Does distance determine the choice of the provider of health care Does distance determine the choice of the provider of health care? - A case of Child Health in the Sundarbans

Background Study Area – Patharpratima block of Sundarbans, South 24 Paraganas- West Bengal. Sundarbans World Heritage site (UNESCO). Dense Mangrove forest area. Climatically vulnerable (Aila 2009 and Seasonal climatic shocks). High percentage of Morbidity and Malnutrition in Children (Future Health System Report 2010). State about sundrbans, its uniqueness, climate change and adaptation

Research Study Future Health Systems Research Consortium (FHS 2010) Research Studies (2011-12) Future Health Systems Research Consortium (FHS 2010) A research consortium of 5 different public health institutions focusing on improving quality and access to healthcare. Institute of Health Management Research – Jaipur (FHS Partner from India). Child Health Survey. GIS Mapping of Providers. Virtual Journey. As the Block have five non-deltaic Grampanchayets and ten deltaic Grampanchayets, one village (Dakshin Durgapur) form non-deltaic region and two villages (Herembogopalpur and Kumarpur) from deltaic region were selected to keep the right proportion.

Geographical Accessibility – Research Papers (FHS) Objective: To determine the importance of Geographical Accessibility in governing provider choice for Child Health Care in the Sundarbans. Children of age 0 to 5 years in age. Health seeking behavior of the Mother/Primary Care giver. Out patient Care for Child Illness.

STUDY AREA- PATHARPRATIMA BLOCK- DELTAIC & NONDELTAIC 15 Grampanchayats. (5 – Non Deltaic; 10- Deltaic grampnachayats)

Data and Methods DATA COLLECTION Child Health Survey- Stratified Random sampling GIS Virtual Journey Methods Logit Regression model – Modeling the effect of Provider Density, Time of travel and Terrain on Health Seeking behavior. Triangulate the results with GIS and Virtual Journey Data.

Table 1: Percentage of Mothers seeking care from different providers for Child OPD care. Qualified/trained provider (%) Not qualified/trained (%) N Antenatal Services 90.52 (C.I 88.83 – 92.21) 9.47 (C.I 7.78 – 11.16) 1161 Delivery of child 44.83 (C.I 42.01 – 47.65) 55.16 (C.I 52.34 – 57.98) 1200 Morbidity in children 14.73 (C.I 12.51 – 16.95) 85.26 (C.I 83.04 – 87.48) 984 Hospitalization in children 93.82 (C.I 88.47 – 99.18) 6.17 (C.I 0.81 – 11.52) 81 Immunization for children 97.85 (C.I 96.65 – 99.06) 2.14 (C.I 0.93 – 3.34) 560 Qualified/trained provider: If treatment is sought from a government facility/ NGO clinic/ Ayurved or homeopathy doctor/ TBA/ ANM/ASHA/Private qualified allopath Not qualified/trained: If treatment is sought from a Rural medical practitioner/Traditional Healer/ Others/At Home

Table 2: Average time taken in minutes to travel to avail the following services from providers Qualified provider/Trained (minutes) Not qualified/Trained (minutes) Difference t statistic P value Antenatal Services Delivery of child 82.51 82.51** 30.83 <0.0001 Morbidity in children 95.89 20.43 75.46** 6.98 Hospitalization in children 169.63 54.00 115.63** 5.17 Immunization for children Qualified/trained provider: If treatment is sought from a government facility/ NGO clinic/ Ayurved or homeopathy doctor/ TBA/ ANM/ASHA/Private qualified allopath. Unqualified/Not trained: If treatment is sought from a rural medical practitioner/Traditional Healer/ Others/At Home. Unequal samples of homogeneous distribution and ,Variance assumed to be unequal.

