T.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 LibraryofCongressControlNumber:2017941545 ©SpringerNatureSingaporePteLtd.2018 Thisworkissubjecttocopyright.AllrightsarereservedbythePublisher,whetherthewholeorpart of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission orinformationstorageandretrieval,electronicadaptation,computersoftware,orbysimilarordissimilar methodologynowknownorhereafterdeveloped. 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Theregisteredcompanyaddressis:152BeachRoad,#21-01/04GatewayEast,Singapore189721,Singapore 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