Tamil Nadu 2003 - of Planning Commission

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DEMOGRAPHY, HEALTH AND NUTRITION ✦ 63 In Tamil Nadu, the private sector accounted for 75 per cent and 72 per cent, respectively of total outpatient care in 1995–6 in rural and urban areas. The corresponding percentages for inpatient care were 58.9 per cent and 64.3 per cent as against the all-India figures of 54.7 per cent and 56.9 per cent. There are only four States—Punjab, Karnataka, Maharashtra and Bihar—in which the proportion of private provision of inpatient care to total in urban areas is higher than that in Tamil Nadu. The private sector in the health sector is far from homogenous. The private corporate sector in health is numerically small but enormously influential in setting trends and standards as well as the terms of reference on issues such as quality. The corporate private health care institutions—including super-specialty hospitals— are largely located in metropolitan and other big cities. What is emerging with the rapid growth of the ‘for-profit’ sector in health care, and of corporate health care enterprises in particular, is a high degree of commercialization of health care as well as systemic dualism. The rich, and in emulation, the not-so-rich, seek and obtain expensive private health care at reputedly world class institutions, while the poor who cannot afford such care go the public sector health institutions, low cost private providers of uncertain quality or sometimes avoid seeking any type of treatment. Despite competition from the private sector, costs have gone up rapidly in both public and private hospitals. The average expenditure on hospitalization per episode of illness has gone up very sharply in the public sector, from Rs 320 to Rs 2080 in rural areas and Rs 385 to Rs 2195 in urban areas at the all-India level. The average cost per hospitalization has also risen sharply in the private sector over this period but the ratio of cost of private care to that of public care has come down from 2.29 and 3.13 to 2.07 and 2.43 in rural and urban areas, respectively. In the case of outpatient care, the cost of care at private facilities has risen more rapidly than that at public facilities. The private–public cost ratios for outpatient care rose from 1.05 and 1.08 in 1986–7 to 1.44 and 1.20 in 1995– 6 for rural and urban areas, respectively. On the whole, cost per hospitalization rose by 132 per cent in rural areas and 146 per cent in urban areas, that is, it more than doubled. While the private sector has played an important role in providing better services, this has led to increased inequality in access to health. This has had a caste dimension as well. Scheduled castes and tribes report poorer health outcomes than the non-SC/ST population. This is because most SCs and STs do not have access to private medical facilities because of the prohibitive cost. The issue of equity in health raises complex questions and needs to be addressed in a multidimensional manner, keeping in mind the dimensions of class, caste, gender and subregions within the State. Apart from the issue of equity that this sort of dualism in access to health care raises, there is also the issue of regulation. The private sector in health has remained largely unregulated even while subsidies to private corporate hospitals have grown. It is widely recognized that there is little standardization of quality or costs of care in the private sector. Special Programmes to Reduce Morbidity With regard to overall morbidity, the NCAER survey found that Tamil Nadu reported a lower morbidity prevalence rate than India in both rural and urban areas in 1993, the figures being 78.5 per 1000 rural (India: 106.7) and 75.7 per 1000 urban (India: 103). In line with the all-India pattern, the rate of prevalence of chronic illness was relatively higher in rural areas. Serious communicable diseases such as typhoid, malaria, chicken pox, cholera, acute gastroenteritis, jaundice, measles, mumps and tuberculosis (TB) accounted for around 12 and 14 per cent, respectively of reported rural and urban morbidity in Tamil Nadu in 1993, not very different from the corresponding all-India percentages of 14.5 and 13.3 per cent. The NCAER survey data suggest that morbidity prevalence rates decline as income increases, in both rural and urban areas. In particular, acute illnesses and serious communicable diseases occur more frequently among low income groups.
