HEALTH CARE:
ACCESS, UTILISATION AND EXPENDITURE
1. Utilisation of antenatal
care services in peri-urban areas of east Delhi
Authors
: Aggarwal O.P., Kumar R., Gupta A., et al.
Source
: Indian Journal of Community Medicine, 1997
Place of study : Delhi
Location :
Peri-urban
Period of study : 1991
Type of research : Empirical, Descriptive, Community-based
Aims: To assess the utilisation of antenatal services in peri-urban areas
of east Delhi.
Methodology: The study population consisted of mothers of 276 live born
children. The data were collected through a semi-structured, open-ended
questionnaire. The survey instruments were pre-tested.
Findings: The findings revealed that 74.3 per cent of mothers had been
registered at one of the medical care centres. Of them, 10.8 per cent did not
receive tetanus toxoid vaccines, 26.4 per cent did not pay even a single visit
during the antenatal period, whereas 23.2 per cent paid five or more visits.
Seventy per cent of the deliveries took place at home, of which 81.9 per cent
were conducted by untrained village dais. Of all mothers, 27.2 per cent did not
receive any iron/folic acid tablets. Mothers who did not registered themselves
were mostly illiterate, belonged to the poorer strata, were generally below 25
years of age and had three or more children. Amongst the unregistered mothers,
95.8 per cent delivered at home and had not received iron tablets or TT
immunisation.
The study recommends that an attempt be made to register all the antenatal
mothers so that they come under the umbrella of the MCH care package for
ensuring safe motherhood and better survival of their children.
Key Words: Antenatal Care, Registration of Antenatal Mothers, Village
Untrained Dais.
2. Managerial gaps in the delivery of ANC services in a rural area of
Varanasi
Author :
Bhattacharya R. and Tandan J.
Source :
Indian Journal of Public Health, 1991
Place of study : Varanasi, Uttar Pradesh
Location
: Rural
Period of study : 1988
Type of research: Empirical, Evaluative, Community-based
Aim: To identify the managerial gaps and demographic and cultural factors
that affect utilisation of ANC services.
Methodology: This was a case study of Tikri village in Uttar Pradesh
with a population of 3,500,
distributed in 12 caste-based hamlets. Fifty-two women in the age-group of
15-39 years from 22 households
(chosen by stratified random sampling methods) were interviewed. A pre-tested
questionnaire was used to
record information about various socio-demographic aspects and cultural
practices related to pregnancy and childbirth.
Findings: Literacy of the women and their husbands was found statistically
significant as were various socio-economic factors affecting the pattern of
utilisation. Unlike many other studies, it was found that women living near a
health centre do not necessarily utilise ANC services more than those residing
far away. This indicated that there are other factors, which influence the
utilisation of health services.
The study also showed that 92 per cent of the primigravidae and all the
multigravidae did not use the services at all. In the case of the
primigravidae, cultural beliefs were very strong and the mother-in-law featured
strongly as a general health care provider. Strong beliefs in natural
childbirth, coupled with a fear and dislike of hospitals, explained why most of
the high-caste families opted for deliveries at home.
Reviewer's note: Though the study was conducted to elicit information on
cultural factors affecting
utilisation, the report scarcely deals with any cultural beliefs or attitudes
of respondents. The term 'case study' has been loosely used. The concept of
managerial gap was neither elaborated nor there are any data to refer it.
Key words: Health Care Provider, Delivery Pattern, Utilisation of ANC
Services.
3. Reasons why reproductive health care seekers sought
admission to tertiary level health care facilities in rural central India
Authors :
Chabbra S. and Saraf S.
Source :
Health and Population – Perspectives and Issues, 1997
Place of study : Sevagram,
Maharashtra
Location :
Rural
Period of study : Not stated
Type of research : Empirical, Descriptive, Health
Centre-based
Aim: To study the perceived reasons for reproductive health care seekers
(women) going in for tertiary-level-health care facilities. And thus plan and
provide appropriate health care at the centre and appropriate training to
nursing students, medical undergraduates and postgraduates.
Methodology: The study was conducted at the Department of Gynaecology and
Obstetrics at the Mahatma Gandhi Institute of Medical Sciences, Sevagram. The
sample consisted of women, excluding very sick ones, who were hospitalised for
reproductive health disorders over a period of six months. The total sample
consisted of 1,120 women. Women came from distances ranging from 3-500 kms.
Findings: The most obvious reasons for seeking treatment at the tertiary
level - irrespective of the nature of the case, locality, age etc.- were
economic, referrals, and the fame of the health facility and expert doctors.
The other common reasons were availability of expertise, insurance benefits and
appropriate health care. Poor people and illiterates preferred to go to
tertiary health care institutions because of economic reasons while the
better-off women went because they were referred. This shows that patients come
here not by choice but for reasons beyond their direct control.
Reviewer's note: There was no attempt to analyse the findings in the tables
presented. The closing discussion bears no relation to the data
presented. In the absence of any data on the satisfaction rating of respondents
on the kind of treatment received and their perceptions of reasons for seeking
treatment from tertiary health care facilities, the study did not meet its
stated aims and objectives.
Key words: Tertiary Level Health Care Facility, Reproductive Health
Care, Women.
4. Factors affecting health seeking and utilisation of
curative health care
Author
: Chirmulay D.
Source
: BAIF Development and Research Foundation, 1997
Place of study : Gujarat, Maharashtra, Karnataka,
Uttar Pradesh and Rajasthan
Location
: Rural
Period of study : Not Stated
Type of research: Empirical, Descriptive, Community-based
Aim: To study the preferences of people regarding health care providers
in relation to their socio-economic backgrounds. To identify necessary
interventions for increasing services to poorer people.
Methodology: This was a cross-sectional study conducted in five states in
selected rural areas. Information was gathered from 3,000 households in each of
the study areas. About 90 per cent of all households could be covered. The
interview schedule contained questions related to demographic information, the
socio-economic status of the household, morbidity in the previous week,
morbidity for specific ailments, and type of treatment sought. Qualitative data
were collected by anthropologists using interview guides and focus-group
sessions on health culture of the area and health-seeking behaviour.
Univariate, bivariate and multivariate analysis were used to understand the
utilisation pattern across different socio-economic groups.
Findings: Inability to move and work and loss of appetite or interest in
the surroundings were considered indicators of sickness. This perception of
'health' influenced the people's choice of provider and their
treatment-seeking behaviour. The perceived quality of services was an important
determinant of the pattern of utilisation. Private practitioners were perceived
to be providing better services because they included injections as part of
every treatment and were willing to make home visits which were convenient,
especially where transportation was inadequate. The government heath services
were not popular because of the longer waiting period involved, the arrogant
attitude and behaviour of all the staff, and non-availability of medicines.
No gender-related differences were noted in the morbidity prevalence and pattern
of treatment-seeking. Levels of education in the family, caste, affordability
(asset-holding) and culture were the factors which determined the utilisation
pattern. In general, those with better levels of education, those belonging to
dominant and higher castes, and those with more assets preferred private
practitioners. However, in traditional and cultural strongholds, relatively
uniform behaviour was observed across caste and economic groups.
Recommendations included improvement of infrastructural facilities at the PHCs,
continuing medical education for PHC doctors and ANMs, improving stocks of
medicines at PHCs, and a re-evaluation of the links between emoluments and
quality of care delivered by medical and para-medical staff.
It is suggested that the image of PHC services in the minds of the community be
improved. Programmes to improve the economic condition of poor rural households
should go hand-in-hand with the development of health infrastructure. This
study (and there are many others) indicates that we are far short of meeting
reproductive health care needs in every sense.
Reviewer's note: This study does not tell us much about the formation of
focus groups and their profile/composition. It does not pin-point the
respondents from each household, and whether the reported
morbidity was proxy. Recording the gender of the respondent is very important
if it is proxy data. The absence of gender differentials as regards reported
morbidity and treatment-seeking needs to be seen in this light. Concepts such
as culture - which has been treated as an independent variable - is not
explained.
The suggestion for programmatic inputs to uplift the economic status of poor
households is far too broad and general, without any concrete suggestions.
Recommendations on improving PHC services are not based on data, as there is no
data on these aspects presented anywhere in the paper. Also, there is no
analysis on the links between utilisation and these factors. The
recommendations seem more general than drawn from empirical data.
Key words: Utilisation of Health Care Services, Traditional Healers,
PHC, Private Practitioners, Socio-economic Status, Tradition, Culture, Gender.
5. Uttar Pradesh male reproductive health survey
1995 - 1996
Author (contributors) : deGraft-Johnson J., Tsui A.O., Buckner B.,
et al.
Source :
The EVALUATION Project, Carolina Population Centre,1997
Place of
study : Nainital,
Aligarh, Kanpur Nagar, Banda and Gonda, Uttar Pradesh
Location :
Rural and Urban
Period of Study :
1995-96
Type of research : Empirical,
Descriptive, Community-based
Aim: To conduct a probability sample survey of married men between the ages
of 15 and 59 with reference to sexual and reproductive health knowledge and
behaviour in relation to their own needs and those of their wives.
Methodology: A household survey of 6,727 husbands was conducted.
This constituted the second stage of a larger 1995 statewide survey of health
and family planning facilities and households, called PERFORM (Programme
Evaluation Review for Organisational Resource Management). The PERFORM Survey,
a stratified, multi-stage cluster sample survey, interviewed nearly 45,000
married women of childbearing age in 40,000 households; 2,500 fixed-site
service delivery points; 6,350 staffers and 22,000 individual health agents in
28 UP districts. The sample of husbands was selected from men meeting the
eligibility criteria of being married, living with the wife and falling between
the ages of 15 and 59 in all households selected for the PERFORM survey in
these five districts.
The various aspects covered in the study were knowledge of and attitudes toward
female reproductive issues; knowledge and use of family planning methods;
physical accessibility and quality of family planning services; domestic
violence; medical and health expenditure; premarital and extramarital sexual
experiences; symptoms of sexual morbidity; gender differences in fertility
intention and contraceptive behaviour. The basic analytical categories used
were residence (rural/urban), literacy, husband's education, number of
children, age of husband, household assets and occupation. As regards
reproductive health services the only aspect covered is family planning
services. In that it had talked of men's cognitive access and physical access
to these services.
Findings: It was found that men's knowledge of FP sources is very high: 98
per cent for any method, 97 per cent for sterilisation, 84 per cent for the
pill, 59 per cent for IUD, 91 per cent for condom and 79 per cent for MTP.
Distance from FP services and time taken to reach these services were the
aspects covered as regards physical access to FP services. The percentage of
husbands reporting travel distances above 10 kms are 29 per cent for
sterilisation, 27 per cent for MTP, 19 per cent for IUD, 6 per cent for the
pill and 4 per cent for condoms. Travel times of 30 minutes or more were
reported by 48 per cent of husbands for IUD, 62 per cent for sterilisation, 58
per cent for MTP, 32 per cent for the pill and 25 per cent for condom. As
regards follow-up visits, only 39 per cent reported a post-sterilisation visit
to the facility and 24 per cent a home visit from a health worker, either for
their wives or themselves. Only 12 per cent received a home visit following
acceptance of a temporary FP method.
The study also marginally covered the issue of domestic violence: it looked
into the type of violence, the period when it started, its frequency, woman's
status vis-à-vis pregnancy and un-consensual sex. The survey shows that
although some husbands were physically abusive of wives, most were willing to
spend on the health care of their wives, children and parents, often to a
greater extent than on themselves. Most annual medical/health expenditures were
for doctors' fees and medicines/drugs, again with wives and children being the
primary beneficiaries.
Men were poorly informed about the female reproductive cycle and signs of
pregnancy complications. Infertility problems were largely attributed to the
wife. Relatively little spousal communication occurs on unwanted pregnancy. As
regards sexual morbidity, 9 per cent report having symptoms currently. The
prevalence of STDs (syphilis, gonorrhea, chlamydia or HIV/AIDS) is probably
higher than indicated by reported symptoms. These findings suggest that there
is a need to improve the existing health care packages/services as regards
content (clinical and non-clinical) and outreach/structure.
Reviewer's note: The communication adequately presents the sampling
method. Similarly, sharing of the difficulties and ethical dilemmas that may
have been faced by field investigators during the conduct of the survey would
have been useful for future research given the complexities of the subject at
hand.
Key words: Reproductive Health, Knowledge, Attitude, Practice,
Prevalence, Utilisation.
