Health Inequalities in South Asia at the Launch of Sustainable Development Goals: Exclusions in Health in Kerala, India Need Political Interventions

A critique of the policy discourse on primary health care under the Aardram mission of Kerala

In 2017, the State of Kerala in India, launched the 'Aardram' mission for health. One of the aims of the mission was to enhance the primary health care (PHC) provisioning in the state through the family health centre (FHC) initiative. This was envisaged through a comprehensive PHC approach that prioritized preventive, promotive, curative, rehabilitative and palliative services, and social determinants of health. Given this backdrop, the study aimed to examine the renewed policy commitment towards comprehensive PHC and the extent to which it remains true to the globally accepted ideals of PHC. This was undertaken using a critical discourse analysis (CDA) of the policy discourse on PHC. This included examining the policy documents related to FHC and Aardram as well as the narratives of policy-level actors on PHC and innovations for them. Through CDA we examined the discursive representation of PHC and innovations for improving it at the level of local governments in the state. Though the mission envisaged a shift from the influence of market-driven ideas of health, analysis of the current policy discourse on PHC suggested otherwise. The discourse continues to carry a curative care bias within its ideas of PHC. The disproportionate emphasis on strategies for early detection, treatment and infrastructural improvements meant limited space for preventive, protective and promotive dimensions, thus digressing from the gatekeeping role of PHC. The reduced emphasis on preventive and promotive dimensions and depoliticization of social determinants of health within the PHC discourse indicates that, in the long run, the mission puts at risk its stated goals of social justice and health equity envisioned in the FHC initiative.

Understanding Dalit equity: a critical analysis of primary health care policy discourse of Kerala in the context of 'Aardram' mission

BACKGROUND

The Government of Kerala in 2017 launched the Aardram Mission with the aim to revamp public health delivery in the State. A key strategy under the mission was its focus on comprehensive primary health care to achieve equitable health care delivery through the Family Health Centre (FHC) initiative. Given this, the current study aims to examine the primary health care policy discourse for their perspectives on caste-driven inequities.

METHODS

The study undertook a Critical Discourse Analysis (CDA) of the primary health care policy discourse in Kerala. This included CDA of spoken words by senior health policy actors and policy texts on Aardram Mission and FHC.

RESULTS

Though equity was a major aspirational goal of the Mission, related policy discourse around equity failed to acknowledge caste as a potential axis of health marginalisation in the State. The dismissal of caste manifested in three major ways within the policy discourse. One, the 'invisibilisation' of caste-driven inequities through strategies of (un)conscious exclusion of Dalit issues and 'obliteration' of caste differences through the construction of abstract and homogenous groups that invisibilise Dalits. Secondly, locating caste as a barrier to primary health care initiatives and health equity in the state, and finally through the maintenance of an 'apoliticised' social determinants discourse that fails to recognize the role of caste in shaping health disparities, specifically among Dalits in Kerala.

CONCLUSION

Given Kerala's renewed commitment to strengthening its public health provisioning, the acknowledgment of caste-driven inequities is invariable in its path toward health equity and social justice.

Health inequities around gender, disability and internal migration: are local governments doing enough

SETTING

The Kerala health system in India has more than 25 years of decentralised implementation experience. Decentralization could assist in addressing health disparities such as gender, disability, and migration.

OBJECTIVE

To explore how inequity issues comprising gender, disability and internal migrations were being addressed at present by the decentralised Kerala health system.

DESIGN

Our approach was qualitative, using document review, key informant interviews and in-depth interviews with policy makers, health staff and other stakeholders.

RESULTS

Gender aspects were incorporated into planning and budgeting, with 10% funds earmarked for women. Projects were gender-specific to women, and within conventional social roles of livelihood, welfare or reproductive health. Recently, transgender focused projects were also initiated. Schemes for people with disabilities remained welfare-centric and driven by top-down policies. The local governments performed beneficiary identification and benefit disbursal. Migrant health aspects were focused on infectious diseases surveillance and later living conditions of migrant workers.

CONCLUSION

The importance that health systems place on socioeconomic determinants of health and fundamental human rights is reflected in the health interventions for marginalised communities. In Kerala, there is now a passive application of central rules and a reluctance to utilise local platforms. Changing this is a necessary condition for achieving equal development.

