Confronting Disparities: Navigating the Path to Inclusive and Quality Healthcare
By Arunima Rajan
Despite legal recognitions, actual access to healthcare remains unequal, suggesting that more practical solutions, beyond legal mandates, are needed to address the systemic barriers.
In the quiet suburbs of Chennai, Amudha pours her soul into cooking for well-to-do families, her days rhythmically paced by the sizzle and spice of her culinary art. This serene routine shatters abruptly when her son, *Kumar, becomes a victim of a harsh traffic accident, leaving him with painful injuries and a grimacing mother. In the face of long queues and cold, clinical spaces, her resolve is tested at every turn.
*Kumar's eventual surgery, funded by a patchwork of loans and donations, marks a bittersweet victory. His recovery is slow, shadowed by the spectre of financial ruin and the daunting prospect of rebuilding their lives. Amudha, back in the kitchens, stirs her pots with a quiet resolve, each dish a silent ode to the struggle for equitable healthcare in the hidden corners of a vibrant city.
It’s not just Amudha’s story. Despite many countries recognizing health as a human right, over half of the world's population lacked full access to essential health services in 2021. World Health Day 2024 focuses on 'My health, my right' to tackle these issues.
"It is our collective responsibility to ensure that healthcare is not a privilege but a fundamental right for all. Regardless of socioeconomic status or geographical location, every individual deserves access to quality healthcare services. As healthcare professionals, we must advocate for policies and initiatives that promote equitable healthcare for everyone. Let's strive to build a society where health is not determined by wealth, but by the commitment to promoting well-being for all,” says Naveen Ganjoo, Senior Consultant - Hepatology & Integrated Liver Care, Aster RV Hospital.
The right to health includes 4 essential, interrelated elements: availability, accessibility, acceptability and quality.
Bridging Gaps and Enhancing Care
Availability in healthcare means having enough quality health facilities and services for everyone, measured through data analysis and surveys to identify coverage gaps across different groups. Accessibility involves ensuring that these facilities and services are reachable by all, considering factors like non-discrimination, physical location, cost, and information availability, with a focus on removing barriers for marginalised and disabled individuals. Acceptability requires health services to be ethical, culturally appropriate, and sensitive to different genders, emphasising patient-centred care and adherence to medical ethics. Lastly, quality in healthcare not only refers to the standards of facilities and services but also includes essential health determinants like clean water and sanitation.
Health as a Human Right
Veena Aggarwal, a Consultant in Women's Health and Trustee at Dr. KK's Heart Care Foundation of India, asserts that the Indian government has actively pursued laws and policies to ensure healthcare accessibility for everyone, reflecting a deep-seated commitment to this fundamental right. She highlights that the Indian Constitution, particularly through its Directive Principles and Article 21, legally enshrines the right to health as part of life and personal liberty, reinforced by Supreme Court rulings that stress health as a basic right. Despite these measures, a significant gap remains between the ideal of universal health access and the reality, with rural and marginalised groups most affected, and issues like privatisation further inflating costs. Aggarwal advocates for a collective effort involving government, healthcare sectors, and civil society to enhance healthcare infrastructure, tackle socioeconomic and gender disparities, and foster investments in health systems. She believes that such a comprehensive approach will propel India toward achieving universal health coverage and improving overall citizen well-being.
Is tech the solution?
Access to diabetes and cardiometabolic care faces geographic and financial hurdles within global healthcare systems, says Dr. Avantika Waring, Chief Medical Officer at 9amHealth. “Studies reveal elevated rates of diabetes-related complications, including hypertension, specifically among marginalised communities. In rural and underserved regions, access to preventive and specialised healthcare is frequently limited. The integration of telemedicine and digital health solutions can overcome geographic constraints, providing remote consultations to encourage proactive health monitoring and timely preventive interventions. From a global perspective, many people live in countries where healthcare may not be easy to access locally, and others have jobs or life circumstances where they are travelling long distances for work or school, so visiting a doctor’s office can be challenging,” concludes Waring.
Tele MANAS Success Story
The government has undertaken initiatives to address the gap in healthcare services in India, the Tele Manas, being a notable example of these efforts. The Tele Mental Health Assistance and Networking Across States (Tele MANAS) initiative, launched on October 10, 2022, during World Mental Health Day, aims to address the long-standing issue of mental health access in India. It provides free tele-mental health services 24/7 across the country, focusing on reaching individuals in remote or underserved areas. To facilitate this service, a toll-free helpline (14416 or 1800-891-4416) is available around the clock, offering healthcare services at no cost, even in the remotest locations. Since its launch, Tele MANAS has counselled over 542,000 individuals and operates through 46 active cells across 34 States/UTs. Demonstrating its widespread impact, the helpline receives more than 2,400 calls daily, indicating a significant stride towards improving mental health accessibility in India.
Caroline Hood has been President and CEO of RS EDEN since January, 2020. Hood has a different take on the issue. She notes that enforcing mental health as a right becomes a tricky conversation as it relates to self-determination, stigma, historically marginalised populations, as well as the history of mental illness. “For example, until very recently, being gay was a mental illness listed in the Diagnostic and Statistical Manual of Mental Health Disorders (DSM) – an insurance-billable “Affliction” that was considered a disease. Access to free, culturally responsive, and ethical mental health care is essential. Enforcement implies a structure in which providing mental health care is at a level of competency and equity which is not there yet,” she explains.