6. Eight million women have unmet family planning needs in Uttar
Pradesh
Authors :
Devi D.R., Rastogi S.R. and Rutherford R.D.
Source :
Unknown
Place of study : Uttar Pradesh
Location
: Rural and Urban
Period of study : 1992-93
Type of research : Empirical, Analysis of NFHS Data
Aim: To provide state-level estimates of family planning practices and to
identify those groups especially in need of family planning services.
Findings: For the 1992-93 National Family Health Survey, data
were collected by interviewing a representative sample of 11,014 currently
married women of reproductive age in Uttar Pradesh. Results showed that nearly
half of currently married women in UP had a need for family planning, either
met or unmet, for Family Planning. The proportion of unmet needs was highest
amongst those who live in rural areas, amongst the illiterate, amongst Muslims,
amongst scheduled tribes and amongst those who had either a small or large number
of children.
Family planning needs were subdivided into 'need for limiting' and 'need for
spacing'. Fifty-five per cent of women in UP with unmet family planning needs
had an unmet need for limiting while 89 per cent had unmet needs for spacing.
The proportion of need for spacing that was unmet was especially high among
women living in rural areas with less education, whether they were Hindus,
Muslims or scheduled tribes. The proportion of needs for limiting varied
sharply by economic status: it was high among women who lived in rural areas,
were illiterate, were Muslims or have at least five living children.
The study points out that the Family Welfare Programme has ample scope for
reducing the proportion of unmet needs. It also recommends greater emphasis on
spacing methods such as pills and condoms, which would be helpful in improving
maternal and child health. As some women prefer to use spacing methods rather
than sterilisation to limit their family size, intensified promotion of spacing
methods may have the added benefit of reducing the unmet need for limiting.
Key words: Women, Unmet Need, Family Planning.
7. Cost of health care: A household survey in an Indian
district
Author :
Duggal R. and Sucheta A.
Source :
Foundation for Research in Community Health, 1989
Place of study : Jalgaon, Maharashtra
Location :
Rural and Urban
Period of study : 1987
Type of research : Empirical, Descriptive, Community-based
Aim: This is part of a larger study to investigate and critically
analyse health expenditure patterns in India at both the micro and macro
levels. It also aimed at evolving a methodology for the study of health
expenditure. This report confines itself to a discussion of the findings of a
household survey to examine disaggregated health expenditure in terms of
various categories of health expenditure and socio-economic differentials.
Methodology: The household survey was a pilot study conducted in one
taluka of Jalgaon district. It was a longitudinal study conducted in three
rounds during January to June 1987. Each round covered a recall period of one
month in each of the three seasons: winter, summer and monsoon.
For the urban sample, six wards were randomly selected from Jalgaon city. For
the rural sample, six villages were randomly selected from Jalgaon taluka.
Approximately 590 households were canvassed. In the first round, 582 households
responded. This number dropped to 525 in the second round, and 522 in the third
round. The investigators tried to ensure that in each round they interviewed
the same respondents. The data from the three rounds was pooled for analysis.
For the purposes of analysis, a household-level variable called 'class' was
created. The class of a household was determined on the basis of the
landholding of the main earner, the per capita consumption, and the educational
level of its members. Both prevalence and incidence of illnesses had been
estimated. Incidence refers only to episodes of illness that started in the
reference period, whereas prevalence refers to all episodes that existed during
the reference period, irrespective of when they began.
Findings: The morbidity prevalence rate for males was 145 per 1,000 and
for females 153 per 1,000 males and females, respectively. Morbidity was
highest among the youngest and oldest age groups. It was higher in rural areas
than in urban areas. Within urban areas, the slum population had a higher
morbidity. Within rural areas, those in remote villages had the highest
morbidity. The poorest class reported the lowest morbidity prevalence rate, and
the richest class reported the highest. Rich classes reported a greater
proportion of acute, minor illnesses.
Health care utilisation: For more than three-fourths of the episodes,
private health care facilities were used. Non-utilisation was higher in rural
areas. At the same time, utilisation of private care was higher in rural areas.
Within urban areas, public facility utilisation was higher among the slum
population. Within rural areas public facility utilisation was higher in
developed areas. The lowest socio-economic class had the highest
non-utilisation rate and the highest public sector utilisation rate.
Health care and expenditure: Fees and medicines together accounted for
the major portion of private health expenditure. The cost per illness episode
was directly proportional to the level of income and consumption expenditure.
The report also looks at indirect costs due to morbidity, in terms of
restricted activity and subsequent loss of income.
Also discussed are methodological issues relating to household surveys on
morbidity and health care.
Key words: Household Health Expenditure, Health Care Utilisation,
Illness, Prevalence, Incidence
8. Unmet health needs and paying capacity of the community
in Sidhpur area: A focus group-based case study
Authors :
Gupta R.B., Pulikkal A. and Kurup S.
Source
: The Journal of Family Welfare, 1995
Place of study : Sidhpur area,
Gujarat
Location
: Rural
Period of study : Not Stated
Type of research : Empirical, Descriptive, Community-based
Aim: To determine the health requirements of the community, the level of
satisfaction with the existing system, the problems with the existing health
system and ways to improve it and people's capacity to
contribute towards the improvement of health services. To build a database on
other related issues in order to develop a self-sustaining health system.
Methodology: The study was conducted by a health intervention agency
called Aga Khan Health Services (AKHS). It conducted a benchmark survey and
also focus group discussions. This particular communication discussed the
results drawn from the qualitative data collected through seven focus groups.
The participants were from six different villages from among the 23 villages
that constituted the work area. A team consisting of a moderator, documentor
and interpreter conducted focus group discussions in order to include the
opinions of all the sections of the community. To avoid domination,
participants of a particular group were selected in such a way that their
background characteristics were similar. Both males and females constituted the
focus groups. A tape-recorder was used to record the proceedings.
Findings: Ismailis, the dominant community in the area, constituted
about 60 per cent of the sample. They were economically better off than their
Hindu counterparts. More than two-thirds of the sample were
literate. The average family size was around three children. The majority were
agricultural labourers.
Health services in the area were inadequate and of poor quality. The AKHS
services, though satisfactory, were inadequate. A full-fledged hospital with
diagnostic, curative and maternal care facilities in Sidhpur town, and primary
health care facilities at the village level, were the immediate needs of the
people. People incurred high health expenditure ranging from Rs 50-2,000 per
illness episode, and Rs 600-1,500 for a delivery. Most of this money was spent
on transport and doctors' fees. The community, especially the Ismailis, was
willing to contribute amounts ranging from Rs 500-10,000 per household, for
building and maintaining a diagnostic and curative centre.
The two communities, Hindu and Ismaili, differed in their awareness of
health care and the pattern of utilisation. The latter were better informed
about preventive health, hygiene and immunisation. This was because of the
higher level of literacy and income. The majority of Ismailis sought health
care from private doctors as they could afford to pay their fees, unlike the
majority of Hindus, who were poor.
Reviewer's note: This approach to effecting improvements in the health
care system is built around the premise that the people themselves should take
the initiative and contribute to building a sustainable health care system if
the public health care delivery system fails. Nowhere is the failure of the
public health care system questioned; nowhere is a mechanism to demand
accountability articulated. Such experiments are limited in scope. They would
not be the solution to the problem.
Key words: Health Care System, Utilisation, Awareness, Sustainable
Health Care System,Paying
Capacity, Focus Group.
9. A study of household health expenditure in Madhya
Pradesh
Author :
George A., Shah I. and Nandraj S.
Source :
Foundation for Research in Community Health, 1994
Place of study : Sagar
and Morena, Madhya Pradesh
Location
:
Rural and Urban
Period of study : 1991
Type of research : Empirical, Descriptive,
Community-based
Aim: The study aimed to collect information on the components of
household expenditure, and to analyse the relationship between household health
expenditure and socio-economic variables. In the process, data on the incidence
and prevalence of morbidity and utilisation of health care were also collected.
Methodology: The study was conducted in 770 households in two districts.
The households were selected on the basis of the Centre for Monitoring the
Indian Economy (CMIE) district-level indicators of economic development. Sagar
is one of the better-developed districts of Madhya Pradesh, while Morena is
under-developed.
For the urban sample, in the first stage of sampling, the district headquarters
and one more town were selected in each district. From each town, two wards
were randomly selected. The village where the PHC was located, the village
where the sub-centre was located, and the remote village (remote in terms of
distance from the PHC) all selected randomly, together made up the rural sample
for that district. In the second stage of sampling, households were randomly
selected from the wards and villages. In all, 770 households were interviewed.
The survey was conducted in two rounds. The monsoon round was conducted in
September 1990, while the winter round was conducted in February 1991. The
recall period was one month. Data from both rounds were pooled for analysis.
For the purpose of analysis, a variable called 'class' was created. The class
of a household was determined on the basis of the landholding of the main
earner, the level of per capita
consumption, and the educational level of its members. Data on prevalence of
morbidity and incidence of morbidity were analysed separately. Prevalence was
defined to include all episodes of illness that prevailed during the month of
reference, even if the episode began prior to the month of reference.
Incidence, on the other hand, only included episodes that began in the month of
reference.
Findings: The prevalence rate of morbidity during the monsoon was 365
and 256 during winter. The incidence rate was 195 in the monsoon and 108 in
winter. Urban areas registered a marginally higher
prevalence rate than rural areas, especially for acute diseases. In rural
areas, prevalence was lowest in places that were further away from health
facilities. Prevalence was lowest in the two lower classes, and highest in the
two upper classes. Higher classes reported greater prevalence of ailments of
the nervous and
cardiovascular system. Except for the age group 25-44, in all other age groups,
male morbidity was higher than female.
The utilisation of the private sector for health care was 69.5 per cent. Only
in 15.7 per cent of the episodes did public health care was sought. Injections
were rampantly given.
Nearly three-fourths of the expenditure per episode was on doctor's fees and
medicines. The cost per episode was slightly higher in rural areas than in
urban areas. Among infants, the expenditure per episode was higher for females
than males. Once again, in the age group 25-44, the expenditure per episode was
higher for females than for males. In all other age groups, it was higher for
males.
Key words: Household, Utilisation, Expenditure, Health Care,
Prevalence.
10. Perceptions and constraints of pregnancy related
referrals in rural Rajasthan
Authors
: Hitesh J.
Source
: The Journal of Family Welfare, 1996
Place of study : Dausa, Rajasthan
Location
: Rural
Period of study : 1993
Type of research : Empirical, Descriptive, Community-based
Aim: To understand the constraints of pregnancy-related referrals.
Methodology: This was part of an action research project. A total of 206
women from 12 sub-centres who were referred for high-level care were picked up
from the registers. They were traced back to record their experiences regarding
referral services. These women were interviewed in-depth to determine their
perceptions regarding the signs of a high-risk pregnancy, and their subsequent
referrals. They were also asked whether they availed of referral services or
not and reasons for doing so.
Findings: Of the 206 women who were referred for various
pregnancy-related high-risk factors, 185 did not avail of the referral. The
common reasons cited were unavailability of transport, unsympathetic attitudes
of health staff, non-availability of doctors especially female doctors at the
referral centres, earlier negative experiences, and expense. The faith of
mothers-in-law in traditional healers and inability to understand the need for
such care also prevent women from availing of referral services. Interestingly,
more than 90 per cent of women who did not avail of referrals stated that the
TBA had advised against it. An absence of follow-up was also mentioned as a
reason for not availing of referrals. The factors that motivated family members
to take the woman to the next level of referral were sound economic status and
possession of private transport. Some women also reported that referrals were
possible because their relatives offered to take care of their homes and
children.
A well-designed IEC programme for family members of pregnant women is recommended.
The health system needs to support TBAs. The referral centre must develop a
follow-up and feedback mechanism.
Key words: Utilisation, Referral Services, Determinants.
11. National Family Health Survey (MCH and Family Planning),
1992-93: India
Author
: International Institute of Population Sciences (IIPS)
Source
: Summary Report, India, NFHS, IIPS, 1995
Place of study : Nationwide
Location
: Rural and Urban
Period of study : 1992-93
Type of research : Empirical, Descriptive, Community-based
Aim: To collect data at the state level on a wide range of areas, such
as issues related to marriage, contraception, child bearing and child rearing;
to estimate the various indicators of health status such as infant mortality
rate and maternal mortality; to examine the pattern of health care delivery and
utilisation; and to study socio-economic differentials.
Methodology: The National Family Health Survey was a household survey
conducted in 24 states and Delhi. Interviews were conducted with a nationally
representative sample of 89,777 ever married women in the age group of 13-49.
