Aruna Kumar Malik*

Health Sector Governance and

Reforms in India

Abstract
The background of India’s health policies, since independence, shows a
systematic documentation that envisaged ambitious health governance
comprising of the delivery of a public health program by the central government
and primary, as well as secondary health care by the state governments. It is
therefore surprising to find that none of the ambitions has been realized. The
delivery of public health programme today is limited and uncoordinated, whilst
primary and especially secondary care is of a poor quality and unaffordable
to the bulk of the population. The health care sector has required much more
intervention. Recent reforms have made some progress in addressing some of
the lacunae but are still handicapped by the pervasive dominance of the private
sector which severely limits the choice of policy tools available to the
government. An attempt is made to assess India’s health policy reforms and
argue that the policy instruments used were inconsistent with the goals it was
trying to achieve.

Introduction
Health and healthcare need to be distinguished from each other for no better
reason than that the former is often incorrectly seen as a direct function of the
latter. Clearly, health is not the mere absence of disease; but good health confers
freedom from illness on a person or group of people – and the inherent ability to
realize their potential. Health is therefore best understood as the indispensable
basis for defining a person’s sense of well-being. The health of populations is a
major or key issue in public policy discourse, distinct in every mature society,
often determining its ultimate deployment. This includes a cultural understanding
of ill health and well-being, the extent of socio-economic disparities, reach of

*
The author is Assistant Professor of Political Science, Gujarat National Law University
(GNLU), Gandhinagar, Gujarat.
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health services, overall quality and costs of care and current bio-medical
understanding about health and illness.
Health care covers not only medical care but also all aspects of pro preventive
care too. It cannot be limited to care only rendered by or financed out of public
expenditure- within the government sector but must also include incentives and
disincentives for self-care by the citizens and care paid to the private sectors to
get over ill health. In India, currently, private out-of-pocket expenditure
dominates the cost of financing health care, and so, the effects are bound to be
regressive. Healthcare at its essential core is widely recognized to be a public
good. Its demand and supply cannot therefore, be left to be regulated solely by
the invisible hand of the market. Nor can it be established on considerations of
utility, maximizing conduct alone.
To contextualize the above governance of healthcare thus requires special
attention and critical assessment through which a larger goal can be achieved.
Governance is increasingly seen as the foundation for good practice, successful
organizations and ethical behavior at any given point of time. The essential
prerequisite of governance is that the responsibility is first defined within an
organization, and then, that the responsible persons defines the outcomes that
are required, measures them, reports them and then judges them accordingly.
Governance in healthcare occurs at many levels and with numerous
professional organizations monitoring as well as changing the practice and
behavior of healthcare professionals. Hospitals and health care delivery
organizations are subject to inspections. One may raise a question of whether
governance and management are one and the same for healthcare purposes.
The answer is a critical one to address, and therefore, a multi-dimensional
approach would probably help us to understand governance more.
Governance and management are definitely not one and the same.
Management is a goal oriented activity inside any organization. Governance on
the other hand is made from outside. Governance is abstract in character, an
architecture resulting from and dealing with multiple organizations. It can be
simplified by Information Communication Technology application.
The Alma Ata Declaration in 1978 gave an insight into the understanding of
primary health care. It viewed health as an integral part of the socio-economic
development of a country. It provided the most holistic understanding of health
and the framework that States needed to pursue, to achieve the goals of
development. The Declaration recommended that primary health care should
include at least: education concerning prevailing health problems and methods
 Health Sector Governance and Reforms in India 223

of identifying, preventing and controlling them; promotion of food supply and

proper nutrition, and adequate supply of safe water and basic sanitation; maternal
and child health care, including family planning; immunization against major
infectious diseases; prevention and control of locally endemic diseases;
appropriate treatment of common diseases and injuries; promotion of mental
health and provision of essential drugs. It emphasized the need for strong first-
level care with strong secondary- and tertiary-level care linked to it. It called
for an integration of preventive, promotional, curative and rehabilitative health
services that had to be made accessible and available to all people, and this was
to be guided by the principles of universality, comprehensiveness and equity.
In one sense, primary health care reasserted the role and responsibilities of
the State, and recognized that health is influenced by a multitude of factors and
not just the health services. It also recognized the need for a multi-sectoral
approach to health and clearly stated that primary health care had to be linked
to other sectors. At the same time, the Declaration emphasized a complete and
organized community participation, and ultimate self-reliance of individuals,
families and communities assuming more responsibility for their own health,
facilitated by support from groups such as the local government, agencies, local
leaders, voluntary groups, youth and women’s groups, consumer groups, other
non-governmental organizations, etc. The Declaration affirmed the need for a
balanced distribution of available resources (WHO 1978).
Keeping this well delineated definition in mind, we can now discuss whether
this holistic concept has been utilized as a framework by our policy-makers to
develop various health policy documents, health committee reports and the five-
year plans since Independence so as to have a proper impact on the health system.
After Independence, India adopted the welfare state approach, which was
dominant worldwide at that time. As with most post-colonial nations, India too
attempted to restructure its patterns of investment. During that time, India’s
leaders envisaged a national health system in which the State would play a
leading role in determining priorities and financing, and providing services to
the population. ‘If it was possible to evaluate the loss, which this country annually
suffers through the avoidable waste of valuable human material and the lowering
of human efficiency through malnutrition and preventable morbidity, we feel
that the result would be so startling that the whole country would be aroused
and would not rest until a radical change had been brought about’ (Bhore
Committee Report 1946).
The emphasis of the first health report, i.e. the Health Planning and
Development Committee’s Report, 1946 (popularly known as the Committee
Report) was more explicit on the role of the State. It was a plan equivalent to
 224 Liberal Studies , Vol. 2, Issue 2, July-December 2017

