Explaining income inequalities and access to healthcare services: The Case of Covid-19 Pandemic in India

Apr 7

Introduction:

On 31 December 2019, the world began its descent into economic uncertainty. There was a change in the consumer's behavior in all aspects of lifestyle. One could see changes in the prices of food items, OTT platforms, and many other areas of life. The pandemic altered the conception of "normal," with which the concept of current spending and the price behavior of consumers also changed.

In the post-Independence era, India has had significant healthcare advances due to the vision of healthcare professionals, advancement in medical technology and scientific discoveries, and the government providing adequate support to setting up hospitals, healthcare centers, pharmacies, etc. However, India's population has increased by leaps and bounds since then. The shortcomings of the healthcare sector were prominently visible in the devastating effect the Covid 19 pandemic had on the country's population.

Exploring the relationship between Income Inequality and access to healthcare:

Over the years, India has experienced severe income/wealth inequality. According to the State of Inequality in India Report 2022, extreme poverty in India has decreased by 12.3 percentage points between 2011 and 2019 and remains low. However, the report observes that rich 0.1% has been found to account for 5 to 7 percent of the national income in the country. In 2019-20, the top 1% earned almost thrice as much as the bottom 10%. National Family Health Survey), 2019-21 report finds that 54% rural population (bottom 40% of the total population) belonged to the two bottom quintiles (poorest and poor) groups, while in the urban area, only 10.4% of the population is poor.

Additionally, 74% of the urban population in India belonged to the top two wealth quintiles (richest and rich). It shows that there is a skewed higher poor population in rural India. It also highlights high regional inequality among the states in the country. Northern and northeastern states are far worse regarding their population percentage in the bottom two wealth quintiles.

With such vast differences in income distribution across the population of India, it is understood how skewed the access to basic means of livelihood would be across the different income groups in the country. The economically poorer sections of the population lack adequate funds even to afford two square meals a day. Many such poor families have negligible access to healthcare facilities or medicines. Lack of basic education is prevalent where the families would prefer their children undertake manual labor to bring extra income into the household rather than go to school. Additionally, the women of such families are at higher risk of developing life-threatening diseases due to improper hygiene and poor living conditions. Many times the accessibility of villages to nearby towns and cities are quite poor in terms of bad quality roads and lack of ambulance facilities. In the absence of primary healthcare services, the people would resort to community healers and Hakeems who are equally unaware of the exact nature of the ailment of people due to lack of proper training and, as a result, instead of the health of a sick person improving it further deteriorates. India has had strong economic growth throughout the years, but this prosperity has not reduced poverty.

Exploring some of the reasons for the high inequality prevalent in India:

Low labor force participation rates:- India has low participation rates, especially among females. Due to the attached social stigma around how women should look after the household while men of the family are the breadwinners, it is seen that a large part of the female population in rural areas which could have been involved in the workforce are not. This is one way in which the high poverty rates of India could have been reduced by the women generating additional incomes.
Ineffective trickle-down effect:- Despite having strong economic growth over the years, the trickle-down effect envisioned by the country's government was ineffective at reducing income inequality. The industry and manufacturing sectors were unable to generate enough jobs for the vast working population of India. As a result, India, despite having a strong agricultural base and a flourishing service sector, lags significantly in manufacturing goods and services.
Political instability leading to migration of people:- India, over the years, has borne the brunt of numerous political instabilities - be it the Bangladesh war, its constant strife with Pakistan, tribal uprisings in different parts of the country, etc, to name a few. All of this has led to the migration of people to different areas of the country which are more peaceful and free from such instability. This has led to increased population pressure over the existing resources of the city or town they migrated to. People might have gone in search of better living conditions; however, they are pushed below the poverty lines due to a lack of enough infrastructure and resources for their sustenance.
A huge proportion of casual workers in the service sector:- The service sector in India is characterized by a prevalence of casual and self-employed laborers. As per the State of Inequality in India Report, 2021, 20.71% were casual workers, 33.50% were regular workers, and 45.78% were self-employed workers(according to an article in Economic Times). In addition, we also must consider the contribution of the female population to the service sector, even though their contribution might not always be measured in monetary terms or even if it is measured, women are generally paid lower than their men counterparts.45% of households in the country have BPL cards (Below Poverty Line) which is a maker to recognize people experiencing poverty. Ideally, the percentage of households having BPL cards should go down over the years.