The methodology and questionnaires used were uniform across the country. The
sample design adopted in each state was a systematic, stratified sample of
households, with two stages in rural areas and three stages in urban areas. The
target sample size was set considering the size of the state, the time and
resources available for the survey and the need for separate estimates for urban
and rural areas. The urban and rural samples were drawn separately and sample
allocation was proportional to the size of the urban-rural population. Three
questionnaires were used to collect the data - household questionnaire,
woman's questionnaire and village questionnaire.
Findings: Fertility continues to decline. The estimated CBR was 28.7 per
1,000 population for the period 1990-92. The TFR was 3.4 children per woman.
Child-bearing in India was found concentrated in the age group 15-29. Women on
an average marry at around 17 years of age. Overall 29 per cent of women in
India have unmet family planning needs. However, 58 per cent of women did not
intend to use contraception at any time in the future, indicating the need to
have a strong IEC component to motivate couples to use contraception.
Utilisation of both antenatal care and delivery services was poor. During the
four years preceding the survey, mothers received ANC care for only 62 per cent
of births, with substantial urban-rural difference. At the national level only
34 per cent of deliveries were assisted by trained personnel, with wide
interstate variations.
The infant mortality rate was 52 per cent higher in rural areas than in urban
areas. The infant mortality rate declined sharply with increasing education,
ranging from a high rate of 101/1,000 live births for illiterate women to a low
of 37/1,000 live births for women with at least a high school education. The
maternal mortality rate was estimated to be 437 maternal deaths per 1,00,000 live
births. Only 35 per cent of children aged 12-13 months were fully vaccinated,
indicating the need for substantial improvement in the vaccination coverage.
Ten per cent of children under age four were ill with diarrhoea. Most mothers
were not aware of ORS, indicating the need to pay attention to the prevention
and treatment of diarrhoea. Inadequate nutrition continues to pose a serious
problem. Data show that there is a need to expand nutritional programmes to
cover infants and very young children. Educational attainment showed a strong
association with every important variable considered in the NFHS. Data show a
sex ratio unfavourable to females, lower female literacy, lower school
attendance rate for girls aged 6-14, low level of female employment, relatively
low female age at marriage, higher female post-neonatal and child mortality
rates, lower immunisation coverage for females, less medical care for female
children and preference for sons. All these offer evidence of
discrimination against females. These are therefore the areas that need to be
addressed in all social development programmes.
Questions regarding knowledge of AIDS, asked in 13 of the 25 NFHS states,
indicate that in most states a large majority of ever-married women had never
heard of the disease. The findings thus provide a clear indication of the
challenges ahead for organisations working in the area of AIDS in providing
even the most basic information about AIDS and ways to prevent the spread of
the disease.
The data reveal that there were considerable variations across states and
communities in all the socio-economic, demographic and health parameters. The
data on various indicators show that India had
experienced a considerable reduction in crude birth and crude death rates.
However, substantial efforts are required to reduce infant and child mortality.
India is doing poorly in the provision and utilisation of health care services,
including antenatal and intranatal care and immunisation services.
Key words: Prevalence, Illness, Treatment, Gender, Women, Infant
Mortality, Maternal Mortality, Status of Outreach Health Services.
12. Use of traditional medical practitioners to deliver
family planning services in Uttar Pradesh
Authors
: Kambo I.P., Gupta R.N., Kundu A.S., et al.
Source
: Studies in Family Planning, 1994
Place of study : Muzaffarnagar, Uttar
Pradesh
Location :
Rural
Period of study : 1984-87
Type of research : Empirical, Descriptive, Community-based
Aim: To test the potential of traditional practitioners in motivating and
recruiting family planning acceptors in order to increase contraceptive
knowledge and use in rural communities; to study the acceptability of
traditional practitioners as providers of family planning services.
Methodology: One PHC block in each intervention and non-intervention
area was selected. The two blocks selected were matched with respect to a few
key variables, such as number of villages, population size, number of
households, eligible couples, traditional medical practitioners, family
planning performance of primary health centres and proximity to district
headquarters. The sample size consisted of 37 villages and 22 traditional
practitioners. The baseline and follow-up (cross-sectional) survey enrolled
about 1,850 women in both areas.
The intervention consisted of training 22 practitioners for 11 days. The
training emphasised motivational and counselling skills and the use of the
cafeteria approach. A comparison of the pre- and post-training questionnaires
revealed a substantial improvement in the knowledge of the trainees.
Practitioners received a monthly honorarium of Rs 50. There was no formal
mechanism for supervising the intervention. However, the informal monthly
meetings between the concerned PHC and district health officials, the
practitioners and the project investigators, provided a forum for interaction
and discussion, replenishing of stocks and monitoring of records. The meetings
also provided opportunities for continuous education.
Findings: The pre-intervention baseline survey revealed the extent of
education and counselling required to overcome the inertia, passivity and
misinformation prevalent in relation to family planning in these
villages. The involvement of traditional practitioners significantly improved
knowledge of both permanent and reversible methods. The use rate for both
permanent and reversible contraceptive methods increased dramatically. For
reversible methods, it was twice as high as for permanent methods. The
increased use of contraceptives occurred largely among young couples,
particularly among those below 25 years. There was a distinct shift from
permanent to reversible methods. Availability of enhanced follow-up services
was an invisible advantage. A higher use rate was observed among groups that
are traditionally difficult to reach, suggesting that accessibility increases
acceptability and indicating that traditional practitioners have the power to
influence such groups. Male acceptance of contraception remained untouched.
This suggested the need for greater efforts to promote male methods. The
majority of women obtained contraceptives from the traditional practitioners.
The author pinpoints some programme areas where positive change is necessary
for large-scale interventions: for instance, a well-organised referral system,
a good supervisory system to monitor the work of these practitioners and a
mechanism to ensure that the relationship between traditional practitioners and
the organised health and family planning infrastructure remains effective.
Key words: Traditional Practitioner, Spacing Method, Family
Planning Services, Male Involvement.
13. Health and development in rural Kerala
Author :
Kannan K.P., Thankappan K.R., Kutty V.R. et al.
Source :
Kerala Sastra Sahitya Parishad (KSSP), 1991
Place of study : Kerala
Location :
Rural
Period of study : 1987
Type of research : Empirical, Descriptive, Community
and Health Centre-based
Aim: Kerala is unique in that it has attained a demographic transition
to low death rates and low birth rates, even in absence of widespread economic
development. However, it has been postulated that the decrease in mortality has
not been accompanied by a similar decrease in morbidity. KSSP conducted this
study to gain an insight into the health status of the people of rural Kerala,
the associations between health status and socio-economic characteristics of
the people, and the utilisation of health care.
Methodology: The health survey was conducted in two parts. One was a
household survey conducted in all the villages of the state in July 1987. A
random sample was drawn from the villages under each panchayat. The recall
period used was two weeks. The second part of the survey involved a census of
health care institutions in all the panchayats and municipal areas of Kerala
during the latter half of July 1987. Only 68 per cent of the total area could
be covered in this census.
For the purposes of analysis, all households were categorised according to
their socio-economic status (SES) and their environmental status (ENS). The SES
was calculated on the basis of per capita income, household land ownership,
household educational status and housing condition. The environmental status
was determined on the basis of source of drinking water, sanitation facility,
cooking device, waste water disposal, solid waste disposal, and cleanliness in
the immediate surroundings of the house.
Findings: Morbidity prevalence rate for acute illnesses was 206.3 and
for chronic illnesses 138.1. The study showed that the morbidity rate in Kerala
(as measured by the KSSP study) was higher than the all-India average (as seen
in the NSS surveys). The authors suggest that the remarkable decrease in
Kerala's
mortality statistics has been a result of medical interventions preventing
death, rather than effective prevention of disease. Poverty had not decreased,
nor had sanitation or drinking water facilities improved. Thus, communicable
diseases continue to prevail. On the other hand, there had been a shift in
Kerala's demographic structure, with a higher proportion of adults and aged
than the all-India average. These groups are more susceptible to chronic
degenerative diseases, and thus Kerala's morbidity statistics were high on this
count as well. Thus, Kerala had a high prevalence of communicable diseases such
as fever and diarrhoea, as well as chronic diseases such as bone and joint
ailments, hypertension.
Class: Both acute and chronic illness prevalence rates decrease with an
improvement in socio-economic status (SES). The decrease in chronic illness
prevalence rates was not as marked as for acute illnesses. Presumably this was
because the lower classes suffer chronic illnesses related to poverty - such as
tuberculosis - whereas the higher classes suffer chronic illnesses related to
affluence, such as hypertension and diabetes. As expected, with an improvement
in environmental status (ENS) also, there was a decrease in the morbidity
prevalence rate.
Gender: The prevalence of chronic illnesses was higher among females
than among males. Compared to men, women were less likely to suffer from
tuberculosis, heart disease, peptic ulcers, and diabetes.
However, they showed a higher tendency to suffer from hypertension, and bone
and joint ailments.
Cost of treatment: There was a positive relation between the cost of
treatment and the socio-economic status of the patient. For those in the lower
SES, the share of transportation in the cost of treatment was much higher than
for the higher SES.
The authors also suggest that the fact that each household was interviewed by
an investigation team of three members including one female investigator, and
the fact that the survey was conducted in the monsoon, when communicable
diseases are most prevalent, may have caused an upward bias in the reporting of
morbidity.
Key words: Prevalence, Morbidity, Cost, Treatment, Gender.
14. Abortion for family planning: Attitude of housewives
of low income group towards abortion for family planning
Author
: Kanitkar S.
Source :
Unpublished
Place of study : Pune, Maharashtra
Location
: Urban
Period of study : Not Stated
Type of research : Empirical, Descriptive, Health Centre-based
Aim: To study attitudes of housewives from low economic groups towards
abortion as a family planning method.
Methodology: A questionnaire was administered to 150 women who underwent
MTP at the out-patient's department, at the Family Planning Association of
India (FPAI) hospital, Pune. Information was gathered on age, income,
occupation, education of husband and wife, number of living children and their
sex, use of contraception, if any, attitudes about MTP as a family planning
method, reasons for MTP, decision-making and psychological post-abortion
consequences.
Findings: Of the 150 interviewees, 133 considered MTP a family planning
method. Sixty-five (64 tubectomies, 1 vasectomy) underwent sterilisation. The
rest (85) opted for CuT. The majority of them (65 of the 80) said that they
wouldn't like to go for MTP again. Of those sterilised, most (53) already had a
family with the desired number of members and the rest (12) said they were not
able to afford more children. Thirty-seven of the 85 seem to have opted for MTP
as a spacing method while another 27 were waiting for living children to grow
up before they went in for sterilisation. Ten gave economic reasons and only
nine underwent MTP on account of failure of contraceptive used. In 115 cases
partners had jointly decided on MTP and in 20 cases, it was the woman who
decided on her own. Mental relief after MTP was expressed by all. Of the total,
119 couples had used some contraceptives in the past. Discontinuation on
account of dissatisfaction with them resulted in these pregnancies. The author
highlights the social sanction and family approval for MTP while discussing the
results. The author advocates the provision of safe abortion services in remote
areas of India to help check population growth and meet the needs of maternal
child welfare.
Key words: MTP, Family Planning.
15. Utilisation and determinants of selected MCH care
services in rural areas of Tamil Nadu
Authors
: Kavitha N. and Audinarayana N.
Source
: Health and Population – Perspectives and Issues, 1997
Place of study : Coimbatore, Tamil Nadu
Location
: Rural
Period of study : 1995
Type of research : Empirical, Descriptive, Community-based
Aim: To explore some of the determinants of utilisation of selected MCH
care services, such as antenatal (antenatal check-up and iron and folic acid
tablets), natal (place of delivery) and postnatal (check-up) health care
services in rural areas of Tamil Nadu.
Methodology: The sample consisted of 134 currently married women with at
least one living child less than four years of age from two villages/district.
Information was gathered on 172 live-born and currently living children. Data
on still births and children who died before the date of the survey were not
collected, so that women did not get emotional and affect the quality of the
response and also the overall response rate.
Caste, respondent's education, spouse's education, respondent's work status,
monthly family income,
exposure to mass media and number of living children were treated as
explanatory variables. Logic
regression coefficients were estimated with 't' values. Also, probabilities
were estimated for each of the dependent variables.
