World Health Survey, 2003 KARNATAKA

World Health Survey, 2003

KARNATAKA

International Institute for Population Sciences (IIPS) Mumbai

World Health Organisation (WHO), Geneva

World Health Organisation - India - WR Office, New Delhi

2006

Contact Information : International Institute for Population Sciences Govandi Station Road, Deonar, Mumbai - 400088. Tel.: 91-22-25575206, 91-22-25563254/55/56 Fax: 91-22-25563257

CONTRIBUTORS M. Guruswamy P. Arokiasamy T.K. Roy H. Lhungdim

Contents Page iv vi vii ix xi xiii

LIST OF TABLES LIST OF FIGURES PREFACE ACKNOWLEDGEMENTS FACT SHEET SUMMARY OF FINDINGS CHAPTER 1 INTRODUCTION 1.1 Health system performance in India 1.2 Share of public and private facilities in health care 1.3 Health system goals 1.4 New health policy in India 1.5 Health related surveys in India 1.6 The world health survey-2003 1.7 Socio-demographic profile 1.8 Health profile of Karnataka

1 1 1 1 2 3 4 5 5

CHAPTER 2 METHODOLOGY 2.1 National sampling 2.2 Sampling for Karnataka 2.3 Questionnaire 2.4 Geographic Information system 2.5 Training data collection and quality assurance 2.6 Income Quintile 2.7 Field Experience of the Investigators 2.8 Limitations of the data/study 2.9 Survey metrics 2.10 Response rate 2.11 Reliability 2.12 Weighting

7 7 8 9 10 10 11 11 12 12 13 14 14

CHAPTER 3 SOCIO-DEMOGRAPHIC PROFILE OF HOUSEHOLD POPULATION AND RESPONDENTS 3.1 Household population profile 3.1.1 Age-sex distribution

15 15 15

i

3.1.2 3.1.3 3.2 3.2.1 3.2.2 3.2.3 3.2.4 3.2.5

Marital status Educational status Socio-demographic profile of respondents (Individual questionnaire) Age-sex distribution Marital status Education status Religion Mother tongue

15 15 17 17 18 18 18 18

CHAPTER 4 RISK FACTORS 4.1 Tobacco consumption 4.2 Alcohol consumption 4.3 Nutrition and Physical activities 4.4 Access to improved water sources 4.5 Access to improved sanitation 4.6 Solid fuel use

19 19 21 22 25 26 27

CHAPTER 5 MORBIDITY PREVALENCE (NEED AND COVERAGE) 5.1 Communicable diseases 5.1.1 Tuberculosis and HIV/ AIDS 5.1.2 Malaria and diarrhea 5.2 Maternal and reproductive health 5.3 Non-communicable diseases 5.3.1 Asthma, Arthritis and angina 5.3.2 Diabetics, depression and psychosis 5.3.3 Vision care 5.3.4 Oral health and injuries

29 29 30 31 31 32 32 32 35 35

CHAPTER 6 HEALTH STATE VALUATIONS 6.1 Health state description 6.2 General health rating 6.3 Work and Household activities 6.4 Mobility 6.5 Self care 6.6 Pain and discomfort 6.7 Cognition 6.8 Inter personal activities 6.9 Vision 6.10 Sleep and energy 6.11 Affect

38 38 38 40 41 42 45 47 49 52 54 55

ii

CHAPTER 7 HEALTH SYSTEM RESPONSIVENESS 7.1 Self assessed need for health care 7.1.1 Self assessed need for inpatient care 7.1.2 Self assessed need for out patient care 7.2 Health system responsiveness 7.2.1 Responsiveness for inpatient treatment 7.2.2 Responsiveness for out patient treatment

58 59 60 61 62 63 65

CHAPTER 8 HEALTH EXPENDITURE, INSURANCE AND HUMAN RESOURCES FOR HEALTH 8.1 Health Expenditure 8.1.1 Health expenditure by type of services 8.1.2 Health expenditure by source of finance 8.1.3 Out of pocket expenditure on health 8.1.4 Catastrophic spending on health 8.1.5 Impoverishment 8.2 Insurance 8.2.1 Insurance coverage 8.3 Human resources for health

67 67 67 67 67 68 69 69 70 70

REFERENCES GLOSSARY APENDIX-A: LIST OF CONTRIBUTORS APPENDIX-B: RESEARCH TEAM AND RESOURCE PERSONS

75 76 79 80

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Tables Page Table 1.1

Trends in health expenditure in India (1997-2001)

2

Table 1.2

Selected socio-demographic indicators for India and Karnataka

5

Table 1.3

Selected health status and health infrastructure indicators for India and Karnataka

6

Table 2.1

Classification of states by region and levels of development

7

Table 2.2

Response and non-response rate in Karnataka, 2003

14

Table 3.1

Distribution of household population by socio-demographic characteristics, Karnataka 2003

16

Table 3.2

Distribution of respondents by socio-demographic characteristics, Karnataka 2003

17

Table 4.1

Percent of respondents consuming tobacco in Karnataka, 2003

20

Table 4.2

Prevalence of infrequent and frequent heavy drinking in Karnataka, 2003

21

Table 4.3

Prevalence of insufficient intake of fruits, vegetables and insufficient physical activity in Karnataka, 2003

23

Table 4.4

Height and weight of women in Karnataka, 2003

24

Table 4.5

Height and weight of men in Karnataka, 2003

25

Table 4.6

Access to improved drinking water in Karnataka, 2003

26

Table 4.7

Access to improved sanitation in Karnataka, 2003

27

Table 4.8

Type of fuel used for cooking in Karnataka, 2003

28

Table 5.1

Coverage of tuberculosis, counseling and testing for HIV/AIDS and condom use in Karnataka, 2003

30

Table 5.2

Percent of children with episode of malaria and diarrhoea and percent treated in Karnataka, 2003

31

Table 5.3

Percent of women screened for cancer in Karnataka, 2003

32

Table 5.4

Percent of mothers who received antenatal care and child who received health care in Karnataka, 2003

33

Table 5.5

Need and coverage of angina, arthritis and asthma in Karnataka, 2003

35

Table 5.6

Need and coverage of diabetes, depression and psychosis in Karnataka, 2003

36

Table 5.7

Need and coverage for vision in Karnataka, 2003

36

Table 5.8

Need and coverage for oral health and injuries in Karnataka, 2003

37

Table 6.1

Respondents-rating of their health in general, Karnataka 2003

39

Table 6.2

Difficulty with ‘work or household activities’ in last 30 days

40

iv

Table 6.3

Difficulty in ‘moving around’ in last 30 days, Karnataka 2003

41

Table 6.4

Difficulty with ‘vigorous activities’ in last 30 days, Karnataka 2003

43

Table 6.5

Difficulty with ‘self-care’ in last 30 days, Karnataka 2003

44

Table 6.6

Difficulty with ‘taking care of and maintaining general appearance’ in last 30 days, Karnataka 2003

45

Table 6.7

Difficulty with ‘bodily aches or pains’ in last 30 days, Karnataka 2003

46

Table 6.8

‘Bodily discomfort’ in last 30 days, Karnataka 2003

47

Table 6.9

Difficulty with ‘concentrating or remembering things’ in last 30 days, Karnataka 2003

48

Table 6.10

Difficulty with ‘learning a new task’ in last 30 days, Karnataka 2003

49

Table 6.11

Difficulty with ‘personal relationships or participation in the community’ in last 30 days, Karnataka 2003

50

Table 6.12

Difficulty in ‘dealing with conflicts and tensions’ in last 30 days, Karnataka 2003

51

Table 6.13

Difficulty with ‘seeing and recognizing a person across the road (20m)’ in last 30 days, Karnataka 2003

52

Table 6.14

Difficulty with ‘seeing an object at arm’s length or in reading’ in last 30 days, Karnataka 2003

53

Table 6.15

Difficulty with ‘sleeping’ in last 30 days, Karnataka 2003

54

Table 6.16

Difficulty with ‘feeling rested and refreshed’ in last 30 days, Karnataka 2003

55

Table 6.17

Feeling ‘sad, low or depressed’ in last 30 days, Karnataka 2003

56

Table 6.18

Difficulty with ‘worry or anxiety’ in last 30 days, Karnataka 2003

57

Table 7.1

Percent distribution of respondents needing health care in Karnataka, 2003

59

Table 7.2

Percent distribution of respondents with self assessed need for health care in the previous 12 months in Karnataka, 2003

60

Percent distribution of respondents with self assessed need for inpatient care in the previous five years in Karnataka, 2003

61

Percent distribution of respondents with self assessed need for outpatient care in the previous five years in Karnataka, 2003

62

Table 7.5

Mean scores of responsiveness on various domains for inpatient care in Karnataka, 2003

64

Table 7.6

Mean scores of responsiveness on various domains for outpatient care in Karnataka, 2003

66

Table 8.1

Household health expenditures in rupees by types of services and Income in Karnataka, 2003

68

Table 8.2

Household health expenditures in rupees by source of finance in Karnataka, 2003

68

Table 8.3

Households with catastrophic health spending by type of health services in Karnataka, 2003

70

Table 8.4

Insurance coverage by residence and household income in Karnataka, 2003

71

Table 8.5

Health professionals per 1,00,000 population in Karnataka, 2003

71

Table 8.6

Percentage distribution of health professionals by type of occupation in Karnataka, 2003

72

Table 8.7

Percentage distribution of health professionals by their current work status Karnataka, 2003

73

Table 7.3 Table 7.4

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Figures

Page Figure 2.1

Distribution of primary sampling units in Karnataka

11

Figure 2.2

Household sample deviation index for Karnataka

13

Figure 2.3

Individual sample deviation index for Karnataka

13

Figure 3.1

Population Pyramid for Karnataka

16

Figure 3.2

Age distribution of respondents by residence in Karnataka, 2003

18

Figure 4.1

Percentage using tobacco by age and sex in Karnataka, 2003

20

Figure 8.1

Percentage of out of pocket expenditure as a share of capacity to pay in Karnataka, 2003

69

Figure 8.2

Structure of out pocket health payments in Karnataka, 2003

69

Figure 8.3

Distribution of households with catastrophic expenditure in Karnataka, 2003

70

Figure 8.4

Human resource for health in Karnataka, 2003

73

Figure 8.5

Age distribution of health professionals in Karnataka, 2003

74

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Preface

The World Health Organization initiated a multi-country World Health Survey programme in 70 countries to provide evidence based health information for health interventions. The core objective of the survey is to strengthen the health information system of the country and develop capacity for policy makers to monitor health system performance in terms of three major components namely burden of disease, health financing and health system performance. The key objective is to provide data on a wide range of population health indicators such as health financing, health insurance, human resources for health, health state valuation, risk factors, mortality by cause, morbidity prevalence, reproductive and sexual health care and health system responsiveness relating to inpatient and outpatient care. The World Health Organization and the Ministry of Health and Family Welfare designated the International Institute for Population Sciences to undertake the World Health Survey in India. The finances and technical assistance were provided by W.H.O, Geneva. Additional funding was provided by WHO, India Office, New Delhi. The World Health Survey covered six major states of India namely Assam, Karnataka, Maharashtra, Rajasthan, Uttar Pradesh and West Bengal, which comprise about 47 percent of the country’s population. The WHS–India covered a representative sample in each state. The pooled sample for India was 10,279 households. The health information questionnaire covered a randomly selected sample of 9994 adult individuals in the ages 18 and above. In Karnataka the survey covered a representative sample of 1473 households and 1431 adult individuals. The WHS used standardized household and individual questionnaires in all the six states that is also used in 70 other countries. The fieldwork for the survey was completed during February to June 2003. The instruments, sampling design, tabulations and structure of state and combined India report were finalized in various regional and international workshops conducted by W.H.O. A Steering Committee of officials from the Ministry of Health and Family Welfare and researchers in the area of population health also guided the conduct of the survey. Six state and India reports are presented to provide key population health indicators to health policy makers and researchers. For the first time in India, data is provided on a variety of population health indicators based on updated definitions of health. There are several other unique features that the report contains. We trust it will be useful for developing a framework for health policy interventions and further research.

