Health care is a particularly favourable area of Science and Technology where one can try to evolve altenate strategies. It offers several 'natural' advantages:
(a) The body of practitioners of the science is very widespread.
(b) An elaborate and sophisticated theoretical framework and basis exists for this practice, which is explicitly stated and relatively well-known.
(c) Knowledge and practice of this area of Science and Technology exists at varied levels – folk classical, general practitioner specialist etc. This has a major implication for jus, which can be seen in comparison with some other areas. If we are to consider an area like agriculture it may be difficult to identify a well defined or separate body expert specialist category with whom we can interact as academics - interaction with farmers will perhaps have to be in the nature of a 'movement'. On the other hand if we take an area! like logic or mathematics there are experts with whom we can have academic kind of interaction but there is no larger constituency 'behind' this.) The area of Health offers this interesting potential where there can be a valuable input even at the academic expert level to what can really become a movement with a very large constituency.
(d) The modern counterpart of this area of Science and Technology has an extensive and well developed "internal critique" and there are certain "alternative movements" - of course within the framework of modernity. However this is a distinct advantage in the task of initiating a dialogue with the counterparts in the modern sector.
(e) The potential 'constituency' is quite large - perhaps this is because the number of 'beneficiaries' of this area of Science and Technology is so vast. The large constituency gives us several allies from all walks of life.
(f) At the official and policy levels there is a clear recognition that this is an area where the modern sector cannot cater to all by a mere "linear expansion" of its current coverage. This is reflected in the positions adopted by the World Health Organisation (WHO) or our own health planners. Hence there is a greater openness here to try out alternative models. However this perriaps also means that the modern sector feels confident that in this area it knows how to "deal with" and contain alternatives well within its own framework.
We now begin with an overview of the Indian Health scene and then proceed to outline the possibilities of building up a Health care system based on the strengths of Indigenous Systems of Medicine (ISM) in this area.
Indigenous Medicine in the Twentieth Century
Ever since the advent of colonial rule in India, Indigenous Systems of Medicine lost state support -which was usually the disbursal of revenue assignments through local bodies, to support both the practitioners as well as the schools of medical education. By the mid-nineteenth century, the allopathic system had become the sole recipient of state patronage. The beginning of the 20th century saw a great revival of nationalist spirit and several efforts were made in this climate to strengthen the Indigenous Systems of Medicine. Various institutions were started for providing education and medical care along these lines. Venkataramana Ayurvedic College and Dispensary, Madras (1905) Takmilut - Tib Institution in Lucknow (1902) are examples in this regard. The All India Ayurvedic Mahasmmelan was formed in 1907. The same spirit was reflected by the Indian National Congress, which passed the following resolution at its Nagpur session in 1920 - "This conference is of the opinion that, having regard to the widely prevalent and generally accepted utility of the Ayurvedic and Unani Systems of Medicine in India, earnest and definite ef-forts should be made by the people of this country to further popularise schools, colleges and hospitals for instruction and treatment in accordance with indigenous systems" (1).
Pre-independence Plans - the Sokhey Committee Report and the Bhore Committee Report
The Indian National Congress in 1930 set up the National Planning Committee (NPC) under the Chairmanship of Jawaharlal Nehru. The sub-committee on National Health of the NPC was formed under the Chairmanship of Col. Santok Singh Sokhey, to assess the health situation and services in the country and recommend measures for their improvement, it submitted an interim report in 1940 and its official report in 1948. Based on its report the NPC resolved ".. to absorb the practitioners of Ayurveda and Unani Systems into the State Health Organisation of Independent India by providing them scientific training where necessary" (2). The Health Survey and Planning Committee appointed in 1944 by the British authorities under the Chairmanship of Sir Joseph Bhore (generally referred to as the Bhore Committee) gave its report in 1946(3). Its recommendations were accepted as the blueprint for the development of the health services in India by the National Government The Bhore Committee suggested a health structure with the district as the main unit for planning arid coordination and the primary health unit as the nucleus of integrated preventive - promotive - curative health care services. It suggested the abolition of licentiate medical courses in order to "standardise" the quality of medical care between the rural and urban areas. Two members of the Committee (Dr.Vishwanath and Dr.Dutt) wrote a "Minute of Dissent" declaring that the basic doctor as envisaged would never willingly fit into the rural scheme except under conditions of destitution.
The Bhore Committee report was also quite hostile towards indigenous systems of medicine. It observed that it was not in a position to assess the real value of these systems of medical treatment in the absence of "investigations" and felt that these systems had little to contribute to public health, preventive medicine, obstetrics or advanced surgery. It called for the expansion of a system of medicine which was neither Eastern nor Western but based on "scientific knowledge and practice belonging to the whole world". Subsequently the Bhore Committee report became in effect the blueprint for the development of health and medical services in India.
