described the colonial context in which the professionalization of obstetrics emerged in tandem with a resigned acceptance of midwifery, I now move quickly through time to the policies and programs of the twentieth century which have informed the structure of public MCH services throughout much of the postcolonial era. In this descriptive chapter I hope to provide a general sketch first of the official structures of health care in India and in Tamil Nadu and then of the actual landscape of MCH care in Kaanathur-Reddikuppam and Nochikuppam. This chapter is intended to provide a basic framework through which to understand the more ethnographically and theoretically engaged chapters which follow. (See Appendix II for an outline of the official structures of rural and urban MCH institutions and practitioners in Tamil Nadu for 1995 that are described in this chapter.)
THE OFFICIAL STRUCTURE: THE BHORE COMMITTEE REPORT
A four-volume report by the colonial government’s Health Survey and Development Committee was published in 1946, known as the “Bhore Committee Report” (Government of India 1946) after the chair of the committee, Sir Joseph Bhore. This committee drew heavily on the recommendations of the Indian National Congress’s National Planning Committee, which was established under Jawaharlal Nehru’s guidance. The Bhore Committee Report attempted to analyze the state of health care in India and to make recommendations for the improvement of health care services in India overall.1 Drawn up on the eve of India’s independence in 1947, the Bhore Committee Report became the template for the structure of health care services in India in the postcolonial era, as reflected in the postcolonial government of India’s Five-Year Plans. The actual implementation of the institutional structures recommended in the report were initiated ten years following its submission. Many of the basic elements of this structure remain in place today.
The Bhore Committee Report called for the establishment of a socialist system of health care, emphasizing public health services and preventative medicine for the rural poor. Madras Presidency had been the first presidency to pass a Public Health Act in 1939, which put the responsibility for the provision of public health services, including maternal and child health, in the hands of the state. With the Bhore Committee Report, public health became the responsibility of the national government, although the implementation remained in the hands of the individual states. The model envisioned in the Bhore Committee Report was a three-tiered referral system, with primary health care services emphasizing preventative care available in primary health centers (PHCs) at the village level,2 secondary curative services available at the district level, and tertiary services available in the urban centers, often attached to medical teaching and research institutions. Rural women seeking allopathic services during childbirth were encouraged and expected to use this three-tiered system according to their needs.
Following the Victoria Fund’s approach, the Bhore Committee Report also posited that the hereditary dais would inevitably remain central to the care of Indian women during childbirth, at least in the short term. The report, therefore, supported efforts to provide basic training to the hereditary dais rather than trying to replace them with a new cadre of midwives. Government support of such dai-training programs continued in independent India, and these programs were included in the government of India’s Five-Year Plans.
In addition to Madras Presidency’s early move to take responsibility for public health services in general, the Madras Presidency’s Department of Public Health also took an active role in overseeing the training and deployment of auxiliary health workers specializing in MCH care, known officially as “health visitors.” In 1938 the Department of Public Health took over these responsibilities from preexisting voluntary organizations such as the India Red Cross Society. Based on a model borrowed from Britain, health visitors were women who were to be trained in such subjects as elementary physiology, home nursing and first aid, household management and dietetics, maternity and child hygiene, and character training and mental hygiene.3 The Bhore Committee Report envisioned that, after completing their training, these health visitors would be appointed to medical institutions serving women and conduct outreach work in the communities surrounding these institutions to provide basic health services and educate others on the merits of these topics.
It was, however, an ongoing struggle to make the establishment of such a cadre of auxiliary health workers a basic structure of the postcolonial public health service sector. Ever since the implementation of the three-tiered primary-health-based structure, state governments have faced great difficulties in convincing urban-trained doctors to take up employment in rural hospitals. This made it politically difficult to establish a cadre of auxiliary medical staff attached to primary health centers who could serve as community health workers, since some felt that the presence of such auxiliary health workers would be an impediment to sincere efforts to staff the PHCs with more-qualified doctors. There were also concerns that these auxiliary workers would begin to work independently of the doctors’ supervision, and that the rural poor would thus be served by under-qualified “quacks.”4
By the mid-1970s, however, the multipurpose-health-worker (MPHW) schemes, modeled after the Soviet system, gained widespread acceptance and were implemented in many Indian states. These schemes called for both a male and female MPHW to be attached to each PHC. The male MPHWs were responsible for several vertical public programs, such as the leprosy, tuberculosis, and malaria programs, in addition to family planning. The role of female MPHWs has, however, been more limited in scope. Female MPHWs’ primary task has been to educate women, collect census-type data, and provide services in the areas of family planning and maternal-child health care more generally. As I discuss in Chapter Five, the family-planning interests and services have largely overshadowed all other aspects of MCH care in India since its independence.
MCH CARE STRUCTURE IN TAMIL NADU IN 1995
Rural Tamil Nadu: The Official Structure for Public MCH Care for Childbirth
This combination of the three-tiered public hospital structure, MPHWs, and trained (and untrained) hereditary dais formed the basis of the official rural public health service structure for MCH care in Tamil Nadu during my research in 1995. It must be underscored that the official structure does not always represent the actual structure of MCH care services in any given area at any given time. What follows in this section is an account of the official structure provided by the Tamil Nadu Department of Public Health.
In 1995 the population of Tamil Nadu was approximately 58 million.5 There were twenty-three districts. The city of Madras made up one district and the remaining districts comprised both urban and rural components. Each district had approximately fifteen to twenty “development blocks,” each serving a population of approximately one million.6 Within each development block, there was one PHC for every 30,000 people. In 1995 there were 1,416 PHCs in Tamil Nadu. Each PHC was to have at least five beds. The majority of the PHC services were outpatient, so few beds were deemed necessary. These PHCs were supposed to be staffed with two doctors (one female and one male), some paramedics, a pharmacist, and health support staff. Each PHC was to have one “sector health nurse” (previously called a “lady health visitor”) supervising six “village health nurses,” or VHNs (previously called “auxiliary nurse midwives” [ANMs]), the rural equivalent of urban female MPHWs. VHNs were responsible for MCH care, while male multipurpose health workers attached to the PHC were responsible for overseeing such things as public health, control of epidemics and specific diseases, and public emergencies. Each PHC was to have approximately six “health subcenters” (HSC) under its domain, which were overseen by the VHNs. In 1995 there were 8,681 HSCs in Tamil Nadu. In the plains areas where transportation was relatively easy, there was to be one HSC for every 5,000 of population. In areas with hilly terrain where transportation was more difficult, there was to be one HSC for every 2,000 to 3,000 of population. The VHNs attached to these HSCs were trained to provide essential obstetric care, including prenatal care, assistance with deliveries, postnatal care, family planning, and basic first aid for mothers and children. They were trained to detect emergency obstetric cases and refer those to the subdistrict-level hospitals,
