Health profile of Kottathara Panchayat

Health profile of Kottathara Panchayat

Profile #3

K.S. Mohindra, S. Haddad, D. Narayana, and S. Aravind

December 23, 2005

Table of Contents

1.0 Introduction to Health Profile .............................................................................................. 1 2.0 Overview of health and health care in Kerala ..................................................................... 1 3.0 Health care resources ........................................................................................................ 3 4.0 Self reported health status and social inequalities in health ............................................... 4 4.1 Measuring health status .................................................................................................. 4 4.2 Assessing socio-economic inequalities in health status ................................................. 5 4.3 Assessing self-reported health across social groups ...................................................... 6 4.4 Self reported health status of Paniya population ............................................................ 8 4.5 Self reported health status of general population (Paniyas are not included) ............... 11 4.6 Summary of health status ............................................................................................. 17 4.7 Disability at the household level ................................................................................... 18 5.0 Determinants of health and their distribution .................................................................... 20 5.1 Demographics ............................................................................................................... 20 5.2 Socio-economic determinants ....................................................................................... 21 5.3 Environmental ............................................................................................................... 22 5.4 Health habits ................................................................................................................. 25 5.5 Health care.................................................................................................................... 32 5.6 Summary of determinants of health .............................................................................. 36 6.0 Burden of Health Care ...................................................................................................... 37 6.1 Health expenditures ...................................................................................................... 37 6.2 Hospital expenditures ................................................................................................... 46 6.3 Coping strategies .......................................................................................................... 48 7.0 References ............................................................................................................................ 50

i

CDS-UdeM 2005

1.0

Health Profile of Kottathara Panchayat

Introduction to Health Profile

This report is the third of seven reports from the action research initiative, Access to Health Care and Basic Minimum Services in Kerala, India, in Kottathara Panchayat, Wayanad. This report aims to provide a planning tool for local health professionals and policy makers by providing basic health and demographic information on the population, and an assessment of the main health needs, and the burden of health care costs in the Panchayat. The current report provides a health profile of the 16,110 individuals living in Kottathara Panchayat. It draws essentially upon the findings of the all-household survey conducted in Kottathara Panchayat during April-June 2003. The report highlights general trends, and disparities that exist among population groups within the Panchayat. Using a standardized approach, the report adopts a user-friendly format (simple tables, graphs, and maps), which will be presented to and discussed with local health professionals, and in institutions of participatory governance (e.g. Grama Sabha, Working groups) encouraging the appropriation of the information. Social groups will be compared according to their poverty status, gender, age, caste and tribal affiliation, in order to assess potential inequalities in health status and determinants of health. Due to the presence of a high proportion of tribes in the total population and large inter-tribal variation, information is presented separately for the most primitive and deprived tribe, the Paniya. The analysis adopts a simple approach to examining health patterns, using two by two tables, because we only control for a limited number of confounders, results should be interpreted with caution. 2.0

Overview of health and health care in Kerala

Kerala has distinguished herself from other Indian states by having succeeded in achieving superior quality of life indicators, despite low levels of income. Mortality rates are considerably lower in this state; infant mortality rates are six times lower than the rest of India, comparable to industrialized nations (Table 1). Also, fertility is lower among women in Kerala compared to India (Table 1). Table 1. Selected mortality and fertility indicators for Kerala and India Crude Death Rate* (2001)

Infant Mortality Rate* (2001)

Total Fertility Rate (1997)

Maternal Mortality Rate** (1997)

Kerala

6.6

11

1.8

195

India

8.4

66

3.4

407

Data Sources: Registrar General, India. Sample Registration System Bulletin, vol 36 (2), October 2002; Registrar General of India, Compendium of India’s Fertility and Mortality Indicators, 1971-1997, New Delhi, 1999. * Crude death rates and infant mortality rates are per 1,000 ** Maternal mortality ratio is the number of maternal deaths per 100,000.

1

CDS-UdeM 2005


Kerala faces a number of health challenges, including the ‘double burden of disease’. Due to the demographic and epidemiological transitions, chronic illnesses are increasing, yet communicable diseases, and so-called ‘diseases of the poor’ continue to have a presence. For example, the prevalence of tuberculosis is higher in Kerala than in India (586 per 100,000 compared to 467 per 100,000) (NFHS, 1992-93). Significant health needs, particularly among an aging population, places a large burden on health care systems. Moreover, although public health care services have been distributed across the population, the quality is deteriorating, and health care costs are placing large burdens on families. A recent study on perceived quality of care found that public health care institutions were rated as low quality, especially with respect to health care workers (Narayana, forthcoming), encouraging patients to turn towards the expanding private sector (Kutty, 2000). Consequently, out-of-pocket expenses for health care have increased for families through rising prices in the private sector, as well as the introduction of user fees in the public sector (Thankappan, 2001). Health care costs are placing large burdens on families. Households spend a high percentage of their annual income on health care, and this percentage has been increasing over time, especially among poorer households (Thankappan, 2001). One study found that 10% of households in Kerala spend more than their annual income on health care (Narayana, 2001).

