The importance of research in “health equity” to policy-making process cannot be exaggerated. As a response to the Report of the Commission on Social Determinants of Health (2008), the WHO has been making efforts to support research that explicitly aims to “measure and reduce” health inequity” within countries and globally. The most important lesson from CSDH’s report is that “health inequity lens” should form an important criterion in the assessment of and social policy, as otherwise we may even be promoting highly unethical research. In simple terms, what is implied here is that, whenever a social policy or programme is put in place, we should ask the question “What is the impact of this policy in reducing health inequity?
There are several ways in which the research community in India (in particular) could respond to this call. I shall not attempt to list the various possible research questions; nor is it necessary to do so, as the CSDH has done this so admirably and in simple terms. But it is useful to highlight the four broad inter-related levels or areas of research in health equity that it has proposed. These are:
- Global factors and processes that affect health equity;
- Structures and processes that differentially affect people’s chances to be healthy within a given society;
- Health system factors that affect health equity; and
- Policy interventions to reduce health inequity, that is how to influence (1)-(3) effectively.
Needless to say that several impediments will come in the way of supporting and promoting studies on these lines. Three key impediments (and these are inter-related again) are obvious in the Indian context: (a) lack of research capacity to undertake research in health equity (b) inadequate institutional mechanisms to generate collect and disseminate reliable and robust data necessary for conducting research in health equity and (c) lack of a healthy collaborative interactions between the research community, public policy makers and the civil society. Some comments on these issues are in order:
Considering the vastness and complexity of the country, the support that health equity research receives today is perhaps one thousandth of the what it deserves, in terms of both money and research expertise. One can literally count the number of social scientists working in health equity issues. Economists are conspicuous by their absence in this area of research. The publications on health equity therefore are abysmally low.
While the national and state level data on vital events are collected systematically fairly periodically (and with some accuracy), our data base on health services utilization and related aspects are woefully inadequate to undertake health equity research. Thanks to the National Sample Survey data on health services utilization, which are being put to good use by the researchers and the government alike? But those who have worked with these data sets are acutely aware of the quality and comparability of data over the period they represent. State governments, perhaps barring a few, have utilized the results of the NSSO data, and even fewer the capacity to analyze them and make use of these their periodic planning processes.
The third impediment referred to above, is even more complex to handle and address. It is in fact a sign of a larger malady from which the entire health system (of which the research community and the government machinery are a part) suffers. Even in Tamil Nadu, where a very large proportion of money allotted to health sector gets spent, very little money (if any) is channeled to the research community in Universities and research institutions. There is little synergy and interactions between the policy makers and the research community in addressing mutually interesting health services issues. The issues are lot more complex than it could be described here in a short space, but suffice to say that the research community has been less forthcoming so far in working with governments in the respective states.
Health equity research will come to occupy the centre of attention in the planning process in the years to come in India, as in other countries. Recent past has seen the establishment of a few Institutions to promote research in health care sector. But the efforts to encourage social scientists to work in health equity should be much more and sustained. Capacity building in health equity research is a long process. A small group of researchers at the Indian Institute of Technology (Madras) spent nearly 3 years (with active support from DFID UK) to enhance their skills in health equity research. As a person involved in coordinating these efforts, I would say that if governments today makes a commitment to promote this discipline, it would take another ten years of sustained efforts to achieve a respectable level of expertise and professional credibility.
Programmatic efforts and policy interventions cannot afford to wait for another ten years required for achieving the skills, the critical mass of scholarships and maturity in collaboration for undertaking health equity research. But the argument of this brief note is two-fold: (a) One is to emphasize the urgency of the efforts required to cultivate research and build research capacity in health equity and (b) to recognize the importance of health equity research in designing (to use a phrase from NRHM) an “effective, affordable and equitable” health systems in India and draw upon the little resources available within country in initiating simple, doable, useful and analytically sound studies that will contribute to health policy and planning process in India. Quick and dirty work are no longer justifiable.
Health Equity research centres around one question: How well are public resources being spent? To put it differently, are the benefits of public spending on health services reaching the poorer sections of the society? Or, to put it even more sharply, are those in the poorer sections of the society getting their fair share of the benefits of government spending on health care services?
Complex questions often could be stated in simple terms. But the answers to such questions may take us take through complex (methodological) steps and exhaustive empirical data. The final evidence should be convincing and compelling, and more importantly, the evidence should be acceptable and practiced. Historically, results of health equity in most parts of the world have faced all these challenges.