Health Status and Access to Health Care Services Disparities among Social Groups in India

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3 Health Status and Access to Health Care Services Disparities among Social Groups in India Vijay Kumar Baraik and P M Kulkarni Working Paper Series Indian Institute of Dalit Studies New Delhi

4 Contents 1. Introduction Sources of Data Measurement of Disparity 7 2. Infant and Child Mortality for Social Groups Indicators Infant Mortality Rate Child Mortality Rate Under-5 Mortality Rate Summary How Nourished are the various Social Groups? Basic Issues Nutritional Status among Women Nutritional Status among Children Anaemia Anaemia among Women Anaemia among Children Summary Child Healthcare Introduction Preventive Care Curative Care Summary Maternal Healthcare Introduction Antenatal Care Tetanus Injection and Iron and Folic Acid Supplements Delivery Care Medical Assistance at Birth/Delivery Summary Concluding Observations 45 Select Bibliography 52 Annexure I 54 List of Tables List of Figures

5 Annexure I Table 1 D, Percentage of Children under Three years of Age with Poor Nutritional Status in terms of various measures of Nutrition by Social Groups, India and Large States Table 1 E, Social Gaps in the Nutritional Status of Children in terms of various measures of Nutrition by Social Groups, India and Large States Table 1 H, Vaccination of Children (aged months at the time of the survey) by Social Groups, India and Large States Table 1 I, Social Gaps in Vaccination for Children, India and Large States Table 1 Q, Antenatal Care - Tetanus Injection and Iron Folic Syrup by Social Groups, India and Large States Table 1 R, Social Gaps in Antenatal Care - Tetanus Injection and Iron Folic Syrup (in percentage points) Table 1 S, Percent of Deliveries Conducted in Health Institutions by Social Groups, India and Large States Table 1 T, Social Gaps Institutional Births/Deliveries (in percentage points) List of Tables Table 1 A, Infant and Childhood Mortality Indicators by Social Groups, India and Large States Table 1 B, Social Gaps in Infant and Childhood Mortality Indicators, India and Large States Table 1 C, Nutritional Status of Women by Social Groups, India and States, Table 1 F, Anaemia among Women by Social Groups, India and Large States, NFHS-2 Table 1 G, Anaemia among Children by Social Groups, India and States, NFHS- 2 Table 1 J, Vitamin A Supplementation by Social groups, India and Large States Table 1 K, Treatment for Diarrhoea of Children by Social Groups, India and Large States Table 1 L, Social Gaps in Treatment for Diarrhoea of Children by Social Groups, India and Large States Table 1 M, Percentage Children with ARI Taken to a Health Facility or Provider by Social Groups, India and Large States Table 1 N, Social Gaps in Percentage - Children with ARI Taken to a Health Facility or Provider by Social Groups, India and Large States, NFHS- 2 Table 1 O, Antenatal Check-up by Health Professionals by Social Groups, India and Large States

6 Table 1 P, Table I U, Social Gaps in Antenatal Check-up by Health Professionals by Social Groups, India and Large states Medical Assistance at Birth/Delivery by Social Groups, India and Large States Table 1 V, Social Gaps in Medical Assistance at Birth/Delivery by Social Groups, India and Large States Table 1 W, Social Group Disparities in Indicators of Health Outcomes and Services List of Figures Figure 1 A,Under-5 Mortality Rates by Social Groups, India and Large States, Figure 1 B, Percentage of Children under Three Years of Age with Poor Nutritional Status in terms of various measures of Nutrition by Social Groups, India and Large States, Figure 1 C, Anaemia among Children by Social Groups, India and States, Figure 1 D, Antenatal Check-up by Health Professionals by Social Groups, India and large States, Figure 1 E, Medical Assistance at Delivery by Social Groups, India and Large States,

7 Foreword The Indian Institute of Dalit Studies has initiated this Working Paper Series for the first time. This Working Paper on the Health Status and Access to Health Care Services is the fourth in the series. The purpose of this Series is to disseminate and share the findings of the core research concerns of the Institute for a wider circulation, and to facilitate informed discussions on a variety of focal issues. The Working Paper Series disseminates both, empirical and theoretical findings of the ongoing research on issues pertaining to the forms and nature of social exclusion and discrimination, caste and untouchability-based discrimination, and inclusive policies for the marginalized social groups in Indian society and in other countries etc. It is hoped that the Working Paper Series will be beneficial to researchers, students, academics, and activists alike, and will also benefit policymaking bodies and civil society organizations. This Working Paper Health Status and Access to Health Care Services Disparities among Social Groups in India illustrates the key aspects of health status with specific regards to access to and utilization of healthcare services among the social groups in India. It undertakes a comparative analysis of the various social groups in India and thereby, brings to the fore, startling disparities in terms of access and outcomes to healthcare. In particular, it addresses the asymmetries within social groups with regards to a multiplicity of indicators such as mortality; morbidity; nutritional status; incidence of anemia; access to vaccination and vitamin A supplementation; treatment for diarrhoea and pneumonia; and maternal health care. The Indian Institute of Dalit Studies gratefully acknowledges the support provided by Christian Aid (India) for the publishing of this Series. Sukhadeo Thorat Managing Trustee

8 About the Authors Vijay Kumar Baraik is Scientist, Indian Space Research Organisation, Ranchi, India. His areas of interest are rural development, geographic information systems (GIS), community health and issues related to the marginalized social groups. He can be contacted at P M Kulkarni is a Professor at the Centre of the Study of Regional Development, School of Social Sciences, Jawaharlal Nehru University, New Delhi, India. His areas of interest are demography and reproductive health. He can be contacted at purushottam_kulkarni@hotmail.com or pmkulkarni@mail.jnu.ac.in

9 Health Status and Access to Health Care Services Disparities among Social Groups in India 1. Introduction Vijay Kumar Baraik and P M Kulkarni The Indian society is characterized by a highly entrenched system of social stratification based on the caste system. The caste system with its graded, differential, ascribed, and hereditary based unequal rights locates the erstwhile untouchables at the bottom of the caste pyramid. As a resultant residue, the Dalits* in India have been, not only historically, discriminated and socially excluded, but are simultaneously, denied certain basic rights even in the contemporary times. Needless, to say that with respect to any indicator of human development and relative social positioning, they continue to be located at the periphery of the society. Similarly, a number of social groups who are geographically isolated have been demarcated as the Scheduled Tribes (STs) these social groups have also been deprived of the benefits of socio-economic developments in the country. In order to discourage the covert and overt forms of discrimination, and in recognition to the relative disadvantages suffered by the Scheduled Castes (SCs) and the STs, the Government of India (GoI) has consistently developed procedural, legal, and other Constitutional safeguards. However, despite the promulgation of statutory legislations of protective discrimination; equity and social justice for these groups is far from being achieved. In matters of healthcare, the STs are at a disadvantage due to their physical isolation from the mainstream population around, which principal health facilities and services are located. Moreover, they are scattered and sparsely distributed within their territories, making it difficult for them to access even free services. On the other hand, the SCs have always been residing in * The words Dalits, Scheduled Castes, and erstwhile untouchables have been used interchangeably in this working paper.

10 Indian Institute of Dalit Studies villages settled by the dominant groups of population, and hence, do not suffer from the degree of physical isolation similar to the STs - health institutions are as close to them as to the other sections of the Indian population. Hypothetically speaking, access to public healthcare services for the SCs, therefore, should be as good as or at par with the Scheduled Caste/Scheduled Tribe ( SC/ST) population. But, this is not so, and the SCs face social discrimination on account of traditional restrictions (based on the notions of untouchability and pollution) on access to public facilities, including health services. Clearly, barriers in access to healthcare; physical in the case of the STs, and social in the case of the SCs, could result in poorer health outcomes vis-à-vis other sections of the population in terms of the prevalence of higher morbidity and mortality levels among the deprived communities. Though discrimination on the basis of caste and untouchability have been explicitly prohibited by law in India for quite some time, but social engineering directed at some of the most profound and entrenched social practices and customary norms of caste relations can change only slowly, and therefore, some amount of discrimination may be presumed to persist. The question that then arises is on the levels of deprivation among these communities in relation to the dominant communities, in terms of the health status, access to, and utilization of healthcare services. The scant, but existing studies on the health related issues of the SCs (See, for instance, Desai: 1976 and Lal et al: 1990) suggest no or minuscule reporting of discrimination in public health institutions. Also, another primary study undertaken by Ravindran (1998) infers to the same conclusion. If discrimination in public health facilities is absent or insignificant, what then are the other factors contributing to the marked differences in the health conditions atleast among the SCs and the other communities? Health status is strongly influenced by household incomes and the educational levels prevalent within a community - the SCs and the STs are at a disadvantage in, both these respects (Chakrabarty: 1998, Ravindran: 1998 and Kulkarni: 2002 b). Income, obviously, has implications for nutrition, housing conditions, access to healthcare, and as a corollary to health status. Lack of education has adverse effects on hygiene, and awareness and utilization of healthcare. Therefore, even if it is assumed that there is no discrimination in health services in the contemporary times, the SCs and the STs are likely to suffer from poorer health outcomes compared to the other sections of the population as a result of the legacy of discrimination. Besides, 2

11 Health Status and Access to Health Care Services - Disparities among Social Groups in India the health conditions of the SCs and the STs could also possibly differ since the nature of disadvantage suffered by them is predominantly different. Further, since the location of the SCs may be region specific, while that of the STs may be sparse and geographically isolated; these two social groups may suffer in varying degrees, in so far as, the extent and nature of discrimination is concerned. Therefore, deprivation suffered by these social groups vis-à-vis the other communities are also likely to differ spatially. Also, the mobilization of these communities towards the establishment of an egalitarian social order, and to challenge the immutable and entrenched social status of the dominant castes has not been homogeneous. In all inevitability, the disparities too, may not be uniform throughout the country. An assessment of disparities across states can help in identifying regions, wherein, such inequities are acute. The principal objectives of this working paper, therefore, are to examine the disparities in the health conditions, access to, and utilization of healthcare services among the three social groups in India, i.e., the SCs, the STs, and the SC/STs. Pertinently, the SCs/STs for the purposes of this working paper include the Other Backward Castes (OBCs) and the non-backward castes or the general sections of the Indian population. Incident to the discussion remains the large constitution of the SCs and the ST populations in 2001, the SCs and the STs constituted 16.2 and 8.1 percent of India s population, and in absolute terms they were 167 and 84 millions respectively (See Census of India, Registrar General of India, 2004) and their relative social positioning in terms of access to and utilization of healthcare services. This working paper at the outset presents an overview of the health conditions of the SCs, the STs, and other sections of population, in terms of available indicators of health conditions, health status, and healthcare utilization. Thereupon, it examines the disparities in various aspects of health among the three social groups. These are assessed for India as a whole, and for seeking states, depending upon the availability of indices, so as to bring to the fore regional patterns, if any. Further, this working paper also delves into certain policy issues related to the healthcare of the scheduled populations. The questions of whether disparities are attributable to continuing discrimination or are they the residual products of deprivation faced in the past are not being addressed at this stage; it is proposed to undertake a larger study at a later stage that would involve analyses of household level data from national surveys, and possibly include undertaking some primary studies. The present working paper is primarily a status report that is expected to provide a mapping of disparities, and could also serve as 3

12 Indian Institute of Dalit Studies a basis for an analytical work in the next phase. For an insight into social disparities in healthcare in India, based on the National Family Health Survey (NFHS), see for instance, Ram et al: 1997, Kulkarni: 2002 a, and Thorat and Sadana: Assessment of Health Status The World Health Organization (WHO) defines health as a state of complete physical, mental, and social wellbeing, not merely, the absence of disease and infirmity. However, in assessment of health conditions of large sections of populations, it is essential to develop a set of indicators that are quantifiable. Therefore, one is, often, restricted to a set of few quantifiable aspects such as, mortality rates, morbidity rates, and the nutritional status, broadly, termed as health outcomes, and access to and utilisation of preventive, promotive, and curative services, broadly termed as healthcare. Mortality The level of mortality is the single most commonly used indicator of health outcomes. Though, the Crude Death Rate (CDR) is usually available, but this is not considered to be a reliable measure for mortality comparisons, since it is influenced by the population age distribution. Life expectancy (expectation of life at birth), on the other hand, is the most preferred measure for survival. This can be computed from age-specific death rates that can be obtained if there is a good system of registration of deaths. However, in India, the civil registration system does not have adequate coverage. The Sample Registration System (SRS) has been providing reasonably reliable data on death rates, but these are not tabulated on the basis of social groups. Besides, the data on age-specific death rates, except those relating of early childhood and old ages are very low, and relatively large sampling errors could prevent meaningful comparison of such rates for sub-populations. For the older age groups, the base populations in sample surveys or registrations could be quite small resulting in large sampling errors. For infant and early childhood mortality, however, large sample surveys or registration systems can yield estimates for sub-populations. Besides, some techniques to estimate mortality during early childhood are also available. Hence, indicators of infant and early childhood mortality upto the age of five years are commonly used to examine differentials in the mortality rates. Morbidity Morbidity is usually measured in terms of prevalence (point prevalence, i.e., prevalence at a point in time, or period prevalence, i.e., prevalence during a specified interval) or incidence, i.e., occurrence during a specified period. Utilisation of hospital and clinical records on patients can be used, alongwith 4

