Social Inequalities in Health Ch 4

8/6/2019 Social Inequalities in Health Ch 4

1/10

Healthnequity nd DemocraticeficitA View romEast ndNorthFast ndia

THE TEAMToa BRccnrMurnr.Esun RaHauaN G,q,nMaNanr MaluuoanS,,NcRAN4uxnenlnePxrya.NxaNaNoyKuunnRaNaPra SpN

ADDITIONAL ACADEMIC SUPPORTSusurraBaNrn;ee tNoM.a.NasEssanxan


2/10

Ineq a ities4. Social nd Economic

in HeathIn the Mahabharata\,Dharma disguised as ayaksha asksKing Yudhisthira: 'lMhatis the greatest achievement of humanity?" The King answered decisively,"Recovery from ill heaith".

The Mahabharatais not the only ancient text to have emphasisedthe role ofhealth and healthcare in human development. Nevertheless, it is only recentlythat the concern for health has taken a "public" line, departing from its eadier,privileged-class exclusivity. And, with growing discourse on democracy andclarity surrounding the concept of development, the discussionand actions onpublic health have tended to follow a line that takes into account the social andeconomic diversitiesof a gtven region, and their implications on health. In AmartyaSen'sanalysis, zrl,rng health status among different sections of the population iscaused by their varying social and economic conditions. V/hile "women emergeas s1'stematicallyunderprivileged vis-a-vis men", this discrimination is furtherextended to different castesand classes.2 he WHO Commisssion on SocialDeterminants of Health observes:

The poor health of the poor, the socialgradient n healthwithin countries,and the marked health inequrties betrveen countries are caused by theunequal distribution of power, income, goods and services,globally andnationally, he consequentunfairness n the immediate, visible circumstancesof peoples' ives - their access o health care, schools and communities,towns or cities - and their chances of leading a flourishing life. This


3/10

A Vr tur noraI

several other diversities has perhaps become more acutely subiected to theimplications of the "toxic combination of poor socialpoJiciesand programmes,unfair economic arrangements,and bad politics." It is perhaps uninformed politicsthat lead to poor financial allocation on health. But, at the same time, we mustrecognise that it is poor social policies and consequent implementational failurethat add to an uneven delivery of public health services,where the medicalisedview of health, with a high class-bias, eigns supreme. This results in an unevendevelopment of the health facilities grving way to a burgeoning private sector.For example, according to recent statistics the number of hospitals grew from1.1.,174ospitals n 1991 to18,218 n 2003.But in this growth the public sectorhasgone down from 43 percent to 25 percent.aAgain, in 2000, the country had1.25 million doctors, but the ratio of doctors to population in rural areas salmost six times lower than that in the urban population.s Again, the ratio ofhospital beds to population in rural areas is fifteen times lower than that forurban areas.6Per capita expenditure on public health is seven times lower inrural areas, compared to government health spending for urban areas. Only'l.7ohof all health expenditure in the country is borne by the state, and 820/ocomes as'out of pocket payments'by the people. This makes the Indian publichealth system grossly inadequateand under-funded. Only five other countries inthe wodd are worse off than India regarding public health spending @urundi,Myanmar, Pakistan, Sudan, and Cambodia;.7 This resulrs in poor healthachievement, which we vrill discuss presently focusing upon some indicators.SunvrvRLNEeuAllr/Let us begin first by undedining survival inequality. In a country where morethan 50 children per thousand do not even see their first birthday, any public


4/10

j L+ Hrp.rrururQutrvnn DrivtlcRLttr::lttir

Table 4.1 Infant Mortaliry Rate among different social *t:*"@

ProPortion of AgriculturalLabourers and IMR in Selected States

" , ' : :

9080706050

*'t jKD

ASM TPRT * INDj** \{tsMEG


5/10

* A Vrrv.r.ncr,,rlsr ann N

According to the data presented in the Table 4.1the infant mortality r tediffers across different economic classes:children in the lowest wealth quintileare more than twice as ikely to die before completing oneyear as the children inthe highest wealth quintile. Importandy, there are regional variations in degreesof economic disadvantage,caused to a Iarge extent by the differential in stateattention on health. According to NFHS III data, n orissa IMR is the highest inthe lowest income group (79.8) and is the lowest among the highest incomegroup Q8). Let us take another example. The overall performance of \festBengal in reducing IMR looks promising, but with a substantial gap of 7,38points between rural and urban areas in this respect, indicating poor policyfocus on health in the rural areas, inhabited largely by the poor and sociallydisadvantagedgroups. There is a strong indication that residing in rural India,belonging to a Scheduledcaste or a scheduled Tribe, and having a ow economicstature have become predictors of ill-health and health inequity in our country.e

From an analysisof the IMR10 and census data for the select stateswe finda very strong correlation between the proportion of agricultural labourer in theworkforce and IMR. The correlation coefficient, (* 0.51), implies that withhigher proportion of agricultural labourers in the workforce, the IMR alsoshoots up.Figure 4.1.,cleaiy lllustrates hat the proportion of IMR hasbeen considerably

higher among the agicultural labourers - who according to census data arcmore likely to belong to SC, ST or other backward classesand religious minorities.Also, a strong correlation between Female Literacy Rate (FLR) and IMR wasfound - the correlation coefficient of O0.61 is indicative of the strong negativeassociation of rvomen's access o primary level education and the mortality oftheir children.9080 +

nEALTI- i l ' , JFQUl lYNU l . lLMULT{AlrL r


6/10

JO

NurRrrroruarNreuRrtwThe story does not end here. Children who survive face gross nutritionaldiscrimination leading to poof health of the population. Undernutrition hasbeen a maior concern in India and its inflated level is ^ m ttef of serious woffy'Forty two pef cent of children under five yeats of age

are underweight whichindicates their being denied of basic nutritional requirements in the very firstyearsof their life.11n \WestBengal thirty nine pef cent areunderweight suggestingchronic and acutemalnutrition.