Findings: Woman's educational level had a positive influence on the
utilisation of antenatal and natal
services. Women from higher castes were also more likely to avail of antenatal
and postnatal care. Women belonging to non-SC communities and of lower parity
utilised the postnatal check-up services more than women of scheduled castes
and higher parity. Monthly family income had a positive influence on postnatal
care. Use of antenatal services had a positive effect on the place of delivery.
Interestingly, working women (mostly engaged in agriculture and weaving) were
less likely to utilise antenatal services than non-working women.
In conclusion it was suggested that education in general and female education
in particular must be
encouraged in rural areas. Adult education and social education could be used
as vehicles for this purpose. Village-level meetings to interact with women,
educate them and clarify issues related to MCH care were recommended.
Reviewer's note: It would have been interesting to know the nature of
women's work which prevented them from seeking antenatal care as compared to
non-working women. The characteristics of the health care system would
constitute another set of explanatory variables, which were not taken into
consideration in this analytical framework.
Key words: MCH, Utilisation, Socio-economic Determinants, Exposure to
Mass Media.
16. Utilisation of reproductive health services in rural
Maharashtra
Authors
: Khan A.G., Roy N. and Surender S.
Source
: The Journal of Family Welfare, 1997
Place of study : Chandrapur, Maharashtra
Location
: Rural
Period of study : 1991
Type of research : Empirical, Descriptive, Community-based
Aims: To examine the factors associated with utilisation of reproductive
health services in rural Maharashtra and to understand the factors that
differentiate users of reproductive health services from non-users.
Methodology: A two-stage stratified random sampling of villages with and
without health facility was done. Two hundred and thirty-five women with at
least one child between one to two years of age were interviewed.
Findings: Only 13 per cent of illiterate women had utilised the overall
reproductive health services. This increased with the educational status of
women. The husband's educational status was more likely to
influence the woman's utilisation of reproductive health services. Variables
like the economic status of the family, type of family and caste did not
influence utilisation patterns. Neither age nor loss of child influenced
utilisation patterns that, however, were associated with increasing parity.
The study finds that utilisation of services was not influenced by village
development factors like population size, proximity to a town, literacy levels
etc. Programme-related factors like the health worker's visits to the village
also did not influence utilisation of services. However, the family's views on
the programme did favourably influence utilisation of services.
The study concludes that knowledge of health services does not by itself
increase its utilisation. The authors recommend the need to involve husbands in
reproductive health care as well as to extend the services especially to
primiparous women.
Reviewer's note: Nowhere in the communication 'reproductive health' is
defined.
Key words: Reproductive Healtb Services, Utilisation, Users,
Non-users, Associated Factors.
17. Childbirth practices among women in slum areas
Author
: Khandekar J., Dwivedi S., Bhattacharya M., et al.
Source
: The Journal of Family Welfare, 1993
Place of study : Allahabad, Uttar Pradesh
Location
: Urban
Period of study : 1989-91
Type of research : Empirical, Descriptive, Health Centre-based
Aim: To examine the pattern and role of practices related to childbirth in
some urban Integrated Child Development Scheme (ICDS) areas of Allahabad.
Methodology: Thirty-five centres were chosen randomly out of a total of
100 centres. Each centre caters to an approximate population of 1,000. All the
pregnant women registered at the selected Anganwadi centres during the course
of one year formed the study population. In all, there were 661 women. Each
Anganwadi centre was visited on a fixed date every month to interview mothers
who registered at the centre during each month.
A pre-tested schedule was administered. A detailed history of past illnesses
including obstetric problems, family history of diseases, information about
tetanus toxide immunisation during the antenatal period, and childbirth
practices including the type of instruments used at the time of delivery were
obtained.
Findings: All the women were permanent residents of the area and were
mostly from the lower socio-economic group. Women undergoing their second or
third delivery utilised these services the least. More primiparas as compared
to others had been immunised. Almost two-fifths of the women had delivered at
home while the rest utilised public or private hospitals. Untrained personnel,
irrespective of parity, conducted the majority of the births. Those who
utilised trained persons for delivery were by and large primiparas. Awareness
of the pregnant woman and the need for trained birth assistance were greater
among women with educated husbands. Among the deliveries assisted by trained
personnel, the perinatal mortality rate was 67.4 per 1,000 live births. It was
154.8 per 1,000 live births in the case of untrained assistance.
The majority of the slum-dwellers surveyed had no faith in hospitals. They preferred
to trust the untrained dai who belonged to the same socio-cultural milieu. The
unhygienic practices of untrained persons were attributed to ignorance,
illiteracy and lack of education of the dais and family members. The
complications occurring during delivery clearly show the inability of untrained
persons to identify 'high-risk mothers'.
In conclusion it is stated that untrained dais play an important role in the
provision of natal care in urban slums. It is essential to train them to make
these services acceptable and safe.
Key words: Natal Care, Untrained Dais, Training, Urban Slums.
18. Health, households and women's lives: A study of
illness and childbearing among women in Nasik district, Maharashtra
Author
: Madhiwalla N., Nandraj S. and Sinha R.
Source
: Centre for Enquiry into Health and Allied Themes, 2000
Place of study : Nasik, Maharashtra
Location
: Rural and Urban
Period of study : 1996
Type of Research : Empirical, Descriptive, Community-based
Aim: To assess patterns in morbidity as reported with and without
probing, utilisation of health facilities and expenditure on health care among
women in rural and urban Nasik district.
Methodology: Nasik district was selected for the study because it is an
averagely developed district as far as the socio-economic and demographic
profile of the rest of the state is concerned. Within the selected district,
Igatpuri taluka was selected for its sizeable tribal and non-tribal population.
The rural sample
consisted of 903 households from Igatpuri taluka, while the urban sample
consisted of 382 households from Nasik town. In all, data were collected for
3,581 women and 3,631 men.
Only women investigators were used, and only women respondents were
interviewed. A list of 14 questions probing specific symptoms was administered
to collect information on indications of illness among the women that might not
otherwise be reported. Since multiple symptoms could be indicative of the same
illness episode, the researchers devised a method of constructing episodes on
the basis of up to three
symptoms, as well as the duration and perceived causes of the symptoms, and the
link of a symptom to a life event. The reference period for questions on
morbidity was one month prior to the interview.
Findings: The morbidity among women was higher than that reported in
earlier household surveys. The morbidity rate for females was found to be 812
per 1,000 and for males it was 307 per 1,000. The morbidity rate for females
was so high, mainly because of the probing. The important categories of illness
for women were fevers and respiratory illnesses, followed by reproductive
illnesses and aches and pains. General aches, pains and weakness were also a
significant category. The pattern of morbidity among women showed links to
their living environment (air, water, food), work, childbearing and
contraception.
Socio-economic status: Morbidity was highest among those who were the
sole women in their household. It was relatively high among scheduled caste
women, and unskilled non-working women.
The relationship between access to health care and reported morbidity:
Women who had easier access to health care facilities (in terms of distance to
the facility) reported higher morbidity.
Health care utilisation: Utilisation of health care by women was low.
Forty-five per cent of the episodes were not treated. Many women resorted to
informal care. Home remedies constituted 15 per cent of the services whereas
self-medication constituted 11 per cent. Use of informal care was higher among
urban than rural women. In urban areas women sought treatment for 49 per cent
of the episodes reported by them and used 21 informal facilities for every 100
episodes. In contrast, rural women sought treatment for 57 per cent of the
episodes and used 15 informal facilities for every 100 episodes. 'Dependent'
women – unmarried girls and aged women – used more health care per episode than
women who were heads of the household or wives of male heads. In general, women
from deprived groups – women from remote villages, scheduled castes and urban
minority communities – did not receive health care for a large proportion of
their illnesses.
Type of health care facility used: In rural areas, 24.2 per cent of all
facilities used and 30.3 per cent of the formal facilities used by rural women
were government facilities or home-based care provided by
government paramedics. In urban areas, 10 per cent of the total facilities and
17.3 per cent of formal facilities used were public sector services. Certain
types of illnesses, such as aches/pains, injuries, weakness and problems of the
sensory organs were mostly treated in the informal sector. Whereas other
illnesses such as fevers and gastrointestinal infections were treated mostly in
the formal sector. Health care utilisation was related to the nature of
illness. Long-term illnesses were not treated as frequently as short-term
infectious illnesses.
The perceived efficacy of treatment was an important factor in determining the
use of health care. For
long-term illnesses women adhered to a mode of treatment which gave them
partial relief if not complete cure. For 12.4 per cent of the episodes
treatment was not sought because health facilities were either not accessible
or inadequate.
The expenditure on health care showed trends corresponding to the utilisation
of health care. Expenditure per episode, per capita and per facility in the
rural areas was higher than urban areas. Among the
components of expenditure, doctor's fees, the cost of medicines and injections
comprised the major part of out-patient expenditure. There was a considerable
difference in the expenditure incurred on men and women in each facility.
The findings on maternity events and contraception revealed the low access to
health care for rural women. Untrained personnel conducted around 70 per cent
of the deliveries in rural areas and 33 per cent in urban areas. Only 38 per
cent of the deliveries were followed by postnatal care; the percentage was
higher in urban areas as compared to rural areas. Public centres were primarily
used for postnatal care due to immunisation facilities. Contraceptive services
were overwhelmingly accessed from the public sector, except for medical shops
where oral contraceptive pills were bought.
At the end, the study raises various key issues on ways to improve women's
health. The study also highlights various problems in the provision of public
health services: the hierarchical structure of the services and the high
dependence of directives from above which allows village-level workers no
autonomy to decide the priorities and programmes for the village. Health
workers complained of a paucity of equipment, drugs, and most importantly, lack
of referral back-up. The health workers were of the view that all these factors
lead to people losing faith in the public health system. The near-total
dependence on private services clearly had a negative impact on poor women who
were driven out by their inability to purchase services. It was evident that
the withdrawal (or absence) of the public sector was resulting in greater
neglect of poor women's health needs.
Reviewer's note: It needs to be noted that the data were both self
reported and proxy. However, the analysis remained aggregated. Disaggregated
data would have given a better picture.
Key words: Prevalence,
Illness, Cost, Treatment, Gender, Women, Utilisation, Expenditure.
19. Non-use, unsatisfactory use and satisfactory use of
contraceptives
Authors
: Mondal A.
Source
: Journal of Obstetrics and Gynaecology, 1992
Place of study : West Bengal
Location
: Rural
Period of study : 1989-90
Type of research: Empirical, Descriptive, Community-based
Aim: To evaluate the magnitude and reasons of non-use and unsatisfactory
use of contraceptives in the existing rural socio-cultural and obstetric
background, to enable effective steps to tackle the problem of population
growth.
Methodology: It was a random survey of 340 women, which included
users, non-users and unsatisfactory users of contraceptives at a PHC (Baduria)
and two adjoining villages. Socio-cultural and obstetric histories were taken.
Information on the use of contraceptives was sought.
Findings: Out of 340 females, 164 did not use contraceptives and 54 were
unsatisfactory users (irregular/<6 months). Early marriage, high parity,
frequent childbirths and lower acceptance of MTPs were the
factors leading to non-use of contraceptives. These women were mostly illiterate,
or had minimal education and belonged to the lower socio-economic classes. Of
them, 42.7 per cent were ignorant about
contraception and 39 per cent were non-serious. A consistent proportion (1/5th
to 1/6th) were unsatisfactory users irrespective of age, religion,
distance, occupation, education and socio-economic status. The findings
suggested that one-time motivation of non-users (61%) and unsatisfactory users
(81%) increased
acceptance of contraceptives and sterilisation. The study recommended long-term
measures directed
towards socio-economic uplift and short-term measures directed towards
identification and health
education of non-users and unsatisfactory users keeping in mind the underlying
causes for increased
contraceptives, MTPs and sterilisation.
Reviewer's note: The authors categorise women with contraceptive use of
less than six months as
'unsatisfied users' but have not specified the cause of discontinuation of
contraceptive use. The concepts such as socio-cultural and socio-economic are
not defined. Besides, analysis does not deal with 'socio-cultural' aspects as
stated in the objectives.
Key words: Contraceptives, Users, Non-users, Socio-cultural
Context.
20. Private nursing homes and their utilisation: A case study of
Delhi
Authors
: Nanda P. and Baru R.
Source
: Health for the Millions, 1994
Place of study : Delhi
Location
: Urban
Period of study : Not Stated
Type of research : Empirical, Descriptive, Health Centre-based
Aim: To examine the characteristics and services of private nursing
homes and hospitals in Delhi. To
analyse the resort patterns of people from different socio-economic groups and
to discern the factors that influenced the choice of health care for specific
groups of people.
