Study on perceptions of marginalized people about health ... · Study on perceptions of marginalized people about health equity in Orissa ACKNOWLEDGEMENT We are highly indebted to

Study on perceptions of marginalized people about health equity in Orissa

AbstractThis report presents the perceptions and views of different marginalized groups in Orissa about health equity, specifically on how current program is addressing those needs and opportunities and suggestions for improvement. Different marginalized groups interviewed in the study reported about their own constraints like

remote & high health relating to

lack of privacy, proper health

note that people of service as

be more on people and the

so that the improved. For emphasizes on

health insurance, health issues, report provides

equity and possible solutions to address some of the issues.

low income, high transportation cost, illiteracy,inaccessibility, dependence on local moneylenders,expenses, etc. as well as also shared the constraintshealth providers like lack of attention, irregular visit,etc. as the reasons for not availing and accessingservices. On the other side, it is very satisfying to those who received services, majority regard the qualitygood or very good. Thus, the emphasis shouldaddressing the constraints of marginalized constraints relating to delivering the health servicesavailability and accessibility of services could be addressing the constraints of people, the study taking risk transfer measures in the form of micro introduction of financial products targeted on introduction of community kiosks, etc. The present lot detail about the perceptions of people on health

Study on perceptions of marginalized people about health equity

Submitted to:

Technical and Management Support Team (TMST), Orissa Health Support Project (OHSP)

C T R A N C o n s u l t i n g A 1 / A 2 , L e w i s P l a z a , L e w i s R o a d , B J B N a g a r , B h u b a n e s w a r , O r i s s a – 7 5 1 0 1 4 , I n d i a Telephone: +91‐674‐3245544 Tele Fax: +91‐674‐2432695 2 / 2 4 / 2 0 0 9

in Orissa

CTRAN Consulting Pvt. Ltd. Bhubaneswar TMST ‐Orissa Health Support Plan

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ACKNOWLEDGEMENT

We are highly indebted to all respondents from marginalized groups and health service providers to have spared their valuable time and information with us. We have no words for the hospitality extended by the marginalized households to our study team and we wish all of them and their fellow community members enjoy good health and better quality of life. We extend our heartfelt thanks to Government of Orissa more specifically the officials of Health and Family Welfare Department and Women and Child Welfare department starting from village and state level for extending all necessary cooperation and information to come out with this report. The Technical Management and Support Team (TMST) to Orissa Health Sector Plan (OHSP) deserves great appreciation for taking up this study on Health Equity in Orissa. We express our sincere appreciation to TMST having chosen us (CTRAN Consulting, Bhubaneswar) for conducting this study. Particularly, we are thankful to Ms. Biraj Laxmi Sarangi, Social Development Specialist, TMST and Ms. Alison Dembo Rath, Team Leader, TMST for technically guiding us for undertaking this study. It is needless to mention the input and support specifically provided by Ms. Biraj in every step of the study process starting from designing of methodology, tools, data collection and report preparation which were of immense help to the study team. Most of all, our sincere appreciation goes to every member of the team more specifically the field investigators and supervisors, who spared no pains to complete this work. If this report turns out to be a useful one, the credit goes to the professionals and investigators, who took pains to collect reliable and adequate information. Mr. Barendra Krushna Sahoo requires special mention and appreciation for his involvement in coordinating the data collection, data quality control, database preparation and assisting in report preparation. It was our pleasure to conduct this study and gather some valuable knowledge and experience while undertaking the study. We hope that the findings of the study would be highly beneficial for the state to design appropriate strategies for addressing health equity issues.

Ashok Kumar Singha Satyanarayan Mohanty

CTRAN Consulting, Bhubaneswar


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CONTENTS EXECUTIVE SUMMARY ................................................................................................................................................... 8

Chapter I ................................................................................................................................................................ 18

1. Study Overview & Methodology ............................................................................................................ 18

1.1 Genesis of the Study .............................................................................................................................. 18

1.2 Need & Relevance of the Study ............................................................................................................. 19

1.3 Objective of the study ............................................................................................................................ 19

1.4 Study Outcome ....................................................................................................................................... 19

1.5 Methodology .......................................................................................................................................... 20

1.5.1 Sampling .......................................................................................................................................... 20

1.5.2 Selection of Districts ........................................................................................................................ 20

1.5.3 Selection of Blocks in the Sample Districts ...................................................................................... 21

1.5.4 Selection of AWCs (Villages) for the Study ...................................................................................... 23

1.5.5 Selection and Coverage of Households ........................................................................................... 24

1.5.6 Tools and Techniques of Data Collection ........................................................................................ 26

1.5.7 Data Analysis and Report Preparation ............................................................................................ 28

1.6 Chapterisation Plan ................................................................................................................................ 28

Chapter II ................................................................................................................................................................ 29

2 Perceptions of Marginalised People about Health Equity in Orissa ....................................................... 29

2.1 Profile of the different categories of marginalised people in the state ................................................. 29

2.1.1 Profile of STs and SCs in the state ................................................................................................... 29

2.1.2 Profile of the women in the state .................................................................................................... 30

2.1.3 Profile of the disabled people in the state ...................................................................................... 30

2.1.4 Profile of the migrants in the state .................................................................................................. 31

2.1.5 Profile of the Adolescents in the state ............................................................................................ 32

2.1.6 Profile of the Aged people in the state ........................................................................................... 32

2.1.7 Profile of the Economically Deprived people in the state ............................................................... 32

2.2 Demographic, Social and Economic Profile of the Respondents ........................................................... 33

2.2.1 Category of Respondents ................................................................................................................ 33

2.2.2 Caste / Ethnic Composition ............................................................................................................. 33

2.2.3 Religion ............................................................................................................................................ 34

2.2.4 Family Type ...................................................................................................................................... 34

2.2.5 Housing Type ................................................................................................................................... 35

2.2.6 Income and Poverty status .............................................................................................................. 35

2.2.7 Literacy / Educational status of Respondents ................................................................................. 36

2.2.8 Marital status of Respondents ........................................................................................................ 37


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2.2.9 Occupation of the Respondents ...................................................................................................... 37

2.2.10 Migrants covered under the study .................................................................................................. 38

2.2.11 Type of disabled persons covered under the study ........................................................................ 39

2.3 Perceptions of Marginalised People with regard to Availability, Accessibility & Quality of Health Services ................................................................................................................................................. 40

2.3.1 Treatment of Illness ......................................................................................................................... 40

2.3.2 Maternal and Child Health Care ...................................................................................................... 55

2.3.3 Family Planning Services.................................................................................................................. 67

2.3.4 Status of linkage of marginalised people under Health Schemes and Programs ............................ 70

2.3.5 Participation in BCC/IEC and community health institutions .......................................................... 76

2.3.6 Out of pocket expenses on health ................................................................................................... 79

2.4 Perceptions of in‐house patients availed treatment in PHC/CHC/District Hospital ............................... 81

Chapter – III ................................................................................................................................................................ 88

3 Suggestions and Recommendations ...................................................................................................... 88

3.1 Suggestions of marginalised people ....................................................................................................... 88

3.2 Recommendations of the study ............................................................................................................. 89

3.2.1 Economic measures / recommendations ........................................................................................ 89

3.2.2 Social measures / recommendations .............................................................................................. 90

3.2.3 Spatial measures / recommendations ............................................................................................. 92

TABLES Table 1 District wise list of Sample Blocks identified under the study................................................................................. 22

Table 2 Categories of respondents covered in each AWC ................................................................................................... 24

Table 3 Category wise total number of households covered in the study ........................................................................... 25

Table 4 Number of exit interviews of in‐house patients conducted in different health facilities ........................................ 26

Table 5 Tools and Techniques used for data collection ....................................................................................................... 26

Table 6 Number of Focused Group Discussions (FGD) with various marginalized groups ................................................... 27

Table 7 Prevalence of different types of disability in Orissa per 1,00,000 population, 2002 .............................................. 31

Table 8 District wise different categories of respondents covered under the study ........................................................... 33

Table 9 Caste/Ethnic composition of households covered under the study ....................................................................... 33

Table 10 Religion of Households ............................................................................................................................................ 34

Table 11 Family Type of Households ..................................................................................................................................... 35

Table 12 Housing type of households .................................................................................................................................... 35

Table 13 Income Level of Households ................................................................................................................................... 36

Table 14 Possession of BPL Card by families .......................................................................................................................... 36

Table 15 Literacy / Educational status of respondents .......................................................................................................... 36

Table 16 Marital status of Respondents ................................................................................................................................ 37

Table 17 Occupational status of respondents ....................................................................................................................... 38


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Table 18 Place of Migration ................................................................................................................................................... 38

Table 19 Duration of Migration (in months) .......................................................................................................................... 39

Table 20 Purpose of migration .............................................................................................................................................. 39

Table 21 Types of disabled persons covered under the study ............................................................................................... 39

Table 22 Knowledge about Health Facilities .......................................................................................................................... 40

Table 23 District wise Knowledge about Health Facilities ..................................................................................................... 41

Table 24 Average distance of Health Facilities from the houses of marginalized people ...................................................... 41

Table 25 Marginalized people suffered from different minor illnesses ................................................................................. 44

Table 26 Heath Care Needs of Migrants during the time of migration.................................................................................. 44

Table 27 Marginalized people visited to health facilities for treatment of minor illness ...................................................... 45

Table 28 Health Facilities visited during the time of migration ............................................................................................. 46

Table 29 Reasons for non‐preferences of any of the public health facilities for treatment of minor illness ......................... 46

Table 30 Problems faced by migrants in availing health services during the time of migration ............................................ 48

Table 31 Status of completion of treatment of minor illnesses in public health facilities ..................................................... 48

Table 32 Quality of service for treatment of minor illnesses in public health facilities ......................................................... 48

Table 33 Marginalized people suffered from different major illnesses ................................................................................. 49

Table 34 Marginalized people visited to health facilities for treatment of major illnesses ................................................... 50

Table 35 Reasons of non‐preferences of any of the public health facilities for treatment of major illness .......................... 50

Table 36 Status of completion of treatment of major illnesses in public health facilities ..................................................... 52

Table 37 Quality of service for treatment of major illnesses in public health facilities ......................................................... 52

Table 38 Deaths due to major illness ..................................................................................................................................... 53

Table 39 Problems reported by marginalized people for the Deaths .................................................................................... 53

Table 40 Knowledge about health personnel and Contacts with them for MCH care ........................................................... 56

Table 41 Status of registration of pregnancy cases with health personnel & receipt of ANC card ....................................... 56

Table 42 Reasons of non‐registration of pregnancies with health personnel & non‐receipt of ANC Card ............................ 57

Table 43 Reasons for not attending VHND ............................................................................................................................ 58

Table 44 ANC Services availed during pregnancy .................................................................................................................. 58

Table 45 Reasons for not availing ANC Services during pregnancy ....................................................................................... 59

Table 46 Satisfaction level on ANC Services availed during pregnancy ................................................................................. 60

Table 47 Status of ANC advice and information on care of infants received by pregnant women ....................................... 61

Table 48 Reasons for not informed about ANC ..................................................................................................................... 61

Table 49 Place of delivery ...................................................................................................................................................... 61

Table 50 Reasons of not preferring health facilities for delivery ........................................................................................... 62

Table 51 Status of linkage under JSY ..................................................................................................................................... 63

Table 52 Status of Post Natal Care ......................................................................................................................................... 63

Table 53 Status of infant care ................................................................................................................................................ 64

Table 54 Quality of post‐natal and infant care ...................................................................................................................... 64

Table 55 Post‐natal contacts with health personnel ............................................................................................................. 64

Table 56 Reasons for less number of contacts with the service providers ............................................................................ 65

Table 57 Status of child health care services ......................................................................................................................... 65


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Table 58 Quality of child health care services ....................................................................................................................... 66

Table 59 Knowledge about different family planning methods............................................................................................. 67

Table 60 Status of use of family planning methods ............................................................................................................... 68

Table 61 District wise the status of use of family planning methods .................................................................................... 68

Table 62 Satisfaction level on family planning services received .......................................................................................... 69

Table 63 Knowledge of marginalised people on various schemes ........................................................................................ 70

Table 64 District wise knowledge of marginalised people on various schemes .................................................................... 71

Table 65 No. of marginalised people linked under various schemes .................................................................................... 71

Table 66 Status of receipt of disability certificate ................................................................................................................. 72

Table 67 Reasons for Non‐receipt of disabled certificate ...................................................................................................... 73

Table 68 Status of possession of aids and appliances by disabled people ............................................................................. 73

Table 69 Reasons for not having required aids and appliances ............................................................................................. 74

Table 70 Constraints to repair/replace aids and appliances .................................................................................................. 74

Table 71 Problems faced by family members to manage disabled person ........................................................................... 75

Table 72 Marginalized people participated in BCC/IEC programs ......................................................................................... 76

Table 73 District wise marginalized people participated in BCC/IEC programs ..................................................................... 76

Table 74 Percent of people understood the health messages .............................................................................................. 77

Table 75 District wise percent of people understood the health messages .......................................................................... 77

Table 76 Membership in community level health institutions .............................................................................................. 78

Table 77 District wise membership in community level health institutions .......................................................................... 78

Table 78 Annual expenses on health ..................................................................................................................................... 79

Table 79 Economic burden felt by the marginalized households due to high health expenses ............................................ 80

Table 80 Sources of mobilizing money for health expenses .................................................................................................. 80

Table 81 District wise exit interviews conducted .................................................................................................................. 81

Table 82 Status of patients having BPL card .......................................................................................................................... 81

Table 83 Number of patients interviewed in different health facilities ................................................................................. 81

Table 84 Illness of patients interviewed in the health facility ............................................................................................... 82

Table 85 Reasons of preferring the health facility ................................................................................................................. 82

Table 86 Distance travelled by patients to reach at health facility ........................................................................................ 83

Table 87 Status of completion of treatment.......................................................................................................................... 83

Table 88 Comfortability of patients in bearing various health expenses ............................................................................... 84

Table 89 Cleanliness of health premise ................................................................................................................................. 84

Table 90 Level of satisfaction of patients on various services provided at the health premise ............................................. 85


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ABBREVIATIONS ANC Antenatal Care ANM Auxiliary Nursing Midwife ASHA Accredited Social Health Activists AWC Anganwadi Centre AWW Anganwadi Worker BPL Below Poverty Line CDMO Chief District Medical Officer CDPO Child Development Project Officer CHC Community Health Centre FGD Focused Group Discussion FP Family Planning HDI Human Development Index ICDS Integrated Child Development Service IFA Iron Folic Acid IUD Intra Uterine Device JSY Janani Surakhya Yozana LHV Lady Health Visitor MCH Maternal and Child Health care MOIC Medical Officer Incharge OBC Other Backward Castes OHSP Orissa Health Sector Plan OHSP Orissa Health Sector Plan ORS Oral Rehydration Solution OSHM Orissa State Health Mission PHC Primary Health Centre PLA Participatory Learning and Action SC Schedule Caste SPSS Statistical Package for social science ST Schedule Tribe TBA Traditional Birth Attendants TMST Technical Management and Support Team VHND Village Health and Nutrition Day WHO World Health Organization

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EXECUTIVE SUMMARY

1. Study Overview & Methodology 1.1 Genesis of the Study The Health Equity study draws its significance from the global initiative to address equity issues in health. Worldwide it has been observed that certain groups of people in specific places enjoy better health as compared to certain other groups of people in the same or other localities. Country like India is not an exception to such disparity. Whether it is life expectancy, death rates, mortality rates, morbidity, etc. some dramatic differences are marked within and among the states of India. Differences by caste, gender, localities, education background, wealth, etc. are quite prominent. In the spirit of attaining equity in health, the Commission on Social Determinants of Health (CSDH) was set up by World Health Organization (WHO) in 2005 to foster a global movement and action on social determinants of health with an aim to achieve health equity. Orissa which is one of the poorest states in India recognizes the health inequity existing in the state. Since the state has maximum percentage of socio‐economically disadvantaged population, the disparities among the different sections of population are quite prominent. The Orissa Health Sector Plan (OHSP) aims to achieve equity in health outcomes and has a key focus on access and utilization of services by vulnerable and marginal groups including women, schedule caste (SC) and schedule tribe (ST) populations. Against this backdrop, the study on perceptions of marginalized people and service providers about health equity was conducted for developing equity strategy and actions to address health equity issues. The study was carried out by CTRAN Consulting with the support from Technical Management and Support Team (TMST) to OHSP. 1.2 Objective of the study This particular study focuses on to:

Understand the perceptions and views of different marginalized groups about health equity, specifically on how current program is addressing those needs and opportunities and suggestions for improvement.

1.3 Methodology Keeping the objective in mind, the study employed combination of different methodologies for collection, analysis and reporting of both primary and secondary data. Ö Employed representative sampling methods for identifying required number of districts and key informants

from different categories of marginalized people. Ö Selected four sample districts viz. Malkangiri, Jagatsinghpur, Bolangir and Keonjhar from different regions of

Orissa (one district each from southern, coastal, western and northern regions) having lowest HDI value of the district in respective region of the state. The purpose was to cover the most marginalized people in the study.

Ö In each sample district, two blocks were identified based on having highest SC and ST population. A total of eight blocks from four districts were covered.

Ö Further from each Block, five villages/AWCs were randomly selected. Each of these villages were again selected using one of the following five criteria viz. villages having highest Scheduled Caste Population, highest Scheduled Tribe Population, more number of BPL Families, more number of migrant population and village located in the most remotest / in‐accessible part of the Block. In total 40 villages/AWCs were covered under the study.

Ö Again from each of these, the study randomly selected 10 households from different categories of marginalized people residing in an AWC (e.g. disabled, migrants, lactating mothers, mothers / fathers of children between 6 months to 6 years, Adolescents, Aged above 60 years and person suffering from any major illness). In total, 400 households were covered under the study.

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Ö Apart from these households, the study also conducted exit interviews of 100 clients from four sample districts (i.e. 25 clients per district) those who had been provided in‐house medical treatment in the Block and

marginalized people.

e and reported in terms of frequency tables whereas the qualitative

er the study, maximum i.e. 43.5% belong to Scheduled Tribes (STs) followed by 36.8% belong to Scheduled Castes (SCs), 16.5% from Other Backward Castes (OBC) and the rest

tianity.

e system of joint family was found to be less prevalent as compared

who

ndents were married.

by 23% on daily

nowledge about facility

District Hospital. Ö Regarding techniques of data collection, the study used household survey, FGD and PLA techniques to map

the perception of Ö Data collected were analyzed using both quantitative and qualitative data analysis methods. The quantitative

analysis was done by using SPSS packagdata were compiled and presented in the form of matrix/response tables.

2. Perceptions of marginalized people about health equity 2.1 Demographic profile of the respondents Ö Of the 400 households covered und

3.2% are from General Castes. Ö Hinduism is the main religion practiced by the majority (97%) of the households covered in the study followed

by the rest (3%) practicing ChrisÖ Exactly two third i.e. 66% households belong to nuclear family and the rest 34% belong to joint family.

Especially among the ST communities, thto the families of other caste groups.

Ö More than 65% households covered in the study live in Kacha House without having electricity. Ö The annual income of more than 82% households covered in the study was below Rs. 25,000/‐. Ö Majority i.e. 75.3% of the households have possessed BPL card. Ö Almost 50% respondents were found to be completely illiterate followed by another 7.3% respondents

can only put their signature but cannot be called as functionally literate. Ö As far as marital status of respondents is concerned, about 63% respoÖ Regarding occupations, about 40% respondents were not engaged in any occupation and were dependent on

their family members. Ö Respondents those who were earning income, 25% were dependent on agriculture followed

wage earning. Very negligible percentages of respondents were engaged in petty business, salaried jobs, etc. 2.2 Perceptions of marginalized communities on availability, accessibility and quality of health services K

d by 80.3% knew PHC/CHC and 79.8% knew about district hospital.

ow about the presence of AWC in their village itself and about 20% did not know about

years of child did not know about AWC as compared to

4%) did not know or see the AWC as compared to male persons (6.5%). This

(8%) did not know about AWC as compared to SCs (6.8%).

ity problems.

ital.

Ö Highest i.e. 92.5% marginalised people knew about Anganwadi Centre (AWC) followe

Ö About 7.5% did not knPHC/CHC and district hospital.

Ö Greater percentage (i.e. 11.7%) of couples below sixAdolescents (6.2%) and Aged (5%).

Ö More percentage of females (8.could be due to the less mobility of females as compared to male persons in the village.

Ö Caste wise greater percentage of STsÖ Only highest percentage of migrants, disabled and aged people were found to be aware about AWC i.e. 97.5%,

95% and 95% respectively. Ö As reported during FGD, the disabled and aged people largely depend on AWC due to their mobilÖ Lowest percentage i.e. 77.5% of aged people knew about CHC/PHC and about 75% each among disabled and

SCs knew about district hospÖ Among different public health facilities, the visibility of sub‐centre was found to be lowest. Almost half i.e.

48.5% of the marginalised people did not know about the sub‐centre. Ö About 43% STs and more than 50% SCs did not know about the availability of sub‐centre in their locality.

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Ö Among all the categories of marginalised people, the visibility of sub‐centre among migrants, aged and female persons was found to be lowest i.e. about 55%, 53% and 52% respectively.

ow

ence of AWC in their village.

rginalized

Ö As per district figure, only 8% in Bolangir knew about sub‐centre. About 66% in Jagatsinghpur did not knabout the availability of sub‐centre in their locality.

Ö About 16% in Jagatsinghpur and 12% in Bolangir did not even know the pres Distance of health facilities and Mobility problems of ma

e of

is about 7 to 10kms across the districts.

Ö With regard to distance of health facilities, the marginalised people have to cover a highest distanc100kms and 50kms to reach at district hospital and at PHC/CHC respectively.

Ö The maximum distance a person has to cover to reach at an AWCÖ Similarly, covering a highest distance of 20kms to reach at a sub‐centre is very much indicative of the fact that

marginalised people have to cover a longer distance to reach at the health facility. Ö During the FGD, the marginalised people shared the following distance and mobility related problems:

Due to long distance of PHC/CHC, people first opt for local sources like Jani/Disari, Pharmacist, Vendor, Medicine Store and ASHA for treatment of their illness.

Usually when people don’t get cured by the treatment of local providers, as a next option they goPHC/CHC for treatment.

to the

Lack of transportation facility forces them to walk long distances. Crossing of river and jungle while going to the health facilities creates lot of difficulty more specifically for the females and children.

Arranging vehicle during emergency is sighted as the biggest problem for them. Due to long distance, people have to incur more expenses on transportation. Due to mobility problem of disabled person, the family members have to take the disabled person on

cycle to the heath facility. The disabled persons find lot of problem especially in taking the public transportation. Due to crowd they

find lot of difficulty to travel in the bus/jeep. Always the aged people have to depend on others for accompanying them to the hospital. Even they have

to also walk down long distances to catch the public transportation. Treatment of minor illnesses Ö As far as minor illnesses are concerned, 75% of marginalised people suffered from fever followed by 71%

suffered from cold, 42% from cough and 35% from headache. Ö The problem of diarrhoea and minor injuries was experienced by maximum aged people (20%) and migrants

ge of people i.e. 40.5% also visited AWC for treatment of their minor illnesses.

treatment of their minor illnesses.

e doctors

(57.5%

ention by providers followed

th facilities. Only 7.7%

ties.

(17.5%) respectively. Ö About 47.5% migrants suffered from various minor illnesses during the time of migration and 15.4% migrants

(only male migrants) encountered injuries at their work place. Ö With regard to treatment of minor illnesses, 47.8% visited the CHC/PHC for treatment of minor illnesses. Ö A significant percentaÖ Highest percentages of people among STs (53.4%) and aged (51.3%) people visited AWC for treatment. Ö As high as, about 55% of disabled people also visited the AWC forÖ Due to temporary status, only 30% migrants visited AWC for availing free medicines. Ö During migration, maximum migrants preferred the private health facilities i.e. 18.2% visited to privat

and 15.2% visited to private hospital for treatment of their illnesses. Ö During post migration period, most migrants were found depending on public health facilities

depended on PHC/CHC followed by 30% on AWC and 22.5% on district hospital). People those who did not prefer a public health facility, 62% of non‐preferencesÖ were due to their own problems of marginalised people and 38% were due to the constraints with providers. Among their own constraints, highest i.e. 21.1% reported long distanÖ ce as the reason followed by 12.4% said influence of family members, 10.4% reported lack of money and 9.5% said high transportation cost. Among the various constraints of providers, maximum i.e. 8.6% reported lack attÖ by 6.1% said more time taken, 5.8% said non‐availability of service providers and 5.7% said lack of trust. As high as 85% reported completion of treatment of minor illness in the public healÖ reported about incomplete and 7.5% said delayed treatment in public health facilities.

Ö Of those who availed treatment, about 76% reported the better quality health services in public facili

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Treatment of major illnesses Ö Highest i.e. 39.3% marginalised people suffered from malaria. The percentage among STs (44.3%) was highest

(5.1%), a greater

eople suffered from Blood Pressure. 10% migrants suffered from major injuries.

AWW/ASHA/ANM who in turn

d 17.6% STs reported long

ent of

son they mostly

Only Blood test and health check‐up are done free of cost at the district hospital. For medicines and other

ne by the doctors at the

hours in the hospital or visit

people even reported about paying service fee to the health providers in public health

because STs stay in remote forest areas which are generally malaria prone. Ö Next to malaria, about 7.5% marginalised people suffered from TB. Comparing with females

percentage of male persons (10.2%) suffered from TB. Ö About 3.8% marginalised pÖ For treatment, maximum i.e. 52.1% depended on CHC/PHC followed by 47.5% depended on district hospital. Ö During FGD, people informed that initially they consult the local providers like

refers them to PHC/CHC and District Hospital for treatment of their major illnesses. Ö Marginalised people who did not prefer the public health facility, 57.6% of their non‐preferences were due to

their own problems and rest 41% were due to the constraints with the providers. Ö Among the own constraints, 18.5% reported about influence of their family members followed by 14% said

long distance of health facilities, 9.2% informed lack of money and 8.4% told high transportation cost. Ö Among the various constraints of providers, 10.1% pointed out lack of trust / faith on providers followed by

8.3% reported lack of attention by providers, 7.3% felt more time taken by providers, and 5.5% pointed out non‐availability of providers in the health facility for their non‐preference. Highest percentage of disabled people (14.3%) gave lack of trust on providers anÖ distance of health facilities as the reason for non‐preferring a particular public health facility. About, 67.6% reported completion of treatment of their major illness. Delayed or prolonged treatmÖ major illnesses in public health facilities was reported by 15.5% of the marginalised people.

Ö About 17% reported non‐completion of treatment of their major illness in public health facilities. The responses given with regard to minor and major illness during FGD are as follows: Ö During rainy season people generally suffer from diarrhoea, vomiting, etc. and in winter sea

suffer from cold, fever, etc. Malaria is the major health problem that they face all throughout the year. Ö People complained of not being cured by the free medicines given by ASHA/AWW. Ö Sometimes, people do not get medicines from ASHA/AWW due to not having adequate stock. Ö

things people have to bear heavy expenses for treatment of their major illness. Ö People are found to be unhappy due to paying service fee to the doctor in the PHC/CHC at Tikarapada in

Bolangir district. Ö Except Jagatsinghpur, people are satisfied with the quality of health check‐up do

PHC/CHC and district hospital. Ö People seem to be unhappy with regard to the non‐availability of doctor at PHC/CHC if they don’t reach the

hospital in the scheduled time. Therefore, either they have to wait for long doctor’s residence for health check‐up or sometimes they have to return back without treatment.

Ö In Jagatsinghpur, facility.

Ö People in Bolangir have the general perception that free treatment from the health providers would not be effective as compared to the paid treatment.

Ö People have to move from facility to facility for non‐availability of all types of health care services in one health facility.

Ö Aged people reported their concern on non‐availability of prescribed medicines in free of cost. Ö Disable persons reported their constraint of depending on family members for visiting health facilities. Knowledge and contacts with maternal and child Health Care providers

21% households (i.e. 84 out of 400) covered inÖ the study had a pregnancy case in their family. Ö Regarding knowledge of MCH providers, majority knew the ANM (88%), ASHA (87%) and AWW (94%)

appointed at Sub‐centre and AWC level. About 6 to 13% people did not know about them. SCs, as high as

e. During the time of pregnancy, the pregnant women had at least five times in contact with ASHA, four times

cy.

Ö When 5.3% STs did not know about ANM, about 16.7% SCs were not aware about ANM. Among20% did not know about the ASHA worker and 13.3% did not know about AWW appointed in their villag

Ö with AWW and three times with ANM during nine months of pregnan

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Ö STs in comparison to contacts with ASHA and ANM (two times) had relatively more contact with AWW (five

thers had at least

NM

acts in Malkangiri district (one time

times) during pregnancy. Ö Regarding contacts with heath personnel within six month of child birth, the lactating mo

two times in contact with ANM and three times in contact with AWW and ASHA each. Ö Specifically the lactating mothers among SC and BPL households had only one time in contact with the A

during first six months of child birth. Ö District wise break‐up of post‐natal contacts shows less number of cont

with ANM, two times with ASHA and three times with AWW). Ö About 16.1% reported their low income as the reason for which they were not contacted by health personnel

and 9.7% cited long distance of their village as the reason for the same. Antenatal Care (ANC) Ö About 90.5% pregnancies were not registered with health personnel. The percentage of pregnancies

registered among SCs (86.7%) was found to be lowest. Ö In total, 89.3% pregnant women were provided with ANC card. Of those who were not given ANC card,

maximum i.e. 41.7% reported lack of contacts by the providers as the reason for the same. Ö The pregnant women who did not prefer to visit the health facility for registration gave reasons like long

distance of health sub‐centre, irregular visit, lack of proper attention & no prior information by providers 52.4% people never attended VHND. The percentage of SCs (40%) attended VHND was as compared to STs (50%) and BPL (47.3%).

t attending the VHND.