13 Health Status and Access to Health Care Services - Disparities among Social Groups in India information on population at risk, but this would be possible, only if, a vast majority of persons having a disease seek treatment and these episodes are recorded. When a large proportion of the population does not obtain healthcare from the registered establishments, the picture from such records could then be biased. The general practice has been to obtain estimates from household surveys in which the prevalence or the incidence of morbidity is ascertained after asking a set of questions for identifying some common diseases to the individual or a member of a household; medical professionals can identify morbidity on the basis of clinical or laboratory diagnosis, but this is rarely done in large surveys due to constraints of resources. Thus, survey estimates are based on morbidity as perceived by the individual or by the head of a household. This introduces a bias since self-perceptions could differ (Murray and Chen: 1994; Sen: 1998). In particular, certain social groups, especially the weaker sections, used to an arduous lifestyle, may not perceive minor illnesses as morbidity, and therefore, may not report them, whereas, the upper classes would. Comparisons of morbidity levels across social classes based on such reports could, therefore, be seriously flawed. Hence, morbidity data has not been used in this working paper, though such estimates are available from some surveys. Nutritional Status A number of indicators are available to measure the nutritional status. These include anthropometric measures such as weights and heights, and proteindeficiency anaemia. For children, height can be compared to standard height for a given age, and weight can be compared to stipulations for a given height, as well as for a given age. In the case of adults, the Body Mass Index (BMI) can be computed to assess energy deficiency or obesity. Blood samples provide Haemoglobin (Hb) level in order to detect protein-deficiency anaemia. Most of these measurements can be undertaken with the help of nursing professionals or trained paramedical workers, and the presence of physicians as such is not necessary, and hence, this is possible in large household surveys. Healthcare Healthcare - preventive, promotive, and curative, plays an important role in determining the health status of an individual. Public health services in India provide immunization services, especially, to children and pregnant women. Besides, certain nutritional supplements are also provided under the child development programmes. Maternal health services, including, care during pregnancy, delivery, and post-partum periods are also provided free by a network of primary health centres, Government maternity homes, and hospitals. Treatment for various illnesses can also be obtained from the 5

14 Indian Institute of Dalit Studies public sector health outlets, the primary health centres, and the Government clinics and hospitals, free or at a nominal cost. Besides, the private sector also provides maternal, as well as, general healthcare, however, at a considerable fee difference. Utilisation of healthcare depends on various factors - availability, awareness, access, and affordability. The economically weaker sections may not be able to afford private sector services and thus, face barriers to entry. It is important to see, therefore, if the utilisation of healthcare services varies by social class, and further, whether the nature of service accessed also varies. For this purpose, child immunisation, maternal care, and treatment seeking behaviours in case of specific illnesses needs to be examined. The working paper for the same focuses on child healthcare, and maternal healthcare. 1.1 Sources of Data As a consequence of the poor coverage of the civil registration system in India and the non-availability of classification by social groups in the SRS, one is compelled to rely on surveys to provide the primary source of data on mortality. Further, as noted earlier, it is necessary to concentrate on infant and child mortality rates. Besides, surveys are also the principal source of data on morbidity, nutritional status, and healthcare. Two recent surveys, the NFHS-1 and the NFHS-2, collected information on a large number of aspects of health conditions, healthcare, and health service utilisation, especially. on women and children (IIPS, 1995; IIPS and ORC Macro, 2000). The NFHS-1, conducted during , covered 25 states, including Delhi, and the NFHS-2 ( ) covered all the 26 states of India. The NFHS-1 sample included 88,562 households and interviewed 89,777 ever-married women of reproductive age; the NFHS-2 sample coverage was about the same size, 91,196 households and 89,199 ever married women. Both the surveys, modelled after the Demographic and Health Surveys (DHS) conducted in many countries used scientific sampling designs - the instruments were tested and developed, and professionals in population and health research monitored data collection and processing. The quality of data obtained from both the surveys is fairly good (Kulkarni: 2004). The surveys obtained detailed fertility histories, and infant and child mortality rates estimated from these were provided by the survey reports. For recent births, questions were asked on ante-natal care, delivery, and post-natal care, as well as, child immunization allowing estimation of the coverage of these services. Morbidity levels for specific diseases were available, especially for children, but were not used here for reasons mentioned earlier. Further, information on treatment sought in the case of specific illnesses was also 6

15 Health Status and Access to Health Care Services - Disparities among Social Groups in India collected. Nutritional status was ascertained from the measurement of weights and heights of the children; this aspect was not fully covered in NFHS-1, but in NFHS-2 the coverage was fairly high. The NFHS-2 also obtained data on protein-deficiency anaemia for women and children and on the BMI for women. The survey reports also provide various indicators on health status for social groups such as the SCs, the STs, and the SC/STs. Some other surveys also provide data on health status. The National Sample Survey Organization (NSSO) also collects data on morbidity and treatment of ailments in some rounds (NSSO: 1998); but these are based on self-reporting. The National Council of Applied Economic Research (NCAER) also collected information on health status in a large survey covering rural India in 1994 (Shariff: 1999). Further, the National Nutrition Monitoring Bureau (NNMB) collects data on the nutritional status for some states (NNMB: 2001). Indirect estimates of child mortality rates based on questions asked in the Censuses to women on the numbers of children ever born and surviving were also available. However, the present working paper is primarily, based on the two surveys, the NFHS-1 and the NFHS Measurement of Disparity For assessing disparities, the levels for the social groups, i.e., the SCs or the STs were compared to the levels for the SC/STs who were treated as a reference group. The NFHS-2 provides the estimates for the OBCs and the SC/STs separately, but the NFHS-1 provides estimations for both these groups together. Therefore, the NFHS-2 estimates for the OBCs and the others are pooled, using appropriate sample sizes, to obtain estimates for the SC/STs. The disparity can be measured as simple gap, i.e., a gap between a social group and the reference group, or as a ratio. Sopher (1980) had suggested an alternative, referred to as Sopher s Index, which is suited to indicators that are in the form of proportions (or percentages), and the possible range of measurement in the Sopher s Index is between 0 and 100. This is computed as log of the odd ratios. Also, Kundu and Rao (1985) had proposed a modification to the Sopher s Index. For the sake of simplicity, this working paper utilizes only the gap measure of disparity, i.e., the gap between the levels of the special group (the SCs or the STs) and the reference group (the SC/STs). 7

16 Indian Institute of Dalit Studies The levels, as well as, the gaps between the social groups are presented in a series of tables. The data utilized are from sample surveys, and it would be appropriate to test if the differences (or the gaps) are statistically significant. However, in the present working paper, this is not the issue of concern - the scheduled groups do face difficulties in accessing healthcare services and subsequently, have poorer health outcomes, therefore, the degree of differences are not in question more than the differences themselves. The main concern is whether the gaps are wide, i.e., whether the scheduled groups are severely deprived. Therefore, the working paper aligns with the presentation of gaps, but without statistical tests. Furthermore, in the case of very small samples (implying high sampling errors); small gaps would not amount to significant differences. This is evident with the data from the NFHS, which does not provide rates or proportions. For instance, in quite a few states that have relatively low ST populations, the sample sizes (of households, women, and children) for the STs are small, and hence, indicators for these groups are not provided. No gaps can then be computed in these cases, and thus, in case of large sampling errors, the comparisons have not been made. Though, the data from the two surveys are presented, no attempt is being made to examine the trends. The gap between the two surveys was too short, only six years, to expect any major changes in the levels. Further, the estimates were from the sample surveys, and in the presence of sampling errors, it would be difficult to detect small changes. The data from the two surveys were used, primarily to see if there were large disparities, and whether, both the surveys indicated the same. The social group comparisons have been made only for 17 large states of India, with populations exceeding five millions. For small states, the NFHS sample sizes were too small to permit computation of separate estimates for the social groups. Besides, in most of the states in the northeast, the population primarily belongs to the STs, with very small other populations in the sample size, which made the comparisons completely irrelevant. Delhi too, has also been excluded since it is special case, being nearly a city-state. The data presented is from surveys conducted in the 1990s, prior to the bifurcation of some large states, and hence, are for the pre-division states. Thus, Uttar Pradesh includes Uttaranchal, Bihar includes Jharkhand, and Madhya Pradesh includes Chhattisgarh. 8

17 Health Status and Access to Health Care Services - Disparities among Social Groups in India It is also important to delineate some other important issues that this working paper does not address. First, as the datasets are, primarily on women of childbearing ages and children, the paper does not attempt an analysis of disparities in adult male health and health of elderly persons. The elderly constitute the vulnerable sections of a society, especially, those from the weaker sections who, often, do not possess property, nor have institutional support may consequently, may have poorer health outcomes. Second, for reasons discussed earlier, morbidity has not been examined. Also, access to healthcare facilities is an important issue that has not been directly dealt with except through utilisation of healthcare. At a later stage, when further analysis is contemplated, it is proposed to address some of the issues more systematically; whether the gaps are significantly large, and in that case, whether there is any accumulated effect of a social group membership or whether the effect is attributable to social and economic factors such as income and parental education etc. 2. Infant and Child Mortality for Social Groups 2.1 Indicators Mortality has been an important, universally accepted, and widely used indicator of health status of any population. Infant and Child Mortality Rates reflect a country s level of socio-economic development and quality of life, and are used for monitoring and evaluating population and health programmes and policies. 1 Infant mortality in India was quite high until the middle of the twentieth century, about a fifth of the newborns died before completing the first year of life. Though, infant mortality has declined substantially over the period of time, the level still remains much higher than that in the developed world. According to the SRS estimates, the Infant Mortality Rate in India was 66 in 2001 (India, Registrar General, 2003), in a stark contrast to a level of less than 10 in many of the developed countries. Similarly, the level of early childhood mortality was also high. There were notable differences within India; with Kerala and some small states having low mortality rates, while the others in the central region indicating higher rates. Clearly, child survival programmes in India needs to be intensified to achieve further reductions in infant and child mortality rates. Further, the analysis also found that the rural mortality rates were considerably higher than the urban mortality rates. Large variations were also, found to exist by social class and standards of living. The NFHS gives estimates of indicators of infant and child mortality by social class. The key indicators are: 9

18 Indian Institute of Dalit Studies Infant Mortality Rate (IMR) This is the proportion of newborns dying before the completion of the first year of age; in life table terms this is denoted as 1q 0 x The IMR is conventionally computed as the number of infant deaths per thousand live births in one year; but, when data on cohorts are available, as in the case of the NFHS, it can be obtained as the proportion noted above. Child Mortality Rate (CMR) This is the proportion of those alive at the age of 01, but die before completing the age of 05; in life table terms this is denoted as 4q 1 x Under-Five Mortality Rate (U-5MR) This is the proportion of the newborns that die before completing five years of age; in life table notation this can be expressed as 5q 0 x The U-5MR incorporates both, infant mortality and child mortality rates. This can be expressed in terms of IMR and CMR as: 5q 0 = 1 - (1-1q 0 ).(1-4 q 1 ) The IMR and the CMR are generally highly correlated since, broadly, the same sets of factors, socio-economic, environmental, and health service related, influence both. However, endogenous factors play a greater role in influencing mortality during infancy, especially, early infancy (called neo-natal mortality), whereas, exogenous factors are more crucial during late infancy and early childhood. Therefore, though the pattern of differentials in these two indicators is likely to be similar, they need not be the same, and hence, estimates of all the three indicators, i.e., the IMR, the CMR, and the U-5MR by social groups in India, and within the large states, as given by the two NFHS surveys, are presented in this working paper. The discussion is focused on disparities among the social groups and not on levels of mortality per se. Therefore, for the sake of analysis, the working paper first, attempts to ascertain the all India nature of disparities, and thereupon, it delves into regional patterns, if any. 2.2 Infant Mortality Rate The IMR in general is very high in India. According to the NFHS-1, the IMR for India as a whole was 86 per thousand (this refers to the ten-year period prior to the survey; since the survey was conducted during , this would imply ). The level was much higher for the SCs (107), but 10

19 Health Status and Access to Health Care Services - Disparities among Social Groups in India Table 1 A, Infant and Childhood Mortality Indicators by Social Groups, India and Large States States/India IMR CMR U-5MR SC ST SC/ST All SC ST SC/ST All SC ST SC/ST All India Andhra Pradesh Assam Bihar Gujarat Haryana Himachal Pradesh Jammu & Kashmir Karnataka Kerala Madhya Pradesh Maharashtra Orissa Punjab Rajasthan Tamil Nadu Uttar Pradesh West Bengal India Andhra Pradesh Assam Bihar Gujarat Haryana Himachal Pradesh Jammu & Kashmir Karnataka Kerala Madhya Pradesh Maharashtra Orissa Punjab * Rajasthan Tamil Nadu Uttar Pradesh West Bengal Note: Source: - indicates that no separate estimate for the social category is presented in the NFHS Report since the number of children covered was very small. NFHS-1, IIPS, 1995; NFHS-2, IIPS and ORC Macro, 2000; and State NFHS-1 and NFHS-2 Reports. 11

20 Indian Institute of Dalit Studies close to the national average for the STs. For the SC/STs, the rate was slightly lower, 82 (See Table 1 A). The all India estimates from the NFHS-2 (corresponding to the period ) were lower at 73; recent estimates by the SRS show that in 2001, the IMR was 66 for India (India Registrar General, 2003)). The SCs (83) and the STs (84) experienced higher than average mortality rates in NFHS-2 too. Both the surveys indicate substantially higher levels of mortality for the SCs than the SC/STs, though, the gap in the NFHS-2 was lower than in the NFHS-1. For the STs, the gap was wider in the NFHS-2 than in the NFHS-1. Overall, both the SCs and the STs were disadvantaged in terms of infant survival compared to the SC/STs; with the degree of acuteness varying. As is evident from table 1 A, there were large inter-state variations. The IMR in general was found to be high in Uttar Pradesh, Orissa, Madhya Pradesh, and Bihar; Rajasthan indicating high IMR levels in NFHS-2, and Assam in NFHS-1. The pattern was almost similar for all social groups with very little variation. For the SCs, Orissa, Uttar Pradesh, Madhya Pradesh, Bihar, Rajasthan, and Andhra Pradesh indicated relatively high IMR levels in both the surveys, and West Bengal and Karnataka in NFHS-1 in that order. Similarly, Orissa, Madhya Pradesh, West Bengal, Andhra Pradesh, and Bihar had high IMR levels for the STs (the highest level was found in Uttar Pradesh (168) in NFHS-1, it is also incident to the analysis that the ST population in Uttar Pradesh is quite small); a few states showed high values in only one of the two surveys. At the other end of the continuum, the IMRs were relatively low for all social groups in Punjab, Jammu and Kashmir, Maharashtra, Himachal Pradesh, and Tamil Nadu (breakdown by social groups is not available for Kerala, and other smaller states as the sample size for some social groups in such states was small). The overall pattern that emerged is of higher IMRs for SCs compared to the SC/STs. The levels of disparities too, were not identical. In many states, the gaps among social groups were large; the IMRs for the SCs being much higher than those for the SC/STs in Andhra Pradesh, Bihar, Madhya Pradesh, and Uttar Pradesh (See Table 1 B). Karnataka, Maharashtra, Orissa, Punjab, and Tamil Nadu also indicated large disparities in one of the surveys. On the contrary, in Gujarat, Haryana, Himachal Pradesh, and Jammu and Kashmir, the IMRs for SCs were not notably higher than those for the SC/STs. 12

