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When Our Health Outcomes Improve, Do They Improve Equally for Everyone?

When Our Health Outcomes Improve, Do They Improve Equally for Everyone?

A woman with breathing problems waits inside an ambulance for her turn to enter a COVID-19 hospital for treatment, Ahmedabad, April 28, 2021. Photo: Reuters/Amit Dave

The financial year 2021-2022 is crucial to build a stronger healthcare system for India. COVID-19 has brought India’s health sector to a standstill, and also widened the digital divide in education, led to huge job losses (especially in the informal sector) and increased women’s burden of unpaid care work.

Inequality is also apparent in the Indian government’s response: citizens abroad were safely flown back to the country during the 2020 lockdown – but migrant workers within the country were left to fend for themselves. Later, when Shramik trains were introduced to help them get home, lack of social distancing and safety protocols led to the workers carrying the novel coronavirus to their home states.

The pandemic highlighted existing inequalities in the country, especially in the health sector, and then made them worse. The high cost of healthcare, especially in private hospitals, makes access to affordable and quality healthcare difficult for the poor. Moreover, the ability to socially distance is weaker for poorer people who live in single rooms with shared toilets. The lockdown affected access to non-COVID-19 medical services, and resulted in a lack of nutrition due to income loss and halt of schemes like the mid-day meals, among the the already marginalised.

These inequalities, and others, were already prevalent in India long before COVID-19. Notable differences in health outcomes based on gender, caste, class, religion and wealth groups have existed through the decades, and are the result of the people’s living environment and their access to good-quality healthcare.

An Oxfam India report found that the average life expectancy in India was up to 69 years by 2015 but that among people of higher income groups was seven and a half years higher than those of lower income groups.1 An upper caste woman also lived 15 years longer on average than a Dalit woman. The infant mortality rate – deaths per 1,000 live births of children under one year of age – is higher among SC/ST groups than in the general category. Even anaemia, a common indicator of nutritional status, reflects income-based inequalities. While 50% of children in the country were anaemic, according to the fourth National Family Health Survey (NFHS), the gap between the bottom 20% and the top 20% income groups was 12%.

In fact, these differences have been visible since the first NFHS, in 1992, up to the fourth one in 2015, although the gap has been reducing steadily.

Also read: Does India Know Anaemia Is Running Amok in the Country?

With the advent of healthcare privatisation, no checks on the cost of care services and low awareness among the poor and marginalised, they become more averse to seeking treatment compared to the more privileged.

Inequality in outcomes stems from inequality in access to medical services and the wider living conditions. India’s commitments to reducing inequality in health outcomes, through the National Health Policy (NHP 2017) and the Sustainable Development Goals (SDGs), aim to institute a holistic development agenda. However, the health emergency caused by COVID-19 highlighted glaring realities of India’s healthcare system.

The score of India’s SDG 3 – which pertains to good health and well-being – is 74 instead of the targeted 100. SDG 3 requires the country to achieve universal health coverage, including access to good-quality essential healthcare services, medicines and vaccines for all, increase health financing and recruitment, and strengthen the capacity to reduce risk. In addition, the averaged scores for Gujarat and Maharashtra place them on top of the list of states working towards SDG 3 – but such scores obfuscate the gains available to different socioeconomic groups.

NHP 2017 recognises the importance of SDGs and has aligned itself to achieving these goals. It aims to increase India’s health expenditure to 2.5% of GDP and improve primary health outcomes through ‘Health and Wellness Centres’. It is working towards an assurance-based approach – aiming to improve access to all sections of society without compromising on the quality of healthcare anyone can access.

While our infrastructure is in desperate need of upgrades, universal health coverage needs to assume centrestage and reduce all the care burdens that increased during the pandemic. So it is imperative that we double down on our pursuit of the SDG and NHP 2017 targets to prepare India against future health risks – while ensuring these efforts are equitably distributed across all socioeconomic groups.

Apoorva Mahendru is a quantitative research assistant with Oxfam India. She has worked on issues of health, gender, water and sanitation, and has a keen interest in policy and governance.


  1. Disclaimer: The author works with Oxfam India

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