MAJOR HEALTH PROBLEMS OF ORISSA

 

By Dr Nihar Ranjan Ray

  

Orissa is a high focus state for its culture, heritage, rich with minerals and diseases as well. It has rated as one of the measurable state so far the health care is concerned. Badly affected by the poverty, illiteracy, natural disasters Orissa registered very poor health indicators as per the WHO reports. Its state with a population of 3.68 crores, comprising of 85% rural habitants, with 22% Scheduled Tribe and 16.5% Scheduled Caste population. From a lot of health issues I need to focus the following topics with bird vision felling their importance and seriousness.

 

 Infant mortality

Infant Mortality Rate (IMR) is only 53 per 1,000 live births in urban areas as compared to 76 in rural areas, only 26.4 per cent of tribal children are immunized when compared to 43.7 per cent among the general population in the State and anemia is very high of 61.2 per cent among women.

The State needed to arrest the malnutrition trend as early as possible. “The level of malnutrition in the State is quite high. Over 30 per cent of children are severely malnourished. As per the latest survey, 40.7 per cent under age of 3 are underweight, 45 per cent are stunted and 19.5 per cent are wasted. About 65 per cent of children aged between 6 and 35 months are anemic.

Maternal mortality rate

One woman dies every seven minutes from complications related to pregnancy and child birth in India and in Orissa nine women die everyday for the same reasons.

The MMR in the state has come down from 367 per one lac (100,000) child births in 1993 to 358 deaths per one lac births in 2003 which is a very negligible drop. In fact there has not been any significant reduction in the rate of maternal deaths in the last few years and this is a worrying factor, said participants at the “Know Your Entitlements” organized here to coincide with the National Safe Motherhood Day.

The White Ribbon Alliance-Orissa in collaboration with Department of Health and Family Welfare, government of Orissa, Unicef and UNFPA organized the workshop.

With a view to curb this problem by minimizing maternal death rate, the White Ribbon Alliance for Safe Motherhood unites individuals, organizations and communities who are committed towards increasing public awareness on this issue and promote Safe Motherhood.

This year, the Central government declared, “Know your Entitlement” as the theme of the National Safe Motherhood Day. The objective was to generate awareness amongst women and family members on their entitlements under various schemes and policies taken up by the government.

Several NGO’s working in the health sector across the state including the Nehru Yuva Kendra which has trained 12,000 youths for the purpose participated in the workshop here today.

Flood ravaged Orissa

Floods cause health problems in Orissa: Oxfam India has warned that 8.5 million people affected by July’s floods are facing serious health threats. 78 870 cases of diarrhoea have occurred, resulting in 41 deaths; 124 cases of jaundice were reported, with two deaths. 300 people have been bitten by snakes, leading to 22 deaths.

Malaria

Malaria is the foremost public health problem of Orissa contributing 23% of malaria cases, 40% of Plasmodium falciparum cases and 50% of malaria deaths in the country. The tribal population are badly affected by the  Malaria. More than 60% of tribal population of Orissa live in highrisk areas for malaria. Though the tribal communities constitute nearly 8% of the total population of the country, they contribute 25% of the total malaria cases and 15% of total P.falciparum cases. Various epidemiological studies and malariometric surveys carried out in tribal population including primitive tribes reveal a high transmission of P.falciparum in the forest regions of India, because malaria control in such settlements has always been unattainable due to technical and operational problems. In a specific

study conducted in undivided Koraput district, it was observed that the district is endemic for malaria and is hyperendemic in top hills where Bondo primitive tribes are residing.

 

Diarrhoeal Disorders

Water-borne communicable diseases like gastrointestinal disorders including acute diarrhoea are responsible for a higher morbidity and mortality due to

poor sanitation, unhygienic conditions and lack of safe drinking water in the tribal areas of the country. In a cross sectional study conducted by RMRC, Bhubaneswar in 4 primitive tribes of Orissa, the diarrhoeal diseases including cholera was found to occur throughout the year attaining its peak during the rainy season .Generally the infants ,preschool children and adolescent groups are mostly affected.

