Chapter 1

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BACKGROUND OF THE STUDY

INTRODUCTION

Health system is interrelated to and interdependent on various other sub systems of

the society. It influences and in its turn is influenced by these sub systems. This

obliterates the misconception that health system is solely responsible for providing

and upholding the health standard of any society. The significance of the inter play

of other socio- economic, political and ecological factors in health is thus exposed.

These factors acquire great significance in the process and as an input in policy,

plan and programme formulation for health initiatives.

The health care system in India largely revolved around a holistic approach to

disease and health care during the ancient and medieval periods not withstanding

the fact that issues of accessibility and availability were relevant even during those

periods. The post medieval and pre independence India witnessed a sharp decline

in the indigenous systems due to the state promotion of the Western medicine by

the colonial rulers and decreasing support of the local rulers resulting in decrease in

the number of practitioners. The Western health care system attracted the Indian

populace due to its quick healing and easy technologies which further weakened

the influence of the indigenous system. The allopathic health care system became

popular in-spite of its very limited availability in pre independence India.

Immediately after independence, the Government of India (Goi) focused its

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attention on providing adequate health care to the people especially in the rural

areas.

The health policies, plans and programmes in India started taking shape prior to

independence along with the growing National Movement. The National Planning

Committee (NPC)1 of the Indian National Congress was set up in 1938. This

Committee set up a sub-committee on National Health chaired by Colonel Santok

Singh Sokhey, which made a penetrating assessment of the health situation and

health services in the country and recommended measures for their improvement in

the Interim Report submitted in 1940. The integration of curative and preventive

functions in a single state agency was urged and it was further stressed that the

maintenance of the health of the people was the responsibility of the State.

Practitioners of Ayurveda and Unani system were to be drawn into the state health

system after giving them further. scientific training where ever necessary. Other

aspects covered were nutrition, expansion of medical education and research,

compilation of an Indian pharmacopoeia and production of drugs. Thus, even as

early as 1940, India's leaders had already envisaged people oriented health care

services and had then advocated the concept of a Community Health Worker

(CHW) to serve the rural community.

After a study of the findings of the National Planning Committee on health ( 1940)

and the growing realisation to meet the health requirements of the community,

National Planning Committee, Sub-Committee on National Health (Sokhey Committee), 1940, Bombay, Vora.

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particularly the rural population, in 1943, the then British Government appointed

the "Health Survey and Development Committee"2 with Sir Joseph Bhore as the

Chairman. The Committee was assigned the task to make a survey of the existing

health conditions and health organisations to make recommendations for future

implementation. The recommendations and guidance provided by the Bhore

Committee formed the basis for organisation of basic health care services in India.

Though followed by several other committees which studied several aspects and

made recommendations for improvement of health care services, Bhore Committee

report, remained as the most potent document covering issues encompassing the

whole gamut of health care services.

The Bhore Committee report was submitted in 1946, which among other things,

laid emphasis on the need for sodal orientation of medical practice, a high level of

public participation to lay special emphasis on preventive work and consequent

development of environmental health. The concept of 'social doctor' who would

combine both curative and preventive measures, was propounded. Suitable housing

, sanitary surroundings, safe drinking water supply, elimination of unemployment

were emphasised as key measures to improve the health standards of the people.

Amongst the most far reaching recommendations was the establishment of a

Preventive and Social Medicine (PSM) Department in every teaching institution

and three months rural internship.

2 Government of India: Health Survey and Development Committee (Bhore Committee) Report, Vol. I-IV, Delhi.

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Specifically the Bhore Committee made two types of recommendations :

a) A comprehensive blue print for the distant future (20 to 40 years) - the

smallest service unit was to be a Primary Health Unit (PHU) serving a

population of 10,000 to 20,000.

b) A short term scheme covering 2 to 5 years period - the emphasis would be

on setting up 30 bedded hospitals, one for ev~ry two Primary Health Unit.

Long Term Recommendations :

A Secondary Health Unit was to be established on every 15 to 25 Primary Health

Units, to assist and supervise them. On three to five such secondary health units in

a district would be the District Health Organisation serving a population of about

thirty lakhs. A health centre with general and special hospitals, having a bed

strength of about 2,500 was to be established at the district head quarters. 650

beds were recommended by Bhore Committee at the Secondary Health Centre

Level and seventy five at the Primary Health Unit Level.

Similarly the ultimate staffing pattern suggested by the committee were generous.

Each Primary Health Unit was recommended to have six medical officers and six

public health nurses, in addition to the nursing staff for the 75 bedded hospital.

Staff and resources were also recommended for controlling and eradicating widely

prevalent diseases such as malana, tuberculosis, venereal diseases, leprosy and

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mental disorders. The Bhore Committee itself realised. that it was difficult to attain

these goals, so they also made several short term recommendations.

Short Term Recommendations :

According to the short term recommendations i.e. two to five years period, the

emphasis was laid on setting up 30 bed hospitals, one for every two Primary Health

Units. District Health Organisations were to initially cover five Primary Health

Units and one Secondary Unit each. This was to be gradually increased to twenty

five primary and two secondary units in a ten years period and only then the

District Health Centres would be established.