The report of the Mudaliar Committee (4) analysed the progress in health conditions and services 15 years after the Bhore Committee Report and made some recommendations about future direction. The report assessed that basic health facilities had not reached at least half the nation. Instead of the "irreducible mini-mum in staff recommended by the Bhore Committee, most PHCs were understaffed and the Secondary Health Centre Programme and district hospitals were similarly lacking staff and facilities. The Committee recommended the consolidation rather than the expansion of the existing PHCs.
In 1977 the Government introduced a programme for training village based health auxiliaries called the Community Health Volunteers (CHV) scheme. The CHVs were part-time workers selected from the villages and trained for three months in "simple preventive and curative skills, both allopathic and indigenous". The CHV scheme resulted from the recommendation of the Shrivasthava Committee (5). This report pointed out that the overemphasis on the provision of health services through professional staff had been counter-productive. Also "... it is de-valuing and destroying the old tradition of part-time, semi-professional workers which the community used to train. On the other hand, the new professional services provided under state control are undeveloped in quantity and unsatisfactory in quality". It therefore recommended the use of trained part-time health auxiliaries having "acceptability to and cultural kinship with the community", as the first link in the health service agency.
The National Health Policy of the Government of India was endorsed by the Parliament in 1983. Parallel to the efforts at formulating a new policy on health, in 1981 the Indian Council of Medical Research (ICMR) and the Indian Council of Social Science Research (ICSSR) set up a study group to evolve an "alternative strategy for health services in India". The study group commissioned twenty two background reports from various experts. This constituted the first detailed assessment of our health care system undertaken in the recent past (6).
An Overview of the National Health Scene
If we consider the pattern of public sector expenditure in health in the post-independence period, in absolute terms the expenditure has increased enormously -nearly 50-fold over the last 40 years. While the outlay was about Rs.65 crores during the First Five Year Plan period (1951 - 1956) it has increased to about Rs.3400 crores during the Seventh Five Year Plan period (1985 - 1990). However, the expenditure in the health sector has not increased in proportion with the total plan outlay. While during the first plan budget under health was 3.32% of the total plan outlay, in the seventh plan the allocation for health represented only 1.88% of the total plan outlay. There are certain major biases in our health system which can be seen by examining the pattern of expenditure and type of expenditure in the post-independence period. Some of the obvious and glaring features of this picture are the imbalance between urban/rural and curative preventive components.
Over 75% of our population resides in rural areas. The rural population in comparison with the urban population has a higher rate of infant and child mortality, a greater incidence of morbidity and malnutrition. One reason for this situation has been the differential distribution of health resources in favour of urban areas. In 1956 (the earliest year for which such figures are available) 25% of all hospital beds were located in rural areas. By 1974 this had declined to 13.7% For the same period (1951 - 74) out of a total of Rs.855 crores for providing drinking water and sanitation facilities, about Rs.566 crores (66.2%) were spent on urban areas and only Rs.289 crores (33.8%) were spent on rural facilities. The share of the Primary Health Centres and training schemes for rural health manpower in comparison to medical colleges and urban hospitals and dispensaries also show similar inequalities (7). According to a detailed analysis of expenditure on health, 61% of the health budget is spent on medical services which are mainly curative in nature while 39% is spent on public health (8).
A noteworthy feature of the evolution of the pattern of expenditure under various heads under, the health sector is the phenomenal growth of expenditure on Family Planning. While during the first plan period the expenditure under the head Family Planning was only 0.15% of the total health budget, it started rising rapidly - it was 1.56% during the second plan, 11% during the fifth plan, while during the seventh plan period it constitutes an incredibly high 95.97% of the health budget of the Union Government!
Indian Systems of Medicine (ISM): An Overview of the Scene
Starting from a meagre outlay of Rs.40 lakhs during the first plan period the budget for the ISMs has increased to Rs.43 crores during the Seventh Plan period. However when seen as a percentage of the total health budget it has increased only about two-fold starting from 0.6% of the total health budget during the first plan period to 1.27% during the Seventh Plan period.
At present there are about 125 colleges which offer degree course in Indian Systems of Medicine j- about 100 of these are Ayurveda colleges, 22 of them Unani and 2 of them Siddha colleges. (Besides there are also 125 Homeopathy colleges which are grouped under the Directorate of Indian Systems of Medicine). In terms of the practitioners of ISM there are about 2.5 lakh Ayurvedic Vaidyas, 25,000 Unani Hakims and 12,000 Siddha Vaidyas. In comparison we can note that there are about 3 lakh Allopathic Doctors and about 4 lakh Para Medical Workers. At present there are 110 Allopathic Medical Colleges.
