THE ECONOMIC WEEKLY M a y 19, 1962

Official Paper

State of the Nation's Health

Report of the Health Survey and Planning Committee (August 1959 — October 1961), Ministry of Health, Government of lndia, 1961. Pp 538.

IN the middle of 1959, the M i n i s t r y of Health of the Government of

Ind i a set up a Commit tee to review the developments that had taken place I n national health i n I n d i a i n the last decade. The Committee consisted of 16 members, most of them eminent physicians and was headed, by Dr A Lakshmanaswami Muda l i a r , Vice-Chancellor of Madras Univers i ty . Af t e r more than two years of hard work this Committee has now published its report runn ing to more than 500 pages. It is an exhaustive and in fo rmat ive report f u l l of detailed facts and statistics regarding different aspects of natio­nal health, such as publ ic health, medical care, communicable disea­ses, medical education, medical re­search, the popula t ion prob lem and medical supplies etc,

The main foundat ion of this re­por t rests on the recommendations made by the Bhore Committee in 1946. In 1943 a Committee was set up, headed by Si r Joseph Bhore, one of the members of the Viceroy's Executive Counci l , to assess the con­di t ions of health then prevai l ing in Br i t i sh Ind ia . It was a much more difficult proposi t ion at the t ime to ce l led a l l the relevant facts and figures as the heal th services were rather in a rudimentary condi t ion . But the Bhore Committee d i d a good deal of useful spade work and pub­lished an excellent repor t incorpor­a t ing their recommendations. The health condit ions in the country were rather in a bad state at that t ime, the infan t m o r t a l i t y rate was 162 per 1,000 and the expectation of l i f e at b i r t h was 26.1 for males and 26.56 for females. Nearly half the total number of deaths were among ch i ldren under 10 years of age, The Bhore Committee Report was mostly based on the v i t a l statis­tics of i l l-health in the absence of data on positive health.

Bhore Committee Report

The Bhore Committee made various recommendations on a heal th programme for the country and the

first term of reference, of the Muda l i a r Committee was to assess how far we had been able to imple­ment those recommendations. The country has developed in many respects since 1946. Changes occur-ed in a very short t ime, po l i t i ca l ly , economically and socially the i m ­pact of wh ich has been qui te great. Under the Const i tu t ion the respon­s ib i l i t ies of the States and Centre in the sphere of nat ional health has been proper ly classified.

The Bhore Commit tee Report was concerned only w i t h the then Br i t i sh Ind ia and the 600 Princely States d i d not come w i t h i n its purview. Af te r the pa r t i t i on , an area of about 3,65,000 sq miles w i t h an estimated populat ion of 88 mi l l ions has been separated f rom the Ind i an Republic against w h i c h 7,16,000 sq miles of Princely States w i t h the estimated popula t ion of 93.2 m i l l i ­ons were added to i t . The inf lux of refugees, normal ly w i t h low health standards due to poverty, has added to the problem.

Rapid economic change is occui-ing in the country as a result of the r a p i d industr ia l isat ion, commu­n i ty project programmes, land ten­ancy reforms etc. Our society is also changing at a rap id pace due to various factors such as spread of education, more employment, the H i n d u Code B i l l , the Employees' State Insurance Scheme, the f ami ly p lanning programme etc. The Muda l ia r Committee has considered most of these developments in their report and taken them in to account in mak ing their recommendations.

Population vs Development One of the impor tan t chapters in

this report is on the populat ion p rob lem. Tha t all our p lanning and economic programmes to develop our country and increase national wealth are being frustrated by the increase of our populat ion is obvi­ous. Unless and u n t i l an effective step is taken to check the g rowth of popula t ion we shall be facing a disaster. The rate of increase of

popula t ion in 1901-1911 was 6.4 per cent, in 1911-31 it was 10.6 per cent, in 1931-34 13.6 per cent and in 1951-56 21.5 per cent. The popu­la t ion stands today at more than 436 mi l l ions as against 360 mil l ions i n 1951.

The urgency of this p rob lem is already wide ly recognised by the Government as well as pr ivate bodies. But the steps taken by the Government seem to be rather half­hearted. In the Firs t Five. Year Plan period, of the total Plan out lay of Rs 2,356 crores, the Planning Commission made a provis ion of only Rs 0.7 crores for f a m i l y plan­n ing . In the Second Five Year Plan per iod, out of a total outlay of Rs 4.500 crores, the budget for f ami ly p lanning was Rs 3 crores on ly . However, in the T h i r d Five Year Plan the planners have given a l i t ­tle more thought to f ami ly p l a n n i n g and have sanctioned a sum of Rs 27 crores out of Rs 8.000 crores for f ami ly planning. T w o theories seem to be prevalent among our planners about populat ion cont ro l .

Some economists ho ld the view that the popula t ion g rowth w i l l automatical ly be reduced w i t h the g rowth of the average standard of l i v i n g . For instance, England and France faced the populat ion problem about a 100 years ago. but in spite of the Catholic religious opposi t ion to b i r t h control in France and social and legal taboo in England, the b i r t h rate came down gradual ly .

