chapter iv health status in tamil nadu and...

CHAPTER IV

HEALTH STATUS IN TAMIL NADU AND

TIRUNELVELI DISTRICT – AN EVALUATION

4.1 INTRODUCTION

The main focus of this chapter is to evaluate the health status in Tamil

Nadu as well as in Tirunelveli district. For the purpose of analysis, health

indicators and its determinants were chosen for the period from 1995-96 to

2009-10. The indicators are determined by numerous factors such as per capita

income, way of life, marital status, housing, sanitation, water supply, health

infrastructure, social organisation, the structure of the economy, nutrition,

education, health services provided by the government, political and

administrative set up, geography climate, religious belief etc.1

Thus it is realised that no universally accepted determinants of health status

have emerged satisfactorily. The most worrying aspect of it is that not all the

determinants are quantifiable and different empirical investigation have resulted

1 K.N. Reddy and V. Selvaraju, “Determinants of Health Status in India - An

Empirical Verification”, 1EA 76th

Annual Conference Volume, 1994, pp.31-33.

141

in different generalisations.2 (Adelman, 1963; Auster, Leveson and Sarachek,

1969; Grossman, 1972; Fuch 1974 and 1982; Benham and Benham, 1975;

2Adelman O., “An Econometric Analysis of Population Growth “, American

Economic Review, Vol. 53 (3), June, 1963. pp. 314-339.

-Auster, R.,I. Leveson and D. Saracheck , “The Production of Health,

AnExploratory Study”, Journal of Human Resources, Vol IV, Fall, 1969, pp.411-436

- Benham, L and A. Benham, “The Impact of Incremental Medical services on

Health statues 1963-1970” in R. Andersen, J. Kravitz and O Andersons (eds) Equity in

Health Services: Empirical analysis of Social Policy, Cambridge, 1975.

- Carrin, Guy, Economic Evaluation of Health Care in Developing Countries,

Croom Helm, London, 1984.

Culyer, Economics of Health, Edward Elgar, England, 1991.

Fuchs V.R., Who shall live? Health Economics and Social Choice, Basic Books

Inc, New York, 1974.

Fuch V.R., Economic Aspects of Health, Chicago University, Chicago. 1982.

Grossman, M., “On the Concept of Health Capital and the Demand for Health”,

Journal of Political Economy, March-April, 1972.

Hadley J., More Medical Care, Better Health?, The Urban. Institute,

Washington D.C., 1982.

Panikar PGK and C.R. Soman, “Health status of Kerela - The Paradox of

Economic Backwardness and Health Development, Centre for Development Studies,

Trivandrum, 1984.

Payer L, Medicine and Culture: varieties of Treatment in the United States,

England, West Germany and Frace, Holt Rinchant and Winston, New York, 1988.

142

Hadley, 1982; Panikar and Soman, 1984; Garrin Guy, 1984; Payer, 1988; Cuyler,

1991 and the World Bank, 1993). The World Bank in its World Development.

Report, 1993 observed that (1) pursuit of economic growth strategies that reduce

poverty, (2) implementation of public health and essential clinical care packages

and (3) increased investment in schooling for girls would enormously improve

health status in developing countries.

4.2. THE ANALYTICAL FRAMEWORK

In order to analyse the trend and growth of health indicators, the following

semi-log trend equation was fitted.3

Y = a + bt .......................... (4.1)

Where,

Y = Value of variable,

t = Time variable.

The above model was computed by the method of least squares.

To analyse the influence of first six determinants on health status namely

life expectancy and birth rate in the study area, a multiple regression model of the

following formula has been used.

3Domodar Gujarati, Essentials of Econometrics, McGraw Hill Inc., International

Edition, New York, 1992, pp.228-229.

143

Y = β0+ β1 X1 + β2 X2 + β3 X3 + β4 X4 + β5 X5 + β6 X6 + U

where,

Y = Life Expectancy / Birth Rate,

X1 = Number of PHCs and health sub-centres,

X2 = Population per bed ratio,

X3 = Number of doctors and nurses in PHCs,

X4 = Population per doctor ratio,

X5 = Female literacy rate,

X6 = Per capita food availability,

U = Disturbance term.

β0, β1 to β6 regression parameters to be estimated and

In order to analyse the influence of the health status namely Death Rate and

Infant Mortality Rate, the following multiple regression model was used.

Y = β0+ β1 X1 + β2 X2 + β3 X3 + β4 X4 + U

where,

X1 = PHC per million population,

X2 = Per capita income,

X3 = Public health expenditure

X4 = Employment in organized sector,

144



The correlation coefficient ‘r’ has been computed and t-test was used to

verify the formulated null hypothesis.

4.3. TRENDS IN INDICATORS OF HEALTH

In the present study four health variables, namely, life expectancy at birth,

birth rate, death rate and Infant mortality Rate are used for measuring the levels of

health status in Tamil Nadu State and Tirunelveli district separately so to make a

comparative analysis. These health variables are known as health indicators. The

health indicators are influenced by many determinants. In this study eighteen

determinants, namely number of Primary Health Centres, population per bed ratio,

number of doctors and nurses in primary health centre, population per doctor

ratio, female literacy rate, per capita food availability, PHC per million

population, per capita income at current prices, public health expenditure, literacy

rate, employment in organised sector, provision of drinking water – villages

covered, couple protection rate, fertility rate, sex ratio, density of population, beds

and hospitals are taken as determinants of health status in Tamil Nadu State as

well as in Tirunelveli district. The study period is 15 years from 1995-96 to

2009-10. The first objective of the present study, namely, to study the levels of

health in the study area is based entirely on secondary statistics. They are

collected from various statistical reports, published by Government of Tamil

145

Nadu, Directorate of Medical and Rural Services, Chennai, Directorate of Public

Health and Preventive Medicine, Chennai, Directorate of Family Welfare,

Chennai Department of Economics and Statistics, Chennai Joint Directorate of

Health and Medical Services, Tirunelveli, Deputy Directorates of Public Health,

Tirunelveli, and Assistant Directorate of Statistics, Tirunelveli.

To attempt to answer the question ‘how healthy’ is the study area (Tamil

Nadu State and Tirunelveli District,) with existing health care services available to

people in these areas, the first objective namely the movements of health

indicators and determinants are analysed. The present study is aimed at,

evaluating the health situation in the study area and suggesting possible lines of

approach in the formulation of health policy and programmes that help to promote

the health status in the coming years.

