William Joe

Socio-economic inequalities in child health: Recent evidence from India

Abstract This paper analyses the Indian National Family Health Survey (2005–2006) data to present certain broad descriptive features of child health inequalities in India and their distribution across well-defined socio-economic groups classified by gender and sector-of-origin, and their dispersal across space. This study finds that poorer sections of the population are beleaguered with ill health whether in the quest for child survival or due to anxieties pertaining to child nutrition. The concentration index value for the indicators of under-five mortality, full immunisation and underweight outcomes at the national level is calculated to be −0.159, 0.204 and −0.158, respectively. The other disturbing finding here is that there are reigning regional and gender disadvantages irrespective of the developmental status of the State. This study would not only help policymakers to recognise these persistent inequalities but also would help understand health performance at the state and regional levels thus facilitating targeting intervention.

Inequalities in Childhood Malnutrition in India: Some Evidence on Group Disparities

Abstract This paper examines inequalities in child malnutrition in India through three distinct — although inter‐related — types of empirical analysis. First, it reports the socio‐economic inequalities in childhood malnutrition across different Indian states. Second, it decomposes the gap in malnutrition between children belonging to poor and non‐poor households to understand the disadvantageous distribution of health determinants and their effects. This analysis indicates that the distribution of endowments and positive maternal characteristics are significant in widening the gap between the child malnutrition among poor and non‐poor households. Third, it examines the inter‐group disparities in child malnutrition and notes that child groups privileged in terms of income, mother’s nutritional status and education have lower malnutrition, whereas the group adverse in all three characteristics endures the most. The paper concludes that policies to reduce malnutrition inequalities should recognize that endowment revisions can be more effective if appended with behavioural interventions.

Distressed financing of household out-of-pocket health care payments in India: incidence and correlates

Out-of-pocket (OOP) health care payments financed through borrowings or sale of household assets are referred to as distressed health care financing. This article expands this concept (to include contributions from friends or relatives) and examines the incidence and correlates of distressed health care financing in India. The analysis finds a decisive influence of distressed financing in India as over 60 and 40% of hospitalization cases from rural and urban areas, respectively, report use of such coping strategies. Altogether, sources such as borrowings, sale of household assets and contributions from friends and relatives account for 58 and 42% share in total OOP payments for inpatient care in rural and urban India, respectively. Further, the results show significant socioeconomic gradient in the distribution of distressed financing with huge disadvantages for marginalized sections, particularly females, elderly and backward social groups. Multivariate logistic regression informs that households are at an elevated risk of indebtedness while seeking treatment for non-communicable diseases, particularly cancer. Evidence based on intersectional framework reveals that, despite similar socioeconomic background, males are more likely to use borrowings for health care financing than females. In conclusion, the need for social protection policies and improved health care coverage is emphasized to curtail the incidence of distressed health care financing in India.

Intersectional inequalities in immunization in India, 1992–93 to 2005–06: a progress assessment

Immunization in India is marked with stark disparities across gender, caste, wealth and place of residence with severe shortfalls among those disadvantaged in more than one dimension. In this regard, an explicit recognition of intersectionality and intersectional inequalities has 2-fold relevance; one, being the pathway of health inequality and the other being its role as a deterrent of progress particularly at higher (better) levels of health. Against this backdrop, this study examines intersectional inequalities in immunization in India and also suggests a level-sensitive progress assessment method. The study uses group analogue of Gini coefficient for highlighting the magnitude of intersectional inequality and for comprehending its association with immunization level. The results unravel the plight of vulnerable intersectional groups and draw attention to disquieting shortfalls among female SCST (scheduled castes and tribes) children from rural areas. There is also some evidence to indicate leveraging among rural males in matters of immunization and it is further discerned that such gender advantage is greater among rural non-SCST community than the rural SCST group. In concluding, the study calls for intensive immunization planning to improve coverage among vulnerable communities in both rural and urban areas.

Refining estimates of catastrophic healthcare expenditure: an application in the Indian context

Empirics of catastrophic healthcare expenditure, especially in the Indian context, are often based on consumption expenditure data that inadequately informs about the ability to pay. Use of such data can generate a pro-rich bias in the estimation of catastrophic expenditure thereby suggesting greater concentration of such expenditures among richer households. To improve upon the existing approach, this paper suggests a multidimensional approach to comprehend the incidence of catastrophic expenditure. Here, we integrate the information on health expenditure with other social and economic parameters of deprivation. An empirical illustration is provided by using nationally representative survey on morbidity and healthcare in India. The results of the multidimensional approach are consistent with the theoretical underpinnings of the ability-to-pay approach and emphasizes on the severity of the problem in rural areas. The suggested methodology is flexible and allows for context-specific prioritization in selection of parameters of vulnerability while estimating the incidence of catastrophic expenditures.

