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Review of Literature and Theoretical Framework
2.1 Introduction
Ilescilrch on thc ut~lrsation and determinants of health care services and related issues
h a ~ c become an imponanl policy issue in the context of both developing and developed
countries. The approaches of the governments towards health care provision and
utilisation have heen different For Instance, in many advanced countries the role of the
statc has bccn ~nstrumcntal and governments budgetary provisions and allocations have
been si~bstanual T h ~ s con~ributed remarkably to overall improvements in the general
hcalth status. uhlch is typically true in thc industrially advanced OECD countries
(Gerdtliam and Junsson, 2002, Jonsson and Musgrove, 1997; Shieber and Maeda, 1997).
In most developing countries. larger vacuum and deeper gap have been left out by the
govcrnlnents as a pollcy inil~at~velalternat~ve to permit large scale private participation
thcrchv encouraging out-of-pocket payment as the method of health care financing for
both outpatient and inpatient care (Sanya1.1996. Selvaraju, 2003). The proportion of
rcour ic allocatloli for rercarch and development in general and health care research in
particular has been much higher in developed market economies and has made
slgniiicant contribution to the overall development of production and service sectors
[Korllai and Ilgglcston. 1001) . On the other hand, in most developing countries, the
nature and cxtc111 ol'~n~er-sectoral co-ordination among the different departments such as
watcr .;upply, irrtyation. sanitation, rural development, human resource developmenr.
puhllc hc~l th . lam~ly wcliarc. tducatlon and housing have been very weak affecting the
tlnct~onal efficiency and long run sustainability of various health care and related
development programmes (GoI, 2002b).
I)ctcrminants ol' population health are complex and the organisational structure of
the health carc systcln bas~call) contributes to the operational efficiency or inefficiency
of thc systcm, llealth care is a typical commodity bought and sold in a (partially)
rcgulatcd or mostly tfcc markct system. Health is an invaluable asset and deterioration or
decline in the health status require appropriate medical intervention. The technology
induced health care has increased the medical expenditure and accentuated the miseries
of thu common man on thu one side. and the changes in medical technology as an
important instrument of the market have thoroughly transformed the profile and pattern
of secondary and tcniary hcalth carc (Kornai and Eggleston, 2001). In general, the
developing countries experience many problems and constraints in the provision of
health care like inadequate essential drugs, lack of qualified medical and para-medical
personnel particularly In rural and tribal areas. insufficient community health care visits,
poor transport and lack of material for dressing and treatment. These constitute the major
suppl! constraints. which rrsrrlcr the utll~sation of the health care services (Ross Mary
McMnhan. 1986. flergwali. et.al, 1973) Thus, in the rural areas of most developing
countrles, supply factors In the form of infrastructural constraints restrict the utilisation
of thc essential health care services On the other hand, the physician parameter act as a
proxy Sor the patient i i i malters relating to the nature and type of diagnostic or
therapeutic procedures and the quantity and quality of (specialised) medical services for
both outpatient and inpatlent care(fuchs. 1972) However, medical science cannot claim
thu hll crcdit kir the impr{~velnents in thc health status. For instance, the American
Medical Association states: "Med~cal Sclence does not seek major credit for the
Improvements In the health level during the past 25 years. Certainly our standards of
living and li~glicr education level have contributed substantially to the betterment of
healtll ievcls" (Quoted In Fuchs. 1972; see also Illich, 1976)
I lealth carc cconomlcs. an Important branch of normative economics deals with, in
general. the production ~ii'llcalrh and consumption of health care services. Health care is
treated as a commodity just like any other commodity in the market and in this process
the iit~lisation of qualiiy hcalth care services has become a serious problem for the
\'ulncrable secuons, marginal cornmunlrles and the rural poor. In the present world of
technology re~olution. health care pricing is generally more skewed and the ability to
pi^? 11I'thc people is a constraint on the utilisation of quality health care services. Thus,
inalntaining individual and community health IS a serlous concern and promoting health
surveillance. achlev~ng equity through proper allocation and redistribution of health care
rcsourccs are important policy issues. At the theoretical and empirical levels, the
determinants ol' product1011 or supply of health and consumption or demand for health
care are crucial in the analysis of the utilisation of medical care services and in the whole
licld t~l'research in health care economics(Wagstaff.1989;Fielder,l981).The determinants
of health owe much to the nature and pattern of the health care provision, medical
infrastructure, the socio-economic status and the cultural aspirations of the people. The
singlc lnost important factor influencing the individual or family health status is the
quality o f life. which would be basically Influenced by the socio-economic and
demopraphic ractors At the policy level. there should be reconciliation between these
micro and macro economic health issues, which are crucial when health status variable(s)
act as a determinant o f labour productivity and economic efficiency (see fig.2.3). In the
long run, cross sectional houseliold health surveys, particularly at the policy level, should
contrihutc fbr sustaining thc health status by improving the overall socio-economic status
and in part~cular the nu t r~ t~ona l standards 1'11~1s. Improving the level o f income through
e~nploymen! yuar;lntcc programtne and. of course, eradication o f poverty and deprivation
act as important detrrinlnants of health status sustainability in the long run (Rothman,
et.al 1998; Sen. 2005)
I:rom a polirical cconom) vie\vpoint, demand for health care and its sustainability
depcnds much on the nature and character uf resource al locat~on in the health sector,
quantity and qualit) of incdlcal car t ser\icea and equity considerations in health care
prov~.;ion. hcalth care ~ n h t r u c t u r e . the a\,ailabil~ty and cost of medical technology.
medical expenditure and the socio-economic status of the patient or the household. Thus.
a broad framework for a scientific understanding and evaluation o f health care requires at
lcast a i'our lilld cl;rbs~licat~on and analysis of the medical care functions viz, preventive
carelmcdicine ( cp ~ncrcascd birth spacing, reduction in family size, communicable and
orher diseases. ctc I: curatl\c carc~medicine (eg treatment of acute infections, reduction
in ~iiotcrnal m o r t ~ l ~ t ! and morhldlt!. and reduction in low blrth weight, etc.); restorative
care ( e g impro\.ement in the functional status as a result of medical treatment for
variour chronic incdicnl conditions) and palliative care (e g, reduction in discomfort and
impro\cd product^\ It!. reduction In paln and other suffering associated with illnesses
such a, cancer. etc I [see Dctcls. 19971 This classification provides a framework to
clinical or hospital care and a gcnciai understanding about improving population health
through appropriatc hcalth care interventions Such an enquiry has imponant
implications for health status obtained through cross sectional household health surveys.
