4.

HIMACHAL PRADESH
I. BACKGROUND SUMMARY especially the rural population constitutes about 91% of the total population. II. HEALTH INFRASTRUCTURE

Himachal Pradesh is a hilly state located in the north- west of the country (Himalayas). The land with wide variations in altitudes ranging from low hills to high mountains with lakes and flowing rivers. Himachal Pradesh came into being as Union Territory on 15.04.1948 with the integration of 30 princely states. in 1966 with reorganization of Punjab, some districts were merged in Himachal Pradesh. It was granted full statehood on 25.01.1971. The state is having 12 districts with a population of 51,70, 877 (1991 census). The density of population is 93 persons per sq.km. The state has an area of 55, 673 sq.km., 10.54% of the Himalayan land. Majority (91.3) of the population is in rural areas. About half the area is covered under tribal belt with just 2.2 lakhs population. The sex ratio is 976 females per 1000 males (as per 1991 census) NFHS-2 has estimated the sex ratio for the state at 1013 in 1998-99. In contrast to all-India, the sex ratio has been steadily increasing. Out of 16,997 villages, only 7,522(44.5%) villages have metalled road connection (7394 kms). Rail communication is a few kms. only. Out of a total of 45, 367 habitations, 26,730 are fully covered and 14,047 are partly covered with piped drinking water. 100% electrification of villages has been achieved, 98% households are electrified. Under central rural sanitation programme 401,331 latrines have been constructed. The total literacy of the state is 63.86% (75.36% male, 52.13% female) 1991 census. Percapita income of Rs. 14,682 in 1998-99. Himachal Pradesh is one of the three leading states in India on the basis of 4 indicators. 1) LIfe expectancy 2) Literacy rate 3) Sex Ratio 4) Lower BPL % age. Based upon sex ratio, female literacy and life expectancy women are favourably placed in the State. Due to the large rural population and hostile geographic and weather conditions, the State is still backward and poor in terms of economy. As per survey in 1998-99 out of 10,36, 996 house-holds in the rural area, 286,112 are below poverty line which is 27.59% of the total households. Population Growth: Population of the state which was 2.8 million in 1961 had grown to 5.1 million in 1991. It has almost doubled in 30 years time. Though the achievement of the State in containing population has been commendable in terms of decrease in CBR, TFR and increase in CPR as compared to many other states. Yet rural CBR 22.9, TFR 2.18 is still high

The state has fairly extensive network of health institutions. Table 1: shows health institutions. District CHs CHCs PHCs CDs ISM Instn SCs Bilaspur 2 5 17 11 67 110 Chamba 4 7 28 11 102 161 Hamirpur 2 5 17 6 72 150 Kangra 8 12 50 34 223 447 Kinnaur 2 3 17 0 44 34 Kullu 1 3 14 5 65 99 L & Speti 1 3 9 5 24 32 Mandi 6 9 44 13 165 300 Shimla 9 6 47 30 149 241 Sirmaur 5 3 24 14 82 143 Solan 5 3 20 17 78 172 Una 2 3 12 9 73 125 Total 8 65 302 167 1153 2069 In addition to the above there are 2 teaching hospitals, 2 Leprosy hospitals, 2 Tuberculosis hospitals, 2 medical colleges, 3 dental colleges, civil dispensaries, run by different departments, police, university boards, projects like NTPC, BSL, Central Government organizations, Semi Government Organization total bed capacity 8747. Indian system of medicine: The state has shown keen interest in promoting the Indian system of medicine specially Ayurveda. The ISM institutions as on 1.1.2000 were 1) Ayurvedic college 1, 2) Ayurvedic Hospitals 22, 3) Ayurvedic dispensaries 1109, 4) Unani dispensaries 3, 5) Homeopathic dispensaries 14, 6) Pancha Karma units 2, 7) Amchi Clinic 4. Total 1153. The total bed capacity in the Department is 410. Private Sector: Large number of private clinics, nursing homes, have come up mainly in Shimla and other district towns. Private hospitals set up at sub divisional levels. Total bed capacity about 500 NGO and voluntary sector is not providing any curative services in the state so far, one free charitable hospital at Hamirpur is set up.

