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					Universal access to health care in India: the case for community action

Nevin Wilson*
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Abstract:

India is a study in diversity and contrasts. The country is an emerging economic power that rivals
China, has created staggering wealth for some of its citizens, contributes significantly to the global
intellectual resource pool in a wide spectrum of areas and contains the largest young population of
any country in the world today. It is the world’s largest democracy and has consistently upheld its
citizens rights to govern themselves. And yet, India is also home to poverty and disease and ranks
poorly in most global development indicators. India bears a fourth of the global burden of
tuberculosis, almost every second child in India is undernourished and a significant proportion of her
population face enormous challenges in accessing basic health care. Despite significant success in
many areas of health care and service delivery, huge inequalities persist, with the poor, the socially
marginalised, the vulnerable disproportionately bearing the greatest burden of disease, morbidity
and death. Is there a role for the community in changing this status quo? How can communities be
engaged to drive this change?

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Evolution of health services in India – an overview of seven decades of planning:

Globally, the Alma-Ata conference and declaration in 1978 is considered a ‘milestone’ in twentieth
century public health. It identified primary health care as the key ingredient to attaining the goal of
health for all. The declaration acknowledged that inequalities in the health status of people was ‘not
acceptable’, it affirmed the rights and duties of people to participate in planning and implementing
their health and made a global call for universally accessible primary health care for all people1.

India started her health planning somewhat earlier! In 1943, India stood at the threshold of her
independence from centuries of foreign rule - her population at that time was about 330 million,
with high levels of poverty, social exclusion and illiteracy. In this setting and about three decades
ahead of the Alma-Ata declaration, a health committee was constituted under the chairmanship of
Sir Joseph Bhore of the then Indian Civil Service to review the existing health conditions in India and
make recommendations for the future. The famous Bhore Committee Report in four volumes was
submitted in 19462 (one year ahead of our independence from British rule) and guided health
planning and the organisation of basic health services in the first Five year plan of the Government

1
  Declaration of Alma-Ata. International Conference on Primary Health Care, Alma-Ata, USSR, 6-12 September
1978.
2
  Report of the Health Survey and Development Committee Volumes I to IV. Published by the Manager of
Publications, Delhi and printed by the Manager, Government of India Press, Calcutta
                                                                                                             2


of India – 1951 to 1955. This was a landmark report - it was exhaustive, thorough and in many
aspects prescient. It carefully chronicled existing knowledge, reviewed and analysed data sources,
factored social dynamics and population characteristics, anticipated community needs and their
development and acknowledged existing capacity for research and programme implementation.
Very early in the 20th century this unique report, set in the context of a developing democracy
emerging from the shadows of colonial rule, emphasised community participation in the
determination of their health using the primary health care approach. One of the important
outcomes of this report was the creation of one primary health centre (PHC) for every community
development block of about 100 villages (about 100,000 population).

The concept of primary health care in India evolved quickly over the next 3 decades so that by the
time India became a signatory to the Alma-Ata Declaration in 1978, different committees set up by
the Government of India had brought health services closer to the people – PHCs served a smaller
population; basic health workers were provided for every 10,000 people; attempts were made to
‘integrate’ within health services and unify responses to health challenges; health sub-centres were
set up for every 5000 people with multi-purpose health workers to staff them; ‘referral’ systems
were conceived linking primary services at the village level to secondary and tertiary services at sub-
district, district and state levels; a Rural Health Service was launched in 1977 which included
community health volunteers who were mostly village women equipped with some short term
training and provided a small incentive345678.

In 1978, India became a signatory to the Alma Ata declaration of ‘Health for all by the year 2000’.
Consequent to this, the government set up a Working Group which then led to a report setting out
targets to be achieved by the year 20009. This also led to the development of the First National
Health policy in 1983 – its goal was to ‘provide universal, comprehensive primary health services’ in
the country. In between, national and international concern that existing resource and other
constraints compromised the ‘health for all’ goals, prompted the setting up of vertical interventions
– immunization, female literacy, family planning among others.