Britain’s National Health Service. Report was based on a countrywide survey

in British India. It was the first organized set of health care data for India. The
poor health status was attributed to the prevalence of insanitary conditions;
malnutrition as well as under nutrition leading to high infant and maternal
mortality rates; inadequacy of the existing medical and preventive health
organizations; lack of general and health education; unemployment and poverty,
all of which produced adverse effects on health and resulted in inadequate
nutrition; improper housing and lack of medical care. Inter-sectoral linkages
were well discussed with nutrition, housing and employment as essential
precursors for healthy living. It considered that the health program in India
should be developed on a foundation of preventive health work and then continue
to proceed in the closest association with the administration of medical relief.
The Committee strongly recommended a health services system based on the
needs of people, the majority of whom were deprived and poor. It felt the need
for developing a strong basic health services structure at the primary level with
referral linkages. It also recommended the need to invest in the pharmaceutical
sector to develop indigenous capabilities and reduce excessive reliance on
multinational companies.
India was therefore one of the few developing countries which adopted a
health policy that integrated the principles of universality and equity. Community
participation and cooperative efforts to promote preventive and curative health
work was important to achieve a vibrant health system. The Committee felt that
large sections of the people were living below the normal subsistence level and
they could not afford to pay for or contribute to the health services. It was decided
that medical benefits would have to be supplied free to all at the point of delivery
and those who could afford to pay should channel contributions through the
mechanism of taxation. Though the report stated that ‘…it will be for the
governments of the future to decide ultimately whether medical service should
remain free to all classes of the people or whether an insurance scheme would
be more in accordance with the economic, social and political requirements of
the country at the time (Bhore Committee Report 1946), one point was apparent-
that no individual should fail to secure adequate medical care, curative as well
as preventive, just because of the inability to pay for it. They recommended that
State Governments should spend a minimum of 15 per cent of their revenues on
health activities.’
The National Planning Committee (NPC) set up by the Indian National
Congress in 1938 under the chairmanship of Colonel S. Sokhey stated that the
maintenance of the health of the people was the responsibility of the State, and
the integration of preventive and curative functions in a single state agency was
 Health Sector Governance and Reforms in India 225

emphasized. The Sokhey Committee Report was not as detailed as the Bhore
Committee Report but endorsed the recommendations of the Bhore Committee
Report and commented that it was ‘of the utmost significance.1
The objectives of the First (1951-56) and Second Five-Year (1956-61) Plans
were to develop the basic infrastructure and manpower, as visualized by the
Bhore Committee. Though health was seen as fundamental to national progress,
less than 5 per cent of the total revenue was invested in health. The following
priorities formed the basis of the First Five-Year Plan: provision of water supply
and sanitation; control of malaria; preventive health care of the rural population
through health units and mobile units; health services for mothers and children;
education, training and health education; self-sufficiency in drugs and equipment;
family planning and population control. Starting from this first plan, vertical
programmes started, which became the centre of focus. The Malaria Control
Program, which was made one of the principal programmes, apart from other
programmes for the control of TB, filariasis, leprosy and venereal diseases, was
launched. Health personnel were to take part in vertical programmes. However,
the first plan itself failed to create an integrated system by introducing this
verticality.
The concern of the Health Survey and Planning Committee (Mudaliar
Committee 1962) was limited to the development of the health services
infrastructure and the health care at the primary level. It felt the growth of
infrastructure needed radical transformation and further investment. Another
major shift came in the Third Five Year Plan (1961-66) when family planning
received priority for the first time. The increase in the population became a
major worry and was seen as a hurdle to the development process. Although the
broad objective was to bring about progressive improvement in the health of
the people by ensuring a certain minimum level of physical wellbeing and to
create conditions favorable for greater efficiency, there was a shift in focus
from preventive health services to family planning. During the Fourth Plan (1969-
74), efforts were made to provide an effective base for health services in rural
areas by strengthening the PHCs. The vertical campaigns against communicable
diseases were further intensified.
During the Fifth Plan (1974-79), policy-makers suddenly realized that health
had to be addressed with equal importance as the other development programmes.
The Minimum Needs Program (MNP) promised to address all this but became
an instrument through which only health infrastructure in the rural areas was to
be expanded and further strengthened. It called for integration of peripheral
staff of vertical programmes but the population control program got further
 226 Liberal Studies , Vol. 2, Issue 2, July-December 2017

