Health needsThe vast variations of rural–urban, class, caste, gender and Health Needs regional variations, hide the magnitude of health deprivation of large masses of the most disenfranchised. For instance, IMR in rural areas at 82 per 1000 live births is nearly double the figure of 45 for urban areas. While urban middle classes in India today have ready access to health services which compare with the best in the world, only 20 countries have a higher IMR than Orissa’s tragic figure of 110 per 1000 births.
In such dismal circumstances, how are the poor in India actually meeting their health needs? Based on a seminal study of nineteen villages, prof. debabar bannerji in “A socio–cultural, political and administrative analysis of health programmes and policies in the eighties: A critical appraisal (1990)” finds that the major felt need of the poor is to find cures for medical problems, and for this they rely chiefly on the western systems of medicine, supplemented by local cures.
The ANM (auxiliary nurse midwife) is perceived by ordinary rural people to be for the service of the influential, whereas the traditional “Dai” is much more accessible. Government hospital at district, CHS or PHC levels, are resorted and devalued by absenteeism and rudeness of staff, long waits, overcrowding, sub–standard or no medicines and corruption. Ironically, it is the so–called registered medical practitioners (RMPs) or quacks who are often the main salvation for the rural poor, supplemented by traditional healers. The few qualified medical practitioners charge high fees, and often have direct commercial links with the neighborhood drug store. Any medical emergency results in economic disaster, even total ruin, of rural poor families.
As a result, PHCs provide less than 8 percent of the medical care sought by rural households, and public hospitals a further 18 percent. The remainder is obtained from private practitioners of the various shades described above.
In a study of the urban poor, amitabh kundu, in “In the name of the urban poor (1993)” similarly found that 48 percent of the urban poor go to private doctors and another 12 percent to private hospitals. Long distances, waiting hours and sullenness or indifference of medical professional discourage them from using public hospitals.
By contrast, it is instructive to examine the experience of China, which has been far more successful in achieving basic health care for her people. Its success has hinged substantially on developing an enormous cadre of health personnel for preventive and curative health services for all levels from the village to the country. It is only in the country (district) hospital that doctors trained in medical colleges as we understand them, are found. Village clinics and primary health centers are managed by village doctors (a new terminology replacing the old ‘Barefoot doctors’) who are trained in preventive and curative medicine of both traditional Chinese and Allopathic schools, for periods ranging from one to three years. These skills are constantly upgraded by apprenticeship and in service courses.
Each country or district has such a training school for high school graduates selected after a competitive examination, which annually turns out enough of such health personnel to adequately service the health needs of the massive rural populations. A vigorous referral system operates, so that only complicated cases arrive at the country hospital.
This effective public health outreach system, with its stress on integrating traditional medicine, and a stress on preventive health has had a dramatic impact on the health profile of the Chinese people. The average life expectancy of the Chinese people has gone up from 35 years in 1949 to 69 years in 1985. Infant mortality fell from 250 to 35 per 1000 between 1949 and 1989. In the same period, medical and health institutions increased 86.4 times and hospital beds 67.7 times.