Sot. Sci:&

Med.. Vol. 11. pp. 535 to 547. Pergamon Press 1977. Printed m Great Britain.

HEALTH MANPOWER STRATEGIES FOR RURAL HEALTH SERVICES IN INDIA AND CHINA: 1949-1975* Population

RUSHIKESH M. MARU Project Unit, Indian Institute of Management, Ahmedabad-380015, Gujarat, India

Abstract-The paper compares and contrasts health manpower strategies for rural health services in India and China. Three major issue areas are analysed in detail: (1) the duration and the nature of medical education, and the need to decentralize curative and public health tasks to para-professionals; (2) concentration of medical manpower in urban areas; (3) utilization of indigenous medicine practitioners in the regular public health network. The author has described the evolution of policies in each of these three issue areas, compared health manpower strategies, and brought out the implications of these strategies for birth control programmes. The study concludes that until 1965, both countries faced similar problems in reorienting health services to rural needs. Since 1966, however, China has made a determined effort to bring rural-orientation in her health manpower policies. While the Indian policy makers are still following the “professional” model of rural health care, the Chinese have gone a long way in implementing a “populist” model in their countryside.

India

and China

began

economic

planning

in the

need for rapid expansion of health manpower through a shortening of the length of medical training. The latter group also advocated the training of a large number of para-professionals with very limited training to undertake simple curative tasks in rural areas. Second, policies had to be devised to redistribute health manpower from urban to rural areas. Solutions had to be found to persuade urban health workers to settle in rural areas; at the same time, the number of para-professionals had to be increased to provide immediate health services to the rural populations. Third, it was argued that indigenous medicine practitioners provided an additional health manpower resource, and therefore, they must be utilised in the regular public health network. This solution was opposed by many who believed that only modem scientific medicine should form the basis of health services. We will describe the evolution of policies in each of these three issue areas, compare the health manpower strategies, and bring out the implications of these strategies for birth control programmes. As ye will see in the following discussion, the mid-1960s marked a turning point in the evolution of health manpower policies in both countries. The Cultural Revolution (1966-1968) in China initiated a number of new policies and forced a quantum jump in the diffusion of some of the existing policies. Although no such dramatic shift in policy occurred after 1965 in India, by the late 1960s and early 197Os, new policies similar to those in China were gaining official recognition and support. It is, therefore, useful to divide our discussion into two different time periods: (1) the pre-1965 period (1945-1965); and (2) the post-1965 period (1966-1975). Apart from the convenience in analysing major policy shifts, such a divi-

536

RUSHIKBH

Table 1. Comparable

M. MARU

levels of government

administration

India

in India and China

China

Central Government

I State

I

People’s Communes (jen-min kung so)

I f Production Briaadet

I

(sheng-ch’an tartui)

Village Production Team (sheng&an tui)t In

is

of government-district

t There is no set China in the

in In some in others a commune in in Liaoning

to natural

38 brigades 38 natural 72 natural 72 teams. F. in the of China, In China: Reassessment of’ the Econmny, Joint Economic Committee, US Congress Washington, July 1975, pp. 376-377.)

sion into time periods

is also neocaaaty

because

we

do not have estimates of high- and middle-level medical manpower for the post-l%5 period in China. For those not familiar with the structure of administration in China, we have outlined comparable levels of government administration in Table 1. PRE-1966 HEALTH

MANPOWER

POLICIES

(1) Training of high- and middle-level medical manpower One of the first organizational tasks facing the new regimes in both countries was the training of a large number of medical personnel to staff rapidly expanding medical care institutions. India was slightly better placed than China in terms of its initial stock of highlevel medical manpower. There were 56,000 Western medicine doctors and 29 medical colleges at the time of independence from British rule [2]. In 1949, on the eve of the communist liberation in China, the estimates of Western medicine doctors varied from 12,000 to 41,000 [3]. The doctorqopulation ratio in India was 16400, and in China, depending on the estimate of total doctors, it could be anywhere from 1:45,000 to 1:14,000. In the next one and a half

decades, both countries made remarkable progress in training high-level medical manpower. Medical colleges in India increased from 29 in 1951 to 87 in 1965-1966; annual admissions to medical colleges also increased from 2500 in 195&1951 to 10,600 in 1965-1966, and to 11,800 in 1969-1974 [4]. We do not have reliable information about the number of medical colleges in China in 1949, but it was reported to be 48 by the end of 1957 and about 60 in 1962 [5]. It is difficult to compare enrohnent figures for India and China since the Chinese figures include dentists and pharmacists. Orleans estimates that the number of medical doctors increased from around 41,tXtO in 1949 to 150,080 in 1966. In India, the number of medical doctors increased from 56,000 in 1950-1951 to 108,000 in 1964. The doctor:population ratios in the mid-1960s were 1:4800 for China and 1:4393 for India (Tables 2 and 3). While the high-level Western style medical education in India and China evolved on similar lines, there were significant differences in the extent and type of middle- and lower-level medical manpower, and in their policies toward the non-Western systems of medicine. A comparison of the estimates of various types of medical personnel presented in Tables 2 and 3 illustrates these policy differences.

537

Rural health services in India and China: 1949-1975 Table 2. Estimated number of medical personnel in the People’s Republic of China, 1966

Number

Type of personnel Graduates of schools of “Western” medicine “Higher-level” schools Doctors Stomatologists Pharmacists “Middle level” schools Assistant doctors Nurses Midwives Dispensers Total medical personnel (Western medicine) Practitioners of “Chinese medicine” Total medical personnel (Western and Chinese medicine)

Ratios* Health workers: 100,000 Population: population health worker

150,000 30,008 20,000

21 4 3

4800 24,008 36,000

170,000 185,000 40,008 100,008 695,000 500,000

23 26 6 14 97 69

4300 3900 18,000 7300 1043 1500

1.195.000

1.66

607

* Baaed on an estimated population of 725 million. Source: Side1 V. W. and Side1 R. Serve the People: Observations in the People’s Republic of China. Beacon, Boston, p. 25, 1974. Chinese leaders, under the guidance of their Soviet advisers, had placed greater emphasis on the develop ment of vocational medical schools from the early 1950s. Thus, by the mid-1960s China had trained

170,000 “Assistant Doctors” who were given 3 years’ training in higher secondary medical schools. There is no comparable category of medical personnel in India. Similarly, China was ahead of India in the number of nurses trained during the same period. The nurse:population ratio in China was 1:3900 in 1966 as compared with 1:10,476 for India in 1964. However, the educational levels of nurses in the two countries are not comparable. A high school diploma or

its equivalent is the basic requirement for admission to nursing school in India; but the Chinese nurses enter vocational schools alkr primary or junior secondary general school education. It might be more appropriate, therefore, to add up both the nursing and midwife categories and then compare total nursing personnel in the two countries. If we combine “nurses” and “nurse midwives” (Table 3), we get a total of 81,619 nursing personnel for India, which gives a nursing persormel:population ratio of 1:5826. Similarly, combining the categories of Ynursesn and “midwives” in Table 2, we get a total figure of 225,OtlO nursing personnel for China and a ratio of one nurs-

Table 3. Medical personnel in India, 1964

Type of personnel Doctors of western system of medicine Dentists Pharmacists Nurses Nurse midwives Total medical personnel (Western medicine) Practitioners of “other” medical systems Total medical manpower (Western and other)

Number 108,240t 8386 70,628$ 45,387 36,232s 268,873 223,22711 429,100

Ratios+ Health workers: 100,008 Population: population health worker 23 2 15 10 8 58 47 105

.

