Special Issue on The Deepening of Disciplinary Content: Public Health in Post-COVID India
Rebuilding India’s Public Health
Keywords. Welfare planning; Reforms; Chaos; pandemic; emerging order
Abstract. 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 has been 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.
What happens to a dream deferred?
Does it dry up
Like a raisin in the sun?
Or fester like a sore-
And then run?
Does it stink like rotten meat?
Or crust and sugar over-
Like a syrupy sweet?
May be it just sags
Like a heavy load
Or does it explode?
(Langston Hughes, 1902-1967)
A pandemic in this milieu vividly exposed its weaknesses, compelling an alternative imagination explored in the last section. The failure of the lockdown; the utter disrespect shown to the working class; neglect of livelihoods, the subordination of science; centralised and irrational planning lacking transparency at all levels indicate what needs to be avoided. Already the government has been forced to cap private sector prices for treatment and fix bed allocation for the same while an undermined public sector has shown its capability to deal with monitoring and control activities however limited. In other words, the chaos in public health carries the kernel of a new order and indicates directions for change.
It is helpful to believe that we are living in a ‘deterministic chaos’ and experiencing the consequences of the flutters of butterflies flapping their wings - that chaos theory talks about; where events in one part of a complex system have implications for distant places. A minute change in initial conditions may lead to radically different behaviour and vague patterns become perceptible which are the precursors of future trends. Often they can show us the way and offer choices if one is serious about the need for change. India’s efforts at health planning in the initial years remained focused on the health service system, realizing the negative influences of the larger system yet, assuming that democratic forces unleashed will transform these. The democratic systems have two basic tenets – ensuring mutually agreed basic rights to all minorities and a system run by decisions based on the majority vote that applies to all. It builds social institutions and processes that inspire trust among citizens. Over time, however, while majoritarianism has consolidated globally, the primary tenet of democratic functioning is getting blurred affecting all spheres of social life, including the health system. At the turn of the century, a global network of policymakers, researchers and civil society organizations re-emphasised the significance of the social influences on health through a Commission on Social Determinants of Health (WHO 2008). Today in India, the health service system stands at the precipice - its crisis accentuated by the COVID-19 pandemic and its limits quite visible. The prevailing deterministic chaos along with its probabilistic processes, discord and entropy, brings the kernel of order and harmony and therefore, hope for the future. The theory of deterministic chaos also points to the limitations of prediction and underlines that in such situations projections will never be perfect (Prigogine and Stengen 1985; Halpern 2018). We can at best look for patterns and take their help in searching for a direction that might lead to harmony. Looking back at the double pendulum of time we identify some visible patterns which, if recognised, may help us dream the possibility of change in the dynamics of our gasping health care system and an alternative.
THE INNOVATIVE CORE OF DREAMS THAT INDEPENDENT INDIA DREAMT
Capitalism survived in the western world through discovering its welfare ‘avatar’ and within that, against the background of fast economic growth in the late 19th and early 20th century, Europe’s universal health care models evolved, financially supported by national taxation or insurance systems. Given a strong welfare base these systems addressed universal medical care needs through provisioning of medical technology by the private and public systems coming together in different organisational forms. Inspired by these, India - during its independence movement – imagined several models of health care for the country. These ranged from the Gandhian Plan (Agarwal 1944), the Bombay Plan by a group of industrialists (Thakur das et al. 1944), the People’s Plan by the Indian Federation of Labour (Banerjee et al. 1944) and, the Sokhey Committee, the Sub Committee on Health, of the National Planning Committee of the Indian National Congress (NPC, 1948). All had different ideological moorings showing different pathways to a shared dream of better living conditions, reducing inequality and providing welfare and basic health care. The Bombay Plan, with a focus on industrialisation, emphasised urban health; others prioritised rural facilities and agricultural development. Technology was central to the People’s Plan and Bombay Plan but with a difference. The former saw indigenous innovation and self-sufficiency as a condition, the latter considered foreign help as inevitable. The Gandhian Plan alone was cautious and, without rejecting technology, it placed people’s control over it as the key. The British Government, under the ethos generated by the National Movement for freedom, set up a Health and Development Committee (Bhore Committee) (Govt. of India 1946) that offered one of the most comprehensive and data-based report of those times. The Committee studied the global experiences of Britain, Australia, Canada, the USA, and Russia from where it drew its own framework for evolving a universal, free, and integrated health care system and drew up concrete plans for it. Building the planned infrastructure was entirely considered to be the responsibility of the Indian state and the plan was to unfold over the next 40 years. This report has often been projected as a blueprint for the health planning of independent India. It has been studied, reviewed and critiqued by many for its strengths and weaknesses but one of its most eminent and distinguishing features was the emphasis it laid upon the link between ill-health and poverty. It noted and commented on this link at several places to underline the fact that health is rooted in the extreme poverty of the population.