(78.2%) households were accompanied by

urine sample done during

eck‐up (71.1%) was also found to be much less as

done in case of only 57.9% pregnant women among STs as compared

ingpur (84.2%).

Ö More than half i.e.found to be quite less

Ö About 40.9% reported lack of awareness about VHND and 28.8% told lack of initiative by the service providers to intimate them before the VHND as the reasons for no

Ö Highest i.e. 94% reported receipt of supplementary nutrition, followed by 91.7% received at least one strip of IFA tablets and 89.3% were given at least one dose of TT.

Ö Weighing, measurement of BP and abdomen check‐up were done at least once in case of about 86.9%, 69% and 81% pregnant women respectively.

Ö About 82.1% were accompanied by ASHA (at least once) to health facilities for availing ANC services. Ö Less percentages of pregnant women among SCs (73.3%) and BPL

ASHA to health facilities for ANC as compared to STs (89.5%). Ö Comparing with SCs (56.7%), only 26.3% STs reported about the testing of

pregnancy. Similarly, only 31.6% STs reported about testing of blood samples during the pregnancy. Ö The percentage of STs who had undergone abdomen ch

compared to SCs (83.3%). Ö The measurement of blood pressure was

to 70% SCs. Ö Relatively fewer percentages of pregnant women in Malkangiri (71.9%) and Keonjhar (73.3%) were undergone

abdomen check‐up as compared to Bolangir (100%) and JagatsÖ Lack of proper attention by health personnel (22.2%) and lack of privacy at health facility for check‐up of

pregnant women (14.3%) were reported as the reasons for not availing the ANC services. Ö Yet, around 78.6% households of those who received various ANC services were found to be satisfied or highly

satisfied with regard to the quality of ANC services. Ö As high as 30.6% people in Malkangiri and 25.9% in Bolangir district reported average satisfaction over the

quality of ANC services. Advices on maternal and child health care

Only 58.3% pregnant women were told about keeping the baby warm immediaÖ tely after the birth. More than 42% pregnant women were not made aware about preventing infant death due to hyperthermia. About 23% were not informed about the different cleanliness need to be maintained Ö during delivery and around 20% were not advised about the correct breast feeding practices. Most importantly, about 18% were not advisedÖ PHC/CHC/Sub‐centre.

About 57% were not advis

to conduct the delivery at the health facilities like

ed for family planning or for delaying the next child. Being asked about the reasons, maximum i.e. 41.6% could not give any reasons.

Ö

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Ö People those who gave reasons, 11.4% reported about irregular visit of health personnel, 11.7% pointed out

ut the time their lack of interest to know the same, 9.4% reported lack of attention by health personnel, etc. as reasons.

Ö Only 72.2% mothers were advised about exclusive breast feeding and only 54.4% were told aboand importance of complementary feeding.

Delivery and Post‐natal care Ö About 39.3% deliveries were conducted at home. The rest 60.7% deliveries were conducted at health facilities.

) and Bolangir (22.2%) districts.

for preferring against visiting the health facility for delivery. pregnant women were covered under JSY in Malkangiri as compared to 78.9% in

nd

Ö District wise break‐up shows that the percentage of home delivery in Malkangiri was very high (about 75%) as compared to Jagatsingpur (10.5%), Keonjhar (20%

Ö The tribal culture and tradition in Malkangiri district was found as a major barrier for institutional delivery. Ö The other reasons were like long distance of health facility (29.2%), high transportation cost (12.3%), no body

to accompany the pregnant women (7.7%) and lack of attention by the service providers (6.2%). Ö Only 54.8% pregnant women were linked under JSY. This could be the reason for which around 12.3%

reported high transportation cost as the reasonÖ District wise only 22.6%

Jagatsinghpur, 73.3% in Keonjhar and 66.7% in Bolangir district. Of the institutional deliveries, only 62% mothers were checked‐up for the second time after delivery within Ö two months of delivery which in case of STs is further low at 54.2% only. District wise only 28.6% lactating mothers in Bolangir district were checked‐up for Ö 2 time within two monthsafter birth.

Ö As far as quality of post‐natal is concerned, more than 75% households reported the availability of better quality of services from health providers.

Child health care Ö Drying and wrapping of babies was done in case of only 74% infants which among BPL families was even less

at 65.5%. In Keonjhar district the drying and wrapping was done in case of only 46.2% of infants.

ing / growth monitoring of child was

to quality of child health care services, 76.3% reported the availability of better quality services.

th providers. Regarding the problems faced by migrants for child health care, maximum i.e. 29.3% reported about lack of

roviders since they migrate for most part of the year.

ed by

ws:

Ö Only 58% infants were checked‐up for the second time within two months of birth (14.3% in Bolnagir). Ö Any immunisation service was received by 89.9% households. The weigh

done in case of 76% children. Only 21% children were supplemented with Vitamin – A. Ö With regardÖ In Malkangiri district, relatively less percentage of marginalised people (only 63.5%) reported about the good

child health care services given by the healÖ

attention by pÖ About 14.6% migrants reported that the health personnel do not recognize them. About 17% said non‐

availability of immunization services at the health facilities. Ö About 9.8% of migrants were not allowed to register for antenatal and post‐natal care services follow

4.9% were not provided supplementary nutrition as their names were not registered with health providers. Ö Various problems that were shared during the FGD with regard to MCH care are as follo

In Malkangiri people still prefer to conduct the delivery by TBA where as in other districts after the appointment of ASHA people mostly prefer to visit the health facilities for delivery.

Mobility of pregnant women was shared as the major problem for them. As high as Rs. 200/‐ to Rs. 500/‐ was spent for taking pregnant women to hospital for check‐up and delivery.

Due to long distance of health facilities, people also reported about the instance of delivery taking place on the way to hospital.

Lack of privacy of pregnant women while the health check‐up at AWC was shared as a de‐motivating factor to avail the ANC services.

People in Bolangir reported about the non‐availability of supplementary nutrition from AWC.

PIn Jagatsinghpur, people reported that the ANM never taking visit to their village. They have to go to anchayat office to avail MCH care from the ANM.

In Bolangir, people reported about lack of initiative by health personnel to make them aware about various ANC services. Lack of attention by ASHA; non‐availability of TT; immunisation; etc. were the other problems reported by them.

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In Jagatsinghpur pregnant women have to go long distance for blood & urine check‐up. In Malkangiri, people reported about the delay by health personnel in PHC/CHC in attending the pregnant women.

Family Planning Services Ö Regarding knowledge about modern family planning methods, female condom (4.3%) was least known to

marginalised people followed by injectables (6%) and IUD/Loop method (9%). half of this

8.3% eligible couples and 2.8% went for IUD insertion.

respectively. services were found to be

Ö Maximum i.e. 87% of marginalised people knew about female sterilisation method. However, onlyi.e. 44.3% of marginalised people were aware of male sterilisation method.

Ö Other modern methods like pill and male condom were only known to less than half of the marginalised people (i.e. 48.3% and 44.8% respectively) covered under the study.

Ö Among the STs, only 4.6% knew about IUD/Loop and 31% knew male sterilisation methods. Among the BPL households, only 8.3% were aware of IUD/Loop method and only 40.5% knew male sterilisation method.

Ö Highest i.e. 10.1% eligible couples use male condom although 44.8% were aware of the same method. While 87% were aware of female sterilisation, only 6.3% eligible couples went for the same.

Ö Less than one percent (i.e. only 0.6%) eligible couples opted for male sterilisation. Ö Pill was used by aboutÖ Among the migrants, greater preference was on use of pills (22.2%) followed by female sterilisation (14.3%). Ö Since migrants are considered as high risk groups to HIV/AIDS, greater emphasis has been laid on use of

condom by migrants for preventing them from HIV/AIDS. However, only 10% migrants reported using same. Ö District wise, the greater preference in Keonjhar district was on use of male condoms (26.4%) as compared to

Malkangiri (0%), Jagatsingpur (4.1%) and Bolangir (5%) districts. Ö Cases IUD insertion was only found in Malkangiri (10%) and male sterilisation in Bolangir district (2.2%). Ö Use of pill was found across all districts with variations in the percentages of people using the same (14% in

Keonjhar, 12.2% in Jagatsingpur, 6.8% in Bolangir and only 3.1% in Malkangiri). Regarding people received different family planning services, highest i.e. 34.8% were provided productsÖ like pills, condoms, etc. followed by 31.8% were provided sterilisation service in public health facilities. Awareness generation and counselling services were provided to only 19.7% and 13.6%Ö

Ö Regarding the quality of services, about 80% those who received family planning satisfied. About 17.2% were found to be dissatisfied with the service.

Ö Higher percentage of females (25%) was found to be dissatisfied with the service. Ö Greater percentage of marginalised people those who availed family planning services in Bolangir district

(33.3%) were found to be dissatisfied. Ö The problems that were shared during FGD with regard to family planning services are as follows:

Greater preference to female sterilization as reported by people across the four districts. In the family planning camps, people are motivated for taking sterilization. Usually women opt for sterilization.

People perceive that sterilization of men would physically weak them so they can’t do any physical labor. People complained about not being checked‐up by health personnel after the family planning operation. Women complained about the side effects such as physical weakness, head drizzling, body pain, etc. of

using the pills. Hardly any awareness or counseling programs are organized for using different methods. Except Keonjhar, people in all the other three districts reported about the non‐availability of family

planning products such as pills, condoms, etc. Due to non‐availability of pills and condoms with ASHA/AWW, people purchase the same from the shop.

Perceptions of in‐house patients in health facilities Ö About 66% in‐patients reported about completion of their treatment in the health facility visited by them

where as 34% could not get cured by the treatment made in the health facility. Ö gaRe rding cleanliness of the health premise in which they were admitted and provided treatment, 75%

reported about the good and cleanliness of the patient consultation room and the patient examination room. than 50% reported about the cleanliness of the waiting room in the health facility visited by the patÖ Less ients.

Ö 51% patients were found either averagely satisfied or dissatisfied on the timings maintained by providers. Ö Due to long hours of waiting at the health facility 58% reported average satisfaction or dissatisfaction. Ö Half i.e. 51% were found satisfied with regard to the privacy of patients maintained in the health facility. Ö Only 47% reported about relief of symptoms due to the treatment in the health facility.

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Ö In overall, only 51% patients were found to be satisfied with the quality of services. Ö Various suggestions made by patients with regard to improving the services in the health facility are as follows

Adequate provisions of Nurse and Doctors; ambulance service; beds; mosquito net and fans; clean drinking water; free nutritious food; medicines in free of cost; blood and urine testing in free of cost and

he attendant in the health facility sufficient blood; staying arrangements for t The providers in health facility should be equipped technically with required infrastructure to provide

treatment to the patients suffering from major illness instead of referring them to other hospital The services and provisions in the health facility should be informed to the people Doctors should keep patience to properly listen the problems of patients before prescribing the medicines Service fee charged by some health providers needs to be completely stopped The doctors should provide equal attention to all categories of patients irrespective of age, economic and

social bar. Benefits received under health schemes and provisions

Programs like National Leprosy Eradication Program (29%), National Vector Borne DiseÖ (24%), National Tuberculosis Control Program (37.3%), National Program for Con

ase Control Program trol of Blindness (25.3%),

ram when it is known that

rt under

Iodine Deficiency Disorder Control Program (27.8%), etc. were found to be less known to marginalized people. Ö Only 11.3% of the adolescents were aware of the Koshori Shakti Yozana and 19% STs knew National Vector

Borne Disease control program. Likewise, only 20% aged people were aware of National Tuberculosis control progÖ

higher percentage of aged people in Orissa suffer from TB. Ö About 46 pregnant women were provided benefit under JSY. Only 24 people were provided suppo

National Vector Borne Disease Control Program of them 17 are from ST communities. Ö Regarding the linkage under government schemes, the following problems were shared by marginalised

people during the FGD: People complained about the role of Sarpanch and sought the intervention of Block Chairman for proper

supervision and monitoring of pension schemes. Lack of initiative by health personnel to make people aware about various health schemes and programs

s have been covered under handicapped pension of Rs. 200/‐ per month.

y was to support / accompany them to meet the

d financial constraint as

ple (those who earlier had such appliances but the same are damaged now) sought

ghted by disabled people during FGD are as follows:

was reported by the majority. Ö With regard to the benefits received by disabled people, 57.5% have the disability certificate. Of those who do

not have disability certificate, about 23.5% were not aware about the place where the certificate is issued. Ö About another 23.5% felt that the authorities are not sensitive towards disabled people hence they are not

being listened or issued a disabled certificate. Ö Only 13 out of 40 disabled personÖ Only 16.2% people were found to be having requisite aids and appliances with them. Ö About 65% were unable to access such facilities since no bod

authorities and 38.7% were unaware about the place or office where the aids and appliances are provided. Ö About 20% felt that the authorities were not sensitive towards them and 16% identifie

the problem for unable to get the aids and appliances. Ö About 9.7% disabled peo

ithe r damaged aids and appliance to be replaced with new ones. Ö Apart from the above, the constraints that were highli

Although the names of disabled persons are registered in the AWC record but hardly any of them are provided with disability certificate.

People have received disability certificate but they have not been linked under handicapped pension scheme. People those who have been linked reported insufficiency of pension amount provided by govt.

For getting pension, the disabled persons need to attend camp generally organized at block headquarter. No officials or authority has ever visited to their village for identifying and issuing disability certificate. ers like ASHA/AWW to make them aware about the various

provisions available for handicapped persons and the procedure to avail the same. There is no effort by village health work

Hardly one to two persons in the village have been provided with aids and appliances. Repair and replacement of appliances is a major problem for them.

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Participation in BCC/IEC and Health Institutions Ö Maximum i.e. 66% people came to know about health messages from radio / TV followed by 34.3% by reading

w any health posters / wall paintings. ns,

ar, only 50% in Malkangiri district watched TV/Radio which could be

ges given in posters/pamphlets/wall paintings. lighted with regard to BCC/IEC are as follows:

or seeing any health posters / pamphlets. Ö Relatively a less percentage of women and aged people read or saÖ Other forms of BCC/IEC programs like streetplay / Palla / Daskathia, community meetings, health exhibitio

etc. were attended by very negligible percentage of marginalised people. Ö In comparison to 86% people in Keonjh

due to less coverage of TV/Radio in Malkangiri district. Ö Only 22% in Keonjhar and 29% in Jagatsinghpur read or saw any health posters/wall paintings in comparison

to 44% and 42% in Malkangiri and Bolangir district respectively. reÖ With regard to the messages understood by people, as high as 91.8% of the marginalised people who we

listening radio/TV could understand the messages given through the same medium. Ö However, relatively less percentage i.e. 71% of marginalised people those who read or saw health posters /

pamphlets / wall paintings could able to understand the messages given in the same. Ö Only 68.9% STs and 66.7% SCs understood the health messages given in the posters/pamphlets/wall paintings.

Only 52.3% in Malkangiri district understood the health messaÖÖ During the FGD, The problems that were high

As reported by people, hardly any BCC/IEC event was organized in the village. People mostly come to know about the health messages from radio/TV and reading posters/pamphlets.

rPeople are illiterate, hence not able to ead the messages and not interesting to watch the BCC shows. Problem in communicating messages during BCC shows, hence unable to understand. BCC/IEC programs are organised in a distant place, hence people face difficulties to attend the same. The timing fixed for BCC/IEC program is not very suitable for people to come & participate in the program.

food committee (4.3%).

d under the study.

tricts.

Ö Regarding people’s participation in community level health institutions, hardly any marginalised person was found to be members of mothers’ committee (5.3%) and

Ö Village Health and Sanitation Committee seems to be non‐existent as only 1.3% were found to be member. In fact, VHSC was not formed in most of the remote villages covere

Ö Only 21.8% of marginalised people were found to be members of SHG, however the health agenda is only a secondary focus of SHG.

Ö District wise analysis shows more percentages of people in Keonjhar were found to be members of mothers’ committee (15%), food committee (14%) and SHG (47%) in comparison to the other dis

Out of pocket expenses on health Ö The average total health expenses of marginalised households was coming to Rs.2,453/‐ per year (Rs. 1488/‐

Rs. .941/‐ respectively.

rage

on medicines, Rs. 427/‐ on transportation, Rs. 374 on pathological testing and Rs. 164/‐ on service fee). Ö The expense incurred on purchasing medicines was found to be highest. Ö In Bolangir and Jagatsinghpur, the total average health expenses of marginalised households was as high as

4037/‐ & Rs.4004/‐ whereas in Malkangiri and Keonjhar it was much less at Rs.521/‐ and RsÖ The migrant households in Jagatsinghpur district incurred highest annual health expenses (i.e. on an ave

Rs. 8850/‐ per annum) as compared to any other marginalised groups. Ö In Bolangir, the households having disabled persons incurred highest health expenses i.e. on an average Rs.

6,627/‐ per annum in comparison to other categories of marginalised people. Ö As a result of high health expenses, maximum percentages of households in Bolangir (68%), Jagatsinghpur

(84%), and Keonjhar district (74%) reported about extra economic burden endured by them to bear the same. In fact, bearing high health expenses was found to be so demanding on them Ö for which around 64.8% marginalised households had to lend money from local money lenders with an exorbitant rate of interest of 5 to 10% per month.

Ö Only 23% marginalised households could manage to meet the full or part of their health expenses from the own source.


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3. Suggestions by Marginalized people and Recommendations of the study The suggestions given by the marginalised people are presented below as verbatim. Before getting into the suggestions, one must note that the marginalised people who gave their suggestions are basically illiterate and less informed, and socially and economically disadvantaged. Thus, these suggestions are more of their expectations

areness programs & motivational camp on health schemes and institutional delivery contacts and their regular supervision

children g) Appointment of health providers in vacant places h) Special attention and provision for treatment of disabled and aged people i) Construction of roads and provision of transportation facilities j) Creation of employment opportunities for migrants and others

Apart from the above suggestions, the study has made certain recommendations especially for addressing the constraints faced by people due to their own marginalisation e.g. lack of money to spend on medicines, long distance of health facilities, etc. Addressing marginalisation of people is undoubtedly requires an integrated effort of providers in various sectors such as education, livelihood, finance, health, etc. Since the root causes of marginalisation are due to various factors like income opportunities in the area, geo‐physical environment of the area, resource availability with the people, tradition and culture of the people, etc. the process of minimising the same would require longer time and more resources. The recommendations are as follows:

a) Risk Transfer: Keeping the economic constraints of people in mind, the health sector can initiate risk transfer measures by introducing micro health insurance schemes.

b) Introducing financial products targeted at health issues: In order to keep both financial institutions and marginalised people in a win‐win situation, the health sector has to make effort to mobilise the financial institutions for designing both savings and loan products that caters to the health needs.

c) Equity sensitive IEC/BCC interventions: As information or knowledge carries lot of significance for attaining better health, purposive IEC/BCC interventions are highly essential. In this regard, the state can take‐up measures like:

i) Introduction of community kiosks ii) Extensive use of mass media, posters/pamphlets, wall paintings, etc. for delivering appropriate

health messages pertaining to the needs of the people and the area. d) Promoting and building social capital / community health institutions e) Measures to improve the rural infrastructure like road, electricity, drinking water, etc. could be taken up

for attaining better mobility of marginalised people more specifically to benefit the pregnant women, children, disabled, aged and people residing in remote or inaccessible areas.

f) Last but not the least, keeping the in‐accessibility and geo‐physical factors into account, provision of ambulance in rural areas could benefit a large number of marginalised people. The other solutions could be like increasing the provision of mobile health clinics and organising health camps on regular basis especially for the benefit of pregnant women, children, disabled, aged and people residing in remote or inaccessible areas.

***

and needs rather than those are solutions to their problems.

a) Provision of health camps for pregnant women, children, disabled, aged people and those people residing in remote or inaccessible areas

b) Provision of ambulance service, free medicine, free aids & appliances for disabled people, own AWC building for maintaining privacy of pregnant women, delivery facilities at PHC (N) and specialist doctors like gynaecologists, card to disabled people for health services, more amount of pension, etc.

c) Provision of ad equate stock of medicines and family planning products with AWW/ASHA and timely replenishment of products

d) Create awe) Ensure regular visit by AWW/ASHA/ANM to their village & homef) Regular distribution of supplementary nutrition to women and


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Chapter I

1. Study Overview & Methodology

her groups of people in the same or other localities. The difference is d,

kground of the people. Particularly, people those ly disadvantaged sections of

disparity among different sections of rates, morbidity status, etc. there are

shal the evidence on what can be

, and age, and the systems put in place to deal with illness. The conditions ineconomic

ourishing life, or whether its life

population, the disparities among the different saddressing health inequity, the Orissa Health Sector Plan (OHSP) has been developed by the government

1.1 Genesis of the Study The Health Equity study draws its significance from the global initiative to address equity issues in health. Worldwide it has been observed that certain groups of people in specific places enjoy better health as compared to certain otnot only observed between countries but also seen within different locations in a country. As observe

ion are closely linked with thethe differences in the health status among different sections of populatsocio‐economic, cultural, geographic and political bacwho have poor health status are most likely belong to the socio‐economicalthe community. Country like India is not an exception to such population. Whether it is life expectancy, death rates, mortality some dramatic differences marked among the states in India. The differences are also quite significant by caste, gender, localities, education background, wealth, etc. both within and between the states of India. Especially people those who are poor, their health status is found to be worse or inferior as compared to those having better socio‐economic status. Therefore, such disparity in the health status is a matter of great concern for any country which can be termed as social injustice in any state or country. In the spirit of attaining social justice in health, the Commission on Social Determinants of Health (CSDH) was set up by the World Health Organization (WHO) in 2005 to mardone to promote health equity, and to foster a global movement to achieve it. Aptly recognized by CSDH is that “within countries there are dramatic differences in health that are closely linked with degrees of social disadvantage. Differences of this magnitude, within and between countries, simply should never happen. These inequities in health, avoidable health inequalities, arise because of the circumstances in which people grow, live, work which people live and die are, in turn, shaped by political, social, and economic forces. Social and

policies including the provisioning of the heath care services have a determining impact on whether a child can grow and develop to its full potential and live a flwill be blighted”. In view of this, the Commission calls on the governments, civil society, WHO, and other national and international organizations to lead global action on the social determinants of health with the aim of achieving health equity. Orissa which is one of the poorest states in India recognizes the need of addressing health inequity existing in the state. Since the state has maximum percentage of socio‐economically disadvantaged

ections of population are quite prominent. In view of


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to address the same. The OHSP aims to ach h outcomes and has a key focus on access and utilization of services by vulnerable and including women, schedule caste (SC) and schedule tribe (ST) populations. It aims at deliverin accountable and responsive health care to reduce maternal mortality; us diseases; under‐nutrition and nutrition diseases and disorders. In view of achieving equity in health, the OHSP intends to develop strategy and action plan to integrate ways to address social exclusion including

. To develop the equity strategy paper there was a felt need to ssess the available evidence/experience in the context of existing program, people’s perception and

ied to understand the reasons of inequities from the perceptions of service providers and service users

ieve equity in healt marginal groups

g infant and child mortality; reduce the burden from infectio

‐related

gender inequality across the programaprovider’s perception in relation to equity. Thus the study on perception of marginalized people and service providers about health equity was conducted. The study was carried out by CTRAN Consulting with the support from Technical Management and Support Team (TMST) to OHSP.

1.2 Need & Relevance of the Study As clear from the genesis of the study that the findings of this study would provide required inputs for developing appropriate strategies and actions to address health inequities in Orissa. The study was first of its kind in the state which emphasizes on understanding the perceptions of marginalized people and providers on health equity issues. Since the state gives importance to deliver responsive and accountable health care, understanding the perceptions of users as well as providers of health services is apparent to know the equity issues that prevails in service provisioning; and service accessing and utilization. Although various health studies that were undertaken in the state clearly reveal the differences in health status among different sections of population however, none of those has actually tr(more specifically the marginalized sections). Therefore, an attempt was made through this study to understand the service providers’ perceptions and also the views and opinions of marginalised people so that appropriate and responsive actions can be initiated by the state to address equity issues in health.

1.3 Objective of the study This particular study focuses on to:

Understand the perceptions and views of different marginalized groups about health equity, specifically on how current program is addressing those needs and opportunities and suggestions for improvement.

1.4 Study Outcome The study was expected to prepare:

A paper on perception of marginalized people and proposed action to address equity issues to achieve equity in health outcomes; and

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1.5 Methodology Keeping the objective and outcome expected from the study, both primary and secondary research methods and techniques were employed for undertaking the study. The details about the methodology including the sampling technique and data collection tools and techniques used in the study are presented hereunder.

1.5.1 Sampling The study used representative sampling methods for identifying required number of districts and for selecting the key informants. Since the focus of the study was on marginalized people, the sampling chnique decided for the study (which is as presented below) tries to inculcate human development

from different categories of marginalized and ulnerable groups such as SCs, STs, Disabled, Migrants, Children and other marginalized groups based on

HDI value of the districts.

that the HDI value of each

taking into account the

etc.

values in which the

been distributed (shown in

tefactors; regional factors; and representative samplesvhealth indicators and economic backwardness.

1.5.2 Selection of Districts In total, four sample districts were selected out of the thirty districts existing in the state for undertaking the study. The steps that were followed for the selection of districts are as follows: i. Keeping the focus of the study in mind, it was oblivious to select those sample districts which have

very low and poor status on the human development parameters so that adequate sample households from different marginalized sections can be covered under the study. Therefore, the study used the Human Development Index (HDI) value as the parameter for selection of districts. In view of this, the study referred the Human Development Report of Orissa, year 2004 to know the

Important to mention here

district was calculated in

various development indicators of health, income, education,

ii. Out of the three ranges of

HDIdistricts of Orissa have

the Orissa map presented here), the study decided to

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take the lowest two ranges of HDI values (viz. ‘<=0.5’ and ’>0.5 and <0.6’) for selection of sample districts. Although, the initial idea was to select only those districts having lower HDI values (i.e.

. ’>0.5 and <0.6’ for selection of sample districts. The only purpose of doing so was to eregional factors so that a representa

iv. Since, almost all the distrithe ‘<=0.5’ range of HDI

the western region of the state viz. Balangir, Bargarh, Sonepur, Nuapada and Sambalpur which fall

cts viz. Malkangiri, Bolangir, Keonjhar and Jagatsinghpur were e study. A brief profile on the demographic and health status of these

Selection of Blocks in the Sample Districts

After the identification of sample districts, two blocks were selected from each sample district for In total, eight Blocks from four sample districts were identified and

one in taking into account the caste factor. Since the Scheduled Castes are considered as the most marginalized groups, only those two

sample districts where the population of SCs and STs that together is highest as compared to the other blocks in the respective district. This was done purposefully so

having HDI value of <=0.5), however, the study team found that the said districts are located mostly in the southern part of Orissa. Since this would not be a representative sample covering different regions of Orissa, the study apart from the said range of HDI value opted for the districts in the next highest range i.e

ncompass the tive

sample of districts could be identified. iii. The districts that were taken into

consideration for selection of sample districts under ‘<=0.5’ and ’>0.5 and <0.6’ HDI values are as given in the box.

cts that fall under

value are located in southern region of Orissa, only one district i.e. Malkangiri was identified from the said range of HDI values. Likewise, out of the five districts in

under ’>0.5 and <0.6’ range of HDI value, Balangir district was selected for having lowest HDI value among the districts in the same range of HDI value. Keonjhar District was identified from the northern region of the State which is the only district figured out under ’>0.5 and <0.6’ range of HDI value from the same region. Lastly, one district from coastal region was selected i.e. Jagatsinghpur which has again lowest HDI value among the districts in the same region that are in the ‘>0.5 and <0.6’ range of HDI values.

v. Accordingly, four sample distri

identified for undertaking thfour districts is annexed.

1.5.3 i.

collection of primary data. covered under the study.

ii. The selection of Blocks was d(SCs) and Scheduled Tribes (STs)Blocks were identified in the

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200

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22


that adequate sample households from SC and ST communities could be covered during the data collection process. Accordingly by applying the said criteria, the study identified two Blocks in each of the sample districts which are as highlighted in the table given below. However, during the time of data collection the study team could not cover the Kalimela Block in Malkangiri district due to Naxal insurgency. Therefore, in place of that Block the study team had to take the next Block (i.e. Mathili Block) that comes as per the criteria.