Lok Swaasthya Paramparaas
Besides the registered practitioners of ISM listed above there is a very large number of practitioners of Lok Swaasthya Paramparaas (Local Health Traditions) spread all over the country. These represent a large cross section of people traditionally trained in the treatment of a number of diseases and this includes some speciality areas such |as bone-setting, .visha chikitsa, marma chikitsa, etc. There is no reliable data on the number of these practitioners. However it is estimated that there are well over 500,000 Dais or Traditional Birth Attendants in India - this would give us some idea about the magnitude of the number of people who have this kind of talent (9).
It appears possible that we can evolve a strategy for health care that can make the best use of our resources by strengthening the Lok Swaasthya Paramparaas. Towards this effort a major input in terms of knowledge can come from the ISMs. Till now we seem to have taken a very restricted view of these Paramparaas simply because of a strong ethnocentric bias in our scientific culture due to which we have tended to view and assess these traditions only from the view point of modern western system of medicine. It seems to us what is called for is a more wholesome approach where these traditions can be understood also from the view of ISMs. One approach could be to document these traditions in order to confirm what is sound and complete or determine what is incomplete and take a closer look at what may be distortions. These "evaluations" need to be undertaken from the point of view of ISMs.
It is necessary to emphasize that we consider the interaction between Lok Swasthya Paramparaas and ISMs to be a 'dialogue' and not merely a passing of judgment upon these Paramparaas by ISMs. The restoration of such dialogue will not only help strengthen ISMs, but also breathe fresh life into the practice and theories of Ayurveda and other Indian Systems of Medicine whose contacts with the larger Indian reality may have slackened due to a variety of reasons.
It has been observed that 90% of the community's curative and preventive health needs could be handled on the spot by Para Medical Workers (10). However whenever such a discussion came up either in the course of an official review (such as the Shrivasthava Committee Report) or in the voluntary sector, the view has tended to be very restrictive in terms of how we plan such a decentralised model. The Para Medical Worker or the Community Health Worker has always been seen only as somebody who is the recipient of a training programme (be it governmentally sponsored or otherwise) namely, a "clean slate" that needs to be written upon. However such a short-sighted view has emerged because of our total inability to realise that there already exist in our communities an enormous resource in the form of people who are the carriers of our Lok Swaasthya paramparaas.
The experience of the People's Republic of China is worth noting in this context. In the words of one of their senior scientists: "Traditional Chinese medicine, with its rich clinical experience, it unique theoretical system and its extensive literature has served to combat illness amongst the Chinese people over many centuries. It represents the crystallization of the Chinese People's wisdom and experience. What has proved effective in clinical practice has been preserved, handed down from generation to generation, and continually improved upon" (11). At present China has about 16,00,000 "Bare foot" rural doctors. Summing up the experience with traditional medicine, a former head of the Scientific and Technological Bureau of the Public Health Ministry of the People's Republic of China stated that "Traditional Chinese medicine and Pharmacology have developed over thousands of years and include the medical knowledge of minorities such as the Tibetans, Mongolians, Vygurs, Yus, and Dais. After the founding of the New China, the Central Communist Party affirmed the advantage of traditional Chinese medicine and formulated a policy of unity between traditional and Western-trained practitioners. Traditional practioners in private practice have been organised and assigned to work at hospitals, and have enjoyed the same status as practitioners of Western Medicine. Practitioners of Western medicine have been encouraged to learn traditional techniques and vice-versa. Western style hospitals have added departments of traditional medicine, and entire hospitals have been dedicated to traditional medicine. Traditional medicine and pharmacology have been systematised and studied by modern scientific methods. Young and middle-aged practitioners, whether or not they began with traditional training, have chosen to follow in the footsteps of older practitioners who have particularly advanced their fields and to further develop these fields".
"The new combination of traditional Chinese and Western medical treatment has improved the rates of both prevention and cure of common and serious diseases. Acute abdominal condition usually requiring surgery can now be treated non-surgically. For example, at the Zuny Medical College in Guizhou Province and the Dalian Medical College in Liaouing Province, 11,122 cases of conditions such as acute appendicitis and acute pancreatitis have been treated since 1958 with combined traditional Chinese and Western methods, with a cure rate of 92.7%. Treatment of bone fractures and bone and joint injuries this way led to a new type of trauma orthopedics. The orthopaedic department of Tianjiu Hospital has developed a system of treatment for bone fracture that has proved its worth in more than 100,000 cases."
