Books
DISINVESTING IN HEALTH: The World Bank’s Prescriptions for Health edited by Mohan Rao. Sage Publications, New Delhi, 1999.
HEALTH care is a public or merit good which no society with a welfare maxim can afford to ignore. Most developing countries have tried to pursue strategies for health care giving primacy to the government’s role in financing and delivering these services. The strategies and policies evolved in the past few decades at the national level and the international discussions on health had a common orientation towards the government sector in terms of policy, financing and management. Health care services were largely seen as government entities to which access could be expanded by increasing public investment.
However, with the decline of the Keynesian argument on the need for state intervention in demand management and the orientation towards liberalisation and privatisation under the structural adjustment programmes (SAP) prescribed by the International Monetary Fund (IMF) and the World Bank for solving the crises in developing countries in the late 1980s and early 1990s, public investment in social sectors, especially in health, suffered a setback.
The World Development Report of 1993, Investing in Health, advocated a three-pronged approach to government policies for improving health in developing countries. First, governments were required/needed to foster policies that would aim at creating an enabling environment for households to improve health by pursuing economic growth policies that would benefit the poor. Second, government spending on health should be redirected to most cost effective programmes that do more to help the poor. Third, governments need to promote greater diversity and competition in the financing and delivery of health services by facilitating involvement of the private sector. The key elements of these initiatives are: (i) PHCs to restrict their activities to selected areas of prevention of communicable diseases and promotion of family welfare; (ii) curative care to be left to the private sector, and (iii) encouraging the private and voluntary sector in health related activities.
At the outset, the World Development Report 1993 (WDR ’93) prescriptions appear to provide the most comprehensive reform package. However, the emphasis on cost effectiveness for allocating government resources as well as the promotion of the private sector in health care, which is a merit good, has raised doubts about the real intentions of the World Bank.
This volume, edited by Mohan Rao, is the product of an intellectual exercise that looks at the World Bank prescriptions in a critical manner. At a national seminar entitled ‘WDR 1993: Investing in Health Implications for Health and Family Welfare in India’, held in December ’94, scholars and activists from a range of disciplines debated the different aspects of conceptual, methodological and empirical strengths and weakness of WDR ’93. The author has put together some of the best scholarship within India in this volume of 15 essays which critically examine the issues related to health care in the context of SAP and WDR ’93. This body of work constitutes the first academic critique of the WDR ’93 from India.
In his introductory chapter, Mohan Rao emphasises the role of organised public action that is most critical in altering the outlay and impact of the web of factors that determine health. Prabhat Patnaik deals with the political economy of structural adjustment, which had paved the way for the advocacy of reform in the health sector. He criticises WDR ’93 for trying to institutionalise dualism in the health sector. The prescription suggests substantial privatisation of the health sector, with a need for public effort to be concentrated in the essential clinical services only, as governments have limited resources. Patnaik criticises this thinking by arguing that the SAP’s prescription of liberalisation which seeks to reduce tax rates and other protection is a cause for reduction in government revenues. It is thus not justifiable to ask the developing countries to cut back on their limited resources. A methodological problem raised relates to the classification of clinical services into ‘essential’ and ‘non-essential’ as this is arbitrary. To him it is apparent that WDR ’93 is an effort by the World Bank to make their reform package socially attractive.
While Patnaik’s focus is on interrogating the motive of the World Bank behind its prescriptions and lack of real social concern, Niraja Gopal Jayal discusses the nature of ‘welfarism’ on which the health policies were supposedly based. The author has attempted to establish the limited welfarist orientation of the Indian state, seen more appropriately as an interventionist one, whose welfarist activities are characterised by inefficiency as well as absence of any concept of welfare as a right. The over-emphasis of the World Bank prescription on cost effectiveness and efficiency seriously dilutes the welfarist concern, while the privatisation agenda takes it to a market orientation which may lead to failures. The World Bank agenda as manifested in WDR ’93 would serve to marginalise the welfare centred policies which are already limited in scope.
The way in which the World Bank’s interventions have affected India’s attitude toward the PHC is the concern of Imrana Qadeer’s essay. She focuses on the fact that inspite of the apparent weakness, the World Bank chose to follow a selective instead of a comprehensive PHC approach, thus shifting the focus from the ‘process’ of intervention to the ‘programmes’ of intervention, that too with an emphasis on cost effectiveness. The prioritisation of ‘essential’ clinical services to the private sector has reduced the PHC to primary prevention and promotion activities. ‘Clinical management’ has thus become the objective of public health of the WDR variety.
Nata Duvury’s paper discusses the gender implication of the new economic policies. The privatisation efforts have adversely affected the female work participation rate. They have also affected poverty levels, which have a deeper impact on women. The burden on women at household production of health has been affected by cuts in public expenditure on social sectors including health, under the SAP.
