16Orissa Human Development Report

CHAPTER 4

Health Condition

Health is an important determinant of well-being in the broadest sense of the term. Improved health is desirable not only in itself, but also because it leads to enhanced

capability to work and to participate in economic development. Improved health and nutritional status contribute to increased life expectancy.

Mortality ConditionThe mortality rate is a robust indicator of the overall health status of a population. The percentage decline of mortality in the 1980s as well as the 1990s has been the least in Orissa. The Crude Death Rate (CDR) in Orissa in 2001 and 2002 was 10.4 and 9.8 respectively.

Infectious and parasitic diseases account for a little more than one-fifth of all deaths in Orissa. Diseases of the circulatory system also have a share of nearly one-fifth in all deaths. Perinatal deaths account for 13 per cent of all deaths. Diseases of nervous system, respiratory system, and digestive system together account for another 20 per cent of all deaths.

Infant and Child MortalityLevel of, and Trend in, Infant MortalityInfant mortality rate (IMR) continues to be the highest in Orissa. The rate of decline in IMR has been rather slow and gives rise to concern: in the 16-year period between 1981–83 and 1995–97, it declined by 25 per cent, i.e., at the rate of about 1.6 per cent per annum.

The relatively slow decline in IMR is partly explicable in terms of the relative decline in different components of infant mortality. Neonatal mortality (NNM) constituted 63.7 per cent of infant deaths. Perinatal deaths alone account for some 35 per cent of infant deaths. Post-neonatal deaths constitute only some 36.3 per cent of all infant deaths. The post-neonatal mortality rate of Orissa seems to have declined to a greater extent than perinatal mortality rate. In fact, SRS data over a long period (1972–95) post-neonatal mortality declined by 62 per cent and neonatal mortality declined by only 33 per cent. However, IMR has come down to 91 in 2001 and further to 87 in 2002. If this rate of decline continues, an IMR of 45 per thousand live births should be reachable by 2010.

Causes of Infant and Child DeathGiven such a weight of IMR and child mortality in overall mortality burden, and concentration of infant deaths in the neo-natal period, it is worthwhile analysing the available data on the causes of infant and child deaths. Prematurity, resulting in low birth weight of babies, is the predominant cause of infant deaths, accounting for 38.5 per cent of

Fig. 4.1Level of, and Trend in, Crude Death Rate, 1980–2000

12.0

7

9.8710

.73

11.0

5

8.73

11.4

9

0

5

10

15

20

IndiaOrissa

1990-921998-2000Per cent decline

17Health Condition

such deaths. Nearly 30 per cent of infant deaths are due to adverse conditions of infections relating to the circulatory system. Broadly speaking, these causes of infant death reflect inadequate antenatal, natal, and post-natal care.

In particular, three factors may explain the high level of IMR in Orissa: first, the poor professional attendance at birth; second, high percentage of low birth weight babies, and third, lack of professional post-natal care. These three factors together have a bearing on neonatal mortality, which, constituted about 64 per cent of infant deaths in Orissa. Maternal malnutrition and malaria are among the important causes for low birth weight babies. It has been estimated that 40 per cent of neonatal deaths occur in the case of low birth weight babies. The coverage of post-natal care seems to be quite poor: only 18 per cent of women were visited by the Auxiliary Nurse Midwife (ANM) within two weeks of delivery.

Lack of access to safe drinking water and adequate nutrition are the other underlying factors behind child deaths. For deaths of children under 5 years of age, diarrhoea accounts for 28 per cent, Acute Respiratory Infection (ARI)/pneumonia for 15 per cent, measles for 10 per cent, tetanus for 6 per cent, and tuberculosis infection, fevers like malaria, typhoid, and hepatitis for the rest. The single most important factor for reducing the prevalence rate and case fatality rate of major infant and childhood diseases is improvement of nutritional status and antenatal and intra-natal care.

