National Seminar on Health Equity in India
Organised by SATHI
2nd & 3rd October, 2008
Purpose of the seminar
One of the key objectives of the "Maharashtra Health Equity and Rights Watch" project was to bring together public health experts, social scientists, health sector NGOs and health activists on the issue of ‘Health Equity’ to develop a discourse on this emerging area of concern in health sector. Similarly the project also aims at exploring possibilities of developing Health Equity research and advocacy by interaction with similar groups across the country. Thus, this seminar was intended to fulfill both these objectives.
Specific objectives of the seminar
In this seminar, the following sessions were designed to cover various aspects related to the issue of Health Equity in India.
This note briefly outlines some of the concerns and issues that were discussed in various sessions of the seminar.
Session I: Socioeconomic inequities in India
In the last two decades, India, termed the biggest democracy in the world is going through economic turmoil. Economists and politicians are going gaga over the growth rate, which had reached above 9% in the year 2006-7, however the fact that this growth is highly skewed in nature is being completely disregarded or is deliberately pushed under the carpet.
The worrisome facts - that there are still 302 million people below the official poverty line (which is considered an under-estimate of the large population deprived of basic necessities of life), about one third of the adult population is below the BMI of 18.5 and more than half of the children below age of 5 years are anthropometrical failures i.e. they are either stunted, wasted or underweight - seldom get any prominence in official documents or media.
The fruits of the global economy are enjoyed by a small section of the society whereas large sections are bearing the brunt of this morbid model of development. As noted by the Research Unit for Political Economy ,
“ … as the NCEUS has pointed out, consumption by the top 4 per cent of the population recorded in the NSS grew at more than six times the rate as consumption by the bottom 36 per cent of the population.”
“A recent study based on income tax returns calculates that the share of the top 1 per cent of Indian households in national income doubled between 1981-82 and 1999-2000 ...”
“This picture of a very skewed distribution of income or expenditure fits in with press reports of an even more skewed distribution of assets: namely, lists compiled by Forbes and Business Standard of the number of billionaires in this poverty-stricken country. …In all there are 53 Indians on the list, with a combined net worth of $334.6 billion (about Rs 13.38 trillion). Their combined wealth increased by 75 per cent over the previous year. … Another way to get a sense of the size of the wealth of the billionaires’ wealth is by comparing it to India’s GDP. The wealth of the Forbes 53 would be around 28.5 per cent of India’s 2007-08 GDP; that of the Business Standard 533 would be around 29.3 per cent of India’s 2006-07 GDP.”
Even today more than half of the country’s population is dependent on agriculture and allied industries for survival. But the share of agriculture in growth of GDP is showing consistent decline over the past decade. (4.72% during 1992-96, compared to 2.30% during 2002-2006). The crisis situation in the agrarian sector has resulted in growing income inequities since incomes of large sections are stagnant or declining whereas a small subset of the population is enjoying very high and growing incomes. This income inequity clubbed with weakening of State intervention in social sectors such as education, health care and public distribution of food grains has resulted in disastrous situation for the poor, especially those who reside in rural areas.
Access to determinants of health like safe drinking water, hygienic living conditions and food security is directly correlated with socioeconomic conditions. As per NFHS 3 survey findings, forty-eight percent of the population in urban areas is in the highest wealth quintile; in contrast only 7 percent of the rural population being in the highest wealth quintile. Similarly, half of the persons in scheduled-tribe households and about one in four (27 percent) persons in scheduled-caste households are in the lowest wealth quintile.
It is essential to examine the inequities in access to determinants of health along with the discussion on inequities in health status and health care access across various groups. (Since each of these determinants requires in depth attention, in its current activity in Maharashtra, the SATHI team has decided to focus attention on one important determinant i.e. nutrition. As a linked activity, we are in a process of bringing out a report on the nutritional crisis and would be organizing a separate workshop on this crucial area.). Food security being vital for maintaining nutritional status and health was touched upon in this seminar.
