PHA-Exchange> PHC in India - A contributin to the 25th anniversary

[Claudio]

PRIMARY HEALTH CARE IN INDIA: AN OVERVIEW*

DEBABAR BANERJI**
> --------------------------
>  *Guest Lecture for National Seminar on Health For All in the New
Millenium, NIHFW, February 24-26, 2003.  **Professor Emeritus, Centre of
Social Medicine and Community Health, Jawaharlal Nehru University.
Emailnhpp at bol.net.in
>

> A WATERSHED IN PUBLIC HEALTH
>
> The concept of Primary Health Care (PHC), which was approved by the World
> Health Assembly in 1977 and endorsed at the International Conference on
> Primary Health Care at Alma Ata in 1978, marks a watershed in the
discipline
> of public health. It had virtually turned the discipline up side down, as
it
> were; technology, administrative practices were subordinated to the needs
of
> the people.  Halfdan Mahler, the then Director–General of WHO, had rightly
> labelled it as a revolution. He had also acknowledged that the work done
in
> India had substantially contributed to the development of the concept of
> PHC.
>
> The concept of Primary Health Care has to be distinguished from the
concept
> of a  Primary Health Centre in India. Failure to do so has very often led
to
> trivialisation of the concept of Primary Health Care. The ideas behind
> setting up Primary Health Centres can be considered as a component of the
> concept of Primary Health Care.
>
> Reference to the term, primary health care, is made in the
Director-General’
> s report to the 53rd meeting of the WHO Executive Board as early as in
> January 1975, proclaiming that `primary health care services at the
> community level is seen as the only way in which the health services can
> develop rapidly and effectively’. He had enunciated seven guiding
principles
> for this purpose:
>
> 1. to shape PHC `around the life pattern of the population’;
> 2. for involvement of the local population;
> 3. for `maximum reliance on the available community resources’, while
> remaining within cost limitations;
> 4. for an `integrated approach to preventive, curative and promotive
> services for both community and for the individual’;
> 5. for all interventions to be undertaken `at the most peripheral
> practicable level of the health services by the worker most simply trained
> for this activity’;
> 6. for other echelons of services to be designed  in support of the needs
of
> the peripheral level; and,
> 7. for PHC services to be `fully integrated with the services of the other
> sectors involved in community development’.
>
> By the time of the Alma Ata Conference on PHC had taken its now well known
> form, it was seen as the `key to attaining’ the target of health for all
by
> the year 2000 (HFA-2000/PHC). Only the outstanding elements of the
> Declaration are being presented below:
>
>  I The Conference strongly reaffirms that health is a fundamental human
> right and that the attainment of the highest level of human health is the
> most important social goal and whose realization requires action in many
> other social and economic sectors in addition to the health sector.
>
>  II The existing gross inequality in health status of the people
> particularly, between developed and developing countries and as well as
> within countries is politically, socially and economically unacceptable
and
> is, therefore, of common concern to all countries.
>
>  III. Economic and social development is of basic importance to the
fullest
> attainment of health for all and to the reduction of the gap between
> developing and developed countries. The promotion and protection of the
> health of the people is essential for sustained social and economic
> development and contributes to better quality of life and to world peace.
>
>  IV. The people have the right and duty to participate individually and
> collectively in the planning and implementation of their health care.
>
>  V. Governments have a responsibility for the health of their people which
> can only be fulfilled by the provision of adequate health and social
> measures. A main social target of governments, international organizations
> and the whole world community in the coming decades should be attainment
by
> all the people of the world by the year 2000 of a level of health that
will
> permit them to live a socially and economically productive life. Primary
> health care is the key to attaining this target as a part of development
in
> the spirit of social justice.
>
>  VI. Primary health care is essential health care based on practical,
> scientifically sound and socially acceptable methods and technology
> universally made accessible to individuals and families in the community
> through their full participation and at a cost the community and the
country
> can afford to maintain at every stage of their development in the spirit
of
> self-reliance and self-determination. It forms an integral part of the
> country’s health system, of which it is the central function and main
focus,
> and of the overall social and economic development of the country. The
first
> level of  individuals, family and the community with the national health
> system bringing health care as close as possible to where people live and
> work and constitute the first of the continuing health care process.
>
> Primary health care
>  1. reflects and evolves from the economic conditions and socio-cultural
and
> political characteristics of the country and its communities and is based
on
> application of the relevant results of social, biomedical and health
> services research and public health experience,
>  2.addressses the main health problems in the community, providing
> promotive, preventive, curative and rehabilitative services accordingly,
>  3. includes at least: education concerning prevailing health problems and
> methods of preventing and controlling them; promotion of food supply and
> nutrition; adequate supply of safe water and sanitation; maternal and
child
> health care, including family planning; immunization against major
> infectious diseases; prevention and control of local endemic diseases and
> injuries; and provision of essential drugs,
>  4. Involves, in addition to the health sector, all related aspects of
> national and community development, in particular agriculture, animal
> husbandry, food, industry, education, housing, public works, communication
> and other sectors, and demands the coordinated efforts of all those
sectors,
>  5. requires and promotes maximum community and individual self-reliance
and
> participation in the planning, organization, operation and control of
> primary health care, making fullest use of local, national and other
> available resources, and to this end develops through appropriate
education
> the ability of the community to participate,
>  6. should be sustained by integrated, functional and mutually supportive
> referral systems, leading to progressive improvement of comprehensive
health
> care to all, giving priority to those most in need,
> 7. relies, at local and referral levels, on health workers, including
> physicians, nurses, midwives, auxiliaries, as needed, suitably trained
> socially and technically, to work as a health team and to respond to the
> expressed health needs of the community.
