Health Situation in India and Jharkhand

Transcription

1 Chapter IV Health Situation in India and Jharkhand Introduction India is drawing the world s attention, not only because of its population explosion but also because of its prevailing as well as emerging health profile. Some progress has been made since independence in die health status of the population. Health status is one of the significant indicators of social and economic well being. So this chapter shows the health scenario of the country and of Jharkhand state by discussing on health services of the country and the State (Jharkhand) which will help to understand the basic health structure/ facilities of the country and different health programmes implemented since independence particularly with reference to Jharkhand, the studied state. Health Service Scenario in India India was once of the leading nation in Health Service Planning with focus on primary healthcare. In 1946, the Health Survey and Development Committee, headed by Sir Joseph Bhore recommended establishment of well structured and comprehensive health service with a good primary healthcare infrastructure. This report not only provided a historical landmark in the development of the public health system but also laid down the blue print of subsequent health planning and development in independent India. Improvement in the health status of the population has been one of the major thrust areas for the social development programmes of the country. This was to be achieved through improving the access and utilisation of health, family welfare and nutritional services with main focus on under served and under privileged segments of populations. Main responsibility of infrastructure and man power building rest with the State Government supplemented by funds from the Central Government and external assistance. Major disease control programmes and Family Welfare Programmes were funded by the Central Government and implemented through the State Government infrastructure. The food supplementation programmes for mother and child were implemented by the state through ICDS infrastructure funded by die Central Government Safe drinking water and sanitation facilities were essential pre-requisite for health. 40

2 From the time of independence health structure was mainly urban based and patients came there for hospitals and clinics provided for this. Limited services were in the rural areas, from the First Five year Plan Central and State Government made efforts to build up three tier health care system and link them through appropriate means and modes. The National Health Policy (NHP) adopted in 1983 reaffirmed India s commitment to Health for All within a context of social justice and democratisation. The NHP-1983 gave a general exposition of the policies required recommendation in die circumstances than prevailing in the health sector. The overall goal of the policy is the universal provision of comprehensive primary healthcare services which are relevant, affordable by the people and the nation. The policy envisages that the achievement of this goal will require (a) reorganisation of the health service infrastructure, (b) major modifications in the existing system of medical education and paramedical training, and (c) integration of health plans with efforts in health related sectors and even with socio-economic development processes. The recommendation of NHP-2002 will attempt to maximize the broad based availability of health services to the citizenry of the country on the basis of realistic consideration of capacity. The main objective of the policy was to achieve an acceptable standard of good health amongst the general population of the country. The approach would be to increase access to the decentralised public health sectors by establishing new infrastructure in deficient areas and by upgrading the infrastructure in the existing institution. Overriding importance would be given to ensuring a more equitable access to health services, access the social and geographical expanse of the country. Emphasis will be given to increasing the aggregate public health investment through a substantially increased contribution by the Central Government It was expected that this initiative will strengthen the capacity of public health administration at the state level to render effective service delivery. The contribution of the private sector in providing health services would be much enhanced particularly for the population group which can afford to pay for services. Primacy will be given to preventative and first line curative initiatives at the primary health level through increased sectoral share of allocation. Emphasis wid be given on rational use of drug within the allopathic system. Increased access to tried and tested sector of traditional medicine will be ensured. Within these broad objectives NHP will endeavour achieve the time bound goal. 41

3 Table 4.1: Goals to be Achieved by Eradicate Polio and Yaws 2005 Eliminate Leprosy 2005 Eliminate Kala Azar 2010 Eliminate Lymphatic Filariasis 2015 Achieve zero level growth of HTV/AIDS 2007 Reduce Mortality by 50% on account of TB, Malaria, other vector water borne diseases 2010 Reduce prevalence of Blindness to 0.5% 2010 Reduce IMR to 30/1000 and MMR to 100/lakh 2010 Increase utilization of public health facilities from current level of <20 to >75% 2010 Establish an integrated system of surveillance, National Health Accounts and 2005 Health Statistics Increase health expenditure by government as a % of GDP from the existing 0.9% 2010 to 2.0% Increase share of Central grant to constitute at least 25% of total health spending 2010 Increase state sector health spending from 505% to 7% of the budget 2005 Further increase to 8% 2010 Source: National Health Policy, The Primary Healthcare Services provide the first level of contact between the population and healthcare providers. In the real scenario many of the existing sub-centres, PHCs and CHCs lack essential physical infrastructure. The main reason behind the poor functioning was inappropriate location, poor access, lack of maintenance, lack of professional staffs, lack of funds for essential drugs and diagnostics machines and lack of First Referral Units (FRUs) for linkage of referral services. Secondary and tertiary care is needed to give a valuable support to primary health care. The secondary and tertiary health care hospitals were currently taking care of primary health care needs of the population in which they are located. Strengthening secondary and tertiary services was an identified priority in the Ninth Five year plan. Along with these the Indian System of Medicine and Homeopathy (ISM&H) consist of Ayurveda, Yoga and Naturopathy, Siddha, Unani and Homeopathy. Some of these systems are indigenous and over the years becomes a part of Indian tradition. Many practitioners are working in different geographical settings and play a good role in improving the quality and out of reach healthcare. These practitioners are close to die community in terms of cultural and social ethos. This system of medicine is affordable and as result of this it was accepted in all segments of the population. The NHP visualised 42

