The document discusses equity in health in India before and after economic reforms, finding that while reported morbidity increased overall, a growing socioeconomic gradient emerged with the poor reporting illness less over time. Reasons for lack of treatment shifted from lack of facilities to financial barriers, with the poor, especially women, more likely to go untreated or discontinue treatment. Intersectional analysis revealed that class and gender interact to further disadvantage the poorest women.
How is India doing on the global nutrition targets?POSHAN
The document analyzes India's progress towards global nutrition targets. It shows that between 2006-2015, India has seen declines in childhood stunting, anemia in women, and low birth weight rates according to national survey data, though some targets remain unmet. Progress varied by state, with some seeing bigger reductions in malnutrition rates than others. Most states also saw increases in exclusive breastfeeding rates over this period.
The document provides information on the National Family Health Survey (NFHS-3) conducted in India in 2005-2006. Some key points:
- NFHS-3 was conducted to provide estimates on family welfare, maternal and child health, and nutrition indicators. It also covered new topics like HIV prevalence.
- Over 124,000 women and 74,000 men were interviewed across India. In Haryana, over 2,700 women and 1,000 men were interviewed.
- The survey found that literacy rates, access to healthcare, and use of family planning methods had increased since the previous surveys, though gaps remained between urban and rural areas.
- Maternal and child health indicators like anten
Measuring people’s perceptions, evaluations and experiences: Why they matter ...StatsCommunications
First webinar of the series: Measuring people's perceptions, evaluations and experiences, 22 September 2020, More information at: http://www.oecd.org/statistics/lac-well-being-metrics.htm
Poverty social exclusion and welfare january 2013 september intake 1fatima d
Poverty can be defined in absolute or relative terms. Absolute poverty refers to a lack of subsistence resources, while relative poverty compares one's resources to what is typical in their society. There are debates around measuring poverty, including whether to use income thresholds or deprivation indices. Structural forces like economic changes that reduce good jobs and weaken families can increase poverty rates. Social exclusion involves being cut off from participation in one's community through factors beyond one's control. Welfare states aim to address poverty and promote social inclusion through state support and benefits.
DEMOGRAPHY and family health census.pptxriyazameer
This document discusses demography and population control. It begins with defining demography as the scientific study of human populations, focusing on size, composition, and distribution. It then provides world population data from 2006 and discusses Malthusian crisis predictions of population outgrowing food supply. The demographic transition model is explained through its four stages of population change during industrialization. Challenges facing less developed countries attempting to progress through the stages are outlined. Key concepts like total fertility rate, population growth rates, and UN population projections to 2150 are briefly covered. The document concludes with discussing India's population challenges and goals of its National Population Policy.
Gender perspectives of reproductive healthvishal soyam
Gender is a social construct that defines the roles and behaviors of men and women within a society. It influences reproductive health through gender differences, inequalities, and inequities in health status and access to care between men and women. Addressing gender is important for designing reproductive health programs and achieving goals like reducing maternal mortality. India has implemented initiatives like the Reproductive and Child Health Program to promote gender mainstreaming and male participation in reproductive health. The program aims to empower women, provide a holistic health approach, and enhance men's responsibilities to help address issues like maternal mortality, family planning, and gender discrimination.
This document discusses poverty, inequality, and methods for measuring them. It begins by defining poverty as a lack of basic needs and outlines its key characteristics. It then defines inequality as disparities in things like income, power, and opportunity. The document examines questions about the relationship between economic growth, income distribution, and poverty. It explores how poverty and inequality are measured using methods like the headcount index, poverty gap, Gini coefficient, and Foster-Greer-Thorbecke index. Overall, the document provides an overview of key concepts and issues relating to poverty, inequality, and their measurement.
How is India doing on the global nutrition targets?POSHAN
The document analyzes India's progress towards global nutrition targets. It shows that between 2006-2015, India has seen declines in childhood stunting, anemia in women, and low birth weight rates according to national survey data, though some targets remain unmet. Progress varied by state, with some seeing bigger reductions in malnutrition rates than others. Most states also saw increases in exclusive breastfeeding rates over this period.
The document provides information on the National Family Health Survey (NFHS-3) conducted in India in 2005-2006. Some key points:
- NFHS-3 was conducted to provide estimates on family welfare, maternal and child health, and nutrition indicators. It also covered new topics like HIV prevalence.
- Over 124,000 women and 74,000 men were interviewed across India. In Haryana, over 2,700 women and 1,000 men were interviewed.
- The survey found that literacy rates, access to healthcare, and use of family planning methods had increased since the previous surveys, though gaps remained between urban and rural areas.
