By Mayurakshi Dutta, Sucheta Sardar*
India has been historically struggling with inequalities in health. It has negatively affected the health and the accessibility to healthcare of the populations marginalised as a result of their gender, caste, religion, location and economic standing. The experiences of different groups of people during the COVID-19 pandemic has proven that social and economic inequality leads to inequalities in health and access to healthcare.
The impact was severely felt during the second wave of the pandemic which has been incomparable in its scale with any global counterparts. Maria Van Kerkhove, the World Health Organization’s COVID-19 technical lead, said, “We have seen similar trajectories of increases in transmission in a number of countries, [but] it has not been at the same scale, and it has not had the same level of impact and burden on the health care system that we’ve seen in India.”
Inequality in health and in access to healthcare systems has been further amplified by the weak public healthcare system, exploitative private players and government interventions that have failed to incorporate the specific needs of the poor and the marginalised groups in its action plans.
Under-prepared Public Healthcare
The public healthcare system in India with its weak and understaffed infrastructure has been overburdened with the consistently rising cases. Private healthcare providers, on the other hand, were charging exorbitant prices, preventing the middle-class and the poor from getting diagnosed and treated until the government intervened to cap their prices.
Even then, private healthcare has remained inaccessible to the poor while the rich have easily availed its services. As such, the poor and the vulnerable have mostly been dependent on the overburdened public healthcare facilities—with insufficient number of beds and inadequate human resources—for treatment or have gone without being diagnosed and treated.
The health system could gradually cope as the daily cases declined from the month of October in 2020 but was not prepared for the second wave which shook the country from April 2021 and was to be significantly worse than the experiences of the past year. India’s failure to expand its health infrastructure proportionate to its population and the inherent inefficiency and shortage of healthcare delivery systems contributed to the weeks of crisis.
Hospitals were accommodating patients beyond their capacity, the acute shortage of oxygen supply brought uncertainty to COVID-19 victims with dwindling oxygen level and crematoriums were incessantly burning with those who lost the fight against this infectious virus. Oxygen and drugs were black marketed at such high prices that its procurement by the poor was impossible, denying them an equal shot at surviving the virus.
A public health researcher and a professor, Keerty Nakray, from Jindal Global Law School has underscored the other side of the coin which ignited the grim and overburdened health situation that India has witnessed. She refers to it as the ‘complete collapse of the preventive side of public health’.
By this, she means the precocious declaration of victory over the pandemic by the Prime Minister of India and the election rallies and religious gatherings which were devoid of the prescribed safety protocols. The message that the virus has been defeated spread across the system: “The health care people are not ready. No one’s procured the oxygen. No one’s gotten any sort of preparation done… When the virus came back, the system was wholly unprepared.”, said an epidemiologist, Lakshminarayan, corroborating Nakray.
Media reported the rich escaping the havoc of the virus to safe locations in private jets costing millions while the middle class and the poor have hung to a thread struggling to get a hospital bed, oxygen and lifesaving drugs.
The Poor and the Marginalised Find It Harder to Follow Protocols
Staying-at-home and social distancing have been additionally promoted by the government along with other safety measures such as wearing of masks and frequent handwashing to curb the spread of the virus. However, maintaining social distance and other sanitary prescriptions become extremely difficult to follow for people who live in cramped spaces and use community toilets. The average household size in India is 4.45 and 59.6 percent of India’s population lives in a room or less.
The precarious nature of living conditions of the marginalised and poor sections of the population makes it extremely difficult for them to follow sanitary prescriptions. Moreover, with no provisions for a separate room in case one has to quarantine, their distress has only increased. It has been easier for the rich and even the middle class to stay at home and follow safety protocols simply because of access to more space.
Non-Covid Illnesses Go Untreated
With the lockdown aimed at checking the spread of COVID-19, health systems prioritized services related only to COVID-19. Human and material resources like hospitals, beds and intensive care units were diverted towards the management and treatment of COVID-19 patients.
Health services catering to non-Covid illnesses were halted, leading to unprecedented hardships and sufferings for chronic patients and those requiring immediate medical intervention such as pregnant women. Accessibility to non-Covid medical services were grimmer for patients in rural and hard-toreach areas as compared to urban areas due to the unavailability of health centres in the vicinity and the lack of transportation facilities.