To study the first objective, movements of health indicators life

expectancy, birth rate, death rate and infant mortality rate in the case of Tamil

Nadu and in the case of Tirunelveli district are examined by fitting a trend relation

Yt = a + bt where t is the time, yt is the value of indicator at time ‘t’ and ‘a’ and

‘b’ are parameters; ‘b’ is giving the trend. The trend is estimated for four chosen

indicators. Moreover the trends in the eighteen chosen determinants are also

obtained to know their movements.

146

4.3.1. Indicators of Heath in Tamil Nadu

Table 4.1 reveals various data related to life expectancy, birth rate, death

rate and infant mortality rate in Tamil Nadu for the period from 1995-96 to

2009-10.

TABLE 4.1

INDICATORS OF HEALTH IN TAMIL NADU

FOR THE PERIOD FROM 1995-96 TO 2009-10

Year Life Expectancy Birth Rate Death Rate IMR

1995-96 64.09 20.3 8.0 54

1996-97 64.10 19.5 8.0 53

1997-98 64.14 19.0 8.0 53

1998-99 64.29 19.2 8.5 53

1999-00 65.31 19.3 8.0 52

2000-01 65.41 19.3 7.9 51

2001-02 65.09 19.1 7.6 49

2002-03 65.11 18.5 7.7 44

2003-04 65.15 18.3 7.6 43

2004-05 66.22 17.1 7.5 41

2005-06 67.11 16.5 7.4 37

2006-07 67.21 16.2 7.5 37

2007-08 67.31 15.8 7.2 35

2008-09 67.75 16.0 7.4 31

2009-10 67.98 16.3 7.6 28

Source: (i) Directorate of Medical and Rural Services, Chennai

(ii) 1991 Census of India

(iii) 2001 Census of India

147

Figure 4.1

Indicators of Health in Tamil Nadu for the Period from

1995-96 to 2009-10

0

10

20

30

40

50

60

70

80

1995-9

6

1996-9

7

1997-9

8

1998-9

9

1999-0

0

2000-0

1

2001-0

2

2002-0

3

2003-0

4

2004-0

5

2005-0

6

2006-0

7

2007-0

8

2008-0

9

2009-1

0

Year

Ind

icato

rs

Life Expectancy Birth Rate Death Rate IMR

148

TABLE 4.2

THE RESULTS OF TRENDS IN THE INDICATORS OF HEALTH IN

TAMIL NADU FOR THE PERIOD FROM 1995-96 TO 2009-10

Model: Yt = a + bt

Sl.

No Health Indicators

Coefficients R

2

a b

1. Life Expectancy at birth 63.3587 0.661*

(11.948) 0.917

2. Birth rate 20.6152 -0.3235*

(-10.269) 0.890

3. Death rate 8.2123 -0.0607*

(-4.998) 0.657

4. Infant Mortality Rate 66.7430 -1.1034*

(-4.257)* 0.582

Source: Computed from secondary data.

: Figures in parentheses are ‘t’ values

* Significant at 5 per cent level.

From Table 4.2 the trend and the annual rate of change of four health

indicators have been observed. Life expectancy at birth has registered an

increasing trend and its annual rate of changes is, 0.661. The birth rate, death rate

and infant mortality rate have shown a declining trend, with the annual rate of

changes being -0.3235, -0.0607 and -1.1034 respectively. All these rates are

significant statistically.

149

Tables 4.1 and 4.2 clearly reveal the following inferences about Tamil

Nadu state:

During the study period, Life expectancy had increased from 64.09 to

67.98 in the state. It had increased at the rate of 0.299 per annum. Among the

four health indicators, Infant mortality rate had undergone the largest change. It

had decreased from 54 to 28 and its higher annual rate of change was -1.1034.

The birth rate had decreased from 20.30 to 16.30 during the study period and the

annual rate of change was -0.3235. The death rate had also declined from 8.00 to

7.60 in the state and the rate of change per annum was –0.0607. The birth rate

increased and death rate had declined but annual rate of the decline in birth rate

(- 0.3235) was higher than the decline in death rate (-0.0607). These trends imply

remarkable enhancement in the health status of Tamil Nadu for the period from

1995-96 to 2009-10.

4.3.2. Indicators of Health in Tirunelveli District

The trend in health indicators in Tirunelveli district has been shown in

Tables 4.3 and 4.4.

150

TABLE 4.3

INDICATORS OF HEALTH IN TIRUNELVELI DISTRICT

FOR THE PERIOD FROM 1995-96 TO 2009-10

Year Life Expectancy Birth Rate Death Rate IMR

1995-96 60.22 21.3 8.5 71.21

1996-97 60.21 20.5 8.4 67.15

1997-98 61.11 20.1 8.2 68.91

1998-99 62.21 19.8 8.6 57.61

1999-00 63.15 19.9 8.0 56.15

2000-01 64.11 19.3 8.0 50.21

2001-02 64.21 19.1 7.6 44.61

2002-03 64.11 18.5 7.9 43.15

2003-04 65.31 18.3 7.7 40.21

2004-05 65.81 17.9 7.5 38.09

2005-06 65.90 17.6 7.8 38.10

2006-07 66.53 17.4 7.5 38.15

2007-08 66.61 17.6 7.4 38.61

2008-09 66.65 17.1 7.6 39.15

2009-10 66.91 16.9 7.3 39.21

Source: (i) Joint Directorate of Health and Medical Services, Tirunelveli..

(ii) Deputy Directorates of Public Health, Tirunelveli..

151

Figure 4.2

Indicators of Health in Tirunelveli District for the Period from

1995-96 to 2009-10

0

10

20

30

40

50

60

70

80

1995-9

6

1996-9

7

1997-9

8

1998-9

9

1999-0

0

2000-0

1

2001-0

2

2002-0

3

2003-0

4

2004-0

5

2005-0

6

2006-0

7

2007-0

8

2008-0

9

2009-1

0Year

Ind

ica

tors

Life Expectancy Birth Rate Death Rate IMR

152

TABLE 4.4

THE RESULTS OF TRENDS IN THE HEALTH INDICATORS IN

TIRUNELVELI DISTRICT FROM 1995-96 TO 2009-10

Model: Yt = a + bt

Sl.