33

Table 2: shows distance from health facility (nearest) Distance in km. Health Facility Source NFHS-1 Distance Sub PHC PHC or Hospital Dispensary Any Centre sub centre clinic health facility Within Village 14.9 3.3 17.8 14.5 28.8 Less than 5 kms 44.5 23.4 51.6 51.1 55.7 5 to 9 kms 17.6 35.5 22.0 18.8 21.7 14.2 10 kms 13.5 38.6 8.4 63.3 10.6 1.3 Median 3.5 6.9 2.9 15.9 3.5 2.2 According to the figures available as on June 2000, maximum radial distance covered by a sub centre, PHC and CHC are 2.93, 7.66 and 16.51 kms respectively. Average rural population covered by health institution is 1) subcentre 2698, 2) PHC 18485 3) CHC 85883. Table 3: Staff Position Staff Position Source Department Sl. No. Category Sanctioned Position Vacant 1. Medical officers 1498 1369 129 2. Staff Nurses 1427 1107 320 3. Female Health Workers 2210 1974 236 4. Male Health Workers 2011 1594 417 5. Sr. Lab Technicians 612 457 155 6. Lab Assistants 169 115 54 7. Pharmacists 857 684 173 8. Chief Pharmacists 80 73 7 9. Radio Grapher 183 143 40 10. Ophthalmic Assistance 145 95 50 11. OTAs 95 77 18 12. Male Health Supervisors 413 385 28 13. Female Health Supervisors 350 385 20 There are many vacancies of medical officers, staff nurses, health workers male and female, technicians and pharmacists.

34

III.

HEALTH SERVICES PROFILE

From table-4 it is observed that communicable diseases are still responsible for dominant morbidity in the state. i) Communicable diseases: Himachal Pradesh population suffers from 3 major groups of communicable diseases 1) Respiratory problem bronchitis, Tuberculosis, ARI 2) Water and Food borne diseases. Diarrhoea, dysentery, amoebiosis, worm infestation, hepatitis, entrifever 3) contact diseases such as skin diseases, RTI, STDS including HIV/AIDS. A. Tuberculosis: Remains the major killer in the state. The existing data reveals that every year about 2000 are likely to suffer from the disease. In 1999-2000, 14463 new cases were detected. The state launched the revised tuberculosis control programme in 3 districts (Kangra, Mandi and Hamirpur) in 1998 followed by 3 more districts in 1999. The rest of 6 districts would be covered in 2000. In this way majority of tuberculosis cases would be detected at the earliest and given very effective short term supervised treatment. B. Leprosy: The problem of Leprosy was quite high in the state. As per 1971 data the prevalence rate was 26 per 1000 population consequent on the successful implementation of programme the prevalence rate has been reduced to less than 1 per 10000 (0.47/10000 as on March 2000) with the successful conduct of M-LEC in the state the disease is likely to be eliminated soon. C. Malaria: The number of Malaria cases has been declining in the state in the past few years API which was 1.5 in 1985 has declined to 0.1 in 1999. P F malaria cases were 4 in 1997, 1 in 1998 and 6 in 1999. The problem of malignant malaria is negligible. D. Diarrhoea: is responsible for a large number of infant deaths. NFHS-2 has estimated as 31% among children under age 3 years. The prevalence of parasitic infection in children below 14 years was at 13.8%. E. RTI/STDs: The problem of RTI/STD is also quite high in the state. Study carried out in Hamirpur district in March 1997 revealed STDs prevalence through syndromic diagnosis as 23.9% and by etiological diagnosis as 3%. The prevalence is higher in women, overall prevalence of RTI, STD is quite high which calls for intensive efforts in managing the diseases at all levels. F. HIV-AIDS: Himachal Pradesh is also affected with HIV-AIDS epidemic. As on 03.09.2000 out of 25935
35

persons screened 254 were found as HIV positive which includes 82 AIDS cases. Over 82% of these cases are from Hamirpur, Kangra, Shimla, Bilaspur and Mandi district. On the basis of HIV sentinel surveillance data collected in 1999 it is estimated that there might be around 3500-4000 HIV positive cases in the state. ii) Non Communicable diseases:

A. Prevention of Blindness: The programme was launched in the state in 1977-78. The objective is to reduce the prevalence of blindness to 0.3% . In the year 1999-2000 a total of 180 eye camps were organized in which 217397 patients were examined for various types of eye ailments and 14318 patients were operated for cataract. The current state target per year is 24000 cataract operations which is based on the prevailing blindness rate and backlog. The state has to reduce the backlog to achieve the objective. The number of cataract cases per year to less than 18000. IV. NUTRITIONAL PROBLEMS

As per nutritional survey conducted by women and social welfare department, Government of India covered 10 districts of state. 0.5% of infants were found to be suffering from Marasmus. 81% of children suffered from mild to moderate malnutrition and 4% from severe degree of malnutrition. 8% of adults suffered from chronic energy deficiency. Goitre was the major nutritional deficiency disorder 2-13% in various groups. Delayed weaning in more than 85% of children and very low exclusive breast feeding among new born 36%. As per NFHS-2, 40% women and 67% children are suffering from anaemia, which is high and warrants focussed attention. V. IODINE DEFICIENCY

Being a sub Himalayan belt Goitre is still a nutritional deficiency disorder. Prevalence of Goitre was high up to 1974. (una 41.2%, Solan 39.9% in 1959 and Shimla 41.6% in 1974) has come down to 2-13% in 1996 for various age groups. As per survey carried out by women and social welfare department prevalence of Goiter in Chamba was 14.25% in 1999. During 19992000, 117699 samples of salt were analysed out of which only 78 samples were found to be without Iodine. VI. REPRODUCTIVE AND CHILD HEALTH PROGRAMME

