Approaches to Development Social and Cultural Foundations of Health

8/10/2019 Approaches to Development Social and Cultural Foundations of Health

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Social and Cultural Foundations of Health

Services SystemsD Banerji

The new leadership of the health services system after Independence readily committed itself to

providing good health services to the vast masses of people of the country, but for this it did not consider

it necessary to bring about any basic changes in the system. The colonels of the Indian Medical Service,

by then greatly depleted by the withdrawal of the British, and the Brown Englishmen were assigned the

very much more challenging task of building the new health services system for India,

Medical colleges grew very rapidly and poured out large numbers of physicians who were mostly

alienated from the masses of the people. A number of hospitals were opened in the urban areas. Out of

the limited resources that were made available for providing preventive services for rural areas, the colonels,

with strong "persuasion" from foreign consultants, set aside big chunks for running mass campaigns

against specific diseases malaria, population growth, small-pox, leprosy, trachoma and filariasis.

Not only have these campaigns hindered the development of a permanent health services system in

the rural areas hut almost invariably they have also failed to achieve the set goals. The country was

persuaded in the late fifties to invest about Rs 1,010 mn to eradicate malaria by 1966, but after an in ve st -

ment of over Rs 3,500 mn the prospect of doing so by even 1979 do not appear to be particularly bright.

The campaign against population growth has turned out to be a similar costly blunder.

Social scientists and health educators from abroad helped the colonels to divert attention from the

basic malady of the system by raising the bogey of resistance of the villagers to acceptance of the Western

system of medicine. Following that reference model, their counterparts in India dutifully echoed their

findings and a large number of positions were created to accommodate such professional health educators

and social scientists within the system.

Findings of a carefully conducted empirical study of health behaviour of rural populations of India

have, however, underscored the fact that there is considerable active interest among villagers in acquiring

both curative and preventive services. Mostly it is the services which have let the people down, rather

than the reverse. Not only are the rural health services very much below what the Bhore Committee's

short-term programme had in 1946 described as the "irreducible minimum requirements" and much below

the actual demands of the people, but even these very limited services are working at an alarmingly lowlevel of efficiency one of the main causes for this being the alienation of the health workers and of the

institutions for education and training of such workers from the masses of th

Health Practices before British

Rule

EVE RY communi ty has a health cul-

ture of its ownits own cult ural mean-

ing of its healt h problems, it s heal th

practices and its corps of practitioners.

As a component of its overall cult ure,

the health culture of a community is

shaped by the interplay of a numberof social, polit ica l, c ultu ral and econo-

mic forces,1 The history of the health

services system in Ind ia provides an

account of the influence of such forces

in giving shape to it. Henry Seigerist2

has drawn attention to this important

aspect by cont rast ing the mani fes tly

high standards of environmental sanita-

tion of the Indus Valley period with

the level of sanit ation that exists in

India today.

Describing the five-thousand-year old

plann ed city of Mohenj o Daro, Mar-

shall3 has remar ked that the publi c

heal th fa cili ties of the cit y was supe-

ri or to those of all other commu niti es

of the ancient Orient. Al mos t all house-

holds had bathr ooms, latrine s, ofte n

water closets and care fully bui lt w ells.

The elaborate nature of the Indus Valley

publ ic health organisa tion provides an

ind ic ati on of the extent of hea lth con-

sciousness among the ancient In di an

people. It is diffic ult to conjecture the

nature of the health problems of those

days, but the great emphasis on the

prev enti ve aspects of disease indica tesa fairly mature attitude of the society

towards the health problems that might

have been prevailing at that time.

The Vedic medicine that developed

after the adve nt of the Ary an s to the

Indus Valley (during the secondmil len-

niu m BC) had begun to show a ten d-

ency to develop rat iona l methods of

approach ing health problems at quite

an early stage.4 Even in the Vedic Sam-

hitas, purely religious books, are found

reflec tion of anatomical, physiological

and pathological views which are neither

magical nor reigious and there are

references to treatme nts wh ic h are

impressively rational.

Furthermore, there exists the famous

decree of Emperor Ashoka Maurya (279-

236 BC) in his second Rock Edict (257-

236 BC) "cel ebrat ing the orga nisat ion

of social medicine shaped by the Em-

peror along the lines of Buddhist thought

and kindred ethics (dharma)"4 The

works of the famous Charaka of the

first century AD and of Susruta of the

fourth century AD laid the foundation

of the hig hly devel oped science of me-dicine whic h flo uri shed in the tent h

centu ry after Chris ta per iod of all

roun d social and economic progress,

oft en cal led the age of Indian . Renais-

sance. The re is also epig raph ical evi-

dence indi cat ing that social medic ine

was practised in medie val South

India.4

Dur ing the subsequent centuries, a

series of political, social, and economic

changes pro fou ndl y disr upte d the eco-

logical balance in Indi an society. Per-

haps the lowest point of this ecological

crisis was reached d ur in g the decline

of the Mughal Empire, a situation

whi ch set the stage for the Bri tis h

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Special Num ber Au gu st 1974 , ECONOMIC AND POLITICAL WEEKLY

conquest of India. Eve n dur ing this

period the system of Indian medicine

had retained some fragments of its past

heritag e; for example, th e surgeons of

the British East India Company learnt

the art of rhinopl asty from I ndi an ex-

ponents of surgery.3 It is notewo rthy

that during the early period of British

rul e in In di a, the West ern system of

medicine, which was still dominated by

such proced ures as pur gin g, leech ing,

scarification and bloo d-l etti ng, could

not be considered to be any superior

to the prevailing methods of the Indian

systems of medicine.

II

Health Practices during British Rule

The social, cultural, economic and

poli tica l changes tha t foll owe d the in-

tro du cti on of Brit ish rule in Indiadealt an almos t fat al blo w to the prac-

tice of the In dian systems of medici ne.

With the imposition of the Britis h rule,

almost every facet of Indian life, in-

cluding the medical and public health

services, was subordinated to the com-

mercial, polit ical and administrati ve

interests of the Imperia l Gov ernm ent

in Lon don . In developing health ser-

vices for certa in li mi te d purposes (for

example, for the army), the patronage

was shifted from the Indian systems of

medicine to the Western system. The

decision to make this shift appears tobe amply vind ica ted by the spectacular

advances in the dif fer ent branches of

Western medicine during the nineteenth

and twenti eth centuries. As a result of

these changes the already stagnant In-

dian systems of med ici ne got caught

in a vici ous cir cle : its very neglect

accelerated its further decline and the

decline, in turn, made it increasingly

diff icul t for it to compete wi th the high-

ly favoured and rapidly flou rish ing Wes-

ter n system in captu ring the imag ina-

tion of the educated population of India,

In the long run, therefore, not only did

the pro fessi on of the In dia n systems

of medicine get inf ilt rat ed by various

kind s o f quacks, bu t the very basis of

the sciences got considerably eroded by

forces of sup ers titi on and of beliefs in

supernatural powers and dieties.5

The Brit ish had int rod uce d Western

medicine in India in the latter half of

the eighteenth century prin cipa lly to

serve their colonial aims and objectives.

Med ical services were needed to sup-

port the British army and British civi-

lian personn el liv ing in Ind ia. Lateron, med ica l services wer e made availa-

ble in a very tiny selected segment of

the native population. At the time of

Independence, only the affluent and

the ruling classes could get adequate

medical services. Of the rest, const itut -

ing mor e tha n 90 per cent of the

popu latio n, only a small fra ctio n could

get some form of medical care from

hospit als and dispensaries ru n by gov-

ernment agencies, missionaries, philan-

thropi c insti tuti ons and private practi-

t ioners.7 Simil arly , publ ic healt h ser-

vices cons iste d of some for m of en-

vir onme ntal sanitation in a few big

cities- For the rest some pub lic hea lth

services were pro vid ed only when

there was an outb reak of massive epid-

emics of diseases such as plagu e, cho-

lera, and small-pox.7 Because of these

condi tion s, in spite of the av ailab ility

of knowledge from the Western system

of medicine, there was widespread pre-

valence of such easily prev enta ble dis-

eases as malaria, tuberculosis, leprosy,

small-pox, cholera, gastro-intestinal in-

fections and infestations, trachoma and

filari asis; Ind ian was among the coun-

tries of the wo rl d wi th the highest

infant and maternal mor bid ity and

mo rt al it y and gross death rates. In

add iti on, there was the enormou s pro-

blem of unde rnut rit i on and maln utri -

tion. India was among the lowest per

capita calorie consuming countries in

the world.7

At the time of Independence, Bri tis h

India (population 300 mill ion ) had

17,654 medic al graduates, 29,870 lic en-

cites, 7,000 nurses, 750 health visitors,

5,000 mid wiv es , 75 pharma cists and

about 1,000 dentists.7

The colo nial character of the heal th

services had also profoundly influenced

almost all aspects of medi cal educa tion

in Indiain shaping the insti tutions,

in developing the course content and,

perhaps most impo rta nt of all, in

sha ping the v alu e system a nd the so-

cial outl ook of the Ind ian physicians,

The first medi cal college in Indi a was

est abli she d way back in 1835. It was

, quite natural that Bri tis h teachers

should have nurtured such institutions

in their infancy. However, along with

the "sci entif ic core" of medi cal sciences

(wh ich was a most welcom e diffu sion

of a cultu ral inno vati on fr om the Wes-

tern wor ld) , there came certain po lit i-

cal, social and cult ural overcoatings

which were definitely against the wider

interests of the country . 8

Also, opport unitie s for medic al edu-

cation in these institutions were made

available to the very privileged upper

class of the society. Ad di ti on al ly , theMedical Council of India accepted the

Bri tis h norms of medica l e ducation in

order to gain rec ogni tion of the I nd ian

medic al degrees from the Bri tis h Med i-

cal Co unc il. This enabled some of the

physicians, who were "the select among

the select", to go to Great Britain to

get higher medical education. Acquir-

ing Fellowships or Memberships of the

vario us Roy al Colleges was generall y

cons ider ed to be the pin nac le of

achievement in their respective fields.

