Social determinants of health in India: progress and inequities across states

Abstract

Introduction: Despite the recognized importance of social determinants of health (SDH) in India, no compilation of the status of and inequities in SDH across India has been published. To address this gap, we assessed the levels and trends in major SDH in India from 1990 onwards and explored inequities by state, gender, caste, and urbanicity.

Methods: Household- and individual-level SDH indicators were extracted from national household surveys conducted between 1990 and 2011 and means were computed across population subgroups and over time. The multidimensional poverty index (MPI), a composite measure of health, education, and standard of living, was calculated for all three rounds of the National Family Health Survey, adjusting the methodology to generate comparable findings from the three datasets. Data from government agencies were analyzed to assess voting patterns, political participation, and air and water pollution.

Results: Changes in the MPI demonstrate progress in each domain over time, but high rates persist in important areas: the majority of households in India use indoor biomass fuel and have unimproved sanitation, and over one-third of households with a child under the age of 3 years have undernourished children. There are large, but narrowing, gender gaps in education indicators, but no measurable change in women's participation in governance or the labor force. Less than 25% of workers have job security and fewer than 15% have any social security benefit. Alarming rates of air pollution are observed, with particulate matter concentrations persistently above the critical level at over 50% of monitoring stations.

Conclusions: This assessment indicates that air pollution (indoor and outdoor), child undernutrition, unimproved sanitation, employment conditions, and gender inequality are priority areas for public policy related to SDH in India.

Figure 1

Multidimensional Poverty Index (MPI) headcount ratio during three rounds of the National Family Health Survey. The headcount ratio is defined as the proportion of the population living in a household which has a weighted deprivation score greater than 0.33 (on a scale of 0 to 1 with 0 being not deprived in any component and 1 being deprived in all ten components), across the dimensions of standard of living, education, and health. SC/ST is Scheduled Caste or Scheduled Tribe; Other is all other castes.

Figure 2

Multidimensional Poverty Index Headcount Ratio: state-level trends. NFHS-1, 2, and 3, disaggregated by urban/rural location and caste, for A) less developed states and B) more developed states. Results are not presented for subpopulations (defined by survey year, state, urbanicity, and caste) if the sample size was less than 100 households.

Figure 3

Change over time in the percentage of eligible households deprived in each of the components of the Multidimensional Poverty Index (MPI). Symbols indicate the dimension of each indicator (circle for health, triangle for education, and square for standard of living).

Figure 4

Interstate variations in the proportion of households using biomass fuel and with unimproved sanitation. Biomass fuel use in A) urban and B) rural areas and the proportion of households with unimproved sanitation in C) urban and D) rural areas. Data are from the 2007-09 District Level Household Survey; as data for Nagaland are not available from this survey, data from the 2005-06 National Family Health Survey are used for this state.

Figure 5

Gender disparities within households. Gender disparities in child death, child underweight, absence of any household member with five or more years of completed education, and any child aged 7-14 not attending school. Symbols indicate the gender for each indicator (square for females, triangle for males).

Figure 6

Gender and caste proportions of candidates in state elections in India, 2005-12. The right axis displays the number of states holding elections in each year.

Figure 7

NAAQS levels of annual mean concentrations of respirable particulate matter (PM ₁₀ ), 2000 to 2010. Measurements taken at air quality monitoring stations during 2000 to 2010. *NAAQS is National Ambient Air Quality Standards. Low/Moderate, High, and Critical refer to annual mean concentrations of less than 60, 60-90, and more than 90 PM₁₀ micrograms/meter, respectively [23].