Other important recommendations made by the Bhore Committee were:

i) Formation of Village Health Committee to secure active cooperation and

support in the development of health programme;

ii) Provision of doctor of the future who should be a 'social Doctor' who

combines both curative and preventive measures;

iii) Formation of a District" Health Board for each district with the district

health officials and representatives of the public;

iv) To ensure suitable housing, sanitary surroundings, safe drinking water

supply, elimination of unemployment and lay special emphasis on

preventive work; and

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v) Intersectoral approach to health services development.

Health Survey and Planning Committee (Mudaliar Committee, 1959-61 )3

recommended initiation of mass campaigns for certain diseases like tuberculosis,

small pox, cholera, leprosy and filiarisis. It was recommended that paramedical

personnel should be given further necessary training in other areas in order to

enable them to undertake multiple activities and then allocate them to rural and

urban centres. One Auxiliary Nurse and Midwife (ANM) for every 5000

population and Auxiliary Male Health Worker for double of this population was

suggested. Integration of medical and health services on an immediate basis was

also put forward as essential measure to strengthen health care services.

A Special Committee was constituted by the Government of India, under the

chairmanship of Dr. M.S. Chadha, 4 the then Director General of Health Services.

The Committee was to find out . the requirements related to the primary health

centres, their planning, the necessary priority required according to the needs of

the maintenance phase of Malaria Eradication Programme and also for other health

activities. The Committee was also to make recommendations regarding the use of

technical and supervisory staff of the NMEP organisation after malaria eradication

had been achieved.

3 Government of India ; Report of the Health Swvey and Planning Committee (Mudaliar Committee), Ministry of Health, 1959-61, New Delhi. Government oflndia: Chadha Committee Report, Ministry of Health, 1963, New Delhi.

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~ The Committee suggested that the maintenance was the responsibility of the

general health services, which should be adequately strengthened, particularly the

rural health services. The Committee also recommended that multi - purpose

domicilliary health services should be developed for all the health programmes.

The Study Group on Hospitals (Ajit Prasad Jain Committee, 1966)5 recommended

that the total bed strength at the primary health centre should be raised from 6 to

10 beds. It suggested that, by 1976 at least one of the sub centres in the block

should be raised to the status of primary health centre (PHC) to reduce the burden

on the existing PHC. The lady doctor for the family planning work at the PHC

should always be in addition to the lady medical officer on the health side. The

laboratory technician at the PHC should be utilised to undertake the examination of

urine, stool and blood of the patients visiting the primary health centre. The

Committee suggested that one of the existing allopathic dispensaries should be

upgraded in any block. Residential facility should be provided to the doctor. The

report underlined the need for setting up of an out patient department and

emergency serv1ces.

Kartar Singh Committe~ (1973)6 recommended for multi purpose workers scheme.

All the basic health services for a target population of 5000 were proposed to be

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6

Government of India : Report of the Study Group on Hospitals (Ajit Prasad Jain Committee, 1966), Ministry of Health, Family Planning and Urban Development, New Delhi. Government of India : Committee on Multipurpose Workers under Health, Family Planning Programmes (Kartar Singh Committee) Report, 1973, Ministry of Health and Family Planning, New Delhi.

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delivered by one female and one male worker. It was suggested that the doctor

who is in-charge of the PHC should have the overall charge of all supervisors and

health workers in his area.

The Srivastava Committee (1974)7 suggested that a nation wide network of

efficient and effective services suitable for our conditions, limitations and

potentialities should be evolved. Steps should be taken to create bands of Para

Professionals or Semi Professional health workers from the community itself to

provide simple protective, preventive and curative services which are needed by

the community. Between the community and the PHC there should be two cadres

of health workers and health assis~ants \supervisors.

This Committee (Srivastava Committee) recommended that "the PHC should be

provided with an additional doctor and a nurse to look after the maternal and child

health services. The possibility of utilising the services of senior doctors at the

medical college, regional , district or taluka hospitals for brief periods at the PHC

should be explored. The PHC as well as taluka, tehsil, district, regional and medical

college hospitals should develop direct links with the community around them, as

well as with one another within ~ total referral services complex. The Gol should

constitute under an act of Parliament, a medical and health education commission

for coordinating and maintaining standards in medical and health education on the

pattern ofUniversity Grants Commission."

7 Government of India :,Report of Study Group on Medical Education and Support Manpower" ('Srivastava Conunittee'), D.G.H.S., New Delhi, 1974.

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The Srivastava Committee also recommended "Reorientation of Medical

Education" (ROME). The recommendations of the ROME by the Srivastava

Committee was processed by the sub - committee of the Ministry of Health and

Family Planning. ROME was initially implemented in 25 selected medical colleges,

however, it was implemented in all medical colleges recognised by the MCI. Under

ROME three PHCs were to be adopted by each medical college where

undergraduate medical students would be posted for a period of one month and

exposed to management of manifold community health problems and- study the- role

of environmental, socio-economic and cultural factors in disease causation.

