2. India’s Health Post-Independence
• Notable successes:
Life expectancy: 32 70
Infant mortality rate: 78 27 (per 1000)
Maternal mortality rate: 556 113 (per 100,000)
Severe malnutrition rate: Decline of 50%
Eradication of small pox, polio
3. Inequities in…
• Health outcomes
• Health insurance
• Health infrastructure
• Quality of Care
4. Health outcomes
• Curative care: IMR, U5MR, MMR; malnutrition; life expectancy, etc.
IMR in bottom quintile is 2.5x highest quintile
U5MR is much higher in a child born female, poor, low-caste, tribal,
rural and in a poor state
MMR range is up to 10x between states
Life expectancy varies by between 7-10 years between states
• Preventive care: Nutrition, immunization, ANC, institutional
deliveries, etc.
5. Shoba Suri, Priya Rampal, and Shruti Menon, “The Uphill Climb to Maternal and Child Nutrition in Northeast India,” ORF
Occasional Paper No. 378, November 2022, Observer Research Foundation.
6. Geographical pattern of maternal mortality ratio by states/union territories in India, HMIS.
Goli S, Puri P, Salve PS, Pallikadavath S, James KS (2022) Estimates and correlates of district-level maternal mortality ratio
in India. PLOS Global Public Health 2(7): e0000441. https://doi.org/10.1371/journal.pgph.0000441
https://journals.plos.org/globalpublichealth/article?id=10.1371/journal.pgph.0000441
7. Shoba Suri, Priya Rampal, and Shruti Menon, “The Uphill Climb to Maternal and Child Nutrition in Northeast India,” ORF
Occasional Paper No. 378, November 2022, Observer Research Foundation.
8. Fig 1. Trends in U5MR among social groups in high focus states, India 1992–2016.
Bora JK, Raushan R, Lutz W (2019) The persistent influence of caste on under-five mortality: Factors that explain the caste-
based gap in high focus Indian states. PLOS ONE 14(8): e0211086. https://doi.org/10.1371/journal.pone.0211086
https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0211086
9. Kumar, C., Piyasa & Saikia, N. An update on explaining the rural-urban gap in under-five mortality in India. BMC Public Health 22, 2093
(2022). https://doi.org/10.1186/s12889-022-14436-7
10.
11. Bhatia, M., Dwivedi, L.K., Banerjee, K. et al. Pro-poor policies and improvements in maternal health outcomes in
India. BMC Pregnancy Childbirth 21, 389 (2021). https://doi.org/10.1186/s12884-021-03839-w
12. Shoba Suri, Priya Rampal, and Shruti Menon, “The Uphill Climb to Maternal and Child Nutrition in Northeast India,” ORF
Occasional Paper No. 378, November 2022, Observer Research Foundation.
13. Shoba Suri, Priya Rampal, and Shruti Menon, “The Uphill Climb to Maternal and Child Nutrition in Northeast India,” ORF
Occasional Paper No. 378, November 2022, Observer Research Foundation.
14. Health infrastructure
• Health facilities that are available, functioning, staffed, and stocked
with medical supplies and medicines
• No. of people served per PHC
~25000 in TN vs. >45000 in UP
• Population per hospital bed
20x in Bihar than Kerala
• Equipment
92% of PHCs in Kerala (have at least 60% of equipment) vs. 6% in
Bihar
• Public infrastructure (roads, electricity, running water)
19. Health insurance
• Awareness, enrolment, utilization
Lowest among households in the 2 lowest wealth quintiles (based
on utilization and claims)
Lower among vulnerable groups (SCs, STs, OBCs, Muslims, elderly,
etc.) associated with catastrophic health expenditure
Lower in rural areas and poorer states (high in Kerala and
Himachal, low in Bihar, MP, UP, Assam)
Enrolment based on gender is similar, but not utilization and
claims; tend to focus on reproductive/maternal health
Dubey S, Deshpande S, Krishna L, Zadey S. Evolution of Government-funded health insurance for universal health coverage in India. The
Lancet Regional Health-Southeast Asia. 2023 Jun 1;13.
