Review of Literature and Theoretical Framework

2.1 Introduction

Ilescilrch on thc ut~lrsation and determinants of health care services and related issues

h a ~ c become an imponanl policy issue in the context of both developing and developed

countries. The approaches of the governments towards health care provision and

utilisation have heen different For Instance, in many advanced countries the role of the

statc has bccn ~nstrumcntal and governments budgetary provisions and allocations have

been si~bstanual T h ~ s con~ributed remarkably to overall improvements in the general

hcalth status. uhlch is typically true in thc industrially advanced OECD countries

(Gerdtliam and Junsson, 2002, Jonsson and Musgrove, 1997; Shieber and Maeda, 1997).

In most developing countries. larger vacuum and deeper gap have been left out by the

govcrnlnents as a pollcy inil~at~velalternat~ve to permit large scale private participation

thcrchv encouraging out-of-pocket payment as the method of health care financing for

both outpatient and inpatient care (Sanya1.1996. Selvaraju, 2003). The proportion of

rcour ic allocatloli for rercarch and development in general and health care research in

particular has been much higher in developed market economies and has made

slgniiicant contribution to the overall development of production and service sectors

[Korllai and Ilgglcston. 1001) . On the other hand, in most developing countries, the

nature and cxtc111 ol'~n~er-sectoral co-ordination among the different departments such as

watcr .;upply, irrtyation. sanitation, rural development, human resource developmenr.

puhllc hc~l th . lam~ly wcliarc. tducatlon and housing have been very weak affecting the

tlnct~onal efficiency and long run sustainability of various health care and related

development programmes (GoI, 2002b).

I)ctcrminants ol' population health are complex and the organisational structure of

the health carc systcln bas~call) contributes to the operational efficiency or inefficiency

of thc systcm, llealth care is a typical commodity bought and sold in a (partially)

rcgulatcd or mostly tfcc markct system. Health is an invaluable asset and deterioration or

decline in the health status require appropriate medical intervention. The technology

induced health care has increased the medical expenditure and accentuated the miseries

of thu common man on thu one side. and the changes in medical technology as an

important instrument of the market have thoroughly transformed the profile and pattern

of secondary and tcniary hcalth carc (Kornai and Eggleston, 2001). In general, the

developing countries experience many problems and constraints in the provision of

health care like inadequate essential drugs, lack of qualified medical and para-medical

personnel particularly In rural and tribal areas. insufficient community health care visits,

poor transport and lack of material for dressing and treatment. These constitute the major

suppl! constraints. which rrsrrlcr the utll~sation of the health care services (Ross Mary

McMnhan. 1986. flergwali. et.al, 1973) Thus, in the rural areas of most developing

countrles, supply factors In the form of infrastructural constraints restrict the utilisation

of thc essential health care services On the other hand, the physician parameter act as a

proxy Sor the patient i i i malters relating to the nature and type of diagnostic or

therapeutic procedures and the quantity and quality of (specialised) medical services for

both outpatient and inpatlent care(fuchs. 1972) However, medical science cannot claim

thu hll crcdit kir the impr{~velnents in thc health status. For instance, the American

Medical Association states: "Med~cal Sclence does not seek major credit for the

Improvements In the health level during the past 25 years. Certainly our standards of

living and li~glicr education level have contributed substantially to the betterment of

healtll ievcls" (Quoted In Fuchs. 1972; see also Illich, 1976)

I lealth carc cconomlcs. an Important branch of normative economics deals with, in

general. the production ~ii'llcalrh and consumption of health care services. Health care is

treated as a commodity just like any other commodity in the market and in this process

the iit~lisation of qualiiy hcalth care services has become a serious problem for the

\'ulncrable secuons, marginal cornmunlrles and the rural poor. In the present world of

technology re~olution. health care pricing is generally more skewed and the ability to

pi^? 11I'thc people is a constraint on the utilisation of quality health care services. Thus,

inalntaining individual and community health IS a serlous concern and promoting health

surveillance. achlev~ng equity through proper allocation and redistribution of health care

rcsourccs are important policy issues. At the theoretical and empirical levels, the

determinants ol' product1011 or supply of health and consumption or demand for health

care are crucial in the analysis of the utilisation of medical care services and in the whole

licld t~l'research in health care economics(Wagstaff.1989;Fielder,l981).The determinants

of health owe much to the nature and pattern of the health care provision, medical

infrastructure, the socio-economic status and the cultural aspirations of the people. The

singlc lnost important factor influencing the individual or family health status is the

quality o f life. which would be basically Influenced by the socio-economic and

demopraphic ractors At the policy level. there should be reconciliation between these

micro and macro economic health issues, which are crucial when health status variable(s)

act as a determinant o f labour productivity and economic efficiency (see fig.2.3). In the

long run, cross sectional houseliold health surveys, particularly at the policy level, should

contrihutc fbr sustaining thc health status by improving the overall socio-economic status

and in part~cular the nu t r~ t~ona l standards 1'11~1s. Improving the level o f income through

e~nploymen! yuar;lntcc programtne and. of course, eradication o f poverty and deprivation

act as important detrrinlnants of health status sustainability in the long run (Rothman,

et.al 1998; Sen. 2005)

I:rom a polirical cconom) vie\vpoint, demand for health care and its sustainability

depcnds much on the nature and character uf resource al locat~on in the health sector,

quantity and qualit) of incdlcal car t ser\icea and equity considerations in health care

prov~.;ion. hcalth care ~ n h t r u c t u r e . the a\,ailabil~ty and cost of medical technology.

medical expenditure and the socio-economic status of the patient or the household. Thus.

a broad framework for a scientific understanding and evaluation o f health care requires at

lcast a i'our lilld cl;rbs~licat~on and analysis of the medical care functions viz, preventive

carelmcdicine ( cp ~ncrcascd birth spacing, reduction in family size, communicable and

orher diseases. ctc I: curatl\c carc~medicine (eg treatment of acute infections, reduction

in ~iiotcrnal m o r t ~ l ~ t ! and morhldlt!. and reduction in low blrth weight, etc.); restorative

care ( e g impro\.ement in the functional status as a result of medical treatment for

variour chronic incdicnl conditions) and palliative care (e g, reduction in discomfort and

impro\cd product^\ It!. reduction In paln and other suffering associated with illnesses

such a, cancer. etc I [see Dctcls. 19971 This classification provides a framework to

clinical or hospital care and a gcnciai understanding about improving population health

through appropriatc hcalth care interventions Such an enquiry has imponant

implications for health status obtained through cross sectional household health surveys.