2.2 1)ctcrminants of Health
I'he World I-leal111 Organi/ation defined health as a "complete slate of physical, mental
and s t rc i a l being. not ~ ~ m p l y the absence of disease." Even though this definition is
narrow. i r provldcs a broader outlook to behavioural and social determinants o f health or
health care. Most cross sectional household health surveys use self-reported morbidity as
the method of disease identity and it considers household as the most significant
producer of health (Mehrotra and Javret. 2002; Segovia et.al, 1989; Sriram, 1991;
Hayncs et.al, 1990). The cross sectional household health survey is a tool for analysing
self-rcported morbidity and provides people centred morbidity and health care utilisation
datahdsc across gender. agc. socio-cconom~c status. sector and systems of medicine. This
also acts as a guidel~ne to health policy. health planning and health management both at
the micro and macro levels (Boote et.al, 2000; Bergwall et.al. 1973). That is, health
status valuation ~nvolvcs the ~dentification and measurement of health status variables
and their determ~nants For instance, in general. health seeking behaviour is the totality
of physical, social. economic. elivironmental and genetic factors. In multi-community
and ~iiult~-castc socicty. bchav~oural and cultural determinants provide specific shape to
the analysis o r demand for health care and its determinants (see figures, 2.1, 2.2 and 2.4).
Frenk et.al ( 1901 1 provide a standard and systematic presentation of health determinants
at thc ~nd~r idua l . household. societal and sbsternic levels by incorporating the multi-
dimensional trait\ ol structural and prox~rnate determinants of health (fig: 2 5a). Health is
the rssult of lnteractlon of thc various indiv~dual and community factors on the one side
and (he a v a ~ l a h ~ l ~ t y and quality ol basic facilities at school orland home on the other
(fig. 2 . 5 ~ ) . 'She tbans-Sroddan model. which 1s relatively involved, characteristically
integrate soc~al. phjsical and genet~c env~ronment with disease,well-being and prosperity
(scc lib: 2 S b ) I:~np~rlcal stud~es habe Identified that at the individual level, apart from
the pligs~c~an I'actor. aye. gender. caste. re l~g~on. language. public policy, socio-economic
statua. locaticin. perce~\cd quality. t!pe of head of household, family structure, family
s1.x Inoomc. e \ p c ~ i d ~ t ~ ~ r e . ~ v a ~ t ~ n p time. travel time. health condition, are the important
ind~v~dual or household determinants of health care service utilisation (Bice.et.al.1972;
Krocger. 1983h: .Adler and Ostrote. 1999: Niraula, 1994; Bergwall, et.al.1973; Fond,
IOYj: Ualtuswn. CI a1 2001. Ibrank~sh et at. 1998, Anderson & N e m a n , 1973. Basu.
1987. Ashokan. 2004: hlusgrove. 1986). Theoret~cally, the determinants of health look
relat~vcly srinplc and revealing but in the actual setting, the nature and extent of
~nterection arc Lcr) cotnplt '~ and Involved. and often irregular and uncertain (Arrow,
1963: Frenk. 2001: Armentan. 1998) The socio-economic. life style and diet related
factors are siyn~ticant determinants of the health seeking behaviour in the globalising
world (Lany. 2001: Lee. 2001). A non-clinical approach must provide a valuable
supplement to the clinical database particularly at the policy level. The policy makers
should accommodate soclal values, which play an important role in the delivery and
distribution 01' nledlcal care resources and the utilisation of health care services The
contemporary health care research focuses attention on efficiency and individual
preference functions as the determinants of the health status (Davis, 2001; Fuchs, 1996).
(icnerallq. therc are two broad approaches to health and development viz, growth
mediated and support led growth The former works through the trickle down effect and
the latter via a programme of democratisation and public intervention particularly in
cducatiun and health care. 'I he second approach aims at capability building through
democratic deccntralisation and people's participation and has been successfully
implc~nentcd In the lowlncomc. Indian state of Kerala (Sen, 1999). Commenting rightly
,In thc true nalurc ol'growth. the India Development Report (2004-05) states, "economic
growth is. after all. for the people. If the people are poor, if they remain unemployed, or
thew livelihoods are threatened. if they don't have access to clean water and clean fuel, if
the) don't have adequate health services. and ~f rural and urban development remains
unsausfactor). then growth loses its lustre"
I hr socio-cul~ural reform movements hake prov~ded the framework for appropriate
gt~vcinmental acrlon through allocatlve and red~stributice mechanisms and contributed
subsranr~ally for equlty and d ~ s t r ~ b u t ~ v e justice rn Kerala. Thus, the role of the state and
other instltuuons has been ~nstrumental in improving the general health status of the
peuplc and hcdlth I > conr~dered as a basic resource rather than a reason for living (Nag,
198.7. Kalr. 198 I I l'hr: Andi.rson-Newman and Kroeger models provide a comprehensive
dn,~l!t~cal Ira~nc\\orh of thc doterln~nants of health care service utilisation by classifying
them ~ n t o toc~ls Ilks prc-dispos~ng. enabling and illness level factors and dividing them
into indiv~dual and soc~ai determ~nants. Such a classification is useful and can be
ektcndrd to ~ d e n t ~ f ) the d~ffcrent~al determ~nants of health care servlce utilisation across
the bectora and sqstenir oi medlclnr: (see tigures 2.3 and 2.4). The multiple factors
influencing the health carc decls~on making process have been traced by them using an
~ndcpcndcnt but s~milar analytical framework.
2.3 Supply of e n d D e m a n d for Health
Demand for health is measured in terms of utilisation of health care services. It is
~nfluunccd h! ~nd~vidua l . environmental, prepayment and health care resource factors
~ncluding accrsr and accepvability I'hese factors are crucial and significant because most
of the health care dererm~nants are outside the formal health care system (Tulchinsky and
Varavikova. 2000: Feldsteln 1966). The final outcome in the whole st tuctu~~? of demand
for health services depends on the strength of interaction between these interrelated
factors. The physician proxy not the patient who reveals the medical preference for both
short duration and long standing morbidity oriand medical intervention for outpatient and
inpatient hospital~clinical services. The physicians and t& hospital industry not only
dctcrm~ne the dcmand ibr health care services, but the nature and type of medical
scwiccs for outpatlent and inpatient care and the demand for pharmaceuticals and
surg~cal and other equipments (Zweifel and Breyer, 1997). The market for health care
services opereter, In the larger context of industrial organisation where quite often the
1'actol.s outsidc the market act as a do~ninant determinant of health care market. Hospitals
wrth w~der medical choices and clin~cal optlons attract more patients and increase the
c ~ a t 1)1' hcnlth cdru mcasured in terms of monetary and non-monetary costs including
input costs.