Family Planing: Providing contraceptive services, resulting in adoption of small family norm by a large number of families is being given by required emphasis under RCH. The state has performed creditably well

Table 4: shows morbidity profile (source MIS of depart) SlNo. Diseases New Cases Cases Total Percent 1. Acute Bronchitis 337915 5118 343033 17.18 2. Anaemia 312070 3695 314765 15.81 3. Chronic Bronchitis 230620 6345 236965 11.86 4. Dental diseases 223139 119 223258 11.18 5. Gastro-entritis 183301 11361 194662 9.75 6. Skin diseases 188610 1901 190511 9.54 7. Tonsil adenoids 129536 13788 143224 7.17 8. Wound Injuries 130153 2581 132734 6.64 9. Intestinal infections 102504 2976 110480 5.53 10. Amoebiasis 102785 3180 105965 5.25 Total 1945633 51064 1996697 100.0 Table 5: shows current and future health indicators for Himachal Pradesh. Indicator Current Likely achievements level 2000 AD 2005 2010 2015 2020 IMR 64(1998) 60 30 20 15 CDR 7.7(1997) 7.5 7.0 6.5 6.0 Child Mortality rate 14.1 10.0 8 6 5 MMR 408(1992) 300 100 75 50 Life Expectancy at Birth 64.6(1995) 65 70 75 78 Babies with Low birth weight 30% 25 20 15 10 CBR 22.6(1997) 21 19 17 15 ECPR 54% 60 70 75 80 TFR 2.14(1998) 2.10 2 1.8 1.5 Antenatal Care 70% 80% 90% 100% 100% Deliveries for trained attendant 78%(1997) 90 100 100 100 Institutional deliveries 29%(1998) 45 55 70 80 Growth Rate 1.48% 1.35 1.2 1.1 <1 Table 6: Child Health Indicators Indicator NFHS-1 (1992-93) NFHS-2 (1998-99) IMR 56 34 NMR 34.2 22.1 PNMR 21.7 12.3 CMR 14.1 8 US MR 69.1 42

36

as CBR has fallen to 22.5 per 1000 and TFR has come down to 2.14 (NFHS-2) couples using family planning methods has increased to more than 60%. Acceptance of male sterilization is high as compared to rest of the country. Average age at marriage for girls has risen to 20. 5 years which has contributed significantly in controlling fertility. Fertility reveals sharp peak in the age group of 20-24 and a sharp decline beyond the age of 25 years (NFHS-2). Home visits by Health worker 11% were for family planning, 51% for health and 1% were for health and family planning. 98% felt that enough time was spent with them. Quality of service: All had received the service for which they had gone. Waiting time was about 15 minutes. 80% reported that staff talked to them nicely, 89% felt that the staff respected their need for privacy, 59% rated the health facility as very clean while 41% it is some what clean. Maternal Care: The performance in the state according to NFHS-2. Institutional deliveries were 29% (80% in Government and 20% others) 71% non institutional deliveries. Only 16% were attended by doctors or by other health professionals, 80% were attended by TBAs and 4% by others. 66% received 2 tetanus toxoid injection. 86% received IFA tablets, 7% received IFA course for 3 months. 78% of births received one antenatal check up. 60% of women were found to be having normal Hemoglobin, more than 11 grams or higher. 31% were mildly anaemic, 8% moderately anaemic, 1% were severely anaemic. Antenal Care in the form of check ups was provided to 92% of pregnant women. Status of maternal care is judged by MMR and IMR. The MMR is 408/one Lakh births (as per 1992) and IMR is 64 (1998). Child Care: The child care is measured by two indicators. IMR and CMR. Table 6 shows various child indicators. Going by SRS estimate the state IMR is less than that of the country (72). The state IMR remained static at 63 for the past 5 years and shown upward trend in 1998 i.e. 64. Immunization: NFHS-2 data Immunization coverage in the state has been high more than 90% coverage ever since UIP was launched in 1985. The state is free from Polio. Incidence of other vaccine preventable diseases is negligible except tuberculosis in children. The survey estimate that only 3% children remained uncovered in the state. 83% received all antigens vaccine specific coverages are 95% BCG, 89% polio and 89% DPT, 89% for measles. Fair amount of drop outs have been reported for polio and DPT.