21 Health Status and Access to Health Care Services - Disparities among Social Groups in India Table 1 B, Social Gaps in Infant and Childhood Mortality Indicators, India and Large States NFHS-1 IMR CMR U5-MR States/India SC/ST- SC SC/ST-ST SC-ST SC/ST-SC SC/ST-ST SC-ST SC/ST-SC SC/ST-ST SC-ST India Andhra Pradesh Assam Bihar Gujarat Haryana Himachal Pradesh Jammu & Kashmir Karnataka Kerala Madhya Pradesh Maharashtra Orissa Punjab Rajasthan Tamil Nadu Uttar Pradesh West Bengal NFHS-2 India Andhra Pradesh Assam Bihar Gujarat Haryana Himachal Pradesh Jammu & Kashmir Karnataka Kerala Madhya Pradesh Maharashtra Orissa Punjab Rajasthan Tamil Nadu Uttar Pradesh West Bengal Note: - indicates that the comparison is not possible since estimates for atleast one group were not available. Source: Computed from Table 1 A. As noted earlier, the STs did not have much higher IMRs than the SC/ STs; this was evidently the case in most states (in a few states, the ST population is quite small and hence, the IMRs for the STs were not available). Though, in Orissa and Madhya Pradesh, the STs have very high IMRs (above 100) but, this was markedly the case for the SC/STs too. It was only 13

22 Indian Institute of Dalit Studies West Bengal (other than Uttar Pradesh) that exhibited a much higher IMR for the STs. Besides, some states like Andhra Pradesh, Gujarat, Karnataka, and Maharashtra also indicated higher than average IMRs for the STs, but in only one of the two surveys. In many states, not only, were the SCs disadvantaged in relation to the SC/STs, but were so vis-à-vis the STs too. Clearly, the two scheduled groups are dissimilar, atleast in terms of the IMRs. 2.3 Child Mortality Rate (CMR) The NFHS-1 estimate of the CMR was 36 per thousand in India; the rate was much higher for both, the STs (49) and the SCs (47) than SC/STs (32).The NFHS-2 estimate was lower (31), but the SCs and the STs continued to suffer from high CMRs (40 and 46 respectively) than the SC/STs (25). Clearly, both the surveys indicate wide gaps between the two scheduled groups and the SC/STs; with the gap for the SCs widening over a period of time. Given the fact that these are sample values, it would be more appropriate to say that the gap still persists. In the CMR also, the spatial pattern was more or less similar to that noted for the IMRs. Relatively high levels of CMRs were found in Madhya Pradesh, Rajasthan, Bihar, and Uttar Pradesh in both the surveys, and in the NFHS-1 for Assam. At the other end, Kerala and some small states had very low CMRs. Rather surprisingly, in Orissa, though, the IMRs were quite high, but the CMRs were below the national average. A very similar spatial pattern was found among the SCs. Uttar Pradesh had the highest level of CMR in NFHS-1, and Madhya Pradesh in NFHS-2. Similarly, the STs too, had very high CMRs in Madhya Pradesh. Generally, the CMRs for the SCs and the STs were higher than the national average in all the states with only a few exceptions; however, the degree of disparity varied. For the SCs, the level was well above that for the SC/ STs in Gujarat and Uttar Pradesh, and also in Haryana, Maharashtra, Karnataka, Orissa, and Tamil Nadu in one of the two surveys. The CMRs for the STs were much higher than the SC/STs in Madhya Pradesh, Orissa, and Rajasthan in both the surveys. While in the case of the IMRs, the SCs seemed to be at a greater disadvantage, the differences in the CMRs between the two social groups were small. However, the pattern of disparity among the two scheduled groups was not consistent over the two surveys. Overall, one can say that the two scheduled groups are at a disadvantage, both in the levels of the IMRs and the CMRs vis-à-vis the SC/STs. 14

23 Health Status and Access to Health Care Services - Disparities among Social Groups in India 2.4 Under-5 Mortality Rate (U-5MR) The U-5MR is structurally composed of the IMR and the CMR as noted at the beginning. Its levels were just over 100 per thousand births in India (with the NFHS-1 estimate being 119 and the NFHS-2 estimate being 102), implying that one in every ten newborns does not survive beyond the fifth year of birth. The level was well above the national average in Uttar Pradesh, Madhya Pradesh, Orissa, and Bihar (and also in Assam and Rajasthan in one of the two surveys). The SCs and the STs also experienced extremely high U-5MRs in these states. Besides, both the SCs and the STs suffered from higher than average U-5MRs in most of the states. The SCs were particularly, disadvantaged in Andhra Pradesh, Bihar, Gujarat, Karnataka, Madhya Pradesh, Rajasthan, and Uttar Pradesh (See Figure 1 A). The STs in Andhra Pradesh, Karnataka, Madhya Pradesh, Maharashtra, Orissa, Rajasthan, Uttar Pradesh, and West Bengal also faced relatively high risks of U-5MRs. Some differences in the nature of disparities, though, were evident among the two surveys. Figure 1 A, Under-5 Mortality Rates by Social Groups, India and Large States, Others SC ST Percent Summary India A.P. Assam Bihar Gujarat Haryana H.P. J&K Karnataka State Kerala M. P. Maharashtra Orissa Punjab Rajasthan Tamil Nadu U. P. W. B. It is a well known fact that the children from the scheduled populations face higher risks of mortality compared to the SC/STs. The examination of the NFHS data indicates that this is the case for most of the states. Only a few states, notably Assam, Haryana, Himachal Pradesh, and Jammu and Kashmir indicated low disparities among the social groups in consideration. 15

24 Indian Institute of Dalit Studies The nature and degree of disparity varied for the two social groups, i.e., the SCs and the STs. The SCs were more vulnerable than the STs in Bihar and Gujarat. On the other hand, the STs were at a greater risk than the SCs in Madhya Pradesh, Rajasthan, and West Bengal. A low level of morality in a given region does not necessarily mean that the same will be reflected among the scheduled populations. In Maharashtra and Tamil Nadu, though the overall level of U-5MR were not high (relative to the national average), the SCs had unusually high mortality rates as estimated by the NFHS-1. This was also evident in Andhra Pradesh, Karnataka, Gujarat, and Punjab in the NFHS-2 (it was not possible to examine the disparities in Kerala, which had very low mortality rates, since the sample sizes for the scheduled groups were too small to permit estimation of infant and childhood mortality rates). The existence of large disparities in states with relatively low levels of mortality is a matter of great concern; clearly, the weaker sections have been deprived of recent advances and improvements in child survival. 3. How Nourished are the various Social Groups? 3.1 Basic Issues Nutrition is a prerequisite to good health and wellbeing of any population and for children particularly, it plays an important role in their physical and cognitive development. Chronic illnesses are, often, associated with poor nutrition, especially, among children. Moreover, the mother s nutritional status affects her own health, as well as, that of her children. In many communities, food intakes are inadequate to provide the requisite quantities of calories, proteins, and other nutrients; the deficiency is acute especially, among the poor. Thus, nutritional intervention is a must for the development of human resources to their highest potential. Several national and international programmes are ongoing in India at various levels, directly addressing the nutritional needs of the children, and that of the expectant and lactating mothers; these include the Integrated Child Development Scheme (ICDS), Mid-day Meals Scheme (MMS) for school going children enrolled in primary classes, and provision of micro-nutrients to pregnant and lactating women etc. Nutritional status can be measured by both, anthropometric measures and clinical tests. For adults, the BMI, which is the ratio of weight (in kilograms) to the square of height (in square meters), is a commonly used measure. The grade of nutrition is determined by the value of the ratio, which indicates under-nutrition if the value is below 18.5; normal status between 18.5 to 25; 16

25 Health Status and Access to Health Care Services - Disparities among Social Groups in India and overweight status above 25. BMI less than 18.5 is known as chronic energy deficiency. In the NFHS-2, the BMI was computed for women in childbearing ages. For children, instead of the BMI, weights and heights are compared to the specified standards. International standards have been established for each sex for weight at specified age (in months); for height at specified age; and for weight at specified height. An individual child s nutritional status is ascertained on the basis of the z score on the international reference for the child s age and sex. Low weight for an age suggests under-nutrition resulting from the lack of food or continuous persistence of diarrhoea or other diseases in the period just before measurement. Children with weights more than two standard deviations below the reference median for that age (Weight < Reference Median 2 Standard Deviations for the age) are considered to be undernourished and those with weights more than three standard deviations below the median as severely undernourished. Low height relative to age, called stunting, indicates chronic under-nutrition resulting from long deprivation in nutrition or long persistence of some disease causing growth retardation. Children with heights more than two standard deviations below the reference median for that age are classified as stunted and those with heights more than three standard deviations below the median as severely stunted. Low weight at a given height, called wasting, indicates acute under-nutrition. Children with weights more than two standard deviations below the reference median for that height are categorised as wasted and those with heights more than three standard deviations below the median as severely wasted. In the NFHS-2, weights and heights of all the children under three years of age of the sampled women were measured by specially trained investigators and the nutritional status was thus, ascertained using international reference curves. One of the major health problems in India is protein-deficiency anaemia; a consequence of poor dietary intakes. Anaemia can be assessed by a simple laboratory test on a blood sample. In the NFHS-2, special kits were provided to take blood samples and measure the levels of haemoglobin. Trained nurses accompanied the survey teams for this purpose. Ever married women of age and children of age 6-35 months were tested for this purpose. Those with haemoglobin levels below 12 grams/decilitre were considered as anaemic; three degrees of anaemia were specified mild ( ); moderate: (7-9.9); and severe: (below 7) - for pregnant women the range was classified as mild anaemia. The working paper now attempts to discuss the levels and inter-state and social group differentials in various indicators of nutrition. 17

26 Indian Institute of Dalit Studies 3.2 Nutritional Status among Women The nutritional status among women as measured by the BMI is directly related to the dietary intake. As expected, Kerala, well known for social development, and Punjab, the major food growing state, have significantly low levels of energy deficiency; with a less than a fifth of women in these states being undernourished (See Table 1 C). The states with a higher level of nutrition deficiency included some of the relatively developed states such as Maharashtra, Karnataka, and West Bengal alongwith Orissa, Bihar, Madhya Pradesh, Andhra Pradesh and Gujarat. Clearly, the correspondence between economic development and nutritional status is not quite strong. States/India Table 1 C, Nutritional Status of Women by Social Groups, India and Large States, Percentage of married women of ages with BMI less than 18.5 SC ST SC/ST All Social Gaps (In percentage points) SC/ST-SC SC/ST-ST SC-ST India Andhra Pradesh Assam Bihar Gujarat Haryana Himachal Pradesh Jammu & Kashmir Karnataka Kerala Madhya Pradesh Maharashtra Orissa Punjab Rajasthan Tamil Nadu Uttar Pradesh West Bengal Note: - indicates that no separate estimate for the social category is presented in the NFHS Report since the number of women covered was very small and comparison was not possible since estimates for atleast one group were not available. BMI: Body Mass Index = Weight (in kilograms)/square [Height (in meters)]. Source: NFHS-2, IIPS and ORC Macro, 2000; and State NFHS-2 Reports. 18

27 Health Status and Access to Health Care Services - Disparities among Social Groups in India The same pattern was evident among women from the SC/STs. However, the pattern indicated variations among inter-social groups. Overall, the scheduled groups had high levels of under-nutrition compared to the SC/STs. This was seen in most of the states with some amount of irregularity in ranking or relative positioning of the states. The major inconsistencies, however, were observed in Assam and Jammu and Kashmir, where the degree of under-nutrition did not seem to vary across social groups. In fact, in Assam, the scheduled groups seemed to be less disadvantaged compared to the SC/STs. The gap between the SCs and the SC/STs was large, over 10 percentage points, in Gujarat, Punjab, Haryana, Tamil Nadu, and Orissa, and about 10 percentage points in some others. However, Maharashtra and Jammu and Kashmir indicated negligible gaps. In these two states, the SCs fared, as well as, or as poorly as the SC/STs. The inter-social group comparison among the STs- SC/STs was not possible in some states such as Punjab, Haryana, Himachal Pradesh, and Uttar Pradesh, as these had very low proportions of the ST populations. Among the rest, the position of the STs was generally quite poor compared to the SC/STs. The disparity was also quite prominent in Tamil Nadu, Gujarat, West Bengal, and Maharashtra. Overall, though, both the SCs and the STs were more undernourished than the SC/STs; the deprivation was greater among the STs. This was markedly so in Maharashtra (in which, the SCs were not worse off than the SC/ STs, but the STs were), Tamil Nadu, and West Bengal (in which, both the SCs and the STs were disadvantaged but the latter more so). Thus, generally, a large proportion of women are undernourished in all the major social groups; the SCs more than the SC/STs, and the STs even more so. Yet, across states, the relative degree of deprivation varied; Assam and Jammu and Kashmir indicated a relatively less degree of social disparity, while some indicated a greater degree of deprivation among the STs than the SCs. It is also a matter of concern that over half of the SC women in Orissa, and over half of the ST women in West Bengal, Orissa, Maharashtra, Tamil Nadu, and Gujarat were undernourished. 3.3 Nutritional Status among Children Under-nutrition is a major factor responsible for the prevalence of high morbidity and mortality levels among the Indian children. The anthropometric measurements in the two NFHS surveys indicate that nearly half of the children had weights and heights, too low for their age compared to the international standards, and were accordingly classified as undernourished and stunted 19