These four consid eratio nscol onial

value system of the B rit is h rule rs, class

orientation of Indian physicians, their

encultu ration in British model led In-

dian medi cal colleges and a mor e

thoro ugh and more extensive indo ctr i-

nat ion of fut ure key leaders of the

In dia n m edic al profess ions in the Ro-

yal Co llegesp rovided a very conge-

nial setting for the creation of what

Lord Macaulay had visualised as

"Brown Englishmen",9 These Brown

Englis hmen acquired domi nan t leader-

ship positi ons in all the facets of the

hea lth services in I ndi a. This arrange-

ment prov ed convenien t to bot h the

parties,' To the Indi an physicians it

ensured powe r, prestige , status and

money at home. Their mento rs fr om

foreign countries retained considerable

infl uenc e on the entire hea lth service

system of the cou ntry by ensu ring tha t

the to p leadershi p of the medi cal pro-

fession in Ind ia remai ned heav ily de-

pendent on them.

IllEvolution of Existing Health

Services Systems

PROFILE OF POLI CY FOR MUL ATO RS AN D

HEALTH ADMINISTRATORS

Af te r Independence, the healt h ser-

vices system of the cou ntr y was shap-

ed by the two key po li ti cal decisions

of the new leadership. Fo llo win g the

political commitments made during the

struggle for Independence, pro visi on of

plank of the Dire ctiv e Principles of

the peopleparticularly to those living

in rural areaswas made an important

plank of the Dire ctiv e Principles of

State Policy of the Cons tit uti on. 9 The

other polit ical c ommitme nt, which

tu rn ed out to be even mo re sacred

and of over ridi ng import ance, was to

bring about the desired changes in the

health services system without making

any basic changes in the then existing

machinery of the g overnmen t.

The personnel of the India n Medi cal

Service of the Br it is h days and the

"Brown Englishmen" were called upon

by the Ind ian leadership to provi de

the initiative in shaping the proposednew hea lt h services system for Ind ia.

These pers onne l, li ke those of the

Indian Civil Service, belonged to elite

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ECONOMIC AND POL ITI CAL WEEK LY Special Nu mbe r Aug ust 1974

class of admini stra tors . Th ey were for-

mer officers of the Br itis h I ndi an Ar m-

ed Forces who had opted for civilian

wo rk. They were also tra ine d in the

trad itio ns of the West ern countries.

Poli tica l independence bro ugh t to the

fore two addi tion al issues wh ich pro-

fou nd ly a ffected the cadre of the In-

dian Medica l Service. Fir stly, the wi th -

drawal by the Br iti sh officers after In-

dependence caused a sudden vacuum in

their ranks . This came as a wi nd fa ll to

a numb er of not-s o-comp etent officers

wh o were catapul ted into positions of

key impo rtan ce simply because they

happened to become senior in the cadre

as a res ult of the very large nu mbe r of

vacancies caused by the departure of

the Bri tis h. Secondly, the adheri ng

strictly to the seniority rules, when the

heal th services were expand ed very

rapi dly to meet the requir ements of

the newly form ulate d health pro-

grammes, the admin istr ation drew

more and more fr om the relativ ely

small grou p of people wh o had en tered

the services in , say, 1930-35, 1935-40

or 1940-45 to meet the very rapidly

increasing manp ower needs for key

posts. As a resu lt, a large nu mbe r of

the ke y posts in the health services

got filled by persons, w ho , even from

the col onial standards, were no t consi-

dered to be bright.

Such a massive dom in ati on of the

organisation by men who were trainedin the colon ial tradi tions and whose

clai m to a num be r of vi ta l posts in

developm ent admi nis tra tio n was based

mere ly on the ir being senior in the

cadre, led to a virtual glorification of

mediocrity, with all its consequences.10

Wh at was even worse , such a sett ing

was in imi cal to the g ro wt h and deve-

lopm ent of the younger generat ion of

work ers. Ofte n these youn g men had

to pay heavy penalties if they happe ned

to show enterprise, init iat ive and ima-

ginat ion in their work . Confor mism

oft en earned goo d rewar ds. Thi s en-sured perpetuation of medio crit y wi th -

in the organisation.

Because of the ir being ina dequ ate fo r

the job , these Brow n Englishmen went

out of the way to appeal to for eig n ex-

perts for help and the lat ter have,

generously resp onded to such entrea-

ties. A larg e num ber of fo rei gn ex-

perts were invited to play a dominant

role in almos t every facet of the hea lth

services system of the coun try.11

MED ICA L COLLEGES, TEACHING HOSPI -

TALS AND OTHER MEDICAL CARE FACI-

LITT ES IN URBA N AREAS

Tw o dive rgent forces in the cou ntry

availabili ty of relatively very much

large r amount s of resources fo r the

health sector and perpetuation by the

technocrat s, the bureaucrats and the

polit ical leadership of the old privile g-

ed class and the Western value system

of the colonial daysgave shape to a

heal th service system wh ic h had a

stron g urban and curative bias and

whi ch favour ed the rich and the priv i-

leged.

It is signifi cant that whe n the coun-

try had only abou t 18,000 gradu ate

physicians and about 30,000 licentiate

physicians,7 one of the fir st maj or deci-

sions of the popul ar gover nment of

Indi a in the fie ld of health was to

abolish the three-year post -matr icul a-

tion licenciate course in medicine.12

While recognising "the great lack of

doctors ", the very large majo rit y of

the members of the Health Survey and

Devel opment C ommi ttee (Bhore Com-

mittee), probably "strongly influenced

by the reco mmend atio ns of the Good -

enough Committ ee in the Un ite d King-

dom",1 3

asserted that resources may be

concentrated "on the production of only

one and that the most high ly train ed

doctor.13

The Committee had made

elaborate recom menda tions concern ing

the trai nin g of wha t it term ed as the

"basic doctor" and stressed that such

tr ai ni ng should inc lude "as an insepa-

rable component, educati on in comm u-

nit y and preventive aspects of medi-

cine".13

The Medi cal Cou ncil of Ind ia, a

dir ect descendant of the Med ica l

Council of Great Britain, which is the

statut ory guard ian of standards of

medical education in India, has issued

repeated warnings against reviving the

licenciate course. The Hea lth Survey

and Planning Committee of 1961

(Mudaliar Committee)12 has also em-

phatically rejected the idea of reviving

such a sho rt- ter m course because they

were "con vinced that the proper deve-

lop men t of the country in the fie ldof hea lth mu st be on the lines of what

we consider as the minimum qualifica-

ti on for a basic doct or " (p 349). It

went on to state : "India is no longer

isolated and is par tici pati ng in all pro-

blems of inte rna tion al health. The

WHO has laid down certain minimum

standards of qualifi cations . In vie w of

In dia being an active member , part i-

cipating in all public health measures

on an international basis, we think it

will be unfortunate if at this stage once

more the revi val of a shor t-ter m medi cal

cours e is to be acce pte d" (p 349).

One of the saddest ironies of the

medical education system in India is

that resources of the community are

utilised to train doctors who are not

suitable for providing services in rural

areas whe re th e vast ma jor ity of the

people live and where the need is so

desperate. By ide nti fy ing itself wi th

the hig hly expensive and ur ba n and

curative orien ted system of medi cine of

the West , the Ind ian system activ ely

encourages the doct ors to loo k do wn

on the facilities that are available wi th -

in the coun try , parti cula rly in the rura l

areas, and they lo ok f or job s abroad

and thus cause the so-called br ai n

dra in. As if tha t is no t enough , till

recently these foreign trained doctors

have been pressurising the com mun ity

to spend even much more resources to

att rac t some of these people back to

the coun try by off erin g them h ig h sala-

ried prestigious positions and maki ng

available to them very expensive super-

soph istic ated med ica l gadgets. These

fore ign trai ned Ind ian specialists, in

turn, actively promote the creation of

new doctors who also aspire to "go to

the States" to earn large sums of mone y

and to specialise. Emphasis on speciali -

sation, incidentally, causes considerable

dis tor tion of the country's h ealt h prio-

rities, thus causing further polarisation

between the haves and the havenots.

Those who are unable to go abroad,

they try to settle d ow n in pr iva te prac-

tice in the urba n areas, oft en li nk in g

their practice wi th honorary or fu ll -fledged jobs in urban health inst i tu-

tions run by the gove rnmen t. Only

some gover nment jobs are non-prac-

tis ing . As a res ult of such consi dera-

tions , a desperately poor cou ntry like

In dia finds itsel f in a paradoxical posi-

tion in relation to the distribution of

the doctors in the cou nt ry: the urb an

popu lati on, wh ic h forms 20 per cent

of the total, accounts for 80 per cent

of the doctors.

