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: http://www.jstor.org/stable/4399614 Accessed: 16/06/2009 01:28
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Health as Development Implications for Research, 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. It is also important to view health more holistically,and understandhow social, cultural,political, economic and otherfactors interact to constrain people's access and contribute to human deprivation. The inter-connections are often complex and policy interventions need to be more people-focused, hroad-based and mnulti-pronged.
IMPRESSIVE achievements and intolerableshortcomingscharacteriseIndia's health performanceover the past 45 years. On the positive front, there has been a steady decline in mortality rates over the years. Life expectancy and infant survival conditions are better than what is normally predicted for a country with India's level of income. And relatively speaking, health conditions in India are ,more favourable than in some of the neighbouring South Asian countries. However,a closer eoaminationrevealsthat India may not be doing as well as is made out to be. For example, Algeria, Botswana, Cameroon, Egypt, Kenya, Libya, Morocco, Togo, Tunisia, Zaire and Zimbabwe are some of the African countries where infant mortality is lower than in India. Again, with the exception of Bolivia, all other Central and South 'American countries report lower child tnonality rates than India. Serious social disparities and abnormally high risks of mortality and morbidity persist. Verylittle is known about morbidity conditions in the country. Much less is known about other psychosocial and cultural dimensions of health, and the actual illness burden facing the majority of people in the country. Given India'soverallachievements,such a performance on the health front is not very encouraging. Per capita incomes, for instance, have steadily increased over the years, and spectacular gains have been made in the field of food production. An enormous pool of skilled scientific, -technical and managerial manpower has been built up. Massive investments have gone into infrastructuredevelopment, and the building up of an industrial base. Despite these achievements, millions of people lack access to basic food, shelter, and safe drinking water. Diseases arising out of acute malnutrition persist, and more than a thirdof the population remainsilliterate. Severe shortages continue in spite of the recent expansion in the provisioning of public health services. 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.This article draws attention to some of the major issues that emerged from the discussions and the imnplicationsfor policy research and pubhli action. It is, however,not intended to be a summaryof the proceedingsof the workshop.
ASSESSINGHEALTHPERFORMANCE

Taking stock of a country's health status is a complicated exercise. In addition to the constraints imposed by a shortage of specialised data, comprehending the various dimensions of healthy living is not easy. Das Gupta, Krishnan and
Chen, for instance, in timia inaugural

presentation,described India as a country experiencing demographic, epidemiologic and health transitions simultaneously and differentially. The direction of the demographic transition and the velocity of fertility,mortalityand population changes are as yet unclear. While India's mortality decline has been underwayfor the past 60 7ears,fertility has begun to decline only over the past 20 years. At the same time, 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, malnutrition and reproduction. Cancer, cardiovascular, and other health problems, often associated with affluence, are beginning to emerge as major causes of death. Concurrently, fresh unanticipated health threats, that include the AIDS epidemic, environmental health hazards and an upsurge of behavioural pathologies like violence, substance-abuseand accidents, complicate the epidemiologic scenario. India also presents a striking picture where people in the same country live in entirely different health worlds, reflecting at many levels, an unfortunate polarisation of health between different groups of people
in society.

An assessment of health status also raises critical questions relating to measurement and interpretation of data. Specifically addressing this issue, Sen

emphasised the need for objectivity in health assessment as a prerequisite for policy interventions. He highlighted problems that commonly arise in connection with assessing the objectivity of health status, the objectivity of cause-effect relations, and the objectivity of counterfactual statements. In any evaluation exercise relating to health, it is essential to understand the context in which a particular statement is made. At the same time, it is necessary to assess the internal analytical consistency of arguments. Sen, for instance, points out that if one were to go by morbidity statistics of the standard kind, Keralareports the highest morbidity rates, and the poor health states of Bihar, Madhya Pradesh, Rajasthan, and Uttar Pradesh roport among the lowest morbidity. 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,while health progresshas helped to reduce mortality, malnutritionexists which manifests itself in ill-health. However, an equally persuasiveargumentcan be made that the more educated population in Kerala has a greaterawarenessand interest in health, and this gets reflected in a higher utilisation of health services. Similarly, the reported self-perception of morbidity is reported to be higher in the US than in Kerala, and once again, such data could be interpretedas denoting better 'health' status in Keralathan in the US. The reality of the situation, of course, could be far more complex. The reportedhigh rates of morbidityin Keralaand low ratesin Bihar, for example, may not reflect the actual rates of illness and ill-health in these two Indian states. What is clear in this case is that a literatepopulation in Keralatends to have a greaterunderstandingof illness, whereas an illiterateand ignorant population as in Bihar may have little appreciation of their health predicament. Also, better access to health services makes it easier for health-care seekers in Keralato avail of such services, thereby increasing their perception and understanding of illness. Information on self-perceived morbidity rates when seen in relation to

