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Review of Healthcare In India
Leena V Gangolli
Ravi Duggal
Abhay Shukla
Centre for Enquiry into Health and Allied Themes, Research Centre of Anusandhan Trust,
Survey No. 2804 & 2805, Aaram Society Road, Vakola, Santacruz East, Mumbai – 400055,
Maharashtra, India; Ph:(+91-22) 26673154, 26673571; Fax :26673156;
Email :cehat@vsnl.com; www.cehat.org
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Published in January 2005
By
Centre for Enquiry into Health and Allied Themes
Survey No. 2804 & 2805
Aram Society Road
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ISBN : 81-89042-40-8
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Preface
The twenty fifth anniversary of Alma Ata Uncontrolled privatisation and the
Declaration was observed last year. Along with international privatisation of pubic sector and
other countries, India had also formulated paucity of funds are leading to the collapse of
various targets to be achieved by the year the public health institutions. The patent rule
2000. However, the achievements were changes and the weakening of the public
minimal even after half a century of health sector pharmaceutical industries have further
planning, and most of the goals could not be deprived the people of essential medicines.
realized. The health situation in our country There is an escalation of medical expenses
continues to be dismal. on an unprecedented scale and more and
more people are denied even primary health
Infant and Child mortality takes away the life care.
of 2.2 million children every year. The target
for 2000 was to reduce Maternal Mortality The situation demands concerted action from
Ratio to less than 200 per 100,000 live births. civil society organizations, People’s Health
However, the MMR remains as high as 407 Movements and other concerned groups and
even today. The most recent estimate of movements to pressurize the Government
complete immunization coverage indicates both at the national and state levels to
that only 54% of all children under age three radically alter the way the health services are
were fully protected. The number of people organized and funded. Priorities are to be
dying of Tuberculosis is almost unchanged changed taking into consideration the health
since Independence and remains at 500,000 problems affecting the marginalized people
every year. 2 million new cases of TB are and the vulnerable sections of the society. The
added each year and the total number of TB National Government should also resist the
patients presently is estimated to be around pressure from the International Financial
14 million, the largest number in any country Institutions to further privatize the health
in the world. India is experiencing a sector, since the Indian health sector is one
resurgence of various communicable diseases of the most privatized in the world.
including Diarrhoeal Diseases, Cholera,
Malaria, Encephalitis, Kala azar, Dengue and It is in this context that CEHAT has compiled
Leptospirosis. The number of cases of Malaria the volume “Review of Health Care in India”
has remained at a high level of around 2 as an input to support the activities of the
million cases annually since the mid eighties. Peoples Health Movement-India (Jan
It is estimated that more than 5 million people Swasthya Abhiyan-JSA). This document is
are suffering from HIV/AIDS and within a few qualitatively and conceptually different from
years India will be overtaking South Africa in similar books published by other agencies
having the highest number of HIV/AIDs cases discussing the health situation in India. The
in the world. articles in the present volume try to analyse
and reinterpret the health situation and
Meanwhile, the international financial health statistics from people’s perspective and
institutions like World Bank, IMF and the with a view to strengthen the emerging
World Trade Organization are thrusting their movement demanding a people’s health policy
neo liberal economic agenda on the for our country.
Government of India, with the effect that there
is a virtual withdrawal of the state from social The document contains 18 chapters and
service sectors like health and education. discusses such varied topics ranging from the
Review of Health Care in India iii

state of the preventive health and nutritional The publication of the document has come at
services for children to the community health a most appropriate time. JSA is today involved
worker program and the public health system. in popular mobilisation by organising Jan
Ritu Priya has written an illuminative article Sunwais (Public Hearings) across the country,
on the public health services in India from a documenting specific cases of denial of health
historical perspective. The population policies care thereby reaching out to people across the
in India are critically analysed by Mohan Rao, country, mobilising the people for their just
while Ravi Duggal has reviewed other health health rights. The document reinforces the
policies. Control of communicable disease has view expressed by JSA that India today
been critically analysed and alternative possesses the human power, infrastructure,
proposals based on national priorities are national financial resources and appropriate
presented by Leena V Gangolli and Rakhal health care know-how to ensure quality health
Gaitonde. The role of community health care for all its citizens. What is needed is a
workers in public health is described by major restructuring and strengthening of the
T. Sundararaman. In the section on women health system. This involves two major
and children, Vandana Prasad examines ingredients: popular mobilisation for
nutritional services for children, NB Sarojini operationalising the Right to Health Care, and
discusses reproductive services for women the political will to implement policy changes
and Padma Deosthali and Purnima necessary to transform the health system.
Manghnani write on the issues related to
Gender based violence and the role of the The present volume shall definitely be a
public health system. The section on Health guiding inspirational document for the
Systems and Resources contains notable People’s Health Movement activists all over
articles on financing by Ravi Duggal, access the country, for building up a popular
issues by TR Dilip, essential drugs by movement to realise health as a fundamental
Srinivasan and Indian Systems of Medicine right for the citizens of India. The CEHAT team
by Leena Abraham and regulation of the members deserve kudos for compiling this
private health sector by Rama V Baru. The extremely valuable document.
material presented in all the chapters is
distilled into the conclusion by Abhay Shukla.
The volume as a whole throws light on some
of the not much discussed areas of the health
sector of the country. The articles in the
volume carry conceptual clarity and Dr.B.Ekbal
ideological lucidity. In addition to the articles, National Convenor
the book contains an appendix of statistical Jan Swasthya Abhiyan and
data, a valuable tool for researchers and Former Vice Chancellor
activists. University of Kerala
Review of Health Care in India iv

Acknowledgements
This review of healthcare is the result of the Finally, we would like to thank NOVIB and
hard work and dedicated efforts of a number Ford Foundation for the financial resources
of people. which made the publication of this book
possible.
We would like to individually thank the
authors for their contributions. There were some unavoidable circumstances,
which resulted in the delay of the release of
We also express our sincere gratitude to Dr. the book and we are sincerely grateful to
Amita Pitre for her participation in the initial everyone who was a part of this process for
planning of the book as well as reviewing some the patience and cooperation extended.
of the chapters ; Ms. Margeret Rodrigues and
Ms.Muriel Carvalho who have provided
invaluable assistance in expediting the
printing and final publishing of the book and Dr. Leena V Gangolli
Ms.Sunanda Bhattacharjea, who assisted in Ravi Duggal
the editing. Dr. Abhay Shukla
Review of Health Care in India v

List Of Abbreviations
AFP Acute Flaccid Paralysis
AIDS Acquired Immunodeficiency Syndrome
ANC Antenatal Care
ANM Auxiliary Nurse Midwife
API Active Pharmaceutical Ingredients
ART Anti Retroviral Therapy
ARV Anti Retroviral
AWC Anganwadi Centres
AWW Anganwadi Worker
BPL Below Poverty Line
CAG Comptroller And Auditor General
CDA Central Drug Administration
CGHS Central Government Health Service
CHW Community Health Worker
CIPR Commission On Intellectual Property Rights
CME Continuing Medical Education
CSR Child Sex Ratio
CSSM Child Survival And Safe Motherhood
CT Computerized Tomography
DALYS Disability Adjusted Life Years
DOTS Directly Observed Treatment, Short Course
DPCO Drug Price Control Order
DPCRC Drug Price Control Review Committee
ECG Electrocardiogram
EDL Essential Drug List
EMR Exclusive Marketing Rights
EPI Expanded Program Of Immunization
ESIS Employees Social Insurance Scheme
FDA Food And Drug Administration
FPP Family Planning Program
GDP Gross Domestic Product
GOBI Growth Montoring Oral Rehydration Therapy Breast Feeding Immunization
GOI Government Of India
GPEI Global Polio Eradication Initiative
HAART Highly Active Anti Retroviral Therapy
HIV Human Immunodeficiency Virus
HSR Health Service Reform
ICDS Integrated Child Development Services
ICPD International Conference On Population And Development
IFA Iron And Folic Acid Tablets
IFR Infant Mortality Rate
IPV Injectable Polio Vaccine
ISM Indian Systems Of Medicine
ISM+H Indian Systems Of Medicine + Homeopathy
IUD Intra Uterine Device
LHV Lady Health Visitor
MAPE Maximum Allowable Post Manufacturing Expense
MCGM Municipal Corporation Of Greater Mumbai
MCH Maternal And Child Health
MCI Medical Council Of India
MDMP Midday Meal Program
MDRTB Multi Drug Resistant Tuberculosis
MMR Maternal Mortality Rate
Review of Health Care in India vii

MNC Multinational Corporations
MOHFW Ministry Of Health And Family Welfare
MPCE Monthly Per Capita Expenditure
MPO Modified Plan Of Action
MPWF Multipurpose Worker Female
MRC Malaria Research Centre
MRI Magnetic Resonance Imaging
MSF Medecins Sans Frontieres
MTP Medical Termination Of Pregnancy
NACO National Aids Control Organization Of India
NCAER National Council Of Applied Economic Research
NFHSI National Family Health Survey
NGOS Non Governmental Organization
NHP National Health Program
NHRC National Human Rights Commission
NIN National Institute Of Nutrition
NIPCCD National Institute Of Public Cooperation And Child Development
NLEM National List Of Essential Medicines
NMEP National Malaria Eradication Program
NPEV Non Polio Entero Viruses
NPPA National Pharmaceutical Pricing Authority
NTCP National Tuberculosis Control Program
NTI National Tuberculosis Institute
NTP National Tuberculosis Program
OBC Other Backward Castes
OPV Oral Polio Vaccine
ORG Organization
ORS Oral Rehydration Salts/ Solution
PDS Public Distribution System
PHC Public Health Centre
PLWHA People Living With Hiv/ Aids
PRI Panchayat Raj Institutions
PSU Peripheral Service Unit
RCH Reproductive And Child Health
RDA Recommended Dietary Allowance
RNTCP Revised National Tuberculosis Control Program
RTI Reproductive Tract Infection
SAP Structural Adjustment Program
SC Scheduled Castes
SLI Standard Of Living Index
SNP Supplementary Nutrition Program
SRB Sex Ratio At Birth
SSA Sex Selective Abortions
ST Scheduled Tribes
STD Sexually Transmitted Disease
STI Sexually Transmitted Infection
TBA Traditional Birth Attendant
TFR Total Fertility Rate
TRIPS Trade Related Intellectual Property
TT Tetanus Toxoid
UIP Universal Immunization Program
VAPP Vaccine Associated Paralytic Polio Myelitis
VDPV Vaccine Deprived Polio Viruses
VHN Village Health Nurse
WHO World Health Organization
WTO World Trade Organization
Review of Health Care in India viii

Contents
Preface B. Ekbal .................................................................................................. iii
Acknowledgements ............................................................................................... v
List of Abbreviations ............................................................................................ vii
List of Tables ....................................................................................................... x
List of Graphs ...................................................................................................... xiv
Errata ................................................................................................................. xv
SECTION 1: INTRODUCTION
Introduction to Review of Healthcare in India Ravi Duggal and
Leena V Gangolli ................................................................................................... 3
SECTION 2: PUBLIC HEALTH POLICIES AND PROGRAMMES

Historical Review of Health Policy Making Ravi Duggal ......................................... 21
Public Health Services in India: A Historical Perspective Ritu Priya ....................... 41
Programmes for Control of Communicable Diseases Leena V Gangolli and
Rakhal Gaitonde ................................................................................................... 75
New Initiatives in the Immunization Programme Anant Phadke ............................. 101
Community Health Worker Programs and The Public
Health System T.Sundararaman ........................................................................... 107
The Way the Wind Blows: Population Policies in India Mohan Rao ......................... 117
Mental Health in India: Review of Current Trends and
Directions for Future Aparna Joshi ...................................................................... 127
SECTION 3: HEALTH CARE ISSUES RELATED TO WOMEN AND CHILDREN

The State of Preventive Health and Nutritional Services for
Children Vandana Prasad .................................................................................... 137
Reproductive Health Services-the Transition from Policy Discourse to
Implemention Sama Team .................................................................................... 153
Gender-based Violence and the Role of the Public Health System Padma Deosthali
and Poornima Maghnani ......................................................................................... 171
SECTION 4: HEALTH SYSTEMS AND RESOURCES

Indian Systems of Medicine (ISM) and Public Healthcare in India Leena Abraham .. 187
Public Health Expenditures, Investment and Financing Under the Shadow of a
Growing Private Sector Ravi Duggal ..................................................................... 225
Extent of Inequity in Access to Health Care Services in India T.R. Dilip ................ 247
Private Health Sector in India-Raising Inequities Rama Baru ................................ 269
Fundamental Right to Health and Health Care S.V. Joga Rao ............................... 279
Availability of Drugs In India S Srinivasan ............................................................. 295
SECTION 5: CONCLUSION
Conclusion: Reclaiming Public Health an Unfolding Struggle for Health Rights and
Social Change Abhay Shukla ............................................................................... 323
SECTION 6: STATISTICAL APPENDIX

Appendix Statistical Tables Prashant Raymus ........................................................ 331
About the Authors
Review of Health Care in India ix

List of Tables
Public Health Services in India: A Historical Perspective.................................... 41
Table 1 Health Status, Socio-economic and Health Services Development
Indicators of Selected Countries by Descending Order of Life
Expectancy Of Females ......................................................................... 70
Table 2 Growth of Infrastructure ........................................................................ 71
Table 3 Public Sector Institutions of Indigenous Systems of Medicine &
Homeopathy and ‘Allopathy’ (1999) .......................................................... 71
Table 4 Five Year Plan Outlay (Centre and States) .............................................. 71
Table 5 Selected Indicators for India for 1901 to 1991 .......................................... 72
Table 6 Status of Health Manpower in Public Health Services in
Rural Areas (June 1999) ......................................................................... 73
Table 7 Ranking of Major Causes of Death (Rural India) ...................................... 73
Programmes for Control of Communicable Diseases ........................................... 75

Table 1 Trends in Malaria from 1951-2000 ......................................................... 79
Table 2 Entry Algorithm for TB Patients to be registered on the RNTCP ............... 87
The State of Preventive Health and Nutritional Services for Children ................ 137
Table 1 Distribution Of Severely Malnourished Children By Age, Pilot Study
NCAER 2001 .......................................................................................... 141
Table 2 Distribution Of Severely Malnourished Children By Age and Sex Pilot
Study NCAER ........................................................................................ 142
Table 3 Comparison of ICDS Figures and GVSUP Figures...................................... 142
Table 4 The Comptroller and Auditor General (CAG) Report ................................ 145
Table 5 Health Checks ...................................................................................... 147
Reproductive Health Services-the Transition from Policy Discourse to

Implemention ..................................................................................................... 153
Table 1 Essential and Expanded Packages of Reproductive Health Services ......... 158
Table 2 Maternal Mortality Rate, Various States, India, 1997 .............................. 160
Table 3 Number and Timing of Antenatal Check-ups and Stage of Pregnancy ....... 161
Table 4 Reason for not Receiving an Antenatal Check-up..................................... 162
Table 5 Distance from the Nearest Health Facility ............................................. 163
Gender-based Violence and the Role of the Public Health System ...................... 171
Table 1 Gender-based Violence Throughout the Life Cycle .................................. 173
Indian Systems of Medicine (ISM) and Public Healthcare in India ...................... 187
Table 1 Infrastructure in ISM & H Summary (2001) ............................................ 213
Table 2 Registered Practitioners in Indian Systems of Medicine & Homeopathy ... 213
Table 3 Number of Hospitals with their Bed Strength under ISM & H
as on 1.4.2001 ...................................................................................... 214
Review of Health Care in India x

Table 4 Statewise Number of Dispensaries under ISM & H as on 1.4.2001
(including Government, Local Bodies and Others) .................................. 215
Table 5 Growth of Registered Practitioners under ISM & H since 1980
(As on 1st January) ................................................................................ 216
Table 6 Number of Registered ISM & H Practitioners (IQ + NIQ) Per Lakh
Population as on 1.1.2001 ..................................................................... 217
Table 7 Statewise Distribution of ISM and Homeopathy Medical Colleges in
India and Their Admission Capacity as on 1.04.2001 ............................... 218
Table 8 Growth of ISM and Homeopathy Medical Colleges in India ...................... 219
Table 9 ISM & H Industry in India ...................................................................... 219
Table 10 Licensed Pharmacies in India ................................................................ 219
Table 11 Rural-urban Distribution of Specialised Treatment Available Under the
Various Central Councils of ISM and Homeopathy .................................. 220

Growing Private Sector ...................................................................................... 225
Table 1 Financing Healthcare in India 2003 ....................................................... 229
Table 2 Selected Municipal Health Expenditures 1951-1998 ............................... 233
Table 3 Growth of Private Health Expenditures in India in Comparison to
Public Expenditures 1951-2003 .............................................................. 234
Table 4 Pattern of Investment and Expenditures on Health and Family Welfare
(Rs. Billions) and selected Health Outcomes .......................................... 242
Table 5 Total Public Health Expenditure (revenue + capital) Trends 1975-2003
and Selected Ratios .............................................................................. 243
Table 6 Maharashtra 2000-01 Public Health Expenditures (Rs. Million) ............... 243
Table 7 Disaggregation of National Public Health Expenditures by
Major Programs ..................................................................................... 244
Table 8 Revenue Expenditure on Health: Union Government and States ............. 245
Table 9 Private Health Expenditure Trends ........................................................ 246
Extent of Inequity in Access to Health Care Services in India ............................ 247

Table 1 Prevalence of Ailments and Hospitalisation Per Thousand Population by
Sex, Social Group and MPCE Groups, India 1995-96 ................................ 249
Table 2 Per cent of Ailments Which Were Untreated by Sex, Social Group and
MPCE Groups, India 1995-96 .................................................................. 251
Table 3 Reasons Reported for Non Treatment of Ailments by MPCE Quartile
Groups, India 1995-96 ........................................................................... 251
Table 4 Source of Inpatient and Outpatient Treatment, India 1995-96 ................. 254
Table 5 Average Medical Expenditure (in rupees) Incurred, During each Episode
of Inpatient Treatment and Outpatient Treatment by Source of
Treatment, India 1995-96 ...................................................................... 256
Table 6 Reported Sources Through Which Inpatient Care Treatment has been
Financed, India ..................................................................................... 257
Review of Health Care in India xi

Table 7 Share of Each Source in Total Reported out of Pocket Expenditure on
Inpatient Care Treatment, India ............................................................ 258
Table 8 Percentage Resorting to Sale of Physical Assets/ Borrowing and Average
Amount Raised Through Borrowing/Selling of Physical Assets, to Finance
out of Pocket Expenditure on Inpatient Care Treatment, India 1995-96 .... 259
Table 9 Access to Reproductive and Child Health Care Services in
India, 1998-99 ....................................................................................... 261
Availability of Drugs In India .............................................................................. 295

Table 1 Drug Monitoring Exercise at the Secondary Hospital ............................... 297
Table 2 Different Prices of Amlodipine ............................................................. 298
Table 3 Comparative Chart Summarising Price Control Scheme under
Various (DPCO) Drug Price Control Orders ............................................ 300
Table 4 Antibiotic Brand Leaders, Market Share and Price Behaviour: A Brief
Overview ............................................................................................... 302
Table 5 A Comparison of Tender Rates and Retail Market Rates ......................... 304
Table 6 Shocking Margins - A Sample Comparison of LOCOST Medicine Prices
and Retail Prices .................................................................................. 305
Table 7 Extent of Trade Margins - Some Examples .............................................. 306
Table 8 Drug Costs and person Days in Terms of Wage Labour ............................ 308
Table 9 Comparison of Prices of Drugs (in Rs. per Unit) Drug Purchased at
Competitive Prices (Rupees) ................................................................... 310
Appendix Statistical Tables ................................................................................ 331

1.1: Crude Birth Rate: All India (per 1000 population) .......................................... S-1
1.2: Infant Mortality Rates: All India (per 1000 live births) ................................... S-3
1.3: Still birth Rate: All India (per 1000 live births) .............................................. S-5
1.4: Total Fertility Rate: All India ....................................................................... S-6
1.5: Percentage Institutional Births: All India ..................................................... S-8
1.6: Percentage Births Attended by Trained Practitioners: All India ..................... S-10
1.7: Neo-natal Mortality Rate: All India (per 1000 live births) ............................... S-12
2.1: Doctors and Nurses: All India (per 100,000 population) .................................. S-14
2.2: Hospitals: All India (per 100,000 population) ................................................. S-15
2.3: Dispensaries: All India (per 100,000 population) ............................................ S-17
2.4: Primary Health Centres and Sub Centres: All India (per 100,000 population).. S-19
2.5: Beds: All India (per 100,000 population) ........................................................ S-20
3.1: Revenue Expenditure on Health ................................................................... S-22
3.2: Capital Expenditure on Health ..................................................................... S-23
3.3: Health Expenditure as percentage of Total Expenditure ................................ S-24
3.4: Total Revenue Expenditure, State and Union ................................................ S-25
3.5: Total Capital Expenditure, State and Union .................................................. S-26
3.6: Revenue Receipts from Public Health and Family Welfare as Percent of
Revenue Health Expenditure ....................................................................... S-27
Review of Health Care in India xii

3.7: Revenue Receipts from Public Health and Family Welfare ............................ S-28
3.8: Revenue Receipts from Medical as Percent of Revenue Health Expenditure ... S-29
3.9: Central Government Health Scheme (CGHS)/
Employees State Insurance Schemes (ESIS) Revenue Receipt ....................... S-30
3.10: Receipts from Services and Fees (Medical) ................................................... S-31
3.11: Revenue Expenditure on Family Welfare ...................................................... S-32
3.12: Capital Expenditure on Family Welfare ........................................................ S-33
3.13: Expenditure on Medical Services ................................................................. S-34
3.14: Total Expenditure on Public Health .............................................................. S-35
3.15: Expenditure on National Disease Programme ............................................... S-36
3.16: Expenditure on Hospitals and Dispensaries ................................................. S-37
3.17: Expenditure on Central Government Health Scheme (CGHS)/
Employees State Insurance Schemes (ESIS) ................................................. S-38
3.18: Revenue Expenditure on Medical Education, Training and Research ............. S-39
3.19: Capital Expenditure on Medical Education, Training and Research ............... S-40
3.20: Revenue Expenditure on Rural Family Welfare Services ............................... S-41
3.21: Revenue Expenditure on Urban Family Welfare Services .............................. S-42
3.22: Revenue Expenditure on Maternal and Child Health .................................... S-43
Review of Health Care in India xiii

List of Graphs
Public Health Services in India: A Historical Perspective.................................... 41
Graph 1 Percentage Distribution of PHCs having all Critical Inputs ................... 56

Growing Private Sector ...................................................................................... 225
Graph 1 IMR Trends in India and Low-income Countries 1960-95 ...................... 230
Graph 2 Slowing Down in Rate of IMR and U-5 Mortality Decline 1971-2001 ...... 231
Graph 3 Public Expenditure Ratios 1976-2001 ................................................... 231
Graph 4 Rural-Urban Differentials in Public Health Expenditure
Maharashtra 2000-01 .......................................................................... 232
Availability of Drugs In India .............................................................................. 295

Graph 1 Savings in Costs of Treatment ............................................................. 311
Graph 2 Comparison of Stock Position before and after Orissa DIMS: Inj.
Anti Snake Venom .............................................................................. 311
Graph 3 Comparison Between Old and New Rates: Orissa DIMS ........................ 312
xiv
Errata
A list of corrected content on respective pages is given below:
Page 22; Footnote 2 should read: “Jaggi O.P. 1979.Western Medicine in India-Medical
Education and Research.Volume XIII of History.”
Page 32; Footnote 37 should read: Planning Commission, Government of India. Sixth Five
Year Plan. 1985
Page 75; Footnote 2 should read: Ministry of Health and Family Welfare. National Health
Policy.2002.
Page 77; Footnote 6 should read: Capra Fritjof. Hidden Connections. Harper Collins.2001
Page 78; Footnote 7 should read: Banerjee D. A social science approach to strengthening
India’s National Tuberculosis Program. Indian Journal of Tuberculosis; 40:61-81
Page 92-93; The quoted material in inverted commas is an excerpt from a joint letter
issues by Jan Swastya Sahyog, SAMA, Prayas (Rajastan) and CEHAT.
Page 189; third last line should read: “this to be an easier route to enter the profession”
Page 190; ninth last line should read: “’scientific status’ as well as the economic and…”
Page 194 ; Footnote 21 should read: Quoted in Rhode…
Page 199; section on Practitioners, fourth line should read: Table 2 (not Table 4)
Page 202; second paragraph last two lines deleted.
Page 297; Footnote 10 should read: op.cit. footnote 8
Page 298; Footnote 14 should read: See Bhargava, Anurag , “Tremendous Variations in
Drug Prices in the Indian Pharmaceutical Market” in Impoverishing the Poor: Pharmaceuticals
and Drug Pricing in India, LOCOST, : Baroda, 2004.
Page 301; Footnote 18 should read : AIDAN and ors. Versus Union of India in the Supreme
Court of India –WP (Civil) 423/ 2003). See also arguments of the case summarized in
LOCOST, 2004.
Page 301; Footnote 19 should read: Rane, op.cit, footnote 9.
Page 311; Citation below Graph 1 should read : Source for Table 9 and Graph 1: Bapna,
J.S. “Rational Drug Use.... New Delhi.
Page 311; Main Text below Graph 1 should read: Similarly though not as dramatically,
......(DIMS). See bar charts below (Graphs 2 and 3) for illustration. (Source for graphs,
Orissa Government documents on DIMS.)
Page 311; Citation below Graph 2 should read: Source for Graphs 2 and 3, Orissa
Government documents on DIMS.
Page S-6 and S-7; Table 1.4 The TFR( Total Fertility Rate) is defined as the average
number of babies born to women during their reproductive years.
Page S-22 to S-26; Table 3.1,3.2,3.3,3.4,3.5 Apart from the CMIE, which has been
mentioned in the sources, data for the 2003 and 2005 columns has also been sourced
from Reserve Bank of India. State Finance-A Study of the Budget 2004-2005.
xv
SECTION 1
INTRODUCTION
Introduction to Review of Healthcare in India
Ravi Duggal, Leena V Gangolli
Poverty is the real context of India. Three- seeking such care is also increasing. This
fourths of the population live below or at means that the already difficult scenario of
subsistence levels. This means 70-90 per cent access to health care is getting worse, and
of their incomes goes towards food and related not only the poor but also the middle classes
consumption. In such a context social security get severely affected.1 Thus India has a large,
support for health, education, housing etc. unregulated, poor quality, expensive and
becomes critical. Ironically, India has one of dominant private health sector, and an
the largest private health sectors in the world inadequately resourced, selectively focused
with over 80 per cent of ambulatory care being and declining public health sector despite its
supported through out-of-pocket expenses. poverty, with the former having curative
The public health services are very monopoly and the latter carrying the burden
inadequate. The public curative and hospital of preventive services.
services are mostly in the cities where only
25 per cent of the one billion population Given the above context the lack of right to
reside. Rural areas have mostly preventive and healthcare is the main reason why health
promotive services like family planning and status of the Indian population is
immunisation. The private sector has a virtual unsatisfactory. Health indicators across the
monopoly over ambulatory curative services board are close to the worst and within the
in both rural and urban areas and over half country inequities across classes are very
of hospital care. Further, a very large severe. For example, the disparity between the
proportion of private providers are not top 18 per cent (socio-economically high)
qualified to provide modern health care households and the bottom 36 per cent (socio-
because they are either trained in other economically low) households, favouring the
systems of medicine (traditional Indian former. In infant and child mortality rates it
systems like ayurveda, unani, siddha, and is of the magnitude of 2 ½ times,2 prevalence
homoeopathy) or worse, do not have any of malaria 3 times, prevalence of tuberculosis
training. These, however, are the providers 4 times, access to antenatal care nearly 4
from whom the poor are most likely to seek times, completed immunisation 2 times,
health care. This adds to the risk faced by the childbirth by doctors 4 times,
already impoverished population. The health malnourishment amongst women in
care market in India, like in the USA, is based reproductive age-group 3 times. 3 This is
on a supply-induced demand and keeps clearly due to inadequate access to healthcare
growing geometrically, especially in the services, because even in conditions of poverty
context of new technologies. The cost of if access to primary healthcare is universal
1
The 52nd Round NSS data reveals that for inpatient care 46 per cent of poorer classes and 34 per cent of the
richer classes either sold assets or took loans to pay for treatment. And those using private hospitals were 16 per
cent more likely to get into indebtedness than those using public hospitals. (NSS-1996 : Report No. 441, 52nd
Round, NSSO, New Delhi, 2000)
2
It is estimated that 2 million children under 5 years of age die every year because of the high child mortality rate.
If the entire country experienced the child mortality rate of Kerala the number of such deaths each year would fall
by a whopping 1.6 million (Shukla A, 2001: Right to Health Care, Health Action, May 2001)
3
NFHS-1998, 2000: National Family Health Survey–2: India, IIPS, Mumbai
Review of Health Care in India ! 3

then it can become a leveller of healthcare the Employees State Insurance Scheme
outcomes. In the case of nutritional outcomes (ESIS), defense, Central Government Health
the disparities are even wider as this is more Scheme (CHGS), railways, post and telegraph,
closely a function of income poverty. Unlike mines etc. These are usually hospitals of
healthcare, social intervention for nutrition various capacities and dispensaries or clinics.
is only rendered during a severe crisis. The
unfortunate reality is that today even during Private ownership is of two kinds, for-profit
crises this does not happen, and shamefully and not-for-profit. The former could be self-
we experience starvation deaths in many employed or individual ownership or various
places in India despite having overflowing other forms of ownership like partnership, co-
storehouses of reserved food-stocks under operative or corporate. The not-for-profit
state control. With such inequities prevailing variety is usually a Trust or a Society, many
it is evident that the healthcare and food of these also being called non-government
distribution systems are biased in favour of organisations (NGOs). These again could be
those with purchasing power and hence such teaching hospitals, hospitals and nursing
a system is grossly discriminatory. homes of various sizes providing a variety of
care, clinics and dispensaries, and diagnostic
The Healthcare System facilities.
The political economy of health care services
in India has various dimensions. Multiple In the post-colonial period there was no
systems, various types of ownership patterns attempt at radical restructuring of health care
and different kinds of delivery structures services as per the framework provided by the
make up a complex plurality that makes the Bhore Committee. On the contrary the
development of an organised system difficult. aspects that contributed to inequality in
Allopathy, ayurveda, homoeopathy, unani, health care were strengthened because of:
siddha, among others, are different systems " the production of doctors for the private
of medicine available in the country. However, sector through state financing,
allopathy is the dominant system of medicine. " the production of bulk drugs to supply
Its domineering influence is evidenced by the at subsidised rates to private
fact that practitioners of other systems of formulation units,
medicine are now also primarily practicing " disproportionate concentration of
allopathy. National surveys done by NSSO medical services in urban areas,
and NCAER and other small-scale studies " financial subsidies by the state for
clearly bring this out. setting up private practice and private
hospitals and allowing large scale
As regards ownership, while the broad international migration of doctors and
characterisation could be made as public and nurses.
private, there are various intricacies involved. All these factors, among others, have
The public sector ownership is divided contributed to increase inequality in health
between central and state governments, and care and underdevelopment of health in India.
municipal and panchayat local governments.
The facilities include teaching hospitals, The constitution of India has made health care
secondary level hospitals, first level referral services largely a responsibility of state
hospitals (community health centres [CHCs] governments but has left enough
or rural hospitals), dispensaries, primary manoeuvrability for the Centre since a large
health centres (PHCs) and sub centres, and number of items are listed in the concurrent
health posts. Apart from this there are public list. And the Centre has used this adequately
facilities for selected occupational groups like to expand its sphere of control over the health

sector.4 Hence the central government has Health, Department of Family Welfare and
played a far more significant role in the health Department of Indian Systems of Medicine
sector than demanded by the constitution. and Homeopathy, and the Directorate General
The health policy and planning framework has of Health Services. The Departments of
been provided by the central government. In Health, Family Welfare and Institutions of
concrete terms, the central government has Indigenous Systems of Medicine &
pushed various national programs (vertical Homeopathy (ISM&H) each have a secretary
programs for leprosy, tuberculosis, blindness, with a hierarchy of additional, joint, deputy
malaria, smallpox, diarrhoea, filaria, goitre and under-secretaries looking after various
and now HIV/AIDS) in which the states had programs of the three departments. The
little say in deciding the design and Directorate General is the technical wing and
components of these programs. The states provides the requisite technical support for
have acquiesced to such programs due to the the various health programs. For some of the
central government funding that accompanies programs/schemes there are directors,
them. These programs are implemented advisors and commissioners and their
uniformly across the length and breadth of deputies and assistants. This fact of an
the country. Then there are the centre’s own elaborate structure at the Central government
programs of family planning and universal level shows the extent of involvement of the
immunisation which the states have to
centre in what is essentially the sphere of the
implement. Hence, central government
provincial government. The same elaborate
intervention in the state’s domain of health
administrative structure (more or less) is
care activities is an important feature that
repeated at the state level. There is a minister,
needs to be considered in any analysis of
secretary and a Director of Health with their
public health care services.
deputies, assistants etc. in each state. To
facilitate interaction between the central
The administrative structure of public health
services in India is ‘two-winged’. First, there government and state governments there is a
is the secretariat of the health ministry and Central Council of Health and Family Welfare,
second there is the technical wing, which is which comprise the health ministers and
called the directorate of health services. Both secretaries from all states and a few
these wings are under the Ministry of health, nominated members. This council is also the
the former under the Secretary of the Ministry primary advisory and policy-making body for
and the latter under the Director General health care in the country. The Planning
(Director in States). The directorate is Commission also has a health cell that
subordinate to the secretariat. At the central supports this advisory and policy-making
government level there is a Ministry of Health function besides preparing detailed plans for
and Family Welfare with Department of the health sector of the country.
4
The Constitutional provisions (Schedule 7 of article 246) are classified into three lists, including a Concurrent
list which both centre and states can govern but the overriding power is with the centre. The list here includes
original entry numbers Central List: 28.Port quarantine, including hospitals connected therewith; seamen’s and
marine hospitals 55.Regulation of labour and safety in mines and oilfields State List: 6.Public health and sanitation;
hospitals and dispensaries 9.Relief of the disabled and unemployable Concurrent List: 16.Lunacy and mental
deficiency, including places for the reception or treatment of lunatics and mental deficients 18.Adulteration of
foodstuffs and other goods. 19.Drugs and poisons, subject to the provisions of entry 59 of List I with respect to
opium 20A.Population control and family planning 23.Social security and social insurance; employment and
unemployment. 24.Welfare of labour including conditions of work, provident funds, employers’ liability, workmen’s
compensation, invalidity and old age pensions and maternity benefits 25.Education, including technical education,
medical education and universities, subject to the provisions of entries 63, 64, 65 and 66 of List I; vocational and
technical training of labour.] 26.Legal, medical and other professions 30.Vital statistics including registration of
births and deaths. (http://alfa.nic.in/const/schedule.html)

With efforts to decentralise governance many These large bureaucracies at the centre and
of the functions are being transferred to the state level and in a few states even at the
district level under the Panchayat Raj Acts in district level “direct and administer” the
various states. Under the health sector a very various health programs through officials and
large domain has been suggested for local medical personnel at the district and lower
authorities to take over.5 However, it must be levels and in metropolitan city hospitals. The
noted that as yet the implementation of these large cities, depending on their population
various provisions is very poor, especially have a few state run hospitals (including
since fiscal decentralisation has not taken teaching hospitals). At the district level on
place. Wherever decentralisation has an average there is a 150 bedded Civil General
occurred, like in Maharashtra since the Hospital in the main district town and a few
sixties, large local bureaucracies have also smaller hospitals and dispensaries spread
emerged at the district and taluka levels. But over the other towns in the district and
even in such cases the impact is poor as the sometimes in large villages. In the rural areas
healthcare services suffer from the same of the district there are rural hospitals,
malaise as in places where there is no primary health centres and sub-centres that
panchayat raj. 6 provide various health services and outreach
services.
5
An example of the Karnataka Panchayat Act is given here: Panchayat level: XVIII. Rural sanitation: (1) Maintenance
of general sanitation. (2) Cleaning of public roads, drains, tanks, wells and other public places. (3) Maintenance
and regulation of burning and burial grounds. (4) Construction and maintenance of public latrines. (5) Disposal
of unclaimed corpses and carcasses. (6) Management and control of washing and bathing ghats. XIX. Public
health and family welfare: (1) Implementation of family welfare programs. (2) Prevention and remedial measures
against epidemics (3) Regulation of sale of meat, fish and other perishable food articles (4) Participation in
programmes of human and animal vaccination (5) Licensing of eating and entertainment establishments. (6)
Destruction of stray dogs. (7) Regulation of curing, tanning and dyeing of skins and hides. (8) Regulation of
offensive and dangerous trades. XX. Women and child development: (1) Participation in the implementation of
women and child welfare programmes. (2) Promotion of school health and nutrition programmes. XXI. Social
welfare including welfare of the handicapped and mentally retarded: (1) Participation in the implementation of the
social welfare programmes, including welfare of the handicapped, mentally retarded and destitute. (2) Monitoring
of the old-age and widows pension schemes.
Taluk Panchyat level: XIX. Health and family welfare: (1) Promotion of health and family welfare programmes.
(2) Promotion of immunisation and vaccination programmes. (3) Health and sanitation at fairs and festivals. XX.
Women and child development: (1) Promotion of programmes relating to development of women and children. (2)
Promotion of school health and nutrition programmes. (3) Promotion of participation of voluntary organisations in
Women and Child Development programmes. XXI. Social welfare including welfare of the handicapped and mentally
retarded: (1) Social welfare programmes including welfare of handicapped, mentally retarded and destitute. (2)
Monitoring the Old Age and Widow’s pensions and pensions for the handicapped
Zillah Panchayat level: XIX. Health and family welfare: (1) Management of hospitals and dispensaries excluding
those under the management of Government or any other local authority. (2) Implementation of maternity and
child health programmes. (3) Implementation of family welfare programmes. (4) Implementation of immunization
and vaccination programmes. XX. Women and child development: (1) Promotion of programmes relating to
development of women and children. (2) Promotion of school health and nutrition programmes. (3) Promotion of
participation of voluntary organizations in women and child development programmes. XXI. Social welfare, including
welfare of the handicapped and mentally retarded: Promotion of social welfare programmes, including welfare of
handicapped, mentally retarded and destitute. (http://www.kar.nic.in/rdpr/acts-frameset.html)
6
In a recent trip to Mizoram we visited a few PHCs and sub-centres. It was astonishing to see that they were well
provided for, as well as optimally utilized by the local community. The districts we visited had one PHC per 7000-
8000 population and a subcentre per 1500 population with reasonably good supply of drugs and well maintained
and clean premises with most staff in position. Fifteen years ago we had visited PHCs in Nagaland and Meghalaya
and they were functioning reasonably well. One feature of these areas is the absence of the private sector, apart
from the fact that the health institutions are reasonably well provided. In contrast in the last ten years we have
visited a number of PHCs, rural hospitals, sub-centres in Maharashtra, Gujarat, Rajasthan and Madhya Pradesh
and invariably inadequate provision was a major concern. Rajasthan was perhaps a little better off and this may
again have something to do with the smaller presence of the private health sector in this state.

At present, there are 17,000 hospitals (34 per per cent of beds were in the private sector.
cent rural), 25,670 dispensaries (40 per cent An estimated 75 per cent of allopathic doctors
rural) and about one million beds (23 per cent were in the private sector, about 80 per cent
rural) for the country as a whole7. In addition of them being individual practitioners. In the
the rural areas have 24,000 PHCs and case of non-allopathic doctors over 90 per cent
140,000 sub-centres. However, when this work in the private sector. Private health
data is represented proportionately to its services, especially the general practitioners,
population we see that urban areas have 4.48 are the single largest category of health care
hospitals, 6.16 dispensaries and 308 beds per services utilised by the people. It is important
100,000 urban population in sharp contrast to note here that in addition amongst persons
to rural areas which have 0.77 hospitals, 1.37 practicing medicine as private practitioners a
dispensaries, 3.2 PHCs and 44 beds per large number of unqualified practitioners also
100,000 rural population. The city hospitals need to be included. Hence, the exact number
and the civil hospitals are basically curative of practicing doctors in the country is not
centres providing outpatient and in-patient known. From available data it is known that
services for primary, secondary and tertiary in year 2000 there were over 550,000
care. In contrast the rural institutions provide registered allopathic doctors and over 700,000
mainly preventive and promotive services like registered non-allopathic doctors. And out of
communicable disease control programs, this total of 1.25 million about 1.04 million
family planning services and immunisation were estimated to be in the private sector.
services; curative care in the rural health Further, in both rural and urban areas a large
institutions are the weakest component in number of unqualified practitioners exist and
spite of a very high demand for such services it goes without saying that they are all a part
in rural areas. As a consequence this demand of the private sector. Beyond this information
is met either by the city hospitals or by private no other knowledge about the private health
practitioners. Medical Education is imparted services sector is available.
largely through state owned or funded
institutions at a highly subsidised cost to the The private health sector, especially the
students. There are 165 recognised allopathic allopathic, constitutes a very strong lobby in
medical colleges in the country producing over India. There is virtually no regulation of this
20,000 medical graduates every year; and out sector. The medical councils of the various
of these, 75 per cent are produced in public systems of medicine perform only the function
institutions. However, the outturn from these of registering qualified doctors and issuing
institutions does not benefit the public health them the license to practice. There is no
services because 80 per cent of the outturn monitoring, continuing education, price
from public medical schools either join the regulation, prescription-vetting etc., either by
private sector or migrate abroad. Here it would the medical councils or the government. The
be in order to provide a brief description of private healthcare sector is strongly backed
the private health sector and health insurance by the private pharmaceutical industry
coverage in India. (largely multinational), which again
constitutes a very powerful lobby that has kept
The private health sector in India, as indicated at bay any progressive policy initiatives, such
earlier, is very large, perhaps the largest in as the recommendation of the Hathi
the world. In 1997 an estimated 68 per cent Committee Report. 8 Pharmaceutical
of hospitals, 56 per cent dispensaries and 37 formulation production in India is presently
7
Central Bureau of Health Intelligence.Directorate General of Health Services, Ministry of Health and Family
Welfare. Health Information of India 2000 &2001.
8
The Hathi Committee’s recommendations pertained to removal of irrational drug combinations, generic naming
of essential drugs, development of a National Formulary for prescription practice.

worth over Rs. 200 billion and over 98 per health expenditure had peaked because of the
cent of this is in the private sector. Thus the large expansion of the rural health
private health services and the infrastructure but after 1986 one witnesses
pharmaceutical industry are together a declining trend in both new investments as
organised into a network that perpetuates one well as expenditures as a proportion to the
of the most powerful private health sectors in GDP, as well as a percentage of government’s
the world. overall expenditures. In sharp contrast out-
of-pocket expenses, which go largely to the
Apart from the above a small section of the private health sector, have witnessed
population, largely what is called the unprecedented increases.
organised sector, that is those working in
government, private industry and services Current Scenario: Health
have some form of health insurance coverage, Communicable diseases not only continue to
either through state mandated social security be the single largest cause of mortality but
like ESIS, CGHS, Maternity Benefit Scheme, prevalence of many diseases like tuberculosis
and various other schemes for mine workers, and malaria has increased and diseases like
plantation workers, beedi workers, cinema AIDS, leptospirosis, dengue etc. have got
workers, seamen, armed forces, railway added to the list.
employees etc., or through employer provided
health services or reimbursements. This Public investment in the health sector since
population estimated to be about 12 per cent the Structural Adjustment Program (SAP) has
of the country’s population might be said to declined and this is reflected in drastically
have right to healthcare, at least during the reduced capital expenditures and no further
working life of the main earner in the family. expansion in the public health infrastructure.
In addition, revenue expenditures on health
Given this domineering position of the private have declined both as a proportion to the GDP
health sector and the context of large-scale as well as a percentage of total public
poverty the health outcomes are not expected spending, and within this reduced
to be very good. There have been substantial expenditure allocation inefficiencies have
improvements in health outcomes such as increased especially after the 5 th Pay
infant mortality rate (IMR), crude birth rate Commission.
(CBR), crude death rate (CDR) and life
expectancy over the years but globally the The above has further reduced the credibility
position of India has not changed significantly and acceptability of the public health system
vis-à-vis these indicators. In fact the latest and one sees declining utilisation rates of
Human Development Report shows a public health facilities. On the other hand the
downward trend in India’s global ranking.9 dominance of the private health sector is
increasing but with absolutely no regulation
This climb down and slowing of growth in and minimum standards being followed. The
India’s human development score is perhaps medical profession pays no heed to self-
linked to the declining investments and regulation or ethics and has never looked at
expenditures in the public health sector (as the possibility of an organised system of
also the social sectors as a whole), especially healthcare. In fact the profession is losing
in the nineties. In the mid eighties public control to the corporate sector, which is now
9
India’s human development index rank is down from 115 in 1999 to 124 in 2000, though still better than the
1994 rank of 138. India is on the fringe of medium and low HDI group of countries. India’s improvement in the
HDI in the last 25 years has been marginal from a score of 0.407 in 1975 to 0.577 in 2000 - this works out to an
average increase of 1.6 per cent per annum. The slowing down of growth is shown in the table below: (Source:
UNDP HDR, various years)

looking beyond the hospital sector at not only encounter etc. While there may be
diagnostics but also consultant services and constitutional and program-based safety nets
general practice. Such a scenario is bound to for many such groups in reality these have
impact on costs and increase the burden on failed to improve their situation. The future
the patients. Such a situation is not good for for many of these groups has more adversities
70 per cent of the country’s population that than hope if present trends continue.
lives in poverty or at subsistence level.
Apart from leprosy, HIV/AIDS has got added
Current Scenario: Disability on as a disease based disability.
As per 1991 NSSO 47th Round estimates about
1.9 per cent of the population, i.e., 19 million The increasing elderly population is another
persons today have physical or sensory group which would need disability support in
disabilities which include visual, speech, the future.
hearing and locomotor disabilities. Sex
differentials show that physical disabilities are Rehabilitation for all disability groups is
higher among males by one-third. In rural extremely inadequate and needs a great deal
areas it was nearly one-fifth higher as of attention from the state, corporates and civil
compared to urban areas. society.
Mental disabilities affect over 2.5 per cent of The Changing Political Economy
the population as revealed by various surveys, India is knocking at global markets. Since the
it being over 3 per cent for children in age mid-1980s India has rapidly integrated with
group 0-14 years. Another one percent of the the world economy and now faces not only
population is mentally ill. the ups but also the downs as protection of
the internal economy has become a thing of
As regards the State-wise distribution of the past. The globalisation of India was
physical disability, the States which have speeded up under the Structural Adjustment
higher prevalence rate, than the national Program designed with World Bank’s
average, were Andhra Pradesh (24.98/1000), assistance to reform India’s economy. A large
Himachal Pradesh (28.70/1000), Karnataka part of the middle class has certainly benefited
(21.31/1000), Madhya Pradesh (27/1000), from the SAP and related initiatives but overall
Orissa (23.06/1000), Punjab (29.36/1000) poverty has not declined - if at all it has added
and Tamil Nadu (23.72/1000). to the misery of the already impoverished
masses.
Among the physically disabled 25 per cent of
the disabled people in the rural areas and 20 Health sector reforms did not stay far behind.
per cent in urban areas suffered from such But the question is, were they reforms in the
severe disabilities that they could not perform positive or progressive sense? In the name of
activities of self-care and daily living even with reforms, again under the aegis of the World
aids/appliances. The NSSO surveys are Bank, and other bilateral and multilateral
considered to be underestimates by many agencies like USAID, DFID, WHO, UNICEF etc.
people involved with working on disabilities. public health investment became even more
selective and targeted at selected populations.
Social disabilities like gender, caste and Thus family planning and immunisation
community also have significant health services, and selective disease programs like
consequences. Thus women, dalits, adivasis, HIV-AIDS, acquired an even more central
religious minorities, sexual minorities etc. position in public health care and other
suffer disabilities due to the violence they face, concerns like curative services, hospital care,
the social and economic discrimination they malaria, tuberculosis, maternity services, etc.

lost further ground. The new priorities were Further, it is the consistent good performance
not priorities determined by those who needed of agriculture that has helped ward off the
health care but by global agents of change severities of SAP, which many other countries
who were in the business of adjusting India have faced. In addition, India’s strong
to the world economy! investments in the past in rural development,
especially employment guarantee programs
Economic reforms towards liberalisation and agricultural subsidies aided in reducing
began in the early 1980s. This is important the adverse impact of SAP. And this is not
to note because often there is a tendency to likely to change thanks to the strong farm
look only at the post-1991 period. Data lobby that is in fact demanding greater
available up to now clearly show that investments and subsidies for the rural
economic performance of the 1980s far economy. Thus at one level India is much
outweighs that in the 1990s. The underlying more exposed to the global market with
fact about this is that in the 1980s there was increasing vulnerability. But at another level
no structural adjustment or World Bank it continues to enjoy an inner strength and
dictat. The classical ‘Hindu’ rate of growth10 autonomy because of its sheer size, its large
in the eighties had doubled from 3 per cent to rural-agricultural population and a large local
6 per cent, without much inflation and with market of its own, despite the fact that
declining levels of poverty. Thus we were
politically the situation is very fluid. This
already liberalising our economy and speeding
background is important for understanding
up growth without the World Bank aiding the
the impact and changes in the health sector.
process.
Impact of Changing Political Economy
In fact, the post -reform (1991) period slowed
down growth, increased poverty and inflation, While the existing situation is very dismal,
and reversed many trends of the 1980s. No the changing political economy does not show
doubt it caught up towards the mid-1990s, too much promise of change for the
but it has not yet surpassed the achievements betterment of health and disability, unless of
of the 1980s. Thus in the eighties India was course there is a radical transformation in
developing rapidly with a gradual globalisation political commitment. For this to occur, the
process and with the advantage of its inner support of civil society pressures and
strength which insulated it from global demands for a transformation of the
shocks. In the 1990s there was rapid healthcare and rehabilitation dispensation
globalisation that exposed India to global will be needed.
fluctuations; if India survived the Asian shock,
which destroyed Indonesia and other The changing political economy demands
Southeast Asian economies, it was because reduced state participation in the economic
of its sheer size and the strengths of its own spheres both in terms of policy and
local markets. Another fact to contend with intervention. Yet, at the same time the new
is the continuing dependence of over two- political economy has failed to strengthen the
thirds of the population on agriculture and welfare role of the state. Under SAP and other
70 per cent of the population living in rural related measures, the state intervention in the
areas. Since the larger impact of macro- economy declined but so have investments,
economic reforms is on the urban-industrial expenditures and interests in the social
sector, which integrates globally with much sectors. This trajectory of growth has
ease, the rural population in a sense still has worsened the situation for the poor and
relative protection from global impacts. subsistent population of the country.
10
A phrase attributed to economist Raj Krishna who used it to illustrate his conclusion that the rate of growth had
remained unchanged at 3.5% in the three decades after independence.

One very clear impact is declining state Another trend that further reduces access is
investments in the health sector. With rising the increased corporate control of health care.
debt burdens of the state the social sectors New medical technologies have helped
are the first to be axed. There has been a complete the commodification of health care
declining trend since 1991 in social sector and this has attracted increased interest from
expenditures, especially by the Central the corporate sector, which has jumped into
government and this is best reflected in the health care business in a very big way.
compression of grants to the states for social With these kinds of pressures the thinking
sector expenditures. Health care expenditures has to change radically if we believe in
too have been affected both in quantitative universal access to healthcare with equity
terms (declining real expenditures) and within a rights-based approach. Achievement
qualitative terms (increasing proportion of of this goal implies that future health priorities
establishment costs and declining proportion have to be defined towards developing an
on medicines, equipment, maintenance and organised system of healthcare that is rights-
new investments). based.
Another very striking impact is the rapidly At the global level, right to healthcare is being
rising cost of medicines. With greater intensely debated in the context of the
dependence on the private health sector even International Covenant on Economic, Social
by the poor this has meant extreme hardship. and Cultural Rights (ICESCR). Article 12 of
With the drug price control virtually on its ICESCR talks about the right to the highest
way out and with India having signed the WTO attainable standard of health which is
treaty on IPR we are moving closer to elaborated in General Comment 14. Civil
international prices of drugs. The combined society groups, especially in developing
effect of the above facts makes a deadly countries have shown increasing concern on
mixture that results in reduced access of the issues of declining access to healthcare and
poor to health care. As stated above the the Peoples Health Movement (PHM) has
historical dominance of the private health care taken up this issue in a big way. In India the
sector in India in provision of ambulatory care PHM India chapter, the Jan Swasthya
and rising costs could spell disaster for the Abhiyan, has recently launched a national
poor given the fact that the State is gradually level initiative to demand a right to healthcare
reducing its responsibilities in providing through an organised universal access system
health care. Since the poor too have been for basic health services. The National Human
active users of private health care their Rights Commission has supported this
dependence on it makes the case for “right to initiative through organisation of regional
health care” an increasingly distant dream on public hearings to illustrate denial of health
the political agenda. care cases as well as to highlight issues and
concerns in formulating a strategy towards
At the global level World Bank is propagating establishing the right to health care.
selective care for selected (targeted)
populations under the public domain. The Overview of the Present Volume
WHO too has dropped its Health for All The present volume is an effort to bring
commitment and fallen in line with the World together these issues and concerns and
Bank thinking. This global pressure on the provides a situational analysis of the
Indian State is evident through its policies of healthcare situation in the country. While
focusing on selective services, for instance efforts have been made to cover all critical
reproductive and child health (RCH) and AIDS dimensions, one cannot stake a claim to this
receive overriding support over primary health book being a comprehensive review of the
care or basic referral services. state of healthcare in India. We accept the

limitations of the volume and have been The first phase showed a period of growth at
unable to cover issues like non communicable all levels. A network of health institutions were
diseases, disabilities, healthcare in hazardous put in place, and the improvement of standard
occupations, health care for vulnerable of living and economic conditions brought
populations like people in conflict areas, about a decline in the mortality rates. The
displaced people and the homeless. second period showed growth of village level
services with the creation of multi purpose
The volume starts with a review of National workers and an attempt at reorienting the
Health Policies, followed by an exploration of medical education towards rural conditions.
the historical context in which the public The third phase saw a boom in the
health system in India evolved. The growth of proliferation of healthcare institutions, both
health services in India can be chronicled over in the private and the public sector. With
four periods from independence to the present international funding for specific programs,
day, with reference to the three social roles public health became preventive medicine. By
the health services were expected to play, the end of the 1980’s, the public health system
which were Public Health Provisioning, Policy was in a crisis. The 1990’s onwards showed
Formulation and Planning for the Health growth at the secondary and tertiary levels
Sector, and Early Detection of Social Pathology. with an increased felt need for hi tech services,
but a decline in accessing healthcare and
At Independence, the recommendations of
treatment.
three Committees were available as a guide
to use while planning the health services:
India’s fight against communicable diseases
is marked by the adoption of western
The Health Survey and Development
influenced biomedical interventions as the
Committee chaired by Sir JC Bhore gave its
sole interventions with little importance given
report in 1946. The recommendations were
based on the principles of equal access, focus to overall socio-economic development. This
on rural areas for service provision, resulted in a vast amount of resources being
comprehensive preventive and curative committed to “vertical programs” thereby
services, a system led by the most “highly leading to a drain on resources for the overall
trained type of doctor”. Major public health development of public health services.
problems were to be controlled by vertical
programs and 15 per cent government The National Health Programs of India are a
expenditure was to be on health. reflection of the reductionism and technical
quick fix solutions, which characterise the
The Chopra Committee on Indian Systems of health system we inherited from the British.
Medicine (ISM) recommended the mutual They medicalise illness and fail to address the
exchange of knowledge between Allopathy and socio-economic and political causes
ISM to bring about enriched integrated underlying that illness.
knowledge systems in 1946.
A number of vertically oriented disease control
The Sokhey Committee (1948) in contrast to programs were adopted by the Government
the above two recommended the development of India and were preferred for their quick
of services and manpower from the grassroots results, which provided the government
level upwards. Youth from each village were freedom from the responsibility of setting up
to be trained as health workers and trained a sustainable network of health services, and
further to become doctors based on their gained favour with international funding
performance. organisations.

A review of the national health programs in emerged as a movement for health rights. Lest
place for the control of malaria, tuberculosis we forget, CHW programs are NOT complete
and HIV/AIDS, in addition to the in themselves and a parallel effort to
immunisation program indicate the restructure and strengthen public services is
shortcomings of such a vertical approach. In necessary.
addition to being dependent on foreign
resources and technology, these programs Population policy has occupied a premier
ignore the local determinants fuelling ill position in India’ s health policy and planning.
health, which also need to be addressed. India’s family planning program, one of the
first official family planning programs in the
Community Health Worker (CHW) programs world, has undergone a series of changes and
play a vital role in the public health system, has adopted different approaches over time.
however, the CHW programs started by the The program depended on the introduction
government often fail. The reasons for failure of new contraceptive technology with each
are varied and are often related to unrealistic idea working for some time until it fizzled out.
expectations for the workers with respect to Over time, the Government of India
designated tasks and geographical outreach. introduced a paradigm shift in the Family
To meet current needs of the rural population, Planning Program strategy, which was
we would need to increase the workforce by reflected in the National Population Policy
about 5 times, and even then, it would not 2000, which endorsed a voluntary target free
solve the problem of geographic outreach. approach, which was to be devoid of incentives
and disincentives.
The mid 1970’s saw the emergence of CHW
programs started by voluntary organisations The current policy scenario, however, shows
and the NGO sector. It was found that a team an alarming variance to the ideals expressed
of trained and guided health workers could above. Recently a number of states like
significantly impact health outcomes Madhya Pradesh, Rajasthan, Andhra Pradesh
irrespective of literacy levels and educational and Haryana introduced a two-child norm
qualifications. policy linked with a series of draconian
measures. These included non-access to
A review of different CHW programs shows school for the third child, non-eligibility for
that factors necessary for success are: strong food through the public distribution system
leadership providing support and training for families with more than 2 children, etc.
throughout the program, a duration of at least Although a number of women’s rights groups
5-10 years, a good quality of referral linkages and health related groups were vociferous in
where higher degrees of illness can be handled their protest to the National Human Rights
and women as health care providers. Commission, the Government of India
announced a bill seeking to restrict people
NGO based CHW programs are dependant on with more than 2 children from contesting
external funding since they have no cost elections.
recovery systems in place, and this is a serious
threat to their sustainability. On the other Policies like those discussed above violate
hand, government programs fail due to principles of equality and justice, are
loopholes in recruitment, poor referral demographically incorrect, and fundamentally
networks, and over-emphasis on curative care. represent a distorted view of the relationship
between population and resources.
CHW programs have a role to play in health
sector reform. In addition to providing primary India is in a phase of demographic transition
education and health services, they have with a sustained and substantial decline in

fertility. Investment in social sectors like School Health and Midday Meal Program in
health, education, employment, food etc and 1960. Although some states have
meeting the unmet needs for family planning implemented these programs, there remains
are required to facilitate the decline in fertility. a lot to be done to ensure these are sustained
However the focus remains fixated on family as routine services for all school going
planning, allocations towards which are children.
increasing compared to public health, which
shows a proportionate decrease in budgetary Reproductive Health Services in India have
allocations. historically been techno centric, based on
demographic goals, and focused on women’s
The disturbing trend of masculinization of sex fertility, particularly the poor. Population size
ratios at birth and among children will only and fertility control captured the minds of
be further fuelled with the two-child norm and Indian Nationalists and Colonialists who felt
further encourage sex selective abortions. the poor caused their own poverty. Following
Independence in 1952, amidst growing
Child Health occupies a special place in public concerns that an overwhelming population
health for a number of reasons including the hampered economic growth and development,
special vulnerability of children to diseases, the Indian State became the first in the world
which are most amenable to preventive action. to initiate an official Family Planning Program.
As a result, health services envisaged by The 1970’s witnessed the emergency with
children’s health programs have been centred coercion reaching its zenith, while the 1980’s
on immunisation and supplementary feeding, ushered in the “educational and wholly
with some attention to promotion of breast- voluntary approach”. Following the ICPD in
feeding and management of diarrhoea and Cairo in 1994, India’s Family Planning Policy
pneumonia. The Integrated Child underwent a paradigm shift from the existing
Development Scheme (ICDS) is the largest method specific target oriented approach to
such scheme and gobbles up most of the an approach towards reproductive health
resources earmarked for childcare. Started in through women’s rights and empowerment.
1975 to serve the population under the age of
6, its objective included preventive health The Reproductive and Child Health (RCH)
services, as well as pre-school non-formal Program adopts a comprehensive approach
education. Unfortunately, there remain gaps which provides a package of services for
in the infrastructure set up through the mothers, children and adolescents. However,
scheme, staffing, equipment, medicine and an assessment of the RCH carried out in five
extent of outreach. states, brought to light the problems women
face in accessing these services. These
The National Crèche Scheme was also started included: inconvenient service timings, class
in 1975, but according to the author’s and caste barriers, physical and verbal
estimation, children in crèches are violence, and low priority for gynaecological
approximately a minuscule 0.7 per cent of the problems, poor counselling and referral
children needing these services. Health services- the RCH leaves a lot to be desired.
services are supposed to include The burden of responsibility for family
immunisation supplementary feeding, health planning falls on the women, since there is
checks, and medicines but evaluation of the no inclusion of men in the program. The RCH
crèche scheme by NIPCCD showed lacunae leaves out of its domain, other important
in all components of the scheme. problems, not related to pregnancy, like
occupational health, domestic violence, and
The School Health Committee started the mental health.

There is an urgent need for a comprehensive each other, are all clubbed together under a
Mental Health Policy to meet the needs of large head: Indian Systems of Medicine (ISM).
people living with mental illness. Services and ISM includes ayurveda, unani, siddha,
laws remain outdated and mental health naturopathy, amchi, to name just a few.
needs have to be brought on to the health
agenda. The health culture of our country is therefore
characterised by a pluralistic nature with an
Gender based violence is regarded the world array of medical systems available to the
over as a public health issue, but in India it consumer, but with a distinct hierarchy of
still lacks the attention it deserves in the systems in terms of recognition and
public health scenario. patronage.
Females are vulnerable to violence throughout It was found that while allopathic practitioners
their lifecycle from the pre-birth risk of sex were urban based, and tended to cater to
selective abortions to inhuman treatment of wealthier sections of society, non allopathic
elderly widows. care givers tended to meet the needs of the
rural population as well as poorer sections of
A number of reasons make the public health society in the urban areas. This led to the
system an important site for the belief that non-allopathic systems fill a
implementation of anti violence intervention geographical and social gap left by allopathy.
programs. For victims of violence it is often Even within ISM, there is the formal state
the first place of contact with the health recognised sector and the comparatively more
system, only public hospitals can register accessible folk care sector made up of spiritual
medico legal cases and private practitioners and ritual healing. The integration of ISM with
often avoid suspected cases of violence. allopathy to facilitate service delivery to
underserved areas was also strongly resisted
Victims face a number of barriers in the by medical associations thereby further
system, mainly staff who are inadequately compartmentalising the system.
equipped to recognise and deal with violence.
Contrary to the beliefs expressed above, the
Intervention programs need to be at multiple state wise distribution of non-allopathic
levels; primary prevention like media, public systems throughout the country is related
awareness campaigns about positive gender more to historical and cultural factors than
roles and the status of women in society help to the distribution of allopathic care.
prevent violence by striking it at the root. Therefore, it is found that states having more
Secondary prevention addresses harm already allopathic facilities than other states tend to
done and minimises further damage, while also have more non-allopathic facilities,
tertiary prevention would be rehabilitative showing that in general there is a state wise
services, like vocational training for gainful concentration of health care facilities.
employment etc.
The widely unregulated pharmaceutical
The entire discussion on public health and industry has benefited from globalisation with
making primary health care accessible to all medicinal plants being exported to countries
has always been centred around allopathy, where people are now switching to more
synonymous with “modern” western medicine “natural” medicines, but draining the
and has sidelined or totally ignored the resources of raw material for domestic use.
systems of medicine that were existing in the
country before colonial rule. Indeed, these In order to ensure universal access to care, it
systems, in spite of being very different from is important to recognise the knowledge and

skilled people in the non-allopathic systems order to ensure health care as a basic right, it
and work toward integrating all systems with will be necessary to reorganise the health
a sharing of resources so that the overall sector, by ensuring primary health and
health personnel force can be expanded and improving efficiency of resource allocation,
enriched. strengthening referral linkages and regulating
the private health sector.
The relationship between the extent of
equitable access to healthcare and the degree Access to health care is defined as the use of
of public financing of healthcare is well healthcare by those who need it. Studies show
known. Analysis of outcome indicators and that gender, social geography, social groups
percentage of public investment in health in and class influence access. Inequities in
a number of countries shows that indicators access to healthcare lead to systematic
are poorer where public investment is low. The differences in health outcomes within different
scenario in India reflects this observation, subgroups of population.
where, declining public expenditures over the
1980s, which further accelerated in the Reported morbidity and ailments are often
1990s, led to a stagnation of the declining under reported, one of the factors being the
infant mortality rates and a resurgence of a perception of health. Therefore observations
number of communicable diseases.
regarding class differentials may not be as
conclusive as the sharp differentials seen in
The decreased public health spending is
rates of hospitalisation, where rates are much
leading to incapacitated public health
higher for urban populations and those
facilities, where, due to insufficient funding,
belonging to higher income groups. Untreated
the staffing levels are far below acceptable
ailments are higher among women, the rural
norms, there is a constant shortage of
population and show class differentials
consumables and all this is housed in
dilapidated buildings. indicating that treatment depends on the
economic background of the person and the
Inefficient use of the meagre funds like salary exposure to healthcare services.
increases without budgetary increases
compound the constraints faced by low The public hospitals are accessed more for
budgetary allocations. New policies admissions and inpatient services, while
encouraging user fees lead to a major chunk private practitioners often provide ambulatory
of expenditure being out of pocket, and care. The finding that strengthens the
pushing poorer sections of society into argument for universal access to healthcare
indebtedness following any catastrophic being a basic right is the fact that the financing
illness or an episode of hospitalisation. The of most healthcare in India is through out of
scarce funds are distributed over an urban- pocket payments, with source of money being
rural hierarchy with curative services being current incomes, savings and often sale of
concentrated in urban areas, while rural areas assets. In fact healthcare expenses push a
are only given preventive and promotive large number of people into debt, which is
health. probably why rates of hospitalisation and
reported morbidity are much lower in poorer
As the public health sector deteriorates, the populations.
largely unregulated private health sector is
growing in leaps and bounds. Up to 85 per Ensuring universal access will mean special
cent of health expenditure is privately funded, efforts to include the most vulnerable and
of which the bulk is out of pocket, causing marginalized populations within the fold of
most of the burden to fall on households. In publicly funded health services.

The private sector in India has managed to citizens, irrespective of their ability to pay. At
permeate through primary, secondary and present, there is a gradual withdrawal of the
tertiary levels of healthcare, in the urban and state from its role in providing health care
rural areas, in all systems of medicine. The through the public health system, and an
burden of financing falls on the shoulders of increasing investment in hi tech, expensive
individual consumers, as 80 per cent of health private health care.
expenditure is out of pocket. Privatisation is
not only limited to healthcare delivery but has The right to health and the availability of
also penetrated the medical equipment and health care are issues that have been
pharmaceutical industry, with multi national addressed all over the world. The United
and national corporate companies Nations has adopted various resolutions
dominating. Education and training have not protecting health rights of people like the
been left out in this widely spread and rapidly Universal Declaration of Human Rights and
progressing phenomenon. the ICESCR. The World Health Organization
Constitution states:
Although showing state wise and state-wide
variations, the private sector is skewed The Constitution of India also covers
towards urban areas, and in rural areas it has health and healthcare, but does not
flourished in economically forward regions. It explicitly recognise right to health as a
tends to be very hi tech oriented, with fundamental right. The Directive Principles
corporate hospitals investing increasingly of State Policy cover various health related
large amounts in medical equipment, issues like provisions for just and humane
particularly diagnostic imaging. In fact, conditions of work, wages for workers, level
investment on imaging equipment far exceeds of nutrition and living conditions for
that on laboratory equipment, and makes up workers, protection of environment etc.
50 per cent of total investment on equipment.
The Supreme Court has passed a number of
Not only is the private sector omnipresent, it judgements dealing with right to access to
is also largely unregulated, thereby medical treatment under various conditions
jeopardising the quality of care provided. A ranging from the right to healthy life to right
study in Mumbai showed that most nursing to privacy as a component of healthcare.
homes are poorly maintained and are staffed Although these judgements support the right
with inadequately trained personnel. There to health, the actual means for enforcing this
are no safe waste disposal facilities, physical right elude the system. Health having many
standards are poor in quality, and none of dimensions and therefore many possible
them were registered with any local authority. definitions, the right to health is a subjective
Physicians in private practice are often driven issue to address. However, the right to health
to over prescription of certain medications, care, ensuring access to appropriate and
irrational use of diagnostics and splitting affordable healthcare including necessary
practices. Many physicians employed in diagnostics and essential drugs can be
government hospitals extend their practice pursued since health care is amenable to
into private clinics and nursing homes. There implementation of judicial orders.
is an urgent need to regulate the quality and
magnitude of the private sector and harness In a country that is a major player in the
its resources to ensure access to all sections international pharmaceutical market,
of society. supplying drugs to other countries at
competitive rates, drugs remain over priced
The judiciary has a vital role to play in and unaffordable to the majority of Indians –
ensuring access to essential services for all health care is the second leading cause for

impoverishment and poverty in India. Lax regulations have led to profiteering by

Estimates show that 30 per cent of morbidities drug manufacturers, traders and retail
go untreated because of poverty. Those pharmacists. The treatment of common
depending on the public sector for care find ailments can mean days or weeks of labour/
that it is not only urban biased but also work to purchase drugs.
burdened with inequities in quantity and
quality of essential drugs. Studies show that The problem of accessibility is further
drug supplies to Primary health centers need complicated by substandard drugs, which
to be doubled to ensure quality care to people flourish due to lax enforcement of laws, paper
accessing public services; predominantly the printing technology, which aids counterfeit,
poor and middle class. Privatised accessibility widespread corruption, and conflict of
to drugs has nurtured the growth of irrational interests between stakeholders.
drug combinations, and highly priced branded There are a number of initiatives to improve
drugs, which synergize to waste a lot of
access to essential drugs like one where NGOs
patients’ money.
supplying generic drugs and pooled
procurement in the public sector, an effort
Over the last 15 years, the Indian government
currently being carried out by the state
has decreased price controls, allowing
governments of Tamil Nadu, Orissa and New
pharmaceutical to engage in rampant
Delhi.
profiteering. The number of drugs under price
control has decreased from 347 in 1979 to 76
in 1995. Relaxing of price control was based Making right to health care a fundamental
on the assumption that competition in the free right is an important step in the overall goal
market economy would drive down prices, but of health as a human right. In reviewing
this is not happening. Shockingly, drugs not healthcare in India, from various angles, we
price controlled include drugs used for the have tried to present a picture of where we
treatment of tuberculosis, malaria, diarrhoea, stand today, and accept that the review could
hypertension, coronary heart disease, and not be as comprehensive as we would have
epilepsy, while those under price control ideally liked. We still hope this volume adds
include hazardous drugs like analgin, to the momentum of the campaign in making
outdated ones like sulphadimidine, and non Health care and thereby, Health, a Reality for
essential drugs like vitamin E. All !

SECTION 2
PUBLIC HEALTH POLICIES AND PROGRAMMES
Historical Review of Health Policy Making
Ravi Duggal
Introduction the early forties would hold good if a similar

Structured health policy making and health enquiry were undertaken today, over half a
planning in India is not a post-independence century later. Instead of the National Health
phenomenon. In fact, the most Service that the Bhore Committee had
comprehensive health policy and plan envisaged, which would be available to one
document ever prepared in India was on the and all irrespective of their ability to pay,
eve of Independence in 1946. This was the further commodification of health care
‘Health Survey and Development Committee services took place strengthening the
Report’ popularly referred to as the Bhore operation of market forces in this sector. The
Committee. This Committee prepared a enclave pattern of development of the health
detailed plan of a National Health Service for sector continues even today - the poor, the
the country, which would provide a universal villagers, women and other underprivileged
coverage to the entire population free of sections of society, in other words the
charges through a comprehensive state run majority, still do not have access to affordable
salaried health service. Such a well-studied basic health care of any credible quality.
and minutely documented plan has not as yet
been prepared in Independent India. Universal coverage of the population through
some health plan is historically well
The Bhore Committee proposals required established today, whether this is through
implementation of structural changes in the health insurance or state run health services.
then health care system, and had they been There is no developed country, whether
implemented they would have radically altered capitalist or socialist, which has not insured
health care access and health status of the through either of the above means or a
Indian masses, especially the 80 per cent combination a minimum standard of health
population residing in rural areas. It is only care for its population. In socialist countries
an embarrassment for the Indian nation that the state provides health care, among other
more than half a century later there is no ‘social services’, as a basic right of the citizen.
evidence of development of health care In advanced capitalist countries social
services to a level that the Bhore Committee security has evolved under the concept of a
regarded as a minimum decent standard. And welfare state and health care is one of the
neither has the health status of the masses prominent elements. However, such assured
altered very significantly – both in terms of universal coverage of health care has not
the technology and means available as well emerged in any satisfactory manner in most
as in comparison with developed countries underdeveloped countries, including India.
today. The gap then and now has not changed “The underdevelopment of health and health
much. services (in these countries) is brought about
by the same determinants that cause
Health services in India today in terms of underdevelopment in general - the pattern of
accessibility are as inadequate and control over resources of these countries in
underdeveloped as they were during the time which the majority of population has no
of the Bhore Committee. The analysis of the control over their resources.”1 But given a
health situation by the Bhore Committee in political commitment some form of a National
1
Navarro, Vicente : ‘Introduction’ in V. Navarro (ed) Imperialism, Health and Medicine, Baywood, New York, 1981

Health Service can be evolved in these but also through charities of the rich traders
countries. and wealthy persons in the kingdom.
Modern medicine and health care were Hence, in the pre-colonial period, which
introduced in India during the colonial period. coincides with the pre-capitalist period,
This was also a period that saw the gradual structured health care delivery had clearly
destruction of pre-capitalist modes of established three characteristics. Firstly, it
production in India. Under pre-capitalist mode was considered a social responsibility and
of production institutionalised forms of health thus state and philanthropic intervention was
care delivery, as we understand today, did not highly significant. Secondly, the services that
exist. Practitioners who were not formally were provided by these facilities were provided
trained professionals but inheritors of a caste- free to all who availed them or had access to
based occupational system provided health them. Caste, class and occupation did
care within ones village. This does not mean however limit access. And thirdly, most of
that there was no attempt at evolving a formal these facilities were located in towns thus
system. Charaka and Sushruta Samhitas, projecting a clear urban bias.
among other texts, is evidence of putting
together a system of medicine. Universities During the colonial period hospitals and
like Takshashila, Nalanda and Kashi did dispensaries were mostly state owned or state
provide formal training in Indian medicine.2 financed. The private sector played a minor
But the little evidence that exists shows that role as far as this aspect of health care delivery
such structured medicine existed mostly in was concerned. However, the private health
towns around the courts of the rulers; and in sector existed in a large measure as individual
the countryside healers operated as practitioners. The earliest data available on
practitioners of what we term today as ‘folk medical practitioners is from the 1881 census,
medicine’ which records 108,751 male medical
practitioners (female occupation data was not
However, the institutions that functioned as recorded!). Of these 12,620 were classified
hospitals were more in the nature of as physicians and surgeons (qualified doctors
punyasthanas, dharmashalas, viharas and of modern medicine) and 60,678 as
maths. They were the Indian equivalent of unqualified practitioners (which included
Western alm-houses, monasteries and Indian System Practitioners). 5 In addition
infirmaries which were provided with stocks there were 582 qualified medical practitioners
of medicine and lodged the destitute, the serving in army hospitals (71). However, the
crippled and the diseased who received every census data does not reveal the proportion of
kind of help free and freely.3 Similarly, during private practitioners. The earliest data
the Mughal Sultanate the rulers established available for private practitioners is for the
such hospitals in large numbers in the cities year 1938 when an estimated 40,000 doctors
of their kingdom where all the facilities were were reported to be active. Of these only 9,225
provided to the patients free of charge.4 These or 23 per cent were in public service and the
activities were financed not only by the kings rest in private practice or private institutions.6
2
Jaggi, 1979: XIII, 1-3
3
Jaggi, O.P.: Western Medicine in India – Public Health and it Administration, Vol XIV of History of Science,
Technology and Medicine in India, Atma Ram and Sons, New Delhi, 1979
4
Ibid.
5
Census – 1881: Census of India 1881 Vol III, GOI, Delhi, 1883
6
Bradfield, EWC: An Indian Medical Review, GOI, New Delhi, 1938

Ravi Duggal
The Bhore Committee Report corroborates this Bhore Committee, were simple: (a) broad
when for 1941-42 it reports 47,524 registered survey of the present position in regard to
medical practitioners in India (17,654 health conditions and health organisation in
graduates and 29,870 licentiates).7 Of these British India, and (b) recommendations for
only 13,000 or 27 per cent worked in future development.10
government and other agencies (including
private institutions) and the remaining were The letter of appointment of the Committee
in private professional practice (ibid. I.13-14). further stated, “A survey of the whole field of
Besides, there were practitioners of non- public health and medical relief has not
allopathic systems, both of the formally hitherto been attempted. The immediate
trained variety and the informal inheritors of necessity for initiating such a survey has
medical practice. One estimate reveals that arisen from the fact that the time has come to
there was one vaid/hakim per 4285 make plans for post-war development in the
population in 1868 i.e. about 47,000 known health field (A Post-war Reconstruction
indigenous practitioners.8 Committee, that later grew into the Planning and
Development Department was set up in 1943
This clearly shows that the private health to make 5 year Plans for India’s development).
sector was fairly large and well established. The Government of India considers that such
It also indicates the early commodification of plans should be based on a comprehensive
health care delivery, which is inevitable under review of the health problem. One of the
capitalism. Given the racial and urban bias difficulties with which the committee will be
of the State health services9 this large group confronted is that of finance. Financial
of private practitioners must have catered to considerations clearly cannot be ignored.
a large chunk of Indians who didn’t have Plans based on assumption that unlimited
access to the State services but who were able funds will be available for recurring
to muster resources to utilise the services of expenditure will have little practical value. On
private practitioners. the other hand it would be equally unwise to
assume that expenditure on health
Eighteenth October 1943 marks a watershed administration will in the future be limited to
in health policy making and health planning the sums that were expended in the pre-war
in India. It was a great historical moment. In years. It is desirable, therefore, to plan boldly,
the midst of World War II and in succession avoiding on the one hand extravagant
to the Quit-India movement the Government programmes which are obviously incapable
of India (Central Government of British India of fulfilment and on the other hand halting
Provinces) announced the appointment of the and inadequate schemes which could have
Health Survey and Development Committee no effect on general health standards and
under the chairmanship of Sir Joseph Bhore. which, would bring little return for the
Its secretary was Dr. K.C.K.E Raja and one of expenditure involved”.11
the joint secretaries Dr. K.T. Jungalwala.
Some of the well-known members included Prior to this in 1938 the Indian National
Dr. J.B. Grant, Dr. B.C. Roy, Pandit P.N. Sapru Congress established a National Planning
and Dr. A.L. Mudaliar. The terms of reference Committee (NPC) under Jawaharlal Nehru.
of this committee, popularly referred to as the One of its sub-committees was on National
7
Bhore, Joseph, 1946 : Report of the Health Survey and Development Committee, Volume I to IV, Govt. of India,
Delhi
8
Indian Medical Gazette: Editorial, III.87, 1868
9
Jeffery, Roger: The Politics of Health in India, University of California Press, Berkeley, 1988.
10
Bhore, Joseph, 1946 : op. cit.
11
Ibid.

Health under the chairmanship of workers trained in the scientific

Col.S.S.Sokhey. Its report, published in 1948, method.
was sketchy compared to the Bhore (e) Adequate steps be taken to make India
Committee Report – it was not as well studied self-sufficient as regards the
and it lacked a detailed analysis of the existing production and supply of drugs,
health situation as well as of the future plans. biological products, scientific and
In fact, it borrowed its analysis of the health surgical apparatus, instruments and
situation from the Bhore Committee and also equipment and other medical
concurred with most of its supplies... No individual or firm,
recommendations.12 Indian or foreign, should be allowed
to hold patent rights for the
On the basis of an interim report of the preparation of any substances useful
National Health sub-committee presented to in human or veterinary medicine.13 (It
the NPC in August 1940, the NPC resolved is interesting to note that on the issue
that: of patents Mr. Ambalal Sarabhai, a
member of the NPC, with obvious
(a) India should adopt a form of health vested interests, dissented and urged
organisation, in which both curative that pharmaceutical patents should be
and preventive functions are suitably treated on the same basis as copy-right
integrated, and administered through in books or industrial patents.
one agency.
(b) Such an integrated system of health The Bhore Committee endorsed this resolve
organisation can be worked only of the NPC through its recommendations. In
under state control. It is, therefore formulating its plan for a National Health
recommended that the preservation Service the Bhore Committee set itself the
and maintenance of the health of the following objectives:
people should be the responsibility of
1. The services should make adequate
the state.
provision for the medical care of the
(c) There should ultimately be one
individual in the curative and
qualified medical man or woman for
preventive fields and for the active
every 1000 population, and one
promotion of positive health;
(hospital) bed for every 600 of
2. These services should be placed as
population. Within the next ten years
close to the people as possible, in order
the objective aimed that there should
to ensure their maximum use by the
be one medical man or woman for
community, which they are meant to
every 3000 of population, and a bed
serve;
for every 1500 of population. This
3. The health organisation should provide
should include adequate provision for
for the widest possible basis of
maternity cases. cooperation between the health
(d) The medical and health organisation personnel and the people;
should be so devised and worked as 4. In order to promote the development
to emphasise the social implications of the health programme on sound
of this service. With this object in view lines the support of the medical and
the organisation should be made a free auxiliary professions, such as those of
public service, manned by whole-time dentists, pharmacists and nurses, is
12
NPC: National Health sub-committee (Sokhey Committee) ed. K.T. Shah, National Planning Committee, Vora &
Co., Bombay, 1948.
13
Ibid.

Ravi Duggal
essential; provisions should therefore scale of efficiency from the point of view of
be made for enabling the staffing and equipment. At the periphery will
representatives of these professions to be the primary unit (one for every 10,000 to
influence the health policy of the 20,000 population with 75 beds, 6 doctors,
country; 20 nurses, 6 public health nurses and other
5. In view of the complexity of modern paramedic and support staff), the smallest of
medical practice, from the standpoint these three types. A certain number of these
of diagnosis and treatment, consultant, primary units will be brought under a
laboratory and institutional facilities of secondary unit (30 primary units per
a varied character, which together secondary unit with the latter having 650 beds
constitute ‘group’ practice, should be with all major specialities and the necessary
made available; medical and non-medical staff), which will
6. Special provision will be required for perform the dual function of providing a more
certain sections of the population, e.g. efficient type of health service at its
mothers, children, the mentally headquarters and of supervising the work of
deficient etc., these primary units. The headquarters of the
7. No individual should fail to secure district (hospital with 2500 beds providing
adequate medical care, curative and largely tertiary care) will be provided with an
preventive, because of inability to pay organisation which will include, within its
for it and scope, all the facilities that are necessary for
8. The creation and maintenance of as modern medical practice as well as the
healthy an environment as possible in supervisory staff who will be responsible for
the homes of the people as well as in the health administration of the district in its
all places where they congregate for various specialised types of service”16
work, amusement recreation, are
essential.14 This health organisation would provide
integrated health services – curative,
The Bhore Committee further recognised the preventive and promotive – to the entire
vast rural-urban disparities in the existing population. ‘The health organisation is
health services and hence based its plan with expected to produce a reasonably satisfactory
specifically the rural population in mind. It’s service for rural and urban communities alike.
plan was for the district as a unit. ‘Two It is based mainly on a system of hospitals of
requirements of the district health scheme are varying size and of differing technical
that the peripheral units of the (health) efficiency. The institutions will play the dual
organisation should be brought as close to role of providing medical relief and of taking
the people as possible and that the service an active part in the preventive campaign’.17
rendered should be sufficiently
comprehensive to satisfy modern standards What would be the structure of this national
of health administration’.15 health plan? Stated in terms of a ratio to a
standard unit of population the minimum
The district health scheme, also called the requirement recommended by the Bhore
three million plan, which represented an Committee was:
average districts population, was to be " 567 hospital beds per 100,000
organised in a 3-tier system ‘in an ascending population
14
15
Ibid.
16
Ibid.
17
Ibid.

" 62.3 doctors per 100,000 population in relation to the minimum requirements of
" 150.8 nurses per 100,000 population 18 any scheme which is intended to demonstrate
an appreciable improvement in the health of
What existed at that time (1942) in India was: the community. For reasons already set out,
" 24 beds per 100,000 population we also believe that the execution of the
" 15.87 doctors per 100,000 population scheme should not be beyond the financial
" 2.32 nurses per 100,000 population capacity of governments.
In contrast what existed in the UK in 1942 …We desire to stress the organic unity of the
was: component parts of the programme we have
" 714 beds per 100,000 population put forward. Large-scale provision for the
" 100 doctors per 100,000 population training of health personnel forms an essential
" 333 nurses per 100,000 population part of the scheme, because the organisation
of a trained army of fighters is the first
We may conclude from the above that the requisite for the successful prosecution of the
health care facilities that existed in India at campaign against diseases. Side by side with
the time of the Bhore Committee were such training of personnel, we have provided
embarrassingly inadequate. In fact, most of for the establishment of a health organisation
these were in urban areas and largely in which will bring remedial and preventive
enclaves of the British Civil administration services within the reach of the people,
and Cantonments. 19 What the Bhore particularly of that vast sections of the
Committee recommended was not excessive community which lies scattered over the rural
when we look at the ratio of facilities already areas and which has, in the past, been largely
existing in the UK even prior to the setting up neglected from the point of view of health
of its National Health Service. protection on modern lines. Considerations
based on inadequacy of funds and
The Bhore Committee ends its report on a insufficiency of trained workers have naturally
clear note of urgency for implementation of necessitated the suggestion that the new
the plan in its full form. ‘The existing state of organisation should first be established over
public health in the country is so a limited area in each district and later
unsatisfactory that any attempt to improve extended as and when funds and trained
the present position must necessarily involve personnel become increasingly available.
administrative measures of such magnitude Even with such limitations the proposed
as may well seem to be out of all proportion health service is intended to fulfil, from the
to what has been conceived and accomplished beginning and in an increasing measure as it
in the past. This seems to us inevitable, expands, certain requirements, which are now
especially because health administration has generally accepted as essential characteristics
so far received from governments but a of modern health administration. These are
fraction of the attention that it deserves in that curative and preventive work should
comparison with other branches of dovetail into each other and that, in the
governmental activity. We believe that we have provision of such a combined service to the
only been fulfilling the duty imposed on us people, institutional and domiciliary
by the Government of India in putting forward treatment facilities should be so integrated
this health programme, which can in no way as to provide the maximum benefit to the
be considered as extravagant either in relation community. There should also be provision
to the standards of health administration in the health organisation for such consultant
already reached in many other countries or and laboratory services as are necessary to
18
19
Jeffery, Roger : op. cit.

Ravi Duggal
facilitate correct diagnosis and treatment. The first Five Year Plan describes the central
Our proposals incorporate these requirements task of planning thus: ‘The problem is not one
of a satisfactory health service. of merely re-channelling economic activity
within the existing socio-economic framework;
…We have drawn attention to these aspects that framework has itself to be remoulded so
of the health programme because we feel that as to enable it to accommodate progressively
it is highly desirable that the plan should be those fundamental urges which express
accepted and executed in its entirety. We themselves in the demands for the right to
would strongly deprecate any attempt, on the work, the right to adequate income, the right
plea of lack of funds, to isolate specific parts to education and to a measure of insurance
of the scheme and to give effect to them against old age, sickness and other
without taking into consideration the disabilities. The Directive Principles of State
interrelationships of the component parts of Policy enunciated in Articles 36 to 51 of the
the programme. Our conception of the constitution make it clear that for the
process of the development of the national attainment of these ends, ownership and
health services is that it will be a cooperative control of the material resources of the
effort in which the Centre, acting with country should be distributed so as best to
imagination and sympathy, will assist and subserve the common good, and that the
guide a coordinated advance in the provinces. operation of the economic system should not
We therefore look forward to a pooling of result in the concentration of wealth and
resources and personnel, as far as economic power in the hands of a few. It is in
circumstances permit, in the joint task that this larger perspective that the task of
lies before the governments”.20 planning has to be envisaged’.21
This above review provides not only a brief However, our postcolonial history is a witness
summary of the Bhore committee report but to the rapid dilution of these progressive
it also lends a contrast to the present level of principles, objectives and resolutions. The
development of health care services. If the States’ plans and policies have in no way made
concern of our health policy is universal a significant impact on redistribution of
access to health care with equity, then the resources for the common good. On the
above discussion is very relevant even today. contrary the policies and plans have helped
in strengthening of inequalities and
With the end of colonial rule in India the underdevelopment continues unabated.
population of the country expected a radical
transformation of the exploitative social The postcolonial period health care sector has
structure that the British rule had nurtured seen private medical practice develop as the
and consolidated. But these expectations core of the health sector in India. The private
were belied, as the new rulers were mere health sector initially strengthened the
indigenous substitutes for the colonial enclave sector, and then gradually spread into
masters. the periphery as opportunities for
expropriation of surplus by providing health
The new rulers mouthed a lot of radical jargon care increased due to the expansion of the
and even put it in writing in the form of the socio-economic infrastructure. It must be
First Five Year Plan document and other more noted that this pattern of development was
specific documents for various sub-sectors of in keeping with the general economic policy
the economy. of capitalism. Thus the health policy of India
20
Bhore, Joseph, 1946 : op.cit.
21
Planning Commission, Government of India First Five Year Plan. New Delhi: Planning Commission, Government
of India, 1951

cannot be seen as divorced from the economic with aid from the Technical Cooperation
and industrial policy of the country. In India Mission of the U.S.A. and technical advice of
until 1982-83 there was no formal health the W.H.O. Malaria at that period was
policy statement. The policy was part and considered an international threat. DDT
parcel of the planning process (and various spraying operations was one of the most
committees appointed from time to time), important activities of the programme. The
which provided most of the inputs for the tuberculosis programme involved vaccination
formulation of health programme designs. with BCG, T.B. clinics, and domiciliary
services and after care. The emphasis
It was not until 1983 that India adopted a however was on prevention through BCG.
formal or official National Health Policy. Prior These programmes depended on international
to that health activities of the state were agencies like UNICEF, WHO and the
formulated through the Five Year Plans and Rockefeller Foundation for supplies of
recommendations of various Committees. For necessary chemicals and vaccines. The policy
the Five Year Plans the health sector with regard to communicable diseases was
constituted schemes that had targets to be dictated by the imperialist powers as in the
fulfilled. Each plan period had a number of other sectors of the economy. Along with
schemes and every subsequent plan added a financial aid came political and ideological
few more and dropped a few. influence. Experts of various international
agencies decided the entire policy framework,
In the 1950s and 1960s the entire focus of programme design, and financial commitment
the health sector in India was to manage allotment.
epidemics. Mass campaigns were started to
eradicate various diseases. These separate During the first two Five Year Plans the basic
countrywide campaigns with a techno-centric structural framework of the public health care
approach were launched against malaria, delivery system remained unchanged. Urban
smallpox, tuberculosis, leprosy, filaria, areas continued to get over three-fourth of the
trachoma and cholera. Cadres of workers medical care resources whereas rural areas
were trained in each of the vertical received ‘special attention’ under the
programmes. The National Malaria Community Development Program (CDP).
Eradication Programme (NMEP) alone History stands in evidence to what this special
required the training of 150,000 workers attention meant. The CDP was failing even
spread over in 400 units to handle the before the Second Five Year Plan began. The
prevention and curative aspects of malaria governments own evaluation reports admitted
control.22 to this failure.
The policy of going in for mass campaigns was To evaluate the progress made in the first two
in continuation of the policy of colonialists plans and to draw up recommendations for
who subscribed to the precepts of modern the future path of development of health
medicine that health could be looked after if services the Mudaliar Committee was set up
the germs which were causing it were in 1959. The report of the committee recorded
removed. But the basic cause of the various that the disease control programmes had
diseases was a social issue, i.e. inadequate some substantial achievements in controlling
nutrition, clothing, and housing, and the lack certain virulent epidemic diseases. Malaria
of a proper environment. These were ignored. was considered to be under control. Deaths
National programs were launched to eradicate due to malaria, cholera, smallpox etc. were
the diseases. The NMEP was started in 1953 halved or sharply reduced and the overall
22
Banerji D., 1985. Health & Family Planning Services in India: an Epidemiological, Socio-cultural and Political
Analysis and a Perspective. Lok Paksh, New Delhi.

Ravi Duggal
morbidity and mortality rates had declined. medical care and this was where the state
The death rate had fallen to 21.6 per cent for governments’ own funds were getting
the period 1956-61. The expectation of life at committed. The Centre through the Planning
birth had risen to 42 years. However, the Commission was investing in preventive and
tuberculosis program lagged behind. The promotional programs whereas the state
report also stated that for a million and half governments focused their attention on
estimated open cases of tuberculosis there curative care – some sort of a division of labour
were not more than 30,000 beds available. had taken place which continues even to the
present.
The Mudaliar Committee further admitted
that basic health facilities had not reached at The Third Five Year Plan launched in 1961
least half the nation. The primary health care discussed the problems affecting the provision
(PHC) programme was not given the of PHCs, and directed attention to the
importance it should have been given right shortage of health personnel, delays in the
from the start. There were only 2800 PHCs construction of PHCs, buildings and staff
existing by the end of 1961. Instead of the quarters and inadequate training facilities for
‘irreducible minimum in staff’ recommended the different categories of staff required in the
by the Bhore Committee, most of the PHCs rural areas. 25 The Third Five Year Plan
were understaffed, large numbers of them
highlighted inadequacy of health care
were being run by ANMs or public health
institutions, doctors and other personnel in
nurses in charge.23 The fact was that the
rural areas as being the major shortcomings
doctors were moving into private practice after
at the end of the second Five Year Plan. The
training at public expense. The emphasis
doctor syndrome loomed large in the minds
given to individual communicable diseases
of planners, and increase in supply of human
programme was given top priority in the first
power in health meant more doctors and not
two plans. But primary health centres
through which the gains of the former could other health personnel. While the third plan
be maintained were given only tepid support.24 did give serious consideration to the need for
more auxiliary personnel no mention was
The rural areas in the process had very little made of any specific steps to reach this goal.
or no access to them. The condition of the Only lip service was paid to the need for
secondary and district hospitals was the same increasing auxiliary personnel but in the
as that of the PHCs. The report showed that actual training and establishment of
the majority of the beds and various facilities institutions for these people, inadequate
were located in the urban areas. The funding became the constant obstacle. On
Committee recommended that in the the other hand, the proposed outlays for new
immediate future instead of expansion of Medical Colleges, establishment of preventive
PHCs consolidation should take place and and social medicine and psychiatric
then a phased upgrading and equipping of the departments, completion of the All India
district hospitals with mobile clinics for the Institute of Medical Sciences and schemes for
treatment of the non-PHC population. But the upgrading departments in Medical Colleges
urban health infrastructure continued to for post graduate training and research
increase to meet the growing demands for continued to be high.26
23
Mudaliar Committee, 1961: Health Survey and Planning Committee, MoHFW, New Delhi
24
Batliwala, Srilatha, 1978: The Historical Development of Health Services in India, FRCH, Bombay
25
Planning Commission, Government of India Third Five Year Plan. New Delhi: Planning Commission, Government
of India, Y 1961
26
Batliwala, Srilatha, 1978: The Historical Development of Health Services in India

In this way we see that the allocation patterns allocation. It was reiterated that the PHC’s
continued to belie the stated objectives and base would be strengthened along with, sub-
goals of the overall policy in the plans. The divisional and district hospitals, which would
urban health structure continued to grow and be referral centres for the PHCs. The
its sophisticated services and specialities importance of PHCs was stressed to
continued to multiply. The 3rd plan gave consolidate the maintenance phase of the
serious consideration for suggesting a realistic communicable disease programme. This
solution to the problem of insufficient doctors acknowledgement was due to the fact that the
for rural areas ‘that a new short term course entire epidemiological trend was reversed in
for the training of medical assistants should 1966 with the spurt in the incidence of malaria
be instituted and after these assistants had which rose from 100,000 cases annually
worked for 5 years at a PHC they could between 1963-65, to 149,102 cases29, and the
complete their education to become full Planning Commission admitted this. FP
fledged doctors and continue in public continued to get an even greater emphasis
service’.27 The Medical Council and the doctors with 42 per cent of health sector (Health +
lobby opposed this and hence it was not taken FP) plan allocation going to it.30 It especially
up seriously. highlighted the fact that population growth
was the central problem and used phrases
The 4th Plan that began in 1969 with a 3
like ‘crippling handicap’, ‘very serious
year plan holiday continued on the same lines
challenge’ and an anti-population growth
as the 3rd plan. It quoted extensively from
policy as an ‘essential condition of success’
the FYP II concerning the socialist pattern of
to focus the government’s attention to accord
society28 but its policy decisions and plans did
fertility reduction ‘as a program of the highest
not reflect socialism. In fact the 4th plan is
priority’. It was also during this period that
probably the most poorly written plan
water supply and sanitation was separated
document. It does not even make a passing
comment on the social, political and economic and allocations were made separately under
upheaval during the plan holiday period the sector of Housing and Regional
(1966-1969). These 3 years of turmoil indeed development.
brought about significant policy changes on
the economic front and this, the 4th plan It was in the 5th Plan that the government
ignored completely. It lamented on the poor ruefully acknowledged that despite advances
progress made in the PHC programme and in terms of the infant mortality rate going
recognised again the need to strengthen it. It down and life expectancy going up, the
pleaded for the establishment of effective number of medical institutions, functionaries,
machinery for speedy construction of beds, health facilities etc, were still inadequate
buildings and improvement of the in the rural areas. This shows that the
performance of PHCs by providing them with government acknowledged that the urban
staff, equipment and other facilities. For the health structure had expanded at the cost of
first time PHCs were given a separate the rural sectors.31 This awareness is clearly
27
Planning Commission, Government of India Third Five Year Plan.op. cit.
28
Planning Commission, Government of India Fourth Five Year Plan. New Delhi: Planning Commission, Government
of India, 1969.
29
Ibid
30
Ibid
31
Planning Commission, Government of India Fifth Five Year Plan. New Delhi: Planning Commission, Government
of India, 1974.

Ravi Duggal
reflected in the objectives of 5th Five Year Plan that each pair of such worker should serve a
which were as follow: population of 10,000 to 12,000. Hence the
multi-purpose worker (MPW) scheme was
1. Increasing the accessibility of health launched with the objective of retraining the
services to rural areas through the existing cadre of vertical programme workers
Minimum Needs Programme (MNP) and the various vertical programmes were to
and correcting the regional imbalances. be fully integrated into the primary health care
2. Referral services to be developed package for rural areas.33
further by removing deficiencies in
district and sub-division hospitals. Another major innovation in the health
3. Intensification of the control and strategy was launched in 1977 by creating a
eradication of communicable diseases. cadre of village based health auxiliaries called
4. Affecting quality improvement in the the Community Health workers. These were
education and training of health part time workers selected by the village,
personnel. trained for 3 months in simple promotive and
5. Development of referral services by curative skills both in allopathy and
providing specialists attention to indigenous systems of medicine. They were
common diseases in rural areas. to be supervised by MPWs, and the
programme was started in 777 selected PHCs
Major innovations took place with regard to where MPWs were already in place.
the health policy and method of delivery of
health care services. The reformulation of This scheme was adopted on the
health programmes was to consolidate past recommendations of the Shrivastava
gains in various fields of health such as Committee 34 which was essentially a
communicable diseases, medical education committee to look into medical education and
and provision of infrastructure in rural areas. manpower support. The committee proposed
This was envisaged through the MNP which to rectify the dearth of trained manpower in
would ‘receive the highest priority and will be rural areas. The committee pointed out that
the first charge on the development outlays ‘the over-emphasis on provision of health
under the health sector.32 It was an integrated services through professional staff under state
packaged approach to the rural areas. The control has been counter productive. On the
plan further envisaged that the delivery of one hand it is devaluing and destroying the
health care services would be through a new old traditions of part-time semi-professional
category of health personnel to be specially workers, which the community used to train
trained as multi-purpose health assistants. and throw up and proposed that with certain
However, the infrastructure target still modifications can continue to provide the
remained one PHC per CDP Block (as in the foundation for the development of a national
FYP I but the average Block’s population was programme of health services in our country.
now 125000)! On the other hand the new professional
services provided under state control are
The Kartar Singh Committee in 1973 inadequate in quantity and unsatisfactory in
recommended the conversion of uni-purpose quality’. This very direct statement from the
workers, including ANMs, into multi-purpose committee that was set up to review medical
male and female workers. It recommended education and its related components
32
Planning Commission, Government of India Fifth Five Year Plan. New Delhi: Planning Commission, Government
of India, 1974.
33
Kartar Singh Committee, 1973: Committee on Multipurpose Worker under Health and Family Planning, MoHFW,
New Delhi
34
Shrivastava Committee, 1975: Report of the Group on Medical Education and Support Manpower, MoHFW, New
Delhi

assumes significance because it showed that emphasis on hospitals, specialisation and

the investment on health care had not been super specialisation and highly trained
going to the people. The main doctors which is availed of mostly by the well
recommendation of the committee was to have to do classes. It is also realised that it is this
part-time health personnel selected by the model which is depriving the rural areas and
community from within the community. They the poor people of the benefits of good health
would act as a link between the MPW at the and medical services’.37
sub-centres and the community. With regard
to medical education the committee cried for The plan emphasised the development of a
a halt to opening of new medical colleges. The community based health system. The
committee emphasised that there was no strategies advocated were :
point in thinking that doctors would willingly a. provision of health services to the rural
go to rural areas because there were a number areas on a priority basis.
of socio-economic dimensions to this issue. b. the training of a large cadre of first level
Thus their option for rural areas was the CHW health workers selected from the
scheme. This attitude was clearly supportive community and supervised by MPWs
of the historical paradigm that rural and and medical officers of the PHCs.
urban areas had different health care needs – c. No further linear expansion of curative
that urban populations need curative care and facilities in urban areas; this would be
rural populations preventive. This also is permitted only in exceptional cases
discriminatory since inherent in this paradigm dictated by real felt need or priority.
is deprivation for the rural masses. Earlier,
in 1967 the Jain Committee report35 on The plan stressed that horizontal and vertical
Medical Care Services had made an attempt linkages had to be established among all the
to devolve medical care by recommending interrelated programmes, like water supply,
strengthening of such care at the PHC and environmental sanitation, hygiene, nutrition,
block/taluka level as well as further education, family planning and MCH. The
strengthening district hospital facilities. The objective of achieving a net reproduction rate
Jain Committee also suggested integration of of 1 by 1995 was reiterated.38
medical and health services at the district level
with both responsibilities being vested in the This plan and the seventh plan too, like the
Civil Surgeon/Chief Medical Officer. But earlier ones made a lot of radical statements
recommendations of this Committee, which and recommended progressive measures. But
is the only committee since Independence to the story was the same - progressive thinking
look at medical care and also for the first time and inadequate action. Whatever new
reported on strengthening curative services schemes were introduced the core of the
in rural areas, were not considered seriously. existing framework and ideology remains
untouched. The underprivileged get worse off
The Sixth Plan was to a great extent and the already privileged get better off. The
influenced by the Alma Ata declaration of status quo of the political economy is
Health For All by 2000 AD and the ICSSR - maintained. However, the Sixth and the
ICMR report.36 The plan conceded that ‘there Seventh plans are different from the earlier
is a serious dissatisfaction with the existing ones in one respect. They no longer talk of
model of medical and health services with its targets. The keywords are efficiency and
35
Jain Committee, 1967: Report of the Study Group on Medical Care Services, MoHFW, New Delhi
36
ICMR-ICSSR, 1980: Health For All – An Alternative Strategy, IIE, ICSSR, Pune
37
Draft FYP VI, Vol. III, 1978
38
Planning Commission, Government of India Sixth Five Year Plan 1980-85. New Delhi: Planning Commission,
Government of India, 1985.

Ravi Duggal
quality and the means to realise them is The salient features of the 1983 health policy
privatisation. Privatisation is the global were:
characteristic of the 1980s and the 1990s and a) It was critical of the curative-oriented
it has made inroads everywhere and especially western model of health care,
in the formerly socialist countries. b) It emphasised a preventive, promotive
and rehabilitative primary health care
The Sixth and Seventh Five Year Plans state approach,
clearly: ‘... the success of the plan depends c) It recommended a decentralised system
crucially on the efficiency, quality and texture of health care, the key features of which
of implementation. ... a greater emphasis in were low cost, deprofessionalisation
the direction of competitive ability, reduced (use of volunteers and paramedics),
cost and greater mobility and flexibility in the and community participation,
development of investible resources in the d) It called for an expansion of the private
private sector (by adapting) flexible policies curative sector which would help
to revive investor interest in the capital reduce the government’s burden,
markets’39 e) It recommended the establishment of
a nation-wide network of
‘Our emphasis must be on greater efficiency, epidemiological stations that would
reduction of cost and improvement of quality. facilitate the integration of various
This calls for absorption of new technology, health interventions, and
greater attention to economies of scale and f) It set up targets for achievement that
greater competition’.40 The National Health were primarily demographic in nature.
Policy of 1983 was announced during the
Sixth plan period. It was in no way an original There are three questions that must now be
document. It accepted in principle the ICMR- answered.
ICSSR Report (1981)41 recommendations as " Firstly, have the tasks enlisted in the 1983
is evidenced from the large number of NHP been fulfilled as desired?
paragraphs that are common to both " Secondly, were these tasks and the actions
documents. But beyond stating the policy that ensued adequate enough to meet the
there was no subsequent effort at trying to basic goal of the 1983 NHP of providing
change the health situation for the better. ‘universal, comprehensive primary health
care services, relevant to actual needs and
The National Health Policy (NHP) in light of priorities of the community’ 43? and
the Directive Principles of the constitution of " Thirdly, did the 1983 NHP sufficiently
India recommends ‘universal, comprehensive reflect the ground realities in health care
primary health care services which are provision?
relevant to the actual needs and priorities of
the community at a cost which people can During the decade following the 1983 NHP,
afford’.42 Providing universal health care as a rural health care received special attention
goal is a welcome step because this is the first and a massive program of expansion of
time after the Bhore Committee that the primary health care facilities was undertaken
government is talking of universal in the 6th and 7th Five Year Plans to achieve
comprehensive health care. the target of one PHC per 30,000 population
39
Planning Commission, Government of India Sixth Five Year Plan 1980-85. New Delhi: Planning Commission,
Government of India, 1985.
40
Planning Commission, Government of India Seventh Five Year Plan 1985-90 Vol. II: Sectoral Programmes of
Development. New Delhi: Planning Commission, Government of India, 1990.
41
ICMR-ICSSR, 1980: Health For All – An Alternative Strategy. op. cit.
42
MoHFW, 1983 : National Health Policy, Govt. of India, Ministry of Health & Family Welfare, New Delhi
43
Ibid.

and one subcentre per 5000 population. This acceptable to the people as evidenced by their
target has more or less been achieved, though health care seeking behaviour. The rural
a few states still lag behind. However, various population continues to use private care and
studies looking into rural primary health care whenever they use public facilities for primary
have observed that, though the infrastructure care it is the urban hospital they prefer.45 Let
is in place in most areas, they are grossly alone provision of primary medical care, the
under utilised because of poor facilities, rural health care system has not been able to
inadequate supplies, insufficient effective provide for even the epidemiological base that
person-hours, poor managerial skills of the NHP of 1983 had recommended. Hence,
doctors, faulty planning of the mix of health the various national health programs continue
programs and lack of proper monitoring and in their earlier disparate forms, as was
evaluatory mechanisms. Further, the system observed in the NHP.46
being based on the health team concept failed
to work because of the mismatch of training As regards the demographic and other targets
and the work allocated to health workers, set in the NHP, only crude death rate and life
inadequate transport facilities, non- expectancy have been on schedule. The
availability of appropriate accommodation for others, especially fertility and immunisation
the health team and an unbalanced related targets are much below expectation
distribution of work-time for various activities. (despite special initiatives and resources for
In fact, many studies have observed that these programs over the last two decades),
family planning, and more recently and those related to national disease
immunisation, get a disproportionately large programs are also much below the expected
share of the health workers’ effective work- level of achievement. In fact, we are seeing a
time.44 resurgence of communicable diseases.
Among the other tasks listed by the 1983 With regard to the private health sector the
health policy, decentralisation and de- NHP clearly favours privatisation of curative
professionalisation have taken place in a care. It talks of a cost that ‘people can afford’,
limited context but there has been no thereby implying that health care services will
community participation. This is because the not be free. Further statements in the NHP
model of primary health care being about the private health sector leave no room
implemented in the rural areas has not been for doubt that the NHP is pushing
44
NSS-1987 : Morbidity and Utilisation of Medical Services, 42nd Round, Report No. 384, National Sample Survey
Organisation, New Delhi; IIM (A), 1985: Study of Facility Utilisation and Program Management in Family Welfare
in UP, MP, Bihar (3 Vols.), Public System Group, Indian Institute of Management, Ahmedabad; NCAER, 1991:
Household Survey of Medical Care, National Council for Applied Economic Research, New Delhi; NIRD, 1989 :
Health Care Delivery system in Rural Areas - A Study of MPW Scheme, National Institute of Rural Development,
Hyderabad; Ghosh, Basu, 1991 : Time Utilisation and Productivity of Health Manpower, IIM, Bangalore; ICMR,
1989 : Utilisation of Health and FP services in Bihar, Gujarat and Kerala, Indian Council of Medical Research,
New Delhi; Gupta, JP and YP Gupta, 1986: Study of Systematic Analysis and Functioning of Health Teams at
District and Block Levels, NIHFW, New Delhi; Duggal, Ravi and S Amin, 1989: Cost of Health Care, Foundation for
Research in Community Health, Bombay; Jesani, Amar et.al., 1992: Study of Auxiliary Midwives in Maharashtra,
FRCH, Bombay; NTI, 1988 : Report of the Baseline Survey Danida Health Care Project 2 Vols., NTI, Bangalore;
ICMR, 1990 : Evaluation of Quality of Family Welfare Services at Primary Health Centre Level, ICMR, New Delhi
45
NSS-1987: Morbidity and Utilisation of Medical Services; Duggal, Ravi and S Amin, 1989: Cost of Health Care;
Kannan KP et.al., 1991 : Health and Development in Rural Kerala, Kerala Shastra Sahitya Parishad, Trivandrum;
NCAER, 1991: Household Survey of Medical Care; NCAER, 1992 : Rural Household Health Care Needs and
Availability, NCAER, New Delhi; George, Alex et.al., 1992 : Household Health Expenditure in Madhya Pradesh,
FRCH, Bombay
46
MoHFW, 1983 : National Health Policy op.cit.

Ravi Duggal
privatisation. NHP adopts the stance that medical education, soft loans to set up medical
curative orientation must be replaced by the practice etc.. The private health sector’s
preventive and promotive approach so that mainstay is curative care and this has been
the entire population can benefit.47 The NHP growing over the years (especially during the
suggests that curative services should be left 1980s and 1990s) at a rapid pace largely due
to the private sector because the state suffers to a lack of interest of the state sector in non-
from a “constraint of resources”. It hospital medical care services, especially in
recommends, “with a view to reducing rural areas.49 Various studies show that the
governmental expenditure and fully utilising private health sector accounts for over 70 per
untapped resources, planned programmes cent of all primary care treatment sought, and
may be devised, related to the local over 40 per cent of all hospital care.50 This is
requirements and potentials, to encourage the not a very healthy sign for a country where
establishment of practice by private medical over three-fourths of the population lives at
professionals, increased investment by non- or below subsistence levels.
governmental agencies in establishing
curative centres and by offering organised The above analysis clearly indicates that the
logistical, financial and technical support to 1983 NHP did not reflect the ground realities
voluntary agencies active in the health field adequately. The tasks enunciated in the policy
... and in the establishment of centres were not sufficient to meet the demands of
equipped to provide speciality and super the masses, especially those residing in rural
speciality services ... efforts should be made areas. ‘Universal, comprehensive, primary
to encourage private investments in such health care services’, the 1983 NHP goal, is
fields so that the majority of such centres, far from being achieved. The present paradigm
within the governmental set-up, can provide of health care development has in fact raised
adequate care and treatment to those entitled inequities, and in the current scenario of
to free care, the affluent sectors being looked structural adjustment the present strategy is
after by the paying clinics”. only making things worse. The current policy
of selective health care, and a selected target
The development of health care services post- population has got even more focused since
NHP provide a clear evidence that privatisation the 1993 World Development Report:
and private sector expansion in the health Investing in Health. In this report the World
sector has occurred rapidly, that in the name Bank has not only argued in favour of selective
of primary health care the state has still kept primary health care but has also introduced
the periphery without adequate curative the concept of DALYs (Disability Adjusted Life
services (while the states’ support to curative Year’s) and recommends that investments
services in urban areas continues to remain should be made in directions where the
strong) and that the state health sectors’ resources can maximise gains in DALYs. That
priority program still continues to be is, committing increasing resources in favour
population control.48 of health priorities where gains in terms of
efficiency override the severity of the health
The expansion of the private health sector in care problems, questions of equity and social
the last two decades has been phenomenal justice. So powerful has been the World
thanks to state subsidies in the form of Bank’s influence, that the WHO too has taken
47
MoHFW, 1983 : National Health Policy op.cit.
48
Ibid.
49
Jesani, Amar and S Ananthram,1993: Private Sector and Privatisation in Health Care Services, FRCH, Bombay
50
NSS-1987: Morbidity and Utilisation of Medical Services; Duggal, Ravi and S Amin, 1989: Cost of Health Care;
Kannan KP et.al., 1991: Health and Development in Rural Kerala; George, Alex et.al., 1992 : Household Health
Expenditure

an about turn on its Alma Ata Declaration. country went through a massive economic
WHO too, in its “Health For All in the 21st crisis. The Plan got pushed forward by two
Century” agenda is talking about selective years. But despite this no new thinking went
health care, by supporting selected disease into this plan. In fact, keeping with the
control programs and pushing under the selective health care approach the eighth plan
carpet commitments to equity and social adopted a new slogan – instead of Health for
justice. India’s health policy has increasingly All by 2000 AD it chose to emphasise Health
been moving in the direction of selective for the Underprivileged.53 Simultaneously it
health care - from a commitment of continued the support to privatisation, ‘In
comprehensive health care on the eve of accordance with the new policy of the
Independence, and its reiteration in the 1983 government to encourage private initiatives,
health policy, to a narrowing down of concern private hospitals and clinics will be supported
only for family planning, immunisation and subject to maintenance of minimum
control of selected diseases. Hence, one has standards and suitable returns for the tax
to view with seriousness the continuance of incentives’ 54.
the current paradigm and make policy
changes which would make primary health The Ninth Five Year Plan by contrast provides
care relevant to the needs of the population a a good review of all programs and has made
reality and accessible to all without any social, an effort to strategize on achievements
geographical and financial inequities. attained and learn from them in order to move
forward. There are a number of innovative
The 7th Five Year Plan accepted the above ideas in the ninth plan. It is refreshing to see
NHP advice. It recommended that that reference is once again being made to
‘development of specialities and super- the Bhore Committee report and to
specialities need to be pursued with proper contextualise today’s scenario in the
attention to regional distribution”51 and such recommendations that the Bhore Committee
‘development of specialised and training in had made. 55 In its analysis of health
super specialities would be encouraged in the infrastructure and human resources the
public and the private sectors’.52 This plan also Ninth Plan suggests the consolidation of PHCs
talks of improvement and further support for and SCs and assures that the requirements
urban health services, biotechnology and for its proper functioning are made available
medical electronics and non-communicable and positions it as an important goal under
diseases. Enhanced support for population the Basic Minimum Services program. Thus,
control activities also continues. The special given that it is difficult to find physicians to
attention that AIDS, cancer, and coronary work in PHCs and CHCs the Plan suggests
heart diseases are receiving and the current creating part-time positions which can be
boom of the diagnostic industry and corporate offered to local qualified private practitioners
hospitals is a clear indication of where the and/or offer the PHC and CHC premises for
health sector priorities lie. after office hours practice against a rent. It
also suggests putting in place mechanisms
On the eve of the Eighth Five Year Plan the to strengthen referral services56.
51
Planning Commission, Government of India Seventh Five Year Plan 1985-90 Vol. II: Sectoral Programmes of
Development. New Delhi: Planning Commission, Government of India, 1990.
52
Ibid.
53
Planning Commission, Government of India Eighth Five Year Plan Highlights. New Delhi: Directorate of Advertising
and Visual Publicity, Government of India, 1992.
54
Ibid.
55
Planning Commission, Government of India Approach Paper to the Ninth Five-Year Plan (1997-2002) New Delhi:
Planning Commission, Government of India, 1997.
56
Ibid.

Ravi Duggal
Yet another unique suggestion is evolving

state specific strategies because states have What is interesting as well is that the 9th Plan
different scenarios and are at different levels also reviews the 1983 National Health Policy
of development and have different health care in the context of its objectives and goals and
needs. The Ninth Plan also shows concern for concludes that a reappraisal and
urban health care, especially the absence of reformulation of the NHP is necessary so that
primary health care and complete reliance on a reliable and relevant policy framework is
secondary and tertiary services even for minor available for not only improving health care
ailments. This needs to be changed through but also measuring and monitoring the health
provision of primary health care services, care delivery systems and health status of the
especially in slums, and providing referral population in the next two decades.59 In this
linkages at higher levels. context the 9 th Plan is critical of the poor
quality of data management and recommends
During the Eighth Plan resources were drastic changes to develop district level
provided to set up the Education Commission databases so that more relevant planning is
for Health Sciences, and a few states have possible. Taking a lead from the 9th Plan the
even set up the University for Health Sciences Ministry of Health and Family Welfare took
as per the recommendations of the Bajaj up the task of formulating a new health policy.
Committee report of 1987.57 This initiative
was to bring all health sciences together, On the eve of the 10th Plan, the Draft National
provide for continuing medical education and Health Policy 2001 was announced and for
improve medical and health education the first time feedback invited from the public.
through such integration. The Ninth Plan has ‘Universal, comprehensive, primary health
made provisions to speed up this process. care services’, the NHP 1983 goal, is not even
mentioned in the NHP 2001 but the latter
During the 8th Plan period a committee to bravely acknowledges that the public health
review public health was set up. It was called care system is grossly short of defined
the Expert Committee on Public Health requirements, functioning is far from
Systems. This committee made a thorough satisfactory, that morbidity and mortality due
appraisal of public health programs and found to easily curable diseases continues to be
that we were facing a resurgence of most unacceptably high, and resource allocations
communicable diseases and there was need generally insufficient –
to drastically improve disease surveillance in
the country. The Ninth Plan proposes to set “It would detract from the quality of the
up at district level a strong detection cum exercise if, while framing a new policy,
response system for rapid containment of any it is not acknowledged that the existing
outbreaks that may occur. 58 In fact, the public health infrastructure is far from
recommendations of this committee have satisfactory. For the out-door medical
formed the basis of the Ninth Plan health facilities in existence, funding is
sector strategy to revitalise the public health generally insufficient; the presence of
system in the country to respond to its health medical and para-medical personnel is
care needs in these changed times. The Plan often much less than required by the
has also proposed horizontal integration of all prescribed norms; the availability of
vertical programs at district level to increase consumables is frequently negligible; the
their effectiveness and to facilitate allocative equipment in many public hospitals is
efficiencies. often obsolescent and unusable; and the
57
Planning Commission, Government of India Eighth Five Year Plan Highlights (1992) op.cit.
58
Planning Commission, Government of India Approach Paper to the Ninth Five-Year Plan (1997-2002) op.cit.
59
Ibid.

buildings are in a dilapidated state. In 2001 is a mere collection of unconnected

the in-door treatment facilities, again, the statements, it is a dilution of the role of public
equipment is often obsolescent; the health services envisaged in the earlier policy
availability of essential drugs is minimal; and is unabashedly promoting the private
the capacity of the facilities is grossly health sector.
inadequate, which leads to over-
crowding, and consequentially to a steep The Ninth Plan also reviews the population
deterioration in the quality of the policy and the family planning program. In
services”.60 this review too it goes back to the Bhore
Committee report and says that the core of
The NHP 2002 needs to be lauded for its this program is maternal and child health
concern for regulating the private health services. Assuring antenatal care, safe delivery
sector through statutory licensing and and immunisation are critical to reducing
monitoring of minimum standards by creating infant and maternal mortality and this in turn
a regulatory mechanism. This has been an has a bearing on contraception use and
important struggle of health researchers and fertility rates.61 This is old logic which the
activists to build accountability within the family planning program has used, except that
private health sector and it is hoped the new earlier their emphasis was on sterilisation. In
policy addresses this issue rigorously. Besides the early 1960s the setting up of subcentres
this, the express concern for improving health and employing ANMs was precisely for the
statistics, including national health accounts, MCH program but at the field level the family
is welcome. A mechanism of assuring planning program hijacked this. This story
statutory reporting not only by the public continues through the seventies and eighties.
system but also the private sector is an urgent MCH became Safe Motherhood, and expanded
requirement so that health information Program of Immunisation and the latter using
systems provide complete and meaningful a mission approach under Sam Pitroda
data. became Universal Program of Immunisation.
In the 7th Plan this got combined again to
The main objective of NHP 2002 is to achieve become Child Survival and Safe Motherhood,
an acceptable standard of good health but the essential emphasis remained on family
amongst the general population of the country planning. But since the 8th Plan and into the
(para 3.1). The goals given in Box IV of the 9th Plan, child survival and safe motherhood
policy document are laudable but how their (CSSM) acquired a genuine seriousness and
achievement will happen in the specified time presently it has been transformed into the
frame has not been supported adequately in RCH program on the basis of the ICPD-Cairo
the policy document. For instance, goal agenda and receives multi-agency external
number 10 ‘Increase utilisation of public funding support to provide need based,
health facilities from current level of <20 to demand driven, high quality integrated
>75%’ is indeed remarkable. What it means reproductive and child health care.62 In the
is reversal of existing utilisation patterns, midst of all this the National Population
which favour the private sector. While we Policy was announced with a lot of fanfare in
support this goal to the hilt we are worried the middle of 2000. It is definitely an
that many prescriptions of the policy favour improvement from its predecessors but the
strengthening of the private health sector and underlying element remains population
hence is contrary to this goal. In sum NHP control and not population welfare. The major
60
GOI, 2002: National Health Policy-2002. Department of Health, Ministry of Health and Family Welfare, Government
of India, New Delhi.
61
62
Ibid.

Ravi Duggal
concern is with counting numbers and hence National Disease Control programmes and
its goals are all demographic. But as has been the National Family Welfare Programme
said earlier there is a distinct improvement totally free of cost to all individuals and
from the past because the demographic goals " essential health care service to people
are placed in a larger social context and if that below the poverty line based on their need
spirit were maintained, then in practice we and not on their ability to pay for the
would definitely move forward. services.
We are now through with the 9th Five-year Plan ... Available funds will be utilised to
and a review of all its innovative suggestions make all the existing institutions fully
shows that we have once again failed at the functional by providing needed
ground level. We have been unable to translate equipment, consumables, diagnostics
these ideas into practice. And despite all these and drugs. In addition to funds from
efforts one can see the public health system the centre, state, externally aided
weakening further. The answer is found in the projects, locally generated funds from
9th Plan itself. It laments that all these years user charges and donations will be
we have failed to allocate even two per cent of used for maintenance and repair to
plan resources to the health sector.63 The ensure optimal functional status and
same reason has killed the initiative shown improve quality of services.64
in the 9th Plan process at the very start by
continuing the story of inadequate resource In the above review of plans and policies an
allocations for the health sector. The approach issue of concern is the influence of
paper to the 10th Five-year Plan maintains international agencies in policymaking and
the continuum from the 9th Plan. It does talk program design both within and outside the
about reorganisation and restructuring of the plans. Right from the First Plan onwards one
health infrastructure and linking it to a can see the presence of international aid
responsibility system on the basis of residence agencies that with a small quantum of money
with a referral system for higher levels of care. are able to inject large doses of ideology. It
The 10th Plan also says that the commitment cannot be a coincidence that almost every
to primary health care, emergency and life- health program the Indian government has
saving services and the national programs taken up since the first plan has been
must continue free of cost but puts in a rider anticipated by some international donor
of user charges for those above the poverty agency. Whether it was the CDP in the 1950s,
line. However, in the same breath it quotes intrauterine contraceptive device (IUCD) and
the NSS 52nd Round, which reveals that, even malaria in the sixties or RCH and AIDS in the
the middle classes fall into severe nineties, most health programs have been
indebtedness for hospitalisation and that shaped through external collaboration.
something towards risk-pooling needs to be Historically, though there is a qualitative and
developed. Interestingly the Draft Tenth Plan quantitative difference.
adopts the following contradictory stance:
Up to the 1980s the influence came through
In view of the importance of health as a critical advice and ideology and hence its penetration
input for human development there will be was limited. Post-eighties there is a lot of
continued commitment to provide: money also coming in, mostly as soft loans
and in tandem with conditionalities, and if
" essential primary health care, emergency we continue without making a paradigm shift
life saving services, services under the and structural changes, we will be transferring
63
64
10thPlan approach paper, pages 39-40

a burden to the next generation which it may and that’s where the decline of the public
be unable to carry! Prior to the 1980s external health system began and continues to this
assistance was mostly grants and very day. The big international donors now are
insignificant in volume. During the entire World Bank, European Union, USAID, and
decade of the seventies about $85 million per DFID and all follow a more or less similar
year of external assistance in the health sector strategy, that is supporting selective health
was being received, largely as grants but after programs targeted at specific population
the World Bank entered the picture in the groups. This approach is unsustainable and
eighties with India Population Projects (IPP) can only distort the healthcare system of the
the scenario changed significantly with the country further and move it away from the
annual average varying between $300 million rights framework.
and $600 million during the 1980s and 1990s,
mainly as loans with the World Bank In conclusion we would like to indicate that
dominating with over two-thirds of such funds the neglect of the public health sector is an
coming from it by the end of the eighties.65
issue larger than government policy
Thus the larger dependence on external
formulation. The latter is the function of the
assistance in the health sector began with the
overall political economy. Under capitalism
IPP of the World Bank, which were essentially
only a well developed welfare state can meet
soft loans and not grants as in the past from
the basic needs of its population. Given the
bilateral and multilateral donors.66 The first
five IPP’s focused on development of the health comparatively weaker capitalist development
infrastructure, especially in rural areas dove- of India the demand of public resources for
tailing with the Minimum Needs Program and the productive sectors of the economy (which
did make a significant impact in strengthening directly benefit capital accumulation) is more
the infrastructure. The subsequent IPPs urgent (from the business perspective) than
changed the strategy to support recurring the social sectors, hence the latter gets only
expenditure and this led to disaster because residual attention by the state. Thus, the
the dependence on World Bank and various solution for satisfying the health needs of the
bilateral donors like ODA (now DFID), USAID, people does not lie in the health policies and
DANIDA, NORAD, SIDA etc. for running plans but is a question of structural changes
various health programs reduced the in the political economy that can facilitate
governments’ own funding of these programs implementation of progressive health policies.
65
Gupta, D and A Gumber, 2002: External Assistance to the Health Sector and its Contributions – Problems and
Prognosis, ICRIER, New Delhi
66
Ibid.