4393 56,702 6732 10,476 13,124 1768 2130 966

Based on estimated mid-year population of 475.5 million. t This figure includes 51,052 licentiates with 3 years of medical school training after high school, Such courses were stopped after independence, and most of them were given an opportunity tu upgrade their training through one or more years of condensed degree courses. $ This figure is for 1965 and includes all those who listed their occupation as a pharmacist irrespective of level of education. g This figure includes Auxiliary Nurse Midwives (ANM), Midwives and Lady Health Visitors (LHV). 11Estimated. The 1961 census estimate is 146,455 non-allopathic medical practitioners-AIMR, Stock of Doctors in Non-Allopathic Systems of Medicine, December 1967, p. 19. Another recent estimate places the figure for 1972 at 300,080 (National health scheme for rural area: proposal of the Union Ministry of Health. J. lndian med. Ass. 60, 76, 1973). The 1964 figure is estimated mid-point between these two figures for 1961 and 1972. Sources: Doctors of Western Medicine: I.C.M.R., Stock of Allopathic Doctors in India, September, 1966, pp. 69-70. Dentists: I.C.M.R., Stock Taking of Dental Personnel in India, September, 1966, p. 13. Pharmacists: Health Statistics of India, 1965, pp. 203-208. Nurses and Nurse Midwives: I.C.M.R., Stock of Nursing Personnel in India, September, 1966, p. 59. l

538

RUSHIKESH M. MARU

ing person for 3222 population. This comparison of middle-level medical manpower clearly establishes quantitative superiority of China vi&-vis India. Qualitative differences between the two countries do exist and, as indicated earlier, India has some advantage over China in this respect. It is difficult to measure the extent of qualitative differences in training. There are differences in requirements for admission to nursing schools, but the actual period of nursing education is about two years in both countries. (2) Utilization of traditional medicine practitioners China has, from the very beginning, made systematic attempts to absorb traditional Chinese medical practitioners into the state-operated health care network. While the attempts to combine Western and Chinese medicine may not have resulted in a new theoretical synthesis of the two systems, there is no doubt that Chinese medical practitioners work side by side with Western trained doctors in hospitals and rural health clinics. Many of them have been given brief training in Western medicine and then were sent to rural areas [6]. There are no systematic estimates of Chinese medical practitioners, but one official estimate places their number at around 500,000. This figure includes all gradations of personnel including those who have learned the art through apprenticeship. In India, we have two different estimates of practitioners of non-allopathic medicine; one gives a figure of 146,455 for 1961, and the other estimate places it around 300,000 in 1972. I have taken a midpoint between these two estimates, which provides a 1964 crude estimate of 223,227 practitioners of nonallopathic medicine in India. These estimates do not show a significant difference between India and China in terms of the number of traditional medicine practitioners per 100,000 population (Tables 2 and 3). However, given the crude level of these estimates, it would be unwise to read too much into these quantitative comparisons. The most important differences between India and China lies in the extent of the utilization of indigenous medicine practitioners. In China, traditional medicine practitioners were systematically absorbed within the state health network from as early as 1954 when they were brought into “united clinics”. These united clinics were mainly in rural areas and consisted of existing private practitioners of both the traditional and western medicine. By 1957, there were more than 50,000 group practice clinics in the countryside. Also, about 20,000 traditional doctors had joined regular governmental health services [A. The commune clinics organized during the Great Leap Forward in 1958-1959 were based on these united clinics and, therefore, continued to utilize traditional doctors for rural health services [8]. In India, the central government was unable systematically to bring indigenous practitioners into the public health network due to opposition from the medical professionals. However, as a result of the encouragement given to the traditional systems of medicine by some state governments, 6469 dispensaries of traditional medicine were established by 1960 [9]. But, these dispensaries were not a part of any nationwide policy of systematically absorbing traditional medicine practitioners into the government health centres in rural areas.

(3) Urban-rural distribution of health facilities The rapid growth of medical personnel did not bring health care within easy reach of the vast masses in the rural areas. The rural sector accounts for 807; of the population in both countries, but only about 30% of the medical personnel were available to rural clinics and health centres. In 1961, 67.3% of allopathic doctors [lo] and 51% of nursing personnel [ 1l] were concentrated in urban centers in India which covered only 17% of the total population. Medical personnel were also concentrated in urban areas in China during the mid-1960s. Mao Tse-Tung, in his famous “June 26 Directive” in 1965, indicted the Ministry of Health for rendering “service to only 15% of the nation’s population” [12]. The Red Guard Bulletin which first published Mao’s directive also attacked the Health Ministry’s leaders for retaining “some 120,000 of the 180,000 high-ranking skilled personnel of the nation in the cities” [13). This gives a rough estimate of the extent of rural-urban maldistribution of health manpower in China which was roughly similar to that in India. Let us briefly recapitulate the state of medical manpower development and distribution in India and China during the pre-1965 period. First, both countries followed similar policies in the training of highlevel medical manpower which resulted in the rapid growth of Western-type medical doctors. Both countries had about the same doctor:population ratio in the mid-1960s. Second, China placed greater emphasis on the training of middle-level medical manpower from the very beginning and remained ahead of India in 1965. Third, while integration of indigenous systems of medicine with the western system was not realized in either country, China was better able than India to absorb the Chinese medicine practitioners into the regular health care network. Finally, more than half of skilled medical manpower remained concentrated in the urban sector in both countries. POST-1965 HEALTH MANPOWER POLICIES The post-1965 developments in China were initiated at the highest level by Mao himself on 26 June, 1965, when he issued an important directive concerning health services. This directive, later known as “June 26 Directive”, attacked the existing health policies of the Chinese Ministry of Health [14]. The extraordinary nature of developments in China since 1965 makes it difficult to discuss each policy issue separately as was done in the previous section. The following discussion will, therefore, be organized by country.

Post-1965 health manpower policies in China Mao’s “June 26 Directive” laid the basis of the post-Cultural Revolution health policy. He defined the problems, suggested new policy guidelines, and triggered a revolutionary struggle to achieve his goals. What were the main issues raised by Mao? What kinds of changes were advocated by him? The following quote from Mao’s “June 26 Directive” clearly reveals the intensity of his feelings on health care issues and the scope of his criticism.