Prof P.N. Mari Bhat Director & Senior Professor International Institute for Population Sciences, Mumbai.

vii

Acknowledgements

The World Health survey - India, 2003 was successfully implemented in six states in the country due to the collaborative efforts of the Evidence, Information and Policy Division of the WHO, Geneva, the WHO-WR office, New Delhi, IIPS, Mumbai and a number of state level research organizations and researchers in the area of population health. Dr. Chris Murray, the then Executive Director and Mr. David Evans, the current Executive Director of the EIP Division provided overall leadership to the WHO-WHS multi country survey in 70 countries. Dr. B. Ustun, the survey coordinator and Dr. Somanth Chatterji, senior scientist guided the India team both in technical and operational aspects of the survey. Dr. G. Rama Rao, as officiating director, IIPS and Dr. P.N. Mari Bhat, Director, IIPS also provided unreserved support in the final stages of the project. Dr. Russell Blamey, quality assurance advisor for WHO and Dr. Nanjamma Chinappa, sampling advisor for WHO-WHS deserve special thanks for their suggestions and support. We express our sincere thanks to the World Health Organization, Geneva for entrusting us with the task of conducting this survey in India. Special thanks are due to Mr. Sunil Nandaraj, National Professional Officer, WR, India for initiating the project, for being a member of the Steering Committee and regularly interacting with us at various stages of the survey. Our sincere thanks are due to the following members of the project Steering Committee for their guidance, support and encouragement. Mr. K.V. Krishnan, formerly Economic Advisor to the Ministry of Health and Family Welfare, Smt. Ganga Murthy, Economic Advisor to the Ministry of Health and Family Welfare, Dr. K.V. Rao, former Chief Director, Ministry of Health and Family Welfare, Mr. D.K. Joshi, former Chief Director, Ministry of Health and Family Welfare, Mr. P. Chattopadhaya, Chief Director, Ministry of Health and Family Welfare, Prof. P.M. Kulkarni, Jawaharlal Nehru University, Prof. C.A.K. Yesudian, Tata Institute of Social Sciences and Dr. Subash Salunke, former Director General of Health Services, Government of Maharashtra. It should be mentioned that a small army of people at various levels and in various places contributed towards the completion of the survey. A research team at IIPS spent seemingly endless hours in preparatory work for the survey, in tabulation and in drafting the reports. Successful completion of the survey was possible largely due to the sincere and painstaking efforts of the research team at IIPS and the field workers who patiently conducted the interviews and collected the required data. We sincerely thank all of them. M. Guruswamy P. Arokiasamy T.K. Roy H. Lhungdim Principal Investigators WHO-WHS (India) 2003 July 2006 IIPS, Mumbai-88.

ix

Fact Sheet - Karnataka World Health Survey, 2003 Population Households covered Individuals covered Number of Primary sampling units Rural Urban Demographic Profile CBR1 CDR1 IMR1 Life expectancy2 Male Female

1473 1431 34 16 19.3 7.2 55 61.6 64.9

Risk Factors (in percent) Prevalence of tobacco consumption Urban Rural

27 16 28

Never had a drink3 Urban Rural

92 97 91

Access to piped water Urban Rural

26 34 24

Access to other sources4 Urban Rural

50 51 44

No access Urban Rural

25 22 25 5 22 1

Access to other improved sources5 Urban Rural

21 35 17

No access to improved sanitation Urban Rural

75 43 82

Fuel Use (in percent) Cooking with electricity/gas Urban Rural Cooking with kerosene Urban Rural

75 35 85

Morbidity (in percent) Tuberculosis screening7 Counseling for HIV/AIDS8 Condom use Malaria9 Diarrhoea Cervical cancer screening10 Breast cancer screening11

1 3 2 14 14 12 5

Maternal Health (in percent) Full antenatal care12 Care for delivery

57 45

Immunization13 (in percent) DPT3 Measles

59 54

Non-communicable diseases14 (in percent)

Sanitation (in percent) Access to flush toilet Urban Rural

Cooking with solid fuel6 Urban Rural

23 59 14 2 6 1

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Angina Need Coverage

7 49

Arthritis Need Coverage

27 73

Asthma Need Coverage

7 74

Diabetes Need Coverage

3 96

Depression Need Coverage

9 13

Psychosis Need Coverage

1 85

Cataracts Need Coverage

12 57

Oral health problems Need Coverage

25 72

Road traffic injuries

3

Other injuries

2

General health rating15 (in percent)

No difficulty Extreme difficulty

77 2

Very Good Overall Male Female Urban Rural

43 45 41 56 44

At arm’s length No difficulty Extreme difficulty

77 1

Very Bad Overall Male Female Urban Rural

Sleep No difficulty Extreme difficulty

80 1

1 1 2 2 1

Depression No difficulty Extreme difficulty

Mobility No difficulty Extreme difficulty

68 1

Vigorous activity No difficulty Extreme difficulty

66 3

Self care No difficulty Extreme difficulty

81 1

Bodily aches or pains No difficulty Extreme difficulty

54 1

Bodily discomfort No difficulty Extreme difficulty

60 1

Cognition No difficulty Extreme difficulty

73 1

Inter-personal activities No difficulty Extreme difficulty

75 2

Health System Responsiveness Rating16

Vision Across the road (20m)

Notes:

1. 2.

3. 4.

5. 6.

7. 8.

71

Reference period is last 7 days Public standpipe, protected tube well, bore well, dug well or spring, rainwater etc. Pour flush toilet, covered dry latrine etc. Coal, charcoal, wood, agriculture/crop, animal dung, shrubs/grass etc. Reference period is last one year Corresponds to all females of age 18-49, pregnant in last 5 years who reported in ANC clinics Reference period is last one year for children under 5 years. Corresponds to females of age 18-69

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Inpatient Services Overall Autonomy Choice Communication Confidentiality Dignity Basic Amenities Prompt attention

81 79 79 84 88 85 81 69

Outpatient Services Overall Autonomy Choice Communication Confidentiality Dignity Basic Amenities Prompt attention

75 74 75 77 80 77 69 72

Health Expenditure (in Rupees) 17 Total Inpatient care Outpatient care Traditional medical practitioners Drugs Others

90 3 31 2 34 21

9.

Females of age 40-69 Corresponds to pregnancies in the last five years for women in ages 18 to 49. 11. Immunization corresponds to children under 5 years, only for cases for which immunization card is shown 12. Reference period is one year prior to the survey. 13. Rating on the day of survey 14. Reference period is last 30 days prior to the survey. 15. Responsiveness measured as normalized mean score which range between 0 and 100; reference period last 12 months 16. Reference period is last one month — Value less than one 10.

Summary of Findings Household and individual respondents profile

heavy drinkers is six percent and heavy drinkers two percent. In Karnataka, fifteen percent men in ages 18 and above ever had alcohol compared to one percent among women. Among males the proportion of infrequent heavy drinkers is 11 percent and five percent were found to be frequent heavy drinkers. Ninety seven percent of urban respondents never had alcohol compared to 91 percent in rural areas. The proportion of infrequent heavy drinkers is higher in rural (seven percent) compared to urban areas (three percent). The proportion of frequent heavy drinkers in rural areas is also more than that in urban areas. The proportion of those who have never had a drink is lower in the lowest income quintile (86 percent) compared to highest income quintile (97 percent). This trend is true in the case of infrequent heavy drinkers. The proportion of frequent heavy drinkers is three percent in the lowest income quintile compared to one percent in the highest quintile. The proportion of frequent heavy drinkers increases with age and is highest at two percent in the ages 70-79. The experience of ever having a drink is reported to be the least among the youngest age group of 18-29 years.

Information was collected on the socio-demographic characteristics of a population of 7838 from 1473 households by their age, sex, marital status, educational status, ethnicity and by language spoken. In the overall household population 51 percent are males and 49 percent are females. The proportion of population in ages less than 15 is 24 percent and the proportion of elderly (60+) is 10 percent. At each level of schooling, males have higher level of educational attainment compared to females. Similarly, the proportion of respondents in urban households enjoying educational attainment is higher compared to rural households. In the individual questionnaire that assesses respondent’s health states, information was collected from 1431 respondents. Among them 51 percent are males and 49 percent are females. Thirty five percent of respondents are from urban areas and 65 percent are from rural areas. Risk factors Use of tobacco The overall prevalence of tobacco use, either smoking or chewing, is 26 percent. The proportion of tobacco users among males is about three times higher compared to females. Prevalence of tobacco use is higher in rural areas compared to urban areas. In the lowest income quintile 31 percent of the respondents use tobacco compared to only eight percent in the highest income quintile. The proportion using tobacco increases with age from 11 percent in the younger ages of 18-29 to 48 percent for the ages 65 and above.

Nutrition About 81 percent of the respondents do not have sufficient intake of fruits and vegetables. The proportion with insufficient intake of fruits and vegetables is 81 percent for males and 80 percent for females. In rural areas, 81 percent respondents have insufficient intake of fruits and vegetables compared to 77 percent among the urban respondents. Lower income quintiles indicate the highest proportion of people with insufficient intake of fruits and vegetables. The proportion with insufficient food intake increases with age and all respondents in the ages 80 and above have insufficient intake of fruits and vegetables.

Alcohol consumption About 92 percent of the respondents reported that they had never consumed alcohol. The proportion of population who are infrequent

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proportion with other improved toilet facilities is 17 percent and 82 percent do not have any access to improved sanitation. As economic status improves, accessibility to both flush toilet and other improved toilet facilities improves. The proportion having access to flush toilet is less than one percent in the lower income quintiles compared to 17 percent in the highest income quintile. The proportion having no access to improved sanitation declines steadily with an improvement in economic status.

Physical activities Twenty six percent of adult respondents are found with inadequate physical activities. Eighteen percent females and 35 percent males have reported inadequate physical activities. The proportion with inadequate physical activity is 35 percent in urban and 24 percent in rural areas. The proportion of respondents with insufficient physical activity increases in the higher incomes quintiles. Drinking water Twenty six percent of the sampled households in Karnataka have access to piped drinking water in their houses and 50 percent have access to other sources of improved drinking water. About 24 percent do not have any access to improved drinking water sources. In urban areas the proportion of households with access to piped drinking water facilities is 34 percent and those to other improved drinking water sources is 44 percent. Twenty two percent have no access to improved drinking water sources in urban areas. In rural areas, 24 percent of households have piped drinking water facilities and 51 percent have access to some other improved sources of drinking water. Twenty five percent households in rural area do not have any access to safe drinking water. The proportion with access to improved drinking water piped to the household increases at higher income quintiles. Only six percent households have access to improved drinking water sources in the lowest income quintile compared to 52 percent in the highest income quintile. 0The proportion of households having access to other sources of improved drinking water declines with an improvement in the economic status.

Solid fuel About 23 percent of households in Karnataka are using either gas or electricity for cooking. The proportion using kerosene is two percent compared to 75 percent using solid fuel. The proportion using electricity and gas is four times higher in urban areas (60 percent) compared to rural areas (14 percent). About five percent of urban households and one percent of rural households use kerosene for cooking. Thirty five percent of urban households are using solid fuel compared to 85 percent of rural households. As economic status improves, households using cooking fuels such as electricity or gas are more compared to those using kerosene or solid fuel. The proportion using electricity or gas steadily increases from six percent in the third income quintile to 74 percent in the highest income quintile. All respondents in the lowest income quintile use solid fuel, which declines to 24 percent in the highest income quintile. Coverage Screening of Tuberculosis, HIV/AIDS and condom use Information on coverage for tuberculosis was collected from the respondents in all the ages and the information on HIV/ AIDS test was collected for women in the reproductive ages who had a live birth in the last five years. The information on use of condoms was collected from the respondents of both the sexes in the ages 1849. Overall, one percent respondents have reported tuberculosis screening. In both urban and rural areas one percent each has been screened for tuberculosis. The proportions screened for tuberculosis in the low-income quintiles is one percent compared to two percent in the third income quintile. About three percent of the respondents have reported having received voluntary

Sanitation Only five percent of households in Karnataka have access to flush toilet with sewage system. The proportion having other improved toilet facilities is 21 percent compared to 75 percent having no access to improved sanitation. In urban areas about 22 percent of households have access to flush toilet with sewage system. The proportion of households with other improved toilet facilities is 35 percent, and 43 percent households do not have any access to improved sanitation. In rural areas, only one percent households have access to flush toilet with sewage system. The

xiv

ages 0-5 years for births during the five years prior to the survey. Fifty seven percent women received full antenatal care and 45 percent women received care at the time of delivery. The coverage of DPT 3 and measles immunization pertains to children less than five years. Fifty nine percent of children received DPT immunization and 54 percent received measles vaccination. It should be noted that this information was collected only from those cases where the immunisation card was shown to the interviewer.

counselling and testing for HIV/ AIDS. This proportion is the same in both urban and rural areas. About five percent in the high-income quintiles have reported HIV/ AIDS test compared to three percent in the lowest income quintile. About one percent of males and two percent of females in the ages 18-49 have reported using condoms. The use of condoms is higher in urban areas (three percent) compared to rural areas (one percent). In the very low-income quintiles less than one percent of respondents reported using condoms and it increases to three percent in the high-income quintiles.

A higher percent of women in urban compared to rural areas received antenatal care and care at the time of delivery. Sixty five percent urban women received antenatal care compared to 54 percent rural women. Only 40 percent rural women received care at the time of delivery compared to 61 percent urban women. The proportion of women receiving care at the time of delivery is 27 percent and antenatal care is about 44 percent in the lowest income quintile compared to 52 percent and 61 percent in the highest income quintile. About 42 percent of women who received antenatal care have no formal education compared to 72 percent women with high school or higher level of education. Thirty five percent of women with no formal schooling received care at the time of delivery compared to 53 percent among women with high school or higher education. The proportion of children who received DPT immunization increases with mother’s education, whereas there is no significant difference in the coverage of measles immunisation by mother’s education.

Malaria and diarrhoea The information on malaria and diarrhoea was collected from the respondents who have children less than five years of age. About one percent of the children had an episode of malaria during one year prior to the survey and all of them received treatment. The reported prevalence of diarrhoea is 14 percent. The proportion of male children with an episode of diarrhoea is nine percent, while 19 percent of female children had an episode of diarrhoea. The prevalence of malaria (two percent) and diarrhoea (15 percent) is high in urban areas. The prevalence of diarrhoea shows a proportionate decline in the higher income quintiles. In the lowest income quintile prevalence of malaria (three percent) is higher compared to the third income quintile (one percent). The prevalence of diarrhoea is 22 percent in the lowest income quintile and comes down to 18 percent in the highest income quintile.

