Questioning Prevailing Paradigm in Public Health

Interruption/Speaker: In the lines of the mortality orbit situation. If we look at what is happening to health infrastructure and manpower. The study is divided into two periods. The 1980s and 1990s. 90s when the structural programme came along. Next slide. Now the study focuses on ten major states. Two each from east, west, north, south and central of India and we have used the government data sources. Now all the detail data is available which can be taken up during discussion. I will just give you the broad features of what has been happening. Specially comparing the 1980s with 1990s. O.K. And the analysis of the two sets. One is what is happening in Rural versus Urban and what is happening in Public Sector versus Private Sector. So that is the basic framework under which we take it up. Now what has been happening throughout the 1990s has been the growth of the community health centres beginning from 1985 with a big thrust. But again through the second half of 1990s some states started showing some stagnation. Now this initial rapid growth in the 80s is because of the thrust in the sixth plan area to build up rural structure. Now what is important is that in the second half of nineties some states started showing a stagnation and decline. A decline particularly in terms of deaths per hundred thousand population. Now it actually showed aerial decline. Now see the important thing. The important thing is just let us draw your attention towards important things. Now the Sub-center i.e. really the grassroot organisation. In terms of 100 thousand population it falls from 60/lakh to 43 per lakh. Now this is of real concern. The second concern is the stagnation and decline in the rural dispensaries and the rural hospitals. And this is in fans across the states. O.K. Next Slide. In however decline in urban dispensaries. Now this is only numbers. Let us convert it in terms of population, the decline is all that more. Now what has been happening in 1990s is that few states particularly Andhra Pradesh, Maharashtra, Gujarat and Karnataka to some extend actually show an increase in hospitals in urban states. And all other states actually show the stagnation. Now in 1980s there had been a growth in Public hospitals which got slowed down in 90s and converses the relationship with Private hospitals which actually grow in 90s which is the Structural Adjustment Programme. Now if we look at the hospital beds which is the last chunk of the hospital bed services. Now the first thing noted among hospital bed is that in terms of hundred thousand rural population there is a decline in hospital beds and the similar trend in urban also. If we look at this slide, the total aggregate figures. The decline from 49 to 44 in two decades. This is the decline. Now look at what is happening to beds in private hospitals. Now you can just work out for yourself. Here the Public sector shows a decline. The private sector changes from 19 to 26. So there is a complete reversal of trends. Now what is happening in Health manpower situation is a) The quality of ? is very poor. b) The number of doctors have been increasing. The entire production of doctors have been increasing. More rapidly then in 90s. More in the states with Private Medical Colleges. But the number of doctors in P.H.Cs had been declining with an exception of Karnataka. So that is one thing about doctors. Now about the Paramedical health workers large numbers had been continuously trained but rarely there is no data of where in which sector there are question (?) marks. Next Slide ! Now we quickly focus on these four states which have shown increase in health infrastructure and manpower and in private society and to some extend in Public Sector as well. Now what we have done is picked up several indication in National Family Health Survey. Now the errors actually show you the trend in which they have been moving between 1992-93 and in second round in 1998-99. In other words this has been the trend in 90s during the reform period. Now about the two very important indicators i.e. the urban and the rural. Though there has been no change in India in National average. Yet in all the States it shows the uniform pattern of moving up. But the child mortality rate showed a decline in these states. Now in terms of discalls. Here the first two data is related to adult diseases Malaria and T.B. primarily. Again there is an upward trend. The malnutrition is either declining or remaining the same. On average on all India level it shows a decline. But two of these states relatively a more prosperous states do not manage to achieve a decline in these indicators. Now even under diahhorea. All these shows a consistent increase in trend. Now these are actually rates not just cases. Now the last two indicators is the proportion of people who are actually accessing health Care Providers for the treatment. For actuate Respiratory Infection and diahhoreas. Though have the trend is; there is no clear trend. But in some cases there is a right growth in the infrastructure and manpower, which not much growth and increase in access of health care. I will stop here and we will take up other discussions.

Dr. Ved Dhar : Now I think this is an important issue and this presentation is open for discussion.

Question 1 : Now in this case study ................... ?

Dr. Ved : Ps. be louder.

Audience: Not audible

Dr. Ved Dhar: As I told you these are preliminary findings of other components of immunisation and the impact of privatisation at the policy level. Now this has translated into policy document in the process.

Question 2: What was the impact of globalisation on Mortality Rate. Men versus Women.............. ?