Rural health services in India and China: 1949-1975 You may tell this to the Health Ministry. That Ministry renders service to only 15% of the nation’s population, and in this 15%, minaly people of some position and rank. The Health Ministry does not belong to the people. It should better be renamed the Urban Health Ministry, or the “Lords” Health Ministry, or the Urban “Lords” health ministry instead. Reform is called for in medical education.. . It is not necessary to have senior middle or junior middle school graduates as qualified students of medicine; a three years’ course to primary school graduates will suffice for our purposes.. . . The methods of detection and treatment of diseases, at present in use in hospitals, are actually not suited to the rural villages. Vast manpower and material resources are committed to the research on so-called “peak” problems.. but little or no attention is paid to the prevention.. . of common diseases. Another odd phenomenon is the wearing of mouth masks by doctors in examining patients regardless of their complaint.. . . Why can’t there be any discretion in the matter? It creates a barrier between doctors and patients. Only some doctors who have been out of college for

one or two years and are not extremely proficient should be left behind in urban hospitals. [15] Mao realized that only a thorough reorientation of health care organization, education, research, and the doctor-patient relationship could make the system responsive to the needs of the common man. He also singled out the highest level of health leadership for attack. This was because Mao was not raising these issues for the first time; he had been pleading for such reorganization since 1949. However, there was strong resistance to Mao’s views from professionals in the China Medical Association, the Ministry of Health, and a powerful group within the Party. Thus, by the mid-196Os, Mao was convinced that an all-out war on the health leadership within the Ministry was a pre-requisite of any radical change. Most medical colleges and schools were closed from 1967 to 1970. The Minister and all the six Vice Ministers of Health came under attack by the Maoist radical groups. According to Lucas, the Health Ministry came under attack as a “target” bureaucracy, with some 16 Ministry officials reported criticized between February and August 1967, for conspiring to sabotage county and district (chu) organizations [16]. The top leadership of the Ministry was completely purged and a new leadership took over at the beginning of 1968. The preceding brief outline of the events which led to change in policies is intended merely to serve as a background for the following description of the policy consequences of the Cultural Revolution. We propose to describe major changes in the four areas of health manpower policy in China. (1) Formal education. The length of medical college training haas been shortened from 5-6 years to about 3 years [17]. Some pre-Cultural Revolution courses were eliminated because they were considered unnecessary for a physician (e.g. higher mathematics). The content of the curriculum also underwent changes, increasing the time spent in actual medical practice and reducing theoretical learning. About onethird of the teaching time is spent in the countryside where students learn from their professors in actual rural conditions [18]. Professors and students are required to treat peasants during their stay in rural

539

areas. Compared to pre-1966 medical education, the post-Cultural Revolution education places greater emphasis on both preventive and Chinese medicine [19]. Entrance requirements have also changed in keeping with revolutionary ideology. Prior to the Cultural Revolution, most students were graduates of senior high school and were selected for their academic achievement. Since the Cultural Revolution, the tendency is to be more flexible in initial school education requirements, as many junior high school graduates are also admitted. The admission procedure is by recommendation and selection. For example, every school graduate works for 2 years in a factory or commune, and then applies to his own work unit for admission to medical college. After the leadership and the masses in his work unit have supported his application, the university makes its own assessment. Finally, the student is selected on the basis of four criteria: 2 years of labour after school; political consciousness and class background; at least a junior high school education; and the age of about 20 years, healthy and unmarried [20]. (2) Community based lower-level medical workers. While high- and middle-level medical personnel are trained in regular schools, many other modes of training are used to expand rapidly the number of lower level field workers, such as “barefoot Sectors” and “health workers” in production brigades and teams. The barefoot doctors are selected by the local communities from among their own members. They may be young peasants, traditional medicine practitioners, or urban youths permanently settled in rural areas. They are initially trained for about 3-4 months, and then sent back to their own communities where they treat common diseases, dispense both Western and Chinese drugs, supervise health workers in their public health tasks, and provide family planning services [21]. After a year or two, many of them go through another round of short training to upgrade their medical knowledge. Thus over a period of 4-5 years, every barefoot doctor is expected to undergo a minimum of 1 year’s training. The health workers are trained for only l-3 months. Both these categories of field workers continue to do part-time farm labor and receive work-points like any other able-bodied peasant. It is estimated that there are about three million health workers or one public health worker for 215 population [22]. The barefoot doctors and public health workers are trained by various methods: mobile medical teams, regular medical schools, internship in commune clinics and country hospitals, half-farm half-study schools [23], and occasionally by senior barefoot doctors. The People’s Liberation Army (PLA) also was mobilized to train barefoot doctors and help brigades to establish cooperative medical care. Since the beginning of the Cultural Revolution, PLA medical departments have trained 370,000 barefoot doctors [24]. Recently some medical schools have started correspondence courses to help train urban youths settled in rural areas 1251. The quality of training varies considerably from region to region and even within each region. (3) Transfer of manpower resources to rural areas. While barefoot doctors and health workers are able to provide basic health care to every production bri-

540

RUSH~~E~H M. Mh~u

gade, their competence is limited and they need to be supported by better-trained physicians. Such technical support and training is provided either by permanent settlement of urban doctors in the countryside or by sending mobile medical teams for periods of 3 months to 1 year. These mobile teams perform major surgical operations, distribute contraceptives, train barefoot doctors and health workers, and also supervise rural health work [26]. One-third of urban hospital personnel are reported to be touring the countryside in mobile teams [27J Lucas catalogued 61 reports between 1957 and 1967 of intended rural destination of urban medical assistance. She calculated the average distance between the rural destination and the nearest provincial source of urban medical service. When this average distance was compared with the average miles travelled by urban medical personnel to known rural destinations, she found that far less than one-half of China’s rural villages were served by urban medical personnel [28]. However, Lucas’ analysis covers the pre-Cultural Revolution period and the first 2 years of the Cultural Revolution when the Health Ministry was still led by medical professionals. How far this situation has changed since 1967 is anybody’s guess. One recent Chinese source claims that “rural areas now account for more than one-half of China’s professional medical workers and medical appropriations” [29]. (4) Policy toward traditional Chinese medicine. The efforts to integrate traditional medicine with Western medicine were intent&d after the Cultural Revolution [30]. This revived prominence for traditional medicine is seen in exhortations in the Chinese press for the cultivation of traditional herbs in communes to meet increasing demand for medicine in rural areas, and to reduce costs. The barefoot doctors’ curriculum includes learning about traditional medicine, and they carry both traditional and Western drugs in their medical bags. There are also reports of increasing popularity of combined treatment of diseases using both kinds of medicine. The traditional medical doctors form an important part of the commune health team. One recent Chinese source claimed that over 30,080 medical workers trained in Western medicine have taken courses ranging from 6 months to 2 years in traditional medicine. This is seven times the number up to 1965 [31]. This may be considerable progress relative to the pre-Cultural Revolution situation, but in absolute terms it is not very sign&ant. The 30,000 Western Medical personnel trained in Chinese medicine constitute less than 10% of total doctors and assistant doctors, and less than 5% of total higherand middle-level personnel in Western medicine. Orleans [32], Croizier [33], and Unschuld [34] have observed that the Chinese regime’s goal of developing a true synthesis of Chinese and Western medical theory and education may remain for a long time an unfulfilled objective. In practice, it seems that the Chinese medicine will continue to be employed side by side with Western medicine until the time China is able to provide adequate allopathic medical care in rural areas. Post-1965 health manpower policies in India While developments in India during the latter part