Exclusive breast feeding is low 36% but is on the rise. Breast feeding however at later periods is almost universal 98.5%. Status of Health: Is measured mainly 3 types of indicators (1) such as life expectancy crude death rate and infant mortality rate (2) Demographic indicators such as crude birth rate, total fertility rate, and general fertility rate (3) Socio economic indicators such as population below poverty line, literacy rate and sex ratio. Life expectancy: Himachal Pradesh has achieved an increase in life expectancy for both the sexes as shown in the table 7. Life expectancy at birth in Himachal Pradesh is much higher as compared to that of the country. Crude death rate: CDR has been declining since 1980 10.4 in 1980, 8.4 in 1990 and 7.7 in 1997 (SRS estimate). Lower than national average indicate improved health status of Himachal Pradesh. Infant Mortality Rate: IMR of the state which was 118 in 1971 as against 129 of the country has declined to 64 in 1998. This figure is below the national average, and it is indicative of improvement in medical care, better nutrition and better obstetric care. Crude Birth Rate: The state has achieved success in bringing down the CBR from 37. per 1000 in 1971 as against 36.9 of the country to 22.6 in 1998 as per SRS data which is close to HFA goal of 21. CBR of the country is 27.2 which is much higher than that of the state. General fertility rate: The GFR of the state was 129.2 in 1982. Since then it gradually declined to 110.7 in 1989 and to 109.3 in 1992 (SRS). Total Fertility Rate: NFHS-2 estimated the TFR at 2.14 children per woman (Rural 2.18 and urban 1.74). This is quite close to the replacement level of TFR 2.1 which the country plans to achieve by the year 2010 under National Population Policy 2000. Urban TFR is already below the replacement level. VII. SOCIO-ECONOMIC POPULATION BELOW POVERTY LINE Urban Areas: Statistical Department of HP found that 12.1% of urban households were below poverty line. The poverty line was calculated at Rs 1200 PA (in 1998).
37

Table 7: Life expectancy at Birth Himachal Pradesh India Period Male Female Male Female 1970-75 54.8 50.9 50.5 49.0 1976-80 58.1 54.9 52.5 52.1 1981-85 58.5 62.9 55.9 55.9 1986-90 62.4 62.8 57.7 58.1 1991-95 64.6 65.2 62.4 62.8 Table 8: Poverty line Year Total Households BPL households % of households BPL 1994 969980 258859 26.69 1998-99 1036996 286112 27.59 Per capita income of the state is Rs 14682 (1998-99) Table 9: shows RHI of India and Northern States (1993) % Birth of % Birth % Medical Female State TFR IMR higher interval attention at literacy RHI order 4+ 36+ Birth rate India 3.4 74 23.5 32 24.45 38.57 42.21 H.P 2.8 63 13.1 21 24.70 52.19 50.94 Punjab 3.0 55 17.3 23.2 89.40 32.22 50.09 Haryana 3.7 63 13.1 20.6 64.70 37.45 41.98 Table 10: Types of Antenatal Care Indicators by State 98-99 Percentage % that % that received % that received % given % received that received received three antenatal check two or more any Iron supply of Iron State at least one or more up in the first tetanus toxoid and folic and folic acid antenatal antenatal trimester of injections acid tabs tabs for 3 + check up check ups pregnancy or syrup months India 65.4 43.8 33.0 66.8 57.6 47.5 Himachal 86.8 60.9 48.2 66.2 85.6 70.9 Rajasthan 47.5 22.9 19.2 52.1 39.3 30.6 Bihar 36.3 17.8 15.1 57.8 24.1 19.8 Goa 99.0 96.7 73.4 86.1 94.7 87.8 Kerala 98.8 98.3 81.1 86.4 96.2 88.6

38

Rural Area: Two surveys conducted by Rural Development Department, Himachal Pradesh in 1994 and 98-99 reveal the poverty line in Table 8. Sex Ratio: The sex ratio is 976 per 1000 males in 1991 census. NFHS-2 has estimated at 1013 in 98-99. The sex ratio is steadily increasing. Literacy: Total literacy is 63.86% in 1991. As per NSSO estimate, in 1997 jumped to 77% (87% male and 70% female) Reproductive Health Index: Himachal Pradesh is the leading State in Northern India with regard to quality of reproductive health. However, it is far behind Kerala with RHI at 84.6 followed by Tamil Nadu with RHI 63.6.
VIII. MATERNAL AND REPRODUCTIVE HEALTH

pregnant women motivating them to obtain antenatal and post-natal care, assessing their health throughout pregnancy and in the post partum period and referring women with high risk pregnancies. The ANM and LHV also assist the medical officer at the PHC. Where health services including antenatal, postnatal care are provided. The aim is that 80% of all deliveries should take place in institutions. 100% deliveries should be attended by trained health personnel. MMR should be reduced to a level of less than 100 per 100,000 live births. Table 10 shows antenatal care by State. Kerala ranks in the top in the country in terms of performance on all six indicators. 99% births received at least one antenatal check up. 98.3% received three or more antenatal check ups. Himachal Pradesh performance is 86.8% antenatal check up atleast once, and 60.9% pregnancies three or more time checkup. The national average is 65.4% and 43.8% respectively. Himachal Pradesh performance is well above the national average. Rajasthan and Bihar performance is very poor with 47.5% and 36.3% respectively. Kerala performed well in tetanus toxoid injections and supply of Iron and folic acid tablets with 86.4% and 96.2% respectively. Himachal Pradesh performance is TT injections 66.2% and Iron folic acid tabs supply is 85.6% which is equal with the national average in TT injections and better performance than the national average in supply of Iron and folic acid tablets. Rajasthan and Bihar show performance in all the indicators. very poor