Coverage of non-communicable diseases Maternal and child health

Asthma, arthritis, and angina

Women in the age group 18-69 were asked if they were screened for cervical cancer and those in ages 40-69 were asked if they were screened for breast cancer. Overall, 12 percent of women in the ages 18-69 had undergone cervical cancer screening and five percent of the women in the ages 40-69 had breast cancer screening. In urban areas 20 percent of women reported cervical cancer screening and eight percent of women breast cancer screening. In the rural areas, the proportion is 11 percent and five percent respectively for cervical and breast cancer screening. More women in the higher income quintiles reported cervical cancer screening than those in the lower income quintiles. Questions were asked regarding the health care services availed by mothers in the ages 18-49 and children in the

Of the 1431 respondents, seven percent have been diagnosed with angina of which 79 percent have received treatment. While 27 percent have been diagnosed with arthritis, 73 percent of them have been covered. Those diagnosed with asthma constitute seven percent and 74 percent of them have received treatment. This clearly indicates that there is a gap between need (cases diagnosed) and coverage (cases treated). The incidence of all these three diseases is more among females than males and more among rural than urban respondents. Also, more respondents in the lower income quintiles have been diagnosed than those in the higher income quintiles. Regarding coverage, while there

xv

is no significant differential between the sexes, it seems to be better in the rural areas than in the urban areas except in the case of asthma. It is also evident that more respondents in the higher income quintiles have been covered (treated) than those in the lower income quintiles.

injuries is three percent in the lowest income quintile and five percent in the highest income quintile.

Diabetes, depression and psychosis

The highest proportion of 43 percent respondents rated themselves to be in very good health followed by 40 percent who rated themselves to be in good health. Eleven percent rated themselves to be in moderate health and about one percent in a very bad health state. Among males, 40 percent have rated themselves to be in good health and 45 percent in very good health compared to 40 percent and 41 percent respectively among females. A greater proportion of urban respondents (56 percent) have rated themselves in very good health compared to rural respondents (40 percent). The proportion of respondents with bad and very bad health is lower at younger ages compared to older ages. Among illiterates, 13 and 38 percent respondents rated themselves to be in a moderate and good health state respectively. The proportion of respondents rating themselves in a very good health state increases with a rise in educational status.

Health state valuations General health rating

Three percent of the respondents have reported a need for diabetes treatment and 96 percent of them have been covered. While nine percent have reported depression among them only 13 percent have received treatment. The reported incidence of psychosis is less than one percent and 85 percent of them have been treated. There is no difference between the sexes in the reported need for treatment of diabetes, but more females than males and more of rural respondents than urban respondents have reported a need for treatment of depression and psychosis. Coverage of vision It was found that a larger proportion of females (13 percent) have been diagnosed compared to males (11 percent) with cataract in their eyes. The proportion diagnosed is twice as large (20 percent) in the urban areas compared to the rural areas (10 percent). Similarly, the proportion diagnosed is 18 percent in the highest income quintile while it is only 12 percent in the lowest income quintile.

Mobility Moving around Sixty eight percent of respondents do not have any difficulty in moving around. About seven percent have moderate, 20 percent have mild, three percent have severe and one percent have extreme difficulties in moving around. About 71 percent of males and 64 percent of females do not have any difficulty in moving around. A higher proportion of females compared to males have mild, severe and extreme difficulties.

Oral health and injuries Twenty five percent of respondents had oral health problems, with a higher proportion of females (27 percent) having oral health problems compared to males (24 percent). However, the proportion receiving treatment is about 75 percent for males and 70 percent for females. About 25 percent of rural and 26 percent of urban respondents have reported oral health problems and 72 percent of these cases have received treatment both in rural and urban areas. The proportion of respondents with oral health problems does not systematically vary by income quintiles. But, the proportion receiving treatment for oral health problems increases with income quintiles.

Difficulty in vigorous activity About 66 percent of respondents reported that they do not have any difficulty in doing vigorous activities. Twenty percent of respondents have reported mild and seven percent have moderate difficulty in engaging themselves in vigorous activities. About three percent have reported that they have extreme difficulty in doing activities that require vigorous labour. Seventy percent of males and 62 percent of females do not have any problem in doing vigorous activities. Higher proportions of rural respondents have moderate, severe and extreme

About three percent of respondents received emergency care for road traffic accidents, with four percent males and one percent females. Two percent each of urban and rural respondents received emergency care for other injuries. The care received for road accidents and other

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bodily discomfort is 64 percent among males and 57 percent among females. The proportion reporting bodily discomfort is lesser in urban compared to rural areas. The proportion of respondents with bodily discomfort increases with age.

difficulties compared to urban respondents when engaged in activities that involve vigorous labour. Self-care Eighty one percent of respondents do not have any difficulty in taking care of themselves. About 82 percent males compared to 79 percent of females do not have any difficulty with self-care. Eighty seven percent of urban and 80 percent of rural respondents do not have any difficulty in self-care. Eighty nine percent of respondents in the younger ages 18-29 do not have any difficulty compared to 51 percent in the ages 80 and above. Seventy two percent of respondents among illiterates do not have any difficulty compared to 95 percent respondents with 11 or more years of schooling.

Cognition Concentration and memory About 73 percent of the respondents do not have any difficulty in concentration or remembering things. The proportion of those who do not have any difficulty in concentration or remembering things is 74 percent among females and 71 percent among males. About 81 percent of urban and 70 percent rural respondents do not have any difficulty in concentration or memory. The proportion of respondents with no difficulty in concentrating or remembering things increases at higher levels of education.

Maintaining general appearance About 72 percent of respondents do not have any difficulties in maintaining general appearance and 19 percent have mild difficulties. Seventy five percent of males and 70 percent of females do not have any difficulty in maintaining general appearance. The proportion of respondents with no difficulty in self-care and maintaining general appearance declines at higher ages.

Learning a new task

Pain and discomfort Bodily aches or pains About 54 percent of the respondents do not have any bodily aches or pains. About 27 percent of the respondents have mild pain, 12 percent have moderate pain and six percent have severe pains in the body. Only one percent of respondents have reported extreme bodily pains. About 60 percent of males and 48 percent of females do not have any bodily aches or pains. A greater proportion of urban respondents (63 percent) compared to rural respondents (52 percent) reported that they do not have any bodily pain. The proportion of respondents with extreme bodily pains increases with age. The proportion of respondents who reported no bodily pain is 45 percent among illiterates and 78 percent among those with 11 or more years of schooling. Bodily discomfort Overall, 60 percent of respondents do not have any bodily discomfort. The proportion not having any

About 75 percent of respondents do not have any problem in learning a new task. Only one percent of respondents reported that they have extreme difficulty in learning a new task. Seventy five percent each of both males and females reported that they have no difficulty in learning a new task. Eighty four percent of urban and 73 percent of rural respondents reported that they do not have any difficulty in learning a new task. The percent of respondents having no difficulty in learning a new task is more among the younger ages. Interpersonal activities Extent of personal relationships / participation in community Seventy five percent of the respondents do not have any difficulty in personal relationships or participating in community level activities. Seventy seven percent males compared to 73 percent females do not have any difficulty. A greater proportion of females have extreme difficulty with respect to personal and community activities compared to males. About 83 percent of urban and 73 percent of rural respondents do not have any difficulty in community activities. Eighty three percent of respondents in ages 18-29 do not have any difficulty in developing personal relationships compared to 66 percent in ages 80 and above. Among illiterates, 66 percent respondents do

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not have any difficulty in developing personnel relationships compared to 88 percent among the respondents having 11 or more years of education. Conflicts and tension About 74 percent of respondents do not have any difficulty in dealing with situations involving conflicts and tensions. The proportion having mild difficulty in dealing with conflicts is 19 percent, moderate difficulty is three percent, severe difficulty is one percent and extreme difficulty is two percent. Seventy seven percent of males and 72 percent of females do not have any difficulty in dealing with conflicts and tensions. Eighty three percent urban and 72 percent rural respondents do not have difficulty. About 82 percent of the respondents in ages 18-29 have no difficulty and the proportion of respondents having no difficulty rises at higher levels of education. Vision Seeing/recognizing a person across the road

Sleep and energy: Difficulties with sleep About 80 percent of respondents do not have any difficulty with sleep. About 14 percent respondents have reported mild, four percent have moderate and two percent have severe difficulties associated with sleep. The proportion of males who do not have any difficulty with sleep is 83 percent compared to 77 percent for females. Respondents reporting difficulty with sleep steadily increases with age. Feeling rested and refreshed Seventy seven percent of respondents do not have any difficulty in feeling rested. A higher proportion of males (80 percent) compared to females (75 percent) reported that they have no difficulty in feeling rested and refreshed. It is found that older respondents have more difficulties than younger respondents. Affect: Feeling sad/depression

Seventy seven percent of respondents do not have any difficulty in seeing or recognizing a person across the road. About 79 percent of males and 75 percent females have no difficulty in seeing or recognizing a person across the road. Seventy six percent of rural and 82 percent of urban respondents do not have any difficulty. About 94 percent of respondents in ages 18-29 do not have any difficulty in seeing and recognizing compared to 37 percent in ages 60-69. The proportion of respondents who reported mild, moderate, severe and extreme difficulties increases with age. Seeing objects at arm’s length About 77 percent respondents do not have any difficulty in seeing an object at arm’s length or in reading. Extreme difficulty in seeing an object at arm’s length is found among one percent of the respondents. Seventy five percent of females and 78 percent of males do not have any difficulty in seeing an object at arm’s length. About 81 percent urban and 76 percent of rural respondents do not have any difficulty in seeing or reading an object at arm’s length. The percent of respondents reporting no difficulty in seeing an object at arm’s length declines with age. About 35 percent of respondents in ages 60-69 do not have difficulties compared to 94 percent in the ages 18-29.

About 71 percent of the respondents do not have any problems of feeling sad, low or depressed. The proportion of respondents feeling low or depressed is 21 percent in mild, five percent in moderate, one percent in severe and two percent in extreme levels of depression. About 73 percent males and 69 percent females do not have any sad feeling or depression. More respondents report no difficulty of sadness or depression in urban compared to rural areas. Worry/ anxiety Seventy eight percent of the respondents do not have any difficulty of worry or anxiety in Karnataka. Eighty one percent males do not have any difficulty of worry or anxiety compared to 74 percent females. The proportion of respondents who do not have any worry or anxiety increases at higher levels of education. Health System Responsiveness Self assessed need for health care The responsiveness of health system is measured by the ability of a health system in a country to meet the health requirement of its population. Respondents who assessed the need for self health care are classified as those who

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needed health care services during the 1) past 12 months 2) 1-5 years 3) more than 5 years and those 4) who did not need health care. The self assessed need for health care includes preventive health care, child health care, dental care, injuries and care for chronic diseases and other diseases. The need for preventive care includes the need for care in immunisation, antenatal check ups and family planning. The self-assessed need for chronic diseases includes high fever, severe diarrhoea, cough, arthritis, asthma and heart diseases.

62 percent. A greater proportion of urban (seven percent) compared to rural (three percent) respondents assessed the need for care in case of acute diseases and the proportion of respondents who needed preventive care, as expected, declines at higher ages. The selfassessed need for care during childbirth does not show much variation between rural and urban respondents. The self-assessed need for care for injury is greater among males compared to females, whereas the need for care for chronic diseases is higher among females (65 percent) compared to males (59 percent).

Sixty percent of respondents and 11 percent of their children needed health care in the one-year prior to the survey. Nineteen percent of respondents and one percent of their children needed health care during the last 1-5 years. Only seven percent of respondents reported that they did not need health care. Marked differences are reported between the sexes who needed health care services for themselves or children in their families in the last 12 months. An equal proportion of 60 percent urban and rural respondents needed health care in the last 12 months. Fifty eight percent of male respondents compared to 62 percent of female respondents needed health care. However, rural-urban and gender differences are smaller in case of children who needed health care. The need for health care increases with the age of the respondents.

Sixty eight percent of respondents in the ages 45-59 have reported a need for treatment of chronic diseases compared to 55 percent in the ages 70 and above. The need for care for other diseases is the same for both males and females (24 percent). The proportion of respondents needing care for other diseases is highest in the age group 30-44. Self assessed need for inpatient care The self-assessed need for inpatient care is presented for child health, maternal health, non-communicable (chronic) diseases and acute diseases. A total of 886 respondents reported a self-assessed need for inpatient care. Among those who needed inpatient care, two percent have assessed a need for inpatient treatment for child health, two percent have assessed a need for maternal health care and three percent for noncommunicable and chronic diseases. About 93 percent of respondents have assessed a need for inpatient treatment of acute diseases.

About 22 percent of male respondents needed health care during the last 1-5 years compared to 17 percent of female respondents. Nineteen percent each of urban and rural respondents needed health care during the last 1-5 years. The need for child health care in the last 1-5 years shows no significant difference by sex, residence and by age. Need for health care during the last 1-5 years rises with increasing age of respondents. Overall, seven percent of male respondents compared to six percent of female respondents did not need health care in Karnataka. About six percent of urban respondents and seven percent of rural respondents did not need health care.

