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International Journal of Health Management and Information (IJHMI)

Volume 2, Number 2, 2011, pp. 119 131

ISSN: 2229-3108

ECONOMIC ANALYSIS OF HEALTH CARE


SERVICES: A STUDY IN TRIBAL AREAS OF
ANDHRA PRADESH - INDIA
B. Suresh Lal

ABSTRACT
The study find out that the common diseases general fever, malaria, typhoid, diarrhea, anemia and
jaundice etc are more common in tribal areas. Majority respondents are suffering from fever (35%)
followed by malaria (20%), typhoid (15%), diarrhea (12%), anemia (8%) and jaundice (10%). This
study examines majority sufferers are low and middle income group. Nearly, 40 percent sample
respondents had spent between Rs.150 to 200 per visit (consultation of the doctor and medicine) and 35
percent respondents had spent Rs.100 to 150 per visit. As a result these diseases causing heavy financial
burden for treatment and loss of employment to the tribals.
Keywords: Tribes, Healthcare, Economic burden, Communicable diseases and unhygienic conditions.

1. INTRODUCTION
After the lapse of 60 years of the Independence, still many tribes are living in poverty, ignorance,
superstitions, inadequate health and marginal medical facilities and services. Thereby thousands
of tribals are not contributing any thing for National development. They are living with meager
sanitary facilities, lack of health awareness, unhygienic conditions and lack of medical facilities
are considered as a major hindrance for poor health conditions. As a result tribes are exposing
too many communicable diseases like viral fever, typhoid, malaria and diarrhea and other
epidemiological diseases. Economic burden of these diseases causing heavy economic loss
including wages and hence, tribes are driven to poverty and then they are leading in a pathetic
life in the study areas.
1.1 The Tribals
India has the largest tribal population in the world. There are about 427 recognized scheduled
Tribal groups in India. As per 2001 Census' the tribal population of India is 84.3 million, larger
than that of any other country in the world. Myanmar, with the tribal population of 44 million
is the second largest. Tribes of Andhra Pradesh have added grandeur to the region with their
rich heritage of culture, innocent lifestyle and age-old ethnicity. In other words, their customs,
Department of Economics Kakatiya University, Warangal-506009, Andhra Pradesh, India

International Journal of Health Management and Information (IJHMI)

rituals, fairs, festivals have drawn the attraction of all the anthropologists of the country who
have conducted surveys on them with enthusiasm and vigor. Presently there are 32 lakh tribals
50 lakh nomads and other backward people in Andhra Pradesh. Their habitat spreads along the
coastal and mountain strip of the Bay of Bengal from the Srikakulam district to the Khammam
and Godavari districts right up to the north-eastwards to the Adilabad region. Maximum of
these tribes of Andhra Pradesh have built their settlements in the hilly and forest regions of the
state. In the manner of making houses also, these tribes of Andhra Pradesh have also left their
marks of exuberance and artistry.
The state of Andhra Pradesh has been chosen as Study area in view the congregation of
larger number of tribals live in below poverty line without any basic medical facilities. There
is an urgent need to concentrate on them for their survival. Failing which the race will be wiped
out due to perpetual contaminated and dangerous diseases prevailing in the entire tribal areas
due to non availability timely Medical assistance and Government sponsored Health Care
Projects in spite of the budgetary allocation of scores of Public money for their welfare and
well being.
1.2 The Connotation
The tribal population groups of India are known to be the autochthonous people of the land.
Tribals are often referred to as ADIVASI, VANYAJATI, VANVASI, PAHARI, ADIMJATI and
ANUSUCHIT JAN JATI, the latter being the constitutional name. The concept of tribe emerged
in India with the coming of the British. Gradually, the concept of reservation emerged and
through that emerged the idea of scheduled tribe in independent India. In India, 427 groups
have been recognized as scheduled tribes. They form approximately 8 per cent of the total
Indian population. These tribal groups inhabit widely varying ecological and geo-climatic
conditions (hilly, forest, desert, etc.) in different concentration throughout the country with
different cultural and socioeconomic backgrounds.
2. REVIEW LITERATURE
The studies on tribal health care are very few, the health status of the tribal populations in India
is very poor. Different studies have been established the same a study on Health Care Services
in Tribal Areas of Andhra Pradesh: A Public Policy Perspective by K. Sujatha Rao find out that
the state's inability to provide a credible and feasible health care system that is accessible and
affordable is indicative of the system failure in an important area of concern. (Basu, 1986,
1990; Chowdhuri, 1986; Rizvi, 1990; Mahapatra et al., 1990 and Swain et al., 1990) have tried
to establish this with the help of morbidity, mortality and health statistics. The widespread
poverty, illiteracy, malnutrition, absence of safe drinking water, sanitary and living conditions,
poor maternal and child health services, ineffective coverage of national health and nutritional
services, have been traced out in several studies as possible contributing factors for dismal
health conditions prevailing among these vulnerable populations (Bhasin, 1990). Safe water
and sanitation are the two basic components of hygiene, which have a strong cultural
determination and key influence on people's health perhaps comparable only to food (Lal B.
Suresh, 2010). Only 31% of rural India has easy access to safe water and only two percent has
access to sanitation facilities (Bhasin, 1994). Very few studies were conducted on economic