No. Health Indicator

Coefficients R

2

a b

1. Life expectancy at birth 60.117 0.510*

(14.284) 0.940

2. Birth rate 21.1476 -0.2992*

(-20.751) 0.970

3. Death rate 8.5266 -0.0825*

(-7.440) 0.809

4. Infant mortality rate 68.8193 -2.514*

(-7.986)

0.830

Source: Computed from the secondary data.

Note : Figures in Parentheses denote ‘t’ values


From Tables 4.3 and 4.4, it has been inferred that the Life expectancy at

birth in the district was 60.22 in 1995-96 and it had risen to 66.91 in 2009-10.

Life expectancy at birth in Tirunelveli district had shown increasing trend and its

annual rate of change was 0.510. During the study period, the birth rate had

decreased from 21.30 to 16.90; the death rate had decreased from 8.50 to 7.30 and

the infant mortality rate had fallen from 71.21 to 39.21. Birth rate, death rate and

infant mortality had shown a declining trend with the annual rates of change being

-0.2992, -0.0825 and –2.514 respectively. Infant mortality rate had declined

largely (-2.514) in the district. The annual rate of change in birth rate and death

rate is more or less equal. The annual rate of change in all the health indicators is

153

statistically significant. These trends highlight the spectacular increase in the

health status of the people in the district during the study period.

The health profiles of Tamil Nadu State and Tirunelveli district are

compared, because the comparative study could be an effective and certain

conclusion could be drawn for policy implications.

Regarding the first health indicator, namely life expectancy at birth, the

annual growth rate had shown an increasing trend both in Tamil Nadu State and

Tirunelveli district. The life expectancy at birth had increased from 64.09 to

67.98 in Tamil Nadu and from 60.22 to 66.91 in Tirunelveli district. The average

life span had increased by 7.20 years both in Tamil Nadu and Tirunelveli district

during the study period. The birth rate had decreased from 20.30 to 16.30 in

Tamil Nadu and in Tirunelveli district it had decreased from 21.30 to 16.90. The

death rate had declined from 8.00 to 7.60 in Tamil Nadu and it had come down

from 8.50 to 7.30 in Tirunelveli district. The infant mortality rate in Tamil Nadu

had declined from 72.11 to 55.21 whereas it had come down from 71.21 to 39.21

in Tirunelveli district. This shows the overall health development in Tirunelveli

district despite its economic development. Health status of Tamil Nadu is better

off than that of Tirunelveli district as per the health indicator, namely life

expectancy at birth. Its annual growth rate was 0.661 in Tamil Nadu whereas it

was 0.510 in Tirunelveli district. Infant mortality rate, birth rate and death rate in

Tamil Nadu state as well as in Tirunelveli district were experiencing a declining

154

trend. The declining trend in infant mortality rate was stronger than that of birth

rate and death rate. The annual rate of decline in death rate and IMR was higher in

Tirunelveli district than in Tamil Nadu. The annual rate of decline in IMR was –

2.514 in the district and –1.1034 in the state. The health status of the district is

better than the state, as far as IMR is concerned. Among the four health

indicators, life expectancy at birth and infant mortality rate were decisive and

dominant in indicating the health status of any region.

Almas Ali and Pratap Sisodia (1995)4 confirmed that the primary

determinants of improved health status of the population had been general

mortality, infant mortality and life expectation at birth. They further stated that

studies on fertility and morbidity and also on the impact of health programmes

and use of health services had been introduced as secondary health indicators.

Nevertheless, the analysis of mortality data was still very much an indispensable

part of the health situation analysis.

The annual growth rate of infant mortality rate in Tirunelveli District was

–2.514, and in Tamil Nadu State it was -1.1034. There was a good sign of health

improvement in Tirunelveli district. The decline in birth rate was higher in Tamil

Nadu whereas the decline in death rate was higher in Tirunelveli District.

Therefore Government of Tamil Nadu has to concentrate on taking steps to reduce

infant mortality rate further in the state. Moreover Tirunelveli district

4 Almas Ali and Pratap Sisodia, “Health Profile of India: An Overview”, Health

for Millions, Souvenir Number, Vol. 21, October 1995, p. 48.

155

administration has to concentrate on multifarious measures to bring down the

birth rate thereby controlling the growth of population and elevating the level of

health status.

4.4 TRENDS IN DETERMINANTS OF HEALTH

Health, economic, demographic, social and educational variables are

among the several factors, which determine the status of health. Table 4.5

explicitly demonstrates the trends in various health determinants in the state of

Tamil Nadu.

TABLE 4.5

HEALTH DETERMINANTS IN TAMIL NADU FOR THE PERIOD

FROM 1995-96 TO 2009-10

Year

Number

of PHCs

+ HSCs

Population

per Bed

ratio

Number of

Doctors +

Nurses

Population

per Doctor

Ratio

Female

Literacy

Rate

Per capita

food

availability

(in Kgs)

1995-96 10106 1926 22262 20511 55.41 143.00

1996-97 10102 1954 23354 20698 56.77 167.20

1997-98 10099 1977 22416 20784 58.12 107.40

1998-99 10090 1995 22470 20853 59.48 114.90

1999-00 10091 2031 22504 20978 60.84 133.00

2000-01 10096 2015 22608 21010 62.20 126.50

2001-02 10099 2017 22664 21018 63.36 135.00

2002-03 10100 2018 22700 21025 64.55 146.60

2003-04 10103 2019 22761 21034 65.31 147.21

2004-05 10106 2021 22799 21045 67.91 149.24

2005-06 10109 2023 22816 21051 68.21 150.15

2006-07 10110 2025 22861 21063 68.31 151.21

2007-08 10113 2027 22893 21065 68.43 152.14

2008-09 10115 2079 22909 21068 68.54 152.31

2009-10 10117 2030 22968 21069 68.91 152.43

Source: (i) ‘Tamil Nadu – An Economic Appraisal’ for various years, Published

by Department of Evaluation and Applied Research, Chennai.

(ii) Statistical Hand Book of Tamil Nadu for various years.

(iii) 1991 Census of India, 2001 Census of India.

156

TABLE 4.5 CONTD.

Year PHC per

million

population

Per capita

income at

current

prices

( in Rs.)