Demographical research shows that the popula t ion f luctuation fo l ­lows a well defined cyclical pa t tern . The first phase is characterised by h igh b i r t h and death rates. The second phase is a t rans i t ion period caused by the impact of impor tan t social and economic developments, in wh ich the death rate is reduced wi thout corresponding decrease in the b i r t h rate, which gives rise to an increase in popula t ion . We in Ind ia , are passing through this phase. The next phase shows a fur ther reduction in the death rate.

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b u t the b i r t h ra te also shows a downward t r end . T h e popula t ion m a y s t i l l continue to grow. The U S S R and some o f the Eastern European countries are passing th rough this phase. Th i s is fol low­ed by a decrease in the b i r t h rate, leading to a balance between b i r t h and death rates. Th i s posi t ion exists in some of the h igh ly ad­vanced countries of the w o r l d .

The second theory is that wh ich advocates the reduct ion of popula­t i on by "family p lann ing th rough the use of contraceptives, mass s ter i l i ­sation of diseased and disabled per­sons, who are a burden to society, legalising voluntary abor t ion as in the case of Japan, use of surgical methods of t empora r i ly incapaciat-i n g females etc.

Population Control : How ?

The members of the Heal th Survey Commit tee could not come to a unanimous decision on this subject of method of f a m i l y plan­n ing and there are two sets of re­commendations :

( a ) The general recommenda­t i on of ma in ly in tens i fy ing the exis t ing f a m i l y p l ann ing programme by t r a i n i n g , education, demographic studies, free supply of contracep­tives, vo lun t a ry ster i l isat ion etc. They have also suggested the forma­t ion of an independent M i n i s t r y a t the Centre to deal w i t h the pro­blem of popula t ion , or enlarging the M i n i s t r y of Hea l th by appoint­ing a Min i s t e r of State fo r f a m i l y p lanning .

( b ) The second recommendation is signed by five eminent physicians for a more drastic f ami ly p lanning programme. A c c o r d i n g to their view, to accelerate f a m i l y p lanning , cer ta in legislations have to be ad­opted such as:

( i ) Graded rate o f taxat ion f r o m the f o u r t h confine­ment onwards,

( i i ) Removal o f disadvant­age of income-tax in respect of unmar r i ed persons,

( i i i ) W i t h d r a w a l o f mate rn i ty benefit in the case of women refusing to ac­cept f a m i l y p lann ing .

( i v ) A b o r t i o n f o r socio-econo­mic reasons.

These recommendations seem to be rather imprac t i ca l at present. But one t h i n g is cer ta in : very

posit ive act ion is to be taken to stop the increase of the rate of b i r t h i n our coun t ry . The m a i n ob­ject ive today in I n d i a is to aocele-rate the movement f r o m the second phase of the demographic cycle to the f o u r t h phase by a posi t ive and planned effort w i t h o u t w a i t i n g f o r the consummation in the normal course of t ime th rough social and economic progress. H o w this is to be done is for the b i g social and economic pundits to decide.

D r u g and Medical Supplier

The Bhore Commit tee recom­mended that the final responsibil i ty for the supply of essential needs of the country in respect of i m ­portant medical requisites should rest w i t h the Government. " I t should be possible to meet the essential needs th rough the con­t r i bu t i on of p r iva te enterprise, sui tably assisted, where necessary, protected by the State where this is found to be fo r pub l i c interest". Th i s recommendation has been a l ­most completely implemented dur­ing the last decade. The indigenous manufacturers of drugs and medi ­cines have developed their produc­t ion considerably, meeting the demand of the country of the essential drugs and medicines. The Government has also undertaken the manufacture of essential drugs l ike ant ibiot ics and sulpha drugs in the publ ic sector. The P i m p r i fac­to ry , for the p roduc t ion of peni­c i l l i n and s t rep tomycin went in to product ion a few years ago.

The fundamental p r i n c i p l e enu­nciated by the Bhore Committee repor t i s that " N o i n d i v i d u a l should f a i l to secure adequate medical care because of the i n a b i l i t y to pay for i t . " The count ry has taken a r ight step towards this di rect ion by establishing the Employees' State Insurance Schemes, cont r i ­bu to ry health scheme. Due to the healthy compet i t ion in the market , the price of drugs has come down continuously since 1946, w h i c h has also helped the mass of the people to afford medical treatment to a greater extent than before.

The m a i n developments in the last decade wh ich have brought about these condit ions are as follows :

( 1 ) Enforcement of D r u g A c t for supervision and control of the manufacture, d i s t r i b u t i o n and sale of drugs in the count ry .

( 2 ) Passing the Pharmacy A c t and setting up the A l l - I n d i a State Pharmacy Counci l fo r the proper dispensing and d i s t r i b u t i o n of medicines by qual i f ied persons.

( 3 ) Passing of the D r u g and Mag ic Remedies Ac t to prevent advert is ing and d i s t r ibu t ion of une­th ica l and spurious drugs

( 4 ) Set t ing up of a Central D r u g Labora tory for testing drugs manufactured in Ind ia .

