few cases of many communicable diseases every year in the US, but through constant vigilance they are confined and stamped out.

The history of public health since 1950 in India illustrates that the organization of services is conducive to successful campaigns followed by unsuccessful “maintenance” phases of disease control programs. For one thing, with the exception of female health workers (who are earmarked for family planning service delivery), other health personnel are considered to be “multipurpose”. In principle this is a good idea, but in practice it means that they are allocated to whatever is deemed a priority at the time, and discouraged from other activities such as maintaining the gains from earlier efforts.

This is searingly illustrated by the fact that India came very close to eradicating malaria through a highly successful campaign in the 1950s — but then the program was put into a “maintenance phase” and malaria resurged. This resurgence has often been attributed to the emergence of DDT-resistant strains of mosquitoes, though it is clear that the government does not really believe this since they continue to use DDT as a main line of defense against malaria. Less attention has been paid to the shortcomings in program design. In the 1950s, the malaria control program was carefully organized, but attention to program organization suffered subsequently. For example, the current program is formulated such that the central government provides the DDT, drugs and other supplies, while the state government is primarily responsible for the manpower costs. It is not uncommon that the states are unable to afford the manpower to adequately supervise the spraying activities, and prepare communities in advance so that they can plaster their homes before the spraying rather than plastering over the DDT. Besides, manpower is diverted: for example, an ORG study found that frontline staff were preoccupied with family planning work at the expense of malaria supervision at critical times.<sup>15</sup> The Five-Year Plans document the rapid shift away from a public health-oriented focus in independent India. Even though little was done on sanitation in the 1950s, the Plans recognized clearly its importance for controlling communicable diseases. Water and sanitation was an integral part of the chapter on health planning, and sanitary inspectors figured as an important cadre of frontline staff. By the 1960s, water and sanitation had been separated out as belonging outside the health sector, and there was little further mention of sanitary inspectors in the Plans.

The reduced focus on public health outcomes was also reflected in other ways in the Plans. For example, there is a striking difference between the discussions of the health programs and of the high-priority family planning program. In successive Plans, the sections on health are concerned with inputs and the current priority thrusts such as universal immunization. For the rest, there is a typically desultory account of policies and programs. Analysis of shortfalls is often devoid of suggested remedies, as in the case of the 9<sup>th</sup> Plan on malaria. Even lip-service ceases to be paid to important issues — for example, the new strategies for malaria make no mention of environmental management.

> 15 Operations Research Group 1988.

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