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Special Issue: Health Inequities in India

Articles

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• Health Inequities in India A Focus on Some Under-researched Dimensions T. K. Sundari Ravindran, Mohan Rao

  The world has never been as rich as it is today. Yet substantial proportions of the global population live short and brutal lives, haunted by hunger, ill-health and disease. The average life expectancy in Sweden countries in 2015 was 82.4 years; that in Swaziland was 58.9 (WHO, 2017). Over the last 30-odd years, as the world entered a neo-liberal turn to economic growth, along with a growing wealth gap between rich countries and poor countries, and between the rich and poor within countries, there is also a growing health gap. For example, the maternal mortality rate in the black population in the United States is three times higher than that in the white and is increasing. In India itself, a person born in Kerala can expect to live 18 years longer than one born in Bihar or Jharkhand.

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• Marginalisation and Access to Safe Abortion A Case Study on the Struggles of a Narikuravar Woman in Kumbakonam, Tamil Nadu Bhuvaneswari Sunil

  This paper explores the realities and complexities experienced by women in marginalised communities in accessing safe abortion services. It specifically explores the experiences that shape the perceptions and behaviour of Narikuruvar women towards accessing both public and private reproductive healthcare facilities. This is illustrated by the case of a married Narikuravar woman who had undergone self-induced abortion in Kumbakonam, a town in Tamil Nadu. In addition, the paper examines the circumstances that force women in the margins to adopt unsafe, self-induced abortion and discusses the strategies used by the Narikuravar woman for self-induced abortion. This is a qualitative research study and has used a phenomenological lens to capture the individual experiences of the woman across diverse life events associated with pregnancy, motherhood and abortion. The paper describes how contextual factors such as lack of access to resources and decision-making structures intersect with other cultural and gender identities of women. The principal argument here is that the needs, aspirations, interests, knowledge and agency of women from marginalised communities are not recognised in public and private decision-making spaces, and this impacts on women’s sexual and reproductive rights.

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• Role of Sex and Gender in Post-Stroke Care A Study in Gandhinagar District, Gujarat S. Solanki-Parmar, N. Nakkeeran, R. Patel, P.S. Ganguly, V. Sodagar, M. Doshi

  Globally, stroke leads to 21.7 per cent of deaths among women in the geriatric age-group. For those who have survived it, it demands prolonged care-giving. A relatively longer life expectancy adds to the higher stroke burden among women compared to men. In a country like India with an aging population, a non-functional healthcare system, and a large number of people living in poverty, the burden of post-stroke care, in entirety, gets shifted to households. Within Indian households, women are seen as the primary caregivers, putting them at risk of physical and psychological stress. Patriarchal social norms also place women stroke survivors in severe disadvantage in many ways.

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• Perceived Barriers to Timely Postpartum Screening of Women with Gestational Diabetes Mellitus (GDM)A Qualitative Study K. Sakeena, T. K. Sundari Ravindran

  Timely postpartum screening for diabetes following a pregnancy with gestational diabetes mellitus (GDM) is crucial to reduce the future risk of incidence of diabetes. This study explored barriers to timely postpartum screening for diabetes mellitus after a pregnancy with GDM, by assessing the concerned women’s views and perceptions. Data for this study pertains to fifteen respondents from among participants in a larger cross-sectional survey conducted in Malappuram District of Kerala among women affected with GDM during a recent pregnancy. The selection was based on detailed responses to open-ended questions asked in the quantitative study. The responses were transcribed and deductively coded. The findings were organized around major themes. We identified five main areas of barriers in the management of diabetes during pregnancy. These were a) inadequate instructions from the healthcare provider who attended the pregnancy and delivery; health services related barriers; perceived difficulties of the oral-glucose-tolerance-test; lack of time owing to multiple roles as mothers and home-maker; and postponing the screening but unable to specify a reason for it. Of these, health-provider and services -related barriers and lack of time owing to multiple responsibilities were the most often- stated barriers. Participants had a general awareness of possible complications following GDM in pregnancy but often could not name specific effects on the woman or child during and after the GDM pregnancy. A majority of the participants were unaware of their elevated risk of developing Type 2 Diabetes Mellitus. The barriers to postpartum screening identified in this study could help planning programmes to assist women in achieving timely postnatal screening for Type-2 Diabetes Mellitus.