The National Population Policy in 2000 set the stage for the delivery of basic reproductive and child
health services at the village level through government and NGO partnerships. A second National
Health Policy was presented in 2002 which acknowledged progress including the eradication of small
pox and guinea worm, and significant advances in the elimination of leprosy and neonatal tetanus.
This policy identified new targets for 2005 and 2010 in alignment with the Millennium Development
Goals. And most recently, the National Rural Health Mission (NRHM) was launched in 2005 with



3
  Report of the Health Survey and Planning Committee, 1962. Chaired by Dr A.L.Mudaliar
4
  Chadha Committee Report, 1963. Chaired by Dr.M.S.Chadha, Director General of Health Services
5
  Mukherjee Committee Report, 1966. Chaired by Shri Mukherjee, Union Health Secretary
6
  Report of the Committee on Integration of Health Services, 1967. Chaired by Dr N.Jungalwalla, Director of the
National Institute of Health Administration and Education
7
  Report of the Committee on Multipurpose Workers under Health and Family Planning, 1973. Chaired by Shri
Kartar Singh, Additional Secretary Health to the Union of India
8
  Report of the Group on Medical Education and Support Manpower, 1975. Chaired by Dr J.B.Shrivastav,
Director General of Health Service
9
  Ministry of Health and Family Welfare, Government of India, New Delhi. Report of the Working Group on
Health For All by 2000 AD, March 25, 1981
                                                                                                               3


opportunities for decentralised health planning from the village level up and community led
monitoring at the level of the district.

The goal of the NRHM is to provide universal access to health care through community involvement,
flexible financing to increase monetary autonomy at different levels, capacity building of different
stakeholders, improved management of human resources with all of this underpinned by rigorous
monitoring against agreed outcomes10. A close look at the operating framework of the NRHM shows
us that the interface of the public health services begins at the village – the most basic unit of society
in the country. There is a matrix which includes the locally elected government or the Gram
Panchayat and community volunteers from the village represented onto a funded health committee.
24x7 emergency health services are available at the PHC level (one for every 30 to 40 villages),
ambulance services are built into the framework and private practitioners of allopathic and alternate
forms of medicine can be accredited.

In 2009, the government drafted the first National Health Bill – it is yet to be tabled in Parliament
and remains a working draft. When enacted, this will be landmark legislation because it recognises
that health care and public health are public goods and that individuals have an equitable right to
health and wellbeing. It emphasises the role of the local government (Panchayati Raj) in self-
determination with respect to health of a community and addresses needs of the marginalised and
vulnerable populations through the social determinants of health. It makes the government and the
public health services accountable to the community they serve11.

What has all this planning translated to?

In January 2011, the Lancet published a series of papers on India titled “India: Towards Universal
Health Coverage”. This series was put together by an eminent group of scientists and health
advocates in the country and reviewed the progress and status of health care in 6 broad areas –
infectious diseases, reproductive and child health, children and nutrition, non-communicable
diseases, health care and equity, human resources and financing and also included a number of
comments from leading personalities in the country on issues related to accessing health care in the
country.

A brief review of the papers in this series reveals the following:

     1. Infectious diseases12: Despite some declines in their burden, infectious diseases still
        contribute to about a third of the enormous disease burden in the country. Except for HIV
        infection and leprosy, major infectious diseases including tuberculosis and malaria are not
        on track to be controlled. There are large gaps in disease surveillance and response systems
        to diseases and the paper clarifies that replicating the model of vertical single-disease
        control is neither efficient nor viable.



10
   Ministry of Health and Family Welfare, Government of India. National Rural Health Mission (2005-2012).
Mission Statement
11
   The National Health Bill, 2009. Ministry of Health and Family Welfare, Government of India Working Draft:
Version January ’09.
12
   Continuing challenge of infectious diseases in India. T Jacob John, Lalit Dandona, Vinod P Sharma, Manish
Kakkar. India: Towards Universal Health Coverage 1. Lancet 2011; 377: 252–69
                                                                                                              4


