Application of Sociological

Concepts UNIT 2 SOCIAL DEVELOPMENT

Structure
2.0 Objectives
2.1 Introduction
2.2 Concept of Social Development
2.3 Indicators of Social Development
2.3.1 Human Development Index
2.3.2 Social Indicators
2.3.3 Environmental Indicators
2.3.4 Basic Needs Indicators
2.3.5 Health for All Indicators

2.4 Planning for Development

2.4.1 Government Planning
2.4.2 Impact of Economic Planning on Health and Health Financing
2.4.3 Effects of Health on Development
2.5 Financial Outlay for Health in the Plans
2.6 State/Central Government’s Role in Health Planning
2.7 Factors Influencing State’s Ability for Financing Health Care
2.8 State Versus the Market in the Health Care
2.9 Let Us Sum Up
2.10 Answers to Check y Your Progress
2.11 Further Readings
2.12 Annexures

2.0 OBJECTIVES
After studying this unit, you should be able to:
z explain the concepts of social development;
z describe the indicators of social development;
z describe the financial outlay for health in various plans; and
z describe the state and central government’s role in health planning.

2.1 INTRODUCTION
The development of a country is measured by its social development. The basic facilities
available to an individual; the health status of people of country; the education level; the
economic development are some of the indicators which give a status to the country as a
developed or developing country. In this unit, the concept of social development is discussed
in terms of social indicators and state government’s role in health planning of the country.
While reading this unit you may collect data from your state on the various aspects specially on
Human Development Index. Let us start with the concept of social development.

2.2 CONCEPT OF SOCIAL DEVELOPMENT

In ordinary sense development means ‘a gradual unfolding’; a fuller working out of the details
of anything; the growth of what is the germ (Oxford English Dictionary). It is in this sense that
we can speak of the development of a child, or of a disease. But it is difficult to speak in the way
30 of social development.
Social development implies that there are only two (related) social processes to which it seems So c i al D e v e l o p m e n t
possible to apply the term ‘development’, namely, the growth of knowledge and growth of
human control over the natural environment as shown by technological and economic
efficiency.

In most recent sociological writings, the term development has been used in quite a different
way; first, to differentiate two broad types of society (industrial and the agricultural) and
secondly, to describe the process of industrialization or modernization. This kind of knowledge
has been represented in a simple historical model as a movement of society through three
stages mainly: traditional society, transitional society and modern society, where the
development of human powers of production is the most significant element in the
transformation of society.

The critics of modernization theory of development however have conceptualized development

not only in terms of economic growth, but also emphasized that development is:

a) the removal of poverty,

b) unemployment,

c) inequality,

d) ill health,

e) ensuring participation in health programmes, and

f) attain good quality of life in the context of overall development of the society.

This holistic approach is embodied in the concept of sustainable development.

The World Population Conference in Bucharest (1974) recognized the linkages between
population and sustained development. Population policies and programmes were to be
reflected as specific national imperatives.

In the Indian context social development implies:

a) eradication of poverty

b) improving productivity

c) provision of minimum needs

d) development of human resources

e) raising status of women

f) improving technical and managerial aspects

Special efforts have been initiated to provide a social safety net to the poor. These efforts have
been directed to break the complex nexus of low literacy, ill health and high fertility. Let us have
a brief look at the programmes directed towards social development.

2.3 INDICATORS OF SOCIAL DEVELOPMENT

In the context of Health For All by 2000 A.D., a level of health has to be achieved in order to
permit the people to lead a socially and economically productive life. With regard to this,
certain variables which are valid, objective, sensitive and specific are necessary to be evolved
as indicators of social development. These indicators could be developed at the
micro(individual) level as well as macro (community/national) level.

Indicators of social development would include the following:

2.3.1 Human Development Index (HDI)

It is a composite measure of human development containing indicators representing three
equally weighted dimensions of human development.
31
Application of Sociological These are:
Concepts
a) Longevity (life expectancy at birth, 1995) ----- 61.6
b) Knowledge (adult literacy) ----- 100% and 0%
(mean years of schooling) ----- 15 and 0 years
c) Income (purchasing power) ----- PPP$ 40,000 and $200
d) High human development ----- > 0.8
e) Medium human development ----- 0.5 to 0.8
f) Low human development ----- less than 0.5

2.3.2 Social Indicators

United Nations Statistical Office has divided social indicators into 13 categories:
a) population
b) family formation
c) families and households
d) learning and educational services
e) income earning activities
f) distribution of income, consumption and accumulation
g) social security and welfare services
h) health services and nutrition
i) housing facilities and its environment
j) public order and safety
k) time use
l) leisure and culture
m) social stratification and mobility

2.3.3 Environmental Indicators

These reflect quality of physical and biological environment in which diseases occur and affect
people. These include:
a) pollution of air and water,
b) solid waste disposal,
c) exposure to radiation and toxic substances,
d) accessibility to safe water, and
e) adequate sanitation facilities at home and surroundings.

