Photo: HT
Photo: HT

Opinion | Socio-economic factors that go against a hale and hearty India

The government’s health initiatives, sadly, remain uncoordinated, ineffective and seemingly oblivious of underlying risks

Oliver Goldsmith famously wrote in 1770, “Ill fares the land, to hastening ills a prey, Where wealth accumulates, and men decay..." Not necessarily, though, since some forms of affluence and socio-economic inequality often work to the benefit of the most disadvantaged in the context of non-communicable diseases, or NCDs.

The big four NCDs—cardiovascular diseases, cancer, chronic respiratory diseases and diabetes—account for 42% of all deaths in India. They contribute 22% of disability-adjusted life-years in India (or DALYs, the combination of years lived with serious illness and those lost due to premature death). So, the cost in terms of lives lost is horrendous. The economic burden of NCDs is already enormous and is set to grow rapidly. For example, macroeconomic cost projections for five major NCDs during 2012-30 are estimated at $4.58 trillion (at 2010 dollar rate). Yet, the present Indian government’s health initiatives remain uncoordinated and ineffective, and seemingly oblivious of the underlying risks.

Our recent analysis, based on the India Human Development Survey 2015, offers useful insights.

A measure of socio-economic hierarchy and deprivation is offered by the caste system, with Brahmins at the top and Adivasis (Scheduled Tribes, or STs) at the bottom. The latter are not just most deprived economically, but also socially excluded because of their location in remote areas.

Compared with the largest group of Other Backward Classes (OBCs) and the more affluent, Dalits (Scheduled Castes, or SCs) and STs were found less likely to suffer from an NCD in 2012. However, the mixed group of Others and More-affluent-than-OBCs were more prone to an NCD. This illustrates that the most disadvantaged were at considerably lower risk of NCDs than the more affluent. In general, SCs and STs live healthier and more active lives, consume healthier food, and thus face lower risks.

A measure of economic affluence is provided by asset quartile data. Relative to the least affluent (i.e. those in the first asset quartile), the most affluent were more prone to an NCD. Affluence is associated with sedentary lifestyles, and with smoking and consumption of alcohol, which heighten the risk of NCDs. Besides, the wealthiest also suffer from greater stress, which enhances these risks.

Social networks make a difference through access to information, healthcare facilities and financial support. Membership of more than one social network, (e.g., self-help groups, women’s associations, farmers’ associations) is associated with considerably lower risk of an NCD relative to those who are not networked.

That membership of networks is closely tied to social capital is indisputable. Three different forms of networking activity are distinguishable: bonding, bridging and linking social capital. Social capital has to do with norms of reciprocity. These norms manifest themselves among people who are alike (family and friends), or in bonding among heterogeneous individuals (say, of different castes), or bridging, and lastly in the establishment of links with official authorities and politicians who hold office.

Bridging and linking social capital tend to matter more in health outcomes. Even though the evidence available is limited and sketchy, this cannot be a reason for not promoting them in the interest of healthcare. However, doubts have been raised about the efficacy of social cohesion when there is extreme economic inequality in the wider environment. Indeed, extreme inequality is so insidious that not only does it weaken social cohesion, but also leads to adverse health outcomes. In a highly unequal environment, individuals lack the necessary empowerment to choose the life they aspire to live. Borrowing from Amartya Sen, they lack the capability to live a productive and healthy life.

Extreme income inequality, following Thomas Piketty, is measured as the ratio of the share in total income of the top 1% to that of the bottom 50% at the state level. The larger the ratio, the greater the risk of high NCD prevalence. Extreme inequality grew during the period 2005 to 2012, worsening in recent years. If wealth generation is inherently unequal, so, too, is income distribution.

The economic burden of NCDs is already huge and set to grow rapidly. Scaling up their prevention and control would cost very little compared to this burden, and provide substantial returns in terms of better health and higher productivity. Prevention of NCDs, thus, ought to be a major priority for India.

A National Health Policy was announced in 2017. It proposed raising public health expenditure progressively to 2.5% of gross domestic product by 2025 and advocated the allotment of a major chunk of resources to primary healthcare, followed by secondary and tertiary healthcare. Besides, the NITI Aayog has set targets for reduction of premature death and morbidity due to major NCDs. A concern, however, is that scant attention is given to where the resources will come from. Still, more important than a higher financial allocation is the reorganization of the healthcare system and its effective regulation. Central to that proposal would be a strengthened public care system, with a clearly defined role for private services, especially in specialized fields.

Vani S. Kulkarni & Raghav Gaiha are, respectively, a teacher of sociology, University of Pennsylvania, US, and (Honorary) professorial research fellow, Global Development Institute, University of Manchester, UK

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