Elsevier

The Lancet

Volume 377, Issue 9764, 5–11 February 2011, Pages 505-515
The Lancet

Series
Health care and equity in India

https://doi.org/10.1016/S0140-6736(10)61894-6Get rights and content

Summary

In India, despite improvements in access to health care, inequalities are related to socioeconomic status, geography, and gender, and are compounded by high out-of-pocket expenditures, with more than three-quarters of the increasing financial burden of health care being met by households. Health-care expenditures exacerbate poverty, with about 39 million additional people falling into poverty every year as a result of such expenditures. We identify key challenges for the achievement of equity in service provision, and equity in financing and financial risk protection in India. These challenges include an imbalance in resource allocation, inadequate physical access to high-quality health services and human resources for health, high out-of-pocket health expenditures, inflation in health spending, and behavioural factors that affect the demand for appropriate health care. Use of equity metrics in monitoring, assessment, and strategic planning; investment in development of a rigorous knowledge base of health-systems research; development of a refined equity-focused process of deliberative decision making in health reform; and redefinition of the specific responsibilities and accountabilities of key actors are needed to try to achieve equity in health care in India. The implementation of these principles with strengthened public health and primary-care services will help to ensure a more equitable health care for India's population.

Introduction

India accounts for a substantial proportion of the global burden of disease, with 18% of deaths and 20% of disability-adjusted life-years (DALYs).1 Although the burden of chronic disease accounts for 53% of deaths (44% of DALYs), 36% of deaths (42% of DALYs) are attributable to communicable diseases, maternal and perinatal disorders, and nutritional deficiencies, which suggests a protracted epidemiological transition.2 A fifth of maternal deaths and a quarter of child deaths in the world occur in India.3, 4 Life expectancy at birth is 63 years for boys and 66 years for girls, and the mortality rate for children younger than 5 years is 69 per 1000 livebirths in India—higher than the average for southeast Asia (63 per 1000 livebirths).5

These data, however, mask the substantial variation in health within India. Although health outcomes have improved with time, they continue to be strongly determined by factors such as gender, caste, wealth, education, and geography.6, 7, 8 Caste in India represents a social stratification: categories routinely used for population-based monitoring are scheduled caste, scheduled tribe, other backward class, and other caste; scheduled tribes (8%) and schedules castes (16%) are thought to be the most socially disadvantaged groups in India.9 For example, the infant mortality rate was 82 per 1000 livebirths in the poorest wealth quintile and 34 per 1000 livebirths in the richest wealth quintile in 2005–06.10 The mortality rate in children younger than 5 years who are born to mothers with no education compared with those with more than 5 years of education was 106 per 1000 livebirths and 49 per 1000 livebirths, respectively, during 1995–96 to 2005–06 (figure 1). The variation in mortality in children younger than 5 years in different states tends to be largely associated with the extent of the economic development of the state (figure 2). India has substantial geographical inequalities in health outcomes—eg, life expectancy is 56 years in Madhya Pradesh and 74 years in Kerala; this difference of 18 years is higher than the provincial differences in life expectancy in China,15 or the interstate differences in the USA.16

Many of the inequities in health result from a wide range of social, economic, and political circumstances or factors that differentially affect the distribution of health within a population. Since some of these inequities in health result from the unfair distribution of the primary social goods, power, and resources, the social determinants of health need to be addressed (panel 1).23, 24 A primary goal of public policies should be to address any inequities in health, with health systems having a special and specific role in the achievement of equity in health care and health, alongside efficiency.21, 22, 25

Key messages

  • Substantial socioeconomic inequalities exist in access to health care in India. In 2005–06, national immunisation coverage was 44%, whereas the coverage was 64% for children of mothers with more than 5 years of education, and 26% for children of mothers with no education. Similarly, even though rates of delivery in institutions have increased with time, only 40% of women in India report giving birth in a health facility for their previous birth in 2005–06, with women in the richest quintile six times more likely to deliver in an institution than those in the poorest quintile.

  • Inadequate public expenditure on health (estimated to be 1·10% of the share of the gross domestic product during 2008–09), and imbalanced resource allocation with much variation between state expenditures on health, restrict capacity to ensure adequate and appropriate physical access to good-quality health services. For example, per person public health expenditures in Bihar were estimated to be INR93 compared with INR630 in Himachal Pradesh in 2004–05. Furthermore, a greater proportion of resources are directed towards urban-based and curative services that suggest an urban bias and rural disadvantage in access to health-care services.