of the 1960s have not been quite as dramatic as in China, there has been a gradual but marked development of rural health services through a network of Primary Health Centers (PHC). India is divided into 5265 Community Development Blocks, which are the basic units of integrated rural development. Primary Health Centers are located at the headquarters of the Block. There were 2800 PHCs in 1960-1961, which covered approximately one-half of the Blocks. By the end of 1971, the number of PHCs doubled to 5131 and covered nearly 95% of the Blocks [35]. There has been considerable progress in medical education and training of paramedical personnel. Between 1960-1961 and 1973-1974, the number of medical colleges increased from 57 to 102; annual admissions from 5800 to 13,OOfl; stock of doctors from 70,080 to 137,930; stock of nurses from 27,000 to 88,000; and the stock of Auxiliary Nurse Midwives and Midwives from 19,908 to nearly 70,000 [3q. The rapid growth of medical facilities and manpower did not alter the rural-urban imbalance. A recent Ministry of Health document estimates that “the qualified medical manpower in the country is distributed in the ratio of 66:33 among the urban and rural areas” [373. This probably refers only to graduates of medical schools. We do not have any recent estimates of rural-urban distribution of middle- and lower-level medical personnel, but there are reasons to believe that they are more equally distributed than the doctors. First, most of the paramedical positions created since 1%3 have been in rural areas. Second, even in 1961 the distribution of nursing personnel between urban and rural areas was in the ratio of 51:49 [38]. The PHCs were originally expected to cover a population of 60,000 to 80,000. However, due to growth in population, the PHCs and their sub-centers are able to give effective service to only about onethird of the population in the vicinity of their headquarters. It is estimated that there will be 137,000 medical doctors available by the end of the Fourth Five Year Plan in 1973-1974, which gives a doctor:population ratio of 1:41,000. As can be seen from Table 4, in 1971-1972 the ratio of middle- and lowerlevel medical personnel to population was approx 1:29,000. Our comparison of pre- and post-l%5 medical manpower indicates remarkable continuity in policy. The main concern was with increasing the stock of manpower; and this was achieved through expansion of medical colleges and paramedical training institutions. Thus, formal full-time education has remained the most important method of training additional medical manpower. It is only in recent years that a serious public debate on medical manpower policy has pressured the government to initiate some policy changes. In the pre-1965 period, the Central Health Ministry was not enthusiastic about the development of indigenous systems of medicine. However, since the late 1960s this attitude has undergone substantial change. A Central Council of Research in Indian Systems of Medicine was established in 1969. A similar Council for Homeopathic Medicine was also started in 1974. This recognition of the non-western medical systems also was reflected in the Central Health Ministry’s “National Health

Rural health services in India and China: 1949-1975

541

Table 4. Field workers in health and family planning program in India: 1971-1972

Type of personnel MCH (maternity and Child Health) workers7 Public health workers Total MCH and public health workers Family planning education workersi Total field workers (health, MCH and FP)

Number 77,687 110,395 188,082 15,333 203,415

Ratios* Field workers : 100,000 Population: population health worker 14 20 34 3 37

7053 4963 2913 35,733 2694

* Based on 1971 population of 547.9 million. t Besides nurse midwives and lady health visitors, this category includes dais-traditional midwives-recruited and trained by the government. $ While all field workers have part-time responsibility for family planning, the “Family Planning Education Workers” devote full-time to education, communication work. Source: For 30,000 Dais included under “MCH” category, see The Fourth Fiue-Year Plan 1969-74: Draft (1969, p. 291). All other figures are derived by regrouping data presented in the Report of the Committee on Multipurpose Workers Under Health and Family Planning Program, Ministry of Health and Family Planning, Government of India, New Delhi, 1973. Scheme for Rural Areas” proposed in 1972. It openly admitted that “in spite of the best etforts all these years to augment the medical facilities in rural areas,

these areas are still lagging far behind the urban areas in the matter of medical relief and care*. As modern allopathic medicine is costly and the doctors are reluctant to go to the rural areas, the Ministry proposed a scheme to absorb 300,000 registered medical practitioners (both qualified and unqualified) in the rural health service. These are private practitioners of the Indian System of medicine, homeopathy, and unani trained in schools or through apprenticeship. The Ministry proposed to train these practitioners of non-allopathic medicine for four months and then place them in rural subcenters, each serving about 2000 population or three to four villages. These rural doctors will carry with them medical kits that would contain both allopathic and non-allopathic medicine. A pilot project in 29 districts was undertaken in 1971-1972 [39]. However, it should be noted that this scheme has not been implemented so far. The Union Ministry also plans to improve the utilization of existing paramedical personnel in the regular rural health centers through a multipurpose health workers scheme [40]. Under the latter scheme nearly all the functionaries in the PHCs will be given multiple duties in public health, family planning, and maternal and child care. Although at present there is partial integration of MCH and family planning in the duties of Auxiliary Nurse Midwives, most of the other workers are concerned primarily with special functional areas of public health, sanitation, vaccination, malaria work, or family planning. Table 3 presents figures for various kinds of health, MCH, and family planning field workers for 1971-1972. If all these workers are assigned multiple tasks, it will help to improve the worker:population ratio for each task. It will also help to better integrate family planning with health care. Under the multipurpose health worker scheme, there will be 203,415 field workers or one field worker for 2700 population. If the Health Ministry’s “National Health Scheme for Rural Areas” is revived and implemented, it would add another 300,000 practitioners of non-allopathic medicine to existing health workers, and bring the total number

of multipurpose health workers to about 503,415, or one such medical worker for 1088 population. Comparative cies

review of post-1965 health manpower poli-

We have separately reviewed health manpower policies for India and China. We would now like to present a comparative view of the two countries. Since the mid-1960s China has made some fundamental changes in all the aspects of training and deployment of health manpower in rural areas. In regular medical education, the curriculum has been shortened, its content has been changed to emphasize preventive and Chinese medicine; learning through practice in actual rural conditions is promoted. In India, until the end of 1975, there have been no major departures from the pre-1965 educational system, except for two minor changes in the content of the medical curriculum: (1) an increase in the number of hours spent on social and preventive medicine; (2) 3 months’ internship in rural clinics. These have not been adequate to reorient the medical education for rural health care [41]. In contrast, Chinese medical students spent one whole year in the countryside. If the mobile medical hospital scheme is fully implemented in India, it would help to increase the period of learning in rural conditions. There are also differences in criteria for admission to medical schools. Chinese students are selected by an elaborate procedure which assures the selection of candidates suitable to rural work in terms of socioeconomic background experience, and motivation. The Indian system favours high middle-class urban youths who are neither inclined nor prepared by previous experience to work in rural areas. Merit still remains the only criterion for entrance to medical schools in India. At the middle and lower levels of medical care, the number of health personnel have tremendously increased in both countries. China has a definite advantage in this respect because of the growth of barefoot doctors and health workers. The barefoot doctor: population ratio is approx 1:763, and the health worker population ratio is 1:265. These workers cannot be. compared with rural health workers in India who are far better trained than their Chinese counter-

