Health as Development: Implications for Research, Policy and Action Author(s): A. K.

Shiva Kumar and Vanita Nayak Mukherjee Source: Economic and Political Weekly, Vol. 28, No. 16 (Apr. 17, 1993), pp. 769-774 Published by: Economic and Political Weekly Stable URL: Accessed: 16/06/2009 01:28
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reflecting at many levels. Life expectancy and infant survival conditions are better than what is normally predicted for a country with India's level of income.fertility has begun to decline only over the past 20 years. -technical and managerial manpower has been built up. malnutritionexists which manifests itself in ill-health. and Uttar Pradesh roport among the lowest morbidity. While India's mortality decline has been underwayfor the past 60 7ears. often associated with affluence.Health as Development Implications for Research. malnutrition and reproduction. an unfortunate polarisation of health between different groups of people in society. and this gets reflected in a higher utilisation of health services. What is clear in this case is that a literatepopulation in Keralatends to have a greaterunderstandingof illness. and the building up of an industrial base. It is also important to view health more holistically. The direction of the demographic transition and the velocity of fertility. and the poor health states of Bihar.This article draws attention to some of the major issues that emerged from the discussions and the imnplicationsfor policy research and pubhli action. However. Cameroon. Sen. Egypt. and the actual illness burden facing the majority of people in the country. have steadily increased over the years. there has been a steady decline in mortality rates over the years.not intended to be a summaryof the proceedingsof the workshop. In addition to the constraints imposed by a shortage of specialised data. The reportedhigh rates of morbidityin Keralaand low ratesin Bihar.while health progresshas helped to reduce mortality. Policy and Action A K Shiva Kumar Vanita Nayak Mukherjee development Policy-makers need to recognise the primacy of good health as an essential component of hutmian in India. Cancer.more favourable than in some of the neighbouring South Asian countries. On the positive front.mortalityand population changes are as yet unclear. for instance. Also. whereas an illiterateand ignorant population as in Bihar may have little appreciation of their health predicament. India also presents a striking picture where people in the same country live in entirely different health worlds. Madhya Pradesh. the objectivity of cause-effect relations. Per capita incomes. It is. Does this then imply that people in Keralaare not as 'healthy' as in the four poor health states? There are some who may argue that in Kerala. for example. better access to health services makes it easier for health-care seekers in Keralato avail of such services. may not reflect the actual rates of illness and ill-health in these two Indian states. cultural. and more than a thirdof the population remainsilliterate. millions of people lack access to basic food. points out that if one were to go by morbidity statistics of the standard kind. Again. the reported self-perception of morbidity is reported to be higher in the US than in Kerala. For example. hroad-based and mnulti-pronged. fresh unanticipated health threats. and spectacular gains have been made in the field of food production. Kenya. Despite these achievements. The reality of the situation. such data could be interpretedas denoting better 'health' status in Keralathan in the US. could be far more complex. epidemiologic and health transitions simultaneously and differentially. however. substance-abuseand accidents. economic and otherfactors interact to constrain people's access and contribute to human deprivation. Keralareports the highest morbidity rates. are beginning to emerge as major causes of death. Given India'soverallachievements.described India as a country experiencing demographic.such a performance on the health front is not very encouraging. Krishnan and Chen.political. cardiovascular. complicate the epidemiologic scenario.a closer eoaminationrevealsthat India may not be doing as well as is made out to be. ASSESSINGHEALTHPERFORMANCE Taking stock of a country's health status is a complicated exercise. Togo. 1993 769 . and the objectivity of counterfactual statements. He highlighted problems that commonly arise in connection with assessing the objectivity of health status. Information on self-perceived morbidity rates when seen in relation to Economic and Political Weekly April 17. and safe drinking water. Rajasthan. that include the AIDS epidemic. shelter. At the same time. The workshop on the 'Futureof Health and Population in India's Development" was intended to take stock of health achievements and to stimulate new thinking on policy initiatives. with the exception of Bolivia. Botswana. Specifically addressing this issue. it is essential to understand the context in which a particular statement is made. Serious social disparities and abnormally high risks of mortality and morbidity persist. Das Gupta. environmental health hazards and an upsurge of behavioural pathologies like violence. Concurrently. all other Central and South 'American countries report lower child tnonality rates than India. and other health problems. Similarly. IMPRESSIVE achievements and intolerableshortcomingscharacteriseIndia's health performanceover the past 45 years. And relatively speaking. At the same time. An enormous pool of skilled scientific. Much less is known about other psychosocial and cultural dimensions of health. health conditions in India are . However. Massive investments have gone into infrastructuredevelopment. for instance. Libya. Severe shortages continue in spite of the recent expansion in the provisioning of public health services. and once again. Verylittle is known about morbidity conditions in the country. Tunisia. it is necessary to assess the internal analytical consistency of arguments. Diseases arising out of acute malnutrition persist. an equally persuasiveargumentcan be made that the more educated population in Kerala has a greaterawarenessand interest in health. for instance. Algeria. Morocco.and understandhow social. of course. comprehending the various dimensions of healthy living is not easy. An assessment of health status also raises critical questions relating to measurement and interpretation of data. Sen emphasised the need for objectivity in health assessment as a prerequisite for policy interventions. In any evaluation exercise relating to health. India appears to be in the midst-of an epidemiologic transition in which chronic and degenerativediseases are increasingly displacing the poverty-relatedhealth problems of infection. in timia inaugural presentation. thereby increasing their perception and understanding of illness. The inter-connections are often complex and policy interventions need to be more people-focused. Zaire and Zimbabwe are some of the African countries where infant mortality is lower than in India.

