Jharkhand Journal of Development and Management StudiesXISS, Ranchi, Vol. 16, No.1, March 2018, pp. 7575-7595

HEALTH ATTAINMENTS AND CHALLENGES INJHARKHAND

Vijay Kumar Baraik1

The State Jharkhand emerged out of the century long struggle bythe tribal people of a particular region historically or geographicallyidentified as Chhotanagpur Plateau and Santhal Parganas.The struggle has been first for a state of ethnic identity and tribalself-rule in line with their cultural identities and management ofthe system followed by the reason of exploitation, suppression,forced land alienation, damage of their own system by the externalworld in the name of development. Everything aforementionedwas at the cost of tribal people. The State got into existence withvery high expectations by not only tribals but also by non-tribalswith a new and dignified identity “Jharkhand”, which was full ofresources but suppressed for ages and pushed towards margins.The new State created a new kind of despair and discontent.Resource appropriation got worse than ever. Worst ever politicalinstability was witnessed in the country with no ideology, no vision,no accountability and so on. The situation worsened due to theextremist activities. In the midst of all these, the reconstruction ofdamaged Chhotanagpur and Santhal Parganas delineated asJharkhand lost its path. Health is also one of such sufferer areas.However, it moved ahead, though stumbling, due to peoples ownwill and efforts, national and international result oriented and timebound health missions. There have been successes amid failuresand challenges with quality being a major issue.

In the backdrop of above, this paper examines theattainments and challenges of Jharkhand in health after morethan a decade of its birth. The analysis is also inter-regional andinter-district for a comparative view with the identification oflagging behind regions in certain indicators. It is based on secondarysources such as National Family Health Survey (NFHS), DistrictLevel Household and Facility Survey (DLHS), Census of India,and Ministry of Health and Family Welfare, Govt. of India andGovt. of Jharkhand. The preliminary results reflect that therehas been remarkable achievement in some indicators like IMR,ANC, institutional births, immunisation, etc., while there arechallenges such as maternal mortality, infrastructure andmanpower, malaria prevalence, access to safe drinking water andsanitation, and distance, geographical condition, connectivity,mobility and seasonal conditions in providing or receiving healthcare services. Besides, there are marked inter-regional and inter-district gaps.Keywords : Health Attainments, Morbidity, Undernutrition,Maternal and Child Care

IntroductionJharkhand was created on 15th November 2000 after a long struggleand movement due to its distinct cultural identity including theexploitations and deprivations of various kinds. After the completionof one decade full of potentials and opportunities, it is expected to have

7575

1 Associate Professor, Discipline of Geography, School of Sciences, Indira GandhiNational Open University (IGNOU), New Delhi, Email- vijaybaraik@ignou.ac.in

7576 Baraik

achievements in the desired direction though the State has undergoneinstabilities of various kinds throughout this period (political instabilitywith ten governments in fifteen years, shortest being of ten days andthree long presidential rules; and bureaucratic instability with highlyuncertain tenures of bureaucrats in any office). It did grow in terms ofPer Capita Income which rose from Rs. 14,292/- in 2001-02 to Rs. 46131/- in 2013-14 but with a wide disparity in the State. Poverty ratio declinedfrom 45.3 per cent in 2004-05 to 36.51 per cent in 2011-12 (Rural-40.84, Urban- 24.83, ST- 54, SC-58 per cent). It is generally felt thatState has remained poor amid tremendous potential. The last decadehas been comparatively very dynamic in many respects due to rapidtechnological development and transformations in all spheres. Thisdecade also brought a prefix ‘e’ in governance and other areas for betterdelivery of services and growth. It has been the decade of informationflow with amazing volume and pace, wide exposure of people, emergenceof a new era with new generation empowered with various means ofinformation and communication confined to a small device. This newgeneration and old ones with a fresh thinking expect from the newState the new pace of result oriented development like other parts ofthe country and globe. However, there is a general feeling of remainingpoor amid vast resources and development prospect. Exuberance ofJharkhandis (people of Jharkhand) and curiosity of outsiders forJharkhand as emerging State due to its vast resource base just gotfaded away over a very short span of time due to failure of the State invarious fronts.

Health is also one such area of expectations in the State, whichis an important factor for normal functioning of human beingwith maximum productivity. It is closely related to human developmentas well and widening opportunities for heading a fuller life. It doesnot only include mortality but also some vital indicators like morbidityand nutritional status and associated factors like access to healthcare services and health care utilisations. Despite health and healthcare being in the centrality of the government policies, variousregions of the State with wide disparity are yet to be fully coveredby health care services. It has big challenges including high levelof prevalence of morbidity. Most importantly, there has been a paradox of poor levels amid plenty of resources and potential inthe State.

The National Family Health Survey (NFHS)-3 and District LevelHousehold and Facility Survey (DLHS)-3 reports indicate the status ofhealth through key indicators in Jharkhand. There are goodachievements in some indicators but challenges are many andenormous. Total Fertility Rate is reaching at its satisfactory level.

Health Attainments and Challenges in Jharkhand 7577

The mortality indicators indicate that despite significant decline inIMR, it is still higher compared to the State like Kerala. MaternalMortality is extremely high. Some of the aspects of maternal and childhealth and health care are also poor than national average. The detailsof above are discussed in the subsequent sections. The paper has beendivided into the following six sections: Introduction, review of literature,health attainments, challenges, State initiatives, policy gaps, andalternatives and conclusions.

Review of literature

There have been research on health and related issues in the State.Though these are issue specific. Jharkhand has always been perceiveddifferently as characterised with tribes as far as the health and healthcare are concerned. And, therefore, the focus of most of the researchhas also been oriented towards this perception. Ivern (1969) through aholistic survey entitled “Chotanagpur Survey” conducted in 1969 saysthat despite health services were introduced in 1864 by the Britishgovernment for its officers and families, Bihar (Chhotanagpur orJharkhand was part of Bihar till Nov 2000) remained neglected forlong compared to the other provinces. Most prevalent incidences ofdisease were dysentery, diarrhoea, respiratory, including TB, eyeinfection, typhoid and skin diseases in entire region. The region specificdiseases were gastro–enteritis, scabies, anemia, malnutrition andparasitical infestations, filariasis, cholera, leprosy, and mental disordersin Chhotanagpur. Lack of safe drinking water, poor housing conditions,lack of sanitary facility and unhygienic practices, poverty and lack ofnutritious balanced diet, apathetic behaviour of care providers, corruptpractices, myths and ignorance, were identified along with inadequatefacilities as main factors of high morbidity and poor health conditionin the region.

