Primary Health Care in India after Alma Ata

power but also to macro-economic events like the rise of oil prices during the 5^th five-year plan (1974-79) which led to drastic revisions (Jeffrey 1988: 153). The influence of foreign assistance on special programmes has already been mentioned above. Although the Planning Commission is influential in allocating the budget for the sectors, it has no control over the actual expenditure of states. Jeffrey finds that actual expenditure is 0.3 to 0.6 % lower than the plan outlays (Ibid.: 158).

The health care system in India before Alma Ata was not able to adequately serve the population of the country. Family planning and management of epidemics were more important in the five-year plans than the extension of primary health care in rural areas.

The programmes started as early as 1951 and 1953 respectively. From the 5^th five-year plan onwards family planning received the single largest share in the health sector outlay (Duggal 2001). Reforms undertaken were not successful in improving equity in health care or the quality of the service. The health system, which still lacked infrastructure and resources, was not open for participation.

2.2.3.2. Primary Health Care in India after Alma Ata

manage health centres, so that the doctor could concentrate on his medical tasks.

However, the training of Community Health Officers was slow and only introduced in a few states. Having a manager and a doctor at the centre at the same time led to power struggles since the hierarchy was not clear. The National Health Policy also envisioned to retrain medical and paramedical staff in community health needs. The refresher courses given could not achieve manpower reorientation. Solutions to improve the inadequacy of the system were sought. Management courses, motivational training, introduction of management information systems and ‘information, education and communication’ (IEC) programmes were the steps taken. All these programmes tried to create awareness at the health personnel and to generate quality in health care. The IEC programme was planned to generate accountability, following the Primary Health Care Approach in educating the people and thereby creating demand for services. Since the same people who delivered the services were in charge of IEC, they gave little priority to the programme (Ibid.: 349).

Unfortunately, the programmes were not successful, because they were not able to remove the lack of understanding of preventive health care. The failure of these programmes results from several factors. First, the large size of the health system made it difficult for the administration to handle training programmes for the whole workforce.

Second, the paucity of good training institutions and trainers constrained the upgrading of skills. Third, the limited financial resources prevented the opening of new institutions. The expansion of rural health infrastructure in numbers, thus, has to be read with care, since it does not include quality issues or functioning of the centres.

2.2.3.2.2. The Community Health Volunteer Scheme

After briefly examining the recommendations of the National Health Policy 1983, it is important to look into the implementation of programme components which can be linked to the Primary Health Care approach in their outline. The main focus will be on the Community Health Volunteer (CHV) Scheme of 1977 and other efforts to increase community participation. Using community health workers was already a part of the recommendations of the National Planning Committee 1946. It was planned to train young men from the villages for 9 month in simple curative care and hygiene for primary health service at the village level. However, the government put the programme aside in 1951, stating that it did not want to give less qualitative care to villagers than to urban dwellers (Jeffrey 1988: 228). It was voluntary agencies which picked up the idea in the 1960ies and 1970ies, and used auxiliary personnel for the delivery of primary health care. Successes from the voluntary sector in India received international recognition and together with the China example of “barefoot” doctors served as role models for the Indian government (Ibid., see above Srivastava committee). When the Bharatiya Janata Party (BJP) government came to power in 1977, it adopted the approach but changed the length of training to 3 month. Additionally, it was planned to add one doctor per Primary Health Centre for training purposes. The implementation progress was slow and further delayed by the reelection of Congress in 1980. By then India had signed the Alma Ata Declaration.

The new government renamed the programme in Community Health Volunteers (CHV)

Scheme. Completion of training of all CHVs was planned for 1984. All states except Kashmir, Kerala and Tamil Nadu implemented the scheme.

In this programme community participation followed a “top-down” approach. Although, the selection of on person per village for training lay in the hand of the community itself, the community was neither involved in the planning phase, nor had any other influence on the programme. Given the huge financial commitment necessary for this programme, Jeffrey finds it surprising that is was implemented despite the lack of demand for it (Jeffrey 1988:

230). Demand here means the articulation of wishes by the rural people themselves. The programme was thought to enhance access to health care, assuming that there is neither a spatial nor a social or cultural barrier to address a local person. Furthermore, the volunteers were to increase the health knowledge in the villages and promote preventive measures, thereby bringing primary health care in every village. First problems arose with the selection process. Local elites used their influence to choose their favourite candidates (Greinacher 1989: 49). In turn they expected the candidates to influence the decisions of villagers in other matters. The training focused mostly on curative aspects, while social aspects were not taught (Chatterjee 1993: 360). Therefore, community health volunteers lacked a clear role definition. While they were intended to be accountable to the community, the communities viewed them as government workers. The misconception of their role was nurtured by three aspects. One was their orientation away from primary health care, secondly they got paid a small fee of Rs. 50 by the government, and lastly they were used by the Primary Health Centre staff in their family planning and malaria programmes (Greinacher 1989: 50). The scheme was further criticised by the Indian Medical Association to produce quacks since some people used the training to start up their own private health practice. After the government reduced its support by 50 % in 1981, several states backed out of the programme not willing to bear the remaining costs.

