth, stagnant water, damp, foul ditches, want of drainage, bad drinking
water, utter neglect of ventilation and of all sanitary measures,
overcrowding of houses, and foul air.” (Indian Medical Gazette, 1871:
VI.214)
The rural areas had to wait till the Government of India Act of 1919
whereby health was transferred to the provincial governments and the
latter began to take some interest in rural health care. In fact, rural
health care expansion in a limited way began in India first from 1920
onwards when the Rockefeller Foundation entered India and started
preventive health programmes in the Madras Presidency in collaboration
with the government, and gradually extended its support for such
activities in Mysore, Travancore, United Provinces and Delhi. The focus
of their activities was on developing health unit organizations in rural
and semi-rural areas, in addition to support for malaria research and
medical education (Bradfield, 1938: 274-275).
The same was true in the case of medical education in India. Europeans
and certain western oriented Indian communities like Christians in
Bengal and Parsis in Bombay largely monopolized it, atleast until 1920
(Ibid, 84).
During the colonial period hospitals and dispensaries were mostly state
owned or state financed. The private sector played a minor role as far as
this aspect of health care delivery was concerned. However, the private
health sector existed in a large measure as individual practitioners. The
earliest data available on medical practitioners is from the 1881 census
which records 108,751 male medical practitioners (female occupation
data was not recorded). Of these 12,620 were classified as physicians
and surgeons (qualified doctors of modern medicine) and 60,678 as
unqualified practitioners (which included Indian System Practitioners)
(Census-1881, 1883: III.72). In addition there were 582 qualified medical
practitioners serving in army hospitals (Ibid, 71). However, the census
data does not reveal the proportion of private practitioners. The earliest
data available for private practitioners is for the year 1938 when an
estimated 40,000 doctors were reported to be active. Of these only 9,225
or 23% were in public service and the rest in private practice or private
institutions (Bradfield, 1938: 2-4).
This clearly shows that the private health sector was fairly large and well
established. It also indicates the early commodification of health care
delivery, which is inevitable under capitalism. Given the racial and
urban bias of the State health services this large group of private
practitioners must have catered to a large chunk of Indians who didn't
have access to the State services but who were able to muster resources
to utilize the services of the private practitioners.
The Bhore Committee endorsed this resolve of the NPC through its
recommendations. In formulating its plan for a National Health Service
the Bhore Committee set itself the following objectives:
The district health scheme, also called the three million plan, which
represented an average districts population, was to be organized in a 3-
tier system "in an ascending scale of efficiency from the point of view of
staffing and equipment. At the periphery will be the primary unit, the
smallest of these three types. A certain number of these primary units
will be brought under a secondary unit, which will perform the dual
function of providing a more efficient type of health service at its
headquarters and of supervising the work of these primary units. The
headquarters of the district will be provided with an organization which
will include, within its scope, all the facilities that are necessary for
modern medical practice as well as the supervisory staff who will be
responsible for the health administration of the district in its various
specialized types of service" (Ibid, II.22).
We may conclude from the above that the health care facilities that
existed in India at the time of the Bhore Committee were embarrassingly
inadequate. In fact, most of these were in urban areas and largely in
enclaves of the British Civil administration and Cantonments (Jeffery,
1988: 98). What the Bhore Committee recommended was not excessive
when we look at the ratio of facilities already existing in the UK even
prior to the setting up of its National Health Service.
Two medical officers along with the public health nurses should engage
in providing preventive health services and curative treatment at homes
of patients. The sanitary inspectors and health assistants should aid the
medical team in preventive and promotive work. Preferably at least 3 of
the 6 doctors should be women.
Each province should have the autonomy to organize its primary units in
the way it deemed most suitable for its population but there was to be no
compromise on quality and accessibility. Hence, a highly dense province
like Bengal may have a primary unit for every 20,000 population but a
province like Sind (now in Pakistan) or Central Provinces (now Madhya
Pradesh) which have a highly dispersed population may have a primary
unit for every 10,000 or even less population unit. The deciding factor
should be easy access for that unit of population.
Secondary Unit: About 30 primary units or less should be under a
secondary unit. The secondary unit should be a 650 bed hospital having
all the major specialties with a staff of 140 doctors, 180 nurses and 178
other staff including 15 hospital social workers, 50 ward attendants and
25 compounders.
The secondary unit besides being a first level referral hospital would
supervise both the preventive and curative work of the primary units.
The 650 beds of the secondary unit hospital should be distributed as
follows :
Medical: 150
Surgical: 200
Ob. & GY.: 100
Infectious diseases: 20
Malaria: 10
Tuberculosis: 120
Pediatrics: 50
650
Certain diseases were singled out for special inputs that would be needed
to control and/or eradicate them. They were singled out because they
constituted a major problem then. And most of them 54 years later still
constitute a major problem in the country. These diseases were malaria,
tuberculosis, small pox, cholera, plague, leprosy, venereal diseases,
hookworm disease, filariasis, guinea-worm disease, cancer, mental
diseases and mental deficiency and diseases of the eye and blindness.