Methodology: Sixty-five private nursing homes of varying sizes (in terms
of number of beds) were selected through stratified random sampling for an
in-depth study. To get an insight into utilisation patterns, 171 users from
different socio-economic groups were interviewed at two government hospitals,
private nursing homes and a resettlement colony.
Findings: The study reveals that there were about 1,300 nursing homes
and 7,000 qualified private doctors in Delhi. Of the 65 nursing homes studied,
only 22 (34 %) were registered. The low level of registration of nursing homes
implies that difficulties in implementing regulatory systems and prescribing
minimum
standards. Nearly 65 per cent of the owners had been in government service,
which according to other studies was a means to build professional and social
contacts to help themselves establish their private practice. The percentage of
promoters from business background increased in proportion to the size of the
establishment. The authors note with concern the increasing 'corporatisation'
of medical care services in Delhi.
On an average consultant doctors were paid a salary between Rs 3,000-5,000;
nurses were paid between Rs 1,000-1,700; technical staff Rs 900-1,200 and ayahs
Rs 500-800. All employed at least one consultant doctor. In most husband-wife
teams, the women doctors were found to be gynaecologists. According to the
doctors, there was a high turnover of nurses because they are often lured away
by better salaries. The 'A' grade nurses prefer the public sector because of
job security and other benefits.
The majority of the owners ranked 'outpatient services' as the area of highest
return, the second being 'maternity services' and the third general surgery and
investigative facilities. The areas of return varied according to the size of
nursing homes. Nearly 98 per cent of the nursing homes offered outpatient
services, maternity and general surgery. Seventy-five per cent had ultrasound
facilities and 63 per cent had X-ray, ECG, EEG facilities. Close to 50 per cent
of the large nursing homes had scans. The larger the size of the nursing home,
the greater the chances of an attached pharmacy.
A fairly large percentage resorted to allopathy, but other systems were also
used in combination with
allopathy. The income level and type of ailment influenced the choice of provider.
Utilisation patterns showed that the private sector was preferred for minor
ailments while the government sector was preferred for hospitalisation for
maternal services and surgery, especially for the lower-income groups. The
attitude of nurses, time spent with the doctor and quality of services
influenced the satisfaction levels of users. It is, therefore, crucial that
funds for government hospitals are not cut indiscriminately.
The study also revealed the haphazard growth of medical services in Delhi –
both public and private services were concentrated in certain pockets, while
large parts of Delhi remained poorly serviced.
One of the major points for policy consideration is that the Delhi Nursing Home
Act of 1953 with
amendments in 1992 needs to be revised to improve effective monitoring of the
growth and quality of services. National-level policies are also required for
regulating and monitoring the private sector.
Key words: Private Health Care Facilities, Human Power, Choice of
Provider, Determinants, Utilisation, Quality of Care..
21. Women and health care in Mumbai: A study of
morbidity, utilisation and expenditure on health care in the households of the
metropolis
Author
: Nandraj S., Madhiwalla N., Sinha R., et al.
Source
: Centre for Enquiry into Health and Allied Themes, 1998
Place of study : Mumbai,
Maharashtra
Location
: Urban
Period of study : 1994
Type of research : Empirical, Descriptive, Community-based
Aim: To document and analyse perceived morbidity patterns; constraints of
women in accessing health care facilities and their utilisation; and patterns
in expenditure on women's health.
Methodology: The study was conducted in the L ward of Greater Mumbai
city, a congested pocket with residential units as well as small-scale
factories and commercial establishments, poor sanitation, insufficient water
supply, acute noise and air pollution. The majority of the population consisted
of migrant labourers and entrepreneurs. The survey was conducted in five
clusters - two slums, two chawls and one apartment block. The selection of the
clusters was on the basis of their 'class character'. The predetermined sample
size was 425. House listings were done in the identified clusters. Households
were identified for survey through systematic sampling. In all, 430 households
were covered in the study.
The data were collected through interview schedules. Since women were the focus
of the study, female investigators conducted the interviews, and the
respondents were all women. A 'probe list' - a list of 14 symptoms - was used
to probe the existence of specific symptoms among women which might otherwise
go unreported. Each symptom reported after probing was recorded as an
independent episode. During the survey a conducive environment was created
which would encourage women to feel unhindered to speak about their health
problems.
Findings: The monthly prevalence rate for males was 169 per 1,000 as
compared to 571 per 1,000 for females after probing. Reproductive illness
accounted for 28.2 per cent of all episodes among females, the majority of them
being related to menstruation and child-bearing. The findings point to a strong
relationship between women's work lives and their health. After probing, women
had a higher morbidity rate than men across all age-groups. Slum-dwellers
suffered higher morbidity than non-slum-dwellers in each age-group, gender
group and occupation group.
Of the total illness episodes, 32.5 per cent were not treated. For 85 per cent
of the illness episodes, private facilities were used. With regard to
deliveries the public sector accounted for only 30 per cent, as compared to the
private sector which accounted for 31.7 per cent. All the three abortions
reported utilised private facilities. Only 38 per cent of the total
contraception users utilised public facilities. There was a wide
disparity in the utilisation of public health facilities at different levels.
In that, tertiary hospitals were
overloaded, the first referral systems like health posts were underutilised.
Utilisation of the formal health sector was lower among women than men.
Access to health care facilities in terms of distance and who provided health
care were major factors which influenced utilisation. In case of nearly
two-thirds of the illness episodes, health facilities with less than 10 minutes
distance from home were approached.
Among women, fevers, respiratory and gastrointestinal illnesses were treated
more than reproductive
illnesses. Unwell men received equal treatment irrespective of age, whereas
among women, those in the age-group of 0-11 years have a higher number of
treated illnesses. The study doesn't show any direct impact of education on
health-seeking behaviour.
The most common reason given for non-treatment of an illness was that the
illness was not serious enough to be attended to. Financial constraints were
also an important reason for non-treatment, more so for women than for men.
Expenditure on women's health care was lower than on males. For those illnesses
that were reported only after probing, expenditure was generally lower than for
the other illnesses.
The findings of the study raise the issue of non-utilisation of health
services, especially by women, both for deliveries and other illnesses, even in
a metropolitan city like Mumbai which has better public health
facilities as compared to other parts of the country.
Key words: Prevalence, Morbidity, Utilisation, Expenditure, Women,
Gender Differentials.
22. Household survey of medical care
Author
: National Council for Applied Economic Research (NCAER)
Source
: NCAER, New Delhi, 1992
Place of study : Nationwide (Major States &
Union Territories)
Location
: Rural and Urban
Period of study : 1990
Type of research : Empirical, Descriptive, Community-based
Aim: To study the nature and type of illnesses suffered by family
members, the system of medicine used and their perceptions of the efficacy of
the systems used.
Methodology: The study was based on an all-India survey which covered
both rural and urban areas in all States and Union Territories except Manipur,
Nagaland, Sikkim, Tripura, Arunachal Pradesh, Andaman and Nicobar islands,
Dadra Nagar Haveli, Lakshadeep and Mizoram. In all, 371 districts were covered.
The sample was a multi-stage stratified sample. For the rural sample, two-five
villages per district were selected, with a probability of selection equal to
the proportion of the population of that village in the district
population. In all, 1,061 villages were selected. All the households in the
village were listed, and then classified according to level of income.
Households were then randomly selected from each income slab.
For the urban sample, all 41 cities of the country with a population of above 5
lakhs were included. The remaining cities/towns were classified into five
strata on the basis of population size, and a random sample was taken from each
stratum. The 632 cities and towns selected covered 61 per cent of the total
urban population. A sample of blocks was selected from each sample town
depending on the size of the town. A total of 1,873 blocks were selected. The
blocks were selected independently for each town with equal probability. All
households in the selected block were listed, and households were randomly
selected from each income slab.
Findings: Morbidity pattern: The prevalence rate of treated
illnesses for the country as a whole was found to be 67.70 episodes in urban
areas and 79.06 illness episodes in rural areas per 1,000 population. Some of
the states which reported a higher rate of illness than the all-India average
were Assam, Jammu and
Kashmir, Kerala, Meghalaya and Pondicherry. In almost all the states the
reported prevalence rate of illness for which treatment was sought worked out
lower for the females than males for both adults and children up to the age of
14 years. This sex differential in morbidity probably showed the extent of
under-reporting of illness by females and lack of medical attention during
illness.
In almost all the states the prevalence rate declined from the low- to the
high-income category, thus
suggesting that people belonging to the lower-income group were more
susceptible to various illnesses, perhaps due to poor living conditions and
lower nutritional status.
Type of morbidity: Fever was the most common ailment treated, followed
by illness due to respiratory and gastrointestinal infections. There was not
much difference in the pattern of illness by place of residence (rural and
urban).
System of medical treatment received: Eighty per cent of the illness
episodes in the urban areas and 75 per cent of the cases in rural areas were
treated under the allopathic system of medicine. The percentage of cases for
which allopathic treatment was sought was slightly higher in high-income
households, especially in rural areas.
Compared to other systems of medical care, people perceive the allopathic
system to be more effective. Nearly 60 per cent of the cases treated by the allopathic
system of the households felt that the treatment was fully effective. A
surprising finding was that a large number of cases (75% in urban and 65% in
rural) where the households resorted to only self-medication they expressed a
feeling that the treatment was fully
effective. The possible explanation of this finding could be that
self-medication was resorted to only for minor treatments. In small proportion
of cases, the household's felt that 'rituals' were fully effective.
Type of health care facility: In 55 per cent of illness episodes
treatment was sought from private facilities, whereas for 33 to 39 per cent of
cases treatment was sought from government facilities. There were wide
variations across states regarding the type of health care facility utilised.
With the increase in the income level of households the dependence on state
health care decreased in both rural as well as urban areas. The study shows the
preference for private doctors in case of minor ailments. The primary health
centres and sub-centres catered to 8.2 per cent of the cases in rural areas.
As regards physical accessibility to health care facilities, it was found that
people residing in rural areas had to travel longer distances as compared to
their urban counterparts. This increased the average cost of treatment of
illnesses. For 54.6 per cent of cases in Meghalaya and 33.5 per cent of cases
in Orissa, people had to travel more than 10 kms to seek treatment.
Household expenditure on health care: In urban areas the average cost of
treating each illness episode was Rs 142.60 as compared to Rs 151.81 for rural
areas. The study reveales that there exists a gender preference in favour of
males in the treatment of illness episodes. This gender discrimination was more
prominent in the urban areas of Haryana, Karnataka, Meghalaya, Orissa, Punjab
and Tamil Nadu and in rural areas of Punjab and Rajasthan. The average
expenditure of treatment was high under the allopathic system followed by the
homoeopathic system of medicine. The study also provides average expenditure by
types of diseases. The data showed that urban households spend a lot in
treating accident cases, whereas in rural areas the average expenditure on
treatment of degenerative diseases was as high as Rs 776.23. The average expenditure
on treating respiratory illnesses was quite low in both rural and urban areas.
Key words: Prevalence, Morbidity, Health Care, Utilisation,
Out-of-pocket Expenditure.
23. NSS 42nd Round (1986-87); NSS 52nd Round (1995-96)
Author
: National Sample Survey Organisation (NSSO)
Source
: Department of Statistics, Government of India, 1992 &1998
Place of study : Nationwide
(Major States & Union Territories)
Location
: Rural and Urban
Period of study : 1986-87; 1995-96
Type of research : Empirical, Descriptive,
Community-based
Aim: 42nd Round: To make an assessment of utilisation of
medical services.
52nd round: To study the curative aspects of the general
health care system in the country; and mother and child health care programmes.
To study the morbidity profile of the population.
Methodology: The NSS surveys are carried out in successive 'rounds'.
Each round is of approximately one-year duration. Questions on morbidity were
first asked in the seventh round of the NSS, in 1953-54. Subsequently three
other surveys included morbidity as a topic. Thereafter, surveys on social
consumption and morbidity were conducted in the 42nd round (1986-87), and in
the 52nd round (1995-96).
Much of the data had been collected from proxy respondents which might
understate the actual level of morbidity. The tools for data collection were
modified in the 52nd round to collect variations in responses and
avoid misreporting.