To be sure, pretending to follow the

recom mendat ions of the Bhore Com-

mit te, soon after Independence up-

graded depar tments of prev enti ve and

social medicine were created in medical

colleges, at the insta nce of the gove rn-

ment and of the Medic al Cou nci l of

In dia , to act as spearheads to br in g

about social orien tat ion of medica l edu-

cati on in Ind ia. Ho wev er, as in the

case of so man y other amb iti ous and

moral ly lof ty government programmes,

concurrently it was also ensured that

the very spirit of this programme was

stifled, if not tota lly destro yed, by

actively discouraging in various ways

its actual imp leme ntat ion . For instance,

instead of mob ili sin g the fittest brains

in the profession to bring about social

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Special Nu mb er Aug us t 1974 , ECONOMIC AND POLITI CAL WEEKLY

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ECONOMIC AND POLI TICA L WEEK LY Special Num ber Aug ust 1974

orientation, most of the positions in

the depart ments of prev entiv e and

social medici ne were filled by the dis-

cards, wh o were often fou nd intellec-

tually inadequate to get into the highly

compet it ive and prestigious c linic al dis-

ciplines, or even the paracli nica l discip-

lines. This gave enoug h opp ortu niti es

to the threatened foreign trained super-

specialists to ridi cul e the en tire discip-

line of pre vent ive and social medic ine

and bring it down almost to the bottom

of the prestige hier arch y of discipline s

in a medical college15

Significantly,

the polit ical leadership the ministers

and legislators, who are beholden to

these super-specialists for their personal

needs of various kinds winked at

this systematic desecration of the

philo sophy of social ori ent ati on of

medical education in the country. 1 6

Alon g wi th the very rapi d prolifera -tio n of very expensive teac hing hospi-

tals for medical colleges, each having

a numb er of specialities and super-

stpecialities, a nu mb er of genera l

hospitals were established in urb an

areas. The numb er of hos pit al beds

shot up from 113,000 in 194612

to the

present figure of 300.000.14

Th ere has

also been a rapid increase in the

numb er of dispensaries for pr ov id in g

curative services to urban populations.

The re wer e over 1,807 ur ban dispensa-

rie s in 1966.17

The devel opmen t of

medi cal colleges, teachin g hos-pitals an d other hospi tals and

medi cal care facilit ies has accounted

for a large chunk of the inves tmen t in

heal th services in the coun try' s Five-

Year Plans.12

The rec urr ing cost for

these ins tit ut ion s accounts for over

thre e-fou rths of the annu al heal th

budget of a State.18

MASS CAMPAIGNS AGAINST SOME MAJOR

HEALTH HAZARDS

The fact that despite their obvious

overr iding impo rtance, preven tive ser-

vices have receiv ed a much lo wer pri o-

rity in the deve lopm ent of the he alth

service system of Ind ia provi des an

ins igh t into th e valu e system of the

colonels of the Ind ia n Med ica l Service,

the Br iti sh trained bureaucrats of the

Indian Civil Service and, above all,

the value system of the poli tic al leader-

ship of free Ind ia. The colonels did

not ap pear to rel is h the prospects of

di r t ying the i r handsget t ing involved

in problems which requir ed mobi l i sa-

tion of vast masses of people living in

rura l areas. Th e rura l pop ulat ionraised in the m ind s of these decis ion-

mak ers the spectre of dif fi cu lt accessi-

bili ty, dust add dirt arid supersti t ious,

ignor ant, i l l-ma nnered and il l i terate

people. Ther efor e, wh en they were

impelled to do some preventive work

in rural areas, characteristically, they

chose to launch military style campaigns

against some specific hea lth prob lems.

Un do ubt edl y, because of the enor-

mous devastation caused by malaria till

the early fifti es, this disease deserve d a

very high pri ori ty. But the programme

became a special f avou rit e of the colo-

nels not o nly because it req ui re d rela-

tively much less communi ty mobili sa-

ti on , but it also pro vid ed them wi th an

oppo rtun ity to build up an adminis tra-

tive fra mew ork to lau nch an all-o ut

assault on the disease in a military

style in develop ing prepa rator y

attack, consoli dation and maintenance

phases, in having "unity of command",

and surprise checks and inspections and

in havin g autho rit y to "hir e and fir e".Some of the foll owe rs of the colonels

in fact went so far as to compare the

malaria campaign wi th a milit ary cam-

paign.19

Ano the r enthusiast for mil ita ry

methods has wr itt en an entire book20

wi th a preface fr om the late P rim e

Minis ter Jawaharlal Neh ru describing

the saga of the gro wt h of the heal th

services in independent India as if he

were describing a mil ita ry campaign.

Experience of impl emen tati on of

India 's Natio nal Tuberc ulosis Pro-

gramme brings sharply into focus the

limi tati ons of this mi lit ar y approach to

develop ing a heal th service system for

the peopl e of this count ry. On the

basis of a series of oper ati ona l resear ch

studies,21

it was demo nstr ated that it

is possible to offer faci liti es fo r diag-

nosis and treatment to over a million

and a ha lf of sput um pos iti ve cases wh o

are known, to be actively seeking help

for their illness from over 12,000 to

15,000 hea lth ins tit uti ons in variou s

parts of the cou ntr y. But because of

failure of the programme administra-

tors to develop a sound health delivery

system on a perm anen t basis for the

rura l popula tions of the count ry, more

tha n a decade after the lau nch ing of

the programme, less than one-fifth of

these sputum positive cases, who have

an active felt need, are being dealt with

by the programme organisation.31

This

provi des an example of ho w the mi li -

taris tic urba n privi leged class value

system has come in the way of building

a he al th service system to meet even

some of the very urgently felt needs

of the people of the co unt ry.

After some pilot projects, a National

Mala ria Con tro l Program me was laun-

ched wi th the help of the Un it ed States

Technical Co-operation Mission, the

Wo rl d Health Organis ation and the

Uni ted Nat ions Internat ional Chi ldren 's

Emergency Fund (UNICEF) in 1953 to

cover all the malarious areas of the

countr y, then involv ing a popu latio n of

165 million.2 0

It achie ved a pheno-

men al success; for insta nce, th e num-

ber of mal ar ia cases for ever y 100 per-

sons visiting hospitals or dispensaries

dec lin ed fr om 10.2 per cent in 1953-54

to 4.0 per cen t in 1958-69.20

This

success emboldened the administrators

to thi nk in terms of tota lly eradica ting

the disease from the country, once and

for all. The danger of the mosq uito s

develop ing resistance to the main

weapon for malaria control, DD T, was

giv en as an addit ion al reason for em-

barking on the eradication programme.

Besides, pressure was also put on India

by for eign consultants fro m W H O and

elsewhere to embark on the eradication

programme as it was to become a part

of the global strategy pro po und ed by

the WHO.20

It was also stated, to give eco nom ic

grounds for the decision, that while

the con tro l prog ramm e was estimate d

to cost about Rs 270 mn in the Second

Five-Year Plan (1956-1957 to 1960-1961)

and Rs 350 mn during the T h i r d Plan

(1961-1962 to 1966-1967) and thereafter

wo ul d con tinu e to rema in a heavy item

of expendit ure, "the cost for the eradi-

cation programme was estimated to be

Rs 430 mn in the last th ree years of

the Second Plan and Rs 580 mn for

the entire Third Plan with the annual

expenditure becomin g negligib le there-

after".20

The imm edi ate successes of

the Nat ion al Mal aria Er adicatio n pro-

gra mme were even mor e spectacular,

but a disastrous snag developed in im-

ple ment ing the mai nten ance phase of

programme , 22 It tur ned out that,

amo ng other fac tor s, because of the

preoccu pation of the administ rators

with specialised mass campaigns against

malaria and other communicable

diseases, they had not paid adequate

attenti on to bu ild ing a permanent health

service systemthe so-called health in-

frastructurestrong enough to carry on

the malaria surveillance work effectively

at the villag e lev el. Thi s has been res-

ponsible for a series of setbacks to the

Nati ona l Mal aria Eradicati on Pro-

gramme, resulting in the reversion, at

a ver y cons ider able cost, of large seg-

ments of the mainte nance phase popu la-

ti on on to cons olid atio n or attack

phases. Instead of gett ing rid of malaria

onc e and fo r all by 1966, as it was en-visa ged in the late fi ft ie s, 40 per cent

of the population is still to reach the

maintenance phase.22

The National

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Special Numb er Aug ust 1974 , ECONOMIC AND POLITICAL WEEKLY

Mala ria Era dica tion Progr amme thus

continues to drain huge quantities of

scarce resour ces even tod ay, thu s

maki ng it even more dif ficu lt to find

resources to develop the health services

infras t ruc ture .

Dur ing the last four years, for ins-

tance , less than 3 per cent of the add i-

tion al pop ula tio n (9.4 unit s) has entered

the maintenance phase.23 Meanwhile ,

the co un tr y is fo rce d to set aside huge

chu nks of its very scarce resources to

prevent the program me from slidi ng

stil l furthe r. As against the envisaged

exp end itu re of Rs 1,015 mn , the

Nat ional Malar ia Eradica t ion Pro-

gr am me has thus far suck ed in over

Rs 2,500 mn. 2 3 In addition, Rs 967 mn

have been set aside for it for the next

five years22 and even this allo cati on

might have to be raised still further.