Table 1 District wise list of Sample Blocks identified under the study

Name of the Districts

Name of the Block Scheduled Castes Scheduled Tribes Grand Total Male Female Total Male Female Total

Malkangiri Korkunda 14827 14381 29208 27915 28190 56105 85313 Kalimela 18296 17636 35932 20117 20348 40465 76397 Mathili 3146 3202 6348 29776 30139 59915 66263 Malkangiri 5438 5376 10814 18425 19019 37444 48258 Kudumulgum 2036 2012 4048 18133 18604 36737 40785 Podia 4872 4777 9649 14207 14428 28635 38284 Khairaput 1299 1248 2547 12264 12806 25070 27617 Balangir Patnagarh 7046 6883 13929 15243 15461 30704 44633 Muribahal 7915 7815 15730 11585 11699 23284 39014 Titlagarh 9246 8979 18225 10269 10365 20634 38859 Saintala 8577 8469 17046 10044 10144 20188 37234 Turekela 5719 5758 11477 11465 11784 23249 34726 Belpara 5379 5282 10661 11866 12106 23972 34633 Balangir 7562 7245 14807 9844 9620 19464 34271 Khaprakhol 4991 5059 10050 12052 12121 24173 34223 Bangomunda 8969 9025 17994 7649 7829 15478 33472 Deogaon 7172 7068 14240 8905 9114 18019 32259 Puintala 11740 11284 23024 3140 3031 6171 29195 Loisinga 6460 6413 12873 8008 7952 15960 28833 Tentulikhunti

(Gudvella) 4894 4626 9520 7744 7680 15424 24944

Agalpur 7034 6822 13856 5475 5515 10990 24846 Keonjhar 7 67264 81240 Kendujhargarh 7112 6864 13976 33787 3347 Harichandanpur 4447 4401 8848 33765 33014 66779 75627 Joda 5033 4846 9879 31061 30652 61713 71592 Banspal 1879 1938 3817 33231 33984 67215 71032 Ghatgaon 2913 2921 5834 31903 31715 63618 69452 Hatadiha 18905 18607 37512 13159 12674 25833 63345 Anandpur‐I 6394 6215 12609 22721 22821 45542 58151 Patana 3378 3447 6825 23847 23905 47752 54577 Jhumpura 3199 3228 6427 24098 24014 48112 54539


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Table 1 District wise list of Sample Blocks identified under the study

Name of the Districts

Name of the Block Scheduled Castes Scheduled Tribes Grand Total Male Female Total Male Female Total

Champua 4379 4271 8650 22781 22638 45419 54069 Telkoi 4718 4734 9452 22413 22105 44518 53970 Saharapada 3405 3394 6799 22057 22595 44652 51451 Ghasipura 12773 12675 25448 12674 12451 25125 50573 Jagatsinghpur Kujang 19341 18611 37952 849 880 1729 39681 Jagatsinghpur 16 76 3 320 15956 322 48 192 540 32816 Tirtol 14885 14897 29782 394 347 741 30523 Balikuda 14933 14713 29646 125 132 257 29903 Ersama 13116 12856 25972 228 195 423 26395 Biridi 1 1 22263 1804 4067 180 161 341 24408 Raghunathpur 9475 9109 18584 507 427 934 19518 Nuagaon 6768 6628 13396 133 114 247 13643

1.5.4 Select AW ill f t

Once the Blo tified, th y t e t AW hich ten AWCs we from each t. In d d Instead of re llage, the stu ted k lo m tive collection of ata from the ina e n m view of the f grassroot ser o f lt rtm AWW, ASHA ) converge L r alth t ervic AWCs, so tha tions of aliz o pr C c studied.

. The following ria were tak ac on AW e. c each for selec e AWCs) in e the e of ur districts.

i) AWC st Scheduled Caste Population ii) AWC ghest Schedu be P t

AWC r o amiv) AWC ber o ant tiv) AWC is located in the em in t o

The purpose ing the abo ria g q m marg group in an A at, the stu ed (F mapping the d respo ea h n ro

ion of Cs (V ages) or the S udy i. cks were iden e stud eam th n selec ed five Cs per Block, w means

re covered distric total, the study covere 40 AWCs from four istricts.venue vi dy op to ta e AWC as the west ad inistra unit forprimary d marg lized p ople. The decisio to take AWCs was ade inact that the s level vice pr viders rom Hea h and ICDS depa ent (viz.and ANM at AWC evel and delive the he & nu rition s es fromt, the percep margin ed pe ple and service oviders in an AW ould be

ii five crite en into count for selecti of five Cs (i. using one riteriontion of fiv ach of sampl Blocks the fo

having highe having hi led Tri opula ion

iii) having more numbe f BPL F ilies having more num f migr popula on which most r otest / ‐accessible par of the Bl ck

behind sett ve crite was to et ade uate sa ple of particular inalizedWC, so th dy could conduct a detailed Focus Group Discussion GD) forperceptions an nses of ch of t e margi alized g ups.


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iii. Secondary data on SC, ST, BPL and Migrant population were referred in order to select the required number of AWC. A list of at least five AWCs as per the said criteria was prepared and one AWC was randomly selected from the said list. Accordingly five AWCs per Block were randomly selected using the said criter

Selection and Households

AWC, 10 sample e covered study. households were vered part the ehold

households per and 100 r distr

Irrespective of a fixed for were lect different categories of d people disabl mig s, lactating mothers, mothers / fathers between months 6 Adolescents, above 60 years person sufferi illness).

i. Since the health k n behavior, perceptions and needs of people vary gender wise the study team intervie household.

ia.

1.5.5 Coverage of i. From each

under the a total of households from different marginalized sections wer In total, 400

Block co as of hous survey (i.e. 50

sample households pe sample ict). ii. the criteri

nalize selection of AWCs, the households se ed from

margi residing in an AWC (e.g. ed, rant of children

major 6 to years, Aged and

ng from any ii see i g

wed both male and female respondents under each category of iv. A detailed break‐up of 10 households which was planned to be covered in each selected AWCs is as

given in the table below: Table 2 Categories of respondents covered in each AWC Category of Households Number of

Households Break‐up of Households as per Male / Female respondent category

Lactating Mother (having child below 6 months)

1 1 Female Respondent

Mo / Father of children between 6 2 1 Male and 1 Female Respondent thermonths – 6 years age group

Adolescent 2 1 Male and 1 Female Respondent

Aged (above 60 years) 2 1 Male and 1 Female Respondent

Major Illness (TB, Leprosy, HIV+, Cancer, etc.)

1 1 Male / Female Respondent

Disable 1 1 Male / Female Respondent

Migrant (only out and distressed migration)

1 1 Male / Female Respondent

v.

area. The idea behind reparation of social map was to get some preliminary understandings about the different

Before selecting the households from different strata of marginalized people, the study team first prepared a social map of the AWC with the help of the inhabitants of that p

Februar

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y

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25


categories of marginalized people residing in that locality so that required number of sample households could be drawn from each category of population.

vi. Keeping the requirements of the study into account, the following criteria were used for selection of households under each strata:

a) Households are economically deprived or from below the poverty line

n be covered

al number of sample households covered under the study is given in the table below:

b) At least 50% households are from SC / ST communities c) Households selected should be from different pockets / hamlets / tagged villages of a

particular AWC so that a geographically representative sample ca

Further to mention here that the study team applied random method for selection of the required sample households for the study.

vii. District and category wise break‐up of tot

Table 3 Category wise total number of households covered in the study

Categories of Marginalized Households

Districts

Bolangir Jagatsinghpur Keonjhar Malkangiri Total

Lactating Mother (having child below 6 months

10 10 10 10 40

Mother of children (6months ‐ 6years) 10 12 10 10 42

Father of children (6months ‐ 6years) 10 8 10 10 38

Adolescent Girl 12 10 10 10 42

Adolescent Boy 8 10 10 10 38

Male Aged Person 10 10 10 10 40

Female Aged Person 10 10 10 10 40

Male Disabled Person 6 2 7 4 19

Female Disabled Person 4 8 3 6 21

Male Person with past/present history of Major illness

4 5 6 5 20

Female Person with past/present history of Major illness

6 5 4 5 20

Male Migrant 4 10 9 8 31

Female Migrant 6 1 2 9

Table Total 100 100 100 100 400

viii. Apart from these 400 sample households, the study also conducted exit interviews of 100 patients

(i.e. 25 patients per district) those who were availing in‐house medical treatment in the Block and

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District level public Hospitals. The district wise break‐up of 100 clients covered in the study is presented in the table below:

Table 4 Number of exit interviews of in‐house patients conducted in different health facilities District Exit Interviews with Clients

No. of Clients in Block Hospital No. of Clients in District Total Clients Hospital

Malkangiri 10 (5 in each of the two sample Blocks) 15 25 Bolangir 10 (5 in each of the two sample Blocks) 15 25 Keonjhar 10 (5 in each of the two sample Blocks) 15 25 J g ta a singhpur 10 (5 in each of the two sample Blocks) 15 25

Total 40 60 100

s the study intended to understand the perceptions and views of marginalized groups, a combination ployed. The details about the

r data collection are presented in a tabu elow:

1.5.6 Tools and Techniques of Data Collection

Aof both qualitative and quantitative methods of data collection was emtools and techniques used fo

lar form b

Table 5 Tools and Techniques used for data ection collCategory of Respondents

Techniques of Data Collection

Tools for Data Collection

Service Users Household Survey Household Interview Schedu sing Perception le uMapping Techn (e.g. Lik ique ert Scaling)

Focused Group Discussion (FGD) using ParticipatoLearning and Action (P

ry LA)

A iled Chec t for FGD deta k Lis PL uideline TA G ool Information Capturing Sheet Ta Recorder pe

The following PLA tools were used whilestep process that was used during the PLA

conducting the FG with the marginalized The step by is presented w.

D belo

people.also

CTRAN Co

February 2

4,

2009

Study on

The total table belo Table 6 NCategory Groups

SCs / STs

Disabled Migrants Families r/inaccessiMother / below 6 yAdolescen

S&R Ma

ChapatDiagram

MobilitMap

Debatin

onsulting Pvt.

perceptions o

number of Fow:

Number of Focof Marginaliz

residing in remible Pockets Father of chiyears age gronts

ap

•To stawas vdifferehelpfu

tti m

•Followand Vrelatevariouaccess

ty

•Then,the mcomm

ng

•Debatthe imamong

. Ltd. Bhuban

of marginaliz

FGDs that we

cused Group zed T

o

mote

ldren up

art with, the Salidated withent categorieul to locate va

wed by the vaein Diagram.d institutionsus services prs) of services,

the same S&marginalisedmunication we

ting exercisemportant PLAg the particul

eswar

ed people ab

ere carried o

Discussions Total No. of FGDs

R

8

8 8 8

8

8

Social map wh the respectes of peoplearious commu

alidation of SThis particuls and their lirovided by th, quality and u

&R map was rpeople. P

ere discussed

on each of thA Techniqueslar group of m

out health eq

ut with diffe

(FGD) with vaRemarks

Across 8 s 4 FGDs ea Across 8 s Across 8 s Across 8 s

Across 8 s 4 FGDs ea Across 8 s 4 FGDs ea

which had beetive marginaliresiding in dunity level ins

S&R map, thear exercise wnkages. Also,hese institutioutility of such

referred to droblems relin this exerci

he equity issus to map thmarginalised p

T

quity in Orissa

rent margina

arious margin

selected blockach with SCs aselected blockselected blockselected block

selected blockach with Fathselected blockach with boys

en drawn forised groups.different locastitutions exis

e group was mwas helpful to, it was helpfons, issues reh services.

o a mobilitylating to dise.

ues during the varied perpeople.

TMST ‐Orissa

a

alized groups

nalized group

ks of 4 districand STs ks of 4 districks of 4 districks of 4 distric

ks of 4 districers and Mothks of 4 districs and Girls

selection of sThe same wations of an Asting in the vi

mobilised top the varma

ful to triggerelating to acce

mapping (geodisatance, tr

he FGD was arceptions and

Health Suppo

is as given i

ps

cts i.e. 1 per b

cts i.e. 1 per bcts i.e. 1 per bcts i.e. 1 per b

cts i.e. 1 per bhers cts i.e. 1 per b

sample houseas helpful toAWC andllage.

wa

draw the Cious health

hse

the discussioessibility (pro

ographic acceransportation

also done as od responses

ort Plan

Pa

2

n the

block

block block block

block

block

eholdsknows also

apattierviceon onogram

ess) ofn and

one ofexists

age

27

CTRAN Co

February 2

4,

2009

Study on

Table 6 NCategory Groups

Aged (abo

It is impoBPL peop

Both quanfield dataanalysis a

The studyanalysis atabular fogeneratedthe qualittables/ma

1.6 Chapter – Chapter –Accessibil Chapter –groups an

onsulting Pvt.

perceptions o

Number of Focof Marginaliz

ove 60 years)

rtant to menle from differ

ntitative and collected thrre as follows

y used requirand generatioorm with fred and presentative analysatrixes.

Chapterisa

– I of the pres

–II presents ity and Quali

–III is the lastnd recommen

Preparaof data struct

. Ltd. Bhuban

of marginaliz

cused Group zed T

o

Total

ntion here tharent strata of

1.5.7

qualitative drough the var:

red software on of data tabequencies, pnted in the resis of informa

ation Plan

sent report de

the perceptty of Health S

t part of this ndations to ad

ation entry ture

eswar

ed people ab

Discussions Total No. of FGDs

R

8 56

at the FGDs wpopulation.

Data Analys

data analysis rious tools. Th

package for bles. Data oupercentages eport based oation was al

eals with the

tions of varioSer

re

vices.

port whichddress inequit

Data Entry

Ta

out health eq

(FGD) with vaRemarks

Across 8 s

were conduc

sis and Repo

methods wehe steps that

carrying oututputs for eacand averageon the study so carried b

study overvie

ous margina

h outlines thety in health.

***

EDeteDat

Generation ofables (single an

variate tab

T

quity in Orissa

arious margin

selected block

ted only with

ort Preparat

re employed were used fo

t the above sch variable wes. Besides, requirementy presentatio

ew and meth

lized Familie

e suggestions

Error ection in ta Entry

f Data nd multi‐les)

TMST ‐Orissa

a

nalized group

ks of 4 distric

h the econom

tion

in carrying oor undertakin

steps of datawere presentemulti‐vitiate ts. Unlike quaon of data i

odology.

es and Group

s given by va

Data ValidationTraingulati

Data Analyusing SPS

Health Suppo

ps

cts i.e. 1 per b

mically depriv

out the analyng the quantit

a computerizaed in the reptables wereantitative anan qualitative

ps on Availa

rious margina

n & ion

ysis SS

ort Plan

Pa

2

block

ved or

ysis of tative

ation, ort in e also alysis, data

bility,

alized

age

28


February 2

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Chapter II

2 Perceptions of Mar th Equity in

a) In the first section, the report has made an attempt to introduce the different categories of marginalised f their status in the state.

b) Second section presents the demographic profile of the 400 respondents covered in the

services such as treatment of illness, maternal health care, child health care, family planning services and status of linkage under different government schemes and provisions.

d) Fourth section presents the perceptions of in‐house patients on the availability and quality of health services

2.1 Profile of the different categories of marginalised people in the state

2.1.1 Profile of STs and SCs in the state

the State of Orissa stands at 81.45 lakh (2001 Census). STs with 62 tribes constitute 2.1% of the total population of the State and 9.7% of the total tribal population of the country. The sex

3 females to 1000 males. The tribal population in the State is verwhelmingly rural, with 94.5% residing in villages. The overall literacy rate of the tribals has increased

among the tribals is onsiderably below the state average at 63.08%. The literacy level of females among tribals is quite low

cheduled Castes population with 95 castes in the State stands at 60.82 lakh, which is 16.5% of the total

verall literacy rate among SCs is 55.53%. However, the SC literacy among females is low as 40.3%.

ginalised People about HealOrissa

This chapter of the report has been structured into the following four sections:

people covered in the study and presents a brief profile o

household survey. c) In the third section, the report has brought out the perceptions of different marginalised people

like STs, SCs, BPL, Disabled, Migrants, Aged, Women, etc. on availing and accessing health care

In the ethnographic map of India, Orissa occupies an important place, for it is inhabited by the largest number of tribal communities as compared to the other States and Union Territories. The tribal communities, in varying concentrations, are found almost in all the districts of Orissa. Each tribe has a cultural identity of its own. The distinctiveness of each tribe is manifested in its language, social organization, and rituals and festivals, and also in their dress pattern, adornments and art and craft. The tribal population of2ratio among ST population is 100ofrom 22.3% in 1991 to 37.4% in 2001. Despite this improvement, the literacy ratecat only 23.4% in 2001. Spopulation of the state (200). As per 2001 Census, the sex ratio among SC is 979 females to 1000 males. Unlike ST, literacy level among SCs is little better. The o


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Both STs and SCs have a history of vulnerability aeconomic conditions in terms of work‐participation, education and health preempting their inclusion and targeting in all developmental activities undertaken by the State. Isolation from the mainstream society, economic and social backwardness, poverty and its manifestations, low levels of literacy and health care, primitive system of production and social and political marginalization further adds to their desolation.

2.1.2 Profile of the women in the state Women constitute 49.29 per cent of the total population in Orissa. Compared to the all‐India level, the state has a relatively favourable sex ratio of 972 females per 1000 males. According to the Orissa Human Development report though the Sex ratio in the state level is 972 per 1000 males it has been showing a declining trend to 950 females per 1000 males in 0–6 year age group. From 1991‐ 99, the overall literacy rate has been increased from 49% percent to 63.1%. Yet more than half of the women are still illiterate. Female literacy in Orissa is 50.51% as compared to the national average of 54.16%. The female literacy of 50.51% is marginally lower than the national average but significantly lower than the male literacy rate of the state (75.35%). The literacy rate is higher in the urban areas than the rural areas. In rural areas the female literacy rate is 46.7% while in the urban areas it is 72.9%. The female literacy gap across urban and rural region is 25.46% as per 2001 census figures, which imply that resource allocation, utilization and proper management of the literacy programmes have benefited the urban women more than the rural women. Among the STs, the female literacy rate is only 23.36% as compared to the male literacy rate of 51.50%. The tribal districts of Nawarangpur, Malkangiri, Rayagada, Koraput, Nuapada, Gajapati, and Kalahandi have been in the bottom rung of the female literacy rates.

2.1.3 Profile of the disabled people in the state Disability can be defined as a person with restrictions or lack of abilities to perform an activity in the manner or within the range considered normal for a human being was treated as having disability. It excluded illness/injury of recent origin (morbidity) resulting into temporary loss of ability to see, hear, speak or move. There are generally five types of disability found, viz. Mental Disability, Visual Disability, Hearing Disability, Speech Disability, and Locomotors Disability. Among all major states in the country, the number of disabled persons in Orissa is highest i.e. 2459 persons as against the national figure of 1755 persons per 1,00,000 persons. Compared to urban area of the state, the prevalence of disability in rural areas (1821 persons) is significantly high (2544 persons). Male and female comparison shows that the prevalence of disability among males (2586 persons) is much higher than the females (2330 persons). Orissa is also far behind the national figure per 1000 distribution of disabled persons of age 5 years and above by level of general education. When the national figure shows that 547 disabled persons per 1000 distribution are illiterate, in Orissa it is as high as 642 persons per 1000 distribution. Of the rest, maximum i.e. 210 are up to primary level, 96 are up to middle and only 52 are up to secondary level of education in Orissa (Source: NSS 58th round, July –

nd prolonged marginalization due to their poor socio‐


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December 2002). Rural/Urban and Sex wis ous types of disabled persons in Orissa is presented in Table 7.

e prevalence of vari

Table 7 Prevalence of different types of disability in Orissa per 1,00,000 population, 2002 Type of Disability

Rural Urban Rural + Urban

Male Female Person e Person Male Female Person Male Femal

Mental Retardation

129 71 100 136 127 131 130 78 104

Mental 182 168 175 169 97 134 18Illness

0 160 170

Blindness 325 287 306 148 248 197 303 282 293

Low Vision 241 270 255 117 199 157 226 261 244

Hearing Disability

642 563 603 467 393 431 621 543 582

Speech Disability

206 176 191 174 145 160 202 173 188

Locomotors Disability

1213 1173 1193 985 653 823 1186 1112 1149

Source: NSS 58th round, July –– December 2002

2.1.4 Profile of the migrants in the state

vices. tence

f the facilities in the vicinity of their place of work and even if they know, the employees do not spare them to visit such facili ack of nutritious food, poor ving conditions, lack of rest puts the health status of the migrant at very low level. The females are

or four magnitudes of out‐migration proportions of each state, it is clear that ajority of the migrants have moved to neighboring states only. However there are exceptions for this.

tal out‐migrants from Orissa.

Migrants suffer more as compared to other categories of population in accessing the health serThis partly because many services are entitlement linked, many migrants are unaware of the exiso

ties between their grueling 12 hr work schedule. Llimore vulnerable than the males. According to census 2001, the total population of India is 1028 million consisting of 532 million males and 496 million females. In 2001, 309 million persons were migrants based on place of last residence, which constitute about 30% of the total population of the country. This figure indicates an increase of around 37 percent from census 1991 which recorded 226 million migrants. According to Visaria (2001), the net inter‐state migration (in terms of persons reporting a place of last residence different from the place of enumeration) was slightly positive but insignificant in influencing the population size or growth both during 1981 and 1991 censuses. Thus, contrary to popular belief there isn’t a significant net out‐migration from the state to other developed regions of the country. From the largest three mFor Uttar Pradesh, which constitutes 41 percent of all our migrants, migration to Maharashtra accounts for 32 percent even though Maharashtra is not a border state. Likewise, out migrants from Orissa preferred Gujarat and Maharashtra as the destination even when these states are not Border States. Out‐migration to these states made up to 34 percent of to


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2.1.5 Profile of the Adolescents in the state Adolescence is a period of transition from childhood to adulthood. It is one of the most important periods of life between the ages of 10 to 19 years. The period is very crucial, since these are the formative year of life of an individual, when major physical, psychological and behavioural changes take place. This is an impressionable period of life. This is also a period of preparation for undertaking greater sponsibilities including healthy responsible parenthood in future. Adolescents form prospective

human resource for ent, significant physiological hanges also take place during adolescence period, both among boys and girls. Health problems of

are partially ependent on others and the rest only 274 persons are independent. As a result of all these factors, the

health status of ir vulnerability towards lness and death. According to NSS 60th round survey (2004), the proportion (per 1000) of aged persons

an areas availed treatment from public ealth facilities.

re the society. Besides, physical growth and developm

cadolescent are very different from those of younger children and older adults. Due to lack of accurate information, adolescents are prone to various behavioural and reproductive health problems. The period of transition from childhood to adult‐hood is hazardous for the adolescent health, because they develop behavioural problems in absence of proper guidance and counselling more specifically due to lack of health information.

2.1.6 Profile of the Aged people in the state With the increase in life expectancy of the people in the state, the population size of older people above sixty years of age has gone up. The demographic transition in particular is posing a major challenge towards physical and social well being of elderly people in the state. The aged people face variety of problems that range from absence of ensured and sufficient income to support themselves, dependency on others, ill health, absence of social security, loss of social role, etc. Of the 1000 aged persons in the state, at least 538 persons are economically fully dependent on others, 163 personsd

aged in particular faces serious challenge which increases theilreporting ailment in Orissa is 77 in rural areas and 54 in urban areas which are below the national average of 88 and 99 respectively. This clearly indicates the low health consciousness among the aged population in the state. Further of the total reported ailment, the percentages of aged who availed treatment comes to 76% in rural and 86% in urban areas. Further break‐up of this on the basis of source of treatment indicates that 51% in rural areas and 54% in urbh

2.1.7 Profile of the Economically Deprived people in the state About 46.8% people in Orissa lives below the poverty line. The per capita income of the state is only Rs. 5985/‐. The poverty ratio in the southern region of Orissa is highest followed by the northern region. Compared to Coastal region (27.4%), the poverty ratio in southern region (72.7%) is at least two and half times and in northern region (59.1%) is at least two times higher. The poverty ration among STs (75.8%) is exorbitantly higher than the SCs (37.1%), OBC (25.8%) and general castes (17.5%) in rural Orissa.


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2.2 Demographic, Social and Economic Profile of the Respondents

2.2.1 Category of Respondents As already outl th us r, a 40 eho re covered un stu

useholds from four sample dis ). Category wise sehold vered stud e in Table 8.

ined in e previo chapte total of 0 hous lds we der the dy (i.e.100 hopresented

each the tricts hou s co in the y ar

Table 8 District wise nt respondents cov d und study differe categories of ere er the Categories of Marginalized Hou lds ricts seho Dist

Bolangir Jagat pur singh Keonjhar Malkangiri Table Total

Lactating Mother (having child below 6 months

10 10 10 10 40

Mother of children (6months ‐ 6years) 10 12 10 10 42

Father of children ths ‐ 6 10(6mon years) 8 10 10 38

Adolescent Girl 12 10 10 10 42

Adolescent Boy 8 10 10 10 38

Male Aged Person 10 10 10 10 40

Female Aged Person 10 10 10 10 40

Male Disabled Person 6 2 7 4 19

Female Disabled Person 4 8 3 6 21

Male Person with past/present history of Major illness

4 5 6 5 20

Female Person with past/present history of Major illness

6 5 4 5 20

Male Migrant 4 10 9 8 31

Female Migrant 6 1 2 9

Table Total 100 100 100 100 400

2.2.2 Caste / Ethnic Composition Of the 400 households covered under the study, maximum i.e. 43.5% belong to Scheduled Tribes (STs) followed by 36.8% belong to Scheduled Castes (SCs), 16.5% from Other Backward Castes (OBC) and the rest 3.2% are from General Castes (Table 9).

Table 9 Caste/Ethnic composition of households covered under the study Castes / Ethnicity District Table Total

Bolangir Jagatsinghpur Keonjhar Malkangiri

Count Row % Count Row % Count Row % Count Row % Count Col %

Scheduled Caste 31 21.1 58 39.5 23 15.6 35 23.8 147 36.8

Scheduled Tribe 43 24.7 8 4.6 64 36.8 59 33.9 174 43.5

Other Backward 23 34.8 28 42.4 11 16.7 4 6.1 66 16.5


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Table 9 Caste/Ethnic composition of households covered under the study Castes / Ethnicity District Table Total

Bolangir Jagatsinghpur Keonjhar Malkangiri


Caste (OBC)

General Caste 3 23.1 6 46.2 2 15.4 2 15.4 13 3.2

Table Total 100 25.0 100 25.0 100 25.0 100 25.0 400 100.0

Since the focus of the study was on marginalized people, more than 80% households covered in the study are from the ST and SC communities who are historically found to be the most vulnerable communities in Orissa. The percentage of tribal households covered in Jagatsinghpur district is comparatively less than the other three districts viz. Malkangiri, Bolangir and Keonjhar as there were hardly any tribal inhabitants in the same district.

2.2.3 Religion eligion wise break‐up of

i.e. 66% households belong to nuclear family and the rest 34% belong to joint family able 11). District wise break‐up shows a contrasting figure of Jagatsinghpur district in comparison to

other dist more than 70% ouseholds belong nuclear family. This very much substantiates to the fact that among the ST

Table 10 Religion of Households Rhouseholds presented in Table 10 shows that about 97% households practice Hindu religion and the rest 3% (only from Malkangiri and Keonjhar district) practice Christianity. Hinduism is the main religion practiced by the majority of the households covered in the study.

2.2.4 Family Type Exactly two third(T

ricts where around 42% families belong to joint family. In rest of the districts,to h

communities the system of joint family is less prevalent as compared to the families of other caste groups.

Districts

Religion Table Total Hindu Christian

No % No % No Row %

Bolangir 100 25.7 100 25.0

Jagatsinghpur 100 25.7 100 25.0

Keonjhar 97 24.9 3 27.3 100 25.0

Malkangiri 92 23.7 8 72.7 100 25.0

Table Total 389 97.3 11 2.8 400 100.0

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2.2.5 Housing Type

red in the live in cha House thout having electricit hich indicates to the fact that the maximum percentage of households covered in the study are so

a Pucca House having electricity. study covered lds who also live in Kacha hous t having tricity con

Housing type of households

More than 65% households coveclearly

study Ka wi y w

marginalized who cannot even possess The also another10% househo e bu elec nection.

Table 12 House Type

Dis trict T otal Bolangir Jagatsinghpur Keonjhar Malkangiri

Count Row % Count Row % Count Row % Count R % ow Count Row %

22.1 36 13.7 74 28.2 94 35.9 262 65.5 Kacha and no electricity 58 Kacha and electricity 14 33.3 17 40.5 9 21.4 2 4.8 42 10.5

44.4 2 11.1 1 18 4.5 Pukka and no electricity 7 38.9 8 5.6Pukka and electricity 1 3.2 27 87.1 1 3.2 2 6.5 31 7.8

d electricity 7 38.9 38.9 4 22.2 18 4.5 Kacha‐Pukka an 7 Kacha‐Pukka & no electricity 13 44.8 5 17.2 10 34.5 1 3.4 29 7.3

100 25.0 25.0 25.0 100 400 Table Total 100 100 25.0 100.0

Dhouseistrict wise break‐up of households shows that 94% households covered in Malkangiri live in Kacha

without having ele Bloangir district. Compared to ese three districts, the households covered in Jagatsinghpur are relatively in a better position having

and Poverty status

s below Rs. That means the average daily e of these ds works to be below ‐ per day. District wise analysis shows the income of 95% in h in

75% Jagatsinghpur below . 25,000/‐.

ctricity followed by 74% in Keonjhar and 58% inthPukka house to live with electricity provision in their house.

2.2.6 Income

ome oThe annual inc f more than 82% household in the study was covered 25,000/‐. incom househol out Rs. 70/

that annual about households Keonj ar, 82% Bolangir, 78%in Malkangiri and in was Rs

Table 11 Family Type of Households Districts

Family Type Total Nuclear Joint

Count Row % Count Row % Count Row %

Bolangir 74 28.0 26 19.1 100 25.0 Jagatsinghpur 43 16.3 57 41.9 100 25.0 Keonjhar 75 28.4 25 18.4 100 25.0 Malkangiri 72 27.3 28 20.6 100 25.0 Table Total 264 66.0 136 34.0 400 100.0


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Table 13 Income Level of Households Annual Income Range

District Table Total Bolangir Jagatsinghpur Keonjhar Malkangiri

Count Row % Count Row % Count Row % Count Row % Count Row %

=< 25,000 82 24.8 75 22.7 95 28.8 78 23.6 330 82.5

25,000 ‐ 50,000 14 24.1 18 31.0 5 8.6 21 36.2 58 14.5

50,000 ‐ 1,00,000 4 33.3 7 58.3 1 8.3 12 3.0

Table Total 100 25.0 100 25.0 100 25.0 100 25.0 400 100.0

Only 15% of the total households had annual income ranging from Rs. 25,000/‐ to Rs. 50,000/‐. That means 97% households covered in the study had income below Rs.50,000/‐ per annum. he rest 3% households

. s the s of study on m rgina peop re deprived people. This corroborates to the fact that about 75% of the total

ds co u BPL card provided by state m (Tab ).

