HEALTH INEQUITIES BY RAMA BARU

National Family Health Survey(NFHS) shows sharp regional and socio-economic splits/differences regarding health
sector with the lowest rung of the strata acc to caste and income, face much of the burden as well as the less-
developed states. This is true since high infant mortality and U5MR(mortality among children younger than 5years)
is inversely proportional to income and this gap is further supplemented by gender and caste divides .Kerala has
shown that educating mothers helps in bringing down the U5MR even in India. Though the All-India average of
U5MR has come down to 74(per 1000) from 101(per 1000) from 1998-2006, the inequalities have increased
especially inter-caste ones, it has worsened the most for the STs. The decade of the 90s has seen a decline in the
improvement of IMR.

Determinants of the Health Inequities

Historical inequities: origins from British Raj& its policies

Socio-economic : based on caste, class and gender

Provision & Access : mainly due to availability, utilization, affordability issues

Health Service provisions

Right from the post-colonial period, there was inadequate finances for health sectors and stronger emphasis on
urban areas, curative services which mainly included Allopathic medicines where the indeigenous medicines systems
like Ayurveda,homeopathy,siddha,unani had a limited role.

Public health institutes

Primary level: Sub-centers and PHC(Primary health center)

Secondary level: community health centres and hospitals

Tertiary level : teaching hospitals

The expansion of facilities hasnt been universal in coverage due to insufficient public investments and lacking
synergies between the role of the centre&state financing and the provisioning of the services since constitutionally
the states are responsible for implementation and centre for directing policies.

A small part of population are covered under public insurance schemes like employees state insurance
scheme,central government scheme,railways and posts and telegraph services.Around 11% are covered by both
public&private insurances.

Private-sector

For-profit and Non-Profit institutions are prominent in delivery of health services where the former is relatively
larger in size.

For-Profit: informal practitioners(largest chunk),clinics,small and large nursing homes, corporate

hosiptals,diaganostic centers and pharmacies.The clinics and small institutions come at the secondary level owned
by physician entrepreneurs and provide inpatient&outpatient services.Tertiary sector is mainly comprised of large
corporate hospitals with only 1-2% of beds in private sector.

Non-Profit : community-level programmes,dispensaries and hosiptals funded by religious organizations

The distribution of private-sector facilities are even more unequal and biased towards urban areas.
Inequities in Access

The main barriers to equity are as follows :

Availability of Care:

The parameters used are in terms of infrastructure,human resources,supplies,bed-population ratios and spatial
distributions.Inter-state variations can be best seen as Kerala and UP serve the extreme examples where thr former
has the best and latter, the worst record.The success of Kerala has essentially been due to the
investment&provisions by the state-government.Where UP has a had a history of high poverty levels and poor
health services&social development.

Utilisation of services

Preventive Services: services such as childhood immunization and ANC(ante-natal(pre-delivery) care) are
effective indicators for assessing the availability,access and quality at primary levels.The full immunization
coverage for All-India average was 44% in 2005-06 with an urban-rural differential of 19% i.e. 39% among
rural and 58% in urban areas. There has been variation among states with Kerala topping the charts and
UP on the wrong end of the table. However, Kerala has shown a drop in coverage from 80 to 75 % and this
can be attributed to financial and human-resource constraints in public health services. The Socio-
economic differences are also considerable.Coverage in the Highest earning groups is almost thrice of that
in lowest income quintile.STs(adivasis) at 31.3% and others at 53.8% are quite far apart in terms of
coverage.Both the groups have seen an increase in coverage but the gap has not narrowed.

ANC

All-India: 51% with rural at 43% and urban at 74%

Kerala: 94% with rural at 92% and urban at 97% UP: 26% with rural at 23% and urban at 41%

Curative services :In recent years, 80% of the times, private sector has been chosen for outpatient care
largely due to weakness in delivery of public health services. Stats for inpatient care were 42% in rual and
38% in urban areas which were 60% in the 1980s. Utilisation is directly related to the increase in income,
thus, in the absence of a public sector, the poor suffer. There are interstate variations in the usage of
these services, with Kerala and Tamil Nadu trumping Bihar and UP. Hospitalisation is ambiguous because
inspite of the public infrastructure, some states show a high dependence on private institutions.
Affordability of health services are determined by the costs and its impact on the households livelihood.
OOP expenditures include direct payments for medicine (major part), consultation, diagnostics and so on.
Indirect costs of loss of work due to illness are not included in OOP. The poorest rural quintile spends 87%
of their OOP on medicine, while the richest urban quintile spends only 65%.
Consumption of healthcare is a bigger financial burden in rural areas because people in urban areas have
easier access to health services. The expenditure burden from day-to-day morbidities (income loss due to
illnesses) is very high, specially in rural areas, as is the burden of hospitalisation.
The burden of health expenditure (bi) is given by:
bi = Xi/Ci
Where Xi is the expenditure burden (day to day morbidities and hospital) and Ci is the aggregate
consumption expenditure per household. This burden is highest for the poorest class, but its also high for
about 90% of the people. Only the very rich can easily afford it.
However, its different for inpatient care. Here, the expenditure burden is very high for the poorest and the richest.
The richest bear the burden of expensive private treatment at corporate hospitals.

