CHAPTER 4
Health Condition
H
ealth is an important determinant of well-being in the broadest sense of the term.
Improved health is desirable not only in itself, but also because it leads to enhanced
capability to work and to participate in economic development. Improved health and
nutritional status contribute to increased life expectancy.
Mortality Condition
The mortality rate is a robust indicator of the overall health status of a population.
The percentage decline of mortality in the 1980s as well as the 1990s has been the least
in Orissa. The Crude Death Rate (CDR) in Orissa in 2001 and 2002 was 10.4 and 9.8
respectively.
Infectious and parasitic diseases account for a little more than one-fifth of all deaths
in Orissa. Diseases of the circulatory system also have a share of nearly one-fifth in
all deaths. Perinatal deaths account for 13 per cent of all deaths. Diseases of nervous
system, respiratory system, and digestive system together account for another 20 per
cent of all deaths.
Infant and Child Mortality
Level of, and Trend in, Infant Mortality
Infant mortality rate (IMR) continues to be the highest in Orissa. The rate of decline in IMR
has been rather slow and gives rise to concern: in the 16-year period between 1981–83 and
1995–97, it declined by 25 per cent, i.e., at the rate of about 1.6 per cent per annum.
Fig. 4.1
Level of, and Trend in, Crude
Death Rate, 1980–2000
20
1990-92
11.49
8.73
10
9.87
11.05
Per cent decline
10.73
15
12.07
1998-2000
5
0
Orissa
India
The relatively slow decline in IMR is partly explicable in terms of the
relative decline in different components of infant mortality. Neonatal
mortality (NNM) constituted 63.7 per cent of infant deaths. Perinatal
deaths alone account for some 35 per cent of infant deaths. Post-neonatal
deaths constitute only some 36.3 per cent of all infant deaths. The postneonatal mortality rate of Orissa seems to have declined to a greater
extent than perinatal mortality rate. In fact, SRS data over a long period
(1972–95) post-neonatal mortality declined by 62 per cent and neonatal
mortality declined by only 33 per cent. However, IMR has come down
to 91 in 2001 and further to 87 in 2002. If this rate of decline continues,
an IMR of 45 per thousand live births should be reachable by 2010.
Causes of Infant and Child Death
Given such a weight of IMR and child mortality in overall mortality
burden, and concentration of infant deaths in the neo-natal period, it
is worthwhile analysing the available data on the causes of infant and
child deaths. Prematurity, resulting in low birth weight of babies, is
the predominant cause of infant deaths, accounting for 38.5 per cent of
16
Orissa Human Development Report
such deaths. Nearly 30 per cent of infant deaths are due to
adverse conditions of infections relating to the circulatory
system. Broadly speaking, these causes of infant death reflect
inadequate antenatal, natal, and post-natal care.
In particular, three factors may explain the high level of
IMR in Orissa: first, the poor professional attendance at
birth; second, high percentage of low birth weight babies,
and third, lack of professional post-natal care. These three
factors together have a bearing on neonatal mortality,
which, constituted about 64 per cent of infant deaths in
Orissa. Maternal malnutrition and malaria are among the
important causes for low birth weight babies. It has been
estimated that 40 per cent of neonatal deaths occur in the
case of low birth weight babies. The coverage of post-natal
care seems to be quite poor: only 18 per cent of women were
visited by the Auxiliary Nurse Midwife (ANM) within two
weeks of delivery.
Table 4.1
Distribution (per cent) of all Deaths (Rural +
Urban) by Major Cause Groups, 2000
Sl.
No.
Per cent to
total
Major cause group
1.
Intestinal, Infectious, and Parasitic
Diseases
21.68
2.
Diseases of the Circulatory System
(Anaemia; heart attacks, etc.)
18.39
3.
Conditions Originating in Perinatal
Period
12.91
4.
Injury, Poisoning etc.
9.54
5.
Diseases of the Nervous System
7.82
6.
Diseases of the Respiratory System
(Asthma & Bronchitis; TB of Lungs;
Pneumonia)
5.97
7.
Diseases of the Digestive System
(Gastroenteritis; Peptic Ulcer;
Dysentery, etc.)
