A MEMORANDUM SUBMITTED TO SHRI ATAL
BEHARI VAJPAYEE, THE PRIME MINISTER OF INDIA, BY MEMBERS
OF THE 'INDEPENDENT COMMISSION ON HEALTH IN INDIA'
Honourable Vajpayee Ji,
We, the Members of the Independent Commission on Health
in India, are privileged to present you the Report of the
Commission. The Commission came into being from the
shared concern on the deteriorating Health and Family
Welfare situation in the country as seen over the last
two decades. The outbreak of Malaria in virulent form in
many parts of the country, return of Dengue and Plague,
the dramatic increase in the diseases of yesteryears like
Tuberculosis, are some clear signs of this decay.
Regrettably, the response of the system to this situation
has mostly been sporadic, feeble and often
unprofessional. The system wakes up from its slumber when
there is an outbreak of a particular crises and then
returns to its former state of inactivity, as soon as the
situation improves slightly. This behaviour has dangerous
consequences and can be compared to that of a
tuberculosis patient who discontinues taking drugs as
soon as he or she feels a little better. Keeping in view
these deep concerns, we felt it necessary to form a
Commission consisting of distinguished persons from the
Health and Development sector, to critically look at the
maladies affecting various arms of the health services of
the country and come out with clear recommendations for
future action. During the last two years, the Commission
examined available documents, secondary data, traveled to
various parts of the country, conducted public hearings
and initiated primary research on areas of critical
concern. This report is the outcome of that long,
painstaking but rewarding process.
Qualitative and quantitative analysis of available data
clearly shows extremely uneven health and development
progress in various parts of the country. Often, this
difference is so dramatic that one can hardly believe
that they are part of the same nation and have followed
the same development patterns for the last five decades.
Even within the States which are doing reasonably well,
there remain regions of darkness where little has changed
since Independence. Obviously, these parts of the country
should be our major concern in the coming decades.
We are also living under two shadows - the familiar one
of infectious diseases like malaria, tuberculosis, etc.
and, in addition, the new and emerging shadow of
non-infectious chronic diseases like cancer and coronary
diseases. The large health infrastructure that has been
set up throughout the country seems to be largely
non-functional and unresponsive. Instead of moving
forward to meet the newer health challenges, it is
sliding backward. Over-centralized and lopsided planning,
inadequate and unbalanced financial outlays, lack of
accountability to communities, low moral values and, very
often, dereliction of duty by medical and nursing
professionals, plague the system. A thorough review of
the National Health Policy and a total revamping and
restructuring of the health infrastructure are
immediately called for.
Due to the prevailing inadequacies in the Government
sector, there has been an unprecedented growth of the
private sector, in both primary and secondary health care
all over the country. Given the current ethical standards
of the medical profession and totally free market
technology-driven operational principles, the private
sector generally does not provide quality health care at
a reasonable cost. Before this sector becomes a public
menace, it is necessary to introduce participatory
regulatory norms.
The voluntary sector, even with its limited presence, is
playing a significant role in reaching out innovative and
quality health services to the needy in remote areas.
There is a need to create an enabling climate for them to
grow further, especially in those pockets of the country
where the overall health and development situation
remains grim.On the population front, even after the two
and a half decades of an aggressive, target-oriented
approach, the desired results have not been produced,
despite huge investments. The indirect adverse impact of
aggressive family planning programmes on the primary
health care infrastructure is well-known. Commendable and
well-founded recommendations of the Swaminathan Committee
continue to gather dust in the Ministry. Though, in
recent times, we have seen some efforts to review past
programmes.
An area of distinct concern for the future is
environmental degradation. Pollution levels in all our
major cities have reached alarming proportions. We are
just waking up to this major health threat. Almost half
of the urban population does not have basic civic
amenities. In the name of industrialization and
development of our backward areas, we are polluting the
limited sources of drinking water of local communities.
The indiscriminate use of pesticides is a cause of
serious long-term concern. Development projects like the
Rajasthan Canal, are carrying malaria to regions where it
did not exist earlier. Non-degradable packaging materials
litter the country. Deteriorating environmental
conditions are also eroding the health culture of our
people. Public places and even the holiest rivers of this
country are fast turning into garbage dumps.