For all these diseases the Committee found that facilities are grossly
inadequate and need urgent attention - proper sanitation and other
public health measures are the key to eradicate or control such diseases
(Bhore, 1946: I.88-132). After a thorough review of the prevalence of
these diseases a detailed plan to deal with them had been outlined. This
plan was to be executed as a part and parcel of the general health
services (Bhore, 1946, II.147-212).
All this shows that the Bhore Committee plan was not only well studied
and argued but also comprehensive and suited to the Indian situation.
The Committee categorically states, "we are satisfied that our
requirements can only be met satisfactorily by the development and
maintenance of a state Health Service" (Ibid, II.13). It recommended that
all services provided by the health organization should be free to the
population without distinction and it should be financed through tax
revenues (Ibid, II.14). It further recommended that the health service
should be a salaried service with whole-time doctors who should be
prohibited from private practice (Ibid, II.15).
The Bhore Committee ends its report on a clear note of urgency for
implementation of the plan in its full form. "The existing state of public
health in the country is so unsatisfactory that any attempt to improve
the present position must necessarily involve administrative measures of
such magnitude as may well seem to be out of all proportion to what has
been conceived and accomplished in the past. This seems to us
inevitable, especially because health administration has so far received
from governments but a fraction of the attention that it deserves in
comparison with other branches of governmental activity. We believe that
we have only been fulfilling the duty imposed on us by the Government
of India in putting forward this health programme, which can in no way
be considered as extravagant either in relation to the standards of health
administration already reached in many other countries or in relation to
the minimum requirements of any scheme which is intended to
demonstrate an appreciable improvement in the health of the
community. For reasons already set out, we also believe that the
execution of the scheme should not be beyond the financial capacity of
governments.
"We desire to stress the organic unity of the component parts of the
programme we have put forward. Large-scale provision for the training
of health personnel forms an essential part of the scheme, because the
organization of a trained army of fighters is the first requisite for the
successful prosecution of the campaign against diseases. Side by side
with such training of personnel, we have provided for the establishment
of a health organization which will bring remedial and preventive services
within the reach of the people, particularly of that vast sections of the
community which lies scattered over the rural areas and which has, in
the past, been largely neglected from the point of view of health
protection on modern lines. Considerations based on inadequacy of
funds and insufficiency of trained workers have naturally necessitated
the suggestion that the new organization should first be established over
a limited area in each district and later extended as and when funds and
trained personnel become increasingly available. Even with such
limitations the proposed health service is intended to fulfill, from the
beginning and in an increasing measure as it expands, certain
requirements, which are now generally accepted as essential
characteristics of modern health administration. These are that curative
and preventive work should dovetail into each other and that, in the
provision of such a combined service to the people, institutional and
domiciliary treatment facilities should be so integrated as to provide the
maximum benefit to the community. There should also be provision in
the health organization for such consultant and laboratory services as
are necessary to facilitate correct diagnosis and treatment. Our
proposals incorporate these requirements of a satisfactory health service.
This above review provides not only a brief summary of the Bhore
committee report but it also lends a contrast to the present level of
development of health care services. If the concern of our health policy is
universal access to health care with equity, then the above discussion is
very relevant even today.
2. The Evolution of Health Plans and Policies
With the end of colonial rule in India the population of the country
expected a radical transformation of the exploitative social structure that
the British rule had nurtured and consolidated. But these expectations
were belied, as the new rulers were mere indigenous substitutes for the
colonial masters.
The new rulers mouthed a lot of radical jargon and even put it in writing
in the form of the First Five Year Plan document and other more specific
documents for various sub-sectors of the economy.
The first Five Year Plan describes the central task of planning thus : "The
problem is not one of merely re-channeling economic activity within the
existing socioeconomic framework; that framework has itself to be
remoulded so as to enable it to accommodate progressively those
fundamental urges which express themselves in the demands for the
right to work, the right to adequate income, the right to education and to
a measure of insurance against old age, sickness and other disabilities.
The Directive Principles of State Policy enunciated in Articles 36 to 51 of
the constitution make it clear that for the attainment of these ends,
ownership and control of the material resources of the country should be
so distributed as best to sub-serve the common good, and that the
operation of the economic system should not result in the concentration
of wealth and economic power in the hands of a few. It is in this larger
perspective that the task of planning has to be envisaged" (FYPI, 1952,
8).
The postcolonial period health care sector has seen private medical
practice develop as the core of the health sector in India initially
strengthening the enclave sector, and then gradually spreading into the
periphery as opportunities for expropriation of surplus by providing
health care increased due to the expansion of the socioeconomic
infrastructure. It must be noted that this pattern of development of the
health sector was in keeping with the general economic policy of
capitalism. Thus the health policy of India cannot be seen as divorced
from the economic and industrial policy of the country.
In India until 1982-83 there was no formal health policy statement. The
policy was part and parcel of the planning process (and various
committees appointed from time to time), which provided most of the
inputs for the formulation of health programme designs.
Planning in India
In the early years after independence the Indian state was engrossed in
helping and supporting the process of accumulation of capital in the
private sector through large scale investments in capital goods industry,
infrastructure and financial services. The social sectors like health and
education were low priority areas. Industrial growth was the keyword.
