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The paper traces the evolution of modern healthcare services on the ground and the changing concept of public health in India to see how these differ from the countries of their origin and why? It traces the transition of public health in India over three distinct periods - the colonial period, its initial welfare oriented social democracy and its drift into the contemporary neo-liberal phase. It explores the links between the shifting political ideologies and health policy and its links with international players, highlighting the structural changes brought in by the Reforms. The Health Sector Reforms have deformed the public sector healthcare system that is now fragmented and stagnating. They have allowed the private/corporate sector to take over medical care, rather than be a partner in strengthening the public sector healthcare system. The conceptual digressions within public health that rationalise the Health Sector Reforms are critiqued and the paper proposes the kind of intellectual enquiry that is required to resurrect public health and make wellbeing of the majority possible.

Using a comprehensive framework (the state’s will to deliver, its institutional strength and its legitimacy), this article assesses the impact of the COVID-19 pandemic on public sector healthcare services in India. The power to deliver was explicit when the interventions were harsh, increasing the burden of death and disease on health services. But when it came to healthcare by the public sector we find a worsening of achievements of non-COVID ailments during the pandemic and an inability to tackle the second wave due to gaps in the nation's infrastructure, a centralised control undermining state authority; and visible results of a flawed policy that pushed further the agenda of making healthcare a profitable business.

In the absence of specific drugs and vaccines, precautions at the personal level (hygiene, maintaining physical distancing and so on), people’s participation in population-level interventions (such as sharing scientific information, case-tracking and strategic area-specific lockdowns) and health service system preparedness are the three key available measures against the COVID-19 pandemic. However, the necessary ingredients for these three measures are missing— induced by poverty and structural inequality; a lack of people’s trust and a crippled public sector in health with a low resource base; shrinking, fragmented and weakened infrastructure that has lost on inter-institutional referral links and monitoring and surveillance systems. Not only has an ill-planned lockdown crippled an already struggling economy and depleted health systems and overshadowed containment efforts but the time has not been utilised to strengthen primary healthcare (PHC) services and secondary and tertiary public sector healthcare infrastructure. A phased relaxation of the lockdown with a comprehensive fiscal stimulus to jump-start the economy, coupled with the strengthening of health systems that put the needs of the poor at the forefront, is suggested.

Assuming impervious boundaries of public health service systems when searching for answers to its problems can be misleading as historically, economic and welfare planning to improve the quality of life of all was considered critical. Despite years of planning, the health sector in India has acquired a tumultuous trajectory with chaos prevailing at different levels – conceptualization, policy, financing, organization and community participation. Using the concept of order in Chaos, this paper attempts to trace four basic underlying elementary patterns in the developmental process rooted in the larger socio-political structures that led to this chaos. Its second section explores the roots from where these patterns explaining the links between health, poverty and inequality in health emanate - the zone of conflict of interests among those who hold power and those whom they represent. It explores how they altered the public health service system and settled in favour of a small but powerful elite (the corporates, the upper-middle class and the professionals) seeking international standards irrespective of the local context. Structural Adjustment and the Health Sector Reforms benefited them by shifting subsidies to the private/corporate sector, transforming services into a costly commodity, fragmented and marginalized primary health care and public hospitals while ushering in hi-tech medicine.

Sheila Zurbrigg, Epidemic Malaria and Hunger in Colonial Punjab: Weakened by Want—The Social History of Health and Medicine in South Asia, Taylor and Francis Books, Routledge, Abingdon, NY, 2019, 470 pp, ₹1,337, ISBN 9780367247300

The current budgetary allocation of ₹20 billion under the Pradhan Mantri Jan Arogya Yojana (PMJAY) is grossly inadequate. Our paper estimates that in the current fiscal year, the scheme will require an allocation of at least ₹420.73 billion to be able to give any meaningful coverage to 0.1 billion targetted families. This paper argues that such an expensive tertiary sector- led medical care coverage model is not the correct approach to ensure Universal Health Care (UHC) in India. A majority of illnesses are treatable at the primary level and an unbalanced promotion of the tertiary sector while neglecting primary healthcare will cause a delay in treatments, resulting in more complex and expensive medical interventions. What India urgently needs is to develop a comprehensive primary healthcare system.

