cannot be transferred to a government structure that allows initiative to be exercised only by those at the top, and in which communications are transferred down the hierarchy but almost never up.
It would be easy to conclude that health policy in India is so closely dominated by national and international class interests that little scope remains for major change. However, this analysis would be too simplistic. In the first place, it ignores the very real achievements of Indian health policy. Health planning has shifted resources towards preventive medicine, rural areas and paramedical workers. Substantial preventive campaigns have been waged against malaria and smallpox. Large numbers of PHCs and subcentres have been built and equipped, and staff have been appointed. In some parts of the country, which admittedly are areas relatively favoured on other counts, many workers are conscientious, and beneficiaries have not been restricted to the higher classes and castes. Paramedical staff may be trained and employed on the cheap, but their numbers have continued to rise, and they are sufficient to supply most of the population with something approaching a reasonable health service. Some of these services have probably helped to support the decline in levels of mortality, halting and uncertain though this has been.
Second, among the various supports of class domination, health policies, health sector assistance and even the operations of pharmaceuticals companies do not have high priorities. More radical health sector proposals (like the nationalisation of drug production) are, of course, fought hard by those whose interests would be directly affected. Furthermore, changes in the local distribution of resources which might be needed if inequalities in health are to be overcome, or if diseases of poverty are to be significantly reduced, will also be fiercely resisted. But very few health proposals come close to such radical ideas. The more notable features of Indian health policy are the extent to which it has shifted towards more appropriate models; and the role of factors internal to the government and political party structure which have limited the implementation of even these relatively modest proposals.
The Indian government has been relatively successful in what it has achieved, measured against its near neighbour, Pakistan, with which it has a shared historical legacy ( Jeffery, 1974; ADB, 1981; Shepperdson, 1981). As always, the frame of reference is crucial: Compared to Pakistan, India's achievements are considerable; compared to the ideals of the planners and proponents of the new perspectives, India comes off much less well. The explanation for these patterns derives from features of the social organization which are well captured by Alavi's discussion of levels of the state and the degree of their integration. "Tight" states have consistencies among the different levels of the state, and integration is close. In these states, whether conservative ( Iran, perhaps) or radical ( China), the class interests that dominate the state are in close accordance with the struc-