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• Gender Equity as a Dimension of Progress Towards Universal Health Coverage Evidence from India’s 71st Round National Sample Survey Alok Ranjan, Adithyan G. S., Daksha Parmar

  Universal Health Coverage (UHC) has emerged as a major health policy discourse across the world. Its proponents claimed it as the third grand transition in health after demographic and epidemiological transitions, whereas others have called it “old wine in a new bottle.” UHC aims that everyone irrespective of their socio-economic status or gender should have access to essential healthcare facilities without facing any financial hardships. Equity is considered to be the central epithet in any UHC model, and in the Indian context, gender equity is a critical factor in the quest for achieving UHC. This study aims to explore progress towards UHC in the dimensions of access and financial protection in India, and differentials in these by sex. The current study is based on India’s recently released data from the 71st Round of the National Sample Survey (NSS), 2014. The survey covered 65932 households (rural: 36480, urban: 29452) in India which included 3,33,104 individuals (men: 1,68,697 women: 1,64,407). Healthcare utilization, hospitalization rate, the proportion of the ailing population (PAP), insurance coverage, out of pocket expenditure (OOPE), catastrophic health expenditure (CHE) and impoverishment were calculated from the data set. By disaggregating the data set by sex, all the above indicators were analyzed through a gender lens. Various other equity dimensions (geographical location, caste, and economic category) were also analyzed in the sex-disaggregated data set. Descriptive statistics were used as the main data analysis technique.

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• Publicly Funded Health Insurance Schemes (PFHIS): A Systematic and Interpretive Review of Studies Does Gender Equity Matter? Rajalakshmi RamPrakash and Lakshmi Lingam

  With the announcement of the National Health Protection Scheme in February 2018 by the Indian Government, the policy direction based on an insurance-based model of health financing as a panacea for all ill-health has become even more evident than in the past. This is surprising, given that the evidence on the positive impact of a publicly funded health insurance scheme (PFHIS) is equivocal. There are only a handful of reviews of studies on national and state level PFHIS on equity dimensions, and none of them have applied a gender lens. The current paper aims to provide a systematic as well as an interpretive review of available literature on PFHIS in India by employing a gender and health equity lens. It aims to understand the evidence on gender dimensions in process indicators (awareness, enrolment, and utilization) and impact indicators (health expenditures and coping mechanisms) of PFHIS. It also aims to answer why we do not know enough about the gendered aspects of PFHIS given their existence for more than a decade. Using PRISMA techniques, a total of 80 papers covering 17 specific states in India were reviewed to aggregate the evidence on gender differences. For the interpretive review, the same studies were critically reviewed to understand the nature of gender analysis and to uncover the reasons for the thin evidence emerging on gender equity in PFHIS.

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• Class and Gender Dynamics of Outsourcing Manpower in the Health Sector From Formal to Informal work Seemi Zafar

  Estimates by academicians have pointed out that salaries appropriate as much as 70 – 80per cent of state budgets, leaving a minuscule share for health infrastructure and other inputs. A solution to the problem has been offered through reforms which have propagated alternative mechanisms of recruiting workforce. These include hiring staff on short-term renewable contracts and outsourcing tasks to a contracting agency. The following paper is a case-study of a tertiary-care hospital which has adopted such hiring practices. This study on contract-hired and outsourced workers aims at documenting the dynamics and implications of reforms in recruitment on the conditions of work of those recruited on such work arrangements, and on the quality of healthcare. This paper draws on a larger qualitative study which examined the implications of health reforms for services provisioning within a tertiary -level government hospital. Between September 2016 and June 2017, in-depth interviews were conducted with 85 health workers including both permanent and casual staff. Prior consent from the Delhi Health Department was solicited for conducting the study. Reforms in recruitment have advocated outsourcing for the lowest rung of employees, while for technical, nursing staff and physicians, the system of contracts has been introduced. Both groups of workers were paid lower than regular employees carrying out the same tasks and had to contend with long-term job insecurity. However, the experiences of outsourced workers revealed a more humiliating working environment. The process of ‘casualization’ of workforce showed a class dimension, further marginalising the already vulnerable sections of society. Also, it was women from the groups who were concentrated in the lowest paid jobs. There appears to be class, caste and gender-based discrimination of employees in the health sector through contracting and outsourcing.