Mohan Rao’s paper traces the fact that WDR ’93 advocates promotion of family welfare. Any reduction in health expenditure under SAP would seriously affect the family planning programme in India, which according to him has failed to take off despite repeated efforts by the government. The SAP prescriptions would cause a further dent in its performance.
A.K. Shiva Kumar’s paper questions WDR ’93, which is dominated by efficiency arguments, marginalising the important questions of ethics and equity. He stresses the importance of using both efficiency and equity criteria for evaluating policy options. Three common notions relating to the equality of access to health care services – physical, economic and social access – are discussed in order to show that health reforms to be sustainable, need to be based on a careful assessment of the country’s health needs, the overall level of people’s entitlements, the effectiveness of current levels of public provisioning of health facilities and the extent to which people are likely to benefit.
Seeta Prabhu’s essay is an empirical examination of the consequences of SAP on central and state government’s public expenditure, especially on medical and public health. She highlights the decline in real public expenditure on health in the last few years, and emphasises that this would undermine the public sector’s role in health care provision.
Rama Baru looks at the structure and utilisation of health services in the Indian states using NSS data. She shows that a shift towards the private sector and privatisation will lead to greater social and regional inequalities as the private sector provision and spread is uneven and guided by the profit motive.
Amit Sen Gupta’s paper analyses the implications of WDR ’93 on infrastructure development in health care and the pharmaceutical industry. He sounds a word of caution in following the World Bank’s prescriptions for the Indian drug industry. In contrast to the WDR ’93 point of view, he argues that to ensure the availability of essential drugs at reasonable rates, state initiative as suggested by the Hathy Committee needs to be sustained.
K.R. Nayar’s paper is concerned with the consequences of globalisation for environmental health not only due to ‘garbage imperialism’ and consumerism, but also because of overall shifts in resource allocation. The WDR ’93 emphasises the household micro environment where traditional concerns of environmental health such as water, health and sanitation are listed as important areas of action. Women’s empowerment in the context of real life situations facing poor rural women, whose health and access to contraception, which forms a major area of concern even in WDR ’93, has been analysed by Arti Sawhney. It is based on experiences in Rajasthan and shows how empowerment of women has been a double edged sword.
N.H. Antia in ‘A prescription for health disaster’ critiques the World Bank for its insensitivity to the cooperative culture and tradition of non-western societies. He criticises it for advocating privatisation and competition in the health sector in developing countries like India where the private sector is already a dominant provider of profit making curative services. Antia feels that an alternate strategy, taking into consideration local health needs and culture, could emerge under local panchayat raj institutions.
Analysing the experiences in health improvement strategies in developing countries, K.V. Narayana argues that the WDR view of attributing mortality decline in developing countries to technical interventions ignores the social origins of ill-health. Limiting the role of the public to narrowly defined public health programmes is not suitable for a country like India, where a large proportion of the poor access health care from the public sector. Utilising NSS data, T.N. Krishan demonstrates that wide disparities exist in the access to health care in India including variations in the burden of treatment and costs. In this situation, the privatisation strategy advocated by the WDR ’93 would be suicidal for a country like India.
The essays in this book represent a pioneering effort aimed at demolishing some ‘myths’ regarding the prescriptions for reforming the health care sector in developing countries. The ‘perceived’ quality of private sector and the advocacy by the World Bank for leaving non-essential health services to the private sector has gained acceptance among a wider population. The book attempts to elucidate the political economy of such a policy and criticises the prescriptions for overlooking the welfare aspects of health reforms in the name of efficiency arguments. The fear is that a shift from low cost care through the public sector to a market based model might lead to a widening of disparities in society. The authors, in advocating pro-people health policies, argue that a withdrawal by the state from its commitments forbore poorly for people’s health.
Notwithstanding this substantial contribution, the collection is marked by serious shortcomings. None of the essays have analysed why WDR ’93 ignored the indigenous systems of medicine, especially in developing countries where they are prevalent. Since India has a developed traditional indigenous bio-medical system, which, if not studied from the point of view of the provision of health care services, should at least have been looked at from the point of view of its contributions to investing in health through the lifestyle, food and cultural aspects. While emphasising the government’s role, the book overlooks such aspects of health care.
Second, the book is critical of any kind of privatisation effort. Most developing countries have an active private sector dominating the health sector in its provision and utilisation. While criticising WDR ’93, the main argument visible in the book is that the poor do not have the ability to pay for health care in a market situation. Also, while examining any proposal, it is useful to suggest alternatives and this is where the scope of the book is limited. Some contributors do offer suggestions, but most limit themselves to mere criticism.