The NSS 42nd round: The survey covered the whole of India
except for a few areas of Jammu and Kashmir and Nagaland. A two-stage
stratified sampling design was adopted. In the first stage villages and blocks
were selected in rural and urban areas respectively, and in the second stage
households were selected. The sample villages were selected with probability
proportional to population with replacement in the form of two independent
inter-penetrating sub-samples (IIPNS). The sample blocks were selected by
simple
random sampling without replacement in the form of IIPNS. The survey was
conducted in a sample of 8,346 villages and 4,568 urban blocks. Two households
from each village/block were selected through stratified random sampling.
The NSS 52nd round: The survey covered the whole of India
except for a few interior areas of Jammu and Kashmir, Nagaland and the Andaman
and Nicobar Islands. A two-stage stratified sampling design was adopted. The
census villages and urban blocks were selected for rural and urban areas
respectively as the first stage and in the second stage the households were
selected. The survey was conducted in a sample of 7,663 villages and 4,991
urban blocks. Ten households from each village/block were selected through
stratified random sampling. In the 52nd round, an equal probability sampling
scheme for villages was used, instead of the usual NSS practice of selecting
villages with a probability proportional to their population.
The data was collected through household interviews. As far as possible, all adult
male members of the household were interviewed. Probes were used to gather
information about the illnesses that might have occurred in the household. The
recall period used was 15 days.
Findings:
The NSS 42nd round: The prevalence rate of hospitalisation
was 28 per 1,000 persons in rural areas and 17 per 1,000 persons in urban
areas. The male-female ratio among hospitalised persons was about 56:44, both
in the rural and urban sectors. The preference for treatment as an in-patient
in a public hospital over other types of hospitals was observed in most of the
states except Andhra Pradesh, rural Kerala, Maharashtra and rural Punjab, where
private hospitals were given preference. The data reveal that the allopathic
system of medicine was used in more than 98 per cent of hospitalised cases in
both rural and urban areas. At the national level, the percentages of
hospitalised cases under the 'no payment' and 'employers' medical
welfare scheme' categories were observed to be 23 and 6 respectively in the
rural sector as against 20 and 13 in the urban sector. The average payment made
to government hospitals was Rs 320 per case as against Rs 733 for private
hospitals in the rural sector. The corresponding figures for the urban sector
were Rs 385 and Rs 1,206 respectively.
It was observed that the number of days spent in government hospitals was more
than in private hospitals for both the rural and urban sectors of India. The
average number of days spent in hospital per hospitalised person was about 16
and 15 days respectively in rural and urban areas. The average total
expenditure was Rs 853 in rural areas as against Rs 1,183 in urban areas. The
average payment to hospital or total
expenditure per hospitalised case varied considerably over the type of
hospital, type of ward and also over the rural and urban sectors of states.
The proportion of ailing persons in the rural sector was higher than in the
urban sector of the country. The proportion of persons with ailments treated
was found higher among males than females in the bottom expenditure groups,
while a reverse pattern was observed in the higher expenditure groups.
In rural India, about 53 per cent of treatment was availed of from private
doctors while public hospitals and private hospitals accounted for 18 per cent
and 15 per cent respectively. The corresponding percentages for urban India
were 52, 23 and 16 respectively. The allopathic system of medicine was used to
treat 96 per cent of cases in both urban and rural areas. At the national level
the average duration of sickness treated was nearly the same irrespective of
the type of institution or the place of residence.
In rural areas the major causes for not seeking treatment were - the ailments
were not considered serious (75%), financial difficulties (15%) and no medical
facility (3%). In urban areas the major causes for not seeking treatment were -
the ailments were not considered serious (81%), financial difficulties (10%)
and no medical facility (less than 1%).
The NSS 52nd round: The data show that the
gender-specific estimated proportion of ailing person (PAP) for acute ailments
was about three times as high as that for chronic ailments. For both rural and
urban areas, age-specific PAPs for acute ailments showed a distinct U-pattern
and positively sloped pattern for chronic ailments. The data show that people
aged 60 years and above were more prone to ailments.
There was no significant difference between rural and urban areas as far as
ailing persons reporting
commencement (PPC) was concerned. This may be due to a higher level of health
consciousness in urban areas as compared to rural households with the same
level of morbidity leading to higher illness reporting. The data show large
interstate and intrastate variations in PAP and PPC.
An analysis of data from Kerala shows that, contrary to popular perception, the
level of morbidity is
relatively high. One of the reasons for this may be that with better health
care facilities in the state, there is a large proportion of the population
aged 60 years or more (9.4%) and this segment is more prone to illness.
In order to establish a relationship between level of health consciousness and
reporting of morbidity, IMR had been taken as a broad indicator of health
consciousness. The data show a very interesting phenomenon: IMRs and PAPs for
rural areas of Kerala, Punjab and Madhya Pradesh show a negative relationship
between IMR and morbidity-reporting, contrary to data on rural areas of Bihar,
Assam, Rajasthan, Orissa and Uttar Pradesh.
A positive association between monthly per capita consumption expenditure
(MPCE) and PAP, in both rural and urban areas was observed. The range of
variations in PAP was larger in rural areas as compared to urban areas. The
level of morbidity increased with a rise in the standard of living. This may be
due to the fact that the reporting of morbidity improves with improvement in
the conditions of living.
The urban morbidity rates were higher than the comparable estimates of the 28th
and 42nd rounds. The observed differences may be due to different
methodologies used to collect the data over this period.
The data on disease-specific morbidity were collected on the basis of
self-perceived morbidity, though this method of collecting information is
highly questionable. The data showed a rise in accident-related
morbidity, especially in urban areas. A declining trend for chronic diseases
were observed.
The survey shows that the percentage of ailing persons treated was higher in
urban areas as compared to rural areas. The percentage of untreated ailing
persons varied from 26 per cent in the lowest income group to 10 per cent in
the highest expenditure group in rural areas. In urban areas it was 9 per cent
and 19 per cent respectively. The survey also examined reasons for not seeking
treatment: the most prominent cause was not perceiving the illness as severe,
followed by financial constraints. It was found that the private sector was
utilised more in cases of non-hospitalised treatment. The comparison between
the 42nd and 52nd round shows that there was a
significant increase in utilisation of the private sector in between the two
rounds. There existed a wide inter-state variation in percentage of treated
ailments as well as use of government sources for treating ailments. Utilisation
of public health care facilities for treatment was found to be among the lowest
in Punjab, Haryana and rural Uttar Pradesh; it was reported to be highest in
rural Orissa and Rajasthan.
During the period 1995-96, about 2 per cent of the urban population and 1.3 per
cent of the rural population was hospitalised at any time during the reference
period. The data did not show any significant
gender-differential in either area.
The estimates showed a strong positive association between average MPCE and the
rate of hospitalisation in both rural and urban areas. There were wide
interstate variations in the rate of hospitalisation. The survey shows that
charitable institutions also played an important role in providing hospitalised
treatment. But still, PHCs and CHCs accounted for a higher proportion of
hospitalised treatment than charitable institutions in rural areas. There was
also a great interstate variation regarding reliance on the public sector for
hospitalised treatment. The proportion (per 1,000) of hospitalised treatment
received from public sector hospitals varied from 225 in rural Andhra Pradesh
to 906 in rural Orissa.
Cost of treatment: The data show that in rural areas Rs 151 was spent on
an average on every episode of non-hospitalised treatment per ailment by a
male, as compared to Rs 137 in case of females. The figures for urban areas
were Rs 187 and Rs 164 respectively. For hospitalised ailments, Rs 3,778 was
spent on an average on every episode by a male in rural areas as compared to Rs
2,510 in case of females. The figures for urban areas were Rs 4,185 and Rs
3,625 respectively. This shows the presence of gender discrimination as regards
expenses incurred per ailment though estimates on the proportion of ailing
persons treated did not reflect any perceptible difference between male and
female populations of either rural or urban areas.
Key words: Prevalence, Morbidity, Health Care, Utilisation,
Out-of-pocket Expenditure.
24. Factors inhibiting the use of reversible contraceptive
methods in rural South India
Authors
: Rajaretnam T. and Deshpande R.V.
Source
: Studies in Family Planning, 1994
Place of study : Belgaum and
Gulbarga, Karnataka
Location
: Rural
Period of study : 1990
Type of research : Empirical, Descriptive, Health
Centre and Community-based
Aim: To assess the perceptions and experiences of programme personnel, from
the district level to the grassroots level, on popularising reversible methods
of family planning in rural areas; to understand the extent of community
leaders' knowledge of reversible methods and their perceptions regarding the
couples accepting them; and to study the knowledge and attitudes of couples
towards reversible methods.
Methodology: The study was undertaken in two districts. Each district
had two sub-divisions with 10-15 PHCs under each sub-division. From each
sub-division one PHC was selected at random. From each of the selected PHCs, a
further three sub-centres were selected in such a way that one was the PHC
headquarter and the other two fell under different primary health units of the
same PHC. All villages covered by these sub-centres were selected as the study
area. In all, 43 villages were covered in the survey. It was proposed to select
1,000 households proportionately from the selected villages by a systematic
cluster sampling
technique. Altogether, 998 households were covered, from which 995 currently
married women (15-44 years) were listed. From these, 815 (82%) women and 136
husbands (from the targeted number of 200) could be interviewed.
Of programme personnel, all the available divisional joint directors and
district health officers of both the districts were interviewed. At the PHC
level, all the available medical officers and the male and female senior health
assistants of the six selected PHCs were interviewed. Similarly, at the
sub-centre, all the available junior health assistants were interviewed. In
all, one divisional joint director and three district health officers, six
medical officers, five senior health assistants and 20 junior health assistants
were
interviewed. For the coverage of community leaders, a maximum of three of the
most influential leaders were identified from each village by interviewing a
sample of currently married women, their husbands, shopkeepers, etc..
Findings: Family planning practice: The data show that the practice
of family planning was limited to sterilisation methods, that women accept
early sterilisation, but usually after having three living children. CPR due to
both reversible and permanent methods was 40.6 per cent for women interviewed
in the study area, whereas the CPR based on the husbands' interview was 41.2
per cent. Contraceptive users had an average of 3.9 living children, while non-users
had 1.9 living children. About 38 per cent of the women had given birth to
their first child within two years of consummation of marriage. The majority of
the non-users had short open birth intervals (less than two years).
Perception of programme personnel: The officers interviewed indicated
that they had not made attempts to ensure better performance for reversible
methods in their areas, nor did they suggest strategies to popularise the
methods. The study indicates the need to motivate middle-level managers to make
efforts to popularise reversible methods. Health workers and supervisors were
not interested in motivating the use of reversible methods. This has led to
ignorance and thus non-use at the couple level. The study findings suggest the need
for commitment of programme managers at all levels, training of supervisors and
health workers to motivate couples and provision of adequate services at
clinics.
Perception of community leaders: Virtually all of them knew about
terminal methods whereas only 73-90 per cent knew about reversible methods
after probing. About one-fourth of the leaders did not know of service sources
for reversible methods, and the majority did not know that field workers were
distributing contraceptives. Government health facilities were cited as the
major source of contraceptive methods. The leaders felt that reversible methods
were unpopular because they were not well-known, because people thought they
had undesirable side-effects or high failure rates, and because people thought
they were
inconvenient to use. When asked how to improve the FPP, the suggestions made
were providing incentives, regular visits by health workers and easy access to
service outlets.
Perception of the community: The majority of the respondents were aware
of the benefits of a longer interval but few were able to achieve it. Knowledge
about service outlets for permanent methods was almost universal. Private
institutions were mentioned more often as service outlets for reversible
methods. The main reason for not using contraceptives was the desire for more
children. And 18 per cent specifically stated that they wanted male children.
The major reasons for the unpopularity of reversible methods were their
side-effects and failure rates.
At the end, three suggestions were made to popularise reversible methods in
rural areas: 1) A strong
commitment from programme managers at all levels. 2) Proper direction and
training of field workers, enable them to educate and motivate couples to use
reversible methods. 3) Provision of adequate services at clinics and in
villages.
Key words: Reversible Contraceptives, Perceptions, Knowledge,
Programme Personnel, Contraceptive Methods, Community Leaders, Community.
25. Gender bias in utilisation of health care facilities in
rural Haryana
Author
: Rajeshwari
Source
: Economic and Political Weekly, 1996
Place of study : Bhiwani and
Kurukshetra, Haryana
Location
: Rural
Period of study : 1991
Type of research : Empirical, Analytical,
Community-based
Aim: To examine the spatial variations in gender bias in the use of
public health care facilities (PHCFs) and in relation to the economic
development of an area.