The history of modern clinical medicine tells us how the practice of medicine evolved through the diagnosis of individuals: the cause of ill-health being first ascribed to the wrath of God, then graduating to natural forces, to specific agents, and eventually malfunctioning bodies. Similarly, therapeutic strategies evolved from prayers and magic; to products derived from herbs, plants, insects and animals; and finally, to surgery, drugs, radio therapy etc. In contrast, the history of public health is of understanding how human illnesses are related to the environment, identifying the key causal factors, and managing them through population level measures. The cases of cholera, cancer, scurvy, pellagra are only a few examples explored by John Snow, Richard Doll, Bradford Hill, James Lind and Gold Goldberger over the 18th and 19th centuries. Using large population level data, they identified the environmental, nutritional and economic and social determinants, often even before the actual causative agents were known (Buck et al., 2000). The development of statistics helped to selectively optimise clinical interventions and promoted prevention over cure. Thus, accurate data, understanding of the environment, and organised clinical interventions (including vaccination and immunisation) became crucial for the growth of public health. Gold Berger’s work on cotton mill workers is an early example of how incomes are related to the incidence of the nutritional disease pellagra. The welfare movement in Britain and Europe gave birth to the welfare state that saw the links between health, poverty, insecurity, and welfare services.

In the launch of Pradhan Mantri Jan Aarogya Yojana (PMJAY), the initiative was projected as a game changer in public-sector health care services for the poor. It would give an insurance coverage for medical costs for hospitalization up to INR 500,000 per family in a year and it would benefit 100 million poor families, or over 500 million people. While giving it the tag of ‘largest government-funded health care programme in the world’ in its inauguration, it was pointed out that the 500 million beneficiaries under this scheme outstrip the populations of the US, Mexico and Canada taken together. But can India really implement the ‘largest government-funded health care programme’, while its government spending on health is one of the lowest in the world? According to the WHO data, India ranks 183rd in terms of government health expenditure as percent of GDP and 159th in terms of per capita government health expenditure in 2015, out of total 193 countries in the world2. Let us have a close look whether the budgetary allocations in this scheme is adequate to fulfil its promises.

Responses to COVID-19 differ across countries depending upon their socio-cultural, economic and political contexts and the strength of their health systems. The pandemic unfolded in India over the months of February and March 2020 amidst a great social and political turmoil.

This chapter illustrates why 66% of women in four study districts in India choose to deliver at home with a traditional dai or midwife at their side, who offers respectful, collaborative, and empowering care, while the poorly staffed and under-resourced primary care facilities continue to provide poor quality and abusive care to the marginalized groups of women, including those from poor, low caste, or tribal communities. We carefully detail the intrapartum and postpartum skills of the dais in their study area, as well as the nurturing care they offer to mothers in the form of labor massage, verbal encouragement, herbal decoctions and traditional foods, and a sense of companionship that is sorely lacking in the minimal and often low-quality care offered at primary health centers in the same regions. The study describes how dais were able to successfully and sustainably resolve complications such as prolonged labor and delayed placental delivery that affected around one-fifth of the births in the study area.

Health and nutrition had always been at the core of welfare that anchored Indian democracy. However, the government’s approach of limiting the assured services and the notion of affordability in establishing universal health coverage indicates that the state’s commitment is shrinking. Political commitments may change in intensity and spheres over time within a given framework, but when the value framework itself changes then fissures of discontinuity appear. India is under one such shift and the present redefining of the health policy objective is reflective of the country’s attempt to get integrated into a fast expanding neo-liberal global market through structural reforms, where health like many other services is a driver of revenue and wealth. Interestingly, despite drastic cuts in financial allocations in welfare, promotion of markets, and rejection of participatory planning at all levels – for political reasons – the language of universality, inclusion and assurance for the disadvantaged, especially the very poor, continues and promotes targeting in official programmes. This chapter examines the shift in policy perspective through a review of four aspects of the Indian experience of health planning: (a) the intensification of health sector reforms in India and its gradual consolidation in the 21st century, (b) medical industry’s perspective regarding the health sector, (c) the National Health Accounts estimation of expenditures for better planning and its official use and (d) contribution of the National Institute for Transformation of India (NITI Aayog) to the HSR. The directions emerging out of these are then analysed for their value for the less privileged and the wisdom of the present policy, and the implications are considered. The scope of this chapter is limited as it primarily addresses the growing shift towards individualised medical care away from the comprehensive approach of public health.

