The thesis is a critical examination of the relationship between different levels of the colonial state and its medical services in the relief of famine in Madras Presidency during 1876-78. The state was irrevocably divided in moral, administrative and financial terms in its responses to famine and the provision of famine relief during this episode These divisions made for inconsistencies in the relief of distress, and resulted in widespread suffering and starvation. However, they also allowed for considerable latitude by the Provincial Government in the implementation of Imperial famine policy, and for the medical profession to gain administrative authority by claiming expertise in the scientific determination of standards of state support for the famine stricken. This famine heralded the beginning of organized all-India state intervention in famine processes through the institution of famine codes and organized bureaucratic machinery for the early prevention of agrarian distress through prompt state intervention. To this extent, this particular episode was a 'prime mover' in the history of the medical profession and the history of state intervention in famine relief in India. The thesis seeks to address critically several problems in the historiography of famine, colonial medicine, disease and the state in modern South Asia through this case study. It attempts to do so through a critical re-examination of material used by previous authors and the use of some hitherto unused sources from the Provincial archives.

Utilisation of medical sources other than the modern Western medicine (Allopathy) is characteristic of most societies. Health-care utilisation studies, in medically pluralistic societies, fall short of providing adequate explanation of how and why different medical sources are used. The present thesis is an attempt to delineate the social psychology of the health-care utilisation behaviour of people in Bombay by concentrating on the interplay between the individual, the social environment and the culture. It, therefore, benefits from disciplines both within and outside mainstream psychology like societal psychology, sociology, anthropology and medicine. The study addresses a twofold question: how are treatment related decisions made and what are their determinants. To answer these questions, an understanding of variables pertaining to the person as well as a consideration of the societal context is necessary. Following a quantitative pilot study, the research involved retrospective data collected with the help of a partially structured questionnaire using a quota sample of 480 Gujarati-speaking adults. The quotas were set for sex, income and illness types. The survey instrument elicited information on predisposing (demographic, social structural, belief and social), enabling (family resources and prior access) and illness (type and manifestation) variables as well as the process of seeking care. The results, highlight that health-care utilisation behaviour in a medically pluralistic setting is not a singular act but a continuously evolving decision-making process wherein sources are used differentially. Typically, the treatment-seeking process began with the use of non-formal sources, followed by an entry into the professional sector, invariably through an Allopathic family doctor. Subsequently, the individuals either revert back to non-formal sources, continue to remain within Allopathy or exhibit an irreversible shift to non-Allopathic formal sources. Accordingly, there exists a need to redefine health-care utilisation behaviour in terms of sequential patterns of usage. These patterns, are determined by individually based variables belonging to all three categories as mentioned above. However, in contrast to certain trends, the effect of demographic, social structural and income variable was very small. Between 18-42% of the respondents within each illness cluster, used two or more formal medical systems. Compared to their counterparts who used only one formal system, the multiple users were more likely to suffer from chronic illnesses, rely on lay advice, prefer non-Allopathic systems and already have an access to non-Allopathic sources of care.

After decades of effort, the health outcomes in India are still poor. In addition to the slow socioeconomic development and sluggish progress in poverty eradication, the ongoing poor health status of individuals living in rural India is often attributed to an inefficient and largely dysfunctional public healthcare system. Although India has developed a huge network of public health facilities, the utilization of services at these facilities still remains abysmal. One of the factors underlying this situation is thought to be the poor availability of human resources in healthcare. Recognising the need to overhaul the system, the government launched the National Rural Health Mission (NRHM), an initiative that aimed to increase health worker availability in public health facilities. It has been more than a decade since the launch of the NRHM, and the time is ripe to evaluate the extent to which health worker availability has improved in public health facilities, and how inequalities in the distribution of health workers in public facilities has changed. Related to this is an important question: What factors shape such distributional inequalities? The NRHM introduced new cadres to the public health system – a 2nd nurse midwife at the sub-centres and a traditional medical doctor at the primary health centres. Thus, this study also investigated the effects associated with the implementation of these workers on healthcare utilization. This study largely uses quantitative tools and secondary data from the District Level Household Survey (DLHS) series. It finds that the overall health worker availability has improved slightly, but the availability of a few health worker cadres, such as male health workers, has deteriorated. The study also found that the distribution of health workers has become more unequal over the study period. While the inequality in the distribution of health workers within states remains considerably high, the inequality in the availability of health workers across states has increased. The study finds a mesh of complex factors affecting the availability and distribution of health workers across health facilities, which include the availability of basic amenities, physical infrastructure, work environments, family and personal choices, misuse of transfer, and deployment policies. It also finds that the utilization of health services is lower at those sub-centres run by a 2^nd ANM compared to those run by permanent ANMs. Evidence about the impact of a 2^nd ANM and AYUSH are inconclusive for most indicators. Thus, the findings of this study suggest that there is a need to further improve health worker availability at rural public health facilities. The emphasis should be on reducing the inequality not only across states, but also within states. Special efforts would be required for north and central Indian states that have struggled to improve their health worker availability during this period. The findings also call for policymakers to devise new strategies to retain health workers in rural and remote areas, while implementing transparent and apolitical transfer and deployment policies. The government should also look into issues as to why those sub-centres run by a 2^nd ANM are not performing at par with those sub-centres run by permanent ANMs.

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Health is deemed central to a nation’s development. Accordingly, health care reform and expansion are key policy priorities in developing countries. Many such nations are now testing various methods of funding and delivering health care to local disadvantaged populations. Similarly, India launched the Rashtriya Swasthya Bima Yojana (RSBY) national health insurance programme for low-income groups in 2008. The RSBY intends preventing catastrophic health-related expenditure by improving recipients’ access to hospital-based care. This thesis is an in-depth qualitative evaluation of the RSBY in Delhi state. It examines the RSBY’s effectiveness in fulfilling its goals and meeting local health care needs. Walt and Gilson’s (1994) actors-content-process-context model informs the research design and an actor-centred “responsive” (Stake 1975) or “constructivist” approach guides data analysis. Three research questions are examined: (i). Why was a health insurance programme launched and why now? Why was this model favoured over alternate methods of service expansion? (ii). Is the RSBY delivered as intended? If not, why? (iii) How does the RSBY affect patients’ access to services? The findings are based on documentary sources, observation of implementation sites and activities and 164 semi-structured interviews with RSBY policymakers, insurers, NGOs, doctors, and patients. The results show improved access to curative and surgical care for RSBY patients. However, RSBY’s focus on hospitalisation and omission of primary and outpatient services had undesired negative effects. The lack of ambulatory facilities led RSBY patients to self-medicate or use dubious quality informal providers. By only allowing inpatient care, the RSBY also seemingly encouraged the substitution of outpatient care with costlier hospitalisations. In effect, the RSBY’s design contributed to cost increases and poor patient outcomes. While more funds and human resources were needed to improve RSBY implementation, the performance of frontline agencies could potentially improve through more stable, longer-term contracts. Similarly, modifying RSBY’s monetary incentives for doctors may lead to better service delivery by them. By evaluating the RSBY’s strong points and shortcomings, this thesis provides key lessons on strengthening policy design and health service delivery in developing countries. Thereby, it makes a broader contribution to understanding the determinants of successful policymaking.