Sinha (2006) describes the high level of morbidity, undernutrition and mortality among tribes in Jharkhand. He highlightsthe availability, accessibility and affordability among other things wherecentrality or nodality should be of prime importance for the location ofservices. He also opined that the primary health sub-centres be replacedwith mobile health care units. However, mobile units should beadditional facilities along with three tier rural health facilities.According to him, spacing of settlements and geographical isolationshould be taken care of while planning health care services. Sinhaalso emphasises on the roles of community based organizations, curbingthe unrestricted growth of unqualified practitioners and regulations of

private health services. A rapid change in the health sector has takenplace in the State due to exogenous and endogenous factors. Holisticstudy on health status involving health status in terms of morbidity,nutritional status and health care utilization in relation to the levelsof development was carried out by Baraik (2002) with special referenceto the Scheduled Tribes of Jharkhand. This research concludes thatdevelopment is needed in this kind of society for the affordability ofminimum health status. It has also empirically found that the tribesin Jharkhand have made much more departure from the preconceivednotion of not preferring modern medicine as they are averse only inminiscule common incidences.

Objectives

The objectives of this paper is to examine the attainments andchallenges of Jharkhand in health since its emergence as a new State.The objectives also include the identification of lagging behind regionsin certain indicators through inter-regional and inter-district analysisfor the proper intervention.

Database and methodology

The data for this paper has been taken from various secondary sources.These sources are: National Family Health Survey (NFHS), DistrictLevel Household and Facility Survey (DLHS); Census of India, RGI,Govt. of India; Ministry of Health and Family Welfare, Govt. of India;and Ministry of Statistics and Programme Implementation, Govt. ofIndia and Govt. of Jharkhand. The major indicators are Fertility,Mortality (IMR, Maternal Mortality), Morbidity (Diarrhoea, ARI),Undernutrition, Health Care (ANC, Institutional Birth Immunisation,Treatment of Diarrhoea and ARI), Health Infrastructure (PHC, CHC,PHSC, Manpower), Communication and Accessibility - Distance andConnectivity, and Amenities- Sanitation and Safe Drinking Water.Simple statistical and graphic representation techniques have beenused in this study.

Findings and discussion

1. Health attainments

Health attainments have been measured through the indicatorsof fertility, mortality, morbidity, and maternal and child care. Itwas observed that in some of the indicators the state has madea significant departure. A very positive sign among the tribal

7578 Baraik

communities in the State is observed, where there is not muchdifference from the average figure. DLHS-3 suggests that thetribals have equally performed in the consumption of the IFAbreaking the traditional myth of being averse of modern health care.It means wherever there is availability and accessibility of modernsources of health care services, the people have proved that it is not anethnic prejudice in the State. Empirical research also suggest thatonly a minuscule tribal population (less than three percent) do notprefer modern medicine in only some cases what others also do thesame (Baraik, 2002).

Fertility and mortality indicators

Total Fertility, IMR and Immunization show very good level ofattainments, where Jharkhand has achieved in bringing down thefertility rates since 2005. Its slow but steady decline has been projectedto achieve replacement-level of fertility (i.e. 2.1) by 2018. It was 3.5 in2005, 3.2 in 2009 and 2.8 in 2012.

Infant Mortality Rate (IMR) is considered as one of the mostimportant indicators of health status and overall quality of life. As perthe data provided in the data portal of the Govt. of India takenfrom Sample Registration System, Jharkhand's achievement inminimizing IMR from 70 to 29 during the period since its existence(2000-2016) is among the good performing states after Sikkim,Tamil Nadu, Delhi, Maharashtra, Punjab, Tripura, Karnataka,Jammu & Kashmir, West Bengal, Himachal Pradesh and Mizoram(Table 1). Though best performing states have achieved remarkablylike Goa, Puducherry, Kerala, Manipur and Nagaland. The IMRin Goa in 2016 is 8. There are some states like Arunachal Pradeshand Mizoram where increased IMR is noticed. (Table 1). Jharkhand'sachievement is more than the national average in terms of bothnumber and percentage from the base level (Chart 1). The presentIMR is lower than Chhattisgarh, Odisha, Madhya Pradesh, UttarPradesh, Bihar, Rajasthan, Haryana, Gujarat, Jammu & Kashmir(J&K), Andhra Pradesh, Assam and Meghalaya. The state hasalmost touched the 12th Plan goal of reduction in IMR at 27.. However,the intrastate situation of IMR across the districts suggests thatchallenge also exists to minimize it in the peripheral and non-industrialdistricts of the state primarily in the districts of Santhal Praganaregion excluding Deoghar, western districts including Chatra,West Singhbhum+Saraikela-Kharsawan, Lohardaga andGumla+Simdega (Table 2).