2.2 1)ctcrminants of Health

I'he World I-leal111 Organi/ation defined health as a "complete slate of physical, mental

and s t rc i a l being. not ~ ~ m p l y the absence of disease." Even though this definition is

narrow. i r provldcs a broader outlook to behavioural and social determinants o f health or

health care. Most cross sectional household health surveys use self-reported morbidity as

the method of disease identity and it considers household as the most significant

producer of health (Mehrotra and Javret. 2002; Segovia et.al, 1989; Sriram, 1991;

Hayncs et.al, 1990). The cross sectional household health survey is a tool for analysing

self-rcported morbidity and provides people centred morbidity and health care utilisation

datahdsc across gender. agc. socio-cconom~c status. sector and systems of medicine. This

also acts as a guidel~ne to health policy. health planning and health management both at

the micro and macro levels (Boote et.al, 2000; Bergwall et.al. 1973). That is, health

status valuation ~nvolvcs the ~dentification and measurement of health status variables

and their determ~nants For instance, in general. health seeking behaviour is the totality

of physical, social. economic. elivironmental and genetic factors. In multi-community

and ~iiult~-castc socicty. bchav~oural and cultural determinants provide specific shape to

the analysis o r demand for health care and its determinants (see figures, 2.1, 2.2 and 2.4).

Frenk et.al ( 1901 1 provide a standard and systematic presentation of health determinants

at thc ~nd~r idua l . household. societal and sbsternic levels by incorporating the multi-

dimensional trait\ ol structural and prox~rnate determinants of health (fig: 2 5a). Health is

the rssult of lnteractlon of thc various indiv~dual and community factors on the one side

and (he a v a ~ l a h ~ l ~ t y and quality ol basic facilities at school orland home on the other

(fig. 2 . 5 ~ ) . 'She tbans-Sroddan model. which 1s relatively involved, characteristically

integrate soc~al. phjsical and genet~c env~ronment with disease,well-being and prosperity

(scc lib: 2 S b ) I:~np~rlcal stud~es habe Identified that at the individual level, apart from

the pligs~c~an I'actor. aye. gender. caste. re l~g~on. language. public policy, socio-economic

statua. locaticin. perce~\cd quality. t!pe of head of household, family structure, family

s1.x Inoomc. e \ p c ~ i d ~ t ~ ~ r e . ~ v a ~ t ~ n p time. travel time. health condition, are the important

ind~v~dual or household determinants of health care service utilisation (Bice.et.al.1972;

Krocger. 1983h: .Adler and Ostrote. 1999: Niraula, 1994; Bergwall, et.al.1973; Fond,

IOYj: Ualtuswn. CI a1 2001. Ibrank~sh et at. 1998, Anderson & N e m a n , 1973. Basu.

1987. Ashokan. 2004: hlusgrove. 1986). Theoret~cally, the determinants of health look

relat~vcly srinplc and revealing but in the actual setting, the nature and extent of

~nterection arc Lcr) cotnplt '~ and Involved. and often irregular and uncertain (Arrow,

1963: Frenk. 2001: Armentan. 1998) The socio-economic. life style and diet related

factors are siyn~ticant determinants of the health seeking behaviour in the globalising

world (Lany. 2001: Lee. 2001). A non-clinical approach must provide a valuable

supplement to the clinical database particularly at the policy level. The policy makers

should accommodate soclal values, which play an important role in the delivery and

distribution 01' nledlcal care resources and the utilisation of health care services The

contemporary health care research focuses attention on efficiency and individual

preference functions as the determinants of the health status (Davis, 2001; Fuchs, 1996).

(icnerallq. therc are two broad approaches to health and development viz, growth

mediated and support led growth The former works through the trickle down effect and

the latter via a programme of democratisation and public intervention particularly in

cducatiun and health care. 'I he second approach aims at capability building through

democratic deccntralisation and people's participation and has been successfully

implc~nentcd In the lowlncomc. Indian state of Kerala (Sen, 1999). Commenting rightly

,In thc true nalurc ol'growth. the India Development Report (2004-05) states, "economic

growth is. after all. for the people. If the people are poor, if they remain unemployed, or

thew livelihoods are threatened. if they don't have access to clean water and clean fuel, if

the) don't have adequate health services. and ~f rural and urban development remains

unsausfactor). then growth loses its lustre"

I hr socio-cul~ural reform movements hake prov~ded the framework for appropriate

gt~vcinmental acrlon through allocatlve and red~stributice mechanisms and contributed

subsranr~ally for equlty and d ~ s t r ~ b u t ~ v e justice rn Kerala. Thus, the role of the state and

other instltuuons has been ~nstrumental in improving the general health status of the

peuplc and hcdlth I > conr~dered as a basic resource rather than a reason for living (Nag,

198.7. Kalr. 198 I I l'hr: Andi.rson-Newman and Kroeger models provide a comprehensive

dn,~l!t~cal Ira~nc\\orh of thc doterln~nants of health care service utilisation by classifying

them ~ n t o toc~ls Ilks prc-dispos~ng. enabling and illness level factors and dividing them

into indiv~dual and soc~ai determ~nants. Such a classification is useful and can be

ektcndrd to ~ d e n t ~ f ) the d~ffcrent~al determ~nants of health care servlce utilisation across

the bectora and sqstenir oi medlclnr: (see tigures 2.3 and 2.4). The multiple factors

influencing the health carc decls~on making process have been traced by them using an

~ndcpcndcnt but s~milar analytical framework.

2.3 Supply of e n d D e m a n d for Health

Demand for health is measured in terms of utilisation of health care services. It is

~nfluunccd h! ~nd~vidua l . environmental, prepayment and health care resource factors

~ncluding accrsr and accepvability I'hese factors are crucial and significant because most

of the health care dererm~nants are outside the formal health care system (Tulchinsky and

Varavikova. 2000: Feldsteln 1966). The final outcome in the whole st tuctu~~? of demand

for health services depends on the strength of interaction between these interrelated

factors. The physician proxy not the patient who reveals the medical preference for both

short duration and long standing morbidity oriand medical intervention for outpatient and

inpatient hospital~clinical services. The physicians and t& hospital industry not only

dctcrm~ne the dcmand ibr health care services, but the nature and type of medical

scwiccs for outpatlent and inpatient care and the demand for pharmaceuticals and

surg~cal and other equipments (Zweifel and Breyer, 1997). The market for health care

services opereter, In the larger context of industrial organisation where quite often the

1'actol.s outsidc the market act as a do~ninant determinant of health care market. Hospitals

wrth w~der medical choices and clin~cal optlons attract more patients and increase the

c ~ a t 1)1' hcnlth cdru mcasured in terms of monetary and non-monetary costs including

input costs.

