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Community Participation and Primary Health Care in India

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Community Participation and Primary Health Care in India Community Participation and Primary Health Care in India Dissertation der Fakultät für Geowissenschaften der Ludwig-Maximilians-Universität München Vorgelegt von Anja Welschhoff Eingereicht am 14. Februar 2006 Community Participation and Primary Health Care in India 1. Gutachter: Prof. Dr. W. Mauser 2. Gutacher: Prof.Dr.H.-G.Bohle Tag der mündlichen Prüfung: 22.05.2007 ii Community Participation and Primary Health Care in India ACKNOWLEDGMENT I want to thank all the staff from the GTZ Basic Health Programmes in Himachal Pradesh, Maharashtra and West Bengal. Without their support this work would not have been possible. My gratitude applies also to the State Health Departments of the respective states, who granted me permission. Further thanks go to all interview partners for their cooperation, to the GEOMED team for their critical appraisal and to my husband. Financial support from GEOMED, Munich University, and from the Fachprogramm zur Förderung der Chancengleichheit für Frauen in Forschung und Lehre, Munich University, allowed me to pursue my dissertation. Special thanks go to: - Dr. J.P. Steinmann, GTZ Health Sector Coordinator for India - Dr. Sattar Yoosuf, Head, Department of Sustainable Development and Health Environment, World Health Organization, Regional Office for South-East Asia - Prof. Surinder Aggarwal, Head, Department of Geography, Delhi University - Sunil Nandraj, National Professional Officer EIP, World Health Organization India - Dr. Erma Manoncourt, Deputy Director, Unicef India - Tim Martineau, Senior Health Advicer, DFID India - Dr. Sharmila Gosh Neogi, Programme Officer, Population Foundation of India - Dr. Helmut Reifeld, Director, Konrad-Adenauer Stiftung India - Dr. Shaloo Puri, Programme Officer, Voluntary Health Association of India - Yasmin Zavery Roy, Programme Manager Health& Education, SIDA India - Dr. Prakash Bhatlawande, State Project Director Reproductive& Child Health, Government of Maharashtra - Dr. Ashok Ladda, Assistant Director of Health Services, Government of Maharashtra - Rajan Mahajan, Executive Secretary, Himachal Pradesh Voluntary Health Association - Dr. R.N. Mahanta, Deputy Director Health, Government of Himachal Pradesh - Prof. S.K. Basu, Director, Institute of Health and Family Welfare West Bengal - Dr. Alok Gosh, Assistant Director Health Services, Government of West Bengal - D.P. Poddar, Executive Director, West Bengal Voluntary Health Association - Major K.P. Malla, Honorary Secretary, Indian Red Cross Society, Darjeeling District Branch - Dr. Suresh Armani, Senior Programme Officer & Coordinator Health, DANIDA India iii Community Participation and Primary Health Care in India CONTENTS 1 HEALTH CARE REFORM IN INDIA .......................................................................... 1 2 FRAMEWORK FOR HEALTH CARE REFORMS...................................................... 6 2.1. HEALTH SYSTEM RESEARCH AND GEOGRAPHY................................................. 6 2.2. PRIMARY HEALTH CARE APPROACH .................................................................. 14 2.2.1. Basic Principles of Comprehensive Primary Health Care .................................. 16 2.2.1.1. Equity ......................................................................................................... 16 2.2.1.2. Community Participation............................................................................. 18 2.2.1.3. The Multisectoral Approach ........................................................................ 21 2.2.1.4. Appropriate Technology.............................................................................. 22 2.2.1.5. Health-promotive and Preventive Approach................................................ 23 2.2.2. Selective Primary Health Care........................................................................... 23 2.2.3. Primary Health Care in India.............................................................................. 24 2.2.3.1. Primary Health Care in India before Alma Ata............................................. 24 2.2.3.1.1. The Health Committees ....................................................................... 25 2.2.3.1.2. The Planning Commission ................................................................... 26 2.2.3.2. Primary Health Care in India after Alma Ata................................................ 27 2.2.3.2.1. The National Health Policy 1983.......................................................... 27 2.2.3.2.2. The Community Health Volunteer Scheme .......................................... 28 2.2.3.2.3. The Integrated Child Development Service Scheme............................ 29 2.2.3.2.4. The Universal Immunization Programme ............................................. 30 2.2.3.2.5. Non-governmental Organizations......................................................... 30 2.2.3.2.6. Conclusion........................................................................................... 31 2.3. DECENTRALIZATION OF HEALTH CARE.............................................................. 32 2.3.1. Frameworks for Decentralization ....................................................................... 32 2.3.1.1. The Public Administration Approach ........................................................... 33 2.3.1.2. Local Fiscal Choice..................................................................................... 34 2.3.1.3. The Social Capital Approach ...................................................................... 34 2.3.1.4. The Principal Agent Approach .................................................................... 35 2.3.1.5. The Decision Space Approach ................................................................... 35 2.3.2. Benefits of Decentralization ............................................................................... 37 2.3.2.1. Community Participation............................................................................. 38 2.3.2.2. Prerequisites for Successful Participation ................................................... 39 2.3.2.3. Accountability ............................................................................................. 41 2.3.2.4. Responsiveness ......................................................................................... 41 2.3.3. Problems of Decentralization............................................................................. 42 2.3.4. Decentralization in India .................................................................................... 43 iv Community Participation and Primary Health Care in India 3 STATUS OF HEALTH CARE IN RURAL INDIA....................................................... 45 3.1. RURAL CHARACTERISTICS .................................................................................. 45 3.1.1. Burden of Disease............................................................................................. 46 3.1.2. Geographical Disparities ................................................................................... 49 3.1.3. Social, Cultural and Gender Disparities ............................................................. 55 3.1.4. Local Elites........................................................................................................ 59 3.1.5. Conclusion ........................................................................................................ 60 3.2. PUBLIC HEALTH SYSTEM...................................................................................... 61 3.2.1. Structure of the Public Health System ............................................................... 62 3.2.1.1. Central Ministry of Health............................................................................ 62 3.2.1.2. Sub-national Agencies................................................................................ 63 3.2.1.3. Rural Public Health Care ............................................................................ 64 3.2.2. Quality of Public Health Care............................................................................. 66 3.2.2.1. Rural Health Facilities................................................................................. 66 3.2.2.2. Public Health Personnel ............................................................................. 67 3.2.2.3. Utilization of Public Health Services............................................................ 67 3.2.2.4. Access to Public Health Services................................................................ 69 3.2.2.5. Availability of Care...................................................................................... 70 3.2.3. National Health Programmes............................................................................. 71 3.2.3.1. Family Welfare Programme ........................................................................ 72 3.2.3.2. Participation in the Family Welfare Programme .......................................... 73 3.2.3.3. National Programmes for Communicable and Non-Communicable Diseases ................................................................................................................................ 74 3.2.3.4. National Programmes Related to Health..................................................... 76 3.2.4. Primary Health Care.......................................................................................... 77 3.3. PRIVATE HEALTH SYSTEM ................................................................................... 78 3.3.1. Private-for-Profit
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