“…mention should be made of certain social factors which are also important in this connection. These include unemployment and poverty and certain social customs such as the ‘purdah’ and early marriage...Unemployment and poverty produce their adverse effect on health through the operation of such factors like inadequate nutrition, unsatisfactory housing and clothing and lack of proper medical care during periods of illness. While recognising that it is not within the scope of our enquiry to suggest ways and means by which poverty and unemployment should be eliminated, we feel that our survey of the causes of ill-health in India will not be complete without drawing attention to the profound influence that these factors exert on the health of the community (emphasis added). In a reaffirmation of the principles regarding health policy in connection with discussions on the Beveridge Report, the British Medical Association emphasised that “the health of the people depends primarily upon the social and environmental conditions under which they live and work, upon security against fear and want, upon nutritional standards, upon educational facilities, and upon the facilities for exercise and leisure” (Govt. of India 1946; Vol 1, p.17).
“the elimination of unemployment, the provision of a living wage, improvement in agricultural and industrial production, the development of village roads and rural communications, as distinct from the great national highways now projected, are all so many facets of a single problem calling urgently for attention, though it lies outside our province to do more than make a passing but pointed reference to them. We should be failing in our duty if we omitted to stress the composite character of the problem with which we are faced and to point out that a frontal attack upon one sector alone can only end in disappointment and a waste of money and effort” (emphasis added) (Govt. of India 1946; Vol. II, p.2).
This link was not a new observation: a young British medical officer, who investigated the 1908 malaria epidemic of Punjab, wrote his treatise on it explaining how poverty and the ensuing under-nutrition explained the malaria epidemics of Punjab and were the driving but unacknowledged force behind the evolution of famine codes (Zurbrigg 2019). Parallel to this was independent observations of Gidden in India about Plague and sanitary conditions (Rao-Cavale Karthik 2017) although his work was ignored by the colonial government. Yet another example is the reaction of Paul Russel, the leader of the Rockefeller Foundation/Ford Foundation team at the 1937 Bandung conference, who rejected the work of younger colleagues John Grant and Selskar M. Gunn of the Foundation, who had experimented with broadening the ambit of prevention by including agriculture, food availability, drinking water, sanitation and rural reconstruction to basic health services in the 1930s in India and China. Their approach sought to integrate preventive and curative strategies (Brown and Fee 2008) while Russel opted for the vertical programmes (ibid). In contrast to these negations, putting forward this relationship between poverty and ill-health and making it the basis for comprehensive health planning, was a new and bold step by this committee; a hallmark of the progressive trends set up by the debates generated by Dadabhai Naroji, Gandhi, Nehru and Ambedkar within the national movement.
The journey, over seventy-three years of reconstruction, has seen the dilution of this principle of placing centre-stage the link between health, health services and poverty and inequality in the health planning process of India and its developmental framework.
This paper explores the patterns that indicate the dilution of this principle. Identifies their roots and examines their chaotic influence on public health planning that is weakening the scaffolding of future dreams. It finally seeks to draw out the probable alternatives emerging out of this chaos that may lead to peace and stability.
THE EMERGING PATTERNS
Problems within the foundation itself
In the first place, the origin of the concept was in itself associated with its dilution as the Bhore Committee asserted the principle but failed to develop checks and balances at every step in time to ward off the possibility of disconnects in the strategies of development, health services and health. It proposed short and long term plans for health services over twenty years each, but in isolation and without incorporating assessments of levels of key non-health inputs. This left an opening for that very delinking that they knew “would lead to disappointment and a waste of money and effort” (Govt. of India 1946: Vol. II. p.2). Secondly, the Committee’s treatment of the ‘apathy’ of the people towards their own ill-health and as the cause of, “continuance of the existing state of affairs through many generations” (Ibid Page 20) was superficial. They located it in people’s tolerance towards their conditions and recognised the need for their involvement in measures to improve the conditions. Yet, the roots of this tolerance and apathy and their health implications were not detailed by the committed elite. Assuming the role of trustees they ignored the different socio-economic and ideological streams that came together at a crucial historical juncture for a larger purpose of winning independence but were not on the same page on methods of resolving many social and economic issues within the society. The issues of caste, class, gender and religion thus remained buried (Thomas 2002). This oversight, no doubt, was an outcome of the Committee members’ complete faith in the motives of the future leadership of the planning team and the self-perception of the virtuosity of the political and administrative class. Thus, the Committee offered no mechanisms to either evaluate this link between health and socio-economic influences by making them a part of its research agenda or to propose that, over time, the quantum of simultaneous growth of work availability, a living wage, livelihood and welfare services (access to food, water for drinking purposes, sanitation, education, basic health services, electricity and, transport), should be assessed. The first principle of scientific thinking - questioning one’s own assumptions and developing feedback loops and looking at the entire system not only at a part - thus got diluted.
