Background Odisha has a high proportion of Scheduled Tribe (ST) and Scheduled Caste populations with low access to health services and poor health outcomes. Strategic equity-oriented initiatives by the state government have begun to reduce the equity gaps in health, nutrition and water, sanitation and hygiene (WASH) outcomes. The departments of Health and Child Development elaborated a Health Equity Strategy (2009) and a Nutrition Operation Plan (2010) to pursue equitable health and nutrition outcomes. This study supports the government to take stock of progress made, identify the remaining gaps and priority areas for future action. The study highlights how government mediates and impacts the social determinants of health, nutrition and WASH through its strategies, programmes and policies.

Methods We used four methods of inquiry: (1) literature and document reviews; (2) analysis of quantitative data from two concurrent monitoring surveys (CCM) capturing outcomes, access to and use of service delivery and health, nutrition, and WASH behaviours; (3) collection and analysis of primary qualitative data in Balasore and Malkangiri districts; and (4) analysis interviews and round-table discussions with stakeholders in three departments (health, nutrition and WASH).

Findings Health, nutrition and WASH outcomes show areas of reduced inequity between CCM-I and CCM-II. Institutional delivery rates increased from 40% to 70% among ST and from 45% to 83% among SC in 2014. Postnatal care was similar across caste/ethnic and income groups in the range of 62% to 66%. Reported full immunisation coverage was over 70% across all caste and tribal groups. The fastest increase in coverage was observed for scheduled tribes from 59% in CCM-I to 71% in CCM-II. Use of impregnated mosquito nets was highest among Scheduled Tribes, and higher in nutrition High Burden Districts (HBD) than in non-HBD.

CCM-II found that less than 72% of children had received Take Home Ration in the previous month, as was the case for 60% of pregnant women. The low receipt of Take Home Ration for children cuts across all income, caste and tribal groups. CCM-II also found that safe drinking water access is highest among Other Backward Castes (OBC) and among the poorest families.

A sharp social gradient in access to sanitation was observed ranging from 1.7% among the poorest to 64.3% in the richest households, reflecting the need for continued focus on the poor. Access to toilets in schools also varied widely with 85% of schools in HBD having separate toilets for boys and girls as opposed to 73% of schools in non-HBD.

Discussion The government of Odisha has created an enabling environment by developing gender- and equity-friendly strategies, programmes and policies, including increased financial outlay and prioritisation. Human resource policies in the health sector including placement of doctors in rural areas and enhanced benefit packages for remote and rural postings have helped fill staffing gaps to some extent. The manifold increase in the drug budget to address high out-of-pocket spending on drugs, and the targeting of financial resources to vulnerable areas and facilities are some of the approaches that are being used to address the equity gaps. Systems strengthening and targeted approaches have translated into significant improvements in access to and utilisation of services in all the three sectors for vulnerable groups.

Aggregate improvements are seen in areas such as (1) antenatal care coverage; (2) institutional delivery; (3) immunisation; (4) exclusive breast-feeding; and (5) availability of safe drinking water. However, focus has been on maternal health care, leaving non-reproductive health problems in the population unattended or with inadequate budget allocation. Also home visits by field workers, early initiation of breast-feeding, timely complementary feeding and access to latrines need more attention. Care for children under three years of age from poorer families, where both parents go out to work needs to be worked out.

Equity gaps have reduced in indicators like antenatal care, institutional delivery, immunisation and early initiation of breast-feeding. However, gaps remain in outcomes like malnutrition levels and child mortality rates. Out-of-pocket spending on health care still remains significant, mainly related to demands for informal payments. Hygiene education and programmes for adolescents have not received sufficient priority so far.

In Odisha, health, nutrition and WASH departments recognise intersectoral convergence as an area that needs strengthening, especially to improve outcomes in remote areas and reduce the disparity among various social groups and economic classes.

No competing interest.