Sakthivel Selvaraj

Health care and equity in India

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 Indias population.

Are self-reports of health and morbidities in developing countries misleading? Evidence from India.

Self-reported measures of poor health and morbidities from developing countries tend to be viewed with considerable skepticism. Examination of the social gradient in self-reported health and morbidity measures provides a useful test of the validity of self-reports of poor health and morbidities. The prevailing view, in part influenced by Amartya Sen, is that socially disadvantaged individuals will fail to perceive and report the presence of illness or health-deficits because an individuals assessment of their health is directly contingent on their social experience. In this study, we tested whether the association between self-reported poor health/morbidities and socioeconomic status (SES) in India follows the expected direction or not. Cross-sectional logistic regression analyses were carried out on a nationally representative population-based sample from the 1998 to 1999 Indian National Family Health Survey (INFHS); and 1995-1996 and 2004 Indian National Sample Survey (INSS). Four binary outcomes were analyzed: any self-reported morbidity; self-reported sickness in the last 15 days; self-reported sickness in the past year; and poor self-rated health. In separate adjusted models, individuals with no education reported higher levels of any self-reported, self-reported sickness in the last 15 days, self-reported sickness in the last year, and poor self-rated health compared to those with most education. Contrary to the prevailing thesis, we find that the use of self-rated ill-health has face validity as assessed via its relationship to SES. A less dismissive and pessimistic view of health data obtained through self-reports seems warranted.

What is the private sector? Understanding private provision in the health systems of low-income and middle-income countries

Private health care in low-income and middle-income countries is very extensive and very heterogeneous, ranging from itinerant medicine sellers, through millions of independent practitioners-both unlicensed and licensed-to corporate hospital chains and large private insurers. Policies for universal health coverage (UHC) must address this complex private sector. However, no agreed measures exist to assess the scale and scope of the private health sector in these countries, and policy makers tasked with managing and regulating mixed health systems struggle to identify the key features of their private sectors. In this report, we propose a set of metrics, drawn from existing data that can form a starting point for policy makers to identify the structure and dynamics of private provision in their particular mixed health systems; that is, to identify the consequences of specific structures, the drivers of change, and levers available to improve efficiency and outcomes. The central message is that private sectors cannot be understood except within their context of mixed health systems since private and public sectors interact. We develop an illustrative and partial country typology, using the metrics and other country information, to illustrate how the scale and operation of the public sector can shape the private sectors structure and behaviour, and vice versa.

Social analysis of sex imbalance in India: before and after the implementation of the Pre-Natal Diagnostic Techniques (PNDT) Act

Background: While the issue of sex imbalance in South Asia is well recognised, less is known about its social patterning. Social patterning in the proportion of sexes was investigated among infants in India before and after the implementation of the Pre-Natal Diagnostic Techniques (PNDT) Act in 1996. The act regulates the misuse of technologies for sex determination of fetuses and subsequent selective abortion. Methods: Multivariable regression analysis was performed on time series data from a nationally representative sample of households with infants. The outcome was log odds of having a male infant. Household income, parental education, social caste, a variable representing periods before and after the implementation of the PNDT Act and state of residence were the main predictors of interest. Results: The odds of having a male infant increased with income quartiles. Heads of household with post-secondary education had a higher odds ratio of having a male infant than those with no formal education. The odds of having a male infant did not differ between high and low caste groups, and was not associated with the educational attainment of the spouse. Punjab had a higher odds ratio of having a male infant compared with Kerala. Kerala, meanwhile, was not particularly different from the remaining Indian states. The odds of having a male infant were similar in the pre- and post-PNDT periods. In the post-PNDT period, the income gradient in the odds of having a male infant was substantially weakened. Conclusion: Social analysis of the distribution of sexes among infants in India suggests that neither improvements in socioeconomic circumstances nor introducing policies that are not aligned with societal norms and preferences are likely to normalise the sex imbalance in India.

Are socioeconomic disparities in tobacco consumption increasing in India? A repeated cross-sectional multilevel analysis

Objectives India bears a significant portion of the global tobacco burden with high prevalence of tobacco use. This study examines the socioeconomic patterning of tobacco use and identifies the changing gender and socioeconomic dynamics in light of the Cigarette Epidemic Model. Design Secondary analyses of second and third National Family Health Survey (NFHS) data. Setting and participants Data were analysed from 201 219 men and 255 028 women over two survey rounds. Outcomes and methods Outcomes included smoking (cigarettes, bidis and pipes/cigar), chewed tobacco (paan masala, gutkha and others) and dual use, examined by education, wealth, living environment and caste. Standardised prevalence and percentage change were estimated. Pooled multilevel models estimated the effect of socioeconomic covariates on the log odds of tobacco use by gender, along with fixed and random parameters. Findings Among men (2005−2006), gradients in smoking by education (illiterates: 44% vs postgraduates: 15%) and chewing (illiterates: 47% vs postgraduates: 19%) were observed. Inverse gradients were also observed by wealth, living environment and caste. Chewed tobacco use by women showed inverse socioeconomic status (SES) gradients comparing the illiterates (7.4%) versus postgraduates (0.33%), and poorest (17%) versus richest (2%) quintiles. However, proportional increases in smoking were higher among more educated (postgraduates (98%) vs high schooling only (17%)) and chewing among richer (richest quintile (49%) vs poorest quintile (35%)). Among women, higher educated showed larger declines for smoking—90% (postgraduates) versus 12% (illiterates). Younger men (15–24 years) showed increasing tobacco use (smoking: 123% and chewing: 112%). Older women (35–49 years) show higher prevalence of smoking (3.2%) compared to younger women (0.3%). Conclusions Indian tobacco use patterns show significant diversions from the Cigarette Epidemic Model—from gender and socioeconomic perspectives. Separate analysis by type is needed to further understand social determinants of tobacco use in India.