Disruptions in the availability of drugs for noncommunicable diseases (NCD), tuberculosis (TB), contraceptive and other essential services were also reported. Telemedicine—the practice of caring for patients remotely—for which guidelines were issued by the Government of India in March 2020 to facilitate access to medical advice made consultations easier. However, for those with no smart phones and internet connectivity, particularly in rural and hard-to-reach areas, seeking medical advice remained a difficult task.
The immunization drive was also disrupted. India vaccinates around 20 million children every year and its disruption might add to the largest number of unimmunized children in the world.
The closure of government health facilities for nonCovid services and loss of livelihoods and incomes combined obstructed the poor from seeking medical care. This inability of the public healthcare services to accommodate the underserved population comprising of the poor, marginalised and women portrays the inefficiencies of the public healthcare system in India to make healthcare accessible and affordable to all.
Overview of india’s public healthcare system
The Health Survey and Development Committee, also known as the Bhore Committee (1946), laid the cornerstones of modern health in independent India with the goal of making healthcare services available to all citizens, notwithstanding their ability to pay. It endorsed targeted interventions for the vulnerable sections of the population through setting up primary health centres (PHCs), recognized ruralurban disparities and made the rural areas, with the district as a unit, the focal point of their proposed development plan.
Other committees such as the Mudaliar Committee (1962) and the Chadha committee (1964) recommended that each PHC, responsible for providing promotive, preventive and curative services, should cater to a population of 40,000 and the provisioning of one basic health worker per 10,000 populations, respectively.
However, public healthcare provisioning, particularly at the primary level has remained poor. The National Health Profile in 2017 recorded one government allopathic doctor for every 10,189 people and one state-run hospital for every 90,343 people. India also ranks the lowest in the number of hospital beds per thousand population among the BRICS nations— Russia scores the highest (7.12), followed by China (4.3), South Africa (2.3), Brazil (2.1) and India (0.5). India also ranks lower than some of the lesser developed countries such as Bangladesh (0.87), Chile (2.11) and Mexico (0.98).
Low Budget for Health
The poor provisioning of public healthcare can be attributed to consistently low budget allocations. The current expenditure on health, by the centre and the state governments combined, is only about 1.25 percent of GDP which is the lowest among the BRICS countries—Brazil (9.2) has the highest allocation, followed by South Africa (8.1), Russia (5.3) and China (5). It is also lower than some of its neighbouring countries such as Bhutan (2.5 percent) and Sri Lanka (1.6 percent). The low priority given to health expenditure is also reflected in the share in total expenditure of the government, which is only 4 percent whereas the global average stands at 11 percent.
In Oxfam’s Commitment to Reducing Inequality Report 2020, India ranks 154th in health spending, fifth from the bottom. This poor spending is reflected in the inadequate health resources and infrastructure. Only around 50,069 health and wellness centres (HWCs), which are envisaged to deliver comprehensive primary healthcare (CPHC) closer to homes, are functional. These centres are only 65 percent of the cumulative target for 2020-21. Moreover, in 2019, less than 10 percent of PHCs were funded as per IPHS norms whereas the rest remained underfunded.
Different studies have proved that low public health expenditure yields worse health outcomes. Studies by Barenberg et al. investigated the impact of public health expenditure on Infant Mortality Rate (IMR) and found a negative relationship between the two. Farahani et al. evaluated the relationship between state-level public health spending of India and individual mortality across all age groups using household-level data from the third National Family Health Survey (NFHS-3) showing that a 10 percent increase in public spending on health decreases mortality by about 2 percent, with effects mainly concentrated on women, the young, and the elderly.
Bhalotra, on the other hand, restricts the sample to rural households and finds a significant effect of health expenditure on IMR by using rural households’ sample. Mohanty and Behera investigated the effects of public health expenditure on various proximate and ultimate health outcomes during 2005-2016 across 28 Indian states to find that per capita public healthcare expenditure has an adverse effect on infant and child mortality rate, as well as malaria cases, and a favourable effect on life expectancy, and immunization coverage across states.
Dependence on Private Care Providers Leads to High OOPE
India’s low spending on public healthcare has left the poor and marginalised with two difficult options: suboptimal and weak public healthcare or expensive private healthcare. In fact, the out-of-pocket health expenditure (OOPE) of 64.2 percent in India is higher than the world average of 18.2 percent. Exorbitant prices of healthcare has forced many to sell household assets and incur debts.