2.3.4 Basic Needs Indicators

ILO has listed certain indicators like:
a) calorie consumption,
b) access to water,
c) life expectancy,
d) deaths due to disease,
e) illiteracy,
f) doctors and nurses per population,
g) rooms per population, and
h) GNP per capita.
32
2.3.5 Health For All Indicators So c i al D e v e l o p m e n t

WHO has listed the following four points:

1) Health Policy Indicators
----- political commitment to health for all
----- resource allocation
----- degree of equity of distribution of health resources
----- community involvement
----- organizational framework and managerial process
2) Social and economic indicators related to health
----- rate of population increase
----- GNP or GDP (Gross National Product or Gross Domestic Product)
----- income distribution
----- work conditions
----- adult literacy rate
----- housing
----- food availability
3) Indicators for the provision of health care
----- coverage of primary health care
----- coverage of the referral system
----- availability, accessibility, utilization, quality
4) Health Status Indicators
----- low birth weight (percentage)
----- nutritional status and psychosocial development of children
----- infant mortality rate
----- child mortality rate
----- life expectancy at birth
----- maternal mortality
----- disease-specific mortality
----- morbidity – incidence and prevalence
----- disability prevalence
Uses of these Indicators:
a) provide yardstick whereby countries can compare their own progress with those of others
b) illustrate the differences in health situation and socio-economic status within the country
c) assist in planning by providing adequate and meaningful information regarding socio-
economic, health and other developmental progress
d) reflect progress towards correcting the social inequalities
e) monitor overall socio-economic development of a country including health programmes
f) assist in identification of socio-economic, health and developmental priorities for
planning appropriate strategies

g) used as markers of progress towards reaching the developmental goals of the societies. 33
Application of Sociological Check Your Progress 1
Concepts
Fill in the blanks:
1) In the Indian context social development implies mainly:
i) ....................................................................................................................................
ii) ....................................................................................................................................
iii) ....................................................................................................................................
iv) ....................................................................................................................................
v) ....................................................................................................................................
vi) ....................................................................................................................................
2) The thirteen categories of social indicators that have been classified by UN Statistical
Office are:
i) ....................................................................................................................................
ii) ....................................................................................................................................
iii) ....................................................................................................................................
iv) ....................................................................................................................................
v) ....................................................................................................................................
vi) ....................................................................................................................................
vii) ....................................................................................................................................
viii) ....................................................................................................................................
ix) ....................................................................................................................................
x) ....................................................................................................................................
xi) ....................................................................................................................................
xii) ....................................................................................................................................
xiii) ....................................................................................................................................

2.4 PLANNING FOR DEVELOPMENT

2.4.1 Government Planning
The Government of India set up a Planning Commission in 1950 to make an assessment of the
material, capital and human resources of the country, and to draft development plans for the
most effective utilization of these resources. In 1957, the Planning Commission was provided
with a perspective Planning Division that makes projections into the future over a period of 20-
25 years. The Planning Commission consists of a Chairman and five members. The Planning
Commission works through 3 major divisions – Programme Advisors, General Secretariat and
Technical Divisions which are responsible for scrutinizing and analyzing various schemes and
projects to be incorporated in the five years plans. Over the years, the Planning Commission has
been formulating successive Five year Plans.

Special efforts have been initiated to provide a social safety net to the poor. These efforts have
been directed to break the complex nexus of low literacy, ill health and high fertility. Let us have
a brief look at the programmes directed towards social development.
Poverty Alleviation Programmes (Initiated in Sixth Five Year Plan)
a) Public Distribution System: To provide subsidized food to the poor.
b) Integrated Child Development Services: To provide basic health, nutrition and education
34 packages to mothers and children.
c) Integrated Rural Development Programme: To provide subsidies and loans to low So c i al D e v e l o p m e n t
income rural households or purchase of productive assets.

d) Jawahar Rozgar Yojana: A wage employment programme for disadvantage groups.

The 8th Plan (1992 to 1997) gave a big thrust to these programmes. Two subschemes related to
IRDP were started:

a) Training of Rural Youth for Self Employment (TRYSEM)

b) Development of Women and Children in Rural Areas (DWCRA). These schemes trained
youths and pursue income generating activities for women.

Agricultural Development Programmes

The new approach in the 8th Five Year Plan has been to shift government activities for
agriculture and the poor from subsidy, towards:

a) Increased provision of appropriate support and infrastructure.

b) Social services to raise productivity.

c) Providing safety nets designed to protect against agriculture and other fluctuations.

d) Providing income support for disabled and poor.

Development for Women’s Welfare

The aim has been to bring women into the main stream of development of the society. Various
schemes have been started for women to raise the employment status, education and health. A
National Commission for Women (NCW) has been established in 1992. The National
Perspective Plan for Women (1998 to 2000) indicates directions to protect the rights and
interests of women.

A number of special schemes for education, vocational training, employment, reservations in

elective offices in local self government have been started. Legislation exists to protect women,
to eliminate discrimination and empower them politically. Specific statutes cover inheritance and
rights to property, marriage, divorce and alimony, suppression of immoral trafficking in females,
prohibition of dowry practice and provision of equal remuneration and misuse of prenatal
diagnostic techniques for sex preselection and abortion of female foetuses.

For improving health status of women following schemes and activities have been started:

a) Scheme of profilaxys against nutritional anaemia: for pregnant and nursing mothers

b) Training of untrained birth attendants: to ensure safe delivery

c) Vaccination against tetanus: for improved antenatal care

d) Special centers for imparting nutritional education

e) Mass education and media activities: to promote and create awareness against early
marriage

f) ICDS is being extended to the welfare of the adolescent girls to enable them to grow up as
better young women

g) Innovative incentive schemes for limiting family size and counter strong son preference:
e.g. Rajlaxmi Scheme evolved by Rajasthan Government and UTI. Similar schemes have
also been started in Maharashtra, Gujarat and H.P.

The Indian economy has made steady progress since Independence to achieve self sufficiency
in agriculture and set up diversified manufacturing base. It has now embarked on a programme
of liberalization and structural reforms to lead to rapid economic growth. Despite these
achievements, poverty alleviation and social sector are yet to show concrete results. 35
Application of Sociological 2.4.2 Impact of Economic Planning on Health and Health Financing
Concepts
Economic growth means more production of goods and services. The total production of
goods and services in a country during a year is measured by the Gross National Product
(GNP) or Gross Domestic Product (GDP). Only final products are added together. Final
products re added together. Final products are those sold directly to users -- for example, a
hospital bed. Intermediate products may be sold to the maker of the bed (e.g. the metal from
which the frame is made, spring or canvas, and the screws and nuts that hold it together) but
these are not added to the value of production.