Withln the neoclassical tradition. the role of the state and the market in the

pro \~+lon of health carc scnlces has been d~fferent For instance, the paternalists

~ n c l u d ~ n g Kcnnclh Arroh. Charles Allan. Musgrave. Klarman etc recommend the state

es thc efficient pro\ ~ d e r of health care services and James Buchanan and Lee strongly

dd\ouatc lor ihc 1narkc.t as the cffic~ent health care sentice provider These two positions1

approaches are basically consistent with market liberalism of the neo-classical variety.

On the other hand. the Keynrs~an and the Marxian approaches accept state as the

'ippruprlate age~,c> lu lmpro\~c thc puhl~c pro~~s ioning of the health care services In the

present context $11 ~ncrcosrd prlvatlsatlon of health care services and diagnostic and

tllcrapcut~c proccdiircs the treatment pattern IS moving towards a clinically or~ented

ind~\~duallst ic and reductionist d i s c ~ ~ l ~ n e '

Henry Aaron (2001) and Rutten et.al (2001) In their critical synoptic review of the

Hand Book of Health Ecdnomics ~dentify a slmplest model of the physician market

a ~ m ~ i a r to the tjin111ar 'hlarrhallian Cross' and ~ncorporates the impact of information

asynllnetry on prov~der choice on the one hand and the nature of physician ~nduced

demand for hcelth care srnJlces on the other. The physician induced demand goes

usually outside the prolile or medical ethics and increases the health care expenditure

substantially. Generally. the ~gnorant and illiterate rural patients depend on the medical

and non-med~cal advice and health care choices of the physicians. At the same time, for

othcrs. 11 has bccome s~gn~l ican t and some times fashionable to "demand" special~sed

med~cal care even for mild or short duration ailments. The market for health care

s c n ~ u c s would bc inlluenced by the demand elasticities (measured in terms of health

pric~ng. locaticrn or quality )and the supply elasticities particularly of the private providers

(delincd in terms of price or the existence of a competitive public sector),which basically

reveals that the nature and determinants of the government provision of medical care

servtces on the one hand and the health policy of the govemment on the other, have been

responsible for the low utilisation of publlc health care services (Hammer. 1997). The

quality of health care senrlces measured In terms of infrastructure including access and

locatt<~n. personnel. abailabilit! or essential drugs and medicines are important

determ~nants ol uul~satlon of health care services (Alderman and Lavy, 1996). The

expenditure relatlng to outpatlent as well as inpatient health care has become an

Important componcnt of monthly household consumption expenditure. Recent studies

havc revealed many-lbld lncrcasc In drug prices. which not only increased the miseries

of the rural poor. the marglnal communit~es and other vulnerable sections of the society

hul 0 1 thc gcnrrol popularlon as well (Rane. 1996). The nature and incidence of illness.

cultural. demugraph~c and econom~c factors. physician's knowledge, patient

charactenstlcs. ~nstltut~onal arrangements and the physician induced factors influence the

dem.lnd tor hcslth carc \enlces (Feldstein. 1966) A major determinant of demand for

health care utll~satlon depends on phbslc~ans' decisions and the patient-physician

undr,rstandlngs or contract5 illahh~nen. 1991 ), l 'he nature and the extent of physician

lndu~sd dcnirnif liv mciflcal Lare IS inore s~gnlficant in countries where the private

health care sector 1s domlnant Thus. the theory of health care decision making is

typically different from the model ( 5 ) relating to general goods and services. That is, the

analyt~cal content ~ I ' h o t h the indl5 ]dual and social choice models are different for health

and other goods and senlcch 1 he demand for health care of the poor and the vulnerable

\cc!lons arc d~l'fercnt becauae the11 uul~sat~on pattern also tnvolves self-medication and

eve11 n ~ n - u ~ ~ l ~ s ~ t ~ o ~ i of health carc ser\lccs Povert) has deteriorated the morbidity

condltlon and the health status of the poor and other vulnerable groups. On the other

hand, geograph~cal proslmlt!. ~(1st of med~cal care. provision of health care services, and

health pollc) of thc gu\crlimsnt are s~gnificant determinants of supply of health care

(t.ok, 1972. V~sarla and Cjumbcr. 1996: Yesudian. 1999: Fielder. 1981: Sauerbom et al.

I VKV. Krireycr. 1VX3h. I lilynss et al. 1990).

I'here are economlc and non-economic barriers. which restnct the demand for

health care and the effic~ency of the health care system. Nature of illness and the felt

necds of the population. provider-consumer relationship (or the doctor-patient

relationsh~p) and the immediate mental make-up of the patient orland the family and the

economic status determine the type and nature of medical intervention (Akin et.al. 1986).

In the present world, technology plays an important role in shaping the nature and type

ul' lnd~vidual and soctal choice relating to the utilisation of health care services. The

technological advantage, the developed health infrastructure and other advantages of the

private medical centres and hospttals on the one side and the provision of the multi-

Ihu~l~ty and supcr cpcctal~ty tllcdical service~ in the same hospitalllocation have attracted

paticnts to the private health Fdc~llty

Market e q u ~ l ~ b r ~ u m ib the ultimate response to supplydemand forces where the

quanuty suppl~sd 15 equal to thc demand for health care servtces at the prevailing market

prlce Contrary to the usual process of market equilibrium, the situation in low-income

countries may be termed as "uneasy or painful equilibrium" where the market drags the

patlsnt consumer to thc prl\atr health care to maintain or improve his health status. In

othur words. the consumers' abilitl-to-pa) and the morbidity pattern are unfavourable to

mi)\! rural patlcnts M ' a l t ~ y time. real. pecuniary and opportunity costs and access to

health care also act as other determ~nanrs of market equilibrium. The physic~an act as

dual drtrrrnlnant both In the demand for and supply of medical care services. The nature

and pattern ~) fhea l th care market and the mrd~cal care industry are totally different from

thc gcncral marhct I'or go~ jds and services Most pattents may be experiencing

~nlc~rmat~on as)mmctr! or and moral hazard whereas the physician has the relative

. I J \ J I I I ~ L ~ C ( 1 1 lnlornidtlon >!lnmetr) (getting relevant and timely ~nformation) on the one

s ~ d c and added mural strength on the ather. llnder these circumstances, the patient IS

conlpelled to accept the ph\slclrtn as a decision-making proxy variable. Imperfect