Interrogating the past does not mean that past achievements could be ignored. First and foremost, tackling absolute poverty did bear fruits, but the achievements left much to be desired as reflected by the Sixth Plan’s assessment where its review of social justice over the two decades - 1960s and 1970s – showed that while the share of the rural poorest 30 per cent in consumer expenditure moved up from 13.1 per cent to 15.1 per cent, the urban poor did not gain even this much. The assets of the lowest 30 per cent rural population had slid from 2.5 to 2.0 per cent. Only the lowest 10 per cent remained where they were (Govt. of India 1981). This was the first and the last such review by the Planning Commission as the Seventh and the Eighth plans were already pushing for privatisation, shifting from total coverage to targeting the poor.
Given the initial scarcity of resources, economic emancipation was generally accepted as the key to achieving a welfare state based on democratic principles by the majority of the leaders. Gandhi was the only major critic of this approach (Rajadhyaksha 2017) which became the central focus of planning. Initially, investments in welfare had a visible space till the 1980s but the centrality of growth accentuated after the 1990s assuming redistribution will follow economic growth. The initial plans, especially the Second plan also introduced a range of socio-economic structural reforms such as industrial policy resolution of 1956, land reforms, improving the irrigation systems, setting up a public distribution system and a network of schools, health care institutions, a Community Development Programme in the villages promoting rural industries, agriculture, community participation, etc. These structural reforms of an agrarian economy, however, brought out the internal conflicts between different interest groups which began to stretch the unity of objectives that were supposed to make sacrifices justifiable and acceptable (Govt. of India 1951). The interests of the ruling caste-class combine were deeply entrenched in the political structure and their impatience was evident in the nature of distortions that emerged. Without going into the details, which are well documented by historians of the early years of independence and health services, we would point out two things: firstly, focus on urban growth, as a consequence of the emphasis on industrial centres from where growth would trickledown, could not effectively reduce inequality (Basu and Mallick 2008). Secondly, stagnating investments over Sixth and Seventh Five Year Plans in health and education in terms of percentage share in the gross national product (GoI 2002) undermined these basic needs of the majority of rural and urban poor which affected them negatively even before the Structural Adjustment Programmes were formally accepted.
The pattern of population growth
The results of the 1961 census became handy in explaining failures of planned development and population explosion became an accepted explanation for these failures. An aggressive Family Planning Programme used sterilisation camps, an oppressive force of emergency, and later a change of nomenclature to become Family Welfare Programme based on a techno-centric approach to maternal and child health. The focus returned to female sterilisation and use of new technologies till it was recognised that population control is just one factor in improving health; the more critical requirements being poverty redressal, the nature of work, women’s employment, education, and access to food and healthcare (Raju and Kumar 1992). Though seventy-four years of trying have brought us to a stage where, despite annual population growth rates coming down to a level of 1.4 to 1.6 1 and annual economic growth rates touching 7 to 9 per cent 2 between 2005 to 2009, inequality has actually risen – both economic as well as social. Till today this reality has neither changed the perspective nor shaken the conviction of contemporary Indian planners that lowering population (inevitably of the poor) will bear fruits. The welfare programme has therefore shifted to using the language of rights and control over their bodies. To push controversial contraceptive technologies women are being offered ‘choices’ and maternity and child care services have remained central to basic services as instruments of limiting family while the rest of the services are dwindling (Scroll 2020).