Reply : See as far as infrastructure is concerned and utilisation of infrastructure goes. The government data is not available gender wise. Even for utilisation there is a separate paper from N.S.S. of data where we will demonstrate as to what is happening in this content. Next ?

I would like to make one observation. General observation. Lot of data we have presented with regard to health statistic to infrastructure and other associated things. What I think as I said earlier what we talk of health in this presentation there was no mention of basic issues like sanitation or water supply or nutrition. And I feel that impact of those perhaps is greater related to the level of health or rather than the hospital bench. Therefore this again is an illustration as to how we are not paying appropriate attention to the major issues. And getting a kind of give and take of ? in international thinking. Another thing, I also think that terming this to an impact of structural adjustments in global context. I have worked in the department for 35 years. And just because it can be attributed just having lots of evidence on determinative of ? rather than any external process. Now this is the danger in looking at this as a result of outside pressure. Because these submissions are outside pressure. Because these submissions are outside. But here if you internalise the problem rather than externalise the problem. Then you have your own solution. And then in terms of India interventions by voluntary agencies. I don't like the word NGO, NGO is a organisation. And there are number of micro projects undertaken by voluntary agencies, which show the way out. Inactively involving the community not only at Micro level but also at the Macro level. Therefore I urge strongly to look upon the problem of our own creations rather than the external. But the question is how we react with them. Therefore let us not blame others. Let us blame ourselves. That will lead us to a solution acceptable to all. I think with this there are no further. ...............

Question 1: National monitoring of data ? ......... your details reflect malnutrition rates declining. I don't know how you reach this conclusion. Because specially in a situation which GRI, diarrohea and fever and malnutrition is declining. It really does not .........? The presentation is the tip of iceberg of what we are doing. And infrastructure says that it will very much incorporated .............. we will take it separately.

Interruption: The National Institute of monitoring bureau looks at adult malnutrition not only towards child malnutrition. And I think adult malnutrition requires important dimensions because we are looking at adult malnutrition for the first time. We have been looking at pediatric malnutrition all this time. Now we are looking at adult malnutrition for the first time. The other thing is the infrastructures. The public health institutions. Then this has already been pointed out. The proliferation and the number of infrastructure elements are not going to look at utilisation. Because in my own experience you can have any number of sub-centres and PHCs. Then there are not doctors, no nurses. The delivery conducted in P.H. institution is something of the order of less than ten per year. The number of malaria cases they report in P.H. institution from Chattisgarh is a laughable figure. So ............. ?

Dr. Ved : I think we should now come to some significant conclusion. The last thing he has given in his presentation has been the breaking down of the public health system another thing about the statistic in India is to draw a conclusion from aggregate data. Now there are so many diversion. So many diversities that I have stopped coming to conclusions. We must go down to the bottom.

