Who coined the term Aamchi Mumbai

The contribution of homeopathy in India

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1 Knowledge The contribution of homeopathy to care in India Part 1 By Martin Dinges .... Summary In India, homeopathy has the strongest position worldwide within a health system. However, this itself is in a catastrophic state due to decades of neglect. The contribution of homeopathy to care varies greatly from region to region. Due to the available information, the main focus is on medical homeopathy in urban practices and primary care within the public health system, which, however, also plays a certain role in rural areas. After a privatization euphoria during the 1990s, the public health system is now being expanded again, creating many positions for homeopathic doctors. Keywords Homeopathy in India, public health, homeopathic doctor's offices, doctor-patient relationship. Summary Homeopathy in India has the world's most powerful position within a health system. This is, however, in a catastrophic state because of decades of neglect. The contribution of homeopathy to supply varies regionally. Based on the available information mainly medical homeopathy in urban clinics and primary care within the public health system is in focus, though this also plays some role in the country. After privatization euphoria during the 1990s now the public health system is again expanded, which develops many jobs for homeopathic doctors. Keywords Homeopathy in India, public health system, homeopathic surgeries, doctor-patient relationship. Samah samae samyati: the simile principle is well known in India. One can look forward to the successful institutionalization of homeopathy in this country. Last but not least, this results in good opportunities for an internship or an internship, e.g. German physicians on site at one of the almost 190 Indian colleges with an attached hospital ward, which are used for university-level training. In addition, the high proportion of almost 14% of all doctors in India who are homeopaths remains impressive, even if one also takes note of the faster growth of Ayurveda and its institutions during the last generation 1. It remains, however, beyond such rough indicators to determine what contribution homeopathy can and does to health care in India under the special conditions of the very developed medical pluralism there. At the same time, a health policy issue is taken up that is also becoming increasingly important in the Federal Republic of Germany: Health services research asks about the appropriate fit between the health needs of the population or selected population groups and the structures of the health care system.2 In this respect, one could possibly also use Indian experience learn something in the Federal Republic. The situation in India is to be presented here primarily with regard to the offer of homeopaths and with the aid of examples. The selection is based on the state of research and is otherwise due to the author's ability to inspect practices, outpatient clinics, hospitals and research institutes in India in recent years. 4 Dinges M. The contribution of homeopathy in India. ZKH 2011; 55 (1): 4 18

2 Brief sketch of the current state of the Indian health system For this purpose, it is important to characterize the state of the Indian health system a good 60 years after independence. The experts agree that it can only be described as catastrophic: The country has now invested much less in this area for two generations than developing countries, whose per capita income is comparable. Instead of at least 2 3% of the gross national product, only just under 1% was spent on the public health system. 3. Many supply projects exist on paper or, at best, as infrastructure, but they do not work. Empty health stations testify to this, as do campaigns that have been adopted and have not been implemented for years. Accordingly, private supply is now dominant, and its importance has even increased since the liberalization spurts of the 1990s. Currently, over 90% of private doctors, over 93% of hospitals, but only 64% of private hospital beds from% of the urban and rural population use the private sector for outpatient cases5 % have been 6. Above all, the poorest and poor turn to suppliers in what is in fact a completely unregulated market. According to the Indian Constitutional Court, this is just as illegal as many slum settlements themselves, but it is growing and thriving just like them. As is well known, the number of slum dwellers is increasing twice as fast as the already rapidly growing Indian population. This galloping urbanization process suggests a distinction between at least 3 medical markets: a rural one with a predominantly very poor population (and only very few affluent customers who can resort to the urban supply), an urban one for the more affluent few and the urban market for the many lower-class patients and the slum dwellers. The private medical market for the urban poor In this urban medical market for the poor, non-academic healers offer their services. Some have rudimentary knowledge of Ayurveda or homeopathy from family tradition, after an assistantship or a discontinued training. As a rule, they treat their patients in a friendly manner, take their time and use powerful drugs or therapies, including conventional medicine. The short distances to the practice, the informality of interaction and the social proximity are essential reasons for the claim, because avoiding loss of time and restoring workforce as quickly as possible are essential for the survival of the patients, many of whom earn their living as day laborers: you rarely have reserves for loss of earnings during several days of illness plus medical bills, if they have reserves at all 7. The private medical market for the affluent urban population There is also a thriving private medical market for the affluent. Last but not least, it includes top medical services offered by highly qualified doctors, often with foreign studies and experience, who work under good conditions in the very modern facilities of some internationally operating hospital groups. The country also advertises that it can offer difficult treatments and operations at much cheaper rates than in the USA, and is successfully trying to find the appropriate, financially strong clientele with clinic locations near international airports. German women, mostly above the 40-year limit, have the largest market share of all guests in wellness tourism. There is no such homeopathic tourism. The expectations of wellness customers are aimed at offers such as Ayurveda, a medicine that they tend to associate with the special spirituality attributed to India. Homeopathy imported from Germany does not correspond to these ideas. The public health sector The public health sector is smaller, but in principle, as in most developing countries, claims to provide basic services for the entire population, especially the poor. In addition, it has developed very differently depending on the state that has the competence for health policy. Indian states with more developed public health systems, e.g. in avoiding child mortality, significantly better results than other countries 10. This also applies, although here the poor, but guaranteed pay of the employees is often the same as elsewhere in the Indian thing M. The contribution of homeopathy in India. ZKH 2011; 55 (1):