4 an important role for the ISM&H practitioners in the delivery of health services. The department of Ayurveda, Yoga and Naturopathy, Unani and Siddha and Homeopathy (AYUSH) was established as Department of Indian System of Medicine and Homeopathy (ISM&H) in Ministry of Health and Family Welfare in March Health Policy and Infrastructure for Rural Areas The selective health intervention during the colonial period resulted in the so-called modem-medicine in India. After independence, the state has chosen to follow these western model. This system, which is highly selective, institutionalised, centralised and top down-not by oversight but by design- and which treats people as objects rather than subjects, has failed to address the needs of the majority, that is to say, the rural poor and indigenous people. While the significant portion of the country s medical needs especially in rural areas have been attended by the indigenous health system. The draft of the NHP has also not given due importance to Indian systems of medicine. The concept of family physicians with social accountability, which has traditional roots and acceptance from the rural masses, has diminished with the existing policies and value system. The present westernised hospital based medical education and training which is supported by public funding has proved beyond doubt that new doctors are not inclined to and capable of meeting the needs of the majority of the'people (rural and tribal people) which is where their services are most required. The current need for the rural areas is medical and paramedical manpower, such as social physicians, public health nurses and midwives and paramedical workers (e g. laboratory technicians, rural health and sanitation workers, health literacy educators, population educators etc.). Some of the rural health technologies propagated was inappropriate such as ORS packets instead of locally available water and cooked cereals, sugar-salt solution and herbal teas which are culturally accepted by the community. During the 80s India continued to expand and improve her public infrastructure for the health service delivery. The NHP-2002 highlights the achievements through the years ( ) in the form of demographic characters, health infrastructures, and epidemiological shifts. 43

5 Table 4.2: Achievements through the Years ( ) Demographic Changes Indicators Life Expectancy (RGI) Crude Birth Rate (SRS) 26.9 (99 SRS) Crude Death Rate (SRS) 8.7 (99 SRS) Infant Mortality Rate (99 SRS) Health Infrastructure SC/PHC/CHC ,363 1,63,181 (99 RHS) Dispensaries and Hospitals (all) ,555 43,322 (95-96 BHI) Beds (Private and Public) 1,17,198 5,69,495 8,70,161 (95-96 BHI) Doctors (Allopathic) 61,800 2,68,700 5,03,900 (98-99 MCI) Nursing Personal 18,054 1,43,887 7,37,000 (99 INC) Epidemiological Shifts Malaria (cases in millions) Leprosy cases per 10,000 population Small Pox (no. of cases) Eradicated - Guinea worm (no. of cases) Eradicated - Polio (no. of cases) No data Source: National Health Policy, The expansion in the infrastructure was undertaken to keep the public health service in rural areas keeping in pace with population growth following the norms that the country had adopted for facilities at the various levels. Though concept of primary health care is appropriate in rural areas but it remained sound on paper only. For example in many places health centres were in poor condition. The necessary staffs were not allocated; equipments are may not be in that state to be used, and supplies of inadequate medicines. Specialist has been appointed in few CHCs only and in many places they are working on ad-hoc basis during their due course of training. These things reflected a clear vision of health arrangements in the rural health centres. One of the most significant developments in health manpower during the 1980s was the concept of the Multi-Purpose-Workers (MPW). It was recommended by Kartar Singh Committee in 1974 but in due course administrative problems weakened this concept. The numbers of centres for MPW training was inadequate. The rapid expansions of health centres during the 80s necessitated the production of even greater numbers of MPWs. The result is that the number of MPWs reported to be in position exceeds the number of trained. Existing training facilities are inadequate and compromises have been made in the duration and content of training resulting altogether in very poor quality training. These gross inadequacies are perhaps a reflection of the lack of commitment to this 44

