~ Pergamon Elsevier Science Ltd. Printed in Great Britainanth.sites.olt.ubc.ca/files/2013/03/Reconsidering-the... · 2016-03-30 · ~ Pergamon 0277-9536(94)00309-2 Sot'. Sci. Med.

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Sot'. Sci. Med. Vol. 41, No. I, pp. 87-98, 1995 Elsevier Science Ltd. Printed in Great Britain

RECONSIDE RING THE POPULARITY OF PRIMARY HEALTH CENTERS IN INDIA: A CASE STUDY

FROM R U R A L M A H A R A S H T R A

V I N A Y R. K A M A T

Department of Anthropology, Haury Building, University of Arizona, Tucson, AZ 85721, U.S.A.

Abstract--Most evaluations of India's primary health care (PHC) program have been critical of the ways government primary health centers have been functioning. It has been commonly noted that utilization of health services is poor and community participation in the PHC outreach program low. Additionally, medical officers and health center staff are often accused of being negligent in their duties. In this paper I argue that it is worthwhile examining how a popular primary health center functions in a context marked by a growing demand for Western medicines. Attention is drawn to the ingenious ways in which health personnel respond to client demands and government medicine shortages. The case of a popular primary health center in rural Maharashtra is presented. This health center is both the site of public and private health care. Discussed is the manner in which rural populations in India maximize available health care options given time, cash and transportation constraints. Current thinking about community health financing is considered in light of existing hea:.th care utilization patterns, community evaluation of free services, perceptions of entitlement and the likely response of practitioners to such schemes.

Key words--primary health care, private practice, community health financing, India

INTRODUCTION

The primary health care (PHC) program in India has been the subject of several evaluation studies conducted from both a macro- and micro-level perspective. Most studies have been quite critical of the ways government primary health centers have been functioning and have painted a rather dismal picLure of the prospects for improving the situation [1-4]. A common assertion made is that while an impressive PHC-inspired policy has been formulated at the national level, its implementation has been effectively forestalled by those with vested interests in maintaining the status quo. Little discussed has been the question of how the public has responded to over a decade of PHC-inspired speeches and programs in the light of their perceived health needs and demands. Also unaccounted for is how health care workers employed in the health bureaucracy respond to demands of the public.

The purpose in this paper is to address these two issues by drawing upon a study conducted in a region of rural Maharashtra, between June 1989 and February 1990 [5]. I argue that PHC, as implemented in rural India, needs to be reconsidered in relatio:n to the growing demand for Western-based medicines, existing patterns of health expenditure and the ingenious ways in which health personnel responcl to client demands. The intentions of the government to meet the felt health needs of the rural people through state-sponsored PHC initiatives are being realized,

though not in the manner stated in the government 's health policy. Government-run primary health centers have become sites where public, as well as private, health care is provided to the community.

Health center doctors in India often engage in private practice and charge their patients fees for their service. This situation has been described in relation to the profit motives of health personnel. I argue that this explanation is too simplistic. Priva- tization of the public health sphere in rural India is, in large measure, an outcome of client demands on a health bureaucracy which has fostered unrealistic expectations in an environment of scarce resources. The use and functioning of primary health centers need to be reconsidered in light of co-existing health care options, economic contingencies and consumer demand. Such consideration may provide useful insights into the potential of community health financing initiatives presently being discussed in India.

In this paper, I begin with a brief description of the research setting followed by a discussion of why the primary health center selected for the study was so popular. My impressions are based on 3 months of observational data, informal discussions with the personnel at the primary health center and the find- ings of a household health survey which focused on health center utilization and community participation [6]. I then turn to lessons learned which bear rel- evance to current thinking about community financing of health care in rural India.

87

88 Vinay R. Kamat

RESEARCH SETTING AND METHODOLOGY

The study area is situated approximately 150 km north of Bombay. Primarily rural, with a mountain- ous terrain, the region of Maharashtra is drought prone and classified by the government as backward in terms of overall socio-economic development. The region is populated by a mix of tribal and non-tribal people, in approximately a 1:3 ratio. The Kunbi- Maratha caste, which is predominantly agriculturist (peasant cultivators), constitutes the dominant peasant caste group in terms of numerical strength, landholding and economic and political power. The catchment area of a local primary health center provided the universe for a household health survey [7].

Six primary health centers are located in the taluka (a sub-district), and the closest health center to the one selected for study is located 6 km away. The health center selected for the study was relatively popular, had a good record of achieving government health targets and served a good mix of tribal and non-tribal populations. Its choice was related to my interest in conducting a case study of a popular primary health center which appeared to be functioning well according to official statistics. At the time the study was conducted, the health center had 18 staff members: one medical officer with a graduate degree (M.F.A.M.) in ayurvedic medicine, one sanitary inspector, one co-ordinator, one lady health visitor (LHV), two nurse-midwives (NM), three male multipurpose workers (MPW), seven auxiliary nurse- midwives (ANMs), one compounder-cum-clerk and one female attendant who had been working at the health center for the past 20 years [8]. The health center had been evaluated by the district health authorities as the second-best primary health center in the district for 2 years running on the basis of immunization and family planning targets achieved. It enjoyed the patronage of a well-known local politician (a member of the parliament for four consecutive terms). The health center was centrally located at the edge of the main road, which cut across a busy market place. The state transport bus stop was located near the entrance of the health center. The health center was surrounded by a compound wall, and living quarters for the staff were located inside the compound [9].

Key informant interviews were held with the health center staff, patients and community members from both tribal and non-tribal groups [10, 11]. Obser- vations of the doctor's interaction with patients were made over a 2-month period during which time I lived in the community. Additionally, a household interview schedule was developed, pre-tested and administered to a sample of 328 households chosen by a multistage stratified (cluster) sampling method. The sample households consisted of 233 non-tribals and 95 tribals. A strategy of proportional to population size sampling was adopted in each area covered

by five sub-centers of the health center to ensure the geographical representation of the study population. A total of five villages and seven tribal hamlets (padas) falling within a radius of 5 km from the health center were covered. These were selected after controlling for their size and distance from the sub- centers and the health centers. Eligible respondents were male heads of the household [12]. Topics covered by the household interview schedule included utilization of the health center, attitude toward the health center personnel, use of the health center's outreach services and participation in the health center's programs.

HEALTH CENTER DOCTOR

Of central importance to this paper is the health center medical officer. In his late forties, the doctor lived with his wife and two teenage daughters in the staff quarters located inside the premises of the health center. His surname and the accent with which he spoke the local language--Marathi--suggested that he was not a native of Maharashtra but hailed from North India. As I got to know him, I learned that he had migrated to Bombay from Rajasthan 20 years earlier. The recipient of a degree from an ayurvedic college, he had initially worked for 2 years as a doctor in an ayurvedic hospital. After joining the rural health services department of the Government of Maharashtra he worked as a medical officer at a primary health center for 18 years. Notably, he worked in the same taluka for this entire period. This is extremely rare for a primary health center doctor in rural India. Most government doctors are transferred or they resign from their jobs within a few years of joining their post.