- Maternal and child health indicators like anten
Measuring people’s perceptions, evaluations and experiences: Why they matter ...StatsCommunications
First webinar of the series: Measuring people's perceptions, evaluations and experiences, 22 September 2020, More information at: http://www.oecd.org/statistics/lac-well-being-metrics.htm
Poverty social exclusion and welfare january 2013 september intake 1fatima d
Poverty can be defined in absolute or relative terms. Absolute poverty refers to a lack of subsistence resources, while relative poverty compares one's resources to what is typical in their society. There are debates around measuring poverty, including whether to use income thresholds or deprivation indices. Structural forces like economic changes that reduce good jobs and weaken families can increase poverty rates. Social exclusion involves being cut off from participation in one's community through factors beyond one's control. Welfare states aim to address poverty and promote social inclusion through state support and benefits.
DEMOGRAPHY and family health census.pptxriyazameer
This document discusses demography and population control. It begins with defining demography as the scientific study of human populations, focusing on size, composition, and distribution. It then provides world population data from 2006 and discusses Malthusian crisis predictions of population outgrowing food supply. The demographic transition model is explained through its four stages of population change during industrialization. Challenges facing less developed countries attempting to progress through the stages are outlined. Key concepts like total fertility rate, population growth rates, and UN population projections to 2150 are briefly covered. The document concludes with discussing India's population challenges and goals of its National Population Policy.
Gender perspectives of reproductive healthvishal soyam
Gender is a social construct that defines the roles and behaviors of men and women within a society. It influences reproductive health through gender differences, inequalities, and inequities in health status and access to care between men and women. Addressing gender is important for designing reproductive health programs and achieving goals like reducing maternal mortality. India has implemented initiatives like the Reproductive and Child Health Program to promote gender mainstreaming and male participation in reproductive health. The program aims to empower women, provide a holistic health approach, and enhance men's responsibilities to help address issues like maternal mortality, family planning, and gender discrimination.
This document discusses poverty, inequality, and methods for measuring them. It begins by defining poverty as a lack of basic needs and outlines its key characteristics. It then defines inequality as disparities in things like income, power, and opportunity. The document examines questions about the relationship between economic growth, income distribution, and poverty. It explores how poverty and inequality are measured using methods like the headcount index, poverty gap, Gini coefficient, and Foster-Greer-Thorbecke index. Overall, the document provides an overview of key concepts and issues relating to poverty, inequality, and their measurement.
The document discusses health inequalities and options for addressing them, including through screening programs and consideration of social determinants of health. It notes that those with greater social and economic disadvantages tend to have poorer health outcomes and less access to healthcare. Screening definitions and programs are reviewed, along with factors influencing individual, community and societal health. Disadvantaged groups, importance of addressing inequalities, and advocacy are discussed. Exercises on deprivation and obesity are included.
This document summarizes a presentation on two papers that examine routes to low mortality in poor countries. The first paper by Caldwell in 1986 used data from 99 third world countries to analyze the relationship between mortality, income, and other factors. The second paper by Kuhn revises Caldwell's analysis using updated data and indicators. Kuhn finds that while some original superior and poor health achievers have converged, education, gender equality, health spending, poverty, and governance continue to influence countries' health achievement relative to their income levels. The discussion considers ways to improve analysis of factors driving health outcomes in developing nations.
GPST1 ERP comm orientn health ineq 03102012 nmc DE and casesnmurraycavanagh
1. The document outlines an education day agenda for GPSTs that includes sessions on community orientation, inequalities in health and healthcare, the relationship between individual patients and the community, and rationing.
2. The community orientation session will discuss the GP curriculum, practice profiles, how involved GPs should be in the community, and balancing individual health needs with those of the community.
3. Issues around inequalities in health and access to healthcare will also be examined, including the inverse care law and findings from reports like the Black Report, Acheson Report, and Marmot Review on social determinants of health.
Presentation Fam Med Masters Seminar Apr 25 07briefJanet2007
The document discusses the impact of poverty on health. It provides background on poverty and health indicators in Canada, showing that those in poverty experience higher rates of chronic disease, infant mortality, lower life expectancy, and worse mental and physical health overall. It suggests that poverty, through factors like inadequate income for nutrition and housing, is the main determinant of these health inequities. The document proposes ways for health providers to help address poverty, such as by expanding assessments of social/economic barriers patients face and connecting them to resources to improve their situations.
There are four main groups of countries in Europe according to their health inequalities profiles: Beveridgean social-democracies, Bismarckian social security systems, Southern post-dictatorial countries, and Eastern countries. The evolution of health inequalities in different countries during crisis years depends on factors like the social protection systems, austerity or anti-austerity policies, and pre-existing public health situations. Common aspects across European countries include the precarization of working conditions and how gender roles affect women's health. Upstream public health policies and downstream policies both need to be implemented to help close the health inequality gap.
The document discusses health equity and the social determinants of health. It defines health as physical, social and mental well-being, not just the absence of disease. Public health is defined as what society collectively does to create conditions for people to be healthy. Health is determined by factors like income, education, housing, environment and social justice. Achieving health equity requires addressing inequalities and injustices to improve health for all.
1) 25 years after the Black report on health inequalities, little has changed in terms of the underlying causes and explanations of inequality.
2) New Labour's policies since 1997 have been ineffective at reducing health inequalities and have in some ways exacerbated them through privatization and marketization of the healthcare system.