Smokeless tobacco control policies in South Asia: a gap analysis and recommendations.

INTRODUCTION Almost a fifth of the worlds tobacco is consumed in smokeless form. Its consumption is particularly common in South Asia, where an increasing array of smokeless tobacco (SLT) products is widely available. Mindful of the growing public health threat from SLT, a group of international academics and policy makers recently gathered to identify policy and knowledge gaps and proposed strategies to address these. METHODS We reviewed key policy documents and interviewed policy makers and representatives of civil society organizations in 4 South Asian countries: Bangladesh, India, Nepal, and Pakistan. We explored if SLT features in existing tobacco control policies and, if so, the extent to which these are implemented and enforced. We also investigated barriers to effective policy formulation and implementation. The findings were presented at an international meeting of experts and were refined in the light of the ensuing discussion in order to inform policy and research recommendations. RESULTS We found that the existing SLT control policies in these 4 South Asian countries were either inadequate or poorly implemented. Taxes were low and easily evaded; regulatory mechanisms, such as licensing and trading standards, either did not exist or were inadequately enforced to regulate the composition and sales of such products; and there was little or no cessation support for those who wanted to quit. CONCLUSIONS Limited progress has been made so far to address the emerging public health threat posed by SLT consumption in South Asia. International and regional cooperation is required to advocate for effective policy and to address knowledge gaps.

Moving to universal coverage? Trends in the burden of out-of-pocket payments for health care across social groups in India, 1999-2000 to 2011-12.

In the background of ongoing health sector reforms in India, the paper investigates the magnitude and trends in out-of-pocket and catastrophic payments for key population sub-groups. Data from three rounds of nationally representative consumer expenditure surveys (1999–2000, 2004–05 and 2011–12) were pooled to assess changes over time in a range of out-of-pocket -related outcome indicators for the poorest 20% households, scheduled caste and tribe households and Muslims households relative to their better-off/majority religion counterparts. Our results suggest that the poorest 20% of households experienced a decline in the proportion reporting any OOP for inpatient care relative to the top 20% and Muslim households saw an increase in the proportion reporting any inpatient OOP relative to non-Muslim households during 2000-2012. The change in the proportion of Muslim households or SC/ST households reporting any OOP for outpatient care was similar to that for their respective more advantaged counterparts; but the poorest 20% of households experienced a faster increase in the proportion reporting any OOP for outpatient care than their top 20% counterparts. SC/ST, Muslim and the poorest 20% of households experienced as faster increase in the share of outpatient OOP in total household spending relative to their advantaged counterparts. We conclude that the financial burden of out of pocket spending increased faster among the disadvantaged groups relative to their more advantaged counterparts. Although the poorest 20% saw a relative decline in OOP spending on inpatient care as a share of household spending, this is likely the result of foregoing inpatient care, than of accessing benefits from the recent expansion of cashless publicly financed insurance schemes for inpatient care. Our results highlight the need to explore the reasons underlying the lack of effectiveness of existing public health financing programs and public sector health services in reaching less-advantaged castes and religious minorities.

Have Socioeconomic Inequalities in Tobacco Use in India Increased Over Time? Trends From the National Sample Surveys (2000-2012).

Introduction: India has experienced marked sociocultural change, economic growth and industry promotion of tobacco products over the past decade. Little is known about the influence of these factors on socioeconomic patterning of tobacco use. This study examines trends in tobacco use by socioeconomic status (SES) in India between 2000 and 2012. Methods: We analyzed data in 2014 from nationally-representative repeated cross-sectional National Sample Surveys (NSS) in India for 1999–2000, 2004–2005 and 2011–2012 (n = 346 612 households). Prevalence and volume trends in cigarette, “bidi” and smokeless tobacco use were examined by household expenditure, educational attainment and caste/tribe status using Two-part model. Results: Prevalence of any tobacco use remained consistent in the poorest households (61.5% to 62.7%) and declined among the richest (43.8% to 36.8%) between 2000–2012. Bidi use declined across all groups (poorest: 26.3% to 16.8%, richest: 19.8% to 10.7%) while cigarette use increased (poorest: 1.2% to 1.3%, richest: 6.5% to 7.0%). Relative to educated and general caste households, between 2000 and 2012 cigarette use in illiterate households increased by 38% and among Scheduled Tribe households increased by 32%. Smokeless tobacco use increased for all households (poorest: 26.2% to 33.9%, richest: 11.4% to 13.5%, Scheduled Tribe: 31.1% to 34.8%, general caste: 13.6% to 18.5%), with greater increases among richer, more educated and general caste households. Conclusion: Marked SES patterning of tobacco use has persisted in India. Improving enforcement of tobacco control policies and monitoring comprehensive smoke-free legislations are needed to address this growing burden. Implications: We found “resilient” tobacco patterns in the last decade despite prevention interventions. SES continues to be inversely associated with tobacco products, with the exception of cigarettes. The declines in bidi use may be getting replaced by increase in cigarette use trends, especially among lower SES groups. The use of smokeless tobacco products has increased across all SES groups and the volume of smokeless tobacco use is not been declining despite a number of policies on tobacco use. This may be attributed to inadequate attention to chewed forms of tobacco in current policies, particularly to implementing pictoral warnings and regulating surrogate advertising. Evaluating the implementation of anti-tobacco policies and ensuring equity dimensions in interventions is urgently needed to address tobacco use inequalities.