 

Micronutrient Deficiency

Orissa is very much infamous for starvation death cases. Micronutrient deficiency is closely linked with nutritional disorders and diarrhoea. Deficiency of essential dietary components leads to malnutrition, protein calorie deficiency and micronutrient deficiencies (like vit A, iron and iodine deficiency). Vitamin A deficiency in the form of Bitot’s spot, conjunctival xerosis and night blindness was observed

 

Skin Infection

Skin problems like scabies is a major health problem amongst the rural population of orissa and the problem is much worse in the primitive tribes because of overcrowding and unhygienic living conditions as also close contacts and lack of health awareness. In a study conducted by the RMRC, Bhubaneswar.

 

Intestnal Paracitism

Intestinal protozoan and helminthic infestations are the major public health problems and were observed in Most of these infections are due to indiscriminate defecation in the open field, bare foot walking and lack of health awareness and hygiene. The problem enhances in the rainy season. These are preventable with repeated administration of anti-helminthic and protozoal treatment at 4 months interval which can be used effectively in national parasitic infection control program.

 

 

 

HEALTH INDICATORS OF ORISSA

             The Total Fertility Rate of the State is 2.6. The Infant Mortality Rate is 73 and Maternal Mortality Ratio is 358 (SRS 2001 – 03) which are higher than the National average. The Sex Ratio in the State is 972 (as compared to 933 for the country). Comparative figures of major health and demographic indicators are as follows: 

Table I: Demographic, Socio-economic and Health profile of Orissa State as compared to India figures 

S. No.

Item

Orissa

India

1

Total population (Census 2001) (in million)

36.80

1028.61

2

Decadal Growth (Census 2001) (%)

16.25

21.54

3

Crude Birth Rate (SRS 2007)

21.9

23.5

4

Crude Death Rate (SRS 2007)

9.3

7.5

5

Total Fertility Rate (SRS 2006)

2.6

2.9

6

Infant Mortality Rate (SRS 2007)

73

57

7

Maternal Mortality Ratio (SRS 2001 – 2003)

358

301

8

Sex Ratio (Census 2001)

972

933

9

Population below Poverty line (%)

47.15

26.10

10

Schedule Caste population (in million)

6.08

166.64

11

Schedule Tribe population (in million)

8.15

84.33

12

Female Literacy Rate (Census 2001) (%)

50.5

53.7

 

 

 Table II: Health Infrastructure of Orissa 

Particulars

Required

In position

shortfall

Sub-centre

7283

5927

1356

Primary Health Centre

1171

1279

-

Community Health Centre

292

231

61

Multipurpose worker (Female)/ANM at Sub Centres & PHCs

7206

6768

438

Health Worker (Male) MPW(M) at Sub Centres

5927

3392

2535

Health Assistant (Female)/LHV at PHCs

1279

726

553

Health Assistant (Male) at PHCs

1279

168

1111

Doctor at PHCs

1279

1353

-

Obstetricians & Gynaecologists at CHCs

231

NA

NA

Physicians at CHCs

231

NA

NA

Paediatricians at CHCs

231

NA

NA

Total specialists at CHCs

924

NA

NA

Radiographers

231

8

223

Pharmacist

1510

1984

-

Laboratory Technicians

1510

311

1199

Nurse/Midwife

2896

637

2259

(Source: RHS Bulletin, March 2007, M/O Health & F.W., GOI) 

Health Institution

Number

Medical College

4

District Hospitals

32

Referral Hospitals

 

City Family Welfare Centre

 

Rural Dispensaries

 

Ayurvedic Hospitals

8

Ayurvedic Dispensaries

624

Unani Hospitals

-

Unani Dispensaries

9

Homeopathic Hospitals

-

Homeopathic Dispensary

603

  

  

  

  

  

Conclusion

     Despite the above said problems we have to make our stands strong to fight against the disease, poverty, illiteracy and natural as well as the man made disasters(Naxlite problem).Now under the able leadership of Mr Naveen Pattnaik Orissa has registered record foreign investment as well as an appreciable economical growth. Now it is time to flex our muscles and brain to expedite our development in health care system. Orissa is doing well in the influence of NRHM .Orissa has many a miles to go to improve its health indicators that needs a lot of patience, composure and brain storming.

