Inequities in Access to Health Services in India: Caste, Class and Region

Despite India’s impressive economic performance after the introduction of economic reforms in the 1990s, progress in advancing the health status of Indians has been slow and uneven. Large inequities in health and access to health services continue to persist and have even widened across states, between rural and urban areas, and within communities. Three forms of inequities have dominated India’s health sector. Historical inequities that have their roots in the policies and practices of British colonial India, many of which continued to be pursued well after independence; socio-economic inequities manifest in caste, class and gender differentials; and inequities in the availability, utilisation and affordability of health services. Of these, critical to ensuring health for all in the immediate future will be the effectiveness with which India addresses inequities in provisioning of health services and assurance of quality care. India, over the last two decades, has enjoyed accelerated economic growth, but has fared poorly in human development indicators and health outcomes. Population averages of health status indicators, such as child health and maternal mortality, remain unacceptably high compared with countries in the south and east Asian region that have similar income levels and rates of economic growth. Underlying the low population level indicators, worrisome inequities coincide with the multiple axes of caste, class, gender and regional differences (Deaton and Dreze 2009; Claeson et al 2000; Subramanian et al 2006). In India, an important determinant of socio-economic inequities in nearly all spheres of well-being is caste. The official classification defines four categories of caste: scheduled castes (SCs), scheduled tribes (STs), Other Backward Classes (OBCs), and others. The SCs, the lowest level in the hierarchy, constitute around 16% of the Indian population, a large percentage of who live in rural areas and are landless agricultural labourers. The STs, or adivasis, often like SCs, suffer economic and social deprivation. They comprise around 8% of India’s population. OBCs and forward castes together comprise 76% of India’s total population (RGI 2001). Taking the under-five-mortality rate (U5MR), i e, mortality among children younger than five years; as an indicator, we describe inequities in the health status. The National Family Health Survey (NFHS 2005-06) reveals sharp regional and socioeconomic divides in health outcomes, with the lower castes, the poor and the less developed states bearing the burden of mortality disproportionately. High rates of infant mortality and U5MR are, in general, inversely associated with income. These inequities are also accompanied by wide gaps across gender and caste (Gwatkin 2000; Subramanian et al 2006). The risks of mortality before the age of five years are higher in girls than in boys; among SCs, STs OBCs as compared to others; and in the rural areas of Uttar Pradesh (UP), one of the poorest states in India, than urban Kerala. Evidence from urban areas in Kerala and from educated mothers (completing 12 years of education) has shown that low mortality in children younger than five years is, indeed, possible in India. U5MR for the richest income quintile earners is three times lower than that for the poorest quintile (Figure 1, p 50). The Indian average for U5MR decreased from a rate of 101 (per 1,000) to 74 (per 1,000) during the accelerated economic growth from 1998 to 2006. However, this is a period marked by increasing inequities, as shown by a high U5MR among the SCs and STs, when compared with the backward classes and others. This s ocial gap had increased dramatically in the 1990s for the STs, in We would like to thank Sandeep Sharma for data processing and research assistance.