At the time of my arrival, the post of chief medical officer in the health center had not been filled for over 7 months. The aforementioned doctor was the sole medical officer at the health center although he only had an ayurvedic degree. Toward the end of my fieldwork, the chief medical officer's post was filled by a doctor who had an M.B.B.S. degree and was preparing for his M.D. qualification. He was approximately 15 years younger than the doctor with the ayurvedic degree. Tensions related to status and reputation arose between the two doctors and this affected the functioning of the health center [13].

PRIVATIZATION OF THE PUBLIC SPHERE: CLIENT DEMANDS AND RESPONSE OF THE HEALTH

BUREAUCRACY

Following intermittent visits to the health center to acquaint myself with the research setting and to establish rapport with the staff, I spent several weeks living on the premises, sharing staff quarters with a senior multipurpose worker [14]. While at the health center I sat in the out-patient department (OPD) observing doctor-patient interactions and engaging

Popularity of primary

in informal discussions with the staff members, especially the doctor [15]. My evening hours were normally spent at the residence of either the doctor or the sanitary inspector. Informal discussions commonly centered around the local political scene and problems related to implementing top-down directed PHC programs, meeting targets and so on [16]. The health center was generally quite busy. Long queues of patients and accompanying family members would wait for hours before being able to see the doctor. On an average day, the doctor had to deal with about 150 out-patients during duty hours plus l0 in-patients. Given the short time spent with each patient and limited stock of government medicine, I wondered what it was that made this particular primary health center so popular. Had it something do with the doctor's personality or reputation for healing compared to other doctors in the region? Or was there something unique about this health center and its staff that attracted so many people?

Informal discussions with key informants suggested that the popularity of the health center was closely linked to the services provided by the doctor.

One informant noted:

There is nothing special about this PHC [17]. It's all because of this doctor. People come and flock at this PHC because of him. Everyone knows that his power of hand (haat goon) is good [18]. After all, he has been here for years now, and has become a 'master of illness' of the local people. Tomorrow if he is transferred to some other PHC 'that PHC' will become popular overnight, and this one would lose its attraction. All these people will go to him, wherever he is. People will continue to come from long distances to seek his treatment. Some of his patients even come from the neighboring taluka.

The doctor took great pride in pointing out to me patients who came to consult him from long distarlces as a result of his good reputation. His long stay in the locality and opportunity to deal with so many patients over the years had earned him community trust. People perceived him as being adept at diagnos- ing and treating 'local health problems' and 'illnesses of the local people'.

Although the doctor had received formal training in ayurvedic medicine, with only a short training course in 'emergency allopathic medicine', he almost exclusively gave allopathic medicine to his patients. Patients had confidence in the doctor's broad knowledge of modern medicines and his experience in using government medicines [19, 20]. However, I was also told by key informants that the doctor had become 'money minded' and because of this his reputation was declining [21]. If the doctor had become 'money minded' and was charging patients fees for service perceived to be high, why were local people continu- ing to consult him and why were the community leaders not doing something to stop the private practice of this health center doctor? Was it because they felt there was little that they could do? Was it because the doctor was indispensable to them? Did lack of response reflect a fatalistic attitude? No doubt

health centres in India 89

the district level health authorities were aware that the doctor was charging patients fees for service. Why was nothing being done about it?

Answers to these questions entail a broader appreciation of patient demands, health center resources, indirect and opportunity costs involved in seeking care elsewhere and the complex transactions that take place between the local people and the health center doctor.

Sitting in the OPD with the doctor, I observed that he often gave his patients the option to choose between his private (khazqi) service, government (sarkari) medicine or a prescription [22]. The social status of the patients, as well as their purchasing capacity, played a significant role in determining which option was offered and chosen. Many people specifically requested the doctor's private services. They indicated at the start of the consultation that they would be willing to pay. In other cases, a suggestion was made by the doctor that 'some medicines' were not freely available, a comment which indirectly invited the patient to request 'special' (khas) or 'good' (bhari) medicines. This choice altered the type of attention received as well as medicine administered. In some cases, patients con- suited the health center doctor to see if the case was serious enough to warrant treatment necessitating special medicines. Initially, they approached him as a public servant for diagnosis. If the illness was serious, they then approached him as a private doctor who could offer good medicines at a cost. Very often what initially appeared to be a free consultation at the health center turned into a private consultation with the doctor at his residence after 5 o'clock.

Toward the end of my study, I asked the doctor about the ethics of private practice. After all, as a government doctor be was paid, in addition to a salary, a non-practicing allowance intended to curtail moonlighting. Instead of being defensive, the doctor was quite willing to discuss his flourishing private practice, conducted both at the OPD of the health center and his residence on the health center grounds after hours. The following section of an interview summarizes his point of view.

Do you see that long queue outside? I have to deal with as many as 150 cases like this every day. These people will not go back satisfied unless I have given them some medicine. Patients would be very happy if I give them an injection. But how can I give every patient who comes here some medicine from the government stock free of charge? I get a fixed quota of medicines from the government which gets depleted in no time. Some of the medicines supplied are useless for the local conditions. I have complained to the district health officer about it several times. Don't you think the Government should supply a sufficient quota of medicines taking into consideration the OPD load of this PHC? People treat this PHC as if it's a hospital. You know what they call me--uncle (kaka), and they think I'm a 'cure-all' doctor. I have my reputation to protect. If I refuse giving them medicines, they will all get angry and spread a bad name for me. So I purchase medicines on my own and share it between patients and charge them for it. Is anything

90 Vinay R. Kamat

wrong in my doing that? But they will say that I'm 'looting' them. If I refer them to the taluka hospital or give them a prescription, they will say that I'm not 'treating' them and avoiding my duty. It's such a difficult job. You tell me what would you do if you were in my place? Let me also tell you there are many who feel that it is below their dignity to be in the queue; others have no patience. They prefer to see me in the evening hours at my residence and expect me to give them khazgi medicines. They can afford to pay. Some of them are well to do; others are local politicians. I have to please them; be in their good books. Actually I'm fed up. You know what village politics is!

As seen by the public, the primary health center is a doctor-centered institution. The quality of curative treatment, not preventive health measures, determine its reputation. This does not correspond to the state's presentation of a health center as primarily being an institution providing preventive health services to the community. According to the health center staff, the doctor 's public image and managerial skills determine the popularity of the primary health center for both patients, staff and the community at large [23]. The performance of a health center doctor affects the capacity of its staff to reach health targets set by health authorities. Also important in determining the popularity of the health center is the community 's expectations of what services they are entitled to free and at a cost. One must bear in mind that in India incentive payments at government offices are more often the norm than the exception [24].