Methodology: Two districts from the state were selected and from each
district two tehsils were selected based on the provision of public health care
infrastucture. In each of these tehsils, two villages were
selected: one with a public health care facility and the other 5-10 kms away
from such a facility. Thus there were four villages with PHCs and the other
four with no PHCs. In all, 389 households spread over eight villages were
studied.
Utilisation was considered with reference to preventive (infant's immunisation,
antenatal care, care during childbirth) and curative care (level of medical
intervention in case of ailment). Availability of public health care
facilities, occupational category as proxy of economic status of the household
and educational status of the head of the household were examined as
determinants of health care utilisation.
Findings: The study show that the availability of public health care
facilities at the place of residence had a positive impact on women's health
status when the comparison was made between the PHC and non-PHC villages. The
data reveal that infant and child mortality was highest where there was no
medical facility and trained birth attendance. It concludes that the level of
female health care is positively affected by economic development and the
gender disparity is reduced with the overall economic development of an area.
The economic status of the household showed an association with women's health
care where public health care facilities were not located nearby. The educational
status of the head of the household emerged as an important factor which had a
positive effect on women's health care (both preventive and curative) in PHC
and non-PHC villages.
It is suggested that the provision of public health care facilities at the
place of habitation coupled with increased educational status or awareness of
various health care programmes would reduce the selective bias against women.
Reviewer's note: A sharing of details of the tools of data collection
and the basic profile of the respondents would have been useful. Also it is not
clear whether the data were proxy.
Key words: Utilisation, Public Health Care Facilities (PHCF),
Gender, Economic Status.
26. Medical management and giving birth: Responses of
coastal women in Tamil Nadu
Authors
: Ram K.
Source
: Reproductive Health Matters, 1994
Place of study : Kanyakumari,
Tamil Nadu
Location
: Rural
Period of study : Not Stated
Type of research : Empirical, Descriptive,
Community-based
Aims: To present the experience of maternity among lower-caste Mukkuwar
women and their responses to modern medical management of pregnancy and birth.
Methodology: An ethnographic approach was used to study maternity practices
amongst lower-caste Mukkuvar women.
Findings: The study argues that a woman's decision on whether or not to
seek medical care during
pregnancy and where to give birth, was influenced by class and caste. The
article highlightes various causes for the non-utilisation of modern medicine
during delivery: prolonged stay during delivery disrupting their daily
activities, caste distance between the provider and the user creates a power
hierarchy, treatment by the hospital staff during delivery is harsh, and there
are unnecessary medical interventions.
From their perspective as fisher-women, the older forms of hierarchy were
simply mapped onto newer versions, with high-caste intolerance of impurity,
pollution and lack of learning transposed into the idiom of hygiene, rationality
and medical science. Despite prolonged exposure to reforms and interventions,
women still derive their fundamental ideas of femininity and maternity from
more archaic religious and regional cultural currents.
Key Words: Perception, Coastal Women, Medical Management, Maternity.
27. Household survey of health care utilisation and
expenditure
Author
: Ramamani S.
Source
: National Council for Applied Economic Research (NCAER), New Delhi,
1995
Place of study : Nationwide (Major States &
Union Territories)
Location
: Rural and Urban
Period of study : 1993
Type of research : Empirical, Descriptive, Community-based
Aim: To collect detailed data on morbidity, health care utilisation and
health expenditure. The study covers both treated and untreated illness
episodes.
Methodology: All the states and Union Territories of the country except
Manipur, Nagaland, Sikkim, Tripura, Andaman and Nicobar Islands, Arunachal
Pradesh, Dadra and Nagar Haveli, Lakshadweep, Mizoram and Jammu and Kashmir
were included. The sample was selected through multi-stage stratified sampling.
All the districts within the selected states and union territories were
covered. From each district, 2 villages were selected with probability
proportional to the population of the village. In all, 718 villages were
selected. For the urban sample, all 53 cities that had a population greater
than 5 lakhs were included in the sample. The other cities and towns were
stratified into five groups on the basis of population size, and a sample of
towns was randomly selected from each group, with an increasing sample fraction
as the size class increased. Blocks between 2 and 30 were randomly selected
from each city/town, depending on the
population size of the town. Thus, 1,509 blocks were selected.
For the household selection, households in selected blocks/villages were listed
- with up to 150 households per block/village. The households were classified
into five income categories, and then sample households were selected randomly
from each stratum. The sample consisted of 18,693 households, with 12,339 urban
and 6,354 rural households.
The survey instrument was a detailed household questionnaire, which was
administered to the head of the household. For all questions relating to
illness and health care utilisation and expenditure, the recall period was one
month prior to the interview. The survey was based on lay reporting of illness
and not on clinical examination. The interviewers were asked to note the
symptoms in detail, as described by the households. Afterwards the symptoms
were classified/grouped under different illness names using the World Health
Organisation's Manual on Lay Reporting of Health Information.
Both the prevalence and incidence of illness were estimated; incidence relates
to all episodes that started in the reference period of one month prior to the
interview, while prevalence relates to all episodes that existed during the
reference period, irrespective of when they started.
Findings: Morbidity profile: The reported prevalence rate of
illness for the reference period was 106.7 and 103.0 per 1,000
population for the rural and urban areas respectively. The prevalence rate of
treated illness was 94 per 1,000 population. The survey results did not
indicate any significant sex differentials in the overall prevalence of
illnesses at the all-India level, although some states did exhibit such
differentials. The prevalence rates of illness by different age-groups reveals
a very high morbidity rate for the 60+ age-group, for both rural and urban
areas. There were wide variations in the reported prevalence rates of illness
across different states, with Kerala having the highest reported morbidity.
Nature of illness: Fever seemed to be the most common illness among both
adults and children, accounting for 30 per cent and 25 per cent of reported
illnesses in rural and urban areas respectively. The next highest reported
morbidity was respiratory infections, which were higher among children than
adults. In the rural areas, the prevalence rate of cardiovascular diseases (per
1,000 population) was 4.5 and 3.1 respectively for adult males and females. The
corresponding figures for urban areas were 9.0 for adult males and 7.7 for
adult females.
The disease pattern was dominated by acute illnesses. Acute illness comprised
73 per cent of the reported illnesses in the rural areas and 68.5 per cent of
the reported illnesses in urban areas. Serious communicable diseases accounted
for 14.5 per cent and 13.3 per cent of all reported illnesses respectively in
rural and urban areas. With the increase in the income status of households,
the prevalence rate of serious
communicable diseases and acute illnesses decreased, and the prevalence of
chronic illnesses increased.
Hospitalisation: The reported number of hospitalisation cases (per 1,000
population) was 7.1 and 9.7 for rural and urban areas respectively. In most of
the states, the number of hospitalisation cases (per 1,000 population) was
lower for females than males.
Untreated illnesses: Approximately 12 and 8 per cent of the illness
episodes were not treated in rural and urban areas respectively. The major
cause cited for non-treatment was 'not considering the illness serious enough'.
Utilisation of outpatient health care services: The percentage of
illness episodes for which treatment had been sought from the private health
sector was 52 and 59 per cent for rural and urban areas respectively. In both
rural and urban areas the utilisation of private health facilities was highest
for acute illnesses.
Self-medication was also found high in treating acute illnesses. In rural
areas, the utilisation of public health facilities for accidents and injuries
was 60 per cent and 70 per cent respectively for the male and female
population. In both rural and urban areas, with an improvement in income and
education of the household, the utilisation of public facilities decreased and
utilisation of private facilities increased. On the whole, for all occupational
categories, the utilisation of private facilities was found higher. For 90 per
cent of illnesses, the allopathic system of medicine was sought.
Utilisation of hospitalisation facilities: For 62 per cent of the
hospitalised illness episodes in rural areas and 60 per cent of the cases in
urban areas, treatment had been sought from public health facilities. The data
reveal that people's dependence on public health facilities was higher for
natal, intra-natal and preventive health care. Home deliveries accounted for
23.4 and 11.2 per cent of the deliveries in rural and urban areas respectively.
The most important reason for using public health facilities in both rural and
urban areas was that they are free/inexpensive. Close proximity was also cited
as a reason for using public health services, whereas 'good reputation' was
cited as an important reason for seeking treatment from private health
facilities. On an average people had travelled longer distances for seeking
treatment in the rural areas as compared to urban areas.
Household expenditure on health care: Expenditure on health care
includes the doctor's fees, cost of
medicine, cost of diagnostic tests, transportation costs, expenses incurred for
special diet for the patient, and other incidental expenses. Poor households
had spent more than 7 per cent of their income on treatment as compared to 2.7
per cent by rich households. Urban households had spent more in treating
illness than their rural counterparts. The average expenditure per illness
episode was lower for children. In both rural and urban areas the average
household expenditure per illness episode was lower for female adults and
female children as compared to males. For treatment as inpatients people seemed
to prefer public health facilities, the most important reason being that they
are less expensive than private health facilities. Poor states like Uttar
Pradesh, Rajasthan and Madhya Pradesh had spent comparatively smaller amounts
per illness episode. In states where the dependence on private health providers
was higher, the amount spent per illness episode was also found to be fairly
high.
Key words: Prevalence, Morbidity, Health Care, Utilisation,
Out-of-pocket Expenditure, Treated and Untreated Illness.
28. Acceptance of family planning and linkages with
development variables: Evidence from an
80-village study in Orissa
Author
: Sinha R.K. and Kanitkar T.
Source
: The Journal of Family Welfare, 1994
Place of study : Cuttack, Ganjam, Kalahandi,
Phulbani and Puri, Orissa
Location
: Rural
Period of study : 1982
Type of research : Empirical, Descriptive, Community-based
Aim: To study intervillage variations in the practice of family planning
by different methods in Orissa; and to study the factors associated with the
differential practice of family planning methods.
Methodology: Data collected in a large sample survey were used. A total of
80 villages, 16 from each district having health facilities and not having
health facilities, were selected from five districts, through a two stage
sampling design. A random sample of 50 households was selected from each of the
villages by probability proportion to size (PPS). Individual-level data on
knowledge and practice were collected from newly-married women in the
household. Village-level data on infrastructural facilities, educational
facilities, health facilities, mass media and other aspects were obtained.
Using the available information a composite village level index (VLI) was
constructed, indicative of the overall developmental status of the village. The
information was divided into eight major categories. The VLI ranged from 0-80
and graded into four groups. The score was observed to range between 7 and 59.
Findings: The average VLI score was 26.8 with a standard deviation of
10.7 and coefficient of variation of 40 per cent, indicating the heterogeneous
development levels of the villages. Literacy levels in the village and the
village level index did not show any association with acceptance of
sterilisation but it was
significantly related to acceptance of spacing methods. Perhaps this was
because sterilisation is a one-time method, requires only one-time motivation
and is aggressively promoted by programme managers. It was also independent of
the acceptor's literacy or educational attainment. On the contrary, the
acceptance of spacing methods takes into account the motivational aspect and
hence was not independent of literacy or educational attainment of the
individual. The existence of PHC/sub-centre facilities in the village did not
have any impact on the acceptance of spacing methods. The findings of this
study clearly bring out the importance of aggregate level development related
variables and education for the promotion of spacing methods.
Key words: Family Planning, Spacing Methods, Development Index.
29. The extent and pattern of utilisation of health services
by rural women: A study in District Rohtak, Haryana
Authors
: Sood A.K. and Nagla B.K.
Source
: Indian Journal of Preventive Social Medicine, 1994
Place of study : Rohtak, Haryana
Location
: Rural
Period of study : Not Stated
Type of research : Empirical, Descriptive, Community-based
Aim: To study the pattern of utilisation of various treatment sources by
rural women for common maternal and child health problems.
Methodology: The study was carried out in block Beri of Rohtak district
in Haryana. Four sub-centre villages were selected by stratified random
sampling considering their distances from the PHC. The
sampling unit was women with children less than six years of age. A list was
prepared in each village of households having women with children less than six
years of age. Systematic random sampling was used to select women for the
survey. In all, 162 women were interviewed through a semi-structured schedule.
Findings: It was observed that nearly 61.8 per cent of the women had
contacted private practitioners, 50.0 per cent had contacted anganwadi centres,
21.0 per cent faith-healers, 18.4 per cent sub-centres, 19.7 per cent PHCs and
6.5 per cent government hospitals in the last six months. During the analysis
of the data the socio-demographic characteristics of the respondents were taken
into account. Some of these factors
directly affected and some indirectly affected medical and health care
utilisation. The data reveal that
respondents who had a lower annual income, lived far from towns, and in
inadequate houses with no
bathrooms showed a preference for home treatment in the initial stages.
