CHAPTER THREE. Social Development in North Karnataka: Status of Health Care Development

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1 CHAPTER THREE Social Development in North Karnataka: Status of Health Care Development

2 Health and education are the most important indicators of social development as they play a critical role in the growth and development of a region. In fact, social sector development has been an important goal of development planning in India since independence. In the recent past, with the broadening in the conceptualization of the notion of individual and social well being, there has been a renewed emphasis and a clearer focus on the importance of social development in development discourse and policy planning. It has made human development and improvement in quality of life as the ultimate objective of development, in general an,~ planning, in particular. In this context both the policy makers and researchers have recognised the critical role of health and health care infrastructure in a region. It also calls for greater state intervention in order to ensure adequate public spending on health and increase health awareness and health education among people, which seems to be the major determinants of better health status of people. There is also a need to create a system in which better health care infrastructure and facilities are distributed equally across regions and among different social categories. In this context, the present chapter aims to analyse the selected indicators of health care facilities and infrastructure in northern region of the state of Karnataka. An attempt has also been made to compare the Hyderabad-Karnataka region with that of the Bombay-Karnataka region and also with that of the state average in the light of growing regional imbalances in health care facilities in the state. These comparisons are intended to unearth the nature of regional backwardness, and intra-regional disparities in the process of regional development as they are related to people and their health status. Importance of Health Health care is one ofthe most important aspects of the public policy of welfare states in the world. Health has been man's one of the greatest possessions of life and his source of real happiness. In terms of resources for socio-economic development, nothing can be considered of higher significance than the health of the people. An investment in health has always been considered as an investment on human resource development on which depends the development of a region and a nation. Development of health in terms of improvement of the quality of life is, therefore, imperative. 123

3 The state government of Karnataka has, of late, recognised the immeasurable value of enhancing the health well being of its people. In fact, good health and a long life is a valued as an attainment in itself, but living a long and a healthy life may not be the only objective in life. Yet, for most people, the realization of other goals and ambitions would very much depend on having a reasonable life span and robust health. It would also provide an opportunity to develop abilities and use the innate potential in pursuit of personal goals. Being healthy and being able to live long also brings some indirect benefits to individuals and als~ to the society as a whole. It enables better utilisation of resources that, otherwise, would be spent on treatment of ill health and ailments, at least, at household level and, perhaps, also at the level of public provisioning for some health care services. The World Health Organisation (WHO) defines health as "A State of complete physical, mental and social well being and not merely an absence of diseases or infirmity". 1 Accordingly, health is a basic need of life which enables full utilization of all other facilities to make life better, richer and more meaningful. It depends on number of factors which fall in the area of action of departments other than health department. In the process, it influences distribution of resources and equity in well-being among people. Apart from the possibility of deploying such resources to meet other personal needs and pursuing development in other areas at a collective level, being healthy gives a health start to a person's well-being. Individuals suffering from ill health or ailments may have to devote a part of their resources to mitigate their suffering and only then may have well-being levels that can be compared with attainments and well-being of healthy persons. Better health, also contributes directly to economic growth as it reduces production losses on account of illness of workers or, potentially, also in terms of higher work productivity for healthy workers. Thus, besides its intrinsic value, a healthy and long life has an instrumental value in attainment of other valued goals in enhancing personal and social well-being. 2 For most individuals the choice to live a healthy life - free from illness and ailments - and a reasonable life span, are crucial attributes in the notion of personal well-being. Similarly, for a society, which is in a transition from high incidence of morbidity and 2 P. J. Kelly and J.L. Lewis, Education and Health, Pergamon Press, Oxford, 1987, p.6. National Human Development Report 2001, Planning Commission of India, Government of India, New Delhi, 2002,p