This contribution joins the debate on the politics of global health, and specifically inequality in health. Focusing on three recent and pertinent reports, it examines two opposing perspectives for dealing with this inequality. Driven by the global financial crisis, one perspective attempts to validate the intervention of global capital through markets, technology and research funding in global health; it promotes a uniform model of universal health care based on medical care through insurances, public–private partnerships and a dominant private sector. The other perspective arises from the specific historical experiences of nation states in which health has been treated as a commodity. It highlights the negative impacts on global health of neoliberal reforms, such as reductions in welfare and increasing inequalities, and critiques the optimization of profits from health services, which undermines the government's role in health care. The article analyses the historical evolution of these perspectives and the two kinds of movements that emerged across the globe. Using the case of India, the authors argue that where neoliberalism prevails, health movements must link up with broader democratic and political movements that work for the realignment of structural inequalities and policy shifts for the well-being of the majority.

The analysis of food consumption data from successive rounds of the National Sample Survey (NSS), from 1993–1994 to 2009–2010, has shown that through the greater part of the post-liberalisation era India has seen a steadily declining level of calorie intake. This phenomenon is often attributed to increasing prosperity, declining morbidity and technological advancements that reduce hard manual labour and, hence, human energy requirement. The validity of this interpretation, however, becomes doubtful with the latest NSS data of 2011–2012 which have shown a noticeable increase of calorie intake. Using data from these NSS rounds, we attempt to make direct estimates of food consumption by different social sections in India. Our findings on declining calorie intakes, even among the poor who already have a very low calorie intake, strongly point towards increasing levels of undernourishment because of reduced access to food for a majority of people. We argue that the redistributive policies that have led to an improvement in food and calorie intake in 2011–2012 must be strengthened rather than undermined.

The transformation of existing knowledge or production of new knowledge is the focus of this article. This theme is explored using women’s health, actions and perceptions, and their interpretations—within a public health perspective—as these evolve around the currently most talked about high-tech obstetric intervention—the practice of surrogacy.The interpretations of words such as production, reproduction, labour and work are central to the present understanding of surrogacy in different societies. At a point in time when social sciences are striving to understand complexities, interconnections and praxis, this article offers a possibility of judicious use of technology and a glimpse, however brief, of man’s natural essence—humanness—the cementing factor in the alternate structure of society waiting to overcome the present conflict between the global hegemonic and democratic forces.The article argues that in contemporary India, the sections where surrogates come from see surrogacy in different ways, and that has to be the starting point for analysis but not the end. Indian law-makers take advantage of this confusion about the nature of surrogacy. It buries the non-exploitative potential of procreation under the ‘compensation for agreeing’ to be a surrogate, denies her rights and undermines the value of gestational motherhood as compared to genetic identity—thus, killing several birds with one stone!

Public–private partnerships (PPP) are being touted as the way forward for health care in the country as demonstrated by the draft chapter of the 12th Five-year Plan for health. The planning commission refers to the Rajiv Gandhi Super Specialty Hospital, Raichur, as ‘evidence’ of ‘good’ PPP without mentioning the multiple problems identified in this model, as documented in an evaluation report by the Government of Karnataka. The concerns raised by the evaluation team and the failure of the Planning Commission to take cognizance of these concerns are discussed in some detail in this article. Some of the issues identified with the PPP model of health care in Raichur are the absence of third-party evaluation, poor utilisation rates, lack of measurable benefit to the BPL population and poor governance and accountability systems.

