degrees of access to formal health services system among different communities in jagat cluster and...

2014

IIMU-Duke

Handoo,Jatinder

[Degrees of access to formal health services system among different communities in Jagat cluster and the Traditional Health Practioners of Udaipur ]

2014 AUTHOR: JATINDER HANDOO PARTNER NGO: JAGRAN JAN VIKAS SAMITI, UDAIPUR, RAJASTHAN.

IIMU-‐Duke Summer School For Future Leaders in Development Programme, 2014 IIMU-‐Duke Summer School For Future Leaders in Development Programme, 2014

ACKNOWLEDGEMENT I would like to acknowledge and put on record help and support from Indian

Institute of Management,Udaipur & Sanford Duke School of Public Policy faculty

Prof. Aniruddh(Duke) and Prof. M.S Sriram (IIMB). I would also like to thank Shri.

Ganeshji founder of JJVS , Shri Pankaj Paliwal,Dr. Rajeshji and Shri. Bhagwatiji of

JJVS for their help in facilitating field visits. Finally a big thank-you to the Bhavsar

family at Jagat who was kind enough to make my stay safe and comfortable during

the field visit. Last but not the least , this effort would have not been possible without

unflinching support from Mr.Rashid Khan Research Officer at IIMU.


Abbreviations Used

AYUSH Department of Indian Systems of Medicine and Homoeopathy

BCR Benefit Cost Ratio Bn Billion CHC Community Health Centre CII Confederation of Indian Industry DNA Daily News Analysis(Newspaper) EU European Union FGD Focus Group Discussion GDP Gross Domestic Product Gen General caste GoI Government of India Govt Government of India HDI Human Development Index HH House Hold IIM Indian Institute of Management INR Indian Rupees JJVS Jagran Jan Viklas Samiti MGNREGA Mahatma Gandhi National Rural Employment

Guarantee Act NPV Net Present Value NRHM National Rural Health Mission OBC Other Backward Caste PHC Primary Health Centre PHFI Public Health Foundation of India RSBY Rashtriya Swasthya Bima Yojna SC Schedule Caste SLRP Strategic Long Term Plan ST Schedule Tribe THP Traditional Health Practictioner ToI Times of India WOFAK Women Fighting AIDS in Kenya


Index

Sr.

No

Section Page No

01 Executive Summary 5-6

02 Introduction 7-8

03 Gunis – The Barefoot Doctors of Udaipur 8-9

04 About Jagran Jan Vikas Samiti 10

05 Field Research

(a) Research Methodology,

(b) Sample Size,

(c) Date from the field 1&2

11-14

06 Approaches to Address Healthcare Question 15

07 Economics of Mobile THP Clinics 16

08 Business Projections , BCR and

recommendation

17-19

09 Select Bibliography 20

Annex-1 : Social Map of Jagat Village 21


Executive Summary

Health is wealth goes an old adage. Access to healthcare facilities and their

healthcare services consumption ensures physical, mental and emotional well being

and thus enhancing economic well being. The wealth of health becomes even more

important in case of poor people simply because a large portion of their income is

result of physical labour. An episode of sickness means deprivation from a square

meal, indebtedness or may be worse

than that. India Census data reveals that

rural poor in India spend around 7% of

their annual consumption income on

healthcare.

India is a vast country facing mammoth

development challenges. To put it in perspective India’s

population surpasses whole of the Europe and Americas and sheer geographical

size surpasses EU member states. India Spent 4.2 % of its GDP on consuming

healthcare services in 2012 which is way lower than the developing countries like

Brazil and China and way lower than the developed countries like UK,USA etc

Public healthcare system in India faces a lot of challenges like understaffed public

health facilities and overcrowded health centres. On one hand, the country flaunts its

open market prowess, rate of economic growth and status of being world’s largest

democracy, However, at the same time around 32% (World Bank Poverty Data1) of its

1 http://povertydata.worldbank.org/poverty/country/IND 2 http://mospi.nic.in/Mospi_New/upload/nsc_report_un_sec_14mar12.pdf

Source: Accenture, 2014


population lives below poverty line of USD1.25 a day, 90% of the work force and

about 50% of the GDP are accounted for by unorganised sectors (Indian National

Statistical Commission,20122) and more than 70% of population lives in Villages.

