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- Convenors:
-
Sandra Obiri-Yeboah
(University of Ghana)
Vidhya Unnikrishnan
Ruby Kodom (University of South Africa)
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- Discussant:
-
Mohammed Ibrahim
(University of Manchester)
- Format:
- Paper panel
- Stream:
- Social protection, health, and inequality
Short Abstract:
The panel seeks to understand how the growing health burden in LMICs in the context of weakened state capacity and limited health provision services affects the poor and marginalized.
Description:
According to the World Health Organization, half of the global population lacks access to essential health services, a gap that is even more pronounced in countries with fragile health systems. Health crises including the rise in non-communicable diseases (NCDs) account for over 60% of deaths globally, with 80% occurring in LMICs. There are several determinants of the rising health crisis including poverty and income inequality. Weak health infrastructure and limited state capacity exacerbate these disparities and disproportionately affect vulnerable populations. The rising health crisis compounds poverty risks, with estimates suggesting that health expenses push approximately 100 million people into poverty annually. This vicious cycle of illness and economic hardship highlights the urgent need for coordinated actions. Effective responses require collaboration among government entities, non-governmental organizations, and community leaders to raise awareness, expand healthcare access, and deliver quality health services to underserved populations.
These issues frame the focus of this panel, which invites papers addressing the following:
1. How are socially differentiated people in LMICs affected by the rising health crisis?
2. How can LMICs mitigate the health risks of rising NCDs in the context of existing socioeconomic inequalities?
3. What roles do state capacity and non-governmental actors play in reducing health-related vulnerabilities and improving healthcare access?
4. How have growing health disparities fueled marginalization, and what strategies can address these inequities?
By examining the interplay between health burdens, state (in)capacity, and socioeconomic inequality, this panel seeks to explore innovative solutions to enhance health outcomes and protect vulnerable populations in LMICs.
Accepted papers:
Paper short abstract:
I aim to bring fresh insights on healthcare access for India’s uninsured 'missing middle,' focusing on chronic disease and provider choice. By sharing findings on affordability, equity, and policy gaps, I hope to spark discussions on strengthening UHC frameworks in fragmented mixed health systems.
Paper long abstract:
This study posits implications on health, equity, and policy by investigating healthcare provider choice among India’s "missing middle," a population excluded from both public health insurance schemes and employer-based coverage. Chronic diseases—requiring long-term care and risking significant financial burdens—pose a critical challenge to this group, raising broader questions about healthcare equity and state accountability. Two hypotheses are examined: (1) chronic diseases drive private healthcare utilization due to perceived quality disparities, and (2) disease severity shifts preferences toward public care as affordability becomes a decisive factor. The study uses data from the National Sample Survey (2017–18) to analyse healthcare access among those suffering from chronic diseases. Using the linear probability model with fixed effects, findings reveal that chronic diseases show increased public care utilization with reduced private care preference. Additionally, disease severity significantly reduces private care choice, underscoring financial vulnerabilities linked to chronic disease and seeking private care. These insights are pivotal for global debates on universal health coverage (UHC). India’s fragmented healthcare landscape reflects broader tensions between privatization and state obligations. Extending government health insurance to the missing middle and strengthening public health systems are essential for fostering inclusive development, that provides health as a human right.
Paper short abstract:
Ghana's climate change policy fails to address the psychological impacts resulting from climate events. This study emphasizes the importance of incorporating climate-related psychological conditions into the policy and the need for the provision of facilities to support vulnerable groups.
Paper long abstract:
Climate change significantly impacts lives and livelihoods. This adversely affects mental health by increasing rates of depression, anxiety, and post-traumatic stress disorder (PTSD). In Africa, women's vulnerability—due to unequal land access, limited financial resources, and traditional gender roles—heightens during extreme climate events like flooding and droughts, which negatively affect their productivity and psychological well-being. Unfortunately, Ghana's climate change policy does not adequately address the psychological impacts related to climate issues. This study focuses on Wungu and Yapei communities in the North East and Savannah regions of Ghana, exploring how climate events influence women's livelihoods and related psychological conditions. Using qualitative data from in-depth interviews and focus group discussions, 22 participants were purposively selected for interviews and 2 focus group discussions were conducted. The findings indicate that flooding and droughts impact women's livelihoods, with majority of them experiencing mental distress such as depression (i.e. inability to sleep and poor eating habits) and anxiety (i.e. nervousness) symptoms linked to climate-related losses. The study highlights the need to incorporate mental/ psychological health considerations into Ghana's climate change policy and enhance support services in vulnerable communities for addressing climate-induced psychological distress.
