Introduction

India's growth hype and dream of emerging as an economic superpower are being challenged and broken today, among other things, by its failure to foster an inclusive growth path and provide to bulk of its population basic amenities of education and health that signals a nations′ social well-being.¹² A significant section of the nations′ population today is deprived of the fruits of development and been kept away from the basic amenities of life-health, education, sanitation, nutrition and so on. The problem exists at two levels - first, the overall achievement across the nation in terms of social sector indicators is very poor and not comparable with even the developing nations of the world and second, there exists great inequality both at interstate and intrastate level in terms of the key components of human development principally health and education.³⁴

There exists sufficient literature to establish that a nation that does not fare well in provision of basic amenities and facilities like health and education shall not be able to develop the full potential and capability of its workforce and at the same time shall fail to shoulder the basic duty of a welfare state. Health status directly affects the productivity and efficiency of people. The uneven distribution of health care facility and attainment of health status is a major cause of concern here. We have on the one extreme state like Kerala and Tamil Nadu that can match the most advanced emerging market economies in health indicators and on the other, states like Bihar and Uttar Pradesh where the situation is pathetic.⁵ Uttar Pradesh and Bihar which are first and third largest state of India respectively from the viewpoint of population not only fair badly in terms of basic health care facilities, but also show wide interregion and interdistrict variations. Such a situation on the one hand works against the interest of the poor and deprived section of population living in these areas and on the other result in the states suffering even after having rather rich natural resource base. It is crucial therefore to understand the extent to which these two backward states fair in terms of health status and health infrastructure and identify the interregion and interdistrict variation there in order to suggest appropriate policy prescription. It is precisely this that the present work attempts to do.

Materials and Methods

Health status and health care are multi-dimensional in nature, so it is difficult to measure them precisely. The present paper attempts to develop suitable indices involving the appropriate indicators to measure the extent of inequality in health status and health care services in the state of Uttar Pradesh and Bihar. District level data on the indicators have been chosen keeping in the view the availability of information.

Source of data

There are two problems related to methodology that the present author has come across - first, problem related to comparability, Government of Uttar Pradesh and Bihar are not well equipped with district wise data on health status and infrastructure for different time period, which restrict us from comparing the extent of inequality in health status and infrastructure over a period of time within the state and outside the state. Second, there are a number of indicators of health status and health infrastructure, but the sources of data for these indicators are varied in the two states making it difficult to use them jointly to develop the composite indices.

District wise data for health status have been taken from Annual Health Survey (AHS 2010-2011)⁶ for both the states. According to AHS (2010-2011) only 70 out of 71 in Uttar Pradesh and 37 out of 38 districts in Bihar have been considered. District wise health infrastructure data have been collected from Shankhikya Patrika (2010-2011),⁷ Uttar Pradesh Planning Commission and Bihar Statistical Hand Book (2010-2011).⁸

Composite indices

The study computes composite indices for health status and health infrastructure. This indices system focuses on relative position of each district of both states in terms of health outcomes and health care services. For the better reliability factor analysis has been used to give weights to the indicators to construct indices for health status and health infrastructure.

First, the values of the selected indicators for all the 70 and 37 districts of Uttar Pradesh and Bihar respectively were collected and tabulated. Then the tabulated data were transformed into standardized X_id ′s, using Equation 1,

Where X_idr stands for actual value of i _th variable for district dr _th (number of district) and Min X_idr stands for minimum value of i _th variable of all districts, Max X_idr stands for the maximum value of the i _th variable within all districts of both states. X_id stands for the standard value of the i _th variable in the d _th district and d _th runs from 1 to 70 in case of Uttar Pradesh, representing the 70 districts of the state of Uttar Pradesh, similarly d _th run from 1 to 37 in case of Bihar.

If, however, X_i is negatively associated with health status and health infrastructure, for, e.g., under five mortality rates, which should keep on declining as health status and infrastructures improve, then Equation (1) can be written as:

Second, using data of all variables of all districts of both states, factor analysis has been used to find out the weights for different variables, the j_th factor F_i can be expressed as:

Where, Wj's are factor score co-efficient

P is the number of variables

X is the score of individual variable of indicator 1.