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other pieces of information, becomes valuable for understanding the overall health picture. Self-perception, therefore, may prove to be a rather unreliable guide to the prevalenceof illness and ill-health, but it does provide important clues to the persistence of such deprivations. Participants also pointed to additional complexities arising from the political economy of health care. Several features of 'health' make it different from other publicly provided goods. The provisioning of health-relatedcommodities and services offers opportunities for price discrimination as resale of the product is virtuallyimpossible. In the Indian context, however, where price discrimination in public hospitals and health-care centres has not been encouraged, both the rich and the poor pay the same price for the service.Since there is often only a nominal charge for the service, the more expensive the service, the higher is the subsidy. Consequently, the rich often get subsidised to a greater extent than the poor. Again, in the marketingof health products,the consumer loses much of his or her sovereignty, as it is the doctor who makes the purchase decision for the consumer. This weakens the influence of the traditional budget constraint on household purchase decisions. Finally,health outcomes are the result of interventions that go beyond the realms of medicine and public health. Consequently, identifying precise causal linkagesbecome extremelydifficult. It was against the backgroundof such considerations that participants at the workshop examined and analysed India's health achievements.
POVERi-Y, DEPRIVATION AND ILL-HEALTH

current levels of living, whereas most health status indicators are a result of cumulated levels of living. Economists have paid considerable attention to defining poverty, estimating its incidence and prevalence.Much less attention has, however, been paid to the impact of poor health on the economics of the individual and the household. Very little, for instance, is known about the impact of illhealth on the economic productivityat the i'ndividual,household and national level. Discussants at the workshop also emphasis.edthat while a focus on poverty, or a shortage of incomes is useful, it is by no means sufficient to focus only on incomes. Dreze, for instance, indicated how exclusive reliance on measures of poverty based on income and expenditure data often tends to mask poor health conditions. There is a need to combine an analysis of per capita expenditures, with demographic and health indicators 'in order to arriveat some plausible explanations for poor health. For instance, high levels of per capita expenditures may provide very little information about the vulnerability of poor and deprived communities. Again, 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.

FooD

SECURITY. MALNUTRITION VULNERABILITY

AND

Several papers presented at the workshop sought to explore the ntlltidimensional and complex linkages between -poverty,deprivation and ill-health. While poverty, or a shortage of income, is customarily identified as a causal factor accounting for poor health, in reality,the pictureis far more complicated. Tendulkar articulated some of the two-way interactions between poverty ar.d health status at the conceptual level. For instance, 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. Nor is it always true that all thdse in poor health conditions necessarily belong to poor households. He also pointed out that the relationship is strongly influenced by the nature of poverty itself, i e, whether it is persistent or transient.Again, the one-to-one correspondence between poverty and health status is further complicated because %povertyis measured on the basis of
770r

Poverty, or the shortage of incomes need not necessarily be correlated in any predictable manner to deprivations in several dimensions of decent living. One such case relates to environmental pollulion. Guha'shistoricalanalysis highlighted tik ;ignificance of environmental sanitation as an essential preventivecomponent of public health interventions. In India, while lethal diseases like cholera and smallpox have been controlled, diseases like dysenterycontinue, despite increasing expenditure on sanitation and water supply. Curative services have controlled mortality, but not morbidity which continues to rise. Guha emphasised that in addition to macro-sanitarymeasures, it is equally important to focus on environmental contamination within the household. Historicalevidence from Britain, for instance,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.A focus on the linkages between deprivation and illhealth also drawsattention to the fact that poor health is not necessarily a 'medical' problem. Thus, merely expanding the supply of health services may not yield desired results, unless deprivations in several human dimensions, such as in education, social freedoms, and so on are simultaneously addressed.