20. Axes of inequality
• Region
• Wealth/economic class
• Caste/tribal identity
• Urban/rural residence
• Gender
• Age
• Migrant status
21. Fig 2. Geographical pattern of maternal mortality ratio by 640 districts in India, HMIS.
Goli S, Puri P, Salve PS, Pallikadavath S, James KS (2022) Estimates and correlates of district-level maternal mortality ratio
in India. PLOS Global Public Health 2(7): e0000441. https://doi.org/10.1371/journal.pgph.0000441
https://journals.plos.org/globalpublichealth/article?id=10.1371/journal.pgph.0000441
22.
23. Karnataka NFHS 5
• What is the key axis of inequality in the report?
• What are the missing axes of inequality?
Editor's Notes
From 1947 to present
From 1990 to present
From 1990 to present
From 1976 to present
1977, 2014
However, these gains have not been distributed equally, and many have levelled off
The existence of vast inequalities is documented across India, for a variety of outcomes and across a variety of social and demographic characteristics
The first set of outcomes have to do with, essentially, not dying – curative care; the second set (more recent) have to do with improving health outcomes – preventive care
MMR is 3-7 times higher in poor, rural, and northern Indian states
While, overall, the IMR has declined in over the years, the IMR in the lowest quintile is 2.5 times that of the highest quintile; in general, a child who is born female, poor, low-caste, tribal, rural, and in a poor state is much more likely to die before the age of 5 than one who is not; caste is inextricably linked to these other demographic identifiers (intersectionality)
From Global Data Lab 2018
Census Population Projection Report 2021
Life expectancy ranges from below 60 in Orissa, UP, Jharkhand, MP, and Chattisgarh (& Assam) to 70 or more in Kerala, Punjab, and Maharashtra
Comparing maternal health care indicators between NFHS 3 (2005–06) to NFHS 4 (2015–16)
Immunization rates for children aged 12-23 months
Vaccination coverage ranges from over 80% in Kerala and TN (and even higher in certain NE states: Manipur, Meghalaya) to below 40% in Bihar, Rajasthan, UP (and Assam & Arunachal Pradesh); coverage is higher for wealthier and higher, non-tribal castes
India has only .5 hospital beds per 1,000 population when the recommended is 3 per 1000
Ranked 155th out of 167 countries
69% in urban areas
Rural Health Statistics, NHM 2019-2020
What is needed for 2020 population levels vs. what is actually available
Only 4% of sub-centers, 13% of PHCs and 4% of CHCs actually meet the Indian Public Health Standards, with many lacking even electricity and water supply; many don’t have labour rooms, operating theaters, or even a minimum number of beds
Rural health statistics, NHM 2019-2020
Problem is acute when it comes to staffing, and here regional variations become evident. In Bihar, for instance, the doctors shortage is 58%.
If you look at specialties like ob-gyn, anaesthetics, surgeons, paediatrician, etc. the shortfall is significant, especially in states that have poor health indicators. For instance, UP needs 2844 specialists but has only 812 in place; Rajasthan need 2192 but has only 438.
In the absence of key personnel and facilities – for e.g., labour rooms, nurses/midwives, ob-gyns – how to safely deliver a baby? Also puts pressure on upstream medical facilities
Some of these factors have been less explored than others
I have not dwelled on gender – as it is often the first variable that outcomes are disaggregated by – but 2 out of 3 women report challenges in accessing healthcare (distance, transportation, permission, decision-making autonomy) and of course broader cultural constraints
I have also not gone into the social elements of care – how providers treat patients (respect, responsiveness, etc.)
Karnataka’s health spending is low compared to other southern states Rs. 791 per capita (Rs. 1022 in Andhra, Rs. 849 in TN, Rs. 1070 in Kerala)
Between district variation in Karnataka – Dharwad & Ballari have a 35% shortfall in PHCs, while Chikmagalur and Hassan have an excess
Only Kodagu’s CHC met standards; Dharwad doesn’t even have one
Residents have to travel great distances to receive care
Vision Group Report 2021 (https://www.deccanherald.com/state/top-karnataka-stories/health-infra-uneven-across-districts-karnataka-health-vision-group-report-1140185.html)
If you were reporting data similar to NFHS, how would you categorize it? What are the key axes of inequality in your community?
Main areas of inequality – health outcomes, infrastructure, or insurance schemes?
What programmes to target these problem areas?