Withln the neoclassical tradition. the role of the state and the market in the
pro \~+lon of health carc scnlces has been d~fferent For instance, the paternalists
~ n c l u d ~ n g Kcnnclh Arroh. Charles Allan. Musgrave. Klarman etc recommend the state
es thc efficient pro\ ~ d e r of health care services and James Buchanan and Lee strongly
dd\ouatc lor ihc 1narkc.t as the cffic~ent health care sentice provider These two positions1
approaches are basically consistent with market liberalism of the neo-classical variety.
On the other hand. the Keynrs~an and the Marxian approaches accept state as the
'ippruprlate age~,c> lu lmpro\~c thc puhl~c pro~~s ioning of the health care services In the
present context $11 ~ncrcosrd prlvatlsatlon of health care services and diagnostic and
tllcrapcut~c proccdiircs the treatment pattern IS moving towards a clinically or~ented
ind~\~duallst ic and reductionist d i s c ~ ~ l ~ n e '
Henry Aaron (2001) and Rutten et.al (2001) In their critical synoptic review of the
Hand Book of Health Ecdnomics ~dentify a slmplest model of the physician market
a ~ m ~ i a r to the tjin111ar 'hlarrhallian Cross' and ~ncorporates the impact of information
asynllnetry on prov~der choice on the one hand and the nature of physician ~nduced
demand for hcelth care srnJlces on the other. The physician induced demand goes
usually outside the prolile or medical ethics and increases the health care expenditure
substantially. Generally. the ~gnorant and illiterate rural patients depend on the medical
and non-med~cal advice and health care choices of the physicians. At the same time, for
othcrs. 11 has bccome s~gn~l ican t and some times fashionable to "demand" special~sed
med~cal care even for mild or short duration ailments. The market for health care
s c n ~ u c s would bc inlluenced by the demand elasticities (measured in terms of health
pric~ng. locaticrn or quality )and the supply elasticities particularly of the private providers
(delincd in terms of price or the existence of a competitive public sector),which basically
reveals that the nature and determinants of the government provision of medical care
servtces on the one hand and the health policy of the govemment on the other, have been
responsible for the low utilisation of publlc health care services (Hammer. 1997). The
quality of health care senrlces measured In terms of infrastructure including access and
locatt<~n. personnel. abailabilit! or essential drugs and medicines are important
determ~nants ol uul~satlon of health care services (Alderman and Lavy, 1996). The
expenditure relatlng to outpatlent as well as inpatient health care has become an
Important componcnt of monthly household consumption expenditure. Recent studies
havc revealed many-lbld lncrcasc In drug prices. which not only increased the miseries
of the rural poor. the marglnal communit~es and other vulnerable sections of the society
hul 0 1 thc gcnrrol popularlon as well (Rane. 1996). The nature and incidence of illness.
cultural. demugraph~c and econom~c factors. physician's knowledge, patient
charactenstlcs. ~nstltut~onal arrangements and the physician induced factors influence the
dem.lnd tor hcslth carc \enlces (Feldstein. 1966) A major determinant of demand for
health care utll~satlon depends on phbslc~ans' decisions and the patient-physician
undr,rstandlngs or contract5 illahh~nen. 1991 ), l 'he nature and the extent of physician
lndu~sd dcnirnif liv mciflcal Lare IS inore s~gnlficant in countries where the private
health care sector 1s domlnant Thus. the theory of health care decision making is
typically different from the model ( 5 ) relating to general goods and services. That is, the
analyt~cal content ~ I ' h o t h the indl5 ]dual and social choice models are different for health
and other goods and senlcch 1 he demand for health care of the poor and the vulnerable
\cc!lons arc d~l'fercnt becauae the11 uul~sat~on pattern also tnvolves self-medication and
eve11 n ~ n - u ~ ~ l ~ s ~ t ~ o ~ i of health carc ser\lccs Povert) has deteriorated the morbidity
condltlon and the health status of the poor and other vulnerable groups. On the other
hand, geograph~cal proslmlt!. ~(1st of med~cal care. provision of health care services, and
health pollc) of thc gu\crlimsnt are s~gnificant determinants of supply of health care
(t.ok, 1972. V~sarla and Cjumbcr. 1996: Yesudian. 1999: Fielder. 1981: Sauerbom et al.
I VKV. Krireycr. 1VX3h. I lilynss et al. 1990).
I'here are economlc and non-economic barriers. which restnct the demand for
health care and the effic~ency of the health care system. Nature of illness and the felt
necds of the population. provider-consumer relationship (or the doctor-patient
relationsh~p) and the immediate mental make-up of the patient orland the family and the
economic status determine the type and nature of medical intervention (Akin et.al. 1986).
In the present world, technology plays an important role in shaping the nature and type
ul' lnd~vidual and soctal choice relating to the utilisation of health care services. The
technological advantage, the developed health infrastructure and other advantages of the
private medical centres and hospttals on the one side and the provision of the multi-
Ihu~l~ty and supcr cpcctal~ty tllcdical service~ in the same hospitalllocation have attracted
paticnts to the private health Fdc~llty
Market e q u ~ l ~ b r ~ u m ib the ultimate response to supplydemand forces where the
quanuty suppl~sd 15 equal to thc demand for health care servtces at the prevailing market
prlce Contrary to the usual process of market equilibrium, the situation in low-income
countries may be termed as "uneasy or painful equilibrium" where the market drags the
patlsnt consumer to thc prl\atr health care to maintain or improve his health status. In
othur words. the consumers' abilitl-to-pa) and the morbidity pattern are unfavourable to
mi)\! rural patlcnts M ' a l t ~ y time. real. pecuniary and opportunity costs and access to
health care also act as other determ~nanrs of market equilibrium. The physic~an act as
dual drtrrrnlnant both In the demand for and supply of medical care services. The nature
and pattern ~) fhea l th care market and the mrd~cal care industry are totally different from
thc gcncral marhct I'or go~ jds and services Most pattents may be experiencing
~nlc~rmat~on as)mmctr! or and moral hazard whereas the physician has the relative
. I J \ J I I I ~ L ~ C ( 1 1 lnlornidtlon >!lnmetr) (getting relevant and timely ~nformation) on the one
s ~ d c and added mural strength on the ather. llnder these circumstances, the patient IS
conlpelled to accept the ph\slclrtn as a decision-making proxy variable. Imperfect
~ n l ~ l r ~ ~ ~ a t ~ u n or ~nformati,>n as!mmctry leads to imperfect market systems contributing to
~ncl'licleni lnarhcr .rr)lut~vn\. and. therefore, go\ernment must intervene In the market
\)\tern
I he ,~ll \~cau,in nlr.ch.iniam ~ n \ o l \ e d In health care resources is a s~gnificant policy
varlable ~nllur.nc~np the dctnand lor health care services particularly in rural areas. The
~ntroduction of user fees as a method of resource mobilisation has reduced the utilisation
01 publlc health care rcr\ lcca alld increased bypassing (Akln and Hutch~nson. 1999).