Even though India has improved its HDI performance by 1.7% since 1980 (The ToI3),

unfortunately India fares extremely poor in UNHDI and ranks 136 globally

The GoI spends 2.5% of its annual budget on public healthcare systems, however

total healthcare costs though is as high as 6% of the GDP. Public expenditure is just

20% of total healthcare costs/year. Which means around 80% of the expenses are

out of pocket (The World Bank Open Data4).

Business Analysts are quite bullish and ride on the growth in the sector, according to

a report the health market in India is going to be of the tune of USD 158 Bn by 2017 (

CII,20135) . Health being the state subject issue in India, states perform at their own

pace and wholesome public health-care for poor is still a mirage.

It is in this context; this study explores and evaluates some banal questions

regarding accessibility of public health care services and how readily they demand

side barriers faced by common people in rural Rajasthan. The study attempts to

evaluate if traditional health practice could be employed in framework of social

business to ensure affordable healthcare service for poor. The research

investigations are carried out with the field support of the staff of Jagran – a

livelihoods NGO at Village Jagat and its adjoining hamlets viz Karakali, Bhatia-talao

and Road-da in Udaipur district of the Indian State of Rajasthan . The study is

2 http://mospi.nic.in/Mospi_New/upload/nsc_report_un_sec_14mar12.pdf 3 http://timesofindia.indiatimes.com/india/India-‐ranks-‐136-‐in-‐human-‐development-‐index/articleshow/18990526.cms 4 http://data.worldbank.org/indicator/SH.XPD.OOPC.ZS 5 http://www.slideshare.net/IBEFIndia/healthcare-‐august-‐2013


carried out as a part of the summer school programme at the Indian Institute of

Management, Udaipur India and Sanford Duke School of Public Policy, Durham NC,

USA.

The study is a diagnostic one and employs eclectic methodologies including

qualitative as well as quantitative. The report is product of 73 person interviews, six

focus group discussions across three hamlets6 ranging from supply-side players

namely public health service providers to traditional healers (gunis) and faith healers

( bhopa). On demand side, a conscious effort was made to meet and capture

information from various sections of village society.

6 A hamlet is a set of houses that are close together, share a community center, and constitute a separate entity. A village is an

administrative boundary. A village comprises 1-‐15 hamlets.


Introduction

The study was conducted in a village called

Jagat (and its adjoining hamlets viz Bhatia

Talao, Rod-da, Karakali ) of Gerwa tehsil in

Udaipur district of Rajasthan State under the

theme of health services . To put findings in

perspective a brief analysis of the key

indicators of state and the district are captured in this part of the report.

Rajasthan is the largest state of India in terms of geographical area and is located in

the western part of the country. Although, it constitutes 10.8% of the area, on

economic and human development indicators it fares poor. In relation to

population, Rajasthan ranks 8th in India (68 Million) which is around 5.6% of India’s

population7. On HDI indicators, it

finds its place among India’s

bottom seven states with an HDI

rank8 of 0.434 (whereas the national

average is 0.467). On economic

indicators, it lags far behind than

other Indian states; its Per capita

Income at current price is USD 587

which is way below the national

India average of USD 795, however

interestingly in terms of State Gross domestic product (SGDP) Rajasthan ranks at

number eight and contributes to 4.1% of India’s GDP (Planning commission of India

7 http://www.census2011.co.in/census/state/rajasthan.html 8 http://en.wikipedia.org/wiki/List_of_Indian_states_and_territories_by_Human_Development_Index


documents9 ). It is in this context, the state subject of public health remains a prime

focus and a challenging area for the state government

Narrowing down to Udaipur district where this study was conducted is one of the

poorest districts of Rajasthan State (and India). The district has 2479 villages spread

across ten sub-districts or blocks. Its total population is 2.6 million out of which

around 82% resides in rural areas. Udaipur is predominately a tribal belt with 60% of

population as schedule tribe in rural areas. In terms of HDI, Udaipur district ranks

20th among all districts in Rajasthan. The data collection took place between June

2014 and July 2014 across Jagat and its three hamlets of Girwa tehsil of Udaipur

district. . The study was conducted in partnership with a mid size reputed NGO,

JJVS.

