SUNANDO ROY January 1995
Developing nations like India suffer from Medical Pluralism, under which in addition to the formal recognizable modern health sector, traditional systems of various sorts coexist and serve a sizable proportion of the people. While the Government, through extension of health care network and production of medical personnel through numerous medical colleges, has created a wide network of health services in the country, a sizable proportion of population is served by a flourishing and heterogeneous private sector in health care.
1.2. Growth of Health Facilities : Health facilities have grown at a rapid pace since independence [Table I.1]. During 1960-1991, the compound annual rate of increase as estimated from data was as follows :
| 1. | Registered Doctors | 5.5 |
| 2. | Doctors per lakh person | 3.2 |
| 3. | Hospitals | 3.4 |
| 4. | Dispensaries | 3.4 |
| 5. | Primary Health Centres | 6.9 |
| 6. | Sub Centres | 7.5 |
| 7. | Beds | 4.6 |
| 8. | Beds per lakh population | 2.4 |
This growth in facilities was also accompanied by substantial increase in the number of nurses, outturn of medical graduates & dentists (Table I.1).
1.3. This growth in health facilities in different parts of the country has been largely due to the intervention of the state. Ever since the beginning of planning, the Government of India took up the responsibility of providing health services to the masses . A number of committees were formed to review the health status of the country and
to frame the health policy for the future. The Health Survey of Development Committee (1946) (Bhore Committee) clearly spelt out the spirit behind the health policy in India. It suggested that the Government should provide everyone, who wished to use it,full range of health care. No one should be compelled to use it. Those who preferred to make own arrangements for medical treatment would be free to do so. But those who would use public health services should get good and hygienic treatment.
1.4 The Bhore Committee (1946) proposed two programmes for the development of health care facilities in the country. The first programme was a short term programme to be implemented within ten years. The second programme was a long term programme to be achieved in the next thirty to forty years.
1.5 The short term programme of the Bhore Committee included the provision of 2 hospital beds per thousand of population by 1961, and setting up of a primary health centre for every 40,000 persons. By 1961 there were only 0.4 beds per thousand of population and 70,000 persons per primary health centre. The long term goal of the Bhore Committee included the provision of 1 bed for 176 persons, a primary health centre. The long term goal of the Bhore Committee included the provision of 1 bed for 176 persons, a primary health centre for each 20,000 persons, a doctor each for 2000 persons and a nurse each for 500 persons. As can be seen from Table I.2 we are far from reaching most of there targets even today.
1.6 .In 1961, the Mudaliar Committee reviewed the progress made in the sphere of health care during the first two plans. The Mudaliar Committee felt that the Bhore Committee targets were too ambitions in considering the meagre resources available for health care. Mudaliar Committee suggested the following targets – 1 hospital bed for 1000 persons, 1 primary health centre for 10,000 persons with 10 beds (as opposed to 75 bedded primary health centres visualised by Bhore Committee) and a doctor for 3500 persons. The Committee also suggested the setting up of eight sub-centres under the supervision of a primary health centre.
1.7 In the 1960s, the population problem was brought into the focus. Primary health centres and sub centres become important delivery points of both health care and family planning. A large body of Para-Medical workers were employed. They were unipurpose workers in the sense that their duties were clearly defined. The Auxiliary Nurse Midwived (ANMs) were responsible for maternal and child care . Four such ANMs were supervised by one lady Health visitor (LHV). A Family Planning Health Assistant (FPHA) did family planning work. Four such FPHAs were supervised by one Block Extension Educator. There were other unipurpose workers such as the Basic Health Workers (BHW) responsible for malaria control and the Vaccinator, who was responsible for small pox prevention. The lack of coordination among these sets of unipurpose workers affected the delivery of health services. The Chadha Committee(1963) therefore recommended the substitution of unipurpose workers by multipurpose workers, performing all the functions of these unipurpose workers in a small area. However, several complexities arose while retraining unipurpose workers into multipurpose workers. The Mukherjee Committee (1968) suggested the re-introduction of unipurpose workers for family planning work. The Kartar Singh Committee (1973) stressed the need for multipurpose workers and suggested that training of all workers engaged in the field of health, family planning and nutrition should be integrated. Following the recommendations of the Kartar Singh Committee, the training of unipurpose workers to convert them into multipurpose workers started on a large scale. By the end of 1987, the multipurpose workers training programme was completed in 369 districts out of 412 districts. Upto this time, almost 88,308 male multipurpose workers and 85,037 female multipurpose workers had been trained.
