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Indian Journal of Community Medicine

Vol. 31, No. 2 (2006-04 - 2006-06)


Reaching Out to the Unreached: Health Care for the Poor in India

G.K. Ingle, A. Nath

Health is a fundamental human right, and it is the responsibility of the governments to provide health care to all people in equal proportions. Evidence from across the world indicates that ill health disproportionately afflicts the poor, since the poor have little or no insurance against risks of ill health.1 The probability of ill health and its adverse effects is much more frequent and severe for those who are poor and this sub group is mostly "unreached" by the existing health care services. If we adopt the $1-a-day international standard, then India has a poverty rate of 34.7% which translates to about 357 million people living below the poverty line.2 Based on the human development index (HDI), India has been ranked 127th in the 2005 Human Development Report3, with an HDI value of 0.602.

There is a glaring contrast in the health status of the rich and poor in India, as shown by the differences in the various health indicators. The poor have much higher levels of mortality, malnutrition and fertility than the rich; the poor-rich risk ratio is 2.5 for infant mortality, 2.8 for under- five mortality, 1.7 for childhood underweight and 2 for total fertility rate (World Bank 2001)4. The disparity is observed to be higher in the rural areas as compared to the urban areas. A study has revealed that 21.5% of scheduled tribes, 18.1% of scheduled castes and 16.8% of others were not been treated for ailments in rural areas while 9.4% of scheduled tribes, 8.4% of scheduled castes and 8.5% of others remained untreated in urban settings.5 Similarly, data from urban slums show that infant and under-five mortality rates for the poorest 40% of the urban population are as high as the rural areas.6

Vector borne diseases, tuberculosis and leprosy are associated with poverty and poor living conditions. Moreover, the emerging AIDS epidemic is most likely to affect the poor and backward groups as they would be less informed about the disease as compared to the rich. Also, they would be less able to cope with its social and economic consequences. The poor are also at risk of suffering from non- communicable diseases. The National Sample Survey shows that this group is more likely to consume tobacco on a per-capita basis which places them at a higher risk of cardiovascular diseases, cancers and COPD. Moreover, there is an increased risk of exposure to indoor pollution, especially amongst the women which increases the risk of COPD and cancer. Non-communicable diseases can thus be very expensive to treat and also unaffordable in view of the absence of convenient health insurance and low public funding for health.7 There is a wide disparity in the treatment seeking of the rich and poor. About 24 percent of the poorest quintile do not seek care, compared to 9 percent of the richest quintile. A lower percentage seeks institutional care as evidenced by the institutional deliveries per 1000 births. The poor have a much lower rate of institutional deliveries; for example the poorest 20 percent have only 100 institutional deliveries per l000 live births compared to the almost 700 deliveries for the richest 20 percent.4 Despite a large public and even larger private health sector, appropriate and affordable health care remains inaccessible to several hundreds of millions, particularly women and children. The quality of health care services for the poor is influenced by a number of factors. At present, the number of health facilities is not adequate for the present population. The shortfalls in the number of health centers as per the norms is 16137 sub centers, 2913 PHCs and 3239 CHCs according to the population as per Census 2001.8

Even though 70% of the population resides in rural areas and only 30% in urban areas, a comparison between urban and rural areas show that urban areas have 4.48 hospitals, 6.16 dispensaries and 308 beds per 100,000 urban population to 0.77 hospitals, 1.37 dispensaries, 3.2 PHCs and 44 beds per 100,000 for rural population.9 The per capita expenditure on public health is seven times lower in rural areas as compared to government health spending for urban areas. Though the spending on healthcare is 6% of gross domestic product (GDP), the state expenditure is only 0.9% of the total spending. Thus only 17% of all health expenditure in the country is borne by the state, and 82% comes as 'out of pocket payment' by the people.10

At the sub-centre level, the vacancy of ANM's is about 5% whilst as many as 50 % of the sub centers do not have a male health worker. A recent survey has also shown that only 38 % of the PHCs'had the required essential manpower and only 31 % had all the essential supplies.8 There is a reluctance among the trained manpower, especially trained doctors to work in rural areas and urban slums. The poor transportation facilities and lack of medical personnels accounts for high morbidity and mortality in the population residing in difficult terrains in these areas. It was estimated that 25% of the people belonging to MP and Orissa and 11% in UP could not access health care services due to locational reasons.7

As a result of lack of faith in the public health sector, more and more people are seeking care from the growing private health care services Over 20 million Indians are pushed below the poverty line every year because of the effect of out of pocket spending on health care.11 Moreover, the quality of health care in the private sector is gradually getting deteriorated because of the absence of regulatory body. Moreover, people in the rural areas and urban slums are vulnerable to seek inappropriate treatment from quacks and unqualified medical practitioners. Factors such as inconvenient timings at the health center, absence of medical personnel and insensitivity to the patients' needs affect the quality of health services.

Increasing the public health expenditure to 2% of the GDP, from the present level of 0.9% which has already been endorsed by the new National Health Policy. This would help to bring about an increased establishment of health centers for the unreached areas, and also to make up for the deficiency of essential supplies. Addressing shortage of trained manpower should be achieved by providing attractive incentives such as better pay, timely promotion, better working conditions and provisions for professional enrichment. Geographical accessibility could be improved by strengthening of transport facilities and provision of well equipped mobile clinics for difficult to access areas. Incorporation of Information technology such as telemedicine will go a long way in reaching out to people residing in the far flung areas. Regulated private sector and certain regulations such as providing emergency medication to a person irrespective of his ability to pay could be made mandatory. Also standard guidelines with regard to treatment and investigation protocols should be laid in order to avoid unnecessary expenditure. Community based health insurance schemes should be encouraged. Strengthening of NGO's and fostering partnerships with private agencies, especially with traditional healers who are still by and large more acceptable to the communities should be undertaken. Performance based monitoring and accountability of the health care services would help to keep track of the quality of care that is provided.

Health disparity between the rich and poor could be overcome by whole hearted commitment and efforts, not only by the government and political leaders but also by the responsible citizens of our country.


  1. World Bank . Investing in health. World Development Report. New York: Oxford University Press for the World Bank.1993.
  2. UNDP Human Development Report 2003.
  3. UNDP Human Development Report 2005.
  4. World Bank. India - Raising the sights: better health systems for India's poor.2001.
  5. Dilip TR. Extent of inequity in access to health care services in India. In: Gangolli L, Duggal R and Shukla A, ed. Review of Health Care in India, CEHAT, Mumbai.2005.
  6. World Health Organization. Creating healthy cities in the 21st century Background paper, UN Conference on Human Settlements: Habitat II, Istanbul 3-14 June, 1996.
  7. Report of the National Commission on Macroeconomics and Health. MOHFW, Govt. of India, 2005.
  8. Ministry of Health and Family Welfare. Health Information of India, Central Bureau of Health Intelligence, Directorate General of Health Services,2002.
  9. Duggal R and Gangolli L. Introduction. In : Gangolli L, Duggal R and Shukla A (eds), Review of healthcare in India, CEHAT, Mumbai.2005.
  10. Central Bureau of Health Intelligence. Directorate General of Health Services, Ministry of Health and Family Welfare. Health Information of India, 2000&2001.
  11. National Sample Survey Organization. 42nd and 52nd Round. Department of Statistics.Govt Of India

Deptt. of Community Medicine Maulana Azad Medical College New Delhi-110002.
Received: 15.2.2006

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