health equity: the indian context subodh s gupta
TRANSCRIPT
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