Addressing Disparities and Ensuring Equity : Healthcare in India

World Health Day, observed annually on April 7, brings global attention to health equity, a vital issue at the core of health and justice worldwide. On this day, the World Health Organization (WHO) reaffirms the principle that health is a fundamental human right, under this year’s theme, “My Health, My Right”. The COVID-19 pandemic, alongside environmental crises and widening socioeconomic disparities, has spotlighted the critical gaps in health care access. Despite over 140 countries recognizing health as a constitutional right, the WHO Council on the Economics of Health for All reveals a startling reality: more than half of the global population lacks full access to essential health services.

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As World Health Day 2024 passes, the push for health equity offers a beacon of hope for millions, transcending beyond the realms of social justice and legislative reforms. The United Nations’ definition of inclusive health care asserts that “everyone, everywhere should have access to the health services they need without the risk of financial hardship.” This vision aligns with the Sustainable Development Goal 3.8, which aims to “achieve universal health coverage, including financial risk protection, access to quality essential healthcare services, and access to safe, effective, quality, and affordable essential medicines and vaccines for all.” This goal is particularly poignant in the context of India, where the quest for inclusive health care is both urgent and complex, given the country’s vast disparities in health access and outcomes.

Essentials of Inclusive Healthcare

Foundation in Inclusion

Inclusive healthcare is not a one-size-fits-all solution but requires a culture deeply embedded within every healthcare organization. This means cultivating an environment where not only physicians but all personnel who interact with patients are sensitive to and knowledgeable about the barriers that individuals might face. Regular training is essential to ensure that healthcare staff are facilitators, not obstacles, to patient care. From the very first patient interaction, the aim should be to foster a sustainable and inclusive atmosphere—a continuous commitment rather than a one-time checklist.

Designing Welcoming Spaces

Inclusive healthcare also involves creating environments that are accessible to everyone, regardless of their physical abilities. This extends to providing patient materials in the languages spoken by the community and ensuring that the layout and amenities of healthcare facilities are accommodating to all. Moreover, the diversity of the staff should mirror that of the patient population, facilitating a more empathetic and understanding healthcare experience.

Accessibility of Materials

Beyond the physical environment, inclusive healthcare ensures that all patient-facing materials are accessible to everyone. This includes offering documents in large print, multiple languages, and formats that are inclusive of all genders and sexual orientations, as well as being culturally sensitive. The goal is to remove any barriers to understanding and utilizing healthcare information effectively.

Emphasizing Patient Involvement

A truly inclusive healthcare system actively involves patients in their own care decisions and considers their unique circumstances and concerns. Providers should strive to engage with patients at their level of understanding, taking into account their educational background, socioeconomic status, and personal access to resources. This approach respects and values each patient as a partner in their health journey, ensuring their needs and preferences are integral to the care process.

Defining Health Equity

Equal Opportunity for All

Health equity is committed to ensuring every person has an equal opportunity to reach their highest health potential, regardless of their background. It acknowledges that health outcomes are significantly influenced by social, economic, and environmental factors, extending beyond mere genetic predispositions. The World Health Organization (WHO) is at the forefront, aiming to eradicate unfair and preventable differences in health across various social and economic groups.

Addressing Fundamental Causes

True health equity involves tackling the underlying causes of health disparities, such as poverty, discrimination, and inadequate access to essentials like high-quality education, nutritious food, clean water, and safe housing. Health equity does not simply provide equal access to healthcare services; it seeks to resolve the foundational issues that lead to health inequalities. These disparities are often exacerbated by global challenges such as pandemics, climate change, and political instability, making this issue particularly resonant in India, a country marked by vast socioeconomic divides.

Comprehensive Approach

Achieving health equity requires a holistic strategy that transcends policy changes to confront the socio-economic determinants of health directly. Ensuring every individual can live a healthy life demands concerted efforts from governments, communities, and individuals to dismantle these barriers and foster environments that promote health for all. This approach aims to empower every citizen, particularly those from marginalized communities, to achieve optimal health through collective and targeted actions.

Challenges to Achieving Health Equity

Global Challenges Impacting Health Equity

• Risks Posed by Pandemics: Global health equity is severely tested by pandemics which often hit marginalized and vulnerable populations hardest, as evidenced by the COVID-19 crisis. These events exacerbate existing health disparities and demand a coordinated international response.
• Climate Change Concerns: Climate change is a significant health risk that disproportionately affects low-income and vulnerable groups. It complicates health care delivery, especially in conflict zones where infrastructure is destroyed, communities are displaced, and access to essential services is cut off.

India-Specific Challenges to Health Equity

• Large and Diverse Population: India’s vast and diverse population presents unique challenges in health equity, with significant disparities in health care outcomes and access. While there have been improvements in health care access, rural areas remain significantly underserved.
• Urban Slums and Health Disparities: Over 17% of India’s urban population lives in slums as per the 2011 Census, facing heightened health risks due to overcrowding, poor sanitation, and limited clean water. Infectious diseases are notably more prevalent in these areas.
• Caste and Gender Disparities: Data from the National Family Health Survey (NFHS)-5 highlights profound health disparities across caste and gender lines, with higher child mortality and lower immunisation rates among Scheduled Castes and Tribes, and high rates of anaemia among women in the lowest wealth quintiles.
• Burden of Non-Communicable Diseases: Non-communicable diseases (NCDs) are responsible for over 60% of all deaths in India. The economic impact of NCDs is projected to exceed USD 6 trillion by 2030, underlining the urgent need for equitable access to treatment and preventive care.
• Critical Shortage of Healthcare Professionals: According to WHO, India has only 0.8 doctors per 1,000 people, well below the recommended ratio, with a severe shortage in rural areas where over 75% of healthcare professionals are based in metropolitan regions.
• Lack of Financial Protection: Despite various government schemes aimed at reducing healthcare costs, out-of-pocket expenditure remains high, especially in urban settings. The NFHS-5 report reveals substantial regional disparities in healthcare expenses and accessibility, highlighting the need for more robust financial protection mechanisms.

