Questioning Prevailing Paradigm in Public Health

Dr. Ritu Priya : We got into second part of our session trying to look at our inspiration. We would like to share with you some of our primary inspirations into trying to look into alternate paradigms. We already are trying to lay out the problems we see with the present paradigm. What I would like to point at the end as in the beginning the lay out by three submissions today. What we are seeing is what is happening in a change in mind sets of people both at the technical level and the Public Health and the Physician level and at the lay people level to acceptance of 'think' which may actually be irrational both at the public level or the individual level. In terms of the way we look at health or the way we look at the prevention and care. All these three dimensions are getting affected in basic conceptualisation. It happens over a period of time with models of development we have. The globalisation today is escalating that at a fast pace. And what allows the people the time over space to think of that irrationality and what would be rational for their own context...... Though the concept in Public Health by converting is everything into one Universal Global Analysis which is what we do when we do an international policy making as happens with globalisation today. And once we have done that the decontextualisation happens automatically. On the other hand to balance that we talk about community participation and people's participation, which ends up actually becoming a tool for implementing what has been planned and pre-packaged and universalised by the globaliser. So the contention is really that unless we look at the understanding of people of their solution they have found for themselves and not that is always going to be the most valuable and the best. It is not that we are romanticising people and their perceptions.

But the fact that because they are living with that complexity, they understand the inter-linkages which we all in Public talk about. We talk about the fact that social, cultural, economic, political facts are very important. And we all recognise the literature in Public Health. But when we come down to actually stringent programmes and policies that somehow had been sidelined in the whole globalising gender because anybody who is dealing with Quality making and international level is not to be blamed for this. They are doing the comparison across the world. And have comparable indices (?) which are comparable, which tend to fudge and downplay the local context. Because you can't compare all the diversity across the world. So when you do that it becomes a reductionist excercise of trying to deliver some socialogical engineering mechanism and some technological solutions instead of looking at ourselves at support structures to the community who can deal with their problems. it tends to turn the table the other way round. Despite whatever discourse we may have on giving people and community a privacy. Now my contention is three points. Let me say the points I would like to raise. One that Public Health itself has two very clear faces. It has a very cohesive potential and it has a very liberated democratising potential. And it seeks experience across the Human History. The cohesive potential is very grossly brought before us. And what I would call a hard cohesion in say in Nazi Era in camps in which doctors were instrumental in research on patients in dealing with the kind of human being ..... (?) Much modern example of that is the soft Annihilation (?) we had during the Emergency in India. These are very rarely recognised as human rights violation as cohesive measure. But is more recognised is the self cohesion of the Model which we adopt today. Where inherent in those becomes the Victim. So the poor who are victims of the Social Context which people talked about in the context of (?) today, are the ones who are poor, because they are illiterate, because they are ignorant and therefore we have to educate them to do the right thing. All we have to have a Supervisor to see that they do it right. We have enough amount of literature showing what we often do in economic conditions in which they live in the constraints of those. And sometimes also they do things which are more rational and actually more effective for them then would have been the things in the proposal. But despite that literature what we carry on doing is blaming them. Even though we may be very empathetic to them. For e.g. the AIDS discourse today. We see that poor is the most vulnerable. Yes! It is because of migration. Yes ? it is because of poverty and its conditions and cause. But yet it is the behaviour of the poor which is transmitting, rather than the fact that is also the other side. It is the consumerist behaviour and the other sections of the society. it is the way of recognizing. it is just not Africa, it is U.S.A. as well in so called forefront of epidemics and continues today despite being affluent to deal as similar to large parts of the third world. So if we want to forget that part of the story and only become blaming the victim. This is one kind of thing which I feel needs a caution. Then when you use that what you are actually doing is trying to manipulate culture and not education. You are trying to understand their culture and them to behave. And that again to me is a kind of culture cohesion. But then if you deligitimise their own experience and their own knowledge base. Now that is a much larger cultural cohesion which is happening today and has happened over the last century when they say with the kind of Welfare Model. When you say the Model, Science, Technology and development models offered to us by the U.N.D.P. etc. are the only models with reference point to the rest of the world, to follow. And if they do not do it then they are underdeveloped countries or underdeveloped societies. And those who do not accept those ......? offered to us of literacy and human development in it. You have literacy and the literacy is equated with knowledge. Which means that if we look at how they started to construct human development. They started with knowledge, health and inputs. And these are three which are absolutely rational. These are the three things that go into the well being. Whether you have got the knowledge to deal with your problems and you have got the physical capacity to do so. So there is Health, Education and Income. But what can be converted into Human Development Building ? It becomes; the knowledge becomes literacy. So if anybody is illiterate their knowledge system is delegitimised. If you are talking of health it becomes legality (?) So quality of life, mobility level is not the issue. Mortality is the issue and if you are looking at the income then you are looking at the household income and not looking at the relationship between the classes and between the household. You are looking at the economic terms in terms of individual household itself. And none of it can be denied. people want to see today. They must be educated. They need health care and must be able to survive better and must have better incomes. If the people are not getting any of them then what I am saying is that you look at it and make your markers of development; human development. That is the problem that I have. Then that colours, the way we choose about health services or education or knowledge or how do we create livelihoods. What I am saying that if we do not look at how we do it and only take these as in points. Then our scope and health become; do we have polio or we do not have polio paralysis. But how we are doing it. What else we are substituting it in the process are issues looked into. That is one part of the story. The second is about what are the alternative ways of looking at these problems. And I think if we can centrally situate people's perception and people's virtues and I would like to differentiate between perception and virtue. Perception is what we are today looking at today. And lots of literature on that and lots of studies which say as to why people want to go to a particular program. Why they wish to go to the private and not the Public Sector. That is the perception which helps us to manage and make people more community oriented. To we that is a very professional and limited way of improving management of already planned programmes. If we want to rethink the way we look at health services we would then have to look much more at World views of people who are actually at the receiving end of our programme. So these two I would like to illustrate with a study. I don't have the final answer of what are the prospectives. But what I am asking for is if we start looking at our understanding of the context. Though people's perception of their own content and their analysis of the world and the way it is relating to them. Secondly of World views which have to give that principles of building frame works. It is not that they have all the knowledge base and the expertise of modern medicine. What are principles for us to construct the strings social frameworks. So providing the benefits of the technology one has to offer over any other medical system has to offer. Modern medicine is not the only medical system. We have others which are fairly recognised today. But how we do we think about it ? How do we relate work with it ?