The emphasis on community participation was to improve the health of people rather than empowerment, thus following Rifkin’s “top-down” approach. Although the outlay of the Community Health Volunteer scheme incorporated primary health care issues, the implementation was not successful.

2.2.3.2.3. The Integrated Child Development Service Scheme

The Integrated Child Development Service (ICDS) Scheme was launched in 1975 and includes a package of services like supplementary nutrition, immunization, health check-up, referral services, treatment of minor illnesses, nutrition and health education for women, preschool education of children in the age group of 3-6 years, and convergence of other supportive services like water supply, sanitation etc. Target groups are children below 6 years, pregnant and lactating women, women in the age group of 15-44 years and adolescent girls in selected blocks (Kishore 2002: 156). The programme is community-based. A local woman is selected and trained for three month to become the Anganwadi worker. She then works in the village covering a population of 1000. In the Anganwadi centre (childcare centre) she prepares and distributes food, maintains growth charts, weighs children and gives non-formal education to the beneficiaries. The Anganwadi also cooperates with the Primary Health Centre staff for health check up,

immunization and referral. The programme started in 33 experimental blocks and expanded to 2996 projects by 1993 (Kishore 2002: 155).

The programme encountered several problems. Communication with the health staff of Primary Health Centres was weak. The programme was more perceived as a feeding scheme by the communities and demand for health services did not increase (Chatterjee 1993: 356). Further, the food was thought as a supplement, but often poor families redistributed their food accordingly, leaving the beneficiary child with the food from the Anganwadi only. The educational efforts fell short to increase health knowledge of mothers, thus, prevention of malnourishment was not achieved. At the begin of the programme participation mechanisms were included, asking the villagers to provide accommodation and to ensure participation of the children. They also were to select the Anganwadi worker. With the rapid expansion of the programme, community participation was cut short. The selection process showed the same mechanisms as in the CHV Scheme. Women with higher educational qualifications and the right connections were preferred. Although the programme was a success in terms of immunization and nutrition coverage, the impact on nutrition status was low. It was found that “children in ICDS areas have similar nutritional status to those in non-ICDS areas” (Chatterjee 1993: 357).

Nevertheless, the ICDS Scheme continues till today.

2.2.3.2.4. The Universal Immunization Programme

The Universal Immunization Programme (UIP) was introduced in 1985 for the immunization of infants and pregnant women. With the support of UNICEF an extensive cold chain was established, which was an enormous effort given the prevailing infrastructure. The public health campaign started was huge and involved also non-governmental organizations. Posters, slogans, radio and television messages were used to inform the villagers about the programme. By 1989 the programme covered all districts of India. Special officers at the district level were appointed for supervising the delivery of the programme through the already existing workers. The programme was a success in its outreach. In 1990 between 70 to 80 % of the target children were immunized (Chatterjee 1993: 352). On the one hand the programme showed that it is possible to provide health services even in remote villages. On the other it also highlighted differences in implementation and outcome between states, districts or blocks even though it is a centrally sponsored programme. Chatterjee finds that “in UIP, the worst performance occurred in the States with the worst health situations and, thereby, greatest preventive health needs.” (Chatterjee 1993: 353).

2.2.3.2.5. Non-governmental Organizations

Another effort to increase community participation was the attempt of the government to involve non-governmental organizations (NGOs). The successes of voluntary organizations in their own health programmes lead to the question what and how these organizations could contribute. NGOs involvement ranges from conducting research over training of government workers to running and managing government health facilities.

However successful these NGO endeavours have been, for example in community

participation, the government was slow to adopt these new ideas. Only few NGOs decided to take over Primary Health Centres, with mixed successes. Bureaucratic constraints, resistance of private practitioners and government staff at the centre, payment delays and lack of support from the district authorities hindered the smooth running of the Primary Health Centres (Vishnu/ Sudarshan 2003: 56). Furthermore, the outreach of NGOs is limited to a small amount of people and areas.

2.2.3.2.6. Conclusion

Despite several attempts India was not able to realise comprehensive primary health care as it was promoted in Alma Ata. Partial success has been achieved with some of the programmes implemented like UIP, ICDS or CHV (see above). In all these programmes communities could only participate in the benefits but were not involved in the planning or implementation. The outline of programmes was determined by the central policy makers.

The influence of local government employees was limited. Their lack of training and, therefore, lack of knowledge regarding the basic principles of primary health care made it difficult to strengthen health prevention and promotion. The curative focus of care prevailed. The influence of stakeholders like local party members or other powerful people affected the location of health centres. Hence, the distribution of resources was not even.

Equal access according to need and equal utilization according to need is, thus, not possible. The highest rating for equity was achieved with UIP, when a universal coverage in immunization services was reached for all beneficiaries. However, UIP as a vertical programme was not linked to other health issues even within the health sector. The multisectoral approach was missing in all these programmes. If multisectoral programmes were tried out like in the Community Development Programme or the Minimum Needs Programme either health did only play a minor role or the focus was solely on health issues. In a way the development in India described above also reflects progress in other developing countries. Successes in immunization programmes and oral rehydration therapy in the 1980ies and failures to control communicable and non-communicable diseases, in particular HIV/AIDS, tuberculosis and malaria, indicate the problems with the implementation of the Primary Health Care Approach (Sanders 2003: 16).