3) The aim of capitalism is the unequal distribution of resources in order to create private profit, which inherently leads to inequality that is detrimental to health.
This document summarizes a study on poverty transitions in rural Bangladesh between 1996-97 and 2006-07. It finds that while poverty declined substantially over this period, some households remained chronically poor. Initial characteristics like education levels and assets affected poverty status, as did common shocks like illness and death of earners. Life histories revealed that dowry payments combined with health expenses sometimes pushed households into chronic poverty. The study concludes there is still work to do in increasing education, building assets, and providing protection from risks like illness through mechanisms like microinsurance.
Even It Up - Time to End Extreme Inequality: Comments by Dean JolliffeWB_Research
Comments prepared for launch event of “Even it Up: Time to End Extreme Poverty”
IMF, October 31, 2014.
The views represented in these comments are those of the author and do not necessarily reflect the views of the World Bank.
CAPE SOCIOLOGY Age and sex structure[1]capesociology
This document discusses key concepts related to age and sex structure of populations including:
- Age and sex cohorts that are used to analyze population structures such as 0-4, 5-9, etc. and how groups like children, youth, and elderly are defined.
- Metrics like sex ratio, dependency ratio, and median age that provide insights into the distribution of populations.
- Factors that influence sex ratios and how they typically change with age. Son preference is also discussed.
- Dependency ratios measure the economic burden on the working population from youth and elderly dependents.
The document provides an overview of the US health system, including:
- A brief history of health insurance in the US from the 1860s to present day.
- An overview of the key payers in the US health system including Medicaid, Medicare, private insurance, and out-of-pocket costs.
- Details on reforms under the Affordable Care Act and changes under the Trump Administration.
- A discussion of proposals for expanding coverage such as Medicare for All and the challenges different stakeholders face in the current system.
The document aims to increase collective understanding of the complex US health system to inform ongoing policy discussions.
The document discusses how health inequalities are socially determined by differences in life chances rather than just lifestyles. It provides evidence from studies showing how stressful work environments and unemployment negatively impact health, with up to 40-64% of health inequalities reduced after adjusting for these social determinants of health. The document advocates for policies focused on improving life chances, such as increasing income, employment opportunities, and participation at work and in communities, as evidenced by some of Labour's past successes in reducing inequalities.
This document summarizes Zimbabwe's experience with measuring poverty and incorporating a gender perspective. It discusses Zimbabwe's current economic challenges including high inflation and declining industries. It then describes the Poverty Assessment Study Surveys that were conducted in 1995 and 2003 to measure poverty levels. These surveys collected extensive data on households, including demographics, education, health, employment, and more. The analysis found that poverty was highest in female-headed households and rural areas. It also produced reports on the gender dimensions of poverty, which found that poverty prevalence was highest for widowed women and de-facto female-headed households. The surveys provided valuable data to inform policies around poverty reduction and development in Zimbabwe.
Poverty and Health - An Inconvenient TruthTimothy Bray
Poverty is a well known correlate of medicine. In this presentation, delivered to the Family Medicine residents at UT Southwestern School of Medicine, we explore the origins of our definitions of poverty and the role it plays in health in Dallas County, Texas.
SDH and Basic Measurments in Epid.22 (1).pdfRiyadu
Social determinants of health are factors that influence individual and population health outcomes. These factors include the physical environment, social and economic conditions, and health behaviors. They account for a significant degree of variability in how long and how well people live. Key social determinants include access to healthcare, income/socioeconomic status, education, physical environment, social support systems, employment status, and community safety. Addressing social determinants through multisectoral policies and interventions can help reduce health inequalities within and between countries.
1) Recent trends show an increase in unintended and unwanted childbearing in the US, disproportionately impacting young, unmarried, and disadvantaged women.
2) Between 1995-2002, the proportion of births identified as unwanted increased across most age and relationship groups due to rising unwanted birth rates.
3) For white women specifically, nearly half the increase in unwanted births was driven by rising rates among both single and married women.
Income inequalities in health presentationPrashanth N S
Presentation on socio-economic inequalities in health in India made at the National Seminar on Health Equity Evidence and Priorities for Research in India conducted by the Sree Chitra Tirunal Institute for Medical Sciences & Technology (SCTIMST), Trivandrum in 2015
My Own Demography 3 Population Pyramid.pptxMUHAMMAD UMAIR
A population pyramid graphically displays a population's age and sex composition using horizontal bars to present numbers or proportions of males and females in each age group. The pyramid shape can indicate factors like birth rates, population growth or decline, health, and development levels. General structures include triangles for growing populations, hexagons for stable populations, and cups for declining populations. A pyramid provides information on metrics like median age, sex ratios, dependency ratios, and expected changes based on current age distributions.