Availability, access, utilisation and stability of food sources which constitutes food security has a direct impact on nutritional status and health. The 61st round of National Sample Survey (2004-05) shows that the daily average per capita intake of food grains and consumption of calories has reduced in successive NSS rounds from 2266 Kcal in the 27th round (1972-73) to 2047 kcal in the latest round (2004-05) in rural areas. All these figures are lower than the recommended daily intake of 2400 Kcal. Similarly the decrease in urban areas in the same period is from 2107 to 2020, the latter figure being below the recommended of 2100 Kcal for urban areas.
Hence another key presentation in this session was particularly focusing on the agrarian crisis in India as it is critical to understand both declining food security and the widening socioeconomic disparities.
This session was intended to outline the broader picture of socioeconomic inequities, so that the discussion on health inequities can be located in the context of our inequitable socio-economic system and the current model of ‘predatory growth’, which has been well analysed by Prof. Amit Bhaduri –
“As the privileged thin layer of the society distance themselves from the poor, the speed at which the secession takes place comes to be celebrated as a measure of the rapid growth of the country. Thus, India is said to be poised to become a global power in the twenty first century, with the largest number of homeless, undernourished, illiterate children coexisting with the billionaires created by this rapid growth. An unbridled market whose rules are fixed by the corporations aided by state power shapes this process. … No society, not even our mal-functioning democratic system, can withstand beyond a point the increasing inequality that nurtures this high growth. The rising dissent of the poor must either be suppressed with increasing state violence flouting every norm of democracy, and violence will be met with counter-violence to engulf the whole society. Or, an alternative path to development that depends on deepening our democracy with popular participation has to be found. Neither the rulers nor the ruled can escape for long this challenge thrown up by the recent high growth of India.”
The session was chaired by Prof. Amit Bhaduri. Following presentations were made in this session.
- Food Security by Dr. Jaya Mehta
Dr. Jaya Mehta spoke about overall socio economic inequities and issues of food security. Download presentation
- Agrarian crisis in India by Dr. Srijit Mishra
The presentation particularly focused on the agrarian crisis in India as it is critical to understand both declining food security and the widening socioeconomic disparities. Download presentation
Session II: Perspectives on health equity
The concept of Health equity is a rich and evolving concept, which is not devoid of debates and contention. While the value of applying a health equity approach might be broadly accepted by most researchers and even policy makers, there are differing opinions about the kind of policy options which should be adopted in order to achieve greater health equity. Keeping this in mind, during this session the following areas were dealt with -
• Discussing some key definitions of health equity in order to more clearly delineate what we understand by the health equity approach; distinguishing between horizontal equity (equal resources for equal need) and vertical equity (greater resources for greater need)
• Contextualising health equity, by clarifying that this approach is not a ‘stand alone’ viewpoint, but rather it complements and reinforces the following existing perspectives and approaches relevant to the health sector -
• Recognising that a wide spectrum of policy implications can be derived, drawing justification from the Health equity approach. These vary in the degree to which they are focused on certain social sections or take up a comprehensive, society-wide agenda, and the degree to which they take the form of ‘system adjustment’ or ‘system change’. Some measures that may be adopted to strengthen health equity include -
It is obvious that these approaches are not mutually exclusive and there is considerable overlap between them. Nevertheless it is considered useful to differentiate between various approaches while deciding about which combination may be adopted. Needless to add, the seminar organizers have a specific perspective and certain preferences about which policy approaches should be adopted to achieve health equity in a comprehensive manner, which were presented during the seminar as an input to further discussion.
• Identification of the specific value that is added by incorporating a Health equity approach in our work. As mentioned above, the Health equity approach is neither something fundamentally new, nor a ‘stand alone’ panacea for the health sector. It needs to be adopted and developed in conjunction with various complementary pro-people perspectives and approaches within and beyond the health sector. Having said this, there are certain definite advantages that may flow from adopting a Health equity approach -
• In this session, an analysis of the manner in which the recent report of the WHO Commission on Social Determinants of Health deals with Health Equity issues was also presented.
