HEALTH ATTAINMENTS AND CHALLENGES IN JHARKHAND Vijay Kumar Baraik 1

Jharkhand Journal of Development and Management Studies XISS, Ranchi, Vol. 16, No.1, March 2018, pp. 7575-7595 HEALTH ATTAINMENTS AND CHALLENGES IN JHARKHAND Vijay Kumar Baraik 1 The State Jharkhand emerged out of the century long struggle by the tribal people of a particular region historically or geographically identified as Chhotanagpur Plateau and Santhal Parganas. The struggle has been first for a state of ethnic identity and tribal self-rule in line with their cultural identities and management of the system followed by the reason of exploitation, suppression, forced land alienation, damage of their own system by the external world in the name of development. Everything aforementioned was at the cost of tribal people. The State got into existence with very high expectations by not only tribals but also by non-tribals with a new and dignified identity Jharkhand, which was full of resources but suppressed for ages and pushed towards margins. The new State created a new kind of despair and discontent. Resource appropriation got worse than ever. Worst ever political instability was witnessed in the country with no ideology, no vision, no accountability and so on. The situation worsened due to the extremist activities. In the midst of all these, the reconstruction of damaged Chhotanagpur and Santhal Parganas delineated as Jharkhand lost its path. Health is also one of such sufferer areas. However, it moved ahead, though stumbling, due to peoples own will and efforts, national and international result oriented and time bound health missions. There have been successes amid failures and challenges with quality being a major issue. In the backdrop of above, this paper examines the attainments and challenges of Jharkhand in health after more than a decade of its birth. The analysis is also inter-regional and inter-district for a comparative view with the identification of lagging behind regions in certain indicators. It is based on secondary sources such as National Family Health Survey (NFHS), District Level Household and Facility Survey (DLHS), Census of India, and Ministry of Health and Family Welfare, Govt. of India and Govt. of Jharkhand. The preliminary results reflect that there has been remarkable achievement in some indicators like IMR, ANC, institutional births, immunisation, etc., while there are challenges such as maternal mortality, infrastructure and manpower, malaria prevalence, access to safe drinking water and sanitation, and distance, geographical condition, connectivity, mobility and seasonal conditions in providing or receiving health care services. Besides, there are marked inter-regional and interdistrict gaps. Keywords : Health Attainments, Morbidity, Undernutrition, Maternal and Child Care Introduction Jharkhand was created on 15 th November 2000 after a long struggle and movement due to its distinct cultural identity including the exploitations and deprivations of various kinds. After the completion of one decade full of potentials and opportunities, it is expected to have 1 Associate Professor, Discipline of Geography, School of Sciences, Indira Gandhi National Open University (IGNOU), New Delhi, Email- vijaybaraik@ignou.ac.in 7575

7576 Baraik achievements in the desired direction though the State has undergone instabilities of various kinds throughout this period (political instability with ten governments in fifteen years, shortest being of ten days and three long presidential rules; and bureaucratic instability with highly uncertain tenures of bureaucrats in any office). It did grow in terms of Per Capita Income which rose from Rs. 14,292/- in 2001-02 to Rs. 46131/ - in 2013-14 but with a wide disparity in the State. Poverty ratio declined from 45.3 per cent in 2004-05 to 36.51 per cent in 2011-12 (Rural- 40.84, Urban- 24.83, ST- 54, SC-58 per cent). It is generally felt that State has remained poor amid tremendous potential. The last decade has been comparatively very dynamic in many respects due to rapid technological development and transformations in all spheres. This decade also brought a prefix e in governance and other areas for better delivery of services and growth. It has been the decade of information flow with amazing volume and pace, wide exposure of people, emergence of a new era with new generation empowered with various means of information and communication confined to a small device. This new generation and old ones with a fresh thinking expect from the new State the new pace of result oriented development like other parts of the country and globe. However, there is a general feeling of remaining poor amid vast resources and development prospect. Exuberance of Jharkhandis (people of Jharkhand) and curiosity of outsiders for Jharkhand as emerging State due to its vast resource base just got faded away over a very short span of time due to failure of the State in various fronts. Health is also one such area of expectations in the State, which is an important factor for normal functioning of human being with maximum productivity. It is closely related to human development as well and widening opportunities for heading a fuller life. It does not only include mortality but also some vital indicators like morbidity and nutritional status and associated factors like access to health care services and health care utilisations. Despite health and health care being in the centrality of the government policies, various regions of the State with wide disparity are yet to be fully covered by health care services. It has big challenges including high level of prevalence of morbidity. Most importantly, there has been a paradox of poor levels amid plenty of resources and potential in the State. The National Family Health Survey (NFHS)-3 and District Level Household and Facility Survey (DLHS)-3 reports indicate the status of health through key indicators in Jharkhand. There are good achievements in some indicators but challenges are many and enormous. Total Fertility Rate is reaching at its satisfactory level.

Health Attainments and Challenges in Jharkhand 7577 The mortality indicators indicate that despite significant decline in IMR, it is still higher compared to the State like Kerala. Maternal Mortality is extremely high. Some of the aspects of maternal and child health and health care are also poor than national average. The details of above are discussed in the subsequent sections. The paper has been divided into the following six sections: Introduction, review of literature, health attainments, challenges, State initiatives, policy gaps, and alternatives and conclusions. Review of literature There have been research on health and related issues in the State. Though these are issue specific. Jharkhand has always been perceived differently as characterised with tribes as far as the health and health care are concerned. And, therefore, the focus of most of the research has also been oriented towards this perception. Ivern (1969) through a holistic survey entitled Chotanagpur Survey conducted in 1969 says that despite health services were introduced in 1864 by the British government for its officers and families, Bihar (Chhotanagpur or Jharkhand was part of Bihar till Nov 2000) remained neglected for long compared to the other provinces. Most prevalent incidences of disease were dysentery, diarrhoea, respiratory, including TB, eye infection, typhoid and skin diseases in entire region. The region specific diseases were gastro enteritis, scabies, anemia, malnutrition and parasitical infestations, filariasis, cholera, leprosy, and mental disorders in Chhotanagpur. Lack of safe drinking water, poor housing conditions, lack of sanitary facility and unhygienic practices, poverty and lack of nutritious balanced diet, apathetic behaviour of care providers, corrupt practices, myths and ignorance, were identified along with inadequate facilities as main factors of high morbidity and poor health condition in the region. Sinha (2006) describes the high level of morbidity, under nutrition and mortality among tribes in Jharkhand. He highlights the availability, accessibility and affordability among other things where centrality or nodality should be of prime importance for the location of services. He also opined that the primary health sub-centres be replaced with mobile health care units. However, mobile units should be additional facilities along with three tier rural health facilities. According to him, spacing of settlements and geographical isolation should be taken care of while planning health care services. Sinha also emphasises on the roles of community based organizations, curbing the unrestricted growth of unqualified practitioners and regulations of