It is important to state that malnutrition is concentrated in particular vulnerable groups within the poor and ultra poor population, i.e. women and children. A multiple regression analysis based on data for 296 districts of India for the year 1981 shows that, holding other variables constant, a 50 per cent reduction in the incidence of rural poverty reduces the predicted value of under-five mortality from 156 per thousand to 153 per thousand, whereas an increase in the crude female literacy from, 22 per cent to 75 per cent reduced the predicted value of under-five mortality from 156 per thousand to 110 per thousand.

Morbidity ConditionExcess Morbidity BurdenThere is an inverse relation between overall mortality rate and overall incidence of disease rate: as mortality declines and life expectancy increases, the chances of survival improve but the propensity to fall ill increases. Conversely, at a high mortality rate, morbidity rate tends to be less. The morbidity incidence rate is significantly higher in the case

Table 4.1Distribution (per cent) of all Deaths (Rural + Urban) by Major Cause Groups, 2000

Sl. No. Major cause group Per cent to

total1. Intestinal, Infectious, and Parasitic

Diseases 21.68

2. Diseases of the Circulatory System (Anaemia; heart attacks, etc.)

18.39

3. Conditions Originating in Perinatal Period

12.91

4. Injury, Poisoning etc. 9.54

5. Diseases of the Nervous System 7.82

6. Diseases of the Respiratory System(Asthma & Bronchitis; TB of Lungs; Pneumonia)

5.97

7. Diseases of the Digestive System(Gastroenteritis; Peptic Ulcer; Dysentery, etc.)

5.24

8. Pregnancy, Childbirth and Puerperium

3.08

9. Endocrine, Nutritional and Metabolic Diseases

2.88

10. Neoplasm 1.93

11. Others 10.56

150

130

110

90

Fig. 4.2Level of, and Trend in, Infant Mortality Rate, 1980-2000

1998-20001980-82 1987-89 1990-92

136.7

123.0 120.3

97.0

18Orissa Human Development Report

of Orissa as compared to Bihar, Madhya Pradesh, Rajasthan, and Uttar Pradesh.

Trend in Morbidity: The Case of Four Major DiseasesMalaria has recently staged a comeback. The relative magnitude of the problem can be gauged from the fact that Orissa, in 1998, accounted for 28.6 per cent of some two million detected cases of malaria in India and 62.8 per cent of all malarial deaths in the country.

Tuberculosis also remains a major public health problem in Orissa. The available data for the period between the mid-1980s and 2000–01 shows that the prevalence rate has not only been high, but has also showed signs of increase from time to time. Though the case-fatality rate has come down,

the percentage of cases in which the treatment course is not completed is high.

The case of gastroenteritis is somewhat similar to tuberculosis. While the case-fatality rate has come down during the period 1979–94, the prevalence rate has steadily increased during the same period. In 2002, there were 156,872 cases of severe diarrhoea resulting in 453 deaths, and in 2003 there were 144,672 cases of severe diarrhoea resulting in 513 deaths.

The case of VPDs perhaps highlights what an aggressive, well-motivated immunisation drive, such as the Universal Immunisation Programme (UIP) introduced in 1985–86, can achieve. Of the six VPDs, the number of reported cases in Orissa came down between 1985 and 1993 in the cases of diphtheria, measles, whooping cough and poliomyletis. It increased during 1980–85 in all cases except whooping cough. The number of reported cases has increased in the cases of tetanus and tuberculosis.

National Disease Control ProgrammesGiven the challenges of public health control and management, vertical disease control programmes have a special significance in the context of Orissa. Malaria, tuberculosis, filariasis, leprosy, corneal blindness, and goitre are major public health concerns. A partial indicator of the amount of effort that is going into the control of these conditions is the magnitude of expenditure on the National Disease Control Programme. Firstly, Malaria control accounts for the bulk of the expenditure. Secondly, allocations to other disease control programmes appear to be inadequate. Finally, there has not been a steady increase in allocation for any of the mentioned programmes.

