HEALTH CARE AND EQUITY IN INDIAINDIA: TOWARDS UNIVERSAL HEALTH COVERAGE

LANCET, 2011; 377: 505-515

Y BALARAJAN, S SELVARAJ, S V SUBRAMANIAN

Review of situation of existing health inequities in India

How to measure health inequity?

EQUITY

Equity is an ethical and value-based concept, grounded in the principles of fairness and distributive justice.

(McCoy, 2003)

WHO defines health equity as the absence of unfair and avoidable or remediable differences in health among population groups defined socially, economically, demographically or geographically.

EQUITY IN HEALTH

o Social gaps in health and health care are unacceptably wideo Gaps between socioeconomic groups: rich-poor, inverse care law;

nonprofessional and professionalo Gaps between geographical groups: interstate, rural- urbano Gender gap in health: neglect and discrimination of femaleso Gaps between racial/ethnic groupso Gaps between age groups

o The concept of equity in health implies addressing differences in health status that are judged to be unnecessary, avoidable and unfair such as disparities in socio-economic status, sex, age, racial groups, rural or urban residence.

HEALTH EQUITY IN INDIA

o Equity in health & health care- long term guiding principle of health policies in India

o A detailed plan for UHC for Indian population was laid down in the Health Survey and Development Committee report in1946.

o Need for UHC reiterated in 1st official NHP-1983.

o In NHP-2000, UHC emphasized on basis of realistic consideration of capacity

o In 2009- National Health Bill.

o Review of situation of health inequity in India

o Objective of study: o Identify key challenges in achievement of equity in service

provision, financing and financial risk protection

SEARCH STRATEGY AND SELECTION CRITERIA

“Health systems”, “health sector”, “equity”, “inequity”, “inequalities”, “access”, “utilization”, “financing”, “regulation”, “service delivery”, “expenditures”, “out-of-pocket” and “quality”

o Academic literature, government reports, multilateral agency reports, commissioned reports in Indian context

o Data obtained from Census of India, Central Bureau of Health Investigation, MOHFW (GoI), National Health Accounts of India, NFHS data and NSSO’s Consumer Expenditure Survey reports

o Reported in 4 parts-o Describe inequalities in health careo Factors affecting supply for health careo Factors affecting demand for health careo Principles for achievement of equity.

INEQUALITIES IN HEALTH CARE

• In 2005-06, national immunization coverage was 44% and inequalities existed by caste, education, household wealth and location

• The absolute gender gap has increased from 2.6% in 1992-93 to 3.8% in 2005-06

• In 2005-06 only 38.7% of women reported giving birth in a health facility for their most recent birth.

• Women in richest quintile were six times more likely to deliver in an institution than those in poorest health quintile

IMMUNIZATION COVERAGE OF 12-23 MONTHS CHILDREN, NFHS-3 (2005-06)

URBANRURAL

LOWEST

SECOND

MIDDLE

FOURTH

HIGHEST

MALE

FEMALE

0

10

20

30

40

50

60

70

80

57.6

38.6

24.4

33.2

46.9

55.3

71

45.341.5

URBAN-RURAL WEALTH QUINTILE GENDER

% O

F CH

ILDR

EN B

Y IM

MU

NIZ

ATIO

N C

OVE

RAGE

Figure 1: Trends in inequalities in coverage of immunisation expressed as rate difference (A) and rate ratio (B)

Rate difference is absolute inequalities. Rate ratio is relative inequalities. The immunisation coverage represents the percentage of children aged 12–23 months who had received full immunisation consisting of BCG, measles, and three doses each of diphtheria, tetanus,

pertussis, and polio vaccines (excluding polio vaccine given at birth). *Reference group. Source: NFHS

Figure 2: Inequalities in mortality in children younger than 5 years in India

Source: NFHS 1,2,3

Figure 3: Association between mortality in children younger than 5 years and state’s domestic product per person (at factor cost at current prices)

Sources :National Family Health Surveys, Office of the Registrar General and Census Commissioner, Ministry of Statistics and Programme Implementation.

Area of each circle is proportional to the size of the population in the state.

ANTENATAL CARE BY A DOCTOR IN THE LAST PREGNANCY ACCORDING TO NFHS-3 (2005-06)

URBANRURAL

LOW

EST

SECOND

MIDDLE

FOURTH

HIGHEST

NO EDUCATIO

N

<5 YEARS COMPLET

ED

6-7 YEARS C

OMPLETED

8-9 YEARS C

OMPLETED

10-11 YEARS COMPLETED

12 OR M

ORE YEA

RS 0

10

20

30

40

50

60

70

80

9076.7

40.6

22.5

36.4

52.4

69

86.2

28.7

51.760.6

69.2

79.288.1

URBAN-RURAL WEALTH QUINTILE EDUCATION LEVEL OF WOMEN

% O

F PR

EGN

ANT

WO

MEN

REC

EIVI

NG

AN

TEN

ATAL

CA

RE B

Y DO

CTO

R IN

LAST

PRE

GNAN

CY

WOMEN DELIVERING AT A HEALTH FACILITY FOR THEIR MOST RECENT BIRTH, NFHS-3 (2005-06)