4 mortality to a state where people generally enjoy long and disease free lives is considered a desirable and valued social change. It is only natural, then, that indicators on health and longevity, as well as indicators that variously capture demographic concerns of a society are important constituents in the framework for evaluating the development process under the human development approach. Organisation of Health Department in Karnataka The Minister of Health and Family Welfare heads the Department of Health in ' Kamataka. At the state level, the entire directorate has been divided into three divisions: Health and Family Welfare Services, Medical Education and the Indian System of Medicine and Homeopathy. The Directorate of Health and Family Welfare Services is mainly responsible for the provision of health care services to people. At the district level, the District Health and Family Welfare Officer (DHO) is responsible for organizing health services that includes promotive, preventive and curative in rural areas and the District Surgeon heading the district hospital is responsible for the provision of medical services in urban areas. The DHO works under the control of Zilla Panchayat and in tum assisted by programme officers like the District Malaria Officer, the District Leprosy Officer and the district TB Officer. The health care delivery system in Karnataka is structured mainly on the basis of national norms that aim to integrate the promotive, preventive and curative aspects of health care. In fact, the present health care system in India has its origin to the recommendations ofthe health survey and development committee appointed in 1943 under the chairmanship of sir Joseph Bhore. 3 Accordingly, there is one district hospital with 250 beds covering approximately 2 million population. At the subdistrict level, there is one sub-district hospital with 100 beds covering approximately population. Similarly at the block level, the norm is a Primary Health Centre The Bhore Committee recommendations for the future development of health sector were based on the following major principles.l) No individual should fail to secure adequate medical care because of inability to pay for it. 2) The health programme must, from the very beginning, lay special emphasis on preventive work with consequential development of environmental hygiene. 3) The health services should be placed as close to the people as possible in order to ensure the maximum benefits to the communities to be served. 4) It is essential to secure the active cooperation of the people in the development of health programmes, and active support of the people is to be sought through the establishment of a Health committee in every village. For more information on health policy, see, Sapru R.K, "Health Care Policy and Administration in India", Indian Journal of Public Administration, 43(3), July-September, 1997, pp

5 (PHC) for every population (20000 population in tribal and hilly areas). 4 Some PHCs have one Medical Officer (MO) and some have two. Para-medical and nonmedical staff assists MOs. A new and peculiar feature of Karnataka's health care delivery system is a Primary Health Unit (PHU). There is a PHU for every population headed by a Medical Officer assisted by para-medical and non-medical staff. Besides, there is a sub-centre for every 5000 population (3000 in tribal and hill areas). One female and male multipurpose health worker assist each. At the village level, there is a trained Dai for every 1000 population., As a forward step, the state government of Karnataka has decentralized the health care and delivery system by giving adequate powers to Panchayat Raj Institutions (PRls). According to the Karnataka Panchayat Raj Act of 1993, Zilla Panchayats are entrusted with the powers to look after the management of hospitals and dispensaries excluding district hospitals and hospitals under direct government management and the implementation of maternity and child health, family welfare and immunization and vaccination programmes. 5 In terms of financial allocations, Zilla Panchayats also implement state sector schemes entrusted to them by the government. Taluka Panchayats look after health and family welfare programmes and promotes immunization and vaccination programmes like Polio etc. at the block level. They also supervise health and sanitation facilities at village fairs and festivals. Similarly, Gram Panchayats at the village level deal with family welfare programmes, preventive measures against epidemics, regulation of the sale of food items, participation in immunization programmes, licensing of eating establishments and the regulation of offensive and dangerous trades. Apart from curative services, the government of Karnataka has been slowly strengthening the health education at all levels. Separate administrative and financial arrangements have been made to promote health education. But its reach has not been even as it is restricted to only urban-centres. Of late, the government is contemplating on including health and sex education as part of school curriculum. Child and mother health has been given priority in the health policy of the state. The State government of Karnataka has felt that the early attention to the health 4 Karnataka State Integrated Health Policy 2003, Department of Health and Family Welfare, Government of Karnataka, Bangalore, 2003, p.6. Human Development in Karnataka 1999, Department of Planning, Government of Karnataka, Bangalore, p

6 and educational status of child population is a rich dividend on its way to form a strong human capital base in the state. In this regard, the Department of Women and Child Development is implementing various programmes to promote child and mother health, special programmes like, Integrated Child Development Scheme (ICDS) etc. Karnataka's Health Policy The health policy of the state government of Karnataka has so far adopted the major policy guidelines of the central government through the framework of successive Five Year Plans, decisions of the Central Council of Health and Family Welfare, central health legislations and national health programmes conceived and developed by the central government. Over a period of time, it is observed that various policies for separate segments of health have been the components of state policy on health. The state government has most often understood that these policies of the central government have served the state effectively and places considerable thrust on them. In a nutshell, the state health policy is shaped by the guidelines of the Government of India rather than the needs of the state despite the fact that health is constitutionally a state subject. The Karnataka State Integrated Health Policy announced in 2003 is a testimony to the fact that it is mainly based on the guidelines of the 2002 National Health Policy of India. However, considerable efforts are visible in the latest health policy of the state wherein some degree of attention is being made towards refashioning the elements concerning specific needs of the state. Significantly, the vary issue of regional imbalances in health care and delivery system has been recognised in the health policy of the state. Health care facilities and health needs vary most often between regions and even districts within a region. A comprehensive Karnataka State Health Policy for the integrated development and functioning of health sector has explicitly articulated the need to address and contain growing regional imbalances in the state. The latest policy, with a strong emphasis on the process and implementation is seen as an instrument for optimal, people-oriented development of health services. The policy, among its major objectives, clearly makes an attempt to pay particular attention to fill the gaps that exist in health care between different regions and among different social 127