/ Educational status of Respondents

ajority of the respondents covered in the study have low educational status as well. Almost 50.5% spondents are illiterate. As very much evident from Table 15, about 7.3% respondents can only affix

their signature but they cannot be rate.

Thad annual income between Rs. 50,000/‐ to Rs. 1,00,000/‐. That means none of the sample households had annual income of above Rsspecifically the economicallyhousehol vered in the st

2.2.7

1,00,000/‐ a focu the was a lized le mo

dy have the govern ent le 14

Literacy

Mre

considered as functionally illite

Table 15 Literacy / Educational status of respondents Literacy / Education

District Table Total

Bolangir Jagatsinghpur Keonjhar Malkangiri Count Row % Count Row % Count Row % Count Row % Count Row %

Illiterate 57 28.2 23 11.4 53 26.2 69 34.2 202 50.5

Can put signature 7 24.1 7 24.1 11 37.9 4 13.8 29 7.3

Below or completed 5th

11 19.6 22 39.3 13 23.2 10 17.9 56 14.0

t7 h Completed 18 25. 32 44.4 13 18.1 9 12.5 72 18.0 0

10th Completed 6 21.4 7 25.0 8 28.6 7 25.0 28 7.0

+2 Completed 1 16.7 4 66.7 1 16.7 6 1.5

Graduation & Above 4 80.0 1 20.0 5 1.3

Table 14 Possession of BPL Card by families Districts

Possession of BPL Card Table Total Yes No

Count Col % Count Col % Count Col %

Bolangir 74 24.6 26 26.3 100 25.0

Jagatsinghpur 64 21.3 36 36.4 100 25.0

Keo 80 26.6 20 20.2 25.0 njhar 100

Ma ngiri lka 83 27.6 17 17.2 100 25.0

Table Total 301 75.3 99 24.8 400 100.0


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Table 15 Literacy / Educational status of respondents Literacy /

Education District Table Total

Bolangir Jagatsinghpur Keonjhar Malkangiri Count Row % Row % Count R Count w % Count Row % Count ow % Ro

Technical 1 .0 50 2 50 1 .0 0.5

Table Total 100 25.0 100 25.0 100 25.0 100 25.0 400 100.0

The rest 42% respondents a terate. Th ak‐up of the literat pondents cate tha ut

completed at leas standard ducation 14% hav er compl 5th stan of ducation or their educational level is below the same. Only 10% of the literate respondents have educational level above 10th standard

s

re li e bre all e res indi t abo18% have t 7th of e and e eith eted dard e

of education.

2.2.8 Marital status of Respondents As far as marital status of respondents is concerned, about 63% respondents are married. Around 29% are unmarried of them a major percentage belongs to adolescent boys and girls.

Table 16 Marital status of RespondentMarital Status

District Table Total Bolangir tsingh h MaJaga pur Keonj ar lkangiri

Count Row % Count Row % Count Row % Count Row % Count Row %

Married 64 25.5 6 2 5.1 58 23 25 6 6 6.3 63 2 .1 1 2.8

Un‐married 26 22.2 32 2 7.4 27 23.1 32 27.4 117 29.3

Widow(er) 9 30.0 2 9 30.0 30 7 6.7 10 33.3 .5

Separate 1 50.0 1 50.0 2 0.5

Table Total 100 25.0 1 .0 100 25 40 1 00 25.0 100 25 .0 0 00.0

About 8% respondents are widow / widower and only 0.5% respondents are separated from their spouse.

2.2.9 Occupation of the Respondents

able 17 shows the occupational t t s of the respondents. While 60% households were engaged in different occupations or to be dependent on their mily members. These dependent respondents could be considered as vulnerable people since they

T s a u

income generating activities, about 40% were foundfahave to depend on others to meet their day to day expenses including the expenses on health. Most of these respondents are either adolescents or disabled people or women or aged members of the sample households covered in the study.


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Table 17 Occupational status of respondents Occupations

District l

Table Tota

Bolangir Jagatsinghpur Keonjhar i Malkangir

Count Row % Count Row % Count Row % t Count Row % Coun Row %

Farmer 24 24.0 13 13.0 20 20.0 43 43.0 100 25.0

Petty Business 2 33.3 1 16.7 2 33.3 1 16.7 6 1.5

Salaried Job 1 12.5 6 75.0 1 12.5 8 2.0

Pension 3 27.3 5 45.5 2 18.2 1 9.1 11 2.8

Agriculture Labour 16 32.7 5 10.2 26 53.1 2 4.1 49 12.3

Artisan 1 33.3 2 66.7 3 0.8

Non‐Agri Labour 6 14.6 7 17.1 11 26.8 17 41.5 41 10.3

MFP C lection 2 ol 1 14.3 8 28.6 4 57.1 7 1.

Traditional Prof. 3 42.9 2 28.6 2 28.6 7 1.8

Dependant 43 27.7 57 17.4 28 36.8 27 18.1 155 38.8

Table otal T 100 25.0 100 25.0 100 25.0 100 25.0 400 100.0

Of the total respondentsby 23% n daily wage ealike petty business, salari

2.2.10 Migrants covered under the study

engaged different 25% we depende agriculture followed o rning. Very negligible percentages of respondents were engaged in occupations

ed

he study interviewed 40 migrants across the four districts (10 migrants from each district) covered under the study.

in occupations, re nt on

jobs, etc.

T Of these 40 migrants, 31 are male and 9 are female.

Table 18 Place of Migration Place

Male Female Total


Outside the Block 4 12.9 1 11.1 5 12.5

Outside‐District 9 29.0 2 22.2 11 27.5

Outside State 18 58.1 6 66.7 24 60.0

Total 1 9 100.0 40 100.0 31 00.0

from thes igr the dy attempted kno ir h pro s a eal re

d dur th e of igra and ring ‐migration period. Da elat to ty alth ices ived one peri ce the d of y

ed for an sis a un study. As r from Table , 60 f th al red under the y mi de th sate ed 27.5% rate utsi he

12.5% went to ide their ow ock. othe rds, aximum people igra to nt socio‐economic and cultu nvironment arnin money.

Specifically e m ants, stu to w the ealth blem nd h th caservices receive ing e tim m tion du post ta r ing availability and accessibili of he serv rece in year od pre ding ate survewere collect aly nd reporting der the clea 123 % o e totmigrants cove stud grated outsi e follow by mig d o de tdistrict and outs n Bl In r wo m m ted completely differe ral e for e g


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Table 19 Duration of Migration (in months) Districts Mean Maximum Minimum

Bolangir 6 5 9

Jagatsinghpur 6 11 2

Keonjhar 6 11 3

Malkangiri 3 7 1

Table Total 5 11 1

People on an average migrated for at least five months of period in a year (Table 19). Also clear from the same table that the duration of migration of these people was ranging from a maximum of 11 months to a minimum of one month in a year.

Table 20 Purpose of migration Purpose of Migration Bolangir Jagatsinghpur Keonjhar Malkangiri Total

Count Col % Count Col % Count Col % Count Col % Count Col %

Better opportunity to work 1 10.0 4 40.0 3 30.0 1 10.0 9 22.5

More Income 7 70.0 5 50.0 6 60.0 9 90.0 27 67.5

Forceful Migration 2 20.0 1 10.0 1 10.0 4 10.0

Total 10 100.0 10 100.0 10 100.0 10 100.0 40 100.0

About 67.5% peo ated for re incom 22.5 d in earch of better work opportu e 0% for ig du ck om o s r

ce.

2.2 disab perso cove e st

disab erso terv d in tudy . 4 are male disa per and . 2.5% are female disabled persons.

Types of disabled persons covered under the study

ple migr earning mo e whereas % migrate snity. Th rest 1 was ceful m ration e to la of inc e opp rtunitie in thei

native pla

.11 Type of led ns red under th udy

Of the 40 led p ns in iewe the s , 19 i.e 7.5% bled sons 21 i.e5

Table 21 D isability Type Bolangir Jagatsinghpur Keonjhar Malkangiri Total


Orthopedically Challenged 3 30.0 5 50.0 6 60.0 4 40.0 18 45.0

Speech & hearing Impaired 3 30.0 2 20.0 3 30.0 5 50.0 13 32.5

Visually Impaired 2 20.0 1 10.0 1 10.0 4 10.0

Mentally Challenged 1 10.0 1 10.0 2 5.0

Multiple Disability 1 10.0 1 10.0 1 10.0 3 7.5

Total 10 100.0 10 100.0 10 100.0 10 100.0 40 100.0

District wise the numbers of different categories of disabled persons covered in the study are presented Table 21. Highest i.e. 45% are orthopedically or locomotors disabled followed by 32.5% are speech or earing impaired, 10% are visually impaired, 5% are mentally challenged and the rest 7.5% are having

multiple disability.

inh


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2.3 Perceptions of Marginalised People with regard to Availability, essibility & Quality of Health ces

e Ill

g into th availability, ac sibili d quality of services provided f atme of various study m pped kno dge arginalised p on rious public he h faci s

e in their locality. A ar fr Tab 2 tha time sur high i.e. 92.5% ple w a Anga adi Centre (AWC) follo by 80.3% kne HC/C and 79.8%

district hospital. other ords ut 7.5% did n now about the presen of AW self an abou % di k abo HC/ and rict tal. le 22

indicates that among the different public health facilities available in their locality, the visibility of sub‐und to lowe almost half .5%) the marginalised people not ab t in the local brie lack o wledge about ifferen th ities matt f

articularly sense tha peop not ow a the lth a en, expec peo a eal e services fr e a pria alth lity

ot happen.

Acc Servi

2.3.1 Treatm nt of ness Before gettin e ces ty an or tre ntillnesses, the a the wle of m eople va alt litieavailabl s cle om le 2 t during the of vey est marginalised peo kne bout nw wed w P HC knew about In w , abo ot k ce C intheir village it d t 20 d not now ut P CHC dist hospi Tab also

centre was fo be st i.e. (48 of did know outhe sub‐centre ir ity. In f, f kno d t heal facil is a er oconcern p in the t if le do kn bout hea facilities nd provisionsthereof, th ting ple to vail h th car om th ppro te he faci wouldn Table 22 Knowledge about Health Facilities Health Facilities Marginalised

Castes Economically Deprived

Gender Life Cycle (stages)

Disabled People

Migrants

Total

SCs

STs

BPL

Male

Female

Adolescents

Couples

<6yr

child

Aged

District Hospital 75.5 81.6 80.4 82.8 77.1 76.3 79.2 87.5 75.0 85.0 79.8 CHC/Rural Hospital/PHC, 80.3 84.5 79.1 78.5 81.8 81.3 81.7 77.5 82.5 82.5 80.3 Sub‐Centre, 49.7 56.9 55.8 55.4 48.1 55.0 54.2 47.5 50.0 45.0 51.5 Anganwadi/ ICDS Centre, 93.2 92.0 94.7 93.5 91.6 93.8 88.3 95.0 95.0 97.5 92.5 Govt. Mobile Clinic 6.1 13.8 9.3 6.5 10.7 7.5 10.0 10.0 5.0 7.5 8.8 Pvt. Hospital 4.1 0.6 17.6 18.8 16.8 21.3 22.5 11.3 5.0 20.0 17.8 Pvt. Doctor/Clinic 16.3 19.0 23.3 29.6 20.1 22.5 25.0 28.8 15.0 27.5 24.5 Pvt. Paramedic 23.1 25.9 2.3 1.6 2.8 2.5 1.7 2.5 2.5 5.0 2.3 Baidya/Hakim/Homeopathy 2.7 0.6 32.2 27 .4 34.6 22.5 39.2 30.0 25.0 30.0 31.3 Pharmacy/drug store 26.5 35.1 37.5 37 .6 34.6 38.8 36.7 35.0 30.0 35.0 36.0 Dai/ TBA 29.9 43.1 21.3 18 .3 19.2 15.0 12.5 31.3 20.0 17.5 18.8 Quack 17.7 24.1 22.6 20.4 22.0 26.3 17.5 21.3 20.0 27.5 21.3 Total 147 174 301 186 214 80 120 80 40 40 400

Segregated analysis of various categories of marginalised groups presented in Table 22 also reveals disparity in their knowledge about health facilities. Surprisingly greater percentage (i.e. 11.7%) of couples below six years of child did not know about AWC as compared to Adolescents (6.2%) and Aged (5%). Also interesting to find in the same table, more percentage of females (8.4%) did not know or see the AWC as compared to male persons (6.5%). This could be due to the less / restricted mobility of females as compared to male persons in the village. Caste wise greater percentage of STs (8%) did not


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know about AWC as compared to SCs (6.8%). In overall, only highest percentage of migrants, disabled d people were found to be awa ut AWC i.e. 97 95% respectiv ported the FGD that the disabled and ed people largely d on AWC due to t r mobility

ompared to other categories marginalised peopl st percentage i.e. 77.5% of aged about CHC/PHC and about 75% each among disab and SCs knew about district hospital.

STs and more than 50% SCs did not know about the availability of sub‐centre in their locality. the categories of marginalised e, the visibility of ‐centre among migran aged and

and age re abo .5%, 95% and ely. As reduring ag epend heiproblems. C of e, lowepeople knew led About 43% Among all peopl sub ts,female persons was found to be lowest i.e. about 55%, 53% and 52% respectively who did not know or see the same facility in their locality.

Table 23 District wise Knowledge about Health Facilities Health Facility Bolangir Jagatsinghpur Keonjhar Malkangiri Total

District Hospital 83.0 70.0 82.0 84.0 79.8 CHC/Rural Hospital/PHC, 80.0 62.0 84.0 95.0 80.3 Sub‐Centre, 8.0 44.0 82.0 72.0 51.5 Anganwadi/ ICDS Centre, 88.0 84.0 99.0 99.0 92.5 Govt. Mobile Clinic 2.0 33.0 8.8 Pvt. Hospital 16.0 14.0 37.0 4.0 17.8 Pvt. Doctor/Clinic 18.0 23.0 37.0 20.0 24.5 Pvt. Paramedic 1.0 5.0 1.0 2.0 2.3 Baidya/Hakim/Homeopathy 16.0 24.0 30.0 55.0 31.3 Pharmacy/drug store 21.0 23.0 60.0 40.0 36.0 Dai/ TBA 3.0 29.0 43.0 18.8

Quack 53.0 7.0 13.0 12.0 21.3

Total 100 100 100 100 100

Districtfo

wise people in the ur districts covered under the study. In Bolangir, hardly 8% knew about sub‐centre. About 66% in

did not even know the presence of AWC in their village. The nowledge about PHC/CHC and district hospital in Jgatasinghpur district was also found to be lowest i.e.

lkangiri and Keonjhar have better out different heal ties as to Jagatsi ur and ct.

break‐up also clearly shows the knowledge disparity among the marginalised

Jagatsinghpur did not know about the availability of sub‐centre in their locality. Highest i.e. 16% in Jagatsinghpur and 12% in Bolangir k38% and 30% respectively. In overall, marginalised people in Maknowledge ab th facili compared nghp Bolangir distri

Table 24 Average distance of h Facilities the hous marginalized ople Healt from es of pe Health Facilities Bolangir Jagatsinghpur Keonjhar Malkangiri Tab e Totall

Mean

Max.

Min.

Mean

Max.

Min.

Mean

Max.

Min.

Mean

Max.

Min.

Mean

Max.

Min.

District Hospital 21.8 60.0 3.0 13.9 65.0 3.0 26.2 65.0 3.0 41.5 100.0 2.1 26.4 100.0 2.1

CHC/Rural Hospital/PHC, 12.9 50.0 0.2 6.1 17.0 0.5 8.2 25.0 1.0 10.6 40.0 1.0 9.7 50.0 0.2

Sub‐Centre 6.6 20.0 1.0 1.7 8.0 0.3 2.8 8.0 0.3 3.4 15.0 0.0 2.9 20.0 0.0

Anganwadi/ ICDS Centre, 1.0 7.0 0.1 1.0 10.0 0.1 1.0 3.0 0.0 0.6 5.0 0.1 0.9 10.0 0.0

Govt. Mobile Clinic . . . 4.3 8.0 0.5 . . . 5.0 75.0 0.1 5.0 75.0 0.1

Pvt. Hospital 10.6 30.0 0.5 8.8 40.0 0.5 15.8 65.0 1.0 7.0 12.0 2.0 12.7 65.0 0.5

Pvt. Doctor/Clinic 9.3 30.0 0.5 3.7 7.0 1.0 4.6 17.0 0.5 6.1 25.0 0.4 5.6 30.0 0.4


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Table 24 Average distance of Health Facilities from the houses of marginalized people Health Facilities Bolangir Jagatsinghpur Keonjhar Malkangiri Table Total

Mean

Max.

Min.

Mean

Max.

Min.

Mean

Max.

Min.

Mean

Max.

Min.

Mean

Max.

Min.

Pvt. Paramedic 5.0 5.0 5.0 2.1 3.0 0.5 3.0 3.0 3.0 14.0 20.0 8.0 5.2 20.0 0.5

Baidya/Hakim/Homeopathy 3.2 10.0 0.5 2.5 7.0 0.5 3.5 30.0 0.5 1.7 21.0 0.0 2.5 30.0 0.0

Pharmacy/drug store 5.2 14.0 0.5 2.2 10.0 0.5 5.9 18.0 2.0 4.4 35.0 0.1 4.8 35.0 0.1

To get a better idea about the location of health facilities, the study collected data on the distance of various public and private health facilities that the marginalised people have to cover for availing treatment of their illnesses. Table 24 shows some interesting findings in this regard. For visiting various health care facilities, the marginalised people have to travel as high as 100kms to as low as 0.10kms to reach at the different health facilities from their own village/house. Among the different public health facilities, the district hospital and the CHC/PHC at the Block level are the two main types of facilities provided by government for which marginalised people have to cover a highest distance of 100kms and 50kms respectively to reach at these health facilities. District wise break up shows that the marginalised people specifically in Malkangiri and Bolangir district have to cover highest distance to reach at district hospital and at PHC/CHC respectively as compared to people in other districts. Interestingly, the aximum distance a person has to cover to reach at an AWC, which is supposed to be located in every

ing up AWC), is about 7 to 10kms as seen across the in ring st dis to reach at a

centre is very much indicati e fac marginalised people have to cover a lon distance to reach at the required health facility. Hence, it is important to kn whether distanc mobility of marginalised people has a with t preference of ple tin re hea facilities for various health care services.

nderstand obil tors tud a le bi a g rp ing t D. T rio ob confront a

d du t D. T res ses w a d g F ar

Group o obilit es

m1000 population (not as per the new criteria of settfour districts covered the study. Si

ve of thmilarly, covet that the

a highe tance of 20kms sub‐gere /lth

owvisiny linkage he peo g diffe nt

Further, in order to u the m ity fac the s y did detai d mo lity m ppin of va ious categories of marginalised

cusse grou s dur he FG he va us pr lems ed by the margin lised

people were dis ring he FG he key pon that ere c pture durin the GD e aspresented below. Responses of SC and ST n m y issu

Due to long distance o C peo rst lo r h ca u ac s twn village or nearb a nera eople to i/Di , P ac Vendor, di

Store and ASHA in their own village for treatment of their illness. When people don’t get cured by

f PH /CHC, ple fi ok fo ealth re so rces/f ilitie available in heir o y are s. Ge lly p visit Jan sari harm ist, Me cine

the treatment of local providers then they go to the PHC/CHC located at Block headquarter for treatment.

Lack of transportation facilities e.g. availability of bus/jeep in the village force them to walk long distances where transportation facilities could be available. In Malkangiri, due to lack of transportation facility, people have to even walk down to PHC/CHC for availing health care. Crossing


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of river and jungle while going to the health facilities creates lot of difficulty for them more specifically for the female members of the family.

During night, people have no other option to consult the local providers even if there is an emergency health problem. ANM/AWW is generally consulted for treatment of such emergency cases.

Arranging vehicle during emergency is sighted as the biggest problem for them. Due to long distance, people have to incur more expenses on transportation. People also prefer the locally available health facilities as they have to incur more expenses on

transportation. Responses of People residing in Remote / Inaccessible Pockets on mobility issues

In Malkangiri, people have to cro river and to reach a C for whi ey face ecifically for ava health care t women and child

ss the hills t PH ch th lot ofdifficulties more sp iling for pregnan ren.

In order to catch the local transpor ople in the te areas h walk lon tances. d also during night time, people find difficulties carry patie o the hospital.

om this, arranging vehicle t health fac also a ma oblem rep d by the

t, pe remo ave to g dis Duringemergency an lot of to nts tApart fr o the ility is jor pr orte m.

People in Malkangiri due to trans tion and communication problem have pend on l /Jani/Disari for tment of ill

es of Disabled People on mobility issues

porta to de locaproviders like Quack trea ness.

Respons

distance of health facility coupl d with lack transportation was hted as Long e of facility highlig themajor constraint by the disabled person. Due to mobility problem of disabled person, the family members have to take the disabled person on cycle to the heath facility.

The disabled persons find lot of problem especially in taking the public transportation. Due to crowd they find lot of difficulty to travel in the bus/jeep.

Dependency on family members was the other major constraint shared by the disabled persons. Dependency with regard to visiting the health facility and dependency to meet the health expenses were the two main problems shared by them.

Responses of Aged People on mobility issues

Long distance and lack of transportation were reported as major problems for them to visit the health facilities. Great ro m as ed them especially during rainy s oner p ble w fac by the eas .

Always they have to d nd on other accompanying them to the l. Sometimes, without of the others to Ev walk do long

h the b r ion

mo lity lat issues, a p has een a he e h e at people suf r n h ta of a t re h lit

ts the peo those er fr d re i il se r sa

epe s for hospitathe support they have to go the hospital. en they have to wn distances to catc pu lic transpo tat .

Apart from the above bi re ed an ttem t b m de re to pres nt t e typ ofillnesses th fer f om a d t e s tus av iling reatment from diffe nt ealth faci ies.Table 25 presen ple who suff ed om iffe nt m nor lnes s. As clea from the me

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table that majority i.e. 75% marginalised people suffered from fever followed by 71% suffered from cough and m h par y othe es of d

people, more percentage of STs (80.5%) suffered fro fev Th of diarrhea and minor was experienced by maximum aged people (20%) and migran respe ely in compa n

ies of margi ze o c re t study.

arginal p le ff d e t m r e

cold, 42% from 35% fro eadache. Com ed to an r categori marginalisem er. e problem

ts (17.5%)injuriesrisoctiv to

other categor nali d gr ups ove d in he

Table 25 M ized eop su ere from diff ren ino illn ssesMinor Illnesses Marginalised Castes Economically Deprived Gender Life Cycle (stages) Total D

isabled People

Migrants

SCs

STs

BPL

Male

Female

Adolescents

Couples <6yr

child

Aged

Fever 75.5 80.5 75.7 73.7 77.1 71.3 81.7 71.3 80.0 72.5 75.5 Cold 74.1 72.4 71.1 66.1 75.2 77.5 79.2 61.3 72.5 67.5 71.0 Cough 40.8 40.2 41.5 41.4 42.5 38.8 47.5 35.0 42.5 30.0 42.0 Diarrhea 10.9 11.5 9.6 11.3 11.2 5.0 12.5 20.0 7.5 5.0 11.3 Vomiting 8.2 8.6 8.6 8.6 8.9 5.0 8.3 7.5 12.5 10.0 8.8 Minor Injuries 9.5 12.1 10.3 15.6 7.0 12.5 7.5 13.8 12.5 17.5 11.0 Headache 33.3 38.5 36.2 40.9 30.4 33.8 38.3 32.5 37.5 32.5 35.3 Indigestion 11.6 6.3 9.6 10.8 8.9 5.0 10.8 13.8 10.0 15.0 9.8 Total 147 174 301 186 214 80 120 80 40 40 400

More cases of minor injuries were found among migrants due to working in harsh circumstances and living in unhygienic conditions suffer from serious occupational health problems and are vulnerable to disease. Those working in quarries, construction sites and mines suffer from various health hazards, mostly lung diseases. As the employer does not follow safety measures, accidents are quite frequent. Therefore during post migration period, about 17.5% reported the problem of minor injuries which they ad acquired during the time of migration. h

Table 26 Heath Care Needs of Migrants during the time of migration Health Care Needs

Male Female Total


Minor Illness 16 51.6 3 33.3 19 47.5

Injuries in workplace 6 20.0 6 15.4

Total 31 100.0 9 100.0 40 100.0

Unlike other categories of marginalised people, the study purposefully made an attempt to know the illnesses suffered by migrants during the time of migration. As clear from Table 26 that maximum i.e. 47.5% suffered from various minor illnesses during the time of migration. About 15.4% migrants (only male migrants) encountered injuries at their work place. With regard to treatment of minor illnesses, the study collected information on the type of health facility visited by different marginalised people; status of completion of their treatment; reasons of

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preferences or non‐preferences of visiting any health facility; and the quality of services provided in different health facilities for treatment of their minor illnesses.

Table 27 Marginalized people visited to health facilities for treatment of minor illness Health Facilities Marginalised


Gender Life Cycle (stages) Disabled

e Peopl

Migrants

Total

SCs

STs

BPL

Male

Female

Adolescents

Couples <6yr

child

Aged

District Hospital 23.8 21.8 21.9 24.2 23.8 18.8 24.2 23.8 30.0 22.5 24.0 CHC/Rural Hospital/PHC, 46.9 52.9 48.5 48.4 47.2 40.0 48.3 47.5 57.5 57.5 47.8 Sub‐Centre, 17.0 29.3 23.6 22.6 20.1 17.5 20.0 23.8 25.0 10.0 21.3 Anganwadi/ ICDS Centre, 32.0 53.4 43.5 39.2 41.6 38.8 35.8 51.3 55.0 30.0 40.5 Govt. Mobile Clinic 1.4 8.6 4.7 3.2 5.1 6.3 5.0 1.3 5.0 2.5 4.3 Pvt. Hospital 5.4 2.3 4.0 5.9 2.8 3.8 5.0 2.5 12.5 4.3 Pvt. Doctor/Clinic 6.1 6.9 7.0 6.5 9.3 6.3 7.5 15.0 7.5 8.0 Pvt. Paramedic 2.0 1.7 1.6 0.9 2.5 2.5 2.5 1.3 Baidya/Hakim/Homeopathy 7.5 11.5 9.3 8.6 9.8 3.8 12.5 11.3 7.5 7.5 9.3 Pharmacy/drug store 12.2 8.6 11.3 9.7 10.3 11.3 10.0 13.8 7.5 2.5 10.0 Dai/ TBA 0.7 3.4 2.3 1.1 2.3 2.5 2.5 5.0 1.8 Quack 6.8 9.2 8.3 8.1 7.5 11.3 5.8 6.3 15.0 5.0 7.8 Total 147 174 301 186 214 80 120 80 40 40 400

Table 27 presents the percentages of various categories of marginalised people those who visited arious public health facilities for treatment of their minor illness. As clear from the same, almost half

r illnesses. Category wise

marginalised groups. The same table also indicate

which is located in the village itself was preferred ostly by the STs, disabled and aged people to get medicines for their minor illnesses which could be

rt from the disabled and aged people the STs also come cross with the mobility problems mainly because they reside in the remote or inaccessible areas.

r treatment

ervices both at home and in the work places, although they are known to be especially vulnerable to health problems, and can serve as carriers of

vi.e. 47.8% visited the CHC/PHC for treatment of minor illnesses. A significant percentage of people i.e. 40.5% also visited AWC for treatment of their minor illnesses followed by 24% visited district hospital and 21.3% only visited the sub‐centre for availing treatment of their minobreak‐up of marginalised groups also indicate that PHC/CHC is the most preferred source of treatment for their minor illnesses across different categories of that highest percentages of people among STs (53.4%) and aged (51.3%) people visited AWC for treatment of minor illnesses. As high as, about 55% of disabled people also visited the AWC for treatment of their minor illnesses. In brief, AWCmdue to their mobility problems. As known, apaa Comparing to other categories, only 30% migrants visited AWC for availing free medicines foof their minor illness. Migrants cannot access various health and family health care programs due to their temporary status. Free public health care facilities and programs are not accessible to them. Migrants suffer from a lack of access to health s

communicable disease. The recent international focus on HIV/AIDS has galvanized governmental attention on the link between migration and the spread of this disease, and has resulted in a large


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number of NGOs working with migrant workers under the National AIDS Control Program, but other health problems of migrants continue to receive short shrift.