     2. Reproductive health, child and health nutrition13: While this paper documents steady
        declines in fertility, maternal, infant and child mortalities and the prevalence of severe
        manifestations of nutritional deficiencies it also clarifies that progress falls short of national
        and Millennium Development Goal (MDG) targets. Significantly, it goes on to point out that
        increases in the numbers of deliveries in institutions have not been matched by
        improvements in the quality of intra-partum and neonatal care. Infants and young children
        do not get the health care they need; access to effective treatment for neonatal illness,
        diarrhoea, and pneumonia shows little improvement; and the coverage of nutrition
        programmes is inadequate. Close to 2 million children below the age of 5 die annually in
        India from preventable causes.
     3. Non-communicable diseases14: This paper documents that chronic diseases and injuries are
        the leading cause of death and disability in India, that they are equally prevalent in poor and
        rural populations and often occur together and that although cost-effective and evidence
        based strategies exist to prevent these diseases, their coverage is low. The paper warns that
        delays in the implementation of prevention and control for these diseases have implications
        for the demographic transition that the country is going through.
     4. Equity15: This paper draws attention to the striking inequalities existing in the access to
        health services in India with the poor and the vulnerable populations disproportionately
        bearing the burden of this inequality. Significantly, the paper documents that more than
        three-fourths of health spending in India is out-of-pocket and met by households; that these
        expenditures account for more than half of Indian households falling into poverty and that
        about 39 million people are pushed into poverty annually because of this.
     5. Human resources for health16: This paper paints a dismal picture of the human resources
        available, within the public services, for health in India with challenges in absolute numbers,
        distribution across the population, quality and skills, training, supervision and governance.
        More than half of all the PHCs in 6 out of 14 most populous states in India did not even have
        60% staffing in 2003; in Orissa with a pre-dominantly tribal population, only 0.25% of the
        PHCs had 60% staffing. In West Bengal it was 5.7% and in Bihar 19.6%.
     6. Financing17: This paper identifies poor financing of health as both a cause and an
        exacerbating factor contributing to inequity, inadequate availability and reach, unequal
        access, poor quality and expensive health care services in the country. Current government
        of spending is very low at 1% of the gross domestic product. More than half of all the PHCs
        in 8 out of 14 most populous states did not even have 60% of the required equipment for

13
   Reproductive health, and child health and nutrition in India: meeting the challenge. Vinod Kumar Paul,
Harshpal Singh Sachdev, Dileep Mavalankar, Prema Ramachandran, Mari Jeeva Sankar, Nita Bhandari,
Vishnubhatla Sreenivas, Thiagarajan Sundararaman, Dipti Govil, David Osrin, Betty Kirkwood. India: Towards
Universal Health Coverage 2. Lancet 2011; 377: 332-49
14
   Chronic diseases and injuries in India. Vikram Patel, Somnath Chatterji, Dan Chisholm, Shah Ebrahim, Gururaj
Gopalakrishna, Colin Mathers, Viswanathan Mohan, Dorairaj Prabhakaran, Ravilla D Ravindran, K Srinath
Reddy. India: Towards Universal Health Coverage 3. Lancet 2011; 377: 413-28
15
   Health care and equity in India. Y Balarajan, S Selvaraj, S V Subramanian. India: Towards Universal Health
Coverage 4. Lancet 2011; 377: 505-15
16
   Human resources for health in India. Mohan Rao, Krishna D Rao, A K Shiva Kumar, Mirai Chatterjee,
Thiagarajan Sundararaman. India: Towards Universal Health Coverage 5. Lancet 2011; 377: 587-98
17
   Financing health care for all: challenges and opportunities. A K Shiva Kumar, Lincoln C Chen, Mita Choudhury,
Shiban Ganju, Vijay Mahajan, Amarjeet Sinha, Abhijit Sen. India: Towards Universal Health Coverage 6. Lancet
2011; 377: 668-79
                                                                                                             5


         provision of basic health services in 2003; in Bihar it was 6.2%, in West Bengal 8.6% and in
         Orissa it was 15.1%.

The series concludes with a ‘call to action’ towards achievement of universal health care in India by
202018. Five key actions are proposed with the aim to achieve this goal by 2020.

     1. The creation of an insurance fund with financing from public, employer and private sources
        to provision health care in the country. This includes mobilising revenues through increasing
        taxes on all tobacco products, alcohol and some foods. Public expenditure on health care
        must rise from 1 to 6% of GDP by 2020.
     2. The establishment of an autonomous council that will support the generation of evidence to
        guide practice in an integrated national health system and monitor its implementation. This
        includes regulatory frameworks to define and monitor standards of care and robust national
        surveillance mechanisms
     3. Development of a policy to promote human resources for health in the country and the
        creation of a national cadre for the health service
     4. Collaboration of all health related ministries and departments in the ministry of health
        specifically those dealing with women and child development and with water and sanitation
     5. Creation of specific evidence based entitlements for health.

The paradox!

