This document summarizes a study examining health inequities among marginalized communities in villages in Sidhi district, Madhya Pradesh. It finds that Scheduled Castes experience the most health inequities due to social segregation and discrimination, while Scheduled Tribes face inequities due to geographical isolation. Both groups experience inadequate and inequitable access to healthcare services. The study uses qualitative methods like group discussions and interviews to understand how caste-based discrimination affects healthcare access and outcomes. It analyzes the data through frameworks of health equity that classify sources of health differences as legitimate or illegitimate based on ethical considerations. The conclusion calls for better monitoring of health inequities using equity metrics and strengthening utilization of services among

1. Qualitative Assessment of
Health Inequity- A study from
the villages in Sidhi district,
Madhya Pradesh
Apurva Kumar
MAD13028

2. Difference in Health Outcomes
Difference in the health outcomes and the
differential access to health services arise
due to:
1) Socio-economic inequities due to caste,
class and gender differentials
2) Health care inequities due to inadequate
availability, utilization, accessibility and
affordability of health services

3. Aim of the Study
• Examine the inequities in health and health care
• Map the inequities using a framework
• Study the evolution of Health Equity idea
• Study the health inequities amongst the SCs
due to social segregation
• Study of health inequities amongst the STs due
to geographical isolation.

4. Rationale of the research site:
Sidhi district has one of the poorest
health indicators in MP, thus making it
the most suitable site to examine
health and health care inequities in
the region (Factsheet Madhya
Pradesh, DLHS-3)

5. MP Factsheet- DLHS 3(2007-2008)

6. Factsheet continued…..

7. Health/Healthcare Inequities and
Marginalised Sections of the Society
• While on one hand the tribal community is
the most geographically isolated community,
sparsely located in the hilly regions; on the
other hand the SC community is the most
socially marginalised community which suffers
the most due to social segregation and caste
based untouchability
• Health care inequities affect both

8. Major Components
• Part 1: Key concepts of Health Equity/ Health
Disparity and Health equity and Social
Determinant of Health (SDH) Approach
• Part 2: Ethics of health and equity (Rawls’s
idea of Justice as Fairness)
• Part 3: Community and the village profile and
Methodology
• Part 4: Findings
• Part 5: Conclusion

9. Part 1: Health Inequality, Health Inequity
and SDH Approach
• Terms health disparity, health inequality
and health inequity have been used quite
frequently and also interchangeably
• Understanding the difference between
the two concepts is important as it will
determine the kind of policies to address
them.

10. Definitions
• Health inequity as the differences in the
health that are “not only unnecessary and
avoidable but are also considered unfair and
unjust”- Margaret Whitehead (1990)
• Health Equity: Something that “implies that
ideally everyone should have a fair
opportunity to attain their full health potential
and no one should be disadvantaged from
achieving this potential, if it can be avoided

11. Definitions Continued…..
• Healthcare Equity: Equal access to
available care for equal need, equal
utilization for equal need, and equal
quality of care for all

12. How is Health Inequality different from
Health Inequity
• “Avoidable, unfair and unjust” disparities are
Health Inequities.
• Not all Health Disparities/Inequalities are
Health Inequities
• Example: Poor health outcome of a low-wage
earning Dalit woman working as a landless
non-agricultural labour ,who could not access
basic health services because of the social
segregation due to her low caste. (INEQUITY)

13. Health Inequity vs Health Inequality
• Difference in nutritional status or the
immunization levels between the children from a
lower caste in remote rural village and the
children born in a rich, upper caste family in
urban India- INEQUITY
• Health disparities between a young adult and an
old man cannot be regarded as unfair and unjust
since physical degeneration is a natural process-
INEQUALITY
• Prostrate problems in men with respect to
women cannot be treated as health inequity
because it’s a biological phenomenon that men
have prostrates-INEQUALITY

14. Averse to Health Inequity-Income
Inequity vs Health Inequity
• Income Inequity- Income incentives (Difference in
reward) are required to elicit effort, skill and
enterprise.
• These incentives can increase the income.
• Health Inequity- Closely tied to inequalities in
basic freedoms and opportunities that people
enjoy.
• Health inequity/ difference in health outcomes
does not follow the income-incentive framework

15. Continued…..
• Health inequities do not provide people
incentives to improve their health. No incentives
reason to accept health inequities.
• Specific Egalitarianism- Certain specific goods
such as health and basic necessities of life should
be distributed less unequally- (James Tobin, 1970)
• Health provides capability to achieve ‘beings’ and
‘doings’- Amartya Sen
• Elimination of health inequity promotes the
opportunity to achieve the maximum health
potential
• Briefly go through the definitions.