Strategies for Achieving Health Equity

Comprehensive Approach Beyond Healthcare Facilities

Addressing India’s health equity challenges necessitates a holistic approach that extends beyond mere improvements in healthcare facilities. Collaboration among the government, civil society, healthcare providers, and communities is crucial to move towards universal health coverage and a more equitable future. Integrating health education into initiatives like the National Health Mission (NHM) can empower individuals to make informed healthcare decisions, fostering a shared community-driven goal towards health equality.

Necessitating Government Intervention

Government intervention plays a pivotal role in shaping the state of healthcare through funding, policies, and legislation. Initiatives like Ayushman Bharat, which provides free health coverage to economically disadvantaged groups, demonstrate a commitment to reducing health disparities. Programs under the National Rural Health Mission (NRHM) and the National Urban Health Mission (NUHM) bridge the healthcare gap between rural and urban India by expanding access and strengthening infrastructure.

Public and Private Sector Collaboration

Collaboration between the public and private healthcare sectors is essential for reaching underprivileged communities. Emphasis on preventive education, workforce development, and infrastructure enhancement can significantly impact health outcomes. Non-governmental organizations (NGOs) and civic societies, in partnership with international and governmental organizations, address regional health concerns through community outreach and culturally sensitive initiatives.

Reliance on International Institutions

International institutions provide vital financial and technical resources to support healthcare systems in developing countries like India. Organizations such as WHO, the Global Fund for AIDS, Tuberculosis, and Malaria, and Gavi-Global Vaccine Alliance bolster health initiatives and promote information sharing to enhance healthcare systems and access to essential medicines and technologies.

Promoting Innovation and Technical Growth

Innovation and technical growth, particularly in digital health, drive accessibility and affordability in healthcare. Research institutes and academic institutions contribute valuable insights into health inequalities and intervention efficacy, supporting evidence-based practices and policies. Technological advancements, including Precision Medicine, Artificial Intelligence, Wearable Devices, and Robotics, enhance diagnostics, treatments, and patient care.

Following Organizations with Strong Local Presence

Organizations with strong local presence actively engage in health equity efforts, ensuring relevance and effectiveness of health programs. Their intimate understanding of community needs enables them to participate comprehensively from planning to evaluation, promoting community empowerment and capacity building.

Adopting Shared Approach and Open Communications

Successful collaborations for health equity rely on open communication, mutual respect, and shared goals. Adaptability to shifting health concerns and community demands strengthens partnerships and empowers communities. Effective communication across sectors enhances health equity, making access to high-quality healthcare a shared reality.

Increasing Allocation as Percentage of GDP

Increasing public health expenditure as a percentage of GDP is essential for addressing health equity. Recommendations to raise public health expenditure to 2.5% of GDP by 2025 aim to improve healthcare accessibility and coverage. Bridging the gap in health insurance coverage, particularly for the “missing middle” population segment, is crucial for ensuring equitable access to healthcare services.

Initiatives for the Healthcare Sector

• National Health Mission: A flagship initiative aiming to provide accessible, affordable, and quality healthcare to all citizens, particularly focusing on maternal and child health, infectious diseases, and non-communicable diseases.
• Ayushman Bharat: Launched with the vision of achieving Universal Health Coverage, Ayushman Bharat encompasses two major initiatives: Health and Wellness Centers to provide comprehensive primary healthcare, and the Pradhan Mantri Jan Arogya Yojana (AB-PMJAY), offering health insurance coverage to economically vulnerable families for secondary and tertiary care.
• Pradhan Mantri Jan Arogya Yojana (AB-PMJAY): Aims to provide financial protection against catastrophic health expenditures, offering cashless coverage of up to ₹5 lakhs per family per year for secondary and tertiary hospitalization expenses to over 500 million beneficiaries.
• National Medical Commission: Established to overhaul the medical education system in India, ensuring quality and accessibility while promoting equitable distribution of healthcare professionals across urban and rural areas.
• PM National Dialysis Programme: Aims to provide affordable and accessible dialysis services to all citizens suffering from kidney ailments, especially those from economically disadvantaged backgrounds.
• Janani Shishu Suraksha Karyakram (JSSK): Seeks to ensure free maternal and child healthcare services to pregnant women and newborns, including free drugs, diagnostics, and transport.
• Rashtriya Bal Swasthya Karyakram (RBSK): A comprehensive child health program that aims to screen children for birth defects, diseases, deficiencies, and disabilities, and provide early intervention and treatment services.

Case Studies: Success Stories in India

Several regions and initiatives across India exemplify excellence in promoting inclusive healthcare, highlighting successful models that have significantly improved access and outcomes for diverse populations.

1. Kerala’s Community Health Programs
   • Overview: Community-driven health programs focusing on accessibility and preventive care.
   • Impact: Improved health indicators such as lower infant mortality rates and better overall health outcomes.
2. Rajasthan’s Bhamashah Health Insurance Scheme
   • Overview: Provides cashless health services to low-income families, with a special focus on women.
   • Impact: Increased use of medical services among enrolled families, particularly in rural areas.

Conclusion

Inclusive Health Care in India is not just a policy initiative but a fundamental right that ensures the well-being of every citizen. While challenges persist, the path forward involves a strategic blend of policy reform, community engagement, and technological innovation. As India continues to make strides in this direction, the vision of a truly inclusive health care system seems increasingly attainable, promising a healthier future for all.