lrllproved hcalth care ~nliastructure and other positive supply side factors have increased
the utilisation of publlc health care services (Deaton. 2002: Amardeep. 2002). At the
pol~cy lebcl. the pol~tical uill of the government should be based on the people centred
and people oriented health care strategy through democratic decentralisat~on as an
F i g 2.1: Fac lo rs i n D e m a n d f o r H e a l t h Services
Indiv idual Cl ienl R c t o r s [e g Age. Sex. Education. Occupation
* Phys~cal * Economic Demand
Suclal * Cultural
Factors
* Access * Acceptab~lity
Prc-pa)mtnl Facttrrr P r t~a t r Insurance
* Tax-based tlealth Insurance * hat~onal Health System * hlanaged Care * Co.pa!metit
5ni1rcr Tulchln5k) and Vara\lhn\.! 1?0001
F i g 2.2: .4 M o d e l o f D e m a n d t o r M e d i c a l C a r e
components o f care
Factors affecting s ph)s~c~sn's use o f the
t r u n t m e n t component, of care
* Inc~dencc o l iilness ePcrcept~orl r i l
~ r l d bel le l * Cultural and
detnograph~i factors
~ond t l l un
~llness *Anllude Iuudrdr weking ~ n c d ~ i i ~ l care * Econom~c faclors
Sourcc Feld<tc~n. Paul J (1966)
+----- I * :;::CanC:elllllcs
~ n ~ l u d e s rrlatlve co\l to the patlent lrom ustng d~fferent components o f care Ins t~ tu~~ona l 3rrangemcnts I'liys~ctan's knou ledee
* Kelallve cost to the phyr~cians from uslny alternallvc sets ofcomponcnts o f care
* Hosplral care ---l * Physlc~an care i t Referrals to speclal~sts
nurslng home care, etc
alternative to the bureaucratic decentralisation in capital and resource scarce but morbid
affluent low income countries (Nerenz, 1996;Maria and Redons.1999; Chemere Dan.
1997. .!arcs and Kasaje. 1998, Annc Mdls ct.al. 1990; Roos.et al. 1996; Levy, 1998;
Welton et.al. 1997; Davis. 2001. W~lkinson. 1999;Filmer et.al, 2000).The discriminatory
and lncfficient provlslon of bas~c publ~c health care services in the rural areas in the third
uurld countrlca havc Increased the cp~demlology of disease burden and the incidence of
med~cal expenditure for both acute and chronic morbidity and outpatient and inpatient
care Appropriate health planning and health management techniques focusing the
rpcc~lic health ~iecds o f the papulat~on and disease surveillance programmes would be
~nstrulnental In dclin~ng thc components of a sound mral health policy (Santana. 2002:
Mvhrotra and Jarrett. 2002. I'oan. et.al 2002; Hong Ha, 2002: Niraula. 1994; GoI, 1993;
Nadc B Brouk5. 1474. hl\bahu. 1986. Mag)ar). 2002, Yesudian. 1999; Turshen. 1989)
2.4 Equity
One of the Important lrsuca ~n\olvcd In the provision of health care is the proper
d~atr~hutlun ol rca<~urce\ lor health care dt.\clopment and its effective utilisation. The
duminat~on ol the prl\ate Iicalth care sector and the appearance of uneth~cal med~cal
practlics hale +~pn~licantl) lncreascd the med~cal expenditure for both outpatient and
Inpallent heal111 care I he ~ n c d ~ c a l expenditure 1s highly skewed across socio-economic
group. caste and rel~glun Stiid~eh ha\e also revealed that these factors are stgnificanr
Jctcrn~~nants of ~ n c d ~ c a l chpcndlturc per normal and caesarean childbirth. That is, inter-
cunililunlt) and C J L I ~ group d~l fe rencc~ In med~cal expenditure are more revealing across
aoc~t)-cconom~c atatus (Ashiih.in. 2005)
I hc tran5ltloli Irom livdlth ri) [he bas~c component of the service sector to the
lucral~\e prolit mallng med~co-~ndustr~al complex has substant~ally reduced health risks
and increased the cost of medical care and the mlsery of the socio-economically
d1sddta11tagt.J Alan! rural pnrlr.nla ekperlsncr difficulties in meeting health expenditure
111 ~ h c l~ghr of ~ncreascd hcdlth care costs and privatisation of health care services In
deniucra~~c avc1ctlt.a. the r ~ ~ l t . of the government as an agent of red~stributive justice and
an ~ I I ' I c I ~ I I I )cri I C U pro\ 1dc1 has been challenged In low income countries l ~ k e Ind~a. the
government has been bas~call! "soti" and less efficient in ach~eving equity or distributive
justice in the health care sector and achiev~ng the objective of horizontal and vertical
hcaltli equity. I'hls IS slgn~ficant but challeng~ng in the context of privatisation of the
health care sector 1.lorirun1al cquitq states that the peopleipatients with similar health
problems should get ~dentical medtcal treatment and in vertical equity patients with
d~ss im~lar ~norhidity pattern should he entitled to get differential health care. Modem
democratic governments fall to introduce appropriate redistributive mechanisms either
through policy alternatives or via legislation to minimise health inequality. In
contcmporar) soc~ct~cs . health ~nequali t~es are more rampant and w~despread and the
poor find 11 very d~fficult to foot health care bllls. The poor are compelled to bypass the
rural publ~c health care system due to the non-availab~l~ty of medical services, essential
~ l sug \ .lnd i~tlicl pilramcdlcdl scruices liealth inequalities in the form of the availability
and non-ava~lab~llt) ol' health care services and infrastructure and disparities across
yocia1 geograph! have been slgnlficant In many Indian states. For instance, the rural-
urhm differences dnd d~spar~rlcs in tcrms of health care spend~ng have been found to be
much hlghcr In 9talua l ~ k c .4ndhra I'radesh. West Bengal. Kerala and Tamilnadu (India:
llural I)e\clopmcnt Kcpon. IL)YY. Gumher. 1997) The democratic decentrallsed health
c,lrc. a!\tcm can X I d~ a pci~erful srrateg! to Improve health inequity by reducing the gap
hettsevn "health h a ~ e s " and "health ha\e nuts" and it encourages rural de\'elopment.