Closely relatedto the theme of deprivation and ill-health is the issue of access to basic food needed for healthy living. Several participants drew attention to the crucial role of food security in protecting the vulnerability of poor households. Chakravarty, for instance, pointed out that during the decade of the 70s in India, adult life expectancy rose without any perceptible decline in the poverty ratios. This goes contrary to the presupposition that a reduction in absolute poverty must be the causal mechanism through which survival chances are improved, if diseases are successfully controlled. Her empirical analysis suggests that while a Malthusian mortality response could emanate from a depressed real income effect, society manages crises better largely through public entitlement routes. As successive mortality peaks were dampened, the survival rates improvedas a whole. Discussions focused particularly on the consequences of famines and food shortageson people's health, and the types of policy interventions that result in positive benefits. Dyson and Mahapatra, for instance, analyse the patterns in mortality rates in Bihar in 1966-67, and in Maharashtrabetween 1970 and 1973 during the food crisis years. They examine whether famine relief measures were successful or effective in affecting demographic consequences like mortality, and how far the geographical distribution of mortality corresponded to various proxy measures for failure of agricultural production. While the evidence from Bihar indicates a predictable pattern, with mortality rising in areas affected by cropfailure, a different picture emerges in Maharashtra,where excessivedeaths were reported in areas with assured rainfall. In seeking explanations to the paradoxical finding in Maharashtra, they point out that it is necessary to understand better the nature and types of human responses to famine conditions. For instance, the higher mortality rates could well be a reflection of distress migration from the dry zone to wet areas. Equally important is the need to assess the extent and effectiveness of relief measures put into place by the state governments. As pointed out by Dreze, Bihar suffered from poor targeting of relief measures, whereas in Maharashtra, the system was far more effective. In any event, however,it is very difficult to interpret the relationship between famine and mortality, especially since increased mortality is not an inevitable component of famine. There is also a complex and less understood interaction with diseases. The analysis of the linkages also has to take into account the

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levels of communication and infrastructure development in the states which may create differential impacts on mortality. Participants also traced the linkages between access to food and nutritional outcomes. Chatterjee, for example, pointed to several factors such as lack of access to resources,inadequate education, intra-household food allocation patterns favouring boys and adult men, and/so on that contribute to malnutrition and poor health. Given how closely many of these considerations are tied to the livelihood patterns of people, especially among the poor, a-careful analysis of the health consequences of the functioning of labour markets, in particular, becomes crucial. Ray raised several issues relating to the linkages between the operation of market forces and nutritional status. He elaborated specifically on the impact of the flexibility of labour markets on energy balance and nutritionrl outcomes. In a situation where the labour market is characterised by flexibility representing the ability of an employer to replace an employee, and surplus labour which implies a low degree of tightness, or a lack of alternatives for the labourer, 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. More severeconsequences emerge with the incorporation of the effects of adaptive mechanisms in the body to lower nutritional intakes. Increased adaptation unambiguously worsens the nutritionil status of the population, as the marketappropriates the surplus generated. Aggregatestatisticssuch as the overallsupply of food in the econQmy, have little to do with the process of deterioration of nutritional status. Participants envisaged an important role for government interventionsin order to ensure peoples access to food especially during periods of shortages. Participants argued for a more careful appraisalof the public distribution system, and a reexamination of issues surrounding food security and entitlements.
DISPARITIES SOCIO-ECONOMIC IN WELL-BEING

whilerural-urban differentials continue to exist, duringt-he 15 years between 1976 and 1990,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. Participants drew attention to the nature, extent, and implications of such differentials. Striking differentials exist in the health conditions between rural and urban areas. Visaria and Gumber point out, for instance, that