The unit analysis has been done then arranged in a hierarchical order on the basis of the factor score. Districts, according to their development scores, have been classified into five levels of development, very high (VH), high (H), average (A), very low (VL) and low (L). While categorising districts in different development classes, 1/5 of the standard deviations of the sectoral scores have been used as class intervals.

The major limitation of this study is that some of the important indicators could not be included, which are necessary for reflecting the real picture of health situation in the two states. Many indicators such as maternal mortality rate and life expectancy at birth, which would have been more relevant in the context of building health status index and health infrastructure index but have not been included in the study due to nonavailability. In the selection of indicators, we have mainly been guided by availability of data for the selected indicators for all the districts of the two states Uttar Pradesh and Bihar.

Results

Health status

The overall performances of Uttar Pradesh and Bihar in terms of health attainment-both health status and health infrastructure is pathetic [Tables 1 and 2]. The values of health status index are very low in both of the states, but it is lesser in case of Bihar (2.49) than Uttar Pradesh (2.806) though the difference is very little, but it establishes that health status of Uttar Pradesh is slightly better than that of Bihar. Not only the average score of health status is low in Bihar, the interdistrict variation in health status is comparatively high. The co-efficient of variation (CV) in health status in Bihar is 38.64% against 29.53% in Uttar Pradesh. However, the point, which should be noted is 43% of districts are below state average in terms of health status in Bihar whereas in Uttar Pradesh 47% of districts are performing below state average. The range (difference between highest and lowest value) of health status is higher in Uttar Pradesh (4.65) than Bihar (3.96).

Health infrastructure

The condition of health infrastructure in these two states are rather dismal and pitiable than health status, poor situation of health infrastructure is evident from the fact that the average score of health infrastructure composite indices are extremely low in Uttar Pradesh (0.364) and slightly better in Bihar (1.202). Most health infrastructure equipped districts among both the states are Sheikhpura (2.99) followed by Jehanabad (2.16) in Bihar and Varanasi (2.15) in Uttar Pradesh. The variation of health infrastructure within the state is unexpectedly high in Uttar Pradesh the CV in health infrastructure is114.54. Interdistrict inequality in health care services in Bihar is comparatively low CV in composite indices score for Bihar is 46.83.

Health status and health infrastructure: A correlation

It is generally believed that there is direct or positive relationship between health status and health infrastructure meaning there by that with increase in health infrastructure there will be definite increase in health status of people. However, the study reveals that there is very low rather insignificant correlation co-efficient between health infrastructure and health status in both the states Bihar (0.22) and Uttar Pradesh (0.44). Tables 3 and 4 categorise different districts of the two states in terms of health status and health infrastructure. For both the states it could be seen that there exists a number of districts, which are ranked high in terms of health status but low in health infrastructure. It point out the lack of efficiency on the part of medical human resources, that is doctors, nurses, medical staff and so on. It also figures out the discrepancy in the governance of the public health institutions. It has been often observed that either doctors are not present at hospitals or they are not attending the patient and engaged in some other works. Poor correlation between health status and health infrastructure also establish that there exist a gap between the policy formulated and policy implemented on the part of governing authority.

Discussion

Although it is a proven fact that among other factors, health status and utilization of health care services go hand in hand,⁹ meaning thereby that there exist a direct relationship between health status and health infrastructure. But unfortunately, this belief is broken when the study found that there is very poor correlation between health status and health infrastructure. The finding forces us to accept that apart from health care facilities there are a number of other factors that can improve the health status. These include the quality of public health infrastructures that includes efficiency, commitment and productivity of human resources in the health sector (doctors, nurses and other medical staff), the level of education of the beneficiaries that decides their hygiene and health consciousness, commitment, care, assistance by international bodies and a host of other things.¹⁰ Intrastate and interstate disparities in the government expenditure in the two states in the social sectors of education and health and supply of drinking water is a major cause of poor health achievement and high health inequality.¹¹

Variation in health infrastructure is far more than variation in health status in both states reflects that there is in general, shortage of health infrastructure especially in backward and rural areas of the states. This requires greater commitment on the part of the government to create the basic facilities and increased role of educational institutions, media and political and social activists to create health consciousness. The magnitude of the problem necessitates coming together of all and sundry to improve the situation.