As successive mortality peaks were dampened. however. Thus.other pieces of is very difficult to interpret the relationship between famine and mortality.deprivation and ill-health. FooD SECURITY. for instance. As pointed out by Dreze. it is by no means sufficient to focus only on incomes. unless deprivations in several human dimensions. MALNUTRITION VULNERABILITY AND Several papers presented at the workshop sought to explore the ntlltidimensional and complex linkages between -poverty. Guha emphasised that in addition to macro-sanitarymeasures. while lethal diseases like cholera and smallpox have been controlled. Consequently. Dreze. Discussants at the workshop also emphasis. or a shortage of income.Much less attention has. in the marketingof health products. becomes valuable for understanding the overall health picture. POVERi-Y. and in Maharashtrabetween 1970 and 1973 during the food crisis years. Tendulkar articulated some of the two-way interactions between poverty ar.ignificance of environmental sanitation as an essential preventivecomponent of public health interventions. social freedoms. Chakravarty. both the rich and the poor pay the same price for the service. whether it is persistent or transient. adult life expectancy rose without any perceptible decline in the poverty ratios. pointed out that during the decade of the 70s in India. Again.A focus on the linkages between deprivation and illhealth also drawsattention to the fact that poor health is not necessarily a 'medical' problem. They examine whether famine relief measures were successful or effective in affecting demographic consequences like mortality. such as in education. especially since increased mortality is not an inevitable component of famine. where price discrimination in public hospitals and health-care centres has not been encouraged. Several features of 'health' make it different from other publicly provided goods. for instance. For instance. Curative services have controlled mortality. the system was far more effective. In India. Discussions focused particularly on the consequences of famines and food shortageson people's health. i e. Self-perception.household and national level. There is also a complex and less understood interaction with diseases.where excessivedeaths were reported in areas with assured rainfall. Nor is it always true that all thdse in poor health conditions necessarily belong to poor households. for instance. Finally. The provisioning of health-relatedcommodities and services offers opportunities for price discrimination as resale of the product is virtuallyimpossible. This weakens the influence of the traditional budget constraint on household purchase decisions.edthat while a focus on poverty. Equally important is the need to assess the extent and effectiveness of relief measures put into place by the state governments. however. While poverty. for instance. Closely relatedto the theme of deprivation and ill-health is the issue of access to basic food needed for healthy living. despite increasing expenditure on sanitation and water supply. Her empirical analysis suggests that while a Malthusian mortality response could emanate from a depressed real income effect. 1993 . In seeking explanations to the paradoxical finding in Maharashtra. however. been paid to the impact of poor health on the economics of the individual and the household. and how far the geographical distribution of mortality corresponded to various proxy measures for failure of agricultural production. For instance. Very little. with demographic and health indicators 'in order to arriveat some plausible explanations for poor health. therefore. Participants also pointed to additional complexities arising from the political economy of health care. may prove to be a rather unreliable guide to the prevalenceof illness and ill-health. identifying precise causal linkagesbecome extremelydifficult. Several participants drew attention to the crucial role of food security in protecting the vulnerability of poor outcomes are the result of interventions that go beyond the realms of medicine and public health. While the evidence from Bihar indicates a predictable pattern. whereas in Maharashtra. merely expanding the supply of health services may not yield desired results. analyse the patterns in mortality rates in Bihar in 1966-67. with mortality rising in areas affected by cropfailure. This goes contrary to the presupposition that a reduction in absolute poverty must be the causal mechanism through which survival chances are improved. In the Indian context. Again. the survival rates improvedas a whole. it is equally important to focus on environmental contamination within the household. diseases like dysenterycontinue. For instance. the higher is the subsidy. the one-to-one correspondence between poverty and health status is further complicated because %povertyis measured on the basis of 770r Poverty. The analysis of the linkages also has to take into account the Economnic and Political Weekly April 17. and so on are simultaneously addressed. high levels of per capita expenditures may provide very little information about the vulnerability of poor and deprived communities. whereas most health status indicators are a result of cumulated levels of living. the rich often get subsidised to a