Pattern of Illness and Early MortalityIn the first stage of ‘health transition’, the preponderance of infectious and communicable diseases is a typical pattern. These diseases also account for much of mortality in this phase. Thus, in case of Orissa, from the latest available data (for the year 1992–93) on the number of outpatient and inpatient consultations and it can be seen that infectious and communicable diseases account for around 50 per cent of both outpatient and inpatient consultations and about 33 per cent deaths. Non-communicable diseases become increasingly important during the second stage of health transition.

Table 4.2Contribution (per cent) to Infant Deaths by Major Causes, Rural Orissa, 1998–2000

Specific causes Per cent of total deaths

Prematurity 38.5

Pneumonia 15.4

Respiratory Infection of newborn 8.7

Anaemia 8.1

Bronchitis and Asthma 5.3

Tetanus 2.9

Diarrhoea of newborn 1.8

Others 19.3

19Health Condition

According to a study by the Administrative Staff College of India in 1999, total person-years (PYs) lost were 381 per 1000 population. This means that each one of 10 per cent of the state’s population lost on an average nearly four years of life on account of early mortality and illness-caused time loss.

Probability of Dying at Different AgesThere is not much of a male–female difference in the probability of dying within both rural and urban areas. However, the probability at birth of dying at the age of 15 years and probability at the age of 15 years of dying at the age 30 years is twice as high in rural areas as compared to urban areas.

Access to and Utilisation of Public Health Care FacilitiesPhysical Access In the case of public health care services, access is an important aspect and a basic requirement. One may distinguish between two kinds of access: physical and economic. Physical access can be either population coverage-based or area coverage-based. Economic access refers to direct cost of accessing the service. For Orissa, as regards population covered per public health facility, while the coverage is better in seven to nine major states, the area coverage, is generally poor.

Similar data for the year 2004 suggests that the area coverage of health institutions has perceptibly improved for the state as a whole and for as many as 14 non-coastal districts. However, for the five inland districts of Balangir, Kalahandi, Mayurbhanj, Phulbani, and Sundargarh, 40 per cent or more of the population still have to travel more than 5 kms to reach the nearest health facility. On the other hand, physical access is relatively better in the case of the coastal districts of Balasore and Puri. The problem of physical access is compounded by two other factors: poor roads as well as poor transport connectivity. At a low level of per capita income, a good indicator of economic access, to public health care facilities is the extent of private expenditure on health care. The available data on the same suggest that it is higher in the backward district of Kandhamal, and is proportionately higher for lower income classes. It is thus not surprising to find that poor physical and economic access affect the utilisation of public health care facilities.

Inter-District DisparitiesEarly marriage of girls, particularly below 18 years of age, may result in greater number of births, high infant mortality, and pregnancy complications. In Orissa, a little below 30 per cent of girls married before 18 years of age, but there was a great deal of inter-district variation. Thus, for the backward districts of Balangir, Boudh, Kalahandi, Malkangiri, Koraput, and Nabarangpur, more than 50 per cent of girls married below 18 years of age while it was less than 15 per cent in the coastal districts of Cuttack, Jagatsinghpur, Jajpur, and Puri.

Table 4.3Number of Reported Cases of Vaccine Preventable Diseases

Vaccine preventable

diseases

Year

1980 1985 1993

Diphtheria 333 474 166

Whooping Cough

13,340 7,223 6,666

Measles 5,132 9,272 3,602

Poliomyelitis 275 981 376

Tetanus 1,609 2,378 2,671

Tuberculosis 10,198 17,589 54,710

20Orissa Human Development Report

The coverage of antenatal care is rather impressive: 73.4 per cent of women had received some antenatal care. There was not much inter-district variation, as in 28 out of 30 districts, more than 60 per cent of pregnant women had received some ante-natal care.

Delivery at a health facility fully ensures professional care during delivery. For the state as whole, such institutional deliveries constituted only 21.9 per cent of all deliveries and in this there is considerable inter-district variation (CV: 52.89).