impetus during the Emergency (1975-77) and most of the basic health workers
got sucked into the family planning program. Meanwhile the Chaddha
Committee Report (1963), the Kartar Singh Committee Report on Multipurpose
Workers (1974) and the Srivastava Committee Report on Medical Education
and Support Manpower (1975) remained focused on giving recommendations
on how the health cadres at the primary level should be distributed. With the
widespread disillusionment with vertical programmes worldwide and the need
to provide universal health services came the Primary Health Care Declaration
at Alma Ata in 1978, which India was a signatory to. The Sixth Plan (1980-84)
was influenced by two policy documents: the Alma Ata Declaration and the
ICMR/ICSSR report on ‘Health for All by 2000’. The ICMR/ICSSR Report
(1980) was in fact a move towards articulating a national health policy that was
thought of as an important step to realize the Alma Ata Declaration. It was
realized that a redefinition and re-articulation was necessary to get back onto
track, an integrated and comprehensive health system that policy-makers had
so far wavered from. It reiterated the need to integrate the development of the
health system with the overall plans of socio-economic and political change.
It recommended that the Government formulate a comprehensive national
health policy dealing with all dimensions e.g., environmental, nutritional,
educational, socio-economic, preventive and curative. The National Health
Policy (1983) attempted to incorporate all these. Provision of universal,
comprehensive primary health services was its goal. A large number of private
and voluntary organizations who were active across the country in the health
field were to support the Government in its efforts to integrate health services.
Evolving a decentralized system of health care and a nationwide chain of
epidemiological stations were some of the main recommendations.
Once again, a selective approach to health care became the focus when a
strong lobby, questioning the financial repercussions of the primary health care
approach came up. Verticality was reintroduced as an ‘interim’ arrangement
and interventions of immunization, oral rehydration, breastfeeding and anti-
malarial drugs were suggested2. This was seen as a technical solution even before
comprehensive primary health care could be realized. UNICEF too came out
with its report on the state of the world’s children’s health and suggested
immunization as the spearhead in the selective GOBI-FF (growth monitoring,
oral rehydration, breastfeeding, immunization, food supplements for pregnant
women and children, and family planning) approach (Rifkin and Gill 1986).
Program-driven health policies were once again the central focus. Hence,
the plan documents emphasized on restructuring and developing the health
infrastructure, especially at the primary level. The Seventh Plan (1985-90)
 Health Sector Governance and Reforms in India 227

restated that the rural health program and the three-tier health services system
need to be strengthened and that the government had to make up for the
deficiencies in personnel, equipment and facilities. The Eighth Plan (1992-97)
distinctly encouraged private initiatives, private hospitals, clinics and suitable
returns from tax incentives. With the beginning of structural adjustment
programmes and cuts in social sectors, excessive importance was given for
vertical programmes such as those for the control of AIDS, tuberculosis, polio
and malaria funded by multilateral agencies attached with specific objectives
and conditions. Both the Ninth (1997-2002) and the Tenth Five-Year Plans (2002-
2007) start with a dismal picture of the health services infrastructure and go on
to say that it is important to invest more on building good primary-level care
and referral services. Both the plans highlight the importance of the role of
decentralization but do not state how this will be achieved.
The National Health Policy (2002) includes all that is wanted from a
progressive document and yet it glosses over the objective of NHP 1983 to
protect and provide primary health care to all. The Policy document suggests
that the integration of vertical programmes, strengthening infrastructure,
providing universal health services, decentralization of the health care delivery
system through Panchayati Raj Institutions (PRIs) and other autonomous
institutions, and regulation of private health care but fails to indicate how it
achieves the goals. It encourages the private sector in the first referral and tertiary
health services. However, to understand the health right within the framework
of standard setting one has to know the delivery of health services in the public
sector.

Delivery of Health Services in the Public Sector

Health Systems; an end in themselves or a means to achieving certain ends?
Worldwide, there seems to be a consensus on measuring health systems in terms
of improving the health status, enhancing patient satisfaction and providing
financial risk protection. ‘In 2000, the World Health Organization (WHO) further
expanded the definition of health. It includes a reduction in disparities for
improving health status and sharing the financial burden in accordance with the
ability to pay as being a fair form of health financing’3. There is, however,
notwithstanding the evolved standards, little consensus on what constitutes an
ideal health system in universally acceptable terminology to enable better inter
country comparisons. This is because, unlike any other sector, health systems
are highly contextualized and influenced by various exogenous factors such as
societal values, epidemiology and disease burden, availability of financial
resources, technical capacity, individual preferences and the nature of demand.
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Technological innovation in the health sector has improved the quality of

life but has also increased costs. In countries that have no social insurance and
where the role of the state is limited, people spend a substantial proportion of
their incomes on seeking medical treatment, and in the process, get impoverished,
thus widening disparities in the health status. To contain spiraling prices and
distortions created by market failures such as moral hazard, asymmetry in
information, induced demand etc., countries resort to multiple policy instruments.
Health systems have five aspects or knobs that interact with each other and
influence its basic nature and direction: (i) financial (tax, user fees, out-of-pocket
expenditure, insurance), (ii) payment systems (how providers are paid: salary,
per service rendered, capitation), (iii) organizational (manner in which the
delivery systems are organized/structured), (iv) legal (regulatory frameworks)
and (v) social (access to health information, advertising).4 The effectiveness
with which these instruments of state policy are designed and used determines
the extent to which the health system is equitable, appropriate or fair. The health
system in India consists of a public sector, a private sector and an informal
network of providers of care operating within an unregulated environment, with
no controls on what services can be provided by whom, in what manner, and at
what cost, and no standardized protocols to help for measuring the quality of
care. There are wide disparities in access, further worsened by the poor
functioning of the public health system.