Behind all of the numbers, proportions, indicators, targets and many, many technical meetings and
published papers, the poor, the vulnerable, the socially marginalised, the tribal, the rural dweller,
the migrant, the slum dweller and the prisoner in India continues to battle enormous challenges in
accessing basic health care, continues to bear the greater burden of disease morbidity and mortality,
are often provided services of poor or no quality, are pushed to sell their meagre possessions and
fall into greater poverty and debt and continue to remain mute spectators to an inequity that will
not just go away.

This situation begs the following questions - Is institutional strengthening of the health services
enough to guarantee equality and universal access to these services? Is removing or addressing
these inequalities simply a matter of greater investment of finances and human resources and
implementation of better policy? Or are we missing something, something which is core to the
discussion around development and health? Where are the people, where are the affected
communities in this conversation, the communities who bear the burden of this inequality?

The averages of national and international metrics hide health inequalities and gains in nationally
averaged outcomes do not translate to increases in access or quality of health services to
disadvantaged communities in India. They risk remaining the ‘last mile’ in the ‘universal’ measure
despite any institutional correction unless they are engaged as communities in determining their
health.

Tuberculosis control in India

18
  Towards achievement of universal health care in India by 2020: a call to action. K Srinath Reddy, Vikram
Patel, Prabhat Jha, Vinod K Paul, A K Shiva Kumar, Lalit Dandona, for The Lancet India Group for Universal
Healthcare. India: Towards Universal Health Coverage 7. Lancet 2011; 377: 760-68
                                                                                                                   6


Let us review the case of tuberculosis, an infectious disease which is not yet controlled in India.
Tuberculosis is a disease that has had sustained and increasing investment over the last century in
India. Research from India in tuberculosis has informed its control globally19. Before chemotherapy
was known, the first sanatoria were set up in India, in the early part of the twentieth century – the
Madanepalle Sanatorium was set up in 191220. By the mid 50’s and early 60’s, as Europe and the
developed world invested in research around chemotherapy and multiple drug regimens to treat
tuberculosis, pioneering work at the Madras Chemotherapy Centre established that ambulatory
treatment provided at the homes of patients was as good as hospital based treatment (this
contributed to the DOTS strategy developed by Dr Karel Styblo of The Union and later endorsed as a
public health strategy to control TB by the World Health Organization21) and that intermittent
supervised regimens were effective. The largest ever BCG campaign also took place in India (1951)
and a semi-vertical National TB Programme was established as early as in 196222. Unfortunately, the
programme in India did not do very well and a programme review in 1992 advised the adoption of
the DOTS strategy into the national programme which then became the Revised National
Tuberculosis Control Programme or the RNTCP23. This revised programme was launched in 1993,
rapidly expanded after 1997 and geographically covered the entire country by 2006. Since then, it
has consistently achieved global performance targets detecting over 70% of the estimated incidence
of new sputum positive TB and successfully treating 85% of those detected, at a national level. The
programme has also expanded its vision in alignment with the World Health Organization’s (WHO)
Stop TB Strategy incorporating objectives of universal access, reduction of human suffering and the
socioeconomic burden associated with TB, protecting vulnerable populations including those co-
infected with HIV and those with multidrug-resistant TB (MDR) and protecting and promoting
human rights in TB prevention, care and control24. The RNTCP in India models a well-functioning
public health service with trained providers providing free and quality assured diagnostic and
treatment services, robust systems for programme monitoring linked to globally approved
performance indicators that assure progress in the control of the disease and incorporating
mechanisms to include the community through NGO engagement and private sector partnerships25.
Despite these ‘successes’, the Global TB Report 2011 reveals that although there has been a
significant and important decrease in the overall mortality from TB in India, the country still accounts
for a fourth of the global incidence of the disease and that overall declines in incidence is very
limited26.

What is staggering and demands attention are the inequalities behind these statistics. At The Union
in Delhi, we recently completed a cross sectional community based survey in 30 districts
representing a sample from 374 districts in the country currently reached for advocacy,