Health Infrastructure in Udaipur District and Jagat

Source : Secondary Data Analysis & Field Survey

9 http://pbplanning.gov.in/pdf/Statewise%20GSDP%20PCI%20and%20G.R.pdf

Public Health Facilities

Numbers in

Udaipur district

Numbers in Jagat ,Karakali

and Road-da

Hospitals 8 0

CHCs 17 0

PHCs 76 3

Child & Maternal Health Centre 8 1

Ayurvedic & Homeopathy

Dispensaries

192

3


Gunis - Barefoot Doctors of Udaipur

District:

Guni10 is a word in hindi language which means ‘a

person of virtue’. A Guni is a traditional health

practitioner who learns the art and science of

traditional health practice and treatment from

existing gunis through undocumented informal

oral forms of learning.

Global Presence and Recognition:

Traditional health practioners are present all over

the world including North America, parts of Europe and Africa. There is tilt towards

traditional systems of medicines because of affordability, accessibility and perceived

safety (Management Sciences for Health policy document, 2012)11. Traditional

medicines are being used by WOFAK in Kenya to manage incidents of illness in case

of AIDS/HIV positive patients. Similarly Nelson.R.Mandela school of medicine at

university of KNZ at Durban, South Africa has developed a biomedical and

traditional healing collaboration against HIV/AIDS.

In India, Department of AYUSH, Ministry of Health and Family Welfare,

GoI vide its policy statement of 2002 provides recognition to the

existence of Traditional Local Health Practitioners. Government of

Manipur has formally recognised and acknowledged the role of

traditional health practioners/faith healers12 (Govt. of Manipur notice,

July 2011)

10 https://technoayurveda.files.wordpress.com/2011/05/201.pdf 11 http://www.msh.org/sites/msh.org/files/mds3-‐ch05-‐traditional-‐medicines-‐mar2012.pdf 12 http://manipurforest.gov.in/notifications/lhtt_notice.pdf

A Guni


In India, Gunis are categorised as traditional health practitioners and they are mainly

found in Udaipur district of Rajasthan state. Gunis primarily treat their patients by use

of herbs and plant based medicines. Gunis treat chronic diseases like

asthma,diabetes,arthritis, hypertension,kidney stones,skin diseases,jaundice,snake

bites, dislocated bones, muscle spasms etc

Traditional health practice is gaining immense currency under AYUSH system of

healthcare in India and being streamlined under NRHM. The traditional knowledge

of folk healers is duly acknowledged by Government of India’s National Policy on

Indian Systems of Medicines and Homeopathy13 .

13 http://indianmedicine.nic.in/writereaddata/linkimages/7870046089-‐Ayush%20%20n%20policy%20ISM%20and%20H%20Homeopathy.pdf

Gunis at Jagran's permanent THP Clinic: L to R – Velchand, Kalulal, Prithvi Raj ,Partapi Bai,Bhagwal Lal.


About Jagran Jan Vikas Samiti

Jagran Jan Vikas Samiti(JJVS) means an association

dedicated to public awareness and self-development

through cooperative efforts. JJVS is a non-governmental

organization registered as trust that focuses on socio-economic

improvements for rural and tribal communities in Rajasthan,

India. Since established in 1985 by Ganesh Purohit, Dhanwar

Dhabai, and Ram Kishore, JJVS has been working with these marginalized

communities by focusing on their traditional System of Medicine and Community

Development. Jagran is run by a 18 member full time and volunteer team. Jagran’s

headquartered in at Udaipur and works in the southern part of the district.

Jagran’s Mission

JJVs is committed to improving the lives of less fortunate people by encouraging

and assisting them in creating sustainable livelihoods. JJVS believes in full

participation of people in all activities to address local challenges

Jagran’s Vision

JJVS’s vision is to create an egalitarian society in which basic needs are fulfilled,

economic inequalities are minimized, and democratic decision-making provide for

the common good.

Jagran’s Approach

JJVS believes the best way to improve the socio-economic status of communities is

to encourage people to determine their own development. Jagran believes in

acknowledging the potential of individuals and communities to alleviate poverty

themselves.

Jagran’s Objectives

• Support appropriate rural development and agricultural-based industries

• Create local solutions to local problems


• Increase awareness about health and education

• Improve the effectiveness of government programs

• Conserve the environment and natural resources

• Organize the community for coordinated campaigns

Field Research

The research began as an exploratory study with a preliminary round of unstructured

interviews and FGDs conducted with various social groups at Jagat village and

adjoining hamlets regarding general socio-economic challenges faced by residents

on daily basis. This exercise was conducted to understand challenges faced by

residents and finally prioritisation of these challenges. The methodology adopted

was stratified convenient sampling as the field visits were supported by Jagran staff.

