Assessing Health Inequalities among

Indian Children:
A Decomposition Analysis

By
Jalandhar Pradhan
Guide: Advisory Committee:
Dr. P. Arokiasamy Prof. S. Parasuraman
Dr. L. Ladu Singh
Introduction
The distributive dimension of health or health inequality has
become prominent on global policy agenda, as researchers
have come to regard average health status as an
inadequate summary of country’s health performance
(WHO, 2000).

In recent times there is renewed interest in assessing

health related inequalities in both developed and
developing countries. Addressing health inequalities is an
urgent concern in developing countries especially in south
Asian countries.

The millennium development goals (MDGs) view the

reduction of health inequalities as its primary health related
goals.
Background of this study

Most health inequality studies until now have in fact

documented differences in average health status across groups
of people.

Sociological focus- examined inequalities in average health

status among social classes (Marmot et al; 1991).

Other scholars- racial or ethnic groups or by educational

attainment or occupation (Kunst 1995; Mackenbach, 1997).

Demographers- age, sex, education and racial groups (Preston,

1991). In low- and middle-income countries there exists a rich
demographic literature on levels and trends in child mortality
and causes associated with them (Hill 1999; Brockerhoff 2000).
Quantifying health inequality

Comparison
Absolute and relative difference
Aggregation
Sensitivity to mean
Sensitivity to population size
Subgroup consideration
Indian scenario

India is the nation with high-level regional inequality;

social hierarchy; and multicultural society.

With high level of economic and social inequality; health

and nutrition inequalities are also pervasive.

A greater inequality in health and nutrition among the

children of deprived group challenging to achieve
millennium development goals set forth by United Nation.
National
Contd…

Performance was found to be very uneven across locations

(rural/urban; north/south), wealth quintiles, and gender.

While health and gender inequalities in child mortality,

nutrition and immunization persist in some parts of India,
and understanding this phenomenon is important in the
context of economic development, policy implications from
evidence of health and nutrition inequalities are not
directly related to the health care system.
Need for the study
Most demographic studies concentrated on examining “between
group" differences. However “within group" differences is critical to
assess total health inequality.

Assessing health inequalities within class is an research agenda;

more importantly, comparative analyses of their determinants.

In common parlance poor are more deprived in health but health

inequality within poor is also significant. One should address this
question scientifically so that one can measure the inequalities
within the deprived groups (poor, SC/ST, rural, illiterate etc.).

These comparative studies are essential for formulating effective

policies, with which governments will be able to reduce these
inequalities.
 Total Health Inequality

Within Group
Between Group Socioeconomic inequality
Among states Ethnic inequality
Gender inequality

Total= ‘Between Group’+ ‘Within Group’

Objectives
To study health inequalities in terms of child survival
across Indian states using new sets of inequality index.
 To assess total health inequality in terms of between and within group
inequalities.
 To compare the estimates of new inequality indices with conventional
inequality estimates i.e. variance, the Gini coefficient, the coefficient of
variation.

To access health inequalities with regard to nutrition,

curative care and immunisation.

To interrelate level of summary indicators of health and

socioeconomic development with the level of health
inequality.
Data

National Family Health Survey-2, 1998-99

CMIE

Census

NSS
Methodology
Objective 1
Between group

First: The first step is to estimate the distribution of the

probability of death (under two) across children in each state
sample. These probabilities will be estimated using the
extended beta-binomial model.

Second: The second step is to transform the estimated

probability of death between birth and age two for each child
(2q0) to the expected survival time in the first two years of
life, S.
 1 e 22 m0
S  
2 m0 2 m0

2m0 can, in turn, be calculated from the probability of dying in the first two years of life,

ln[1 2 q0 ]
2 q0 :2 m0  
2
Inequality Index (II) developed by WHO working group

 
n n 3

II  
i 1 j 1
si  s j / 2n 2 s

Where, si is the expected survival time between birth and age two of individual i, and
s is the average expected survival time in the first two years of life in the population.
Within Group

Socioeconomic inequality (Concentration index by Wagstaff)

Ethnic inequality (Brockerhoff and Hewett)

Gender inequality (WHO)

Ranking of states with respect to above inequality indices

For comparison, estimates of child survival inequality will be
calculated for three other commonly uses summary measures of
distributions-the variance, the Gini Index, and the coefficient of
variation.

After that the states will be ranked according to their values. A

pair wise rank order correlation will be done to examine their
consistency.
Objective 2
The achievement can be measure by the following
index:

I (v )   (1  C (v ))
n
C (v)  1   ( yi / n. ) wi ( Ri, v )
i 1

v= the degree of inequality aversion

C(v)=Concentration index
n=Sample size
yi=ill health indicator of person i
Ri=Fractional rank in the living standards distribution of the i th person
• Higher level of v decreases the weight on higher income groups
and increases the weight on lower income groups. If v=1
corresponds to an equal weight on all individuals so the score is
percentage of population immunised or malnourished; v=2 uses
the implicit weight of the standard concentration ratio. As the
value of v increases, most of the weight falls in the lower strata.

• If the adjusted score that increases more for lower value of v

evidences that richer portion of the population benefited most and
vice-versa.
Objective 3

The following indicators will be used to interrelate with the

level of health inequality

 Per capita income

 Share of SDP spent on health
 Level of poverty
 Income inequality
 Mean probability of death (2q0)

Regression analysis will be employed to interrelate above

socioeconomic indicators with health inequality indices.
Thank You