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SOCIO-ECONOMIC INEQUALITIES IN ACCESS TO MATERNAL HEALTH CARE IN INDIA: CHALLENGES FOR POLICY

Prof. Rama V. BaruCentre of Social Medicine and Community HealthJawaharlal Nehru UniversityNew Delhi

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Overview

This paper provides a brief overview of socio- economic inequalities in access to maternal

health services in India

It explains why these inequalities persist

It argues that commercialisation

of health services is a determinant of accentuating inequities and contributing to poverty

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The acceleration of economic growth since 1981 has not translated adequately into a sustained improvement in India’s human development outcomes[GDP growth: 1950-80 = 3.5; 1980-2000= 5.5; 2000-2011= 8.0 approx]

MMR and Under five mortality are unacceptably high and the decline has been slow. This is a cause for concern for both national and global policy (Subramanian et al :2006).

India offers a complex picture of multiple inequalities. There

are regional, sub regional, social and economic dimensions of inequality along multiple axes of class, caste, gender and religion

Broadly, these inequalities get reflected in health outcomes and

access to health services

The available macro data sets enable us to examine these relationships and the patterns

However these data sets do not lend themselves to an analysis of

intersectionality

between these various inequalities (Iyer

et al : 2007)

A few micro studies have analysed the relationship between inequalities, commercialisation and access (Jeffery et al :2007; 2008; 2010)

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Inequalities in Under-Five Mortality in India, 2006

14

3034

59

7074

79

95 96101

117

0

20

40

60

80

100

120

140

UrbanKerala

Motherswith more

than 12years of

education

Highestquintile

Non ST,SC and

OBC

Male All India Female Motherswith no

education

ST Lowestquintile

Rural UP

Und

er 5

Mor

talit

y

Source: Baru et al (2010) Inequities in Access to Health Services in India: Caste, Class and Region, Economic & Political Weekly,September 18, 2010 vol xlv no 38. Pp 49-58

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Social Gap in Under-Five Mortality

for three periods 1992-

1993*, 1998-99 and 2005-06

38 37

2924

44

37

21

14

119

101

74

0

20

40

60

80

100

120

140

1992-93 1998-99 2005-06NFHS Years

Und

er 5

Mor

talit

y R

ate

SC-OtherST-OtherOBC-OtherAll India

Source: Baru et al (2010) Inequities in Access to Health Services in India: Caste, Class and Region, Economic & Political Weekly,September 18, 2010 vol xlv no 38. Pp 49-58

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Full Immunisation Rate*, Inequalities in utilisation of preventive care

24.4

31.3

23

35.538.6 39.7

43.5

57.6

71

75.3 75.2

0

10

20

30

40

50

60

70

80

Low

est Q

uint

ile

Sche

dule

d tr

ibe

Utta

r Pra

desh

All

Indi

a (1

992-

93)

Rur

al

Sche

dule

d ca

ste

All

Indi

a (2

005-

06)

Urb

an

Hig

hest

Qui

ntile

Ker

ala

Mot

hers

with

mor

eth

an 1

2 ye

ars

ofed

ucat

ion

Full

Imm

unis

atio

n (%

)

Source: Baru et al (2010) Inequities in Access to Health Services in India: Caste, Class and Region, Economic & Political Weekly,September 18, 2010 vol xlv no 38. Pp 49-58

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Socio-economic inequalities and access to delivery services

16 18

3338 39

51

100

0

20

40

60

80

100

120

R ural U P ST SC OB C A ll Ind ia N o n ST , SC andOB C

U rb an Kerala

Source: IIPS and Macro International (2007): National Health and Family Survey – 2005-06 (NFHS 3), Mumbai.

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Delivery in health facility across wealth index

8

14

23

2724

13

24

39

58

84

0

10

20

30

40

50

60

70

80

90

Lo west Seco nd M id d le F o urt h Hig hest

W ealt h Ind ex

Percentage delivered in Government Health facilityTotal Percentage delivered in Health facility

Source: IIPS and Macro International (2007): National Health and Family Survey – 2005-06 (NFHS 3), Mumbai.

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Commonly cited reasons for inequities

supply side factors like weak public provisioning; poor quality of services

Demand side factors-

lack of knowledge; cultural beliefs; poverty; lack of purchasing power

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Determinants of inequities in access

Health service determinants and socio- economic determinants. Both these intersect

and are responsible for the persistence of inequities

Commercialisation

of health services has been a key factor perpetuating inequities in access

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Defining commercialisation

Commercialisation includes processes like marketisation, commoditisation, privatisation and liberalisation.

“

the provision of health care services through market relationships to those able to pay; investment in, and production of those services, and of inputs to them, for cash income or profit, including private contracting and supply to publicly financed health care; and health care finance derived from individual payments and private insurance”

(Mackintosh &Koivusalo: 2005,p.3)

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Attitude to public and private sectors is sharply divided between the academic view of privatisation

and the approach of policymakers

Need to ‘unbundle’

the complexity of commercialisation

of health service systems-

private and public

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Commercialisation

and embodying inequality: Evidence from India

Historical roots of commercialisation

of Indian public

sector in provisioning and drugs

Formal and informal payments in public services during post independence period

Growth and diversification of ‘for profit’

health services

since 1970s

India has a large, differentiated ‘for profit’

sector

(Muraleedharan: 1999; Nandraj

and Duggal

:1997; Baru:1998)

Formal and informal providers (Narayana:2006; Singh: 2010)

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Institutional arrangements replicate the social hierarchy (Baru:1998)

Differences in qualification of providers, scale of operation and quality of care

Lack of regulation

Complex inter relationships between public sector doctors and paramedical personnel with private institutions (Baru:1998)