Public

health

Expedition

(Rs in

lakhs)

Literacy

Rate

Employment

in Organised

Sector

(in ‘000)

Number of

Villages

with Safe

Drinking

Water

1995-96 0.040 7352 13071.34 65.66 2898.80 8134

1996-97 0.040 8282 25842.28 66.73 2412.70 9439

1997-98 0.042 11573 29955.36 67.81 2563.20 10541

1998-99 0.042 13985 36419.21 68.90 2571.10 11627

1999-00 0.043 15798 42399.00 69.93 2584.30 12431

2000-01 0.043 16114 48080.93 73.50 2592.60 13382

2001-02 0.043 17008 47807.58 72.30 2596.20 14463

2002-03 0.044 17893 50100.92 73.47 2611.70 15676

2003-04 0.045 17914 52114.15 74.15 2761.15 16211

2004-05 0.045 17924 53211.41 75.21 2863.43 17621

2005-06 0.045 17931 53421.11 77.14 2961.43 18341

2006-07 0.046 17943 54561.25 77.21 2998.64 18462

2007-08 0.046 17961 56241.15 77.61 3024.69 18499

2008-09 0.046 18291 57319.21 78.62 3036.15 19211

2009-10 0.047 18314 58624.19 79.41 314125 19341



(iv) Statistical Hand Book of Tamil Nadu for various years.

(v) 1991 Census of India.

(vi) 2001 Census of India.

157

TABLE 4.5 CONTD.

Year

Couple

protect

Rate

Fertility

rate

Sex

ratio

Density of

population

per sq.km.

Number of

Beds in

PHCs

Number

of

Hospital

1995-96 50.90 2.2 981.00 445.00 29812 306

1996-97 51.80 2.1 981.00 451.00 30108 306

1997-98 53.00 2.0 982.00 456.00 30397 314

1998-99 54.90 2.0 982.00 462.00 30503 314

1999-00 54.60 2.0 984.00 468.00 30641 314

2000-01 56.20 2.0 984.00 473.00 30716 314

2001-02 57.30 2.0 980.00 475.00 30769 314

2002-03 58.70 2.0 986.00 478.00 30791 314

2003-04 59.21 2.0 991.00 479.00 30821 321

2004-05 61.21 1.9 991.00 479.00 30845 321

2005-06 61.25 1.7 991.00 479.00 30859 321

2006-07 62.24 1.7 993.00 481.00 30877 321

2007-08 62.31 1.7 993.00 481.00 30899 321

2008-09 65.21 1.7 993.00 481.00 30905 321

2009-10 65.20 1.6 993.00 481.00 30935 321



(vii) Statistical Hand Book of Tamil Nadu for various years.

(viii) 1991 Census of India.

(ix) 2001 Census of India.

158

TABLE 4.6

RESULTS OF TRENDS IN HEALTH DETERMINANTS IN TAMIL NADU STATE FOR

THE PERIOD FROM 1995-96 TO 2009-10 Model: Yt = a + bt

Sl.

No Determinants of Health

Coefficients R

2

a b

1. PHCs and HSCs (X1) 10092.79 1.3678*

(4.051) 0.558

2. Population per bed ratio (X2) 1957.95 6.5642* (5.086)

0.666

3. Doctors and Nurses (X3) 22514.16 27.2714*

(1.859) 0.210

4. Population per doctor ratio(X4) 20703.58 30.986*

(5.412)* 0.693

5. Female literacy rate (X5) 55.543 1.026*

(15.192) 0.947

6. Per capita food availability (X6) 128.893 1.624

(1.862) 0.210

7. PHC per million population (X7) 0.040 0.0047*

(15.958) 0.951

8. Per capita income (X8) 10033.58 698.16*

(5.768) 0.719

9. Public Health expenditure (X9) 23581.867 2712.008*

(7.983) 0.830

10. Literacy rate (X10) 64.972 1.005*

(37.601) 0.991

11. Employment in organised Sector (X11) -39012.68 7814.92

(1.740) 0.1889

12. Provision of drinking water

– Villages Covered (X12) 8258.590

829.167*

(19.027) 0.9653

13. Couple protection rate (X13) 50.03009 1.0298* (31.394)

0.9869

14. Fertility rate (X14) 2.20381 -0.0371*

(-8.925) 0.8596

15. Sex rate (X15) 978.971 1.053*

(13.939) 0.9372

16. Density of population (X16) 451.780 2.4357*

(7.443)* 0.8099

17. Beds (X17) 30155.304 62.903*

(6.1427) 0.7437

18. Hospitals (X18) 307.628 1.0714*

(7.368)* 0.8068

Source: Computed from secondary data

Note : Figures in parentheses denote ‘t’ values

*Significant at 5 per cent level

159

4.4.1 Determinants of Health in Tamil Nadu

From the Table 4.5 and 4.6 it has been revealed that in terms of

determinants in Tamil Nadu, all the determinants were significant except one

determinant namely per capita food availability which has not recorded any

significant trend. All others have shown significant and positive trends except

PHC per million population and the fertility rate which are favourable to improve

the health status. Among the 18 selected determinants, 15 determinants have

significant and positive trends. Per capita income at current prices, public health

expenditure, and provision of drinking water villages covered, have shown the

highest growth rate; whereas female literacy rate, literacy rate, couple protection

rate, sex ratio and number of hospitals have shown the lowest growth rate. The

growth rate of other determinants was moderate during the study period in the

state. The favourable and unfavourable monsoons during the study period

resulted in fluctuations in food production and output. This was the reason for

insignificant and negative trend in per capita food availability in the state.

Secondly, PHC per million population was statistically significant and its growth

was marginally negative. Thirdly the fertility rate had also negative trend which

exhibited the awareness of people in small family norms.

Per capita income at current prices in the state had increased from Rs.7352

to Rs.18314 that is, a two fold increase during the study period. Public health

160

expenditure had risen from Rs.13071.34 lakhs to Rs.58624.19 lakhs, a three fold

increase. The inflationary effect might have partly contributed to this huge

income in public health expenditure. Villages covered for provision of safe

drinking water, increased from 8134 to 19341. The female literacy rate had been

accelerated from 54.35 to 71.99 in the state, thanks to Total Literacy Campaign

launched by the National Literacy Mission, New Delhi between 1991 and 1995.

The per capita food availability in the state increased from 117.30 kilograms to

146.60 kilograms during the study period. PHC per million was 0.082 in 1994-95

and it had declined to 0.044 due to growing population, low commitment to open

up new additional PHCs and cut in health budget during the last decade, owing to

the impact of globalisation and New Economic Policy of 1991.