5.24
8.
Pregnancy, Childbirth and
Lack of access to safe drinking water and adequate nutrition
Puerperium
are the other underlying factors behind child deaths.
9.
Endocrine, Nutritional and Metabolic
For deaths of children under 5 years of age, diarrhoea
Diseases
accounts for 28 per cent, Acute Respiratory Infection
10.
Neoplasm
(ARI)/pneumonia for 15 per cent, measles for 10 per cent,
Others
11.
tetanus for 6 per cent, and tuberculosis infection, fevers
like malaria, typhoid, and hepatitis for the rest. The single
most important factor for reducing the prevalence rate and case fatality rate of major
infant and childhood diseases is improvement of nutritional status and antenatal and
intra-natal care.
3.08
2.88
1.93
10.56
It is important to state that malnutrition is concentrated in particular vulnerable
groups within the poor and ultra poor population, i.e. women and children. A multiple
regression analysis based on data for 296 districts of India for the year 1981 shows that,
holding other variables constant, a 50 per cent reduction in the incidence of rural poverty
reduces the predicted value of under-five mortality from
Fig. 4.2
156 per thousand to 153 per thousand, whereas an increase
Level of, and Trend in, Infant Mortality
in the crude female literacy from, 22 per cent to 75 per cent
Rate, 1980-2000
reduced the predicted value of under-five mortality from
156 per thousand to 110 per thousand.
150
136.7
Morbidity Condition
Excess Morbidity Burden
There is an inverse relation between overall mortality rate
and overall incidence of disease rate: as mortality declines
and life expectancy increases, the chances of survival
improve but the propensity to fall ill increases. Conversely,
at a high mortality rate, morbidity rate tends to be less. The
morbidity incidence rate is significantly higher in the case
17
Health Condition
130
123.0
120.3
110
97.0
90
1980-82
1987-89
1990-92
1998-2000
Table 4.2
Contribution (per cent) to Infant Deaths by Major
Causes, Rural Orissa, 1998–2000
Specific causes
Per cent of total
deaths
Prematurity
38.5
Pneumonia
15.4
Respiratory Infection of newborn
8.7
Anaemia
8.1
Bronchitis and Asthma
5.3
Tetanus
Diarrhoea of newborn
Others
of Orissa as compared to Bihar, Madhya Pradesh, Rajasthan,
and Uttar Pradesh.
Trend in Morbidity: The Case of Four Major Diseases
Malaria has recently staged a comeback. The relative magnitude
of the problem can be gauged from the fact that Orissa, in 1998,
accounted for 28.6 per cent of some two million detected cases
of malaria in India and 62.8 per cent of all malarial deaths in
the country.
Tuberculosis also remains a major public health problem in
Orissa. The available data for the period between the mid1.8
1980s and 2000–01 shows that the prevalence rate has not
19.3
only been high, but has also showed signs of increase from
time to time. Though the case-fatality rate has come down,
the percentage of cases in which the treatment course is not completed is high.
2.9
The case of gastroenteritis is somewhat similar to tuberculosis. While the case-fatality
rate has come down during the period 1979–94, the prevalence rate has steadily increased
during the same period. In 2002, there were 156,872 cases of severe diarrhoea resulting
in 453 deaths, and in 2003 there were 144,672 cases of severe diarrhoea resulting in 513
deaths.
The case of VPDs perhaps highlights what an aggressive, well-motivated immunisation
drive, such as the Universal Immunisation Programme (UIP) introduced in 1985–86, can
achieve. Of the six VPDs, the number of reported cases in Orissa came down between
1985 and 1993 in the cases of diphtheria, measles, whooping cough and poliomyletis. It
increased during 1980–85 in all cases except whooping cough. The number of reported
cases has increased in the cases of tetanus and tuberculosis.
National Disease Control Programmes
Given the challenges of public health control and management, vertical disease control
programmes have a special significance in the context of Orissa. Malaria, tuberculosis,
filariasis, leprosy, corneal blindness, and goitre are major public health concerns. A
partial indicator of the amount of effort that is going into the control of these conditions
is the magnitude of expenditure on the National Disease Control Programme. Firstly,
Malaria control accounts for the bulk of the expenditure. Secondly, allocations to other
disease control programmes appear to be inadequate. Finally, there has not been a
steady increase in allocation for any of the mentioned programmes.