Universal Commitment Required
“Individuals have very different views of what constitutes health. And even in the richest countries, resources are limited. But we have so many enormous opportunities to improve the lives of individuals in low and middle income countries, that we must make a universal commitment to tackle this low hanging fruit. At the present moment, for instance, we are witness to the WHO business case for screening for and treating as well as preventing Tuberculosis in Brazil, South Africa, Georgia, and Kenya. There is an enormous return on public and/or private investment in implementing these programs, but it requires the collective public health approach to operationalize and realise that. This is but one example. PEPFAR is another one,” says Howard Forman, the Director of the MD/MBA program at Yale School of Management. “We must continue to confront our emerging leaders with not just the business case for health and healthcare but also the moral and ethical case. Each country; each community; each region faces different challenges; but we must shine a light; we must identify opportunities; we must make equity not just an opportunity but an achievement,” he adds.
Lack of conviction about Universal Healthcare
Oladele Ogunseitan is a Professor of Public Health and founding Chair of the department of Population Health and Disease Prevention at University of California, Irvine. He notes that the most pressing challenge that low- and middle-income countries face in ensuring universal access to quality healthcare services is the lack of conviction that universal health coverage is the priority for countries with a high burden of disease. Instead, countries spend on weapons and war, and governments are plagued by corruption or unstable democratic regimes. The World Health Organization has been advocating Universal Health Care for a long time. Building the infrastructure for accessible health care also includes training and retaining the workforce of health professionals including public health practitioners, who can work in rural and urban communities.
“There is an abundance of data on disease burden in many resource-constrained settings, however, we lack the implementation science-oriented infrastructure to translate the data into healthcare outcomes in such settings. Public health education is a limiting factor because relatively simple hygiene practices can go a long way to reduce the disease burden. International organisations and governments can also reduce the “brain drain” that keeps trained healthcare personnel from working in the countries of great need. Financial and infrastructural incentives are essential,” explains Ogunseitan.
He also adds that retention of healthcare personnel is crucial. Recently, an innovative model of retention is being piloted whereby if a single trained healthcare personnel is attracted to work in an affluent country, that country will commit to training or providing funds for training at least two healthcare professionals who will work in the less-affluent country of origin. If scaled up, this strategy has the potential to enhance healthcare delivery in an equitable manner, globally.
Leveraging Spatial Analysis to Uncover and Address Health Inequities
Dr Dustin Duncan is professor and Associate Dean at Columbia University.He is a spatial epidemiologist, who focuses on understanding health disparities based on where people live. But can spatial analysis and mapping techniques be used to identify and address health inequities in India, particularly in marginalised communities?
“Spatial analysis, which starts with geo-visualisation (mapping), helps us understand the spatial patterns of disease, or put differently, spatial clusters. Such analyses initially suggest that environmental factors may be risk factors for disease. It also suggests where interventions should take place, both of which can be incredibly helpful for public health researchers and practitioners. I have primarily applied spatial analysis methods primarily in the U.S. but these methods can be applied to understand inequities in health across the globe, including in India,” he explains.
Beyond Healthcare: Addressing Fundamental Needs and Rights for Marginalised Communities
While healthcare access and quality are important determinants of health in Africa and elsewhere, fundamental needs such as adequate employment, safe housing, and clean water are sorely needed. Policies are needed to address these basic human rights, in addition to healthcare, to prioritise marginalised communities.
Duncan is in Africa right now, doing a site search for a new healthcare facility he is planning there to serve the health needs of marginalised communities there. “It is clear that we need to centre community voice, representation, and ownership in all of our work. This is critical. Centering the community and exhibiting cultural humility improves the research, including the cultural rigour of the research,” adds Duncan.
He just finished research on the health needs of trans women of colour in NYC. “My research suggests that there is differential healthcare access for marginalised communities, including sexual and gender minorities. Beyond access to health care, it is clear what is needed is quality health care that takes a human-centred and holistic perspective. For example, in a pending study that my team is near completing, we show that access to gender-affirming care and specific gender-affirming care procedures reduced psychological distress among the transgender women of colour in New York City. Unfortunately, in countries where gender diversity is not recognized, access to gender-affirmation would be difficult, if not impossible, to obtain,” he concludes.
Making Healthcare LGBTQIA+ Friendly
“Research has proven that social and economic marginalisation of LGBTQIA+ individuals and the community lead to healthcare inequities and poorer health outcomes,” says Alex Juusela, OB/GYN at Detroit Medical Center. “Therefore, it is important to resolve inequities at the healthcare system, insurance, and point of care levels. Legislation and equitable care should be designed and developed using evidenced-based research and resources,” he adds.
“From a healthcare delivery standpoint, it is important to establish an atmosphere of inclusion, safety, and affirming healthcare environment. Staff education regarding recognition of the discrimination, harassment, and the implicit and explicit biases faced, instruction on appropriate terminology and language, the healthcare needs of LGBTQIA+ individuals, as well as staff implicit bias training help create an inclusive environment and decrease negative patient encounters.
In order to create a more inclusive environment, the institution or office’s nondiscrimination policy should be clearly visible, there should be access to a gender neutral restroom(s), staff should be trained on how appropriately ask the preferred patient names and pronouns, as well as how to apologise if mistakes are made, patient forms should include write-in or check box options for all gender and sexual orientations, and the responses should be included in the medical record and used in every patient encounter,” he concludes.