Systemic ills

A scholarly work on public health with immense value for pedagogical purposes.

ANY contemporary text on public health presupposes an approach that views diseases and disease control through the curative prism rather than the preventive one. Texts critiquing dominant health ideologies and health systems that have led to unspeakable inequities among populations are rare. The inequities, surprisingly, are today a characteristic not only of developing countries but also of developed ones. Public Health in India, a series of papers written by Imrana Qadeer, seeks to analyse all that went wrong with India's approach to health over the years. Imrana Qadeer is a qualified doctor with a passionate commitment to the rights of the poor, and her writings reflect all that and much more.

In the introductory note by the series editors, the author is described as the epitome of an interdisciplinary vision based on linkages between biomedical and social science orientations. Imrana Qadeer, who retired as a professor from the Centre of Social Medicine and Community Health at Jawaharlal Nehru University, New Delhi, has not only trained many students to think critically and laterally on public health but actively advocated the cause of universal public health, an entitlement that is under serious threat. She has always been very precise in her observations, as is reflected in her view that policy decisions on almost anything, including health, reflect a certain kind of politics eventually. The papers are also about her own reflections in the course of the myriad discussions she has had with people over the years.

Her writings are broadly divided into four categories, which raise pedagogical concerns, policy issues and ideological approaches to health. The four sections discussed in the 17 papers in the book are Knowledge and pedagogy in critical public health, The health status of Indian people: Critical reflections, Policies and planning for health in India and Health and ill-health in a neo-liberal world.

The papers in this first series were written by Imrana Qadeer at various points of her career. They have been compiled in the form of a book that will be hugely valuable for pedagogical purposes and also as a scholarly work on public health.

Trajectory of HSR

Political economy of knowledge: A case of systems research in primary health care in India, the first paper in Part I of the book, sets the pace for the rest of the volume. In it she explains, by tracing them historically, the distortions that crept into health systems research (HSR), which was once a very fashionable tool developed by the World Health Organisation (WHO) to respond to the health management needs of developing countries and link health planning to socio-economic development.

HSR itself develops from systems research, a concept that was applied to technical production systems and later to health and other social sectors. The idea was that all these problems could be solved by good management techniques. On the face of it, it did not appear superficial, but by ignoring the larger determinants of health it got reduced to a concept that could be manipulated by all and sundry using all kinds of jargon.

The application of the HSR model to the primary health care (PHC) system would not have been entirely out of place had it not been for the fact that it ignored quality of life problems in the existing levels of poverty. In time, the definition of HSR was reduced and the linkages were diluted, and by the 1990s, HSR in Indian planning had undergone a transformation; the introduction of reforms in the health sector also happened then. The HSR of the 1990s in PHC reflects little of the debates of the 1970s and the 80s and inevitably, population number and not the problems of population, monetary costs for the state and not the social costs for the poor, and hi-tech instead of a mix of socially sensitive technological strategies became the central focus of the systemic view of donor-promoted HSR, writes Imrana Qadeer.

The second paper in the same section, Beyond Medicine: An analysis of the health status of the Indian people, looks at several dominant perceptions, with a dash of humour. Imrana Qadeer notes that the talk of community health and appropriate technology has become the in thing'. She observes that slogans such as Health for All by A.D. 2000 were just steps for promotion and achievement.

Even though the number of representatives in the area of health has increased, with each claiming to be a spokesperson of public health, there is eventually very little either of the public or of health in their overall activities and understanding. She says that not many have tried to understand the health status of the masses. This chapter looks at the major health problems in the country, using government data to show that the so-called preventable diseases are the major causes of death and disease and that they have persisted in spite of the expansion in the health services structure.

Socio-economic processes play a large role in determining the health of the people, she argues correctly, going on to suggest that in India, very little attention is paid to class analysis of mortality and morbidity rates and patterns. There is no doubt that certain sections of the population have higher mortality and morbidity rates owing to their poor socio-economic status.

Neither the Census nor the Sample Registration System, she writes, provides information on the economic backgrounds, and this makes an economic class analysis of mortality and morbidity difficult. The low investment in health and the disproportionate growth in the expenditure in family planning services also merit a study, she says.

The choice of a perspective, she says in the third paper Critique of Methods and Science , is critical to the effective inclusion of macro-analysis in the theoretical frame of epidemiology. While classical epidemiology looks at populations as an organic whole with its own classes, social groups and their economic and political relationships, and studies the impact of its dynamics on disease phenomena, modern epidemiology, with its high-risk approach, focusses on individuals.

The fourth paper, Health Services System in India: An expression of socio-economic inequalities, is unforgiving about the state of public health in the country. It argues that the health system in any country mirrors the inequalities in the larger social system.