28 Indian Institute of Dalit Studies (See Table 1 D in Annexure I). Also, the analysis evidently brought out variations across the states; in terms of weight, at least one-fourths of the children were undernourished in all the large states. The lowest level of under-nutrition was seen in Kerala, which also indicated the lowest levels of mortality in India. At the other end of the spectrum was Bihar, closely followed by Madhya Pradesh. Interestingly, in a number of states, the under-nourishment levels were close to 50 percent and in Orissa, Rajasthan, Uttar Pradesh, and Maharashtra more than half of the children were undernourished. At the national level, the degree of under-nutrition was higher among the SCs and the STs as compared to the SC/STs. Overall the gap was not very wide; about five-ten percentage points (the NFHS-2 indicated wider gaps than the NFHS-1), but in many states, the condition of the SCs and the STs was much worse than the SC/STs. In particular, in Gujarat, Haryana, Himachal Pradesh, Jammu and Kashmir, Orissa, Punjab, Karnataka, Kerala, Uttar Pradesh, and West Bengal, a gap of over ten percentage points was seen among the SCs and the SC/STs in at least one of the surveys (See Table 1 E in Annexure I). The STs also, did not fare well, especially in Gujarat, Himachal Pradesh, Karnataka, Kerala, Andhra Pradesh, Madhya Pradesh, and Maharashtra; Assam was an exceptional case that indicated lower undernutrition levels among the STs compared to the SC/STs (See Figure 1 B). Though, the status of the STs was very low compared to the SC/STs, the National Nutrition Monitoring Bureau (NNMB), 2001 found some improvements in the nutritional status of the ST population over the years. Figure 1 B, Percentage of Children under Three Years of Age with Poor Nutritional Status in terms of various measures of Nutrition by Social Groups, India and Large States, Others SC ST Mortality India Andhra Pradesh Assam Bihar Gujarat Haryana H. P. J. & K. Karnataka Kerala States M.P. Maharashtra Orissa Punjab Rajasthan Tamil Nadu U. P. W. B. 20

29 Health Status and Access to Health Care Services - Disparities among Social Groups in India A similar picture was evident for the indicator of stunting; nearly a half the children were stunted, i.e., too short for their age (See Table 1 D in Annexure I). Again, Kerala had the lowest level of stunting followed by Tamil Nadu. Also, Assam and the north-central states of Uttar Pradesh, Bihar, Madhya Pradesh, and Haryana had a high prevalence of stunting. Stunting was more common among the SCs and the STs than the SC/STs, by about 10 percentage points in the NFHS-2; the NFHS-1, though, indicated a narrower gap, but with similar trends. The gap between the SC and the SC/ST children was wide in a few states like Kerala, Punjab, Jammu and Kashmir, Orissa and Uttar Pradesh; Gujarat and Haryana also indicated some gaps, but there was no regional pattern as such (See Table 1 E in Annexure I). Interestingly, Assam was again an exception, wherein, the SC and the ST children were slightly better off than the SC/STs, but the gap was not considerable. Among the Indian children, wasting is less common (16-18 percent), than under-nourishment and stunting (See Table 1 D in Annexure I). Thus, the Indian children are short and also underweight for their age, but not much underweight for their height. The social gaps in wasting were also not large; slightly higher percentages among the STs were wasted than the SC/STs and the SCs. In most of the states, the social gaps too, were narrow. 3.4 Anaemia Anaemia is a neglected and most prevalent deficiency among the Indian children and women. Iron deficiency is recognized as one of the most potent forms of malnutrition in the world. Anaemia has detrimental effects on the health of women and children leading to both, maternal and prenatal mortality. Anaemia also results in an increased risk of premature delivery and low birth weight. Anaemia among young children is a matter of serious concern because it can result in impaired cognitive performance, behavioural and motor development, coordination, language deve-lopment, as well as, increased morbidity from infectious diseases (IIPS and ORC Macro, 2000, p. 271). Women and children are supposed to be the most vulnerable groups. The NFHS-2 has made data on anaemia available. As the test for anaemia requires drawing blood (from a finger prick), consent of the woman (parents/ guardians in case of children) is necessary. The NFHS-2 was quite successful in obtaining this and thus, getting test results for a large proportion of women and children was facilitated. As a result, it was possible to examine levels, as well as, differentials. 21

30 Indian Institute of Dalit Studies 3.5 Anaemia among Women In India, 52 percent of women in the reproductive ages are anaemic; 35 percent mildly anaemic; and 17 percent moderately or severely anaemic (below 10.0 grams/decilitre). It is the moderate or severe degree of anaemia that causes concern, and the prevalence of these is not very high. But the national average marks large variations across states and social groups. Among the large states, Assam had the highest prevalence (27 percent) of moderate or severe form of anaemia, and conversely, Kerala the lowest (3 percent), distantly followed by Himachal Pradesh (9 percent). Most other states have anaemia levels close to the national average, within five percentage points (See Table 1 F). States/India Table 1 F, Anaemia among Women by Social Groups, India and Large States, NFHS-2 Percentage of married women of ages with moderate or severe anaemia Social Gaps (in percentage points) SC ST SC/STs All SC/ST -SC SC/ST-ST SC-ST India Andhra Pradesh Assam Bihar Gujarat Haryana Himachal Pradesh Jammu and Kashmir Karnataka Kerala Madhya Pradesh Maharashtra Orissa Punjab Rajasthan Tamil Nadu Uttar Pradesh West Bengal Note: - indicates that no separate estimate for the social category is presented in the NFHS Report since the number of children covered was very small and comparison was not possible since estimates for atleast one group were not available. Source: NFHS-2, IIPS and ORC Macro, 2000; and NFHS-2 State Reports. The SCs and the STs also indicated higher levels of moderate or severe anaemia, but the gap between the SCs (18.8 percent) and the SC/STs (15.4 percent) was quite narrow. However, in a few states, Punjab, Karnataka, West Bengal, Orissa, and Bihar, a large gap, over five percentage 22

31 Health Status and Access to Health Care Services - Disparities among Social Groups in India points, showing poorer conditions for the SCs compared to the SC/STs was evident. The pattern among the STs, however, was not similar. First, even at the all India level, the STs seemed to have much greater degree of anaemia (23.7 percent) than the national average. Besides, in quite a few states, notably Bihar, West Bengal, and Orissa, the levels among the STs were higher by over 10 percentage points than the SC/STs. Also, in Madhya Pradesh and Gujarat wide gaps were noticed. The STs in the great central Indian tribal belt running from Gujarat in the west to West Bengal in the east seemed to suffer from anaemia to a high degree. 3.6 Anaemia among Children It is indeed sad that in most of the major states of India, a majority of children suffer from some form of anaemia. At the all India level, the percentage of children (of age months) suffering from moderate and severe forms of anaemia was quite high (51.3 percent), i.e., a half of the children had moderate or severe forms of anaemia (See Table 1 G). Kerala, well known for its high levels of social development, indicated the lowest levels of anaemia prevalence (19 percent). Rather unexpectedly, Punjab and Haryana, agriculturally prosperous states, had high levels of anaemia alongside Rajasthan. Figure 1 C, Anaemia among Children by Social Groups, India and Large States, Percent India A. P. Others SC ST Bihar Gujarat Haryana H. P. J. & K. Karnataka Kerala State M. P. Maharashtra Orissa Punjab Rajasthan Tamil Nadu U.P. W. B. The conditions of the SC and the ST children were worse, with 7-8 percentage point higher anaemia prevalence, than children from the SC/STs. In a few states, Andhra Pradesh, Haryana, Jammu and Kashmir, Orissa, and West 23

32 Indian Institute of Dalit Studies Bengal, the deprivation among the SCs was relatively higher. On the other hand, Gujarat, Kerala, Madhya Pradesh, and Himachal Pradesh indicated near equity. In West Bengal, Bihar, Madhya Pradesh, and Orissa, the STs suffered substantially more than the SC/STs ( See Figure 1 C). This inference was similar to what was observed in case of anaemia for women and elucidates deprivation among the tribal population residing in the central tribal belt as a whole. Table 1 G, Anaemia among Children by Social Groups, India and Large States, NFHS-2 States/India Percentage of children of age months with moderate or severe anaemia Social Gaps SC ST All SC-ST SC/ST SC/ST-SC SC/ST-ST India Andhra Pradesh Assam* Bihar Gujarat Haryana Himachal Pradesh Jammu and Kashmir Karnataka Kerala Madhya Pradesh Maharashtra Orissa Punjab Rajasthan Tamil Nadu Uttar Pradesh West Bengal Note: - indicates that no separate estimate for the social category is presented in the NFHS Report since the number of children covered was very small and comparison was not possible since estimates for atleast one group were not available. * NFHS Report does not give data on severe anaemia for Assam. Source: NFHS-2, IIPS and ORC Macro, 2000; and NFHS-2 State Reports. 3.7 Summary Various indicators clearly show that the nutritional status of the women and the children in India is quite poor. Over one-thirds of the women suffered from chronic energy deficiencies evident from the BMI, anthropometric measures indicated that nearly a half the young children were undernourished or stunted, and over a half the children were categorised as being moderately or severely anaemic; the situation was not so bad for children in the case of 24

33 Health Status and Access to Health Care Services - Disparities among Social Groups in India weight for height (wasting), and for women in case of anaemia, yet, about one-sixths were moderately anaemic. The nutritional status is naturally incumbent upon food availability and accessibility. Regions with high food production are expected to have good nutritional status as are regions with high income levels, provided they have access to markets. The overall picture one gets from the discussion in the preceding sections is that the interlinkage between economic development and nutritional status is not strong among the states in India. Even prosperous state like Punjab did not fare well in most indicators, except the BMI; Maharashtra too, fared does quite poorly in most. On the other hand, Kerala indicated better nutritional status for almost all indicators utilized than other large states of India. Of course, incomes and agricultural production need not be the prime determinants of nutrition. An analysis of state-level data by Radhakrishna and Ravi (2004) that utilized poverty estimates based on the NSSO and malnutrition as estimated by the NFHS-2 indicated that poverty has significant effects on malnutrition, but also added that a good deal of variation remains unexplained. Good public food distribution systems or other food security measures can enhance access to food even in less developed areas. Further analysis is needed to examine causes of regional variations in the nutritional status among the various states of India. Groups with poor incomes may suffer on account of low purchasing power and it is no surprise that the SCs and the STs, with low incomes and other endowments, are more deprived compared to the SC/STs. As it is, energy deficiency and malnutrition as assessed by anthropometric measures in India are high, and the conditions are worse for the scheduled groups. Assam being an exception; there was little relative deprivation among these groups for the state; Maharashtra, Andhra Pradesh, and Bihar also did not indicate much gaps among the SCs and the SC/STs. But generally, the poor nutritional conditions in India combined with relatively high deprivation among the SCs and the STs imply that the health statuses of these social groups are miserable. A half of the women from the SC community in Orissa and the ST community from West Bengal, Orissa, Maharashtra, Tamil Nadu, and Gujarat were found to be undernourished; a situation that clearly calls for special attention to the socially weaker sections in these states. Both the NFHS surveys show that nearly a half of the children had weights and heights far too low for their ages. Kerala at the lower end of the continuum for under-nourishment and stunting, and Bihar, Madhya Pradesh, Orissa, Rajasthan, Uttar Pradesh, and Maharashtra at the higher end provide a wide 25

34 Indian Institute of Dalit Studies spectrum. The disparities between the SC/STs and the SCs children in the nutritional status revealed a high degree of deprivation among the children in many states; even in Kerala with the highest level of social development, the SC children were remarkably deprived. The same was true for the STs in Gujarat, Himachal Pradesh, Karnataka, Kerala, Andhra Pradesh, Madhya Pradesh, and Maharashtra. Assam was again an exceptional case where the SC and the ST children were slightly better off than their SC/STs counterparts, but the gaps were not large. Anaemia among women was relatively less common and naturally, hardly any social gaps were visible except for a high degree of deprivation among the ST women in West Bengal and Orissa. But, nearly a half of the children suffered from moderate and severe forms of anaemia. Kerala indicated the lowest level of anaemia prevalence, and unexpectedly, Punjab and Haryana (agriculturally prosperous states) had high levels of anaemia alongwith Rajasthan. The conditions of the SC and the ST children were worse in many states. In states along the central tribal belt, the conditions of the STs were very poor compared to the SC/STs. The various indicators of nutritional deprivation do not behave in an identical fashion across the states; yet, one can perceive a general pattern, which symbolizes a lack of strong association between economic development and the nutritional status, and poorer conditions for the SCs and the STs in many state Therefore, the issue of nutrition needs examination, not only, from the point of view of economic development, but also, from the factors of regional characteristics, socio-cultural practices, and food distribution and food security systems. 4. Child Healthcare 4.1 Introduction Infancy and early childhood are the periods of life during which a person is highly vulnerable to morbidity and mortality. Besides, health during the early period of an individual s life has long-term implications for her/his physical, as well as, cognitive development. Naturally, healthcare during early childhood is crucial, and has been receiving its due attention from the national and the international agencies. This includes preventive care, mainly, immunization; promotive care like nutrition; as well as, curative care. Since child immunization has played an important role in preventing the incidence of certain deadly diseases; many programmes have been introduced to achieve 26

35 Health Status and Access to Health Care Services - Disparities among Social Groups in India complete immunization. Supplementary nutrition is also provided, especially to the children from the vulnerable sections. If the public programmes are successful in catering to the needs of various sections of the society, social gaps should not be large. In this section, this working paper examines the levels and gaps in preventive care, nutritional supplements, and curative care for common childhood diseases. 4.2 Preventive Care Vaccination Child immunization has been in vogue for quite some time. Smallpox vaccination was fairly common in the past, but has been discontinued after the eradication of the disease. At present, vaccination against six preventable diseases (tuberculosis, diphtheria, pertussis, tetanus, poliomyelitis, and measles) is recommended for children s immunization and is provided free of cost by various public health programmes. Immunization programmes have been in operation in India for quite some time; the Universal Immunization Programme (UIP) was introduced in India in the mid 80s in all districts across the country with an objective of immunizing atleast 85 percent of all infants against preventable diseases till Unfortunately, despite the existence of such programmes, the nation has not been able to achieve the desired levels, and the set target dates have been extended repeatedly. For a child, the recommended set of immunizations include three doses each of DPT (diphtheria, pertussis, tetanus) antigen and polio vaccine, one dose of BCG (against tuberculosis), and one dose of measles vaccine, before the completion of one year of age. The NFHS had obtained data on these variables for the children of age group months at the survey from the women interviewed. Table 1 H in Annexure I shows two indicators each from the NFHS-1 and NFHS-2; firstly, the percentage of children that received all the recommended doses (BCG, measles, three doses each of DPT and polio), and secondly, the percentage of children that received none of the stipulated doses. The coverage, therefore, was not universal, with only about 40 percent of children receiving all the recommended doses. There was a vast difference between two groups of states; Kerala, Punjab, Tamil Nadu, Maharashtra, and Himachal Pradesh have a good coverage, over 60 percent, whereas, Bihar, Uttar Pradesh, Madhya Pradesh, Rajasthan, and Assam fared very poorly, with less than a quarter of children in these states being completely immunized. Also, West Bengal and Orissa had poor immunization coverage. 27