Keywords: Flooding, Droughts, Depression, Anxiety, Mental health, psychological distress
Paper short abstract:
This paper investigate the effectiveness of PFHIs on their primary objective i.e. in providing financial risk protection or reducing out of pocket expenditure (OOPE) on hospitalisation care in India in 2017-18. For this, an instrumental variable analysis is carried out.
Paper long abstract:
Globally, there is an evident policy emphasis to achieve the longstanding objective of universal health coverage (UHC). Publicly funded health insurance schemes (PFHIs) are increasingly becoming one of the prominent ways of financing healthcare, especially in low-and-middle-income countries (LMICs) like India. These schemes are envisioned to achieve the SDG 3.8 - “ensuring financial protection against catastrophic health expenditure (CHE) and access to affordable and quality healthcare for all.” It becomes imperative to investigate the effectiveness of PFHIs on their primary objective i.e. in providing financial risk protection. This study uses secondary data on household social consumption on health from three NSS rounds- 60(2004), 71(2014) and 75(2017-18). Through an instrumental variable (IV) analysis, to address any possible endogeneity, we aim to determine the relationship between PFHI enrolment and out-of-pocket expenditure (OOPE) for hospitalization care. We find that CHE incidence between ‘PFHI covered’ and ‘not insured’ households is found to be statistically insignificant. Finally, IV regression finds no evidence of a statistical relationship between PFHI enrolment and reduction in OOPE incurred per hospitalization case in 2017-18. This highlights the schemes’ ineffectiveness in ensuring financial protection. Existing studies show that PFHIs tend to be concentrated in private sector and do not ensure equity in access. Given that healthcare is fraught with information asymmetries and externalities, our analysis indicates that practice of Purchaser-provider split and strategic-purchasing inherent in PFHIs demands greater attention. Our analysis provides evidence of the ineffectiveness of insurance-based model in solving UHC problem of the country and questions their concerted expansion.
Paper short abstract:
Drawing on interviews with patients, carers, and healthcare professionals in Kenya and Tanzania, we explore how socio-economic inequalities shape experiences of cancer and access to cancer care, producing what can be understood as 'social pain'.
Paper long abstract:
Drawing on interviews with patients, carers, and healthcare professionals in Kenya and Tanzania, we explore how socio-economic inequalities shape experiences of cancer and access to cancer care, including timely diagnosis, treatment, palliation, and dignity in survivorship. Even where free cancer treatment policies or insurance schemes exist, the costs associated with diagnostic and other procedures, of travel to seek care, and of filling gaps in state provision, such as purchasing medicines, can be catastrophic. For many, cancer significantly impacts livelihoods and may necessitate sale of assets, further compounding socio-economic inequalities. Furthermore, the cost burden of cancer threatens the ability of patients and those who care for them to perform valued social roles and realise their aspirations, and reliance on family and friends for financial and other support can undermine social relationships and generate stigma and isolation. Those suffering from cancer in Kenya and Tanzania, and the healthcare professionals, family and friends who care for them, often understand the pain produced by cancer, therefore, not only as an individual and medicalised phenomenon, but as something that is fundamentally social. Recognition of ‘social pain’ often informs discussion of palliation in clinical settings, which might involve social workers and spiritual leaders as well as clinicians and medication. Beyond individual treatment plans, however, we argue that meaningfully addressing the pain and suffering caused by cancer in requires understanding how it is produced by wider socio-economic inequalities and structural vulnerabilities.
Paper short abstract:
This paper analyses how state and non-state health actors working on suicide prevention in Tharparkar, Pakistan, understand caste and gender as etiologies of high number of suicide. These understandings deepen the existing inequalities in accessing healthcare and further depoliticises mental health.
Paper long abstract:
While my PhD fieldwork was interested in the logics of psychiatrisation within suicide prevention programmes, many of my interlocutors wanted me to research on a completely different question of ‘why people were taking their own lives?’. Most suicides reported in Tharparkar, the district reporting highest number of suicides in Pakistan, are seemingly amongst the scheduled-caste Hindu women. This has led to the public health discourse in the region often answering the question of ‘why’ with responses steeped in cultural determinism–holding individuals rather than structures responsible for poor quality of life–such as ‘lack of awareness about mental health’, 'lower rate of education’, and ‘religious predisposition to self-immolation’.
Drawing on these discourses, I argue that etiologies of suicides in Tharparkar center caste and gender as a way to push the accountability from structures to individual and from the political sphere to the personal through usage of language such as ‘awareness’ and ‘predisposition’.
