Primary Health Care in India before Alma Ata

The guidelines of Alma Ata were wide-ranging. The implementation depended on the political will and the means in the respective countries. India signed the Alma Ata Declaration. Building a health care system after independence was one of the major tasks the new nation had to fulfil. The health care system of the British was highly centralized and racially segregated. The influence of indigenous medicine declined during the colonial times, which was a result of the internal division of its practitioners and the loss of social status as consequence of the promotion of Western medicine through the British (Jeffrey 1988: 57-58). In India the primary health care idea was under discussion long before 1978. The Bhore Committee in 1946 already recommended promoting health and using the health system for preventive as well as for curative care (Duggal 2001). It was this report which provided the framework for later health policies (Jeffrey 1988: 112).

The establishment of primary health units at the village level to bring the service as close to the people as possible, cooperation of the people in the health programme, and adequate medical care for all individuals, irrespective of their ability to pay for it, were included in the Bhore Report (Ranga Rao 1993: 20-21). The report acknowledged that rural provision is the cornerstone for the economic development of the country. The

existing rural-urban disparities were recognised. Therefore, the committee had planned a 3-tier district health scheme with primary units covering a population of 20,000, secondary units for supervision of primary units and extended services covering 600,000 population and the headquarter at the district level (Ibid., Duggal 2001).

Within the scope of the Community Development Programme launched in 1952, the setting up of one Primary Health Centre (PHC) per Block was accepted by the Central Council of Health in 1953 (Ranga Rao 1993: 70). The ratio of PHC to population was thus much lower than Bhore’s recommendation. It meant one primary unit for 70,000 people, covering 100 villages (Duggal 2001). Gradually the number of PHCs rose from 725 in the 1^st five-year plan to 22,842 in the 9^th five-year plan 2001 (MoHFW 2003: 167). For each PHC several Sub-Centres (SC) were created which serve as first contact point.

The above mentioned concepts include elements of the later Primary Health Care Approach. Equal distribution of resources according to population ratio, more access for rural communities, participation of the people, and the removal of disparities are some of them.

2.2.3.1.1. The Health Committees

In a time when India struggled to establish a solid democracy despite widespread poverty, social unrest, famine and epidemics, several committees were established to assess the progress of and recommend health care reforms which promoted basic health services for all. The committees were named after their chairpersons Mudaliar (1959), Chadah (1963), Mukerji (1965), Mukherjee (1966), Mungalwala (1967), Katar Singh (1973), and Srivastava (1975) (Ranga Rao 1993: 22-26).

The report of the Mudaliar Committee stated that not much improvement in health infrastructure and health outcomes had taken place (Duggal 2001). Funds were committed to urban areas and personnel were reluctant to go to rural areas. The recommendations included the demand for qualitative improvement of primary health care e.g. consolidation of PHCs (Ranga Rao 1993: 23). Integration of health and family planning and the introduction of one male and one female multi-purpose worker per 10,000 population to deliver the services was proposed by the Chaddah Committee in 1963 (Duggal 2001). Home visits and collection of vital statistics were included into their work schedule (Ranga Rao 1993: 23). The Mukherjee Committee in 1966 was mainly concerned with the Family Planning Programme. It suggested a vertical structure for the programme. The next committee in turn favoured the integration of all levels in health organization and personnel (Mungalwala Committee). Instead of segmentation into different programmes it called for a unified approach for all problems (Ibid.: 24). The Katar Singh Committee in 1973 had been asked to recommend a structure of integrated services, assess the feasibility of appointing multi-purpose workers and examine the mobile family planning unit for integrated medical and public health work (Ibid.).

Accordingly the conversion of uni-purpose workers into multi-purpose male and female workers was planned (Duggal 2001). Medical education and manpower were on the agenda of the Shrivastava Committee. The employment of paraprofessional or semi-professional workers from the community itself as a link between the Sub-Centres and the

community to provide simple services was one proposal (Ibid.; Ranga Rao 1993: 25).

Solving the lack of doctors for rural areas through the opening of more medical colleges was marked insufficient. Therefore, they opted for the Community Health Worker scheme.

The recommendations of the different committees already incorporate the major concepts of the Primary Health Care Approach as described above. Equity in health care through equal distribution of financial and human resources to rural areas is apparent in all reports. Direct access to the health services through health workers was proposed in 1963, which picked up Bhore’s recommendations. Community participation in the Community Health Worker scheme, appropriate technology and promotive and preventive interventions are highlighted. However, the multisectoral approach apparently did not receive much emphasis in the committee’s recommendations. Although principles of primary health care are included in the different recommendations, it becomes clear from the repetitions in these reports that the implementation either did not take place or that it was not successful. To obtain a holistic picture of the health care system in India before Alma Ata, it is important to look at another influential commission.

2.2.3.1.2. The Planning Commission

The health system was more influenced by the decisions of the Planning Commission (Ranga Rao 1993: 22-26). The Planning Commission is the most influential political body in India. All budget allocations for the five-year plans are decided there. The budget distributed by this commission was not always in line with the committee’s recommendations. Examining the allocation of resources for health care gives an insight into political priorities of the Indian government. The Planning Commission does allocate the budget to all sectors. While India focussed very much on economic growth and agricultural development, the social sector including health and education had a low priority (Duggal 2001). Economic uplift and secure food supply for the ever growing population were the burning issues at hand. Agricultural programmes like the “Green Revolution” received highest attention.

Jeffrey did a detailed study on plan and non-plan expenditure in health care till the 6^th five-year plan (1980-85) (Jeffrey 1988: 146-166). He found that the Planning Commission had favoured preventive health care and had directed expenditures towards primary care.

Furthermore, the influence of foreign assistance on the commission had created pressure for preventive, single-disease control programmes (selective primary health care), which were dominant in the 1960ies. Finally he states that the share for family planning measures has increased, while the overall government budget for health and health related issues declined in absolute terms if measured in percentage of GDP. Contrary to Jeffrey, Duggal says that three-fourth of medical care resources were still directed to urban areas during the first two five-year plans (1951-56; 1956-61), while the Community Development Programme aimed at rural areas failed (Duggal 2001). The difference in opinion can be linked to the different viewpoints. While Duggal puts more emphasis on basic health facilities and, therefore, highlights infrastructural aspects of primary health care, Jeffrey also includes the individual communicable disease programmes into his considerations. Jeffrey relates the variations in expenditure not only to the kind of party in

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