36 Indian Institute of Dalit Studies In the NFHS-1, the coverage among the SCs was much below that for the SC/STs, but the NFHS-2 showed relatively narrower gaps (See Table 1 I in Annexure I). In most of the states, the gap was close to 10 percentage points in the NFHS-1, but had become very narrow by the NFHS-2. Punjab was an exception; the gap has widened substantially in this state, primarily because of a large rise in the coverage for the SC/STs, but not for the SCs. Madhya Pradesh, also continued to indicate wide gaps in both the surveys. Overall, it would be correct to say that in immunization, the SCs got nearly as much coverage as the SC/STs and that the public immunization programmes in India seem to cater to the SCs nearly as successfully as to the SC/STs. The STs, however, continued to be deprived in relation to the other communities. Poor vaccination among the STs was observed in almost all the states for which data was available. The deficiency was often of 10 percentage points, which was quite large given that the coverage of complete immunization is only around 40 percent. The conditions of the ST children in Bihar, Rajasthan, Madhya Pradesh, and Uttar Pradesh were quite miserable. While in these states, the general coverage in itself was poor, further deprivation suffered by the STs speaks volumes for the immunization efforts. Interestingly, only two states, Maharashtra and Gujarat, were able to reach a reasonable section of the ST population for providing vaccinations. The negative indicator; percentage of people not getting immunized was generally small, especially in the NFHS-2; 14 percent of the total children in India had not received any kind of immunization and the social break-up was 15, 24, and 13 percent for the SCs, the STs, and the SC/STs respectively. This indicator naturally demonstrates the states and the social groups in nearly, the reverse order of percentage getting all the recommended doses. Moreover, non-immunization was very high, over 20 percentage points for the SC/STs in Assam, Uttar Pradesh, and Rajasthan; for the SC children in Bihar; and for the ST children in Bihar, and Madhya Pradesh. Nevertheless, a positive trend of decline in non-immunization was evident between the NFHS-1 ( ) and the NFHS-2 ( ). Vitamin A Supplementation Deficiency of vitamin A is one of the most common nutritional disorders in the world, and a principal causative factor for blindness at an early age. The vitamin A supplementation in the form of oral doses is provided by the public health programmes in India for children below the age of five years. The 28

37 Health Status and Access to Health Care Services - Disparities among Social Groups in India NFHS-2 collected information on this aspect for children between the age groups of months at survey. Though doses are to be administered at regular intervals; tabulations are provided for the percentage of those who received atleast one dose, to ascertain the penetration of the programme. The picture was quite dismal, only 30 percent children received atleast one dose; while only a very small fraction received all the requisite doses (See Table 1 J). The state wise pattern for this healthcare indicator differed from that seen in many other indicators. Kerala and Tamil Nadu did not top the list. Rather surprisingly, in Tamil Nadu the coverage was well below the national average and Kerala too, lagged behind in this indicator of child care. Instead, Himachal Pradesh, Maharashtra, and Punjab fared well. However, following the usual pattern; Bihar, Rajasthan, Uttar Pradesh, and Assam had very low coverage. Table 1 J, Vitamin A Supplementation by Social groups, India and Large States States/India Percent of Children who Received at least one dose NFHS-2 ( ) Social Gaps SC ST SC/ST All SC/ST-SC SC/ST-ST SC-ST India Andhra Pradesh Assam Bihar Gujarat Haryana Himachal Pradesh Jammu and Kashmir Karnataka Kerala Madhya Pradesh Maharashtra Orissa Punjab Rajasthan Tamil Nadu Uttar Pradesh West Bengal Note: Source: - indicates that no separate estimate for the social category is presented in the NFHS Report since the number of children covered was very small and comparison was not possible since estimates for atleast one group were not available. NFHS-2, IIPS and ORC Macro, 2000; and State NFHS-2 Reports. The coverage was poorer for the SCs and the STs compared to the SC/ STs, but the gap was narrow, by about five percentage points. Generally, 29

38 Indian Institute of Dalit Studies there was not much difference between the SCs and the SC/STs in most of the states. But there was a wide gap between the STs and the SC/STs in Maharashtra, Andhra Pradesh, and Orissa. The departure from the pattern of inter-state variations, as well as, the relatively narrow gaps suggested that Vitamin A supplementation was not taken as seriously as immunization and delivery care by the more developed states or the socially advanced groups. Perhaps, it was considered a food supplement meant for the poor, and the upper classes or the upper castes did not seek this kind of service. 4.3 Curative Care Treatment in case of an illness depends on a variety of factors - realisation of the illness; recognition of the need for treatment; awareness of the source; and access to the treatment (the latter may in turn depend on physical location and affordability). At the cost of repetition, it must be noted here that purpose of this working paper was not to ascertain the levels of and differentials in the prevalence of a disease, since self-reported prevalence is, often not comparable across social groups, but was rather directed at whether treatment was taken or not in case a disease was perceived to have occurred. For children, questions were asked about two common childhood diseases; diarrhoea, and acute respiratory infection (ARI). Treatment for Diarrhoea Diarrhoea is a major killer disease for children under five years of age worldwide. Dehydration or loss of electrolytes is fairly common, and if no treatment is provided, could lead to an eventual possibility of death. Even otherwise, the child could become weak raising the risks of contacting other diseases. Oral or intra-venous re-hydration is the most commonly given treatment. The latter is expensive and not easily available in most villages. The Government has initiated Oral Re-hydration Therapy Programme as one of its priority activities to curb diarrhoea. The NFHS survey also covered these aspects regarding each child of less than three years of age to ascertain whether she/he suffered from diarrhoea during the two-week period before the interview, and in each such case whether the child was taken to a health facility or provider for treatment. The two surveys indicated that diarrhoea was taken seriously by the families, and nearly 60 percent of children were taken to health facilities or providers 30

39 Health Status and Access to Health Care Services - Disparities among Social Groups in India for treatment (See Table 1 K). Moreover, the regional picture was slightly different than that observed for many indicators earlier. Instead of Kerala and Tamil Nadu, the north-western states of Punjab, Haryana, Himachal Pradesh, and Jammu and Kashmir were far ahead of the national average in the matter of seeking treatment for diarrhoea. Only the state of Assam was well below the national average in both the surveys. Table 1 K, Treatment for Diarrhoea of Children by Social Groups, India and Large States States/India NFHS-1 ( ) NFHS-2 ( ) Percent taken to Health Percent taken to Health Care Provider Care Provider SC ST SC/ST All SC ST SC/ST All India Andhra Pradesh Assam Bihar Gujarat Haryana Himachal Pradesh Jammu & Kashmir Karnataka Kerala Madhya Pradesh Maharashtra Orissa Punjab Rajasthan Tamil Nadu Uttar Pradesh West Bengal Note: - indicates that no separate estimate for the social category is presented in the NFHS Report since the number of children covered was very small. Source: NFHS-1, IIPS, 1995; NFHS-2, IIPS and ORC Macro, 2000; and State NFHS Reports. The social disparity was low. There was hardly any difference between the SCs and the ST/STs; in both the groups, treatment was sought in about 31

40 Indian Institute of Dalit Studies percent of the cases at the national level (See Table 1 K). In most of the states, the gaps were narrow (exceptions were Andhra Pradesh and Tamil Nadu, but only according to the NFHS-1). In a few states (Rajasthan, Uttar Pradesh, and Bihar in NFHS-1 and Maharashtra in NFHS-2) the tendency to get treatment was higher among the SCs compared to the SC/STs. On the other hand, the STs were not as successful in obtaining treatment in case of diarrhoea. The gap was about 10 percentage points nationally, and very high in Bihar and Orissa as seen in the NFHS-2 (See Table 1 L). Table 1 L, Social Gaps in Treatment for Diarrhoea of Children by Social Groups, India and Large States States/India Social Gaps (in percentage points) NFHS-1 ( ) NFHS-2 ( ) SC/ST-SC SC/ST -ST SC-ST SC/ST -SC SC/ST -ST SC-ST India Andhra Pradesh Assam Bihar Gujarat Haryana Himachal Pradesh Jammu & Kashmir Karnataka Kerala Madhya Pradesh Maharashtra Orissa Punjab Rajasthan Tamil Nadu Uttar Pradesh West Bangal Note: Source: - indicates that the comparison was not possible since estimates for atleast one group were not available. Computed from Table 1 K A plausible reason for the lack of difference between the SCs and the SC/STs was that the risk associated with diarrhoea was well recognized by parents and an affected child was taken to a service provider. It is not clear why this was not done by the STs to the same extent as the SC/STs. Perhaps, the lack of access to a provider poses the problem, or the severity of the disease was not realized, or possibly, home remedies were resorted to. 32

41 Health Status and Access to Health Care Services - Disparities among Social Groups in India Treatment for Acute Respiratory Infection ARI, primarily pneumonia, is a major cause of illness among infants and children, and is the leading cause of childhood mortality throughout the world. Early diagnosis and treatment with antibiotics can prevent a large proportion of ARI/pneumonia related deaths. As was the case with diarrhoea; data on the incidence of and treatment to ARI were also been collected by the NFHS for children below three years of age for the two-week reference period before the survey. This aspect was covered only in a few states in the NFHS-1, but in all the states in the NFHS- 2. Therefore, the discussion primarily pertains to the NFHS-2 results. Generally, a majority of the children reporting symptoms of ARI were taken to a health centre or to a care provider (See Table 1 M). The inter-state patterns closely resembled those evident for the treatment of diarrhoea. The practice of taking children for treatment was more prevalent in the north-western states than in most other states. Maharashtra, Kerala, and Table 1 M, Percentage Children with ARI taken to a Health Facility or Provider by Social Groups, India and Large States States/India NFHS-1 NFHS-2 ( ) SC ST SC/ST All SC ST SC/ST All India Andhra Pradesh Assam Bihar Gujarat Haryana Himachal Pradesh Jammu & Kashmir Karnataka Kerala Madhya Pradesh Maharashtra Orissa Punjab Rajasthan Tamil Nadu Uttar Pradesh West Bengal Note: Source: - indicates that no separate estimate for the social category is presented in the NFHS Report since the number of children covered was very small. NFHS-1, IIPS, 1995; NFHS-2, IIPS and ORC Macro, 2000; and State NFHS Reports. 33

42 Indian Institute of Dalit Studies Tamil Nadu also fared quite well. Conversely, a majority did not get any treatment for ARI in Assam. The children from the SC families did not get as much care as the SC/STs, and the ST children even less so (See Table 1 N). The gaps were wide in Andhra Pradesh, Bihar, Madhya Pradesh, Orissa, and Gujarat. Table 1 N, Social Gaps in Percentage - Children with ARI Taken to a Health Facility or Provider by Social Groups, India and Large States, NFHS-2 State/India Social Gaps SC/ST-SC SC/ST -ST SC-ST India Andhra Pradesh Assam Bihar Gujarat Haryana Himachal Pradesh Jammu & Kashmir Karnataka Kerala Madhya Pradesh Maharashtra Orissa Punjab Rajasthan Tamil Nadu Uttar Pradesh West Bengal Note: - indicates that the comparison is not possible since estimates for atleast one group were not available. Source: Computed from Table 1 M. 4.4 Summary To sum up, the scheduled groups were not as well served as the SC/STs in child healthcare. The STs were at a greater disadvantage than the SCs. Recent evidence indicates that in immunization coverage the SCs have nearly caught up with the SC/STs; this was true at the national level, and also in most states, but was evidently not the case with the STs. Locational disadvantages, presumably, prevents the STs from securing even basic preventive healthcare services. Besides, the coverage of the childhood immunization was quite poor in many states, and as a corollary, quite dismal for the STs in these states. The inter-state variations in immunization 34

43 Health Status and Access to Health Care Services - Disparities among Social Groups in India coverage were quite large; Bihar had extremely poor coverage in contrast to Kerala and Tamil Nadu; states that were close to achieving universal immunization, compared to intra-state social group variations. Thus, spatial, rather than social factors seem to dominate immunization. The campaign type approaches followed in immunization programmes ensure that all the sections within an area get coverage; it could be good or poor depending on the strength of the campaign. This was probably the reason that the SCs were nearly, as well or poorly served as the SC/STs in most of the states. But, this inference does not hold true for the STs that are spatially separated from the other social groups. The propensity of taking treatment in case a child was suffering from diarrhoea did not differ much between the SCs and the SC/STs at the national level, though a few states did indicate wide gaps. This does not necessarily imply that the SC children received as good treatment as the SC/STs; the issue of quality of treatment was not addressed here, and in all inevitability, the children from the weaker sections cannot easily access high quality services. But, the children from the STs were even more disadvantaged and were less likely to access any treatment. For the ARI, both the scheduled groups did not fare as well as the SC/ST children; again the ST children found it more difficult to access care than the SC children. 5. Maternal Healthcare 5.1 Introduction Worldwide about 500,000 women die every year from complications during pregnancy and childbirth, and most of these deaths occur in developing countries (World Health Organization, 1999 cited in IIPS, ORC Macro, 2000, p. 195). Although, reliable national estimates of maternal mortality are not available for most countries, South Asia is thought to have among the highest maternal mortality rates in the world. The NFHS-2 estimates that the maternal mortality ratios (MMRs) were quite high in India, i.e., 540 per 100,000 live births. This implies that more than 100,000 women in India die annually due to complications related to pregnancy and childbirth. This finding reinforces the urgency of ensuring that all pregnant women receive adequate antenatal care during pregnancy, and that all deliveries take place under hygienic conditions with the assistance of trained medical practitioners ((IIPS, ORC Macro, 2000, pp ). 35