Evolution of the Health System in India: An Overview

The evolution of India’s health system can be categorized into three distinct
phases:
• Phase I (1947-83)-when the health policy was based on two principles:
(i) that none should be denied care for want of ability to pay, and (ii)
that it was the state’s responsibility to provide health care to the people.
• Phase II (1983-2000)-when the first National Health Policy of 1983
articulated the need to encourage private initiative in health care
service delivery, while at the same time expanding access to publicly
funded comprehensive primary health care.
• Phase III (post-2000)-which is witnessing a further shift that has the
potential to profoundly affect the health sector in three important ways:
(i) utilization of the private sector resources for addressing public
health goals; (ii) liberalization of the insurance sector to provide new
avenues for health financing; and (iii) redefining the role of the state
from being only a provider to a financier of health services as well.
 Health Sector Governance and Reforms in India 229

Phase I (1947-83)
At the time of Independence, malaria affected almost a quarter of India’s
population; virulent diseases such as smallpox, plague and cholera were rampant,
maternal mortality was over 2000 per 100,000 live-births and longevity of life
was less than 32 years (Bhore 1946). While the public sector consisted of a few
city hospitals, the private sector consisted largely of individual practitioners of
Indian systems of medicine and licentiates practicing in villages, as family
doctors. With meager resources, this period saw the effective containment of
malaria, bringing down the incidence from an estimated 750 lakh to less than
20 lakh, eradication of smallpox and plague, halving of the maternal mortality
rate (MMR), reduction of the infant mortality rate (IMR) from 160 per 1000
live-births to about 105, containing epidemics of cholera and increasing longevity
of life to almost 54 years. Institutes of excellence such as the All India Institute
of Medical Sciences (AIIMS) were set up for research and quality training,
making India an exporter of highly trained medical doctors. These gains were
in no small measure due to the strong foundation of public health on which the
health system was grounded and the highly professionalized cadre of public
health specialists who provided leadership from the front, camping in villages
in hostile environmental conditions, whether to eradicate smallpox or supervise
the malaria worker.
However, under the overarching influence of modernization that
characterized the post-colonial phase of global development, the urge to be on
par with the western norms of modern medicine proved to be too strong to
resist. India, unlike China, missed the opportunity to launch public health
campaigns to promote, at the community and individual household levels, healthy
lifestyles alongside the expanding public investment to assure universal access
to water, sanitation, nutrition and education. Instead, and more particularly during
the 1960s and 1970s, public health campaigns were focused only on promotion
of the small family norm and family planning. India also failed to utilize the
strengths of the traditionally used and accepted modes of medical treatment
and gave undue emphasis to allopathy, gradually laying the foundation for an
expanded market of the western style of curative services, which are urban
based as well as expensive.

Phase II (1983-2000): The National Health Policy of 1983

Despite the remarkable achievements in disease control, the failure to control
the population, the lack of access to basic health facilities in rural areas, and the
international commitment to focus on providing comprehensive primary care
as envisioned by the Alma Ata Declaration in 1978, led to the formulation of
 230 Liberal Studies , Vol. 2, Issue 2, July-December 2017

the National Health Policy of 1983. Limited resources to meet the growing
demand of health services led to the mobilisation of the private sector to shoulder
some part of the burden. An estimated Rs 6500 crores worth of subsidy in terms
of exemptions in customs duty for import of equipment, subsidized inputs such
as land, etc. were extended to stimulate private investment in health.
Alongside, the focus of state policy shifted to primary health care to reduce
the iniquitous urban-rural divide and expand access to the rural populations,
particularly the poor. Lack of resources resulted in segmenting health into
independent silos of disease control programs rather than visualizing health
care as a continuum of service. Such segmentation led to simplistic formulations
of the role of state being confined to primary health care and a selected list of
diseases and health interventions, rather than being responsible for the well-
being and health of the people. This phase witnessed an expansion of health
facilities for providing primary health care in rural areas and the implementation
of national health programs (NHPs) for disease control under vertically designed
and centrally monitored structures.
The adoption of this twin strategy had its advantages. With less than Rs 200
per capita investment (2000), prioritization of interventions that benefit the poor
and entail wide externalities, provided a moral and technical justification. Besides
the establishment of health facilities in accordance with a population norm,
guinea worm was eradicated and the disease load due to infectious diseases
reduced and deaths averted. During the 1990s, with assistance from the World
Bank, NHPs were up scaled with impressive outcomes: the cure rate of
tuberculosis (TB) under the Directly Observed Treatment, the (DOTS) program
doubled and averted an estimated 50 lakh deaths, leprosy was eliminated except
in 70 districts, the incidence of cataract as a cause of blindness reduced from 80
per cent to less than 50 per cent and the number of polio cases decreased
drastically from 29,709 to about 100.
Fiscal stress gave rise to innovation; various States attempted to improve
the overall performance of public health facilities by a combination of policies-
improved availability of inputs, greater flexibility in spending; defining
responsibilities and rationalizing performance outputs; widening the scope for
involvement of local bodies, non-governmental organizations (NGOs), etc. Table
2 gives a broad idea of the policy areas, the direction and nature of such
innovations and names of the pioneer states. The initiatives taken and the
outcomes are impressive when analyzed in reference to wide disparities in
income and socio-cultural behavior, a fast-changing economic scenario,
comparatively unstable political environment (in several States) and a near
 Health Sector Governance and Reforms in India 231

stagnant average per capita investment in primary health care of Rs 105. Despite
the reduced health spending as a result of fiscal pressures that States faced during
this period, most of them took advantage of available opportunities to achieve
whatever they could, underscoring the fact that a limited level of investment
can only give a commensurate level of outcome. Notwithstanding the above
factors, five serious omissions occurred in the public health policy: (i) the private
sector was encouraged without provisions for regulations, standards and
accreditation processes; (ii) there was an absence of surveillance and
epidemiological surveys to get a more accurate understanding of the changing
profile of disease prevalence and incidence, which is necessary for measuring
risk factors, designing interventions and launching information campaigns to
reduce risky behavior; (iii) advantage was not taken of the 73 rd and 74th
Constitutional Amendments for decentralizing program implementation to the
local bodies/community for increasing accountability in the system; (iv) neglect
of research and development to promote technological innovation; and (v)
inadequate investment in developing the critical mass of required skills and
human resources. In other words, the governments ran public health programs
that would have been more cost-effective for the communities and local bodies
and in the process neglected their more fundamental responsibility of
governance- of laying down a framework, defining the rules of the game and
monitoring systems to see that no player takes undue advantage in the health
sector.