The patterns of inter-sectoral development for health
Instead of focusing on the elimination of unemployment, the provision of a living wage and other structural issues as pointed out above for increasing capabilities for self-care, the focus in planning over time wavered towards programmatic interventions to attain equity in specific areas of welfare. Thus, following the twenty point programmes, the Sixth Plan came up with the Minimum Needs Programme and identified elementary education, rural health, rural water supply, rural roads, rural electrification, housing assistance to rural landless labourers, environmental improvement of urban slums, and specific nutrition interventions. State-level interventions into employment generation in Maharashtra and Food Provisioning schemes of Tamil Nadu also came into being, but a national strategy for generating employment and giving living wages and livelihoods became peripheral in the overall developmental strategy by the 1990s. This programmatic approach expanded but received only a small share of the GDP with no accompanying structural change, leaving intact the economic and social constraints that ailed the system. Secondly, many of these programmes were initiated as short-term interventions till people took charge of their lives with sustainable livelihoods and living wages. This did not happen due to the iniquitous nature of economic development. The programmes lingered and are today being dubbed wasteful, a drain on the economy and populist props. Even the politically favoured programmes of Swachh Bharat and National Rural Drinking Water Programme aimed to achieve certain objectives by 2017, but could not. “It aimed to provide all rural habitations, government schools, and Anganwadis access to safe drinking water. Of this, only 44% of rural households and 85% of government schools and Anganwadis were provided access. It also aimed to provide 50% of rural population potable drinking water (55 litres per capita per day) by piped water supply. Of this, only 18% of rural population was provided potable drinking water. Out of a target of 35% of rural households only 17% of rural households were given household connections.” 3 Programmatic integration of nutritional services, Family Planning, Maternal and Child Health, were attempted within the health sector itself in the limited frame of ‘targeted populations.’ This pattern of refraining from intervening against the interests of the ruling classes and giving only a marginal share to the deprived persisted despite slogans proposing the opposite – be it ‘inclusive development’ or ‘Sabka Sath Sabka Haath’. The Niti Ayog of the new government through the National Nutrition Mission further reinforces programmatic intervention omitting the need for focusing on food production and public distribution strategies.
The emerging patterns of selective targeting
Over these seventy-three years then, there has been a shift from the universalisation of services to focusing on targets. Initially, the targets were primarily demographically vulnerable for focused provisioning as in ICDS, MDMP and service achievement (which in Family Planning Programme turned into targeting the poor men and women). When official measures of poverty became the instruments for provisioning for the poor, targeting acquired a very different hue. In India, absolute poverty not relative poverty is the reference point. This means that rising inequality is ignored as are the populations just on or above the poverty line. An inadequate methodology based on calorie intakes continuously reduced the estimated levels of official absolute poverty levels that were ridiculously inadequate (Patnaik 2006). Targeting them for services meant never addressing the roots of the problem (the linkages that we began with) and excluding a large number of underserved above the poverty line. The problem of underestimation was compounded as the working poor whose calorie requirements were the highest were denied their due because of the official use of an average figure for calorie requirement for ease of measurement (Qadeer et al. 2018). Requirements of Aadhar or other identification papers entangled them further in bureaucratic procedural barriers that left many uncovered. Targeting thus often became a means of exclusion.
THE STRUCTURAL ROOTS OF THE SHIFTING PATTERNS IN WELFARE PLANNING AND PUBLIC HEALTH PRINCIPLES
The roots from where these patterns around explanations of the link between health, poverty and inequality in health emanate, seem to be in the zone of conflict of interests among those who hold power and those whom they represent. The socio-economic differentials in life expectancy, mortality and morbidity all highlight the importance of poverty and the role caste plays in determining and accentuating the disadvantages to the poor (Asaria et al. 2019; June et al. 2011; Ghosh and Arokiasamy 2009). Added to this is the gender dimension that specifically affects the younger women and their nutrition (Mitra and Rao 2017). To then hold responsible the ‘apathy of the people’ for their ill-health and also as the cause of, ‘continuance of the existing state of affairs’ (Govt. of India 1946; Vol 1, p.20) is not a convincing assessment for the time when perhaps these structural constraints were no less visible. Yet, this belief occupies a prominent space in the realm of ideas even today. Apathy as we understand is more on the part of those who run the system or benefit from it and is evident in the unfolding history of public health in independent India. The initial interventions based on the assumption that population control, focused welfare inputs, and targeting will lift the poor out of their economic morass and oppression (breaking the chain of mechanisms of persisting poverty), did result in a certain degree of distributive justice (equity), as pointed out earlier but not equality that called for structural changes that enhanced capacity and expanded opportunities. The economic growth however remained low. This generated the debates around state versus market as instruments of distribution, greater need for borrowing and importing technology. Self-sufficiency, autonomy, and aid without dependence became debatable notions. From a mixed but regulated economy India opted for deregulation of private investments by mid-seventies and the balance of payment crisis of 1991 pushed it into accepting Structural Adjustment Reforms and enter a new phase of integration into global markets. This meant opening the economy to global influences. Economic growth became central with the assumption that a trickle-down will follow and investment into welfare was rolled back. Subsidies for food, education, health, etc. were dubbed as wasteful expenditures.