1.8 The Srivastava Committee (1975) stressed the importance of community health care and felt that medical education is urban oriented with heavy reliance on curative methods and sophisticated diagnostic aids. It gives little emphasis on preventive and promotive aspects of community health. In 1977, in line with the recommendations of Srivastava Committee the Community Health Workers Scheme was introduced. According to this scheme, there should atleast be one para medical personnel at the village level to take care of the basic preventive and curative needs of the community. He was also expected to promote health consciousness among the members of the village. The utility of the community workers have been felt by later official reports; GOI (1977), GOI (1979), GOI (1981) and National Health Policy of 1983. All these reports agreed that despite the growth in the quantity of health facilities and strength of health manpower, it has failed to reach the masses. Therefore strategies should be undertaken so that health care reaches the masses.
1.9 The delivery of health care remains the responsibility of the State governments. The Central Government looks after Medical Education, health research and some best hospitals in the country.The health service infrastructure in a state is presented in Diagram I.1.
The Community Health worker represents the lowest point of delivery of health services. They operate at the village level. The sub centres are manned by 2 multipurpose workers. The primary centres should have atleast 10 beds (Mudaliar Committee recommendation), 3 doctors and 50 other staff. The community health centre, each for one community development block should have 30 beds, 6 doctors and 8 nurses. The district hospitals represents the highest point of health services delivery system in a district. The district hospitals are supervised by the state hospitals. Apart from the state hospitals, there are also some special hospitals of the state government providing specialised care for particular diseases.
| Diagram I.1 Health care delivery system in the States of India |
| State Hospital |
| District Hospital |
| Sub-divisional Hospital |
| Community Health Centres |
| Primary Health Centres |
| Sub-centre |
| Community Health Worker |
| Sources : National Health Policy, Lok Sabha Secretariat (1982). |
1.10 Divergence From Norms: Health care facilities have increased considerably in the past four decades of planned development in India. The numbers of hospitals, doctors, nurses and paramedical forces has gone up substancially. But to understand the extent of progress, one must compare the health facilities to the various norms suggested by various committees on health in India. Such a comparative picture is presented in Table I.2.
In table I.3, we compare the provision of health facilities with some advanced countries as also with some developing countries with well-developed health facilities. One can see that India is trailing way behind not only of the advanced world but also the developing nations in the provision of public health facility.
1.11 Inequality : While health facilities are not adequate in India, the resources are distributed extremely unequally among regions and social groups :
1.12 Urban-Rural Discrepancy Studies in the field of health have noted sharp urban-rural disparities (Table I.4).
1.13 The distribution of manpower among the urban and rural sectors is highly unequal. Only 27 per cent of doctors (73090 out of 268712) trained in allopathy were in rural areas in 1981.[1] Among Nurses, only 37.8 per cent of 1,54,230 Nurses were serving in rural areas in 1981.This does not compare favourably with 49.5 per cent in 1961 and 39.6 per cent in 1951. The number of Doctors increased by 63000 in the sixties (1960-70) of which 26,000(41.27 per cent) went to serve in rural areas.This proportion declined drastically in the 1970’s when only 14,000 (12.1 per cent ) of 1,16,000 additional doctors went to serve in rural areas. Duggal (1995:41) has shown considerable rural urban disparity in the distribution of health services(Table I.5). This disparity has resulted in the dependence of the rural sector on paramedical forces. In 1987, there were 85,000 male health workers and 107264 female health workers operating in rural areas. Apart from this, there were 3,87,472 community health volunteers.[2] In contrast, only 19,750 doctors and 10,216 nurses were in Government institutions in rural areas in 1987.