The inter-district disparity comes down in the case of safe deliveries at health facility plus deliveries at home attended by a trained professional, as a large number of districts move up to the category of 20–40 per cent of safe deliveries, thus increasing the average of safe deliveries to 36.46 per cent. But this means that still about two-thirds of deliveries are unsafe, i.e., not attended by any trained professional. Access to post-natal care seems to be poor in Orissa. The percentage of women visited by ANM within two weeks of delivery was only about 18. There is a fairly significant inter-district variation in this respect around the low mean (CV: 34.53). Twenty districts with less than 20 per cent of women having been visited by ANM within two weeks of delivery include not only the backward districts in the KBK (Kalahandi, Balangir, and Koraput) region, but also, a number of coastal districts as well as northern districts.

The percentage of women who develop pregnancy and delivery related complications range from one-third (delivery complications) to nearly three-fourth (pregnancy

Map 4.1Per cent of Girls Married at Age Less than 18 Years(for married since 1 January 1996)

<2020-4040-60>60

Percent of girls marriedat age less than 18 Yrs.

KeonjharBalasore

Bhadrak

Kendrapara

Jagatsinghpur

Cuttack

JajpurDhenkanal

Khurda

Puri

W E S T B E N G A

L

Bargarh

Malkangiri

Jharsuguda

SambalpurDeogarh

Sundargarh

Angul

Nayagarh

Ganjam

Gajapati

Kandhamal

Boudh

Sonepur

BalangirNuapada

Kalahandi

Rayagada

Nabarangpur

Koraput BA

Y O

F B E N G A L

J H A R K H A N D

A N D H R A P R A D E S H

CH

HA

TT

I SG

AR

H

Mayurbhanj

21Health Condition

complications). There is a great deal of inter-district disparity in respect of both abortion complications (CV: 36.13) and delivery complications (CV: 41.15).

Immunisation coverage in the state cannot be said to be satisfactory. Only about 60 per cent of children are completely immunised. In as many as 14 districts, the immunisation coverage is between 40–60 per cent. About nine per cent of children have received no immunisation at all. This implies that some 32 per cent of children are only partially immunised. A fairly significant inter-district variation (CV: 28.79) is observed here.

The incidence of diarrhoea among children is fairly high: 30.28 per cent. In 25 districts, the incidence is between 20 to 40 per cent. Still, the inter-district variation is fairly large (CV: 32.12). Nearly 25 per cent of children are treated with ORS. There is, however, considerable inter-district variation in this respect (CV: 43.51).

Social Disparity in Health Status: Tribal HealthThe tribal population is the most disadvantaged social group in Orissa. A clear manifestation of this is the distinctly higher incidence of poverty among the tribal population as compared to the general population or to even Scheduled Caste population.

While infant mortality rate and under-five mortality are respectively 10.3 per cent and 19.6 per cent higher for Orissa’s tribal population as compared to the state’s population as a whole, the child mortality rate is 52.7 per cent higher.

Map 4.2Per cent of Safe Deliveries(Institutional deliveries and deliveries at home)

<2020-4040-60

Percent of safe deliveries

KeonjharBalasore

Bhadrak

Kendrapara

Jagatsinghpur

Cuttack

JajpurDhenkanal

Khurda

Puri

W E S T B E N G A

L

Bargarh

Malkangiri

Jharsuguda

SambalpurDeogarh

Sundargarh

Angul

Nayagarh

Ganjam

Gajapati

Kandhamal

Boudh

Sonepur

BalangirNuapada

Kalahandi

Rayagada

Nabarangpur

Koraput BA

Y O

F B E N G A L

J H A R K H A N D

A N D H R A P R A D E S H

CH

HA

TT

I SG

AR

H

Mayurbhanj

22Orissa Human Development Report

Immunisation coverage is the poorest in the case of tribal population compared to other social groups and the aggregate population: only 26.4 per cent of tribal children are completely immunised against all vaccine-preventable diseases and 18.2 per cent did not receive any vaccine at all, and thus 55.4 per cent of children are only partially immunised.