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• Integrating Gender in Medical Education A Step in Addressing Health Inequities Sangeeta Rege and Padma-Bhate Deosthali

  Medicine, as a field, has been critiqued for being gender biased and not accounting for social determinants that shape health conditions, access to healthcare, and health outcomes. Gender bias permeates many aspects of medicine in India: clinical practice, research, health program delivery, and medical education. In 2007 the World health organization (WHO) acknowledged the imperative of systematic integration of gender in the curricula of undergraduate medical students. This paper is a case study describing the process of implementing the ‘Gender in Medical Education (GME)’ project in Maharashtra by the Centre for Enquiry into Health and Allied Themes (CEHAT), the Department of Medical Education and Research, Maharashtra (DMER) and the Maharashtra University of Health Sciences (MUHS). The paper aims to illustrate the complex steps involved in integrating gender concerns into an undergraduate medical curriculum. The GME project consisted of five components, some implemented sequentially and others taking place simultaneously. Three of the components are relevant to this paper. The first component involved ascertaining interest and support for the project from the concerned authorities. The second component consisted of identifying from among medical educators in the state, a core group of champions for the integration of gender into the undergraduate medical curriculum and building their capacity for gender-analysis of health issues. A third component involved the core-group of-medical-educators working with experts to revise the UG medical curriculum and make it gender-sensitive.

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• Unmet Health Care Needs Among Urban Poor Population of Thiruvananthapuram, India Sreejini Jaya

  In recent times, a significant proportion of the global population lives in an urban context, as cities offer unparalleled opportunities for livelihood. In an urban setting, when a majority of programmes, data, and services focus on urban averages, the intra-urban differences are often missed, rendering urban health inequities invisible. The objective of this paper is to examine the unmet health care needs of the urban-poor population, through examining the many steps involved in having one’s health care need to be met, from finding a suitable health provider through to having the health problem resolved. After providing an overall picture of unmet needs and associated barriers, we delve deeper into the pathways to unmet need for care for acute morbidity conditions. A cross-sectional epidemiological survey was conducted to assess the health care needs of the urban- poor population and a series of case profiles to identify those people who get left behind within the poor urban section. The study population comprised the urban-poor population of Thiruvananthapuram Municipal Corporation. Households enlisted in the ‘Below Poverty Line’ (BPL) list ward-wise for urban Kerala were the study universe, and the sample was selected using multi-stage cluster sampling. The most recent episode of illness or health care need in the sample household within the reference period was documented, and five categories of health care needs were captured. We examined the outcome variable ‘unmet health care needs’ through a sequential five-step process: Sought health care; Consulted health provider; Started treatment; Completed/ On-going treatment; Health problem resolved.

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• Service Coverage and Financial Risk Protection Among Urban Poor Under Tamil Nadu’s Voluntary Government-sponsored Health Insurance Scheme Philip, NE*

  Providing financial risk protection (FRP) to the poor and vulnerable population by preventing the incurrence of Catastrophic Health Expenditure (CHE) is critical to achieving Universal Health Coverage in any country. The World Health Organization has endorsed the ability of pre-payment financing mechanisms such as Social Health Insurance (SHI) to provide FRP and to improve access to healthcare for the poor. The state of Tamil Nadu in India introduced one of the early state- sponsored health insurance programmes in 2009, known since 2012 as the Chief Minister’s Comprehensive Health Insurance scheme (CMCHIS). The scheme covers lowincome households for hospitalizations. In this paper we examine the extent to which CMCHIS has enabled urban poor households to meet all their healthcare needs without the risk of incurring CHE. We conducted a ten-month longitudinal study of 600 urban- poor households, selected using multi-stage random sampling, in the Kanyakumari district of Tamil Nadu. We categorized the poor households into four, based on their socioeconomic status: very poor, poor, marginal and vulnerable. Four waves of data were collected at zero, one, six and ten months, from six wards of two municipalities. Healthcare needs of the household were defined as any household member having chronic disease, seeking out-patient care (acute morbidity) or in-patient care (hospitalization).