Table 28 Health Facilities visited during the time of migration Health Facilities

Male Female Total


District Hospital 7 11.9 2 28.6 9 13.6

CHC/Rural Hospital/PHC 12 20.3 2 28.6 14 21.2

Sub‐Centre 8 13.6 1 14.3 9 13.6

Anganwadi/ ICDS Centre 6 10.2 6 9.1

Other Public Sector 2 3.4 2 3.0

Pvt. Hospital 9 15.3 1 1 14.3 0 15.2

Pvt. Doctor/Clinic 11 18.6 1 14.3 12 18.2

Baidya/Hakim/Homeopathy 2 3.4 3.0 2

Pharmacy/drug store 1 1.7 1 1.5

Quack 1 1.7 1. 1 5

Total 59 100.0 7 100.0 66 100.0

However during t e o ration, particularly peop s o ra outside t

privat lth fa ies for availi car vi N im .2% visited rivate tors and 15 to t p for tment o ei es

he dependency on private health facilities was found to be more especially during the time of

le, the study made an attempt to know from people those ho were not visiting any of the public health facilities about the reasons of non‐preferring the same for

be particularly helpful for eries to know that preve ple in accessing the h facilities and

ereby results in health ity. Ac gly th tegy t ress t sons of he equity eloped and ex ted.

he tim f mig le tho e wh mig ted the s ate mostly visited the e hea cilit ng health e ser ces. ext to PHC/CHC (21.2%), max umi.e. 18 to p doc .2% visited priva e hos ital trea f th r illn ses. Tmigration as compared to their dependency during post‐migration period. Especially in the post migration period, highest percentages of migrants were found depending on public health facilities. As already mentioned highest i.e. 57.5% depended on PHC/CHC followed by 30% on AWC and 22.5% on district hospital, very much like the other categories of marginalised people reside in the village. Coming to preferences of marginalized peopwtreatment of their minor illnesses. The analysis presented in Table 29 wouldthe state machin the reasons nt peo ealth th inequ cordin e stra o add he rea alth incould be dev ecu

Table 29 Reasons for non‐preferences of any of the public health facilities for treatment of minor illness

Reasons Marginalised Castes

Economically Deprived

Gender Life Cycle (stages) Disabled People

Migrants

Total

SCs

STs

BPL

Male

Female

Adolescents

Couples <6yr

child

Aged

More Distance 19.4 23.5 20.9 20.3 21.7 11.4 19.9 24.7 20.4 18.1 21.1 Lack of money 8.9 11.9 10.5 10.6 10.2 6.3 7.6 12.6 15.3 9.4 10.4


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Table 29 Reasons for non‐preferences of any of the public health facilities for treatment of minor illness

Reasons Marginalised Castes



Migrants

Total

SCs

STs

BPL

Male

Female

Adolescents

Couples <6yr

child

Aged

No Transportation Facility 2.4 4.2 3.0 2.9 4.1 2.5 4.7 2.7 2.2 3.9 3.6 High transportation cost 8.5 10.2 9.5 9.1 9.8 4.6 8.7 9.4 10.2 10.2 9.5 Influence of family members

15.1 9.4 12.5 14.0 11.1 0.7 12.1 12.1 8.0 9.4 12.4

Tradition 0.2 0.3 0.5 3.9 0.4 0.4 0.2

Loss of wage 1.0 0.6 0.8 0.5 1.2 0.9 0.9 0.4 1.5 0.9

No permission from family members

2.4 5.3 3.3 3.7 4.3 1.8 7.1 2.2 2.2 4.1

Total n co strof ow n aints 62.2 Lack of attention 11.7 5.5 8.6 10.4 7.1 43.8 7.4 8.5 8.8 11.0 8.6 More time taken by providers

5.6 7.3 6.4 6.8 5.4 5.8 4.9 4.0 7 .3 10.2 6.1

No Free Medicine 5.4 4.4 5.4 3.9 5.6 4.6 4.5 6.3 5.8 6.3 4.8 Need to wait long hours 2.6 3.4 3.1 2.4 3.3 1.6 3.6 2.7 3.6 3.1 2.9 Fees to pay 3.2 1.9 2.6 1.9 3.0 0.5 2.9 2.2 5.8 3.1 2.5 Lack of Trust/Faith on service provider

6.7 4.7 6.0 5.5 5.8 7.9 5.4 4.5 4.4 8.7 5.7

Non‐availability of service provider

5.4 6.6 5.8 5.8 5.7 3.0 7.6 6.3 3.6 5.5 5.8

Need to pay for Urine/Blood Testing

0.3 0.2 0.3 0.2 0.2 0.1

Improper referral service 1.2 0.5 1.0 1.1 1.1 0.7 1.6 0.9 0.8 1.1 Improper behavior 0.4 0.2 0.2 0.5 0.3 0.2 0.7 0.7 0.4

Total of the constraints with the providers 38.0 Total Responses 496 620 1049 616 736 571 448 223 137 127 1,352 Total Respondents 133 161 270 164 197 75 114 69 37 32 361

Table 29 presents the various responses given by marginalised groups with regard to their non preferences of public health facilities. As clear from the same table that about 62% of non‐preferences were due to their own problems of marginalised people and 38% were due to the constraints with the service providers. Among their own constraints, highest i.e. 21.1% reported long distance as the reason followed by 12.4% said about influence of family members, 10.4% reported lack of money and 9.5% said igh transportation cost as the reasons of non‐preferring a public health facility. Among the various h

constraints of providers, maximum i.e. 8.6% reported lack attention by providers followed by 6.1% said more time taken, 5.8% said non‐availability of service providers and 5.7% said lack of trust as the reasons for not preferring a particular public health facility. Before knowing the status of completion of treatment of minor illnesses in public health facilities, the constraints faced by migrants specifically during the time migration have been presented here.

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Table 30 Problems faced by migrants in availing health services during the time of migration Problems

Male Female Total


Health facilities are in distant place 5 16.1 1 11.1 6 15.0

No health facilities at work place 9.7 3 33.3 6 .0 3 15

No medicines available 2 22.2 2 5.0

High transportation cost 7 2.6 1 8 202 11.1 .0

Demand money 6 19.4 2 22.2 8 20.0

High cost in private facilities 9 9.0 9 222 .5

Total Responses 31 100.0 9 100.0 40 100.0

The problems that the migrants faced f availing ealth services are presented in le

e. 22.5% reported high of treatment in priva health facilities as th ajor problem ces. About 20% ach said money emanded the providers an gh

ts to visit the health cilities as main difficulties for ailing proper healt re s. About 15% each reported lo distance health f and non‐availability of th at work place as the major prob confronted by them

or and accessing h Tab30. Maximum i. cost te e mof availing health servi e that d by d hitransportation cos fa the av h caservice ng of acilities healfacilities lems . Apart from knowing the constraints of different marginalised groups, an attempt has been made here to know the status of completion of treatment of minor illnesses especially in the public health facilities. Table 31 Status of completion of treatment of minor illnesses in public health facilities Status Marginalised



Disabled People

Migrants

Total

SCs

STs

BPL

Male

Female

Adolescents

Couples <6yr

child

Aged

Complete 88.7 81.8 84.7 78.9 89.8 85.7 86.3 81.5 94.2 85.0 84.9 Delayed 4.5 9.8 8.7 11.2 4.8 8.2 8.1 5.6 4.3 7.5 7.7 In‐complete 6.8 8.4 6.5 9.9 5.5 6.1 5.6 13.0 1.4 7.5 7.5 Total Responses 177 275 413 242 293 98 161 108 69 40 535 Total Respondents 111 139 230 137 170 62 96 56 36 28 307

With regard to the status of completion of treatment, it is clear from Table 31 that as high as 85%

alth facilities. about incomplete treatment and 7.5% said delayed treatment of minor

in public health so the s ble centages of marginalised people report ut delay ‐complete treatment in public hea facilities as compared to female persons. As far as quality of treatment is concerned, about 76% or av b f ality health

reatment of r illnesses in pu cilities l .

marginalised people reported completion of treatment of their minor illnesses in the public he Only 7.7% reported

illnesses facilities. Aled abo

clear from ed and in

ame ta that more per male lth

qurep ted aila ility o betterservices for t mino blic fa (Tab e 32)


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Table 32 Quality of service for treatment of minor illnesses in public health facilities Quality Marginalised Castes Economically Deprived Gender Life Cycle (stages)

Disabled

People

Migrants

Total

SCs

STs

BPL

Male

Female

Adolescents

Couples

<6yr child

Aged

Very Poor 0.7 0.2 0.8 0.7 0.6 1.7 1.4 0.7 Poor 1.1 1.4 1.4 1.9 1.7 1.2 3.4 2.9 2.0 1.8 Average 24.9 20.6 20.1 23.5 20.6 25.3 22.3 23.5 13.0 12.2 21.9 Good 61.1 60.1 62.9 60.0 60.1 58.6 57.8 58.0 71.0 63.3 60.1 Very Good 13.0 17.9 15.3 13.8 16.9 16.2 18.1 13.4 11.6 22.4 15.5 Total Responses 185 291 437 260 301 437 166 119 69 49 561 Total Respondents 114 144 237 143 173 237 99 59 36 30 316

Apart from minor illnesAs clear from

se riou pes of m illnesses fe b op re se in Table the same that highest i.e.39.3% marginalised people suffered from malaria. Category wise

break‐up of marginalised people indicate that highest percentage of STs (44 a cat ies arginalis ple b s s ly y m f ar

e generally malaria prone areas.

inal peo suffered differe a illnesses

s, va s ty ajor suf red y pe le a pre nted 33

.3%) suffered from m laria as compared to otherwhich ar

egor of m ed peo ecau e ST most sta in re ote orest eas

Table 33 Marg ized ple from nt m jor Illness Marginalised

Castes Econo micallyDep rived

Gender Life Cy tacle (s ges) Disabl

People ed

Mi

nts gra

T otal

SCs

STs

BPL

Male

Female

lescnts

Couples <6yr

chil

Aged

Ado

e d

TB 5.4 8.6 7.0 10.2 5.1 1.3 1.7 2.5 2.5 2.5 7.5 Leprosy 1.4 0.6 1.3 1.1 1.4 1.3 Asthma 3.4 1.7 1.6 1.9 1.3 1.7 2.5 2.5 5.0 1.8 Diabetics 1.4 0.6 1.7 2.2 0.9 2.5 2.5 2.5 1.5 Blood Pressure 3.4 2.9 2.7 3.8 3.7 3.8 5.0 5.0 7.5 3.8 Malaria 32.0 44.3 41.9 37.6 40.7 42.5 38.8 38.8 42.5 39.3 Cancer 1.4 1.1 1.0 1.1 1.4 2.5 1.3 Major Injuries 2.7 1.1 3.3 3.8 2.8 1.3 5.0 5.0 10.0 3.3 Medicine Reaction 2.0 1.1 2.0 1.1 2.3 1.3 1.3 1.3 2.5 1.8 Sicilian 0.7 0.3 0.5 1.3 0.3 Piles 0.6 0.5 0.3 Hydrosol Operation 0.7 0.3 0.5 1.3 0.3 Cataract 0.7 0.3 0.5 1.3 1.3 0.3 Paralysis 2.7 1.0 1.1 0.9 1.3 1.3 1.3 2.5 1.0 Fids 0.5 1.3 1.3 0.3 Rheumatism/Arthritis 0.7 0.6 0.3 0.9 0.5 Exima 0.7 0.3 0.5 1.3 1.3 0.3 High Fever 0.3 0.5 0.3 Gastroenteritis 0.7 0.3 0.5 0.3 Gynic Problem 0.5 0.3 Brain Malaria 0.3 0.5 0.3 Jaundice 0.6 0.3 0.5 0.3 Severe Diarrhea 1.1 0.9 0.5 Total 147 174 301 186 214 80 120 80 40 40 400


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Next to malaria, about 7.5% marginalised people suffered from TB. Comparing with females (5.1%), a ercentage of male persons (10.2%) suffered from TB. N hest i.e. 3.8% ginalised

ople suffered from Blood Pressure and 3 ffer m m njur compared to ent ople, highest pe entage (10%) red from majo ries

ring the time of mi tion.

greater p ext hig marpe .3% su ed fro ajor i ies. As differcategories of marginalised pe rc of migrants suffe r injuwhich they had acquired du gra

Table 34 Marginalized people visited to ealth facilities for eatme major nesse h tr nt of ill s Health Facilities Marginalised

Castes Economically Depr ed iv


Migrants

Total

SCs

STs

BPL

Male

Female

Adolescents

Couples

<6yr child

Aged

District Hospital 48.1 39.3 44.8 51.5 44.4 35.7 58.8 53.3 65.0 46.2 47.5 CHC/Rural Hospital/PHC 53.2 60.7 58.6 52.4 51.9 47.6 47.1 51.1 65.0 42.3 52.1 Sub‐centre 13.9 31.8 25.4 29.1 14.3 14.3 23.5 20.0 30.0 19.2 20.8 Anganwadi/ICDS Centre 19.0 40.2 30.9 33.0 24.1 26.2 17.6 24.4 35.0 30.8 28.0 Government Mobile Clinic 1.9 0.6 1.5 2.4 0.8 Private Hospital 8.9 3.7 6.1 7.8 7.5 7.1 12.1 2.2 15.4 7.6 Private Doctor / Clinic 10.1 9.3 6.6 8.7 9.0 11.9 12.1 2.2 5.0 7.7 8.9 Private Para‐medic 1.3 0.6 1.5 2.4 1.5 2.2 0.8 Hakim/Baidya/Homeopath 3.8 3.7 5.5 8.7 1.5 7.1 1.5 6.7 10.0 7.7 4.7 Pharmacy/Drug store 5.1 8.4 7.2 8.7 6.0 7.6 13.3 5.0 7.2 Dai/TBA 1.3 1.9 2.2 1.9 1.5 4.8 4.4 10.0 1.7 Quack 1.3 5.6 2.8 3.9 2.3 3.0 6.7 3.0 Total 147 174 301 186 214 80 120 80 40 40 400

As far as treatment of major illnesses is concerned, a grea cent of people ( 52.1%) depended on CHC/PH r treatment of ir major esses llow 5 ep ed district hospital (Table 34). Availability of provision for treatment of jor esse Malaria, TB, Asthma,

, etc. is the reason for wh hest percenta t C District l in compariso facilities like S enter an C. in e o D p fo d

lly cons the l provid AWW/ASHA/ANM w in n s HC C ital f eatment of the jor illnesses. Als m sa ta tha s h s

0% STs and 35% disabled people visited the AWC for the same.

ter fo ma

pered illn

ageby 47.

s like

i.e. onC fo the illn % d end

Diabetics major ich hig ges of people visi ed PHC/CH andHospita n to ub‐c d AW Dur g th time f FG , peo le in rmethat they initia ult loca ers like ho tur refer them to P /CHand District Hosp or tr ir ma o clear fro the me ble t a igh a4

Table 35 Reasons of non‐preferences of any of the public health facilities for treatment of major illness

Marginalised Castes


Gender Life Cycle (stages) Disabl

Total

ed Peopl

Migrants

e

SCs

STs

BPL

Male

Female

Adolesc

Coupl

<6yr

Aged

ents

es

child

More Distance 10.4 17.6 15.1 13.8 14.2 14.8 13.2 13.0 12.7 5.3 14.0 La .2ck of money 7 12.0 9.6 10.9 8.1 7.1 9.1 10.4 11.1 5.9 9.2 High transportation cost 10.4 8.2 9.1 9.0 8.1 8.4 6.8 9.7 9.5 4.6 8.4


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Table 35 Reasons of non‐preferences of any of the public health facilities for treatment of major illness

Marginalise Castes


Gender Cycle (stages)

ed P

Migrants

Total d

Life Disabl

eople

SCs

STs

BPL

F

esce

Couples

AMale

emale

Adol

nts

<6yr child

ged

Tradition 3 0. 0.6 1.3 0.3 Loss of wage 0.4 0.3 0.2 0.4 0.5 0.6 0.3 No Transportation Facili 4.0 8 ty 2.0 2. 3.9 2.3 2.6 3.2 2.6 2.6 2.9 No permission from family members

3.6 5.1 3.9 1.6 5.5 2.6 2.3 3.2 1.6 3.3 4.0

Influence of family members 24.4 12.2 16.4 18.3 18.6 16.8 16.9 20.1 20.6 8.6 18.5 Total of own constraints 57.6

Lack of attention 7.2 7.2 7.1 7.1 9.1 5.2 10.0 7.1 9.5 3.3 8.3 No Free Medicine 5.6 4.5 5.0 5.1 3.8 4.5 2.7 5.2 9.5 3.3 4.3 More time taken by providers 5.6 8.5 7.0 6.8 7.6 9.0 9.6 7.8 3.2 2.6 7.3 Need to wait long hours 3.2 2.9 2.6 3.5 3.0 1.3 5.5 2.6 1.6 0.7 3.2 Fees to pay 2.0 1.3 1.6 1.0 1.9 1.3 1.8 1.3 4.8 1.5 Lack of Trust/Faith on service provider

11.6 8.5 11.8 9.0 10.8 12.9 11.9 5.8 14.3 5.3 10.1

Non‐availability of sprovider

5.6 7.4 1.6 3.3 ervice 4.8 5.7 4.2 9.0 2.7 10.4 5.5

Improper referral service 1.6 1.9 1.9 1.9 2.1 4.5 3.2 2.0 Improper behavior 0.3 0.2 0. 0.1 5

Tot the w the vidal of constraints ith pro ers 42.3 Total Responses 250 376 31 4 76 783 617 1 72 219 154 63 Total Respondents 77 101 174 97 130 65 42 20 22 227

The reasons of not preferring th ublic healt es for tm t o aj r te

. As clear from e tab at about 57.6% of non‐ er es were due t ei n bl ity conditions of marginalis ple e. c money, igh n tation c

of family mem ers, etc. The rest 41% re due th servicettention, oper aviour, no medicin c.

the own constraints reported by marginalised people, h or d (i.e. 18.5%) about fam emb which acte a key reason b d ‐pr ferri a particular pu

lity. Next h st i.e. 4% said lon tance of h alth ilit s as n on t ferences. Followed to about 9. informed ou ck m ney d % h

as reasons for not preferring a particular public health acility.

e various constraints f providers, imum i.e. out lac of t /lowed b 3% reported lack o tention by pro more me kend 5.5% pointed out on‐availabil f providers th ealt faci y as he reasons n

g a particular public he facility.

e p h faciliti trea en f m or illnesses are p esen d in Table 35 th le th pref enc o th r ow pro emsor vulnerabil the ed peo g. la k of h tra spor ost,influence b we to the constraints wi the providers e.g. lack of a impr beh free e, et Among ighest rep te the influence of their ily m ers d as ehin non e ng blichealth faci ighe 1 g dis e fac ie the mai reas for heirnon‐pre this 2% ab t la of o an 8.4 told ightransportation cost the f Among th o max 10.1% pointed k rust faith on providers fol y 8. f at viders, 7.3% felt ti ta by providers, an n ity o in e h h lit t for on‐preferrin alth


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52


Specifically among the disabled people, as high as 14.3% gave lack of trust on providers as the reason for non‐preferring a particular public health facility followed to influence of family members. Long distance of health facilities was reported by highest percentage of STs (i.e. 17.6%) as the main reason for non‐preferring a particular public health facility which is obvious to the fact that maximum STs live in remote or inaccessible areas.

Table 36 Status of completion of treatment of major illnesses in public health facilities Status Marginalised Castes Econom d ically Deprive Gender Life Cycle (stages) D

isabled People

Migrants

Total

SCs

STs

BPL

Adol

Coupl

Male

Female

escents

es <6yr

child

Aged

Complete 67.9 64.9 66.8 62.8 72.1 67.3 74.2 72.7 67.5 80.6 67.6 Delayed 9.4 22.2 15.9 18.6 12.6 20.0 12.4 13.6 7.5 11.1 15.5 In‐complete 22.6 13.0 17.3 18.6 15.3 12.7 13.5 13.6 25.0 8.3 16.9 Total Responses 106 2185 95 172 183 55 89 66 40 36 355 Total Respondents 71 94 165 93 119 39 60 38 19 20 212

With regard to the status om on of tre ent, it is ar m e h 7. a al

completi of treatment of r major nes ls a e same table mi ts (i 0.6%) re ed abou e p n re en th m to er marginalised g ps. Dela or lo d tr tm o jor llne

lic health facilities w reported by 15.5 the ma ali people. re nletion of treatment eir illness blic hea a s

of c pleti atm cle fro Tabl 36 t at 6 6% m rgin isedpeople reported on thei ill s. A o cle r from th thathighest percentage of gran .e. 8 port t th com letio of t atm t of eir ajorillnesses in comparison oth rou yed pro nge ea ent f ma i sses in pub as % of rgin sed The st 17% reported on‐comp of th major in pu lth f cilitie .

Table 37 Quality of service for treatment of major illnesses in public health facilities Quality Marginalised Castes Economically Deprived Gender Life Cycle (stages)

Disabled

People

Migrants

Total SCs

STs

BPL

Male

Female

Adolescents

Couples

<6yr child

Aged

Very Poor 0.9 0.5 0.7 0.6 1.1 2.2 1.5 0.8 Poor 3.7 5.3 4.0 2.3 7.5 1.8 9.9 4.5 2.5 5.0 Average 20.6 16.5 19.2 22.0 16.7 18.2 18.7 14.9 22.5 18.9 19.2 Good 55.1 51.6 51.5 49.7 53.8 56.4 45.1 50.7 55.0 48.6 51.8 Very Good 19.6 26.1 24.6 25.4 21.0 23.6 24.2 28.4 20.0 32.4 23.1 Total Responses 107 188 297 173 186 55 91 67 40 37 359 Total Respondents 71 95 165 93 120 39 61 38 19 20 213

Regarding the quality of servic atme or illnesses indicate that of the tot arginalised people those who were availing treatment from public health facilitie bo 75% reported availability of better quality health service

e for tre nt of maj al ms a ut

s.


February 2

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Table 38 Deaths due to major illness Districts Accident Cancer TB Table Total Brain Malaria

Count Row t Cou w % % Cou % Coun Row % nt Ro Count Row nt

Bolangir 4 57.1 1 14.3 2 28.6 7

Jagatsinghpur 0

Keonjhar 1 33.3 1 33.3 1 33.3 3

Malkangiri 2 100. 2 0 Table Total 7 58.3 1 8.3 3 25.0 1 8.3 12

Of the 400 households cover study, th case ur one ar ce g the survey

In en these the h d b m ri r e to cancer and one death each was due to TB and accident. Some of the problems that were

the ti as n in t 9

ed in the dea d ing ye pre din wasreported in 12 households. were due

sev of cases deat was ue to rain ala a. Th ee d aths

faced during treatment of se pa ents are give able 3 .

Table 39 Problems reported b arginalized peop r e y m le fo the D aths Bo langir Keo njhar Malkangiri Total Could not take to hospital due to dist ance 6.3 16.7 7.4 Lack of money 31.3 60.0 16.7 33.3 Not Aware of any proper health facility 6.3 20.0 16.7 11.1 High transportation cost, hence did not take to hospital 6.3 16.7 7.4 More time spent avel during tr 16.7 3.7 No Free Medicine 6.3 3.7 No transportation facility 6.3 20.0 7.4 Waited long hours for treatment / delayed tr ent eatm 31.3 16.7 22.2 Incomplete treatment 6.3 3.7 Total Responses 16 5 6 27

Total Death Cases 7 3 2 12

Highest i.e. 33.3% reported lack of money as the reasons for death where as 22.2% pointed out delayed treatment in health facilities as the reason for death. For them, the deaths could have been avoided if early treatment had been taken‐up.

regard to treatment of illness, the other problems that wereWith discussed by the marginalised people during the time of FGD are as presented below: Responses of SC and ST on problems of availing treatment for illness

During rainy season people generally suffer from diarrhea, vomiting, etc. and in winter season they mostly suffer from cold, fever, etc. Malaria is the major health problem that they face

all throughout

the year. For all type of major illness, people prefer the district hospital or the PHC/CHC at the Block headquarter. Availability of free medicine is the other attraction for visiting the health facilities.

Since the major illness suffered by people requires various pathological tests including X‐RAY,people have no option to visit other than

the district hospital.


February 2

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For treatment of minor illness, people usually prefer to visit ASHA/AWW to get the medicine. Although, people appreciate the availability of free medicine from ASHA/AWW, they are found to be only dissatisfied when they do not get cured by the medicines given by ASHA/AWW.

Sometimes, people also do not get medicines from ASHA/AWW due to not having adequate stock. Only Blood test and health check‐up are done free of cost at the district hospital. For medicines and other things people have to bear heavy expenses for treatment of their major illness.

People are found to be unhappy due to paying service fee to the doctor in the PHC/CHC at arapada inTik Bolangir district.

Except Jagatsinghpur, people are satisfied with the quality of health ck done b e d ors at the PHC/CHC and ct hospital.

che ‐up y th oct distri

People seem to unhap with regard the non‐availability of c P /CH they don’t the hospital the ed time. e, to t lo ho in

pital or visi ctor’ idence for lth check o e e return t treatm beca do no e any ot t e je h

the lage.

be py to do tor at wai

HC C ifng reach in schedul Therefor either they have for urs the

hos t do s res hea ‐up r sometim s they hav to back withou ent use they t hav her option to ca ch th only bus/ ep t at is available to ir vil

Non‐availability doctor Harichanda PHC in Keonjhar a c shared by peopl of in npur is major con ern ethose who are dependent on the same.

Responses of marginalised people residing in Remote / Inaccessible pockets on treatment of illness

Non‐availability of health sub‐centre in the remote locality of Keonjhar and Bolangir district was reported.

Non‐availability of doctors in PHC was reported by the people as a major barrier to get health care in Jagatsinghpur district. In Bolangir, due to long distance of PHC people in the remote area services

less visit to the PHC. Due to non‐availability of better health care services, people prefer to visit the CHC located at distant place rather visiting the nearby PHC in Jagatsinghpur cdistri t.

Free medicine AWW/ASHA as reporte pl u ck of medicine with them creates problem.

provided by w d by peo e b t lack of adequate sto

People suffering m min were d to be more in ny aso a was found as or health lem ered by ex g g i e

gatsinghpur, le reported about th jor illnes C e ia D u r

fro or illness foun rai se n. M laria themaj prob suff the most cept in Ja atsin hpur distr ct. Howev r in Ja peop e ma s like hick ngun and eng feve .

People reporte out ing high r t in e nistri spita

d ab bear transportation and othe cos s for avail g tr atme t at PHC/CHC/D ct ho l

In Jagatsinghpur, people even reported about paying service fee to the health providers in public health facility.

People in Bolangir have the general perception that free treatment from the health providers would not be effective as compared to the paid treatment.

The other major problem reported by people is the non‐availability of all types of health care services in one health facility, as a result of which they have to visit from one health facility to another facility for availing health care services.

Feb

r24,

9


rua

y

200

Page

55


Irregular visit of health personnel and non‐availability of health personnel were the other problems rted by pe time

es of aged ople eatme of illn

repo ople during the of FGD.

Respons pe on tr nt ess

The first and foremost ern shared by them is th lack o per attention by the alth nnel whe they v e health facility They were of the the doctors trea

le of other age

conc e f pro given heperso n isit th . opinion that t themlike peop group.

Non‐availability of all the prescribed medicines from the health facility in free of cost was reported by them as one of the major problems.

Non‐availability of doctors in the health facility was shared as another major problem for availing treatment. As a result of which many a time they had to return without being checked‐up by the doctors.

Although the aged people appreciate the initiative of government available through AWW/ASHA, they seemed to be unh r n

for making free medicines c he appy fo ot getting ured by t same

medicines. Constraint of meeting health expenses was expressed by th jority. ount 200/‐

their basic mi m requirements as rted b

people on treatment of illness

e ma The am of Rs. paidas old age pension is not sufficient to meet nimu repo y themost.

Responses of disabled No special attention given to disabled persons by health personnel with rd to chec

sts and medicines were reported as proble the disabled people Accordin isabled persons were treated like the able person by the health providers

rega health k‐up,pathological te ms by . g tothem, the d s .

Dependency on family members for visiting health facilities was shared as the other major

2.3.2 Maternal and Child Health Care

made an attempt to understand the availability, ccessibility and quality of maternal and child health care services from the perceptions of marginalised

hers and fathers and mothers of hild between six months to six years year old. Recall method was used to know their perceptions on

40, 21% households (i.e. 84 out of 400) covered in the study had a pregnancy case in

ANC

constraint faced by the disabled persons. Dependency with regard to visiting the health facility and dependency to meet the health expenses were the two main problems shared by them.

Apart from treatment of illnesses, the study alsoapeople. In this regard, the study specifically interviewed lactating motcvarious maternal and child health care services received by them. As clear from Tabletheir family during last one and half year preceding the date of survey. Of them, about 65.5% households belong to BPL category. About 45.2% belong to STs and 35.7% belong to SCs. Various related questions were asked to these households and the responses provided by them are as presented here in this section of the report.

February

2009


24,

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56


Table 40 Knowledge about health personnel and Contacts with them for MCH care Health Personnel

Marginalised Castes Economically Deprived Total

SCs STs BPL

Knowledge (%)

Contacts (nos.)

Knowledge (%)

Contacts (nos.)

Knowledge (%)

Contacts (nos.)

Knowledge (%)

Contacts (nos.)

ANM 83.3 3 94.7 2 90.9 3 88.1 3 ASHA 80.0 6 89.5 4 85.5 4 86.9 5 AWW 86.7 4 100.0 5 96.4 4 94.0 4 LHV 3.3 ‐ 7.9 ‐ 5.5 ‐ 7.1 ‐ Total Respondents

30 30 38 38 55 55 84 84

As far as knowledge about health personnel is concerned, majority knew the ANM (88%), ASHA (87%) and AWW (94%) appointed at Sub‐centre and AWC level for getting MCH care. That means about 6 to 13% people did not know about AWW/ASHA/ANM appointed in their village / Sub‐centre (Table 40) for availing ANC services. As also clear from the same table that SC households were less aware of the health personnel in comparison to STs. When 5.3% STs did not know about ANM, about 16.7% SCs were not aware about NM. Again among SCs, as high as 20% did not know about the ASHA worker and 13.3% did not know

H roviders, a significant percentage i.e. 10.5% were not aware about ASHA. Thus, it is important to note

rtain households from MCH care.

l is presented in Table 40. As per the table, at least five times they had in

provide ANC services at Sub‐

Ts is only two times. STs in comparison to contacts with ASHA

nel. That

Aabout AWW appointed in their village. Although, STs are relatively better aware about the MCphere that lack of knowledge of people about MCH providers could be one of the factors leading to exclusion of ce During the time of pregnancy, the mean number of times that the pregnant women had in contact with various health personnecontact with ASHA, four times with AWW and three times with ANM during nine months of pregnancy. While ANM has been placed by government as a key health personnel tocentre and village level, according to Table 40 the pregnant women had only three times in contact with ANM during the pregnancy which among Sand ANM had relatively more contacts with AWW (five times) during pregnancy. As clear from Table 41 that about 9.5% pregnancies were not registered with health personmeans the rest 90.5% pregnancies were registered with the health personnel. The percentage of pregnancies registered among SCs (86.7%) was found to be lowest in comparison to other categories of marginalised groups.