This I:, s~gnificant In countr~es \ r ~ t h ulde spread spatial heterogeneity, socio-cultural and
C I ~ I I I L dl\ers~t!. snd. o f i~lilrac.. nhcn a slgnlficant proportion of the rural population
I ~ \ e s helo\\ thc poten! I~ne illeaton. 2002. House. 2001, Adler and Newman. 2002;
~11n.ir~Icep. 2001. L\d\artc,, iL)74. Mechan~c. 2002. Marmot, 2002). Table 2.3 provtdes a
,!\tcln\ dnalbsla 01 ~lrcdlcal c u e I-losp~tala hlth wlder and special~sed health care
C I ~ I I I C ~ ~ attract patltnts and p o , ~ t ~ \ e l j Increases the cost of medical care. measured In
tcrniz c ~ f monctar! and niln-in~inctar! costs In developing countries. where public health
Inrulancc IS ~ r i ~ ~ y ~ i ~ l i i . i ~ n .ind modest the wdening of the therapeutic choices and
Inno\dlluns In medl~a l technolog! have ~ncreased the health care expenditure
suhstanr~all)
2.5 Socio Economic Status and Health
l'ducat~on, occupation and income are the three general components of Soc~o-Economic
Status or Soclo-llconom~c (jroup (SES'SEG). These components and the dynamics
~nbolbcd therc In, shape the nature of pathways Thus, a general model of the pathways
by whlch socio-econorn~c st;itus lnfluencea health is summarised in figure 2.6 The SES
IS a composite ~ndcx and analytical tool used mainly in health care and epidemiological
data analysis, l 'he causality between SES and health is bidirectional and the causal path
from the SES to health IS stronger than the reverse. The SES influences health and illness
throuyh environmental resources and psychological and physiological factors.
Psycliological and environmental indices have been excluded and only quantitative
\ar~ahlt.s have been ~ncludcd in the construction of the SES index. Providing appropriate
weightage to the different components of the socio-economic status is difficult but it is
analyr~cally s~gn~f ican t and useful in the methodology of SES construction. We have
adoplcd percapita cxpcnditurc. percapita education score, percapita land and housing
condl~lons (rool'and f1oor)aa the Sour basic components of the soc~o-economic status and
dlflcrcnt~al weights-40 percent. 30 percent. I S percent, and 1 5 percent have been
rchpcil~vely awgnvd (sec 1)caton. 2002. Bice et.al. 1972; Dunlop et.al. 2000; Adler and
()stroke. 1999: Adler and Nehman. 2002; House. 2001; Kannan et.al, 1991)
Fig 2.3: A Schematic V ~ e w o f Health Economies -- X I a t i . t l r ~ r ~ R . m U h , 1
U -. . 1Oo7n ho H.4* i"h T&.,.. ",*"h, ~ ,h , . '1 j I~lq.""".l h ~ . d . C a n m p & o n l,.\'nb,*
! F e + - , ,,:,, , , A , 5 o , b,du, ,,, ,!u, ~ . -. -i p ~ ' * ~ ' d u c ' ' D n ~ l m m ~ "'
i d.,,. mu.,,: ..,,,I.,, , .,I. ,a!,\. , ( - , / r. llr,. ,.. i," I
i i
Fig: 2.4 A Syslerns Analysis of Hea l th C a r e
individual object~ves:
party ~npui," (influenced by
Objectives Income, Le~sure
Hospital
Objecl~res Those ol 'ch~ef phlrtc~ans
Cap~ral Iechnology
Source Z w r ~ f c l and Breyer (1997)
Fig: 2.5s: Determinants 01 Health Level
Basic Determinants
* Pupulatlon * Env~ronrnent * Genome ( B ~ o l o g ~ c a l Rlsks) t Social Orpan~zat~on (Economic structure, political
mst~tut\oor. science and Technology, culture and ~dealog))
bucietsl 1 1 Structural Determinants I L i.e\el o l h e a l t h L Occupational btructure L Social stralifical~on
Redistribut>ve mrchan~srns-Taxes and Subsldles
4 P r e r i m r l r Dere rm~nsn t r
Household
L \+or l lng cond~rlons (Occupar~onal rtsks) L I l i l ne sond~lions (soc~al rjsks)
S l ' u h l ~ i l > it,nfcrred ent~tlements + kducmlon, roc~a l securlt)
+Vdrket baaed entirlemenls Food and Houslng L L ~ f e rr)le (Behav~oural r ~ s k s l + Health care s)stem
I)~,ca\c agcnc) [ l l ~ ~ i l a g ~ c d l / He.. \ D~agnos~s and
C'helnicdl. Treatment
Ph>r~cal. status Env~ronrnental
- Uctcr~n~na l~on ... ...--.b Health act~ons
Source Irenk n al (1'491)
Fig: 2.5b Determinants 01 Population Health: Evans-Stoddart Model
Fig 2 . 5 ~ Dcterm~nants 01 llealth
Individual !
Fig: 2.6 hludel o f the Pathways b! whlch SES influences health
-. - SES Exposure IO I I-
Constra~nls cnrctnogens and * E\tsrnal palhogens
en\ lronrnent * 5oc1al Health
stir lronment * a n d Performrnce of * Resources health-relevant Illness
behaviours
Psyrhuluy~cal ~nflucncrr
CNS and Endocrine
t Cognition * Immune and cardiovascular
Source Adlrr and Ortrove (IP99)
Fig: 2.7 Kroegers Model of llealth Seeking Behaviour
I a b l c : ? . I ~ ( j r n c r ~ ~ ~ ~ b l i c Heslth Studies , -
91. Stud) Focus 8 Major Findings
?"' : -~ ! i I Perce~ved susceptibil~ty, ser~ousnesr, perce~ved j
I , Rosens~och Behavoural benefits and barr~ers to tak~ng the decision are
Solon el a1 ' I (1067)
L-. I _ .