Jill Blumenthal MD of UC San Diego presents "Free to Be You and Me: Providing Culturally-Sensitive Patient Care to Transgender Individuals" at AIDS Clinical Rounds
The document discusses health inequalities and options for addressing them, including through screening programs and consideration of social determinants of health. It notes that those with greater social and economic disadvantages tend to have poorer health outcomes and less access to healthcare. Screening definitions and programs are reviewed, along with factors influencing individual, community and societal health. Disadvantaged groups, importance of addressing inequalities, and advocacy are discussed. Exercises on deprivation and obesity are included.
This document summarizes a presentation on two papers that examine routes to low mortality in poor countries. The first paper by Caldwell in 1986 used data from 99 third world countries to analyze the relationship between mortality, income, and other factors. The second paper by Kuhn revises Caldwell's analysis using updated data and indicators. Kuhn finds that while some original superior and poor health achievers have converged, education, gender equality, health spending, poverty, and governance continue to influence countries' health achievement relative to their income levels. The discussion considers ways to improve analysis of factors driving health outcomes in developing nations.
GPST1 ERP comm orientn health ineq 03102012 nmc DE and casesnmurraycavanagh
1. The document outlines an education day agenda for GPSTs that includes sessions on community orientation, inequalities in health and healthcare, the relationship between individual patients and the community, and rationing.
2. The community orientation session will discuss the GP curriculum, practice profiles, how involved GPs should be in the community, and balancing individual health needs with those of the community.
3. Issues around inequalities in health and access to healthcare will also be examined, including the inverse care law and findings from reports like the Black Report, Acheson Report, and Marmot Review on social determinants of health.
Presentation Fam Med Masters Seminar Apr 25 07briefJanet2007
The document discusses the impact of poverty on health. It provides background on poverty and health indicators in Canada, showing that those in poverty experience higher rates of chronic disease, infant mortality, lower life expectancy, and worse mental and physical health overall. It suggests that poverty, through factors like inadequate income for nutrition and housing, is the main determinant of these health inequities. The document proposes ways for health providers to help address poverty, such as by expanding assessments of social/economic barriers patients face and connecting them to resources to improve their situations.
There are four main groups of countries in Europe according to their health inequalities profiles: Beveridgean social-democracies, Bismarckian social security systems, Southern post-dictatorial countries, and Eastern countries. The evolution of health inequalities in different countries during crisis years depends on factors like the social protection systems, austerity or anti-austerity policies, and pre-existing public health situations. Common aspects across European countries include the precarization of working conditions and how gender roles affect women's health. Upstream public health policies and downstream policies both need to be implemented to help close the health inequality gap.
The document discusses health equity and the social determinants of health. It defines health as physical, social and mental well-being, not just the absence of disease. Public health is defined as what society collectively does to create conditions for people to be healthy. Health is determined by factors like income, education, housing, environment and social justice. Achieving health equity requires addressing inequalities and injustices to improve health for all.
1) 25 years after the Black report on health inequalities, little has changed in terms of the underlying causes and explanations of inequality.
2) New Labour's policies since 1997 have been ineffective at reducing health inequalities and have in some ways exacerbated them through privatization and marketization of the healthcare system.
3) The aim of capitalism is the unequal distribution of resources in order to create private profit, which inherently leads to inequality that is detrimental to health.
This document summarizes a study on poverty transitions in rural Bangladesh between 1996-97 and 2006-07. It finds that while poverty declined substantially over this period, some households remained chronically poor. Initial characteristics like education levels and assets affected poverty status, as did common shocks like illness and death of earners. Life histories revealed that dowry payments combined with health expenses sometimes pushed households into chronic poverty. The study concludes there is still work to do in increasing education, building assets, and providing protection from risks like illness through mechanisms like microinsurance.
Even It Up - Time to End Extreme Inequality: Comments by Dean JolliffeWB_Research
Comments prepared for launch event of “Even it Up: Time to End Extreme Poverty”
IMF, October 31, 2014.
The views represented in these comments are those of the author and do not necessarily reflect the views of the World Bank.
CAPE SOCIOLOGY Age and sex structure[1]capesociology
This document discusses key concepts related to age and sex structure of populations including:
- Age and sex cohorts that are used to analyze population structures such as 0-4, 5-9, etc. and how groups like children, youth, and elderly are defined.
- Metrics like sex ratio, dependency ratio, and median age that provide insights into the distribution of populations.
- Factors that influence sex ratios and how they typically change with age. Son preference is also discussed.
- Dependency ratios measure the economic burden on the working population from youth and elderly dependents.
The document provides an overview of the US health system, including:
- A brief history of health insurance in the US from the 1860s to present day.
- An overview of the key payers in the US health system including Medicaid, Medicare, private insurance, and out-of-pocket costs.
- Details on reforms under the Affordable Care Act and changes under the Trump Administration.
- A discussion of proposals for expanding coverage such as Medicare for All and the challenges different stakeholders face in the current system.
The document aims to increase collective understanding of the complex US health system to inform ongoing policy discussions.