This article locates health care and technology within the shifts in capitalist evolution from welfare to neoliberal development and examines why the concept of Comprehensive Primary health care has been distorted by the market to varying extents globally. Its focus is on India’s planning process where the thrust is to transform health services into commodities and tools of extraction of profit to which all levels of health care are subordinated. Since the 1990s, all Plans, official planning committees and legislations are meant to mould services in this direction. Instead of an integrated health service with primary health care getting support from the secondary and tertiary, the current thrust of the planning process has been to fragment health service into independent components—UHC, tertiary care and NRHM—in the name of providing rural and urban health services. In each of these strategies, public–private partnerships, commercialisation and appropriation of the public resources are the dominant trends. UHC thus no more remains the state-led integrated and inclusive service but a Trojan horse of the neoliberal strategy.

A systematic review of the available literature on goiter and other iodine deficiency disorders (IDDs) was carried out with the aim of analyzing available evidence and providing inputs to the policy makers and program formulators regarding the entire issue. The findings point to major issues such as the following: methodological issues in epidemiology of goiter and other iodine deficiency disorders (IDDs); lacunae in causal linkages; inadequate attention to multicausality; flawed assessment of the impact of intervention, i.e., iodized salt; and harmful effects of iodine not given due cognizance. Most of the research to date has been unidirectional and does not provide comprehensive data on all aspects of IDDs. To further compound the issue, many independent researchers, on finding something different from the existing dominant paradigm (iodized salt as panacea for goiter) have tended to ignore these in their final conclusions and recommendations. Thus, evidence from this systematic review demonstrates enough basis to start a debate on the entire issue, recognizing opposing research findings while continuing with the present strategy. This imposes specific problems and necessitates area-specific solutions instead of a universal solution, which apart from being less effective may be harmful in the long run.

Imrana Qadeer examines whether the Millennium Development Goals (MDG) are different from past approaches to maternal mortality in South Asia and critically assesses how they address the underlying inequities that determine reproductive health policies. She argues that policies to reduce maternal mortality can work, but that these strategies require a long-term perspective that is based on holistic development of the people and not just a select section given that maternal mortality is largely the outcome of poor general health and socio-economic constraints. Development (2005) 48, 120–126. doi:10.1057/palgrave.development.1100188

Summary The Public-Private Mix for Directly Observed Treatment, Short Course (PPM-DOTS) programme has been hailed as a success story in international cooperation. However, the evidence emerging from a range of sources suggests that this confidence may be motivated more by a desire to eulogize participation by private providers per se rather than on evidence of impact in terms of the cases treated. This review of literature has therefore been triggered by the need for a sober assessment of the progress of the strategy of PPM-DOTS to date, and queries the extent to which tuberculosis control is embedded in sustainable national tuberculosis control programmes. Our concerns over PPM-DOTS relate to three factors: Firstly, there is growing doubt about the stewardship role of the state in LICs to adequately supervise the private for-profit sector. There is evidence from some regions that the current arrangements further weaken what remains of the public health system. Secondly, the nature of the private for-profit sector, which in most settings is highly diverse, requires a coherent national health system absent in many cases; this fragments tuberculosis control, and undermines the long-term sustainability of PPM-DOTS. Thirdly, the complex nature of partnerships and the frequent lack of adequate public sector supervision are leading to a rise in multidrug resistance as reported from many regions.

This debate piece focuses on the concerns of the human papilloma virus (HPV) vaccine specifically in India. It discusses the efficacy of the vaccine side effects cost effectiveness and marketing techniques. It provides strong recommendations and demands to the Indian Government as to how the HPV vaccine should be handled in terms of other reproductive health services the trials and studies that are currently under way and financing and prioritization.

The program of universal salt iodization (USI) was intensified in the 1990s. Unfortunately, a recent World Health Organization review finds that there was a global increase of 31.7 percent in total goiter rate from 1993 to 2003. However, the WHO review places only 1 country as severely, 13 as moderately, and 40 as mildly deficient in populations' iodine nutrition, and places 43 countries at optimal, 24 at high, and 5 at excessive levels of iodine nutrition. Thus, it is imperative to weigh the benefits and risks of intensifying USI further. The WHO review places India in the category of “adequate” iodine nutrition, but in 2005 the Government of India promulgated a universal ban on sale of non-iodized salt, calling iodine deficiency disorders (IDDs) a major public health problem. This article attempts to understand these contradictions and weigh the benefits and costs of USI. Based on a review of studies since the 1920s, the authors reconstruct the evolution of IDD control in India. Conceptual and methodological limitations challenge the evidence base and rationale of stricter implementation of USI now. Finding evidence for its negative impact, the authors recommend a reexamination of the USI strategy and propose a safer, people-centered, ecosocial epidemiological approach rather than a universal legal ban.