542

Rusmxasti M. MARU

parts. Also, while the Indian health workers are fulltime functionaries, their Chinese counterparts are peasants who spend part of their time on health work. We may take into consideration these differences by roughly equating one Indian field worker to two Chinese barefoot doctors/health workers. Even after allowing for these adjustments, China has more health workers per population than India. As against the adjusted barefoot doctor :population ratio of 1:1526 and health worker:population ratio of 1530, the Indian ratio of health worker to population is 1: 3000. If the recent policy proposals in India regarding utilization of practitioners of non-allopathic medicines are implemented, there will be approximately one health worker for 1088 population. This would largely bridge the quantitative gap between India and China in rural middle- and lower-level health manpower. China has been able rapidly to cover every brigade with barefoot doctors and health workers due to multiple strategies of training such as mobile teams, halffarm half-study schools, regular middle-level public health schools, inset-vice training at various levels, and correspondence courses. India mainly has depended on regular middle-level training institutions. The Chinese have been more flexible than their Indian counterparts in applying formal educational criterion for admission to para-medical courses. China has also used the “echo principle” in training, which essentially means that health functionaries at each level should train workers at the next immediate lower level [42]. Lack of standardization and poor quality are the two most important shortcomings of the Chinese paramedical training. But this may be a short-term problem because barefoot doctors’ skills are continually being upgraded every year or two through repeated rounds of further training. In this way, at the end of 5 years each barefoot doctor will have acquired a minimum of 1 year’s training. Both India and China have encouraged the development of indigenous medical systems. But China has vigorously pursued this objective and extensively utilized practitioners of traditional Chinese medicine in rural health care. This has helped to augment health manpower and reduce the cost of medical care. In India, the medical profession has so far successfully resisted any attempts to bring non-allopathic medicine practitioners into the regular health care network. This may soon change under the new policy of the new government, but we cannot be certain. No action has been taken since 1972 when the Union Ministry first proposed to bring non-allopathic practitioners in rural health service [43]. The Indian government also has started a new scheme of mobile hospitals for rural areas. As an experimental project, 23 mobile medical hospitals were attached to medical colleges in 1971. These mobile hospitals are fully equipped and have 50 beds for inpatient care [44]. These hospitals are designed to provide modern medical care in rural areas and train medical students under rural conditions [45]. Again, this scheme has so far not become an integral part of the national health policy. In the wake of an armed conllict with Pakistan in 1971, the government introduced a “National Service Bill” in Parliament, approved in May of 1972.

The Bill provides that any “qualified person” under the age of 30 shall be liable to be called up to perform “national service” for a period not exceeding 4 years. National service is defined as “any service which is likely to assist the defence of India or civil defence or the efficient conduct of military operation” and “such social services as the Central government may. . . by notification, specify”. The statement of Objects and Reasons appended to the Bill mentions “difficulty in recruiting engineers and doctors for programs such as family planning, health schemes in rural areas and construction projects in remote areas” as one of the reasons for introducing the Bill [46]. As far as we know, these powers have not been used so far. Both India and China have found it difficult to persuade urban doctors to settle permanently in rural areas. Even in China where the government assigns jobs to every college graduate, and where dissenting leaders of the medical profession and the Party were purged during the Cultural Revolution, it has not been possible radically to alter the distribution of high-level medical manpower in favour of the countryside. What has been achieved is a primary health network built from local resources supplemented by part-time rural assignments for urban doctors and mobile medical teams. The Chinese also have developed a unique referral chain from commune clinics to the country hospitals, as well as a linkage system in which all advanced medical colleges and hospitals are systematically made responsible for certain backward geographical areas. For example, the major medical colleges dispatch mobile medical teams to the backward provinces. There are a number of models of such linkage (kua-kuo) systems, but, generally, each special district forms a linkage system. “Each of the major hospitals is assigned a number of rural counties and assumes the responsibility for expanding and strengthening the medical resources of the latter.*’ [47-j Such a systematic network of linkages between urban and rural health institutions compensates for the lack of permanent transfer of highlevel medical manpower, ot the rural areas. At the same time, it optimizes the use of scarce highly qualified manpower resources. The Indian government recently has formulated the policy of requiring medical colleges to look after Primary Health Centers and provide referral and special services [48]. Manpower policies for birth control programs India and China have chosen to integrate birth control program with health care organizations [49]. In both countries birth control services are provided by health functionaries. Thus, the health manpower development has become one of the important determinants of the spread and effectiveness of birth control programs. What are the implications of health manpower policies outlined in the previous section for birth control? First of all, the number and distribution of health manpower should be considered. As China has achieved better results than India in this respect, the Chinese health system is better equipped to provide birth control services at the grass-roots level. Second, depending on the methods of birth control used, skill

Rural health services in India and China: 1949-1975

and training of health personnel becomes important. The growth of high-level medical manpower has been similar in both countries, and the doctor:population ratios also are comparable. Both countries face shortages of college-trained doctors. As India has relied heavily on clinic-based methods of IUD and sterilization, the availability of doctors has remained a major bottleneck. This is particularly acute for female doctors. China has some advantage in this regard because of the better availability of assistant doctors for the commune clinics. It is difficult to compare the availability of female doctors in India and China, but there is some indirect evidence to suggest that this may be better in China. In 1964, out of the total number of 108.240 doctors in India, only 12,339 were women doctors [50]. We do not have similar national statistics for China. A few travellers’ reports indicate that in some medical schools, female students constituted about one-third of the total [Sl]. Given the shortages of high-level medical manstrategies were power. different organizational adopted to improve the utilization of existing resources. For example, China has increasingly emphasized non-clinical methods, such as late marriage and oral pills. India did not shift to nonclinical methods, but placed greater stress on vasectomy, which requires less skills and hospital care than female sterilization. Vasectomy has also an added advantage of being a male method. In rural areas where male doctors are relatively easier to recruit than female doctors, vasectomy is more appropriate than female methods, such as tubectomy and IUD. Apart from changing the relative mix of methods, both countries have relied heavily on mobile teams for providing birth control services. In China, birth control is one of the many tasks assigned to mobile medical teams. In India, mobile sterilization units are created in 1964. In 1966, this scheme was extended to IUD. One mobile sterilization unit and one mobile IUD unit were established for a population of 500,000 to 750,000. Since September 1967, these units also carried general medicine for emergency medical relief. As of March 1973, there were 399 sterilization units and 456 IUD units. Since then a number of these units have been closed down due to poor performance and extension of sterilization and IUD services through regular health organization. There were 321 units functioning in the country during 1975-1976 [52-J. The shortage of trained physicians can be relieved by training paramedical workers to perform sterilizations and to insert IUDs. The Indian health leadership has until very recently maintained that only a fully-trained physician should be allowed to do operations and insert IUDs. This view was strengthened in the late 1960s when a sudden drop in the acceptance of IUDs was attributed to complaints of bleeding. pain. and other side effects in a large percentage of women. During 1975, it was decided that properly trained selected nursing personnel may be allowed to do IUD insertions [53]. The Chinese barefoot doctors and midwives distribute conventional contraceptives and oral pills, but cases of sterilization and IUD are generally referred to commune or county hospitals. However. in remote areas paramedics have been trained to insert IUDs [54].