As per NFHS-2, the percentage of children having three common childhood diseases—namely respiratory infection, diarrhoea, and fever—during a reference period of two weeks among the tribal population is surprisingly lower than for the population as a whole as well as for other social groups such as Scheduled Caste and other backward population.

The nutritional status of tribal children is apparently not much worse as compared to that

of other social groups and the population as a whole. The incidence of anaemia among children is, however, much higher among tribal population.

As in the case of tribal children, the nutritional status of tribal women is also not much worse than that in the case of the general population or that of women belonging to other disadvantaged social groups such as Scheduled Caste and Other Backward Castes. However, the incidence of anaemia amongst tribal women is significantly higher than that for other social groups.

There are two indicators of maternal health—extent of antenatal check-up and delivery care. As regards the former, we find that among tribal women, 37 per cent did not have any antenatal check-up. This is much higher than it is for the population as a whole (20.3 per cent) as well as for other social groups. On the other hand, among tribal women, a

much lower percentage had professional antenatal check-up.

While institutional delivery is low in the case of Orissa (22.7 per cent), it is even lower in the case of tribal women (8.7 per cent). Similarly, professional assistance during delivery in the case of tribal women is only 36.1 per cent as against 55.6 per cent for the population as a whole.

Trend in and Pattern of Health ExpenditureThere is a squeeze on budgetary allocation to the health sector through the second half of the 1990s. On the other hand, health budget as per cent of GSDP steadily declined during the first half of the

Fig. 4.3 Childhood Vaccination

26.4

18.2

44.5

8.6

46.5

8.1

49.3

5.3

43.7

9.4

0

20

10

30

40

50

Other TotalOBCSCST

Completely immunisedNot immunised at all

Social group

80

60

40

20

0

Fig. 4.4Anaemia among Women (%)

OtherST SC OBC

74.766.3

61.354.4

Social group

23Health Condition

1990s. It gained some ground thereafter but the level of the early 1990s has not been reached.

The primary and secondary tiers each account for around 20 per cent of the budget allocation while the tertiary level claims 60 per cent. What this means is that primary health care and first referral services, are underfunded. This results in a shortage of drugs, equipments and other materials in the primary and secondary level of institutions. This, in turn, results in overburdening the tertiary level services, as patients seek from tertiary institutions, treatment which could easily be given at the primary or secondary level.

Policy ImplicationsThe Government of Orissa has put in place a comprehensive and integrated medium-term health policy. Under this, several strategies and action points for the development of the health sector have been spelt out. A major thrust of the policy is to achieve equity in health care by reducing disparities on four counts: regional; the poor and disadvantaged social groups (STs and SCs); gender; and vulnerable groups (persons with disabilities and elderly persons). The avowed approach aims to have a participatory public health and primary health care orientation.

However, it needs to be pointed out that while time-bound targeted reductions in IMR and MMR have been spelt out, the specific requirements of these policy goals and their organisational and financial implications have not been spelt out. While the thrust of the state’s New Health Policy is, broadly speaking, in the right direction, a few additional policy recommendations are in order. These are as follows:

(i) Almost 75 per cent of the incremental budgetary allocation to the health sector should be devoted to the primary and secondary tiers.

(ii) In remote and tribal districts where minimum health services are not available because of poor functioning of public health care institutions, an attempt should be made to involve Panchayati Raj Institutions (PRIs), local NGOs, and Self-help Groups in managing such institutions.

(iii) There should be a concerted effort to increase institutional/safe deliveries —at a faster pace. This should be particularly targeted at the tribal population.

(iv) Malaria is the most critical public health problem in the state. To deal with this, vector control programmes need to be intensified.

(v) The child immunisation drive needs to be intensified, as only 60 per cent of the children in the age group 12–36 months are completely immunised.

Fig. 4.6Distribution of Budget Expenditure: 1995–96

Primary level(22%)

Secondary level

(19%)

Tertiary level(59%)