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SOCIO-ECONOMIC INEQUALITIES IN

ACCESS TO MATERNAL HEALTH CARE


IN INDIA: CHALLENGES FOR POLICY

Prof. Rama V. Baru


Centre of Social Medicine and Community Health
Jawaharlal Nehru University
New Delhi

Overview

This paper provides a brief overview of socioeconomic 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

The acceleration of economic growth since 1981 has not translated adequately
into a sustained improvement in Indias 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


140

117

120

101

Under 5 M ortality

100

96

Mothers
with no
education

ST

79

80

70

74

59

60

40

30
20

95

34

14

Urban
Kerala

Mothers Highest
with more quintile
than 12
years of
education

Non ST,
SC and
OBC

Male

All India

Female

Lowest
quintile

Rural UP

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

Social Gap in Under-Five Mortality for three periods 19921993*, 1998-99 and 2005-06
140

119

120

101

Under 5 Mortality Rate

100

80

74

60

SC-Other
ST-Other
OBC-Other
All India

44
40

38

37

37
29

24

21

20

14

1992-93

1998-99

2005-06

NFHS Years

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

75.3

75.2

Mothers with more


than 12 years of
education

80

Kerala

Full Immunisation Rate*, Inequalities in utilisation of


preventive care
71
70

57.6

50

40

39.7

Scheduled caste

43.5
38.6

Rural

Full Immunisation (%)

60

35.5
31.3

30
24.4

23

20

10

Highest Quintile

Urban

All India (2005-06)

All India (1992-93)

Uttar Pradesh

Scheduled tribe

Lowest Quintile

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

Socio-economic inequalities and access to delivery


services
120

100
100

80

60
51

40

20

38

39

OB C

A ll Ind ia

33

16

18

R ur al U P

ST

SC

N o n ST , SC and
OB C

U r b an Ker ala

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

Delivery in health facility across wealth index

90
84

Percentage delivered in Government Health facility


Total Percentage delivered in Health facility

80

70

58

60

50
39
40

27

30
24

24

23

20
13
10

14

Lo west

Seco nd

M id d le

F o urt h

Hig hest

W ealt h Ind ex

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

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

Determinants of inequities in access

Health service determinants and socioeconomic 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 systemsprivate 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 commercialisationpublic 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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Summing Up

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
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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 Oxfam
Working Paper Series.
Bonu, S, I Bhushan and D H Peters (2007): Incidence, Intensity and Correlates of Catastrophic Out-ofPocket 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
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 Home
Deliveries: 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 of
liberalisation 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 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
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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
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and Family Welfare, Government of India, New Delhi.
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for Maternal Health Care Services in Five Countries:Policies and Perspectives. Policy Working Paper
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study. Unpublished MPhil dissertation, Jawaharlal Nehru University, New Delhi.
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sectional study BMC Public Health 2011, http://www.biomedcentral.com/1471-2458/11/150
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American Journal of Public Health, 96, pp 818-25
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