greater extent than the poor. Guha'shistoricalanalysis highlighted tik .d health status at the conceptual level.the pictureis far more complicated. indicated how exclusive reliance on measures of poverty based on income and expenditure data often tends to mask poor health conditions. estimating its incidence and prevalence. Economists have paid considerable attention to defining poverty. Historicalevidence from Britain. per capita h'ealthexpenditure is likely to be an extremely poor indicator of both the quality of services available and also the access to the health services. is customarily identified as a causal factor accounting for poor health. He also pointed out that the relationship is strongly influenced by the nature of poverty itself. a different picture emerges in Maharashtra. It was against the backgroundof such considerations that participants at the workshop examined and analysed India's health achievements.Since there is often only a nominal charge for the service.demonstratesthat improvements in domestic micro-environment contributed significantly to a dramatic decline in infant and child mortality in the first decade of the 20th century. or a shortage of incomes is useful. is known about the impact of illhealth on the economic productivityat the i'ndividual. DEPRIVATION AND ILL-HEALTH current levels of living. Bihar suffered from poor targeting of relief measures. the more expensive the service. they point out that it is necessary to understand better the nature and types of human responses to famine conditions. Dyson and Mahapatra. or the shortage of incomes need not necessarily be correlated in any predictable manner to deprivations in several dimensions of decent living.Again. and the types of policy interventions that result in positive benefits.the consumer loses much of his or her sovereignty. but it does provide important clues to the persistence of such deprivations. in reality. as it is the doctor who makes the purchase decision for the consumer. In any event. if diseases are successfully controlled. Consequently. society manages crises better largely through public entitlement routes. not all households classified as poor because of their inability to afford normative minimum standards of living need necessarily be suffering from poor health conditions. the higher mortality rates could well be a reflection of distress migration from the dry zone to wet areas. but not morbidity which continues to rise. There is a need to combine an analysis of per capita expenditures. One such case relates to environmental pollulion. for instance.

The significance of economic development as an important leveller. Ray argued that the flexibility of the labour market becomes critical with increased flexibility contributing to a deterioration in the nutritional status of the workforce. and between rural and urban areas across the states. but due to resource constraints and certain socio-cultural obstacles common to women. Striking differentials exist in the health conditions between rural and urban areas. the health-seeking behaviour was more encouraging among children than among women. It is. The analysis pointed to three crucial domains of public policy intervention: public actioln for women's empowerment. Guha Sapir. Compared to backward caste families. She pointed out that while an urban bias did exist in the provisioning of health and other services vis-a. or rural Uttar Pradesh in terms of geophysical. highlighted the conseque?ces of material and social deprivation on the health status of a scheduled caste community in Chinglepet district of Tamil Nadu. The universally applied rural model of primary health-care centresin India often does not incorporate differences in health and nutritional profiles of the rural and urban communities. in particular. Among the principal factors contributing to such differentials are the inadequate levels of literacy. Several reasons were advanced for the existence of such large rural-urban differentialsin health status within the country. The lack of access of the urban poor was accentuated by the severe shortages of good health services. Sundari. with the experience of other high infant mortality states reveals that infant survival was crucially dependent upon maternal capabilities. and other factors. a-careful analysis of the health consequences of the functioning of labour markets. Karnataka and Tamil Nadu. political. The morbidity profile of women and children are not very different from other castes. Social. and women's freedoms to act in W*sthat are likely to be beneficial to the child. duringt-he 15 years between 1976 and 1990. Recent analysis also suggests that proportion of the poor among urban populations is lower than the corresponding proportion among ruralpopulations. and there existed a relationship between the nature of illness and symptoms and healthseeking behaviour. Participants envisaged an important role for government interventionsin order to ensure peoples access to food especially during periods of shortages. two Indian states with the lowest infant mortality rates. and public action for improving the techno-managerialefficiency of health . For instance.vis rural areas. Similarly. Drawing attention to the large interstate differentials in infant mortality that exist. but