Another argument forwarded is that government funds are limited because of SAP policies. However, even if the government were to double its revenue, it would not be sufficient to ensure adequate investment for preventive and promotive care, leave alone the entire health sector including curative care. It should be remembered that in the past, an expansion of the private sector helped reduce the burden of curative care services on the public sector. This helped the public sector to concentrate on preventive care services and promotive care.
Fourth, even if the government provides health care services, the burden of illness will affect the people in terms of the working hours lost, dependants, nature of illness, and so on. Therefore, there is no harm in charging user fees for services provided by the government sector from people who have the ability to pay.
Finally, while strongly criticising private sector promotion in health care advocated by WDR ’93, the authors are silent as to how the private sector is growing relatively within the health sector, and why people prefer it. Since this collection does not look at the maladies in public sector provision, it fails to make suggestions regarding strategies for improvement.
Mala Ramanathan and Deepa Sankar
DRUG SUPPLY AND USE: Towards a Rational Policy in India by Anant Phadke. Sage Publications, New Delhi, 1998.
THE book under review attempts to analyse the production pattern of drugs in India, the predominance of irrational drug formulations, and the role of the drug industry and doctors in sustaining this irrationality. The author’s association with the Movement for a Rational Drug Policy makes him focus, in part I of the book, on the international track record of the drug industry. Part II of the book reports on a three-year study (1991-93) conducted in the Satara district of Maharashtra.
During the ’90s, both the global and national research and policy process were impacted by a utilitarian perspective that employs a consequentialist calculation and comparison of policies to determine which reform will achieve the best results for the least input. This book displays a similar orientation. It starts with the premise that drug production and use in India is irrational, irrespective of whether the drugs are produced by MNCs or by Indian companies. Using evidence from the western world, the first section of the book locates the drug industry within the profit centred market. Anant Phadke underscores the irrationality of the production pattern in India in two ways. First, it does not cater to the needs of the majority of the Indian people. Second, it violates medical principles by producing various irrational, obsolete, hazardous drugs, and their combinations.
In analysing Ayurvedic drug production the author observes the absence of regulations or set standards to judge the quality of the end product marketed as Ayurvedic medicine. Since the method of preparation is of paramount importance in Ayurveda, any deviation from the method described in an Ayurvedic text is hazardous. Therefore, some mechanism must be instituted to ensure the correct method of preparation. The author believes that there are statutory provisions, like section 33 EED of Drugs and Cosmetic Acts 1940, which would minimise this irrationality. The only problem is to put them into effect, which requires political will.
The drug industry operates on market principles. In a country like India where the vast majority of the Indian population is excluded from this mechanism, the average technical knowledge of the consumer is rather low and technical guidance scarce, the role of government becomes important. Its role is crucial in terms of locating the drug policy in an overall framework of health and health services. So how would banning a few drugs, making some statutory provisions, or providing universal health insurance make any difference? The author’s observation that the track record of the drug industry worldwide is not reassuring and that even the FDA of USA does not have sufficient resources to tackle the industry’s irrationality, is an eye opener. However, these issues have been examined somewhat tangentially. He does not address issues like why the Indian drug policy is biased in favour of the drug industry? Or why government control, despite experimenting with various versions of drug policies and drug price control orders (DPCOs), has been ineffective?
The book becomes more interesting when it describes how drug action groups lobbied for a rational drug policy. Citing two success stories of drug action groups, AIDAN and DAF, the chapter delineates the impediments in the formation of an effective drug policy that could make available the right kind of medicines at affordable prices to people.
In the chapter devoted to ‘irrational drug use by doctors’ the author argues that since additional expenses on account of irrational drugs are not borne by doctors, they are not concerned about the financial implications of irrational prescribing. Second, drug companies try to oblige doctors with free gifts, drugs and entertainment.
Undoubtedly, there is massive variation in medical practices. One factor responsible for the deviation from good practice is not poor medical knowledge but poor communication, including negligence in addressing the concerns of patients. It is unlikely that any continuing medical education or an open book examination system containing multiple choice questions would help. Guidelines, regulations and provisions are no answer. The important issue is whether the clinicians and the public believe in and use them? Another aspect of the problem in need of review is why people are encouraged to use medication even when the side effects are not clearly discernible? Any attempt at a quick-fix answer to these questions is unjustified.
