Expert Committee on Public Health Services
As early as in 1938, Subhash Chandra Bose, the then Congress President, had set up the National Planning Committee, with Jawaharlal Nehru as its Chairman. The reports of its two subcommittees, one on National Health and another on Population, are still great sources of inspiration in terms of the vision they had for the country, after it attained Independence. In a sense the political ferment of that time was directly associated with the setting up of the Bhore Committee in 1943, which submitted its report in 1946. The Bhore Committee report served as the blueprint for ushering in the Golden Age of Public Health, with the network of Primary Health Centres as the sheet anchor.
The setting up of the Mudaliar Committee in 1961 turned out to be the last effort made by the Government of India to make a comprehensive review of the health services of the country with a view to ‘updating’ the recommendations of the Bhore Committee. Though one can not be very enthusiastic about the recommendations of that Committee because the contrast with the report of the Bhore Committee in terms of scholarship and rigour of work was dazzlingly sharp, the Mudaliar Committee, nevertheless, made a valiant effort to look at the major facets of the health services of the country. After that there was a vast wasteland as far as the government’s effort to assess the health service system was concerned.
Following the famous Alma Ata Declaration on Primary Health Care in 1978, calling for Health For All by 2000 AD (HFA -2000/PHC), the Indian Council of Social Science Research (ICSSR) and the Indian Council of Medical Research (ICMR) came together at the initiative of J P Naik and set up a committee which was asked to come out with a critique of the health service system of the country and offer recommendations for attaining HFA-2000/PHC. The Committee submitted its report in 1981. It fell far short of meeting the challenging task assigned to it. That since 1981 little efforts were made to take stock of the health service system of the country and find ways of strengthening it, is a telling commentary on the state of the health services themselves. Indeed, the authorities concerned felt so insecure that they actively avoided any move to make an assessment.

While being fully aware of the limitation of the resources available to it, VHAI had stepped in to make desperate efforts to fill the void and raise the ‘voice of the voiceless’.

As if that was not enough, it had gone on to define its task in most formidable terms:

1. Those who live ‘On the other side of the Moon’
VHAI has coined this very expressive term to draw attention to those whom the rulers of the country will rather like to forget. I had used the word, forget, to describe them as the ‘Forgotten People’. This took me to the quotation from the Czech writer, Milan Kundera, whom I have so often quoted earlier in these columns; "Man’s struggle against oppression is a struggle between memory and forgetfulness". It is often ‘forgotten’ by the powers that be, both of the socialist and ‘non-socialist’ hues, that most of the population of the country has been banished to live on the other side of the moon. This was poignantly revealed just the other day (June 8 1998), when a powerful cyclone struck the Saurashtra coast of Gujarat. It is now revealed that a number of ‘unknown’ people had lived in far fetched areas along the coast, desperately trying to keep alive by making salt from the sea water. It is also learnt that they were from outside Gujarat, some coming from far off regions of the country. Acute pangs of hunger drove them to take up the killing work of salt making at the coast. They were so cut off from the rest of the population that there was no question of their getting the cyclone warning given by the Meteorological Department of the Government of India. When the cyclone struck ‘an unknown number of these unknown people were swept into the sea by very high tidal waves’.
In their disappearance, these unknown people have left a message for all those who swear by socialism, those who never tire of swearing to dedicate themselves to the poorest of the poor. But will the message be received by the socialists? It is almost certain that this message will be lost on them, as have been the torrents of similar messages in the past. Our socialists are busy jumping into the bandwagon of globalization; they are impatient to get into the fast track ‘information highway’ so that they can savor the juicy fruits served to them by the international media of mass communication, including the Internet.
VHAI took upon itself the virtually impossible task of focusing on three most neglected groups - the Adivasis, the hill people and those who live in desert areas.