New Speaker : For me it is a very early expression. And what I am sharing is what I have learned from a group of Dalit construction workers coming from Rajasthan to Delhi to work. Do gives me an insight into how perception which we see as coming from a limited context with a limited learner's base helps me understand and explains me some other things which I am not able to otherwise. Just to take an example from categories been discussed. What we see across in lots of macro data is yet mortality is very markingly declining. And that is a very important indicator of improvement in health stages. But what we also feel to have in our content is there is no can content (?) increases in height . That is an experience of most societies in the world that as development has occured and health status has improved, height has improved simultaneously. This indicates that mortality improvement happened there with quality of life. And the kind of material people have and nutritional improvement in nutritional status. And in our content we do not have any improvement in height but decline in mortality. How do I interpret that ? I would interpret it one in terms of inputs of modern science. Then possibility is that they have got a more stable source of livelihood. They have got a more stable food base and therefore a just subsistence level of food to keep people alive. And therefore mortality declined. Why levels remain low ? We see from atleast upto 1980 to improvement of happening at almost the same rate. And there was step decline in mortality with stable livelihood and food security base. What happens over 1990s is the depletion not entirely on necessarily of actual user but of the stability of the users. Then you have more contractility of labourers, uncertainty in agriculture and you have all these years of drought and low agriculture produce which creates a situation of instability of livelihood over period of low food or no food which we have able to cover over the period from independence upto 1990 through our democratic processes. Democratic political processes, which for all their limitations did not leave to improvement in lives of people and when we did this research with the construction workers with an idea that modern medicine and modern science did not have anything to offer and was not appreciate for these reasons etc. etc. These taught me that yet modern development has given us a lot. And what given the World charges in Social Content. Whether they had been able to get out or whole nature of untouchability or Dalithood they had been living earlier. The very stark loss of dignity which they had. It is this change in their social content which they see as an improvement of their well being over the years. Along with that comes the improvement in livelihood because they were able to latch to modern development sectors like construction. If they had only remained in agriculture they would not have achieved this. So there they are at the bottom of it. They are there as unskilled workers. So in their perception there is an improvement because they are out of the symbols of untouchability and lower castes. And within the system there is the possibility of moving to the highest levels. Socially and this is the major improvement and that to me is also a significant indicator of the even though limited benefits democracy has been able to give to the lowest of our Section. When we see now in 90s the reversal of that process. We now found anti-mandal agitation, anti reservation agitations and lot of much more questioning we had from Independence onwards which one could see as we got out of rational movement and served us as people's movement is now lost. And what is supposed to be our response in a structured adjustment in our economy or in our health systems to help health reforms. Rich are only advancing the Anti Democratic process further and not the democratic process which we are able to build. So in the 1990s we see the quality in our society and within the health sector we have already seen that in the changes within the health sector policies. Now examples of what is we their understanding which gives me the true touch. They talked about their life, how do they see their life ? How is it different ? how do you see your health ? Has it changed ! Over the last fifty years. They were very clear. Social well being has improved but health has deteriorated. To me that was a puzzle because we had been told that if well being improved, the health is going to get improved automatically and that will be the radical understanding. But that was not how it was. And then on further interaction we understood that for them well being was more of a word as social well was improved. Dignity had returned to them. And youths had collective entities. And livelihood had established to some extend. What they said is that they have lost on the nature of Social Relationships and human relationships. What was within them and their group within their families, within their kinship and the kind of human relationship they had with others within the village. The kind of human relationship in terms of sharing, caring and interaction which is at loss today and that too according to them is a negative even on their health. Because it was Social Support Structures which get them going even for the period of low resources. And that sharing is what allows them to continue but is lost today. Secondly they told much more about the fact that there more people now who are cheating, who would be more violent to have more conflict and so on. So that is one part of the Social Relationship. The second they say is that the automatic resource base they say in terms of ecological resource base, which they had not been able to form is the forest where they went to graze their cattle and so on; which is lost today as has all been taken up by modern agriculture. So there were these kind of future they would see. Now why they call their health as poorer was because they actually saw their heights were declining. Now one could visibly see that. Learning from them I tried to take the heights of different generations. And over two generations one could see that they have decreased by atleast two centimeters. That was of so much concern that to me is corroborated by the method of picture that shows as an aggregate level height has not improved. Which means that if it improved for 'some' as the better off for others it did not improve for some at the other end. Only them it remained for some as the 'Static'. So that is one kind of fact which they showed as I had not studied or experienced a similar part or design anywhere.

