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Equity and Health in the Era of Reforms
1. Equity and Health in the Era of
Reforms
Gita Sen
Indian Institute of Management
Bangalore
4th Krishna Raj Memorial Lecture on
Contemporary Issues in Health and Social
Sciences
CEHAT / Anusandhan Trust, Mumbai, April 9, 2010
2. Acknowledgements
• First of all, of course, to Krishna Raj, about
whose contribution to informed public debate
in this country, enough can never be said. I am
deeply honoured, beyond my ability to
adequately express.
• Many thanks to the Anusandhan Trust,
eSocialSciences; Dept. of Economics,
Mumbai University; P.G. Dept. of Economics,
SNDT Women’s University and Tata Institute
of Social Sciences (TISS) for inviting me to
give this lecture
3. Acknowledgements
• I also want to acknowledge my long intellectual
partnership with Dr Aditi Iyer in our joint work
on equity and intersectionality, and all the fun
we have had doing it! This lecture is based
partly on that previous work, and on our
ongoing analysis of the NSS 60th round for
which Aditi provides the data and analysis
muscle!
• Prof Chandan Mukherjee who has been our
great support and colleague in this work from
early on.
• And to Vasini Vardhan, many thanks for her
hard work on the literature review.
5. Equity in health – why do we care?
• Isn’t a consideration of the level (average or that
of the lowest in the socioeconomic order)
enough? Why should we be concerned about
relative levels?
• 3 approaches: Ethicist / social activist versus
pragmatist /policy administrator
▫ Raise the average level
▫ Raise the minimum level
▫ Reduce inequality
6. Equity in health – why do we care?
• A problem of communication?
• A problem of information?
• A problem of politics / ideology?
• All the above, BUT
• Focusing on the average level or on improving
the health of the worst off also plays safe; it
doesn’t always ask hard questions about social
structures that a focus on inequality almost
inevitably leads to.
7. Inequality matters – Wilkinson’s
answer
• Richard Wilkinson: “Almost everyone benefits from
greater equality. Usually the benefits are greatest
among the poor but extend to the majority of the
population.”
• (Acknowledgement to Prof R Wilkinson for the next
slides)
8. Health and Social Problems are not Related to Average Income in
Rich Countries
Index of:
• Life expectancy
• Math & Literacy
• Infant mortality
• Homicides
• Imprisonment
• Teenage births
• Trust
• Obesity
• Mental illness – incl.
drug & alcohol
addiction
• Social mobility
Source: Wilkinson & Pickett, The Spirit Level (2009) www.equalitytrust.org.uk
9. Health and Social Problems are Worse in More Unequal Countries
Index of:
• Life expectancy
• Math & Literacy
• Infant mortality
• Homicides
• Imprisonment
• Teenage births
• Trust
• Obesity
• Mental illness – incl.
drug & alcohol
addiction
• Social mobility
Source: Wilkinson & Pickett, The Spirit Level (2009) www.equalitytrust.org.uk
10. Equity in health – the fallacy of
congruence
• Yes, inequality matters for health but what kind
of inequality?
• Can different dimensions of inequality be viewed
as collapsible into each other?
• Does focusing on economic class inequality tell
us enough? Does it tell us the right things?
• Does how we look at inequality need to be both
multi-dimensional and intersectional?
11. Equity in health – the fallacy of
congruence
Wilkinson & Pickett: “…what matters is the extent
of social class differentiation. No one suggests
that it is blackness itself which matters. Rather it
is the social meaning attached to it – the fact
that it serves as a marker for class and attracts
class prejudice – which leads both to worse
health and to wider income differences.” (Social
Science and Medicine 62 (2006) pp 1778-9)
13. Health care – 1986-87 to 2004
• Extends our earlier analysis (Sen, Iyer and George,
EPW April 6, 2002) of NSS surveys on morbidity
and health care (42nd round – 1986-87 and 52nd
round – 1995-96) to the 60th round – 2004
• Looks at both economic class & gender –
interpretation draws on insights from our work in
Koppal
• Some changes in definitions and reference
periods which I will only touch upon in places,
and are being discussed in detail in our
forthcoming paper
14. Features of the benchmark period
India’ s health care system already highly
inequitable by the mid 1980s prior to the
start of economic reforms in 1991
>70% health expenditure out of pocket
Large rural – urban differences in
availability of services
Poor quality and uneven reach of public
services
Highly unregulated private sector
15. Features of the benchmark period
contd
However:
Public hospitals (even if doubtful quality)
available to the poor especially for
inpatient care
Significant drug price control (over 300
drugs) in the essential, controlled price
list
Thriving (pre-WTO) indigenous drug
production (through reverse engineering)
kept drugs available and competitively
16. Key Questions
• What happened in the period after economic
reforms began?