Recently launched long-term programmes to meet some of
the above challenges are mostly selective - large
vertical programmes on AIDS, Malaria, Tuberculosis and
Immunization, principally supported by International
Organisations. Convergence of these programmes with
existing primary health care priorities would have had
the possibility of revitalizing the primary health care
infrastructure. It is very important to review and recast
these selective programmes. Often, these new programmes
do not even follow the basic framework and priorities of
the Five-Year Plan document. The grim tale of poverty and underdevelopment of
millions of our citizens was brought home, time and
again, during the visits of the Commission to Rajasthan,
Uttar Pradesh, Orissa, Madhya Pradesh, Assam, etc. In
spite of numerous well-meaning but centralized and
unimaginative economic development schemes of the
government, their socioe-conomic condition remains
overwhelmingly distressing. We came across countless instances of
communities putting up a brave struggle against all these
odds. Time has come for us to stand up and recognize this
growing menace and change the direction of our poverty
eradication programmes with a decentralised, imaginative
and participatory model, as has been exemplified by many
voluntary organisations. The economic development of
one-third of our total population needs to be undertaken
with appropriate inputs for their social development.
Perhaps, in the health and development agenda of India,
solving their problems will remain the most complex
challenge for many years to come.
Within this generally depressing picture, we have also
come across many heart warming experiences - the
significant impact of the efforts of voluntary
organisations and charismatic Government officials in the
area of leprosy eradication. Tamil Nadu is a good example
of a State where the health situation has improved
significantly in recent years due to the multi-faceted
development efforts of the Government. The city of Surat
has been dramatically spruced up by local authorities
after the horrendous outbreak of Plague. We have also
come across numerous imaginative, people-centered and
effective health and development projects run by
voluntary organisations. These examples give us hope for
the future and indicate the direction in which the health
and development paradigm needs to be shifted.
We have to look beyond the so-called predominantly
reductionist biomedical model of health care to a
holistic model of health care which puts the human being
at the centre. We need a disciplined conversation between
the modern allopathic system and the traditional system,
each checking and fertilizing the insights of the other.
The health of a nation is the sum total of the health of
its citizens and communities. A healthy nation is,
therefore, only feasible if there is total participation
of its citizens towards this goal. In the last five
decades, we have followed a path of social transformation
which mainly relies on five major institutions, namely,
the Parliament, the Assembly, the Cabinet, the
Bureaucracy and Party functionaries. In the absence of
mediating and reconciling agencies between the State and
society, the State lacks a base and remains remote and
insensitive to people’s needs. Unfortunately, our
development efforts have not been rooted in our
traditional institutions and community initiatives which
exist in some form or the other throughout the country.
Progress is easiest made if we are tuned in with the
national genius which has developed over the centuries,
with certain special traits. If it is ignored or
discarded, it will lose its bearing and roots and
gradually its vitality.
We feel that the nation needs to address this critical
issue of continuing decay in the health and family
welfare situation in the country. This calls for decisive
action led from the highest level. Otherwise we might
enter the 21st century as a nation with diverse unsolved
ailments and chronic ill-health. We are not confident
that things can be improved merely from internal policy
analysis within Government, given the past unsatisfactory
record in reforming and revitalizing the Health and
Family Welfare Sector.
We strongly believe that external non-governmental inputs
must therefore, be invited to remove the cobwebs in the
present health policy, inject fresh ideas about a more
just and caring health sector which does not reject the
needs of our poor. Our Report contains some contributions
to this end. We feel that the time has come to set up a
central high level mechanism such as a Technology Mission
for revitalizing our health sector. The mechanism can work only with support from
the highest level. It can work only by enriching what
works and rejecting what does not, infusing fresh ideas
and new dynamism based largely on our local wisdom and
international experience of problem solving. The Mission
can also play a key role in suggesting that direction of
health reform, in the light of the overall liberalization
of economic policies by Government, keeping always in
view the distinguishing features of social, as different
from economic development. It could also work out how
health infrastructure can be decentralised, made
participatory, appropriate and accountable to the public
at large.
The Mission can also play an important role in helping
the National Institutions to redefine their role so that
they can play their originally perceived leadership role.
After close interaction with the profession, especially
those in private practice, the Mission can create an
enabling climate for growth of quality, accountable and
affordable medical care in the private sector. Another
important task for the Mission could be to encourage
growth and development of committed and dedicated
Voluntary Sector to set up Health and Family Welfare
services in the remote and difficult areas.
We feel that to provide a necessary cutting edge, such a
mechanism should be under your esteemed Office or under
the Minister of Human Resource Development. Our
experience has been that the Ministries themselves find
it difficult to bring about necessary paradigm shift
since they cannot jump across their own shadow.
Therefore, besides their own introspection within the
Ministry at both Central and State level, the Mission can
work as an important catalytic agent. The Mission can
utilize the voluntary services of distinguished people
from the field of public health and can be headed by such
a person.
Honourable Prime Minister, we feel that the continuous
neglect of the health of the people can cost the nation
dearly. We urge your Government to take immediate
assertive action to redeem the current situation. Let us
recall the words of Sri Aurobindo "Work as if the
ideal has to be fulfilled swiftly and in this life
time".
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