6 lowest level worker. During Ninth plan several centrally sponsored schemes including / Family Welfare Programmes (RNTCP), National Malaria Eradication Programme (NMEP) will provide funds for the recruitment of manpower but it also does not full fill the gaps in this. Tribal Health and Policies As the present research was conducted on tribal population, it may not be out of context to discuss specifically on the tribals. The tribals constitute a sizeable population of India. Almost 68 million people in this country are tribe. There are 437 different groups of tribes in this country. The population of tribe in this country is 8.2 percent of India s total population (Census, 2001). Nearly 635 tribes are located in five different parts of India. Three-forth of tribal population was located in eight states of the country. However the North-east and Jharkhand provinces are dominated by tribes only. Largest numbers of scheduled tribes are in Orissa with 62 scheduled tribal communities (22.1 percent) but the highest percentage was in Jharkhand (26.3 percent) (Census, 2001). It is a matter of concern that though tribal people usually live close to nature and in and around healthy surroundings of natural environment and they apparently appear to be normally healthy person but majority of them need health care of one kind or the other on account of abject poverty, malnutrition, lack of safe drinking water, poor sanitation and hygienic condition etc. Lack of awareness and socio-cultural barriers and apathy to prefer available health services in whatever form and extent these are also causes adversely on the health status of the tribal people. In wake of opening of tribal areas, highways and changes occurring on account of industrialization, modernization and communication facilities, health problems and diseases too affect the tribal people. Endemics viz. malaria, vulnerability to diseases like deficiency of G6PD, venereal diseases and AIDS are not untouched in the pockets of tribal populations all over the country. However, lack of safe drinking water and malnutrition are two well recognised major health hazards. It was rather difficult to establish that tribals have a satisfactory dietary pattern in view of deficiency of calcium, vitamin A, vitamin C, riboflavin and animal protein is usually found in their diet. Malnutrition and under-nutrition are common observance in case of primitive tribal groups who largely depend upon food either gathered or cultivated by them using simple 45

7 methods. The nutritional status of tribal women directly influences their reproductive performances and infants health status crucial for his survival, growth and development. General scene with regard to tribal health portrays a common picture that tribals suffer from many chronic diseases of which vector and water borne diseases take heavy toll than any other diseases. Contaminated water was also source of intestinal and skin diseases. Diarrhoea, dysentery, cholera were some common diseases needing attention on medical account to keep the tribals away from these diseases. Similarly on nutritional backdrop, deficiency of certain minerals and other elements was also taking the tribal population within clear control. It was common that iodine deficiency causing goitre was widely spread in the Himalayan ranges and terai areas. G6PD syndrome and varieties of fevers were common among the tribes of Gujarat, Madhya Pradesh and parts of Rajasthan. Recent blow of instance of AIDS can also not be ruled out especially for the tribes. Anaemia is a major problem for the women in India and more so in the tribal belt. The NHP accorded a high priority to provision of health services to those residing in the tribal and backward areas as well as areas detected of endemic diseases. In this regard in Eighth Plan provisions of preventive, promotive and curative services through the primary health care institutions and at the village level through the trained health workers. It was a notable fact that in tribal inhabited areas the population coverage norms of PHIs is relaxed to one PHC for every 20,000 population and one sub-centre for 3000 population while choosing the villages for sub-centres the state has advised to set up villages having 20% or more scheduled caste population and 7.5% in tribal areas. But the fact is that there were 20,097 sub-centres functioning against a requirement of 28,383 sub-centres for tribal areas. Health Scenario of Jharkhand Jharkhand is one of the empowered action group state, continues to share a number of characteristics with other backward states of India such as high infant mortality, low immunization of children and expectant mothers, high mortality due to infectious and contagious diseases, high maternal mortality and low institutional delivery. These coupled with poor accessibility to health care facilities and high cost of treatment by households have made all the achievements in health sector insignificant. Despite the National Rural Health Mission (NRHM) and Government s commitment to improve the availability of and access to quality health care by people, especially for those residing in the rural area, 46