Table 1 and 2 give an overview of plan expenditure in India by major
sectors of the economy and of the health sector. It is evident from these
tables that Economic Services have right through from plan one to plan
nine been allocated over four-fifths of the resources and the social
sectors like health, education, water supply and housing have received
only residual resources.
At this point it’s worth asking the question as to who benefits from this
vast expenditure on economic services?
Like crop production, irrigation too increased nearly fourfold between the
first and ninth five year plans from 23 million hectares in 1951 to 84
million hectares in 1999. But who has benefited from all this? It is
mainly the rich and the middle peasantry who has gained from programs
under agriculture and irrigation under the various five-year plans. A
large proportion of the small peasantry has been marginalized or wiped
out over the years increasing the ranks of the rural proletariat. (see D.
Bandopadhyay "Land Reforms in India: An analysis", Economic and
Political Weekly, June 21-28, 1986).
The sectors that have received over 55% of plan resources are industry,
power, and transport and communication. These constitute the basic
economic infrastructure of an industrial economy. Why has the state
deemed it necessary to invest such large resources to these sectors of the
economy neglecting the social sectors (education, housing, health, social
welfare etc.) where the state's role is more crucial, especially in an
underdeveloped country like India? Infact, it is clearly evident that over
the years investment in the health sector has declined sharply in terms
of the share it gets in the plan kitty.
The public sector industry, which is mainly in basic and capital goods
sector, has been incurring net losses, with the exception of the petroleum
industry (which over the years has accounted for about 70% of the
profits of the public enterprises). Most of the produce manufactured by
these public enterprises is consumed by the private manufacturing
sector to make finished goods and hence the public sector's losses must
be viewed in this context, that is, the public sector is basically
subsidizing the private sector. To illustrate this with a simple example
we can take the use of energy, which is produced almost wholly by the
public sector. Between 1951 and 1985 on an average three-fifths of the
energy utilization has been by the industrial sector and only about 12%
by the households. Today while the share of the industrial economy is
lower at 40% it is power-driven agriculture which has raised its share
from 4% in 1951 to 30% in 1998 and the household share being 20% in
the same year.
When we consider the fact that even after 50 years of planning three-
fourths of the population still lives at the subsistence level or below it,
and industrial development has reached a level that has generated
employment in the organized sector for only about 10% of the work-force,
it becomes clear that the bulk of planning has not benefited the vast
majority in any significant way.
Health care facilities are far below any acceptable human standard.
Even the targets set out by the Bhore Committee on the eve of India's
independence are nowhere close to being achieved. We have not even
reached half the level in provision of health care that most developed
countries had reached between the two world wars. Curative health care
services in the country are mostly provided by the private sector (to the
extent of two-thirds) and preventive and promotive services are almost
entirely provided by the State sector.
From the above discussion it is evident that the Five year plans to which
large resources were committed have not helped uplift the masses from
their general misery, including the provision of health care.
In the fifties and sixties the entire focus of the health sector in India was
to manage epidemics. Mass campaigns were started to eradicate the
various diseases. These separate countrywide campaigns with a techno-
centric approach were launched against malaria, smallpox, tuberculosis,
leprosy, filaria, trachoma and cholera. Cadres of workers were trained in
each of the vertical programmes. The National Malaria Eradication
Programme (NMEP) alone required the training of 150,000 workers
spread over in 400 units in the prevention and curative aspects of
malaria control (Banerji, 1985).
Within CDP the social sectors received very scant attention. Infact CDP
meant, for all practical purposes, agricultural development. This proved
to be so in the subsequent plan periods when CDP got converted into
various agricultural programs like Intensive Agricultural Districts (or
Area) Program (Green Revolution!) in the early sixties; when that failed
then the Small Farmers Development Agency and the Marginal Farmers
and Agricultural Laborers Program in the late sixties, and still later the
Integrated Rural Development Program. Seeing the success of the
Employment Guarantee Scheme of Maharashtra the emphasis shifted to
rural employment programs like National Rural Employment Program,
Jawahar Rozgar Yojana and Employment Assurance Scheme. Besides
this women’s empowerment became a major development issue in the
nineties and schemes like Development of Women and children in rural
areas, micro-credit programs etc..were floated and presently all such
schemes have been integrated into the Swaranjayanti Gram Swarozgar
Yojana. These changing nomenclatures do not necessarily reflect
structural changes but merely repackaging of the same continuum since
the CDP days. We have seen earlier that all the investment in agriculture
to date has had a very small impact on food production and even today
over four-fifths of the population dependent on agriculture lives on the
threshold of survival. Similarly the impact of the rural development
programs has been limited. Yes, they have helped stall absolute poverty
and have helped as fire-fighting mechanisms but they have not produced
sustained results. They have not impacted on poverty in structural
terms. The numbers of poor keep rising each year while economists and
planning commission experts keep fighting on proportions over and
under the poverty line! For the politicians rural development investment
is critical to their survival and they use it as appeasement to seek favour
from the electorate.