543

As birth control programs were expanded to rural areas, a large number of medical and health personnel had to be trained for the new task. In China, mobile medical teams were used to train most rural medical personnel [55]. Birth control was included in the curriculum for the training of barefoot doctors [56]. The higher level doctors were trained through short-term in-service training at hospitals and medical schools. Travellers’ reports and articles in Chinese biomedical journals describe general health training, but rarely discuss training for birth control. It is, therefore, impossible to assess the quality of birth control training and the proportion of various types of health personnel trained. Given the official policy to shorten all medical training, it is realistic to assume that both the duration and the quality of birth planning training is not better than that in India. In India, birth control training is given through a number of different organizational channels. It is included in the regular curriculum of medical colleges and nursing schools. But most of the medical personnel and extension education workers are trained in 44 Regional Family Planning Training Centers and in 16 Regional Family Planning Field (Mobile) Units. There are five Central Institutes which impart training to trainers, i.e. those employed in the regional training centers and key personnel working at the state and district levels. Family Planning training is also imparted in 330 ANM Centers, 21 LHV training centers, and 291 general midwives training centers. The Indian Medical Association conducts a series of courses for private medical practitioners [57]. India has, therefore, utilized regular training institutes, mobile teams, and part-time in-service courses for birth planning training. In most cases, the duration of training ranges from a few days to a month. While there virtually is no information on quality of birth control training in China, we know more about Indian training programs because they have been evaluated by the U.N. Advisory Mission [58], the Planning Commission [59], and Parliament’s Estimates Committee [60]. These evaluation reports found that a large percentage of the program staff have not been trained, and of those who have, many have attended only short courses [61]. The duration and content of training were not adequate to prepare the worker for effective family planning work; training was particularly lacking in preparation for work in rural areas. Also, training facilities were not being fully utilized because departmental heads did not attach much importance to training and were unwilling to release their staff for the training period. China and India have to train not only health workers, but also others who are assigned communication tasks. In China, the Communist Party secretaries and women’s work cadres attached to birth planning committees at various levels are mainly responsible for mass propaganda and persuasion. We are not clear about how they are trained. It is possible that most of them are given technical knowledge through short orientation courses by public health officials. In India, Block Extension Educators (BEE) and Health Assistants (HA) at the PHC level do fulltime mass propaganda and persuasion work. These are trained by various regional training centers and mobile field units.

RUSHIKESH

544

The Chinese health and family planning training always includes an ideological orientation for workers to prepare them for serving in rural areas. This kind of ideological training continues on the job through short study sessions organized by the local Party Committees [62]. Indian Health and family planning training lacks this motivational aspect. The Indian training program is less decentralized than the Chinese program. India has relied mainly on training centers and to a lesser extent on mobile units. The U.N. Advisory Mission recommended that a greater part of the training program should be decentralized to the district level and continuous education should be provided through in-service training programs [63]. CONTRASTING MANPOWER

MODELS

OF HEALTH

DEVELOPMENT

The foregoing comparative analysis of health manpower policies in India and China brings out two contrasting models of health manpower development. One model is based on professional concern for quality of health care, concentration of health personnel in urban areas, unwillingness to recognize indigenous medical practitioners as participants in the regular health care network, and opposition to delegation of the primary curative functions to paramedical personnel. For the sake of brevity, we shall call this a “professional” model of health manpower development. An alternative model emphasizes redistribution of medical manpower and physical facilities in favor of rural and poorer sections of the society. This, in turn, requires a rapid increase in admissions to medical colleges, shortening the duration of the medical curriculum, and greater emphasis on the use of para-professionals and indigenous medical practitioners in regular health organizations. The proponents of this second model, however, urge that the twin criteria of quality and wider accessibility of health care cannot be fulfilled simultaneously at the present stage of development in poor countries such as India and China, and that accessibility must get precedence over quality for a certain transitional period of development. In contrast with the “professional” model, we shall call this a “populist” model of health manpower development. It should be made clear that the professional and the populist models are not mutually exclusive. Every society has a different combination of elements from each of these models, depending on its needs, resources, and value orientations. The main difference between the two models is in terms of the predominance of either professional concern with quality of health care, or of the populist concern with serving the largest number of people. When the professional model is predominant, the principal question that policy makers ask themselves is: “which of the manpower strategies are likely to provide the best possible health care?” But when the populist model is prevalent, policy makers are guided by a different set of questions, such as: “which of the manpower policies will enable us to reach the largest number of our clients?” and “which one will provide at least primary health care to the poorest and the remotest sections of our society?” [64]

M. MARU The professional model dominated the health manpower policy process in China during 1949-1957 and again in 1961-1965, whereas the populist model has been most influential during the Great Leap Forward period of 1958-1960 and since the Cultural Revolution (19661968) to the present. In India the professional model was the main framework of health policy until 1966. The populist model has gained increasing theoretical acceptance from the Ministry of Health and Family Planning during late 1960s and early 1970s. However. there still remains a big gap between theory and practice, between planning and implementation [65]. The events since the declaration of emergency on 26 June, 1976, have once again raised high hopes about the implementation of a people-oriented health care system. The Srivastava Committee recommended a complete overhaul of the present medical education system and rural health services to better serve the needs of rural areas. An action plan based on these recommendations was drawn up by the Union Ministry of Health and was accepted by the Central Council of Health in April 1976. The three most important elements of the action plan are: (1) Community health worker; (2) multi-purpose health workers trained from the existing uni-purpose field workers; (3) a referral network based on assigning Primary Health Centers to medical colleges and district hospitals. It is interesting to note that each of these elements of the new Indian health policy have been important ingredients of the Chinese health manpower strategy since the Cultural Revolution. Will the state of emergency help to change the orientation of health services from urban-rich to rural-poor in India? Since new measures in health and family planning have been initiated only in May 1976, it is too early to answer this question. Nevertheless, it is widely believed that a political system wedded to socialist ideals and free of pressures from opposition parties and interest-groups should be able to effectively implement new policies. The Chinese experience however shows that neither a general commitment to socialist ideal nor the centralization of power in the hands of the leadership are sufficient conditions for building an egalitarian society. On the contrary, such a system can become highly bureaucratic and elitist. The Cultural Revolution was Mao’s personal war on bureaucratic and elitist tendencies in Chinese society in general as well as within the health bureaucracy and profession in particular. Unfortunately, we are trying in India to achieve major social changes through administrative first. The emergency has not only failed to change this bureaucratic model of social change, but, in fact, it has further strengthened it. Without any basic changes in either the composition or the attitudes of the existing political, bureaucratic and professional elite, the present tactics of imposing social change through administrative proclamations and orders may take us further, but not far enough. To conclude, we would like to suggest that China has gone far ahead of India in implementing egalitarian goals of health policy. Also, the broad principles of the Chinese rural health policy are relevant to us in India. The Indian leaders have already started reor-

