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The right to health should be enacted as a fundamental right, demands Oxfam India in its Inequality Report 2021. The report analyses the country’s weak public healthcare system, health inequalities and the ongoing pandemic.
Titled India’s Unequal Healthcare Story, the report provides a comprehensive analysis of the health status across different socioeconomic groups such as marginalised communities that suffer from ill-health the most.
“The general category performs better than SCs and STs, Hindus perform better than Muslims, the rich perform better than the poor, men are better off than women, and the urban population is better off than the rural population on various health indicators,” said the report in its introduction.
Further in the report there is a closer look at health inequalities during the recent health emergency.
India’s healthcare and Covid 19
While analysing state performance in terms of the global pandemic, the report found that states that attempt to reduce social inequalities and spend more on health reported lower confirmed cases. However, states attempting to reduce inequalities showed lower recovery rate as well.
According to contributor Apoorva Mahendru, this may be because the ‘Reduced Inequality Index’ used by the report does not take into account factors like social distancing, access to improved water and sanitation. Such access contributes greatly to recovery from Covid-19. These same factors are not easily available for marginalised communities.
Similarly, higher-income groups could easily arrange for transport to hospitals. Among the lowest income bracket, comprising households with a monthly income of Rs. 15,000, the report found that 30 percent had to arrange for transport themselves. In households with income of Rs. 30,000 or less, 14.8 percent and 22.2 percent faced issues of slow response and quality of food served, respectively.
“Percentage of respondents in low-income brackets facing discrimination in the community due to being Covid positive was five times than those in high-income brackets,” said the report.
Further, over 50 percent of people hailing from Scheduled Castes (SC) and Scheduled Tribes (ST) faced difficulties in accessing non-Covid medical facilities compared to 18.2 percent in the general category. In the same way, only 3.9 percent of general category respondents depended on springs or streams for water consumption. The figure for Scheduled Castes was four times that of the open category. This means that more SCs were forced to use unsafe sources of water.
In terms of gender disparity, 33.9 percent of female respondents experienced anxiety, irritation and anger, and sleep-deprivation during the lockdown compared to 18.2 percent males.
“This is because of an increase in women’s unpaid care work burden at home, increase in cases of domestic violence, and probability of re-employment of women lesser than that of men post-lockdown,” said the report.
Experts also pointed out that current vaccination drives are blind to the digital divide in India. At the beginning of the pandemic, only 15 percent rural households had internet connection, smartphone users in rural India were almost half of urban India. More than 60 percent of women across 12 states said they had never used the internet. SCs and STs with smartphones stood at 25 and 23 percent respectively, while 43 percent open category individuals had access to smartphones.
“The number of Covid cases doubled in the second wave. The second wave hit the middle class more with 90 percent of all cases in Mumbai concentrated in high-rise buildings, while 10 percent were in slums,” said the report.
Considering infrastructure, India ranks 155 out of 167 countries on bed availability. It has five beds and 8.6 doctors per 10,000 of its population. However, only 40 percent of beds are concentrated in rural India that houses 70 percent of the population.
Social inequalities and its impact on healthcare
Using National Family Health Survey (NFHS) 3 and 4 data, the report stated that literacy rate for general category women is 18.6 percent higher than SC women and 27.9 percent higher than ST women.
“Education, specifically of women, has a direct effect on improving the health outcome at the level of the household as educated women are known to take informed healthcare decisions,” said contributor Khalid Khan.
Thus, the health inequality is evident in the attainment of female literacy with a gap of 55.1 percent between the top and bottom 20 percent of population in 2015-16.
In case of water and sanitation, two out of three households have access to improved, non-shared sanitation facilities in the general category. Meanwhile, SC households are 28.5 percent behind the open category and ST are 39.8 percent behind them. It is worth noting that poor water, sanitation and hygiene conditions were responsible for 1,00,000 deaths from diarrhoeal diseases in under-five children in 2015 in India.
Moreover, while 93.4 percent of households in the top 20 percent have access to improved sanitation, only 6 percent have access in the bottom 20 percent, a difference of 87.4 percent.
Regarding household expenditure on health, one in every six rupees spent on hospitalization by households is financed through borrowings. Less than one-third of households were covered by a government insurance scheme in 2015-16.
Another indicator of health inequality are institutional and home births. Though the gap in the institutional delivery of rural-urban, caste, religion and income groups has been declining over the decade, inequality prevails across these categories.
Institutional births in ST households were 15 percent below general category births in 2015- 16. There is a 35 percent gap in institutional births between the lowest and highest 20 percent wealth quintile groups in 2015-16.
Further, despite improvement in child immunisation, female-child immunisation rate continues to be below that of the male child. Similarly, more children in urban areas are immunised compared to rural children. Immunisation of SCs and STs is behind that of other caste groups. The child immunisation of the high wealth quintile group is much higher than of low wealth quintile.
Even in terms of nutrition, the difference between stunted children in SC and ST households and those in general category households is 12.6 and 13.6 percent, respectively. One in every two children are anaemic, wherein 60 percent of anaemic children are from SC and ST households.
Efficacy of government intervention
In the last 10 years, around 18 percent Indians have begun seeking some form of healthcare when they report being sick. Still, the current health status is a testament to the unfulfilled dream of ‘Health for All’ said contributor Mayurakshi Datta.
“The right to the highest attainable health is far from being realized. This holds especially true for the socially and economically marginalised,” said Datta.
In the 2021-22 budget, the health ministry has been allocated Rs. 76,901 crore, 9.8 percent less than Rs. 85,250 crore reported from revised estimates of 2020-21. Moreover, public funds for health have also been invested specifically on secondary and tertiary care rather than primary healthcare. Meanwhile, private healthcare providers are thriving, widening inequalities along caste, class, gender and geography.
“Health insurance schemes are being promoted as a way to achieve UHC [Universal Health Coverage] and to reduce OOPE [Out-of-Pocket Expenditure]. But evidence shows that the limited scope and coverage of the insurance schemes cannot address the all-encompassing requirements of UHC,” said the report.
So what next?
Aside from a call for right to health and free vaccine policy, the report called for an increase in health spending to 2.5 percent of GDP at the union and state level.
They also called upon the government to ensure that union budgetary allocation in health for SCs and STs is proportionate to their population while dedicating two-thirds of the concerned budget to primary healthcare. The centre should provide financial support to states with low per capita health expenditure to reduce inter-state inequality in health.
Regions with higher concentration of marginalised population should be identified and public health facilities should be established, equipped and made fully functional as per Indian Public Health Standards (IPHS).
While the report does not endorse Government-financed Health Insurance Schemes (GFHIS) as a way to achieve UHC, it is imperative that GFHIS widens its ambit to include outpatient costs as a way to reduce out-of-pocket expenditure (OOPE).
Experts also called for a centrally-sponsored scheme that earmarks funds for free essential drugs and diagnostics at all public health facilities. Further, rights under the Patients’ Rights Charter should be made enforceable by law.
The private health sector must be regulated by ensuring that all state governments adopt and effectively implement Clinical Establishments Act. They also called for regularisation of women frontline health workers services especially Accredited Social Health Activists (ASHAs), establishing government medical colleges with district hospitals prioritising their establishment in hilly, tribal, rural and other hard-to-reach areas, enhancing medical infrastructure and establishing contingency plans for scenarios such as the second wave of the pandemic.
Report can be read here:
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