Using China Mills’ work on problematisation of poverty through psychiatrisation, the paper analyses how, in the case of Tharparkar, poverty and caste both are problematised, and explanations and interventions are targeted ‘at the level of the individual psyche rather than on the structural landscapes that produce and sustain poverty/caste' (2015:4). In doing so, the paper demonstrates how these discussions surrounding etiologies of death by suicides in Tharparkar contribute to the ongoing depoliticisation of distress, while simultaneously creating justification for pharmaceutical and psychiatric interventions instead of systemic changes.
Paper short abstract:
In this study, we argue for a greater focus on children in social protection research and offer a more nuanced understanding of the effects (or lack thereof) of cash transfers on children’s access to healthcare.
Paper long abstract:
Through an investigation of the Livelihood Empowerment Against Poverty cash transfers and the National Health Insurance Scheme, this study traces the impact of social protection and complementary services on children’s healthcare access in Ghana. We focus on four implementation districts with differing poverty levels and state infrastructural power. Data is based on qualitative-dominant mixed methods involving a survey of programme beneficiaries and qualitative interviews and focus group discussions with household members, community elites, service providers and government officials. We complement this with an econometric analysis of the determinants of children's healthcare access before and after the implementation of social protection programmes, using Multiple Indicators Cluster and Ghana Living Standards Surveys. We triangulate the results with extensive reviews of programme documents, NGO and media reports. We find that linking cash transfers to health insurance may enhance healthcare access for children, although other factors, including the generosity of benefits, quality of service and state capacity, may moderate uneven outcomes.
Paper short abstract:
Exploring ownership in Chinese health initiatives, this study reveals its dual impact on marginalized populations’ access. Balanced stakeholder engagement is key for reducing health inequalities in LMICs.
Paper long abstract:
This study delves into the dynamics of state capacity, healthcare disparities, and socio-economic inequality in the Chinese health sector, particularly focusing on the role of ownership in mitigating health-related vulnerabilities and improving healthcare access for marginalized populations. It analyzes three key initiatives, each addressing a distinct health crisis: the World Bank/UK Basic Health Services Project (1998-2007) for rural health system strengthening amidst marketization, the Gavi Hepatitis B vaccination project (2002-2010) for reducing Hepatitis B prevalence, and the Global Fund HIV/AIDS Rolling Continuation Channel (2010-2014) for enhancing civil society engagement with “most-at-risk populations” in HIV/AIDS. Data from 67 project and policy documents, 282 literature sources, and 56 stakeholder interviews were analyzed. The study reveals a nuanced donor–recipient relationship. Key practices, including multi-stakeholder governance, donor–recipient co-financing, and alignment with existing management and service delivery systems, technical and institutional capacity building were instrumental in establishing local ownership, advancing agenda and facilitating project transitions into local health systems. However, challenges were identified in ad-hoc transition processes without coordinated donor–recipient planning due to the strong ownership demonstrated by Chinese counterparts. This research thus highlights the complex interplay between ownership and healthcare delivery. While strong ownership can lead to successful integration of project components, it can also pose risks such as marginalization of certain populations and exclusion of essential health services for the poor. The study emphasizes the need for a balanced approach that considers local health needs and long-term sustainability, emphasizing the importance of ownership building and sustained stakeholder engagement for health outcomes in LMICs.
Paper short abstract:
The paper identifies the determinants of NCDs in India using a panel dataset. The paper also explores the role of healthcare facilities and social protection policies on whether this can mitigate NCDs. Our findings suggest expanding medical facilities and pensions can mitigate NCDS in India.
Paper long abstract:
Old-age morbidity is a rapidly worsening curse in India. The swift descent of the elderly in India (60 years +) into non-communicable diseases (e.g., cardiovascular diseases, cancer, chronic respiratory diseases, and diabetes) could have disastrous consequences in terms of impoverishment of families, excess mortality, lowering of investment and deceleration of economic growth. Indeed, the government must deal simultaneously with the rising fiscal burden of NCDs and substantial burden of infectious diseases. The present study seeks to answer three questions: Why has the prevalence of two NCDs, diabetes and heart diseases risen in recent years? Given the surge in these diseases, whether social protection policies and restructuring of medical services can mitigate such surges in the near future? A related but equally important concern is whether lifestyle and dietary changes could be induced to further prevent the rising burden of these NCDs. Our analysis is based on the only all-India panel survey-India Human Development survey that covers 2005 and 2012. This survey was conducted jointly by University of Maryland and National Council of Applied Economic Research, New Delhi. A robust econometric methodology-specifically, 2SLS- is used to address the endogeneity of key explanatory variables. The results here stress the need to make sure that pension and healthcare reforms are accompanied by greater awareness, expansion of old age pensions and public hospitals, and effective regulation of both public and private hospitals.