Sources of Financing Healthcare: There are two main sources of finance Households own resources or
borrowings. In rural areas, about 20% of outpatient care is financed by borrowings, and it rises to 40% for
hospitalisation. This is more so for the rural population. Many times the poor finance this expenditure by
cutting down consumption of other members of the family.

Factors affecting Equity in Access to Health Services

1. Insufficient Investments in the Public Sector:

 The per capita bilateral and multilateral donor funding for health is one of the lowest for countries of the
same income level

Government spending, at approximately 20% of the health expenditure, is among the lowest in the world.

There exist large inter-state variations in availability of health services.

The private sector has expanded by drawing upon public subsidies, allowing public appointed doctors to
undertake private practice, tax concessions on medical technology imports and so on.

2. Unregulated Commercialisation and Rising Costs:

Due to unregulated commercialisation there is variability in standards and costs which lead to an
adverse impact in cost and quality of services.

The cost of healthcare in the private sector is uncontrolled

For a normal delivery, the cost in a public hospital is Rs. 0 to Rs. 128, whereas in the private
institutions it is Rs 472 to Rs. 1,573.

The Clinical Establishment (Registration and Regulation) Bill, 2007 seeks to regulate the private
and non-governmental health institutions by laying standards at secondary and tertiary levels.

Regulation of provisioning, pharmaceuticals and technology is still in its rudimentary state. Even
when legislation exists, the rules and stadards are not properly implemented.

3. Health Sector Reforms:

Introduction of market principles to improve efficiency and quality of healthcare as part of the Structural
Adjustment Program (1990s)

Introduction of User fees, contracting services to the private sector and private-public partnerships were
introduced.

In Andhra Pradesh, these reforms had resulted in greater utilisation of public health services. However, the
poorest are excluded due to user fees.

Tamil nadu Medical Supplies Corporation (TNMSC) has been successful in streamlining drug procurement,
distribution and cost control for public services. A drug committee identifies a list of essential drugs and
this is circulated to all healthcare institutions and pharmaceuticals. The committee invites tenders and pays
the supplier after quality control.

4. Variable Quality of Care in Public and Private Sectors:

It depends on technical competence, accessibility, amenities, staff, and supplies. Public sector suffers
from indifferent staff, lack of adequate infrastructure and so on.

Patients at Public institutions are dissatisfied because they are not satisfied by medical treatment or
lack of availability of services (rural) and long waiting (urban).

Healthcare practitioners are more skilled and knowledgable in richer areas, than poorer areas.

Informal practitioners adopt irrational treatments for communicable diseases and also for
maternal/postpartum care. This is highly dangerous and results in morbidities.

Private hospitals have a strong tendency to over-care according to the patients ability to pay.
 A study of rural private hospitals has shown that most do not have the facilities to provide even the
basic care. The doctors and nurses are not qualified enough and the record-keeping is inadequate.

5. Lack of accountability in Public and Private Sectors:

Corruption, Absenteeism and indifferent behaviour of the staff are areas that lack accountability
in the public sector. For private institutions, it is the over-use of technology and the unethical
practices.

Abenteeism is more prevalent in poorer areas, among primary doctors rather than health
workers.

Corruption is marked in the recruitment, transfer and promotion of personnel; admission for
medical education and procurement of technology.

Doctors earn commission for prescribing diagnostic tests and certain brands of drugs.

Accountability is not only a public sector problem, even private institutions suffer from weak
regulations.

6. Barriers for Marginalised Populations:

The poor get the least access to preventive and curative health services.

They face financial and cultural barriers in obtaining services.

Untreated morbidities are higher for women vs men, rural vs urban, SCs and STs vs Other Castes.

Equity Enhancing Initiatives

11th Plan Document: It took notice of link between poverty and ill health, weakness of public provisioning,
regulation of the private sector and the rising costs of healthcare. It provides for greater needs of the
marginalised sections.

All India Drug Action Network: Campaigned for a rational drug policy.

NGOs campaigned for the need to make health a right.

Jun Sunwais: Deal with the denial of healthcare to people and structural inadequacy to provide healthcare.
They put pressure on the government to regulate inequities.

National Rural Health Mission: The NRHM tries to address issues like underinvestment, human resources,
infrastructure and quality in the public sector. It also initiated several measures for accountability. There
are marked inter-state differences in the taking up of the program.

Rashtriya Swasthya Bima Yojana: RSBY is a health insurance scheme for those below the poverty line to
protect them from major expenses. But the burden is quite high for the rest of the population also.

The Way Forward

Most of the current programs are centrally sponsored by separate ministries with little or no coordination
between them. They tend to target marginal sections of the society. There is a need for a greater synergies
across ministries and levels of implementation.
 Regulation of private and public sector is required for controlling costs, improving quality and
accountability. A combination of legislation, professional organisations, consumer rights groups and public
action is needed for improved accountability.

New and innovative systems of monitoring and evaluating progress towards equity need to be introduced.
A health equity gauge that helps to track inequities, like those in South africa, could be implemented.

Health Security needs to become a priority. It leads to acceleration and sustainance of Economic Growth.
India needs to stand out as a distinguished middle income country with improved standard of living and
reduced levels of human deprivation.