As mentioned earlier, the health center studied was evaluated as second-best in the entire district. What puzzled me was how a health center having a doctor who spent so much of his time and energy in the OPD was able to do so well meeting predetermined health targets (mostly family planning and immunization) [25]? Was this because of staff outreach efforts or did the popularity of the doctor and his private practice influence utilization of the health center's preventive services? I asked the doctor about the importance he gave to preventive versus curative services. In response, he showed me a neatly drawn weekly timetable, according to which he had to be in the field for half a day, at least three times a week. He then admitted that he rarely visited the villages. The reason he gave was that he had to attend to so many patients every day that it left him with hardly any time to visit the villages. Moreover, the vehicle at the health center had broken down and had been left unrepaired for months. He made it a point, however, to describe his work at the OPD as contributing to PHC preventive health goals. If he was able to offer to the community something they wanted, then their willingness to accept what the health center had to give (preventive health) would rise concordant with trust. This sentiment was echoed by other health center staff as well.

Family planning and immunization targets were aggressively pursued by the doctor and his staff. Their achievements were accomplished less by day-to-day encouragement and monitoring, and more by crash-

course tactics. During January and February, sterilization camps are conducted all over the taluka. All primary health centers and taluka hospitals have to meet family planning and immunization targets. The entire infrastructure of the taluka hospital (including vehicles and doctors) is mobilized to provide backup to family planning-related activities at all primary health centers. The 31st of March, which is the end of the official financial year in India, is the cut-off point for health authorities to conduct an 'audit ' of the performance of the primary health centers. A minimum of 12 family planning cases (normally tubectomy cases), is allotted to all health center field staff, six cases being allotted to staff working at the health center.

Cases were often referred to as 'my' case and 'your ' case by the health center workers as though they were commodities. The names of potential cases were jealously guarded. While the health center did not have a list of all households in its catchment area, a list of 'eligible couples' for family planning was meticulously maintained and updated. The threat of transfer to a more remote primary health center led health center staff to aggressively pursue their targets. Disputes over one staff member's 'stealing' another staff member 's family planning 'case' by allegedly bribing the potential/prospective candidate (or an important family member) to become his or her case were not uncommon. Also common was the practice of a staff member bribing the local birth attendants to persuade a potential case to go in for tubectomy. The bribe usually consisted of a sack full of grain plus 200 300Rs (16 R u p e e s = U S $ 1 in 1989). Local school teachers and other village level workers on the government 's payroll are also assigned family planning targets, and they too often resort to bribery and incentive gifts to meet their targets. One of my key informants, a gramsevak--a development worker, told me how he had become involved in a controversy over a 'case' with the health center staff. This had threatened not only his job, but his political ambitions in the region.

The politics of achieving health targets is the predominant concern of the health development bureaucracy. Methods for reaching targets are not officially questioned. Those who achieve targets are praised, while those who fail to meet their quota are criticized irrespective of other services provided. Because the health center studied achieved targets, it was not scrutinized. The doctor there was considered 'good' .

UTILIZATION OF HEALTH SERVICES

Health researchers have shown that health care decision-making in rural India is influenced by a complex of pre-disposing, enabling and service factors including lay notions of etiology and perceived severity; previous treatment experiences; practitioner accessibility and reputation, expectations from treat-


ment and consumer demands; time constraints and the micro-economics of health care seeking [26]. For most types of illnesses therapy choice is based on pragmatic considerations such as perceived afford- ability (cost reckoning), geographical accessibility and time constraints [27]. Health-seeking behavior is flexible. People switch from one medical system or source of therapy to another, or use the service,; of more than one practitioner simultaneously [28].

During preliminary fieldwork, I mapped the health care arena of the study locality and during the household survey I asked informants about their consultations with (a) the doctor at the health center, both as a public servant and as a private practitioner, (b) six popular indigenous practitioners, (c) two private registered medical practitioners (RMPs), (d) 18 community health workers (CHWs), (e) 23 trained birth attendants (TBA) and (f) the pharmacist in the local medicine shop. The pharmacy was the only shop in the village where people could purchase pre-packed medicines--Western drugs as well as commercially-prepared ayurvedic medicines. The shop was located in the hub of the main market place near the health center. According to some informants, the owner of this shop had an understanding with the health center doctor. They believed that he shared with the health center doctor a portion of his profits from drug sales and complimentary gifts from pharmaceutical companies [29]. I also asked informants about their consultations to the rural hospital located at the taluka headquarters--about 30kin from the health center.

A sample of 328 heads of households, from wilhin a radius of 5 km 2 from the health center, were interviewed. To get an idea of the nature and magnitude of illnesses affecting the study population, respondents were asked to provide information on the illnesses currently affecting any household member on the day of the interview. Recall of major illne.,;ses during the 4-month period prior to the interview were also recorded [30]. Reported illnesses and frank symptoms fell into 12 broad categories, ranging from cough/cold and diarrhea to TB and leprosy. "['he information collected was not intended to yield accurate data on disease prevalence, but rather to provide descriptive data on general patterns of curative resort. The first two resorts for any illness present or recalled were recorded. The order, but not the speed of treatment, was recorded.

In the majority of the cases recorded, the afflicted persons obtained relief from the first source of health care from which they sought treatment. More than half the sample households in the study locality reported approaching the health center doctor as the first resort to deal with a wide range of their illne,;ses [31]. This pattern contrasts markedly with pattern,,; of health care seeking reported in several other Indian studies. These studies document the popularity of home remedies and private medical practitioner's services [32-34]. Results of the survey demanded


scrutiny. Based upon a subsample of follow-up interviews, I strongly suspect that consultations with the health center doctor in his capacity as a private doctor were reported as a 'visit to the government doctor. ' Informants who paid for service often did not volunteer this detail until specifics of the consultation were probed. In other cases, an initial consultation with the government doctor for a diagnosis ended in 'private practice', defined by medicines received from the doctor's private stock.

Further analysis of the data showed that, in some instances, patterns of curative resort were illness specific. For illnesses such as jaundice/hepatitis (kavil), people preferred consulting a specific herbalist/bhagat although this often required travel- ling long distances. For worms, the local pharmacist was usually consulted as it was felt that there was little need for diagnosis of the problem. Past experience in dealing with a particular illness was one of the most important factors affecting treatment-seeking decisions. Once people knew that a medicine was effective for a particular type of illness, they often purchased it directly from the shop. The data support the notion that allopathic medicine is very popular among the people in the rural hinterlands, wherever it is available. This should not be interpreted to mean that the local population is ideologically committed to modern medicine. Shifts from one system of medicine to the next (from an indigenous practitioner, or a bhagat, to modern medicine or vice versa) tended to be pragmatic. They were most commonly reported when symptomatic relief was not realized after a few days. Other studies have shown that people often make simultaneous use of apparently divergent therapy systems. In the present study, this was rare, presumably for economic reasons. People waited to see the effect of one medicine before trying another.