• Important policy shifts:
▫ Sharp reduction in the controlled drugs list leading to
significant increases in drug prices
▫ Entry of user fees and two-tier services in public
hospitals – those below the poverty line are supposed
to get services free including drugs, but this is rarely
the case (under the counter payments, and drugs
have almost always to be purchased outside)
• Did gender and class inequalities in access to care
change?
17. Evidence
• We will look through gender and economic
class lenses at:
▫ untreated morbidity
▫ reasons for non-treatment
▫ the shifting public – private mix
▫ the cost of care
• Simple gradient – gap methodology to
examine inequality
18. But first a word about self-reported
illness
Concerns about under-reporting of illness
especially by the poor and women led the
National Sample Survey to try to improve
coverage through better training and
instructions to enumerators etc.
Q: what was the result?
20. Rates of perceived morbidity: Male versus Female (Rural)
25
No. per 100 persons
20
15
10
5
0
Quintile 1 Quintile 2 Quintile 3 Quintile 4 Quintile 5
(poorest) (richest)
Rural
Male (1986-87) Female (1986-87)
Male (1995-96) Female (1995-96)
Male (2004) Female (2004)
21. Rates of perceived morbidity: Male versus Female (Urban)
25
No. per 100 persons
20
15
10
5
0
Quintile 1 Quintile 2 Quintile 3 Quintile 4 Quintile 5
(poorest) (richest)
Urban
Male (1986-87) Female (1986-87)
Male (1995-96) Female (1995-96)
Male (2004) Female (2004)
22. • What does the pattern over time in self-reported
morbidity tell us? NSS made a serious attempt to
improve its capture of illness; yet a class gradient
has emerged in both rural and urban areas, and
more for women than men. Very little gender gap
among rural poor.
• Not plausible that the rich are more ill
• Under-reporting due to ‘normalisation’ of illness by
poor (both men and women) even more sharp in
relative terms?
Q: whose ill-health is the NSS capturing better?
23. Summary Results – Morbidity Reporting
Morbidity
• 1986-87 (pre-reform benchmark, 42nd round)
– No significant class gradient (based on MPCE
fractiles) or major gap in self-reported morbidity for
either women or men
• 1995-96 (52nd round)
– Across the board increase in self-reported morbidity,
with the emergence of significant class differences in
reporting; also some more gender differences
• 2004 (60th round)
▫ Even further sharpened class gradient for both women
and men; sharper gender differences but at the upper
end
26. Never treated vs discontinued
treatment?
• Difference between those never treated and
those who discontinued treatment?
• Apparently - an increase in those discontinuing
treatment, becoming greater by 2004 and with a
sharper gradient
• May indicate a shift from never being treated to
discontinuing treatment even though illness
continued
30. Summary Results – Untreated morbidity
Untreated Morbidity
• 1986-87 (pre-reform benchmark, 42nd round)
– Significant class gradient and gender differences in untreated
morbidity – women and the poor worse off; gender gap mainly at
the bottom (rationing?)
• 1995-96 (52nd round)
– The class gradient worsened for all groups
– Some improvement in rates for poorest women (not sure why) ,
but sharp worsening for poorest men – perverse catch up?
– Gender gap tended to close at the bottom
• 2004 (60th round)
▫ Not much change but some worsening of the gradient for rural
men – gender gap almost closed – perverse catch up at the
bottom?
