socio-economic inequalities in access to maternal health care in india

7/24/2019 Socio-economic Inequalities in Access to Maternal Health Care in India

http://slidepdf.com/reader/full/socio-economic-inequalities-in-access-to-maternal-health-care-in-india 1/21

1

SOCIO-ECONOMIC INEQUALITIES IN

ACCESS TO MATERNAL HEALTH CAREIN INDIA: CHALLENGES FOR POLICY

Prof. Rama V. Baru

Centre of Social Medicine and Community Health Jawaharlal Nehru University

New Delhi



2

Overview

This paper provides a brief overview of socio-

economic inequalities in access to maternalhealth 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



3

The acceleration of economic growth since 1981 has not translated adequatelyinto 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 hasbeen 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, subregional, social and economic dimensions of inequality along multiple axes ofclass, caste, gender and religion

Broadly, these inequalities get reflected in health outcomes and

access tohealth 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)



4

Inequalities in Under-Five Mortality in India, 2006

14

3034

59

7074

79

95 96

101

117

0

20

40

60

80

100

120

140

Urban

Kerala

Mothers

with more

than 12

years of

education

Highest

quintile

Non ST,

SC and

OBC

Male Al l India Female Mothers

with no

education

ST Lowest

quintile

Rural UP

U n d e r 5

M o r t a l i t y

Source: Baru et al (2010) Inequit ies in Access to Health Services in India: Caste, Class and Region, Economic &

Political Weekly,September 18, 2010 vol xlv no 38. Pp 49-58



5

Social Gap in Under-Five Mortality

for three periods 1992-

1993*, 1998-99 and 2005-06

38 37

29

24

44

37

21

14

119

101

74

0

20

40

60

80

100

120

140

1992-93 1998-99 2005-06

NFHS Years

U n

d e r 5 M o r t a l i t y R a t e

SC-Other

ST-Other

OBC-Other

All India

Source: Baru et al (2010) Inequit ies in Access to Health Services in India: Caste, Class and Region,

Economic & Political Weekly,September 18, 2010 vol xlv no 38. Pp 49-58



6

Full Immunisation Rate*, Inequalities in utilisation of

preventive care

24.4

31.3

23

35.5

38.6 39.7

43.5

57.6

71

75.3 75.2

0

10

20

30

40

50

60

70

80

L o w e s t Q u i n t i l e

S c h e d

u l e d t r i b e

U t t a

r P r a d e s h

A l l I n d i a

( 1 9 9 2 - 9 3 )

R u r a l

S c h e d u l e d c a s t e

A l l I n d i a

( 2 0 0 5 - 0 6 )

U r b a n

H i g h e s t Q u i n t i l e

K e r a l a

M o t h e r s

w i t h m o r e

t h a n 1 2

y e a r s o f

e d u c

a t i o n

F u l l I m m u n i s a t i o n ( %

)

Source: Baru et al (2010) Inequit ies in Access to Health Services in India: Caste, Class and

Region, Economic & Political Weekly,September 18, 2010 vol xlv no 38. Pp 49-58



7

Socio-economic inequalities and access to delivery

services

16 18

33

38 39

51

100

0

20

40

60

80

100

120

Rur al U P ST SC OB C A l l Ind i a N o n ST , SC and

OB C

Urb an Kera la

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



8

Delivery in health facility across wealth index

8

14

23

27

24

13

24

39

58

84

0

10

20

30

40

50

60

70

80

90

Lo west Seco nd M i d d l e Fo ur t h Hi g hes t

Weal th Index

Percentage delivered in Government Health facility

Total Percentage delivered in Health facility

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



9

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



10

Determinants of inequities in access

Health service determinants and socio-

economic determinants. Both these intersectand are responsible for the persistence of

inequities

Commercialisation

of health services has been

a key factor perpetuating inequities in access



11

Defining commercialisation

Commercialisation includes processes like

marketisation, commoditisation, privatisation andliberalisation.

“

the provision of health care services through market relationships tothose 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)



12

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



13

Commercialisation

and embodying inequality:

Evidence from India

Historical roots of commercialisation

of Indian publicsector in provisioning and drugs

Formal and informal payments in public services during post independence period

Growth and diversification of ‘for profit’

health servicessince 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)



14

Institutional arrangements replicate the socialhierarchy (Baru:1998)

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

Lack of regulation

Complex inter relationships between publicsector doctors and paramedical personnel with

private institutions (Baru:1998)



15

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 adefining aspect of being poor –

i.e. those who are poorest

cannot afford access to care

(Hart:2000; Garg &Karan:2005; Bonu

et al 2007)



16

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



17

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 institutionsforce women into purchasing from the free market



18

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

Back and forth linkages between public and private sector; betweenformal 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 publicinstitutions and personnel. Normative values of public institutionshave been gradually eroded (Baru:2005)



19

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



20

Selected References

Baru, R (1998): Private Health Care in India: Social Characteristics and Trends (New Delhi: Sage

Publications).

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 OxfamWorking 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-PocketExpenditures 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

Iyer, A, G Sen and A George (2007): “The Dynamics of Gender and Class in Access to Health Care:Evidence from Rural Karnataka, India”, International Journal of Health Services, 37(3): 537-54

Jeffery, P, A Das, J Dasgupta and R Jeffery (2007): “Unmonitored Intrapartum Oxytocin Use in HomeDeliveries: Evidence from Uttar Pradesh, India”, Reproductive Health Matters, 15(30), 172-78.

Jeffery,P and Jeffery, R (2008) ‘Money itself discriminates obstetric emergencies in the time ofliberalisation’ Contributions to Indian Sociology, vol 42, no 1. pgs 59-91

Jeffery, P and Jeffery, R (2010) “ Only when the boat has started sinking: A maternal death in ruralnorth 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 RuralMaharashtra, Centre for Enquiry into Health and Allied Themes, Mumbai



21

Narayana, K V (2006): “The Unqualified Medical Practitioners: Methods of Practice and Nexus withQualified 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 DeterminantsFramework”, Indian Journal of Medical Research, (126), October, pp 355-63

Praveen Kumar Pathak, Abhishek Singh, S. V. Subramanian (2010) Economic Inequalities in MaternalHealth 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).

Rani, M, S Bonu and S Harvey (2007): “Differentials in the Quality of Ante Natal Care in India”,

International

Journal for Quality in Health, pp 1-10.

Rao, S (2005): “Delivery of Services in the Public Sector: Financing and Delivery of Healthcare Servicesin India”, National Commission on Macroeconomics and Health Background Papers, Ministry of Healthand Family Welfare, Government of India, New Delhi.

Rao, S, M Nundy and A S Dua (2005): “Delivery of Health Services in the Private Sector: Financing andDelivery 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 Feesfor Maternal Health Care Services in Five Countries:Policies and Perspectives. Policy Working PaperSeries No. 16, USAID, June.

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

Skordis-Worrall et al. Maternal and neonatal health expenditure in mumbai slums (India): A crosssectional study BMC Public Health 2011, http://www.biomedcentral.com/1471-2458/11/150

Subramanian, S V, S Nandy, M Irving, D Gordon, H Lambert and G D Smith (2006): “The Mortality Dividein India: The Differential Contributions of Gender, Caste and Standard of Living across the Life Course”, American Journal of Public Health, 96, pp 818-25

Unisa, S (1999): “Childlessness in Andhra Pradesh: Treatment Seeking and Consequences’,Reproductive Health Matters, 7(13), pp 54-64, May

http://www.biomedcentral.com/1471-2458/11/150



socio-economic inequalities in access to maternal health care in india

Documents