7578 Baraik private health services. A rapid change in the health sector has taken place in the State due to exogenous and endogenous factors. Holistic study on health status involving health status in terms of morbidity, nutritional status and health care utilization in relation to the levels of development was carried out by Baraik (2002) with special reference to the Scheduled Tribes of Jharkhand. This research concludes that development is needed in this kind of society for the affordability of minimum health status. It has also empirically found that the tribes in Jharkhand have made much more departure from the preconceived notion of not preferring modern medicine as they are averse only in miniscule common incidences. Objectives The objectives of this paper is to examine the attainments and challenges of Jharkhand in health since its emergence as a new State. The objectives also include the identification of lagging behind regions in certain indicators through inter-regional and inter-district analysis for the proper intervention. Database and methodology The data for this paper has been taken from various secondary sources. These sources are: National Family Health Survey (NFHS), District Level Household and Facility Survey (DLHS); Census of India, RGI, Govt. of India; Ministry of Health and Family Welfare, Govt. of India; and Ministry of Statistics and Programme Implementation, Govt. of India and Govt. of Jharkhand. The major indicators are Fertility, Mortality (IMR, Maternal Mortality), Morbidity (Diarrhoea, ARI), Undernutrition, Health Care (ANC, Institutional Birth Immunisation, Treatment of Diarrhoea and ARI), Health Infrastructure (PHC, CHC, PHSC, Manpower), Communication and Accessibility - Distance and Connectivity, and Amenities- Sanitation and Safe Drinking Water. Simple statistical and graphic representation techniques have been used in this study. Findings and discussion 1. Health attainments Health attainments have been measured through the indicators of fertility, mortality, morbidity, and maternal and child care. It was observed that in some of the indicators the state has made a significant departure. A very positive sign among the tribal

Health Attainments and Challenges in Jharkhand 7579 communities in the State is observed, where there is not much difference from the average figure. DLHS-3 suggests that the tribals have equally performed in the consumption of the IFA breaking the traditional myth of being averse of modern health care. It means wherever there is availability and accessibility of modern sources of health care services, the people have proved that it is not an ethnic prejudice in the State. Empirical research also suggest that only a minuscule tribal population (less than three percent) do not prefer modern medicine in only some cases what others also do the same (Baraik, 2002). Fertility and mortality indicators Total Fertility, IMR and Immunization show very good level of attainments, where Jharkhand has achieved in bringing down the fertility rates since 2005. Its slow but steady decline has been projected to achieve replacement-level of fertility (i.e. 2.1) by 2018. It was 3.5 in 2005, 3.2 in 2009 and 2.8 in 2012. Infant Mortality Rate (IMR) is considered as one of the most important indicators of health status and overall quality of life. As per the data provided in the data portal of the Govt. of India taken from Sample Registration System, Jharkhand's achievement in minimizing IMR from 70 to 29 during the period since its existence (2000-2016) is among the good performing states after Sikkim, Tamil Nadu, Delhi, Maharashtra, Punjab, Tripura, Karnataka, Jammu & Kashmir, West Bengal, Himachal Pradesh and Mizoram (Table 1). Though best performing states have achieved remarkably like Goa, Puducherry, Kerala, Manipur and Nagaland. The IMR in Goa in 2016 is 8. There are some states like Arunachal Pradesh and Mizoram where increased IMR is noticed. (Table 1). Jharkhand's achievement is more than the national average in terms of both number and percentage from the base level (Chart 1). The present IMR is lower than Chhattisgarh, Odisha, Madhya Pradesh, Uttar Pradesh, Bihar, Rajasthan, Haryana, Gujarat, Jammu & Kashmir (J&K), Andhra Pradesh, Assam and Meghalaya. The state has almost touched the 12th Plan goal of reduction in IMR at 27.. However, the intrastate situation of IMR across the districts suggests that challenge also exists to minimize it in the peripheral and non-industrial districts of the state primarily in the districts of Santhal Pragana region excluding Deoghar, western districts including Chatra, West Sin ghbhu m+saraikela-kh arsaw an, Lohar daga and Gumla+Simdega (Table 2).