Paper long abstract:
We leverage the expansion of the National Social Assistance Program (NSAP) in India in 2006 to estimate the impact of access to public pensions on three measures of depression for the elderly in below poverty line households, using a regression discontinuity design based on age-eligibility cutoffs. We focus on India given that it is the largest lower-middle-income country in terms of population, has limited welfare safety nets, and relatively large proportions of disadvantaged people with mental health vulnerabilities. We find that becoming eligible for public pensions reduces the likelihood that the elderly poor are depressed. In particular, the intent-to-treat estimate is a 10.1 percentage point decline in the broadest measure of depression. Our gender-specific analyses reveal heterogeneous impacts across demographic groups. More specifically, widowed populations, the majority of whom are elderly poor women, gain the most. Our investigation into the underlying mechanisms reveals that pension eligibility improves mental health through decreased labor market participation, increased healthcare utilization, improved lifestyle choices, enhanced life satisfaction and greater control over resources. Our results offer insights for shaping effective social assistance policies aimed at raising the welfare of the most at-risk populations in resource-constrained contexts.
Paper short abstract:
This study underscores a widening spatial disparity in health infrastructure adequacy as urban population densities grow. Policy implications include an urgent need for equitable distribution of health facility investments, prioritizing high-density, underserved poor and vulnerable populations.
Paper long abstract:
Access to health facilities has become pivotal in universal health coverage, particularly for rapidly urbanizing cities in low-and middle-income countries (LMICs). Despite research on health facility access, monitoring and tracking of spatial adequacy of the health facilities against changing city population density over time and space remains partially explored. This gap limits understanding of the extent of adequacy or inadequacy of urban health infrastructure and how vulnerable city dwellers cope. The current study, examines the spatiotemporal correlation of urban population density and health facility inequalities in the Greater Accra Metropolitan Area (GAMA) of Ghana, from 2010 to 2022 Using geostatistical analysis of population census data of 25 Metropolitan, Municipal and District Assemblies in GAMA and number of health facilities per unity area, the findings revealed significant spatial inequality of health facilities access. Densely populated areas such as Accra and Ashaiman had fewer health facilities relative to their populations, while sparsely populated peri-urban areas exhibited comparatively better accessibility. Vulnerable populations in underserved areas relied on informal healthcare providers and faced increased travel distances to facilities, exacerbating health inequities. The study underscores a widening disparity in health infrastructure adequacy as urban population densities grow. Policy implications include an urgent need for equitable distribution of health facilities, prioritizing high-density, underserved areas, and leveraging spatial equity for planning future healthcare facility investments. The findings call for a holistic urban planning strategy to mitigate the inequalities of health access for achieving the global Sustainable Development Goal Three (SDG3) in rapidly urbanizing LMIC cities.
Paper short abstract:
The present study aimed to examine the disease burden and financial burden of water, sanitation and hygiene (WASH) related diseases among individuals using the 75th Round of the National Sample Survey in India.
Paper long abstract:
This study aimed to examine the disease burden and financial burden of water, sanitation and hygiene (WASH) related diseases among individuals in India. Data were drawn from the 75th Round of the National Sample Survey: ‘Household social consumption: Health’. A multilevel logistic regression model was employed to assess the effect of community-level factors on the prevalence of these diseases. The prevalence of WASH-related diseases in India was at 5.7% of all outpatient visits and 6.9% of all hospital admissions during 2017–18. Nearly 66% of all outpatient malaria visits in rural areas were associated with restrictions on daily activities of ailing individuals. The mean out-of-pocket expenditure across all WASH-related diseases was ₹703 per outpatient visit and ₹9656 per hospital admission. The monthly OOPE on outpatient care for 74% of persons with jaundice in rural areas was greater than their monthly per capita consumption expenditure and 97% of persons with malaria in urban areas faced catastrophic OOPE on outpatient care. Each hospital admission for jaundice in urban areas led to an earning loss of ₹2260. The intra-class correlation from the multilevel logistic regression for diseases prevalence were 0.28 and 0.26 for outpatient and inpatient cases, indicating the role of household and community-level factors in the prevalence of disease variation. However, there is a high prevalence, financial burden and effect of community-level factors on WASH-related diseases in India. The findings reinforced that the holistic strengthening of WASH facilities is required to mitigate the avoidable burden of these diseases in India.