Just illustrating by taking two other examples. And relating them to policy making today. If we look at the criteria which they have for different sets, different systems of medicine, different doctors and thereby choosing to whom they would go to, whether private, public system or modern or Indigenous System. How we show their criteria. One is their level of knowledge. And they were absolutely clear. They could make out who one the indigenous doctors, who are the trained who are untrained doctors. And those who are trained had more knowledge. The one at the government hospital had better knowledge then the one doing the private practice for the clear understanding. What they saw and also acknowledge over the example of a traditional practitioner, where they could look at the pulse and thereby diagnose the nature of the disease. That was clinical skill and that was knowledge. Now this was what was experienced as knowledge as one of the first criteria. The second criteria was the degree of seriousness of attention that the provider gave to them and their problems. And I think I don't need to explain that. The third criteria was the one I wish to differentiate in behaviour and seriousness of attention as one. Now this attention to the problem is one but then behaviour in terms of the Social Interaction is the third part which they saw as important. And the fourth was the degree of commercialisation they saw in the interaction. Now the degree of seriousness is what they saw in the Private Practitioners which they gave much more then the public Practitioners. Only thing is that he did not have the more knowledge to offer. Even though he was more serious he did not have the knowledge the government doctor had. When they talk of Social Relationship and Social discrimination they with their experience of untouchability and the loss of dignity were more sensitive about the whole issue of dignity then those of other castes and classes. And therefore they saw social discrimination behaviour. But now it was not in caste terms. Now it was in terms of they being poor and rural, with their language and discriminated cloths. So it was seem as .....

...... Now that is within negative to what they see as the Moral Position. And in a system without morality is not something they can believe in. While a practitioner came with a system of being a part of a practitioner who gave the knowledge which he had which would help the understanding which says, if I commercialise it I would actually loose the benefits of power which it has. It is the very common understanding of the practitioner. So there were the difference which they see very clearly. Now the principles of Quality. Clearly what we can see as indicators of Quality is one that if we want people to be able to understand and make best use of modern medicine then you have to have an ethic morality about it. And two dimensions of it had been Equality and Non-commercialisation. And thereby what we have seen from public and private sector. I don't have to talk about. But what it means is for a public sector it means a change in entire world view of class, social context and what we mean by expert and modern knowledge vis a vis the old folk knowledge and the dignity of that. If I would, No I think I will stop there. If there are any questions ? Thak you !