7580 Baraik Table-1. State wise trends of infant mortality rate in India, 2000-2016 State/UT 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Period Decline %age Decline Andhra 65 66 62 59 59 57 56 54 52 49 46 43 41 39 39 37 34 31 47.7 Pradesh Arunachal 16 7 23 21 25 27 31 31 31 27 25 23 24 24 30 30 36-20 -125.0 Pradesh Assam 75 74 70 67 66 68 67 66 64 61 58 55 55 54 49 47 44 31 41.3 Bihar 62 62 61 60 61 61 60 58 56 52 48 44 43 42 42 42 38 24 38.7 Chhattisgarh 79 77 73 70 60 63 61 59 57 54 51 48 47 46 43 41 39 40 50.6 Delhi 32 25 33 26 32 35 35 36 35 33 30 28 25 24 20 18 18 14 43.8 Goa 21 14 16 13 18 16 15 10 10 10 10 11 10 9 10 9 8 13 61.9 Gujarat 62 60 60 57 53 54 53 52 50 48 44 41 38 36 35 33 30 32 51.6 Haryana 67 66 62 59 61 60 57 55 54 51 48 44 42 41 36 36 33 34 50.7 Himachal 51 43 61 42 51 49 50 47 44 45 40 38 36 35 32 28 25 26 51.0 Pradesh Jammu & 50 48 47 44 49 50 52 51 49 45 43 41 39 37 34 26 24 26 52.0 Kashmir Jharkhand 70 62 58 51 49 50 49 48 46 44 42 37 38 37 34 32 29 41 58.6 Karnataka 57 58 55 52 49 50 48 47 45 41 38 35 32 31 29 28 24 33 57.9 Kerala 14 11 10 11 12 14 15 13 12 12 13 12 12 12 12 12 10 4 28.6 Madhya 88 86 85 82 79 76 74 72 70 67 62 59 56 54 52 50 47 41 46.6 Pradesh Maharashtra 48 45 45 42 36 36 35 34 33 31 28 25 25 24 22 21 19 29 60.4 Manipur 22 10 - - - - - 10 14 16 14 11 10 10 11 9 11 11 50.0 Meghalaya 66 51 66 56 43 49 53 52 58 59 55 52 49 47 46 42 39 27 40.9 Mizoram 18 18 6 16 27 - - - 37 36 37 34 35 35 32 32 27-9 -50.0 Nagaland NA NA NA NA 17 18 20 19 26 26 23 21 18 18 14 12 12 5 29.4 Odisha 95 91 87 83 77 75 73 71 69 65 61 57 53 51 49 46 44 51 53.7 Punjab 52 52 51 49 45 44 44 43 41 38 34 30 28 26 24 23 21 31 59.6 Rajasthan 79 80 78 75 67 68 67 65 63 59 55 52 49 47 46 43 41 38 48.1 Sikkim 47 29 25 22 30 30 33 33 33 34 30 26 24 22 19 18 16 31 66.0 Tamil Nadu 51 49 44 43 41 37 37 35 31 28 24 22 21 21 20 19 17 34 66.7 Telangana - - - - - - - - - - - - - - - 34 31 - - Tripura 35 35 33 23 30 31 36 41 34 31 27 29 28 26 21 20 24 11 31.4 Uttar 83 83 80 76 72 73 71 69 67 63 61 57 53 50 48 46 43 40 48.2 Pradesh Uttarakhand 50 48 44 41 42 42 43 48 44 41 38 36 34 32 33 34 38 12 24.0 West Bengal 51 51 49 46 40 38 38 37 35 33 31 32 32 31 28 26 25 26 51.0 Andaman & 16 7 23 21 25 27 31 31 31 27 25 23 24 24 22 20 16 0 0.0 Nicobar Islands Chandigarh 27 16 22 12 22 19 23 35 28 25 22 20 20 21 23 21 14 13 48.1 D&N Haveli 57 61 51 49 34 43 24 29 34 37 38 35 33 31 26 21 17 40 70.2 Daman & Diu 54 43 30 36 30 28 37 28 31 24 23 22 22 20 18 18 19 35 64.8 Lakshadweep 22 38 15 21 39 22 25 38 31 25 25 24 24 24 20 20 19 3 13.6 Puducherry 20 22 25 27 26 28 28 16 25 22 22 19 17 17 14 11 10 10 50.0 India 68 66 63 60 58 58 57 55 53 50 47 44 42 40 39 37 34 34 50.0 Source: Sample Registration System (downloaded from http://niti.gov.in/conten)t/infantmortality-rate-imr-1000-live-births

Health Attainments and Challenges in Jharkhand 7581 Table-2. Infant mortality rates in Jharkhand, 2011 District Total Rural Urban Jharkhand 38 42 24 Garhwa 36 36 36 Palamu + Latehar 44 45 26 Chatra 46 47 39 Hazaribagh + Ramgarh 31 32 29 Kodarma 30 31 27 Giridih 32 33 - Deoghar 34 33 35 Godda 58 59 - Sahibganj 56 58 36 Pakur 54 54 - Dumka + Jamtara 44 44 - Dhanbad 26 35 19 Bokaro 28 33 23 Ranchi + Khunti 32 37 22 Lohardaga 54 57 30 Gumla + Simdega 45 46 24 West Singhbhum + Saraikela Kharsawan 53 56 29 East Singhbhum 25 29 21 Source: Annual Health Survey Bulletin 2011-12, Jharkhand, RGI, New Delhi Gumla has achieved the lower female IMR than male and the male-female IMR is equal in Chatra, Koderma, Godda, Dhanbad, Ranchi (Including Khunti) and Pashchimi Singhbhum. In rural area the female IMR is lower in East Singhbhum, West Singhbhum (including Saraikela-Kharsawan), Gumla (including Simdega), Dhanbad, Godda, and Koderma. If these districts control the female IMR in urban areas, it will be a very good achievement. It is also an achievement of the State to bring IMR of females at par with or better than males in those districts where the society may traditionally be perceived with gender biasness (non-tribal districts). Chart 1

7582 Baraik Maternal Mortality Rate (MMR) given by the Sample Registration System, Census of India is still very high (261) while the national average is 212 and is 81 in Kerala. Also, MMR for combined Bihar and Jharkhand has declined from 312 in 1999-01 to 167 in 2011-13 (Chart 2). It achieved more than few states like Assam, Uttar Pradesh/ Uttarakhand, Rajasthan, Odisha and Madhya Pradesh/Chhattisgarh. However, the MMR is still above Kerala (61), Maharashtra (68), Tamil Nadu (79), Andhra Pradesh (92), Gujarat (112), West Bengal (113), Haryana (127), Karnataka (133) and Punjab (141). The decline is noticed with the pace of national average only (around 16 per cent). It is still very high and need to be minimized urgently and with good pace. Chart 2 Maternal and child care The age at marriage of boys and girls has marginally gone up during the two District Level Health Surveys (DLHS) held during 2002-04 (DLHS-2) and 2007-08 (DLHS-3). The two DLHSs reveal that the Any Ante Natal Check-up received by mothers rose from 51.2 per cent to 55.9 per cent. The State has made a remarkable progress in full immunization from 25.7 to 54.1 per cent and reached the level of national average (54.0 per cent). TT injection has witnessed a rise of 6.2 percentage points. The sharp and remarkable jump has been recorded in the consumption of 100 IFA Tablets from 12.0 to 56.3 per cent. The ARI and fever are well taken care in the State. Tribals equal achievement in IFA breaking the myth of aversion from modern medicine is also a good achievement. The growth in immunization in BCG from 50.8 to 85 per cent, OPV3 from 34.8 to 64.4, DPT from 35.6 to 62.6 per cent and Measles