16. Health Inequities by Braveman &
Gruskin
• Not all health inequalities are unfair, and
hence not all health differences can be
described as health inequities.
• Only the health disparities that are unjust,
unfair, arise due to ‘unjust social structures’
and inequitable distribution of resources can
be regarded as health inequities.
• Importance of SDH to operationalise the
inequity

17. Social Determinants of Health
Approach
• Tracing the causalities of health inequities
• To examine the social mechanism/ dynamics, that
drive the health outcomes
• WHO’s epidemiological approach vs SDH
approach
• Influences on health -Non-medical conditions
that arise from the social context of the individual
or population-difference in class status, caste
hierarchy, gender differential, and geographical
location, living and working conditions

18. Advantages of SDH approach
• Has helped in tracking the causes, sources and
social dynamics of health outcomes that
emerge from social conditions and factors.
• This approach had a huge implication in
devising interventions and policies to address
health inequities that arise from unjust social
structures.
• The SDH approach helped in designing the
health equity monitoring frameworks

19. Equity, Ethics and Justice
• The guiding idea for health equity comes from
Rawls’s idea of ‘Justice as Fairness’
• Negative Thesis- Feature of persons being born in
different social conditions such as rich/poor
family, male/female and one ethnic group or the
other is purely in an arbitrary manner, hence the
citizens should not be entitled to enjoy the
benefits of social cooperation on the basis of
his/her social conditions
• A Disadvantaged social group should not be
perpetually deprived of social goods because of
its lower social status

20. Justice As Fairness
• Positive Thesis: Emphasizes that all social goods
like health should be distributed equally
amongst the individuals irrespective of the
caste, class, race or gender.
• Thesis lead to 2 hypothesis:
a) Individuals should have a ‘fair equality of
opportunity’ regardless of whether they were
born in a disadvantaged or advantaged society
b) Equitable distribution of resources especially if
it’s a social good like health

21. Community Profile
1) The Scheduled Castes:
• Castes following the traditional occupations-
Chamar, Kumhar and Basod
• Low levels of education, poor, no capital assets,
engaged in agricultural/non-agricultural labour,
kuchha houses
• Few men involved in traditional occupations and
rest moved to labour
• Many women practice cutting of umbilical cords
and cleaning during pregnancy of dominant caste
women

22. Community Profile
2) The Schedule Tribe
• Gond community- relatively better than the SCs
in the sense that most of them have land and
‘pucca’ houses
• Have large shares of land
• Dominant caste-Practice caste based
discrimination against SCs
• Caste and power hierarchies quite visible during
study
• History of Nara Maveshi Movement of 1960s-STs
called SC families to get settled in their villages

23. Village Profile
• Villages- Badera, Thegrahi, Sendora, Kham,
Bhagohar and Karwahi
• About 40 km from Sidhi district
• Situated around the hills and surrounded with
forests, thus making the overall terrain
difficult wrt mobility
• Geographically isolated and lacked
connectivity with city
• Villages not connected with all-weather roads

24. Village Profile
• Few houses had electricity
• No piped water
• Accessibility to PHC- a major constraint

25. Other Details
• Public health workers-ASHA, ANMs and MPWs
from ST community practised caste based
untouchability while discharging their duties as
health worker (INSTITUTIONALISED RACISM by
Camara Jones of HSPH)
• SCs, who have historically faced social
segregation, faced caste based discrimination
while accessing the health care services
• STs and SCs both have to face the inadequacies of
health care services-accessibility, quality and
poor infrastructure
• Heavy dependence on local healers- Health
centre is the last option

26. Methodology
• Informal Group Discussions- Rapport Building
• Formal Group Discussions and semi-structured
interviews- To understand health care
inadequacies and caste based discrimination
• Two visits to the Karwahi PHC
• Semi structured interviews with women-
Gender equity and health
• Semi structured interview- Health workers and
local healer

27. Findings and Discussion
• In order to examine the health inequities we
should look at the sources of health
differences and classify the sources as
‘legitimate’, if it is ethically acceptable and
‘illegitimate’, if the health differences arise
from ethically unacceptable sources
(Fleurbaey and Schokkaert. 2009)
• The framework uses two different definitions
of health inequity- equal opportunity for
health and policy amenability

28. FS Framework
• Equal Opportunity for Health-Health outcomes
due to sources beyond individual control are
‘unfair’. Age is legitimate source of health
variation, whereas low social status as in case of
SCs is an illegitimate source of health variation
• Policy Amenability- Health outcomes affected (or
can be changed) by policy level interventions
• FS Framework in A Three Stage Approach to
Measuring Health Inequalities by Yukiko Asada et
al (2014)

29. Conclusion
• Monitoring the Inequity, using measures like self
reported morbidity, hospitalization rate,
hospitalization expenditure, unmet need etc
• Using Equity Metrics- example Indonesia
• Strengthen partnerships between data collection
bodies and respective health ministries
• Shift focus from access to utilization
• Utilization is lower among SCs due to social
segregation, therefore health care inequity
should be better measured by taking utilization
into account