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Inequality between states harms health in India

‘Nations Within a Nation’

A groundbreaking new study published today in The Lancet spotlights a major concern about healthcare in India: the vast disparities between its states.

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‘Nations within a nation.’ Map of states of India.

‘Nations Within a Nation’, touted as ‘the first comprehensive analysis of health in India’, shows that the ‘substantial gains in healthcare’ made by India in recent years have not been evenly distributed across its 29 states and seven union territories. These inequalities are particularly pronounced in terms of how different disease threats are emerging across the nation.

India currently manages a dual burden of communicable and noncommunicable disease. Responding to this dual burden presents a major challenge to public health systems in the country. Compounding this issue is interstate discrepancies.

Noncommunicable diseases (NCDs) now constitute the majority of the disease burden in many Indian states. The same is true at the national level. NCDs account for 53 percent of the disease burden in India and, according to the study, six out of every ten deaths.

‘Wide inequalities’

However, many states – particularly those at lesser levels of economic development – continue to suffer a high burden of communicable, maternal, neonatal, and nutritional diseases (CMNNDs). Large gaps exist between states in terms of their epidemiological transition level (ETL), which the study defines ‘on the basis of the ratio of DALYs [disability adjusted life years] from communicable, maternal, neonatal and nutritional diseases (CMNNDs) to those from noncommunicable diseases (NCDs) and injuries combined.’

Between some states, the ETL gap is as wide as 24 years.  In states such as Bihar, Jharkhand, and Uttar Pradesh, NCDs make up around 50 percent of the disease burden, whereas, in Goa, Kerala, and Tamil Nadu, NCDs make up around 75 percent of the disease burden. “This has resulted in wide inequalities in the magnitude and progress against various diseases and their causes,” says the study’s leader, Professor Lalit Dandona of the Public Health Foundation of India (PHFI) in Gurugram.

‘Uneven progress’ 

By No machine-readable author provided. Gurukkal assumed (based on copyright claims). [Public domain], via Wikimedia Commons
A woman is examined by a doctor in Kerala.
India has undeniably made significant improvements on crucial health indicators. CMNNDs are decreasing. Life expectancy has risen since 1990 by almost a decade, to 66.9 years for women and 70.3 years for women. The mortality rate under five years has declined,  standing at 50 deaths per 1,000 live births for the 2015-16 period. This is compared to 74 deaths per 1,000 live births for the 2005-06 period. Malnutrition rates are falling, as are rates of infectious diseases such as tuberculosis.

Undermining much of this progress, however, are the inequalities at the centre of the Lancet report.

Life expectancy for women is over 12 years more in Kerala than in Uttar Pradesh. The rate of tuberculosis varies as much as ninefold between states, with the poor at greatest risk of contracting the disease.

Rates of child and maternal malnutrition, which the study identifies as ‘still [the] leading risk factor for premature death and poor health’,  continue to be high, particularly in states at a lower ETL, such as Assam, Bihar and Uttar Pradesh.

In the case of Jharkhand, death and illness due to diarrhoeal diseases are nine times more common than in Goa. In the case of Rajasthan, lower respiratory infections are seven times more common than in Kerala. The study identifies both conditions as  ‘primarily [causing] illness and death in children and mothers.’

Worryingly, the study spotlights ‘major differences in the burden of leading diseases’, even in states at similar levels of socioeconomic development. This is indicative of ‘vast health inequalities’ – from which even the wealthiest and most developed states in India are not immune.

What is to be done?

The study highlights that India is a country of contrasts. It is one which – for the sake of its own development – cannot afford to be complacent in tackling either NCDs or CMNNDs.

As Professor Dandona observes,  “what we have being doing up to now is not enough” – and the findings of the study will have “major policy implications for national and local governments.” What is needed is an approach which utilises  ‘the state-specific findings now identifying the diseases and risk factors that need most attention in each state.’ Crucial to this  is the need for ‘a comprehensive health information system to improve data collection and quality in many states.’

In the seventy years since its independence, India has made great strides, including in healthcare. Yet more needs to be done, as great swathes of the population continue to live blighted by poverty, hunger and disease. Until the health inequalities between states are addressed, this state of affairs can only be expected to continue.

The Lancet study can be accessed here.


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