2. Rejuvenating the ‘Decaying’ Health Service System of the Country
By any count, this is an audacious venture. The long neglect and the resultant decay of the health services throughout the length and breadth of others, has led to a situation where the authorities concerned have become oblivious to even the most elementary duty of identifying outbreaks of epidemics and taking the emergency antiepidemic measures; the decay of the health service system has led to an outbreak of a virtual ‘epidemic of epidemics’. VHAI undertook the stupendous task of identifying the causes of this decay and suggesting remedial measures. This meant looking, in a time perspective, into the extensive network of medical care services, the national health programmes, other public health activities, role of international and other foreign agencies in influencing health policies and programmes, health manpower development, research, health administration, regional variations, and so on. Suggestions for relating health services to the people, particularly to those who live on the other side of the moon, naturally became a key task to be undertaken.
Two separate, independent all-India surveys on utilization of medical services have shown that the extensive network of primary health centres and their sub-centres plays almost no part in meeting people’s needs; that people have to spend what amounts to them a substantial proportion of their income in meeting the cost of services from other sources; and that in the case of the poor, meeting the cost of medical services, is the second most common cause of rural indebtedness, next only to dowry.

3. Improving Key National Health Institutions
It was recognized that the key national institutions indeed provide the key to the formulation of a prescription for action. They play the pivotal role of giving the inputs in the form of education and training of health workers of various kinds, research and evaluation. It is essential to determine their present state and to recommend how they can play the key role expected of them.

4. The Family Planning Impasse
The impasse is vividly manifested in the fact that while the allocations for family planning shot up from Rs 6.5 million in the First Plan to a colossal 10,000 times increase to Rs 65,000 million in the Eighth Plan, the SIZE of population growth in the country had continued to make an upward trend, decade after decade. In 1951 the population was 351 million and now it is reaching the billion figure.
‘Greater the allocation for family planning and greater the growth in the size of the population’ can well be coined as a sardonic joke, were it not for the serious implications it has for almost every facet of life of the people of the country. Population growth is not the cause of poverty, as has been tomtommed by the peddlers of a Malthusian approach to the problem; it is the poverty, it is the abandonment of those who live on the other side of the moon, which contributes to population growth.
Given the power relations in the country, it is unrealistic to expect such sober analysis by the authorities. In fact, they go a step further to accuse that ‘the fruits of development are eaten away by increasing population growth’; they are so steeped in the intoxication (alcoholic?) of power that it did not occur to them to ask the logical question: who had been eating the fruits of development during past five decades? For those who live on the other side of the moon, population growth is the ultimate weapon that they can use to compel the rulers to take cognizance of their existence. As if the task is not heavy enough, VHAI also decided to include the analysis of this enormous problem and suggesting solutions in its agenda for work.

Speaking for the Voiceless
VHAI set out to undertake this venture by constituting the Independent Commission on Health in India (ICHI). It consisted of two retired IAS officers, three senior clinicians, two senior health administrators, a demographer and three activists of younger age, who have distinguished themselves in their work in non-governmental organisations, with VHAI providing the convener and two secretaries to the Commission. Because of this composition of ICHI, the format has necessarily to be a sectoral one. A summary or an abstract has been published in the form of a combined issue of HEALTH FOR THE MILLIONS (Vol. 23; Nos. 5&6, 1997) and a somewhat more detailed version has appeared in the form of a monograph, which was formally submitted to the Prime Minister on 13 May 1998. There is besides, a yet unpublished full version of the report. It may be emphasized here that it is not the intention here to analyse or review these documents. The intention is to draw attention to a major effort to articulate the ‘voice of the voiceless’.
It so happened that, considering the enormous range of the area to be covered, I had suggested an alternative approach, based on my work in this field for almost half a century. VHAI had agreed to partly fund that venture by commissioning the Nucleus for Health Policies and Programmes (NHPP), New Delhi to enable me to carry out the work. I have produced a 83-Chapter, 1400 computer page report under the title "India’s Forgotten People and the Sickness of the Public Health Services - A Prescription for the Malady". An abstract of the voluminous work has been published in the previous three contributions under this column. Apart from the 1400 page manuscript, a smaller, 400-500 page manuscript is ready and available for interested scholars for photocopying/reference. NHPP being a self-financing organization, not dependent on any donor agency, the manuscripts will be considered for publication by the NHPP only when they are assured of its commercial viability.
This contribution to ‘Voice for the Voiceless’ is being made to put ICHI and the three-part abstract published under this column in perspective. As both documents are about the plight of the people o the other side of the moon/forgotten people, I felt it worthwhile to put the ideas contained in them together to make a stronger case for paying attention to the existing decay of the health services system and offer suggestions for making them more meaningful to the people who had been denied access to them for so long.

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