Health Attainments and Challenges in Jharkhand 7583 from 31.2 to 70.5 per cent was also observed during these two surveys. The latest figures are expected to be further better since the DLHS-3. There is a sharp drop of percentage of children not received any vaccination to single digit level from more than 45 per cent in the DLHS-2 but has still remained double of the national average. On the other hand the same is half a per cent in Kerala. The preliminary report of NFHS-4 reveals that there are some indicators, where very impressive progress is observed like institutional births have seen notable jump from 18.3 per cent in NFHS-3 (2005-06) to 61.9 per cent in NHFS-4 (2015-16). Similarly, sharp rise are observed in safe delivery from 27.8 to 69.6 per cent (rural- 57.3 per cent), full immunization from 34.2 to 61.9 per cent and children with diarrhoea received ORH from 17.4 to 44.8 per cent. There are also some indicators which did not see very good progress. Like full ANC increased from 4.9 to 8.0 per cent, IFA consumption for 100 days rose from 9.5 to 15.3 per cent, children with ARI taken to health facility progressed from 63.0 to 67.2 per cent only. Decline of under nutrition also experienced a slow progress during this period, where stunting declined from 49.8 to 45.3 per cent, wasting from 32.3 to 29.0 per cent, and underweight from 56.5 to 47.8 per cent only. Among adults, the percentage of women having BMI below 18.5 reduced from 42.9 to 31.5 per cent and males from 38.6 to 23.8 per cent. 2. Challenges There are many challenges, which significantly overcast the achievements. The challenges are in mortality and morbidity, maternal and child care, nutrition, drinking water and sanitation, facilities and services, infrastructure and manpower, etc. discussed ahead. Mortality and morbidity indicators The State has reduced the IMR in extraordinary manner. However, it needs to be brought down to single digit level. There is also a big challenge amidst good achievements to minimize IMR in the peripheral and non-industrial districts of the State (Santhal Pargana region excluding Deoghar, south and western districts (Chatra, West Singhbhum+Saraikela-Kharsawan, Lohardaga and Gumla+Simdega). Maternal Mortality has not much declined (2001-312, 2010-267) since the creation of the State and is still very high. There still long way to go in minimizing maternal mortality as there has not been much decline (2001-312, 2010-267) since the creation of the State. The government sources reveal that Jharkhand has the second highest cases of Malaria - (152061) next to Odisha (294759) in India even after having prolonged programme on malaria eradication by the government.

7584 Baraik Maternal and child care During the two District Level Health Surveys (DLHS) held in 2002-04 (DLHS-2) and 2007-08 (DLHS-3), Any Ante Natal Check-up received by mothers improved from 51.2 per cent to 55.9 per cent (Table 3). However, the percentage of mothers who had three or more ANCs is almost static with 30.7 and 30.5 per cent respectively during two surveys. It also indicates that about 25 per cent mothers go for less than three ANCs. In case of full ANC, it is further poor and almost static in two surveys with 9.1 and 9.3 per cent respectively. No Ante Natal Care is very high (total-40.6, ST- 50.0 per cent) compared to the average figures for respective groups of the country (Total-22.8, ST- 29.4 per cent) as reflected by NFHS-3. Though TT injection has witnessed a rise of 6.2 percentage points and the sharp and remarkable jump recorded in the consumption of 100 IFA Tablets it is still far from the full coverage. The percentage of mothers receiving full antenatal care in NFHS 4 (2015-16) was only 8.0 per cent moving from 4.9 per cent in NFHS-3 (2005-06). Table-3. Health indicators of Jharkhand, 2002-04 and 2007-08 Indicators DLHS-3 (2007-08) DLHS-2 (2002-04) Total Rural Urban Total Rural Urban Mean age at marriage for 22.9 22.4 25.5 22.4 21.7 24.8 boys (marriages that occurred during the reference period) 3 Mean age at marriage for 18.3 18 20.3 17.9 17.3 20.2 girls (marriages that occurred during the reference period)3 Antenatal care (based on women whose last pregnancy outcome was live/still birth during the reference period)3 Mothers who received any 55.9 52.9 84.5 51.2 42.3 82.8 antenatal check-up (%) Mothers who had three or 30.5 26.9 65.2 30.7 21 65 more ANC (%) Mothers who consumed 100 56.3 57.4 45.6 12 7.5 27.9 IFA Tablets (%) Mothers who had full 9.1 7.2 27 9.3 5.1 24.4 antenatal check-up6 (%) Delivery care (based on women whose last pregnancy outcome was live/ still birth during reference period) Institutional delivery (%) 17.8 13.4 59.3 21.2 10.1 60.6 Delivery at home (%) 81.8 86.2 40.3 78.5 89.6 39.1 Delivery at home conducted 7.2 7.6 5 7.7 6 13.6 by skilled health personnel (%)

Health Attainments and Challenges in Jharkhand 7585 Safe Delivery7 (%) 25 21 64.3 26.7 15.5 65.9 Child Immunization Children 12-23 months fully 54.1 52.4 69.3 25.7 18.9 49.7 immunized (%) Children (age 9 months and 61.6 60 76.6 11.3 8.3 21.9 above) received at least one dose of vitamin A supplement) (%) Treatment of childhood diseases (based on last two surviving children born during the reference period) Children with diarrhoea in 21.3 19.9 38.6 24.9 20.8 39.5 the last 2 weeks who received ORS12 (%) Children with acute 62 61 75.4 58.4 55.2 69.9 respiratory infection or fever in last 2 weeks who sought advice/treatment (%) Source: DLHS-1 and DLHS-2 One major concern during two surveys was why the institutional (21.2 per cent in DLHS-2 to 17.8 in DLHS-3) and safe (26.7 per cent to 25.0 per cent) deliveries have declined during DLHS-2 and DLHS-3 period as the base level is already low. The current survey, however, reflects remarkable coverage as mentioned in the attainment section. A very high maternal mortality rate may be a reflection of this poor maternal care in the State. The two DLHSs reveal that the State has made a remarkable progress in full immunization from 25.7 to 61.9 per cent in 2015-16. Institutional and safe deliveries are still far from the desired level in the state as these are 17.8 and 25.0 per cent respectively. Within the state, Institutional Deliveries are still very poor in majority of the districts with less than 10 per cent in Latehar and Sahebganj. Majority of the districts show less than 20 per cent institutional deliveries. A little improvement is seen in the rural areas in delivery care. There are wide rural-urban gaps observed in these indicators except the consumption of IFA Tablets. The urban centric health care is a big challenge in the State. In terms of curative care, health care among children is poor in Jharkhand in case of diarrhoea treatment through ORS supplement as only 44.8 per cent children received ORS. Similarly, there is a decline in the percentages of aware women about danger sign of ARI and diarrhoea care of children.

