Dr. S. Albones Raj
Inclusionist Policies and Exclusionist Outcomes: Some Reflections on
Politics of Health Care in India
This article argues that inclusion and exclusion could occur
at multiple levels. It further contends that dysfunctional exclusion is often a
structurally produced and systemically sustained. Social identities – as men
and women, ruaralite and urbanite, dalit and non-dalit – provide differential
access to social space to different social actors. T.K.Oomen, in the maiden
issue of International Journal of Sociology (1985), introduced the
‘insider-outsider’ framework, which was staunchly rooted in Interactionist
traditions of sociology. Though the Inclusion-Exclusion framework is couched
largely in structuralist diction, the epistemic resemblance to Oomen’s dualist
approach is unmistakable. Dwelling upon the state of the nation, Ommen traces
the evolution of social identities through the socio-political history of
Indian society. Interestingly enough,
the ‘insider’ is not necessarily ‘included’, as the ‘outsider’ is not
necessarily ‘excluded’ in the social space!
This article
attempts to draw attention to two instances of exclusion in the domain of
health care in India noted by scholars consistently over years, despite the
well-intentioned Inclusionist policy of the State. This paper, while seeking to
describe the nature of exclusions under reference and explore the causes for
the same, also makes a plea for an effective realization and utilization of
community resources, inter alia, as a mitigative and as an inclusive measure.
This article and its contents should not be misconstrued as an attempt
to contest or belittle the efficacy of other instruments of mitigation.
However, this article does debunk the cacophony of decentralization being
touted as a panacea for the ills plaguing the system of health care in India.
The Two Scenarios
The scholarship
on health information system (HIS) is polarized on their interpretation of the
shape of world’s health in general and in India in particular. Scholars with
the demographic leaning are inclined to point to the inexorable deterioration
and the catastrophic course the world has chosen, partly by default and partly
by design. The teeming millions of the world’s major cities and the mounting
problems they face - with very little hope of alleviation and relief – are
taken as ominous signs of the suicidal course we opted to take. The doomsday
cultists, as they are called, blame the generations of men and women for having
witlessly ravaged the world’s resources without any passing thought for the
posterity.
The source of inspiration for this article is a highly
readable book authored by Lomborg (2005). Lomborg, a Statistician by
profession, represents the all-is-well school of thinkers, à la utopians. He
presents a powerful argument that we, as earth’s inhabitants, are indeed doing
well, albeit belatedly. On health, Lomborg was quick to point out that the life
expectancy has increased in the industrialized nations of the West and also in
developing nations of the world. The increase in life expectancy from 31 years
in 1909 to 41 in 1950 and 65 in 1998. As for AIDS claiming heavy toll among
humans, he is hopeful that
“In the long run, massive AIDS prevention programs such as
Uganda’s show the way, having dramatically lowered prevalence
rates” (2005: 52)
In the same vein, he claims that
“…Victory over infectious diseases is clearly demonstrated…. The
important killers, pneumonia and tuberculosis have decreased
dramatically over the past century …“ (2005:54)
For Lomborg, the conditions of living have considerably
improved for the humanity and this has had a telling impact on the survival
probabilities of all populations including those of India. The middle-ground
approach suggested by the present author is laced with objective criticism of
the health reality in India – wherein an attempt is made to pinpoint the
desiderata in health policy and its actualization – and a down-to-earth
methodology for tackling the same at the community level.
The two
contrasting ‘realities’- cataclysm and utopia - captured in the preceding
paragraphs, command wider support, though not to the same degree, in the
academia.
The Indian Context:
“Chennai City has mosquito
density of 117/10 man hours and larval density of
42/positive dip against the norm of 50-80/10 man hours and 5/positive
dip,
respectively. Pulianthope, which is zone 3 of the Chennai Corporation
has the
highest mosquito density of 275/10 man hours and a larval density of 85/
positive dip, followed by Tondiarpet with the mosquito density of 159/10
man
hours and Triplicane with 128/10 man hours”
- The Hindu, dated 1st February 2007
“The wide gap between policy statements, technical prescriptions and
actual implementation of the same still persists"
- India Health Report, 2003
“Health budget was gradually reduced during the period 1988-2001 from
56 to 48 per cent”
- Report of the Independent Commission on
Health in India, 1997
“New strain of malaria constitutes an old problem with a new challenge”
-K. Park,
2002
The assorted excerpts of assertions featured above paint a
grim picture of the Indian, hopelessly trapped in a tragic present and an
apocalyptic future. It would appear as though the India, like the ‘cursed
world, of the Time and the New Scientists, is fighting a loosing battle against
forces of morbidity and mortality – the defeat guaranteed by our own
‘dysfunctional civilization’ and misplaced priorities. The dooms day is, however, not just round the
corner – so it would appear. Metaphorically, the India’s self-defeating course
is punctuated with occasional success, bolstering its confidence to knock the
challenger – communicable and non-communicable diseases - out of the ring, only
to find the challenger springing back into action with a renewed vigor and
stratagem. It would also appear that ‘rules of engagement’ would also include
‘know thy enemy’ i.e. awareness about the precipitative and necessary
conditions causing illness. Awareness is
a powerful weapon in the armory of the mankind in its relentless battle against
forces of morbidity, at all stages. However, if Misra, Chattarjee and Sujatha Rao
are to be believed, in our battling strategy we have slighted and
under-estimated the power of health education
“Health education has always occupied a lower priority in Indian
public
policy. Its allocation under different budget, taken together is not
more
than 1- 2 per cent of annual health budget. Lack of information is one
of
the major barriers to the effective access to services. The pulse polio
campaign is an example of how people change behavior in response to
information.”