Public Health Services in India: A Historical Perspective
Ritu Priya
“Each pattern of approach to health care experience has been mixed, and that both the
emerges as a logical outcome of a given political, gains and the negative consequences are the
social and economic system. These forces logical outcome of choices made when
generate an unwritten policy frame which adopting models of planned development at
influence the health of a population”. the time of Independence. The paper ends with
Debabar Banerji some lessons drawn from past experience for
evolving a pro-poor, pro-people health care
Throughout known history, human beings system in the present context.
have made efforts to explain illnesses and
devised methods to deal with them, Some Perspectives on Public Health
individually and collectively. Indian society Services
has been no different. So when health service
development was undertaken as a focus of The Roles Expected of Public Health
planned activity by the state in Independent Four phases of the growth of health services
India, it was to add substantially to the can broadly be discerned in Independent
existing systems of health care. The latter had India:
not been able to grow over the years to meet - the immediate post Independence
the new challenges posed by the dynamic period of the 1950s to the mid-1960s,
health situation. The knowledge systems of - the next fifteen years up to 1980,
health care had gone into a decline and were - the period of the 1980s and
incapable of adapting to the changing social - the current phase starting from 1991
and physical environment as well as the when we formally adopted new
political and cultural context. The health economic policies.
status and morbidity profile and any major
determinants in the population have to guide This paper will examine the evolution and
the structure and functioning of any public status of the public health service system over
health system. These will to some extent also these four periods with reference to the
reflect the impact of the latter. All these following social roles it is expected to play:
dimensions require that health service
development relate to the specific social and 1. Public Health Service Provisioning – To act
epidemiological context, with a necessary as ‘the caring arm’ of society that
responsiveness to change as these parameters minimises suffering through the delivery
change over time. The question that causes of preventive and curative services. This
concern is whether the public health service would include services at the primary,
system developed in post-Independence India secondary and tertiary levels, their
was able to do so? What are the challenges management and quality of functioning.
and the way forward today? 2. Policy Formulation and Planning for the
whole health sector – Its role as the
In order to answer these questions this paper organisational wing for application of
examines the evolution of health services in knowledge about health and disease. This
post-Independence India up to the present would include surveillance, research,
time, against public health principles and the analysis and policy formulation on priority
debates on structure and content of a health problems, manpower development and
care system. The argument is that the deployment, optimising infrastructure and

technology inputs for all sections of health epidemiological rationale, and attitudes of the
service providers. The public, private (formal personnel. This, in turn, is dependant upon
and informal) and NGO sectors as well as the ‘culture of health services’, which consists
the indigenous systems of medicine and of the organisational principles, motivations
homeopathy (ISM&H) at primary, secondary of personnel at all levels and their interactions
and tertiary levels of health care comprise among themselves as well as with those to
the ‘health service system’ in the country. whom they provide services.
Health planning and policy formulation
exercises must include all these within The dimensions of the culture of health
their purview. Drugs quality control, services reflects in the bureaucratisation/
production and regulation etc. would fall rigidity or flexibility, technology-centred
within its ambit. perspective of people’s lives-centred
perspective, disease-oriented or positive
3. Early Detection of Social Pathology – To health-oriented approach. It can shape into a
act as the eyes and ears of society to caring and problem-solving or hierarchical and
recognise social pathology through control-exerting approach, an integrated
symptoms that manifest in the form of systemic or isolated programmatic approach.
health problems. It must provide warnings The dominant societal perspectives and
about prevailing unhealthy social development ideologies as well as the
structures and environmental conditions organisational structure, structures of
to society. Public concern and public policy financing, decision-making and
could then identify what needs to be done implementation within the health services also
by other sectors of planned development shapes this culture. The professional/
and other segments of social action to deal technical background and social background
with the root causes. of the service providers further contributes to
this institutional sub-culture. Once the
The first role is the most publicly visible task. culture is established it perpetuates itself
The second is what is done in the back rooms
within the health services, and also tends to
to make the first happen and decides its fate.
diffuse into other related institutions further
The third is what is viewed merely as a spin-
strengthening the hold of its dominant
off from the services, but is what could lead
paradigm.
to effective action for improving the health
status of populations.1
It is important to recognise that the health
system has a strong ‘information gap’ – that
Issues of Quality and Functioning of
the balance of power is strongly in favour of
Public Health Services: An Interaction
the ‘expert’ i.e. the doctor, and the service
of Social and Technical Factors
system as a whole versus its ‘beneficiaries’,
With the large health service infrastructure
the lay public. However this expert based
in India today, both government and non-
government, the central issue appears to be system often lacks knowledge of the social and
the quality of its functioning. Quality of public cultural context in which it functions, as well
health services is defined by the extent of their as other forms of ‘science of the body’. The
availability and coverage, economic inherent information gap allows the dominant
affordability and social accessibility to all system to build its own legitimacy and
sections of society, efficacy, safety and hegemony, and cover up its limitations.
1
The Sanitary Movement arose in Europe to handle rising communicable diseases and resulted in improving the
unhygienic conditions of towns in the post-Industrial Revolution period and living and working conditions of the
industrial workers. Acknowledgement of the negative impact of the World Bank – IMFs Structural Adjustment
Policies first came from deteriorating health indices in Latin America and Africa leading to efforts at ‘humanising’
the present form of globalisation.

Ritu Priya
However, since the health services interact model of development was one expression of
with the masses, they have to some extent to the differing perspectives2 3 Nehru favoured
be responsive to popular culture and popular bringing the state-of-the-art development of
expectations. That is what allows for the West to India, with the proviso of a self-
democratic pressure in an expert-biased reliant base for its production. Gandhi
system. People value the systems for its questioned its relevance for improving the lot
expertise but do not like to be exploited of the rural and the poor of India. He was
because of it. Therefore the elements of faith against the fetishism of technological advance
and trust are a central part of any health care as a criterion for development, placing
system. emphasis on knowledge that increased
people’s control over their own lives. Another
The specialised information of the providers ideological tension at the time of Independence
is a social asset that must grow and provide was the Gandhi-Hindu identity
maximum benefit. However, the narrower the fundamentalist confrontation as Gandhi
social and cultural gap between the provider sought to reinterpret both traditional and
system and the lay public, the more likely is folklore, to devise a new social order that
the service system to be accountable to the allowed for fulfilling the basic needs with
people. The philosophical moorings that give dignity for all, reinforcing pluralism and
direction to the growth of both health-related communal harmony. The Hindu-
knowledge and the health services are fundamentalist forces attempted to reinforce
therefore of crucial significance. It is in this the upper caste version of Hinduism and build
context that three models available for planned a centralised organisational structure for it.
development at the time of India’s The starting point for the Gandhian
Independence acquire relevance. perspective was ‘where the daridra narayan
was’ and to create conditions so that people
The Dialogue Between Development could improve their own condition.4 On the
Models other hand it also advocated a ‘resocialisation’
The effort of planned public health service of the upper castes/classes/male power
development was part of the task of ‘modern wielders of Indian society, building upon their
development’ that sought to bring all the existing traditions of equality and caring to
benefits of science and technology being transform them into being supportive of the
enjoyed by the imperial West to the masses in necessary social change. With the perspective
the colonised East. One ideological tension at that social disruption was worst visited
that time was around the vision of what and through violence upon the daridra narayan
how to constitute ‘modern development’. The the effort was to change social relationships
other was the role of the state Vs private capital ‘from within’. This was not in the abstract
as the owner of productive assets and the but in concrete material forms of livelihood,
provider of services, including health care. We life styles and consumption patterns, basic
discuss both very briefly. education and health care. It relied upon the
creative potential and wisdom of the Indian
The Debate over Knowledge Systems & countryside to build its own future, drawing
Technology upon external resources according to its own
The Nehru-Gandhi debate on India’s future visions.
2
Hardiman D., 2003. Gandhi in this Time and Ours Permanent Black, Delhi.
3
Gandhi M.K., 1945. Letters to Nehru. Collected Works of Mahatma Gandhi. Publication Div. GOI, New Delhi.
4
Daridra narayan used by Gandhi for the ‘last man’; in today’s development terminology it connotes those in the
deepest poverty, to whom he wanted to ensure ‘agency’, and whose benefit he saw as the centre of all planning
(Gandhi’s talisman).

At Independence, recommendations of three learning between ‘Allopathy’ and the

committees were available for formulation of Indigenous Systems of Medicine (Ayurveda,
plans for health services development. The Unani and Siddha, the ISMs). Their
Bhore Committee, the Health Survey and recommendation was that some practitioners
Development Committee chaired by Sir J.C. of each be given education in the other
Bhore, was set up by the British Government systems evolving into one integrated
in India in 1942. The Bhore report in 1946, is knowledge system.
what has provided the basis of health service
development in Independent India. It outlined The Sokhey Committee 1948, the Sub-
the blueprint of a long term and short term committee on Health set up by National
plan for a health service delivery structure Planning Committee of the Indian National
based on the principles of (i) equal access Congress which was spearheading the
irrespective of the ability to pay, (ii) rural areas nationalist movement against the British
to be the focus of services, (iii) provision of colonial power in India, differed from the top
comprehensive preventive and curative down approach of both these committees. It
services, and (iv) that co-operation of the recommended that manpower and services be
people be sought by the service system which developed from below upwards; youth in every
should be led by ‘the most highly trained type village be trained in primary health tasks and
of doctor’. This involved the setting up of
that those who perform well be trained further
medical colleges and ‘at least a few high quality
to become doctors, including those who were
advanced institutions’ for research and
already practicing indigenous systems.
training of health personnel. While these
would be located in major urban areas, a
Thus three models of development can be
three-tier health care delivery structure would
identified:
serve each district, from the secondary level
i) the ‘international standards’
district hospital to the primary health centres
and sub-centres at village level. In addition, development model represented by the
major public health problems requiring urgent Nehruvian perspective and the Bhore
attention were to be controlled through special Committee,
vertical programmes. Specific attention was ii) the ‘revival of ancient canonical
given in the report to identifying the causes of traditions’ model represented by the
ill health and disease. Recommendations were Hindu Mahasabha in Indian polity of
made for dealing with many of them (e.g. that time. For health services it was
setting up the Town and Country Planning the stream espousing revival of the
Organisation for urban and rural environment ancient indigenous systems without
planning; and increasing food production for generating conditions for a critical re-
improving nutrition. Thus it set the stage for examination and creative advancement
performance of all the three roles of public within them, (which the Chopra
health mentioned above. It is noteworthy that committee recommendations do not
it expected 15 per cent of total government represent, but which provided part of
expenditure to be on health. the pressure for setting up of the
committee itself and for its
The Chopra Committee on the Indigenous implementation),
Systems of Medicine 1946, set up to rectify iii) the ‘people-centred and pluralistic’
the lack of planning for these in the Bhore development model represented by
Committee Report,5 recommended a mutual Gandhi and the Sokhey Committee.
5
GOI,1946: Report of the Health Survey and Development Committee (Bhore Committee). Government of India,
Delhi, Manager of Publications.

Ritu Priya
As in all ‘models’, these should be read as ideal the People’s Plan prepared by the Indian
type symbolisation, which are not exclusive Federation of Labour7 and the Bombay Plan
watertight compartments but overlap at representing the industrial capital’s
several points with each other. perspective8.
All three Committee reports reflect the ‘Except for the Gandhian Plan, where the faith
accepted supremacy of modern medicine and in technology was subordinate to people, all
the objective of eventually making its services others believed in the power of technology’9.
available to all. Moreover they also reflect The People’s Plan and the Bombay Plan both
different dimensions of the complex reality– visualised the ‘best’ technologies and hospitals
respectively, the need for ‘scientificity’ as for disease control. However, the People’s Plan
defined by the then dominant and growing was in tandem with the Gandhian Plan in
‘modern medical science’, the validity of ISMs emphasising the role of agriculture and health
as ‘medical sciences’ that provided benefit to of the rural areas. The Bombay Plan focussed
large numbers, and the need to start building on urban services for industrial growth and
a health system from the base. After ‘education’ to improve rural people’s health.
Independence the Bhore Committee Report
was chosen to provide the vision for health Both the Bombay Plan and the People’s Plan
services development and to this day remains saw doctors and nurses as the only legitimate
the reference document. Unfortunately it did providers of health care. However the People’s
not incorporate the latter two dimensions and Plan placed sole responsibility for health on
thereby created a comprehensive blueprint for the State, the Bombay Plan held it responsible
a top down, health service system with a for institutional growth and personnel training
homogenising, non-pluralistic approach. Nor but not for controlling the private sector in
was its expectation of budgetary allocation health. The Gandhian Plan emphasised
ever fulfilled, the maximum over all the Five- people’s role in self-care10 .
year Plans being one-third of what was
requested. With adoption of the top-down model of
economic development and the supremacy of
The Debate on Public Vs Private Sector in state-of-the art technology based health
Health Services services for improving health, the Gandhian
Besides the perceived role of medical and Sokhey committee approaches were
technology in improving health, ownership, marginalised.
financing and provisioning of services were
also important considerations for health Current Relevance of the Development
service development at the time of Model Debates
Independence. Besides the Bhore and Sokhey Over half a century later, when much water
committee reports, the positions stated in has flown down the ‘development’ channel,
three Plans for overall economic development symbols and metaphors of these debates may
also influenced health service development– be considered irrelevant for dealing with the
the Gandhian Plan of Economic Development6, practical tasks today. The Nehruvian/Bhore
6
Agarwal B.N., 1944: The Gandhian Plan of Economic Development for India, Bombay, Padma Publications.
7
Banerjee, B.H.E. et al, 1944: People’s Plan for Economic Development for India, Delhi, Indian Federation of
Labour.
8
Thakurdas, Purshotamdas et al, 1944: A Brief Memorandum Outlining a Plan of Economic Development for
India, Calcutta, Central Publications Branch.
9
Qadeer I., 1997. Impact of SAP on Concepts in Public Health. Paper presented at International Seminar on
‘Impact of Structural Adustment Policies on Primary Health Care in South Asia’, CSMCH- JNU, New Delhi.
10
ibid

Committee/ internationalist model of health dominating, but giving some concessions to the
service development with self-reliance and latter (as the growth of institutions of ‘modern
access to services to all irrespective of the ability medicine’ and Ayurveda, Siddha, Unani and
to pay as a principle goal has served India fairly Homeopathy demonstrate). The ‘people centred’
well. Health status has improved significantly, model and dialogue between the knowledge
with life expectancy increasing almost twofold systems get lost somewhere in between. Yet
( life expectancy nearly doubled from 32 in 1951 this periodically resurfaces whenever faced
to 59 in 1991). An enormous health service with a social crisis and efforts are made to
infrastructure is in place, both in the public and build in correctives. But the entrenched
private sectors. Drugs, medical equipment and economic and cultural/social ‘right’ springs
manpower development capacities are well back as soon as the crisis is seemingly over.
entrenched. A mixed economy saw the public
sector lead health service development together Alternatively, it is also arguable that it was
with significant growth of the private sector. the lack of adequate fund allocation that led
Subsequently the private sector has overtaken to the limitations of the public sector. The
the public and developed technologically to the public plus private out-of-pocket expenditure
extent that India is already on the map of on health on an average for the total
‘medical tourism’ in the perspective of other population (that hides a wide disparity) is 5.1
‘developing’ countries as well as the first world pr cent of GDP, higher than most ‘developing’
countries seeking state-of-the-art services at low countries including China, the Latin American
cost! countries, and even Eastern Europe most of
which spend 3.5-4.5 per cent of their GDP and
However, the rise and decline of the public close to West Europe and Japan that spend
sector with continuing lack of access to quality 5.5-8 per cent. However the public spending
care by the majority raises a question about on health is among the lowest in the world,
whether this was not the inevitable logic of whether compared to the developed or
the choices that had been made at developing countries (Table 1, row 14), only
Independence. The history of the evolution of 17.5 per cent of the total. Countries with much
health services in India, findings of periodic lower per cent of GDP spent on health but a
official evaluations (showing inequitable greater share of it through the public sector
growth and poor quality of existing services, have achieved much better health indices,
diagnosed as results of ‘urban-oriented, such as Sri Lanka and China (Table 1,
curative, technology centred evolution, columns 6 and 8). WHO estimates put India
alienated from the masses’) and subsequent in the lowest category of countries for ‘access
efforts at reorienting its development is to essential drugs’, i.e. countries where less
evidence of the primary tension that continues than 50 per cent of the population has any
to pose a challenge to this day 11,12,13,14. The access. Therefore, the public allocation to
immediate issues may change but the health is an important factor. However, also
triangular contest continues. The to be recognised is the fact that these countries
internationalist model and the revivalist have have much lower levels of poverty (Table 1,
coexisted in the mainstream, the former row 10), 6.6 per cent of Sri Lanka’s population
11
Shrivastava Committee, 1975: Health Services and Medical Education: A Programme for Immediate Action, Group
on Medical Education and Support Manpower. Ministry of Health and Family Planning. Government of India, New
Delhi.
12
Government of India, 1982: Statement on National Health Policy, Ministry of Health and Family Welfare, New
Delhi.
13
ICSSR-ICMR, 1981: Health for All: An Alternative Strategy – Report of a Study Group Set Up Jointly by Indian
Council of Social Science Research and Indian Council of Medical Research, Pune, Indian Institute of Education.
14
GOI, 2002: National Health Policy-2002. Department of Health, Ministry of Health and Family Welfare, Government
of India, New Delhi.

Ritu Priya
and 18.8 per cent of China’s living below 1 on to create a health service system more
US dollar per day as compared to India’s 44.2 responsive to people’s needs. The Primary
percent. The relative importance of these two Health Care approach adopted internationally
factors as determinants of the difference in in 1978 as the Alma-Ata Declaration
health status is difficult to assess, but that articulated it with great impact. It focussed
both are problems that need urgent attention on ‘comprehensive services’ which are
for improving health status is well accepted. ‘accessible, affordable and acceptable to the
An equally serious consideration is the nature people’ along with ‘intersectoral collaboration’
of spending of the public funds for health, for improving health status of the
since increased funding may go into irrational populations 16 . A questioning of the
expenditure by following the ‘standards’ set development paradigm by developing and non-
by the private sector or the ‘international aligned nations, forced adoption of a
standards’ and only be wasted without democratic instrument such as the Alma-Ata
improving health status in any significant way. Declaration. Yet even this Declaration was
The USA, which has the highest GDP and very soon subverted in spirit, though not fully
spends the maximum on health through both refuted. What came to be known as the
the public and private sectors has lower health Selective Primary Health Care approach was
indices as compared to Japan and Sweden. It adopted in practice over the early 1980s,
has extremely high proportions of iatrogenic shifting to techno-fixes in areas of ‘child
ill health in the total patients reported by the survival’, ‘safe motherhood’ and other vertical
health services. disease control programmes 17. The dominant
mindset had already imbibed the ‘fetish of
Clearly, the public services created a demand technology’ and therefore the selective
for modern health services by making a approaches detracting from the
widespread network of services available but comprehensive approach made a quick
were unable to cater to the demand by making comeback, and have only gained in strength
them accessible to all. This left the patients since. The Health Sector Reforms of the 1990s
with perceptions of medical treatment and ‘felt which promoted commercialisation of the
needs’ that made them spend on private public sector and corporatisation of the private
services 15. What is also clear is that private sector were argued on the basis of the
spending is not on essential drugs. Thus the importance of ‘transfer of technology’ from the
high expenditure on health care is an outcome industrialised countries, This meant seeking
of the combination of a top-down iniquitous international financial aid to provide
economic growth that has allowed conditions technology based services to improve the
of high morbidity to continue combined with a quality of services.
top-down technocentric health service
development and preponderance of an The present dominant thinking on improving
unregulated, expensive private sector over a the public health services is reflected in the
weaker public sector. Planning Commission’s preparatory
documents for the tenth Five Year Plan (2002-
Alongside the dominant trend in health service 2007). ‘The existing health system suffers from
development, attempts have constantly been inequitable distribution of institutions and
15
Banerji D., 1973. Impact of Rural health Services on the Health Behaviour of Rural Populations in India: A
Preliminary Communication. EPW, Vol. 8, pp. 2261-68.
16
WHO, 1978: Primary Health Care– Report of the International Conference on Primary Health Care, Alma Ata,
USSR, September 6-12, Geneva, World Health Organisation.
17
Chen L. (1988): ‘Ten Years After Alma-Ata – Balancing, Different Primary Health Care Strategies’ in State of the
Art Lectures-XIIth International Congress for Tropical Medicine and Malaria Ed. A de Geus Suppl. To Trop. And
Geog. Med. 40(3) pp.

manpower. Some of the factors responsible for ‘Several possibilities were repudiated in
the poor functional status of the system are: the 1930s. India could have adopted a
mismatch between personnel and wide variety of standards of training
infrastructure, lack of Continuing Medical designed to match varying local needs;
Education (CME) programmes for orientation or she might have preferred a single
and skill upgradation of personnel, lack of ‘national’ medical system with the
appropriate functional referral system, indigenous systems integrated into it.
absence of well established linkages between Instead, she chose a British model. This
different components of the system.’ This is a British pattern was rapidly subverted
limited ‘diagnosis’ that identifies structural in just those ways which the I.M.S. (the
and functional problems but does not relate Indian Medical Service) was overtly
them further to their roots that lie in the
most worried about – a politicisation of
inappropriate technology-centred and
medicine in the public sector and a
bureaucratic policy approaches. Thereby the
commercialisation of medicine in the
recommendations for ‘reforms’ can only
private.’
promote the existing mindset, further
compounding the problems.
This logic has, since the 1990s, been carried
Standards and Quality of Medical even further leading to a commercialisation
of the public sector as well as a politicisation
Service Providers
of the private sector!
The development of manpower and research
capacities exemplifies the roots of the problem.
In the 1940s, there existed a fairly high The mindset of the leaders of the health
registered doctor: population ratio of one system, the doctors, was created through the
doctor per 6,300 persons. Almost two-third of development of health services and medical
these were ‘licentiate doctors’ with a 3-year research under colonialism. It catered to
training as against the 5-year M.B.B.S. public health services through the Indian
graduate18. After a bitter debate about ‘quality Medical Service or provided manpower for
of medical manpower’ in the 1930s, the medical care through private practice,
licentiate courses had not initially been ‘…symbolised by the cantonments,
recognised by the Great Britain Medical civil lines, hill stations, and civil
Council. So there were several options before stations, came to exist wherein the
the country in the 1940s – i) The one and only growth of the health system, the
‘best’ type of doctor with 5 years of medical curative medical system and the
education acceptable to the Great Britain research system took place organically,
Medical Council, ii) the licentiate doctor with co-terminus with the needs of the
3 years of education who was below the metropolis.’ Further, the colonial policy
Medical Council’s standards, and iii) the ‘encouraged the expansion of the
creation of a new kind of doctor with organic private medical profession (both
links to existing indigenous knowledge as well European and Indian), for a few medical
as an awareness of the elements of the modern colleges were a cheaper (but not
medical system. The Bhore Committee necessarily an effective) alternative to
reopened this issue and decided (despite expanding government resources on
strong dissent by some members) against
sanitary reforms for the general
continuing the licentiate courses, settling for
population’.
nothing less than the ‘highest standards’.
18
GOI,1946: Report of the Health Survey and Development Committee (Bhore Committee). op.cit.

Ritu Priya
It was the growing pressure of the national it is the greater value placed on one or the other
movement for Independence from colonial rule which has changed. In the first three decades
that forced the imperial government to concern after Independence, the emphasis had shifted
itself with public health services for the to the public sector and since the mid-1980s,
masses and so it set up the Bhore Committee the leadership role is again being handed over
in 194319, to give itself ‘a human face’. to the private sector. The nature of the private
sector is also changing, with greater
Roughly three-fourth of the doctors were in corporatisation and the highest ‘quality’
the private sector even in the 1940s 20. The services are perceived to be provided by the
government doctors also engaged in private corporate private sector. However the failure
practice, which was officially seen as a source of the ‘market’ in health services is also well
of additional remuneration and experience for acknowledged. Diverse roles of the state, civil
them. The Bhore Committee recognised that: society and the community are envisaged to
overcome this ‘market failure’ as well as to
‘…the practice has so far been to permit overcome the alienation of the health service
private practice, but the desirability of system from the lay people.
doing so in the future requires serious
consideration… that prohibition of But, as the NHP 200221 and the Tenth Plan
private practice was essential in order documents show, the perspective for setting of
to ensure that the poor man in the rural inappropriate ‘standards’ and ‘quality’ are not
areas received equal attention with his viewed as part of the root of the problems of
richer neighbour’. the health services. Both contain a substantial
diagnostic analysis of the shortcomings of the
Yet it did not recommend this forcefully. On health sector but focus only on limitations of
the contrary it recommended that: ‘the financial resources and managerial
capacity’22. The revival of medical licentiates,
‘In hospitals attached to teaching greater involvement of paramedical personnel
medical institutions it is considered and practitioners of Institutions of Indigenous
desirable that there should be a Systems of Medicine & Homeopathy (ISM&H)
proportion of medical men who combine in delivery of medical services is suggested as
hospital teaching work with private a compromise on standards to improve
practice so as to enable them to gain coverage and ensure ‘equity’ in access to
the wider experience that contact with health care. There is not even one statement
the general public ensures.’ about the alienation of the services and
providers from the lay people, something that
The dichotomised thinking on defining ‘quality’ the NHP 1983 had clearly delineated and that
for public health and for medical care is a vast number of studies have strongly
evident. demonstrated23. The documents read as if the
limited role of medicine, the even smaller role
Thus the public-private links have existed of high-tech medicine, the increasing costs of
throughout the evolution of the health services, irrational medical management and
19
GOI, 1946: Report of the Health Survey and Development Committee (Bhore Committee). op.cit.
20
GOI, 1962: Report of the Health Survey and Planning Committee (Mudaliar Committee). Ministry of Health,
Government of India, New Delhi.
21
GOI, 2002: National Health Policy-2002. op.cit.
22
Ibid
23
FRCH (1994) Health Research Studies in India: A Review and Annotated Bibliography. Foundation for Research
in Community Health, Bombay.

iatrogenesis (disease created by the doctor) are policy prescriptions are undermining these
unheard of, at a time when these are well achievements. They also attempt to ignore or
acknowledged components of the dilemmas counter the questioning of the dominant model
confronting public health policymakers world- of development adopted at the time of
wide. The NHP 200224 contains pious hopes Independence and instead pursue it even more
that aggressively. How will standards and quality
be determined in the coming years; by the
‘the creation of a beneficiary interest in needs of medical tourism and the private
the public health system will ensure a corporate sector or the diversity of needs of
more effective supervision of the public people in India’s metropolises, small towns,
health personnel through community ‘accessible’ villages and the remotest villages?
monitoring than has been achieved That is the crux of the present struggle.
through the regular administrative line
of control’ and that ‘any policy in the We cannot continue to repeat the solutions of
social sector is critically dependent on the 1950s and 1960s. With about one doctor
the service providers treating their registered with the Medical Council of India
responsibility not as a commercial (MCI) per 1800 persons and 17,000 more being
activity, but as a service, albeit a paid produced annually, do we need to revive the
one’. licentiate? Will it reduce the alienation of the
system from the layperson, or only create
Thus the administrative structures have been further hierarchies of dissatisfied personnel?
absolved of the responsibility of ensuring The licentiates, who constituted almost two-
adequate quality of functioning. No analysis thirds of the doctors and thereby contributed
has been attempted of the existing lack of to the high doctor: population ratio of one
accountability of the system and the providers doctor per 6,300 persons existing in India in
to the community. No link is seen at all the 1940s, were irrationally done away with
between the quality of functioning of the as an outcome of the debate on ‘standards’ of
services with the structure of the system or medical education. However, the licentiates
the knowledge-gap, perspective-gap, and the were themselves not an answer to the problem
social hierarchy that exists between the of lack of organic links of the doctors with the
service providers and the lay people. Leaving majority of India’s citizens. They were as
it to ‘supply’ and ‘demand’ mechanisms concentrated in the cities as the ‘fully qualified’
appears to be the logic, with the unquestioned doctors, and the alienation of both from the
assumption that state-of-the-art medical majority is evidenced in the fact that ‘when
services are the model the country must 11 poorly paid jobs were advertised in Aden,
follow. 995 licentiates and 428 graduates applied.’ 25
Would it be more appropriate to devise ways
It was the dialectic between the logic set by the of strengthening the existing providers of
choices about ‘standards and quality’ during health care to the poor– the public sector
the colonial rule and the imperatives of public paramedics and the ‘informal’ providers?
health plus public pressure that shaped the What criteria would be appropriate to assess
health service system and continues to do so. the optimal requirement of standard of
The outcome of this dialectic can be seen in services and personnel under diverse
the nature of growth of the health services as conditions? These are the questions we
discussed in the following section. The current urgently need to address.
24
GOI, 2002: National Health Policy-2002. op.cit.
25
Indian Medical Gazette, 1937 as quoted in Jeffery, 1979.

Ritu Priya
The current crisis created by globalisation on hospitals and Primary Health Centres were set
the one hand and the space provided by the up fairly rapidly while the sub-centres at
simultaneous rhetoric of democratic ‘people’s village level lagged behind (Table 2). Medical
participation’ on the other provides another graduate education grew while nursing and
opportunity for advancing the people-centred other health personnel lagged behind.
development of health services. Can we Abolition of the licentiate course,
confront the tension between different models recommended by the Bhore Committee, was
of development, and generate a creative finally accomplished in 1956.
dialogue to mainstream the people-centred
perspective and evolve/reform public health The vertical programmes (for small pox and
systems accordingly? Or will we let the twin malaria) grew, while general health services
faces of the ‘economic and cultural right’ get lagged behind. This perpetuated the creation
together against people’s interests? The of an urban-oriented, curative, and biomedical
approach to population control represents the expertise-centred professional mindset of the
same struggle of perspectives. Examining the health personnel. The stage was set for the
process of development of public health technical perspective and hierarchical, doctor-
services in India may help us in identifying centred culture of the health services that was
the specific direction a people-centred to follow. As a concession to the Chopra
approach should take at this juncture so that committee, a significant number of
the ‘Right to Health Care’, once achieved as a institutions of Institutions of Indigenous
legal/constitutional instrument can be given Systems of Medicine & Homeopathy (ISM &
appropriate content.. H) were set up but with nominal financial
allocations as compared to the allopathic
It is with reference to this complex of issues institutions (Tables 3 & 4). The village level
that we can trace the growth of health services workers were remembered only after two
over the four phases from 1950 to the present. decades when the Village Health Worker
scheme was started in 1977.
The Growth of Public Health Services
1950 – 65: A Period of Growth at All Levels During this period there were achievements
Public Health in its modern form entered India made in terms of a network of health
as an independent sphere of activity during institutions being established, significant
the colonial period, initially after 1857 to deal control over malaria that was the biggest killer
with problems faced by the British army and at the time (from an estimated 75 million cases
then grew rapidly around 1900 in response and 1 million deaths in the 1940s to a mere
to large-scale epidemics. Research institutions 50,000 cases and no deaths in 1961) and
were set up in the first three decades of the elimination of smallpox in large parts of the
20th century such as the All India Institute of country. Economic conditions, food
Public Health & Hygiene and the Malaria production and standards of living also
Institute. Municipalities provided some health improved. As a result mortality rates
related services to a limited population in the continued to decline (Table 5).
urban areas, with dispensaries and hospitals
growing sporadically. Later, in the first half of 1966 – 1980: A Period of Growth of Village
the 20th century, some experiments and small- Level Services
scale efforts were started to provide services The end of the 1960s witnessed a crisis in
to the rural population as well. terms of wide spread drought that raised
questions about the development model
In the immediate post-Independence period adopted so far, coinciding with an
of the 1950s and 1960s, advanced research international questioning of the continuing
institutions, medical colleges with tertiary hegemony of the earlier colonising countries.

The response of the powerful sections was to rural conditions and experience in working
raise the bogey of ‘population explosion’ that under those constraints. The Community
was eating into the gains of development. The Health Volunteer Scheme (CHVs) for training
global oil crisis in the 1970s led to cutting villagers to provide basic preventive and first
back on public expenditures on social sectors. aid services at the doorstep was another such
The churning led to some shifting of focus to initiative. The CHVs were to act as a two-way
rural areas and ‘people’s knowledge’ so that channel for communication between the
the Alma-Ata resolution on Primary Health service system and the community, a form of
Care in 197826 came to be internationally ‘community participation’. However, with no
accepted as the approach for health service effective change in the culture of the health
development. The National Health Policy of service system, or questioning of the content
1983 evaluated the development of services of its services, none of the systemic visions
up to then as ‘urban oriented and curative’. changed. The scheme only created menials for
The example of China’s barefoot doctors and the health service personnel, while many of
civil society initiatives such as the Jamkhed them also became privately practicing ‘doctor
project provided alternative visions. sahibs’.
The pace of infrastructure development picked The spread of service institutions, even though
up markedly at the sub-centre level (Table 2). limited, had generated a demand for services
Within the health sector, the limited in the general population. A large number of
achievements of the Family Planning medical professionals ‘of the highest order’,
Programme (FPP) and resurgence of cases of i.e. the medical graduates, and a cadre of
malaria all across the country coupled with paramedics had been created. However, with
increasing deaths forced some rethinking. The inadequate infrastructure, a growing social
isolation of these vertical programmes from alienation between the service system and the
the general health services was acknowledged general population, as well as the social
as one of the causes of their limited success hierarchy in the caste/class background of the
and this led to efforts for their integration with service providers and the served, the quality
the general health services. The needs of these of services provided got little attention. As
programmes, and their funds, gave the demand grew and the institutions at PHC and
impetus for increasing the village level secondary referral level did not expand (Table
infrastructure; so even while the latter 2), services grew outside the public sector.
expanded its vision remained ‘vertical’ and
‘selective’. The 1980s: A Boom in Health Care
Institutions
The newly created ‘multi-purpose workers’ Over the 1980s health care institutions
(MPWs), the personnel working in the proliferated at all levels but more so at the
community, were forced to focus on tasks of primary level in both public and private
the FPP and malaria control as the whole sectors. Visions got further narrowed with the
system still gave these problems priority. international discourse and programmes
Initiatives such as the Reorientation of Medical retreating from the Primary Health Care
Education (ROME) scheme was an attempt at Approach to ‘Selective’ Primary Health Care
improving the quality of services at peripheral in 1980 27,28 . Specific disease control
levels by exposing the medical students to programmes and population control got
26
WHO, 1978: Primary Health Care– Report of the International Conference on Primary Health Care, Alma Ata,
USSR, September 6-12, Geneva, World Health Organisation.
27
Banerji D., 1985. Health & Family Planning Services in India: an Epidemiological, Socio-cultural and Political
Analysis and a Perspective. Lok Paksh, New Delhi.
28
Chen L. (1988): ‘Ten Years After Alma-Ata. op.cit.

Ritu Priya
international professional support and funds. During this period, the larger economy and
Public health got bogged down in managing polity moved from the national movement’s
the family planning and health programmes, idealism and Nehru’s notion of socialistic self-
reneging from the third role it was expected reliance to a more blatant internationalist
to play, that of identifying society’s pathology elitism to procure for the better-off sections
and thereby providing recommendations for of society state-of-the-art consumer goods and
other sectors for action to improve the health services. The seeds for this had been sown
of the population. ‘Public health’ became earlier by the Nehruvian model that had posed
‘preventive medicine’. these as the ideal standards for quality of life.
The large number of trained medical and
The departments of Preventive & Social paramedical professionals and practitioners
Medicine in medical colleges reflected this in of ISM & H not absorbed by the public sector,
the education they imparted to the medical got into private practice to cater to the demand
undergraduates, the ‘social’ dimensions being at all levels of care and for all sections. This
taught, if at all, very superficially. Public comprised the non-formal practitioners at
health research, which had been imbued to village and slum level, the formally trained
some extent with a social orientation focusing practitioners for the urban better off running
on people’s life conditions in the 1950s and clinics, polyclinics, nursing homes and
1960s, as in the case of tuberculosis and
hospitals with a wide range of quality and
occupational health29 had by now stalled.
pricing of services. The commercial interest
There was little in the environment to promote
in health services increased with competition,
creative engagement with the survival
marketing strategies of the pharmaceutical
problems of the people. For the ‘highest order
industry, expansion of diagnostic services and
of doctors’ professional excitement and
specialists who garnered patients through
rewards lay elsewhere. Research institutions
commissions to the public sector care
primarily followed the ‘advanced’ countries,
mimicking their research to become poor grade providers and the private general practitioners.
copies. Having always been out of reach of ‘the The public sector personnel, frustrated by the
people’, these mystical centres of science and distortions and limitations within the public
technological advancement remained alien to sector and lured by the commercial sector,
the majority, beyond all checks and controls increasingly built links with the private sector,
of their own society. Committed individuals further depleting quality of the public sector.
or groups of individuals did exist as exceptions Technocentric and commercial attitudes came
to prove the rule, who attempted to relate to together to create an explosion of irrational
the poor and the rural sections and they kept health care.
the institutions going with some meaningful
activity30. But they had to constantly struggle More over the management of patients
to swim against the stream. However, for even increasingly incorporated unnecessary
the majority of ‘committed’ doctors, ethical procedures and over-medication that
state-of-the-art practice with a humane touch influenced lay people’s expectations.
was the ideal, socialised as they were by the Administering injections when oral medication
Nehruvian vision of development. is available and effective is an obvious
29
Kurian C.M., 2002. The State’s Perception of Worker’s Health in India – The Case of Occupational Health
Research. Unpub. M. Phil Dissertation.
30
Singh,V., 2002: A Public Sector Doctor’s Musings– What Many People Do Not Know About the Public Sector,
Proceedings of the workshop on Societal Concerns and Strategies for AIDS Control in India, January, 2002,
Jawaharlal Nehru University, New Delhi.
Sarkar A., 2002: Reflections on the Primary Care Services of a Newly Formed State, Proceedings of the workshop
on Societal Concerns and Strategies for AIDS Control in India, January, 2002, Jawaharlal Nehru University, New
Delhi.

example31 People of all sections resorted to inputs. More generalist medical officer
different providers at different times, based personnel had been sanctioned than the
on the problem at hand and their assessment required norm and were over-filled, but
of the various medical knowledge systems and backward areas had serious shortfalls (Table 6).
a choice of private and public sector providers
within ‘modern medicine’. The public sector With the cumulative economic growth and a
doctors were considered most knowledgeable special emphasis on poverty alleviation
but negligent and rude, and the services in programmes over the 1980s, proportion of
general ‘patient unfriendly’ with inconvenient population that had income below the poverty
timings and problems of physical access. The line declined markedly. Infant Mortality Rates
private sector was perceived to have less (IMRs) too, declined sharply. However,
knowledge and more commercial interests, but changing ecological conditions and non-
was more patient-friendly. People also believed sustainability of technocentric disease control
the medicines being given through private programme implementation, along with large-
practice were ‘better’ relative to the routine scale movement of people due to the skewed
and limited options perceived at the public nature of economic development and
institution 32,33 . So there was a constant livelihood changes, led to the return of
movement between the public and private communicable disease epidemics (e.g. kala-
institutions as well as pluralistic use of azar in Bihar and West Bengal since the late
different folk/traditional/modern systems for 1970s, falciparum malaria and cholera in
different diseases when an illness persisted Delhi since the late 1980s). Non-
or became serious. Professional bodies with communicable diseases began to rise too,
civil society collaboration such the ICMR- creating a double burden of disease. Demand
ICSSR Study Group on Health for All for services increased, 6 per cent of GDP being
advocated for expansion of public health spent on health services, but there was no
services with specialists of curative medicine trustworthy health service system to cater to
and epidemiology at a new tier of institutions. the demand, despite an enormous health
The result was the Community Health Centre service infrastructure.
and an increasing the number of PHCs to serve
a population of 30,000 rather than the Thus by the end of the 1980s the public health
1,00,000 they were initially meant to cover system was in a crisis, with increasing demand
(but were covering almost double due to for health care, increasing but inadequate
population increase with no institutional infrastructure, poorly functioning primary
expansion). The FPP affected by excesses of level institutions and a competitive, expanding
the national emergency period 1977-80 private sector. Simultaneously the country
needed a new face and got termed Family experienced an economic crisis of poor
Welfare. ‘India Population Projects’ and ‘Area ‘balance of payments’ and no foreign currency
Projects’ brought unprecedented international reserves. On the latter front we gave in to the
funds for infrastructure strengthening. The World Bank - IMF led Structural Adjustment
number of primary level institutions increased Programme (SAP). For the former we adopted
substantially. However the personnel Health Sector Reforms as well as even more
essentially performed FPP tasks, health care selective and technology-centred changes in
taking a back seat. CHCs were set up but with the vertical programmes. ‘People’s
inadequate sanction of posts and specialist participation’ rose to the occasion once again
31
Reeler A.V., 2000. Anthropological perspectives on injections: a review. Bulletiin of World Health Organisation,
78(1), 135-143.
32
Banerji D., 1982. Poverty, Class and Health Culture in India, Vol. I.Prachi Prakashan, New Delhi.
33
FRCH 1994. Health Research Studies in India: A Review and Annotated Bibliography. Foundation for Research
in Community Health, Bombay.

Ritu Priya
as a crisis management exercise. It also suited Improving quality of health services was
the SAP agenda of withdrawal of the state from universally viewed as an imperative. However
the social welfare sectors by shifting there is wide divergence of views on which
responsibility on to ‘the people’. The paradox components of the service system to prioritise
is that it also created an opportunity for and what constitutes ‘quality’. Strengthening
creative engagement, going back to the initial the services from a Primary Health Care
and continuing tension, between the formal perspective is one approach, increasing
system and the majority comprising the poor availability of state-of-the-art medical
and the rural sections. technology through institutions meeting
‘international standards’ is the other end of
Since the 1990s: Growth at Secondary and the spectrum of perspectives. While stating
Tertiary Levels with Commercialisation and the objective of strengthening Primary Health
Corporatisation Care, the internationally propagated Health
Despite the crisis, it has to be acknowledged Sector Reforms (HSR) are building legitimacy
that, by 1990-91 development had progressed for the latter. The latter attracts the middle
in India on several fronts but at its own slow class, suits professional aspirations of a
and steady pace (Table 5). It was slower than section of medicos and the medical corporate
many other ‘developing’ or ex-colonised sector. It is also conducive from the
countries, but still high relative to the per perspective of the internationally powerful
capita income levels (Table 1). We also had lobbies of the pharmaceutical and medical
the health infrastructure, manpower, equipment industry as well as insurance
technology and production capacity for each capital. The HSR initially included cutbacks
of these. The crisis was therefore confronted on public health expenditure, instituting user
by a multitude of efforts at strengthening the fees for public services, promoting ‘public -
health services. Measures for ‘Health Sector private partnership’ in various forms,
Reforms’ were put forth by the international providing state support to private sector
agencies, with the World Bank overtaking service development, and decentralisation of
WHO and UNICEF as the agencies leading in health services 34 . Strengthening Primary
international health analysis and policy Health Care in the public sector was reduced
formulation. However, the central and state to primary level services while secondary and
governments have adopted and/or are still in tertiary level services, which are the greatest
the process of working out, diverse measures. profit-makers, were to be promoted in the
It is therefore important to examine the policy private sector.
proposals, the actual measures adopted, and
the processes of decision-making that are still In India, the checks imposed in earlier decades
on and involve a struggle between on the fetish for state-of-the-art technology
acquiescence and resistance to anti-poor, anti- by the other pro-poor, pro-people perspectives
people measures as well as using the were weakened by dominance of the neo-
opportunity for change in favour of pro-poor, liberal, market-friendly environment. The
pro-people measures. One clear lesson from focus for improving functioning now became
the experience of these years is that the responsibility of secondary and tertiary
development of public health services in a hospitals, besides the private sector being
particular manner can provide structures for an encouraged through state subsidies.
escalation of the ongoing processes of
commodification of health and While the private sector has certainly
commercialisation of the health services at a experienced a boom since the ’80s, there was
mass level. a cut in expenditure for the public sector
34
World Bank 1993: World Development Report 1993: Investing in Health, OUP, New York.

general health services in the early 1990s (see HIV and AIDS), millions of dollars of World
data on budgetary allocations in annexure). Bank loans have been incurred. The
Shortages of drugs and reagents increased, programmes were now dependant on
except for the Reproductive and Child Health technological approaches that were even more
Programme (that incorporated Family expensive and difficult to sustain 35 .
Planning). The decrease in recruitment of MPW Consequently, certain primary level services
(male) and increase in Auxiliary Nurse Midwife were strengthened in terms of the isolated
(ANMs) reflects this focus and the imperative disease control programmes but the general
of budget cuts. Activities for diseases thought health services deteriorated further,
to be controlled by then– plague, kala-azar exemplified in the poor infrastructure and
cholera – declined or were disbanded essential inputs at the PHCs. The decline of
altogether due to budgetary cuts (e.g. their routine immunisation coverage as shown in
surveillance systems and chlorinating of wells Government of India 2002 figures is one
were disbanded in many parts of the country). reflection of this deterioration.
On the other hand the national control Recognising the failure of the market in health
programmes for other diseases, which depend care through the experience of decreasing
on mass use of pharmaceutical products, utilisation of health services and failure of
expanded with the input of new drug regimens several mass programmes to meet their
and delivery systems. Supported by the false objectives (such as Rollback Malaria, RCH, the
promise of ‘eradication’ (as for leprosy and the FPP), emphasis is now returning at the
Pulse Polio campaign) or the exaggerated fears international level to strengthening public
of drug resistance (as in the case of health services and is declining on the
tuberculosis) and devastation (as in case of imposition of user fees. 36 The budgetary
Source : Planning Commission, GOI, September 2002. Report of the Steering Committee on
Health for the Tenth Five Year Plan (2002-2007).
35
Qadeer I., 2000: Health Care Systems in Transition III. The Indian Experience Part I. Journal of Public Health
Medicine, 22(1), 25-32.
36
Task Force on Health Systems Research, 2004: ‘Informed Choices for Attaining the Millenium Development
Goals: Towards an International Cooperative Agenda for Health Systems Research’, Lancet, 364, 997-1003.
Palmer N. et al, 2004: ‘Health Financing to Promote access in Low Income settings– How Much Do We Know?’
Lancet, 364, 1365-70.

Ritu Priya
allocations at national level and by most states on their own (i.e. without central support) by
have risen in absolute terms since the mid- developing projects for international funding
1990s37, 38 However the allocations still remain or through administrative changes. The wide
inadequate relative to the rise in salaries and range of ‘reform measures’ implemented
cost of other inputs such as drugs and include the following:
equipment. Increasing expenditure is also
going into new management structures with 1. Strengthening Management Structures
decreasing public accountability. for greater efficiency, which involved setting
Simultaneously ‘social marketing’ or up of autonomous societies for public health
propaganda for the specific disease control programmes and services, changing
programmes is using the perceived public good procurement procedures and personnel
of preventive efforts to gain legitimacy for management processes. Tamil Nadu led in
medical technology such as vaccines, evolving centralised drug and equipment
distracting from the role of secure livelihoods, procurement arrangements as well as in
labour conditions, nutrition and healthy obtaining international funds directly by
environments for prevention of disease and bypassing the central government.
promotion of health.
The State and district level societies with
The overall impact has been to increase the ‘felt autonomous funding for specific tasks (e.g. the
need’ for hi-tech health services but a decline State AIDS Control Societies and the District
in the ability of all to access treatment. NSS Tuberculosis Control Societies) tend to
data shows an increase in ‘not taking verticalise and isolate the specific programmes
treatment due to financial reasons’ increasing even further as well as to implement services
from 15 per cent in rural areas in 1986-87 to through the private and NGO sectors rather
25 per cent in 1995-96, and from 10 per cent than strengthen the public sector.
to 20 per cent in urban areas over the same
period.39 2. Contracting Staff – Attempts have been
made to fill vacancies of doctors, ANMs and
Health Sector Reforms laboratory staff by hiring contractual
Specific measures adopted as ‘Reforms’ in the personnel (as in Andhra Pradesh [A.P.],
health services varied across states. As Uttaranchal).
development trajectories differed, a north and
east versus south and west gap became 3. Strengthening Infrastructure
prominent across the 25 states and 7 union " At Primary level, buildings were built
territories, the latter regions faring much and equipment bought for PHCs,
better in industrial and economic upgraded PHCs and CHCs under the
development, health services and health RCH programme. Directly observed
indices.40 Health being a state subject and treatment, short course (DOTS) centres
different parties, particularly with regional for the Revised Tuberculosis Control
parties coming into power, saw many state Programme and urban health posts
governments attempt to deal with the crisis were added to the repertoire of primary level
37
Pratibha, J. 2004: ‘Status of Health Care in Indian States: An Overview’. Paper presented at the 30th MFC
Annual Meet, Feb. 2004, Bhopal.
38
GOI, 2002: National Health Policy-2002. op. cit.
39
Iyer, A. and G. Sen, 2000. “Health Sector Changes and Health Equity in the 1990s”. In Shobha Raghuram [ed.]
Health and Equity– Effecting Change. HIVOS, Bangalore
40
Baru R.V., 1999. The Structure and Utilisation of Health Services: an Inter-State Analysis. Rao M. (Ed.) Disinvesting
in Health– The World Bank’s Prescriptions for Health, Sage, New Delhi.

institutions. recurring expenses and drug supplies etc.

" At Secondary level, district hospitals in remain unmet. Imposition of user fees without
some states were put under the any improvement in services tends to push
management of autonomous patients from the public to private institutions.
‘corporations’ with the help of
international loans as part of ‘Health 4. Public-Private Partnership is also being
Systems Development Projects’. formally institutionalised in several ways.
Upgrading buildings and equipment at Outsourcing specific segments such as
the secondary level, charging user fees laundry, catering and security is being widely
were part of the package deal. A.P. and practiced. Referral linkages with private
Punjab led in terms of such secondary practitioners and laboratories have been
level institutional corporatisation with developed for specific tasks (such as RCH
grand new buildings which are often referral, laboratory support for Revised
not patient friendly; increase in National Tuberculosis Control Program
equipment and procedures but with (RNTCP) through franchising mechanisms. A
user charges; often with continuing proposal that is under discussion is to allow
poor conditions at the primary care use of health institutions’ premises and
level. New secondary level hospitals infrastructure to private practitioners. The
were set up in some states (e.g. in Delhi). stated purpose is to increase ‘efficiency’.
" At Tertiary level, several states set up
5. Public Institution Sale to the Private
tertiary institutions on the pattern of
Sector by disinvestment of secondary and
AIIMS, with implementation of user
tertiary hospitals that have been declared
fees. Subsidies were also given to the
‘under-utilised’, mismanaged, or requiring
private sector by way of free/highly
funds for upgrading is frequently being
subsidised land and waiving of import
discussed but is not known to have been
duty on medical equipment with the
implemented anywhere as yet.
objective of obtaining availability of
state-of-the art medical technology. The 6. Public-NGO Links have been built through
public sector employees with access to experiments with NGOs taking over organising
free health services –e.g. through the of services at primary level or working in close
Central Government Health Scheme collaboration (e.g. SEARCH in Gadchiroli) and
(CGHS) and the Employees State innovating on content of services.
Insurance Scheme (ESIS) have been
allowed greater referral to the private Another important link has been the
sector for tertiary care. Thus the public sensitising of health personnel to social issues
exchequer is paying an increasing by the NGOs, e.g. Gender sensitisation, AIDS-
proportion to the private sector for related issues, NGOs facilitating community-
provision of tertiary services instead of provider dialogue, ethics in health research
improving its own provider role and (e.g. MASUM in Pune, Rupantar in
deciding upon standards of rational Chhatisgarh, CEHAT in Mumbai). Karnataka’s
patient management. Task Force on Health and Family Welfare had
strong civil society collaboration and has
As a consequence of these ‘reforms’ new, contributed to strengthening Primary Health
sparkling white buildings can be seen at Care in the state.
various levels of the health services, but they
often lack the bustle and crowds one 7. Public-Community Links are being
associates with medical institutions since developed through involving Panchayati Raj
manpower continues to be short of the Institutions in management of primary level
stipulated minimum, requirements of institutions and having administrative control

Ritu Priya
over non-medical staff. (Madhya Pradesh as well as regulatory mechanisms are

[M.P.], Kerala), community involvement and gaining centre stage. The major thrust on
village level cadre (as in M.P, Chhattisgarh, the plea of improving quality has been on
Rajasthan, Uttaranchal), AIDS care as a experimenting with changes in financing
continuum from community to institution and management structures to suit
(several experiments are under way). Madhya administrative control by international
Pradesh, Rajasthan and H.P. pioneered the funders, insurance companies and local
process of initiating structures for people’s private enterprise. While quality may have
involvement in reforming medical institutions improved on some counts in a section of
to upgrade infrastructure and facilities. This the public sector medical institutions,
has been mediated by local committees for several structural issues have to be
fund collection and utilisation through examined for a sound assessment:
voluntary contributions and citizen’s " When ‘reforms’ are being done
committees to assist in management of the piecemeal for different parts of the
institution. Kerala heralded the participatory system, what quality criteria are being
planning process from village level upwards compromised? How is a cohesive
through its people’s planning exercise in system expected to function?
health and other fronts. The 73rd and 74th " What are the mechanisms for
amendments have set the stage for involving monitoring and accountability of work
Panchayati Raj institutions across the that is contracted out? Experience
country, but without the groundwork of a worldwide has shown that they
people’s mobilisation (as in Kerala by the increase cost and bring down quality41,
KSSP) the impact on health services still refuting the argument of ‘efficiency’.
remains to be seen. " Increasing management structures have
added to capital and recurring costs but
8. Campaign Mode e.g. of the Pulse Polio has it really improved service outcomes?
Initiative, Family Health Awareness Campaign " What are the mechanisms envisaged for
where personnel and public attention are improving performance of health
diverted from routine activities, but wide personnel? The increasing
coverage and public participation is elicited management structures are more for
for specific disease control. financial flows for internationally
funded programmes (e.g. state and
Current Scenario of Health Services district level societies for AIDS and
Since so many diverse steps have been taken, tuberculosis programmes).
and the same measures may have varied " If quality control structures from within
impact in the diverse contexts across states, the service system are set up (e.g.
it is difficult to assess the outcome of these quality control circles in Gujarat) what
‘reforms’ as a single phenomenon. However norms are there to ensure that the
the following generalisations can be made management systems will behave
about the existing scenario of public health differently from those existing at
services, reflecting positive and negative present and be able to implement
elements of the current phase: - quality standards?
1. There is a ferment within the health " The experience with contract staff in
services after a period of routine activity several states such as A.P. and
at low levels of functioning. Uttaranchal has been that they are on
2. Issues of defining quality and standards the lookout for other options and this
41
Twaddle, 2002. Health Care Reform and Global Hegemony. Andrew C. Twaddle (ed.) Health Care Reform Around
the World, Auburn House, Connecticut.

mobility adds to the waste and poor and/or buildings and equipment but with
quality. low staff recruitment and poor
" Dai training and integration of maintenance expenditure, resulting in
practitioners of indigenous systems of increasing exclusion of the poor and
medicine into national health marginalised sections.
programmes is envisaged to improve
access of populations in remote area. 7. The central issue of performance of
Have any lessons been learnt from personnel has been by-passed completely.
previous similar attempts? For instance
are their existing strengths being 8. Even if the private or NGO sectors are to
identified and built upon or are they to perform certain tasks, surveillance,
become another set of disgruntled monitoring and regulation will be
workers who face indignity, and stop necessary. A responsible, efficient, public
using what ever skills they do have? system will still be mandatory.However,
the impact of ‘reforms’ on attitudes and
3. Increasing fragmentation of public mindset regarding the public health
services into isolated primary/secondary/ system has been regressive.
tertiary levels, vertical programmes/
general health services, surveillance/ 9. The public sector services have become
programme implementation activities, the followers of the private sector in
routine activities/campaigns, are spheres of medical technology and skills
reversing the acknowledged need for a rather than the leaders that they were in
comprehensive health service catering to the 1970s and even in the 1980s 42 .
the health needs of the marginalised However, the relevance and rationality of
sections. use of the new technologies still remains
to be studied.
4. Decentralisation is happening more as
delegation of duties rather than 10. Specialists of repute in government
devolution of powers to peripheral levels, hospitals have shifted in significant
with exceptions such as in Kerala. ‘Local numbers from the public to private
needs assessment’ has been a good institutions. What is noteworthy is the fact
management tool but it has little to do that large numbers of doctors still choose
with local people’s ‘felt needs’. to stay on despite the wide difference in
remuneration. That they continue to work
5. The primary level institutions continue to with commitment amidst adverse
be seen by the community essentially as conditions of overcrowding and resource
‘family planning’ and immunisation constraints while dealing with a greater
centres. proportion of patients from the poor
sections with their own constraints needs
6. There has been upgradation of the health to be recognised43. They are also known
service infrastructure, but in several areas to use more rational treatment methods
the upgrading has meant new institutions than the private practitioners44
42
Jaiswal A 2002: Changing Urban Public Health Service System: Some Observations. Background note. Proceedings
of a workshop ‘Societal Concerns and Strategies for AIDS Control in India’. January 2002, The Centre of Social
Medicine & Community Health, Jawaharlal Nehru University, New Delhi.
43
Singh V: A Public Sector Doctor’s Musings: What Many People May Not Know About The Public Sector. Proceedings
of a workshop ‘Societal Concerns and Strategies for AIDS Control in India’. January 2002, Centre of Social Medicine
& Community Health, Jawaharlal Nehru University, New Delhi.
44
Phadke A.R., 1996: The Quality of Prescribing in an Indian District. The National Medical Journal of India, 9(2):
60-65.

Ritu Priya
11. However, the perceived technologically

advanced status of private institutions While there is evidence of increasing incidence
and the shift of doctors has further eroded of non-communicable diseases, probably due
the legitimacy of the public institutions. to greater diagnostic skills and some due to
Patients too continue to shift from the changes in life styles, preliminary results of
public to the private sector. an ongoing analysis of the causes of death data
reveals only a marginal increase in percentage
Meanwhile the health services have to of deaths due to non-communicable diseases
deal with people’s increasing vulnerability such as coronary heart disease, diabetes and
to communicable and non-communicable cancers (Centre of Social Medicine &
diseases, as we will see in the following Community Health [CSMCH], ongoing).
pages. So despite recent changes, the Asthma and bronchitis have always been a
crisis of the health system seems to have major cause of death but now this morbidity
been further compounded rather than in children is part of a worldwide phenomenon
dealt with. of an epidemic of allergic diseases.
Environmental contamination with chemicals
Trends in Morbidity and Mortality Profile hazardous to human health has been widely
While the national data on health status is documented by environmental scientists but
weak, it is adequate for identifying broad there is little hard data on such non-
trends of some indices. Gains in health status communicable morbidity.
are evident in the doubling of life expectancy,
from 31.7 years in 1947 to 63.5 in 1996-2001. What has also been significant is the increase
Infant Mortality Rate declined from 134 to 70 of a third set – the unnatural causes of death –
per 1000 live births. The negative impact of which reflect a serious situation of ‘lack of
the economic and health service changes since wellbeing’ and social ‘ill-being’. With the
the late 1980s on health status can be seen international scenario of only one power bloc
by the slowing down of the decline in Infant surviving, the iniquitous, high consumption,
Mortality Rates (see data in appendix). high energy-using, ecologically destructive
and unsustainable life style has been
Morbidity continues to be high. Changes in established as the desired goal of all
pattern of serious morbidity can be seen from development seekers. The elite of the third
the major causes of death (Table 7). While world including India became impatient to
change in morbidity rates is difficult to realise this dream that now seemed attainable.
monitor, data clearly shows that diseases of They were therefore ready to abandon the
poor living conditions – communicable diseases promise of a ‘socialist, secular, republic’ as
and malnutrition – remains the major cause of articulated in the Indian constitution.
morbidity and premature mortality in endemic Ideologies of individual merit began to
situations. Localised diarrhoea disease overshadow more collectivist thinking.
outbreaks, malaria epidemics with deaths,
dengue, plague and Japanese encephalitis The communities felt threatened and
epidemics have been reported with greater retaliated with a chauvinistic strengthening
frequency over the ‘90s. There had been of community identities. Failure of their
marginal improvement in nutritional status members’ individual struggles for material
by the end of the 1980s and even that is now attainment was explained by ‘unfair
reversed (Table 8). With continuous drought advantages’ given to other communities rather
years, deaths due to communicable diseases than by systemic factors, as the anti-Mandal
and even starvation have been reported in agitations demonstrated. Conflicts surfaced,
large parts of the country. communal violence was fanned, crime

increased, women’s increasing assertiveness control programmes, it is showing no concern

resulted in a backlash that intensified violence about pesticide toxicity and other
against women. As a consequence of Dalit environmental hazards, whether towards
assertiveness anti-reservation campaigns and workers handling chemicals or to the general
atrocities on dalits resumed. public. There are increasing problems now
afflicting the labouring sections more than the
Individual aspirations reached a high but urban middle class, and they bring into
without adequate societal support and where- question the dominant model of socio-
with-all for their fulfilment. Mental health economic development.
problems increased and suicides rose. 45
Manufacturing and transport technologies Research, Surveillance and Policy Processes
were upgraded and expanded without The orientation of the public health system
adequate checks and controls for safety. Thus and changes within it has been supported by
accidents, injuries, homicides and suicides the scientific base of research, surveillance
became a significant segment of the causes of and teaching. Planning, administrative and
morbidity and death (Table7). management structures and processes have
been in tandem with the public health
The public health system is beginning to knowledge perspective.
recognise these issues (e.g. gender disparity,
poverty, and migration as causes for Research and Surveillance
morbidity). However it is then camouflaging A large network of public health related
the issue by medicalising the problems and research institutions have developed over the
providing ‘symptomatic relief’ through medical 20th century, some were set up in the colonial
technology without making an adequate period and most others added post-
‘diagnosis’ or examination of root causes. In Independence. The Indian Council of Medical
fact, it is not delving into the depth of these Research and its subsidiary institutions
issues in the Indian context but only echoing (currently numbering 21) have played a major
words from international discourse, as role in health research in the country, with
demanded by ‘project partners’ i.e. the funding pioneering studies to their credit in the fields
agencies.46 That the RCH programme did not of nutrition, tuberculosis, leprosy, malaria and
succeed in making any dent in Maternal traditional medicines. Right from the 1970s
Mortality47, though unfortunate, is therefore to the early 1980s this influenced public
not surprising. Moreover, the health services health programmes and research not only in
did not prevent the starvation deaths or even India but also internationally. While the
detect them. While recognising the increasing approach was largely bio-medical and
non-communicable diseases such as coronary laboratory oriented, there was simultaneously
heart disease, diabetes and cancers against a strong stream of community-based research
which there are internationally supported to feed into public health programmes based
45
Suicides by farmers due to differential attainments of their peers who migrated, and the inability to pay back
loans taken for capital intensive agriculture but resulting in crop failure have occurred in large numbers in
several states. For women of reproductive age group (15-44 yrs) in rural India, suicide has become the number
one cause of death. Stigma and fear associated with HIV positivity has added to the suicides due to illness.
46
Most public health personnel are very sceptical and actually see a lot of these issues as part of the ‘international
fashion’ since they have witnessed several such proclamations of paradigm shifts and yet little effective improvement.
Often they also perceive that the proposed activity is not appropriate for the context they work in. Higher clinical
efficacy is what is most easily perceived as ‘effective improvement’ and so a new drug regimen (as in DOTS for
tuberculosis) or vaccine enthuses them more than, say, a CHW scheme or ‘women’s empowerment’
47
NFHS, 1999: National Family Health Survey 1998-99. As quoted in National Conference on Implementation of
National Population Policy with Special Reference to Health Issues of Women and Children: Background Notes. GOI,
Department of Family Welfare, MOHFW: Delhi.

Ritu Priya
on field realities. The backdrop of the national Nutrition Monitoring Bureau’s regular
movement, the Nehruvian notion of self- household level survey that identified trends
reliance and this contact with the ‘community’ in nutritional status has been whittled down;
sensitised at least some scientists to the the focus shifted from national level to surveys
necessity of finding solutions suited to the of one or two district and middle class diets,
Indian context with its vast majority in rural obesity etc. become issues of special focus in
areas, a low infrastructure and low income place of the stratified analysis by occupation
setting, with immense geographical, socio- or caste groups53. There is also a distancing
economic and cultural diversity. They were from monitoring nutritional status for all ages
able to show the inappropriateness of towards National Nutrition Status Surveillance
internationally accepted technologies and through children who are ICDS beneficiaries
tenets and demonstrate effectiveness of other ‘for early intervention’. But the NIN could not
options that needed less financial and detect or predict the deaths due to drought in
infrastructural inputs (e.g. on the issue of the late 1990s and more recent years, or even
protein supplementation which was shown to mention them post facto.
be wasteful by Gopalan at the National
Institute of Nutrition (NIN)48 and taken up by The multi-disciplinary NTI which formulated
Sukhatme at the FAO in the 1970s,49 of mass the national programme in the 1960s, trained
radiography for tuberculosis screening by the personnel and monitored the programme for
national programme which was substituted over 30 years was side-lined in the Revised
by symptoms and sputum examination by National TB Control Programme when the
Banerji & Andersen at National Tuberculosis global DOTS strategy was adopted by India in
Institute (NTI) in the 1960s,50 of hospitalisation 1993. The National AIDS Research Institute
for treatment for pulmonary tuberculosis by (NARI) set up in the 1980s is extremely narrow
the Tuberculosis Chemotherapy Centre 51 in scope and vision compared to the NTI set
which demonstrated the adequacy and up in 1959, despite the stronger recognition
benefits of domiciliary treatment). From the of wider social issues involved in AIDS control.
mid 1980s on one can see the loss of autonomy It has also had a minor role to play in
in these institutions as they have been affected formulation of the National AIDS Control
by the changing environment of international Programme.
health research and policy making.
This is not to say that earlier all was well with
The ICMR seems to have moved from agenda the institutions. Prima facie, one can see that
setting (e.g. by the ICMR-ICSSR Study Group they had not been effective in influencing
which produced a report ‘Health for All: An mainstream public health perspectives despite
Alternate Strategy’ in 198152 and the ‘Task the pro-people research findings and
Forces’ set up for identifying the research recommendations. When the Bhore
agenda in problems significant for Indian Committee report became the vision over-
public health in 1982) to following ‘national riding the Sokhey Committee the larger logic
priorities’ set elsewhere. The NIN’s National had already been set.
48
Gopalan, C. (1973): Effect of Calorie Supplementation on the Growth of Under-nourished Children, American
Journal of Clinical Nutrition, Vol. 26, pp. 253.
49
Sukhatme, P.V. (1972): India and the Protein Problem, Ecology of Food and Nutrition, Vol. 1, pp. 268.
50
Banerji, A. and S. Andersen (1963): A Sociological Study of the Awareness of Symptoms Suggestive of Pulmonary
Tuberculosis, Bulletin World Health Organization, Vol. 29, No.5, pp 665-683.
51
Tuberculosis Chemotherapy Centre, (1959) Concurrent Trial of Home and Sanatorium Treatment of Pulmonary
Tuberculosis in South India, Bull. WHO, Vol. 211, pp. 51-144.
52
ICSSR-ICMR, 1981: Health for All: An Alternative Strategy
53
NIN, Annual Reports, 1972-2002 National Institute of Nutrition, Indian Council of Medical Research, Hyderabad.

The change in the 1990s has been that now it study on the Health Industry conducted by a
is not even the professional logic that is market research company commissioned by
deciding priorities and direction of research. the Confederation of Indian Industry (CII) to
It is led more than ever before by examine the ground for entry of private
internationally initiated and funded medical insurance and managed hospital
programmes (such as RCH, DOTS for TB services (a package of pre-decided services for
control, Roll Back Malaria, Leprosy a pre-paid price) illustrates the quality of
Eradication, Polio Eradication, AIDS control). market research. It calculates that India’s
The programme priority and content is already population can be divided into 7 per cent
decided, only supportive research is required upper class (defined as those with annual
from the Indian institutions (e.g. identifying incomes of at least Rs.5 lakh per capita), 21
local strains of organisms, vectors, resistance per cent middle class (2-5 lakh per capita) and
levels etc. and documenting people’s 72 per cent poor (below 2 lakh per capita) and
perceptions in order to inform ‘social then uses these percentages to calculate the
marketing’ and ensure implementation market for medical insurance54. Going by these
through health related social science figures means that just the 7 per cent upper
research). class earn more than India’s total GDP The
deterioration in quality of data of NFHS round
Surveillance has always been weak (except for II as compared to round I has been attributed
malaria during the 1960s and 1970s). in large part to the shift from the public
However earlier sentinel surveillance was institutions to the private market survey
possible as a majority of people accessing agencies for data collection55.
medical services came to public institutions
that did the reporting. Now with 80 per cent Planning Process
outdoor and 55 per cent indoor patients going This brings us to how planning is done for the
to the private sector, reporting becomes even public health system. The planning shifts in
worse and surveillance weaker. India are clearly part of a global pattern. They
always have been, but largely as ‘professional
Further, research for management of the logic’ of health scientists who followed a
public health service system is being done similar pattern because of universal
more and more through NGOs or market application of a common knowledge system.
research organisations rather than through Democratic pressures led to variations in
health research organisations. In the absence delivery systems for universal access and
of a theoretical grounding and with a implementation under diverse socio-
dependence on international funding, economic, political and cultural situations56.
accountability shifts from professionalism to However, with the present undemocratic
international health development agendas, international political environment,
even further away from the vast majority of international health planning is also affected57.
India’s people than in the earlier periods. The attempt is to homogenise the delivery
Findings of this research then provide the system to one that is market friendly for the
basis for Health Sector Reform– for user fees, pharmaceutical industry and structured to
for privatisation, for medical insurance… A facilitate operations of the insurance
54
CII - McKinsey & Company 2002: Healthcare in India– The Road Ahead. McKinsey & Company –Confederation
of Indian Industry, New Delhi.
55
Rajan, S.I. & James K.S., 2004: ‘Second National Family Health Survey– Emerging Issues’, EPW XXXVIII (35),
pp 647-51.
56
Banerji D., 1985. Health & Family Planning Services in India
57
Koivusalo & Ollila, 1997. Making a Healthy World– Agencies, Actors and Policies in International Health. London,
Zed Books.

Ritu Priya
companies58. Since the 1990s the changes treatment that people resorted to the medical
have been led by arguments of global finance services of the public sector at secondary level,
capital, so that HSR affected all countries, rich if not the tertiary. This was where money was
and poor. Having implemented the HSR being spent, which often led to long-term debt
recommendations in the 1980s, and that pressured households below the poverty
experienced their negative impact, the line. By privatising these services, the patients’
European countries abandoned them within burden was added to rather than relieved.
a few years59. But the professional rationale Besides, the primary level strengthening does
continues to operate for the ‘developing’ world not add to general medical care since it is more
from analyses by the simplistic logic of for implementation of the chosen vertical
economists rather than ecologically and national programmes than for general
socially oriented epidemiologists with an services. The result is that 25 per cent of
understanding of the complexities of patients were found avoiding treatment
phenomena related to health and disease. The because of unaffordable cost in 1995-96 as
use of Disability Adjusted Life Years (DALYs) against 15 per cent in 1986-8763.
for computing ‘burden of disease’ is a perfect
example 60. This technocrat’s tool negates As we have seen, the mindset of a vast
epidemiological complexity, the holistic articulate segment in countries such as ours
perceptions of lay-people and provides data was ready to espouse the ‘reforms’. ‘Leaders’
that shifts priorities away from health of the private sector in medical care have
problems of the poor and towards technology become part of the advisory bodies for
centred measures61,62. planning and have supported the reforms
whole-heartedly. Health services are viewed
Even when the globalisers are forced to give increasingly as money-spinners for the
in to contingencies of local context, their country, ‘The health care institutions can
international prescriptions do not relate to transform India into a major medical tourism
people’s perceived needs and behaviour. The destination.’64
World Bank’s prescription of selectively
strengthening the primary level services and However, compulsions of democratic
continuing them as free services while leaving pressures and resistance by committed
the secondary and tertiary levels to the private persons from within the public services itself
sector is an illustration. Minor ailments were has not allowed wholesale adoption of the
generally being dealt with at low cost at home, proposed ‘reforms’. Civil society has been
or through indigenous healers, or ‘informal’ involved through consultative processes, as
medical practitioners, whichever was easily advisory groups in the planning processes.
available and dependent on the concerned This provides opportunities for innovating
illness. It was in cases of more serious illness towards a people-centred view. Sensitisation
or that which did not respond to the initial of the public services to issues of gender,
58
Qadeer I. & Sagar, A., 2001. ‘Health’. In Alternative Economic Survey 2001. Rainbow Publishers, Lokayan, Azadi
Bachao Andolan and Alternative Economic Survey Group, Delhi.
59
Segall, M. 2000. “From Cooperation to Competition in National Health Systems–and Back: Impact on Professional
Ethics and Quality of Care”. International Journal of Health Planning and Management 15: 61-79.
60
World Bank 1993: World Development Report 1993
61
Sayers B.McA. & Fliedner T.M. 1997: The critique of DALYs: a counter-reply, Bulletin of the World Health
Organization, 75(4): 383-384.
62
Priya R., 2001. ‘DALYs As A Tool For Public Health Policy: A Critical Assessment’ in Qadeer I, Sen K & Nayar
Kr (Ed), Public Health & The Poverty Of Reforms: The South-Asian Predicament, Sage Pub. 2001.
63
Iyer, A. and G. Sen, (2000) “Health Sector Changes and Health Equity in the 1990s”. In Shobha Raghuram [ed.]
Health and Equit– Effecting Change. HIVOS, Bangalore
64
GOI, 2002: Report of the Steering Committee for the Tenth Plan, Government of India, Planning Commission,
September 2002, New Delhi.

poverty, rational therapeutics and human What we constantly need to get back to is the
rights has been their significant contribution. organic holism of people’s life concerns. Isolated
However the planning processes have measures for urgent action may be necessary
themselves been fragmented, lacking a but can only be effective when constructed with
comprehensive systems perspective. The a holistic long-term perspective incorporating
Bhore Committee gave the blueprint for a people’s priorities. Understanding their
‘comprehensive public health system’ but did worldview and visions of a good life and better
not give due consideration to other health may be necessary.65 The need of a poor
components of the ‘health service system’– the woman for treatment of her husband’s fever,
private sector and the ISMs. In addition it her child’s diarrhoea… has to be catered to if
recommended heavy investment in specific she is to access the services for her own
verticalised disease control programmes as a problems, reproductive or otherwise. 66
fire-fighting strategy for the major killers. Together with ensuring access, the service
Consequently, the development of health providers have to be made sensitive to her
services in the immediate post-Independence individual special needs. The price for ignoring
decades focussed largely on the latter. The of people’s need for comprehensive services
National Health Policy 1983 attempted to bring by the service planning process is being paid
the focus back on a ‘comprehensive public for heavily by human lives.
health system’ with a Primary Health Care
approach. The National Health Policy 2002 has Addressing the Unresolved Alienation
entirely given up the concept of Haunting Public Health
comprehensiveness by fragmenting even the In this era of globalisation, market and
public health system into a separate ‘primary international finance led development opened
sector’, ‘secondary sector’ and a ‘tertiary the floodgates for the logic of private capital
sector’. While espousing the cause of to invade the public sector. However the
strengthening the ‘primary sector’ it advocates
dominant model of development adopted by
increase in financial allocations, expenditure
the country had also created conditions and
on drugs and a strengthening of drug-based
mindsets that provided an ‘indigenous’ logic
vertical programmes. What is not spelt out is
for following these prescriptions. Experience
the proportion of expenditure envisaged for
shows that inappropriate plans to provide
these programmes and their drugs versus the
international state-of-the-art standards to all,
general health service requirements. In the
end up providing second and third rate services
name of financial and administrative
strengthening in a ‘realistic’ manner ‘in the to resource poor segments, whether in
socio-economic circumstances currently development of housing, water supply and
prevailing in the country’, the NHP 2002 only sanitation or medical services67. If we cannot
ends up reversing the gains in building the put 15 per cent of the national budget
public health system of the country. The only allocation to health, we cannot implement the
‘inclusiveness’ it demonstrates is for the Bhore Committee’s long-term plan. So we
private sector and the NGOs in the public either concentrate resources in a limited
health programmes, but without any suitable population and coverage is poor, as of PHCs
mechanisms for setting ‘standards’ and in the 1970s. Alternatively we spread
ensuring adherence to them in practice. resources too thin and the services are
65
Priya. R., 1995. ‘Dalit Perceptions Of Health’, Seminar, No. 428, April 1995.
66
Health Watch Trust 1999: The Community Needs-Based Reproductive and Child Health in India. Progress and
Constraints. Health Watch Trust, Jaipur.
67
Shrivastava Committee, 1975: Health Services and Medical Education; Priya R., 1993. ‘Town Planning, Public
health and the Urban Poor– Some Explorations from Delhi’. EPW, Vol. XXXVII No.7;

Ritu Priya
available but grossly inadequate in quality, as management’ under the conditions of the
in the 1990s. Disillusionment sets in, saps corporate sector institutions such as the
worker morale, promotes corruption and Apollos and Max-Pharmas then becomes
discourages utilisation of public services if questionable as the basis for defining desirable
options are available. So it becomes a battle standards for the country.
between ‘coverage’ and ‘quality’; between
‘social justice’ and ‘growth’; planning Towards People-Centred Reforms
processes choose one or the other. We cannot go back to 1947 and start again on
a people-centred model. However, application
If somehow miraculously both criteria are met, of principles of the model is still a viable option
what will it mean for health care in the present – that of incrementally upgrading services in a
environment? It will give access to services rational manner, starting with existing
that are iatrogenic, expensive and dependency resources at the community level. Structural
creating68. But this argument can be used to rootedness in the local context and a scientific
justify denial of services to marginalised methodology for planning processes that
sections. So do we end up promoting the triangulates people’s perceptions, providers’
market for medical care? The only way out of perceptions and epidemiological rationality
this conundrum is to increase access and would minimise suffering due to health
simultaneously promote a non-medicalised, problems most effectively. Changes in ‘people’s
non-commodified view of health and disease perceptions’ over time would have to be taken
among medical professionals, paramedics and into consideration as well as their diversity
the lay public. The co-existence of different across different social segments. Measures
paradigms of treatment and healing also appropriate for the marginalised sections are
provides options and checks the hegemonic most likely to be least commodifying and most
power of one expert system. cost efficient and therefore useful for all
sections.
This requires a reorientation of perspectives
within medical education such that a central This implies that we conceptualise the health
place is given to the concepts of multicausality service system at the broadest level based on
of ill-health, the natural history of disease in common behaviour of lay people and the
populations and processes underlying experience of health care systems. The
spontaneous cure. The role of medical entrenched ‘ideology’ is that ‘prevention’ is the
interventions, whether preventive or curative task of public health and ‘cure’ of clinical
needs to be understood within this medicine. This denies curative services their
perspective. Then rational management of place as the core of any health service, with
health problems will follow. The relationship prevention of disease and promotion of health
of economic, social and political context with as individual and systemic level efforts.
health is another component that needs to be Experience shows that the immediacy of felt
part of the medical professional’s need is for treatment of illness.
understanding. The issue of ‘standards’ and
‘equality’ of health services too will then It needs to be acknowledged that: i) Medical
acquire a different hue. Linked to social care is already the core in practice wherever
structure and issues of the poor, the dalits, primary level services are functioning well, ii)
tribals, women, standards and quality will Disease control programmes are largely based
have to be redefined from the base of the on early diagnosis and cure, iii) When data is
pyramid so as to ensure rational and safe generated by reporting of cases by all medical
measures at minimal cost. ‘Rational care providers, identification of priority needs
68
Illich, I., 1977. Limits to Medicine– Medical Nemesis: The Expropriation of Health. Penguin, Harmondsworth.

for health planning and research have a personnel should be improved

sounder basis, iv) Good medical services that administratively through rewards and
build trust of the community in the health care recognition for good performance and
system, and thereby strengthen response to disciplining for non-attendance,
preventive measures, v) Effective public sector negligence and malpractice. Support
services help competitively regulate prices and mechanisms must also be created for
quality of private services69, and vi) While the public health personnel for dealing
medical care reduces suffering, rise in health with the inherent legal, social and
status happens much more by non-health health hazards of their occupation. At
sector action and societal changes in access the same time an environment of caring
to food, environmental sanitation and socio- and commitment to patients and the
cultural issues of life style patterns. community must be encouraged.
" Breaking the commercial nexus of
Clearly, the ‘culture of health services’ has to ‘commissions’ and ‘cuts’ with
change towards principles of relating and malpractice and corruption would be
responding to local context, transparency, crucial, as it will undermine any such
ethical practice and integrated thinking for efforts.
prevention and cure. The challenge is to bring " Upgrading skills and knowledge of the
this about through political, administrative, informal care providers along with
professional and community interaction. curbing irrational practices, through
Techno-managerial correctives alone cannot short term training programmes and
improve India’s public health. courses is likely to improve services
reaching the poor.
Fortunately, several theoretical and practical " Developing systems of societal checks
efforts are already in progress that can be and balances requires organic links of
drawn upon to address this challenge. Once the institutional system with the
the general direction has a wide consensus, community. Mechanisms that bring
lessons from history and the disparate efforts together both the public and private
currently under way can be brought together sector under common structures of
to inform policy formulation and planning. community control would be of value.
Some urgent tasks that can be undertaken Processes of coalition building at local
with this conceptualisation could include: level to monitor public and private
sector health services for their technical
Strengthening Health Services that the Poor quality, ethics of practice and pricing
Sections Access– the public sector and the should be evolved. Administrative
‘informal’ providers. Now, with the widespread structures for support of such
use of modern medicine and its terminology community regulation will be essential.
even by lay people, the content of the public " Strengthening the regulatory role of
services can be viewed as the ‘dominant public health for drug quality and price
rational system’ and the latter can be viewed control and minimum standards of
as the ‘modern folk practitioners’. The formal safety.
private sector will then be forced by the market
logic of competition to perform with greater To Identify the Essential Package of
responsibility. Some possible measures: Services necessary for dealing with patients
at the three levels of care in each district and
" Using good personnel management state based on epidemiological rationality and
principles, functioning of health people’s felt need. This would include
69
Krishnan, T.N. 1996. “Hospitilization Insurance: A Proposal”. Economic and Political Weekly, April 13. Pp.944-946.

Ritu Priya
considerations and steps such as the activities on health e.g. malnutrition

following: through livelihood insecurities and
agricultural policies, morbidity due to
" ‘People should not be “educated” to violence against women, mental stress,
discard the health measures that they diseases due to rural degradation and
have previously adopted unless a migration, toxicity through
convincing case can be made to show environmental pollution, injuries
that, taking into account their through vehicular and occupational
perception of the problems and under accidents… It should use this to build
the existing conditions of resource pressure for correctives at the larger
constraints, it is possible to have an levels, which would be genuine ‘primary
alternative technology which will yield prevention’.
significantly greater benefits to the " Develop processes and structures for
people in terms of alleviation of the linking health institutions with other
suffering that is caused by their health support services in the community e.g.
problems’.70 for battered women, destitute women
" Developing a home to hospital and aged, terminally ill persons,
continuum for diagnosis and type of orphans etc.
treatment. This would allow for
integration of the priority disease
For Measures Such as All the Above, it would
control programmes with the general
be necessary to develop criteria, principles and
health services, increasing convenience
guidelines for ‘quality’ and ‘standards’, with
for patients and cost-effectiveness for
the widest possible discussion and
the health system.
consultation.
" Channelling the ISM & H to genuinely
develop their own professional and
scientific logic is a challenge that must Built around a dialogic process rather than
be taken up, moving beyond merely one based on reproach or confrontation, such
‘using’ their vast public infrastructure measures would strengthen the existing
for improving coverage and health care resources and simultaneously deal
implementing programmes based on with the roots of the problems of the health
‘modern medicine’. services and prevent its alienation from the
majority of lay people.
To Develop a System of Disease Reporting
and Surveillance for Tracing Trends of Finally, all this would require a vision of
Health Problems Through Local Community development at the top of the policy-making
Involvement ladder and indicate that it is ready to engage
Selected private and public sector institutions with the realities of the Indian situation and
in each district and diverse socio-economic the initiative of the Indian people and is not
segments could also be included. This should mesmerised by international standards or
feed back for local action as well as be collated prescriptions.
for state and national planning. In addition,
the following activities would lead to a holistic Acknowledgements: I am grateful to Profs. Arun
approach to public health problems: Kumar, Rama Baru and Alpana Sagar for
" The public health system must be able discussions with them and to Vijaya Sivaraj for
to monitor impact of other development assistance in generating some of the tables.
70
Banerji D., (1979) Place of Indigenous and Western Systems of Medicine in the Health Services of India.
International Journal of Health Services, 9 (3) , 511-529.

Table 1
Health Status, Socio-economic and Health Services Development Indicators of Selected Countries
by Descending Order of Life Expectancy Of Females
Indicators Japan Sweden U.S UAE Poland S.Lanka Thailand China Russia Brazil Egypt India Bhutan Pakistan Bangla Nepal S.Africa
1.Life expectancy at Female 84.4 82.2 79.9 78 77.5 75.3 73.2 72.8 72.5 72 68.8 63.8 63.2 59.8 59.5 58.3 53.9
birth 2000 Male 77.4 77.2 74.1 73.7 69.2 69.5 67.3 68.5 60.1 64.1 65.7 62.8 60.8 60.2 59.4 58.8 50.2
2.IMR (per 1000 live births) 1970 14 11 20 61 32 65 74 85 29 95 157 127 156 117 145 165 80
2000 4 3 7 8 9 17 25 32 18 32 37 69 77 85 54 72 55
3.Infants of low birth
weight (%) 95-2000 7 4 8 .. 6 17 7 6 7 9 10 26 15 21 30 21 ..
4.Tuberculosis cases
(per 100,000) 1999 32 5 6 33 31 38 48 36 91 47 18 123 57 14 62 117 323
5. GDP Percapita(PPP US $) 2000 26,755 24,277 34,142 17,935 9,051 3,530 6,402 3,976 8,377 7,625 3,635 1,412 1,928 1,602 1,327 9,401
6.HDI rank 2002 9 2 6 46 37 89 70 96 60 73 115 124 140 138 145 142 107
7.GDP Percapita minus
HDI rank 2002 2 15 -4 -19 16 19 0 0 -2 -13 -10 -1 7 -7 -5 6 -56
8.GDP Per Capita
growth rate (%) 75-2000 2.7 1.4 2 -3.7 .. 3.2 5.5 8.1 -1.2 0.8 2.9 3.2 4 2.8 2.2 2.1 -0.7
9.Richest 10% to poorest 10% 4.5 5.4 16.6 .. 7.8 7.9 11.6 12.7 23.3 65.8 5.7 9.5 .. 6.7 7.3 9.3 42.5
10.% of population below
income:
$1a day (1993 PPP US$) 83-2000 .. 6.6 <2 18.8 11.6 3.1 44.2 .. 31 29.1 37.7 11.5
$2a day (1993 PPP US$) 6.3* 13.6* .. 45.4 28.2 52.6 26.5 52.7 86.2 .. 84.6 77.8 82.5 35.8
11.Carbon dioxide emissions
(per capita metric tons) 1980 7.9 8.6 20.1 35.8 12.8 0.2 0.8 1.5 .. 1.5 1 0.5 0 0.4 0.1 (.) 7.7
Review of Health Care in India

1998 9 5.5 19.9 37.5 8.3 0.4 3.2 2.5 9.8 1.8 1.6 1.1 0.2 0.7 0.2 0.1 8.7
!
12.Cigarette consumption 1992- 3,076 1,060 2,193 .. 2,631 392 1,014 1,790 2,081 813 1,221 119 .. 620 232 604 1,088
70
per adult (annual average) 2000
13.Adult literacy rate (%) Female ..d ..d ..d 79.3 99.7 89 93.9 76.3 99.4 85.4 43.8 45.4 .. 27.9 29.9 24 84.6
2000 Male ..d ..d ..d 75 99.7 94.4 97.1 91.7 99.7 85.1 66.6 68.4 .. 57.5 52.3 59.6 86
14.Health expenditure
Public (as % of GDP) 1998 5.7 6.6 5.7 0.8 4.7 1.7 1.9 2.1 2.5 2.9 1.8 0.9 3.2 0.7 1.7 1.3 3.3
Private (as % of GDP) 1.6 1.3 7.1 7.6 1.5 1.8 4.8 3 1.2 3.6 .. 4.2 3.6 3.1 1.9 4.2 3.8
Per Capita (PPP US $) 2,243 2,145 4,271 1,428 285 29 112 40 .. 308 .. .. 36 18 12 11 230
15.Physicians per
100,000 people 1990-99 193 311 279 181 236 36 24 162 421 127 202 48 16 57 20 4 56
16.One year olds fully
immunised Against TB (%) 1999 .. 13 .. 98 96 97 98 92 96 93 99 68 90 78 91 86 97
Against Measles (%) 94 96 92 95 99 95 96 90 97 99 95 50 76 54 71 73 82
Source: Human Development Report, 2002, UNDP, New York

Note: * $11 a day in place of $2.
Ritu Priya
Table 2
Growth of Infrastructure
SC PHC Dispensary Hospitals Med. Colleges

51 – 56 - + + - +
56 - 61 - + ++ + ++
61- 66 - + - ++ ++
66 - 71 + - - + -
71 - 76 + - - + -
76 - 81 + - - + -
81- 86 ++ + + - -
86 - 91 ++ +++ - ++ +
91- 96 - - + ++ ++
96 - 99 - - - - Some dereco
gnised
Source:Based on data from Health Information of India, 1999,

Directorate General of Health Services, Govt. of India.
Table 3
Public Sector Institutions of Indigenous Systems of
Medicine & Homeopathy and ‘Allopathy’ (1999)
ISM&H ‘Allopathy’
Dispensaries 16,002 10,709
Hospitals 2,764 4,653
Colleges 322 147
Student annual admission 3,846 ~17,000
capacity (estimated from
incomplete data)

Table 4
Five Year Plan Outlay (Centre and States)
1951-56 1992-97 1997-2001
(Ist Plan) (VIIIth Plan) (IX Plan)
Health 65.2 7,494.20 19,,818.40
Family Welfare 0.1 6,500.00 15,120.00
ISM&H - 108.00 266.35
Total 65.3 14,102.20 35,204.95


Table 5
Selected Indicators for India for 1901 to 1991
1901 1911 1921 1931 1941

Growth Rate of Population 6.23 0.86 10.63 15.02
Gr Rate of national income 23.35 -8.79 29.31 8.46
Gr rate of Per capita income 12.98 -1.37 6.57 -5.41
Share of Agriculture 0.73 0.69 0.68 0.59 0.57
Share of Manufacturing 0.11 0.12 0.14 0.16 0.16
Birth Rate 47.3 46.3 46.6 43.1 41.9
Death Rate 43.7 49.8 37.3 31.5 25.2
Life Expectancy at Birth 23.0 20.2 26.7 3.7 32.1
Literacy Rate/Students% 2.0 2.9 3.6 3.7 5.4
Railway Passengers (mill.) 183.1 366.6 534.6 505 651.6
Net Avail Food (ton/yr) 0.17 0.18 0.18 0.17 0.15
Share of Urban Population % 10 9.4 10.2 11.1 12.8
Poverty Ratio (3)
1951 1961 1971 1981 1991

Growth Rate of Population 21.63 24.82 24.64 23.85
Gr Rate of national income 46.73 73.75 35.39 73.37
Gr rate of Per capita income 19.82 12.54 7.27 36.32
Share of Agriculture 0.56 0.52 0.46 0.40 0.33
Share of Manufacturing 0.15 0.19 0.22 0.24 0.28
Birth Rate 39.9 41.7 36.9 33.9 29.5
Death Rate 27.4 22.8 14.9 12.5 9.8
Life Expectancy at Birth 32.1 41.3 45.6 50.4 58.7
Literacy Rate/Students%(2) 18.3 28.3 34.4 43.6 52.2
Railway Passengers (mill) 1284 1594 2431 3613 3858
Net Avail Food (ton/yr) 0.15 0.17 0.17 0.17 0.19
Share of Urban Population % 16.1 20 27
Poverty Ratio (3) 56.4 45.6 35.6
Sources: Economic Survey 1997 for data from 1951 to 1991.

Kumar (1984) for data from 1901 to 1941
Notes: 1. 1901 to 1941 is NDP at 1946-47 prices. Rest, GDP at factor cost at 1980-81 prices.
2. Literacy up to 1941 is students as % of population.
3. Poverty ratio for 1971 refers to 1972-73 and 1981 to 1982-83
4. Data up to 1941 and after are not directly comparable due to partition
Kumar, D. (1984).The Cambridge Economic History of India Volume II: c.1757 c.1970. Hyderabad: Orient
Longman.
Table from Kumar A. (2002): ‘Globalization of the Indian Economy: Some Current Issues Pertaining to The
Health Sector’, paper presented at the Workshop on ‘Societal Concerns and Strategies for AIDS Control in
India’, January 18th-20th, CSMCH-JNU and CSDS, Delhi.

Ritu Priya
Table 6
Status of Health Manpower in Public Health Services in Rural Areas
(June 1999)
Required Sanctioned In Position Vacant

1. Specialists (CHC) 11,740 6,579 3,741 2,838
2. PHC Doctors 22,975* 29,702 25,506 4,199
3. Block Extn. Educator - 6,534 5,508 892
4. Health Assistants 22,975 26,427 22,265 4,162
5. LHV 22,975 22,479 19,429 3,133
6. MPW (Male) 137,271 87,504 73,327 14,177
7. ANM 160,246 144,012 134,086 9,947
* One per PHC

Source: Health Information of India, 1999.
Table 7
Ranking of Major Causes of Death (Rural India)
Top Fifteen Causes (excluding senility)**
1940s* 1978 1988 1995
1. Fever (58.4%) 1. Asthma 1. Bronchitis & 1. Bronchitis &
2. Respiratory Asthma Asthma
diseases (7.6) 2. Pneumonia 2. Heart attack 2. Heart Attack
3. Dysentery & 3. TB of lung 3. TB of lung 3. TB of lung
diarrhoea (5.2) 4. Fevers not 4. Pneumonia 4. Prematurity
4. Cholera (2.4) classifiable
5. Small Pox (1.1) 5. Heart Attack 5. Prematurity 5. Pneumonia
6. Plague (0.5) 6. Anemia 6. Fevers not 6. Cancer
7. Others (25.8) classifiable
7. Gastro-enteritis 7. Paralysis (cerebral) 7. Paralysis
(cerebral)
8. Paralysis (cerebral) 8. Anemia 8. Anemia
9. Debility & Mal- 9. Gastro-enteritis 9. Fevers not
nutrition classifiable
10. Cancers 10. Cancers 10. Congestive Heart
Disease
11. Typhoid 11. Typhoid 11. Vehicular
Accidents
12. Tetanus 12. Resp. Inf. of the 12. Suicide
Newborn
13. Acute Abdomen 13. Acute Abdomen 13. Acute Abdomen
14. Drowning 14. Congestive Heart 14. Typhoid
Disease
15. Vehicular Accident 15. Dysentery 15. Jaundice
Sources: *Bhore Committee Report **Survey of Causes of Death, Registrar General of India, respective
years.

Programmes for Control of Communicable Diseases
Leena V Gangolli, Rakhal Gaitonde
Introduction with the construction of a large number of

“Epidemics are like signposts from which the Sub-Centers, Primary Health Centers. There
statesman of stature can read that a was also a huge increase in the number of
disturbance has occurred in the development medical colleges 3. The establishment and
of his nation—that not even careless politics consolidation of our pharmaceutical industry
can overlook.” that was producing almost the whole range
—Rudolf Virchow (1848) of necessary drugs also marked this period.
There was also the burgeoning of the private
Today 57 years after independence and four medical sector with the establishment of large
years after the turn of the century when the corporate hospitals.
people of the world were supposed to have
achieved Health for All, the Indian people are The Indian economy also further ‘opened up’
facing the so called triple burden of disease: and took to the triple mantra of liberalization,
continuing burden of communicable diseases, privatization and globalization from the 90’s.
increasing burden of non-communicable This move promised overall development and
disease, a health system not developed transfer of the increasing wealth produced to
enough to tackle them both1. the poor through the ‘trickle down’ effect.
However more than a decade after the
While in the initial years immediately after initiation of ‘reforms’ the poor and the
independence we made great strides in marginalized and the common citizen in
reducing the burden of malaria, eradication general have clearly rejected these reforms as
of smallpox and significant improvement in seen in the elections of 2004, calling for a
the life expectancy. The later years, especially serious re-look at the reform process, that
after the 1980’s were marked by a stagnation should go beyond political expediency and
in many epidemiological indices as well as re- short term measures.
emergence of many of the communicable
diseases2. This later period was characterized In the international scene especially in the
among other things by the increasing burden field of communicable diseases the field was
of malaria, continuing burden of tuberculosis marked by increasing interest of the developed
with very little impact despite great effort in countries in this field after years of neglect –
the National Tuberculosis Program, increasing thanks to the fear of the spread of these
number of epidemics that were inadequately diseases to their own countries from the
tackled, and epidemics of leptospirosis and developing countries and the re-emergence of
arboviruses especially dengue, and the newly certain diseases like Tuberculosis and
emerging HIV / AIDS. emergence of new diseases like HIV / AIDS.
The period of the 1980s was also marked by We are thus in the midst of an era of great
an increase in the health care infrastructure, promise, and ‘development’ but marked by the
1
Frenk, Julio, Jose Luis Bobadilla, Jaime Sepulveda, Jorge Rosenthal, Enrique Ruelas.1989. Quoted from Jamison
Dean T, Mosley Henry W, Measham Anthony R, Bobadilla Jose Luis. Editors, Disease Control Priorities in Developing
Countries. Oxford Medical Publications. New York.
2
Govt. Of India.
3
National Health Policy. 2002. Ministry of Health and Family Welfare.

continuing misery of millions of citizens, generating new knowledge and new grounds
increasing inequity, worsening state of health for action.”4
in many cases and increasing pressure from
international donor agencies to adopt narrow The socio-ecological model identifies five levels
‘technological and bio-medical’ interventions. of influence on health and health behavior:
individual, interpersonal, organizational,
In this chapter, the authors will attempt to community and public policy5. The model has
present a brief analysis of the State of India’s several key assumptions including:
health from the perspective of our experience
with communicable diseases. 1. Humans shape and are shaped by their
environment. In other words, the
A Critical Framework to Analyse Control interactions between individuals and
of Communicable Diseases in India their environment are reciprocal.
While the etio-pathogenesis of the 2. The environment comprises multiple
communicable diseases has been well worked settings that can be viewed as a set of
out this knowledge has failed to contribute to ‘nested structures’ or overlapping
their overall control due to the fact that both levels.
the incidence of communicable diseases as 3. Approaches to assessment and
well as the morbidity due to them is related intervention that address both
to a complex set of factors, and cannot be individual and contextual factors are
explained adequately by simplistic linear more effective than approaches that
models. focus on a single level alone.
The Relevance of a Social-ecological This means that health risks and

Approach to Disease opportunities for improved health exist at
With the increasing work done in General every level of the socio-ecological model. To
Systems Theory and Complexity Science we be effective interventions must collectively
have come to appreciate that the complexity address risks and opportunities at all five
of any system has to be acknowledged and levels, and interventions that target the outer
studied rather than brushed under the carpet. levels of the socio-ecological model improve
Among the various application of these theories health by modifying underlying factors that
and their related cousins to the field of health influence disease.
is a group of theories combining the terms
‘ecological’ and ‘social’. These theories have Thus the health of a given community is not
attempted to explain and identify the complexity determined merely by the presence of genes,
and different levels of influence on health. germs, toxins or health care services alone,
rather it is equally influenced by larger social,
In a recent review the author says, “With these economic, political, cultural aspects. In other
constructs at hand, we can begin to elucidate words the health of a given society is closely
population patterns of health, disease and linked to the paradigm of development that is
well-being as biological expressions of social chosen.
relations, and can likewise begin to see how
social relations influence our most basic While in the west health may have improved
understanding of biology and our social (or disease may have declined) in parallel with
constructions of disease thereby potentially improvements in technology, this
4
Krieger Nancy, 2001. Theories for social epidemiology in the 21st century: an ecosocial perspective. International
Journal of Epidemiology; 30:668-677.
5
Accessed on the internet from Chapter 6. NewLeaf …Choices for a healthy living. www.sph.unc.edu

improvement also occurred with concomitant technology may be proven to be cost-effective

socio-economic development. In the in preventing a particular communicable
developing countries however while there is disease, it is the effectiveness rather than the
huge effort in implementing bio-medical, efficacy that will ultimately influence the
technological vertical programs, there is little overall impact. In developing countries where
recognition of the critical importance of over there is tremendous diversity in populations,
all socio-economic development. In India also including geographical, climatic, ecological as
we seem to have borrowed certain bio-medical well as income disparity, food insecurity,
measures (under donor pressure?) from the unequal access to resources, education and
west (that too in a diluted and partial manner) health care services, the mere introduction
and are implementing these in a vertical form, of an efficacious technology need not ensure
in isolation from the kind of comprehensive the desired or expected impact. In fact the
environmental and socio-economic introduction of any technology without paying
improvements in the west that were largely attention to these larger contextual factors
responsible for communicable disease control may lead in many circumstances to more
there. harm than good.
Our experience so far has amply demonstrated As mentioned earlier the Government of India
in the Indian context that by continuing to adopted numerous vertically oriented disease
ignore the social, economic and cultural control programs. The vertical programs were
reality of the people’s lives, their aspirations attractive to the political leaders for a number
and priorities, health planners and of reasons. They were expected to give
professionals will never be able to fulfill the spectacular results within a short time; they
promise of Health for All the government made dealt with health problems that were
to the people. The consistent choice of vertical extensively prevalent.They were thus assured
programs over more ‘horizontal’ approaches support from international organisations and
has not only ignored local contexts but also western countries, and this approach seemed
led to a consistent neglect of the general to offer a simple and less resource-demanding
health system which is crucial to addressing alternative to establishing a network of
the felt needs of the people as well as to permanent health services to cover vast
provide a basis for sustainability for any other populations of the country. They could also
health program. Moreover by ‘verticalizing’ or avoid the awkward questions of poverty /
‘selectivizing’ our approach we have inequity inefficiency etc. and thus ensure the
approached the issue of health very status quo. Vertical programs are also more
simplistically, ignoring the complex issues easily quantifiable and definable with most
which we must tackle if there is to be any components in the planners ‘control’, this
hope for Health for All. gives a sense of security to most planners.
Vertical programs also have a higher
Limitations of the Bio-medical, Vertical probability of ‘achieving targets’ in the short
Programme Approach term, though their sustainability in the long
Both the structure of society and the term is questionable.
technology used by society is a reflection of
that society’s (or the dominant of that In this process, finally the programme
society’s) worldview, and culture (dominant planners are left trying to balance donor
culture) seems to replicate that worldview in pressure and their need to show results to
all its various aspects including health care their constituencies, the national ‘need’
systems / services and policies6. While a given (political) to do something while not
6
Capra Fritjof 2003. Hidden Connections.

questioning the status quo too much on the 7. In turn weaknesses in the infrastructure
one hand, and the needs and aspirations of have made it difficult to maintain a disease
the people on the other hand. at a low level of incidence after the attack
and consolidation phases are over.
With this backdrop, many criticisms and
analyses for the disappointing results of the With such an overall perspective, this chapter
vertical programs have been made, the attempts to look at the Indian experience with
following is an example of an analysis by communicable disease that led to the present
Banerji7. through the experience with four major
diseases, Malaria, tuberculosis, HIV / AIDS
1. An overestimation of potency of the and polio. The experience of the various
technical tools, while the importance of malaria programs shows us that despite
some other factors (e.g. Ecology of the money and ‘simple’ technology’ no program
parasite or the intermediate host and can have a lasting impact or be sustainable
community participation) have been unless supported by a well-developed general
underestimated. It has been assumed that health system. The Tuberculosis program
merely tackling one part / node in a though developed indigenously and based on
complex web will be enough. While such social science inputs failed to deliver, again
an approach may give short-term results due to the lack of adequate functioning of the
- its long term effects and sustainability is general health system and the failure to
certainly suspect. recognize the private sector and its irrational
2. Underestimation of biological practice as a major player. The HIV / AIDS
consequences - especially the development program is an example of a program that is
of resistance.
largely driven by western and donor pressures
3. Underestimation of social / cultural
and technical quick fixes, not realizing or
consequences - more survival but not
acknowledging the complex socio-economic-
means to improve or optimize quality of
cultural-political dimensions of the problem.
life.
The polio story gives a similar moral.
4. Adequate attention not being paid to
Attempting to only tackle the ‘possible’ (polio
dealing with problems in all their
is one of the few ‘eradicable’ diseases though
dimensions - even technical tools have
their sociological, cultural and economic not necessarily the disease with the greatest
and ecological dimensions, and these need morbidity) in a situation where even the bare
to be addressed. minimum health services do not function is
5. There was gross underestimation of the fraught with dangers for the new program, as
organizational and management needs for well as for the existing general health system.
implementing the programs on such a
large scale. Malaria
6. Diversion of the bulk of the very limited “The history of malaria contains a great lesson
resources made available for developing for humanity...that we should be more scientific
rural health services; towards the vertical in our habits of thought, and more practical in
programs has had a very damaging impact our habits of Government. The neglect of this
on the development of a network of lesson has already cost many countries an
permanent health institutions to meet the immense loss of life and in prosperity.”
other health needs of the people. - Ronald Ross, 1911
7
Banerji D 1993. A social science approach to strengthening India’s National Tuberculosis Program. Indian
Journal of Tuberculosis

Current Status of the Problem is difficult, as in villages there is no system of

A plateauing in the number of malaria cases routine death certification. Deaths in women
and deaths at a relatively high level, and a and children occur mostly at home, often before
gradual increase and plateauing in the any contact has been made with the formal
proportion of P falciparum among cases of health service. Only the PHC hospitals, where
malaria characterize the present situation of a limited number of sick patients come for
malaria in India. treatment, can give a reasonably accurate
Table 1 indication of the malaria mortality rate. The
Trends in Malaria from 1951-2000 problem is compounded by poor infrastructure
making the access of government facilities
Year Cases P falciparum further difficult for seriously ill patients. Neither
(in millions) cases (in millions) there are telephone services in majority of the
1951 75 government maintained health centers and
1961 .049 dispensaries within the PHC/Block nor
1981 2.7 ambulances to take patients to a better
1991 2.11 0.92 equipped hospital, if necessary. The
1993 2.27 0.85 widespread food shortage increases
2000 2.20 1.04 susceptibility to infections. Thus the inference
Source: National Health Policy – 2002; Health is that the number of malaria infections and
information of India, MOHFW -1993; NMEP -1976-95 associated deaths could indeed be much higher
than reported (emphasis added) due to the fact
However, these numbers are grossly that the clinical malaria cases and suspected
underreported, and may be regarded as deaths have been excluded for want of blood
indicative of trends at best. slide and their report. Consequently the
reported data on morbidity and mortality
According to a WHO document, portray only a trend and not the absolute
“the true malaria incidence is thought to be figures as reported earlier from Orissa.”9
several times higher than the reported
incidence”, which “would represent 11 to 15 The Fall and Rise of Malaria in India
million cases in India which represents 74% of This plateauing of malaria cases and deaths
the malaria cases in this (South east Asia) at a high level is despite having a national
Region.”8 program in place from 1952. Historically the
program made huge strides bringing down the
The reasons for this massive underreporting number of cases of malaria from nearly 75
are not difficult to understand, given the fact million to a mere 49 thousand, however these
that 75-80% of outpatients seek care from the huge successes were followed by a resurgence
private sector, which is not bound to any form in the number of cases and a stagnation at
of disease reporting, and considering the the 2 million level [see Table 1].
major gaps in malaria surveillance and official
death reporting. Such underreporting While the initial success led to the renaming
especially of malaria mortality, is brought out of the malaria ‘control’ program into
by a recent study in Madhya Pradesh and ‘eradication’ program the setback of the 1970’s
Chhattisgarh done by scientists of Malaria forced the government to re-look at the
Research Centre, Jabalpur: strategies. In an analysis of the situation the
“However, measuring mortality from malaria following are quoted as possible reasons 10:
8
Najera J.A.,Hempel J.The Burden of Malaria. WHO document CTD/MAL/96.10
9
MRC Field station Jabalpur 2004
10
Malaria control in India, Vol. 1. Ministry of Health and Family Welfare.

1. Disruption in supplies of insecticides malarial burden on adivasi (tribal)

received under bilateral assistance in populations.
the wake of the Indo-Pak war, and the
fact that the very small indigenous P. Falciparum Infections on the Rise
production was inadequate to meet the MPO operations were able to control the
requirements of the country. P.Vivax infections to some extent, but were
2. Slow development of health much less successful in tackling the more
infrastructure in maintenance phase dangerous and epidemiologically labile P.
areas despite plans and preparations Falciparum infections, a fact documented by
recommended. the noted Malariologist, V.P. Sharma:
3. Delayed financial allocations and “Epidemiological investigations revealed that
administrative bottlenecks. reduction in malaria incidence following the
4. Decreased supervision, diversion to MPO was due to reduction in P. vivax and not
other activities. P. falciparum. As a result, P. falciparum
5. Lack of true community participation. percentage continued to rise from 26% in 1965
6. Precipitation of resistance to to 50% in 2000.”12
insecticides in vectors.
7. Rapid escalation of costs of pesticides. A similar trend of rising P. Falciparum
8. Development of resistance of the infections, linked with Chloroquine resistance
parasite. has been noted by scientists of the Malaria
9. Low involvement of local bodies. Research Centre the district level in M.P.:
10.Improper environmental impact “Analysis of malaria data collected by the
assessment of various development Malaria Research Centre (MRC) Field Station,
projects that came up around that time Jabalpur for trends (1986-2000) in five villages
that became foci of outbreaks. of Mandla revealed that in 1986 malaria was
mainly due to P. vivax and P. falciparum was
Subsequent to this the government launched only 27% (Fig 3). However, from 1988 onwards
the Modified Plan of Operation and more there was a steady increase in P. falciparum
recently, with recognition of the receding goal and infection due to both parasites were almost
of eradication, in 1999 the National Malaria equal in 1991 (P. vivax 49.5%, P. falciparum
Eradication Programme was rechristened as 50.5%). From 1992 onwards there was an
the National Anti Malaria Program. These increase in P. falciparum proportion while P.
programs were all characterized by a limited vivax was on decline. There was an abrupt
bio-medical-technological understanding and increase in P. falciparum in 1996 and in 1999-
approach to the problem. They continued to 2000, the infection caused by P. falciparum
focus on early diagnosis and treatment and was over 90%. (emphasis added) ... The striking
insecticide spraying, the only difference being increase in the proportion of P. falciparum
the focus on different population groups (the infections over P. vivax may be because of
urban areas and the tribal areas in the Urban prevailing chloroquine resistance against P.
Malaria Scheme and the Enhanced Malaria falciparum which is existing in the area since
Control Program respectively)11. Meanwhile, 1980.13
the recent resurgence of malaria has been
characterized by a rising proportion of P. Indiscriminatory, often low dose treatment
Falciparum cases, focal outbreaks (often with Chloroquine for all fever patients
related to ecological disturbances), and a high approaching Government health facilities,
11
Kishore J 2002. National Health Programs of India, 4th edition. Century Publication, New Delhi.
12
Sharma V.P.Malaria and poverty in India. Current Science, Vol. 84, No. 4, 25 February 2003
13
Malaria Research Centre, Jabalpur 2004

along with irrational Chloroquine regimes morbidity in this state increased from
often being prescribed in the private sector is 107 797 cases (24% P. falciparum) in
likely to have contributed to this trend of rising 1993 to 229 772 (38% P. falciparum) in
Chloroquine resistance. 1994 (WHO-WER 1997) implying more
than a doubling in the number of
Recurrent focal outbreaks malaria cases
The period since the mid-1990s has witnessed
a number of focal outbreaks of malaria in The malaria outbreak of Rajasthan in 1994 is
different parts of the country, including in a classic example of ecological disturbances
areas hitherto not considered malaria prone. related to ‘development’ projects directly
This has been noted in an article by the leading to a massive outbreak of malaria.
Director and other senior scientists of the
Malaria Research Centre: Ecotypes of Malaria: Consequences of
“After a more or less static situation of malaria Flawed Development, Burden on the
for a decade upto 1993, there have been focal Marginalised
outbreaks since 1994. During 1994, the states Another feature in the period of resurgence
of Rajasthan, Manipur and Nagaland reported has been the emergence of specific ‘ecotypes’
outbreaks. During 1995, the states of Assam, of malaria, esp. in the 1990s. These ecotypes
Maharashtra and West Bengal reported essentially represent disturbed ecosystems
outbreaks. During 1996, the states of presenting as high malarial incidence foci:
Rajasthan and Haryana had malaria outbreaks Urban and peri-urban malaria, Irrigation
and during 1997, Gujarat and Goa reported malaria, Forest malaria, Migration malaria
malaria outbreaks. During 1998 there were and Tribal malaria. It is not difficult to
focal outbreaks in Bhandara district in understand that a model of development
Maharashtra, and Calcutta in West Bengal. Goa based on increasing volumes of massive
has been recording increasing malaria seasonal migration, especially from tribal and
incidence continuously for a few years.”14 forested areas, with migrant workers living
and working in extremely rudimentary
The Great Indian Thar Desert, which conditions in urban and peri-urban areas is
covers 62% of the state of Rajasthan directly responsible for the epidemiological
and is home to 39% of the state’s features of many of these inter-related
population, is being irrigated by the ecotypes. Similarly uncontrolled irrigation,
Indira Gandhi Canal (IGC) Project, without health impact assessments or
funded by the World Bank. Due to measures to prevent waterlogging and vector
seepage of water in the IGC command breeding, present another facet of agricultural
area, the desert is now converted to development that is taking its deathly toll in
marshland (1000 hectares converted to terms of outbreaks of malaria even in areas
marshland, and 8600 hectares of land, where the disease was virtually unknown.
permanently inundated), an extremely What is less commonly recognized is that the
favourable environment for the burden of morbidity in these ecotypes is heavily
breeding of mosquitoes. (Shiva and skewed towards those populations which are
Shiva) In the malaria epidemic in 1994, already marginalised: adivasi (tribal)
over 60 % of the cases were due to the communities, seasonal migrant workers,
fatal P. falciparum resulting in 452 agricultural labourers and peasants directly
malaria deaths being officially reported engaged in agricultural work. The linkage
in Rajasthan in that year. (WHO- between malaria and poverty has now been
SEARO). The total reported malaria explicitly recognized, and prevalence of
14
Lal S; Sonal GS; Phukan PK.National Anti Malaria Programme.

malaria is higher in states with a higher level evaluation” 17 , was and continues to be
of poverty: ignored.
“A study on the relationship between poverty In their analysis of the situation the Expert
and malaria revealed that the malaria scenario Group identifies the following problems18:
in the last three decades shows a clear
divergence, i.e. declining trend of malaria in 1. Consistent under-reporting, which
well-performing states and a reverse situation weakens and undermines the planning
in states whose economy continued to be process.
stagnant. Thus malaria was linked with 2. Lack of flexibility – which does not allow
poverty, and poverty with environmental a diversity of responses to the diverse
degradation. Improvement in the prevailing local situations.
malaria situation requires a determined effort 3. An acute shortage of entomologists and
at the highest level of governance to make a the improper deployment or support to
difference. Key to malaria control lies in those who are in the public health
understanding local malaria with a primary system and NMEP.
attack on poverty and malaria receptivity.” 15 4. Continuing neglect or near total
absence of environmental impact
It is well known that brunt of this resurgence, assessment of development projects.
whether in Eastern and Central India or in 5. Lack of adequate surveillance and
the North-east, has been borne adequate supply of drugs.
disproportionately by adivasi communities, 6. Lack of behavioral sciences and socio-
already confronting erosion of livelihoods and anthropological and health economic
displacement in myriad forms. According to research competence, especially in the
one estimate, 54 million tribals of various area of community participation.
ethnic origins residing in forested areas and
accounting for 8% of the total population, The Expert Group has noted, “The whole
contributed 30% of total malaria cases, 60% ‘development model’ adopted by India has
of total Plasmodium falciparum cases and been responsible for migration becoming an
50% of malaria deaths in the country.16 increasingly significant factor”.
Searching for Alternatives: Socio-ecological The analysis of the Expert Group and a
Approach, Strengthening Public Health reading of the situation after the turn of the
Systems with Focus on Primary Health millennium show that approaching the control
Care, Actively Involving Communities of malaria in a simplistic and unipurpose
The advice of the Malaria Expert Group in fashion cannot work. A present analysis of
1997, “Programme and policy planners in the malaria program not only has to deal with
Malaria Control must actively study and parasite and vector resistance, drug shortages
contextualize the wider socio-economic- and financial shortages, but also contend with
cultural-political context in which their global warming, the El nino effect, WTO and
strategies must be located. A broader context drug pricing, migration and urbanization, and
of public policy must therefore inform their breaking down of local communities thanks
deliberations, their understanding and their to globalization. Complex situations call for
strategies for action, research, training and actions at many fronts and levels, and these
15
Sharma V.P. Malaria and poverty in India. Current Science, Vol. 84, No. 4, 25 February 2003
16
Sharma, V.P. Reemergence of malaria in India Indian J Med Res 103: 26, 1996.
17
Narayan Ravi, Sehgal P N, Shiva Mira, Nandy Amitabha, Abel Rajaratnam, Kaul Sunil Editors 1997. Towards an
Appropriate Malaria Control Strategy. Voluntary Health Association of India, New Delhi.
18
Ibid

strategies need to be sensitive to local Going back to the socio-ecological model of

situations if they are to make any impact. health mentioned earlier – we see that all the
present efforts of malaria control have
Moreover as the Expert Group observes, concentrated on the personal or at most family
“Malaria control becomes part of a Primary level (early diagnosis and treatment, spraying
Health Care strategy only when the principles in the houses, personal protection methods),
of (i) Community Participation; (ii) Appropriate
this neglect of the larger, community level,
technology; (iii) Intersectoral coordination and
and policy level and international level will
(iv) Social equity become central to the
strategy of the control program”. It also only be detrimental to the program. And
suggests, “it is the active mobilization, finally, the role played by the larger context
involvement and participation of the of our globalised and liberalized economy, in
community in the planning, implementation fuelling malaria resurgence, needs to be put
and monitoring of the health program that is explicitly on the agenda and confronted:
the crucial challenge”19.
“Economics is central to the history of the rise
As an alternative to the continuing techno- and fall of nations, and to the history of disease
managerial and linear approach to the in the people who constitute nations. The
problem of malaria that characterizes the current love affair with free market economics
present day situation the Expert Group as the main driving force for advance of
suggests (among other things)20: national wealth puts severe limitations on the
essential involvement of communities in malaria
" Improving the existing surveillance
management. The task of malaria control or
system.
elimination needs to be clearly related to the
" Strengthening the entomological
assessment / monitoring capability at basic macroeconomic process that preoccupies
the state and district level. governments, not cloistered away in the health
" Strengthen the diagnostic capacity of sector.”21
malaria at the PHC level.
" Building Environment Impact Tuberculosis
Assessment competencies in the “The dramatic increase in the global prevalence
country. of TB since the 1980s has brought about a stark
" Strengthen multi-disciplinary nature of reversal in the public health optimism of earlier
the present planning process. decades. A disease that according to many
" Urgent need to rediscover the commentators was destined for complete
community in any malaria control eradication in the 1970s has rapidly become
strategy in keeping with the Primary the centre of a global health crisis. The ‘new’
Health Care approach, which is a
TB is in fact derived from a combination of
national commitment.
different developments such as collapsing
" Ensuring that malaria becomes part of
an integrated, people oriented, health care services, shifting patterns of poverty
decentralized, enabling / empowering and inequality, the spread of HIV, and the
health policy in which the people / emergence of virulent drug-resistant strains.”
community becomes central to the - Matthew Gandy and Alimuddin Zumla, The
whole policy framework. return of the white plague
19
Narayan Ravi, Sehgal P N, Shiva Mira, Nandy Amitabha, Abel Rajaratnam, Kaul Sunil Editors 1997. op.cit.
20
Ibid.
21
Kidson C, Indaratna K.Ecology, economics and political will: the vicissitudes of malaria strategies in Asia.
Parassitologia. 1998 Jun;40(1-2):39-46.

Current Status of the Problem were being sent back by the doctors with
India is the country with the largest number symptomatic treatments and cough mixture26.
of TB cases in the world - accounting for nearly Consideration of tuberculosis as a problem
one-third (30%) of the global TB burden 22. In of suffering (the felt need approach) and
India itself there are an estimated 2 million patients’ recourse to general health services
people detected with tuberculosis every year, provided the basis for integration of NTP with
and around 5 lakh deaths occur yearly due the general health services. Thus NTP was
to the disease. The total number of patients designed to “sail or sink” with general health
with Pulmonary tuberculosis has been services27 .
calculated at a staggering 17 million
patients. 23 These rates have remained Global Tuberculosis Situation (Grouping of
stagnant from the time of the first studies done Countries)
as far back as 1954-58 24 . The average
prevalence of smear-positive cases has been Annual risk Annual Group
estimated at 2.27 per thousand and average of infection Group
annual incidence of smear-positive cases at (ARI) (%) decline (%)
84 per 1,00,000 annually.25 According to a 0.1 - 0.01 10 Group I
recent assessment which categorizes Industrialised
countries into groups I to IV based on their countries
level of tuberculosis control, India has the (Netherlands,
epidemiological trend in common with the Norway, etc.)
countries of sub Saharan region, with an 0.5 - 1.5 5-10 Group II
Annual Risk of Infection between 1 and 3 per Middle income
cent, and an annual decline of around 0-3 countries(Latin
per cent, belongs in the category IV of poorest America, West
control. & North Africa,
etc.)
These summary figures convey the scale and 1 – 2.5 5 Group III
urgency of the problem of Tuberculosis in Middle income
India, which form the context within which countries(East
the National Tuberculosis Control Programme & South East
may be analysed and assessed. Asia, etc.)
1 - 2.5 0–3 Group IV
The Revised National Tuberculosis Control (Sub-Saharan
Programme Africa and
The National Tuberculosis Program was Indian
introduced in 1962. Research has clearly Sub-continent,
shown that nearly 60 – 70% of patients with etc.)
symptomatic tuberculosis were indeed visiting
(Chakraborty, 2003)
the health services. However majority of them
22
Ed. Nayak, R., Shaila, M. S. and Ramananda Rao, G Status of Tuberculosis in India – 2000.Society for Innovation
and Development / Indian Institute of Science, Bangalore, 2000
23
Chakraborty A.K. Epidemiology of tuberculosis: Current status in India. Indian J Med Res 120, October 2004,
pp 248-276
24
Kishore J 2002. National Health Programs of India, 4th edition. Century Publication, New Delhi
25
ibid.
26
Banerji D, Anderson S 1963. A sociological study of the awareness of symptoms suggestive of pulmonary
tuberculosis. Bulletin of the World Health Organization; 29:665.
27
Journal of Tuberculosis; 40:61-81.