3 Administration and sloppy completion of tasks in schools leads, if not at all, to absence from work: Some try to earn a second income while on duty 11. The health stations are often completely inadequate with medication or equipment. 12. Medicines are used not infrequently used inappropriately by health workers or carers: antibiotic therapy lasting only 2 days is one of the many reported examples. The sale of medicines provided free of charge by the state, which is of course forbidden, is another common allegation of abuse. The local population often has little else to do, apart from switching to the private sector, than to pay for better or worse if they want to receive a service at all. The quality control of care and the verification of the staff presence by the health administration are completely inadequate, as the higher-level batches often also have a greater interest in supplementing their low salaries than in helping the population13. In addition, the public sector is often deprived of patients described as distant, bureaucratic and completely disinterested in dealing with the sick person and unwilling to enter into dialogue. The health market as a mirror of social differences Overall, the medical offer reflects the extreme social inequalities (Tab. 1): a massive undersupply of the large majority of the population of the poor due to malnutrition, inadequate water supply and, above all, illiteracy, especially among the Women, a poorer nutritional and nutritional table. Table 1 Population, poverty, literacy and public health care in India 1951, 1991 and population Proportion of the urban population (in%) Literacy rate (in%) Population below the poverty line (in%) Total, 9 25.0 27, all 18.33 52.20 65.49 men 27.16 64.13 75.96 women 8.86 39.28 54, all 54.9 36.0 26.1 rural population 56.4 37, 3 27.1 City population 49.0 32.4 23, Number of Primary Health Centers Number of Community Health Centers Number of allopathic doctors (registered by Med. Counc. Of India) Doctors per inhabitant Dinges M. The contribution of homeopathy i n India. ZKH 2011; 55 (1): 4 18

4 has health status and has much lower health resources; this undersupply affects the Indians living in the countryside in particular; There are strong regional differences between relatively affluent and poorer regions as well as between states with health policies that have often been serious for decades, e.g. Kerala and other countries, which in this field can only be characterized as examples of state failure 14. These regional disparities have been increasing since the beginning of the economic boom in the late 1990s. Is privatization a way out? A few years ago, a report initiated by the World Bank and the WHO called for the privatization of the previously publicly organized state health care 16 in India. This should help to remedy the abuses described. However, states that have taken steps towards privatization have now found that only the supply of the more affluent has improved slightly.17 On the other hand, a large part of the population is even worse off than before: it becomes even stronger with a more market-oriented organization of supply marginalized. That is not surprising, because the market-like organization of health can only serve needs, i.e. needs that have been registered in the market with banknotes. Anyone who does not have the banknotes signal will no longer be noticed. As opposed to an often ideologically excessive market liberalism, the realization is now gaining ground that public-private partnerships could be a solution 18. The situation is still extremely unsatisfactory, because a health system that is supposed to provide services against the background of so much poverty , but is characterized by ongoing underfunding by the public sector, it is very difficult to even begin to achieve one's goals. After all, the quality of homeopathic treatment depends on the care context. Against this background, both the public measures to improve the offer and the private, philanthropic initiatives must be taken into account. Regional comparison of homeopathy in India First of all, it should be remembered that homeopaths in India can and must offer a much wider range of health services than in Germany. The spectrum of diseases is larger, since in addition to all the common symptoms in our country, tuberculosis, cholera, typhoid, malaria, meningitis, dengue fever etc. also occur frequently. In addition, certain diseases are treated homeopathically because expensive drugs are not available or affordable locally for many patients, such as insulin for diabetes. Finally, reference should be made to locally specific diseases such as the seasonal fever, which opens up special treatment options for homeopathy because of its symptom-related approach 19. Known indications are used on site 20. Development has varied regionally since the beginning First of all, their geographically very different distribution in India should be remembered. One of the first more thorough (English-language) articles on homeopathy in India showed the status up to the 1960s 21. A very clear focus, as since the 19th century, was Bengal. This refers to the continuing history of the spread of homeopathy in India 22. In the then British administrative capital Calcutta, contacts with Europe were particularly strong and cultural life flourished. The medical innovations were also willingly taken up here. This was especially true for homeopathy, which is considered modern and which came from Germany, which is considered to be highly developed. In the course of the 19th century, a compact core of homeopathic doctors, publishers and training centers developed locally, partly with the strong support of laypeople 23. From Calcutta, homeopathy spread primarily along the great courses of the Ganges Basin in north-east India. There were also other local starting points. Lahore is best known, today in Pakistan, where the Transylvanian-born homeopathic doctor Dr. Johann Martin Honigberger () practiced in 1839. A number of places close to the coast, mostly in the south, such as Mangalore, which European missionaries or healers reached directly by sea, remained significant in the long term. Some founded medical wards there, some of which to this day 24. During the 1920s at the latest, it was increasingly a combination of British officials or judges (and their wives) and lay healers or doctors who led to the establishment of the first homeopathic practice on site. However, none of these places, even Bombay or Madras, the other two regional metropolises, could demonstrate the importance of Bengal as a cultural center of British In-Dinges M. The contribution of homeopathy in India. ZKH 2011; 55 (1):