Dr. Dhar : A detailed discussion was there on the presentation of our alternatives. May I now call upon the next speaker on Women Perception on it.

Speaker : This is the condition of poor. Women are going to talk about the last and the least O.K. So I will be talking about the women who are living in poor households in West Bengal, on the basis of my Research in 90s and followed by interventions in the districts and also with the workers who are working and interacting closely with the women. Trying to articulate their daily work and position and Quality. Therefore mentioned have is the whole policy which directly takes women into consideration. The national Health Policy, the Nutrition policy, the population Policy and also the Policy of Women empowerment. And I would be naming two major issues which cuts across all the social groups. With women living in all Social Groups in West Bengal. And try to see what women have to say as we have articulated in this presentation. And I think that part of issues where women say that they wish to participate in the country. So the first thing I would like to talk about is how many women view their health and how their men talk about their health and wherever there are gaps where it is immediately required to be addressed. I am not talking about the long term on that. So the one thing when we talk to women on health are the signs of illness, treatment and all that. But deeper if you go into the interaction they talk about general things like what role they are playing and their social existence. One woman said look when leaves fall from the tree into the pond. Now if you look at that leaf it looks apparently that when you touch it, it crumbles and that is how our real existence is. And if you go further deeper into it they talk about their worlds that most of their time is going into production i.e. Social and Biological and all kinds of production. And they see that the environment is changing and with that there are more difficulties in finding work and committing to the place of work. And also making good living for the family since market prices are coming down. And what they are saying is when we look at the testimonials we find that this work and the pressure of its terms and conditions and the economic activities outside the work and the work they are doing at home is also changing because the other members men and women, daughter and son and other relatives are also changing. They are going into education and other diverse employment and they are getting less time for the household. So that burden is coming on women. So the challenge is to combine both the changing world outside and the changing world within the home. This is the challenge. And as a consequence they are losing more. Now these women are engaged in construction work, in the fields as agriculture labour, as domestic help in better off households and as cheap wage labourers in household industries of embroidery and doll making out of clay. So there they are compromising their nutrition, their milk, their sleep at night and all together it is creating a lot of tension within and outside the family, violence and its impact on physical existence. Many many people say emotional stress is better. But they are also undergoing very important emotional pressures out of these happenings. Now what is happening that there are strings of changes out of this also. There are individual labour women also. Individual women are found that they are breaking all this and then they are able to absort and they are able to enjoy better health than their counterparts. How is it possible ? It is the individual women themselves and the environment that men are providing around or families are providing around them. you may see that women talk about a space about themselves. We observe this only at individual or not at the larger level. Now the women say especially those who were in the household industry they say that earlier we started getting engaged in this industry when the industry was coming up we used to go for work show. We used to spend 8 hours, 6 hours, chat, do our work, take our wages and come back. It is not that they had no space where they could share. And also domestic ones were unorganised. There was no union as men had in agriculture. So unionisation. let us go for unionisation. Options do come out when we think of changing the situation. In this space men say that it is not only we will solve the Health Problem but also illness and doctor and all that problems. But we will be also able to sort out other problems like violence in the family and somebody who needs counselling. Then it is not an individual problem but it becomes a group problem and group responsibility. Let me go to the second point, which is that in West Bengal, in most of the district there is a shift. There is a shift from Home delivery to institutional delivery. And look at that a society which is so much concerned about the women's Biological reproduction that there is a big show. There is a little concern for their illness or lower outputs when they are not keeping well. And how do they express this illness. When you want to access you go for data information, the system is complex. Even the system is very complex for forget about the system for women for betterment in that village. Also the burden of illness is higher on these women. And where do they go ? First there is a delay. The delay is because the women bound by social norms is not or should not is supposed to express her illness. She is supposed to make a self denial, keeping her illness to herself and when finally her daily work is hampered and if she is bedridden or her output is so much hampered that others do take a notice of it then only she is been taken for some kind of cure. What kind of curity ? If we look at data that women are getting the worst wages these poor social economic group. These women then are usually going to religious groups. These religious group often take them to a ride. They are often trafficking their daughters in the name of marriage with well off. it is hard for the families to realise that their daughters will never return as been trafficked through marriage. So this is the condition. Now what are the things that we should exercise to come out of it. The whole perception of women is that it has been told on several platforms that women are not only Biological Reproducers but this has to reach also the policy makers that we have to identity the linkages about the illness or ill health. And those linkages have to be addressed by policies through intersectional policy linkages. Secondly is 'priority'. Their priority. The classical progress do not address their priorities. Now you must have read the Report on Quinon Sterlisation. Now Quinon which is a banned anti malarial drug is used for sterlisation of women. Now women are going there because it gives them the privacy. Women don't have to rush to the nearby City Hospital, stay there for two days and does not have to regret to public that she had gone out for sterlisation. So the kind of Public Health care is what we are talking about. The most urgent need is for a comprehensive Primary Health Care, where the local resources and local knowledge among the adivasis in Dalits in West Bengal., We have lots to do besides environment that is going on, logging going on, besides the ponds being dried up as a consequence of change in Bio structure in land reforms and all. Like cutting of Mangoe grooves and all. Despite of all this, a lot of knowledge base is leaving. Interestingly people in the villages are not organised they do not take tradition in organised manner. So the kind of comprehensive healthcare we are talking about, we are looking forward to Archieves where Local Resouces and local knowledge base ill be taken care of. Now I will finish in two minutes not five minutes. Also in this context if the policies do not address and they also talk about the main target as employment apart from their own terms and conditions. They say that if they get a better salary, they can take and spare some time to help us in domestic work. Now change is also occurring where they are also helping in domestic works. So with this I see and my sole point how you reach the Public Health Care or the Primary Health Care in a comprehensive manner using the local resources or the local knowledge base, and if you can't do that then we (women) will continue to visit and use Quinon Sterlisation for reproductive health. Thank You!