The proportion of males reporting of a need for inpatient child health care is three percent compared to one percent for females. Three percent of female respondents required inpatient care for maternal health services. Three percent of urban and two percent of rural respondents reported a need for inpatient child health care. The proportion of respondents who need care for noncommunicable (chronic) diseases does not vary much between the sexes and by residence, but the proportion of respondents who need care for non-communicable (chronic) diseases increases with age and is highest (four percent) in the age groups 45-59. Ninety four percent male respondents and 93 percent female respondents reported a need for care for acute diseases. However,

Overall, 1018 respondents reported a self-assessed need for health care in the last 12 months. The self-assessed need is four percent for preventive care, one percent for childbirth care, four percent for dental care and six percent for injuries. The self assessed need for treatment of other diseases is 24 percent and for chronic diseases

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the proportion needing care for acute diseases increases with age. In the ages 70 and above all respondents require care for acute diseases.

The highest responsiveness rating is for child treatment (90) whereas the lowest rating is for acute diseases (78). The responsiveness rating of private health care is 82 compared to 79 for government health services, indicating a relatively poor rating of public health services. Male respondents have rated highest responsiveness for dignity (92) for inpatient services used in the last 12 months. Dignity was followed by confidentiality (90). Prompt attention had the lowest responsiveness rating for inpatient services by the male respondents. On the contrary, female respondents have rated highest responsiveness for confidentiality (86) followed by communication (84). A marked gender differential can be observed in the ratings of various domains of responsiveness for inpatient services. Overall, male respondents (83) compared to female respondents (78) rated higher responsiveness for all the domains of inpatient services.

Self assessed need for outpatient care A total of 1046 respondents reported a need for outpatient health care in the five years preceding the survey. About five percent of respondents have reported the need for outpatient treatment for child health, three percent for maternal health and 18 percent for noncommunicable (chronic) diseases. About 73 percent of the respondents have reported a need for outpatient treatment of acute diseases. Self assessed need for child health care is reported by four percent of male respondents compared to six percent of female respondents. Five percent respondents in both urban and rural areas reported a need for child health care. About six percent of female respondents have reported a need for outpatient treatment for maternal health services. The reported need for maternal health care is higher in the urban areas (five percent) than in the rural areas (three percent).

Both urban (87) and rural (89) respondents have rated highest responsiveness for confidentiality. Confidentiality was followed by prompt attention by urban respondents (83). In the case of rural respondents confidentiality was followed by dignity (86) and communication (86). Communication had the lowest responsiveness rating by urban respondents (77) for inpatient services. Rural respondents rated prompt attention with the lowest responsiveness for inpatient services. However, no clear urban-rural differences can be observed in the overall responsiveness for inpatient services used in the previous 12 months in Karnataka.

Fourteen percent of males need outpatient care for noncommunicable (chronic) diseases compared to 23 percent female respondents. The self-assessed need for care for such diseases varies from 10 percent in urban areas to 21 percent in rural areas. A higher proportion of respondents at the older ages need outpatient care. Responsiveness for inpatient treatment

From the distribution of responsiveness by education of the respondents, we can see that the rating of responsiveness is higher among educated respondents except for the domains of dignity and prompt attention where it is higher for illiterate respondents. Responsiveness is higher among the respondents utilizing private health care services except for the domains of communication (85) and confidentiality (88), where it is higher among the respondents utilizing government health services.

The overall rating of 81 for health system performance indicates that the health system is performing reasonably well in Karnataka. The overall rating of autonomy is 79, choice 79, communication 84, confidentiality 88 and basic amenities 81. Dignity receives a responsiveness rating of 85 and prompt attention receives the lowest rating of 69. The responsiveness rating differed little between the sexes. Urban respondents rated responsiveness at 82 compared to a rating of 81 by rural respondents. The rating of responsiveness increases with the level of education of the respondents. Responsiveness rating of inpatient services is slightly higher among those with worse health condition (82) compared to those with better health (75).

Females in Karnataka have reported higher responsiveness than males for all the seven domains except for the domain of confidentiality where the score is higher among males (80). Similarly, respondents residing in urban areas have rated higher responsiveness than those residing in rural areas for all the domains.

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From the distribution of responsiveness by education of the respondents, one can find that the rating of responsiveness is lower among illiterate respondents in comparison to those better educated.

rated at 64 for basic amenities by illiterates compared to 76 by those with high school and above education. Respondents with better health rated higher responsiveness for choice of treatment, communication, confidentiality, dignity and availability of basic amenities. On the other hand, the rating of autonomy is higher among those with worse health. For outpatient child treatment, responsiveness is rated at 21 for dignity compared to 18 for basic amenities. For acute diseases, responsiveness was rated at 79 for confidentiality compared to 67 for basic amenities.

Confidentiality received the highest ratings for child, maternal, chronic and acute diseases treatment with lowest rating for prompt attention for all categories of inpatient treatment. For childcare, rated responsiveness was 90. In maternal care, the rating of responsiveness for dignity is 89 and 95 for confidentiality. Responsiveness for outpatient treatment

Health expenditure

The overall rating for outpatient responsiveness is 75, indicating that the system is performing well, but not very well. For outpatient care the overall ratings of autonomy is 74 and choice is 75, communication 77, confidentiality 80 and prompt attention 72. For outpatient care also, dignity receives the highest rating of 77 while basic amenities receives a responsiveness rating of 69. The responsiveness ratings do not differ much between the sexes. Urban respondents rated responsiveness at 87 compared to 72 by rural respondents. Responsiveness shows an increase with the level of education of the respondents. Responsiveness of outpatient services is rated higher among those with better health condition (77) compared to those with worse health (75).

Health expenditure by type of services The World Health Survey collected data on household expenditure on various services during the last one month. A household in Karnataka spends 90 rupees a month for health treatment. Households on average spent 34 rupees for drugs, 31 rupees for outpatient treatment, three rupees for inpatient treatment, two rupees for traditional medicines and 20 rupees for other expenses related to treatment in a month. Household spending on health treatment increases at higher income quintiles. In the fourth income quintile, households spend 143 rupees compared to 37 rupees in the lowest income quintile. The household health expenditure on inpatient treatment, out patient treatment, drugs and other related expenses again increase at the higher income quintiles. However, health spending on traditional medical treatment declines at the higher income quintiles.

Male respondents have reported higher responsiveness for confidentiality whereas female respondents have reported higher responsiveness for autonomy, choice of treatment, communication, basic amenities and prompt attention. Urban respondents have rated higher responsiveness for all the domains in outpatient services.

Health spending on inpatient fees in the lowest income quintile is less than a rupee compared to eight rupees in the highest income quintile. The health spending on drugs is the highest in the middle-income quintile. The spending for outpatient treatment by respondents in lowest income quintile is 16 rupees and increases to 47 rupees in the fourth income quintile.

Confidentiality had the highest responsiveness rating by both urban and rural respondents for outpatient services. Confidentiality was followed by communication, basic amenities, autonomy, dignity, choice, and prompt attention for urban respondents. For rural respondents confidentiality was followed by communication, dignity, choice, autonomy, prompt attention and basic amenities. A wide gap is observed in the overall level of responsiveness between urban and rural respondents. The responsiveness rating for dignity is 69 among illiterates and 83 among those with high school education. On the other hand, responsiveness is

Out of pocket expenditure on health There are about 68 percent of households whose health payments share of households’ capacity to pay (OOPCTP) is less than 10 percent. In 14 percent of households, out of pocket expenditure ranges between 10-20 percent and in 11 percent of households out of

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pocket of expenditure as a share of capacity to pay is between 20-40 percent. In seven percent of the households out of pocket of expenditure is equal to or above 40 percent, which by definition constitutes catastrophic payments. The highest proportion of out of pocket health payment is for drugs (37 percent) followed by payments for outpatient treatment (34 percent), 23 percent in other category and four percent for inpatient care. Expenditure on traditional medicines is about two percent of out of pocket expenditure on health. Catastrophic spending on health The households with catastrophic spending on health on average spent 193 rupees for health treatment in the last one month. Of this, the amount spent on drugs constitutes the highest proportion of 63 rupees followed by outpatient fees of 63 rupees. Health spending is 15 rupees for inpatient fees, 47 rupees for other treatment related costs and six rupees for traditional medicines. The total health expenditure increases at the higher income quintiles. In the lowest income quintile, on average, the catastrophic expenditure is 180 rupees compared to 262 rupees in the highest income quintile. Higher income quintile households spend more on inpatient fees while lower income households spend more on outpatient fees. The amount spent on traditional medical practitioners is more in the lower income quintiles than the higher income quintiles. There is not much of variation across the income quintiles in the amount spent on drugs. Expenditure on other items related to health care ranges from 34 rupees in the lowest income quintile to 56 rupees in the highest income quintile. Insurance coverage In the World Health Survey, information was collected on the coverage of both mandatory and voluntary insurance. Overall, less than one percent of the respondents are covered any insurance plan. Voluntary and mandatory insurance coverage are respectively less than one percent each. In both urban and rural areas less than one percent of respondents are insured. Both voluntary and mandatory insurance coverage exist mainly in urban areas. Most of the insured persons are to be found in the higher income quintiles. This is a common trend both for mandatory and voluntary insurance coverage.

Human resources for health Of the total sampled household population in Karnataka three percent are in health related professions. There are 64 physicians, 64 nursing and mid-wife and 128 health related support staff available per 100,000 people in Karnataka. Nine percent of males and four percent of females are in health related professions among household members. About 12 percent of health professionals are from urban households and four percent from rural households. About seven percent of health professionals are in the lower income quintiles and this increases to 38 percent in the higher income quintiles. In Karnataka, of the total health professionals 25 percent are physicians, 25 percent are nurses and midwives and 50 percent are other health and support staff. In the physician category, all are males and the proportion of females is higher in nursing and midwifery compared to males. In other health and support occupations, there are more males than females. There are more physicians in the urban areas than in the rural areas, but nursing and midwifery personnel and other health and support staff are to be found more in rural areas. Physicians, nurses and midwives are highly concentrated in the high-income quintiles whereas professionals in other health and support occupations are concentrated in lower income quintiles. The qualification of a health professional is a major component affecting the quality of the health services rendered. All the physicians and most of the nursing and midwifery personnel have university education. The work status of the professionals indicates that 53 percent physicians worked in the last one year and the rest did not work not because they could not find a job or for other reasons. Among other health and support occupation professionals, 46 percent worked in the last one year and 54 percent did not work for other reasons. The primary work location of the health professionals indicates that 18 percent physicians, 93 percent nursing and midwifery professionals and 16 percent other health and support occupation professionals are working in public health services. The proportion of professionals working in the private health services is 82 percent for physicians and 72 percent for other health and support occupation. The proportion of professionals in non-health services is eight percent for nurses and midwives and 12 percent for other health and support occupations.

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Chapter 1

Introduction

1.1 HEALTH SYSTEM PERFORMANCE IN INDIA Health systems deserve the highest priority in the endeavour to improve the health of the people as they provide the critical inference between life saving and life enhancing interventions and the people who need them (Sankar and Kathuria, 2004). The World Health Organisation (2000) made an attempt to measure the efficiency of health systems in 191 countries across the globe using five performance indicators and found that regions vary enormously in their levels of development in health outcomes in spite of similar levels of income and educational attainment. An assessment of the health system performance in India in terms of health outcome indicators shows tremendous improvement in the last 50 years. Life expectancy had risen from 36 years in 1951 to 62.1 years in 1995-2000 (United Nations, 2003). Infant mortality had been halved from 146 in 1951 to 66 in 2001. The crude death rate had been reduced from 26.1 in 1970 to 8.4 in 2001 (Sample Registration System, 2003). The factors contributing to such vast improvements in health have been the three tier system of community health centres, primary health centres and primary health sub-centres, countrywide immunization drives and improvements in determinants such as water supply, sanitation and socio-economic conditions. However, this achievement has been very inadequate compared to our health policy goals. More importantly, there was very slow progress in the 1990s in health status improvement, as several of the above indicators show a plateau. Moreover, the improvement in health status has been very uneven across the country, where states such as Kerala have health indicators comparable

with the middle-income countries and other states such as Uttar Pradesh, Madhya Pradesh and Orissa are at lower levels comparable to Sub-Saharan Africa. It is therefore necessary to understand the potential for health system improvements in the states. Health system performance needs to be assessed not only by the health sector endowments but also by its efficient use. 1.2 SHARE OF PUBLIC AND PRIVATE FACILITIES IN HEALTH CARE In India, the public sector plays an important role in the rural health delivery system. In urban areas the public and private health systems complement each other. Nevertheless, the performance of the public health system in rural areas is of great significance as it largely determines the overall health outcome in the states. In India, patients from both rural and urban areas overwhelmingly choose public facilities (Government hospitals, Community Health Centres and Primary Health Centres) for inpatient care. The reliance on public hospitals for inpatient care is greater in hilly and backward states, among scheduled castes and tribes and those belonging to the lower monthly per capita expenditure quintile. Total health expenditure was 5.3 percent of the Gross Domestic Product (GDP) of India in 1997 and 5.1 percent in 2001. This indicates a decline in the proportion of health expenditure as a percent of GDP. Private health expenditure as a percent of total expenditure on health was 84 percent in 1997 and 82 percent in 2001. On average, a household spends Rs. 250 per capita per annum on health services. This health expenditure is 40 percent higher in urban households than in rural households. Health expenditure is also positively related to overall

Introduction

1

Table 1.1 Trends in health expenditure in India, 1997-2001 Health Expenditure/Year