19
   Epidemiology of tuberculosis with particular reference to India. Stefan Grzybowski. Indian J of Tuberculosis.
1995: 42: 195-200
20
   The Magic Mountain Revisited: History of the Madanapalle TB Sanatorium. Sheela Prasad, B. Venkat Raju.
Economic and Political Weekly Vol 43, No.33, (Aug 16-22, 2008), 52-60
21
   The Union: 90 years of collaboration and innovation. View or download from
www.theunion.org/index.php/en/who-are-we/history-of-the-union (page 7)
22
   Evolution of Indian NTP. D.R.Nagpaul. The Indian J of Tuberculosis, April 1997. Vol 44, No.2, Page 59-60
23
   DOTS progress in India: 1995-2002. G.R.Khatri. Tuberculosis (2003) 83, 30–34
24
   The Stop TB Strategy. WHO 2010.
25
   Revised National Tuberculosis Control Programme. Revised Schemes for NGOs and Private Providers 2008.
Central TB Division, Directorate General of Health Services, Ministry of Health and Family Welfare
26
   Global Tuberculosis Control: WHO Report 2011.
                                                                                                            7


communications and social mobilisation for TB through a Global Fund Round 9 Grant.27 Patients
were identified through a door-to-door survey and interviewed using a semi-structured
questionnaire. Some of the findings from this survey are captured below:

        Almost half (46%) of those identified as TB patients were obtaining treatment for their TB
         outside the public health services. This finding alone points to serious issues with access to
         TB services and has implications for TB control28
        More than half (54.7%) of the TB patients identified were within the age group 19-45 years!
         Almost half of them (43.4%) were illiterate – only 1.3% of TB patients were graduates and
         above! A third (32.5%) were daily wage labourers, almost a fifth (16.6%) were agriculture
         workers and another fifth (20.9%) were housewives.
        More than half of all TB patients (56%) used wood fuel for cooking in their homes. Another
         fifth (21.5%) used dung cakes and close to 10% used agriculture crop waste, straw, shrubs
         and grass as their cooking fuel – effectively 87.5% of TB patients used fuel that seriously
         polluted the air they breathed in their homes. This combined with the finding that over two
         thirds of these patients (70.4%) of them lived in kacha or semi-pucca housing also has
         serious implications for TB control. Knut Lonnroth and colleagues estimate that the relative
         risk of indoor air pollution for active TB disease is 1.5 and that the population attributable
         fraction to this risk is about 26%29!
        More than two third (79.1%) of TB patients identified in this survey had a monthly income of
         less than INR 4000 – roughly $ 80 USD per month. (interestingly more than half of them
         (52.4%) owned a mobile phone! about a third also owned a colour television, although this
         was more in the South (72.4%) versus 15 % in the North and 15% in the Eastern parts of the
         country).

While the study had its limitations (discussed in the paper published with Plos One in September last
year 28), the inequalities among TB patients across this sample of districts are striking and unless
addressed will compromise any effort to control tuberculosis.

Inequality and health

Much has been written about inequality and health. Inequality is often linked to poverty and many
public health programmes attempt to measure their impact on poverty alleviation through complex
studies. Governments including the Government of India prioritise service delivery to the poor
through several mechanisms including identifying them through defining poverty using an income
metric. But it is evident that poverty is not simply the lack of money. It is that for sure, but also much
more. Poverty has to do with the lack of any social opportunity, with the lack of personal dignity,
with the lack of community empowerment, with the lack of the right to participate fully in society
and determine and have control over one’s life. Vulnerable communities such as tribal communities
in India experience this on a day to day basis, as they live on the fringes of the forests which were
once their homes. Tribal communities contribute to close to 8% of India’s population (about 70

27
   Knowledge, attitudes and practices study of tuberculosis in India (under publication)
28
   Satyanarayana S, Nair SA, Chadha SS, Shivashankar R, Sharma G, et al. (2011) From Where Are Tuberculosis
Patients Accessing Treatment in India? Results from a Cross-Sectional Community Based Survey of 30 Districts.
PLoS ONE 6(9): e24160. doi:10.1371/journal.pone.0024160
29
   Chapter 12: Tuberculosis: the role of risk factors and social determinants. Knut Lonnroth et al.
                                                                                                          8


million people) – in states like Orissa, it is over a fifth of the population, with more than 60 ethnic
groups in just that one state!

Can poverty be waved away with a magic wand! Does increasing economic growth and rising per
capita income translate to reductions in poverty and improvements in health, at a community level,
for already disadvantaged communities? In his keynote address to the World Health Assembly at
Geneva in 1999, recorded as a reflection titled ‘Health in Development’ in the Bulletin of the World
Health Organization Professor Amartya Sen asks “Is health best promoted through the general
process of economic growth which involves a rising real national income per capita, or is the
advancement of health as a goal to be separated out from the process of economic growth seen on
its own?”30 Prof Sen concludes that major health improvements can be achieved, even in poor
economies, through using available resources in a socially productive society. This is a concept that
those working to improve health equally across populations must recognise and prioritise. The
Nobel Laureate goes on to argue in his book ‘Development as Freedom’ that development has to be
primarily concerned with enhancing the lives we lead and the freedoms that we enjoy emphasising
that freedom from avoidable ill-health (such as TB) and from escapable mortality (such as that
resulting from tobacco use) are among the most important of these freedoms31 (examples in
parenthesis mine).

