1. HEALTH EQUITY: THE INDIAN CONTEXT Subodh S Gupta

2. Health Indicators among selected countries CountryIMR (per 1000 LB)MMR (per 100,000 LB Female Life Expectancy (yrs) India5825966.9 China325674.2 Japan31086.1 Republic of Korea32081.5 Indonesia3623069.9 Malaysia94176.2 Vietnam2713073.5 Bangladesh5238065.1 Nepal5874063.4 Sri Lanka159277.5

3. National averages often mask substantially worse outcomes for many disadvantaged groups of population

4. Infant Mortality Rate according to wealth quintiles

5. Infant Mortality Rate in different states according to wealth quintiles

6. U5 Mortality Rate in different states according to wealth quintiles

7. Framework for identifying pathways leading to health inequities

8. Introduction  The political economy context  The organisational structure and delivery mechanism  Health financing mechanisms  Coverage patterns  Current status of health and health care

9. Per Capita Gross Domestic Product (PPP)

10. Percent population below poverty line (GOI data)

11. The Political Economy Context  Second most populous country  A democratic federal structure; subdivided into states and Uts; further into districts  Local levels of governance (Panchayat Raj)  Health – a state subject

12. Alapuzzha in Kerala Vs. Kishanganj in Bihar

13. Characteristics of Indian Health System  Complex mixed health system - Tax based health finance system with small health insurance sector - Publicly financed government health system - Fee-levying private health sector

14. Health Expenditure in India

15. Sources of Health Care Financing in Different Countries

16. Financial Protection in Health  Individuals should be able to access health care when they need it and not be prevented from doing so by excessive cost.  When they do access health care, they should not incur costs that prevent them from obtaining other basic household necessities such as food, education and shelter.

17. Catastrophic Health Expenditure  If health expenditures exceed a certain percentage of household income or capacity to pay, and therefore drive a household into poverty or prevent a household from buying other essential items including food and education.  Twelve percent of households have catastrophic health expenditure.  About a third of poor households have catastrophic health expenditure.  Impoverishment due to catastrophic health expenditure is higher (about half) among middle economic status households.

18. Percent of Households Compromising or Postponing Consumption Decisions after Seeking Inpatient Care (3 Districts, West Bengal)

19. Relative Share of Sources of Financing to Pay for Inpatient Care (3 Districts, West Bengal)

20. Percent of Rural Persons with an Illness who could not Seek Treatment due to Financial Constraints, by Economic Quintile (3 districts, West Bengal)

21. Effect of Economic Reforms on Public Health  Increasing unregulated privatisation with little accountability to patients  Systematic deregulation of drug prices resulting in skyrocketing prices of drugs  Selective intervention approach instead comprehensive primary health care

22. Health Inequity in outcomes  Rural/ Urban/ Urban (slum)  Inter/ Intra state  Socio-economic status  Gender  Caste  Religion

23. Coverage with health services according to wealth quintile

24. U5 Mortality Rate in different states according to wealth quintiles

25. Underweight by Wealth Quintiles Percent

26. Undernutrition in Children under Age 5 INDIA Percent Poor nutrition contributes to 54% of deaths under age 5

27. Trend data provides strong evidence of declines in the sex ratio of the population age 0-6 and the sex ratio at birth…. …females are under-represented among births and over- represented among births that die.

28. After the first month of life, girls are more likely to die than boys: The child mortality rate is 61% higher for girls than for boys.

29. The three different levels of government action  First Level: The Macro Level The level of the government's national budget. Here, the major concern will be the amount of resources allocated to health, but an important secondary concern will be the possible reallocations of budgets to reach poor people better.  Second Level: The Health System Level Here, the concern will be to put together reforms and improve incentives to get the system to function better for poor people.  Third Level: The Micro Level The service delivery level, where the focus will be on how to implement specific activities to reach poor people. Work at these three levels is interdependent

30. Health Financing  Pricing policies that reduce and/or eliminate user fees for basic services;  Cross-subsidization of health services that benefit the poor;  Strengthening exemption mechanisms services;  Expanding social insurance to cover informal sector workers;  Developing community-financing arrangements;  Developing equity funds to pay for the poor

31. Thank you Achieving health equity within a generation is possible. It is the right thing to do, and now is the right time to do it. - Commission on Social Determinants of Health