8 the improvement in public health care services in the states has not shown marked improvement in public health indicators. Many factors contribute to the poor health status including poverty, poor infrastructure and high morbidity. Poverty associated communicable diseases like tuberculosis and malaria along with maternal mortality and morbidity comprise a major portion of the disease burden. Malaria is endemic with Sequent epidemic outbreaks of Plasmodium falciparum malaria (about 50%). Over 60,000 deaths occur every year due to tuberculosis. Prevalence of leprosy is 10 per 10,100. The poor performance of state in most health indicators and service utilisation were given in the Table 4.3. Table 4.3: Health Indicators Teenage pregnancies (15-19 yrs) 27.5 Neonatal Mortality 48.6 Infant Mortality (SRS 2007) 49 (NFHS-m, ) 68.7 Three or more ANC visits 35.9 Percentage given or bought IFA 49.5 Percentage who took IFA for at least 90 days 14.2 Percentage who received all recommended types of ANC 7.5 (ANC check-ups, TT, IFA) Percentage of deliveries assisted,by Health Personnel 27.8 Fully immunized months (BCG, measles, three doses of DPT 34.2 and polio) Prevalence of any Anaemia (age 6-59 months) 70.3 Source: NFHS-3 ( ), SRS 2007 The crude birth rate in the state is 26.2 per 1000 (SRS, 2007) while the infant mortality rate is 49 (SRS, 2007) and 69 per 1000 live births (NFHS-III, ). 60 percent of infant deaths are neo-natal deaths. Only 52 percent children are fully immunised (as per CES, 2007) and 35 percent according to NFHS-III. About 78 percent of children were anaemic (NFHS-III, ) and 59 percent of children below three years of age were underweight. Maternal mortality was high at 371 per 100,000 live births (SRS, 2003). Around 45 percent women have reproductive health problems and 30 percent women complain of reproductive tract infection. About 70 percent of women in Jharkhand were anaemic and about 30 percent of them were moderately to severely anaemic. According to state government figure among all pregnant women, antenatal care was received by only 38 47

9 percent (whereas NFHS-III shows 36%), IF A consumption was 15 percent (NFHS-1II) and 50 percent received tetanus toxoid injection. Nearly 80 percent deliveries take place at home. Only 31% of all couple use any modem methods of family planning (NFHS-III). Permanent sterilization particularly female sterilization dominates (23%) and total unmet need for family planning was as high as 24%. Above statistics shows that in almost every health indicators Jharkhand fares poorly. Health services and Infrastructure According to the state health report there was a huge gap in the current availability and proposed numbers of health facilities in die state. The state has only 3958 sub-centres whereas the requirement is of 5057 health sub-centres. For PHCs the current availability is 330 while the proposed number was Table 4.4 shows the status of infrastructure and staffing of Public Health System in Jharkhand. Table 4.4: Health Infrastructure of Jharkhand as on 2006 Particulars Required In position Shortfall Sub-centre PHC CHC Health Assistant (Female)/LHV at PHCs Health Assistant (Male) at PHCs Obstetricians & Gynaecologists at CHCs Physicians at CHCs Paediatricians at CHCs Total specialist at CHCs Radiographers Pharmacist Laboratory Technicians Nurse/Midwife Source: Bulletin of Rural Health Statistics in India Infrastructure Division MoHFW/GoI 48

10 Table 4.5: Health Infrastructure Gaps (District) Districts Population CHCs PHCs HSCs covered Existing (in no.) Propose d (in no.) Existing (in no.) Proposed (in no.) Existing (in no.) Proposed (in no.) Bokaro Chatra Deoghar Dumka Jamtara Dhanbad E.Singhbhum Garhwa Giridih Godda Simdega Gumla Hazaribagh Koderma Lohardaga Pakur Palamu Latehar Ranchi Sahibganj ' Saraikela W.Singhbhum Jharkhand Source: Government of Jharkhand Infrastructure gaps and institutional challenges were clear from Table 4.5. It is interesting to note that 37 percent of Sub-centres, 67 percent PHCs and 82 percent of the CHCs were never constructed in the state. National Rural Health Mission (NRHM) in Jharkhand Government of India has launched the National Rural Health Mission to carry out necessary correction in the basic health care delivery system. After four years of implementation of NRHM, Jharkhand is still struggling to capture the opportunity for expansion of health services to the last person and meeting the missions, goal and objective such as reduction in IMR and MMR, access to public health services, prevention and control of communicable and non-communicable diseases, access to primary health care, population stabilisation, gender and demographic balance, revitalisation of local health tradition and mainstreaming AYUSH and promotion of 49