44 Indian Institute of Dalit Studies It is with this view that maternal and child healthcares have been one of the important components of the health programmes in India and were integrated with the Family Welfare Programmes. Later on, maternal healthcare came under the umbrella programme Child Survival and Safe Motherhood in the early 1990s, and thereupon, under the Reproductive and Child Health (RCH) programme in the late 1990, which integrated maternal health, child health, and fertility regulation with reproductive health programmes. Maternal health programmes include the provision of antenatal care (ANC), delivery care, and postnatal care (PNC). In India, ANC is provided in the public sector through a network of primary healthcare centres and urban health posts, primarily, by female health workers who are expected to visit women in their homes and provide the basic services. The programme calls for atleast three ANC visits; two doses of Tetanus Toxoid (TT) vaccine; detection and treatment of anaemia in mothers, especially, administering of iron and folic acid supplements; and management of high risk pregnancies. Institutional care at deliveries and professional assistance to home deliveries are also encouraged, alongwith, postnatal care, and identification and management of reproductive tract and sexually transmitted infections. In addition to the primary health centres and sub-centres; community health centres, public hospitals, and maternity homes also provide various services, especially, management of deliveries. Services are also provided by the private health service providers and some voluntary organizations. Most of the services in the public sector are provided free of cost so that even the poor are not deprived of professional maternal healthcare. Besides, the network of health centres makes access easy. Thus, in principle, the coverage should be close to universal. However, various surveys indicate that a large proportion of women do not get adequate access to healthcare during pregnancies and deliveries. The NFHS-1 collected information on antenatal, delivery, and post-natal care for (up to two) pregnancies during a period of four years prior to the survey for all the women interviewed in the survey. The NFHS-2 also obtained such information for a period of three years preceding the survey. As the information relates to a very recent period; the data may be considered to be fairly reliable. The working paper now delves into the percentages of pregnancies that received antenatal check-up by qualified personnel; received TT injections and supply of iron supplements. It further, looks into the deliveries conducted in medical institutions (primary or community health centres, maternity homes, or other hospitals, public or private), and deliveries that received professional assistance. 36

45 Health Status and Access to Health Care Services - Disparities among Social Groups in India 5.2 Antenatal Care Antenatal Check-up The coverage of antenatal care in India is heading towards a high level. The NFHS-2 estimates that during the late 1990s, antenatal check-up was conducted by qualified professionals in about 65 percent of the births (See Table 1 O). Kerala was the forerunner in this with near universal coverage closely followed by Tamil Nadu, which was also nearing full coverage levels. Andhra Pradesh, too, had translated its effort into good results (93 percent coverage), followed by Maharashtra and Bengal (90 percent coverage each). Other states, which recorded high coverage of antenatal check-up, were Himachal Pradesh, Karnataka, Gujarat, and Jammu and Kashmir. Orissa also indicated good achievement in this indicator. However, at the other end of the continuum were Uttar Pradesh and Bihar with very poor coverage (34 and 36 percent respectively). Table 1 O, Antenatal Check-up by Health Professionals by Social Groups, India and Large states Percent of Women that received Antenatal Check-up States/India NFHS-1 ( ) NFHS-2 ( ) SC ST SC/STs All SC ST SC/STs All India Andhra Pradesh Assam Bihar Gujarat Haryana Himachal Pradesh Jammu & Kashmir Karnataka Kerala Madhya Pradesh Maharashtra Orissa Punjab Rajasthan Tamil Nadu Uttar Pradesh West Bengal Note: Source: - indicates that no separate estimate for the social category is presented in the NFHS Report since the number of women covered was very small. NFHS-1, IIPS, 1995; NFHS-2, IIPS and ORC Macro, 2000; and State NFHS Reports. 37

46 Indian Institute of Dalit Studies The pattern has not changed much over the period of time, though generally, the levels of coverage have improved between the two NFHS surveys. Kerala remained at the apex, while Tamil Nadu also held the same position rankwise; conversely, on the other end of the spectrum, Rajasthan and Bihar fared poorly. Uttar Pradesh had slipped to a very low level. Interestingly, the level for Orissa had risen substantially. Overall, the coverage was lower for the SCs and the STs compared to the SC/STs; the deprivation was especially greater for the ST women (See Table 1 P). This was not unexpected, considering that the ST population reside in relatively isolated, and often, in hilly areas and have poor access to health services. On the other hand, though, the SCs did not get as much care as the SC/STs, the gap was relatively narrow. The SCs, though, generally discriminated against, reside in village s alongwith the SC/STs, and were more successful than the STs in obtaining access to healthcare services. Table 1 P, Social Gaps in Antenatal Check-up by Health Professionals by Social Groups, India and Large states Social Gaps (in percentage points) State NFHS-1 ( ) NFHS-2 ( ) SC/STs-SC SC/STs-ST SC-ST SC/STs-SC SC/STs-ST SC-ST India Andhra Pradesh Assam Bihar Gujarat Haryana Himachal Pradesh Jammu & Kashmir Karnataka Kerala Madhya Pradesh Maharashtra Orissa Punjab Rajasthan Tamil Nadu Uttar Pradesh West Bengal Note: - indicates that the comparison is not possible since estimates for at least one group were not available. Source: Computed from Table 1 O. The relative derivation of the SCs and the STs was evident in almost all the states (See Figure 1 D). Assam was a notable exception, but this was not due 38

47 Health Status and Access to Health Care Services - Disparities among Social Groups in India to a good coverage for the scheduled groups in the state, rather on account of poor coverage for all the communities. Since Kerala had reached a near universal coverage, obviously, hardly any difference among the social groups was visible. In many other states, the gaps among the SCs and the SC/ STs were narrow. However, a few states exhibited large scale disparities among the SCs and the SC/STs; Rajasthan, Karnataka, Haryana, and Uttar Pradesh in the two surveys, and Bihar, West Bengal, and Punjab in atleast one round of the NFHS. Figure 1 D, Antenatal Check-up by Health Professionals by Social Groups, India and Large States, Others SC ST Percent India A. P. Assam Bihar Gujarat Haryana H.P. J. & K. Karnataka State Kerala M. P. Maharashtra Orissa Punjab Rajasthan Tamil Nadu U. P. W. B. In almost all the states that have substantial ST populations, the social gaps among the SC/STs and the STs were quite wide compared to the SC/ STs and the SCs. Both the surveys depicted such trends. In some states, the condition of the STs was extremely poor compared to the SC/STs. Andhra Pradesh, Madhya Pradesh, Maharashtra, and Uttar Pradesh were notable in this aspect, and in a few other states also, the condition of the STs was quite dismal. 5.3 Tetanus Injection and Iron and Folic Acid Supplements Two TT injections are recommended to be given during a pregnancy. Tamil Nadu led in administering TT injections alongwith Kerala. In all the states, 60 percent or more women were immunized for tetanus as estimated by the NFHS-2 (See Table 1 Q in Annexure I). In the lowest slab were the BIMARU states. The pattern closely matched with that for the antenatal check-up; 39

48 Indian Institute of Dalit Studies however, overall, the coverage of TT injections was higher than that of antenatal check-ups by about 10 percentage points - injections were given on a large scale and on fixed days to improve awareness and accessibility. On the other hand, check-ups were individually catered and hence, had presumably low coverage. The social disparities in the coverage of TT were, more or less, similar to those observed for antenatal check-ups. Wide gaps among the SCs and the SC/STs were seen in a few states; Karnataka, Rajasthan, Uttar Pradesh, and Himachal Pradesh in NFHS-1, and Bihar in NFHS-2 (See Table 1 R in Annexure I). By the late 1990s, the practice of administering TT injections was fairly widespread among the SCs as well, resulting in the incidence of small social gaps. The distribution of Iron and Folic Acid (IFA) supplements was not as common as the administration of the TT injections or of antenatal check-ups (See Table 1 P). At the national level, only 51 percent of women received such supplements. Injections seemed to be more successful in reaching the needy than clinical check-ups or oral medicine. The overall pattern for the IFA supplements was fairly similar to that seen for the TT injections with minor variations. However, the social gaps were narrower as the coverage levels are lower (See Table 1 R in Annexure I). 5.4 Delivery Care Place of Delivery In India, a majority of deliveries, especially in the rural areas, continue to take place at home. Only a small proportion of deliveries take place in health institutions such as hospitals, maternity homes, primary health centres, and sub-centres (public or private). The NFHS-1 and the NFHS-2 estimates of percentage of deliveries in health institutions were 26 and 34 percent respectively, with about 15 percent of the deliveries being conducted in public institutions, that is, in Government hospitals and health centres. There were, however, large inter-state variations in the practice to seek institutional delivery care. As estimated by the NFHS-2, only 15 percent in Uttar Pradesh and Bihar, and 18 percent in Assam received any kind of institutional care (See Table 1 S in Annexure I). Even a state with high social development, Himachal Pradesh, had a very low percentage (29 percent according to the NFHS-2) of women seeking institutional delivery care. Women in Rajasthan, Orissa, and Madhya Pradesh also did not receive much institutional delivery care. Kerala and Tamil Nadu did exceptionally well, and were the top ranking 40

49 Health Status and Access to Health Care Services - Disparities among Social Groups in India states as was the case with many other indicators. Overall, the utilization of public maternity facilities was poor in most of the states. In a few of the states, not even 10 percent of deliveries were conducted in public facilities. At the national level, the SC women received much less institutional care compared to the SC/STs, by about 10 percentage points; and the ST women received even less so, by about 20 percentage points (See Table 1 T in Annexure I). In delivery care from the public sector, the gaps were narrower; in fact, the percentage of deliveries taking place in Government institutions was almost the same for the SC and the SC/ST women, and was only marginally lower for the ST women according to the NFHS-2. Obviously, women from the non-scheduled groups, being financially better off, utilised the private sector substantially more than the scheduled women. The social gaps among the SC and the SC/STs women in securing institutional delivery care were wide in most states. Exceptions were Kerala and Maharashtra, wherein, the gaps were narrow. In some states like Assam, Himachal Pradesh, and Bihar, the gaps were narrow, but these states indicated low levels of coverage for all the communities. In the case of deliveries at public institutions, the social gaps present a totally different picture. First, the SC and the SC/ STs gap were generally narrower for care in Government institutions than in overall care. Only Orissa and Jammu and Kashmir indicated wide gaps in the NFHS-2. In a few states, the SCs actually received greater coverage from the public sector than the SC/STs; notably in Kerala, and to some extent in Gujarat, as well as, in Maharashtra and West Bengal in the NFHS-2. This does not, however, imply that the Government sector seeks to cater more to the SCs, but rather that the SC/STs, having greater financial resources, prefer the private sector for delivery care. Overall, the STs received much less institutional care than the SCs and the SC/STs. This was true in most of the states with substantial ST populations; the sole exception being Assam. In the matter of deliveries in public institutions, the gaps persisted, but were narrower. Thus, the STs received poorer delivery care than the SCs and the SC/STs in both, public institutions, as well as, through the private sector. In this manner, a clear contrast was evident among the SCs and the STs. While the SCs were not able to obtain private delivery care as much as the SC/STs - affordability being the main obstacle - the STs do not receive either, the public or the private sector service as much as the SC/STs. 41

50 Indian Institute of Dalit Studies 5.5 Medical Assistance at Birth/Delivery Lack of professional assistance at delivery is a major cause of maternal and neonatal mortality. Traditionally, village midwives and women at home have been assisting women during delivery. Many women have now begun to seek the help of doctors or atleast trained midwives at the time of delivery. According to the NFHS-1, 34 percent and according to the NFHS-2, 42 percent of deliveries were assisted by a professional, that is, a doctor or a trained midwife (See Table 1 U). In a few states like Kerala and Tamil Nadu, the percentage was quite high, close to or over 90 percentage points. Andhra Pradesh, Punjab, and Maharashtra were also progressing towards higher levels. But, the poorest conditions were evident in Assam, Bihar, Madhya Pradesh, Orissa, and Rajasthan, with only percent coverage. Table 1 U, Medical Assistance at Delivery by Social Groups, India and Large States Percent of Deliveries with Medical Assistance NFHS-1 ( ) NFHS-2 ( ) States/India SC ST SC/STs All SC ST SC/STs All India Andhra Pradesh Assam Bihar Gujarat Haryana Himachal Pradesh Jammu & Kashmir Karnataka Kerala Madhya Pradesh Maharashtra Orissa Punjab Rajasthan Tamil Nadu Uttar Pradesh West Bengal Note: Source: - indicates that no separate estimate for the social category is presented in the NFHS Report since the number of women covered was very small. NFHS-1, IIPS, 1995; NFHS-2, IIPS and ORC Macro, 2000; and State NFHS Reports. As noted earlier in many other indicators, the SCs fared poorly compared to the SC/STs, and the STs were even worse-off (See Table 1 V). The pattern was similar in many states, but there was a departure from the general pattern in a few states. Kerala indicated narrow gaps because professional care was available to nearly all the sections including the SCs, and Assam 42

51 Health Status and Access to Health Care Services - Disparities among Social Groups in India Table 1 V, Social Gaps in Medical Assistance at Delivery by Social Groups, India and Large States Social Gaps (percentage points) NFHS-1 ( ) NFHS-2 ( ) State SC/STs-SC SC/STs -ST SC-ST SC/STs -SC SC/STs -ST SC-ST India Andhra Pradesh Assam Bihar Gujarat Haryana Himachal Pradesh Jammu & Kashmir Karnataka Kerala Madhya Pradesh Maharashtra Orissa Punjab Rajasthan Tamil Nadu Uttar Pradesh West Bengal Note: - indicates that the comparison is not possible since estimates for atleast one group were not available. Source: Computed from Table 1 U. Figure 1 E, Medical Assistance at Delivery by Social Groups, India and Large States, Percent India A.P. Others SC ST Assam Bihar Gujarat Haryana H.P. J&K Karnataka State Kerala M.P. Maharashtra Orissa Punjab Rajasthan Tamil Nadu U.P. W.B. and Bihar indicated narrow gaps because the coverage was low among all the social groups (See Figure 1 E). Medical assistance was good in Tamil Nadu; though, there were visible gaps among the SCs and the SC/STs. Further, the ST and the SC/ST gaps were quite wide in almost all the states 43