7 categories in the state. It also makes a commitment to move towards greater equity in health and health care facilities and infrastructure within a reasonable time frame, which is a positive sign for equitable growth of health sector in the state of Karnataka. 6 Besides, the Karnataka Vision statement for better health and health care, of late, is concerned about the current inequalities and inequalities in health status by region, urban/rural location, gender, social and economic groupings. 7 The vision statement also recognises the critical role of the state to initiate and steer policies to ensure equity and quality of health care. It also attempts to encourage greater publicprivate partnership in provision of quality health care in order to better serve the undeserved regions. In a nutshell, the health policy seems to remain consistent with the separate policies that may be formulated for related social sectors and, along with the latter, which would constitute the charter for social development of the people of the state. Development of Health Care in Karnataka The performance of Karnataka in terms of providing basic health care facilities has been moderate though there are certain areas of concern like growing regional imbalances. But the growth trajectory has been on the path of rapid development. In terms of the number of health care institutions, there is a substantial increase from 1248 in to 2,624 in This speaks for a growth rate of3 percent per annum. Furthermore, the available data for the number of beds in government hospitals show an increase from 13,786 in to 43,867 in The population covered per government medical institution was in This growth trajectory suggests that the state of Karnataka has made tremendous progress in the past century, particularly after independence. Since 1956, several gains have been made in health and health care in Karnataka. Life Expectancy at Birth (LEB) has increased from to 61.7 years and from to 65.4 years for males 6 The other objectives of the state health policy are: to build on the existing institutional capacities of the public, voluntary and private health sectors: to make use of public health approach, focusing on determinants of health such as food and nutrition, safe water, sanitation, housing and education: to expand beyond a focus on curative care and further strengthen the primary health care strategy: to encourage the development of Indian and other systems of medicines. More significantly, the state health policy views health as a reasonable expectation of every citizen and will work within a framework ok social justice. Furthermore, the policy is intended to be a guiding document that needs to evolve and be changed in response to changing situations. Karnataka State Integrated Health Policy, Department of Health and Family Welfare, Government ofkarnataka, Bangalore, 2004, p

8 and females respectively, between 1951 and The Infant Mortality Rate (IMR) declined from as high as i 48 per 1000 live births in 1951 to 69 in 1981 and further to 57 in Significantly, in this sensitive key indicator, the target of 60 fixed in the 1983 National Health Policy has been achieved. The Crude Death Rate (CDR) has fallen from 40.8 per 1000 population in 1951 to 22.0 in 2000 and the total fertility rate from 6.0 children in 1951 to 2.13 in The disease of small pox has been completely eradicated. Significantly, the state has become free from plague and more recently of guinea worm infection. The incidence o,f polio cases has been reduced to zero by December 2000 and until now, for more than two years, the 'nil' status has been maintained. The progress in bringing down CDR by more than two thirds from 25.1 in 1951 to 7.8 in 2000 is noteworthy. But all the gains made since post-1956 Karnataka in health sector have not been translated into equitable distribution between regions and among people in the state. Certain pockets in the periphery have remained backward in terms of health care and infrastructure in the state. Regional Variations in Health Care in North Karnataka One of the greatest ironies of modern times is the fact that the percentage of people who can afford good health care is constantly decreasing despite the fact that the medical science field has moved forward by leaps and bounds. Especially in India and Indian states we have the strange situation of people coming from abroad for advanced treatment and yet, rural India that feeds the entire country, does not have access even to primitive medical facilities. The state of medical care in Karnataka is no exception to this scenario. Bangalore, the capital city of Karnataka attracts people from outside the country for better treatment and students from other states in India for better medical educational opportunities, which is popularly known as Medical Tourism. But medical facilities and infrastructure have been unevenly spread in the state. In this regard, the study adopts a different and unique method of studying the growing regional imbalances in development of health care facilities by looking from two angles i.e., input indicators and output indicators of health care development in the state. Ibid, p