11 better healthy life style. The mission has also envisaged a number of outcomes at the community level which include availability of trained community level worker (Sahiya) at the village level, with a drug kit for generic ailments, empowerment of PRIs and decentralization of health system. The mission was committed to provide quality health care at the grassroots but there are lot of implementation challenges in achieving the mission s goal and providing health care services to rural population. Integrated Child Development Services (ICDS) Children are the first call on agenda of human resource development - not only because young children are the most vulnerable, but because the foundation for life long learning and human development is laid in these crucial early years. India is the home to the largest child population in the world. The development of children is the first priority on the country s development agenda, not because they are the most vulnerable, but because they are our supreme assets and also the future human resources of the country. In these words, our Tenth Five Year Plan ( ) underlines the fact that the future of India lies in the future of Indian children - across income groups, geographical locations, gender and communities. Government of India proclaimed a National Policy on Children in August 1974 declaring children as, "supremely important asset". The policy provided the required framework for assigning priority to different needs of the child. The programme of the Integrated Child Development Services (ICDS) was launched in 1975 seeking to provide an integrated package of services in a convergent manner for the holistic development of the child. Objectives of ICDS were to lay the foundation for proper psychological development of the child, improve nutritional & health status of children 0-6 years, reduce incidence of mortality, morbidity, malnutrition and school drop-outs, enhance the capability of the mother and family to look after the health, nutritional and development needs of the child, and achieve effective coordination of policy and implementation among various departments to promote child development. The Scheme provides an integrated approach for converging basic services through community-based workers and helpers. The services are provided at a centre called the Anganwadi. The Anganwadi, literally a courtyard play centre, is a childcare centre, located within the village itself. A package of following six services is provided under the ICDS Scheme: 50

12 Supplementary nutrition Non-formal pre-school education Immunization Health Check-up Referral services Nutrition and Health Education The three services namely immunization, health check-up and referral are delivered through public health infrastructure viz. Health Sub-Centres, Primary and Community Health Centres under the Ministry of Health & Family Welfare. Table 4.6: Target Groups & Service Provider Services Target Group Services Provided By Supplementary Children below 6 years; Anganwadi Workers (AWW) & Nutrition pregnant and lactating Anganwadi Helper (AWH) mothers Immunization Children below 6 years; ANM/MO pregnant and lactating mothers Health Check-ups Children below 6 years; ANM/MO/AWW pregnant and lactating mothers Referral Children below 6 years; AWW/ANM/MO pregnant and lactating mothers Pre-School Children 3-6 years AWW Education Nutrition & Health Education Women (15-45 years) AWW/ANM/MO 51

13 Table 4.7: List of Medicine Kits consists of items and their quantities SI No. Product Name Strength Quantity 1 Paracetamol Tablets IP 500 mg 500 Tabs x 1 Jar 2 Paracetamol Syrup IP 125 mg/ 5ml 500 ml. XI bottle 3 Mebendazole Tablets IP 100 mg 450 Tabs x 1 Jar 4 Benzyl Benzoate Application IP 25% w/w 500 ml x 1 bottle 5 Chloramphenicol Eye Ointment 1% w/w 3.5 gm x 10 tubes 6 Sulphaeetamide Sodium Eye Drops IP 10% w/w 10 ml. x 6 vials 10% w/w 7 Gention Violet 2% w/v 2% w/v 100 ml x 1 Bottle 8 Fovidone Iodine 5% w/w 5 gm x 5 Ointment 9 ORS-Citrate IP Sodium chloride 3.5 gms, potassium chloride 1.5 gms, Sodium Citrate 2.9 gms, Dextrose Anhydrous 20.0 gms, Total 27.9 gms, (to be dissolved in one litre of water 10 Absorbent cotton rolls of 400 gms. (sterilized) As per IP 1996 tubes 50 sachets 400 gms x 2 rolls 11 Cotton Bandage 5 Cmsx 5 mtrs. x 1 12 Booklet in Hindi Language Source: Department of Social Welfare, Women and Child Development, Government of Jharkhand Discussion From the above discussion it was clear that since independence government adopted several policies and implemented programmes in respect of health and family welfare. The major thrust of Health Service Planning is on Primary Health Care which helps to improve the social development programmes of the country. Major disease control programmes and family welfare programmes are funded by the Central Government and implemented through the State infrastructure. The food supplementation programme for mother and child are implemented through ICDS infrastructure funded by the Central Government. The National Health Policy accorded a high priority to provision of health 52

14 services to those residing in the tribal, hilly and backward areas as well as detection and treatment of endemic diseases affecting the tribal population. It has been noted that the overall health status of the poor and tribal people over large parts of Jharkhand is very poor. The reason for poor health status is due to lack of quality health services. The factors that hinder proper implementation of NRHM are due to lack of systematic coordination and implementation of various programmes and mechanism of Government of Jharkhand. 53