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• Social Exclusion and Health of Muslim Communities in Maharashtra Sana Contractor, Tejal Barai-Jaitly

  The relationship between social exclusion and health is a complex one. Social exclusion predisposes affected communities to a variety of social and economic vulnerabilities with the potential to jeopardize their health. These result in the community being ‘left out’ deliberately, discouraging social participation or even actively denying them services. The institutional structures that perpetuate social exclusion differ by gender, class, sexual orientation, race, ethnicity and other similar structures. In India, religious identity is one such structure, and Muslims (a religious minority) is one such socially excluded group. This paper examines the health status of Muslims in the State of Maharashtra. It describes the socioeconomic context of Muslims and explores how this influences the health of the community. Using secondary data, it also seeks to compare how Muslims fare on key health indicators versus other socio-religious groups in India. This paper is based on analysis of the National Family Health Surveys, District Level Household Surveys, and the National Sample Survey Organizations data sets. It also draws upon published literature, particularly primary studies commissioned by the Maharashtra State Minority Commission in 2013.

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• (Un) popular Traditional Medicine Community Perceptions, Changing Practices, and State Policy in Nepal Bamdev Subedi, Lakshmi Raj Joshi

  Traditional medicine refers to different forms of medicines and therapeutic practices, both popular and scholarly. This paper draws on the field data collected from two villages of Nepal to reflect on whether popular traditional medicine is becoming unpopular among the rural communities. The article looks into community perceptions, changing practices and therapeutic choices among the local people. Inequalities and differences were observed in the use of popular traditional medicine (PTM) and scholarly traditional medicine (STM). We found that the overall popularity of PTM has declined over the past few decades. Field narratives and treatment- seeking data show the falling use of PTM. It appears that the present trajectory of healthcare development has had a damaging effect on PTM. STM, which has been recognized as part of national health care system, gets some support for its growth and development but PTM, on which still a large number of people rely, lacks such support. We argue that the damages to PTM will have a serious implication from a health equity perspective. Rising inequities in health cannot be addressed without taking PTM on board. Furthermore, the damages to PTM will have a damaging effect on the growth and development of STM as well. We question the policy rhetoric of “promoting Ayurveda and other alternative systems” and “making health care services accessible to all.” We conclude that promotion of positive aspects of PTM can contribute to the advancement of STM. Making healthcare services more accessible and affordable lies not in the growth of an unregulated private sector and pushing towards biomedicine- based- government- healthcare provisioning. It depends on the promotion and strengthening of the public sector with a balanced role for traditional medicine, both popular and scholarly.

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• Recognizing Maternal Health as a Community Issue Using a Survey Tool to Develop Social Accountability Interventions Amongst Community Leaders in Three Districts of Gujarat Vaishali Zararia, Renu Khanna

  SAHAJ (Society for Health Alternatives), a non-government organization (NGO) and two other partner NGOs have been working since 2012 with tribal and marginalized communities in three districts of Gujarat to strengthen social accountability for maternal health. This paper discusses the results of an evaluation conducted during April 2016-March 2017 to assess the changes in community leaders’ knowledge, attitudes and understanding towards maternal health. The evaluation was conducted in 45 control and 43 project villages. This evaluation assessed the effectiveness of the NGOs’ interventions (from a gender and rights perspective) wherein the organizations’ staff disseminated focused messages about maternal health, government entitlements, and strategies for improving accountability among community members. The evaluation consisted of three components: a baseline quantitative survey (April 2016), longitudinal qualitative research consisting of participant observation of periodic review meetings and field activities (April 2016-March 2017), and an end-line survey (March 2017). Significant improvements were seen in knowledge levels of antenatal care (ANC) services available, highrisk symptoms, handling emergency obstetric situations, maternal-health entitlements, and maternal death reviews. Significant improvements were also seen in views and understanding towards maternal health as a Gram Sabha (village council) issue and on the responsibilities of the Panchayat (village government) towards maternal health. There was also an increase in the number and variety of maternal health issues discussed in Gram Sabha meetings and increased participation of community members and local health system-actors. In a setting with community organizations and strong NGO support, systematic multi-method dissemination of key maternal health messages, along with discussions and actions through the Panchayat, can succeed in making maternal health a community issue.

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