In spite of this , the chances of era di-cating malaria in the foreseeable future

does not appear to be ver y br ig ht . So

the country will be compelled to keep

on pou ri ng resources in to th is pro-

gr am me to see th at the disease does

not com e bac k in an epi dem ic fo rm as

it has happened in some' other coun-

tries.

Als o, foll owi ng the mode l of the

NM E P, a specialised mil it ar y style cam-

paig n was lau nch ed in 1963 to

eradicate small-pox wit hi n three years.20

Once again the camp aign conspic uously

fail ed to achieve the obje ctive of eradi-catio n. Only recentl y (1973-74) yet

another campaign has been launched to

eradicate small-pox "once and for a ll ". 2 2

A mass campai gn to pr ov id e BCG

vaccin ation to cover the entire popul a-

ti on of the cou ntr y, and to con tin ue to

do so periodically, was the first effort

to deal wi t h the pro blem of tuber culos is

in India as a publ ic heal th pr oblem .22

This programme has also failed to yield

the desired results.21

Special campa igns have also been

launched against leprosy, filariasis ,

trach oma and cholera wi th even mor ediscouraging results.22

The he al th service system of the

country had hardly recovered from the

consequences of the very cos tly f ailu res

of the mass campaigns a gainst mala ri a,

small-pox, leprosy, filaria and trachoma,

when a large bul k of in ves tme nt in

heal th was corner ed by another specia-

lised campaig nth is tim e it was against

the rapidly ris i ng popu lat ion of the

count ry. The Fou rth Plan investm ent

in fam ily pla nni ng was Rs 3,150 mn as

against Rs 4,500 mn for the rest of the

heal th sector of the count ry. 20 This

inv olv ed dep loy ment of an army of

125,000 persons.10

All of them were

1338.

specially earm arke d for doi ng fam il y

plann ing wo rk only. Signifi cantly, once

again, this pro gra mme was also deve-

lope d by officers bel ong ing to the I nd ia n

Medi cal Servicethe colonels , wi th

strong backi ng from fore ign consultants

fr om various agencies. Predict ably,

once again, this cam paign also fail ed to

attain the demographic objectives, w it h

disastrous consequences, bo th to the

prog ramme s for socio-ec onomic deve-

lo pm ent as well as to the d evel opme nt

of a sound infr astr uctur e of healt h

services for the count ry. 1 0

Recogn ising , at long last, th e wea k-

nesses of th e cam pai gn app roa ch, re-

cently the Gove rnme nt of Ind ia has

veered round to the idea of providing an

integr ated package of healt h, fami ly

planning and nu tr it io n services wi th

par tic ula r emphasis on the weaker sec-

tions of the community, 2 . This package,

in tu rn , is a par t of a bigge r package

of the Mi ni mu m Needs Programmes of

the Fi ft h Five-Ye ar P lan (1974-1979)

which is meant to deal with some of

the very urgent social and economic

needs of the rur al pop ulat ion s of the

country .2 6

D E V E L O P M E N T O F A P E R M A N E N T I N T E -

GRATED HE AL TH SERVICE SYST EM FOR

RURAL AREAS

The Health Survey and Development

Commit tee , 1 3 w hi ch was set up by the

Bri tis h In dia n Gove rnme nt in 1943 to

dr aw a bl uep ri nt of hea lth services forthe post-War British India, had shown

exceptional vision and courage to make

some very bol d recommendat ions. These

incl uded develo pment of an elaborate

heal th service system fo r the cou ntr y,

givi ng key impo rtan ce to preven tive

aspects wi t h the "co unt rys ide as the fo-

cal point".1 3

To forestall any cri tici sm of

prac tica bili ty, poi nti ng out the achieve-

ments in heal th in the Soviet Uni on

within a span of 28 years (1913-1941),

it asserted that its rec omme nda tio ns

are quite practi cal, in fact relat ively

very modest , pr ovi ded there was thewill to develop the health services of

the country.13

Unfortunate ly , however ,

the leaders wh o too k over fr om the

Bri tis h did not show this wi ll . They

had quoted, often out of context, the

recomme ndatio ns of the Bhore Com mit -

tee to jus ti fy abo liti on of the licenciat e

course and to esta blis h a ver y lar ge

numb er of medical colleges w it h

sophisticated teaching hospitals in urban

areas. They also in vo ke d the Bhor e

Comm itt ee to jus tif y setting up an even

more sophis t ica ted Al l - In di a Ins t i tu te

of Medical Sciences in New Delhi onthe model of the Johns Hopkins Medi-

cal Cent re of the US A. 1 2 A number of

other postg radu ate centres for medi cal

education were also set up in due course.

It, however, took them over seven years

even to start open ing pr im ar y he alth

centres to prov ide inte grate d curativ e

and prev enti ve services to rur al pop ula -

tions of the country. 28 These prim ary

health centres were a very far cry from

wh at was suggested by the Bho re

Co mm it te e: the y di d not have even a

fou rth of " the i r reducible mini mum

requ irem ents" of s taff reco mmen ded by

the Bhore Co mmit tee for a given popu-

lat ion (and tha t to o only as a sho rt- ter m

measure).13 Fur the rmor e, it took more

tha n 10 years to cover the ru ral popu la-

tion s in the cou ntr y even w i t h this

manifestly rudimentary and grossly

inadequate type of pri mar y health

centres.

The entry of the Nat ion al Mal ari a

Erad icati on Prog ramme into the main-tenance phase and c onc urr ent develop-

men t of an exten sion approa ch to

fam ily planni ng pro vid ed a transient

impetus to pro vid ing integrated health

and fami ly plan ning services thr oug h

mult ipur pose male and female workers. 2 3

But the clash of interest s of the m alar ia

and the fam ily plann ing program mes

again led to the formation of unipur-

pose worke rs for malar ia and famil y

p la nn ing .3 0 Wh at was even worse,

appli catio n of very intensive pressure

on various workers of prim ary health

centres to attain certain f amil y plann-in g targets led to the negl ect of wh at -

ever health services which were earlier

bein g pr ov id ed by the PHCs, thus

causi ng a series of fu rt he r setbacks to

different health programmes.10 Materna l

and child health services, malaria and

small-pox eradica tion, envir onmen tal

sani tat ion and con tro l of other com-

mu ni cab le diseases, such as tuber -

culosis, leprosy and trachoma, arc

examples of the services which suffered

as a resu lt of pre occ upa tio n of health

workers with achieving the prescribed

family planning targets .

Very recently, following the recogni

tio n of the fact tha t a unipur pose, hig h

pressure mi li ta ry type campai gn ap

proach which does not ensure a con

current gro wth and developmen t of

other segments of hea lth and n ut ri ti or

services (and growth and development

in other socio-economic fields) wil l not

be able to yield the desired results, as

poi nte d out above, decisions have

already been taken to Int egr ate malar ia

fam ily plann ing, mater nal and child

health, small-pox and some other pro

gramm es and thus pro vid e an ent ir

package of healt h, fami ly planni ng an

nu tr it io n services to the com mun it

1338


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ECONOMIC AND POLITICAL WEEKLY Special Num ber Aug ust 1974

through male and female multipurpose

health workers ,25

,26

INDIAN SYSTEMS OF MED ICA L SERVICES

There are three majo r indige nous

systems of medi cine in Ind ia: Ay urv eda

the Hindu medical system; Unani

the Greek system of medic ine wh ic h

was brought to India from West Asia

by the Muslim rulers of India; and the

Siddha system, which can be considered

to be a specialised branch of Ayurveda.

After Independence, these systems

were subjected to tw o contr adicto ry

pulls: their being firm ly rooted in the

cultu re of the people of the countr y

for centuries and thei r ric h heritage

invo ked considerable admirat ion and

even a certain degree of emot ion al

attachmen t f rom a large section of the

population of the country. At the same

tim e, lon g neglect of these systems of

medic ine led to a very sharp deter iora-

tio n in the body of know led ge, in the ir

institu tions for tra inin g and research in

their pharm acopia and drug ind ust ry

and in their corps of prac titi oner s.

Ther efore , whi le the leaders of inde-

pendent Ind ia bu il t almost the entire

hea lth services on the lines of the

Wes ter n system, they have, fr om the

very beginnin g, shown sympathy for

the In dia n systems of medic ine and

have made available some grants for

con duc tin g research in these system,

for supporting educational institutions

and for providing some services to the

community.31

IV

Present State of the Hea lth Services

Cons ider ing th e size of the popul a-

tio n and the s taggering natu re of its

health problems, the existing health

services are grossly inadequ ate. Fur ther -

more, the bul k of the expen ditur e is

earmar ked for cura tive services and

these services are predominantly

situated in urban areas and they are

more accessible to the more privileged

sections of the society. The priv ileged

popu latio n has the additi onal advantage

of being able to pay to avail of private

nur sin g hom e services and services of

private practitione rs who are located

almost entirely in urba n areas. Of the

total number of doctors in India 53 per

cent are in priva te practic e; another

7 per cent are employed in the private

sector;32 the community spends about

Rs 100,000 f or the tra in ing of one

doctor.