52 Indian Institute of Dalit Studies except Assam. In a few states; Andhra Pradesh, Gujarat, Orissa, and Maharashtra, the gaps were extremely high. The poor coverage for the ST women could be on account of poor access to health professionals, but also possibly because of the continuing trust on traditional midwives of medical system. 5.6 Summary The importance of maternal healthcare has been well recognised in India for long. The recent reproductive and child health programmes have placed greater emphasis on these aspects of health. Yet, the recent surveys reveal that the goal of providing professional healthcare during pregnancy and delivery is far from being achieved. While a few states, notably, Kerala and Tamil Nadu, are nearing complete coverage in many aspects of maternal care; the situation is quite poor in states like Uttar Pradesh, Bihar, and Rajasthan; Orissa seems to have improved recently and risen over the latter states. Since maternal healthcare is provided free of cost by the primary healthcare network involving community health centres, primary health centres, and sub-centres, all sections of the population should be able to access this service. Yet, the coverage is lower for the scheduled groups, and the deprivation is worse for the ST women than the SC women; probably, the result of the locational disadvantages faced by the STs. But, that this is not the only factor contributing to deprivation is evident from the fact that in many states, even the SC women did not get the same care as the SC/ ST women. Generally, the gaps among the SCs and the SC/STs were narrow for antenatal check-ups, but in some states, even in respect of this indicator wide differences were visible. It was also observed that states with substantial ST populations had wide social gaps among the SC/STs and the STs. Institutional delivery was not as easily obtainable as antenatal care. Nationally, only about a third of the deliveries were conducted in healthcare institutions. Again, there were large inter-state variations, with Kerala and Tamil Nadu at the higher end and the north-central states at the lower end of the continuum. In most of the states, the public maternity facilities had not attracted a large proportion of the expectant mothers. Since reliance on private delivery care was high, and professional care, obviously, entails substantial costs, the weaker sections cannot be expected to get much delivery care from that sector. As a result, the gaps among the SC/STs and the SC women in public healthcare for deliveries were not wide, but in the case of total 44

53 Health Status and Access to Health Care Services - Disparities among Social Groups in India institutional delivery a vast difference was visible. The STs also did not receive as much public healthcare or private care. By implication, the STs suffered the most in utilization of delivery services. Assam was a notable exception, but in this state all the sections received very poor service, much below the national levels. A similar picture was seen in the case of professional assistance at delivery. Despite the fact that lack of medical assistance at delivery is a major cause of maternal and neonatal mortality; the dependence on traditional birth attendants (trained or untrained) and midwives was high. The practices related to health and life-cycle (birth and death) are very complicated in relatively less developed societies. Some of these practices exist, concomitantly, with the modern practices in the developed society. The poor coverage of the ST women might also be attributable, in part, to their continuing faith in the traditional systems, in addition to inaccessibility to the system in physical, economic, and also social sense. The question whether some social groups, especially, the STs, did not get or did not feel the need to obtain modern healthcare for delivery remains to be investigated. 6. Concluding Observations India, like most countries in the world, has been passing through a phase of health transition. The nature of transition, as the timing, in the developing world has been different than that experienced by today s developed world. Major declines in the mortality rates in India began only after the first quarter of the twentieth century, and the process accelerated after the middle of the century. Improving health conditions - not just in terms of life expectancy - has been one of the goals of all Governments since Independence, and even prior to that the Bhore Committee had addressed this important issue. Provisions of public healthcare have been one of the prime instruments towards achieving this goal. Health depends on a variety of factors; household incomes, awareness, food availability, housing conditions, environmental sanitation, medical technology, and health services. As the weaker sections of the society, the poor, as well as, the socially disadvantaged would have difficulty in obtaining preventive, promotive, and curative healthcare from fee charging private sources; the public health services were instituted to provide many of these so that these sections were not deprived of essential healthcare. The networks of primary health centres, designed soon after Independence and restructured and strengthened later have been playing an important role 45

54 Indian Institute of Dalit Studies in the provision of healthcare. Public hospitals, as well as, trusts and charitable institutions have also made an important contribution. Over the years, there has been a substantial decline in the mortality rates; with life expectancy rising from about 22 years to over 60 years through the twentieth century. Yet, this impressive improvement has been short of expectations and has not matched the advances made by many other developing countries. China for instance, has shown much greater achievements over the same period as has Sri Lanka. Besides, these averages mask large inter-state variations within India. While a few states like, Kerala and Goa have achieved very low mortality levels, some states continue to suffer from the incidences of high mortality. Orissa and some other central states are, particularly, at a disadvantaged situation in this regards. But the focus of this working paper is to encapsulate another dimension of the variations, namely, those by social groups. The SCs and the STs in India have faced historical and continuing forms of discrimination and deprivation, and this has, obviously, reflected in the incidence of poor health conditions among them relative to the SC/STs. In the preceding sections, it was established that the socially weaker sections have higher mortality rates, poorer nutritional conditions, and that the women and children from the marginalized sections receive less healthcare than their SC/ST counterparts. In essence, at the conceptualization stage of this working paper, equality in health conditions was not hypothesized. It was, in fact, thought that the conditions of weaker sections would not be as good as those of the SC/STs. But, the data indicated that the conditions were quite worse for the SCs compared to the SC/STs, and were even worse off for the STs. Given, the fact that the overall conditions, even for SC/STs are not satisfactory, this in itself implies that those for the scheduled sections of the population would be dismal. Furthermore, in some states, the situation was much worse than at the national level, and therein, too, the scheduled sections of the population were in a miserable state of affairs. The results for the social group differentials at the national level, and also in large states indicate wide gaps in some states and narrow in the others, especially for the SCs. But, the number of states examined was large and the results varied across the indicators. Is there a pattern? In order to unearth a pattern, a summary of the results is presented in Table 1 W. The table provides the number of indicators in which wide disparities, with gaps of 10 or more percentage points, was evident among the SCs and the SC/STs, and 46

55 Health Status and Access to Health Care Services - Disparities among Social Groups in India similarly, among the STs and the SC/STs. The indicators have been grouped into two sets; first, those related to health outcomes (mortality and nutritional status), and second, those related to health services (child and maternal healthcare). A few of the indicators were not available in the NFHS-1 and hence, the number of indicators is 33; 13 on outcomes, and 20 on services. Table 1 W, Social Group Disparities in Indicators of Health Outcomes and Services, India and Large States States/India Number of Indicators showing High SC/ST vs. SC Disparity Number of Indicators showing High SC/ST vs. ST Disparity Outcomes Services Total Outcomes Services Total India Andhra Pradesh Assam Bihar Gujarat Haryana Himachal Pradesh Jammu & Kashmir Karnataka `19 Kerala Madhya Pradesh Maharashtra Orissa Punjab Rajasthan Tamil Nadu Uttar Pradesh West Bengal No. of Indicators Used Notes: A gap of 10 or more points in an indicator is treated as high disparity. Positive values indicate the number of indicators in which the value for the SC/ STs was worse than the SC/STs by atleast 10 points. Negative values indicate the number of indicators in which the value for SC/STs was better than the SC/STs by atleast 10 points. Source: Extracted from tables in the preceding sections. At the national level, both the SCs and the STs seem to have suffered nearly equally in health outcomes; in about 5 or 6 indicators (out of the 13 listed), the gap was large, over 10 percentage points. It has been noted earlier that in the infant and the childhood mortality rates, the SCs and the STs did not differ much, and both had higher than average mortality rates. Health outcomes are influenced substantially by household endowments via food intakes, housing conditions, and the ability to secure paid healthcare; both the scheduled groups are at a disadvantage here and seem to suffer equally. The social gaps in health outcomes could be attributed to differences in 47

56 Indian Institute of Dalit Studies household endowments. Public services do try to provide help in reducing mortality and improving nutrition, yet social group differences persist. But, the case of services was quite different. Whereas, the SCs received poor service in only 05 indicators (out of the 20 considered), the STs received poor service in as many as 16 indicators. Thus, the health services were not able to reach the STs in a satisfactory manner. The SCs were relatively better served, though, not to the same extent as the SC/STs. Interestingly, most of the services listed; immunization, maternal care, and even some aspects of curative care are to be provided by the public healthcare network, and thus, differential access of the social groups points to the failure of the public healthcare system to reach the scheduled groups, especially, the STs. The pattern of disparity varied across states. Treating differences of 10 percentage points or more as large; it was apparent that the large gaps were prevalent in both the surveys. However, no clear regional pattern emerged from the analysis, but, there were individual states that indicated a departure from the overall picture. Assam was a strange exception with the scheduled groups; both the SCs and the STs, actually delineating some indicators better than the SC/STs (note the negative values for Assam in Table 1 W). But, the overall conditions were so poor in Assam, especially in services, that this was not a matter of satisfaction for the scheduled groups - equality at the lower end of the spectrum is not something to be happy about. In Maharashtra, though, the SCs were nearly at par with the SC/STs in getting services, but were poorer in outcomes. This was also true for Kerala. The pertinent question that then arises is why are some states more successful than the others in catering to the health needs of the SCs? It would be wrong to presume that social segregation has totally disappeared in these states. Maybe the answer lies in the fact that there is awareness, as a result of social movements, among the scheduled groups that enables them to demand and access public healthcare. Maharashtra, for instance, has been known for active Dalit movements. Further, Kerala also has a history of strong anti-caste movements. In Kerala, the reach of many services was found to be nearly universal, and thus, all sections received fair access. Or perhaps, the service network in these two states is so well developed and managed that it is equitably accessible to the SCs, as well as, to the SC/STs. On the other hand, Punjab, Haryana, Uttar Pradesh, Orissa, and Rajasthan were states in which the conditions of the SCs were quite poor relative to the SCS/STs. Is this due to continuing discrimination or overall inefficiency of 48

57 Health Status and Access to Health Care Services - Disparities among Social Groups in India the services needs to be ascertained? The relative role of the social movements and efficiency mode of the service delivery systems too, needs to be investigated. The situation of the STs was as bad as that of the SCs in outcomes, and was in actuality, quite worse in services. This was true in almost all the states with large ST populations (in states with relatively small ST populations, the sample size for the STs was too small in the surveys to permit estimation of indicators). Again Assam was an exception as noted above. The disparity was also found to be severe for the states in the central tribal belt of Orissa, Madhya Pradesh, Maharashtra, Gujarat, and Andhra Pradesh, and in Karnataka (atleast 20 of the 33 indicators indicated high disparity). West Bengal, Bihar, Uttar Pradesh, and Rajasthan also indicated fairly high disparity levels. Thus, with the exception of Assam, the STs indicated poor health outcomes, and received poor health services compared to the SC/STs. In services, the gap among the SCs and the STs was quite conspicuous. The fact that the STs - mostly residing in hilly or isolated settlements - would not be able to access health services as easily as the other sections of the society has been long recognised. Therefore, the health service management in India has always made special provisions for the tribal and the hilly areas. A lower population-health centre ratio has been prescribed for such areas. Currently, while one primary health centre is recommended for a population of 30,000; in the tribal areas, the ratio is stipulated to be 1:20,000. Similarly, one health sub-centre is prescribed for a population of 3,000 in the tribal areas, instead of the stipulated 5,000 for other areas. But, despite such provisions the access of the STs to healthcare services continues to be poor and inadequate. In spite of the favourable ratios, the STs received poor services in almost all the states. Either, these ratios were not being implemented in the sense of positions actually occupied, or given the unfavourable geographic conditions, even better ratios are needed. It is also possible that the quality of services was poor in the tribal areas. This contrasts with the relatively low disparities for the SCs in the case of service indicators. Maharashtra presents a classic case. Herein, the SCs seemed to receive/ access as much public healthcare as the SC/STs, but the STs were severely deprived. This suggests that the credit should probably go to the SCs for success in accessing healthcare, rather than to the overall efficiency of the 49

58 Indian Institute of Dalit Studies service delivery system. Or perhaps, the state needs to make concerted and sustained efforts to reach the STs. It has already noted earlier that the issue of whether social disparities are attributable to deficiencies in services (including discrimination), or to other factors (disparities in income and education, on account of past discrimination) are not being addressed in the present working paper. However, some recent research has systematically examined these aspects for a few selected states. An analysis of the NFHS data for Tamil Nadu indicated that the poor delivery care among the SCs was on account of poverty, rather than caste per se (Sivakami and Kulkarni: 2003). Further, Roy et al. (2004) investigated these issues for a large number of states that have substantial SC and ST populations. Their analysis showed that even after controlling for the effects of education and standards of living (proxy variable for income); a higher percentage of the SC women had low BMIs in the north-central states (Bihar, Orissa, Madhya Pradesh, and Rajasthan), and Gujarat, but not in Maharashtra, Karnataka, Andhra Pradesh, and Uttar Pradesh. The ST women in some states also indicated poor BMIs after controlling for other effects. In maternal care, the SC- SC/ST disparity persisted in only a few states once other factors were introduced, but the ST- SC/ST disparity continued to persist in a large number of states. The detailed analysis confirmed the overall patterns - in health outcomes, the disparities were high for both, the SCs and the STs compared to SC/STs, but in the case of services, the STs faced higher disparity than the SCs in relation to the SC/STs. Therefore, the overall picture that emerges is a complex one. Though, at overall levels, the mortality rates declined in India, the situation was not same across social groups. Also, there were wide inter-social group variations among the SCs, the STs, and the SC/STs within the states in terms of health outcomes and utilisation of services. Since, perceptibly, socially weaker sections tend to be economically weak; health outcomes for them are likely to be poorer than for the SC/STs, and such an inference was evident despite the fact that public health services in India are particularly, designed to ensure that the weaker sections are not deprived of essential healthcare on account of lack of affordability to pay for the private services. But, clearly the scheduled groups remained deprived even in the utilisation of basic health services. It is difficult to say whether this disparity has attenuated or accentuated over time since the gap between the two surveys (the NFHS-1 and the NFHS-2) was too short to assess changes, and data of a similar nature for earlier time points was not available. But, there were distinct 50