Economic Analysis of Health Care Services: A Study in Tribal Areas ...

analysis of the health care services of tribal populations of North Telangana of Andhra Pradesh
such as on Koya, Gond and Lambada (Lal B. Suresh, 2007).
3. EPIDEMIOLOGICAL STATUS IN TRIBAL AREAS
The tribal sub-plan areas is spread over nine districts and consists of about 33 tribes and 22
lakh of the total 42 lakh ST population in the state. Available evidence suggests that poverty is
the prime cause for ill health, persistent morbidity and early death. However, lack of access to
right foods: iron, protein and micro-nutrients such as iodine and vitamins, is the principal cause
for the very high incidence of nutritional deficiency diseases: anaemia, diarrhoea, nightblindness,
goitre, etc. These factors combined with lack of access to basic health care services is the main
reason for the unexceptionally adverse differentials with the more developed parts of the state:
maternal mortality is eight per 1000, (going up to 25 among some tribal groups) as against four
per 1000 for the state; infant mortality rate is 120-150 per 1000 compared to 72 per 1000, and
while it is nine per 1000 crude death rate, with 30 percent under-five mortality for the state,
among some of the major tribal groups such as Savaras, Gadabas and Jatapus, the death rate is
as high as 15-20 per 1000 with over 50 percent of deaths of children under five. [3] Longevity
of life is lower; there is evidence of a faster decline in the sex ratio during the decade 1981-91
and an unacceptably high level of about 75 percent stunting/wastage among children. Under
TB and malaria, the tribals suffer disproportionately to their population - the rate of incidence
of TB among tribals is estimated to be double and under malaria, case incidence is estimated to
be over 18 per 1,000, mostly of the P Falciparum variety, accounting for 75 percent of the
state's total deaths on account of malaria.
4. METHODOLOGY
4.1 The Study Areas
Koya and Gond were the tribals chosen in the districts Adilabad and Warangal of North
Telangana, Andhra Pradesh. They mainly depend on Agriculture and Forest produce. The data
were collected through household interview schedule in two villages were randomly selected
from the two sample mandals i.e., Indravelly and Eturnagaram. Data on health and hygienic
practices such as environmental sanitation (housing, water), frequency of Illness by water,
cases of sickness, personal hygiene, use of drugs and drug dependence, causation of disease
and their treatment is collected from the sample villages. The study was carried out on tribes
have distinct health problems, mainly governed by multidimensional factors like their habitat,
difficult terrain, ecologically variable niches, illiteracy, poverty, isolation, superstition and
deforestation. Hence an integrated multidisciplinary approach has been adopted to study the
tribal health problems.
4.2 Objectives
To study the socio-economic conditions of the tribal people and their demand for health care
service. To find the availability and adequacy of healthcare facilities in the study area. To
examine the impact of these diseases on health conditions and on the economic burden of
tribal population.

