Health care and equity in India

In the last decade or so, except for GDP growth, in most development indicators, India has significantly lagged behind the rest of the world – particularly in health care.

India's share in global deaths, maternal and prenatal disorders, communicable disease, infant mortality and morbidity, and nutritional deficiencies, to name a few, is staggering.

The paper titled ‘Health care and equity in India' in Lancet , by Balarajan et al. – 2011, gives a detailed account of the key challenges that the country faces with respect to health care provision, equity financing, and financial risk protection. It highlights how inequalities in socio-economic status, geography, and gender are intertwined with poor health metrics in India, using the three National Family Health Survey (NFHS) data.

The paper is divided into supply and demand side factors that affect health care access, and principles for achieving equity in health care.

Supply-side factors

The authors present evidence on the wide disparities in public spending across different States in India, skewed spending on urban population, and inadequate expenditure on preventive services – factors that lead to unequal distribution of health care provision.

One of the alarming statistics they provide (based on another study) is that in rural Rajasthan, 40 per cent of private providers did not have a medical degree, and 20 per cent had not completed secondary education. At this juncture, it is interesting to note that in India, obtaining a medical college admission is significantly dependent on the student's socio-economic background and not merely his or her past academic achievements.

So it helps to understand whether such selective (non-academic) entry metrics negatively affect the quality of health care supply by producing more number of less competent professionals. If it does, then it amplifies the existing health care disparities in the following way. The politically and economically influential groups typically seek health care services from the best qualified professionals. Only the remaining less skilled professionals are available to treat the common man and the rural population which already faces impediments to health care access.

Demand side factors

The authors have rightly pointed out that insufficient public financing, inefficient risk pooling, and heavy out-of-pocket expenditure affect equity in health care financing. They present statistics on the scanty insurance coverage over the population, and an increasing out-of-pocket expenditure, both of which significantly affect the demand for health care.

These two issues particularly affect the poorest of population whose expenditure share on health care is increasing rapidly over the years. The paper presents statistics on how corruption during hospital admission and treatment negatively affects health care demand.

Overall, the authors give a complete account of the important demand determinants of health care access.

Achieving Equity

The authors propose many suggestions to achieve equity in health care access in India. Creating an intelligence system like in Thailand, that integrates data management and its application, would help monitor and assess health care system performance efficiently.

Partnership with research and academic institutions could help co-ordinate and disseminate knowledge through sharing of best practices, and lead to efficient and effective utilisation of resources.

They also suggest a complete review and formalisation of processes involved in service-delivery mechanism by involving the Centre, State and local governments.

Increasing accountability, transparency and leadership combined with political priority for health care equity can potentially help increased and efficient health coverage, especially for the poor.

Increasing health care consciousness through awareness and education can largely address the demand-side challenges that the country faces.

Another move that could significantly ensure effective implementation of health care plans is to instate a few external agencies (independent of the government) that can periodically assess the execution of the health care plans.

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