If we examine the relation between mortality and the Gross National Product (GNP), we find that
as the GNP per head goes up, mortality comes down. This is true of most countries. The Infant
Mortality Rate (IMR) comes down even more sharply. In 1993, Life Expectancy at birth in the
poorest countries was about fifty years, while in the richest countries it was seventy-six year.
Although, on the whole, there is a strong correlation between life expectancy and the GNP per
capita, there are some notable exceptions. Countries like Sri Lanks, China and the state of
Kerala in India for instance, have life expectancies, which are far above the average of the
developing countries as a group. These societies have achieved higher health status at low
level of economic development, mainly on account of the higher investment on primary
education and primary health care over a long period of time.

In most of the present day developed countries, the mortality rates fell considerably much
before the modern inexpensive antibiotics came into existence during the post war period.
Improvements in public health standard increased the level of income; this together with
universal primary education are responsible for such a remarkable fall in the mortality rates.

On the contrary, in the less developed countries the decline in mortality has been due to
widespread application of antibiotics and immunization measures. Some improvement in safe
drinking water supply has also contributed to some extent. In general, however, even today the
public health standards, particularly in the matter of the disposal of human faeces, are very
inadequate.

The greatest difference in the life expectancies, in the developed and developing countries,
relate to those of children. In the developing countries, as a child grows, the life expectancy at
various ages rises at a fare rate upto the early adulthood. This is because the infant mortality
rates are very high. If the child can manage to live up to the age of five, then it can expect to
live much longer than he/she could at birth. In the developed countries, since the infant
mortality rates are low, there is not much difference between life expectancy at birth and life
expectancy at early adulthood.

If we take cross-section relationship, the correlation between national income and life
expectancy is positive, but reaches a plateau at high income levels. Further, if we draw a curve
to show the changes in this relationship over time, we would find the curve shifting upward.
Thus, life expectancy has gone up at each income level. Some researchers have found that a
growing national income accounts for only about a tenth of a quarter of this rise in life
expectancy, and the rise has been accounted for by other factors. In many cases a direct social
health policy, which provided certain nationally desired levels of health and sanitary services,
education and nutrition, helped to reduce the mortality rates. This, along with an international
speed of modern medicine, has helped to narrow the gap between the life expectancy of the
developed and developing nations, much more than the narrowing in the gap between their
incomes.

2.4.3 Effects of Health on Development

We just discussed the relation of economic development with health or rather one aspect of it,
namely, life expectancy. Now we shall discuss the effect of health on development.

