Table Of ContentT.K. Sundari Ravindran
Rakhal Gaitonde Editors
Health
Inequities
in India
A Synthesis of Recent Evidence
Health Inequities in India
T.K. Sundari Ravindran Rakhal Gaitonde
(cid:129)
Editors
Health Inequities in India
A Synthesis of Recent Evidence
With Forewords by Sharmila Mhatre and Lesley Doyal
123
Editors
T.K.SundariRavindran RakhalGaitonde
Achutha MenonCentrefor Health Science Centrefor Technology andPolicy (CTaP)
Studies Indian Institute of Technology Madras
SreeChitra TirunalInstitute for Medical Chennai, Tamil Nadu
SciencesandTechnology India
Trivandrum, Kerala
India
ISBN978-981-10-5088-6 ISBN978-981-10-5089-3 (eBook)
https://doi.org/10.1007/978-981-10-5089-3
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Foreword I
Theinceptionofthisbookstemsfromadesiretounderstandandprofilethetheory
and practice of redressing inequities in the Indian context and the admiration for
Prof. Ravindran, who in our first meeting elegantly argued both the theory and
politics of equity. At that time in 2012, I headed a health systems programme for
the International Development Research Centre (IDRC), a Canadian crown cor-
poration mandated to support research for development. The IDRC programme at
that time wanted to build a critical mass of researchers who could unpack the
theoreticallayersofequity,innovatenewframeworksandmethodstocontributeto
healthier communities. This book shows only some ofthe fruits of labour by Prof.
Ravindranandhercolleagues.Itdoesnotrevealtheinnumerableconsultations,the
mobilisation of researchers, the training of emerging scholars, the forged collabo-
rations amongresearchersandpractitionersacross Indiaandoutside thecountryin
the “journey of ideas” articulated in this book.
Theintroductorychapterprovidesanoverviewofthechaptersinthisbookwith
the last chapter asking researchers to join the political project of researchers, fun-
ders,practitionersandpolicymakerscomingtogethertoredressinequities.In2017,
this call for action strikes achord—with therise ofnationalism and discrimination
bythosewhothreatensocialorderexplicitlyonthelinesofraceandreligion.Inthe
world we live in today, the urgency for this political project is even clearer. The
concept of health equity as discussed by the authors continues to be a greater
challengeandcannotberelegatedtotheboundariesofresearch.Asaconstructand
analytical frame, health equity as a political project is one strategy to achieve
fairness, and open and vibrant democratic societies.
Sharmila Mhatre, Ph.D.
Deputy Director
Public Health Program, Open Society Foundations
New York, USA
v
Foreword II
Thisbookrepresentsanimportantcontributiontothegloballiteratureoninequities
inhealth.Muchhasbeenwrittenonthistopicinrecentyears,butIndiahasreceived
relatively little attention. This is especially surprising since it has a particular rele-
vancetocurrentdebatesabouttherelationshipbetweenhealthandeconomicgrowth.
Viewed from a geopolitical perspective, it is counted among the six countries
referred to as BRICS (Brazil, Russia, India, China and South Africa). All have
experienced rapid economic growth in recent years and all are advancing rapidly
throughbothdemographicandepidemiologicaltransitions.However,thebenefitsof
this growth remainunequallydistributed inall BRICS but especiallyin India.
Dataonthedistributionofeconomicresourcesarerelativelysparse,butthereis
clear evidence that inequalities within India increased over the past two decades.
Amajorreasonforthishasbeenthefailureofeconomicgrowthtogenerateenough
formalemploymentwithabouthalftheworkforcestillengagedinlowproductivity
agriculture.Thisinturnreflectstheearliershiftingovernmentpoliciesfrompublic
spendingasastimulustoeconomicgrowthtowardsneo-liberalstrategiesinvolving
deregulation and an emphasis on increasing the consumption of the rich and the
growingmiddleclass.Asaresult,Indianowhasthehighestpovertyrateamongthe
BRICS countries with more than 40% of the population living on less than USD
1.25 per day. We can begin to see from this very crude data that the resources
available to meet the basic needs of the Indian population as a whole, are very
limited whenmeasuredagainstcomparable countries.Similarly, there aredramatic
internal inequalities in access to resources. While some groups and individuals are
becoming extremely rich, the vast majority remains poor and, as the book shows,
this is reflected in patterns of morbidity and mortality.