The health sector organization under CDP was to have a primary health
unit (a very much diluted form from what was suggested by the Bhore
Committee) per development Block (in the fifties this was about 70,000
population spread over 100 villages) supported by a Secondary health
unit (hospital with mobile dispensary) for every three such primary
health units. The aim of this health organization was "the improvement
of environmental hygiene, including provision and protection of water
supply; proper disposal of human and animal wastes; control of epidemic
diseases such as malaria, cholera, small pox, TB etc.; provision of
medical aid along with appropriate preventive measures, and education
of the population in hygienic living and in improved nutrition" (FYPI,
227).
The Mudaliar Committee further admitted that basic health facilities had
not reached atleast half the nation. The PHC programme was not given
the importance it should have been given right from the start. There
were only 2800 PHCs existing by the end of 1961. Instead of the
"irreducible minimum in staff" recommended by the Bhore Committee,
most of the PHC's were understaffed, large numbers of them were being
run by ANM's or public health nurses in charge (Mudaliar, 1961). The
fact was that the doctors were going into private practice after training at
public expense. The emphasis given to individual communicable
diseases programme was given top priority in the first two plans. But
primary health centers through which the gains of the former could be
maintained were given only tepid support (Batliwala, 1978).
The rural areas in the process had very little or no access to them. The
condition of the secondary and district hospitals was the same as that of
the PHC's. The report showed that the majority of the beds and various
facilities were located in the urban areas. The Committee recommended
that in the immediate future instead of expansion of PHC's consolidation
should take place and then a phased upgrading and equipping of the
district hospitals with mobile clinics for the treatment of non-PHC
population. But the urban health infrastructure continued to increase to
meet the growing demands for medical care and this was where the state
governments own funds were getting committed. The Centre through the
Planning Commission was investing in preventive and promotive
programs whereas the state governments focused their attention on
curative care – some sort of a division of labor had taken place which
even continues to the present.
The third Five Year Plan launched in 1961 discussed the problems
affecting the provision of PHCs, and directed attention to the shortage of
health personnel, delays in the construction of PHCs, buildings and staff
quarters and inadequate training facilities for the different categories of
staff required in the rural areas. (FYP III, 657) The Third Five Year Plan
highlighted inadequacy of health care institutions, doctors and other
personnel in rural areas as being the major shortcomings at the end of
the second Five Year Plan (Ibid, 652). The doctor syndrome loomed large
in the minds of planners, and increase in supply of humanpower in
health meant more doctors and not other health personnel. While the
3rd plan did give serious consideration to the need for more auxiliary
personnel no mention was made of any specific steps to reach this goal.
Only lip service was paid to the need for increasing auxiliary personnel
but in the actual training and establishment of institutions for these
people, inadequate funding became the constant obstacle. On the other
hand, the proposed outlays for new Medical Colleges, establishment of
preventive and social medicine and psychiatric departments, completion
of the All India Institute of Medical Sciences and schemes for upgrading
departments in Medical Colleges for post graduate training and research
continued to be high (Batliwala, 1978).
In this way we see that the allocation patterns continued to belie the
stated objectives and goals of the overall policy in the plans. The urban
health structure continued to grow and its sophisticated services and
specialties continued to multiply. The 3rd plan gave a serious
consideration for suggesting a realistic solution to the problem of
insufficient doctors for rural areas "that a new short term course for the
training of medical assistants should be instituted and after these
assistants had worked for 5 years at a PHC they could complete their
education to become full fledged doctors and continue in public service"
(FYP III, 662). The Medical council and the doctors lobby opposed this
and hence it was not taken up seriously.
India was the first country in the world to adopt a policy of reducing
population growth through a government sponsored family planning
programme in 1951. In the first two plans the FP programme was
mainly run through voluntary organizations, under the aegis of FPAI.
Faced with a rising birth rate and a falling death rate the 3rd plan stated
that "the objective of stabilizing the growth of population over a
reasonable period must therefore be at the very center of planned
development". It was during this period that the camp approach was
tried out and government agencies began to actively participate in
pushing population control. This was also the time when family
planning became an independent department in the Ministry of health.
The 4th Plan which began in 1969 with a 3 year plan holiday continued
on the same line as the 3rd plan. It quoted extensively from the FYP II
about the socialist pattern of society (FYP IV, 1969, 1-4) but its policy
decisions and plans did not reflect socialism. Infact the 4th plan is
probably the most poorly written plan document. It does not even make
a passing comment on the social, political and economic upheaval during
the plan Holiday period (1966-1969). These 3 years of turmoil indeed
brought about significant policy changes on the economic front and this,
the 4th plan ignored completely. It lamented on the poor progress made
in the PHC programme and recognized again the need to strengthen it. It
pleaded for the establishment of effective machinery for speedy
construction of buildings and improvement of the performance of PHCs
by providing them with staff, equipment and other facilities. (ibid, 390)
For the first time PHCs were given a separate allocation. It was
reiterated that the PHC's base would be strengthened along with, sub-
divisional and district hospitals, which would be referral centers for the
PHCs. The importance of PHCs was stressed to consolidate the
maintenance phase of the communicable diseases programme. This
acknowledgement was due to the fact that the entire epidemiological
trend was reversed in 1966 with the spurt in incidence of malaria which
rose from 100,000 cases annually between 1963-65, to 149,102 cases
(GOI, 1982). This was admitted by the planning commission. FP
continued to get even a more greater emphasis with 42% of health sector
(Health + FP) plan allocation going to it (FYP IV, 1969, 66). It especially
highlighted the fact that population growth was the central problem and
used phrases like "crippling handicap", "very serious challenge" and an
anti-population growth policy as an "essential condition of success" (Ibid,
31-32) to focus the government's attention to accord fertility reduction
"as a program of the highest priority" (ibid, 391). It was also during this
period that water supply and sanitation was separated and allocations
were made separately under the sector of Housing and Regional
development. (ibid, 398-414).