International Journal of Health Management and Information (IJHMI)

4.3 Hypothesis
Healthcare system improves the living standards of Tribals, Healthcare system brings socioeconomic standards among Tribals and Helath care system gives sustainability and overall
growth of tribal areas.
5. TRIBALS HEALTH PROBLEMS
5.1 Upper Respiratory Tract Infection
After anaemia, the respiratory disease including upper respiratory tract infection was more
commonly prevalent (14.9% in Bondo, 16.6% in Didayi, 13.6% in Kondha and 8.3% in Juanga)
and accounts for a high infant mortality due to inadequate vaccination, lack of early diagnosis
and prevention (GP Chhotray: Unpublished observation). Similar observations were made in
Birhor (11.2%) and Sahariya (57.5% in children aged 0-4 years and 56.9% in children aged 5 14 years) tribes of Madhya Pradesh.
5.2 Malaria
Malaria is the foremost public health problem of Orissa contributing 23% of malaria cases,
40% of plasmodium falciparum cases and 50% of malaria deaths in the country. More than
60% of tribal population of Orissa lives in highrisk areas for malaria. Though the tribal
communities constitute nearly 8% of the total population of the country, they contribute 25%
of the total malaria cases and 15% of total P.falciparum cases. Various epidemiological studies
and malariometric surveys carried out in tribal population including primitive tribes reveal a
high transmission of P.falciparum in the forest regions of India, because malaria control in such
settlements has always been unattainable due to technical and operational problems. In a specific
study conducted in undivided Koraput district, it was observed that the district is endemic for
malaria and is hyperendemic in top hills where Bondo primitive tribes are residing. A prospective
study conducted by RMRC, Bhubaneswar during 2000-2003 in Malkangiri, Kandhamala and
Keonjhar districts, showed slide positivity rate (SPR) of 14.2% in Bondo, 14.4% in Didayi,
10.5% in Kondha and 9.5% in Juanga primitive tribes. The Pf percent was 93.5% in Bondo,
91.6% in Didayi, 92.7% in Kondha and 91.2% in Juanga population and the spleen rate in
children of 2 to 9 years was 25.8, 35.1, 26.3 and 24.4% in Bondo, Didayi, Kondha and Juanga
tribes respectively(GP Chhotray: Unpublished observation).
5.3 Diarrhoeal Disorders
Water-borne communicable diseases like gastrointestinal disorders including acute diarrhoea are
responsible for a higher morbidity and mortality due to poor sanitation, unhygienic conditions
and lack of safe drinking water in the tribal areas of the country. In a cross sectional study conducted
by RMRC, Bhubaneswar in 4 primitive tribes of Orissa, the diarrhoeal diseases including cholera
was found to occur throughout the year attaining its peak during the rainy season (From July to
October). During 2002 to 2003, 12.7% of Bondo, 13.2% of Didayi, 10.4% of Kondha and 12.6%
of Juanga children (0- 6 years) and 10.9% Bondo, 11.6% Didayi, 10.2% Kondha and 6.9% Juanga
adult population presented with acute diarrhoea. Bacteriological study of the rectal swabs revealed
Vibrio cholerae in 2.5%, Escherichia coli in 39.2%, Salmonella in 0.23% and Shigella spp in
1.8% of all culture positive cases while 56.3% of rectal swabs were culture negative. Among the

Economic Analysis of Health Care Services: A Study in Tribal Areas ...