9 Input Indicators Health Input indicators are those indicators which are provided by the state to improve the status of the health of people residing in a region. Input indicators will have larger role to play in inducing the necessary changes in building better health care infrastructure and delivery mechanisms. Besides, it places higher responsibilities on the state, as provision of basic health care is the constitutional obligation on the part of the state. Whatever emerges out of these input indicators is the output, which is supposed to be people-centric and should benefit all people irrespective of caste, class, gender and regional consideration. Furthermore, input indicators of health status of a region are the most important measure of development as it places enormous responsibility on the part of the state. Adequate and timely inputs by the state would not only create better healthcare infrastructure but also enhances its accessibility and thereby better outputs in health delivery system. Besides, it also explains the critical and effective role of state governments in fulfilling constitutional obligations. As per the Constitution of India, the provision of healthcare infrastructure is the primary responsibility shared by the central state and local governments, although it is primarily a state responsibility in terms of directing and ensuring equitable health services across regions. In this regard, we have taken six indicators in the health sector to compare among districts and regions in northern parts of the state of Karnataka such as availability of hospitals and beds, number of doctors, access to basic sanitation facilities, rural water supply, nutritional status of children and women as input indicators and infant mortality rate, maternal mortality rate, life expectancy at birth, sex ratio, crude birth rate and crude death rate as output indicators health care development in North Karnataka. Health Care Infrastructure The Government of Karnataka has, of late, accorded primary importance to health sector, particularly health care infrastructure. Several efforts have been put in place to improve the standard of living of people and thereby create a positive influence on the health and well being of the citizens of the state. The structural units of health sector are predominantly the health care infrastructure and its related health 130

10 care financing, which are the key input indicators in the health delivery system. 9 The state is following the national pattern of three tier health infrastructure in rendering primary health care through PHCs, Sub-Centres and Community Health Centres (CHCs) to its people by way of implementing various national and state health programmes of public health importance through its network of various types of health and medical institutions. At the state level, the Department of Health and Family Welfare has been playing a vital role in implementing the health care services. Furthermore, a wide network of health care institutjons with updated infrastructure exists to provide quality health care in the state at all levels- primary, secondary and tertiary. In terms of availability of health care infrastructure, the state of Karnataka presents a very mixed scenario though the state is equally placed with Kerala in terms of total beds available per lakh of population at Adequate health care infrastructure is critical in improving the health status of people, particularly in backward regions. In this regard, healthcare infrastructure such as number of hospitals and beds, PHCs, PHUs, dispensaries, drug shops, blood banks, family welfare centres etc. play an important role in enhancing rural health. But the physical infrastructure required for better health is not even between regions in Karnataka. Healthcare infrastructure is relatively better in urban and developed districts than in the rural and backward districts. In this regard, the following table 3.1 provides information on the availability of basic health care facilities in northern parts of the state for the year It is important to note the fact that sharp regional imbalances in terms of health care facilities and infrastructure persists even after five decades of planning in the state. 9 For more details on the status of financial allocations O[l social development in Kamataka see, concept paper of the Kamataka Development Report 2004, prepared by the Institute of Social and Economic Change (ISEC), Bangalore. 131

11 Table 3.1 Provision of Health Care Facilities in North Karnataka District Hospitals Primary Health Primary Health Dispensaries Drug Blood State Private Indian System of Centres Units Shops Banks Government Medicine (PHCs) (PHUs) Number Beds Number Beds Number Beds Number Beds Number Beds Number Beds Belgaum Bijapur I Bagalkot I Dharwad I Gadag Haveri so U.Kannada Bombay Karnataka Bellary II IO I Bidar I Guibarga IO 8I II Raichur IO Koppal Hyderabad Karnataka North Karnataka. South 9I I I 750 I4I Kama taka STATE Source: Compiled from the Kamataka At A Glance , Directorate of Economics and Statistics, Government of Kamataka, Bangalore-2005, pp.l

12 The above table shows the district-wise distribution of healthcare facilities within North Karnataka region. As evident from the above table, the provision of healthcare facilities has not improved even in The number of Primary Health Centers (PHCs) in the Bombay-Karnataka region and the Hyderabad Karnataka region was 418 and 295 respectively. But the figure for Hyderabad Karnataka region is the lowest in the state. In terms of blood banks, the Bombay Karnataka region accounted for 25 while it is as low as 13 in the Hyderabad Karnataka region. Similarly, there exist significant regional variations between the Bombay-Karnataka region and the Hyderabad-Karnataka region in terms of number of hospitals and beds, PHCs, PHUs, dispensaries, drug shops etc. It clearly shows the fact that public health facilities are unevenly distributed in northern region of the state. Consequently, all the districts of the Hyderabad-Karnataka region and parts of the Bombay-Karnataka region such as Bagalkot and Gadag have remained backward in terms of health care infrastructure. Furthermore, there is a trend that shows urban-rural divide, with most of the well-equipped hospitals are located in a few urban agglomerations of the state. Consequently, it provides limited access to rural poor. It also provides restricted access to different social groups. It can be seen in rising morbidity and mortality rates among the marginalized such as the Scheduled Castes and Scheduled Tribe populations in the state. 10 Availability of Hospitals Beds per Lakh Population Morbidity and illness is generally high in any developing country, which is on the path of modernization and has recovered from the long period of colonial exploitation. It requires frequent hospitalization of patients for treatment of diseases, which in turn necessitates availability of adequate number of hospital beds. The number of beds in Karnataka increased from 13,786 in to in Increase in the number of beds in different districts varies significantly as there is a clear divide between North and South Karnataka. 11 The districts in South Karnataka Human Development in Karnataka-1999, Department of Planning, Government of Karnataka, Bangalore, 1999.p-31. Panchamukhi P.R, "North-South Divide: Karnataka's Development Scenario", CMDR Monograph Series No. 21, CMDR, Dharwad, 2005, p.is. 133