Pattern of Illness and Early Mortality
In the first stage of ‘health transition’, the preponderance of infectious and communicable
diseases is a typical pattern. These diseases also account for much of mortality in this
phase. Thus, in case of Orissa, from the latest available data (for the year 1992–93) on the
number of outpatient and inpatient consultations and it can be seen that infectious and
communicable diseases account for around 50 per cent of both outpatient and inpatient
consultations and about 33 per cent deaths. Non-communicable diseases become
increasingly important during the second stage of health transition.
18
Orissa Human Development Report
According to a study by the Administrative Staff College of
India in 1999, total person-years (PYs) lost were 381 per 1000
population. This means that each one of 10 per cent of the
state’s population lost on an average nearly four years of life
on account of early mortality and illness-caused time loss.
Table 4.3
Probability of Dying at Different Ages
There is not much of a male–female difference in the
probability of dying within both rural and urban areas.
However, the probability at birth of dying at the age of 15
years and probability at the age of 15 years of dying at the age
30 years is twice as high in rural areas as compared to urban
areas.
Number of Reported Cases of Vaccine
Preventable Diseases
Vaccine
preventable
diseases
Year
1980
1985
1993
Diphtheria
333
474
166
Whooping
Cough
13,340
7,223
6,666
5,132
9,272
3,602
275
981
376
1,609
2,378
2,671
10,198
17,589
54,710
Measles
Poliomyelitis
Tetanus
Tuberculosis
Access to and Utilisation of Public Health Care
Facilities
Physical Access
In the case of public health care services, access is an important aspect and a basic
requirement. One may distinguish between two kinds of access: physical and economic.
Physical access can be either population coverage-based or area coverage-based.
Economic access refers to direct cost of accessing the service. For Orissa, as regards
population covered per public health facility, while the coverage is better in seven to
nine major states, the area coverage, is generally poor.
Similar data for the year 2004 suggests that the area coverage of health institutions has
perceptibly improved for the state as a whole and for as many as 14 non-coastal districts.
However, for the five inland districts of Balangir, Kalahandi, Mayurbhanj, Phulbani, and
Sundargarh, 40 per cent or more of the population still have to travel more than 5 kms
to reach the nearest health facility. On the other hand, physical access is relatively better
in the case of the coastal districts of Balasore and Puri. The problem of physical access is
compounded by two other factors: poor roads as well as poor transport connectivity.
At a low level of per capita income, a good indicator of economic access, to public health
care facilities is the extent of private expenditure on health care. The available data
on the same suggest that it is higher in the backward district of Kandhamal, and is
proportionately higher for lower income classes. It is thus not surprising to find that
poor physical and economic access affect the utilisation of public health care facilities.
Inter-District Disparities
Early marriage of girls, particularly below 18 years of age, may result in greater number
of births, high infant mortality, and pregnancy complications. In Orissa, a little below 30
per cent of girls married before 18 years of age, but there was a great deal of inter-district
variation. Thus, for the backward districts of Balangir, Boudh, Kalahandi, Malkangiri,
Koraput, and Nabarangpur, more than 50 per cent of girls married below 18 years of
age while it was less than 15 per cent in the coastal districts of Cuttack, Jagatsinghpur,
Jajpur, and Puri.
19
Health Condition
The coverage of antenatal care is rather impressive: 73.4 per cent of women had received
some antenatal care. There was not much inter-district variation, as in 28 out of 30
districts, more than 60 per cent of pregnant women had received some ante-natal care.
Delivery at a health facility fully ensures professional care during delivery. For the state
as whole, such institutional deliveries constituted only 21.9 per cent of all deliveries and
in this there is considerable inter-district variation (CV: 52.89).
The inter-district disparity comes down in the case of safe deliveries at health facility
plus deliveries at home attended by a trained professional, as a large number of districts
move up to the category of 20–40 per cent of safe deliveries, thus increasing the average
of safe deliveries to 36.46 per cent. But this means that still about two-thirds of deliveries
are unsafe, i.e., not attended by any trained professional.