Just as you have financial capital, and physical capital, like machines and machine tools, you
also can think of people as a type of capita, which, if invested wisely upon health and
education, will provide returns through better skills, higher productivity and improved well
being. Thus, health improves the quality of the human capital. But this process is slow and
long drawn. We shall briefly list the positive effects of health and development.
36
i) Many areas which are not habitable because of infestation with diseases can be made fit So c i al D e v e l o p m e n t
for settlement through disease control programmes and thus it can help in the utilization
of idle resources of that area.
ii) Good health can promote good labour morale and lead to greater productivity potential.
iii) Good health affects intelligence, inadequate diet and lack of maternal care can cause
mental retardation and other mental problems thereby affecting productivity of an
individual.
iv) Better health is generally associated with better capability and leadership.
Better health induces positive attitudes conducive to economic growth and modernization. The
people with good health are generally enthusiastic and try to achieve higher and higher goals in
life.
a) Causes of Health Problems in the Developing Countries
Here we investigate for the relatively high incidence of sickness and disease in the developing
countries. Much of the sickness is caused by the preventable infectious diseases, poverty, low
public health standards, lack of adequate medical care, insanitary living conditions, and
demographic factors.
In the developing countries, the high fertility is often the cause of the high mortality among
the children and mothers. The infant mortality and maternal mortality rates are high, and are the
main cause of the low life expectancy. The high fertility leads to the greater susceptibility to
disease and illness among the children and mothers. If a baby is born into a family, which
already has many children, it runs a high risk of death. This is because high fertility is usually
associated with low birth-spacing, exposing both mother and child (due to low birth weight) to
a higher incidence of diseases. Further, in large families, resources are spread thinly. These problems
are compounded by the fact that the utilization of the modern health facilities during pregnancy
and at the time of delivery is very low in many developing countries. Most states in India are no
exception of this. This puts both mother and child at high risk of morbidity and mortality.
Let us now turn to malnutrition. Malnutrition, for the poor people; usually means
undernutrition. It is most prevalent among the children. It is a situation, where the average
daily calories and protein intake is less than the minimum daily requirement. We can deduce,
when a person’s calories-intake is less than what is required, although the minimum
requirement vary according to the climate, the people’s body weights, and the activities they
are engaged in. You must have heard to diseases like Kwashiorkor and Marasmus. These are
caused by protein and calorie deficiency. Further malnutrition makes people susceptible to
many other diseases. Malnutrition among children may stunt their growth and impair their
physical and mental development, permanently. Aggravating the situation of the actual
shortfall, in the nutritional requirement, is the fact that in the developing countries food is
unequally distributed even among the family members. The children, in general, and the
female children, in particular, are often discriminated against, or given as much food and
medical care as the others.
Consumption of food depend, like those of other goods, on income and prices. The Economists
know that when households’ incomes rises, households tend to spend an increasing amount
but a decreasing proportion of their income on food. At the lower levels of income, the
proportion of money spend on food is very high, leaving little for other necessities. Even the
expenditure on food may not be adequate to meet the minimum food requirement. In most
societies, the governments step in an subsidize foodgrains through a public distribution
system. They also run special nutrition programmss to cover the vulnerable groups, particularly
children.
Malnutrition affect children, and pregnant and nursing women more than the rest of the population.
Hence, often special nutrition programmes are targeted at these groups. Maternal and Child
Health (MCH) services and the Integrated Child Development Scheme (IDCS), India, are examples
of these schemes. Similar schemes exist in most countries, including the developed countries.
The environmental and sanitary factor are important determinants of health of the people.
Contamination of water supply often leads to typhoid, dysentery, and other water-borne
diseases. As indicated above, considerable proportion of childhood morbidity and mortality 37
Application of Sociological can be reduced simply by providing clean drinking water to those who have no access to it.
Concepts
Water-borne diseases form a significant proportion of the total morbidity in most parts of India.
Policies to improve sanitation, usually focus on human and animal waste disposal, and an
effective sewage system. Fecal contamination of water sources is the main cause of the water-
borne diseases. Improvement in human and animal waste disposal will considerably reduce the
spread and prevalence of the water-borne diseases.
Housing is another component of Sanitation. Housing in the developing countries is often
sub-standard. Houses lack ventilation, access to sunlight and sufficient space, and are usually
unclean. Insufficient space, ventilation, sunlight, etc. are problems primarily in the urban area.
These conditions spread air-borne diseases, such as the upper respiratory tract infection and
Tuberculosis.
Let us now talk about the medical services in the developing societies. Most developing
countries display certain common characteristics. Their spending on the medical services is,
usually, inadequate, and much of what is spend is allocated to the tertiary level facilities, which
means large hospitals with modern facilities. The advanced medical services and facilities, at
the tertiary level, are available only to the well-to-do sections of the population. Many doctors
come from the middle and upper stratum of society, and due to prestige and status values,
prefer to do research and work on the western style or modern medicine. Quite often, they are
reluctant to practice in the rural and semi-urban areas. The reluctance is mainly on account of
inadequate social infrastructure (such as schools, recreations, etc.) in the rural areas. Thus,
subject like bypass-surgery receive a great deal of attention, while primary health care is
neglected. Due to the inadequate attention given to the primary health care, and, the
consequent absence of a proper referral system, one finds congestions at the tertiary level
hospitals, and inadequate utilization of the secondary level facilities (such as, district
hospitals). This kind of lopsided-use of facilities results in the higher overall cost of care, as the
unit costs of treatment at tertiary level facilities tend to be very high.
A characteristic feature in the developing societies is what Michael Lipton has described as
the ‘urban bias’. It means that most of the resources, aid and assistance are cornered by, and
directed towards the urban areas and urban people. Even in the urban areas, it is the elite who
get a disproportionate share of the benefits. Yet, another worrying feature is that most
developing countries spend much less on preventive services as compared to the curative
services. This is not as it ought to be. Curing illnesses of all poor people is an economically
daunting task. The preventive care is inexpensive. Services, like vaccination, innocculation, are
inexpensive ways of presenting illness. Similarly, proper sanitation and the availability of clean
drinking water, in the developing countries also need to be laid greater stress on than is being
done at present. On the community health services, the management of health services by the
professional experts, even belonging to areas outside of health, say, a non-physician auxillary
worker at the grassroots level who is trained to assist the health personnel; and a better use of
the referral system.