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Health sector reforms accelerated commercialisation-

public and private (Qadeer

et al: 2002)

High out of pocket private spending (Bonu

et al:2007)

Adverse consequences for access; cost and quality of care in public and private sectors (Nandraj

& Duggal

:1997; Bonu

et al :2007)

Cause for households going into poverty and also a defining aspect of being poor –

i.e. those who are poorest

cannot afford access to care (Hart:2000; Garg &Karan:2005; Bonu

et al 2007)

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Rise in cost of care, high out of pocket expenditure, rising burden on households leading to differential levels of impoverishment of households across income quintiles for maternal health services (Skordis-Worrall :2011; Pathak

et al:2010)

Significant poor-non poor gap in access to maternal health services (Pathak

et al:2010)

Reasons for these trends are attributed to growth of ‘for profit’

services and a deficient public sector

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Consequences of commercialisation

for maternal health services

Informal payments for antenatal, delivery and post natal services to the public sector form a significant percentage of expenditure on maternal health services

(Sharma et al: 2005;Pathak et al: 2010; Skordis-

Worrall:2011)

Informal charging in the public sector is linked to abuse, exclusion and impoverishment. Indifferent and rude behaviour of health personnel

(Pathak

et al: 2010; Jeffery&Jeffery: 2010; Unisa: 1999)

Shortage of supply of drugs through public institutions force women into purchasing from the free market

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The contracting out of ultrasound facilities by public sector and referral from public to private sectors adds to out of pocket expenditure (NFHS 3: 2007; Jeffery & Jeffery: 2010)

Back and forth linkages between public and private sector; between formal and informal sector for maternal health services. (Unisa: 1999; Narayana:2006; Singh:2009; Jeffery & Jeffery: 2010)

Paying for care has therefore become entrenched in public and private sectors. This has resulted in the blurring of the roles

of public and private sectors (Baru

& Nundy:2008)

Rising commercialisation has altered the behaviour of public institutions and personnel. Normative values of public institutions have been gradually eroded (Baru:2005)

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Complex interaction between socio-economic inequalities and health services

Commercialisation

as a driver of inequities in access

Health services planning and regulation must be in tandem to address inequities caused by commercialisation

Recognising

the limits of health services in addressing inequalities in access

Addressing structural inequalities beyond health services

Need for inter sectoral coordination and greater convergence between health services and strategy for poverty reduction

Summing Up

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Selected References

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Baru, R and Nundy, M ( 2008) Blurring of Boundaries: Public-Private Partnerships in Health Services in India. Economic and Political Weekly, January 26th 2008. pp.62-71

Baru,R and Bisht, R (2010) Health service inequities as challenge to health security, IHD and Oxfam Working Paper Series.

Bonu, S, I Bhushan and D H Peters (2007): “Incidence, Intensity and Correlates of Catastrophic Out-of- Pocket Health Payments in India”, ERD Working Paper No 102, Asian Development Bank, October; Manila, Philippines.

Garg, C and A K Karan (2005): “Health and Millennium Development Goal 1: Reducing Out-of-Pocket Expenditures to Reduce Income Poverty-evidence for India”, EQUITAP Project, Working Paper No 15, Institute of Health Policy, Colombo

Hart, T J (2000): “Commentary-Three Decades of the Inverse Care Law”, British Medical Journal, 320 (7226): pp 18-19.

IIPS and Macro International (2007): National Health and Family Survey – 2005-06 (NFHS 3), Mumbai

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Jeffery, P and Jeffery, R (2010) “ Only when the boat has started sinking: A maternal death in rural north India” Social Science and Medicine. November. 71(10), pp.1711-1718

Muraleedharan, V R (1999): “Characteristics and Structure of the Private Hospital Sector in Urban India: A Study of Madras City”, Small Applied Research Paper 5, Partnerships for Health Reform Project, ABT Associates Inc, Bethesda.

Nandraj, S and R Duggal (1997): Physical Standards in the Private Health Sector: A Case Study of Rural Maharashtra, Centre for Enquiry into Health and Allied Themes, Mumbai

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Narayana, K V (2006): “The Unqualified Medical Practitioners: Methods of Practice and Nexus with Qualified Doctors”, Working Paper No 70, Centre for Economic and Social Studies, Hyderabad.

Nayar, K R (2007): “Social Exclusion, Caste and Health – A Review Based on Social Determinants Framework”, Indian Journal of Medical Research, (126), October, pp 355-63

Praveen Kumar Pathak, Abhishek Singh, S. V. Subramanian (2010) Economic Inequalities in Maternal Health Care: Prenatal

Care and Skilled Birth Attendance in India, 1992–2006. PLOS open access journal

Qadeer, I, K Sen and K R Nayar (2001): Public Health and the Poverty of Reforms: The South Asian

Predicament (New Delhi: Sage Publications).

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Journal for Quality in Health, pp 1-10.

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Rao, S, M Nundy and A S Dua (2005): “Delivery of Health Services in the Private Sector: Financing and Delivery of Health Care Services in India”, National Commission on Macroeconomics and Health Background Papers, Ministry of Health and Family Welfare, Government of India, New Delhi

Sharma,S, S. Smith, E. Sonnavelett, M.Pine, V. Dayaratna, R. Sanders (2005) Formal and Informal Fees for Maternal Health Care Services in Five Countries:Policies and Perspectives. Policy Working Paper Series No. 16, USAID, June.

Singh, K (2009) Practices of unqualitied practitioners in urban slums of south west delhi: an exploratory study. Unpublished MPhil dissertation, Jawaharlal Nehru University, New Delhi.

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