1997

1998

1999

2000

2001

Total expenditure on health (as a percent of GDP) Government expenditure on health (as a percent of total expenditure on health) Private expenditure on health (as a percent of total expenditure on health) Government expenditure on health (as a percent of total government expenditure) External resources for health (as a percent of total expenditure on health) Out of pocket expenditure (as a percent of private expenditure on health)

5.3 15.7 84.3 3.2 2.3 100

5 18.4 81.6 3.5 2.4 100

5.2 17.9 82.1 3.3 2.2 100

5.1 17.6 82.4 3.1 2.2 100

5.1 17.9 82.1 3.1 0.4 100

Source: World Health Report, 2003

household expenditure (NCEAR, 1992). Private health spending in India is one of the highest in the world and indicates an inefficient way of financing healthcare that leaves people highly vulnerable. Government expenditure on health as a proportion of total government expenditure was 3.2 percent in 1997 and 3.1 percent in 2001. Table 1.1 presents the trends in health expenditure in India under different domains. Private facilities are used largely in urban India. However, private practitioners are well spread and found even in remote and backward areas, and they are usually contacted for day to day health care needs before availing distantly located public facilities. In the public sector, 70 percent of hospitals and 85 percent of hospital beds are located in urban areas. These facilities are used more often in cases of severe and catastrophic illness, which the private practitioners are reluctant to handle. The growth of corporate hospitals has taken place because of the development of a health care market in which investment in state-of-the-art medical technology can yield a good return. Although the private sector accounts for a significant portion of the health system facilities, human resources and expenditure in India, no adequate mechanism has been developed to monitor and regulate the activities of the private health sector. Thus, there is a need to generate a systematic information database through an effective interface between nursing homes and the local supervising authority to collect data on disease patterns for taking policy decisions on public health matters. In most countries health sector reform involves a change in the respective shares of tax revenue, social or private

2

Health System Performance Assessment

insurance, user fees and external aid in financing the health sector. Also, the range of services provided in the public and private sectors tend to differ. A shift takes place in the role that the state plays in the regulation and provision of health care services and the development of various types of public-private partnerships. Decentralisation, integration of services, including sector-wide approaches and reforms in logistics occur. The reform process is also affected by the geopolitical context in which a health system is embedded. This includes the bargaining position of the country in the international setting, the level of external debt and financial stability of the country and the impact of the past political structure on the health care system. 1.3 HEALTH SYSTEM GOALS The main goals of the health system in India are health responsiveness and fairness in financing. The health of the population should reflect the health of individuals throughout the life course and include prevention of both premature mortality and non-fatal health outcomes as key components. Responsiveness has two key sub-components: respect of persons and client orientation (WHO, 2002). Respect of persons involves the elements of dignity, autonomy and confidentiality and captures aspects of the interaction of individuals with the health system that often have an important ethical dimension. Client orientation includes prompt attention to health needs, basic amenities of health services such as clean waiting rooms or adequate beds and food in hospitals, access to social support networks for individuals receiving care and choice of institutions and individuals providing care.

There are also cross-system goals to evaluate how much the health system helps or hinders education, democratic participation, economic production etc. One of the more important cross-system goals that should be emphasised is the contribution of the health system to economic production and social aspects like education. 1.4 NEW HEALTH POLICY IN INDIA The National Health Policy (2002) of India has noted that improvement in health status in terms of indicators such as infant mortality rate, morbidity prevalence and life expectancy has been very uneven across the ruralurban areas. Also, the statistics reveal wide differences between the attainments of health goals in the better performing states (Kerala, Maharashtra, Tamil Nadu) compared to the low-performing states (Rajasthan, Uttar Pradesh, Orissa, Bihar, Madhya Pradesh). However, The national average of health indices hides the wide disparities in public health. Given a situation in which the national averages in respect of most indices are themselves at unacceptably low levels, the wide inter-state disparities imply that for vulnerable sections of society in several states, access to public health services is nominal and health standards are grossly inadequate. There is also a big divide with respect to health care access between the poor and the rich and

by many indicators of socio-economic development. In the wider context of health system goals, a new National Health Policy was formulated in 2002 to cater to the changes in determinant factors relating to the health sector. The health policy was revised and restructured based on the United Nations Millennium Development Goals. The main objective of the National Health Policy 2002 is to achieve an acceptable standard of good health amongst the general population of the country. The approach would be to increase access to a decentralised public health system by establishing new infrastructure in the existing institutions. A comprehensive evidence base is an important input for effective health policy interventions. The lack of evidence base from the routine health information system is a common limitation in many developing countries including India. Given this background, the World Health Survey intends to provide evidence on the health status of the Indian population. 1.5 HEALTH-RELATED SURVEYS IN INDIA In India, the census and vital (sample) registration system provide reliable data on several social-economic and demographic aspects of the population. However, very little information is available on population health, morbidity and health system performance indicators.

THE NEW NATIONAL HEALTH POLICY (2002) HAS SPECIFIED THE FOLLOWING GOALS: GOALS

YEAR

Eradicate Polio and Yaws. Eliminate Leprosy. Eliminate Kala Azar. Eliminate Lymphatic Filariasis. Achieve zero level growth of HIV/AIDS. Reduce mortality by 50 percent on account of TB, malaria and other vector and water borne diseases. Reduce prevalence of blindness to 0.5 percent. Reduce IMR to 30/1000 and MMR to 100/lakh. Increase utilisation of public health facilities from current level of 75 percent. Establish an integrated system of surveillance, national health accounts and health statistics. Increase health expenditure by government as a percent of GDP from the existing 0.9 percent to 2.0 percent. Increase share of central grants to constitute at least 25 percent of total health spending. Increase state sector health spending from 5.5 percent to 7 percent of the budget. Further increase state sector health spending to 8 percent of the budget.

2005 2005 2010 2015 2007 2010 2010 2010 2010 2005 2010 2010 2005 2010

Source: National Health Policy, 2002, Delhi, Government of India

Introduction

3

In view of the lack of routine health information, organisations such as the National Sample Survey Organisation (NSSO) and the National Council of Applied Economic Research (NCAER) have undertaken surveys on morbidity and health care. In different rounds of the health and morbidity survey, the NSSO gathered information on physical and mental disability, morbidity, maternal and child health, utilisation of medical services, medical expenditure on different treatments and injuries. Micro and macro level information on medical care, health care needs of population in different states were assessed in the NCEAR survey (NCEAR, 1992). More recent are the National Family Health Survey (NFHS) and Rapid Household Survey (RHS). The two rounds of NFHS (1992-93; 1998-99) focus on women in the ages 15-44 and provide information on the use of family planning methods, infant and child mortality, immunisation, morbidity pattern including the prevalence of diarrhoea, malaria, leprosy, physical handicap, nutritional status of women and children, maternal and child health and quality of care. The RCH surveys are designed to provide data at the district level on maternal and child health and various health infrastructure facilities covering primary health subcentres, primary health centres (PHC), community health centres (CHC), first referral units (FRU) and hospitals. In a nutshell, all these surveys are focussed on a variety of demographic indicators, general morbidity prevalence rates and maternal and child health indicators. Although the NSSO focuses on morbidity prevalence, it is not sufficient to assess health system performance in terms of the rising need for treatment and those actually treated, health system responsiveness and the self assessed health state of the population which are very critical inputs for health policy initiatives. Also, the survey coverage and information generated are based on advanced social survey research techniques.

collecting good quality baseline information on health outcomes in a population as a result of investment in health systems. The broad objectives of the survey programme are to provide low cost information that would supplement the information provided by the health information systems of a country and to develop the capacity of policy makers to monitor the performance of the health system. A modular approach has been adopted with the survey instrument divided into separate modules for various health and mortality components. The modules cover the following important aspects of health at the household and individual levels e.g. health expenditure, socio demographics, health states of population, risk factors, mortality, morbidity prevalence, health system responsiveness for inpatient and outpatient care, and social capital. An eventual outcome of the survey is to assess health status of the population using the following three summary measures (a) Disability adjusted life years (DALY), (b) Disability adjusted life expectancy (DALE) and care (e.g. Child survival) and (c) Equality in health. In the past, health status assessment concentrated on morbidity and mortality statistics along with the incidence and prevalence of communicable diseases. Now, with the epidemiological transition from communicable to non-communicable diseases, measuring the prevalence of chronic diseases and injuries that are non fatal has become more relevant in understanding the health status of populations (World Health Report, 2002).

1.6 THE WORLD HEALTH SURVEY – 2003

In India, the survey covered a representative sample of 10750 households in six states namely Assam, West Bengal, Rajasthan, Uttar Pradesh Maharashtra and Karnataka. In Karnataka, the survey covered a representative sample of 1473 households. This database gathered on Karnataka is to be used to create a state health policy to ensure better monitoring of health status of the population, responsiveness of the health system and measurement of health related parameters.

The World Health Survey (WHS) is a multi-country survey program with the primar y objective of

This is also an attempt to understand how people perceive and report their health status and measure the

4

Health System Performance Assessment

performance of the health system. A comparative profile of health status and socio-economic conditions in India and Karnataka are provided as a background for presenting the survey findings.

women in the same age category is 19 years. The total fertility rate is 2.4 and the mean ideal number of children is 2.3. The infant mortality rate is 55 per 1000 live births. 1.8 HEALTH PROFILE FOR KARNATAKA

1.7 SOCIO-DEMOGRAPHIC PROFILE Table 1.2 presents a socio-demographic profile of Karnataka. The state population constitutes five percent of the country’s population. It has 27 administrative districts with a population density of 275 persons per sq. km. The sex ratio is 964 females per 1000 males. The state is urban to the extent that 34 percent of its population is residing in the urban areas. The decadal growth rate of population was 17 percent during 1991 -2001 and the literacy rate was 67 percent (Census of India, 2001). The annual growth rate of population in Karnataka was 1.6 percent during 1991– 2001. Hindus constitute 85 percent while 11 percent are Muslims and four percent belong to other religions. The median age at marriage among women of age 2049 is 17 years and the median age at first birth among

Table 1.3 provides data on health status and health infrastructure for India and Karnataka. While 65 percent of women received antenatal care at the national level, the corresponding figure for Karnataka is 86 percent. Sixty percent of the children are fully immunised in Karnataka compared to 42 percent in India. Thirty four percent of the deliveries at the all India level were conducted in medical institutions while in Karnataka it was 51 percent. The expectation of life at birth was 62 years for males and 65 years for females in 2001 (Census of India, 2001). The elderly population of ages 60 and above was eight percent in 2001. The under five-mortality rate is 62 for boys and 65 for girls and the adult mortality rate for the ages 15 – 59 is 29 for men and 22 for women (Sample Registration System, 2003).

Table 1.2 Selected socio-demographic indicators for India and Karnataka Socio-demographic indicators

India

Karnataka

Population 1 ( 2001)

1,027,015,247

52,733,958

Annual Population growth rate1 (1991-2001)

1.93

1.59

324

275

27.78

33.98

933

964

67.0

67.04

1

Density of Population per sq. Km (2001) 1

Percent Urban (2001) 1

Sex Ratio (Females per 1000 males) 1

Literacy Rate (2001)

CBR2 (2001) 3

CPR 19983 4

TFR (15 – 49) 4

Population (60+)

Total Male

76.3

76.29

Female

57.4

57.45

25.9

20.4

45.4

55.4

3.2

2.4

7,66,22,000

4,062,022

Sources: 1. Office of the Register General and Census Commissioner, Census of India, 2001, Provisional Population Tables, New Delhi: Office of the Register General and census Commissioner. 2. Guilmoto and Rajan S.I (2002) 3. Family Welfare Programme in India year Book 1997-98, Department of Family Welfare, Ministry of health & Family Welfare, Government of India, New Delhi. 4. International Institute for Population Sciences (IIPS) and ORC Macro. 2000, National Family Health Survey (NFHS-2), 1998-99: India. Mumbai: IIPS

Introduction

5

Table 1.3 Selected health status and health infrastructure indicators for India and Karnataka Health status and health infrastructure indicators

India

Karnataka

Percent of women who received ante – natal care1 (1998-99) Percent of children who received 2 doses of tetanus toxoid vaccine 1 (1998-99) Percent of births delivered in medical institution1 (1998-99) Percent of deliveries assisted by health professionals1 (1998-99) Percent of children fully immunized1 (1998-99) CDR1 (1998-99) CBR1 (1998-99) IMR1 (1998-99) Under 5 mortality rate1 (1998-99) Life Expectancy at Birth (1996–2001) 3 Males Females

65.4 66.8 33.6 42.3 42.0 9.7 29.3 67.6 94.9 62.4 63.4

86.3 74.9 51.1 59.1 60.0 7.2 19.3 55 15 61.6 64.9

Sources: 1. International Institute for Population Sciences (IIPS) and ORC Macro. 2000, National Family Health Survey (NFHS-2), 1998-99: India. Mumbai:IIPS 2. Sample registration system (2003).

Both the crude death rate and the infant mortality rate are lower in Karnataka compared to the national average. Also, life expectancy at birth for both males and females

6

Health System Performance Assessment

is much higher in Karnataka than in India. Compared to 42 percent in India, about 59 percent pregnancies are attended by health professionals in Karnataka.