This paper explores the forces that led to the conceptualisation of the National Rural Health Mission (NRHM) including the role of the Common Minimum Programme and the Structural Adjustment Programme. The paper analyses the key components of the NRHM in terms of the theoretical frameworks of decentralisation, integration of programmes, primary health care, community health workers and standards.

Indian society is distinguished by marked cultural pluralism and a relatively young population that in 1999 has grown to one billion. Its regional and economic diversity and complex social structure and extremes of poverty and wealth make planning a challenging task. Developing economic self-reliance tackling poverty and building a strong welfare state were major commitments of the newly independent India. After 1949 a conscious effort was made to invest in education and health services. Constitutionally health services were the responsibility of the provincial states. The role of central government was to define policies provide a national strategic framework financial resources and specified services such as services for people crossing international borders and medical education. In the 26 States and two Union Territories districts were the operative units wherein the population of about 1.3-1.5 million was served by a network of Primary Health Centres (PHCs) and sub-centres organized as a pyramid with the district hospital at the apex. Health sector planning had two major thrusts: the first to build an infrastructure to provide basic medical care maternal and child health (MCH) services health information education and referral services; and the second to develop specific national health programmes to control communicable diseases provide family planning services (FPSs) and control severe forms of nutritional deficiencies. To carry out these tasks a support system had been developed which included education and training research health information and monitoring drug and equipment production etc. (excerpt)

Senior physicians of modern medicine in India play a key role in shaping policies and public opinion and institutional management. This paper explores their perceptions of medical tourism (MT) within India which is a complex process involving international demands and policy shifts from service to commercialisation of health care for trade, gross domestic profit, and foreign exchange. Through interviews of 91 physicians in tertiary care hospitals in three cities of India, this paper explores four areas of concern: their understanding of MT, their views of the hospitals they work in, perceptions of the value and place of MT in their hospital and their views on the implications of MT for medical care in the country. An overwhelming majority (90%) of physicians in the private tertiary sector and 74.3 percent in the public tertiary sector see huge scope for MT in the private tertiary sector in India. The private tertiary sector physicians were concerned about their patients alone and felt that health of the poor was the responsibility of the state. The public tertiary sector physicians’ however, were sensitive to the problems of the common man and felt responsible. Even though the glamour of hi-tech associated with MT dazzled them, only 35.8 percent wanted MT in their hospitals and a total of 56 percent of them said MT cannot be a public sector priority. 10 percent in the private sector expressed reservations towards MT while the rest demanded state subsidies for MT. The disconnect between their concern for the common man and professionals views on MT was due to the lack of appreciation of the continuum between commercialisation, the denial of resources to public hospitals and shift of subsidies to the private sector. The paper highlights the differences and similarities in the perceptions and context of the two sets of physicians, presents evidence, that questions the support for MT and finally analyzes some key implications of MT on Indian health services, ethical issues emerging out of that and the need for understanding the linkages between public and private sectors for a more effective intervention for an equitable medical care policy.