Phase III (post-2000): National Health Policy II, 2002

By the year 2000, India had still not achieved 13 out of the 17 goals laid
down in the first National Health Policy of 1983. Analysis of the 52nd Round
National Sample Survey (NSS) on the utilization of health services showed that
during 1986-96, there was a decrease in the utilization of public facilities for
outpatient care from 26 per cent to 19 per cent; a decrease in access to free care
from 19 per cent to 10 per cent and an increase in the number of people not
seeking health care due to financial incapacity.
State-wise comparisons showed that the poorest people in the poorer States
of UP and Bihar had to pay substantial amounts for outpatient treatment resulting
in low utilization of public facilities, indicating an appalling breakdown of the
public health system. On the other hand, in Assam and Orissa, a large proportion
of people did not avail any treatment at all. If these statistics are considered
along with the number of untreated ailments due to financial reasons, the picture
is dismal, as it further reiterates the failure of the public health system in providing
risk protection to the people who are in real need of it. Since the average cost of
 232 Liberal Studies , Vol. 2, Issue 2, July-December 2017

outpatient treatment for every episode of illness is equivalent to three to five

days’ wage of one earning member of the family, this is a virtual breakdown of
the system.
Alarmed by the falling levels in the utilization of public facilities, and to
reduce the burden of disease affecting the poor, the government brought forth
the National Population Policy (2000), the National Health Policy (2002), and
the AYUSH Policy (2000), reiterating its resolve and commitment to achieve a
set of goals by 2010. The goals envisaged were: to increase public investment
in health from the current level of 0.9 per cent to 2 per cent 3 per cent; to
increase the utilization of primary care facilities from less than 19 per cent to
over 75 per cent; to reduce the MMR by three quarters from the current level of
over 540 per 1000; to reduce the IMR from 62 per 1000 live-births to less than
30, eradicate polio, eliminate leprosy, reduce deaths on account of TB and malaria
by over 50 per cent, etc. Many of these objectives are in consonance with the
Millennium Development Goals (MDGs) for 2015. The following section will
highlight the inherent issues that may constrain the government from achieving
these goals within the given time-frame unless addressed on a priority basis and
immediately. Some of the relevant data presented below has already been
discussed above.

Organizational Structure of the Public Health Sector Delivery System

There has been a clear absence of any deliberate strategy to use the
organizational tool for achieving public health goals, except family planning,
until the Sixth Five-Year Plan when, under the Minimum Needs Program,
concerted efforts were made to focus on expanding access to primary care in
rural areas. Thus, built over several years, the public health delivery system
consists of a large number of dispensaries, primary health care institutions, small
hospitals providing some specialist services, large hospitals providing tertiary
care, medical colleges, paramedical training institutions, laboratories, etc.
The failure to improve the health status, to be accountable and responsive
to people’s needs or to protect them from financial risk has brought into focus
the functioning of the public health system, underscoring its failure in fulfilling
many such legitimate expectations. The focus of this section is to understand
the causal factors that have led to such a failure. These causal factors can be
divided into three broad groups:
1. Poor goal setting and lack of formulation of strategic interventions;
2. Management Failures;
3. Limited role of the State.
 Health Sector Governance and Reforms in India 233

Goal-setting and Strategic Interventions

The public health system is inaccessible, disconnected from public health
goals and inadequately equipped to address people’s expectations. For the
majority of citizens, the public health system is out of their reach due to distance,
lack of money, lack of confidence in the system or the availability of a cheaper
alternative. The organizational structure requires a villager to travel an average
distance of 2.2 km to reach the first health post for getting a Paracetamol; over
6 km for a blood test and for nearly 20 km for proper hospital care. Given the
poor road connectivity, the unreliability of finding the provider at the health
centre, the indirect costs for transport and wages foregone, the marginal cost of
availing a public service far outweighs that of getting some treatment from the
local quack. Further, even when accessed, there is no continuity of care
guaranteed5. In other words, the segmentation of the health system into primary,
secondary and tertiary, administered and monitored by different bodies, with no
coordination in their working, has resulted in the dilution of the concept of the
integral nature of health care wherein curative services have become a continuum
of the preventive health care, promoting health
In eight States, substantial investments were mobilized from the World Bank
to upgrade, strengthen and establish hospitals at the district, sub-district and
block levels. The comprehensive definition of the primary health infrastructure
(Health for All Report of 1980) however got further distorted with the community
health centers (CHCs) being rechristened as first referral centers (FRUs),
divorcing them from their contextual framework. In Andhra Pradesh, Karnataka,
Punjab, etc. the World Bank-funded CHCs were brought under the administrative
control of autonomous Directorates dealing with secondary level hospitals while
those CHCs not covered under the project continued to be administered by the
Director of Health Services. An evaluation report of West Bengal, AP, Karnataka
and Punjab showed that while these states were successful in improving the
quality of care in urban and semi-urban areas (Table 5), an expected outcome,
such as, for example, an increase in institutional deliveries was not realized.
Had the focus been on establishing the referral system and linkages with the
other World Bank-assisted disease control and Reproductive and Child Health
(RCH), investments made for strengthening the health systems would have had
a considerable impact on reducing maternal, neonatal and infant deaths, or deaths
due to malaria, TB which require hospitalization. This experience clearly
demonstrates that mere increase in investments in infrastructure does not
automatically translate into better health outcomes.
It also underlines the urgent need for conceptual clarity on the expectations
of the organizational structures that have been established and the urgent need
 234 Liberal Studies , Vol. 2, Issue 2, July-December 2017