13 are well equipped with adequate health institutions and hospital beds. But the most affected districts are those ones belonging to the Hyderabad-Karnataka region. The number of hospitals in rural areas is just only 25 percent, which is far lower than the other southern states. The following table 3.2 provides district wise details about the availability of hospitals per lakh population in North Kamataka. Table 3.2 Number of Hospital Beds per Lakh Population in North Karnataka Districts Belgaum Bijapur Bagalkot* Dharwad Gadag* 54 Haveri* U.K Bellary Bidar Gulbarga Raichur Koppal* STATE Source: District Socio-Economic Indicators 1994, and Kamataka At A Glance ,Directorate of Economics and Statistics, Government ofkarnataka, Bangalore,l995, p.l25. From the above table it is very clear that the provision of hospital beds in North Kamataka is uneven over the last four decades. In North Kamataka, except the districts of Bellary and Dharwad, all other districts have poor health infrastructure for people. The districts of the Hyderabad-Kamataka region have less number of hospitals compared to the state average of 88. The district ofbagalkot in the Bombay Kamataka region and the district of Raichur in the Hyderabad-Kamataka region have much less number of hospital beds per lakh population for the year In fact, the above data suggests that all the districts of North Kamataka have not made significant progress in terms of health care facilities. Availability of Medical Institutions per Lakh Population in North Karnataka Like other healthcare infrastructure, availability of medical institutions with all facilities is the crucial input indicator of a health status of a region. Medical institutions serve the immediate health needs of people and offers adequate medical care and treatment for health problems. However, the availability of medical 134

14 institutions has not been even across the districts of North Karnataka. The following table 3.3 provides information on district wise number of medical institutions in North Karnataka for the years to Table 3.3 Number of Medical Institutions per lakh population in North Karnataka District Belgaum Bijapur Dharwad U.K Bellary Bidar Gulbarga Raichur STATE Source: Human Development in Karnataka 1999, Department of Planning, Government of Kamataka, Bangalore, 1999, p.242. From the above table it is evident that there is not very significant increase in the number of medical institutions per lakh population over the decades for the districts of North Karnataka. Furthermore, there is a clear regional pattern as southern districts have progressed well in comparison with northern districts in the state. All the districts in North Karnataka except Dharwad have figures lower than the state average. But the figures for Hyderabad-Karnataka region is very poor as Raichur and Bidar districts continue to lag behind in number of medical institutions over the last four decades which is a cause of concern. Lack of adequate medical institutions has far-reaching implications on the status of the health of people residing in backward areas. As a resuit, the Hyderabad-Karnataka region has not been able to register impressive growth in terms of health infrastructure leave aside the quality of delivery systems in the region, which is stated to be poor and dismal. The official report of the government of Karnataka on the status of health has observed that the public health care facilities are unevenly spread across the state, with both health infrastructure as well as health status being poor in the northern districts Human Development in Karnataka 1999, Department of Planning, Government of Kamataka, Bangalore, p

15 Availability of Doctors per 10,000 Population Availability of doctors is considered as the most critical factor in ensuring medical facility, more particularly in rural areas as health care of rural people depends mainly upon the government hospitals. Number of doctors per I 0,000 population is used as an indicator to measure the health care infrastructure in this study. In Karnataka, as in the case with other health infrastructure, the availability of doctors has not been even. They are unevenly distributed across the regions and districts with rural areas being affected the most. As per the data available for the year 2001, the number of doctors per 10,000 population in Karnataka is 2.77, which is also the state average. The following table 3.4 shows the availability of doctors per 10,000 population (both government and private) for the districts ofnorth Karnataka, Table 3.4 Availability of Doctors per Population in North Karnataka in 2001 District Allopathic Homeopathic Govt. Doctors Total Number Doctors Doctors Doctors in Indian population of Doctor (Allopathic) Medicine per 10,000 Svstem population Belgaum I Bijapur Bagalkot Dharwad Gadag Haveri U.K Bombay Karnataka Bellary Bidar Gulbarga Raichur Koppa Hyderabad Karnataka North Karnataka South Karnataka STATE Source: Final Report of the High Power Committee for Redressal of Regional Imbalances in Karnataka, Government of Karnataka, Bangalore, 2002, pp