important differences emerge in the causes of morbidity. Fifty-one per cent of the children who had a health problem had been referred for medical help.infant mortalityratesin rural areashavedropped marginally fasterthan Ecorlomic and Political Weekly An extremely disturbing feature of the Indian experience has been the perpetuation and possible accentuation of various forms of inequalities. the urban-bias in the provisioning of health-care services discriminated against the urban systems. Crook also suggested that a contiguity of cultural experience and a similarityin the levelsof service provisioning tend to reduce the rural-urbangap. as the marketappropriates the surplus generated. Comparing the experiences of Kerala and Manipur. extent. especially among the poor. In addition to literacy attainment.inadequate education. and the better access. Further indication of differentials in health status of people belonging to different socio-economic groups is provided by examining data relatingto populations classified as scheduled castes and scheduled tribes in the country. 1993 . for instance. for instance. political and epidemiological parameters of the urban poor also tend to be substantially different from their rural counterparts. Increased adaptation unambiguously worsens the nutritionil status of the population. Crook. that in urban areas. Kerala (socio-politically advanced) and Bihar (completely backward) with the rest of India. risks and fluctuations in earnings arising from crop failures. Very little is known about the health conditions of different soeio-economic groups. or a lack of alternatives for the labourer. Participants also traced the linkages between access to food and nutritional outcomes. rural Kerala differs significantly from rural Manipur. Kumar also highlighted the importance of occupational and marital choices in influencing child survival. Kumarargued that high infant mortality rates are not necessarily a medical problem. Duggal outlined the regional disparities in health-caredevelopment comparing the experiencesof Maharashtra(an industrially advanced state). and implications of such differentials. have little to do with the process of deterioration of nutritional status. with its bearing on health and 771 April 17. Aggregatestatisticssuch as the overallsupply of food in the econQmy. He also points out that while malnutrition can be present in both urban and rural areas. pointed to several factors such as lack of access to resources. Ray raised several issues relating to the linkages between the operation of market forces and nutritional status. however.levels of communication and infrastructure development in the states which may create differential impacts on mortality. and a reexamination of issues surrounding food security and entitlements. Participants drew attention to the qualified health workersin urban areas. the study found that both infant and under-fivemortality rates and-marital fertility rates are much higher amdng the scheduled caste families. for instance. In a situation where the labour market is characterised by flexibility representing the ability of an employer to replace an employee. populations are not homogeneous.even in the urban areas. mass starvation has been observed principally in the rural communities. and the pattern suggested that a conscious selectivity prevailed in favour of women who were most at risk and whose opportunity costs of being ill was quite high.especially among women in rural areas. only 15 per cent sought medical help. At the same time. DISPARITIES SOCIO-ECONOMIC IN WELL-BEING whilerural-urban differentials continue to exist. but are linked in complex ways to a whole set of social. and surplus labour which implies a low degree of tightness. economic. and other characteristics. for example. important to note that major differencesexist within the rural areas itself. There is low utilisation of health servicesand complications associated with pregnancyand childbirth are considerably higher among scheduled caste women than among women belonging to backward castes. The low utilisation of health services was neither due to ignorance or cultural beliefs. for instance. Punjab (agriculturally advanced). public action for improved access. lack of sanitation and pollution were found to be largely confined to families belonging to scheduled castes living in separate hamlets. For example. Participants argued for a more careful appraisalof the public distribution system. More severeconsequences emerge with the incorporation of the effects of adaptive mechanisms in the body to lower nutritional intakes. Among women. presented the results of a study of urban slum dwellers in Calcutta. becomes crucial. infrastructural. Visaria and Gumber point out. Chatterjee. Given how closely many of these considerations are tied to the livelihood patterns of people. attributes the lower levels of mortality in urban areas to better access to curative medical services in urban areas than in the rural areas. as is demonstrated by the southern states of Kerala. intra-household food allocation patterns favouring boys and adult men. He elaborated specifically on the impact of the flexibility of labour markets on energy balance and nutritionrl outcomes. and/so on that contribute to malnutrition and poor health.