The challenge of building rural health services, State's responsibility in providing these and training paramedical personnel to carry out limited curative and preventive responsibilities were part of India's development thinking before and after independence. The Sub-Committee on Health of the National Planning Committee of the Indian National Congress set up in 19381, the Gandhian Plan2, the Bombay Plan3, and the People's Plan4 of 1944 despite major differences in addressing the issue of economic growth and poverty, unanimously agreed on building rural health services. The Bhore Committee Report5 called for an integrated 3-tier health infrastructure to provide basic services for the rural areas. Reviewing past achievements, the Mudaliar Committee Report6 in 1962 offered financial options for building health services. India's mixed economy attempted to accommodate a welfare policy that led to expansion of health service infrastructure, manpower and public sector drugs and instruments production units. The training of paramedics was a key activity through nursing, ANM and Basic Health Workers and Health Assistant's training schools. After the Third Plan this emphasis got diluted. Investments in health services continuously declined and urban hospital based services got priority over the rural 3-tier system proposed by Bhore Committee. To contain the emerging dissatisfaction in rural areas, the State introduced the Minimum Needs Programme in the Fifth Five Year Plan (1974)7, the Community Health Workers Scheme in 1979, and expanded and restructured primary health Centre network adding Community Health Centres in the Sixth Five year Plan (1981)8. The acceptance of Alma Ata declaration of Comprehensive Primary Health Care in 19789, the National Rural Health Mission (NRHM) of 2005, training Accredited Social Health Activists (ASHAs) and now the proposal for a shorter training for rural practitioners, all were meant to strengthen rural infrastructure. The para-medics, however, remained neglected as a variety of male and female health workers were integrated into multi-purpose workers of both sexes in 197310 without much attention to improving the number and quality of training schools. Instead of an effective integrated manpower, capable of responding to the needs of rural areas the State created an army of ASHAs with limited skills to apparently provide full coverage. Absence of an effective infrastructure in rural areas and a medical education based on colonial vision of medicine that divided clinical medicine and public health failed to inspire doctors to work in PHCs though their numbers continued to rise as private medical schools expanded and further undermined public health component of medical education. Concentration in cities and out migration characterized this set of personnel. This paucity of personnel in rural areas created a huge gap between needs and availability of public sector providers. People depended upon private providers from different systems of healing such as AYUSH and folk medicine, and the fastest growing among these were the informal allopathic practitioners. This trend was more in the well off areas as compared to other relatively poor areas where profits are difficult in private practice. Was it wrong then to believe that adequate primary health care for all is possible? Or, did the system fail because the steps required by the policy for building rural health services were scuttled? The answer to this question lies not within the health service system, but in the larger developmental process. Since 1970s, the ongoing global collapse of the welfare States made them forego their political promises. They opted for structural adjustments that called for withdrawal of State investments in welfare, and its centrality in provisioning of welfare services. The Indian State too succumbed to this pressure informally over 1980s and formally in 1992. The State itself accepted its institutional inefficiency and inability to deliver services; corruption within and lack of managerial proficiency was assumed as incurable and all these were used to cover up the structural distortions introduced over the years. Private sector as an alternative became the State favourite at its own cost, leading to significant shifts of subsidies from public to private sector. The evidence often showed their anti-poor inclination such as failure of olymeriza private tertiary care institutions to provide free care to the poor in 10 per cent of their indoor beds and 25 per cent of the OPD patients11. Health Sector Reforms further transformed this sector into an industry which is expanding at 12 per cent CGPA (cumulative growth per annum) since 2008 and its market is poised to gross Rs.1.3 trillion in revenue by 202012. According to investment Commission of India, the Confederation of India and the consultant firm Mc Kinsey, the main sources of this growth are hospitals, nursing homes, medical equipments, laboratories and upcoming specialities such as aesthetics and weight loss, health insurance, medical tourism and expanding private medical education13. In the process, the very nature of definitions of primary health care and public health changed. From ‘comprehensive’ primary health care the policy makers moved to ‘selective′, and then ‘primary level’ and latter ‘essential’ care thus, fragmenting content and delinking levels. The tertiary institutions were absolved of the responsibility to support the secondary institutions and were free to become a part of the global health market. Market forces and availability of technology and not epidemiological priorities regulated them. This led to a schism in services, urban hi-tech curative, and rural ill staffed, ill equipped institutions dependent on ASHAs and AWWs for community work. The focus of rural services narrowed down to population control, maternal and child health and a few disease control programmes14 while the medical market penetrated it through first referral private institutions for curative care, private practice by government personnel and other forms of public private partnerships. Today, the rural health service is characterized by its inadequacy and poor utilization. The NRHM, that was to change this reality, apart from provisioning of materials and finances, has actually delinked primary from the tertiary level, focused on private partners for first level and secondary referrals and use of contract workers15 rather than developing manpower specially paramedics. The new cadre of ASHAs in absence of this support remains necessary but not sufficient as is evident from the current Annual Health Survey of the Office of the Registrar General of India16. ASHA under the “Janani Suraksha Yojana” can take the woman to the PHC but cannot impact maternal and infant mortality in majority of the high priority States. The rural elite are moving to urban medical markets and 65 per cent of rural population uses Indian systems of medicine17. An empiricist, a-historical analysis of the situation can at best show us the present pattern of preferences but it does not show us why these preferences are as they are. If people use private services because, these are ‘close at hand, better or cheap for basic needs’ then, should we be pragmatic and use their actions to accept the status quo or should we explore it further? This is the dilemma for Gautham et al18 in this issue. There are problems with their choice. Public health teaches us to olymeri death and suffering not only as an end in itself but also as one of its various tools, that when used judiciously, changes the epidemiological history of diseases and becomes the experiential basis for olymeriza people's participation in disease control strategies. A balanced curative and preventive strategy is then its essence and not only basic clinical services. Should it not be possible for trained paramedics, part of the public health team, to provide that basic care which the informal private practitioners are providing- many of whom are from the government health services? The notion of ‘basic diseases of the poor’ too needs to be shed off as they bear the brunt of common and uncommon diseases and their complications due to the delays in treatment and neglect and therefore, deserve more attention! One, therefore, needs to ask where do local practitioners send their patients when they cannot handle them? The solution to the challenge of handling rural health needs lies in strengthening the public sector rural infrastructure as a whole including primary, secondary and tertiary referral facilities and integrating national disease control programmes and not in accepting the informal practitioners as permanent solution or equipping primary rural institutions without adequate support from secondary and tertiary levels. This calls for restructuring NRHM. To use people's health olymeri as justification of status quo in a context ridden with constraints, promotes the interests of the medical market ignoring the needs of the rural population. If the people in rural areas are not impressed by the NRHM and yet seek modern medicine in private sector then, is it not our professional responsibility to search for the cause of this contradiction and examine the constraints of their context rather than accept the obvious structural and functional flaws? In building a comprehensive rural health service, linking up private providers with primary institutions may be the first step in the alternative strategy but that strategy must evolve out of an analysis of the subverted policies and not pragmatism that overlooks the undermining of the principles of public health planning.