7586 Baraik Under nutrition Very high level of under nutrition exists among the children of Jharkhand. The NFHS-3 given on Table 4 reveals that 76.6 per cent are under grown, 44.1 per cent are wasted (low weight for height) and 82.6 per cent are under weight. Among these 26.8, 11.8 and 26.1 percent children are severely stunted, wasted and underweight respectively. The underunitrition is much higher among ST children with corresponding figures of 84.4, 51.5 and 97.9 per cent for under-height (stunted), wasted, and underweight. Height and Weight for Age are in a very miserable condition where just 2.1 per cent children have normal weight. Severely stunted, wasted and underweight ST children are 29.9, 11.9 and 33.6 per cent respectively with not much difference. 43 per cent (ST-47.2 per cent) women and 38.6 percent (ST-42.1 per cent) men are found to be thin, among which 18.0 per cent (ST-18.9 per cent) women and 13.8 per cent (ST-12.5 per cent) men are moderately/ severely thin. The NFHS-4 indicates that there has been significant reduction in the under nutrition among children as the percentages of stunted, wasted and underweight children are 45.3, 29.0 and 47.8 which are still very high. Similarly, the percentages of thin man and women in 2015-16 are 31.5 and 23.8. Anaemia is also very high among women (70.6 percent, ST- 85.0 per cent) and children (77.9 per cent, ST-79.5 percent), which is towards extreme side among STs (Table 4). There is no very good progress in this regard as anaemia is prevalent among 65.2 and 69.9 per cent women and children respectively in 2015-16. Table-4. Under nutrition in Jharkhand Under Nutrition Total (%) ST (%) Under Growth-Stunting (Height for Age) 76.6 84.4 Underweight (Weight for Age) 82.6 97.9 Wasting (Low weight for Height) 44.1 51.5 Severely stunted 26.8 29.9 Severely underweight 26.1 33.6 Severely wasted 11.8 11.9 Thin Men 38.6 42.1 Thin Women 43.0 47.2 Moderately/Severely Thin Men 13.8 12.5 Moderately/Severely Thin Women 18.0 18.9 Anaemia among Women 69.5 85.0 Anaemia among Children 70.3 79.5 Source: NFHS-3, 2005-06

Health Attainments and Challenges in Jharkhand 7587 Drinking water and sanitation Water quality has also been sources of many diseases. As per the Census 2011, 87.27 per cent inhabited villages had the access to the sources of safe drinking water facilities, which need to be 100 percent. Sahebganj has reflected comparatively very low percentage (60.86) of villages having access to the safe drinking water. It has to go beyond this to the habitation level and household level availability of safe drinking water for full coverage. At the household level, 85.5 per cent households have access to the sources of safe drinking water in India as per the Household Tables 2011. In Jharkhand the percentage of such households is 60.1 and it is 53.5 per cent among ST households. The all sources of drinking water located away from the households is 17.6 per cent in India while it is 31.9 per cent in Jharkhand. It goes further high to 42.3 per cent households of STs. Hand pumps are located away from 43.7 per cent households in Jharkhand. This problem of difficult physical access to drinking water urgently needs to be addressed as a noble human cause. Similarly, 77.0 per cent households do not have latrine facilities as compared to 49.8 per cent in India, which is highest in the country reflecting a very poor condition of hygiene in the State. On the other end, there are states which have less than 5 per cent households in this category. These are closely associated with health and need to be addressed urgently for good health. Facility and access One group of the major challenges in health care service providing or receiving is the geographical condition, distance, connectivity, mobility and seasonal conditions. Though the Census of India does not provide distance from settlement points to the service centres, it gives average distance of a village irrespective of its area and spread of settlements. As per the Village Directory, 2011 Census, 15.6 per cent villages have Primary Health Sub Centres, while 68.9 per cent villages have this at a distance within 5 kms, and the percentages of villages having access to this facility at a distance of 5-10 kms and more than 10 kms are 15.1 and 0.5 respectively. The situation is worrisome in case of access to the Primary Health Centre which is located at 4.6 per cent villages only and accessible within 5 kms, 5-10 kms and above 10 kms of distance to 13.9, 33.3 and 48.1 per cent villages (Chart 3).

7588 Baraik Chart 3 In this case distance and proportion of villages have positive relation. The percentage of villages having PHC at above 10 kms of distance goes as high as 73.7 in Dumka followed by more than 60 per cent in Ranchi and Simdega and above 50 per cent in Jamtara, Garhwa, Giridih, Khunti and Purbi Singhbhum (Table 5). Moreover, the location and distance with all barriers should always be considered from each settlement of a revenue village and not only from the boundary of the revenue villages as these factors play vital role in health care from both ends-service providers and receivers. Table-5. Percentage of inhabited villages by distance from PHC in Jharkhand, 2011 District Distance Number of Villages Total Percentage of Villages 0 KM Outside 5-10 Above Villages 0 KM Outside 5-10 Above Village but KM 10 KM Village but KM 10 KM Within Within 5 KM 5 KM Bokaro 21 89 207 294 611 3.4 14.6 33.9 48.1 Chatra 71 275 442 589 1377 5.2 20.0 32.1 42.8 Deoghar 118 343 860 1033 2354 5.0 14.6 36.5 43.9 Dhanbad 87 300 381 307 1075 8.1 27.9 35.4 28.6 Dumka 70 168 470 1980 2688 2.6 6.3 17.5 73.7 Garhwa 47 32 276 489 844 5.6 3.8 32.7 57.9 Giridih 27 299 774 1458 2558 1.1 11.7 30.3 57.0 Godda 306 283 688 411 1688 18.1 16.8 40.8 24.3 Gumla 48 114 341 439 942 5.1 12.1 36.2 46.6 Hazaribagh 43 220 421 509 1193 3.6 18.4 35.3 42.7 Jamtara 23 115 297 647 1082 2.1 10.6 27.4 59.8 Khunti 18 92 233 411 754 2.4 12.2 30.9 54.5 Kodarma 9 115 170 283 577 1.6 19.9 29.5 49.0 Latehar 22 141 235 351 749 2.9 18.8 31.4 46.9 Lohardaga 25 53 99 175 352 7.1 15.1 28.1 49.7 Pakur 70 146 401 524 1141 6.1 12.8 35.1 45.9