"Anaethesia by acupunture in a Chinese creation and a significant achievement in combining traditional Chinese and Wetern medicine... Acupunture anaethesia has been widely used in cranial, cervical, thoracic and abdominal opertions. It has also been used successfully in complex heart surgery and in the replantation of served limbs".(12.13)
The reason we have cited the Chinese experience in such detail is not so much to plead that such an integration should be reproduced here. It is rather to convey that various non-Western societies are evolving their own ways and means for coming into their own, in a world which was till recently dominated politically and in ideas by the Western civilisation.
If we reorient our thinking and take a more open minded and realistic view it can be seen that strengthening of the Lok Swaasthya Paramparaas could itself lead to a different model of health care systems. It is possible to envisage a scenario wherein well over 2/3rd of the health needs of the community can be taken care for at the level of the village or the village panchayat union. Of the remaining l3rd, it is quite conceivable that barring about 10% of the needs, the rest can be organised at the level of a formation that is larger than a village but not larger than a taluk. This would call for a re-orientation and re-organisation of our health policy along the following lines.
(a) The Strengthening of the Lok Swaasthya Paramparaas
This requires a knowledge input as well as a resource input. A knowledge input can come in the form of interaction with practitioners of ISM. A resource input would be in the nature of a reallocation of the health budget so that a major proportion can be retained and spent at the local level. Simultaneously this would also call for a strengthening of the resource-base on which Lok Swaasthya Paramparaas are dependent - this is primarily the resource of the village forests and the medicinal plants.
(b) The Strengthening of the ISM Community
Such an approach would call for a re-orientation of education in the ISM wherein their major role becomes strengthening and revitalisation of Lok Swaasthya Paramparaas. The ISM community would also need to spell out its perspective on various community health issues and develop a methodology for research and development which is a statement of the basic worldview and approach of the ISMs in today's context and conditions.
(c) A Dialogue with Modern Medicine
The interaction of ISMs with modern medicine have to-date been quite unbalanced and lopsided. This has been more in the nature of being "run over" by various aspects of modernity which the ISMs have accepted or have had grafted on to them at random. However there is need for a different type of an interaction wherein the ISMs need to digest and assimilate those aspects of modernity/modern medicine which can be of any relevance to them. A dialogue with modern medicine is required in order to arrive at a meaningful demarcation of areas or sectors where the two systems can operate by themselves, and areas where there can be joint work or collaboration.'
l."What is the role of Indigenous Medical Sciences in our Health CaroSystem?" PPST Bulletin, Vol.4, No.l, (June 1984) 64 - 95.
2. National (planning Committee, Sub ommittee on Health (Sokhey Committee) Report (Bombay, Vora) 1948.
3. Government of India, Health Survey and Development Committee (Bhore Committee), Reports (VolsJ - IV) (New Delhi, Manager of Publications) 1946.
4. Government of India, Health Survey and Planning Committee (Mudaliar Committee) Report (New Delhi, Manager of Publications) 1961.
5."Health Services and Medical Education: A Programme for Immediate Action". Government of India, Group on Medical Education and Support Manpower (Shriv'astava Committee) (Ministry of Health and Family Planning, New Delhi) 1975."
6. Health fort Alb An Alternative Strategy (Report of a-Study Group set up jointly by the Indian Council of Social Science Research and the Indian Council of Medical Research) (Indian Institute of Education, Pune) 1981. However, this does not include the 22 background reports from various experts commissioned by the Study Group - they remain unpublished to-date.
7. "Political Economy of State Health Financing" by Ravi Duggal, Radical Journal of Health Vol.1 (December 1986) 79-85.
8. S.Kulkarni, Health Expenditure Analysis (Part I) (Indian Council of Social Science Research, New Delhi) 1979.
9. For an introduction to this topic see Local Health Traditions: An Introduction by A.V. Balasubramanian and ! Vaidya M. Radhika (Lok Swaasthya Parampara Samvardhan Samithi, Madras) 1989.
10. K.S.Sanjivi "Rational Approach to Community Health" The Hindu, December 23, 1975.
11. R.H. Bannerman, John Burton and Ch'en Wen-Chieh (ed) Traditional Medicine and Health Care Coverage (World Health Organization, Geneva) 1988, p.68
12. Chen Haifeng and Shen Chenry. "Health Care in China" A unique partnership between ancient and modern medicine" Impact of Science on Society Issue No.143 (1986) ;
13. Hon Zhaotang 'Traditional Chinese Medicine" Beijing Review May 19,1986,15-23.