Health Attainments and Challenges in Jharkhand 7579

Andhra 65 66 62 59 59 57 56 54 52 49 46 43 41 39 39 37 34 31 47.7PradeshArunachal 16 7 23 21 25 27 31 31 31 27 25 23 24 24 30 30 36 -20 -125.0PradeshAssam 75 74 70 67 66 68 67 66 64 61 58 55 55 54 49 47 44 31 41.3Bihar 62 62 61 60 61 61 60 58 56 52 48 44 43 42 42 42 38 24 38.7Chhattisgarh 79 77 73 70 60 63 61 59 57 54 51 48 47 46 43 41 39 40 50.6Delhi 32 25 33 26 32 35 35 36 35 33 30 28 25 24 20 18 18 14 43.8Goa 21 14 16 13 18 16 15 10 10 10 10 11 10 9 10 9 8 13 61.9Gujarat 62 60 60 57 53 54 53 52 50 48 44 41 38 36 35 33 30 32 51.6Haryana 67 66 62 59 61 60 57 55 54 51 48 44 42 41 36 36 33 34 50.7Himachal 51 43 61 42 51 49 50 47 44 45 40 38 36 35 32 28 25 26 51.0PradeshJammu & 50 48 47 44 49 50 52 51 49 45 43 41 39 37 34 26 24 26 52.0KashmirJharkhand 70 62 58 51 49 50 49 48 46 44 42 37 38 37 34 32 29 41 58.6Karnataka 57 58 55 52 49 50 48 47 45 41 38 35 32 31 29 28 24 33 57.9Kerala 14 11 10 11 12 14 15 13 12 12 13 12 12 12 12 12 10 4 28.6Madhya 88 86 85 82 79 76 74 72 70 67 62 59 56 54 52 50 47 41 46.6PradeshMaharashtra 48 45 45 42 36 36 35 34 33 31 28 25 25 24 22 21 19 29 60.4Manipur 22 10 - - - - - 10 14 16 14 11 10 10 11 9 11 11 50.0Meghalaya 66 51 66 56 43 49 53 52 58 59 55 52 49 47 46 42 39 27 40.9Mizoram 18 18 6 16 27 - - - 37 36 37 34 35 35 32 32 27 -9 -50.0Nagaland NA NA NA NA 17 18 20 19 26 26 23 21 18 18 14 12 12 5 29.4Odisha 95 91 87 83 77 75 73 71 69 65 61 57 53 51 49 46 44 51 53.7Punjab 52 52 51 49 45 44 44 43 41 38 34 30 28 26 24 23 21 31 59.6Rajasthan 79 80 78 75 67 68 67 65 63 59 55 52 49 47 46 43 41 38 48.1Sikkim 47 29 25 22 30 30 33 33 33 34 30 26 24 22 19 18 16 31 66.0Tamil Nadu 51 49 44 43 41 37 37 35 31 28 24 22 21 21 20 19 17 34 66.7Telangana - - - - - - - - - - - - - - - 34 31 - -Tripura 35 35 33 23 30 31 36 41 34 31 27 29 28 26 21 20 24 11 31.4Uttar 83 83 80 76 72 73 71 69 67 63 61 57 53 50 48 46 43 40 48.2PradeshUttarakhand 50 48 44 41 42 42 43 48 44 41 38 36 34 32 33 34 38 12 24.0West Bengal 51 51 49 46 40 38 38 37 35 33 31 32 32 31 28 26 25 26 51.0Andaman & 16 7 23 21 25 27 31 31 31 27 25 23 24 24 22 20 16 0 0.0Nicobar IslandsChandigarh 27 16 22 12 22 19 23 35 28 25 22 20 20 21 23 21 14 13 48.1D&N Haveli 57 61 51 49 34 43 24 29 34 37 38 35 33 31 26 21 17 40 70.2Daman & Diu 54 43 30 36 30 28 37 28 31 24 23 22 22 20 18 18 19 35 64.8Lakshadweep 22 38 15 21 39 22 25 38 31 25 25 24 24 24 20 20 19 3 13.6Puducherry 20 22 25 27 26 28 28 16 25 22 22 19 17 17 14 11 10 10 50.0India 68 66 63 60 58 58 57 55 53 50 47 44 42 40 39 37 34 34 50.0

Source: Sample Registration System (downloaded from http://niti.gov.in/conten)t/infant-mortality-rate-imr-1000-live-births

7580 Baraik

Stat

e/U

T

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

Per

iod

Dec

line

%ag

eD

eclin

e

Table-1. State wise trends of infant mortality rate in India,2000-2016

Table-2. Infant mortality rates in Jharkhand, 2011District Total Rural UrbanJharkhand 38 42 24Garhwa 36 36 36Palamu + Latehar 44 45 26Chatra 46 47 39Hazaribagh + Ramgarh 31 32 29Kodarma 30 31 27Giridih 32 33 -Deoghar 34 33 35Godda 58 59 -Sahibganj 56 58 36Pakur 54 54 -Dumka + Jamtara 44 44 -Dhanbad 26 35 19Bokaro 28 33 23Ranchi + Khunti 32 37 22Lohardaga 54 57 30Gumla + Simdega 45 46 24West Singhbhum + Saraikela Kharsawan 53 56 29East Singhbhum 25 29 21

Source: Annual Health Survey Bulletin 2011-12, Jharkhand, RGI, New Delhi

Gumla has achieved the lower female IMR than male and themale-female IMR is equal in Chatra, Koderma, Godda, Dhanbad, Ranchi(Including Khunti) and Pashchimi Singhbhum. In rural area the femaleIMR is lower in East Singhbhum, West Singhbhum (includingSaraikela-Kharsawan), Gumla (including Simdega), Dhanbad, Godda,and Koderma. If these districts control the female IMR in urban areas,it will be a very good achievement. It is also an achievement of theState to bring IMR of females at par with or better than males in thosedistricts where the society may traditionally be perceived with genderbiasness (non-tribal districts).

Chart 1

Health Attainments and Challenges in Jharkhand 7581

Maternal and child careThe age at marriage of boys and girls has marginally gone up duringthe two District Level Health Surveys (DLHS) held during 2002-04(DLHS-2) and 2007-08 (DLHS-3). The two DLHSs reveal that the AnyAnte Natal Check-up received by mothers rose from 51.2 per cent to55.9 per cent. The State has made a remarkable progress in fullimmunization from 25.7 to 54.1 per cent and reached the level ofnational average (54.0 per cent). TT injection has witnessed a rise of6.2 percentage points. The sharp and remarkable jump has beenrecorded in the consumption of 100 IFA Tablets from 12.0 to 56.3 percent. The ARI and fever are well taken care in the State. Tribals’equal achievement in IFA breaking the myth of aversion from modernmedicine is also a good achievement.

The growth in immunization in BCG from 50.8 to 85 per cent,OPV3 from 34.8 to 64.4, DPT from 35.6 to 62.6 per cent and Measles

7582 Baraik

Maternal Mortality Rate (MMR) given by the Sample RegistrationSystem, Census of India is still very high (261) while the nationalaverage is 212 and is 81 in Kerala. Also, MMR for combined Biharand Jharkhand has declined from 312 in 1999-01 to 167 in 2011-13(Chart 2). It achieved more than few states like Assam, Uttar Pradesh/Uttarakhand, Rajasthan, Odisha and Madhya Pradesh/Chhattisgarh.However, the MMR is still above Kerala (61), Maharashtra (68), TamilNadu (79), Andhra Pradesh (92), Gujarat (112), West Bengal (113),Haryana (127), Karnataka (133) and Punjab (141). The decline isnoticed with the pace of national average only (around 16 per cent).It is still very high and need to be minimized urgently and with goodpace.

