The document discusses the Indian healthcare system, including its historical evolution, constitutional rights related to health, and the inequalities in access to healthcare across various demographics. It highlights the phases of health service development, significant public health policies, and the impact of socioeconomic factors on access to healthcare. A case study of the M-East ward in Mumbai illustrates the severe inequities and challenges faced by disadvantaged populations in accessing healthcare services.

1. Indian Health Care System
And Inequality In Access
MODULE TEACHERS:
Dr. Archana Diwate and Dr. Smitha Nair
Class Schedule: 6th
September and 11th
September 2024

2. Learner Objectives
• To situate health care systems within the broader social
context.
• To trace the evolution and challenges of Indian health
care systems both in the pre and post reforms period.
• To familiarize the extent of inequalities in population
health and its linkage with access to health care systems.

3. Content

Why Health becomes a right?

Health care as Public good

Constitutional Provisions on health

Evolution of Health services:

1940s-2017

Access to HSS

By class, caste, region and gender

Factors influencing Access

4. Concepts
• Health: WHO in 1946 for the first time tried to define health in a holistic
way by adopting the definition of “A state of complete physical, mental
and social wellbeing and not merely the absence of disease or infirmity”.
The concept of health is thus influenced by the interplay of macro, meso
and micro level socio economic, political and other factors or determinants
of health.
• Health care: Health care is the maintenance or improvement
of health via the diagnosis, treatment, and prevention
of disease, illness, injury, and other physical and mental impairments in
human beings.

5. • System: Derived from latin word ‘systema’ and ancient greek ‘sustema’
which means organized whole body (eg:respiratory system)
• Health Care System: The organized system of health care that is
responsible for providing primary, secondary and tertiary care to the
larger population which include preventive, promotive, curative and
rehabilitative services.
• The health care system is intended to deliver the health care services. It
constitutes the management sector and involves the organizational
matters. For the proper provisioning of health services community
participation is important

6. • Why Health is A Right?
• ➢ Constitutional Obligations:
• Articles 14, 15 and 21 (rights to life,
equality and non discrimination,
• Article 17 (abolition of
untouchability);
• Article 23 (prohibition of traffic in
human beings and forced labour);
• Article 24 (prohibition of employment
of children in factories, etc.)
International treaties India has signed:
• Eg. International covenant on SEC
rights; International HR legislations
Principle of Bhore Committee: blue print in
creating India’s health service,
“No Individual should fail to secure adequate
medical care because of inability to pay for
it”
Supreme court rulings have linked the right
to health and health care to the right to life
under Article 21
• Bandua Mukthi Morcha vs Union of India
(case)

7. Characteristics of Health Care
As Health becomes right of a citizen, health care services being the
major determinant of health of a population, its provisioning has to
follow the principle of a Public Good.
Two characteristics of Public Good:
❖ Non-excludability:
❖ Non Rivalry:
Health care as a means to an end (achieve health)
Organizing health care: Mixed system (Public and Private);
Welfarist; The Role of the state has to be central.

8. Evolution Of Indian Health Services
1st phase: Bhore committee and NHP(1940-78); FP
2nd
Phase: 1978-91; MCH; CSSM; Unicef role;
3rd
Phase: 1991-2005 HSR; reforms and privatisation
4th
Phase: 2005-2015 NHM and UHC
Current phase: Ayushman Bharat

9. 1st
Phase: Health Planning Till 1980s
 Bhore committee
 Disease control programmes predominantly family planning
programme
 Vertical disease control hampering the structure and
funcitioning of health services
 Water supply removed from health sector in 5th
plan period
 ICDS became an independent entity with minimum
intersectoral linkage with health

10. Levels of Health Care
• Health care can be described at three levels: Primary, Secondary and Tertiary
• Primary Care level: first level of contact of individuals, the
family and the community with the national health system
where ‘essential health care’ is provided. It is at this level
that the health care will be most effective.
Primary
Care
• Intermediate health care level. At this level more complex
problems are dealt with.
Secondar
y Care
• Specialized level than secondary care level and requires
specific facilities and attention of highly specialized health
workers . The care is provided by medical institutions and
other hospitals
Tertiary
Care

11. Public Health Care System – Three Tier System
• The health care infrastructure in rural areas has been developed as a three-tier
system
Community health
centre
Sub-centre
Primary health
centre