Following the period of slow growth up to the mid-seventies, where the economic growth rate hovered around 3-4 per cent, it increased to over 7 per cent and the per capita income increased by 7.5 times till the early years of the second decade of the 21st century. The poverty level of 41.8 (rural) and 25.7 (urban) in NSS 2004-05 came down to 25.7 and 13.7 (22% overall) in 2011-12. Though the actual estimates of decline may be disputed, interventions through NREGA, the Forest Rights Act, expanded feeding programmes contributed to it. They also emphasised the need for shifting from poverty alleviation to rights-based interventions and capability building approaches (Himanshu 2020). The concentration of wealth and increasing inequality accompanied this success. The refusal of the state to release the 2017-18 NSS data tells a sad story, as the leak of the official data indicates a lowering of consumption rates in rural areas and its near-stagnation in the urban population and an overall rise in poverty (ibid). Rising unemployment, falling wages, incomes and growth rates make the current challenge of enhancing welfare more difficult as inequality gets entrenched into the system and achieving even equity becomes difficult. From 2016, the professed advantage of growth is also lost with a visible decline in GDP growth. 4
In achieving equity in health care the assumption over the 1980s was that the rising middle class could now pay for itself, only the poor needed support. This was far from reality as the top 20 per cent in fact hogged 49 per cent of the institutional bed days and 46.5 per cent of the free ward days as against just 26.6 per cent of the bed days and 27.8 per cent of free ward days by the bottom 20 per cent with the lowest consumption (NCAER 2002). Efforts to create a social security net to lessen the burden of Structural Adjustment Programmes on this vast majority in the early 1990s therefore barely succeeded in improving the living conditions and access to health services of the socially marginalised. Health Sector Reforms accentuated the tilt towards urban medical care institutions, the decline of rural health service infrastructure, withdrawal of resources from public sector, the import of high tech and promoting privatisation. Tertiary medical care was opened to the market, user fees were introduced in public hospitals, private investment in the public sector was encouraged along with public-private partnerships and handing over of medical education to private entrepreneurs. Moreover, manpower was casualised as were supportive services in hospitals. The rural infrastructure suffered in terms of resources and manpower. These shifts reduced the utilisation of public sector services due to rising costs and the proportion of those who went untreated among the poor went up (Ghosh 2014; Qadeer 2019). All this is known to have brought down the quality of care. This, the state proposed, was unavoidable as ‘there is no alternative’ (TINA). The Promise of Universal Health Care too transformed into state-funded insurance schemes in the name of supporting the poor and ended up transferring state funds to the private sector instead of strengthening public sector institutions. The Central Government’s annual budgets have lately expanded financial investment the most in this area in the total health budget at the cost of key areas of basic care (Ghosh and Qadeer 2018). In this process, the little that people had in the form of traditional systems of medicine was lost with the dwindling forests, and the negligence of the state and the non-medical inputs into health, so central to achieving wellbeing, were side-lined.
The beneficiaries of this model, no doubt, were those who were diversifying their profits in medical care institutions (the rural rich, like the sugar cane and cotton producers), the growing middle class that had all the urban social services and now were not happy with the public hospital, the professionals themselves who were no more those who participated in the struggle of independence and for a less iniquitous India, but those who have often trained abroad with little awareness of social roots of ill-health and the conditions of the majority in India. For the majority of them, international standards and the necessity of high-tech for best treatment was the only way to practice medicine. Added to this were the politicians who made use of state funds to have the best treatment either in India or abroad and often were active in the business of running hospitals and medical colleges (Diwate 2019). This small but powerful section of society had a significant impact on policy decisions. Over time institutions of policymaking, planning and implementation of programmes began operating in the revenue-generation profit-maximisation mode. Health services thus became a commodity and not so much service, making the size of the patient’s pocket more important than the seriousness of the ailment. Fortunately, science grows only through testing assumptions and the proposition of TINA, we believe, is falsifiable historically as well as in the contemporary experience.