In di a has barel y half a bed per

thousand popul ation , whi le the corres-

pond ing figu re is over 10 for the indus-

trialised countries14

Of these beds,

90 per cent are located in cities and

towns wher e only o ne-f ift h of the po-

pul ati on lives. Even the 10 per cent of

the beds which are primarily meant for

rura l populations are ill-st affed , i l l -

equipped and ill-financed. 17 Th e ex-

penditure for curative services is about

three times as much as for preventive

services.18 Ag ain , in terms of the pre-

ventive services, while over 90 per cent

of the urban population is provi ded

with some degree of protected water,

onl y 4 per cent of vil lag es get pip ed

water supply; wh ile about 40 per cent

of the urban population has a sewerage

system, it is almost non-existent for

the rural population. 33

Pri mary heal th centres and thei r sub-

centres form the sheet anchor of rural

healt h services of India . There are

over 5,195 PHCs in the country; thereare 32,218 sub-centres attached to these

PHCs.14

Each PHC and its sub-centres

are expected to prov ide inte grat ed

health, family planning and nut ri ti on

services to a popu lati on of about

100,000. Pro vis ion of medi cal care,

environmental sanitation, maternal and

chi ld health services, fami ly plan ning

services, eradication or control of

some of the communicable diseases and

collection of vital statistics are some

of the functions of a PHC. 28 However,

both quanti tativel y as well as qualita-

tively the resources made available ata PH C are grossly in adeq uate fo r serv-

in g the pop ula tio n assigned to

The re are now 103 med ica l colleges

wh ic h have an annual admiss ion capa-

cit y of over 13,000.14

The numb er of

doctors available in India has now in-

creased to 137,930.14 The re are 88,000

tra ine d nurses, 32,000 sanitary inspec-

tors and 54,000 auxi liar y nurse mi d-

14

wives.

The gover nment is at present financ-

ing about 9,000 dispensaries and 195

hospitals w hi ch offer the services ac-

cor din g to the Indi an systems of medi -

cine. There are 44,460 institutionally

qualified and 111,371 no n-ins titu tiona lly

qualified Ayur vedic registered practi-

tioners in the coun try; the correspond-

ing figur es for the Un an i and the Si ddha

systems are 6,013 and 18,507 and 625

and 14,785, respectively.31 The govern-

ment runs two postgraduate colleges in

Ayurveda and one in Unani; there are

also 91 Ayur ved ic , 10 Un an i and one

Siddha undergraduate colleges.31

Tha t the present hea lth services

system of India needs considerable im-

provement is dramatically brought home

by the fact that in the year 1974 India

happens to be one of the few countries

in the wor ld w hi ch has not yet suc-

ceeded in eradic ating small-pox. Mu ch

remains to be done before it will be

possible to cont rol such apparently

easily con tro lla ble diseases as tub er-

culosis, lepros y, tr acho ma and filaria-

sis.23

The f act that the Nationa l

Malaria Eradication Programme conti-

nues to be a very heavy drain on the

very limited resources even today, in-

stead of bein g eradi cated by 1966, also

provides an in di ca tio n of the serious

weaknesses in the system.

V

Commu nity and Hea lth Services

Systems

Health administrators sought to

secure some degree of socia l legi tim acy

for their actions by getting some not

very wel l define d or even relev antsocial, cul tur al and psych ologic al con-

siderations raised by social scientists

and health educators. Their appeal was

particularly directed towards the then

dom ina nt grou p of social scientists

which was engaged in generating social

science know ledg e to legi timi se the

existin g social st ructu re and social rela-

tions.37

,38

The response was generous.

Eminent social scientists from the West,

such as McKim Marriot,3 9

Morris

Carstairs,40 Morris Opler,41 H A Go uld 4 3

and E Wood4 3

came out to dra w atten -

tion to certain basic cultural and socialfactors wh ich mi tiga te against accept-

ance of modern medical practices in

the mostly tradition-bound, caste-

ridden, rigidly hierarchical, illiterate

and superstitious rural communities of

India. Thei r Indi an disciples du tif ull y

carried on the ref rai n by dra win g

similar conclusions on the basis of their

own "studies". Studies of Hasan,44

Dhi l lon ,4 5

Khare,46

Kakar" and Prasad48

offer examples of such Indian workers.

The repor t on the Conferenc e on

Social and Cultur al Factors in Env iro n-

mental Sanitation49 represents an ins t-

ance of the collectiv e wisd om on this

subject of a group of eminent Indian

social scientists wh ic h was broug ht to-

gether by the Ford F ound atio n. Ignor-

ing the vital necessity of "distinguishing

between the true clinical core ofscienti-

fic medicine and the sur roundin g folk-

lore, magic, custom, and faddism that

are included in our institution ofmedi-

cine",50

they we nt on to find ways of

overcoming the cultural resistance of

villagers to instal latio n of sanitary latr i-

nes. They overlooked some basic

epidemiological, clinic al, social, eco-

nomic and even cultural issues which

ought to have called into question the

1339.


8/14

Special Num ber Aug ust 1974 , ECONOMIC AND POLITICAL WEEKLY

very rationale of selling such latrines

to rural populations.6,

50 The ir deep-

seated bias, wh ic h perhaps con tri bu ted

to their in ab ili ty to take a hol ist ic vie w

of the social, cul tur al and techno logi cal

interaction in the sanitation programme,

made them behave more like salesmen

th an lik e scientis ts wh o possess the

competence to use the conceptual and

methodolo gical rig our of their discipline

to make an objective analysis of the

situation. '51

The profession of health educatio n

also came in very handy to health ad-

ministrators in giving a facade ofleg i t i -

macy to the health service system built

by them. As pra ctit ion ers of social

science kno wle dge wh ic h was generated

by scholars like Ma rr io t, Carstairs,

Hasan and Khare, the administrators

found it convenient to assign to them

the task of "educ ating " the com mu-nity to pave the way for acceptance of

the Western system of medici ne. Wh en

the administrators in India, with strong

backing from consultants from abroad,

launched a country-w ide f amily plan-

ning programm e w hic h requir ed accep-

tance of family planning practices in a

poverty-stricken population, with very

poor heal th services, extensi ve un-

employment and social injustice,10

they

once again found it convenient to call

upon the health educators to sell this

brand of family planning to the masses.

It is significant that the leaders of thehealt h educat ion profess ion, bo th in

India as well as from other countries,

wi ll in gl y allowe d themselves to be

iden tifie d wit h a progr amme whic h in-

volved motivating individuals to accept

fam ily p lan ning practices by using per-

suasion, administrative coercion and

monetary enticements.24

A carefully conducted sociological

study of tuberculosis patients in a rural

district in South India51

,21

revealed

that more than half of the these cases

visited a government ins ti t uti on ofmod ern medi cine , whe re they were

almost invariably dismissed with a

bottle of cough mixt ure. These find -

ings were diametrically opposed to what

was forecas t by social scientis ts lik e

Mar rio t and Carstairs. Aga in, a num-

ber of studies of treatm ent defau lt

among tuberculosis patients getting

domiciliary treatment revealed that by

far the most important causes of default

were attributable to l imitations at the

tech nica l level and in the fi eld of ad-

min is tra tio n of the services, rather

than to the patients ' own behav i-our.

53,

54,

55 Yet, despite these very

clear-cut findings, health educators and

community health workers have kept

harp ing on the need f or "ed ucat ing"

the public about tuberculosis.56 ,57 They

coul d not think of "educa ting" th e pro-

gra mme admin istr ators to take int o ac-

count the community health behaviour

and accordi ngly formula te suitable ser-

vices. They have wr it te n numer ous

account s as to ho w the vil lage rs in

Indi a refused small-pox vacc ina tion be-

cause of their superst itious fait h in the

goddess "Sitala", but they could not

take note of the very glaring fact that

a much larger number of persons re-

main unva ccina ted because nobo dy

has cared to offer facilit ies of vacci na-

tion to them.35

VI

A Recen t Study of Hea lth Behavi-

our of Rural Populations in India

Tak ing note of the l imi tati ons in

social science studies in health fields inIn di a, an att empt was mad e by the

author to narrow this gap by consider-

ing the activities of the primary health

centre as a purpo sive inte rv en ti on to

change for the better some aspects of

the pre-ex istin g health cul ture of the

co mm un it y served by it. A research

stu dy was design ed to exam ine the

current status and the nature of this

interaction between the health services

that are introduced through the PHCs

and the pre-existing culture of rural

popu latio ns in Indi a. A repor t on this

study has already been published in

this journal.3 6

Only the bro ad outl ine

of the study design and the pri ncip al

findin gs are being sum maris ed here to

draw attention to some aspects of the

health behavio ur of rural pop ulations

wh ic h appear to be of signi ficanc e in

shaping the future pattern of the health

services system of the cou ntr y.

In ord er to get data on he al th be-

haviour of rural populations under

relatively more favourable conditions, a

deliberate effort was made to select, in

the first instance, P HCs and villageswh ic h are muc h above the average.

The stu dy has been com plet ed in

16 villa ges, 10 of wh ic h also serve as

the headquarter village of a PHC.

These PHC are from seven states of

the country, belonging to seven regions.