In a later book that Professor Sen co-authored with Jean Dreze – Hunger and public action, they
recognise two distinct processes to rapidly reduce mortality and morbidity – one process they call
‘growth-mediated’ and the other ‘support-led’32. The first process works with fast economic growth
and usually accrues to sections of the population directly benefiting from this economic growth. The
support led process they argue works best through a ‘programme of skilful social support of health
care, education and other relevant social arrangements’, and is exemplified in the Indian state of
Kerala where there has not been such a dramatic increase in per capita income, but reductions in
inequalities and priorities being allocated to health care.

The community as a resource for better health in India

Sir Michael Marmot, in his Harveian Oration to the Royal College of Physicians in 2006, argued that
‘the unnecessary disease and suffering of disadvantaged people, is a result of our failing to meet
fundamental human needs of autonomy, empowerment and human freedom – the active
involvement of individuals and communities in decisions that affect their lives is crucial.’33

Community engagement is not a new concept and is increasingly a part of almost every disease
control programme in India. Although the value and importance of community engagement for
better health has been recognised from the time of the Bhore Committee, the actual practice of it
within the health services is limited, sporadic and almost always not prioritised. When resources are
allocated, activities focussing on community engagement get a low priority, very limited budget and
little appreciation or acknowledgement. The barriers to civil society accessing resources from the
public services to mobilise their engagement are many, arduous and often beyond their limited
capacity.
30
   Health in development. Amartya Sen. Critical Reflection. Bulletin of the WHO, 1999, 77(8), 619-623
31
   Development as Freedom, Amartya Sen. Oxford, Oxford University Press, 1999
32
   Hunger and Public Action, Amartya Sen and Jean Dreze. Oxford: Clarendon Press, 1989.
33
   Health in an unequal world. Michael Marmot. Harveian Oration. Lancet 2006; 368:2081-94
                                                                                                             9


There does not seem to be one correct, single or best method to engage with communities and it is
very likely that singular models will be difficult to replicate or expand to scale. On the other hand,
there is learning from the many different models in India that can motivate, guide and attract public
investment for better impact. NGOs play a vital role in community engagement. The NGO space is a
relatively new space that has opened up in the country – there were few NGOs before the 70’s in
India as this space was occupied by a social welfare state. However, this now crowded space needs
support, investment and time for NGOs to stabilise, organise and grow in technical and financial
capacity. Investing in this space will also carry risk – much more risk than in say providing a bank loan
for buying a car or a house. But this risk can be mitigated by processes that build capacity and
strengthen communities to own their health agenda.

Donor agencies and public health services are often a barrier to community engagement. Most
donors want their funds / grants linked to performance indicators that measure progress in disease
notification / treatment outcomes and reductions in prevalence. These indicators often do not
account for the contribution by and from communities which are often qualitative and when
quantitative have problems with attribution and ownership with the public health services within
which they must operate. Outcomes from community education for better health are not always
evident immediately and are also challenging to measure – while some of these outcomes make for
good ‘success stories’, they do not often sustain interest for further investment. Donors and public
services are also easily distracted by emerging issues such as MDR in the case of TB control, which
while being of great importance, must not detract from basic TB control services. The community is
most often an unequal partner with the public health services and much investment is necessary –
human resource, technical support, funding and education to reduce this inequality.

Where is power located in India to make a difference for health?

India is the world’s largest democracy and in the most recent national election in 2009, over 700
million people voted across the country through a mostly peaceful process. Elections are very
public, consume media attention and politicians woo their constituencies using language, caste,
religion, community, even their poverty! Elections have just started in the state of Uttar Pradesh and
the media debates on what governments and politicians have done or not done or done incorrectly
abound. This is a very large state which has some of the poorest health indicators - close to 200
million people live here or almost a fifth of India. But health is not an issue that is discussed seriously
in this election campaign nor was it an issue that drove or decided the last or any of the previous
elections! Is this not a paradox? Logically, one presumes that power, to make a difference for their
health, vests with the people of India if they are able to determine who governs them. And yet it
seems that health is not the overriding priority for the people when they decide who should govern
them!