Chart 2

from 31.2 to 70.5 per cent was also observed during these two surveys.The latest figures are expected to be further better since the DLHS-3.There is a sharp drop of percentage of children not received anyvaccination to single digit level from more than 45 per cent in theDLHS-2 but has still remained double of the national average. On theother hand the same is half a per cent in Kerala.

The preliminary report of NFHS-4 reveals that there are someindicators, where very impressive progress is observed like institutionalbirths have seen notable jump from 18.3 per cent in NFHS-3 (2005-06)to 61.9 per cent in NHFS-4 (2015-16). Similarly, sharp rise are observedin safe delivery from 27.8 to 69.6 per cent (rural- 57.3 per cent), fullimmunization from 34.2 to 61.9 per cent and children with diarrhoeareceived ORH from 17.4 to 44.8 per cent. There are also some indicatorswhich did not see very good progress. Like full ANC increased from 4.9to 8.0 per cent, IFA consumption for 100 days rose from 9.5 to 15.3 percent, children with ARI taken to health facility progressed from 63.0to 67.2 per cent only. Decline of under nutrition also experienced aslow progress during this period, where stunting declined from 49.8 to45.3 per cent, wasting from 32.3 to 29.0 per cent, and underweightfrom 56.5 to 47.8 per cent only. Among adults, the percentage of womenhaving BMI below 18.5 reduced from 42.9 to 31.5 per cent and malesfrom 38.6 to 23.8 per cent.2. ChallengesThere are many challenges, which significantly overcast theachievements. The challenges are in mortality and morbidity, maternaland child care, nutrition, drinking water and sanitation, facilities andservices, infrastructure and manpower, etc. discussed ahead.Mortality and morbidity indicatorsThe State has reduced the IMR in extraordinary manner. However, itneeds to be brought down to single digit level. There is also a bigchallenge amidst good achievements to minimize IMR in the peripheraland non-industrial districts of the State (Santhal Pargana regionexcluding Deoghar, south and western districts (Chatra, WestSinghbhum+Saraikela-Kharsawan, Lohardaga and Gumla+Simdega).Maternal Mortality has not much declined (2001- 312, 2010-267) sincethe creation of the State and is still very high. There still long way togo in minimizing maternal mortality as there has not been muchdecline (2001- 312, 2010-267) since the creation of the State.

The government sources reveal that Jharkhand has the secondhighest cases of Malaria - (152061) next to Odisha (294759) in Indiaeven after having prolonged programme on malaria eradication by thegovernment.

Health Attainments and Challenges in Jharkhand 7583

Maternal and child careDuring the two District Level Health Surveys (DLHS) held in 2002-04(DLHS-2) and 2007-08 (DLHS-3), ‘Any Ante Natal Check-up’ receivedby mothers improved from 51.2 per cent to 55.9 per cent (Table 3).However, the percentage of mothers who had three or more ANCs isalmost static with 30.7 and 30.5 per cent respectively during twosurveys. It also indicates that about 25 per cent mothers go for lessthan three ANCs. In case of full ANC, it is further poor and almoststatic in two surveys with 9.1 and 9.3 per cent respectively. No AnteNatal Care is very high (total-40.6, ST- 50.0 per cent) compared to theaverage figures for respective groups of the country (Total-22.8, ST-29.4 per cent) as reflected by NFHS-3. Though TT injection haswitnessed a rise of 6.2 percentage points and the sharp and remarkablejump recorded in the consumption of 100 IFA Tablets it is still farfrom the full coverage. The percentage of mothers receiving fullantenatal care in NFHS 4 (2015-16) was only 8.0 per cent movingfrom 4.9 per cent in NFHS-3 (2005-06).

Table-3. Health indicators of Jharkhand, 2002-04 and 2007-08

Indicators  DLHS-3 (2007-08) DLHS-2 (2002-04)Total Rural Urban Total Rural Urban

Mean age at marriage for 22.9 22.4 25.5 22.4 21.7 24.8boys (marriages that occurredduring the reference period) 3Mean age at marriage for 18.3 18 20.3 17.9 17.3 20.2girls (marriages that occurredduring the reference period)3Antenatal care (based on women whose last pregnancy outcome waslive/still birth during the reference period)3Mothers who received any 55.9 52.9 84.5 51.2 42.3 82.8antenatal check-up (%)Mothers who had three or 30.5 26.9 65.2 30.7 21 65more ANC (%)Mothers who consumed 100 56.3 57.4 45.6 12 7.5 27.9IFA Tablets (%)Mothers who had full 9.1 7.2 27 9.3 5.1 24.4antenatal check-up6 (%)Delivery care (based on women whose last pregnancy outcome was live/still birth during reference period)Institutional delivery (%) 17.8 13.4 59.3 21.2 10.1 60.6Delivery at home (%) 81.8 86.2 40.3 78.5 89.6 39.1Delivery at home conducted 7.2 7.6 5 7.7 6 13.6by skilled health personnel (%)

7584 Baraik

Safe Delivery7 (%) 25 21 64.3 26.7 15.5 65.9Child ImmunizationChildren 12-23 months fully 54.1 52.4 69.3 25.7 18.9 49.7immunized (%)Children (age 9 months and 61.6 60 76.6 11.3 8.3 21.9above) received at least onedose of vitamin A supplement) (%)Treatment of childhood diseases (based on last two surviving childrenborn during the reference period)Children with diarrhoea in 21.3 19.9 38.6 24.9 20.8 39.5the last 2 weeks who receivedORS12 (%)Children with acute 62 61 75.4 58.4 55.2 69.9respiratory infection or feverin last 2 weeks who soughtadvice/treatment (%)

Source: DLHS-1 and DLHS-2

One major concern during two surveys was why the institutional(21.2 per cent in DLHS-2 to 17.8 in DLHS-3) and safe (26.7 per cent to25.0 per cent) deliveries have declined during DLHS-2 and DLHS-3period as the base level is already low. The current survey, however,reflects remarkable coverage as mentioned in the attainment section.A very high maternal mortality rate may be a reflection of this poormaternal care in the State. The two DLHSs reveal that the State hasmade a remarkable progress in full immunization from 25.7 to 61.9per cent in 2015-16.