~ n l ~ l r ~ ~ ~ a t ~ u n or ~nformati,>n as!mmctry leads to imperfect market systems contributing to

~ncl'licleni lnarhcr .rr)lut~vn\. and. therefore, go\ernment must intervene In the market

\)\tern

I he ,~ll \~cau,in nlr.ch.iniam ~ n \ o l \ e d In health care resources is a s~gnificant policy

varlable ~nllur.nc~np the dctnand lor health care services particularly in rural areas. The

~ntroduction of user fees as a method of resource mobilisation has reduced the utilisation

01 publlc health care rcr\ lcca alld increased bypassing (Akln and Hutch~nson. 1999).

lrllproved hcalth care ~nliastructure and other positive supply side factors have increased

the utilisation of publlc health care services (Deaton. 2002: Amardeep. 2002). At the

pol~cy lebcl. the pol~tical uill of the government should be based on the people centred

and people oriented health care strategy through democratic decentralisat~on as an

F i g 2.1: Fac lo rs i n D e m a n d f o r H e a l t h Services

Indiv idual Cl ienl R c t o r s [e g Age. Sex. Education. Occupation

* Phys~cal * Economic Demand

Suclal * Cultural

Factors

* Access * Acceptab~lity

Prc-pa)mtnl Facttrrr P r t~a t r Insurance

* Tax-based tlealth Insurance * hat~onal Health System * hlanaged Care * Co.pa!metit

5ni1rcr Tulchln5k) and Vara\lhn\.! 1?0001

F i g 2.2: .4 M o d e l o f D e m a n d t o r M e d i c a l C a r e

components o f care

Factors affecting s ph)s~c~sn's use o f the

t r u n t m e n t component, of care

* Inc~dencc o l iilness ePcrcept~orl r i l

~ r l d bel le l * Cultural and

detnograph~i factors

~ond t l l un

~llness *Anllude Iuudrdr weking ~ n c d ~ i i ~ l care * Econom~c faclors

Sourcc Feld<tc~n. Paul J (1966)

+----- I * :;::CanC:elllllcs

~ n ~ l u d e s rrlatlve co\l to the patlent lrom ustng d~fferent components o f care Ins t~ tu~~ona l 3rrangemcnts I'liys~ctan's knou ledee

* Kelallve cost to the phyr~cians from uslny alternallvc sets ofcomponcnts o f care

* Hosplral care ---l * Physlc~an care i t Referrals to speclal~sts

nurslng home care, etc

alternative to the bureaucratic decentralisation in capital and resource scarce but morbid

affluent low income countries (Nerenz, 1996;Maria and Redons.1999; Chemere Dan.

1997. .!arcs and Kasaje. 1998, Annc Mdls ct.al. 1990; Roos.et al. 1996; Levy, 1998;

Welton et.al. 1997; Davis. 2001. W~lkinson. 1999;Filmer et.al, 2000).The discriminatory

and lncfficient provlslon of bas~c publ~c health care services in the rural areas in the third

uurld countrlca havc Increased the cp~demlology of disease burden and the incidence of

med~cal expenditure for both acute and chronic morbidity and outpatient and inpatient

care Appropriate health planning and health management techniques focusing the

rpcc~lic health ~iecds o f the papulat~on and disease surveillance programmes would be

~nstrulnental In dclin~ng thc components of a sound mral health policy (Santana. 2002:

Mvhrotra and Jarrett. 2002. I'oan. et.al 2002; Hong Ha, 2002: Niraula. 1994; GoI, 1993;

Nadc B Brouk5. 1474. hl\bahu. 1986. Mag)ar). 2002, Yesudian. 1999; Turshen. 1989)

2.4 Equity

One of the Important lrsuca ~n\olvcd In the provision of health care is the proper

d~atr~hutlun ol rca<~urce\ lor health care dt.\clopment and its effective utilisation. The

duminat~on ol the prl\ate Iicalth care sector and the appearance of uneth~cal med~cal

practlics hale +~pn~licantl) lncreascd the med~cal expenditure for both outpatient and

Inpallent heal111 care I he ~ n c d ~ c a l expenditure 1s highly skewed across socio-economic

group. caste and rel~glun Stiid~eh ha\e also revealed that these factors are stgnificanr

Jctcrn~~nants of ~ n c d ~ c a l chpcndlturc per normal and caesarean childbirth. That is, inter-

cunililunlt) and C J L I ~ group d~l fe rencc~ In med~cal expenditure are more revealing across

aoc~t)-cconom~c atatus (Ashiih.in. 2005)

I hc tran5ltloli Irom livdlth ri) [he bas~c component of the service sector to the

lucral~\e prolit mallng med~co-~ndustr~al complex has substant~ally reduced health risks

and increased the cost of medical care and the mlsery of the socio-economically

d1sddta11tagt.J Alan! rural pnrlr.nla ekperlsncr difficulties in meeting health expenditure

111 ~ h c l~ghr of ~ncreascd hcdlth care costs and privatisation of health care services In

deniucra~~c avc1ctlt.a. the r ~ ~ l t . of the government as an agent of red~stributive justice and

an ~ I I ' I c I ~ I I I )cri I C U pro\ 1dc1 has been challenged In low income countries l ~ k e Ind~a. the

government has been bas~call! "soti" and less efficient in ach~eving equity or distributive

justice in the health care sector and achiev~ng the objective of horizontal and vertical

hcaltli equity. I'hls IS slgn~ficant but challeng~ng in the context of privatisation of the

health care sector 1.lorirun1al cquitq states that the peopleipatients with similar health

problems should get ~dentical medtcal treatment and in vertical equity patients with

d~ss im~lar ~norhidity pattern should he entitled to get differential health care. Modem

democratic governments fall to introduce appropriate redistributive mechanisms either

through policy alternatives or via legislation to minimise health inequality. In

contcmporar) soc~ct~cs . health ~nequali t~es are more rampant and w~despread and the

poor find 11 very d~fficult to foot health care bllls. The poor are compelled to bypass the

rural publ~c health care system due to the non-availab~l~ty of medical services, essential

~ l sug \ .lnd i~tlicl pilramcdlcdl scruices liealth inequalities in the form of the availability

and non-ava~lab~llt) ol' health care services and infrastructure and disparities across

yocia1 geograph! have been slgnlficant In many Indian states. For instance, the rural-

urhm differences dnd d~spar~rlcs in tcrms of health care spend~ng have been found to be

much hlghcr In 9talua l ~ k c .4ndhra I'radesh. West Bengal. Kerala and Tamilnadu (India:

llural I)e\clopmcnt Kcpon. IL)YY. Gumher. 1997) The democratic decentrallsed health

c,lrc. a!\tcm can X I d~ a pci~erful srrateg! to Improve health inequity by reducing the gap

hettsevn "health h a ~ e s " and "health ha\e nuts" and it encourages rural de\'elopment.

