Questioning Prevailing Paradigm in Public Health

Dr. Ritu Priya: We welcome you in this W.S.F. session title Questioning Prevailing Paradigm in Public Health putting people in center stage. Why is it that we are having this session in the fag end of the World Social Forum, where there have been a fair number of discussions in WSF and two whole days of discussion here on 14th & 15th. People in the three collaborating organisations all feel similarly that while there are a number of critique of the public health system and recognisation of its limitations there is need to question even the questions been posed today by those who recognise the problem and want to do something about them. The kind of limitations that are clearly recognised and well documented attempts are been made to deal with them. If I put them broadly one of three kinds. One is about the cost and therefore lack of access of the poor. And lack of availability in areas distant from towns and large village. So availability and access is one problem which is recognised. The second is the problem of .......................... priorities not been according to the majority. That is the 2nd problem and therefore the issue become as a issue which need to the dealt as priority issue. The third is an issue which is least talked today, but which was very well articulated in 1970s and 80s, which is saying that we are talking about inhalation of the lay person from the expert and technocrat and they have taken over the control annihilating the common person loosing control both over their life in different spheres. Now that is the third issue. What is most talked about today is the 1st and 2nd issue and the third is hushed in the background. If at all it is talked about it is talked in terms of need to community participation. And that participation is seen much more in terms of its implementation then bringing it centrally into decision making. When it is talked of discussion making it is talked of terms of virtually having one or two people of those section in decision making for e.g. Panchayati Raj Institutions. But our understanding is that it is inadequate to address i.e. it cannot be addressed separately all three separately. They are linked issues. And you cannot deal with one without dealing with other. And three issues can be dealt effectively only if we question the prevailing paradigm that underline the development of these particular prospective. If I very briefly illustrate what I am saying. First about cost and access. If something one talks about both cost and what kind of fund is required if public sector can foot the bill. The whole demand for increasing the Public Budget for health from 0.9% to as now govt. says should increase to 2% and demand for increase to 6%. Our understanding is that even that is not an adequate mechanism. Even if you have a budget of 6% but if same paradigm continues if will not really be socially objective. So if the funding goes with improved privatisation and the priority of the poor are taken even that is not adequate. The priorities today are communicable diseases for e.g. if you take the global fund it is for T.B, Malaria, AIDS all of which are priority areas in Public Health problems. And yet if that is not adequate how these priorities are dealt with, is also to be looked at. Now that is where the third question comes in of how is it that you decide which are priorities measures to be taken and what is the delivery system going to be to deliver those. So what kind of technology and what kind of persons are actually going to deliver that is a separate issue, which is deals more with the paradigm of development itself. And that is linked to access and the appropriate list of context of majority. Now putting all three together we feel is what questioning paradigm is about? We already had two workshops in World Social Forum, one on AIDS and the one on coming of the aged, which again fall on this broad framework actually. Both of them questioning the prevailing paradigms, within these two specific areas. What we want to do in this workshop is to take out more broadly the overall health service system issues. So the first presentation that we have from the Centre of Social Medicine and Community Health. Back on structural adjustments and health sector reforms back on health service system as a whole. The second one you will see is about the pulse polio program so that is our specific program and the kind of issues we have. The third one is about the T.B. programme and docs. And all three will cover the range of issues we have in present paradigm of health sector development. The second part deals with what are the alternatives we have to offer. What are the exploring prospective and what direction we have for the alternate exploring prospective. We hope after that we will have time for discussion and drawing much more inputs from you.

Now I introduce Dr. Ved Dhar for most of us he does not need an introduction. He had been a pioneer in the field of preventive and social medicine in the country. We look up to him as an inspiration in the kind of critique we seek in prevailing paradigm and towards an alternative we seek in guidance.