Utilization of the health center's preventive health services

Details regarding the use of various services available to the public at the health center were also elicited from the respondents. Respondents were first asked about their awareness of the various services available at the health center [35]. They were then asked if any member of the household had "ever utilized the services available through the health center at least once during the past 2 years." The frequency of utilization was not probed [36]. The survey revealed that at least one member of every household had utilized the out-patient department (OPD) services at least once. In 80% of households, one member had used immunization services; 63% had used antenatal and post-natal services, 62% had taken treatment for malaria; 62% had received oral rehydration therapy (ORS); 52% had undergone sterilization (mostly tubectomy); 51% had received post-operative care; 42% had attended eye camp(s) organized by the health center; 30% had utilized

92 Vinay R. Kamat

maternity (confinement/delivery) services; 20% had taken treatment for snake bite; another 20% for scorpion sting; 19% had accepted contraceptives; 11% had taken treatment for tuberculosis; 8% had taken treatment for dog bite; and 4% had taken treatment for leprosy. Contrary to expectations, ethnic background (whether the household was tribal or non-tribal) and household income were not found to have a statistically significant influence on the number of services utilized.

Non -utilization of services

Non-utilization of health center services was, in part, related to perceived need. Seventy percent of non-users who required antenatal care (N = 154) and post-natal care (N = 140) reported 'no felt need', and the remaining 30% stated that they were not aware of this service [37]. In the case of contraceptives, of 264 non-users, 73% reported 'no felt need' and the remaining 27% noted that they still wanted a child and had no interest in protection. With respect to sterilization, of 158 respondents interviewed, 30% reported 'no felt need', and the remaining 70% mentioned that they still wanted a child, often adding that they desired a male child. As for immunization, in 66 households where this service had not been utilized even once, 59% of the respondents mentioned that they were not aware of this service; 29% reported 'no felt need' and the remaining 12% were found to be childless.

Whether local people consult .field staff jor health problems

Asked if any household member had consulted health center field staff for some health problem in the past 6 months, 56% said yes (64% of tribals, 53% of non-tribals). When probed what was entailed in these consultations, 84% of respondents said that they had asked field staff for aspirin or chloroquine tablets and the remaining 16% reported receiving anti-natal and post-natal check-ups. Aside from medicines for fever or body pain, health center field staff were not consulted for other illnesses. Respondents noted their tendency to by-pass the sub-center and to go directly to the health center when they were ill [38]. This was reflected in the heavy out-patient department (OPD) load at the health center on any given day.

ATTITUDE OF THE LOCAL POPULATION TOWARD HEALTH CENTER STAFF

Many PHC evaluation studies in India have given the impression that the attitude of the rural population toward the government primary health center staff is predominately neutral, if not unfavorable. This is often cited as an important reason why PHC-inspired programs in the country have not realized more encouraging results [39]. In the present study, the attitude of the respondents was ascertained by recording responses to 12 attitudinal statements

[40]. Responses to these statements revealed that people were favorably disposed toward some aspects of the health center staff, but were critical of other aspects of their behavior. Seventy-four percent of the respondents felt that the health center had brought some health benefits to their households. The remaining respondents regarded the health center as a 'showpiece' (dekhava) of the government that did not serve their real health needs. Sixty-two percent believed that the health activities of the health center would contribute significantly to their well-being in the future [41]. Fifty-six percent of the respondents voiced the opinion that the field staff were efficient and hardworking and that they did their best to improve the health of the local people. Contrary to other studies, 61% of respondents did not feel that the staff discriminated between those who were poor and those who were better off [42, 43]. Fifty-one percent of the respondents stated a marked preference for the health center doctor as compared with two other local private practitioners who were practicing in the main village [44]. They felt that the doctor was competent to the extent that he could give them appropriate treatment for common illnesses of that place. Seventy percent of respondents mentioned that the health center doctor's power of hand (haat goon) was good and that the treatment he gave was generally effective.

With respect to criticism of the doctor and the health center staff, 62% of the respondents felt that, "all too often', the doctor redirected patients to the taluka hospital to evade his own responsibility. I discussed this perception with the doctor. He noted that he did refer many patients to the taluka hospital, but viewed this as acting responsibly given the severity of cases involved and his lack of resources and expertise. Patients in a very serious/critical condition were often brought to him for treatment. He refused to handle the case if he lacked expertise or if required facilities/medicines not available at the health center or in his staff quarters. He was fearful of compli- cations that might develop and mindful that deaths occurring at the health center could destroy his reputation.

Forty-four percent of respondents believed that the doctor's fees-for-service was unfair. For example, some believed he charged fees when no special medicines were required. Seventy-nine percent felt that the health center field staff rarely consulted the local people, but imposed their programs on them. Several respondents stated that health center staff activities were driven by a target agenda and that PHC programs were predetermined, not responsive to local needs.

WHY THE HEALTH CENTER WAS SO POPULAR

Health center popularity was ascertained by a set of questions which probed the relative popularity of all six primary health centers located in the taluka.

Popularity of primary health centres in India 93

Respondents were also asked to comment on the difficulties encountered when utilizing health center services. Ninety-six percent of the respondents stated that they preferred to visit the health center when medical need arose. Seventy-four percent indicated that geographical accessibility was the main reason for their preference. Another 17% stated that they sought treatment at the health center because the doctor was available most of the time, unlike at the neighboring primary health centers. The data suggest that the health center is popular because of its good location near the main market place, and the availability of the doctor, be his services free or for a fee.

When respondents were asked to note difficulties impending efforts to seek help at the health center, the most commonly reported problem (68%) was long queues and a lengthy waiting period. Twenty percent of respondents noted that they received superficial treatment by the doctor or were discriminated against by health center staff, and 4% said that the health center staff were discourteous. These factors led people to consult the doctor after hours as a private patient. Patient's ability to seek both public and private care contributed to the health center's popularity.

C O M M U N I T Y P A R T I C I P A T I O N

Community participation in PHC has been described in a number of ways, ranging from active involvement in decision-making about health care delivery to passive support of health care activities, and from the planning of services to mere 'consultation of the people'. In the rhetoric of PHC, participation is a process which facilitates the empowerment of the disadvantaged so that they will be in a position to safeguard their own interests. Several advantages of promoting people's participation in primary health care programs have been identified. For example, it is suggested that better communication between clients and health care personnel leads to the better tailoring of health care interventions befitting local conditions. Participation is attributed to help the bureaucracy respond to change and bringing abo at a more appropriate allocation of scarce health care resources [45].