Respondents who preferred
hospitals, especially government hospitals, had higher age of head of
household, lower levels of education and high preference for government
hospitals. PHCs and hospitals were mostly preferred for prolonged ailments or
severe ailments not cured by other sources. Those who preferred a place which
gives "quick relief" were characterised by higher income, better
condition of the house, higher education of head of family, residence in main
village, higher social participation, separate bathrooms in the house and
electricity. On the other hand, those who mentioned a preference for place of
treatment due to 'free services' had poor living conditions, lower incomes and
lower levels of cleanliness in the home.
The data showed that the higher the educational level, income and lower family
size, the higher the
preference for a hospital as the place for delivery. Religion and social
participation determined the
preference for the local dai. Hindus with lower social participation preferred
a local dai for delivery.
Religion, household size and social participation determined the use of family
planning methods. The larger the household size and higher the social
participation, the higher the acceptance of family planning methods. For
treatment of infants, 27.5 per cent preferred mostly traditional practices, 4.6
per cent preferred modern practices and 67.7 per cent preferred both. Those
preferring native practices had lower levels of education, lower levels of
cleanliness, higher family size and lower social participation. They lived away
from town.
The article also highlighted the findings of three other studies on health care
utilisation undertaken in
various parts of the country.
Reviewer's note: The recall period is six months. A separate
presentation of maternal health and child health problems would have been
insightful. The article does not clearly define the concept of 'social
participation'.
Key words: Maternal Health Problems, Child Health Problems, Treatment
Sources.
30. Please use the health services: More and more
Authors
: Srivastava R.K. and Bansal R.K.
Source
: World Health Forum, 1996
Place of study : Kheda, Gujarat
Location
: Rural
Period of study : 1992-1995
Type of research : Empirical, Descriptive, Community-based
Aim: The long-term objective was that family size should be reduced and
the people's quality of life be raised. The immediate objectives of the project
were to bring about an increase in awareness of modern contraception from 48
per cent to 73 per cent, to reduce the infant and under-five mortality rate to
below the country's rural average; and to raise the status of women.
Methodology: The project was initiated in 30 villages where there was
already a well-established network of primary care centres. It was an
intervention project, therefore, no strict methodology was followed.
Findings: The paper details the various activities undertaken in the
project. The interventions were essentially IEC activities carried out by
village family welfare workers with the involvement of the milk cooperatives
and supported by a central team from a medical college. The unique feature of
the project was that village health workers were available throughout the day,
and basic drugs were made available at all times. Also, the project provided an
opportunity to medical students to relate theory to practice. The article also
describes the constraints that affected the project. The authors claim that
substantial progress can be made through this kind of initiative, although it
would take much longer to see its direct benefits.
Reviewer's note: The sharing could be used to draw lessons from to
improve government health services for better utilisation.
Key words: Modern Contraception, Status of Women, Village Health
Workers.
31. Introductory small cash incentives to promote child
spacing in India
Authors
: Stevens J.R. and Stevens C.M.
Source
: Studies in Family Planning, 1992
Place of study : Thanjavur, Tamil Nadu
Location
: Rural
Period of study : 1985-91
Type of research : Empirical, Descriptive, Community-based
Aim: To evaluate the cost-effectiveness of monthly introductory small
cash incentives as a strategy to increase the use of modern temporary methods
of contraception among rural Indian women.
Methodology: A four-phase intervention study was designed to evaluate
such a strategy. In phase 1, small incentives as an intervention to promote
acceptance and continuation of spacing methods were pilot-tested. In phase 2, a
controlled study, the impact of interventions in terms of cash incentives and
five visits with contact persons was compared with the control area. Phase 3
was designed to study the impact of (a) smaller cash incentives with only one
visit and (b) of only contact persons. The results of these two
strategies were compared. Phase 4 was to introduce this intervention strategy
through the government health services in three places - in the slums of Madras
city (incentive); in two PHCs in rural areas
(intervention area – incentive + contact person, control area - only contact
person).
The sample size varied in these phases. In Phase 1, a total of 398 women were
acceptors of spacing
methods. In Phase 2, 500 women in each intervention and control area were
enrolled in the study. An evaluation survey of Phase 2 included random samples
of 150 women each from the intervention and
control area. In Phase 3,250 women were enrolled in each of the two
intervention areas. The evaluation survey of Phase 3 included a random sample
of 100 women from both intervention programmes. In Phase 4, 2,821 women were
acceptors in the slums of Madras; 475 and 3,068 women enrolled in the two PHC
areas.
Findings: The programme demonstrates the power of small cash incentives
to rapidly attract potential women acceptors to the clinic. It is evident that
this method overcame disinterest, inertia, and passivity of poor and illiterate
women towards available contraceptive methods.
Phase 1 showed that small cash incentives were very effective in promoting
participation in the project. During this phase the programme achieved very
high acceptor rates for temporary methods. Critics
suggested that this phenomenon might well be owing less to the incentives and
more to the fact that women preferred to come to a high quality private clinic
where they were treated with concern and respect, rather than to insensitive
government facilities.
Phase 2 showed that though initial acceptance was higher with introductory
incentives, subsequent delivery of condoms and pills by the village contact
person was similar in both incentive and non-incentive villages. Follow-up
population-based surveys indicate that the quality of knowledge was better and
the number of users was greater in the incentive villages.
Phase 3 demonstrated that a single introductory incentive or appointment of
contact person only recruited more women acceptors, but knowledge and evidence
of actual use of spacing methods was less.
Phase 4 attempted to introduce the introductory incentive programme in urban
and rural government clinics yielded mixed results. In urban slums, government
health services were rapidly able to upscale the
programme. In the rural PHCs, the staff were unable to upscale the programme on
their own.
The authors conclud that introductory incentive programmes served to increase
awareness and acceptance of spacing methods though the continuation rate was
only about 50 per cent. Many women distrust
government services because of the rude behaviour of the health personnel, but
the authors argue that incentives were less coercive than the conditions under
which poor women live because it served to diminish the timidity of women.
Key words: Cash Incentives, Use of Contraception.
32. Households, kinship and access to reproductive health care
among rural Muslims in Jaipur
Authors
: Unnithan-Kumar, M.
Source
: Economic and Political Weekly, 1999
Place of study : Jaipur, Rajasthan
Location
: Rural
Period of study : Not Stated
Type of research : Empirical, Descriptive, Community-based
Aim: To situate reproductive health care in the context of women's
perceptions and experiences of illness in general as well as in terms of the
material, ideological and political dynamics of household, kin and gender
relations.
Methodology: The paper does not detail the methodology used to conduct this
research. The study was conducted in the rural Nagori Sunni community in Jaipur
district.
Findings: It was found that most of the reproductive problems of women were
related to menstruation and white discharge. There was a high incidence of
maternal morbidity and anaemia along with child mortality. Women articulated
their health problems in very general terms. Women perceived their illness as
related to causes lying outside the purely physiological domain. References to
the influence of the soul and spirit upon a person's health indicated that the
health of the individual and the social body was connected in public
perception.
Women tended to use the services of private medical practitioners and
traditional healers much more than government institutions. Of the health
services available within a radius of 1-6 kms, none of the private doctors
frequented by the Nagori Muslims offered reproductive health examinations or
antenatal check-ups for women. In seeking medical attention with regard to
reproductive health related problems, women had to traverse greater distances.
For reproductive health services women went equally to private and government
doctors but preferred to see government doctors in private where they were
promised greater attention.
It was found that the sexual division of household labour and the division of
labour among women of the household had implications for women's health. It
imposed the physical burden of hard and continuous labour with little respite
during weakness or illness. It also made it difficult for women to take time
out to consult health specialists. The toll on women's health varied with the
development cycle of the household. The division of household tasks worked in
favour of the age of women only if they had younger women to shoulder the
heavier tasks. The average monthly income of families was Rs 1,500-2,000,
besides three quintals of wheat from a single agricultural season. Most of the
women were found engaged in agricultural activity, which is seasonally
determined. One of the common work-related physical ailments which Nagori women
suffer was prolapse of uterus. It was found that gender ideologies played an
important role in the inequitable distribution of resources in the household
and had its implications for women and children's health.
In the majority of cases a woman's marital home was within a radius of 1-4 kms
from their natal home. The social and physical proximity of natal kinspersons
had important implications for Nagori women's access to health care services in
many ways. These mainly included additional human power, emotional support and
financial support. The average health expenditure for women alone over 10 months
was Rs 1,000-10,000. This high expenditure on health was a result of treatment
delayed till the acute stage.
The author in the end draws conclusions for policy. These include the need to
address the question of access to existing services, provision of facilities
which take into account the context-specific, gender and age health needs of
the local populations; the need for a health programme to be broad-based so as
to tackle wider sources in the environment from which diseases stem. It was
recommended that women's access to health care services could be improved by
encouraging all sorts of health delivery activity - private, govern
ment and NGO - in a manner that recognises their specific strengths and
weaknesses. In order to establish an effective referral network, it is
suggested that resource persons within each village be located who are not only
informed about matters of hygiene and basic medication but also about health
services, health rights and statistics and the politics of health matters in general.
Reviewer's note: In the absence of any reference made to the
methodology, the potential of such studies and methodologies used (the
ethnographic approach seems to have been used) remains obscure. It makes a
significant contribution for there are not many studies dealing with Muslim
women and their health
concerns.
Key words: Muslim Women, Reproductive Problems, Reproducive Health
Problems, Support, Health
Expenditure.
33. Unmet need for family planning in Gujarat: A qualitative
exploration
Authors
: Visaria L.
Source
: Economic and Political Weekly, 1997
Place of study : Bharuch and Panchmahal,
Gujarat
Location
: Rural
Period of study : 1989 and 1995
Type of research : Empirical, Descriptive, Community-based
Aim: To understand the reasons for the unmet need for family planning
from the women's perspective. To
explore the reasons underlying the gap between intentions to limit fertility
and action; and to understand when and how the intentions to limit family size
are translated into reality.
Methodology: A quasi-longitudinal study design was adopted in two
districts of Gujarat, covering the same population at two points of time - 1989
and 1995. The data were collected through 11 focus groups and
in-depth interviews. The participants for focus groups were carefully selected.
About 18 to 20 women were invited for each discussion. Efforts were made to
make each group as homogeneous as possible in terms of caste, level of literacy
and acceptance of sterilisation.
Findings: The issues discussed broadly were women's desired fertility
and their reasons for wanting a specific number of children, sex preference of
wanted children, apprehension about use of contraceptive methods for limiting
and spacing children and inter-spouse communication on issues related to
sexuality, desired fertility and contraceptive use. The author had frequently
referred to NFHS data for giving a
macro-perspective.
The women reported that if their husbands wanted more children, they had no
choice but to comply. Most women desired two to three children provided there
was at least one son, preferably two. But on their own,
women didn't mind not having sons.The reason for the desired fertility was
mainly economic. When asked whether not having children would eventually not
bring more income in the house, they appeared much more concerned about the
present outflow of income as opposed to an unknown future inflow.
Son-preference was universal and strong, the ideal family notion comprising 50
per cent or more sons.
Contraceptive use primarily depended on socio-cultural factors like familial
and societal pressure to prove fertility immediately after marriage, a near
lack of communication between husband and wife on issues related to sexuality,
pregnancy and contraception, and pressure to have at least one son. Lack of
autonomy, inability to negotiate fertility, sexuality and contraception, and
the fear of being discarded by the husband forced women to rationalise their
fertility behaviour soon after marriage.
The author examined the logic behind women's preference for sterilisation over
spacing: women preferred to complete their desired family and then go in for
sterilisation that involved fewer hassles. The fear of side-effects and the
apprehension of inability to conceive after use of spacing methods also made
women prefer limiting methods to spacing methods. The women voiced their
complaints against the health workers,
indicating that they were provided with little information or supplies. They
said that the nurse (health worker) worked efficiently only when she was
concerned about 'targets'.
Finally, the author suggests some programmatic implications - viz. counselling
of couples together on
contraception, broadening the scope of the family planning programme to include
all those with potential need, i.e. men and women, married and unmarried, with
the emphasis on sex education. The author
suggested undertaking similar studies in order to get a ground level
perspective on the situation.
Key words: Unmet Need, Family Planning, Targets, Efficiency, Sex Preference, Desired Family Size, Women's Autonomy.
(Complied
by Sunita Bandewar and Shelley Saha)
Centre for Enquiry
into Health and Allied Themes