It was in the 5th Plan that the government ruefully acknowledged that
despite advances in terms of infant mortality rate going down, life
expectancy going up, the number of medical institutions, functionaries,
beds, health facilities etc, were still inadequate in the rural areas. This
shows that the government acknowledged that the urban health
structure had expanded at the cost of the rural sectors. (FYP V, 1974,
234) This awareness is clearly reflected in the objectives of 5th Five Year
Plan which were as follows : (Ibid, 234).
The methods by which these goals were to be achieved were through the
MNP, the MPW training scheme, and priority treatment to backward and
tribal areas.
Major innovations took place with regard to the health policy and method
of delivery of health care services. The reformulation of health
programmes was to consolidate past gains in various fields of health
such as communicable diseases, medical education and provision of
infrastructure in rural areas. This was envisaged through the MNP which
would "receive the highest priority and will be the first charge on the
development outlays under the health sector (Ibid, 234). It was an
integrated packaged approach to the rural areas. The plan further
envisaged that the delivery of health care services would be through a
new category of health personnel to be specially trained as multi-purpose
health assistants. However, the infrastructure target still remained one
PHC per CDP Block (as in the FYPI but the average Block's population
was now 125000)!
In the 5th Plan water supply and sanitation got a greater emphasis. It
was one of the important objectives in the MNP to provide adequate
drinking water to all villages suffering from chronic scarcity of water.
The outlay during this plan period for water supply was Rs. 10,220
millions, almost an equal amount to that allocated to the health sector
(Ibid, 264).
The provision of safe water supply and basic sanitation is either absent
or grossly inadequate for the vast majority of the population of India in
both rural and urban areas. The major cause of the various diseases
which affect the Indian population such as diarrhoea, amoebic
dysentery, cholera, typhoid, jaundice are water borne. These diseases
are also carried and spread due to lack of basic sanitation. To alleviate
this problem in 1960 the National Water Supply and Sanitation
Committee (Simon Committee) was formed to review the progress made
under the national programmes in the first 2 plans. The report came out
with the finding that the states themselves lacked data and information
regarding the magnitude and nature of the problem. It stressed the need
for an immediate survey and investigation to obtain correct data on the
existing conditions both in urban and rural areas on which future
planning and implementation could be based. It strongly recommended
that the end of the 3rd plan must provide minimum drinking water to all
villages in the country (Simon, 1960). This did not happen even till the
end of the 5th Five Year Plan.
The Sixth Plan was to a great extent influenced by the Alma Ata
declaration of Health For All by 2000 AD (WHO, 1978) and the ICSSR -
ICMR report (1980). The plan conceded that "there is a serious
dissatisfaction with the existing model of medical and health services
with its emphasis on hospitals, specialization and super specialization
and highly trained doctors which is availed of mostly by the well to do
classes. It is also realized that it is this model which is depriving the
rural areas and the poor people of the benefits of good health and
medical services" (Draft FYP VI, Vol. III, 1978, 250).
This plan and the seventh plan too, like the earlier ones make a lot of
radical statements and have recommend progressive measures. But the
story is the same - progressive thinking and inadequate action.
Whatever new schemes are introduced the core of the existing framework
and ideology remains untouched. The underprivileged get worse off and
the already privileged get better off. The status quo of the political
economy is maintained. However, the Sixth and the Seventh plans are
different from the earlier ones in one respect. They no longer talk of
targets. The keywords are efficiency and quality and the means to realize
them is privatisation. Privatisation is the global characteristic of the
eighties and the nineties and it has made inroads everywhere and
especially in the socialist countries.
The Sixth and Seventh Five Year Plans state clearly : ".......... the success
of the plan depends crucially on the efficiency, quality and texture of
implementation. ...... a greater emphasis in the direction of competitive
ability, reduced cost and greater mobility and flexibility in the
development of investible resources in the private sector (by adapting)
flexible policies to revive investor interest in the capital markets" (FYP VI,
1980, xxi and 86)
A health policy is thus the expression of what the health care system
should be so that it can meet the health care needs of the people. The
health policy of Independent India, adopted by the First Health Ministers'
Conference in 1948 were the recommendations of the Bhore Committee.