Consider able atte nti on was paid to

developing a metho dolo gical approach

that is specially tailored for studying

the health behaviour of villagers (in-

cludin g their behaviour in relat ion to

the P HC se rvices) again st the back -

gro und of the tota l village culture. Re-

search investigators lived in thesevillages for three to five mon ths . Ap ar t

fro m ma ki ng special efforts to get them-

selves accepted by all the segments of

the village community and collector

data thr oug h village informa nts, the

investigators identified informants and

some "o rd ina ry " members fro m each

segment of the villa ge co mm un it y and

made observations and conducted depth

interviews to unders tand the health

cul tur e of each segment of the vil lage

against the bac kg rou nd of its tot al cul-ture. They also prepared case reports

to pr ovid e a deeper insight into the res-

ponse of the dif fer ent segments to

health problems in the fields of medical

care, family planning, maternal and child

healt h, com muni cable diseases, env iro n-

men tal sanit ation , etc. Docum ents have

been prepar ed to enable all t he inves ti-

gators to cover uniformly all the major

areas in re lat io n to these pro ble ms.

Th ei r stay in the vil lag e also enabled

them to make direct observations

fol low ed by depth interv iews, of th

actual behavi our of the villagers whe n

they encounte red certa in specific heal th

problems. They could also study the

interaction between the PHC personnel

and the villagers, both when the former

visite d the village and when the villa -

ge rs /b oth when the forme r visi ted the

villa ge and whe n the villag ers vi site d

the PHC. Ap ar t fro m these efforts to

ensure that in-depth qualitative data

were obtained fr om all the segments

of the entire village community accord-

ing to we ll defined wo rk procedures and

check lists, a qua ntit ativ e dime nsio n

was given to the main qu alit ativ e data

by framing an unstructured interview

schedule on the basis of these data and

admi nist erin g it to a 20 per cent strati -

fied rand om sample of the villa ge

households.

As an add itio nal safeguard, after com-

plet ion of the field wo rk in the villages

of a PHC , some of the data c onc ern ing

the health behavio ur of the comm unit y

were cross-checked with personnel at

the level of the corr espo ndin g seven

State Directorates of Health Services.An additional three states were added

to the original seven to examine how

far the findi ngs f rom these seven wer

app lica ble to the othe rs. These te

states cover ed 77.8 per cent of tl

popu latio n of the country. Recognising

that the complex natu re of the subject

of this study called for a new and

rather exacting met hod olo gic al ap-

proa ch, special safeguards wer e adop ted

to ensure that the data collected by a

the investigators were of a minimum

acceptable quality.

Taking into account the social and

eco nom ic status of the people , the epi-

demio logy of heal th pro blems and the

nature of the Health services available,

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ECONOMIC AND POLITICAL WEEKLY Special Num ber Augus t 1974

it is not surpris ing tha t problems of

medical care should be by for the most

urge nt concern among the heal th pro-

blems in rur al population s. But the sur-

prising finding is that the response to

the ma jor me dical care problems is

very much in favour of the Western

(allopat hic) system of medi cine, irres-

pecti ve of social, econo mic and occupa -

tional considerations. Avai lab ili t y of

such services and capacity of1 patients

to meet the expenses are the two major

const rainin g factors. On the who le, the

dispensar y o f the PH C proj ects a very

unf lat ter ing image. Because of this and

because of its limited capacity it is

unabl e to satisfy a very s ubs tant ial pro-

po rt io n of the demand of the villagers

for medi cal care services. This enor-

mous unm et felt need for medical care

services is the main motive force in the

crea tion of a very large numb er of theso-called Registered Med ica l Practi -

tioners (RMP s) or "quacks" . The

RM Ps are thus in effect created as a

resu lt of the inabi lit y of the PHC dis-

pensary or other qualified practitioners

of Wester n medici ne to meet the

demands for med ica l care services in

the villages. It is wo rt h not ing that

all these RM Ps use allop ath ic medic ines

rather than ayu rvedic or unani medi-

:ines. Wh en these RMP s prove ineffec-

tive, depending on the economic status

of the individual and the gravity of his

illness, villagers actively seek help fromgovern ment and privat e medica l agen-

cies in the adjoining (or distant) town

and cities.

Ther e are, however, numerous instan -

ces of ad opt ion of h eal ing practices

from qualified or non-qualified practi-

tioners of the di fferen t Ind ian systems

of medici ne and home opathy and fro m

other non-professional healers. But

among those who suffer from majo r ill-

nesses, only a very t iny fra ctio n pre-

ferentially adopted these practices, by

positively rejecting the facilities of the

Weste rn system of medicin e whi ch aremore efficacious and which are easily

available and accessible to them.

Us ual ly these practices an d hom e re-

medies are adopted (i) side by side with

Western medicine; (ii) after Western

medicine fails to give benefit; (iii) when

Wes ter n me dica l services are not avail-

able or accessibl e to the m due to

vario us reasons; and, (iv) mos t "fre -

quently, when the illness is of a minor

nature.

Ano the r very significant findin g of

this study is that the family planning

programme has anded up in projecting

an image which is just the opposite of

what was actually intended. The image

of the family plannin g worke rs in rur al

areas is that of persons w ho use co-

erci on and other ki nds of pressure

tactics and who offer bribe s to entice

people int o accepting vasectomy or

tub ect omy . Because of the fai lur e of

family planning workers to develop a

rapport with the villagers, sometimes

the villagers are unable to meet their

needs for fami ly pl ann ing services.

Ther e are several instances of mot hers

who, fail ing to get suitable family plan-

ni ng services fr om the PHC , too k re-

course to induced abortions to get rid

of unw ante d pregnancies. This not only

points to the failure of the programme

to meet their needs for the services but

it also draws attention to the failure of

the programme to offer suitable abor-

tion services to mothers with unwanted

pregnancies, despite the passage of the

abortion bill.

An oth er significan t find ing of this

study is that ther e is cons ider able

unmet felt need for the services of the

Auxiliary Nurse Mid-wife (ANM) at the

time of chi ld bir th . Villagers are keen

to have the ANM's services because

they consider her to be more skilled

than the traditional dai. Where ver the

ANMs have provided the services, the

dia's role has become less sign ific ant.

The overall image of the A N M in

villages, particularly in North India, is

tha t of a perso n who is distant f ro m

themmeant only for special people orfor those ,wh o can pay f or her services.

She is no t for the po or. She can be

called only when there are compl ica-

tio ns and th en also she has to be p aid .

Because of the inacces sibi lity of the

AN Ms , the majo rit y of the deli veries

even in the villages where the PHC is

located are conducted by dais and rela-

tives and neighbours. In villages wi th

no PHC, their sway is almost complete.

As in th e case of the R egiste red Me di -

cal Practi tione rs, confinem ent by rela-

tives and friends and by indigenous

dais is popular among the village rs notbecause of their intrinsic superiority but

becaus e in the absence of suit abl e ser-

vices from the A N M / L ad y Doctor, they

are compelled to settle for something

which they consider to be inferior but

wh ic h is all th at is available and ac-

cessible to the m. They actively seek

more specialised services either from

the PHC or from the towns and cities

when the dais are unable to tackle com-

plicated cases.

The only two programmes which can

be st ated to have r each ed the grass-

roots l evel in the villag es are those

concer ning mal aria and small-pox. Des-

pite several complai nts regardin g the

sinc erity of these wor ker s, ther e is

almost a universal agreement among

the villagers that these workers do visit

the commu nit y. A significant finding

is that these workers do not encounter

any major obstacle in gettin g part icip a-

ti on of the comm uni ty in these pro-

grammes. Except whe n the re are

understandable compulsions , such as

the prospect of a pov erty -st rick en

mother losing wages for 4-5 days in the

peak agr icu ltu ral season due to the

child's vaccination reactions and some

cases of orthodoxy, there is general ac-

ceptance of small- pox vac cin ati on in

village commu niti es. The numbe r of

child ren wh o are left unvacc inated due

to lapses of the par ents ap pear to be

a very small fraction of those who re-

main unvaccinated due to lapses of the

vaccinators and their supervisors.

Patients suffering from tuberculosis,leprosy and trac homa get very l it tl e

service from the corresponding national

programmes. It is remar kable t hat des-

pite this, they actively seek help from

elsewhere from nearby towns or even

bi g cities. Such hel p is not only m uc h

more expensive and bothersome but it

is also mu ch less efficaci ous, bo th

clin icall y as well as epidemi ologica lly.

Other preventive measures, of course,

are almost non- exist ent.

Exten sive preval ence of abjec t

pover ty, as a result of wh ic h mor e t han

half of the po pula tion is unable tomeet even the mi ni mu m dietic calorie

needs and appalling condi tions of sani-

tati on, water supply, housing and edu-

catio n present an ecolo gical sett ing

wh ich is conducive to widespread pre-

valence o f vari ous types of he alt h pro-

blems in the comm unit y. These heal th

problems for m only a small compo nent

of the ov erall glo omy p ict ure of the

way of life in Indian villages. Ignor-

ance, superstition, suspicion, apathy and

fatalism should thrive in such a milieu.

It is, therefore, a tribute to the strength

of the culture of the rur al popul ations

that, despite these overwhelming odds,

their health behaviour has retained so

much of rationality.

Because of thei r urban ori enta tion ,

wor kers of rural heal th and other deve-

lop men tal agencies gener ally have a

strong distaste for r ural lif e. This

distaste is for the entire way of life

and no t si mply fo r the very poor faci -

lities available there. Health workers

ten d to keep a distan ce fro m the ru ra l

pop ula tion as a who le. How eve r, as

they are requ ire d to wo rk f or rur al

populations, they take advantage of the

village power struct ure and confine

themselves, as far as possible, to satis-

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ECONOMIC AND POLITICAL WEEKLY Special Number August 1974

fying the privileged gentry of the village.