5 Fig. 1: Map of the Indian states and union territories. AN Andaman and Nicobar Islands, AP Andhra Pradesh, AR Arunachal Pradesh, AS Assam, BR Bihar, CG Chhattisgarh, CH Chandigarh, DN Dadra and Nagar Haveli, DD Daman and Diu, DL Delhi, GA Goa, GJ Gujarat, HR Haryana, HP Himachal Pradesh, JK Jammu and Kashmir, JH Jharkhand, KA Karnataka, KL Kerala, LD Lakshadweep, MP Madhya Pradesh, MH Maharashtra, MN Manipur, ML Meghalaya, MZ Mizoram, NL Nagaland, OR Orissa, PB Punjab, PY Puducherry, RJ Rajasthan, SK Sikkim, TN Tamil Nadu, TR Tripura, UA Uttarakhand, UP Uttar Pradesh, WB West Bengal (West Bengal). achieve this. This is also the reason why a large part of the publications on homeopathy until the 1930s were published, if not in English, then almost exclusively in the Bengali language.25 However, this limited their scope and effectiveness at the same time. In any case, against this background it is easy to understand that the first official recognition of homeopathy took place in Bengal in 1937. For the Indian Union this lasted until 1974 and was bought with the recognition of lay healers as registered healers 26. The health policy goal was a uniform and binding state register of those entitled to therapy. The regional presence continues to be very uneven Nowadays homeopathy continues to have a regional focus (overview of the Indian states Fig. 1). It is still particularly weak in the extreme northeast of India, beyond the country of Bengal, which is now divided into the Indian state of West Bengal and the state of Bangladesh. However, in Shillong in Meghalaya (north of Bangladesh), the Central Council of Research in Homeopathy under the leadership of Dr.Eswara Das, the former director of the National Institute of Homeopathy in Calcutta, planned a new national research institute. It should also give homeopathy additional momentum in these somewhat remote countries 27. A highly specialized, orthodox medical institute already operates on the same campus; an Ayurveda clinic is also planned, so that the best conditions for practiced medical pluralism also exist here in research. At the same time, these states are currently using the possibilities of another central government campaign to set up positions for health workers trained in homeopathy, who are supposed to close the supply gap below the training level of full medical practitioners28 Developments are often very small-scale. Systematic research on the spread of homeopathy since its recognition in 1974 is lacking. At least a snapshot of the current status in the first decade of the new millennium is to be offered here 29. For this purpose, the population of the Indian states was compared with the number of homeopathic doctors in order to determine the doctor density. In the Indian case, this means that all registered and institutionally qualified practitioners who are entitled to therapy are recorded. As a result, however, the other healers, who are very important for the poor population, are not taken into account here 30. After all, this gives at least a rough overview of the doctor density, which is a central indicator of the supply situation. As in Indian statistics, the overview table often follows the geographical location of the Indian states from north to south (Tab. 2). The figures show very clearly that the overall level of care has improved considerably compared to 1961. At that time there were 63 homeopathic doctors for every million Indians; in the first decade of the new millennium it was four times as much. On the other hand, one would have to offset the number of homeopathic lay healers, which in 1961 was even greater than that of allopathic doctors in many states 32. Accordingly, the care does not have to have been four times better, but at least the more thorough training is likely to have significantly increased the quality. The information on medical care provided by conventional physicians is instructive for a comparison over time, which is unfortunately not entirely direct: between 1951 and 2005, the number of doctors per 1 million population increased from 170 to 700 33. The data on homeopathic doctors also provide a ranking of the states according to supply density (Tab. 3) derive Dinges M. The supply contribution of homeopathy in India. ZKH 2011; 55 (1): 4 18

6 Tab. 2 Provision of homeopathic practitioners and training places in colleges by federal state (status: 2001/2008). Hom. Practitioners per inhabitant Number of inhabitants per practitioner (rounded) Practitioners (absolute figures) State or Union territory from north to south Population (rounded to the nearest million) Training place in hom.Colleges per inhabitant (rounded) 23, India as a whole, Jammu & Kashmir 10 18, Himachal Pradesh, Punjab, Chandigarh not specified Uttarakhand, Haryana, Delhi, Rajasthan, Uttar Pradesh, Bihar, Arunachal Pradech, Nagaland 2 4, Tripura 3 12, Meghalaya 2 2, Assam, West Bengal ka Jharkhand, Orissa, Chhattisgarh, Madhya Pradesh, Gujarat, Maharashtra, Andrha Pradesh, Karnataka, Goa, Kerala, Tamil Nadu Dinges M. The contribution of homeopathy in India. ZKH 2011; 55 (1):

7 Tab. 3 Ranking of the Indian states according to supply density (status 2001/2008). Rank State or Union Territory 1 Nagaland Maharashtra West Bengal Bihar Chandigarh Kerala Tamil Nadu Goa Haryana Delhi 4197 Average inhabitants per practitioner Indian Union Himachal Pradesh Uttar Pradesh Madhya Pradesh Punjab Meghalaya Andhra Pradesh Karnataka Arunachal Pradunisgarissa is the first Rajasthan Jstahanu Tripura Asshattunlich Space for Nagaland, on the edge of Burma, which can perhaps be explained by a very generous licensing practice 35. The results for the large territorial states are likely to be more realistic. For example, the vastly improved position of the large, central-western state of Maharashtra (with the capital Mumbai), which has improved enormously compared to the 1960s. At that time, Maharashtra was poorly cared for with a number of doctors that did not correspond to half the Indian average.36 On the other hand, continuity is evident in the good rankings of West Bengal and Bihar as classic homeopathic regions, while the states of Assam, also in the northeast, and Orissa in particular, have fallen sharply behind . Chandigarh is a special case as the capital territory of two federal states with good educational institutions: doctors like to stay in the university town like in Germany. Kerala and Tamil Nadu in South India were also relatively well taken care of in the early 1960s, while Haryana and little Goa are newcomers in this group. In the former Portuguese colony conquered by the Indian Union in 1961, the Shri Kamaxidevi Homoeopathic Medical College and Hospital in Shiroda was founded in 1998. India's most populous state, Uttar Pradesh, located in the Ganges plain, and central Madhya Pradesh, like Haryana, hold intermediate positions. The south-west of the country (Karnataka), the south-east (Andhra Pradesh) and even more Orissa, which borders on Bengal to the south, are far worse supplied. Far behind are Rajasthan in the northwest as well as some eastern peripheral states and the Muslim-influenced Jammu and Kashmir, where Unani and Ayurveda traditionally play such an important role as Indian medical systems that homeopathy is less in demand. Prospects for Future Development The future role of homeopathy in care in the individual states is based on the capacity of the colleges. If there are colleges with a large training capacity, then one can safely assume that the spread of homeopathy will be greatly promoted in the affected region. The recruitment of students and their subsequent activities are predominantly regional in character, despite the considerable migration in India. Only a small number of those doing postgraduate studies change places of study, if at all. Otherwise, marriage is a common reason for mobility. The capacity is calculated from the ratio of the training places to the population of the affected state (Tab. 4). 10 Dinges M. The contribution of homeopathy in India. ZKH 2011; 55 (1): 4 18