In spite of this broad sociological framework " Systematic monitoring, supervision

and integration with the general health and cohort analysis.
services a recent review noted that “thirty
years of NTP, from 1962 – 1992, became Banerji says, “the assumption that the drug
notable on account of the achievements falling administration must be directly observed by
far below expectations, frustrating shortages RNTCP staff, not only involves considerable
of anti-tuberculosis drugs, and annoying expense, which includes high cost of the
deficiencies of budgets, logistics, supervision technology used, but it also requires
and corrective action”28 enormous managerial and organizational
efforts to ensure that the patients, who are
A formal evaluation by the WHO and SIDA scattered over large areas, receive
concluded that the program suffered from – treatment” 31 . In one pilot study of the
managerial weakness, inadequate funding, implementation of RNTCP in Hoogly district
over reliance on X-ray as the means of of West Bengal, “the performance data
diagnosis, non-standard treatment regimens, revealed that, epidemiologically the RNTCP
low rates of treatment completion and a lack covered less than a fifth of the sputum positive
of systemic information on treatment cases as assessed by the prevalence figures
outcomes29. of the National Sample Survey of 1955 –58.
Also RNTCP is sucking in a substantial
Based on this ‘failure’ of the NTP the proportion of resources from the already
government of India introduced a resource starved infrastructure, thus causing
internationally funded program designated as problems for implementing other health
the RNTCP in 1992-93. The 5 main programmes, including, ironically,
components of the RNTCP were30: implementation of NTP in the non-project
areas”32.
" Political commitment
" Diagnosis primarily on the basis of Problems with DOTS
sputum examination. Randomised controlled studies in South
" Regular and un-interrupted supply of Africa33and Thailand34 gave conflicting results
anti-TB drugs. with regards to DOT vs non-DOT. A
" Direct observation of every dose. subsequent study in Pakistan35 showed that
28
Nagpaul D R 1997. Editorial – Evolution of Indian NTP. Indian Journal of Tuberculosis; 44:59-60.
29
Khatri G R 1999. The Revised National Tuberculosis Control Program: A status report on first 1,00,000 patients.
Indian Journal of Tuberculosis; 46:157-66.
30
ibid
31
Banerji D 1993. op.cit
32
ibid
33
Zwarenstein M, Schoeman J, Vundule C, et al. Randomised controlled trial of self-supervised and directly
observed treatment of tuberculosis. The Lancet 1998; 352:1340-43. Quoted form. Walley John D, Khan Amir M,
Newell James N, Khan Hussein M. effectiveness of the direct observation component of DOTS for tuberculosis: a
randomized controlled trial in Pakistan. The Lancet 2001; 357:664-69.
34
Kamolratanakul P, Sawert H, Lertmaharit S et al. Randomised controlled trial of directly observed treatment
(DOT) for patients with pulmonary tuberculosis in Thailand. Transactions of the Royal Society of Tropical Medicine
and Hygiene 1999; 93:552-57. Quoted from Walley John D, Khan Amir M, Newell James N, Khan Hussein M.
effectiveness of the direct observation component of DOTS for tuberculosis: a randomized controlled trial in Pakistan.
The Lancet 2001; 357:664-69.
35
Walley John D, Khan Amir M, Newell James N, Khan Hussein M. effectiveness of the direct observation component
of DOTS for tuberculosis: a randomized controlled trial in Pakistan. The Lancet 2001; 357:664-69.

there was no difference in the two groups. registers for follow up. However, a study
Studies also showed that all interventions conducted in New Delhi 38 showed that a
(including reminder cards, education, home number of patient, provider and broader social
visits etc) introduced to increase adherence factors are leading to the non registration of
were effective36. However it was noted that a number of people. The most common reason
there were no randomized trials assessing for non enrolment from the side of the patients
DOT at that time. These two groups of studies is one of logistics-for daily wage labourers, or
question the WHO’s and RNTCP’s over those in school, or those who live too far from
insistence on the DOT component, while the DOT center, coming to the center on
suggesting that there were numerous other alternate days for medicine was not possible.
interventions that have evidence for their From the provider side, patients were often
effectivity. What is equally important are the not registered for DOT and would be offered
questions of acceptability of DOT by the the standard chemotherapy (12-18 months,
patients as well the cost of implementing and unsupervised), if it was felt that they may not
sustaining a DOT strategy – especially in adhere to the DOT regime and hence adversely
resource poor settings. affect the results of the particular clinic. The
study showed that providers had identified a
DOT creates numerous problems to the number of factors which they felt would
patients including direct and indirect costs – hamper treatment completion, and developed
almost equal to a weeks wages for the a means for identifying patients they
intensive phase according to the Pakistan suspected would discontinue. Based on the
study, the question of acceptability of the data collected in the study, the authors
observer, lack of escorts for women, rudeness constructed an algorithm for TB patients to
of the health care staff, stigma attached etc. be registered in RNTCP.
Studies have similarly suggested that
compliance is better among patients who are The exclusion factors in the table represent
observed by persons of their choice rather the most vulnerable of society and those for
than those imposed by the health system37 whom the care and support of the public
health system is most essential. However, the
Inbuilt Barriers to Access in the DOTS target driven approach taken by international
Programme and national tuberculosis policy forces the
The program guidelines state that all front line providers to focus on cure rates. The
individuals presenting to the clinics and whole system is geared to cure and not to care
diagnosed with tuberculosis need to be put for patients. To really care, the other needs of
on the RNTCP regime and entered in the the patients need to be addressed as well. For
36
Volmink Jimmy, Garner Paul. Systematic review of randomized controlled trials of strategies to promote adherence
to tuberculosis treatment. British Medical Journal 1997; 315:1403-06.
37
Department of Community Health, Christian Medical College, Vellore. Unpublished.
38
Singh V et al. TB control in Delhi, India. Tropical Medicine and International Health. Vol7 No8, pp 693-700,August
2003

Table 2
Entry Algorithm for TB Patients to be registered on the RNTCP 39
Suitability for RNTCP assessed through: Patient “suspect” if

Proof of Residence: No ration card, or
" Ration card, voter’s card or any other legal A married woman staying with her
document parents, not enrolled on their ration card.
" Guarantor from the Community
Duration of stay in the area: Recently moved to Delhi
" Long term residence in Delhi Short stay at current address
Recent migrant with family still in
the village
Job/Occupation Daily wage earner (construction worker)
" Permanent or government job Factory worker with shift duties
Contract workers ( export
garment workers)
Visit by DOT centre worker Difficult to reach the patient
" Overall impression of patient’s home ( residence is far from the centre)
" Convenience to clinic and/or for defaulter House is difficult to locate.
retrieval
example, the DOTS program in New York considered as infectious.”

City40 recognized that many of its beneficiaries
were homeless people and started offering The review notes that“the WHO advice to
food coupons with the daily dose of medicines. National TB Programmes still states that “the
highest priority for an NTP is the identification
Exclusion of “Low-Priority” Patients and cure of infectious cases, i.e. patients with
Médecins Sans Frontières recently conducted smear-positive pulmonary TB”; that one of the
a review of the current global strategy for roles of case definition is to “prioritise treatment
controlling TB, including the DOTS strategy. of sputum smear-positive cases”; and that
One of the findings of this review was that “from a public health perspective, extra-
the DOTS approach tends to exclude ‘low pulmonary TB is not of great importance
priority’ patients. because patients with this form of disease are
“The conviction that TB control was the main not infectious”. Treatment for chronic and
goal led to an acceptance that the individual MDRTB patients is discouraged …”
needs of the “few” – actually almost 50% of all
TB patients – were outweighed by the public “MSF staff has observed that in some countries
health good of the “many”. … there was little smear-negative patients are deliberately not
interest in developing better tools or strategies treated, particularly when there are resource
for “low-priority” patients, i.e. anyone not constraints. … In some cases, countries exclude
testing smear-positive and therefore not patients previously treated under non-DOTS
39
Singh V et al. TB control in Delhi, India. Tropical Medicine and International Health. 2003 op.cit.
40
World Health Organization.Stop TB at the Source, TB Programme.1995

regimens even though this may represent 10- devoted to direct observation – could be spent
50% of patients in some settings 41 ; or by strengthening the public health system in
disadvantaged patients are excluded from best a more effective manner, is a matter of further
available treatment”.42 study and debate.
Increased Burden on Patients and Health Questions About Effectiveness of DOTS

Systems While within the DOTS model, the positive role
The MSF review notes that “DOTS places an of better availability of drugs has been noted,
enormous social and financial burden on the contribution of the ‘Direct observation’
patients, who are sometimes required to (DO) component is more doubtful. The MSF
undergo lengthy hospitalisation or stays in or review has noted:
near treatment centres in order to meet the
direct observation (DO) requirement. DO (Direct “DO does not systematically improve adherence
Observation) continues to be one of the most to treatment: compliance depends on a whole
contentious aspects of DOTS. …But DO is time- range of cultural, social and economical factors,
consuming and labour-intensive and requires and other strategies for improving adherence
continuous motivation and training of health might be as effective as DO. In a randomized
care workers to be effective. Individuals controlled trial comparing self-administered
suffering from TB sometimes perceive the DO and directly observed treatment of TB, self-
requirement as implying that they are incapable supervision outcomes equivalent to DO were
or irresponsible with regards to their own health reported.”
– some patients even view DO as demeaning
or punitive….” A recent major study in Mumbai noted that
despite well administered DOT, only 70% of
“While first-line TB drugs are affordable, they patients achieved cure, raising questions
require an expensive and cumbersome system about the actual effectiveness of DOTS:
of administration. …the cost of administering
the drugs in the recommended manner is far “While all the patients at our center received
higher than the cost of the drugs themselves. fully supervised treatment as recommended by
These costs are one of the chief obstacles to the WHO, this is not routine practice under
expanding DOTS, in particular in high-burden Indian RNTCP. Recent studies have shown that
TB/HIV settings.” only one out of five DOTS workers ensures
supervised swallowing of the doses, while
The MSF review estimated that in India, the others either ask the patient to go to the next
cost of drugs per treated case of infectious room or hand over the entire weekly pack to be
TB was US$ 7, while the additional costs to taken at home. So, what started off as DOTS
the public health system, related to direct ends up being POTS (partially observed
observation etc. were of the order of $50 to treatment, short course) or even KNOTS
$194. Whether these large additional (knowing but not observing treatment, short
resources – primarily related to the staff time course).”
41
Cox H & Hargreaves S. To treat or not to treat? Implementation of DOTS in Central Asia; Lancet, 2003, Vol 361,
p. 715. Reported cases in Kazakhstan, China and India.
42
http://www.ncbi.nlm.nih.gov/entrez query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12167096&dopt=Abstract):
Singh V. et al. TB control, poverty, and vulnerability in Delhi, India, in Trop Med Int Health. 2002 Aug;7(8):693-
700. Operational research studies in two pilot sites in New Delhi from 1996 to 1998 showed that health workers
screened patients to determine their ability to conform to the direct observation. If the health worker was confident
that the patient would comply and/or be easy to trace in the community in the event of ‘default’, they were
provided with short-course treatment under the RNTCP. Other patients, largely those who were in absolute poverty
and socially marginalized, were put on standard TB treatment as for the previous National TB Programme. The
programme was evidently excluding the most vulnerable from the best available care.

“Despite claims of high cure rates when using The training component requires a motivation
DOT under RNTCP, only 70% of patients in our building and interpersonal communication
study were cured or completed treatment improvement, as another behavioral
despite fully supervised therapy. The results intervention. People often access the private
are similar to those observed in some of the sector because they feel the staff in the public
recent case-control studies. Reasons for the sector treat them rudely.
lower cure or completion rate in our study could
be that the reliable microscopy laboratory used RJ, a 38 year old man registered under
by our centre was better able to detect treatment RNTCP had been regularly taking his
failure, that there was a high default rate owing drugs under DOT for 2 weeks. In spite
to the availability of loose drugs and loss of of a perennial water shortage in the
cases to private doctors, or that the cure rates center, a jug of water was usually made
claimed by the RNTCP are of questionable available by the health worker. On one
reliability.” occasion, there was no water in the jug,
and when RJ requested the health
The Need to Address Patient and Provider worker for water, the health worker,
Attitudes already under a lot of stress himself,
The current programme has also failed to threw away the treatment card.
address the health seeking behavior of people Therefore, after 2 weeks of DOT he left
who often first seek care from the private and went back to the private doctor. He
sector, for its perceived better quality43, the is now continuing with the private sector.
anonymity it offers (versus having a health ( Jaiswal A.et al. Adherence to TB
worker come home for an inspection, and Treatment in Delhi. Tropical Medicine
thereby the social stigma of tuberculosis) and and International Health. Vol8 No7,pp
often because that is where medicines are 625-633,July 2003)
available. It has also failed to influence
prescribing practices of private health care Keeping in view the multiple problems with
providers, who do not follow a protocol and this ‘One size fits all’ approach, rather than
thereby contribute to multidrug resistance, investing all one’s scarce resources and
in addition to referring the patients to public getting rigid and inflexible over a costly and
care after they are seriously ill and can no as yet un-proven component of the DOTS
longer be looked after in the private sector. In strategy, it may be better that one should
a survey conducted in Mumbai, it was found assess the situation locally and come up with
that up to 80 different drug combinations were locally relevant and appropriate interventions
being used, most of which were using the already available evidence. In other
inappropriate 44. The threat of multi drug words, there is a need to look for flexible
resistance looms large, acquired resistance for solutions that fit into local cultural contexts.
INH can be as high as 67%45. A WHO global Supportive motivation to take regular
review of drug resistance in TB has noted, treatment could be carried out by trained
based on studies in Tamil Nadu that 24% of people in a community. For example,
all TB patients suffer from drug resistance to medicines could be made available through
at least one of the four frontline drugs46. Anganwadis, where mothers bring their
43
International Institute for Population Sciences and ORC Macro. National Family Health Survey (NFHS-II) 1998-
99. India.
44
Uplekar M, Rangan S. Tackling TB-the search for solutions. The Foundation for Research in Community Health,
1996. and Stop TB at the Source, TB Programme, Who, 1995, page 12.
45
Jain NK et al Initial and Acquired Isoniazid and Rifampicin resistance to M tuberculosis and its implications for
treatment. Indian Journal of Tuberculosis 1992;39:321-4
46
World Health Organization, 2000

children, or through schools, where women cautions us – that everything coming from the
drop their children. The basic idea is that if west need not be appropriate or even right.
planners and policy makers move from cure We need to come up with our own experiences
to care and are really committed to bringing and operations research, like we have already
down tuberculosis in the country as opposed shown we are capable of in the development
to meeting targets every year, a lot of creative of the NTP.
innovations can be tried and we can have a
program more suitable for our local needs. HIV/AIDS
HIV / AIDS is deeply symbolic of the collective
Sinking together or rising to meet the challenge? malaise our society faces in the era of
The experience of the TB programs teaches globalisation and liberalisation. It has been
us that inspite of there being a multisectoral said with justification that HIV / AIDS is a
inputs in the development of the NTP, because development issue, that HIV / AIDS is a
it was integrated with the general health resurgent infectious disease, that HIV / AIDS
system, it failed, as the general system could is a public health crisis, and that HIV / AIDS
not respond to the challenge. is a major rights issue for a range of people
whom this problem impinges upon. Keeping
One example of this is the continuing major these and other dimensions in mind,
infrastructural gaps in the Primary Health nosweeping generalisations or vertical
Care system, preventing timely diagnosis of solutions are likely to be able to address this
cases. The diagnosis of tuberculosis requires problem in its entirety. Neither exaggeration
acid fast staining of the sputum, to detect nor denial is likely to serve the cause of
tuberculosis bacilli. Naturally this requires not
tackling the problem effectively. The complex
only laboratories with microscopes, but also
and multidimensional nature of the problem
adequate and regular stocks of reagents for
requires among other things, an approach
staining, and trained personnel to detect the
that can grasp the myriad socio-economic
bacteria and safely dispose of the slides.
processes fuelled by the process of
However, a Facility survey carried out by the
globalisation-liberalisation responsible for the
IIPS showed that out of 7959 PHCs surveyed
emergence and spread of the epidemic, the
across India, only 46% have a laboratory. In
states like Gujarat, Maharashtra, Haryana, health system crisis that needs to be urgently
and Punjab, 90% of PHCs have a laboratory, addressed in order to present an integrated
while in others like Assam, Bihar, Madhya response to it, the range of socio-behavioural
Pradesh and West Bengal, not even 20% have factors that need to be addressed for
a laboratory. Only 39% of PHCs have a lab prevention, and the rights of affected persons
technician, essential for any functional case to comprehensive care and social acceptance
detection process.47 as part of a larger vision of health related
human rights.
As Banerji says, “if the health system is
inadequate, NTP also suffers from the Current Status of the Problem
inadequacies. The solution, thus, does not lie The first serological evidence of HIV infection
in attempting to remove inadequacies in the in India was discovered amongst female sex
NTP alone but rather in the entire health workers in Tamil Nadu in 1986. Since then,
services system”48. The other important lesson studies conducted all over India have shown
comes from recent evidence regarding the that the infection is prevalent in a number of
effectiveness of the DOT component, this population groups as well as locations. Today,
47
International Institute for Population Sciences. Facility Survey.1999. page 103
48
Journal of Tuberculosis; 40:61-81

HIV has been detected in 29 of India’s 32 predominant mode of spread is through sexual
states and territories. The epidemic is contact (80%, World Bank, 85% UNAIDS),
considered generalized ( with the prevalence while the other 15% is accounted for by the
amongst pregnant women attending antenatal other modes.
clinics being more than 1%) in six states and
union territories- Andhra Pradesh, Karnataka, Interventions to control the spread have
Maharashtra, Manipur, Nagaland, and Tamil therefore concentrated on these three modes
Nadu.49 and have been linked with a verticalization of
the program. Efforts are concentrated on
The National AIDS Control Organization of creating awareness of the disease, safe sexual
India ( NACO) estimates the number of people practices and distribution of condoms.
with HIV in India at 5.1 million in 2004.(These Measures have also been initiated to provide
estimates are based on sentinel surveillance anti retroviral therapy (ART) to people
data collected at antenatal clinics and sexually suffering from HIV in a phased manner.
transmitted disease clinics all over India.)
India has the second highest number of people However, most of the existing approaches fail
living with HIV/AIDS in the world after South to take into consideration the other key
Africa. India accounts for almost 10 per cent determinants that lead to the spread of HIV:
of the 40 million people living with HIV/AIDS socioeconomic factors (poverty, lack of
globally and over 60% of the 7.4 million people education, unemployment, marginalisation of
living with HIV/AIDS (PLWHA) in the Asia and women), industrialization and development
Pacific region. Given the large population concentrated in urban areas, migration
base, a rise of just a few percentage points in patterns, macro-economic policies, national
the HIV prevalence rates can push up the debt etc.
number of those living with HIV/AIDS to
several millions.50 Economic Policies and the Impact on HIV
“ Structural Adjustments raise particular
However, it should be kept in mind that problems for governments because most of
present estimation of the HIV burden in India the factors which feed the AIDS epidemic are
is based on 36 parameters, of which 6 are also those factors that come into play in
based on sentinel centers (data for women Structural Adjustments Programs” ( Dr. Peter
comes from sentinel surveillance at 200 Piot, Director UNAIDS)
antenatal clinics, and for men from 166
sexually transmitted disease clinics51. The In response to indebtedness, governments in
other 30 parameters are based on debatable developing countries have been forced to
assumptions. Changing a few of these increase export oriented industrialization and
assumptions could change the NACO estimate to reduce government expenditure. The model
significantly52. adopted for economic growth has led to the
growth of industry and therefore employment
Determinants of the Spread of HIV in urban areas. This has brought about
Of the three modes of spread of HIV- sexual migration from rural communities into the
contact, mother to child transmission, and cities. Long periods of separation from
through infected blood (transfusions and families, a sense of loneliness and alienation
intravenous drug use), in India, the and work related pressures often drive people
49
Over M et al. HIV/AIDS Treatment and Prevention in India Modeling the Cost and Consequences. The World
Bank.2004.
50
Ibid
51
Ibid
52
Ibid.

into high risk behaviors, including use of that the roots of the epidemic can be attacked.
drugs and alcohol and multiple sex partners.
Mobile populations like migrant laborers also The Public Health System and HIV/AIDS
become the route for infection to spread to The findings of the facility survey discussed
other geographic locations as well as back to in the sections above bring to light the fact
their spouses. Poverty and unemployment that unless there is serious effort at
also drive people into transactional sex, again strengthening the public health system in all
involving multiple partners and sometimes the states, there is no way the health system
reduced negotiation power for safe sex will be equipped to even challenge the
practices. epidemic, let alone contain it. Health facilities
will need to have much more than just stocks
Public sector services, like health care and of condoms and awareness posters. The early
education, are often the worst hit in attempts diagnosis and treatment of HIV and
to reduce government expenditure. The opportunistic infections requires
introduction of user fees for health care comprehensive strengthening of diagnostic
reduces access to care for financially facilities, availability of trained personnel and
vulnerable people. This will not only impact functional health systems at all levels. As a
their general health adversely, it will also block group of community-oriented health activists
their access to information and therefore has noted:
awareness of HIV and their access to diagnosis
and treatment of HIV and opportunistic “… the goal of urgent, major
infections. Withdrawal of the government from strengthening of the public health
primary education tends to increase the rate system in India, which today has
of dropouts, particularly of girls and increase reached crisis point, in order to make it
their vulnerability in a number of ways-they an effective vehicle for delivery of a range
will miss out on the awareness drives carried of services including those required to
out through schools, and with no education tackle HIV-AIDS. Health systems,
and therefore a chance at financial self including staff, infrastructure,
reliance, may be driven into commercial sex. equipment and supplies, organizational
The removal of food subsidies would make frameworks, financing systems and
food more expensive for families, therefore delivery mechanisms, cannot be made
leading to reduced consumption and effective to tackle a single disease,
malnutrition as well as driving the women and without overall comprehensive
children of the household into commercial sex strengthening.
to feed the family. In fact, when it comes to care of
people with HIV/AIDS, there should be
A completely biomedical approach to tackling seamless continuity from basic health
AIDS therefore can only hope to deal with the care to HIV care. A functional health
‘iceberg’ of infected people or so-called ‘high care system is necessary for Primary
risk groups’. Even though awareness drives Health Care, but essential for care of
and condom distribution are seen as HIV/ AIDS. This is because in developing
preventive measures, these initiatives fail to countries, infections such as
address what drives people into vulnerable tuberculosis, diarrhoea and pneumonia
situations exposing them to unsafe sex in the are among the commonest
first place. Unless there is a questioning of manifestations of HIV-disease and, in
the developmental processes and attention is fact, these illnesses may cause mortality
given to access to health care, education and in a patient with HIV disease even before
food security for socio economically vulnerable manifestations of classical AIDS show
sections of the population, there is little hope up. Therefore an effective programme for

the care and support of HIV / AIDS, There are a number of other services
which is no doubt essential, is not which are vital and an only be delivered
possible without an effective programme through an overall strengthened health
for basic health care that effectively system. The virus incapacitates the immune
diagnoses and treats all the common and system of the person, making him/her
important infections. … susceptible to opportunistic infections (for
example, bacterial infections like tuberculosis,
To take this point further, any hospital fungal infections like candidiasis, viral
or health care facility, which expresses infections like herpes and cytomegalovirus)
incapacity to look after patients with HIV and neoplasia ( for example, Kaposi’s
/ AIDS, is not capable of looking after sarcoma). Opportunistic illnesses vary across
any sick person. To put it the other way countries, with tuberculosis accounting for
round, any place that looks after sick almost 50% of opportunistic infections in
people should follow standard people with HIV/AIDS in India. The most
precautions (such as sterilisation, waste common presentation of people with
disposal and infection control) and Tuberculosis and HIV is weight loss, which
logically should also have the capacity might often be missed as a symptom of
to look after patients with HIV / AIDS. tuberculosis in a health system where chronic,
Since the serological status of the vast productive cough is regarded as the cardinal
majority of patients with HIV / AIDS is symptom of TB. Additionally, as the CD4
not known, it is clearly more important to count declines, people with active tuberculosis
work for overall well-functioning health are less likely to produce positive sputum
systems rather than segregated HIV / smears than people without tuberculosis.53
AIDS care centres.
Keeping the health system context in mind,
There is no doubt that patients with HIV there are certain considerations to be kept in
/ AIDS require special care that must be mind while using antiretroviral therapy in
urgently provided for. But it is also true resource poor settings. The public health
that these people need a functioning and system presently in place is hardly equipped
strengthened health-care system more for the management of drug toxicity ( ranging
than others do, and our approach should from mild irritation to potentially life
be based on that. An exclusive emphasis threatening illness), monitoring for adherence,
on HIV / AIDS care is justifiable and testing for drug resistance. Experience
wherever well-functioning health care with tuberculosis control in India has shown
systems exist. But in countries where that drug resistance evolves from what is
basic health care is not ensured, called “therapeutic anarchy”54, which is the
prioritising HIV/AIDS care in isolation erratic and unscientific prescription of drugs.
will not only be met with lack of success All these drugs are freely available over the
in the public health sense; it may also counter. The lack of regulation of the medical
jeopardise the struggle for basic health sector has allowed non qualified practitioners
care by sidelining it and making it appear to flourish and promise miracle cures for HIV.
less relevant.” Even among qualified professions, there are
large variations in prescribing practices, few
Further, it should be emphasised that the adhering to standard treatment protocols, as
management of HIV positive people does not shown in the studies related to tuberculosis.
start with a positive ELISA and end with ART. European studies show that adherence levels
53
Over et al, 2004. op cit
54
(John J.T. HAART in India: Heartening prospects & disheartening problems Indian J Med Res 119, June 2004,
pp iii – vi)

of at least 95% are required to prevent number of patients post-test counseled, and
resistant HIV forms from developing 55 a single rapid test may be sufficient. 58
Preliminary data from a survey of doctors Nevertheless, confirmatory tests (ELISA and
prescribing antiretroviral therapy reveal that Western Blot) would need to be carried out
only 30% of patients who are started on ART on those testing positive in the screening, and
remain on therapy one year, and overall these tests would need to be made accessible
adherence is low among patients.56 A study through laboratories in the public health
in Mumbai showed that 18% of patients newly system.
diagnosed with HIV are already resistant to
one anti retroviral.57 Care and Support Activities, According to
Need, Complexity and Cost
Keeping these facts in mind, it is clear that
rolling out of anti-retroviral therapy must be Essential Care Package
anchored in a larger context, and must be " HIV voluntary counselling and testing
accompanied by effective measures for " HIV screening of blood for transfusion
strengthening capacities of the Public health " Psychosocial support for PLWHA and
system, and regulations to ensure adherence their families
to rational treatment protocols in both private " Palliative care
and public sectors. Further, it would be " Treatment of common HIV-related
irrational to implement ART while infections : pneumonia, diarrhoea, oral
disregarding a range of less resource thrush, vaginal candidiasis and
demanding measures, which are very pulmonary TB
important in the management of a person with " Nutritional care
HIV/AIDS. Such important complementary " STI prevention (including condom use)
measures include effective treatment of and care
common opportunistic infections, intensified " Family planning
case-finding and treatment of TB, proper " Prevention of mother to child
nutritional care, psychosocial support for transmission of HIV
persons living with HIV/AIDS and their " Cotrimoxazole prophylaxis among HIV-
families and appropriate palliative care. infected people
" Universal precautions
Similarly, regarding low-cost diagnostics, " Health policy activities, such as the
rapid on site tests are available which can be regulation of care delivery and drugs
used for screening purposes. These do not supply
require highly specialized training and can be " Recognition and facilitation of
stored at room temperature. In high community activities that mitigate the
prevalence, resource-poor settings, rapid on- impact of HIV infection (including legal
site HIV testing is feasible, accurate and highly structures against stigma and
cost-effective, substantially increasing the discrimination)
55
Paterson D.L et al. Adherence to Protease Inhibitor Therapy and Outcomes in Patients with HIV Infection.
Annals of Internal Medicine 1331:21-30.
56
Hira S.K. Study of ART prescribing physicians in India. A background paper to HIV/AIDS Treatment and
Prevention in India. Washington DC. World Bank.
57
Hira S.K. Patten of Resistance to ARV Drugs in Mumbai. Paper presented at the Second International
Conference on HIV/AIDS and Substance Abuse, December 1-3, 2002. Mumbai.
58
Wilkinson D, Wilkinson N, Lombard C, Martin D, Smith A, Floyd K, Ballard R. On-site HIV testing in
resource-poor settings: is one rapid test enough? AIDS. 1997 Mar;11(3):377-81.

Care and Support Activities of access to health care as well as quality of

Intermediate Complexity and/or Cost health care. Anecdotal evidence suggests that
ALL THE ABOVE PLUS HIV positive people are often denied
" Intensified case finding and treatment admissions into hospitals, discharged upon
for TB, including for smear negative and discovery of their HIV status,isolated in the
disseminated TB among HIV-infected wards, denied operative procedures unless
people they procure universal precaution kits and
" Preventive therapy for TB among HIV- meted out discriminatory treatment by health
infected people care providers59.
" Systemic antifungals for systemic
mycosis (such as cryptococcosis) In addition to ensuring access to diagnosis
" Treatment of HIV-associated and treatment of opportunistic infections and
malignancies : Kaposi’s sarcoma, HIV infection , special attention needs to be
lymphoma and cervical cancer given to the protection of certain rights of
" Treatment of extensive herpes PLWHA in the context of the social impacts of
" Post exposure prophylaxis of HIV infection. This includes the right to
occupational exposure to HIV and rape employment protecting people from losing a
" Funding of community efforts that job due to HIV status, property inheritance
reduce the impact of HIV infection laws which are of vital importance to women
whose husbands have died of AIDS and who
Care and Support Activities of High have been thrown out by their families. The
Complexity and/or Cost latter mentioned law is of great importance
ALL THE ABOVE PLUS in the Indian context where women are often
" Highly active antiretroviral therapy married to infected men with the intention of
(HAART) care giving during the period of illness and
" Diagnosis and treatment of HIV-related are deserted by the family upon the death of
infections that are difficult to diagnose the man. The woman is often left without any
and/or expensive to treat, such as property and is herself infected.
atypical mycobacterial infections,
cytomegalovirus infection, Studies show that a rights based approach
multiresistant TB, toxoplasmosis, etc has a longer lasting impact. Empowerment of
" Advanced treatment of HIV related the commercial sex workers of Sonagacchi in
malignancies Calcutta improved their negotiation ability for
" Specific public services that reduce the safer sex and has actually brought down rates
economic and social impacts of HIV of sexually transmitted diseases. There are
infection similar efforts being replicated in other parts
of the country. The clean needle exchange
The Rights of People Living with HIV/ program being carried out in Manipur is
AIDS (PLWHA) another example of an intervention where a
The connection between vulnerability of vulnerable group (intra venous drug users)
certain social groups and communicable are being protected from the spread of HIV
disease, particularly HIV has already been instead of being blamed and ostracized for
discussed. Within this context, PLWHA are their vulnerability.
further marginalized both by the general
public and the health system due to stigma Creating and preserving an environment in
and fear associated with HIV. This impacts which the rights of PLWHA are respected and
59
Lawyers Collective, presentation made to State Human Rights Commission at Mumbai Jan Sunwai on 23rd
November 2004

protected will allow voluntary testing and recently updated the “HIV/AIDS Medicine
diagnosis instead of driving the epidemic Pricing Report” which includes price
underground as is the result of the traditional information on various drugs for different
public health approach of isolation and countries. Governments, donors, NGOs,
contact tracing. Diagnostic tests are presently PLWHA and other stakeholders have to
beyond the reach of the common person negotiate “best prices” when purchasing AIDS
(ranging any where between Rs 500 in the related drugs.
public sector to Rs 1400 in the private sector).
The costs of these tests in addition to Various legal mechanisms that have been
treatment costs push HIV off the priority list used to reduce costs are:
for people who are more concerned about " Use of generics
feeding the family. " Price studies
" Differential pricing (so called tiered
Patents and the Impact on HIV pricing) for developing countries: some
Essential drugs in managing HIV/AIDS major pharmaceutical companies
patients are : ( Glaxo Wellcome, Merck, Boehringer-
1. Anti-infective agents to treat or prevent Ingelheim,Hoffmann- La Roche and
opportunistic infections (as Bristol: Accelerating Access
tuberculosis, etc) programme) have recently offered price
2. Palliative drugs to relieve pain, physical
cuts of up to 85% (which leaves their
and mental discomfort
drugs still more expensive than generic
3. Anti-retrovirals (ARVs) to limit the
drugs)
damage that HIV does to the immune
" International procurement (e.g. mass
system and to prevent mother-to-child
bulk procurement by
transmission
WHO,UNAIDS,IDA etc)
" Technology transfer (eg Brazil offers
Anti retroviral drugs are very expensive
because of patent regimes, which mean that technology transfer for South South
the original producer of the drug has complete cooperation)
rights over the production and sale of the
drug. Even if developing countries can A detailed discussion on the importance of
produce the drug indigenously, they have to patents, TRIPS/ WTO regulations and the
respect the patents, thereby driving costs. benefits of generics is found in this book, in
the chapter on Access to Essential Drugs, by
Huge disparities in prices for the same Srinivasan.
product are being observed on the world-wide
market. Generics cut costs dramatically – this Summing Up
explains why it costs the Brazilian public In this chapter the authors have attempted
health sector the same amount to treat 1000 to describe the present scenario of
PLWHA as it does the Thai government to treat communicable diseases in India with special
350 (looking at drug costs only). On the other emphasis on the way we reached where we
hand, even drugs of the same company are are and what are our problems now. We have
being sold at very different prices in different invoked the socio-ecological model and
countries. Pfizer’s Diflucan costs nearly 49% systems theory to show that such complex
less in Thailand than in Guatemala. MSF has issues as health and disease cannot be
joined a UNICEF/UNAIDS/WHO/EDM adequately analyzed using simplistic and
initiative to create a database with relevant linear models of cause and effect. One has to
information for drug procurement to improve recognize the multiple dimensions of health
access to HIV/AIDS related drugs.They have and disease and the multiple levels of

influences that can affect the incidence and (at least in India) much earlier.
prevalence of disease.
While we have not covered all the different
Among the recurring themes in the chapter disease control programs we have
are: concentrated on a few to highlight the main
" Problems with the ‘vertical program’ as themes of the various national disease control
an implementation strategy: Not only programs. While the analysis may seem
does it see the problem in isolation from somewhat critical, one cannot deny the
other diseases, but also leads to a remarkable strides forward taken by India as
neglect of the general health system. a whole and by the health system in
This invariably results in a fragmented particular. And more than anyone the credit
approach and a very costly and should go to those unsung heroes / heroines
unsustainable program. and foot soldiers of the health care system –
" The importance of the general health the ANMs, the multipurpose workers, the
system: The general health care anganwadi and balwadi workers and various
system, specifically the public health other staff including the doctors in various
system, is crucial to the proper primary health centres and district hospitals.
functioning of any program. Not only However as it is said “those who do not learn
does it respond to the ‘suffering’ of from history and condemned to repeat it”, it
individuals, but it is the only answer is crucial to look back and analyse the
to sustainability. functioning of each program so that one can
" The importance of involving the understand and get out of the present crisis
community: While the experts may have in health care and health. This crisis being
knowledge regarding the technology characterised by growing and persisting
and its effects it is the people who re- inequities among rural / urban and caste /
interpret this technology to make it class wise groupings and the poor health of
relevant, appropriate and affordable.
women as a whole and the increasing lack of
Examples from all over have shown
access and decreasing food security etc
that without complete participation of
thanks to the effects of liberalisation,
the community one cannot have a
privatisation and globalisation today.
sustainable and effective system.
The theme broadly has been the betrayal of
We have tried to trace the development of the
the dream of Primary Health Care. While in
Government of India’s programs to control
communicable diseases and to also provide the case of our efforts against malaria, our
the historical context of the development of programs have paralleled the development
these programs. While the Alma Ata and thinking that was going on
declaration was signed in 1978, the internationally, the TB program was one that
foundation and spirit of the Primary Health was developed in India and was and still
Care movement (if we could call it that) were remains a model in multi disciplinary
clearly visible in the health planning planning. While both the programs may have
documents of India even before independence. used different strategies the successes of both
Both the Sokhey committee and the Bhore were totally dependent on the presence of or
committee enunciated the principles of development of a high quality general health
‘comprehensive preventive and curative service. The fact that the government of India
services’. Thus while the Alma Ata declaration continued to put all effort in the
certainly gave a boost to the concept and a implementation of the various vertical
clear goal to work toward, the blue print for programs at the cost of the general heath care
such a health care system may be obtained services is probably one of the key reasons

for their failure and stagnation. The HIV / have certain limitations in leading community
AIDS program is being continuously dictated initiatives, and to strengthen the effective
by western thought and ideas and being led organised intervention of community
by donors. The present push for free ART members in various aspects.
without paying attention to the crumbling and
sometimes non-existent public health system Further, the private medical sector cannot be
which would be expected to deliver health care excluded if there is to be any genuine health
to HIV-AIDS affected persons is an example. sector reform; ignoring the existence of the
private sector will not make it go away.
The Way Forward Considering that about 80% of out patient
While it is tempting to say that the way care is provided through private practitioners,
forward is to ‘horizontalize’ all of health care this sector must be involved in effective
delivery, horizontalization itself without a notification, surveillance and following
whole series of philosophical, attitudinal and standard treatment protocols related to
skill-based changes is of no use. The limited communicable diseases.
success of the overnight horizontalization of
the leprosy program in Tamil Nadu is an In keeping with the multi causal approach to
example. What is required is a close problem solving, reorganization of the system
integration between a greatly strengthened will only play a part of improving the situation.
general public health system and special Another important aspect that needs to be
programmes addressing specific health addressed is behaviour. Behaviour and its
problems, capable of reaching out to persons impact on health have been extensively
whose problems may suffer invisibility, stigma addressed in interventions related to
or discrimination. Even the general health communicable diseases such as HIV/AIDS
system should have an orientation to address However, the fact that behaviour is not just
the needs of those who are really marginalized an individual phenomenon, but is strongly
and destitute. The efficiency of any program influenced by the larger social and cultural
should be measured based on the spread of milieu, needs to be taken into account before
benefits and change in various levels of ‘blaming victims’ or adopting mechanical and
disaggregated data rather than indices derived at times humiliating approaches to modifying
from aggregate data. behaviour, of which ‘Directly Observed
Therapy’ is one. Compared to such an
What is really required is for the government approach, well conceived and appropriate
to decide to resist the temptation of people’s campaigns and health awareness
succumbing to external (donor) pressure, to activities, based on a collaborative and
look instead toward the collective wisdom of participative approach may be more effective
Community health professionals and in influencing behaviour in a healthy
development workers who are in touch with direction.
the local reality. Another key principle is that
of decentralization. While the introduction of This brings us to the other crucial principle
Panchayati Raj is certainly a step in the right is that of community or people’s participation.
direction, the act needs to be followed up by While this has been a much used and even
capacity building, empowering and delegating misused term in the last few decades,
both planning and financial powers to the especially since Alma Ata, the peoples
panchayats and Gram Sabhas. This should participation envisaged actually means getting
be combined with giving space to Community the people involved at all levels of planning
Based Organisations in the decision making and implementation and actually listening to
and monitoring process, to complement them to understand their point of view and
Panchayats which in their present form may respecting their values and value systems.

While these values have been reflected in The principles of universal, comprehensive
various people’s movements and innovative Primary Health Care, envisioned in the 1978
NGO and community led projects aimed at Alma Ata declaration should be the basis for
improving health and development keeping formulating policies related to health. Now more
than ever as equitable, participatory and
equity and justice paramount, they have best
intersectoral approach to health and health
been articulated in the recently adopted
care is needed.
Peoples Health Charter. We will end this
chapter with a few quotes from the charter The charter:
that call for a revitalization of the principles Demands a radical transformation of the WHO,
of Alma Ata in a radically changed milieu60: so that it responds to health challenges in a
manner, which benefits the poor, avoids vertical
Health is primarily determined by the political, approaches, ensures intersectoral work,
economic, social and physical environment and involves people’s organizations in the World
should, along with equity and sustainable Health Assembly, and ensures independence
development, be a top priority in local, national form corporate interest.
and international policy making.
Demands that governments promote finance
and provide comprehensive Primary Health
The participation of people and people’s Care as the most cost effective was of
organizations is essential to the formulation, addressing health problems and organising
implementation and evaluation of all health and public health services so as to ensure free and
social policies and programs. universal access.
60
People’s Charter for Health 2000. Gonomudran Bangladesh

New Initiatives in the Immunization Programme
Anant Phadke
During the last 10 years, two new initiatives Data from the Americas, from Vietnam
have emerged related to the Expanded and now even from India (Mumbai, U.P)
Programme of Immunization (EPI). The Polio clearly show that majority of patients
Eradication Programme was launched in of Acute Flaccid Paralysis (AFP) are not
1995. The Universal Hepatitis-B vaccination due to the polio virus but due to Non
has been launched from 2003 in selected Polio Entero-Viruses (NPEV).1 This fact
districts as a pilot programme and is likely to substantially changes the cost-efficacy
be expanded thought the nation in a couple estimation of polio-vaccination.
of years. Though both the programmes have 2. Majority of the Sabin viruses
been rigorously pushed by certain vested administered to children revert to the
interests and have the enthusiastic sanction virulent form within a month! 2,3 (There
of the Indian Academy of Pediatrics, there are was no question of such reversion in
serious questions about both if we case of the small pox vaccine, the
scientifically, objectively assess the Public eradication initiative that is often used
Health importance of these new vaccination as an example and precedent). Hence
drives. OPV cannot be stopped even if the
incidence of paralytic polio due to the
The Polio Eradication Programme wild virus is reduced to zero.
The Polio Eradication Initiative in India was Dr. J. John, the architect of the current
launched in 1995, as part of the Global Polio eradication strategy in India has
Eradication Initiative (GPEI). It aimed at admitted, “Among strains of Polio-
eradication by the year 2000. The target is viruses in the environment, 69% of type
now postponed to 2004-07, but this aim is I, 92% of type 2, and 55% of type 3
unlikely to be achieved. It is time to take a viruses were found to be neuro-virulent
review of this objective of eradication of polio revertants. There is clearly a signal for
by vaccination. In a memorandum submitted the hidden risk inherent in the
to the WHO on 7th April 04, seventeen public continued use of OPV.”4 It has also
health experts in India have argued that “the been admitted that “ Until recently,
goal of GPEI was flawed from the time of its awareness of vaccine-associated
conception and is unlikely to achieve its stated paralytic poliomyelitis (VAPP) has been
objectives this year or in the coming years.” poor and quantitative risk analysis
scanty but it is now well known that
There are a number of critical observations the continued use of OPV perpetuates
and arguments, which question the wisdom the risk of VAPP. Discontinuation or
of the Polio eradication strategy – declining immunization coverage of
1. Earlier, all limb-lameness was OPV will increase the risk of emergence
assumed to be due to the polioviruses. of circulating vaccine-derived
1
Kapoor A, Ayyagari A, Dhole TN. Non-polio enteroviruses in acute flaccid paralysis. Indian Journal of Pediatrics
2001; 68:927-929.
2
Dunn G, Begg NT, Cammack N, et al. Virus excretion and mutation by infants following primary vaccination with
live oral polio vaccine from two sources. J Med Virol 1990; 32:92-5.
3
Abraham R, Minor P, Dunn G, et al. Shedding of virulent poliovirus revertants during immunization with oral
poliovirus vaccine after prior immunization with inactivated polio vaccine. J Infect Dis 1993;168:1105-9.
4
John TJ. Polio eradication in India: what is the future? Indian Pediatr 2003;40:455-62.

polioviruses (cVDPV) that re-acquire there may not be a case of paralytic

wild virus-like properties and may polio, wild virus may continue to
cause outbreaks of polio. To eliminate circulate amongst this pool of ‘covered
the risk of cVDPV, either very high but un-immunized’ population through
immunization coverage must be sub-clinical infections. In the above
maintained as long as OPV is in use, quoted paper J. John has also pointed
or IPV should replace OPV. While out “The resultant population mix of
progress is made towards eradication, non-immune children and recently
VAPP is now becoming more frequent immunized vaccine virus-shedding
than polio attributable to wild children offered the milieu for a
poliovirus infection.”5 During 1998 to revertant virus to spread silently and
2001 out of 5495 cases of poliomyelitis cause outbreaks, as seen in Egypt and
1770 were VAPP cases!6. In view of the Haiti.” Surveillance based on follow-up
problem of VAPP, J. John has of AFP cases cannot monitor this silent
suggested a shift to Injectable Polio spread. Has sewage been monitored for
Vaccine (IPV). The cost of IPV is today presence of the polio viruses? Has
Rs.450/- per dose 7, i.e. about 100 poliovirus been eliminated from the
times that of OPV. Even if it is brought sewage of those developing countries
down drastically when millions of doses who have been giving only IPV without
are bought in bulk, the total cost would radically improving the sanitary
be too much to bear for a country like conditions? In absence of improvement
India. in sanitation, can polio-virus be
3. Smallpox virus was eradicated from eradicated from human environment?
human environment through Without a definitive answer to these
vaccination. Can this be done for polio questions, we cannot claim that the
virus? Elimination of the wild virus Polio eradication strategy has a sound
would require that every child in the public health basis.
developing world should receive the 4. There are reports that immuno-
Sabin vaccine. But given the social compromised individuals continue to
barriers to access of various types and excrete vaccine derived revertant
to social conflict situations in some part neurotropic viruses for years.8,9,10 With
of the country or the other, is this the HIV epidemic, will not this be a
possible ? Even if 100% coverage is significant phenomenon?
achieved, uptake rate may not be 5. There have been reports of reduced
100%. Hence even if for a few years, coverage for other vaccines in the EPI,
5
John TJ. Polio eradication: End-stage challenges, vaccine-associated paralytic poliomyelitis. Bull World Health
Organ 2004;82
6
Mittal SK, Joseph Methew. Vaccine Associated Paralytic Poliomyelitis, Indian Journal of Pediatrics 2003;
70: 573- 577.
7
Together We Make India Polio Free, Unicef, 2000, page 7.
8
Kew OM, Sutter RW, Nottay BK, McDonough MJ, Prevots DR, Quick L, et al. Prolonged replication of a type 1
vaccine-derived poliovirus in an immunodeficient patient. J Clin Microbiol 1998; 36:2893-9.
9
Walter R, Maureen EB. The biological principles of poliovirus eradication. J Infect Dis 1997;175:286-92.
10
World Health Organization. Primary immunodeficiency diseases: Report of a WHO scientific group. Clin Exp
Immunol 1997;109 (suppl 1):1-28.

Anant Phadke
due to the additional work of the pulse respectively per DALY for their control
strategy. 11,12,13 programmes. Whereas polio received 1998
6. Epidemiology tells us that though for dollars per DALY though it contributed only
aerogenous infections vaccines have a 0.04% to this disease burden. There is thus
very important role in control of mind bogglingly excessive funding to the polio-
diseases, for diseases, which spread via eradication programme compared to the
faeco-oral route, the main measure has morbidity load it has generated.14
to be public sanitation and personal
hygiene. In absence of these basic The sensible thing would be to abandon
measures, to attempt to eradicate any eradication of polio as the immediate objective
enteric infection through mere and aim at polio control as has been done in
vaccination is highly questionable. In the past for four other diseases for which
the current ‘campaign for eradication eradication programme was launched initially.
of Polio’ there is no thought of allocating (hookworm, yellow fever, malaria and yaws).
more funds for sanitation! Improved Along with measures for improvement in water
water supply and sewage management supply and sanitation, OPV programme be
would also help to reduce lakhs of continued in developing countries till the cost
diarrhoeal deaths, hepatitis A, E, of IPV is brought down to that of OPV (i.e. if it
enteric fever and other gastrointestinal is brought down to one hundredth of the
infections along with polio. current cost!)
7. In the current year (2004), in India, Rs
1100 crore will be spent for the Universal Hepatitis-B Vaccination
eradication of polio; more than double The Universal Hepatitis-B vaccination
the amount spent last year! This is programme aims at reducing, eventually
many times more than the expense on eliminating the morbidities and deaths due
all the other vaccines in the EPI put to sequelae of hepatitis-B infection. But this
together! strategy is highly questionable on grounds of
its cost implications, its effectiveness as well
Despite the basic flaws in this programme, as due to its unfavourable cost-efficacy.
why have the Indian policy makers taken it 1. Currently the Hepatitis-B vaccine cost
up? Apart from the highly technocentric is Rs. 150 /- per child, for three doses.
paradigm of such vertical programmes, the For mass vaccination, we will assume
push by the funders also seems to be a major that the vaccine would be available at
factor. Jeremy Shiffman has compared disease a lower price, @ Rs. 50 per child. Even
burden in the developing countries with the then it will be almost equal to the
annual donations by donor agencies combined cost of the other 5 vaccines
measured in terms of dollars per DALY in the EPI! The annual cost of the
(Disability Adjusted Life Years). He found that vaccine for the 250 million newborns
during 1996-2001, tuberculosis and malaria alone would be Rs. 1250 million (@ Rs.
which contributed 9.10%, 14.3% respectively 50 per child). This equals the national
to the total burden among 20 diseases, budget for TB control. (TB kills 5 lakh
received annual donation 3.82, 6.64 dollars adults annually and is the number one
11
Lessons learnt from pulse polio immunisation programme. AIIMS-India CLEN PPI Program Evaluation 1997-98
Team. J Indian Med Assoc 2000;98:18-21.
12
Mathew JL, Gera T, Mittal SK. Eradication of poliomyelitis in India—future perspectives. Pediatr Today 2000;3:647-
60.
13
Kishore J, Pagare D, Malhotra R, Singh MM. Qualitative study of wild polio cases in high risk districts of Uttar
Pradesh, India. Natl Med J India 2003;16:131-4.
14
Shiffman Jeremy. Donor funding priorities for communicable disease control in the developing world. Paper
presented during the 11th Canadian Conference on International Health, 25th to 27th October 2004; Ottawa, Canada.

killer of adults in India). Is it justified 40 years to stop vertical transmission.

to spend on a priority basis so much To stop horizontal transmission
funds on one single vaccination on this amongst above 40-year population
low prevalence disease? also, it will take further 25 years of
2. Unlike in the West, vertical Universal Vaccination, because average
transmission of Hepatitis B from life- expectancy at birth in India is 65
Hepatitis-B positive mothers to their years and it will take these many years
newborns, is the most important mode before every Indian would be protected
of it’s spread in India. Prevention of this by this vaccination programme for
vertical transmission requires that the infants. During these coming 65 years,
newborns be given the first dose of the the life expectancy would further
vaccine during first 12 hours of birth. increase, with the resultant
The WHO, the American Academy of consequences for this programme.
Pediatrics have recommended that the 3. The WHO has recommended universal
first dose of HBV must be given as early hep-B-vaccination for countries with
as possible and in any case not later hep-B carrier rate of more than 2%.17
than 48 hours after birth.15 However, However, in India, the hep-B carrier
in India, since 77% births take place rate is less than 2 %. The oft-quoted
at home, this condition cannot be met estimate of 4.7% is based on the
in majority of the cases. The first dose mistake of equating hepatitis-B
of Hep-B vaccine would be given in the positivity-rate with carrier-rate and
Indian National Immunization also involves a simple arithmetical
Programme at the earliest, with the error!18 Selective Vaccination is in use
BCG vaccination visit and generally in low prevalence countries like Japan,
with the DPT-vaccination visit at 6 U.K. Netherlands. Thus on the grounds
weeks after birth (In many places BCG of low carrier rate alone, it is clear that
vaccine is also given during the DPT the Universal Strategy is not applicable
vaccination visit!). Inability to give it in in India. Final decision should depend
the first 12 hours after birth means that upon our health-care priorities, funds
at least in 77% of births, the newborns required and comparative cost-efficacy
will not be protected from vertical of different options.
transmission. It is well known that 4. The Indian Academy of Pediatrics has
newborns that get infection at birth are recommended Universal Hepatitis B
very likely to become hep-B carriers.16 Vaccination of newborns in India,
This most vulnerable group is precisely without estimating in any detail the
the one that would remain uncovered burden of morbidity and mortality due
by Universal Vaccination in India. to HB-disease, and without estimating
its cost-efficacy in terms of cost per
To put things in perspective, even if all life years saved due to HB-
newborns are successfully protected by Vaccination. We (Phadke and Kale)
vaccination in infancy, it will still take have estimated in a somewhat detailed
the Universal Vaccination Programme and rigorous manner, the comparative
15
Mittal SK and Nirmal Kumar. Optimizing Hepatitits-B Vaccine use in India, Pediatrics Today; July-August 1998,
9-41
16
Harrison’s Principles of Internal Medicine, 14th edition, Eds. Fauci, Braunwald, Isslebacher, et al.McGraw-Hill,
1998, P 1685.
17
Ghendon Y. WHO Strategy for the global diminution of new cases of hepatitis B, Vaccine 1990,
8: S 129-133
18
Phadke Anant, Kale Ashok. HBV Carrier Rate in India (letter to the editor), Indian Pediatrics 2002; 39: 787.

Anant Phadke
cost-efficacy of Hepatitis B vaccination B vaccination ranged from Rs. 440 to

in India. Available Indian data on Rs.6433 per life year saved for different
prevalence of HBsAg positivity rates in age groups, with a weighted average of
different age groups and from extensive Rs.2713. For infants, the cost efficacy
Western studies on sequelae of HB- of Hepatitis-B vaccination was Rs. 558
infection have been used. Number of (12.4 US dollars) as compared to Rs.
persons from hypothetical cohorts of 1 43 (0.96 US$) per life year saved in case
million each for age-groups, <1, 1 to<5, of measles vaccination.19 By using a
5 to<15, 15 to<35, 35 to< 65, who different method (Markov-model),
would suffer from and die due the five Aggarwal, Ghoshal, and Naik,20 have
diseases caused by HBV-infection – arrived at a marginal cost-efficacy of
acute hepatitis, chronic persistent US $16.27 per life year gained, a
hepatitis, chronic active hepatitis, value similar to our estimation.
cirrhosis, hepatocellular carcinoma,
was estimated. Based on this, cost- These four considerations taken together put
efficacy of HB vaccination was a big question mark on the Universal Hepatitis
calculated and compared with that of B Vaccination strategy.
measles vaccination. It was found that
the average lifetime risk of dying due One can conclude that, the New Initiatives in
to the sequelae of HBV-infection in the the Immunization Programme are highly
normal population and HBV-carriers is questionable, on the grounds of Public Health
very low- 0.053 % and 1.39% and hence need to be reassessed by having a
respectively. The cost-efficacy of hep- scientific public debate on it.
19
Mimeo, revised version of -Phadke Anant, Kale Ashok, Some Critical Issues in the Epidemiology of Hepatitis – B in
India. Indian Journal of Gastroenterology, 2000; 19 (Suppl. 3): C76-C77.)
20
Aggarwal Rakesh, Ghoshal Uday, Naik Subhash. Assessment of cost-effectiveness of universal hepatitis B
immunization in a low-income country with intermediate endemicity using a Markov model, Journal of Hepatology;
2003; 38:205-222.

Community Health Worker Programs and
The Public Health System
T. Sundararaman
Introduction treatment on the first day of fever or even

Community health worker programmes have available at the sub-centre to deliver babies.
repeatedly been tried by the government – and Moreover, many of these activities involve
have repeatedly failed. The surprise is not any education and behaviour change where only
longer in its failure. The surprise is how one persons input is inadequate. None of the
despite such a poor track record they always above activities are such that one can just
do bounce back – in one form or another. In take it out of the list to limit it. They are all
some form or other some member of the local essential to achieve basic improvements in
community at some stage has always had to health care. It follows that we need more
be chosen to provide some health related human power at that level to implement it.
inputs. Indeed, there is evidence to show that the
ANM copes with much of her work by making
It is time to pose different questions of the her own informal local arrangements with
Community Health Worker (CHW) persons whom she can get to volunteer for
programmes. The first of these that we would this purpose.
like to ask is – why do they keep being
resurrected? What are the compulsions that The ANMs workload
bring them back? And why is it that while on 1. Immunisation
the one hand a very large number of NGOs 2. Ante-natal care
have shown considerable success with such 3. Conduct of home delivery and delivery
programmes the government has not been at subcenter.
able to achieve positive results? From the 4. Post-natal care
answers to this question rises the possibility 5. Advise on neonatal care
of building an approach which may be 6. Vitamin A and Iron-folic acid
promoted by advocacy when the programme distribution
is revived again – at the state or central level. 7. Family planning advice and services
including provision of Oral Pills,
There is a simple explanation for their condoms and IUD.
bouncing back – in the present day Indian 8. Health education and counselling on
context, such a programme is needed, even child and maternal nutrition;
9. Early detection and referral of
essential, to any major effort at public health.
pneumonia and prompt and proper
The set of functions that needed to be
management of diarrhoea, with health
performed at the village and family level – have
education to mothers for the same also.
almost all been designated as functions of the
10. Fever survey and presumptive
auxiliary-nurse- midwife (ANM). Yet even a
treatment of fever with preparation of
little introspection would show that it is
peripheral smears for blood smear
impossible for her to complete all these tasks.
examination for parasites needs to be
Some of the tasks are mutually exclusive and
done. Mechanism of collecting reports
some impractical. Thus if one has to go to in time with adequate treatment for
different habitations for immunisation and smear positive cases.
house visits, then one is not available in every 11. Identification of possible cases of
hamlet for providing presumptive malaria tuberculosis and collection of sputum.

Community Health Worker Programs and The Public Health System
12. Identification of possible cases of on paper. Most ANMs are able to just about
leprosy. manage immunisation and some degree of
13. Treatment of reproductive tract family planning services and that too because
infections and counselling on family life. they informally always request volunteers like
14. Identification of cases of curable
depot holders or link workers or just their
blindness including cataract.
15. Identification of people with disability
personal contacts to help out on some of the
with advice on available services. other tasks. Necessarily therefore some
16. Registration of pregnancies, marriages, volunteer at the habitation level is needed to
births, deaths, act as a link between the ANM and the
17. Education of adolescent girls population for service delivery as well as to
18. School health programmes take on a number of functions currently
19. Village women’s meetings on health. assigned to her.
20. Attending some panchayat meetings on
health.
Limitations in Expanding the MPW Force
21. First contact curative care and
replenishment of drug stocks in
One possible solution is to increase the
hamlets. number of female multipurpose workers
22. Advise on safe drinking water and (MPWF). Could we afford (at current salary
sanitation scales) one ANM per thousand population?
That would mean raising the workforce five
Problems of Geography times. Even then outreach to remote areas
The problem of outreach is further would remain.
compounded in most states by the problems
imposed by the social geography of the state. Experiences from many places repeatedly
For example the state of Chhattisgarh has reiterate the advantages of health education
54000 hamlets and only 4000 female being accomplished by a member of the
multipurpose workers. A population of 3500 community for whom the messages are
is typically spread out over 7 to 15 hamlets, intended. Messages received from a woman
notionally constituted into 2 or 3 villages. (The of the village have the same language, the
distinction between villages in a tribal area is same idiom, are adapted to their culture much
not sharp). These 7 to 15 hamlets may be better than would be the case for a person
spread over a wide area of over 10 km – or appointed from outside. This again is much
even more. Roads between them are often more so in states where we have so many
non-existent. Roads to the hamlets are often different tribal groups and dialects. Moreover,
there but transport services are frequently a woman of the same group would have an
inadequate. Add to these natural obstacles, instinctive understanding of what women
rivers and forests that cut off villages during already know and what they do not and why
the monsoons for a whole three months. We certain beliefs are held or why certain
can see that the task of visiting all the hamlets messages are not understood. A local CHW
even once a month is daunting as it is usually can address these problems much better than
possible to visit a maximum of only one or a person coming in from outside. The
two hamlets per day. And if we require the Community health worker will be needed in
ANM to visit the hamlet when people are every village as the major carrier of health
available, when they are not out at work - how education- at least till such time as general
can she get back to headquarters the same education has universalised and reached an
night? And how many nights in a month is it adequate quality and where adequate health
possible for her to stay away from her home? education is easily accessed by the general
population from public sources. (The current
In practice therefore, though the list of tasks, jingles and hoardings that market certain key
is long and impressive many tasks remain only messages selected by the health

T. Sundararaman
establishment are not to be confused with a of community health action was that
health education programme). substantial improvements in health status
can be brought about by a team of well trained
Pioneers in Community Health and guided community health workers despite
Worker Programmes their having low literacy skills and educational
Community Health Programmes became well- levels. Let us briefly look at some of these
known in voluntary organisations and NGO pioneering community health worker
sectors in the mid 1970s. Since then, many programmes in India.
organisations have replicated different forms
of community health work across the world. Of the above list the first six are important
India too has a rich experience of such because they have generated substantial data
programmes. One aspect that was established to show improvements in health status and
beyond any reasonable doubt by the pioneers much of this has been published in
Some of the Major Pioneer Programmes that have Defined this Community
Health Worker Approach
Venue/Name of the Project Organisation and Approx.
key resource person project size
associated with it
1. Comprehensive Rural Health Dr. Mabelle and 100 villages
Programme- Jamkhed, Dr.Rajnikant Arole.
Aurangabad district , Maharashtra
2. Comprehensive Rural Health Dr.N H. Antia, 30 villages
ProjectMandwa; Maharashtra Foundation for Research
in Community Health
3. SEWA- Rural, Bharuch, Gujarat Society for Education 35,000
Welfare ad Action-Rural. population
Dr Anil and Lata Desai;
Dr Mirai Chatterjee.
4. RUHSA project, Vellore district, Rural Unit for Health 84 hamlets;
Tamilnadu and Social affairs- about 1 lakh
(associated with CMC population
Vellore) Dr DS Mukherji,
Dr.Rajarathinam Abel
5. SEARCH project, Gadchiroli, SEARCH :Dr Rani Bang
Maharashtra and Dr. Abhay Bang
6. KEM Rural Health Project Extension service of 186,442-
King Edward Memorial approx.
Hospital Dr B J Coyaji one block
7. Vivekananda Girijana Seva Samithi, H S Sudarshan
Billi Ranga hills, Karnataka
8. Comprehensive Labour welfare Dr V Rahmathullah 2.5 lakhs-
scheme and United Planters mainly tea
association of Southern India, Idukki garden workers
(and Tata Tea plantations. Munnar)
9 Raigarh Ambikapur Health Association Sr. Georgina 150 villages,
2.5 lakh
population

international peer reviewed journals. The in curative care but had great difficulty in
other projects listed have important getting accepted as midwives or in doing
innovations or situations that are worth preventive and promotive work. Moreover they
studying closely, even though they have not found it difficult to stay in villages. Nor was it
focussed on such data. We note that there possible to afford an ANM in each and every
are many other important CHW programmes village. Analysing this, the Arole’s recognised
like CHDP, Pachod, the Banwasi Sewa that when it came to preventive and promotive
Ashram the Deendayalu project in Chittor, messages the cultural gap between the ANMs
AWARE programme in Naydupeta of Andhra and the village led the villagers to disregard
Pradesh, ACCORD programme in Gudalur. We their messages. To quote, ‘the nurses are
are, however, constrained by lack of both different, they dress differently. Sometimes
space and data to discuss all these. our women do not understand their language.
They use big words and strange phrases that
We describe below two of these path-breaking we have never heard before. They keep aloof,
programmes and touch upon how the other and do not like to meet our women in the field.
programmes related to them. They are not able to explain things to our
women and not sensitive to our beliefs.’ –
Comprehensive Rural Health Project: Dr Raj report of a sarpanch to Raj Arole about why a
Arole and Dr Mabelle Arole, Ahmednagar
very good ANM was being ineffective stated
District – Jamkhed.
during an evaluation session – quoted in the
This programme is the most well known
book “Jamkhed.” The book comments that in
pioneer in this area. Indeed it was to influence
China too similar problems had been noted.
all discussions on community health workers
It was decided therefore to limit the ANM to a
ever since its inception and in a modest way
weekly visit and instead create a cadre of
even the framing of the Alma Ata declaration
health workers. With the withdrawal of the
of 1978. This programme was led by two
doctors- a husband and wife pair of Dr Mabelle ANM to the health centre as part of the
Arole and Dr Rajnikant Arole. Both had medical team, they became not only more
graduated together from medical college in effective but more cheerful in all their
1959, they worked for three years in villages functions, including support to the
and then moved to learn higher skills in the community health workers. They were able
US, working at the Cleveland Clinic and John to play an important role in the community.
Hopkins – two of the most renowned public
health programmes before returning to India Faced with a very limited success in the ANM
in 1970. centred approach, largely because of her
inability to reach the hamlets regularly and
The Jamkhed programme started in 1970 because of the cultural and social gap between
attempting to build a programme around a her and the population she has to serve, they
health centre linked to weekly village visits decided to start by training village level
by the doctors supported by ANMs, much like volunteers – that too women.
what was then available in the government
system – one woman for 5000 population. From the very beginning the Jamkhed strategy
They started with six ANMs. But over the next had been planned as a multipurpose service
two years they had to change their strategy. and as part of this, farmer’s clubs were
The ANMs were to stay in a village and attend initiated in all the villages. By 1975 farmers
and provide services to about five villages clubs had come up in 30 villages. These clubs
each. However, though trained and intensely became the focal point of all the comprehensive
supported by the doctor couple the results health activities planned. The selection of the
were not encouraging. They were successful CHWs was also a farmer’s club function.

T. Sundararaman
CHWs selected were women, usually married centres as the village health workers enjoyed
and resident in the village. Most of them had at Jamkhed. But the government PHC staff
children, but a home situation where they are not trained or even inclined to provide
could be helped. Some were widowed and support or consider VHGs as learners and
needed the small financial support that the competent equals. The government did not
programme provided. They were all selected make provisions for ongoing refresher training
by the farmer’s clubs, which were active of the VHGs and did not have facilities for
sensitised entities, which knew how to act in overnight accommodation’. To modify these
consultation with the team. problems, twelve local NGOs were selected
and trained to provide this support and this
Training consisted of an initial weeklong helped limit the problem by providing some
orientation followed by periodic weekend visits quality monitoring and training support. In
and reviews. The ANMs served to play a major this process women were also developed as
role in training and even senior voluntary trainers.
health workers (VHWs) helped significantly.
Training was participatory with a lot of group What were the health outcomes to be learned
discussions and practical demonstrations. from Jamkhed? There is considerable data on
Considered cultural adaptation of messages this. The infant mortality rate (IMR) fell over
to suit the social milieu could take place. The four years from 176 to 60 and then a slower
programme went on to plan women’s fall over the years to about 18 to 20 by 1992.
development groups as well. By 1975 the Birth weights increased by 0.75 kg. The crude
programme had an impact in 30 villages. It birth rate fell from 40 to less than 20 over
was then decided to expand the programme this twenty-year period. And couple protection
and over the next five years it did expand to rates reached desirable norms. Certain areas
175 villages. like a marked son preference affecting gender
ratios below the age of 15 had not changed –
Meanwhile in 1977 the government partly but on the whole the programmes impact was
influenced by this programme and also driven unquestionable. The impact was mainly on
by its own compulsions launched a child health and the major strides forward
community health volunteer programme later were apparent in the first five-year period.
known as the village health guide programme. Socio-economic indicators, knowledge
The government approached the Jamkhed attitudes and perceptions also showed positive
team to help them conduct the programme in changes.
the entire district. This was accepted. Teams
from the programme visited the villages Rural Unit for Health and Social Affairs
explaining the programme, helping in (RUHSA- Vellore)
selection and then later undertaking the This is a creation of Christian Medical College
training. Training was one week at the (CMC) Vellore, one of the premier medical
Jamkhed centre, one week visiting and colleges in the country. This programme was
working with one of the established VHWs and set up in 1977 to integrate health care with
another two weeks at Jamkhed. Further, once socio-economic development as part of the
every three months there was a training Reorganisation of Medical Education (ROME)
session at the centre with monthly one-day effort. The structure of the programme had
sessions at the primary health centre (PHC). five family care volunteers each catering to
about 200 families organised under a full time
This programme however did not have the paid community organiser for every 1000
desired impact. To quote ‘Voluntary health families. This is called a Peripheral Service
groups (VHGs) expected the same kind of Unit (PSU) and was visited by a mobile medical
support from the staff at their primary health team once a week. There were 16 such PSUs

and four such mobile teams operating out of Some Other Innovations
two central service units. These two central SEARCH Gadchiroli has also generated rich
service units also acted as the first referral figures of improvement in infant mortality.
points of the programme. The family One notable addition is that the Gadchiroli
volunteers who were the main workforce group addressed the problem of neonatal
received continuous training and support mortality too in some detail. They established
from the community organisers. that with the right training inputs and two
visits in the post-partum period even neo natal
The strategy to link health and development mortality could decline with effective
was known as the TEAM approach – training, community health worker participation. The
education, agriculture and animal husbandry importance of demonstrating this was
and medicine. The target groups were women important, since in many other CHW
and children, educated unemployed youth programmes all elements of infant mortality
and socio-economically weaker sections of the and child mortality showed improvement
community. The programme therefore except for neonatal mortality.
involved setting up dairy and sheep
cooperatives and a weaver’s cooperative and SEWA-Rural in Gujarat broke fresh ground
a chicken broiler programme. Kitchen gardens in working with the government system and
and water management was also integrated. building up frameworks in which the existing
Securing bank financing for such initiatives ANM structure and the CHW structure created
was also a major thrust in the effort. could synergise.
At the level of organisation village advisory The RAHA ( Raigarh and Ambikapur
committees, youth clubs, women’s groups and programme) needs to be noted not only
young farmers clubs were developed. Adult because of the difficulty of terrain but also
education and women’s organisations became because in such terrain where both
thrust programmes. Some of the impressive government and private sector penetration
results in the health section was the work was minimal a health insurance system that
focus on child malnutrition. Severe generated substantial funds and participation
malnutrition in this area fell from 26 per cent from the community was set up. This was long
in 1978 to less than 2.5 per cent in 1988. The before health insurance became a central
birth rate fell form 36 to 23.3 per cent, but feature of health care debates and it was more
this was parallel with the rest of the state. motivated by the internal necessities of
The decline in infant mortality was significant, providing health care outreach systematically
it fell from 116 to 50.8, which was better than rather than from any pressure to establish a
the state figure of 93.0 at that juncture. model. The funds generated from such peoples
Service indicators including inpatient and contributions were only a small part of the
outpatient figures in the referral centres, over all expenditure but it did ensure a better
pregnancy registration and immunisation quality of care to all its participants.
coverage all improved remarkably. Similar to
other models in this field, the first five years NGO Experience In Community Health
showed the steepest improvement after which – An Overview
the slope flattens but continues to improve The above examples illustrate three types of
over the next five years. About 66 to 80 per motives for initiating community health
cent of the improvement was in the first five worker programmes. One is a set of doctors;
years. often a doctor couple who wish to put their

T. Sundararaman
skills to use in the service of the poor. Another Problems in Large Scale Replication by
is institutions that are trying to establish a the Government
model that involves scientific demonstration The major government led programmes are
of the validity of the approach and the Community Health Volunteer (1978), the
development of tools to replicate them. Yet Village Health Guide (1984) the Jan Swasthya
another variety was the experiment with Rakshak (1987), the Janswasthya Rakshak
plantation workers whose prime motivation (1995) and the Drug Depot Holder, and the
is cost effective quality care for the workers. Malaria Link Worker.
Whatever the motivation, whatever the
starting points, whatever the routes eventually Government Programmes
taken, there seems to be a residuum of Important government run CHW programmes
absolute non-negotiables in the success of any in contrast to NGO led CHW programmes have
CHW programme. had the following problems:
a. Almost all the programmes have
These Non-negotiable Elements for
selected mainly or only male health
Success could be Enumerated as follows:
workers.
1. A good quality of referral linkages, b. Selection has either been by the local
usually in the form of a ten to 30 government functionary whose
bedded rural hospital, where higher understanding of the programme
degrees of illness are handled varies, or it is left to the elected
adequately. panchayat or the dominant section of
2. Duration of project for at least five to the village. In both cases patronage has
ten years. corrupted the choice.
3. High quality leadership providing c. In almost all cases there has been very
active support and training throughout poor quality of support after the
the programme – with no end point at training period is over and there is no
all to this process of support and continued plan of training.
training. d. There is minimal or non-existent
4. Women as healthcare providers, referral back up as the health system
especially at the community level. is dysfunctional.
e. Curative care has been over-
The limitations of the above programmes are emphasised and preventive care even
also clear. They cover only a minuscule part if covered in the training is not
of the population and beyond establishing a practiced in the field – leading to a
particular approach and tools to implement situation where many of the men
it, they cannot have much impact on the over trained as CHWs set up as under-
all health situation. Besides this, none of them qualified hazardous practitioners of
recover more than a fraction of the costs – irrational allopathic medical practice.
even where this has been tried – and therefore
are dependent on continued government Why has there been this inability to integrate
support or external aid with all the limitations these five basic lessons into the government
and insecurities of such funding. CHW programmes? One must beware of one-
Sustainability of the project depends on how line answers to this question. In the process
long such financial support is forthcoming of programme design and implementation,
though some of the health gains, (especially different sections and institutions (or
secondary) that contribute to increased stakeholders if one is comfortable with the
knowledge and better practices are term), contend to shape the programme.
irreversible. Though their interests overlap,

implementation is viewed from their individual commitments. At the practical level

and distinctly different interests and government policy may well shift to merely
perspective – and in the process these five the selection and monitoring of NGOs. In the
lessons get filtered out. Thus to the political long run in such a scenario only service
leadership the attraction of the scheme lies delivery NGOs who can cut corners or those
in the fact that it can be presented as a scheme whose claims of performance do not match
for providing a livelihood to educated youth, with actual activities,would survive.
somewhat like learning a trade. By converting
the opportunity to be trained into this trade Community Health Worker Programmes
into a large-scale patronage system where as Health Sector Reform
panchayat leaders are involved in selection There has also been considerable divergence
and the young beneficiaries are grateful to the between different NGO organised community
government of the day it becomes a source health programmes in their approach and
for gaining political mileage. This is most relationship to the public health system. Many
clearly seen in the recent Jan Swasthya NGO programmes here and world wide were
Rakshak scheme of Madhya Pradesh. The based on the premise that as the public health
underlying cause is the persistence in system is dysfunctional, at least in so far as
selecting male CHWs, allowing panchayats to reaching the poor was concerned – a more
control selection and the emphasis on curative effective way of reaching the poor was
care. To the leaders who decide on policy – necessary. No synergy with the public health
there is frustration with the failure of the system was considered – giving up the latter
public health system to deliver. To them this as a lost cause. Curiously there was often a
programme is a low cost option to arrange for considerable agreement on this between
some degree of health care to reach the poor radical proponents of a health rights approach
together with a higher visibility and and those whose work was an extension of
recognition for the project from the people and philanthropy. Often such CHW programmes
the government. This partly explains the had their own referral centre. Only a few
insufficient investment in continued long- amongst them sought synergy with the public
term training and training materials and health system.
support in building up referral systems. It goes
along inadvertently with a lack of will to In an era of globalisation and an ideologically
manage the problems of the public health driven retreat of the state, this lesser role for
system. The inability of a bureaucracy – that the government in health care provision
too a medical bureaucracy – to initiate and proved even more attractive and public policy
sustain the mobilisation processes that such increasingly talked of handing over areas and
a programme needs contributes its part to the programmes to the NGO sector. This was,
misfortunes. Moreover the medical however, not part of a planned way to increase
bureaucracy remains distrustful of the CHWs effectiveness but merely a shift in
partly because they perceive them as responsibility and reneging on a more
competitive in rural practice. There is a proactive government role. The cost
misgiving that the creation and empowerment effectiveness of the CHW programmes in
of a new force would challenge the omissions particular as compared to conventional public
and failures of key functionaries in the current health systems seemed to find favour with
public health system. In the NGO health international funding agencies.
sector this programme represents an
opportunity for it to expand its sphere which In contrast to these there is a trend in the
in itself is welcome – except that at the CHW programmes since the 1990s to change
theoretical level it may be instrumental in the CHW programme into a movement for
causing the state to renege from its health rights. Early examples of this approach

T. Sundararaman
are three relatively small and tentative pioneer services. These cannot be substituted for by
programmes. These are the CEHAT facilitated community action. To pose a CHW programme
initiatives in co;;aboration with people’s without a parallel effort to restructure and
movements – Adivasi Mukti Sanghatana, the strengthen public health services would be
Kasthakari Sangathan and the dam displaced only an unethical attempt to use community
peoples movements in south Maharashtra. health worker programmes to transfer the
There has also been the PRAYAS work in blame of ill-health back on to the community.
Rajasthan and the larger programme efforts In contrast, access to such public services in
through the various health activists of the an affordable way for the poor, is a basic
peoples’ science movements in the states of human right and the health worker
Tamilnadu, Bihar and Uttaranchal. The much programme tries to build a consciousness and
more ambitious Mitanin programme in an organisation of people to lead towards this
Chhattisgarh state that aims to cover everyone goal. In programmes like the work of CEHAT
of the state’s 54,000 habitations is also built or the Tamilandu or Bihar peoples’ science
on these same principles. In these movements there is no formal cooperation
programmes the community and health with the government health system but this
worker is more a health activist, someone who has to be secured by action from below and
mobilises the community for a more effective this cooperation being available sporadically
and accountable public health system. This cannot be relied on.
is supplemented by providing health
education and organising the community for The health activist in her daily work and the
self help – equally important goals in women’s health committee contribute to this
themselves. This community health worker, goal of strengthening public health systems
or should we say activist, far from being by organising and empowering women and by
independent or parallel to the public health sensitising panchayats to health care needs
system is an intrinsic part of it and the and prevalent health services. Her stubborn
programme ensures that the public health facilitation of village level services of the
system be better utilised and become more government employees is a more effective and
effective. This increased utilisation comes Gandhian way of ensuring accountability in
from securing community participation for a hardened system, than mere complaints and
health programmes which not only involves protests. However activities like Jan Sunwai
increasing knowledge of government health and on special issues even agitational action
programmes and facilitation to its employees have been very central to effective
but actually redesigning these programmes programmes as seen in places like Sendwa
to include participation by the community. and Madurai.
Local area planning in health, involving the
panchayats in the process, is one of the When the government constructs and
interim outcomes of the programme and is a participates in such a CHW programme and
major tool for such restructuring to enable even leads it as in the Mitanin programme of
the health systems to be more responsive to the state of Chhattisgarh it is a recognition
local priorities and specific needs. that civil society action and community
empowerment are central to the improvement
While one is convinced that by health workers of public health systems. It illustrates that
providing health education inputs and first such action is desirable and should be
contact curative care, substantial encouraged. Most state governments are far
improvements in health status can be gained, from having recognised this dimension and
programmes like the Mitanin programme (that even in Chhattisgarh the arrangement is
typically do not have their own dedicated fragile and easily reversible. That is one reason
referral centres) depend on the availability and why the campaign for a right to health care
accessibility of good quality public health must make a health activist a major peg of its

campaign in every village. We do have a large and increasing number of

programmes, which are NGO run and parallel
Once such a perspective is in place it is easy to the state with few linkages between the two,
to ensure participation of women as health where the NGOs main role may be stated as
workers. It is also possible to posit a continued service delivery. We do, however, see a growing
training and support mechanism to facilitate belief and support for the approach that
the health workers action and conceivably replication of NGO programmes is the best
insist and move in the direction of health way forward – even to the extent of contracting
sector reform. out the whole states health systems to not
just CHW programmes but even PHCs and
One index of such recognition is the forging sub-centers to NGOs.
of a stable state cum civil society partnership
We also have programmes where the
at the policy and the implementation levels.
government would consider NGOs as players
This would provide leadership to the
with no additional role and the government
programme – thereby ensuring that the highly
with relatively low investment runs the
motivational quality of support systems that programme with assistance from the
a CHW needs are put in place – instead of panchayats. These are often fuelled by an
passively abandoning the programme to the understanding that the main gap in service
health/medical bureaucracy. The Mitanin delivery is people’s lack of awareness and lack
programme rests on such a foundation, but of willingness to cooperate. This premise is
given the nature of governance the spirit and subsequently reinforced by the failure of the
mechanisms of partnership have to be programme. In such a situation responsibility
constantly nurtured and safeguarded of not only CHW programme failure but also
that of the entire public health system gets
Linking with the Panchayats shifted back to the people.
A further role that community health workers
have had to play is in their interaction with Yet another approach is to push for
panchayats. This has always been central in strengthening public health systems from
government thinking ever since the 73rd and above through health advocacy and policy
74th constitutional amendments sought to level partnerships between government and
make panchayats functional bodies. Almost civil society, while simultaneously building up
all community health worker programmes a grassroots level pressure for improvement
have required selection or at least endorsement of health systems through an appropriately
by the panchayats. The effort has been to use designed CHW programme. The disadvantage
this as a link with the elected representatives of such partnerships is that the problem of
and as an effective mechanism for panchayats building and sustaining them is so difficult
in the health arena. Success may have been that setbacks can easily occur. The advantage
of this approach to strengthen the health
limited, but as long as we concede that local
system is that it is able to engage in a dialogue
bodies have a role in health care services, we
and dispel the different illusions and myths
would need to search for a method to build
that have been created to justify the current
such capabilities and systems as would help
state of affairs. It might well provide a
them exercise this role. If we have not found considerable degree of relief to people in their
it yet, we certainly need to find it in the future. suffering, strengthening their ability to cope
with poverty and its consequences even while
Conclusion they move towards gaining more of the
In the current phase of the Community Health knowledge, the skills, the organisation and
Worker Programme – there is no clear pattern the optimism that is needed to promote social
that has emerged as dominant. change.

The Way the Wind Blows: Population Policies in India
Mohan Rao
Introduction document entitled India’s Family Welfare

India was one of the first countries in the world Programme: Towards a Reproductive and Child
to have an official family planning programme Health Approach in June 1995 2 . The
and policy. Over the years, the population Government of India, on its part, in
issue came to dominate health concerns, even enunciating a new Reproductive and Child
as the programme lurched from one approach Health (RCH) approach, visualised a
to another. Each programme twist, often paradigm shift in the family planning
relying on new contraceptive technology, programme strategy. Indeed, reflecting this,
appeared to work for a while before running the National Population Policy (NPP)
aground. Thus the programme moved from enunciated in 2000 was premised upon the
the extension education approach, to the RCH approach although it entailed a neglect
IUCD approach, to the vasectomy camp of Primary Health Care (PHC).3 Thus, it was
approach, to placing reliance on female not framed in demographic terms, and was
sterilisation. Towards the end of the 1980s, it committed to a voluntary, target-free approach
was increasingly being realised, albeit that abjured incentives, and in particular,
grudgingly, that the colossal family planning disincentives.
programme in India, arguably one of the
largest public health initiatives in the world, Yet even before this approach, with all its
had been far from successful. Partly as a result limitations, can be given a fair chance, there
of this realisation, partly as a result of is already manifest an impatience, a call for
pressures generated by women’s groups and giving greater teeth to the programme, for
health groups calling for a radical ‘showing political will’. It is in this context that
reconsideration of the programme’s goals and in its first section this paper discusses the
objectives, and to some extent in preparation current policy scenario while the second part
for the third decennial International points to some fundamental arguments that
Conference on Population and Development have been ignored. The third section draws
(ICPD) at Cairo in 1994, the Government of attention to how the focus on family planning
India initiated a search for a new direction to has impinged on health sector development
population policy. At the ICPD itself, a new while the final section highlights some
approach to population policy was advocated worrying tendencies in the wider context that
in the Plan of Action, one which was not policy makers need to take note of in any
demographically driven but instead policy discourse.
emphasised on the one hand, the
empowerment of women and, on the other, The Current Family Welfare Policy
an approach of reproductive health care1. The Scenario
World Bank, whose commanding role in the On the 30th of July 2003, a three-judge Bench
health sector had reached an apogee, not of the Supreme Court of India upheld a
perhaps coincidentally, brought out a Haryana Government law prohibiting a person
1
ICPD Secretariat (1994), Programme of Action of the International Conference on Population and Development, New
York.
2
World Bank (1995), India’s Family Welfare Programme: Towards a Reproductive and Child Health Approach, New
Delhi.
3
Government of India (2000), Department of Family Welfare, National Population Policy 2000, New Delhi.

from contesting or holding the post of a staff to performance in family planning and
sarpanch or panch in the Panchayati Raj so forth.
Institutions (PRIs) of the state if he or she had
more than two children. The Bench observed Health and women’s groups approached the
that ‘disqualification on the right to contest National Human Rights Commission (NHRC)
an election for having more than two living in 2002 with a memorandum that the two-
children does not contravene any child norm was discriminatory, anti-
fundamental right, nor does it cross the limits democratic and violative of commitments
of reasonability. Rather, it is a disqualification made by the Government of India in several
conceptually devised in the national interest’4 international covenants. The NHRC issued
orders to the concerned State governments,
Interestingly, while the Supreme Court spoke and, at a National Colloquium on the 9th and
about the ‘torrential increase of population’, 10 th of January 2003, attended by
earlier the Rajasthan High Court judges, representatives of these State governments,
hearing a similar set of petitions, in their a Declaration was issued.
ruling argued: ‘These provisions have been
enacted by the legislature to control the This NHRC Declaration, ‘notes with concern
menace of population explosion… The that population policies framed by some State
government is spending large sums of money Governments reflect in certain respects a
propagating family planning. One of the
coercive approach through use of incentives
agencies to which the project of family
and disincentives, which in some cases are
planning has been entrusted for
violative of human rights. This is not
implementation is the gram panchayat. The
consistent with the spirit of the National
panches and sarpanches are to set the
Population Policy. The violation of human
example and maintain the norm of two
rights affects, in particular the marginalised
children. Otherwise what examples can they
and vulnerable sections of society, including
set before the public?’5
women’6. The Declaration also noted: ‘ further
Haryana is not the only state that has a that the propagation of a two-child norm and
population policy with such features, which coercion or manipulation of individual fertility
are not only at variance with the NPP but also decisions through the use of incentives and
strike at the heart of the commitments to disincentives violate the principle of voluntary
reproductive health and rights made by the informed choice and the human rights of the
government at the ICPD. Other states, such people, particularly the rights of the child’
as Andhra Pradesh, Madhya Pradesh,
Rajasthan and Uttar Pradesh, also carry this However the NHRC Declaration, as much as
policy prescription in their population policies. the concerns of health groups and women’s
Between them they also advocate a mind- groups, apparently fell on deaf ears, as the
boggling host of incentives and disincentives: Supreme Court ruling has come in for
restricting schooling in government schools widespread middle-class approbation. Indeed,
to two children; restricting employment in the Supreme Court ruling perhaps renders
public services to those with two children; redundant some of the private member’s bills
linking financial assistance to PRIs for in Parliament that have been tabled to
development activities and anti-poverty variously increase incentives or disincentives.
programmes with performance in family Two of them, one named the Population
planning; linking assessment of public health Stabilisation Bill 19997, and the other, the
4
Venkatesan, J, “Two Child Norm Upheld”, The Hindu, 31st July 2003.
5
Sarkar, Lotika and Ramanathan, Usha (2002), “Collateral Concerns”, Seminar, 511.
6
National Human Rights Commission (2003), Declaration: National Colloquium on Population Policies, New Delhi.
7
Lok Sabha Secretariat (1999), The Population Stabilisation Bill, 1999, (Dr.V.Saroja, M.P.), New Delhi.

Mohan Rao
Population Control Bill 2000 8, for instance, Fundamental Problems with the
moot the idea of a one-child norm along with Coercive Family Planning Approach
a number of incentives and disincentives, The problem with these punitive approaches
including disqualification of persons with is both fundamental and pragmatic.
more than one child from contesting elections. Fundamentally, it represents a profound
Yet another bill, the Bachelor’s Allowance Bill misunderstanding of the relationship between
20009, suggests incentives to those men who population and resources. Pragmatically, they
remain bachelors. Men, who, taking are demographically unnecessary, and indeed
advantage of the incentives, subsequently get counterproductive. They are also morally
married, are to be fined and imprisoned. The compromised since they violate the principle
Population Control Bill 2000 10, also seeks to of natural justice, creating two sets of
punish people who violate the small family citizenship rights on the basis of fertility.
norm with rigorous imprisonment for a term Indeed such policies represent going back to
of five years and a fine, not less than the days before universal suffrage when
Rs.50,000. The Population Control and Family property rights decided citizenship claims.
Welfare Bill, 1999, proposes in addition to
incentives and disincentives, the compulsory There is a vast amount of empirical evidence
sterilisation of every married couple having of the profoundly anti-Malthusian relationship
two or more living children.11 These efforts at between population and resources. Tilly, on
prescribing a two-child norm seem to be found the basis of a historical review, concluded:
also in unlikely quarters. Incredibly, the Tamil ‘Over the long run, population growth and
Nadu agricultural labourer’s insurance bill economic expansion generally accompany
stipulates that labourers losing their limbs each other. Likewise economic decline and
can only receive insurance compensation if demographic contraction tend to occur
they have no more than two children. together. 13 The classic by Habakkuk on
population growth in eighteenth century
Not to be left behind, the Government of India England outlines five ways in which
announced its plans in April 2003 to introduce substantial population increase stimulated
in the Lok Sabha the Constitutional economic growth.14 Kuznet’s concluded that,
(79 th Amendment) Bill seeking to restrict other things being equal, population growth
persons with more than two children from also has a positive effect on savings.15 Indeed
contesting elections 12. This Bill, introduced examining regional statistics on the growth
in the Rajya Sabha in 1992, would first have of population and industry, the favourable
to pass the lower house. The Health Minister, economic effects of population density and
speaking in the Lok Sabha, announced that population growth are ‘confirmed to an
should there be consensus on the Bill, the embarrassing degree’. 16 In agrarian
government was prepared to introduce it in economies, Boserup’s work revealed how
the ongoing session of Parliament. population pressure induces technical
8
Lok Sabha Secretariat (2000), The Population Control Bill, 2000, (Mr.U.V.Krishnam Raju, M.P.), New Delhi.
9
Lok Sabha Secretariat (2000), The Bachelors’ Allowance Bill, 2000, (Mr.Chandrakant Khaire, M.P.), New Delhi.
10
Lok Sabha Secretariat (2000), The Population Control Bill, 2000, (Mr.Y.S.Vivekananda Reddy, M.P.), New Delhi.
11
Lok Sabha Secretariat (1999), The Population Control and Family Welfare Bill, 1999, ( Mr.Sushil Kumar Shinde,
M.P.), New Delhi.
12
“Bill to Curb Population on Anvil: Sushma”, The Hindustan Times, 10th April 2003.
13
Tilly, Charles (1978), “Introduction” in Charles Tilly (Ed), Historical Studies of Changing Fertility, Princeton
University Press New Jersey.
14
Habakkuk, John (1971), Population Growth and Economic Development since 1750, Leicester University Press,
Leicester.
15
Kuznets, Simon (1956), Economic Development and Cultural Change, Chicago University Press, Chicago.
16
Clark, Colin (1968), Population Growth and Land Use, Macmillan, London.

change, increasing productivity. 17 One Hastening this, however, requires investments

striking empirical truth in the history of health in the social sectors – health, education,
is that improvements in human longevity have employment, food and so on – precisely
been associated with increases in human measures that are being undermined by neo-
populations. A graph of the growth of liberal economic policies.
populations superimposed on that of human
longevity reveals their astonishingly close Interestingly, the NFHS-2 also reveals that the
association. All these lessons were lost to us fertility rate that is currently sought, 2.13, is
in Cold War politics that brought to the fore a lower by 0.72 child (that is by 25 per cent)
completely different, and alarming, than the current TFR of 2.85. This is to say, if
understanding of the issue. unwanted births could be reduced, the TFR
would drop to the replacement level of fertility.
A more recent and comprehensive 1986 review Indeed this is acknowledged in the NPP, which
sponsored by the U.S. National Academy of therefore marks as its priority, meeting the
Sciences issued a cautiously worded unmet need for health and family planning
statement, to the dismay of the community of services. To propose punitive measures, in
doomsday demographers, noting that this context, is thus clearly absurd.
population growth has both positive and
negative impacts and that the actual net What is also important to acknowledge is that
impact cannot be determined based on given the age structure of the population,
existing evidence.18 population growth will continue despite fall
in the birth rate due to what demographers
Pragmatically, such moves are even call momentum, i.e. the effect of a young age
demographically unnecessary. There is a structure caused by high population growth
substantial demographic transition underway rates in the recent past. With a large
in the country. The Total Fertility Rate (TFR) proportion of the population - almost 60 per
has declined by almost half a child in the six cent - below the age of 30 years, further
and half years between NFHS I and II. growth of population is inevitable, unless of
Replacement level, or close to replacement course mortality increases, which cannot be
level fertility, has been reached in Kerala, the aim of policy. Population momentum
Tamil Nadu, Karnataka, Goa, Andhra Pradesh, contributes to as much as 69.7 per cent of
Himachal Pradesh, Delhi and Punjab. It is true current population growth.20
that the TFR is high in Uttar Pradesh (U.P),
Bihar, Madhya Pradesh (M.P) and Rajasthan. Above all, it is imperative to bear in mind that
But even in these states it has declined demographic transition is not merely a
between the two surveys from 4.82 to 3.99 in geographical phenomenon, but is deeply
U.P, 4 to 3.49 in Bihar, and from 3.90 to 3.31 imprinted by social inequalities. Thus those
in M.P. Rajasthan is the only large state where sections of the population that have benefited
the TFR has increased from 3.63 to 3.78.19 In through post-Independence development, and
other words, a substantial and sustained are thus assured incomes, child survival,
fertility decline is underway in the country. social security, health and education have
17
.Boserup, Ester (1981), Population and Technological Change: A Study of Long-Term Trends, University of Chicago
Press, Chicago.
18
Kelley, Allen and McGreevey, William Paul (1994), “Population and Development in Historical Perspective” in
Robert Cassen (Ed), Population and Development: Old Debates, New Conclusions, ODC, Washington DC, cited in
Desai, Sonalde, (1998), “Engendering Population Policy”, in Krishnaraj, Maithreyi, Sudarshan, Ratna M. and
Shariff, Abusaleh (Ed), Gender, Population and Development, OUP, Delhi.
19
International Institute for Population Sciences, National Family Health Survey (NFHS-2), Mumbai, 2000.
20
Sen, Gita and Iyer, Aditi (2002), “Incentives and Disincentives: Necessary, Effective, Just?”, Seminar 511.

Mohan Rao
completed their demographic transition. On controlling numbers.

the other hand, vast sections of the population
– particularly the dalits, the adivasis and the Given the failure of approaches that had been
Other Backward Castes (OBCs) – who have hitherto followed, the GOI appointed a
not so benefited are lagging behind in Working Group on Population Policy in 1980
demographic transition. The NFHS for 1998- to frame a policy framework and programme
99, notes that the Infant Mortality Rate (IMR) content to family planning.21 The report of
among the schedule castes (SCs), schedule the Working Group argued that population
tribes (STs) and OBCs is 83, 84 and 76 and development are two sides of the same
respectively, compared to 62 for Others. coin, and that if the programme has to be
Similarly the Under Five Mortality Rate is 119 successful it would be necessary to focus on
among the SCs, 126 among the STs 103 substantial and sustained declines in infant
among the OBCs compared to 82 among the and child mortality, and increases in literacy,
Others. Not surprisingly, the NFHS also shows but also on increases in employment, income
that the TFR is 3.15 for SCs, 3.06 for STs, and nutritional status. It was also recognised
2.66 among OBCs and 3.47 among illiterate that development towards these ends must
women as a whole. It is, in contrast, 1.99 particularly benefit women.
among women educated beyond the tenth
grade and thus more likely to be better off. Today we find that not only has there not been
Imposition of the two-child norm, and the an improvement in infant and child survival
disincentives proposed, would mean that the of the range anticipated, indeed the 1990s
majority of the deprived populations would have witnessed stagnation in these
bear the brunt of the state’s withdrawal of programmes. Along with the shrinking of
ameliorative measures, pitiably inadequate as funds for public health and the concentration
they are. With the recent Supreme Court on vertical programmes, to the neglect of
judgement, the majority of these populations general health services, one singular feature
will be debarred from their right to contest that emerges is what can be termed ‘the family
elections in PRIs through one fell stroke of planning approach to health sector
the Supreme Court pen. development’. Thus it has been goals in family
planning that have contoured health sector
The Impact of Family Planning Policy development in the country.
on Health Sector Development
One reason for the plethora of policy initiatives This is evident from the financial allocations
that strike at the heart of commitments made made over the years to health and family
at Cairo is an emerging elite group planning. While allocations to health as a
increasingly distancing itself from the proportion of the budget, and indeed the GDP,
concerns of the poor in the country. Another have shown a secular decline, that towards
reason is the apparent sense of frustration family planning has shown a proportionate
that things do not seem to be working fast increase. Thus commencing in the First Plan
enough on the population control front. Why with a minuscule 0.1 per cent of the budget,
then has the family planning programme when health obtained 3.3 per cent, the
reached the impasse it apparently has? One allocations to family planning increased to 1.5
fundamental reason of course is that we have per cent in the Eighth Plan, when health
failed in the provision of primary health care, obtained 1.75 per cent, and to 1.8 per cent in
partly on account of the preoccupation with the Ninth while health obtained 1.1 per cent.
21
Government of India , Planning Commission (1980), Report of the Working Group on Population Policy, New
Delhi.

At the same time expenditure on mother and own priorities and programmes.
child health (MCH) has declined over the
years. 22 The pursuit of targets in family Both the NPP and the Ninth Plan document
planning and the priority that has been recognise that there is a large need to augment
accorded to it has meant that other aspects and strengthen health care services and to
of health care have been neglected, including meet the unmet needs for contraception.
the provision of MCH services. Thus it is not Indeed the Ninth Plan document also noted
surprising that the NFHS -2 results show that that one of the priorities for the programme
‘mothers in India received ante-natal check would be to reduce high wanted fertility due
ups for only 65 per cent of births during the to prevailing high IMR that is estimated to
three years preceding the survey, almost contribute 20 per cent to the population
unchanged from 64 per cent in NFHS-1.’23 growth rate. The unmet need for contraception
Indeed considering all the components of ante contributes another 20 per cent.26
natal care (ANC), the NFHS-2 notes that ‘for
India as a whole, mothers of only 20 per cent Clearly then, given this realisation, policy
of births received all the components of initiatives relying on incentives and
Antenatal care’ (ibid.: 305). It is not surprising disincentives are unnecessary, if not absurd.
too that communicable diseases and anaemia However what is also ignored is the larger
continue to be predominant causes of context that frames both health and
maternal deaths. population policy.
So overwhelming has been the influence of Macroeconomic Reforms and

targets in the programme that pursuit of Determinants of Health and Population
sterilisation goals to the neglect of health A question infrequently asked is what have
occurs even today despite an apparent official the macro-economic reforms of the nineties
commitment to a target-free approach. Thus meant for the critical determinants of health?
women and children, and indeed men, are How do these in turn impinge on demographic
denied essential health care even as the Public determinants?
Health Care (PHC) system is geared towards
meeting family planning targets.24 Indeed While the evidence is often said to be
even abortion services are not accessed by ambiguous, there is a substantial body of
women seeking them primarily because they evidence that suggests that reforms have
are tied to family planning, sterilisation in meant a deceleration of employment in both
particular. 25 rural and urban areas 27 , a significant
casualisation of the work-force, especially
Thus the entire PHC system has been involving the female labour force28, and a
suborned for family planning, distorting its sharpening of income inequalities with a
22
Qadeer, Imrana (1998), “Reproductive Health: A Public Health Perspective”, Economic and Political Weekly, Vol.XXX,
No41.
23
IIPS (2000), National Family Health Survey 1998-99, Mumbai.
24
Menon, Shreelatha (2004), “The State of the Art Cycle Pumps”, in Mohan Rao (Ed), Reproductive Health and
Women’s Lives in India, Kali for Women, New Delhi (forthcoming).
25
van Hollen, Cecilia (2004), Birth on the Threshold, Kali for Women, New Delhi (forthcoming).
26
Government of India, Planning Commission (Undated), Ninth Five Year Plan 1997-2002, New Delhi.
27
Sen, Abhijit (2002), “Agriculture, Employment and Poverty: Recent Trends in Rural India”, paper presented at the
International Conference on Agrarian Reforms and Rural Development in Less Developed Countries, Kolkota. See also
Radhakrishna, R.(2002), “Agricultural Growth, Employment and Poverty: A Policy Perspective”, Economic and Political
Weekly, Vol.XXXVII, No.3, 19th January.
28
Unni, Jeemol (2001), “Gender and Informality in Labour Market in South Asia”, Economic and Political Weekly,
Vol.XXXVI, No.26.

Mohan Rao
contraction of incomes in the lower deciles of As compared to a buffer stock norm of 17

the population. 29 Thus the Economic million tonnes of food grain, India sits on a
Survey,2001-200230 notes that in the period shameful and growing stock of 58 million
1978 to 1983, the rate of growth of population tonnes. This indeed attests to the “success”
was 2.19 per cent per annum while the rate of the reforms, the deflationary measures have
of growth of employment kept close at 2.17 indeed reduced incomes among the mass of
per cent per annum. Between 1983 to 1988, the population, and thus led to increasing
the rate of growth of population came down amounts of unsold food stocks, both due to
to 2.14 per cent per annum, while the rate of increasing unemployment and decreasing real
growth of employment declined to 1.54 per wages The Economic Survey 2001-2002
cent. Between 1988 and 1993, while the rate admits that increases in procurement prices
of growth of population maintained a decline, have meant that market prices have at times
to 2.10 per cent per annum, employment been lower than the rates being offered at the
generation increased to 2.43 per cent per public distribution system (PDS), leading to a
annum. Between 1993 and 2000, while the low off-take. For the below poverty line (BPL)
rate of growth of population came down category, there has been a 61.4 per cent
further to 1.93 per cent per annum, increase in the issue price of wheat and rice.
employment generation declined to the At the same time, an estimated 350 million
abysmal level of 0.98 per cent per annum. people are unable to meet their minimal
While public sector employment grew at 1.52 calorie requirements. The NFHS reveals that
per cent per annum between 1983-94, it more than a third (36 per cent) of women in
showed a negative growth of –0.03 per cent India had a BMI below 18.5, indicating an
between 1994-2000. Between 1991 and 2000, extraordinarily high prevalence of hunger, and
the growth rate in the organised private sector 52 per cent of women were anaemic. Almost
declined from 1.24 per cent per annum to 0.97 half the children under 3 years of age (47 per
per cent per annum. The Economic Survey cent) were underweight, and a similar
also notes ‘ a declining trend in the importance percentage (46 per cent), were stunted. The
of self-employed category in both rural and proportion of children severely
urban areas and an overall increase in the undernourished was 18 per cent according
casualisation of the women work force from to weight for age and 23 per cent according
31.4 per cent in 1972-73 to 40.9 per cent in to height for age. Wasting affected 16 per cent
1997’. 31 An NCAER study 32 concluded of children in this age group.33
‘feminisation of wage labour is a reality across
a large number of states…and is indicative of Further, health expenditure has shown a
a bias against women’. Even in the so-called secular decline as a percentage of government
developed states, the employment budgets, particularly marked in the
opportunities available to women are primarily programmes for the control of communicable
in manual wage labour. Indeed this study also diseases, while, as we noted earlier, that for
notes an increasing participation of female family planning has shown a continuing
children in wage labour. increase. At the same time, the state has
29
Dev, S.Mahendra (2001), “Economic Reforms, Poverty, Income Distribution and Employment”, Economic and
Political Weekly, Vol.XXXVI, No.26.
30
Government of India (2002), Ministry of Finance, Economic Survey 2001-2002, New Delhi.
31
Ibid, p.246.
32
Shariff, Abusaleh (1999), India Human Development Report: A Profile of Indian States in the 1990s, Oxford
University Press, New Delhi.
33
International Institute for Population Sciences (2000), National Family Health Survey (NFHS-2), 1998-99, India,
Mumbai.

provided impetus to the growth of the private Not unrelated to the above features of the
sector in health care through a range of current scenario, a deeply disturbing
subsidies and schemes. The collapse of the phenomenon is the masculinisation of sex
public health system, a system without which ratios at birth and of juvenile sex ratios. Over
of course the RCH approach cannot be the twentieth century the decline of the sex
implemented, has meant that increasing ratio in the country has been secular and fairly
numbers of the poor are thrown at the door monotonous. The 2001 Census however
of the private medical care sector. Central indicated a happy improvement in the overall
Statistical Organisation (CSO) consumption survival of females as the sex ratio increased
estimates 2001-02 reveal that private from 927 to 933. This was however
consumption expenditure is Rupees 956 per accompanied by a decline in the sex ratio in
capita34, of which 85 per cent of this is out-of- the 0-6 years from 945 to 927 between 1991
pocket. (Rupees 812) While there is gender and 2001. The decline was steeper in the
parity at lower levels of expenditure, higher classical region of the north and west referred
levels of expenditure are associated with to by Oldenberg as the Bermuda triangle for
marked gender disparities. Higher levels of missing females.38 What is more alarming is
gender differentials in health expenditure are that this decline in CSR is spreading beyond
also evident in the 0-4 year age group. this region and to communities hitherto
Although the richer classes spend more in considered immune. Indeed the
absolute terms, they spend an insignificant masculinisation of CSR has been particularly
amount in relation to their household precipitate among the SC population. 39
incomes. The poorest spend substantially Accompanying this has been a marked
more proportionate to their incomes. It is thus masculinisation of the sex ratio at birth (SRB).
not surprising that even as health care A norm of 105 male births to 100 female births
becomes more inaccessible, expenditure on was arrived at in 1958. SRS based estimates
health care is emerging as the leading cause of the SRB in 1998 shows an all-India figure
of indebtedness.35 At the same time, reports of 111 males per 100 females, indicative of
of starvation deaths and outbreaks of female Sex Selective Abortions (SSA).40
epidemics have started pouring in.36
A large number of explanations have been
The NCAER study therefore concludes, ‘Cuts proffered for the devaluation of female lives.
in public expenditure as a result of structural These range from marriage and kinship
adjustment and privatisation of health care patterns, to female work participation rates
will adversely affect the poor and vulnerable’.37 in wheat and rice cultivation, to laws
The conclusion then is inescapable: that governing inheritance of property and so on.
reforms which bypass vast sections of the Evidence of this was evident as early as the
population cannot but retard demographic 1961 Census as revealed by Krishnaji,
transition. revealing a significant relationship between
34
EPW Research Foundation. National Accounts Statistics of India. 1950-51 to 2000-01.Fourth Edition ( 2002)
35
Krishnan, T.N. (1999), “Access to Health and the Burden of Treatment: An Inter-State Comparison”, in Mohan
Rao (Ed), Disinvesting in Health: The World Bank Prescriptions for Health, Sage, New Delhi.
36
Baru, Rama V. and Sadhana, G. (2000), “Resurgence of Communicable Diseases; Gastroenteritis Epidemics in
Andhra Pradesh”, Economic and Political Weekly, Vol.XXXV, No.40.
37
.Shariff (1999), op cit.p.148.
38
Oldenberg, P. (1992), “Sex Ratio, Son Preference and Violence in India”, Economic and Political Weekly, Vol.XXVII,
No. 49.
39
Agnihotri, S.B. (2000), Sex Ratio Patterns in the Indian Population: A Fresh Exploration, Sage, New Delhi.
40
Premi, M.K.,(2001), “ The Missing Girl Child”, Economic and Political Weekly, Vol.XXXVI, No.21.

Mohan Rao
landholding and negative sex ratios.41 Harris We are thus poised at a critical turning point
White42, Judith Heyer43 and Alice Clark44 have where population policy is concerned. On the
all drawn attention to the imbrication of one hand, that there are critical gaps in the
Brahminical marriage patterns among other health sector is accepted. There is also
castes, the interlocking of class and social increasing realisation that without
mobility and the spread of dowry. I would comprehensive primary health care, without
suggest that along with the spread of Hindutva linking health with overall development,
ideologies, state policies are also actively without reinstating the state’s commitment
contributing to the reinforcement of to health of the people, health improvements
are bound to be chimerical. Precisely due to
traditional anti-female ideologies and in
the political unwillingness to translate this
engendering masculinity. It is also now
realisation into policies we see on the other
abundantly clear that given the ideology of
hand efforts to move towards more
son-preference in India, particularly marked authoritarian approaches to achieve
in the high fertility areas of the country, a demographical goals, betraying the
vigorous pursuit of the two- child norm is commitments made at the International
today an invitation to sex-selective female Conference on Population and Development
abortion. and in the National Population Policy.
41
Krishnaji, N. (2000), “Trends in Sex Ratio: A Review”, Economic and Political Weekly, Vol.XXXV, No.14.
42
Harris-White, Barbara et al (1996), “Development, Property and Deteriorating Life Chance for Girls in India: A
Preliminary Discussion with Special Reference to Tamil Nadu”, paper presented at the Silver Jubilee Seminar,
MIDS, Chennai.
43
Heyer, Judith (1992), “The Role of Dowries and Daughters’ Marriages in the Accumulation and Distribution of
Capital in a South Indian Community”, Journal of International Development, Vol.4, No.4.
6
Clark, Alice W.,(1987), “Social Demography of Excess female Mortality in India”, Economic and Political Weekly,
Vol.XXII, No.17.

Mental Health in India: Review of Current Trends and
Directions for Future
Aparna Joshi
WHO (1946) defines health as a state of eco-political-cultural factors play an

complete physical, mental and social well- important role in determining an individual’s
being and not merely the absence of disease mental health.
or infirmity. Yet emotional and mental health
aspects of the definition have not received The scope and importance of mental health
much prominence over the years. Inspite of has been very simply yet precisely delineated
heavy social and economic costs incurred by by one of the earliest Indian Psychiatrist,
mental illnesses and suffering, mental health Govindswamy in 1948.”The field of mental
continues to be a neglected issue by policy health in India has three objectives. One of
makers in India. these has to do with mentally ill persons. For
them the objective is the restoration of health.
WHO defines mental health as (1981), “mental The second has to do with these people, who
health is the capacity of the individual, the are mentally healthy but who may become ill if
group and the environment to interact with one they are not protected from conditions that are
another in ways that promote subjective well- conducive to mental illness, which however are
being, the optimal development and use of not the same for every individual. The third
mental abilities (cognitive, affective and objective has to do with the promotion of mental
relational), the achievement of individual and health with normal persons, quite apart from
collective goals consistent with justice, and the any question of disease or infirmity. This is
attainment and preservation of conditions of positive mental health. It consists in the
fundamental equality” protection and development of all levels of
human society, of secure, affectionate and
This definition not only keeps the individual satisfying human relationships and in the
at the center but also goes beyond in reduction of hostile tensions in the community”.1
connecting it with the larger social context. It
also goes beyond a reductionist biological History of Mental Health Care in India
model of mental health. While acknowledging The field of mental health in India has
the role of social context, it highlights the undergone many changes after independence.
importance of justice and equality framework Until independence, the traditional approach
and it’s impact on an individual’s mental towards the mentally ill had been custodial
health. This definition has another advantage rather than therapeutic. This is reflected in
in going beyond the illness focus and therefore the report of the Indian Medical Review (1938),
incorporating positive aspects of mental which mentions presence of 17 mental
health. hospitals in British India as an exclusive
approach to mental health care 2 . The
The definition bears special relevance to dominant force in mental health development
Indian context given the scarcity of resources after independence has been the policies
and poor living conditions, where social and relating to primary health care. For example
1
Murthy R. S., 2000. Development of Mental Health Care in India 1947-1995, New Delhi, Voluntary Health
Association Of India
2
Ibid

Mental Health in India: Review of Current Trends and Directions for Future
Bhore Committee Report (1946) was one of " Mental and behavioral disorders affect
the first revolutionary alternative to the more that 25% of people at any given
existing health system in the country. time. This means 450 million people
worldwide are affected by mental
The focus gradually shifted from neurological or behavioral problems at
institutionalization to setting up mental any given time.
health services within the community. Yet it " 1 in every 4 families has 1 member
took about three decades for the integration with mental illness.
of mental health in primary care and setting " 1 in every 100 suffers from a severe
up of general hospital psychiatric units mental disorder, which would
(GHPUs) and district mental health constitute about 10 million citizens of
programmes. Training General Practitioners India.
was another strategy adopted in " Up to 20-40% attending primary
decentralizing mental health services. The health care services or general health
National Mental Health Programme (1982) care settings, suffer from Common
was the outcome of developments of providing Mental Disorders (CMDs)3
mental health care through the various
methods mentioned above. The programme It’s therefore not difficult to imagine the
aimed at ensuring availability and enormous social and economic burden and
accessibility of minimum mental health care human suffering caused by mental illnesses.
for all and also promoting community
participation in mental health services as two Mental Health Service Scenario in India
important objectives besides many others. Despite the fact that mental health problems
are so common and contribute to the global
The voluntary sector has also played a crucial burden of disease and disability, the disparity
role in demonstrating quality and community between mental health needs of a population
approach to mental health services as well as and available services remains too huge.
in bringing rights discourse to the current
mental health scenario. In a seminal article Dr. R.S. Murthy states,
that the number of qualified psychiatrists
Magnitude of Mental Health Problems working both in the government and private
Some of the studies done in the area of practice settings is estimated to be about
magnitude of mental health problems and 2,000 in 19974. However the number of other
disability caused due to the same reveal the mental health professionals like clinical
following: psychologists (500), psychiatric social workers
" Mental & Behavioral disorders (MBDs) (300) and psychiatric nurses (600) remains
account for 12% of the global burden to be the same as the figures quoted by the
of diseases. National Mental Health Programme, 1982. The
" Unipolar depression to be the second recent Atlas project of the WHO reports that
leading cause of global burden of all countries in the South-East Asian region
disability by 2020. and nearly all countries in Africa have less
" 87,300 suicide deaths every year than one psychiatrist for 1,00,000 population.
worldwide. The population of India now exceeding 1
3
Women’s Mental Health – Evidence Based Review, 2000. Desjarlis R et. al. 1995.World Mental Health – Problems
and Priorities in Low Income Countries, New York, Oxford University Press. Patel V, 2003. Common Mental
Disorders in General Health Care: Evidence for policy, practice and research in India. The Sangath Society, Goa.
www.disabilityindia.org
4
Murthy R. S., 2000. op.cit.

Aparna Joshi
billion people has access to less than 4,000 Despite the growth of private psychiatric
psychiatrists as compared to the nearly institutions, the core of residential care for
80,000 psychiatrists for 840 million in patients with serious mental illnesses, have
Europe5. A recent mental health survey report been government-run mental hospitals. Apart
conducted by WHO states that in India there from the labels and the stigma attached, more
is allocation of only 0.25 beds for psychiatric serious attention needs to be drawn to the
disorders per 10,000 citizens. The report also functioning of the hospitals and the gross
suggests that more than 680 million people, atrocities against the mentally ill even after
the majority of whom are in Africa and Asia, several public interest litigations and Supreme
have access to less than one psychiatrist per Court initiatives, as well as media exposure.
million6. According to the data of the National These have exposed the gross neglect and
Human Rights Commission, there are about exploitation of the mentally ill in the
3,500 psychiatrists, 1,000 psychiatric social institutional settings. “Quality Assurance in
workers, 1,000 clinical psychologists and 900 Mental Health”, a project undertaken in 1997
psychiatric nurses in the country7. and published in 1999 by NHRC highlights
many of these violations. “38% of the hospitals
One of the reflections of lack of adequate still retain the jail like structure that they had
human resources and lack of access to basic at the time of inception… 57% have high walls…
mental health care services can be seen in
Overcrowding in large hospitals was evident…
the budgetary allocations to the field of mental
The overall ration of cots: patient is 1:1.4
health. Mental health budgets of majority of
indicating that floor beds are a common
the countries constitutes less than one
occurrence in many hospitals. Many hospitals
percent of their total health expenditure, India
have problems with running water… Water
being no exception to this rule. A budgetary
storage facilities are poor in 70% of hospitals…
allocation of Rs. 28 crores had been made
89% had closed wards, while 51% has
during the ninth five-year plan period for the
National Mental Health Programme. Though exclusively closed wards… Leaking roofs,
there is now a proposed allotment of Rs. 220 overflowing toilets, eroded floors, broken doors
crores for the mental health sector during the and windows are a common site… Only 14%
tenth five-year plan, the meager budgetary of the staff felt their hospital in-patient facilities
allocations mentioned above show low was adequate. Less than half of the hospitals
prioritization accorded to the mental health have clinical psychologists and psychiatric
sector7. social workers… trained psychiatric nurses
were present in less than 25% of the hospitals…
The disparity between needs and services Even routine blood and urine examination
becomes even more glaring, when one looks facilities were not available in more than 20%
at the nature and the range of existing state- of the hospitals… Only about 36% of mental
run mental health services. The most eye- hospitals have a separate facility for vocational
opening example is the plight of government training… Only 4 provide day-care services.
mental hospitals/institutions in India. 8.33% of government psychiatric hospitals have
5
Patel V, Thara R. 2003. Meeting Mental Health Needs of Developing Countries – NGO Innovations in India. Sage
Publication, New Delhi.
6
Murthy RS, 2001. Letter to Editor – Lessons from the Erwadi Tragedy for Mental Health Care in India, Indian
Journal of Psychiatry, 2001, 43/4, Accessed from <http: //www.ijponline.org/oct 2001/indljp.letters.html> on
January 22, 2005
7
Kakade S. et.al. 2001. Mahajan Committee Report: A Bombay High Court Report on status of mental hospital
services in Maharashtra with recommendations for reform. Center for Advocacy in Mental Health, Pune

rehabilitation wards and half-way home only 8 out of the 12 providing Child Guidance
facilities are affordable only to the upper socio- Clinic (CGC) facilities, 2 providing deaddiction
economic groups”.8 facilities. Approximately 300 beds are
available in these 12 hospitals. Facilities for
This clearly brings out the state of institutionalization are available only at the
government-run mental health institutions regional mental hospital, Thane.
and overall mental health service scenario in
India. The range of services provided by the
Voluntary sector includes 2 half-way homes,
Urban Mental Health Scenario – A Case 5 day-care centers, 5 support groups, 6 help
Study of the City of Mumbai lines, 8 deaddiction centers and a few child
Mumbai is a prototypical example to urban guidance clinics.
mental health issues. The fast city life,
modernization, overcrowding and poor Mental health training opportunities in
conditions, rising crime and violence and Mumbai constitute of Teaching Hospitals at
insecurities resulting out of the same, the municipal level offering courses in
diminishing support systems are some of the Psychiatry, Mumbai University & SNDT
many stressors experienced by people in offering courses in clinical psychology at post-
Mumbai. graduate level, Tata institute of social sciences
offering courses in psychiatric social work and
Organized government sector in Mumbai courses for psychiatric nursing being offered
caters to a large population and consists of by SNDT and other teaching hospitals9.
government and municipal corporation
hospitals. Every year, this sector caters to The figures mentioned above bring out
approximately 33 - 40,000 newly diagnosed scarcity of mental health training and service
mentally ill patients and the follow-up consists options in a metro city like Mumbai. Existing
of 1.8 - 2 lakh patients having common mental services are concentrated at the city level and
disorders. Private sector consisting of may leave out many, who live in suburbs.
practicing psychiatrists, charitable trusts and Access and affordability to psychosocial
private hospitals, serve three times more the services seems to be still beyond reach for
patients seen in the organized public sector. most.
The number of Psychiatrists in teaching
hospitals is 60 and another 160-90 in private Gaps in the Existing Mental Health
practice. The number of psychiatric social Service System
workers is 20 in public hospitals and 40 in Biomedical Bias
different NGOs. Clinical Psychologists on the The existing services display a biomedical
other hand are 700 in number, out of which bias, resulting in drug prescription as the first
100 are in an organized academic sector. Out and many a time the last service option being
of the rest only 40% are actively working in provided. The biomedical bias neglects the role
the field of mental health. of social determinants in the etiology and
outcome of mental illness and distress. To
There are 12 municipal and government clarify this further we can take example of a
hospitals providing mental health services in woman facing violence at home. When such a
Mumbai. The range of services available in woman approaches the mental health care
these government hospitals are Out-patient system for somatic symptoms or trauma
and In-patient facilities, referral services with caused by violence, she is often given a
8
Kakade S. et.al. 2001. Mahajan Committee Report: A Bombay High Court Report on status of mental hospital
services in Maharashtra with recommendations for reform. Center for Advocacy in Mental Health, Pune
9
34thAnnual Conference of the Indian Psychiatric Society, western zonal branch (ACIPS-WZB), Mumbai. 2003.

Aparna Joshi
psychiatric diagnosis and prescribed drugs pronounced effects on users of mental health
for. The context of violence is never touched services. This is because psychotropic drugs
upon. Naturally a mere prescription approach are prescribed for a longer duration (often even
is bound to fail in such a case. a lifetime) as compared to drugs for physical
disorders. This really keeps economically
Availability and Accessibility vulnerable sections of the society deprived of
The National Mental Health Programme, 1987, mental health services or result in poor drug
hopes to serve various objectives. Ensuring compliance.
availability and accessibility of minimum These medicines are also known to have
mental health care for all, particularly to the severe disabling side effects, which are never
most vulnerable and underprivileged explained to the client or the caregivers, nor
sections of population, is the first and the is information about diagnosis and treatment
foremost of the list. Besides this it also aims procedures shared with them.
at encouraging application of mental health
knowledge to general health care and Electro Convulsive Therapy
promoting community participation in the Though unmodified ECT, (ECT without
mental health service development. anesthesia), is an undesirable practice, it is
often followed by private practitioners and
However since National Mental Health state run facilities.
Programme is not followed in many states,
even the basic mental health services may not There is enough evidence which documents
be available to those who are in need of these the multiple side effects or complaints
services. following ECT. These could range from
headaches and nausea to irreversible memory
Unequal distribution of services is another loss. The recent APA Task Force on ECT, 2001
point of concern. Most available services, notes that mortality rates with ECT (modified
though medical in nature, are concentrated i.e. ECT with anesthesia) may be as high as 1
in metro cities or are available at district in 10,000 patients, whereas consumers quote
levels. Money and time involved in reaching it to be as high as 1 in 100.
these services may make them inaccessible
for many. The European CPT (Convention for the
Prevention of Torture) 2002 prohibits the use
Given this picture, availability of psychosocial of direct ECT as a form of torture10. Thus ECT
and rehabilitation services like counseling, without anesthesia is a human rights
halfway homes, de-addiction centers etc. violation.
remains a rarity.
The procedure of direct ECT has recently been
Mental Health Services for certain special placed as controversial and contested issue
interest groups such as wandering mentally before the Supreme Court, through a petition
ill, street children, prison inmates, women in filed by ‘Sarthak’, a mental Health NGO based
prostitution are virtually non-existent. in New Delhi11.
Psychotropic Drugs Even psychiatry textbooks clearly state that

Shortage or non-availability of medicines is a ECT should be used only under specific
perpetual difficulty faced by many government circumstances (e.g. catatonia, stupor, serious
run hospitals. This shortage has more suicidal ideation, treatment resistant cases,
10
Waikar et. al. 2003. ECT without anesthesia is unethical. Issues in Medical Ethics, Vol. XI, No.2, April-June,
2003.
11
Waikar et. al. 2003. Electro convulsive Therapy: therapy or torture? Health Action, November, 2003.

etc.) However what we often see in practice is involved; the quality of person’s social
ECT being used as the first choice of treatment environment influences both vulnerability of
by many private practitioners. One ECT may mental illness and the course and outcome
cost anywhere between Rs. 500/- to Rs. 1000/. of that illness.
The financial gains in administering ECT
(which is usually administered in a set of six Mental disorders are not simply symptoms of
ECTs per patient) are pretty obvious from this. broader social conditions, nevertheless,
poverty, lack of security, violence, lack of
ECT is also used to control and manage healthy family relationships during childhood
patients in many state- run homes, even when and trauma or significant losses are crucial
it’s not required. Both the patients and the factors for mental illness12. Similarly gender
caretakers are not informed or taken consent is another critical determinant of mental
about the procedures. Modified ECT requires health. Mental health definition by World
availability of emergency medical services, Health Organisation strongly brings out the
which are absent in most cases. role of psychosocial factors in mental health.
Thus strict guidelines need to be established Research literature on common mental

for when and how ECT should be disorders (depression, phobic disorders,
administered. generalized anxiety disorders, adjustment
disorders etc) from South Asia convincingly
Quality of Care demonstrate the high prevalence of common
Lack of consent, denial of right to information, mental disorders and the strong associations
abuse (emotional and at times sexual) at the with female gender, poverty and low education
hands of mental health professionals, gender and with disability13.
insensitivity are some other issues regarding
quality of mental health services offered. This overwhelming fact, points out to the need
for developing holistic understanding of
The death of 26 persons with mental illness mental health. A holistic understanding would
killed in the tragic fire accident on 6th August not be illness-centric. It will concentrate on
2001, at Erwadi, focuses on the need for the individual factors, but at the same time
improving quality of mental health care. The consider the social, economical, political
NHRC data cited in earlier sections of this context in which individuals live.
report also substantiates this fact.
The current understanding and
To summarize, the existing mental Health implementation of mental health programs
Care System has inadequacies and limitations seems to be focused on curative aspects. This
both quantitatively and qualitatively. would invariably result in preoccupation with
illness and symptoms and may neglect the
Alternative Paradigms in Mental Health vital concept of well-being. A holistic
The current understanding of mental health understanding on the other hand, would
and mental illness is predominantly require, inclusion of both preventive and
biomedical in nature. This is in spite of the promotive aspects.
fact that current research provides strong
evidence for bio-psychosocial nature of mental We need to develop multi pronged solutions
disorders. Whatever physiological processes to deal with mental health issues. This first
12
Desjarlis R et. al. 1995.World Mental Health – Problems and Priorities in Low Income Countries, New York,
Oxford University Press.
13
Patel V, 2003. Common Mental Disorders in General Health Care: Evidence for policy, practice and research in
India. The Sangath Society, Goa.

Aparna Joshi
includes availing a range of services, such as, the functioning of mental hospitals in the
awareness creation, counseling, work with country. This law views mental illness as a
families, support groups, day-care centers, ‘Law and Order’ problem. Therefore the
halfway homes, de-addiction centers, child procedure of involuntary commitment is
guidance clinics, crisis centers for women required to be activated in order to protect
victims of violence and a host of other society from the disruptive & dangerous
supportive services such as shelters, manifestations of mental illness. Mental
vocational training centers, employment hospitals are, thus required to function as
bureaus etc. custodial houses and not treatment centers14.
The way mentally ill is defined in the Act is
Secondly it would require widening our too vague and stigmatizing.
understanding of who the mental health
service providers should be & creating a new As compared to this Mental Health Act, of
cadre of them. Role of other mental health 1987 is a more progressive legislation. The
professionals such as psychologists, social way it defines mental illness is less
workers, counselors etc. needs to be clearly stigmatizing. The act primarily talks about
articulated. admission and discharge procedures to
mental or psychiatric hospitals, along with
All this requires a shift from a specialist- licensing procedures. The act places the
oriented model. Generating newer training responsibility for planning and monitoring
options and fostering a true multidisciplinary mental health functions on the state and
spirit, become prerequisites in such a case. details out structures to carry the same.
This would truly help us in moving away from
a hospital-based model to community-based It has a section on protection of human rights
alternatives. of mentally ill persons. This section helps to
prevent any kind of abuse or exploitation
In addition to all this we must utilize culturally during treatment period and ensure dignified
relevant support systems such as families, status to mentally ill people while accessing
neighborhood, community groups etc as mental health services. It also has a provision
healing spaces. Traditional & indigenous of Legal Aid for mentally ill people having
healing practices need to be explored and insufficient Legal representation and who are
researched further. These practices are in need of the same.
already being utilized by a large number of
people in our country. They are also close to Unfortunately not all states have formed the
explanatory models and cultural experiences state level Mental Health Authority and
of people. The western-medical model of initiated the process of planning of state
mental health discards all these practices as mental health services, licensing of the
unscientific and exploitative. The author is hospitals and related matters.
aware of certain oppressive and exploitative
elements in such practices, especially for Besides this the Mental Health Act has certain
certain vulnerable sections (e.g. women and limitations.
children). However, further research is 1. It is still custodial in nature.
required in this area, which will help us know 2. It remains silent on matters pertaining to
the efficacy of such practices and strengthen care, treatment and rehabilitation.
the therapeutic value offered by them. 3. There is no provision, which requires that
commitments to a psychiatric hospital
Mental Health Law should be ordered only if less restrictive
The Indian Lunacy Act of 1912(ILA) regulates alternatives are inappropriate14.
14
Dhanda A, 1993. Mental Health Law and Policy: Need for Co-operation. Mental Health in India – Issues and
Concerns, Mane P & Gandevia, K (eds), Mumbai, Tata Institute Of Social Sciences.