Panikar and Soman5 analysed the health status of Kerala and found out

that a mere linear expansion of curative medical care facilities could not take the

state anywhere to the goal of heath for all; already public and private expenditure

together were absorbing a high and increasing proportion of the state income,

without any visible impact on the incidence of diseases. Therefore, the goal of

better health had to be sought through development of the non-health care sectors

including food, housing, water supply and sanitation, as suggested by Panikar and

Soman.

5P.G.K. Panikar and C.R. Soman, “Health Status of Kerala – Paradox of

Economic Backwardness and Health Development”, Centre for Development Studies,

Thiruvananthapuram, 1984, p. 147.

161

As per the documents of National health Policy, 2002, prepared by

Ministry of Health and Family Welfare, New Delhi, Tamil Nadu fits in the

category of better performing states in health sector in India.

• Health determinants namely number of PHCs and HSCs, female literacy

rate, per capita income, employment in organised sector and provision of

safe drinking water do play an influencing role in enhancing the health

status of the state.

• Government may pay attention to improving these determinants so that the

outcome will be productive further in improving the health status vis-à-vis

standard of living.

The trends in the determinants of health in Tirunelveli district for the

period 1994-95 to 2008-09 is presented in Table 4.7.

162

TABLE 4.7

DETERMINANTS OF HEALTH IN TIRUNELVELI DISTRICT FOR THE

PERIOD 1995-96 TO 2009-10

Year

Number

of

PHCs

+HSCs

Population

per Bed

ratio

Number

of

Doctors+

Nurses

Population

per Doctor

ratio

Female

literacy

rate

Per capita

food

availability

(in Kgs)

1995-96 211 2066 214 16174 54.35 70.50

1996-97 224 2071 220 16098 55.61 71.10

1997-98 231 2076 224 16043 60.21 70.60

1998-99 245 2082 226 16091 61.41 70.10

1999-00 261 2087 231 16041 63.15 85.20

2000-01 271 2091 243 15933 64.21 80.40

2001-02 278 2093 254 15896 66.41 85.40

2002-03 284 2095 261 15809 67.29 83.90

2003-04 289 2099 273 15754 69.45 85.61

2004-05 290 2117 281 15702 70.65 86.43

2005-06 295 2118 285 15691 70.91 87.91

2006-07 299 2119 291 15673 71.51 88.21

2007-08 303 2121 311 15521 71.91 89.11

2008-09 307 2129 324 15541 71.93 89.21

2009-10 310 2133 343 15521 71.99 89.41

Source: (i) Joint Directorate of Health and Medical Services, Tirunelveli.

(ii) Deputy Directorates of Public Health, Tirunelveli.

163

TABLE 4.7 CONTD.

Year

PHC

Per million

population

Per

capita

Income

(in Rs.)

Public health

Expenditure

(Rs.in lakhs)

Literacy

Rate

Employment

in Organised

Sector

(in ‘000)

Number

of

Villages

with Safe

Drinking

Water

1995-96 0.043 4450 603.15 66.10 554 592

1996-97 0.044 5761 1110.50 67.21 528 599

1997-98 0.047 6186 1365.21 68.32 506 599

1998-99 0.045 6993 1400.11 69.44 499 611

1999-00 0.047 7899 1500.10 70.58 472 611

2000-01 0.047 8057 18991.15 71.80 473 611

2001-02 0.048 8508 21411.51 73.12 481 623

2002-03 0.048 9849 22611.55 74.23 493 623

2003-04 0.049 9921 23451.65 79.15 499 623

2004-05 0.049 9934 24691.22 81.61 511 631

2005-06 0.049 9945 25641.24 82.15 524 631

2006-07 0.051 9953 27999.15 82.19 539 631

2007-08 0.051 9964 28981.15 82.61 549 631

2008-09 0.051 9966 29908.61 83.14 561 631

2009-10 0.030 9977 29915.15 83.15 574 649



164

TABLE 4.7 CONTD.

Year

Couple

protection

Rate

Fertility

rate Sex ratio

Density of

population

Number of

Beds in

PHCs

Number

of

Hospital

1995-96 45.15 2.5 997 379 784 15

1996-97 46.21 2.5 998 385 792 15

1997-98 49.15 2.3 999 389 799 15

1998-99 51.21 2.2 1001 391 816 15

1999-00 53.43 2.2 1004 394 819 15

2000-01 56.24 2.1 1006 412 822 15

2001-02 59.61 2.2 1009 414 831 15

2002-03 61.21 2.1 1013 416 843 17

2003-04 62.15 2.0 1015 418 849 17

2004-05 63.24 2.0 1017 419 853 17

2005-06 64.15 2.0 1018 422 861 21

2006-07 65.11 1.9 1019 424 871 21

2007-08 65.41 1.9 1022 433 874 21

2008-09 65.49 1.9 1024 435 879 21

2009-10 65.51 1.9 1026 439 884 21



165

TABLE 4.8

RESULTS OF TRENDS IN HEALTH DETERMINANTS IN

TIRUNELVELI DISTRICT FOR THE PERIOD FROM

1995-96 TO 2009-10 Model: Yt = a + bt

Sl.

No Health Determinants

Coefficients R

2

a b

1. PHCs and HSCs (X1.1) 250.933 9.6750*

(12.918) 0.9277

2. Population per bed ratio (X2.1) 2061.485 4.7892* (24.082)

0.9780

3. Doctors and Nurses (X3.1) 194.571 8.8535*

(19.748) 0.967

4. Population per doctor ratio (X4.1) 16228.219 -49.466*

(-21.585) 0.9728

5. Female literacy rate (X5.1) 55.794 1.2839*

(11.711) 0.9134

6. Per capita food availability (X6.1) 70.0225 1.522*

(7.172) 0.7982

7. PHC per million population (X7.1) 0.0436 0.0054*

(11.377) 0.9087

8. Per capita income (X8.1) 5463.609 378.407*

(7.803) 0.8240

9. Public health expenditure (X9.1) -2932.062 2529.686*

(9.048) 0.8629

10. Literacy rate (X10.1) 64.2893 1.4205*

(15.087) 0.9459

11. Employment in Organised sector (X11.1) 490.019 3.4392

(1.930) 0.222

12. Provision of drinking water –

Villages covered (X12.1) 593.133

3.3250*

(11.875) 0.9156

13. Couple protection rate (X13.1) 45.5380 1.5850* (12.168)

0.9192

14. Fertility rate (X14.1) 2.45619 -0.0428*

(-10.298) 0.8908

15. Sex ratio (X15.1) 993.6000 2.2000*

(34.045) 0.9889

16. Density of population (X16.1) 377.790 4.1928*

(16.647) 0.9551

17. Beds (X17.1) 780.666 7.225*

(33.878) 0.9888

18. Hospitals (X18.1) 12.9428 0.5571*

(7.776) 0.8230

Source: Computed from Secondary data.