However, with the advent of planning the levels of health care, as
recommended by the Bhore Committee, were diluted by subsequent
committees and the Planning Commission. In fact, until 1983 there was
no formal health policy, the latter being reflected in the discussions of
the National Development Council and the Central Council of Health and
Family Welfare, and the Five Year Plan documents and/or occasional
committee reports as discussed above. As a consequence of the global
debate on alternative strategies during the seventies, the signing of the
Alma Ata Declaration on primary health care and the recommendations
of the ICMR-ICSSR Joint Panel, the government decided that the above
fora may have served the needs in the past but a new approach was now
required,
"It is felt that an integrated, comprehensive approach towards the
future development of medical education, research and health
services requires to be established to serve the actual health needs
and priorities of the country. It is in this context that the need has
been felt to evolve a National Health policy," (MoHFW, 1983, p 1)
During the decade following the 1983 NHP rural health care received
special attention and a massive program of expansion of primary health
care facilities was undertaken in the 6th and 7th Five Year Plans to
achieve the target of one PHC per 30,000 population and one subcentre
per 5000 population. This target has more or less been achieved, though
few states still lag behind. However, various studies looking into rural
primary health care have observed that, though the infrastructure is in
place in most areas, they are grossly underutilised because of poor
facilities, inadequate supplies, insufficient effective person-hours, poor
managerial skills of doctors, faulty planning of the mix of health
programs and lack of proper monitoring and evaluatory mechanisms.
Further, the system being based on the health team concept failed to
work because of the mismatch of training and the work allocated to
health workers, inadequate transport facilities, non-availability of
appropriate accommodation for the health team and an unbalanced
distribution of work-time for various activities. In fact, many studies have
observed that family planning, and more recently immunisation, get a
disproportionately large share of the health workers' effective work-time.
(NSS,1987, IIM(A),1985, NCAER,1991, NIRD,1989, Ghosh,1991,
ICMR,1989, Gupta&Gupta,1986, Duggal&Amin,1989, Jesani et.al,1992,
NTI,1988, ICMR,1990)
Among the other tasks listed by the 1983 health policy, decentralisation
and deprofessionalisation have taken place in a limited context but there
has been no community participation. This is because the model of
primary health care being implemented in the rural areas has not been
acceptable to the people as evidenced by their health care seeking
behaviour. The rural population continues to use private care and
whenever they use public facilities for primary care it is the urban
hospital they prefer (NSS-1987, Duggal & Amin,1989, Kannan
et.al.,1991, NCAER,1991, NCAER,1992, George et.al.,1992). Let alone
provision of primary medical care, the rural health care system has not
been able to provide for even the epidemiological base that the NHP of
1983 had recommended. Hence, the various national health programs
continue in their earlier disparate forms, as was observed in the NHP
(MoHFW,1983, p 6).
As regards the demographic and other targets set in the NHP, only crude
death rate and life expectancy have been on schedule. The others,
especially fertility and immunisation related targets are much below
expectation (despite special initiatives and resources for these programs
over the last two decades), and those related to national disease
programs are also much below the expected level of achievement. In fact,
we are seeing a resurgence of communicable diseases.
With regard to the private health sector the NHP clearly favours
privatization of curative care. It talks of a cost that "people can afford",
thereby implying that health care services will not be free. Further
statements in the NHP about the private health sector leave no room for
doubt that the NHP is pushing privatisation. NHP adopts the stance that
curative orientation must be replaced by the preventive and promotive
approach so that the entire population can benefit (Ibid., 3). The NHP
suggests that curative services should be left to the private sector
because the state suffers from a "constraint of resources" (Ibid., 5). It
recommends, "with a view to reducing governmental expenditure and
fully utilizing untapped resources, planned programmes may be devised,
related to the local requirements and potentials, to encourage the
establishment of practice by private medical professionals, increased
investment by non-governmental agencies in establishing curative
centers and by offering organized logistical, financial and technical
support to voluntary agencies active in the health field ... and in the
establishment of centers equipped to provide specialty and super
specialty services ... efforts should be made to encourage private
investments in such fields so that the majority of such centers, within
the governmental set-up, can provide adequate care and treatment to
those entitled to free care, the affluent sectors being looked after by the
paying clinics". (Ibid, 7-8)
The expansion of the private health sector in the last two decades has
been phenomenal thanks to state subsidies in the form of medical
education, soft loans to set up medical practice etc... The private health
sector's mainstay is curative care and this is growing over the years
(especially during the eighties and nineties) at a rapid pace largely due to
a lack of interest of the state sector in non-hospital medical care services,
especially in rural areas (Jesani&Ananthram,1993). Various studies
show that the private health sector accounts for over 70% of all primary
care treatment sought, and over 40% of all hospital care (NSS-1987,
Duggal&Amin,1989, Kannan et.al.,1991, NCAER,1991, George
et.al.,1992). This is not a very healthy sign for a country where over
three-fourths of the population lives at or below subsistence levels.
The above analysis clearly indicates that the 1983 NHP did not reflect the
ground realities adequately. The tasks enunciated in the policy were not
sufficient to meet the demands of the masses, especially those residing in
rural areas. "Universal, comprehensive, primary health care services",
the 1983 NHP goal, is far from being achieved. The present paradigm of
health care development has in fact raised inequities, and in the current
scenario of structural adjustment the present strategy is only making
things worse. The current policy of selective health care, and a selected
target population has got even more focused since the 1993 World
Development Report: Investing in Health. In this report the World Bank
has not only argued in favour of selective primary health care but has
also introduced the concept of DALYs (Disability Adjusted Life Year’s) and
recommends that investments should be made in directions where the
resources can maximise gains in DALYs. That is, committing increasing
resources in favour of health priorities where gains in terms of efficiency
override the severity of the health care problems, questions of equity and
social justice. So powerful has been the World Bank's influence, that the
WHO too has taken an about turn on its Alma Ata Declaration. WHO in
its "Health For All in the 21st Century" agenda too is talking about
selective health care, by supporting selected disease control programs
and pushing under the carpet commitments to equity and social justice.