1 Anderson & Nrwma1rn(IV73)
, 1 - 1 6 ' Kroeyer I
( IqSja) I t I s i
. . b e t w ~ n rural and urban.
k { - T & T - -%k hnks cn publ~c ' K d e q u t c inst~tutlonal capacli and the severity 1 1 , , . 1 LZo?! , 1 Ieallh care system / of market failures
Murray CJL(1996)
Mehrotra and Javren (2002) --i
. - . . .. --- - Morb~d l r y T Differences between sel f ~e rce l ved and observed I
~ o n c e p t u a l l s ~ t i o n Health service
. . * ~ . - Comprehcns~ve health surve)
In India
Household is the most Important producer and
Us 142 60 per illness episode in urban area. Rs 1 15 1.81 per eplsode in the rural areas. with wlde
to the road and rervlce centre, are positlvcly l lcdthcare related to the use o f health care. Age o f the
srrvlce utillsation respondents and household size negatively associated w ~ t h health care use. Caste IS
.~ ! unlmpottant 1 Coclo-cultural factors and governmental suppon
Mor,allt) ; programs In the field of health and education 1 reduced monal i ty low Income countrlcs lncludlng /
~
4 h e lndlan state o f Kerala
( IU78 i d ~ s i r ! b u ! ! c ~ a, ,)avlF , 121,01, 1 50 i1a l valueand
Heath care ---. . Murra) a C'hen
. . f l l - - ~ ~ ~ - . + . -. Morbid't) cllnlcal d~agnos~s
. , . nd utllisatlon o f medlcal services
I Soc~al values crucial In determlnlng the dellvery and dlstributlon o f health care resources.
1 Self- perce~ved symptoms are a key Input to
I uchr L. , lq,?l Pti)sic!ansand lr,edlcrl care
Mcdlcai care decis~ons are physlclan induced ...~, .
I,drker , 1 4 8 2 , l l i ) ~ i \ eho ld health P rov~de i a standard methodology for sample
. . s u r ~ r ) ' household health survey uslng a two-week recall L.. --
In d e m o c r a t ~ ~ socletles to Improve population 1 1 I I l 'npul~ l lnn hcalth liedlth, resource reallocation f rom health care to
astlvltles that more dlrectly prevent illness ~ --
Lcadrr,hlp challenSe Lack o f political will of the modern governments \I r l t on et a1 I 14'471 In care , prefer market orlented solutions to complex health
. . *- . .~ . -. - care probiems -- ~III<:ILL;V~C I el r l lr i lcprrted rural Integration-cllnlcal. functional. physician system
l IVY7) , lic,~!ili _ ~mindcial
2 4 Yoder R I I Y ~ Y ! I
I,r rr idre Soc~o.econom~c characteristics quallty o f care arc
-- I the -- Dctermlnants ofdemand -----I The nature o f cholces and health seeklng I
Kur,i i hedlth I hehavlour In cruclal for rural health planning and 1
lo0. uhbch ind~cater that peoples abll ity to pa) l mas the c ruc~a l determinant o f health care
1 and I I and 17 days for urban IPS. , 7 , 8 --?----. Basic determ~nants basic, structural. proximate, at ,
;'> I TenL J e l AI I 1 0 0 \ ~ "::::::;" system!c, soc~etbl, m l~ tu l lona i , hou~eho.' and
I ' .- 1 ~ n d ~ v ~ d u a l levels ! , U.rsrldn ,, , , O x O , : HeJllh cconij,neir,cs I-~rovldes an analytical survey of British applied I
osltlve health econometrtcs stud~es. . ldenttfies the role of vub l~c health (indirectly) and 1
processors in medical care Health determinants include: biological, socio-economic, racial-ethnic, psychological. env~ronmental, bio-medical rlsk
general model o f he-lth status
C tnrintunity approach '' 119q8) I" hcalth research
I
: ; 2 ' t i umhu~ I IOU71 M n r h d ~ f ) hurden
clmlcal medlclne(d~;ectl~)ln lmprovlng health status In splre of enormous investments In the health sector, panlcularly cancer, the relation between health care spending and health o f populations remalns weak. The rate o f hospital~sation per I000 populatlon differs across provinces In Canada For ~naance. it IS 75 In Winnipeg, 110 In non- Wtnn~peg and 90 in Manltoba Argues for
populatlon hcalth lnformat~on system __ It lncludes the panerns of utilisat~on by age and sex as well as economic, organisatlonal and cultural delermlnants o f and access to utlllsat~on of health care Community based approach include the need ' demand for care, co-morbtdlty and use o f health rervices, relation o f natural history of disease to Ihe use o f health serv~ces . -
urban centres. The reported annual rates o f hospitai~sat~on for males exceeded those for males in rural and urban Ind~a. The rate ofhospital~sation rhowed a rlse with MPCE Average duratlon of
I able: 2.2 Soc~u-Kcynutnnr Slnlic: and Demand for Medical Care ..-._---._7
I ~ l . n o I Study Focus. . ' Ma 'o r findin s 1 , , l)eai<,ll i2(,(,2, pol,c> .
i ~ c ~ i e ' i ; i y d z ~ o n seiarately p:otective o f health SES 1 . .. . . - - and health negalively related
1 1 - i d l e r rnc ' Labour market Inequality and inequality In SES defined in
SES and health terms of educat~on. ~ncome, occupation detcnorates the gaps between the hcalth "haves" and "have nots"
, stay varied between 13 and 18 days for rural IPS /
I i "";;c,:; r r rv lcES.- . l O f ~ d
h s n i v e correlation between SES and use o f med~cal care 1 1 SCrvICes
I - - - - -- - V i i a " i i a ; b for health services IS hlghly skewed. Costs and 1 I. 1 Fuchs(l996) 1. health care 1 benefits of care different across SES, age, sex, and social
eeoeraohv
1 Adler and 8 Ostrovr
I I O Q ~ I S i S and hcalth 1 Breast cancer and mal~gnant melanoma rates hlgher among
upper SES group .,,., ' i a v l n . ~ I Soc~al ralue and / Sochal values determining the delivery and distributhon o f
, _ 1 ~ - - *0_1 . + -&?!thhcare , health care resources
l u Fond. Anne Pr~rnar) health 1 Consumer's socio-economhc characteristics, qualhry o f care (1995) iarc the r n a ~ d c t e r m i n a n u ofcare.
, , Wade and 1 Rural lhealth .Thenlure ofchotces and the health seekhna behavlour cruchal " 1 B ~ ~ k s I 1979) m;dna$rmet_ 1 for rural health plannrnp and management.