Health Attainments and Challenges in Jharkhand 7589 Palamu 79 185 902 545 1711 4.6 10.8 52.7 31.9 Pashchimi 22 207 625 788 1642 1.3 12.6 38.1 48.0 Singhbhum Purbi 15 232 555 807 1609 0.9 14.4 34.5 50.2 Singhbhum Ramgarh 9 88 129 79 305 3.0 28.9 42.3 25.9 Ranchi 57 127 323 789 1296 4.4 9.8 24.9 60.9 Sahibganj 138 203 429 579 1349 10.2 15.0 31.8 42.9 Saraikela- 20 245 446 435 1146 1.7 21.4 38.9 38.0 Kharsawan Simdega 17 31 128 273 449 3.8 6.9 28.5 60.8 Jharkhand 1362 4103 9832 14195 29492 4.6 13.9 33.3 48.1 Source: Census of India, 2011 Negotiating with the geographical (physiographical) factors is very important as the state is highly undulated with lots of physical barriers between patient and the health centre and lack of transport network and facilities for mobility. Approach to pucca road to 64.4 per cent inhabited villages by 2011 (Village Directory, Census of India, 2011) was a major challenge providing or availing services or making services approachable/ accessible, which becomes further difficult during and post monsoon season. The shortage of infrastructure and manpower is also a big problem. The pressure of more than a lakh rural population per Primary Health Centre is in the districts of Deoghar, Giridih, Godda, Khunti, Ramgarh, Garhwa and Hazaribagh closely followed by Sahebganj. Similarly, ten thousand and above rural population per health subcentre is in the districts of Giridih, Chatra, Palamu and Hazaribagh (Table 6). The other area of concern is the meeting the shortfall of manpower as per Indian Public Health Standard (IPHS) norms. As per the CS Review done on 11-07-2013 on the status of the Dept. of Health, Medical Education and Family Welfare, Govt. of Jharkhand, the gaps in existing and IPHS norms are huge. The shortfall of man power as per IPHS norms till 2012 was 2569 Medical Officers, 2635 Staff Nurse, 958 Pharmacist, 831 Lab Technician, 57 Radiographer, 890 Lady Health Visitor, and 400 Dresser (Table 7). The Jharkhand Economic Survey states that till March 2016, there had been shortfall of manpower in varying degrees, while the additional manpower in ANM is still continuing. Since there is high demand and no more aversion from modern health care, it is a challenge to provide accessible, affordable and quality health care services of all kinds by proper planning. Approach to health and health care are taken standalone way and therefore, a big challenge is also to have integrated approach associating all other determinants and their departments with the aspects of health and health care utilization.

7590 Baraik Table-6. District-wise number of persons per health facility in Jharkhand 2001 and 2011 District Number of Sub Number of Primary Population per Population per Centres Health Centres Health Sub-Centre Health Centre 2001 2011 2001 2011 2001 2011 2001 2011 Bokaro 54 116 16 16 18019 9299 60813 67418 Chatra 12 93 8 11 62451 10537 93677 89085 Deoghar 49 181 18 5 20521 6816 55863 246742 Dhanbad 59 141 19 28 19352 7972 60092 40146 Dumka 106 258 40 36 9881 4772 26185 34202 Garhwa 54 132 18 12 18386 9493 55157 104426 Giridih 99 181 29 15 18001 12362 61451 149163 Godda 67 185 24 10 15089 6752 42122 124913 Gumla 144 242 26 13 5505 3967 30488 73856 Hazaribagh 44 146 31 14 28313 9994 40186 104228 Jamtara 26 132 13 15 22973 5419 45945 47686 Khunti 55 108 8 4 7373 4508 50692 121726 Koderma 32 65 13 6 12895 8846 31743 95836 Latehar 57 97 9 10 9379 6960 59399 67512 Lohardaga 51 73 11 10 6242 5539 28939 40438 Pakur 47 121 13 9 14162 6884 51203 92546 Palamu 41 171 36 21 35090 10023 39963 81613 Pashchimi 59 342 28 15 17676 3755 37245 85620 Singhbhum East Singhbhum59 244 8 18 15115 4178 111473 56629 Ramgarh 35 54 6 5 14361 9824 83773 106098 Ranchi 122 365 35 28 11489 4540 40049 59176 Sahibganj 39 155 16 10 21273 6393 51852 99090 Saraikela- 51 194 29 12 13510 4156 23760 67193 Kharsawan Simdega 82 162 13 7 5858 3436 36949 79519 Jharkhand 1444 3958 467 330 14510 6330 44865 75924 Source: i) Village Directory, Census of India 2001, ii) Data Portal India, http:// data.gov.in/ Table-7. Medical Officers & Paramedics status (HSC -3958, PHC -330, CHC -188, SDH -10, DH -22) Category Total Sanctioned Working Working Working Working Shortfall Required (Regular) (Regular) Contractual State Total as per as per (NRHM) Contract (Regular+ IPHS IPHS Contractual) Norms 2010 Medical 4451 2048 1510 50 322 1882 2569 Officers* ANM 7916 6020 4668 3269 1192 9129 1213 additional ANMs Staff Nurse 3381 379 276 371 99 746 2635 Pharmacist 1332 385 122 94 158 374 958 Lab Technician 1338 443 144 223 140 507 831 Radiographer 169 50 32 80 0 112 57 Lady Health 1045 473 155 0 0 155 890 Visitor Dresser 488 471 88 0 0 88 400 HSC Health Sub Centre, PHC- Primary Health Centre, CHC- Community Health Centre, SDH- Sub-Divisional Hospital, DH- District Hospital Source:http://jrhms.jharkhand.gov.in/FileUploaded%20By%20User/ Final%20CS%20ReviewHealth%20%20PPT%20%2011.07.2013.pdf

