In India, despite improvements in access to health care, inequalities are related to socioeconomic status, geography, and gender, and are compounded by high out-of-pocket expenditures, with more than three-quarters of the increasing financial burden of health care being met by households. Health-care expenditures exacerbate poverty, with about 39 million additional people falling into poverty every year as a result of such expenditures. We identify key challenges for the achievement of equity in service provision, and equity in financing and financial risk protection in India. These challenges include an imbalance in resource allocation, inadequate physical access to high-quality health services and human resources for health, high out-of-pocket health expenditures, inflation in health spending, and behavioural factors that affect the demand for appropriate health care. Use of equity metrics in monitoring, assessment, and strategic planning; investment in development of a rigorous knowledge base of health-systems research; development of a refined equity-focused process of deliberative decision making in health reform; and redefinition of the specific responsibilities and accountabilities of key actors are needed to try to achieve equity in health care in India. The implementation of these principles with strengthened public health and primary-care services will help to ensure a more equitable health care for India's population.
Introduction
India accounts for a substantial proportion of the global burden of disease, with 18% of deaths and 20% of disability-adjusted life-years (DALYs).1 Although the burden of chronic disease accounts for 53% of deaths (44% of DALYs), 36% of deaths (42% of DALYs) are attributable to communicable diseases, maternal and perinatal disorders, and nutritional deficiencies, which suggests a protracted epidemiological transition.2 A fifth of maternal deaths and a quarter of child deaths in the world occur in India.3, 4 Life expectancy at birth is 63 years for boys and 66 years for girls, and the mortality rate for children younger than 5 years is 69 per 1000 livebirths in India—higher than the average for southeast Asia (63 per 1000 livebirths).5
These data, however, mask the substantial variation in health within India. Although health outcomes have improved with time, they continue to be strongly determined by factors such as gender, caste, wealth, education, and geography.6, 7, 8 Caste in India represents a social stratification: categories routinely used for population-based monitoring are scheduled caste, scheduled tribe, other backward class, and other caste; scheduled tribes (8%) and schedules castes (16%) are thought to be the most socially disadvantaged groups in India.9 For example, the infant mortality rate was 82 per 1000 livebirths in the poorest wealth quintile and 34 per 1000 livebirths in the richest wealth quintile in 2005–06.10 The mortality rate in children younger than 5 years who are born to mothers with no education compared with those with more than 5 years of education was 106 per 1000 livebirths and 49 per 1000 livebirths, respectively, during 1995–96 to 2005–06 (figure 1). The variation in mortality in children younger than 5 years in different states tends to be largely associated with the extent of the economic development of the state (figure 2). India has substantial geographical inequalities in health outcomes—eg, life expectancy is 56 years in Madhya Pradesh and 74 years in Kerala; this difference of 18 years is higher than the provincial differences in life expectancy in China,15 or the interstate differences in the USA.16
Many of the inequities in health result from a wide range of social, economic, and political circumstances or factors that differentially affect the distribution of health within a population. Since some of these inequities in health result from the unfair distribution of the primary social goods, power, and resources, the social determinants of health need to be addressed (panel 1).23, 24 A primary goal of public policies should be to address any inequities in health, with health systems having a special and specific role in the achievement of equity in health care and health, alongside efficiency.21, 22, 25
Key messages
•
Substantial socioeconomic inequalities exist in access to health care in India. In 2005–06, national immunisation coverage was 44%, whereas the coverage was 64% for children of mothers with more than 5 years of education, and 26% for children of mothers with no education. Similarly, even though rates of delivery in institutions have increased with time, only 40% of women in India report giving birth in a health facility for their previous birth in 2005–06, with women in the richest quintile six times more likely to deliver in an institution than those in the poorest quintile.
•
Inadequate public expenditure on health (estimated to be 1·10% of the share of the gross domestic product during 2008–09), and imbalanced resource allocation with much variation between state expenditures on health, restrict capacity to ensure adequate and appropriate physical access to good-quality health services. For example, per person public health expenditures in Bihar were estimated to be INR93 compared with INR630 in Himachal Pradesh in 2004–05. Furthermore, a greater proportion of resources are directed towards urban-based and curative services that suggest an urban bias and rural disadvantage in access to health-care services.
