No quote best synthesizes my thoughts as I start to pen the introductory article of my blog, which revolves around the realities of the healthcare system in India. Although enormous strides have been made to improve health accessibility, outcomes, availability, and quality in India since independence in 1947, major inequalities still exist among different social groups. The 2017 National Health Policy outlined equity through affirmative action, universality through active prevention of exclusions, and pluralism in its key policy principles. In this article, I have elucidated select social determinants which succinctly portray the embedded health inequities in India.
Gender inequities have been well documented in India, which has an overall sex ratio of 919 females to 1000 males. In 2017, Vilms et al did a cross-sectional analysis of health outcomes (e.g., neonatal illness, care-seeking for neonatal illness, hospitalization, immunizations, and post-natal home visits by frontline workers) of infants in the Indian state of Bihar and found out that female infants were less likely to receive care if ill and had lower rates of reported illness. Further, female infants were less likely to have had a postnatal checkup within their first month. This inequity was further accentuated in lower income families and those with more children. Unsurprisingly, these differences were not present for immunization and frontline worker home visits as they are mandated by state governments through ASHA (Accredited Social Health Activists).
The caste system is a socio-cultural concept unique to India and neighboring South Asian countries, in which society is hierarchically stratified according to varnas (transl. groups), with Brahmins occupying the apex and Dalits (transl. Scheduled Castes) and Adivasis (transl. Scheduled Tribes) being at the bottom of the pyramid. Multiple studies have demonstrated how Dalits are marginalized with respect to access to quality healthcare through direct and structural biases. Together, Dalits and Adivasis comprise 24.2% of the total Indian population.
One such study by Mishra et al. analyzed the impact of socio-economic inequities like casteism in access to maternal health benefits in India. They assessed the coverage of Janani Suraksha Yojana (transl. Mother Protection Program), a public cash transfer program aimed at reducing the maternal mortality rate and encouraging institutional childbirths. They found out that among the different caste groups, coverage of the program varied, with coverage of Dalits and Adivasis trailing behind that of other caste groups. Due to this program, on an absolute basis, the uptake of maternal health services increased among marginalized women, but the disparity in benefit between Dalits and non-Dalits was huge.
To underscore the supply side health inequities in India, Ransing et al. examined the distribution of psychiatry trainee seats and mental health institutions across Indian states. They found out that maldistribution of psychiatry trainee seats existed, with some states having a surplus of psychiatrists and others having a very poor psychiatrist to patient ratio; unsurprisingly, the states with very poor psychiatrist-to-patient ratios were also faring poorly on per capita income and other social determinants. Overall, India is way behind the ideal ratio of 1 psychiatrist per 100,000 population, with India churning out just 868 new psychiatrists every year for a population of 1.3 billion people.
Although dimensions of health inequity are multiple and convoluted in India, there have been previous efforts to uproot them. One such effort was the 2014 Mission Indradhanush (transl. Mission Rainbow), which intended to achieve universal full childhood immunization. With sustainable financing, political will, and micro-planning to target the unvaccinated, the program led to an uptick of 6.7% (versus 1% uptick previously) in full immunization coverage after its second phase.
India needs to have a paradigm shift in its approach to tackling health inequity. When left to individual families, female infants in Bihar had a lower likelihood to receive institutional medical care, but when immunization was driven through frontline worker home visits, they received equal care to male infants. Similarly, government health programs aimed at marginalized social groups have historically proven to be more effective than free market demand and supply forces. Often, inequity is problematized as plugging in necessary gaps, but as the above examples reinforce, mandating social inclusion through government policies is the most viable articulation and implementation of health equity, making it a tough pill to swallow.