This I:, s~gnificant In countr~es \ r ~ t h ulde spread spatial heterogeneity, socio-cultural and

C I ~ I I I L dl\ers~t!. snd. o f i~lilrac.. nhcn a slgnlficant proportion of the rural population

I ~ \ e s helo\\ thc poten! I~ne illeaton. 2002. House. 2001, Adler and Newman. 2002;

~11n.ir~Icep. 2001. L\d\artc,, iL)74. Mechan~c. 2002. Marmot, 2002). Table 2.3 provtdes a

,!\tcln\ dnalbsla 01 ~lrcdlcal c u e I-losp~tala hlth wlder and special~sed health care

C I ~ I I I C ~ ~ attract patltnts and p o , ~ t ~ \ e l j Increases the cost of medical care. measured In

tcrniz c ~ f monctar! and niln-in~inctar! costs In developing countries. where public health

Inrulancc IS ~ r i ~ ~ y ~ i ~ l i i . i ~ n .ind modest the wdening of the therapeutic choices and

Inno\dlluns In medl~a l technolog! have ~ncreased the health care expenditure

suhstanr~all)

2.5 Socio Economic Status and Health

l'ducat~on, occupation and income are the three general components of Soc~o-Economic

Status or Soclo-llconom~c (jroup (SES'SEG). These components and the dynamics

~nbolbcd therc In, shape the nature of pathways Thus, a general model of the pathways

by whlch socio-econorn~c st;itus lnfluencea health is summarised in figure 2.6 The SES

IS a composite ~ndcx and analytical tool used mainly in health care and epidemiological

data analysis, l 'he causality between SES and health is bidirectional and the causal path

from the SES to health IS stronger than the reverse. The SES influences health and illness

throuyh environmental resources and psychological and physiological factors.

Psycliological and environmental indices have been excluded and only quantitative

\ar~ahlt.s have been ~ncludcd in the construction of the SES index. Providing appropriate

weightage to the different components of the socio-economic status is difficult but it is

analyr~cally s~gn~f ican t and useful in the methodology of SES construction. We have

adoplcd percapita cxpcnditurc. percapita education score, percapita land and housing

condl~lons (rool'and f1oor)aa the Sour basic components of the soc~o-economic status and

dlflcrcnt~al weights-40 percent. 30 percent. I S percent, and 1 5 percent have been

rchpcil~vely awgnvd (sec 1)caton. 2002. Bice et.al. 1972; Dunlop et.al. 2000; Adler and

()stroke. 1999: Adler and Nehman. 2002; House. 2001; Kannan et.al, 1991)

Fig 2.3: A Schematic V ~ e w o f Health Economies -- X I a t i . t l r ~ r ~ R . m U h , 1

U -. . 1Oo7n ho H.4* i"h T&.,.. ",*"h, ~ ,h , . '1 j I~lq.""".l h ~ . d . C a n m p & o n l,.\'nb,*

! F e + - , ,,:,, , , A , 5 o , b,du, ,,, ,!u, ~ . -. -i p ~ ' * ~ ' d u c ' ' D n ~ l m m ~ "'

i d.,,. mu.,,: ..,,,I.,, , .,I. ,a!,\. , ( - , / r. llr,. ,.. i," I

i i

Fig: 2.4 A Syslerns Analysis of Hea l th C a r e

individual object~ves:

party ~npui," (influenced by

Objectives Income, Le~sure

Hospital

Objecl~res Those ol 'ch~ef phlrtc~ans

Cap~ral Iechnology

Source Z w r ~ f c l and Breyer (1997)

Fig: 2.5s: Determinants 01 Health Level

Basic Determinants

* Pupulatlon * Env~ronrnent * Genome ( B ~ o l o g ~ c a l Rlsks) t Social Orpan~zat~on (Economic structure, political

mst~tut\oor. science and Technology, culture and ~dealog))

bucietsl 1 1 Structural Determinants I L i.e\el o l h e a l t h L Occupational btructure L Social stralifical~on

Redistribut>ve mrchan~srns-Taxes and Subsldles

4 P r e r i m r l r Dere rm~nsn t r

Household

L \+or l lng cond~rlons (Occupar~onal rtsks) L I l i l ne sond~lions (soc~al rjsks)

S l ' u h l ~ i l > it,nfcrred ent~tlements + kducmlon, roc~a l securlt)

+Vdrket baaed entirlemenls Food and Houslng L L ~ f e rr)le (Behav~oural r ~ s k s l + Health care s)stem

I)~,ca\c agcnc) [ l l ~ ~ i l a g ~ c d l / He.. \ D~agnos~s and

C'helnicdl. Treatment

Ph>r~cal. status Env~ronrnental

- Uctcr~n~na l~on ... ...--.b Health act~ons

Source Irenk n al (1'491)

Fig: 2.5b Determinants 01 Population Health: Evans-Stoddart Model

Fig 2 . 5 ~ Dcterm~nants 01 llealth

Individual !

Fig: 2.6 hludel o f the Pathways b! whlch SES influences health

-. - SES Exposure IO I I-

Constra~nls cnrctnogens and * E\tsrnal palhogens

en\ lronrnent * 5oc1al Health

stir lronment * a n d Performrnce of * Resources health-relevant Illness

behaviours

Psyrhuluy~cal ~nflucncrr

CNS and Endocrine

t Cognition * Immune and cardiovascular

Source Adlrr and Ortrove (IP99)

Fig: 2.7 Kroegers Model of llealth Seeking Behaviour

I a b l c : ? . I ~ ( j r n c r ~ ~ ~ ~ b l i c Heslth Studies , -

91. Stud) Focus 8 Major Findings

?"' : -~ ! i I Perce~ved susceptibil~ty, ser~ousnesr, perce~ved j

I , Rosens~och Behavoural benefits and barr~ers to tak~ng the decision are

Solon el a1 ' I (1067)

L-. I _ .