Price elasticity of tobacco products among economic classes in India, 2011–2012

Objectives The objectives of this study are to: (1) examine the pattern of price elasticity of three major tobacco products (bidi, cigarette and leaf tobacco) by economic groups of population based on household monthly per capita consumption expenditure in India and (2) assess the effect of tax increases on tobacco consumption and revenue across expenditure groups. Setting Data from the 2011–2012 nationally representative Consumer Expenditure Survey from 101 662 Indian households were used. Participants Households which consumed any tobacco or alcohol product were retained in final models. Primary outcome measures The study draws theoretical frameworks from a model using the augmented utility function of consumer behaviour, with a two-stage two-equation system of unit values and budget shares. Primary outcome measures were price elasticity of demand for different tobacco products for three hierarchical economic groups of population and change in tax revenue due to changes in tax structure. We finally estimated price elasticity of demand for bidi, cigarette and leaf tobacco and effects of changes in their tax rates on demand for these tobacco products and tax revenue. Results Own price elasticities for bidi were highest in the poorest group (−0.4328) and lowest in the richest group (−0.0815). Cigarette own price elasticities were −0.832 in the poorest group and −0.2645 in the richest group. Leaf tobacco elasticities were highest in the poorest (−0.557) and middle (−0.4537) groups. Conclusions Poorer group elasticities were the highest, indicating that poorer consumers are more price responsive. Elasticity estimates show positive distributional effects of uniform bidi and cigarette taxation on the poorest consumers, as their consumption is affected the most due to increases in taxation. Leaf tobacco also displayed moderate elasticities in poor and middle tertiles, suggesting that tax increases may result in a trade-off between consumption decline and revenue generation. A broad spectrum rise in tax rates across all products is critical for tobacco control.

Price Elasticity of Tobacco Products Among Quintile Groups in India, 2009-10

Background: Globally, policy-makers are currently grappling with both economic and non-economic measures to combat tobacco consumption. Among economic measures, advertising/sponsorship ban, alternative cropping and alternative livelihood measures are considered, in addition, to imposing heavy taxes on all tobacco products. However, the price responsiveness of major tobacco products has not been extensively studied empirically in the Indian context, especially by income status of consumers. Objective: The key objective of this study is to examine the pattern of price elasticity of major tobacco products (bidi, cigarette and leaf tobacco) by income quintiles. Methods: The study utilizes data from Consumer Expenditure Survey of households, a nationally representative data collected by the National Sample Survey Organization (NSSO) for the 66th (2009-10) round. The sample size was 100,855 households, of which 50,074 were tobacco using households. The study draws its theoretical framework a model developed by Deaton (1988, 1997) to estimate own and cross price elasticity of three types of tobacco products. The model uses the augmented utility function of consumer behavior, with a two-stage two-equations system of unit values and budget shares. The price elasticity is estimated after correcting for the effect of any measurement error in unit values and budget shares arising due to differences in quality of products. Results: Unit values were highest for both bidis and cigarettes in the richest quintile groups (Rs 0.363 and 2.52, respectively). Highest unit value for leaf tobacco was Rs. 3.27 in the second richest quintile group. Budget share regression coefficients show that an increase in household size will increase the budget share of both bidis and leaf tobacco by 0.001% for both urban and rural areas (p-value Conclusions: Overall, rural elasticities were higher than urban, indicating that rural consumers are more price responsive. Bidis were the most price elastic of all tobacco products, suggesting that increases in bidi prices will deter bidi consumption. Leaf tobacco displayed moderate elasticity, suggesting that increases in tax may result in a tradeoff between consumption decline and government revenue. Elasticities for cigarettes were the least of all products, suggesting that cigarette smokers are more resistant to price changes. However, elasticities by quintile groups indicate high price responsiveness in the wealthier quintiles for cigarettes and bidis, suggesting that increases in prices will also affect their consumption patterns. Overall, while a broad spectrum rise in tax rates across all tobacco products are critical, simplifying tax structure and tax governance must receive utmost importance in the current policy regime against tobacco control.