? The Alma Ata Declaration8 enjoined the concept of primary health care, which

advocated among other things, community self reliance and involvement in health

services decision making. National health administrators were asked to provide

integrated health services - curative, preventive, promotive and rehabilitative - to

those who have little or no access to health care.

Among the most significant contributions of the Alma Ata Conference were

redefining health, defining the fundamental principles of health development and

Primary Health Care.

Health was defined as "a state of complete physical, mental and social well being

and not merely the absence of disease or infirmity, is a fundamental human right

8 World Health Organisation and UNICEF (1978),Primary Health Care : Report of the International Conference on Primary Health Care", Alma Ata, USSR, Geneva, WHO.

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and that the attainment of highest possible level of health is a most important social

goal whose realisation requires the action of many other social and economic

sectors in addition to health sector."

The fundamental principles of health development as embodied by the Alma Ata

Declaration were :

• The Governments have the responsibility for the health ofthe people .

• It is the right and duty of the people to participate in development of

health both individually and collectively.

• It is the duty of the Government and health professions to provide

relevant information to the public on health matters.

• Development of health is to be based on self - determination and self -

reliance in health on the part of the individual, the community and the

Nation.

• There is interdependence of individuals, communities and countries

based on common concern for health.

• There should be more equitable distribution of health resources within

and among countries.

• There should be preferential allocation of resources to those in greatest

social need and the health system should adequately cover all the

population.

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• Emphasis must be on preventive and promotive measures well

integrated with curative, rehabilitative and environmental measures.

• There is a great need for relevant bio-medical and health services

research and speedy application of research findings.

• Social orientation of health workers of all categories to serve the

people properly would be important.

• Development and application of appropriate techriology through well

defined health programmes integrated into a country wide health

system, based on primary health care and incorporating the above

concepts would be most vital.

Alma Ata Conference defined Primary Health care as "essential health care based

on practical, scientifically sound and socially acceptable methods and technology,

made universally accessible to individuals and families in the community through

their full participation and at a cost that the community and country can afford to

maintain at every stage of their development in the spirit of self reliance and self

determination."

The Alma Ata Declaration has further stated that at least the following should be

included in Primary Health Care :

I. Education of the People concerning prevailing health problems and

methods of preventing and controlling them.

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2. Promotion of food supply and proper nutrition.

3. Adequate supply of safe water and basic sanitation.

4. Maternal and Child Health care and Family Planning.

5. Immunisation against the major infectious diseases.

6. Prevention and control oflocally endemic diseases.

7. Appropriate treatment of common disease and injuries.

8. Provision of essential drugs.

Government of India and Medical Council of India adopted a plan of reorientation

of medical education 9 in 1977 by involving medical colleges in adopting three

PHCs where undergraduate medical students would be posted for a period of one

month and exposed to management of manifold community health problems and

study the role of environmental, socio - economic and cultural factors in disease

causation.

The Report of the Working Group10 on "Health For All- An Alternate Strategy"

made recommendations for significant changes in the entire health services system

based on the socio - economic and political needs of the country. Greater emphasis

on cultural, social and moral aspects of medical profession has been suggested. The

group believed that over education is counter productive and that man and

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10

Government of India (1970)Report of the Committee on Medical Education (B.P.Patel), Secretary, Ministry of Health and Family Planning, Delhi ICMR & ICSSR (198l).,Health For All - An Alternative Strategy", Report of a study group set up by ICI\.1R & ICSSR, Indian Institute of Education, Delhi.

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environment to be presented as a bio-cultural science m an inter-disciplinary

holistic approach. The document reflected a change in the thought process of the

policy makers.

The post independence era, in the wake of providing health facilities for all realised

the importance of integrated health care delivery system whereby various elements

of the health care system- viz. health programmes, health services and other

structural and organisational aspects of the system as well as the. complex inter play

of external factors was not to be viewed in isolation. The foresight and forethought

of our health planners enabled the establishment of our health care system to cater

·to the needs of the people. There is therefore, a need to see that how far these

policies and guidelines have been implemented and benefited the common people.

For this purpose a compreh~nsive review of studies I literature has been

undertaken in the following chapter.

STUDY OUTLINE

This thesis has been presented in the following sequence.

Chapter one has dealt with the introduction to the study topic i.e. health care

administration and the impact of various committees on its evolution.

Chapter two contains the review of the literature related to the topic.

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Chapter three deals in detail with the objectives and research design of the study.

Chapter four deals in detail, the profile of the study area where a comparative

study of Una and Shimla districts has been undertaken especially with respect to

physiographic and socio-economic characteristics.

In chapter five, district health organisation, its structure, staffing pattern, the

various inter linkages along with the inter sectoral supports and community

participation in health care delivery are discussed.

Chapter six elaborates the community needs and perceptions. The main focus is

on the attitudes of the people towards health and hygiene, awareness levels and

their health seeking behaviour.

Finally chapter seven identifies the emerging issues and gives suitable

recommendations for interventions in the health care system.