16 The above table shows growing regional imbalances in terms of availability of doctors within North Karnataka. It is evident from the above table that all the districts of Hyderabad-Karnataka region have the ratio below state average of 3 doctors for every 10,000 population. There are only 2 doctors for every 10,000 population in all the five districts of Hyderabad-Kamataka region. The district of Dharwad has the highest value of 7, which is the most developed district in the Bombay-Karnataka region. It has an average of 3 doctors per 10,000 population. It is significant to note that all the districts of Hyderabad-Karnataka region have 2 doctors for every \ population, which is not only lowest in North Karnataka but also in the whole state. As a result, the Hyderabad-Karnataka region fails to receive better health care for its people. It is important to note. that the health of the people, among other things, depends upon the number of doctors available in backward regions. In this regard, rural areas in backward regions are the most affected regions as they suffer from double disadvantage. It is also observed that the government doctors do not prefer to stray in rural areas even though residential buildings are constructed for them in rural places. Role of Family Welfare Centres The role of family welfare centres in providing basic health care and information is well established. They are the vital centres for counseling in rural areas. Besides, they are useful in developing preventive health care as it is mostly ignored in rural areas. It is often considered as unusual to visit health personnel or centre when a person maintains a normal health. In this regard, family welfare centres attempt to fill the gap created by illiteracy and ignorance by way of awareness programmes and campaigns. They educate people about the need for maintaining sanitation and hygiene, proper nutrition during pregnancy and early childhood, control and preventive measures against common and communicable diseases and epidemics, birth control measures, spacing pregnancies, preventing early marriages, helping people to know about deadly diseases like HIV and AIDS and other services that help people to lead a better and healthy life. Although, the state government of Karnataka has identified the critical role played by family welfare centres, particularly in promoting rural health, the spread of such vital centres has been uneven in the state. The backward districts in North Karnataka have continued to remain deprived of these 137

17 centres in adequate number. The following table shows the district wise information of availability of family welfare centres in north Karnataka. Table 3.5 District wise Number of Family Welfare Centres in North Karnataka ( ) Districts Centres Sub-centres Centres Sub-centres Belgaum Bijapur Bagalkot Dharwad Gadag* Haveri* U.K Bombay Karnataka Bellary Bidar Gulbarga Raichur Koppal* Hyderabad Karnataka North Kamataka South Karnataka STATE Source: Compiled from Kamataka at a Glance for the year & , Directorate of Economics and Statistics, Government ofkarnataka, Bangalore, p.69 & 73 respectively. From the above table, it is clear that the state government has not opened any new family welfare centre since Among the existing family welfare centres, more number of them is concentrated in southern region of the state. There exist regional imbalances within North Karnataka also as more number of family welfare sub-centres are established in Bombay-Karnataka region. There are only 82 centres and 1385 sub-centres in Hyderabad-Karnataka region whereas the number for Bombay-Karnataka region is 121 and 1966 respectively. Although the Hyderabad Karnataka region is catching up with other regions in the recent past, it is a matter of great concern for the policy makers to pay more attention to Hyderabad-Karnataka region while devising policies to promote rural health and correct regional imbalances in health care facilities and infrastructures. 138