In 1996 safe motherhood and child health services were incorporated into the RCH and fertility regulation interventions with reproductive health programme. The important elements of the programme are: 1) provision of antenatal care including atleast three antenatal visits. Iron prophylaxis for antenatal and lactating mothers, two doses of tetanus toxoid vaccine detection and treatment of anaemia in mothers, management and referral of high risk pregnancies. 2) Encouragement of institutional deliveries or home deliveries assisted by health trained personnel. 3) provision of postnatal care including at least three postnatal visits. 4) Identification and management of reproductive tract and sexually transmitted infections. In rural areas Government delivers reproductive and other health services through its network of PHCs and subcentres and other Government facilities. In addition, pregnant women and children can obtain services from private maternity homes, hospitals, and NGOs. In urban areas reproductive health services are available through Government or municipal hospitals, nursing homes operated by NGOs and private nursing homes. In rural areas health worker (F) or ANM is posted at sub-centre to provide basic maternal health, child health and family welfare services to women and children, either in their homes or in the subcentre. Her work is over seen by LHV posted at PHC. The ANM is responsible for registering
39

Table 11 shows the Maternal care assistance during delivery. For India, average mothers of only 20% of births received all of the required components of antenatal care, where as in Himachal Pradesh 30.2% of births received all the required components of antenatal care which is just above the national average. Three indicators show a high of 64.9%, 93.0%, 94.0% in Kerala. In Himachal Pradesh only one indicator 30.2% is above national average of 20.0%. The other indicators are below the national average. Rajasthan and Bihar performance is very poor in all the indicators. In Kerala two indicators deliveries in medical institutions and deliveries assisted by health professionals i.e. 93.0% and 94.0% is highest in the country. In Himachal Pradesh (deliveries) births delivered in Medical institutions is poor and below the national average performance. The percentage of deliveries assisted by health professionals is increased in every state.

Maternal Care indicators for births during the three years preceding the survey by state India 1998-99 % who received % of births % of deliveries % of non % of non all recommended delivered in assisted by a institutional institutional State types of ante a Medical health deliveries with deliveries with natal care institution professional a postpartum a postpartum checkup within check up within 2 months of birth 2 days of birth India 20.0 33.6 42.3 16.5 2.3 Himachal P. 30.2 28.9 40.2 21.2 2.9 Rajasthan 8.3 21.5 35.8 6.4 0.5 Bihar 6.4 14.6 23.4 10.0 1.4 Goa 60.6 90.8 90.8 41.0 6.9 Kerala 64.9 93.0 94.0 27.4 7.5 Percentage of currently married women reporting various symptoms of RTI reproductive tract infections by state 98-99 % with any % with the % with only % with % with % with any abnormal symptoms abnormal painful bleeding reproduction State vaginal of a urinary vaginal intercourse after inter health discharge tract infection discharge often course ever problem or symptoms of UTI India 30.0 17.8 35.9 12.5 2.3 39.2 Himachal 26.5 14.3 30.8 8.6 0.7 33.7 J&K 50.5 31.0 56.5 21.7 2.3 60.5 Meghalaya 64.2 24.5 66.2 20.2 3.6 66.9 Andhra Pradesh 38.2 18.8 44.0 16.9 2.9 48.5 Karnataka 13.5 7.2 17.7 2.7 0.3 18.8 Table 13: Shows the quality of care indicators for home visits by the health worker Quality of care indicators for home visits State % with no % who said % who said % who discuss home visits worker spent worker talked FP during enough time them nicely home visit India 87.0 89.5 78.4 14.5 Rajasthan 88.2 95.5 56.0 22.0 Bihar 97.6 85.3 68.2 20.8 HimachalPradesh 96.3 91.5 75.9 17.8 Kerala 82.0 97.3 97.8 12.2 Orissa 91 84.8 73.4 12.2 Table 12:

Table 11:

40

Reproductive health problems: Absence of reproductive tract infections (RTIS) is essential for reproductive health of both women and men and is critical for their ability to meet their reproductive goals. RTIs can cause pregnancy related complications, congenital infections, infertility and chronic pain and a risk factor for HIV. Table 12 shows reproductive Tract infections by State. The percentage of currently married women with any abnormal vaginal discharge ranges from 13.5% in Karnataka to 64.2% in Meghalaya. Himachal Pradesh percentage is 26.5. The national average is 30.0% so Himachal Pradesh is below the national average. Jammu and Kashmir stands next to Meghalaya which is the highest in the country. The percentage of RTI ranges from 7.2% in Karnataka to 31.0% in Jammu and Kashmir. Himachal Pradesh is 14.3% which is well below the national average. The percentage of painful intercourse ranges from 2.7% in Karnataka, 21.7% in Jammu and Kashmir. Himachal Pradesh is well below the national average with 8.6%. The percentage of bleeding after intercourse ranges from 0.3% in Karnataka to 3.6% in Meghalaya. Himachal Pradesh is 0.7% below the national average of 2.3%. The prevalence of all the 4 RTI problems is in Jammu and Kashmir, Meghalaya, Andhra Pradesh, prevalence of RTI is lowest in Karnataka and Highest in Meghalaya. In summary 1/3 of ever married women in India report at least one RTI related to vaginal discharge or urination. 2/5 report at least one RTI related to vaginal discharge urinations and intercourse. The majority of women bear the problems silently without seeking advice or treatment. RTI is wide spread among all groups of women in almost all states. Women who seek advice or treatment for reproductive health problems do not usually go to Government health professionals. These findings highlight the need to educate women regarding the symptoms and consequences of reproductive health problems and the urgent need to expand counselling and reproductive health services in both rural and urban areas particularly through public sector. Quality of Health Care: Use of health care services is strongly influenced by the standard of living of the household. As the standard of living increases, use of private sector services increases. 79% of households with a high standard of living use the private medical sector compared with 63% of households with low standard of living. Even among low standard households, only 1/3 typically use public sector services for their health care. The majority of households 59% in Himachal Pradesh normally use the public sector
41

when a household member gets sick. Utilization of private sector services is much lower in Himachal Pradesh. 41% than in India as a whole 69%. The majority of households seek care from the public sector. Private doctors are the single most important source of care in Himachal Pradesh over all 5 types of health providers are used as a source of treatment by 95% of household, private doctors 31%, Government dispensaries 18%, CHC, PHC, Rural Hospitals 18%, private hospitals or clinics 10%. Urban and Rural households equally utilize the services in the public medical sector. In urban areas 51% households seek care from Government or Municipal Hospitals. In rural 20% households seek care from CHC, PHC and rural hospitals, 20% seek care from Government Dispensaries services. 14% seek care from Government or Municipal hospitals. In Himachal Pradesh 31% rural households seek care from private doctors, 25% households of urban area. The health workers are required to monitor various aspects of health of women and children provide information related to health and family welfare. Counsel and motivate women to adopt appropriate health and family welfare practices and deliver other selected services. In Himachal Pradesh 96.3% of women did not receive any home visit from a health worker or family planning worker in the past 12 months compare to the national average of 87%. In Kerala 82% women did not receive home visit. In Bihar it is 97.6% of household women not received home visit by a health or family welfare worker. In Himachal Pradesh 17.8% discussed family planning with the health worker compared to the national average of 14.5%. In Orissa it is 12.2% and below the national average. Rajasthan and Bihar are above the national average with 22.0% and 20.8% respectively. Health workers rarely discuss family planning with women during home visits. The median waiting time to receive the required services was 15 minutes in Himachal Pradesh and 10 minutes in Rajasthan. The national average is 29.1 minute. In Bihar and Kerala it is half an hour and Orissa 20 minutes. In Himachal Pradesh 59.4% report that the facility was very clean, compared to the national average of 67.1%. In Kerala 88.1% report that the facility was very clean. In Rajasthan only 39.3% report that the facility was very clean. The majority of women in Bihar, Kerala and Orissa report that the median waiting time is very long. In Rajasthan the median waiting time is less than ten minutes.

Table 14: shows quality of care indicators for facility visits. Quality of care indicators for facility visits State Median % who said % who said % who said % who rated waiting staff spent staff talked staff respect facility as time enough time to them nicely their need to very clean privacy India 29.1 94.9 72.9 78.4 67.1 Rajasthan 9.5 96.0 45.9 85.8 39.3 Bihar 29.1 90.6 70.5 76.7 66.4 Himachal 14.6 98.3 80.1 89.1 59.4 Kerala 29.8 98.1 95.2 96.5 88.1 Orissa 19.2 90.8 62.9 57.0 46.8 Table 15: Percentage of ever married women consuming specific food at least once in a week. Milk Pulses Green Other Fruits Eggs Chicken State or beans leafy vegetable meat or curd vegetables fish India 55.0 87.8 85.2 93.1 33.0 27.8 31.9 Punjab 91.1 99.2 99.1 99.5 50.7 10.8 3.6 Bihar 46.7 88.7 96.0 96.1 18.3 22.1 21.5 Maharashtra 47.3 94.5 87.9 91.1 44.7 34.4 38.2 Karnataka 75.5 98.6 93.3 91.8 53.7 39.9 33.9 HimachalPradesh 87.0 99.1 94.3 98.8 71.7 14.7 6.2 Table 16: shows nutritional status of women Height Weight for Height Mean Percentage Mean Percentage Percentage Percentage State height below body-B with BMI with BMI of with BMI of cm 145 cm mass-M below 25 kg/m2 30 kg/m2 index-I 18.5 kg/m2 or more or more India 151.2 13.2 20.3 35.8 10.6 2.2 HimachalPradesh 152.7 6.1 20.8 29.7 13.1 2.3 Rajasthan 153.7 5.6 19.9 36.1 7.1 1.6 Bihar 149.5 19.5 19.4 39.3 3.7 0.5 Karnataka 152.0 9.6 20.4 38.8 13.6 2.9

