HEALTH EQUITY: THE INDIAN CONTEXT

Subodh S Gupta

Health Indicators among selected countries

Country IMR (per 1000 LB)

MMR (per 100,000 LB

Female Life Expectancy (yrs)

India 58 259 66.9

China 32 56 74.2

Japan 3 10 86.1

Republic of Korea

3 20 81.5

Indonesia 36 230 69.9

Malaysia 9 41 76.2

Vietnam 27 130 73.5

Bangladesh 52 380 65.1

Nepal 58 740 63.4

Sri Lanka 15 92 77.5

National averages often mask substantially worse outcomes

for many disadvantaged groups of population

Infant Mortality Rate according to wealth quintiles

Poorest Q2 Q3 Q4 Richest0

10

20

30

40

50

60

70

80

IMR

IMR

Infant Mortality Rate in different states according to wealth quintiles

Poorest Q2 Q3 Q4 Richest0

20

40

60

80

100

120

IndiaTamilnaduGujaratBiharUttar PradeshRajasthanAssam

Framework for identifying pathways leading to health inequities

Introduction

The political economy context The organisational structure and delivery

mechanism Health financing mechanisms Coverage patterns Current status of health and health care

Per Capita Gross Domestic Product (PPP)

Percent population below poverty line (GOI data)

The Political Economy Context

Second most populous country A democratic federal structure; subdivided

into states and Uts; further into districts Local levels of governance (Panchayat Raj) Health – a state subject

Alapuzzha in Kerala Vs. Kishanganj in Bihar

Characteristics of Indian Health System

Complex mixed health system - Tax based health finance system with small health insurance sector

- Publicly financed government health system - Fee-levying private health sector

Health Expenditure in India

Sources of Health Care Financing in Different Countries

Financial Protection in Health Individuals should be able to access

health care when they need it and not be prevented from doing so by excessive cost.

When they do access health care, they should not incur costs that prevent them from obtaining other basic household necessities such as food, education and shelter.

Catastrophic Health Expenditure

If health expenditures exceed a certain percentage of household income or capacity to pay, and therefore drive a household into poverty or prevent a household from buying other essential items including food and education.

Twelve percent of households have catastrophic health expenditure.

About a third of poor households have catastrophic health expenditure.

Impoverishment due to catastrophic health expenditure is higher (about half) among middle economic status households.

Percent of Households Compromising or Postponing Consumption Decisions after Seeking Inpatient Care(3 Districts, West Bengal)

Relative Share of Sources of Financing to Pay for Inpatient Care(3 Districts, West Bengal)

Percent of Rural Persons with an Illness who could not Seek Treatment due to Financial Constraints, by Economic Quintile(3 districts, West Bengal)

Effect of Economic Reforms on Public Health

Increasing unregulated privatisation with little accountability to patients

Systematic deregulation of drug prices resulting in skyrocketing prices of drugs

Selective intervention approach instead comprehensive primary health care

Health Inequity in outcomes

Rural/ Urban/ Urban (slum) Inter/ Intra state Socio-economic status Gender Caste Religion

Coverage with health services according to wealth quintile

Imm

unizat

ion

Cover

age

Skilled

Pro

vide

r at b

irth

Use o

f mod

ern

cont

race

ptive

IFA

cons

umpt

ion

>90

020406080

100

24.4 19.434.6

10

33.2 31.843.5

13.2

46.9 49 49.8

21.5

55.367.2

55.2

30.6

71

88.8

5849.1

Poorest Q2Q3Q4Richest

U5 Mortality Rate in different states according to wealth quintiles

Poorest Q2 Q3 Q4 Richest0

20

40

60

80

100

120

140

160

IndiaTamilnaduGujaratBiharUttar PradeshRajasthanAssam

0

10

20

30

40

50

60

70

Lowest Second Middle Fourth Highest

5749

4134

20

Underweight by Wealth Quintiles

Percent

Undernutrition in Children under Age 5INDIA

Percent

Undernutrition Among Children Under Five Years

47

1619

2022

2629

3236

3941

4445

4648

DR 2007Swaziland 2006-07Zimbabwe 2005-06

Cameroon 2004Kenya 2003

Malawi 2004Guinea 2005Nigeria 2003

Mali 2006Cambodia 2005-06

Ethiopia 2005Madagascar 2003-4

Niger 2006Nepal 2006

Bangladesh 2007India 2005-06

Prevalence of under-weight higher in India than in any of the other 40 countries with DHS surveys in the last 5 years.

Percent underweight (NCHS/WHO Growth Reference)

Poor Nutrition as a Contributing Factor to Under-Five Mortality

Contribution to Under-5 Mortality

Severe malnutrition 11%

Mild to moderate malnutrition

43%

Neonatal deaths

Malaria

Measles

Other causes

Diarrhoea

ARI

Poor nutrition contributes to 54% of deaths under age 5

NFHS-1 (1992-93)

NFHS-2 (1998-99)

NFHS-3 (2005-06)

934 926 918

Fem

ales

per

1,0

00 m

ales

Sex ratio of population age 0-6

Trend data provides strong evidence of declines in the sex ratio of the population age 0-6 and the sex ratio at birth….

…females are under-represented among births and over-represented among births that die.

NFHS-1 (1987-91)

NFHS-2 (1993-97)

NFHS-3 (2000-04)

936 931910

9911,011

1,045

Sex ratios at birth of live births and births

that have diedLive Dead

• After the first month of life, girls are more likely to die than boys: The child mortality rate is 61% higher for girls than for boys.

Lowest Second Middle Fourth Highest

41

28

18

95

2418

116 4

Female Male

Wealth quintile

Child mortality: Deaths between the ages of 1-4 years per 1,000 children surviving to

age 1 year

The three different levels of government action

First Level: The Macro LevelThe level of the government's national budget. Here, the major concern will be the amount of resources allocated to health, but an important secondary concern will be the possible reallocations of budgets to reach poor people better.

Second Level: The Health System LevelHere, the concern will be to put together reforms and improve incentives to get the system to function better for poor people.

Third Level: The Micro LevelThe service delivery level, where the focus will be on how to implement specific activities to reach poor people.

Work at these three levels is interdependent

Health Financing

Pricing policies that reduce and/or eliminate user fees for basic services;

Cross-subsidization of health services that benefit the poor;

Strengthening exemption mechanisms services; Expanding social insurance to cover informal

sector workers; Developing community-financing arrangements; Developing equity funds to pay for the poor

Thank youAchieving health equity within a generation is possible. It is the right thing to do, and now is the right time to do it. - Commission on Social Determinants of Health