HEALTH CARE: ACCESS, UTILISATION AND EXPENDITURE

 

SELECTED ANNOTATIONS

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.

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(Complied by Sunita Bandewar and Shelley Saha)
Centre for Enquiry into Health and Allied Themes