V.cholerae isolates V.cholerae O1 Ogawa was the predominant serotype. The acute diarrhoeal
problem was basically due to the poor environmental hygiene, lack of safe drinking water, improper
disposal of human excreta which was further aggravated by low literacy, low socioeconomic
status coupled with blind cultural belief, lack of access to medical facilities leading to serious
public health problem encouraging faeco-oral transmission of enteric pathogens (GP Chhotray:
Unpublished observation). In a similar study conducted by RMRC, Jabalpur in Hill Korwas, it
was observed that 0.1% population suffered from acute diarrhoea.
Intestinal Parasitism Intestinal protozoan and helminthic infestations are the major public
health problems and were observed in 44.6% Bondo, 44.9% Didayi, 31.9% Juanga and 41.1%
Kondha primitive tribes of Orissa. Amongst helminthic infestation hookworm was most common
(21% in Bondo, 18.7% in Didayi, 14% in Juanga and 18.2% in Kondha). Children (aged 0-14
years) were more affected than the adults. A repeat stool examination after 4 months of
antihelminthic and antiprotozoal treatment revealed significant reduction in the worm burden
(from 38.9 to 18.9%). Most of these infections are due to indiscriminate defecation in the open
field, bare foot walking and lack of health awareness and hygiene. These are preventable with
repeated administration of antihelminthic and protozoal treatment at 4 months interval which
can be used effectively in national parasitic infection control programme.
6. RESULTS AND DISCUSSION
The Age wise distribution of the sample respondents as shown in the table-1, reveals that
majority of the respondents belong to the age group of 41-50 years i.e., 75 out of the 200
accounting for 37.5 percent. Further, 50 out of 200 belong to the old-age group. The age group
between 21-40 years respondents 75 their percentage 37.5, this is very productive age group.
As the figures presented in the table indicates that out of the total 200 subjects male are
179 and female are only 21, their percent 89.5 and 10.5 respectively. It also finds that, there are
families headed by women in the tribals.
The literacy status of the subjects as shown in the table reveals that 150 out of 200 tribals
are illiterates i.e., 75 percent and 50 out of 200 sample are literates accounting for 25 percent.
The data reveals the evil effect of illiteracy. It confirms our understanding that illiteracy causes
ignorous. This ignorance is the mother of all evils.
Community is said to be a unique social institution, which established its own kind of
working and living values among its members. Traditionally, because of this very reason, one
finds Socio-Economic difference between one community and another community.
Table reveals that the 88 percent of the tribals belong to the nuclear and 12 percent to joint
families. It indicates that family which keeps less number of helping hands is producing higher
number of the children. It may be to supplement the income of the family. Under the present
study, there is a domination of nuclear family.
A family which is longer in size with less income cannot lead a happy life. As a result, the
members in the family have welfare and opportunities to be developed in a healthy family
atmosphere. On the other side, a family, which is limited in size and is well planned, assumes
all possible development opportunities to its members and helps them to protect themselves
from insecurities of life. In the area of study, the average size of the tribals family was six.
However, in view of the above facts, information regarding the type of family has been drawn
from the subjects.

International Journal of Health Management and Information (IJHMI)


Table 1
Sl. No

Classification

No. of Subjects

Percentage

Age Composition of Sample Respondents:


1.

21-30 yrs

35

17.5

2.

31-40 yrs

40

20 .0

3.

41- 50 yrs

75

37.5

4.

Above 50 yrs

50

25.0

179

89.5

Sex-Wise Classification
1.

Male

2.

Female

21

10.5

1.

Illiterate

150

75.0

2.

Literate

50

25.0

176

88.0

24

12.0

Education Status:

(Primary Level)
Family Type:
1.

Nucleus

2.

Joint

Family Size:
1.

Below 4 members

116

58.0

2.

5-6 members

66

33.0

3.

Above 7 members

18

9.0

129

64.5

Occupational-Wise Classification
1.

Agriculture

2.

Agri-Laboure

51

25.5

3.

Others

20

10.0

150

75.0

Income -Wise Classification


1.

Low (Rs.Below-20,000)

2.

Middle (Rs.20,000-40,000)

30

15.0

3.