59 Health Status and Access to Health Care Services - Disparities among Social Groups in India differences in the nature and extent of disparities for the two scheduled groups. That some states have been significantly more successful than the others in providing essential maternal and child healthcare services effectively demonstrates the ability of the service network to meet such needs. Since the structure of the healthcare delivery system does not differ much across states, it is apparent that some states have been able to make the system function more efficiently. In these states, the SCs received nearly as good services as the SC/STs. If the other states can emulate the successful states in providing services to a broad spectrum, it is possible that the weaker sections could be as well served as the SC/STs. Though, this would not necessarily ensure absolute equity in health outcomes since economic conditions also play a focal role in overall health status; essential services could go a long way in reducing disparities. In addition to efficiency of the service delivery network, one must also see if awareness of and demand for the right to services are also factors of importance in improving utilisation of services. But, the case of the STs is different. The public health services have not been able to reach them satisfactorily in spite of built-in provisions to make up for their locational disadvantages. Clearly, much more needs to be done in that regard. There has to be a rethinking of not just the populationfacility ratios, but also, the structure, strategy and functions of the delivery system in the ST areas need to be rethought. Finally, health services are only a part of the solution. Food security, education, and housing conditions, including household and environmental sanitation are areas that need to be strengthened. In other words, a constellation of health services and other dimensions of development are inevitable to attain the goals of participatory development. This, needless to say, requires strong public commitment, huge resources, and political will. 51

60 Indian Institute of Dalit Studies Select Bibliography 1. Chakrabarty, G., Scheduled Castes and Tribes in Rural India - Their Income, Education and Health Status, Margin, Volume 30, Number 4, 1998, pp Desai, I.P., Untouchability in Rural Gujarat, Popular Prakashan, Bombay, Duggal, R., Health Care Budget in Changing Political Economy, Economic and Political Weekly, Volume XXXXII, 1997, pp India, National Family Health Survey, , IIPS, Mumbai, India, National Family Health Survey, , Mumbai, IIPS and ORC Macro, India, Registrar General, SRS Bulletin, Volume 37, Census of India, 2001, Population Profiles (India, States and Union Territories), Office of the Registrar General, New Delhi, India, Kulkarni, P.M., Special Population Groups, Seminar (Special Issue on Beyond Numbers - A Symposium on Population Planning and Advocacy), Number 511, March 2002, pp , Inter-State Variations in Human Development Differentials among Social Groups in India, New Delhi, National Council of Applied Economic Research, Kulkarni, Sumati, Inputs and Processes - An Inside View, Economic and Political Weekly, Volume XXXIX, Number 7, 2004, pp Kundu, A. and J.M. Rao, Inequality in Educational Development - Issues in Measurement, Changing Structure and its Socio-Economic Correlates with Special Reference to India in Raza, M. (Eds.), Educational Planning - A Long Term Perspective, National Institute for Educational Planning and Administration and Concept Publishing Company, New Delhi, 1985, pp Lal, S.K. and U.R. Nahar, Extent of Untouchability and Pattern of Discrimination, Mittal Publication, New Delhi, Murray, C. J. L. and L. C. Chen, Understanding Morbidity Change in Chen, L. C., Kleinman, Arthur, and Norma C. Ware (Eds.), Health and Social Change in 52

61 Health Status and Access to Health Care Services - Disparities among Social Groups in India International Prospects, Harvard School of Public Health, Boston, 1994, pp Diets and Nutritional Status of Tribal Population - Report on First Repeat Survey, , National Nutrition Monitoring Board, NIN and ICMR, Hyderabad, Morbidity and Treatment of Ailments, 52 nd Round, Report Number 441, July 1995-June 1996, National Sample Survey Organization, Department of Statistics, Government of India, Radhakrishna, R. and C. Ravi, Malnutrition in India - Trends and Determinants, Economic and Political Weekly, Volume XXXIX, Number 7, 2004, pp Ram, F., Pathak, K.B., and K.I. Annamma, Utilisation of Health Care Services by the Under Privileged Sections of Population in India - Results from NFHS, Indian Associations of Social Sciences Institutions Quarterly, Volume 16, Numbers 3 & 4, 1997, pp Roy, T.K., Kulkarni, S., and Y. Vaidehi, Social Inequality in Health and Nutrition in Selected States, Economic and Political Weekly, Volume XXXIX, Number 7, 2004, pp Sen, A., Objectivity of Health Assessment in Das Gupta, M., Chen, L.C., and T.N. Krishnan (Eds.), Health, Poverty and Development in India, Oxford University Press, Delhi, 1998, pp Shariff, A., India - Human Development Report, A Profile of Indian States in the 1990s, National Council of Applied Economic Research, United Nations, and Oxford University Press, New Delhi, Sopher, D.E., Sex Disparity in Literacy in Sopher, D. E., (Eds.) Exploration of India -Geographical Perspective on Society and Culture, Longman, London, 1980, pp Sundari Ravindran, T.K., Social Inequality and Child Health Status in Das Gupta, M., Chen, L.C., and T.N. Krishnan (Eds.), Health, Poverty and Development in India, Oxford University Press, New Delhi, 1998, pp Thorat, S.K. and N. Sadana, Will Strategy of Disincentive and Targeting Help to Control Population Policy, 2002, Mimeograph. 53

62 Indian Institute of Dalit Studies List of Tables Table 1 D, Percentage of Children under Three years of Age with Poor Nutritional Status in terms of various measures of Nutrition by Social Groups, India and Large States NFHS-1 ( ) States/India Weight for Age (Under-nutrition) Height for Age (Stunting) Weight for Height (Wasting) SC ST SC/ST All SC ST SC/ST All SC ST SC/ST All India Andhra Pradesh Assam Bihar Gujarat Haryana Himachal Pradesh Jammu and Kashmir Karnataka Kerala Madhya Pradesh Maharashtra Orissa Punjab Rajasthan Tamil Nadu Uttar Pradesh West Bengal NFHS-2 ( ) India Andhra Pradesh Assam Bihar Gujarat Haryana Himachal Pradesh Jammu and Kashmir Karnataka Kerala Madhya Pradesh Maharashtra Orissa Punjab Rajasthan Tamil Nadu Uttar Pradesh West Bengal Note: - indicates that no separate estimate for the social category is presented in the NFHS Report since the number of children covered was very small. Source: NFHS-1, IIPS, 1995; NFHS-2, IIPS and ORC Macro, 2000; and State NFHS Reports. 54

63 Health Status and Access to Health Care Services - Disparities among Social Groups in India Table 1 E, Social Gaps in the Nutritional Status of Children in terms of various measures of Nutrition by Social Groups, India and Large States States/India Weight for Age (Under-nutrition) SC/ST-SC SC/ST-ST SC-ST NFHS-1 ( ) Height for Age (Stunting) SC/ST -SC SC/ST -ST SC-ST Weight for Height (Wasting) SC/ST -SC SC/ST-ST SC-ST India Andhra Pradesh Assam Bihar Gujarat Haryana Himachal Pradesh Jammu & Kashmir Karnataka Kerala Madhya Pradesh Maharashtra Orissa Punjab Rajasthan Tamil Nadu Uttar Pradesh West Bengal NFHS-2 ( ) India Andhra Pradesh Assam Bihar Gujarat Haryana Himachal Pradesh Jammu & Kashmir Karnataka Kerala Madhya Pradesh Maharashtra Orissa Punjab Rajasthan Tamil Nadu Uttar Pradesh West Bengal Note: - indicates that the comparison is not possible since estimates for atleast one group were not available. Source: Computed from Table 1 D. 55

64 Indian Institute of Dalit Studies Table 1 H, Vaccination of Children (aged months at the time of the Survey) by Social Groups, India and Large States States/India Percentage that received, All the recommended doses of vaccinations SC ST NFHS-1 ( ) Percent that received, e of the recommended doses of vaccinations SC/ST All SC/ST All SC ST India Andhra Pradesh Assam Bihar Gujarat Haryana Himachal Pradesh Jammu and Kashmir Karnataka Kerala Madhya Pradesh Maharashtra Orissa Punjab Rajasthan Tamil Nadu Uttar Pradesh West Bengal NFHS-2 ( ) India Andhra Pradesh Assam Bihar Gujarat Haryana Himachal Pradesh Jammu and Kashmir Karnataka Kerala Madhya Pradesh Maharashtra Orissa Punjab Rajasthan Tamil Nadu Uttar Pradesh West Bengal Note: Source: - indicates that no separate estimate for the social category is presented in the NFHS Report since the number of children covered was very small. NFHS-1, IIPS, 1995; NFHS-2, IIPS and ORC Macro, 2000; and State NFHS Reports. 56

65 Health Status and Access to Health Care Services - Disparities among Social Groups in India States/India Table 1 I, Social Gaps in Vaccination for Children, India and Large States All Recommended Doses NFHS-1 ( ) e SC/ST-SC SC/ST-ST SC-ST SC/ST-SC SC/ST-ST SC-ST India Andhra Pradesh Assam Bihar Gujarat Haryana Himachal Pradesh Jammu and Kashmir Karnataka Kerala Madhya Pradesh Maharashtra Orissa Punjab Rajasthan Tamil Nadu Uttar Pradesh West Bengal NFHS-2 ( ) India Andhra Pradesh Assam Bihar Gujarat Haryana Himachal Pradesh Jammu and Kashmir Karnataka Kerala Madhya Pradesh Maharashtra Orissa Punjab Rajasthan Tamil Nadu Uttar Pradesh Note: - indicates that the comparison is not possible since estimates for atleast one group were not available. Source: Computed from Table 1 H. 57

66 Indian Institute of Dalit Studies Table 1 Q, Antenatal Care - TT Injection and Iron Folic Syrup by Social Groups, India and Large States States/India NFHS-1 ( ) Percent of women that received TT Injection Percent of women that received IF tablets or syrup SC ST SC/STs All SC ST SC/STs All India Andhra Pradesh Assam Bihar Gujarat Haryana Himachal Pradesh Jammu & Kashmir Karnataka Kerala Madhya Pradesh Maharashtra Orissa Punjab Rajasthan Tamil Nadu Uttar Pradesh West Bengal NFHS-2 ( ) India Andhra Pradesh Assam Bihar Gujarat Haryana Himachal Pradesh Jammu & Kashmir Karnataka Kerala Madhya Pradesh Maharashtra Orissa Punjab Rajasthan Tamil Nadu Utter Pradesh West Bengal Note: Source: - indicates that no separate estimate for the social category is presented in the NFHS Report since the number of women covered was very small. However, the STs do not seem to get the tetanus protection as much as the SCs. Wide gaps were seen in almost all the states. Injection campaigns do not seem to reach the tribal populations that suffer from locational disadvantage. NFHS-1, IIPS, 1995; NFHS-2, IIPS and ORC Macro, 2000; and State NFHS Reports. 58

67 Health Status and Access to Health Care Services - Disparities among Social Groups in India States/India Table 1 R, Social Gaps in Antenatal Care - TT Injection and Iron Folic Syrup (in percentage points) SC/STs-SC TT Injection SC/STs-ST NFHS-1 ( ) IF Tablets or Syrup SC-ST SC/STs-SC SC/STs-ST SC-ST India Andhra Pradesh Assam Bihar Gujarat Haryana Himachal Pradesh Jammu & Kashmir Karnataka Kerala Madhya Pradesh Maharashtra Orissa Punjab Rajasthan Tamil Nadu Uttar Pradesh West Bengal NFHS-2 ( ) India Andhra Pradesh Assam Bihar Gujarat Haryana Himachal Pradesh Jammu & Kashmir Karnataka Kerala Madhya Pradesh Maharashtra Orissa Punjab Rajasthan Tamil Nadu Uttar Pradesh West Bengal Note: - indicates that the comparison is not possible since estimates for atleast one group were not available. Source: Computed from Table 1 Q. 59

68 Indian Institute of Dalit Studies Table 1 S, Percentage of Deliveries Conducted in Health Institutions by Social Groups, India and Large States States/India NFHS-1 ( ) Public Institutions All Institutions (Public and Private) SC ST SC/STs All SC ST SC/STs All India Andhra Pradesh Assam Bihar Gujarat Haryana Himachal Pradesh Jammu & Kashmir Karnataka Kerala Madhya Pradesh Maharashtra Orissa Punjab Rajasthan Tamil Nadu Uttar Pradesh West Bengal NFHS-2 ( ) India Andhra Pradesh Assam Bihar Gujarat Haryana Himachal Pradesh Jammu & Kashmir Karnataka Kerala Madhya Pradesh Maharashtra Orissa Punjab Rajasthan Tamil Nadu Uttar Pradesh West Bengal Note: - indicates that no separate estimate for the social category is presented in the NFHS Report since the number of women covered was very small. For deliveries during the three year period before the survey. Source: NFHS-1, IIPS, 1995; NFHS-2, IIPS and ORC Macro, 2000; and State NFHS Reports. 60

69 Health Status and Access to Health Care Services - Disparities among Social Groups in India Table 1 T, Social Gaps Institutional Deliveries (in percentage points) State NFHS-1 ( ) SC/STs-SC Public Institutions SC/STs -ST SC-ST All Institutions (Public and Private) SC/STs -SC SC/STs -ST SC-ST India Andhra Pradesh Assam Bihar Gujarat Haryana Himachal Pradesh Jammu & Kashmir Karnataka Kerala Madhya Pradesh Maharashtra Orissa Punjab Rajasthan Tamil Nadu Uttar Pradesh West Bengal NFHS-2 ( ) India Andhra Pradesh Assam Bihar Gujarat Haryana Himachal Pradesh Jammu & Kashmir Karnataka Kerala Madhya Pradesh Maharashtra Orissa Punjab Rajasthan Tamil Nadu Uttar Pradesh West Bengal Note: - indicates that the comparison is not possible since estimates for atleast one group were not available. Source: Computed from Table 1 S. 61

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