The document discusses how health inequalities are socially determined by differences in life chances rather than just lifestyles. It provides evidence from studies showing how stressful work environments and unemployment negatively impact health, with up to 40-64% of health inequalities reduced after adjusting for these social determinants of health. The document advocates for policies focused on improving life chances, such as increasing income, employment opportunities, and participation at work and in communities, as evidenced by some of Labour's past successes in reducing inequalities.
This document summarizes Zimbabwe's experience with measuring poverty and incorporating a gender perspective. It discusses Zimbabwe's current economic challenges including high inflation and declining industries. It then describes the Poverty Assessment Study Surveys that were conducted in 1995 and 2003 to measure poverty levels. These surveys collected extensive data on households, including demographics, education, health, employment, and more. The analysis found that poverty was highest in female-headed households and rural areas. It also produced reports on the gender dimensions of poverty, which found that poverty prevalence was highest for widowed women and de-facto female-headed households. The surveys provided valuable data to inform policies around poverty reduction and development in Zimbabwe.
Poverty and Health - An Inconvenient TruthTimothy Bray
Poverty is a well known correlate of medicine. In this presentation, delivered to the Family Medicine residents at UT Southwestern School of Medicine, we explore the origins of our definitions of poverty and the role it plays in health in Dallas County, Texas.
SDH and Basic Measurments in Epid.22 (1).pdfRiyadu
Social determinants of health are factors that influence individual and population health outcomes. These factors include the physical environment, social and economic conditions, and health behaviors. They account for a significant degree of variability in how long and how well people live. Key social determinants include access to healthcare, income/socioeconomic status, education, physical environment, social support systems, employment status, and community safety. Addressing social determinants through multisectoral policies and interventions can help reduce health inequalities within and between countries.
1) Recent trends show an increase in unintended and unwanted childbearing in the US, disproportionately impacting young, unmarried, and disadvantaged women.
2) Between 1995-2002, the proportion of births identified as unwanted increased across most age and relationship groups due to rising unwanted birth rates.
3) For white women specifically, nearly half the increase in unwanted births was driven by rising rates among both single and married women.
Income inequalities in health presentationPrashanth N S
Presentation on socio-economic inequalities in health in India made at the National Seminar on Health Equity Evidence and Priorities for Research in India conducted by the Sree Chitra Tirunal Institute for Medical Sciences & Technology (SCTIMST), Trivandrum in 2015
My Own Demography 3 Population Pyramid.pptxMUHAMMAD UMAIR
A population pyramid graphically displays a population's age and sex composition using horizontal bars to present numbers or proportions of males and females in each age group. The pyramid shape can indicate factors like birth rates, population growth or decline, health, and development levels. General structures include triangles for growing populations, hexagons for stable populations, and cups for declining populations. A pyramid provides information on metrics like median age, sex ratios, dependency ratios, and expected changes based on current age distributions.
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1. Equity and Health in the Era of
Reforms
Gita Sen
Indian Institute of Management
Bangalore
4th Krishna Raj Memorial Lecture on
Contemporary Issues in Health and Social
Sciences
CEHAT / Anusandhan Trust, Mumbai, April 9, 2010
2. Acknowledgements
• First of all, of course, to Krishna Raj, about
whose contribution to informed public debate
in this country, enough can never be said. I am
deeply honoured, beyond my ability to
adequately express.
• Many thanks to the Anusandhan Trust,
eSocialSciences; Dept. of Economics,
Mumbai University; P.G. Dept. of Economics,
SNDT Women’s University and Tata Institute
of Social Sciences (TISS) for inviting me to
give this lecture
3. Acknowledgements
• I also want to acknowledge my long intellectual
partnership with Dr Aditi Iyer in our joint work
on equity and intersectionality, and all the fun
we have had doing it! This lecture is based
partly on that previous work, and on our
ongoing analysis of the NSS 60th round for
which Aditi provides the data and analysis
muscle!
• Prof Chandan Mukherjee who has been our
great support and colleague in this work from
early on.
• And to Vasini Vardhan, many thanks for her
hard work on the literature review.
5. Equity in health – why do we care?
• Isn’t a consideration of the level (average or that
of the lowest in the socioeconomic order)
enough? Why should we be concerned about
relative levels?
• 3 approaches: Ethicist / social activist versus
pragmatist /policy administrator
▫ Raise the average level
▫ Raise the minimum level
▫ Reduce inequality
6. Equity in health – why do we care?
• A problem of communication?
• A problem of information?
• A problem of politics / ideology?
• All the above, BUT
• Focusing on the average level or on improving
the health of the worst off also plays safe; it
doesn’t always ask hard questions about social
structures that a focus on inequality almost
inevitably leads to.
7. Inequality matters – Wilkinson’s
answer
• Richard Wilkinson: “Almost everyone benefits from
greater equality. Usually the benefits are greatest
among the poor but extend to the majority of the
population.”