  • More than three-quarters of health spending in India is paid privately. High out-of-pocket health expenditures, therefore, are a major source of inequity in financing of health care and in financial risk protection from health adversities. This effect is disproportionate across population groups; health expenditures account for more than half of Indian households falling into poverty, with about 39 million Indian people being pushed into poverty every year.

  • Between 1986–87 and 2004, the absolute expenditures per outpatient visit and inpatient visit in rural and urban areas increased, particularly affecting the ability of the poorest individuals to access services. Although costs have increased in the public and private sectors, the increase has been much faster (>100%) in the private sector. Expenditures for drugs, which represent 70–80% of out-of-pocket expenditures for outpatients, have been increasing with time at a rate that is at least twice as fast as the general price increase.

  • Policies oriented towards incorporation of equity metrics in monitoring, assessment, and strategic planning of health care; investment in development of a rigorous knowledge base of health-systems research; development of equity-focused process of deliberative decision making in health reform; and redefinition of the specific responsibilities and accountabilities of key players along with strengthening the foundation of public health and primary care, provide an approach for ensuring more equitable health care for India's population.

Equity in health and health care has been a long-term guiding principle of health policy in India, with a commitment to provide for the needs of individuals who are poor and underprivileged. A detailed plan for provision of universal coverage for the Indian population through a government-led health service was set out in a report by the Health Survey and Development Committee in 1946.26 Since then, health policies and priorities have been outlined in the Five Year Plans, developed as part of India's centralised planning and development strategy. The need for universal comprehensive care was reiterated in the first official National Health Policy proposed in 1983.27 Shaped by the Alma Ata Declaration,28 recommendations emphasised in this policy were improved primary health care, decentralisation of the health system, improved community participation, and expansion of the private sector to reduce the burden on the public sector.27 Although the second National Health Policy in 2002 continued to support India's vision, it was undertaken on the “basis of realistic considerations of capacity”.29 In 2009, the Government of India drafted a National Health Bill for the legal system to recognise the right to health and right to health care with a stated recognition to address the social determinants of health.30 However, implementation of policy commitments to equity in health care remains a challenge because of India's institutional and implementation capabilities,31 and is also a challenge for the global health community.19

In this report, we first describe the inequalities in access to health care. By use of a supply-demand framework, we discuss the key challenges in the achievement of a health system that provides equity in service delivery, and health financing and protection of financial risk (figure 3).

Section snippets

Inequalities in health care

In India, individuals with the greatest need for health care have the greatest difficulty in accessing health services and are least likely to have their health needs met.32, 33, 34, 35 We conceptualise access as the ability to receive a specific number of services, of specified quality, subject to a specified constraint of inconvenience and cost,36 with use of selected health services as a proxy for access. To show the persisting inequities in health care in India, we focus on access to

Factors affecting supply of health care

Efficient allocation of resources between primary, secondary, and tertiary care, and geographical regions is crucial to ensure the availability of appropriate and adequately resourced health services.22 In India, this challenge is compounded by low public financing with substantial variation between states.41 India's total expenditure on health was estimated to be 4·13% of the gross domestic product (GDP) in 2008–09, of which the public expenditure on health was estimated to be 1·10%.42 Private

Factors affecting demand for health care

Insufficient public financing, lack of a comprehensive method for risk pooling, and high out-of-pocket expenditures because of rising health costs are key factors that affect equity in health financing and financial risk protection.41 Evidence from surveys of national expenditures suggests that inequalities in health financing have worsened during the past two decades.45 Only about 10% of the Indian population are covered by any form of social or voluntary health insurance, which is mainly

Principles for achievement of equity

The heterogeneity in the scale and interplay of the substantial challenges to health care in the states and districts needs contextually relevant solutions. India has made much progress in the past few years, with several innovative pilot programmes and initiatives in the public and private sectors, and the establishment of the National Rural Health Mission in 2005 being the most noteworthy government-led initiative (panel 2).41, 51, 91 This initiative has signalled the repositioning and

Conclusion

A cogent moral, social, and economic argument exists for investment in the achievement of health-care equity for Indian people. Recent rapid economic growth provides a unique opportunity to increase financial commitments to support the public health system and health-systems research. India can also draw from its booming technology sector to innovate and strengthen the development of health information systems, which has already begun. Furthermore, an opportunity exists to harness the

Search strategy and selection criteria

We searched a wide range of sources, including academic literature, government reports, multilateral-agency reports, and commissioned reports relating to inequalities, inequities, health, and health systems in the Indian context that were published in English. Search terms included “health systems” “health sector”, “equity”, “inequity”, “inequalities”, “access”, “utilization”, “financing”, “regulation”, “service delivery”, “expenditures”, “out of pocket”, and “quality”. Data were obtained from

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