4. The role of psychiatrists and general " Need to constitute ethical guidelines for
practitioners in certification and admission best practices in mental health
procedures is detailed out. However, the role including ECT use
of the other mental health professionals such " Need to go beyond the existing bio-
as clinical psychologist, psychiatric social medical model in context of MH
workers and psychiatric nurses receives no services.
mention. This cleanly brings out low " Need for a shift from a hospital-based
prioritization accorded to psychosocial model to a community-based model of
management in treatment of mental disorders. mental health
" Need to pay attention to and devise
These limitations highlight the fact that, strategies for addressing common
though non-implementation of Act is an issue mental disorders as the current policy
of concern, the Act itself requires being re- prioritizes the severe and chronic
looked at. illnesses and neglects common mental
disorders
Another recent statute of importance to " Need to highlight and implement
mental health field is PDA. The Persons with preventive and promotive strategies as
Disabilities –Equal Opportunity, Full part of mental health programme
participation and protection of Rights Act of " Alternative paradigms in mental health
1995.The act includes mental illness as a need to be explored, researched and
disability besides other physical disabilities. utilized for effective service provision
As the name suggests, it gives equal " Need to ensure
opportunities to disabled people, protects " increased participation of different
their rights and ensures full participation in stakeholders in service planning
the society. It also creates opportunities and " Need to devise and implement relevant
statutory obligation for social justice to the mental health training mechanisms
disabled persons included15. and include mental health in existing
medical curricula
Though inclusion of mental disability in the
" Need to ensure equal opportunities for
Act has come under a lot of controversy, the
mentally disabled persons in areas of
act, if implemented will go a long way in
welfare and livelihood
ensuring mentally disabled their due rights.
" Need to pay special attention to
advocacy and rights-based agenda in
Recommendations for a Comprehensive mental health
Mental Health Policy And Service " A dire need for progressive mental
" Need for increase in budgetary health legislation
allocations for mental health. " Mental health being also a
" Need to increase the number of mental developmental issue, there is a need
health services available. to design welfare and economic
" Need for inclusion of psychosocial
policies, which will promote overall
services for improvement in the range
mental health.
and quality of available mental health
services
All this points towards the need for a
" Immediate need to improve the comprehensive National Mental Health
conditions of state-run mental Policy.
hospitals
15
Banarjee G, 2001. The Concept of Disability and Mental Illness. Mental Health Reviews, Accessed from <http: /
/www.psyplexus.com/excl/cdmi.html> on January 22, 2005.

SECTION 3
HEALTH CARE ISSUES RELATED TO
WOMEN AND CHILDREN
The State of Preventive Health and
Nutritional Services for Children
Vandana Prasad
Introduction routed through the general health care tier of

Children (0-14 yrs) comprising 30 per cent of subcentres, community health centres,
our population form a large group which is primary health centres (PHCs) and secondary
both specially vulnerable and beleaguered by and tertiary care government hospitals.
a host of public health problems. Child health Nevertheless, some special structures for care,
is also special, in that, like the health of the including health care, have been in existence
pregnant woman and foetus, it is most for many years. The most notable of these is
amenable to preventative action. Public health the Integrated Child Development Services
strategies have taken cognisance of this fact Scheme (ICDS). Others include crèches for
through the ages and provided a special and working and ailing mothers, the school health
significant focus on ‘maternal and child health service and the school 1 Midday Meal
(MCH)’. Programme (MDMP). Newer structures have
been envisaged/created to deal with
This has been reflected in our country by ‘disability’ and mental health problems.
programmes that have gone under various
names in the last decade – MCH, CSSM1 and Of these structures, those providing general
reproductive and child health (RCH), as well care like the ICDS and the crèche scheme,
as strategies such as GOBI2, IMCI etc. (some have a dual role to play in child health. Firstly,
of these have been dealt with in the following an important preventative one which makes
sections). it imperative to study their outreach and
universality, and secondly as a vehicle for
The health services rendered or envisaged by specific health services such as immunisation,
these programmes have largely been those of supplementary feeding, health checks and
immunisation and supplementary feeding. To referral. How they perform in both these areas
some extent, they have also tried to tackle requires evaluation and analysis.
breast-feeding issues and the management of
common and fatal diseases like diarrhoea and Government schemes and strategies have also
pneumonia. made a shift to recognise and ‘use’ so called
public-private partnerships to move their
However, the best of strategies may only be maternal and child health strategies. This has
as good as the systems that exist for their been most visible in the reproductive and child
delivery. This appears to be the crux of the health (RCH) programme which has involved
problem in actually being able to show a NGOs in a large way for training and
significant impact upon the indicators of child facilitation as well as delivery of services.
morbidity and mortality which have only
shown very slow improvement through the NGOs have also devised their own parallel
decades. strategies and programmes for child health
with the help of a range of funding agencies
Much of the delivery mechanism has been sometimes carrying target specific agenda like
1
Child survival and safe motherhood
2
A UNICEF package for growth monitoring, oral rehydration therapy, breast feeding and immunisation

The State of Preventive Health and Nutritional Services for Children
AIDS. However, the scale of these programmes and services)

remains small.
Box 1: Package of Services of the ICDS
Simultaneously, a huge chaotic burgeoning Programme
of private practice at various levels also
impacts child health, often in complete Package of Services of the ICDS
disjunction with public health strategies. Programme
1. Supplementary nutrition ( SNP)
This section will attempt to look at the data 2. Immunisation
that exists for the State systems of health care 3. Health check ups
specifically related to children and try to 4. Treatment of common diseases like
analyse the strengths and weaknesses that diarrhoea, dysentery, respiratory
exist within them and contribute to the infection, skin and eye diseases
efficacy or lack of it. The bulk of the focus will 5. Deworming
be on to ICDS as the largest scheme soaking 6. Referral services
up most of the budget for child care with the 7. Nutrition and health education
greatest potential for an impact on health. 8. Growth monitoring and promotion
9. Vitamin A and IFA supplementation
General health care services, immunisation 10.Pre school non formal education
and RCH have been dealt with in the following (Most of the services pertain to health and
sections. Documentation of the role of child nutrition)
health services given by NGOs is patchy and
does not provide much data. However, the Target Population
general approach, strategies and health 1. Children under 6 yrs
services may be discussed very briefly by 2. Adolescent girls 11-15 yrs in select
example. areas
3. Women in age group 15-45 yrs
The private systems of health care form the
lion’s share of curative care being accessed About 50 per cent of the population!
by even the poorest people in India for their
children. However, little genuine data exists However, as with many well-conceptualised
about its impact on child health. Clearly more schemes, this one also fell far short of its
research is required in this area, but this facet objectives due to gross inattention to setting
may have to remain outside the scope of this up implementation capacities within the
paper. scheme. It was as though having articulated
a good intention, there was no real will to have
it translated into action. To clarify, 150 million
Health and Nutritional Services for the odd children in this critical age group (157.9
Under Sixes million as per Census 2001) were to be
The Integrated Child Development Services covered by a scheme that considered this an
Scheme essential service that was supposed to link
This scheme has been in existence since 1975 up both to formal systems of health and
to serve the comprehensive needs of children education and informal or ‘voluntary’ effort,
under the age of six. Conceptually progressive yet was kept short on both funds and
for its time at the point of inception, it was personnel, making it virtually impossible to
envisaged as the vehicle for preventative achieve its targets. The entire task of looking
health services as well as pre school education after the young children of a population of
or Early Childhood Care and Education 1000 both at the centre and within homes in
(ECCE)/Development. (see box for objectives the community was to be undertaken by a

Vandana Prasad
single poor, poorly trained and very poorly " The other main body of recent work on
remunerated ‘honorary’ worker aided by an the ICDS has been developed by the
even worse off ‘helper’. (It may be noted that NCAER which conducted first a Pilot
with effect from April 2002 the honoraria of Study and then a nation-wide
workers and helpers has been increased from Concurrent Study on the ICDS from
rupees 500 to 1000 and 250 to 480 rupees 1996 onwards, reported in June 2001.3
and they have also been authorised maternity The concurrent evaluation is a large and
leave for 135 days.) comprehensive study covering 60,000
AWCs and 1.8 lakh beneficiaries from
The team with their meagre resources and 4000 operational blocks. (These will be
lack of infrastructure (sometimes not even a referred to as ‘the Pilot Study,’ and ‘the
roof or room and often within the living NCAER Study’ respectively.) Though the
quarters of the worker) was meant to study paints an overall satisfactory
comprehensively look after the needs of India’s picture of the functioning of the ICDS,
malnourished and poverty stricken children some glaring facts are apparent between
and achieve goals that would translate to the lines. The pilot study itself expresses
statistics of better growth and lower mortality. the apprehension that centres may be
One wonders how much could have been forewarned to present a picture that
achieved if the scheme had been formulated exceeds reality and that is how it appears
with a serious intention all those years ago when stark differences are apparent
as a formal service with formal ‘workers’, between ‘the study’ and experience cited
proper infrastructure and facilities and on the ground. Some of these differences
adequate budgets. and findings will be presented.
Now, over 25 years down the line, the lack of The main issues of health care services within
achievement in the main indices of child the ICDS may be stated as
health and nutrition with all their impact on 1. Outreach and universality of coverage
education and educatability, population " In terms of geography
stabilisation and general morbidity of the " In terms of age group
adolescent and adult population (specially 2. Access
female) are staring us in the face and costing " Caste and tribe issues
the national exchequer increasingly more " Geography
every year. 3. Infrastructure
4. Actual provision of health services
" The ICDS has been reviewed and through the ICDS system and
evaluated periodically by many agencies. convergence with other health care
The Comptroller and Auditor General systems
(CAG) of India came out with an annual 5. Nutritional services and Health
report for the year ended March 1999 education for Older Children
for submission to the President. The
Report of the Comptroller and Auditor Outreach and Universality of Coverage
General of India (Union Govt. – As per the Annual Report of the Department
Performance Appraisal – No. 3 of 2000) of Women and Child Development (2002-
reviewed amongst other schemes 2003) of the total number of 5652 blocks in
reviewed the mid day meal programme the country, (tribal 759, rural 4533 and urban
as well as the ICDS. Henceforth, this will 360), 4761 blocks are covered by ICDS
be referred to as ‘the CAG report’. Projects. Of these, 922 are being funded by
3
Distribution Of Severely Malnourished Children By Age, Pilot Study NCAER 2001

loans from the World Bank though 187 are to However, only half this number of those
become operational during 2003. registered were found to be present a week
before the survey. There was a significant male
Of the 4730 General ICDS Projects, 3873 are bias to child registration. This was more
currently operational. The remaining 857 pronounced as the age of the child increased
blocks are to be covered during the course of and girls were held back from the centre to
the Tenth Plan. (However it is worth noting assist at home.
that universalisation of the ICDS has been
on the cards since 1997) Access
In our experience, access, both in terms of
Currently, services are said to be provided to geography and social exclusion on the basis
33.2 million children under the age of 6 years of tribe and caste has been a long-standing
( 21 per cent of the under six population) of issue for the implementation of the ICDS.
which 17.65 million attend centres, and 6.2
million pregnant and lactating mothers However, according to the NCAER study, the
through 580 000 anganwadi centres. Yet, as average distance between anganwadi centres
per the norm of one anganwadi per 1000 (AWCs) and their beneficiaries is only 139.9
population there should be 1 million meters (the longest distance being about 500
anganwadis (about twice as many) meters) and average time taken to reach a
centre is 7.5 minutes. Previous studies had
However, the World Bank thinks otherwise.
pointed to about 80 per cent of AWCs being
Proposing a draft of measures for priority
within 3 kms, i.e. even the standard used was
action, it said that in the ICDS Programme,
of 3 kms. The NCAER study also reports that
the reach should be 6-24 month old children
discrimination on the basis of caste and tribe
as well as pregnant women, especially those
was negligible. Again, experience and micro
living in hamlets. It also recommended the
studies (for example PRAXIS-CARE India
freezing of further expansion until quality and
study on Underlying Causes of Poor RCH) in
impact are improved measurably and that
many States including Karnataka, UP,
meeting substantially higher standards in Jharkhand, Rajasthan, Chattisgarh, and
current programme areas was also necessary. Orissa tell a very different story of children
There are about 1.2 million anganwadi being segregated, made to sit outside etc.
workers and helpers and a staffing gap of Caste also plays a role in appointments to
46849 anganwadi workers. related posts. It is equally true that in many
places the anganwadi has been able to break
caste barriers when a motivated AWW ensures
Registration that there is no discrimination.
The NCAER study showed 65 per cent of
eligible children and 75 per cent of eligible Infrastructure
women to be registered. Of the eligible women The NCAER study found that most AWCs
registered, 62 per cent were enrolled for the functioned out of their own premises. 40 per
supplementary nutrition (SNP), 60 per cent cent were in pucca (permanent/cemented)
for ante natal care (ANC), 40 per cent had iron structures and 20 per cent were in kutcha
and folic acid tablets (IFA) and health checks, (temporary/mud and thatch) structures .13.8
27 per cent received tetanus toxoid injections per cent were functioning out of the house of
(TT) and 24 per cent were referred. Children the anganwadi worker (ANW) and 1.9 per cent
between 13 and 36 months had the highest were still functioning in open spaces, e.g.
level of enrolment and children between 37 under trees. This translates to about 1 lakh
months and 72 months the least. ‘kutcha’ anganwadis catering to about 80 lakh

Vandana Prasad
children and about 11,000 AWCs in the open However, the following figures are still quoted
catering to about 90,000 children. by the study on malnutrition Less than 25
per cent of the registered children suffered
Only 17 per cent had toilets and 49.2 per cent from undernutrition. Severe malnutrition was
had adequate cooking space. It is significant at less than 3 per cent and moderate
that 25 per cent of the AWCs did not have malnutrition at 11.3 per cent.
weighing scales!
In terms of age group, National institute of
Provision and Facilitation of Health Nutrition figures for rural areas show higher
Services through ICDS System figures: 6.4 % children in the pooled age group
Health Check Up and Referral Services of 1-3 and 3-5 show severe malnutrition.4
The NCAER study revealed a low rate of health
checks at 29.4 per cent of children and 43 It would be fair to question the veracity of
per cent of eligible women. 24 per cent of these figures on the basis of the information
pregnant and lactating women received above as well as micro studies that hint at
referral as well as 11 per cent of the enrolled underreporting through the ICDS, one
children. example of which is given below. NCAER’s own
pilot study shows large numbers of children
According to the CAG report: in the category of severe malnutrition but the
figures have not been presented in a way that
Box 2: Findings of the CAG Report percentages can be drawn since the total
regarding Health Checks number of children is not given! Figures for
female children having severe malnutrition
1. Base line surveys for identification were found to be much higher than for male
of beneficiaries were not done in children in the pilot study. These findings
most States. seem to be overturned in the larger concurrent
2. The range of shortfall in health evaluation.
checks was from 0 to 90 per cent of
that required. The following comparison was made between
3. In eight states no records or referral ICDS figures and assessments made by Gyan
cards were kept or available Vigyan Samiti, Uttar Pradesh in the
4. Reasons for non referral included anganwadi centre at Ranikheda, a district of
cost of transportation and medicine Bachhrawa.
These Figures reflect:
Growth Monitoring
1. Inadequate registration ( though it
As mentioned previously, 25 per cent of AWCs justsatisfies the norms of 80 children
did not even possess weighing scales. Only per AWC)
40 per cent of AWCs were maintaining growth 2. Over reporting of ‘normal’ children
charts. Reasons for not maintaining charts 3. Underreporting of Grade I and Grade
included lack of time and training. IV children
Table 1
Distribution Of Severely Malnourished Children By Age, Pilot Study NCAER 2001
Moderate Malnutrition Severe Malnutrition

6-12 mths 13-36mths 37-72mths 6-12mths 13-36mths 37-72mths
6.4% 7.7% 15.7% 1.3% 3.6% 1.4%
4
Diet and Nutritional Status of Rural Population. National Institute of Nutrition. Indian Council of Medical Research.

Table2
Distribution Of Severely Malnourished Children By Age and Sex Pilot Study NCAER
0-6 mths 6-12 mths 1-3 yrs 3-6 yrs

Male Female M F M F M F
2 67 13 127 38 293 31 224
Table 3
Comparison of ICDS figures\and GVSUP figures
Normal Grade I Grade II Grade III Grade IV

ICDS figures 36.255% 26.25% 25% 12.5.5 —-
80 children
0-6yrs
GVSUP figures 9.8% 55.3% 21.9% 11.36% 1.5%
132 children
0-6yrs
Thus, the important service of growth 26.7 per cent of eligible women received TT
monitoring through the ICDS to prevent injections.
malnutrition seems to be in dire straits.
Medicine Kits
Immunisation A provision of Rs. 300 per year per centre was
According to the CAG report: made available to state governments for
purchase of medicines for use by the ICDS!
Box 3: Findings of the CAG Report However, in 1984, it was decided that
regarding Immunization medicine kits be procured centrally. Since
there were poor systems for distribution,
1. In 15 states there was no medicine kits were not supplied in the years
identification of beneficiaries or 1992-95 and 1998-99. Even within this
monitoring of achievements measly budget, the following irregularities
regarding immunisation. were noted according to the CAG report:
2. In 17 states, the average shortfall in
immunisation was 20 per cent. 1. Medicine kits in excess of functioning
3. From 1992 to 1999, there has been anganwadi centres were purchased for
no significant improvement in Rs 58,300,000 without satisfactory
immunisation coverage. explanation.
4. Vaccine wise coverage showed 2. Simultaneously, medicine kits were not
measles as the least covered vaccine supplied to anganwadis on grounds of
(in concordance with NFHS II ) non-availability!
5. In test-checked projects, the 3. Medicine kits of Rs 6,450,000 received
vaccinated number was invariably in 1996-97 remained unutilised till
more than the number of identified 1999!
beneficiaries suggesting 4. 2074 kits worth Rs 8,150,000 were
manipulation of data. distributed to officials not connected
with the ICDS.
However the NCAER study states that 74 per 5. Substandard cotton and medical items
cent of the children were immunised. Only were found in the kits.

Vandana Prasad
Only 26 per cent AWCs were found to be using However, the CAG study revealed:
medical kits according to the NCAER study.
Reasons for non-usage included non- Box 5: Findings of the CAG Report
availability and out dated medicines. regarding Supply of Vitamin A and IFA
Tablets
Nutritional Services and Health
Education 1. The Ministry of Health and Family
According to the CAG report Welfare was unable to provide any
records of Vitamin A distribution
1. In 91 per cent of the projects, no 2. No record of receipt or distribution
health awareness activities, film of Vitamin A was found in any of
shows/slide shows etc were the 72 projects tested in five states
carried out. This was due to non 3. In four states there was no supply
availability of media, defective of Vitamin A at all during 1992-99
projectors and other equipment, 4. In 234 out of 283 projects in eight
lack of training for use of states no beneficiaries received
equipment and of course, general Vitamin A
lack of time and motivation
2. In 11 states, there was a 27 per As mentioned above, only 44 per cent of
cent shortfall in home visits. eligible women were even registered for IFA
as per the NCAER study. Vitamin A was
These broad findings were echoed by the supplied only to 20 per cent of the households
NCAER study. Alarmingly, though many as per the pilot study.
women (three out of four eligible) reported
receiving postnatal home visits by the Supplementary Nutrition
anganwadi worker AWW)/Auxiliary nurse Supplementary Nutrition is supposed to be
midwife (ANM)/Lady Health Visitor (LHV), provided to children and to expectant and
only 31 per cent were advised on colostrum nursing mothers from low-income families for
feeding. 300 days in a year. The aim is to supplement
the daily nutritional intake by 300 calories
Supply of Vitamin A and IFA Tablets and 8-10 gm protein for children; 600 calories
Under the National Prophylaxis Programme and 20gm protein for severely malnourished
for prevention of blindness, all children are children and 500 calories and 20-25gm
expected to get vitamin A supplements proteins for expectant and nursing mothers.
starting at 9 months of age and then six The prescribed financial norm is Rs 1 per
monthly till 3 years of age. Adolescent girl beneficiary per day on an average and this is
children and women in the age group 15-45 to include the cost of food, transport,
are expected to receive both vitamin A and administration, fuel and condiments which is
Iron and Folic Acid tablets. This was to be obviously too little. The expenditure is borne
indented by the State nodal department from by the state governments. A further central
the State Health and Family Welfare assistance is provided under the Pradhan
Department. Mantri Gramodaya Yojna for all children

under 3 yrs below the poverty line for meeting According to the NCAER study, more than 67
gaps in RDA 5 (not to replace the per cent of AWCs provided supplementary
supplementary nutrition being provided nutrition (SN ) for over 21 days in the month.
through the ICDS scheme).
Of the beneficiary children enrolled, 53.5 per
However, here is what the CAG report had to cent were receiving single diet, 1.4 per cent
say about supplementary nutrition: received double diet. 62 per cent of eligible
women received SN.
1. Budget and expenditure for
supplementary nutrition was lower Fourteen per cent of households found the
than required in five states of food to be of poor quality ( range 1 per cent to
Karnataka, Manipur, Mizoram, Punjab 64 per cent ). However, on the whole, children
and Sikkim and ranged from 16 - 69 and parents appreciated the food available.
per cent of required expenditure.
2. 11 states were not able to furnish Box 6: Implementation of Poverty
details of registration of beneficiaries. Alleviation & Food-based Schemes in Bihar
(On an average, there should be 40
children under 3 yrs, 40 children 3-6 The State Government has admitted that
yrs, 2 adolescent girls and 20 pregnant there is no feeding of children under this
and lactating mothers per anganwadi) scheme in the first few months of the
3. 23 per cent of identified beneficiaries financial year, as financial sanction is
were not covered in 21 states. not issued in time. This year too,
4. All states suffered disruptions in financial sanction was issued only on
supplementary nutrition for a variety the 18th August. The State government
of reasons including lack of funds, lack has written to the Accountant General
of food supplies, lack of systems of to permit opening of Personal Ledger
distribution and general negligence. Accounts at the district level so that the
Disruptions as severe as for over 250 balance of the previous year does not
days in a yearwere noticed in some lapse on the 31st March. Hopefully this
cases. will ensure that centers run all the 12
5. Lab tests are mandated once a month months of the year, provided funds are
to ensure nutritional content. However, made available for feeding the children.
these were rarely carried out. Where Discussion with the Field officers and
tests were conducted, the food was Project Director ICDS revealed that actual
much lower than prescribed in terms feeding at the center takes place for
of protein and caloric content. This is hardly two to four months in a year, and
hardly surprising considering the that too for a limited number of children,
inadequate funds allocated. Five states just 25 per center (as against an average
clearly expressed their inability to of 200 children per centre). This is both
supply adequate food within the norm contrary to the GoI guidelines as well as
of 1 rupee per beneficiary per day. Supreme Court orders that are quoted
6. Sub standard oil, infested gram, below:
inedible food, adulterated suji
State Government is spending just 15
(semolina) and food unfit for human
paise per day per child on the cost of
consumption were all beingconsumed.
grain and its conversion to cooked meal.
7. No therapeutic food was given in nine
states to severely malnourished Source : N.C. Saxena, Commissioner, Food Security,
children and babies. Supreme Court
5
Recommended dietary allowance

Vandana Prasad
Table 4
The Comptroller and Auditor General (CAG) Report
(Figures in percentage)
No. Process indicators Orissa Andhra Pradesh
Targets Achieve Targets Achieve
ments ments
1. Early Registration of Pregnant Women 50 13.4 50 71.5
2. Total Registration of Pregnant Women 80 72 80 87.2
3. Obstetrical & nutritional risk assessment 100 5.5 100 39.7
of thoseRegistered
4. Tetanus toxoid immunisation of pregnant women 80 84.3 90 93.5
5. Consumption of iron and folic acid tablets for 60 33.1 60 21.8
at least 12weeks by pregnant women
6. Administration of post-partum Vitamin A to 80 16 80 4.7
attendedDeliveries
7. Food supplementation for at least 20 weeks to 60 33.5 80 49.5
registeredpregnant women with inadequate
nutrition status
8. Food supplementation for at least 16 weeks to 90 43.2 90 42.9
registeredlactating women with malnutrition in
pregnancy.
9. Immunisation (UIP-6) of children 85 63.1 90 71
10. Vitamin A megadose (100,000-200,000) 80 14.8 80 35.8
semi-annually tochildren 6-36 months
11. Regular growth monitoring (>9 times a year) of 80 69.8 80 65.2
children 0-3 years
12. Supplementation of monitored children 0-3 years 90 17.5 90 67.2
withgrade II-IV malnutrition.
13. Completed referral of severely malnourished 80 13.3 80 6.0
children(Grade III & IV ) or non-responding
children 0-3 years toVHN/MPWF and PHC
14. Quarterly growth monitoring, weighing and 60 74.2 80 53.4
charting ofchildren 3-5 years (>3 times of year)
15. Referral of severely malnourished children 90 NA 90 6.0
3-5 years ofage to MPWF/PHC
16. Administration of Vitamin A megadose semi- 70 NA 80 35.8
annually tochildren 3-5 years of age.
17. Routine deparasitisation of monitored children in 80 17.7 90 16.9
mainlyinfected communities as determined by
parasite surveys.
18. Households use of oral rehydration in the last 50 84.1 60 6.5
incidenceof diarrhoea in the target group.
19. Treatment of pneumonia by MPWF/anganwadi 20 12.3 30 64.3
workers with Cotrimexazole in cases of acute
respiratory infection(ARI).
20. Additional feeds of local weaning food initiated 50 28.6 60 93.9
by 6months infants.
6
Multipurpose worker female

World Bank ‘Assisted’ Projects workplace, such as the Acts for Mines,
922 Health and Nutritionprojects are being Plantations and Construction Work. Even
funded through World Bank Loans. These these suffer from non-implementation.
have specific targets and process objectives However, the bulk of women requiring
that pertain to better impact on infant childcare remain uncovered by law and would
mortality rate (IMR) and malnutrition as well be potential beneficiaries of a scheme such
as immunisation coverage. as this had it been designed to work better.
The issues regarding this service and their

However, no expenditure was incurred on
analysis is as follows:
therapeutic food against an allocation of
Rs.76,700 000 as per the CAG report.
Outreach and Coverage
An evaluation of the World Bank I and II This scheme was also started in 1975 but has
projects by National Institute of Nutrition in remained static at 12,470 crèches catering to
the states of Orissa and Andhra Pradesh found about 311,000 beneficiaries since 1994! A
that achievements were generallymuch below further 4885 crèches exist as on 27 January
2003 through the National Crèche Fund
targets (see table below).
which was set up in 1994 with a corpus of
Rs.199, 000,000 made available through the
It is immediately obvious that though there
Social Safety Net Adjustment Credit from the
is a greater focus and more funds in the World
World Bank. The total number of children thus
Bank assisted programmes, the problem of
accommodated is a measly 430,000. This
service delivery, specially referral and supply
figure should be related to the fact that about
of ‘material’ through the system in terms of
150 million poor women work in the
supplementary food, vitamin A and anti
unorganised sector, the Female Work
helminthics still remains. In effect, neither
Participation Rate is about 47.5 - 58.2 percent
pregnant women who are at risk, nor severely 7
and these women might be having about 50-
malnourished children are managed
60 million children in the age group 0-6 years.
effectively due to lack of material, By this estimation, children in crèches are
infrastructure and inadequate linkages with approximately a minuscule 0.7 percent of
the systems involved in health and nutrition those who may require crèches!
related services.
Most of these crèches are run by ‘voluntary’
The Crèche Scheme for Working and agencies who are paid 90 per cent of the total
Ailing Mothers, National Crèche Fund running costs as per scheme (Rs 18,480 per
This scheme was set up as a childcare support crèche per year or 1540 per crèche per month)
to women at work. However, like the ICDS, it by the Central Government. Other costs have
did not take into account the scale of the need to be met by them. The scheme stipulates that
it was meant to address. There are over 150 only children of family incomes less that 1800
million women who work in the unorganised rupees per month may be considered. This is
sector in this country as agricultural workers, most unreasonable, specifically in the urban
construction workers and home based -poor setting.
workers of various kinds.
Health services apart from general care are
Some of these areas of work have specific laws supposed to include immunisation,
that amongst other entitlements also spell out supplementary nutrition and health checks
mandatorychildcare arrangements at the and medicine.
7
Jhabvala. R, 1995

Vandana Prasad
However, the crèches running under the Health Checks

National Crèche Fund are required to become When the crèche scheme was introduced, Rs
‘self supporting ‘ after a period of five years! 150 per month was budgeted for weekly visits
by a doctor and medicines. Even this
25 per cent of crèches under this fund are ridiculous sum was subsequently withdrawn
envisaged to be anganwadi cum crèche and instead Rs 125 was provided as medicine
centres. In these centres a paltry monthly and contingency fund!
amount of 675 rupees extra are to be made
available.This small sum is to support for two The salient findings regarding health checks
crèche workers at a monthly honorarium of were as follows:
Rs 300 each and a 75 rupees contingency
fund! The discrimination against crèche 1. In 58 per cent of the sampled units
workers is obvious even within the very poorly no health checks had ever happened
paid echelons of childcare workers as a whole. since the withdrawal of the health
check money (see table below).
As per an evaluation of the Crèche Scheme
done by NIPCCD8, the state of health services Table 5
provided through it were reviewed as follows: Health Checks
Supplementary Nutrition No. Periodicity No. of Perce

The salient features found were that units ntage
1. In 5 per cent of crèches surveyed no 1. Weekly 0 0
nutrition was being provided 2. Monthly 93 31
2. 82 per cent of crèches reported 3. Three monthly 22 07
disruption in nutritional services every 4. Six monthly 08 03
now and then 5. Yearly 03 01
3. 19 per cent provided only boiled chana 6. Never 174 58
(chick peas) and pulses
4. In 84 per cent there was no effort t o Growth Monitoring
provide special food for under threes Growth monitoring was carried out in a very
5. Even milk did not exist in crèches cursory way and that also only during a health
serving infants! check if that took place. No equipment was
6. Children were fed only once during available for growth monitoring nor was any
their stay of 5 - 7 hours worker trained in growth monitoring.
7. 67 per cent crèches served a good
quantity of food. Immunisation
8. It was found that quantities were most The crèche took no initiative or responsibility
likely to be inadequate where ready to for immunisation. There was no system for
eat food was served as compared to doing so. Children were reported to be
local cooked food. immunised by parents but there was no
9. However almost all crèche workers and documentary evidence.
mothers felt that their children relished
whatever they got at the crèche. Health Education, Mothers’ Meetings,
10.Only 65 per cent of children were made Home Visits
to wash their hands before eating " Only 42 per cent mothers reported ever
8
Gopal A.K and N. Khan, 1999

having been invited for a meeting at the School Health Service

crèche. 24 per cent had been going The School Health Service in India dates back
once a month, 14 per cent once in to 1909 when Baroda became the pioneer to
three months and 4 per cent once in start medical checks for children in schools.
six months. In 1960, following upon recommendations by
" 41 per cent of workers had never the Bhore Committee (1946) and the
conducted home visits. However, 9 per Secondary Education Committee (1953), a
cent did daily home visits. School Health Committee was set up by the
Government of India to suggest ways of
The crèche scheme is obviously beset by improving the health and nutrition of school
severe problems of poor value reflected by a children which made detailed
poorly designed scheme with bare minimum recommendations towards school health
resources and poorly paid and trained services and the mid day meal programme.
workers. Where things are functioning well,
it can only be due to the motivation and It is the PHC that is supposed to be
additional resources of the handling ‘voluntary responsible for carrying out school health
agency’. Though only a small number of services within its jurisdiction and these
children are being catered to by this highly services should ideally include
inadequate scheme in terms of percentage,
we are talking of over 4 lakh vulnerable and
" Health checks
valued babies and children. The potential for
" Follow up and remedial action
impact through schemes such as this is
" Prevention of communicable
immense and their neglect amounts to cruelty,
diseases
negligence and a violation of rights, apart from
" Ensuring a healthy school
being a wasted opportunity.
environment
Quality is of concern even in commercially " Nutritional services
run crèches and there is an urgent need " First aid and emergency care
for regulation of this service for the same " Mental health
reasons as above. These, as a number of " Dental health
small studies have shown, suffer from " Eye health
overcrowding, lack of trained personnel " Health education
and poor attention to health services even " Early diagnosis and management of
though the charges are sometimes fairly disability
high. " Proper maintenance of records
Health and Nutritional Services for However, it may be sufficient indictment of

Older Children through Schools the priority given to this task that this service
does not find any reference either in the
Just as children under six are to be kept
Annual Report of the Ministry of Health or
healthy through the services of the ICDS, it is
the school that is envisaged to look after the that of the Department of Education.
comprehensive needs of children over six
years of age. Though its primary function is It can safely be assumed that the existence
educational, the institution is well recognised and performance of this service would have a
the world over to perform a role that covers direct correlation with the concerned state’s
children’s over all well being. As with the general situation of health care though with
ICDS, the school system in India is supposed a low priority. Some NGOs have also chosen
to provide both health and nutritional this area to ‘support’ government schools and
services. offer school health programmes.

Vandana Prasad
Some positive reports are summarised below and hospital in the State.
to illustrate the fact that the service does and
can be made to function. Chandigarh
This programme is an on-going activity at the
New Delhi School Health Clinic located in the Sector 19
School Health Scheme was introduced in the Dispensary. Last year 146 schools were
year 1981 with a view to provide basic medical covered and 63,239 students were given a
services to the students studying in various check-up. Students suffering from various
government schools in Delhi. The students diseases were referred to nearby hospitals and
covered under the School Health Scheme are dispensaries for treatment. The most
thoroughly examined once a year and commonly detected problem was anaemia,
necessary steps are taken to immediately followed by worm infestation, night blindness,
control any negative findings, if any are found. ear problems, scabies, pyoderma, eye and
dental problems.
Besides serving a basic purpose the School.
Health Scheme also actively participated in Tamil Nadu
The State of Tamilnadu in India has one of
implementing various programmes of public
the best school health services in the country.
health importance in schools.
In terms of healthcare, all the schools
(government and private) in a particular area,
The programme is currently implemented in
are under a PHC medical officer. Thursdays
all 1200 schools of the Delhi Government and
are exclusively reserved for school health. This
aided schools in partnership with 16 NGOs.
PHC medical officer forms two or three teams
About 12 lakh children are covered under it
using the paramedical force at his disposal
(Directorate of Health, New Delhi).
and develops an action plan by which a team
makes at least three visits in a year to each of
Sikkim
the schools in his area, on a rotation basis.
School Health Programme which was initiated
He will pay at least one visit in a year to
in the year 1979 was made more eachand screen all children. Each child is
comprehensive in nature and coverage. It given a health card that is maintained by the
covers students from class I to V with services school Headmaster and updated by the health
like immunisation, health check up, Health team. The state through the state medical
Education and Teachers Training. Every year services corporation (TNMSC) supplies a fixed
Primary School Teachers are also trained set of drugs exclusively to be used during the
under this programme. Similarly, 15 Schools school health programme to each PHC at the
under Rangpo PHC have been taken up under start of the year. An up to date morbidity
National School Health Programme. Special pattern during each visit is compiled at the
School Health Check up Scheme was end of the month and sent to the district and
launched from 22 July 1996 for screening all then forwarded to the state headquarters. As
Primary School Children for minor ailments a part of the programme, at least one teacher
like anaemia, night blindness, pyoderma, from each school has been trained by the PHC
scabies, dental caries etc. The scheme was medical officer to detect minor ailments and
launched in co-ordination with the Education report immediately to the medical officer.
Department and 873 Schools and 94,707 Modules in the regional language have been
children were screened under the Special developed at the state level and distributed
School Health Scheme of which 51,324 to them. The modules also have techniques
children were treated in the health centres to teach ‘health’ to children’.9
9
Dr.D.Sathyanarayanan, Institute of Community Medicine, Madras Medical College, Chennai

UNDP and School Health Midday Meal Programme

UNDP is extending support to a government This programme was also recommended as
project that has been created to develop and early as 1960 by the School Health Committee
demonstrate three inter-related but and was to be operational all over the country
independent model interventions in the areas through the efforts of the state government.
of Multi-sectoral Approach to Health, School
Health and Community Health Care The largely languishing MDMP gained a fresh
Financing. The project is based on the impetus after a Supreme Court Order dated
assumption that empowered communities, in 28 November 2001 that directed all state
partnerships with local government units and governments to introduce cooked mid day
Community-Based Organisations/Non- meals in primary schools within 6 months.
Governmental Organisations, can plan,
implement and manage their own health The status, as per the Annual Report of the
programmes. This programme covers selected Department of Education, 2001–2002 is that
sites in the states of Uttar Pradesh, it is offering support to over 100 million
Uttaranchal, West Bengal, Kerala, Karnataka children in the country. Gujarat, Kerala,
and Delhi. Pondicherry and Tamil Nadu were providing
cooked meals, 89 tribal blocks in Madhya
Assisted by a local health NGO, this pilot Pradesh and 85 tribal blocks in Chattisgarh
initiative focuses on building capacities of are also providing cooked meals. In Orissa,
school teachers, Parent Teacher Associations 8KBK and 74 non KBK blocks were providing
(PTAs) and Government health personnel in cooked meals. Karnataka was providing
select clusters, and has helped to develop a cooked meals in 7 educationally backward
common perspective and understanding of the districts. Ready to eat food was being provided
health of children. in New Delhi and other states were providing
food grains.
The intervention supports training of one
teacher from each class to do the initial However, the picture is changing steadily as
screening of children in her/his class. PTAs there has been continuous pressure by NGOs
are playing a critical role not only in participating in right to food and right to
monitoring the programme interventions but health campaigns as well as the
also in carrying the issues of hygiene and Commissioners appointed by the Supreme
sanitation into their own neighbourhoods. Court to oversee the implementation of its
orders vis a vis food related schemes and
Fresh Approach, Gujarat services. Going by the most recent reports,
Bihar and Uttar Pradesh remain the only two
‘Focusing Resources on Effective School
states where there has been no or negligible
Health (FRESH)’ offers the additional package
compliance with the Supreme Court order.
of Vitamin A, iron and antihelminthics along
A recent survey (January – April 2003)
with the mid day meal programme covering 3
conducted by the Centre for Equity Studies,
million school children in Gujarat.
New Delhi10 shows a heartening situation in
Clearly, good quality school health services the three states studied, namely Chattisgarh,
need to be ‘re discovered’ and pushed as an Rajasthan and Karnataka with much
essential preventative and promotive health appreciation for the MDMP by the community
service for children. at large.
Mid-Day Meals Responsible for Leap in Female Enrolments in Primary Schools. Centre for Equity Studies, New
10
Delhi.

Vandana Prasad
Though the MDMP is known more as a of funds, corruption and apathy.

significant educational and social intervention
than one in the area of health, it completes In particular, the ICDS scheme which has
the comprehensive ‘school health’ package in great potential for improving the health of a
concept. (the reality is that abbreviated vast number of children under the age of six
versions of school health services are piggy years, needs universalisation, regularisation,
backing the MDMP rather than vice versa as better support in terms of funds and
many states add packages of iron, vitamin A personnel, better convergence with other
and antihelminthics to it). Undoubtedly, the systems of health and education,
surety and comfort of a hot mid day meal at decentralisation of programme and greater
school contributes to the overall food security value and demand from the community.
of our children and institutionalises another
The picture that comes through from the facts
system to buffer children against starvation
stated above confirms the general apathy and
in acute situations of drought and famine. It
low priority that surrounds the rights of
needs to be promoted and nurtured as a
children. Where resources are stretched, the
routine service that should be available to all least vocal and least powerful people are the
school going children. ones to be neglected most. However, there is
a growing environment of strong articulation
Conclusion on behalf of children, both internationally and
It is clear that there is no lack of theoretical within the country. As basic minimum public
understanding of the role of preventative services suffer the threat from privatisation,
health and nutritional services for keeping there is also a growing and strengthening
children healthy. Nor is there any debate on public understanding of their role and
the fact that this makes great sense in terms requirement. Surely, this must and will lead
of economy and development. Nevertheless, to the simple, straightforward action of
services for children suffer from inadequate providing more and better comprehensive
schematic implementation mechanisms, lack services for all our children.

Reproductive Health Services - The Transition From
Policy Discourse to Implementation
Sama Team
Introduction availability of the reproductive health services

To discuss the current ‘status of reproductive for women, with an analysis and critique of
health services for women in India’ it is the reproductive health approach and also
imperative to locate it within the larger highlighting the major contentions and
narrative of needs and issues that women debates of the reproductive and child health
confront on a regular basis. In this context, (RCH) programme.
it bears pointing out that women are not a
monolithic category. They live in very different Unravelling the Historical Context
economic, cultural and social circumstances. It is important to map the historical trajectory
This fact has been completely ignored by the of the country’s family planning programme
planners in India, which has resulted in the (FPP) which clearly brings out the planners’
targeting of the underprivileged sections, obsession with demographic goals, especially
particularly poor women being forced to with its continued focus on fertility control
undergo sterilisation and other family and on women as targets of services. The
planning measures. When we focus on the population field has undergone many
present scenario of reproductive health changes, as lessons from experience have
services for women in India, we need to been incorporated into policy and action. No
analyse the developments chronologically doubt, the ideological underpinnings of the
looking at different plans and policies of visionaries or planners have undergone a
population control in India and also observe reorientation in the past five decades, yet their
the shifts over time in ideology and approach. approach remains techno-centric and top-
Reproductive health services no doubt are an down, subsequently thrusting their ideas and
essential part, but not the whole of the belief systems on the poor, particularly the
package of interventions and policies women, whose voices and opinions are easily
necessary for the promotion of women’s suppressed.
reproductive health. This is because
reproductive health is not purely about While interest in Malthusian and eugenicist
techno-centric strategies and neglect of ideas dated to the late nineteenth century, it
general health problems. It is to some extent was in the 1920s that discussions about
the articulation of the social and structural population size and experiments in birth
constraints that women confront. This paper control and family planning began among
tries to address the evolution of the concept Indian nationalists and colonialists. The
of ‘reproductive health’ – providing a brief earliest advocates of reproductive control in
historical background of reproductive health India were primarily male Indian and British
services and its focus on population policies. bureaucrats, statisticians, social scientists,
Secondly, we discuss the issues that have and other social reformers who had been
been highlighted in the ‘reproductive health’ influenced by the new theories. Crucial to
agenda while delineating the shifts in the these developments was the availability of new
family planning strategies. Furthermore, this information from the censuses (which began
paper touches upon the assessment and in 1881) that gave analysts a better sense of
*
Contributed by Dharashree Das with Manjeer Mukherjee and N.B.Sarojini.

Reproductive Health Services - The Transition From Policy Discourse to Implementation
the size and rate of increase of the population.1 countries, by the 1970s, the social and
Advocates or the supporters of British rule economic conditions had by and large
lauded the benefits of birth control, arguing improved. Women had begun to assert their
that the poor were the cause of their own rights over their bodies, to demand the right
poverty. Some Indian nationalists claimed of abortion and the choice to be the sole
that mass destitution was the result of colonial decision-maker in the matter of having or not
exploitation and had nothing to do with the having a baby.2 Whereas women’s movements
rate of growth of the population. Many others in the third world were linked with nationalist
saw birth control as a means to national struggles against powerful political and
regeneration through improved maternal and economic forces. Women asserted their
infant health and survival, which in turn entitlement rights, and the right to equal
would improve national health and the wages and work. The birth control movement
economy. Opponents of birth control came with its promotion of contraception, gained
from a number of camps: those who supporters in the west as women believed that
associated birth control with immorality, it would enable them to have greater control
which included Mahatma Gandhi, who also of their lives. But this argument was seen as
advocated sexual restraint to lower fertility; culturally problematic within the Indian
those who felt it conflicted with religious context given the different needs and demands
sanctions and was destructive of female of women.
purity; and finally, those who saw it as a threat
to the political power of minorities. A Paradigm Shift
Since the late 1940s, the Indian state has been
Social and political activists, particularly the deeply involved in planning the nation’s
All India Women’s Conference, joined the future, creating a certain vision or desire for
public discussion on fertility regulation in the an ordered society through its population
early 1930s. Within the context of nation policies, as a part of its development goals.
building they supported the use of In 1945 the Bengal Famine Inquiry
contraception to improve female and infant Commission called for population control as
health. They put greater emphasis on female an integral part of planned development. This
health, particularly for the poor or working- was followed in 1946 with a recommendation
class women, than did their male from the Bhore Committee for the
counterparts. However, their promotion of development of a population policy from a
birth spacing for such women, rather than public health perspective. Finally, in 1949,
women’s right to reproductive control, the Family Planning Association of India was
signalled their public investment in the born out of sustained interest on the part of
hegemonic nationalist image of the Indian voluntary organisations and private advocates
woman as mother. In fact, only a small of birth control.3 There was an emergence of
minority of Indian women saw birth control neo-Malthusian concerns that too many
as a means to greater female autonomy. people reproducing too rapidly retards
economic growth, increases poverty and over
In this context, it is important therefore to stretches social services etc. As a
highlight the differences in the nature of consequence, the Indian State was the first
demands that women made in different parts in the world to initiate an official Family
of the world. In some of the Western Planning Programme in 1952, commencing in
1
Chatterjee, Nilanjana and Riley, Nancy E. (2001) ‘Planning an Indian Modernity: The Gendered Politics of
Fertility Control’, Journal of Women in Culture and Society; Signs: vol.26, no.3, pp. 811-845.
2
Qadeer, Imrana (1998) ‘Reproductive Health: A Public Health Perspective’, Economic and Political Weekly, 10th
October, pp. 2675-2684.
3
Chatterjee, Nilanjana and Riley, Nancy E. (2001) op cit

Sama Team
the first Five Year Plan with a ‘clinic approach’. In this context, it is interesting to note that
This ‘clinic approach’ was strongly influenced despite India’s opposition to target oriented
by the Planned Parenthood movement in the fertility control policy at the Bucharest
West. conference, in 1976 the government declared
the impracticality of ‘waiting for education and
Apparently, it was noticed that few people economic development to bring about a drop
made use of the services of family planning in fertility’. The government’s next resort was
clinics, thereby in the Second Five Year Plan what it described as a ‘frontal attack on the
a number of changes were introduced. problem of population’.5 This resulted in an
Initially, the main objective of the Family emergency and in 1977 the Congress
Planning Programme was to improve women’s government fell, and one of the main charges
health because it was perceived that the levelled against it was the imposition of a
reasons for women’s ill health were narrowly coercive fertility control programme. As a
spaced pregnancies and births, expedited by result, attention was focused on female
marriage at a very early age. Reducing fertility sterilisation, which formed an important
through family planning services provided by component of the Sixth and Seventh Plan
the government was considered to be an periods. Thereafter, the system of monetary
offshoot of the process of securing women’s incentives and the women-centric programme
health. Thereby, the first decade of the of sterilisation within the FPP in India came
programme focused on providing education, in for criticism.
marriage and child counselling, rather than
medical intervention for birth control.4 It is Nevertheless, in the past five decades there
interesting to note that the government’s effort has been a reorienting of strategy. The child
in promoting fertility control has changed from survival movement and safe motherhood
decade to decade. It is only in the following initiatives have resulted in the Indian FPP
year i.e., in the 1960s (due to the 1961 census collaborating with other programmes. The
that marked a significant rise in population vast network of sub-centres, primary health
growth rates) that the focus shifted from centres and community health centres also
improving the health of women and children provides valuable health services for mothers
and was geared towards controlling the rise and children inclusive of the family planning
in population growth. Family planning services.6 Therefore, the FPP expanded its
centres were expanded and new depots set services to include— Maternal and Child
up for the distribution of contraceptives. The Health (MCH) and Child Survival and Safe
government’s approach became method- Motherhood (CSSM) programmes.
specific – the sterilisation programme was
intensified and intra-uterine contraceptive More recent initiatives are also in the pipeline,
devices and condoms promoted . for instance, interventions and programmes
for the prevention of HIV/AIDS and sexually
Subsequently, in declaring that ‘development transmitted infections (STIs). The challenge
is the best contraceptive’, India called for a is to strengthen all these services by
broad integrated approach to population expanding their reach and improving their
control at the first United Nations World quality and to effectively integrate these
Population Conference in Bucharest in 1974. services within the ongoing programmes.
4
Rishyasringa, Bhanwar in Ramasubban, Radhika and Jejeebhoy, Shireen J., ed. (2000) ‘Social Policy and
Reproductive Health’ in Women’s Reproductive Health in India, Rawat Publications, Delhi.
5
6
Rishyasringa, Bhanwar in Ramasubban, Radhika and Jejeebhoy, Shireen J., ed. (2000) op cit

A Genealogical Sketch of the Concept pregnancies. Therefore, the impetus provided

of ‘Reproductive Health’ and its by the women’s movement and the forceful
Transition to RCH voicing of concerns regarding women’s health
It is imperative to note that the 1980s saw at the third decennial International
the emergence of a new perspective on family Conference on Population and Development
planning. Furthermore, the Ministry of Health (ICPD) at Cairo in 1994 (see box), led to a
and Family Welfare proclaimed in a policy paradigm shift in India’s FPP. It moved from
statement that ‘compulsion in the area of the existing numerical, method-specific target
family welfare must be ruled out for all times approach towards an approach of
to come. Our approach is educational and reproductive health care and women’s rights
wholly voluntary’.7 Even the name of the and empowerment.
programme was changed from that of ‘family
planning’ to ‘family welfare’. As a Family The ICPD Draft Programme of Action:
Welfare programme, it brought a fresh The ICPD document defines
perspective by emphasising the importance reproductive health as physical, mental
of responsible or planned parenthood. It and social well being (not just the
focussed on promoting change not only in absence of disease), and the ability to
attitudes about family size and planning but exercise one’s human sexuality without
related issues such as age at marriage, dowry, health risks. Sexual health is defined
son preference, and female foeticide. During as the integration of physical, emotional,
the 1980s, the Indian State also reiterated its intellectual and social aspects of sexual
commitment to population control as an being, and the objective of sexual health
integrated part of general development. services should be to encourage
personal relationships and individual
In fact, the global women’s movement had development, not just treatment of
played a vital role in changing the course of reproductive health problems and
the FPP. Women’s groups’ world-wide were sexually transmitted diseases.The
critical of the over-emphasis on ‘demographic document declares that sexual and
goals’ and the targeting of women solely as reproductive rights include certain
‘procreators’ in FPP’s. Applying the feminist human rights that are already officially
principle, women activists argued that every recognised: basic rights of individuals
woman has the right to control and enjoy her and couples to decide on the number
own sexuality, to regulate her fertility through and spacing of their children, and right
access to information and services, to remain to information and accessible services
free of reproductive morbidity and to bear and to that end; the right to respect for
raise healthy children.8 As a consequence, security of the person and physical
the emphasis was to suggest changes in the integrity of the human body; and the
existing family planning approaches to right to non-discrimination and freedom
reallocate resources among different current from violence.
programmes, to adopt the life-cycle approach Source: (S. Correa, 1994: see chapter 2, ‘Sexual and
in order to include women of all age groups, reproductive health and rights: the southern feminist
and to empower women to enjoy and manage approach’, p.67).9
their sexuality without the fear of unwanted
7
8
Social Assessment of Reproductive and Child Health Programme-A Study in 5 Indian States; Assam, Haryana,
Maharashtra, Orissa and Uttaranchal (Part-I), coordinated by Shalini Bharat (Prof. and Head, Unit for Family
Studies,Tiss) and supported by Ministry of Health and Family Welfare and DFID, New Delhi, Sept.2003
9
Correa, Sonia (1994) ‘Population and Reproductive Rights: Feminist Perspectives from the South’ , Kali for
Women publishers,New Delhi.

Sama Team
The concept based itself on the belief that it " bear and raise healthy children;
‘moves birth control out from under the " remain free of disease, disability, fear, pain
umbrella of family planning and planned or death associated with reproduction (and
parenthood, with their patriarchal the reproductive system) and sexuality.
connotations, into the realm of individual Reproductive health is thus seen as a part of
rights to sexual and reproductive health’. women’s reproductive rights.
Thus, reproductive health was posed as an
ideal, a dream to move towards – but this In addressing the needs of women and men,
necessarily requires us to come up with such an approach places an emphasis on
different strategies specific to the varying developing programmes that enable clients to
social contexts prevailing in different parts of make informed choices; receive screening and
the globe.10 In this regard, what needs to be education and counselling services for
pointed out is the fact that our planners often responsible and healthy sexuality; access
fail to understand that there is a common services for preventing unwanted pregnancy,
thread linking reproductive health, general safe abortion, maternity care and child
health and socio-economic conditions. And survival, and for the prevention and
to our utmost surprise, the concept of management of reproductive morbidity
reproductive health has failed to clearly including reproductive tract infections (RTIs),
articulate these inter-linkages. sexually transmitted infections (STIs), and
gynaecological problems.12 But the problem
However, reproductive health issues suddenly lies in the fact that there exists a wide social
catapulted to centre-stage by the media and and cultural gap that exists between the
by international agencies when the ICPD providers and users of services. Thereby, the
Programme of Action focused centrally on user’s perspective needs to be emphasised
these issues. At this historical juncture, it is within the overall framework of the service
important to state that the demand for delivery system and particularly that of
reproductive rights and health did not women as they face a host of problems to
originate in Cairo, and that it is not an original access the health services. More important,
idea formulated by population control the RH services must be integrated within the
agencies or international agencies that have ongoing existing programmes.
supported them.11 The women’s movements’
definition of reproductive rights since its ‘Package’ of Reproductive Health
inception has included reproductive health as Services
an integral part of it. Two separate packages of reproductive health
services – an essential package and an
The definition of reproductive rights is expanded package are discussed here. The
essentially understood as the right of women to: services included in the essential package are
" regulate their own fertility safely and recommended as a part of the government’s
effectively, by conceiving when desired, programme. All these services are
terminating unwanted pregnancies, and theoretically included in the national
carrying wanted pregnancies to term; programme and are specified in the numerous
10
Qadeer, Imrana (1998) ‘Reproductive Health: A Public Health Perspective’, Economic and Political Weekly,10th
October, pp.2675-2684.
11
Ravindran, Sundari T.K. (1998) ‘Reclaiming the Reproductive Rights Agenda: A Feminist Perspective’ in
Reproductive Health in India’s Primary Health Care, published by Centre of Social Medicine and Community
Health, New Delhi.
12
Pachauri, Saroj (1996) ‘A Shift from Family Planning to Reproductive Health: New Challenges’ in Population
Policy and Reproductive Health (ed.) by K.Srinivasan, Hindustan Publishing Corporation (India), New Delhi.

policy and programme documents. However, services is to be implemented.

there have been serious problems with regard
to its implementation at various levels of the It is also important to look at the expanded
health delivery system. There exist major gaps reproductive health services package, which
between what is on paper and what is on the at present has limited application. But it has
ground .13 Even though the essential package been discussed for two reasons. Firstly,
is recommended, there are major constraints because it is imperative to plan for additional
that impedes programme implementation services, particularly for the most advanced
such as —access to services, quality of care- states as well as for urban areas where it is
included lack of equipment, supplies and
possible to establish referral linkages with
skills with the service providers, supervision
multiple health facilities that are operating
and support, and programme financing.
in these areas. Secondly, we should look at
These constraints must be given due
the feasibility of implementing this package
importance, particularly in regions and states
with weak infrastructural capacity if the of services in a few selected areas within the
essential package of reproductive health more advanced states even today.
Table 1
Essential and Expanded Packages of Reproductive Health Services
Essential Reproductive Health Expanded Reproductive Health

Services Package Services Package
Prevention and management of Prevention and management of
unwanted pregnancy unwanted pregnancy
Services to promote safe motherhood Services to promote safe motherhood
Services to promote child survival Services to promote child survival
Nutritional services for vulnerable groups Nutritional services for vulnerable groups
Prevention and treatment of reproductive Prevention and treatment of
tract infections and sexually reproductive tract infections and
transmitted infections sexually transmitted infections
Reproductive health services for Reproductive health services for
adolescents adolescents
Prevention and treatment of
gynaecological problems including
cervical cancer and infertility
Screening and treatment of breast cancer
Health, sexuality and gender information, Health, sexuality and gender
education and counselling information, education and counselling
Establishment of effective referral systems Establishment of effective referral systems
Source: Saroj Pachauri in K.Srinivasan ed., 1996.14
13
Pachauri, Saroj (1996) op.cit.
14
Ibid.

Sama Team
Reproductive health services are an essential within the national context. In November
part, but not the whole, of the package of 1994, a joint mission of the Government of
interventions and policies necessary for the India and the World Bank was set up to
promotion of women’s reproductive health. undertake a sectoral review. In 1995, the
World Bank submitted a report entitled
Rhetoric and Reality ‘India’s Family Welfare Programme: Toward a
There exists a wide gulf between rhetoric and Reproductive and Child Health Approach’ to
reality in the planners’ vision of promoting the the Government of India. The government
RH approach and the actual implementation decided to adopt the policy and as a first step,
of the RH services. removed method-specific contraceptive
targets nation-wide. As part of India’s
Reproductive Health Services commitment to the ICPD, the government
Population control programmes have been too launched the National Reproductive and Child
narrowly focused on limiting population Health programme in October 1997. The RCH
through the provision of family planning programme was designed to be ‘people-
services. In India, the focus has been primarily centred’ and ‘rights-oriented’. The thrust of
to achieve demographic targets by increasing the programme was on effecting changes both
coverage with contraceptives with a focus on at the level of policy as well as at programme
female sterilisation. Stressing only the family management and implementation levels.
planning dimension of reproductive health
and subsequently neglecting women’s choices The new approach encourages smaller
has failed both to improve the reproductive families by helping clients meet their own
health situation substantially and to satisfy health and family planning goals. Instead of
the unmet need for family planning. The birth control being the sole focus, it seeks to
current focus on reproductive health, provide a full range of maternal and child
including the shift in 1997 to the reproductive health services.16
and child health programme, signifies the
need to reorient programme strategies. The The Reproductive and Child Health
need is to centre more on a holistic Programme, lays emphasis on a
reproductive health approach, informed client comprehensive approach which includes a
choices and women-based services – services ‘package’ of services for the prevention and
that respond to clients’ and especially management of unwanted pregnancies;
women’s health needs in ways that are promotion of safe motherhood and child
sensitive to the socio-cultural constraints survival; nutritional services for vulnerable
women and adolescent girls face in acquiring groups; services for the prevention and
services and expressing health needs.15 We management of reproductive tract infections;
also need to encourage male participation by and reproductive health services for
ensuring that men take responsibility for adolescents.17
family planning, and child rearing.
The magnitude of women’s reproductive
Following the Cairo conference, the health problems in India is immense. The
Government of India set in motion a process rates of mortality and morbidity related to
to translate the ICPD Programme of Action pregnancy and childbirth continues to remain
15
Ramasubban, Radhika and Jejeebhoy, Shireen J., ed. (2000) ‘Introduction’ in Women’s Reproductive Health in
India, Rawat Publications, Delhi.
16
Rishyasringa, Bhanwar in Ramasubban, Radhika and Jejeebhoy, Shireen J., ed. (2000) ‘Social Policy and
Reproductive Health’…
17
Maita, Kuhu (2001) ‘Priority Actions for Safe Motherhood-Emerging Challenges’, Health for the Millions, May-
June, vol.27,no.3,pp.7-9.

high. This is primarily due to the the maternal mortality rate across states.
inaccessibility of timely and quality emergency
obstetric care for a majority of pregnant Table 2
women in rural areasand lack of safe abortion Maternal Mortality Rate,
care. India accounts for 19 per cent of all live Various States, India, 1997
births world-wide, and for as many as 27 per
cent of all maternal deaths. It is essential to State Deaths
understand that women bear a per
disproportionate burden of reproductive 1,00,000
health problems. live births
India 408
Services to Promote Safe Motherhood Low Human Development
Services for maternity care should be designed
Bihar 451
to ensure timely detection, management and
referral of complications during pregnancy Madhya Pradesh 498
and delivery. Antenatal services should be Andhra Pradesh 154
strengthened – so as to detect complications Orissa 361
and also offer information to women on Rajasthan 677
nutrition, hygiene and immunisation etc. West Bengal 264
Post-partum services should be provided for
both mother and child. More importantly,
Medium Human Development
PHCs must be upgraded to provide facilities
for delivery and also be able to handle other Gujarat 29
complications. But when we study the ground Karnataka 195
reality, the absence of certain basic services Maharashtra 135
is quite conspicuous. Tamilnadu 76
Kerala 195
The two National Family Health Surveys
(NFHS), carried out in 1992-1993 and in Source: Economic Survey 2000-01, India (cited in
1998-1999, found maternal mortality to be Jeyaranjan and Swaminathan, Hivos).20 (Maternal
mortality rate is defined as the number of maternal
high (437 and 540 respectively). Moreover,
deaths to women age 15 to 49 per 1,00,000 live
complications during pregnancy are greater
births).
for adolescents (under age 16) and older
women (over age 40).18 In both NFHS-1 and
NFHS-2, the rural MMR (Maternal Mortality What has to be seriously taken note of, is the
Rate) is much higher than the urban MMR fact that maternal deaths are not only an
(434 compared with 385 in NFHS-1 and 619 outcome of biological factors but of women’s
compared with 267 in NFHS-2).19 Moreover a poverty, powerlessness, low social status and
majority of maternal deaths are preventable lack of control over resources, lack of access
given that both knowledge and means of to health care, along with the poor quality of
prevention are available. MMR for India is delivery system. Malnutrition, infection, early
408 per 1,00,000 live births and ranges and repeated childbearing and high fertility
between 29 in Gujarat, 76 in Tamil Nadu and also play an important role in poor maternal
677 in Rajasthan. The table below provides health conditions in India.
18
Maita, Kuhu (2001) op.cit.
19
NFHS II (National Family Health Survey-2) 1998-99, India, IIPS (International Institute for Population Sciences)
Mumbai and ORC Macro, USA, 2000.
20
Jeyaranjan, J. and Swaminathan, Padmini ‘Understanding Persistent Poverty in India’ by Hivos (Humanist
Institute for Co-operation with Developing Countries, Netherlands.

Sama Team
The high level of mortality during childbirth residence. The median number of check-ups
or soon after childbirth indicates the is higher in urban areas (4.2) than in rural
inadequacy of facilities available for antenatal areas (2.5). The number of antenatal check-
care and deliveries across the country. The ups and the timing of the first check-up are
NFHS confirms that few women have access important for the health of the mother and
to adequate antenatal care. The table below the outcome of the pregnancy (NFHS-2).
provides us with empirical evidence that
substantiates our argument. Women’s lack of autonomy in decision-
making, their limited physical access to
We can see that the antenatal visits are facilities and the poor quality of services and
generally infrequent and occur late in care they receive at facilities are major
pregnancy. There are substantial differences obstacles to timely health care. Moreover,
in the number of antenatal check-ups by access is related to a woman’s social status,
Table 3
Number and Timing of Antenatal Check-ups and Stage of Pregnancy
Per cent distribution of births during the three years preceding the survey by number of antenatal
check-ups and by the stage of pregnancy at the time of the first check-up, according to residence,
India, 1998-99
Number and timing of check ups Urban Rural Total

Number of antenatal check -ups
0 13.6 39.8 34.0
1 6.0 8.8 8.2
2 10.5 14.1 13.3
3 14.5 14.2 14.3
4+ 54.7 22.4 29.5
Don’t know/missing 0.7 0.8 0.7
Total percent 100.0 100.0 100.0
Median number of check-ups (for those who 4.2 2.5 2.8
received at least one antenatal check-up)
Stage of pregnancy at the time of the first
antenatal check-up)
No antenatal check-up 13.6 39.8 34.0
First trimester 55.1 26.6 33.0
Second trimester 24.2 25.5 25.2
Third trimester 6.9 7.6 7.4
Don’t know/missing 0.2 0.4 0.4
Total percent 100.0 100.0 100.0
Median months pregnant at first antenatal 3.0 3.9 3,5

check-up (for those who received at least
one antenatal check-up)
Number of births 7,191 25,202 32,393
Note: Table includes only the two most recent births during the three years preceding the survey.
Source: NFHS II (1998-99)
as determined by her level of education, customary (4 per cent) or were not allowed by
income and decision-making power within the their families to have one (9 per cent). High
family. Even when health services are costs account for another 15 per cent of cases
available, women may not be able to utilise and lack of knowledge, distance, and lack of
them due to various socio-cultural transport are other reasons (NFHS-2).
constraints, which pervade many societies.
The table below explains the reasons why In India, due to several socio-cultural
women do not often receive antenatal- check practices followed in the community, the
up, both in urban and rural areas. majority of births, even now, occur at home.
Only 33 per cent of deliveries take place in
It shows Per cent distribution of births during health facilities. Among deliveries at home, a
the three years preceding the survey to traditional birth attendant attends to 50 per
mothers who did not receive an antenatal cent of them, while a health professional
check-up by main reason for not receiving an attends to less than one in every eight.
antenatal check-up, according to residence,
India, 1998-99 It is also an established fact that most deaths
occur in the early postnatal period and
The table shows the per cent distribution of traditional practices prohibit newly delivered
births in the three years preceding the survey women and their babies from leaving the
where mothers did not receive any antenatal house for the first 40 days after delivery. For
check-ups in a health facility or at home by example, reports suggest that up to 60 per
the main reason for not receiving check-ups. cent of all maternal and neonatal deaths occur
For almost three-quarters of the births to within five days of delivery and only one in
mothers who did not have any antenatal eight cases occurred after 15 days or more .21
check-ups, mothers did not consider having Yet health workers visit only about one-third
a check-up to be necessary (60 per cent) or of the newly delivered women in the first week
Table 4
Reason for not receiving an antenatal check-up
Reason for not receivingAntenatal check-up Urban Rural Total

Not necessary 63.4 59.1 59.5
Not customary 3.8 4.3 4.3
Costs too much 11.3 15.0 14.7
Too far/no transport 0.9 3.9 3.7
Poor Quality Service 1.6 0.8 0.8
No time to go 2.6 1.7 1.8
Family did not allow 11.3 8.2 8.5
Lack of knowledge 3.2 4.2 4.1
No health worker visited 0.2 1.6 1.5
Other 1.7s 1.1 1.2
Total percent 100.0 100.0 100.0
Number of births 978 10,040 11,018
Note: Table includes only the two most recent births during the three years preceding the survey.
Source: NFHS II (1998-99)
21
Maita, Kuhu (2001) op.cit.

Sama Team
after delivery. The NFHS-2 also indicated that importance in saving women’s lives during any
only 17 per cent of non-institutional births obstetric emergencies, etc.
were followed by a check-up within two
months of the delivery. These findings clearly There are many reasons why women are
indicate that pregnancy- related illnesses take unable to access health care facilities, even
a heavy toll on women’s lives during the in times of emergency. To begin with, health
postpartum period. In this context, it is worth services may not be available at a convenient
mentioning that a recent study on factors time and place. The table here gives us an
contributing to maternal death in Andhra account of the outreach of our health service
Pradesh, Madhya Pradesh and Orissa revealed system.
that out of the 170 maternal death cases
The above table summarises the findings on
investigated, 106 deaths had occurred during
distance from a health facility. The unit of
the postpartum period. The commonest form
analysis is ever-married women age 15-49
of complication was fever and bleeding.
who reside in rural areas. 13 per cent of rural
women live in a village with a Primary Health
Establishment of effective referral systems Centre, 33 per cent live in a village with Sub-
The referral systems are of paramount Centre, and 37 per cent live in a village with
significance, as these are vital for other facilities are 10 per cent for hospitals
implementing all the mentioned essential and 28 per cent for dispensaries or clinics.
packages of reproductive health services. For Nearly half of women (47 per cent) live in a
this we have to establish linkages at the village that has some kind of health facility.
community level. In this regard decentralised Median distances from particular health
participatory planning is required for facilities are 4.9 km for a Primary Health
implementing basic health services in the Centre, 1.3 km for a Sub-Centre, 6.7 km for a
remotest areas. This would also be of hospital, and 2.4 km for a dispensary or a
Table 5
Distance from the Nearest Health Facility
Percentage distribution of ever-married rural women age 15-49 by distance from the nearest
health facility, India 1998-99
Distance Health Facility
PHC Sub-centre Either Hospital Dispensary/ Any
PHC or Clinic health
Sub-centre facility
Within village 13.1 33.0 36.5 9.7 28.3 47.4
<5 Km 28.4 39.7 40.8 25.0 32.4 38.9
5-9Km 29.2 16.3 15.3 25.1 17.4 9.7
10+Km 28.8 9.6 7.0 40.0 21.7 3.9
Don’t know/ 0.5 1.4 0.3 0.2 0.2 0.2
missing
Total % 100.0 100.0 100.0 100.0 100.0 100.0
Median distance 4.9 1.3 1.0 6.7 2.4 0.0
Note: the category ‘< 5 km’ excludes cases where the facility is within the village cases and cases with a
facility less than 1 km. from the village are assigned a distance of zero.
Source: NFHS II (National Family Health Survey-2) 1998-99, India, IIPS (International Institute for Population
Sciences) Mumbai and ORC Macro, USA, 2000.

clinic. 14 per cent of rural women need to youngest women and women with only one
travel at least five kilometres to reach the child, who also have the highest unmet need
nearest health facility. for spacing. There are huge differences in the
unmet need by States. The unmet need varies
The other key findings of NFHS-2 with regard from less than 10 per cent in Punjab, Haryana,
to reproductive health care, are as follows: and Andhra Pradesh to 25 per cent in the
" 99 per cent of currently married women larger States of Uttar Pradesh and Bihar to
know of at least one modern method of more than 30 per cent in small Northeastern
contraception, but only 48 per cent use States of Nagaland and Meghalaya .
a contraceptive method;
" mothers of only 20 per cent of live At this juncture, it is important to note that
births received all the required the knowledge about contraception is nearly
components of antenatal care. universal in India i.e., around 99 per cent of
currently married women know at least one
Prevention and Management of Unwanted modern method of contraception. Female
Pregnancy sterilisation is the most widely known method
The family planning programme has relied (98 per cent) followed by male sterilisation (89
heavily on female sterilisation. In this case, per cent). Knowledge of the officially
the service providers should be sensitive to sponsored spacing methods i.e. pill (80 per
client preferences and choices of cent), condoms and intra-uterine devices
contraceptives. They must also ensure that (IUDs) (71 per cent each), however is less
contraceptives are delivered safely and there widespread. Nonetheless, there has been an
should be proper follow-up and counselling increase by about 10-13 percentage points in
services. the knowledge of temporary methods since
NFHS-1. However, the knowledge of
In this context it is relevant to note the temporary methods is much lower in rural
prevailing data. As the NFHS-II reveals that areas than in urban areas. Across states the
almost 16 per cent of currently married knowledge of temporary methods is
women in India have an unmet need for family particularly low in Andhra Pradesh, Madhya
planning. Based on the population of around Pradesh, and Orissa. In spite of the increase
1027 million, this indicates approximately 40 in the knowledge, the use of modern
million women with an unmet need for temporary methods increased only from 6 per
contraception. The unmet need for family cent in NFHS-1 to 7 per cent in NFHS-2.
planning includes the unmet need for spacing
and the unmet need for limiting births. In The situation appears to be worse in case of
India the unmet need for spacing births is the abortions, as the need for MTP (Medical
same as the unmet need for limiting the births Termination of Pregnancy) services is
(8 per cent). If all the women who say that exploited, and illegal abortions are rampant,
they want to space or limit future births were invariably using crude methods to induce
to use family planning the contraceptive abortions in the most unhygienic settings.
prevalence rate would increase to 64 per cent India was one of the first countries to pass a
of currently married women. This indicates law – Medical Termination of Pregnancy Act
that 75 per cent of the total demand for family (MTP Act) in 1971, which was implemented
planning is being met. However, only 30 per in the country in 1972. Despite the fact that
cent of the demand for spacing is being met.22 the MTP Act has been implemented, data on
In fact, the unmet need is highest among the the magnitude and the patterns of induced
Gupta, K. (2001) ‘Fertility and Contraceptive Prevalence in India-Glimpses from NFHS-II’, Health for the Millions,
22
May-June, vol.27, no.3, pp.13-15.

Sama Team
abortion in India remain incomplete. There is prolapse and problems of intercourse. Several
considerable inter-study variation in community and hospital-based studies
estimates of the abortion ratio. While rates conducted in the country during the last
based on government statistics and large scale decade indicate that approximately 26 to 77
surveys using fewer probing questions suggest per cent of women were clinically observed to
a ratio of 1.3-2.1, national estimates based be suffering from one or more gynaecological
on various sources and assumptions arrive morbidities. The proportion of women
at figure of 18 and 45. 23 Small-scale reporting for vaginal discharge ranged from
community-based studies however suggest 13 to 68 per cent .25 Studies in India have
rates somewhere in between. One of the most documented the high prevalence of RTIs
thorough investigations of abortion in rural including sexually transmitted infections
India indicates 14 induced abortions per 100 among women at a community level. Seminal
live births. However, today a majority of the work by Bang et al (1989) 26 in rural
abortions are carried out illegally which has Maharashtra, showed that in a sample of 650
lead to increased maternal morbidity and women from 2 villages, 92 per cent of all
mortality in our country. A large number women examined had at least one or more
(13%- AAP-I data) of abortions occur after the gynaecological or sexual disease.
detection of a female foetus. Abortions
following sex-determination are necessarily It is imperative to state that frequent
delayed into second trimester and often pregnancies, abortions and unclean cervical
beyond the legal limit of 20 weeks placing procedures increase the risk of infection.
women at huge health risks . Also according Untrained personnel, who can not ensure
to the Sample Registration Survey, 1998, 8.9 clean delivery practices, often attend to a
per cent of all maternal deaths are due to majority of births. As per the NFHS-2, trained
unsafe abortions (9,000 to 10,000 maternal personnel attended only 42 per cent of births
deaths per year) and many more women are during the three-year period preceding the
impaired permanently by complications.24 survey . Consequently, poverty, gender
inequalities and cultural norms, and the
Prevention and Treatment of Reproductive interaction between these factors are critical
Tract Infections Including Sexually to understand the dynamics of gynaecological
Transmitted Infectionsand Other morbidity among women. High prevalence of
Gynaecological Problems. RTIs indicates serious gender imbalances.
There is another dimension of reproductive Gender-based inequalities influence women’s
ill health among women – one that is endured vulnerability to infections i.e. in most of the
silently or considered a normal part of cases women are not able to control their
womanhood. These are RTIs and other husband’s sexual activities or negotiate with
gynaecological morbidities, and include a their husband for protection from STDs.27
range of conditions such as menstrual More important, contraceptive use (IUDs and
problems, white discharge, infertility, cancers, tubectomy) has been shown to be associated
23
Ramasubban, Radhika and Jejeebhoy, Shireen J., ed. (2000) ‘Introduction’ in Women’s Reproductive Health in
India, Rawat Publications, Delhi.
24
Vishwanath, Sneh and Tiwari, Sudha (2001) ‘Manual Vacuum Aspiration -An Option for making early abortion
safe’, Health for the Millions, May-June, vol.27, no.3, pp.36-37.
25
Agarwal, D. (2001) ‘Reproductive Tract Infections -Challenges and Responses’ Health for the Millions, May-
June, vol.27, no.3, pp.21-23.
26
Bang, R, Bang ,A. Baitule, M, Chaudhury, Y.,Sarmukaddam, S, and Tale, O.1989, High Prevalence of
Gynaecological Diseases in Rural Indian Women.Lancet, 8629: 85-88
27
Ooman, Nandini in Ramasubban, Radhika and Jejeebhoy, Shireen J., ed. (2000) ‘A Decade of Research on
Reproductive Tract Infections and Other Gynaecological Morbidity in India: What We Know and What We Don’t
know’ in Women’s Reproductive Health in India, Rawat Publications, Delhi.

with RTIs. IUDs, for instance, are believed to This first phase of the RCH programme has
facilitate the ascent of pathogens into the ended and the government has entered the
upper tract causing RTIs. Some studies have next phase wherein the focus is ‘on promoting
also found that women mention that ‘Copper- state ownership and provision of RCH services
T’, a common term in India for IUDs, as a in a cohesive manner in partnership with all
possible reason for menstrual problems and stakeholders’ . In order that the design and
RTIs . development process of RCH II be informed
by the previous phase, the MOH&FW
Besides the above cited issues regarding the proposed an assessment of RCH I from the
rhetoric and reality surrounding reproductive perspective of its accessibility and
services, there are also other factors like the responsiveness to different beneficiary groups,
burden of household work which also includes particularly the poor and the marginalised;
the task of child caring and rearing, that their participation in planning,
results in high morbidity and mortality among implementation and monitoring; the capacity
women. Other basic issues of livelihood like of the public sector to deliver quality services
inadequacies of food, shelter, provision of and the viability of public-private partnership.
water and proper sanitation facilities have led In this regard, a 5-state (Assam, Haryana,
women to become susceptible to a host of Maharashtra, Orissa and Uttaranchal) social
diseases. Not to deny the constraints of class, assessment of RCH I has been carried out to
caste and gender and issues of entitlement, draw up policy and programmatic
employment and educational status of women recommendations, which we have briefly
that further creates unequal power relations discussed in the following section.
and oppresses women.
The major objective of this study has been to
Assessment of Reproductive and Child analyse the RCH policy and programme from
Health Services/Current Scenario and a human rights and gender based perspective
Status of RCH Services and to undertake a qualitative assessment of
In its first phase (1997-2002) the objective of RCH programme beneficiaries and a
the RCH programme was to benefit poor rural stakeholder analysis to identify issues related
women between the ages 15-49 and children to access and of equity of health services.
below 5 years by improving their health
condition and accessibility to services. The By design all the sites, with the exception of
programme also aimed to provide user- Mumbai, were chosen to represent states with
friendly services to couples to enable them to poorer performance on family planning
space or limit births according to their needs. indicators namely, number of births, couple
In more specific terms the programme was protection rate etc. The indices range from a
redesigned to include district level planning low of 13.87 to a high of 94.90. Among the
and monitoring to enhance responsiveness to study locations Gurgaon district in Haryana
local needs, increased client focus and has the lowest ranking with composite index
improved quality care, decentralisation and value of less than 40. In other words, the
local ownership and improved referral system district has lower ANC coverage, poorer couple
for health care seekers. At the level of service protection, lesser child immunisation rate,
delivery the programme aimed to revitalise the more than 3 birth orders, adverse female to
existing network of rural health functionaries male child sex ratio, low female literacy and
through better supplies of drugs and comparatively higher non-institutional child
equipment, training and better IEC.28 deliveries. The other districts, except for
Social Assessment of Reproductive and Child Health Programme-A Study in 5 Indian States; Assam, Haryana,
28
Maharashtra, Orissa and Uttaranchal (Part-I), coordinated by Shalini Bharat.

Sama Team
Mumbai, have indices between 40 and 60, health system to problems of mobile
which is still in the low-average category. populations, compromises their fundamental
Mumbai on the other hand has a higher right to health and health services.
performance rating compared to all other
study locations. It was seen that treatment of gynaecological
morbidities among women continued to
This study in a nutshell provides us the receive low priority from healthcare providers.
existing ground realities and certain facts from Counselling and referral services received still
the field that helps us identify the various lower priority. Ill-health due to untreated side-
constraints experienced by vulnerable groups effects of contraceptives and post-delivery
in accessing the health care services. One of complications continue to burden women,
the objectives of this study was also to assess raising questions about the seriousness of the
the capacity and constraints of government government health services to move away from
field workers and other staff to deliver RCH fertility focused agenda towards improving the
services to the marginalised and the socially reproductive health of women. The inability
disadvantaged groups. of the program in involving men in the
responsible use of contraception methods and
At all the study sites it was recognised that in ensuring women’s reproductive health
non-availability of health services during brings the gender dimension of the RCH
timings suitable to the slum beneficiaries kept program to sharp focus and subsequently
away most of the potential users from availing points to the urgent need of balancing the
the services. Class and caste dimensions are gender equation in it. Insufficient emphasis
perceived as interfering with service delivery on involving men in RCH means a heavy
in the communities. In Haryana and Assam, burden on women for planning families and
beneficiaries claimed that ANMs visited the essentially renders the RCH programme
homes of only the rich and the upper caste ‘women-centric’. In all the study locations,
groups. There is also the feeling that the poor men perceived the RCH programme to be
are not attended to because they are ‘poorly women and child focused reinforcing their
dressed’ and lack sophistication. Reports from view that family planning is all about women
Osmanabad support these observations where taking the major responsibility. It has also
health providers did not touch patients who been assessed that adolescent health is
dressed shabbily and appeared dirty. Widely completely neglected and is seen to be
reported cases of abuse (both physical and ‘culturally outside the purview of the RCH
verbal), by hospital service users across program’. Certain observations have revealed
communities have contributed to a very poor the loopholes and the inadequacies of the RCH
image of government health facilities among approach in reaching out to ‘unmarried’
slum residents. There is widespread feeling adolescents. In fact, the RCH programme
among the poor and the socially works with the notion that marriage alone
disadvantaged that they are subjected to brings adolescents under the fold of
abusive treatment because of their poverty reproductive health services. Consequently,
and low social and educational status. the needs of those not married go
Motivation to use government health facilities unrecognised and unaddressed.
is severely affected, as a result, and the poor
use it only as the last option. In fact it is The RCH programme is now being
interesting to point out, that there is implemented based on an incremental
inadequate coverage of the children and approach. The National Population Policy,
female members of migrant and other mobile 2000 (NPP 2000), affirms the commitment of
populations for immunisation and other Government of India to the philosophy of RCH
health services. The unresponsiveness of the and provides a policy framework for

prioritising strategies to meet the RCH needs RCH programme even in the third year 1998-
of the people and to achieve ‘replacement level 99, the assessment programme undertaken
fertility by 2010 AD’. through the machinery of large scale objective
sample surveys called ‘Rapid Household
In accordance to the ongoing approach, i.e. Surveys’ (RHS) at district level did somehow
the Reproductive and Child health (RCH) ‘misfire’ without achieving the original
approach implemented after ICPD 1994, it objective of evaluation. Stated below are the
should be noted that the programme has indicators of the RCH survey of (1998-99):
switched over to being ‘Target Free in 1996’,
and the Government of India since then is in Essential Indicators (Percentage) on RCH
the process of integrating various existing Care Include (as in 1998-99):
vertical programmes and incorporating
various new services like management of " Percentage of illiterate women in
Reproductive Tract Infections (RTIs) and Rep. Age group: 56.1
Sexually Transmitted Infections (STIs) into " Percentage of women with
primary health care. Thus the age-old target knowledge of modern methods of
based system for family planning was FP : 57.8
dispensed with resulting in a paradigm shift " ANC –at least 3 visits: 44.2
in the entire approach. The relevant " Delivery at health institutes: 34.0
programme of actions of ICPD, 1994, states " Safe delivery: 40.2
‘reproductive health program must make " Children with birth weight below
significant efforts to improve quality of care’.29 2500 gm: 16.9
" Fully immunised children: 54.2
Looking at the present ground reality, it is " Women with pre-natal
ironical to state that the year 1996-97 was complications: 41.3
the landmark year of change in regard to the " Symptom of RTI/STI: 29.7
concept of quality of care in India. At the same " Males with symptom of
time in 1996-97 the government at the centre RTI/STI: 12.3
and all the state governments were to " Awareness of women on
introduce an absolutely new system called HIV/AIDS: 41.9
‘decentralised participatory planning’ for " Awareness of males in 20-5 on
implementing the RCH programme. In fact, HIV/AIDS: 60.3
the most important feature in RCH is that an
innovative assessment programme was Concluding Observations
undertaken as a World Bank project to assess Despite the guidelines of the RCH programme
simultaneously and the existing reproductive health services,
" the perception of the clients about RCH there are certain issues that have been
services, completely neglected and ignored by the
" to assess the quality of services that the experts. Women are unable to seek care for
clients are supposed to receive from the problems that are not related to pregnancy
service deliveries under the RCH and other gynaecological complications. For
programme and instance there are no services for occupational
" to assess the availability of the service health problems, domestic violence or abuse
facilities in various health centres. and mental health. In addition to this, the
policies deny a commitment to respond to
Unfortunately since most of the state women’s health needs throughout their life
governments could not start implementing cycle and to go beyond the constricted
29
Saha, P.K., (2004)-Paper presented on Quality of Reproductive and Child Health Care in India: Assessing the
Status on 4th March, in Centre of Social Medicine and Community Health, JNU, New Delhi.

Sama Team
conceptualisation of their reproductive roles with basic comprehensive services and

focussing concern only with childbearing. The priorities of people must be taken into
policy often overlooks the fact that account. Above all, people’s felt and expressed
reproductive morbidity refers to health needs must be first considered, and not the
problems related to reproductive organs and State’s imperative for fertility control.
functions, including and outside of
childbearing. It covers both gynaecological These issues explain that although
and obstetric morbidity as well as related reproductive health problems, per se, are
morbidity, such as urinary tract infections, rooted in the biomedical sphere, their origins
anaemia, high blood pressure and obesity.. often lie in human behaviour that is embedded
in social and culturally constructed patterns
Thereby the policies and programmes provide of gender relations. The need of the hour for
a fractured solution. The point that needs to the policy makers is to prioritise and shape
be reiterated is that there should be a proper
programmes and policies accordingly, that can
primary health care system with proper
make the concept a reality. Clearly, the answer
referral systems for women, men and children.
to reproductive health and rights lies in
It would be counterproductive to have
developing a holistic perspective. This involves
reproductive health as yet another vertical
fundamental changes in power dynamics
programme. Reproductive health services
through greater opportunities. This is because
must be integrated within the strengthened
primary health care system. It is an reproductive health and rights are not issues
undeniable fact that reproductive health that can be solved within the confines of
constitutes an important aspect of women’s population and health policies as they
health. However, the challenge is to define themselves are subject to the vicissitudes of
priorities within it according to the objective changing paradigms and ideologies. While
and subjective definitions of women’s needs, emanating from the dominant ideology, they
and to make it a part of a larger developmental tend to fall short of grasping intersectoral
programme, based on equity of distribution linkages that would create enabling
and also on access and control of productive circumstances to achieve any degree of
resources. If the current image has to be success, not only in medicine and
overthrown then policies for health must be technological interventions alone but, also in
linked with adequate social policies for all addressing the socio-economic context and
underprivileged sections. The ongoing gender inequality that impinges upon
programme must be completely integrated reproductive and sexual health issues.

Gender-based Violence and the Role of the
Public Health System
Padma Deosthali and Purnima Manghnani
Introduction—Violence as a Public discrimination against females and societal

Health Issue norms that devalue women. 2 While any
Violence is widely recognised as a global analysis of gender-based violence is
public health concern. Research indicates that incomplete without accounting for social
violence – in the form of war, conflict inequity due to gender, it cannot alone
situations, homicide, suicide, domestic account for the occurrence of such violence.
violence, maltreatment, and communal Other factors—personal, situational, and
violence – is widespread and leads to socio-cultural must also be taken into
significant adverse health and social account.3
consequences for victims and their
communities.1 For the purposes of this paper, In this paper, gender-based violence is
we are employing the World Health presented primarily within the public health
Organization’s (WHO) definition of violence: framework. It should be noted, however, that
“The intentional use of physical force or power, the authors recognise violence against women
threatened or actual, against oneself, another as a fundamental violation of human rights
person, or against a group or community, that and a crime against women and society. The
either results in or has a high likelihood of authors adhere strongly to the belief that all
resulting in injury, death, psychological harm, people have the right to live a life free of
maldevelopment or deprivation”. violence and that governments around the
world are compelled to protect their citizens
Violence often occurs when there is an from such abuse. All citizens also have the
imbalance of power between individuals or right to bias-free, affordable and accessible
groups of people or nations. Due to inherent legal, social and health care services that can
social inequalities and hierarchies in society help to mitigate the negative consequences
with regard to sex, religion, race/ethnicity, of the inflicted violence.
sexual orientation, class, caste, and nation
status, violence prevails. Indian society is Within the public health framework, violence
deeply hierarchical and organised according is conceptualised as a problem that can be
to structural inequalities. Gender-based prevented and its consequences alleviated
violence, torture, and caste and communal through social and health based
violence are a few of the predominant interventions. Public health strategies can
manifestations of these hierarchies and function at various levels in responding to
inequalities, and demand serious attention violence – at the individual, community, and
and intervention by the Indian public health societal levels. As victims and survivors of
care system. Gender-based violence is violence approach the health care system for
unmistakably linked to the systematic relief of the resulting physical and
1
Mercy JA, Krug EG, Dahlberg LL, and Zwi AB. 2003. “Violence and Health: The United States in a Global
Perspective.” American Journal of Public Health, 93 (2): 256—261
2
United Nations Development Fund for Women (UNIFEM). 2003. Not A Minute More: Ending Violence Against
Women. Accessible via the Worldwide Web at: www.unifem.org
3
Heise, Lori L. 1998. “Violence Against Women: An Integrated, Ecological Framework.” Violence Against Women,
The Hidden Health Burden. The World Bank: Washington, D.C., 1994.

Gender-based Violence and the Role of the Public Health System
psychological trauma, health care factors at multiple levels which have been
professionals play an important role in the deemed significant by the current body of
treatment of such injury, rehabilitation of research at the –
victims, and prevention of further trauma " individual level (witnessing marital violence
(secondary and tertiary levels of care). With as a child; being abused during childhood;
regard to prevention – or primary level care – growing up with an absent or rejecting
community-based public health interventions father),
can be instrumental in changing social norms, " microsystem or situation in which the abuse
creating social pressures against violent takes place (male dominance in the family;
behaviour, and educating the public about the male control of wealth in the family; marital
health, social, and legal consequences of conflict; use of alcohol),
violence. While the public health system is " exosystem or informal/formal social
recognised as one of the most critical sites for structures (unemployment among men; low
addressing violence, it currently lacks the socioeconomic status of family; social
capacity and sensitivity to adequately and isolation of women and their families;
effectively respond to the needs of victims and associations with negative or sexually
survivors. aggressive peers), and the
" macrosystem or the larger set of social and
This paper focuses on the nature and types cultural beliefs and norms that influence
of gender-based violence, the health the other levels in this framework (cultural
consequences of such violence, and the definitions of masculinity linked to
current limitations of the public health system dominance, toughness, or male honour;
in responding to victims of gender-based rigid gender roles; men’s sense of ownership
violence. The paper also presents a public or entitlement over women; approval of
health model for responding specifically to physical punishment of women; cultural
victims of domestic violence – at the primary, belief that condones the use of physical
secondary, and tertiary levels – and presents violence as a means of to resolve
the Dilaasa Crisis Centre for Women at K.B. interpersonal conflicts)(Ibid.).
Bhabha Hospital in Mumbai, India, as a case
study of one of many efforts to address While violence against women and gender-
violence against women. based violence are used interchangeably, the
term violence against women is limited to acts
Gender-based Violence of violence and abuse directed against adult
Gender-based violence refers to violence females. In 1993, when the United Nations
experienced by females throughout the adopted the Declaration on the Elimination
various stages of their life. Such violence is of Violence Against Women, the General
rooted in social inequality between males and Assembly defined violence against women as:
females – an outcome of the females’ lack of “Any act of gender-based violence that results
access to social, health, educational, and in or is likely to result in, physical, sexual or
political privilege. In her paper promoting an psychological harm or suffering to women,
integrated and multi-leveled framework for including threats of such acts, coercion or
explicating the causes of violence against arbitrary deprivation of liberty, whether
women, Heise 4 argues that previous theories occurring in public or private life” (Economic
focused almost entirely on either individual and Social Council, 1992). Gender-based
factors or socio-structural factors. She violence is defined elsewhere as: “Any act of
propounds that a complete understanding of verbal or physical force, coercion or life-
violence against women must incorporate threatening deprivation, directed at an
4
a)Heise L, Raikes A, Watts CH, and Zwi AB. 1994. “Violence Against Women: A Neglected Public Health Issue
in Less Developed Countries.” Soc Sci Med, 39 (9): 1165—1179.

Table 1
Gender-based Violence Throughout the Life Cycle
Life Phase Types of Violence
Pre-birth " Sex selective abortion
" Abuse of women during
pregnancy (emotional &
physical impact on
woman; impact on birth
outcome)
" Unequal access to food
and health care
Infancy " Female infanticide " Unequal access to
" Physical, sexual, & food & health care
psychological abuse
Childhood " Forced child marriage " Incest
" Female genital mutilation " Child prostitution
" Physical, sexual, & " Unequal access to
psychological abuse food, health care, &
education
Adolescence " Dating and courtship " Sexual assault and rape
violence " Forced prostitution
" Sexual coercion " Traffickingv Incest
" Unequal access to food, " Sexual violence in the
health care, & education workplace
" Psychological, physical, " Partner homicide
sexual abuse by family
members
Child-bearing Years " Domestic violence " Forced abortions/forced
(social isolation; pregnancies
physical, psychological, " Sexual violence in the
sexual, & economic workplace
abuse by family " Unequal access to food
member/s) and health care
" Rape (including marital " Forced prostitution and
rape) pornography (sexual
" Dowry demands; Dowry- exploitation)
related homicide
" Partner homicide
Old Age " Physical, sexual, and
psychological abuse by
family members and/or
other caretakers
" Neglect and maltreatment
by family members and/
or other caretakers
" Forced suicide or
homicide of widows
" Unequal access to food
and health care

individual woman or girl that causes physical The most severe health consequence of
or psychological harm, humiliation or gender-based violence perpetrated by intimate
arbitrary deprivation of liberty and that partners and family members is homicide.8
perpetuates female subordination”.5 In the United States, domestic violence
accounts for more than one-half of the
Gender-based violence manifests itself in homicides of women each year.9 This body of
many forms: sex-selective abortion, incest, research also indicates that the majority of
trafficking, marital rape and other forms of murdered adult women are killed by their
sexual assault, sexual harassment in the husband, partner, ex-husband, or ex-partner
workplace, forced suicide, dowry-related and in the majority of murder cases, the
homicide, and various forms of physical and woman was battered when she was alive.10
emotional abuse perpetrated by intimate
partners. While uniform global and national It should be emphasised that the relationship
prevalence rates of gender-based violence do between gender-based violence and health is
not exist due to differences in the definition
not unidirectional; violence produces negative
of violence and research methodologies,
health effects while certain health conditions
research studies conducted both
internationally and within India indicate that can increase a woman’s vulnerability to
the abuse is widespread and grossly victimisation. For example, pregnancy
underreported. 6 What follows is a chart increases a woman’s risk of being battered.
summarising the various types of violence to Additionally, some studies indicate that
which females are vulnerable throughout their women who have been battered during
life cycle (adapted from Heise et al., 1994)7 pregnancy are at an increased risk of being
killed or of killing—in self-defence—their
Health Consequences of Gender-based abuser.11
Violence
Gender-based violence has severe Physical health consequences directly linked
consequences for the physical, emotional, and to intimate partner violence include broken
social well being of women victims and bones, facial trauma (such as fractured
survivors. Research demonstrates that this mandibles), tendon or ligament injuries,
violence impacts women’s health in myriad chronic headaches (a likely result of
ways – both directly and indirectly – and can neurological damage from the untreated loss
lead to chronic debilitating conditions and of consciousness often reported by battered
even death. women), undiagnosed hearing, vision and
5
a)Heise L, Raikes A, Watts CH, and Zwi AB. 1994. “Violence Against Women: A Neglected Public Health Issue in
Less Developed Countries.” Soc Sci Med, 39 (9): 1165—1179.
b) Heise L, Germaine A, and Pitanguy J. Violence Against Women: The Hidden Health Burden. The World Bank:
Washington, D.C., 1994.
6
Ellsberg M, Heise L, and Shrader E. Researching Violence Against Women: A Practical Guide for Researchers and
Advocates. Center for Health & Gender Equity and the World Health Organization, 1999; Jesani, Amar. 2002.
“Violence Against Women: Health Issues Review of Selected Indian Works.” Samyukta: A Journal of Women’s
Studies, 2 (2): 57—73
7
See footnote 4.
8
Campbell J, Lewandowski L. 1997. “Mental and Physical Health Effects of Intimate Partner Violence
on Women and Children.” Anger, Aggression, and Violence (The Psychiatric Clinics of North America),
20 (2): 353—374.
9
Fagan J, Browne A. 1994. “Violence Between Spouses and Intimates: Physical Aggression Between Women and
Men in Intimate Relationships.” Understanding and Preventing Violence, Volume 3: Social Influences. Washington,
D.C., National Academy Press.
10
Ibid.
11
Wilson M, Daly M. 1993. “Spousal Homicide Risk and Estrangement.” Violence and Victims, 8: 316.

concentration problems (also possible due to dysfunction, pelvic pain, dysmenorrhea, other
neurological damage from injuries sustained), genito-urinary health problems, and
chronic irritable bowel syndrome, and other unintended pregnancy. 14 With regard to
stress-related problems. 12 Abuse during intervention, it is interesting to note that
pregnancy can lead to low birth weight research in the West demonstrate that women
outcomes, infection (particularly related to respond without objection when asked
forced sex during pregnancy), worsening of directly by health care professionals about
chronic problems already demonstrated by the sexual abuse. In fact, the health care system
pregnant woman (such as hypertension and is identified as ‘…the only place where women
diabetes), as well as miscarriage. are likely to receive appropriate care for this
aspect of their battering experience.’15
In their review paper, Campbell &
Lewandowski (1997) described a study With regard to mental health, the primary
conducted by Plichta (1996), 13 in which mental health consequence of battering within
women facing physical violence by a spouse an ongoing intimate relationship is depression
or live-in partner were significantly more likely and the strongest risk factor for identifying
than other women to describe their health women facing violence in one study based in
status as fair. Yet their poor health was often a primary health care setting was found to be
diagnosed as due to sexually transmitted
depressive symptomology.16 Research on the
infections (STIs) and other gynaecologic
association between depression and domestic
illnesses, and they recounted needing medical
violence consistently demonstrates greater
attention but not receiving it. It is noteworthy
depressive symptomology among battered
that the increased risk of STIs among women
women as compared to other women.17 In fact,
facing violence, including HIV/ AIDS, is not a
the frequency and severity of current physical
consequence of risky sexual behaviours on
violence and stress are greater predictors of
the part of women but, rather, a direct result
of sexual assault/rape by their partners and depression among battered women, than are
to lack of protection during sexual intercourse prior histories of mental illness or
at the male partner’s insistence. In addition demographic, cultural, and childhood factors.
to the increased STIs risk, women facing High rates of Post-traumatic Stress Disorder
sexual violence are vulnerable to pelvic (PTSD) are also well-documented in battered
inflammatory disease, vaginal and anal women and the greatest indicator of PTSD
tearing and trauma, unexplained vaginal illustrated by research to date is the severity
bleeding, bladder infections, sexual of current violence.18
12
Campbell J, Lewandowski L. 1997. “Mental and Physical Health Effects of Intimate Partner Violence on Women
and Children.”…
13
Plichta, SB. 1996. “Violence, Health and Use of Health Services.” In Women’s Health and Care
Seeking Behavior. Baltimore: Johns Hopkins University Press, pages 237—270.
14
Eby K, Campbell J, Sullivan C, Davidson WS. 1995. “Health Effects of Experiences of Sexual Violence for
Women with Abusive Partners.” Health Care for Women International, 16: 563—576.
15
and Children.” Anger, Aggression, and Violence (The Psychiatric Clinics of North America), 20 (2): 353—374.
16
Hamberger LK, Saunders DG, Hovey M. 1993. “Prevalence of Domestic Violence in Community Practice and
Rate of Physician Inquiry.” Family Medicine, 24: 283—287; Campbell J, Lewandowski L. 1997. “Mental and
Physical Health Effects of Intimate Partner Violence on Women and Children.”
17
Gleason, WJ. 1993. “Mental Disorders in Battered Women: An Empirical Study.” Violence and Victims, 8: 53—
68; McCauley J, Kern DE, Kolodner K, et al. 1996. “The ‘Battering Syndrome’: Prevalence and Clinical Symptoms
of Domestic Violence in Primary Care Internal Medicine Practices.” Ann Intern Med, 123: 737—746; Ratner PA.
1993. “The Incidence of Wife Abuse and Mental Health Status in Abused Wives in Edmonton, Alberta.” Can J
Public Health, 84: 246—249.
18
and Children.”

Herman (1992)19 proposes that the mental resulting physical and psychological trauma.
health impact of ongoing and recurrent abuse Second, the public health system occupies an
and trauma is distinct from the impact of important role in the struggles of victims and
exposure to a single traumatic event. It is survivors to achieve justice. It serves as the
suggested that there are three different levels only institution that can produce medical and
of mental health response to violence – forensic evidence formally recognised by the
alterations in affect (depressive affect), criminal justice system. For example, only a
alterations in the perception of the abuser (the public hospital has the authority to register
perception of the abuser as all-powerful and medico legal cases (MLCs). For victims and
invincible by severely battered women), and survivors of violence, the public hospital is
alterations in sense of self (feelings of self- also the only place where treatment can be
blame or diminishing sense of self also obtained because private practitioners often
reported by severely battered women).20 This turn away cases of suspected violence, such
framework for looking at the mental health as suspected rape or assault. In addition to
impact of violence is extremely salient in light providing an opportunity for intervention with
of the fact that research uniformly victims and survivors of violence, the system
demonstrates that battering perpetrated provides a place where gender- and violence-
against women by their family members and/ sensitisation programmes targeting the
or intimate partners increases in both general public, health care providers,
frequency and severity over time. administrators, policy makers, and project
developers can be carried out.
Other mental health consequences of violence
include: feelings of anger and helplessness, Barriers to Intervention
self-blame, anxiety, phobias, panic disorders, Despite the critical role of the public health
eating disorders, low self-esteem, nightmares, system in responding to victims of violence,
hyper vigilance, heightened startle, memory there are a number of barriers inherent to it.
loss, and nervous breakdowns. Violence can One of the most challenging barriers is that
also give rise to unhealthy behaviors, such medical professionals are not equipped to
as smoking, alcohol and drug abuse, sexual respond adequately and sensitively to the
risk-taking, and physical inactivity. Self- issue of violence against women. This is due
harming behaviours—such as fasting—are to a number of factors, including general
also serious consequences of victimisation. indifference to victims of domestic violence
and the likelihood that health professionals
The Public Health System as a Site for also subscribe to dominant societal norms
Intervention which legitimise violence against women.
The public health system has been identified There is evidence that even when women
as an important site for the implementation facing violence are identified within the health
of anti-violence intervention programmes for care system, health care providers have a
a number of reasons. First, the health care tendency to focus on the physical
system is often the first contact for victims consequences of abuse, to be condescending
and survivors of violence, who approach and distant, and to blame women for the
health care providers for treatment of the violence they face.21 Within India, the medical
19
Herman, J. 1992. Trauma and Recovery. New York: Basic Books.
20
Dutton, MA. 1992. Empowering and Healing the Battered Woman. New York: Springer
21
and Children.”…; Kurz D, Stark E. 1988. “Not-So-Benign Neglect: The Medical Response to Battering.” In K. Yllo
and M. Bograd (Eds.) Feminist Perspectives on Wife Abuse. Newbury Park, CA: Sage; Layzer JI, Goodson BD, de
Lange C. 1986. “Children in Shelters.” Children Today, 15: 6—11; Vavarro FF, Lasko D. 1993. “Physical Abuse as
Cause of Injury in Women: Information for Orthopaedic Nurses.” Orthopaedic Nursing, 12: 37—41; Warshaw, C.
1989. “Limitations of the Medical Model in the Care of Battered Women.” Gender and Society, 3: 506—517

education system does not mention violence " Health professionals do not see their
as a health problem, nor does it include role in addressing domestic violence,
training or information on responding to as it is perceived to be a law and order
victims and survivors. This discretion could problem and an issue that requires
be a result of the fact that within the medical intervention by the police.
context, violence is comprehended as a social " Women self-reporting assaults are not
problem and/or private family matter, as it informed about the importance or
does not fit into the traditional illness model. purpose of the medico legal
As noted elsewhere, ‘The concern for violence procedure.
is conspicuous by its virtual absence in " At all levels of hospital staff, domestic
medical discourses. The special medical needs violence is not understood as a
and rehabilitation of victims and survivors of violation of the rights of women.
violence are hardly ever discussed by Rather, it is accepted as a norm and
doctors.22 as an integral part of married life.
" Research findings also indicate that
Formative research, conducted in 2000 by the hospital staff’s approach to domestic
Centre for Enquiry into Health and Allied violence is a victim-blaming one, in
Themes (CEHAT) during the planning and which women are blamed for the
implementation stages of the Dilaasa Crisis abuse perpetrated against them.
Centre for Women at K.B. Bhabha Hospital " Hospital staff members are class
in Mumbai, illuminated a number of oriented and nurture a communal
behaviour patterns, perceptions, and beliefs bias when confronted with domestic
held by medical professionals with regard to violence: it is perceived to be more
their roles in responding to the needs of prevalent among the poor, the
victims of violence. The Dilaasa team uneducated, and within religious
conducted in-depth face-to-face interviews minority communities.
with all levels of medical, paramedical, " Overall, the perceptions held by
administrative, and labour staff within the hospital staff demonstrate that they
Hospital. The team also conducted systematic too have been socialized by
non-participant observation of the Bhabha mainstream (and therefore sexist)
Hospital Casualty Department. What follows belief systems regarding women’s
is a brief summary of the key data findings. status, women’s rights, and gender
roles.
" Hospital staff—at all levels—do not
recognize domestic violence as a During this research phase, the Dilaasa team
health issue (despite the fact that they also examined and analysed the medico legal
recognize the health implications of register within the Casualty Department to
violence). gain a greater understanding of the types of
" Health care professionals perceive cases of violence registered here. This
domestic violence as a personal and examination brought to light the improper and
family matter, in which they should incomplete documentation of all medico legal
not interfere. (For example, if the cases, including those cases of gender-based
injuries examined contradict the violence.
reported history, they will refrain from
further probing into the matter or The data findings from Dilaasa’s unpublished
questioning the given history.) studies further substantiate earlier research
22
Jesani, Amar. 1995. “Violence and the Ethical Responsibility of the Medical Profession.” Issues in Medical
Ethics, January—March, 3 (1). Accessible via the Worldwide Web at: www.issuesinmedicalethics.org.

conducted by Shally Prasad.23 In her research ubiquitous and that the immediate and long-
on the medical, legal, and police responses to term adverse consequences of such violence
victims of gender-based violence in New Delhi, are well documented, public health efforts
Prasad concluded that the medico-legal must also focus its strategies on harm
responses to domestic violence, dowry-related reduction (secondary-level intervention) and
violence, and rape are grossly inadequate. Her treatment and rehabilitation (tertiary-level
conclusion was that state procedures and intervention).
systems designed to address violence against
women actually impede women’s access to Within the public health system, doctors and
needed services, further perpetrating injustice other health care providers, programme
and abuse against victims. Key data findings planners, and policy makers play specific roles
of her study—gathered primarily from semi- in both responding to victims of gender-based
structured interviews with female survivors violence and contribute to violence prevention
of abuse, police officers, case workers, NGO efforts at all three levels noted above. These
leaders, lawyers, physicians, and government roles, as well as those of policy and the media,
officials are summarised below: are summarised below and employ primary,
secondary, and tertiary public health
" Police continually turn away and create prevention strategies.
many obstacles for women in their attempts
to report their victimisation. Primary Prevention
" Physicians—both private and state- Primary prevention strategies refer to those
employed—seldom make efforts to identify efforts that can prevent violence from
cases of domestic violence. occurring in the first place. In order to achieve
" Police and physicians frequently interfere a no-tolerance approach towards gender-
with the filing of rape cases—by questioning based violence, norms and assumptions about
the victim’s story, delaying medico-legal violence against women and girl within all
authorisations, and not collecting needed facets of society must be challenged and
medical and forensic evidence. changed. ‘Society’ here refers to the public,
" There is great disparity between medico- the public health system and to the
legal protocol and actual implementation government and the criminal justice systems.
of those protocols, such as rape
examinations. In this regard, various forms of media and
" Victim-blaming attitudes are rampant public awareness campaigns can play a
within the health care, legal, and criminal critical role in fostering a greater public
justice systems, resulting in victims’ understanding of discrimination against and
reluctance to approach these systems for exploitation of women. Media can also play a
redress. role in limiting derogatory images of women
and erroneous myths about violence
Opportunities for Intervention committed against women, such as the belief
The public health model places utmost that women who are being abused must have
importance on the prevention of injury and done something to provoke the violence.
ill health (primary-level intervention). With Simultaneously, the media can also promote
regards to gender-based violence, this would positive images of girls and women. They
encompass the elimination and prevention of could portray parents’ joy after giving birth to
all forms of abuse against women and girls. a baby girl; women whose success is
However, due to the fact that such violence is determined by education or occupation rather
23
Prasad, Shally. 1996. “The Medicolegal Response to Violence Against Women in India: Implications for Women’s
Citizenship.” Paper presented at the International Conference on Violence, Abuse, and Women’s Citizenship,
Britain, UK.

than by her physical appearance and of men thus granting them credibility and authority
(such as men standing up to other men who within the community to initiate discussions
are abusers and resist perpetrating violence around sensitive topics such as violence
in their own families). The public should also against women.
be educated on the international, central
government, and state laws prohibiting In conducting anti-violence work at the
violence against women, as well as the primary prevention level, the role of men
punitive consequences they may face should cannot be omitted. Male CHVs can be trained
they violate these laws. to organise and implement educational and
awareness-building activities for adolescent
Media campaigns carried out elsewhere to boys and men on gender inequality, positive
increase public awareness about gender roles, and healthy relationships. These
interpersonal violence, gang violence, programmes should also educate men
domestic violence, rape, and sexual concerning the various tools men use to
harassment through multiple media forms control and exert power over women,
such as television, radio, and informational alternatives to using violence in relationships,
booklets have demonstrated increased public the laws which condemn violence against
knowledge about these various topics. It has women, the health and social consequences
often resulted in a positive shift in attitudes
of violence against women, as well as the
and social norms concerning domestic
consequences they could face if they break
violence and gender relations. Evaluations of
the law. The key to preventing domestic
these campaigns have also documented
violence is to change the social norms that
willingness to positively alter women’s own
sanction the use of violence against women.
behaviour and to stand up against the
In addition to working with boys and men
occurrence of gender-based violence in their
(potential perpetrators of violence), CHVs can
own communities. 24
also engage with adolescent girls and women.
Within the Indian health care setting, Awareness-building activities for girls and
community health volunteers (CHVs) can be women can increase their ability to identify
instrumental in carrying out primary the various forms of violence they may
prevention public health efforts. From the encounter in their lives. These activities
public health system, these workers are the should increase their knowledge about their
primary and vital link to both men and women rights, increase their understanding of what
in the community. Their role requires them constitutes a healthy relationship, increase
to conduct home visitations and respond to their self-esteem and the belief that they do
various health needs, including not deserve to be abused. This would instil in
immunisations, family planning, and disease them a belief in gender equality, and increase
surveillance. Due to their visibility in their capacity to stand up to and challenge
communities and the fact that CHVs generally violence and/or the threat of violence. Efforts
belong to the community in which they work, to promote women’s empowerment, economic
they are very conscious of and alert to the independence, and political representation
culture, norms, and practices of their also constitute primary prevention strategies.
respective communities. They generally As these characteristics represent ‘essential
practice within a culture-appropriate markers of gender equality,’ they are essential
framework and are not viewed as outsiders, to ending violence against women.25
24
World Health Organisation 2002
25

Secondary Prevention and protect the rights of its women citizens.

Secondary prevention strategies involve efforts
to minimise harm already done and to prevent In response to the various loopholes created
further injury from occurring. Such strategies by the added clauses, women’s groups in India
to combat violence against women include have come together to create an external
policy changes criminalising all forms of committee comprised of various experts in the
violence against women and prosecuting the field of gender-based violence, human rights,
perpetrators of that violence. In India today, and the law. The role of its members is to
there are certain forms of gender-based review the Bill in consultation with women’s
violence that are not considered criminal by groups and advocates, vocalise reservations
current law. For example, rape is defined about the new version of the Bill, and
strictly as forced penile-vaginal intercourse communicate recommended changes to the
outside marriage and excludes forced anal Ministry of Law.
sex, forced oral sex, and the use of other
objects and body parts. This current legal In addition to the creation of new policies
definition of rape not only fails to protect prohibiting all forms of violence against
women from other methods of rape, it women and girls, it is critical that efforts are
precludes the legal protection of non-female also made to ensure that laws already in
victims of rape and women who are raped by existence are properly implemented. Such
their husbands. efforts should attempt to increase feelings of
social responsibility among those whose duty
Under the Indian Domestic Violence Bill, it is to implement law and protect citizens.
domestic violence is a criminal offence. The These efforts should also seek to diminish (and
Bill – written by the Lawyer’s Collective26 in ultimately eliminate) the widespread
collaboration with various grass roots corruption and bribery that prevent victims
women’s organisations is currently pending from attaining or even seeking justice due to
in Parliament. Despite this progress, several their lack of faith in the system. While many
aspects of the Bill are problematic and limit forms of gender-based violence are illegal
victims’ ability to seek justice. After the Bill according to Indian civil law, many practices
was submitted by the Lawyer’s Collective, the such as sex-selective abortion and dowry-
Ministry maintained the same structure and related homicides are rampant, reaching
content of the proposed Bill, but added new epidemic proportions.
language and clauses that will likely create
great barriers in prosecuting perpetrators. Another secondary public health prevention
One added clause states that in order to hold strategy is to develop a trustworthy,
offenders accountable, victims must accessible, and co-ordinated reporting system
demonstrate that the occurrence of domestic that protects the safety, confidentiality and
violence is habitual. The new language also anonymity of women reporting violence, their
excludes from the definition of domestic supporters and advocates, and those witness
violence any act of violence committed in ‘self- to the acts of violence. Such a reporting
defence’. While the Indian Government claims system should involve not only the public
to protect women from domestic violence health system but should also include the
through this legislation, the new clauses police and other constituents of the criminal
create opportunities for perpetrators to justify justice system, and should incorporate
their offences. There is indication that there elements and approaches that are gender-
is no strong political will in India to chart out sensitive and rights-based. The public health
26
The Lawyer’s Collective is a New Delhi-based NGO working to increase the criminal justice system’s response to
gender-biased violence and other forms of oppression against women and girls.

system cannot be viewed in isolation from the case paper form for medical staff to indicate
criminal justice system in any discussion whether cases of domestic violence were
about preventing and responding to violence referred to Dilaasa. In addition to this,
against women. placards listing the vital signs and symptoms
of domestic violence are displayed in all
Within the health care setting, both health outpatient departments in order to assist
care and social service providers can play doctors in screening and increase the visibility
important roles in facilitating women’s of domestic violence as a health issue.
reporting of the abuses they are facing and in
educating women about available medical and For patients, media can also be a powerful
social services. Health care providers such tool to increase awareness of domestic
as doctors and nurses can be educated in violence as a health issue. Placing posters in
regard to all forms of gender-based violence hospitals and other public places conveys a
and helped to consider the issue as an message that violence against women is a
important public health concern. These crime and does not have to be endured
providers can also be trained to identify abuse silently. Pamphlets, brochures, and placards
among their patients by employing careful and also increase awareness of the existing
sensitive probing techniques, providing a safe organisations and programs that provide
and confidential space within the health care useful and needed services for victims.
setting for the sharing of histories of violence,
and by assuming a non-judgemental and In addition to sensitising health care
caring demeanour and attitude. These providers, patients, and the general public, it
providers can also be trained to carry out is imperative for policy makers to acknowledge
proper and thorough documentation of recent domestic violence as a public health issue of
incidents of abuse, the resulting injuries, and great concern and importance. Decision
the history of violence, and to subsequently makers’ ability and willingness to establish
make referrals to the appropriate agency or policy and protocols within the health care
department for further care and emotional and system to respond to gender-based violence
social support. is contingent upon their commitment to the
issue. Only then can they advocate for the
Research suggests that, in addition to provider allocation of resources to train health care
training programmes, instituting changes in providers, monitor/evaluate anti-violence
in-patient care procedures (such as placing efforts, and co-ordinate with other service
reminders for providers in patient charts to agencies for victims of gender-based violence.
screen for abuse or incorporating abuse- Within any large or bureaucratic system,
related questions in standard patient intake mandate from the higher level is necessary
forms) significantly impact the behaviour of for any institutional change to occur.
health care providers. At the Dilaasa Crisis
Centre for Women, a hospital-based With regards to CHVs (see above sections), at
intervention program providing emotional and the secondary prevention level, they can play
social support for women facing domestic a role in organising both men and women on
violence in Mumbai, a number of such the issue of gender-based violence. They can
strategies were used. On the case paper forms use methods such as protesting outside a
used by medical staff for each patient of the known abuser’s home to exert social
hospital, ‘domestic violence’ was added to the pressure 27 and identify resource agencies
list of health problems for which doctors within the community who can respond to the
routinely screen. There is also a place in the needs of victims. Through work conducted by
27
Exerting social pressure through such means can also function as a primary prevention strategy by deterring
other men in the community from perpetrating violence against women.

Dilaasa with CHVs, the Centre realised the within clinical settings are most likely called
crucial link between the domestic violence upon to intervene at the tertiary level. As noted
victims and the health care system that these in the previous section, doctors and nursing
workers form. During sensitisation training staff are expected to fulfil the following roles:
conducted for CHVs by Dilaasa, it was (1) screening, (2) documentation, and (3)
discovered that while these community-based referral. Health care providers – particularly
health workers are easily able to identify doctors – are in a unique position to identify
women facing violence, their training and victims of violence. In addition to the fact that
background do not equip them with the they are often the first contact for victims
necessary skills to adequately respond to the seeking treatment, they are highly regarded
emotional needs of women facing violence and seen as neutral entities to whom patients
even though women openly shared their can easily confide. This unique position
histories of violence with them. While CHVs affords doctors the ability to enquire into the
may be unable to provide the social and current (or most recent) episode of violence,
psychological support women seek, they can as well as the history of abuse. Furthermore,
provide supportive and gender-sensitive within the public health system, doctors are
messages and aid women in accessing needed the only individuals with the authority to
physical and mental health care. register medico-legal cases, conduct
autopsies, collect important forensic evidence,
Tertiary Prevention and carry out post mortem examinations. All
Tertiary prevention efforts refer to strategies these procedures are necessary to prove the
aimed at addressing previous exposures to incidence of violence and punish the
physical, emotional, sexual violence, and their perpetrator.
sequel. Within the public health framework,
such strategies would involve the delivery of Dilaasa as a Model
mental health and support services based The Dilaasa Crisis Centre for Women is a joint
within community or health care settings. initiative of the Brihanmumbai Municipal
Such services would involve gender-sensitive Corporation (BMC) and CEHAT. It is a public
counselling, advocacy, referrals to other hospital-based crisis centre that provides
needed social services (such as shelter, legal social and psychological support to women
aid, educational and job training programs, facing domestic violence. In addition to
and medical services), and assistance in providing emotional support through ongoing
negotiating and accessing these various, and counselling, Dilaasa provides women with
often fragmented, service systems. Such referrals to medical care, filing of complaints
interventions should focus on empowering at the police station, shelter, legal agencies,
women and helping them to attain violence- and other social services and helps to facilitate
free lives without judgement or imposition of women’s access to these needed services. The
our own ideas and opinions. This can be other key functions of Dilaasa are training,
accomplished through validation of the research, and networking. Dilaasa is the first
trauma associated with abuse, education project of its kind in India with the aim of
about various options women have, and help sensitising the public health system to gender-
with identification of personal and social based violence and establishing a hospital-
network strengths. based crisis centre in India for women victims
and survivors of violence.
Once women enter the health care setting,
the levels of violence—as well as their physical With regards to training, the entire staff of
and psychological injuries—are likely to have K.B. Bhabha Hospital has been sensitised to
reached unbearable and severe states. the issue of gender and trained in the area of
Because of this, doctors and nurses working domestic violence as a health issue. In

addition to this widespread training, a core " The establishment of the Centre itself
group of hospital staff demonstrating demonstrates the successful
leadership and passion for this issue have mainstreaming of domestic violence within
emerged and been trained as key trainers. The the public health system.
formation of the core group will hopefully lead " The BMC has shown willingness to replicate
to one of the most important objectives of the Dilaasa model in other hospitals under
Dilaasa’s training program—the formation of its authority.
a permanent and institutionalised training cell " CEHAT has trained the deputed staff of the
within the public health system. The ongoing BMC to conduct ongoing awareness
training of health care professionals will building and training activities, as well as
hopefully instil in them the attitudes, manage the Centre’s functioning once
knowledge, and tools to respond sensitively CEHAT withdraws from the project.
and effectively to victims of violence. Their
ability to view, screen, document, and refer The activities of Dilaasa do assume a more
victims is integral to their roles as health care clinical and ‘treatment-based’ orientation and
providers and could undo many of the operate primarily at the secondary and tertiary
common misconceptions they hold about levels of the public health prevention model.
violence against women, victimisation, and This is due to a number of factors. Firstly,
their role in responding to this public health the Centre is based in a hospital and serves
problem. Regarding research activities, in women who have already been victimised by
addition to the formative research described violence in their homes. Due to the
above, research conducted to evaluate the characteristics of this population, it is
impact of hospital staff training is ongoing and essential that services provided are tailored
the Centre is currently conducting an to their needs— to save lives, to prevent
exploratory study on the impact of crisis further injury and harm, and to help bring
counselling on the lives of women coming to healing to the injuries and trauma they have
Dilaasa. already suffered.
Through networking efforts, Dilaasa has also
Despite the focus on secondary and tertiary
helped to create visibility of domestic violence
strategies, the ultimate goal of this work is to
as a health issue within other health facilities
eliminate all forms of violence against women
of the BMC. Gender-sensitisation and training
and prevent violence from ever occurring.
on domestic violence for staff from other
However, the distressing truth is that violence
hospitals is currently underway. Dilaasa is
against women is rampant and within our
also outreaching to other organisations to
context – where services are so sparse and
establish additional referral links. Besides
the issue remains a taboo topic, efforts have
this, relationships with primary health care
primarily focused on the crisis needs of
facilities are being developed to increase
women. While it takes an extremely long time
identification of victims and survivors, and to
increase referrals to the Dilaasa Crisis Centre. to change social norms and attitudes, which
remains the key element in preventing
Some of the successes of the Centre to date violence against women, all such work is
include the following: important and essential. Thus, in the next
phase of the Dilaasa project, primary
" Increased referral rates to the Centre, an prevention activities will be designed and
indicator of its accessibility and usefulness carried out. In particular, Dilaasa will create
to women facing violence formal linkages with constituents
" Increased awareness and an enhanced representing all levels of the health care
understanding of women’s health care delivery system in order to institutionalise
needs among health care providers anti-violence work throughout the system.

Conclusion of violence – socially and institutionally

While global, national, and local anti-violence entrenched sexist beliefs/practices and
movements have made significant gender inequality – are mutable. While these
contributions to the field, violent crimes social and structural changes are extremely
committed against women remain a huge difficult to achieve, such work is essential and
health and social problem and the prevalence unavoidable in order to end gender-based
of such violence has not been reduced violence
dramatically.28 Creating new programs and
protocols to respond to women facing violence, In addition to primary prevention efforts, one
conducting cutting edge research on the cannot ignore the fact that a large number of
epidemiology of gender-based violence, and women are already accessing the health care
increasing public visibility of this issue system for complaints arising from violence.
through activism is vital. According to There is therefore also a need to plan and
UNIFEM’s most recent report, Not A Minute
implement programmes within the health care
More (released November 2003)29, one in three
system that provide the much-needed social
women around the world will be raped,
and psychological support required by women
coerced into unwanted sexual relations, or
in crises and to reduce harm caused by the
abused in one or other form during her
violence. Violence against women has only
lifetime. It is clear that the labour and the
advancements made in the last decade are recently been acknowledged as a public health
not enough. concern and thus greater efforts must be
made to sensitise all levels of the system to
Violence against women can be prevented and the roots, nature and consequences of such
its impact reduced in the same way that public violence, as well as to the opportunities for
health efforts have prevented and reduced intervention.
pregnancy-related complications,
occupational hazards, and infectious diseases Operating at the various levels described
resulting from contaminated food and water. throughout the paper is essential to ensure
The factors that contribute to the prevalence all women’s right to live a life free of violence.
28
29
Ibid.