In doing so they (a) win approbation

and rewards f rom the so-called com mu-

nity leaders who have the ear of their

superior officers and of the pol iti cal

leaders at the higher levels; (b) deal

with the least disagreeable segment of

the village community; and (c) get a

fr ee ha nd to " tac kle " t he rest of the

communi ty.

The findings of this study br in g

out some of the key issues which are

of far-reac hing significance for the

future development of the health

services system of the c ou nt ry :

(1) It brin gs out clearly that there

is no significant cultural

resi stan ce to acceptanc e of

modern medicine as long as

the y are effica cious and are

available and accessible to thepeople. This finding, therefore,

seriously calls in to ques tion

the belief of a very sig nifi cant

section of health administra-

tors , social scientists and

health educators that there is

considerable cultural resistance

to the acceptance of mo de rn

medical practices in ru ral

populations in India.

(2) The exis ting heal th services

are working at a grossly low

level of efficiency, which has

led to considerable under-util isation. Priority should,

therefore, be given to ensuring

that this pro ble m is over

come.59

(3) The re is also consid erable

scope for bring ing about quali-

tative improvements in the

existing health services system

in rural areas by bringing it

more in tune with the social

and cul tur al setti ng of the

village communities.

(4) Fin ally , after ensuring areasonable level of utilisation

of the existing capacities

quan tita tive ly and after brin g-

ing abou t qua lit ati ve changes,

there is a str ong case for mak -

ing quan titat ive expansion of

the hea lth services to meet

the requirements of rural

populations. This wi ll imply

rect ific ation of the existing

imbalance in allocation of

resources, re qui rin g a sh ift in

investment from urban to rural

areas, fr om cura tiv e to pre-ventive and from the privile g-

ed to the underprivileged.

VII

Summary

Ther e has been a cum ula tiv e in-

crease in the knowl edg e of the medi cal

sciences which has at times grown al-

most at an exponential rate. How eve r,

the actual application of this knowledge

to societies is determined by a number

of pol itic al, social, cultu ral , economic

and technolo gical factors. In ancient

Indi a, wh en these factors were favour-

able, despite the very rud imen tar y

nature of the available kno wled ge, the

people enjoyed a much higher level of

healt h services than wh at is availabl e

at pre sen t In fact these favo urab le

cond itio ns created a setting wh ich

enabled the society to make significant

contributions to the body of medical

know ledge thr oug h Chara ka and

Susru ta, for insta nce. The decline of

the society in the subsequent centuries

saw a decli ne in the hea lth service

system. Colonisation of the country by

the Br it is h, whe n every facet of its

activities was subor dinat ed to the inter-

est of the Impe ria l Gover nment in

Lond on, dealt almost a fatal blo w to

the sti ll active Ind ian systems of med i-

cine. The entire health service system

of the count ry was purposiv ely develop-

ed to provide the Western system of

medical services to a small privileged

group the armed forces, the British

civilians and the In di an gentry. Med i-

cal colleges were opened to prepare

Brown Englishmen, medical insti tution s

were establis hed to serve the gentr y

living in urban areas and officers of the

armed forces med ical services were

bro ugh t in to adminis ter the healt h

services.

Wi th the advent of Independence ,

the new leadership readily c omm itt ed

itself to pro vid ing good health ser-

vices to the vast masses of people of

the country, but for this it did not

consi der it necessary to br in g about

basic changes in the syste m. Thecolonels of the Ind ian Med ical Service,

by then greatly depleted by the wi th -

draw al of the Briti sh, and the Br ow n

Engl ish men were assigned the very

much more challenging task of building

the new hea lth services system fo r

Indi a. Medi cal colleges grew very

rapidly and these colleges poured in a

large nu mber of physicians who were

mostly alienated from the masses of

the people. A nu mbe r of hospi tals w ere

opened in urb an areas. Out of the

li mit ed resources that were made avail-

able for pr ovi din g preven tive servicesfor rural areas, the colonels, with strong

"persuasion" from foreign consultants,

set aside big chunks for running mass

campai gns agai nst spec ific diseases

malaria, popula tion growth, small-pox,

leprosy, trac homa and filar iasis . N ot

only have these campaigns hi nd ere d

the development of a permanent health

services system in the rural areas but

almost invariably they have also failed

to achieve the set goals. The country

was persua ded i n the late fif tie s to in-

vest abo ut Rs 1,010 mn to erad icate

mal ari a by 1966, bu t, even aft er an in-

ves tme nt of over Rs 3,500 mn, the

prospect of doing so even by 1979 do

not appear to be part icul arly bri ght .

The campaign against po pul ati on

gro wth has tur ned to be a simil ar

costly blunder.

Social scientists and heal th educato rs

fro m abroa d helpe d the colonels to

divert attention from the basic malady

of the system by raising the bogey of

resistance of the villagers to acceptance

of the Western system of medicine.

Following that reference model,58

their

counterparts in India dutifully echoed

their fi ndin gs and a large num ber of

positions were created to accommodate

such professional health educators and

social scientists wi th in the system.

Findings of a carefully conducted

empir ical study of health behaviou r of

rural populations of Ind ia have been

presented to underscore the fact that

already ther e is cons idera ble active

interest among villagers in acqu irin g

both curative and preventive services.

Mostly it is the services which have let

the people down , rather than the

reverse. Not only are the rural health

services very mu ch bel ow wh at the

Bhore Committee's shor t-ter m pro-

gram me had called in 1946 the "i rr ed u-

cible min imu m re quire ments" and much

belo w the act ual demands of the peo-

ple, but even these very l im it ed ser-

vices are working at an alarmingly low

level of efficien cy one of the mai n

causes for this being the alienation of

the health worker s and of the in st it u-tions for education and tra ini ng of

such workers from the masses of the

people of the cou ntr y.

Note s

1 Galdston, Iago (196 1): "Do ctorand Patient m Medi cal Hi st or y:The Seventh An nua l Max DanzisLecture", Newark NJ ; TheNew ark Beth Israel Hos pita l.

2 Mart i-I bane z, F (1960): "H enr ySeigerist on History of Medicine",New Yo rk : MD Publications.

3 Mar shall , J H (1931): "M oh en joDaro and the Indus Valle y Ci vi li-

sation" London: A Probsthein.4 Zimm er, H R (1948): "H in du

Medici ne", Ba ltimor e: Johns Hop-kins Press.

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Special Nu mb er Aug ust 1974 , ECONOMIC AND POLITICAL WEEKLY

1344.


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ECONOMIC AND POLITICAL WEEKLY Special Nu mb er Au gu st 1974

5 Basham, A L (1954 ): "The Wa nde rThat Was Ind ia" , Lon don : Sidg-wick and Jackson, p 500.

6 Banerji, D (1964): . "H eal th Pro-blems and He al th Practices inModern Ind ia: A Histor ical Inter-pre ta t ion" , The Indian Practioner,XXII, 137-143,

7 Indi a, Governm ent of, He alth

Survey and Development Committee (1956) : Report. Vol ume I,De lh i: Manager of Publication s.

8 Bane rji, D (1973) : "Social Orie nta-tion of Medical Education inIndia" , Economic and PoliticalWeekly, Vo l VIII, pp 485-488.

9 Basu. D D (19 70) : "Short er Con-sti tuti on of Indi a", Calcutta ; S CSarkar, pp 230-235.

10 Banerji, D (1971 ). "Famil y Plann-ing in Ind ia: A Crit ique and aPerspective" , New De lh i: People'sPublishing House.

11 Banerji , D (1973): Populat ionPlanning in Ind ia: Nati ona l andForeign Priorities, International

Journal of Health Services, 111 :No 4.

12 India , Govern ment of, Min ist ry ofHealth, Health Survey and PlanningCommitte e (1961): Report Vol umeI, New De lhi: Min ist ry of Healt h.

13 Ind ia, Gov ernm ent of, Hea lth Sur-vey and Development Committee(1946): Report, Volum e I I , Del hi:Manager of Publications.

14 India , Government of, Mi nis tr y ofHealth and Family Planning (1973):Pocket Book of Health Statistics,New Del hi: Central Bureau ofHealt h Intelligence, Director ateGeneral of Health Services.

15 Ramal ingas wami, P and Ne ki , K

(1971) : "Student s' Preference ofSpecialities in an In dia n Medi calCollege", British Journal of Me di -cal Education, V: 204-209.

16 Nation al Inst itute of Healt h Ad-mini str ati on and Educ atio n (1966):Repo rt and Recom menda tion s ofthe Conferen ce on the Teaching ofPreventive and Social Medicine inRelation to Health Needs of theCoun try, New Del hi: Nat iona l In-sti tute of Health Admi nis trat ionand Education.

17 India. Gover nment of, Min is try ofHealth, Family Planning and UrbanDevelopment, The Study Group onHospit als (196 8): Report, New

Del hi: Mini str y of Healt h, FamilyPlanning and Urban Development.

18 West Bengal, Direct orate of HealthServices fl9 71) : "Hea lth on theMarch 1948-1969: West Bengal",Calcut ta: State Healt h IntelligenceBureau.

19 Ramak rish na, S P (1960 ); " A nExa min ati on of Resemblance andDivergence Between War andMalaria Eradication", Bulletin ofthe National Society of India for

Malaria and Other MosquitoBorne Diseases, 8: 3-4.