Chapter 2

Methodology

2.1 NATIONAL SAMPLING It was planned to survey a target sample of 10,000 households in India. Since it was decided to focus the survey at the state level, six states namely Assam, West Bengal Rajasthan, Uttar Pradesh, Maharashtra and Karnataka were selected. The selection of states was done considering their geographic location and the level of development. All the states with a population five million or more (except Jammu and Kashmir) of India were sub divided into six regions as north, central, east, north east, west and south. The level of development was measured considering four indicators, namely infant mortality rate, female literacy rate, percentage of safe delivery and per capita income. The infant mortality rate is a good barometer of a country’s level of development in terms of mortality and health transition. The female literacy rate is an important determinant of mother’s utilization of different health care services and is also a proxy for her family’s utilization of the available health care services. While the percentage of safe deliveries indicates the

extent of maternal morbidity and utilization of health care services, per capita income indicates economic development. A composite index of the level of development was computed by giving equal weights to the above four indicators. The states were classified into six levels of development (in decreasing order) based on the composite index shown in table 2.1. The states were selected purposively in such a manner that one state is selected from each region as well as from each level of development category. Karnataka in the southern region happened to represent the second highest development category. The other five states ranked according to level of development are Maharashtra (from west), West Bengal (east), Assam (north east), Rajasthan (north) and Uttar Pradesh (central). The national level estimates are computed by pooling the state level estimates. Allocation of households among the six selected states was done comparing their population size and the fact that we need to have separate estimates for each of them. The households to be selected in a state were

Table 2.1 Classification of states by region and levels of development Region\Level of Development

I

North

II Punjab

III Himachal Pradesh, Uttaranchal

Central East North East West South

Maharastra Kerala, Tamilnadu Note: *States in bold were selected for the survey.

IV

V

Haryana

Rajasthan

Madhya Pradesh

Chhattisgarh

West Bengal

Bihar

VI

Uttar Pradesh Orissa, Jharkhand

Assam Gujarat Karnataka

Andhra Pradesh

Methodology

7

distributed among its rural and urban areas in proportion to the state population. 2.2 SAMPLING FOR KARNATAKA Sampling for Rural Areas A two stage stratified sampling was used for the selection of the households in rural areas. The village was considered as the primary sampling unit (PSU). In Karnataka, the target sample size was 1300 households. It was decided that 25 households would be covered in each selected PSU, which resulted in the selection of 50 Primary sampling units in the state. Thirty four Primary sampling units were selected in the rural areas and selection of the villages was done by probability proportionate to size sampling. The village size was obtained from the 1991 census but reconfirmed with the 2001 census village directory. Before selection, villages were stratified using geographic region and village size. In each region, villages were further classified by village size of these categories as less than 250 households, between 250 and 500 households, and more than 500 households. The level of female literacy was finally used for implicit stratification. This meant that villages within each stratum were ordered according to the level of female literacy. Villages having less than five households were deleted from the list, and those of size between five and 50 were linked with nearby villages to form a PSU. The Primary sampling units were selected systematically from the list using probability proportionate to size sampling. For each selected PSU, the census maps were obtained from the 2001 census with the cooperation of the Office of the Registrar General and Census Commissioner of India. Considering the non-response rate, a uniform number of 28 households were selected from each PSU systematically. Sampling for Urban Areas In the urban areas, a three-stage design was used with the selection of wards, census enumeration blocks and households in that order. All the urban wards in the

8

Health System Performance Assessment

state were arranged according to the size of the city/ town and geographic region. The cities/towns were classified on the basis of their population, using the 1991 census. The following four classes were considered. The census enumeration blocks were taken as the primary sampling units in the urban areas. In Karnataka eight census wards fell within the sampling framework and resulted in the selection of 16 census enumeration blocks. In the first stage of sampling for the urban areas, the cities\towns were classified on the basis of their population, using 1991 census as base data. Group 1: Cities with population more than 10 lakhs Group 2: Towns with population between 2 to 10 lakhs Group 3: Towns with population between 50,000 and 2 lakhs Group 4: Towns with population less than 50,000. Selection of Households and individuals From each PSU a fixed number of 25 (+3) households in rural areas and 30 (+3) households in urban areas were selected. In each household a general information table was filled for all adult members, segregated by sex. Two census enumeration blocks (as per 2001 census) were selected from each selected ward in the urban areas and thirty households were selected systematically in each census enumeration block. A key informant of the household answered all queries about himself (or herself ), and about the family members in the household questionnaire. An adult member (18+) of the household was randomly selected using KISH tables for answering the individual questionnaire modules. The KISH table is a statistical tool to facilitate randomness while selecting one adult member per family and to avoid taking the head of the family each time as the respondent. A total of 1473 households and 1431 individuals age 18 and above were covered in Karnataka. The pooled sample for India from six states is 10,279 households and 9994 adult respondents for the individual questionnaire.

2.3 QUESTIONNAIRE The survey was conducted with the face-to-face interview technique using two instruments provided by the WHO after extensive pre-testing in selected countries (including India) and standardization across 70 countries. Household questionnaire The first is the household questionnaire. The first section called the coversheet is structured to collect data on sampling, geo-coding as well as contacts and recontacts. The household roster lists all the residents in the selected household along with details about their relationship, age, education, marital status and whether the person had worked or been trained in a health related field. The roster was used to select respondents eligible for application of the individual questionnaire. The Kish tables were used to select one person from the list of those eligible. The second section contains the household consent form, data on malaria prevention and the use of bed nets, health insurance and community health insurance programs, permanent income indicators, household expenditure on food, housing, education and health care expenditure. The final part of this questionnaire contains data on health occupations. Individual questionnaire The individual questionnaire uses the modular approach and is divided into nine sections. In the first module, individual consent is first obtained and questions about the respondent’s socio-demographic characteristics are then asked. The second module is on health state descriptions where the respondent is asked to rate his physical and mental health. This section covers health states in terms of mobility, self-care, pain and discomfort, cognition, interpersonal activities, vision, sleep and energy and affect. This module also contains ten vignettes about health state descriptions. The next module pertaining to health state valuations contains two record sets that are used in the specified

manner. The first record set contains data on amputation, alcohol dependence, limited long distance vision, chronic pain and total blindness. After a series of fourteen questions, an ordinal ranking exercise was carried out where the respondents were asked to rank these health states from best to worst. The second record set contains questions on amputation, insomnia, arthritis, major depression and quadriplegia. A similar ranking exercise was also carried out. The fourth module contains questions related to risk factors such as consumption of tobacco and alcohol, nutrition, physical activity including both vigorous and moderate activity and environmental risk factors related to water, sanitation and the fuel used. The fifth module contains questions related to mortality. The first section in this module contains questions on birth history to assess infant and child mortality while the second section deals with an assessment of adult mortality including sibling survivorship and a verbal autopsy to assess cause of death. In the sixth module questions about coverage are asked. The first section deals with the diagnosis and treatment of chronic conditions such as arthritis, back pain, angina, asthma, depression, schizophrenia, diabetes, HIV/AIDS and tuberculosis. This section also contains an inventory of medicines and drugs. The next section in this module contains questions on cervical and breast cancer followed by questions on maternal health care. The section on child health includes questions on both preventive and curative care. This module also contains questions on reproductive and sexual health care, vision care, oral health care, and care for road traffic and other injuries. The seventh module deals with health system responsiveness. Starting with a general evaluation of health systems, the module covers areas such as the importance of health care, seeing health care providers, outpatient and care at home and inpatient hospital care. This module also has ten vignettes related to the questions.

Methodology

9

The eighth module contains questions on health goals and social capital and has an ordinal ranking exercise for health system goals. This module also has ten vignettes. The ninth and final module contains interviewer’s observations about health problems noticed during the course of the interview. Vignettes The responsiveness section of world health survey focused on the vignette linked questions for cross population comparability, which illustrate differences when making comparisons of measurements derived from self reports. The self assessed experience of a respondent recorded with different self reports in a population could vary due to differences in characteristics of the population. The linkage to vignettes for these particular questions means that individual’s response can be made comparable across both sub groups within countries and across countries. The responses on the health system performance by the respondents were ranked on an ordinal scale (bad-1, good-2, moderate-3, good-4, very good-5). It provides the scale cardinal properties so that the differences between one and two and two and three for example, have the same meaning. This is an essential step to say whether the difference between “very good” (labelled five) and good (labelled four) is the same as the difference between “good” and “moderate” (labelled three).

longitude of every household surveyed were recorded. The readings were taken in degrees up to five decimal points. This ensured that every household was distinctly located in the GIS. This data can be useful to digitally map the location of primary sampling units and households and to create thematic maps for spatial analysis. 2.5 TRAINING, DATA COLLECTION AND QUALITY ASSURANCE The training for the investigators and supervisors were conducted for eight days in March 2003 in Bangalore in collaboration with The National Institute for Mental Health and Neuro Sciences. All the investigators for the world health survey in Karnataka were graduates and some had previous experience in similar large-scale sur veys. During the training programme the investigators were provided with the background, rationale of the study, techniques of interview and a thorough understanding of each question in the instrument. The roles and responsibilities of the investigators were explained in detail. Apart from presentations and discussions by medical experts and WHO advisors, the training program was organized and conducted by the principal investigators. The training program also contained video presentations and mock interviews. At the end of training, a pilot test and field training was organised for the investigators followed by an interactive secession to discuss feed back from field training.

Secondly, the responses on each domain are rescaled from zero to 100, by setting all the responses equal to and better than the experience described in the best vignette to 100, and all responses described as equal to or worse than the experience in the worst vignette, to zero.

In Karnataka, three field teams, with each comprising one supervisor and four investigators completed the survey during March-May 2003. Double entry of data in all the filled in questionnaires was done at the International Institute for Population Sciences using software provided by the WHO.

2.4 GEOGRAPHIC INFORMATION SYSTEM [GIS]

The World Health Organisation deputed a quality assurance advisor to monitor the progress of the survey in India in accordance with the recommended plans with respect to sampling, instrument, training of investigators, pilot test, retest and sur vey implementation. The advisor submitted an overall assessment to WHO, stating that that WHS in India was progressing well.

A new dimension of the WHS is the geographic information that is useful to analyse and display data related to positions of the clusters sampled for the survey. The location of each surveyed cluster was obtained with the highest precision using the global positioning system (GPS) device. The latitude and

10

Health System Performance Assessment

Figure 2.1 Distribution of Primary Sampling Units in Karnataka INDIA WHS 2003 Sampling Distribution Karnataka

Data Source: - Cluster Location: collected with GPS devices during WHS 2003 - Administrative Boundaries: SALB Data set 2000

• Surveyed

cluster

Population 0-2 3-5 6-25 26-50 51-100 101-500 501-2500 2501-5000 5001-130000 Administrative Border

- Population figures: extracted from the Landscan database Map Projection: UNprojected (Geographic) Reference System: WGS 84 datum Map created 14 October 2004

The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organisation concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. @ WHO 2004. All rights reserved.

2.6 INCOME QUINTILE The quintiles used in this analysis reflect relative inequalities in income within each state. In this report, the income quintile is based on possession of 20 permanent income (assets) such as number of rooms in the house, chairs, tables, cars, electricity, bicycle, clock, bucket, washing machine for dishes, washing machine for clothes, refrigerator, telephone, mobile/cellular telephone, television, computer, moped/scooter/ motorcycle, livestock (cattles only), sewing machine, radio/transistor/tape-recorder and bullock cart. Quintile is a statistical division of sample households based on income (assets) distribution of the total sample into five equal parts. The variable takes on the values 1-5 with 1 being the quintile with the poorest households and 5 being the quintile with the richest households. The analysis comparing the bottom quintile to the top quintile within each data set will be reflecting those in relative poverty. The quintile division has been done for 10578 households for which income data was collected. Each quintile has an equal number of 2116 households.

2.7 FIELD EXPERIENCE INVESTIGATORS

OF

THE

The first reaction of the investigators when they saw the questionnaire was one of disbelief because most of them had never seen such a lengthy instrument before. However, through rigorous training with detailed explanations and examples, they had grasped the content of the questionnaire by the end of the training programme. When the investigators were taken to the field for practice interviews, it was found that they frequently had to refer to the question-by-question manual provided by the WHO. Consequently, the interviews took longer than expected and fatigue set in by the end of the second interview. However, this stage was passed after a few interviews, and as the investigators became familiar with the questionnaire the interview could be completed in the expected duration of about 90 minutes. Initial challenges of the investigators were to keep the respondents interested in the interview and to complete the interview in one session or in a subsequent session.

Methodology

11

A problem faced by the investigators was questions from those who were not selected in the sample. The investigators had to explain why everybody in the village could not be interviewed and how sampling was done. It was a policy of IIPS not to pay any monetary incentive to the respondents. This was beneficial, as otherwise individuals not selected may have demanded interview and payments. A practical problem was that of carrying the bundles of questionnaires from place to place. But this was overcome as each research team was provided with a vehicle throughout the survey. While the overall response in Karnataka was very good, in urban areas it was slightly less enthusiastic than in rural areas. 2.8 LIMITATIONS OF THE DATA/STUDY The information collected in World health Survey is selfreported by the respondents and therefore caution is needed when interpreting the data on morbidity and health state valuations. A few of this are mentioned below. 1. The data on morbidity prevalence depends on the extent of accuracy of respondents reporting. 2. The estimates relating to age-sex distributions, child and adult mortality may be affected by under-reporting or by smaller number of cases. 3. Indicators in this report may be similar to those used in NFHS and NSSO but the method of calculation might vary and therefore the estimates may vary. 4. The seasonal variations could affect the availability and thereby the intake of fruits and vegetables. The survey was carried out during the February to May. Also, observance of religious customs and practices could influence the intake of fruits and vegetables on particular days of intake. 5. No height measuring board and weighing scale were used for measuring height and weight. Height and weight data were collected only from those respondents who knew and reported their height and weight. So the data does not represent the full sample and is subject to reporting errors. Nonetheless, results are consistent with the findings of other studies.