Institutional and safe deliveries are still far from the desiredlevel in the state as these are 17.8 and 25.0 per cent respectively.Within the state, Institutional Deliveries are still very poor in majorityof the districts with less than 10 per cent in Latehar and Sahebganj.Majority of the districts show less than 20 per cent institutionaldeliveries. A little improvement is seen in the rural areas in deliverycare.

There are wide rural-urban gaps observed in these indicatorsexcept the consumption of IFA Tablets. The urban centric health careis a big challenge in the State.

In terms of curative care, health care among children is poor inJharkhand in case of diarrhoea treatment through ORS supplementas only 44.8 per cent children received ORS. Similarly, there is a declinein the percentages of aware women about danger sign of ARI anddiarrhoea care of children.

Health Attainments and Challenges in Jharkhand 7585

Under nutritionVery high level of under nutrition exists among the children ofJharkhand. The NFHS-3 given on Table 4 reveals that 76.6 per centare under grown, 44.1 per cent are wasted (low weight for height) and82.6 per cent are under weight. Among these 26.8, 11.8 and 26.1 percentchildren are severely stunted, wasted and underweight respectively.The underunitrition is much higher among ST children withcorresponding figures of 84.4, 51.5 and 97.9 per cent for under-height(stunted), wasted, and underweight. Height and Weight for Age are ina very miserable condition where just 2.1 per cent children have normalweight. Severely stunted, wasted and underweight ST children are29.9, 11.9 and 33.6 per cent respectively with not much difference. 43per cent (ST-47.2 per cent) women and 38.6 percent (ST-42.1 per cent)men are found to be thin, among which 18.0 per cent (ST-18.9 percent) women and 13.8 per cent (ST-12.5 per cent) men are moderately/severely thin. The NFHS-4 indicates that there has been significantreduction in the under nutrition among children as the percentages ofstunted, wasted and underweight children are 45.3, 29.0 and 47.8 whichare still very high. Similarly, the percentages of thin man and womenin 2015-16 are 31.5 and 23.8.

Anaemia is also very high among women (70.6 percent, ST- 85.0per cent) and children (77.9 per cent, ST-79.5 percent), which is towardsextreme side among STs (Table 4). There is no very good progress inthis regard as anaemia is prevalent among 65.2 and 69.9 per centwomen and children respectively in 2015-16.

Table-4. Under nutrition in Jharkhand

Under Nutrition Total (%) ST (%)Under Growth-Stunting (Height for Age) 76.6 84.4Underweight (Weight for Age) 82.6 97.9Wasting (Low weight for Height) 44.1 51.5Severely stunted 26.8 29.9Severely underweight 26.1 33.6Severely wasted 11.8 11.9Thin Men 38.6 42.1Thin Women 43.0 47.2Moderately/Severely Thin Men 13.8 12.5Moderately/Severely Thin Women 18.0 18.9Anaemia among Women 69.5 85.0Anaemia among Children 70.3 79.5

Source: NFHS-3, 2005-06

7586 Baraik

Drinking water and sanitation

Water quality has also been sources of many diseases. As per the Census2011, 87.27 per cent inhabited villages had the access to the sources ofsafe drinking water facilities, which need to be 100 percent. Sahebganjhas reflected comparatively very low percentage (60.86) of villageshaving access to the safe drinking water. It has to go beyond this tothe habitation level and household level availability of safe drinkingwater for full coverage.

At the household level, 85.5 per cent households have accessto the sources of safe drinking water in India as per the HouseholdTables 2011. In Jharkhand the percentage of such households is60.1 and it is 53.5 per cent among ST households. The all sourcesof drinking water located away from the households is 17.6 per centin India while it is 31.9 per cent in Jharkhand. It goes further highto 42.3 per cent households of STs. Hand pumps are located awayfrom 43.7 per cent households in Jharkhand. This problem of difficultphysical access to drinking water urgently needs to be addressedas a noble human cause. Similarly, 77.0 per cent households do nothave latrine facilities as compared to 49.8 per cent in India, whichis highest in the country reflecting a very poor condition of hygienein the State. On the other end, there are states which have lessthan 5 per cent households in this category. These are closelyassociated with health and need to be addressed urgently for goodhealth.

Facility and access

One group of the major challenges in health care service providingor receiving is the geographical condition, distance, connectivity,mobility and seasonal conditions. Though the Census of India doesnot provide distance from settlement points to the service centres,it gives average distance of a village irrespective of its area andspread of settlements. As per the Village Directory, 2011 Census,15.6 per cent villages have Primary Health Sub Centres, while68.9 per cent villages have this at a distance within 5 kms, andthe percentages of villages having access to this facility at a distanceof 5-10 kms and more than 10 kms are 15.1 and 0.5 respectively.The situation is worrisome in case of access to the Primary HealthCentre which is located at 4.6 per cent villages only and accessiblewithin 5 kms, 5-10 kms and above 10 kms of distance to 13.9, 33.3 and48.1 per cent villages (Chart 3).

Health Attainments and Challenges in Jharkhand 7587

In this case distance and proportion of villages have positiverelation. The percentage of villages having PHC at above 10 kms ofdistance goes as high as 73.7 in Dumka followed by more than 60 percent in Ranchi and Simdega and above 50 per cent in Jamtara, Garhwa,Giridih, Khunti and Purbi Singhbhum (Table 5). Moreover, the locationand distance with all barriers should always be considered from eachsettlement of a revenue village and not only from the boundary of therevenue villages as these factors play vital role in health care fromboth ends-service providers and receivers.Table-5. Percentage of inhabited villages by distance from

PHC in Jharkhand, 2011District Distance Number of Villages Total Percentage of Villages

0 KM Outside 5-10 Above Villages 0 KM Outside 5-10 AboveVillage but KM 10 KM Village but KM 10 KM

Within Within5 KM 5 KM

Bokaro 21 89 207 294 611 3.4 14.6 33.9 48.1Chatra 71 275 442 589 1377 5.2 20.0 32.1 42.8Deoghar 118 343 860 1033 2354 5.0 14.6 36.5 43.9Dhanbad 87 300 381 307 1075 8.1 27.9 35.4 28.6Dumka 70 168 470 1980 2688 2.6 6.3 17.5 73.7Garhwa 47 32 276 489 844 5.6 3.8 32.7 57.9Giridih 27 299 774 1458 2558 1.1 11.7 30.3 57.0Godda 306 283 688 411 1688 18.1 16.8 40.8 24.3Gumla 48 114 341 439 942 5.1 12.1 36.2 46.6Hazaribagh 43 220 421 509 1193 3.6 18.4 35.3 42.7Jamtara 23 115 297 647 1082 2.1 10.6 27.4 59.8Khunti 18 92 233 411 754 2.4 12.2 30.9 54.5Kodarma 9 115 170 283 577 1.6 19.9 29.5 49.0Latehar 22 141 235 351 749 2.9 18.8 31.4 46.9Lohardaga 25 53 99 175 352 7.1 15.1 28.1 49.7Pakur 70 146 401 524 1141 6.1 12.8 35.1 45.9