31. Insights from Koppal on untreated
morbidity
• Traditional analysis too simplistic and may
actually mask what is actually going on, not only
in terms of gender, but even in terms of class
• Apparent class results may actually be
gendered results
32. 2. Method:
Illustration of hypotheses testing
• Illustrative evidence from cross-sectional household
health survey in Koppal district
– 60 villages, 1920 households, 12,328 individuals
– Health seeking and expenditures during pregnancy,
for short- and long-term illness
• Illustration of intersectional analysis for long-term illness:
non-treatment and discontinued treatment
33. Non-treatment of long-term ailments
Likelihood of non-treatment of long-term ailments:
Differences by gender and economic class
6.00
5.00
4.00
Odds ratios
3.00
2.00
Poorest Poor Non-poor Poor men Non-poor Poorest
1.00
w omen w omen w omen men men
■ p < 0.05 □ p > 0.05 □ Reference group
34. Discontinued treatment for long-term ailments
Likelihood of discontinued treatment for long-term ailments:
Differences by gender & economic class
1.75
1.50
Odds ratios
1.25 Non-poor Poor
w omen men
1.00
Poorest Poorest Poor Non-poor
w omen men w omen men
■ p < 0.05 □ p > 0.05 □ Reference group
35. Continued treatment for long-term ailments
Likelihood of continued treatment for long-term ailments:
Differences by gender & economic class
Poorest Poor Poorest Non-poor
w omen w omen men w omen
1.00
0.90 Non-poor Poor
men men
0.80
Odds ratios
0.70
0.60
0.50
0.40 ■ p < 0.05 □ p > 0.05 □ Reference group
36.
37. Distribution of reasons for non-treatment: Rural India
100
80
Percentage
60
40
20
0
Male (1995-96) Female (1995-96) Male (2004) Female (2004)
Rural
Medical facility unavailable Financial barriers Illness not "serious" Other reasons
38. Distribution of reasons for non-treatment: Rural India
100 100
80 80
60 60
40 40
20 20
0 0
Q1 Q2 Q3 Q4 Q5 Q1 Q2 Q3 Q4 Q5
Male (1995-96) Female (1995-96)
Financial barriers Illness not "serious" Other reasons Financial barriers Illness not "serious" Other reasons
100 100
80 80
60 60
40 40
20 20
0 0
Q1 Q2 Q3 Q4 Q5 Q1 Q2 Q3 Q4 Q5
Male (2004) Female (2004)
39. Distribution of reasons for non-treatment: Urban India
100
80
Percentage
60
40
20
0
Male (1995-96) Female (1995-96) Male (2004) Female (2004)
Urban
Medical facility unavailable Financial reasons Illness not "serious" Other reasons
40. Distribution of reasons for non-treatment: Urban India
100 100
80 80
60 60
40 40
20 20
0 0
Q1 Q2 Q3 Q4 Q5 Q1 Q2 Q3 Q4 Q5
Male (1995-96) Female (1995-96)
Financial barriers Illness not "serious" Other reasons Financial barriers Illness not "serious" Other reasons
100 100
80 80
60 60
40 40
20 20
0 0
Q1 Q2 Q3 Q4 Q5 Q1 Q2 Q3 Q4 Q5
Male (2004) Female (2004)
41. Summary results – reasons for non-
treatment
• 1995-96 (52nd round)
– Gender difference – men more likely to
say ‘financial reasons’ than ‘illness not
serious’
–Significant class gradient in all groups
• 2004 (60th round)
▫ Even worse at the bottom in terms of
financial reasons; 40% of women in
quintile 1 (rural), and almost similar for
men
▫ Yes; health care costs have increased for
everyone but more damaging for the poor
47. Summary results – public-private mix
1986-87
• Private-public mix
–70% of outpatient (OP)care was in the
private sector (private doctors), but
–60% of inpatient (IP)care was in the public
sector (largely public hospitals) – both
rural and urban
• Cost of care
–Private : public cost of care practically
equal in OP, but a little over double for IP
48.