( 5 ) Establishment in the publ ic sector of plants f o r the manufacture o f pen ic i l l i n and D D T w i t h the assistance of the U N I C E F.

(6) Increase in the product ion of drugs by indigenous manufac­turers who supply the bulk of the needs of the country .

( 7 ) The finalisation of schemes of manufacture of ant ib io t ic phyto-chemicals, synthetic drugs and surgical instruments in the pub l i c sector, w i t h the help of the U S S R Government.

( 8 ) The issue of licences fo r the manufacture of many essential pharmaceutical chemicals l i ke vita­mins, hormones, insulins, sulpha drugs ant i tubercular drugs and ant ib iot ics in the pr ivate sector to meet the needs of our count ry and reduce the burden on our foreign exchange reserves.

Patent Laws Need Change The Muda l i a r Commit tee has

also recommended certain modif i ­cations in the present patent laws in our country. These suggestions seem to be quite adequate at the present junc ture and w i l l relieve us in a few years' t ime f r o m the burden of p a y i n g royalties to the foreign manufacturers for the manufacture of some impor t an t l i fe saving drugs.

F r o m the committee's report i t appears, inc identa l ly , that there is a dispute as to the parentage of the d r u g indus t ry . T h e Heal th M i n i s t r y claims tha t drugs indus­t r y is its legal of fspr ing though at present i t is under the custody of the M i n i s t r y of Commerce and Indus t ry . The Hea l th Survey Com­mit tee w h i c h was set up by the Heal th M i n i s t r y criticises strongly the implementa t ion of the Indus­t r i a l Development and Regulation A c t as appl ied to d rug industry . I t suggests that the development of the pharmaceutical industry should

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be based on the need of the u l t i -mate consumer, rather than on the indus t r ia l pol icy of the Government. They feel that the present dual con­t ro l should he done away w i t h and the licensing for d r u g manufacture should be the function of the M i n i ­s t ry of Heal th . There should be a liaison officer between the Heal th M i n i s t r y and the M i n i s t r y of Com­merce and Indus t ry (Development W i n g ) .

More Doctors for Villages

To prov ide adequate medical care to the vast popu la t ion of our coun t ry is a gigant ic task. We are hopelessly short of finances, qual i f ied personnel, hospitals and dispensaries. We have made some progress since 1946 and at present the posit ion is as shown in the Table.

C e r t a i n p r i m a r y heal th centres have been opened up d u r i n g the last few years in some States to cater to the r u r a l popula t ion .

The Commit tee has recommended various measures fo r ra is ing the standard of medical care. B u t the m a i n p rob lem is the shortage of finance and qual i f ied personnel. 82.7 per rant of the popula t ion of I nd i a is in the ru r a l areas. The qual if ied doctors and nurses are concentrated m a i n l y in the urbato areas and are reluctant to go to the ru ra l areas, where there are very few facil i t ies and amenities f o r their da i ly l i f e . There should therefore, be some incent ive for them to go to the r u r a l areas fo r the i r professional practice. The pure ly chari table mot ive is not enough for a qua l i f ied person to cut off himself f rom modern ameni­ties of l i fe and to l ive in adverse condit ions in villages. Regarding finances the Committee has re­commended the in t roduc t ion of a system of graded charges for hospi­tal services. It has also suggested that the poss ib i l i ty of l evy ing some sort of a heal th cess should be ex­plored . These recommendations are w o r t h considering.

Publ ic health is a very vast sub­ject . No last ing improvement of publ ic health can be achieved w i t h ­out arousing the active interest and enl is t ing the pract ical co-operation of the people themselves. Th i s can only be achieved by educating the masses and ra is ing the i r stan­dard of l i v i n g through economic development. However, there are some basic publ ic health program­mes wh ich the State should under­take, l ike water supply, sanitat ion, protect ion f r o m communicable dis­eases by vaccination, care of mothers and chi ldren, i m p r o v i n g the n u t r i ­t ional standard of food, housing in the urban and ru r a l areas, etc. Certain steps are being taken in this d i rec t ion by various State Governments. Thanks are due to various in ternat ional organisations l ike W H O, U N I C E F, T C M,

Colombo Plan , Rockfeller Founda­t i o n , F o r d Foundat ion and C A R E , who have assisted great ly and are s t i l l g i v i n g us l ibera l grants fo r i m ­p rov ing p u b l i c health and n u t r i t i o n .

The m a i n communicable diseases which are endemic in our country, such as mala r ia , tuberculosis, f i l a r i -asis, small pox, cholera, leprosy, venereal diseases, etc, are being tackled qui te effectively and there is a definite gradual decrease in their incidence.

The recommendations made by the Muda l i a r Committee are w o r t h close study. It would be interest-i n g to know as to what happens to the reports made by different com­mittees. A r e they summari ly put in cold storage or do the Central and State Governments take any cognisance of the i r recommenda­tions and t r y to implement them ? I t may be mentioned in passing that in the recently-formed Cabinet at the Centre, health is given a back-bench pos i t ion , headed by a Minis ter of State, wh ich is quite cont rary to the recommendations of the M u d a l i a r Committee.

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