Tackling epidemics

Part II looks keenly at specific areas such as the resurgence of epidemics in the 1980s. The paper Contextualising Plague: A reconstruction and an analysis notes how the government seems more preoccupied with India's image abroad and has failed to use the principles of epidemiology to assess, control and alleviate human suffering. The paper highlights the flaws in the classical sanitarian approach which reduces epidemics to endemic status.

The author underscores the need for a multi-pronged strategy firmly entrenched in the socio-economic context, an idea that gets a fillip in the very next paper, Paralytic Poliomyelitis in a rural area of North India. Effective immunisation is the need of the hour, she says. She notes that some children in the villages of Sonepat (Haryana), the area under study, received immunisation and yet contracted paralytic poliomyelitis. In a large number of cases, the children became paralysed soon after they received the doses.

Imrana Qadeer argues that merely providing for services is not enough; quality and rehabilitation, where required, should be part of the overall approach. A review of policies restricting budgetary outlays to all such related aspects was equally necessary, she says.

The paper on Reproductive Health: A public health perspective takes the argument for an integrated approach even further. Reproductive health, she writes, cannot be handled in isolation. The paper looks at the concept of reproductive health from the 1980s onwards and its consequences for health research and family planning policies (FPP) in India, including the virulent advocacy of FPP in the developing world and the reasons for it. It points out how reproductive health and population growth are viewed by the women's movement, the government, and international agencies. Each is at variance with the other, and for good reason.

Health planning

The third part of the book argues that despite the tomes of information and experience, health planning in India is in a state of disarray. The first 30 years of health planning, argues the author, involved identifying linkages with developmental processes and self-evaluation. Non-performance was at least acknowledged. The section highlights the gradual shift in approach to health planning. Perhaps this was a natural outcome of the overall shift in the planning process itself.

The overall goals of the various plans beginning with that conceived by the National Planning Committee set up in 1938 under Jawaharlal Nehru and the subsequent ones such as the People's Plan, which was a brainchild of the post-War reconstruction committee of the Indian Federation of Labour, and the Gandhian Plan were to improve the standards of living, reduce inequality and provide public utilities. The constraints, if any, were perceived to be in the areas of manpower, technology and institutional facilities. The vision was near-perfect.

The main effort, Imrana Qadeer says, was to improve nutrition, investment in the health sector, water supply and sanitation. The pressure of the national processes that were created through these multifarious plans, including the Bombay Plan which focussed on industrial growth, resulted in the government setting up the Bhore Committee under Sir Joseph Bhore, a civil servant. Health, unfortunately, continued to be kept independent of overall planning in the assumption that inequality would be tackled, the author says.

Drowning reality

The present trend in planning is not one of analysing evidence, she says, but of drowning reality by presenting large quantities of descriptive statistics without disaggregation or analysis. It is not surprising that the health chapters of the Five-Year Plans become bulkier over time but without any substance, Imrana Qadeer writes. Clearly, there is enough and more evidence through government surveys to show that the state of India's health is far from satisfactory. The withdrawal of welfare and the emergent neoliberal agenda with its thrust on monetarism, markets and centralised control over the global economy have impacted health-sector planning, she says.

The emergence of the middle class, which demands better health facilities and advanced medical services, helped the state in its neoliberal policy shifts. Imrana Qadeer quotes Nehru, who envisioned the use of science and technology to bring freedom and opportunity to the common man, to the peasants and workers of India, to fight poverty, ignorance and disease, and to build a prosperous progressive and democratic nation which will ensure justice and fullness of life to every man and woman. A lot of developments have happened since Nehru's days in health-sector planning, not all of which can be said to be in line with his vision.

Two chapters in Part III devote themselves to a critique of the National Population Policy and the aggressive push for public-private partnerships in health care. A sharp and precise critique of both the draft National Strategy for Social Marketing (NSSM) and the National Health Policy is included in these chapters. The NSSM pushes policy in a direction that changes priorities, making need-based, comprehensive health planning peripheral while legitimising the interests of the private sector.

The volume is well edited and assumes relevance in the context of renewed discussions on universal health care by the government today. It is not that all that is being said is new; it has been there for quite a long time but was deliberately neglected.

The shift from universal health care to targeted interventions and the focus on short-term goals such as the Millennium Development Goals have done colossal damage to the state of India's health. Notwithstanding the outcry against successive governments' approach of viewing health as an isolated part of the planning process, policymaking has shied away from mentioning the word universal for the social sector for more than two decades now.

If universal health care is back on the agenda as a concept, it is a welcome shift. But it needs to be backed by financial commitment by none other than the state.