Table 4.2 Nutritional Inequality among Children in Different Social Groups and Economic Classes

Again, the regional contfasts in undernutriotion are glaring: it is acute inBihar (55.9 per cent) and Jharkhand (56'5 per cent)' followed by N{eghalaya(48.8per cent),while the rate s much lower in Mizotam (19'9 per cent)' Sikkim(19.7 per cent) and Manipur Q2.I per cent)' Once againwe find a connecflonbetween he nutritionai leveland the wealth ndex of the households.A decreasein family income appears to contribute to a higher Percentageof underweight


7/10

West Bengal 63 per ceqt of children comes under the normal grade and 33 percent of children comes under grade I and grade II level which is moderatelyunderweight and four per cent of children are in the grade III and grade IVlevel which is severelyunderweight. But, the district-vzisevariations in nutritionaldeficiency are wide: the proportion of children in the normal grade iscomparafively higher in Darjeeling and North 24 parganas (75 per cent) and thepercentage of children in the grade III and grade IV level rs the highest inPaschim Medinipur(l3 per cent).12The nutritional problem is comparativelylower among the Hindus than among the Muslims. In \westBengal the differencebetween the Muslims and the Hindus in this regard s of 2.6 percenragepoints(Hindu - 40.3,Muslim - 37 7),while in Tripura it is n the order of 17percentagepoints (Hindus - 36.5 and Muslims - 53.5).As regardssocial dentity. the nutritionaldeficiency is higher among the Scheduled tribes followed by the Scheduledcastes. In \il/estBengal he underweight children among SCs,STs and oBCs are40, (r0and 23 per cent respectively. utJharkhand hasperformed very poorly rnthis respectwherc under-wcight hildrenamong SCs,STs,and OBCs are77,79and 67 per cent respectivel )r.Pni rrlLt wcLo f: ANl/\[ v1l\ Ati]) I' i 5or-t - ti,r.truotvic D vtDt:

A Vrrw nor.,l ;rsr NDNcrlH Ensr llnrn 37

Anaemia is a very common ailment in india, a direct result of nutritir>nalcleficiencies.Anaemia has a detrimental effect on the health of women and

Table 4.3 Prevalence of Anaemia among children from different social groups and economic classes

As*xtn : :Anin*chtiPradb-sh69.656,g.41.1,64.4442NA59.2 '


8/10

38 Hrnru trrQutn.n nDrl'tocRpltctrtcit

children, and may become an undedying causeof maternal moftality and pennatalmortality. It also results n an increasedrisk of premature delivery and low birthweight of children. It is a serious problem for young children because it can,.rJt in impaired cognitive performance, behavioural and motor development'coordination, language development and scholastic achievement as well asincreasedmorbidity from infectious diseases'

Despite such dire implications, our public policy has not yet been able topfotect sevenry per cent of chjldren from becoming anaemic.l3V/hile there isno palpable g.rrd.r difference in the prevalence of anaemiaamong children(thegap widens ^t ^l^tef stage), here is a close linkage with the anaemrastatusof tn.it mothers. Almost fifty-five per cent of women in India suffer fromsome kind of anaemia.

That the social underdogs afe more vulnerable to ^n emiacan be seenfromthe NFHS data. For example, in \flest Bengal the highest :ra;te f anaemia isfound among ScheduledTribe or adivasiv/omen (78 per cent) and correlatively"lso "-ong Scheduled Tribe children (86 per cent)14, hus establishing therelationshif between a mother's health and that of her biological child' Similarpattern is evident in the neigbouring states. t is observed that this prevalence ofanaemiadecteasesvith inctease n female literacy and alsowith an improvementin the wealth quintile status. Promoting female htetacy,therefore, appears o beone maior social intervention in our attempt to enhance equity in health.

Table 4.42Prevalence of Anaemia among women from different and economic classesocial grouPs


9/10

A Vrr i ; n

There appears a wide gender gap in anaemiaamong adults: while anaemiaamong women in the country is 55 percent t is found tobe 32 per cent amongmen. The statesunder consideration,all exlubit a similat pattetn (exceptingM*ip*discussed n detarl n the previous section). Again, anaemiais found to be higherin rural areas,among children with illiterate parentage,men, women and childrenbelonging to scheduledcasteand scheduled ribe communities, and, obviously,among the poor.

Itrreunitrv NAccrss rn l-" lEALIH{AR[Large scalesurveyshave observedthat a higher percentageof poor do not seekcare when ill. The reasons vary from lack of adequate health facilities in theviciniry to long waiting times to financial reasons; hus covering the enrire gamutof inequality. A recent study has shown that people belongrng to the highereconomic classesuse their personal reference to 'manage' better facilities andhealth c^re at the hospitals.Despite being neligible for BPL cards, hey use hesecardsto avail free services.rs

Not much seems o have changedover time in terms of improved access otreatment for those who belong to the low income groups. Although servicesare avitlable the very focus of these public health facilities, namely, cheap andfree services to the tradiuonally disadvantaged and the impoverished, hassomehow become lost over time, leaving them vzith no option other thandepending on the unqualified privatemedicalpractitioners for their basichealthcarerequirements.Various studieshave addressed his basic ssueof the problem ofaccess o health care delivery. Unfortunately, however, as we can see, he picturehasstill remained largely the same.Age-old problems still exist within our deliverysystem,and despite numerous attempts, much remains to be achieved.People


10/10

Dircrr

Documents

Social Inequalities in Health Ch 4