We have excellent evidence from the country for over a decade and published in the best peer
reviewed papers that tobacco use is harmful to health and is the most significant cause of morbidity
and death in India. A paper published in the NEJM in 2008 estimates that about one million people
die every year in India due to smoking34. The morbidity and mortality from using smokeless tobacco
adds another dimension to this conversation. Globally, increasing tobacco taxes has been

34
  Source: A nationally representative case-control study of smoking and death in India. N Engl J Med 2008:
358: 1137-47
                                                                                                              10


demonstrated as the single most effective means of reducing tobacco use, particularly among young
people. And yet, at the policy level, the administration of tobacco taxes in India leaves much to be
desired – it does not promote public health, let alone generate revenue even in the current revenue
hungry setting. A report in the Business Standard of Jan 27, 2012 states that the government plans
to increase excise on diesel cars in the upcoming budget 2013 (although more people are buying
these cars due to the existing government subsidy on diesel), but will not raise taxes on cigarettes
lest it promote ‘smuggling’35. We saw a similar reluctance on policy for better public health in the
case of graphic health warnings on tobacco products over the last 4 years (another intervention that
has demonstrated decreases in consumption of tobacco), but this had a somewhat different
outcome. Civil society activism coupled with judicial intervention from the highest court in the land
forced the government to implement graphic health warnings on tobacco products. Today,
numerous villages, districts, towns, cities and even two states (Sikkim and Mizoram) have declared
themselves ‘Smokefree’, strongly enforcing the law prohibiting smoking in public places. In the last
two outcomes – graphic warnings and smoke free jurisdictions, limited financial and technical
support to an already active and vigilant civil society, catalysed change both in policy and
implementation. Clearly power vests with the Corporate Sector to influence policies for health (in
this case negatively, by the powerful tobacco industry); however, an engaged community of people
empowered with limited funding and high quality technical support can clearly make a difference
and effectively influence policy for public good.

Corruption is an issue that is increasingly occupying public attention in the country. Over the last 18
months, India and the world have been astonished at the way in which the Indian government and
the parliamentary legislative process have been questioned and influenced in the country. This
refers to the movement to introduce a Jan Lokpal Bill36 and legislate for people’s power in justice
(essentially the creation of a citizens’ ombudsman). There were a number of actors involved and the
setting is complex – the idea for such a bill is not new, it is many decades old; there are parallel
institutions (Lok Ayuktas37) already functional in some states; the Right to information Act is a
powerful enabler; activists like Anna Hazare and others were able to provide leadership at the
community level and become rallying points for people’s attention and so on. But what stands out,
over the many detailed analyses, criticism and writing of this movement against corruption in the
country, is the potential of the people in India to force or drive change!

In conclusion

Professor Amartya Sen concluded his keynote address to the World Health Assembly in 1999 with
this compelling statement - “The Public has to see itself not merely as a patient, but also an agent of
change. The penalty of inaction and apathy can be illness and death”.30

The most valuable resource available to us in India are the communities we serve and work with. If
they are not part of a call to action, universal access to health care will remain a distant dream,
despite increasing investments in human resource and financing over the coming years.


35
   http://www.business-standard.com/india/news/diesel-cars-could-burnbigger-hole-in-pocket/462958/
36
   Jan Lokpal Bill is essentially the creation of a citizen’s ombudsman through a proposed anti-corruption law in
India
37
   The Lok Ayukta is an anti-corruption ombudsman organisation set up in some Indian states on the
recommendations of the Administrative Reforms Commission of 1966
                                                                                                              11


Communities in India are also not equal. This inequality is across a mind boggling array of
differences. Addressing inequalities in health care in India means acknowledging these differences,
engaging with communities uniquely, identifying and prioritising their needs, bringing investment to
address these needs and working with them to improve their health. And unless communities are
engaged, universal access to health care will remain a distant dream.

*
 Dr Nevin Wilson currently serves with the International Union Against Tuberculosis and Lung Disease (The
Union) as Regional Director of their South-East Asia Office located in New Delhi, India. The views expressed in
this essay are his personal views and do not reflect the views, positions or strategies of The Union.
Dr Wilson can be contacted at NWilson@theunion.org

				
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