India's health policy too has been moving increasingly in the direction of
selective health care - from a commitment of comprehensive health care
on the eve of Independence, and its reiteration in the 1983 health policy,
to a narrowing down of concern only for family planning, immunisation
and control of selected diseases. Hence, one has to view with seriousness
the continuance of the current paradigm and make policy changes which
would make primary health care as per the needs of the population a
reality and accessible to all without any social, geographical and
financial inequities. Table 3 gives a good idea of how the health
infrastructure in India has evolved over the years.
The 7th Five Year Plan accepted the above NHP advice. It recommended
that "development of specialties and super-specialties need to be pursued
with proper attention to regional distribution" (FYP VII, 1985, II, 273) and
such "development of specialised and training in super specialties would
be encouraged in the public and the private sectors". (Ibid., II, 277). This
plan also talks of improvement and further support for urban health
services, biotechnology and medical electronics and non-communicable
diseases (Ibid, II. 273-276). Enhanced support for population control
activities also continues (Ibid., II. 279-287). The special attention that
AIDS, cancer, and coronary heart diseases are receiving and the current
boom of the diagnostic industry and corporate hospitals is a clear
indication of where the health sector priorities lie.
On the eve of the Eighth Five Year Plan the country went through a
massive economic crisis. The Plan got pushed forward by two years. But
despite this no new thinking went into this plan. Infact, keeping with the
selective health care approach the eighth plan adopted a new slogan –
instead of Health for All by 2000 AD it chose to emphasize Health for the
Underprivileged (FYP VIII, 322). Simultaneously it continued the support
to privatization, “In accordance with the new policy of the government to
encourage private initiatives, private hospitals and clinics will be
supported subject to maintenance of minimum standards and suitable
returns for the tax incentives.” (ibid, 324)
The 9th Five Year Plan by contrast provided a good review of all
programs and strategised on achievements hitherto to come up with
innovative ideas to strengthen the public health system. It is refreshing
to see that reference was once again made to the Bhore Committee report
and contextualised today’s scenario in the recommendations the Bhore
Committee had made. (FYP IX, 446) In its analysis of health
infrastructure and human resources the Ninth Plan says that
consolidation of PHCs and SCs and assuring that the requirements for
its proper functioning are made available is an important goal under the
Basic Minimum Services program. Thus, given that it is difficult to find
physicians to work in PHCs and CHCs the Plan suggests creating part-
time positions which can be offered to local qualified private practitioners
and/or offer the PHC and CHC premises for after office hours practice
against a rent. Also it suggests putting in place mechanisms to
strengthen referral services. (ibid, 454)
During the Eighth Plan resources were provided to set up the Education
Commission for Health Sciences, and afew states have even set up the
University for Health Sciences as per the recommendations of the Bajaj
committee report of 1987. This initiative was to bring all health sciences
together, provide for continuing medical education and improve medical
and health education through such an integration. The Ninth Plan has
made provisions to speed up this process. (ibid, 468)
During the 8th Plan period a committee to review public health was set
up. It was called the Expert Committee on Public Health Systems.
This committee made a thorough appraisal of public health programs
and found that we were facing a resurgence of most communicable
diseases and there was need to drastically improve disease surveillance
in the country. The Ninth Plan proposed to set up at district level a
strong detection cum response system for rapid containment of any
outbreaks that may occur.(Ibid, 477). Infact, the recommendations of
this committee formed the basis of the Ninth Plan health sector strategy
to revitalize the public health system in the country to respond to its
health care needs in these changed times. (Ibid, 499) Also the Plan
proposed horizontal integration of all vertical programs at district level to
increase their effectiveness as also to facilitate allocative efficiencies.
What is also interesting is that the 9th Plan also reviewed the 1983
National Health Policy in the context of its objectives and goals and
concluded that a reappraisal and reformulation of the NHP was
necessary so that a reliable and relevant policy framework was available
for not only improving health care but also measuring and monitoring
the health care delivery systems and health status of the population in
the next two decades (Ibid, 503). In this context the 9th Plan was critical
of the poor quality of data management and recommended drastic
changes to develop district level databases so that more relevant
planning was possible (Ibid, 472). Taking lead from the 9th Plan the
Ministry of Health and Family Welfare worked out a new Health Policy
document.