The triple burden of disease, destitution, and debt: Small business-women's voices about health challenges after becoming debt-ridden

More than 115 million women across the world are borrowers of microfinance loans. However, there is concern that women from poor backgrounds who take loans may suffer from multiple challenges of physical and mental health burdens. In this qualitative study we aimed to identify the types of health challenges faced by active women borrowers of microfinance loans. Open ended questions were asked from 442 women across seven cities and four provinces of Pakistan. Categories were developed through the content analysis approach using NVIVO. We have been able to identify thirteen different health challenges faced by poor women borrowers under two broad headings of "environmental factors" and "healthcare delivery system." We recommend the introduction and expansion of different health and social development services by microfinance provider's to support the health needs of poor women clients. Women also need support from the Government of Pakistan in improving access to education, health coverage, and formal sector work opportunities. Our study implies increased health policy support for disadvantaged women borrowers of microfinance across the world.

Role of science in environmental conservation leading to sustainable development

Sustainable development is the development of people’s needs without harming the environment. From this study we would like to discuss how to apply basic science for sustainable development. Most of the time people do not think about the environment during development projects. They only think about their profits. As a result of these unplanned development projects, so much harm occurs to the environment such as water pollution, air pollution, climatic changes, global warming and greenhouse effect. Loss of biodiversity is another crucial problem occurs due to industrial revolution. Most of the time people cut forests and trees for different development projects. Because of these activities many animals lost their habitats and so many plants and natural water resources get destroyed. Do not stop development projects but should think twice before doing any action that harmful to the environment and also it will affect directly or indirectly to animals and mankind. Basic and General science provide good solution for the problems that have created due to industrial activities.

Grappling with Morphine: A Local History of Painkiller Use in Kerala, India

In this article I argue that the scarcity of painkillers in the Global South is driven by a central asymmetry in which the health of developed countries is valued over that of the much poorer countries that comprise the rest of the world. To elucidate this point, I argue that by examining the history of various legal institutions and specific events, like the opioid crisis, that have shaped the global production of opium and production in India, one will be able to see the genealogy of the imbalance and inequality that has always affected care. I turn to the state of Kerala to explore instances in which these legal inflections live within the contemporary guidelines for palliative care, and thus constantly affect the supply and delivery of care. This also ties in with the much longer history of opium control for the growth of the global pharmaceutical industry, within which India has been uniquely placed.

Emerging challenges in the health systems of Kerala, India: qualitative analysis of literature reviews

Purpose

The substantial increase in non-communicable diseases (NCDs) is considered a major threat to developing countries. According to various international organizations and researchers, Kerala is reputed to have the best health system in India. However, many economists and health-care experts have discussed the risks embedded in the asymmetrical developmental pattern of the state, considering its high health-care and human development index and low economic growth. This study, a scoping review, aims to explore four major health economic issues related to the Kerala health system.

Design/methodology/approach

A systematic review of the literature was performed using PRISMA to facilitate selection, sampling and analysis. Qualitative data were collected for thematic content analysis.

Findings

Chronic diseases in a significant proportion of the population, low compliance with emergency medical systems, high health-care costs and poor health insurance coverage were observed in the Kerala community.

Research limitations/implications

The present study was undertaken to determine the scope for future research on Kerala's health system. Based on the study findings, a structured health economic survey is being conducted and is scheduled to be completed by 2021. In addition, the scope for future research on Kerala's health system includes: (1) research on pathways to address root causes of NCDs in the state, (2) determine socio-economic and health system factors that shape health-seeking behavior of the Kerala community, (3) evaluation of regional differences in health system performance within the state, (4) causes of high out-of-pocket expenditure within the state.

Originality/value

Given the internationally recognized standard of Kerala's vital statistics and health system, this review paper highlights some of the challenges encountered to elicit future research that contributes to the continuous development of health systems in Kerala.

Pathophysiological Mechanisms Underlying Excess Risk for Diabetes and Cardiovascular Disease in South Asians: The Perfect Storm

BACKGROUND

South Asians are at a significantly increased risk of type 2 diabetes (T2D) and cardiovascular disease (CVD), are diagnosed at relatively younger ages, and exhibit more severe disease phenotypes as compared with other ethnic groups. The pathophysiological mechanisms underlying T2D and CVD risk in South Asians are multifactorial and intricately related.

METHODS

A narrative review of the pathophysiology of excess risk of T2D and CVD in South Asians.

RESULTS

T2D and CVD have shared risk factors that encompass biological factors (early life influences, impaired glucose metabolism, and adverse body composition) as well as behavioral and environmental risk factors (diet, sedentary behavior, tobacco use, and social determinants of health). Genetics and epigenetics also play a role in explaining the increased risk of T2D and CVD among South Asians. Additionally, South Asians harbor several lipid abnormalities including high concentration of small-dense low-density lipoprotein (LDL) particles, elevated triglycerides, low high-density lipoprotein (HDL)- cholesterol levels, dysfunctional HDL particles, and elevated lipoprotein(a) that predispose them to CVD.