Figures in parentheses denote ‘t’ values.


166

4.4.2. Health Determinants in Tirunelveli District

It has been observed from Tables 4.7 and 4.8 that the health profile of

Tirunelveli district is substantiated and supplemented by secondary data for the

period of 15 years between 1993-94 and 2007-08. Regarding the trends in the 18

health determinants, only PHC per million population has no significant trend and

the remaining determinants are significant and all are positive except population

per doctor ratio. Per capita incase and public health expenditure have shown the

highest annual growth rate. Female literacy rate, per capita food availability,

literacy rate, Sex ratio and number of hospitals have shown the lowest annual

growth rate. The growth rate of remaining determinates was moderate during the

study period in the district. Population per doctor ratio showed a declining trend.

It is a welcome feature. A doctor could render qualitative health service only if

the number of patients to be attended, would be minimum. The female literacy

rate in the district had shown an increasing trend and this would reduce infant

mortality rate as tested statistically and proved empirically.

While comparing the trends of health determinants at state level and district

level, it is found that the growth rate of female literacy level (1.28) is higher in

Tirunelveli than that of Tamil Nadu (1.03). Consequently infant mortality rate is

less in Tirunelveli district than that of Tamil Nadu. Population per doctor ratio

(30.986) and population per bed ratio (6.5642) have higher growth rate at the state

167

level than that of district level. The growth rate of per capita income is less in

Tirunelveli district (378.407) than that of Tamil Nadu State (698.160).

Among 29 districts in Tamil Nadu, Tirunelveli district is economically in

the forefront. The health profiles and literacy profile are encouraging in this

district. The number of PHCs in Tamil Nadu increased from 10106 to 10117 and

in Tirunelveli district it increased from 282 to 403 during the study period. The

female literacy increased in Tamil Nadu from 55.41 to 68.91 and in Tirunelveli

district it increased from 54.35 to 71.99. The per capita food availability

increased in Tamil Nadu from 143.00 kilograms to 152.43 kilograms, whereas in

Tirunelveli district it increased from 70.50 kilograms to 89.41 kilograms. The

fertility rate in Tamil Nadu had decreased from 2.20 to 1.606 whereas in

Tirunelveli district it had decreased from 2.50 to 1.90. The per capita income in

Tamil Nadu had increased from Rs.7352 to Rs.18314 but in Tirunelveli district it

was Rs.4450 in 1995-96 and it increased to Rs.9977 in 2009-10.

Overall analysis reveals that Primary Health Centres and Health Sub-

Centres, female literacy rate and per capita income are having the highest growth

rate and they are vital factors to determine the health status in the district.

168

4.5. DETERMINANTS OF HEALTH STATUS

In this section, an attempt has been made to analyse the influence of the

determinants on the health indicators, in the study area from 1995-96 to 2009-10,

using secondary data collected for Tamil Nadu State and Tirunelveli District.

Four important health indicators are selected to evaluate the health status.

They are (i) life expectancy at birth, (ii) birth rate, (iii) death rate and (iv) infant

mortality rate. Secondary data were collected for the selected 18 health

determinants. Several combinations of determinants were tried, taking into

consideration, the interrelation among the determinants and suitable models were

arrived at. Hence out of 18 determinants, only 10 health determinants are used for

the purpose of analysis. The selected determinants are

(i) Number of PHCs and Health Sub-Centres

(ii) Population per bed ratio

(iii) Number of doctors and nurses in PHCs

(iv) Population per doctor ratio

(v) Female literacy rate

(vi) Per capita food availability

(vii) PHC per million population

(viii) Per capita income

(ix) Public health expenditure

(x) Employment in organised sector

169

To analyse the influence of first six determinants on health status namely

life expectancy and birth rate in the study area, a multiple regression model of the

following formula has been used.

Y = β0+ β1 X1 + β2 X2 + β3 X3 + β4 X4 + β5 X5 + β6 X6 + U

where,

Y = Life Expectancy / Birth Rate,

X1 = Number of PHCs and health sub-centres,

X2 = Population per bed ratio,

X3 = Number of doctors and nurses in PHCs,

X4 = Population per doctor ratio,

X5 = Female literacy rate,

X6 = Per capita food availability,



It is estimated by the method of least squares separately for Tamil Nadu

and Tirunelveli district. The study period is about 15 years from 1995-96 to

2009-10. The computed results are in the Table 4.9 for life expectancy.

170

TABLE 4.9

RESULTS OF MULTIPLE REGRESSION ANALYSIS FOR TAMIL NADU

AND TIRUNELVELI DISTRICT – LIFE EXPECTANCY AT BIRTH

Variables Parameter Estimates

Tamil Nadu Tirunelveli District

Intercept 0.781 23.32

X1 -2.941*

(-3.110)

0.041*

(3.211)

X2 0.048

(0.101)

-0.016

(-1.03)

X3 1.214

(1.018)

-0.110*

(-2.951)

X4 0.162

(0.311)

-0.005

(-0.792)

X5 0.241

(1.041)

0.371

(1.4217)

X6 -5.271

(-0.816)

0.051*

(2.671)

R2 0.939 0.991

No. of observations 15 15

Figures in bracket represent t- value.

* Indicates that the co-efficients are statistically significant at 5 per cent level.

From Table 4.9 it has been inferred that the number of PHCs and HSCs

was significant and influencing the life expectancy at birth at state level. The

number of PHCs and HSCs, the number of doctors and nurses, and per capita food

availability were significant with marked influence on the life expectancy at birth

at District level.