(Mishra et al 2003:64).
Crediting health education as an effective way of enlisting people in
the crusade against forces of morbidity, they state
“An activity associated with health education is the securing of social
support to enable the effective implementation of disease control measures”
(Ibid, P-65). Thus, notwithstanding the proven efficacy of
health education, continued lack of adequate emphasis on health education
amounts to self-disarming ourselves in the face of a formidable and vengeful
foe. The table below presents a picture of dismal apathy towards health
education and training over different plan periods. The decreasing investment
in the form of percentages spanning over eight Five Year Plans tell their own
tale.
Plan Allocation for Health Education and Training in Five
Year Plans (in Percentage)
1951-6 1956-61 1961-6 1966-9 1969-74 1974-9 1980-5 1986-91
15.4 16.0 14.1 9.6 8.5 4.8 -- 1.3
Source: Health Statistics of India, 1988
That health itself occupies a place nadir in the national
agenda becomes apparent from the table below:
Investment in Health (in percentage)
I Plan II Plan III Plan IV
Plan V Plan VI Plan VII Plan VIII Plan
3.3 3.0 2.6 2.1 1.9 1.8 1.8 1.7
Source: Economic Survey 1991-02
One begins to
surmise that our health policy framers, after all, have their well-thought-out
strategy in place and that they do not mind losing a skirmish, having set their
eyes on winning their own battle of Plasy! It would even look that our precious
little resources are being judiciously marshaled and strategically invested
keeping in view the big picture and the ultimate victory! Perhaps reducing the
pain of the suffering masses has taken precedence over health education - so
one would reason. But then, the following observations of Mishra et al (2003)
on the need to intensify rigor in program monitoring would make one suspect
whether the systemic failure still plagues various programmes of health.
• “Untimely
and inadequate procurement of insecticides.
• Low
limits for the payment of wages and non-availability of recurring budgets to
engage labor for spraying operations.
• Lack of
systems for the evaluation of insecticides application equipment. Inadequate monitoring of insecticide
resistance against malaria.
• Lack of
evidence-based data on vectors responsible for malaria transmission and
transmission period
• Lack of
evidence for the introduction of new insecticides and Lack of control on free availability and
use of anti-malarials, delayed slide examinations and lack of information on
the status of drug resistance”.
• “Untimely
and inadequate procurement of insecticides.
• Low
limits for the payment of wages and non-availability of recurring budgets to
engage labor for spraying operations.
• Lack of
systems for the evaluation of insecticides application equipment. Inadequate monitoring of insecticide
resistance against malaria.
• Lack of
evidence-based data on vectors responsible for malaria transmission and
transmission period
• Lack of
evidence for the introduction of new insecticides and
• Lack of
control on free availability and use of anti-malarials, delayed slide
examinations and lack of information on the status of drug resistance”.
Any discerning reader of statistics could see as to why the
alarmists are deeply concerned and sound the same in their typical shrill
voice. The correlation, if not causal
connection, between the programmatic failure and the data on mosquito
infestation in Chennai quoted from a survey published in ‘The Hindu’ is
unmistakable. Tamilnadu, in general, has
been commended as one of the consistently well-performing states in the health
front with ‘low endemicity’ (Mishra et al 2003). But Tamilnadu, too, conforms
to the all India pattern of not taking recourse to health education, the two exceptions
being pulse polio and HIV/AIDS campaigns. Lack of clarity apart, community
action is yet another notable lacunae in the whole schema of well-ness programs
promoted by the state and private players – a theme I shall return to in the
ensuing pages
Epidemiogical Polarization:
Critics of our health and disease prevention policies have
sounded yet another note of caution on the oft-bandied ‘Decentralization’. The
zeal with which many programs are sought to be decentralized in some states,
notably, Uttar Pradesh, Madhya Pradesh, Rajasthan, Bihar and Assam have not
brought in significant improvement in health administration and health program
implementation (Central Bureau of Health Information, Government of India 1991
& 2001). The BIMARU states, as they are called, have registered low
progress on poverty-reduction, in particular and in the economic front, in
general. There appears to be a convergence between the low economic index these
states have registered and the abysmally poor performance in the area of
disease containment. One cannot dismiss this as serendipitous coincidence. The
states under reference have not been able to augment their financial resources
and are unable to bear the recurring cost on account of program implementation.