and reproductive health in particular remain does so for women.Unlike Punjab. and to a lesser extent in M'aharashtra. Further. 1993 .other social indicators was evident in the case of Punjab. over the years. Maharashtra has an urban bias.A significant proportion of such deaths among women are the combined effects of poor health. Discussants identified specific health problems women face. and in the process of empowerment of the people so they can effectively demand better healthcare facilities. with pockets of urban areas reapingthe growth benefits of the state. Poor nutrition of girls especially in childhood and adolescence have serious consequences. Dyson suggests that part of the phenomena could well be due to problems of enumeration in the Census. This is especially among widows who live alone and those who live in households eaded by individuals other than their sons or themselves. Navaneethamand Rajan.The reproductivemorbidity profiles of women which include gynaecological. WOMEN'S HEALTH AND CONCERNS NEGLECTED A recurrenttheme of the workshop was a consideration of the gender biases in health. where the rural-urban differentials are narrow. Part of the problem lies in the higher risks of mortality and the poorer health conditions that women face. indicate that women's health in general. and their interpretationas a worseningof women'shealth conditions. Bhat. and the need to focus more carefully on women's health issues. thesc issues. In this context. in their paper. the gender gap in health and survival is smaller than for women who are deprived of economic independence. On the other hand. by examining the relationship between women's roles and the gender gap in health and survival. pp viii + 420 Rs 240 Avilablc from OXFORD UNIVERSITY PRESS Bombay Delhi Calcutta Madras Economic and Political Weekly April 17. and whose status is dependent on their reproductive success. participants also drew attention to the need for paying special attention to the problems of the more vulnerable among them. Another major area of disparitiesabout which very little is known relates to the health status of differentage groups of the population. The deprivation of widows is quite severeand their relative mortality risk is quite high. En with rAdicalpolicics. Concurrently. anaemia.severalissues relating to worrmen's edpcation. In addition to focusing on health problems of women in general. there is an urgent mWen need expressed to understand the health vulnerabilities of women. Bhat contends that the method is well suited to the natureof data availability in India. the indicated decline in the female-to-male ratio in the 1991 Census need not be seen as indicative of worsening relativefemale survivalchances. very little attention had been paid to the health problems of adolescents. but the low levels of health sery'iceutilisation. employment.Latus economic policies that differentiates between rural and urban areas. he argues that when the Census coverage deteriorates. levels of government provisioning. In addition. have been largely obfuscated. in Kerala. it is therefore more than ever necessary today to recognise the magnitude of the problem and the inadequacy of the measures adopted so far to deal with it. what still remains is massive and of a kind that is not remedied quickly or smoothly. Chen and Dreze highlighted the peculiareconomic and social vulnerability of this group of women. and made a strong case for a gender-focused understanding of health issues. Much of India's decline in the female-to-male ratio for 1991had occurredbecause of the dramatic worsening of the ratio in Bihar. the burden of work shouldered by women gives rise to constraints making it difficult for them to seek health-care. It is not just early marriages-andadolescent child-bearing that leads to this situation. Participants also drew attention to the unfavourable levels and trends in femaleto-male ratios in India's population. poor nutrition. and a prolonged and closely spaced period of fertility stretching from adolescence to menopause. toxemia. Basu suggests that where women are active and have more access economicaHly to social space. and so on need to be addressed. In addition to foc"ving on gender differences in health between and women. and 8 per cent of the decline in the MMR (per birth) is explained by the change in the age schedule of fertility. social freedoms.a decomposition of maternal mortality between 1972-76 and 1982-86 shows that 20 per cent of the decline in the maternal mortality rate (MMR per woman) could be attributedto the decline in fertility. Many participants felt that while infants and children had attracted attention from policy-makers. Incidence of maternalmortalityappearsto be relatively high in the northern and eastern parts of India. For instance. TRUST BOOKS SAMEEKSHA Selections of Articles from Economic and Poldcal Weekly General Editor: Ashok Mitra Poverty and Income Distribution Edited by K S Krishnaswamy While there has been. Discussions also focused on the low levels and declining trends in the femaleto-male ratios. it also drew attention to the extremely limited knowledge that existed on the health conditions and responses of widowc Participants also pointed out that focusing on women's health issues does not necessarily imply an increased provisioning of medical services targeted towardsthem.00. the socio-political process has !nsured better distributivejustice. haemorrhage and abortions. Factors that contribute to regional diparities in include differencesin macrohealth s. who form 8 per cent of the total female population a-%J number more than 25 million (1981 Cens4s). present an indirect method for estimation of the magnitude of the incidence of the maternal mortality in India.000 births for India as a whole. Application of the method to the Sample RegistrationSystem Data of 1982-86 produces an estimate of maternal mortality of 555 per 1. For example. the shifts in income and occupational structures to make a dent on it will take more than the rest of this century. a perceptibic increase in per capita incomc and expenditure and possibly some decline in the incidence of poverty In India. for instance. whose movements are restricted. adults and the aged in particular. for instance. fertility rates classified by age of the mother and an assumption of the age-pattern of maternal mortality. and the poor quality of lkealth-care receivedduring pregnancyare also responsible for both the high levels of neo-natal 772 mortality and maternal mortality. Jejeebhoy and Rao. Focus!ng on widows. argue that high mortality rates among women as revealed by maternal deaths due to sepsis. In the welter of recent exchaes between the government and the opposition as well as between planners and market advocates on the strategy of growth. obstetrical and contraceptive morbidity is an area that needs careful examiriation. While the study sought to understand the special constraints imposed on widows by the socio-economic and cultural environment. The method is based on agespecific death rates by sex.