Dr. Ved Dhar : Thank you very much. Actually I had been highly sensitive to time factor, and I always try and make sure one has to live with it. The topic we are considering in part one is accountability of prominent international institution......... V.P.P. as national policy makers as health sectors....... in interaction with globalisation.......... really needs. And unless we take the right type of background we are going to get away in the flow of thinking which is my phase absolutely univalent to our situation in developing countries like India in particular. So when we talk about Health the primary determinents of health are nutrition, environment and life styles. And health services of our system do not do anything in these areas. In fact Dr................ has already rightly condemned these vital health services. Because in our country the water supply is not fit. Even in capital city like Delhi, although we say 90% of the composition is covered, it is not covered. I always say that there will be a safe water supply in India if nobody buys water. Therefore if that situation is going to come, I am not willing to accept that we have water supply safe. Sanitation lives without the better? Nutrition ...... we have plenty of food but it is a question of reaching the food to the right type of people, on time. Therefore what I feel is that basic necessities of health like sanitation, food, minimum livelihood, environment housing have been taken care of western world already. And therefore when they talk about health they talk about their concurrent issues like high cost of medical care. And when they talk to us and admit their advice, they naturally speak something based on their experience, and like a fool we accept their viewpoint. So request of mine to you is to come on ground to see what is in our country, and go ahead. This is the first point I wanted to make in this background. Second point is long time last thirty to forty years we had had been talking about community participation. Lots of things have been done. Community participation had been defined and if you see on ground at grassroots then is very little of so called community participation. And advocating it for long time, now is the time to ask people to participate in our programs. This is the only way in which we can satisfy the local base. When we have already taken the path of decentralisation, we must be honest to that. We must develop a future to see that not only Panchayats but Gram Sabha also become strong enough. Therefore our duty really is to empower Gram Sabhas and to take care of them and to build up a system and the leadership from below. And this is only in which we can represent and now we are concentrating in an independent commission. To give you only one e.g. if you see the National Draft policy. Now it is finalised. But the draft contains an entire section headed by a non-health? Environment, water supply, disposal of excreatea nutrition and? An independent commission fortunately fought for it and these chapters were eliminated from the National Health Policy. Therefore this is what I am giving as a background. Therefore whatever we have discussed I think we shuold discuss in this issue. Not that high tech cost top medical care is not our issue. But the issue is how we should lead our priorities. This is not my time to speak loud and not as to how we should define our Public Health Policies. I have written everything in this 260 paper showing the tactics of preventive Public Health Care System in India. How the changes have taken place? And how we have accommodated ourselves. I am sure of course that all our progress has been inspite of government. It is because of the people I am therefore highly optimistic about it. And it is matter of time that people will take over the government. Therefore with this I conclude.

Dr. Ritu Priya : We need to also introduce the organisations which organised this workshop. Now Swasthya Panchayat is the working group within LOKAYAN. And Lokayan is an action research organisation working on the issues of democracy and decentralisation and development. Swasthya Panchayat deals with the Public Health kind of issues there. State of Social Medicine, Community Health at Jawaharlal Nehru University is a teaching cum research institution, and globalisation and social policy programme is a project of two institutions i.e. University of Sheffield and Steckates in Finland and we have out from there to tell us very briefly about it. We have a lot of material here. Some of it is for display while some is for distribution. We pass it on which for distribution and for other we invite you to come and see and look at it after the session is over. And anything you need out of it you let us know and give us your addresses and them we can see what we can do about it.

Speaker from Finland: I am very pleased to be able to be here. I am ? from Helsinki Finland as spokeswomen herein India as no one from permanent staff could come. Now this is eight years programme on globalisation and social policy and will end in 2005. And infact it is here in collaboration with four organisations the status of all which were mentioned by RITU. The graphics and main topic of the programme. One is interplezit and explicit description of international social policy of inter-governmental organisations such as U.N. and ? institutions and T.N.Cs and second contributions of International organisations; International NGOs and other formal and global actors to global discourse in social policy and the third one is role of public. Private Partnerships in role of Health Policy. Fourth is the development of the system of Trans-national Social distribution, social federation, social tradition and empowerment. And fifth the methods and concept used by different agencies co-opted in social policies of countries to shape their interventions. And the last one is the role of international organisations and trans national social movements in shaping global social and health rights. And the discussed problem is discussed in this channel. Global social policy channel published since last three years. Three times a year. And Kaff ? is taking care of all after the end of each channel as to what is going in Social and Health issues in U.N. family institutions and so forth. And there is a description here if someone is interested. Then there is organising of Cuff international Cuff seminar. Next will be the seventh Cuff seminar which is to forum the rights to influence the health social policies in Sep. 2004 in Canada organised by the ? university in Canada. And come the publications.............. ? the first one is one Social Governance. The second one is about public private health partnerships in U.N. by one of senior researchers. And the third one is W.C.O. agreement on health by ................. ? and then in coordination with those working on field and sending Newsletters and information. Thank you! Are there any questions ?

Dr. Ved Dhar : I think now we will go to the first presentation. And this is all on structural adjustments program on health in India and S-East Asia. I would request the speaker because of the time constrain to first present the recommendation and the conclusion and the supporting thing should be done only if the time permits. I think we should take about ten minutes since I want the discussion to be encouraged.

Interruption : But for the first session half hour has been allotted.

Dr. Ved Dhar : Half hour. But we cannot have half an hour. In case half an hour is given then I am not responsible for time. I have no objection. O.K. 20 minutes. I will give a warning after 15 minutes and 20 minutes is time out.