Dr. Dhar : May I now call upon the last speaker. She will be talking on RETHINKING ON HEALTH SYSTEM and shall outline it.

Speaker : See I will not talk for much time in case anyone wants to go. Just few points to compliment all the speakers talking here. The Health and Services in the country is undergoing massive destructing. There are three things that are happening. One is increasing privatisation. The income and Health Insurance or private health insurance as an answer to people's poverty and its inability to pay. And third the government sector being privatised and dismantled.

I see the story goes to the 90s and late 80s when Structural Adjustment Programme was imposed on several countries which had fallen to so called Debt Trap. So the World Bank then in the medical world information increasingly was coming up about the Structural Adjustment Programme and its negative impact and the policy of the programme. So the World Bank come out with the Report in 1993 which is called Investing and Health Care but basically it should have been termed disinvesting and health care. Because number one it says that state should retreat from its welfare obligation. But as one of its welfare obligation only a cluster of services should be provided and this cluster of services will be prioritised on the basis of what the World Bank says word 'rally'. Now it was supposed to be superior to what measures we had been using like mortality mobility, life expectacy, duration of illness etc. etc. This is supposed to unify divisions. It is because of these 'dallies' today we have Polio as number one priority in the country. Although if we look at other indicators it is not a priority. So we are told you use dallies to set up left priorities. But the second consequence of the World Bank Report has been that government will now retreat from the secondary and Terteriory premises. And instead will become purchases of services. Why ? because increasingly we are getting a data that one of the reasons for Rural indebtness is paying for the medical cost. Now earlier also people were poor. Now why has this become a very important area of indebtness. Because now medical technology as a part of this entire modern medicine is increasing and this is increasing the cost. And much of the medical technology which is been promoted is irrational and hazardous and use of itself had never proved to be effective in diagnosis and treatment. The third thing is that Alma Atta Declaration is which is supposed to be the fiftyth year of Alma Atta Declaration Sorry ! Twelvth (12th) year of Alma Atta Declaration. It is the declaration of Primary Health Care. Now the use of Primary Health Care is now been seen synonymous with Primary Level Care. So Primary Level Care is what you will get at the Primary Health Center. So what is the use of Primary Health Care to me is that at Alma Alta was there was a thought behind it or are we looking at it in a retrospective manner. Why the word, 'Primary' was used ? and why 'Universal Care' was not used ? See the choice of words are always very important. And we never debated then and we are not even debating it today. Now I don't want to go into what is the state of affairs today. Many people had talked about it.