2

CDS-UdeM 2005

3.0


Health care resources

In Kottathara, there is one primary health centre (PHC), situated in ward 8, and four sub-centres, which are situated in wards 1, 4, 6 and 10 (Map 1). In addition to Kottathara’s subcentres, residents who live in areas on the border of the Panchayat visit subcentres in the neighbouring Panchayats of Panamaram and Padinharathara. There is a homeopathic and ayurvedic dispensary each in the Panchayat.

Map 1

3

CDS-UdeM 2005


There are several hospitals near Kottathara. Kalpetta, the district headquarters is 20 kms away, where a number of hospitals are located (Leo Hospital, Aroma Hospital, and Fathima Matha Hospital). For residents living in wards further away from Kalpetta, notably, Myladi and Vypadi, they may visit government hospitals in Vythiri (Taluk hospital) or Mananthavady (District hospital) 1. In addition to geography, Kottathara residents preferred to visit private hospitals, especially for inpatient care, even though government hospitals provide free care. Residents perceive a better quality of care in private facilities, with respect to quality of physicians and nurses, availability of beds, and of medicine. However, if patients are unable to pay for care, they will most likely go to the District hospital. For outpatient care, and minor health problems, residents generally go to a public facility. 4.0

Self reported health status and social inequalities in health 4.1

Measuring health status

In this profile, we measure health status through self-reported health. Several different indicators are employed, depending on the age group (Table 2). We have not included all the indicators for analysis in this report due to limitations in space. These indicators will be presented in other documents. Table 2. Indicators of reported health Indicator Health problem

Definition

Scale

Health problem experience during the 4 weeks prior to the survey.

Binomial

The original 5 point likert scale (excellent, very good, Poor perceived good, bad, very bad) was collapsed into a binomial scale. health Bad or very bad are classified as “poor health”.

Binomial

Population Children*+

Adults

Disability

Physical incapacity or handicap, including locomotor, visual, hearing, speech, and amnesia.

Binomial

Children, adults

Chronic illness

Illness lasting 6 months or longer.

Binomial

Children, adults

Limitations in activities

The original 3 point likert scale (greatly limited, moderately limited, not limited) was collapsed into a binomial scale. Greatly limited or moderately limited are classified as “limited in activities”. The following activities are included ; ‘physically demanding tasks’, ‘moderately demanding tasks’, and in ‘doing one’s work’.

Binomial

Adults

* A parent or another adult household member reported health of children. + Health problem was not employed for adults and elderly populations because this indicator is often considered unreliable for measuring adult health, and is not sufficiently sensitive to social or economic inequalities in health (Wagstaff, 2000).

1

Information on health care preferences of Kottathara residents is based on findings from focus group discussions.

4

CDS-UdeM 2005


We use two approaches to measuring illness and poor health in the population. First, we use prevalence and incidence rates. A prevalence rate tells us the total number of individuals who have an attribute or illness at a given moment in time divided by the population at risk of having the attribute or illness (Last, 1988). An incidence rate provides information on new cases occurring during a period of time. Incidence rates are used when examining health problems, because this indicator includes episodes of illness occurring during the period of the past four weeks. For other indicators prevalence rates are used. Second, we present relative risks(RR), which measure the strength of an association comparing two populations, a population exposed to a particular risk factor (e.g. toxic chemicals) to a population who is not (e.g. no toxic chemicals). Relative risks are ratios of incidence rates. A relative risk of 1 means there is no association (e.g. risk of having an illness is the same for individuals exposed to chemicals or not). A relative risk greater than 1 suggests that individuals exposed to the factor increases the likelihood of having an illness. The stronger the association the higher will be the relative risk. If relative risk scores are below 1 this suggests a protective factor. In addition to risk factors that are modifiable (e.g. smoking), relative risks can be used for risk markers, which are risks that are not modifiable (e.g. sex, age). Relative risks can also be used for assessing socio-economic inequalities in health by comparing group(s) to the most advantaged group (Braveman et al., 2004). In section 4.5 we consider the following groups as advantaged; men, individuals from APL households (and households above the State Specific Poverty Line or ASSPL), forward castes, non-wage labourers, and educated persons (based on findings of the Poverty Profile and substantive theory). For comparisons among social groups, where there are three main groups, Other ST/SC are compared with forward castes, and then OBC are compared with forward castes (see section 4.3 for explanation why Paniyas are not included in comparisons). In section 5 we use relative risks to explore several known risk factors (e.g. smoking, poor housing conditions).