12. Three Tier System
Humphries, Claire; Jaganathan, Suganthi; Panniyammakal, Jeemon; Singh, Sanjeev; Dorairaj, Prabhakaran;
Price, Malcolm; et al. (2020). Structure of the Indian public healthcare system according to Indian Public Health
Standard Norms.. PLOS ONE. Figure. https://doi.org/10.1371/journal.pone.0230438.g001
Population
wise
division

13. 2ND
PHASE
PHC and Alma Ata
Principles of PHC
1983 National Health policy
Diverted focus by UNICEF to Selective PHC approach:
Technocentric fix

14. 3RD
PHASE
WDR 93: Investing in Health
Neoliberal policies of government
Structural Adjustment Policies in Health: HSR
• Reduction in public funding
• Increased privatisation
• PPP in health in the name of efficiency
Culmination in NHP 2002: open call for privatization
Health became Medical care: Curative care driven model
Lost focus of SDH and PHC

15. 4th
Phase
UPA govt and CMP in health : NRHM
Attempt to strengthen the then eroding Public sector
Mix of new public management and partnership with NGOs
Universal health Coverage/ Care: Politics of Insurance model
Niti Ayog- Report on investment opportunities in India’s health care sector
2021
Health care as an Industry – ripe for investment, encouragement of FDI and
push for greater privatisation
COVID scenario-???

16. Poor Provisioning Leads To Poor Access
• Source: Baru et al. (2010) Inequities in Access to Health
Services in India: Caste, Class and Region, EPW, 45, 38, 49-58.

17. Inequity In U 5 MR
• Source: Baru et al. (2010) Inequities in Access to Health Services in
India: Caste, Class and Region, EPW, 45, 38, 49-58.

18. A Case Of M Ward In Mumbai
• The M East ward in Mumbai has the lowest human
development index and nearly 80% of the population lives in
slums.M-East is the poorest and most deficient in civic services
of Mumbai’s 24 administrative wards. The differences
between the civic amenities available to middle-class
apartment blocks and the slums are stark and has recorded
one of the highest fatality rates due to COVID-19.
• Most of the people were daily wage laborers or contractual
laborers. 56% of M east ward survived on borrowed money.
49% of the people in the area were earning below Rs 6000
a month and 46.7% of the people had no income.
• Infrastructure- Poor and congested housing conditions,
community water was available for one hour a day.
Sanitation facilities- (1 toilet for 190 households)

19. Access To Health Care For M Ward Residents
• Patients with chronic diseases - Discontinued medicine. People with urgent health-care
needs- e.g. dialysis patients , cancer patients- No access to health care services
• Government hospitals were overburdened with COVID positive cases. Non -COVID patients
had no access to health care services. Even in case of non-covid hospitals many of them
were turned away because of the facilities were full. Pregnant women, children with severe
acute malnutrition, elderly patients were among worse affected .
• Private health care facilities- not affordable/not available - Quacks with questionable
degrees were the first to open up after the unlock began
• Diagnostic facilities in government facilities were not accessible. Private diagnostic
facilities were expensive. In many cases these services were not nearby and transport
became a major barrier. Private transportation was very expensive. In many cases pregnant
women were not able to get a scan done.

20. Factors Influencing Access
Insufficient investments in Public sector
Failure to recognize public health as a public good
Unregulated commercialisation and rising costs
Health sector reforms that weaken public sector
Variable quality and lack of accountability in public and private sectors
Underserved areas, marginalised and vulnerable communities

21. References
• Baru, R., Acharya, A., Acharya, S., Kumar, A. S., & Nagaraj, K. (2010).
Inequities in access to health services in India: caste, class and region. Economic
and political Weekly, 49-58.
• Ghosh, SM and Qadeer, I (2020) Public Good Perspective of Public health,
Evaluation health system response to covid 19, EPW, vol.55, 36, 40-48.
• Should health care be a fundamental right? A conversation with Dr T.
Sundararaman and Dr Abhay Shukla by Ramya Kannan, access at:
https://www.thehindu.com/opinion/op-ed/should-healthcare-be-a-fundamental-ri
ght/article31528818.ece
,
• Podcast: https://www.youtube.com/watch?v=yWkbepumqiQ