There was still financial support for the CHW scheme in Maharashtra during the period of the research project although it ceased by the end of 1990 [46]. There were 18 CHWs on the payroll of the health center [47]. Local awareness regarding the activities of the CHWs was low. Most respondents believed that their CHWs were doing some nominal community health work for the health center which went unnoticed. The doctor and the staff members at the health center had little to say about what the CHWs should be doing. Local CHWs were primarily appointees of the local politicians (often their rela- tives or protegees), and any kind of questioning fi'om

the health center staff was perceived as inviting trouble. The doctor explained:

In principle, the scheme is good. But honestly, I really don't care what happens with the CHWs [48]. They don't help us in any way. Besides, I don't have to pay them out of my pocket. Their honorarium comes under a separate scheme, and my job is to hand it over to them. They come to show me their face once a month, and that is all. Its all politics, and I think its a waste of government money.

Queried on the survey were popular opinions about the community health worker plan and PHC rhetoric to 'place the health of the people in their own hands.' Also investigated were villagers' impressions as to whether community participation existed in any of the following forms: (a) community input into the planning, implementation or evaluation of health care delivery; (b) co-operation of the people with the health center staff in terms of voluntary contributions of cash, kind, labor and other resources to facilitate the implementation of PHC programs; (c) monitoring of health staff activities, including the lodging of complaints for staff incompetency; and (d) use of the local leadership to bring pressure on Health Center staff to ensure better services.

The survey data showed that, during the l-year period prior to the survey, a majority (60%) of the respondents had not interacted with field staff in any way which would indicate cooperation. The remaining 131 (40%) respondents had personally helped or co-operated with the health center field staff in implementing their programs. Thirty-seven percent of these 131 respondents had helped staff conduct immunization programs at the community level, another 34% had helped disinfect wells and 4% had helped in conducting family planning activities, including moti- vating eligible couples to seek sterilization. The remaining 25% said that they had helped the health center staff in 'every possible way', meaning in all their activities. Differences in co-operation were reported by tribals and non-tribals. Twenty-seven percent of the tribals and 45% of non-tribals said that they had cooperated with field staff. This striking difference between the two ethnic groups might be accounted for by (a) economic status: non-tribals are relatively better-off in terms of their socio-economic resources, a factor which enhances their opportuni- ties for participation, (b) the physical distance between the health center and the tribal padas and (c) the social distance between the Health Center staff and the tribals.

Out of 197 respondents who had not co-operated or participated in PHC program implementation, only a small percentage (17%) stated that 'non- availability of time' was the primary reason. The large majority (83%) mentioned simply that they had not had an opportunity thus far to take part in PHC program implementation and that their assistance had not been requested by the health center staff. People expected the Health Center staff to 'persuade' them to co-operate. For their part, health center staff

SSM 4 1 ' 1 ~

94 Vinay R. Kamat

displayed little interest in encouraging the local population to participate in health center programs aside from complying with requests for vaccinations and family planning. Discussions with health center field staff on the topic of community participation revealed that staff viewed the local people as unmoti- vated and unco-operative by their very nature. Most felt that it was useless trying to persuade them to get involved in their programs.

These data shed light on an important aspect of community participation in rural India. As Madan (1987) has cogently argued, in an ideal situation community participation is emergent, the initiative comes from the people themselves. Government agencies and NGOs may facilitate this process by providing guidance and start-up assistance. In reality, however, what generally happens is that:

Co-operation has to be sought and people have to be motivated to participate in health schemes [49].

Lodging complaints against the health center staff

Complaints are often lodged against government officials in India. However, only 6% of the sample said that they had lodged a complaint against a health center staff member during the year prior to the interview. Most complaints made against health center staff were oral complaints made to either the health center doctor or a local politician. Complaints mostly pertained to rude behavior, superficial treatment and non-visits of field staff to their village. The situation in the study area corroborates what Jeffery had to say about consumer pressure with regard to primary health care in India. He noted:

In India, in any case most consumer pressure tends to be weak, sporadic, local and specific and to disappear very quickly. Fairly typical is the pressure that can be generated over the siting of a primary health center. Politicians can mobilize local support for a decision that will favor one village over another. Sometimes this support can be sus- tained to challenge an apparently unfavorable decision using courts and channels higher in the political party. An unknown number of PHCs have been delayed or built in the 'wrong' place in this way. But maintaining pressure to ensure that the PHC is properly funded, staffed, and organized to make best use of its limited resources is often beyond local political resources [50].

While 61% of the survey respondents stated they had no grievances against the health center staff, the remaining 39% voiced specific complaints. These respondents were either fearful of repercussions if they lodged a formal complaint or felt that lodging a complaint was a futile exercise since there was no one to hear such complaints and take disciplinary action.

The local village health committee (VHC) is supposed to be the most concrete expression of decentralization and democratization of health. In the present situation, the VHC was dormant. Although the names of the members (most of them prominent local politicians) were prominantly displayed on the wall at the entrance of the health center, the committee rarely met to deliberate or hear

grievances from the community or the health center staff. Although regulations stipulate a meeting of the VHC every 3 months, this never happened because the local politicians who are its members are too busy with party politics. Whatever little consumer pressure could be brought to bear on the Health Center staff was realized through a local activist organization [51]. The words of a local tribal activist attending the health center with his sick child, capture the double bind that confronts those who would like to initiate change:

We can't put too much pressure on the staff here. They get agitated very easily and then become rude. We also don't want them to lose their jobs. After all, they too have a family and stomachs to fill. Poor people in this area, especially tribals like me are very often at the mercy of this doctor. The fact is that we need them more than they need us. So we have to tolerate. Three years ago, when more than 30 children in the neighboring villages died of measles, I was at the forefront of a protest (morcha) directed against this very doctor to protest against his negligence. But as you can see, I've come here with my sick child. I'm at his mercy now.

CONCLUSION

Primary health centers in India have become sites where doctors provide public as well as private health services. Private practice by primary health center doctors is legally proscribed in most states of India and a non-practicing allowance is provided as a disincentive. This has not disuaded many health center doctors from engaging in private practice. I have argued in this paper that it is not just profit motives which have led doctors to private practice. In order to become popular, government doctors must respond to consumer demand in a context where government resources are scarce and need to be rationed. A government doctor is often placed in a situation of having to attend to patients when government medicines are not in stock. To retain popularity and protect his reputation, a doctor may stock his own medicines in addition to writing prescriptions.