Based on the inputs received from local residents, theme of the research narrowed

onto public health related issues and accessibility to the available health services. In

this contact the research question was framed, is mentioned below:

1. To ascertain Degrees of access to formal health services system among

different communities in Jagat cluster14 and the alternatives.

Research Methodology:

The research was conducted using a stratified random sampling and both

Quantitative and Qualitative techniques were used to capture end respondents’

data. Tools like surveys, FGDs, Key Informant and semi structured interviews were

employed to capture data.

14 Jagat cluster includes Jagat Village and three other hamlets viz Karakali, Bhatia Talao and Road-‐da.


Sample Size:

Population of Jagat-cluster is 1013 HH. Data was captured from 65 HH by personal

interviews including six FGDs, 4 semi structure Key informant interviews conducted

in Jagat village and three adjoining hamlets in a longitudinal fashion.

Data from the field:

Figure 1

Total number of respondents contacted during the field visits between the months

of June & July were 73. Jagat village & adjoining hamlets were selected randomly.

Interestingly the sample was dominated by women(39 out of 73 were women) as


most of the times men were out of the house for manual labour or other household

works, thus researcher was able to contact those available and willing to participate.

Udaipur district itself is a ST dominated district with around 62% of tribal population.

The social stratification of the sample is in-line with the social construct of

communities with 62% of respondents being ST, followed by SC (18%), Gen (14%)

and OBC (8%). The team was able to get the highest number of respondents from a

ST dominated hamlet called Bhatia Talao. During the FGDs and personal interviews

maximum number of respondents in Jagat-cluster told that the first choice of health

service provider for them is Government PHC followed by Bengali doctor. Those

from OBC and general category could afford private healthcare at Udaipur.

Interestingly the data shatters some dominant myths about choice of villagers in

prioritising health service providers. Only 8.2% told they opted to use services of

traditional health providers –locally called Gunis and just 5.4% confirmed they avail

services of faith healers called Bhopas. However, less percentage cited here is in no

way a reflection on the efficiency of Gunis or Bhopas. One of the key reasons cited

by respondents in case of Gunis was that recovery time in case of THP system was

usually higher than the recovery time in case of Allopathic system of treatment.

Trade-off between quick relief and THP pushes people towards

dilapidated public health infrastructure (PHC/CHCs etc) and local

private service providers colloquially called Bengali doctor.


Figure 2

Another set of questions were targeted to ascertain status of healthcare finance,

exploring mobile phone as a channel to deliver health services and capture demand

side barriers to the access to health. Interestingly 14% of HHs owned health

insurance coverage (RSBY Health Insurance). This is very encouraging finding

because in Rajasthan just 3% of HHs (Reddy & et.al,Pg 25, PHFI 2011) have any form

of health insurance . However, the insurance percentage is again in-line with the

national health insurance coverage in India with is slightly less than 15% (DNA

News15), about 62% owned a checking account in bank – thanks to MGNREGA wage

payments which are routed through a bank account . Only 42% respondents

reported they own a mobile phone. However mobile phone ownership was

negligible among women folk and handsets were mainly owned by men. In terms of

15 http://www.dnaindia.com/health/report-‐health-‐insurance-‐in-‐india-‐still-‐remains-‐an-‐untapped-‐market-‐1891509


barriers to access public health services, the biggest barrier reported by villagers was

non availability of health care personnel at public health care service stations like

PHC &CHC. A health care research study in Udaipur (Bannerjee, Deaton &Duflo,

2012) corroborates finding that absenteeism is as high as 36-45% on weekly basis in

rural health service points (PHCs/CHCs etc) and has effect on public health

adversely. Cost of healthcare was interestingly not among top three barriers because

Indians shell out around 70% of their healthcare expenses from out-of-pocket16.

Interestingly qualitative data from discussions with PHC/CHC staff and multiple

FGDs revealed that access to health services is function of economic and social

status of villagers. Upper caste General category people almost always consumed

private health services in nearby Udaipur, whereas OBCs and SCs prioritised PHC

and CHC and eventually also accessed health services in Udaipur. It was only

economically disadvantaged and socially ostracised and weak Bhil17 community at

hamlet Bhatia Talab who had really hard time in accessing public health care

facilities at nearby Jagat Village (around 3Km). They could hardly afford to consume

private health services at Udaipur and were totally dependent on public health

services and some Gunis and Bhopas.