7588 Baraik

Chart 3

Palamu 79 185 902 545 1711 4.6 10.8 52.7 31.9Pashchimi 22 207 625 788 1642 1.3 12.6 38.1 48.0SinghbhumPurbi 15 232 555 807 1609 0.9 14.4 34.5 50.2SinghbhumRamgarh 9 88 129 79 305 3.0 28.9 42.3 25.9Ranchi 57 127 323 789 1296 4.4 9.8 24.9 60.9Sahibganj 138 203 429 579 1349 10.2 15.0 31.8 42.9Saraikela- 20 245 446 435 1146 1.7 21.4 38.9 38.0KharsawanSimdega 17 31 128 273 449 3.8 6.9 28.5 60.8Jharkhand 1362 4103 9832 14195 29492 4.6 13.9 33.3 48.1

Source: Census of India, 2011

Negotiating with the geographical (physiographical) factors isvery important as the state is highly undulated with lots of physicalbarriers between patient and the health centre and lack of transportnetwork and facilities for mobility. Approach to pucca road to 64.4 percent inhabited villages by 2011 (Village Directory, Census of India,2011) was a major challenge providing or availing services or makingservices approachable/ accessible, which becomes further difficult duringand post monsoon season.

The shortage of infrastructure and manpower is also a bigproblem. The pressure of more than a lakh rural population per PrimaryHealth Centre is in the districts of Deoghar, Giridih, Godda, Khunti,Ramgarh, Garhwa and Hazaribagh closely followed by Sahebganj.Similarly, ten thousand and above rural population per health sub-centre is in the districts of Giridih, Chatra, Palamu and Hazaribagh(Table 6). The other area of concern is the meeting the shortfall ofmanpower as per Indian Public Health Standard (IPHS) norms. Asper the CS Review done on 11-07-2013 on the status of the Dept. ofHealth, Medical Education and Family Welfare, Govt. of Jharkhand,the gaps in existing and IPHS norms are huge. The shortfall of manpower as per IPHS norms till 2012 was 2569 Medical Officers, 2635Staff Nurse, 958 Pharmacist, 831 Lab Technician, 57 Radiographer,890 Lady Health Visitor, and 400 Dresser (Table 7). The JharkhandEconomic Survey states that till March 2016, there had been shortfallof manpower in varying degrees, while the additional manpower inANM is still continuing.

Since there is high demand and no more aversion from modernhealth care, it is a challenge to provide accessible, affordable and qualityhealth care services of all kinds by proper planning. Approach to healthand health care are taken standalone way and therefore, a big challengeis also to have integrated approach associating all other determinantsand their departments with the aspects of health and health careutilization.

Health Attainments and Challenges in Jharkhand 7589

Table-6. District-wise number of persons per health facilityin Jharkhand 2001 and 2011

District Number of Sub Number of Primary Population per Population perCentres Health Centres Health Sub-Centre Health Centre

2001 2011 2001 2011 2001 2011 2001 2011Bokaro 54 116 16 16 18019 9299 60813 67418Chatra 12 93 8 11 62451 10537 93677 89085Deoghar 49 181 18 5 20521 6816 55863 246742Dhanbad 59 141 19 28 19352 7972 60092 40146Dumka 106 258 40 36 9881 4772 26185 34202Garhwa 54 132 18 12 18386 9493 55157 104426Giridih 99 181 29 15 18001 12362 61451 149163Godda 67 185 24 10 15089 6752 42122 124913Gumla 144 242 26 13 5505 3967 30488 73856Hazaribagh 44 146 31 14 28313 9994 40186 104228Jamtara 26 132 13 15 22973 5419 45945 47686Khunti 55 108 8 4 7373 4508 50692 121726Koderma 32 65 13 6 12895 8846 31743 95836Latehar 57 97 9 10 9379 6960 59399 67512Lohardaga 51 73 11 10 6242 5539 28939 40438Pakur 47 121 13 9 14162 6884 51203 92546Palamu 41 171 36 21 35090 10023 39963 81613Pashchimi 59 342 28 15 17676 3755 37245 85620SinghbhumEast Singhbhum59 244 8 18 15115 4178 111473 56629Ramgarh 35 54 6 5 14361 9824 83773 106098Ranchi 122 365 35 28 11489 4540 40049 59176Sahibganj 39 155 16 10 21273 6393 51852 99090Saraikela- 51 194 29 12 13510 4156 23760 67193KharsawanSimdega 82 162 13 7 5858 3436 36949 79519Jharkhand 1444 3958 467 330 14510 6330 44865 75924

Source: i) Village Directory, Census of India 2001, ii) Data Portal India, http://data.gov.in/

Table-7. Medical Officers & Paramedics status(HSC -3958, PHC -330, CHC -188, SDH -10, DH -22)

Category Total Sanctioned Working Working Working Working ShortfallRequired (Regular) (Regular) Contractual State Total as per

as per (NRHM) Contract (Regular+ IPHSIPHS Contractual) Norms2010

Medical 4451 2048 1510 50 322 1882 2569Officers*ANM 7916 6020 4668 3269 1192 9129 1213

additionalANMs

Staff Nurse 3381 379 276 371 99 746 2635Pharmacist 1332 385 122 94 158 374 958Lab Technician 1338 443 144 223 140 507 831Radiographer 169 50 32 80 0 112 57Lady Health 1045 473 155 0 0 155 890VisitorDresser 488 471 88 0 0 88 400

HSC – Health Sub Centre, PHC- Primary Health Centre, CHC- Community Health Centre,SDH- Sub-Divisional Hospital, DH- District Hospital

Source:http://jrhms.jharkhand.gov.in/FileUploaded%20By%20User/Final%20CS%20ReviewHealth%20%20PPT%20%2011.07.2013.pdf

7590 Baraik

3. State initiativesInitiatives for maternal and child careThe state has taken many initiatives in achieving health goals. Tominimize Maternal Mortality (MMR), the initiatives are throughcash incentive for institutional delivery, cashless delivery (JananiShishu Suraksha Karyakram-JSSK), free health care services, drug,blood, diet to pregnant women, mamta vahan, free c-section facilitiesin First Referral Units (FRUs) anaemia control, IF supplements(life cycle approach), de-worming, blood bank, normal pregnancy andnormal child birth, immediate referral facility for complicated cases,enhancing delivery service centres and operationalize 24x7 deliveryservices in the PHCs. Besides this other initiatives planned will furthercontribute to the decline of MMR and improving mother and childhealth.