SECTION 4
HEALTH SYSTEMS AND RESOURCES
Indian Systems of Medicine (ISM) and
Public Health Care in India
Leena Abraham
Introduction The ISM sector today includes a vast network

In contemporary India, alongside the large of practitioners, training institutions, research
network of allopathic medicine (also called institutions and drug manufacturers with
modern medicine or bio-medicine), traditional national and international recognition. ISM
medical systems such as ayurveda, unani, can no longer be ignored not only because of
siddha and naturopathy provide health care its numerical strength (Table 1) but because
services to a vast population. However, these it is actively engaged in the political, economic
systems, officially called ‘Indian Systems of and to some extent the epistemological
Medicine’ (ISM) and popularly known as discourses of contemporary times.
‘indigenous systems’, have received little
attention in the public health care discourse At the political level ISM symbolises cultural
in India. The dominant medical discourse nationalism and contributes to strengthening
projects ISM as the ‘unscientific other’ and of the national identity, in the context of
assigns it a peripheral, residual role in the
globalisation. At the economic level, ISM
overall health care system, which is designed
opens up several avenues for newer
and organised on the principles and practices
commodities and services that can be
of allopathy. The Government of India, under
profitably marketed and exported. At the
the banner ‘Indian Systems of Medicine’,
epistemological level, it is engaged in a process
recognises ayurveda, unani, siddha,
naturopathy and yoga as valid medical of validation of traditional knowledge
selectively using elements of modern science
systems1. This has provided political visibility
and besides, it represents alternative world
to these systems although the financial views. 2 Thus ISM has emerged as an
allocation by the state, for all these systems important player in India, influencing the
together, constitutes only around five percent
overall health culture in a significant manner.
of the total, with ninety five per cent being
The issues concerning ISM are complex and
allocated for the allopathic system. Despite
far too many. In this paper a modest attempt
formally recognising ISM, state has not
is made to highlight some of these issues that
formulated any clear policies to utilise its
services in providing public health care in have implications for public health care in
India. Although marginalised by the medical India.
discourse and neglected by the State for over
a century, ISM not only survived but has ! The first three sections of the paper will
emerged as a powerful sector in the field of provide an overview of the development of
health care. It has grown mainly through the ISM focussing on the historical, cultural
informal private sector in health care. and institutional contexts.
1
Homeopathy, a distinct system from ISM, is also recognised by the state as a valid medical system. Homeopathy
came to India during the colonial times and has become a popular system of health care. Although it has a
distinct history of development in India, in this paper, homeopathy has been discussed along with ISM as the
overall state policies and the medical discourse treats it as a marginal system.
2
Bode, Maarten (2004) ‘Ayurvedic and Unani Health and Beauty Products: Reworking India’s Medical Traditions’.
University of Amsterdam, Ph.D. Thesis.
Review of Health Care in India " 187

Indian Systems of Medicine (ISM) and Public Health Care in India
! The section that follows will provide a followed the general neglect of these systems
description of the spread of resources and by the State.
infrastructure in ISM and
! the last section will draw attention to some The reasons for the neglect of ISM by the state
of the current issues concerning ISM that are both historical and political. The
have implications for public health care traditional medical systems such as ayurveda
in the country. and unani, the main providers of health care
until the turn of the twentieth century, met
Development of ISM Discourses of with mixed responses from the colonial
Tradition and Modernity: The Historical powers. Until the 1830s, indigenous systems
Context3 were looked upon as a cheap source of health
The vast colonial historiography of medicine care and at times were admired for the
has expanded our knowledge of the contexts vastness and depth of their knowledge. There
that led to the establishment of allopathy and were occasions even later, in the second half
its hegemony in India4. We also know of the of the nineteenth century especially after the
colonial character of the health care system mutiny, when the colonial administration
that was established. However, we know very relied on practitioners of these systems in
little about the history of ISM. While there is order to extend health services to the rural
some anthropological and sociological masses 5 or used them as carriers of modern
research on ISM in more recent times, they medicine in order to make it more acceptable
have been very sketchy. The general neglect to the masses.6 However, the colonial state
of research on ISM by the social sciences has systematically refrained from officially
3
This section is based on a research study on the social history of ISM education in India, Abraham, L (2001), The
Social History of Medical Education (ISM) in India. Mumbai, Tata Institute of Social Sciences (unpublished
monograph).
4
There is a large volume of literature on the colonial history of allopathic care in India: Jaggi, O.P. (1969-1980)
History of Science, Technology and Medicine in India, 15 Vols., Delhi, Atma Ram and Sons. Arnold, D. (ed.) (1988)
Imperial Medicine and Indigenous Societies, Delhi, OUP; Ramasubban 1988, Imperial Health in British India,
1857-1900’ in Disease, Medicine and Empire edited by MacLeod and Lewis, London, Routledge; Jeffrey, Roger
(1988). The Politics of Health in India. Berkeley, University of California Press; Bala, P. (1991) Imperialism and
Medicine in Bengal: A Socio-historical Perspective, New Delhi, Sage Publications; Harrison, M (1994) Public
Health in British India: Anglo-Indian Preventive Medicine 1859-1914. Cambridge History of Medicine Series, New
Delhi, Cambridge, University Press; Kumar, A. (1998) Medicine and the Raj: British Medical Policy in India, 1835-
1911. Delhi, Sage; Pati, Biswamoy and Mark Harrison (eds.) (2001) Health, Medicine and Empire: Perspectives on
Colonial India. New Delhi, Orient Longman.
ISM history is a relatively neglected area of research. The few studies on ISM include: Brass, P.R. (1972) ‘The
Politics of Ayurvedic Education: A Case Study of Revivalism and Modernization in India’, in Education and Politics
in India edited by Susanne H. Rudolph and Lloyd I. Rudolph, Delhi Oxford University Press; Bhardwaj, S.M.
(1980) ‘Medical Pluralism and Homeopathy: A Geographic Perspective’, Social Science and Medicine, Vol.14B,
209-216; Bhardwaj, S.M. (1981) ‘Homeopathy in India’, in The Social and Cultural Context of Medicine in India,
edited by Giri Raj Gupta, Main Currents in Indian Sociology, Vol. 6, New Delhi, Vikas Publication House; Bala P.
(1984) ‘Ayurveda and the British Raj : Factors Influencing State Policy in British India’, Studies in History of
Medicine, Vol.7, Nos.1-2, 13-15; Pannikkar, K. N. (1995) Culture, Ideology, Hegemony: Intellectuals and Social
Consciousness in Colonial India. New Delhi, Tulika; Visvanathan, Shiv (1997) A Carnival for Science: Essays on
Science, Technology and Development, Delhi, Oxford University Press. ( Chapter 4. Modern Medicine and its Non-
Modern Critics: A Study in Discourse); Hausman, G. J. (2002) Making Medicine Indigenous: Homeopathy in
South India, Social History of Medicine, Vol. 15, 303-322. Recently there have been some publications in the early
history of ayurveda, unani and homeopathy. They include Meulenbeld, G. J. and Dominik Wujastyk (eds.) (1987)
Studies on Indian Medical History, Egbert Forsten, Groningen and Zysk, K. G. (1991) Asceticism and Healing in
Ancient India: Medicine in the Buddhist Monastery. New York, OUP.
5
Arnold, D. (ed.) (1988) Imperial Medicine and Indigenous Societies, Delhi, OUP.
6
Hume, J. C. (1977) Rival Traditions : Western Medicine and Ynan-I-Tibb in the Punjab, 1849-1889, Bulletin of the
History of Medicine, pp.214-231.

Leena Abraham
recognising the indigenous systems as well and hakims. This period of ISM history,
as from any financial assistance that especially the end of the nineteenth and the
contributed to the development of these beginning of the twentieth century, is a period
systems. Various economic and political that brought fundamental changes in the
contingencies prevented the colonial character of these systems. New medical
administration from banning these systems, colleges in ayurveda and unani were started,
although it was considered on a few occasions. some of the traditional patsalas and tols
(schools) were converted to modern medical
The colonial health policies were based on colleges and manufacturing and marketing of
western science and mostly aimed to meet the ayurvedic and unani products using modern
requirements of the colonial power. By the technology were established. All this changed
early 20 th century, the exclusive state the practice of the hitherto traditional
patronage of the allopathic system and the systems. Some of these developments were
development of the allopathic profession had used to counter the argument that they were
shaped a medical discourse that privileged ‘unscientific’, to demonstrate that they adapt
‘scientific’ medicine and led to the hegemony to changing modern situations as well as to
of allopathy. The neglect by the colonial state show that they were not ‘closed systems’ by
and more importantly the discrediting of ISM adopting elements of modern medicine
and the humiliation experienced by its including pharmacology. Later some of the
practitioners, led to the formation in 1907of pharmaceutical companies even set up
their political organisation, the All India research units that were modern and that
Ayurvedic Mahasammelan (Ayurvedic appear similar to the pharmaceutical firms of
Congress). By then it became clear to the allopathy. Ayurvedists were at the forefront
proponents of ISM that the traditional systems of this movement with the active involvement
had only rhetorical value for the Nationalist of hakims.
movement, which did not embody any genuine
concern for their development. Under the new The counter ayurvedic discourse however
organisation, attempts were made to address fundamentally changed both the form and
the issues of the ‘scientific status’ and the content of ayurveda. This period, which
criticism that these systems of knowledge had extended upto the 1960s, is also marked by
declined from a glorious past and were in a intense debate within ayurveda, between the
state of degeneration and disarray. The purists (adherents of shuddha/classical
leadership was provided by stalwarts like tradition or the revivalists) and the modernists
Hakim Ajmal Khan, Pandit Shiv Sharma, (advocates of modernisation and innovation)
Vaidyaratnam P. S. Varrier and others. which even led to a radical attempt at
integrating allopathy with ayurveda in their
The Ayurvedic Congress began to address the medical colleges.7 This attempt was a failure
issue of state recognition vigorously. They not only due to the unresolved theoretical
challenged the ‘unscientific’ status ascribed incompatibility of the two systems but also
to them which they argued was unfair and due to the inability to prevent attempts made
politically motivated. Their attempts to revive to use this as a back door entry into the
the status were not confined to such political allopathic system. The aspirants to the much
measures alone but efforts were coveted allopathic medical profession found
simultaneously made towards modernising this to be easier route to enter the profession
and institutionalising training, research and which invited severe criticisms from the
manufacture of drugs by some of the vaidyas allopathic profession. There were prolonged
7
Brass, P.R. (1972) ‘The Politics of Ayurvedic Education: A Case Study of Revivalism and Modernization in India’,
in Education and Politics in India edited by Susanne H. Rudolph and Lloyd I. Rudolph, Delhi Oxford University
Press.

nationwide strikes in allopathic medical ISM and Medical Pluralism: The Cultural
colleges against the integration and what was Context
termed as ‘diluting’ and ‘corrupting’ the Although the public health care system
‘scientific’ knowledge. The professional excludes ISM, the health culture in India
interests of the allopathic community and the continues to be pluralistic in nature as people
political pressure that they were able to bear negotiate therapies of the various medical
upon the state brought an end to this systems. They use all or some of these systems
experiment. The traditional systems, either simultaneously or sequentially, for a
especially ayurveda, survived despite such single ailment or for different ailments. The
turmoil from within the system and attack choice of therapy may vary according to
from outside. This is evident from the fact that gender, age group or other social and
the number of medical colleges, practitioners economic status of individuals within the
and pharma companies in ayurveda and family. This phenomenon is so ubiquitous that
unani has grown many fold over the years. perhaps there are no families in India that
Thus the ISM sector today is characterised have not contributed to therapeutic pluralism.
by pluralism, where traditional practices This is a unique situation where a dynamic
continue along with the modern. therapeutic pluralism is supported by
epistemologically and culturally divergent
In post independent India, the development medical systems and practices that compete
model that was adopted, based on and co-exist with each other.
modernisation and ‘scientific development’,
not only promoted allopathy but could not find In the building of modern India, however, it
any relevance for traditional systems in this was visualised that the traditional, indigenous
model 8. This strengthened the hegemonic practices along with their practitioners would
position of allopathy and reaffirmed the status gradually give way to modern medicine as
of the traditional systems as being modern education and health care facilities
‘unscientific’. However, a banning of these spread through the country. The latter did
systems was never considered for various happen, but the indigenous systems did not
reasons; they continued to provide health care disappear. Instead, a medical pluralism based
services to the masses of India, there were on a hierarchy of medical systems has
practitioners and supporters of these systems emerged. The politics of health care in the
who were politically powerful and moreover, colonial and postcolonial period that shaped
the cause of these medical systems were used the present day biomedical discourse also
in the rhetoric of cultural nationalism against transformed medical pluralism from being
western imperialism of the colonial powers. non-hierarchical in the pre-colonial times to
While the ground reality became the a hierarchical one in post-colonial times9. The
instrumental factor for the continuation of ‘scientific’ status as well the economic and
traditional systems, the economic and political political power that each system wields, both
power of the lobbyists, especially of ayurveda nationally and internationally, determine their
and unani, forced the government to extend positioning in the hierarchy. Allopathy
legitimacy to these systems and their occupies the privileged and incomparable
practices. In the nationalist rebuilding of position in this regard, followed by Ayurveda
India, the rhetoric of the ‘glorious past’ which and other systems. It is privileged by the
included ayurvedic knowledge continued to ideology of science, as being the only
be evoked. legitimate scientific system which places it in
8
The Bhore Committee Report (1946) which provided the blue print for health care planning in independent India
found no place for ISM.
9
Abraham, L (2001), The Social History of Medical Education (ISM) in India. Mumbai, Tata Institute of Social
Sciences (unpublished monograph).

Leena Abraham
a superior position vis-à-vis all other medical the folk classificatory models of illness13 while
systems. others argued that people’s health care
behaviour was influenced by a broad cultural
The development of medical pluralism, the framework that was derived from the
structural and cultural bases of pluralism and ayurvedic system.14 Some of the authors also
the economics and politics that shape this demonstrated that people extend the same
phenomenon have not yet received adequate ayurvedic framework to the understanding of
academic attention. However, there is some modern systems such as allopathy.15 Briefly
social science literature on why people stated, sociologists argued that people use
continue to use traditional systems. Social non-allopathic systems because they were
science research in the 1960s and 1970s inexpensive, easily available and the
argued that allopathy was physically interaction with practitioners took place in the
inaccessible to a large segment of the Indian comfort of a familiar social and cultural
people, especially to the rural masses, and it setting. Unlike the sociologists who stressed
was this vacuum that the other systems the material aspects of health care,
occupied.10 This line of argument continued anthropologists stressed the cultural,
with the added note that the physical distance idiomatic and the cognitive aspects of healing.
between the rural poor and the elite doctors
was exacerbated by social distance. 11 In Apart from some of these reasons, in recent
general, it was argued that poverty, social years, as personal anecdotes and media
inequality and backwardness resulting from reports show, there is a growing
lack of education, drive people to traditional disenchantment with the claims of allopathy
practitioners, described often as ‘quacks’. In in providing satisfactory cures for many
the 1980s, several anthropologists argued that ailments and also with rising unethical
it is the cultural belief systems of the rural practices such as excess medication and use
people that largely determined their health of unnecessary and invasive methods of
seeking behaviour.12 Some authors elaborated diagnosis, with the side effects of several
10
Gould H.A. (1965) ‘Modern Medicine and Folk Cognition in Rural India ‘, Human Organisation, Vol.24, 201-
208; Madan, T.N. (1969) ‘Who Chooses Modern Medicine and Why? ‘, Economic and Political Weekly, Vol.4, 245-
253; Paul, B.D. (ed.) (1975) Health, Culture and Community, New York, Russell Sage Publication; Minocha, A.
(1980) Medical Pluralism and Health Services in India, Social Science and Medicine, vol.14, 217-223; Banerji, D.
(1981a) ‘The Place of Indigenous and Western Systems of Medicine in the Health Services of India’, Social Science
and Medicine, Vol. 15A, 109-114.
11
Djurfeldt, G. and Lindberg S. (1976) Pills against Poverty: A Study of the Introduction of Western Medicine in a
Tamil Village, New Delhi, Oxford and IBH Publishing Co.; Banerji, D. (1981b) ‘Crisis in the Medical Profession in
India’, Economic and Political Weekly, Vol. 24, 1091-1092; Banerji, D. (1982) Poverty, Class and Health Culture
in India. New Delhi, Prachi Prakasan.
12
Leslie, C. (1980) ‘Medical Pluralism in World Perspective ‘, Social Science and Medicine, Vol.14, 191-195;
Gupta, G.R., (ed.)(1981) The Social and Cultural Context of Medicine in India, Main Currents in Indian Sociology,
Vol. 6, New Delhi, Vikas Publication House; Nordstorm Carolyn, R. (1988) ‘Exploring Pluralism – The Many Faces
of Ayurveda’, Social Science and Medicine, Vol.27, No.5, 479-489.
13
Nichter Mark (1980) ‘ The Lay Person’s Perception of Medicine as Perspective into Utilization of Multiple Therapy
Systems in the Indian Context’, Social Science and Medicine, Vol. 14B, 225-233.
14
Kakar, S. (1982) Shamans, Mystics and Doctors : A Psychological Inquiry in India and Its Healing Traditions,
Delhi, Oxford University Press; Zimmermann, F. (1987) The Jungle and the Aroma of Meats: An Ecological Theme
in Hindu Medicine. Berkeley, University of California Press; Lambert, H. (1992) ‘The Cultural Logic of Indian
Medicine : Prognosis and Etiology in Rajasthani Popular Therapeutics’, Social Science and Medicine, Vol.34,
No.10, 1069-1076; Langford, J. (1995) ‘Ayurvdic Interiors : Person, Space and Episteme in Three Medical practices’,
Cultural Anthropology, Vol. 10, No.3, 330-366.
15
Leslie Charles (1992) Interpretations of Illness: Syncretism in Modern Ayurveda, Paths to Asian Medical
Knowledge, (eds.) Charles Leslie and Allan Young, Berkeley, University of California Press, 177-208; Leslie, C.
and A. Young (1992) Paths to Asian Medical Knowledge. Berkeley, University of California Press.

medications used in the treatment of chronic research for the allopathic system as well as
ailments coupled with the increasing use of for the state18. There has been no engagement
surgeries; practices that are often driven by with the critique of the various medical
an overriding motivation for profits. The systems, their structural bases, cultural
inability of the allopathic system to deliver manifestations and their shifting axis of
services, the market induced demand for power. What has been lost is a body of
alternative care, the growing popularity of research that produced incisive analyses of
‘natural’ cures and the government policy of medical pluralism and how it is shaping the
recognising multiple health care systems health care realities of people on the one hand
provide the broader social and political and how people use pluralism in an enabling
contexts for the growth of medical pluralism. manner to shape their own health care
By neglecting ISM, social science research has destinies on the other.
abdicated the responsibility of critically
evaluating the largest segment of health care The class analyses undertaken provided
and failed to contribute to an understanding excellent expositions of the class bias in
of the complex health care reality in India, service delivery and the class character of
research that would have contributed to allopathic medical education. At the same
designing more equitable and wide spread time the health care scenario was visualised
health care services16. This is because the where the English speaking, elite
researchers remained committed to professionals provided primary care to the vast
allopathy17 and continued to stay with the public. Medical care would be elitist, upper
conviction that modern medicine by virtue of class, but was expected to fulfil the dream of
the superiority of its scientific knowledge will equity in a society that is vertically and
eventually replace traditional and other horizontally divided along class, caste, gender
systems of care. The social science research and ethnic axis. When health care, including
in health closely followed the objectives of primary care, was seen as a highly specialised
allopathy and was critical only in so far as its area of knowledge it only strengthened the
practices deviated from its stated goals or hegemony of the allopathic profession. It was
when the state showed unwillingness to either unfashionable or inconceivable to
adequately supply allopathic care. The bulk recognise the services of the non-allopathic
of social science research has been advocacy practitioners and to consider their inclusion
16
Documents such as the one prepared by Naik, J.P. (1977) An Alternative System of Health Care Services in
India: Some General Considerations, in An Alternative System of Health Care Services in India: Some Proposals,
by J. P. Naik. Bombay: Allied Publishers Private Ltd., pp. 3-30; Banerji, D. (1977) Formulating an Alternative
Rural Health Care System for India: Issues and Perspectives, in An Alternative System of Health Care Services in
India: Some Proposals, edited by J.P. Naik, Bombay, Allied Publishers Private Ltd., 31-50; ICSSR and ICMR
(1981) Health for All: An Alternative Strategy, Pune, Indian Institute of Education have paid very little attention to
the issue of ISM and the army of indigenous practitioners. Subsequent publications on public health care in India
continue to show the same apathy. For e.g., this glaring neglect can be seen in the two major publications on the
health status of Kerala (Panikar, P.G.K. and C.R. Soman (1984) Health Status of Kerala. Trivandrum, CDS;
Kannan, K.P., et al. (1993) Health and Development in Rural Kerala. Trivandrum, Kerala Shastra Sahitya Parishad)
which do not mention ayurveda or homeopathy although these two systems are widely used in the state.
17
Perhaps this was also because some of the leading social science researchers in health were themselves trained
allopathic doctors.
18
It is interesting to note that the focus of many research studies was ‘compliance’: why are people not ‘complying’
with allopathic care? And why are the allopathic practitioners not ‘complying’ with the plans and the programmes
of the government.

Leena Abraham
into the formal health care system19. However, and institutions. It includes a small public
the continued political pressure from the ISM sector and a large private sector based on the
sector and the repeated recommendations of sources of financing. Then there are trained
a number of committees set up by various practitioners and untrained practitioners, and
governments led to the setting up of various there are practitioners who have received their
institutions of ISM by the state. training through an institution or through
apprenticeship.
Development of ISM in Independent India
The neglect of ISM by the state which began The classification presented in Figure 1
during the colonial times did not significantly combines categories used in the analyses of
change after the independence. Although medical systems and lay categories. In the
several committees were set up after field all these categories overlap in complex
Independence to look into various aspects of ways. This classification must be used as a
ISM and Homeopathy and several heuristic device for the purpose of analysis
recommendations were gradually and communication rather than as mirroring
implemented, the Indian state did not actively the reality. Distinctions can be made not only
intervene until the 1970s (See Appendix I). between medical systems and practices, but
Until then, the state neither actively supported are discernible also within each system and
ISM nor strictly regulated their practices. The each category of practitioners. Ayurveda, for
minimal yet continuous support extended by instance, is not a unified system of medicine.
the state provided legitimacy for the existence Seeing it thus obscures the diversity of textual
and practice of these systems. More interpretations and therapeutic practices that
importantly, the lack of active support led to goes on in the day-to-day practice of ayurveda.
several paths of institutional development Broad classifications also tend to obscure
initiated from within, especially in the areas ‘cross practices’ followed by practitioners of
of medical training and pharmaceutical all systems of medicine. Nevertheless, we use
production20. The flip side of the argument is these categories as signposts to explore the
that, by neglecting this sector, the state ISM sector in India.
allowed an unregulated growth of the private
sector, which has resulted in a scenario that The Informal Sector
appears quite chaotic. Along with the state recognised medical
practices, there is a vast spectrum of informal
The ISM sector, as Figure 1 shows, consists health care services that may be based on the
of a large category of practitioners and medical knowledge and practices of ISM. Some
institutions unlike the more homogenous and of these services may also combine spiritual
monolithic allopathic system. It includes both and ritual healing along with medical care (Fig
a formal sector and an informal sector, a 1). A distinguishing feature of this folk
division that can be made based on state spectrum of care is that the knowledge and
recognition of the practitioners (registered) skills are not codified in texts. They are vested
19
For instance, the responses to train the dais were lukewarm and the policy to keep them at the lowest level of
health care services was never questioned. The resistance by the allopathic profession towards integrating different
systems of medicine and their opposition to introduce allopathic subjects into the ISM courses were endorsed by
the social scientists. The catch 22 situation continued: practitioners of ISM lacked scientific knowledge and
therefore their practices were invalid while scientific knowledge could not be given to them because their practices
were invalid.
20
The contributions of several individuals and pharmaceutical establishments are significant. Noteworthy are
names such as P.S. Varier of Kerala, Nanal of Maharashtra, the Azziz brothers of Lucknow etc. Firms such as
Zandu, Dabur and Himalaya drug company popularised the ‘ayurvedic’ brand name. This period is marked by
several innovations in modernising the traditional systems.

with individual healers and transmitted orally. There have been two lines of institutional
Although their practices are strictly speaking, development initiated by the state: one for the
‘illegal’ they are not banned by the state. They regulation of educational standards and
are ‘quacks’ in the eyes of formal medical professional practices and the other
systems but there is no concerted effort to concerned with the promotion of research. The
discredit or displace them. They continue to Central Council of Indian Medicine
provide health care services both in the established in 1971 and the Central Council
hinterland of rural India and in the heart of of Homeopathy established in 1973 are
cities. The folk practitioners are roughly responsible for maintaining uniform
estimated to be over a million (1991 standards of education in these systems
estimates). There is really no way of arriving throughout the country and also for the
at a reliable count of these practitioners. Yet, regulation of the professional practice of
as one anthropologist observed on the basis these systems. There are four separate central
of his extensive stay and field visits through councils to support research in ISM and
the country, these practitioners along with the Homeopathy. Since 2003 all the activities
ISM practitioners are ‘the most accessible and associated with ISM and homeopathy have
most used source of medical care in the been brought under the administration of a
country’21. Thus the overall contribution of separate ministry called the Ministry of
ISM to health care in India has been almost AYUSH.
exclusively through the private informal
sector. The services of the informal sector cut Several institutes were set up under the
across class, caste and gender barriers and Ministry of Health and Family Welfare as
they treat not only somatic illnesses but a autonomous organisations to provide
range of psychosomatic conditions as well. leadership in training and research. They
Thus a large informal sector carries on include the Rashtriya Ayurveda Vidyapeeth
unregulated, while a much smaller formal at Delhi, the National Institute of Ayurveda
sector is developed by the state. at Jaipur, the National Institute of
Homeopathy at Calcutta, the National
ISM and the State: Legitimacy Through Institute of Unani Medicine at Bangalore, and
Institutionalisation the National Institute of Naturopathy at Pune.
The state financed institutional development Apart from the above institutes, the Gujarat
of ISM and Homeopathy in post-colonial India Ayurveda University at Jamnagar and the
really took off only in the 1970s and 1980s Banaras Hindu University at Varanasi also
when institutions structurally similar to those offer post-graduate training and research in
in allopathy were established in ayurveda and ayurveda.
homeopathy. Till then there was confusion in
the administration in terms of the direction The training and research institutions in ISM
that these ‘indigenous’ systems should take, are structurally designed along the model of
how they would modernise and to what extent. allopathic institutions. They offer degrees
The confusion is evident from the number of similar to that of allopathy and are affiliated
committees that was set up and the to various universities. The guiding principle
contradictory recommendations contained in of these institutions is to ‘modernise’ the
the reports of these Committees 22 traditional systems using the ‘scientific
(Appendix 1). approach’. For instance The National Institute
21
Rhode, Jon Eliot and Hema Viswanathan (1995) The Rural Private Practitioner, Delhi, Oxford University Press.
22
For details of the recommendations of the important committees, see Brass (1976)

Leena Abraham
of Ayurveda at Jaipur was established in 1978 Four apex bodies were also established to
as ‘an apex institution of ayurveda in the promote research in ISM and Homeopathy.
country to develop high standards of teaching, They are the Central Council for Research in
training and research in all aspects of Ayurveda and Siddha (CCRAS), Central
ayurvedic system of medicine with a scientific Council for Research in Unani Medicine
approach’23. There are several institutes in (CCRUM), Central Council for Research in
ayurveda that are engaged in teaching, Homeopathy (CCRH), and Central Council for
training and research at under-graduate and Research in Yoga and Naturopathy (CCRYN).
post-graduate levels and offer Ph.D. degrees24. The objectives of these bodies, as stated in
Similarly, the National Institute of the annual reports, are to initiate, guide,
Homeopathy (NIH) at Calcutta was established develop, co-ordinate and fund ‘scientific
in 1975 to provide leadership in scientific research’ in the respective medical systems.
development and institutionalisation of The four Councils are autonomous bodies
homeopathy. It is affiliated to the University fully financed by the Government of India and
of Calcutta and has been conducting the are conceived as counterparts of the Indian
degree course in homeopathy (Bachelor of Council of Medical Research (ICMR) for
Homeopathic Medicine and Surgery, BHMS) allopathy.
since 198425. The NIH has an out patient
department, haematological and biochemical As the annual reports for various years (1988
laboratories, rural mobile units, medical and to 2001) show, research studies are
surgical specialities, modern radiological undertaken by these councils especially the
facilities and a 50 bed hospital. While these CCRAS and CCRH. The Ayurveda research
facilities bring homeopathy structurally and council conducts clinical studies of diseases26
organisationally in line with similar and undertakes medico-botanical surveys,
institutions in allopathy, some facilities such cultivation of medicinal plants and carries out
as a herbal garden, address the specific need chemical, pharmacological and toxicological
of homeopathy. The herbal garden maintained studies of ayurvedic drugs. Drug
by the Institute meant for acclimatising standardisation research is stated to be an
imported species of plants and as a repository important area of research. The CCRAS also
of authentic specimens of medicinal plants, publishes three journals: ‘Journal of Research
is perhaps the only structure that retains the in Ayurveda and Siddha’, ‘Bulletin of Medico-
‘identity’ of homeopathy. The state financed Ethno-Botanical Research’ and the ‘Bulletin
institutional developments in unani, of Indian Institute of History of Medicine’. The
naturopathy and yoga are at a basic level. The homeopathic research council (CCRH)
activities through The National Institute of constituted in 1978, carries out clinical
Unani Medicine at Bangalore, established in research through the two research institutes
1987 in collaboration with the Government at New Delhi and Mumbai and through a
of Karnataka, and The National Institute of number of Clinical Research Units (14) spread
Naturopathy at Pune established recently are across the country. It also conducts drug
yet to really take off. research and disseminates information
23
Government of India 1996, Annual Report 1994-95
24
The Institute for Post-Graduate Teaching and Research at Jamnagar offers a M.D. (Ayurveda) degree in different
specialisations. It is also a WHO collaborative centre that offers training in ayurveda to foreign scholars. The
Rashtriya Ayurveda Vidyapeeth at Delhi was established in 1988 to impart advanced training beyond the post-
graduate level.
25
Earlier, the institute conducted a two year diploma course called Dip. NIH.
26
A list of 25 such diseases was mentioned under this programme in the Annual Report of 1994-95. Many of the
diseases covered are the ones commonly prevalent in India.

through its publications, ‘Quarterly Bulletin’ homeopathy. Quality and reliability of the
and ‘CCRH News’. The volume of research drugs have been a concern of the state from
work carried out by these three councils, early on as these issues have been raised in
through a net work of small units spread public debates from time to time. The
throughout the country, is minimal but is of Pharmacopoeial Laboratory for Indian
symbolic significance as it provides state Medicine (PLIM) was established in 1970,
legitimacy to these systems. There is little or before the establishment of the medical and
no research is being done through the research councils in ISM and Homeopathy.
councils of unani, yoga and naturopathy27. More recently the drugs of ISM have been
brought under the purview of the Drugs and
There have been a few attempts to involve Cosmetics Act, 1940. A drug control cell for
these councils and incorporate their research the Indian Systems of Medicine was set up in
outcomes into the government health 1992 to assist the Drugs Controller of India
programmes. For example, the CCRAS to deal with issues concerning ISM drugs.
participated in the plague prevention and the Besides supporting the structures and
malaria control programmes of the institutions for standardising and testing of
government. It has patented and drugs, the government also undertakes
commercialised a drug called Ayush – 64 for manufacture of ayurvedic and unani
the treatment of Vishmajwara (Malaria) medicines. The Indian Medicines
developed at the Regional Research Institute Pharmaceutical Corporation Ltd (IMPCL) at
at Jaipur. An oral contraceptive called Almora in Uttar Pradesh was started in 1983
‘Pippalyadi yoga’ developed by the CCRAS has for this purpose.
been incorporated into the National Family
Welfare Programme. The integration of ISM ‘Scientific’ Development and Subordination
into the state health care system has so far As the foregoing discussion shows, the state
been limited to such experiments. supported institutionalisation of ISM and
Homeopathy which began in the 1970s is
The state has also been involved in the steadily growing. It is quite evident that the
production and regulation of ISM drugs. To development of the structures and
address the issue of uniform standards in organisations for training and research in ISM
drug preparation, government has established and Homeopathy has closely followed the
two pharmacopoeia committees, one for ISM allopathic model. However, the different
and another for homeopathy. These systems have been allowed to retain their
committees are expected to prepare the official individual identities. Through these processes
drug formularies or pharmacopoeia which of institutionalisation and modernisation
could then be used to ensure uniform based on the allopathic model, the issue of
standards throughout India 28 . The ‘scientific status’ of ISM which was a strong
government has also established two and recurrent theme in the medical discourse
pharmacopoeia laboratories at Ghaziabad in post colonial India has been partly
near Delhi for testing of drugs in ISM and addressed by the state. From time to time,
27
The work of the Central Council for Research in Yoga and Naturopathy, established recently, is limited to
providing financial assistance to voluntary yoga and nature cure institutions and supporting nature cure training
programmes.
28
The Ayurveda Committee published the Ayurvedic Formulary of India in two parts containing 444 and 190
compound formulations respectively and Ayurvedic Pharmacopoeia of India Part I containing 80 monographs on
single drugs of plant origin so far. The second and third volumes of Ayurvedic Formulary of India (English
version) has been recently (2000-2001) published. The first part of the National Formulary of Unani Medicine
(Urdu version) containing 441 formulations was released in 1994. The work of the Siddha Committee and the
Homeopathic Committee are only in their initial stages.

Leena Abraham
the support extended by state to the by ayurvedists, both the traditionalists as well
‘traditional’ or ‘unscientific’ systems came as the modernists, was to restore the status
under fire from the powerful allopathic of ISM to a legitimate official status equal to
profession and the intellectual elites of the that of allopathy. 30 The state supported
country as spreading quackery. The state institutionalisation, by modelling it on the
financed institutional development certainly allopathic system, in effect, has reaffirmed the
set in motion a process of ‘scientisation’29, of subordinate status of ISM and H by forcing
carrying out research to validate the medical the latter into a continuous process of
theories, practices and drugs using concepts, validation through the theories and methods
methods and theoretical knowledge of modern of the former. The futility of setting such goals
science. The aim of these modern institutions and their likely consequences for the medical
of ISM and homeopathy is to conduct systems were known to the advocates of ISM
‘scientific research’ and to ‘prove’ the ‘scientific and was publicly debated even before
value’ of their knowledge. This is most evident independence. Varier’s articles in
in the testing and ‘proving’ of the drugs. The ‘Dhanvantari’ as well as Srinivasamurthi’s
31
initiatives by the state reflect an approach note in the Report of the Committee on
towards mainstreaming ISM using the Indigenous Systems of Medicine (1923)
strategy of scientisation. articulate these concerns well. The structures
and network of institutions that the state have
The state not only acts as an agency that established are elaborate and to dismantle
monitors and regulates the practice of these structures or to withdraw its
medicine but is also actively involved in the commitment would be a difficult proposition
production of practitioners as well as of drugs. for the state as it has been deeply entrenched
The volume of state production, as the next in the promotion of a hierarchical medical
section on the infrastructure shows, is small pluralism in India.
in comparison to the contribution of the
private sector. Yet, it reflects the state’s Prior to the state sponsored institutional
commitment towards modernising and development of ISM, various models of
institutionalising the traditional systems. The institutionalisation had been initiated by
need for institutionalisation, a need acutely ayurvedists and hakims32. Their efforts were
felt by many prominent advocates of ISM and focussed around manufacturing and
recommended by the numerous committees marketing of drugs. For instance, P.S. Varier
set up by the government since of Kerala, staying clear of the ‘scientisation’
Independence, was addressed by the state by process, initiated a line of development by
superimposing a blue print of the allopathic modernising the manufacturing of ayurvedic
structure onto the traditional systems. This medications by ingeniously adopting elements
move was devoid of any consideration of the from modern science and technology to
epistemological basis of these systems as well increase efficiency of production while
as their systemic requirements. The objective adhering to the classical formulas of
of institutionalisation proposed and initiated medications. The aim was to spread the cause
29
Banerjee Madhulika (2004) Local Knowledge for World Market: Globalising Ayurveda, Economic and Political
Weekly, Jan 03, Vol. 39.
30
Brass, P.R. (1972) ‘The Politics of Ayurvedic Education: A Case Study of Revivalism and Modernization in India’,
in Education and Politics in India edited by Susanne H. Rudolph and Lloyd I. Rudolph, Delhi Oxford University
Press.
31
Pannikkar, K. N. (1995) Culture, Ideology, Hegemony: Intellectuals and Social Consciousness in Colonial India.
New Delhi, Tulika; Krishnankutty, Gita (2001) A Life of Healing: A Biography of Vaidyaratnam P.S. Varier, New
Delhi, Viking by Penguin Books India.
32
Gangadhara Ray of Bengal started large scale manufacture of ayurvedic drugs as early as 1884 (Bala 1991).

of ayurveda rather than to subordinate its (Table 1) is large enough to warrant detailed
interests by chasing the elusive goal of disaggregated analyses of their distribution
‘scientific’ status. The profits gained from the across the country. The data on health care
sale of drugs were used in activities to support facilities such as hospitals, beds and
other areas of development such as starting dispensaries in ayurveda, unani and
training institutions and research. Similar homeopathy in different states (Tables 3 and
attempts were made by others in Bengal, 4) show that the actual size and spread of ISM
Maharashtra and Tamil Nadu. Yet another line and homeopathy is significant and show some
of development focussing again on the drug interesting features and trends.
manufacturing, combined modern science
(elements of modern pharmacology and Firstly, as the data suggest, the facilities are
biochemistry) to modify the ayurvedic drugs not evenly distributed throughout the
to suit the demands of modern times. The country. They are concentrated in a few states
focus was on improving the convenience of such as Maharashtra, U. P., Karnataka and
their use both by the practitioners and the Kerala. These facilities are virtually absent in
clients. They also used modern techniques of the north eastern states, Jharkand,
promotional and marketing strategies Chattisgarh, Arunachal Pradesh and Assam.
employed by the allopathic pharmaceutical The strong presence of tribal medicine in some
firms 33 . The multiple strategies of of these states35 and the continuation of a
institutionalisation initiated by private history of absence of these systems in these
agencies contributed significantly to the parts of India may have resulted in such a
modern development of ayurveda. wide disparity in the spread of the facilities.
Some of the states have fewer hospitals with
Infrastructure in ISM in-patient care, but have more dispensaries.
In addition to the state financed health care States such as Maharashtra, U.P., Karnataka
infrastructure in ISM and Homeopathy there and Kerala have a large number of hospitals
exists a vast infrastructure developed and and beds with U.P., far exceeding the others
promoted by the private sector34. A complete in the number of hospitals.
picture of the infrastructure available in ISM
and Homeopathy in contemporary India is Secondly, if the data is a reliable indicator,
difficult to draw mainly because data different medical systems are popular in
collection and documentation in ISM are different parts of the country and the situation
restricted mainly to the Government sector. seems to have changed since the 1960s36.
The following section will provide an overview Although pluralism to some degree is seen in
of the infrastructure currently available in ISM most states, it is more evident in Maharashtra,
in terms of hospitals, dispensaries, Madhya Pradesh, U.P. and Karnataka where
practitioners, training institutions and all the three systems are represented through
pharmaceutical industries across the country. their health care institutions. West Bengal was
historically a centre of both ayurveda and
Hospitals, Beds and Dispensaries homeopathy; it had a tradition of famous
The infrastructure available in ISM and H ayurvedic practitioners (Kavirajs) and
33
Examples of these models of development include Dabur, Zandu and The Himalaya Drug Company.
34
This excludes the untrained, unrecognised informal practitioners of ISM & H.
35
Roy Burman, J.J. (2003) Tribal Medicine: Traditional Practices and Changes in Sikkim, New Delhi, Mittal
Publications
36
A comparison with the situation in 1960s provided by Bhardwaj, S.M. (1980) ‘Medical Pluralism and Homeopathy:
A Geographic Perspective’, Social Science and Medicine, Vol.14B, 209-216 is useful here. This comparison illustrates
the dynamic character of medical pluralism.

Leena Abraham
homeopathy took root in India through Bengal care planning machinery. Another point that
and flourished there.37 Despite this, West the above data indicates is the changes that
Bengal has a smaller presence of medical are taking place in the health care culture of
institutions in these systems. The popularity the country. While the tradition of medical
of ayurveda has certainly declined with the pluralism continues in some regions, it has
spread of allopathy while the popularity of weakened in some others.
homeopathy still continues. However, the
homeopathic tradition perhaps is continuing Practitioners
through the informal, non-institutionalised According to recent data 39 there are nearly
sector38. 6.9 lakh registered qualified practitioners of
ISM and H in India, of which about 2 lakh are
Thirdly, the argument that the absence of non- institutionally qualified (NIQ) (Table 4).
allopathic facilities is the reason for the This means, as per the 2001 census, there
popularity of ISM does not hold for many will be about 67 registered practitioners of ISM
states. Often, states with better distribution and homeopathy per one lakh of population.
of allopathic facilities are also better served Three fourths of the registered ayurveda
with ISM and H facilities. For example, Kerala, practitioners and half of the homeopathy and
Maharashtra and Karnataka seem to support unani practitioners are institutionally trained
ISM and H along with allopathy. Similarly, which shows the impact of institutional
the overall development status of the region developments in these systems. Most of the
in terms of education and health indicators practitioners of siddha however do not have
do not seem to explain either the presence or any institutional training. (See Table 2, Table
the absence of ISM and H. If social and 5)
economic backwardness is the reason for the
strong presence of ISM and H in U.P, the same The trend in the growth of practitioners in the
cannot be said of Mahrashtra, Karnataka and various medical systems since 1980 (Table 5)
Kerala. shows that the total number has almost
doubled in the last 20 years. The number of
It is possible that these figures do not entirely institutionally trained practitioners has been
represent the ground reality since they leave steadily growing and shows a four fold
out the informal sector. However, there surely increase in the last twenty years while the
would have been compelling reasons either number of non-institutionally trained
for starting these institutions or for supporting practitioners shows a marginal increase up
the already existing ones. The above data to 1995 and thereafter shows a decline. The
though it reflects only the formal sector, increasing number of medical colleges in these
endorses the fact that the health culture of systems and the stricter implementation of
the country is essentially pluralistic in registration requirements have led to a steady
character, a point time and again stressed by decline in the registration of non-
anthropological studies and a point that is institutionally trained practitioners. However,
persistently ignored by the development the non-institutionally qualified siddha
discourse in the country and by the health practitioners show an increase and this trend
37
Gupta, B. (1976) ‘Indigenous Medicine in Nineteenth and Twentieth Century Bengal ‘, in Asian Medical Systems,
edited by Charles Leslie. Berkeley, University of California Press; Bala, P. (1991) Imperialism and Medicine in
Bengal ; Bhardwaj, S.M. (1980) ‘Medical Pluralism and Homeopathy; Bhardwaj, S.M. (1981) ‘Homeopathy in
India’, in The Social and Cultural Context of Medicine in India, edited by Giri Raj Gupta, Main Currents in Indian
Sociology, Vol. 6, New Delhi, Vikas Publication House.
38
Some of the major manufacturers of homeopathic medicine are located in West Bengal and several homeopathy
short-term courses are being run from the state.
39
Government of India (2001) Indian Systems of Medicine and Homeopathy in India, 2001. Planning and Evaluation
Cell, Ministry of Health and Family Welfare.

may continue so because of the continued medical colleges in ISM in place of the
practice of registering them and there are not traditional training institutions. At present,
many new training institutions coming up in there are 196 medical colleges that offer
this system. There is a sudden drop in the undergraduate training in ayurveda
non-institutionally trained homeopaths and (B.A.M.S.), 166 in homeopathy (B.H.M.S), 39
a sudden rise in the institutionally qualified in unani (B.U.M.S.) and 2 in siddha (B.S.M.S.).
homeopaths in the last two years; A reduction The annual turnover of graduates from these
of over 14,720 practitioners in the former and 403 medical colleges is around 20,000. These
a rise of 17, 825 practitioners in the latter are figures that are comparable to that in the
category. Either this is due to a reporting error allopathic system. The colleges in ayurveda
or it is due to a real increase as a result of the and homeopathy (Table 7) are spread across
untrained acquiring degrees/diplomas after the Indian states, while that of siddha and
registering as NIQ practitioners. Again, the unani are concentrated in a few states. The
distribution of ISM practitioners shows wide two siddha colleges are located in Tamil Nadu
variation across the states (Table 6). and have a total admission capacity of 150.
Practitioners per lakh population among the Out of the 39 unani colleges, 10 are located
larger states range from 146 in Bihar to 24 in in U.P., 6 in Maharashtra, 5 in Bihar and
Orissa. Assam and Jammu and Kashmir have Rajasthan, and Madhya Pradesh and
very few qualified ISM and H practitioners. Karnataka have 3 each. Others are thinly
spread across various other states. The total
What this data however shows is that the undergraduate student intake in all the 39
government’s decision not to register unani colleges is 1410. (See Table 7)
untrained practitioners since 1978 was not
strictly adhered to. As Rohde and As the data show, at present, the private sector
Viswanathan 40 found, some of the young investment in medical education in ISM and
untrained practitioners used back dated H is much higher than the government
experience certificates to avail registration contribution. At the time of independence
facility that was extended only to those however, there were twice as many
practitioners who did their apprenticeship government ayurveda colleges as private ones.
under trained or experienced practitioners. Although the private sector began to grow in
The registration rules have become more the mid 1980s, it shows an unprecedented
streamlined and stricter in recent years. This growth since the 1990s (Table 8). The private
move is likely to curb the registration of sector growth in ayurveda is localised while
untrained practitioners. While the stricter that of homeopathy is spread across a few
registration rules may to a great extent clean states. A large number of medical colleges in
up the formal sector, it may not be effective ayurveda and homeopathy have mushroomed
for the larger informal sector. ( See Table 6) in Karnataka and Maharashtra under the
expansion of the ‘capitation’ fee regime. This
Medical Education occurred in two spurts. In Maharashtra, the
Medical education in ISM has undergone first spurt was during 1989-92, when 18 new
several changes as a result of several political private ayurveda colleges were established. In
and economic factors.41 as well as due to the Karnataka during 1991-93, 13 new colleges
efforts made by forces within ISM to were started. The second spurt in
modernise and institutionalise.42 All these Maharashtra is more recent, i.e., between
factors have resulted in the growth of modern 1999 and April 2001, during which 17 new
40
Rohde, Jon Eliot and Hema Viswanathan (1995) The Rural Private Practitioner, Delhi, Oxford University Press.
41
Jeffery, R. (1982) ‘Policies Towards Indigenous Healers in Independent India ‘. Social Science and Medicine,
Vol.16, 1835- 1841.
42
Leslie, C. (ed.) (1976) Asian Medical Systems: A Comparative Study. Berkeley, University of California Press.

Leena Abraham
private colleges have been added. The independence there were more unani colleges
corresponding period for Karnataka is 1996- than homeopathic colleges in India. The
99 when 25 new colleges were added. Barring popularity of unani over the years seems to
these states, Punjab and Madhya Pradesh have declined perhaps due to the declining
have shown some growth in ayurvedic interest in Urdu and Persian languages and
education post 1995 with an addition of 5 and literature. Possibly for the same reason, both
3 colleges respectively. The expansion of the the practitioners and the clients of Unani have
private sector in ayurvedic education in other been confined mainly to the Muslim
states has been much less significant. community. The Sanskrit texts of ayurveda
have been translated into Hindi and other
In the case of homeopathic education, in regional languages as well as into English.
Maharashtra during 1988-92, 18 new colleges These books have a more popular base than
and in the second phase, i.e., during 1999- the translations of Unani texts, which are not
2001, 5 new colleges were started. Karnataka easily available in many Indian languages.
has not shown the same enthusiasm towards
homeopathy while Madhya Pradesh has Finally, the periods of growth of educational
promoted education in homeopathy in recent institutions in ISM and H differ considerably
years with eight out of 16 colleges coming up across states: Gujarat during the 1960s, Bihar
during 1999-2000. Similarly, seven out of the and Haryana in the 1970s, U.P in the 1960s
11 colleges in Tamil Nadu have come up and 1970s and Maharashtra, Karnataka, M.P
during 2000-2001. Gujarat and Bihar are the and the Punjab in the 1990s. The variation in
other two states that have shown some private the patterns of growth as well as the impetus
sector investment in homeopathic education. for growth in different states calls for a deeper
exploration of the local political and economic
The investments in ayurvedic and alliances and developmental factors. In
homeopathic education show some interesting Maharashtra, one may hypothesise that the
features. The state of U.P. relies almost opportunity to expand the political and
exclusively on government funding. The economic bases of the sugar lobby, using Rajiv
government runs nine out of 12 ayurveda Gandhi’s move to open up the private sector,
colleges and all the 10 homeopathic colleges. resulted in the mushrooming of these colleges.
In M. P. much of ayurvedic education is These efforts may now benefit from the current
government supported and almost all of political ideology based on cultural
homeopathic education is privately funded. nationalism in providing legitimacy for the
While in states like Kerala and West Bengal expansion of ISM colleges, which were started
the private and public investment are more exclusively with a profit motives.
or less balanced. These two states have not
shown any significant growth in medical The Pharmaceutical Industry in ISM and H
education in recent times. There are also The pharmaceutical industry is a significant
instances when the growth depended much player in health care as it influences the cost
on the enthusiasm of state ministers. For and quality of health care services as well as
instance, in Gujarat, out of the total of 9 acts as an important source of information. It
ayurveda colleges, five were started during the is an agency that provides continuing
mid 1960s when Pandit Vyas, a strong education to all categories of practitioners. The
advocate of shuddha ayurveda, was the health industry is continuously expanding in spite
minister. of the fact that more than 60,000 allopathic
formulations are available in India. While the
Most of the Unani medical colleges are major issues of quality of drugs, use of banned
concentrated in the three states of U.P., and spurious drugs, increasing costs,
Maharashtra and Bihar. At the time of inadequate research and development and

now the issue of WTO regulations are being number of manufacturers fall in the category
debated in the context of allopathic care, a of cosmetics, OTC (over the counter) drugs,
rapidly expanding drug industry in ISM and neutraceuticals or food supplements.
H has not received adequate attention. There
are a large number of ISM drugs and products The ISM and H industry in India is estimated
in circulation in India and there is no clear to be worth Rs. 4,200 crore with ayurveda
estimate of the volume of their production and alone accounting for more than 80 per cent
their use. For instance, the annual reports of the share (Table 9). Large production units
state that although the number of drugs in ISM and H industry are few in number,
mentioned in the ayurvedic classical texts is and the manufacture of the bulk of ayurvedic
estimated to be about 15,000, only about products is carried out through a number of
1,500 drugs, mentioned in around 50 texts, small manufacturers. Although there are
are estimated to be currently in use in India. nearly 10,000 licensed pharmacies in India
However, there are no uniform standards of (Table 10), the actual volume of
preparation of drugs in ISM. Drug Production pharmaceutical production is difficult to
in ISM is a completely unregulated sector as estimate as there could be many small
admitted by the Government in the document unlicensed producers as well as home based
‘National Policy on Indian Systems of Medicine producers especially of ayurvedic medications
and Homeopathy-2002’43. According to this Table 9: ISM & H Industry in India and Table
document, ‘the safety, efficacy, quality of 10: Number of Licenced Pharmacies in India.
drugs and their rational use have not been
assured…. There is no assurance whatsoever Contemporary ISM Practices: Issues and
that Formularies and Pharmacopoeia Concerns
standards are being followed by the Indian The attempts by the state to regulate ISM
Systems of Medicine & Homeopathy drug medical practices have been feeble so far and
manufacturers.’ (p. 4-5). Further, the there have been no systematic efforts to
document states that the lack of enforcement evaluate the ISM sector. There are several
of rules is not the only problem but the issues related to the contemporary practices
secretive and exploitative manner of procuring of ISM that warrant serious attention. Due to
plant raw materials have not only led to the paucity of data on current ISM practices, the
depletion of plant resources but also to issues discussed are based on media reports,
rampant adulteration and substitution of anecdotes and observations made by
drugs. researchers studying allopathic care. Only
detailed research in different settings across
It appears that both the traditional as well as regions and communities will show the nature
the modern sectors of the ISM industry are and relevance of ISM practices in
growing by the increasing number of new contemporary India. An attempt is made in
products being launched as well as by the the following section to identify some of the
annual growth of some of the companies that important issues and discuss some of the
produce ISM and H products. 44 Both the criticisms against ISM. Some of the general
traditional and the modern sectors45 have criticisms against ISM practices include
large as well as small manufacturers. Both prescription of allopathic medicines (the
the categories produce proprietary medicines ‘cross’ practices), practice of medicine by
and a few patented drugs. The products of a untrained persons and authenticity of
43
Government of India (2003) National Policy on Indian Systems of Medicine and Homeopathy -2002. Ministry of
Health.
44
Cygnus Vol.3, October 2003
45
Examples of the former include The Kottakkal Arya Vaidya Sala, and The Coimbatore Arya Vaidya Pharmacy.
The latter include the Himalaya Drug Company, Zandu Pharmaceuticals, Ajanta Pharma, Dabur etc.

Leena Abraham
medications and medical claims. Apart from untrained practitioners. The first category
these issues, there are issues of availability have received formal training through an
of trained ISM practitioners across rural and institution and hold a degree or diploma. But
urban areas, issues concerning degrees and not all these degrees and diplomas are valid
titles and more importantly the issue of or recognised by the Central Councils of ISM
erosion of knowledge and that of integration and Homeopathy. The second category of non-
of ISM into the mainstream health care institutionally trained practitioners includes
system. Some of these issues have emerged those who have completed a period of at least
as a result of the historical neglect of the 5 years of apprenticeship under the guidance
systems by the state and some have resulted of a well known trained practitioner. Once
from a lack of professionalism within ISM. The again under this category there are well-
state’s laxity towards controlling malpractices trained practitioners and those who have
in health care in general and the ISM sector neither completed the stipulated years of
in particular have led to a situation where apprenticeship nor received any useful
health care is emerging as a sector that is training. Finally, there are those with no
controlled by the profit motives of the market. training, formal or informal. Some of them are
self-taught using texts and others have picked
Absence of Professionalisation up skills from ‘here and there’. In the field
Most people, particularly in rural areas, do the above classifications are
not worry much about the qualification of the indistinguishable. While the Councils provide
practitioner (with or without a degree) or the the lists of valid degrees, there is no way of
registration status (professional or quack) or knowing the list of invalid degrees/diplomas.
the kind of medical system (allopathy, It is almost impossible for the learned and
homeopathy or ISM) as long as they get relief the laypersons alike to select a practitioner
and the practitioner is accessible. The apathy exclusively on the basis of their training.
of the people, the laxity on the part of the state
and a market for health care providers of Although terms such as ‘qualified’ and
various kinds have all contributed to the ‘trained’ have been used frequently in this
creation of an absurdly large number of titles, paper, they represent an array of degrees,
degrees, diplomas in ISM and H. Unlike the diplomas and different qualifying conditions
allopathic doctors who form a relatively that are difficult to comprehend or even
homogenous group with regard to their recognise as a medical qualification. For
training and professional status, the ISM instance, Ashtekar and Mankad46 in their
practitioners are a heterogeneous group. study of 5 blocks in Nashik district in
Maharashtra found 43 different titles being
Based on the nature of training received, the used by the practitioners47. The nomenclature
practitioners of ISM and H can be broadly and other qualifying conditions have changed
classified into three categories: institutionally several times over the years and vary from
trained, non-institutionally trained and state to state. Further, the same form of
46
Ashtekar, Shyam and Dhruv Mankad (2001) Who Cares? Rural Health Practitioners in Maharashtra, Economic
and Political Weekly, Vol. 36, Nos. 5 and 6, 448-453.
47
They are 1 ABS, 2 AMS, 3 AVV, 4 AV VG, 5 AV VHM, 6 AVR, 7 BAMS, 8 BDS, 9 BEMS, 10 BHB, 11 BHMS, 12
BIAM, 13 BIMS, 14 BOM 15 DMYS, 16 CCH, 17 DAMS 18 DCH, 19 DHB, 20 DHCH, 21 DHMS 22 GFAM, 23
DORL, 24 DSAC, 25 DSCH, 26 DYNS, 27 GAMS, 28 GCAM 29 MD(A), 30 GRMP, 31HMDS, 32 LCEH, 33 LCPS 34
MBBS, 35 MD 36 PMP, 37 MD(G), 38 MEMS, 39 MFAM, 40 MFPAM, 41 MS, 42 NDDA 43, RMP . Ashtekar, Shyam
and Dhruv Mankad (2001).

training is called by different names in homeopathy practitioners, conclude that

different places and times 48 . There are people are ‘tricked’ by these ‘quacks’ through
Sanskrit and vernacular titles and sometimes ‘irrational’ practices. It must be noted
there are only abbreviations. In the 1970s, however, that some of these practices are no
an attempt was made to have uniform titles different from what the non-medical staff in
across the country with titles such as PHCs routinely carry out – dispense drugs and
Bachelor of Ayurvedic Medicine and Surgery give injections in the absence of medical staff.
(B.A.M.S,) and similarly B.U. M. S. for Unani What appears as ‘tricking the poor’ could also
and B.H.M.S. for homoeopathy and B.S.M.S. be seen as people’s strategy to influence the
for Siddha. Very recently, there has been a supply of health care to suit their needs. By
move to use the Sanskritic versions of these demanding ‘coloured tablets’ (allopathic
titles. For example, B.A.M.S. is referred to as drugs) and ‘sui’ (injections) that the private
Ayurveda Acharya and the postgraduate allopaths routinely prescribe or that the PHCs
degree in ayurveda (M.D. Ayurveda) as do not stock in sufficient quantities, at a lower
Ayurveda Vachaspati (Government of India price and at their convenience, the local ISM
2001). The lack of uniformity in training and practitioners become conduits between rural
qualifications, a feature essential for claiming people and the distant allopathic care. In this
professional status, has hampered the growth way, people try to overcome the major hurdles
of ISM. in accessing allopathic care. The high cost
including that of travel incurred for reaching
The absence of professionalisation has also a private allopathic doctor and the encounter
led to several practices that are damaging to with an indifferent practitioner are thus
the systems. Two issues with regard to the circumvented. What are generally condemned
type of medicines used by the ISM as illegitimate practices or ‘cross practices’ are
practitioners are of special concern. Firstly, often part of a complex social mechanism of
the (mis)use of allopathic medicines without matching the demand and supply of care.
adequate training and secondly the use of
drugs containing high quantities of harmful Allopathic medicines dispensed by the ISM
ingredients such as lead, steroids, etc. The practitioners are often compounded at the
use of allopathic drugs is not restricted to the clinic or repackaged as Rohde and
trained ISM practitioners and is quite common Viswanathan found in their study of rural
among the untrained practitioners as well.49 practitioners of U.P. 50 The ISM practitioners
The high doses of harmful substances in many who purchase the drugs in bulk from
of the ISM medications seems to be a far more pharmacies in nearby towns and repack them
serious issue than the common ‘cross to bring down the costs of care are in effect
practices’ as the former can result in the acting as agents of allopathy. The local
failure of vital organs or can be lethal. At pharmacies are the main sources of
present, the mechanisms by the state to information on allopathic drugs for the ISM
control such practices are inadequate and and H practitioners. Information is also
there are no internal safe guards developed gathered from agencies that carry out various
by ISM to curb such perilous practices. vertical disease control programmes of the
government. India produces more drugs than
Many studies which report the use of any other country and more than 60 per cent
allopathic drugs and injections by ISM and of patients who buy medicines over the
48
The list of recognised medical degrees in ISM and H on the website of the Ministry runs into more than thirty
pages.
49
Neumann, A.K., J.C. Bhatia, S.Andrew and A.K.S. Murthry (1971) ‘Role of the Indigenous Medicine Practitioners
in Two Areas of India: Report of a Study’, Social Science and Medicine, Vol. 5, 137-39.
50
Rohde, Jon Eliot and Hema Viswanathan (1995) The Rural Private Practitioner, Delhi, Oxford University Press.

Leena Abraham
counter do so without a prescription. Large the volume of the contribution of ISM and H
scale unethical use of diagnostic techniques or the quality of services provided. Studies
and drugs even within the allopathic system have shown that the practitioners of ISM and
are common51. The cost cutting and cross H provide basic primary care in places where
practices of ISM must be viewed in the light allopathic care is either unavailable or
of these facts. The misuse by the lower inaccessible due to the direct or opportunity
categories of ISM practitioners will be limited costs involved. Some of the anthropological
to the use of common medicines and saline studies mentioned earlier, which were carried
injections and are likely to be controlled by out in rural areas, show that people’s choice
the high cost of other drugs and diagnostic of care is determined also by a health culture
techniques. The practices that are ridiculed that classifies ill health into categories based
such as the symbolic display of a stethoscope on what is believed to cause these diseases.
or thermometer or any such equipment can Such cultural considerations also determine
be overlooked in the context of more serious the choice of practitioners or the system of
malpractices referred to earlier. care that villagers seek. From these studies
and the author’s own observations it is fairly
The lack of consensus with regard to clear that people have no conceptual difficulty
interpretations of medical texts and in switching between systems or
communication of the knowledge across the
practitioners.52 What appears to be irrational
spectrum of practitioners are two other issues
shopping around for remedies nevertheless
that may come in the way of
has some complex rationale based on local
professionalisation of ISM. The institutional
knowledge, peoples’ experience of different
development located in and around urban
systems and practitioners, and their material
areas, over the years, has widened the divide
conditions. Different analyses give primacy to
between the trained and the untrained
one of these factors over the others based on
practitioners. This certainly would have
resulted in the depletion of traditional their theoretical and disciplinary positions.
knowledge, as there has been no attempt so Anthropologists tend to focus on the folk
far to strengthen the knowledge base of the health culture and the ‘folk classificatory
traditional practitioners. Further ruptures models of illness and cure’ while the
have occurred in the transmission of sociologists and economists focus almost
knowledge through family tradition as exclusively on the material contexts of
children of relatively better off practitioners diseases and care. However, the actual health
are no longer continuing the tradition as it care seeking behaviour for each episode of
does not increase opportunities for social and illness may depend on various factors. The
economic mobility. The vacuum thus created nature of choice of medical service by people
will be filled, as is always the case, with more reveals a complex conceptual bifurcation of
and more charlatans. illnesses and a structural division of areas of
medical care. Illnesses that are seen as non-
From Alternative Care to Cosmetic Care life threatening, mental illnesses, chronic and
As far as the type of health care services lingering ailments are generally seen by people
provided by the ISM and H practitioners are as belonging to the domain of non-allopathic
concerned, they range from basic primary care systems. On the other hand, acute and critical
to specialised treatment. The data available conditions clearly pertain to the domain of
is insufficient to arrive at any assessment of allopathy.
51
Greenhalgh, Trisha (1987) Drug Prescription and Self-Medication in India: An Exploratory Survey, Social Science
and Medicine, Vol. 25, No. 3, 307-318.
52
Abraham, L. (1989) Medical Pluralism in Kerala: A Sociological Study. Ph.D. Thesis, University of Bombay,
Bombay (unpublished).

The ISM sector expands health care choices anthropological perspective sensitises one to
available to people as it operates with a the semiotics of health care and forces an
broader concept of health taking into account analysis of the layers of meanings that are
various social and cultural dimensions of attached to people’s relationships to body,
illness and care. People from rural areas often birth, death, illnesses, cure and to ecology and
use these practitioners because of their overall cosmos. The former perspective stresses the
satisfaction with their experience: low cost, science of health care while the latter
effectiveness and a social interaction that is perspective throws light on the art of healing.
reassuring. The urban poor also use them
because they find them as good or as bad as In the recent years however, there has been a
the allopathic practitioners. The better off shift within ISM initiated by the market from
urban people use their services for a variety being a ‘holistic’ or alternative health care
of reasons – in search of an alternative and system to providers of peripheral services. The
holistic cure or because they believe these pharmaceutical industries along with the
medicines are harmless or because they are industries of tourism and cosmetics are
just desperate for a cure. Cultural affiliations increasingly using metaphors drawn from ISM
and family socialisation also influence to promote products that are not even
individual health care habits. For example, it remotely concerned with health care. These
is not uncommon to find migrants from Kerala market driven trends are likely to undermine
in a metropolis like Mumbai going in search the value of these systems by reducing them
of ayurvedic medications from the outlets of to mere sources of cosmetic care.
known ayurveda pharmacies in their home
state. Similarly, one often finds educated Inadequate State Policies and Programmes
Bengalis in search of a ‘good’ homeopath in As pointed out earlier the state policies and
places where they are now located due to their programmes do not reflect any intention of
employment. Over all, the economics of cure, utilising the services of ISM in extending
a complex pluralistic health care culture that public health care. The institutional
socialises individuals’ orientation to health development supported by the state has
determines people’s ‘health care seeking resulted in creating a subordinate layer of
behaviour’. The cultural component may vary service providers who have lost their
in shades and degrees, based on geographic professional identity53. It has also led to the
location, caste and community affiliations and skewed distribution of ISM services across the
educational status. The economics of cure and country. For instance, despite the fact that
the culture of health care, in themselves the less developed state of U.P. and the
constitute a complex set of factors, and when relatively better developed state of
played out in conjunction with each other and Maharashtra both have an abundant supply
along with other social markers of inequality of non-allopathic practitioners, trained and
such as gender, caste, class and ethnic untrained, the rural urban distribution of
locations, render the health care scenario far these services remain skewed. The rural areas
more complex. This complexity is not of Varanasi district, in the 1980s, had between
apparent when health care behaviour is 50-70 traditional practitioners per 1000
viewed from a narrow biomedical perspective population.54. These were mainly unqualified
merely as treatment of specific diseases. An practitioners who provided full time or part
53
They are neither allopathic practitioners (although they gain some knowledge of allopathic subjects) nor are
they well trained in their own systems as they are not exposed to the best practices in their own systems. The
emphasis on modern scientific development has resulted in their developing a feeling of inferiority or at best has
made them poor imitators of the allopathic system. Through this process of allopathisation the ISM practitioners
are forced into a defensive position. Such a climate hampers critical interrogation and development.
54
Shukla, K.P. and C.P. Mishra (1991) ‘Traditional Healers in Health Care’, in Sociology of Health in India, edited
by T.M. Dak, Jaipur, Rawat Publications, 106-122.

Leena Abraham
time health care of some kind and a majority where there is some dignity to life beyond the
of them were either illiterate or semi-literate. bitter struggle for survival and of course
Although a large proportion of practitioners through the spread of critical awareness
of ISM and H serve rural areas, studies show through political and mass mobilisations. One
that the trained practitioners tend to cluster lesson that the Kerala ‘model of development’
around more developed regions of the has shown, a lesson that is not discussed
countryside. A recent study in rural however, is the way its people ensure a steady
Maharashtra shows a practitioner population supply of quality care in all medical systems.
ratio of 1:175055, which includes both, trained Of course it has erred by pharmaceuticalising
and untrained practitioners. The study points health care and by the overuse of allopathic
out that within rural areas, the economically medical facilities making it one of the state’s
backward tribal areas are served by fewer chief health care problems 56 but tries to
trained practitioners of ISM as compared to balance the ill-effects by seeking antidotes
other relatively prosperous areas. Thus the from other systems. In the process the state
trained ISM and H practitioners behave much has accumulated yet another feather in its
like their counterparts in allopathy in their small cap- the largest consumer of allopathic
reluctance to serve economically backward and non allopathic medicines. This situation
regions. However, the study also found that is remediable and the next wave of
the more prosperous rural areas have more mobilisation will certainly focus on this issue.
qualified ISM and H practitioners than The essential difference between the two
allopathic doctors. situations is that in one people are pushed
further and further into the lap of providence
While private practitioners of ISM and H serve and the other in which people (not individuals)
the rural population, the government-financed can exercise their right to rewrite health care
institutions such as medical colleges, histories and destinies.
hospitals and institutions that provide
specialist treatment in these systems, are The successive national governments have in
concentrated in urban areas (Table 11). Out recent years actively pursued the processes
of the 600 beds available for specialised of formalisation and professionalisation of the
treatment in ayurveda, 505 are in urban ISM and H. A separate department of ISM
areas. Extending government services in ISM and H was created under the Ministry of
and H (by college trained practitioners) to the Health and Family Welfare in the year 1995
rural areas may be a difficult task, a situation with the intention of promoting development
similar to that of allopathic doctors. and propagation of ISM and Homeopathy57.
Recently, in the year 2003, the Department
The policies of the government will neither of ISM and H has been elevated to the status
attract nor force trained practitioners to the of a separate ministry and is renamed as
under served areas and populations. Any Ministry of ISM and H, which is also referred
attempt by the government to identify and ban to as Ministry of AYUSH (some documents and
all charlatans will also be futile. Both these websites refer to it as Department of AYUSH).
can be achieved only in a society with a critical However, there are no indications of bringing
population of literate and educated persons, ISM into the public health care system. From
55
Ashtekar, Shyam and Dhruv Mankad (2001) Who Cares? Rural Health Practitioners in Maharashtra, Economic
and Political Weekly, Vol. 36, Nos. 5 and 6, 448-453.
56
Saradamma, R. D., Nick Higginbotham and Mark Nichter (2000), ‘Social Factors Influencing the Acquisition of
Antibiotics Without Prescription in Kerala State, South India’, Social Science and Medicine, Vol. 50, 891- 903
57
The Department is headed by a Secretary to the Government of India who is assisted by a Joint Secretary, four
Directors/Deputy Secretaries, four advisors and several Deputy Advisors of Ayurveda, Siddha, Unani and
Homeopathy. The administrative set-up of ISM and Homeopathy in various states differ slightly.

the point of view of the development of ISM, finally lead to a situation wherein the cost of
these changes are cosmetic in nature and are care may escalate and care may be more
irrelevant. From a political and ideological cosmetic in nature58.
point of view such moves may be seen as
contributing to cultural nationalism. With the increasing global market for
medicinal plants, there is a rush to export
Privatisation and Globalisation them. A WHO projection estimates a global
Some of the recent trends emerging in the herbal market of US$5 trillion by 2050 from
contexts of privatisation and globalisation on the current level of US$62 billion. The reason
the one hand and the growth of cultural for this growth is ascribed to the global trend
nationalism on the other may have important towards herbal products that are believed to
implications for the development of ISM and be safer, natural and economical. At present
for achieving universal, community based India’s share of the global market of US$62
health care. ISM is ideally located to serve the billion is only 0.3 percent. In the year 2002,
interests of both cultural nationalism on the Indian export of herbal products amounted
one hand and globalisation on the other. to Rs. 874.1 crores while that of China was
Historically ISM was used in furthering Rs. 9600 crore. 59 However reliable these
cultural nationalism and it can become an ally estimates may be, the point is that both the
of such interests in future too. The expansion market in India as well as the government
of markets for specific ISM commodities and have identified medicinal plants as a potential
services, both domestic and global, area for export expansion. Towards this end,
diversification into popular ‘alternative’ and the national policy on ISM and H- 2002
‘holistic’ health care, medical tourism and the advocates the establishment of an Export
creation of a large army of private practitioners Authority to boost export capability and a
are likely to bring in a new discourse around Medicinal Plants Board has been recently
ISM. The unregulated private sector growth established to regulate and to ensure supply
in health care in a society whose sizable of medicinal plants to the pharmaceutical
population is disempowered by illiteracy, industry. The objective is to meet the stricter
inadequate food supply and basic amenities international quality requirements for export.
of survival can be crippling. The optimistic One of the consequences will be a further
endorsement of the free play of market forces depletion of plant raw materials for the
as equalisers does not seem to hold in the domestic ISM sector, a factor reported to be
case of primary care in the rural areas. We affecting the quality and quantity of
have seen earlier that the trained ISM production of medicine.
practitioners concentrate their services in
urban areas and more developed regions. The The bulk of the products of large and medium
logic of the market will not drive practitioners ayurvedic pharmaceutical industries are food
who have invested large sums of money in supplements (also called neutraceuticals, a
their training through private institutions to term that camouflages the fact that they are
rural areas or to cater to the urban poor. They nonessentials), those that fall in the category
are more likely to be found providing ‘alternate of tonics and cosmetics and semi-cosmetics
care’ or ‘holistic care’ in the urban areas and (such as medicated hair oils). The proportion
servicing a growing market that is being of essential medications is negligible and their
created for the middle classes. The furthering production is carried out mainly in the
of commercial interests through a traditional sector. Although some of these
pharmaceuticalisation of ISM and H may producers are large and have modernised their
58
This is already evident in the marketing of selected ayurvedic practices as rejuvenating therapies which are
offered for a premium as part of what is called health tourism.
59
Cygnus, Vol. 3, October 2003.

Leena Abraham
production technology, they have a restricted The colonial and postcolonial history of ISM
clientele. Such skewed growth of ISM products suggests that the formal integration of medical
and services, despite the rhetoric of cultural systems is not an easy task. The study of
nationalism in contemporary times, is unlikely medical pluralism shows that people resolve
to strengthen the medical systems. issues of medical integration in their everyday
life situations by respecting multiple world-
Universal Health Care Through views and by adopting a pragmatic approach
Integrated Health Services in the selection of a therapeutic system or a
In an ever expanding, unregulated private type of practitioner. Such a resolution is not
sector growth in health care, how can ISM easy at the level of discourse or politics. Such
resources contribute to public health attempts foreground epistemological
problems? As the discussion so far shows, the questions and raise the issue of validating
resources available in the ISM and H sector knowledge systems. The wholesome faith
are vast, varied and useful. The questions that entrusted with modern science to validate all
arise are should they continue to grow knowledge forms will have to be addressed.
independently or should they be integrated For any formal integration of ISM and
with the allopathy based public health care allopathy, a dismantling of the hegemony of
system. If the objective of public policy is to allopathy and the hierarchy of medical
make basic health care available to people in systems is a requisite and this will be possible
an affordable and comfortable manner, then only by expanding and democratising the
in the present scenario, there seems to be no process of knowledge production and
alternative other than to mobilise all resources validation. Authority based on class, caste,
towards this end irrespective of the system of gender, and ethnicity or for that matter
cure or practitioners. Studies have shown that scientific methodology or other sources of
the untrained practitioners are willing to power will then come under critical
undergo training in allopathic care to upgrade interrogation. This may be possible by
their services.60 The myth that only highly enhancing the critical role of human agency
qualified doctors can deal with basic health by increasing access to knowledge and by
care has been sufficiently demolished by widespread political participation.62
various experiments of training dais and
village health workers as well as various NGO Encouraging learning across borders, through
experiments of training illiterate or short term courses in different medical
semiliterate persons who successfully provide systems may be one of the practical ways of
basic health care in many parts of rural initiating the dismantling of hegemony. A
India.61 China had successfully demonstrated critical appreciation of each other is also
the integration of medical systems decades possible through the sharing of knowledge.
ago through its ‘barefoot doctors’. China’s There already exists an informal division of
success story may have been partly the result areas of expertise and people navigate these
of strictly enforced planning process but at divisions using their commonly shared
the same time there was a conscious attempt experiences. It would be best to support
to demystify western medicine and to people’s ability to seek care by making
recognise the role of Chinese medicine in information available. Home remedies are
providing primary care. commonly used and self medication is
60
Neumann, A.K., J.C. Bhatia, S.Andrew and A.K.S. Murthry (1971) ‘Role of the Indigenous Medicine Practitioners
in Two Areas of India: Report of a Study’, Social Science and Medicine, Vol. 5, 137-39.
61
Antia, N.H. and Kavita Bhatia (1993) Peoples Health in People’s Hands. Pune, Foundation for Research in
Community Health.
62
Freire, Paulo (1973) Pedagogy of the Oppressed. New York, Herder and Herder

rampantly practised by people throughout equitable health care for the country. There
India. In such a situation it is wiser to equip is a need to encourage research on the history
people to use health care more judiciously of ISM, on critical contributions of ISM as well
than advise them to stay away from such as on issues concerning the erosion of
practices. More specifically, at the knowledge base and the effects of
organisational level, attempts should be made commoditisation and globalisation on ISM.
to include primary as well as specialised care What ISM really needs to do at the practical
based on ISM in the existing public level is to critically interrogate its knowledge
institutions of health care 63 . By starting bases and practices while at the theoretical
integration at the lowest levels of care such level provide an alternate world-view, by
as primary care in remote areas, as strengthening its ecological and holistic view
experimented earlier 64, will reinforce the of health.
subordinate status of ISM and such efforts
may be subverted, rightly so, by ISM The spread of literacy and education, mass
practitioners themselves. media and expansion of facilities in modern
health care especially in the last two decades
The attempts to integrate medical knowledge have influenced people’s health care practices.
and practice will remain inadequate if they These influences, however, have not widened
are not accompanied by integration at the gap between allopathy and ISM in people’s
different levels of research and training with minds because they see that in practice the
a clear objective of working out a model of gap between systems are narrowing; both rely
primary health care based on different on the pharmaceutical industry for
systems. The next step should be to develop information, both increasingly engage in
referral systems to specialised care of different syncretic practices, the cost of consultations
medical systems. The recent move by the and drugs are on the rise and an erosion of
government to have a separate ministry of medical ethics has taken place across the
ISM, may succeed in drawing special attention spectrum of practitioners.
to the needs of ISM, but may sharpen the
differences between ISM and allopathy. It is Conclusion
only logical to organise the health ministry However strong the homogenising tendencies
according to the type of care primary, of modernity may have been, in the area of
secondary and tertiary instead of according health care, a hierarchical medical pluralism
to the interests of the medical systems. The continues and with renewed vigour.
existing structure highlights the identity of Historically pluralism has been a
the medical systems while submerging the characteristic feature of health culture in
issues of health care. India with medical systems such as Ayurveda,
Unani and Siddha along with numerous
There has been little research into the traditions of tribal and folk medicines
contribution of the ISM and H, the major providing basic to specialised care. The
developments in this sector over the last fifty encounter with allopathy in the colonial
years and the future of the different context and the policies of British
constituents in terms of their potentials and administration changed the character of
prospects for achieving universal and medical pluralism from a non-hierarchical to
63
Specialised care in ISM especially in ayurveda is available in the private sector for those who can afford the high
cost.
64
In the 1980s, some of the state governments (for e.g., Maharashtra) had appointed BAMS and BHMS, degree
holders of ayurveda and homeopathy, in PHCs where allopathy doctors refused to serve. However, they were to
dispense allopathic medicine. This is reminiscent of the colonial experiment of using indigenous practitioners to
take allopathic care to rural India.

Leena Abraham
a hegemonic and hierarchical pluralism. The markets. These interests are reflected in the
colonial and post independent periods focus on the export of a few ISM products
brought about major structural and cultural (almost exclusively of ayurvedic products).
changes in the organisation and practice of Such moves are likely to reduce the
ISM. The paths of institutionalisation followed significance of ISM to supplier of products
in independent India, modelled on the such as cosmetics and food supplements
allopathic system, continue to emphasise the rather than strengthen its inherent qualities
subordinate status and marginal location of and capabilities in achieving universal
ISM. While at the practical level medical primary health care and providing avenues
pluralism flourished, at the level of discourse, of alternative care.
all attempts have been to cleanse the society
of the unscientific and the traditional practices Even in a climate of receding welfare measures
through the spread of modern medicine. by the state and the escalating cost of private
health care, demand for universal primary
The cause of ISM was taken up, although health care by integrating resources from
briefly, by the nationalist movement as a various medical systems has not gained
weapon against the cultural hegemony of the significance. While a general understanding
imperial power, but soon class interests and of the political economy of health must shape
a development discourse based on modern policies, an adherence to seeing people as
science dominated over the issue of ISM. completely vulnerable who need a prescription
Thereafter the state has extended token for every ailment or as pawns of the market
support to ISM and the subsequent policies needs serious revision, a revision that
reflect different group interests within ISM – accounts for the agency of the people to define
those who wanted to modernise and those who their ‘needs’ and to make ‘choices’ by
wished to reassert its traditional roots. Recent expanding and democratising access to
developments promoted by the knowledge and services. This means taking
pharmaceutical sector under privatisation and pluralism into account while planning public
globalisation have further changed the basic health care.
character of these medical systems from being
alternative health systems to sources of Acknowledgements
peripheral health products. The state, I thank Ravi Duggal, Amita Pitre and
pharmaceutical industries and more recently Leena V. Gangolli of CEHAT for inviting me to write
politics rooted in promoting narrow interests this paper. Manorama Savur, Padma Velaskar
of cultural nationalism have charted the and Nakkeeran provided critical comments. I
course of development of ISM. The impetus thank Nirmala Momin who meticulously typed
for development is not generated from within many drafts and tables and Justin Thomas
ISM but is increasingly being driven by narrow who assisted with the tables. K.Subramaniam
political interests and by the dictates of global provided editorial help and valuable criticism.

Figure 1
Classification of Type of Care, System of Care and Type of Practitioners
Indian Health Care System
Allopathic Care Non-allopathic Care
Public Sector Private Sector ISM & H Folk spectrum

(Govt.) Ayurveda, Unani, Siddha, Naturopathy (untrained)
Yoga and Homeopathy

"
Formal Sector Informal Sector Traditional Non-
Traditional
212
(Trained/registered) (untrained)
Public Sector (Govt.) Private Sector - Tribal Medicine - Electropathy

- Bone Setters Magneto
- Vaidus Therapy
- Folk Healers - Quasi
- Religious/Quasi- Allopathic
Religious Curers Practices
- Home Remedies
etc.
Leena Abraham
Table 1
Infrastructure in ISM & H Summary (2001)
1. Hospitals 3,841
2. Beds 65,753
3. Dispensaries 23,597
4. Undergraduate Medical Colleges 405
5. Admission capacity 16,845
6. Post-graduate Institutions 77
7. Admission capacity 991
8. Registered Practitioners 6,88,802
9. Plan Outlays
9th Plan Outlay 266.35 crores
Expenditure 364.43 crores
10 Plan Outlay
th
775.00 crores
Sources: Tenth Five Year Plan (2002-2007) Health, Sectoral Policies and Programmes.
Planning Commission, Govt. of India, Vol. II, pp. 81-164, Indian Systems of Medicine and
Homeopathy in India, 2001, Planning and Evaluation Cell, Dept. of ISM an Homeopathy,
Ministry of Health and Family Welfare, Govt. of India, New Delhi.
Table 2
Registered Practitioners in Indian Systems of Medicine & Homeopathy
Sr. Number of Registered Practitioners

No. System of As on 1.1.2000 As on 1.1.2001
Medicine IQ NIQ Total IQ NIQ Total
1 Ayurveda 330576 96928 427504 333956 96934 430890
2 Unani Medicine 20934 21511 42445 21597 21511 43108
3 Siddha 4381 12218 16599 4613 12484 17097
4 Naturopathy 380 49 429 406 49 455
5 Homeopathy 110317 83830 194147 128142 69110 197252
Total 466588 214536 681124 488714 200088 688802
Figures are Provisional.
IQ: Institutionally Qualified NIQ: Non-Institutionally Qualified
Source: Compiled from Indian Systems of Medicine and Homeopathy in India, 2001, Planning and
Evaluation Cell, Dept. of ISM an Homeopathy, Ministry of Health and Family Welfare, Govt. of India, New
Delhi, pp. 87.

Table 3
Number of Hospitals with their Bed Strength under
ISM & H as on 1.4.2001
Sr. States/Uts Ayurveda Unani Homeopathy Total
No. Hosp. Beds Hosp. Beds Hosp. Beds Hosp. Beds
1 Andhra Pradesh 8 464 6 310 6 300 21 1209
2 Arunachal Pradesh 1 10 1 50 2 60
3 Assam 1 100 3 105 5 230
4 Bihar 11 1120 5 414 11 400 27 1934
5 Chattisgarh 2 115 2 115
6 Delhi 5 535 2 216 3 150 11 951
7 Goa 3 185 1 125 4 310
8 Gujarat 48 1845 14 774 62 2619
9 Haryana 7 695 1 10 8 705
10 Himachal Pradesh 22 390 24 415
11 Jammu & Kashmir 2 100 2 200 5 310
12 Jharkhand 1 120 2 104 3 224
13 Karnataka 118 6937 13 302 21 882 170 8707
14 Kerala 110 2798 32 1070 144 3928
15 Madhya Pradesh 36 1410 2 270 29 1085 67 2765
16 Maharashtra 78 11304 8 1225 83 6277 169 18806
17 Manipur 1 10 3 75
18 Meghalaya 0 0
19 Mizoram 1 14
20 Nagaland 0 0
21 Orissa 8 416 7 175 15 591
22 Punjab 14 1044 6 160 20 1204
23 Rajasthan 80 984 5 120 6 200 93 1326
24 Sikkim 0 0
25 Tamil Nadu 5 425 1 54 11 480 250 2830
26 Tripura 1 10 1 10 2 20
27 Uttar Pradesh 2047 10477 252 1619 36 399 2335 12495
28 Uttaranchal 322 1605 2 8 10 8 334 1621
29 West Bengal 3 309 1 100 14 671 18 1080
30 A & N Islands 1 10
31 Chandigarh 1 150 1 25 2 175
32 D & N Haveli 0 0
33 Daman & Diu 0 0
34 Lakshadweep 0 0
35 Pondicherry 0 0
36 C.G.H.S. 1 25 1 25
37 Cent. Res. Councils 22 515 12 280 6 119 42 999
38 M/o Railways 0 0
39 M/o Labour 0 0
40 M/o Coal 0 0
Total 2955 43973 312 5128 307 13694 3841 65753
Source: Indian Systems of Medicine and Homeopathy in India, 2001, Planning and Evaluation Cell, Dept.
of ISM an Homeopathy, Ministry of Health and Family Welfare, Govt. of India, New Delhi, pp. 46-47.

Leena Abraham
Table 4
Statewise Number of Dispensaries under ISM & H as on 1.4.2001
(including Government, Local Bodies and Others)
Sr. States/U.T./Others Ayurveda Unani Siddha Homeo- Yoga Naturo- Amchi Total
No pathy pathy
1 Andhra Pradesh 1437 195 - 290 1922
2 Arunachal Pradesh 2 - 41 1 44
3 Assam 329 1 - 75 25 2 432
4 Bihar 522 128 - 181 831
5 Chattisgarh 0
6 Delhi 132 18 - 88 238
7 Goa 59 - - 16 75
8 Gujarat 821 - - 216 8 1045
9 Haryana 424 20 - 20 464
10 Himachal Pradesh 1112 3 - 14 5 1134
11 Jammu & Kashmir 240 178 - 25 443
12 Jharkhand 0
13 Karnataka 590 51 - 42 11 694
14 Kerala 713 1 6 2804 3524
15 Madhya Pradesh 2086 56 - 202 2344
16 Maharashtra 463 23 - - 486
17 Manipur - - - 9 1 10
18 Meghalaya - - - 7 7
19 Mizoram - - 1 1
20 Nagaland - - - 2 2
21 Orissa 524 9 - 503 35 30 1101
22 Punjab 481 26 - 105 612
23 Rajasthan 3486 79 - 121 3 3689
24 Sikkim - - - 1 3 4
25 Tamil Nadu 11 6 326 41 1 1 386
26 Tripura 30 - - 66 96
27 Uttar Pradesh 650 148 - 1376 2174
28 Uttaranchal 70 - - 48 118
29 West Bengal 285 - - 899 1184
30 A & N Islands - - - 8 8
31 Chandigarh 6 - - 5 11
32 D & N Haveli 4 - - 1 5
33 Daman & Diu 1 - - - 1
34 Lakshadweep 2 - - 1 3
35 Pondicherry 11 - 13 1 25
36 C.G.H.S. 32 10 2 34 3 81
37 Cent. Res. Councils 6 5 2 40 1 54
38 M/o Railways 38 - - 124 162
39 M/o Labour 126 1 3 29 159
40 M/o Coal 28 - - - 28
Total 14721 958 352 7411 65 56 34 23597
Source: Indian Systems of Medicine and Homeopathy in India, 2001, Planning and Evaluation Cell, Dept.
of ISM an Homeopathy, Ministry of Health and Family Welfare, Govt. of India, New Delhi, pp. 48.

Table 5
Growth of Registered Practitioners under ISM & H since 1980 (As on 1st January)
Ayurveda Unani Siddha Homeopathy Total

Year IQ NIQ Total IQ NIQ Total IQ NIQ Total IQ NIQ Total IQ NIQ Total
1980 88265 83893 220497 7049 11080 27166 1594 16577 18171 26703 79209 105912 123611 190759 371746
1985 100085 96319 251071 8219 16101 28382 1156 10376 11532 43966 79886 123852 153426 202682 414837
1990 216344 100926 337966 13116 21314 35350 1467 10334 11801 69194 79513 148707 300121 212087 533824
1995 251262 104554 355816 16809 24018 40827 2103 10334 12437 89309 83314 172623 359483 222220 581703
2000 330576 96928 427504 20934 21511 42445 4381 12218 16599 110317 83830 194147 466588 214536 681124
2001 333956 96934 430890 21597 21511 43108 4613 12484 17097 128142 69110 197252 488714 200088 688802

IQ: Institutionally Qualified

NIQ: Non-Institutionally Qualified
"
Note: Total of IQ and NIQ registered Practitioners of Ayurveda and Unani may not tally for some years as break-up has not been
216
furnished by some States/UTs.
Source: Compiled from Indian Systems of Medicine and Homeopathy in India, 2001, Planning and Evaluation Cell, Dept. of ISM and
Homeopathy, Ministry of Health and Family Welfare, Govt. of India, New Delhi.
Leena Abraham
Table 6
Number of Registered ISM & H Practitioners (IQ + NIQ)
Per Lakh Population as on 1.1.2001
Sr. Name of the State/U.T. ISM & H Doctors as ISM & H Doctors per lakh of
No. on 1.1.2001 (IQ+NIQ) population (as per 2001 Census)
1 Andhra Pradesh 28765 38
2 Arunachal Pradesh - -
3 Assam 714 2.7
4 Bihar 161010 146.7
5 Goa - -
6 Gujarat 22096 43.7
7 Haryana 26031 123.5
8 Himachal Pradesh 8466 139.3
9 Jammu & Kashmir 505 5
10 Karnataka 18442 35
11 Kerala 22968 72.1
12 Madhya Pradesh 55227 68
13 Maharashtra 80950 83.7
14 Manipur - -
15 Meghalaya 229 9.9
16 Mizoram - -
17 Nagaland 1996 100.4
18 Orissa 8781 23.9
19 Punjab 33429 137.6
20 Rajasthan 32458 57.5
21 Sikkim - -
22 Tamil Nadu 36538 58.8
23 Tripura - -
24 Uttar Pradesh 94163 54
25 West Bengal 44689 55.7
26 A & N Islands - -
27 Chandigarh 297 33
28 D & N Haveli - -
29 Daman & Diu - -
30 Delhi 11048 80.2
31 Lakshadweep - -
32 Pondicherry - -
INDIA 688,802 67.1
IQ: Institutionally Qualified NIQ: Non-Institutionally Qualified
Figures of Jharkhand are included in Bihar, Chattisgarh in Madhya Pradesh and Uttaranchal in Uttar
Pradesh.
Source: Compiled from Indian Systems of Medicine and Homeopathy in India, 2001, Planning and Evaluation
Cell, Dept. of ISM an Homeopathy, Ministry of Health and Family Welfare, Govt. of India, New Delhi, p.88.

Table 7
Statewise Distribution of ISM and Homeopathy Medical Colleges in India and
Their Admission Capacity as on 1.04.2001
Ayurveda Unani Homeopathic
Govt. Others Total Govt. Others Total Govt. Others Total
Sr. Name of the No. Adm No. Adm No. Adm No. Adm No. Adm No. Adm No. Adm No. Adm No. Adm
No States/U.Ts. Coll- Capa- Coll- Capa- Coll- Capa- Coll- Capa- Coll- Capa- Coll- Capa- Coll- Capa- Coll- Capa- Coll- Capa-
eges city eges city
1 Andhra 3 110 1 40 4 150 1 50 1 50 2 100 4 155 - - 4 155
Pradesh
2 Assam 1 50 - - 1 50 - - - - - - 3 90 - - 3 90
3 Arunachal - - - - - - - - - - - - - - 1 50 1 50
Pradesh
4 Bihar 5 38 7 140 12 178 1 40 4 170 5 210 1 80 10 550 11 630
5 Chattisgarh 1 55 - - 1 55 - - - - - - - - 2 125 2 125
6 Delhi 1 40 - - 1 40 1 40 1 50 2 90 2 100 - - 2 100
7 Goa - - 1 40 1 40 - - - - - - - - 1 50 1 50
8 Gujarat 5 209 4 153 9 362 - - - - - - - - 14 975 14 975
9 Haryana 1 UP 4 200 5 200 - - - - - - - - - - - -
10 Himachal
Pradesh 1 50 - - 1 50 - - - - - - - - - - - -
11 Jammu &
Kashmir - - 1 40 1 40 - - 2 40 2 40 - - - - - -
12 Jharkhand - - 1 40 1 40 - - - - - - - - 2 100 2 100
13 Karnataka 3 150 44 1585 47 1735 1 50 2 60 3 110 1 40 11 555 12 595

14 Kerala 3 120 2 90 5 210 - - - - - - 2 100 2 100 4 200

"
15 Madhya
Pradesh 7 155 2 70 9 225 1 30 2 90 3 120 1 50 15 1075 16 1125
218
16 Maharashtra 4 220 53 2480 57 2700 - - 6 250 6 250 - - 43 3305 43 3305
17 Orissa 3 90 3 60 6 150 - - - - - - 4 125 3 115 7 240
18 Punjab 1 30 9 360 10 390 - - - - - - - - 5 290 5 290
19 Rajasthan 2 120 2 80 4 200 - - 3 50 3 50 - - 4 150 4 150
20 Tamil Nadu - - 4 100 4 100 1 40 - - 1 40 1 50 10 500 11 550
21 Uttaranchal 2 NP 1 NP 3 NP - - 1 NP 1 NP - - - - - -
22 Uttar Pradesh 9 90 3 40 12 130 3 140 7 230 10 370 10 NA - - 10 NA
23 West Bengal 1 60 - - 1 60 - - 1 30 1 30 5 250 8 350 13 600
24 Chandigarh - - 1 40 1 40 - - - - - - - - 1 50 1 50
Total 53 1587 143 5558 196 7145 9 390 30 1020 39 1410 34 1040 132 8340 166 9380
NP: Not Permitted UP: Under Process NR: Not Reported NA: Admission not allowed for the year 2000-2001.
Admission capacity of 33 ayruveda colleges is not available.
Source: Compiled from Indian Systems of Medicine and Homeopathy in India, 2001, Planning and Evaluation Cell, Dept. of ISM an
Homeopathy, Ministry of Health and Family Welfare, Govt. of India, New Delhi.
Leena Abraham
Table 8
Growth of ISM and Homeopathy Medical Colleges in India
Year Ayurveda Unani Homeopathy

Govt. Non- Total Govt. Non- Total Govt. Non- Total
Govt. Govt. Govt.
Before 1950 21 12 33 6 3 9 5 3 8
1951-1960 9 11 20 0 1 1 1 10 11
1961-1970 7 5 12 1 1 2 12 12 24
1971-1980 10 15 25 2 1 3 10 23 33
1981-1990 2 21 23 2 5 7 5 31 36
1991-2000 3 72 75 2 11 13 3 46 50
2001 (upto April) 0 1 1 - - - 0 1 1
Information not 1 6 7 1 3 4 - 4 4
available
53 143 196 14 25 39 36 130 166
Cell, Dept. of ISM an Homeopathy, Ministry of Health and Family Welfare, Govt. of India, New Delhi.
Table 9
ISM & H Industry in India
Rs. 4,200 crore industry (ayurveda accounts for Rs. 3,500 crore)
7,000 manufacturers of ayurvedic products
Large (> Rs. 50 crore) 10
Medium (Rs. 5-10 crore) 25
Small (Rs. 1-5 crore) 965
Very Small (<Rs. 1 crore) 6,000
Source: Dept. of ISM & H 2001 Tenth Five Year Plan (2002-2007) Health, Sectoral Policies and Programmes.
Planning Commission, Govt. of India, Vol. II.
Table 10
Licensed Pharmacies in India
Ayurveda 8,533
Unani 462
Siddha 385
Homoepathy 613
Total 9,992
Source: Dept. of ISM & H 2001 Tenth Five Year Plan (2002-2007) Health, Sectoral Policies and Programmes.
Planning Commission, Govt. of India, Vol. II.

Table 11
Rural-urban Distribution of Specialised Treatment Available Under the
Various Central Councils of ISM and Homeopathy
Sr. Urban Rural Total
No Name of the Facility No. of Doctors Beds No. of Doctors Beds No. of Doctors Beds
facility facility facility
1 Specialised Treatment in 26 134 505 7 21 95 33 155 600
Ayurveda (Hospitals and
Dispensaries)
2 Specialised Treatment in 17 97 280 - - - 17 97 280
Unani Medicine (Hospitals
and Research Units)
3 Specialised Treatment in 36 86 44 10 30 75 46 116 119
Homeopathy (Hospitals
and Research Units)
4 Treatment-cum- 41 60 715 19 27 550 60 87 1265
propagation centres
and patient care centres
in Yoga and Naturopathy
5 Hospitals and - - - - - - 70 - 25
Dispensaries of Amchi
and Tibetan System of
Medicine
Grand Total 120 377 1544 36 78 720 226 455 2289
Cell, Dept. of ISM an Homeopathy, Ministry of Health and Family Welfare, Govt. of India, New Delhi.

Leena Abraham
Appendix I
Developments in the History of Ayurveda in the 20th Century
Year Important Events Observations, Outcomes

1907 Establishment of All India Ayurveda Professional interest group of Indigenous
Mahasammelan (Ayurvedic Congress) practitioners
1917 Dr. Komar Commission To investigate the indigenous system; of medicine
(one-man commission)
1920 Indian National Congress Convention at Recommended acceptance of Ayurvedic system of
Nagpur medicine in India’s National Health Care System
1920 Indian National Congress Demanding Government patronage for Ayurveda-
Provincial Government began to grant assistance.
1921-22 Bengal Government Committee —
1921 Committee on Indigenous Systems of —
Medicine, Madras
1925 Committee of Ayurvedic and —
Unani System, United Provinces
1925 Council of State Boards and Faculty —
of ISM
1926 Committee on Indigenous Systems of —
Medicine, Ceylon
1928 Committee of Enquiry into the —
Indigenous Medicine, Burma
1937 Committee appointed to examine —
indigenous system of Medicine
C.P. and Berar
1938 Indigenous Medicine enquiry —
committee, Punjab
1942 A Committee to go into the question of —
enquiring into the indigenous system of
medicine, Mysore
1945 Bhore committee, Government of India Proposed the creation of a chair of history of
medicine in medical Colleges in India.
1945 First Health Minister Strongly worded resolution stating that provision
should be made for training and research in
indigenous system of medicine. Persons trained
in the system may be absorbed in the state health
organisations
1946 Utkal Ayurvedic committee, Orissa —
1947 Indian systems of medicine, Enquiry —
committee, Bombay.
1947 Screening committee to report on the —
steps to be taken for the development
of Ayurveda in Assam.
1947 Government of United Provinces set up —
reorganisation committee of Ayurvedic
and Unani system
1946-48 Chopra committee (Prof. R,N. Chopra, Made recommendations about general education
Government of India of students and teachers, control of education
research, drug standardisation, medical relief
and integration


1955 Dave Committee (Shri. D.T.Dave) Establishing standards in respect of education
and regulation of the practice of ISM.
1956-57 Establishment of Institute of Post- —
Graduate Training and Research in
Gujarat Ayurvedic University,
Jamnagar, Gujarat
1958 Pharmacopoeial Laboratories for ISM at To mark out standards and develop tests for single
Ghaziabad drugs and compound formulations
1959 UDUPA Committee (Prof. K.N. Udupa) Suggested measures to be applied for research in
Govt. of India to assess and evaluate ayurveda and their recommendation helped in
the present status of ayurvedic system creation of post-graduate institute of medicine,
of medicine Banaras Hindu University, Varanasi. Central
Council for research in Indian systems of medicine
and creation of composite drug research schemes.
1959 Mudaliar Committee (Dr. L/Mudaliar) —
1961 G.Borker - reviewed the overall development of ISM till
that time.
Health in independent India by Ministry of
Health, Government of India, New Delhi
1962 Pandit Committee (Pt. G.C.Pandit), Govt. of Helped in the establishment of Jamnagar institute
India of ayurveda.
1962 Ayurveda Pharmacopoeia —
1962 Vyas Committee (Sh. Mohan Lal P. Vyas, Helped in creation of Shuddha Ayurvedic board.
health Minister of Gujarat on a resolution Draft syllabus for professional Shuddha
passed by central council of health in the ayurvedic degree
annual meeting
1963-64 Establishment of Post Graduate Institute —
of Ayurveda at Banaras Hindu University,
Varanasi, Uttar Pradesh
1969 Central council for Research in Indian Established as autonomous body for organising
Medicine and Homeopathy research in ISM and Homeopathy
1969 Drug and cosmetic act, 1940 Amendment approved by the Parliament to include
ISM Medicines/drugs
1976 Publication of Part - I of Ayurvedic —
formulary containing 444 preparations
1976 Establishment of National Institute of —
Ayurveda, Jaipur
1976-77 Development of State ISM pharmacies For the Development of ISM pharmacies
including drug tests laboratories (Centrally
sponsored scheme)
1978 Central council for research in Ayurveda Central council for research in Indian medicine
and Siddha and homeopathy was bifurcated into four councils
and out of these, one devoted to ayurveda and
Siddha is called central council for research in
ayurveda and Siddha
1981 Indian Medicines Pharmaceutical To supply medicines to Government institutes or
Corporation Limited (IMPCL) at Mohan, research units and also for open market in due
in Almora, Uttar Pradesh. course.
1989 National Academy of Ayurveda —
1995 Creation of separate Department of Indian
Systems of Medicine & Homeopathy in
Ministry of Health & Family Welfare,
Govt. of India —

Leena Abraham

1997 Implementation of Central Scheme in 33 —
organisations for development of agro-
techniques of important medicinal plants
1998 Implementation of Central Scheme in —
32 laboratories for developing
pharmacopoeial standards of Medicinal
Plants/ISM Formulations
1998 Establishment of speciality clinic of —
Ayurveda in Central Govt. Hospital
(Safdarjung Hospital) New Delhi
1998-99 Implementation of IEC (Information, —
Education and Communication) Scheme
for NGOs for propagation and
popularisation of Ayurveda & other
systems
1999 Introduction of Vanaspati Van Scheme for —
large scale cultivation of Medicinal Plants
2000 Publication of 2nd volume of Ayurvedic —
Pharmacopoeia
2000 Introduction of 7 Ayurvedic Medicines in —
RCH Programme
2000 Constitution of Advisory group for —
research in Ayurveda
2000-01 Implementation of Central Scheme of —
assistance for strengthening of State
Drug Testing Laborites and Pharmacies
2001 Publication of 3rd volume of Ayurvedic —
Pharmacopoeia
2001 Publication of English edition of 2nd volume —
of Ayurvedic Formulary of India
2002 Task force set up to strengthen Indian —
Systems of Medicine
2002 National Policy on Indian Systems of —
Medicine and Homeopathy
2003 Establishment of Medicinal Plants Board —
Ministry of AYUSH
Compiled from Annual Reports for various years and website of the ISM & H, Government of India.

Public Health Expenditures, Investment and Financing
Under the Shadow of a Growing Private Sector
Ravi Duggal
Introduction developed and underdeveloped economies. In

Access to healthcare with equity and universal most developed countries where healthcare
coverage is critically linked with public access is near universal, public financing
financing of healthcare services. Countries whether through state revenues and/or social
that have near universal access and relative insurance, has been the critical component
equity in access to healthcare have organised in realising universal access with equity.2, 3
healthcare systems where public financing
accounts for over two-thirds of healthcare Further, health and development cannot be
spending. 1 Health outcomes like infant seen only in terms of averages because
mortality rate, life expectancy, under-5 differences across regions and within them
mortality rate are also intimately associated may be very sharp. Thus the true test of equity
with the proportion of public investment in and universal access would mean that
the health sector. It is not only in developed irrespective of geographic, financial and social
countries like Canada, Australia, Sweden, differentiation healthcare is accessible to all
United Kingdom etc. where we see such and this gets reflected in reduced class and
association but also in a number of developing geographical differentials of health outcomes,
countries that are not very different from the as has happened in the countries referred to
level of economic development in India. Thus above. Such an achievement is only possible
countries like Sri Lanka, China, Costa Rica, with larger public investment and
Thailand, South Korea, Turkey, which have expenditures in the health sector. This is the
in recent years put in efforts at organising missing link in India. At one level there are
their healthcare systems and where larger rural-urban hierarchies in type and quality
public budgets are allocated to healthcare, of health services available to the urban
have far out performed India in health sectors, which take away most of the curative
achievements. care budget and often two to three times the
resources in proportion to their strength in
The pattern of development of the health the population, and at another level rural
sector is closely linked to the political economy areas get mostly preventive and promotive
and the level of economic development. While services like family planning, immunisation,
economic development can create conditions ante-natal care and disease surveillance for
for better access to healthcare as well as a selected communicable diseases. At another
better average standard of living and hence level there are sub-regional hierarchies in the
improved health outcomes, a political form of pockets of growth (industrial centres,
economy based largely on private health green revolution areas) and exclusion of sub-
financing can create large adversities for regions in development (adivasi areas, remote
health not only for the poorer sections of and hilly terrains). Equitable distribution of
society but also the middle classes. Thus the health resources across various regions and
role of public financing is critical in both sub-regions can improve access to healthcare
1
WHO, 2002: World Health Report 2001, WHO, Geneva
2
Roemer, Milton, 1985: National Strategies for Health Care Organisation, Health Administration Press
3
OECD, 1990 : Health Systems in Transition, Organisation for Economic Cooperation and Development, Paris

Public Health Expenditures, Investment and Financing Under the Shadow of a Growing Private Sector
as well as health outcomes substantially, even facilities are getting incapacitated because the
in the absence of economic development. Thus necessary inputs that are needed to run these
state intervention in the health sector can facilities are not being adequately provided
make a tremendous difference to the health for. The 2002 National Health Policy
of the people, especially those who are unashamedly acknowledges that the public
economically and socially underprivileged. healthcare system is grossly short of defined
requirements, functioning is far from
While India lost the opportunity of satisfactory, that morbidity and mortality due
implementing a national healthcare system to easily curable diseases continues to be
immediately following Independence via the unacceptably high, and resource allocations
Bhore Committee 4 recommendations and generally insufficient:
made very poor investments in the public
health sector over the years, the mid-seventies “It would detract from the quality of the exercise
became a turning point for major investments, if, while framing a new policy, it is not
especially in rural India via the Minimum acknowledged that the existing public health
Needs Program. The 5th to 7th Plan period may infrastructure is far from satisfactory. For the
be regarded as the ‘golden era’ of public health out-door medical facilities in existence, funding
sector performance in India when not only is generally insufficient; the presence of medical
public investments and expenditures in and paramedical personnel is often much less
healthcare peaked but also health outcomes than required by the prescribed norms; the
witnessed substantial improvements. availability of consumables is frequently
negligible; the equipment in many public
The achievements of the public health sector hospitals is often obsolescent and unusable;
made during the eighties in improving health and the buildings are in a dilapidated state. In
outcomes received a set back with the the in-door treatment facilities, again, the
economic crises of 1991 and the subsequent equipment is often obsolescent; the availability
economic reforms which followed under the of essential drugs is minimal; the capacity of
Structural Adjustment Program (SAP) strategy the facilities is grossly inadequate, which leads
commandeered by the World Bank. As to over-crowding, and consequentially to a
mentioned earlier, during the 5th to 7th Plan steep deterioration in the quality of the
period public health services and public services.”5.
health investment were relatively robust and
this got reflected in faster improvements in This is largely caused by compression of
health outcomes, to begin with in developed public spending in the health sector and
states and soon followed by the secondly due to allocative inefficiencies
underdeveloped. This approach received a set caused by unprecedented increases in salaries
back at the turn of the nineties when resource as a consequence of the 5th Pay Commission
commitments in the public health sector implementation (around 1996-1998). Non-
declined, and especially so in the developed salary components have shrunk considerably
states. as budget increases do not factor for allocative
efficiencies for effective running of the public
This is reflected at one level in slowing down health system. This coupled with privatisation
of improvements in health outcomes and the policies, including introduction and/or
widening rural-urban gap of these outcomes. increase in user charges, have taken the
At yet another level the public health care public health system to the brink of collapse.
4
Bhore, Joseph, 1946 : Report of the Health Survey and Development Committee, Volume I to IV, Govt. of India,
Delhi
5
MoHFW, 2002: National Health Policy 2002, para 2.4.1, GOI, New Delhi

Ravi Duggal
With greater dependence on the market for indebtedness. National surveys show loans for
healthcare, access becomes more difficult for healthcare to be the number one reason for
an increasing number of people. families, especially the poor, getting trapped
into indebtedness. 8 This is unflinching
The evidence for this is clearly brought out in evidence supporting the hypothesis of
the changes one sees across the 42nd and 52nd criticality of public financing for good
Round NSS surveys6, when over this decade healthcare and health outcomes.
utilisation of private health services, especially
in the hospital sector, increases substantially, Another dimension of the reform process is
out-of pocket spending gallops, indebtedness that of disinvestments by the state in
due to healthcare affects nearly half the users economic activities. This is supposed to
and the proportion of non-utilisation also release resources for a larger role of the state
increases. This coupled with poor in social sectors -the ‘human face’ in the
commitment of public resources to healthcare reforms/adjustment process. While
is the main cause for poor health outcomes divestment of public sector undertakings has
in. been taking place, there is no evidence of
increased support to the social sectors like
In fact, when we relate health outcomes with health and education. This is perhaps due to
expenditures we see that in comparison to the simultaneous shrinking of state revenues
similarly developed countries India’s due to cuts in tax rates, excise duties etc.
performance is the worst despite India having which reduces the states share in the national
one of the highest total health expenditures income, that is declining Tax/GDP ratios (from
amongst these countries.7 This is largely due a peak of over 16 per cent in the mid-eighties
to the fact that in India the spending is mostly currently down to 13 per cent)9. This trend is
out-of-pocket because public resources in itself a threat to public spending because
committed are very low. In a scenario of not only are the promised additional resources
poverty such a mechanism of financing will not available for the social sectors but also
never show up good health outcomes because some support which was available through
out-of-pocket health expenditures for the poor public sector enterprises is now getting
as well as the not so poor means foregoing diminished and is already getting reflected in
other basic needs or worse still getting into increased unemployment ratios which are up
6
NSS-1987:Morbidity and Utilisation of Medical Services, 42nd Round, Report No. 384, National Sample Survey
Organisation, New Delhi; and NSS-1996:Report No. 441, 52nd Round, NSSO, New Delhi, 2000
7
Health Outcomes in Relation to Health Expenditures
Total Health Public Health U-5

Expenditure Expenditure Mortality Life Expectancy
as % of GDP as % of total Male Female
India 5 17 95 59.6 61.2
China 2.7 24.9 43 68.1 71.3
Sri Lanka 3 45.4 19 65.8 73.4
Malaysia 2.4 57.6 14 67.6 69.9
South Korea 6.7 37.8 14 69.2 76.3
Source: Changing the Indian Health System – Draft Report, ICRIER, 2001
8
NSS-1987:Morbidity and Utilisation of Medical Services, 42nd Round, Report No. 384, National Sample Survey
Organisation, New Delhi; and NSS-1996:Report No. 441, 52nd Round, NSSO, New Delhi, 2000
9
DEA, 2003: Economic Survey 2002-03, GOI, New Delhi

from around 2 per cent in the eighties to over preventive and promotive services like family
7 per cent presently10. Further, data from planning and immunisation. The private
countries having near universal access to sector has a virtual monopoly of ambulatory
healthcare and/or having much better health curative services in both rural and urban
outcomes than India shows that Tax/GDP areas and nearly two-thirds of hospital care.
ratios in those countries are in the range of Further, a very large proportion of private
20-45 per cent11 . For instance the OECD providers are not qualified to provide modern
group of countries which have most of the healthcare because they are either trained in
countries with universal healthcare access other systems of medicine (traditional Indian
average a Tax/GDP ratio of 37 per cent12. What systems like ayurveda, unani and siddha, and
is worse in India is that the tax revenues are homoeopathy) or worse, do not have any
largely indirect taxes, which means that the training, and these are the providers who the
burden of taxes is greater on the poorer poor are most likely to seek healthcare from.
sections of society. In India the direct tax In the underdeveloped states the proportion
proportion is only about 20 per cent13 as of unqualified or inadequately trained
compared to most other countries, especially practitioners is much higher. This adds to the
those with reasonable social security support risk faced by the already impoverished
mechanisms, where it is between 45 and 65 population. The healthcare market is based
per cent.14 on a supply-induced demand and keeps
growing geometrically, especially in the
The social sectors, which are of primary context of new technologies. The cost of
importance for human resource development, seeking such care is also increasing. This
are critically dependent on public financing. means that the already difficult scenario of
The latter becomes even more important in access to healthcare is getting worse, and not
the context of poverty because such support only the poor but also the middle classes get
creates equity even with high levels of income severely affected.15 Thus India has a large,
poverty. In India three-fourths of the people unregulated, poor quality, expensive and
live below or at subsistence levels. This means dominant private health sector, and an
70-90 per cent of their incomes goes towards inadequately resourced, selectively focused
food and related survival consumption. In and declining public health sector despite its
such a context social security support for poverty, with the former having curative
health, education, housing etc. becomes monopoly and the latter carrying the burden
critical. Ironically, India has one of the largest of preventive services.
private health sectors in the world with over
80 per cent of ambulatory care and 65 per The total value of the health sector in India
cent of hospitalisations being supported today is over Rs.1500 billion or US$ 34 billion.
through out-of-pocket expenses. This works out to about Rs.1500 per capita
which is 6 per cent of GDP (see Table 1 below).
The public curative and hospital services are Of this 15 per cent is publicly financed, 4 per
mostly in the cities. Rural areas have mainly cent is from social insurance, 1 per cent
10
DEA, 2003: Economic Survey 2002-03, GOI, New Delhi
11
World Bank, 2001: World Development Report 2000/2001, Oxford, Washington DC
12
http://www.oecd.org/document/8/0,2340,en_2649_201185_1962312_119690_1_1_1,00.html (download date
26/12/2003)
13
Ghosh, Jayati, 2001: Who Pays the Taxes, Frontline, Vol. 18 No. 11, May 26
14
same as footnote 11
15
The 52nd Round NSS data reveals that for inpatient care 46% of poorer classes and 34% of the richer classes
either sold assets or took loans to pay for treatment. And those using private hospitals were 16% more likely to get
into indebtedness than those using public hospitals. (NSS-1996: Report No. 441, 52nd Round, NSSO, New Delhi,
2000)

Ravi Duggal
Table 1
Financing Healthcare in India 2003
Estimated users in millions Expenditure (Rs. Billions)
Public Sector 250@ 252 (17)*
Of which Social Insurance 55 30 (2)
Private Sector 780@ 1250 (83)**
Of which social insurance 30 24 (1.6)
Private insurance 11 11.5 (0.8)
Out of Pocket 739 1214.5 (80)
Total 1030 1552 (100)
@ Estimates based on National Sample Survey 52nd Round, and Labour Year Book
* Finance Accounts of Central and State Governments, and Labour Year Book
** Private Final Consumption Expenditure from National Accounts Statistics
Figures in parentheses are percentages
private insurance and the remaining 80 per assets. Insurance contributions, whether for
cent being out of personal resources as user- social insurance schemes or as private
fees (85 per cent of which goes to the private insurance premiums, constitute a very small
sector). Two thirds of the users are purely out- proportion.
of-pocket users and 90 per cent of them are
from the poorest sections. The tragedy is that Trends in Public Health Expenditures
in India, as elsewhere, those who have the Public investment in the social sectors in India
capacity to buy healthcare from the market has been a cause for concern. The decision to
most often get healthcare without having to be a mixed economy trying to marry socialism
pay for it directly, and those who are below and capitalism has not worked either system.
the poverty line or living at subsistence levels In retrospect the large public sector economy
are forced to make direct payments, often with failed in realising both economic and social
a heavy burden of debt, to access healthcare goals. On the contrary it helped accumulation
of private capital but the Indian bourgeoisie
from the market. National data reveals that
and the State did not have the vision to
50 per cent of the bottom quintile sold assets
promote a welfare state. Right from the first
or took loans to access hospital care. Hence
plan onwards the health sector has received
loans and sale of assets are estimated to
on one hand inadequate resources and on the
contribute substantially to financing
other these resources largely benefited the
healthcare. This makes the need for insurance small urban-industrial economy. Table 1
and social security even more imminent. profiles the investment and expenditures in
the health sector since the first plan period.
Public financing of healthcare comes largely It is clearly evident that the state has over
from state government budgets, about 80 per the years committed merely around 3 per cent
cent, and the balance from the Union of public resources for the health sector and
government (12 per cent) and local this has invariably been less than 1 per cent
governments (8 per cent). Of the total public of GDP. As a consequence the out-of-pocket
health budget today about 10 per cent is burden of households has been the main
externally financed in contrast to about 1 per source of financing healthcare. Of the total
cent prior to the Structural Adjustment loan health expenditure in India the public sector
from the World Bank and loans from other contributes around one-fifth and this has
agencies. Private financing is mostly out-of- remained more or less constant over the years.
pocket with a large proportion, especially for This level of state’s investment in the health
hospitalisations, coming not from current sector is not adequate to ensure universal and
incomes but from savings, debt and sale of equitable healthcare access.