This session was chaired by Ravi Duggal. The presentations in this session included-
- Perspectives on Health Equity by Dr. Abhay Shukla
Dr. Abhay Shukla gave an overview of various perspectives on health equity as they exist today. He enunciated the overlap between equity approach and other approaches such as Social justice principles, the Right to Health approach, comprehensive PHC approach, integrated health system approaches and other such approaches. Download presentation
- Equity and Health- Final report of the commission on social determinants of health by Dr. Amit Sengupta
Dr. Amit Sen Gupta discussed the equity approach as articulated in the WHO Commission on Social Determinants of Health document.Download presentation
Session III: Overview of health status and health care access inequities at national level
After looking at various perspectives on Health Equity, it was worthwhile to actually look at the data regarding health status and health care inequities in India. The following session threw light on the important statistics as revealed from various rounds of the National Family Health Survey and NSSO surveys. This session also deliberated upon underlying policy related issues such as inequities in health care infrastructure in rural and urban areas.
For example, the World Health Survey India (2003) report reveals that the availability of health professionals per 100,000 population is greater among urban population compared to rural, higher income quintile compared to lower income quintile. Physicians are three times higher in urban areas compared to rural areas. The primary work location of the health professionals indicates that almost four-fifth of the physicians (79 percent) are working in private health facilities, whose services are available only to those who can afford their fees.
This inequitable distribution of human resources is one of the examples of the underlying processes which result in health status and health care access inequities. Similar inequities can be shown in budgetary allocation for public health in urban and rural areas. The report of Commission on Macroeconomic and Health indicates , “In India, as in most countries, there is a clear urban-rural, rich-poor divide. Affluent sections, urban populations and those working in the organized sector covered under some form of social security such as the ESIS or CGHS, have unlimited access to medical services. The rural population and those working in the unorganized sector have only the tax-based public facilities to depend on for free or subsidized care, and private facilities depending on their ability to pay. The impact on equity then gets determined on whether the tax-based public facilities are able to provide a similar quality of care as provided under the Social Health Insurance Scheme. Because, if funding is low and the quality of care falls below expectation, is inaccessible, entails informal payments, etc. then the benefit of free care at the public facility gets neutralized with the second option of paying out-of-pocket to a relatively hassle free private provider available close by, making the system of financing inequitable as well as inefficient.”
Dr. D. Narayana chaired this sessions. This session comprised of following presentations-
- Health Inequality in India- Evidence from NFHS III by Dr. U. S. Mishra
Dr. Mishra provided the evidence of Health Inequality in India on the basis of NFHS 3 data. He underlined the importance of studying both the actual income levels and the income inequalities together while studying health inequalities. Download presentation
- Health Policies and Inequities by Ravi Duggal
Ravi Duggal discussed underlying policy issues which lead to health inequities at national level. Download presentation
Session IV: Gender dimension of Health Inequity
The subsequent session was dedicated to understanding the gender dimension of health inequity. Gender inequities often include both types of inequities i.e. vertical inequities as well as horizontal inequities. Moreover, women have to face additional health risks due to the inferior status ascribed to them by society. Gendered division of workload, reproductive responsibilities coupled with inadequate nutrition and violence make women further vulnerable to ill-health. Gender inequities in access to health care and health status are based on gender inequities reflected in the health system, and inequitable distribution of resources within the community as well as within the household. It may also be kept in mind that gender interacts with socio-economic status, and these key stratifiers may interact with each other. As noted by Aditi Iyer et al –
“Responses to long-term ailments showed elements of class inequalities as well as both types of gender bias—pure and rationing. These class variations can themselves be properly understood only through a gender lens. Apparent class differences in non-treatment, discontinuation, or continuation of treatment were almost entirely due to differences among women rather than men. … Rationing through discontinuation of treatment was an important phenomenon and was particularly gender-biased among poor households in quintiles 2 and 3. Men in these households seemed to be able to insulate themselves and to pass on the burden to women. However, in the poorest households, where women perhaps could be pushed no lower, men were also forced to curtail treatment. This shows just how acute the problem of health care affordability has become, and how rationing systems at work within households reproduce gender and economic inequalities.”