• (Acknowledgement to Prof R Wilkinson for the next
slides)
8. Health and Social Problems are not Related to Average Income in
Rich Countries
Index of:
• Life expectancy
• Math & Literacy
• Infant mortality
• Homicides
• Imprisonment
• Teenage births
• Trust
• Obesity
• Mental illness – incl.
drug & alcohol
addiction
• Social mobility
Source: Wilkinson & Pickett, The Spirit Level (2009) www.equalitytrust.org.uk
9. Health and Social Problems are Worse in More Unequal Countries
Index of:
• Life expectancy
• Math & Literacy
• Infant mortality
• Homicides
• Imprisonment
• Teenage births
• Trust
• Obesity
• Mental illness – incl.
drug & alcohol
addiction
• Social mobility
Source: Wilkinson & Pickett, The Spirit Level (2009) www.equalitytrust.org.uk
10. Equity in health – the fallacy of
congruence
• Yes, inequality matters for health but what kind
of inequality?
• Can different dimensions of inequality be viewed
as collapsible into each other?
• Does focusing on economic class inequality tell
us enough? Does it tell us the right things?
• Does how we look at inequality need to be both
multi-dimensional and intersectional?
11. Equity in health – the fallacy of
congruence
Wilkinson & Pickett: “…what matters is the extent
of social class differentiation. No one suggests
that it is blackness itself which matters. Rather it
is the social meaning attached to it – the fact
that it serves as a marker for class and attracts
class prejudice – which leads both to worse
health and to wider income differences.” (Social
Science and Medicine 62 (2006) pp 1778-9)
13. Health care – 1986-87 to 2004
• Extends our earlier analysis (Sen, Iyer and George,
EPW April 6, 2002) of NSS surveys on morbidity
and health care (42nd round – 1986-87 and 52nd
round – 1995-96) to the 60th round – 2004
• Looks at both economic class & gender –
interpretation draws on insights from our work in
Koppal
• Some changes in definitions and reference
periods which I will only touch upon in places,
and are being discussed in detail in our
forthcoming paper
14. Features of the benchmark period
India’ s health care system already highly
inequitable by the mid 1980s prior to the
start of economic reforms in 1991
>70% health expenditure out of pocket
Large rural – urban differences in
availability of services
Poor quality and uneven reach of public
services
Highly unregulated private sector
15. Features of the benchmark period
contd
However:
Public hospitals (even if doubtful quality)
available to the poor especially for
inpatient care
Significant drug price control (over 300
drugs) in the essential, controlled price
list
Thriving (pre-WTO) indigenous drug
production (through reverse engineering)
kept drugs available and competitively
16. Key Questions
• What happened in the period after economic
reforms began?
• Important policy shifts:
▫ Sharp reduction in the controlled drugs list leading to
significant increases in drug prices
▫ Entry of user fees and two-tier services in public
hospitals – those below the poverty line are supposed
to get services free including drugs, but this is rarely
the case (under the counter payments, and drugs
have almost always to be purchased outside)
• Did gender and class inequalities in access to care
change?
17. Evidence
• We will look through gender and economic
class lenses at:
▫ untreated morbidity
▫ reasons for non-treatment
▫ the shifting public – private mix
▫ the cost of care
• Simple gradient – gap methodology to
examine inequality
18. But first a word about self-reported
illness
Concerns about under-reporting of illness
especially by the poor and women led the
National Sample Survey to try to improve
coverage through better training and
instructions to enumerators etc.
Q: what was the result?
20. Rates of perceived morbidity: Male versus Female (Rural)
25
No. per 100 persons
20
15
10
5
0
Quintile 1 Quintile 2 Quintile 3 Quintile 4 Quintile 5
(poorest) (richest)
Rural
Male (1986-87) Female (1986-87)
Male (1995-96) Female (1995-96)
Male (2004) Female (2004)
21. Rates of perceived morbidity: Male versus Female (Urban)
25
No. per 100 persons
20
15
10
5
0
Quintile 1 Quintile 2 Quintile 3 Quintile 4 Quintile 5
(poorest) (richest)
Urban
Male (1986-87) Female (1986-87)
Male (1995-96) Female (1995-96)
Male (2004) Female (2004)
22. • What does the pattern over time in self-reported
morbidity tell us? NSS made a serious attempt to
improve its capture of illness; yet a class gradient
has emerged in both rural and urban areas, and
more for women than men. Very little gender gap
among rural poor.
• Not plausible that the rich are more ill
• Under-reporting due to ‘normalisation’ of illness by
poor (both men and women) even more sharp in
relative terms?
Q: whose ill-health is the NSS capturing better?
23. Summary Results – Morbidity Reporting
Morbidity
• 1986-87 (pre-reform benchmark, 42nd round)
– No significant class gradient (based on MPCE
fractiles) or major gap in self-reported morbidity for
either women or men
• 1995-96 (52nd round)
– Across the board increase in self-reported morbidity,
with the emergence of significant class differences in
reporting; also some more gender differences
• 2004 (60th round)
▫ Even further sharpened class gradient for both women
and men; sharper gender differences but at the upper
end
26. Never treated vs discontinued
treatment?
• Difference between those never treated and
those who discontinued treatment?