Throughout the book there is the continuing theme about rational medical practice and deviation from it. ‘A Study of Drug Use and Supply in Satara District’ presented in the second part of the book, places the onus of irrationality of practice primarily on the practitioners. Though one is sympathetic to the central concern of the author, it needs to be recognised that there are serious methodological problems in measuring rationality of medical prescriptions. The author’s definition of rationality and his methodology is however questionable. This is mainly due to variations in medical practice, the available infrastructure and facilities, and the type of consumers the practitioners serve in, particularly in their ability to pay, their prevailing health conditions and the problems they are likely to suffer from. Is it scientific to analyse the ‘rationality’ of a medical prescription without considering the context of medical practice and without appreciating the health beliefs and choices of the patient as a part of the medical process?
Even in the strict domain of biomedical rationality, prescriptions can only be judged on the basis of diagnosis made and medical advice given. It is therefore more important to examine the process of arriving at a diagnosis, specially from such a varied bunch of practitioners. In case of unqualified local practitioners the diagnosis is primarily based on symptoms, as also their experience regarding the patients feedback and affordability. For the qualified practitioner, the diagnosis depends partly on symptoms but also on clinical findings and investigation reports. Equally influential is rapport with the patient. In the public health sector, practitioners diagnoses are heavily influenced by the infrastructural set up, supply of medicine, time constraints, programme records and, of course, the clientele – the poor population. These aspects have not been touched upon in the study. It is difficult to appreciate his elaborate system in which he gives different scores to different prescriptions, even while acknowledging that the criteria he uses are arbitrary.
There is no doubting the author’s sincerity and convictions, particularly about the need to deliberate irrationality/rationality. While wider issues are difficult to tackle, something can be done within the given situation. This is based on the author’s calculations that if one translates the irrationalities in drug prescription into the cost of medicines and prevent those irrationalities, the cost reduction would be sufficient to take care of all outdoor patient care, indoor care and even preventive care in a district like Satara (Maharashtra).
India’s economic reforms have led to reduced budget provisions for the public health sector. Consequently, the patients have to bear the exorbitant expenditure created by the play of market forces in medical practice. Irrational prescriptions are thus profitable for drug manufacturers. India, whose vast majority lives below the poverty line, can ill-afford such irrationality.
The book, unfortunately, lacks a comprehensive account of the issues related to a rational drug policy. Why is it that the study failed to come up with even one rational prescription? What seems to have been ignored is the fact that it is not the doctors who use medicines. Therefore, the ‘rationality’ of medical practice has to incorporate the patient’s perspective. Second, it needs to be analysed why the drug policy continues to be seen as a part of industrial policy rather than the health policy. Third, there is need for a political economy explanation as to why an egalitarian model of development does not exist which would ensure easy accessibility to the health services for the mass of people. An extensive debate leading to the evolution of a rational drug policy and legitimate health concerns of the people is warranted in the light of questions raised by the book.
Ritu Priya
IMPLEMENTIN A REPRODUCTIVE HEALTH AGENDA IN INDIA: The Beginning edited by Saroj Pachauri. Population Council, New Delhi, 1999.
THE book under review is timely in more ways than one. India has just begun to move away from a target oriented, sterilization based family planning programme to a quality conscious and gender sensitive, reproductive health programme. This is not easy. The early years of change were characterized by a concomitant presence of scepticism, apprehension and misgivings at all levels due to a removal of family planning targets. Demographers (who have played a critical role and greatly influenced programme thrusts in the past) and bureaucrats (both medical and administrative) have been particularly sceptical of the shift for a variety of reasons. Some of these reactions are borne out of quantitative thinking, hierarchical functioning style typical of bureaucracy and a mindset of control rather than support, and an unrealistic expectation of quick results from a programme which is so radically different from earlier approaches.
Based on carefully chosen articles, Saroj Pachauri has tried to address several issues that constitute the core concerns of the new programme. The book helps to clarify the nature of ‘paradigm shift’, contextualizes the family planning programme, discusses the operational aspects of programme implementation, and at the same time retains a philosophical and theoretical framework.
The first section (eight articles) deals with the implementation aspects of reproductive health policy. Of these, two are reprinted from other sources whereas the other six have been specially written for this book. Although reflecting the experiences of the early stages of programme implementation, most articles provide compelling evidence and arguments in support of the positive changes taking place under the new regimen. They also argue for a more rigorous and committed implementation of the reproductive health agenda rather than reverting back to the target regime. For example, Khan and Townsend show that family planning programme performance had plateaued and begun to decline well before targets were removed, and that any further improvement in performance would have been difficult to achieve even if the target approach had been continued.
