India’s low spending on public healthcare systems and focus on supporting private healthcare has led to serious inequalities in access to healthcare, especially during the Covid 19 pandemic, according to a new study.
The Oxfam report — ‘Inequality Report 2021: India’s Unequal Healthcare Story’ — released on Tuesday says that states attempting to reduce existing inequalities and with higher expenditure on health had lower confirmed cases of Covid-19.
“There are two facets to what we have found. First is states that have for the past few years been reducing inequalities, such as inequalities to access to health between the general category and SC and ST populations, have less confirmed cases of Covid – such as Telangana, Himachal Pradesh and Rajasthan. On the other hand, states that have had higher GDP expenditure on health, such as Assam, Bihar and Goa, have higher recovery rates of Covid cases,’’ said Apoorva Mahendra, researcher at Oxfam India and one of the authors of the report.
The report marks Kerala as a success story in handling the pandemic.
“Kerala invested in infrastructure to create a multi-layered health system, designed to provide first-contact access for basic services at the community level and expanded primary healthcare coverage to achieve access to a range of preventive and curative services…expanded the number of medical facilities, hospital beds and doctors…” it noted.
The report stated that those in higher income brackets, and with access to health infrastructure, had to face less visits to hospitals and Covid centres than those belonging to lower-income groups. People belonging to lower-income groups also faced five times more discrimination on being found Covid-positive than those in higher-income groups, it reported.
Over 50 per cent of people from SC and ST communities faced difficulties in accessing non-Covid medical facilities, compared to 18.2 per cent of people in the ‘general’ category.
The report points out that the vaccination drive against Covid-19 ignores the country’s digital divide — entering the pandemic, only 15 per cent rural households had an internet connection; smartphone users in rural India were almost half of those in urban areas. More than 60 per cent of women across 12 states had never used the internet, it reported.
“Our analysis finds that existing socioeconomic inequalities precipitate inequalities in the health system in India,” Amitabh Behar, CEO, Oxfam India, said. “Thus, (people in) the general category performs better than the Scheduled Castes (SCs) and Scheduled Tribes (STs); Hindus perform better than Muslims; the rich perform better than the poor; men are better off than women; and the urban population is better off than the rural population on various health indicators.”
Behar said that while India has made strides in healthcare provisioning, this has been more in support of private healthcare — and not public — leaving the underprivileged at a great disadvantage.
The average medical expenditure per hospitalisation case has tripled between 2004 and 2017, making it difficult for poorer and rural households, it said. The report noted that one rupee in every Rs 6 spent on hospitalisation came through borrowing; while urban households depended on savings, rural households depended on loans. This need to borrow further discourages the marginalised from accessing health care, it stated. Less than one-third of households in the country were covered by a government insurance scheme in 2015-16, it said.
The report said: “India’s low spending on public healthcare has left the poor and marginalised with two difficult options: suboptimal and weak public healthcare or expensive private healthcare. In fact, the out-of-pocket health expenditure of 64.2 percent in India is higher than the world average of 18.2 percent. Exorbitant prices of healthcare has forced many to sell household assets and incur debts. Though asset selling has reduced to a certain extent, over 63 million people are pushed to poverty every year due to health costs alone, according to government estimates.”
Other socioeconomic factors also lend to access to health, which has affected the outcome of the pandemic, it reported. For instance, the literacy rate for women in the general category is 18.6 per cent higher than SC women, and 27.9 percent higher than ST women, which means women in the general category not only have a better understanding of the health infrastructure available but also have better access.
Female literacy rate is highest amongst Sikhs and Christians at over 80 per cent, followed by Hindus at 68.3 per cent, and Muslims at 64.3 per cent, the report said.
Despite improvement in child immunisation, the rate of immunisation of girls continues to be below that of the male child; immunisation of children in urban areas is more than those in rural areas; and immunization of SCs and STs is behind that of other caste groups, the study found. The child immunisation of the high-wealth quintile group is much higher than that of low-wealth quintile. More than 50 percent of children still do not receive food supplements in the country, it reported.
Percentage of mothers who have received full antenatal care declined from 37 percent in 2005-06 to 21 percent in 2015-16, it found. Full antenatal care for urban areas is close to two times that of rural areas, and immunisation among Muslims the lowest — lower than the SC/ST populations.
“These existing inequities are exacerbated further during a health crisis like the pandemic,” Mahendra said. “The investment in public health infrastructure is so little that the number of beds in the country has actually come down — from 9 beds per 10,000 persons in the 2010 Human Development Report, to only 5 beds per 10,000 persons today.”
The National Health Profile in 2017 recorded one government allopathic doctor for every 10,189 people and one state-run hospital for every 90,343 people. India also ranks the lowest in the number of hospital beds per thousand population among the BRICS nations at 0.5 — it is lower than lesser developed countries such as Bangladesh (0.87), Chile (2.11) and Mexico (0.98).
Rural India houses 70 percent of the population, while it has 40 percent of hospital beds, the report said.
The poor provisioning of public healthcare can be attributed to consistently low budget allocations, Mahendra noted.