Rural health services in India and China: 1949-1975

545

10. Stock sf Allopathic Doctors in India, New Delhi: Institute of Applied Manpower Research, 1966, p. 20. 11. Stock of Nursing Personnel in India, New Delhi, Institute of Applied Manpower Research, 1966, p. 21. 12. “Chairman Mao’s June 26 Directive” was first published 26 June, 1967, commemorative issue of Huang-I Chan-pao (Red Medical Battle Bulletin), and Pa-i-pa Chen-vao (August 18 Battle Bulletin), a tabloid published’ by ‘the Revolutionary Committee of Grand Alliance of Pekine Medical and Health Circles and “August 18” Join; Headquarters of Peking Medical College, Red Guard Congress; SCMP, No. 198, p. 30 (hereafter referred to as “June 26 Directive”). 13. Monstrous crimes of urban “Lords” health ministry in opposing June 26 Directive, Peking, Hung-l Chanpao and pa-i-pa Chan Pao (26 June, 1967); SCMP, No. 198, p. 34. 14. See [12] above. Acknowledgements-This paper is a slightly modified ver15. All quotes are from Mao’s “June 26 Directive”, SCMP, sion of a Chapter in the author’s Ph.D dissertation, subNo. 198, p. 31. mitted to the University of Michigan, Ann Arbor, U.S.A. 16. Lampton, December, 1973, op. cit., Chap. 9; Lucas A. The research for this study was carried out during E. Legitimate criticism of cultural Revolution rhetoric: 1975-1976 when the author was a visiting Faculty Associan analysis of Mao’s indictment against the Ministry ate at the Center for Population Planning, University of of Public Health. Unpublished paper, Harvard UniverMichigan. It was supported by a research grant from the sity, Spring 1970, p. 4. Interdisciplinary Communication Program of the Smith17. There are many first-hand reports of medical educasonian Institution, Washington, D.C. The author wishes tion, but the two most prominent are by Side1 V. W. to thank the following individuals for commenting on an Medical personnel and training, 1973, op. cit., pp. earlier draft: Pi-Chao Chen, Jason Finkle, Richard Park, 164-167; and Diamond E. G. Medical education and Samuel Eldersveld, Ruth Simmons and Michel Oksenberg. care in People’s Republic of China. J. Am. med. Ass. 1552, 1971. While the general aim was to reduce course work to three years. there were variations. For REFERENCES example, Victor Li was told at the Chung-San Medical School in June, 1973, that the 3 years’ course was to 1. See Rushikesh M. Maru, Birth control in India and be preceded by 6-9 months of preparatory courses in the People’s Republic of China: a comparison of (Victor Li, 1973 Field Notes, unpublished note, Stanpolicy evolution, methods of birth control, and proford University, 1973, p. 8). gram organization, 1949-1974, unpublished Ph.D dissertation, Department of Political Science, University 18. Revolution in education improves medical teaching. NANA-English, Shen Yang 2124175; SCMP, 5806: of Michigan, Ann Arbor, 1976. March 7, 1975, pp. 175-176. 2. India Pocket Book of Economic Information: 1971 19. Victor Li mentions four slogans which guide the direc(Government of India, Ministry of Finance, Departtion of medical training: (1) Combining theory and ment of Economic Affairs, New Delhi: 1971), p. 206. practice; (2) Combining Chinese and Western Medi3. Orleans L. A. Medical education and manpower in cine; (3) Combining healing and teaching; and (4) communist China. In Aspects of Chinese Education Operating school with open doors (Victor Li, 1973 (Edited by Hu C. T.), p. 21. New York, 1969. This Field Notes, op. cit., p. 9). is the most recent systematic survey of Chinese medical 20. Victor Li, 1973 Field Notes, op. cit., pp. 6-7. education. 4. India Pocket Book of Economic Information, 1971, op. 21. For an excellent account of the training of barefoot cit. p. 206. By 1975-1976, there were 106 medical coldoctors, see Horn J. S. Away with All Pests: An English Surgeon in People’s China : 1954-I 969. Monthly Review leges in India. The annual admission capacity is about 13,000 and the annual outturn is estimated at over Press, New York, 1969, pp. 135-140. 10,000 (Report 1975-1976, Government of India, 22. These are very rough estimates by Teh-Wei Hu. An Ministrv of Health & Familv Plannine_, New Delhi. economic analysis of cooperative medical services in 1976, p: 42). the People’s Republic of China. Unpublished paper, 5. Side1 V. W. Medical personnel and their training. In 28 December, 1974, p. 126, 14a. Medicine and Public Health in the People’s Republic 23. Shansi Province reported 270 half-farm half-study of China (Edited by Quinn J. R.), p. 156. National Instimedical schools in 1966. Shan-hsi Wei-sheng (Shansi tute of Health, Washington, D.C., June 1972. Health), June 1966; JPRS: 39, 807, February 7, 1967; 6. For a brief discussion of Chinese policy toward tradiquoted in Orleans, 1969, p. 39. 24 PLA medical workers help rural areas train barefoot tional medicine, see Crozier R. C. Traditional medicine as a basis for Chinese medical practice. In Quinn J. doctors. NCNC-English. Pekina. Januarv 25. 1974: SCMP: 5545-49, p.1104.’ -’ R. (Ed.), op. cit. 7. Ho Piao. Development of Hygiene and Health Work 25. The correspondence course is a very recent developduring rhe First Five Year Plan CMO, Vol. 75, No. ment and is still at an experimental stage. “Make strenuous efforts to run correspondence courses well 12, December 1957, DD. 955-956. 8. Lampton D. M. The-politics of public health in China during the movement to criticize Lin Piao and Confu1949-1969. PbD dissertation, Stanford University, cious”, Jen-min Jeh-pao (People’s Daily) 11 November, December 1973, pp. 96 and 189. 1974; CB: 1023, 15 January, 1975, pp. 46-52. 9. Annual Report of the Director General of Health Ser26. “Seminar of Rural Mobile Medical Units, Hupeh Provices 1960 (Central Bureau of Health Intelligence, vince”, Wu-han I-hsueh Tsa-chih (Wuhan Medical Directorate General of Health Services, Ministry of Journal), Vol. 3, No. 4, August 1965, pp. 257-259; Ku Health, Government of India, New Delhi), pp. Yu-ling. “Problems of Mobile Medical Teams for 287-292. Rural Areas”. Chiang-hsi I-yao Tsa-chih (Kiangsi

ienting health policies in similar lines. The actual action strategies may, of course, differ according to variations in local needs and conditions. However, the task of implementing egalitarian health policies through the existing elite system may not be easy. The Chinese experience suggests that neither a general commitment to socialism nor concentration of powers in the hands of a small political-administrative elite can become an adequate mechanism for major social changes. Only a leadership determined to restructure both attitudes and power relationships within the political-administrative system will succeed. Such a restructuring must, among other things, involve debureaucratization and decentralization of power to the people.