42

Nutritions and prevalence of anaemia: The consumption of wide variety of nutritious foods is important for womens health. Adequate amounts of proteins, fat, carbohydrates, vitamins and minerals are required for a well balanced diet. Meat, fish, eggs and milk as well as pulses and nuts are rich in proteins. Green leafy vegetables are rich source of Iron folic acid, vitamin C, Carotene, riboflavin and calcium. Many fruits are good source of vitamin C. Bananas are rich in carbohydrates. Papaya, Mangoes and other yellow fruits contain carotene which is converted to vitamin A. Vitamin A is also present in milk and milk products as well as egg folks. Table 15 shows food consumption by women. More than 91% of women in Punjab consume milk or curd at least once in a week. In Himachal Pradesh it is 87% of women consume milk or curd. The national average is 55%. So Himachal Pradesh is well above the national average. In Bihar and Maharashtra only 46.7% and 47.3% of women consume milk or curd. This is poor compared to Punjab and Himachal Pradesh. Pulses or beans are eaten regularly by a majority of women in every state. Green leafy vegetables and other vegetables are eaten regularly by majority of women in every state. In Himachal Pradesh they consume 94.3% and 98.8% respectively. In Himachal Pradesh chicken, meat or fish consumption is very less 6.2% which is below the national average of 31.9%. In Punjab the chicken, meat or fish eaters is only 3.6%. In Himachal Pradesh 71.7% of women consume fruits which is double the national average i.e. 33%. State differentials in the mean height of women are not large, but women in northern region are 1-3 cm taller than average. The shortest are from north eastern region. The national average is 151.2 cm. Himachal Pradesh is 152.7 cm which is higher than the national average. Obesity is least common in north-east region. In Himachal Pradesh it is 2.3% which is more than the national average of 2.2%. IX. ANAEMIA AMONG WOMEN

may also result in an increased risk of premature delivery and low birth weight. Every detection of anaemia can help to prevent complications related to pregnancy and delivery as well as child development problems in India under the Government RCH programme. Iron and folic acid tablets are provided to pregnant women in order to prevent anaemia during pregnancy. People with Anaemia are substantial in every State in India. The lowest prevalence of anaemia is found in Kerala with 22.7%. Himachal Pradesh having 40.5% anaemia. The national average is 51.8% so Himachal Pradesh prevalence is below the national average. Majority of women in 10 states and many of the north eastern states are anaemic. More than 1/4 of women suffer from moderate to severe anaemia in north eastern states, Bihar and Rajasthan. Even in Maharashtra 2.9% are severe anaemic where as in Himachal Pradesh 0.7% are severe anaemic. The national average is 1.9% severe anaemic. X. INFANT FEEDING

Proper infant feeding starting from the time of birth is important for the physical and mental development of the child. Breast feeding improves the nutritional status of children and reduces morbidity and mortality. Breast milk not only provides important nutrients but also protects the child against infection. The timing and the type of supplementary foods introduced in an infant diet also have significant effects on the child nutritional status. Under RCH programme the Government of India recommends that infants should be given only breast fed milk from birth to age four months. Most babies do not require any other foods or liquids during this period. Initiation of breast feeding immediately after child birth is important because it benefits both mother and child. Breast feeding is nearly universal in India. Only few children are put in breast immediately after birth. 16% of children began breast feeding within one hour of birth and 37% began within one day. 63% squeezed the first milk from the breast before they began breast feeding. In 20 out of 25 states, the mothers of most children squeeze the first milk from the breast before feeding. Mizoram and Tamil Nadu in which majority of children were breast fed within one hour of birth 54.6% and 50.3%. Less than 5% in Rajasthan and 6.2% in Bihar were breastfed within one hour of birth. In Himachal Pradesh 20.7% were breastfed within one hour of birth. The national average is 15.8%. So Himachal Pradesh is above the national average.
43

Anaemia usually results from a nutritional deficiency of Iron and B12 and some other nutrients. This type of anaemia is commonly referred to as Iron deficiency anaemia. Iron deficiency is the most wide spread form of malnutrition in the world affecting more than two billion people. In India anaemia affects an estimated 50% of the population. Anaemia may have detrimental effects on the health of women and children and may become an underlying cause of maternal mortality and perinatal mortality. Anaemia