............. the earlier seminar in 1989. And those who are interested can see how the debate has worked. Some more people are going to collaborate in this paper now. Dr. Ritu Priya, Dr. Anand Patkay, Dr. Ajit Das Gupta. So in course of next two three months this paper will emerge. I shall also say that whenever in Delhi or here whenever I talk to people that I am going to speak against Pulse Polio. I think everybody is a bit shocked and they try to check again. That shows that how much credibility this programme has gained from across the nation. But if I sort of pose problem statement. The phenomenon which I am trying to address in this paper then you will see the other side of it. The Polio eradication program in India as part of ...... now it is very important to understand. Dr. Dev Dhar has cancelled the ? to blame other. But I think the weight of my entire paper is in blaming others. So the polio eradication program in India is a part of the Global Polio Eradication initiative. Now we have to keep that in mind if we wish to understand what was happening and what is happening now. And it started in 1995. Infact it started in 1994 in three states in the country and it went down to the National level. Those who are initiating this programme promise they promised that polio will be eradicated. If we do all that they are asking us to do, Polio will be eradicated from India and from the World by year 2000 and by 2005 AD, the world will express and certify that world is polio free and the polio vaccination programme will stop in the whole world. That was the kind of thing which was put on the table. What we see now is that this target of elimination of polio or what they are saying as Polio Virus. There is no problem with the Polio Paralysis as such. They are not bothered about that. Their target is elimination of Polio Virus. This target has been postponed now to year 2004. December they will be able to achieve eradication of the white Polio Virus. And they may perhaps be able to certify by 2007 year that world is Polio Free. They are already late. After nine years of effort all of us have seen and there is another four five years of journey in front of us. And it is finally reminding everybody practically everyone who are looking at it closely. That objective of Polio eradication will not be achieved. So this is the kind of situation we are into. So when people are still believing that it is going to achieve that is the contrast we have. Now how can we make a sense of this. They have promised the moon. After Small Pox eradication this was the big effort of the Scientific Technical Establishment of the World. Is it possible for us to suggest something positive in terms of achieving this goal. For example not taking such expensive costly experiments in future. So this is the problem I am trying to deal with in this paper. I should also say right in the beginning that in this year 2004, we will see further intensification of Polio Eradication Program Activities. We all of us perhaps have already seen on T.V. everyday the entire nation is been extorted (?) that we are not bringing the children to Polio Booths. We are not taking the drops. In one way the two great dignitaries of Bollywood are trying to shame the nation saying that you are not listening to what we are saying to you. It is not only this but the Chief Ministers of the States and there are thirteen states now where Polio cases are still been reported. They will be directly accountable. So they will be asked as to why you still have Polio Cases. So the District Magistrates in the district will be directly responsible to ensure that such things do not happen. Things on which they have no control. But we can take all that bad things and that is another phenomenon we need to understand. How does this happen that CM or DM of the state rather then the health establishment are trying to be accountable for this and are answering sorry. First I think I have to talk about myself as to why I am talking about all this and I should explain all this. What is the purpose of this background and generally when a critique has a policy or programme then we sort of have a go at a equity show, where some people are getting services some people are not getting any services. Sometimes we are trying to criticise the market sector government sector sometimes we criticise the drug companies and pharmaceutical market sector doing that and then we sort of a government policy blame on inefficacy of government system not doing well with bureaucracy etc. etc. And sometimes we blame the private sector or the public sector. These are the kind of critique generally which are on the table which we see as health policy or Health Programmes. My case study of the Global Polio Initiative is a story of the current flaws of Globalisation and Global Governance as applicable to the health sector. So how global governance is trying to govern in the health sector by Polio Initiative Programme I am trying explain that I think in my point of view it is important for everybody to understand the real story. The second...... then I have also started talking about all these things then people start searching Oh ! we also have these questions in our mind but they have never been articulated. Then people start asking the same questions which I am trying to ask in this paper. Now I am also trying to illustrate that in this Polio eradication initiative as we have seen in India the private sector, the civil society, the bureaucracy, the politician, the grass root participation and all are coming together to make sure that the children are getting the drops. So it is the kind of model for participatory health delivery. Again this is a very very questionable kind of model and I am trying to illustrate this by this paper. And what remains unrecognised in this is that behind all this package of participation is the scene actors calling these shots and using the strings. Again some people say there are good faces of globalisation while other say that there are bad faces of globalisation and this initiative is taken as the good face of globalisation. What is been told to us in 1968 that there are 3 lakh 50,000 cases of Polio Paralysis in the world. So every year these many children were getting crippled, and now it is claimed that we have almost reached to zero. Now crippling of the children by Polio has stopped. Therefore this global initiative in which a large number of international organisations, large number of countries have worked together to achieve something, hence this is a good face of globalisation. In this paper we are trying to question all that. And we are also trying to show that what they are trying to achieve is to set up a network of surveillance for the emerging biological diseases of the world. When these deceases were emerging in the last twenty years because of many reasons. There too the C.D.C. London team would come and pick up the samples. Now it was a very difficult process. Now by this Polio Program SARRAC etc. will make sure that these laboratories are established in other countries including our country. In our country nine laboratories are established under this programme. So initially they have a check for the polio but later on the surveillance can be used for all kind of emerging biological diseases. Also there is a concern in their minds it is also possible for manufacturing various kinds of bio-terrorism. So there is a whole laboratory containment program now whereby they want to make sure that all the laboratories are in their eyes. So I am not saying this is a bad kind of endeavour. Everybody has a right to its nation's security. So it is the larger programme of Bio-defence by United State Government. And that is the real motive and not the. The last point in terms of my paper is that it is an entire global governance in bureaucracy and quality which has embarked into a programme which fails to deliver. Now it is not possible for them on their own to come out of it. Why is that a large number of expert doctors in this country, a large number of Pediatricians, large number of competent civil servants, politicians all are facing this problem. What to do about this. They are not able to come out of it. So there are lots of reasons because of which they are not able to see out of this entire game. An independent citizen action is required to say that do not do this and say that the King is Naked. So these are the kind of things I am trying to do with this paper. Whether I am able to demonstrate all this remains to be seen. Anyway in terms of the facts now I am coming to the bare facts. You see in 1950s this vaccine was discovered by two different persons. There was a Sabine Vaccine which was an inactivated vaccine given intra-muscularly. Then the other oral Polio vaccine came, now used in our country. And very quickly after these discoveries America tried to use Sabine Vaccine and by early 1960s it appeared that Polio had been eradicated from U.S.A. so that was a great success. And then after the great Small Pox eradication the Rotary International decided that next thing they should do is work for Polio eradication from the World, taking inspiration from the American experiment. And in 90s the Latin American countries were declared Polio Free. By 1993 the World Health Organisation certified that Latin America is Polio Free. So that was an institution. So what happened in Latin America was that they started these National Immunisation Days and it was thought that the routine immunisation cannot eliminate the routine Polio Virus and if you have the immunisation of the entire population on a single day that is perhaps the technique which will eliminate the virus. So in 1994 and 1995 by various mechanism WHO created a whole advocacy to start this program in India. What we are trying to advocate in this paper is that WHO always knew that this programme cannot succeed in India. Despite that they embarked this program. What were the reasons for this. There were two main reasons for this. There were two main reasons for saying that's why this program could not succeed in India. Dr. Dev Dhar has done much more comprehensive survey on these and he has done much more elaboration on these issues. So those who want to go on these details can have a look into it and we can provide that. But I am focussing on two main issues. One is that the potency of vaccine was always doubtful. And we have the data now which shows Amitabh Bachhan saying you don't take vaccine. But that is not true. 50% of the children who are getting Polio Paralysis now have taken four or four plus vaccines doses. So you have to keep in mind this. WHO has also a way to justify their theory. But the fact of matter is that Polio Vaccine has less efficacy in the Tropical Climate countries. Whatever may be the reasons for that. And WHO knew that all along right since 1980s. The second thing is that the transfer of Latin American countries and their experience to Indian experience was not justified because Latin American countries have already achieved 80% to 90% of the coverage of the Polio immunisation. So that was the National Immunisation day for an attempt to finish the incomplete task. In India the routine immunisation coverage is very very low for many many states. Health Systems are weak. So WHO know very well that the parallel is not really applicable and they can't succeed. Yet they embarked on this experiment thinking perhaps we may. It was a bluff. Now we need to know that beginning with two immunisation day of 95] 96] 97, 98 and 99. WHO then told this country that look it is because of you that the entire world is suffering because in several other countries we have been able to achieve the eradication by oral Polio Vaccine using the same methods. So we just can't do with two immunisation days. So we need to increase the Immunisation days. So we sort of had four national rounds. The states which were weaker will have more than four sub-immunisation days and areas which were having mopping up rounds. So various types of supplementary immunisation activities were started in 2000 leading to as many as 25-30 doses with children in the life span of 0 to 5 years. And nobody questioned that. How can you give 25 to 30 doses to a child. There is an anxiety to the mother. Nobody asks the question how many doses should I take before my child gets protected. So that is there. My ten minutes are over. So I will stop here. If there are questions, I will answer if there are no questions I will take my further five minutes to make few more points.