The Report of the Women and Gender Equity Knowledge Network (WHO Commission on Social Determinants of Health) highlights the role of gender in strongly interacting with other axes of inequity
“Gender intersects with economic inequality, racial or ethnic hierarchy, caste domination, differences based on sexual orientation, and a number of other social markers. Only focusing on economic inequalities across households can seriously distort our understanding of how inequality works and who actually bears much of its burdens. Health gradients can be significantly different for men and women; medical poverty may not trap women and men to the same extent or in the same way. The standard work on gradients and gaps tells us easily enough that the poor are worse off in terms of both health access and health outcomes than those who are economically better off. But it does not tell us whether the burden of this inequity is borne equally by different caste or racial groups among the poor. However, it does not tell us how the burden of health inequity is shared among different members of poor households. Are women and men, widows and income-earning youths equally trapped by medical poverty? Are they treated alike in the event of catastrophic illness or injury? When health costs go up significantly, as they have in many countries in recent years, do households tighten the belt equally for women and men? And are these patterns similar across different income quintiles? This poses a challenge for policy to ensure not only equity across but also and simultaneously within households.”
These are some of the challenges which necessitate specific attention to gender inequities in the context of other dimensions of health inequity. Thus this session was aimed at taking stock of the situation in India regarding the concerns articulated above.
The session was chaired by Renu Khanna and following presentations were made in this session.
- Gender and Health- Challenges for Research and Advocacy by Dr. Lakshmi Lingam
Dr. Lakshmi Lingam (Tata Institute of Social Sciences) addressed the issues related to lack of access for women on one hand and on the other hand there is also evidence that there are cases of misguided access which can be seen in the case of alarmingly rising number of hysterectomies. Download presentation
- Gender Inequality as reflected in Health Research by Neha Madhiwalla
Neha Madhiwala presented the various mechanisms in which patriarchy through the systems like household, markets and the state agencies create gender inequities. Neha drew attention to the fact that gender inequities are not just the gaps between men and women but we need to look at the gap between aspiration and opportunity, between need and access and between rights-entitlement and provisioning. These points were further illustrated using the examples from the field research conducted by CSER. Download presentation
Session V: Moving towards a system for Universal access to health care
While discussing inequities in access to quality health care, in the Indian context we are confronted not only with inequities emanating from the public health system, but more importantly the inequities generated by predominance of the much larger private medical sector. As we know, the private medical sector in India commands nearly 80% of allopathic doctors and provides about 80% of outpatient care and 60% of inpatient care. Due to charging of fee-for-service by almost the entire private medical sector, this situation translates into massive class based and urban rural inequities (which overlap with each other) in access to health care. For example, according to NSS 60th round data, in rural areas 24.1% persons in the poorest MPCE class reported non-treatment of ailment spells, compared to only 5.5% in the richest MPCE class in urban areas. In rural areas, financial constraints were cited as reason for non-treatment of illness episode by 28% of those who had not availed of treatment (NSS 60th round, 2004), this proportion having increased from 24% in the previous NSS round (NSS 52nd round, 1995-96).
In this situation, there is a clear need to devise methods of regulating and harnessing the predominant private medical resources in a manner that rational health services become available to all without any constraint of ability to pay. This envisages moving towards a system for universal access to health care which would ensure equity in access to health care. Keeping this in mind, in this session following aspects were discussed -
• Modes of regulation of the private medical sector, with a view to rationalizing and harnessing private sector resources towards a system for Universal access to health care. Legal regulation to ensure minimum physical and humanpower standards in private facilities is conceptually relatively straightforward, yet even this long overdue measure is yet to be implemented across the country. Further the more complex yet crucial issue of regulation of rationality of care needs to be tackled urgently and decisively, since curbing of large scale over-medication and irrational medication, over-investigation, unnecessary surgeries etc. would lead to both major reduction in overall health care expenditures as well as better health care outcomes.
• Modes of interaction between the public health system and the private health sector towards universal access. Here in contrast to the dominant form of ‘Public Private Partnerships’, we may like to explore forms of public control and accessing of private medical resources which expand access to health care in a rational and equitable manner. Here, for example, the criterion of strengthening Public health facilities (as possible in specific types of insourcing of skills) instead of weakening the public health system (as seen in most types of outsourcing), may need to be considered.
• Discussing the features of an equitable health care system, such as -
Some key experiences of processes in other developing countries (e.g. Thailand, Brazil, Costa Rica, Sri Lanka) which have achieved universal access to health care may also be touched upon in the discussion.
This session was chaired by Dr. Vandana Prasad and Dr. Amar Jesani was a discussant for this session. The presentations in this session included-
- Regulation and harnessing private sector resources towards a system for Universal access to health care by Dr. Muraleedharan V.R.