Inordertomakesenseofthesevariations,weneedtolookinmuchmoredetail
at the nature of Indian society and the obstacles it presents to the optimisation of
health. So far, there is little more than statistical data available to facilitate this
analysis. However, this collection aims to go a step further. It will begin by out-
liningsomeofthenewconceptualframeworksemerginginthehealthfieldtomake
sense of national and global diversity. This will be followed by case studies
vii
viii ForewordII
applying these new approaches to what is known about the complex and hetero-
geneous structures of Indian society.
Recent literature in the field of health has moved away from what has been
called the “medical model” towards the recognition that an individual’s health is
shaped not just by biological factors, but by the “social determinants of health” as
key factors in explaining variations in morbidity and mortality both between and
within countries. The most obvious link is of course the one between
socio-economic status and sickness or early death. But gender too has been iden-
tifiedasakeydeterminantalongwithotherfactorsincludingrace/ethnicityandage.
However, it is often forgotten that the form and significance of these influences
willvarybetweensettingsaswilltheirimpactonhealth.Hence,amajorsectionof
this collection outlines the particular nature of these social processes as they are
playedoutinIndia.Atthesametimeresearchershaveincreasinglyrecognisedthat
these different influences do not operate in isolation but are in constant interaction
with each other.
This has led to the increasing use of the paradigm of “intersectionality” which
began in the US in the context of activism among black women. (The basic
proposition was that it was inappropriate to simply add together “black” and
“women” when the relationship was in fact multiplicative and mutually reinforc-
ing.) This interactive framework is now being used more widely in the context of
health, although most studies have been done in the global North. This collection
attempts to apply these ideas in a specifically Indian context as we can illustrate
here through examining the case offemale gender.
South Asia in general and India, in particular, are frequently cited as extreme
examples of male domination. One of the most widely used illustrations of this
point is the data on sex ratio at birth. Between 1951 and 2011, a UN study found
thatthechildsexratiodroppedfrom976girlsper1000boysin1961,to927girlsin
2001andto918girlsin2011.Viewedmorebroadly,recentresearchbytheWorld
EconomicForumshowedthatIndiacamelowestamongalltheBRICScountrieson
the global gender gap index and ranked 108 in the world overall. This is not of
course a biological phenomenon, but rather a cultural one based on “son prefer-
ence” which in turn has economic origins.
Girl children are frequently viewed as a burden since they require a dowry in
order to marry and are unlikely to be able to support their parents in old age. This
low status and discrimination follows them through life. A foetus known to be
female may be aborted before birth and a newborn girl abandoned while female
childrenareoftengivenlessfoodandmedicalattention.Inadulthood,mostwomen
havelittlepowerinthefamilyespeciallyinthecontextofsexandreproductionand
areusuallyemployedinlow-paidinformalworkaswellashavingresponsibilityfor
subsistence work and domestic labour.
Not surprisingly, this can have serious effects on their health in a number of
different ways. One of the most striking effects in recent years has been their
increasedvulnerabilitytoHIVinfection.Thisdoeshavesomebiologicalbasissince
women are more vulnerable than men to infection from a single heterosexual
encounter. But more importantly evidence shows that some 90% of monogamous
ForewordII ix
married women who are positive have been infected by their husbands, showing
theirlimitedautonomyeveninthemostintimatepartsoftheirlives.Closelylinked
totheirsituation inthefamily,Indianwomen exhibithighratesofdepressionwith
some studies showing them to be two or three times more likely than men to be
affected in this way especially during their childbearing years.
