Where have we gone wrong?
It is ironical that in acknowledgment of this gloomy scenario, it is the Government of India’s own 1982 Statement on national health policy, which provides a most succinct diagnosis of what had gone wrong. And yet, in the course of more than a decade that has followed, we have done little to switch gears to a new path, even though it is clear that the answers for achieving more equitable public health are not difficult to find, given the political and administrative will.
To quote from the 1982 statement
“The existing situation has been largely engendered by the almost wholesale adoption of health manpower development policies and establishment of curative centers based on the Western models, which are inappropriate and irrelevant to the rural needs of our people and the socio–economic conditions obtained in the country. The hospital bases, disease and cure–oriented approach towards the establishment of medical services has provided benefits to the upper crusts of society, specially those residing in the urban areas. The proliferation of this approach has been at the cost of providing comprehensive primary health care services to the entire population, whether residing in the urban or the rural areas. Furthermore, the continued high emphasis on the curative approach has led to the neglect of the preventive, promotional, public health and rehabilitative aspects of health care. The existing approach, instead of improving awareness and building up self–reliance, has tended to enhance dependency and weaken the community’s capacity to cope with its problems. The prevailing policy in regard to the education and training of medical and health personnel at various levels, has resulted in the development of a cultural gap between the people and the personnel providing care. The various health programmes have, by and large, failed to involve individuals and families in establishing a self–reliant community. Also, over the years, the planning process has become largely oblivious of the fact that the ultimate goal of achieving a satisfactory health status for all our people can not be secured without involving the community in the identification of their health needs and priorities as well as in the implementation and management of the various health and related programmes”.
A major cause of poor public health is the low status of women in India, both within the family and in the community. The worsening adverse sex ratio tells untold stories about routine and all pervasive discrimination against females from birth, reflected in poor nutrition, poor education, greater psychological stresses and lower priority for curative services. Females in almost all age groups fall ill and die more often than males due to such neglect. The discrimination also increases their vulnerability at child birth and they give birth to unhealthy babies. This will be dealt with in detail in a subsequent chapter.
Low political and administrative priority to health
The abysmally low priority to public health is reflected in not only consistently low budget allocations for health by both central and state government, but also in the neglect of public health issues in election manifestos and policy statements of priorities of various governments. At the district level, general administrators like the District Magistrate tend to reduce district health management to reviewing family planning and more recently immunization targets, the transfer and postings of doctors and responding to epidemics as and when they occur. There is little understanding of public health issues, the social basis of disease, or the importance of building partnerships. There is complete lack of disease surveillance; we do not have a district health map, we look at figures that denote activities or personnel and not at impact. Rarely is the importance of district level health planning and management understood, nor the need for continuous surveillance and periodic assessment of health needs and the impact of health programmes is appreciated.