Dr. Muraleedharan gave the rationale for regulation of private sector and elucidated the conceptual framework for health sector regulation. In his presentation, Dr. Muraleedharan also commented about the enforcement of regulation taking Transplantation of Human Organs Act 1994 and Consumer Protection Act 1986/1995 as examples. Download presentation
- Modes of interaction between public and private health sectors towards universal access by Dr. T. Sundararaman
Dr. T. Sundararaman discussed the modes of interaction between public and private health sectors taking examples from National Rural Health Mission, which is the flagship programme of UPA Government. In his presentation, Dr. Sundararaman highlighted the need for harnessing the private sector for universal system for health care access. He presented the various dimensions of Public Private Partnerships as they exist today under NRHM.
- Options for a universal access system in India by Dr. Abhay Shukla
Dr. Abhay Shukla presented various options for a system of Universal access to health care in India. Taking examples of health care systems in Thailand and Brazil, he demonstrated the feasibility of Universal system in India. He elaborated the features of an equitable health care system and principles of universal access. Download presentation
Session VI: Health Equity issues related to NRHM
NRHM is a major programme to improve rural public health services, introduced by the UPA government in April 2005. One of the objectives stated in the mission document of National Rural Health Mission is that NRHM seeks to improve access of rural people, especially poor women and children, to equitable, affordable, accountable and effective primary healthcare.
The NRHM - ‘Framework for Implementation’ document mentions that - “Promoting Equity is one of the main challenges under NRHM. Empowering those who are vulnerable through education & health education, giving priority to areas/hamlets/households inhabited by them, running fully functional facilities, exemption for below poverty line families from all charges, ensuring access, risk pooling, human resource development / capacity building, recruiting volunteers from amongst them are important strategies under the Mission. These are reflected in the planning process at every level. Studies have revealed the unsatisfactory health indicators of socially and economically deprived groups and NRHM makes conscious efforts to address this inequity. The percentage of vulnerable sections of society using the public health facilities is a benchmark for the performance of these institutions.”
Keeping this context in mind, this session was aimed at discussing the strategies enunciated in NRHM to address health inequities in India, and examining the specific strategies and extent to which NRHM is addressing the massive challenge of reducing inequities in health status and access to health care in India.
To emphasise a community-oriented perspective, this session took into account the findings of the People’s Rural Health Watch report, which is a Jan Swasthya Abhiyan initiative to audit the performance of health services in rural areas, with a focus on NRHM.
Dr. Raman Kutty chaired this session. NRHM perspective was presented by Dr. Sundararaman.
Dr. Indira Chakravarty made a presentation on Inequities in Health Services- Equity Concerns in NRHM. Indira presented the findings of the People’s Rural Health Watch report. She delineated the approaches of NRHM to equity like the commitment to increase central budgetary allocation for health, a community health worker (ASHA) at the village level, and the formulation of Indian Public Health Standards (IPHS) etc. Download presentation
Session VII: Broadening Health Equity activities in India
Concluding session of the seminar was in a form of a group discussion, which was moderated by Dr. Anant Phadke. Some of the suggestions regarding health equity research and advocacy initiatives were as follows:-
Suggestions related to health equity research-
1. Health equity research should include measurement of inequities in the health outcomes, health care access and the underlying processes which lead to these inequities.
2. Health equity approach can be applied for monitoring in cases such as tracking the progress towards Millennium Development Goals.
3. Need for studying various dimensions of gender inequities was reiterated.
4. It was suggested that we should start a website/ blog / e-group for regular exchange and circulation of relevant background material.
5. This forum can also be used for discussing the nuances of health equity issue.
Suggestions regarding advocacy
Since a system of Universal access to healthcare was proposed as one of the approaches for reduction in health inequities, it was suggested that this approach needs further detailing so that our demands for this system become more precise. This may then be taken by other platforms like JSA for advocacy.
The seminar concluded on a positive note with a resolution to continue this dialogue.
Overall, the seminar was successful in initiating a discourse on the issue of health equity in India. The presentations by the speakers and the discussions that took place in these two days brought out various dimensions of health equity in India. We are hoping to continue this interaction in the group in future.