18 Access to Basic Sanitation Facilities Provision of basic sanitation facilities is considered as the most significant input indicator of better health. There is no doubt that the use of sanitary latrine and hygienic living conditions improves the health of the people. The status of availability of household toilets is very poor and uneven in the State. Though awareness of the need for proper sanitation and toilet facilities has grown in recent days, only 34 per cent of the households have access to toilets in the State of Karnataka. Within this 34 per cent of the households, there exists rural-urban divide as only 6.85 per cent of households in rural areas have access to toilet facilities. 13 The figures related to this aspect suggest that the majority of the population in the state tend to use open spaces for defecation. This is seen as one of the major causes for the prevalence of diseases related to worm infections as well as of diarrhoea, typhoid, polio and cholera. This dismal position is the characteristic feature of rural Karnataka and the northern districts have not made impressive progress in this regard. The following table shows the parentage of households with toilet facilities. Table 3.6 Percentage of Households with Toilet Facilities in North Karnataka District Total Rural Urban Belgaum Bijapur Dharwad U.K Bellary Bidar Gulbarga Raichur STATE Source: Census of India 1991, tables on Houses and Household Amenities, quoted in Human Development in Kamataka, 1999, p.l55. As evident from the above table, only 24.1 per cent of the households in the state have access to basic amenities such as toilets. The situation in rural areas of the state continues to be the cause of concern for the state as majority of the rural population still uses open spaces for defecation. It is only 6.9 per cent of the rural people, who enjoy access to basic sanitation facilities. The situation in Hyderabad Karnataka region seems to be very poor as about only 2 per cent of the households have access to toilet facilities. The district of Raichur in Hyderabad-Karnataka region 13 Human Development in Kamataka, op cit, No.4, p

19 and Bijapur in Bombay-Karnataka region are the most backward districts in terms of basic sanitation facilities. Absence of basic sanitary facilities causes greater discomfort for women not only in rural areas but also in urban areas. Women who have to wait for twilight are subject to harassment and considerable discomfort. Even when common toilets are built in rural areas and slums, people tend to go away from them as they are poorly maintained. The biggest problem in maintaining common toilets is the lack of water as rural areas deprived of even potable water to drink. However, the government, of late, has taken steps to l?rovide toilet facilities to all the houses by way of both financial and material help to construct toilets in their homes. But it is observed that these programmes have not been so successful as on the one hand, people have not shown considerable response and interest, on the other hand, rampant corruption and mis-utilisation of funds meant for these programmes has been the predominant scenario in rural Karnataka. Rural Water Supply Availability of clean drinking water is the most basic requirement for maintaining a good state of public health. In fact, it is the primary responsibility of the state to ensure potable drinking water to all households. The national norms for the supply of water for domestic purposes aim at providing at least 40 liters per capita daily to rural habitations to meet minimum requirements. 14 Provision of safe drinking water is essential as it has a very significant bearing on matters pertaining to life and death including health and food security. It is estimated that poor quality and inadequate quantity of water accounts for about 10 percent of the total burden of disease in a developing country. 15 In this way, water plays a critical role in promoting or damaging the health and welfare of not only the born but also ofthe unborn. In Karnataka, 72 per cent of households have access to potable water covering 81 percent of urban and 67 percent in rural households. For the state as a whole, 52 per cent of households have access to piped water for drinking, 25 per cent get water from a hand pump and 17 per cent draw water from open wells, which is open to contamination. 16 But the measures of the state government to provide drinking water Report of the Human Development in Karnataka, Department of Planning, Government of Karnataka, Bangalore, 1999, p.157 Report of the High Power Committee for Redressal of Regional Imbalances in Karnataka, Government ofkarnataka, Bangalore, 2002, p.418. See National Family Health Survey- I, Karnataka Summary Report, 19?2-93, p

20 facility have yielded in uneven results. As in other states, Karnataka is also suffering from intra and inter-district disparities in the spatial distribution of drinking water facilities. The following table 3.7 presents the intra-region disparities in North Karnataka. Table 3.7 District wise Number of Habitations having Access to Drinking Water Facility in North Karnataka, 2000 District Number of Total numj:>er of Percentage of habitations in 40 or Habitations habitations with 40 morelpcd or more LPCD Belgaum BUapur Bagalkot Dharwad Gadag Haveri Uttara Kannada Bombay Karnataka Bellary Bidar Gulbarga Raichur Koppal Hyderabad Karnataka North Karnataka South Karnataka STATE Source. Compiled from the High Power committee for the redressal of Regional Imbalances in Karnataka, Government of Kama taka, Bangalore, 2002, p.ll9. It is evident from the above table that the northern region of the state continues to lag behind in terms of safe drinking water facility compared to southern region of the state. Within northern region of the state, there are wide differences between the Bombay-Karnataka and the Hyderabad-Karnataka region as the average for Liter Per Capita Daily (LPCD) is lowest for the region. Although the region is on par with the national norm, the feudal control over water resources in the region has deprived most of the rural poor from having access to safe drinking water facility. In general, the interior districts of North Karnataka continue to suffer from inadequate water supply even during winters. Public taps, the main source of drinking water get water practically once in a week in Haveri district of the Bombay-Karnataka region. It is significant to note that had the Tungabhadra and Varadha. river drinking water 141