16 http://www.worldbank.org/en/news/feature/2012/10/11/government-‐sponsored-‐health-‐insurance-‐in-‐india-‐are-‐you-‐covered 17 http://rajasthan-‐tourism-‐guide.com/bhils-‐tribe-‐in-‐rajasthan.html


Approaches to Address Health Question

Barriers to access discussed above are key

impediments in ensuring a healthy village

society. It was also evident from the FGD

data that not everyone is village & hamlets

were equally excluded. Those with

purchasing power (mostly upper caste and

OBCs) were relatively better-off and thus

had lower degrees of exclusion to health

services than socially and economically disadvantaged community of Bhils of hamlet

Bhatia-Talao.

There are three potential solutions which

were explored;

(a) Mobile THP Clinic at Bhatia Talao for

chronic ailments,

(b) Mobile Phone based health solutions

like mHealth,

(c) A health Information campaign

across hamlets to increase

information about public health services

Mobile THP clinic is Social Business approach to address health issues at Bhatia

Talao. The model is hub and spoke based which involves running a 12 months pilot

project by holding non-stationery mobile health facilities once per week at the

hamlet (spike) and promoting follow-up visits by patients at permanent THP

clinic(hub) of Jagran located at village Vali which is 3.5 km from Bhatia Talao. Four

specialist traditional health practitioners (Gunis) along with an Ayurvedic medical

practioner would provide their services for eight hours at mobile THP on a

Proposed Location for Mobile THP Clinic at Bhatia Talao

Bhatia Talao Hamlet


designated day at a centrally located place. Mobile THPs are proposed to address

hurdles like staff absenteeism, distance, higher cost etc. Traditional Health

Practitioners are local people who live around same village and available 24x7 , they

don’t just provide medical consultation but herbal medicines to patients . The

supply chain is herbal and RAW material available locally thus, cost implications per

episode are far lower.

Based on the respondents views during FGDs and data collected during survey ( Fig

2), lack of health information was cited as one on the top 5 hurdles in accessing to

healthcare. Survey also revealed that around 42% villagers own mobile handset.

Thus, mHealth and health information campaign are other projects to address

health-care and information asymmetry.

Based on the soft infrastructure (mobile connectivity) in the hamlet, need of target

customers and institutional capabilities and SLRP of JJVS in the field of THPs plus

their willingness to explore the approach as a pilot, Mobile THP clinic approach is

suggested for implementation.

Economics of Mobile THP Clinics:

General Assumptions:

A set of general assumptions are made for working out detailed economics of

Mobile THP clinic. Assumptions on average no of patient foot-fall and cost of service

are made on the basis of FGD discussions. Villagers spend at-least INR 300/episode

of illness at present.

1. Average foot-fall at Mobile THP is 30 patients/clinic/week, which means 120

patients across 5 practioners(Gunis)/month,

2. Due to well designed publicity and targeted messaging there is increase of

5% footfall every month,

3. Each customer (patient) pays INR 40 as fee at mobile THP clinic.


4. Of all patients visiting at mobile THP clinic , 50% come for a follow-up visit at

permanent THP Clinic of JJVS at Vali village,

5. Pull based foot-fall at permanent THP clinic increases at the rate of 5% per

month,

6. The project is launched as a pilot for 12 months and upon encouraging results

continues for five years in the same format.

7. It is assumed that THP health services demand will grow at modest

12%/Year18 as against 15% country’s health sector growth rate.

18 India’s health sector grows at the rate of 15% per annum http://articles.economictimes.indiatimes.com/2013-‐12-‐02/news/44657410_1_healthcare-‐sector-‐healthcare-‐delivery-‐fortis


Business Projections

Gross Revenue at Mobile THP Clinic

Months

Projected Footfall per Month at Mobile THP Clinic (5% incremental/month)

Consultation fee/visit(INR)

Annual Revenue/Fee (at Mobile THP Clinic) INR

Sep 120 40 4800 Oct 126 40 5040 Nov 132.3 40 5292 Dec 138.915 40 5556.6 Jan 145.86075 40 5834.43 Feb 153.1537875 40 6126.1515 March 160.8114769 40 6432.459075 April 168.8520507 40 6754.082029 May 177.2946533 40 7091.78613 June 186.1593859 40 7446.375437 July 195.4673552 40 7818.694209 Aug 205.240723 40 8209.628919

G.Total

INR 76402.2073

Gross Revenue at Permanent THP Clinic during follow-up visits

Months

Follow-up visit Footfall at THP Clinic at Vali (50% follow-up

visits.