171

Seeta Prabhu (1994)6 made a study on the financing of health sector in

Maharashtra and she concluded in her work that the health infrastructure

especially PHC was significant in influencing life expectancy at birth. She

suggested that concerted actions on the part of the government to improve the

access to public health facilities to be taken to improve the health status in

Maharashtra.

Sarma (1994)7 studied the relationship between poverty, nutrition and

infant mortality among the Kandha tribes of Orissa state and found that changes in

food intake material and low per capita food availability were responsible for the

poor health status of tribes in Orissa. Per capita food availability is a dominant

factor, influencing the longevity of life in any region.

The computed regression results for Birth rate separately for Tamil Nadu

and Tirunelveli district are given in Table 4.10.

6K. Seeta Prabhu, “Financing of Health Sector in Maharashtra”, Conference

Volume, Indian Economic Association, Bombay, 19-21 February, 1994.

7R.P. Sarma, “Poverty Nutrition and Infant Mortality among the Kandha Tribes of

Orissa “, Conference Volume, Indian Economic Association, Bombay, 1994, p. 54.

172

TABLE 4.10


AND TIRUNELVELI DISTRICT – BIRTH RATE



Intercept 68.631 36.41

X1 0.004

( 0.381)

-0.042

(-1.061)

X2 0.021

(1.091)

0.056

(1.121)

X3 -0.004

(-0.691)

0.272*

(3.711)

X4 -0.014*

(-2.911)

-0.018

(-1.241)

X5 -0.012

(-0.101)

-2.161*

(-2.341)

X6 0.004

(0.612)

0.196*

(2.450)

R2 0.912 0.874

Number of Observations 15 15



Table 4.10 revealed that birth rate was influenced by the following

determinants. At state level, birth rate was influenced by population per doctor

ratio. At district level, female literacy rate and per capita food availability played

a major role in determining the birth rate. As female literacy increased, birth rate

decreased. There was a positive relationship between per capita food availability

and birth rate.

173

Bhattacharya (1982)8 was of the opinion that continued progress in health

care would lower the rate of population growth. Health status would not change

as long as the population remained below subsistence level. The relationship

between health status and birth rates was mutual. It implied that enhancing the

health status would lower the birth rate and increasing the birth rate would not

enhance health status.

Rajalakshmi and Hepzi (1993)9 had observed a similar relationship that a

cross sectional analysis of birth rate and female literacy rate revealed a strong

tendency towards lower birth rate. Education of women was found to have a

positive influence on the practice of family planning. The study concluded that

substantial reduction in the birth rate could be achieved by increasing female

literacy rate.

Gopalan et al., (1971)10 had also the same inference that there was a

positive correlation between per capita food availability and birth rate.

Reproduction was normal between 15 and 45 years of the woman. The food

availability was an important factor for reproduction.

8N. Bhattacharya, “Health Care and Its Problem in West Bengal”, Conference

Volume, 25th

Annual Conference of the Indian Public Health Association, Washington,

D.C., Vol. 19-24, 1982. 9N. Rajalakshmi and J. Hepzi, “Linkage Effect of Female Literacy on

Demographic Structure”, Women and Economy, Nancy David and V. Loganathan

(Eds.), Mother Theresa Women’s University, Madras, 1993, pp. 366-378. 10C. Gopalan, S.C. Balasubramanian, B.V. Ramasri and Visweswara Rao, “Diet

of Pregnant Women”, Diet Atlas of India, ICMR, Hydrabad, 1971, p. 60.

174

In order to analyse the influence of the health status namely Death Rate and

Infant Mortality Rate, the following multiple regression model was used.

Y = β0+ β1 X1 + β2 X2 + β3 X3 + β4 X4 + U

where,

X1 = PHC per million population,

X2 = Per capita income,

X3 = Public health expenditure

X4 = Employment in organized sector,



The above model was estimated by method of least squares separately for

Tamil Nadu and Tirunelveli district.

The computed results are given in Table 4.11 for Death Rate.

175

TABLE 4.11


AND TIRUNELVELI DISTRICT – DEATH RATE



Intercept 7.823 -14.781

X1 18.621*

(3.124)

116.84*

(5.627)

X2 -1.512

(-0.211)

-0.001

(-0.048)

X3 1.048

(0.371)

-2.671

(-0.048)

X4 -0.007

(-0.711)

0.006

(1.421)

R2 0.867 0.851

Number of Observations 15 15



Table 4.11 shows that the results of multiple regression analysis at state

level as well as at district level. PHC per million populations did play a vital role

in minimising the death rate. In rural area, PHC was easily accessible for medical

intervention and death could be avoided.

Chitra (1994)11 pointed out that PHCs were playing a major role in bringing

down the death rate. She also suggested that health services should be expanded

11Chitra, “Women Campaign for New Plan to Curb the World’s Population”, New

York Times, April 13, 1994, pp. A1-A12.

176

to include parental care, child survival efforts, educating girls, promoting

women’s equality and finally reducing the death rate.

The computed results for infant mortality rate are given in Table 4.12.

TABLE 4.12


AND TIRUNELVELI DISTRICT – INFANT MORTALITY RATE



Intercept -4.381 -3791.12

X1 2.632

(0.711)

0.381

(1.211)

X2 -3.412*

(-2.789)

9.411

(1.021)

X3 -0.004

(-1.941)

0.642

(0.471)

X4 0.801

(0.414)

1742.13*

(2.971)

R2 0.912 0.721

Number of observations 15 15



Table 4.12 clearly reveals the influence of health determinants of infant

mortality rate. At the state level, female literacy rate was found to strongly

influence the infant mortality rate. At the district level, PHC per million

populations was playing a vital role in reducing infant mortality rate.

177

Similar inference was drawn by Manonmoney (1994)12 in her research

paper that among all the determinants of ‘health status’ in Tamil Nadu from 1981-

82 to 1990-91, services of PHC had been the most important variable in reducing

the infant mortality rate and thereby increasing the health status of the state.

Reddy and Selvaraju (1994)13 concluded that female literacy had a

significant bearing on health status, since female health education reduced infant

mortality rate. The authors viewed that there was an urgent need to step up

expenditure on women’s education. It might not help improve health status in the

short run, but may help increase human capital and productivity and thereby

economic growth.