The state has initiated number of new born child care with atarget towards full immunization, control of childhood anaemia,diarrhoea care, vitamin supplements, ARI treatment, establishmentof malnutrition treatment centres, maternity care centres and thesemay have been the factors in reducing IMR significantly in the State.A good achievement in leprosy eradication is also observed whereJharkhand has almost achieved at par with national level (CS Review).To reach the remote areas, distribution of bicycles (10400 distributed,16000 more in the plan) is a very welcome step in improving motherand child health as it contributed in education among girl children inthe State (CS Review).Infrastructure, facilities and manpowerAs far as health infrastructure and amenities are concerned, at presentthe State has 3958 Health Sub-Centres, 330 Primary Health Centresand 188 Community Health Centres and the proposed numbers ofthese facilities are 7088, 1126 and 235 respectively (Department ofHealth, Medical Education, Research and Family Welfare, 2012)). Itis good to see that the State is moving forward to develop healthinfrastructure as per IPHS norms. As per the population norms ofIPHS, the present pressure on each kind of health centre in rural areais too high - 6330 persons per Health Sub-Centre, 75924 persons perPrimary Health Centre and 133272 persons per Community HealthCentre. The government has initiated for the optimization of populationper health facilities as per the set standards and targeted to meet theset standard which will be 3535, 22251 and 106617 rural persons asper 2011 Census per Health Sub-Centre, PHC and CHC. It will belittle above the threshold values determined for the tribal and hillyareas.

Health Attainments and Challenges in Jharkhand 7591

4. Policy gapsThere are gaps in the health care initiatives in the states. Firstly,there are large villages having difficult access to the health care servicesdue to location, distance, connectivity and other factors of accessibility.The establishments of more hospitals are being done without muchrationale as these are taking place not in the gap areas but in thoseareas, which already have the facilities.

There are also some non-scientific and irrational policy decisions.For example Jharkhand Tribal Development Programme started inPhase I and II in tribal dominated districts raise a question for leavingSimdega and Gumla districts, which are the districts with highest STpopulation. Similarly, more infrastructure are being created in thosedistricts which are already having or have access to such services andthe districts or regions like Palamu and Simdega are continuouslyneglected. It will never lead to the equitable distribution of the resources.Besides, there are also gap in the adequate infrastructure and manpower as per prescribed norms. Finally, there is a complete lack in theintegrated approach as health and health care are still seenindependently.

Alternatives and ConclusionsThe State has made marked progress in some of the indicators,especially IMR by reducing it at par with the leading states. Slow butsteady Total Fertility Rate is moving towards desired direction. Healthcare in terms of maternal and child care have also shown good progressover the period. There are various initiatives also. However, thechallenges are much more than the achievements in the State. In thelast decade, significant emphasis has been received in the health sectorunlike the preceding times and a number of international and nationallevel important programmes have been initiated. A number of surveys,database preparations, and efforts have been made in the State enablingresearch, evaluation, planning and implementation quick and on realtime basis. Among all these programmes, National Rural HealthMission (NRHM) has its own objectives in line with the national andMillennium Development Goals (MDG) objectives.

The State is known for poor response to the modern medicine ormodern health care due to its cultural characteristics, though the tribalpopulation is only about 26.3 per cent. Over the period this aversionfrom modern medicine has gone away, and especially, in the last decadethere has been tremendous transformation in the health care psychologyof the people for the demand of quality health care (Baraik, 2002). Themindset has changed to a considerable extent. There might be somecontinuity of orthodox or traditional thinking and practices juxtaposed

7592 Baraik

with this. There might also be certain level of superstition due tohistorical roots and weak and less effective modern system in terms ofquick demonstration effect in the society. Nevertheless, people arenow open to the modern health care services and the time has come tomeet the demand as enough level of awareness has grown among thepeople and more people are moving towards nearby health/urban centresfor getting health care services on need. It is the time to offer qualityservices to affordable cost at accessible points to make the State healthy.Otherwise the disbelief and unreliability will be formed again to persistfor further longer time.

To meet the objectives, many initiatives are needed. Firstly,availability and accessibility should be addressed properly. Besidespopulation norm, there should also be mapping of gap areas or areasdeprived of services due to geographical factors and distance andlocating/relocating service points accordingly for complete coverage uptolast person in the last mile as the State is plateau region and is highlyundulating in physiography. The surrounding areas around Ranchi,Jamshedpur, Dhanbad and now proposed hospital at Dumka andChaibasa are covered by hospitals and medical college. Setting up ofMedical Colleges with 300 bedded Hospitals at Palamu, Chaibasa,Dumka, Hazaribagh and Ranchi planned by the government issurprising as a large unserved area in and around Simdega has notfigured in the plan. Good hospitals should also be developed in the gapareas like Simdega and Daltonganj as the distance of good hospitalslocated at Ranchi are more than 100 kms. These centres can servelarge area. Modern GeoInformatics tools and techniques should beutilized for planning, management, monitoring and assessment so thattimely decision and provision can be made available at the time ofemergency or regular requirements. In this direction, IntegratedHealth Management System (Baraik, 2003) should be of a great value.These are helpful as Quick Decision Support System (QDSS) inplanning, management and monitoring. Telemedicine may be anotherway to provide super-specialized health care facility in the various partsof the State, if implemented effectively.

Looking at the existing infrastructure and manpower, facilities,strength, extensions of service centres along with access may solvemany associated problems. However, policy should be very carefullyframed and adopted due to specific regional and socio-economiccharacteristics in the State.