• Apparently - an increase in those discontinuing
treatment, becoming greater by 2004 and with a
sharper gradient
• May indicate a shift from never being treated to
discontinuing treatment even though illness
continued
30. Summary Results – Untreated morbidity
Untreated Morbidity
• 1986-87 (pre-reform benchmark, 42nd round)
– Significant class gradient and gender differences in untreated
morbidity – women and the poor worse off; gender gap mainly at
the bottom (rationing?)
• 1995-96 (52nd round)
– The class gradient worsened for all groups
– Some improvement in rates for poorest women (not sure why) ,
but sharp worsening for poorest men – perverse catch up?
– Gender gap tended to close at the bottom
• 2004 (60th round)
▫ Not much change but some worsening of the gradient for rural
men – gender gap almost closed – perverse catch up at the
bottom?
31. Insights from Koppal on untreated
morbidity
• Traditional analysis too simplistic and may
actually mask what is actually going on, not only
in terms of gender, but even in terms of class
• Apparent class results may actually be
gendered results
32. 2. Method:
Illustration of hypotheses testing
• Illustrative evidence from cross-sectional household
health survey in Koppal district
– 60 villages, 1920 households, 12,328 individuals
– Health seeking and expenditures during pregnancy,
for short- and long-term illness
• Illustration of intersectional analysis for long-term illness:
non-treatment and discontinued treatment
33. Non-treatment of long-term ailments
Likelihood of non-treatment of long-term ailments:
Differences by gender and economic class
6.00
5.00
4.00
Odds ratios
3.00
2.00
Poorest Poor Non-poor Poor men Non-poor Poorest
1.00
w omen w omen w omen men men
■ p < 0.05 □ p > 0.05 □ Reference group
34. Discontinued treatment for long-term ailments
Likelihood of discontinued treatment for long-term ailments:
Differences by gender & economic class
1.75
1.50
Odds ratios
1.25 Non-poor Poor
w omen men
1.00
Poorest Poorest Poor Non-poor
w omen men w omen men
■ p < 0.05 □ p > 0.05 □ Reference group
35. Continued treatment for long-term ailments
Likelihood of continued treatment for long-term ailments:
Differences by gender & economic class
Poorest Poor Poorest Non-poor
w omen w omen men w omen
1.00
0.90 Non-poor Poor
men men
0.80
Odds ratios
0.70
0.60
0.50
0.40 ■ p < 0.05 □ p > 0.05 □ Reference group
36.
37. Distribution of reasons for non-treatment: Rural India
100
80
Percentage
60
40
20
0
Male (1995-96) Female (1995-96) Male (2004) Female (2004)
Rural
Medical facility unavailable Financial barriers Illness not "serious" Other reasons
38. Distribution of reasons for non-treatment: Rural India
100 100
80 80
60 60
40 40
20 20
0 0
Q1 Q2 Q3 Q4 Q5 Q1 Q2 Q3 Q4 Q5
Male (1995-96) Female (1995-96)
Financial barriers Illness not "serious" Other reasons Financial barriers Illness not "serious" Other reasons
100 100
80 80
60 60
40 40
20 20
0 0
Q1 Q2 Q3 Q4 Q5 Q1 Q2 Q3 Q4 Q5
Male (2004) Female (2004)
39. Distribution of reasons for non-treatment: Urban India
100
80
Percentage
60
40
20
0
Male (1995-96) Female (1995-96) Male (2004) Female (2004)
Urban
Medical facility unavailable Financial reasons Illness not "serious" Other reasons
40. Distribution of reasons for non-treatment: Urban India
100 100
80 80
60 60
40 40
20 20
0 0
Q1 Q2 Q3 Q4 Q5 Q1 Q2 Q3 Q4 Q5
Male (1995-96) Female (1995-96)
Financial barriers Illness not "serious" Other reasons Financial barriers Illness not "serious" Other reasons
100 100
80 80
60 60
40 40
20 20
0 0
Q1 Q2 Q3 Q4 Q5 Q1 Q2 Q3 Q4 Q5
Male (2004) Female (2004)
41. Summary results – reasons for non-
treatment
• 1995-96 (52nd round)
– Gender difference – men more likely to
say ‘financial reasons’ than ‘illness not
serious’
–Significant class gradient in all groups
• 2004 (60th round)
▫ Even worse at the bottom in terms of
financial reasons; 40% of women in
quintile 1 (rural), and almost similar for
men
▫ Yes; health care costs have increased for
everyone but more damaging for the poor
47. Summary results – public-private mix
1986-87
• Private-public mix
–70% of outpatient (OP)care was in the
private sector (private doctors), but
–60% of inpatient (IP)care was in the public
sector (largely public hospitals) – both
rural and urban
• Cost of care
–Private : public cost of care practically
equal in OP, but a little over double for IP
48.