in urban areas. It is, however, important to note that major differencesexist within the rural areas itself, and between rural and urban areas across the states. For instance, rural Kerala differs significantly from rural Manipur, or rural Uttar Pradesh in terms of geophysical, infrastructural, and other characteristics. Similarly,even in the urban areas, populations are not homogeneous. Very little is known about the health conditions of different soeio-economic groups. Guha Sapir, for instance, presented the results of a study of urban slum dwellers in Calcutta. She pointed out that while an urban bias did exist in the provisioning of health and other services vis-a- vis rural areas, the urban-bias in the provisioning of health-care services discriminated against the urban poor. The lack of access of the urban poor was accentuated by the severe shortages of good health services. Social, political and epidemiological parameters of the urban poor also tend to be substantially different from their rural counterparts. 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. Several reasons were advanced for the existence of such large rural-urban differentialsin health status within the country. Crook, for instance, attributes the lower levels of mortality in urban areas to better access to curative medical services in urban areas than in the rural areas. He also points out that while malnutrition can be present in both urban and rural areas, mass starvation has been observed principally in the rural communities. Recent analysis also suggests that proportion of the poor among urban populations is lower than the corresponding proportion among ruralpopulations. Among the principal factors contributing to such differentials are the inadequate levels of literacy,especially among women in rural areas, risks and fluctuations in earnings arising from crop failures, and the better access.to qualified health workersin urban areas. Crook also suggested that a contiguity of cultural experience and a similarityin the levelsof service provisioning tend to reduce the rural-urbangap, as is demonstrated by the southern states of Kerala, Karnataka and Tamil Nadu. 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. Sundari, for instance, highlighted the conseque?ces of material and social deprivation on the health status of a scheduled caste community in Chinglepet district of Tamil Nadu. Compared to backward caste

families, the study found that both infant and under-fivemortality rates and-marital fertility rates are much higher amdng the scheduled caste families. The morbidity profile of women and children are not very different from other castes, but important differences emerge in the causes of morbidity. For example, lack of sanitation and pollution were found to be largely confined to families belonging to scheduled castes living in separate hamlets. 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, but due to resource constraints and certain socio-cultural obstacles common to women. At the same time, the health-seeking behaviour was more encouraging among children than among women. Fifty-one per cent of the children who had a health problem had been referred for medical help, and there existed a relationship between the nature of illness and symptoms and healthseeking behaviour. Among women, only 15 per cent sought medical help, 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. Drawing attention to the large interstate differentials in infant mortality that exist, Kumarargued that high infant mortality rates are not necessarily a medical problem, but are linked in complex ways to a whole set of social, political, economic, and other factors. Comparing the experiences of Kerala and Manipur, two Indian states with the lowest infant mortality rates, with the experience of other high infant mortality states reveals that infant survival was crucially dependent upon maternal capabilities, and women's freedoms to act in W*sthat are likely to be beneficial to the child. In addition to literacy attainment, Kumar also highlighted the importance of occupational and marital choices in influencing child survival. The analysis pointed to three crucial domains of public policy intervention: public actioln for women's empowerment, public action for improved access, and public action for improving the techno-managerialefficiency of health .care systems. Duggal outlined the regional disparities in health-caredevelopment comparing the experiencesof Maharashtra(an industrially advanced state), Punjab (agriculturally advanced), Kerala (socio-politically advanced) and Bihar (completely backward) with the rest of India. The significance of economic development as an important leveller, with its bearing on health and
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other social indicators was evident in the case of Punjab, and to a lesser extent in M'aharashtra.Unlike Punjab, where the rural-urban differentials are narrow, Maharashtra has an urban bias, with pockets of urban areas reapingthe growth benefits of the state. On the other hand, in Kerala, the socio-political process has !nsured better distributivejustice. Factors that contribute to regional diparities in include differencesin macrohealth s,Latus economic policies that differentiates between rural and urban areas, levels of government provisioning, and in the process of empowerment of the people so they can effectively demand better healthcare facilities. Another major area of disparitiesabout which very little is known relates to the health status of differentage groups of the population. Many participants felt that while infants and children had attracted attention from policy-makers, very little attention had been paid to the health problems of adolescents, adults and the aged in particular.
WOMEN'S HEALTH AND CONCERNS NEGLECTED