The multipurpose workers were found to neglect thier duties in rural areas and engage themselves in corrupt practices.[3] Low remuneration and inadequate supervision has been sighted as major limitations to the smooth functioning of the Community Health Workers.[4] For Nurses, low social status of the profession, unsatisfactory working conditions, low hierarchical status have acted as deterrants to serving in rural areas.
1.14 . The doctors were extremely reluctant to work in urban areas. Even in cities , they preferred private practice for higher returns.Banerjee(1985) therefore felt that improvement in Doctor-Population ratio is not a true indicator of development of health services for the masses. Recent works have started emphasising the need to provide incentives to doctors serving in rural belts.[5] The negligence of the doctors to move to rural areas can be explained by their high opportunity cost. Kansal (1992 : 2050) estimated the average monthly income of private medical practitioners in Delhi and found it to be Rs. 24800 per month for Graduates and Rs. 34470 for Post Graduates. In his survey while 49.7 per cent of the Government doctors earned below Rs. 7000 per month, 80.8 per cent of private practitioners earned more than Rs. 12,500 per month. However, the monthly income levels of the supporting staff including Nurse, Receptionist, Aya/sweeper, Attendant were more in Government than Private sector. GOI (1981) suggested a rural posting allowance, a non practicing allowance which is 50 per cent higher than in urban areas, educational allowance for children, house rent allowance and if applicable, a family separation allowance. World Development Report (1993:139) felt that each doctor should spent 5 years in rural posting. It has also been felt that doctors serving in rural areas, should get a posting of their choice after return. [Antia & Bhatia (1993)]
1.15 It has been noted by many that the use of highly trained health manpower in India is woefully inefficient (Manga 1990:8). Urban concentration and large outflow of doctors from this country leads to a colossal waste of public expenditure on training the health manpower.
1.16. The facilities provided in rural centres wrer extremely inadequate. IIM(1985) painted a grim picture of the sub centres with inadequate staff, materials and considerable corruption at lower levels.[6] Drugs supplied were sold via backdoor and the staff took bribes or charges for providing services which were supposed to be free.
1.17.Primary Health Centres were found to be inadequately staffed. In 1987, there were only 1.4 doctors per Primary Health Centre. The ICMR(1987) study revealed complete breakdown of services at the PHC level with one PHC catering to as many as 1,20,000 persons in Uttar Pradesh and Bihar.Gupte (1993 : 16-17) and Banerjee (1992) highlighted the adverse effects of clubbing of health and family planning services. This, in their views, has created a misplaced emphasis in the working of the health workers as they put more effort in family planning at the cost of health services due to the target orientation in family planning.
1.18 Hospitals in Urban areas too presented an unflattering image. As a major portion of resources are channelised to the cities, hospitals at the district level were in a bad shape. Newspaper reports about the condition of hospitals in the state of West Bengal depict a sorry state of affairs in State run hospitals Hospitals in West Bengal have been depicted as shelters of stray animals and anti-social elements along with over overcrowding,absence of manpower and materials.[Table I.6].
Chatterjee and Seeta Prabhu (1993) noted that health status was dependent on health infrastructure. The poor quality of health infrastructure in lower rungs add to the inequality of health facilities.
[1] . Duggal, Nandraj, Shetty (1992 : 37)
[2] . as on 31.12.1987
[3] . See for micro level field studies : Bose (1981), Shah(1989),Talwar and Bhandari(1989).
[4] Bose(1981).
[5] GOI(1981), Antia and Bhatia(1993).
[6] . Corruption, negligence have been highlighted by Yesudian (1984) and Quadeer (1977).
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