2.5 FINANCIAL OUTLAY FOR HEALTH IN THE PLANS

India and most other developing nations have the explicit goal of providing health services to
the entire population by 2000 A.D. But the fact remains that the current spending on basic
public health facilities, in these countries, is very much inadequate for realizing this goal.
Moreover, there is little private spending on low cost public services, like health education,
immunization, etc.
Per capita spending on health is low in the middle-income and low-income countries as
compared to high income countries. In 1990, for instance, India spend about 12 US dollars per
head per year on health care. The percentage of Govt. health expenditure to total expenditure
was 2.16% in India (1985). As income rises, demand for health care rises more than
proportionately. This happens partly because the composition of disease gradually changes
from more preventable infections like cardiovascular diseases. This phenomenon is called
epidemiological transition. The latter types of diseases are very expensive to treat. Thus, in the
developed countries, greater effect in lower morbidity and mortality can be brought about by
preventive measures, which are inexpensive. For instance much before the invention of
38 penicillin, mortality rates had significantly come down in the present day developed or rich
countries, due to the provision of sanitation and basic (or primary) health care services. In the So c i al D e v e l o p m e n t
early 19th century, even those countries had very high proportion of infectious diseases.
Modern medicine played a lesser role in those societies. All this is important to remember, when
one examines the amount of allocation made to preventive and to curative medical care in the
developing countries today.
Another feature of health care facilities in the developing countries is that the funds for such
services are still provided largely by private individuals. In countries like India and Bangladesh,
about 60 to 70 per cent of the total expenditure on health services is provided by private
individuals.
But, in terms of the quantum of services provided, the share of the private sector is likely to be
less, because its services tend to be quite expensive when compared to the services provided
in the government facilities. Actual service output of private and public sector is not available,
at present. No system exists to collect such statistics, systematically.
a) Finance for Health Care Services
Health-financing, by most of the governments in the developing countries, is supported by
general tax revenues. Many countries have social security systems for a section of their
population. For example, in India, the Central Government employees can avail of the Central
Government Health Scheme (CGHS) facility, and the industrial workers in the organized sector
have the benefit of Employees State Insurance (ESI) to meet their health care needs. General
cost recovery and user charges from a very small portion of the government’s revenue for
direct financing of health care services. Fees charged in the government hospitals, in India,
covered less than two per cent of the expenditure on hospitals in 1990-91. This, in fact, fell from
around six per cent in the early seventies.
In the private sector, on the other hand, the physicians and other health personnel are financed
completely by fees for services and other user-charges. In most developing nations, third party
payments and medical insurance is rare, though in some countries, like India, for instance,
medical insurance is gradually making an appearance. In particular, the employees of the public
sector undertaking, and private corporate sector are covered by a number of company-
sponsored insurance schemes. The magnitude of these schemes is not known.
What is the kind of spending and its structure required for the developing countries? For this,
it is essential to estimate that cost of a package of basic health intervention like immunization,
prenatal and post-natal care, and other primary health care interventions. But, these estimates
can vary over time and across regions. In India, there is a general belief that, proportionately,
more is spend on the curative rather than preventive services. But the funds cannot be entirely
redirected from the curative to the preventive services, or from the tertiary to the primary care.
Hospitals are necessary, too. What could be done is that the referral system, which is almost
non-existent, at present should be improved.
If we take the type of the patients that are admitted to hospitals, we find that a large part
consist of those suffering from diarrhoea, gastro-intestinal diseases, respiratory diseases,
tuberculosis, complication from malnutrition, and so on. These diseases can be prevented
easily by laying greater stress on sanitation and preventive public health care, and by
strengthening the primary health centers in the rural areas, local dispensaries in the urban
areas, and the secondary level hospitals (district hospitals). Thus, if we do a cost-effectiveness
analysis for most hospitals in the developing countries, we shall find that although a necessary
expenditure, the hospital system is likely to be less cost effective in comparison to the primary
level facilities and preventive services.
What is the basic reasons for the paucity of funds in the health sector? The main reason seems
to be that in most developing countries, the health care system is highly centralized. Moreover,
the pricing mechanism is very poorly utilized as a revenue-generating process and as a method
to enforce a rational referral system. We shall touch upon this point in greater detail a little later.
Apart from insufficient spending on health care, the quality of services is poor too. One reason
is that health care personnel in the government and public sector are often poorly paid and
poorly equipped in terms of other support facilities. For instance, drug budgets and essential
maintenance expenditure are often not fully met. This happens particularly when there are
budget cuts. Since salaries cannot be cut, any budget cut is met by reducing expenditure on
support expenditure such as medicine, equipment and maintenance. 39
Application of Sociological b) Health Plans and Outlays in India
Concepts
The overall health planning aspiration has oriented itself to being biased towards preventive
public oriented services, with greater emphasis on the rural areas. At least, this is what all
plan documents emphasis. The picture in reality, is very different. The health service in India
is urban-biased, elite-oriented, and curative in nature. Expenditure on health flow a lot to the
urban hospitals. However, some success has also been achieved in the public preventive
services.
c) Achievement in Health After Independence
There has been a significant achievement in the country in the area of health. Smallpox has
been eradicated. Morbidity and mortality due to cholera, malaria and various other diseases
have declined. The Crude Birth Rate (CBR) and Infant Mortality Rate (IMR) have declined to
28.5 (per 1000 population) and 74 (per 1000 live births) as compared to 41.7 and 146 in 1951-61.
The Crude Death Rate declined form 22.8 per 1000 population in 1951-61 to 9.2 per 1000
population in 1993: (SRS). Similarly, life expectancy at birth went up from about 32 years in
1947 to 60 years in 1994. In spite of these achievements, diseases, disability and deaths on
account of several communicable diseases are still high. Several non-communicable diseases
have emerged as new public health problems.
Mortality and morbidity levels have tended to vary across regions (see Table 2.1). The North
Indian States have higher mortality and fertility. These also have higher female mortality. If we
take rural death rates, states like Bihar, UP, Madhya Pradesh and Rajasthan have levels higher
than the national average. Doubtless, economic and sociological factors play a role, and,
what we have discussed in the section on the link between economic development and
health, holds true here. Poverty, low literacy and poor social infrastructure have all
contributed to the prevailing dismal picture.
Although, there is usually a positive relationship between economic development and the
levels of health, it does not hold true in every case. Economically, advanced states like
Punjab, Haryana and Maharashtra have low mortality rates, but so does relatively poorer
Kerala. Indeed, Kerala is a classic case of a state transcending economic constraints, and
showing remarkably high health and social indicators levels.
Table 2.1: Selected indicators of Human Development for Major States

Literacy Rate 2001 IMR Death Birth

Life expectancy Rate Rate
State at birth (Years) Total Male Female (Prov. Est. of the
1986-90 Percent Percent Percent SRS-1998)
(Per thousands)
1 2 3 4 5 6 7 8

1) Andhra Pradesh 59.1 44.09 71 51 66 8.4 22.4

2) Assam 53.6 52.89 72 56 78 10.2 27.9
3) Bihar 54.9 38.48 62 35 67 10.6 31.1
4) Gujarat 57.7 61.29 80 59 64 8.1 25.5
5) Haryana 62.2 55.85 79 56 69 7.8 27.6
6) Karnataka 61.1 56.04 76 56 58 8.0 22.0
7) Kerala 69.5 89.81 94 88 16 6.0 18.3
8) Madhya Pradesh 53.0 44.20 77 51 97 12.6 30.7
9) Maharashtra 62.6 64.87 86 68 49 7.2 22.5
10) Orissa 54.4 49.09 76 51 98 12.2 25.7
11) Punjab 65.2 58.51 76 64 54 7.9 22.4
12) Rajasthan 55.2 38.55 76 44 83 9.0 31.6
13) Tamil Nadu 60.5 62.66 82 65 53 8.0 19.2
14) Uttar Pradesh 53.4 41.60 71 44 85 11.4 32.4
15) West Bengal 60.8 57.70 78 60 53 7.3 21.3

All India 57.7 52.21 76 54 9.2

40
d) Health Plans and Outlays So c i al D e v e l o p m e n t

In terms of expenditure, health includes medical and public health expenditure. Health-related
expenditures include family welfare, nutrition, etc. Health in India is primarily the concern of the
State Government: family welfare, however, is looked after by the Central Government.