Table 41 Status of registration of pregnancy cases with health personnel & receipt of ANC card Marginalised Castes Economically Deprived Total

SCs STs BPL

Registration ANC Card




% who were registered 86.7 83.3 92.1 92.1 92.7 92.7 90.5 89.3


February 2

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Table 41 Status of registration of pregnancy cases with health personnel & receipt of ANC card Marginalised Castes Economically Deprived Total

SCs STs BPL

Registration ANC RegistratioCard

n ANC Card



and received ANC card Total Cases 30 30 38 38 55 55 84 84

The reasons reported for non‐registration of pregnancies with health personnel are as presented in Table 42. Maximum i.e. 41.7% were of the opinion that lack of contacts by the health personnel is the reason for which they could not register the pregnancy. About 33.3% said that they preferred against visiting any health facility for registration and 25% reported that they are not aware about the registration.

Table 42 Reasons of non‐registration of pregnancies with health personnel & non‐receipt of ANC Card Reasons of non‐registration % Reasons of non‐receipt % Not aware about the need of registration 25.0 Not aware about the issue of card 33.3 Did not go to any health facility for registration 33.3 Never demanded for card 22.2 No health personnel contacted us 41.7 Health personnel does not provide cards 44.4 Total Responses 12 Total Responses 9 Specifically, the pregnant women who did not prefer to visit the health facility for registration gave the following reasons:

Long distance of Health sub‐centre Irregular visit of health personnel to the health facility Lack of proper attention by health personnel No prior information by ASHA/AWW/ANM

In comparison to the rcent less i.e. 89.3% pregnant omen were provided with ANC . While sent percent of the registered cases among STs and BPL

e 42).

in VHND for availing the maternal health care. As also clear from the

percentage of pregnancies registered (90.5%), one pecardw

were provided with ANC card, at least three percent less of the registered cases (i.e. 83.3%) among SCs were provided with ANC card (Table 41). According to those who did not receive ANC card, 44.4% were of the opinion that health personnel did not provide them the ANC card followed by 33.3% reported that they were not aware about the issue of card and 22.2% were of the opinion that they themselves never demanded to the health personnel for the issue of card (Tabl The Government of Orissa has introduced Village Health and Nutrition Day (VHND) as one of the important initiatives for delivering maternal and child health care. In this regard, the study made an attempt to know about the percentage of people those who attended VHND especially the pregnant women. As clear from Figure 1, more than half i.e. 52.4% people never attended VHND. Only 47.6% marginalized people participated

February

2009

24,

CTRAN Co

Study on

same figuof SCs (4was founcompared(47.3%).

eas The r ofor notgiven in

T

reported about VHlack of inproviders before thefor not att

Table 43 Never held Not aware Organized aDifferent caNo prior infNo attentioHealth pers

Health persAbortion

Total Respo

Table 44 p84 pregnsupplemegiven at leonce in accompan

Table 44 ANC Service

Weighing MeasuremePressure Testing of UTesting of BAbdomen C

onsulting Pvt.

perceptions o

ure that the p40%) attendnd to be quitd to STs (50%

ons thatattendin

weg V

Table 43. Abolack of a

HND and 28nitiative by th to intimae VHND as thtending the V

Reaso

at AWC which is aste group are noormation about n in the FHND onnel did not tu

onnel do not co

onses

presents the nant womenentary nutritioeast one dosecase of abonied by ASHA

ANC Ses

ent of Blood

Urine Sample Blood Sample Check‐up

. Ltd. Bhuban

of marginaliz

ercentage ed VHND te less as %) and

share

BPL

re d VHND are out 40.9% awareness 8.8% told he service ate them he reasons VHND (Table 4

ns for not att

in a distant placot informed the date/No fix

urn‐up on FHND

me with vaccine

status of varn who wereon, followed e of TT. Weigout 86.9%, 6A (at least onc

ervices availeMarginalised

Castes

SCs STs

86.7 81.670.0 57.9

56.7 26.363.3 31.683.3 71.1

eswar

ed people ab

43).

tending VHN

ce

xed day

es and medicine

ious ANC serve availing suby 91.7% re

ghing, measur69% and 81%ce) to health f

ed during pre Economic

Deprive

BPL

6 83.69 63.6

3 38.26 47.31 78.2

0

SCs

STs

L

Marginalised

Castes

Econ

omical

ly Dep

rived

BP

Total

out health eq

D

s

vices that weuch servicesceived at learement of BP% pregnant facilities for a

egnancy cally ed

Bolang

100.0100.0

27.844.4100.0

0 20

Figure 1 W

T

quity in Orissa

ere received bs, highest i.ast one strip P and abdomewomen resvailing ANC s

District w

gir Jagatsingh

0 89.50 89.5

8 89.54 89.50 84.2

40

40

50

47.3

47.6

Women (%)

TMST ‐Orissa

a

3.0 40.9 4.5 3.0 28.8 6.1 6.1

6.1 1.5

66

by the pregnae. 94% repof IFA tableten check‐up wpectively. Abservices.

wise ANC status

hpur Keonjhar

86.7 53.3

40.0 46.7 73.3

60

who attend

Health Suppo

ant women. Oported receipts and 89.3% were done atbout 82.1%

s

r Malkangiri

78.1 46.9

25.0 31.3 71.9

80

ded VHND

ort Plan

Pa

5

Of the pt of were t least were

Total

86.9 69.0

42.9 50.0 81.0

100

age

58


February 2

4,

2009

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59


Table 44 ANC Services availed during pregnancy ANC Services Marginalised


District wise ANC status Total

SCs STs BPL Bolangir Jagatsinghpur Keonjhar Malkangiri

Tetanus 96.7 81.6 89.1 100.0 94.7 53.3 96.9 89.3 Iron Folic Acid Tablet or Syrup

90.0 92.1 92.7 100.0 94.7 86.7 87.5 91.7

De‐worming 43.3 39.5 41.8 66.7 31.6 40.0 37.5 42.9 Supplementary Nutrition from AWC

93.3 94.7 98.2 88.9 89.5 93.3 100.0 94.0

Accompanied by ASHA to health facility

73.3 89.5 78.2 83.3 89.5 86.7 75.0 82.1

Referral Service 33.3 26.3 30.9 50.0 47.4 6.7 28.1 33.3 Total Cases 30 38 55 18 19 15 32 84

Comparing with SCs (56.7%), only 26.3% STs reported about the testing of urine sample done during

had undergone abdomen as also found to be much les s sureme bl of only 57.9% preg

ared to 70% S nte less percentag en among SCs (73.3%) and B (78. were accompanied by ASHA to he

cilities for ANC as compared to STs (89.5%). However, in overall less percentage of pregnant women

istrict wise break‐up of various ANC services indicate that the pregnant women in Bolangir and services as compared to Malkangiri and Keonjhar district.

nd 53.3% pregnant women in Malkangiri (100%) and Jagatsinghpur (89.5%) district. A

check‐up of pregnant women. Relatively fewer ercentages of pregnant women in Malkangiri (71.9%) and Keonjhar (73.3%) district were undergone

pregnancy. Similarly, only 31.6% STs reported about testing of blood samples during the pregnancy. The percentage of STs who check‐up (71.1%) w s acompared to SCs (83.3%). The mea nt of ood pressure was done in case nantwomen among STs as comp Cs. I resting to also mention here that es ofpregnant wom PL 2%) households althfaamong STs received different ANC services as compared to SCs and BPL households. DJagatsinghpur district received better ANC Measurement of blood pressure was done in case of 46.9% aand Keonjhar district respectively as compared to Bolangirsimilar difference was also found in case of abdomenpabdomen check‐up as compared to Bolangir (100%) and Jagatsingpur (84.2%) district. As far as testing of urine and blood samples are concerned, very less percentages of people in Malkangiri (25% urine and 31.3% blood), Keonjhar (40% urine and 46.7% blood) and Bolangir (27.8% urine and 44.4% blood) district were provided with the same services.

Table 45 Reasons for not availing ANC Services during pregnancy Not visited health facility due to distance 8.7 Not visited health facility due to loss of wage 6.3 Health personnel do not visit on regular basis 13.5 Need to wait long at health facility, hence returned 5.6 No waiting room at health facility 6.3 No privacy at health facility for check‐up 14.3 Health personnel does not give proper antenatal care 22.2 Belong to different caste, hence no attention by health personnel 5.6 Belong to lower income group, hence no attention by health p 4.0 Not interested 6.3

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Table 45 Reasons for not availing ANC Services during pregnancy Don't Know the reason 7.1 Total Responses 126

Total Respondents 25

People those who were not availing any of the said services, the reasons cited by them are as presented

tion by health personnel was reported by the maximum i.e. 22.2% for llowed by the same, about 14.3% informed about lack of privacy at egnant women as the reason for the same. Irregular visit by health

13.5% respondents.

on ANC Services availed during pregnancy

in Table 45. Lack of proper attennot availing the ANC services. Fohealth facility for check‐up of prpersonnel was reported by about

Table 46 Satisfaction levelSatisfaction Level Marginalised


District wise status Total


Highly Dissatisfied 2.0 0.5 0.7 1.7 0.7 Dissatisfied 4.4 2.5 1.6 2.0 0.6 6.4 2.6 Average 16.7 21.6 17.0 25.9 5.2 5.0 30.6 18.1 Satisfied 64.7 57.7 67.1 55.8 77.9 57.0 54.9 61.7 Highly Satisfied 12.3 18.3 13.7 15.6 16.2 38.0 6.4 16.9 Total Responses 204 241 371 147 154 173 574 100

Yet, around 78.6% households of those who received various ANC services (Ta were found to be

sfied with regard to the quality of ANC services provided the health personnel. cates disparity in the satisfaction level over services. Specifically

s of people (61% and 71% ectively) were found over ANC services as compared to Keonjhar (95%) and Jagatsing (94%) district. As high

s 30.6% people in Malkangiri and 25.9% in Bolangir district reported average satisfaction over the

About 23% were not formed about the different cleanliness need to be maintained during delivery and around 20% were

ore specifically on exclusive breast feeding for six months th. antly, about 1 to conduct

delivery at the health fa like PHC/CHC/Sub‐centre. About 57% were not advised for family planning or for delayin ne hild. All se find d t a ingly,

ate steps need ta by the iders for ming pregnant wo about e of o CH . Lack o ort to in care racar ving be MCH outcomes.

ble 46)satisfied or highly sati by However, district wise break‐up indi ANCin Malkangiri and Bolangir district, fewer percentage respto be satisfied pur aquality of ANC services. Table 47 presents various antenatal care advices and information received during pregnancy. It is interesting to find from the same table that only 58.3% pregnant women were told about keeping the baby warm immediately after the birth. More than 42% pregnant women were not made aware about this vital information particularly to prevent infant death due to hyperthermia. innot advised about the correct breast feeding practices mat least first of child bir

cilities Most import 8% were not advised the

g the xt c the ings nee to be reflec ed upon nd accordappropri to be ken prov infor men som the most vital information n M care f eff form people on various MCH and p tices could be one of the b riers for achie tter

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Table 47 Status of ANC advice and information on care of infants received by pregnant women ANC Advice / Information Marginalised Castes Economically Deprived Total

SCs STs BPL

Expected delivery date 76.7 44.7 61.8 59.5 Deliver in a Hospital or Healt ity 83.3 78.9 82.1 h Facil 78.2Taking Rest 86.7 86.8 85.5 86.9 Taking Nutritious food 90.0 94.7 94.5 90.5 Need of each ANC 66.7 76.3 72.7 73.8 Signs of Pregnancy Combleeding, co

pli s (vaginal nvulsions, prolonged labour)

43.3 39.5 cation 49.1 44.0

Place to visit if any pregnancy complications 53.3 50.0 60.0 53.6 Breast Feeding 80.0 76.3 76.4 79.8 Keeping the baby warm 60.0 55.3 60.0 58.3 Cleanliness during delivery 76.7 73.7 72.7 77.4 Family Planning or delaying next child 40.0 44.7 47.3 42.9 Total Cases 30 38 55 84

Being asked about the reasons, maximum i.e. 41.6% could not give any reasons because of not having any knowledge on the same. People those who gave reasons, 11.4% reported about irregular visit of health personnel, 11.7% pointed out their lack of interest to know the same, 9.4% reported lack of attention by health personnel, etc. for not being advised on ANC and infant care.

Table 48 Reasons for not informed about ANC Not visited the health facility due to distance 7.1 Health facility does not open regularly 4.0 open regularly, 3‐Health facility remains closed 3.7 Not visited the health facility due to loss of wage 2.6 Irregular visit of health personnel to health facility 11.4

Need to wait long at health facility, hence returned 0.9 Health personnel do not give proper attention 9.4 Belong to different caste, hence no attention by health personnel 3.7 Belong to lower income group, hence no attention by health personnel 3.4 Not permitted to go out of home 0.6 Not interested to know 11.7 Don't Know the reason 41.6 Total Responses 351

Regarding the place where delivery was conducted, Table 49 shows that as high as 39.3% deliveries

ucted at health facilities. were conducted at home. That means the rest 60.7% deliveries were cond

Table 49 Place of delivery Place of delivery Marginalised Econom

Castes ically

Deprived District wise status Total


Home 43.3 44.7 49.1 22.2 10.5 20.0 75.0 39.3 Govt./Municipal 43.3 31.6 36.4 38Hospital

.9 57.9 60.0 12.5 36.9

CHC/Rural 6.7 23.7 12.7 38.9 15.8 20.0 12.5 20.2


February 2

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Table 49 Place of delivery Place of delivery Marginalised




Hospital/PHC Pvt. Hospital 3.3 10.5 2.4 Pvt. Doctor/Clinic 3.3 1.8 5.3 1.2 Total Cases 30 38 55 18 19 15 32 84

District wise break‐up shows that the percentage of home delivery in Malkangiri was very high (about 75%) as compared to Jagatsingpur (10.5%), Keonjhar (20%) and Bolangir (22.2%) districts covered under

study. Certainly such high percentage of home deliveries is a matter of serious concern for the state

The tribal culture a in Mal giri dis s a ie utional lly t bal omen in lkangiri district do not refer to stay outside home

not take d fr people than th or munity members. F stituti l as they ha st o to t days outside of their me and the f ooke

prefer st ng the th facili deliv fr his rea the local /TBA fo nducting delive ather rring

stitutional delivery.

theespecially in view of high MMR in the state.

nd tradition kan trict wa found as a m jor barr r for institdelivery. Cultura he tri w Ma p of theirand they do foo om other eir family com or in onadelivery ve to ay tw hree ho take ood c d byothers, they again visiti heal ties for ery. Apart om t son, tribalpeople traditionally prefer the Dai r co the ry r prefe thein

Table 50 Reasons of not preferring health facilities for delivery Health facility in a distant place 29.2 Health facility does not open regularly 6.2 Health facility remains closed 1.5 Not visited the health facility due to loss of wage 1.5

Irregular visit of health personnel to health facility 6.2 Need to wait long at health facility 1.5 Health personnel do not give proper attention 6.2 No body to accompany 7.7 High transportation cost 12.3 Village Dai is better than health personnel 6.2 Tradition 9.2 Don't Know 3.1 Born on the way 6.2 No body to attend in the heath facility during night 1.5 Delivery happened in the night 1.5 Total Responses 65

The other reasons given by the people for not preferring the institutional delivery are presented in Table 50. Long distance of health facility (29.2%), high transportation cost (12.3%), no body to accompany the pregnant women (7.7%) and lack of attention by the service providers (6.2%) were the reasons shared by most of the marginalised people for not preferring the institutional delivery.


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Table 51 Status of linkage under JSY Place of delivery Marginalised

Castes Economically De prived


SCs STs gir Jagatsinghpur eonjhar MalkangiriBPL Bolan K % who were linked under JSY

53.3 47.4 50.9 66.7 78.9 73.3 25.0 54.8

Total Cases 30 38 19 15 32 84 55 18

Keeping the high transportation cost in count of the compone pt by governme the

e i bear t ansportation cost regnant women alth delivery. However, only 54.8% pregn women were lin JSY as evid

be the reason for ch aro 12.3% reported transportation co the the facili delivery (Table

istrict wise break‐up of JSY coverage presented in table 51 shows a dismal status in Malkangiri district

to ac , one nts ke nt inJanani Surakhya Yozana (JSY) schem s to he tr of p to hefacilities for ant ked under ent fromTable 51. This could whi und high st as reason for preferring against visiting health ty for 51). Dwhere only 22.6% pregnant women were covered under JSY as compared to 78.9% in Jagatsinghpur, 73.3% in Keonjhar and 66.7% in Bolangir district.

Table 52 Status of Post Natal Care Post‐natal care indicators Marginalised




If institutional delivery, status of health check‐up of mother immediately after delivery

100.0 91.7 93.1 100.0 100.0 92.3 88.9 96.0

Status of health check‐up of mother within two months after delivery

73.3 54.2 65.5 28.6 85.7 69.2 66.7 62.0

Supplementary Nutrition to Mother

93.3 87.5 93.1 92.9 92.9 92.3 77.8 90.0

Table 52 shows the post delivery status of services received by lactating mothers cifically within two

particularly of those 61.7% deliveries that were conducted h facilities. Of nal deliveries, only 62% mothers were checked‐up for the seco time after delivery

ithin two months of delivery which in case of STs is further low at 54.2% only. When 94% pregnant

only 28.6% lactating mothers in Bolangir district were checked‐up for two r b 85.7% in Malk eonjhar and 66.

Malkangiri district were ed for t time within two months after birth.

53 shows tha ing wrappi f babies ediately r the bi healt f only infants which ng BPL families was e less at 65.5%. As c

(spemonths after birth), at healtthese institutio nd wwomen were given supplementary nutrition during pregnancy, less percentage i.e. 90% were provided the same during lactating period. District wise break‐up shows that2nd time within months afte

checkirth where ashe second

angiri, 69.2% in K 7% in

Table t dry and ng o imm afte rth in h facilities wasdone in case o 74% amo ven lear from Table


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53 that specifically in Keonjhar district the drying and wrapping of babies was done even in case of much lesser percentage of infants (i.e. only 46.2%). Table 53 Stat f inf care us o ant Infant Care Indicators Marginalised




Status of Breast Feeding by of Bawithin one hour of birth

100.0 95.8 96.6 100.0 100.0 92.3 100.0 98.0

Weighing of the baby 93.3 91.7 93.1 92.9 92.9 84.6 100.0 92.0 Drying and wrapping of the Baby 73.3 75.0 65.5 100.0 71.4 46.2 77.8 74.0 Status of Health check‐up of baby immediately after birth

100.0 95.8 96.6 100.0 100.0 92.3 100.0 98.0

Status of Health check‐up of baby within two months after birth

66.7 45.8 62.1

Table 53 also shows that only 58% infants were checked‐up for the second time within two months of birth. Like the lactating mothers, only 14.3% infants in Bolnagir district were checked‐up within two months after birth.

Table 54 Quality of post‐natal and infant care Service Quality Marginalised




Very Poor 1.2 0.8 1.0 0.4 Poor 3.6 4.6 3.5 0.7 1.3 2.3 12.4 3.3 Average 21.8 21.5 17.2 24.3 19.4 13.5 30.9 21.4 Good 59.4 54.6 58.9 59.2 71.9 57.9 44.3 60.0 Very Good 13.9 19.2 20.4 15.8 7.5 26.3 12.4 15.3 Total Responses 165 260 314 152 160 133 97 542

As far as quality of post‐natal and infant care is concerned, more than 75% households reported the

quality of services from health providers. Of those who availed post‐n and ality of services was reported by about 21.3% households whereas

households felt poor quality of services given by the providers

l within six month of child birth, Table 55 shows t the ast two times in contact with ANM and three times in contact with AW and

cally the lactating mothers among SC and BPL households had only one in

availability of better atal infant care services, the average quonly 3.7% Regarding contacts with heath personne hatlactating mothers had at le WASHA each. Specifi timecontact with the ANM during first six months of child birth. District wise break‐up of post‐natal contacts shows that the lactating mothers had less number of contacts in Malkangiri district (one with ANM, two times with ASHA and three times with AWW) as

to other districts during first six months of child birth. compared


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Table 55 Post‐natal contacts with health personnel Health Personnel Marginalised




ANM 1 2 1 2 2 2 1 2 AWW 2 3 3 3 3 4 3 3 ASHA 3 3 3 3 5 5 2 3 Total Cases 30 38 55 18 19 15 32 84

The reasons reported by mothers for not regularly being contacted by health personnel are given in Table 56. Especially among those who gave reasons, about 16.1% reported their low income as the reason for which they were not contacted by health personnel. About 9.7% cited long distance of their village as the reason for which the providers do not take regular visit to their village hence they had less umber of contacts with the providers. n

Table 56 Reasons for less number of contacts with the service providers

Residing in distance pocket, hence no body visits 9.7 Belong to different caste, hence no attention by ANM, 4.8

Belong to lower income group, hence no attention by ANM 16.1 Any Other 1.6

Don't Know the reason 67.7

Total Responses 62

The status of various other child health care services received by the marginalised households is

As c fr e sam at only % mot were ab xclu 54.4% were told about the time and importance of complementary feeding. Any was 89.9% seholds. e 57 shows the ghin

monitoring of child was done in case of 76% children. The percentage of children supplemented ith Vitamin – A was found to be only 21% among the marginalised households.

presented in Table 57. breast feeding and onlyimmunisatio

lear om th e th 72.2 hers advised out e sive

n service growth

received by hou Tabl also that wei g /

w

Table 57 Status of child health care services Services Marginalised Castes Economically Deprived Total

SCs STs BPL

Advice relating to exclusive breast feeding

74.1 66.7 67.9 72.2

Advice relating to complementary feeding

48.1 52.8 50.9 54.4

Immunization Card 85.2 91.7 88.7 87.3 Immunization Services 85.2 94.4 88.7 89.9 Weighing / Growth Monitoring 84.6 77.8 81.1 80.8 De‐worming 18.5 30.6 26.4 24.1 Vitamin‐A supplementation 37.0 19.4 26.4 29.1 Spot feeding 22.2 27.8 32.1 29.1 Take Home Ration 63.0 55.6 69.8 59.5 Pre‐school Education 11.5 22.6 25.0 22.2 Total Cases 30 38 55 84


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Only 11.5% children among SCs attended pre‐school education and about 22.2% children among the same marginalised castes were given spot feeding at the AWC. Very less percentage of children (i.e. 9.4% only) among STs was given Vitamin‐A supplementation. 1

Table 58 Quality of child re health ca services Quality Marginalised




Very Poor 0.7 0.6 0.2 Poor 2.8 2.1 2.0 0.9 1.0 4.4 2.1 Average 19.7 25.4 20.1 19.8 16.3 5.0 32.1 21.4 Good 48.6 47.7 53.2 49.1 72.1 53.3 44.0 53.4 Very Good 28.2 24.9 24.6 30.2 10.6 41.7 19.5 23.1 Total Responses 142 193 293 106 104 60 159 429

With regard to quality of child health care services, Table 58 shows that of those who availed various

elatively less percentage of STs (i.e. 72.6%) reported about the availability of better child health care ss percentage of marginalised people (only 63.5%)

t the ca given by the health

e FGD, th oblems that were shared by the ouples below six yea ild wit gardrnal and child ca re as presented hereunde

child health care services more than 76.3% reported about the availability of better quality services given by the providers. Rservices. Specifically in Malkangiri district, relatively lereported abou good child health re services providers.

During th e pr c rs ch h re to mate health re a r:

In Malkangiri people sti fer to co the deliv TBA where as in distri fter of A p mostly p to visit th alth faci s for delivery.

ll pre nduct ery by other cts a the appointment ASH eople refer e he litie

Mobility of pregnant women was shared as the major problem for them. As high as Rs. 200/‐ to Rs. 500/‐ was spent for taking pregnant women to hospital for check‐up and delivery.

Due to long distance of health facilities, people also reported about the instance of delivery taking place on the way to hospital.

Lack of privacy of pregnant women while the health check‐up at AWC was shared as a de‐motivating factor to avail the ANC services.

People in Bolangir reported about the non‐availability of supplementary nutrition from AWC. In Jagatsinghpur, people reported that the ANM never take visit to their village. People have to go to Panchayat office to avail MCH care from the ANM.

In Bolangir, people reported about lack of initiative by health personnel to make them aware about various ANC services. Lack of attention by ASHA; non‐availability of TT; immunisation; etc. were the other problems reported by them.

In Jagatsinghpur, people have to go long distance for blood and urine check‐up during pregnancy. In Malkangiri, people reported about the delay by health personnel in PHC/CHC in attending the pregnant women.


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In districts like Keonjhar and Malkangiri, people were found to be dissatisfied with regard to the vided by alk e informed abo l visit of ASHA

their village. In Keonjh ople rep t lack of initiatives taken by ASHA for providing proper health care peo includin e MCH s o d e to

gligence and lack of ttention by ASHA, ople have t pend o fo delivery.

services pro ASHA. In Mar, pe

angiri, peoplorted abou

ut the occasiona to

to ple g th service . People als reporte that dune a pe o de n Dai/TBA r

Apart from cultural barrier, people prefer cal Dai/TB for conducting the d very mainly due stance of heal cilit

came across with problems of availing better health are services from the providers in their locality. As rightly reported by the maximum i.e. 29.3% of

igrate for most part of the year. In addition to them, about 14.6% reported that the health personnel do not recognize them.

of immunization services at the health facilities. st to register for antenatal and post‐natal care es

4.9% were not provided supplementary nutrition due to their name was not registere ith .

2.3.3 Family Planning Services

odern methods like pill nd male condom were only known to less than half of the marginalised people (i.e. 48.3% and 44.8%

about rent family ning methods

lo A eli to long di th fa ies.

Apart from capturing the above responses, the study also made an attempt to know the constraints faced specifically by the migrants for availing maternal and child health care services. During the time of interaction with migrants, the problems reported by them were found to be little different to that of the other categories of marginalized people covered under the study. Since, majority of them migrated for more than five months in a year; they particularlycmigrants, the health providers do not give proper attention to them since they m

About 17% said about the non‐availability Moimportantly, 9.8% of migrants were not allowed servicfollowed by d wthe health providers

Table 59 presents the knowledge of various categories of marginalised groups about different family planning methods. Among the different modern methods given in the table, female condom (4.3%) was least known to marginalised people followed by injectables (6%) and IUD/Loop method (9%). Maximum i.e. 87% of marginalised people knew about female sterilisation method. However, only half of this i.e. 44.3% of marginalised people were aware of male sterilisation method. Other marespectively) covered under the study.

Table 59 Knowledge diffe planMethods Marginalised


Gender People in different stage fe cycle s of li

Migrants Total

SCs STs BPL Male Female Adolescents Adults

Female Sterilization 89.8 81.0 85.0 83.9 89.7 85.0 94.2 87.5 87.0 Male Sterilization 49.7 31.0 40.5 41.6 35.0 50.8 57.5 47.3 44.3Pill 49.7 49.4 47.5 40.9 54.7 43.8 71.7 45.0 48.3 IUD/LOOP 13.6 4.6 8.3 12.1 5.0 18.3 7.5 9.0 5.4 Injectatbles 5.4 4.0 6.3 7.0 5.1 5.0 7.5 12.5 6.0 Male Condom / Nirodh 42.2 46.0 43.2 40.2 48.8 60.8 50.0 50.0 44.8Female Condom 5.4 2.3 3.7 5.9 2.8 3.8 5.0 15.0 4.3 Total Respondents 147 174 301 214 80 120 40 400 186

Fe

ry

0


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As also clear from Table 59 that the STs in comparison to other categories of marginalised groups were least aware about the various modern methods of family planning. Among the STs, only 4.6% knew about IUD/Loop and 31% knew male sterilisation methods. Next to STs, the marginalised people belong BPL category were also less aware about modern family planning methods. Among the BPL

od and only 40.5% knew male sterilisation method.

Table 60 Status of u mily pla thods

tohouseholds, only 8.3% were aware of IUD/Loop meth

se of fa nning meMethods Marginalised

Castes Econom icallyDeprive d

Couples with child <6yrs

Migrants District wise status Total

SCs STs BPL angir Jagatsinghpur Keonjhar Malkangiri Bol

Female Sterilization

10.6 5.0 5.1 5.3 14.3 10.2 6.3 7.6 6.3

Male Sterilization

1.9 0. 28 2. 0.6

Pill 9.6 5.8 8.4 9.3 22.2 6.8 12.2 14.0 3.1 8.3IUD/LOOP 12.5 4.0 4.5 10.0 2.8Male Condom / Nirodh

9.7 12.5 11.5 16.4 10.0 5.0 4.1 26.4 10.1

60 shows the variousTable types of family planning methods used by the eligible couples among

y 0.6%) eligible couples

Since migrants are considered as high

and cases of male sterilisation were found only in Bolangir district

the percentages of people using the same (14% in Keonjhar, 12.2%

different marginalised groups. Highest i.e. 10.1% eligible couples use male condom although 44.8% were aware of the same method. While 87% were aware of female sterilisation, only 6.3% eligible couples went for the same. Relatively little higher percentages of migrants (14.3%) and SCs (10.6%) went for

sterilisation method. Apart from the same, less than one percent (i.e. onlfemaleopted for male sterilisation. Next to male condom, pill was used by about 8.3% eligible couples. The rest 2.8% went for IUD insertion. Among the migrants, greater preference was on use of pills (22.2%)

by female sterilisation (14.3%) and male condom (10%).followedrisk groups to HIV/AIDS, greater emphasis has been laid on use of condom by migrants for preventing them from HIV/AIDS. However, the study revealed that only 10% migrants were using condom. District wise disparity in the use of family planning methods was also found during the study. As clear from Table 60 that in Keonjhar district the greater preference was on use of male condoms (26.4%) as compared to Malkangiri (0%), Jagatsingpur (4.1%) and Bolangir (5%) district. IUD insertion was only und in Malkangiri district (10%)fo

(2.2%). A single case of female sterilisation was not found in Keonjhar district. Use of pill was found across all districts with variations in in Jagatsingpur, 6.8% in Bolangir and only 3.1% in Malkangiri district).