Though asset selling has reduced to a certain extent, over 63 million people are pushed to poverty every year due to health costs alone, according to government estimates.35 A study shows that around 74 percent of hospitalization cases are financed through savings while 20 percent of the cases are financed through borrowing. In rural areas, however, the main source of healthcare financing continues to be selling of household assets and mortgaging ornaments to borrow at high interest rates, followed by income/ savings. The increase in private healthcare providers along with the weak public healthcare system that has failed to address socioeconomic determinants of health has led to inequalities in health.
Inequalities in health
The signing of the Alma-Ata Declaration in 1978 shows that India acknowledges the impact social inequalities have on health. Even so, the status of health and access to healthcare has remained unequal. Different literatures have propounded that the burden of illhealth is borne disproportionately by people of lower socioeconomic status.
Jungari and Chauhan studied the inequalities in health status of women and children in India from NFHS-3 data to find that the STs and SCs from poor wealth quintile and North Indian women and children are at a greater disadvantage in all indicators of women and child health as compared to other groups.
Moradhvaj and Saikia examined gender disparities in healthcare expenditure and healthcare financing strategy on girls and women aged 15 and above and found that average healthcare expenditures are lower for women in adult age groups compared to men regardless of the type of disease and duration of stay in the hospital.
Inequalities in health also exist among countries. The status of health in India has improved over the
years across many indicators such as IMR, Under-5 Mortality Rate, Maternal Mortality Rate but ranks lower in comparison to its neighbouring countries and BRICS counterparts.
For instance, the global average for life expectancy is 72.6 years but India (69.42) remains below the global average. It is also lower than the neighbouring countries Nepal (70.8), Bhutan (71.8), Bangladesh (72.6), and Sri Lanka (77) and its BRICS counterparts Brazil (75.9), China (76.9), and Russia (72.6).41 Similarly, access to healthcare has improved from a rank of 153 in 1990 to 145 in 2016 but is lower than Bangladesh (132), Sri Lanka (71), Bhutan (134) and its BRICS countries Brazil (96), Russia (58), China and South Africa (127).
Inequality reduction through UHC
To ensure and improve access to quality healthcare services for all, the High Level Expert Group constituted by the Planning Commission of India in October 2010 recommended the implementation of UHC. The WHO defines UHC as a health system in which all individuals and communities can access a full spectrum of essential and quality health services from health promotion to prevention, treatment, rehabilitation, and palliative care, without suffering any financial hardships.
It is thus, not just a health financing system or a mechanism to provide a minimum package of health services. It encompasses all components of the health system: health service delivery systems, the workforce, facilities and communications networks, technologies, information systems, quality assurance mechanisms, and governance and legislation. It simultaneously ensures a progressive expansion in coverage of health services and financial protection as more resources become available.
It also includes population-based services such as public health campaigns, adding fluoride to water, controlling mosquito breeding grounds, and so on. A comprehensive provisioning of public health as water, sanitation and primary healthcare is the most efficient and cost-effective way to achieve UHC around the world.
Evidence from Thailand and Sri Lanka, which have performed better than India with regard to universal access to healthcare, shows that these countries have a high public provisioning of services. Also, evidence from developed countries like Germany, Sweden, Canada and developing countries like Costa Rica reveal that successful insurance-based healthcare system was attained with high levels of public spending and government provisioning of healthcare services.
The guiding principle behind UHC is non-exclusion and non-discrimination, comprehensive care, financial protection and protection of patient’s rights and guarantees. The goal is to ensure that every citizen can avail good quality primary, secondary and tertiary healthcare while also reducing OOPE. If UHC in its truest sense is applied to India, its implications will be manifold.
Existing health inequalities could be reduced to a great extent through UHC as public health can reduce the disease burden and address social determinants of health and public healthcare will provide quality and affordable health services which will be accessible to economically and socially marginalised groups without incurring any financial shock. It has the potential to reduce inequalities in health.
In the words of Amartya Sen: ‘No country has ever successfully provided universal health coverage without the strong support and commitment of the public health sector.’
However, the government of India has adopted health financing selectively through insurance as a way to achieve UHC without paying heed to infrastructural and workforce gaps of the public health sector. Insurance-based systems alone provide very little incentive for capacity building and for the promotion of primary and preventive care.
*Excerpts from the chapter “The Need to Examine Health Inequalities” in “Inequality Report 2021: India’s Unequal Healthcare Story”, published by Oxfam India. Click here to download full report