The Ministry of Health and Family Welfare, Labour and the Department of Social Welfare are
the agencies at the Centre primarily concerned with health. Other specific programmes like the
Minimum Needs Programme, which has nutrition as a component, also have a bearing on the
health policies.

Expenditures on preventive campaigns such as those on malaria, family welfare, etc. come
under the plan expenditure category of the government expenditures. Share of total government
outlay on the health-related matters rose from 2.7 per cent of the plan outlay in the First Five
Year Plan to 3.9 per cent in the Sixth Plan. As a proportion of national income, expenditure on
health-related items has increased from 0.42 per cent in first five year plan to 1.6 per cent in
1991-1992.

In the Seventh Plan, health outlays met by the central expenditures accounted for 10 percent of
the total health outlay. The centrally-sponsored health programme accounted for 16.4 percent,
and those funded by the States or Union Territories accounted for 73.5 per cent. In the Seventh
Plan itself of the total planned outlay in the health sector, outlay on total health (all components
considered), accounted for 22.8 percent of the total outlay, family planning accounted for 21.8
per cent, nutrition for 11.7 per cent, and water supply and sanitation for 43.7 per cent. Among
the components or the total health, outlay on the control of communicable disease account for
6.9 per cent, medical educations and research and training for 7.3 per cent, and hospitals and
dispensaries for 8.6 per cent.

The total outlay for the central health sector and family welfare programme during eighth five-
year plan is given in Annexure 1 and 2.

There has been very little analysis of where the government health rupee is going. Studies
indicated that largest part of government spending goes towards curative care and 53.3 per
cent is attributed to urban based services, whereas only 23 per cent of population were in
urban areas. There is, however, a clear trend towards increasing expenditure on rural primary
health care services especially MCH services and family welfare programmes. The outlays
and expenditure under the family welfare programme is given in Annexure 2.

The breakdown of government expenditure by Programme category is given in Fig. 2.1 below.

Fig. 2.1: Breakdown of governmental expenditure by programme categories

41
Application of Sociological In conclusion, we can make the point that the Planning Commission, which has stressed
Concepts
public preventive services, and the Health Ministry, which has usually emphasized urban
curative facilities, have sometimes appears to have worked at cross purposes. Another point
we can make is that family welfare has assumed increasing importance, especially with respect
to expenditure. Finally, the share of the government budget expenditure going to health has
not seen any dramatic increase.

2.6 STATE/CENTRAL GOVERNMENT’S ROLE IN

HEALTH PLANNING
Since “health” is an important contributory factor in the utilization of manpower, the Planning
Commission gave considerable importance to health programmes in the Five-Year Plans. For
the purpose of planning, the health sector has been divided into many sub-sectors.

To give effect to a better coordination between the Centre and state Government, a Bureau of
Planning was constituted in 1965 in the Ministry of health. The main function of this Bureau is
compilation of national Health Five-Year Plans. The Health Plans is implemented at various
levels, e.g. Centre, State, District, Block and Village.

At the Centre: The Official “organs” of the health system at the national level consist of:
(1) The Ministry of Health and Family Welfare; (2) The Directorate General of Health Services;
and (3) The Central Council of Health and Family Welfare.

At State Level: The State Ministry of Health is headed by a Minister of Health and Family
Welfare and a Deputy Minister of Health and Family Welfare. The Health Secretariat is the
official organ of the state ministry of health and is headed by Deputy Secretaries.

2.7 FACTORS INFLUENCING STATE’S ABILITY FOR

FINANCING HEALTH CARE
A large number of factors influence the states’ ability to fund health facilities adequately, to
maintain a certain nationally desired level of quality and quantity of services. Important
among these are: the states’ capacity to raise revenues from the taxes assigned to them, the
share they get in certain sharable taxes levied by the Central Government; and various types
of general purpose, specific purpose grants they get from the centre.

All these factors set a broad constraint on how much a state spends on health care. Some of
these factors are in the control of the state government and the rest are determined by the
practices followed by the Central Government and some independent agencies, such as the
Finance Commission.

The only factor in the hands of state governments is its power to raise revenue by way of
taxes, rates and hospital fees. Here too poorer states can’t raise as much as richer states.
Since the maximum difference in income levels is 1 to 3, such high differences exist even in
the ability to spend on health care. The only way to reduce inter-state differences is by
inducing more Central funds into the poorer states. In recent years, the Centre has been
trying to give relatively more grants to the poor states. The vast differences in the ability to
provide health care is the main reason for the Central Government directly intervening in
some nationally important disease control programmes, immunization programmes and in
the construction of the rural-health facilities. The poor states would not have been in a
position to spend adequate amount on all the activities in which the Centre is directly
involved.

Further, unlike many less developed countries, the impact of foreign aid on the states’
spending on health care has been insignificant. Until recently our reliance on foreign aid has
been minimal. Over 90 percent of our national investments have been funded by internal
savings. What foreign aid we received went for economic infrastructure, and very little for
social services like education, health, housing and urban development. For instance, out of
the total outlay of the states on externally aided projects, the share of economic infrastructure
was about 84 percent during the Sixth Plan (1980-85), and 75 percent during the Seventh Plan
42
(1985-90). Thus, foreign aid has not been instrumental in enhancing in any significant way So c i al D e v e l o p m e n t
the states’ ability to spend on the health sector.