The central assistance, though sizeable, has to be combined with the state’s
resources to ensure the achievement of targets. Thus, there appears to be a
polarization among Indian states in disease prevalence and their ability to
arrest the same.
Problems related
to health are rooted in political economy and sociology of these states.
Understandably, these economically backward states are unequal to the challenge
posed by the vectors and unhygienic conditions found in these states. Needless
to point out that for these states, health education constitutes the last and
the least important item in the states’ agenda. Such states are fit cases for
centralized administration of health infrastructure and of health program
implementation. However, the central administration with its vast resources –
human, expert and financial – would be willing to redistribute its resources so
as to reinvigorate health education programs itself is a moot point. Thus, the far-from satisfactory strides we
made in the arena of health in some states could be our Waterloos, but then we
have our Plassys as well! One of the useful lines of investigation is – albeit
qualitative – the probable relation the body politics may have with the poor
performance of these states in the arena of health. Scholarship on politics –
from Aristotle through Tocquiville to Lipset - has virtually deified
centralization as the hallmark of democracies, paying rich dividends in all
fronts of development in the long run!
Community as Social Capital –The Forgotten Cinderella of
Health and Vector Management:
Wisdom dictates that in any battle no efforts should be
spared in vanquishing a formidable foe. A battle-wise general, in mounting a
war strategy, would enlist allies so as to make a short work of his enemies.
The war on diseases is currently being fought single-handedly by the state
agencies, by alienating the community.
Community’s power and potential in combating vectors remains vastly
untapped and, wherever used, under-utilized.
Commenting on the role of local community and its involvement in health
programs, Mishra et al (2003) observe that
“The inclusion of health concerns with water and sanitation programs,
adult literacy, poverty alleviation and developmental projects is limited. So
is the cooption of local bodies and NGO’s to share responsibility, except in
the cases of the leprosy, HIV/AIDS control programs. For example, in a highly
community-based and localized programs such as malaria, the involvement of
local bodies is almost non-existent – whether in introducing bio-environmental
control methods or ensuring compliance to sanitary laws, or providing the
required administrative and political leadership. Such involvement of the community and local
bodies, at both village and town levels is emerging as an imperative for
effective control of communicable diseases”
It is true that no single blueprint for community action is available
for replication elsewhere. It is a sociological truism that no two communities
are alike. Nor is the magnitude and type of health problem facing communities
is the same! A centralized approach, under the circumstances, would not pay
dividends. A decentralized strategy aimed at community mobilization leading to
collective and concerted action in vector control and disease management has
greater probability of achieving the goals and best suited for the
epidemiologically polarized regions of the Indian subcontinent.
A Note on Community Resources and Action:
Sociologists
and political scientists have generated vast array of data on the power of the
local communities. Professional social workers and social entrepreneurs have
carried out path-breaking studies and experiments on community organization and
group work (Vasantha Kumaran et al 2004, Kramer and Specht 1971, Henderson et
al 1980). But the phrase ‘community involvement’ is often paraphrased to mean
‘community cooption, at best and ‘community cooperation’, at worst. Not
infrequently, reports and literature on the role of community in health speak
of ‘non-cooperation’ and ‘community apathy’. Lack of awareness, which is often
litanously associated with illiteracy, is blamed for the ‘poor response’ of the
masses. Praxiologically, the ‘outside’ cooperation is wanting! The community is
a passive recipient of the ‘gift of awareness’ from the all-knowledgeable
bureaucrat-cum-expert. The act of
receiving and translating and effecting a behavioral modification is understood
to mean ‘cooperation’. The follow-up often meant monitoring whether the
recipient of the ‘precious knowledge’ takes initiative to actualize the same in
day-today routine of his.
To sum up, the
article seeks to inform the advocacy research on health care to take note of
the lacunae in implementation of health programmes in the much-acclaimed
‘progressive’ states in India and to critiquing of the oft-touted decentralized
programme implementation. Even while advocating caution against claims of
panaceal decentralization, this article highlights the need to reinforce the
health initiatives at the community level in all earnestness.