>
> The foregoing quotations from official WHO documents (unavoidably
> repetitive) show  how revolutionary have indeed been the ideas which
> culminated from the Alma Ata Declaration on Primary Health Care. These
ideas
> are being put together below in a summary form:
>
>  1.Health is considered as a fundamental right. The state has the
> responsibility to enforce this right.
>
> 2. Instead of starting with various types of health technologies and
> considering people as almost passive recipients for them, the Declaration
> sought to reverse the relationship by considering people as the prime
movers
> for shaping their health services. It sought to strengthen the capacity of
> the people to cope with their health problems which they have developed
> through ages.
>
> 3, It also visualised a wider approach to health by strengthening such
> intersectoral areas as ensuring adequate supply of potable water,
> environmental sanitation, nutritive food and housing.
>
> 4. It called for social control of the health services that are meant to
> strengthen people's coping capacity.
>
> 5. It considered health as an intergral whole, including promotive,
> preventive, curative and rehabilitative components. Any concept of
> `selective care' was considered antithetical to the concept of PHC.
>
> 6. Health services ought to cover the entire population, including the
> underserved and the unserved.
>
> 7. Those aspects of traditional systems of medicine, which are proven
> to be efficacious or which are the only one accessible to the people,
ought
> to be used in providing PHC.
>
> 8. Choice of Western medical technology should conform to the cultural,
> social, economic and epidemiological conditions prevailing in countries.
>
> 9. Particular care is to be taken to use only essential drugs.
>
> It may be emphasised that PHC is a PROCESS; it provides a road map for
> developing heath service in different countries of the world. Health
service
> development in India is taken up here as a case study.
>
> INDIA’S EARLY PROMISE OF PROGRESS TOWARDS THE PHC APPROACH
>
> Only some highlights are considered sufficient to elaborate this aspect.
> Social and political churning of the anti-colonial struggle led to the
> establishment of a Sub-committee (Sokhey Committee) on National Health of
a
> National Planning Committee, which, in 1938, recommended that people
chosen
> from villages be given some basic training to enhance the capacity of
> villagers to cope with their health problems. The Bhore Committee, which
> submitted its report in 1946, was guided by such lofty principles as
`nobody
> should be denied access to health services for his inability to pay’ and
> that the focus should be on rural areas, with emphasis on preventive
> measures. Following the acceptance of the report by the newly independent
> country, a start was made in 1952 to set up Primary Health Centres to
> provide integrated promotive, preventive, curative and rehabilitative
> services to entire rural populations as an integral component of a wider
> Community Development Programme.
>
> Departments of social and preventive medicine in medical colleges were
> upgraded to give social orientation to medical education. Apart for the
> already existing highly rated institutions like the All India Institute of
> Hygiene and Public Health and the Malaria Institute of India, institutes
> such as the National Institute of Communicable Diseases, National
Institute
> of Health Administration and Education (NIHAE) and the National
Tuberculosis
> Institute (NTI) were established in the 1960s, to provide support to
> education, training and research to the budding health service system of
the
> country.
>
> During 1961-64, interdisciplinary research work done at NTI received
> worldwide attention. Formulation and use of operational research approach,
> development of people oriented technology, responding to the expressed
> health needs of the people, were some of the outstanding features of the
> National Tuberculosis Programme (NTP) developed at NTI. NTP was designed
to
> sink or sail with the general health services. Halfdan Mahler had pointed
> out how some of the ideas generated at NTI contributed to the formulation
of
> the concept of Primary Health Care.
>
> Later, in 1977, the social and political ferment generated during 1975-77
> impelled the political leadership to fulfil the vision of the Sokhey
> Committee to have one Community Health Worker and a trained birth
attendant
> (TNB) for every 1000 population to entrust  “people’s health in people’s
> hands”.
>
> With the rapid expansion of the primary health care system to cover the
> entire rural population of the country, at least on paper, India had
> developed a network of health services which compared favourably with any
> country in the world with similar socio-economic situation; there was a
> Community Health Worker and a TBA for every 1000 population, a sub-centre
> with a male and a female multipurpose  health worker for 5000 people, a
> primary health centre for every 30,000 people and a community health
centre
> for 100,000 persons, with  referral and supervisory and supportive
echelons
> which went right to the  national level.
>
> By 1978 India thus came quite close to the concept of PHC that was adopted
> at Alma Ata – commitment of governments to health as a right; primacy to
> expressed health needs; community self-reliance and community involvement;
> intersectoral action in health; integration of health services; coverage
of
> the entire population; choice of appropriate technology.