•
More than three-quarters of health spending in India is paid privately. High out-of-pocket health expenditures, therefore, are a major source of inequity in financing of health care and in financial risk protection from health adversities. This effect is disproportionate across population groups; health expenditures account for more than half of Indian households falling into poverty, with about 39 million Indian people being pushed into poverty every year.
•
Between 1986–87 and 2004, the absolute expenditures per outpatient visit and inpatient visit in rural and urban areas increased, particularly affecting the ability of the poorest individuals to access services. Although costs have increased in the public and private sectors, the increase has been much faster (>100%) in the private sector. Expenditures for drugs, which represent 70–80% of out-of-pocket expenditures for outpatients, have been increasing with time at a rate that is at least twice as fast as the general price increase.
•
Policies oriented towards incorporation of equity metrics in monitoring, assessment, and strategic planning of health care; investment in development of a rigorous knowledge base of health-systems research; development of equity-focused process of deliberative decision making in health reform; and redefinition of the specific responsibilities and accountabilities of key players along with strengthening the foundation of public health and primary care, provide an approach for ensuring more equitable health care for India's population.
Equity in health and health care has been a long-term guiding principle of health policy in India, with a commitment to provide for the needs of individuals who are poor and underprivileged. A detailed plan for provision of universal coverage for the Indian population through a government-led health service was set out in a report by the Health Survey and Development Committee in 1946.26 Since then, health policies and priorities have been outlined in the Five Year Plans, developed as part of India's centralised planning and development strategy. The need for universal comprehensive care was reiterated in the first official National Health Policy proposed in 1983.27 Shaped by the Alma Ata Declaration,28 recommendations emphasised in this policy were improved primary health care, decentralisation of the health system, improved community participation, and expansion of the private sector to reduce the burden on the public sector.27 Although the second National Health Policy in 2002 continued to support India's vision, it was undertaken on the “basis of realistic considerations of capacity”.29 In 2009, the Government of India drafted a National Health Bill for the legal system to recognise the right to health and right to health care with a stated recognition to address the social determinants of health.30 However, implementation of policy commitments to equity in health care remains a challenge because of India's institutional and implementation capabilities,31 and is also a challenge for the global health community.19
In this report, we first describe the inequalities in access to health care. By use of a supply-demand framework, we discuss the key challenges in the achievement of a health system that provides equity in service delivery, and health financing and protection of financial risk (figure 3).
Section snippets
Inequalities in health care
In India, individuals with the greatest need for health care have the greatest difficulty in accessing health services and are least likely to have their health needs met.32, 33, 34, 35 We conceptualise access as the ability to receive a specific number of services, of specified quality, subject to a specified constraint of inconvenience and cost,36 with use of selected health services as a proxy for access. To show the persisting inequities in health care in India, we focus on access to
Factors affecting supply of health care
Efficient allocation of resources between primary, secondary, and tertiary care, and geographical regions is crucial to ensure the availability of appropriate and adequately resourced health services.22 In India, this challenge is compounded by low public financing with substantial variation between states.41 India's total expenditure on health was estimated to be 4·13% of the gross domestic product (GDP) in 2008–09, of which the public expenditure on health was estimated to be 1·10%.42 Private
Factors affecting demand for health care
Insufficient public financing, lack of a comprehensive method for risk pooling, and high out-of-pocket expenditures because of rising health costs are key factors that affect equity in health financing and financial risk protection.41 Evidence from surveys of national expenditures suggests that inequalities in health financing have worsened during the past two decades.45 Only about 10% of the Indian population are covered by any form of social or voluntary health insurance, which is mainly
Principles for achievement of equity
The heterogeneity in the scale and interplay of the substantial challenges to health care in the states and districts needs contextually relevant solutions. India has made much progress in the past few years, with several innovative pilot programmes and initiatives in the public and private sectors, and the establishment of the National Rural Health Mission in 2005 being the most noteworthy government-led initiative (panel 2).41, 51, 91 This initiative has signalled the repositioning and
Conclusion
A cogent moral, social, and economic argument exists for investment in the achievement of health-care equity for Indian people. Recent rapid economic growth provides a unique opportunity to increase financial commitments to support the public health system and health-systems research. India can also draw from its booming technology sector to innovate and strengthen the development of health information systems, which has already begun. Furthermore, an opportunity exists to harness the
Search strategy and selection criteria
We searched a wide range of sources, including academic literature, government reports, multilateral-agency reports, and commissioned reports relating to inequalities, inequities, health, and health systems in the Indian context that were published in English. Search terms included “health systems” “health sector”, “equity”, “inequity”, “inequalities”, “access”, “utilization”, “financing”, “regulation”, “service delivery”, “expenditures”, “out of pocket”, and “quality”. Data were obtained from
Disease and injury country estimates. Death and DALY estimates for 2004 by cause for WHO Member States. Department of Measurement and Health Information
SK Reddy et al.
