The need to address structural inequality in the provision of healthcare in India

Inequality as a fact of life has been long embedded into our everyday consciousness. From broader socio-economic disparity to uneven access to education and health to even inadequate knowledge of and protection by law and administration, it permeates most aspects of our everyday existence. Although cyclical factors are responsible to an extent, most are structural in nature and origin. However, no other inequality possibly hurts both individuals and communities as much as unequal access to healthcare services does.

Structurally, the unequal access to healthcare chiefly operates at two levels. One, at the demographic level, wherein one’s gender, caste, income, age, and education mainly determine his/her availing of healthcare services, qualitatively as well as quantitatively. And two, at the regional distributional level where inter-state, rural-urban and small-town-big city differentials come into play.

The state of affairs at present: the demographic inequality

Demographically speaking, gender has been one of the core faults lines along which that gulf between healthcare haves and have-nots has persisted for long. Not only are the key statistics such as sex ratio, female life expectancy at birth, maternal/neonatal/infant mortality rate, maternal care &nutritional access, among others, abysmal, the deep-rooted social stereotypes also gives them limited access to medical services in general. A Harvard university research conducted in collaboration with AIIMS and Prime Minister’s Economic Advisory Council has revealed that only 37% of women get access to health care, as compared to 67% of men.Based on another observational study, nearly twice as many hospital visits were made by men and boys vis-à-vis women and girls in the younger age groups.

Also, the proportion of expenditures on health is typically more for the poorest households than the wealthy ones.

Moving on from gender, caste divide has been another factor bedevilling healthcare access. Besides lower access to use of preventive and maternal services, discriminate physical restrictions and longer waiting time for lower caste groups is a routine affair. Research shows that lower caste groups were denied entry into private health centres and clinics in about 21% of villages, or if admitted, received discriminatory treatment in 10-15% of the villages.

Then in terms of age, research advances that healthcare financing falls among inpatients aged 60 years and older implying that households avoid using distressed or emergency resources for older age people.Likewise, those less educated and aware are likely to face greater hurdle in accessing healthcare.

The locational/regional inequality

Not only India is notorious for its rural-urban divide in terms of healthcare access, there is a glaring inter-state and intra-state differential too. According to a NITI Aayog report, whereas Kerala, Andhra Pradesh and Maharashtra were top performers, Bihar and UP have remained at the bottom. Based on a WHO report, in terms of density of health workers, there was a 6-fold differential between Bihar, the state with the lowest density and Chandigarh, the state with the highest density. Similarly, UP’s concentration of nurses was less than half the share of the state in the national population. Interestingly, West Bengal had 30% of all homeopathic doctors in the country.Then within these states, there is a gap between different districts.

What is the way forward?

First and foremost, there has to be recognition at the top policymaking and government levels that there is a twin problem of demographic issues as well as distributional disparity which hampers the emergence of an equal and equitable access to healthcare services in the country.

Second, in order to address the demographic aspect, there is a need for evolving individual policy frameworks for individual factors. For instance, while the social component of gender imbalance as well as caste discrimination can be attended to through stronger legal interventions and conducting awareness campaigns, the economic part can be dealt with through educational and general economic/financial empowerment of women and weaker castes. Compulsory state sponsored health insurance schemes that provide essential health cover to all citizens particularly those who are disenfranchised would ensure that everyone can access healthcare. Primary care too has remained vestigial in India for a variety of reasons. This means that the healthcare load of the population lands almost entirely on hospitals, an expensive way to serve the people with basic ailments. The setting up of a robust primary care system would go a long way in correcting this anomaly. Additionally, civic amenities and services such as those relating to hygiene, garbage disposal, pure drinking water, open drainage etc needs to be rapidly shored up. It must be reiterated here that communicable diseases are primarily caused by a lack of these factors. If made available these would certainly reduce the health burden in the country. Relatedly, the income inequality can be tackled through broader economic policy measures. Preferably, creation of several thousand pockets of local healthcare economies drawing on local resources spread throughout the country would go a long way in creating both local health infrastructure and a value chain lifting people’s income, which in turn would improve their healthcare access.

Third, in order to deal with the distributional imbalance, a comprehensive nation-wide health infrastructure development roadmap must be prepared which envisages touching every village and even every nook and cranny in the country. Resource allocation and deployment must be based in accordance with the population of each state, district and village while considering the prevalence of specific health issues and diseases in each region. There must be a redistribution of and shift from excessive resource investment into metros and big cities to smaller towns and rural areas. While providing for primary care centres at the smallest administrative units, it must also be ensured that the quality of personnel and services is not compromised. At the same time, quality secondary and tertiary care centres as also a few super speciality hospitals must be built in tier II and III towns. Low-cost high-quality service models need to be worked out to cater to these underserved segments. With private sector taking the lead in setting up secondary and tertiary care facilities, the government should extend full support through simpler and relatively inexpensive land acquisition policies, tax incentives and modest utility costs, among others.

Fourth, given that health is a state subject, states should offer full support while raising their own health expenditure as a proportion of the state’s GDP. Needless to say, the Centre must raise its health expenditure share to around 5 percent of the GDP.

Fifth, preventive care must be given added attention through greater adoption of medical devices such as blood pressure monitor, blood glucose monitor etc while using technology to maintain online health records. Prodded by recent Covid19-induced higher hygiene and sanitation consciousness, this culture would strengthen preventive care there-by addressing inequality.

Sixth, there is also need for capacity building. Besides setting up of medical schools in the remotest corners, the medical educational curricula and training must be improvised in a way that it creates more qualified young professionals while encouraging them to serve in smaller towns and villages. Compulsory posting in the smaller towns and countryside should be a mandatory part of course completion and certification.

Thus, to address structural issues, the government must also ensure that apart from core health aspects, those ‘outside health’ such as the provision for basic consumption and essential commodities is also made to everyone. The mantra is to lift all boats together and not in phases and pockets.

It must be remembered that like education, good health is a precursor to the prosperity of a Nation. Hence our fervent hope is that policy makers take note of the urgency to address structural inequalities in healthcare in India to enable its continued progress.



Views expressed above are the author’s own.



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