High (Rs.40,000-60,000)

20

10.0

Source: Data compiled from field study

It also presents that the 116 (58 %) out of 200 size of the family members are below 4. 33
percent of the sample tribals family has 5-6 members and nine percent of family has more than
7 members in the family.
Information regarding the present occupation pursued by the tribals subjects is given in
table. Majority of the subjects have practicing agriculture i.e., 64.5 percent. Followed by AgriLabour and others their percent is 25.5 and 10 respectively.
The economic position of a family plays a useful and important role in the proper welfare
and development of its members. A family with better income keeps adequate resources for

Economic Analysis of Health Care Services: A Study in Tribal Areas ...

proper future development of its members. The economic condition of the family to which the
tribals belong. The data presented in the table shows that 75 percent of tribals income is below
rupees 20,000, 15 percent have it between rupees 20,000 to 40,000 and 10 percent subjects is
having Rs. 40,000 to 60,000 per annum. It is depending on seasonal, because agriculture is
gambling of monsoon.
Table 2
Annual Expenditure on Food
Expenditure on Food (Rs)
Sl. No

Income
Group

Less than
10,000

10,00020,000

20,00030,000

Above
30,000

Low

120 (80)

24 (16)

6 (4)

150 (100)

Middle

20 (66.66)

09 (30)

1 (3.33)

30 (100)

High

15 (75)

5(25)

140 (70)

48 (24)

12 (6)

Total

Total

20 (100)
-

200 (100)

(The figures in parenthesis are percentage to total)

Expenditure on Food: The annual expenditure on food incurred by the sample subjects is
classified into four categories- less than Rs. 10,000, Rs. 10,000 to Rs. 20,000, Rs. 20,000 to
30,000 and above Rs. 30,000 is presented in the table-2.
As shown in the table-2, 140 subjects (70 per cent) had spent less than Rs. 10,000 annually
48 (24 per cent) subjects had spent between Rs. 10,000 to 20,000, followed by 12 subjects (6
per cent) had spent between Rs.20, 000 to 30,000.
When the subjects are classified according to income group in terms of annual expenditure
on food, it was found that out 150 subjects belonging to low income groups, 120 subjects (80
per cent) has spent less than Rs. 10,000. 24 subjects (16 per cent) has spent between Rs.10, 000
to 20,000, only six subjects (4 per cent) has spent between Rs. 20,000 to 30,000. None were
having affordability to spent Rs. more than 30,000 annually on food in low income group.
Among the middle income group, majority of subjects 20 (66 per cent) had spent rupees
less than 10,000. In the high income group, 15 subjects (75 per cent) had spent between Rs.
10,000 to 20,000.
Expenditure on Cloth: Next to food, expenditure on cloth is an important item of expenditure.
The annual expenditure incurred by the subjects on cloth during the survey year is presented in
the table-3. The table reveals that 150 subjects (cent percent) from low income group and 25
subjects (83 per cent) from middle income group had spent less than Rs.2, 000 annually on
clothes. 12 (60 per cent) subjects had spent between Rs. 4,000 to 6,000 annually on clothes.
The expenditure on health is an important factor, which influences the demand for health
care services. The pattern of expenditure on health by the various income group of respondents
is presented in table-4. Of the total subjects, 115 (57.5 per cent) had spent more than Rs. 4,000
annually, followed by 40 subjects (20 per cent) had spent between Rs.3, 000 to 4,000. 30
subjects (15 per cent) had spent between Rs. 2,000 to 3,000. Only 15 subjects (7.5 per cent) had

International Journal of Health Management and Information (IJHMI)

spent less than Rs.1,000. Among the low income group subjects had spent high amount on
health i.e., more than Rs. 4000 per annum. Among the middle income group subjects had spent
between Rs. 2000 to 3000. Where as high income group subjects spent very marginal amount
less than Rs. 2000. It indicates that more the income less expenditure on health or their income
goes up, expenditure on health decreases.
Table 3
Annual Expenditure on Cloth
Expenditure on Cloth (Rs)
Sl. No