URBANRURAL

LOW

EST

SECOND

MIDDLE

FOURTH

HIGHEST

NO EDUCATIO

N

<5 YEARS COMPLET

ED

6-7 YEARS C

OMPLETED

8-9 YEARS C

OMPLETED

10-11 YEARS COMPLETED

12 OR MORE YEA

RS 0

102030405060708090

67.5

28.9

12.7

23.5

39.2

57.9

83.7

18.4

36.3

47.957.7

72.2

86.4

URBAN-RURAL WEALTH QUINTILE EDUCATION LEVEL

% O

F W

OM

EN D

ELIV

ERIN

G AT

HEA

LTH

FACI

LITY

FO

R TH

EIR

LAST

CHI

LD B

IRTH

In2005-06 , 38.7% of births at health facility

FACTORS AFFECTING SUPPLY IN HEALTH CARE

o In 2008-09,India’s total expenditure on health was estimated to be 4·13% of the GDP -1.10% public expenditure on health

o India having one of the highest proportions of household out-of-pocket health expenditures in the world— 71·1% in 2004–05

o 29·2% of public expenditures (both central and state) allocated to urban allopathic services compared with 11·8% of public expenditures allocated to rural allopathic services in 2004–05.

o Physical access is a major barrier to preventive and curative health services for India’s (>70%) rural population

o In 2008, an estimated 11,289 government hospitals had 4,94 ,510 beds, with regional variation ranging from 533 people per bed in a government hospital in Arunachal Pradesh to 5494 in Jharkhand

o Another challenge to assurance of equity in health care is that the most disadvantaged individuals are more likely to receive treatment from less qualified providers.

• Quality affected by ↑ rates of absenteeism among health workers, restrictions in opening hours, insufficient drugs / other supplies, poor-quality work environments, inadequate provider training and knowledge

• Regulatory deficiencies in the private sector were partly redressed by the inclusion of private medical practice in the Consumer Protection Act in 1986

• Other regulatory agencies-– Insurance Regulatory and Development Authority, – Central Drug Standard Control Organisation, – National Pharmaceutical Pricing Authority, – state drug controllers and the nursing home acts of different cities and

states, and until recently the – Medical Council of India

FACTORS AFFECTING DEMAND FOR HEALTH CARE

o Only about 10% of the Indian population are covered by any form of social or voluntary health insurance, which is mainly offered through government schemes for selected employment groups in the organised sector

o In 2004–05, about 14% of rural households and 12% of urban households spent more than 10% of their total consumption expenditure on health care.

Figure: Increase in Number of Poor Due to OOP Payments (in million)

• In 2004–05, about 39·0 million Indian people fell into poverty every year as a result of out-of-pocket expenditures

39·0 million

30·6 million

8·4 million

Figure 5: Effect of out-of-pocket payments on poverty ratios in India

Source: Calculations were based on Consumer Expenditure Surveys 1993–94 (50th Round),1999–2000 (55th Round),and 2004–05 (61st Round)

o The proportion of drugs that are price controlled has decreased greatly— about 90% of drugs were price controlled in the 1970s, but now only about 10% are.

o Between 1996 and 2006, the cost of a selected group of drugs rose by 40%, whereas the prices of drugs on the list of essential drugs rose by 15% and those not on the list and not price controlled rose by 137%

o Corruption is common in the health sector

o 20% reported irregular admission processes, 15% reported corruption after admission, [doctors (77%) and hospital staff (67%)] (Thampi GK)

Conceptual model of challenges to achievement of equity in health care

EQUITYACCESS

Equity in financing and financial risk protection

Equity in service delivery

QualityStructuralProcessServiceClinical

SUPPLY DEMANDResource allocation Costs Optimum Services and care Geography

Health care Additional

Behavioral and cultural factorsPhysical access Knowledge

Education InformationHuman resources for health

Technology

PRINCIPLES FOR ACHIEVEMENT OF EQUITY

o Equity metrics, as applied to data for health and health systems, needs to be integrated into all health-system policies and implementation strategies, and at every stage of any reform process.

o Strengthening partnership between organizations that gather data and the ministry of public health would encourage the development of equity monitoring.

o A concerted effort is needed to improve the knowledge base of health-systems research and health-equity research.