20 Borka r, G (1961): "H eal th in Inde-pendent Ind ia" , Revised Edit ion ,New Delhi : Mi nist ry of Health.

21 Banerji D (19 71) . "Tub ercul osis :A Problem of Social Planning inIndia" . NIHAE Bulletin, 4: No 1,

22 India, Government of, Min ist ry ofHea lth and Family Plann ing (1973):Memor andu m on Centrally Spon-sored and Pur ely Ce ntr af Schemesfor the Fifth Five-Year Plan,New Delhi: Ministry of Health.

23 India, Government of, PlanningCommission (1972); The FourtiPlan; Mi d-ter m Appraisal, Volu me

II , New Delhi: Planning Commi-ssion.

24 Bane rji, D (1972 ): "Prospects ofControlling Population Growth inIndia", Economic and PoliticalWeekly, Vol V I I , pp 2067-2074.

25 Indi a, Gove rnme nt of. Plan ning

Five-Year Plan : 1974-1979, Vo lu -me II , New Delh i: Planning Com-mission.

26 India, Government of, PlanningCommissi on (1973): Draf t Fi ft hFive-Year Plan : 1974-79, Vol umeI, New Delh i: Planning Commi -ssion.

27 Dhir, S L (1971): "Ma lari a Eradi-

cation Programme and Integrationof Mass Eradication Campaigns inGeneral Health Services", The

Journal of Communicable Diseases,3: 1-12.

28 Dut t, P R (1965): "R ura l Heal thServices in In di a: Prim ary He alt hCentres", Second Edi tion , NewDel hi: Central Health EducationBureau.

29 India, Government of, Min ist ry ofHealth, Committee on Integrationof He alt h Services (1963) : Repor t.New Del hi: Mini stry of Health.

30 India, Governmen t of, Min ist ry ofHealt h and Family Planning, Com-mitt ee on Basic Heal th Services

(1966): Report, New Delhi : Mi ni -stry of Hea lth and Family Plan-ning.

31 India, Govern ment of, CentralCouncil of Heal th (1974): "Ind ianSystems of Med ici ne and Homo-eopathy", Agenda item No 6. NewDelhi: Ministry of Health.

32 Insti tute of A ppl ied Manpo werResearch and the Nat ion al Ins tit uteof Health Ad mini stra tion and Edu-cation (1966): "Stock of All opa th-tic Doctors in India". IAMR Re-port No 2/19 66, N ew Delh i : Ins-titu te of App lied Manpo werResearch.

33 India, Governme nt of, Min ist ry of

Health and Family Planning(1973): Report 1972-73, NewDel hi: Min ist ry of Health andFamily Planning.

34 The Johns Hopkins Uni vers ity ,School of Hygien e and PublicHealth, Department of InternationalHealth (1970): "Functional Analy-sis of Needs and Services", Bal ti-more: The Johns Hop kins Uni ver-sity.

35 National Institute of Health Ad-mini str atio n and Educ ation (1972):"Study of District Health Adm ini -strati on, Rohtak (Phase 1), N I H A EResearch Report No 7, NewDelhi: National Insti tute of Health

Administration and Education.36, Bane rji, D (1973): "He alt h Be-

haviou r of Rural Populat ions:Impact of Rural Health Services",

Economic and Political Weekly,Vol VIII, pp 2261-2268.

37 Valentine, CAS (1969): "Cul tureand Pover ty; Criti que andCounter-Proposals", Chicago: TheUni ver sit y of Chicago Press, pp48-127.

38 An dr es ki . S C ( 1972): SocialSciences as Sorcery". London:

An dr e Deutsch, pp 59-154,39 Mar rio t, M (1955): "Western

Medicine in a Village in NorthernIndi a", in "Heal th Culture andCommunity", (ed) B D Paul, NewYo rk . Russell Sage Fo unda tion .

40 Carstair s, G M (1955 ); "Me dic ineand Faith in Rural Rajasthan", inHealth Culture and Community",(ed), B D Paul, New York : RusselSage Foundation.

41 Opler, M E (1962) : "C ul tu ra l De-fin itio n of Illness in Village Ind ia" ,

Human Organisation 21, No 4.

42 Gou ld, H A (1957): "Impli cation sof Tech nolo gica l Change for Folkand Scientific Medicine", Ameri-

can Anthropologist, 59: 507-516 ,43 Woo d, E (1960); R ural Hea lth

Promot ion, Kurukshetra, 8(5): 23and 26,

44 Hasan, K A (19 67) : "C ul tur alFrontiers of Health in VillageIndia ", Bombay : Asia.

45 Dh il lo n, H S and Kar, S B (1963):"Beh aviou ral Sciences and Publ icHealth", Indian Journal of Public

Health, V I I : 19-24.

46 Khare. R S (1963): "F olk Medi -cine in a No rth I ndia n Vill age ",

Human Organisation, 2 2: No 1.

47 Kakar, D N, Srinivas Mur th y, S Kand Parka r, R L (19 72): "People'sPerception of Illness and their Use

of Medi cal Care Services in Pun-ja b" , Indian Journal of MedicalEducation, X I : 286-298.

48 Prasad, B G (19 61) : "Some Com-mon Beliefs and Cu stoms in Rela-tio n to He alt h and Disease in Utt arPradesh", The Antiseptic, 58:225-238.

49 India, Government of, Min is try ofHeal th (1956): Conferen ce on So-cial and Cultural Factors inEnvironmental Sanitation in RuralIndia, New Delhi: PublicationDivision.

50 Foster. G M (1958): "Prob lems ofIntercultural Health Programmes",Ne w Yo rk : Social Science Research

Council.51 Banerji, D (1973) : "A Criti cal

Review of the Role and Utilisationof Social Scientists in Pro mot ingSocial Science Research in HealthFields in India", Journal of the

Indian Medical Association, 6 0 :145-147.

52 Bane rji, D and Anderse n, S (1963):"A Sociologic al Study of Aw are -ness of Sym pto ms Sugg estiv e ofPulmonary Tuberculosis", Bulletinof the World Health Organisation,29: 665-684.

53 Ander sen, S and Ban erj i, D(1963): "A Sociologi cal En qu ir yinto an Urb an Tuber culos is Pro-

gramme in India", Bulletin of theWorld Health Organization, 2 9 :685-689.

54 Ba nerj i, D (1967): "Beh avio ur of

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Special Nu mbe r Au gus t 1974 , ECONOMIC AND POLITICAL WEEKLY

Tuber culos is Patients Tow ards aTreatment Organisation OfferingLimited Supervision" , Indian Jo ur -nal of Tuberculosis X I V : 156-172.

55 Sigh , M M and Baner ji, D (19 68) ;"A Fo llo w- up Study of Patients ofPulmonary Tuberculosis Treatedin an Urban Clinic", Indian Journalof Tuberculosis, X V : 157-164.

56 State Hea lth Edu cat ion Bure au,UP (1968): "A t t i t ude TowardsTuberculos is", Lu ck no w: StateHealth Education Bureau, UP.

57 Mi tr a. A C and Gupta, B P(1965) : "People's Kno wle dge andAtt i tu de Towards Tuberculosis" ,

Health Centre Journal (Punjab),September 1965.

58 Singh, Yogendr a (1973): "TheRole of Social Sciences in India:A Sociology of Knowledge", So-ciological Bulletin 22: 14-28.

59 Indi a, Govern ment of, Min is tr y ofHealth and Family P lanning, Com-mittee on Uti lis ati on of PHC Bedsin Ind ia (1974 ): Report , Ne w

Del hi : Min ist r y of Heal th andFamily Planning,

Standard Mills

ST AN DA RD MIL LS i s making a r ran-

gements for foreign exchange loans and

final isin g for eign orders to expa nd ca-

pacity for manufacture of caustic soda,

fro m 51,990 tonnes to 86,650 tonnes

per annum for wh ic h it has got a

'letter of int ent' . The company has

also secured a 'let ter of int ent ' for hy-

drogen and is seeking an industrial 1i -

cence. Mean whil e, the plant for addi-

tional pro duct ion of potassium carbon-

ate, designed, fab rica ted and erected

ind igen ous ly, has been gi vi ng the de-

signed output rate. The chloromethane

plant has also commenced pro duct ion.

The f ul l cap acity of the exp ande d caus-

tic soda plant could be achieved only

towa rds the end of last year owin g to

delay in the receipt of second rectffor-

mer from Heavy Electricals India. Du-

ring the year ended March last, sales

of the chemicals d ivi sio n (net of ex-

cise) were better at Rs 10.62 crores,

compared to Rs 9.80 crores during the

previo us perio d of 15 mont hs. The tex-

tile division had to contend with the

fuel crisis and a 41-day strike in the

Bombay city units; and net sales were

Rs 24. 95 crores as again st Rs 30. 60

crores. Exports of textile products fet-

ched Rs 126 lakh s, agai nst Rs 87 lakhs,

and those of the chemic al pro duct s Rs

98 lakhs, against Rs 28 lakhs. The

comp any has been recogni sed as an

'expo rt house' for chemicals since

March. Additions and replacement of

plant, machiner y, and buil ding s in thetextile di visio n, cost the company

about Rs 67 lakhs, and those in the

chemicals div isi on Rs 202 lak hs.

1346.

Documents

Approaches to Development Social and Cultural Foundations of Health