Health and the state in India

Abstract

This thesis concerns the development of health policy-making in India, in the context of theories of the State in underdeveloped countries. In order better to understand the structures and processes which characterise health policy and implementation after Independence in 1947, a historical approach is used. The thesis falls into two parts. Part A (Chapters 1-4) deals with health status and health policy under British rule, and Part B (Chapters 5-11) covers the same topics for Independent India. Both Parts start by locating health policy in the context of levels, differentials and changes in morbidity and mortality, and looking at some of the 'non-health policy' factors which might contribute to the decline in basic levels of mortality since 1881. Under the British, this relates particularly to famine relief policies, accompanied by commercialisation of agriculture and trade in food products; for Independent India, the role of welfare policies which provide a 'floor' to consumption seems important. In neither period can rising real incomes in themselves provide a satisfactory explanation for mortality decline.

The likely role of health services is considered in the following chapters, though the focus of this account is on the processes by which health policies emerge, rather than with their outcomes. Part A addresses a number of arguments which claim that the effect of Imperialist rule was to destroy local healing traditions (Chapter 2), and that Imperialist health services were narrowly conceived in terms of social control, in the provision of services for the Army and the protection of the health of the ruling elite (Chapters 3 and 4). Both arguments are criticised for being too partial. It is suggested that Imperialist interests did not totally dominate health activities, but nonetheless, the impact of services was restricted by their urban, curative focus.

Part B looks closely at the evidence for the pattern of health expenditures by the Central and State Governments since 19 47, and suggests that there has been more space for preventive and public health measures than has usually been recognised (Chapter 6). Chapter 7 explores the national context of policy making, noting the relatively weak role of the Indian Medical Association, and Chapter 8 provides an international focus, looking at pharmaceuticals companies, migration and foreign aid. Chapter 9 takes a close look at policy regarding medical and paramedical personnel, and Chapter 10 discusses the structures and processes of the Government medical bureaucracy. The Conclusion (Chapter 11) considers the 'new approaches' to health provisions, in the private sector and in Government, and suggests that their impact will be much less than has been claimed. In general, it is argued that populist health policies have increasingly replaced 'top-down socialist' ones. Neither have been particularly successful, because they have been permeated by clientelist political institutions. But an adequate account of these policies must give due weight to their achievements as well as their limitations.