Visaria and Visaria, on the other hand, present cases from Tamil Nadu and Rajasthan on the field level realities of implementing a target free approach. They show that while the programme continues to be expressed in quantitative terms, workers are no longer being reprimanded for not meeting targets. This is an encouraging sign to enhance self-esteem of workers and is, therefore, likely to positively influence the quality of services. They comprehensively review activity specific expenditure to show that expenditure in services has increased over the past five years, although this increased expenditure cannot be attributed to the GOI commitment to ICPD goals. While appreciating external financial assistance that the government has been able to raise to support initial programme activities, they stress the need to raise domestic resources to ensure sustainability. Central to a sustainable programme is its ability to correctly and adequately monitor and evaluate its activities.
Murthy and, in another chapter, Pathak, Ram and Verma discuss the challenges of the new monitoring system and point out the need for greater sensitivity to state specific requirements while deciding upon monitoring indicators. Murthy, however, points out that the government’s excessive preoccupation with an elaborate monitoring system has led to a neglect of other important aspects of the programme. Anjali Nayyar presents a comprehensive review of various advocacy efforts that have gone into the initial stages of programme implementation and points to the ills of the target approach. She argues that advocacy should continue to remain an integral part of the reproductive health programme given the environment of scepticism and apprehension.
Dileep Mavlankar proposes a comprehensive approach of human resource management to ensure continuing focus on quality or client needs, currently missing in the programme. He also emphasises the need to devise ways to ensure accountability, a concern which would increase once the private sector comes to play an important role in providing reproductive health services. Bhatia and Cleland, using health seeking behaviour data from a field study conducted in Karnataka, argue in favour of promoting a viable and efficient private sector, though they too simultaneously argue for evolving a system to monitor quality.
Given the extant emphasis on promoting family planning among married women of age group 15-49 years, the youth/adolescents have remained neglected. The school based population education or family life education programmes did little to address the reproductive health needs of this segment of the population. Sagari Singh points out that despite some major governmental and non-governmental efforts the youth continue to be ignored, are ill-informed and remain at best token partners in the reproductive health programme. Based on a review of some community based programmes, Masuma Mamdani argues that the most effective reproductive health programmes for youth and adolescents invariably include more than information or services and address larger issues. She also points to the need for a database to evaluate the effectiveness of community based programmes.
A critical strata that has remained out of the purview of family planning programme is men, despite ground realities of family institutions and gender relations. Saraswati Raju reviews some of the major NGO efforts in reaching out to men and presents different strategies that would be necessary for their greater involvement. She, however, argues for serious government interventions to upscale and replicate NGO work rather than leave the responsibility of ‘social change’ entirely to the NGO sector.
In another important article Swapna Mukhopadhyaya and Jyotsana Sivaramayya argue that a vertical health programme which is unsure of its location within the local scenario, can neither empower women nor ensure sustainability. They point to the need for locating the reproductive health programme within the ‘panchayat’ structure.
The final section of the book includes seven articles of which three address the issues concerning HIV/AIDS. Other issues addressed include reproductive tract infection, abortion, safe motherhood, sexuality and sexual behaviour. Radhika Ramasubban critically examines several cultural and programmatic factors responsible for the absence of a clear policy on HIV/AIDS in India. She calls for clear commitments, a public discourse on sources of infection, and an integrated approach. Geeta Sethi on the other hand, presents a detailed description of government response to HIV/AIDS which centres around the activities of the National AIDS Control Organization (NACO). One, however, does not know whether these programmes have been effective. In the coming years, it is obvious that the NGO sector will play an important role in HIV/AIDS prevention efforts. Verma, Mane and Bhende review some of the strategies of the NGO sector in its response to HIV/AIDS, particularly in relation to women. They argue that gender disparity will have to be centrally addressed for these programmes to be effective.
The challenge of assessing the extent of RTI in a community-based intervention has been addressed by Masuma Mamdani. Similarly, abortion is another area which challenges effective community based intervention since it is difficult to assess the actual extent of the problem. Khan and his colleagues point to the gap between demand for abortion services and their actual provision. Dileep Mavlankar reviews safe motherhood efforts in India and points out that they should receive much greater priority. The final chapter of the book discusses the status of research on sexuality and sexual behaviour in India. In an exhaustive and insightful review of major intervention research projects on sexual behaviour and other available literature, Pelto suggests a new research agenda in the area of sexual behaviour. He points to the need for developing culture specific conceptual frameworks of sexual behaviour, rather than studying sexual acts in isolation.
The volume could also have addressed other critical reproductive health areas such as infertility, quality of care and violence against women. Nevertheless, given the range of issues discussed and the database provided, this volume is an important resource material for researchers and policy and programme personnel alike. It should also serve as an important source of baseline information for a programme which needs much greater commitment and conviction than what is visible now.
Ravi K. Verma
MEDICAL EDUCATION AND HEALTH CARE: A Pluridimensional Paradigm by J.S. Bajaj. IIAS, Shimla, 1998.