Hence, we can see that any attempt to link the health of women to their gender
mustexplorethelinkswith otheraspectsoftheirsociallocation. Thisisespecially
important when we come to issues of poverty and discrimination. Unlike many
othercountriessocio-economicstatusinIndiacannotbereadoffinanysimpleway
fromthedistributionofincomeandwealth.Insteadthecastesystemdefinesagroup
at the very bottom of the social hierarchy. Previously defined as “untouchables”
they are now referred to as Dalits (officially known as Scheduled Castes), and
constitute one-sixth of the population. Within the Dalit group itself, women are
usuallythe“poorestofthepoor”withtheirpositionattheintersectionofcaste,class
and gender, rendering them vulnerable to both direct and indirect violence. They
have little access to basic services including health care with cultural norms of
“natural”castehierarchiesandfemalesubjugationcombiningtopreventthemfrom
realising their potential for health.
Thisbriefexampleoftheimpactoffemalegenderonhealthisdevelopedfurther
asthiscollectionexplorestheheterogeneityofIndiansociety.Theaimisnotjustto
describe inequities in health as they emerge from official statistics, but rather to
explore their origins in the constantly shifting dynamics not just within India but
alsobetweenIndiaandtherestoftheworld.Thisrequirestheuseofarangeofboth
quantitative and qualitative methodologies across a variety of settings. By this
means, the book plays an important part in the creation of an effective evidence
base for tackling the health inequalities that have so plagued India despite recent
economic growth.
Lesley Doyal
Emeritus Professor
University of Bristol
Bristol, UK
Acknowledgements
The research on which this book is based, was undertaken as part of the project,
Closing the Gap: Health Equity Research Initiative in India supported by IDRC,
Canada,implementedbytheAchuthaMenonCentreforHealthScienceStudies,Sree
ChitraTirunalInstituteforMedicalSciencesandTechnology,Thiruvananthapuram,
India.Thisbookwasinspired bymanypeople whohavespentalifetime working
towardssocialjusticeandequityinhealth,andweowemuchtoalltheirwork.The
editors would like to express our gratitude to all those who offered comments at
various stages of development of the chapters in this book, and to Dr. Sharmila
MhatreandProf.LesleyDoyalwhograciouslyagreedtowritetheForewordstothe
book.SpecialthanksareduetotheInstituteanditsadministrationforthesupportthey
haveprovided,andmembersoftheClosingtheGapProjectTeamandstudentsofthe
Achutha Menon Centre for Health Science Studies, who helped with editing and
finalisingthemanuscript.
xi
Contents
1 Structural Drivers of Inequities in Health. .... .... .... ..... .... 1
T.K. Sundari Ravindran, Rakhal Gaitonde
and Prashanth Nuggehalli Srinivas
2 Conceptual Approaches to Examining Health Inequities. ..... .... 31
Rakhal Gaitonde
3 Research on Inequities and Inequalities in Health in India:
A Mapping of the Field... ..... .... .... .... .... .... ..... .... 55
Rakhal Gaitonde
4 Health Inequities in India by Socio-economic Position... ..... .... 67
Prashanth Nuggehalli Srinivas
5 Inequities in Health in India and Dalit
and Adivasi Populations.. ..... .... .... .... .... .... ..... .... 97
Sudharshini Subramaniam
6 Gender-Based Inequities in Health in India ... .... .... ..... .... 121
Priyadarshini Chidambaram
7 Other Socially Constructed Vulnerabilities: Focus
on People Living with HIV/AIDS and Internal Migrants. ..... .... 157
Grace A. Chitra
8 The Role of the Health System.. .... .... .... .... .... ..... .... 189
Rakhal Gaitonde
9 Health Equity Research: A Political Project... .... .... ..... .... 221
T.K. Sundari Ravindran, Rakhal Gaitonde,
Prashanth Nuggehalli Srinivas, Sudharshini Subramaniam,
Priyadarshini Chidambaram and Grace A. Chitra
xiii