for standardization of facilities across the country. Shortage of funds has been
primarily responsible for the non-availability of facilities in accordance with
the norms set by the government; and inadequate provisioning of critical inputs
such as drugs, equipment, facilities such as operation theatre, etc. Due to lack
of budgets and the pressure to achieve targets, several States upgraded the two-
roomed sub-centers to PHCs with no place for laboratory, examination,
pharmacy, etc. Most of them are non-functional. There are PHCs with over 33
sub-centers and there are sub-centers which cover over 200 habitations. It is
estimated that 25% of people in Madhya Pradesh and Orissa, and 11% in Uttar
Pradesh could not access medical care due to hospital location reasons (NSS-
India Health Report, 2003).
The question that arises then is to what extent was infrastructure an important
determinant in health outcomes? Was there any association? Box 1 reveals the
mockery we have made of the health care service delivery system by having
sub-centers function in non-standardized places, denying dignity and privacy to
women who visit the ANM for treatment and care. Some of the evidence gives
the levels of utilization of the PHC facilities. It links outcomes with the
infrastructure to examine if there is any such association. What emerges from
the data is that while in the poorer performing States, the ratio of facilities to
100,000 population are on par with the rest of the States, and even better than
that in Andhra Pradesh and West Bengal, the health outcomes are poor. This
shows that it is not mere establishment of a physical facility but a combination
of factors such as distance, availability and quality of skills, adequacy of
infrastructure and access to alternative sources of care that seem to influence
health-seeking behavior and determine outcomes which have been captured by
a set of indicators such as complete immunization, percentage of those severely
malnourished, full antenatal coverage, safe and institutional deliveries and finally,
the IMR and the under-five mortality rate (U5MR). While it is clear that
infrastructure development had little linkage to goal setting, it is also seen that
policy interventions per se often lacked focus, were not based on hard evidence,
and had weak institutional capacity to translate policy into action.

Weak Evidence Base for Interventions

Neither the Ministry at the Centre nor at the State level has adequate in-
house capability to design research studies, collect data and analyze research
findings of the various health interventions to enable evidence-based policy-
making. Substantial resources are being spent on programmes and interventions,
which have a poor evidence base. For example, there is no evidence to indicate
the current burden of malaria, or maternal mortality. Similarly, hardly any studies
 Health Sector Governance and Reforms in India 235

are available to assess the efficacy of the use of a drug or of a treatment protocol
in different settings and conditions for formulating differential strategies to suit
the diverse conditions prevailing in India.
Such non-availability of good quality research for evidence based policy
formulation is one instance of the health delivery system failing to see the woods
for the trees. For example, the principal goal of the National Reproductive Health
Program is to reduce maternal mortality. Over 100,000 women die every year
due to pregnancy-related reasons that necessitate skilled attendance and some
surgical interventions. The international definitions of skilled attendants
disqualify either the traditional birth attendants (TBAs) or the 18 months’ trained
ANMs. Surgical interventions on the other hand require some basic infrastructure
such as access to blood, an operation theatre, access to personnel skilled in
surgery and administration of anesthesia, etc. Hence, public policy should have
been focused in all these years on making investments on development of the
infrastructure and building-up of a professional and skilled cadre of attendants
for facilitating safe and institutional deliveries. Instead, the focus was on
prohibiting the available care in the form of TBAs and ANMs. The failure to
link intervention with evidence has resulted in poor outcomes.
The organizational strategy consisted of three concepts: (i) Village-level
clinics conducted by a professional health team consisting of a medical doctor,
a trained nurse, laboratory assistant, etc. to provide antenatal care (ANC) and
examine other ailments, with the auxiliary nurse attending to the mandatory
registrations of all pregnant women, other public health duties and promoting
institutional deliveries, etc; (ii) Investment in establishing well-equipped
maternal and child health (MCH) clinics/hospitals for delivery; and (iii) a strong
health management information system (HMIS) and monitoring system including
a regular medical audit of every maternal death for taking corrective action.
Compared to the above factors, India for several years promoted training of
village-based TBAs, consistently lowered the quality of training and
competencies of the ANMs and neglected supervision and monitoring.
Resorting to such low-cost solutions helped avoid committing resources
required for the establishment of the requisite infrastructure and human resource
development. The example of MMR is useful as it is a good proxy for
demonstrating the effectiveness of the health system. A similar mismatch between
goal and strategic intervention is evident in the case of reducing the IMR. While
40 per cent of deaths take place within one week of birth, and nearly 23 per cent
on account of upper respiratory tract infections and diarrheal diseases, strategies
required to address these causal factors have been overshadowed by the
 236 Liberal Studies , Vol. 2, Issue 2, July-December 2017