AS the first, and so far only, representative of the medical profession on the Planning Commission, J.S. Bajaj’s insights into the travails of our medical education system merit serious notice. Structured around his Radhakrishnan memorial lecture (1994), this set of essays touches on a variety of themes ranging from medical education to population policy, reproductive ecology, quality of life, environment and development and nutrition and poverty.
Bajaj points out that though both the Bhore Committee Report (1946) and the Radhakrishnan Committee Report (1949) stressed the utmost need to familiarise medical professionals with Indian systems of medicine as also ensure the necessary balance between doctors, nurses and paramedical staff and between general doctors and specialists – 50 years down the road we have not even begun to correct the distortions already evident at the time of Independence.
At that stage there were only 17 medical colleges in the country with an annual intake of 1400 students; today we have around 150 medical colleges producing 16000 medical graduates. Not only does the basic medical course completely bypass Indian systems of medicine, thereby strengthening the bias against indigenous practitioners, the system provides for nearly 10,000 post-graduate seats. The net implication of this runaway increase and distortion in our medical education is that we have an over-supply of over-qualified (though ill-trained) specialists who hover around urban complexes, mainly in private practice, while the rest of the medical system remains starved of necessary personnel.
Worse, despite the recommendations of numerous expert groups, no serious effort has been made to stop the proliferation of colleges and seats or focus attention and resources on the training of mid-level/paramedical professionals. If anything, the profession has been able to manipulate the political system so as to retain its monopoly over medical treatment. What is surprising is that Bajaj, despite such gloomy analysis, remains an optimist.
The lessons from the other essays underscore the same message. The population programme, while incorporating all the welcome concepts of eschewing targets, strengthening women’s empowerment through education, moving to a family (rather that woman) oriented approach and so on, continues in the rut of somehow meeting sterilisation targets. Similarly, notwithstanding the clear linkages between nutrition and health or more generally the non-medical factors influencing the health of the population – the profession’s focus remains on strengthening the curative apparatus.
In this year of Health for All, it is imperative that our planners and politicians heed J.S. Bajaj’s wise words and act on them. Otherwise, we will continue to suffer the consequences of distorted priorities.
Seminarist
VOLUNTARY ACTION IN HEALTH AND POPULATION: The Dynamics of Social Transition edited by Sunil Misra. Sage Publications, New Delhi, 1999.
THE book under review presents case studies of 14 action research projects supported by the Population Foundation of India. These projects were ending or had ended in 1995-96 and the case studies were written as qualitative evaluation of these projects – the purpose was to ‘assess their quality of programme operations, their overall impact, the extent of people’s participation, and the level of sustainability after the project funding was over.’
The case studies relate to: reducing infant mortality and fertility (3 case studies); integrated health, family planning and development (3 case studies); reproductive health and family planning in urban slums (4 case studies); reproductive health and family planning among industrial workers (3 case studies); and, family planning through rural medical practitioners (1 case study).
Given the main agenda of the council, the focus of all the action research projects was on fertility reduction. The case studies, though conducted by different people, are written in a standardised format and read uninspiringly.
All the projects studied were implemented through existing local NGOs and coordinated with the government health functionaries, used locally drawn community health volunteers, aimed to create awareness and in some cases provide services. Creation of IEC material, conducting entry level surveys, and in some cases starting balwadis or using peer communicators/trade unions for spreading the message of family planning or responsible sexual behaviour were the main activities. Though important steps, there was nothing new in most of these projects. Further, the inability of most projects to quantify their achievements or even measure their impact defeated the very purpose of having action research projects.
Nevertheless they do provide some important lessons: awareness generation must be backed with good service provision, people respond to programmes which address their felt needs like child care services, 3 or 5 years is a very short period for showing impact on fertility regulation or sexual behaviour and so on. Also that adopting a strategy just because it is currently fashionable without thinking of the long term implications may lead to complications. For example, in a number of projects the community health volunteers on whom the project was pegged refused to continue once their honorariums were withdrawn after project completion, making project gains unsustainable and leaving communities dissatisfied. This also raises the issue of responsibility of the NGOs and funding agencies to the community.
All the action research projects tackled the problem at the same level, i.e. the functioning of the existing system, and there too usually at the level of improving community use of the services provided by the existing system. A questioning of the system, its compartmentalised way of functioning, the narrow definitions and goals set by it and a dehumanising of the services was not studied by any of the projects. A look at some of these issues would have improved our understanding of the possible role of NGOs in the health and population sector.
