Synthesis of evidence on health inequities associated with class / economic inequalities

Prashanth Nuggehalli SrinivasInstitute of Public Health, Bangalore

NATIONAL SEMINAR ON HEALTH EQUITY EVIDENCE AND PRIORITIES FOR RESEARCH IN INDIA

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)

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

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)

Class/income inequalities

• Income positively correlated with health outcomes globally

• Income as one of the drivers of health

• The poor cannot buy into health

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”.

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?

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

Mapping results

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

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.

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

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…)

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)

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 group and 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

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

GapsMethodological 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

Thank you