Health Attainments and Challenges in Jharkhand 7591 3. State initiatives Initiatives for maternal and child care The state has taken many initiatives in achieving health goals. To minimize Maternal Mortality (MMR), the initiatives are through cash incentive for institutional delivery, cashless delivery (Janani Shishu Suraksha Karyakram-JSSK), free health care services, drug, blood, diet to pregnant women, mamta vahan, free c-section facilities in First Referral Units (FRUs) anaemia control, IF supplements (life cycle approach), de-worming, blood bank, normal pregnancy and normal child birth, immediate referral facility for complicated cases, enhancing delivery service centres and operationalize 24x7 delivery services in the PHCs. Besides this other initiatives planned will further contribute to the decline of MMR and improving mother and child health. The state has initiated number of new born child care with a target towards full immunization, control of childhood anaemia, diarrhoea care, vitamin supplements, ARI treatment, establishment of malnutrition treatment centres, maternity care centres and these may have been the factors in reducing IMR significantly in the State. A good achievement in leprosy eradication is also observed where Jharkhand has almost achieved at par with national level (CS Review). To reach the remote areas, distribution of bicycles (10400 distributed, 16000 more in the plan) is a very welcome step in improving mother and child health as it contributed in education among girl children in the State (CS Review). Infrastructure, facilities and manpower As far as health infrastructure and amenities are concerned, at present the State has 3958 Health Sub-Centres, 330 Primary Health Centres and 188 Community Health Centres and the proposed numbers of these facilities are 7088, 1126 and 235 respectively (Department of Health, Medical Education, Research and Family Welfare, 2012)). It is good to see that the State is moving forward to develop health infrastructure as per IPHS norms. As per the population norms of IPHS, the present pressure on each kind of health centre in rural area is too high - 6330 persons per Health Sub-Centre, 75924 persons per Primary Health Centre and 133272 persons per Community Health Centre. The government has initiated for the optimization of population per health facilities as per the set standards and targeted to meet the set standard which will be 3535, 22251 and 106617 rural persons as per 2011 Census per Health Sub-Centre, PHC and CHC. It will be little above the threshold values determined for the tribal and hilly areas.

7592 Baraik 4. Policy gaps There are gaps in the health care initiatives in the states. Firstly, there are large villages having difficult access to the health care services due to location, distance, connectivity and other factors of accessibility. The establishments of more hospitals are being done without much rationale as these are taking place not in the gap areas but in those areas, which already have the facilities. There are also some non-scientific and irrational policy decisions. For example Jharkhand Tribal Development Programme started in Phase I and II in tribal dominated districts raise a question for leaving Simdega and Gumla districts, which are the districts with highest ST population. Similarly, more infrastructure are being created in those districts which are already having or have access to such services and the districts or regions like Palamu and Simdega are continuously neglected. It will never lead to the equitable distribution of the resources. Besides, there are also gap in the adequate infrastructure and man power as per prescribed norms. Finally, there is a complete lack in the integrated approach as health and health care are still seen independently. Alternatives and Conclusions The State has made marked progress in some of the indicators, especially IMR by reducing it at par with the leading states. Slow but steady Total Fertility Rate is moving towards desired direction. Health care in terms of maternal and child care have also shown good progress over the period. There are various initiatives also. However, the challenges are much more than the achievements in the State. In the last decade, significant emphasis has been received in the health sector unlike the preceding times and a number of international and national level important programmes have been initiated. A number of surveys, database preparations, and efforts have been made in the State enabling research, evaluation, planning and implementation quick and on real time basis. Among all these programmes, National Rural Health Mission (NRHM) has its own objectives in line with the national and Millennium Development Goals (MDG) objectives. The State is known for poor response to the modern medicine or modern health care due to its cultural characteristics, though the tribal population is only about 26.3 per cent. Over the period this aversion from modern medicine has gone away, and especially, in the last decade there has been tremendous transformation in the health care psychology of the people for the demand of quality health care (Baraik, 2002). The mindset has changed to a considerable extent. There might be some continuity of orthodox or traditional thinking and practices juxtaposed

Health Attainments and Challenges in Jharkhand 7593 with this. There might also be certain level of superstition due to historical roots and weak and less effective modern system in terms of quick demonstration effect in the society. Nevertheless, people are now open to the modern health care services and the time has come to meet the demand as enough level of awareness has grown among the people and more people are moving towards nearby health/urban centres for getting health care services on need. It is the time to offer quality services to affordable cost at accessible points to make the State healthy. Otherwise the disbelief and unreliability will be formed again to persist for further longer time. To meet the objectives, many initiatives are needed. Firstly, availability and accessibility should be addressed properly. Besides population norm, there should also be mapping of gap areas or areas deprived of services due to geographical factors and distance and locating/relocating service points accordingly for complete coverage upto last person in the last mile as the State is plateau region and is highly undulating in physiography. The surrounding areas around Ranchi, Jamshedpur, Dhanbad and now proposed hospital at Dumka and Chaibasa are covered by hospitals and medical college. Setting up of Medical Colleges with 300 bedded Hospitals at Palamu, Chaibasa, Dumka, Hazaribagh and Ranchi planned by the government is surprising as a large unserved area in and around Simdega has not figured in the plan. Good hospitals should also be developed in the gap areas like Simdega and Daltonganj as the distance of good hospitals located at Ranchi are more than 100 kms. These centres can serve large area. Modern GeoInformatics tools and techniques should be utilized for planning, management, monitoring and assessment so that timely decision and provision can be made available at the time of emergency or regular requirements. In this direction, Integrated Health Management System (Baraik, 2003) should be of a great value. These are helpful as Quick Decision Support System (QDSS) in planning, management and monitoring. Telemedicine may be another way to provide super-specialized health care facility in the various parts of the State, if implemented effectively. Looking at the existing infrastructure and manpower, facilities, strength, extensions of service centres along with access may solve many associated problems. However, policy should be very carefully framed and adopted due to specific regional and socio-economic characteristics in the State. As land utilization pattern of 2012-13 suggests, land under current fallow is roughly equal to the net sown area. The Net Sown Area (NSA) is 17.6 per cent whereas the total fallow along with cultivable waste land is 31.1 per cent. In addition to this, culturable waste land