A primary health center doctor who is in a position to provide people with a ready supply of drugs gains popularity. Faced with a severe shortage of medical supplies from the government much of the time, the doctor described in this paper developed pragmatic ways of dealing with a heavy patient load. By purchasing medicines and reselling them to patients who could afford to pay for the medicines, he made a small profit while meeting local demand for 'special' medicines. At the same time, he was able to conserve government medicine for the most needy. This strategy was not without social costs. For those unable to pay for special medicines or consultations after hours, the doctor appeared 'money minded. '

Offering 'special' medicines to paying patients was interpreted by the poor as offering greater care and concern. An implicit message concerning government medicine was also conveyed. By engaging in private practice, the doctor indirectly conveyed the message

Popularity of primary health centres in India 95

to local people that 'government ' medicine was in- ferior to medicines available at a cost. More and more people, including the poor, perceived 'special medicines' to be a necessity and a demand-supply feed- back loop was set into motion. I observed many patients insisting that the doctor give them khazgi

medicine even before he offered it to them as an option. Seeking private care at a primary health center was deemed practical by these people even if they grumbled about being unable to pay.

A long-standing assumption upheld by health policy makers in India has been that the Indian population cannot afford to pay for health services. This assumption is being challenged by studies which suggest that the poor in India are spending a significant percentage of their household income on health care [52]. Given the country's economic problems, disease burden and increase in demand for drug:~, it is doubtful that the government of India will ever be in a position to adequately stock rural primary health centers with enough of those drugs required for routine health problems [53]. Given this scenario, the crucial question is how better public medical care can be made available to those with limited means who are already paying for private medical services. A core issue is the adequacy of a sufficient supply of drugs. Is there a way in which primary health centers can maintain an adequate supply of medicines and become self-sufficient and self-supporting? Are local communities willing to participate in financing health services, to what extent and how? Programs f iom other parts of the world suggest that commu]aity financing may be achieved with some measure of success [54]. Within India, some non-governme:atal organizations (NGOs) and a few public hospitals have been attempting to generate funds from the local population by fee-for-service health schemes [55].

Past experience with community development programs in India has shown that it is counterproductive to romanticize community participation [56]. Rural India is socially stratified, ethnically divided and politically factionalized. This does not mean 1hat groups of people cannot be mobilized around sets of activities for mutual benefit. N G O s involved in community health and development work in both rural and urban India have shown that people can be effectively mobilized around a common initiatiw: or specific activity [57]. The survey data presented in this paper suggest that the majority of the tribal and non-tribal people interviewed were willing to assist health center staff if given guidance. As specific initiatives were not forthcoming, their participalion was minimal. Beyond the rhetoric of bottom up planning, they awaited initiatives to which they could respond given real life contingencies and available resources.

How would a local population such as this respond to a community health financing scheme? More specifically, how would the public, health center staff and local practitioners respond? On the basis of

data presented in this paper, I would suggest that community response to such programs needs to be considered in relation to existing health care utilization and expenditure patterns in rural India as well as perceptions of quality of care [58]. It is necessary to consider perceived need, including need for 'special medicines' as distinct from 'government medicines'. As we have seen in this paper, demand for special medicines has been fostered by government doctors who convey the impression that government medicines are less effective than brand medicines available at a price. It is necessary to consider how private medical practitioners and local drug retailers/ pharmacists will respond to community financing schemes. If drugs are more readily available at the health center, will private practitioners feel threatened? Will pharmaceutical companies try and dis- credit medicines stocked and distributed at health centers? How will such schemes affect primary health center staff? Will sale of medicines at the health center enhance staff status or reduce it? Will pressure be placed on health center staff to engage in more curative work? Will this reduce or increase preventive health care provision?

These questions call for research which attends to the market dynamics that shape the behavior of health care providers as well as consumers in rural India. The real life contingencies of primary health center staff and local population needs to be recog- nized before efforts are made to change the existing health care system.

Acknowledgements--I would like to acknowledge the support and encouragement I received from Dr C. A. K. Yesudian during the collection of field data and Dr Mark Nichter during writing up of the results. Constructive criticisms were received from Dr Gill Walt on an earlier draft of this paper.

REFERENCES

1. Banerji D. Poverty, Class and Health Culture in India, Vol. 1. Prachi Prakashan, New Delhi, 1983.

2. Jobert B. Populism and health policy: the case of community health volunteers in India. Soc. Sci. Med. 20, 1-28, 1985.

3. Nichter M. The primary health center as a social system: PHC, social status and the issue of team work in South Asia. Soc. Sci. Med. 23, 344-355, 1986.

4. Jeffery R. The Polities of Health in India. University of California Press, Berkeley, CA, 1988.

5. Kamat V. R. Political and cultural context of primary health care implementation: study in a region of rural Maharashtra. Ph.D dissertation, Tata Institute of Social Sciences, Bombay, India, 1991.

6. Two indicators which reflect the success or failure of PHC programs at the grassroots level are (a) the extent to which PHC services are utilized by the target population and (b) the extent to which the community supports or actively participates in PHC activities. Less explicit in PHC literature is the nature of the linkage between these two processes. See Bossert J. J, and Parker D. The political and administrative context of primary health care in the third world. Soc. Sei. Med. lg, 693-702 1984.

96 Vinay R. Kamat

7. One of the oldest primary health centers in a taluka of central Maharashtra was selected for study, hereinafter referred to as the 'health center'.

8. The sanitary inspector was in his mid-twenties, had his formal training in public health, was second in com- mand at the health center. I found him to be very meticulous in maintaining health center records.

9. At the time when I started my fieldwork, an annex structure was being constructed to augment the facilities at the health center. Plans were under way to upgrade the health center to a rural hospital over time.

10. Discussions with the health center staff focused on such topics as their perceived roles and responsibilities, job satisfaction, opinions regarding the C HW scheme, their attitude toward the local people, the difficulties encountered, especially in enlisting people's participation in the process of implementing PHC programs, and team work.

11. Outside of the health center, my key informants included leaders of a local activist organization (tribal and non-tribal), three non-tribal locality leaders, two local politicians, a gramsevak, the officer in charge of the Anganwadi program and a few community members.

12. My original idea of interviewing women was abandoned during pretesting as a result of non-co-operation related to gender sensitivity. However, during most of the interview situations with fathers, the wife-mother was present. I was thus able to verify the information on household illnesses and ante-natal and post-natal care utilization with the wife-mother on the spot.

13. This issue lies outside the scope of this paper, but it is not uncommon in India, especially where one doctor has a popular private practice. Tensions arise between doctors of different age cohorts and gender. On the issue of team work, status and structural conflicts at the primary health center level in India and Sri Lanka, see [3].

14. I also visited the health center intermittently during the household health survey and for 2 weeks following the completion of the survey.