The quality of government services is no better. unqualified.He questions the reliabilityot the Census data for Bihar particularly since the intercensal growth rate in population between 1981 and 1991does not correspond to the increases suggested by trends in birth and death ratesgiven by the Sample Registration System data.straintswhich severelyrestrictedthe scope tions and interventions that are very dif. Several common themes for research 773 Economicand Political Weekly April 17. Most often. What underlies the success of this As agents of social mediation. he pointed out vices. and the oversocial mediation in health-care. The Bengal.that these models were far from perfect. At the same time. voluninitiative is the spread of education. argues that statistics on health expenditures that are currently available grossly underestimate the total expenditures on health. The key infant mortality rates. High rates of use of private sector services seem to be prevalent in both urban and rural areas across all income groups. there is a growing body of evidence to suggest that private health expenditures constitute a larger and more significant proportion of total health expenditures. for instance. that is an important determinant explaining the size and composition of the national health expenditure. and limited their potenferentfrom one that concentratesprimari. it is nonetheless important for health financing and pricing decisions to be related to people's access to quality services. The issue of health finaticing and pricing of services were also subjects of discussion. he pointed to the detrimentaleffects that colonialism of the past and the excessive dependence on SOCIAL MEDIATIONAND INSTITUTIONAL international agencies in the present are STRUCTURES likely to have on the development of an endogenously strong people-oriented Extending the need for a more holistic community health system.Kabirand emphasis on technical solutions rather Krishnan used Kerala'shealth experience than on more holistic approaches to the to illustrate the powerful role of social health care crisis in the country. Dave ly on an expansion of health services. in both rural and urban areas that have generated an increase in accessibility to health care.voluntary sector in providing health tegration of women and women's health services in the socio-economically and into the mainstream of the development geographically backward areas of the process. an exposure to inperiod of acute caste-consciousness. the abdication of political responthe importance of political structuresand sibility by politicians. locational and numerous managerial and other coneconomic access offers policy prescrip. strong and indesirous of achieving improved health dependent forms of institutions at the outcomes for the society. But' based on the limited evidence available regarding the quality of private health services. mortality and than democratically controlled. The also highlighted some of the efforts of the second key lesson from Kerala is the in. and the numerous problems with the interpretafigures tion and use of such expenditurce for designing policy interventions.tial for making a large-scaleimpact. The Malabar local community level have not developed. He also pointed out that it is the dynamic private sector. sable relevance for any meaningful development process. an equally important dimension is the evaluation of the impact that such expenditures has on the heatlthstatus of people. and to a lesser extent in West were applied to Malabar as well.of their activities. a politically responsive environment Unfortunately however. However. it is not the qualified licensed physicians. by various agents helped formulationand implementationhas been to change the social and behavioural atinfluenced over the years by a dominant titudes of the people in Kerala during a bureaucraticstructure. While estimating the levels of expenditures is one part of the exercise.political processesand care services in the country. building up local social forces at the health policies and programmes which village level as is demonstrated in Kerala. What emerges from the existing data available is that India spends relatively heavily on health. in 1956. care. Mukhopadhyay. While much of the data pertain to government health expenditures. Kabir and Krishnan emphasise that arid most voluntary agencies faced a primary focus on social. unusual in its variety and scope. where ed the emergence of this sector in India caste-rigidities and social stratification and discussed alternatehealth models that continue to dominate. tary sector non-governmental organisaespecially among women. where support from localised parresultant improvements in Malabar have ty structures based on ideological party been impressive. tracother regions and states in India. In this context. The Kerala experience and international donor agencies has led also illustratesthe complementary nature to a dependence which places severeconof health and education.They dem6nstratedhow relevant stand more closely how state and civil and timely interventions. Kabir and Krishnan. Banerjiemphasised the role of different socio-cultural and political forces that have shaped public health practice in !ndia. intermediation in bringing about health Jeffery emphasised the need to undertransition. several important components of legitimate health expenditures are excluded from standard computations. however. A third important lesson is the different levels society interact. 