2.8 STATE VERSUS THE MARKET IN THE HEALTH

CARE
We have talked of health care and its provision. The question now arises: what is the best
mode of the provision of health care? Does the government do a better job of provision or
does the private sector do it better? Should there be a mix of the two? If health care is to be
provided by the private sector, should the government regulate the private sector? And,
then, to what extent? These are some of the issues that we discuss in this section.

a) The Arguments for the Market

Two main arguments have been put forward as justification for the market. The first is that
the market provides incentives, and utilizes the self-interest of people in a way no
government could hope to match. Why is self-interest important? According to Adam Smith,
who may be regarded as the founding father of economics, people’s self-interest often makes
them work towards an end which was no part of their original intention. Suppose, I am a
baker. I look after my self-interest, and want to earn money by selling bread. I do not take
your interest explicitly into consideration. However, you enjoy your breakfast with my bread,
which, of course, was not part of my intention. Smith calls this the principle of the invisible
hand in his book, “ An Enquiry into the Nature and Cause of the Wealth of Nations”,
published in 1776.

Thus the market system provides incentives, and taps peoples’ self-interest. The other
argument is that the market economizes on information. The market system reduces the
cost of gathering, processing disseminating information. There are hundreds of units in
an economy. There are the suppliers of goods, producers of goods buyers, middlemen
speculators, and so on. All these people are scattered. The market it is contended,
performs the task of helping to exchange information about who wants to sell (what and
how much), who wants to buy (what and how much), what are the prices offered, and so
on. The price-system serves to relate the demand to the supply, and brings about a
coincidence of wants.

However, there exist certain conditions, which must be fulfilled in order for the market to
work. First the markets should be competitive in the sense of the inability of any particular
seller or buyer or group of sellers or buyers to substantially influence prices and the
quantities produced and sold. Competitive market result in situation, which the economics
call pareto optimal. This means a situation where it is impossible to make someone better off
without, at the same time, making someone else worse off. Second there must not be
externalities in production and/or consumption. Externalities arise, where action by one
person affects the benefits, for better or worse, the action of other agents. If you train
workers, and I get to employ them, then I derive external benefits from your action, which, I
do not pay for. If my factory units produced smoke, and pollute the atmosphere, then the
people around the factory get external harmful effects, which means that they get a polluted
atmosphere through my action. We shall see, in due course, that externalities provide one of
the strongest arguments for intervention by the State, which brings us to the role of the
State. But, first, since we are talking of health, a word on the nature of the commodity, health.

b) Health as a Commodity

To discuss health, we must note that goods are of two types --- Public and private. Private
goods are where consumption by one person excludes the use by someone else at the same
time, that is, where what is called the ‘exclusion principle’ applies. Your pen is an example. So is
your shirt. Things are public goods, when the exclusion principle does not apply. National
Defence is an example. So are television programmes and roads. Everyone can use them
together. You cannot stop others from using the road. Some goods are public only to an extent.
Beyond that, these become private, and they are called local public goods.

The question is, what kind of a things is a health? Here, we might point out that health is
not commodity, but health care is. Health has only use-value, but no exchange value. You 43
Application of Sociological cannot buy or sell health: you can exchange health care or medical care. Right. So, is health
Concepts
care private or public? Your benefit from your doctor is a private affairs (the doctor’s
services), but public health programmes like disease-control sanitation, etc. are public goods.
Sometimes, a single service can be both private and public at the same time. For instance, if
our doctor vaccinates you, that single shot is a private service but it leads to reducing the
level of risk for everyone, and is, hence, a public service. Thus, we see that health care is a
complex kind of commodity.

Another feature about health care is that it has to do with the uncertainty associated with it,
particularly in relation to heavy expenditure of catastrophic episodes. You do not know when
you will need health care. Moreover, health care can provide utility only when you get some
prior disutility through ill-health. So the need for health care is an uncertain, quirky thing.
Furthermore, you do not know how much of health care you need. You also cannot determine
the quality of health care you are getting. You enter into an agency relationship with the
provider of health care. We shall discuss all these aspects in greater detail in the subsequent
section. Suffice it to say here, that the whole question of medical ethics and the role of the
state is linked to these aspects of the nature of health care as commodity.

c) The Role of the State

The traditional role of the State has been seen to be the provision of public goods and
correcting the externalities. The State has to provide the public health programme, sanitation,
clean drinking water, nutrition, etc. particularly in the poor countries. Another traditional role
of the State in health stems from the argument that health should be treated as a basic right of
people, much like justice and freedom, and must; like these, be provided by the State. But the
question is, huge amount of resources being necessary, is health care really a right?
Resources cannot just be squandered. Some economists have argued for the State because
of the uncertainty being associated with health care. They have urged the development and
provision of medical insurance, for instance.

d) Market Failure and the State

‘Market Failure’ occurs when externalities are presents, competitive conditions are absent,
and pareto optimality does not hold. In these conditions, the State has a positive role to play.
However, when the State is inefficient, there are large political costs of the government
interventions. The situation is sometimes described as the ‘government failure’.

The government interventions in health care market promote efficiency by correcting the
divergence of private and social benefits under private health care.

Check Your Progress 2

1) What are the main arguments in favour of resources allocation by the market?

.............................................................................................................................................

.............................................................................................................................................

.............................................................................................................................................

.............................................................................................................................................

.............................................................................................................................................

2) What do you understand by ‘market failure’?

.............................................................................................................................................

.............................................................................................................................................

.............................................................................................................................................

.............................................................................................................................................

44 .............................................................................................................................................
 So c i al D e v e l o p m e n t
2.9 LET US SUM UP
In this unit we have learnt about social development, indicators of social development,
government planning for development, impact of economic planning and health financing,
economic development indicators, Financial outlay from health in the plans and role of state
and centre in health planning.