8 Tab. 4 Rank of the Indian federal states and union territories according to training capacity in homeopathic colleges (status 2001/2008). Rank State or Union Territory 1 Chandigarh Goa & Arunachal Pradesh Maharashtra Gujarat Madhya Pradesh Punjab Himachal Pradesh Karnataka Inhabitants per training place average Indian Union Tamil Nadu Delhi Bihar Chhattisgarh Rajasthan West Bengal Kerala Uttarakhand Orttissa Jharkhand Assam 2 Pradesh Pradesh Abb India Homoeopathic Congress of the Homoeopathic Medical Association of India, Delhi. Maharashtra, the west and the center of the country then have very good growth prospects, the traditional strongholds such as Kerala and Tamil Nadu in the south and West Bengal are already much weaker. The north-east of India and the large states of the Ganges plain such as Uttar Pradesh or Haryana also have particularly poor growth prospects. This is all the more astonishing as the populous Uttar Pradesh at least boasts of having one of the few state colleges in India in the state capital Lucknow and the only minister who is only supposed to be responsible for homeopathy Colleges in Chandigarh and Delhi somewhat relativized. Finally, with regard to regional differentiation, it should be noted that the national medical congresses (Fig. 2) also depict cultural boundaries between North and South India. Despite their name, they are in fact often regional congresses. So the Bengali and other participants from Maharasthra come to Delhi, but practically no one further from the south. And a national congress in Mysore (Karnataka) is also attended almost exclusively by doctors from this and possibly some neighboring countries. Of course, this is not least due to the travel expenses. However, it does not necessarily promote integration and even distribution in the territory. After all, all heads of the almost 190 colleges are automatically members of the Central Council of Research of Homeopathy, so that at least starting from here certain standards and goals can be promoted for the whole country. 23 Haryana Dinges M. The contribution of homeopathy in India. ZKH 2011; 55 (1):

9 Medical homeopathy a predominantly urban phenomenon The private medical practice as the most important field of activity Of the homeopaths registered in 2008, the vast majority of them work in their own practice. Estimates of doctors in all medical fields in India show a value of 81% in the private sector 38. Since the proportion of homeopathic doctors employed in private hospitals or in pharmaceutical research is small, the assumption that 4/5 work in private practice is likely to be a be usable in magnitude. Incidentally, the gender distribution among university-educated people is still very unequal: Doctors are currently men and women, although the number of students in the colleges is now largely balanced 39. Medical homeopathy is still regarded as a predominantly urban medical offer. This does not distinguish them from the other medical directions, whose medical representatives prefer to live in cities and open practices because of the better earning opportunities and the educational and cultural offers. However, it means that around 4/5 of the population can usually only visit a homeopathic doctor's practice if they are driving into a city. 40 Otherwise they are dependent on the non-institutionally qualified healers who exist in practically every village and, insofar as they offer homeopathy, have acquired their knowledge through assistant work or reading. In order to survive, the city's medical practices must first take care of wealthy patients and, for economic reasons, can at most take care of other customers for philanthropic motives. However, one hears or reads again and again about doctors who work a few hours a week for free in a slum, their slum clinic 41. Correspondingly tiered tariffs up to free treatment are one method of making this possible. The municipal medical practices are again very different depending on the district. As is generally the case in the private sector, individual practices are the most widespread 42. In order to reach a sufficiently large clientele of wealthy patients, some doctors have several practice locations. You practice here one weekday or morning, the next day or afternoon in another part of the city, sometimes even in 3 locations 43. According to these doctors, the costs for renting the room are not really significant. Large practices and patient expectations Another strategy of very recognized homeopathic doctors is to open an easily accessible inner city practice 44. This has been reported from cities with less chaotic traffic conditions such as Amravati (Maharasthra) and Lucknow (Uttar Pradesh). The practice organization relies more on a concentration of the offer. Younger colleagues, most of whom have just finished their training, are employed as assistants. In both of these practices, 3 of the up to 6 half-day assistants can work at the same time. You will initially take on the third of the patients who only come to the practice for a possible repeated ordination of a drug. Schumann reports a case from New Delhi in which the patient complained that the homeopathic doctors there did not give the name of the drug, so that she could not treat her daughter independently 45. This may be the reason for the relatively high proportion of visits to the practice for a repetition. In contrast, Frank reports from Bengal that the doctors are explicitly betting that the patients know the name of the remedy. This guarantees traceability and repeatability. It also enables the patient to get a second opinion from another doctor. They would have experienced discussions about the choice of remedy in their well-informed patients because they remembered a symptom that went with a remedy and that they did not currently have at all. The only exception is the prescription of placebos after a single dose. Here the placebo is prescribed by a code understood by the pharmacist (zero potency sign). This is hidden from the patient so that he or she can do something for their health by taking it. Under no circumstances should the impression arise that the doctor does not want to help as soon as possible 46. The impatience of Indian patients towards all medical fields is well known in research. 47 It means that Indians tend to take too many medications in the hope of a speedy recovery, which tends to be carried over to homeopathy as well. With this type of therapy, however, there is also the fact that patients often find the anamnesis too time-consuming: For example, Bengali patients complained about the sense of asking the doctor about dreams or the tolerance of salt and asked for a quicker choice of a remedy. Frank rightly states that there is a cultural contrast to patient expectations in Germany, where the detailed consultation with the doctor is seen more as a strength of homeopaths 48.Bengali doctors otherwise tended to do the examination in order to save time Homeopathy in India. ZKH 2011; 55 (1): 4 18