'eclectic providers' who practice all kinds of treatments in small towns. Indian health policy of the society. Among other approach to health. Berman. Participantshighlight6othe inadequacy of reliable data. especially given that the commitments have contributed signiachievements have been recorded in a ficantly to real achievements in healthrelatively short period of a generation. 1993 . with multiple systems of medicine coexisting side by side. had succeeded in Travancoreand Cochin for instance. In addition to questioning the reliability and comparability of health expenditure data. participants also drew attention to problems of quality and affordability of health care services. for instance. However. discussants pointed factors constraining the proper expansion out that health-care is a concern in which and implementationof appropriatehealth economic interests. highlightedthe dominance of bureaucratic Several participants including Banerji. Banerji also social mediation play significant roles. But she argued that their finanprimacy given to preventive and public cihI instability and reliance on national health measures. and its indispen. when compared to some other countries of the Asian region. there is little cause for optimism that it contributes significantly to improvements in the health status of the population. power lacking in epidemiological knowJeffery. The most signifi-' had been developed to provide low-cost cant aspect is the need to focus less on the and effective health servicesin many parts supply of health-related goods and ser. region had historically lagged behind the Institutions have tended to be centralised princely states of Cochin and Travancore and bureaucratically controlled rather in indicators like fertility. throwing serious doubts on its role in contributing to improved health status at an all-India level.straints on their activities. service organisation. While no direct correlation can be easily established between health expenditures and health outcomes. villages. The Kerala tions have played an important role in experience has several lessons to offer to India. although in specific states Qf India the picture is different. and the existence initiatives were initiated and sustained in of a skewed and uneven infrastructure.of the country. Such ternational experiences. and more on the access to health. highlighted ledge. to implementing health reforms lies in when Malabar became a part of Kerala. both as a percentage of gross domestic product as well as in absolute US dollar terms. but a large number of lesser qualified.

) Rs.Nirmala.. . for example.. T N Krishnan and Chen. Murthy. 'Hungry is Not Healthy! The Nutritional Challenge to Health and Development in India'. 'Prioritiesin Health and Nutrition of the Urban Poor: The Calcutta Slums'. Darya New 1. No uniform picture emerges from an analysis of the experiences of countries that had achieved significant reductions in infant mortality and increases in life expectancy.. 'Objectivity. Lalita.395 (Eds.:: . 'Social Intermediation and Health Transition: Lessons from Kerala'. Nigel.. ensuring access to food. The . Berman. various forms of social protection and insurance need to be encouraged and introduced in order to safeguard the interests of the more vulnerable groups in society.. Wadhwa & (Ed. 'Voluntary Agencies in Health Care: Need for a New Paradigm..S..) Rs. PUBLISHERS DISTEBUTORS (P)LTD. . FortilIty: Study of Peninsulr India/M.. Roger. Ravi. The issue is one of deciding the package of interventions that will provide the best form of social securjty to the vulnerable sections of society. 'Maternal Advancement. Bibliography Banerji... Guha. there are arso countries like China. While various incentives for increased public provisioningof services needs to be encouraged. Nagaraian Rs.::::::::::: . Alaka Malwade. there is need to stimulate demand for health services througheducation and awarenessbuilding. Sahooand L ProbbmandPerspective/ RK. Tendulkar.. 'India's Health Expenditures'. Similarly.OmrrBqjkhaif Womren Work: and ChangingScenado K Mahadevan Rs.for instance. 'Women'sRoles and the Gender Gap in Health and Survival'. Lincoln C. . 'Poverty and 'Turning Point' in Adult Male Mortality Rates in India (1970-87)'... there was much left to be accomplished in the area of health. Sen.::. generatingemployment opportunities. Chatterjee. for instance. Cuba. Tim..::::.. DeI2.:.. . The need to view health as development itself and not as a consequence. 'Maternal Mortality in India: Estimates from an Econometric Model'.K. Amartya. Sundari.. Jamaica and Costa Rica that have achieved significant welfare gains despite their low levels of incomes. 'Labour Markets. Crook... :: :. Arup. Options. . Duggal.:::. 