1. Life, Death and Development on the Margins: Infant and Child Mortality and the Health Interventions of the State in Orissa, India Nick McTurk University of Dundee

2. Context of Orissa The determinants of Infant and Child Mortality in India and Orissa Differential impacts of Health infra-structure in India’s States Introducing Orissa’s State Healthcare System Healthcare in Orissa: a S trengths, W eaknesses, O pportunities & T hreats analysis Conclusions: marginality and mortality Outline of Presentation

3. Political Map of India State of Orissa

4. District Map of Orissa Primary Research Locations Coastal Plains Hilly Interior

5. Infant Mortality Rates in 1991 and 2000 Sources: Sen, A. (1999); Sample Registration System (2000) RegionInfant Mortality Rate 1991 Infant Mortality Rate 2000 India8068 WorstOrissa12495 ThreeMadya Pradesh 11787 Indian StatesUttar Pradesh9783 Sub-Saharan Africa 104- WorstMali161- ThreeMozambique149- S-S African Countries Guinnea- Bissau 148-

6. Determinants of Infant Mortality (India 1991 and 2001 Secondary Data) Rural IMR 1991Rural IMR 2001 Female Literacy -0.725**-0.698** Hospital Beds -0.688**-0.758** Male Literacy -0.661**-0.502* Safe Water Access -0.571*0.054 (1991 Data) *Statistically significant at 0.05 **Statistically significant at 0.01

7. Standard Residual Outliers for Hospital Beds per Million and Infant Mortality in Rural India 19912001

8. Determinants of Infant and Child Mortality (Orissa 1991 and 1999 Secondary Data) IMR 1991 CMR 1991 IMR 1999 Females well educated -0.753**-0.776**Female Literacy -0.800** Sched. Caste0.5470.726**PHC0.579** Utility Access-0.523-0.560* PHC -0.176 -0.151 *Statistically significant at 0.05 **Statistically significant at 0.01

9. Determinants of Neonatal, Infant and Child Mortality (Orissa Primary Data) Poverty (NMR, IMR & CMR) Distance to Health Facility (NMR & IMR) Poor Healthcare Practice (NMR, IMR & CMR) Scheduled Caste & Other Backward Class (IMR & CMR) Utility Access (IMR & CMR)

10. Spatialities of Infant Mortality and Health Infrastructure Rural IMR (1999)PHC/million (2001)

11. The State Healthcare System Tertiary Institutions Secondary Institutions Primary Institutions 11 Specialist Hospitals 3 College Hospitals District H.Q. Hospitals Community Health Centres (Serve 80 – 120,000) Primary Health Centres (Serve 20 – 30,000) Sub-Centres (Serve 3 – 5,000) I.C.D.S. (Serve 900-1200) Rural Orissa District Towns Cities

12. S.W.O.T. analysis of the State Healthcare System

13. Strengths and Weaknesses of the State Healthcare System Strengths Targeted at the poor Utilised by the poor (Modest) attributable mortality reductions Weaknesses Resource, facility and staff shortages Rife political interference and corruption Some policies are incommensurate with assistance of the poor

14. PHC/population by District

15. Opportunities and Threats to the State Healthcare System Opportunities Joined-up government Investment in primary services Intensified utilisation of media resources Threats Ineffective referral function Poor reputation Financial and spatial inaccessibility

16. Patient Referral within the State Healthcare System Tertiary Institutions 11 Specialist Hospitals 3 College Hospitals Patient Referral Secondary Institutions District H.Q. Hospitals Community Health Centres (Serve 80 – 120,000) Primary Health Centres (Serve 20 – 30,000) Patient Referral Primary Institutions Sub-Centres (Serve 3 – 5,000) Self Referral I.C.D.S. (Maternal and Child Health Outreach Services) 48% (of first referrals) 36% (of first referrals)

17. Conclusions: marginality and mortality Orissa’s Infant and Child Mortality decline lags behind other States in India because of lack of investment in rural State Healthcare and Development infrastructure. Socio-Spatial inequalities in survival are tempered by… Spatial marginality and healthcare access: Orissa’s population is 87% rural, predominately inhabiting small villages scattered across inaccessible terrain, poverty reduces mobility, restricting access to State healthcare facilities. Social marginality and healthcare access: The Scheduled Caste & and Other Backward Class groups who depend upon ineffective State services suffer higher mortality rates than other groups with more financial and socio- political clout.

18. Thanks for listening Nick McTurk University of Dundee n.j.mcturk@dundee.ac.uk