>
> Indeed, the country incorporated most of the ideas on PHC in its National
> Health Policy of 1982, which called for jettisoning of what it termed as
> `health manpower policies and establishment of curative centres based on
> western models, which are inappropriate and irrelevant to the real needs
of
> the people and the socio-economic conditions prevailing in the country’.
>
> Obviously, there were gaping holes between the policy commitments and
their
> implementations. However, the reasonably correct commitments made in the
> initial phase could have been used as a springboard for more effective
> implementation of PHC in India.
>
> BELYING THE EARLY PROMISE
>
> The seeds of a retreat from the promising start were sown as early as in
> 1967, when the ministry of health was bifurcated into two separate
> departments of health and family welfare. According of over-riding
priority
> to family welfare led to gross neglect of the health services. In the much
> watered down 2002 version of their National Health Policy, the Government
of
> India has belatedly recognised that such vertical programmes are not only
> not cost-effective but they inflict major damage to the growth and
> development of the health services of the country.
>
> Then, there were the far-reaching consequences of the responses of the
rich
> countries to the declaration of self-reliance by the poor people of the
> world. They `invented’ an approach, which, as has been pointed out in the
> foregoing, was the very antithesis of the concept of PHC, and called it
> `selective primary health care’ (SPHC). Under the substantially changed
> political equations between and within countries, the political
leaderships
> of poor countries were `persuaded’ by rich countries to give up some of
the
> key elements of PHC in their health services in favour of SPHC. The rich
> countries mobilised organisations such as the WHO and the World Bank to
> promote its agenda of SPHC. This led to opening up a virtual barrage of
what
> the intenational agencies called International Initiatives. These
`vertical’
> or `categorical’ programmes were prefabricated, technocentric programmes,
> which were imposed on the poor countries of the world. Worse still, as has
> been observed in the National Health Policy of 2002, experience in
> implementing such programmes show that despite massive investment in them
on
> a global scale, they have fallen far short of the forecasts made at the
time
> of their launching, and, in the bargain, caused further damage to the
> already battered general health services.
>
> Ironically, the very decimation of the infrastructure of the health
services
> has made it so difficult to implement vertical programmes like those for
> universal immunization,  national AIDS control, revised national
> tuberculosis control and polio eradication. For instance, as the National
> Tuberculosis Programme of 1963 was designed to `sink or sail’ with the
> general health services, a logical line of action would have been to take
> steps to stem the disintegration of the general health services. Instead,
> the proponents of SPHC made the sociologically astonishing hypothesis that
> even if people are offered services as envisaged in the NTP of 1963, they
> would court death or continue to suffer due to their `non-complaint’ or
> `defaulting’ behaviour; the revised programme envisaged that the people
> would be prevented from death or suffering by ensuring that they take the
> prescribed medicines under direct observation. A PHC approach would have
> considered actions against tuberculosis and other diseases as integral
> components of a people oriented health services.
>
> In addition to the imposition of the International Initiatives, with the
> imposition of the  Structural Adjustment Programme by the IMF, along with
> others, health services in India had to suffer the consequences of drastic
> reduction in the health budgets at the centre and in the states. They were
> also made to provide encouragement to the private sector in health and
were
> asked make `cost recovery’ from the pitiably meagre allocations made for
the
> government funded health services. Moves towards globalisation have led to
> the commodification of the medical services, thus leaving in the lurch the
> vast proportions of patients who are unable to pay exorbitant rates
charged
> by the private sector.
>
> PRESENT STATE OF THE HEALTH SERVICES
>
> Not unexpectedly, an Independent Commission on Health in India, which
> submitted its report to Prime Minister Vajpayee, has pointed out that the
> health services `are in an advanced stage of decay’. Documents from the
> Planning Commission paint an equally gloomy picture. A study of a national
> sample of community health centres by  the Programme Evaluation
Organisation
> of the Planning Commission has revealed that virtually none of them is
> working at its optimal level. The 1998 Round of the Family Health Survey
> revealed that India is among the countries having the highest rates of
> maternal mortality. Another nationwide survey of medical expenditure
> conducted by the National Council of Applied Economic Research revealed
> that, among the poor, expenditure incurred to meet the medical needs is
the
> second most important cause of rural endebtedness.
>
> PROMOTING PRIMARY HEALTH CARE IN INDIA
>
> Considering the state of administration of health services, initiative for
> action must come from the political leadership and the civil society. They
> will have to take steps to educate and train what was termed at the
National
> Institute of Health Administration as Managerial Physicians – those who
have
> managerial and public health competence of high order. For this it will be
> necessary to rejuvenate the existing national institutions.
>
> Managerial physicians will be placed in key positions for promoting PHC.
It
> will also require a fundamental review of the cadre structure of the
health
> personnel, both at the centre and in the states. The cadre ought to allow
> selected, highly competent managerial physicians to attain the same status
> as their counterparts in the Indian Administrative Service.