                             

                                                                       Dr.Nihar Ranjan Ray

                                                                       Dt.29th july 2008

By: Dr Nihar Ranjan Ray

A review of health seeking behavior: problems and prospects

  

Author: Sara MacKian               Article reviewed by: Dr Nihar Ranjan Ray

  

INTRODUCTION:

 

Health seeking behavior refers to all those things humans do to prevent diseases and to detect diseases in asymptomatic stages. In contrast illness behavior refers to all those activities designed to recognize and explain symptoms after one feels ill, and sick role behavior refers to all those activities designed to cure diseases and restore health after a diagnosis has been made.

I agree to the author that there is growing recognition, in both developed and developing countries, that providing education and knowledge at the individual level is not sufficient in itself to promote a change in behavior. We need do something extra or focus to a different dimension to bring effective changes in health indicators. One more important thing that the author has insisted that factors promoting ‘good’ health seeking behaviors are not rooted solely in the individual, they also have a more dynamic, collective, interactive element. Understanding of the social capital and proper understanding of health seeking behavior could reduce delay to diagnosis, improve treatment compliance and improve health promotion strategies in a variety of contexts. Author has given utmost importance to make studies of health seeking behavior more useful from a health systems development perspective. In initial part of the article the author suggested the two approaches namely

(a) Health care seeking behaviors: utilization of the system

(b) Health seeking behaviors: the process of illness response

According to author variety of studies were conducted on the basis of macro analysis. Taking age, sex, geographical region etc.. But author aptly suggested that these determinants can be further broken to smaller fragments like Status of women, Elements of patriarchy, Social Age and sex, Socioeconomic Household resources Education level, Maternal occupation, Marital status, Economic status, ‘Cultural propriety’, Economic Costs of care Treatment, Travel time, Type and severity of illness Geographical Distance and physical access, Physical, Organizational Perceived quality and so many to identify the reality of the back ground problems. Despite the ongoing evidence from different studies that people do choose traditional and folk medicine or providers in a variety of contexts which have potentially profound impacts on health, few studies recommend ways to build bridges to enable individual preferences to be incorporated into a more responsive health care system. I find it most interesting that has been quoted by (Needham et al, 2001).  As they suggested “the need to improve integration of private sector providers with public care to tackle this problem in a better way” And with the Indian perspective at least I can’t agree with Ahemad et al that the training to these non formal providers are wrong. At least we can use their community motivation in a modern way so that the health seeking behavior of these people will change gradually.

 Now it is time to focus upon to understand the psycho logical process of these people as discussed in the section  Health seeking behaviors: the process of illness response. The understanding of the ‘healthy choices’, in either their lifestyle behaviors or their use of medical care and treatment. Among the different models discussed here namely (a) social cognition models (b) Health belief model (c) health locus of control

 

•(a)  social cognition models:

Predicting health behavior with social cognition models as per the figure illustrates I am completely agree with the author as she criticizes the model as “The downfall of these models is that most view the individual as a rational decision maker, systematically reviewing available information and forming behavior intentions from this. They do not allow any understanding of how people make decisions, or a description of the way in which people make decisions.”

•(b)  Health belief Model:

The health belief model is a largely accepted theory and like any other theory it has its limitation also like the author writes “The health belief model has been criticized for portraying individuals as asocial economic decision makers, and its application to major contemporary health issues, such as sexual behavior, have failed to offer any insights” Any how I personally feel this can be a model of reference for contemporary diseases. and also what I feel this model is still holds good in describing the STIs though stigma, shame ness and sexual conservativeness comes into play.

