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Not just medical care, social factors too play an important role in determining one’s health status. These factors are also responsible for the gaps in health among the various strata. Lack of availability and accessibility to resources that improve health among the socially disadvantaged groups are major factors contributing to this health inequity.
These social factors have been termed as social determinants of health and have been defined by the WHO’s Commission on SDH (CSDH) as “the conditions in which people are born, grow, live, work, and age including the health system.” According to the Commission, this means that health cannot be achieved by medical care alone; it is also a social phenomenon.
Among the 10 social determinants of health, social gradient has been deemed to be the strongest predictor of health and wellbeing. It is measured by variables such as income, education, occupation or housing. The lower the socioeconomic position, the higher the risk of poor health.
The extreme poor or the poorest of the poor are the worst off. The World Bank has defined “extreme poverty” as living on less than $1.90 per person per day. This amounts to Rs. 135 per person per day and around Rs 4000 per person per month.
Much progress has been made to make health care accessible to the poor; but, inequities still persist.
The high out of pocket expenditure further add to the financial burden. Many people are pushed below poverty line on account of the high medical expenses in what has been termed as “the medical poverty trap”.
About 55 million Indians were pushed into poverty in a single year because of having to fund their own healthcare and 38 million of them fell below the poverty line due to spending on medicines alone, as per a study published in the British Medical Journal. Health expenditure is considered to be catastrophic if it constitutes more than 10% of overall household consumption or income (TOI, Jun 13, 2018).
Evidently, there is a need to reduce the health inequity.
This has been addressed in the National Health Policy 2017 as a key policy principle, which states “Reducing inequity would mean affirmative action to reach the poorest. It would mean minimizing disparity on account of gender, poverty, caste, disability, other forms of social exclusion and geographical barriers. It would imply greater investments and financial protection for the poor who suffer the largest burden of disease”.
Right to health and access to healthcare is a fundamental right under Article 21 of the Constitution. Article 41 also provides for ensuring assistance during old age, sickness, and disablement.
The Ayushman Bharat scheme, which provides up to Rs 5 lakh cover, is one step towards this end. This year, constitutional amendment bill providing for 10% reservation to the economically weaker sections of the General Category was notified. These are in a bracket of less than 8 lakh annual income.
Only by reducing the health inequity, can the goal of universal health coverage be realized.
In the coming budget, the government needs to bring this 8 lakh limit to the definition of EWS for the purpose of ESI, health subsidy and Ayushman Bharat subsidy. Those above this bracket should be able to buy their insurance on their own.
Dr KK Aggarwal
Padma Shri Awardee
President Elect Confederation of Medical Associations in Asia and Oceania (CMAAO)
Group Editor-in-Chief IJCP Publications
President Heart Care Foundation of India
Past National President IMA