A recurrenttheme of the workshop was a consideration of the gender biases in health, and the need to focus more carefully on women's health issues. Discussants identified specific health problems women face, and made a strong case for a gender-focused understanding of health issues. In addition to foc"ving on gender differences in health between and women, there is an urgent mWen need expressed to understand the health vulnerabilities of women. Participants also drew attention to the unfavourable levels and trends in femaleto-male ratios in India's population. Part

of the problem lies in the higher risks of mortality and the poorer health conditions that women face. Jejeebhoy and Rao, for instance, argue that high mortality rates among women as revealed by maternal deaths due to sepsis, anaemia, toxemia, haemorrhage and abortions, indicate that women's health in general, and reproductive health in particular remain largelyneglected.A significant proportion of such deaths among women are the combined effects of poor health, poor nutrition, and a prolonged and closely spaced period of fertility stretching from adolescence to menopause. Poor nutrition of girls especially in childhood and adolescence have serious consequences. It is not just early marriages-andadolescent child-bearing that leads to this situation, but the low levels of health sery'iceutilisation, and the poor quality of lkealth-care receivedduring pregnancyare also responsible for both the high levels of neo-natal
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mortality and maternal mortality. In addition, the burden of work shouldered by women gives rise to constraints making it difficult for them to seek health-care.The reproductivemorbidity profiles of women which include gynaecological, obstetrical and contraceptive morbidity is an area that needs careful examiriation. Bhat, Navaneethamand Rajan, in their paper, present an indirect method for estimation of the magnitude of the incidence of the maternal mortality in India. The method is based on agespecific death rates by sex, fertility rates classified by age of the mother and an assumption of the age-pattern of maternal mortality. Bhat contends that the method is well suited to the natureof data availability in India. Application of the method to the Sample RegistrationSystem Data of 1982-86 produces an estimate of maternal mortality of 555 per 1,00,000 births for India as a whole. Incidence of maternalmortalityappearsto be relatively high in the northern and eastern parts of India. Further,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, and 8 per cent of the decline in the MMR (per birth) is explained by the change in the age schedule of fertility. In addition to focusing on health problems of women in general, participants also drew attention to the need for paying special attention to the problems of the more vulnerable among them. Focus!ng on widows, for instance, who form 8 per cent of the total female population a-%J number more than 25 million (1981 Cens4s), Chen and Dreze highlighted the peculiareconomic and social vulnerability of this group of women. The deprivation of widows is quite severeand their relative

mortality risk is quite high. This is especially among widows who live alone and those who live in households eaded by individuals other than their sons or themselves. While the study sought to understand the special constraints imposed on widows by the socio-economic and cultural environment, 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. Concurrently,severalissues relating to worrmen's edpcation, employment, social freedoms, and so on need to be addressed. For example, by examining the relationship between women's roles and the gender gap in health and survival, Basu suggests that where women are active and have more access economicaHly to social space, the gender gap in health and survival is smaller than for women who are deprived of economic independence, whose movements are restricted, and whose status is dependent on their reproductive success. Discussions also focused on the low levels and declining trends in the femaleto-male ratios, and their interpretationas a worseningof women'shealth conditions. Dyson suggests that part of the phenomena could well be due to problems of enumeration in the Census. For instance, he argues that when the Census coverage deteriorates,it does so for women. In this context, the indicated decline in the female-to-male ratio in the 1991 Census need not be seen as indicative of worsening relativefemale survivalchances. Much of India's decline in the female-to-male ratio for 1991had occurredbecause of the dramatic worsening of the ratio in Bihar.

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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.