12

Health System Performance Assessment

2.9 SURVEY METRICS The survey metrics section deals with an assessment of quality of data in terms of household and individual sample deviation index, response rate, comparison of test and re test estimates and kappa values that plot the item responses. Sample deviation index The representative nature of the surveyed population is assessed in terms of Sample Deviation Index (SDI). It is divided into two viz. household sample deviation index and individual sample deviation index. Household sample deviation index When a multi-stage cluster stage sampling is employed, where homogeneity is large within clusters and small between clusters, representation is a concern. The sample deviation index for each category is the ratio of the proportion of a sub group in the sample to that in the population. The sub groups used in this survey include age group and sex. The sample deviation index in figure 2.2 presents three different lines on the graph showing the sample deviation index for the household population in Karnataka. A ratio close to 1 indicates that the sample is representative of the population considering sex and age. The p value is 0.00 showing a significant difference between the sample and population, but this may be due to the large sample size. The pi-star value is small (0.15) and indicates that only 15 percent of the sample does not follow the characteristics in age and the sample can be considered as representative. The index indicates slight over representation in the ages 29-34. In the older ages there is a small deviation and the sample is slightly over represented. This is due to a small number of observations in the 84 plus age group. Individual sample deviation index Figure 2.3 presents the sample deviation index for the individual respondents. All the ratios are close to 1 indicating that the sample is representative of the population considering sex and age. The p value is 0.00 showing a significant difference between the sample and

population, but this can be due to the small sample size (N=1473). The pi-star value is small (0.18), indicating that only 18 percent of the sample does not follow the characteristics in age and the sample can be considered as representative. The index indicates slight over representation in the ages 34-39 and 59-64. 2.10 RESPONSE RATE The response rate for household and individual questionnaires indicates the extent of response from household key informant and adult respondents respectively. The response rate has a direct relationship with the degree of representation of the sample. In Karnataka, a total of 1473 households were covered and 1431 individuals were the response cases that amount to a 97 percent response rate.

In the world health survey, India, the final result codes with respect to completion of questionnaire are 1) interview completed 2) interview partially completed 3) interview refused 4) interview not conducted. Response rate is the percent of interviews fully and partially out of all households completed i.e., (1+2)/ (1+2+3+4). Non-response rate is percent of households who refused to answer or could not be contacted (3+4)/ (1+2+3+4). As found in other large-scale surveys, the overall response rate of 94 percent is very good. However, this may mask the variations in response rates by socio-demographic characteristics of the respondents. To study such variations, non-response rate have examined for selected characteristics such as place of residence, age, sex, and education. The response rate is higher in rural compared to urban areas, among females compared to males, among younger ages

Methodology

13

Table 2.2 Response and non-response rate in Karnataka, 2003 Characteristics Residence Urban Rural Missing Sex Male Female Missing1 Age group in years 15-29 30-39 40-49 50-59 60-69 70+ Missing1 Education Illiterate Literate Missing1 Total

Response rate

Non-response rate

Total

Percent

N

Percent

N

96.2 97.7 -

508 923 -

3.8 2.3 -

20 22 -

528 945 -

96.4 98.0 -

660 771 -

3.7 2.0 -

25 16 1

685 787 1

96.6 97.9 97.5 98.4 94.9 98.3 -

453 371 232 185 131 59 -

3.4 2.1 2.5 1.6 5.1 -

16 8 6 3 7 1 1

469 379 238 188 138 60 1

96.8 97.5 -

514 917 -

3.2 2.6 -

17 24 1

531 941 1

97.2

1431

2.9

42

1473

Note: - No cases reported 1 Characteristics is not available.

compared to older ages and among illiterates compared to literates. The non-response is about twice higher in urban (8.5 percent) compared to rural areas (4.2 percent), for females (2.3 percent) than males (5.9 percent). Nonresponse rate is about 50 percent higher for literates (4.4 percent) than for illiterates (2.9 percent). About two percent cases are missing with respect to age, sex and education of the respondents (see Appendix I). 2.11 RELIABILITY The World Health Survey has provided an inbuilt retest mechanism to check the reliability of data. In Karnataka, retest interview was conducted among 10 percent of households. The retest was conducted in 10 percent of randomly selected Primary sampling units out of total Primary sampling units covered in Karnataka. Different teams of investigators were used for retest. A statistical comparison on selected indicators of data from first interview and retest interview shows no significant difference.

14

Health System Performance Assessment

2.12 WEIGHTING The World Health Survey (India) in 6 states adopted a multistage stratified cluster sample design. Design weights were calculated taking the specific sample design into consideration. Both household and individual weights were calculated to perform analysis at the household and individual level. The distribution of these weights was then inspected and outlier weights that were below 1% and over 99% of the distribution were trimmed such that weights below the 1st percentile were set to the weight of the 1st percentile and weights over the 99th percentile were set to the weight of the 99 th percentile. Post stratification corrections were made to these weights to compensate for undercoverage. The UN 2000 population figures for India were used as the reference population. All analyses that are reported are carried out using these normalized probability weights and variance estimations take into account the complex design with the Taylor series method implemented in STATA.

Chapter 3

Socio-demographic Profile of Household Population and Individual Respondents The World Health Survey in Karnataka collected information on the socio-demographic profile of the household population and the individual respondents in the state. The individual members are the respondents from whom a comprehensive range of health information is generated. 3.1 HOUSEHOLD POPULATION PROFILE This section provides the distribution of household population characteristics namely age, sex, marital status and education. A household roster was administered to a key informant of the household. The age-sex distribution covers the population of all ages, marital status is calculated for the population in ages 15 and above and educational status for ages above six. The information was collected from 1473 households. The household population size was 7838 with about the same proportion of males and females. About 66 percent of the household population was found in rural areas and the rest in urban areas. 3.1.1 AGE-SEX DISTRIBUTION Table 3.1 presents the socio-demographic characteristics of household population by age, sex, marital status, and educational status. In the survey, data was collected according to different age groups and by residence. The age–sex structure is presented by three major age groups of 0-14, 15-59 and 60 above. Of the total household population, 24 percent of the population belong to the younger ages of less than 15, 66 percent in the 15-59 and ten percent in the older ages of 60 and above. In urban areas, 22 percent of the population belongs to the 0-14 age group compared to 24 percent in rural areas. In urban areas 69 percent

of population belongs to the working age group (1559) compared to 66 percent in rural areas. The proportion of elderly population (60+) is almost the same in both urban and rural areas. In both urban and rural areas 51 percent are males and the rest are females. The population pyramid (Figure 3.1) depicts the agesex distribution of household population covered in Karnataka. Overall, the population proportion by age and sex in Karnataka World Health Survey is very consistent with NFHS-2 data. 3.1.2 MARITAL STATUS Information on marital status of the household population aged 15 and above was collected. The population never married is 28 percent and the currently married is 68 percent. The proportion of population widowed is four percent while the separated and divorced account for one percent. The proportion of never married population is 34 percent in urban areas and 26 percent in rural areas. The population currently married is 60 percent in urban areas and 69 percent in rural areas. 3.1.3 EDUCATIONAL STATUS The educational status of household population in ages six and above is presented in Table 3.1. At each level of schooling, males have higher educational attainment compared to females. Differences are also found by residence with urban areas indicating higher completion rates at all levels of education. Among males, 12 percent have had no formal education compared to 25 percent among females. Ten percent males have formal education but had completed less than primary school education while

Socio-demographic Profile of Household Population and Individual Respondents

15

Table 3.1 Percent distribution of household population by socio-demographic characteristics, Karnataka 2003 Characteristics

Urban

Rural

Sex1 Male Female

50.8 49.2

51.0 49.0

Age group in years1 0-14 15-59 60+

21.6 69.1 9.3

24.2 65.8 10.1

Marital status2 Never married Currently married Separated Divorced Widowed Cohabiting Missing

34.0 60.0 0.3 0.03 5.1 0.6

26.2 69.3 0.03 0.1 3.4 1.1

11.7 10.0 31.3 21.7

25.1 16.0 25.4 16.4

Education status3 Male No formal schooling Less than primary school Primary school completed Secondary school completed Note:

Total

Characteristics

High school completed 51.0 College completed 49.0 Post graduate degree completed Missing 23.7 Female 66.4 No formal schooling 9.9 Less than primary school Primary school completed 27.6 Secondary school completed 67.6 High school completed 0.1 College completed 0.1 Post graduate degree completed 3.7 Missing Household size1 1.0 1-5 6-10 11+ 22.7 Mean number of HH 14.9 Population in all ages 26.5 Population in ages 6+ 17.4 Population in ages 15+

Urban

Rural

Total

9.9 13.0 2.4 0.1

9.7 5.2 2.0 0.1

9.8 6.6 2.0 0.1

21.8 8.8 32.0 19.3 8.0 9.1 0.4 0.6

41.1 13.2 25.4 12.3 4.8 2.8 0.3 0.1

37.5 12.4 26.6 13.6 5.4 4.0 0.3 0.2

23.8 62.2 14.0 5.3 2767 2545 2067

20.7 54.8 24.6 5.5 5071 4609 3650

21.2 56.1 22.7 5.4 7838 7154 5717

1

Age, sex and household size distribution is calculated for the total population (all ages) Marital status distribution is calculated for the population in ages 15+ 3 Education status distribution is calculated for the population in ages 6+ - No cases reported 2

among females this is 16 percent. Among males 31 percent have completed primary school but not secondary education, which is 25 percent for females.

16

Health System Performance Assessment

About 22 percent of males have completed secondary education compared to 16 percent of females. The gap widens between males and About 21 percent of

Table 3.2 Percent distribution of respondents by socio-demographic characteristics, Karnataka 2003 Characteristics

Urban

Rural

Age group in years 18-19 20-29 30-39 40-49 50-59 60-69 70+

7.6 24.7 25.2 15.2 13.4 9.5 4.4

9.8 27.1 18.9 14.5 14.7 9.5 5.6

Sex Male Female

47.8 52.2

51.2 48.8

Marital status Never married Currently married Separated Divorced Widowed Cohabiting

25.1 67.8 0.1 6.3 0.7

23.6 67.3 0.8 0.4 6.4 1.6

Education status Male No formal schooling Less than primary school Note:

10.4 8.5

30.2 11.2

Total 9.4 26.6 20.1 14.6 14.5 9.5 5.3

Characteristics Primary school completed Secondary school completed High school completed College completed Post graduate degree completed

Female No formal schooling Less than primary school Primary school completed 50.6 Secondary school completed 49.5 High school completed College completed 23.9 Post graduate degree completed 67.4 Religion 0.6 Hindu 0.3 Muslim 6.3 Others 1 1.5 Mother tongue Kannada Marathi Others 2 26.7 10.7 Total

Urban

Rural

Total

9.2 7.7 32.6 28.4 3.2

8.1 9.7 16.8 22.7 1.3

8.3 9.3 19.6 23.7 1.6

24.4 7.1 12.1 14.3 23.4 18.2 0.6

52.7 6.8 8.0 10.6 12.0 10.0 -

47.1 6.8 8.8 11.3 14.3 11.6 0.1

76.1 16.1 7.8

93.7 3.6 2.8

90.4 5.9 3.7

44.6 10.4 44.9

82.5 4.4 13.2

75.4 5.5 19.1

508

923

1431

1

Others include Christian, Sikh, Buddhists, Jains, others etc. Others include in order with their proportion such as Tulu, Urdu, Telugu, Tamil, Malayalam, Konkani, Koorgi etc. - No cases reported 2

the households in Karnataka have a household size of less than five members and 56 percent have a household size of 6-10 members. Twenty three percent have a household size of more than 10. The overall mean size of household is five persons. In rural areas, 21 percent households have a size of less than five members compared to 24 percent in urban areas. The mean size of the household is 5.5 in rural areas compared to 5.3 in urban areas. 3.2 SOCIO-DEMOGRAPHIC PROFILE OF RESPONDENTS (INDIVIDUAL QUESTIONNAIRE) This section provides the characteristics of respondents of age 18 and above by age, sex, marital status, educational and ethnic status. These are respondents of the survey selected for the individual questionnaire.