15. Initially, the health center staff suspected that I was an activist from Bombay who had come to conduct an inquiry into the functioning of the health center. Over time, I won the confidence of the staff and established my identity as a student doing a confidential study of community health issues.

16. The political situation in the study area was very tense around the time that my preliminary fieldwork was going on. The taluka had been a stronghold of the congress (I) for several years. A local politician from the village in which the health center was located had been elected as a member of the parliament for four consecutive sessions. However, in light of the Hindu fundamentalist sentiments being invoked by the BJP on the national scene, the Shiv Sena and BJP had formed an alliance to challenge the stronghold of the congress. As a result of the tense and potentially violent political situation that prevailed in the study site, I had to postpone the household survey until the elections were over. The political tensions continued for 3 months after the election, and during the last round of the survey, I had to conduct interviews after sunset to avoid contact with local political groups.

17. In their day-to-day conversations, the local people referred to the Health Center as sarkari davakhana literally, government dispensary.

18. The concept of 'power of hand' has been referred to as 'a practitioner's personal capacity to heal a patient. Whether treatment answers to a patient or not involves not only a practitioner's knowledge of body, habit and medicine but empathy and the quality of communication between the practitioner and patient'. See Nichter M. and Nordstorm C. A question of medicine

answering: health commodification and the social re- lations of healing in Sri Lanka. Culture Med. Psychiat. 13, 367-390, 1989. Ascertaining the extent to which this factor played a part in determining the popularity of the doctor was difficult in as much as power of hand was often attributed to a doctor after he had cured a case.

19. Alland (1970) has pointed out that it is often Western medicines rather than 'Western medicine' which appeals to non-Western populations. See Alland A. Adaptation in Cultural Evolution: an Approach to Medical Anthro- pology. Columbia University Press, New York, 1970.

20. In Sri Lanka it was found that people in rural situations often have more faith in Western medicine than in practitioners trained in Western medicine. When people are seeking traditional healers, even ayurvedic practitioners, they will travel long distances to one who is trusted or is believed to specialize in a specific complaint. However, when going to a hospital or modern doctor, people visit the nearest, at least in the first instance. See Caldwell J. and Santow G. Selected Read- ings in the Cultural, Social and Behavioural Determinants of Health. The Australian National University, Canberra (reprinted, 1991). In the present case, the doctor had a background in ayurvedic medicine. While he mostly resorted to using allopathic medicine, his background in ayurvedic principles may have helped him develop rapport with patients by referring to popular health concerns.

21. My key informants told me of a rumor that the doctor had plans to resign from his current job to build a polyclinic, just across from the health center, so that he could engage in full time private medical practice. According to the rumor, the doctor had begun charging his patients more money during the last few months of his role as health center doctor.

22. It is not unusual for doctors to accept money from patients at government health centers in India. Indeed it is probably more the norm than an exception. While this practice is illegal, health authorities overlook it because they themselves are part and parcel of this system. The situation was summed up by a key informant as: "You also eat, and let us also eat."

23. I do not wish to underplay the important role played by the other staff at the primary health center level. The point that I am trying to make here is that the doctor can make or break the situation at the primary health center level. This depends on how he perceives his role in relation to his staff and what managerial skills he uses to 'get the work done' and have targets met.

24. See Nichter M. Paying for what ails you: socio-cultural issues influencing the ways and means of therapy pay- ment in South India. Soc. Sci. Med. 17, 957-965, 1983.

25. For a good discussion on the problem of ' targets' in India, see Jeffery R. [4].

26. Economic considerations are commonly cited as important determinants of how people choose between different types of practitioners and therapy systems. The least expensive course of action is often the most common strategy followed by impoverished villagers in India. See Beals A. Strategies of resort to curers in South India. In Asian Medical Systems: A Comparative Study (Edited by Leslie C.). University of California Press, Berkeley, CA, 1976; Nichter M. [24]; Nichter M. Cultural interpretations of stages of malnutrition among children. A South Indian case study. In Anthro- pology and International Health. South Asian Case Studies. Kluwer, Boston, MA, 1989.

27. Leslie C. The ambiguities of medical revivalism in modern India. In Leslie C. [26] pp. 356-367; Beals A. [26]; Frankenberg R. Allopathic medicine, profession and capitalist ideology in India. Soe. Sci. Med. 15, 115-125, 1981.


28. See Beals A. [26]; Jeffery R. [4]; Kakar D. N. el al. Peoples perception of illness and their use of medical care services in Punjab. Indian J. Med. Educ. I1, 286-290, 1972; Sauerborn R. Low utilization of community health workers: results from a household interview survey in Burkino Faso. Soc. Sci. Med. 29, 1163-1174, 1989,

29. I was tempted to probe into the dynamics between the Health Center doctor and the owner of this provision shop-cum-pharmacy. I had to drop this idea after being cautioned by informants that my broader research interest in this area would be jeopardized if the doctor or the shop owner suspected that I was probing into this aspect.

30. The recall period was rather long. The data are there- fore only suggestive and do not reflect the prevalence data.

31. Variation in illness specific patterns of health zare seeking were noted. For example, as compared with 65% of cases reporting fever, and 53% reporting diarrhea who had sought help from the health center doctor in the first instance, only 18% of those reporting jaundice and 20% of those reporting measles had sought help from the health center doctor. Fifty-Four percent of those reporting jaundice had first sought help from an indigenous health practitioner, and 47% of those reporting measles had resorted to home remedies. Significant differences in patterns of resort were also found between tribal and non-tribal population groups across reported illnesses. For details see [5] pp. 202--203 and appendices.

32. Nichter M. [26]; Caldwell J. and Santow G. [22]. 33. One plausible explanation for this difference could be

the non-reporting of routine home remedies. Methodo- logical limitations of the survey method in eliciting accurate data on pattern of resort have been discussed by researchers. See Caldwell J. and Santow G. [22]; Kroger A. Health interview surveys in developing countries: a review of methods and results. In;. J. Epidem. 12, 465--479, 1983; Kroger A. Anthropological and socio-medical health care research in developing countries. Soc. Sci. Med. 17, 147-161, 1983; Leslie C. Medical pluralism in world perspective. Soc. Sci. ?~led. 14, 191-195, 1980; Nichter M. [26]. The problem of non-reporting of routine illnesses and reluctance to discuss culturally sensitive illness during health surveys has been documented in Asia. For example, in Indonesia, childhood diarrhoea is so common that it is considered normal (a transient complaint). Diseases such as tuberculosis are considered shameful and are under-reported; see Buzzard S. Appropriate research for primary health care: an anthropologist 's view. Soc. Sci. Med. 19, 1984; Caldwell J. and Santow G. [22].