But just one the Analysis. In a critique of why the situation have is what it is today. Colonisation is seen as an important reason. We talk about our colonial heritage. So who is perpetuating our colonial heritage. So therefore I call, my papers 'health Care under Neocolonisation' because this is what our elite is doing at the way the health care system is going out today. Was it an accident, a chance or a choice. So we have to have a historical perspective. Many of us are still you know when the debate started in 1975s as a part of critique of this things particularly our organisation i.e. medico Friends Circle'. So look at the debate as we look at it. Particularly let us look at the question of class location of doctors. Let us look at the caste location of doctors. Let us look at because today they say commercialisation. The different caste is coming in. Did the earlier caste go abroad ? Now what happened to that ? When we talk about we do not have enough doctors, let us look at the number of doctors we have produced. So I don't want to go, I am just giving. So our question should what was the Road taken and what was the Road Block taken. Now the final things is today the National Health Policy of 2002 is almost entirely or dictorial World Bank Policy in many ways. And also if we look at the economic policy. So here we are looking at the dual policy. One policy for the Rich and one for the Poor. Again I want to reemphasise, this has been our policy since independence including Bohar Committee. So we have to again re-look at with the wisdom and the experience we have gained today. The other question we have to talk about is the Role of the NGO sector. The earlier voluntary sector which had its root to the earlier missionary sector. Now some of the debates within this sector. Now how is this sector looking at the changes ? Because I don't see this question of health taken up by Trade Unions. Trades unions see health as occupational hazard. Thats why they very often are interested in it. But now they are going to face these problems because E.S.I. are going to be privatised. And I am afraid the workers themselves would take; this is a wonderful idea because E.S.Is had been de-generating over the last several years although the capital the amount of money they had accumulated is very large. Now we have to look at this why this kind of public Finance and inner form of insurance fail. See there are reasons but I am only phase is that I think that it is wonderful that we initially started this prevailing paradigms both within the dominant system addressed in our own authoritative kind of system. And we have to start looking at the alternatives and what are the strategies and we are in search of what I call a constituency. Who is going to look at it. Because if we do not do it today, in five years time I can assure you we will not have anything to dream like this. Everything would have got dismantled. And therefore we have got to think about it. Yet to say the dismantling of Public Health Sector, it is bad. It is very bad. So you have to talk about Re-Reforming Public Sector. Private cannot be an alternative to a bad functioning Public Sector. And we have to say that dismantling of the Public Health Sector is a worker's issue. It is a villain's issue. It is a reproductive rates issue. it is a women's issue. It is everybody's issue including the middle class and the upper class. Because middle class is also getting into financial crisis. Because now they have to buy. So that is where insurance is going to come. So all I want to say as in the beginning that I hope we will all put our various pieces of puzzles we have with us to make a different kind of policy. Let us formulate another kind of policy. Let us have an open debate. let us have and call for transparency of every kind including all these global thing. Thank you !

Dr. Dhar : Thank You ! Now the presentation is open for the discussion.

Dr. Ritu : I think everybody is on the move. So either if anybody has something burning.

Speaker : I did not hear anybody touching distress things like politics. We talked about the Primary Health Care. So I will talk about this.

Dr. Ritu : So you may talk about this. O.K. Fine.

Speaker : I also want to remind everyone that we have to find ways to intervene politically, not merely as a 'Pressure Cooker' Way. Diagnose and participation is necessary. For politically and democratic awareness we have to go back to the state powers. Unless we have a political action to take up our agenda, I think we will be........

Dr. Ritu : I think I agree with you. I think that is why as I said 57 years of Road Blocks.

Dr. Dhar : I think you should respond after all questions are been put together. Anybody else.

Speaker : Can I make an announcement. See ! the Medico Friends Circle is having an annual meeting in Bhopal on 27th, 28th and 29th. Feb. 2004. All of you are invited. And we are going to discuss, dismantling of Public Health Sector.

Question : Are you going to put this on your Web/Net

Speaker : On 27th, 28th and 29th Feb. 2004 in Bhopal And it is very crucial that you all come and participate. We have three days and we may have lots of interactive sessions.

Dr. Dhar : Today I will only conclude the proceedings. I think the best alternative is to go back to Alma Atta and the Primary Health Care. Now if Primary Health Care you read the document gives you seven No ! Nine elements of Primary Health Care are taken care of. This includes everything including Primary Welfare, health. You name it you will find it and it will be taken care of. Now this comes under primary and requires secondary and Territory Health Care Support also which cannot be dealt with for various reasons. Technological, Scientific. But 95% problems can be solved if the composite and integrated way of taking care of Primary Health Care System. And for your information Independent Commission on Health is already working on it and it will also ensure what can states do ? Because much Action lies with the State Government rather than the Central Government. And I hope these inputs will be of use to all of you. Thank you very much.

Intervention : I think we have to draw the attention to People Healths movement and People Health Association of India in Calcutta Assembly had put forward a manifesto and if someone wants to have an insight about the alternatives. Thank You !

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