1 Anderson & Nrwma1rn(IV73)

, 1 - 1 6 ' Kroeyer I

( IqSja) I t I s i

. . b e t w ~ n rural and urban.

k { - T & T - -%k hnks cn publ~c ' K d e q u t c inst~tutlonal capacli and the severity 1 1 , , . 1 LZo?! , 1 Ieallh care system / of market failures

Murray CJL(1996)

Mehrotra and Javren (2002) --i

. - . . .. --- - Morb~d l r y T Differences between sel f ~e rce l ved and observed I

~ o n c e p t u a l l s ~ t i o n Health service

. . * ~ . - Comprehcns~ve health surve)

In India

Household is the most Important producer and

Us 142 60 per illness episode in urban area. Rs 1 15 1.81 per eplsode in the rural areas. with wlde

to the road and rervlce centre, are positlvcly l lcdthcare related to the use o f health care. Age o f the

srrvlce utillsation respondents and household size negatively associated w ~ t h health care use. Caste IS

.~ ! unlmpottant 1 Coclo-cultural factors and governmental suppon

Mor,allt) ; programs In the field of health and education 1 reduced monal i ty low Income countrlcs lncludlng /

~

4 h e lndlan state o f Kerala

( IU78 i d ~ s i r ! b u ! ! c ~ a, ,)avlF , 121,01, 1 50 i1a l valueand

Heath care ---. . Murra) a C'hen

. . f l l - - ~ ~ ~ - . + . -. Morbid't) cllnlcal d~agnos~s

. , . nd utllisatlon o f medlcal services

I Soc~al values crucial In determlnlng the dellvery and dlstributlon o f health care resources.

1 Self- perce~ved symptoms are a key Input to

I uchr L. , lq,?l Pti)sic!ansand lr,edlcrl care

Mcdlcai care decis~ons are physlclan induced ...~, .

I,drker , 1 4 8 2 , l l i ) ~ i \ eho ld health P rov~de i a standard methodology for sample

. . s u r ~ r ) ' household health survey uslng a two-week recall L.. --

In d e m o c r a t ~ ~ socletles to Improve population 1 1 I I l 'npul~ l lnn hcalth liedlth, resource reallocation f rom health care to

astlvltles that more dlrectly prevent illness ~ --

Lcadrr,hlp challenSe Lack o f political will of the modern governments \I r l t on et a1 I 14'471 In care , prefer market orlented solutions to complex health

. . *- . .~ . -. - care probiems -- ~III<:ILL;V~C I el r l lr i lcprrted rural Integration-cllnlcal. functional. physician system

l IVY7) , lic,~!ili _ ~mindcial

2 4 Yoder R I I Y ~ Y ! I

I,r rr idre Soc~o.econom~c characteristics quallty o f care arc

-- I the -- Dctermlnants ofdemand -----I The nature o f cholces and health seeklng I

Kur,i i hedlth I hehavlour In cruclal for rural health planning and 1

lo0. uhbch ind~cater that peoples abll ity to pa) l mas the c ruc~a l determinant o f health care

1 and I I and 17 days for urban IPS. , 7 , 8 --?----. Basic determ~nants basic, structural. proximate, at ,

;'> I TenL J e l AI I 1 0 0 \ ~ "::::::;" system!c, soc~etbl, m l~ tu l lona i , hou~eho.' and

I ' .- 1 ~ n d ~ v ~ d u a l levels ! , U.rsrldn ,, , , O x O , : HeJllh cconij,neir,cs I-~rovldes an analytical survey of British applied I

osltlve health econometrtcs stud~es. . ldenttfies the role of vub l~c health (indirectly) and 1

processors in medical care Health determinants include: biological, socio-economic, racial-ethnic, psychological. env~ronmental, bio-medical rlsk

general model o f he-lth status

C tnrintunity approach '' 119q8) I" hcalth research

I

: ; 2 ' t i umhu~ I IOU71 M n r h d ~ f ) hurden

clmlcal medlclne(d~;ectl~)ln lmprovlng health status In splre of enormous investments In the health sector, panlcularly cancer, the relation between health care spending and health o f populations remalns weak. The rate o f hospital~sation per I000 populatlon differs across provinces In Canada For ~naance. it IS 75 In Winnipeg, 110 In non- Wtnn~peg and 90 in Manltoba Argues for

populatlon hcalth lnformat~on system __ It lncludes the panerns of utilisat~on by age and sex as well as economic, organisatlonal and cultural delermlnants o f and access to utlllsat~on of health care Community based approach include the need ' demand for care, co-morbtdlty and use o f health rervices, relation o f natural history of disease to Ihe use o f health serv~ces . -

urban centres. The reported annual rates o f hospitai~sat~on for males exceeded those for males in rural and urban Ind~a. The rate ofhospital~sation rhowed a rlse with MPCE Average duratlon of

I able: 2.2 Soc~u-Kcynutnnr Slnlic: and Demand for Medical Care ..-._---._7

I ~ l . n o I Study Focus. . ' Ma 'o r findin s 1 , , l)eai<,ll i2(,(,2, pol,c> .

i ~ c ~ i e ' i ; i y d z ~ o n seiarately p:otective o f health SES 1 . .. . . - - and health negalively related

1 1 - i d l e r rnc ' Labour market Inequality and inequality In SES defined in

SES and health terms of educat~on. ~ncome, occupation detcnorates the gaps between the hcalth "haves" and "have nots"

, stay varied between 13 and 18 days for rural IPS /

I i "";;c,:; r r rv lcES.- . l O f ~ d

h s n i v e correlation between SES and use o f med~cal care 1 1 SCrvICes

I - - - - -- - V i i a " i i a ; b for health services IS hlghly skewed. Costs and 1 I. 1 Fuchs(l996) 1. health care 1 benefits of care different across SES, age, sex, and social

eeoeraohv

1 Adler and 8 Ostrovr

I I O Q ~ I S i S and hcalth 1 Breast cancer and mal~gnant melanoma rates hlgher among

upper SES group .,,., ' i a v l n . ~ I Soc~al ralue and / Sochal values determining the delivery and distributhon o f

, _ 1 ~ - - *0_1 . + -&?!thhcare , health care resources

l u Fond. Anne Pr~rnar) health 1 Consumer's socio-economhc characteristics, qualhry o f care (1995) iarc the r n a ~ d c t e r m i n a n u ofcare.

, , Wade and 1 Rural lhealth .Thenlure ofchotces and the health seekhna behavlour cruchal " 1 B ~ ~ k s I 1979) m;dna$rmet_ 1 for rural health plannrnp and management.

