3 STATUS OF HEALTH CARE IN RURAL INDIA
3.1. RURAL CHARACTERISTICS
3.1.2. Geographical Disparities
Figure 3.5: Percentage of Persons Below Poverty Line 1999-2000
Figure 3.6: Health Status Indicators for Poorest and Richest Quintile of Population Health Status Indicators for Poorest and Richest Quintile of
Population 1992-93
109
155
60
4,1
44 54
34
2,1 0
20 40 60 80 100 120 140 160 180
Infant mortality (<1y, per 1000)
Under-5 mortality (per 1000)
Childhood underweight (in %)
Total fertility rate
Poorest 20% Richest 20%
Source: own design; data: Misra et al. 2003: 28 Percentage of Persons Below Poverty Line 1999-2000
0 10 20 30 40 50 60
Jammu & Kashmir Goa Chandigarh Punjab Himachal Pradesh Delhi Haryana Kerala Gujarat Rajasthan Andhra Pradesh Mizoram Karnataka Andaman& Nicobar Islands Tamil Nadu Pondicherry Maharashtra West Bengal Manipur Uttar Pradesh Nagaland Arunachal Pradesh Meghalaya Tripura Assam Sikkim Madhya Pradesh Bihar Orissa
Rural Urban Combined Source: own design; data: Ministry of Health and Family Welfare 2003: 96
An extensive survey of India’s public services covering access, utilization, quality, reliability and satisfaction for drinking water, health care, road transport, public distribution system and primary schools covered 36,542 households in all over India (Paul et al.
2004). As a result of the study the states were sorted into three groups according to their performance in all sectors (see Table 3.1).
From each performance category one state was selected for this study. In terms of health care Maharashtra showed the second best performance, Himachal Pradesh ranked 5th and West Bengal showed the second worst performance (see Table 3.1). The three states also differ in their economic performance and in their poverty rates (see Figure 3.4 and 3.5). Access to drinking water, health care, public transport, public transportation and primary schools of the first level states, Andhra Pradesh, Karnataka, Kerala, Tamil Nadu, Gujarat, and Maharashtra, by far exceeded the access rates of the third level states, Assam, West Bengal, Orissa, Rajasthan, and Bihar (Ibid.: 931). Public transport shows the most significant differences in access rates. In the first level states 84 % of the population have access to it, compared to only 26 % of the third level states. For health care the figures are lower with 48 % in the well performing states and 32 % in the less performing states. The states ranked second level for their performance are Haryana, Himachal Pradesh, Punjab, Madhya Pradesh, and Uttar Pradesh. Utilization and reliability of health are surprisingly the same in third level states compared to first level states (see Figure 3.7). Satisfaction with health care reflects the mismatch between demand and access, hence, it is very low with 21 % for the first level states and only 7 % for the third level states.
DW Health Transport PDS Education Overall
First level
Andhra Pradesh 7 16 4 2 4 5
Karnataka 2 6 3 3 3 3
Kerala 13 7 7 5 8 6
Tamil Nadu 1 4 2 1 1 1
Gujarat 3 1 1 6 2 2
Maharashtra 5 2 5 4 4 4
Second level
Haryana 11 9 8 11 13 10
Himachal Pradesh 4 5 6 13 15 7
Punjab 14 3 10 10 16 11
Madhya Pradesh 6 10 13 8 6 8
Uttar Pradesh 9 7 9 14 7 9
Third level
Assam 15 10 14 7 11 14
West Bengal 7 15 11 15 13 13
Orissa 10 13 15 9 10 12
Rajasthan 12 12 12 16 9 15
Bihar 16 14 16 12 12 16
Table 3.1: Ranking of Relative Performance of States in Public Services (Paul et al. 2004: 930; DW= Drinking Water; PDS= Public Distribution Services)
Figure 3.7: Contrasts in Health Care Performance Between Categories of States
Primary schools have the highest utilization rates, followed by public distribution, with health care coming last (1st level: 52 %/ 3rd level: 53 %). While the difference for utilization of public transport is again very high (75 %/ 8 %), the other services show similar figures for first and third level states. Drinking water has the highest reliability (76 %/ 72 %), followed by health care (68 %/ 68 %), public transport (22 %/ 10 %) and primary schools (24 %/ 12 %) coming last. Satisfaction with public services is low for all categories ranging from 10 % for public distribution to 30 % for drinking water in the first level states and from 3 % to 14 % for the same categories in the third level states. It is further interesting to notice that there are no significant differences between poor and non-poor households for access to most public services in the top six states, although access to health care is a bit lower (Ibid.).
However, access to health care, public transport and public distribution decreases further for poor households from the five second-level to the five third-level states, showing that states which have a low overall performance also have more inequality in public services.
Hence, poor households benefit less from public services than non-poor households. The access data for antenatal care and immunization services from another study support these findings (see Figure 3.8 and 3.9). Low standard of living has negative effects on utilization rates of these services. Andhra Pradesh and Tamil Nadu are an exception.