Consultant Fee at

permanent THP Clinic

at Vali (INR)

Annual Revenue/Fee at follow-up visit

(INR) Sep 60 50 3000 Oct 63 50 3150 Nov 66.15 50 3307.5 Dec 69.4575 50 3472.875 Jan 72.930375 50 3646.51875 Feb 76.57689375 50 3828.844688 March 80.40573844 50 4020.286922 April 84.42602536 50 4221.301268


May 88.64732663 50 4432.366331 June 93.07969296 50 4653.984648 July 97.73367761 50 4886.68388 Aug 102.6203615 50 5131.018074

G.Total

INR 47751.37956

NPV of Benefits:

Assumption: Benefits increase at modest 12% per-annum

Year Benefit NPV (INR) 0 124153.5869 124153.5869 1 139052.0173 8690.75108 2 155738.2594 608.3525756 3 174426.8505 42.58468029 4 195358.0725 2.98092762 5 218801.0412 0.208664933

G.Total 133498.4648

NPV of Costs

Assumption: Cost increases at 10% per-annum

Year Total Cost NPV (INR)

0 81600 81600 1 89760 5610 2 98736 385.6875 3 108609.6 26.51601563 4 119470.56 1.822976074 5 131417.62 0.125329605

G.Total 87624.15182


Interest Rate/Cost of Funds: 15% /Year

BCR: 1.523

Recommendation:

The study provided an opportunity to researcher to get in touch with both

stakeholders viz villagers, public and private health services providers, Government

officials, staff and management of JJVS –the partner NGO. In addition, a

comprehensive analysis of existing literature was done. Based on the feedback

during interactions with multistakeholders, discussions with villagers, review of

literature, primary data analysis, a few things became very clear:

(a) Any solution/approach has to be local so that the barriers of access primarily

distance and absenteeism are overcome,

(b) It has to be cost effective for consumers(villagers) ,

(c) Since partner NGO is an important stakeholder , any solution proposed

should be in synchronisation with partner NGO’s capabilities and strategic

Long Term Planning,

(d) Finally the project should generate adequate financial returns to be

sustainable.

Based on above parameters, this study recommends launch of Mobile

THP Health Clinics at Bhatia Talao hamlet


Select Bibliography

1. Akhilesh, Arora, Verma (2014) , Delivering e-health in India, Analysis and

Recommendations, Accenture India

2. Annual Economic Review (2012-13), Govt. Of Rajasthan,

3. AYUSH (2012), National Policy of Indian Systems of Medicine & Homeopathy,

GoI,

4. Banerjee,Deaton,Duflo (2004) ,Health, Healthcare and Economic

Development, Wealth, Health and Health Services in Rural Rajasthan ,

American Economic Association,

5. Basic Data Sheet of Udaipur district, Census (2001) GoI,

6. District Human Development Report Udaipur, Government of Rajasthan

(2010), Gudwani,Mitra et.al , India Healthcare: Inspiring possibilities,

Challenging

7. Journey,McKinsey&Company(2012),

8. Newsletter Vol 1, NCRI (2010)

9. Manipur Government Notice No.3/21/T&W/2010/MBB, 2011,

10. Poverty data, The World Bank open data website, 2014

11. Reddy et.al (20110, A critical Assessment of Existing Health Insurance Models

in India, PHFI,

12. Traditional & Complementary medicines policy, MSH (2012)


Annex-1 Social Map of Jagat

Social Map of Village JagatDist : Udaipur, Tehsil : Girwa, Vill: Jagat, Village Code:106607Pop’n: 3683, #HH: 791

SC&ST GENHariJans

9%

60%

31%

Social Stratification

SC ST Gen


For Feedback & Suggestions

[email protected]

Twitter: @jatinhandoo

.

degrees of access to formal health services system among different communities in jagat cluster and...

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