Graph 1
IMR Trends in India and Low-income Countries 1960-95
180
150 India
120
Low-income countries
90
Indian Urban
60
30 India Rural
0
1960 1970 1980 1990 1995 2000
Years
Source: SRS Bulletins and UNDP HDRs
If we look at health outcomes like infant private sector expansion in the health sector,
mortality rate (IMR) and life expectancy we though post-SAP even private health
find that the change has been very slow. This expenditures showed a decline but in latter
is clearly linked to poor investments in the half of the nineties they began climbing again.
public health sector. And as a consequence (Table 1 and Table 9) The impact of this
India has been lagging behind the average IMR changinng political economy has been
of the low-income countries. discussed in the introduction.
From the above graph it is clearly evident that While overall public health investment and
India, with improved public health expenditures have been low and inadequate
investments in the eighties (Table 1 and 2 ), to meet the healthcare needs of the population
caught up with the rest of the low income at large, there are hierarchies within this
countries on the one hand and on the other, health spending. The most obvious hierarchy
the rural urban gap narrowed to some extent, is the rural-urban dichotomy in public health
but the sharp declines seen in the eighties investment and expenditures. The rural areas
has turned to stagnation or slower decline in across the country have public health services
both IMR and U-5 mortality post 1991 (Graph that largely focus on preventive and promotive
2). The post-SAP period saw a declining trend aspects. Thus immunisations for children and
in public resources being committed to the pregnant women, antenatal care, surveillance
health sector and the stagnation in health of selected diseases and family planning
outcomes is largely a consequence of this. services constitute the key focus of the
Graph 3 and Table 2 show the trend of public primary healthcare system provided for rural
health spending from 1976 to 2001 and it is India. The component for ambulatory curative
evident from this that in the eighties public services is grossly inadequate under the
health expenditures as a percent of GDP as primary healthcare system. In contrast the
well as the proportion of total government focus in urban healthcare is largely curative
spending peaked and then began to decline. with dispensaries and hospitals taking away
What was worse is the proportion of capital most of the health resources. Since India lacks
expenditure, which was halved during the a national health accounting system,
nineties as compared to the eighties; and this disaggregation of public spending across rural
meant that new investments in public health and urban areas for the country as a whole is
had almost stopped. This was the period of difficult to compile. However we have done

Ravi Duggal
Graph 2
Slowing Down in Rate of IMR and U-5 Mortality
Decline 1971-2001
40.0
35.0
30.0 Infant
25.0
20.0 Mortality
15.0 decline
10.0
5.0 Under-5
0.0 Mortality
1971-81 1981-91 1991-01 decline
Year
Source: 1. upto 1986 – Combined Finance and Revenue Accounts, respective years, GOI, New Delhi; 2.
1987 –2003 Finance Accounts of States and Union Government, respective years; and RBI – Finances of
the State Governments, respective years, RBI, Mumbai; 3. GDP and Population data - National Accounts
Statistics, CSO, 2003
Graph 3
Public Expenditure Ratios 1976-2001
3.7 12
3.2 10
2.7 8 GDP%
2.2 6 Govt. expend %
1.7 4 Capital Ratio
1.2 2
0.7 0
1976 1981 1986 1992 1996 2001
Year
this exercise for Maharashtra state to estimate preventive and promotive programmes
rural-urban differentials in allocation of referred to earlier. In contrast in the urban
resources (Table 6 / Graph 4). areas it is a good mix of curative, preventive
and promotive services, with curative services
The rural-urban distribution of resources at comprising nearly half the urban health
one level favours urban health facilities with budget. While this data is from Maharashtra,
over 60 per cent of allocations for urban areas in other states the rural-urban disparity
where 40 per cent of the population resides, should not be very different, infact the
but more important, at another level the allocation of resources to rural areas in the
service-mix of healthcare in the two regions under-developed states is likely to be worse.
differs significantly. The rural areas get only
half the resources of what urban areas get on Apart from state budgets allocating a more
a per capita basis, and within this low favourable proportion of resources to urban
allocation only 4 per cent is for medical care areas the latter also have the advantage of
and a little over one percent for capital local government resources to support urban
expenditures. (Table 6) The rest is on public healthcare. While municipal budgets

Graph 4
Rural - Urban Differentials in Public Health
Expenditure Maharashtra 2000-01
100% Capital
Other FW
80% MCH
Family
60% Planning
Public
40% Health
Medical
20% care
0%
Rural Urban Total
Source: Performance Budgets, Ministry of Health and Family Welfare, Govt of Maharshtra 2002-03, Mumbai,
2003
are not compiled for the country as a whole, municipal health expenditure as a ratio to
some occasional evidence available suggests total municipal expenditure, especially so
that urban areas, especially cities and metros, during the post SAP period.
get large resources for healthcare further
enhancing what the state governments also The above analysis is restricted only to
contribute. Data of selected municipal municipal corporations but in addition there
corporations show that over the years there are other levels of municipal bodies such as
seems to be a changing trend in municipal municipalities and municipal councils and for
health expenditures wherein state resources rural areas there are local governments like
for urban areas seem to be expanding.16 The zilla parishads (earlier called district boards)
table below gives a trend of municipal health and panchayat samitis. Data for these are
spending over the years for selected municipal more difficult to come by. During the 1950s
corporations17 and indicating ratios to state and early 1960s the ministry of health used
government expenditures, which shows a to report health expenditures of such bodies
clear declining trend. in their Health Statistics of India. For instance
in 1951 Rs. 22 million (6 per cent of the total
What is evident from the above table is that expenditure) was reported as expenditure on
viewed as a ratio to public spending on health by district boards and this was as much
healthcare the overall resource commitments as 10 per cent of what governments were
in municipal budgets for healthcare are spending on healthcare in the same year. This
declining. This may also mean that many came down to a mere Rs.9 million in 1961,
municipalities over time have been unable to which was less than one percent of what
raise resources and hence may be reducing governments were spending on healthcare.
their presence in the health sector. This is This is clear evidence for the fact that health
borne out by the declining proportion of expenditures which were decentralised in
Duggal Ravi, S Nandraj and S Shetty: State Sector Health Expenditures 1951-1985, FRCH, 1992, Mumbai
16
Interestingly for health expenditures of all municipal corporations in the country Mumbai alone accounts for a
17
whopping 35%

Ravi Duggal
Table 2
Selected Municipal Health Expenditures 1951-1998
Municipal Health 1951 1961 1971 1981 1986 1991 1996 1998
Expenditure (24) (26) (29) (31) (39) (36) (27) (24)
In Rupees million 12 264 467 1478 3098 5395 5447 7838
% Health to total
expenditure 32 29 29 29 28 26 17 19
% to govt health
expenditure 55 24 14 12 10 11 5 6
Figures in parentheses refers to number of municipal corporations
Source: CSO: Statistical Abstract of India, respective years, Govt of India, New Delhi
municipal and district authorities were getting million in 1986 (22 per cent of govt. health
centralised at the state level. Thus the expenditure). These constituted about 37% of
decentralisation that existed in the early years total municipal expenditures. However
post-independence instead of being between 40 per cent and 50 per cent was
strengthened, as suggested by the Balwant supported through grants from the
Rai Mehta committee, was gradually left to governments. What this translates into still
wither away. is between 11- 15 per cent additional health
expenditures for urban populations over and
Another set of data that is available nationally above what governments were spending. Thus
on local government expenditures, both urban urban areas at one level get about two-thirds
and rural, is salaries and wages for medical of government health expenditures for less
and public health in local governments. This than one-third of the population that live in
expenditure for instance was Rs. 22.44 billion urban areas and in addition get about 10 to
in 2000-01 as compared to Rs. 4.97 billion in 15 per cent of this additionally for healthcare
1990-91 18 . In addition expenditures on support from municipal budgets.
commodities and services would be there but
this is not known at the national level. While rural-urban differential health
Ofcourse, between 10 to 40 per cent for urban expenditures are not available in the national
bodies and between 60 and 80 per cent for health accounts, we do have data on
rural bodies is the grant component from expenditures across major health programs.
government which is also reflected in the Table 4 shows that until the beginning of the
governments expenditure and hence has to 1990s the proportion across programs
be netted. maintained an astonishing consistency. What
we see since then is a decline in proportion of
In the seventies and eighties a number of expenditure on hospitals and dispensaries,
studies by National Institute of Urban Affairs capital expenditures, and disease programs.
(NIUA)19 were undertaken and this provided One program that has gained substantially is
some comprehensive data on municipal the Mother and Child Health (MCH) now called
finances and expenditures. Data from these Reproductive and Child Health (RCH) together
studies show that municipal gross financing with the family planning program due to an
of health budgets was Rs. 2156 million in increased focus on antenatal care and child
1975 (ratio of 30 per cent of govt health immunisation. Capital expenditures have
expenditure), Rs. 3792 million in 1980 (29 per seen a real beating (Table 5) and hence there
cent of govt health expenditure) and Rs. 6500 have been virtually no new investments in the
18
CSO, Statistical Pocketbook India 2002, GOI, NewDelhi
19
A Study of Financial Resources of urban local bodies in India, NIUA, 1983, New Delhi; Upgrading Municipal
Services, NIUA, 1989, New Delhi

Table 3
Growth of Private Health Expenditures in India in Comparison to
Public Expenditures 1951-2003
1951 1961 1971 1981 1986 1991 1995 1996 1997 1998 2000 2003
Health Public 0.22 1.08 3.35 12.86 29.66 50.78 82.17 101.65 113.13 126.27 219.59
Expenditure Private 3.65 10.99 52.84 90.54 146.98 278.59 329.23 373.41 459.00 835.17 1250.0
Rs. Billion
Health Public 0.25 0.71 0.84 1.05 1.19 0.92 0.95 0.91 0.88 0.81 0.87 1.00
Expenditure Private 2.25 2.60 4.06 3.61 2.88 3.04 3.07 3.00 3.30 4.76 5.60
as percent
of GDP
Private:
Public ratio
(times) __ 3.4 3.3 4.1 3.1 2.9 3.4 3.3 3.3 3.6 4.7 5.7
Source: Public Expenditures from Finance Accounts of state and central govts., and private
expenditures from national Accounts Statistics of CSO.
public domain during the 1990s and budgets is that of allocative efficiency of
subsequently. However, the decline under the resources. In the 1990s budgets shrank, yet
budget head ‘hospital and dispensaries’ and salaries (post-1996) increased very
‘disease programs’ may not be actually so. In substantially and this upset availability of
the finance accounts there have been changes resources for non-salary components in most
in reporting in which external budgetary states and this added salt to the wounds of
support is shown under a separate head and the ailing public health system. It is only in
since such resources have come largely to the the last one or two years that the ratio of salary
hospital sector (health sector reform projects to non-salary is coming back to the pre 1996
of World Bank, EU etc.) and to disease period.
programs like AIDS and tuberculosis, there
is perhaps no real decline in these two heads. To sum up, the collapse of the public health
So the astonishing consistency seems to system during the last decade is somewhere
continue perhaps reflecting that there is very linked to the falling levels of public health
little drive for change in the method of public investment and the declining public health
health spending. expenditures and this in a situation of
continuing poverty can only lead to increased
Further when we look across states the adversities in health outcomes. Even in a state
declining trend in public health expenditure like Kerala we see stagnation in health
during the 1990s is almost universal (Table 8). outcomes like infant and child mortality rates
The collapse is taking place across the length due to the fiscal crises of the state government
and breadth of the country and this is a very but more important due to the unprecedented
serious concern. Yet one sees increased growth of the private health sector in Kerala.
proportions being allocated in the central
government’s budget but this is also a matter Private Health Expenditures
of concern because most of this increase is The private health sector has always been a
due to external funding for vertical health very substantial entity in India, especially for
projects like health sector reforms projects of ambulatory care. However for hospitalisations
the World Bank and EU, RCH projects of until the mid-eighties the private sector was
various bilateral and multilateral donors, HIV/ a reasonably small player but since then it
AIDS funding etc. grew by leaps and bounds and overtook the
public hospital sector around the mid-nineties
Another concern vis-à-vis public health (Table 9 ). From the 1970s on private spending
Ravi Duggal
on healthcare grew gradually, peaking around of drug prices, increased reliance on market
the early 1980s. As mentioned earlier, the mechanisms to address welfare needs, and
eighties was the growth phase of public health weakening of public health systems. Thus the
investment and hence we see private health main hurdles to healthcare access are poverty
expenditures decline during that period and the changing political economy and the
because of improved access to public inequities associated with it.
healthcare facilities. The impact of SAP
affected both the public and private health While data on the number of public healthcare
sectors but by mid-1990 the private health facilities is available, the data about its use is
sector recovered dramatically and since then not available in any systematic manner. The
it has grown at the cost of the public health service statistics lack an epidemiological basis
sector. It must be remembered that 80-85 per and are reported more in terms of targets and
cent of private health expenditure is incurred achievements, which have little meaning for
out-of pocket and the burden is directly on the purpose of any analysis. State
household budgets. Further, less than 10 per Performance Budgets do give some relevant
cent of the workforce is in the organised utilisation data but these documents are not
sector, which may have either social insurance easily available nor the health statistics
or medical benefits coverage from employers, authorities compile data from them. In the
estimated to cover about 15 per cent of the case of the private health sector data is
population. This means that as much as 85 conspicuous by its absence. However, in
per cent of the population, largely poor and recent years, national surveys like the NSSO
subsistence level households, contribute utilisation surveys in 1987 and 1996, the
entirely out-of-pocket to access private health NCAER surveys in 1990 and 1993, NFHS
services and as we have seen earlier this is surveys in 1993 and 1999, and the RCH rapid
often coming not from current incomes but household survey in 1999, apart from the
from loans and sale of assets. smaller studies, have provided reasonably
good estimates of utilisation of health services
Comparison of utilization and health and healthcare expenditures. The NSSO data
expenditure data across the 42nd (1987) and reveals that the share of outpatient services
52nd (1996) Rounds of NSS shows a very provided by public institutions has declined
alarming trend. There is upto 30 per cent from 26 per cent to 23 per cent in rural areas
decline in use of public healthcare facilities over the decade (1986-1996) and from 27 per
in both rural and urban areas over the decade. cent to 22 per cent in urban areas. This
Why is this so? Partly the answer is within decline has been mainly in utilisation of out
the same data set. The cost of seeking patient departments(OPDs) of public
treatment even in public hospitals has hospitals, as the use of Public Health Centres
increased over five-fold (in private it is nearly (PHCs) and dispensaries has remained the
seven times). During the same period the same in the overall proportion. This also
purchasing power of the poorer classes has means that the weight of PHCs, Community
not changed in any substantial way and as a Health Centres (CHCs) and dispensaries in
consequence the 52nd Round shows higher public provision of OPD services has increased
levels of untreated morbidity, especially significantly, perhaps a result of expansion
amongst the poorer groups. The other part of of the primary healthcare sector, especially
the answer is the declining investment and in the rural areas. Thus the share of PHCs,
expenditures in the public health sector. It CHCs and dispensaries in public facilities for
can be argued that these trends are closely OPD care increased from 31 per cent to 42
linked with a wide spectrum of changes in per cent in the rural areas during this period
the economy since the mid-1980s, which have and in the urban areas from 11 per cent to 15
led to privatisation of services, deregulation per cent. In case of inpatient care the public

Social Health Insurance workers, mine workers, building/

Apart from general public health construction workers, head load workers to
expenditures a select population working in meet social security benefits like healthcare,
the organised sector gets access to education, recreation, water supply, housing
healthcare resources due to their etc. In 2002-03 these funds expended Rs.
employment. The total employment in India 350 million on healthcare, which was about
today is estimated at 400 million but of this half the expenditure of the welfare funds.
only 28 million is in what is called the
organised sector, which is covered by From rest of the organised sector, largely
comprehensive social security legislation, the middle and upper middle classes,
including social health insurance. The about 30 million persons are provided
largest of this is the ESIS which covers 8 healthcare protection from employers
million employees, and including family through reimbursements and/or employer
members provides health security to 33 provision. This is estimated at about Rs.24
million persons. In 2002-03 the ESIS billion per year, averaging Rs.3000 per
Corporation spent Rs.12 billion on employee per annum. Thus about 10
healthcare for its member beneficiaries percent of the country’s population has
averaging Rs.365 per beneficiary. This some form of social insurance cover for
effectively covers a mere 3.2% of the health through their employment.
population. Another about half per cent of
the population is covered through the CGHS. From time to time the government has also
In the same year the CGHS spent Rs. 2 introduced social security schemes,
billion averaging Rs. 450 per beneficiary. including health cover for various groups
While these social insurance plans have of population, especially the poor or below
been around for a long time, their credibility poverty line groups, in the unorganised
is at stake and large scale out-sourcing to sector, like the Krishi Shramik Samajik
the private sector is taking place. ESIS has Sanstha Yojana, National Social Assistance
private panel doctors in large cities who Program, National family benefit scheme,
provide ambulatory care to those covered National maternity benefit scheme,
under ESIS whereas their own doctors in handloom workers thrift, health and group
dispensaries and hospitals run by ESIS are insurance, agricultural workers central
increasingly idling. Similarly under CGHS, scheme, janashree bima yojana, state govt
those covered are being given “choice” to welfare funds, national illness assistance
access private healthcare by being given fund and state illness funds etc. But these
reimbursements which for instance for a by- schemes are not run on a regular basis,
pass surgery could go upto Rs.150,000 for that is if a person gets a benefit once there
a senior bureaucrat when the same would is no guarantee that the same person
cost about Rs.40,000 in a public institution continues to get access to that scheme on
like AIIMS. a regular basis. No firm figures of their
coverage are available because most such
Further, other government employees like schemes, like the latest community health
the Railways, Defence Services and the P&T insurance scheme in the 2003-04 budget,
dept. have significant healthcare services are populist announcements to lend social
and/or reimbursements for their employees credibility to the budget and when the next
which amounts to a significant Rs.16 billion budget comes the scheme gets quietly
per annum and this averages a whopping archived.
Rs. 1150 per beneficiary. Also welfare
funds have been created by Acts of - Ravi Duggal, Financing Healthcare in
parliament for specific occupational groups, India – Prospects for Health Insurance
including those in selected unorganised Express Healthcare Management journal,
sector groups, like beedi workers, plantation March 1-16, 2004

Ravi Duggal
sector is still a major provider but here too a investment elsewhere often has a positive
declining trend is seen. The NSSO data impact on health. Yes, that is true, provided
indicates that in 1986-87 the public such health impacting investment is available!
institutions accounted for 60 per cent of all India’s social infrastructure is inadequate and
hospitalisations and this came down to 44 per poor across the board. Whether it is
cent in 1995-96, the decline being 40 per cent education, sanitation, drinking water, rural
in urban areas and 36 per cent in rural areas. transportation, electricity supply, water
The largest losers were public hospitals, with harvesting etc.., they are worse if not as bad
PHC and CHC showing a marginal as the public healthcare services. Over the
improvement like in the case of OPDs. years public health services have deteriorated.
If one reviews health plans and policies one
When we look at this utilisation data of public sees a clear direction of abdication of
facilities in the context of public investment responsibility by the State. From
and expenditures on healthcare in the last comprehensive basic care we have moved
decade or so, the declining pattern of towards a program based approach (much like
utilisation begins to make sense. Late 1970s fire-fighting) and now even getting selective
and 1980s was a major growth phase for about programs and recipients of these
public health infrastructure, especially in services. This approach of the State has
rural areas. Even in the nineties rural hospital created favourable conditions for the private
growth had been substantial. But overall health sector to grow from strength to
investment and growth in healthcare by the strength, and often aided by public
state has been declining. This is reflected in resources.20
lower growth in real expenditures and
declining capital expenditures. This has been The other argument that investing in
especially true for medical care, which is healthcare is gilt-edged because it has wide
purely a state government activity. The fifth ranging spin-offs in the overall economy is also
pay commission impact has been devastating; very credible. Kerala in south India is a very
with the proportion of medical care good example. Kerala is economically less
expenditure on salaries shifting from around developed but has the best health profile in
60 per cent prior to the fifth pay commission the country. This is because of its long history
to over 80 per cent a few years later. Thus the of public investment in healthcare services
shift in favour of the private health sector for in both rural and urban areas. Conversely,
availing medical care in the last decade or so with declining investment in the last decade
is not surprising because private health we see adversities in Kerala’s health profile.
facilities have grown much more rapidly in Similarly metropolitan areas like Mumbai,
contrast to public facilities, which at best have Delhi, Chennai, Bangalore, Ahmedabad,
stagnated. In the context of overall poverty Indore etc. have seen vast investments in
this is a disturbing trend because the poor, public health services and these are reflected
who constitute a very large majority of the in reasonably good health outcomes. In recent
country’s population, have to increasingly rely years one can see deterioration because of
on the private healthcare market whose cost reduced investments and expenditures, which
is growing much faster than the means at the is forcing people to increasingly access
disposal of such people. Hence health security healthcare from the private sector that is
of the large majority of Indians is threatened. expanding rapidly. Moreover, these prime
public health services have come under the
Conclusions purview of privatisation and user fees have
One question often raised is ‘Why Invest in been introduced across the board with the
Health?’ and as one argument states that consequence that a large number of poor who
20
Duggal, Ravi, 2000: The Private Health Sector in India – Nature, Trends and a Critique, VHAI, New Delhi

were the main users of these services have surveys of household expenditures and
moved away from them. indirectly by extrapolating on the basis of the
strength of the private health sector. It is today
With such a health system in the country the estimated to be over 5 per cent of GDP, more
health of the people cannot be particularly than double that of estimates available for the
good. There is no dearth of evidence to show 1960s and 1970s.
that India’s health indicators are one of the
worst in the world. Infact the latest Human A restructured and organised healthcare
Development Report shows a downward trend system, which brings private health sector
in India’s global ranking21 Therefore there is a under a regulated public domain, would need
crying need to reorganise the country’s far lower resources. Estimates calculated for
healthcare system. The future lies in creating the basic healthcare package, including
an organised and regulated healthcare existing public secondary and tertiary services
system, which is responsive to people’s needs would cost a little over 3 per cent of the GDP22.
and accountable to them. While This would mean a whopping saving of 40 per
reorganisation will be a long-term process, cent of what is now being spent and it would
beginnings will have to be made by be coupled with much better quality and
rationalisation of the existing healthcare effective services. In terms of sharing costs
system. For example, strengthening primary the public share would definitely need to go
care (especially first line curative) services, up and private resources would be
organising a referral system for secondary and channelised through employers, employees
tertiary care, reallocation of resources on a and insurance funds or other collective
more equitable basis etc. mechanisms of pooling resources like few
NGOs, unions etc. have demonstrated. The
Public spending on healthcare as seen above State would have to raise additional resources
is barely 1 per cent of GDP as it stands today. through earmarked taxes and cesses for the
This infact is a decline over earlier years, health sector. This would mean a greater
especially the mid-1980s when it was 1.32 burden on those with capacity to pay but there
per cent of GDP at the national level. Nearly would be an overall saving of out-of-pocket
70 per cent of state spending goes to urban expenses for all but especially for the poor.
areas, mostly for hospitals. The balance of 30
per cent in rural areas is spent mostly on Thus the new strategy would focus both on
family planning services, immunisation and strengthening the state-sector and at the
selected disease surveillance. Private out-of- same time also plan for a regulated growth
pocket expenditures on healthcare are not and involvement of the private health sector.
available in any organised way. At best There is a need to recognise that the private
estimates can be made based on sample health sector is huge and has cast its net,
21
India’s human development index rank is down from 115 in 1999 to 124 in 2000, though still better than the
1994 rank of 138. India is on the fringe of medium and low HDI group of countries. India’s improvement in the
HDI in the last 25 years has been marginal from a score of 0.407 in 1975 to 0.577 in 2000 - this works out to an
average increase of 1.6% per annum. The slowing down of growth is shown in the table below: (Source: UNDP
Human Development Report, various years)
1975 1980 1985 1990 1995 2000

HDI score 0.407 0.434 0.473 0.511 0.545 0.577
Annual % increase — 1.3 1.8 1.6 1.3 1.1
over previous period
22
Duggal Ravi: : Health and Development in India – Moving Towards Right to Healthcare, Draft paper for Harvard
School of Public Health initiative on Right to Development, 2002

Ravi Duggal
irrespective of quality, far wider than the state- While reorganisation of the health sector will
sector health services. Through regulation and take its own time, certain positive changes
involvement of the private health sector an are possible within the existing setup through
organised public-private mix could be set up macro policy initiatives - the medical councils
which can be used to provide universal and should be directed at putting their house in
comprehensive care to all. What we are trying order by being strict and vigilant about
to say is that the need of the hour is to look at assuring that only those qualified and
the entire healthcare system in unison to registered should practice medicine,
evolve some sort of a national system. The continuing medical education (CME) should
private and public healthcare services need be compulsory and renewal of registration
to be organised under a common umbrella to must be linked to it, medical graduates
serve one and all. A framework for basic passing out of public medical schools must
minimum level of care needs to be spelt out put in compulsory public service of atleast five
in clear terms and this should be accessible years of which three years must be at PHCs
to all without direct cost to the patient at the and rural hospitals (this should be assured
time of receiving care. not through bonds or payments but by
providing only a provisional license to do
Today we are at the threshold of another supervised practice in state healthcare
transition which will probably bring about institutions and also by giving the right to
some of the changes like regulation, price pursue postgraduate studies only to those
control, quality assurance, rationality in who have completed their three years of rural
practice etc.. This is the coming of private medical service), regulating the spread of
health insurance that will lay rules of the private clinics and hospitals through a strict
game for providers to suit its own for-profit locational policy whereby the local authority
motives. While this may improve quality and should be given the right to determine how
accountability to some extent it will be of very many doctors or how many hospital beds they
little help to the poor and the underserved need in their area (norms for family practice,
who will anyway not have access to this kind practitioner : population and bed : population
of a system. Worldwide experience shows that ratios, fiscal incentives for remote and
private insurance only pushes up costs and underserved areas and strong disincentives
serves the interests of the haves. If equity in and higher taxes for urban and over-served
access to basic healthcare must remain the areas etc.. can be used), regulating the quality
goal then the State cannot abdicate its of care provided by hospitals and practitioners
responsibility in the social sectors. The state by setting up minimum standards to be
need not become the primary provider of followed, putting in place compulsory health
healthcare services but this does not mean insurance for the organised sector employees
that it has no stake in the health sector. As (restructuring the existing Employees State
long as there are poor the state will have to Insurance Scheme (ESIS) and merging it with
remain a significant player, and interestingly the common national healthcare system
enough, as the experience of most developed where each employee has equal rights and
countries show, the state becomes an even cover but contributes as per earning capacity,
stronger player when the number of poor for example if each employee contributes 2%
becomes very small!23 of their earnings and the employer adds
23
Data from OECD countries clearly shows that the State is a major player in health financing and over three-
fourths of the resources for the health sector in these countries, except USA, comes from the public exchequer;
even in the USA it is over 40%(OECD, 1990: Health Systems in Transition, Organisation for Economic Cooperation
and Development, Paris) but in India the State contributes less than one-fifth, the balance coming out of pocket
of households.

another 3% then nearly Rs.100 billion could local needs but within a broadly defined
be raised through this alone), special taxes policy framework of public health goals
and cesses for health can be charged to " Strictly implementing the policy of
generate additional resources (alcohol, compulsory public service by medical
cigarettes, property owners, vehicle owners graduates from public medical schools,
etc.. are well known targets and something as also make public service of a limited
like one percent of sales turnover for the duration mandatory before seeking
products and a value tax on the asset could admission for post-graduate education.
bring in substantial resources), allocation of This will increase human resources
existing resources can be rationalised better with the public health system
through preserving acceptable ratios of salary substantially and will have a dramatic
: non-salary spending and setting up a referral impact on the improvement of the
system for secondary and tertiary care. These credibility of public health services
are only some examples of setting priorities " Essential drugs as per the WHO list
within the existing system for its should be brought back under price
improvement. control (90% of them are off-patent)
and/or volumes needed for domestic
Further as an immediate step, within its own consumption must be compulsorily
domain, the State should undertake to produced so that availability of such
accomplish the following: drugs is assured at affordable prices
" Allocation of health budgets as block and within the public health system
funding, that is on a per capita basis " Local governments must adopt location
for each population unit of entitlement policies for setting up of hospitals and
as per existing norms. This will create clinics as per standard acceptable
redistribution of current expenditures ratios, for instance one hospital bed per
and reduce substantially inequities 500 population and one general
based on residence. 24 Local practitioner per 1000 persons. To
governments should be given the restrict unnecessary concentration of
autonomy to use these resources as per such resources in areas fiscal
24
To illustrate this, taking the Community Health Centre (CHC) area of 150,000 population as a “health district”
at current budgetary levels under block funding this “health district” would get Rs. 30 million (current resources
of state and central govt. combined is over Rs.200 billion, that is Rs. 200 per capita). This could be distributed
across this health district as follows : Rs 300,000 per bed for the 30 bedded CHC or Rs. 9 million (Rs.6 million for
salaries and Rs. 3 million for consumables, maintenance, POL etc..) and Rs. 4.2 million per PHC (5 PHCs in this
area), including its sub-centres and CHVs (Rs. 3.2 million as salaries and Rs. 1 million for consumables etc..).
This would mean that each PHC would get Rs. 140 per capita as against less than Rs. 50 per capita currently. In
contrast a district headquarter town with 300,000 population would get Rs. 60 million, and assuming Rs. 300,000
per bed (for instance in Maharashtra the current district hospital expenditure is only Rs. 150,000 per bed) the
district hospital too would get much larger resources. To support health administration, monitoring, audit, statistics
etc, each unit would have to contribute 5% of its budget. Ofcourse, these figures have been worked out with
existing budgetary levels and excluding local government spending which is quite high in larger urban areas.
(Duggal, Ravi 2002: Resource Generation Without Planned Allocation, Economic and Political Weekly, Jan 5,
2002)

Ravi Duggal
measures to discourage such to make them more effective. This will

concentration should be instituted.25 contribute towards improvement of
" The medical councils must be made quality of care in the private sector as
accountable to assure that only well as create some accountability
licensed doctors are practicing what " Strengthen the health information
they are trained for.26 Such monitoring system and database to facilitate better
is the core responsibility of the council planning as well as audit and
by law which they are not fulfilling, and accountability.
as a consequence failing to protect the
patients who seek care from To conclude, it is evident that the neglect of
unqualified and untrained doctors. the public health system is an issue larger
Further continuing medical education than government policy making. The latter is
must be implemented strictly by the the function of the overall political economy.
various medical councils and licenses Under capitalism only a well-developed
should not be renewed (as per existing welfare state can meet the basic needs of its
law) if the required hours and population. Given the backwardness of India
certification is not accomplished the demand of public resources for the
" Integrate ESIS, Central Government productive sectors of the economy (which
Health Scheme (CGHS) and other such directly benefit capital accumulation) is more
employee based health schemes with urgent (from the business perspective) than
the general public health system so the social sectors, hence the latter get only a
that discrimination based on residual attention by the state. The policy
employment status is removed and route to comprehensive and universal
such integration will help more efficient healthcare has failed miserably. It is now time
use of resources. For instance, ESIS is to change gears towards a rights-based
a cash rich organization sitting on approach. The opportunity exists in the form
funds collected from employees (which of constitutional provisions and discourse,
are parked in debentures and shares international laws to which India is a party,
of companies!), and their hospitals and and the potential of mobilizing civil society
dispensaries are grossly under-utilised. and creating a socio-political consensus on
The latter could be made open to the right to healthcare. There are a lot of small
general public efforts towards this end all over the country.
" Strictly regulate the private health Synergies have to be created for these efforts
sector as per existing laws, but also an to multiply so that people of India can enjoy
effort to make changes in these laws right to health and healthcare.27
25
Such locational restrictions in setting up practice may be viewed as violation of the fundamental right to
practice one’s profession anywhere. It must be remembered that this right is not absolute and restrictions can be
placed in concern for the public good. The suggestion here is not to have compulsion but to restrict through fiscal
measures. In fact in the UK under NHS, the local health authorities have the right to prevent setting up of clinics
if their area is saturated.
26
For instance the Delhi Medical Council has taken first steps in improving the registration and information
system within the council and some mechanism of public information has been created.
27
Duggal, Ravi: Health and Development in India – Moving Towards Right to Healthcare, Draft paper for Harvard
School of Public Health initiative on Right to Development, 2002

Table 4
Pattern of Investment and Expenditures on Health and Family Welfare
(Rs. Billions) and selected Health Outcomes
Public Health Investment and Expenditures Private Health Total Health Health Outcomes
Plan Period Health Health Health Percent Percent Percent Private Private Total Public as IMR at Life
& FW & FW & FW Health Health Plan H& Health Health Health % of Total end of Expect-
Plan as percent Expend- & FW of & FW of FW Expd. Expen- as % of Expen- Health plan ancy
Expd. of Plan iture – Total GDP diture GDP diture period during
plan+ Govt plan
non plan Expd. period
First Plan (Actuals) 0.65 3.33 2.27 3.74 0.44 28.63 7.5 1.46 9.77 23.2 148 37
(1951-56)
Second Plan (Actuals) 1.46 3.12 3.93 3.52 0.56 37.15 13.2 1.88 17.13 22.9 138 44
(1956-61)
Third Plan (Actuals) 2.51 2.92 6.68 2.65 0.62 37.57 26.89 2.53 33.57 19.9
(1961-66)
Annual Plans (Actuals) 2.11 3.18 6.84 2.8 0.69 30.85 26.92 2.71 33.76 20.3 129 51
(1966-69)
Fourth Plan (Actuals) 6.14 3.89 19.91 3.35 0.84 30.84 67.02 2.83 86.93 22.9 129
(1969-74)
Fifth Plan (Actuals) 12.53 3.18 34.33 2.86 0.81 36.5 148.21 3.52 182.54 120 52
(1974-79)
Annual Plan 3.84 3.3 11.29 3.19 1.04 34.01 45.85 4.21 57.14 19.8 114 52
(1979-80)
Sixth Plan (Actuals) 34.12 3.12 95.72 3.15 1.1 35.64 354.64 4.06 450.36 21.3 96 55
(1980-85)

!
Seventh Plan (Actuals) 68.09 3.11 556.05 3.35 80 58
(1985-90)
242
Annual Plans 37.71 3.06 109.95 2.94 0.99 34.3 307.63 2.8 417.58 26.3 79 59
(1990-91, 1991-92)
Eighth Plan (Actuals) 141.1 2.9 434.34 2.52 0.93 32.49 1352.23 2.88 1786.57 24.3 71 61
(1992-97)
Ninth Plan 299.96 3.19 847.69 2.65 0.97 35.38 3054.24 3.49 3901.93 21.7 66 65
(Anticipated Exp.)
(1997-2002)
Tenth Plan 589.2 3.86 1785* 2.5* 1* 33* 7500* 4.28* 9285* 19.2* 60* 67*
(draft outlay) 2002-2007
Source - For Plan data: 1. Indian Planning Experience - A Statistical Profile, Planning Commission, GOI, New Delhi, 2000; 2. Ninth Five
Year Plan, Planning Commission, GOI, New Delhi, 1998; 3. Draft Tenth Five Year Plan, www.planningcommission.nic.in/ ; For Total
public health expenditures (ministries of Health and FW : 1. upto 1986 – Combined Finance and Revenue Accounts, respective years, GOI,
New Delhi; 2. 1987 –2002 Finance Accounts of States and Union Government, respective years; and RBI – Finances of the State Governments,
respective years, RBI, Mumbai; For private health expenditures & GDP data – National Accounts Statistics, CSO, 2003; For health outcomes
– Registrar General of India, respective years. *Projections estimated by author
Ravi Duggal
Table 5
Total Public Health Expenditure (revenue + capital) Trends 1975-2003
and Selected Ratios
Year Total Public Percent of Percent of per capita capital as
Health GDP Total govt. (Rupees) ratio to
Expenditure Expenditure revenue
(Rs.billions) expend
1975-76 6.78 0.90 3.13 11.16 0.11
1980-81 12.86 0.99 2.96 18.94 0.08
1985-86 29.66 1.19 3.29 39.28 0.09
1991-92 56.40 0.96 2.96 65.89 0.08
1992-93 64.64 0.74 2.71 74.13 0.04
1993-94 76.81 0.98 2.89 86.21 0.04
1994-95 85.65 0.93 2.33 94.33 0.05
1995-96 96.01 0.89 2.47 103.57 0.04
1996-97 109.35 0.88 2.43 115.96 0.04
1997-98 127.21 0.92 2.50 132.65 0.05
1998-99 151.13 0.94 2.66 155.01 0.04
1999-00 172.16 0.96 2.61 173.72 0.05
2000-01 186.13 0.98 2.69 182.66 0.04
2001-02RE 211.06 1.02 2.72 203.53 0.05
2002-03BE 219.59 1.00 2.60 208.54 0.05
Table 6
Maharashtra 2000-01 Public Health Expenditures (Rs. Million)
Type of Expenditure Rural Urban Combined
Medical care* 259.55 (4.09) 7457.24 (74.59) 7716.79 (47.22)
Public Health 4514.34 (71.15) 1947.33 (19.48) 6461.67 (39.54)
Family Planning 677.57 (10.68) 61.70 (0.62) 739.27 (4.52)
MCH 136.91 (2.15) 58.68 (0.58) 195.59 (1.20)
Other FW 672.34 (10.60) 167.77 (1.68) 840.11 (5.14)
Capital 84.41 (1.33) 305.04 (3.05) 389.45 (2.38)
TOTAL 6345.12 (100.00) 9997.76 (100.00) 16342.88 (100.00)
Percent to Combined 38.82 61.18 100.00
Per Capita 113.85 243.73 168.92
* Includes teaching hospitals, medical education and ESIS; Figures in parentheses are column percentages
Note: In addition urban areas have municipal health expenditures, which can be substantial in bigger
cities; for instance Mumbai city alone has a municipal health budget equivalent to the entire medical
care budget of Maharashtra state.

Table 7
Disaggregation of National Public Health Expenditures by Major Programs
Year 1950-51 1960-61 1970-71 1980-81 1985-86 1990-91 1994-95 2000-01
A: Amount in Rupees Million
Revenue expenditure 218.55 1076.82 3351.18 11888.12 27153.91 51031.67 81740.53 178900
Health
Disease programmes 23.73 280.51 456.86 1540.33 3174.14 5537.2 8537.43 14062.94
Hospitals & 96.15 427.92 1249.59 5147.53 10270.37 15372.22 21574.44 39273.97
dispensaries
ESIS, CGHS 29 152 1001 2698.47 4280.23 8392.38
Medical education, 10.91 60.31 239.6 1077.9 2353.92 5706.57 9555.48 19190.85
training and
research
Family welfare — — — 1359.09 4735.69 7927.97 12679.49 24153.8
excluding MCH*
MCH services* — — — 60.38 136.14 465.29 1486.48 4948.52
Health 30.62 119.65 671.9 583.99 1285 2298.98 3706.05 9390.75
administration
Capital expenditure — — — 969 2507.22 2513.87 3909.47 7632.4
health*
B: Percentage Distribution
Total Health 100 100 100 100 100 100 100 100
Disease programmes 10.86 26.05 13.63 12.96 11.69 10.85 10.44 7.86
Hospitals and 43.99 39.74 37.29 43.3 37.82 30.12 26.39 21.95
dispensaries
ESIS, CGHS 2.69 4.54 8.42 5.29 5.24 4.69
Medical education 4.99 5.6 7.15 9.07 8.67 11.18 11.69 10.73
training and
research
Family welfare* — — — 11.43 17.44 15.53 15.51 13.5
MCH services* — — — 0.51 0.5 0.91 1.82 2.77
Health 14.01 11.11 20.05 4.91 4.73 4.51 4.53 5.25
administration
Capital Expenditure __ __ __ 7.54 8.45 4.69 4.56 4.09
Health*
Notes: Please note that the sub-heads do not add up to the Total as some sub-heads like public health
training, health statistics, health transport, public health laboratories etc.. are not included here.
Percentages for all programs are a proportion of total revenue health expenditure, except for capital
which is a proportion of total health expenditure.
* (i) Family welfare and MCH from 1950-51 to 1970-71 included in medical and public health account
heads. (ii) Capital expenditure health are shown separately only from the 70s prior to which it was
under the ministry of works.
Source: Up to 1985-86 is Combined Finance and Revenue Accounts, Comptroller and Auditor General of
India, respective years. Other years – Finance Accounts, respective states.
Note: From mid-nineties external funding for hospital sector reforms and for select disease programs
has increased sharply and these are recorded under separate budgetary heads and hence the decline we
see in the budget head ‘hospitals and dispensaries’ and ‘disease programs’ may not be really so.

Ravi Duggal
Table 8
Revenue Expenditure on Health: Union Government and States
Year 1950-51 1960-61 1970-71 1980-81 1985-86 1990-91 1994-95 1999-00 2000-01
A: Amount in Rupees Million
Major States
Union Govt. 19.97 267.8 284.35 1022.18 2561.51 5523.53 8189.19 17219.15 25864.76
Andhra Pradesh — 75.57 259.39 876.22 1837.6 3268.04 5601.91 10940.18 12860.91
Assam 6.29 30.42 74.93 232.6 647.08 1103.1 1921.47 3070.24 3461.82
Bihar 16.47 65.27 162.53 544.11 1235.89 2713.33 4128.06 10162 9964.3
Gujarat — 31.88 213.87 641.99 1480.69 2510.76 4131.96 9131.27 8937.52
Haryana — — 75.58 238.17 597.82 819.28 1427.65 2839.31 2909.09
Jammu Kashmir — 10.4 46.29 196.74 420.23 756.28 1569.14 3352.51 3610.48
Karnataka 0.46 46.36 159.53 603.49 1385.49 2430.15 4577.49 8682.94 9035.63
Kerala — 44.49 150.11 570.92 1133.97 2127.69 3432.39 6880.37 6738.91
Madhya P’desh 7.01 55.62 197.04 687.85 1500.99 2745.52 4473.32 8365.2 8319.9
Maharashtra 4.59 90.68 385.33 1252.05 2694.69 4774.24 7580.35 13547.7 15953.42
Orissa 6.97 25.9 107.59 408.74 739.01 1350.29 2157.21 4256.7 4331.06
Punjab 7.83 42.11 98.31 387.11 842.18 1662.89 2261.66 5445.62 6375.88
Rajasthan — 44.98 212.21 569.01 1225.32 2506.66 4608.69 8580.3 8775.99
Tamil Nadu 41.89 83.12 278.5 882.32 1885.52 3790.06 6100.09 11414.77 11604.94
Uttar Pradesh 30.02 74.01 281.12 1116.18 3712.27 6214.3 8981.31 12702 14102.2
West Bengal 37.17 88.18 266.91 1096.08 2015.23 4330.13 5262.32 12274.95 13766.15
Other States
Arunachal — — — 42.07 82.91 170.62 280.94 539.6 536.1
Pradesh
Goa, Daman Diu — — 19.51 53.58 118.87 238.38 362.76 765.88 823.64
Mizoram — — — 37.9 89.3 149.18 257.83 536.9 538.5
Pondicherry — — 10.95 35.02 83.61 181.88 281.42 731.51 804.16
Himachal P’dsh — — 39.88 154.63 324.4 667.33 1163.7 2478.2 2630.6
Manipur — — 10.89 53.63 95.9 188.2 284.13 753.4 663.7
Meghalaya — — 10.65 66.56 124.93 207.62 304.18 636.8 705.1
Nagaland — — 17.82 55.92 158.73 245.92 323.41 626.3 764.36
Sikkim — — — 12.79 37.47 79.31 144.1 336.51 317.3
Tripura — — 13.79 44.19 122.3 277.09 358.31 711.3 827.34
Delhi — — — — — — 1573.51 3913.6 4392.4
Chattisgarh — — — — — — — — 771.2
Jharkhand — — — — — — — — —
Uttaranchal — — — — — — — — 342.2
All India 218.55 1076.82 3351.18 11888.12 27153.91 51031.68 81738.5 150733.21 178189.04
B: As Percentage of Total Government Revenue Expenditure
Major States
Union Govt. 0.47 2.53 0.58 0.48 0.52 0.54 0.46 0.5 0.75
Andhra Pradesh — 8.89 8.74 7.55 6.61 5.94 5.89 6.06 5.57
Assam 6.74 7.51 6.2 6.51 6.75 5.81 5.87 5.25 5.39
Bihar 6.32 9.02 6.53 5.72 5.68 5.48 5.46 6.3 6.95
Gujarat — 6.22 9.75 7.11 7.51 5.8 5.48 5.21 4.05
Haryana — — 8.09 5.94 7 4.24 * 4.08 4.05
Jammu Kashmir — 8.58 6.68 7.35 7.61 6.06 6.21 5.54 5.45
Karnataka 0.35 5.83 6.32 6.74 6.6 6.12 6.3 5.7 5.42
Kerala — 9.67 9.16 8.55 7.85 7.53 6.77 5.95 5.67
Madhya Pradesh 2.48 8.42 9.66 6.77 6.69 5.78 5.73 5.18 5.55
Maharashtra 6.22 7.6 8.38 6.53 5.97 5.45 5.12 4.59 4.27
Orissa 5.8 7.29 7.69 7.47 7.38 5.4 5.35 5.03 4.9
Punjab 3.8 7.12 7.22 7.04 7.24 5.54 3.74 5.34 5.44

Table 8 continued ...

Year 1950-51 1960-61 1970-71 1980-81 1985-86 1990-91 1994-95 1999-00 2000-01
Rajasthan — 9.89 9.64 8.28 8.11 7.2 6.83 6.39 5.84
Tamil Nadu 7.05 9.12 8.66 7.66 7.7 6.72 6.33 5.51 5.34
Uttar Pradesh 5.79 5.13 6.79 6.5 9.75 6.52 5.83 4.42 4.54
West Bengal 9.89 9.48 8.8 9.83 8.92 8.44 6.9 6.3 6.23
Other States
Arunachal — — — 6.86 5.85 6.61 6.41 6.57 5.9
Pradesh
Goa, Daman — — 15.01 10.29 8.22 8.65 7.6 5.33 4.82
and Diu
Mizoram — — — 7.03 6.8 4.91 5.56 6 5.27
Pondicherry — — 13.96 10.6 9.11 8.91 7.84 8.65 8.75
Himachal — — 6.39 8.24 7.89 7.4 7.21 6.48 6.01
Pradesh
Manipur — — 7.17 7.68 6.15 5.6 5.59 5.55 5.87
Meghalaya — — 11.04 11.12 9.2 6.68 6.66 6.11 6.53
Nagaland — — 7.24 6.11 6.96 5.85 5.53 5.31 5.92
Sikkim — — — 4.17 4.83 6.19 2.74 2.23 4.16
Tripura — — 7.91 5.07 6.53 5.57 * 4.87 4.77
Delhi — — — — — — — 11.11 11.88
Chattisgarh — — — — — — — — 4.78
Jharkhand — — — — — — — — —
Uttaranchal — — — — — — — — 3.75
All India 2.69 5.13 3.84 3.29 3.29 3.02 2.67 2.97 3.13
Notes: — = Not applicable; * = Not available.
Source: Up to 1985-86 is combined finance and revenue accounts comptroller and auditor general of
India GOI, respective years, Other years – Finance Accounts, respective states, respective years; RBI,
Finances of the Sate Governments, respective years.
Table 9
Private Health Expenditure Trends
Year Private Health Percentage % of Total Health Total Health Expenditure
Expenditure of GDP Expenditure (Public - Private)
(Rs.billions) Rs. Billion
1975-76 24.66 3.26 78.43 31.44
1980-81 52.84 4.06 80.43 65.70
1985-86 90.54 3.61 75.32 120.20
1991-92 160.65 2.73 74.01 217.05
1992-93 175.57 2.61 73.09 240.21
1993-94 195.43 2.50 71.78 272.24
1994-95 278.59 3.04 76.48 364.24
1995-96 329.23 3.07 77.42 425.24
1996-97 373.41 3.00 77.35 482.76
1997-98 458.99 3.30 78.30 586.20
1998-99 653.40 4.04 81.21 804.53
1999-00 835.17 4.76 82.91 1007.33
2000-01 981.68 5.18 84.06 1167.81
2001-02* 1100.00 5.32 83.90 1311.06
2002-03* 1250.00 5.60 85.06 1469.59
* estimates by author
Source: CSO – GOI National Accounts Statistics, 2003

Extent of Inequity in Access to Health Care
Services in India
T.R. Dilip
Health outcomes such as life expectancy, Morbidity and Hospitalisation

incidence of diseases or self-reported health Health status is measured and affected by
status are not randomly distributed illness, and various surveys have documented
throughout the population in India. There are it on the basis of prevalence. Prevalence of
systematic differences between men and ailments during a 15 days reference period
women, between different subgroups of and of hospitalisation during a one year
population and this may well be linked to reference period for instance, was used in the
inequities in access to healthcare. Access to 52nd round NSSO Survey. Most of the surveys
healthcare, defined as use of health care by (Duggal and Amin 1989 3; Sundar 1992 4;
those who need it1, is an essential indicator NCAER 1992; Satyasekar, 19975 NSSO, 1998;
for health sector policy making. Review Gumber and Kulkarni, 2000 6 show that
suggests that gender in combination with morbidity rates are higher in rural areas than
caste and class is influencing both users and inas compared to urban areas. A few others
providers of health care services in the (Duraisamy, 1995 7 ; Sundar 1995 8 ;
country.2 Here the equity in access to health Madhiwala, et al, 20009) found that morbidity
care is examined by studying variation in rates were higher in urban areas. Reported
health status, health service facility use, morbidity is likely to vary not only between
expenditure on treatment of ailments and countries but also within a country by region
source of financing of health care services by and community. The self reported morbidity
selected variables that determine health is found to be higher among the rich rather
outcomes. These key variables are gender, than the poor in many countries (Gumber and
social geography, social groups and class. Berman, 199710; Murray and Chen, 199211).
1
Makinen M, Waters H and Rauch M (2000) Inequalities in health care use and expenditure: Empirical Evidence
from Developed countries in Transition, Bulletin of WHO 78: 55-65
2
Saha S. and Ravindran T.K.S. (2002) Gender Gaps in Research on Health Services in India Journal of Health
management 4(2): 185-214.
3
Duggal, R. and S. Amin (1989) Cost of Health Care: An Household Level Survey in an Indian district, Bombay:
Foundation for Research in Community Health.
4
Sundar, Ramamani (1992) Household Survey of Medical Care’, Margin 24(2): 169-175.
5
Satya Sekar P. (1997) Levels of Morbidity in Andhra Pradesh, Economic and Political Weekly, XXXII(13): 663-72.
6
Gumber, A. and V. Kulkarni (2000) Health Insurance for Workers in Informal Sector, Detailed Results from a Pilot
Study, New Delhi: National Council for Applied Manpower Research.
7
Duraisamy, P. (1995) Morbidity in Tamil Nadu: Levels, Differentials and Determinants, Economic and Political
Weekly, 33(17): 982-990.
8
Sundar, Ramamani (1995) Household Survey of Health Care Utilisation and Expenditure, Working Paper No 53,
New Delhi: National Council for Applied Economic Research.
9
Madhiwala, N. S. Nandraj and R. Sinha (2000) Health Households and Women’s Lives: A Study of Illness and Child
Bearing among Women in Nasik District, Mumbai: Centre for Enquiry into Health and Allied Themes.
10
Gumber, A. and P. Berman (1997) Measurement and Pattern of Morbidity and Utilisation of Health Services:
Some emerging issues from recent health surveys in India, Journal of Health and Population in Developing Countries,
Fall 1997: 16-43.
11
Murray C.J.L. and L.C. Chen (1992) Understanding Morbidity Change, Population and Development Review, 18
(3): 481-503.

Extent of Inequity in Access to Health Care Services in India
According to NSSO (1998) the self reported The ailments reported have been classified as
morbidity information they collected may have acute and chronic ailments based on duration
been affected by proxy reporting, health care of ailments. Ailments which normally last for
consciousness, level of living and recall lapse. less than 30 days were classified as acute
There are also studies which show how factors ailments and ailments which last for more
like physical accessibility of health care than 30 days are taken as chronic ailments.
services and capacity to seek health care Acute ailments were reported in rural and
services creates artificial differentials in urban areas, at a rate of 42 per thousand
morbidity and hospitalisation rates within a population and 41 per thousand population
population.12 For this reason, morbidity is respectively, while chronic ailments were
included here as a proxy indicator of access reported at a rate of around 14 per thousand
to health care in the country. population in both rural and urban areas.
Both prevalence of acute and chronic ailments
Table 1 shows that ailments were reported were slightly higher among females than
during the 15-day reference period at a rate males. Another notable observation is higher
of 55 per thousand population in rural areas. prevalence of chronic ailments in high social
Rural-urban differentials were negligible in groups than that in low social groups. The
this aspect. But the gender differential showed class differentials observed above remained
morbidity to be marginally higher among the same as the prevalence of acute and
females than males in both rural and urban chronic ailments were reported to be higher
areas. While analysing the prevalence of in high MPCE quartile groups than in the low
ailments across various social groups, it was MPCE quartile groups. Class differentials in
observed that morbidity rates in rural areas, chronic ailment could be justifiable as surveys
varied from 42 per thousand population have shown higher prevalence of lifestyle
among the ‘scheduled tribes (ST) population’ related chronic ailments in the population.
to 54 per thousand population among However, differentials of this magnitude in
‘schedule caste (SC) Population’ and to a high acute ailments are not permissible as they are
58 per thousand population among ‘Others’ mostly short duration communicable minor
category, who are relatively better off than ailments, whose prevalence is usually
their SC/ST counterparts. Similar type of expected to be higher among the poorer
differentials across caste groups was seen in sections of the society. Therefore one can
urban areas. Class differentials were marked, suspect that under reporting of minor health
as there was a consistent increase in reported ailments among lower classes is arising a
ailments with every increase in monthly per result of their poor health care consciousness,
capita expenditure (MPCE) level. Reported while the rich seek care for similar ailments
morbidity rates increased between lowest and and for conditions which their poorer
highest MPCE quartile groups from 41 per counterparts do not perceive as an ailment
thousand population to 76 per thousand requiring medical attention. All these
population in rural areas and from 44 per observations are related to equity dynamics
thousand population to 67 per thousand in reporting of illness and their differentials
population in urban areas. It must be noted in ability to access health care.
here that the gap between MPCE and social
groups is less in urban areas as compared to This type of inverse relationship between
rural areas because the former have relatively economic background and reported health
much better access to public health services. status is usually observed in morbidity data
12
Dilip T. R. (2002). Understanding Levels of Morbidity and Hospitalisation in Kerala, India. Bulletin of World
Health Organisation 80(9): 746-751.

T.R. Dilip
Table 1
Prevalence of Ailments and Hospitalisation Per Thousand Population by Sex,
Social Group and MPCE Groups, India 1995-96
Acute ailment Chronic ailment Any ailment 1 Hospitalisation
Rural Urban Rural Urban Rural Urban Rural Urban
Male 41 39 13 13 54 51 14 20
Female 44 43 14 15 57 58 13 20
Social Group
ST 38 36 5 8 42 45 13 22
SC 42 42 12 11 54 53 9 19
Others 43 41 15 15 58 55 12 20
MPCE quartile
0-25 34 37 9 9 41 44 5 13
25-50 41 41 10 13 50 52 9 17
50-75 45 43 15 16 57 56 13 19
75-100 54 46 26 25 76 67 26 30
Total 42 41 13 14 55 54 13 20
Source: Computed from 52nd round NSS data based on Schedule 25.0.
1
Sum of acute and chronic ailment are may not add ing up to any ailment as a small proportion
reported more than one ailment in the survey.
based on cross sectional surveys especially Further, the annual hospitalisation rate was
in scenarios where access to healthcare is not much lower in rural areas (13 per thousand
universal. Class differentials were even population) than in urban areas (20 per
sharper in the case of hospitalisation, an event thousand population). Thus, the presence of
which should be relatively free from or exposure to health care services intensifies
underreporting. Annual hospitalisation rate their utilisation as the utilisation of hospital
increased from 5 to 26 per thousand services are higher in urban areas, which have
population in rural areas and from 13 per a higher concentration of health services than
thousand population to 30 per thousand rural areas.
population in urban areas, between lowest
and highest MPCE quartile groups. Untreated Ailments
Though the need for medical treatment arises
This data reconfirms that inequities in access with the onset of illness, it is not necessary
amongst lower socio-economic groups plays that all ailments receive treatment. Factors
a critical role in their perception of illness and responsible for non-treatment of ailments
health seeking behaviour, especially so in a include delay in recognition of the problem,
context where health care has to be purchased delay in decision to seek treatment, difficulties
from the market. The relatively lower in commuting to health facilities and inability
differentials across subgroups in urban areas to pay for medical care. All these factors are
further proves this point because urban areas closely related to the socio-economic
have better access to public health facilities background of the ailing person. The present
which being free of cost are relatively class knowledge on level of untreated ailments in
neutral. India is limited to information from population

based surveys, where the extent of untreated women members in the household, which
ailments reported depends on perceived/ enabled them to bring out the health problems
reported morbidity. Level of reported of females, where risk of reporting an ailment
morbidity as observed above is a subjective as well as chances of seeking treatment are
phenomenon influenced by proxy reporting, lesser than for males. Another study finds that
health care consciousness, level of living and 16 per cent of ailments of the women
recall lapse. Under reporting of untreated interviewed remained untreated, which is
ailments arises also because of these reasons. attributed to the fact that women accept such
More often in morbidity surveys it is the symptoms as part of their normal life and do
untreated ailments that are more likely to be not seek treatment.18 Again there is evidence
under reported than treated ailments. All the to show that the illiterate households rely
same, a sizeable proportion of the ailments more than educated households on self
reported by respondents in a population- medication and advice from untrained medical
based survey does not receive medical personnel, leading to a high level of untreated
treatment. It is well known that the utilisation ailments among them.19
of available health care services is dependent
on many factors including recognition of Here, we analyse prevalence of untreated
illness, perceived efficiency of available health ailments (Table 2) as well as reasons of non-
care, access to health care and pricing treatment of ailments in India using NSS 52nd
factors. 13 Therefore an examination of Round data. As per the survey definition,
untreated ailments will be useful in untreated ailments included self-medication
understanding the equity in access to health and home remedies and no recourse to health
care in a population. care. About 17 per cent and 9 per cent of
ailments remained untreated in rural areas
An untreated ailment is a common and urban areas respectively. Results show
phenomenon in India, which is reported to untreated ailments to be higher
be higher in rural areas than in urban areas.14
Surveys have pointed out that 9 to 17 per cent " in rural areas than in urban areas,
of ailments in the population remain " among females than males,
untreated.15 The level of untreated ailments " SC/ST population than among non-SC/
is even higher according to micro level studies ST population,
like Madhiwala et al., 200016 and Nandraj et " in lower MPCE quartile as compared to
al., 200117, which also show that untreated higher MPCE quartile groups.
ailments are higher among females than
males. In fact these two surveys used female The observation that females are at a higher
investigators and the respondents were risk of having untreated ailments was clearer
13
Murray C.J.L. and L.C. Chen (1992) Understanding Morbidity Change, Population and Development Review, 18
(3): 481-503.
14
Duraisamy, P. (1995) Morbidity in Tamil Nadu: Levels, Differentials and Determinants, Economic and Political
Weekly, 33(17): 982-990.
15
Sundar, Ramamani (1995) Household Survey of Health Care Utilisation and Expenditure, Working Paper No 53,
New Delhi: National Council for Applied Economic Research.
16
Madhiwala, N. S. Nandraj and R. Sinha (2000) Health Households and Women’s Lives: A Study of Illness and Child
Bearing among Women in Nasik District, Mumbai: Centre for Enquiry into Health and Allied Themes.
17
Nandraj S., N. Madhiwala, R. Sinha, and A. Jesani (1998) Women and Health Care in Mumbai, Mumbai: Centre for
Enquiry into Health and Allied Themes.
18
Bhatia, J.C. and J. Cleadland (2001) Health Care Seeking and Expenditure by Young Indian Mothers in the Public
and Private Sector, Health Policy and Planning, 16(1): 55-61.
19
Visaria, P., A. Gumber and P. Jacob (1996) Morbidity, Health Care Utilisation and Expenditure Pattern in Andhra
Pradesh, Kerala, Madhya Pradesh and Punjab 1986-87, Ahmedabad: GIDR

T.R. Dilip
Table 2
Per cent of Ailments Which Were Untreated by Sex, Social Group and
MPCE Groups, India 1995-96
Rural Urban
Sex
Male 15.8 8.1
Female 18.3 8.8
Social Group
ST 21.5 9.4
SC 18.1 8.4
Others 16.8 8.5
MPCE quartile
0-25 23.1 13.2
25-50 18.1 7.9
50-75 17.2 6.4
75-100 11.1 5.8
Total 17.1 8.5
Source: Computed from 52nd round NSS data based on Schedule 25.0
Table 3
Reasons Reported for Non Treatment of Ailments by MPCE Quartile Groups,
India 1995-96
Reason Sex Social Group MPCE Quartile
Male Female ST SC Others 0-25 25-50 50-75 75-100 Total
Rural
No medical facility 8.5 9.6 25.7 6.4 7.4 14 7.7 7.3 5.4 9.1
Lack of faith 4.5 3.1 3.1 6.6 3 3.9 4.2 3.7 3 3.7
Long waiting 0.8 0.2 0.1 0.8 0.4 0.5 0.8 0.2 0.3 0.5
Financial problem 25.6 23.7 20.8 33.2 22.6 31.7 22.4 21.4 19.9 24.6
Ailment not serious 50.4 53.2 40.5 43.8 55.9 41.8 54.6 56.4 58.7 51.9
Others 10.2 10.3 9.7 9.3 10.7 8.1 10.3 11 12.7 10.1
Total 100 100 100 100 100 100 100 100 100 100
Urban
No medical facility 0.9 0.7 3 2.1 0.5 1.1 1.3 - - 0.8
Lack of faith 5.5 5.1 - 5.9 5.9 8.3 5.7 0.8 1.9 5.3
Long waiting 1.1 1 4 0.1 1.2 0.4 1.9 1 1.8 1.1
Financial problem 17.7 21.6 12.7 34.6 17.5 30.7 11.7 15.6 10.3 20
Ailment not serious 64 56 57.7 43.7 62.5 46.5 68.2 68.9 73.7 60.2
Others 10.7 15.6 22.7 13.7 13 13 11.2 13.7 12.3 12.6
Total 100 100 100 100 100 100 100 100 100 100
Source: Computed from 52nd round NSS data

in rural areas than in urban areas. There is a cent of the untreated ailments in 0-25 MPCE
decline in the share of untreated ailments quartile group, which incidentally has the
from the lowest to highest MPCE groups from largest share of untreated ailments (see Table
23 per cent to 11 per cent in rural areas and 2) were because of financial reasons. The class
from 13 per cent to 6 per cent in urban areas. differentials and rural-urban differentials
It is evident that the risk of untreated ailments indicate that the level of untreated ailment
increases with poorer physical as well as depends on the economic background of the
financial access to health care services. ailing person and their exposure to health care
services.
Analysis of reasons reported for non-
treatment of ailments showed that among the Source of Medical Care
untreated ailments reported, ‘ailment not Government owned public sector health care
serious’ was cited as the major reason for not services are provided through a vast net-work
seeking treatment. The proportion reporting of teaching hospitals, general hospitals,
‘ailment not serious’ was 52 per cent in rural district and sub district hospitals, community
areas and 60 per cent in urban areas. At the health centres, primary health centres,
same time 25 per cent and 20 per cent municipal dispensaries and maternity homes
reported ‘financial problem’ as a reason for and sub centres. The only other alternative
not seeking treatment in rural and urban source of health care in the country is the
areas respectively. A notable proportion of private health care sector where the utilisation
ailments in rural areas remained untreated is mainly determined by the potential to pay
because of lack of medical facilities. Rural- for health care. The presence of a voluntary/
urban differentials showed that the proportion charitable sector is limited as one can see that
not receiving treatment because of ‘financial only about 4 per cent and 1 per cent uses
problem’ and ‘lack of medical facility’ to be services in this sector for inpatient treatment
higher in rural areas than in urban areas. and outpatient treatment respectively.20 In
Gender differentials were only marginal in the almost all the national level studies the level
case of reasons reported for non-treatment of of utilisation of health care services from the
ailments. Caste wise differentials showed the private sector is higher than from that of the
reason ‘financial problem’ to be severe among public sector (NSSO, 1992; NCAER, 1992;
SC population in both rural and urban areas. Sundar 199521; NSSO 1998). In fact all these
The unusual observation that the reason studies clearly indicate class differentials in
‘financial problem’ is less of an issue for ST utilisation of health care services from public/
population might be due to their low level of private sector. Apart from this between 1986-
perceived morbidity (Table 1). Further, the 87 and 1995-96 there has been a decline in
reason ‘non availability of health facility’ is a the proportion seeking health care services
prominent reason reported by ST population, from the public sector from about 27 per cent
with 26 per cent amongst them reporting this to 19 per cent for outpatient care services and
reason from rural areas. This is expected as from 60 per cent to 44 per cent for inpatient
tribal settlements are usually in remote care services.22 Here the issue is that the
pockets of rural areas. There is a clear decline utilisation pattern does not necessarily reflect
in number of persons not seeking care their actual choice of health care. For example
because of non availability and financial a study in Mumbai showed that, it is mainly
problems from the lowest MPCE categories to the non-availability of public health care
the highest MPCE categories. Around 31 per services in close proximity to their habitation
20
NSSO,1998
21
Sundar, Ramamani (1995) op.cit.
22
NSSO 1998.

T.R. Dilip
that forces people to seek care from the private India.

sector.23
Unlike in the case of inpatient care services,
We examine below the inequalities inequities the proportion utilising outpatient care
in utilisation of health care services from services from the public sector was only about
public/other sources (Table 4). Here ‘public 20 per cent. Differentials in level of utilisation
source’ includes; public hospital, primary of outpatient care services from public sector
health centres/community health by gender, residence and economic
centres(PHC/CHC), public dispensaries and background of patients were only marginal.
ESI doctor/hospital. The ‘other sources’ is The fact that outpatient care services are
basically the private sector comprising ‘private relatively very much cheaper than inpatient
hospitals, private nursing homes, private care services and easily accessible through a
doctors and charitable institutions. The large network of qualified and unqualified
percentage utilising health care services in the medical practitioners might have contributed
public sector for inpatient care services was to this phenomenon. Still the level of use of
45 per cent and 43 per cent in rural areas public health care services is much higher
and urban areas respectively. Selection of among ST population (30 per cent in rural
source of treatment for inpatient care services areas and 27 per cent in urban areas) than in
was not found to be influenced by gender of
other sub groups.
the ailing patient. It is very clear that the ST
and SC population are relying heavily on
Out of Pocket Expenditure on Medical
public sources for inpatient treatment. Here,
Treatment
more than the caste status it is their lower
Inequalities due to financial burden of
ability to pay that contributes to their high
accessing of health care are most likely to be
level of dependence on the public sector.
best reflected in out of pocket expenditure for
About 61 per cent of the lower MPCE quartile health care. Information on health care
groupof the population in both rural and expenditure incurred on treatment of ailments
urban areas utilised services in public sector has been gathered in a number of studies in
for inpatient care., in the lower MPCE quartile India. These studies shown that fees and
group. At the same time in the higher MPCE medicines accounted for at least two thirds of
quartile group, the proportion using services the expenditure on medical care expenses
in the public sector was 36 per cent and 28 (Duggal and Amin, 198924; Kannan, et al.
per cent in rural areas and urban areas 199125; Sundar, 199226). Notable variations
respectively. This shows that the economic also exist in this out-of-pocket expenditure
background of the ailing person is a crucial on medical care. Average expenditure on
factor that determines source of utilisation of medical care was found to rise with monthly
inpatient care services. All this underlines per capita consumer expenditure or per capita
the critical role of the public sector in income of the household (NSSO, 1992; Visaria
maintaining equity in access to heath care in and Gumber 1994; Rajarathnam, et al.199627;
23
Dilip T.R. and Duggal R (2003) Demand for Public Health Care Services in Mumbai, Mumbai: CEHAT
24
Duggal, R. and S. Amin (1989) Cost of Health Care: An Household Level Survey in an Indian district, Bombay:
Foundation for Research in Community Health.
25
Kannan, K.P. K. R. Thankappan, V. Raman Kutty and K. P. Aravindan. (1991) Health and Development in Rural
Kerala: A Study of Linkages between Socio-economic Status and Health Status, Trivandrum: Kerala Shastra Sahithya
Parishad.
26
Sundar, Ramamani (1992) Household Survey of Medical Care’, Margin 24(2): 169-175.
27
Rajarathnen J. et al. (1996) Morbidity Pattern Health Care Utilisation and Per Capita Expenditure in Rural
Population of Tamil Nadu, National Medical Journal of India, 9(6): 91-96.

Table 4
Source of Inpatient and Outpatient Treatment, India 1995-96
Rural Urban
Source of treatment Source of treatment
Public Other Total Public Other Total
Inpatient Care
Sex
Male 43.9 56.1 100 43.8 56.2 100
Female 47 53 100 42.3 57.7 100
Social Group
ST 66.2 33.8 100 57.8 42.2 100
SC 53.8 46.2 100 56.8 43.2 100
Others 41.1 58.9 100 40.2 59.8 100
MPCE Quartile
0-25 61.2 38.8 100 60.8 39.2 100
25-50 57.7 42.3 100 48.3 51.7 100
50-75 46.8 53.2 100 40.3 59.7 100
75-100 35.6 64.4 100 28.3 71.7 100
Total 45.3 54.7 100 43.1 56.9 100
Outpatient Care
Sex
Male 19.5 80.5 100 18.5 81.5 100
Female 20 80 100 18.3 81.7 100
Social Group
ST 30.1 69.9 100 27.6 72.4 100
SC 18.5 81.5 100 22 78 100
Others 19 81 100 17.6 81.6 100
MPCE Quartile
0-25 21.8 71.2 100 21.5 78.5 100
25-50 17.7 82.3 100 18.4 81.6 100
50-75 21.2 78.8 100 20 80 100
75-100 18.7 81.3 100 13.5 86.5 100
Total 19.7 80.3 100 19.9 80.1 100
Source: Computed from 52nd round NSS data based on Schedule 25.0.

T.R. Dilip
Visaria, et al. 199628 Satya Sekar, 199729; poorest quartile depend on public health care
NSSO, 1998). However the medical care services for inpatient care services (Table 4)
expenditure incurred by a poor household in while the richest quartile depend mostly on
comparison to its expenditure/earning potential the private sector. Still, the richest quartile is
is likely to be much higher than that of the rich spending more on health care in both the
(Krishnan, 1999). Analysis of out of pocket public and private sector than the poorest
expenditure is necessary to understand the quartile. This indirectly shows that the poor
reasons behind differentials observed above in customarily seek care from the private sector
terms of willingness to perceive illness and seek for treating ailments that are not costly while
care and decision to seek care from public/ the rich chiefly seek care from public sector
private sources, across the sub groups under sources for treating ailments that involve
study. higher costs.
Average medical expenditure incurred on

treatment of an ailment in an inpatient and Average medical expenditure for treatment of
outpatient care unit is presented in Table 5. an ailment in an outpatient care unit was
Here medical expenditure includes 158.00 rupees in rural areas and 178.00
expenditure on medicines, fees paid for rupees in urban areas. As in the case of
medical and para-medical services, charges inpatient care services the outpatient care
for diagnostic services, charges for operation treatment was relatively costly in urban areas
and therapy, charges for ambulance and cost than in rural areas in both public and private
of oxygen, blood, etc. For inpatient care sources of treatment. Here also the average
services, the average medical expenditure was medical expenditure on treatment of ailment
2976.00 rupees in rural areas and 3618.00 is higher for males than females. There was a
rupees in urban areas. Expenditure on consistent increase in the average expenditure
medical treatment was higher in urban areas incurred on treatment of ailment with every
than in rural areas in both public and private increase in socio-economic status, in both
sources of treatment. these sources of treatment.
Cost of inpatient care is higher for males than It was clear that the rich were spending more
females in both the sources of treatment. on medical care, which was found to be true
Average medical expenditure was lowest for even for public health care sectors, which
ST groups, followed by SC groups and ‘Others’ further strengthens the earlier findings that
respectively. Average medical expenditure was that the rich prefer public sector sources of
found to increase with every increase in MPCE treatment for handling treatments which are
quartile group and that too very sharply in relatively expensive. Earlier it was observed
the 75-100 MPCE quartile group. Average that the level of utilisation of health care
expenditure varied between lowest and services by the rich from public sector sources
highest MPCE quartile groups from 899.00 was relatively lower among high MPCE
rupees to 4875.00 rupees in rural areas and groups. Poor spend less if they are going to
from 941.00 rupees to 8122.00 rupees in public/private sector while the rich are
urban areas. These two observations elaborate spending more even if they are using the
the pattern of selection of source for health public sector services. Moreover the services
care services across classes in the country. in the public sector are not as cheap as they
We have already seen that the majority in the ought to be and patients were spending a
28
29
Satya Sekar P. (1997) Levels of Morbidity in Andhra Pradesh, Economic and Political Weekly, XXXII(13): 663-72.

substantial amount from their pocket for in staff and equipment in public facilities force
treatment. According to the national level the patients ,especially the poor, to go to
facility survey (IIPS 2001), 11 per cent of the private health care facilities for selected
district hospitals, 31 per cent of sub-district services, resulting in higher out of pocket
hospitals, 51 per cent of CHC’s and 44 per expenditure.
cent of PHC’s were short of basic equipment
for functioning. Along with this 16 per cent of Financing of Out of Pocket Expenditure on
district hospitals, 54 per cent of sub-district Health Care Services
hospitals, and 75 per cent of CHC’s and 62 Since there is a high level of out-of-pocket
percentage of PHC’s were short of adequate expenditure while accessing inpatient care
staff for efficient functioning. Such shortages services it is necessary to see how the
Table 5
Average Medical Expenditure (in rupees) Incurred, During each Episode of Inpatient
Treatment and Outpatient Treatment by Source of Treatment, India 1995-96
Average Medical Expenditure (in rupees)
Inpatient care/ Rural Urban
Outpatient care Source of treatment Source of treatment
Public Other Total Public Other Total
Inpatient care
Sex
Male 1980 4766 3544 2202 5638 3859
Female 1469 3032 2297 1652 4724 3383
Caste
ST 943 2419 1442 1127 2873 1802
SC 1418 6465 3748 1287 2842 1911
Others 1966 3535 2890 2148 5323 3977
MPCE quartile
0-25 642 1305 899 580 1547 941
25-50 811 1785 1223 1047 2387 1708
50-75 1159 2299 1766 1647 3172 2497
75-100 3239 5777 4875 5670 9180 8122
Total 1739 4001 2976 1945 5001 3618
Outpatient care
Sex
Male 124 173 163 153 191 184
Female 99 163 150 141 180 173
Caste
ST 84 96 92 114 106 108
SC 126 154 149 154 157 156
Others 112 179 166 147 192 184
MPCE quartile
0-25 80 121 112 172 129 139
25-50 92 145 136 110 169 158
50-75 117 165 155 115 198 181
75-100 145 219 205 216 244 241
Total 111 168 158 147 185 178
Source: Computed from 52nd round NSS data

T.R. Dilip
Table 6
Reported Sources Through Which Inpatient Care Treatment
has been Financed, India
Source Rural Urban
Current income 38.4 40.2
Past savings 38 37.2
Sale of assets 6.6 2.7
Borrowings 39.7 22.9
Other Sources 10.7 8.6
Employer 1.1 3.7
Other agencies 0.1 0.5
Total# 100 100
Source: Computed from 52nd (1995-96) Round NSS Data
# percentages will not add up to hundred as multiple sources have been reported
households of ailing persons are meeting their middle income groups thought that there was
health care costs. The burden of health care no need to for such schemes as they had not
will be more among sections that do not come under gone any major illness 32. There are
under any health insurance scheme. Only 10 studies from other regions that point to the
per cent of the Indian labour force is in the willingness of the population to participate in
organised sector and a large part of these 27 health insurance schemes33. These schemes
million employees and their families have are yet to become popular34. The major factor
access to insurance/medical benefits to cover towards lack of interest of insurance
treatment costs30. Even many of the employees companies in promoting voluntary medical
in the private sector, who have health insurance is because of low profitability, high
insurance, come under the above schemes. risk and lack of demand35. In this situation
The NSS data 31 showed the insurance scheme one has to examine how expenditure on health
enrolment rate to be negligible. Another care affects the overall economic condition of
estimate says that about 10 per cent of the ailing person’s household, by analysing
households in India receive support from the source of financing of out of pocket
different agencies for medical treatment, expenditure on health care services.
which seems to be an over estimate. Not only
is the enrolment in insurance schemes low, The present mode of finance reported to meet
the willingness as well as ability to participate out of pocket expenditure incurred while
in such schemes is low. For example, a study accessing inpatient treatment in given in Table
in Delhi showed that most low and many 6. This is based on details of expenditure
middle income households considered the incurred during each episode of
premium beyond their reach and even the hospitalisation reported during the one year
30
Gill, Sonya and S.N. Kavadi (1999) Health Financing and Costs- A comparative Study of Trends in 18 Countries with
Special Reference to India, Mumbai/Pune: Foundation for Research in Community Health.
31
32
Gupta, Indrani (2000) Willingness to Avoid Health Costs Results From a Delhi Study, Discussion Paper Series no.
20/000, New Delhi: Institute of Economic Growth
33
Mathiyazhajan, K. (1998) Willingness to Pay for Rural Health Insurance Through Community Participation in
India, International Journal of Health Planning and Management, 13: 47-67.
34
Gumber, A. and V. Kulkarni (2000) Health Insurance for Workers in Informal Sector, Detailed Results from a Pilot
Study, New Delhi: National Council for Applied Manpower Research.
35
Gumber, (2002) Gumber. A. (2002) Structure of India’s Health Care Market: Implications for Health Insurance
Sector, Regional Health Forum, Volume 4.

Table 7
Share of Each Source in Total Reported out
of Pocket Expenditure on Inpatient Care Treatment, India
Source Rural Urban

Current income 11.4 13.3
Past savings 31.8 37.2
Sale of assets 9.2 4.5
Borrowings 38.8 25.6
Other sources 7.8 10.0
Employer 0.8 8.7
Other agencies 0.2 0.7
Total 100.0 100.0
Figures based on reported expenditure in rupees from different sources
Source: Computed from 52nd Round (1995-96) NSS data.
reference period used in the survey. Major the survey, 26 per cent and 39 per cent has
sources of financing in India are current been raised through borrowings in urban
income, past savings and sale of assets/ areas and rural areas respectively. Another 5
borrowings. It is visible that in the absence of per cent in urban areas and 9 per cent in rural
a cost sharing mechanism, the expenditure areas has been raised through sale of physical
on medical care especially inpatient care assets. As expected the contribution of
services affects their current income and employer and other agencies combined was
present saving. About 38 per cent used their only 9 per cent in urban areas and a further
savings to pay for inpatient care treatment. low of 1 per cent in rural areas. Burden of
paying for health care is much higher in rural
The most critical observation is that health areas, where the coverage of public health care
expenditure related borrowing is reported by services is poor and where majority of work
23 per cent in urban areas and 40 per cent in force is in the unorganised sector.
rural areas. Another 3 per cent in urban areas
and 7 per cent in rural areas had to sell their Over all there is strong evidence to believe
household assets (jewellery, animals, other that expenditure on inpatient care treatment
physical assets) to meet the expenditure on is pushing a large proportion of hospitalised
inpatient care treatment. Only around 4 per persons household’s into debt i.e. borrowing/
cent in urban areas and 1 per cent in rural sale of assets. Here only the out of pocket
areas have received support from employer expenditure on medical care is examined and
or other agencies to meet their health care the situation would be even worse, if we look
expenses. Over all it shows the burden at expenses in terms of wages lost by the
associated with inpatient care treatment to patient/ accompanying person due to
be higher in rural areas than in urban areas. hospitalisation. The differentials in household
level economic consequences of paying for
To make it clearer, the share of each source health care across subgroups under
in reported medical expenditure on inpatient examination is presented in Table 8.
care treatment is computed and presented in
Table 7. Past savings accounted for 37 per Altogether, the proportion of ailing persons
cent and 32 per cent of out of pocket households falling into debt (borrowing/sale
expenditure on inpatient care treatment in of assets) due to out-of pocket expenditure
urban and rural areas respectively. Out of the incurred on inpatient care treatment was
total out of pocket expenditure reported in about 44 per cent in rural areas and 25

T.R. Dilip
Table 8
Percentage Resorting to Sale of Physical Assets/ Borrowing and Average
Amount Raised Through Borrowing/Selling of Physical Assets, to Finance out of
Pocket Expenditure on Inpatient Care Treatment, India 1995-96
% borrowing/ selling assets to Avg. amount (in Rs.) raised through
finance treatment borrowing/selling assets
Rural Urban Rural Urban
Sex
Male 46 26 1561( 44) 1178 (31)
Female 40.5 23.3 1143 (50) 1085 (32)
Social Group
ST 49.7 25.4 851 (59) 592(33)
SC 53.2 31.7 1386(37) 757(40)
Others 40.3 23.7 1412(49) 1213(31)
MPCE Quartile
0-25 46.7 28.6 502(59) 368(39)
25-50 43.5 27 670(55) 689(40)
50-75 42.4 23.5 919(52) 627(25)
75-100 43.4 20.6 2138(44) 2309(28)
Source of Treatment
Public Sector 40.3 20.9 988(57) 654(34)
Private Sector 48.5 28.2 1756 (44) 1508(30)
Total 43.5 24.6 1371(46) 1140(32)
Source: Computed from 52nd Round (1995-96) NSS data
Figures in parentheses are percentages to total average medical expenditure
(refer Table 5)
percent in urban areas. The risk of resorting borrowings/sale of physical assets shows an
to sale of assets/borrowing is higher if patient almost similar relationship with average
is a male than for a female. The practice of medical expenditure on inpatient care (Table
resorting to sale of assets/borrowing is 5). The amount raised through borrowings or
common across all classes in rural areas, but sale of assets is higher for males than females
in urban areas the risk of debt is lesser among and higher in the private sector than in the
richer quartile groups when compared to the public sector. There is an inverse relationship
poorer quartile groups. It is very clear that between average amount raised through
the risk of falling into debt is much higher if borrowing/sale of assets and socio-economic
treatment is sought from the private sector background of the patient. Also, differentials
(49 per cent in rural areas and 28 per cent in across groups in terms of proportion of
urban areas). However the observation that expenditure met out of debt is marginal.
40 per cent in rural areas and 21 per cent in However, the impact of such borrowing is
urban areas are falling into debt due to out of likely to remain for a longer period on the
pocket expenditure, despite seeking care from poorer socio-economic sections where the
public sector services is a serious issue that debt recovering potential is lower than those
has to be given due attention. from better off sections. Further, when we look
at debt as a proportion to medical
The average amount raised through borrowing expenditure, we find the same inverse
or sale of assets is also presented in Table 8. relationship with class and caste.
In short, the average amount raised through Interestingly, the debt ratio for females is

higher even though the borrowed amount is women should receive two doses of TT.
lower. This probably indicates that women’s However, 24 per cent of them were not
access to healthcare is given importance receiving the same. As observed in the case
mostly during catastrophic situations. of ANC, the percentage not receiving TT
vaccinations was much higher in rural areas
Access to Reproductive and Child than in urban areas and in the low socio-
Health Care Services economic class than in high socio-economic
Under the newly initiated Reproductive and groups.
Child Health (RCH) programme, the major
emphasis is on integrated delivery of services Iron Folic Acid (IFA) Supplementation:
for fertility regulation, maternal and child According to RCH programme a pregnant
health, safe abortion and reproductive tract woman should consume 100 IFA tablets
infections and sexually transmitted diseases during pregnancy. However, 42 per cent of
(RTI/STDs). If we look at budgetary allocation women are not receiving any IFA
on health and family welfare activities we can supplementation during this period. Coverage
see that the over all share in expenditure on of IFA supplementation was much lower in
health registered a decline, while the share rural areas than in urban areas. Similarly,
on family welfare within the total budgetary across social groups and SLI groups, the
allocations on health continued to grow better off sections had significantly higher
steadily36. Below we examine the differential coverage.
in access to RCH care services across various
sub-groups of population in the country. Place of Delivery: Another important thrust
of the RCH programme is to encourage
Antenatal Check: The NFHS- 2 collected deliveries under proper hygienic conditions
information on antenatal check ups received under the supervision of trained health
by pregnant women for two most recent births professionals. Majority of the deliveries (66
in the three years preceding the survey per cent) in the country are still home
through visiting a doctor or any other health deliveries. Non institutional deliveries are as
professional in a medical facility, or during high as 75 per cent in rural areas and a
home visits from a health worker. More than relatively lower 35 per cent in urban areas.
one third of the pregnant women in the Another critical observation is that about 83
country have not received this check up. The per cent of deliveries among ST’s who live in
percentage of pregnant women who did not remote areas are non-institutional deliveries.
receive this ANC check up was 40 per cent in Across SLI groups, there was a decline in non
rural areas and 14 per cent in urban areas. institutional deliveries from 71 per cent in low
Economic background of the ailing person was SLI groups to 36 per cent in high SLI groups.
found to have considerable influence on
access to ANC check up, as the proportion The other indicator of access to safe delivery
not receiving antenatal care declined from 45 is births attended by a trained health
per cent in low standard of living (SLI) group professional (Doctor/Nurse/Midwives and
to only 12 per cent in high SLI group ,nearly lady health visitors (LHV’s). The observation
a fourfold difference. that 57 per cent (including those managed by
traditional birth attendants [TBA]) of the
Tetanus Toxoid (TT)Vaccination: An deliveries were not attended to by health
important cause of death among infants in professionals further underlines poor access
India is neonatal tetanus. According to the to safe delivery care services in the country.
national immunisation schedule, pregnant Proportion of births not attended by health
36
Duggal R. (1997) Health Care Budgets in Changing Political Economy. Economic and Political Weekly 32: 1197-
1200.

Table 9
Access to Reproductive and Child Health Care Services in India, 1998-99
No ANC No TT No IFA Non -instit- Births not No post Current Home Full Vitamin
check injecti- tablet/ utional attended partum contrac- visits by immun- A Suppl-
up1 ons 1 syrup 1 delivery 1 by health check up# eptive health ization ement-
$
professi- use worker of ation for
onal 1 child- children 3
ren 2
Place of Residence
Rural 39.8 28.2 47.5 75.3 66.2 83.9 44.7 14 36.6 27
Urban 13.6 9.9 24.3 34.9 26.6 80.4 68.2 10 60.5 38.7
Social Groups
SC 38.2 25.8 45.4 63.2 62.8 83 44.6 13.4 40.2 27.1
ST 43.1 38.7 51.4 82.9 76.6 85.9 39.1 17.9 26.4 26
OBC 34.8 23.8 43.2 63.9 54.8 84.4 46.8 13.6 43 26.8
Others 27.9 19.2 37 59.9 50.9 81.7 53.5 11.3 46.8 34.8
Standard of Living
Low 45.1 34.1 54 71.4 74.2 84.5 39.5 14.2 30.4 21.7
Medium 32.8 22.3 40.6 65.1 55.4 83.5 48.4 13.3 43.2 30.9
High 12.4 6.4 20.1 35.6 24.3 79.5 61.2 10.3 64.7 43.3
Total 34 24.1 42.4 66.4 57.4 73.5 48.2 13 42 29.7

!
Source: IIPS and ORC Macro (2000)
1
based on information births during three years preceding the survey date
261
2
percentage of children aged 12-23 months who received all immunization
3
percentage of children aged 12-35 who received at least one dose of vitamin A supplementation
#
for non institutional birth only
$
ever married women who had at least one home visit by health or family planning worker 12 months preceding the survey
T.R. Dilip
professionals was as high as 66 per cent in by health or family planning worker in the 12
rural areas and 27 per cent in urban areas. months preceding the survey. The issue
Risk of not having a health professional at requires serious attention at policy level.
the time of delivery was found to be very high
among ST and STC and in low SLI category. Immunisation of Children: The national
immunisation programme is implemented on
Post Natal Check Up: The RCH programme a priority basis in India, and the vaccination
recommends three post partum visits, as the of children against tuberculosis, diphtheria,
health of both mother and new born child pertussis, tetanus, poliomyelitis and measles
depends on care she and her new born receive has been regarded as a corner stone in child
during the first few weeks after delivery. The health care system in the country38. NFHS 2
NFHS-2 gives information on post natal check shows only 42 per cent of children aged 12-
up for non institutional deliveries for the three 23 months to be fully immunised against
years prior to the survey. It was disturbing to these diseases. When 64 per cent of children
see that 74 per cent of them did not receive in urban areas were full immunised only 37
even a single post natal check up. There were per cent in rural areas had such protection.
no significant differentials in seeking post- Another critical observation was that only 26
partum check up in all subgroups who have per cent of children among ST population were
undergone non institutional deliveries. fully immunised. Differentials across standard
of living of population shows that 65 per cent
Current Use of Family Planning: NFHS-2 of children belonging to high SLI category were
shows 48 per cent of currently married women fully immunised, while only 30 per cent in
to be using some method of contraception. low SLI category were fully immunised.
However this figure is quoted as low when
compared to contraceptive use in other Vitamin A Supplementation of Children:
regions in Asia37. Current use of contraception The NFHS-2 also gives information on
was 68 per cent in urban areas and 44 per proportion of children aged 12-35 months who
cent in rural areas. As one can expect, the received at least one dose of vitamin A
level of contraception use was found to be supplementation. Only 30 per cent of children
lower in SC/ST and OBC groups when in India are reported to have received the
compared to ‘others’ subgroup and in low SLI same. As expected, the proportion of children
category than in high SLI category. receiving vitamin A supplementation is high
in urban areas and for those belonging to
Home Visit by Health and Family Planning higher socio-economic stratas.
Worker: Under the family welfare programme
health or family planning workers are required Over all the analysis shows that though the
regularly to visit each household in their RCH programme was successful in spreading
assigned area to monitor various aspects of the message of family planning services across
health of women and children, to motivate the country as well as bringing the population
women to adopt appropriate health and family closer to heath care services, the programme
planning practices and deliver other selected was not highly successful in terms of other
services. Table 9 reflects the sorry state of components of the RCH care services
affairs of health worker visit programme in programme. There is a long way ahead to
the country. Only 13 per cent of ever married attain goals mentioned in the National
women had reported at least one home visit Population Policy as well as the National
37
International Institute for Population Sciences (IIPS) and ORC Macro (2000) National Family Health Survey (NFHS-
2), 1998-99. Mumbai: IIPS.
38
Ibid

T.R. Dilip
Health Policy in terms of access to ante natal tribal areas. Besides which the SC population
care, safe delivery and immunisation of generally resides in remote areas and they too
children. Apart from that there are large scale have a similar burden while accessing health
inequities across population groups in care services. Thus the case of SC & ST
accessing reproductive and child health care population shows how caste along with class
services in the country. contribute to differentials in utilisation of
health care services. Public sector services
Conclusion were widely used by these two sub groups,
This paper portrays the large scale rural- who have high levels of untreated ailments
urban, gender, caste and class wise inequities and a higher financial burden associated with
in access to heath care services in India. Due treatment of ill health.
to limitations in availability of data, the quality
of health care services component could not Gender differentials were not highly visible
be explored here. Differentials in access across in the case of morbidity rates, prevalence of
vulnerable sections would only widen further untreated ailment and selection of source of
if we examine access to good quality health health care. However systematic differentials
care services. Unevenness in access to health were observed in the case of expenditure on
care will be lower only if the health system is health care services. Average amount spent
responsive to needs of the population. Despite on treatment was always higher for males
its huge size, India’s health care system is than females. The tendency to borrow money
unable to respond adequately to public needs or sell assets to meet out of pocket
mainly due to the uneven distribution and due expenditure on medical care was also higher
to the unregulated nature of the private health for males than for females. This means that
sector. Adding to the problem is the absence larger household resources were available to
of any major risk pooling mechanism to males as compared to females to access health
finance the health care system. This only care services. So this limited analysis
makes inequities more adverse. indicates that gender differentials in access
to health care is probably more due to biases
The urban bias in location of health care within the household due to the lower status
services is grossly responsible for the high of women, rather than any bias from the
differentials in access to health care services provider side.
across rural and urban areas. One major
observation that clearly substantiates our Expenditure on medical care seems to have a
argument that strengthening of the public negative impact on economic condition of the
sector would reduce inequities in access to households. Borrowing/sale of assets is
health care, is the case of relatively low widely prevalent in all classes of the study
differentials across caste and class groups in population. But the amount borrowed in
urban areas characterised by a higher comparison to average medical expenditure
concentration of health services, than in rural on treatment was higher among low socio-
areas. economic groups than the higher socio-
economic groups. Impact of such borrowing
In the absence of risk pooling mechanisms, will leave an impact for a longer period on
the health care market is behaving in such a these poor sections where debt recovering
way that capacity of ailing persons to pay for potential is lower than their counterparts who
health care as become a primary determinant are relatively rich. This risk of falling into debt
of access to health care in the country. Apart might have acted as a barrier for the poor in
from this factor, differential access observed accessing health care services, which leads
in the case of ST population is also due to to a low over all level of hospitalisation and
poor availability of health care services in reported morbidity among them.

Altogether the challenges at policy level will health care enjoyed by richer groups. Health
be to find mechanisms to provide high quality care needs of the vulnerable sections will be
services to vulnerable sections in the fulfilled only if we improve the coverage and
population and thus enable these population efficiency of public health care services in
groups to attain the same level of access to remote areas.

T.R. Dilip
Appendix I
Prevalence of Ailments and Annual Hospitalisation Rates, India 1995-96
Prevalence of ailment in last 15 days Annual
state/ Acute ailment Chronic ailment Any ailment Hospitalisation
u.t. Rate
Rural Urban Rural Urban Rural Urban Rural Urban
Andhra Pr. 43 41 22 20 64 61 14 17
Arunachal Pr. 23 41 1 1 24 42 33 32
Assam 72 74 9 13 80 86 9 16
Bihar 26 32 10 10 36 41 5 12
Goa 27 27 18 7 44 34 26 25
Gujarat 35 26 11 10 46 36 14 21
Haryana 47 46 14 17 61 63 25 25
Himachal Pr. 64 53 29 15 90 66 21 19
J&K 43 46 9 8 52 54 11 17
Karnataka 31 28 14 12 44 40 14 18
Kerala 80 61 38 27 118 88 70 65
Madhya Pr. 36 30 5 7 41 38 7 15
Maharashtra 37 35 15 13 52 48 19 26
Manipur 5 2 3 1 8 2 12 10
Meghalaya 33 33 1 1 35 34 13 25
Mizoram 14 11 4 0 18 12 19 25
Nagaland 30 42 1 4 31 46 12 14
Orissa 56 52 6 10 62 62 13 16
Punjab 56 60 20 25 76 85 14 17
Rajasthan 22 24 6 9 28 33 8 14
Sikkim 34 18 3 4 38 22 6 10
Tamil Nadu 39 44 13 14 52 58 18 23
Tripura 106 75 11 23 117 96 34 42
Uttar Pr. 49 57 12 15 61 72 8 14
West Bengal 47 49 19 16 65 65 11 22
A. & N. Island 25 14 2 1 27 15 45 34
Chandigarh 135 85 18 48 153 133 13 21
Dad. & Nag. Hav. 48 55 9 2 57 57 35 16

Daman & Diu 20 34 23 9 43 43 22 51
Delhi 22 31 0 12 23 43 14 13
Lakshadweep 34 46 26 2 57 48 49 53
Pondichery 87 57 4 10 91 67 44 22
All India 42 41 13 14 55 54 13 20
Source: NSSO (1998)

Appendix II
Level of Untreated Ailments and Use of Public Sector for Treatment by
States, India 1995-96
% of ailments % using public % using public for
untreated for outpatient inpatient treatment
treatment
Rural Urban Rural Urban Rural Urban
Andhra Pr. 25.5 15 23.3 11.5 22.5 36.2
Arunachal Pr. 40.9 11 47.6 82.8 65.5 89.5
Assam 44 36.4 45 34.9 73.8 65.2
Bihar 21.9 15.5 5.1 19.1 24.7 34.6

Goa 0.3 13.3 8.5 16.2 45.4 39.6
Gujarat 7.9 3.5 18.4 18.2 32.1 36.9
Haryana 3 1.6 13.4 10.1 30.5 37.3

Himachal Pr. 12.5 2.8 38.7 48.1 86.5 91.3
Jammu & Kashmir 6.3 2.4 44 28.2 97.7 95.9
Karnataka 22.3 8.6 31.6 18.7 45.8 29.8

Kerala 11.7 10.8 29.8 30.5 40.1 38.4
Madhya Pr. 16.3 6.7 25.8 20 53.3 56
Maharashtra 11.4 7.7 11.9 11.6 31.2 31.8

Manipur 41.8 69.7 34.2 0 89.2 78.3
Meghalaya 60.3 39.6 75.1 21.4 94.3 52
Mizoram 37 42.2 79.6 60 92.5 84

Nagaland 11.7 3 26.8 6.1 84.1 50.4
Orissa 32.3 13.4 37.8 32.4 90.6 81
Punjab 1 3.5 7 7.2 39.4 27.6

Rajasthan 10.2 10.4 40.7 40.9 64.9 73.1
Sikkim 18.7 3.5 68.2 40.8 96.1 80.9
Tamil Nadu 22.4 8 30.1 24.3 41.1 35.7

Tripura 43.4 25.6 28.3 11.3 92.5 73
Uttar Pr. 9.4 6.5 4.2 10.3 47.1 39.8
West Bengal 19.9 10.1 12.9 13.8 82 72.1

A. & N. Islands 20.2 15.1 72.8 60.4 99.8 93.8
Chandigarh 7 5.2 36.5 61.5 78.8 67
Dad. & N. Hav. 1 0 49.7 5.2 48 23.4

Daman & Diu 1.8 0 59.2 26.6 26.2 61.8
Delhi 8.8 15.2 43.1 25.8 25.1 51
Lakshadweep 0 0 71.5 83.6 73.9 71.8

Pondichery 6.1 18.7 77 15.6 81.8 76.1
All India 17.3 9.3 18.2 17.4 45.3 43.1

Source: NSSO (1998)

T.R. Dilip
Appendix III
Average Total Expenditure on Inpatient and out Patient Treatment by
States, India 1995-96
Average. Total Expenditure on Average Total Expenditure on
outpatient treatment inpatient treatment
Rural Urban Rural Urban
Andhra Pr. 116 143 6428 4886
Arunachal Pr. 490 219 1464 2909
Assam 83 110 1945 3790
Bihar 220 176 3860 3724

Goa 197 123 3291 2590
Gujarat 144 211 2663 3327
Haryana 183 402 3224 6537

Himachal Pr. 97 143 2530 2643
Jammu & Kashmir 214 164 2548 3612
Karnataka 91 155 2997 3593

Kerala 119 108 2293 1927
Madhya Pr. 129 351 2191 2774
Maharashtra 144 170 3089 3997

Manipur 351 194 4058 5650
Meghalaya 32 83 857 1375
Mizoram 37 86 536 948

Nagaland 270 790 3026 7809
Orissa 99 117 1641 3868
Punjab 173 155 4988 5712

Rajasthan 172 176 3038 3149
Sikkim 63 252 1854 5558
Tamil Nadu 79 117 2840 3934

Tripura 55 129 614 2356
Uttar Pr. 202 212 4349 5896
West Bengal 105 124 1957 3217

A. & N. Islands 25 50 133 1221
Chandigarh 36 200 1720 3701
Dad. & N. Hav. 85 112 1262 4285

Daman & Diu 73 114 5097 990
Delhi 138 171 4443 6170
Lakshadweep 56 5 1385 1708

Pondichery 11 45 381 3735
All India 144 175 3202 3921

Source: NSSO (1998)

Reproductive and Child Health Indicators by States, India 1998-99

State % with at % receiving % receiving % births % with Contra- % of
‘least one 2 or more IFA tablet/ in medi- post ceptive children
antenatal TT syrup 1 cal instit- partum use fully
checkup1 injections1 utions1 checkup immun-
within ized 3
2 months
of birth2
Delhi 83.5 84.9 77.8 59.1 19.5 63.8 69.8
Haryana 58.1 79.7 67 22.4 15.7 62.4 62.7
Himacchal 86.8 66.2 85.6 28.9 21.2 67.7 83.4
Pradesh
Jammu & 83.2 77.7 70.8 35.6 27.6 49.1 56.7
Kashmir
Punjab 74 89.9 79.6 37.5 20.3 66.7 72.1
Rajasthan 47.5 52.1 39.3 21.5 6.4 40.3 17.3
Madhya 61 55 48.9 20.1 10 44.3 22.4
Pradesh
Uttar Pradesh 34.6 51.4 32.4 15.5 7.2 28.1 21.2
Bihar 36.3 57.8 24.1 14.6 10 24.5 11
Orissa 79.5 74.3 67.6 22.8 19.2 46.8 43.7
West Bengal 90 82.4 71.6 40.1 31.6 66.6 43.8
Arunachal 61.6 45.6 56.3 31.2 10.5 35.4 20.5
Pradesh
Assam 60.1 51.7 55 17.6 25.5 43.3 17
Manipur 80.2 64.2 50 34.5 27.1 38.7 42.3
Meghalaya 53.6 30.8 49.5 17.3 20.8 20.2 14.3
Mizoram 91.8 37.8 72.7 57.7 20.9 57.7 59.6
Nagaland 60.4 50.9 42.5 12.1 4.3 30.3 14.1
Sikkim 69.9 52.7 62.4 31.5 38 53.8 47.4
Goa 99 86.1 94.7 90.8 41 47.5 82.6
Gujarat 86.4 72.7 78 46.3 10.4 59 53
Maharashtra 90.4 74.9 84.8 52.6 29.8 60.9 78.4
Andhra 92.7 81.5 81.2 49.8 44.9 59.6 58.7
Pradesh
Karnataka 86.3 74.9 78 51.1 35.3 58.3 60
Kerala 98.8 86.4 95.2 93 27.4 63.7 79.7
Tamil Nadu 98.5 95.4 93.2 79.3 53 52.1 88.8
India 65.4 66.8 57.6 33.6 16.3 48.2 42
Source: IIPS and ORC macro (2000)
1
maternal care indicators based on births during last 3 years
2
post partum carte in the case of non institutional births
3
children of age 12-23 months vaccinated against BCG, measles doses of DPT and polio vaccines

Private Health Sector in India- - Raising Inequities
Rama Baru
Introduction and research, also require to be studied. This

This chapter proposes to examine the trends then helps to locate the extent and nature of
in privatisation in the health service system privatisation in the health services system and
over the last four decades. It provides an has implications for its regulation.1
overview of the extent of privatisation in the
different sub systems of the health service The significant presence of the private sector
system viz. provisioning, financing, at the primary, secondary and tertiary levels
technology/drugs and medical/para medical of care is well acknowledged as shown by a
education. In addition it also examines the number of studies. A number of micro studies
accommodation of private interests in the on utilisation have in fact highlighted the
public sector. Based on available studies this dependence of different strata of a given
paper analyses the characteristics of the population on private practitioners, both
private sector at the primary, secondary and trained and untrained, for primary level care
tertiary levels of care in terms of social
across states.2
background of promoters, infrastructure
available, services offered, manpower
These studies have shown that there is
employed, cost of services etc. The insights
plurality among the private practitioners
from these studies will form the basis to
ranging from untrained practitioners
comment on the need for regulation of various
aspects of the private sector. It also examines dispensing allopathic medicines to a range of
a few initiatives for regulation of the private practitioners who practice traditional, folk and
sector including the status and possibilities indigenous systems of medicine. Many of them
for self-regulation. dispense allopathic medicine along with
traditional cures. These practitioners are not
The last four decades have seen the expansion restricted to urban areas alone and their
of the private sector in health care. A lot of presence is extensive even in rural areas.3
the public debate and research has focussed Analyses of the various rounds of National
on the private sector in the provisioning of Sample Survey data on utilisation of medical
medical care. While the analysis of the private service in fact corroborate the findings from a
sector in provisioning of services is very range of micro studies. For minor ailments a
important, other aspects of the health service majority of the people use the services of a
system that include technology, drugs, private practitioner. This was seen in both
medical and paramedical education, financing rural and urban areas and across states.
1
Baru et al ,(2001) ‘State and Private Sector in India: Some Policy Options’ in Private Health Sector in India:
Review and Annotated Bibliography, Mumbai, CEHAT, IIT & Centre of Social medicine and Community Health,
Jawaharlal Nehru University.
2
Bisht, R.(1993), ‘Understanding Environmental Health: A study of Some Villages in Pauri Garhwal, Unpublished
M.Phil dissertation, Jawaharlal Nehru University, New Delhi; Soman,K. (1992) ‘An Exploratory Study of Social
Dynamics of Women’s Health in Adityapur Village of Birbhum District’ Unpublished M.Phil dissertation, JNU,
New Delhi; Krishnan, T.N. (1994) Access to Health and Burden of Treatment: An Interstate Comparison’ Discussion
Paper Series no. 2, Studies in Human Development in India. UNDP project, Trivandrum ; Kakade, N.(1998) ‘The
Development of Public Health Services and their Utilisation: A Case Study of the Bombay Municipal Corporation’
Unpublished M.Phil Dissertation, Jawaharlal Nehru University, New Delhi.
3
Vishwanathan & Rohde: ( 1990) Diarhoea in Rural India: A Nationwide Study of Mothers and Practitioners: An
All India Summary, Indian Market Research Bureau and UNICEF, New Delhi

When it comes to hospitalisation the picture Kerala, Tamilnadu that have high private
is more complex. Here the extent of growth sector growth, there was greater reliance on
of private medical care at the secondary and the private sector for hospitalisation. The
tertiary levels, its variations across states and utilisation of the private sector corresponds
the differential purchasing power across to income levels viz. the higher and middle
various strata determines the utilisation income groups use it more than the poorer
pattern. For example, the analyses showed sections.4 During the mid nineties what is
that the economically developed states had a significant is the rise in costs of medical care
higher utilisation of the private sector and in both the public and private sectors and also
those who used these services were largely a greater reliance on the private sectors.5
from the middle and upper middle income
groups. In those states where the private Private interest is not restricted to
sector was not significant, the reliance on the provisioning alone but has penetrated
public sector was very high. In fact one could financing, technology and drugs, medical and
characterise the structure of the private sector paramedical education as well. In financing
as pyramidal, with the base consisting of the nearly 80 per cent of health expenditure is
large number of individual practitioners who from out of pocket sources. This essentially
maybe trained or untrained. The middle level means that households are incurring
is occupied by institutions providing both out expenditure in both public and private sectors
patient and inpatient care and promoted on consultation, drugs, diagnostics and also
largely by single entrepreneurs, mostly indirect costs like transportation, wage loss
doctors. These are mostly located in urban etc. During the late nineties the government
areas but in some states they are located in has allowed foreign joint ventures in the
towns and even villages. The apex of the private health insurance sector. Multinational
pyramid is occupied by large hospitals that and national private companies dominate both
are promoted as trust, private limited or the pharmaceutical and equipment
corporate enterprises. These offer super industries. There has been an increase in the
speciality services and are located largely in trends of import of medical equipment in the
the metropolises. This segment would country through the 1990s. Between 1993-
constitute roughly around one percent of the 94 and 1996-97 the value of imports increased
total beds in the private sector. Analysis of nearly four fold and this trend has been
The National Sample Survey 42nd round shows steadily increasing over the subsequent
that across states there is a high dependence years.6 A study from Chennai showed that it
on the private sector for out patient services is the hospitals with high bed capacity and
in both rural and urban areas. Here the out those in the corporate sectors that invest more
patient services are provided by a variety of intensively on intensive care and therapy
providers, both trained and untrained. The equipment. In these categories the
picture on utilisation is more mixed when it investment in imaging equipment is higher
comes to hospitalisation across states. The than laboratory equipment. Investment in
major trend during the mid 1980s showed a imaging equipment accounts for 50 per cent
high reliance on public hospitals for major of the total investment. Privatisation of
illnesses at the All India level but there were medical education emerged as a phenomenon
significant inter state variations. In states like during the late 1980s and was confined to
Andhra Pradesh, Maharashtra, Gujarat, states like Maharashtra, Karnataka and later
4
Baru, (1998) Private Health Care in India: Social Characteristics and Trends, New Delhi, Sage.
5
Iyer,A. and Sen,G. (2000)Health Sector Changes and Health Equity in the 1990s in India’ in Health and Equity-
Effecting Change, Technical Report Series 18. Edited by Shobha Raghuraman, Bangalore, HIVOS publications.
6
Baru, (1998) op.cit.

Rama Baru
to states like Tamilnadu and Andhra Pradesh. some insights into the infrastructure that is
The trend towards privatisation has increased available, personnel employed, technology use
in the last few years and there has been a and also the extent of use of government
great deal of debate on the quality of teaching doctors as consultants to these hospitals.
and also the capitation fees charged by these
colleges. A number of private centres have In the following section we analyse the
mushroomed for training nurses, midwives characteristics of the private sector at the
and also technicians across states but there secondary and tertiary levels of care based
is no reliable data on the numbers or the on studies available from different parts of the
quality of training they are imparting. The country. Majority of these studies have been
corporate hospitals have started nursing and conducted during the late 1980s and 1990s.
other schools for training various categories
of paramedical personnel. Characteristics of the Private Sector in
Medical Care: An Analysis of Available
Characteristics of the Private Sector in Studies
Provisioning The distribution of private nursing homes and
In defining the characteristics of the private hospitals presents a picture of variation. The
sector we are interested in the variations in private sector is skewed in favour of urban
size, services provided and location of these areas, economically better-developed states
enterprises. In order to get some insight into and within states in districts that are
this an analysis of various studies on the economically more prosperous.7 This study
private sector at the secondary level has been demonstrated this association across the
carried out. A number of studies on the developed and poorer districts of Andhra
characteristics of the private sector have been Pradesh. Analyses of the ratio of private to
published during the 1990s. These studies public beds across states shows a similar
are urban based and have been carried out trend. Some states like Andhra Pradesh,
in the larger cities like Delhi, Mumbai, Kerala, Maharastra, Punjab, Gujarat have a
Kolkata, Chennai and Hyderabad. They have higher private bed strength compared to
collected information based on a sample public beds.8 These are also the states that
survey on the following aspects: These include would fall into the ‘middle’ and ‘better off’
information on the ownership, size, bed category. These studies give us some broad
strength, services offered; availability of high trends but do not give us insights into the
technology equipment and also extent of characteristics of private providers, services
government doctors serving as consultants. offered, technology used and manpower
All the studies show that there are some employed. For the purpose of gaining a better
common trends in terms of characteristics. insight, an attempt has been made to analyse
These various studies on the characteristics available studies on private provisioning.
of the private sector at the secondary and Most of these studies are based on small
tertiary levels of care show a high degree of samples and confined to the larger cities in
variability in terms of bed strength that ranges the country. (See Table 1)
from 5 up to even a 100. It is mainly
dominated by sole proprietorship and Based on an in-depth study of 24 nursing
partnership enterprises that are promoted by homes in Bombay, 50 per cent were found to
doctors. Apart from variation in size and be housed in a poorly maintained building in
services rendered, this research provides a dilapidated condition. Most of the nursing
7
Baru, R. (1987) Regional Variations in Health Services: A study of Selected districts of Andhra Pradesh, Unpublished
Mphil dissertation, Jawaharlal Nehru University, New Delhi
8
Baru, (1998) op.cit.

homes were congested and the majority of families. Promoters of the nursing homes had
them had no scrubbing room. Less than a difficulty in getting trained nurses and
third had qualified nurses employed in them. therefore many of them relied on poorly
None of the nursing homes had waste disposal trained or untrained persons. All these
facilities and disposed of all their waste in nursing homes had consultants attached to
municipal bins. In addition they did not them for various specialisations.11
maintain any records of notifiable diseases
treated in their institutions.9 A study of A study of 73 hospitals in Chennai providing
private hospitals from two talukas in rural both out patient and in-patient care at the
Maharashtra also showed up the poor quality secondary and tertiary levels of care, but
in physical standards. In this study 49 excluding the corporate and trust hospitals
hospitals were surveyed and it was found that showed similar trends as those observed in
none of them had registered with any other cities. The study found that 68.5 per
authority. Most of them had a bed strength cent of the sample hospitals were under sole
of 6 to 15. Allopathic doctors ran a majority proprietorship, 20.5 per cent were
of the nursing homes but doctors qualified in partnerships and 11 per cent were private
other systems of medicine managed around limited. The average bed strength was 22.6.
29 per cent of these. 39 per cent of these Majority of these hospitals were run on their
nursing homes functioned without a full time
own premises and more than 80 per cent of
doctor or visiting consultant and most of them
them had less than 400 sq.ft available per bed.
employed mostly unqualified persons as
Often the space available for out patient
paramedial staff. Some of them did not
services, consultation room etc. was very
employ any paramedical staff at all. The
limited. 53 per cent had a pharmacy shop
services that were offered by these nursing
on the premises and according to the owners,
homes were meagre. Only 2 per cent had
having a pharmacy increases, ‘ access to care,
emergency services, 18 per cent had facilities
for pathological tests and none of them had overall revenues and also their
blood bank facilities.10 competitiveness.’ 12 As far as staffing is
concerned most of the hospitals employ
specialists and physicians on a part time basis
In a study of 68 nursing homes drawn from
different areas of Delhi, Nanda and Baru but duty doctors on a regular basis. Many of
found that there was much heterogeneity in these specialists are government doctors with
terms of size and scale of operations. These 66.3 per cent of the nursing homes having
nursing homes offered both out patient and government doctors as visiting consultants.
in patient services that included special focus However there was variation in the
on maternity and surgical services. As far as dependence of nursing homes on government
social background of promoters is concerned, doctors across ownership categories. 63.8 per
the majority of promoters of small nursing cent of sole proprietorship nursing homes,
homes belonged to business and professional 25.5 per cent in the partnership category and
backgrounds while those owning larger only 10.6 per cent in the private limited are
nursing homes belonged largely to business dependent on government doctors.
9
Nandraj:(1992) Private Nursing Homes/Hospitals: A Social Audit, Committee for Regulating Private Nursing
Homes and Hospitals, Mumbai High Court.
10
Nandraj and Duggal: (1997) Physical Standards in the Private Health Sector: A Case Study of Rural Maharashtra,
Mumbai, CEHAT
11
Nanda,P. & Baru,R.(1993) Private Nursing Homes and their Utilisation: A Case Study of Delhi, Voluntary
Health Association Of India, New Delhi.
12
Muraleedharan, VR. (1999) Characteristics and Structure of Private Hospital Sector in Urban India: A Study of
Madras City, Applied Research Paper 5, Bethesda, Maryland: Partnership for Health Reform Project, ABT Associates

Rama Baru
87 per cent of the nursing homes offer doctors were aware of the provisions of the
gynaecology and obstetric services, this is Consumer Protection Act.14
followed by general medicine, surgery and
paediatrics. A comparative study between A district level study of private providers in
Chennai and Chidambaram shows a great Madhya Pradesh showed that primary level
deal of variation in the cost of services. For practitioners who were both formally and
example, the charges for caesarean section informally trained were predominant. There
in Chennai is double that in Chidambaram. was a plurality of practitioners who were
In terms of infrastructure and space distributed in both rural and urban areas.
availability, it is much poorer in Chidambaram This study showed that the qualified
as compared to Chennai.13 practitioners, rural private practitioners and
owners of nursing homes and hospitals were
Most of the medium and small hospitals do dominated by the forward caste and trading
not have adequate capital to invest in community combine. The proportion of
diagnostic facilities therefore there is a tie up backward classes, schedule castes and tribes
with diagnostic centres for referrals. 89 per was low and ranged from about 5to 20 per
cent of the hospitals have a contract with cent of all the practitioners. This study also
diagnostic centres or tertiary hospitals for CAT showed that there is much variability across
scan and MRI. There are commissions paid the different categories of nursing homes in
to the doctors for every referral that is made terms of infrastructure, manpower and costs.
to the diagnostic centre. There is a great Keeping in view the different levels of care,
degree of variation in the charges and a great this investigation also underlined the need for
deal of arbitrariness in the fixing of fee regulating the private sector.15
schedules. As a result the patient does not
know how much they will be charged for A recent study of private nursing homes in
various procedures. Kolkata showed that the maximum growth in
these institutions occurred between 1968-87.
Studies of private doctors in Ahmedabad There was considerable variation in terms of
conducted among 500 doctors showed that size and scale of operations. 40 per cent of
92 per cent were sole proprietors and the nursing homes were managed on a sole
depended solely on their personal capital for proprietorship basis and 24 per cent were
setting up the nursing home. This study partnerships. The distribution of beds across
revealed that majority of the private providers categories also varied with 31 per cent of beds
experienced a shortage of trained paramedical in private limited category, 23 per cent in
staff and hence hired mostly untrained public limited, 20 per cent in the sole
persons for this job. When asked about the proprietorship, 18 per cent in the partnership
major forms of malpractice prevalent in the and 8 per cent in the Trust categories. The
private sector they ranked several issues that bed strength varied from 4 to a maximum of
include over prescription of drugs, splitting 186 across these various categories. All these
practices among doctors, inadequate nursing homes provide both out patient and
measures for waste disposal and over in patient facilities. A small percentage of
prescription of diagnostics. Majority of the them have diagnostic facilities and
13
Muraleedharan, VR.(1997) Hospital Services in Urban Tamilnadu: A Survey of Maternity Services in Madras
City and Chidambharam (Cuddalore Region), Report prepared for Citizen, Consumer and Civic Action Group,
Chennai.
14
Bhat: (1999) ‘Characteristics of Private Medical Practice in India: A Provider Perspective’ in Health Policy and
Planning, vol.14, no.1: pp.26-37.
15
TARU (2002) ‘Study on the Dynamics and Structure of Private Health Care in Madhya Pradesh’ Report Submitted
to Government of Madhya Pradesh and DFDI, UK

pharmacies attached to them. The most however the medium and larger hospitals are
commonly provided service was gynaecology/ able to employ consultants and also doctors
obstetrics followed by general surgery and on a part time or full time basis.
general medicine. The availability of medical
technology was largely restricted to ECG, X- The other important issue has been the rise
rays, microbiology, biochemistry and in the cost of medical care and the variability
haematology. Since doctors largely promoted in costing of services across the public and
these enterprises, they also worked in these private sectors as well as within the private
hospitals. Nearly half of these enterprises had sector. A study of costs of some specific
residential nurses, however, the majority of interventions in private hospitals in
them were trained only on the job.16 Hyderabad and Chennai clearly showed this
variability. The study found for normal
It is well known that the beds in the private deliveries, caesarean sections and
sector have increased several fold during the hysterectomies there was variation in median
last four decades. At the all India level it has costs across different categories of private
roughly doubled between the early 1980s and hospitals. For hysterectomy in Chennai the
late 1990s. Some states have seen a faster median cost varied from Rs 22,886 for an
growth than others and the data from some average of 6 days in corporate hospitals, in
of the in-depth studies from Hyderabad, the trust category it ranged from Rs 7,200 to
Jaipur and Kolkata show that majority of the Rs 13,063 with an average of 9 to 16 days of
institutions at the secondary and tertiary hospitalisation. In the single owner category
levels have a variable bed strength. They offer the median costs was Rs 13,030 with an
mainly gynaecology and obstetrics services average of 11 days of hospitalisation.
along with other specialities; these are
dependent on the size of the enterprise and This kind of a trend was similar in the case of
the availability of consultants. These studies other interventions like those concerning
show that the dependence on government diabetes, cardiovascular diseases etc.17
doctors as consultants is high among the
medium sized hospitals. Most of these An additional issue that is of importance is
hospitals have basic equipment like X-ray the extent of irrational practices by doctors
machines, ECG and ultrasound. However, the in the private sector when it comes to
smaller hospitals do not have the capital to treatment of a number of communicable
invest in diagnostic facilities and therefore diseases that form a part of the National
refer cases to larger hospitals or diagnostic Disease Control programmes. Several studies
centres. All these studies have shown that have shown that private practitioners adopt
commissions are received for referrals made irrational, ineffective and sometimes harmful
to diagnostic centres. Most of the smaller practices while treating tuberculosis, malaria,
hospitals are unable to employ duty doctors cholera and other diseases. 18 These
or even trained paramedical personnel, practitioners do not give information regarding
16
Roy, B. (2002) ‘Evolution, Social Dynamics and Patterns of Private Medical Care in Calcutta: An Exploratory
Study’ Unpublished M.Phil dissertation, JNU, New Delhi,2002
17
Baru,R. et al (1999) Efficacy of Private Hospitals and the Central Government Health Scheme: Study of Hyderabad
and Chennai, Project Report submitted to the Ministry of Health and Family Welfare, Administrative Staff College
of India, Hyderabad.
18
Priya, R. et al (1989) Sunder Nagari Mein Ulti-Dust Ja Prakop Va Uski Roktham (The Gastro-enteritis outbreak
and Its Control in Sundar Nagri: An Assessment at Community Level), Mimeo, Sable Sangh with support from
ICSSR, New Delhi; Phadke,A. (1998) Drug Supply and Use: Towards a Rational Policy in India, Delhi, Sage;
Uplekar,M., Shepard, DS.(1991) Treatment of Tuberculosis by Private General Practitioners in India, Mumbai,
FRCH; Kamat, V. (2001) Private Practitioners and their Role in Resurgence of Malaria in Mumbai and Navi
Mumbai, India: Serving the Affected or Aiding an Epidemic? Health Policy and Planning, ( 53) pp885-909

Rama Baru
the number of cases treated to the public between the public and private sectors. This
surveillance system, even when most of these kind of a trend also has a negative impact on
diseases are notifiable by law. teaching, research and patient care in public
hospitals. Several state governments have
Issues for Regulating the Private Sector attempted the banning of private practice but
The need for regulating the private sector this has met with a great deal of resistance
arises from the heterogeneity of institutions by doctors. Several cases across states show
in the private sector; the lack of standardised that government doctors challenge such ban
costs, variability in infrastructure, manpower orders by the High Court and often manage
etc. The variability in infrastructure, to reverse the ban after it is imposed. The
manpower, services and costs is bound to extent of entrenchment of private interests
affect the quality of care in the private sector. and their complex nature has meant a
Studies have shown that there is an irrational tremendous challenge for state governments.
use of drugs and technology in the private
sector and as a result the costs get pushed Experiences of Regulation
up. The lack of adherence to standardised There are many ways in which regulation can
regimes for the treatment of several be affected. Very often it is a combination of
communicable diseases actually impact on its regulatory practices that is seen to be effective.
effectiveness. This has adverse consequences The state plays a very important role in
for the programme in terms of control of the defining the regulatory framework but it
diseases. cannot be the sole actor. It is neither feasible
nor desirable to have a sole actor for regulating
Regulating the private sector should not only the private sector. An important participant
be restricted to provisioning of medical care in regulating the private sector is the
but also other subsystems like medical and professional body itself. Experiences of
para-medical education, drugs, technology developed countries clearly show that
and financing. Therefore for any regulation professional associations can play an
to be effective, a systemic perspective is important role in self-regulation and setting
needed and in addition the issue of private standards in the private sector. Given the
practice by government doctors needs to be power that professionals wield in society, any
included.
effort at regulation has to be done in
consultation with professional organisations.
Private practice by government doctors is a It is well documented that medical
widespread phenomenon across states and is professional organisations are normally
deeply entrenched in a plurality of forms. It
aligned with conservative politics of any given
includes individual private practice and
state and therefore tend to oppose efforts to
acting as consultants in nursing homes which
regulate the private sector. Regulation is seen
has been changing over the last few decades.
as an act of infringement of the rights of
During the 1950s and 1960s it was mainly
individual doctors. Apart from professional
confined to consultations in either their
organisations, consumer groups can also play
residence or clinic but with the growth of the
a very important role in regulating the private
private sector the nature of practice changed.
Increasingly government doctors started sector.
acting as consultants in private nursing
homes and in some cases had even started The next section reviews the legal provisions
setting up their own nursing homes. This that are available for regulating the private
resulted in further blurring of their interests sector.

Regulations Available for the Private handling consumer complaints compared to

Sector the public hospitals.
There are four different authorities for
regulating the private sector. These include Apart from the mechanisms for redressal at
the Medical Council of India, the Local Bodies, the hospitals, consumer courts have dealt
Food and Drug Administration Authority and with cases of medical negligence mainly from
the Nursing Home Acts of different cities/ the private sector. This study showed that
states enacted by the respective governments. the medical cases filed with consumer courts
While these various bodies have the power to formed a very small percentage to the total
regulate the private sector, they are doing very number of cases. The functioning of
little in this respect. For example, the Medical consumer forums were a major source of the
Council of India and the State Medical problem and the experience of both providers
Councils have to regulate medical education and consumers have largely been negative.
and professional practice, but have been This is because there are an inadequate
largely ineffective. number of forums for the cases registered and
the resolution of cases usually takes more
Apart from these legal bodies the consumer than the stipulated period of 90 days. The
courts have also been an important forum for people who access the consumer courts
the redressal of medical negligence. A recent mainly belong to the middle classes with fixed
study on consumer redressal mechanisms has incomes. This essentially means that the rural
explored the facilities available at the hospital and urban poor, scheduled castes, tribes and
level for filing complaints against medical women are largely unrepresented or under
negligence and also through the consumer represented.19
forums. This study was conducted in three
cities – Delhi, Lucknow and Hyderabad. The If we review the various efforts of state
study showed that there was slackness on the governments to regulate the private sector we
part of hospitals offering redressal. In both find it has met with tremendous resistance
public and private hospitals there were few from professional bodies who view it as an
who had a standardised procedure to handle infringement of their professional autonomy.
complaints and did not have a written manual In this scenario various possibilities are being
regarding the same. It was observed that the
discussed and one of them is a system for
large and medium sized hospitals in both the
hospital accreditation.20
public and private sectors had units to resolve
consumer disputes but this was not the case
The accreditation system does not preclude
for smaller hospitals. An analysis of the type
other forms of regulation and can be
of complaints commonly received in public
complementary to efforts of the government.
and private sectors was revealing. In the
Accreditation will necessarily involve the
public hospitals the most commonly received
complaints related to sanitation, followed by professionals in any agreement regarding the
hospital utilities and medial care. In the initiation and implementation of such a
private sector complaints regarding sanitation process. As Nandraj et al observe, the body
was the highest, followed by hospital utilities to put such a system of accreditation into
and billing. This study also showed that the place could be set up by the government or
private sector seemed to be more adept at as a voluntary autonomous body.
19
Misra and Kalra: (2001) ‘A Study on the Regulatory Framework for Consumer Redress in the Health Care Sector
in India’ in A Vision For India’s Health System: National Consultation Workshop, New Delhi, sponsored by
Ministry of Health and Family Welfare and The World Bank.
20
Nandraj et al (1999) Accreditation of Hospitals: Breaking Boundaries in Health Care, Mumbai, CEHAT

Rama Baru
Conclusion differential quality of services, it does not

This paper has reviewed and analysed the tackle the problem of inequities that are
growth and characteristics of the private created by the private sector. These could be
sector in medical care. The private sector has regional, social and economic inequities. It is
grown and diversified over the last three here that the role of the state cannot be
decades and has emerged as an important restricted to only regulating but it also needs
practitioner in the provision of medical care to define the scope and role for the private
in both rural and urban areas albeit the sector. This would then require that the state
variations it presents across states. It has is able to delineate the nature and extent of
also shown that the private sector is a private sector participation in the delivery of
heterogeneous entity offering services of health services. This would essentially mean
variable quality. It is also unregulated and that the role of the state becomes crucial in
this has become an area of immense policy planning financing and delivery of health
concern in recent times. The paper also takes services. It is here that the philosophy of
a systemic view for regulating the private primary health care becomes extremely
sector since commercial interests are not relevant because it did give primacy to the
restricted only to provisioning but also span state to plan and provide health services on
the other subsystems like medical and the principles of universality, equity and
paramedical education, drugs and technology, comprehensiveness. There is sufficient
finance and research. In addition it also evidence from the last five decades that the
highlights the need to account for the nature growth of markets do undermine the very
of interrelationships between the public and principles that were enunciated in the Alma
private sectors especially in the form of private
Ata document. The evidence from developed
practice by government doctors and public
and developing countries shows that markets
subsidies to the private sector. While the
in health care have increased inequities in
issues for regulation are complex, the
access and utilisation, increased costs of
legislation and other efforts so far have been
services, promoted greater dependence on
piecemeal and rather ineffective across states.
technology and accessibility to services being
Ultimately health is a state subject and any
determined on the principle of payment. With
efforts at evolving a regulatory framework have
to be initiated at the state level. However, euphoria over markets waning, the
this does not preclude the centre from importance of the state is gradually being
initiating a dialogue between the major revived across the ideological spectrum in
participants who would be involved and various hues. It is therefore important to
affected by regulation in order to provide a recognise the relevance of Alma Ata at this
workable framework. juncture and revisit the importance of the
state in public provisioning of inputs that
While the regulation of the private sector is contribute to health improvements and access
absolutely essential in order to address the to health services.

Fundamental Right to Health and Health Care
S. V. Joga Rao
Introduction are experiencing phenomenal expansion.

It is a fact that accessible and affordable health
care is still a mirage to many of our people. This social context has strained the
The position has not undergone any significant conventionally understood foundations of
improvement, even after completing more than doctor – patient relationship. This gradually
50 years of governance since independence. resulted in growing awareness and concern
in society on the need to protect patient’s
The present day context paints a clear rights. Professional accountability from the
contrasting trend pertaining to economics of medical professionals and establishments has
health care services. On the one hand, one acquired a new dimension in the process. The
discerns a consistent dwindling of State result is a rising number of cases being filed
budgetary allocation on public health and on against doctors, nursing homes and hospitals
the other, a meteoric rise of private investment seeking diverse legal remedies, in different
on a massive scale in health care delivery. This courts and forums.
investment finds its way in different
dimensions of health care activity which In addition, society has also witnessed active
include establishing nursing homes, hospitals, judicial intervention in recognising and
diagnostic centres and rehabilitation homes, constitutionalising the right to health as a
pharmaceutical and bio-tech sectors, medical fundamental right. The judiciary has
equipment firms, medical and health shouldered the responsibility in two different
insurance and also institutions imparting ways in the context of health care, namely,
medical and allied education. recognising and enforcing right to health care
as a fundamental right and regulating health
This trend quite clearly indicates two patterns
care delivery. The recent pronouncements and
of development. The health care industry has
directives by the Supreme Court pertaining
scaled up its offer of superior quality of medical
to mentally ill and pre-natal diagnostic
services with emphasis on specialities and
techniques regulation clearly indicates this
super specialities. Technology driven health
trend.
care services offered by some of the corporate
centres are undoubtedly comparable to
international standards. However, the Still whatever has been attempted has not in
available health care services particularly any fundamental sense, addressed the issue
those in the private sector are only accessible of accessible and affordable health care
to those who can afford the cost. If not, denial services. What needs to be done? What is the
of service is the consequence. Nevertheless, way forward? An attempt is made to understand
those who cannot afford it are driven to the and respond to these issues of an intriguing
private health care sector owing to the fact nature. This paper outlines evolution of
that the government hospitals are no longer Constitutionalisation of the right to health in
in a position to cater adequately to the health the light of international and national
care needs of the people. In other words, the perspectives, evaluates strengths of judicial
role of the State in the context of health care is interpretation and recommends certain
fast shrinking, at the same time, market players measures while designing the way forward.