The main focus of this unit is to understand the role of government planning and policies on
health. This is an important unit for the students of medical profession.

2.10 ANSWERS TO CHECK YOUR PROGRESS

Check Your Progress 1

1) i) Eradication of poverty

ii) Improving productivity

iii) Provision of minimum needs

iv) Development of human resources

v) Raising status of women

vi) Improving technical and managerial aspects.

2) i) Propulation

ii) Family formation

iii) Families and households

iv) Learning and education services

v) Income earning activities

vi) Distribution of income, consumption and accumulation

vii) Social security and welfare services

viii) Health services and nutrition

ix) Housing facilities and its environment

x) Public order and safety

xi) Time use

xii) Leisure and culture

xiii) Social stratification and mobility

Check Your Progress 2

1) Refer Section 2.8(a).

2) Refer Section 2.8(b).

2.11 FUTHER READINGS

Berman, Peter, (1991), Health Economic, Health Financing and Health Needs of Women and
Children of India, Ford Foundation.
45
Application of Sociological Bhaduri, A. (1990), “Emerging Challenges in Nursing Education”, Nursing Journal of India, Vol.
Concepts
LXXXI, No. 4, (Apr. 90).

Bose, A., Desai, P.B., Mittra, A., Sharma, J.N. (Eds.) (1974), “An Alternative Approach to India’s
Development”, Population in India’s Development 1947-2000, Indian Association for
the Study of Population, Delhi.

Bottomore, T.B. (1972), “Change Development, Progress”, Sociology – A Guide to Problems

and Literature (revised Ed., Third Impression), Blackie and Son (India) Ltd.

Department of Family Welfare, GOI (1994), “Population Policy, Planning and Programme
Framework”, India: Country Statement, International Conference on Population and
Development, Cario.

Fairchild, H.P. (Ed.) (1964), Dictionary of Sociology, Littlefield, Adams & Co., Paterson, New
Jersey, U.S.A.

Gore, M.S. (1988), “Social Development: The Asian Experience”, Bharatiya Samajik Chintan
(Special Issue), Vol. XI, No. (1-4), Mar-Dec.88, Indian Academy of Social Sciences,
Allahabad.

International Encyclopaedia of Social Sciences, Vol. 15, 1972.

Jeffery, Rager, (1988), The Politics of Health in India, University of California Press, Berkeley.

Joshi, P.C., Mahajan (Ed.) (1992), Studies in Medical Anthropology, Reliance Publishing House,
New Delhi.

K. Park, (2002), Park’s Text Book of Preventive and Social Medicine, 17th edition,
M/s Banarsidas Bhanot Publishers.

Luthans, F. (1977), Organisational Behaviour, McGraw Hill, New York, p. 25.

Mehta, S.R. (1992), Society and Health – A Sociological Perspective, Vikas Publishing House
Pvt. Ltd.

Mhetras, V.J. (1966), “Diagnosis and Evaluation”, Understanding Social Caste Work,
Manaktalas, Bombay.

Nayar, P.K.B. (Ed.) (1982), Sociology in India – Retrospect and Prospect, B.R. Publishing
Corporation, Delhi-52.

Prasad, L.M. “Nature of Behavioural Science”, Organisation Theory and Behaviour, Sultan
Chand & Sons, 23, Daryaganj, New Delhi.

Reinke, W.A., (1988), Health Planning for Effective Managment, Oxford University Press;
Oxford.

Strauss, R. (1957), “The Nature and Status of Medical Sociology”, American Sociology Review,
22 (April) pp. 200-04.

Wooldridge, P.J. et. al. (1968), “The Behavioural Sciences and the Health Related Professions”,
Behavioural Science, Social Practice, and the Nursing Profession, The Press of Case
Western Reserve University, Cleveland, Ohio-41106.

World Bank Policy Paper, 1987, Financing Health Services in Developing Countries, World
Bank; Washington.

46
 Annexure 1 So c i al D e v e l o p m e n t

Eighth Plan Outlay ---- Health Sector

(Rs. Crores)

Sl. Programme States/UTs. Centrally Central Total

No. Sponsored Schemes
Programmes
1 2 3 4 5 6

1) Minimum Needs Programme/Rural Health 2250.38 - 1.00 2251.38

2) Control of Communicable Diseases 1031.00 14.75
3) Hospitals and Dispensaries - 94.00
4) Control/Containment of Non-communicable
Diseases - 85.00
5) Medical Education the Training 3525.44 - 267.00 5324.54
6) ICMR 124.50
7) Indian System of Medicine and
Homoeopathy 5.00 83.00
8) ESI - -
9) Other Programmes 20.00 74.75
Total 5775.92 1056.00 744.00 7575.92

47
Application of Sociological Annexure 2
Concepts
Outlays and Expenditure Under the Programme
(Rs. Crores)

Period Outlays Expenditure

First Plan (1951-55) 0.65 0.14

Second Plan (1956-61) 5.00 2.15
Third Plan (1961-66) 27.00 24.86
Annual Plan
(Inter Plan) (1966-69) 82.90 70.46
Fourth Plan (1969-74) 285.80 284.43
Fifth Plan (1974-79) 285.60 408.98
Annual Plan (1978-79) 111.80 107.60
Annual Plan (1979-80) 116.20 118.52
Sixth Plan (1980-85) 1309.00 1475.73
Seventh Plan (1985-90) 2868.00 3105.21
Annual Plan (1990-91) 675.00 949.89
Annual Plan (1991-92) 749.00 1022.53
Eighth Plan (1992-97) 6500.00
Annual Plan (1992-93) 1000.00 1190.40
Annual Plan (1993-94) 1270.00 1522.62*
Annual Plan (1994-95) 1430.00

* Anticipated

48