immunization programs, particularly the one for polio. The single-point pursuit
of polio eradication has resulted in adversely affecting the routine immunization
program, which was initiated in 1986 as a Technology Mission for achieving
full protection against all vaccine- preventable diseases by 2000. As per a
household survey conducted in 1998 and again in 2003 (Indian Institute of
Population Sciences 2004), the data for 220 districts showed that in the majority
of the districts, there was either a declining performance or no improvement at
all under the Universal Immunization Program (UIP).
Second, the high percentages of drop-outs for oral poliomyelitis virus (OPV3)
indicated the wrong perception among mothers of the need to adhering to the
immunization protocol (Table 6). Discussions with field staff seemed to suggest
that this decline was largely on account of the emphasis given to polio, which
not only commanded better resources and visibility in the media but also
consumed nearly one-third of the time, 30 times the cost and exhausted the staff
in 2003, the Government of India (GOI) had to dispatch half the departmental
officers to oversee the Pulse Polio Initiative (PPI) Round due to resistance from
the local staff which had got tired of participating in one campaign after another-
4 rounds of PPI with each round requiring one whole month of preparation, two
family health awareness programs camps of the National AIDS Control
Organization (NACO), health melas of the GOI, leprosy household rounds for
identification of left-out cases, registration of patients with guinea worm
infection, RCH camps, family planning targets, and so on. Such isolated
programmatic approaches have made it impossible to allow the health system
to develop. Therefore, even as we get set to achieving zero polio prevalence in
India, the question of whether vertically driven strategies implemented in a
campaign mode, which are also resource intensive and neglect equally important
public health functions, are worthwhile or not still remains unanswered.

Inadequate Capacity to Plan and Implement at the Centre, State, and

District Level
Failure to develop a public health cadre and widening the eligibility criteria
to include clinicians, without making public health training a mandatory
requirement for working in posts that need public health skills, have adversely
affected the implementation of public health programmes. Non-reservation of
posts or the absence of a dedicated public health cadre have also reduced the
employability of persons trained in public health resulting in an accumulated
shortage of the critical mass of epidemiologists, biostatisticians and other
personnel. With radiographers, orthopaedicians, surgeons working as an
Additional Chief Medical Officers (ADMO) in charge of the RCH program or
 Health Sector Governance and Reforms in India 237

programmes for malaria or TB, or IAS officers as project officers of HIV/AIDS,

etc., the lack of technical capacity in providing the required level and quality of
leadership at the State/district-level has been a serious handicap. Mavlankar
(Mavlankar 1999), persuasively argues that one reason for the successful
implementation of the maternal health strategies is that the availability of
technical capacity to design and monitor at all levels, from the village to the
Central Government. In India with a billion populations has one Director- level
officer for MH in the Ministry of Health at the Centre. Besides the gross
inadequacy of the number, technical posts in the Central Government are manned
by personnel drawn from the Central Health Service with no fixed tenure or any
pre-qualifications. For example, a Director of MH should have knowledge of
public health, obstetrics and midwifery and related fields. While so the personnel
of the Central Health Service have a distinct handicap of not only not having
these technical qualifications but also no experience of working in a PHC or a
CHC, made worse with no field training upon recruitment as is the case with
Indian Administrative Service (IAS) officers.
Lack of technical expertise and non-availability of the critical mass or a
minimal number at the Central and State levels are reasons for public health
programs lacking in focused designing, development of national treatment
protocols and standards, the non-integration with other related sectors/ such as
TB with HIV, HIV with MH, MH with malaria, health with nutrition or water,
etc.; or absence of technical leadership in States and districts on the
operationalization of interventions based on technical norms; or assessing and
building up of technical skills and human resources required by the program.
Most importantly, this absence of adequate technical skills have also been
responsible for the near absence of operational research for obtaining the
evidence base for designing better targeted programs in keeping with the wide
social and geographical disparities that characterize India. Instead, at the Central
and State levels, almost 40% of the time of these ill-equipped officers in charge
of complex programs is spent in attending to administrative duties.
The situation in the States is no better. A survey conducted in six States to
assess the technical capacity of these States for maternal health (MH) programs,
(or for that matter malaria) showed that except one Deputy Director-level officer
in Kerala, in none of the other five States of Tamil Nadu, Maharashtra, Rajasthan,
Gujarat and Chhattisgarh was there even one officer exclusively earmarked for
monitoring the maternal health program (Mavlankar 1999). The situation in the
districts is worse. The void in the unavailability of such capacity for surveillance
and monitoring at district levels has temporarily been addressed under the TB
control and Polio Pulse programs by taking persons on a contract basis-many
 238 Liberal Studies , Vol. 2, Issue 2, July-December 2017

from the government itself, thus further weakening the already fragile technical
capacity required for implementing the large number of government programs.
In addition, there is also the question of the State Governments ability to sustain
these program-based consultants after withdrawal of external support.
The collection and review of data is hardly given any importance, leave
alone analyzing it for future planning. Monitoring is essentially confined to the
bare minimum of NHP targets and now, polio pulse immunization targets. In
the absence of any system of surveillance or epidemiological data gathering,
planning interventions lack an evidence base and also make it impossible for
the system to be responsive to felt needs. A study conducted in Zenana Hospital
in Udaipur, Rajasthan found that during 1983-93 nothing had changed despite
the improved road network and awareness levels.6
The researcher further observes that the failure of the system to provide
ambulance services, which resulted in incurring expenditures on transport
ranging between Rs.150 and 300, borrowed from moneylenders ‘leaving the
people poorer both materially and emotionally when despite their desperate
efforts the woman’s life could not be saved’. The study also showed that during
this period while there was a drop in eclampsia, there was a six-fold increase of
deaths on account of malaria induced anemia and abortions induced by
unqualified practitioners ‘Abortion and emergency obstetric services remain
almost unavailable to the vast majority of the rural women.’