Income
Group

Less than
2,000

2,0004,000

4,0006,000

Above
6,000

Total

Low

150 (100)

150 (100)

Middle

25 (83.33)

5 (16.66)

30 (100)

High

12(60)

8(40)

140 (70)

5 (2.5)

12 (6)

Total

20 (100)
200 (100)

(The figures in parenthesis are percentage to total)

Table 4
Annual Expenditure on Health
Expenditure on Health (Rs)
Sl. No

Income
Group

Less than
2,000

2,0003,000

3,0004,000

Above
4,000

Low

--

10 (6.66)

30 (20)

110 (73.33)

Total
150 (100)

Middle

--

15 (50)

10 (33.33)

5 (16. 66)

30 (100)

High

15 (75)

5 (25)

--

--

20 (100)

15 (75)

30 (15)

40 (20)

115 (57.5)

Total

200 (100)

(The figures in parenthesis are percentage to total)

7. COMMON DISEASES
The common diseases affecting the tribals in the study areas are: general fever, malaria, typhoid,
diarrhea, anemia and jaundice. The common disease and the number of tribals affected by the
disease are presented in the table-5.
Of all, the common diseases affected 598 tribals, belonging to 200 sample households,
during the period of survey. Highest number of tribals 230 (38.4 per cent) of the total, was
affected by general fever. 117 tribals (19.5 per cent) were affected by Malaria. 95 tribals (15.8
per cent) were affected by Typhoid, 92 tribals (15.3 per cent) were affected by Diarrhea. Anemia
contracted 35 tribals (5.8 per cent) and 29 tribals (4.8 per cent) were contracted by Jaundice.
The tribals affected by various diseases are distributed to the sample households classified
as low, middle and high income group.

Economic Analysis of Health Care Services: A Study in Tribal Areas ...


Table 5
Classification of tribals Affected by Common Disease
Sl. No Common
Disease

Low
No. of
Tribals

Middle
Average No. of
Tribals

High

Total No.
of Tribals

Percent of
the total

Average No. of Average


Tribals

Fever

150

10

68

6.8

12

230

38.4

Malaria

60

45

4.5

12

117

19.5

Typhoid

40

2.6

40

15

3.7

95

15.8

4.

Diarrhea

50

3.3

34

3.4

92

15.3

35

5.8

29

4.8

598

100

5.

Anemia

20

1.3

15

1.5

Jaundice

15

10

Total

335

212

51

Fever: Fever had affected 150 tribals in the low-income group, 68 tribals in the middle
income group and 12 tribals in the high income group.
Malaria: water borne disease, had affected 60 tribals in the low-income group, 45 tribals
in the middle income group and 12 tribals in the high income group.
Typhoid: a contagious disease, had hit 40 tribals in the low-income group, 40 tribals in the
middle income group and 15 tribals in the high-income group.
Diarrhea: In the low income group 50 tribals were affected by diarrhea, in the middle
income group 34 and high income group eight tribals were affected.
Anemia: 20 tribals from low income and 15 tribals from middle income group were affected
by anemia. None from the high-income group were affecting by anemia.
Jaundice: Similarly, the disease, jaundice had affected 15 tribals from low-income, 10
tribals from middle income group and four from high income group tribals were affected by
jaundice.
8. SUGGESTIONS AND CONCLUSION
A total health programme for the tribal villages is a pre-requisite to check and eradicate vectorborne and water-borne diseases. Facilities may be created in the tribal areas so as to attract hundred
percent deliveries in the hospitals. All preventive vaccinations and injections may be given free of
cost to the tribal people including Hepatitis B and anti-measles vaccines. It is, therefore, essential
to update and provide 24-hours hospital facility to the people in the tribal area. It is necessary to
conduct frequent surveys on the food habits, nutrition, health practices of the tribals. It will help
the authorities to take suitable measures to improve the health of the tribals.
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