Responding to the threat of chronic diseases in India
Lancet
(2005)
The state of the world's children 2009: maternal and newborn health
(2009)
The state of the world's children 2008: child survival
(2008)
World health statistics 2010
(2010)
SV Subramanian et al.
Health inequalities in India: the axes of stratification
Brown J World Aff
(2008)
SV Subramanian et al.
The mortality divide in India: the differential contributions of gender, caste, and standard of living across the life course
Am J Public Health
(2006)
SV Subramanian et al.
Indigenous health and socioeconomic status in India
PLoS Med
(2006)
Census atlas of India, 2001
(2008)
National Family Health Survey (NFHS-3): 2005–06: India. International Institute for Population Sciences (IIPS) and Macro International
National Family Health Survey (MCH and family Planning) India 1992–3. International Institute for Population Sciences (IIPS) and Macro International
National Family Health Survey (NFHS-2, 1998–99: India. International Institute for Population Sciences (IIPS) and Macro International
State Domestic Product (State series). National Accounts Division. Central Statistical Organisation of India. Ministry of Statistics and Programme Implementation. Government of India, Kolkata, 2009
S Burd-Sharps et al.
The measure of America: American human development report, 2008–09
(2008)
Commission on social determinants of health. Closing the gap in a generation: health equity through action on the social determinants of health: final report of the commission on social determinants of health
(2008)
I Kawachi et al.
A glossary for health inequalities
J Epidemiol Community Health
(2002)
S Harper et al.
Implicit value judgments in the measurement of health inequalities
Milbank Q
(2010)
DR Gwatkin
Health inequalities and the health of the poor: what do we know? What can we do?
Bull World Health Organ
(2000)
M Whitehead
Concepts and principles of equity in health
(1990)
The world health report 2000: health systems: improving performance
(2000)
MJ Roberts
Getting health reform right: a guide to improving performance and equity
(2008)
J Rawls
A theory of justice
(1999)
N Daniels
Just health: meeting health needs fairly
(2008)
T Evans et al.
Challenging inequities in health: from ethics to action
(2001)
J Bhore et al.
Report of the Health Survey and Development Committee
(1946)
National health policy
(1983)
WHO and UNICEF. Primary health care: report of the International Conference on Primary Health Care, Alma-Ata, USSR,...
National health policy
(2002)
The national health bill
(2009)
L Pritchett
Is India a flailing state?: detours on the four lane highway to modernization
Health policies reflect the ideas and interests of the actors involved. The Indian Government constituted many health committees for policy recommendations on myriad issues concerning public health, ranging from tribal health to drug regulation. However, little is known about their composition and backgrounds. We reviewed these committees to map the actors and institutions.
We elicited information on all relevant health committees available in the public domain. All were constituted post-independence, except two, with recommendations that remain pertinent to date. Data for chairpersons and members - their professions, gender, institutions, and location were extracted and analysed. Reliable online sources were used to collate the information.
We identified 23 national health committees from 1943 to 2020 with available reports. There were 25 chairpersons and 316 members. All except three chairpersons were men. Among members, only 11% were women. The majority (51%) had experience working in health systems; however, most were medical doctors, with negligible representation of other cadres. We noted the centralization of location, with 44% of members based in the national capital of Delhi. Government administrators were maximally represented (55%), followed by medical academia (19%). Post-2000, we have observed slightly improved diversity across some parameters like gender (15% women vs 9% earlier) and affiliation. However, the centralization of the location to the national capital had increased (55% post-2000 vs. 39% pre-2000).
Indian health committees lack diversity in representation from multiple perspectives. Henceforth, health policymakers should prioritize including diverse social, geographical, and health systems actors to ensure equitable policymaking.