( T u o types health benefits (a) consumption benefits o f health

!: M u u r ~ n c ~ i J M 1 Dcmand for In the form o f increased utllhty and (b) investment benefits o f

I (19821 health j health in the form of healthv time available for activ~ties such i I , as consumption, working and hnvestment In health

I ! Hakkincn.l! I Demand for j A s~gnificant ponion o f health care utilisatton depends on 11991 1 1 _ health 1 doctors' declshons and is generated by pauent-doctor contacts ,

Murra) FI dl Anributes o f health variat~ons across individuals lnclude I

1191)91 I iedhh~nrqual~t ! chance. genes. physical and soc~al environment a n d ! ' lnteractlon between enes and the envhronment I *'derrnan dnd I O,,i;h t i ~ u ~ i n l l o w R o m e households are w i l l ~ n g to pay for '

l.a\) I 19461 a ~ s ~ l ~ s e r \ i c e s provlded by the government _J

'Table 2.3 Heal th Care Financing /Expenditure ~ . . . -. -. - . . .. .-- Sl.no Stud! I Focu, j M a j o r Findings

. .. .- . . .. --- - Private sector crucial In the provision o f health care servlces in \'~e!nom An average household spends $9 1 a month on health 1 care or $1 12 annually I The households spend a larger share o f thew Income on health (around 3 4 percent) as compared to 1 09 percent of the state

i o n ~ r m m e n t r tn 1901.9d k-z- . . .- . . . . , . - ' . I Uugal dnd k,i ' The percapita annual household medtcal expenditure worked

2 , Am,n (1989, 1 "u!-F,Rsj82 49, w h ~ c h was 7.64% o f the total consumptlon

I'""", !&an ba~reerelathon to rural areas

~ l i , l d d i , d --[; SOchaI tnsurancc contr~butions, prtvate lnsuranc]

(2001 1 tinarlclng , prrmiums, communtty Ananclng, out- of-pocket payments are 1 r ~ s o u r c e s o f health finance

Rural The Chlnese study revealed that high medical expenditure, the

7 LIU et a1 (1995) prhmary cause of poverty panicularly after the global~sation

+ -. a enda Averaee medical exoend~ture oer eohsode was Rs.850. Rs 1065

Medical / for IP-care in rural bnd urbanare; respeclively and Rs 70 and / expend~ture Rs 97 for OP care In rural and urban areas In 1993.

. - 1 I

.- - . - .-

Study [ Focus - I.-.- M a j o r Findings

(1995) i data bas"' ma~n iy urban biased.

Jackson i 2000 ) Ger~atr~c care and! Causal llnk between ageing and medical expenditure

*"-*,.A;,,,.*

o f expendtture on child btrIh In rural Kerala ~arabana I 0ne.seventh o f the households in Kerala spend more than 20% j2001) 1 ACLe'b I o f the~r annual ~ncome on med~cal ex endihre.

I ulasldhrr tkpendlture-? E G i a t D r y resource alloc:ion and cxpendlture , ,,,,,., , cumpress~on & 1 compresston In the soctal sector badly affected the educattonal ,,",,I 8

healrh sector and hector In lnd~a - - - - - -- J Table 2.4 Political Economy and Equity

-r.s.tu.d~ ;..- -.. -1 , Fucu! _+-. - , M a j o r findings

sd,,ldnd,P \uc~aI LOW SES Increases the rtsk o f poor health Strong assoclatlon between soc~ai class (low Income) and low 1 ZZ:h ~ service ul t l~sat~on ,

Mechdn~i D 114th , Development strategies to Improve populauon health I t?Uo?) ; 1nequd11!\ : m2lncrease health tnequalttles

,

I Access IS equitable when the use of health servlces 1s

(20021 1 Hrs l lh rqulty 1 determtned by demographic factors and need and not ' I b) soctal character~sttcs or the abillty to pay

I : Underddeelopmcnr 1s due to hlghly skewed or Yd$,+rru.\ '

Table: 2.5 Rural Health

' . L3roor1 1?79 , p:ldL:%fi~ . -2r.i +@r r,ra healtr plann~ng and mana"gcmen1 I , f luao- C. m n J I ! 51ya- 1) ofrne pat.ents sobgnt medtcal lreatmenl

health wry~ey_lxreaees the ut~l isat~on o f med~cal care services

l'able: 2.6 Other Related Studies I 1 M a j o r findings

Will~amson tnv~ronmentai / Environment. the basis for aublic health and 1 1 (1996) 1 health / soclal medicine.

Protecting workers' Interests, betterment o f

2 fn~~ronmentaland worklng condlt~ons Inside the industry and Muk1'I' iYv7' ' I c ~ c ~ p d l ~ o n a l health env~ronmental protect~on out slde poses X ~ I O U S

- c- . . . - - j threat lo occuparlonal health 4 srare of successful menral functtonlng, resulting

. . ( 1996)

..

Health plannlnp i transponatlon , communlcatlon and environment) ' an Important determinant o f utilisation and non-

+-~-- util isat~on o f health care facilit~es.

Wade and Brooka The nature o f choices and health seeking

(1979) , behaviour is cruc~al for health plannlng and

mana ement I ,. .! . 'Mar~dn.~ and Health car; :Three dimensions o f health care decenrral~sation-

Law plays an tmponant role in regulating the Marun.K and

I ,ohn,on~, hw and 1 ~nteraction between factors external to publ~c 1

health, through the regulation o f activ~t~es and

i 13 Bhat. Rdlncsh

+.- Abu-Zetd and

I S ' Da_nr (1985) . j. ,.. . . . - . - .

1 ~ ~ ~ ~ a n d j c c e: a1 l199U)

I ' 7 hhSUI lY** !

behaviours. Increase Investment in technology and proper

Ptivate Sector management of health care resources Regulate the rlvate secror throu h a ro riate le tslatlons I

Gender .=I-JJ=+ and health Higher female morbidiry

,,ssrna, flea ,n I Lo* antenatal care dur~ng pregnanc) in sp re o f

. . ---- tnc ava11ab.l.t) o f s ~ c h fa;~ t es In :he PHCr Uomen's educartoi Income fam, \ strJ;rJrc and ktnsh~p stgn~ficant determtnants and occuparton. ~ santtatlon factlltles lnslgntficant derermlnants of ~ health care service uttlisatton . . . . -- -

, Inpartent rate 23 per1000 during 365 d F s T h e ' Morbtdlty and ( monthly prevalence rate for routlne illnesses was

utll~satmn 64 per I000 m rural and only I 1 per IOW ~ I populatton In urban arcas

burden / The reported annual rates o f hosp~tal~sat~on for

~ &- . males exceeded males In rural and urban lndla - i i Hosp~tal cost variations are due to differences in