64 ✦ T AMIL NADU HUMAN DEVELOPMENT REPORT AIDS Control The first case of HIV in India was reported in Tamil Nadu in 1986. Since then, a number of measures have been taken to address the issue of AIDS control. Tamil Nadu was the first State in the country to form a State-level AIDS Control Society to implement the programme in a fast track mode in partnership with non-government organizations (NGOs), community-based oganizations (CBOs), the private sector as well as national and international agencies. All 29 districts of the State have reported AIDS cases. It is estimated that there could be 300,000–350,000 HIV positive cases. A major thrust in Tamil Nadu in tackling the AIDS epidemic has been in the area of IEC. Other elements of the strategy to control AIDS include: modernization of blood banks and promotion of voluntary blood donation; control of sexually transmitted diseases; interventions focused on high risk groups; surveillance; and training of health system personnel. Two major agencies in the State involved in the area of sexually transmitted disease (STD)/HIV/AIDS prevention and control are: the State AIDS Control Society and the APAC, administrated by the Voluntary Health Service (VHS) with funding from United States Agency for International Development (USAID). Both work in close collaboration with NGOs. The components of the programmes of intervention include development and use of IEC materials, behaviour change communication, increased quality of STD care services, training clinical and non-clinical personnel counselling for STD/HIV/AIDS patients, partner treatment, condom promotion etc. However, despite greater knowledge related to STD and HIV among respondents, the perception of risk remains relatively low. Malaria Control The National Malaria Control Programme (NMCP) was launched in Tamil Nadu in 1953. Following its perceived success, the National Malaria Eradication Programme (NMEP) was launched in 1958–9. Initial optimism that malaria could be completely eradicated was belied by the resurgence of malaria during the mid-1960s. A modified plan of operation seeking to control rather than eradicate malaria was introduced in 1977. It sought to integrate malaria control with primary health care rather than treat it as a separate wing of the Directorate of Public Health, with field activities also remaining outside the purview of the PHCs. Areas have been classified as epidemicprone areas, tribal areas with malarial problems, and urban areas with malarial problems. Another classification is that of urban malaria, coastal malaria and riverine malaria. An analysis of the incidence of malaria in the State shows that malaria remains an urban problem. While the incidence of total malaria cases has come down from around 100,000 cases in 1992–3 to around 35000 cases in 2002, the share of urban malaria cases has gone up from 65 per cent to 84 per cent during the same period. Of the total malaria cases reported in the State, the share of Chennai has gone up from 48 per cent in 1992 to 79 per cent in 2002. Since the malaria mosquito breeds in fresh water, a campaign to cover overhead tanks with tight-fitting lids could yield a breakthrough in Chennai and other cities and towns. Simultaneously, vector control through anti-larva work, active surveillance by door to door visits and treatment, and educating private practitioners are needed to tackle the problem. Leprosy Eradication The National Leprosy Eradication Programme (NLEP) was launched in 1994–5. With the introduction of multidrug therapy in 1981, there has been a remarkable improvement in the treatment and recovery of leprosy patients. In Tamil Nadu, the prevalence rate has been brought down rapidly from 118 per 10,000 population in 1983 to a mere 2.2 in 2002. Taking into account the changes in trends and profile of leprosy, the State government decided to integrate leprosy services into general health services. Leprosy curative services are now available in all PHCs, corporations, municipal hospitals and government dispensaries. The programme components
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Tamil Nadu Human Development Report
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Contents List of Boxes v List of Fi
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List of Boxes 1.1—Education in Ea
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List of Tables 1.1—Basic Demograp
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List of Appendix Tables A1—Index
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Foreword Chapter 1 I have pleasure
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xiv ✦ A CKNOWLEDGEMENTS The exerc
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KAMALUDDIN AHMED ‚ŒSÿ ÿÙ¡Ÿ
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Introduction ‘Human Development i
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TAMIL NADU—A PROFILE ✦ 1 Chapte
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TAMIL NADU—A PROFILE ✦ 3 popula
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6 ✦ T AMIL NADU HUMAN DEVELOPMENT
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8 ✦ T AMIL NADU HUMAN DEVELOPMENT
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10 ✦ T AMIL NADU HUMAN DEVELOPMEN
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12 ✦ T AMIL NADU HUMAN DEVELOPMEN
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Appendix Tables
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A4.2—HEALTH PROFILE—TAMIL NADU
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