Access to post-natal care seems to be poor in Orissa. The percentage of women visited
by ANM within two weeks of delivery was only about 18. There is a fairly significant
inter-district variation in this respect around the low mean (CV: 34.53). Twenty districts
with less than 20 per cent of women having been visited by ANM within two weeks of
delivery include not only the backward districts in the KBK (Kalahandi, Balangir, and
Koraput) region, but also, a number of coastal districts as well as northern districts.
The percentage of women who develop pregnancy and delivery related complications
range from one-third (delivery complications) to nearly three-fourth (pregnancy
Map 4.1
Per cent of Girls Married at Age Less than 18 Years
(for married since 1 January 1996)
K H A N
A R
D
J H
WE
ST
Sundargarh
BE
N
G
Jharsuguda
Sonepur
H
A
R
Bargarh
Keonjhar
Deogarh
Dhenkanal
IS
G
Boudh
Kalahandi
Rayagada
O
Gajapati
A
Y
B
F
B
G
E N
<20
20-40
>60
AN
E
SH
20
Orissa Human Development Report
A
L
Percent of girls married
at age less than 18 Yrs.
40-60
AD
Jagatsinghpur
Puri
Ganjam
Nabarangpur
PR
DHRA
Kendrapara
Khurda
Kandhamal
Malkangiri
Jajpur
Cuttack
Nayagarh
Nuapada
Koraput
Balasore
Bhadrak
Angul
Balangir
CHHA
TT
Sambalpur
A
L
Mayurbhanj
complications). There is a great deal of inter-district disparity in respect of both abortion
complications (CV: 36.13) and delivery complications (CV: 41.15).
Immunisation coverage in the state cannot be said to be satisfactory. Only about 60 per
cent of children are completely immunised. In as many as 14 districts, the immunisation
coverage is between 40–60 per cent. About nine per cent of children have received no
immunisation at all. This implies that some 32 per cent of children are only partially
immunised. A fairly significant inter-district variation (CV: 28.79) is observed here.
The incidence of diarrhoea among children is fairly high: 30.28 per cent. In 25 districts,
the incidence is between 20 to 40 per cent. Still, the inter-district variation is fairly large
(CV: 32.12). Nearly 25 per cent of children are treated with ORS. There is, however,
considerable inter-district variation in this respect (CV: 43.51).
Social Disparity in Health Status: Tribal Health
The tribal population is the most disadvantaged social group in Orissa. A clear
manifestation of this is the distinctly higher incidence of poverty among the tribal
population as compared to the general population or to even Scheduled Caste
population.
While infant mortality rate and under-five mortality are respectively 10.3 per cent and
19.6 per cent higher for Orissa’s tribal population as compared to the state’s population
as a whole, the child mortality rate is 52.7 per cent higher.
Map 4.2
Per cent of Safe Deliveries
(Institutional deliveries and deliveries at home)
K H A N
A R
D
J H
WE
ST
Sundargarh
BE
N
G
Jharsuguda
Bargarh
Sonepur
A
R
H
Keonjhar
Deogarh
Dhenkanal
IS
G
Boudh
Jajpur
Kendrapara
Cuttack
Nayagarh
Nuapada
Kalahandi
Puri
Ganjam
Nabarangpur
Jagatsinghpur
Khurda
Kandhamal
Rayagada
O
Gajapati
A
Y
B
Koraput
Balasore
Bhadrak
Angul
Balangir
CHHA
TT
Sambalpur
F
B
G
E N
A
Percent of safe deliveries
<20
20-40
40-60
Malkangiri
ANDHR
A
A
PR
DE
L
SH
21
Health Condition
A
L
Mayurbhanj
Immunisation coverage is the poorest in the case
of tribal population compared to other social
groups and the aggregate population: only
26.4 per cent of tribal children are completely
immunised against all vaccine-preventable
diseases and 18.2 per cent did not receive any
vaccine at all, and thus 55.4 per cent of children
are only partially immunised.