Dr. Rajeev Dass Gupta : O.K; I am Rajeev Dass Gupta from J.N.U. I will straight away to the point after the guidelines from the Chairman. Now these are the preliminary findings of a collaborative project we had been working on for the last 3 years called Monitoring Shifts in Health Sector in South Asia. With partners from S. Asia which is India, Bangladesh, Shri Lanka and Nepal. And two European partners from Netherlands and Finland. And the broad objective of this concept adoption has been to documentation in health sector in South Asian countries in the context the reform process and the structural adjustment programmes. Now first I will give a very brief recount of what has been the experience of Bangladesh and Shri lanka since they are not been represented here, and then we will move on to the Indian situation in detail and link it to the main theme. Now the overall picture in Bangladesh show a decline in mobility (?) particularly in rural areas. Now in group death rate and natural mortality rate there is a narrowing of differences in rural and urban segments. But there was no improvement in material mortality rates during the last ten years of reforms. But what is of concern in Bangladesh is that female infant mortality rate remains higher and also it is very closely related with hardcore rural poverty. So that is where the challenge lies. Now overall as far as malnutrition indicators go in Bangladesh they are on decline to go slow. And the immunisation programme that show a successful level actually shows the coverage of 5% decline during the structural adjustment program. Two diseases which the Bangladesh partners have focussed. One is pulmonary tuberclosis which was on one the decline till 2000 has started showing an upward trend and incidence of acute respiratory infections have gone up through its fatality rate has declined somewhat.

Now the broad trend in Shri Lanka is that trends of all is more or less positive not to recount all these indicators. However again the concern is about Malaria and Tuberculosis in Shri Lanka where these are on the rise. Though the immunisation coverage has been progressively going up yet in last one to two years they had been experiencing measles outbreak among older children. So these are their areas of concern. As far as India goes is concerned they have four presentations. The first on mortality and mobility. The second on health services infrastructure and health manpower. The third on access to utilisation of health services in terms of consumption patterns. And the fourth a qualitative study on the impact of decentralisation of Public Hospitals at the district level. So the first presentation is mortality and mobility.

Anchor: Thank you Dr. Rajeev Dass Gupta. And Sanga Mitra is from the Center of Social Medicine and Community Health, J.N.U. Part of the project Rajeev has talked and referred to last time has been done at National Level title "mobility and motality" on basis on survey .........................? Now looking at motality the national level scenario that we suggest any change, we see that actually no change has taken place. But if we go into the sub-regional differential we see that even left ruled states have shown on increase in the death which naturally happened to be the North Indian State, Eastern States and Coastal State like Goa, Maharashtra, A.P. and Tamil Nadu. Looking at the children aged 4 yrs. There has been a fast increase in children in the urban areas. On.................. contrast to rural areas. And similar picture emerges for adolcent. And it has.............. ? increased in terms of rural urban, coming to I.M.I. At the national level it appears to have reduced. But again at the same national level there have been certain disparity which has been reflected very shortly with under developed states again a very wide demarcation we make in northern states and the southern states. Then Meghalaya, U.P., M.P. very sharply show the I.M.?. above 85.

If you look at P.M.O., at national level which help to show reduction between the two type ............ ? I am referring to the National Health & Family survey which we dealt here in 1991-92, 93 in second survey done during 98-99. But through the 90s................. globalisation. But difebrigated figures suggest there are disparities which are sharply reflected in terms of the state and medium margin state in N.E. Therefore if we look at the scenario which emerges between I.M.F. and C.N.F. ? both sum to have increased in Northern States, North eastern states and Goa. And let me come to the reflection from ? motality. Although the survey suggests that has been increase from 424 deaths to a hundred thousand life deaths in the first phase. But it also suggests that upper ......... ? has increased to 540 for second ....... ? But the statistical insignificance of this increase because of the sample variation over different states is suggesting that this increase is not impacting upon the depression. If we look at the ? This is in the scenario which emerges from the data survey and set. Most states although show an increase as per ? States such as Manipur, Madhya Pradesh, Nagaland, Meghalaya show an increase in 11,000 plus. If we see more developed states like Karnataka, Andhra Pradesh, Gujarat reflect an increase. If you look at in terms of the degree surprisingly these best developed states like Rajasthan and U.P. should not have decreased. Then if you look at fighting against malaria again the most modern state has shown a decrease in terms of hundred thousand person suffering from malaria. Similarly pattern is reflected here in contrast of backward states to the most developed states. If you look at the increase we see Andhra, Karnataka, Goa, Maharashtra reporting an increase vis a vis Rajasthan, Uttar Pradesh, Madhya Pradesh reporting a decrease. And a upper hand is given to most north-eastern states depicts an increase of 13,000 + plus more people who had been suffering in this tenth plan. Similarly Gujarat plan which is more developed shows a negative growth. As far as child mobility, SAVY allows us to look at AIR fever and diaghoera. We see that there has been an increase in two types of ? if look at the figures almost doubled. Particularly not many children who have received O.R.S. for diaghoerra have reduced from 31% to marginal. Immunisation of course shows an increase from 35% to 42%. And mark states can be J&K, M.P., Arunachal, Assam which reflect on the decrease. I would just like to sum in terms of seeing that very little mortality. The national level adult mortality remains unchanged. The under five mortality apparently reduces. The ........... ? so it remains unchanged. And other said national level governance disparity ? which needs care. And mobility in adult and child mortality have three indicators which have been chosen. Therefore the emerging issues which come out. Looking at national level policies and programmes the very basic infrastructure and the very access and utilisation of care and what is happening and perhaps vis-a-vis community participation vis-a-vis sensitisation. I think I will end here. Thank you.

Anchor : Now who wants to follow ?

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