Health care systems in transition III. India, Part I. The Indian experience.

Indian society is distinguished by marked cultural pluralism and a relatively young population that in 1999 has grown to one billion. Its regional and economic diversity and complex social structure and extremes of poverty and wealth make planning a challenging task. Developing economic self-reliance, tackling poverty and building a strong welfare state were major commitments of the newly independent India. After 1949, a conscious effort was made to invest in education and health services. Constitutionally, health services were the responsibility of the provincial states. The role of central government was to define policies, provide a national strategic framework, financial resources and specified services such as services for people crossing international borders and medical education. In the 26 States and two Union Territories, districts were the operative units wherein the population of about 1.3–1.5 million was served by a network of Primary Health Centres (PHCs) and sub-centres organized as a pyramid with the district hospital at the apex. Health sector planning had two major thrusts: the first, to build an infrastructure to provide basic medical care, maternal and child health (MCH) services, health information, education and referral services; and the second, to develop specific national health programmes to control communicable diseases, provide family planning services (FPSs) and control severe forms of nutritional deficiencies. To carry out these tasks, a support system had been developed which included education and training, research, health information and monitoring, drug and equipment production, etc. Unfortunately, India’s grand plans for health sector development began to be distorted when the overall planning process shifted emphasis in the 1980s and a growth-centred economic approach began to take root in India as in other world economies. This economic philosophy, which was premised on a ‘trickle down’ view of the benefits of economic growth, resulted in the growth of urban centres which overshadowed the development of the vast rural hinterlands and which themselves were left to the mercy of feudal interests. Thus, though annual growth rate rose from 2.8 per cent in 1961–1966 to 5.7 per cent in 1980–1985, significant regional disparities have become more visible. To tackle the disparities within the health sector, under cover of the National Emergency in 1976, extreme coercion and force was used in an attempt to control population numbers in order to deal with the developmental crisis. The failure of India’s vertical programmes, such as the National Malaria Eradication (NMEP) and Family Welfare Programmes (FWP), generated pressures for modification of these vertical programmes. By the late 1970s these programmes were integrated into the general district health services, yet they retained their predominance in terms of policy planning and funding. Consequently, they subsumed the resources of the general health services and undermined programmes such as tuberculosis control and MCH services. Despite signing the WHO Alma Ata declaration in 1978, distortions in resource distribution between rural and urban services, preferences for hi-tech and specialized medical care over primary care, and a shift of priorities back in favour of the social élite, in terms of both problem identification and infrastructure growth, have remained unchanged. The impact of this early development varied. During the 1980s the comprehensive PHCs advocated by WHO were modified into selective PHCs, as proposed by critiques of the Alma Ata declaration. By the end of the 1980s, a substantial health service infrastructure had been developed. The number of PHCs had increased to such an extent that their coverage could be reduced from 100 000 to 30 000 people, and the sub-centres now covered a population of 5000 instead of the earlier 10 000. Each Community Health Centre, the level below the District Hospital, covered a population of 100 000. The medical schools and specialized hospitals were mainly located in the urban areas along with their municipal services. Substantial numbers of professional and paramedical personnel had been trained (Table 1). In addition to this, institutions of traditional systems