546

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Medical Journal), Vol. 5, No. 8. Sept. 1965, pp. 987-990; “Birth control is an important mission of a field team”, Kuang-tung I-hsueh, hsien-tai I-hsueh-pan (Kwang-tung Medical Journal), Modern Medicine Edition), Vol. 4, No. 3, June 1966, pp. 141-144. 27. NCN.4, Peking, 25 June, 1973; FBIS, Vol. 1, No. 123. 28. Lucas, Spring 1970, op. cit., pp. 40-42. 29. Growth of commune clinics shows emphasis on rural health. NCNA, Peking, 25 June, 1973; FBI& Vol. 1, No. 123. 30. Traditional Chinese medicine and the struggle between the Confucian and Legalist schools. Chin. med. J. No. 10, October, 1974. 31. Medical workers make new advances in traditional Chinese medicine. NCNA, Peking, 30 December, 1974; SCMP; 5771:1/12/75, pp. 27-30. 32. Orleans L. A. Health Policies and Services in China, 2974. Sub-Committee on Health of the U.S. Senate; Washington, D.C. March, 1974, pp. 10-11. 33. Croizier, 1973, op. cit., pp. 17-18. and ecology of 34. Unschuld P. The so&-organization medical practice in Taiwan, as quoted by Crozier, 1973, op. cit., p. 18. 35. The 1960-1961 figures are from The Fourth Five Year Plan: 1969-74; Draft. New Delhi, Planning Commission: 1969, p. 314. The 1971 figure is from the “National Health Scheme for Rural Areas: Proposal of the Union Ministry of Health”, J. Indian med. Ass. 60, January 16, 1973, p. 75. By December 1975, 5320 PHCs and 33,291 Sub centers were established (See Report, 1975-76, op. cit., p. 10). 36. Fourth Five Year Plan: 1969174: Draft, 1969, op. cit., p. 314. The 1973-1974 figures are targets, not final figures. 37. “National Health Scheme for Rural Areas”, 1973, op. cit., p. 75. 38. See reference in [ll]. 39. National health scheme for rural areas. 1973, op. cit., pp. 75-77. 40. Report of the Committee on Multipurpose Workers under Health and Family Planning Program Ministry of Health and Family Planning, New Delhi (15 September, 1973). 41. National Conference on medical education, September, 1971, New Delhi: summary of group discussions. J. Indian med. Ass. 59, September 1972, p. 254. The same conference also criticized Indian medical education for lack of community orientation, too much dependence on class notes, and inadequate attention to practical work in wards and in field clinics. 42. The medical college trains doctors and assistant doctors who in turn train barefoot doctors and midwives who in turn train health workers. 43. Doctor in the village (Editorial), Times of India, 8 June, 1975. 44. J. Indian med. Ass. 55, 16 November, 1970, p. 362. 45. Tahiliani N. D. et al. Initial experiences in a mobile hospital. J. Indian med. Ass. 60, 16 January, 1973, pp.

51. In 1970, out of 600 students enrolled in Dr. Sun YetSen Medical School in Canton, approx 250 were female. (Sidel, op. cit., p. 164). Victor Li notes that during 1973 about one-third of the students at the Chung-shan Medical School were women. (Li. op. cit.. p. 7). 52. 1973 figures are from Report of the Committee on Multipurpose

53. 54.

55.

56.

57. 58.

Workers

under Health

& Family

Planning,

September 1973, op. cit., p. 87. Report 1975-1976, op. cit., p. 87. See Pi-chao Chen. The planning of births programme in the People’s Republic of China. Unpublished manuscript, Ann Arbor, Michigan, November 1974, p. 29. Also see Chen, China’s population program at the grassroots level, Studies in Family Planning 4 (No. 8). August 1973, p. 224. Kuan-tung I-hsueh-Hsien-tai I-hsueh pan (Kwangtung Medical Journal-Modern Medicine Edition), No. 3, June 1966, pp. 141-144; Chung-i tsa-chih (Journal of Chinese Traditional Medicine), No. 9, September 10, 1965, pp. 5-7. Examples of barefoot doctor’s curriculum can be found in the contents of the Barefoot Doctor’s Handbooks translated by Side1 (op. cit., pp. 167-169), and Chen (August 1973, op. cit., p. 226). Progress of Family Planning Program in India, New Delhi, Ministry of Health and Family Planning, March 1972, pp. 434$. U.N., An Evaluation of the Family Planning Program of the Government of India, 13 October, 1969, pp. 47-50.

59. Planning 60.

61.

62.

63. 64. 65.

Commission,

Family

Planning

Program

in

An Evaluation,

April 1970, pp. 61-73. Estimate Committee (1971-1972). Family Planning Program. Fifth Lok Sabha, 13th report. Lok Sabha Secretariat, New Delhi, April 1972, pp. 165-184. We do not have any national estimate of percentage of sta!T trained in family planning. However, a study conducted in 45 HPCs of Allahabad Division in Uttar Pradesh shows that 65% of the PHC staff had attended family planning training. Most of these stafI members were trained for one day to a month. (Misra B. D. et al. Family Planning in Uttar Pradesh-Final Report of the Kanpur Project. Ann Arbor, Michigan, May 1975, unpublished manuscript, Chap. lo., p. 31). “Preliminary experiences in the motivation of training methods for part-time hygiene personnel in rural villages”, CHEKTC (Chinese Journal of Pediatrics), No. 5, October 1965, pp. 343-346. U.N. (October 1969) op. cit., p. 49. For a detailed discussion of these models as applied to health policies in India and China, see Rushikesh M. Maru, 1976, op. cit., Chap. 6. See “Medical education: sound and fury signifying nothing”, Economic and Political Weekly, 24 January, 1976. oo. . . 92-93: and “Medical services: window-dressing”, Economic & Political Weekly, 8 May, 1976. pp. 683-685. India:

66-68.

46. Tauro A. J. A. The National Service Bill. Manpower Journal 8, April-June 1973, pp. 60-70. 47. Pi-chao Chen Public health development and birth planning in the People’s Republic of China. Unpublished monograph, Ann Arbor, Michigan, June, 1975, chap. IV, p. 7. 48 See Dr. Karan Singh’s statement in The Times of India, 19 April, 1976. 49 For a comparison of the extent and nature of health and family planning integration in the two countries, see Rushikesh Maru, op. cit., Chaps. 4 and 6. 50 I.A.M.R., Stock of‘ Alloputhic Doctors in India. 1966, op. cir.. p, 67.

List of abbreviations

CB CHEKTC FBIS JPRS NCNA SCMP

for references

Current Background (U.S. Consulate General, Hong Kong). Chung-hua erh-k’o tsa-chih (Chinese Journal of Pediatrics). Foreign Broadcast Information Services (Far East, Washington: U.S. Government). Joint Publications Research Service (Washington. D.C. U.S. Government). New China News Agency (Peking). Survey of China Mainland Press (U.S. Consulate General, Hong Kong).

Rural health services in India and China: 1949-1975 EPILOGUE

The Present article was written before the revocation of emergency on 21 March 1977 and installation of new Janata party government in place of the Congress government. One of the major policy pronouncements of the new government has tilted the Indian health policy more towards the populist model. Mr. Raj. Narain, the present health minister, is a product of grass roots politics in India. Before joining the Janata party, he was front rank leader of the erstwhile Praja Socialist party. After assuming office his first move was to call a meeting of the state health ministers and health secretaries and present them with a

547

new health policy framework which seeks to train 580 thousand community health workers (CHWs). These community health workers will be selected by the village communities from their own village and trained by the government for three months to provide primary health care services in rural areas. Mr. Narain also emphasized that the new government firmly believes in integration of health and family planning services. In fact, in keeping with this new philosophy, the title of the family planning department has been changed to Department of Family Welfare. Although it is too early to evaluate the new policy, it seems clear that it will be more egalitarian than the one pursued by the Congress government in the past.

Health manpower strategies for rural health services in India and China: 1949-1975.

Sot. Sci:& Med.. Vol. 11. pp. 535 to 547. Pergamon Press 1977. Printed m Great Britain. HEALTH MANPOWER STRATEGIES FOR RURAL HEALTH SERVICES IN INDI...
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