10 personal, keep it short. This particularly meets the expectations of (Muslim) women. In contrast, they complain of difficulties with lower-class patients who cannot describe their symptoms in a sufficiently differentiated manner. For example, instead of statements about stabbing or pressing pain, some patients occasionally could only elicit body-language references to the affected area. In addition, these assistants take the first anamnesis, which takes up to 30 minutes for chronic diseases, otherwise around 10 minutes. For our ideas of discretion, it is astonishing that the case is taken at 3 tables next to each other in a room that also serves as a waiting room (Fig. 3). Accordingly, one can get the medical history of the neighboring patient. This also applies to other people waiting, at least those in the first row. Apparently this is done and generally accepted in many practices 49. The door to the head doctor's room is also always open 50. After taking the anamnesis, the experienced senior assistant suggests a remedy. Only in the event of uncertainty will the choice be discussed with the boss. The practices are open from am and then in the evening from am. In one morning alone, a total of 90 patients, 6 of them with initial treatment, can be cared for. For the practice in Amravati there were over 40 patients per day 51. A frequency of patients per day is reported from a practice in Calcutta with 2 assistants 52. Despite the low starting salary, this assistantship is attractive for the younger doctors. You will get to know a large number of cases, benefit from the experience of the senior assistant and the doctor and set up your own practice in the evening without having to make a living from it. If you open a practice in the surrounding area, the reputation of the famous therapist from the city promotes your own opportunities. Unfortunately, it is not possible to calculate practice densities for individual cities, as the information on the yellow pages of the telephone books is very incomplete 53. After all, it is possible for Chandigarh to cover the territory of the common capital of the two northern Indian states of Punjab and Haryana as well as for the capital city of Delhi. Based on 80% doctors in private practice, there would be one homeopathic doctor for a good 3750 patients in Chandigarh and one homeopathic doctor for every 5250 people in Delhi. From this it can also be concluded that the supply in partly large territorial states such as Maharasthra and West Bengal is no less dense than in these cities. Fig. 3: Treatment places for the assistants as well as the assistant and the visitor in a doctor's practice in Amravati. Medical homeopathy The public primary care, not just an urban phenomenon Fluctuating and regionally different development In addition to the private offer, the public health system in India offers homeopathic treatment. Its aim has always been to actually take care of everyone. The Alma Ata charter reaffirmed this on the way to achieving the WHO program goal of global health for all in 2000. The relative weight of the public offer is not easy to assess. It is true that the private sector has grown considerably since independence.However, in earlier studies, the private sector was often underestimated because of the government's development goals and the associated development policy fixation on the public health system.54 After enthusiasm for the liberalization of the health market in the 1990s, which was also reflected in the slower growth of the primary health care centers during This decade (in Tab. 1) is visible, in the last few years (since approx. 2001) the public infrastructure has been targeted again- thing M. The contribution of homeopathy in India. ZKH 2011; 55 (1):

11 Tab. 5 Provision of homeopathic doctors in dispensaries, ranking of the states (as of 2008) Rank of inhabitants per hom. Doctor in PHC State Number of hom. Doctors in PHC Nagaland Arunachal Pradesh Tripura Orissa Kerala West Bengal Uttarakhand / Uttaranchal Uttar Pradesh Pondicherry Delhi Meghalaya 15 Average Indian Union Chandigarh Punjab Gujarat Manipur Goa Andra Pradesh Rajasthan Assam Chattisgarh Madhia Pradesh Himachal Pradesh Bihar Jharkand Haryana Karnataka Tamil Nadu Dinges M. The contribution of homeopathy in India. ZKH 2011; 55 (1): 4 18