4.6. COMPARATIVE ANALYSIS

The comparative analysis between Tamil Nadu State and Tirunelveli

district has resulted in the following conclusion:

Both at the state level and the district level, PHC’s are important

determinants to maintain and enhance health status. So the government of Tamil

12N. Manonmoney, “An Economic Analysis of Health Status in Tamil Nadu”,

Conference Volume, Indian Economic Association, 76th

Annual Conference, Bombay,

19-21 February, 1994.

13K.N. Reddy and V. Selvaraju, “Determinants of Health Status in India: An

Empirical Verification”, Conference Volume, Indian Economic Association, Bombay,

19-21 February, 1994, pp. 31-33.

178

Nadu and the District Health Administration have to concentrate on equipping

PHC’s further with infrastructural facilities and imparting periodical training to

the medical and paramedical staff. Female literacy rate in Tamil Nadu (68.91 per

cent) and in Tirunelveli district (71.99 per cent) is helpful in reducing the infant

mortality rate to 55.21 per 1000 in the former case and to 39.21 per 1000 in the

latter case. Per capita food availability in the study area increases nutritional

status and thereby augments the health status. The number of doctors and the

nurses are instrumental in reducing the mortality rate and morbidity rate in the

study area.

It is clearly evident from the above analysis that there was gradual increase

in health status not only in Tamil Nadu State but also in Tirunelveli District

Government has to make arrangement to open up new additional PHCs, where the

coverage of population exceeded 30,000 population in community development

blocks in Tamil Nadu.

4.7. TESTING OF HYPOTHESIS

“A hypothesis is testable if other deductions can be made from it which in

turn, can be confirmed or disproved by observation”.14

In this section two

hypotheses are framed based on the secondary data collected at the level of

government offices, in Tirunelveli District.

14C. William Emory, Business Research Methods, p. 33.

179

Null Hypothesis

H0 : The first hypothesis states that infant mortality rate

is independent of female literacy rate.

This hypothesis have emerged from the second objective of the study

namely analysing the influence of health indicators on the health status of the

study area. The movement of female literacy rate and infant mortality rate in

Tirunelveli district for the study period has been presented in Table 4.13.

180

TABLE 4.13

FEMALE LITERACY RATE AND INFANT MORTALITY RATE IN

TIRUNELVELI DISTRICT FOR THE PERIOD 1995-96 TO 2009-10

Year Female literacy rate Infant mortality rate

1994-95 54.35 71.21

1995-96 55.61 67.15

1996-97 60.21 68.91

1997-98 61.41 57.61

1998-99 63.15 56.15

1999-00 64.21 50.21

2000-01 66.41 44.61

2001-02 67.29 43.15

2002-03 69.45 40.21

2003-04 70.65 38.09

2004-05 70.91 38.10

2005-06 71.51 38.15

2006-07 71.91 38.61

2007-08 71.93 39.15

2008-09 71.99 39.21

Source: 1. Deputy Directorates of Public Health, Tirunelveli..

2. Assistant Directorate of Statistics, Tirunelveli.

181

TABLE 4.14

CORRELATION BETWEEN FEMALE LITERACY RATE AND INFANT

MORTALITY RATE IN TIRUNELVELI DISTRICT

Variables Coefficient ‘r’ t-values

Calculated Tabulated

Female literacy

rate and Infant

mortality rate

-0.8753 3.671* 2.120

Source: Computed from Secondary data

*Significant at 5 per cent level

Table 4.14 shows the negative correlation between female literacy rate and

infant mortality rate. The value of correlation coefficient is –0.8753. It is

observed that infant mortality rate goes on decreasing as the female literacy rate

increases in the district.

The calculated ‘t’ value is 3.671, which is significant at 5 per cent level.

Since the calculated value is greater than the tabulated value (2.120), the null

hypothesis is rejected. Thus, it may be concluded that the infant mortality rate is

highly influenced by female literacy rate in Tirunelveli district. It is statistically

tested and empirically verified.

182

Suman Jain (1994)15 also drew similar conclusion from his study that

women’s education resulted in lower child mortality by improving child health

and survival by improving hygiene, nutrition and feeding practice and timely

medical intervention. Female literacy had been instrumental in lowering the

infant mortality rate.

Null Hypothesis

H0: The second hypothesis states that total government

spending for health care has not improved the life

expectancy at birth of the people.

The nature of public health expenditure and life expectancy at birth in

Tirunelveli district between 1994-95 and 2008-09 is shown in Table 4.15.

15Suman Jain, “Gender and Survival – A Comparative Analysis of Kerala and

Karyana”, Conference Volume, Indian Economic Association, February 19-21, 1994,

pp. 37-41.

183

TABLE 4.15

PUBLIC HEALTH EXPENDITURE AND LIFE EXPECTANCY AT

BIRTH IN TIRUNELVELI DISTRICT

Year Public Health Expenditure

(Rs. in Lakhs) Life Expectancy at Birth

1995-96 603.15 66.22

1996-97 1110.50 60.21

1997-98 1365.21 61.11

1998-99 1400.11 62.21

1999-00 1500.10 63.15

2000-01 18991.15 64.11

2001-02 21411.51 64.21

2002-03 22611.55 64.31

2003-04 23451.55 65.31

2004-05 24691.22 65.81

2005-06 25641.24 65.90

2006-07 27999.15 66.53

2007-08 28981.15 66.61

2008-09 29908.61 66.65

2009-10 29915.15 66.91

Source: (i) Deputy Directorate of Public Health, Tirunelveli.

(ii) Assistant Directorate of Statistics, Collectorate, Tirunelveli.

184

TABLE 4.16

CORRELATION BETWEEN PUBLIC HEALTH EXPENDITURE

AND LIFE EXPECTANCY AT BIRTH IN TIRUNELVELI

DISTRICT

Variables Coefficient ‘r’ t-values

Calculated Tabulated

Public health

expenditure and

life expectancy at

birth

0.8837 12.61* 2.120

Source: Computed from secondary data.


From Table 4.15 it has been observed that the life expectancy at birth goes

on increasing as public health expenditure has increasing trend. It is understood

from Table 4.16 that there is positive correlation between public health

expenditure and life expectancy at birth. In Table 4.16 the value of ‘r’ is 0.8837.

The calculated ‘t’ value is significant and greater than the tabulated ‘t’ value.

Hence the null hypotheses is rejected. Thus, it may be concluded that total

government spending for health care has improved the life expectancy at birth of

the people in the district.

chapter iv health status in tamil nadu and...

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