49. Hospitalised patients in public hospitals - Rural
Class Distribution: 1986-87, 1995-96, 2004
40.0
30.0
y = 2.8802x + 2.7649
20.0 y = -0.6619x + 16.933 y = 1.1377x + 9.7351
10.0
0.0
00 to 10 10 to 20 20 to 40 40 to 60 60 to 80 80 to 90 90 to 100
MPCE Fractiles
1986-87 1995-96 2004
Linear (1995-96) Linear (1986-87) Linear (2004)
50. Hospitalised patients in private hospitals - Rural
Class Distribution: 1986-87, 1995-96, 2004
40.0
30.0 y = 5.2561x - 6.7386
20.0 y = 3.4704x + 0.4043
y = 0.8385x + 10.932
10.0
0.0
00 to 10 10 to 20 20 to 40 40 to 60 60 to 80 80 to 90 90 to 100
MPCE Fractiles
1986-87 1995-96 2004
Linear (1995-96) Linear (1986-87) Linear (2004)
51. Hospitalised patients in public hospitals - Urban
Class Distribution: 1986-87, 1995-96, 2004
40.0
30.0
y = -1.511x + 20.33
20.0 y = 0.3122x + 13.037
10.0 y = -1.421x + 19.97
0.0
00 to 10 10 to 20 20 to 40 40 to 60 60 to 80 80 to 90 90 to 100
MPCE Fractiles
1986-87 1995-96 2004
Linear (1995-96) Linear (1986-87) Linear (2004)
52. Hospitalised patients in private hospitals - Urban
Class Distribution: 1986-87, 1995-96, 2004
40.0
30.0
y = 3.5131x + 0.2334
20.0
y = 0.2487x + 13.291
10.0 y = 1.7397x + 7.3269
0.0
00 to 10 10 to 20 20 to 40 40 to 60 60 to 80 80 to 90 90 to 100
MPCE Fractiles
1986-87 1995-96 2004
Linear (1995-96) Linear (1986-87) Linear (2004)
53. Summary results – hospital use
Service utilization
• 1986-87 (pre-reform benchmark, 42nd round)
– No major class gradient in overall hospital use for
inpatient (IP) care – both rural and urban
• 1995-96 (52nd round)
– Distribution of hospital use tilts sharply towards the
upper end
– Those at the top use not only more of the private
hospitals but also of the public hospitals
• 2004 (60th round)
▫ Some flattening of the slope of the distribution but still
significant (except for public urban hospitals)
54.
55. Expenditure on inpatient care: All India
12000
10000
8000
1986-87
6000 1995-96
2004
4000
2000
0
Public Private 12000
Rural
10000
8000
1986-87
1995-96 6000
2004
4000
2000
0
Public Private
Urban
56. Average medical expenditures on hospitalisation at
constant (1986-87) prices
3500
3000
2500
2000 1986-87
1995-96
1500 2004
1000
500
0
Public Private 3500
Rural 3000
2500
1986-87 2000
1995-96
2004 1500
1000
Source: Selvaraj and Karan
(2009) 500
0
Public Private
Urban
57. Summary results of the comparison
• Overall, reporting on illness, extent of non-
treatment and discontinued treatment went up
sharply
• Serious increases in the costs of care, and in
financial reasons for non-treatment (related
largely to drug prices but also possibly to user
charges?)
• Micro level in-depth studies on reasons for
households falling into poverty (e.g. Anirudh
Krishna) show that health expenditures are a
major reason (among the top 3)
58. Summary results of the comparison
• Class gradients sharply worse in the mid-1990s with
some moderation in 2004 but still sharp
• Gender gaps persist but moderated in some
instances – perverse catch up by poorest men in
terms of non-treatment and financial reasons for it
• Hospital use for care – the better off are more likely
to go to private hospitals for inpatient care but they
use more of both private AND public hospitals
(some reversal in urban public hospitals in 2004)
• The poorest still depend on public hospitals (>55%
of use) even in 2004 even though they cater more to
the rich
59. Recent policy trends
The only game in policy town is the
National Rural Health Mission:
Many pluses – increasing health budget,
focus on maternal mortality, strong
leadership and management inputs, good
technical backstopping, openness to civil
society and to third party review
What about health inequality, overall
access to the poor, and health costs? Drug
prices?
60. Conclusions
• Health inequalities have both over time and
cross sectional dimensions – both gender and
class
• Period of economic reforms has sharply
worsened access, use and cost of care to the
poor
• Non-treatment and discontinuation have gone
up
61. Conclusions
• Gender differences are important but poorest men
appear to be catching up with poorest women in
perverse ways
• Caveat: what about caste?
• However, our Koppal work raises larger
methodological issues about how to analyse the
intersections between different dimensions of
inequality
• Simplistic class and gender analysis not enough –
may mask or even distort our analysis of what is
happening
62. Closing words
• Studying inequality is not just about
methodology but also politics…
• Additional insights from Koppal about
intersectionality - Not just the extremes but what
is happening to the groups in the middle – those
who may be advantaged on one dimension and
disadvantaged on others?
63. Closing words
• Nuanced, unprejudiced and open analysis is the
best tribute we can pay to Krishna Raj’s
extraordinary work and life…
• Thank you.