12th expanded. Nevertheless, there are considerable gaps compared to the requirements on which the health administration is based for planning 55. The infrastructure statistics of the AYUSH department show 6030 dispensaries, i.e. polyclinics or outpatient clinics, with homeopathic practitioners who, with the exception of the smallest territories in Tab 5 are shown. They give an idea of ​​the considerable contribution that these institutions could make to primary care. As is often the case, there is no information on the troubled territory of Jammu and Kashmir, in which homeopathy is not of great importance. What is more regrettable is the information gap on the Maharasthra, which is so well cared for by private doctors. The high number of such institutions in some countries already shows that by no means all of them can be located only in the cities. In the large states of the north-east such as Uttar Pradesh, West Bengal and Orissa, as well as in Kerala in the south, a large part of these dispensaries is likely to be in the country or at least in smaller places. What is striking again is the relatively good position of some states north of Bangladesh such as Nagaland, Tripura and Meghalaya. It is also currently not clear whether the poorer or better supply of homeopathic doctors in the dispensaries correlates with the generally less good or better facilities of the individual states with public health centers. Official duties and private practice in competition A job in one of the state dispensaries is definitely attractive for young doctors because it allows them to achieve a secure basic income early on. In addition, the salary should be acceptable or even relatively good, at least in some countries. The legal regulations for additional private practice vary from state to state. Some categorically exclude this in order to avoid conflicts of interest, which are usually decided in favor of private practice, as in 18th century Europe: The doctor who is already paid in the public service can earn additional income with the privately treated patients that is more interesting for him than a stronger involvement in the dispensary. In this context, it is reported for doctors in all medical fields that certain treatments or medications are withheld from patients in the Primary Health Center. Instead, the practitioner specifically refers them to private practice, because allegedly they could only receive these services there 56. Because such machinations are difficult to control, some states have decided in favor of a general ban on private practice, which, however, involves the recruitment of doctors, at least for one longer duration of activity, can make it more difficult. Various solutions to this problem have been tried. In Andra Pradesh financial incentives were created for younger doctors, who were to be recruited for three years to work in the tribal areas, i.e. the areas of the tribal populations. In Kerala, a job as a country doctor was made a prerequisite for postgraduate studies, or some of the places were reserved for doctors with this background. Another way there was decentralization: Responsibility for the health centers was transferred to the local political community, the Panchayat (village council). In this way, all 419 vacancies (except for 5) could be filled in a relatively short time. Inspired by this self-interest, the village monitored the attendance times of the doctor, who therefore actually worked in the health center during working hours. He was also allowed to practice privately in the evenings. This still led to the neglect of visits to the local hospital and fieldwork, but the involvement of the village brought competent medical professionals to these villages for the first time, actually and not just on paper. In contrast, the absences from the place of work with doctors with permission to practice private practices in neighboring Tamil Nadu were much higher because politically no one had the courage to decentralize 57. Obviously, the solution of such and other problems of primary care lies in the authorization (like the bad, but common German translation of the English term empowerment means) of the village for self-control. In any case, an exclusive activity in the public health system of a medium-sized community can also be a good future investment for building up a patient clientele on site, if the later transfer to private practice is successful. Difficult conditions in the dispensaries Otherwise there seem to be motivational problems here and there for doctors employed in the public service. For example, the Belgian researcher Dusleichenit reports on the basis of longer participatory observations in (the former French colony) Pondicherry in south-east India, which has now been renamed Puducherry, that the homeopathic doctor there was consistently listless, kept his patients standing and paid little attention to them did not really listen, but just wanted to choose the remedy as quickly as possible in order to deal with them immediately 58. Much of this behavior is due to the poor material conditions of these dispensaries: seating or even a waiting room Thing M. The contribution of homeopathy in India. ZKH 2011; 55 (1):

13 Fig. 4: There are no educational materials on health care at the Pandit Jawaharlal Nehru Memorial Institute of Homoeopathic Medical Sciences, Amravati, India, January. For better or worse, the patients always crowd the hallways. Both health administrations and the sick expect doctors to treat as many patients as possible. This inevitably leads to a homeopathy that is very similar to our much-criticized five-minute medicine in the box office practice. The treatment numbers from other dispensaries in Delhi, where sometimes 80 to 160 patients have to be channeled through the practice in 6 hours (and that on 6 days of the week what workload!), Can lead to even shorter treatment times. That would be cases per hour, i.e. 2-3 minutes per patient. The statistical average is 70 patients. A good half come because of the usual seasonal infections or breathing problems, which can indeed be treated very quickly with proven indications. Otherwise, overtime is not uncommon. The reason is the professional and medical ethics accepted and practiced by the employees not to turn away anyone from a public service care center who appears within the opening times 59. In any case, the queues in the two primary health care centers in Delhi I visited show above all that the demand is still much greater than what the public utility systems can offer. Plans for the future These have been systematically expanded again for some time, because the special supply gap in the area of ​​primary care in contrast to the sometimes better financed, higher levels of care and the special need of the marginalized population groups and the lower classes for a certain enthusiasm for a one-sided liberalization and privatization even by the Politicians are seen more strongly again 60. For the increasing number of homoeopathic graduates pouring out of the colleges, this also results in better career prospects. So in Delhi where Dr. R.K. As head of the homeopathy department of the health administration, Manchanda is pursuing a clear strategy of expanding homeopathy in basic care between April 2008 and January 2011, almost 40 more homeopaths have already been employed in public primary care units 61. So far, only 43 primary health care centers in the state of Karnataka have had homeopathic doctors employed (as of 2008). According to Dr. B.T. Rudresh to employ a homeopath in all 175 centers 62. In Uttar Pradesh new positions for homeopaths in primary care were created in the budget year 2007 / alone, which corresponds to an increase of almost 10% in a single year 63. The chief resigned in Goa as well Minister, Shri DV Kamat, during the event for the opening of the traveling exhibition on the history of homeopathy in Margao, said he wanted to employ homeopaths in all 19 PHC 64. Currently (2008) there are only two. However, he pointed out that there was still a lack of suitable applicants. The problem should soon be resolved with 50 new students entering the university every year. Homeopathy in the Network of Various Forms of Therapy One should not imagine these dispensaries as facilities exclusively occupied by a homeopathic doctor. Rather, traditional doctors, representatives of Ayurveda or other medical fields are active there, depending on the local conditions. In addition to 98 homeopaths, the AYUSH health administration of the Delhi Union Territory employs 148 Ayurveda practitioners, 25 for Unani, 4 for yoga, 10 for naturopathic treatments and 2 for Amchi (Tibetan medicine) 65 in the Primary Health Care Centers. Depending on your own assessment of your illness, head for the therapist in the medical discipline of your choice. This system is called the cafeteria approach 66. Apparently the system works well: The 16 Dinges M. The contribution of homeopathy in India. ZKH 2011; 55 (1): 4 18