Inconsistent Procedures
Rules and procedures do not synchronize with objectives of a program or
foster any accountability among the functionaries. For example, unsafe abortion
is said to cause at least 8 per cent of all maternal deaths. Yet field surveys
showed that untrained and unqualified providers in the informal sector routinely
conduct illegal abortions. This flourishing clandestine business is because of
government procedures that take over fifteen months for getting a centre certified
the conflicting provisions such as the requirements for a person trained in medical
termination of pregnancy to be working at the centre, but then having no facilities
to train such private providers, etc. It is for such reasons that a large State like
Rajasthan has only 338 certified private facilities with 78 per cent of them in
nine districts, five districts having no private facility and six having one7. With
no effective intervention to ensure government facilities having all the required
skills, equipment and drugs, the number of deaths due to unsafe abortions remains
high.
 Health Sector Governance and Reforms in India 239

Management Failures
Management failure due to a combination of reasons such as low budgets,
untimely and irregular supplies, corrupt practices and poor governance has
adversely affected the functioning of the health system. The dispersed and
disaggregated nature of responsibilities and conflicting job profiles make
accountability a difficult proposition. While the Secretary of the Department of
Health has no control on when and how much money will be made available to
implement programs, the medical officer (MO) in the peripheral centre has no
administrative powers over the front-line workers and other functionaries
working under him. With most supplies such as vaccines and drugs being
provided by the Centre for the NHPs, the States have little control to ensure
outcomes, as in several instances procurement delays by the Centre can take as
long as over one financial year, affecting the credibility of the system. All these
factors have serious implications for the quality of management and efficiency.8

Conclusion
The overview of the plans and policy reports not only throws light on the
gap between the rhetoric and reality but also the framework within which the
policies have been formulated. There has been an excessive preoccupation with
single purpose driven programs. Above all, the spirit of primary health care has
been reduced to just primary level care. The health reports and plans mostly
concentrated on building the health services infrastructure and even this lacked
a sense of integration. Most of the policy reports miss out on the importance of
a strong referral system. Instead, there has been more emphasis on building the
primary level care and even that has lacked proper implementation. The Bhore
committee report and later, the Primary Health Care Declaration discussed the
operational aspects of integrating the other sectors of development related to
health. The multi-sectoral approach that is much needed and the inter-sectoral
linkages that are essential for a vibrant health system have not been well thought
out, and there has been no plan drawn out for it later. The outline of plan
documents and their implementation have been incremental rather than being
holistic. It is important to question whether it is only the low investment in
health that is the main reason for the present status of the health system or is it
also to do with the framework, design and approach within which the policies
have been planned.
Technological advances, profitable investments and good policies can be
turned to naught in the presence of a system lacking in leadership, direction and
a core sense of integrity, pervading all the levels of health care. Unless all
stakeholders are motivated by a set of values: of compassion and human concern
 240 Liberal Studies , Vol. 2, Issue 2, July-December 2017

for the sick and ill and of not accepting a system which allows people to be
denied health care due to circumstances beyond their control; the sense of
equality and dignity in the health system will continue to reflect the cement and
mortar issues of the expanding medical and drug industry, which can, in the
absence of the guiding hand of the state, degrade human suffering into an
opportunity for making profits. It then becomes critical to define the role of the
State as the current utilitarian liberal approach of the health sector offers no
acceptable solution. The issue is broader and needs to be examined within the
context of the principles that underlie the concept of social contract of Rousseau
or sense of justice of Rawls. If these principles enshrined in our Constitution
are adhered to, then the State will need to intervene both intelligently and firmly.

Notes
1. Debabar Banerji, Health and Family Planning Services in India: An Epidemiological,
Socio-Cultural and Political Analysis and a Perspective, Lok Paksh, New Delhi, 1985.
2. K.S. Warren, “The Evolution of Selective Primary Health Care”, Social Science and
Medicine, Centre for Communication Programmes, Johns Hopkins Bloomberg School of
Public Health, 1988, Vol. 26, Issue 9, pp. 891-898.
3. WTO, “The World Health Report 2000”, Health Systems: Improving Performance, World
Health Organisation, Geneva, 2000.
4. William C. Hsiao, “Unmet Health Needs of Two Billion: Is Community Financing a
Solution?”, Discussion Paper on Health, Nutrition, and Population Family (HNP) of the
World Bank’s Human Development Network, The International Bank for Reconstruction
and Development / The World Bank 1818 H Street, Washington, D.C., 2001.
5. P.D. Sen, “Community Control of Health Financing in India: A Review of Local
Experiences, Bethesda, Maryland”, Abt Associates, Partnerships for Health Reform, xvii,
Technical Report No. 8, USAID Contract No. HRN-5974-C-00-5024-00) October 1997,
p. 83.
6. V. Pendse, “Maternal Deaths in an Indian Hospital: A Decade of No Change?”, in Safe
Motherhood Initiatives: Critical Issues, eds. by Marge Berer and T.K. Sundari Ravindran,
Oxford, England, Blackwell Science, 1999, pp. 119-26.
7. Kirti and Sharad Iyengar, “Elective Abortion as a Primary Health Service in Rural India:
Experience with MVA”, Reproduction Health Matters, 2002, Vol. 10, No. 19, pp. 54- 63.
8. D.V. Mavalankar, “Study of Technical top Management Capacity for Safe Motherhood
Program in India”, Study Commissioned by the World Bank, New Delhi (Unpublished
Monograph).