Table 61 District wise the status of use of family planning methods Count % Awareness Generation 13 19.7 Counselling 9 13.6 Providing products 23 34.8 Sterilisation 21 31.8

Total Responses 66 Total Respondents 53


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The study also made an attempt to know the different family planning services provided to the marginalised people. As presented in Table 62, only 53 out of 400 marginalised households received different family planning services. Of the total responses captured in this regard, highest i.e. 34.8% were provided products like pills, condoms, etc. followed by 31.8% were provided sterilisation service in public health facilities. Awareness generation and counselling services were provided to only 19.7% and

Table 62 Satisfaction level on family planning services received

13.6% respectively.

Satisfaction level

Marginalised Castes


Gender Couples with child <6yrs

Migrants District wise status Total

SCs STs BPL Male Female Bolangir

Jagatsinghpur

Keonjhar

Malkangiri

Highly Dissatisfied

14.8 4.8 3.8 9.4 7.4 18.2 7.7 10.0 10.0 6.9

Dissatisfied 7.4 16.7 11.9 3.8 15.6 11.1 9.1 33.3 10.0 10.3Average 8.3 4.8 3.8 3.1 18.2 6.7 5.0 3.4Satisfied 55.6 58.3 59.5 69.2 56.3 55.6 54.5 46.7 84.6 50.0 80.0 62.1Highly Satisfied

22.2 16.7 19.0 19.2 15.6 25.9 13.3 7.7 35.0 17.2

Total Responses

27 24 42 26 32 27 11 15 13 20 10 58

Total Respondents

24 23 37 24 29 24 10 15 12 16 10 53

Regarding the quality of services, about 80% those who received family planning services were found to be satisfied. About 17.2% . Among the different categories f marginalised people, higher percentage of females (25%) was found to be dissatisfied. During the

shared by the eligible couples with regard to family planning ervices are as presented hereunder:

were found to be dissatisfied with the service o

time of FGD, especially the female members of marginalised households expressed their dissatisfaction over the side effects of female sterilisation. Greater percentage of marginalised people those who availed family planning services in Bolangir district (33.3%) were found to be dissatisfied as compared to other districts covered under the study. During the FGD, the problems that weres

Greater preferenc te repo people istre to female s rilization as rted by across the four d icts. People complained a be ‐up by the health the family planning operation.

bout not ing checked personnel after

Only during the tim fa plann ps ple motiv for tak teriliz . Us t for st ti eople l perc tha rilizat men ld ph w

as a result th nno any sical la

e of mily ing cam , peo are ated ing s ation uallywomen op eriliza on. P stil eive t ste ion of wou ysically eakthem ey ca t do phy bor.

Apart from Sterilization, condom an lls are mos evalen ily pla me use r, ly or c lin gram organ for u diffe

ily pla m s.

d pi the t pr t fam nning thods d bypeople. Howeve hard any awareness ounse g pro s are ized sing renttypes of fam nning ethod

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Except Keonjhar, people in all the other three districts reported about the non‐availability of family planning products such as pills, condoms, etc. Hardly any counseling of eligible couples on family planning was done by ASHA/AWW in these districts.

Due to non‐availability of pills and condoms with ASHA/AWW, people purchase the family planning products from the shop.

People especially women complained about the side effects such as physical weakness, head

2.3.4 St link people under Health Schemes and Programs

also made an effort to know the percentages of marginalised people having knowledge about s health sc mes and programs run by governmen Table 63 presents the details about

wledge of rg sed people on various government schemes. A r the table rogra l os dicat ), Na al Vector Borne ease Control Program (24

l Tuberculosis Control Program (37.3%), National Program for Control of Blindness (25.3%), dine Deficiency Disorder Control Program (27.8%), etc. were found to be less known to the

drizzling, body pain, etc. of using the pills.

atus of age of marginalised

The studythe variou he t. thekno ma inali s pe same , p mslike NationaNationa

Lepr y Era ion Program (29% tion Dis %),

Iomarginalized people. Maximum i.e. 95.3% were aware of Old Age Pension followed by 84.8% were aware of Widow Pension scheme and 82.8% marginalized people knew about Janani Surakhya Yozana (JSY). Higher percentages of people knew about these schemes which perhaps because of the monetary benefits provided to people under these schemes.

Table 63 Knowledge of marginalised people on various schemes Schemes Marginalised



Disabled

Migrant

Total

Peopl

s

e

SCs

STs

BPL

Male

Female

esce

es d

Aged nts

<6yr

Adol

Couplchil

Janani Surakhya Yozana 85.0 79.3 80.4 80.6 84.6 80.0 90.8 66.3 85.0 87.5 82.8Balika Samrudhi Yozana 25.9 22.4 21.3 21.0 26.6 22.5 33.3 11.3 17.5 30.0 24.0Kishori Shakti Yozana 10.2 7.5 8.3 6.5 9.8 11.3 8.3 3.8 12.5 12.5 8.3National Program for Control of Blindness (NPCB)

36.7 16.1 22.6 25.8 24.8 25.0 31.7 20.0 22.5 30.0 25.3

Iodine Deficiency Disorder Control Program (IDDCP)

34.0 24.1 27.6 22.6 32.2 37.5 37.5 11.3 27.5 17.5 27.8

National Leprosy Eradication Program

39.5 19.5 27.2 32.3 26.2 26.3 36.7 15.0 32.5 32.5 29.0

National Vector Borne Disease Control Program

30.6 19.0 22.9 22.0 25.7 17.5 35.8 7.5 30.0 27.5 24.0

National Tuberculosis n o ram

44.9 27.6 35.5 38.7 36.0 31.3 48.3Co tr l Prog

20.0 32.5 37.5 37.3

Handicapped Pension 74.1 62.6 71.8 76.9 63.1 60.0 69.2 65.0 87.5 80.0 69.5Old age pension 95.2 93.7 96. 95.7 94.9 93.8 91.7 98.8 5 97.5 95.33 97.Widow pension 87.1 81.0 84.4 86.6 83.2 85.0 86.7 80.0 90.0 82.5 84.8Total 147 174 30 186 214 80 120 80 40 400 1 40

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Table 63 also shows that only 11.3% of the adolescents were aware of the Koshori Shakti Yozana. Only 19% STs knew National Vector Borne Disease control program. When maximum percentage of STs suffered from malaria, the knowledge of ST households on National Vector Borne Disease control program carries greater significance. Likewise, only 20% aged people were aware of National Tuberculosis control program when it is known that higher percentage of aged people in Orissa suffer from TB.

Table 64 District wise knowledge of marginalised people on various schemes Schemes Bolangir Jagatsinghpur Keonjhar Malkangiri Total Janani Surakhya Y 86.0 79.0 74.0 82.8 ozana 92.0 Balika Samrudh ani Yoz a 16.0 27.0 16.0 37.0 24.0 Kishori Shakti Yozana 7.0 0 12. 8.3 4.0 10. 0 National Progr r Control of Blindness (NPCB) am fo 9.0 42.0 8.0 42.0 2 5.3

Iodine Deficien so ontro ram ( P) 37.0 27.0 41cy Di rder C l Prog IDDC 6.0 .0 27.8

National Leprocy Prog Eradication ram 13.0 41.0 22.0 40.0 2 9.0National Vecto e se Co Progr 38.0 .0 43r Born Disea ntrol am 15 .0 24.0 National Tuberculosis ol Pro Contr gram 13.0 73.0 13.0 50.0 37.3 Handicapped Pension 84.0 71.0 49.0 74.0 69.5 Old age pension 100.0 94.0 92.0 95.0 95.3 Widow pension 7 94.0 .0 93.0 84.8 5.0 77 Total 100 100 100 100 400

District wise disparity with regard to the knowledge of marginalised people on various schemes is presented in Table 64. None of the households in Bolangir district was aware of National Vector Borne Disease Control Program. Less percentage of people in Malkangiri (74%) and Keonjhar (79%) district were aware of JSY. In view of high percentage of home deliveries recorded in Malkangiri district, it is important for the state to create more awareness on JSY scheme to promote institutional delivery in the ame district. s Table 65 No. of marginalised people linked under various schemes Schemes Marginalised


Migrants

District Wise Total


Janani Surakhya Yozana 16 18 28 3 12 15 11 8 46Balika Samrudhi Yozana 3 2 5 1 3 1 3 7Kishori Shakti Yozana 2 1 2 1 1 2 3National Program for Control of Blindness (NPCB)

1 1 1 1 1 2

Iodine Deficiency Disorder Control Program (IDDCP)

4 4 7 2 2 4

National Leprosy Eradication Program

3 7 10 1 1 1 11 1 14

National Vector Borne Disease Control Program

5 17 16 2 1 10 13 24

National Tuberculosis Control Program

4 8 12 2 6 5 4 15

Handicapped Pension 10 18 29 5 4 3 22 4 33Old age pension 24 48 67 9 13 8 45 18 84Widow pension 21 28 47 11 1 13 34 12 60Total 147 174 301 40 100 100 100 100 400


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Number of marginalised people linked under various schemes is presented in Table 65. Highest i.e. 84 out of 400 people have been linked under old age pension scheme. As evident from Table 65 that majority i.e. 67 of them are from BPL families. Next to old age pension, a total of 60 people have been

regnant women were provided benefit under JSY. Only 24 people were

me re from Keonjhar district (around 45 people). In comparison to other districts, the people who have

linked under widow pension scheme followed by 33 people have been linked under Handicapped Pension Scheme. About 46 pprovided support under National Vector Borne Disease Control Program of them 17 are from ST communities. District wise break‐up shows that more than half of the 84 people linked under old age pension scheabeen linked under widow pension are also highest in Keonjhar district (around 30 people). Lowest numbers of people have been linked under various schemes in Malkangiri and Bolangir district. Regarding the linkage under government schemes, the following problems were shared during the FGD:

People seem to be dissatisfied for not able to access the benefits under pension schemes. They complain about the role of Sarpanch and seek the intervention of Block Chairman for proper supervision and monitoring of pension schemes.

Lack of initiative by health personnel to make people aware about various health schemes and programs was reported by the majority. People were found unaware about the various health schemes run by government.

Except JSY and Pension schemes, majority of the people in Jagatsinghpur, Bolangir and Malakngiri are not aware abou e other development program eradication program, DOTS, etc. However, p those who availed benefit under JSY expressed their satisfaction on the scheme.

Apart from understanding the above problems, the study o categorically m an attempt to know the benefits received by disabled people under different schemes and provisions. Among the various

gina people cove under y, ble eop re fa e st as far and availing he services ne and e nt

r ce . Keep their v r ty ac t t ta s vis d th ab person g. pro n disability ifica ai d lia s,

Detailed perceptions of with availing th reunder.

atus ce f disabi certificate

t most of theople

s such as leprosy

als ade

categories of mar lized red the stud disa d p le a in ct th movulnerable group as accessing alth in ge ral ben fits under differeschemes in specific a e con rned ing ulne abili into coun he s te ha pro ionespecial benefits for

pensions,e dis led s e. visio of cert te, ds an app nce

handicappedas presented he

etc. disabled people regard to e same are

Table 66 St of re ipt o lity Receipt of Disability Certificate

Gender of Persons Disabled District statuswise Total

Male Female gat pur Keonjhar alk Bolangir Ja singh M angiri

Count Col % Count Col % Count Count Count Col % Count Col % Count Col % Count Col %

Yes 11 57. 12 1 4 0.0 6 .0 .0 5 9 57. 4 7 7 60 6 60 23 57.

No 8 42.1 9 42.9 6 6 3 30.0 4 40.0 4 40.0 17 42.5

Total 19 100.0 21 100.0 10 10 10 100.0 10 100.0 10 100.0 40 100.0


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As presented in Table 66 that 23 out of 40 i.e. 57.5% have the disability certificate. About 17 i.e. 42.5% did not have the disability certificate. District wise break‐up shows that more number of people covered in Jagatsinghpur did not have the disability certificate (Table 66). The study further probed into the matter and tried to know the reasons of not being issued a disability certificate to them from the perceptions of disabled people themselves. Since disability certificate is rucial for a disabled person in order to avail various benefits rendered by government, the study

to kncattempted ow the reasons from the disabled people themselves.

Table 67 Reasons for Non‐receipt of disabl rtificateed ce Reasons Count Col %

Not Aware 4 23.5%

Unable to access authorities those who issue the certificate 4 23.5%

Those who have to give certificates are not sensitive 4 23.5%

Those who have to give certificates are not available 1 5.9%

Authorities demand bribe to issue a certificate 1 5.9%

Not meeting the required criteria 1 5.9%

No body to accompany 4 23.5%

Total Responses 17 100.0%

The reasons that were shared during the household interview are as presented in Table 67. As per the table, about 23.5% were not aware about the place where the certificate is issued or they were not aware about the procedures of getting a disabled certificate. Similar percentages of people were unable to access the authorities for issuing of the certificate which could be due to again lack of awareness or due to lack of attention by the service providers. About another 23.5% felt that the authorities are not sensitive towards disabled people hence they are not being listened or issued a disabled certificate. gain same percentage of disabled people was found to be never approached to any authority for the

em to meet the concerned ty. One person du e reported about the b ded by the autho

to issue the certificate. In c anoth isa d person, although, the person went to meet the concerned authority to get cate the to as not

stud am ss h one erson ho was nied by author y for not uired criteria of ng disabili certificate. Only out of disabled persons

dy w e ge ng handicapped pension of Rs. 200/ month.

Acertificate since no body from their village was ready to accompany thauthori ring the tim

ase of of interviewer such d

ribe deman rity bleperson the certifi but had return back the authority was

available. Lastly, the y c e acro wit p w de the itfulfilling the req getti a ty 13 40covered under the stu er tti ‐ per Table 68 Status of possession of aids and appliances by disabled people Possession of Aids and Appliances

Gender o sabled P on f Di ers Total

Male Female


Yes 2 10.5% 22.2% 16.2% 4 6

No 17 89.5% 14 77.8% 31 83.8%

Total 19 100.0% 100.0% 18 37 100.0%

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Since mobility of the disabled people is one of the major constraints associated with disability, the provision of requisite aids and appliances carries greater significance for the disabled people. In view of this, only 16.2% people were found to be having requisite aids and appliances with them. The rest 83.8% did not have the aids and appliances which in addition to their disability pose a major challenge for them to become mobile and functional. This is one of the important findings that the state needs to look in for initiating action to functionalize the disabled people so that they can be able to do at least some of their own works. Since more numbers of orthopedically disabled people were covered in the study, the emand for a wheel chair was found to be highest among the disabled people followed by instruments d

for the hearing impaired people.

Table 69 Reasons for not having required aids and appliances Reasons

Gender of Disabled Persons Total

Male Female


Not Aware about the availability 6 35.3% 6 42.9% 12 38.7%

Have Aids and Appliances but are damaged/unaware of 2 11.8% 1 7.1% 3 9.7% where to get replacement

People/Place for getting aids and appliances is not disability friendly

2 11.8% 4 28.6% 6 19.4%

Financial constraints 3 17.6% 2 14.3% 5 16.1%

Difficulty to go distant place 1 5.9% 1 7.1% 2 6.5%

No provision to deliver at home 1 5.9% 1 7.1% 2 6.5%

No body to support/accompany for the same 10 58.8% 10 71.4% 20 64.5%

Not interested 2 11.8% 2 6.5%

Total Responses 17 100.0% 14 100.0% 31 100.0%

Table 69 presents the reasons for not having the requisite aids and appliances. Out of 31 people those ho did not have the same, about 65% were unable to access such facilities since no body was to

esented in Table 70.

Constraints to repair/replace aids and appliances

wsupport / accompany them to meet the authorities. Next to this, about 38.7% were unaware about the place or office where the aids and appliances are provided. About 20% felt that the authorities were not sensitive towards them and 16% identified financial constraint as the problem for unable to get the aids and appliances. About 9.7% disabled people (those who earlier had such appliances but the same are damaged now) sought their damaged aids and appliance to be replaced with new ones but they were found to be unaware about the place where they can replace the same. Of the six disabled people those who had aids and appliances, the problem they came across with regard to repairing and replacing the aids and appliances are pr

Table 70 Count Col %

Money Problem 2 33.3

Don’t free service 2 33.3

Health facility is 66.7not available 4

Pension 1 16.7

Free treatment 33.32

Total 6 100.0%

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Apart from the above, the constraints that were highlighted by disabled people during the time of FGD are presented hereunder:

Although the names of disabled persons are registered in the AWC record but hardly any of them are provided with disability certificate.

People have received disability certificate but they are not given handicapped pension. The pension amount given by government is not sufficient. The disabled persons need to attend the camp which is generally organized at block

headquarter for availing the pension. No officials or authority has ever visited to their village for identifying and issuing disability

certificate. There is no effort by village health workers like ASHA/AWW to make them ab e

ed persons and the procedure to avail the sam aware out th

various provisions available for handicapp e. Hardly one to two persons in the villa

is a ge have been provided with aids and

major problem for them.

the problems of disabled people, the study also attempted to the p s the family members of disabled people.

appliances. Repairand replacement of appliances

Apart from knowing know roblemcome across by

Table 71 Problems faced by family members to manage disabled person Problems

Gender of Disabled Persons Total

Male Female


Handicap certificate not issued 7 41.2% 7 36.8% 14 38.9%

Unable to manage the disabled person hence require assistance from govt. (pension, house & cycle)

10 58.8% 14 73.7% 24 66.7%

Not able to go outside for work 3 17.6% 1 5.3% 4 11.1%

High dependency 4 23.5% 3 15.8% 7 19.4%

Unable to know their problems 2 11.8% 2 5.6%

The pension amount is insufficient 1 5.9% 3 15.8% 4 11.1%

Do not know about the procedure of getting handicapped pension, hence not applied

1 5.3% 1 2.8%

Unable to avail better health care facilities from government for the disabled person

6 35.3% 4 21.1% 10 27.8%

Total Responses 17 100.0% 19 100.0% 36 100.0%

Table 71 prethem to manmembers

sents the responses of 36 disabled people on the pr s faced by age the health ms of a disabled perso ir family. Of them, about 66.7% family

reported t ‐ability nage the led pers their fa demanded from government in terms pped and and appliances support. i.e.

expressed the issatisfac r not be provided capp certificat % ported non‐availability of better health care services in public health facilities. Four out of 36 family

members reported the pension amount as insufficient to meet some of their basic expenses.

the family members of oblemproble n in the

heir in to ma disab on in mily, hence,assistance of handica pension aids Next 38.9% ir d tion fo ing the handi ed e. 27.8re


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2.3.5 Participation in BCC/IEC and community health institutions Table 72 shows the status of marginalised people participated in the BCC/IEC programs. As clear from the same table that maximum i.e. 66% people came to know about health messages from radio / TV followed by 34.3% by reading or seeing any health posters / pamphlets. Relatively less percentage of STs (61.5%), women (60.7%) and disabled people (60%) came to know about health messages from radio/TV. In comparison to other categories of marginalised people, a less percentage of women and aged people read or saw any health posters / wall paintings. Other forms of BCC/IEC programs like streetplay / Palla / Daskathia, community meetings, health exhibitions, etc. were attended by very negligible percentage of marginalised people.

Table 72 Marginalized people participated in BCC/IEC programs Marginalised


Gender Life Cycle (stages) Disabled Peopl

e

Migrants

Total

SCs

STs

BPL

Male

Female

Adolescents

Coupl

es <6yr

child

Aged

Read or Seen any health Posters / Pamphlets / Wall Paintings

34.7 34.5 31.9 41.9 27.6 45.0 35.0 22.5 30.0 40.0 34.3

Community/Group health meetings

4.1 4.6 5.0 4.3 5.1 2.5 5.8 1.3 7.5 2.5 4.8

Street Play/Palla/Daskathia 14.3 17.8 16.3 18.8 12.6 20.0 15.0 12.5 17.5 12.5 15.5 Health Exhibitions 1.4 1.7 1.3 1.1 1.4 2.5 1.3 2.5 1.3 Health Camps 13.6 5.7 9.0 10.2 9.8 6.3 11.7 6.3 15.0 15.0 10.0 Listened Radio / Watched TV 67.3 61.5 63.5 72.0 60.7 72.5 73.3 46.3 60.0 77.5 66.0 Total 147 174 301 186 214 80 120 80 40 40 400

District wise variations were also found with regard to the participation of marginalised people in BCC/IEC programs (Table 73). In comparison to 86% people in Keonjhar, only 50% in Malkangiri district watched TV/Radio which could be due to less coverage of TV/Radio in Malkangiri district. Only 22% in Keonjhar and 29% in Jagatsinghpur read or saw any health posters/wall paintings in comparison to 44% and 42% in Malkangiri and Bolangir district respectively.

Table 73 District wise marginalized people participated in BCC/IEC programs Bolangir Jagatsinghpur Keonjhar Malkangiri Total Read or Seen any health Posters / Pamphlets / Wall Paintings

42.0 29.0 22.0 44.0 34.3

Com n ymu it /Group health meetings 3.0 3.0 6.0 7.0 4.8 Street Play/Palla/Daskathia 21.0 4.0 20.0 17.0 15.5 Health Exhibitions 3.0 2.0 1.3

Health Camps 5.0 21.0 8.0 6.0 10.0

Listened Radio / Watched TV 57.0 71.0 86.0 50.0 66.0 Total 100 100 100 100 400


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With regard to the messages understood by people, it is clear from Table 73 that as high as 91.8% of the marginalised people who were listening radio/TV could understand the messages given through the ame medium. However, relatively less percentage i.e. 71% of marginalised people those who read or

health messages given in the posters / pamphlets /

ssaw health posters / pamphlets / wall paintings could able to understand the messages given in the same. Only 68.9% STs and 66.7% SCs understood the wall paintings. Table 74 Percent of people understood the health messages Marginalised



Disabled People

Migrants

Total

SCs

STs

BPL

Male

Female

Adolescents

Couples <6yr

child

Aged

Read or Seen any health Posters / Pamphlets / Wall Paintings

66.7 68.9 68.0 75.6 65.0 66.7 71.4 72.2 66.7 93.8 71.0

Community/Group health meetings

50.0 85.7 71.4 85.7 54.5 100.0 50.0 0.0 100.0 100.0 66.7

Street Play/Palla/Daskathia

81.0 64.5 73.5 77.1 70.4 56.3 77.8 70.0 85.7 80.0 74.2

Health Exhibitions 40.0 50.0 66.7 25.0 100.0 0.0 28.6 Health Camps 100.0 90.0 96.3 94.7 95.2 100.0 92.9 100.0 100.0 100.0 95.0 Listened Radio / Watched TV

90.6 91.2 90.2 94.6 88.8 94.5 89.4 91.4 87.0 93.5 91.8

in Malkangiri district understood the ealth ges given in p /

Bolangir a 6% i alkan uld a e Table 75 shows that only 52.3% h messa osters pamphlets / wall paintings. About 78% inmessages given through radio/TV.

nd 81. n M giri co underst nd th

Table 75 District wise percent of people understood health messages the Bolangir Jagatsingh ur p Keonjhar Malkangiri Total Read or Seen any health Posters / Pamphlets / Wall Paintings

71.4 75.9 100.0 52.3 71.0

Community/Group health meetings 66.7 33.3 100.0 57.1 66.7 Street Play/Palla/Daskathia 52.4 75.0 100.0 70.6 74.2 Health Exhibitions 66.7 28.6

Health Camps 100.0 90.5 100.0 100.0 95.0

Listened Radio / Watched TV 77.8 100.0 100.0 81.6 91.8 Total 100 100 100 100 400

During the FGD, The problems that were highlighted by marginalized people with regard to BCC/IEC are as follows:

As reported by people, hardly any BCC/IEC event was organized in the village. People mostly come to know about the health messages from radio/TV and reading posters/pamphlets.

People are illiterate, hence not able to read the messages

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Problem in communicating messages during BCC shows, hence unable to understand Not interesting to watch the BCC shows BCC/IEC programs are organised in a very distant place Mobility problem to attend the BCC/IEC program The timing fixed for BCC/IEC program is not very suitable for people to come and participate in the program

Apart from BCC/IEC, the study also attempted to get information on people’s participation on community level health institutions promoted by the providers. As clear from Table 76, that hardly any marginalised person was found to be members of mothers’ committee (5.3%) and food committee (4.3%). Village Health and Sanitation Committee seems to be non‐existent as only 1.3% were found to be member of the same. As reported during the time of FGD that the VHSC was not formed in most of e remote villages covered under the study. Only 21.8% of marginalised people were found to be

f SHG.

Table 76 Membership in unity le th institutions

thmembers of SHG however, the health agenda is only a secondary focus o

comm vel healInstitutions Marginalised Castes Economi y Dep d call rive Migrants Total

SCs STs LBP

Mothers' Committee 6.1 5.2 5.3 5.0 5.3 Food Committee 5.4 3.4 7 5 4.3 4. 2.Village Health & Sanitation Committee 2.0 0.6 1.3 1.3 SHG 19.0 23.6 23.3 27.5 21.8 Total Respondents 147 174 301 40 400

District wise analysis shows that VHSC been in Ma and district

ot been form in t red un th tud in tsinghpur d never, in Keonjha tric latively e perc e people e d e

(15 foo mmitt 4%) S 4 i o o

has formed only lkangiri Bolangir where as the same has n ed he villages cove der e s y Jaga an Keo jhar district. How r dis t re mor entag s of wer foun to b members of mothers’ committee %), d co ee (1 and HG ( 7%) n comparis n to the ther districts.

Table 77 District wise membership in community level health institutions Bolangir Jagatsinghpur Keonjhar Malkangiri Total Mothers' Committee 2.0 15.0 4.0 5.3 Food Committee 1.0 1.0 14.0 1.0 4.3 Village Health & Sanitation Committee 1.0 4.0 1.3 SHG 12.0 18.0 47.0 10.0 21.8

Total Respondents 100 100 100 100 400

Irrespective of institutions, the health issues that are ly d the g are main isc in ussed m ineet as follows:

Irregular visit of health personnel Improper attention by health personnel No prior‐information to service receivers about visit of th personnel the heal Lack of coordination between health personnel Monetary problem to meet the health expenses


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2.3.6 Out of pocket enses ealth

nses, the expenses incurred on purchasing medicines was found to be highest as ompared to bearing the expenses towards service fee and the costs towards transportation and

found with regard to the health xpenses incurred by pe la ats , th health expensemarginalised households was as high as Rs. 4037/‐ and Rs. 4004/‐ respectively where in Malkangiri and Keonjhar it was much less at i.e. Rs. 521/‐ and Rs.941/‐ respectively.

exp on h Apart from the above, the study also collected information on the various types of health expenses that were incurred by the marginalised households in the last one year preceding the date of survey. The same are presented in Table 78. The average total health expenses of marginalised households was coming to Rs.2,453/‐ per year (Rs. 1488/‐ on medicines, Rs. 427/‐ on transportation, Rs. 374 on pathological testing and Rs. 164/‐ on service fee). Also clear from Table 78 that among the various types of health expecpathological tests. However, district wise significant variation wase ople. In Bo ngir and Jag inghpur e total average s of

as

Table 78 Annual expenses on health Particulars Econ lly Depomica rived Mar e eginalis d Cast s D

isabled

People

Migrants

Total

BPL SC/ST

Bolangir Service Fee 128 180 194 31 154

Testing 510 622 1,003 312 533 Medicine 2,957 3,047 4,670 1,815 2,670 Transportation Cost 695 750 760 473 680 Total Average Annual Health Ex penses 4290 4599 6627 2631 4037

Jagatsinghpur Service Fee 258 273 140 586 405

Testing 711 559 521 1,100 625 Medicine 2,175 1,887 766 5,157 2,313 Transportation Cost 630 484 227 2,007 661 Total Average Annual Health Expenses 3774 3203 1654 8850 4004

Keonjhar Service Fee 31 35 24 38 31

Testing 170 178 101 82 181 Medicine 532 543 662 389 532 Transportation Cost 195 192 270 123 197 Total Average Annual Health Expenses 928 948 1057 632 941

Malkangiri Service Fee 14 20 4 33 20

Testing 104 103 83 169 104 Medicine 186 218 133 331 255 Transportation Cost 109 120 46 234 142 Total Average Annual Health Expenses 413 461 266 767 521

Districts Total Service Fee 106 123 97 155 164

Testing 363 354 460 380 374 Medicine 1,432 1,367 1,594 1,778 1,488 Transportation Cost 396 368 351 625 427 Total Average Annual Health Expenses 2297 2212 2502 2938 2453


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Category wise analysis of marginalised people indicates that the migrant households in Jagatsinghpur district incurred highest annual health expenses (i.e. on an average Rs. 8850/‐ per annum) as compared

districts. In Bolangir, the households annum in

people in the same district. Similar trend of health holds having disabled persons incurred

annum) although the amount is much less in

more health expenses (i.e. on an average Rs. 767/‐ per month) in comparison to e other categories of marginalised people in the district.

to any other categories of marginalised groups across the four having disabled persons incurred highest health expenses i.e. on an average Rs. 6,627/‐ percomparison to other categories of marginalisedexpenses was also found in Keonjhar district where the househighest health expenses (i.e. on an average Rs. 1057/‐ percomparison to the households having disabled persons in Bolangir district. In Malkangiri, the migrant households incurred th

Table 79 Economic burden felt by the marginalized households due to high health expenses District Economically Deprived Marginalised Castes D

isabled

People

Migrants

Total

BPL SC/ST

Bolangir 70.3 70.3 80.0 80.0 68.0 Jagatsinghpur 85.9 83.3 90.0 90.0 84.0 Keonjhar 72.5 72.4 40.0 80.0 74.0 Malkangiri 33.7 35.1 20.0 40.0 35.0 Total percentages 64.1 63.2 57.5 72.5 65.3 Total Respondents 301 321 40 40 400

The same could be the reason for which imum entages of households in Bolan (68%)

(84%) including the people i onjhar rict (74%) reported about the e economic ult of bea high health expenses (Ta

able 80 Sources of mobilizing money for health expenses

max perc gir andJagatsinghpur n Ke dist xtraburden endured by them as a res ring ble 80).