Fig. 4.3
Childhood Vaccination
50
49.3
46.5
44.5
43.7
40
30
26.4
20
18.2
8.6
10
0
ST
8.1
SC
9.4
5.3
OBC
Other
Total
Completely immunised
Social group
As per NFHS-2, the percentage of children
having three common childhood diseases—
namely respiratory infection, diarrhoea, and
fever—during a reference period of two weeks
among the tribal population is surprisingly
lower than for the population as a whole as well
as for other social groups such as Scheduled
Caste and other backward population.
Not immunised at all
The nutritional status of tribal children is
apparently not much worse as compared to that
of other social groups and the population as a whole. The incidence of anaemia among
children is, however, much higher among tribal population.
As in the case of tribal children, the nutritional status of tribal women is also not much
worse than that in the case of the general population or that of women belonging to
other disadvantaged social groups such as Scheduled Caste and Other Backward Castes.
However, the incidence of anaemia amongst tribal women is significantly higher than
that for other social groups.
There are two indicators of maternal health—extent of antenatal check-up and delivery
care. As regards the former, we find that among tribal women, 37 per cent did not have
any antenatal check-up. This is much higher than it is for the population as a whole (20.3
per cent) as well as for other social groups. On the other hand, among tribal women, a
much lower percentage had professional antenatal
check-up.
Fig. 4.4
Anaemia among Women (%)
80
74.7
66.3
60
61.3
54.4
40
20
0
ST
SC
OBC
Social group
Other
While institutional delivery is low in the case of
Orissa (22.7 per cent), it is even lower in the case of
tribal women (8.7 per cent). Similarly, professional
assistance during delivery in the case of tribal
women is only 36.1 per cent as against 55.6 per cent
for the population as a whole.
Trend in and Pattern of Health Expenditure
There is a squeeze on budgetary allocation to the
health sector through the second half of the 1990s.
On the other hand, health budget as per cent of
GSDP steadily declined during the first half of the
22
Orissa Human Development Report
1990s. It gained some ground thereafter but the level of the early 1990s has not been
reached.
The primary and secondary tiers each account for around 20 per cent of the budget
allocation while the tertiary level claims 60 per cent. What this means is that primary
health care and first referral services, are underfunded. This results in a shortage of
drugs, equipments and other materials in the primary and secondary level of institutions.
This, in turn, results in overburdening the tertiary level services, as patients seek from
tertiary institutions, treatment which could easily be given at the primary or secondary
level.
Policy Implications
The Government of Orissa has put in place a comprehensive and integrated mediumterm health policy. Under this, several strategies and action points for the development
of the health sector have been spelt out. A major thrust of the policy is to achieve equity in
health care by reducing disparities on four counts: regional; the poor and disadvantaged
social groups (STs and SCs); gender; and vulnerable groups (persons with disabilities
and elderly persons). The avowed approach aims to have a participatory public health
and primary health care orientation.
However, it needs to be pointed out that while time-bound targeted reductions in IMR
and MMR have been spelt out, the specific requirements of these policy goals and their
organisational and financial implications have not been spelt out.
While the thrust of the state’s New Health Policy is, broadly speaking, in the right
direction, a few additional policy recommendations are in order. These are as follows:
(i)
Almost 75 per cent of the incremental budgetary allocation to the health sector should
be devoted to the primary and secondary tiers.
(ii) In remote and tribal districts where minimum health services are not available
because of poor functioning of public health care institutions, an attempt should
be made to involve Panchayati Raj Institutions (PRIs), local NGOs, and Self-help
Groups in managing such institutions.
(iii) There should be a concerted effort to increase
institutional/safe deliveries —at a faster pace.
This should be particularly targeted at the tribal
population.
Fig. 4.6
Distribution of Budget Expenditure: 1995–96
(iv) Malaria is the most critical public health problem
in the state. To deal with this, vector control
programmes need to be intensified.
(v) The child immunisation drive needs to be
intensified, as only 60 per cent of the children
in the age group 12–36 months are completely
immunised.
23
Health Condition
Tertiary level
(59%)
Primary level
(22%)
Secondary
level
(19%)