21 projects completed on time, the situation would not have been so bad today. It was also learnt that the project works on these two rivers in North Karnataka have been lingering due to various reasons like lack of funds and also due to political reasons. 17 The problem of poor availability of drinking water in Hyderabad-Karnataka region continues to be the cause of concern for the state despite continuous efforts are being made. However, the situation in the recent past has been impressive because of the implementation of special programmes such as Rajiv Gandhi National Drinking Water mission in the most backward districts of North Karnataka during the period between and with the central assistance. Nutrition Nutrition is one of the core components of good health and considered as an input indicator to the health. It is significantly co-related with health and morbidity aspects of health. The under-nutrition is a condition that often emerges from inadequate intake of food essential nutrients in our food intake. In some cases, it is the result of lack of availability of food items for the people in the most backward regions. Over half of the children under age five years in India are malnourished. Such a critical condition has far reaching impact on the cognitive development and learning potential of the children. Among adults, high incidence of malnourishment reduces the capacity to work and productivity and thus enhances mortality and morbidity. In general, malnourishment is more predominant among women, who come from poor families. It is also a common feature in rural areas where women and children are often under-nourished. The National Family Health Survey-11 (NFHS) conducted for the period of , there were 47 per cent ofthe malnourished children under the age of3 years in India. In India, the percentage of undernourished children on height-for-age and. 17 The politics in completion of river water projects has affected their timely completion as the sitting MLA's of the region have shown great deal of disinterest in completing projects as they were initiated by their predecessors. For more details on this issue, see, Raghunandan P.M, "In Kamataka District, Water Once a month", Indian Express, New Delhi, December 27, 2002, p.6. For private control over water resources, see, Alam Jayanti, "Water, Not for Private Ownership", Economic and Political Weekly, July 24, 2004, pp The author underscores the need for equitable rights over water as it is of great importance to people. The author also criticizes the private ownership of water resources such as multinationals and the state policy of supplying adequate amount of water supply in favour of national capitals and major cities. 142

22 weight-for-height basis was 45.5 per cent and 15.5 per cent respectively. 18 Malnourishment is not a characteristic feature of children alone. Large proportion of women in rural poor households suffers from malnourishment. Over half of the evermarried women and three-fourth of the children suffer from anemia. Similarly, the NFHS conducted in Kamataka in , about 22 per cent of the children in the state were low birth weight and weighed less than 2500 grams at the time of birth. This is testimony to the fact that mothers suffer from poor nutritional status. It is also observed that in North Kamataka, the levels of under-nutrition are much higher in rural areas than in urban areas. Besides, there exist wide region-wise disparities within the state of Kamataka in terms of physical target achieved under the programme of prophylaxis against nutritional anemia in Kamataka. Gulbarga district in Hyderabad-Kamataka region continues perform poorly as the percentage of target achieved was just about 82 per cent. But the district of Bangalore (Rural) achieved the target of 262 per cent in respect of mother beneficiaries. In respect of child beneficiaries again the district of Gulbarga achieved only 30 per cent target whereas Kodagu district achieved a target of 236 per cent. Thus, the Hyderabad-Kamataka region in North Kamataka continues to remain poor in terms of supplementary nutrition programme. Furthermore, an anthropological study has found out that the weights and heights of boys and girls of 6-18 years of age was below the ICMR and MCHS standards in northern parts of Kamataka. In this regard, the Hyderabad-Kamataka region presents a dismal status of child nutrition in Kamataka To measure nutritional status of children, three indices are used generally. They are height-for-age, weight-for-height and weight-for-age. The height-for-age index examines linear growth retardation and is an indicator of chronic under nutrition. The weight-for-height index compares body mass to body length. It reflects under-nutrition. The weight-for-age is a composite measure of both chronic and acute under-nutrition. For information on this issue, see, Arnold Fred et al, "Indicators of Nutrition for Women and Children: Current Status and Recommendations", Economic and Political Weekly, February 14, 2004, p.667. Another indicator of nutritional status used widely is the Body Mass Index (BMI), which is defined as the weight in kilograms divided by the height in meters squared (Kg/m2). This indicator is used to assess both thinness and obesity. It is also helpful in detecting the risk of health or nutritional disorders. For more details on strategies to improve nutrition among children and women, see, Gopalan G. and Aeri Bani Tamber, "Strategies to Combat Under-Nutrition", Economic and Political Weekly, August 18,2001, p See, Khadi P.B and et al, "Weights and heights of Rural Boys and Girls in Northern Karnataka", Man in India, Vol.84, No. 1-2, January-June 2004, p.71. The article also highlights on the need for better physical development in order to stimulate their cognitive and mental development as it influences children's behaviors both directly and indirectly. 143

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