According to the statistical analysis of millions of consultation data, 14 patients have clear, sometimes overlapping preferences depending on their illnesses. Doctors from the various disciplines, including conventional medicine, also recognize this in principle and refer patients to each other if they need additional diagnosis or if they consider another procedure to be more relevant. Homeopaths are particularly competent in dealing with childhood diseases and chronic ailments, Ayurveda doctors with metabolic problems. Part 2 on further care in rural areas, hospitals, patient motivation and health campaigns will follow in a later edition of the ZKH. To be found online at: Literature Notes [1] Badura B, Kirch W, Wolters P. Needs-based supply and quality improvement. German Society for Public Health (Ed.). Public health research in Germany. Bern: Hans Huber; [2] Barua N. How to develop a pro-poor private health sector in urban India? Global Forum for Health Research; Forum 9; Mumbai, India; September [3] Bhardwaj SM. Medical Pluralism and Homeopathy: A Geographic Perspective. Social Science and Medicine 1980; 14B: [4] Collins D, Morduch J et al. Portfolios of the Poor. How the world s poor live on $ 2 a day. Ranikhett: Permanent Black; [5] Dinges M. Homeopathy in India. A relegation within the Indian health system? ZKH 2008; 2: [6] Frank R. Globalization of alternative medicine. Homeopathy and Ayurveda in Germany and India. Bielefeld: Transcript Verlag; [7] Gangadharan K. Paradigm Shift in Health and Education in India. New Delhi: Serials Publications; [8] Jütte R. A late homeopathic great power: India. In: Dinges M, ed. World history of homeopathy. Munich: C-H Beck; 1996: [9] Kleinman A. Patients and healers in the context of culture. An exploration of the borderland between anthropology, medicine and psychiatry. Berkeley: University of California Press; [10] Krishna A. One illness away: why people become poor and how they escape poverty. Oxford: Oxford University Press; [11] Kurth BM (Ed.). Monitoring of health care in Germany. Cologne: Deutscher Ärzteverlag; [12] Misra R, Chatterjee R, Rao S. India Health Report. New Delhi: Oxford University Press; [13] Poldas SVB. History of homeopathy in India: from its introduction to the first official recognition Stuttgart. Haug; [14] Rai V, Simon WL. Think India. The Rise of the World s next superpower. New Delhi: Plume; [15] Rao M. Eliding History. The World Bank's Health Politics. In: Kumar D, Ed. Disease and Medicine in India. A Historical Overview. New Delhi: Tulika Books; 2001: [16] Robert C. L homeopathie en Inde. Diss. Med. Grenoble; [17] Sainath P. Everybody loves a good draft. Stories from India's poorest districts. London: Headline Book Publishing; [18] Schmacke N, Hrsg. Perspectives of patients on their care by homeopathic doctors a qualitative study: a project of the AOK Baden-Württemberg and the Arbeits- und Coordinationstelle Gesundheitsversorgungsforschung (AKG); Final report. Bremen: Work and coordination office for health care research at the University of Bremen; [19] Schumann U. Homeopathy in Modern Indian Health Care: A Medium of Cultural Identity. Münster: Lit-Verlag; [20] Suresh M. Economics of Primary Health Care. New Delhi: Mohit Publications; [21] Varman R, Vikas RM. Rising Markets and Failing Health: An Inquiry into Subaltern Health Care Consumption under Neoliberalism. Journal of Macromarketing 2007; 27, 2: [22] Venkat Raman A, Björkman JW. Public-Private Partnerships in Health Care in India. Lessons for developing countries. London: Routledge; See also Dinges Badura, Kirch, Wolters 1999: 253, 4. The German Medical Association has meanwhile also taken on the topic: Kurth The first research results are now also available for a German federal state: Schmacke Gangadharan 2009: 130; Venkat Raman, Björkman 2009: Misra, Chatterjee, Rao 2003: 102 f. 5 Barua 2005: 1 f. Hsre / docs / paper_gf9_nupurbarua.pdf. 6 Misra, Chatterjee, Rao 2003: Krishna On the reserves also existing in households below the poverty line see Collins, Morduch et al. 2010: esp. 38, 41, 43 f. 8 Barua 2005: 1 f. 9 Rai, Simon 2007: Misra , Chatterjee, Rao 2003: 120. Incidentally, this also applies on a global scale and explains the excellent health indicators of the Scandinavian countries, which on the whole spend less on health than the USA, but show better results. 11 This is euphemistically referred to in India as moonlighting, as if it only happened at night. 12 Cf. the stimulating if linguistically problematic case study by Suresh 2008: esp. 104, 110, Sainath On urban conditions see: How the system turned sick. The city s hospitals are everybody s last resort; Hindustan Times, Mumbai, Tuesday March 9, 2010 (Metro special): On the lessons from Kerala see the articles on health in Gangadharan Selected socio-economic indicators of the Indian government for cbhidghs.nic.in/indicator%20of%20hii2005. htm (). 16 S. on this Dinges 2008: Varman, Vikas 2007:; so also Rao 2001: 272. Dinges M. The contribution of homeopathy in India. ZKH 2011; 55 (1):

