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

1. Synthesis of evidence on health inequities
associated with class / economic inequalities
Prashanth Nuggehalli Srinivas
Institute of Public Health, Bangalore
NATIONAL SEMINAR ON HEALTH EQUITY
EVIDENCE AND PRIORITIES FOR RESEARCH IN INDIA

2. Layered inequalities
• Economic
inequalities most
well researched &
possibly most
“obvious”
• Economic
inequalities:
income, wealth and
consumption (also
applies to health)
Barton and Grant (2006) adaptation of
Dahlgren and Whitehead (1991)

3. Indian health system worsens income/class inequity
• Healthcare expenditure financed by people out of pocket, at the
point of service delivery (high OOPs)
• Poor social protection: Neither universal nor well targeted
Oxfam

4. Class, for us means…
“…division of society by the level of access that a
group had to economic resources, indicated for
example by income, consumption, wealth or
standard of living, as found in the articles
reviewed for this synthesis.” (cf. UK context)

5. Class/income inequalities
• Income positively
correlated with health
outcomes globally
• Income as one of the
drivers of health
• The poor cannot buy
into health

6. Equity ≠ Equality
• Absence of particularly unfair
differences; Social and political
disadvantages -> adverse societal
conditions that prevent these
populations/population sub-groups
from realising individual measures
to overcome health or social
inequalities.
• “ (lack of) social justice is killing
people on a grand scale”
• “inequitable distribution of power,
money and resources as one of the
underlying causes of inequities in
health”.

7. Objectives
• What kind of patterns have been reported
with respect to class inequalities in health?
• What are the drivers/mechanisms of these
inequalities? What maintain/accentuate
them?
• What gaps exist with respect to research on
class inequalities in health in India?

8. Methods
• Mapping papers on equity using search of databases as well as additional
inputs
– Who is conducting or has conducted research (individuals and
institutions) on health–inequity issues in India since 2000?
– What were their areas of research, conceptual paradigms, and
methodological approaches?
• Classification by axis: Class, caste, gender, other vulnerabilities and health
systems
• Sub-categorised within each axis along those that report:
– Description/patterns
– Asociations and socio-economic-political and cultural correlates,
– mechanisms and/or pathways
– Interventions

9. Mapping results

11. Data extraction
Quality framework
• Are the aims and objectives of the research clearly stated? (A/a)
• Is the research design clearly specified and appropriate for the aims and objectives of the
research? (B/b)
• Do the researchers provide a clear account of the process by which their findings we
reproduced? (C/c)
• Do the researchers display enough data to support their interpretations and conclusions?
(D/d)
• Is the method of analysis appropriate and adequately explicated? (E/e)
Dixon-woods et. al. 2006

12. Synthesis
• The synthesis exercise was built on the critical interpretive
synthesis methodology proposed by Dixon-Woods et al. 2006.
• This was followed by critically interpreting the meaning of
such existing disparities, and making sense of how they come
to exist. The process involved continuously going back to the
papers to establish links between the inequities and their
causes.
• Recurring themes were identified and categorized together.
The CSDH health equity conceptual framework was useful in
organizing the results of the synthesis.

13. How and what were studied?
• Wealth index
• Concentration index
• Decomposition of CI and isolating drivers of poor CI
• ANC, PNC and childbirth
• Immmunisation coverage
• Family planning services
• Childhood malnutrition
• Maternal and childhood anaemia
• Maternal, infant and child mortality and morbidity

14. Broad patterns and correlates
• Clear income gradient in public health across states and districts with positive associations
with literacy and rural residence. Wealth strongest marker of anaemia status, more so than
education and caste
• Economic constraints influence choice of various health services, in several contexts public
services “a lesser good” (cf. childbirth, inpatient care, skilled birth attendance)
• Unequal access to a variety of services, schemes and programmes for poorer sections
• Somewhat a pattern of rich seeking care in for-profit organised private while the poor
delaying care or at public (although not generalisable)
• Postnatal care most unequal among maternal health services (cf. discrimination)
• Although inequalities generally lower in economically better-off states (many of them in
south India), paradoxically being in a “better-off” state not always good for the poor in these
states. Similar patterns in outcomes (cf. U-5 mortality inequalities better in “poorer” states,
but…)

15. Inequalities in processes
• Provision of maternal health advice concentrated among
the rich
• Family planning advice most unequal, while breastfeeding
advice most equal
• Inequalities in advice pronounced in lower level facilities
• Discrimination at the point of service delivery leading to
denial, “less” services, poor awareness and/or poor quality
services (cf. positive(?) eg. higher surgical family planning
services utilisation among SC/ST)

16. Inter-state variations
• Quality of services for poor marginally better off in the south Indian states
• Poor benefitted least across states; even in Tamil Nadu poor women maternal health
care services coverage increments better off among the richer (most advantageous
were non-poor mothers from Tamil Nadu or Maharashtra, living in urban areas, with
above primary education and literate husband, with low parity and some exposure to
mass media)
• State governance patterns could explain the comparably worse class inequalities in
some states, most prominently system leakages, poor adaptation to target groupand
better allocations and management (state failure)
• Highly unequal states are characterised by the simultaneous existence of
overconsumption by privileged groups and food insecurity among the poor
• Several “worse-off” talukas within “better-off” districts (“92 districts with sub-districts
from top and bottom 20%”); problems related to systematic poverty and disadvantage likely
to have more ill-effects where local capacity is poor

17. Inequities in outcomes & explanations
• Poorest areas have shown slower pace of decline in maternal
mortality than richer areas
• Subsidizing effect of public programs aimed at reducing mortality
among children
• Maternal literacy and authonomy as possible mitigators, albeit
possibly requiring “higher” class to manifest
• Poor social cohesion and in unequal societies and poor access to
social networks, the latter more so in poorly governed settings
• Pre-existing vulnerabilities accentuate ill-effects of otherwise
“bearable” shocks

19. Gaps
Methodological gaps
– Econometric methods
– Very few qualitative studies
– “To what extent” & “how much” versus “How” and “Why” questions
Content gaps
– Discrimination inferred and reported, often not studied
– Drivers/maintainers/perpetuators of inequality
– NFHS-based and dominance of MCH
– Regional gaps (North-east)
– Intersectional research unpacking the “poor” or the “middle” classes
– psychosocial, behaviour and biological dimensions of people’s
circumstances and their contribution to driving inequities nearly
absent

20. Thank you