sable relevance for any meaningful development process. Banerjiemphasised the role of different socio-cultural and political forces that have shaped public health practice in !ndia. In this context, 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. Among other approach to health, discussants pointed factors constraining the proper expansion out that health-care is a concern in which and implementationof appropriatehealth economic interests,political processesand care services in the country, Banerji also social mediation play significant roles. highlightedthe dominance of bureaucratic Several participants including Banerji, power lacking in epidemiological knowJeffery, Kabir and Krishnan, highlighted ledge, the abdication of political responthe importance of political structuresand sibility by politicians, and the oversocial mediation in health-care.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. intermediation in bringing about health Jeffery emphasised the need to undertransition.They dem6nstratedhow relevant stand more closely how state and civil and timely interventions,at different levels society interact. Indian health policy of the society, 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, an exposure to inperiod of acute caste-consciousness. Such ternational experiences, and the existence initiatives were initiated and sustained in of a skewed and uneven infrastructure. a politically responsive environment Unfortunately however, strong and indesirous of achieving improved health dependent forms of institutions at the outcomes for the society. The Malabar local community level have not developed. 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, mortality and than democratically controlled. The key infant mortality rates. However, in 1956, to implementing health reforms lies in when Malabar became a part of Kerala, building up local social forces at the health policies and programmes which village level as is demonstrated in Kerala, had succeeded in Travancoreand Cochin for instance, and to a lesser extent in West were applied to Malabar as well. The Bengal, where support from localised parresultant improvements in Malabar have ty structures based on ideological party been impressive, especially given that the commitments have contributed signiachievements have been recorded in a ficantly to real achievements in healthrelatively short period of a generation. service organisation. What underlies the success of this As agents of social mediation, voluninitiative is the spread of education, tary sector non-governmental organisaespecially among women. The Kerala tions have played an important role in experience has several lessons to offer to India. Mukhopadhyay, for instance, tracother regions and states in India, where ed the emergence of this sector in India caste-rigidities and social stratification and discussed alternatehealth models that continue to dominate. 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- of the country. However, he pointed out vices, and more on the access to health- that these models were far from perfect, care. Kabir and Krishnan emphasise that arid most voluntary agencies faced a primary focus on social, locational and numerous managerial and other coneconomic access offers policy prescrip- straintswhich severelyrestrictedthe scope tions and interventions that are very dif- of their activities, and limited their potenferentfrom one that concentratesprimari- tial for making a large-scaleimpact. Dave ly on an expansion of health services. The also highlighted some of the efforts of the second key lesson from Kerala is the in- 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. A third important lesson is the country. But she argued that their finanprimacy given to preventive and public cihI instability and reliance on national health measures. The Kerala experience and international donor agencies has led also illustratesthe complementary nature to a dependence which places severeconof health and education, and its indispen- straints on their activities.

The issue of health finaticing and pricing of services were also subjects of discussion. Participantshighlight6othe inadequacy of reliable data, and the numerous problems with the interpretafigures tion and use of such expenditurce for designing policy interventions. Berman, for instance, argues that statistics on health expenditures that are currently available grossly underestimate the total expenditures on health. While much of the data pertain to government health expenditures, there is a growing body of evidence to suggest that private health expenditures constitute a larger and more significant proportion of total health expenditures. What emerges from the existing data available is that India spends relatively heavily on health, both as a percentage of gross domestic product as well as in absolute US dollar terms, when compared to some other countries of the Asian region. At the same time, however, several important components of legitimate health expenditures are excluded from standard computations. He also pointed out that it is the dynamic private sector, unusual in its variety and scope, with multiple systems of medicine coexisting side by side, that is an important determinant explaining the size and composition of the national health expenditure. High rates of use of private sector services seem to be prevalent in both urban and rural areas across all income groups. But' based on the limited evidence available regarding the quality of private health services, there is little cause for optimism that it contributes significantly to improvements in the health status of the population. Most often, it is not the qualified licensed physicians, but a large number of lesser qualified, unqualified, 'eclectic providers' who practice all kinds of treatments in small towns, villages, in both rural and urban areas that have generated an increase in accessibility to health care. The quality of government services is no better, throwing serious doubts on its role in contributing to improved health status at an all-India level, although in specific states Qf India the picture is different. 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. While estimating the levels of expenditures is one part of the exercise, an equally important dimension is the evaluation of the impact that such expenditures has on the heatlthstatus of people. While no direct correlation can be easily established between health expenditures and health outcomes, it is nonetheless important for health financing and pricing decisions to be related to people's access to quality services. Several common themes for research 773