( T u o types health benefits (a) consumption benefits o f health
!: M u u r ~ n c ~ i J M 1 Dcmand for In the form o f increased utllhty and (b) investment benefits o f
I (19821 health j health in the form of healthv time available for activ~ties such i I , as consumption, working and hnvestment In health
I ! Hakkincn.l! I Demand for j A s~gnificant ponion o f health care utilisatton depends on 11991 1 1 _ health 1 doctors' declshons and is generated by pauent-doctor contacts ,
Murra) FI dl Anributes o f health variat~ons across individuals lnclude I
1191)91 I iedhh~nrqual~t ! chance. genes. physical and soc~al environment a n d ! ' lnteractlon between enes and the envhronment I *'derrnan dnd I O,,i;h t i ~ u ~ i n l l o w R o m e households are w i l l ~ n g to pay for '
l.a\) I 19461 a ~ s ~ l ~ s e r \ i c e s provlded by the government _J
'Table 2.3 Heal th Care Financing /Expenditure ~ . . . -. -. - . . .. .-- Sl.no Stud! I Focu, j M a j o r Findings
. .. .- . . .. --- - Private sector crucial In the provision o f health care servlces in \'~e!nom An average household spends $9 1 a month on health 1 care or $1 12 annually I The households spend a larger share o f thew Income on health (around 3 4 percent) as compared to 1 09 percent of the state
i o n ~ r m m e n t r tn 1901.9d k-z- . . .- . . . . , . - ' . I Uugal dnd k,i ' The percapita annual household medtcal expenditure worked
2 , Am,n (1989, 1 "u!-F,Rsj82 49, w h ~ c h was 7.64% o f the total consumptlon
I'""", !&an ba~reerelathon to rural areas
~ l i , l d d i , d --[; SOchaI tnsurancc contr~butions, prtvate lnsuranc]
(2001 1 tinarlclng , prrmiums, communtty Ananclng, out- of-pocket payments are 1 r ~ s o u r c e s o f health finance
Rural The Chlnese study revealed that high medical expenditure, the
7 LIU et a1 (1995) prhmary cause of poverty panicularly after the global~sation
+ -. a enda Averaee medical exoend~ture oer eohsode was Rs.850. Rs 1065
Medical / for IP-care in rural bnd urbanare; respeclively and Rs 70 and / expend~ture Rs 97 for OP care In rural and urban areas In 1993.
. - 1 I
.- - . - .-
Study [ Focus - I.-.- M a j o r Findings
(1995) i data bas"' ma~n iy urban biased.
Jackson i 2000 ) Ger~atr~c care and! Causal llnk between ageing and medical expenditure
*"-*,.A;,,,.*
o f expendtture on child btrIh In rural Kerala ~arabana I 0ne.seventh o f the households in Kerala spend more than 20% j2001) 1 ACLe'b I o f the~r annual ~ncome on med~cal ex endihre.
I ulasldhrr tkpendlture-? E G i a t D r y resource alloc:ion and cxpendlture , ,,,,,., , cumpress~on & 1 compresston In the soctal sector badly affected the educattonal ,,",,I 8
healrh sector and hector In lnd~a - - - - - -- J Table 2.4 Political Economy and Equity
-r.s.tu.d~ ;..- -.. -1 , Fucu! _+-. - , M a j o r findings
sd,,ldnd,P \uc~aI LOW SES Increases the rtsk o f poor health Strong assoclatlon between soc~ai class (low Income) and low 1 ZZ:h ~ service ul t l~sat~on ,
Mechdn~i D 114th , Development strategies to Improve populauon health I t?Uo?) ; 1nequd11!\ : m2lncrease health tnequalttles
,
I Access IS equitable when the use of health servlces 1s
(20021 1 Hrs l lh rqulty 1 determtned by demographic factors and need and not ' I b) soctal character~sttcs or the abillty to pay
I : Underddeelopmcnr 1s due to hlghly skewed or Yd$,+rru.\ '
Table: 2.5 Rural Health
' . L3roor1 1?79 , p:ldL:%fi~ . -2r.i +@r r,ra healtr plann~ng and mana"gcmen1 I , f luao- C. m n J I ! 51ya- 1) ofrne pat.ents sobgnt medtcal lreatmenl
health wry~ey_lxreaees the ut~l isat~on o f med~cal care services
l'able: 2.6 Other Related Studies I 1 M a j o r findings
Will~amson tnv~ronmentai / Environment. the basis for aublic health and 1 1 (1996) 1 health / soclal medicine.
Protecting workers' Interests, betterment o f
2 fn~~ronmentaland worklng condlt~ons Inside the industry and Muk1'I' iYv7' ' I c ~ c ~ p d l ~ o n a l health env~ronmental protect~on out slde poses X ~ I O U S
- c- . . . - - j threat lo occuparlonal health 4 srare of successful menral functtonlng, resulting
. . ( 1996)
..
Health plannlnp i transponatlon , communlcatlon and environment) ' an Important determinant o f utilisation and non-
+-~-- util isat~on o f health care facilit~es.
Wade and Brooka The nature o f choices and health seeking
(1979) , behaviour is cruc~al for health plannlng and
mana ement I ,. .! . 'Mar~dn.~ and Health car; :Three dimensions o f health care decenrral~sation-
Law plays an tmponant role in regulating the Marun.K and
I ,ohn,on~, hw and 1 ~nteraction between factors external to publ~c 1
health, through the regulation o f activ~t~es and
i 13 Bhat. Rdlncsh
+.- Abu-Zetd and
I S ' Da_nr (1985) . j. ,.. . . . - . - .
1 ~ ~ ~ ~ a n d j c c e: a1 l199U)
I ' 7 hhSUI lY** !