The Ninth Plan also reviewed the population policy and the family
planning program. In this review too it goes back to the Bhore Committee
report and says that the core of this program is maternal and child
health services.. Assuring antenatal care, safe delivery and immunization
are critical to reducing infant and maternal mortality and this in turn
has bearing on contraception use and fertility rates. (Ibid, 519). This is
old logic which the family planning program has used, only earlier their
emphasis was on sterilization. In the early sixties the setting up of
subcentres and employing ANMs was precisely for the MCH program but
at the field level this was hijacked by the family planning program. This
story continues through the seventies and eighties. MCH became Safe
Motherhood, and expanded Program of Immunization and the latter
using a mission approach under Sam Pitroda became Universal Program
of Immmunisation. In the 7th Plan this got combined again to become
Child Survival and Safe Motherhood, but the essential emphasis
remained on family planning. But since the 8th Plan and into the 9th Plan
CSSM acquired a genuine seriousness and presently it is transformed
into the RCH program on the basis of the ICPD-Cairo agenda and
receives multi-agency external funding support to provide need based,
demand driven, high quality integrated reproductive and child health
care. (ibid, 519 and 557). In the midst of all this the National Population
Policy was announced with a lot of fanfare in the middle of 2000. It is
definitely an improvement from its predecessors but the underlying
element remains population control and not population welfare. The
major concern is with counting numbers and hence its goals are all
demographic. But as I said earlier that there is improvement from the
past because the demographic goals are placed in a larger social context
and if that spirit is maintained in practice then we would definitely move
forward.
However a review of the 9th Plan and of all its innovative suggestions
shows that we had once again failed at the ground level. We were again
unable to translate these ideas into practice. And despite all these efforts
one can see the public health system weakening further. The answer is
found in the 9th Plan itself. It laments that all these years we have failed
to allocate even two percent of plan resources to the health sector (ibid,
503). The same reason has killed the initiative shown in the 9th Plan
process at the start itself by continuing the story of inadequate resource
allocations for the health sector.
On the eve of the 10th Plan, the National Health Policy of 2002 was
announced, inviting feedback from the public for the first time. It
acknowledges that the public health care system is grossly short of
defined requirements, the morbidity and mortality due to easily curable
diseases is unacceptably high and the resource allocations are generally
insufficient. Given the context that health researchers and activists have
long advocated for mechanisms to build accountability within the private
health sector, NHP 2002 states an intention to regulate the private health
sector through statutory licensing. The express concern for establishing
a well worked out referral system and improving overall health statistics
is also admirable. However, it remains quite unclear how the goals will
be actually achieved given the framework of the policy. For instance, goal
10 aims to “increase utilization of public health facilities from current
level of <20 to >75%”, thereby projecting the reversal of the existing
utilization patterns that favor the private sector. While this goal is
commendable, there are no corresponding large scale measures planned
to achieve this, and it is worrisome that many prescriptions of the policy
seem to favor strengthening the private health sector. Overall, the 2002
NHP seems like a collection of unconnected statements, a dilution of the
role of public health services and an unabashed promotion of the private
health sector.
The 10th Five-year Plan maintains the continuum from the 9th Plan. It
does talk about reorganization and restructuring of the health
infrastructure and linking it to a responsibility system on the basis of
residence with a referral system for higher levels of care. The 10th Plan
also says that the commitment to primary health care, emergency and
life-saving services and the national programs must continue free of cost
but puts in a rider of user charges for those above poverty line, and in
the same breadth it quotes the NSS 52nd Round which reveals that even
middle classes go into severe indebtedness for hospitalization and
something towards risk-pooling needs to be developed (10th Plan
approach paper, pages 39-40). However the Tenth Plan adopts the
following contradictory stance: In view of the importance of health as a
critical input for human development there will be continued
commitment to provide:
* essential primary health care, emergency life saving services, services
under the National Disease Control programmes and the National Family
Welfare Programme totally free of cost to all individuals and
* essential health care service to people below poverty line based on their
need and not on their ability to pay for the services.
... Available funds will be utilized to make all the existing institutions
fully functional by providing needed equipment, consumables,
diagnostics and drugs. In addition to funds from the centre, state,
externally aided projects, locally generated funds from user charges and
donations will be used for maintenance and repair to ensure optimal
functional status and improve quality of services.
Upto the eighties the influence came through advice and ideology and
hence its penetration was limited but post-eighties there is a lot of money
also coming in, mostly as soft loans and along with conditionalities, and
if we continue without making a paradigm shift and making structural
changes, we will be transferring a burden to the next generation which it
may be unable to carry! Prior to the eighties external assistance was
mostly grants and very insignificant in volume. During the entire decade
of the seventies about $85 million per year of external assistance in the
health sector was being received, largely as grants but after World Bank
entered the picture in the eighties with IPP projects the scenario changed
significantly with the annual average varying between $300 million and
$600 million during eighties and nineties and mostly as loans with World
Bank dominating with over two-thirds of such funds coming from it by
end of the eighties (Gupta and Gumber, 2002).
This does not mean that international donor organizations do not have a
role to play. The Rio Declaration had mandated that the developed world
be obligated to provide development grants to the tune of 0.72% of their
GDP. The international treaty organizations have failed in securing this
obligation from developed countries. These grants are important in
assisting the less developed countries in meeting obligations to assure
rights that state parties have agreed to respect, protect and fulfill under
various international covenants and treaties. But the developed world is
no where close to realizing this obligation and the less developed world
instead has to face the humiliation of indebtedness to these very
developed countries and institutions like the World Bank, the Asian
Development Bank etc.
References