15 18 More on this at the end of the article. 19 S. Schumann U 1993: 172 ff. 20 Dr. Ashok Sharma, Chief Medical Officer Homoeopathy, Government of Delhi, interview in Govt. of Delhi Health Center Vivek Vihar, New Delhi (January 14, 2009). 21 Bhardwaj 1980: Poldas Jütte To Pater Augustus Müller S.J. e.g. Poldas 2010: See the list in Poldas 2010: 208, Tab Cf. on this Dinges 2008: 62 f. 27 Conversation with Dr. Eswara Das, Consultant Adviser (Homoeopathy), Department of AYUSH, Ministry of Health & Family Welfare (December 16, 2010, Kolkata). 28 Interview with Dr. U. Schumann (November 15, 2010, New Delhi). 29 The Summary of Infrastructure Facilities under Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homeopathy (AYUSH) as on shows the last officially announced status of the homeopathic infrastructure: asp? Lid = 44 (retrieval); the latest officially published data on the population census are from 2005 and relate to 2001, namely Distribution of Population, Sex Ratio, Density & Growth Rate 2001 Census at: hia2005 / htm (access). Even if it is methodologically not entirely satisfactory to compare data from 2008 with those from 2001, they should convey meaningful orders of magnitude. Despite the rapid growth, the population proportions are unlikely to have shifted very much between the individual states, nor did the number of doctors and admission capacities of the colleges so much that the regional comparison sought here would be decisively changed. Small territories like the Andamans and Nicobars were left out; The initial statistics did not contain any information on Sikkim, Manipur, etc. 30 p. On lay healers below in the comments on care in the country. 31 Bhardwaj 1980: Bhardwaj 1980: see above Tab The following tables are shorter because information on practitioners or training places is missing for some territories.35 Unfortunately, an inquiry about this could not be answered before the editorial deadline. 36 Bhardwaj 1980: Information in conversation with Dr. S. Singh, Lucknow (December 22, 2010); Mr. Rajesh Tripathi, Honorable Minister of State for Homeopathy and Charitable Works; (Accessed January 7, 2011). 38 Misra, Chatterjee, Rao 2003:% 20Draft% 20% 28For% 20Website% 29 / SECTION% 203.% 20Medical% 20Manpower / 3.2% 20a.pdf. 40 For the outreach campaigns of urban colleges in the countryside, see below. 41 Frank 2004: 137; Robert 1989: Venkat Raman, Björkman 2009: 43-43 Frank D: 2004: 119. Interviews of the author with doctors from Mumbay and Delhi; also on Delhi Robert 1989: 137, The following information is based on interviews and visits to the practice with Dr. Arora in Lucknow () and Dr. Dhole in Amravati (January 24, 2007). 45 Schumann 1993: Frank 2004: 142 f. 47 Frank 2004: Frank 2004: 139, 141, for example in a rural hospital near Agra, see below. 50 Incidentally, we also observed this in ambulances, but not consistently. 51 Written information from Dr. S. Dhole from August 17, 2004: Frank reported that in 2004: 119; we ourselves had to make this experience again when we tried to identify a well-known hom. doctor in Lucknow. The information on Nagpur (with 2.4 million inhabitants and allegedly 44 hom. Doctors) was demonstrably incomplete: webindia123.com/dpy/maharashtra/nagpur/ Doctors- + Homeopathic / 1 / (access). Prof. Dr. Martin Dinges Institute for the History of Medicine of the Robert Bosch Stiftung Stuttgart Straussweg 17, Stuttgart 54 Misra, Chatterjee, Rao 2003: Gangadharan 2009: 127 f. 56 Misra, Chatterjee, Rao 2003: Misra, Chatterjee, Rao 2003: 125, Dusleichenit H: L homeopathie biomédicale du docteur K. Ethnography d un homéopathe india. Previously unpublished Conference paper of the conference L exportation de l homeopathie: le cas de l Inde de Sud (Université Louvain-La Neuve, November 28, 2008). 59 Conversation with Dr. R.K. Manchanda, Dep. Director Hom., UCT Government of Delhi, January 13, 2009 and letter dated Health research had repeatedly warned of the one-sidedness of the privatization strategy of the 1990s. 61 Letter from Dr. R.K. Manchanda, communication from Dr. B.T. Rudresh, board member of the Rajiv Gandhi University of Health Sciences, at the conference of the Homeopathic Medical Association of India in Mysore, September 18, 2010, congress report by Dr. R.K. Manchanda homeopathy.html (access). 64 Opening address on June 29, 2010; for the PHCs see (retrieval). 65 Amchi is a traditional medical system practiced in Ladhakh and parts of Jammu and Kashmir. It is a combination of Ayurveda and Chinese medicine and contains some Tibetan elements. In the meantime, the central government is even considering whether to rename the AYUSH department, including Amchi, to AYUSHA (written information from Dr. R.K. Manchanda). linkimages / delhi.pdf (download). 66 Cf. Kleinman, born 1953, studied law, history and political science. Deputy Head of the Institute for the History of Medicine at the Robert Bosch Stiftung, Stuttgart, and associate professor for modern history at the University of Mannheim. List of publications on the Internet under 18 Dinges M. The contribution of homeopathy in India. ZKH 2011; 55 (1): 4 18