34. It is possible that the data were biased and that I was associated with the health center.

35. Awareness regarding health center services was found to be very high among the local people. No doubt its near ideal location brought most of the people in contact with the Health Center at one point of time or the other.

36. Questions pertaining to the frequency of utilization of each of the services were omitted from the interview schedule after it was pretested. Ascertaining the frequency of utilization of each of these services with ~ fair amount of accuracy was not deemed feasible.

37. Questions pertaining to antenatal and post-natal care were asked only those respondents who had reporled a pregnancy/childbirth in the family during the 2 year period prior to the interview.

38. During an informal staff meeting at the Health Center, I asked the ANMs about their presence at the sub- centers. All of them complained that the physical location of the sub-centers was such that it was ridicu- lous for the health authorities to expect them to stay in


them. They often spoke of being "unwilling to risk putting their lives in danger."

39. Banerji D. Rural social transformation and changes in health behaviour. E P W ! July, 1474-1480, 1989; Jeffery R. [41.

40. These statements were constructed after a thorough review of literature and some preliminary fieldwork. In particular, the source that helped me the most was Dr Werner's 'Where there is no doctor. ' However, it took me several hours of discussion of the statements with my key informants to ascertain whether they were comprehensible after being translated into the local language. The interview schedule was pretested three times. For details on attitudinal statements and pretesting procedure see [5] appendix VIII and pp. 123-125, respectively.

41. Some of the respondents specifically mentioned that it was the health center that had been responsible for successfully eradicating guineworm (locally known as naru), a disease which was endemic in the study locality.

42. Banerji D. Health behaviour of rural populations: impact of rural health services. E P W 8, 2261-2268, 1973; Jeffery R. [4].

43. Two key informants (leaders of the local activist organization) told me that the health center doctor engaged in a peculiar discriminatory practice five years ago. He used a piece of cloth as a barrier between his hands and the part of the body of a tribal patient that had to be touched (e.g. counting the pulse). It was only after these local activists lodged a complaint with the district level health authorities regarding this discriminatory practice that the doctor discontinued it.

44. As discussed earlier, people in the study locality often consulted the health center doctor as a private practitioner, a situation that has not been reported in other studies which have compared the popularity of primary health center doctors with other local private doctors.

45. Brownlea M. Participation: myths, realities and prog- nosis. Soc. Sci. Med. 25, 6054514, 1987; De Kadt E. Community participation for health: the case of Latin America. Wld Dec. 10, 573-584, 1982.

46. The community health workers scheme, launched in India in the late seventies, symbolized the most concrete expression of community participation in PHC inspired programs at the grassroots level. The scheme itself has been subjected to several evaluations. See, for example, Maru R. The community health volunteers scheme in India. Soc. Sci. Med. 17, 1477-1494, 1977; Jobert B. [2]; Jeffery R. [4].

47. I met only five CHWs during my stay in the different villages while conducting the interviews.

48. At the same time, the doctors and the other health center staff were very vocal about their appreciation for the locally trained birth attendants (TBAs). Most of them had been trained at the health center, and a good rapport was maintained between the TBAs and the health center staff. As mentioned elsewhere, unlike the CHWs, birth attendants played a crucial role in helping the health center staff meet their family planning targets.

49. Madan T. N. Community involvement in health policy: socio-structural and dynamic aspects of health beliefs. Soc. Sci. Med. 25, 615-620, 1987.

50. Jeffery R. [4]. 51. One informant narrated an episode that had occurred

three years prior to my fieldwork. A measles epidemic had broken out in some of the villages which came under the jurisdiction of a neighbouring primary health center in which the health center doctor worked. The measles-related deaths had attracted the attention of the press, and the incident was widely reported in the local and city newspapers. Following an inquiry into the incident, the doctor was suspended, only to be reinstated within weeks after another inquiry which

98 Vinay R. Kamat

concluded that he was not at fault because he was on leave at the time that the measles-related deaths occurred.

52. For some interesting comparative data on health expenditure in India, see Parker R. Health care expenditure in a rural Indian community. Soc. Sci. Med. 22, 23-27, 1986; Nichter M. The household production of health: documenting the relative contribution of pluralistic therapy systems. Paper presented at the Third Inter- national Congress on Traditional Asian Medicine, Bom- bay, India, 4-7 January 1990 (unpublished manuscript). Indeed, a few studies suggest that at some levels of relative poverty, rural households spend more on health care than urban households. See, for example, George A. and Nandaraj S. State of health care in rural Maharashtra: a comparative analysis. EPW XXVIII (32-33), 7-14 August, 1671 1683, 1993.

53. For an excellent overview and analysis of India's health problems from a political economy perspective see Shepperdson M. The political economy of health in India. In The lndian National Congress and the Political Economy in India: (1885 1985) (Edited by Shepperdson M. and Simmons D.). Gower, London, 1988.

54. See, for example, Creese A. L. User charges for health care: a review of recent experience. Hlth Policy Plann. 6, 309-319, 1991; Xingyuan G., Bloom G., Shenglan T.. Yingya Z., Shouqi S. and Xingbao C. Financing health care in rural China: preliminary report of a nationwide study. Soc. Sci. Med. 36, 385-391, 1993; Berman P.. Barbara A. O. and Ascobat G. Treatment use and expenditure on curative care in rural Indonesia. Hlth Policy Plann. 2, 289-300, 1987.

55. See Dave P. Community and self-financing in voluntary health programmes in India. Hlth Policy Plann. 6, 20-31, 199 I. While some experiments have been success- ful in mobilizing financial resources from the local community, the question remains how feasible it is to generalize community health financing on a larger scale without the special involvement of NGOs. Even if NGOs were to be involved in national community financing initiatives, it remains to be seen what chal- lenges they would face moving from small scale demon- stration projects to large scale initiatives.

56. As pointed out by other researchers, it is misleading to reify the community or consider it a homogeneous whole. Segall, for example, has cautioned that:

In official mythologies of community participation, communities are portrayed as harmonious entities existing in an unproblematic relationship with governments and even sometimes with the wider economy. But communities are divided and stratified socially, and they exist within the social class structure of the national society.

Segall M. The politics of primary health care. IDS Bull. 14, 27 37, 1983.

57. Pioneering examples in this case are the health and development projects in Jamkhed and Pachod in rural Maharashtra.

58. The quality of care provided by different types of doctors in field conditions requires investigation. At issue is whether the treatment practices of 'ayurvedic doctors', such as one described in this paper, differ from doctors having MBBS training with respect to both common cases treated and response to emergencies.

~ Pergamon Elsevier Science Ltd. Printed in Great Britainanth.sites.olt.ubc.ca/files/2013/03/Reconsidering-the... · 2016-03-30 · ~ Pergamon 0277-9536(94)00309-2 Sot'. Sci. Med.

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