CONCLUSION

In this comprehensive review, we have discussed risk factors that provide insights into the pathophysiology of excess risk of T2D and CVD in South Asians.

Field-testing of primary health-care indicators, India

Objective

To develop a primary health-care monitoring framework and health outcome indicator list, and field-test and triangulate indicators designed to assess health reforms in Kerala, India, 2018–2019.

Methods

We used a modified Delphi technique to develop a 23-item indicator list to monitor primary health care. We used a multistage cluster random sampling technique to select one district from each of four district clusters, and then select both a family and a primary health centre from each of the four districts. We field-tested and triangulated the indicators using facility data and a population-based household survey.

Findings

Our data revealed similarities between facility and survey data for some indicators (e.g. low birth weight and pre-check services), but differences for others (e.g. acute diarrhoeal diseases in children younger than 5 years and blood pressure screening). We made four critical observations: (i) data are available at the facility level but in varying formats; (ii) established global indicators may not always be useful in local monitoring; (iii) operational definitions must be refined; and (iv) triangulation and feedback from the field is vital.

Conclusion

We observe that, while data can be used to develop indices of progress, interpretation of these indicators requires great care. In the attainment of universal health coverage, we consider that our observations of the utility of certain health indicators will provide valuable insights for practitioners and supervisors in the development of a primary health-care monitoring mechanism.

The Health of Indigenous Populations in South Asia: A Critical Review in a Critical Time

Despite South Asia's promising social inclusion processes, staggering social and health inequalities leave indigenous populations largely excluded. Marginalization in the South Asian polity, unequal power relations, and poor policy responses deter Adivasi populations' rights and opportunities for health gains and dignity. The ongoing COVID-19 pandemic is likely to result in a disproportionate share of infections and deaths among the Adivasis, given poor social conditions and exclusions. Poor health of indigenous people, inequalities between indigenous and non-indigenous groups, and failures in enforcing constitutional and legal provisions to reclaim indigenous land and cultural identity herald deeper structural and political fractures. This article unravels health inequalities between the Adivasis and non-Adivasi populations in their social context based on a critical review of secondary sources. We call for intersectoral policies and integrated health care services to address systemic inequalities, discrimination, power asymmetries, and consequent poor health outcomes. The current COVID-19 pandemic should be viewed as a window to pursue real change.

Challenges to the development of a health care practice model for hospital social work in India

India has a long history of delivering a western model of social work despite being challenged by unique structural challenges, as well as demographic and social changes impacting the types of presentations to hospitals. This paper reports on a project that explored the professional roles of Indian social workers in hospital settings, and documented some of the critical factors that impede capacity to meet the demands of a changing health care system. Extracted themes from participants identified a lack of role descriptions, professional supervision, and national standards as contributing to a lack of confidence in asserting strong professional identity and contribution to patient care.

Socio-economic and environmental factors influenced the United Nations healthcare sustainable agenda: evidence from a panel of selected Asian and African countries

The objective of the study is to evaluate socio-economic and environmental factors that influenced the United Nations healthcare sustainable agenda in a panel of 21 Asian and African countries. The results show that changes in price level (0.0062, p < 0.000), life risks of maternal death (4.579, p < 0.000), and under-5 mortality rate (0.374, p < 0.000) substantially increases out-of-pocket health expenditures, while CO₂ emissions (5.681, p < 0.003), prevalence of undernourishment (15.184, p < 0.000), PM_2.5 particulate emission (1557, p < 0.000), unemployment, and private health expenditures (30.729, p < 0000) are associated with high mortality rate across countries. Healthcare reforms affected by low healthcare spending, unsustainable environment, and ease of environmental regulations that ultimately increases mortality rate across countries. The Granger causality estimates confirmed the different causal mechanisms between socio-economic and environmental factors, which is directly linked with the country's healthcare agenda, i.e., the causality running from (i) CO₂ emissions to life risks of maternal death and under-5 mortality rate, (ii) from depth of food deficit to incidence of tuberculosis and unemployment, (iii) from PM_2.5 emissions to infant mortality rate, (iv) from foreign direct investment (FDI) inflows to PM_2.5 emissions, (v) from trade openness to greenhouse gas (GHG) emissions, and (vi) from mortality indicators to per capita income, while there is a feedback relationship between health expenditures and per capita income across countries. The variance decomposition analysis shows that (i) under-5 mortality rate will increase out-of-pocket health expenditures, (ii) unemployment rate will increase mortality indicators, and (iii) health expenditures will increase economic well-being in a panel of selected countries, for the next 10 years.