THERE IS AN ALTERNATIVE
If we look back at Public Health, best defined as, “the art and science of preventing disease, prolonging life and promoting health through the organized efforts of society” (Acheson 1988), its scope is universal and its success demands conditions under which people can fully and willingly participate in preventing deterioration of their health and maintaining/improving it. Public health focuses on the entire spectrum of health and wellbeing, not only the eradication of particular diseases. Is it then compatible with the emerging patterns that are shaping services? The question of this compatibility has never been adequately debated with the most well-meaning public health experts finding ways out by searching for appropriate technologies and getting trapped in greater dependence. The social origins of technology itself and the need for appropriate conditions for their application remained equally obscure. Deeply entrenched and much written about, these structural roots of distortions and chaotic patterns still evade the consciousness of the newly emerging Indian elite.
The COVID-19 pandemic in the year 2020 and its handling by the state unveiled the anti-people, exclusionary and undemocratic nature of state policies. All linkages between the disease, health services, employment, living wages, water and food supplies and sanitation burst open under the harsh lockdown that was imposed to suppress the spread of the pandemic. This was despite the knowledge that alone it can at best delay the peak but cannot eliminate the virus. The centralised management of the pandemic control, the shift from the health ministry and health workers to the home ministry and police, the use of a 123 years old draconian legislation to control and punish instead of promoting a scientific approach among citizens and encouraging their participation, a clear bias in favour of promoting the private sector in diagnostic and curative activities and a total lack of transparency in state investments for strengthening health service infrastructure, neglect of protection for the medical teams especially in the rural areas and its front line workers, has led to an unsavoury situation (Qadeer and Ghosh 2020). States were denied their share in decision making and finances (including their legitimate share in GST) and the lockdown was used to suppress dissent. This could be of any kind be it against CAA, NPR, NRC, Delhi riots or for violation of human rights as well as humiliating specific communities – like the Muslims and the Dalits and the informal sector workers as a whole. This ill-thought-out lockdown destroyed not just an economy in decline but the lives of 401 million informal non-agricultural and 428 million agricultural workers and their families (ILO 2018); 92 million of these urban informal workers were instantly hit and forced to vacate the cities being engaged in the urban informal sector. As if their walking hundreds of miles, staying hungry and dying was not enough, their rights were further undermined by the new labour laws passed in 2020 and many of them discovered on their return that they had lost their jobs (Damin 2020: The Hindu 2020, 5 Oct. page 2). This act too negates the fact that industrial profits are not just monetary gains of the industrialists, the labourer’s health itself must be counted as a component of that profit and be treated as a right embedded in living wages and health insurance and not as benevolence.
India has all the pieces of a shattered dream of health services lying around. It also has the experience and lessons from the past. The problem with picking up those pieces is that they would not fit within the contemporary socio-political reality. If there is a need to dream it is about how to let people live with security, dignity, and freedom to exercise constitutional rights and practice democracy so that they could pick up the scattered pieces together and reconstruct a lost dream with their very own creativity and imagination - a possibility that has been demonstrated (Shukla and Arathi 2019). There is the need to recapture a bit of Mahalanobis and Nehru’s imagination who talked of ‘the unfolding unknown feedback loops’ in the Second Five Year Plan. The unknown is no more so; firstly, it is those very basic conditions that the structural constraints deny a large section of its citizens. Resolving the caste, class, religious and gender conflicts is necessary for rebuilding lives and capabilities, not only focusing on economic growth without livelihoods. Secondly, it is also the realisation that technology devoid of a social base for application can become a monster that controls and destroys, not heals. The present chaos in other words carries the kernel of order as the government is forced to cap the prices of the private sector, take over beds for COVID-19 wards in private hospitals and the public sector institutions despite their undermining show their strength in monitoring, surveillance by grass-root workers and service provisioning by beleaguered professionals. All these trends show us the way forward. This understanding of the structural roots of ill-health is the irrevocable first step towards reimagining public health. Public health is a complexity that emerges out of the interacting socio-economic, political, medical, epidemiological, technological, organisational and environmental forces within a population. It demands that we make a distinction between ‘health systems’ and ‘health service systems’ (its subsystem). While working within the latter, the need to demand that the larger system be put right - including its authoritarian tendencies - is the second step in reimagining public health. This helps delineate what we can do, demand and dream.
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