An analysis of action research projects running with the help of different types of NGOs could have been rich and insightful. The varied challenges posed by different geographical and socio-cultural conditions and the different strategies adopted to meet these challenges depending on each NGOs respective strengths and weaknesses could have been discussed. The pros and cons of each of these strategies and the lessons to be learnt for all concerned – the project planners, the NGOs and funding agencies – could have been elucidated. Are some kinds of projects more effective than others? Are some NGOs better suited than others? How can the gains be made sustainable? What could be the role of funding agencies in ensuring better results? These are some questions that could have been addressed. Instead, the editor only provides general conclusions such as there is need for careful selection of NGOs, more careful project planning, good quality baseline surveys and so on. There is no reference to the kind of baseline surveys possible, the factors to be considered while selecting NGOs, the possible processes of evaluation etc. That NGOs can play an important role along with the government in bringing about social change is well-known. What is less understood is the extent to which the NGOs can be used, the bureaucratic hurdles that hamper their work and how these can be overcome. In other words, it is the how of things that has been largely ignored.
Where the editor does take up the how – as in his suggested model for NGO-GOI collaboration – he has been both unimaginative and non-appreciative of the philosophy of voluntary (NGO) work. Asserting that the role of NGOs should be to create a ‘favourable climate’ for the government’s service provision mechanism (which in effect is a birth control provision mechanism) doesn’t stand in good stead. Admittedly, a number of NGOs today are doing just this kind of work, but that is lamentable, not ideal. The primary responsibility of an NGO is towards the community it serves. If the interests of the community match with the interests and employed methods of the government, what he suggests may work. But, given the present situation in our country, one has to reiterate that NGOs are not expected to be a mere extension of the government system that disregards people’s felt and expressed needs, and imposes on them larger state goals of population control – no matter how well camouflaged in the latest jargon.
His understanding of what needs to be done as a part of the health system is more useful. He rightly suggests that it is possible to replicate some of the work done by the NGOs in the larger system and that duplication of efforts between NGOs themselves can be avoided. This however is an uphill task.
Overall, what emerges is a lack of conceptual clarity. What does the editor want to say? Did he wish to speak about the various strategies adopted to tackle the ‘population problem’? In which case the studies could be clubbed as those targeting the ‘problem’ in isolation, clubbing it with the problem of infant mortality, or within a wider mesh of reproductive health or an even wider model of integrated health. There could have been some discussion of the relative success and problems of each approach. He could have concentrated on the difference in approaches used and experiences with different population groups, for example, rural as compared to urban or unorganised workers as compared to organised workers. He does touch on some of the issues, though peripherally: Like the point that integrated health projects are difficult to implement as they require coordination with more government departments or that it is easier to work with organised sector workers as employers assist in the effort.
In short, the editor misses out on the opportunity to highlight systemic and methodological issues relevant for project planners, implementers, funders and others working on issues of public health.
Sapna Agarwal
ABORTION IN THE DEVELOPING WORLD edited by Axel I. Mundigo and Cynthia Indriso. WHO and Vistaar Publications, Delhi, 1999.
THE 1994 Cairo Conference on Population and Development and the 1995 Beijing World Conference for Women gave a green signal to reinitiate work on minimising the consequences of unsafe abortion, and on strengthening services where abortion is legal. The WHO initiated the research contained in this book long before that time. Interestingly, the authors note that when the research initiative came up for approval, it received the full support of the organisation’s donors and the World Health Assembly. It is indeed commendable that there was unanimity in acknowledging the importance of the subject, and that this research was taken up at a time when public debate was so highly charged. The 22 studies contained in the book provide information from 16 countries, mostly in Latin America and Asia. Creditably, the attempt has been to concentrate on countries where abortion is either illegal or highly restricted.
The highlight of the book is a section on abortion among adolescents. The studies provide information on a population strata whose importance is only now being acknowledged, and whose needs are not clearly understood by programme managers. The study from Tanzania had not, in fact, started out to focus on adolescents, but stumbled upon the fact that an enormous number of the abortions were among young girls. With the increasing risk of contracting AIDS from sex workers, older men are seeking out young girls, and they, taking up with sugar daddies, are finding themselves having to deal with more gifts than they bargained for. A study from China shows how the increasing age at marriage has resulted in premarital cohabitation. This, combined with a lack of body knowledge and contraceptive information – even in China – has resulted in increased abortions among young girls.
In Korea, migration and urbanisation among young women, an increasing age at marriage and a growing sense of independence, has increased premarital sexual activity. Surprisingly, the study shows that not only is knowledge of contraception limited but that most single women would hesitate to use it because it would be contrary to their self-image as moral beings. This no doubt offers a lesson for programme planners, since most end up designing contraceptive services without regard to this important insight into the psyche of young women.