250 P.. . Basu. Pravinand Gumber. There is a strong need for co-operation and collaboration between differen't groups in society. of Indian oslims: Iar MortalWy ShukJa (Ed.Balakishnan and 'Nair (Eds. Development Population and Perspectives/P. Shireen J. 'Social Inequality and Access to Health:Study of a Scheduled Caste Population in Rural Tamil Nadu'. Sumit. An implication is that local community organisations have to assume a far greater role in the provisioning and monitoring of health than what has been envisaged thus far.. The discussions left no doubt that despite India's spectacular achievements in many fields.. A major component of this would be the strengthening of people's awareness through concerted efforts at public advocacy. 450 Chi-Hsion Tuan V. Improvements in management and administration of the public health servicesare essential. Capabilities. .. Kumar. Chakravarty. and contribute to health improvements.of economic growth was a significant departure from tradition..:. . 'On the Demography of the 1991 Census. necessary elements of a national policy aiming to promote people's health status. Guha Sapir. Despite undertaking detailed planning exercises..and public action emerged from the discussions. At the same time. . Dave... Jean.'Political Economy of Public Health Practice in India'. AnanRoad. and increasingpublic awareness are. Debrmy.. Problem:Perspectivesfrom Indi. . The attention of policy-makers has to shift from narrowly focusing on an increased provisioning of health services to a more holistic approach that looks at people's access and social security.. and Infant Mortality: An Economic Analysis of Inter-StateDifferentials in India.. Methodologyand Ecology.A . 1993 . There is also an urgent need to re-examine the whole structure of financial and political incentives underlying government's resource allocation within a democratic framework.) Rs. the high levelsof illiteracy.) Childen at Work: Problemsand Polky OpttonslBhagwan Singhand Pd.H IO E. Chen. M and Krishnan. Krihnan K MAhadevan Rs... 'A Note on the Connection between Poverty and Health Status. . Peter. India's achievements are far from impressive.. 'Unsafe Motherhood: A Review of Reproductive Health in India'. ForeignInvestmentLawand Polky In TheElderly hI Population Developed Select DevelopingCountries/ andDeveloping World: Policis..Suresh. . T K. Krishnan. B.. A K Shiva. 'Urban Mortality 4nd Uirbanisation in India'.. . Dyson. 'Differences in the Utilisation of Health Services in Western India: 1980-81 to 1986-87. & Seema Singh Rs.. 'Problems.. Debabar. Monica. Murthy.::. pointed to the dangers of current policy discussions getting derailed into political misdirection by the extremely simplistic formulation of the problem as a choice between 'pro-market'or 'pro-government' policies. Marty and Dreze. K Navaneethamand S Irudaya Rajan. Dyson. also raised the issue of ethics in management and highlighted the need for a new consciousness among public service 774 managers. Alok. 3278368 Fax:091-01143264368 Economic and Political Weekly April 17. 'Issues in Health Policiesand Management in India'. Debarati. Tim and i1-ahapatra.primacy of good health as an essential . Compared to some of these low income countries. 480 Diobtfedby: Economicsof Child-Labour and < D.and the severeshortages in public health services that exist in the country today. 130 in IndialAlakh Sharma N.. 'Health and Development Transitions in India: Public Policies and Action. Jeffery.. In the field of public health services. 'EnvironmentalSanitation in the H4ealth Transition:India and the Wkstin the 19th and 20th Centuries.:. Meera. Priti. Chi-Hsien Tuan and Chinaand Australia/K Mahadevan. 320 ReadinghIPopulation earch: R Policy. 'Widows and Health in Rural North India'. 225 Deterninants and plicaio/ Mahanty M. While there are some high growth countries. .O. Jejeebhoy. Mukhopadhyay.. Immediate priority needs to be assigned for new policy initiatives in health and the social sectors in general.: . Bhat.:. . 'Regional Disparities in Health Care Devtiopment: A Comparative Analysis of Maharashtraand Other States. 'Towarda Political Economy of Health Care in India and Pakistan' Kabir. P N Mari. Gani & Sumangala B. Debraj.) Rs. the failure of policy in India is evident when we look at the poor health conditions.. Visaria. Health and Policy. and Challenges: Financing Voluntary Health' Action'. K Mahadeva (Eds. promoting equal opportunities for different groups in society. 'On the Demographic Consequences of the Bihar Famine of 1966-67 and the Maharashtra Drought of 1970-73. 190 Phones: 3261466.. . there is lack of incentives for efficient provisioning of public health services. Anil.T. Das Gupta. collective public action needs to be stimulated in order to monitor performance and ensure accountability.. Another area that requires immediate attention relates to institutional innovation and incentives. Promoting education.. Adaptive Mechanisms and Nutritional Status' Sen. Ray. enhancing social freedoms. :: :::::::-:. T N.compbnent of human development implies {hat the focus of policy interventions ought to be more broad-based and multipronged.