They show a pro-poor bias for antenatal care. Women with higher living standards, in turn, have better access to the services in nearly all states. Access to drinking water and primary schools shows no pro non-poor bias in either of the categories. These services
Source: own design; data: Paul et al. 2004: 931 Contrasts in Health Care Between Categories of States
(in %)
48 52
68
21 32
53
68
7 0
10 20 30 40 50 60 70 80
Access Utilization Reliability Full Satisfaction Top Six States Bottom Five States
seem to reach all groups equally. From this data it can be assumed that there will be a large difference between decentralization and community participation in the public health sector in Maharashtra, Himachal Pradesh and West Bengal, reflecting their different performance levels.
Figure 3.8: Percentage of Women Covered by Antenatal Care by Standard of Living11
Figure 3.9: Percentage of Women Covered by Immunization Services by Standard of Living
11 - Low standard of living refers to kutcha house - a house structure made of unburnt bricks, bamboo, mud, grass, leaves, reeds, or/ and thatch. High standard of living refers to pucca house - a house structure made of cement, concrete, oven-burnt bricks, stones, stone blocks, jackboard, tiles, timber, galvanized tar, corrugated iron sheets, or/ and asbestos sheets (Misra et al. 2003: 139).
Source: own design; data:
Misra et al. 2003: 135
Percentage Covered by Antenatal Care 2000
0 10 20 30 40 50 60 70 80 90 100
Uttar Pradesh Rajasthan Madhya Pradesh Orissa Maharashtra Andhra Pradesh Tamil Nadu Kerala
Low Standard High Standard
Source: own design; data:
Misra et al. 2003: 135
Percentage Covered by Immunization Services 2000
0 10 20 30 40 50 60 70 80 90 100
Andhra Pradesh Tamil Nadu Kerala Maharashtra Orissa Rajasthan Uttar Pradesh Madhya Pradesh
Low Standard High Standard
However, the benchmarks for public services in the above mentioned states do not necessarily correspond with their ratings for economic performance (see Figure 3.4).
States having similar per capita net domestic products like Andhra Pradesh and West Bengal, took the 5th and the 13th rank in public service performance (see Table 3.1). The same holds true for the amount of poverty in the states, Rajasthan (15th rank) comes just behind Gujarat (2nd rank) (see Figure 3.5, Table 3.1). Maharashtra and West Bengal do have equally high poverty rates (see Figure 3.5), but are worlds apart in their performance ranking (see Table 3.1). Only for Assam, Orissa and Bihar are performance of public services, economic performance and people below poverty line consistently bad. From this comparison two things become clear. First, states with low economic performance like Madhya Pradesh and Uttar Pradesh can still have good performance in public services (8th and 9th rank). While, states with high per capita net state domestic product like Haryana might not perform well in public services (7th rank). Second, high poverty rates do not automatically imply lack of public services or inequality in access to it (see Madhya Pradesh, Uttar Pradesh). Therefore, assumptions concerning linkages between indicators in Maharashtra, West Bengal and Himachal Pradesh have to be made with care and need to be confirmed through local research.
Figure 3.10: Rural and Urban Infant Mortality Rates 2000
Economic status, poverty and performance of public services differ among the states and between urban and rural areas. Although the study of Paul et al. does not make a distinction between urban and rural areas, health indicators reflect the disparities existing there (see Figure 3.10). Infant mortality rates (IMR) are much higher in rural areas of states (except Kerala) than in urban areas, indicating a lower health status. IMR in
Source: own design; data: Ministry of Health and Family Welfare 2003, p. 44 Rural and Urban Infant Mortality Rates 2000
0 20 40 60 80 100 120
Kerala West Bengal Punjab Maharashtra Tamil Nadu Himachal Pradesh Bihar Karnataka Gujarat Haryana Andhra Pradesh All India Assam Rajasthan Uttar Pradesh Madhya Pradesh Orissa
Rural Urban
Himachal Pradesh and Maharashtra are higher than in West Bengal, although their performance in the public health sector is better. Hence, poor households in rural areas are deprived in double respect. First, a higher percentage of poor people live in rural areas. Second, a higher percentage of poor have a low health status compared to non-poor. Access to public health services, in turn, is lower in rural areas and also lower for the poor (see above). Thus, the higher demand of poor rural population is not met.
Besides the grouping of states after their economic, poverty or access indicators, they can also be grouped according to their status of health transition (see Table 3.2). While the Southern states of Kerala and Tamil Nadu are already in a middle to late transition and have a high institutional capacity, the majority of states including West Bengal and Maharashtra are in an early to middle transition and have only low to moderate institutional capacity. Orissa, Rajasthan, Madhya Pradesh and Uttar Pradesh are in a very early transition phase with very low to low institutional capacity, whereas Assam and Bihar show no signs of health transition (Peters et al. 2002: 8).
Table 3.2: Health Transition in Major Indian States