Dr. Dhar : Although it is claimed about life long doses there are still a large number of people who are unprotected by Polio. Polio management is entirely different from Small Pox. In Polio management if we look at ......... ? But remember...... The second point is Polio spreads through the Thesis (?). The second matter in India is of waste Biological. Even in countries the sewage into rivers. Indian Rivers are distributing thousands of tons of sewages all over the country each day. Because of the defective system. Once I wrote to the immunisation minister. Therefore our Virus is continuously multiplying and in 2000-2001 outbreak of Polio Virus in Uttar Pradesh where over 2000 treatments were affected. This has been examined in detail by various organisations. And last and finally what we are doing this eradication for. Ultimately we see that we get rid of vaccine. Frankly we are not going to get this Polio Virus eradicated even till 2050. Unless we improve the overall system. And question is if we are certifying after two years - because we are very good masters of what we call mid-day emergency. So we may do everything at every cost and see that we have low polio output data. What does that mean that even if we certify low polio we will continue to vaccinate with the same spirit and as extension of Pulse Polio. And it is a possibility. There extension of vaccination polio after certification of W.H.O. is totally correct. Now how many years there had been cases of Polio. I am talking about the span right from the initiative of U.N. If anybody wants more details you can go through the details. Now this is open for discussion.

For Hindi click here

Copyleft. Any part of the content on this site can be used, reproduced, or distributed freely by anyone, anywhere and by any means. Acknowledgement is appreciated.

Designed and maintained by CAPITAL Creations, New Delhi. Phone 91-11-26194291