Table 17: Shows anaemia among women by state Percentage of women with State with any anaemia Mild anaemia Moderate anaemia Severe anaemia India 51.8 35.0 14.8 1.9 Rajasthan 48.5 32.3 14.1 2.1 Bihar 63.4 42.9 19.0 1.5 Maharashtra 48.5 31.5 14.1 2.9 Karnataka 42.4 26.7 13.4 2.3 Himachal 40.5 31.4 8.4 0.7 Kerala 22.7 19.5 2.7 0.5 Table 18: shows breast feeding by state. Percentage started Percentage started breast Percentage whose mother State breast feeding with feeding within one day squeezed first milk from in one hour of birth after birth the breast India 15.8 37.1 62.8 Rajasthan 4.8 33.6 69.1 Bihar 6.2 20.7 42.1 Mizoram 54.0 78.2 60.7 Tamil Nadu 50.3 78.7 21.5 Himachal Pradesh 20.7 42.3 86.2 Table 19: shows nutritional status of children under three years. Weight for age Height for age Weight for height State % below % below % below % below % below % below -3 SD -2 SD -3 SD -2 SD -3 SD -2 SD India 18.0 47.0 23.0 45.5 2.8 15.5 Rajasthan 20.8 50.6 29.0 52.0 1.9 11.7 Bihar 25.5 54.4 33.6 53.7 5.5 21.0 Maharashtra 17.6 49.6 14.1 39.9 2.5 21.2 Kerala 4.7 26.9 7.3 21.9 0.7 11.1 Himachal 12.1 43.6 18.1 41.3 3.3 16.9 Table 20: Anaemia among children Percentage of Children with Sta Anaemia Mild Anaemia Moderate Anaemia Severe Anaemia India 74.3 22.9 45.9 5.4 Rajasthan 82.3 20.1 52.7 9.5 Bihar 81.3 26.9 50.3 4.1 Maharashtra 76.0 24.1 47.4 4.4 Kerala 43.9 24.4 18.9 0.5 Himachal Pradesh 69.9 28.7 39.0 2.2
44

Himachal Pradesh and Punjab were two states where 86.2% and 87.3% mothers squeeze the first milk from breast before feeding. Inadequate nutrition is a problem throughout India but the situation is better in some states. Undernutrition is most pronounced in Bihar and Rajasthan 25.5% and 20.8% respectively. In Himachal Pradesh it is 12.1%. The national average is 18% so Himachal Pradesh is less than the national average. Kerala is lowest with 4.7% and least evident. Levels of under nutrition are high in all the states. XI. ANAEMIA AMONG CHILDREN

In Himachal Pradesh it is 2.2%. In Rajasthan it is 9.5% severe anaemic children. XII. IODIZATION OF SALT Iodine is an important micronutrient. Lack of iodine in the diet can lead to Iodine deficiency disorders, which according to WHO can cause miscarriages, brain disorders, retarded psychomotor development. Iodine deficiency is the single most important and preventable cause of mental retardation world wide. Iodine deficiency can be avoided by using salt that has been fortified with iodine. Table 21 shows use of Iodized salt by State. The use of adequately iodized salt is uniformly high in north eastern states and in most states of north region. The all India average for use of iodized salt is 72%. In Himachal Pradesh it is 97% so higher than the national average. In Mizoram use of Iodized salt by households is highest (99%) in the country. In southern region use of Iodized salt ranging from 37% in Tamil Nadu to 64% in Goa. In Kerala 52.4%. It is clear that in many states the lax enforcement of salt Iodization regulations in effect at the time of NFHS -2 was thwarting efforts to eliminate Iodine deficiency disorders in India.

Anaemia is a serious concern for young children because it can result in impaired cognitive performance behavioural and motor development coordination, language development as well as increased morbidity from infection diseases one of the most vulnerable group in children age 6-24 months. Table 20 shows anaemia among children by state. Kerala is the only state where less than half of children are anaemic. The highest prevalence of anaemia is found in Rajasthan and Bihar with 82.3% and 81.3%. In Himachal Pradesh it is 69.9% which is less than the prevalence rate of National average 74.3%. Indias average severe anaemic rate is 5.4%.

REFERENCES a) b) Indian Society of Health Administrators, Strengthening Health Systems in North Eastern States,1995-96 International Institute of Population Sciences, National Family Welfare Survey, 1998-99, Mumbai, India, October 2000

Table 21: Percent distribution of households by degree of Iodization of salt according to state 199899. State Not Iodized 7PPM 15PPM 30PPM Missing Total Percent India 28.4 21.6 16.8 32.6 0.7 100.0 Rajasthan 37.1 15.3 21.9 24.4 1.3 100.0 Bihar 22.9 30.1 26.6 20.4 0.0 100.0 Maharashtra 32.0 6.9 11.0 49.1 1.0 100.0 Kerala 47.6 13.2 5.6 33.7 0.0 100.0 Himachal Pradesh. 3.2 6.2 14.9 75.6 0.1 100.0 Mizoram 0.7 8.0 27.9 63.3 0.0 100.0
45