As land utilization pattern of 2012-13 suggests, land undercurrent fallow is roughly equal to the net sown area. The Net SownArea (NSA) is 17.6 per cent whereas the total fallow along with cultivablewaste land is 31.1 per cent. In addition to this, culturable waste land

Health Attainments and Challenges in Jharkhand 7593

accounts for 4.4 per cent. The cropping intensity is only 117.86 percent. By better agricultural practices food, nutrition and health maybe addressed significantly.

The Report “Transforming Jharkhand, The Agenda for Action”for the planning of Jharkhand recommends the privatisation of ruralhealth, which will be a big disaster as private service providers workwith profit making motive. As the State has very high poverty level inthe rural area, hardly any private player would be willing to operate.In such case the rural population will be again left helpless on theirown fate in the absence of government and private health care providers.Even if some private health care providers come up, affordability willbe a major issue. It is urban centric and elite recommendation.Health is not uni-dimensional, and is a result of the overall developmentof a society. It cannot be seen independent of socio-cultural factors,economic factors like employment and occupation, income generationand affordability, political factors, literacy and educational level, healthawareness, access to food and nutrition, quality of housing, source ofdrinking water, sanitation and hygiene, lifestyle, health policy,programmes and implementation, etc. All these factors are interlinkedand interwoven when matter of influence on health comes. Example isdrastic reduction in IMR with high level of under nutrition amongchildren. Therefore, the whole concept of health and disease should belooked into with a holistic and integrated approach in a larger contextthan just health and disease. It should be integrated with education,employment and income, agriculture and food productivity andavailability, infrastructure and amenities including safe drinking waterand sanitation to overcome the major barriers – physical, social,financial and ignorance.

Since there is high demand and no more taboo or imposition ofmodern health care, it is a challenge to provide accessible, affordableand quality universal preventive and curative health care services ofall kinds to the people as the NRHM envisaged in 12th plan. Now allwant to witness the success. A new and lot more result oriented,informed, pro-active and participatory society is seen ahead creatingdemands for quality and accessible health care services!

REFERENCES

Baraik, V. K. (2002). Socio-economic development and changing health conditionsamong the Scheduled Tribes of Chhotanagpur. New Delhi: Centre for theStudy of Regional Development, JNU (PhD Thesis).

Department of Health, Medical Education, Research and Family Welfare (2012).Draft of 12th Five Year Plan (2012-17) and Annual Plan (2012-13). Ranchi:Govt. of Jharkhand. Retrieved from http://jharkhand.gov.in/New_Depts/healt/Final%2012%20five%20year%20plan%20final%20%2031.03.12.pdf)

7594 Baraik

Government of India.(2016). Agriculture-Statistical Year Book India 2016.Ministry of Statistics and Programme Implementation, Govt. of India.Retrieved from http://www.mospi.gov.in/statistical-year-book-india/2016/177

State wise Infant Mortality Rate(IMR) of India from 1971 to 2012. Ministry ofHealth and Family Welfare, New Delhi. Retrieved from https://data.gov.in/resources/state-wise-infant-mortality-rateimr-india-1971-2012.

Government of Jharkhand. (2010). Annual Plan 2009-10. Department of Health,Family Welfare, Medical Education & Research. Retrieved from http://documents.gov.in/JH/12893.pdf

Review by Chief Secretary 11.07.2013. Ranchi: Department of Health, MedicalEducation & Family Welfare, Govt. of Jharkhand. Retrieved from http://jrhms.jharkhand.gov.in/FileUploaded%20By%20User/Final%20CS%20ReviewHealth%20%20PPT%20% 2011.07.2013.pdf

Government of India, Ministry of Health and Family Welfare. (2008). Nationalfamily health survey (NFHS-3), India, 2005-08, Jharkhand. Mumbai: IIPS.Retrieved from file:///C:/Users/Welcome/Downloads/Jharkhand_report.pdf

Government of India, Ministry of Health and Family Welfare. (2017). Nationalfamily health survey (NFHS-4), 2015-16. State fact sheet, Jharkhand.Mumbai: IIPS. Retrieved from http://rchiips.org/nfhs/pdf/NFHS4/JH_FactSheet.pdf

Government of India, Ministry of Health and Family Welfare. (2010). DistrictLevel Household and Facility Survey (DLHS-3), 2007-08, Fact sheet,Jharkhand. Mumbai: IIPS. Retrieved from http://rchiips.org/pdf/rch3/state/Jharkhand.pdf

Government of India, (2010). 4th Common Review Mission (Dec. 16-22), Jharkhand.National Rural Health Mission, Ministry of Health and Family Welfare.Retrieved from http://nhm.gov.in/images/pdf/monitoring/crm/4th-crm/report/jharkhand.pdf

Government of Jharkhand. (2017). Jharkhand Economic Survey 2016-17.Planning-cum-finance Department, Finance Division. Retrieved fromh t t p s : / / f i n a n c e - j h a r k h a n d . g o v . i n / p d f / b u d g e t 2 0 1 7 _ 1 8 /JHARKHAND_ECONOMIC_SURVEY_2016_17_FINAL.pdf

Government of Jharkhand, 12th Five Year Plan. (2012-17). State Annual Plan2012-13. Retrieved from http://planningcommission.nic.in/plans/stateplan/Presentations12_13/jharkhand12_13.pdf

Government of India. (2009). Jharkhand Fact Sheet 2009, Coverage EvaluationSurvey. New Delhi: UNICEF and NIHFW. Retrieved from file:///C:/Users/Welcome/Downloads/Jharkhand.pdf

Ivern, F. (1969). Chotanagpur survey. New Delhi: Indian Social Institute.RGI. (2001). Census of India, 2001. New Delhi: Govt. of India.RGI. (2011). Census of India 2011, Jharkhand, Household Tables. New Delhi:

Govt. of India.RGI. (2011). Census of India 2011, Jharkhand, Village Directory. New Delhi:

RGI.RGI. (2013). Annual Health Survey Bulletin 2011-12, Jharkhand. New Delhi:

Govt. of India.RGI. (2013). SRS Bulletin (Sample Registration System), Vol. 48, No. 2. New

Delhi: Govt. of India.Sinha, S. (2002). Health status and health care among tribals: The case of

Jharkhand. In S. Prasad & S. Sathyamala (Eds.), Securing Health for All:Dimensions and Challenges (pp.- 380-398). New Delhi: Institute for HumanDevelopment.

Health Attainments and Challenges in Jharkhand 7595