49. Hospitalised patients in public hospitals - Rural
Class Distribution: 1986-87, 1995-96, 2004
40.0
30.0
y = 2.8802x + 2.7649
20.0 y = -0.6619x + 16.933 y = 1.1377x + 9.7351
10.0
0.0
00 to 10 10 to 20 20 to 40 40 to 60 60 to 80 80 to 90 90 to 100
MPCE Fractiles
1986-87 1995-96 2004
Linear (1995-96) Linear (1986-87) Linear (2004)
50. Hospitalised patients in private hospitals - Rural
Class Distribution: 1986-87, 1995-96, 2004
40.0
30.0 y = 5.2561x - 6.7386
20.0 y = 3.4704x + 0.4043
y = 0.8385x + 10.932
10.0
0.0
00 to 10 10 to 20 20 to 40 40 to 60 60 to 80 80 to 90 90 to 100
MPCE Fractiles
1986-87 1995-96 2004
Linear (1995-96) Linear (1986-87) Linear (2004)
51. Hospitalised patients in public hospitals - Urban
Class Distribution: 1986-87, 1995-96, 2004
40.0
30.0
y = -1.511x + 20.33
20.0 y = 0.3122x + 13.037
10.0 y = -1.421x + 19.97
0.0
00 to 10 10 to 20 20 to 40 40 to 60 60 to 80 80 to 90 90 to 100
MPCE Fractiles
1986-87 1995-96 2004
Linear (1995-96) Linear (1986-87) Linear (2004)
52. Hospitalised patients in private hospitals - Urban
Class Distribution: 1986-87, 1995-96, 2004
40.0
30.0
y = 3.5131x + 0.2334
20.0
y = 0.2487x + 13.291
10.0 y = 1.7397x + 7.3269
0.0
00 to 10 10 to 20 20 to 40 40 to 60 60 to 80 80 to 90 90 to 100
MPCE Fractiles
1986-87 1995-96 2004
Linear (1995-96) Linear (1986-87) Linear (2004)
53. Summary results – hospital use
Service utilization
• 1986-87 (pre-reform benchmark, 42nd round)
– No major class gradient in overall hospital use for
inpatient (IP) care – both rural and urban
• 1995-96 (52nd round)
– Distribution of hospital use tilts sharply towards the
upper end
– Those at the top use not only more of the private
hospitals but also of the public hospitals
• 2004 (60th round)
▫ Some flattening of the slope of the distribution but still
significant (except for public urban hospitals)
54.
55. Expenditure on inpatient care: All India
12000
10000
8000
1986-87
6000 1995-96
2004
4000
2000
0
Public Private 12000
Rural
10000
8000
1986-87
1995-96 6000
2004
4000
2000
0
Public Private
Urban
56. Average medical expenditures on hospitalisation at
constant (1986-87) prices
3500
3000
2500
2000 1986-87
1995-96
1500 2004
1000
500
0
Public Private 3500
Rural 3000
2500
1986-87 2000
1995-96
2004 1500
1000
Source: Selvaraj and Karan
(2009) 500
0
Public Private
Urban
57. Summary results of the comparison
• Overall, reporting on illness, extent of non-
treatment and discontinued treatment went up
sharply
• Serious increases in the costs of care, and in
financial reasons for non-treatment (related
largely to drug prices but also possibly to user
charges?)
• Micro level in-depth studies on reasons for
households falling into poverty (e.g. Anirudh
Krishna) show that health expenditures are a
major reason (among the top 3)
58. Summary results of the comparison
• Class gradients sharply worse in the mid-1990s with
some moderation in 2004 but still sharp
• Gender gaps persist but moderated in some
instances – perverse catch up by poorest men in
terms of non-treatment and financial reasons for it
• Hospital use for care – the better off are more likely
to go to private hospitals for inpatient care but they
use more of both private AND public hospitals
(some reversal in urban public hospitals in 2004)
• The poorest still depend on public hospitals (>55%
of use) even in 2004 even though they cater more to
the rich
59. Recent policy trends
The only game in policy town is the
National Rural Health Mission:
Many pluses – increasing health budget,
focus on maternal mortality, strong
leadership and management inputs, good
technical backstopping, openness to civil
society and to third party review
What about health inequality, overall
access to the poor, and health costs? Drug
prices?
60. Conclusions
• Health inequalities have both over time and
cross sectional dimensions – both gender and
class
• Period of economic reforms has sharply
worsened access, use and cost of care to the
poor
• Non-treatment and discontinuation have gone
up
61. Conclusions
• Gender differences are important but poorest men
appear to be catching up with poorest women in
perverse ways
• Caveat: what about caste?
• However, our Koppal work raises larger
methodological issues about how to analyse the
intersections between different dimensions of
inequality
• Simplistic class and gender analysis not enough –
may mask or even distort our analysis of what is
happening
62. Closing words
• Studying inequality is not just about
methodology but also politics…
• Additional insights from Koppal about
intersectionality - Not just the extremes but what
is happening to the groups in the middle – those
who may be advantaged on one dimension and
disadvantaged on others?
63. Closing words
• Nuanced, unprejudiced and open analysis is the
best tribute we can pay to Krishna Raj’s
extraordinary work and life…
• Thank you.