Right to Health: The International Organization has been playing a laudable role
Perspective at the international level with a view to ensure
Right to health and availability of qualitative the availability of the highest standards of
health services are issues that are relevant health care to people all over the world. The
all over the world. Hence, these issues also Preamble of the World Health Organization
form topics of debate at various international Constitution states that:
levels. The United Nations, in particular, has
been active in adopting various resolutions to 1. The enjoyment of the highest standards of
safeguard the interests of individuals in health is one of the fundamental rights of
ensuring their health and well being. every human being without distinction of
race, religion, political belief, and economic
The Universal Declaration of Human and social condition.
Rights states that: 2. The health of all peoples is fundamental
“Everyone has the right to a standard to the attainment of peace and security and
of living adequate for the health and is dependent upon the fullest co-operation
well-being of himself and his family, of individuals and states.
3. The achievement of any state in the
including food, clothing, housing, and
promotion and protection of health is of
medical care, and necessary social
value to all.
services, and the right to security in
4. Unequal development in different countries
the event of unemployment, sickness,
in the promotion of health and control of
disability, widowhood, old age or other
disease, especially communicable disease,
lack of livelihood in circumstances
is a common danger.
beyond his control.”1
5. Healthy development of the child is of basic
importance; the ability to live
International Covenant on Economic,
harmoniously in a totally changing
Social and Cultural Rights proclaims
environment is essential to such
that:
development.
“The State parties to the present 6. The extension to all people of the benefits
Convention recognise the right of of medical, psychological and related
everyone to the enjoyment of the knowledge is essential to the fullest
highest attainable standard of physical attainment of health.
and mental health.”2 7. Informed opinion and active co-operation
on the part of the public are of the utmost
The International Covenant on Civil and importance in the improvement of the
Political Rights 1966, the UN Declaration on health of the people.
Elimination of All Forms of Discrimination 8. Governments have a responsibility for the
Against Women 1967, the Convention on the health of their people, which can be fulfilled
Elimination of All Forms of Discrimination only by the provision of adequate health
Against Women 1979 and the Convention on and social measures.
the Rights of the Child have all been framed
to protect apart from others the health care Article 2 of the same Constitution deals with
rights of women, children and other functions that, directly and indirectly, require
discriminated sections of the society. the application of legal principles, such as:
World Health Organization 1. to act as the directing and co-ordinating

For more than fifty years, the World Health authority on international health work;
1
Article 25 of the Universal Declaration of Human Rights (1948)
2
Article 12 of the International Covenant on Economic, Social and Cultural Rights (1966)

S. V. Joga Rao
2. to propose “Conventions, Agreements and The making of law is necessary when the treaty
Regulations”, make recommendations with or agreement operates to restrict the rights of
respect to international health matters, citizens or other or modifies the laws of the
and to perform such duties as may be State. If the rights of citizens or others, which
assigned thereby to the Organization and are justiciable, are not affected, no legislative
are consistent with its objective; and measure is needed to give effect to the
3. to develop, establish and promote agreement or treaty.4
international standards with respect to
food, biological, pharmaceutical and Health and Health Care: National
consumer products. Perspective
Health and health care have been covered
Several international agencies have also lent both under the Constitution of India and in
support to public participation in health care. different legislation. The Constitution does not
The World Health Organization Alma Ata explicitly recognise right to health as a
Declaration 1978, states that: fundamental right. Similarly, different
legislative enactments passed with regard to
“The people have the right and duty to health and health care deal more with the
participate individually and collectively regulatory aspects rather than the right to
in the planning and implementation of health. It can be interpreted that these
their health care.” statutes recognise right to health in a given
context in an indirect sense.
Impact of International Instruments in
a National Context Constitutional Provisions Preamble
The issue is how far these international Preamble to the Constitution of India
obligations, agreements, treaties and categorically directs the State to initiate
covenants bind the Indian State and measures aiming at improving the health of
Nationals? To what extent, can these the people. This is to be inferred from the
instruments can be invoked and relied upon broader parameters of social and economic
in Indian Courts? justice.
Chief Justice Sikri in Keshavananda Bharati’s3 Fundamental Rights

case, observed that, in view of Art. 51, the Part III of the Constitution deals with various
Supreme Court must interpret the language fundamental rights. A perusal of the same
of the Constitution, if not intractable, in the reveals the following fundamental rights,
light of the United Nations Charter and the which are related to the health and health care
solemn declaration subscribed to by India. of the people.
According to the Supreme Court, the executive Equality before law: According to this
is qua the State, competent to represent the fundamental right, the State shall not deny
State in all matters international and may by to any person equality before the law or equal
an agreement, convention or treaties incur protection of the laws within the territory of
obligation, which in international law are India.5
binding on the State. But the obligations
arising under the agreement or treaty are not Protection of Life and Personal Liberty:
by their own binding upon Indian nationals. According to this fundamental right, no person
3
AIR 1973 SC 1461
4
See PUCL v. Union of India AIR 1997 SC 1203; PUCL v. Union of India AIR 1997 SC 568; Visakha v. State of
Rajasthan (1997) 6 SCC 241
5
Art. 14

shall be deprived of his life or personal liberty conditions of work and for maternity relief.9
except according to the procedure established
by law.6 Living Wages for workers: The State shall
endeavour to secure, by suitable legislation
Directive Principles of State Policy or economic organisation or in any other way,
Essential premise of these principles is to to all workers, agricultural, industrial or
provide direction to various State otherwise, work, a living wage, conditions of
Governments to undertake and initiate work ensuring a decent standard of life and
required measures in the interests of the full enjoyment of leisure and social and
community. With regard to health and health cultural opportunities and, in particular, the
care, the following principles have direct State shall endeavour to promote cottage
bearing on which the States must strive to industries on an individual or co-operative
secure: basis in rural areas.10
Duty of the State to raise the level of nutrition

(c) that the health and strength of workers,
and the standard of living and to improve
men and women, and the tender age of
public health: The State shall regard the
children are not abused and that citizens are
raising of the level of nutrition and standard
not forced by economic necessity to enter
of living of its people and the improvement of
vocations unsuited to their age or strength;
public health as among its primary duties, and
(d) that children are given opportunities and in particular, the State shall endeavour to
facilities to develop in a healthy manner and bring about prohibition of the consumption
in conditions of freedom and dignity and that except for medical purposes of intoxicating
childhood and youth are protected against drinks and of drugs which are injurious to
exploitation and against more and material health.11
abandonment.7
Organisation of agriculture and animal
Right to work, to education and to public husbandry: The State shall endeavour to
assistance in certain cases: The State shall, organise agriculture and animal husbandry
within the limits of its economic capacity and on modern and scientific lines and shall, in
development, make effective provision for particular take steps for preserving and
securing the right to work, to education and improving the breeds, and prohibiting the
to public assistance in cases of slaughter, of cows and calves and other milch
unemployment, old age, sickness and and draught cattle.12
disablement, and in other cases of undeserved
want.8 Protection and improvement of environment
and safeguarding of forests and wild life: The
Provision for just and humane conditions of State shall endeavour to protect and improve
work and maternity relief: The State shall the environment and to safeguard the forests
make provision for securing just and humane and wild life of the country.13
6
Art. 21
7
Art. 39
8
Art. 41
9
Art. 42
10
Art. 43
11
Art. 47
12
Art. 48
13
Art. 48A

S. V. Joga Rao
Fundamental Duties State List contained in the Seventh Schedule

Fundamental Duties incorporated under Art. to the Constitution of India, empowered to
51A recognise some pertinent principles in make laws with respect to public health and
this connection. They include, sanitation, hospitals and dispensaries. Both
the Centre and the States have power to
It shall be the duty of every citizen of India: legislate in the matters of social security and
social insurance, medical professions, and,
(g) to protect and improve the natural prevention of the extension from one State to
environment including forests, lakes, another of infectious or contagious diseases
rivers and wild life, and to have or pests affecting man, animals or plants, by
compassion for living creatures; entries 23, 26 and 29 respectively contained
(h) to develop the scientific temper, in the concurrent list of the Seventh
humanism and the spirit of inquiry and Schedule.17
reform;
(j) to strive towards excellence in all Legal Insight
spheres of individual and collective There is a considerable amount of legislation
activity so that the nation constantly (both by the Central and State Governments
rises to higher levels of endeavour and respectively), which deal directly with the
achievement.14 subject matter of health and health care. As
has been stated earlier, these legislations deal
Constitutional Remedies more with the regulatory aspects of health care
Remedy to move the Supreme Court delivery in a given context.
Right to seek legal remedy before the Supreme
Court is itself recognised as a fundamental Some of those legislations include, Medical
right. By widening the scope and ambit of Termination of Pregnancy Act, 1971, Medical
locus standi, the Supreme Court gave fillip to Termination of Pregnancy Rules, 1975,
the birth of public interest litigation. As a Medical Termination of Pregnancy
consequence, it is not necessary that only a Regulations, 1975, Mental Health Act, 1987,
person whose rights are violated or the victim Central Mental Health Authority Rules, 1990,
have to appear before or move the Supreme State Mental Health Authority Rules, 1990,
Court or High Court for the purpose of legal National Trust for Welfare of Persons with
remedy. Any person or organisation is entitled Autism, Cerebral Palsy, Mental Retardation
to approach the Court and plead for redressal and Multiple Disabilities Act, 1999, The
in a representative capacity.15 Persons with Disabilities (Equal
Opportunities, Protection of Rights and Full
Remedy to move the High Court Participation) Act, 1995, The Persons with
Similarly Article 226 recognises the right to Disabilities (Equal Opportunities, Protection
move the High Court for the purpose of of Rights and Full Participation) Rules, 1996,
enforcing fundamental rights.16 Through these The Pre-Conception and Pre-Natal Diagnostic
remedies, the aggrieved person is entitled to Techniques (Prohibition of Sex Selection) Act,
redress his or her grievances. 1994, The Pre-Conception and Pre-Natal
Diagnostic Techniques (Prohibition Of Sex
Legislative Competence Selection) Rules, 1996, Transplantation of
The State legislature is, under entry 6 of the Human Organs Act, 1994, The
14
Art. 51A
15
Article 32
16
Article 226
17
Justice R.K. on Doctor Abhichandani, “Human Rights: Role of Courts in realisation of The Rights”, Lawshop
Patient and the Law, TILEM, National Law School, Bangalore.

Transplantation of Human Organs Rules, be of good quality. The State should allocate
1995, Bio-Medical Waste (Management and sufficient funds for this purpose. The State
Handling) Rules, 1998 and Drugs and Magic can never disown its responsibility to provide
Remedies (Objectionable Advertisements) Act, medical facilities, as that would be a violation
1954 etc. of Article 21. Though an employee may be
given a choice to get treated in any private
Right To Health: Judicial Perspective hospital in the country, the amount of
Though right to health has not been expressly reimbursement may be limited and a
incorporated in the Constitution as a committee of experts would decide the limit.
fundamental right, because of innovative
judicial interpretation, right to health has However, the Court further held that provision
acquired that status. Scope for such an of medical facilities to citizens could not be
interpretation has been created by the dictum unlimited. It has to be based on financial
of Supreme Court in Menaka Gandhi v. Union resources. The principle of fixing a rate and
of India18 wherein, while interpreting Article scale is justified, and cannot be held to violate
21 the Supreme Court has unequivocally held Articles 21 or 47 of the Constitution.
that reasonableness, justness and fairness
must form part of the procedure established Right to Life Includes Right to Health
by law. The State is now mandated to provide While dealing with Paschim Banga Khet
to a person all rights essential for the Mazdoor Samiti and others v State of West
enjoyment of the right to life in its various Bengal and another20, the Supreme Court had
perspectives. Consequently, the right to health an opportunity to enquire into the lethargic
and access to medical treatment has been attitude of the Government in providing
brought within the fold of Article 21. warranted medical facilities. The Court held
that providing adequate medical facilities is
Constitutional Remedies an obligation undertaken by the Government
The Supreme Court has been instrumental, in a welfare State. The Government discharges
through many meritorious judgements, in this obligation by running hospitals and
ensuring the protection of an individual’s right health centres that provide medical care to
to health and right of access to medical the persons seeking to avail of these facilities.
treatment under various conditions. Article 21 imposes an obligation on the State
Examined below are some decided cases and to safeguard the right to life of every person.
some rulings that lay down various criteria to Preservation of human life is thus of
regulate and standardise health services. paramount importance. The Government
hospitals run by the State are duty bound to
Right to a Healthy Life extend medical assistance for preserving
In the context of State of Punjab v Ram human life. Failure on the part of a
Lubhaya Bagga19, the Supreme Court observed Government hospital to provide timely medical
that the right of a citizen, under Article 21, to treatment to a person in need of such
live enforces an obligation on the State. This treatment results in violation of his right to
obligation is further reinforced under Article life guaranteed under Article 21. A
47. It is the primary duty of the State to secure compensation of Rs. 25,000 was awarded in
health to its citizens. Government hospitals this case.
and health centres should be easily reachable
to all sections of the people and they should In Akhila Bharatiya Soshit Karamchari Sangh
18
AIR (1978) SC 597
19
AIR 1998 SC 1703
20
AIR 1996 SC 2426

S. V. Joga Rao
v Union of India,21 the Supreme Court pointed all the help he can and see that the
out that fundamental rights are of no value person reaches the proper expert as
unless they are enforced by resort to Courts. early as possible.
The directive principles cannot, in the very 2. Legal protection to doctors treating
nature of things, be enforced in a court of law, injured persons:
but that does not mean that they are less A doctor does not violate the law of the
important than fundamental rights or that land by proceeding to treat an injured
they are not binding on various organs of the victim on his appearance before him,
State. either by himself or with others.
3. No legal bar on doctors from attending
Right to Treatment in an Emergency to the injured persons:
Situation There is no obstacle laid down by law
The Supreme Court, in Paramanand Katara v for a medical professional, when he is
Union of India and others22, ordered medical called upon to attend to an injured
institutions to provide treatment immediately, person needing his medical assistance
irrespective of whether or not procedural immediately.
formalities have been complied with. The
Court observed that the preservation of human Workers’ Right to Clean Environment and
life is of paramount importance. Whether the Health Care Facilities
patient is an innocent person or a criminal While judging Bandhua Mukti Morcha v Union
liable to punishment under the laws of the of India,23 the Supreme Court held that it is
society, it is the obligation of those who are in the fundamental right of everyone in the
charge of the health of the community to country, assured under the interpretation
preserve life so that the innocent may be given to Article 21 in Francis Mullin’s case,24
protected and the guilty may be punished. to live with human dignity, free from
Article 21 casts the obligation on the State to exploitation. This right must include the
preserve life. The doctor at the Government protection of the health and strength of the
hospital positioned to meet the state obligation workers, men and women, and children of
is, therefore, duty bound to extend medical tender age against abuse; opportunities and
assistance for preserving life. Every doctor, facilities for children to develop in a healthy
whether at a Government hospital or manner and in conditions of freedom and
otherwise, has a professional obligation to dignity; educational facilities; just and
extend his services with due expertise for humane conditions of work and maternity
protecting life. The Court laid down the relief. No State, neither the Central
following guidelines for doctors, when an Government nor any State government has
injured person approaches them: the right to take any action that will deprive a
person of the enjoyment of these basic
1. Duty of a doctor when an injured necessities.
person approaches him:
In CESE Ltd v Subash Chandra Bose,25 the
Whenever a doctor who is approached Court held that the health and strength of a
by an injured person finds that some worker is an integral facet of the right to life.
better assistance is necessary to save The aim of fundamental rights is to create an
the life of the person, he should render egalitarian society to free all citizens from
21
{1981} 1 SCC 246
22
AIR 1989 SC 2039
23
AIR 1984 SC 802
24
AIR 1980 SC 849
25
{1992} 1 SCC 461

coercion or restrictions by society and to make to equality under Article 14 and the right to
liberty available for all. The Court further held life under Article 21.
that the term health implies more than an
absence of sickness. Facilities of health and Right to Healthcare for Convicts and Under
medical care generate devotion and Trials
dedication, to give the workers’ the best, The Supreme Court, while recognizing the
physically as well as mentally, in productivity. custodial rights of individuals in Supreme
Court Legal Aid Committee through Honorary
While dealing with Vincent v Union of India26, Secretary v State of Bihar and Others29 ruled
the Supreme Court held that a healthy body that it is the obligation of the police to ensure
is the very foundation for all human activities. appropriate protection of the person taken into
That is why the adage ‘Sariramadyam khalu custody, including medical care if such a
dharma sadhanam’. It is an obligation of the person needs it. The State of Bihar was
State to ensure the creation and the sustaining directed to pay a compensation of Rs.20,000
of conditions congenial to good health. to the legal representative of the deceased.
In Consumer Education and research Centre Liability on the Part of Philanthropic

v Union of India27, the Court ruled that the Institutions
right to health and medical care, to protect In A.S. Mittal and Others v State of Uttar
health and vigour, while in service or after Pradesh and others,30 the Supreme Court
retirement, is the fundamental right of a ruled that a mistake by a medical practitioner,
worker. The State, be it the Union or the State which no reasonably competent and careful
Government or an industry, public or private, practitioner would have committed, is a
is enjoined to take all such action that will negligent one. The Court further held that
promote health, strength and vigour of the maintenance of the highest standards of
workman during the period of employment aseptic and sterile conditions at places where
and leisure, and health even after retirement, ophthalmic surgery, or any surgery, is
as basic essentials to live life with health and conducted cannot be over emphasized. It is
happiness. Denial thereof denudes the not merely on the formulation of theoretical
workman the finer facets of life violating Article standards but on the professional
21. commitment, with which the prescriptions are
implemented that the ultimate result rests.
While highlighting the importance of Directive However, the standards of cleanliness and
Principles, the Supreme Court repeated its hygiene in public hospitals leave a lot to be
stand in Kirloskar Brothers Limited v desired. Owing to a general air of cynical
Employees State Insurance Corporation.28 It irreverence and compliance with the
observed that in expanding economic activity continuing deteriorating standards the very
in a liberalised economy Part IV of the concept of standards and the imperatives of
Constitution enjoins not only the State and their observance tend to be impaired. The
its instruments, but even private industries remedy lies in a strict adherence to the virtue
to ensure safety to the workman and to provide of method, and the laying down of practical
facilities for the health and vigour of the procedures in minute details and by exacting,
workman, as assured in relevant provisions not merely expecting, strict adherence to these
in Part IV, which are integral parts of the right procedures. The Court held that the State
26
AIR 1987 SC 990
27
AIR 1995 SC 922
28
{1996} 2 SCC 682
29
{1991} 3 SCC 482
30
AIR 1989 SC 1571

S. V. Joga Rao
Government should afford the victims some person’s right to be informed.

monetary relief in addition to the sum of
Rs.5,000 already paid by way of interim relief. The Court held that the right to privacy is an
The State Government was directed to pay a essential component of the right to life as
further sum of Rs. 12,500 to each of the provided by Article 21. This right however, is
victims. not absolute and may be lawfully restricted
for the prevention of crime, disorder, or
Right to Privacy (as a component of protection of health or morals or protection of
healthcare) right and freedom of others. The Court further
The Supreme Court of India, in Mr. A v held that having regard to the fact that the
Hospital Z,31 observed that the right to privacy appellant was found to be HIV positive, its
has been culled out of the provisions of Article disclosure would not be in violation of either
21 and other provisions of the Constitution the rule of confidentiality or the appellant’s
relating to Fundamental Rights read with right to privacy, as Ms. W, whom the appellant
Directive Principles of State Policy. In several was likely to be marry, was saved in time by
judgements, the Supreme Court has made such disclosure. She would have been
attempts to trace the origin of the ‘right to infected with the dreadful disease had the
privacy’ and it was ultimately laid down as marriage taken place and been consummated.
under:
Subsequently, in response to an interim
Depending on the character and the application filed for clarification, the Supreme
antecedents of the persons subjected to Court32 held that, the appellants’ right was not
surveillance, as also the objects and the affected in any manner in revealing his HIV
limitation under which surveillance is made, status to the relatives of his fiancée.
it cannot be said that surveillance by
domiciliary visits would always be Right to Health of the Mentally Ill
unreasonable restrictions upon the right of While dealing with complaints related to the
privacy. Assuming that the fundamental rights functioning of Ranchi Mansik Arogyashala,33
explicitly guaranteed to the citizen has the Supreme Court held that the running of a
penumbral zones and that the right to privacy mental hospital was part of the State’s
is itself a fundamental right, that fundamental obligation to its citizens. The State
right must be subject to restrictions on the Government has to realise this obligation by
basis of compelling public interest. running the hospital in a perfect standard and
by serving the patients in an appropriate
The right to privacy may arise out of a manner. It was directed that the quality of
particular relationship, which may be hospitals should improve and patients should
commercial, matrimonial or even political. The have the benefit of modern scientific treatment
doctor-patient relationship, though basically keeping in mind the fact that the methods
commercial, is professionally a matter of adopted for the treatment of the mentally ill
confidence and therefore, doctors are morally have undergone many rapid changes.
and ethically bound to maintain Adjudging that a hospital is not a place for
confidentiality. In such a situation, public cured people to stay, it was found necessary
disclosure of even true private facts may that a rehabilitation centre should be
amount to an invasion of the right of privacy, established for those persons who, after
which may sometimes lead to the clash of one getting cured, are not in a position to return
person’s right to be alone with another to their families or seek employment.
31
{1998} 8 SCC 296
32
2002 SOL Case No. 657
33
AIR (1989) SC 348

Similar concerns have been expressed by the health as follows:

Supreme Court in connection with recent
incidents happened at Erawadi. “In a series of pronouncements during recent
years this Court has culled out from the
Protection Against Injurious Drugs provisions of Part IV of the Constitution these
New and emerging diseases, combined with several obligations of the State and called upon
the rapid spread of pathogens resistant to it to effectuate them in order that the resultant
insecticides, are major challenges to human pictured by the Constitution Fathers may
health. To meet these challenges, new drugs become a reality. As pointed out by us,
have to be found. However, the Central maintenance and improvement of public
Government, by Section 26 A of the Drugs and health have to rank high, as these are
Cosmetics Act, 1940, is empowered to indispensable to the very physical existence
prohibit, in public interest, the manufacture, of the community and on the betterment of
sale or distribution of any drug that is likely these depends the building of the society of
to involve any risk to human beings or animals which the Constitution makers envisaged.
or if it does not have the claimed therapeutic Attending to public health in our opinion,
value. therefore, is of high priority-perhaps the one
at the top.”(p. 995)
In Vincent v Union of India,34 the petitioner
challenged the drug policy of the Government. On Quality of Blood for Transfusion
Directions were sought from the Supreme Transfusion of blood can at many times saves
Court for banning import, manufacture, sale the life of a patient, but it can also take away
and distribution of drugs, which were that life, if the transfused blood is
recommended for banning by the Drugs contaminated. In Part XII- B of the Drugs and
Consultative Committee, and for cancellation Cosmetic Rules, 1945 provisions are made to
of the licences authorising such drugs. The regulate blood collection and storage by
respondents contended that the matter of prescribing the equipment and supplies
public health is incorporated only in the required for a blood bank.
Directive Principles and so they are not
enforceable before a Court of law. The In connection with a Public Interest Litigation35
Supreme Court observed that the Central highlighting serious deficiencies in the matter
Government should adopt an approved of collection, storage and supply of blood
national policy and prescribe an adequate through various blood centres, the Supreme
number of formulations that would meet the Court constituted a committee to examine the
requirements of the people. Injurious drugs schemes suggested by the petitioner and the
must be totally eliminated from the market. Union of India. The Court held that the
Drugs that are found to be necessary must be Government should take suitable action for
manufactured in abundance and must be the implementation of the plans suggested by
made available to the needy. The prices of the the committee and gave the following
drugs should be regulated. For every illness directions:
that can be cured by treatment, the patient
must be in a position to get medicine. This is i) The Union of India should establish
an obligation on the State in view of the National Council of Blood
Directive Principles of State Policy that Transfusion, a registered society to be
constitute Part IV of the Constitution. The funded by Government of India, with
Court asserted the significance of public empowerment to raise its own funds.
34
AIR 1987 SC 990
35
(1996) 1 SCC 753

S. V. Joga Rao
ii) The State Governments should Responsibilities of Municipalities and

establish State Councils in Panchayats
consultations with the National Article 242-W of the Constitution provides that
Council. the legislature of a State may endow the
iii) The activities of the National and municipalities with such powers and authority
State Councils should include as may be necessary to enable them to
launching of effective motivating function as institutions of self-government for
campaigns for voluntary blood the performance of functions and
donations, launching programmes of implementation of schemes including (as per
blood donations in educational the Twelfth Schedule) those related to public
institutions, among the labour, health, sanitation conservancy and solid waste
industry and organisations of various management. Duties of the local authorities
services including civic bodies and in such spheres include establishment and
training of personnel in relation to maintenance of dispensaries, expansion of
operations of blood collection, storage health services, regulating or abating offensive
and utilisation. or dangerous trades or practices, providing a
iv) The National Council should conduct supply of water, potable and sufficient for
training programmes, establish preventing danger to the health of the
institutions for research in collection, inhabitants from insufficiency or the lack of
processing, storage, distribution and quality of the existing water supply, public
transfusion of human blood and its vaccination, cleaning public places and
components. removing harmful substances, disposal of
v) The National Council should start night soil and rubbish, providing special
special postgraduate courses in medical aid and accommodation for the sick
medical colleges in blood collection, in times of dangerous diseases, taking
storage, transfusion etc. measures to prevent the outbreak of
vi) The Government of India should communicable disease etc. Alliances between
make donations to the National and the local government authorities and the State
State Councils tax-free. Government are crucial in the matter of
vii) The Government must ensure that promoting public health.
the blood banks operating in the
country are duly licensed every year. On Medical Negligence
viii) Professional donor system should be The patient has a right to be treated with a
eliminated in two years. reasonable degree of care, skill and knowledge.
A mistake committed by a medical
Welfare of Children practitioner, due to carelessness and lack of
In Sheela Barse (II) v Union of India,36 the competency, will be termed as negligence. In
Supreme Court held that the Nations’ children Dr. L.B. Joshi v Dr. T.B. Godbole, 37 the
are very important assets. Children’s Supreme Court held that a person who holds
programmes should find a prominent part in himself ready to give medical advice and
our national plans for the development of treatment implies that he has enough skill and
human resources, so that our children grow knowledge for the purpose. He owes a duty of
up to become physically fit, mentally alert and care to the patient in deciding whether to
morally healthy citizens, endowed with skill undertake the case and what treatment to
and motivation needed by the society. give. A breach of such duty gives a right of
36
AIR (1986) SC 1773
37
AIR (1969) SC 128

action to the patient for negligence caused by and efforts are to be made to sustain the same.
the doctor. In a country like ours, it may not be possible
to sophisticated hospitals, but definitely
The Supreme Court has held that the fact that villagers of this country within their limitations
doctors are governed by the Indian Medical can aspire to have a primary health centre.
Council Act and are subject to the disciplinary The Government is required to assist people,
control of the Medical Councils does not offer and its endeavour should be to see that the
any comfort to a person who has suffered due people get treatment and lead a healthy life.
to negligence and such a person has a right Healthy society is a collective gain and no
to seek redress. The service rendered to a Government should make any effort to
patient by a medical practitioner (except where smother it. Primary concern should the
the doctor renders service free of charge to primary health centre and technical fetters
every patient or under a contract of personal cannot be introduced as subterfuges to cause
service), by way of consultation, diagnosis and hindrances in the establishment of health
treatment, both medical and surgical, was held centre”.
to fall within the fold of “service” as defined
in Section 2(i) (O) of the Consumer Protection Accordingly, appropriate directions have been
Act, 1986. issued by the High Court mandating the State
Government to forthwith establish the primary
State’s Duty to Establish PHCs health centre.
In this case, the petitioner an ex-sarpanch of
a gram panchayat has approached the High Right to Health: Contradictions and
Court seeking issuance of appropriate Critique
direction to the State of Orissa to establish
We have briefly dealt with relevant and
and run a primary health centre.
applicable Constitutional provisions and legal
enactments regarding health as the subject
On the basis of demands of the local people
matter, as well as focussed on judicial
and public at large, the Government of Orissa
interpretation of right to health in diverse
decided to open certain primary health centres
contexts. A critical perusal of these parts
in selected areas. They accordingly issued a
clearly indicates the premise oriented
notification, wherein it was stated that the
required and identified facilities must be contradictions, which may be explained in the
provided by the concerned gram panchayat following way.
for the purpose of establishment and running
of the said primary health centres. In respect of health, Constituent Assembly
Debates (CAD) reveal the nature of
Despite substantially complying with the said deliberation and its unambiguous stand
requirements, the authorities concerned have reflecting health as a matter of governance
not shown any initiative in materialisation of rather than an individually claimable or
the project. enforceable right. In fact, the documented
debate requires to be comprehended in the
In response to the writ filed, the High Court context of the then existing global and
held that, “Life is a glorious gift from God. It ideological preference to civil and political
is the perfection of nature, a masterpiece of rather than to socio-economic rights. Perhaps
creation. Human being, is the epitome of the this is the reason why health related goals and
infinite prowess of the divine designer. Great targets have become subject matters of
achievements and accomplishments in life are directions under Directive Principles of State
possible if one is permitted to lead an Policy in our Constitution rather than
acceptably healthy life. Health is life’s grace enforceable individual rights as envisaged

S. V. Joga Rao
under the chapter of fundamental rights. in the present day affairs. With the forces of
Accordingly, health as an attainable goal was liberalisation and market economy, the role
construed more as an outcome of collective and responsibility of the State with regard to
endeavour of the State’s Governance, but not health has started withering to a substantial
as a consequence of an enforceable individual extent. Where do we draw the line? Does that
fundamental right. mean the State has no role whatsoever (except
for regulatory purposes) in the health sector
To a pointed question as to why Directive in a market economy? Such a significant issue
Principles of State Policy were made requires detailed debate.
unenforceable in or before a Court of law, Dr.
Ambedkar, purportedly responded by saying This is the backdrop in which, the Supreme
that the concerned government will be Court of India in the year 1997 has
unseated by the electorate, should there be pronounced that right to health is a
any failure in implementing these directives. fundamental right. After a gap of nearly 48
Paradoxically, this directive itself draws its years, Supreme Court felt the need for
strength from a very weak assumption that Constitutionalising the right to health as a
Indian society is a vigilant body when it fundamental right. From then onwards, in bits
participates in electoral processes in a and pieces, judicial intervention has come
democratic set up. This is a myth. The last about with regard to the right to health.
fifty years of governance has proved it beyond
reasonable doubt. Far from unseating In this respect also, there appears to be a
governments from political power, the issue contradiction of sorts. What do we mean, when
of public health has till date never acquired we say right to health?
centre stage status in public discourse.
Naturally, owing to this fact, implementation The term “health” is a very subjective one. It
of these constitutional directives has become can mean different things to different people.
more a matter of political discretion rather There are people who consider themselves
than governments’ mandate. healthy if they do not have any disease or
disability. Some people with only minor
While sensing this, the judiciary in its own troubles may perceive themselves to be in poor
way explored remedial measures of extracting health in case their concept of health involves
State’s accountability by a two-fold approach. a higher degree of well being. Certain other
On one hand, started liberalising the narrow people, who have any disease or disability,
contours of locus standi resulting in public may, in spite of these problems, term
interest litigation and on the other, judicially themselves healthy if they are able to manage
enforcing select unenforceable directive their condition so that it does not have any
principles on par with fundamental rights. The great adverse impact on the way they live.
first approach enabled the judiciary to pave
the way for pronouncing and recognising The main focus of the health care sector has
unenumerated fundamental rights. The often been the presence or absence of
second approach underscored the need for sickness, disease, injury and disability among
meaningful implementation of directives in the the population. However, this does not
overall community interest. Apart from this, constitute the whole picture. According to the
it also sent signals to the States on their role World Health Organization, health is “a state
in governance oriented accountability. of complete physical, mental and social well-
being and not merely the absence of disease
This is why the directives on health have never or infirmity”. This definition extends the notion
found political favour in our context leading of health to add to it a sense of positive well
to absolute adhocism and tokenism resulting being.

There are many dimensions to the concept of system more vulnerable to disease. People’s
health– physical, mental and social. During outlook on life can affect lifestyle choices,
times of difficulty, strengths in one particular which, in turn can influence the status of their
area of health may be counted on to health.38
supplement weaknesses in other areas. For
example, the physical ill health experienced If this is the prevailing and acceptable
by older people can be, at least partly, understanding as to what constitutes health,
balanced by positive reserves of mental health, the judicial interpretation of right to health
and/or a supportive social environment. Two as a fundamental right poses more challenges
major dimensions of health are discussed than it seeks to resolve when it comes to
below: meaningful and realistic enforcement of the
right to health. Let me explain further.
Physical Health
Physical health is associated with the Naturally, this kind of understanding takes
functioning of the physical body. There are within its fold umpteen dimensions which
many diseases, injuries and disabilities that logically forms part of the judicial
can affect the functioning of the human body. interpretation. For instance, in an
Every disease has its own features and innumerable number of studies, it has been
processes and knowledge of these becomes documented in our own socio-economic
important in dealing with the health of context that lack of potable drinking water is
individuals affected by them. the root cause for many of our health hazards.
Undoubtedly, if governance takes appropriate
Mental Health measures to provide potable drinking water,
The term mental health relates to the millions of our population will be saved from
emotions, thoughts and behaviour of people. related illnesses. Unhesitatingly, failure
Normally, a person with good mental health amounts and constitutes infringement of ones
is able to take care of day-to-day events and right to health. Whether our judiciary will be
obstacles, work towards goals, and function able to reiterate this stand is the most question.
effectively in society. However, even minor
mental health problems can affect every day Similarly, in case of healthcare, delivery
activities so that individuals are not able to centres in the form of primary health centres,
function, as they would wish to, or are a lot needs to be done to make them accessible
expected to, within their family and to cater to health needs.
community. More serious and long-term
mental health disorders may be diagnosed in Again, availability of affordable and essential
an individual when he or she reaches a specific drugs is another related sphere, which
level of personal activity centred dysfunction. warrants immediate attention from the State.
These two dimensions of health – physical and Will the judiciary be able to provide remedies
mental, interact with one another. People with for these omnibus kinds of problems that
illness or disability may often feel depressed constitute essential facets of health? Any
or anxious about their condition. On the other attempt in this respect will naturally attract
hand, positive emotions may contribute to a criticism against the Judiciary claiming
person’s ability to recover from disease, while trespass into executive functions of State
unhappiness or the lack of a strong sense of governance. Ultimately the focus boils down
purpose may be factors that make the immune to budgetary allocation of resources which is
38
“Health”, Measuring Wellbeing: Frameworks for Australian Social Statistics, Statistical Concepts Library, Australian
Bureau of Statistics, 2001.

S. V. Joga Rao
a matter of political prioritisation in our ultimately paves the way for

democratic set up which is always considered incorporation into our Constitution as
as a prerogative of political authority. No a fundamental right.
doubt, the judiciary in its own way, recognised
and reiterated the compulsive role and Focus on Right to Healthcare
responsibility of the State particularly with Essential components of the right to
regard to public health, in different contexts. healthcare must include a) appropriate
However, these singular efforts have failed to infrastructure in the form of primary health
bring about the desired social change in its centres with attendant basic facilities; b)
larger perspective. It is known that every time skilled human resources like medical
when action is needed, the State expresses professionals and other health care and
its inability owing to constraints of a financial paramedical staff rendering required range of
crunch or crisis. services; c) medicines and supplies which are
basic and essential; d) emergency medical
Or even if a contextual attempt were made, it care; e) patient information, redressal and f)
would remain more as rhetoric without any monitoring and professional accountability.
practical enforcement. In other words, either
way, the ultimate purpose may not be served. Out of all the pronounced judicial
What then needs to be done? interventions in respect of health and health
care, instance of Orissa High Courts’
" Strategically, it is desirable to direct the pronouncement deserves our attention.
judicial focus to health care rather than Following can be discerned from the
health as such. Scope and ambit of judgement.
health care is relatively narrower than
health, amenable to meaningful " specific judicial order directing the State
implementation of judicial orders. Government to establish and run primary
Accordingly, specific and precise health care centres. In addition,
dimensions or facets of health care emphasising the significance of such
must be clearly spelt out. In addition, measure in our socio-economic context.
wherever it is required, efforts must be Neither a rhetoric or populist observation
made to strengthen already existing nor a non-implementable direction;
statutory guidelines or mandates or " such mandate was made possible because
applicable judicial orders. This is the of the existing framework that underscores
first step. the participatory role of local self-
" Secondly, instead of focussing government. In other words, if the local
exclusively on judicial intervention and government succeeds in its task, through
remedies, it is necessary to initiate the judicial intervention, pressure can be
appropriate processes to sensitise the brought against the State to implement the
political authorities as well. This framework. Hence, it is necessary for us to
requires a concerted action to bring focus on generating such frameworks
health care within political discourse. contextually. This is absolutely possible
Collective efforts must be made to because, in several States, Ministry of
convince political leaders about the Health and Family Welfare has already kept
mileage that health issues can draw in in place such proposals by framing relevant
the political processes. rules and regulations. Efforts must be made
" Thirdly, attempts must be made to to infuse life into such proposals by
legislate the right to health care with garnering and mustering strength from the
all its essential components, which local communities;

" this is made possible on account of another Right To Health Care: Prescription for a Way
reason i.e., specificity in seeking judicial Forward
intervention which can be implemented in Accessible and affordable health care services
a given context and community. Efforts is our goal. In the light of our own experiences,
this goal requires the following processes.
must be made more at a decentrtalised and
community level in seeking judicial " instead of focussing on right to health
intervention and implementation of those as a fundamental right it is desirable
measures. to confine the debate to action for a
" contextually, this can be construed as an right to health care;
appropriate tool for initiating political " efforts must be made to realise and
process as something, which the achieve meaningful implementation of
community longs to have, can be achieved already pronounced judicial orders
in a very tangible sense. pertaining to the right to health care;
" community support supplemented by
political processes must be given
No doubt, this intervention only relates to the
attention to drive home the need for
establishment of a primary health centres, but placing health care as an issue in our
this approach renders direction to us to public life;
replicate such precedents suitably customised " statutory formalisation of right to
and tailor-made to the context concerned, and health care must be lobbied either with
move forward in meaningfully achieving other the help of judicial intervention or
facets of health care as well. political prioritisation or both.

Availability Of Drugs In India
S Srinivasan
Overall Drug Scenario AIDS drug pricing in South Africa, the poor
The drug (medicines) availability situation average Indian finds the costs of drugs
in India is one of poverty amidst adequacy – unaffordable. For many, getting sick in India
there is poverty of supply of even essential and buying medicines is a sure route to
drugs to the poor despite adequate drug further impoverishment and penury3. Many
production. The Indian pharmaceutical people are forced to sell their cows, buffaloes
market, with estimates for annual domestic and even their homes whenever they try to
sales ranging between Rs. 200 to Rs. 400 access health services. Health care is the
billion rupees (US $ 40-80 billion), implies second leading cause of indebtedness in rural
that per capita annual ‘availability’ of drugs India.
is now Rs. 200 to Rs. 400. Probably, the
actual sales are at least Rs. 300 per capita Drugs are overpriced and unaffordable – let
at 2003 prices. 1 The government quotes there be no mistake about it, even though
lower figures. But it should be borne in mind some of them may be the ‘cheapest’ in the
that as per the ORG data, the total moving world. We will show below that the margins
annual turnover from the retail sales of 300 are extremely high in drug pricing and that
brands alone is a whopping Rs. 19,000 more ‘players’ in the drug business has not
crores2. The ORG data does not take into resulted in lower drug prices.
account institutional and governmental
purchases, which would also be of very How many drug units are there and how
considerable magnitude. Nor does it take many formulations are made in India? As
cognisance of the black market or the against the frequently quoted figure of about
various “schemes”, which are not in reality 20,000 manufacturing units, the actual
billed. number of drug manufacturing licenses
issued was - bulk drugs (1333), formulations
Even as large Indian drug companies make (4534), large volume parenterals, (134) and
international pharma majors rue about HIV/ vaccines (56). The total number of
1
This figure, at variance from Government of India’s own figures of US $ 3.5 billion, is in an August 2003 letter
from the WHO to the Mashelkar Committee and quoted by the latter in its report. The WHO letter went on to
assure that “the majority of the Indian pharmaceuticals are produced by large manufacturers according to WHO
Good Manufacturing Practices (GMP).” This figure has to be seen in the context of another figure: India produces
8% of the drugs available in the global market in terms of volume but the domestic market is valued at less than
1% of the global market.
2
ORG Nielsen Data as of Oct 2003. The retail audit gives figures that are not really retail sales but price to the
retailer from the wholesaler/stockist.
3
The Reserve bank of India (RBI) Rural Indebtedness survey of late eighties showed that amongst non-production
loans healthcare was the first reason and amongst all loans it was the 2nd reason for indebtedness. The 52nd NSS
Round on morbidity, utilisations and expenditure records indebtedness due to hospitalization. NSS 42nd and
52nd round and various other surveys show that between 15-40% of reported morbidities were unattended because
of economic reasons. The Rural Labour Enquiry Report On General Characteristics Of Rural Labour Households
(55th Round Of N.S.S.) 1999-2000 shows that men (women) on the average worked for 222 (122) wage days in a
year and lost 31 (77) days in a year due to sickness. See http://labourbureau.nic.in/
RLE992k%20GenChar%20Annex%20I.htm. The average earnings for all households for men ranged from Rs. 40
to Rs. 54 (Rs. 28 to Rs. 34 for women) and at least 25 percent of rural households were indebted at any point of time.

manufacturing units engaged in the inadequate public health sector. It has been
production of bulk drugs and formulations estimated that about 30 per cent of
is not more than 5877.4 According to the morbidities are left unattended due to
Director, National Pharmaceutical Pricing poverty.7
Authority of the Government of India (NPPA),
the number of APIs (Active Pharmaceutical A district level detailed exercise - in Satara
Ingredients) used is 550, APIs manufactured district, Maharashtra - a decade ago - had
is 400, and formulations marketed are shown that in 1991-92, if the per capita
20,000 under 8000 brand names.5 The NPPA availability of Rs. 100/- per year (1991-92
monitors about 20,000 formulations. 6 prices) were to be rationally and equitably
Although NPPA monitors only 8000 brands used, all the drug-needs of the people for
in 20,000 packs, the actual number of primary level care would have been met.8
brands in the market would be higher. Even Though the consumer price index has doubled
if we assume that on an average each of since then, yet the per capita availability of
the 4534 formulators produce only 5 brands, drugs has increased by at least 50 per cent
the total number of brands would be about due to the explosive increase of drug
20,000. Many of the big companies have over production from Rs. 50 to 70 billion rupees
50 brands at a time. in 1992 to Rs. 200 to 400 billion rupees in
2003. However, availability of drugs for the
There has been a very rapid development of majority of the people remains poor due to
the drug industry in India, especially after the the deterioration of public health services on
Indian Patent Act 1970. As a result, the per the one hand, and on the other hand the
capita availability of drugs in India has continuing accelerated increase in drug
increased phenomenally during last 50 years prices9.
from Rs. 4 in 1948 to Rs. 300 in 2003, at
current prices. Even after deflating this figure In the coming pages, we will substantiate this
for price-rise, the rise is still considerable. conclusion of ‘poverty amidst adequacy’.
However, the tragedy is, a majority of the
people do not get adequate quantity and Poor Availability in the Public Sector
quality of drugs they need. There is great The proportion of out patient cases and
inequality in access to these drugs because hospital beds in the public sector is only about
of poverty, unnecessarily high drug prices due 20 and 40 per cent of the total respectively.
to unrestricted profiteering and a grossly Added to this is the increasing under supply
4
Besides there are 199 medical devices units, 638 surgical dressings and 272 disinfectant units, 4645 loan licences
and 318 repackaging units, 1806 blood banks, 2228 cosmetics units and 287other units not covered in the above
categories. [Source: Mashelkar Committee Report (2003). Figures arrived at after soliciting information from each
FDA or equivalent of all states of India.]
5
Dr Appaji, Director, NPPA, at a WHO-SEARO workshop on “Medicines in SEA Region”, Chennai, Dec 22, 2003.
6
According to NPPA’s figures, 56 percent of these formulations available are based on a single ingredient bulk drug,
20 percent on 2 bulk drugs, 8 percent on 3 bulk drugs, 4 percent on 4 bulk drugs, 2.5 percent on 5 bulk drugs and
9.5 percent on 5 or more bulk drugs. Appaji as cited before.
7
See footnote 3 above.
8
For a complete summary of conclusions of the Satara Study by Phadke, et al, see: Phadke, Anant. Drug Supply
and Use: towards a rational policy in India, Sage Publications, New Delhi, 1998. Or see
http://www.locostindia.com/CHAPTER_2/Essential%20drugs_5.htm
9
See for example the article “Continuing Rise in Drug Prices- Brand Leaders Show the Way” by Wishvas Rane,
Economic and Political Weekly, July 24-30, 1999 at
http://www.epw.org.in/showArticles.php?root=1999&leaf=07&filename=352&filetype=html
Also see Rane’s “Have Drug Prices Fallen?”, Economic and Political Weekly, November 1 , 2003 at http://
www.epw.org.in/showArticles.php?root=2003&leaf=11&filename=6439&filetype=pdf

S Srinivasan
of drugs to the pubic health facilities. The available on MCGM schedule. These
Satara district study10 had shown that if all included antibiotics such as norfloxacin and
the patients coming to the primary health tetracycline, vaginal pessaries (used in
centres (PHCs)– 20 per cent of the total out treatment of reproductive tract infections),
patients in the community – were to be treated antispasmodics, anti-inflammatory drugs,
adequately, rationally, drug supply to the hormone based drugs, neuro-regulators and
PHCs would have to be almost doubled. drugs used for treatment of infertility. Most
However, instead of increasing the allocation common reason for non-availability of drug
to health, Maharashtra government’s health was “Not on MCGM schedule”.’11
expenditure declined from 1 per cent to 0.6
per cent of State Domestic Product, during Table 1
1985-86 to 2002-03. The proportion of Drug Monitoring Exercise at
Central Government’s expenditure on health the Secondary Hospital
care as a proportion of GDP, reduced from
n = 148 (%)
1.3 per cent to 0.9 per cent during the same
All prescribed medicines
period, while the WHO recommendation has
available at the hospital
been 5 per cent! Out of the total drug
pharmacy 29 (20 %)
consumption in India, only a very small
Some medicines or part
proportion is consumed in the public sector,
quantity available at the
which caters primarily to the poor and the
hospital 32 (22 %)
middle class. The situation was in any case
None of the prescribed
bad even a decade ago as seen from the Satara
medicines available at
district study. The drug-supply to the public
the hospital 74 (50 %)
sector in Satara District was a mere Rs. 5.6
Information not available 13 ( 9 %)
million, as compared to the most minimum,
reliable estimate of a drug sale of Rs. 213
million in the private sector during 1991-92. A review of the drugs listed in the Essential
Things have worsened since then thanks to Drug List (EDL) and comparison with the
the new economic policy in the 1990s, Drugs Schedules of MCGM for May 2001
expenses on public health as a proportion of ‘showed that, of the 264 drugs listed in the
government expenses has further declined. EDL, 140 (53%) were not available on the
MCGM drug schedules. Of the 123 drugs
A recent study in Mumbai substantiates these categorised in EDL as belonging to “U”
complaints. The Municipal Corporation of (universal) category, 50 (40.7%) were not
Greater Mumbai (MCGM) is probably the on MCGM Schedule.’12
richest such city level corporation in India and
the city of Mumbai is the pharmaceutical and Privatised Drug Accessibility
business capital of India. A drug monitoring Given such a poor, gross under supply of
exercise (see Table 1) at a secondary hospital drugs in the public health facilities, most
of the MCGM revealed ‘that a little more than of the drugs available in India are through
half (34 out of 60) the drugs prescribed for the market. This privatised drug
patients/clients seeking services at accessibility is quite problematic in view of
gynaecology out-patient clinic were not high levels of poverty and unrestricted
For a complete summary of conclusions of the Satara Study by Phadke, et al, see: Phadke, Anant. Drug Supply
10
and Use: towards a rational policy in India, Sage Publications, New Delhi, 1998. Or see
http://www.locostindia.com/CHAPTER_2/Essential%20drugs_5.htm
11
Anagha Pradhan, Renu Khanna, Korrie de Koning and Usha Ubale in “Quality Assurance in a Public Health System:
Experiences of Women Centred Health Project, Mumbai, India”, SAHAJ, Baroda, 2004
12
Anagha Pradhan, et al, op.cit.

profiteering by the drug-industry, combined High Priced Branded Drugs

with a lot of wastage of patients’ money on The second important cause of high prices
account of irrational fixed dose is that most of the drugs marketed in India
combinations and wastage on promotional are under brand names. Paracetamol tablet,
expenses (huge expenses on ‘promotional’ the simple medicine for reducing pain and
activities are necessary for the private fever costs around 13 paise to produce.
sector but it merely adds cost to the When sold under its brand name Crocin,
patient.) Let us first dwell a while on this Metacin, Calpol, etc., the same tablet costs
phenomenon of irrational drug four to fives times the cost price! The not
combinations. for profit Baroda-based NGO, LOCOST, sells
it at Rs 1.60 per strip of 10 tablets.
Irrational Drug Combinations
Out of about 1500 scientifically proven drugs The price of the brand can vary very widely,
mentioned in standard medical textbooks, depending upon various marketing
a little less than 400 are Essential Drugs. considerations and has no relation to the cost
Out of these 400, only about 40 are rational of production. Table 2 demonstrates this in
fixed dose combinations (like iron-folic acid, case of amlodipine, an antihypertensive drug
oral rehydration salt, co-trimoxazole, etc.) (drug for high blood pressure). It shows that
recommended by standard textbooks. All there is an 862 per cent difference between
other fixed dose combinations are the cheapest and the costliest in a drug with
at least 40 formulators. The multinational
irrational. In India, all available studies
has the drug with the maximum price. Similar
show that most of the fixed-dose
examples abound in other drugs.14
combinations studied were irrational.13 In
these irrational combinations, there
Table 2
generally is one drug that is useful,
Different Prices of Amlodipine15
whereas others are unnecessary additions.
These additions unnecessarily increase Brand name Company Price per tab.
prices; add to the task of quality and price of 5 mg*
control as well as side effects. These Amlogard Pfizer Rs. 4.81
irrational fixed dose combinations are an Stamlo Dr. Reddy’s Rs. 2.47
important cause of unnecessarily high drug Amlogen Alkem Rs. 1.20
prices, which in turn act as a barrier to Amlodac Alidac Rs. 0.50
access to drugs for poor people. Source of prices: April-June 2002 edition of CIMS
13
See for instance: Pharmaceuticals: Restrictions in Use and Availability (WHO/EDM, 2001); Guide to good
prescribing: A practical manual (WHO/EDM, 1994); WHO Policy Perspectives on Medicines 2002, June: The
Selection of Essential Medicines (WHO/EDM, 2002); The Use of Essential Drugs: Ninth Report of the WHO Expert
Committee (WHO/EDM, 2000). See also for analyses of Indian situation prevailing:
a) Desai, S.V. 1990. ‘Anaemia and Oral Haematinic Preparations’. Drug Disease Doctor; Vol. 3, No. 2.
b) Desai, S.V. and R.S. Desai. 1991. ‘Rational Cough Mixtures: Analysis of Proprietary Preparations’. Bulletin
of Society for Rational Therapy, Vol. 3, No. 5.
c) Modak, Shishir. 1984. Rationality Analysis of Anti-diarrhoeal Preparations. Medico-Friend Circle, Pune.
d) Phadke, Anant. 1985 ‘Scientific Scrutiny of Over the Counter Drugs’. Medical Service, Oct-Nov, pp. 30-42.
e) Phadke, Anant and Deepak Deshpande. 1992. ‘A Review of Haematinics Marketed in India’. Drug Disease
Doctor. No. 28, pp. 88-92.
f) Rane, Wishwas. 1994. ‘Ayurvedic Drug Formulations: Are They Rational?’ Paper Presented at the IOCU-
ACASH Workshop on Consumer Education, Drugs and Media, April 3-4, Bombay, p.5.
g) Uhrig, Jamie and Penny Dawson. 1985. A Rationality Study of Analgesics and Antipyretics. Medico-Friend
Circle, Pune.
14
See Bhargava, Anurag , “Tremendous Variations in Drug Prices in the Indian Pharmaceutical Market” in
LOCOST (2004), op.cit.
15
Courtesy Anurag Bhargava for Table 2 as also for reference in footnote16.

S Srinivasan
A study published by Roy and Rewari in the are effectively denied access even to life-
Indian Journal of Pharmacology 16 that saving drugs.
surveyed the variation in prices of 84
formulations used in the management of Decontrol of Drug Prices
cardiovascular diseases in the Indian market Medicine is a unique commodity. Consumer
concluded that variation in prices ranged from resistance is lowest here as a suffering patient
2.8 per cent to 3406 per cent. is in a compromised physical, mental
framework and is ready to pay excessively to
The same drug company prices the same drug get relief. The prescriber does not pay and
under different brand names at different the buyer does not decide if and which
prices, sometime the drugs are ‘positioned’ in medicine to buy.
the same state for different market segments.
For example cefuroxime tablets are Further, in India, in absence of any regulation
manufactured by GSK under the brand names of the medical profession or the drug industry
of Ceftum and Supacef at different prices - the individual consumer is more vulnerable
Rs. 80.91 and 63.01 respectively for 125 mg than in, say, Western Europe, where it is the
tablets and Rs. 150.34 and 144.94 publicly funded powerful health insurance
respectively for 250 mg tablets. Similarly system that negotiates the prices with the
ciprofloxacin 250 mg Tablets are drug-companies. Hence to protect the
manufactured by Lupin under the brand interests of this vulnerable group, drug prices
names of Ciprova and Lucipro 250 at different should be under control. But during the last
rates of 41.79 and Rs. 31.62 respectively. 15 years, the Indian government has reduced
Again, gentamycin injection by PCI sells as price-controls drastically, exposing the patient
G-Mycin and Gentasporin at Rs. 6.80 and 7.68 to the profiteering of the drug-industry.
respectively.
Table 3 shows that the number of drugs
Since the consumers are not aware that these under price control have progressively
different branded products contain the same decreased from 347 in 1979 to 76 in 1995
medicines and anyway, it is the doctor who and the margin allowed on even ‘essential
decides which brand to prescribe, they do not drugs’ under price-control has increased
even know that they have been cheated! All from 40 per cent to 100 per cent. The drugs,
medical textbooks and other health which have been taken out of price-control,
authorities naturally deal with only generic have shown a higher price-rise than those
names. The government can decide that all under price-control. Earlier there were
drugs will be sold only under the generic categories and the more essential had
name, with the drug company’s name in lesser profit margins. For instance in the
brackets. This will enable patients to 1987 drug policy there were two categories:
compare prices of the same drug being Category 1 were those drugs required for
marketed by different companies. On the the National Health Programme and the
other hand, doctors while prescribing can MAPE (maximum allowable post
choose between companies depending upon manufacturing expense) incurred from the
the reputation of the company. In 1975, the stage of manufacturing to retailing and
Health committee had recommended a manufacturers’ margin allowed for drugs in
process of beginning the process of abolition this category was 75 per cent; Category II
of brand names. But this recommendation were drugs other than those in category I
was not implemented. Thanks to higher but which are also considered essential for
prices of branded drugs, many poor people health needs and a MAPE of 100 per cent
16
V. Roy, S. Rewari (1998). “Ambiguous Drug Pricing: A Physician’s Dilemma”. Indian Journal of Pharmacology,
30: 404-407.

for formulations was allowed while fixing and out-patient drugs. The price regulations
the prices for this category of drugs. are used as an instrument to keep their
health budgets within reasonable limits. In
It was the stated aim of the Pharmaceutical these countries, a substantial proportion of
Policy of 2002 (henceforth PP 2002) to reduce the population is covered through health
the ‘rigors of price control’. It was widely insurance and public health schemes. As a
expected by industry that only about 30 to result, the consumers are not affected
34 drugs would remain under price directly by the high prices of drugs or high
control.17 costs of medical services, but are made to
pay for the increased prices/cost through
Even the so-called free market countries of high insurance premium. As opposed to this,
the EU and UK have some form of controls a substantial proportion of the population
– price controls, volume controls and cost- in India is market dependent and have to
effectiveness controls. Twelve out of 16 West meet all their expenses out of their own
European countries control prices of drugs pocket on this account, making price
directly. Even the Report of the Government regulation of pharmaceutical products in
of India’s Drug Price Control Review the market unavoidable.”
Committee (DPCRC) noted that:
Nevertheless the Government has chosen
“…in most other countries, the regulation to ignore this advice as evidenced by its
of the drug prices is considered necessary intentions to ‘lessen the rigors of price
to contain public expenditure due to control’ in Pharmaceutical Policy 2002. The
government’s role in funding social health Policy of 2002 itself is riddled with illogic
and insurance schemes that cover hospital as pointed out in a Supreme Court Petition
Table 3
Comparative Chart Summarising Price Control Scheme under Various (DPCO)
Drug Price Control Orders
DPCO 1979 DPCO 1987 DPCO 1995 Present
Mar 2004
1 No of drugs under Price Control 347 142 76 74
2 No. of categories under which the
abovedrugs were categorised 3 2 1 1
3 MAPE % allowed on normative/
National ex-factory costs to meet
Post-manufacturing expenses and
to Provide for margin to the mfrs.
Category I 40% 75% 100 % 100%
Category II 55% 100% N.A.
Category III(Single ingredient 100% N.A. N.A.
Leader products)
4 Total Domestic pharma sales 90 % 70 % 50 % —
covered under Price-Control
(Approx.)
N.A. = Not Applicable
The Karnataka High Court had stayed the pricing part of the policy that would lead to further decontrol and the
17
matter is now in the Supreme Court pending appeal by the Government of India.

S Srinivasan
by AIDAN and others18 and would result in on market share it shows that for most of
reducing the basket of price control to less the products, around 40–50 per cent of the
than 30. We show below - briefly - how the market is cornered by the leading 3-4
policy’s assumption that competition and products. This happens in almost all the
free market works to bring down prices and products. All the drugs mentioned in the
make drugs abundantly available is not table are antibiotics and antibacterials of
tenable, especially in the absence of well- one kind or the other. All but one namely
functioning public health services and/or cephataxime will be out of price control as
universal access to health insurance. per PP 2002.
Competition Does Not Always Lead to In all these (that is the drugs for instance
Lowered Prices cited in Table 4) we find that the top-selling
The basic premise of removing price controls brand of a particular category often is also
has been that competition will lower prices one of the higher priced and usually is the
and that a free market exists now that we are highest priced. The brand leader is also the
in a post-liberalisation era, at least freer as price leader. If true competition and free
compared to earlier times. For example the market characteristics were present, the
document Modifications in Drug Policy 1986 brand leader, that is the top selling brand,
had this criteria: ‘Drugs in which there is
would almost always sell at the lowest
sufficient market competition viz. at least 5
prices. The conclusion to be drawn is that
bulk drug producers and at least 10
competition does not always work in
formulators and none having more than the
pharmaceuticals in the retail market in
40% market share in the Retail Trade (as per
bringing down the prices, especially when
ORG) may be kept outside the price control.’
there are many players, and therefore price
control is necessary. Competition seems to
In reality prices of drugs have been
constantly on the rise.19 work in bringing the price of the monopoly
producer in the early stages of the product
There is no free market operating in the area life cycle of a drug formulation. But when
of medicines, in pharmaceutical industry and the company knows that the sensibilities
in health and hospital services sector. The of the consumer/patient can be played upon,
buyer/end user namely the patient has no then the same drugs are priced to attract
choice. Informed choice involving techno- the high-end consumer.
scientific issues is not possible for the lay
consumer. Instead it is the doctor/prescriber For competition to work, a referee is needed
who makes the choice for the consumer. The in the form of an efficient regulatory agency
consumer has no easy way of evaluating with teeth – an agency that responds to
doctor’s prescriptions and advice. Both these market signals with alacrity. (The fact that
assumptions – of a free market and that of competition does not lead, necessarily, to
competition reducing prices – are lowered prices in the pharma sector has
contestable. been acknowledged by no less than a former
chairperson of the National Pharmaceutical
Table 4 gives further justification of our Pricing Authority, Mr Arun Kumar. See
assertion of weak and imperfect interview with Shri Arun Kumar, The
competition. If we go through the column Economic Times, Sept 5, 2000.)
18
AIDAN and ors. Versus Union of India in the Supreme Court of India–WP (Civil) 423/ 2003). See also for
arguments of the case summarized in Impoverishing the Poor: Pharmaceuticals and Drug Pricing in India, LOCOST,
and Baroda, 2004. Hereafter LOCOST, 2004.
19
Rane, op.cit, footnote 6.

Table 4
Antibiotic Brand Leaders, Market Share and Price Behaviour: A Brief Overview
Drug Product Market Brand Name Market Product Remarks
Turnover of Product Share of Leader is
of Product Leader (s) Product Price
in Rs. Leader Leader?
crores (in %)
Cefataxime Injection 122 Taxim 63% Yes
Ceftrioxone Injection 136 Monocef 35 % No Price Leader is
Becef
Cefuroxime Tablets 13 Ceftum 38 % Yes
Cephalexin Capsules Phexin No Price Leader Ceff
171 Sporidex 69 % No is 10 % more
costly
Amoxycillin Capsules 212 Mox 47 % Yes
Novamox Yes
Amikacin Sulphate Inj 69 Mikacin 68 % No
Amicin No
Chloramphenicol 41 Chlormycetin 86 % Yes Chloromycetin is
Capsules the costliest
Enteromycetin Yes
Paraxin Yes
Kemicetine Yes
Ampicillin + Cloxacillin 109. Megapen 78 % No
Caps Ampoxin No
Ciprofloxacin Capsules 272. Cifran 56 % Yes Four brands
Ciplox Yes dominate the
Ciprobid Yes market; the
Alcipro Yes product is costly;
but still would
not be in price
control as per
PP 2002.
Currently in
price control.
Doxycycline Capsules 63. Microdox 46 % Yes
Doxy - 1 Yes
Roxithromycin 98 Roxid 49 % Yes
Capsules
Erythromycin Tablets 95 Althrocin 84 % Yes
Erythrocin No
Azithromycin 63 Azithral 30 % Yes
Norfloxacin Tablets 53 Norflox 61 % Yes
Gentamycin 38 Genticyn 33 % Yes
(All data as per ORG-AC Nielsen Retail Audit, Oct 2003). Table reproduced from LOCOST 2004, op.cit.

S Srinivasan
marketing overheads of the market leader

Drugs in Price Control and those out
of it: Theatre of the Absurd20 be rubbed off on to the consumer. For that is
what we are doing when we legitimise a
If you look at the list of drugs that are higher price of a brand: reward a company
out of price control, one would be amazed for its inefficiency and inability to sell at a
to see the following critical drugs in the
lower price thereby increasing the costs of
list despite selling at variable prices in
health care.
the market: Oral Rehydration Salt (ORS,)
very useful in most of the diarrhoeas;
all anti cancer drugs; drugs for TB (like Top-Selling 300 Drugs in India: Many
INH, ethambutol, pyrazinamide); drugs Promoting Wants but Not Meeting Needs21
for malaria (primaquine, quinine,
artemesin); all drugs for HIV/AIDS; " If we examine the list of top 300
drugs for leprosy (dapsone, clofazimine); brands (as per ORG-Nielsen Oct
diethylcarbamazine citrate (for filariasis); 2003, see Table 4 for a partial list),
atenolol, enalparil, hydrochlorthiazide, we find that only 115 brands are of
amlodipine (all drugs for hypertension); drugs that are mentioned in the
glyceryl nitrate, isosorbide nitrate, beta National List of Essential Medicines
blockers and calcium channel blockers (NLEM) 2003, i.e., only 38% of brands
(for coronary artery disease); vaccines of the top selling ones are of drugs
of every kind including cell culture mentioned in the NLEM, the other
derived rabies vaccine; anti-tetanus 62% are of drugs which do not find
serum, anti-diptheria antitoxin; anti-D mention in the NLEM. Of these 62%
immunoglobulin;phenytoin, brands comprise drugs, which are
carbamazepine, valproic acid higher priced alternatives without
(anticonvulsants). On the other hand the a clear therapeutic advantage, and
DPCO list of 74 drugs in price control many drugs, which are
include hazardous drugs like analgin,
unnecessary, irrational and even
phenylbutazone; an outdated drug like
hazardous. The number of drugs
sulphadimidine; and non-essential
represented by these 115 brands is
wonders like Vitamin E, diosmine,
only 68.
pantothonate and panthenols and
" The National List of Essential
becampacillin.
Medicines includes 354 drugs. The
majority of the top selling brands
Considering the pharmaceutical market,
where the products determine life and death, are of drugs which are outside the
it becomes imperative that a different kind of National List of Essential Medicines,
‘marketing’ structure dictate, keeping in mind which means that the majority of
that high cost often means a choice between the drugs which are the most cost-
living and dying. We believe that even though effective for the treatment of
marketing ‘creativity’ in the market should priority health needs of the people
be rewarded, it should not be unreasonable are not the ones which are selling
to the extent that the inefficiencies and the most.
20
Box courtesy Anurag Bhargava. See for detailed discussion: Bhargava, Anurag . “Price Control Policy and
Public Health: Irrelevance and Danger of Applying only Economic Criteria”, in LOCOST 2004, op.cit.
21
Source: ‘Anomalies in Drug Pricing’ by Anurag Bharagava in mfc bulletin, June-July 2004. See also: Surviving
the Pharmaceutical Jungle by Nobhojit Roy and Neha Madhiwalla is a new study on the unethical promotional
practices of pharma companies in India. See also the Indian Journal of Medical Ethics, Jan-Feb 2004. For the
study see www.issuesinmedicalethics.org/docs/Pharmrpt.pdf

" A cough syrup, which has potential bewildering number of

for addiction (Corex) and has been combinations.
banned from distribution in many " A significant number of the top
states of the north-east, is the top selling formulations are
selling medicine brand in the combinations of drugs, rather than
country with an annual turnover of single ingredients. In fact there are
nearly Rs. 80 crores. Elsewhere, a 118 combinations in the list of 300.
combination of multivitamin, Only around 20 of these
minerals, and ginseng unknown to combinations are rational, the rest
the pharmaceutical world outside are combinations, which lack any
India is ranked 27th in this list and therapeutic rationale.
has sales of Rs. 47 crores.
" Nise (generic: nimesulide), the 14th Profiteering by Drug Industry
top-selling brand, is a pain and fever This is the most important reason for making
relieving drug withdrawn from drugs inaccessible to the ordinary people.
distribution in its country of origin Table 5 reveals the extent of profiteering
and not available because of its
toxicity in UK, USA, and other Table 5 compares the retail market prices
developed countries, nor even in of six common medicines with those paid
neighbouring Sri Lanka and by the Tamil Nadu Government through its
Bangladesh. It is freely available in open, transparent tendering process. The
India as a single drug and with a Tamil Nadu Medical Services Corporation
Table 5
A Comparison of Tender Rates and Retail Market Rates
Drug Name Name of Firm Tender Unit Mfr. Retail Over- Tender
Rate Market price Rate as
(Rs.) Price Index percent
(Rs.) Col of Retail
(6)/(3): Mkt.
Price
(1) (2) (3) (4) (5) (6) (7) (8)
Albendazole Cadila 22.60 10×10 Torrent 1190 52.65 1.89
Tab IP Pharmaceuticals tablets
400 mg P Ltd
Bisacodyl Tab Lark Laboratories 16.50 10×10 German 717 43.45 2.30
IP 5 mg (I) Ltd tablets Remedies
Alprazolam Bal Pharma Ltd 3.50 10×10 Sun Pharma 141.5 40.43 2.47
Tab IP 0.5 mg tablets
Diazepam Pharmafabricon/ 3.05 10×10 Ranbaxy 92.5 30.33 6.26
Tab IP 5 mg LOCOST tablets
Folic acid Aurochem India 5.89 10×10 Smith Kline 148.5 25.21 3.97
and Ferrous P Ltd tablets
Tab NFI
Amylodipine Lark Laboratories 9.10 10×10 Lyka 148.5 16.32 6.13
Tab 2.5 mg (I) Ltd tablets
Excerpted from: Srinivasan, S. “How Many Aspirins to the Rupee? Runaway Drug Prices”,
Economic and Political Weekly, February 27-March 5, 1999.

S Srinivasan
(TNMSC) ensures that drugs brought tender awards are available on the web
through the tenders are of good quality. By (http//www.tnmsc.com/ 11rate0304doc).
way of example, it will be seen from Table 5 The Tamil Nadu Medical Services Corporation
that Cadila, a reputed concern can sell in (TNMSC) ensures that drugs brought through
bulk, Tab. Albendazole for 22 paise whereas the tenders are of good quality.
the same tablet is sold by Torrent in the
In government tenders crores of tablets are
retail market for Rs. 11.90 a tablet! Through
brought at a time. Thus many companies can
the retail market prices in strip form are
afford to give special low rates by reducing
bound to be higher than the tender prices
the rate of margin, as they earn their money
for bulk purchases, when they are 15 to 53 at one go when the medicines are supplied
times higher, to be sure this is a result of in bulk on approval of the tender. Hence a
the mind boggling profiteering by the drug better comparison of retail market prices will
industry with those paid by the Tamil Nadu be done by comparing these with the Maximum
Government through its open, transparent Retail Prices of LOCOST, the not for profit
tendering process. The prices of finalised initiative in drug-production and sale of
Table 6
Shocking Margins - A Sample Comparison of
LOCOST Medicine Prices and Retail Prices
No Name of Strength Use LOCOST MRP of [Retail
Drug Baroda Standard Market
Price* Company* Prices/LOCOST
prices] x 100
1. Albendazole 400 mg Against worm Rs. 11.00 per Rs. 9.00 per Tab 818
Tabs infestation strip of 10 Tabs (strip of 1 Tab)
2. Amlodipine 5 mg Anti hyper- Rs. 2.50 per Rs. 21.77 per 870
Tabs tensive (for strip of 10 Tabs strip of 10 Tabs
high BP)
3 Amoxycillin 500 mg Antibiotic Rs. 19.75 per Rs. 68.60 per strip 347
Capsules strip of 10 Tabs of 10 Caps
4 Atenolol 50 mg Anti Rs. 2.80 per Rs. 20.00 per strip 714
Tablets hypertensive strip of 14 Tabs of 14 Tabs
(for high BP)
5 Enalapril 5 mg Anti Rs. 3.00 per Rs. 22.58 per strip 753
Maleate hypertensive strip of 10 Tabs of 10 Tabs
(for high BP)
6 Fluconazole 150 mg Antifungal Rs. 35.00 per Rs. 29.50 per cap 8429
Capsules strip of 10 Caps (Strip of 1 Cap)
7 Glibencla- 5 mg Anti diabetic Rs. 1.50 per Rs. 3.73 per strip 249
mide Tab strip of 10 Tabs of 10 Tabs
lets IP
8 Metformin 500 mg Anti diabetic Rs. 3.00 per Rs. 6.45 per Strip 215
Tablets strip of 10 Tabs of 10 Tabs
9 Paracetamol 500 mg Fever Rs. 2.00 per Rs. 6.90 per 345
Tabs – 500 reducing strip of 10 Tabs strip of 10 Tabs
mg
10 Rifampicin 450 mg Anti TB Rs. 32.00 per Rs. 59.12 per strip 185
Capsules strip of 10 Caps of 10 Caps.
* Drug Today (April - Jun 2003). LOCOST Prices as of June- Sep 2003.

quality generic drugs for the non-profit sector. manufacturer to-distributor margins are
This comparison is done in Table 6. separate from these. The DPCRC [Drug
Price Control Review Committee 1999,
Huge Margins for the Traders Chapter VI, Summary and Recommendations,
The new phenomenon in recent years has 11 (vii)] had this to say:
been the huge trade margins available to
the pharmaceutical distributors and “It has also been observed that some of the
retailers. These huge margins have arisen manufacturers tend to provide unduly high
due to the competition between big and small trade margins, adversely affecting the
companies to capture the ‘branded-generic consumer interest. Therefore, the
market’. The competition between committee is of the view that to discourage
companies is benefiting the traders rather unethical practices by the players, the
than lowering the prices for consumers. difference between the first sale price of a
This huge margin for traders or to any bulk formulation by the manufacturers and the
buyers like doctors, hospitals are given in retail price printed on the label be limited
Table 7. Note in Table 7, the margins in Col to a maximum of 40 per cent of the MRP in
(i) are only from distributor to retailer. The the case of decontrolled formulations.”
Table 7
Extent of Trade Margins - Some Examples
(All prices in rupees. Source of Prices: Distributor’s Documents)
Sr. Brand Content (s) Manufacturer Use Packing Distri- MRP Trade
No. Name Unit butor’s Margin
Price Percent-
age[(g)/
(h)] x 100
(a) (b) (c ) (d) (e) (f) (g) (h) (i)
1. Ibu Gesic Ibuprofen Cipla Ltd. Pain, 500 ml 25.00 60.00 240
500 Ml 100 mg per fever,
5 ml inflam-
mation
2. Mycobact Ethambutol Cipla Ltd. Anti-TB, 10 x 10 135.00 400.00 296
800 800 mg tabs Leprosy
3. Tetrabact- Tetracycline Cipla Ltd. Anti- 10 x 10 44.00 84.60 192
250 biotic
4. Cofdex P Cough Cipla Ltd. Cough 60 ml 8.50 22.70 267
expectorant Syrup
substances
5. Tricast – Casting Samyang Casting 1 pc 240.00 570.00 238
Orthopaedic Plaster Corpn. – Plaster
Polyster Korea Mktd
Casting By Cipla
Tape
6. Nicispas Nimesulide Cipla Ltd. For Fever 10 x 10 35.00 250.00 714
100 mg + and Pain
Dicyclomine
20 mg
7. Pyzid-750 Pyrazinam- Cipla Ltd. Anti TB 10 x 10 175.00 650.00 371
ide 750 mg
8. Pregtest Kit Pregnancy Cipla Ltd. Pregnancy 1 kit 13.00 35.00 269
Test Kit Test Kit

S Srinivasan
Table 7 Continued...
Sr. Brand Content (s) Manufacturer Use Packing Distri- MRP Trade
No. Name Unit butor’s Margin
Price Percent-
age[(g)/
(h)] x 100
(a) (b) (c ) (d) (e) (f) (g) (h) (i)
9. Coxkit-4 Combinat- Cipla Ltd. Anti TB 15 x 2 x 276.00 551.10 200
ion of Anti 1 kit
TB drugs
10. Protibin Vitamins and Cipla Ltd. Vitamins 200 ml 17.50 55.00 324
Nutrients and
Nutrients
11. Gentacip- Gentamycin Cipla Ltd. Eye drops 600 x 3.50 7.09 203
Eye Drops Sulphate 5 ml
12. Cafepar Paracetamol Cipla Ltd. For fever 10 x 5 x 105.00 800.00 762
500 mg + and pain 10
Caffeine
25 mg
13. Doxicip- Doxycycline Cipla Ltd. Antibiotic 20 x 10 140.00 295.80 210
100 Cap 100 mg
14. Fericip Tab Iron Cipla Ltd. Irrational 10 x 10 170.00 450.00 265
– Chewable Polymaltose Iron
Tablets with Folic supplem-
Acid ent for
anaemia
15. Vasotop Nimodipine Cipla Ltd. For High 10 x 10 250.00 600.00 240
30 mg BP
16. Megaclox- Ampicillin Cipla Ltd. Irrational 190.00 600.00 316
Lb 250 mg + combina-
Cloxacillin tion of
250 mg Antibiot-
ics 10x10
17. Nicip Md Nimesulide Cipla Ltd. For fever 10 x 5 x 100.00 1450.00 1450
100 mg 10
18. Okaflox- Ofloxacin Okasa
400 400 mg Pharma. Ltd. Antibiotic 10 x 10 330.00 1600.00 1531
Wilful ignorance of the Government’s own

committees? 22
22
Even as we go to the press the Union Minister for Chemicals and Fertilizers Ram Vilas Paswan himself “found
this out when he ordered a market study of formulations of three widely used drugs namely nimesulide, omeprazole
and cetrizine in the Delhi market. Take the case of nimesulide as an example. The study shows that while the
wholesale price of generic nimesulide 100 mg is only Rs.1.20 for a 10 tablet strip, its MRP is a high as Rs. 30 in
case of one company. At the same time, the MRP of Dr Reddy’s brand, Nise, is Rs.38.61.Many such products with
wide price variations have been brought out by the study. A nationwide study of generic pricing could be much
more revealing than the Delhi one.” Source: P.A.Francis, ‘Paswan on the Right Track’ in Pharmabiz.com, August
10, 2004. Hope the Government has woken up and we see some positive action.

Stranglehold of Retail Pharmacists: understanding” in which they agree to

‘A Parallel Government’ increase profit margins to pharmacies.”
Irrational drugs and tonics and syrups often
enjoy 500-1000 percent trade margins. Now “They have to surrender,” Mr. Mehta says,
these margins are available even in generic speaking from his tiny office at the rear of
drugs, which are otherwise rational. The a wholesale apparel centre in Bombay. The
situation in this regard in small towns and chemists association, he says, is like “a
taluka level places and in states with parallel government.” 24
relatively weak drug administration is really
alarming. Drug producers are at the mercy Comparison with Earning of a Wage
of retail pharmacists (at last count more than Labourer
250,000 all over India)23. But in this the drug What is the implication of this profiteering
producers are also to be blamed. They bribe for a labourer, who earns Rs.60/- a day?
doctors as well as retail pharmacists to push Anurag Bhargava has worked this out in
sales. Retail pharmacists refuse to sell case of ten common illnesses (see Table 8).
products of particular companies if margins In the accompanying table, the cost of drug
are not increased. treatment is compared for some common
illnesses in terms of number of days of
“Dilip Mehta, president of the All India earnings that a labourer would have to
Organisation of Chemists and Druggists, which spend to buy these drugs. This table gives
represents 500,000 Indian pharmacists, boasts an idea about how hard it is for a labourer
of how his association also has forced drug to buy these exorbitantly costly drugs in his
companies to sign “memorandums of struggle for survival.
Table 8
Drug Costs and person Days in Terms of Wage Labour
Problem Upper level of drug costs No. of person-days to
be spent in earning
the drug cost.
1. Streptococcal pharyngitis (sore throat) Rs. 109.8 1.8
2. Bacillary dysentery Rs. 84.2 1.4
3. Treatment of iron deficiency anaemia Rs. 3744 62.4
for 6 months
4. Tuberculosis treatment for 6 months Rs. 2616 43.6
5. Treatment of multi-drug resistant TB for Rs. 44190 736
18 months
6. Hypertension treatment for 1 year Rs. 1076.75 17.95
7. Diabetes mellitus with oral drugs like Rs. 2073.2 34.5
glicazide
8. Coronary artery disease Rs. 12541.4 209
9. Prevention of Hepatitis A Rs. 1856 30.9
Source- Bhargava, Anurag in: LOCOST, Impoverishing the Poor, op.cit., page 48.
Assumptions made in the calculations are also discussed therein.
23
According to the Mashelkar Committee Report: “From the information conveyed by the States, it is observed that
there are 418411 total number of sales licenses including 253666 retail licenses and 145447 wholesale licenses
and a combined figure of 19298 retail and wholesale licences given by Karnataka. This total number is not
absolute because majority of the sales units have both retail as well as wholesales licenses. Currently, there are
935 Drug Inspectors in all States/UT’s in the country put together. Presuming that the number of sales units to
be inspected will be approximately 300,000, the number of Drugs Inspectors required is estimated to be 1500.”
24
‘Drug Firms’ Incentives Fuel Abuse by Pharmacists in India’, Daniel Pearl and Steve Stecklow in The Wall Street
Journal, August 16, 2001.

S Srinivasan
Substandard Quality
Access to substandard drugs is no access What’s the Actual Situation on the
at all. In India, substandard drugs Ground?25
According to Harinder Sikka, senior
significantly add to the problem of
President, Nicholas Piramal, there are
accessibility. The Government-appointed
only 600 inspectors for 20,000 registered
Mashelkar Committee (2002-03) examined
drug producers in the country.
various estimates, widely varying, and often
fuelled on guesstimates and speculation and
In Delhi, for example, 20 inspectors are
concluded that there is no authentic data
on duty for 8,000 registered chemist shops,
on the extent of the problem. ‘Based on the
which means one inspector for 400
samples tested by the State authorities,
shops. “The inspectors have obviously
data were analysed for the period 1995- chosen the best way out. Concentrate
2003. According to these data, the extent on a few chosen chemists and improve
of sub-standard drugs varied from 8.19 to your lifestyle,” Sikka says tongue-in-
10.64 per cent and of spurious drugs varied cheek.
between 0.24 per cent to 0.47 per cent.’
(See also the adjoining boxes, ‘What’s the He, though, strongly defends the death
actual situation on the ground’ and ‘Paucity penalty suggested by the Mashelkar
of Testing Laboratories’.) committee and gives the example of a
Chandigarh-based company that was
Several possible factors contribute to using contaminated tap water instead of
proliferation of substandard drugs. Some of the drugs in vials….
the prominent ones pointed out by the .
Committee are: …. Sikka has a simple question: “A
majority of these manufacturers operate
" Lack of enforcement of existing laws. from garages and hovels. Who is renewing
" Weak penal action their CGMP licences?”
" Very remunerative trade
" Large scale sickness in small scale
Paucity of Testing Laboratories
pharmaceutical industry
“Only 17 States have drug testing and
" Availability of improved printing
even among these laboratories, only
technology that helps in about 7 have the capacity to test all
counterfeiting classes of drugs. On an average, about
" Lack of coordination between various 36,000 samples are tested annually, both
agencies in the Central and State drug testing
" Too many retail and whole sale laboratories. The number is, however,
chemist outlets inadequate as compared to number of
" Inadequate cooperation between batches of thousands of formulations
stakeholders. manufactured in the country. Because
" Lack of control by importing/ of less capacity to test, the time taken
exporting countries to complete the testing of drug samples
" Wide spread corruption and conflict is observed to be taking even a year. This
of interests does not serve any purpose. As a result,
25
“An overdose of intention”, September 15, 2003 at http://www.rediff.com/money/2003/sep/15guest.htm

samples of less than 1 % of the batches groups called the Comprehensive Medical
of drugs manufactured in the country Services India (CMSI) has been in existence
are exposed to scrutiny by the in Chennai for the last 10 years. Centralised
Government drug testing laboratories. bulk purchase efforts like that of the CDMU
The number of samples that are reported (Central Drug Marketing Unit), Kolkatta, at
every year as not of standard quality by negotiated prices from a variety of
the Central and State Government manufacturers, has also resulted in
laboratories are only indicative of lax considerable savings to the institutional
quality assurance system in the consumer. The Methodist Church-run
manufacturer’s quality control labs and Bangarpet Tablet Industry near Bangalore,
are not representative of the actual has been supplying low priced medicines to
situation in the country. The limitations missionary health institutions since 1919.
in testing of drug samples in the
government labs are related to the Pooled Procurement in Public Sector
absence or lack of sophisticated In the public sector too there have been
instruments, lack of trained analysts, some very good initiatives to buy quality
lack of commitment, lack of reagents, drugs in bulk at the lowest rates.
non-validated methods, shortage of
funds, inadequate number of staff and Most impressive of these are the pooled
in many cases a combination of more procurement efforts of the governments of
than one of these constraints.” Tamil Nadu, Delhi State and Orissa. In
addition they have affected considerable
Source: Mashelkar Committee Report savings in terms of expenditures on drugs,
(2003) increased availability of drugs at all levels
Rays of Hope of government health services, and in
In this overall depressing scenario on the general advocated rational use of medicines
availability of quality drugs for the majority, by formulating standard treatment
there have been some positive initiatives, guidelines. The Tamil Nadu the process is
which offer a ray of hope. also very transparent and the prices of
finalised tender awards are on the web (see
NGO Initiatives for instance at http://www.tnmsc.com/
For the last 20 years, LOCOST, a non-profit l1rate0304.doc ). Table 5 gives an idea of
NGO enterprise has been supplying quality the tremendous savings accrued to the
drugs in generic name to the non-profit Tamil Nadu government due to this pooled
health NGOs at very low prices. The extent procurement. Table 9 and Graphs 1,2,3
in saving for the consumer can be seen from further give an idea about such savings by
Table 6. A similar effort of church-based the Delhi and Orissa State governments.
Table 9
Comparison of Prices of Drugs (in Rs. per Unit)
Drug Purchased at Competitive Prices (Rupees)
Drugs Open Pooled % cost
tender procurement reduction
Syr Amoxycillin 14.65 7.50 50
Tab Erythromycin (250 mg) 3.24 1.54 50
Tab Atenolol (50 mg) 0.42 0.17 60
Inj Ranitidine 1.87 1.63 12.50
Inj Diazepam 5.53 0.93 80

S Srinivasan
Graph 1
Savings in Costs of Treatment
Comparative cost of treatment on pooled
procurement followed by STGs
Retail Sector Pooled Procurement PP & STG
80
70
60
50
40
30
20
10
0
Diarrhoea ARI HT* Asthma*
* Cost of treatment for a fortnight

Source for Tables 9 a & b: Bapna J S, P.53. in Bapna J S “Rational Drug Use and Economic
Gains: The Delhi Experience” in The Medicines Scenario in India: Perceptions and
Perspectives edited by Banerji A, for Delhi Society for Promotion of Rational Use of Drugs,
New Delhi (undated) and Dr Nirmal Gurbani (2004), DSPRUD, New Delhi.
Similarly though not as dramatically, prices decreased and stock position of items increased
in Orissa after the Drug Inventory Management System (DIMS). See bar charts below (Tables
10 and 11) for illustration. (Source for tables, Orissa Government documents on DIMS).
Graph 2
Comparison of Stock Position before and after Orissa DIMS:
Inj. Anti Snake Venom
1500
1000
500 340 355

210
60 100
0 0 95 - 96
0
Jaipur Kandhamal Koraput Nayagarh 01 - 02
Districts
*Source for Tables 10 and 11, Orissa Government documents on DIMS.

A few other state governments namely like India. The Committee however has lost
those of Rajasthan, Maharashtra, Haryana, a good opportunity to recommend putting
Himachal Pradesh, Andhra Pradesh, Madhya pricing policy and health related drug policy
Pradesh, Karnataka, Assam and Chhatisgarh under the ambit of one single authority.
have also taken steps to regularise their drug
purchase list by making the focus on essential The Mashelkar Committee had toned down
drugs and rational medicines and formulating its earlier recommendations for death
standard treatment guidelines. penalty to make offences of spurious drugs
manufacturers ‘cognisable and non-
Mashelkar Committee Recommendations
bailable’. The Government of India has
The recommendations of the Mashelkar
nevertheless gone ahead and introduced a
Committee (2003), if implemented, will help
bill in the Parliament awarding capital
to curb spurious, substandard drugs. The
punishment to those indulging in
Mashelkar Committee has recommended total
overhauling of the drug control administration manufacture or sale of spurious drugs. One
and has recommended a structure, almost like suspects that this was at the behest of the
that of the US FDA, involving several divisions big manufacturers who are worried at the
- a centralised regulator called the Central many ‘me-too’ copies, both genuine and fake.
Drug Administration (CDA). This is a radical However, the Committee has not addressed
departure from the existing structure, which the problem of unlimited profiteering and
is a decentralised one as health and the presence of irrational and unscientific
pharmaceuticals come under the concurrent drugs. Restricting profit levels and the list
list of the Constitution - to be looked at by of drugs that can be made in India to
both the Centre and the state. Obviously the essential, scientific drugs could have
move to break the nexus between drug considerably lessened the burden of testing
companies and state FDA officials runs the and regulating. Are not irrational drugs a
risk of over centralising in a vast country variety of spurious drugs? Are not high priced
Graph 3
Comparison Between Old and New Rates: Orissa DIMS1
80 75.355
75
70 65.95
65
60
55
50 45.755
45
40 34.7 36.85
35
30 26.7
25 19.3
20 13.4 12.61
15 10.95
10 2000
5
0 2001
2001
2002
26
DEPM Items
26
DEPM rates refer to Directorate of Export Promotion & Marketing –items reserved for the small-scale
sector in Orissa.

S Srinivasan
drugs, killers as much as fake drugs –slow 1970 was the key to the Indian pharma
but eventually immiserating the patient? industry, making India’s legal regime on
drugs instrumental in the growth of the
Some Developments of 2004 large generic drug industry and low drug
Supreme Court Case pricing by international standards. It did not
The Karnataka High Court gave a stay on recognise product patents for drugs (product
that part of the pricing policy (PP 2002) that patents prevent third parties from making,
had to do with reducing the list of drugs using, offering for sale, selling or importing
under price control. The Government of for these purposes) but only process patents
India, and not surprisingly, all the leading and monopoly rights were in the public
drug industry lobbies of India, have appealed domain. Through the process of reverse
against the stay in the Supreme Court27 . engineering, generic version of new drugs
The All India Drug Action Network (AIDAN), could be legally produced.
LOCOST, Jana Swasthya Sahyog (JSS), and
the Medico Friend Circle (MFC) have joined Since then, as part of its so-called WTO
issue and have filed a series of affidavits in obligations, India has already partially
the matter, questioning the wisdom of the ‘complied’ with TRIPS/WTO provisions by
criteria for drug price control in introducing amendments (in 1999 and 2002
Pharmaceutical Policy 2002 (PP 02); the and by the Patents Rules, 2003) by amending
policy will cause an increase, as we have its Patents Act 1970. These amendments
indicated above, in the price of medicines covered the following:
and therefore have a long-term effect for " extended the term of patent to 20
the worse on the health of people, especially years (previously 7 years for drugs),
poor people. This litigation, with hearings " expanded the definition of invention
slated for early 2004, is also occurring at a and the scope of patentability even as
critical juncture when India’s state of public it abolished patents on plants, animals
health is still grappling with old diseases and micro-organisms,
while new ones like HIV/AIDS, diabetes and " introduced license of rights,
cardiovascular problems have got added on formulated a more stringent
to the disease burden. Complicating this compulsory license formulation28,
issue is the impending regime of WTO/ " introduced provisions for exclusive
TRIPS effective January 2005. marketing rights, parallel importation,
Bolar provision (as per this provision,
India, Patents Act, WTO/TRIPS, and EMRs is an act of making, constructing,
The changes being brought into the Indian using or selling a patented invention
patent Act 1970 will further erode the solely for obtaining regulatory
accessibility of the new drugs to the vast approval under the laws of India or
majority of the Indian people. It is now another country. This does not
generally accepted that the Patents Act constitute an act of infringement –
27
Namely SLP(C) 3668/2003 filed by Union of India asking for impugnment of the order of the Karnataka High
Court dated 12.11.02. The latter order (in WP No 21618/2002 Lt. Col. (Retd) Gopinath and another versus the
UOI) stayed the operation of that part of the Pharmaceutical Policy 2002 that affected drug price control. The
Supreme Court while suspending the order of the Karnataka High Court has asked the Government of India to
ensure that essential drugs do not go out of the price control – pending full hearing. Arguments presented in the
case by AIDAN and others are summarized in LOCOST 2004, op.cit.
28
Compulsory licenses are license granted by the State to commercially exploit a patented product/ process
during the protected period on grounds of (a) public requirement not satisfied (b) high pricing. Recently - in
early 2004 - the National Working Group on Patent Laws has identified nine situations under which compulsory
licenses can be granted and has suggested these be incorporated in the third set of amendments to the
Patents Act 1970.

that is, a small amount of raw rights for a period of five years. Novartis
material can be imported before its was the first company to be given an EMR
patent expiration so that consumers for a drug in India. The drug in question,
can have the competitive product Imatinib mesylate, once known as STI571,
available when the patent expires), is sold by Novartis as “Gleevec” in the United
" introduced the burden of proof on the States and as “Glivec” elsewhere. Novartis
alleged infringer (to avail this used its EMR in India to block anybody
provision, the patentee must first making its drug and equivalents – despite
prove that the product is identical to the local manufacturers in India making
the product directly obtained by Glivec, an anti cancer drug, at a tenth of
infringing the patented process), the price. Novartis is also resisting giving
" introduced disclosure requirements in to compulsory license for the drug in
for biological material (non-disclosure Korea despite efforts by NGOs and other
or wrong disclosure of source or interest groups29.
geographical origin of a biological
material used in the invention and Earlier, Natco, one of the manufacturers of
anticipation of the invention through the drug challenged the patent office’s
prior knowledge, oral or otherwise, decision and filed a case in the Delhi High
within any local or indigenous Court. The petition has also challenged the
community have been made grant on another ground – the fact that
additional grounds for opposition/ Novartis is believed to have got its EMR on
revocation) and HIV Provision. the basis of a patent application that was
filed in 1998 for a new form of the drug,
The 2004 Amendment Agenda – the third called the ‘betacrystalline form’, and not for
such set of amendments since 1999 –– an entirely new drug. Queering the pitch
includes introduction of a Product Patent is the proviso that companies can be given
Regime, abolishes Pre-grant Opposition EMRs only for drugs patented after January
(opposition from concerned parties before 1, 1995 and domestic pharma companies
granting the patent to the patent applicant), are challenging the patent office’s decision
and Experimental Exceptions, and possibly on these grounds. The original imatinib
acceding to data exclusivity provisions (data mesylate patent dates back to 1993 in the
exclusivity provides for a period of protection West.
during which test and clinical trial data of
one company may not be relied upon by Litigation on the issue of EMR for the drug
another company to obtain a marketing took a fresh turn in January 2004 with
authorisation of the same drug). However Novartis getting a stay from the Madras High
these are matters of severe debate and one Court restraining six drug companies from
of the few instances where the efforts of manufacturing and distributing imatinib
public interest groups and the Indian drug mesylate. The six companies are Cipla, Sun,
manufacturers lobby like Indian Drug Ranbaxy, Hetero, Emcure and Intas and
Manufacturers’ Association (IDMA) converge. they have been restrained from the
Dilution/abolition of pre-grant opposition manufacture, sales, distribution, marketing
has been severely opposed by the Indian and export of the generic version or
drug industry (as represented by IDMA, IPA) chemical equivalent of Novartis’ Glivec.
so has the provision for exclusive marketing
rights (EMRs). In other such instances, during September
2003, GlaxoSmithKline filed a case in the
An EMR gives a company exclusive marketing Delhi High Court against the Government’s
29
See http://www.cptech.org/ip/health/gleevec/

S Srinivasan
decision not to grant an EMR to GSK for its called it illogical, irrational and
anti-diabetic drug rosiglitazone. A similar unconstitutional and has quoted in support
case has been filed in the Calcutta High a 1999 report of the Law Commission of
Court, by Swiss company Hoffmann-La India, which said that EMRs and patent
Roche, for the rejection of its EMR rights go together, and cannot be separated.
application for its anti-retroviral or anti- ‘Without a clear patent right, there cannot
AIDS drug saquinavir. However, be any product marketing exclusivity.’31
Wockhardt’s topical antibacterial drug (Editors Note: Appendix 1, at the end of the
nadifloxacin or Nadoxin has been granted chapter, discusses suggestions for Patents
an EMR. Amendment Bill)
[As we go to the press the Cancer Patients
What Needs to be Done
Association of India has challenged the
In this chapter we have surveyed factors that
grant of exclusive marketing rights (EMR)
through a writ petition in the Supreme Court impinge on the availability of essential drugs
of India. The Supreme Court has issued in India. What needs to be done to remedy the
notice in the matter. The Petitioners have situation? The following policy measures are
filed this petition in public interest under needed:
Article 32 of the Constitution of India on
account of the violation of the right to health " Prioritising drugs available in India
and equality of cancer patients suffering to essential drugs as per the
from Chronic Myeloid Leukaemia (CML).] Government’s own NEML (2003) or the
13th Model List of Drugs of the WHO32.
There is an increasing opinion in India that " Ensure adequate production of
acceding to the EMR provision was a mistake. essential drugs.
There is hardly any difference between an " Critical role of the public sector to
EMR and an exclusive patent.30 In fact with ensure national self-reliance and
an EMR, you get the benefits of a patent availability of essential drugs
without detailed examination, and/or pre- " Weeding out all irrational and
grant opposition. The IDMA President has harmful medicines 33 .
30
“EMRs and Patents: Same Difference” by Rakesh Prasad, counsel to the Directorate General of Anti Dumping
and Allied Duties at http://www.rediff.com/money/2004/feb/16guest1.htm
31
At the IDMA Annual Meeting, 2003 quoted in IDMA Bulletin, Dec 31, 2003, Vol. XXXIV, No. 48.
At the same meeting, the keynote speaker from USA, William Haddad, initiator of the Drug Price Competition
and Patent Restoration Act (Hatch-Waxman) and founder of the Generic Pharmaceutical Industry Association,
pointed out that during the TRIPS discussions India was classified as a “lesser developed nation” (LDC) and
suddenly by the time of Doha, India was excluded from the list of 49 LDCs that were given till 2016 to comply
with. WTO. Haddad suggests that for the purposes of TRIPS alone, India claims its status as an LDC – galling
though it may be to the India Shining lobby – and has become a major supplier of medicines to the third world.
A suggestion seriously worth pursuing.
32
For the 13th WHO Essential Drugs list see http://www.who.int/medicines/organization/par/edl/
eml.shtml. For National Essential Medicines List (NEML) 2003 see http://www.expresspharmapulse.com/
nedl.pdf
33
One should add after Phadke (1998) the following concomitant steps also need to be taken: standardization
of medical care starting with standard treatment guidelines; a comprehensive Rational Drug Policy that includes
no unnecessary formulation presentations in terms of syrups, capsules and injections; a vaccine policy strictly
guided by science of public health and prioritization of use of public money; a limited list of over the counter
drugs to be available; promotion of drugs under only generic names with strict regulation of promotional activities
of drug companies; strict guidelines of sponsorship, if at all, of symposia and other scientific meetings; mandatory
disclosure of funding and potential conflict of interests in all research and publications; a limit on cross-
practice; compulsory continuing medical education of doctors; improvement in medical education as well as
medical education fee regulation; a systematic policy of research on non-allopathic drugs as well as a pricing
and marketing policy for non-allopathic drugs.

" Price Control on all essential drugs Failing which enhancing scope of
marketed in India compulsory licensing.
" Introduction of Essential Drug Lists " Transparent decision making in
and Standard Treatment Guidelines matters of EMRs, patents, data
especially in health facilities of the exclusivity, etc., keeping in mind the
governments at the Centre and State interests of the people of India.
followed by legal changes to enable " Medicine be available only under the
production and marketing of only generic name with company’s name
essential drugs in India (that is in in parentheses.
both private and public sectors). " Compulsory continuing medical
" Transparent Pooled procurement in education of doctors.
all States as in Tamil Nadu and Delhi " Strict control over promotional
State Governments after assessing activities of drug companies.
rational, essential drug needs (which " Universal Health Access and Health
has resulted in procurement of drugs Insurance for every citizen of India
for the public health facilities at a by increasing the government’s per
rate which is up to 2 per cent of the capita expenditure on health34.
prices in the retail market!).
" Implementing the Mashelkar
Committee recommendations Acknowledgements: In putting together this
without centralisation and report, published/unpublished works have
bureaucratisation. been freely borrowed especially that of
" Action on corruption at all levels of LOCOST, SAHAJ, Anurag Bhargava and T
drug administration including in the Srikrishna. Sources have been credited as far
drug industry as possible. Anant Phadke went painstakingly
" Refusal to change the Indian Patent to edit the original effort for brevity as well as
Act (1970) At the minimum level, no relevance to this volume on State of India’s
product patents on diseases of the Health Services. Thanks also to Phadke and
national programme and more careful Ravi Duggal in sourcing some of the references.
orchestration of the health needs of Inadvertent omissions are regretted and may
India, especially the poor, when be pointed out to S.Srinivasan at
amending the Patents Act again. sahajbrc@icenet.co.in
34
“…It may be asked, whether India has the resources today to give health care insurance to everybody. The
answer is yes. We are already spending about 6% of our Gross Domestic Product (GDP) on health-care. But the
state’s share in only 21% of this expenditure. This share is lower than that seen even in Bangladesh (33%) and
Pakistan (53%). In most developed capitalist countries, this share is 70 to 80% and even in the U.S. - the
supposed heaven of private medical care, the state’s share in total health-expenditure is 44%. … the governments
in Sri Lanka, Bangladesh, Pakistan … spend a higher proportion for health-care than private health-expenditure,
why can’t the Indian government do this? The people are already paying 4.5% of GDP in the private sector. If the
government spends 5% of GDP on health-care by almost quadruplicating its current health-expenses, then an
additional special health-tax proportional to income, to meet the extra needs for a Universal Health Insurance can
be justified. Instead of paying directly to the often exploitative private sector as is done today, people would be
willing to pay a health-tax to the local government who could in turn pay the private practitioners as per negotiated,
rational rate-structure. Thus without people having to pay more on health-care than what they are paying today,
India can provide for expenses for a Universal Health Insurance of up to 9.5% of GDP. This much expense should
suffice. Though higher in absolute terms, the health-expenditure in Japan, Germany, Canada, France is in the
range of 4.5 to 9.5% of the GDP. What is needed in India is intensive public pressure on the Indian government
to divert more resources towards health-care.” (Phadke 1998, op.cit., chapter on “What Can be Done?”)

S Srinivasan
Appendix 1
Suggestions for Patents (Third) Amendment Bill to Amend
the Indian Patents Act 1970
Amit Sengupta
As per the provisions of the TRIPS agreement Finger) have, of late, recognised the
under the WTO, India is required to amend inherent inequity in the TRIPS agreement
its Patent Laws to provide for a TRIPS and some have even questioned the logic of
compliant regime, and there has been incorporating TRIPS into the WTO system
extensive debate within the country about in the first place. Similarly, in its report of
what the contours of India’s Patent Laws September 2002, the Commission on
should be. The 1970 Patents Act has served Intellectual Property Rights (CIPR)
the country well, and was instrumental in established by the Government of U.K has
development of the indigenous industry – made a pointed reference to the likely
to a point where the Indian pharmaceutical adverse impact of the global enforcement
Industry is the leader in the developing world. of the new intellectual property regime on
It is thus imperative that any fundamental the cost and availability of medicines to
changes in the 1970 Patents Act need to be developing countries and the need to use
carefully examined, so as not to compromise the mechanism of “compulsory licensing”
the interests of people’s health, and the to mitigate such impact.
interests of promoting a self-reliant
indigenous Pharmaceutical Industry. The devastating HIV-AIDS epidemic across
the globe, particularly in African countries,
Despite diverse contentions about the
has served to focus on the inhuman conduct
impact of TRIPS compliant Patent Laws on
of global pharmaceutical MNCs who
domestic industry – especially in developing
continue to sell drugs to treat HIV-AIDS at
countries - there is a wide consensus that
20-50 times their actual cost by seeking
domestic laws, while being TRIPS compliant,
shelter under laws mandated by the TRIPS
need to make full use of “flexibilities”
agreement. In fact it was left to Indian
available in the TRIPS agreement. This was
companies like Cipla to offer these drugs at
reiterated in unequivocal terms by the WTO
vastly reduced prices and thereby provide
Doha Declaration on TRIPS Agreement and
Public Health (2001), which, inter alia, some succour to those affected by HIV-AIDS.
commented that countries have the The conduct of these MNCs has also led to
sovereign right to enact laws that safeguard an upsurge of public opinion the world over,
domestic interests, and clearly provided that including in the US and EU, questioning
the member countries had the right to its rationale, particularly in the area of
protect public health and to promote access public health. Organisations such as the
to medicines for all. Medecns Sans Frontieres (Doctors Without
Borders) have provided a powerful voice to
Experience with TRIPS since 1995 this upsurge and soon became a global force
It needs to be underlined that a wide body contending the rationale of the new IPR
of experience has accrued in a large number regime. These developments ultimately
of countries since the TRIPS agreement resulted in the Doha Declaration on TRIPS
came into force in 1995. Several economists Agreement and Public Health (November
of repute who otherwise are fully supportive 2001) seeking to limit, to some extent, the
of the free trade theory and the WTO (viz. damage done by the TRIPS agreement and
Jagdish Bhagwati, Dani Rodrik, Michael its underlying philosophy.

These experiences of the last 10 years without an informed discussion, will not be in
clearly call for a independent approach when the larger interests of the country.
India is poised to amend its Patent laws to
make it fully “TRIPS compliant”. Broad Areas of Concern
The broad areas which require further
Safeguard National Interests amendments in the Indian Patent Act 1970
In pursuance of the necessity to make (as amended by the Patents Act 2002) and
India’s Patent Laws TRIPS compliant, the the draft Patents Bill 2003 are as follows.
Indian Parliament has enacted two
legislations through the Patents Patentable Subject Matter
(Amendment) Acts of 1999 and 2002. In The term “invention” should be reserved for
order to fulfil the conditions in the TRIPS a “new” product or process involving an
agreement, a Third Amendment is now to inventive step and capable of industrial
be tabled in Parliament. Unfortunately, the application”. All three criteria, “novelty”,
Patents (Amendment) Bill of 2002 did not “inventive step” and the quality of being
make full use of the flexibilities available “capable of industrial application”, must be
in the TRIPS agreement, which were further insisted upon. This is necessary in order to
emphasised in the Doha Declaration. It is limit the number of applications and to
necessary that the draft Patent Bill 2003 discourage frivolous claims. The Report of
incorporate amendments that address the the US Federal Trade Commission says that
gaps in the Indian Patent Act 1970 (as over one thousand patent applications are
amended by the Patent (Amendment) Acts filed every day in the US, where such huge
of 1999 and 2002), so that we make full use volumes have resulted in many frivolous
of flexibilities available in TRIPS. It is also claims being admitted. With the
necessary to press for a review of the TRIPS introduction of product patent in India from
agreement itself – something that is mandated 1.1.2005 a similar situation is likely to arise,
in the original agreement, but has not been having a serious impact on our industrial
followed up. Such a review is necessary to economy, creating spurious monopolies for
address the imbalance in favour of otherwise common products for which
developed countries inherent in the TRIPS people will have to pay high prices.
agreement.
What are not inventions (and thus not
The NDA government had circulated the patentable)
draft Third Patents (Amendment) Bill in The Indian Patent Act allows patenting of
2003. The Bill could not be discussed in “micro-organisms” and “non-biological and
Parliament, because of the change in microbiological processes”. Patenting of
Government. these inventions are under mandated
review by the WTO since 1999. In the
The draft Bill, was entirely inadequate in absence of any decision, patenting of these
addressing domestic concerns relating both inventions should not have been provided.
to health care and development of the Further, all life forms and research tools
indigenous industry. Further, it seeks to for biotechnology should also be excluded
reverse salutary provisions in the original from scope of patentability. A host of
Patents Act of 1970 e.g. by further diluting developing countries, the African countries
the provision for “pre-grant opposition”. The in particular, have agreed that life forms of
UPA Government is now poised to introduce all hue should be excluded from
the same Bill (drafted by the earlier NDA patentability and India has tacitly supported
government) in the Winter session of these countries. The draft Bill 2003 has also
Parliament. Any hasty passage of the Bill, restricted the scope of exclusion from

S Srinivasan
patentability for computer programmes, and date of application. In all such cases if any
this needs to be remedied so that we do production activity has been started by any
not encourage monopolies by the likes of enterprise during the transition period,
Microsoft. then that enterprise should be allowed to
continue production on payment of a
Compulsory Licensing nominal royalty to the patent-holder, after
Compulsory Licensing is an instrument the patent has been granted, instead being
available in the TRIPS agreement to accused of violating the patent. In the
safeguard the legitimate interests of absence of such a provision there would be
consumers by limiting the possibility of a spiraling rise in prices of patented
monopolies being created in different products even when Indian companies
sectors. Unfortunately the Indian Act has would be in a position to produce these
not made full use of the flexibilities products at much lower costs. The recent
available in the TRIPS agreement in this case of the anti-cancer drug Glivec (where
regard. The Indian Act and the proposed Novartis, after being granted a monopoly
amendment provides no scope for the through an EMR has restrained six Indian
issuing of a compulsory licensing in cases companies from producing the drug and at
where, notwithstanding the offer of the same time has hiked the price of the
reasonable commercial terms and
drug far above what was being charged by
conditions to the patent holder by an
the Indian companies), points to many such
enterprise, the patentee does not respond
occasions in the future.
within a stipulated period of time. Countries
like Brazil and China have passed
Royalty payment
legislations allowing compulsory licensing
The quantum of royalty payable if a
in such circumstances.
compulsory licence is issued should be
Export by a Licensee explicitly stipulated within a range, say 4-5
The TRIPS agreement allows exports by percent, of the sales turnover at ex-factory
manufacturers who produce through a price. This would ensure that costs of drugs
compulsory licence. Unfortunately the produced through a compulsory licence
Indian Act does not explicitly provide for this. remain within affordable limits and also
This is of particular importance in the case prevent unnecessary litigation and delays
of pharmaceuticals where Indian licensees in enforcing of such licences.
can export drugs to the developing country
markets at relatively lower prices, to the Pre-Grant Opposition
mutual benefit of both. The TRIPS Agreement does not preclude the
possibility of pre-grant opposition to Patents
Transitional Arrangement and Mailbox that are filed. There is no justification for
As per the TRIPS agreement, India has the removal of the existing provision of pre-
provided for the receipt of patent applications grant opposition from the Patents Act, as is
through a mailbox between 1.1.1995 to being proposed in the draft Bill 2003. Many
31.12.2004. These applications are to be countries, including developed countries
examined after 1.1.2005 and patents, if like Australia, Japan, Canada and UK
granted, would be effective from the latter provide for pre-grant opposition in their
date for a period of twenty years from the national laws.

SECTION 5
CONCLUSION
Conclusion: Reclaiming Public Health
An unfolding struggle for health rights and social change
Abhay Shukla
The Present Health System Crisis dilapidated state. In the indoor treatment
‘The existing state of public health in the facilities, again, the equipment is often
country is so unsatisfactory that any attempt obsolescent; the availability of essential drugs
to improve the present position must is minimal; the capacity of the facilities is
necessarily involve administrative measures grossly inadequate, which leads to over-
of such magnitude as may well seem to be crowding, and consequentially to a steep
out of all proportion to what has been deterioration in the quality of the services.’
conceived and accomplished in the past. This
seems to us inevitable, especially because - National Health Policy, 2002
health administration has so far received from
governments but a fraction of the attention These excerpts from two major official
that it deserves in comparison with other documents, separated by fifty-six years of
branches of governmental activity …we have ‘development’ of public health in India, give
provided for the establishment of a health us some idea of how public health has fared
organisation which will bring remedial and in half a century of post-Independence India,
preventive services within the reach of the and where it stands today. It is in such a
people, particularly of that vast section of the setting that the authors contributing to this
community which lies scattered over the rural report have critically analysed, from a pro-
areas and which has, in the past, been largely people perspective, and from different angles
neglected from the point of view of health and in various contexts, the state of health
protection on modern lines.’ care in India. It was considered neither
possible nor desirable that this report be cast
- Bhore Committee report, 1946
in a monolithic framework; rather the differing
shades of opinion and emphasis of various
‘…there is no gainsaying the fact that the
authors add to the richness of its analysis,
morbidity and mortality levels in the country
and capture a diversity of critical opinion. This
are still unacceptably high. These
notwithstanding, certain broad contours
unsatisfactory health indices are, in turn, an
about the ‘State of health care in India’ seem
indication of the limited success of the public
to emerge from the broad panorama covered
health system in meeting the preventive and
by this report, and an attempt to briefly sketch
curative requirements of the general population.
some of these contours will be made in this
… It would detract from the quality of the
sub-section.
exercise if, while framing a new policy, it were
not acknowledged that the existing public
health infrastructure is far from satisfactory. One theme that emerges clearly is that the
For the outdoor medical facilities in existence, objective of universal access to quality health
funding is generally insufficient; the presence care, envisaged over half a century ago at the
of medical and para-medical personnel is often dawn of Independence, remains unrealized.
much less than that required by prescribed Public health has effectively remained a low
norms; the availability of consumables is priority for the Indian state in terms of
frequently negligible; the equipment in many financing and political attention.
public hospitals is often obsolescent and Consequently, there has been a major and
unusable; and, the buildings are in a growing divergence between the policy

Conclusion: Reclaiming Public Health An unfolding struggle for health rights and social change
rhetoric (Bhore committee, Alma Ata with the retreat from the goal of universal
declaration) and actual implementation. This access, special health needs of women and
has contributed to the slow and inadequate children have become further sidelined or
improvement in health of the population, in inadequately addressed, while important
the period of over half a century of concerns like violence as a public health issue
development of health systems in India. remain effectively unrecognised and
unaddressed.
Closely related to this, and compounding this
situation has been a Techno-managerial This situation of crisis seems to be an
model of health care inspired by the West, appropriate time to place the goal of universal
with an inability to evolve effective indigenous access to appropriate health care on the
models and appropriate technologies, or to agenda, and to rebuild a social consensus on
effectively integrate modern and indigenous the high priority that must necessarily be
systems of medicine (in contrast to China for given to public health. While developing such
example). The system of Health planning and initiatives, we can draw upon the legal and
decision making has been highly centralized constitutional provisions for the Right to
and top-down with minimal accountability, Health Care, the declared yet never fulfilled
little decentralized planning or scope for health entitlements of the people of this
genuine community initiatives; the failure of country. The time has come to demand closing
most State supported community health of the gaps between entitlements and reality,
worker schemes being one of the most striking while simultaneously redefining and
consequences of this . The family planning expanding the horizon of entitlements; and
programme has been the most dominant to reclaim public health as an essential,
amongst various externally imposed priorities, universal good in the framework of Human
attempting to reduce the poor as a substitute rights.
to reducing poverty, drawing scarce resources
away from public health, distorting the public The Medium Term Future Goal
health system and alienating it from the Reclaiming public health, demanding a
people. system for universal access to appropriate
health care, in a rights based framework
In this situation of inadequate and top-down
development of public health, the impact of We thus find ourselves at a crossroads: health
globalisation-liberalisation has led to an care can be considered a commodity to be sold,
ultimate denouement; there has been a or it can be considered a basic social right. It
retreat from even the nominal universal health cannot comfortably be considered both of these
care access objectives. Guided by at the same time. This, I believe is the great
prescriptions from agencies such as the World drama of medicine at the start of this century.
Bank, public health care is being further And this is the choice before all people of faith
constricted to certain ‘cost effective’ and good will in these dangerous times.
preventive-promotive services and selective
interventions such as Family Planning, - Paul Farmer
paralleled by spiraling and unregulated
expansion of the private medical sector. Given the context described in detail in this
report, today we face a situation that presents
This phase has witnessed staggering health both a historic crisis and a unique
inequities, resurgence of communicable opportunity. On one hand, the public health
diseases and an even more unregulated drug system is in a crisis; on the other hand, the
industry with spiraling drug prices, adding new National Government is forced to accept
up to the current crisis in public health. Along that certain measures to strengthen public

Abhay Shukla
health will have to be taken, in order to with an air of ‘neutrality’, though their effects
alleviate the situation. This opens certain in the health sector, in terms of suffering and
spaces for pro-people civil society lost lives, have been devastating in scale and
organizations to intervene in shaping of Public depth –
health policy at various levels.
The big bankers of the world, who practice the
A Contention Between Two Paradigms terrorism of money, are more powerful than
As we attempt such intervention, we may keep kings or field marshals, even more than the
in mind that while the health system is Pope of Rome himself. They never dirty their
usually an instrument of maintaining the hands. They kill no one: they limit themselves
hegemony of the dominant social order, it can to applauding the show.
also be an arena for asserting people’s claims
for services and accountability, and hence Their officials, international technocrats, rule
people’s power. In this context, in the arena our countries: they are neither presidents nor
of health care, today two competing paradigms ministers, they have not been elected, but they
confront each other. The ruling paradigm may decide the level of salaries and public
be characterised as ‘Health care as commodity expenditure, investments and divestments,
/ health care as safety net’. In this paradigm, prices, taxes, interest rates, subsidies, when
citizens should generally purchase health care the sun shines and how frequently it rains.
as a commodity (mostly from the private However, they don’t concern themselves with
medical system) and the role of the state is to the prisons or torture chambers or concentration
only provide rudimentary preventive services, camps or extermination centres, although these
and some elementary health care to the house the inevitable consequences of their acts.
poorest sections of the population, who may The technocrats claim the privilege of
not be able to afford health care in the market. irresponsibility: “We’re neutral” they say.
It may be noted that within this paradigm the
dominant mode is the commodification of health - Eduardo Galeano
care, and the safety net relates only to the
exceptions, to certain ‘non-marketisable’ Confronting this ruling paradigm is the
preventive services (e.g. immunization, emergent, people’s paradigm of ‘Health care
surveillance) and concerning the most as a Human Right’. The human rights
indigent section of the population, who would approach to health is of course not novel,
be completely incapable of accessing services since it had been implicit in various
in the market. Profit driven, often exploitative community-based and alternative approaches
and irrational marketised care is the ‘real face’ to health care during the last few decades.
while the safety net is the mask, which we But with the debilitation and ‘internal
are supposed to be gullible enough to perceive demolition’ of the public health sector, and
as a ‘human face’; this, in a nutshell, is wholesale ‘takeover’ by the private medical
‘Liberalisation with a human face’ in the sector especially in the ‘lost decade of
health sector. Of course, this is a somewhat liberalisation’ of the 1990s, the need to assert
idealized description of the ruling paradigm, the undeniable responsibility and public
which in practice today is unable to provide accountability of the state for health care has
the ‘safety net’ even for the poorest, whom it become imperative and urgent, leading to the
is nominally concerned about. The dominant current relevance of an explicit human rights
paradigm, whose nature and effects are approach to health. Given the deepening crisis
critically analysed throughout this report, is in public health, the coming period is likely
imposed with impressive ‘technical’ to see a growing public contention between
arguments such as cost-efficiency and macro- these two paradigms. As Paul Farmer has
economic considerations, which are presented noted, these two paradigms cannot

comfortably coexist with each other, and they infrastructure, humanpower, services
will have to be publicly debated, while and supplies at various levels, restoring
definitive choices will have to be made. the basic functionality of the system
Following on this it may be submitted that a and rebuilding public confidence.
task before public health academics, pro- However, such rejuvenation would not
people health professionals, health activists, be possible without bringing the public
people’s movements and developmental to the centre of the public health system.
organisations is to strongly and unequivocally Mechanisms for public accountability
assert the position, that Health care is a Human would need to be put in place (see
Right in all public platforms and through all below), along with reorientation of staff
means of mobilization available. As in other at various levels to rebuild their
social sectors, such assertion can lead to motivation and responsiveness.
widening popular support for this position, " The base of strengthened public health
providing the basis for a people’s counter- would need to be a framework of
vision to emerge, challenging the dominant comprehensive Primary Health Care
paradigm. including Community health workers
in every habitation, much more
Some Policy Objectives to Work Towards functional and accountable Primary
With this perspective, it may be suggested that health centres and First referral units,
a policy goal we can work towards is combined with a range of appropriate
establishment of a system for Universal access preventive and promotive activities.
to appropriate, quality health care as a right. The indispensability of Community
Concretising this goal will of course require health workers (Chapter 5) has been
considerable debate within the health noted time and again, yet the need for
movement, and documents such as the strong community anchoring, flexibility
People’s Health Charter may provide a broad and local evolution of diverse models,
framework for such discussions. A complex emphasis on empowering women, role
and difficult process of social mobilisation, of community representation and
policy debate and shaping of political will demand generation by the CHW, and
would be required to make such a situation hence a strong, equitable (not top-
even partly a reality. As mentioned above, it down) linkage with the public health
would not be just a narrow ‘demanding of system need to be considered while
existing entitlements’ but would also require developing these programmes. This
a broader interpretation of health rights, with would need to be accompanied by a
a progressive redefining of entitlements. It significant degree of genuine
may be suggested that we would need to work decentralisation of planning (which
for some of the following objectives (a presupposes decentralisation of
demonstrative, not exhaustive list), in order finances and power, not just
to move towards achieving this larger goal: responsibility), and evolving options
" First and foremost, a considerably relevant to various local situations,
strengthened, accountable and while adhering to the broad principle
reoriented public health system. Such of universal and equitable access.
a rejuvenation of the public health " Linked with such strengthening of the
system would require changes at levels public health system, to
of policy, structure, programmes, and institutionalize accountability would
processes; several of such changes that require a legal and constitutional
are required have been pointed out in framework to assure health services as
various chapters of this report. Such a Right. The definition of ‘essential
strengthening should ensure adequate services’ i.e. the range of services that

Abhay Shukla
would be ensured for all citizens as a sections would need to be brought

legal entitlement, has been an issue of under its ambit comprehensively and
severe political contention in all effectively. Since insurance is based on
countries wherever the ‘universal the principle of cross subsidization,
access package’ has been defined. with the well subsidizing the sick, and
Once a legal right to health care is the rich subsidizing the poor, any
considered, the same tussle may be system of insurance that only targets
expected to take place in India, and the the poor cannot be genuinely effective.
task of the health movement would be Targeted approaches will not work,
to make sure the range of services is since a health system only for the poor
as comprehensive as possible, and to usually lands up becoming a poor
ensure that the services required by health system.
various marginalized sections and " Specific Health care requirements of
groups with special needs are definitely various groups with special needs –
included. such as women, children, and elderly
" The above processes would obviously persons – would need to be met
necessitate mechanisms for through sets of special measures,
substantially raising public finances for sensitively delivered by the general
the public health system, through health system. A range of such
general taxation along with various measures have been described in
forms of special taxation and cesses for chapters 6 and 7 of this report.
health security. Corporations and Women’s health will have to be
employers in both organized and conceptualized and addressed in a
unorganized sectors could be required framework larger than reproductive
to contribute substantially to the health, reaching women in all stages
general health system, even as their of the lifecycle, while services for the
employees including unorganized entire range of women’s health issues
workers receive good quality health are integrated with an upgraded
care coverage from a strengthened general health system. To give justice
health system. Ending subsidization of to reproductive health itself, it will have
the private medical sector and to be saved from the clutches of the
effectively taxing this sector, especially Family Welfare programme, and all
its upper end; a special health security coercive measures for population
cess on all financial transactions above control should be regarded as serious
a certain level; and preferential human rights violations (Chapter 9)
taxation of industries with negative and terminated. In the context of
health impacts are some other children’s health and nutrition, ICDS
measures that have been suggested. As will require universalisation, enhanced
a form of cross-subsidisation, funds and staffing support, systematic
Universal social insurance with linkage with the health care and
premiums being integrated with the education systems, and a much greater
taxation system, may be seriously role to the community. Concerning
considered (Chapter 12). However, health care, children, perhaps more
there have to be mechanisms to ensure than any other population group,
that the significant proportion of the require a well functioning health
population that is poor, and already system at all levels, from community
pays indirect taxes, is exempted from health workers to tertiary hospitals;
such premiums. At the same time, in this system would need to be attuned
a universal system, the well-to-do to meet the special needs of children.