In the course of any discussion on problems of food production and hunger in the Third World it is not unusual to come across a heavy emphasis on the cultural backwardness and traditional outlook of the common people. A study of the Indian situation, however, shows that the more important issues lie within the sphere of planning and policy making. It is not traditionalism but the intensive area development model and the resultant inequality which is primarily responsible for the nutrition problems of the majority of the population. The paper here examines in some detail one aspect of the nutrition policy; the nutrition distribution programmes in the context of the total developmental strategy. India's nutrition programmes were meant to ameliorate hunger and malnutrition among the vulnerable section. But the existing socio-economic and political structure of the society has so affected the formulation and implementation of these programmes that they have practically become irrelevant. The inadequacy of resources, the inefficiency of the delivery services and the maldistribution of the available resources, weighted in favour of the richer section, combine to make ineffective all welfare programmes for the poor. Further, the herding of the heterogeneous programmes under an all-India nutrition policy deprives the national policy of a uniform conceptual basis and, therefore, undermines its rationality. In their present form the nutrition programmes lack an epidemiological perspective. They are not effectively integrated with the health services of the country. Their coverage of the vulnerable groups has no scientific basis and is most inadequate. An examination of these issues shows that any serious attempt at planning feeding programmes must take note of the available infrastructure which at present is not only inadequate but also ineffective insofar as the objective of reaching the poor is concerned. Secondly, if an integrated programme has to be offered, then nutrition programmes must find their place in the list of the health priorities and only when their impact and feasibility are. demonstrated effectively within the available infrastructure should they become a part of the package. Thirdly, it is worth keeping in mind that even if feasible nutrition programmes are evolved they can only function as temporary relief measures for a small number of people. A lasting improvement in the nutritional status of the vast majority is a function of their productive capacity and hence of their socio-economic development which must simultaneously occur and form the backbone of any nutritional policy.

A pair of female xiphomonomphalus conjoined twins developed acute renal failure as a result of renal vein thrombosis at the age of 21 days. They were successfully managed by exchange transfusions at a stage when careful monitoring and restoration of pH, electrolyte, and fluid homeostasis seemed inadequate to sustain life.