In Karnataka information was collected from 1431 individuals, of which 508 are from urban areas and 923 are from rural areas. 3. 2.1 AGE-SEX DISTRIBUTION Table 3.2 shows the socio-demographic characteristics of respondents by age, sex, marital status, educational status and ethnicity. About 27 percent of the respondents are in the age group 20-29 with the next highest proportion of 20 percent in the ages 30-39. The lowest proportion of five percent is found in the ages 70 and above (Figure 3.2). 3.2.2 MARITAL STATUS The proportion of never married respondents is 28 percent and currently married is 68 percent. The

Socio-demographic Profile of Household Population and Individual Respondents

17

proportion of widowed, separated and divorced is about four percent. The never married population is 34 percent in urban compared to 26 percent in rural areas. The proportion of currently married population is higher (69 percent) in the rural areas than in the urban areas (60 percent). 3.2.3 EDUCATION STATUS Information was collected about the educational status of the individual respondents aand it was found that at each level of schooling, males have higher educational attainment compared to females. Differences are also found by residence with urban areas indicating higher completion rates for all the levels of education. Among males, 27 percent have no formal education, whereas this proportion is 47 percent for females Among males, nine percent have less than primary school education and this proportion is 11 percent for females. Eleven percent of males and seven percent of females have completed primary school education. The proportion of males who have completed high school education is 24 percent and is higher than that of their female counterparts (12 percent). Also, similar malefemale difference is found in the completion of college

18

Health System Performance Assessment

education. The proportion of those who have completed college is 24 percent for males and 12 percent for females. 3.2.4 RELIGION About 90 percent of the respondents are Hindus, six percent Muslims and persons from other religions constitute four percent. The concentration of Hindu population is higher in rural areas compared to urban areas. On the other hand, Muslims, Christian and Jain respondents are concentrated more in urban than in rural areas. 3.2.5 MOTHER TONGUE In Karnataka, 75 percent of adult respondents reported Kannada as their mother tongue. Other languages spoken such as Tulu, Telugu, Tamil, Malayalam, Konkani, Coorgi etc. account for 19 percent. Six percent of the respondents reported Marathi as their mother tongue. About 83 percent rural respondents compared to 45 percent urban respondents speak Kannada. Respondents speaking other languages are concentrated more in urban (45 percent) compared to rural (13 percent) areas.

Chapter 4

Risk Factors

People are exposed to an almost limitless array of risks to their health throughout their lives in the form of communicable and non-communicable diseases. They are also exposed to injury, violence and natural catastrophes. Risk factors are defined as attributes, characteristics or exposure that increase the likelihood of developing a disease. In the context of public health, population measures of risk factors are used to describe the distribution of future disease in a population, rather than predicting the health of a specific individual. Knowledge of risk factors can then be applied to shift population distributions of these factors and to reduce the risks for the people, especially where individuals have very little control over their exposure to risks. This chapter identifies the risk to health and measures how these risks are distributed in the population and how they are linked to health outcomes. It is necessary to identify risks to focus on the interventions that can improve health of future populations through effective inter sector collaborations. The rationale behind the inclusion of risk factors in the World Health survey is: 1) It has the greatest impact on mortality and morbidity from non communicable diseases and 2) modification is possible through effective primary prevention if measurement of risk factors is valid and reliable. Data have been collected on five major risk factors such as use of tobacco, alcohol consumption, nutrition, categories of physical activities and environmental related risk factors. Consumption of tobacco and liquor has considerable impact on the health of the individual because of their detrimental effects. The nutrition content of food, vegetables and the level of physical activity etc, are directly associated with health.

The environmental risk factors such as access to improved drinking water, improved sanitation facilities and the use of fuel for cooking etc. are crucial determinants of human health. Environmental challenges in the home, work place, out door and transportation environments vary considerably between countries and within a given country. Interventions towards safe environments offer a large potential for disease prevention and can help reduce health inequalities. The questions in the risk factor module were asked to all respondents in ages 18 and above. 4.1 TOBACCO CONSUMPTION Smoking is the main way tobacco is used world wide, and the manufactured filter tipped cigarette is becoming increasingly dominant as the major tobacco product. Other forms of smoked tobacco are potentially as dangerous, although the adverse consequences of some of them are more limited because the smoke is not usually inhaled. In certain cultures tobacco is chewed, sucked or inhaled with adverse effects on the local tissues. Chewing tobacco is the most widespread form of tobacco consumption in India. All forms of tobacco consumption are dangerous, whether smoked or chewed. Table 4.1 presents the percentages of men and women in ages 18 and above who use tobacco and liquor in Karnataka. Among 1431 respondents, 26 percent use tobacco either for smoking or chewing. The proportion of tobacco users among males is more than two times higher compared to females. Of the 660 male respondents, 37 percent consume tobacco compared to 15 percent among females. Use of tobacco is more

Risk Factors

19

Table 4.1 Percent of respondents consuming tobacco [smoke, chew] in Karnataka, 2003 Characteristics

Number of Prevalence persons with (%) daily consumption

N

Sex Males Females

255 115

36.48 14.69

660 771

Residence Urban Rural

83 287

15.80 27.98

508 923

Income quintiles* Q1 Q2 Q3

120 121 69

30.80 33.54 20.89

374 360 315

Characteristics

Number of Prevalence persons with (%) daily consumption

N

Q4 Q5

43 17

16.72 8.05

248 134

Age group 18-24 25-34 35-44 45-54 55-64 65+

21 69 87 88 59 46

10.67 21.64 23.72 34.97 37.59 47.50

261 386 301 233 146 104

Total

370

25.70

1431

Note: applicable to all persons in the ages 18 and above. * The quintile is a statistical division of the sampled households into five parts based on permanent indicators measured by the asset distribution in the household.

in rural areas (28 percent) than in urban areas (16 percent). This is consistent with the NFHS finding that chewing of pan masala or tobacco is more common in rural areas than in urban areas (NFHS-II). The data shows that the proportion of respondents using tobacco decreases at higher income quintiles. The quintile is a statistical division of the sampled households into five parts based on permanent indicators measured by the asset distribution in the household. The variable takes on values from Q1 to Q5 with households in Q1 being the poorest and those in Q5 being the richest. At the lowest income quintile 31 percent of the respondents use tobacco compared to eight percent in

20

Health System Performance Assessment

the fifth income quintile. The proportion using tobacco increases with age from 11 percent in ages 18-29 to 48 percent in ages 65 and above. Figure 4.1 presents the variation in tobacco use by sex in Karnataka. It is evident that the level of tobacco use at all ages is much higher among the males than females. However, a slight decline in tobacco use is observed among men in their late thirties but increases again among those in their late forties (ages 45 and above). Among women, the increase in tobacco use continues till ages 45-54 and then it starts to decrease thereon. Older men (ages 55 and above) are more likely to use tobacco than their counterparts.

The male-female gap in tobacco use becomes more pronounced in all the age groups. However, fewer females (10 percent) in the age groups below 25 to 44 use tobacco compared with men (close to 40 percent). In the case of males, use of tobacco is much higher and it increases with increasing age. Among females higher use of tobacco observed in the younger ages but the use declines in the older ages (above 55 years). 4.2 ALCOHOL CONSUMPTION Alcohol consumption has a U-shaped relationship with ischaemic heart disease and is a strong risk factor for hepatic cirrhosis and many other types of injury (particularly motor vehicle accidents). It has also been constantly and positively associated with cancers such as breast cancer (WHO, 2004). Defining the risk associated with its consumption is therefore, complicated. The pattern of drinking itself strongly influences the risk of non-communicable diseases, with

occasional heavy drinking associated with injury and with hemorrhagic stroke. It is very difficult to obtain the exact statistics regarding the consumption of alcohol because it varies from culture to culture and from society to society. So, in order to avoid the difficulties, the survey has collected the information on the amount of drink consumed by an individual in the past seven days. The data collection was done by days of the week. The World Health Organization classified drinkers into two categories such as infrequent heavy drinkers who had drinks for two days in a week and frequent heavy drinkers who had drinks more than four days in a week. It needs to be mentioned that social stigma attached to drinking, if any, might result in underreporting of the event. Such under reporting is likely to be linked to socio-economic and demographic characteristics of individuals. The proportions of males who never had alcohol are 92 percent (Table 4.2), infrequent heavy drinkers six

Table 4.2 Prevalence of infrequent and frequent heavy drinking in Karnataka, 2003 Characteristics

Sex Male Female Residence Urban Rural Income quintiles Q1 Q2 Q3 Q4 Q5 Age group 18-29 30-44 45-59 60-69 70-79 80+ Total

Never had a drink

Prevalence (%)

Number of infrequent heavy drinkers1

Prevalence (%)

Number of frequent heavy drinkers2

Prevalence (%)

N

554 758

84.5 98.9

78 12

10.9 1.0

28 1

4.6 -

660 771

488 824

96.8 90.5

17 73

2.9 6.8

3 26

2.8

508 923

209 200 268 355 280

85.6 87.3 91.6 93.2 97.3

30 21 18 15 6

11.6 10.5 6.4 3.4 2.0

6 8 6 6 3

2.8 2.3 2.0 3.5 -

245 229 292 376 289

441 449 258 113 40 11

96.5 88.7 89.8 87.7 86.8 100.0

9 33 27 15 6 -

3.1 7.2 6.5 11.0 10.9 -

3 13 8 3 2 -

4.1 3.7 -

453 495 293 131 48 11

1312

91.6

90

6.1

29

2.3

1431

1

Note: Infrequent heavy drinkers: 1 to 3 days with 5+ standard drinks per one week (in last 7 days) 2 Frequent heavy drinkers: 4+ days with 5+ standard drinks per one week (in last 7 days) - No cases reported

Risk Factors

21

percent and heavy drinkers two percent. Ninety seven percent urban respondents never had alcohol compared to 91 percent in rural areas. The proportion of infrequent heavy drinkers is more in rural areas (seven percent) compared to urban areas (three percent). Also, the proportion of frequent heavy drinkers in rural areas is more than that in urban areas. The proportion of respondents who have never had a drink in the lowest income quintile is 86 percent compared to 97 percent in the highest income quintile. In the case of infrequent heavy drinkers it is 12 percent in the lowest income quintile and only two percent in the highest income quintile. The proportion of frequent heavy drinkers is three percent in the lowest income quintile compared to less than one percent at the higher income quintiles. The proportion of frequent heavy drinkers is highest at four percent among those in ages 30-44. The experience of ever having a drink is reported to be the least among the people in the youngest age group of 18-29 years. 4.3 NUTRITION AND PHYSICAL ACTIVITIES Intake of fruits and vegetables Information on dietary habits and its changing pattern are ver y important for rational planning and improvement on nutrition related health policies and programmes. Information on fruits and vegetables and their intake can provide an idea of a causal association of consumption and the reduction in cardio vascular diseases and certain cancers. The measurement of certain selected items such as fruits and vegetables have been taken to indicate the availability of nutrition since data is not collected on overall food intake. The WHO recommended two categories of intake of fruits and vegetables such as sufficient (five or more servings per one typical day) and insufficient (less than five servings per one typical day) intake. It needs to be mentioned here that in India intake of fruits and vegetables, particularly in rural areas, depends largely on what is grown and readily available free of cost and is therefore purely seasonal in nature.

22

Health System Performance Assessment

Table 4.3 presents the proportion of population with insufficient intake of fruits and vegetables in Karnataka. It also presents the level of insufficient physical activities in the state. About 81 percent of the respondents do not have sufficient intake of fruits and vegetables. The proportion with insufficient intake of fruits and vegetables is 81 percent for males and 80 percent for females. In rural areas, 81 percent respondents have insufficient intake of fruits and vegetables compared to 77 percent among the urban respondents. Lower income quintiles have a higher proportion of respondents with insufficient intake of fruits and vegetables. The proportion with insufficient food intake increases with age and all the respondents in the ages 80 and above have insufficient intake of fruits and vegetables. Physical activities Physical activities refer to the activities undertaken at work, around the home and garden, to get to and from places (i.e. for transport) and for recreation, fitness exercise or sport. Regular physical activity has a significant protective effect against ischaemic heart diseases, ischaemic stroke, type two diabetes, breast cancer and colon cancer. Emerging evidence indicates that physical activity is important in preserving the residual fraction once peripheral arterial disease and chronic airways disease have developed. This increases sensitivity to insulin, raises HDL cholesterol levels and reduces blood pressure. In addition, recreational physical activity helps to reduce minor anxiety, depression and weight. The world health survey considers only activities meeting specific thresholds of intensity that were undertaken in the seven days preceding the survey. Twenty six percent of respondents are found with inadequate physical activity. Eighteen percent males and 35 percent females have reported inadequate physical activities. The proportion with inadequate physical activity is 35 percent in urban and 24 percent in rural areas.

Table 4.3 Prevalence of insufficient intake of fruits & vegetables and insufficient physical activity in Karnataka, 2003 Characteristics

Sex Male Female Residence Urban Rural Income quintiles Q1 Q2 Q3 Q4 Q5 Age group 18-29 30-44 45-59 60-69 70-79 80+ Total Note:

1

2

Number of persons with insufficient intake of fruits & vegetables1

Prevalence (%)

Number of persons with inadequate physical activities2

Prevalence (%)

N

544 629

81.2 80.1

138 246

17.7 34.6

660 771

401 772

77.4 81.4

177 207

35.2 24.0

508 923

234 204 253 287 195

95.4 85.5 87.8 77.1 64.9

71 51 62 101 99

28.6 23.6 23.6 26.8 28.2

245 229 292 376 289

377 400 226 113 46 11

79.4 77.1 79.7 89.1 95.9 100.0

123 112 76 52 16 5

24.3 18.4 30.7 41.8 31.3 36.9

453 495 293 131 48 11

1173

80.6

384

26.1

1431

Fruit & Vegetables: 5 or more servings per one typical day. Insufficient intake of fruits and vegetables: Less than 5 servings per one typical day. Physical Activity: Sufficiently active for health: ‘time’>=150 minutes. Insufficiently active 1