 

It may be right that the way Mc Phill et all thinks “developed country research has a better track record of exploring this broader contextual picture, whilst work in developing countries tends not to acknowledge the poor relationship between knowledge and health seeking behavior.” Apart from the KABP model I find the description of the Reflexive communities are interesting .Reflexive communities reflect the particular ways of behaving, thinking and reaching decisions of individuals or groups, that in turn reflect the social construction of their position in wider society at a particular place and time. Information regarding health seeking has many facets and determinants like ‘moral, affective, aesthetic, narrative and meaning dimensions’. So more scientific way of approach will be ‘aesthetic reflexivity’ which “means making choices about and/or innovating background assumptions and shared practices upon whose bases cognitive and normative reflection is founded” In order to understand how people reach the decision  we need to know also how  the underlying, unspoken, unconscious feelings and assumptions which support that cognitive process. These concepts that are been discussed here  are seems to be more theoretical to practice . But still these issues are need to be addressed aptly for events like HIV/AIDS . I and I am completely agreed with Harvey that “the way people perceive risks and experience risk should be a matter for public policy”

 

Health seeking behavior and the probes: a review

Health seeking behavior differs for the same individuals or communities

when faced with different persons, times& illnesses.   The article has described some of the examples here. They have  given a very nice example here regarding the health seeking practices of women when faced with abnormal vaginal discharge, as opposed to malaria. I think this is more a big problem in countries like India & Bangladesh than the developed worlds. Again the shortage of the female Health care staffs worsens the problem. And the most important thing that I feel is most of the sensitive illnesses or diseases or public health problems are having this problem. Or thinking in the reverse way that due to this embedded problem it is very difficult to address these problems or not getting quick results. Among the examples I try to touch them in short. Only the key issues are given as described the author. I think she has identified it very nicely from different studies.

 

Tuberculosis

(a) Late presentation and delayed diagnosis are  problems for TB, reflecting both

individual and social factor. Delay can be related to social stigma, gender, fear or multiple health seeking.

(b) Culturally sensitive and situated understanding of health seeking behavior may

Provide better  treatment compliance and shorten delay of diagnosis.

©Health education should be started  at family and community level to improve

awareness and to avoid stigma.

(d)The doctor-patient relationship may need particular attention in relation to TB due to the lengthy treatment period.

 

Maternal and child health

(a) The way in which women reach the decisions they can have a great influence

on child morbidity and mortality and is therefore worthy of continued study.

(b) There may be a better ways of exploring women’s involvement in health

system and social structures .

 

Diabetes Type 1

(a)Perhaps the lack of material suggests there is more work needed in this area?

          (b)The doctor-patient dynamic can potentially be used to promote ‘good’ health

seeking behavior and compliance with treatment, and is an issue reflected across

the probes.

  

Social capital and Health & Development

Social resources norms and networks or processes and conditions within society that allow for the development of human and material capital. So  social capital is created and used through individual participation. Bonding social capital which links members of a particular group, and bridging  social capital which links across groups. So the first one when addresses the Horizontal Equity the later addresses the Vertical Equity. Social capital provides a means of shifting the focus from individuals to social groups, and the social involvement of the actions of individuals. Though it varies from community to community but social capital also has implications for the operation of health systems description of that in detail is beyond the scope of this literature.

Health seeking behavior in the context of health systems

Non formal practitioners  and birth attendants so embedded in the existing social

fabric and reflexive communities so that mostly the women deny delivery in favour of trained public service doctors. And in the Indian sub-continent  public doctors running private clinics alongside their public role, where they can charge patients they have referred from the public system, may have the effect of undermining trust in the wider system.

Conclusion

  “To begin to picture the resources and constraints…the way the actor experiences them, is to take a crucial step towards understanding why and how people do what they do”

   This statement by  Wallman and Baker I think we always need to remember be coz Health care is a system that is so much embedded into the society and individuality of the people that if you search for the influencing the factors than finally you will get all the branches of science on your table. So to be practical is more important than criticizing any issue theoretically and parallely we can’t ignore any issue how ever that may seem impractical. That is the beauty and problem of designing the policy for the Health care. What I feel like head of the family neglects himself in due course of taking care of other family members we should not land in a troubled water by focusing more on the peripheral issues of Health care delivery system than the center stage. We should not forget to address the problems of the internal clients to provide a better motivated care to the external clients. Which in my view very poorly addressed in international, national & regional level. And last but not the least is the financing system and its proper management is the key issue.

 

                   Dr Nihar Ranjan Ray

                   Indian Institute Of Public Health, Gandhinagar

By: Dr Nihar Ranjan Ray