The authors have measured the health expenditure-induced removable poverty in India using nationally representative consumer expenditure surveys of three quinquennial rounds conducted by the National Sample Survey Organization (NSSO). This study has also focused on the reflections of Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY), the world's largest Government-funded health insurance scheme, on these poverty rates in the country. The study has used headcount, payment gap, and concentration index to measure the economic burden and impoverishment impact of out-of-pocket (OOP) health expenditure. The analysis shows that the incidence and depth of poverty are substantially understated because of overlooking OOP health expenditure in the country's standard poverty measure. Outpatient care contributes almost four times more than inpatient care to health expenditure-induced impoverishment in India, though this care has not been covered in the AB-PMJAY. Muslims, among all religious groups, Scheduled Castes among social groups, and casual labourers among different household types are more vulnerable to OOP health expenditure-induced removable poverty in the country. Poverty, in general, has dropped significantly, but the share of health expenditure-induced poverty in general poverty has increased substantially. It has risen considerably in rural areas and among India's most vulnerable sections of society in the past 20 years. We emphasised that universal health insurance coverage is needed in India. Implementing comprehensive health insurance schemes that cover both inpatient and outpatient care can help alleviate the financial burden of healthcare expenses on households and contribute to reducing poverty rates.
India has committed to formulating a roadmap for realising a resilient health system, with digital health being an important element. Following the successful implementation of a free telemedicine service, eSanjeevani, India published the Telemedicine Practice Guidelines in 2020 to scale telemedicine use in India. The current study aims to understand the perspective and use of telemedicine by medical doctors in India after the release of these guidelines.
Data were acquired through an anonymous, cross-sectional, internet-based survey of medical doctors (n = 444) at a pan-India level. Replies were subjected to statistical analysis.
Telemedicine was used for various non-mutually exclusive reasons, with the top two reasons being live audio or video consultations (60.4 %) and online payments (19.1 %), and smartphones were the most frequently used device type (60.6 %). Among various benefits of telemedicine, almost all respondents (93 %) recognised the potential for telemedicine to reduce COVID-19 infection risk for healthcare professionals. Interestingly, nearly 45 % of respondents felt that limited and fragmented insurance coverage was an important limitation to the practice of telemedicine in India, and 49 % believed reduced patient fees for teleconsultations could help incentivise telemedicine use.
This study helps to appraise the use of telemedicine in India after the publication of telemedicine guidelines in 2020. Furthermore, the findings can inform the development of telemedicine platforms, policies and incentives to improve the design and implementation of effective telemedicine in India.
The first Lancet Oncology Commission on Global Cancer Surgery was published in 2015 and serves as a landmark paper in the field of cancer surgery. The Commission highlighted the burden of cancer and the importance of cancer surgery, while documenting the many inadequacies in the ability to deliver safe, timely, and affordable cancer surgical care. This Commission builds on the first Commission by focusing on solutions and actions to improve access to cancer surgery globally, developed by drawing upon the expertise from cancer surgery leaders across the world. We present solution frameworks in nine domains that can improve access to cancer surgery. These nine domains were refined to identify solutions specific to the six WHO regions. On the basis of these solutions, we developed eight actions to propel essential improvements in the global capacity for cancer surgery. Our initiatives are broad in scope, pragmatic, affordable, and contextually applicable, and aimed at cancer surgeons as well as leaders, administrators, elected officials, and health policy advocates. We envision that the solutions and actions contained within the Commission will address inequities and promote safe, timely, and affordable cancer surgery for every patient, regardless of their socioeconomic status or geographic location.
This study concerns the reproductive health care of women of reproductive age in the selected Aspirational districts in India. This paper mainly aims to identify the level of accessibility and availability of reproductive health care and their interlinking with the health outcomes in terms of institutional delivery and percentage of women who received any Antenatal Check-up.
This is a cross sectional study.
A composite index has been constructed at the district level for every indicator (accessibility, availability, and health outcome) to identify the level of accessibility and availability and to analyse the association between accessibility, availability, and health outcomes using the Pearson chi-square test and ternary diagram. The thematic maps used for showing the disparities of indicators in the selected Aspirational districts.
After developing the composite index for accessibility and availability of health care, it is shown that the districts which ranked in accessibility, not ranked in availability of health care. The study reveals that the overall composite index for ranking the districts in terms of accessibility and availability, closely associated with the health outcomes. Accessibility and availability are also associated with the health outcome of reproductive health in Aspirational districts in India. Accessibility of health care services is more significant for better health outcomes than the availability of health care services in the Aspirational districts in India.
Accessibility and availability are the component for access to health care and influence the health outcome.