Model-Logit Regression Response Variable- Health seeking Behavior of Mothers for Child OPD Care. (Dichotomous variable- ‘0’ Unqualified provider & ‘1’ for Qualified provider’) Predictors- Time of travel (in minutes) - Continuous Terrain HR Density (Total number of Frontline workers working in the geographical area for 1000 population – ANM/ASHA) – Continuous variable RMP Density (Total number of RMPs working for 1000 population)- Continuous variable Controlled for Background Characteristics Child’s Sex Age of Mother Education of the Mother Family size Birth order of child Religion and Caste

BACKGROUND CHARACTERISTICS- Predictors Significant variable Model 1 BACKGROUND CHARACTERISTICS- Predictors Significant variable ODDS RATIO Education of Mother Illiterate (Ref), Can read/write/count, Primary, Secondary or higher Caste General (Ref), OBC, SC/ST Religion Hindu (ref), Non Hindu Age of Mother 20 yrs (ref), 21- 25 yrs, 26- 30 yrs,31-50yrs Family size Nuclear (ref), Joint/Extended Joint/Extended 1.60** Economic category (No surplus meal/day-ref) (not adequate food, not adequate few months, surplus food) surplus food 2.50** Birth order of child First (Ref), Second, Third or above Third and above 0.44** (N) 984 Chi2 47.53 P value 0.0002 Pseudo- R2 0.05

Model 2 Background characterisics+ GEOGRAPHICAL ACCESSIBILITY-Predictors ODDS RATIO Economic category (Surplus food) Surplus food 4.32* Time taken to reach facility 1.02** Terrain(categories exclusive of one another) Pucca(Ref) Kuccha 0.21** Both Kuccha and Pucca 0.55* Controlling for background variables (N) 984 Chi2 236 P value <0.0000 Pseudo- R2 0.29

Model 3 Background + Geographical accessibility+ Provider density- Predictors ODDS RATIO Economic category (Surplus food) Surplus food 4.32* Age of the Mother (0-20yrs ref), (30 and above) (30 and above) 2.26* Time of travel 1.02** Kuccha (Pucca ref) 0.27** ANM+ASHA Density (Continuous variable) 2.5 RMP Density 0.43* Controlling for background variables and geographical accessibility factors (N) 984 Chi2 247.34 P value <0.0000 Pseudo- R2 0.30

By groups: Deltaic and Non Deltaic Deltaic- 5 GPs Non Deltaic- 10 GPs

Model 3 Background + Geographical accessibility+ Provider density- Predictors DELTAIC REGION NON DELTAIC REGION RMP Density(Continuous variable) 0.25** - HR Density (Continuous variable) 205** Time of Travel 1.02** Terrain- Kuccha Pucca(Ref) 0.37* 0.14** Economic status (No surplus food through out year –ref) Surplus food through out year 9.1** Education of Mother Illiterate(ref), Higher secondary or above 5.9* Family Nuclear (ref), Joint/Extended 2.98** Religion Hindu (ref), Non Hindu 2.59** (N) 529 436 Chi2 160.6 104 P value <0.00001 Pseudo- R2 0.37 0.30

BPHC/ PHC/SC RMP

DISCUSSION Is the norm of a fixed number of facilities per ‘n’ of a population enough to cater to the issue of geographical accessibility? What are the issues?

FHS- RESEARCH STUDIES (Virtual Journey) Key problems in commuting for Health care- Cost (Minimum of 100/- for vans to 3000/- for a ferry across the river during nights) Time (Non availability of the transport means at night or early hours) Non availability of doctors in PHC/BPHC. AFFORDABILITY (HUGE COSTS IN TRANSPORT), GEOGRAPHICAL ACCESSIBILITY.

Why do people go to RMPs? They provide credit facility. They provide transport facility. They are always available and within reach. Tale about delta nondelta difference of political impact and stress on strong social network is depend on this and ultimately affect care seeking.

DISCUSSION IPHS- Indian Public Health Standards “ In the field of rural health, the objective was to establish: one Sub-centre for a population 5000 people in the plains and for 3000 in tribal and hilly areas, one Primary Health Centre (PHC) for 30000 population in plains and 20000 population in tribal and hilly area, and one Community Health Centre (CHC/Rural Hospital) for a population of one lakh. However, as the population density in the country is not uniform, it shall also depend upon the case load of the facility and distance of the village/habitations which comprise the Sub-centre.”

ACTION POINT RMPs Public facility Focuses on holistic service (care, credit, transport though of clinically questionable quality). Need a service oriented approach. Geographical accessibility is more than the number of facilities per population. And hence might need to consider modifying the package of services from health centers in remote areas.

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