behaviours. Increase Investment in technology and proper
Ptivate Sector management of health care resources Regulate the rlvate secror throu h a ro riate le tslatlons I
Gender .=I-JJ=+ and health Higher female morbidiry
,,ssrna, flea ,n I Lo* antenatal care dur~ng pregnanc) in sp re o f
. . ---- tnc ava11ab.l.t) o f s ~ c h fa;~ t es In :he PHCr Uomen's educartoi Income fam, \ strJ;rJrc and ktnsh~p stgn~ficant determtnants and occuparton. ~ santtatlon factlltles lnslgntficant derermlnants of ~ health care service uttlisatton . . . . -- -
, Inpartent rate 23 per1000 during 365 d F s T h e ' Morbtdlty and ( monthly prevalence rate for routlne illnesses was
utll~satmn 64 per I000 m rural and only I 1 per IOW ~ I populatton In urban arcas
burden / The reported annual rates o f hosp~tal~sat~on for
~ &- . males exceeded males In rural and urban lndla - i i Hosp~tal cost variations are due to differences in
1 9 o luu i~hu ie , l lu\p~tal lcngth o f ' average length of stay Increased ut~llsation o f OP
I 1978 I s~d\ ! care factlit~es wll l reduce the leneth of 1
2 4 1 Udllc! i?0!l21 _ u i & s ~ i n lof health care servlces among the rural elderly I Access. resources. distance. transDortatton tlme. 1
1 - _. _ _ - I
has ttai~satton
: ?,, ~ I h b 1 5 ,,IIC! Uusscl RIs& cost o f IP hospiu care has increased the
, (1'172 1 1 OP and IP carc ; use o f OP hospltal care and the substttur~on of ,
8 hos ital OP care for IP care. < -
1 !I ~ ~ ~ n ; ; dlld -- ' k%Zand OP and 0u;atlent vlrtts and ~npatlcnt admtss~ons decline :
. , office hours are the supply stde factors and age. 1
2 5 sex, family stze. social structure. race, educatton. / ~~~~~a t t on .~~ l t u re .~ncome .~nsu rance and need are !
Benth>t!l!l (1982) IP care
I laynci and Ue!~:h.~m! 1'1821
Ahu-leid and Ildnn ( 1981
I ll) I (1992) .~ . ..> - - .--
Bhatt~a and Cleland (1995)
with decreasin accessib~li 2 2 4 Hard[, C et a1 1 facllon ; a s ,$ton in p?bllc OP health care .
I 1 t2004l , . - -. Access and monthlv DercaDlta consumer !
. - 1 - - 1 sources of health care more than at later partty 1 I Women's education. Income, fam~ly structure. )
I
/ health and ktnsh~p slgn~ficant determinants and women's 1 / occuparton, sanltatlon facllitles were not /
- - - I Access and OP and I IP carc use
? -
h,aternal health . . . . - -
1 1 Insignificant I
Outpatlent vtslrs and Inpatlent adm~sslons decline I wtth decreasing accesslblltty LOW antenatal care durlng pregnancb In splte of : the ava~lability ofsuch services in the PHCs 1 -
Ilealrh Pos~ttve cffect of maternal schooling o the usc of prenatal and delivery care services. Educarlonal level, economlc status, and rcltgton
Maternal health are signtficant predictors o f maternal servlce
1 Maternal health That is. mother's at first partty consult modern
,8u!uuejd qijeaq put? (~ilod q11e.y 01 aur(apln4 e apl\old
pue aseqoiep am qileaq [euo!9al aqi a~oldur! plnw slt[.l sarpnis ~I~JP-LII pi111 J!II.>:,~s
103 paau aqi siu!odu!d pue sasr.uas ales qilcaq loj pueuap 3q1 UI ~deil ~JIPIF~J sa1~11i1apr
ma!.%al iuasald aql 'sale1 asuale~ald Ll!p!q~o~u Aurlnse?~ JI.~ pa<oldwa ylomaurrq
les!dl~ue aqi s! di!p!q~om pauoda~-jlas jo idajuoj aq~ q~l~aqjo u0115npo~d 3~1~uanllur
salqe!loA aql pue sas!,uas am qijeaq 30 uolsi.to~d jo ui ilddns pue uo!lesll!ln
JO suual u! palnseau s! ales qireaq JOJ puwap aqj pxqnxrp uaaq .>\rq sa71 \I>\
ales qileaq loj pueuap puejo .Clddns aql ur patlo.\ui wnqql p~uaioq~ J~I ~xdeq:, SI~[I 111
uo!snpuoa
'(87 arn8g aas) sas!Nas ares qlleaq jo uo!ies!l!in pur! iilpiqlour 4~11s<[eur: lq yiomaurelj
e padola~ap pue paypow aheq am 'ra~amo~ saj!.uas an:, qlleaq jo uones!llin aq~
Bu!sX[eue 103 (9661) Xe~nm pue '(~~61) uoslapuv .(L : a-ln3y aas pue ';g01) 15831>1\/1
Xq pasn ylotnaweg lelaua8 aqi molloj a,q ixaiuo:, leuo13a~ xlissds .?ql ~II ~mlipuadus
les!pau pue alas pue do 'Ll!p!qlow JO siueurtuJsiap puu xnleu aql ;iurq.;uppe Ie \uie
L11esg!aads Lqnbua iuasaid aql .amisnlis .-iseasy jo alnieu jeiau>R sqi uo~j iualJjj!p
aq dew ales dl puz do 30 sluou!uuaiap aqL n'l!p!q~om jo slueu!ulalap pua ul~llad
'amleu aqi uo snsoj '1elauaB u! 'am3 qileaq uo saipnig .IT UI pa,\[oAu! slsos jesipau-uou
pue [es!pam aql pue sas!Nas ares qlleaq ~uanedu! pue iualiedinn JC) u~aiied UOIIF\I~II~
aqi ssalppe 01 pau!orisuo~ uaaq aheq sa!pnis asaqj, suo!%s~ sso~st! ulalled iro!~es~lrin pue
IS03 '~l!p!ql~Ul aql U! sdo8 q3lEaSal SalE3!pU! JlnlClalll JlqE[!!%" JJyl JO MJl,\Jl aq.L
I saxnms are3 qlleaq yqnd jo i(l!lenb rood j leulalaw Pue sql~j11~ - / lL 1 -. . .. - .. . .- . . . .
I In general. two stream\ of hcalth care provlslon are advocated, one 1s the state regulated and the
other market determ~ned The Keynes~an and the Marxian economists argue in favour o f
governmental provision o f health care as the efic~ent alternative to the prlvate provision by the
market W l th~n the neo-cla<a~cal trad~fion there are two groups of thought Keynestan economics
ddvoiatcd Itic i o n ~ c p l ol wcllarr ,Idle focustnp on [he provlslon o f soclal servlces ltke educat~on,
health. trdn\por[ and h o u r ~ ~ ~ g a, the bas~c measures to ach~eve and malntarn full employment. On
the othcl hdnd. thc Markidti vdrlcty stdles that accumulation (profitable ~nvestment) and
l e g i t t ~ i i ~ s d ~ ~ ~ r n I v r i ~ a l l un i i ~on d~tiis at mil~ntalnlng peace and stab~lity In a clasr dom~nated
soclety) are the two bas~c functions o f the state In a capltallst soctety (see Navarro. 1974.
Santhana. 2002. Rothman. 1998. Keth1nent,l99l)
top related