Utilization of alternative systems of medicine as health care services in India: Evidence on AYUSH care from NSS 2014

AYUSH, an acronym for Ayurveda, Yoga and Naturopathy, Unani, Siddha, Sowa-Rigpa and Homeopathy represents the alternative systems of medicine recognized by the Government of India. Understanding the patterns of utilization of AYUSH care has been important for various reasons including an increased focus on its mainstreaming and integration with biomedicine-based health care system. Based on a nationally representative health survey 2014, we present an analysis to understand utilization of AYUSH care across socioeconomic and demographic groups in India. Overall, 6.9% of all patients seeking outpatient care in the reference period of last two weeks have used AYUSH services without any significant differentials across rural and urban India. Importantly, public health facilities play a key role in provisioning of AYUSH care in rural areas with higher utilization in Chhattisgarh, Kerala and West Bengal. Use of AYUSH among middle-income households is lower when compared with poorer and richer households. We also find that low-income households display a greater tendency for AYUSH self-medication. AYUSH care utilization is higher among patients with chronic diseases and also for treating skin-related and musculo-skeletal ailments. Although the overall share of AYUSH prescription drugs in total medical expenditure is only about 6% but the average expenditure for drugs on AYUSH and allopathy did not differ hugely. The discussion compares our estimates and findings with other studies and also highlights major policy issues around mainstreaming of AYUSH care.

Horizontal Inequity in Elderly Health Care Utilization: Evidence from India.

Against the backdrop of population aging, this paper presents the analysis of need-standardised health care utilization among elderly in India. Based on nationally representative morbidity and health care survey 2004, we demonstrate that the need for health care utilization is indeed pro-poor in nature. However, the actual health care utilization is concentrated among richer sections of the population. Further, the decomposition analysis reveals that income has a very strong role in shifting the distribution of health care away from the poor elderly. The impact of income on utilization is well-demonstrated even at the ecological-level as states with higher per capita incomes have higher elderly health care utilization even as the levels of need-predicted distribution across these states are similar. We also find that the distribution of elderly across social groups and their educational achievements favours the rich and significantly contributes to overall inequality. Nevertheless, contribution of need-related self-assessed health clearly favours pro-poor inequality. In concluding, we argue that to reduce such inequities in health care utilization it is necessary to increase public investments in health care infrastructure including geriatric care particularly in rural areas and underdeveloped regions to enhance access and quality of health care for the elderly.

Understanding the null-to-small association between increased macroeconomic growth and reducing child undernutrition in India: role of development expenditures and poverty alleviation.

Abstract Empirical evidence suggests that macroeconomic growth in India is not correlated with any substantial reductions in the prevalence of child undernutrition over time. This study investigates the two commonly hypothesized pathways through which macroeconomic growth is expected to reduce child undernutrition: (1) an increase in public developmental expenditure and (2) a reduction in aggregate income‐poverty levels. For the anthropometric data on children, we draw on the data from two cross‐sectional waves of National Family Health Survey conducted in 1992–1993 and 2005–2006, while the data for per capita net state domestic product and per capita public spending on developmental expenditure and headcount ratio of poverty were obtained from the Reserve Bank of India and the Government of India expert committee reports. We find that between 1992–1993 and 2005–2006, state‐level macroeconomic growth was not associated with any substantial increases in public development expenditure or substantial reductions in poverty at the aggregate level. Furthermore, the association between changes in public development expenditure or aggregate poverty and changes in undernutrition was small. In summary, it appears that the inability of macroeconomic growth to translate into reductions in child undernutrition in India is likely a consequence of the macroeconomic growth not translating into substantial investments in development expenditure that could matter for childrens nutritional status and neither did it substantially improve incomes of the poor, a group where undernutrition is also the highest. The findings here build a case to advocate a ‘support‐led’ strategy for reducing undernutrition rather than simply relying on a ‘growth‐mediated’ strategy. Key messages Increases in macroeconomic growth have not been accompanied by substantial increases in public developmental spending or reduction in aggregate poverty headcount ratio in India. Association between increases in public development expenditure or poverty headcount ratios and changes in child undernutrition, in particular, child stunting, is small to null. Reducing the burden of undernutrition in India cannot be accomplished solely relying on a growth‐mediated strategy, and a concerted support‐led strategy is required.

Inter-Group Inequalities in Child Undernutrition in India: Group Analogue of the Gini Coefficient and Atkinson's Index

Studies of undernutrition in India (and elsewhere) have focused exclusively on interpersonal inequalities, and estimates of the magnitude of inter-group inequalities are unavailable. A focus on “horizontal”, or group-based, inequalities offers vital policy insights that would be lost in an approach based purely on interpersonal inequalities. We therefore apply the group analogues of Atkinsons index and the Gini coefficient to shed light on the disproportionate burden of undernourishment borne by rural and historically vulnerable caste groups. Furthermore, the prominent determinants of inter-group disparities are identified through Blinder–Oaxaca decomposition analysis. The paper calls for explicit targeting of backward castes across the country and improved inter-sectoral collaboration to ensure equitable access to education, health care and water and sanitation, particularly across underdeveloped regions.

HIV prevention: Towards a "structural-plus" approach

Lack of integration and coordination between HIV prevention programmes and developmental programmes explain why many countries have not been able to halt the epidemic, and others still have unacceptably high prevalence. A framework is presented here with supporting evidence to argue that existing structural interventions may be unsustainable in the long run because they do not address core developmental issues or the “structural plus factors”. This problem emanates from the almost total administrative and intellectual disconnect between policies that address development issues and those that address HIV prevention. Usual prevention packages may result only in short term benefits. To get the most out of limited global resources on prevention, it is critical that planners recognize and understand that parallel policies for AIDS prevention and development are not going to be cost-effective and sustainable, and the only option is to approach prevention as well as development in an integrated manner.