TSource Economically Deprived Marginalised Castes D

isabled

People

Migrants

Total

BPL SC/ST

Own 23.9 21.8 28.0 13.3 23.0 Money lender 61.2 62.1 60.0 76.7 64.8 Friends/Relatives 14.9 15.2 12.0 6.7 15.7 Bank 0.9 3.3 0.8

In fact, bearing high health expenses was found t de th h d 6

eholds had to lend money from money lenders w an exor nt rat f Only 23% margina househ could m ge to m the fu r

of their health expenses from the own source.

o be so manding on em for w ich aroun 4.8% marginalised hous local ith bita e ointerest of 5 to 10% per month. lised olds ana eet ll opart


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2.4 Perceptions of in‐house patients availed treatment in PHC/CHC/District

Apart from covering y also conducted 100 exit terviews of in‐house patients in PHC/CHC and in district hospital (conducted 25 exit interviews in each

Hospital

different sections of marginalized people, the studinsample district) in order to know their responses on the services availed, problems encountered and level of satisfaction on the services provided in the health facility.

Table 81 District wise exit interviews conducted Respondents Bolangir Jagatsinghpur Keojhar Malkangiri Total


Patient himself 17 68.0 15 60.0 15 60.0 8 32.0 55 55.0

Patient's Family Member 8 32.0 10 40.0 9 36.0 14 56.0 41 41.0

Other Attendant 1 4.0 2 8.0 3 3.0

Other 1 4.0 1 1.0

Total 25 100.0 25 100.0 25 100.0 25 100.0 100 100.0

As clear from Table 81 that more than 55% exit interviews were responded by the patient himself /

d in case of about 41% the fa pa the questions askthe exit interview.

Status of patients having BPL c

herself an mily members of the tient responded to ed in

Table 82 ard Districts

Yes No Total

Count Col % Row % ount Col % w % nt CC Ro Cou ol %

Bolangir 17 23.9 68.0 8 27.6 32.0 25 25.0

Jagatsinghpur 13 18.3 52.0 12 41.4 48.0 225 5.0

Keojhar 18 25.4 72.0 7 24.1 28.0 25 25.0

Malkangiri 23 32.4 92.0 2 6.9 8.0 5 252 .0

Total 71 100.0 71.0 29 100.0 29.0 100 100.0

About 71% patients interviewed belong to BP ily. In Malkangir gh as 92 tie re

lies. L fam i, as hi % pa nts a from

BPL fami

Table 83 Number of patients interview different health ed in facilities Districts CHC/PHC DHH PHC (N) SDH Total


Bolangir 5 20.0 15 60.0 5 20.0 25 25.0

Jagatsinghpur 9 36.0 16 64.0 25 25.0

Keojhar 7 28.0 15 60.0 3 12.0 25 25.0

Malkangiri 10 40.0 15 60.0 25 25.0

Total 31 31.0 61 61.0 3 3.0 5 5.0 100 100.0


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As clear from Table 83 that 61% patients were interviewed in district hospital and about 31% were covered in PHC/CHC.

Illness of patients interviewed e health facility Table 84 in th Illness Bolangir Jagatsinghpur Keojhar Malkangiri Total

Count Col % Count Count Col % ount C C CCol % C ol % ount ol %

Cold/ Fever 2 8.0 4 16.0 3 12.0 9 9.0

Malaria 7 28.0 1 4.0 4 16.0 5 20.0 17 17.0

Operation of back bone

1 4.0 1 1.0

Kidney Problem 2 8.0 2 2.0

Brain Malaria 3 12.0 2 8.0 1 4.0 6 6.0

Stomach pain 1 4.0 1 4.0 2 2.0

Blood pressure 1 4.0 1 4.0 2 2.0

Delivery 7 28.0 6 24.0 13 13.0

Minor Injury 2 8.0 3 12.0 5 5.0

Diarrhea 6 24.0 6 24.0 12 12.0

Hernia Operation

2 8.0 4 16.0 1 4.0 7 7.0

Vomiting 1 4.0 1 1.0

Cataract 1 4.0 1 1.0

Pneumonia 1 14.0 1.0

Dysentery 1 4.0 1 1.0

Accident 1 4.0 3 4 4.0 12.0

Loose motion 1 4.0 1 1.0

Anemia 1 4.0 1 1.0

T.B. 2 8.0 2 2.0

Urine Problem 1 4.0 1 1.0

Headache 1 4.0 1 1.0

Chest problem 1 4.0 1 1.0

Leg & Hand Swelling

2 8.0 2 2.0

Weakness 1 4.0 1 1.0

Cholera 1 4.0 1 1.0

Sugar 2 8.0 2 2.0

Total 25 100.0 25 100.0 25 100.0 25 100.0 100 100.0

The illness for which they visited th fferent health facilities esented in Maximum i.e. about 23% visited the health facility for treatment of malarial / Brain malari wed 13% for

ery of child, 12% for diarrhea, out 7% patients were rgone hernia atio

e di are pr Table 84.a follo by

deliv etc. Ab unde oper n.

Table 85 Reasons of preferrin the health facility g Reasons

Bolangir Jagatsinghpur Keojhar Malkangiri Total


Less Distance 7 8.6 12 14.5 11 11.5 11 18.3 41 12.8


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Table 85 Reasons of preferring the health facility Reasons



Better Location 9 10.8 13 13.5 11 18.3 33 10.3

Better Attention 19 23.5 14 16.9 8 8.3 13 21.7 54 16.9

Free Medicine 4 4.9 6 7.2 14 14.6 8 13.3 32 10.0

Less Expensive 2 2.5 10 12.0 8 8.3 4 6.7 24 7.5

No service fee 8 9.9 10 12.0 14 14.6 3 5.0 35 10.9

Influence of family members

14 17.3 14 16.9 10 10.4 38 11.9

Trust/Faith on service provider

20 24.7 2 2.4 1 1.0 3 5.0 26 8.1

Free Urine/Blood Testing

1 1.0 3 5.0 4 1.3

Proper referral service

1 1.2 6 7.2 7 7.3 1 1.7 15 4.7

Good behaviour 5 6.2 7 7.3 2 3.3 14 4.4

Good hygiene 1 1.2 1 1.0 1 1.7 3 0.9

No need of care taker

1 1.0 1 0.3

Total Responses 81 100.0 83 100.0 96 100.0 60 100.0 320 100.0

The reasons for preferring the said health facility (as given in the previous slide) are presented in Table 85. As clear from the Table that maximum i.e. 16.9% visited the health facility because of better attention provided by doctors followed 12.8% visited because of less distance of health facility, about 10% each visited for better location of health facility and for availability of free medicines, etc. In case of 11.9% patients, the advice of family members played a key role for visiting the said health facility.

As clear from Table 86 that the patients have to travel a maximum distance of 100kms in order to avail treatment from the said health facilities. The average distance travelled by a patient to reach at the health facility is about 25kms.

Table 87 Status of completion of treatment Districts Completed Not‐completed Total

Count Row % Count Row % Count Col %

Bolangir 17 68.0 8 32.0 25 25.0

Table 86 Distance travelled by patients to reach at health facility Mean Maximum

Bolangir 24 70

Jagatsinghpur 10 30

Keojhar 20 95

Malkangiri 25 100

Table Total 20 100

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Table 87 Status of completion of treatment Districts Completed Not‐completed Total

Count Row % Count Row % Count Col %

Jagatsinghpur 21 84.0 4 16.0 25 25.0

Keojhar 21 84.0 4 16.0 25 25.0

Malkangiri 7 28.0 18 72.0 25 25.0

Total 66 66.0 34 34.0 100 100.0

During the time of exit interview of patients, 66% patients reported about completion of their treatment

d not get cured by the treatment made in the y.

in the health facility visited by them where as 34% coulhealth facilit

Table 88 Comfortability of tients be g various health nses pa in arin expe Travel costs Total Me icines d Total Laboratory stigations inve Total

Count Row % Count Count Row % Count Count Row % Count

Bolangir 21 84.0 25 24 96.0 25 20 80.0 25

Jagatsinghpur 7 28.0 25 7 28.0 25 11 57.9 19

Keojhar 24 96.0 25 22 88.0 25 15 60.0 25

Malkangiri 16 64.0 25 11 44.0 25 15 60.0 25

Total 68 68.0 100 64 64.0 100 61 64.9 94

Regarding various health expenses incurred by patients, only 64% to 68% were found comfortable in bearing different types of health expenses. That means almost 40 felt uncomfortable in bearing the

bout 72% in Jagatsinghpur were found uncomfortable regard to bearing the ses on medicine and travel The n peo mfort bear expenses

Malkangiri is slig less at .

same. A with expen costs. perce tage of ple finding unco able to the on

medicines in htly 56%

Table 89 Cleanliness o premise f health Level Bolangir Jagatsinghpur Keojhar Malkangiri Total


Cleanliness of waiting area

Good 17 68.0 2 8.0 11 44.0 17 68.0 47 47.0

Average 8 32.0 12 48.0 6 24.0 7 28.0 33 33.0

Poor 11 44.0 8 32.0 1 4.0 20 20.0

Total 25 100.0 25 100.0 25 100.0 25 100.0 100 100.0

Cleanliness of Consultation Ro om

Good 21 84.0 10 40.0 21 84.0 23 92.0 75 75.0

Average 4 16.0 13 52.0 3 12.0 2 8.0 22 22.0

Poor 2 8.0 1 4.0 3 3.0

Total 25 100.0 25 100.0 25 100.0 25 100.0 100 100.0

Cleanliness of Examination Room

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Table 89 Cleanliness of health premise Level Bolangir Jagatsinghpur Keojhar Malkangiri Total


Good 21 84.0 13 56.5 16 64.0 22 88.0 72 73.5

Average 4 16.0 10 43.5 8 32.0 3 12.0 25 25.5

Poor 1 4.0 1 1.0

Total 25 100.0 23 100.0 25 100.0 25 100.0 98 100.0

Apart from knowing the status of completion treatment, the study so atte ted map

people on cleanliness of the health premis in which they were admitted d atme . Tab shows that com ared t the cl liness the waiting room h r of patients ( 3/4th or reported about the an cleanliness of e pa t room nd th tient ex ination m. Less than % reported abou the cl line f

ting room i the health facility sited b patie

of al mp to theperceptions of the e anprovided tre nt le 89 p o ean of ighepercentage i.e. 75%) good d th tienconsultation a e pa am roo 50 t ean ss othe wai n vi y the nts.

Table 90 Level of sat ction o atient vario serv ed at the health p iseisfa f p s on us ices provid rem Services

Satisfaction level


Count Co l % Count Col % Count Col % Count C % ol C t oun Col %

Timings kept by the health facility

Very dissatisfied 1 4.0 8 32.0 9 9.0

Dissatisfied 6 24.0 1 4.0 1 4.0 8 8.0

Average 3 12. 0 14 56.0 6 24.0 11 44.0 34 34.0

Good 21 84. 0 4 16.0 10 40.0 13 52.0 48 48.0

Highly tisfied sa 1 4. 0 1 1.0

Total 25 10 0 0. 25 100.0 25 100.0 25 10 0 0. 100 100.0

Waiting time

Very dissatisfied 1 4. 0 1 4.0 6 24.0 8 8.0

Dissatisfied 12 48.0 2 8.0 1 4.0 15 15.0

Average 7 2 8.0 11 44.0 4 16.0 13 52.0 35 35.0

Good 16 6 4.0 1 4.0 10 40.0 11 44.0 38 38.0

Highly tisfied sa 1 4. 0 3 12.0 4 4.0

Total 25 10 0 0. 25 100.0 25 100.0 25 10 0 0. 100 100.0

Behavior of doctor/health staff


Dissatisfied 1 4.0 1 1.0

Average 1 4. 0 5 20.0 3 12.0 9 9.0

Good 17 6 8.0 19 76.0 12 48.0 20 80.0 68 68.0

Highly sfied sati 7 28.0 7 28.0 1 4.0 15 15.0

Total 25 100.0 25 100.0 25 100.0 25 100.0 100 100.0

Competence of doctor/ health staff


Dissatisfied 2 8.0 1 4.0 3 3.0

Average 1 4.0 4 16.0 2 8.0 9 36.0 16 16.0

Good 19 76.0 19 76.0 11 44.0 15 60.0 64 64.0

Highly satisfied 5 20.0 6 24.0 11 11.0

Total 25 100.0 25 100.0 25 100.0 25 100.0 100 100.0

Health information provision

Very dissatisfied 5 20.0 5 5.0

Dissatisfied 9 36.0 2 8.0 5 20.0 16 16.0

Average 12 48.0 13 52.0 2 8.0 12 48.0 39 39.0

Good 12 48.0 3 12.0 14 56.0 7 28.0 36 36.0

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Table 90 Level of satisfaction of patients on various services provided at the health premise Services

Satisfaction level



Highly satisfied 1 4.0 2 8.0 1 4.0 4 4.0

Total 25 100.0 25 100.0 25 100.0 25 100.0 100 100.0

Physical examination conducted on the client for the symptoms specified

Very dissatisfied 2 8.0 10 40.0 1 4.0 13 13.0

Dissatisfied 4 16.0 3 12.0 1 4.0 8 8.0

Average 4 16.0 10 40.0 2 8.0 14 56.0 30 30.0

Good 18 72.0 9 36.0 8 32.0 9 36.0 44 44.0


Total 25 10 0.0 25 100.0 25 100.0 25 100.0 100 100.0

Availability of medicines


Dissatisf d ie 3 12 .0 12 48.0 4 16.0 3 12.0 22 22.0

Average 5 20.0 8 32.0 5 20.0 11 44.0 29 29.0

Good 14 56.0 4 16.0 12 48.0 9 36.0 39 39.0


Total 25 10 0 0. 25 100.0 25 100.0 25 100.0 100 100.0

Availability of immunization services


Dissatisf d ie 5 20.0 1 4.0 6 6.0

Average 14 56.0 6 24.0 2 8.0 12 48.0 34 34.0

Good 7 28.0 14 56.0 16 64.0 9 36.0 46 46.0

Highly satisfied 4 16.0 1 4.0 1 4.0 6 6.0

Total 25 100.0 25 100.0 25 100.0 25 100.0 100 100.0

Relief of symptoms


Dissatisfied 3 12.0 2 8.0 3 12.0 8 8.0

Average 5 20.0 12 48.0 7 28.0 12 48.0 36 36.0

Good 19 76.0 9 36.0 6 24.0 9 36.0 43 43.0


Total 25 100.0 25 100.0 25 100.0 25 100.0 100 100.0

Referral services


Dissatisfied 1 4.0 1 4.0 1 4.0 3 3.0

Average 14 56.0 14 56.0 2 8.0 13 52.0 43 43.0

Good 8 32.0 10 40.0 14 56.0 11 44.0 43 43.0


Total 25 100.0 25 100.0 25 100.0 25 100.0 100 100.0

Privacy of the client


Dissatisfied 1 4.0 3 12.0 2 8.0 2 8.0 8 8.0

Average 6 24.0 12 48.0 2 8.0 12 48.0 32 32.0

Good 18 72.0 10 40.0 11 44.0 10 40.0 49 49.0

Highly satisfied 2 8.0 2 2.0

Total 25 100.0 25 100.0 25 100.0 25 100.0 100 100.0

Availability of service providers during need


Dissatisfied 3 12.0 1 4.0 3 12.0 7 7.0

Average 1 4.0 12 48.0 2 8.0 15 60.0 30 30.0

Good 18 72.0 12 48.0 10 40.0 9 36.0 49 49.0


Total 25 100.0 25 100.0 25 100.0 25 100.0 100 100.0

Over all Very dissatisfied 6 24.0 6 6.0


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Table 90 Level of satisfaction of patients on various services provided at the health premise Services

Satisfaction level



service quality

Dissatisfied 1 4.0 3 12.0 1 4.0 1 4.0 6 6.0

Average 5 20.0 11 44.0 9 36.0 12 48.0 37 37.0

Good 12 48.0 11 44.0 6 24.0 12 48.0 41 41.0


Total 25 100.0 25 10 0.0 25 100.0 25 100.0 100 100.0

Table 90 presents the level of satisfaction of patients on the quality of services that were availed during the treatment in the health facility. With regard to the timings maintained by the health providers,

51% patientsabout were found either averagely satisfied or dissatisfied. Due to long hours of waiting at for the same. Little

acy of clients maintained the health reported about toms e health

In overall, only patien were found to be with the qual of services ies.

ggestions tha e bee ade w provin servic in the h facilit e lows

the health facility 58% reported about their average satisfaction or dissatisfactionabove half of the patients i.e. 51% were found satisfied with regard to the privin facility. Only 47% relief of symp du to tme thethe trea nt in facility. 51% ts satisfied ity provided athealth facilit Various su t hav n m ith regard to im g the es ealth y aras fol

Adequate provisions of Nurse and Doctors; ambulance service; beds; mosquito net and fans; clean drinking water; free nutritious food; medicines in free of cost; blood and urine testing in free of cost and sufficient blood in the health facility

The waiting room of patients and toilets in the health premise should be kept clean The providers in health facility should be equipped technically and with required infrastructure to

provide treatment to the patients suffering from major illness instead of referring them to other hospital

The servi facility sh informed ple ces and provisions in the health ould be to the peo Stayin nge s for enda t sh mg arra ment the att nt of the patien ould be ade Doctors should keep patience to properly listen the problems of patients before prescribing the

medicines Service char some ealth pr ne to be letely pped fee ged by h oviders ed comp sto Patients ould wait long d by e serv ovider treatment sh not be ed for perio th ice pr s for The doctors should provide equal treatment all ca es of patien e of

economic and social bar.

*

to tegori ts irrespectiv age,

**


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Chapter – III

Sugg tion nd co en tion

the previous chapter, the report has made an attempt to bring out the availability, accessibility and

ug

tin ges ons, the reade this ort need to w that the s gestio s we f al le who are illi les orm , an ey are also th socially

antaged ople eref , the dy s tri p ent sug tion arginalised as verbatim. The important ngs note that the suggestions given

people are re ir e ctat eds er t th tiolem study ha rpose lly added another section at e end this apte

ake recomm s for ad ressin the constraint mar alise ople atta g be r health.

k) Provi health c s fo egnan wom children, disabled, aged an ople sidi remote

ce service vi equate stock of medic es an mily n products wit AWW/ASHA

timel ishment products n) Provi own AW ildi r ma ainin vac pre t women o) Cons ads d provision of ranspo ation ilitie

providers in vacant plac ond r supervision of AWW/ASHA/ANM by s ervis level fficialsrovi delivery facilities PHC ( and s ctor e gynaecologists, et

s) Provi all types icine r mi t) Provi d s f ed and disabl d peop

Create on health programs d schemes rga ational p for institu nal delivery

Provi free aids appliances f disable persons x) Speci ention and visi r treatment isab and d people

3 es s a Re mm da s Inquality of various health services availed by people and the problems perceived by them for not being able to avail or access the same services. In this chapter, an effort has been made here to bring out some of the important suggestions given by the marginalised people covered under the study. Considering all the problems reported by the marginalised people and the suggestions made by them, the study at the end of this chapter has made certain recommendations to improve the availability, accessibility and quality of health services.

S s of m3.1 gestion arginalised people Before getthe margin

g into the sug ti r of rep kno ug n re oised peop terate and s inf ed d th bo and

economically disadv pe . Th ore stu ha ed to res the ges s ofm people other thi to here bythe marginalised mo of the xpe ions and ne rath han ose are solu ns to their prob s. Hence, the s pu fu th of ch r tom endation d g s of gin d pe in inin tte

sion of amp r pr t en, d pe re ng in or inaccessible areas

l) Provisionm) Pro

of ambulansion of ad in d fa planni g h andy replen ofsion of C bu ng fo int g pri y of gnantruction of ro an t rt fac s

p) Appointmenq) Cr) P

t of health esuct regula up ory o sion of at N) pecialist do s lik c. sion of of free med s fo nor illnessession of free me icine or ag e le

u)v) Ow)

awareness annise motiv cam tiosion of and or theal att pro on fo of d led age


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y) Card to disabled people for attaining better health services z) Increase of pension amount (from Rs. 200/‐ to Rs. 600/‐ ested i aa) Regular visit to their e W /Abb) Creat e opportunities migrants an othe) Hom contacts for pr acta g wo

of supplementary wom n and ldren

Recommendations o study

m have bee made re ar onl ddre e c strai faced y pe ue to their arginalisation e ck of spend on icin long tanc health cilities, etc. report prepared o perception serv providers ha commende eas overcome nts a ssocia ed with the health providers hence this repo does t

de those ommendatio .

marginalisation of eople undou an integ d ef rt of vider various ctors such tion, livelihood, Since the caus of ue to various income in the area, geo‐physical of the area,

rce availability with the ople itio d culture of pe etc e process o nime wo onger time nd mo reso M of e iss un the nstr s d w y of services are not u er th ect ntrol p vide us, ey would

latively tak period addres For address the in e it would quire to provision develop knowledge and of peopl provide be

portatio and communi ion ies, . wh em lves ld n m ime forces be e impact on enhan g the ome nd affording capacity people so t can m expenses including the expenses on health. en th facto that d to

arginalisati eople, th tud s ma an attempt here to omm d o eas hich could b lised in les of e an our . Th omm dat tha ve

here ca be categorise der e he con ic, and ati

3.2 Economic asur rec me tion

g) Risk ping economic c nstraints of people in d, th health ctor n init transfer introducing micro health insurance mes As reported in equity

statu a ge percentag of people in issa not nder y he insur chemes. rdly y pe fro the argin ed sections lin d u sur schemes w h m e du the k o are on e sa th sur

prod mpanies th not t their eds.

as sugg n keonjhar) villag by AW /ASHA NM

ion of employm nt for d rs cc e egnant and l tin men dd) Regular

3.2

distribution nutrition to e chi

f the The recom endations that n he e to y a ss th on nts b opled own m .g. la money to med es, dis e offa The n the s of ice s re d m uresto the constrai which re a t rt noinclu rec ns Addressing p is btedly requires rate fo pro s inse as educa finance, health, etc. root es marginalisation ared factors like opportunities environment resou pe , trad n an the ople, . th f mi ising the samassociate

uld require l a re urces. ost thes ues like co aintith deliver nd e dir co of the ro rs, th th

re e longer to s. example to low com of people, re resources/funds, skill e, ttertrans n cat facilit etc ich th se wou eed ore t , ef t and resourpeople

fore the sam cin inc a of thaeet their Giv e rs lea the

m on of p e s y ha de rec en nly those m uresw e rea s investment tim d res ces e rec en ions t ha beenmade n d un thre adings, viz. E om Social Sp al.

.1 me es / om nda s

Transfer: Kee the o min e se ca iaterisk

in

measures by sche . thes paper that lar e Or are placed u an althance s Ha an ople m m alis are ke nderance hic ay b e to ir lac f aw ness th me or e in anceucts of the co at do match o ne

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Since the study has come out with the finding that high health expenses enhance the risk of people and further marginalise them in terms of increasing their dependence on usuri cal moneylenders, it becomes apparent for the health s to d k at a

t imise vulnerability the le. I regard, health insurance mpa s need the e to e o ith some specific health in nce duc that the t margin d population can reap ben fit of same. Var other e country have already initia and ning states ca analysed to make the same viable in Orissa.

tion loans e.g. the loans for the purpose of health, education, etc. While the financial institutions understand that the loan for health purposes does not give any direct monetary gain

the purpose of health. The same study has also revealed greater dependence of poor people on local moneylenders during the time of health problems which in turn marginalises the poor

ke effort to mobilise the financial institutions for designing , aligning health

people etc. There

are mobilised for the same.

e realised through using SHG as a medium.

a) Equity sensitive IEC/BCC interventions: As information or knowledge carries lot of significance for attaining better health, purposive IEC interventions are highly essential. In this regard, the state can take‐up the following measures:

i) Introduction of community kiosks would be one such initiative for providing at least some basic information to people on health and sanitation. As it has come out in the study that

ous loector intro uce ris mitig ing me sures

tha would min the of peop n this co nie to be mobilised by stat com ut w sura pro ts so

mos alise sections of the e the ious states in th ted this step lear from those n be

h) Introducing financial products targeted at health issues: Apart from insurance product, the

state can act on promoting other financial products meant for health purposes since the provision of village health fund is not sufficient enough to cater the health requirements of all the marginalised people. All the financial institutions including micro and macro level institutions require to be mobilised for such purposes. A recent study on microFinance has revealed that the financial institutions are giving more focus on productive loans as compared to consump

to them as well as to the people, they need to realise the intangible returns of lending money for

people due to getting trapped by the usurious money lending activities of the local moneylenders. In order to keep both financial institutions and marginalised people in a win‐win situation, the health sector has to maboth savings and loan products that caters to the health needs. In this regardloans / consumption loans with a productive loan could be a solution so that the person can repay both the loans from the return on productive investments. The other solution could be introducing seasonal‐savings product exclusively for the purpose of health. With the assistance from government, financial products specific to different categories of marginalisedcould be introduced e.g. products for disable, aged, migrants (remittance product),could be other such solutions but provided the financial institutionsAs 20 to 30% marginalised households were found in the study as members of SHG, the same could b

3.2.2 Social measures / recommendations

/BCC


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people without proper info lace to place or source to source for availing health treatment, there money, time, etc. for the same. The community kiosks could be also used to people about correct health care practices.

ach at the health facility.

marginalised people in mind. For example, if caste feeling in particular area is a barrier to avail health services the BCC/IEC interventions need to be designed accordingly to address the same. Also for example, if illiteracy of people is a

he BCC/IEC interventions should be designed nd the health messages. Also, if people

better relate to the fellow people around them then the posters/pamphlets/wall paintings

concerned. Any initiatives that promote volunteerism are found to be not sustainable and not

t examples before us are the concept of peer educators / change hers’ committee, etc. which did not yield required results when

income, infrastructures, etc. has achieved better results as the engagement of

ny body was found members of effective delivery of health services. Thus, the

rspective of how state can

ealth activities. Although the W&CD vings and credit activities with health

duction of fine system for the members of pre‐school education, etc. could be very

on SHG members to

rmation visit different pby spends lot of

informThe same could be also used to arrange logistics for the people to re

ii) The other solution could be using mass media, posters/pamphlets, wall paintings, etc. for delivering appropriate health messages pertaining to the needs of the people and the area. Although the state has already into these initiatives, the visibility, outreach and relevance of methods used are requiring attention so that majority of the marginalised people could participate and understand the valuable information provided for the same. The messages need to be designed in keeping into account the audience more specifically the multi‐caste, multi‐lingual and multi‐cultural

problem to know right health practices taccordingly so that illiterate people can understa

should show pictures of their own people so that people can relate themselves better with the person in the picture.

b) Promoting and building social capital: This is one such area that the health sector needs to

build on from the experiences and learning that were gained from the past history. In the past, various health institutions were formed and promoted. The result of promotion of such institutions does not show any encouraging results as far as community engagement is

owned by people in the long run despite significant efforts of health providers have gone into promoting the same. The besagents / food committees / motthe same only promoted volunteerism. Aligning volunteerism with tangible gains to people involved in the same in terms offound in case of SHG. The study also found similar findings with regard tomarginalised people in community level institutions. Hardly asuch institutions and was engaged for facilitating state needs to analyse the promotion of recently introduced VHSC from the pethe same can be sustained and owned by people in the long run. Apart from this, the also see how effectively they can engage the SHGs in hdepartment is already into the same, but alignment of saactivities is to be achieved. Small initiative like introthose who have not availed e.g. TT, immunisation, effective. Similar other initiative could be like entrusting responsibilitymobilise their neighbours or fellow villagers to attend the VHND.

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3.2.3 Spatial measures / recommendations

road, electricity, drinking water, etc. could be more specifically to benefit the

ple residing in remote or inaccessible areas. would benefit not

only the health sector but also the other sectors as well. Equitable distribution of state budget and investment is essential in this regard.

b) Last but not the least, keeping the in‐accessibility and geo‐physical factors into account,

a) Measures to improve the rural infrastructure like

taken up for attaining better mobility of marginalised people pregnant women, children, disabled, aged and peoAlthough it would require huge resources for the state to invest, the same

provision of ambulance in rural areas could benefit a large number of marginalised people. The other solutions could be like increasing the provision of mobile health clinics and organising health camps on regular basis especially for the benefit of pregnant women, children, disabled, aged and people residing in remote or inaccessible areas.

***

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Study on perceptions of marginalized people about health ... · Study on perceptions of marginalized people about health equity in Orissa ACKNOWLEDGEMENT We are highly indebted to