Social, Cultural and Gender Disparities

Himachal Pradesh and Maharashtra are higher than in West Bengal, although their performance in the public health sector is better. Hence, poor households in rural areas are deprived in double respect. First, a higher percentage of poor people live in rural areas. Second, a higher percentage of poor have a low health status compared to non-poor. Access to public health services, in turn, is lower in rural areas and also lower for the poor (see above). Thus, the higher demand of poor rural population is not met.

Besides the grouping of states after their economic, poverty or access indicators, they can also be grouped according to their status of health transition (see Table 3.2). While the Southern states of Kerala and Tamil Nadu are already in a middle to late transition and have a high institutional capacity, the majority of states including West Bengal and Maharashtra are in an early to middle transition and have only low to moderate institutional capacity. Orissa, Rajasthan, Madhya Pradesh and Uttar Pradesh are in a very early transition phase with very low to low institutional capacity, whereas Assam and Bihar show no signs of health transition (Peters et al. 2002: 8).

Table 3.2: Health Transition in Major Indian States

localised in its appearance. For the production of social structures “jati” (subcaste) is of greater relevance than “varna” (see Mukherjee 2000). Caste is a concept deeply embedded in Hinduism. Members of other religions are placed outside the caste system.

While the classification through “jati” is established through birth and more dependent on religion, occupation, cultural tradition and ethnicity, class is rather defined through economic assets like ownership of land. Both systems have strong hierarchies with “jati”

being endogamous. In literature rural Indian society is divided in six classes: “landlords and rentiers, capitalist farmers, rich peasants, middle peasants, poor peasants, and landless labourers” (Das 2001: 350). Membership to class, thus, follows Marx’s theory of capitalism.

Poverty has an important impact on health as shown above (see Figure 3.6). Therefore, distribution of poverty among groups of rural society is essential for examining health.

Research studies on rural India show that poverty is more concentrated in scheduled castes and tribes which are at the bottom of the caste hierarchy (Gang et al. 2005).

Krishna reveals similar results in his detailed household level study (Krishna 2004). The probability of being poor or of falling into poverty is much higher among scheduled castes and scheduled tribes than for upper castes. On the other hand the percentage of these lower castes escaping from poverty is also higher. The reasons for falling into poverty are the same among all caste groups, in most cases “a combination of health and health-related expenses, high-interest private debt, and social and customary expenses” such as death feasts and marriages (Ibid.: 128). One factor that also emerges from his study is information. High-quality information is crucial for escaping poverty, at the same time as lack of information may lead to poverty. Hence, wrong choices in seeking health care are linked to a decline into poverty. Kinship networks and connections to influential people therefore become more important as survival strategies. Although these two studies show general tendencies for lower castes to be in lower class, thus combining caste and class, they do not deny that upper castes may also be poor.

In their study on the allocation of publicly-provided goods Betancourt and Gleason find a significant variability in districts (Betancourt/ Gleason 2000). They explain this variability by the influence of caste and religion. Rural areas of districts with higher proportions of scheduled castes or Muslims acquire lower public input (Ibid.: 2177). Jeffrey on the contrary assessed the influence of social status on access to state bureaucrats, police or judiciary in rural India (Jeffrey 2002). His study shows similar results on an individual basis, dominant classes are more successful in influencing decisions of local police or politicians than scheduled castes and Muslims. Hence, he uses social status as determinant, which is composed by class and caste membership. While researching inequalities in immunization rates for children within states, Pande and Yazbeck found that gender, wealth and place of residence influenced immunization rates (Pande/

Yazbeck 2003). Girls from poor households in rural areas were least likely to receive full immunization, whereas boys from rich households in urban areas were most likely to receive full immunization. Hence, female gender, poverty and rural residence are further discriminating factors and reasons for inequality in health care. The Primary Health Care Approach highlights education as a means to achieve better health status. The link

between educational status of women and infant mortality can be seen in Figure 3.11. The higher educated the mother, the lesser the plausibility of death for her infant. Therefore, health status is not only influenced by caste, class and poverty, but also by education.

Literacy rates are significantly lower in rural than in urban areas and for women than for men (Ministry of Home Affairs 2002). Thus, lack of education poses another threat for the health status of rural people, especially for women. Besides other factors it is religious affiliation which also influences contraceptive use in rural areas, therefore, supporting the thesis that elements of social status affect health behaviour and health needs (Chacko 2001).

Figure 3.11: Mother’s Education and Infant Mortality Rate

All the above mentioned studies show that researchers have focused on class or caste relations as well as on social status. The distinctions they make between the categories are not always clear. Using scheduled tribe and scheduled caste as well as religious affiliation as indicators is supported by the data generated by the government. However, social relations and power structures in the villages are established through all characteristics of social status including caste and class. The studies prove that members of scheduled castes and scheduled tribes as well as Muslims in rural areas are more likely to have lower social status, reflected in poverty rates and access data. At the same time lower social status is linked to less service provision in health care and other sectors.

Figure 3.12 and 3.13 correspond with these findings and also show that scheduled tribes and scheduled caste have higher mortality rates and less access to immunization services than other castes (Misra et al. 2003: 47,135). Therefore, it can be concluded that the driving factors for vulnerability in health are low class and caste, female gender, illiteracy or low educational status and Muslim religion. Members of these vulnerable groups have the highest mortality and morbidity risks.

Source: Misra et al. 2003: 79 Mother's Education and Infant Mortality Rate (per 1000)

32,8

48,1 58,5

86,5

0 10 20 30 40 50 60 70 80 90 100

High school and above Middle school

complete Literate, <middle

school Illiterate

Figure 3.12: Mortality Rates for Scheduled Caste/ Scheduled Tribe and Others

Figure 3.13: Percentage Covered by Immunization Services by Caste

Percentage Covered by Immunization Services by Caste

0 10 20 30 40 50 60 70 80 90 100

Rajasthan Madhya Pradesh Uttar Pradesh Orissa Andhra Pradesh Maharashtra Kerala Tamil Nadu

SC/ST Others

Source: own design; data:

Misra et al. 2003: 135 Mortality Rates for Schedules Caste (SC) and Scheduled Tribes

(ST) (Rate per 1000)

0 20 40 60 80 100 120 140

Neonatal Post-neonatal Infant (<1 year) Under 5 years SC ST Others

Source: own design; data:

Misra et al. 2003: 47