Economicand Political Weekly April 17, 1993

and public action emerged from the discussions. The need to view health as development itself and not as a consequence,of economic growth was a significant departure from tradition. The .primacy of good health as an essential ,compbnent of human development implies {hat the focus of policy interventions ought to be more broad-based and multipronged. 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. Promoting education, generatingemployment opportunities, ensuring access to food, enhancing social freedoms, promoting equal opportunities for different groups in society, and increasingpublic awareness are, for example, necessary elements of a national policy aiming to promote people's health status. Similarly, 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. There is a strong need for co-operation and collaboration between differen't groups in society. Sen, for instance, 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. 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, and contribute to health improvements. 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. While there are some high growth countries, there are arso countries like China, Cuba, Jamaica and Costa Rica that have achieved significant welfare gains despite their low levels of incomes. Compared to some of these low income countries, India's achievements are far from impressive. Despite undertaking detailed planning exercises, the failure of policy in India is evident when we look at the poor health conditions, the high levelsof illiteracy,and the severeshortages in public health services that exist in the country today. Another area that requires immediate attention relates to institutional innovation and incentives. In the field of public health services, there is lack of incentives for efficient provisioning of public health services. Improvements in management and administration of the public health servicesare essential. Murthy,for instance, also raised the issue of ethics in management and highlighted the need for a new consciousness among public service
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managers. At the same time, there is need to stimulate demand for health services througheducation and awarenessbuilding. 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. While various incentives for increased public provisioningof services needs to be encouraged, collective public action needs to be stimulated in order to monitor performance and ensure accountability. A major component of this would be the strengthening of people's awareness through concerted efforts at public advocacy. 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, there was much left to be accomplished in the area of health. Immediate priority needs to be assigned for new policy initiatives in health and the social sectors in general.

Bibliography
Banerji, Debabar,'Political Economy of Public Health Practice in India'. Basu, Alaka Malwade, 'Women'sRoles and the Gender Gap in Health and Survival'. Berman, Peter, 'India's Health Expenditures'. Bhat, P N Mari, K Navaneethamand S Irudaya Rajan, 'Maternal Mortality in India: Estimates from an Econometric Model'. Chatterjee, Meera, 'Hungry is Not Healthy! The Nutritional Challenge to Health and Development in India'. Chakravarty, Lalita, 'Poverty and 'Turning Point' in Adult Male Mortality Rates in India (1970-87)'. Chen, Marty and Dreze, Jean, 'Widows and Health in Rural North India'.
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Crook, Nigel, 'Urban Mortality 4nd Uirbanisation in India'. Das Gupta, Monica, T N Krishnan and Chen, Lincoln C, 'Health and Development Transitions in India: Public Policies and Action. Dave, Priti, 'Problems, Options, and Challenges: Financing Voluntary Health' Action'. Duggal, Ravi, 'Regional Disparities in Health Care Devtiopment: A Comparative Analysis of Maharashtraand Other States. Dyson, Tim, 'On the Demography of the 1991 Census. Dyson, Tim and i1-ahapatra, Arup, 'On the Demographic Consequences of the Bihar Famine of 1966-67 and the Maharashtra Drought of 1970-73. Guha, Sumit, 'EnvironmentalSanitation in the H4ealth Transition:India and the Wkstin the 19th and 20th Centuries. Guha Sapir, Debarati, 'Prioritiesin Health and Nutrition of the Urban Poor: The Calcutta Slums'. Jejeebhoy, Shireen J, 'Unsafe Motherhood: A Review of Reproductive Health in India'. Jeffery, Roger, 'Towarda Political Economy of Health Care in India and Pakistan' Kabir, M and Krishnan, T N, 'Social Intermediation and Health Transition: Lessons from Kerala'. Kumar, A K Shiva, 'Maternal Advancement, Capabilities, and Infant Mortality: An Economic Analysis of Inter-StateDifferentials in India. Mukhopadhyay, Alok, 'Voluntary Agencies in Health Care: Need for a New Paradigm. Murthy,Nirmala, 'Issues in Health Policiesand Management in India'. Ray, Debraj, 'Labour Markets, Adaptive Mechanisms and Nutritional Status' Sen, Amartya, 'Objectivity, Health and Policy. Sundari, T K, 'Social Inequality and Access to Health:Study of a Scheduled Caste Population in Rural Tamil Nadu'. Tendulkar,Suresh, 'A Note on the Connection between Poverty and Health Status. Visaria, Pravinand Gumber, Anil, 'Differences in the Utilisation of Health Services in Western India: 1980-81 to 1986-87.
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Economic and Political Weekly

April 17, 1993