7594 Baraik accounts for 4.4 per cent. The cropping intensity is only 117.86 per cent. By better agricultural practices food, nutrition and health may be addressed significantly. The Report Transforming Jharkhand, The Agenda for Action for the planning of Jharkhand recommends the privatisation of rural health, which will be a big disaster as private service providers work with profit making motive. As the State has very high poverty level in the rural area, hardly any private player would be willing to operate. In such case the rural population will be again left helpless on their own fate in the absence of government and private health care providers. Even if some private health care providers come up, affordability will be a major issue. It is urban centric and elite recommendation. Health is not uni-dimensional, and is a result of the overall development of a society. It cannot be seen independent of socio-cultural factors, economic factors like employment and occupation, income generation and affordability, political factors, literacy and educational level, health awareness, access to food and nutrition, quality of housing, source of drinking water, sanitation and hygiene, lifestyle, health policy, programmes and implementation, etc. All these factors are interlinked and interwoven when matter of influence on health comes. Example is drastic reduction in IMR with high level of under nutrition among children. Therefore, the whole concept of health and disease should be looked into with a holistic and integrated approach in a larger context than just health and disease. It should be integrated with education, employment and income, agriculture and food productivity and availability, infrastructure and amenities including safe drinking water and sanitation to overcome the major barriers physical, social, financial and ignorance. Since there is high demand and no more taboo or imposition of modern health care, it is a challenge to provide accessible, affordable and quality universal preventive and curative health care services of all kinds to the people as the NRHM envisaged in 12th plan. Now all want to witness the success. A new and lot more result oriented, informed, pro-active and participatory society is seen ahead creating demands for quality and accessible h ealth care services! REFERENCES Baraik, V. K. (2002). Socio-economic development and changing health conditions among the Scheduled Tribes of Chhotanagpur. New Delhi: Centre for the Study of Regional Development, JNU (PhD Thesis). Department of Health, Medical Education, Research and Family Welfare (2012). Draft of 12th Five Year Plan (2012-17) and Annual Plan (2012-13). Ranchi: Govt. of Jharkhand. Retrieved from http://jharkhand.gov.in/new_depts/ healt/final%2012%20five%20year%20plan%20final%20%2031.03.12.pdf)

Health Attainments and Challenges in Jharkhand 7595 Government of India.(2016). Agriculture-Statistical Year Book India 2016. Ministry of Statistics and Programme Implementation, Govt. of India. Retrieved from http://www.mospi.gov.in/statistical-year-book-india/2016/ 177 State wise Infant Mortality Rate(IMR) of India from 1971 to 2012. Ministry of Health and Family Welfare, New Delhi. Retrieved from https://data.gov.in/ resources/state-wise-infant-mortality-rateimr-india-1971-2012. Government of Jharkhand. (2010). Annual Plan 2009-10. Department of Health, Family Welfare, Medical Education & Research. Retrieved from http:// documents.gov.in/jh/12893.pdf Review by Chief Secretary 11.07.2013. Ranchi: Department of Health, Medical Education & Family Welfare, Govt. of Jharkhand. Retrieved from http:// jrhms.jharkhand.gov.in/fileuploaded%20by%20user/final%20cs%20 ReviewHealth%20%20PPT%20% 2011.07.2013.pdf Government of India, Ministry of Health and Family Welfare. (2008). National family health survey (NFHS-3), India, 2005-08, Jharkhand. Mumbai: IIPS. Retrieved from file:///c:/users/welcome/downloads/jharkhand_report.pdf Government of India, Ministry of Health and Family Welfare. (2017). National family health survey (NFHS-4), 2015-16. State fact sheet, Jharkhand. Mumbai: IIPS. Retrieved from http://rchiips.org/nfhs/pdf/nfhs4/ JH_FactSheet.pdf Government of India, Ministry of Health and Family Welfare. (2010). District Level Household and Facility Survey (DLHS-3), 2007-08, Fact sheet, Jharkhand. Mumbai: IIPS. Retrieved from http://rchiips.org/pdf/rch3/state/ Jharkhand.pdf Government of India, (2010). 4 th Common Review Mission (Dec. 16-22), Jharkhand. National Rural Health Mission, Ministry of Health and Family Welfare. Retrieved from http://nhm.gov.in/images/pdf/monitoring/crm/4th-crm/ report/jharkhand.pdf Government of Jharkhand. (2017). Jharkhand Economic Survey 2016-17. Planning-cum-finance Department, Finance Division. Retrieved from h t t p s : / / f i n a n c e - j h a r k h a n d. g o v. i n / p d f / b u d g e t 2 0 1 7 _ 1 8 / JHARKHAND_ECONOMIC_SURVEY_2016_17_FINAL.pdf Government of Jharkhand, 12 th Five Year Plan. (2012-17). State Annual Plan 2012-13. Retrieved from http://planningcommission.nic.in/plans/stateplan/ Presentations12_13/jharkhand12_13.pdf Government of India. (2009). Jharkhand Fact Sheet 2009, Coverage Evaluation Survey. New Delhi: UNICEF and NIHFW. Retrieved from file:///c:/ Users/Welcome/Downloads/Jharkhand.pdf Ivern, F. (1969). Chotanagpur survey. New Delhi: Indian Social Institute. RGI. (2001). Census of India, 2001. New Delhi: Govt. of India. RGI. (2011). Census of India 2011, Jharkhand, Household Tables. New Delhi: Govt. of India. RGI. (2011). Census of India 2011, Jharkhand, Village Directory. New Delhi: RGI. RGI. (2013). Annual Health Survey Bulletin 2011-12, Jharkhand. New Delhi: Govt. of India. RGI. (2013). SRS Bulletin (Sample Registration System), Vol. 48, No. 2. New Delhi: Govt. of India. Sinha, S. (2002). Health status and health care among tribals: The case of Jharkhand. In S. Prasad & S. Sathyamala (Eds.), Securing Health for All: Dimensions and Challenges (pp.- 380-398). New Delhi: Institute for Human Development.