4.2

Assessing socio-economic inequalities in health status

The choice of indicator used to measure poverty can influence the nature of results obtained in assessing health disparities (Wagstaff et al., 1991). Using the BPL approach to classify poverty is advantageous as it provides information for programs and schemes targeting BPL households. However, the BPL classification employs a number of criteria (including land ownership and housing), and therefore, we cannot specifically examine the relationship between income and health, especially the socio-economic gradient in health. Moreover, BPL does not perfectly classify the poor. Although BPL households were generally poorer than APL households, BPL households were not necessarily the poorest (see Poverty Profile). Using the State Specific Poverty Line (SSPL), which classifies poor as those households whose income 2 falls under 5400 rupees 3, and income quintiles allows us to better isolate the effect of income and health. We adopt the three approaches to assess socio-economic disparities.

2

Note that income is measured by per capita household consumption in the household Our data pertains to 2003-04. The price increase during the four years is around 20 percent in Kerala. In order to take into account the price increase between the two periods, we use an adjusted SSPL of rupees 450 per capita per month in 2003-04. 3

5

CDS-UdeM 2005

4.3


Assessing self-reported health across social groups

The profile explores disparities in health across social groups (caste and tribal affiliations). And because health status was assed through self-reports of the population, issues of comparability arose. Large socio-cultural differences between groups can increase difficulties in comparing health status when health is measured through self-reporting. Amartya Sen refers to a ‘perception bias’ that may arise among individuals who lack the informational base to assess their own poor health status, and consequently they do not report existing health problems (Sen, 1994; 2002). It has been observed that in low-income countries, the poor report less ill-health even though they experience higher mortality rates than non-poor. Factors such as lack of education, and limited interactions with health professionals are important information for assessing a person’s own health. In Kottathara, in addition to cultural differences among the Paniyas, the Poverty Profile demonstrates that there is a wide disparity in levels of deprivation between Paniya and the other social groups. Table 3 sums up this disparity; Paniyas have lower incomes, fewer assets, participate less in community organization, and have lower levels of education, all of these factors lead to a decrease in opportunities, including the capacity to lead healthy lives. Table 3. Comparison of selected socio-economic characteristics of Paniya and other groups Socio-economic characteristic Households classified as BPL (%) Average income (Rs per capita per year) Households owning no land (%) Households participating in community organization+ (%) Individuals never attending school (%)

Social group Paniya Other 83.7% 38.0% 4,911 8,972 13.2% 1.6% 19.6% 50.3% 52.0% 10.1%

Data source : Kottathara Survey (2003) + At least one member in the household participates in a community organization.

6

CDS-UdeM 2005


Because we know that the poorer and most deprived groups also have the poorest health, we should expect that Paniyas are the least healthy. However, Table 4 indicates that compared to other social groups, Paniyas do not report a worse health status, rather they report that they experience less health problems! The relative risks fall below 1 indicating that Paniyas are less likely to report poor health compared to other social groups. This suggests to both women and men. Associations are particularly pronounced for chronic illness. The prevalence rate for men from other social groups reported chronic illness almost two times more often (11.8% compared to 6.3%). The relative risk, 0.53 shows that Paniyas are 50% less likely to report chronic illness compared to men from the other social groups (which the two stars indicate is a highly statistically significant finding).

Table 4. Comparison of selected health indicators of Paniya and other groups for males and females of working age populations, prevalence and relative risk Adults (15 to 59 years) Females Indicator (prevalence)

Paniya (1)

Other groups (2)

Males Relative risk (1) / (2)

Paniya (1)

Other groups (2)

Relative risk (1) / (2)

Poor perceived health (%) Disability (%) Chronic illness (%) Limited in physical level activities (%) Limited in moderate level activities (%) Limitations in doing one’s work (%)

16.4 3.5 11.8 18.4 11.2 6.4

19.0 4.2 17.9 25.4 11.7 4.5

0.86 0.83 0.66** 0.72** 0.96 1.42*

8.4 2.2 6.3 10.9 6.0 3.6

13.9 3.7 11.8 17.9 8.8 3.6

0.60** 0.59* 0.53** 0.61** 0.68** 1.00

Population size

685

4,591

5,276

585

4,574

5,159

Statistical note: SPSS, statistical significance of these risks were estimated through chi-square test; *p