Placebos are better
DESPITE its eminent contributors, publisher and volume, Reaching India's Poor seems to be only rationalising the diminishing role of the state in the public health sector. The introduction says that government programmes have been to unable to reach the poor while the nongovernmental organisations (NGOs) have successfully addressed their problems. The current shifts in health policy favouring the privatisation of the health sector is proof of the government's inability to meet the country's health requirements all on its own. The pressure from the World Bank and the International Monetary Fund to cut down state expenditures on social sectors have not been mentioned in the context of the Indian government's health policy.
There are 12 case studies of NGO projects, including a section in which the key issues have been discussed. It glorifies the voluntary sector and projects it as the repository of India's pluralistic society. The key areas identified are "health transition" and "emerging challenges" (which implicate AIDS), "reproductive health" and the "changing role of NGO's" (which indicates working with the government). But it does not take into account the overall context and the historical background of these issues.
Devoid of historical and contextual analysis, the effort becomes more of the propagandising of a viewpoint rather than a "systematic" analysis of NGO experience, as claimed by its editor.
The 12 case reports of voluntary health projects are largely descriptive, and do not present an analytical perspective of successes and achievements. Information on users is scant, and the views of the recipients are conspicuous by their absence. Of 12 projects, 2 are on family planning, 2 focus on maternal and child health, and the 8 others provide some degree of integrated and comprehensive healthcare.
A large number of voluntary groups in India have been documented as working in the health sector. Of these, surely many more than 12 have achieved various levels of success? The criteria for the selection of the projects are not explicit. However, the majority are generously funded by international agencies, and are broadbased, for they have inputs other than for promoting health alone.
Some are attached to government institutions like the CMC in Vellore and the KEM in Pune, and essentially focus on family planning and maternal and child health. The fact that this in itself may be the cause of their "success", or that the biased selection and lack of comparison with unsuccessful projects makes their conclusions regarding issues of success methodologically baseless, does not seem to worry the editor.
After repeatedly cautioning the readers about the problems of generalisation from their kind of database, the authors proceed to draw -- generalisations. For example, in the 3rd section, Berman and Dave conclude that voluntary groups are "more efficient" than public services costwise, without comparing the actual activities, the coverage, and the type of services provided by the 2 kinds of institutions. They generalise on the basis of 4 not-so-complete case reports and appear to be more keen to legitimise "user fees" and "health insurance" rather than in examining the limits of these strategies in the context of the poorest.
The book also raises issues such as people's participation, community health volunteers, organisational prerequistes for success, upscaling, and measuring the success of NGOs. Most of the authors write without relating themselves to the case reports. Some raise their pet horses without even systematically presenting the workshop discussions, which are supposed to have augmented their understanding. Obviously, the authors of this section did not study all the projects themselves. As a result, the book does not hold together.
Apart from lacking methodological rigour, there is a lot of disparity in the articles included. The issues that the book never confronts include: if NGO experience has to be channelled into public sector activity, then it is not enough to identify the positive elements of NGO experience alone. It calls for an analysis of its limits, and what will have to be done to those if the positive experience of the NGOs has to be assessed. Methodologically and analytically weak, the book fails to deliver what it promises.
---Imrana Qadeer is head of the Department of Community Medicine, Jawaharlal Nehru University.