Important currently unaddressed areas would never agree to observe ceilings

such as Violence against women would on costs, and the latter because it may
need a range of measures integrated not be able to meet minimum quality
with the public health system as criteria. However, the former may be
detailed in Chapter 8. heavily taxed and restricted to catering
" Specific major health problems, both to a very narrow, high income clientele,
communicable diseases such as TB while the latter could be replaced in
and HIV-AIDS, and non-communicable rural areas over a period of time, by
health issues such as mental health well-trained and equipped community
would need to be addressed through health workers linked to the public
programmes closely integrated with a health system.
robust comprehensive health system, As a next step, private medical facilities
as detailed in Chapter 4. These that have demonstrated that they
programmes integrated with the follow minimum standards and
comprehensive system could subsume treatment guidelines may be
and replace the current selective, progressively brought under the
vertical programmes. Concerning umbrella of a Universal access system
communicable disease control, the and may be contracted by this publicly
emphasis would need to be on social- regulated system to provide services,
ecological methods appropriate to while the recipient of care is not
various diseases and situations, with required to pay while receiving these
involvement of communities in services.
planning and implementation, which " Much more effective public health
are presently major gaps. support to indigenous healing systems
" Progressively bringing the private is required, including active research
medical sector under social regulation on areas such as community based
would be essential for realization of evaluation of indigenous healing
health rights in any meaningful methods and synergistic combination
manner. A first step in this direction with modern medicine. The level of
would consist of legally and public funding for ISM institutions,
organizationally ensuring that this both for care and research would need
sector meets minimum standards, to be substantially increased to make
follows standard treatment guidelines, this possible.
and observes ceilings on prices of The present paradoxical situation
essential health services. While such where a large proportion of non-
measures would be resisted by much allopathic doctors routinely and mainly
of the private medical profession, there practice allopathy needs to be
may be sections of rational doctors who addressed, with a view to ensuring
could participate in the formulation of rational and accessible care to all. One
standards and guidelines, and could option is to offer additional training in
promote self-regulation. However, rational use of modern medicine for
paradoxically, two extreme ends of the Primary health care to non-allopathic
spectrum in private medical care – the practitioners who want to practice
Luxury tertiary medical sector at one allopathy at the primary level; similarly
end, and the low-cost, completely allopathic doctors may be encouraged
unqualified rural practitioners (often to opt for additional training such as
termed ‘quacks’) at the other end, may in Basic Ayurveda / Basic herbal
both try to totally escape the net of medicine, to practice certain basic
regulation. The former, because it elements of these healing systems. The

Abhay Shukla
emphasis would need to be on A genuine concern may be raised, as to

integration of systems and creation of whether it is realistic to expect all these, and
‘Basic doctors’ who can provide a range other similar changes to materialize in the
of appropriate care especially at the present larger socio-political scenario. There
primary level. is no guarantee that the state and the political
" Ensuring access to essential drugs in system will respond to demands and
a rights based framework, both in form assertions of health rights, howsoever justified
of ensuring availability of the range of and popularly supported they may be. Each
essential drugs free of cost in public of the changes mentioned above would require
health facilities, and stringent price protracted, sustained efforts. Given this
control by inclusion of all essential scenario, what can, and should be attempted,
drugs in the DPCO, are objectives to is to strongly assert people’s Right to health
work towards in the immediate future. care, while presenting a powerful alternative
Promotion of generics, effective drug vision of a pro-people health system, through
quality control and elimination of various forms of mobilisation and political
irrational formulations and action. If this gains broad and sustained
combinations are issues already on the popular support, the system is likely to
agenda. With India moving towards respond and to yield health rights in certain
becoming WTO compliant, the demand form. Even if partial, these can become the
to keep essential drugs and drugs basis for extension of rights, by further
related to major public health problems mobilisation and struggle, since rights
outside the purview of TRIPS naturally lend themselves to extension and
regulations can attract broad popular expansion. A large, long-term vision can guide
support, with the potential of becoming small, yet definite advances in the short term;
a flashpoint issue to oppose the current the Rights approach allows us to link the two.
framework of hegemonic globalisation. However, at some point of time the system
" Operationalising accountability and may reach its limits of responsiveness, and
redressal mechanisms to ensure may stonewall further demands. Such a
regular civil society monitoring and scenario is likely, relating not to health rights
inputs at various levels (village / block alone, but regarding an entire range of social
/ district / state / national), which and economic rights, due to the congealing
would be the concrete form of the of powerful vested interests at national and
public re-entering and reclaiming the transnational levels. Yet if by the time such a
public health system. Panchayati Raj juncture is reached, the large majority of
institutions, complemented by various social opinion is in favour of a radical
community based organisations restructuring of society in order to enable
including women’s groups could play popular aspirations to be met, and these
a key role in ensuring accountability popular forces are organized in a coherent
of the health system. If a community form, then the stage may be set for larger
anchored village worker programme is transformation.
developed, the health worker
supported by a village health group The Long Term and Larger Vision
could play a role in ensuring improved Linking the struggle for health rights to the
utilization and accountability of struggle for a spectrum of rights, with a vision
services. At the same time, an effective of systemic change
redressal system would be required to
deal with complaints and denial of “Should medicine ever fulfil its great ends, it
health care in various forms through must enter into the larger political and social
responsive, time bound mechanisms. life of our time; it must indicate the barriers

which obstruct the normal completion of the life improvement in the situation of the working
cycle and remove them.” people, and of various deprived and
- Rudolf Virchow marginalized sections of society. It can also
be one channel for people to assert their
History says, Don’t hope strength, by demanding that public
On this side of the grave, institutions work for them effectively. This can
But then, once in a lifetime become one of many arenas of public
The longed for tidal wave organization and mobilisation, of assertion of
Of justice can rise up people’s power. In this broader context, the
And hope and history rhyme. ‘Right to Health care’ and certain other health
- Seamus Heaney related rights are potentially at least partially
achievable in the current social framework.
Can the goal of ‘Health for All’ can be achieved
in the present socio-economic system, in the However, achievement of the ‘Right to Health’
context of systemic exploitation responsible for all, in its fullest comprehensive sense,
for massive poverty and structural inequities, which constitutes our larger vision, is
in the broader setting of large scale global inextricably linked with larger social
expropriation, mediated by trade and transformations. Hence the struggle for public
facilitated by global financial institutions? One health, in its deepest sense as envisaged by
answer would be, ‘Health for All’, in its fullest Virchow, necessitates that health activists
and most humane sense – requiring, among also engage with such a larger vision and
other conditions, comprehensive nutritional broader struggles.
and food security (linked to livelihood
security), universal access to safe drinking Keeping this in mind, the struggle for health
water and sanitation, provision of healthy rights must move on to link with several other
housing and local environments, universal struggles for the rights to food, water,
healthy working conditions and a safe general education, housing, livelihood and social
environment, access to health related justice in various forms, not only because
education and information for all, and an these rights are extremely germane to the
equitable, gender-just social milieu, free from improvement of health, but also because the
violence - should remain our larger vision. struggle for health rights must form one
While definite progress can be made towards strand of a much larger struggle to challenge
achieving these goals in the present socio- the dominant social order. Establishing
economic situation, this is unlikely to be people’s Right to health care, even in a partial
achieved in entirety within the globally form, may be one of the platforms for
defined, economic and social framework developing people’s awareness and strength,
prevailing in India today. and for beginning to shape certain incipient
The achievement of a strengthened public models of the future within the present. But
health system, which is more accountable to moving further, a broader movement needs
ordinary citizens, is a potentially achievable to take shape, to present coherent alternatives
goal to fight for within the existing system. in myriad spheres of life, to give people
Similarly, the health movement must lend it capacity and hope, to challenge the dominant
strength and voice to movements for system, and to nurture the tender saplings of
improving health related entitlements such the future, even in the harsh world of today.
as nutritional services and food security, clean Only such a movement can also dream of
drinking water, sanitation and safer replacing the current unhealthy and
environmental and working conditions, which inequitable socio-economic system, by one
may be achieved to certain extent. Such that is far more just, humane and healthy, in
struggles can lead to some concrete the world of tomorrow

SECTION 6
STATISTICAL APPENDIX
APPENDIX
STATISTICAL TABLES
Compiled by : Prashant Raymus from CEHAT Database
Statistical Tables
TABLE TITLE PAGE

NO. NO.
1. OUTCOME INDICATORS
! 1.1 Crude Birth Rate: All India ....................................................................... S-1
! 1.2 Infant Mortality Rate: All India ................................................................. S-3
! 1.3 Still Birth Rate: All India ........................................................................... S-5
! 1.4 Total Fertility Rate: All India ..................................................................... S-6
! 1.5 Percentage Institutional Births ................................................................. S-8
! 1.6 Percentage Births Attended by Trained Practitioners ................................ S-10
! 1.7 Neo-natal Mortality Rate: All India ............................................................ S-12
2. INFRASTRUCTURE AND RESOURCES
! 2.1 Doctors and Nurses: All India ................................................................... S-14
! 2.2 Hospitals: All India ................................................................................... S-15
! 2.3 Dispensaries: All India ............................................................................. S-17
! 2.4 Primary Health Centres and Sub Centres: All India .................................. S-19
! 2.5 Beds: All India .......................................................................................... S-20
3. PUBLIC HEALTH EXPENDITURES
! 3.1 Revenue Expenditure on Health ............................................................... S-22
! 3.2 Capital Expenditure on Health ................................................................. S-23
! 3.3 Health Expenditure as Percentage of Total Expenditure ........................... S-24
! 3.4 Total Revenue Expenditure, State and Union ........................................... S-25
! 3.5 Total Capital Expenditure, State and Union ............................................. S-26
! 3.6 Revenue receipts from Public Health and Family Welfare as
Percent of Revenue Health Expenditure ................................................... S-27
! 3.7 Revenue Receipts from Public Health and Family Welfare ......................... S-28
! 3.8 Revenue Receipts from Medical as Percent of
Revenue Health Expenditure .................................................................... S-29
! 3.9 Central Government Health Scheme (CGHS)/ Employees State
Insurance Schemes (ESIS) Revenue Receipt ............................................. S-30
! 3.10 Receipts from Services and Fees (Medical) ................................................ S-31
! 3.11 Revenue Expenditure on Family Welfare .................................................. S-32
! 3.12 Capital Expenditure on Family Welfare ..................................................... S-33
! 3.13 Expenditure on Medical Services .............................................................. S-34
! 3.14 Total Expenditure on Public Health .......................................................... S-35
! 3.15 Expenditure on National Disease Programme ........................................... S-36
! 3.16 Expenditure on Hospitals and Dispensaries ............................................. S-37
! 3.17 Expenditure on Central Government Health Scheme (CGHS)/
Employees State Insurance Schemes (ESIS) ............................................. S-38
! 3.18 Revenue Expenditure on Medical Education, Training and Research ........ S-39
! 3.19 Capital Expenditure on Medical Education, Training and Research .......... S-40
! 3.20 Revenue Expenditure on Rural Family Welfare Services ........................... S-41
! 3.21 Revenue Expenditure on Urban Family Welfare Services .......................... S-42
! 3.22 Revenue Expenditure on Maternal and Child Health ................................ S-43
GLOSSARY .............................................................................................. S-44
Compiled by : Prashant Raymus
1.1: Crude Birth Rate: All India (per 1000 population)
1981 1986 1991

State/Year
Total Rural Urban Total Rural Urban Total Rural Urban
Andaman & Nicobar 34.0 35.5 22.7 25.5 27.0 20.6 20.0 21.5 15.2
Andhra Pradesh 31.7 32.7 27.5 31.6 32.4 28.7 26.0 26.5 24.4
Arunachal Pradesh NA 32.1 NA 40.2 40.7 33.9 30.9 31.6 24.0
Assam 33.0 33.8 23.2 34.7 35.5 24.8 30.9 31.7 21.3
Bihar 39.1 39.7 33.9 36.5 37.2 29.8 30.7 31.3 25.5
Chandigarh 24.6 32.9 23.4 23.7 29.6 23.2 13.9 19.2 13.5
Chattisgarh - - - - - - - - -
Dadra & Nagar Havel NA NA NA NA NA NA NA NA NA
Delhi 26.9 36.0 25.8 29.5 35.9 29.0 24.7 30.2 24.2
Goa,Daman & Diu 15.5 16.3 13.2 20.2 19.9 20.8 16.8 16.7 16.9
Gujarat 34.5 36.1 29.8 32.2 32.9 30.8 27.5 28.2 25.9
Haryana 36.5 37.8 29.6 35.3 36.9 29.6 33.1 34.7 27.2
Himachal Pradesh 31.5 32.4 17.3 30.6 31.3 20.0 28.5 29.2 18.6
Jammu & Kashmir 31.6 33.9 21.4 33.4 35.6 25.4 NA NA NA
Jharkhand - - - - - - - - -
Karnataka 28.3 29.2 25.7 29.0 29.9 26.8 26.9 27.9 24.0
Kerala 25.6 26.0 23.5 22.5 22.4 23.0 18.3 18.4 18.1
Lakshadweep(I) NA 29.7 NA 32.1 37.0 26.8 27.1 30.0 23.8
Madhya Pradesh 37.6 38.8 31.4 37.2 39.0 30.1 35.8 37.3 29.7
Maharashtra 28.5 30.4 24.5 30.1 31.7 27.4 26.2 28.0 22.9
Manipur 26.6 26.8 24.4 25.7 27.4 20.2 20.1 20.7 18.0
Meghalaya 32.6 35.0 18.5 35.4 38.3 21.7 32.4 35.4 18.7
Mizoram NA NA NA NA NA NA NA NA NA
Nagaland NA NA NA 25.2 26.6 18.6 18.5 20.4 10.1
Orissa 33.1 33.4 29.3 32.5 33.2 26.8 28.8 29.6 21.6
Pondicherry 21.7 22.8 14.7 22.5 23.4 21.8 19.2 20.5 18.1
Punjab 30.3 30.8 28.5 28.7 29.0 27.6 27.7 28.5 25.6
Rajasthan 37.1 38.3 31.2 36.4 37.9 29.8 35.0 36.0 30.3
Sikkim 31.0 32.2 26.6 32.1 33.8 24.4 22.5 24.2 14.4
Tamil Nadu 28.0 29.7 23.9 23.8 24.1 23.1 20.8 20.8 20.8
Tripura 26.4 27.6 14.8 28.5 29.1 22.4 24.4 25.4 15.5
Uttar Pradesh 39.6 40.8 31.5 37.5 39.1 30.7 35.7 37.2 29.0
Uttaranchal - - - - - - - - -
West Bengal 33.2 37.0 20.0 29.7 33.5 20.1 27.0 30.3 18.5
All INDIA 33.9 35.6 27.0 32.6 34.2 27.1 29.5 30.9 24.3
Sources: Health Information of India,CBHI,GOI, respective years
Note: NA - not available; Data for Chattisgarh, Jharkhand, Uttaranchal are included in their parent
state
(Cont...)
Review of Health Care in India " S-1

Statistical Tables
(Cont...) 1.1: Crude Birth Rate: All India (per 1000 population)
1996 1998 2000

State/Year
Andaman & Nicobar 18.5 19.1 16.8 17.7 18.0 16.8 19.1 19.0 19.3
Andhra Pradesh 22.8 23.5 20.6 22.4 22.8 21.1 NA 21.7 NA
Arunachal Pradesh 21.9 23.0 10.4 22.5 23.3 13.6 NA 23.1 NA
Assam 27.6 28.9 20.7 27.9 28.7 20.2 NA 27.9 NA
Bihar 32.1 33.1 23.6 31.1 32.1 23.1 NA 32.8 NA
Chandigarh 17.5 20.9 17.2 17.9 21.3 17.5 17.5 18.9 17.3
Chattisgarh - - - NA 24.5 NA NA 29.2 NA
Dadra & Nagar Havel 28.9 29.5 22.7 34.1 23.4 23.4 34.9 35.9 24.0
Delhi 21.6 25.5 21.1 19.4 20.9 19.3 20.3 21.4 20.1
Goa,Daman & Diu 14.4 15.5 13.0 14.3 14.6 14.0 NA 14.3 NA
Gujarat 25.7 26.9 23.0 25.5 27.0 22.2 NA 26.8 NA
Haryana 28.8 30.1 24.1 27.6 28.8 23.3 26.9 28.0 23.0
Jammu & Kashmir NA NA NA NA NA NA 19.6 20.5 16.5
Jharkhand - - - - - - NA 28.8 NA
Karnataka 23.0 24.2 20.3 22.0 23.1 19.4 22 23.3 19.1
Kerala 18.0 18.0 17.9 18.3 18.3 18.2 17.9 18.0 17.5
Lakshadweep(I) 23.4 23.8 23.1 23.0 23.5 22.3 26.1 27.6 24.6
Madhya Pradesh 32.3 34.2 23.0 30.7 32.1 23.1 31.2 33.4 23.5
Maharashtra 23.4 24.0 21.0 22.5 23.6 20.8 20.9 21.4 20.3
Manipur 19.6 20.6 17.1 19.0 19.9 16.7 18.3 19.1 16.2
Meghalaya 30.4 33.2 16.3 29.2 31.8 15.6 28.5 31.0 15.3
Mizoram NA NA NA 15.8 18.1 13.1 NA 19.2 NA
Nagaland NA 14.5 14.5 NA NA 11.9 NA N.A. 12.2
Orissa 27.0 27.7 21.3 25.7 26.4 20.9 24.3 24.9 20.1
Pondicherry 18.1 20.7 16.3 18.2 18.3 18.1 NA 18.4 NA
Punjab 23.7 25.2 19.1 22.4 23.7 18.5 21.5 22.7 18.5
Rajasthan 32.4 34.0 25.1 31.6 33.1 24.7 31.2 32.8 25.0
Sikkim 20.0 20.3 11.3 20.9 21.2 13.5 21.8 22.1 14.8
Tamil Nadu 19.5 20.0 18.4 19.2 19.7 18.1 19.2 20.0 18.0
Tripura 18.4 19.2 14.2 17.6 18.2 14.8 16.5 17.0 14.0
Uttar Pradesh 34.0 35.0 28.0 32.4 33.4 27.2 32.8 34.0 27.2
Uttaranchal - - - - - - NA 24.6 NA
West Bengal 22.8 25.3 16.0 21.3 23.4 15.2 20.6 23.0 14.0
All INDIA 27.5 29.3 21.6 26.5 28.0 21.1 25.8 27.6 20.7
state

1.2: Infant Mortality Rates: All India (per 1000 live births)
1981 1986 1991

State/Year
Andaman & Nicobar NA NA NA NA NA NA 30.0 31.5 23.0
Andhra Pradesh 86.0 93.0 52.0 82.0 87.5 59.0 73.0 77.0 56.0
Arunachal Pradesh NA NA NA NA NA NA 64.5 67.1 27.2
Assam 106.0 107.0 76.0 109.0 111.0 69.0 81.0 83.0 42.0
Bihar 118.0 124.0 60.0 101.0 104.0 68.0 69.0 71.0 46.0
Chandigarh NA NA NA NA NA NA 35.3 32.2 35.7
Chattisgarh - - - - - - - - -
Dadra & Nagar Haveli NA NA NA NA NA NA 68.0 68.0 0
Delhi NA NA NA NA NA NA 42.7 69.4 39.8
Goa,Daman & Diu NA NA NA NA NA NA 20.8 25.4 11.7
Gujarat 116.0 123.0 89.0 107.0 124.0 66.0 69.0 73.0 57.0
Haryana 101.0 108.0 52.0 85.0 91.0 58.0 68.0 73.0 49.0
Jharkhand - - - - - - - - -
Karnataka 69.0 77.0 45.0 73.0 82.0 47.0 77.0 87.0 47.0
Kerala 37.0 40.0 24.0 27.0 28.0 20.0 16.0 17.0 16.0
Lakshadweep(I) NA NA NA NA NA NA 43.8 66.7 11.9
Madhya Pradesh 142.0 152.0 80.0 118.0 124.0 82.0 117.0 125.0 74.0
Maharashtra 79.0 90.0 49.0 63.0 73.0 44.0 60.0 69.0 38.0
Manipur NA NA NA NA NA NA 21.7 22.1 20.0
Meghalaya NA NA NA NA NA NA 57.0 61.5 18.3
Nagaland NA NA NA NA NA NA 6.6 7.4 0
Orissa 135.0 140.0 68.0 123.0 127.0 75.0 124.0 129.0 71.0
Pondicherry NA NA NA NA NA NA 21.2 21.8 20.7
Punjab 81.0 88.0 51.0 68.0 72.0 55.0 53.0 58.0 40.0
Rajasthan 108.0 118.0 53.0 107.0 113.0 71.0 79.0 84.0 50.0
Sikkim NA NA NA NA NA NA 51.0 53.8 29.5
Tamil Nadu 91.0 103.7 55.3 80.0 92.6 54.0 57.0 65.0 42.0
Tripura NA NA NA NA NA NA 56.2 56.9 45.7
Uttar Pradesh 150.0 157.0 97.0 132.0 140.0 88.0 97.0 102.0 74.0
Uttaranchal - - - - - - - - -
West Bengal 91.0 98.0 44.0 71.0 75.0 55.0 71.0 76.0 47.0
All India 110.4 119.1 62.5 96.4 104.6 62.0 80.0 87.0 53.0
state
(Cont...)

Statistical Tables
(Cont...) 1.2: Infant Mortality Rates: All India (per 1000 live births)
1996 1998 2000

State/Year
Andaman & Nicobar 29.5 36.6 6.6 30.0 37.0 9.0 23.0 27.0 10.0
Andhra Pradesh 65.0 73.0 38.0 66.0 75.0 38.0 NA NA NA
Arunachal Pradesh 38.6 40.3 0 44.0 46.0 10.0 NA NA NA
Assam 74.0 79.0 37.0 76.0 80.0 36.0 NA NA NA
Bihar 71.0 73.0 54.0 67.0 68.0 51.0 NA NA NA
Chandigarh 27.0 44.6 24.6 32.0 44.0 30.0 28.0 38.0 26.0
Chattisgarh - - - NA 36 NA NA NA NA
Dadra & Nagar Haveli 57.2 61.2 0 61.0 65.0 7.0 58.0 62.0 14.0
Delhi 40.7 36.2 41.3 36.0 36.0 36.0 32.0 32.0 32.0
Goa,Daman & Diu 24.8 26.7 21.6 44.0 46.0 10.0 NA NA NA
Gujarat 61.0 68.0 46.0 64.0 71.0 46.0 NA NA NA
Haryana 68.0 70.0 60.0 70.0 72.0 59.0 67.0 69.0 57.0
Jammu & Kashmir NA NA NA NA NA NA 50.0 51.0 45.0
Jharkhand - - - - - - - - -
Karnataka 53.0 63.0 25.0 58.0 70.0 25.0 57.0 68.0 24.0
Kerala 14.0 13.0 16.0 16.0 15.0 17.0 14.0 14.0 14.0
Lakshadweep(I) 16.3 22.0 10.8 26.0 22.0 30.0 27.0 25.0 29.0
Madhya Pradesh 97.0 102.0 61.0 98.0 104.0 56.0 88.0 94.0 54.0
Maharashtra 48.0 58.0 31.0 49.0 58.0 32.0 48.0 57.0 33.0
Manipur 23.6 23.6 23.7 25.0 22.0 26.0 23.0 23.0 25.0
Meghalaya 47.7 48.9 36.3 52.0 54.0 36.0 58.0 61.0 32.0
Mizoram NA NA NA 23.0 26.0 18.0 NA NA NA
Nagaland 32.8 NA 32.8 NA NA 16.0 NA NA 23.0
Orissa 96.0 99.0 65.0 98.0 101.0 66.0 96.0 99.0 66.0
Pondicherry 14.6 21.9 8.4 21.0 31.0 14.0 NA NA NA
Punjab 51.0 54.0 40.0 54.0 58.0 40.0 52.0 56.0 38.0
Rajasthan 85.0 90.0 60.0 83.0 87.0 60.0 79.0 83.0 58.0
Sikkim 52.9 53.0 50.6 52.0 52.0 44.0 49.0 49.0 36.0
Tamil Nadu 53.0 60.0 39.0 53.0 59.0 40.0 51.0 57.0 38.0
Tripura 48.5 48.6 47.6 49.0 50.0 39.0 41.0 42.0 32.0
Uttar Pradesh 85.0 88.0 67.0 85.0 89.0 65.0 83.0 87.0 65.0
Uttaranchal - - - - - - - - -
West Bengal 55.0 58.0 44.0 53.0 56.0 41.0 51.0 54.0 37.0
All India 72.0 77.0 46.0 72.0 77.0 45.0 68.0 74.0 43.0
state

1.3: Still birth Rate: All India (per 1000 live births)
1981 1986 1991

State/Year
Andhra Pradesh 13.8 15.1 7.3 11.9 10.5 17.2 14.7 13.8 18.5
Assam 16.8 17.4 6.1 14.2 14.4 11.6 13.8 14.1 7.4
Bihar 11.2 12.0 4.2 9.0 9.3 5.7 5.1 5.2 4.5
Chattisgarh NA NA NA NA NA NA NA NA NA
Gujarat 4.4 3.8 6.7 6.2 4.9 9.3 5.8 4.5 9.0
Haryana 11.5 12.0 7.5 13.2 14.8 6.0 11.3 12.5 5.6
Himachal Pradesh NA NA NA 8.3 8.5 3.8 13.7 14.1 3.6
Karnataka 11.7 13.1 7.6 11.5 12.2 9.6 20.4 22.1 15.2
Kerala 11.3 12.4 4.8 10.3 10.1 11.0 9.2 10.2 4.6
Madhya Pradesh 9.5 9.1 11.9 8.2 7.8 10.5 11.4 11.7 10.3
Maharashtra 8.3 9.8 4.4 12.1 13.7 8.9 11.4 11.2 11.8
Orissa 9.8 10.1 5.8 14.6 15.6 3.6 17.8 18.3 12.0
Punjab 13.2 14.3 8.6 12.9 14.7 7.8 24.7 27.6 16.1
Rajasthan 7.6 8.1 5.0 7.7 7.7 7.8 5.9 6.5 2.7
Tamil Nadu 8.6 9.9 4.8 10.4 11.4 8.5 9.9 8.4 12.7
Uttar Pradesh 12.6 13.5 4.4 8.6 9.3 4.7 8.5 8.9 5.9
West Bengal 9.2 9.4 7.7 12.7 13.4 9.6 12.4 13.6 7.2
All INDIA 10.6 11.4 6.2 10.2 10.5 9.0 10.7 10.9 9.6
(Cont...)
(Cont...) 1.3: Still birth Rate: All India (per 1000 live births)
1996 1998
State/Year
Total Rural Urban Total Rural Urban
Andhra Pradesh 9.0 9.0 9.0 9.0 9.0 8.0
Assam 11.0 10.0 14.0 17.0 18.0 15.0
Bihar 12.0 12.0 11.0 11.0 12.0 6.0
Chattisgarh 6.0 5.0 13.0 4.0 4.0 2.0
Gujarat NA NA NA NA NA NA
Haryana 4.0 3.0 5.0 4.0 3.0 4.0
Himachal Pradesh 10.0 10.0 9.0 12.0 12.0 8.0
Jammu & Kashmir 7.0 6.0 8.0 12.0 12.0 7.0
Karnataka NA NA NA NA NA NA
Kerala 14.0 13.0 16.0 21.0 21.0 21.0
Madhya Pradesh 10.0 9.0 11.0 15.0 14.0 17.0
Maharashtra 10.0 10.0 7.0 7.0 7.0 4.0
Mizoram 12.0 14.0 10.0 11.0 12.0 9.0
Orissa NA NA NA NA NA NA
Punjab 15.0 16.0 8.0 17.0 18.0 8.0
Rajasthan 10.0 11.0 7.0 17.0 18.0 11.0
Tamil Nadu 6.0 6.0 5.0 NA NA NA
Uttar Pradesh 11.0 10.0 11.0 13.0 14.0 9.0
West Bengal 8.0 8.0 6.0 6.0 6.0 4.0
All INDIA 13.0 13.0 12.0 8.0 9.0 5.0
Note: NA - not available

Statistical Tables
1.4: Total Fertility Rate: All India
1981 1986 1991

State/Year
Andaman & Nicobar NA NA NA NA NA NA 2.6 2.4 3.3
Andhra Pradesh 4.0 4.2 3.0 3.8 4.1 3.1 3.0 3.1 2.5
Arunachal Pradesh NA NA NA NA NA NA 3.9 4.0 2.9
Assam 4.1 4.2 2.6 4.0 4.2 2.5 3.5 3.6 2.1
Bihar 5.7 5.8 4.8 5.2 5.3 4.2 4.4 4.5 3.5
Chandigarh NA NA NA NA NA NA 1.2 2.0 1.2
Chattisgarh - - - - - - - - -
Dadra & Nagar Havel NA NA NA NA NA NA 5.4 3.9 NA
Delhi NA NA NA NA NA NA 1.6 3.0 1.5
Goa,Daman & Diu NA NA NA NA NA NA 1.4 1.6 1.2
Gujarat 4.3 4.6 3.4 3.8 4.0 3.3 3.1 3.2 2.9
Haryana 5.0 5.3 3.5 4.4 4.8 3.3 4.0 4.3 3.0
Jharkhand - - - - - - - - -
Karnataka 3.6 3.8 3.0 3.5 3.7 2.9 3.1 3.3 2.5
Kerala 2.8 2.9 2.4 2.3 2.3 2.2 1.8 1.8 1.7
Lakshadweep(I) NA NA NA NA NA NA 5.4 3.1 8.1
Madhya Pradesh 5.2 5.5 3.9 4.9 5.4 3.5 4.6 4.9 3.4
Madras NA NA NA NA NA NA NA NA NA
Maharashtra 3.6 4.0 3.0 3.6 4.0 3.0 3.0 3.4 2.5
Manipur NA NA NA NA NA NA 2.2 2.5 1.4
Meghalaya NA NA NA NA NA NA 3.9 4.5 1.5
Nagaland NA NA NA NA NA NA 2.3 2.3 2.0
Orissa 4.3 4.3 3.7 4.2 4.3 3.1 3.3 3.4 2.3
Pondicherry NA NA NA NA NA NA 1.5 1.9 1.3
Punjab 4.0 4.1 3.4 3.4 3.6 3.1 3.1 3.2 2.8
Rajasthan 5.2 5.5 4.2 5.0 5.3 3.8 4.6 4.9 3.7
Sikkim NA NA NA NA NA NA 3.3 3.1 10.5
Tamil Nadu 3.4 3.7 2.7 2.7 2.8 2.4 2.2 2.3 2.0
Tripura NA NA NA NA NA NA 3.8 3.8 3.8
Uttar Pradesh 5.8 6.1 4.1 5.4 5.8 4.0 5.1 5.4 3.7
Uttaranchal - - - - - - - - -
West Bengal 4.2 4.8 2.4 3.6 4.2 2.3 3.2 3.6 2.1
All INDIA 4.5 4.8 3.3 4.2 4.5 3.1 3.6 3.9 2.7
Sources: Sample Registration System, Statistical Report, respective years; Compendium of India’s fertility
and mortality indicator 1971-1997 base on the Sample Registration System,1999
Note: NA - not available; Data for Chattisgarh, Jharkhand, Uttaranchal are included
in their parent state (Cont...)

(Cont...) 1.4: Total Fertility Rate: All India
1996 1998 1999

State/Year
Andaman & Nicobar 1.9 2.0 1.6 NA NA NA NA NA NA
Andhra Pradesh 2.5 2.7 2.1 2.4 2.6 2.1 2.4 2.5 2.1
Arunachal Pradesh 2.8 2.9 1.2 NA NA NA NA NA NA
Assam 3.2 3.4 2.1 3.2 3.4 2.0 3.2 3.3 1.9
Bihar 4.5 4.6 3.2 4.3 4.5 3.1 4.5 4.7 3.4
Chandigarh 2.1 2.6 2.1 NA NA NA NA NA NA
Chattisgarh - - - - - - - - -
Dadra & Nagar Havel 3.5 3.6 2.4 NA NA NA NA NA NA
Delhi 1.6 1.7 1.6 NA NA NA NA NA NA
Goa,Daman & Diu 1.5 1.6 1.3 NA NA NA NA NA NA
Gujarat 3.0 3.2 2.6 3.0 3.3 2.5 3.0 3.2 2.4
Haryana 3.5 3.8 2.7 3.3 3.5 2.7 3.2 3.3 2.6
Jammu & Kashmir NA NA NA NA NA NA NA NA NA
Jharkhand - - - - - - - - -
Karnataka 2.6 2.8 2.1 2.4 2.6 2.0 2.5 2.7 2.0
Kerala 1.8 1.8 1.8 1.8 1.8 1.9 1.8 1.8 1.8
Lakshadweep(I) 2.8 2.9 2.7 NA NA NA NA NA NA
Madhya Pradesh 4.1 4.4 2.5 3.9 4.1 2.6 3.9 4.3 2.6
Madras NA NA NA NA NA NA NA NA NA
Maharashtra 2.8 3.2 2.4 2.7 2.9 2.3 2.5 2.7 2.3
Manipur 2.4 2.6 2.1 NA NA NA NA NA NA
Meghalaya 4.0 4.5 1.7 NA NA NA NA NA NA
Nagaland 1.5 NA 1.5 NA NA NA NA NA NA
Orissa 3.1 3.3 2.3 2.9 3.0 2.3 2.7 2.8 2.2
Pondicherry 1.8 2.0 1.6 NA NA NA NA NA NA
Punjab 2.8 3.0 2.2 2.6 2.7 2.1 2.5 2.6 2.1
Rajasthan 4.2 4.5 3.0 4.1 4.4 3.0 4.2 4.4 3.0
Sikkim 2.5 2.6 1.4 NA NA NA NA NA NA
Tamil Nadu 2.1 2.2 1.8 2.0 4.8 3.6 2.0 2.1 1.8
Tripura 2.1 1.0 0.6 NA NA NA NA NA NA
Uttar Pradesh 4.9 5.1 3.7 4.6 4.8 3.6 4.7 5.0 3.6
Uttaranchal - - - - - - - - -
West Bengal 2.6 2.9 1.8 2.4 2.7 1.7 2.4 2.7 1.6
All INDIA 3.4 3.7 2.4 3.2 3.5 2.4 3.2 3.5 2.3
Sources: Sample Registration System, Statistical Report, respective years; Compendium of India’s fertility
and mortality indicator 1971-1997 base on the Sample Registration System,1999
state

Statistical Tables
1.5: Percentage Institutional Births: All India
1981 1986 1991

State/Year
Andaman & Nicobar NA NA NA NA NA NA NA NA NA
Andhra Pradesh 16.6 7.8 56.9 28.5 13.5 65.7 37.7 21.4 78.1
Arunachal Pradesh NA NA NA NA NA NA NA NA NA
Assam 16.1 7.6 41.3 15.6 10.4 45.9 18.3 12.9 50.9
Bihar 8.3 2.2 37.1 9.6 8.6 25.7 11.7 9.5 28.2
Chandigarh NA NA NA NA NA NA NA NA NA
Chattisgarh - - - - - - - - -
Delhi NA NA NA NA NA NA NA NA NA
Goa,Daman & Diu NA NA NA NA NA NA NA NA NA
Gujarat 12.4 6.3 43.9 21.4 14.9 56.7 23.5 16.3 64.8
Haryana 6.5 2.7 16.1 15.7 15.0 18.2 19.9 16.9 32.7
Jharkhand - - - - - - - - -
Karnataka 19.7 9.9 59.5 27.0 16.8 57.1 40.6 30.5 73.4
Kerala 52.7 46.3 77.4 78.1 76.5 85.0 91.5 90.6 95.3
Lakshadweep(I) NA NA NA NA NA NA NA NA NA
Madhya Pradesh 10.5 0.5 46.0 13.3 2.1 47.8 13.2 5.3 50.2
Maharashtra 26.5 10.9 69.5 33.7 20.2 72.0 34.3 20.9 75.9
Manipur NA NA NA NA NA NA NA NA NA
Meghalaya NA NA NA NA NA NA NA NA NA
Nagaland NA NA NA NA NA NA NA NA NA
Orissa 5.3 0.9 14.7 5.4 3.7 29.0 9.8 6.4 33.8
Pondicherry NA NA NA NA NA NA NA NA NA
Punjab 2.2 1.7 3.3 7.0 6.1 9.4 7.3 5.2 13.0
Rajasthan 3.1 0.4 11.3 3.8 1.4 16.4 5.0 2.6 16.8
Sikkim NA NA NA NA NA NA NA NA NA
Tamil Nadu 31.0 24.2 62.1 41.5 30.0 78.2 56.8 46.2 89.1
Tripura NA NA NA NA NA NA NA NA NA
Uttar Pradesh 5.8 0.3 14.6 3.6 1.8 13.1 4.5 2.7 14.1
Uttaranchal - - - - - - - - -
West Bengal 32.1 10.2 71.9 28.2 20.8 76.9 30.7 23.4 78.0
All INDIA 17.7 10.6 38.8 20.7 14.3 47.8 24.3 17.6 53.8
Sources: Sample Registration System, Statistical Report, respective years
state
(Cont...)

(Cont...) 1.5: Percentage Institutional Births: All India
1996 1998 1999

State/Year
Andhra Pradesh 42.1 31.0 81.6 42.8 31.3 81.8 43.0 31.4 81.9
Assam 20.9 18.3 52.7 21.1 18.5 53.0 21.0 18.6 53.0
Bihar 15.1 13.7 31.3 15.4 14.1 31.6 15.8 14.2 31.7
Chandigarh - - - - - - - - -
Gujarat 36.6 21.3 74.0 36.3 21.8 74.4 36.3 21.9 74.5
Haryana 24.3 20.0 44.6 24.7 20.3 44.9 24.8 20.4 45.0
Jharkhand - - - - - - - - -
Karnataka 49.2 37.7 80.1 49.2 37.9 80.4 49.0 38.0 80.5
Kerala 97.1 96.5 98.9 97.1 96.6 98.9 97.1 96.6 98.8
Madhya Pradesh 14.2 8.5 57.1 14.7 8.7 57.8 16.4 8.8 57.9
Maharashtra 47.4 30.0 79.3 47.8 30.1 79.7 48.6 30.2 79.7
Orissa 13.3 10.7 39.0 13.9 11.1 39.8 14.1 11.3 39.9
Punjab 12.5 12.4 12.8 12.7 12.6 13.1 12.8 12.7 13.2
Rajasthan 7.8 4.3 28.7 8.0 4.6 29.2 8.1 4.7 29.3
Tamil Nadu 64.7 52.2 92.4 64.8 52.4 92.7 64.7 52.5 92.7
Uttar Pradesh 7.5 5.5 19.6 7.8 5.9 20.0 8.0 6.0 20.1
Uttaranchal - - - - - - - - -
West Bengal 35.9 26.8 75.6 36.2 27.1 76.0 35.8 27.0 79.1
All INDIA 25.2 17.7 59.5 25.4 18.0 59.6 26.6 18.2 59.7
state

Statistical Tables
1.6: Percentage Births Attended by Trained Practitioners: All India
1981 1986 1991

State/Year
Andhra Pradesh 15.8 15.1 19.1 18.8 20.5 11.4 19.6 24.5 7.5
Assam 5.3 4.0 9.1 9.4 8.7 13.5 10.7 9.8 16.2
Bihar 5.3 4.5 8.6 12.4 10.8 25.1 15.3 13.5 29.2
Gujarat 23.0 24.5 15.5 30.4 33.9 11.6 33.6 36.6 16.2
Haryana 58.2 57.8 59.3 63 63.9 59.5 64.5 65.4 60.9
Jharkhand NA NA NA NA NA NA NA NA NA
Karnataka 13.8 14.8 9.7 26.6 30 16.8 23.5 26.2 14.8
Kerala 16.9 17.6 14.2 7.9 7.7 9.2 5.0 5.3 3.7
Madhya Pradesh 7.2 6.7 8.7 11.9 11.3 13.8 14.1 13.0 19.1
Maharashtra 10.2 9.4 12.2 12.7 10.8 18.2 15.5 14.8 17.7
Orissa 12.1 8.9 19.0 14.0 13.5 22.4 18.0 16.6 27.8
Punjab 54.6 46.1 75.7 70.5 66.4 81 87.2 87.9 85.2
Rajasthan 12.7 8.0 27.2 12.8 9.6 29.2 19.4 16.7 33.0
Tamil Nadu 18.1 17.4 20.9 18.6 20.7 12.0 18.8 22.7 6.8
Uttar Pradesh 23.2 10.2 44.0 21.8 16.9 48.2 26.6 20.1 61.1
Uttaranchal NA NA NA NA NA NA NA NA NA
West Bengal 3.3 2.5 4.7 6.9 6.5 9.6 9.3 9.0 11.5
All INDIA 18.5 15.7 27.0 19.1 17.7 25.0 21.9 20.8 26.9
State
(Cont...)

(Cont...) 1.6: Percentage Births Attended by Trained Practitioners: All India
1996 1998 1999

State/Year
Andhra Pradesh 27.5 32.3 10.7 27.7 32.6 11.1 27.7 32.7 11.2
Assam 16.0 14.9 28.1 16.1 15.2 28.2 16.2 15.3 28.3
Bihar 19.1 17.1 42.0 19.4 17.5 42.3 19.8 17.4 41.9
Chattisgarh - - - - - - - - -
Gujarat 37.6 44.7 20.1 38.3 45.2 20.3 38.4 45.3 20.3
Haryana 67.9 70.7 54.7 68.1 71.0 54.5 68.0 71.1 54.3
Jharkhand - - - - - - - - -
Karnataka 25.5 29.3 15.4 26.0 29.8 15.7 26.2 29.9 15.8
Kerala 1.8 2.2 0.4 1.8 2.3 0.3 1.8 2.3 0.4
Madhya Pradesh 21.7 21.1 26.2 22.1 21.5 26.3 22.3 21.6 26.5
Maharashtra 20.4 20.8 19.5 20.6 21.1 19.6 20.6 21.2 19.7
Orissa 23.2 21.7 37.2 24.0 22.6 37.2 24.1 22.7 37.3
Punjab 85.8 85.8 86.4 86.1 86.0 86.4 86.1 86.1 86.4
Rajasthan 25.9 23.6 40.3 26.3 24.0 40.6 26.4 24.1 40.7
Tamil Nadu 20.9 27.3 6.8 21.5 27.9 6.9 21.6 28.0 6.9
Uttar Pradesh 41.7 37.9 65.8 42.0 38.1 66.0 42.3 38.2 66.1
Uttaranchal - - - - - - - - -
West Bengal 13.6 12.0 19.8 13.9 12.6 19.9 13.9 12.7 19.8
All INDIA 28.5 27.9 31.1 28.8 28.2 31.4 28.9 28.3 31.5
State

Statistical Tables
1.7: Neo-natal Mortality Rate: All India (per 1000 live births)
1981 1986 1991

State/Year
Andhra Pradesh 60.1 64.9 36.7 56.5 62.4 33.3 50.5 53.9 36.6
Assam 66.9 67.8 49.4 74.3 75.5 54.7 53.4 54.8 26.8
Bihar 74.3 78.1 38.8 62.0 64.0 39.0 41.4 42.9 24.9
Chandigarh - - - - - - - - -
Gujarat 74.9 82.1 49.3 76.0 90.2 41.8 45.1 50.2 31.8
Haryana 57.7 61.6 29.7 49.2 55.0 24.3 40.0 42.4 28.7
Jharkhand - - - - - - - - -
Karnataka 48.6 54.9 29.3 54.4 60.8 35.5 52.9 59.5 31.4
Kerala 25.7 27.1 16.8 19.1 21.0 7.8 11.3 11.6 10.3
Madhya Pradesh 80.7 85.6 50.0 66.1 69.4 49.0 68.1 73.0 42.0
Maharashtra 53.9 62.8 30.6 43.8 50.8 29.6 38.2 44.8 23.1
Orissa 79.7 82.9 38.0 72.4 75.7 34.4 74.7 77.6 37.7
Punjab 48.8 53.5 28.2 38.7 40.3 21.6 33.5 37.8 21.1
Rajasthan 59.6 65.2 28 62.6 67.4 35.9 48.4 52.0 28.7
Tamil Nadu 62.6 71.2 38.1 57.1 67.0 37.1 42.6 49.3 29.6
Uttar Pradesh 96.2 101.2 55.5 77.8 82.8 50.7 64.3 67.1 48.5
Uttaranchal - - - - - - - - -
West Bengal 63.9 68.8 32.5 42.8 46.9 25.6 43.6 48.0 24.7
All INDIA 69.9 75.6 38.5 59.8 65.5 36.2 51.1 55.4 32.2
State
(Cont...)

(Cont...) 1.7: Neo-natal Mortality Rate: All India (per 1000 live births)
1996 1998 1999

State/Year
Andhra Pradesh 46.0 50.0 30.0 46.0 52.0 26.0 46.0 52.0 26.0
Assam 47.0 50.0 27.0 51.0 53.0 26.0 53.0 55.0 26.0
Bihar 45.0 47.0 30.0 44.0 45.0 29.0 41.0 43.0 29.0
Chattisgarh - - - - - - - - -
Gujarat 38.0 41.0 31.0 44.0 49.0 29.0 43.0 49.0 28.0
Haryana 41.0 42.0 36.0 41.0 43.0 29.0 39.0 42.0 29.0
Jharkhand - - - - - - - - -
Karnataka 39.0 47.0 17.0 42.0 50.0 17.0 43.0 52.0 17.0
Kerala 10.0 10.0 10.0 11.0 11.0 12.0 11.0 10.0 14.0
Madhya Pradesh 64.0 66.0 44.0 61.0 63.0 45.0 61.0 64.0 45.0
Maharashtra 33.0 40.0 20.0 29.0 33.0 22.0 29.0 34.0 22.0
Orissa 64.0 66.0 40.0 60.0 64.0 30.0 61.0 64.0 30.0
Punjab 34.0 37.0 25.0 33.0 35.0 25.0 34.0 36.0 26.0
Rajasthan 56.0 59.0 37.0 50.0 53.0 33.0 50.0 53.0 34.0
Tamil Nadu 39.0 45.0 28.0 35.0 39.0 27.0 36.0 39.0 29.0
Uttar Pradesh 51.0 54.0 34.0 52.0 55.0 33.0 52.0 56.0 33.0
Uttaranchal - - - - - - - - -
West Bengal 36.0 39.0 25.0 30.0 33.0 21.0 31.0 33.0 23.0
All INDIA 47.0 50.0 28.0 45.0 49.0 27.0 45.0 49.0 28.0
State

Statistical Tables
2.1: Doctors and Nurses: All India (per 100,000 population)
1981 1986 1991 1996 1999 2000

State/Year
Doctors Nurses Doctors Nurses Doctors Nurses Doctors Nurses Doctors Nurses Doctors Nurses
Andaman &
Nicobar NA NA NA NA NA NA NA NA NA NA NA NA
Andhra Pradesh 43.05 20.32 46.97 24.18 50.17 25.09 62.86 68.68 71.11 131.60 73.29 133.42
Arunachal
Pradesh* * NA * NA * NA * NA * NA * NA
Assam 36.35 13.00 42.19 12.24 46.84 10.13 50.85 9.22 52.85 10.01 53.72 33.29
Bihar 26.30 11.09 29.17 11.50 30.54 10.28 34.91 10.49 37.69 10.61 38.65 10.65
Chandigarh NA NA NA NA NA NA NA NA NA NA NA NA
Chattisgarh Included in Madhya Pradesh
Dadra &
Nagar Haveli NA NA NA NA NA NA NA NA NA NA NA NA
Delhi NA NA 73.75 NA 106.60 NA 131.74 NA 148.09 NA 152.31 NA
Goa,Daman &
Diu NA NA NA NA NA NA 57.21 NA 116.82 NA 127.85 NA
Gujarat 42.99 14.45 48.75 17.21 54.21 71.28 59.10 118.69 62.29 166.08 63.67 137.59
Haryana NA 13.97 1.74 18.38 3.91 20.55 4.82 22.93 4.94 21.08 5.03 63.41
Himachal
Pradesh NA 4.44 NA 6.49 NA 29.47 NA 78.20 NA 98.51 NA 96.81
Jammu &
Kashmir 44.53 NA 49.85 NA 57.10 NA 60.47 NA 62.22 NA 62.22 NA
Jharkhand Included in Bihar
Karnataka 51.05 13.94 62.03 20.88 72.95 52.03 91.84 55.53 104.52 148.92 109.29 146.36
Kerla 45.95 37.48 54.61 136.25 66.89 78.17 80.86 81.7 88.97 167.32 91.87 185.65
Lakshadweep(I) NA NA NA NA NA NA NA NA NA NA NA NA
Madhya Pradesh 8.07 15.50 13.21 17.73 16.90 106.94 23.48 133.25 28.01 131.95 29.75 142.95
Maharashtra 65.43 54.03 55.36 47.41 62.54 50.26 71.30 110.15 78.01 112.01 79.97 106.30
Manipur* * NA * NA * NA * NA * NA * NA
Meghalaya* * NA * NA * NA * NA * 0 * 0
Mizoram* * NA * NA * 0 * 17.36 * 55.55 * 164.91
Nagaland* * NA * NA * NA * NA * NA * NA
Orissa 30.67 11.26 32.63 13.65 35.02 65.19 36.89 89.51 37.93 89.18 38.27 105.06
Pondicherry NA NA NA NA NA NA NA NA NA NA NA NA
Punjab 127.88 94.56 130.00 105.48 131.33 122.03 130.20 140.59 129.64 155.52 129.66 152.45
Rajasthan 25.43 15.33 28.10 19.12 31.91 22.31 33.87 44.48 34.85 38.69 34.87 44.79
Sikkim NA NA NA NA NA NA NA NA NA NA NA NA
Tamil Nadu 65.68 51.75 74.18 51.57 83.10 61.40 93.17 134.90 100.11 130.28 102.26 166.95
Tripura* NA NA NA NA NA NA NA 11.52 NA 15.42 NA 15.50
Uttar Pradesh 21.54 6.78 22.71 7.63 23.85 9.72 1.22 0.46 0.20 0.08 0.11 0.04
Uttranchal Included in Uttar Pradesh
West Bengal 60.15 16.23 61.27 18.70 61.29 27.02 61.60 46.68 61.72 65.51 61.75 53.94
All India 39.22 21.95 41.69 27.00 46.51 40.20 34.68 60.16 49.31 73.61 54.27 75.89
Sources: Health Information of India,CBHI,GOI, respective years;Census of India, Population Profiles
(India,States and Union Territories), Office of the RGI,2004
Note: NA - not available; Population figures for the year 1986,1996,1999,2000 are calculated on the
basis of growth rate; * Doctors for these states are included in Assam since the Medical Council
for these states is common.

2.2: Hospitals: All India (per 100,000 population)
1981 1986 1991

State/Year
Rural Urban Total Rural Urban Total Rural Urban Total
Andaman & Nicobar 7.19 6.04 6.89 5.12 3.14 4.63 1.94 5.34 2.85
Andhra Pradesh 0.41 3.52 1.14 0.37 2.92 1.02 0.66 4.67 1.74
Arunachal Pradesh 2.71 14.48 3.48 1.03 6.69 1.73 1.59 5.42 2.08
Assam 0.20 3.57 0.54 0.24 3.56 0.60 0.76 4.70 1.20
Bihar 0.03 2.37 0.32 0.12 2.13 0.38 0.10 1.96 0.35
Chandigarh 0 0.47 0.44 1.89 0.40 0.54 0 0.35 0.31
Chattisgarh - - - - - - - - -
Dadra & Nagar Haveli 1.03 0 0.96 0.89 0 0.82 1.58 0 1.44
Delhi 0.44 1.06 1.01 0.13 0.94 0.87 0.42 0.91 0.86
Gujarat 0.13 7.53 2.43 0.39 10.55 3.77 0.70 11.20 4.32
Haryana 0.06 2.79 0.66 0.07 1.94 0.52 0.06 1.75 0.48
Jammu & Kashmir 0.04 2.62 0.58 0.19 2.73 0.77 0.26 2.72 0.84
Jharkhand - - - - - - - - -
Karnataka 0.18 1.73 0.63 0.16 1.64 0.61 0.08 1.93 0.65
Kerala 2.88 3.42 2.98 0.94 2.03 1.20 6.72 7.77 7.00
Lakshadweep(I) 9.25 0 4.97 9.05 0 4.32 8.85 0 3.87
Madhya Pradesh 0.17 1.95 0.53 0.13 1.86 0.51 0.65 0.48 0.61
Maharashtra 0.25 4.10 1.60 0.38 5.17 2.17 0.71 5.76 0.27
Manipur 1.34 1.86 1.48 0.92 2.02 1.22 1.58 0.79 1.36
Meghalaya 0.09 4.14 0.82 0.08 4.15 0.83 0 2.42 0.45
Mizoram 1.61 2.46 1.82 0 4.67 2.01 1.08 3.15 2.03
Nagaland 4.43 4.16 4.39 3.07 5.26 3.43 2.10 4.80 2.56
Orissa 0.62 5.11 1.15 0.61 4.23 1.07 0.43 3.90 0.89
Pondicherry 0 3.80 1.99 0 2.32 1.42 0 1.93 1.24
Punjab 0.91 3.10 1.51 0.87 2.82 1.43 0.63 2.34 1.13
Rajasthan 0.09 2.86 0.67 0.07 2.54 0.62 0.04 1.98 0.49
Sikkim 1.26 1.96 1.88 0 11.26 1.56 0 13.51 1.23
Tamil Nadu 0.30 1.75 0.78 0.32 1.67 0.78 0.24 1.67 0.73
Tripura 0.11 5.76 0.73 0.24 3.80 0.74 0.43 3.08 0.83
Uttar Pradesh 0.10 3.22 0.66 0.08 2.71 0.59 0.07 2.36 0.53
Uttranchal - - - - - - - - -
West Bengal 0.38 1.77 0.75 0.30 1.66 0.67 0.27 1.51 0.61
All India 0.35 3.12 0.99 0.28 3.21 1.01 0.57 3.50 1.32
Sources: Health Information of India,CBHI,GOI, respective years;Census of India, Population
Profiles(India,States and Union Territories), Office of the RGI,2004
Note: Hospital includes government, local bodies, private and voluntary organisation; NA - not available;
Population figures for the year 1986,1996,1999,2000 are calculated on the bases of growth rate;
Hospitals figures (prior to 1997) are generally inclusive of CHC’s; from 1992 excluding CHC’s;
Reduction in rural hospitals (from1998) due to exclusion of CHC’s; Data for Chattisgarh,
Jharkhand, Uttaranchal are included in their parent State
(Cont...)

Statistical Tables
(Cont...) 2.2: Hospitals: All India (per 100,000 population)
1996 1999 2001

State/Year
Andaman & Nicobar 3.13 4.08 3.43 0.85 3.48 1.73 0.83 3.44 1.68
Andhra Pradesh 1.69 17.82 4.75 1.95 24.29 5.25 1.91 99.62 5.45
Assam 0.70 3.90 1.09 0.66 3.48 1.03 0.65 3.40 1.01
Bihar 0.13 2.26 0.39 0.13 2.43 0.39 0.13 2.63 0.40
Chandigarh 0 0.14 0.13 0 0.51 0.45 0 0.49 0.44
Chattisgarh - - - - - - NA NA NA
Dadra & Nagar Haveli 0 6.14 1.62 1.81 0 1.37 0 5.94 1.36
Delhi 0.21 0.65 0.62 NA NA NA NA NA 4.04
Goa,Daman & Diu 5.91 10.86 8.18 4.28 12.8 8.43 3.98 12.5 8.10
Gujarat 0.61 14.03 5.47 0.58 12.73 5.12 0.56 12.41 4.99
Haryana 0.06 1.37 0.42 0.05 1.21 0.39 0.05 1.16 0.37
Jammu & Kashmir 0.95 0.09 0.74 0.04 1.63 0.43 0.04 1.59 0.42
Jharkhand - - - - - - - - -
Karnataka 0.08 1.67 0.60 0.07 1.53 0.57 0.07 1.49 0.55
Kerala 6.41 7.48 6.69 8.74 0.98 6.72 NA NA 13.92
Lakshadweep(I) 6.97 0 3.55 0 7.29 3.37 0 7.42 3.30
Madhya Pradesh 0.51 0.75 0.57 0.53 0.74 0.59 NA 0.59 0.16
Maharashtra 0.90 7.31 3.53 0.65 7.72 3.65 0.63 7.53 3.56
Manipur 1.67 0.92 1.49 0.72 0.89 0.76 0.76 0.87 0.78
Meghalaya 0 2.27 0.44 0 2.03 0.40 0 1.54 0.30
Mizoram 1.46 2.86 2.14 0 2.79 1.39 0.22 2.27 1.24
Nagaland 1.53 3.51 1.87 0.55 2.33 0.10 0.55 2.33 0.85
Orissa 0.98 2.91 1.25 0.33 3.22 0.76 0.32 3.14 0.74
Pondicherry 0 1.71 1.12 0 4.59 3.05 0 4.47 2.98
Punjab 0.49 1.97 0.98 0.47 1.80 0.93 0.47 1.75 0.90
Rajasthan 0.04 1.74 0.43 0.03 1.59 0.40 0.03 0.76 0.20
Sikkim 0 10.01 1.05 0 3.35 0.38 0 3.34 0.37
Tamil Nadu 0.25 1.35 0.69 0.25 1.18 0.67 0.25 1.16 0.65
Tripura 0.52 2.67 0.87 0.54 2.82 0.93 0.19 4.03 0.84
Uttar Pradesh 0.002 2.09 0.02 0.0002 1.94 0.004 0.01 1.89 0.05
Uttranchal - - - - - - - - -
West Bengal 0.21 1.39 0.54 0.19 1.32 0.51 0.18 1.36 0.51
All India 0.67 4.10 1.61 0.69 3.76 1.55 0.36 3.60 1.52
Note: Hospital includes government, local bodies, private and voluntary organisation; NA - not available;
Population figures for the year 1986,1996,1999,2000 are calculated on the bases of growth rate;
Hospitals figures (prior to 1997) are generally inclusive of CHC’s; from 1992 excluding CHC’s;
Reduction in rural hospitals (from1998) due to exclusion of CHC’s; Data for Chattisgarh,
Jharkhand, Uttaranchal are included in their parent State

2.3: Dispensaries: All India (per 100,000 population)
1981 1986 1991

State/Year
Andaman & Nicobar 43.85 12.09 35.50 15.93 9.43 14.3 0.97 6.67 2.49
Andhra Pradesh 1.31 1.35 1.32 1.22 1.58 1.32 0.28 0.25 0.27
Arunachal Pradesh 11.18 0 10.45 4.14 1.12 3.85 3.98 0.90 3.59
Assam 2.26 1.47 2.18 2.08 1.14 1.98 1.49 1.13 1.45
Bihar 1.61 0.18 1.43 2.49 0.16 2.19 0.55 0.14 0.49
Chandigarh 17.38 4.49 5.31 16.98 4.75 5.95 10.58 4.69 5.30
Chattisgarh - - - - - - - - -
Delhi 16.81 7.26 7.96 12.61 6.41 7.04 10.22 6.45 6.83
Gujarat 1.62 0.85 1.38 5.83 16.61 9.43 9.31 26.29 15.17
Haryana 1.47 3.57 1.93 0.47 2.49 0.95 0.31 4.32 1.30
Jammu & Kashmir 13.14 2.14 10.82 11.59 1.77 9.36 9.92 1.47 7.90
Jharkhand - - - - - - - - -
Karnataka 4.37 2.57 3.85 4.27 2.21 3.66 1.94 1.67 1.86
Kerla 3.43 0.84 2.95 5.08 6.58 5.46 6.73 6.61 6.70
Lakshadweep(I) 9.25 0 4.97 0 0 0 0 0 0
Madhya Pradesh 1.26 1.11 1.23 0.84 0.77 0.82 0.30 0.82 0.42
Maharashtra 3.02 10.34 5.58 1.59 24.61 10.20 1.64 27.52 11.66
Manipur 4.69 0.80 3.66 4.10 0.67 3.18 3.68 0.59 2.83
Meghalaya 5.21 0.41 4.34 4.45 0.35 3.71 1.45 0.61 1.30
Mizoram 0 0 0 7.26 0 4.52 5.92 0 3.19
Nagaland 11.00 5.82 10.19 7.32 5.84 7.05 5.69 3.84 5.37
Orissa 0.96 2.48 1.14 0.81 1.99 0.96 0.48 1.51 0.62
Pondicherry 7.97 1.58 4.63 6.91 3.25 4.84 3.78 2.90 3.22
Punjab 10.62 4.22 8.85 4.30 4.12 9.65 8.74 3.74 7.26
Rajasthan 3.21 4.72 3.52 2.55 4.83 3.06 0.06 2.54 0.63
Sikkim 1.90 0 2.26 0 0 0 36.54 0 33.21
Tamil Nadu 0.96 2.22 1.38 0.85 2.14 1.29 0.40 1.91 0.92
Tripura 6.57 2.66 6.14 11.35 1.75 10.07 20.12 1.42 17.26
Uttar Pradesh 1.30 2.07 1.44 1.30 1.8 1.39 1.18 1.56 1.26
Uttranchal - - - - - - - - -
West Bengal 0.68 1.03 0.77 0.91 0.86 0.89 0.83 0.76 0.81
All India 2.21 3.23 2.45 2.38 6.35 3.37 1.86 7.24 3.24
Note: Dispensaries includes government, local bodies, private and voluntary organisation; NA - not
available; Population figures for the year 1986,1996,1999,2000 are calculated on the bases of
growth rate; Dispensaries figures (prior to 1997) are generally inclusive of PHC’s ,from 1997
excluding PHC’s; Reduction in figures (from1998) is due to conversion to PHC’s; Data for
Chattisgarh, Jharkhand, Uttaranchal are included in their parent state
(Cont...)

Statistical Tables
(Cont...) 2.3: Dispensaries: All India (per 100,000 population)
1996 1999 2001

State/Year
Andaman & Nicobar 44.76 30.62 40.56 2.98 33.03 12.97 3.75 30.98 12.64
Andhra Pradesh 0.43 0.72 0.49 0.20 0.29 0.22 0.20 1.20 0.23
Assam 1.37 0.93 1.32 1.31 0.83 1.25 1.28 0.81 1.22
Bihar 0.55 0.16 0.50 0.55 0.17 0.51 0.55 0.18 0.51
Chandigarh 11.22 4.27 4.99 10.00 2.91 3.63 NA NA NA
Chattisgarh - - - - - - - - -
Goa,Daman & Diu 40.46 50.51 45.15 3.76 0.84 2.38 3.73 0.82 2.32
Gujarat 8.21 28.86 15.70 7.80 26.19 14.68 7.63 25.54 14.32
Haryana 0.29 3.41 1.15 0.23 1.61 0.64 0.22 1.59 0.61
Jammu & Kashmir 8.57 1.23 6.77 5.14 0.85 4.08 5.01 0.83 3.97
Jharkhand - - - - - - - - -
Karnataka 1.80 1.46 1.69 1.64 1.34 1.54 1.61 1.30 1.51
Kerla 6.39 6.42 6.40 0.17 0.16 0.17 0.17 0.16 0.17
Lakshadweep(I) 3.48 7.13 3.55 0 0 0 0 0 0
Maharashtra 0.67 21.52 9.22 4.57 8.37 6.19 4.47 8.17 6.04
Manipur 2.42 0.55 1.95 2.15 0.53 1.77 2.10 0.52 1.73
Meghalaya 1.14 0.50 1.02 1.05 0.45 0.93 0.97 0 0.78
Mizoram 4.38 0 2.26 2.98 0 1.50 NA NA NA
Nagaland 1.17 0 0.97 1.88 1.16 1.75 1.88 1.17 1.76
Orissa 3.66 1.38 3.33 3.90 1.17 3.50 3.82 1.14 3.42
Pondicherry 3.56 2.56 2.91 0.63 1.74 1.37 0.61 1.70 1.33
Punjab 8.02 3.35 6.53 7.70 2.90 6.10 7.56 2.83 5.96
Rajasthan 0 2.37 0.55 0 2.08 0.49 0 2.03 0.47
Sikkim 33.59 0 30.11 0 0 0 0 0 0
Tamil Nadu 0.41 1.54 0.86 0.42 1.36 0.84 0.42 1.33 0.82
Tripura 18.73 1.23 15.88 23.29 1.13 19.54 NA NA NA
Uttar Pradesh 0.03 1.38 0.05 0.003 1.28 0.01 0.10 1.25 0.13
Uttaranchal - - - - - - - - -
West Bengal 0.76 0.69 0.74 0.76 0.65 0.73 0.23 0.33 0.26
All India 1.75 6.37 3.00 1.67 3.73 2.29 1.49 3.60 2.08
Note: Dispensaries includes government, local bodies, private and voluntary organisation; NA - not
available; Population figures for the year 1986,1996,1999,2000 are calculated on the bases of
growth rate; Dispensaries figures (prior to 1997) are generally inclusive of PHC’s ,from 1997
excluding PHC’s; Reduction in figures (from1998) is due to conversion to PHC’s; Data for
Chattisgarh, Jharkhand, Uttaranchal are included in their parent state

2.4: Primary Health Centres and Sub Centres: All India (per 100,000 population)
1981 1986 1991 1996 1999 2000

State/Year
PHCs SCs PHCs SCs PHCs SCs PHCs SCs PHCs SCs PHCs SCs
All India 1.11 11.03 2.44 17.09 3.30 20.91 3.23 19.86 3.17 18.95 3.10 18.63
Andaman & Nicobar 1.44 0.72 5.69 24.47 8.26 46.67 7.61 42.97 7.24 41.32 7.54 41.90
Andhra Pradesh 1.03 10.74 2.22 15.49 2.64 16.24 2.56 20.28 3.01 19.46 2.52 19.19
Arunachal Pradesh 7.62 NA 9.90 9.75 4.24 26.93 5.53 27.40 5.28 28.76 7.51 31.56
Assam 0.82 4.91 1.72 13.87 2.65 26.50 2.86 24.41 2.73 23.24 2.64 22.13
Bihar 1.00 10.53 1.76 14.02 2.94 19.73 2.96 19.82 2.97 19.88 2.97 19.89
Chandigarh NA 13.90 9.43 18.86 0 18.13 0 14.96 0 14.44 0 13.90
Chattisgarh - - - - - - - - - - - -
Dadra & Nagar Haveli 2.07 7.23 3.55 17.74 3.94 26.82 4.00 22.66 3.61 21.68 3.49 20.96
Delhi 1.77 8.18 1.05 5.52 0.84 4.43 0.84 4.44 0.85 4.44 0.85 4.44
Goa,Daman & Diu 2.04 17.28 1.89 23.66 3.36 25.80 2.76 25.36 2.59 25.01 2.84 26.83
Gujarat 1.07 11.50 1.70 23.71 3.37 26.91 3.26 24.67 3.12 23.43 3.17 23.04
Haryana 0.88 10.30 2.19 17.57 3.18 18.53 2.90 16.69 2.73 15.67 2.68 15.35
Himachal Pradesh 1.95 18.33 3.86 22.21 4.07 39.20 5.08 38.71 5.81 38.56 5.54 37.95
Jammu & Kashmir 1.90 8.42 2.57 10.45 5.02 28.92 4.92 24.98 4.53 22.87 4.40 22.21
Jharkhand - - - - - - - - - - - -
Karnataka 1.16 13.07 1.74 17.92 4.06 25.08 4.85 24.66 4.89 23.77 4.83 23.48
Kerla 0.86 8.69 2.08 15.70 4.24 23.78 4.25 22.62 4.15 21.95 4.03 21.73
Lakshadweep(I) 32.38 NA 31.66 63.32 30.98 61.97 13.93 48.76 12.07 42.23 11.50 40.26
Madhya Pradesh 1.60 14.20 1.99 15.82 2.32 23.43 3.54 25.03 3.68 26.03 3.73 26.36
Maharashtra 1.11 9.91 3.00 19.92 3.46 19.38 3.25 18.63 3.11 17.80 3.19 17.54
Manipur 2.97 14.54 3.76 28.67 4.96 31.54 4.28 26.03 3.81 23.19 3.67 22.32
Meghalaya 2.19 8.86 4.06 23.42 4.91 22.84 4.86 22.61 4.68 20.75 4.55 22.09
Mizoram 3.76 38.18 13.45 50.02 10.22 65.62 13.37 78.78 12.59 76.90 13.01 77.61
Nagaland 2.60 11.61 6.25 23.13 3.30 24.37 2.41 17.83 2.00 14.84 2.62 17.18
Orissa 1.35 11.98 2.60 17.02 3.63 21.61 3.75 20.15 4.41 19.32 4.35 19.06
Pondicherry 4.16 16.64 14.16 25.21 8.94 27.17 12.63 25.92 12.19 25.00 12.04 24.71
Punjab 1.07 18.57 13.48 20.39 3.30 20.74 3.18 18.74 3.06 18.05 3.02 17.82
Rajasthan 0.87 7.95 1.92 15.62 4.05 23.57 4.16 24.18 3.94 23.35 3.86 22.90
Sikkim 4.74 14.54 5.82 27.05 6.23 38.44 5.60 34.29 5.12 31.36 4.97 30.44
Tamil Nadu 1.25 11.81 2.14 20.77 3.90 23.60 4.00 24.21 4.07 24.58 4.09 24.71
Tripura 1.53 7.17 3.82 12.83 2.35 22.69 2.20 21.49 2.23 20.64 2.20 20.43
Uttar Pradesh 1.02 12.30 1.90 16.76 3.28 18.07 0.09 0.46 0.01 0.05 0.005 0.02
Uttaranchal - - - - - - - - - - - -
West Bengal 0.83 7.72 2.81 17.04 3.13 15.95 2.35 14.66 2.23 14.39 2.20 14.15
All India 1.11 11.03 2.44 17.09 3.30 20.91 3.23 19.86 3.17 18.95 3.10 18.63

Note : NA - not available; Population figures for the year 1986,1996,1999,2000 are calculated on the
bases of growth rate; Data for Chattisgarh, Jharkhand, Uttaranchal are included in their parent
state

Statistical Tables
2.5: Beds: All India (per 100,000 population)
1981 1986 1991

State/Year
Andaman & Nicobar 232.91 550.03 316.31 180.94 659.82 310.36 99.17 723.10 265.80
Andhra Pradesh 9.43 242.06 63.68 8.64 212.49 60.89 12.53 205.23 64.36
Assam 12.13 382.09 48.69 15.33 399.49 56.79 20.00 350.43 56.67
Bihar 8.86 253.25 39.33 14.97 255.24 45.93 3.06 228.44 32.69
Chandigarh 104.28 264.87 254.64 56.58 253.23 236.10 0 260.49 233.64
Chattisgarh - - - - - - - - -
Dadra &
Nagar Haveli 51.67 0 48.23 48.80 0 44.96 52.07 0 47.66
Delhi 13.71 227.12 211.61 10.51 215.04 196.85 16.02 216.25 196.08
Gujarat 10.48 290.92 97.71 13.37 305.75 110.55 31.27 361.85 145.28
Haryana 10.05 248.71 62.27 5.14 197.81 50.97 4.52 168.79 44.98
Jammu & Kashmir 5.10 308.39 68.94 6.70 456.98 109.59 8.18 421.39 106.65
Jharkhand - - - - - - - - -
Karnataka 13.99 264.10 86.25 13.95 253.37 86.24 10.81 249.12 84.50
Kerala 112.58 450.45 175.92 149.22 444.79 219.72 202.36 429.94 262.43
Lakshadweep(I) 231.27 0 124.23 316.59 0 151.19 309.83 0 135.38
Madhya Pradesh 3.21 146.28 32.24 2.97 144.74 34.37 43.33 21.38 38.25
Maharashtra 13.52 306.69 116.22 17.44 323.65 132.01 25.98 331.57 144.21
Manipur 38.45 230.12 89.10 30.50 211.58 79.90 57.45 137.45 79.47
Meghalaya 7.13 592.54 112.89 6.09 703.97 135.26 0 495.38 92.12
Mizoram 86.03 276.65 133.06 61.85 390.32 206.26 95.75 3120 195.43
Nagaland 136.86 410.03 179.24 50.51 403.14 109.42 38.45 380.84 97.39
Orissa 10.16 293.57 43.59 9.80 266.61 42.68 12.46 262.67 45.93
Pondicherry 25.66 717.30 387.28 30.73 568.20 360.43 13.07 534.83 347.00
Punjab 68.51 250.72 118.95 73.96 229.79 173.06 54.28 213.46 101.32
Rajasthan 5.93 225.63 52.16 5.98 223.27 54.35 3.11 181.81 43.99
Sikkim 72.06 391.51 161.33 0 1181.84 163.51 0 1418.69 129.16
Tamil Nadu 12.46 233.29 85.23 14.91 226.44 86.26 11.89 234.23 87.82
Tripura 5.25 492.09 58.74 7.40 343.61 54.93 11.77 297.83 55.53
Uttar Pradesh 7.83 219.01 45.74 7.59 188.20 42.23 6.93 164.04 38.10
Uttaranchal - - - - - - - - -
West Bengal 23.69 270.05 88.89 17.59 272.33 86.67 15.41 250.55 80.03
All India 16.51 261.56 73.64 18.09 256.74 77.41 22.21 241.04 78.46
Note: Beds includes Hospital and Dispensaries bed of government, local bodies, private and voluntary
organisation; NA - not available; Population figures for the year 1986,1996,1999,2000 are
calculated on the bases of growth rate; Reduction in beds (from 1999) is due to exclusion of
CHC’s, Sanatorium and TB clinics; Data for Chattisgarh, Jharkhand, Uttaranchal are included
in their parent state
(Cont...)

2.5: Beds: All India (per 100,000 population)
1996 1999 2001

State/Year
Andaman & Nicobar 154.42 567.50 281.13 66.03 490.21 207.17 64.60 478.49 199.63
Andhra Pradesh 19.49 318.38 74.08 26.12 651.48 117.04 25.61 2671.44 121.39
Assam 18.43 290.47 51.60 17.54 259.54 48.78 17.16 253.49 47.66
Bihar 4.04 259.63 34.46 4.05 278.86 34.87 4.06 301.41 35.16
Chandigarh 0 71.23 63.92 0 255.39 229.29 0 249.72 224.18
Chattisgarh - - - - - - - - -
Dadra &
Nagar Haveli NA 235.34 63.86 72.87 0 55.07 22.90 285.36 69.77
Goa,Daman & Diu 176.70 361.74 261.59 93.31 485.74 283.58 91.01 472.30 275.32
Gujarat 24.31 391.33 157.35 23.09 355.14 147.12 22.58 346.21 143.49
Haryana 4.07 135.14 40.03 3.78 113.22 35.82 3.69 102.35 32.23
Jammu & Kashmir 118.44 6.35 91.03 1.21 81.26 21.10 1.18 79.31 20.56
Jharkhand - - - - - - - - -
Karnataka 10.84 222.83 80.23 11.16 204.66 76.71 10.96 199.42 75.01
Kerala 196.28 415.69 253.68 321.33 287.16 312.45 NA NA 308.17
Lakshadweep(I) 243.82 0 124.25 0 255.10 118.02 0 259.58 115.42
Maharashtra 20.05 193.58 91.19 15.70 240.22 110.99 15.38 234.29 107.10
Manipur 22.43 138.80 74.97 35.61 183.99 71.11 37.50 180.39 71.38
Meghalaya 0 470.37 90.46 0 412.28 80.9 0 273.72 53.60
Mizoram 91.43 288.22 186.65 29.75 236.99 132.94 11.20 NA 116.10
Nagaland 23.45 278.46 67.37 16.35 242.70 55.35 16.39 243.30 55.48
Orissa 17.86 201.48 44.17 5.36 196.49 34.04 5.25 192.45 33.32
Pondicherry 12.31 471.65 313.33 0 515.21 342.46 0 595.73 396.57
Punjab 47.18 181.25 90.43 45.39 162.47 85.28 44.56 158.66 83.26
Rajasthan 2.96 171.83 42.13 2.73 158.65 39.20 2.13 125.79 31.05
Sikkim 0 1151.37 120.23 0 1338.22 151.72 0 1336.23 147.92
Tamil Nadu 12.19 188.80 82.85 12.38 165.89 80.01 12.52 162.59 78.61
Tripura 14.61 296.42 60.63 14.41 280.38 59.59 6.20 294.60 55.40
Uttar Pradesh 0.18 144.91 1.66 0.02 134.51 0.25 0.59 131.11 3.92
Uttaranchal - - - - - - - - -
West Bengal 11.83 236.78 74.29 8.92 222.03 68.46 8.33 224.10 68.68
All India 19.73 202.34 69.02 21.27 193.05 70.94 9.85 178.79 69.34
Note: Beds includes Hospital and Dispensaries bed of government, local bodies, private and voluntary
organisation; NA - not available; Population figures for the year 1986,1996,1999,2000 are
calculated on the bases of growth rate; Reduction in beds (from 1999) is due to exclusion of
CHC’s, Sanatorium and TB clinics; Data for Chattisgarh, Jharkhand, Uttaranchal are included
in their parent state

Statistical Tables
3.1: Revenue Expenditure on Health

(Rs. in Millions)
State/Year 1981 1987 1991 1996 1998 2001 2003 2005
Andhra
Pradesh 1121.00 2875.29 3268.04 6049.33 8480.45 12860.91 13440.00 16400.00
Arunachal
Pradesh 58.00 189.82 170.62 325.24 418.13 536.10 587.30 670.80
Assam 357.00 1222.98 1103.10 2175.10 2526.79 3461.82 3240.00 6530.00
Bihar 675.00 1997.02 2713.33 4971.43 5800.77 6801.75 2910.00 7010.00
Chhattisgarh - - - - - 771.20 2520.00 3280.00
Goa,Daman
& Diu 62.00 191.09 238.38 416.85 567.28 823.64 920.80 1106.30
Gujarat 736.00 2280.73 2510.76 4678.70 6256.43 8937.52 8470.00 8950.00
Haryana 367.00 897.4 819.28 1600.63 2230.81 2909.09 3430.00 3920.00
Himachal
Pradesh 240.00 524.11 667.33 1287.13 1753.63 2630.60 2776.40 2928.60
Jammu &
Kashmir 259.00 671.33 756.28 1766.09 2292.14 3610.48 4271.70 4491.20
Jharkhand - - - - - 622.03 3570.00 3570.00
Karnataka 705.00 1922.12 2430.15 4964.56 6243.66 9035.63 9540.00 10650.00
Kerala 644.00 1437.51 2127.69 3965.82 4890.66 6738.91 7590.00 9870.00
Madhya
Pradesh 1175.00 2961.44 2745.42 4629.64 5849.83 8319.9 7610.00 9270.00
Maharashtra 1615.00 5131.96 4774.24 8898.22 10967.12 15953.42 16550.00 18650.00
Manipur 60.00 213.65 188.20 366.81 458.49 663.70 596.90 867.90
Meghalaya 74.00 128.75 207.62 351.65 459.46 705.10 818.70 919.40
Mizoram 65.00 196.96 149.18 277.76 NA 538.50 663.40 580.30
Nagaland 106.00 280.28 245.92 504.50 573.14 764.36 808.90 718.60
Orissa 549.00 1268.27 1350.29 2548.28 2969.79 4331.06 4600.00 6460.00
Pondicherry 43.00 112.81 181.88 373.89 484.56 804.16 NA NA
Punjab 489.00 1202.01 1662.89 2568.54 3832.28 6375.88 6100.00 7740.00
Rajasthan 797.00 2189.83 2506.66 5146.32 6253.99 8775.99 8990.00 11240.00
Sikkim 17.00 52.14 79.31 191.32 212.67 317.30 399.10 546.40
Tamil Nadu 1048.00 2829.29 3790.06 6981.77 8995.58 11604.94 11880.00 13820.00
Tripura 41.00 133.62 277.09 401.29 579.69 827.34 841.40 966.00
Union
Government 1082.00 1671.28 5523.53 8787.91 14033.92 24840 29900.00 39000.00
Uttar Pradesh 1488.00 3755.17 6214.30 10051.86 3223.12 14102.2 15650.00 22070.00
Uttaranchal - - - - - 342.20 1580.00 2540.00
West Bengal 1344.00 2731.26 4330.13 6175.02 944.48 13766.15 13290.00 2670.00
All India 15217.00 39068.12 51031.68 90455.66 101298.90 178900.00 189130.00 235710.00
Sources: Upto 1987 is combined Finance and Revenue Accounts Comptroller and Auditor General of
India GOI,respective year; For year 2001 is State Finance A Study of Budget of 2002-03, RBI;
For year 2003 and 2005 is Public Finance November 2004 ,CMIE.
Note: 2005 Budget estimates; NA - not available; Data for Chattisgarh, Jharkhand, Uttaranchal are
included in their parent state

3.2: Capital Expenditure on Health

(Rs. in Millions)
State/Year 1981 1987 1991 1996 1998 2001 2003 2005
Andhra Pradesh 25.00 53.67 29.90 11.89 26.11 479.40 330.00 590.00
Arunachal Pradesh 2.00 33.30 16.60 44.19 64.50 62.70 50.70 50.40
Assam 40.00 163.06 179.29 90.51 36.62 93.27 60.00 290.00
Bihar 70.00 631.81 63.89 0.54 12.88 NA 130.00 80.00
Chhattisgarh - - - - - 20.50 200.00 500.00
Goa,Daman & Diu 15.00 118.32 87.57 78.92 37.01 39.85 45.60 46.30
Gujarat 9.00 394.74 13.26 30.15 141.09 251.67 170.00 190.00
Haryana 29.00 42.36 51.78 66.33 94.51 73.62 80.00 150.00
Himachal Pradesh 19.00 230.51 56.11 76.95 146.58 366.40 198.00 574.40
Jammu & Kashmir 49.00 541.85 133.09 184.27 233.91 215.61 357.10 505.30
Jharkhand - - - - - NA 530.00 440.00
Karnataka 9.00 165.65 65.65 169.20 836.90 1017.56 510.00 430.00
Kerala 24.00 399.79 92.20 206.27 213.78 167.91 450.00 300.00
Madhya Pradesh 15.00 127.81 70.61 176.01 273.14 296.00 190.00 390.00
Maharashtra 55.00 182.06 209.22 162.87 237.51 389.44 960.00 530.00
Manipur 7.00 134.32 14.58 16.59 10.16 2.50 26.80 76.50
Meghalaya 3.00 144.93 33.68 90.46 97.13 99.20 118.90 137.90
Mizoram 1.00 54.10 5.90 13.59 NA 100.90 41.00 1.80
Nagaland 8.00 76.74 56.37 52.68 64.24 129.35 82.80 458.00
Orissa 16.00 66.13 55.53 104.51 111.80 258.31 380.00 640.00
Pondicherry NA 8.62 1.56 2.04 6.01 11.00 NA NA
Punjab 34.00 66.64 33.88 35.76 28.35 25.48 0.00 260.00
Rajasthan 22.00 936.42 72.09 606.03 911.66 253.88 140.00 240.00
Sikkim 8.00 20.74 21.76 83.45 28.39 29.90 33.30 20.80
Tamil Nadu 58.00 126.68 105.08 201.18 394.65 270.49 480.00 910.00
Tripura 3.00 78.92 26.09 23.65 31.07 35.50 119.60 239.10
Union Government 608.00 301.82 210.68 293.17 525.82 277.36 380.00 500.00
Uttar Pradesh 75.00 286.86 545.55 541.27 928.15 488.50 140.00 1780.00
Uttaranchal - - - - - 0 250.00 660.00
West Bengal 65.00 94.64 269.91 123.92 NA 1293.80 420.00 950.00
All India 1203.00 5482.49 2521.83 3486.40 5491.97 7632.40 8010.00 13310.00

Statistical Tables
3.3: Health Expenditure as percentage of Total Expenditure
State/Year 1981 1987 1991 1996 1998 2001 2003 2005

Andhra Pradesh 5.80 7.88 5.53 4.65 5.44 4.74 3.96 3.53
Arunachal Pradesh 5.91 9.77 4.89 4.66 5.04 NA 4.68 4.45
Assam 3.96 10.21 NA 5.84 5.87 4.66 3.69 3.06
Bihar 3.78 8.49 5.10 5.79 5.24 4.01 3.17 3.24
Chhattisgarh - - - - - 4.13 3.99 3.74
Goa,Daman & Diu 7.19 13.45 8.70 5.39 4.89 3.90 4.02 3.27
Gujarat 4.38 9.58 5.03 4.70 4.57 3.38 3.21 3.05
Haryana 4.33 8.25 4.11 2.95 3.27 3.26 2.88 2.59
Himachal Pradesh 6.63 13.50 3.32 6.16 7.04 5.64 4.50 5.08
Jammu & Kashmir 3.79 12.50 5.56 5.50 4.97 4.89 5.30 4.78
Jharkhand - - - - - NA 4.18 3.65
Karnataka 3.79 8.23 5.40 5.28 5.85 5.11 4.17 3.49
Kerala 6.56 9.85 7.21 6.53 5.68 5.25 4.74 4.71
Madhya Pradesh 4.94 10.11 5.16 4.81 4.57 5.09 4.11 3.39
Maharashtra 4.85 9.38 5.13 4.56 4.29 3.87 3.71 3.51
Manipur 2.60 12.61 4.38 4.83 4.48 4.82 2.89 3.72
Meghalaya 6.25 13.25 6.26 6.19 6.86 5.65 5.88 5.23
Mizoram 7.89 11.85 3.50 4.18 NA 4.96 5.01 3.96
Nagaland 5.39 10.88 5.96 5.95 5.68 4.87 4.65 4.68
Orissa 5.17 8.50 5.13 5.16 4.82 4.15 3.75 3.90
Pondicherry 9.05 10.01 7.82 0.03 0.04 NA NA NA
Punjab 3.67 10.52 6.73 4.62 4.93 4.54 3.54 3.10
Rajasthan 4.85 14.48 6.50 5.70 7.97 5.16 4.24 3.94
Sikkim 4.49 6.44 7.89 2.72 1.92 3.67 2.03 2.56
Tamil Nadu 6.18 10.04 6.91 6.29 6.28 4.86 4.10 4.20
Tripura 2.51 7.37 5.18 14.74 4.79 4.04 3.79 3.79
Union Government 0.22 0.29 0.56 0.46 0.52 0.77 0.76 0.83
Uttar Pradesh 4.69 9.08 6.31 6.03 1.74 3.98 3.75 4.49
Uttaranchal - - - - - 3.08 3.77 4.34
West Bengal 6.30 9.73 8.37 6.43 NA 5.63 4.95 0.93
All India 1.52 3.95 2.93 2.01 1.75 2.77 2.41 2.42

3.4: Total Revenue Expenditure, State and Union

(Rs. in Millions)
State/Year 1981 1987 1991 1996 1998 2001 2003 2005
Andhra
Pradesh 17263.00 32444.98 55047.85 106136.8 145442.90 230700.00 260570.00 341520.00
Arunachal
Pradesh 820.00 1663.04 2582.21 5072.79 6646.24 9084.50 10313.90 11650.60
Assam 9276.00 11603.86 NA 35757.62 40385.52 64170.00 71120.00 149830.00
Bihar 17173.00 25277.37 49523.76 82067.27 105304.40 143450.00 73820.00 163410.00
Chhattisgarh - - - - - 16120.00 55300.00 76060.00
Goa,Daman
& Diu 843.00 1719.87 2754.05 7849.88 11219.24 19619.70 20000.00 26350.60
Gujarat 14995.00 24656.49 43311.83 87660.97 121431.40 220410.00 214400.00 237860.00
Haryana 8128.00 9673.64 19330.73 53615.55 66171.67 71810.00 93420.00 116840.00
Himachal
Pradesh 3380.00 4640.69 9014.75 19043.48 26991.40 43761.80 51411.60 57910.70
Jammu &
Kashmir 6833.00 7287.06 12477.17 28149.55 41905.21 66853.30 64126.80 79676.30
Jharkhand - - - - - - 77370.00 78440.00
Karnataka 17127.00 22047.28 39710.85 84811.81 108902.1 166850.00 188140.00 254370.00
Kerala 8965.00 16547.67 28249.51 58263.77 82411.21 118780.00 147560.00 189710.00
Madhya
Pradesh 21485.00 25481.01 47461.15 91308.69 117264.40 149860.00 145600.00 182610.00
Maharashtra 30944.00 49807.58 87536.73 171683.9 228965.10 374010.00 404740.00 479040.00
Manipur 2239.00 1980.55 3358.61 6187.72 7924.43 11308.80 14151.00 16868.30
Meghalaya 1021.00 1552.76 3107.74 5803.94 6851.09 10794.70 12045.50 16171.30
Mizoram 704.00 1798.21 3040.31 5647.16 NA 10216.10 11309.60 11837.40
Nagaland 1857.00 2687.00 4204.72 8344.83 9881.77 14202.40 15062.80 17533.10
Orissa 9057.00 12479.55 21905.33 46978.17 55351.67 88290.00 100150.00 140840.00
Pondicherry 419.00 1029.38 2042.05 4217.61 5640.47 NA NA NA
Punjab 13463.00 12020.88 25199.05 56349.93 78352.03 117130.00 148250.00 191210.00
Rajasthan 15102.00 18667.08 34799.45 83315.56 89860.64 150350.00 170160.00 195880.00
Sikkim 439.00 812.64 1281.48 8811.83 12581.94 7633.10 18826.20 17548.70
Tamil Nadu 17040.00 27757 56382.28 109105.70 149508.60 217520 256880.00 281290.00
Tripura 1489.00 2295.31 4970.32 1048.56 10603.89 17340.30 19607.20 22157.00
Union
Government 737004.00 579112.30 1029642 1983023 2777323.00 2778390.00 3396270.00 3854930.00
Uttar Pradesh 28511.00 43491.50 95383.57 175558.60 221950.30 310330.00 329390.00 427860.00
Uttaranchal - - - - - 9140.00 36760.00 58640.00
West Bengal 21315.00 26974.85 51281.19 86262.66 113218.80 221030.00 231610.00 277980.00
All India 1006892.00 965509.60 1733598.00 3412078.00 4642089.00 5693610.00 6686970.00 8019680.00

Statistical Tables
3.5: Total Capital Expenditure, State and Union

(Rs. in Millions)
State/Year 1981 1987 1991 1996 1998 2001 2003 2005
Andhra
Pradesh 2480.00 4703.79 4619.07 24221.96 10860.05 50490.00 86950.00 139910.00
Arunachal
Pradesh 195.00 621.46 1245.40 2862.03 2935.69 2978.70 3318.80 4549.40
Assam 755.00 1968.59 NA 3006.94 3293.15 12140.00 18240.00 72970.00
Bihar 2540.00 5704.45 4936.20 3819.68 5602.69 26010.00 22010.00 55440.00
Chhattisgarh - - - - - 3050.00 12920.00 24950.00
Goa,
Daman & Diu 228.00 580.61 993.01 1355.76 1142.59 2530.00 4050.00 8930.00
Gujarat 2026.00 3264.50 6893.35 12606.47 18591.96 51340.00 54810.00 61720.00
Haryana 1023.00 1722.55 1861.63 2858.74 4922.07 19780.00 28250.00 40090.00
Himachal
Pradesh 526.00 949.72 12768.07 3084.56 0 9387.50 14752.70 11025.50
Jammu &
Kashmir 1304.00 2420.42 3518.36 7294.24 8894.69 11437.30 23248.30 24910.60
Jharkhand - - - - - - 20720.00 31320.00
Karnataka 1717.00 3331.28 6548.08 12404.50 12099.53 29790.00 52600.00 63360.00
Kerala 1219.00 2110.45 2559.63 5634.66 7388.66 12710.00 22110.00 26140.00
Madhya
Pradesh 2608.00 5074.63 7122.56 8603.45 16778.00 19380.00 44290.00 102410.00
Maharashtra 3486.00 6825.65 9639.43 27034.81 32117.89 48070.00 67430.00 68090.00
Manipur 336.00 779.07 1275.99 1752.02 2545.61 2502.20 7422.90 8494.70
Meghalaya 211.00 513.24 749.46 1341.51 1258.79 3444.00 3898.90 4050.90
Mizoram 133.00 321.31 1392.00 1329.50 NA 2663.30 2738.70 2865.90
Nagaland 257.00 595.75 869.54 1014.06 1336.84 4152.30 4106.10 7588.60
Orissa 1878.00 3227.28 5510.61 4469.07 8560.27 22190.00 32530.00 41160.00
Pondicherry 56.00 183.13 304.98 1098124 1281973.00 NA NA NA
Punjab 781.00 38.52 0 0 0 23980.00 24090.00 67000.00
Rajasthan 1787.00 2925.89 4900.52 17574.66 0 24590.00 45260.00 95630.00
Sikkim 118.00 318.42 0 1271.89 0 1839.20 2493.90 4599.20
Tamil Nadu 851.00 1689.60 0 5151.00 0 26850.00 44690.00 69560.00
Tripura 262.00 588.35 882.28 1833.86 2152.60 4010.10 5761.90 9672.40
Union Govt 39827.00 109913.10 NA NA NA 477530.00 607700.00 923360.00
Uttar Pradesh 4813.00 1018.94 11775.77 NA 16676.34 56490.00 91480.00 102980.00
Uttaranchal - - - - - 1970.00 11730.00 15020.00
West Bengal 1067.00 2068.99 3686.21 11642.77 6337.93 46370.00 45510.00 111350.00
All India 72484.00 163459.70 94052.15 1260292.00 1445468.00 1034300.00 1495660.00 2279090.00

3.6: Revenue Receipts from Public Health and Family Welfare as Percent of
Revenue Health Expenditure
State/Year 1981 1987 1991 1996 1998 1999

Andhra Pradesh 4.42 1.58 0.31 0.13 0.19 0.13
Arunachal Pradesh 1.83 0.53 0.02 0.06 0.05 NA
Assam 0.97 0.18 0.10 0.07 0 0.01
Bihar 1.34 1.68 0.35 0.27 0.27 0.16
Chhattisgarh - - - - - -
Goa,Daman & Diu 23.84 16.49 0.10 0.68 0.56 NA
Gujarat 4.03 0.60 0.89 0.23 0.17 NA
Haryana 1.51 2.29 0.12 0.79 0.11 0.15
Jammu & Kashmir 1.98 1.15 0.02 0.02 0.07 0
Jharkhand - - - - - -
Karnataka 1.04 1.15 0.23 0.09 0.12 1.15
Kerala 5.00 0.13 0.16 0.08 0.10 0.11
Madhya Pradesh 2.36 2.50 0.52 0.48 1.02 0.21
Maharashtra 1.86 0.95 0.70 0.74 0.61 0.73
Manipur 1.58 0.79 1.96 0.13 0.04 NA
Meghalaya 0.96 1.63 1.32 0.85 0.16 NA
Mizoram 0.17 0.69 0.32 0.10 NA NA
Nagaland 0.88 0.39 0.11 0 0 NA
Orissa 1.77 2.73 0.20 0.12 0.17 0.11
Pondicherry 4.07 2.12 0.15 0.06 0.07 0.05
Punjab 2.63 1.88 1.28 0.41 0.18 0.07
Rajasthan 17.7 15.06 0.05 0.09 0.06 0.02
Sikkim 0.29 0.50 0 0.31 0.12 0.12
Tamil Nadu 1.10 1.23 0.37 0.28 0.2 0.20
Tripura 0.73 0.78 0.15 0.02 0.03 NA
Union Government 2.22 4.44 1.58 1.79 2.84 1.22
Uttar Pradesh 0.37 0.43 0.31 0.44 1.83 NA
Uttaranchal - - - - - -
West Bengal 0.60 0.33 0.14 0.05 0.37 0.02
All India 2.86 2.16 0.52 0.43 0.67 0.35
Sources: For 1981 and 1987 is combined Finance and Revenue Accounts Comptroller and Auditor General
of India GOI,respective year. Other years -Demand for Grants, respective States.
state

Statistical Tables
3.7: Revenue Receipts from Public Health and Family Welfare
(Rs. in Millions)
State/Year 1981 1987 1991 1996 1998 1999
Andhra Pradesh 49.50 45.49 10.20 8.04 16.03 13.66
Assam 3.45 2.26 1.11 1.46 0.05 0.13
Bihar 9.03 33.64 9.42 13.27 15.75 10.76
Goa,Daman & Diu 14.78 31.52 0.23 2.84 3.19 NA
Gujarat 29.63 13.77 22.42 10.74 10.47 NA
Haryana 5.56 20.53 0.98 12.69 2.54 4.38
Jammu & Kashmir 5.13 7.72 0.17 0.36 1.53 0.01
Karnataka 7.30 22.04 5.51 4.30 7.40 10.65
Kerala 32.19 1.88 3.3 3.27 4.85 5.91
Madhya Pradesh 27.77 73.89 14.28 22.04 59.52 17.07
Maharashtra 30.01 48.58 33.57 65.89 67.37 84.70
Manipur 0.95 1.69 3.69 0.48 0.19 NA
Meghalaya 0.71 2.10 2.75 2.98 0.74 NA
Mizoram 0.11 1.35 0.47 0.28 NA NA
Nagaland 0.93 1.08 0.26 0.01 0 NA
Orissa 9.72 34.59 2.68 2.99 4.95 4.35
Pondicherry 1.75 2.39 0.28 0.21 0.36 0.28
Punjab 12.87 22.64 21.23 10.50 7.02 3.47
Rajasthan 141.07 329.87 1.26 4.39 3.72 1.76
Sikkim 0.05 0.26 0 0.60 0.25 0.51
Tamil Nadu 11.51 34.81 14.17 19.39 17.83 22.41
Tripura 0.3 1.04 0.42 0.07 0.16 NA
Uttar Pradesh 5.45 16.20 19.31 44.32 58.89 NA
West Bengal 8.09 8.94 6.20 2.92 3.54 2.71
All India 435.51 844.40 262.93 392.48 682.09 386.85
state

3.8: Revenue Receipts from Medical as Percent of Revenue Health Expenditure
State/Year 1981 1987 1991 1996 1998 1999

Andhra Pradesh 4.37 2.71 3.28 2.23 2.52 2.26
Assam 1.12 0.83 1.68 1.17 1.08 1.53
Bihar 5.78 2.64 2.41 1.84 1.84 2.09
Goa,Daman & Diu 1.61 0.63 3.54 5.26 5.14 NA
Gujarat 7.34 4.88 8.33 5.96 7.34 NA
Haryana 7.63 4.28 7.64 6.40 9.26 5.89
Jammu & Kashmir 0.77 1.05 0.6 0.78 1.05 1.08
Karnataka 5.25 4.26 4.31 4.30 4.95 0
Kerala 5.90 3.92 4.13 5.93 4.49 3.93
Madhya Pradesh 0.85 1.18 2.58 1.88 2.44 1.29
Maharashtra 0.62 0.68 1.48 0.98 1.30 0.91
Manipur 16.67 16.31 37.67 23.79 31.13 NA
Meghalaya 0 0.51 2.01 1.19 0.40 NA
Mizoram 0 0.07 0.78 0.54 NA NA
Nagaland 0 0.44 1.58 0.90 0.51 NA
Orissa 0 0.48 0.02 0.01 0.01 0
Pondicherry 6.98 2.02 2.55 2.68 2.60 2.98
Punjab 1.43 2.33 1.85 1.35 1.62 1.56
Rajasthan 3.76 2.36 3.66 2.19 3.38 1.88
Sikkim 194.12 82.45 80.97 86.16 79.04 35.30
Tamil Nadu 0 0 0.01 0.03 0.01 0.04
Tripura 0 0.26 0.94 1.02 0.63 NA
Uttar Pradesh 3.36 1.00 2.53 1.37 6.76 NA
West Bengal 8.63 4.67 4.95 3.61 40.88 3.11
All India 3.67 2.34 3.09 2.62 3.41 2.10
state

Statistical Tables
3.9: Central Government Health Scheme (CGHS)/

Employees State Insurance Schemes (ESIS) Revenue Receipt
(Rs. in Millions)
State/Year 1981 1987 1991 1996 1998 1999
Andhra Pradesh 41.00 68.29 90.18 101.01 176.57 192.51
Arunachal Pradesh NA 0 0 0 0 NA
Assam NA 0 0 0 0 0
Bihar NA 7.83 0 25.95 38.60 84.49
Goa,Daman & Diu NA 0.28 6.38 13.04 11.48 NA
Gujarat 47.00 19.40 116.44 193.68 380.09 NA
Haryana 26.00 17.71 51.75 87.66 183.06 149.29
Himachal Pradesh NA 0 4.50 2.65 2.23 7.15
Jammu & Kashmir NA 0 0 0 0 0
Karnataka 24.00 23.56 65.80 172.57 259.14 NA
Kerala 26.00 41.04 66.05 153.27 183.55 173.78
Madhya Pradesh NA 14.75 15.83 62.97 20.25 0.70
Maharashtra 158.00 215.02 195.33 358.82 543.80 574.28
Manipur NA 0 0 0 0 NA
Meghalaya NA 0 0.32 0.45 NA NA
Mizoram NA 0 0.22 0.17 NA NA
Nagaland NA 0 0 0 0 NA
Orissa 5.00 24.25 23.31 26.53 48.24 64.53
Pondicherry 2.00 1.16 2.87 7.12 6.80 12.24
Punjab 18.00 7.15 30.48 71.5 91.13 121.20
Rajasthan 25.00 33.85 41.70 111.66 143.45 NA
Sikkim NA 0 0 0 0 0
Tamil Nadu 10.00 119.35 154.25 275.02 340.47 548.44
Tripura NA 0 0 0 0 NA
Uttar Pradesh 36.00 0.02 79.31 59.28 175.22 NA
West Bengal 100.00 100.86 176.05 11.86 NA 80.94
All India 538.00 731.20 1157.64 1870.57 2776.30 2257.28
Sources: For 1981 and 1987 is combined Finance and Revenue Accounts Comptroller and Auditor
General of India GOI,respective year. Other years -Demand for Grants, respective States.
state

3.10: Receipts from Services and Fees (Medical)
(Rs. in Millions)
State/Year 1981 1987 1991 1996 1998 1999
Andhra Pradesh 2.00 0.07 2.24 3.32 4.17 1.98
Arunachal Pradesh NA 0 0.14 0 0 NA
Assam NA 0 0 0 5.04 0
Bihar 26.00 0 0.21 0.41 0.42 1.20
Goa,Daman & Diu NA 0 0.61 0.99 3.51 NA
Gujarat 2.00 0 5.64 11.21 13.10 NA
Haryana NA 0 1.19 1.80 2.20 3.05
Himachal Pradesh 2.00 0 1.51 5.99 6.88 7.19
Jammu & Kashmir NA 0 0 0 0 0
Karnataka 6.00 0 1.78 1.15 0.26 NA
Kerala 5.00 0.51 5.56 56.92 3.24 2.93
Madhya Pradesh 1.00 0 0.85 1.11 0.95 1.43
Maharashtra 7.00 0.03 32.11 57.52 57.8 57.60
Manipur NA 0 0.26 2.82 1.21 NA
Meghalaya NA 0 0.61 1.21 -1.00 NA
Mizoram NA 0 0 0 -1.00 NA
Orissa NA 0 1.54 0.43 2.10 0.84
Pondicherry NA 0 1.10 2.08 2.24 2.77
Punjab 3.00 0 7.98 11.37 41.17 10.72
Rajasthan 2.00 0 13.79 11.96 0.46 NA
Sikkim NA 0 0.06 0 0 0
Tamil Nadu 17.00 0 8.89 15.65 16.29 20.78
Union Government 4.00 0 8.70 13.48 20.92 26.27
Uttar Pradesh 2.00 0 13.45 6.55 10.24 NA
West Bengal 7.00 0 8.61 18.49 NA 8.89
All India 86.00 0.61 116.83 224.46 190.20 145.65
state

Statistical Tables
3.11: Revenue Expenditure on Family Welfare
(Rs. in Millions)
State/Year 1981 1987 1991 1996 1998 1999 2001
Andhra Pradesh 124.00 373.03 612.32 1290.69 1657.63 2207.36 2727.74
Arunachal Pradesh 1.00 2.41 6.82 11.85 24.37 NA 21.60
Assam 19.00 127.30 179.13 377.19 326.00 397.91 697.27
Bihar 88.00 315.42 556.80 1531.42 1570.93 2034.16 1584.96
Chhattisgarh - - - - - - -
Goa,Daman & Diu 2.00 5.49 11.42 12.87 22.11 NA 31.03
Gujarat 100.00 323.93 423.61 761.16 978.83 NA 1327.69
Haryana 24.00 98.90 134.42 308.23 354.11 443.63 340.45
Himachal Pradesh 18.00 62.08 121.82 194.72 228.44 302.91 321.10
Jammu & Kashmir 11.00 29.85 65.99 167.35 238.27 278.00 189.34
Jharkhand - - - - - - -
Karnataka 83.00 286.31 382.71 914.76 1124.41 925.36 1368.06
Kerala 59.00 175.46 357.87 590.17 694.30 794.68 921.90
Madhya Pradesh 103.00 403.92 451.45 779.5 836.88 1007.31 1092.8
Maharashtra 128.00 445.00 644.71 1315.34 1206.03 948.16 1774.97
Manipur 7.00 15.44 28.20 59.88 62.20 NA 76.30
Meghalaya 4.00 12.49 20.22 49.74 62.51 NA 74.00
Mizoram 2.00 7.66 14.78 21.70 NA NA 49.50
Nagaland NA 13.89 17.97 72.37 48.31 NA 84.61
Orissa 64.00 172.22 300.49 612.21 618.86 835.20 759.23
Pondicherry 2.00 5.39 5.58 10.30 15.55 17.84 25.77
Punjab 32.00 136.95 195.40 379.74 367.55 415.82 448.36
Rajasthan 71.00 261.97 464.51 1068.12 1162.48 1567.63 1457.47
Sikkim 1.00 5.20 11.41 35.21 29.70 48.43 47.30
Tamil Nadu 88.00 335.17 630.77 1223.56 1536.02 1915.87 1888.15
Tripura 2.00 13.60 32.74 85.36 141.15 NA 184.04
Union Government 126.00 439.88 677.27 1347.68 3257.84 3134.02 6632.46
Uttar Pradesh 178.00 956 1494.29 2180.81 3223.12 NA 2671.10
Uttaranchal - - - - - - -
West Bengal 83.00 302.18 550.56 909.66 944.48 1502.68 1857.51
All India 1419.00 5327.14 8393.26 16311.59 20732.08 18776.97 28654.71
of India GOI,respective year. Other years -Demand for Grants, respective States; For year 2001
is State Finance A Study of Budget of 2002-03, RBI
state

3.12: Capital Expenditure on Family Welfare
(Rs. in Millions)
State/Year 1981 1987 1991 1996 1998 1999 2001
Andhra Pradesh 1.00 8.32 0.28 0 0 0 0
Arunachal Pradesh 0 0 0 0 0 NA 0
Assam 3.00 28.23 6.10 1.02 1.85 3.07 1.99
Bihar 7.00 40.20 0.17 0 6.44 0 0
Chhattisgarh - - - - - - -
Goa,Daman & Diu NA 0 0 0 0 NA 0
Gujarat 1.00 1.63 2.03 1.20 0.15 NA 0
Haryana 4.00 1.39 1.41 19.13 15.82 46.13 3.20
Himachal Pradesh 2.00 7.65 33.15 8.99 -0.05 0.19 0
Jammu & Kashmir 0.19 0 7.70 0.82 0.35 0 0.03
Jharkhand - - - - - - -
Karnataka NA 112.71 48.95 31.02 155.31 NA 301.48
Kerala 2.00 137.57 50.30 22.90 26.66 13.69 4.93
Madhya Pradesh NA 41.36 14.47 48.89 107.15 54.74 31.10
Maharashtra NA 0.90 8.02 0.28 0.11 7.08 0.30
Manipur 0.06 3.36 2.44 0.05 0.01 NA 0
Meghalaya 0.04 2.07 0 0 0 NA 0
Mizoram NA 0 0 0 NA NA 0
Nagaland 1.00 0 1.63 0 0 NA 0
Orissa NA 0 8.57 0 0 0 0
Pondicherry NA 0 0 0 0 0 0
Punjab 4.00 18.75 1.03 2.46 0.04 NA 0
Rajasthan 6.00 1.57 27.25 94.80 340.14 46.59 78.70
Sikkim NA 0 0 0 0 0 0.03
Tamil Nadu 3.00 15.42 19.89 57.71 0.47 -0.24 1.59
Tripura 0.01 0.85 1.63 0.61 0.06 NA N.A.
Union Government NA 47.59 1.07 0.84 0.46 0.79 185.19
Uttar Pradesh 8.00 21.69 35.59 60.78 3.12 NA 0.45
Uttaranchal - - - - - - -
West Bengal 3.00 1.98 134.93 0 NA 0.07 0
All India 45.30 493.24 406.61 351.50 658.09 172.11 608.03
of India GOI,respective year. Other years -Demand for Grants, respective States; For year 2001
is State Finance A Study of Budget of 2002-03, RBI
state

Statistical Tables
3.13: Expenditure on Medical Services
(Rs. in Millions)
State/Year 1981 1987 1991 1996 1998 1999
Andhra Pradesh 601.00 1147.05 2056.16 3671.83 5438.70 6719.37
Assam 204.00 558.82 904.55 1581.97 1771.78 1605.21
Bihar 439.00 1099.86 1797.36 2961.96 3751.49 4186.05
Goa,Daman & Diu 59.00 135.76 293.73 444.26 535.07 NA
Gujarat 392.00 918.92 1654.43 3075.70 4257.85 NA
Haryana 162.00 342.69 598.30 1118.35 1455.68 2090.64
Jammu & Kashmir 221.00 472.01 771.03 1588.04 1367.60 2254.08
Karnataka 426.00 1093.01 1885.60 3856.91 5396.78 NA
Kerala 482.00 1022.06 1636.15 3212.95 3970.58 4440.01
Madhya Pradesh 449.00 1058.74 1917.02 3332.83 4340.19 6003.53
Maharashtra 795.00 1480.17 2341.87 4092.37 5328.13 6091.55
Manipur 36.00 77.20 133.90 260.94 284.24 NA
Meghalaya 45.00 98.03 178.36 328.01 417.10 NA
Mizoram 28.00 88.70 118.11 221.07 NA NA
Nagaland 53.00 149.14 247.15 380.05 553.72 NA
Orissa 267.00 547.36 868.24 1649.62 2009.41 2637.74
Pondicherry 28.00 79.27 158.09 322.30 426.60 501.34
Punjab 322.00 677.26 1306.20 1982.79 3090.41 4340.64
Rajasthan 397.00 970.76 1819.39 4023.95 4966.78 6270.88
Sikkim 13.00 36.98 80.41 222.59 193.98 366.45
Tamil Nadu 772.00 1629.58 2685.27 4929.51 6559.37 8007.69
Tripura 38.00 114.52 219.66 304.67 406.63 NA
Uttar Pradesh 752.00 1485.93 4074.00 6580.28 820.08 NA
West Bengal 932.00 1851.76 3350.70 4636.86 NA 8615.33
All India 8986.00 19691.21 36369.63 62593.67 68550.84 80003.99
of India GOI,respective year. Other years -Demand for Grants, respective States;
state

3.14: Total Expenditure on Public Health
(Rs. in Millions)
State/Year 1981 1987 1991 1996 1998 1999
Andhra Pradesh 420.00 1400.56 629.18 1098.70 1410.23 1475.02
Assam 171.00 671.69 192.61 305.43 463.78 337.78
Bihar 211.00 1173.35 422.89 478.59 484.79 556.16
Goa,Daman & Diu 16.00 168.16 20.80 38.64 47.11 NA
Gujarat 251.00 1430.99 443.95 870.79 1160.69 NA
Haryana 206.00 496.78 136.93 221.25 499.71 499.31
Jammu & Kashmir 76.00 711.32 44.65 194.15 919.83 462.37
Karnataka 205.00 595.74 178.54 331.07 404.06 NA
Kerala 125.00 502.21 175.57 346.07 412.90 502.75
Madhya Pradesh 638.00 1585.23 433.09 644.43 838.75 1428.67
Maharashtra 747.00 3387.95 1988.86 3653.10 4670.36 4808.10
Manipur 24.00 251.97 38.24 62.53 122.20 NA
Meghalaya 27.00 161.09 42.72 64.36 76.98 NA
Mizoram 36.00 154.70 22.19 48.58 NA NA
Nagaland 59.00 193.99 35.54 104.76 35.35 NA
Orissa 234.00 614.82 228.52 390.96 453.32 595.22
Pondicherry 13.00 36.77 19.77 43.33 48.42 50.41
Punjab 165.00 435.69 194.14 239.31 402.63 426.65
Rajasthan 345.00 1891.95 267.60 565.48 696.25 715.59
Sikkim 11.00 30.70 9.25 16.97 17.38 25.30
Tamil Nadu 243.00 975.80 559.21 972.17 1294.37 1743.82
Tripura 4.00 83.57 49.15 34.30 62.92 NA
Uttar Pradesh 625.00 1578.41 1155.97 1771.26 104.95 NA
Uttarannchal - - - - - -
West Bengal 391.00 669.98 563.85 752.42 NA 1377.27
All India 6032.00 21046.97 8376.05 14512.84 16772.53 18823.98
of India GOI,respective year. Other years -Demand for Grants, respective States;
state

Statistical Tables
3.15: Expenditure on National Disease Programme
(Rs. in Millions)
State/Year 1981 1987 1991 1996 1998 1999
Andhra Pradesh 132.00 321.45 535.70 937.24 1221.91 1254.94
Assam 40.00 108.21 162.80 276.69 414.08 275.40
Bihar 70.00 183.91 314.05 355.27 401.85 452.14
Goa,Daman & Diu 6.00 9.93 12.79 24.88 30.24 NA
Gujarat 94.00 208.41 282.94 652.46 852.47 NA
Haryana 48.00 105.84 112.90 181.29 447.75 433.41
Jammu & Kashmir 10.00 19.64 16.35 44.62 29.34 63.50
Karnataka 74.00 167.75 126.77 247.23 303.55 NA
Kerala 30.00 57.38 88.05 208.71 225 290.00
Madhya Pradesh 107.00 180.75 296.63 464.29 699.10 853.54
Maharashtra 192.00 520.93 622.48 1011.08 1154.26 1435.68
Manipur 17.00 22.57 35.50 61.22 117.64 NA
Meghalaya 17.00 21.04 32.61 49.33 57.21 NA
Mizoram 7.00 15.41 20.93 43.02 NA NA
Nagaland 8.00 25.60 35.49 101.66 32.17 NA
Orissa 77.00 165.41 174.82 290.99 322.15 358.68
Pondicherry 4.00 9.51 16.32 35.06 39.70 42.34
Punjab 53.00 119.23 170.20 198.70 345.10 355.15
Rajasthan 104.00 149.09 221.18 475.94 590.05 597.69
Sikkim 2.00 4.73 7.48 13.99 14.04 20.20
Tamil Nadu 37.00 55.36 455.65 801.31 1048.01 1332.12
Tripura 6.00 22.16 40.22 23.51 50.89 NA
Uttar Pradesh 217.00 537.82 1029.40 1661.62 NA NA
West Bengal 96.00 193.94 429.740 555.21 NA 989.70
All India 1542.00 3417.05 5537.20 9464.63 9650.42 10270.93
of India GOI, respective year. Other years -Demand for Grants, respective States.
state

3.16: Expenditure on Hospitals and Dispensaries
(Rs. in Millions)
State/Year 1981 1987 1991 1996 1998 1999
Andhra Pradesh 411.00 813.17 1083.63 1928.78 3017.52 3542.16
Assam 136.00 352.50 364.75 674.37 673.51 704.47
Bihar 282.00 660.59 389.29 680.51 929.54 1066.64
Goa,Daman & Diu 37.00 97.38 123.35 216.29 289.72 NA
Gujarat 233.00 542.46 NA 1197.90 1450.05 NA
Haryana 64.00 139.70 166.50 371.55 424.33 583.59
Jammu & Kashmir 113.00 247.67 502.93 1063.49 296.43 986.19
Karnataka 261.00 747.95 582.96 1080.51 1393.35 NA
Kerala 310.00 653.26 928.48 1561.17 1963.70 2159.79
Madhya Pradesh 307.00 684.81 840.62 1509.82 1644.38 2060.06
Maharashtra 355.00 787.45 1264.15 2447.46 2972.69 3390.11
Manipur 22.00 53.16 36.49 105.89 86.85 NA
Meghalaya 36.00 59.21 70.06 117.86 142.82 NA
Mizoram 22.00 73.67 27.52 51.55 NA NA
Nagaland 39.00 114.11 126.15 183.45 178.78 NA
Orissa 187.00 375.26 334.80 659.82 766.04 944.00
Pondicherry 23.00 65.60 123.82 245.40 274.62 328.89
Punjab 201.00 460.03 522.56 792.47 1198.09 1421.61
Rajasthan 241.00 581.39 738.81 1306.71 1522.34 2022.56
Sikkim 6.00 19.98 38.33 90.78 105.69 259.62
Tamil Nadu 551.00 1192.42 1405.88 2625.39 3334.46 3890.94
Tripura 31.00 89.98 115.00 154.61 195.51 NA
West Bengal 529.00 1063.84 1594.30 2286.99 NA 4368.51
All India 5146.00 11602.10 15372.22 27258.90 25426.68 30471.74
state

Statistical Tables
3.17: Expenditure on Central Government Health Scheme (CGHS)/

Employees State Insurance Schemes (ESIS)
(Rs. in Millions)
State/Year 1981 1987 1991 1996 1998 1999
Andhra Pradesh 63.00 68.52 138.13 266.97 339.78 381.93
Arunachal Pradesh NA 0 11.66 30.39 13.86 NA
Assam 6.00 6.62 14.09 28.49 31.88 55.40
Bihar 13.00 20.83 38.60 63.93 86.88 82.38
Goa,Daman & Diu NA 1.38 7.41 14.93 25.15 NA
Gujarat 75.00 164.49 NA 411.92 478.15 NA
Haryana 22.00 41.07 66.85 129.91 154.87 230.84
Himachal Pradesh NA 1.40 56.03 10.82 12.81 20.75
Jammu & Kashmir 2.00 0 0 0 0 0
Karnataka 44.00 89.72 138.56 264.06 302.74 NA
Kerala 46.00 65.27 126.13 243.76 254.54 285.79
Madhya Pradesh 20.00 41.88 81.27 147.21 193.69 252.55
Maharashtra 209.00 270.24 396.10 533.35 652.02 783.17
Meghalaya NA 0 0 0 0 NA
Mizoram NA 0 0 0 NA NA
Nagaland 2.00 0 0 0 0 NA
Orissa 10.00 25.39 34.41 59.39 77.76 104.06
Pondicherry 3.00 6.49 13.31 23.56 29.45 41.41
Punjab 24.00 46.61 91.44 154.36 217.95 256.73
Rajasthan 19.00 44.74 65.83 125.69 153.16 202.24
Sikkim NA 0 0 0 0 0
Tamil Nadu 67.00 127.79 233.47 392.53 508.20 632.72
West Bengal 118.00 216.39 300.32 365.56 NA 645.06
All India 1001.00 1680.77 2698.47 4708.67 5231.44 6056.52
state

3.18: Revenue Expenditure on Medical Education, Training and Research
(Rs. in Millions)
State/Year 1981 1987 1991 1996 1998 1999
Andhra Pradesh 65.00 144.72 253.68 432.77 534.26 581.95
Arunachal Pradesh 1.00 2.11 7.20 3.12 11.55 11.55
Assam 19.00 42.48 96.26 139.90 156.98 179.65
Bihar 41.00 181.86 212.58 303.80 481.31 546.82
Goa,Daman & Diu 5.00 16.75 27.75 46.30 52.33 62.54
Gujarat 44.00 86.58 217.24 432.67 588.70 NA
Haryana 35.00 81.77 147.38 262.15 347.20 501.51
Jammu & Kashmir 43.00 124.02 120.17 253.05 673.61 986.00
Karnataka 57.00 109.72 220.15 448.72 749.53 NA
Kerala 50.00 117.03 226.05 422.39 577.84 618.85
Madhya Pradesh 36.00 75.21 144.50 286.36 424.16 528.89
Maharashtra 105.00 186.73 370.10 635.72 1277.25 1255.89
Manipur 3.00 6.00 18.85 14.01 37.63 NA
Meghalaya 2.00 5.64 7.03 12.27 16.73 NA
Mizoram NA 2.02 4.81 12.56 NA NA
Nagaland 1.00 2.23 2.48 11.21 2.66 NA
Orissa 24.00 55.04 110.72 176.27 244.44 296.75
Pondicherry 1.00 1.51 7.14 18.45 51.70 77.59
Punjab 41.00 72.16 168.70 217.37 330.08 585.83
Rajasthan 43.00 99.96 188.10 378.46 445.56 669.78
Sikkim NA 0.15 0.39 1.28 0.90 0.87
Tamil Nadu 72.00 141.14 322.14 558.97 833.76 929.39
Tripura 2.00 7.33 14.13 0.18 17.22 NA
West Bengal 63.00 133.15 321.00 487.04 NA 817.32
All India 1078.00 2763.24 5706.57 10082.64 13005.88 15757.85
state

Statistical Tables
3.19: Capital Expenditure on Medical Education, Training and Research
(Rs. in Millions)
State/Year 1981 1987 1991 1996 1998 1999
Andhra Pradesh 4.00 4.58 0.28 NA 0 0
Arunachal Pradesh NA 0 0 0 0 NA
Assam 11.00 11.38 54.52 5.11 3.24 2.10
Bihar NA 0 0 0 0 0
Goa,Daman & Diu 10.00 13.12 78.41 64.15 27.88 NA
Gujarat 1.00 6.64 5.61 2.82 25.88 NA
Haryana NA 9.89 21.45 15.85 13.43 14.82
Jammu & Kashmir 39.00 22.42 125.39 183.45 65.99 20.42
Karnataka 1.00 0 6.18 0 49.84 NA
Kerala 7.00 29.59 28.81 92.57 139.37 195.66
Madhya Pradesh 1.00 6.84 17.14 1.66 1.08 0.81
Maharashtra 31.00 33.04 53.70 75.23 61.73 108.12
Meghalaya NA 0 0 0 0 NA
Mizoram NA 0 0 0 NA NA
Orissa NA 0.06 5.93 1.70 14.62 15.10
Pondicherry NA 0 0 0 0 0
Punjab 2.00 0.85 18.21 17.45 13.31 9.87
Rajasthan 4.00 27.17 28.50 104.57 171.47 159.61
Sikkim NA 0 0 0 0 0
Tamil Nadu 7.00 25.89 53.29 6.41 11.81 NA
Tripura NA 0 0 0.07 0.30 NA
Uttar Pradesh 4.00 8.41 21.88 19.96 39.71 NA
West Bengal 7.00 43.92 19.22 42.05 NA 43.55
All India 185.00 256.37 571.10 782.37 921.70 876.62
state

3.20: Revenue Expenditure on Rural Family Welfare Services
(Rs. in Millions)
State/Year 1981 1987 1991 1996 1998 1999
Andhra Pradesh 66.00 197.80 348.53 678.82 922.94 1040.54
Arunachal Pradesh NA 0 0.08 0 0 NA
Assam 7.00 34.72 93.90 196.95 233.18 288.30
Bihar 48.00 158.74 369.07 708.41 890.11 801.89
Goa,Daman & Diu 1.00 2.74 4.74 7.32 9.43 NA
Gujarat 36.00 109.39 235.15 460.76 595.58 NA
Haryana 10.00 29.20 54.91 109.58 140.30 200.49
Jammu & Kashmir 4.00 15.16 44.86 74.32 84.00 86.11
Karnataka 27.00 81.86 7.28 13.65 11.97 NA
Kerala 31.00 84.57 205.65 345.73 413.61 480.16
Madhya Pradesh 44.00 90.21 210.78 361.49 459.51 578.74
Maharashtra 46.00 88.62 149.90 232.30 304.08 292.11
Manipur 2.00 6.69 14.79 16.90 21.10 NA
Meghalaya 1.00 4.37 9.71 21.29 29.17 NA
Mizoram 1.00 1.72 4.30 8.98 NA NA
Nagaland NA 8.30 12.98 24.89 37.89 NA
Orissa 22.00 42.07 123.79 191.91 245.18 368.69
Pondicherry 1.00 1.24 2.05 3.38 5.60 6.89
Punjab 16.00 34.45 81.24 109.78 156.86 201.82
Rajasthan 21.00 81.31 193.62 432.67 493.01 657.65
Sikkim NA 2.53 6.63 24.71 19.29 33.12
Tamil Nadu 43.00 80.11 280.87 497.48 658.71 873.15
Tripura 1.00 3.98 19.23 27.71 54.07 NA
Union Government NA 0.86 3.94 6.61 10.93 11.73
West Bengal 26.00 152.03 351.83 541.46 NA 1032.07
All India 554.00 1764.63 3727.60 6543.31 5916.71 7126.63
state

Statistical Tables
3.21: Revenue Expenditure on Urban Family Welfare Services
(Rs. in Millions)
State/Year 1981 1987 1991 1996 1998 1999
Andhra Pradesh 3.00 10.07 18.62 32.57 39.25 36.18
Arunachal Pradesh NA 0 0.02 0.18 0.24 NA
Assam 1.00 1.60 2.86 3.33 4.51 6.08
Bihar 1.00 2.27 6.68 4.00 6.28 7.05
Goa,Daman & Diu NA 0 0.91 1.32 2.11 NA
Gujarat 7.00 12.66 13.43 28.47 31.67 NA
Haryana NA 0.98 2.98 4.93 7.14 8.58
Himachal Pradesh NA 0 3.32 4.91 6.30 8.16
Jammu & Kashmir 1.00 0.50 1.31 1.77 0.98 1.04
Karnataka 4.00 7.68 11.99 21.35 21.15 NA
Kerala 1.00 1.60 2.19 0.56 0 0.01
Madhya Pradesh 3.00 10.71 19.57 44.70 59.60 65.66
Maharashtra 3.00 23.83 38.05 62.16 72.95 63.87
Manipur 1.00 0.09 0.20 1.59 3.27 NA
Meghalaya NA 0.13 1.17 2.47 2.79 NA
Mizoram NA 0.20 0.77 0.30 NA NA
Orissa 1.00 1.23 7.58 12.01 14.93 20.74
Pondicherry NA 0 NA NA NA NA
Punjab 1.00 2.23 12.58 23.02 29.89 48.51
Rajasthan 2.00 8.09 16.85 22.77 28.22 41.50
Sikkim NA 0 0 2.08 2.31 3.60
Tamil Nadu 4.00 12.29 59.85 257.41 98.98 72.17
Tripura NA 0.20 0.66 0.34 0.19 NA
West Bengal 4.00 10.21 15.41 16.26 NA 24.44
All India 43.00 124.01 300.01 638.67 446.50 422.86
state

3.22: Revenue Expenditure on Maternal and Child Health
(Rs. in Millions)
State/Year 1981 1987 1991 1996 1998 1999
Andhra Pradesh 3.00 5.42 52.34 233.76 291.21 393.46
Arunachal Pradesh 1.00 1.14 0.13 0 0 0
Assam 3.00 11.67 10.80 110.62 25.70 21.68
Bihar 2.00 3.11 9.64 471.41 45.08 825.53
Goa, Daman & Diu NA 0 0.11 0.29 0.75 NA
Gujarat NA 1.59 15.61 24.45 19.70 141.25
Haryana 1.00 5.80 14.57 31.77 59.59 80.41
Jammu & Kashmir NA 0.34 0.47 0.60 0.21 0.08
Karnataka 3.00 17.49 27.89 141.25 118.16 3.18
Kerala NA 0.98 37.80 76.20 60.10 15.05
Madhya Pradesh NA 1.42 12.48 16.59 23.10 22.72
Maharashtra 4.00 28.45 119.85 381.02 382.75 157.16
Manipur NA 0.90 1.55 6.82 3.36 NA
Meghalaya 1.00 0.93 3.53 14.88 16.46 5.40
Mizoram 1.00 1.25 2.50 3.72 NA 23.58
Nagaland NA 0.26 0.55 5.53 2.74 5.34
Orissa NA 1.83 7.16 11.65 7.01 6.42
Pondicherry NA 0.05 0.31 1.55 1.91 3.45
Punjab NA 0 0.97 112.93 0.22 0
Rajasthan 7.00 23.66 63.08 210.39 210.8 324.05
Sikkim NA 0 0.40 0.97 1.09 0.60
Tamil Nadu 3.00 14.86 37.92 203.67 383.36 323.02
Tripura NA 1.28 2.70 0.61 20.99 NA
West Bengal 1.00 1.62 5.11 19.18 NA 143.16
All India 62.00 148.61 465.29 2354.14 2817.83 4028.78
state

Statistical Tables
Glossary
Central Government Health Scheme (CGHS)/ Employees State Insurance Schemes (ESIS) expenditure
on provision of care for the organized sector employees through insurance
Family Welfare this head includes all Family planning Expenditure like FW Centres (rural and urban),
services and supplies, compensation , training for Family planning programs etc. it also includes maternal
and Child Health Expenditure
Family Welfare Expenditure includes expenditure on a) direction and administration of family welfare,
mainly the FW department, bureaucracy at the center, state and divisional level b) Compensation paid
to motivators and acceptors of Vasectomy, tubectomy and IUCD’s c) provision of family Planning
services to rural and urban areas
Family Welfare Receipts Comprise the sale of contraceptives, service fees and miscellaneous recovery
of payments
Health Expenditure includes three account heads ‘ Medical ‘, ‘ Public Health’ and ‘Family Welfare’
the sum of Revenue and Capital account of these head is Total Health Expenditure
Hospital and Dispensary Expenditure incurred on provision of Curative care through hospitals and
dispensaries
Maternal and Child Health expenditure incurred on maternal child health,including immunizations,
ante-natal and post-natal programs
Medical Education Training and Research expenditure incurred on a) education of doctors and
nurses in the various medical colleges and nursing institutions. This does not include expenditure on
the teaching hospital, which is accounted under Hospital and Dispensaries b) Training of most of the
health workers under the various diseases control programes like MPWs, Health Assistants, Supervisors
etc.c) Traning of Auxiliary nurse Midwifes (ANM) , Health Visitors,Dai’s and other staff connected with
family planning programmes c) traning of health personnel of other systems’ of medicines namely
Ayurveda, Homepathy, Unnani, Siddha etc this also includes expenditure on their hospitals and
dispensaries
Medical Services includes wide rage of programs like a) Medical relief consisting of conventional
curative medical facilities such as Hospitals and Dispensaries; Indigenous system of medicine and
Health insurance schemes for organized sector employees and their families (Employees State Insurance
and Central Government Health Schemes) b) Medical education and research (doctors and nurses)
c) Direction and administration
National Diseases Control Programmes includes expenditure Incurred on various disease control
programmes run by the government. These include Malaria, Tuberculosis, Leprosy, Blindness, Filaria,
Guinea worm, mental health, Goitre, sexually transmitted diseases and Diarrohea.
Public Health consisting of Prevention and Control of Communication Diseases. This also includes
training of all paramedical health workers for the public health programs and other small programs like
Food and Drug Administration, Public health Laboratories etc.
Public Health Receipts comprise of service and service fees, collection of payments for services rendered,
sale proceeds of sera and vaccine, fines and other minor receipts in the public health account.

Revenue Receipts from Health Programs These receipts are internal accruals of the various health
departments and programs. They are generally in the nature of fees and administrative charges( Medical
care and Medical education), Services charges (Laboratory and diagnostic services), Premium contribution(
ESIS / CGHS) Sale of drugs and contraceptives and fines and levies.
Total Expenditure this includes expenditure by all Government departments under the consolidated
fund. As per budgetary classification of expenditure it includes Revenue and Capital account. Capital
account consists entirely of expenditure on creation of assets or discharge of liabilities and thus correspond
to the economic definition of Capital Expenditure. The expenditure on State administration, debt servicing,
interest payments, grants-in-aid to various institutions, and expenditure on current consumption of
goods and services of the department of government on activities of non-capital character are booked as
revenue expenditure.

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Review of Healthcare In India

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Review of Health Care in India  iii

Review of Health Care in India  iv

Review of Health Care in India  v

Review of Health Care in India  vii

Review of Health Care in India  viii

SECTION 2: PUBLIC HEALTH POLICIES AND PROGRAMMES

SECTION 3: HEALTH CARE ISSUES RELATED TO WOMEN AND CHILDREN

SECTION 4: HEALTH SYSTEMS AND RESOURCES

SECTION 6: STATISTICAL APPENDIX

Review of Health Care in India  ix

Programmes for Control of Communicable Diseases ........................................... 75

Reproductive Health Services-the Transition from Policy Discourse to

Review of Health Care in India  x

Public Health Expenditures, Investment and Financing Under the Shadow of a

Extent of Inequity in Access to Health Care Services in India ............................ 247

Review of Health Care in India  xi

Availability of Drugs In India .............................................................................. 295

Appendix Statistical Tables ................................................................................ 331

Review of Health Care in India  xii

Review of Health Care in India  xiii

Public Health Expenditures, Investment and Financing Under the Shadow of a

Availability of Drugs In India .............................................................................. 295

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impoverishment and poverty in India. Lax regulations have led to profiteering by

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Introduction the early forties would hold good if a similar

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Health under the chairmanship of workers trained in the scientific

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assumes significance because it showed that emphasis on hospitals, specialisation and

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Review of Health Care in India iii

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