The study of adolescents from Mexico is among the most powerful in the book. It attempts to unravel the language used to talk about the body, sex and pregnancy, important when working with the youth and designing information or counselling programmes for them. The study shows what and who influences the decision to abort – what role is played by a supportive or otherwise boyfriend in the decision making process. It is usually the mother, with another female figure, who helps clinch the decision and find an abortionist – the boyfriend usually plays no role in the latter process. In Mexico he does not even pay for it, though in Tanzania he might, probably as a result of being older and better off. Lack of money is a recurrent theme in the stories told by women – whether it is to bring up the child they have conceived, or to pay for a safe abortion, or even an unsafe one.
The studies show how, for providers of health services, there is often a conflict between personal values and client needs. Many don’t approve of abortion, but will do it themselves, or refer clients if they come face to face with a woman who is confronted by a cruel reality and has few choices. They are pragmatic enough to acknowledge that if an abortion is inevitable, it is better that it be safe, because it is women rather than the health systems who have to deal with the consequences of botched abortions. Fortunately, it does not seem to be necessary to resolve an ethical debate to prevent disability and death. The book offers perspectives of doctors, traditional birth attendants, herb vendors and even pharmacists who give women drugs to abort. Of course, for many service providers the prime consideration is not compassion but cash, especially where abortion is illegal.
It should come as no surprise that the studies demonstrate that women don’t like to rely on abortion to contracept, and that even when abortion is easily available they use it with hesitation and ambivalence. Abortion becomes necessary when contraception fails or when it is not available or accessible. The mantra, clearly, is that one should provide quality family planning services. In many different ways, throughout the book, women say ‘contraception is troublesome’. Women want information, they want to be treated with respect at health centres, they are afraid of side effects, and shun inconvenience. What may be, due to its lower effectiveness, an unacceptable family planning method for service providers, will often be highly acceptable to women because of its convenience – withdrawal being one example.
Sadly, ‘Had I known,’ is a phrase often heard from young women who didn’t know what they were letting themselves in for. This thought runs as a common thread throughout the book. Had they known the horrors of abortion or had they known about contraception properly, they would have acted differently. The studies illustrate the importance of providing sex education to young people, both boys and girls, in a responsible and sensitive way. This, at least, is now being more seriously attempted by programmes, though more in response to concerns about AIDS than abortion.
The book examines the quality of abortion services, and indeed the availability of family planning services and information post-abortion. Regretfully, it appears that the notion of abortion not being used as a method of family planning may, for some time to come, remain mere rhetoric at the policy level, as efforts at post-abortion counselling are still weak in most programmes.
The book contains many important lessons for policy-makers and programme managers. However, it tends to paint a somewhat patchy picture. It might have been more effective had it set out not just to publish the research carried out as part of this particular initiative, but to provide a more comprehensive picture in different regions and conditions under which abortion is provided. Though the book looks at the abortion-contraception relationship, service quality issues, women’s perspectives and provider perspectives, one doesn’t see the totality in any one country or region, and the reader is left with a feeling of incompleteness. It would also have been good to see some comparative analysis, for example, of the abortion-contraception relationship in situations of legal and illegal abortion.
It is disappointing that there is not a single study from India, a country where an estimated 6.7 million abortions take place each year. The absence couldn’t have been because of the focus on countries with restrictive abortion policies, since one finds that the maximum number of studies are from China. One hopes that India is not absent because of a lack of good research proposals! Fortunately, a major national study on abortion is now being formulated which should provide a comprehensive understanding of the situation in this country.
One also misses an analysis of the connections between abortion and STD or HIV. There is little on the relationships between sexual violence and abortion. And one would have liked to understand better the perception of men. The editors acknowledge these gaps, and had these studies been conducted after the mid-90s, undoubtedly these issues would have received more attention.
Some of the studies do touch upon the gender dimension, though one would have liked to see it handled more centrally. The Mexico studies clearly demonstrate how women use pregnancy to control a relationship and shore-up their self-esteem. Power dynamics are visible in who influences the decision to abort, who pays for it, and who has to find the abortionist. Whose pleasure, whose pain? Women have a simple definition of service quality for abortion: a procedure that is done quickly and painlessly. It is interesting to note the emphasis given to pain in the client definitions of quality. In fact, for many women the absence or presence of pain strongly influences the decision to abort.
The book contains a chapter on the methodologies used in these studies. This may offer useful lessons for those planning research on abortion. Especially useful would be the experience of those who have conducted research in a context where abortion is illegal. Most notably, the book discusses how the research has already influenced policy. Examples have been provided of how research has informed, or indeed generated, public debate in some countries. There are also examples of how service institutions have taken steps to improve quality of care on the basis of research findings. Now that’s research for action!
Ena Singh
* The views expressed are personal and not those of the organization where the author works.