The Case of Covid 19 Pandemic:

All in all, Covid-19 transformed consumer lives; it covered a "decade in days," for instance, the occurrence of economic downturn, preference shifts of consumers, and digital acceleration. With the advent of Covid 19, hospitals became understaffed and overburdened. Doctors and nurses, the backbone of the country's healthcare system, were also affected by Covid due to a lack of proper protection and a shortage of masks, PPE kits, sanitizers, ventilators, and so on, leading to a shortage of medical professionals in hospitals.

Patients were the most affected especially if they were from the lower economic classes in society. Due to a lack of proper funds to devote to the well-being of the family members, extremely costly treatment options at private hospitals, and lack of adequate hospital beds in government hospitals, many families lost their near and dear ones due to Covid. While the economically well-off sections of the society resorted to panic-buying of masks, thermometers, oximeters, and oxygen cylinders, the worst sufferers remained the people without access to proper basic healthcare facilities. Even when Covid 19 vaccines started rolling out, they stayed out of reach of a huge section of the population initially due to limited stocks, overbooking of the limited vaccination slots, and the prices being significantly high.

Another aspect often overlooked in the discussion of healthcare is that of mental health and well-being. During the pandemic, the mental health of the population was greatly affected. From the fear of contracting the virus and getting sick to being forced to stay cooped up in their homes due to the lockdown implemented to curb the spread of the virus- cases of stress, anxiety, depression, and insomnia rose manifold. Coupled with that, the increased hours spent by children and adults alike in front of the screen, be it doing office and school work or simply for recreational purposes, did nothing to improve the mental health of the people. The people who could afford counseling sessions, meditation, or yoga sessions i.e., the economically well-off portion of society, found a way to deal with the issues of depression and anxiety. The ultra-rich could even afford to go on vacations and quarantine privately in their posh holiday homes in the countryside in some countries outside India. The economically weaker section did not have access to such luxuries of life. The constant fear of getting infected by the virus, fear of losing their jobs due to the rampant closure of business establishments and work shifting largely to the online mode, financial insecurity, and the fear of being unable to provide proper medicines and other healthcare services in case a family member gets infected all contributed to the worsening of mental health among these groups of people.

The pandemic brought to the world stage the dire state of the healthcare sector in India. To combat the situation, the government had to increase budget expenditure towards healthcare by about 137% in the 2021 budget. India spent around 1.8 % of its GDP on healthcare, which was very low compared to the global average of 6 %. Still, even this provided some welcome relief to the already tense situation in the country.

Policy Suggestions:

Monitoring infrastructure to rebuild the health sector of the country:-As we recover from the pandemic, it becomes important to create and monitor certain thresholds for public health infrastructure based on population. For example, regardless of whether an area is classified as rural or urban, if it has a certain population level, it would benefit from having a proper hospital rather than a single physician primary healthcare center with limited personnel and resources. Establishing such benchmarks (in terms of physical infrastructure, specialization of personnel, and relevant support staff) and reworking them as necessary can go a long way in building a population with a healthy life expectancy in India, where low state capacity falls short of the demands of secondary or tertiary care.
Proper budgetary allocation for the healthcare services in the country:-Further, given the burden on urban healthcare systems, budgets need to be expanded to improve the healthcare infrastructure supply aligned with the disease progression in cities. This must result from greater decentralization of finances and responsibilities and revenue from the booming medical tourism in India.
Building the knowledge base of medical professionals and proper skill development:-Moreover, along with an increase in the budget, there needs to be the proper capacity to manage that spending. With the increasing use of technology and healthcare analytics to treat diseases, healthcare professionals must acquire skills to harness data and interpret it to provide decision-making support to medical practitioners. Over and above this, as COVID-19 has highlighted the need for the management of epidemics and pandemics, there must be a mandate for public health professionals in government.