o Use of evidence based assessment during its health sector reforms through specific organization commissioned to coordinate and disseminate the knowledge developed, e.g. the National Health Systems Resource Centre

o A framework such as Benchmarks for Fairness for guidance on equity concerns and formalization of process of decision making on resource allocation and service delivery planning

o Urgent reform of India’s ineffective regulatory mechanisms and legal processes

PRINCIPLES FOR ACHIEVEMENT OF EQUITY

CONCLUSION

o With improved capability and capacity to plan and implement public health services from within the MoHFW, a more coordinated approach would be possible

o The foundation for primary health care for all- with a holistic approach to intersectoral responses has been emphasized in the 11th five year plan and the NRHM

o With recent rapid economic growth there is an opportunity to increase financial commitments to support public health system and health system research

MEASURING HEALTH INEQUITY

DIFFERENT MEASURES OF HEALTH INEQUITY

o The range (rate ratio and risk ratio)o Population attributable risk (PAR)o The Gini coefficient (associated Lorenz curve)o The concentration index (associated concentration curve)o The index of dissimilarityo The slope index of inequality (associated relative index of

inequality)

THE RANGE

o Most commonly usedo Comparing experiences of the top and the bottom socio-economic groupso Rate difference or rate ratioo Overlooks changes occurring in intermediate groups

POPULATION ATTRIBUTABLE RISK

o Etiologic fraction- standard repertoire of epidemiology

o Proportional reduction in overall morbidity or mortality that would occur in a hypothetical case if everyone experiences the rates of the highest socio-economic group.

o Difference between the overall rate and the rate for the highest socioeconomic group, expressed as % of the overall rate.

LORENZ CURVE

Gini coefficient (G)= concentration area = ACB maximum concentration area ADB

G ranges between 0 to 1.

GINI COEFFICIENT (ASSOCIATED LORENZ CURVE)

B

A

C

D

CONCENTRATION INDEX /CONCENTRATION CURVE

o Concentration index

o where p is the cumulative percent of the sample ranked by economic status, L(p) is the corresponding concentration curve ordinate, and T is the number of socioeconomic groups.

o It plots the cumulative % of health variable against the cumulative % of population ranked by socioeconomic status

o Curve above the diagonal concentration among the poor

o Curve below the diagonal concentration among the rich

o Curve on the diagonal = equality

C = (p1L2 - p2L1) + (p2L3 - p3L2) + … + (pT-1LT - pTLT-1)

CALCULATION OF CI FOR U5MR IN INDIA BY WEALTH QUINTILE

Wealth quintile

No. of births

Relative proportion %

Cumulative Proportion % (p)

U5MR per 1000

No. of deaths

Relative proportion %

Cumulative proportion% (L)

CI

1 14057 25% 25% 100.5 1413 34% 34% -0.00822 12351 22% 47% 89.6 1107 27% 61% -0.02973 11021 20% 67% 71.9 792 19% 81% -0.06204 10210 18% 85% 51.2 523 13% 93% -0.07995 8256 15% 100% 33.8 279 7% 100% 0.0000

55895 73.595 4114 -0.1798

WEALTH QUINTILE NUMBER OF BIRTHS U5MRPoorest 14057 100.5Second 12351 89.6Middle 11021 71.9Fourth 10210 51.2Richest 8256 33.8

CONCENTRATION CURVE FOR U5MR IN INDIA BY WEALTH QUINTILE

0.00 0.10 0.20 0.30 0.40 0.50 0.60 0.70 0.80 0.90 1.000.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00

CONCENTRATION CURVE FOR IMR IN INDIA BY WEALTH QUINTILE

0.00 0.10 0.20 0.30 0.40 0.50 0.60 0.70 0.80 0.90 1.000.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00

CONCENTRATION CURVES FOR NMR, PNMR, CMR AND U5MR BY WEALTH QUINTILES

0.00 0.20 0.40 0.60 0.80 1.000.00

0.20

0.40

0.60

0.80

1.00

Equity line NMR PNMRCMR U-5MR

CONCENTRATION CURVE FOR LAST CHILD BIRTH AT ANY HEALTH FACILITY, PUBLIC HEALTH FACILITY AND PRIVATE HEALTH FACILITY

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 10

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

EQUITY LINE AT ANY HEALTH FACILITY

AT PUBLIC HEALTH FACILITY AT PRIVATE HEALTH FACILITY

INDEX OF DISSIMILARITY

• Represents the proportion of total health that would be needed to be transferred from individuals whose health is above average to those whose health is below average, to achieve a situation of total equality.

• ID= ∑ I Pip-Pih I 2

REFERENCES

• Wagstaff A, Paci P, van Doorslaer E. On the measurement of inequalities in health. Soc Sci Med 1991;33:545–57.

• Mackenbach JP, Kunst AE. Measuring the magnitude of socio-economic inequalities in health: an overview of available measures illustrated with two examples from Europe. Soc Sci Med 1997;44:757–71.

• Murray CJL, Gakidou EE, Frenk J. Health inequalities and social group differences: what should we measure? Bull World Health Organ 1999;77:537–43.

• Enrique Regidor. Measures of health inequalities: Part 1 and part 2. J Epidemiol Community Health, 2004; 58: 900-903