1 9 o luu i~hu ie , l lu\p~tal lcngth o f ' average length of stay Increased ut~llsation o f OP

I 1978 I s~d\ ! care factlit~es wll l reduce the leneth of 1

2 4 1 Udllc! i?0!l21 _ u i & s ~ i n lof health care servlces among the rural elderly I Access. resources. distance. transDortatton tlme. 1

1 - _. _ _ - I

has ttai~satton

: ?,, ~ I h b 1 5 ,,IIC! Uusscl RIs& cost o f IP hospiu care has increased the

, (1'172 1 1 OP and IP carc ; use o f OP hospltal care and the substttur~on of ,

8 hos ital OP care for IP care. < -

1 !I ~ ~ ~ n ; ; dlld -- ' k%Zand OP and 0u;atlent vlrtts and ~npatlcnt admtss~ons decline :

. , office hours are the supply stde factors and age. 1

2 5 sex, family stze. social structure. race, educatton. / ~~~~~a t t on .~~ l t u re .~ncome .~nsu rance and need are !

Benth>t!l!l (1982) IP care

I laynci and Ue!~:h.~m! 1'1821

Ahu-leid and Ildnn ( 1981

I ll) I (1992) .~ . ..> - - .--

Bhatt~a and Cleland (1995)

with decreasin accessib~li 2 2 4 Hard[, C et a1 1 facllon ; a s ,$ton in p?bllc OP health care .

I 1 t2004l , . - -. Access and monthlv DercaDlta consumer !

. - 1 - - 1 sources of health care more than at later partty 1 I Women's education. Income, fam~ly structure. )

I

/ health and ktnsh~p slgn~ficant determinants and women's 1 / occuparton, sanltatlon facllitles were not /

- - - I Access and OP and I IP carc use

? -

h,aternal health . . . . - -

1 1 Insignificant I

Outpatlent vtslrs and Inpatlent adm~sslons decline I wtth decreasing accesslblltty LOW antenatal care durlng pregnancb In splte of : the ava~lability ofsuch services in the PHCs 1 -

Ilealrh Pos~ttve cffect of maternal schooling o the usc of prenatal and delivery care services. Educarlonal level, economlc status, and rcltgton

Maternal health are signtficant predictors o f maternal servlce

1 Maternal health That is. mother's at first partty consult modern

,8u!uuejd qijeaq put? (~ilod q11e.y 01 aur(apln4 e apl\old

pue aseqoiep am qileaq [euo!9al aqi a~oldur! plnw slt[.l sarpnis ~I~JP-LII pi111 J!II.>:,~s

103 paau aqi siu!odu!d pue sasr.uas ales qilcaq loj pueuap 3q1 UI ~deil ~JIPIF~J sa1~11i1apr

ma!.%al iuasald aql 'sale1 asuale~ald Ll!p!q~o~u Aurlnse?~ JI.~ pa<oldwa ylomaurrq

les!dl~ue aqi s! di!p!q~om pauoda~-jlas jo idajuoj aq~ q~l~aqjo u0115npo~d 3~1~uanllur

salqe!loA aql pue sas!,uas am qijeaq 30 uolsi.to~d jo ui ilddns pue uo!lesll!ln

JO suual u! palnseau s! ales qireaq JOJ puwap aqj pxqnxrp uaaq .>\rq sa71 \I>\

ales qileaq loj pueuap puejo .Clddns aql ur patlo.\ui wnqql p~uaioq~ J~I ~xdeq:, SI~[I 111

uo!snpuoa

'(87 arn8g aas) sas!Nas ares qlleaq jo uo!ies!l!in pur! iilpiqlour 4~11s<[eur: lq yiomaurelj

e padola~ap pue paypow aheq am 'ra~amo~ saj!.uas an:, qlleaq jo uones!llin aq~

Bu!sX[eue 103 (9661) Xe~nm pue '(~~61) uoslapuv .(L : a-ln3y aas pue ';g01) 15831>1\/1

Xq pasn ylotnaweg lelaua8 aqi molloj a,q ixaiuo:, leuo13a~ xlissds .?ql ~II ~mlipuadus

les!pau pue alas pue do 'Ll!p!qlow JO siueurtuJsiap puu xnleu aql ;iurq.;uppe Ie \uie

L11esg!aads Lqnbua iuasaid aql .amisnlis .-iseasy jo alnieu jeiau>R sqi uo~j iualJjj!p

aq dew ales dl puz do 30 sluou!uuaiap aqL n'l!p!q~om jo slueu!ulalap pua ul~llad

'amleu aqi uo snsoj '1elauaB u! 'am3 qileaq uo saipnig .IT UI pa,\[oAu! slsos jesipau-uou

pue [es!pam aql pue sas!Nas ares qlleaq ~uanedu! pue iualiedinn JC) u~aiied UOIIF\I~II~

aqi ssalppe 01 pau!orisuo~ uaaq aheq sa!pnis asaqj, suo!%s~ sso~st! ulalled iro!~es~lrin pue

IS03 '~l!p!ql~Ul aql U! sdo8 q3lEaSal SalE3!pU! JlnlClalll JlqE[!!%" JJyl JO MJl,\Jl aq.L

I saxnms are3 qlleaq yqnd jo i(l!lenb rood j leulalaw Pue sql~j11~ - / lL 1 -. . .. - .. . .- . . . .

I In general. two stream\ of hcalth care provlslon are advocated, one 1s the state regulated and the

other market determ~ned The Keynes~an and the Marxian economists argue in favour o f

governmental provision o f health care as the efic~ent alternative to the prlvate provision by the

market W l th~n the neo-cla<a~cal trad~fion there are two groups of thought Keynestan economics

ddvoiatcd Itic i o n ~ c p l ol wcllarr ,Idle focustnp on [he provlslon o f soclal servlces ltke educat~on,

health. trdn\por[ and h o u r ~ ~ ~ g a, the bas~c measures to ach~eve and malntarn full employment. On

the othcl hdnd. thc Markidti vdrlcty stdles that accumulation (profitable ~nvestment) and

l e g i t t ~ i i ~ s d ~ ~ ~ r n I v r i ~ a l l un i i ~on d~tiis at mil~ntalnlng peace and stab~lity In a clasr dom~nated

soclety) are the two bas~c functions o f the state In a capltallst soctety (see Navarro. 1974.

Santhana. 2002. Rothman. 1998. Keth1nent,l99l)