Paper short abstract:

Health equity is essential for individuals, serving as both a means and an end in their lives, providing fair and just opportunities to access healthcare. This paper aims to explore and analyze health equity through Sen's capability approach among the people of Baramulla District, situated on the Line of Control between India and Pakistan.

Paper long abstract:

Health is both the means and ends to a quality life for a human being. It serves as a gateway to accessing other opportunities, including quality education and progress in economic and social aspects. Therefore, it's crucial to assess the extent to which health equity has been provided to the community and its agencies. This paper aims to explore and analyze the scope of health equity in the borderland district of Baramulla, Jammu and Kashmir.

The paper uses the capability approach to examine the significance of health equity through Sen’s capability framework, which revolves around two claims: the freedom to achieve well-being and agency. Freedom stands as the pivotal component in this framework. However, Martha Nussbaum presents a list of central human capabilities necessary for a life of human dignity, differing from Amartya Sen’s approach, which focuses on expanding human capability without a specific list. This difference can be seen as an attempt to address life's subjective and uncertain aspects. Nussbaum's suggestive list cannot universally define human capabilities.

The capability approach retains its significance in providing health equity, which is central to human development. Especially during the COVID-19 pandemic, amid public health crises and social injustices, achieving health equity becomes a fundamental goal for policymakers, health establishments, and communities. Health equity implies fair and just opportunities to achieve highest level of health. Achieving equitable health requires a collaborative effort from individuals and institutions over a longer period. The process of expanding human capability should not be solely viewed as the government's responsibility but also involves social institutions. Here, the role of agency becomes crucial in how agencies respond to the community's health needs and how the community accesses health through these agencies.

Freedom, central to Sen’s capability approach, plays a pivotal role in India's diverse demographics, where inequality persists in society. Inequality obstructs access to healthcare services in remote areas, exacerbating the burden of healthcare costs and potentially intensifying poverty. Thomas Piketty's work on inequality underscores the challenge of reducing inequality in development, as individuals play a central role in this process. However, addressing inequality extends beyond income inequality alone. Unequal access to opportunities in personal and social spheres poses a threat to human well-being. Institutional frameworks that facilitate these opportunities are influenced by people's exercise of freedom, enabling them to participate in social decision-making processes that promote the advancement of these opportunities.

However, the notion of equality as a solution to inequality is subject to debate, raising several questions. One such question pertains to the diversity among individuals and the diverse aspects of equality and inequality. Differences among people extend beyond external factors such as entitlement, natural or social environment, encompassing internal factors like age, gender, and physical and mental abilities. It is important to acknowledge and address this human diversity instead of dismissing it, to effectively address and rectify inequality, ensuring a sustainable existence for all. These factors significantly influence people's ability to exercise health equity.

India, with its wide range of diversity in geography, social, and economic status, experiences both inherent and constructed inequalities. Baramulla, situated on the Line of Control between India and Pakistan, presents a distinct scenario. Here, the local health department has achieved 100 percent immunization coverage and notably reduced infant and maternal mortality rates. This case exemplifies health equity at the last mile, highlighting successful efforts to address healthcare disparities in challenging circumstances.

The study employs vulnerability analysis, utilizing three key indicators, to assess health equity. In Baramulla district, various factors contribute to vulnerability regarding health issues, such as geographical accessibility, proximity to health facilities, community mobility, distance from the district headquarters, and the socio-economic conditions of the community. While two pregnant women with a haemoglobin (HB) level of 6 may be medically categorized at the same vulnerability level, these indicators can significantly impact their overall vulnerability. For example, a woman residing in a remote and inaccessible area, far from health facilities, will face higher vulnerability compared to a woman with the same HB level residing in Baramulla town. Furthermore, including more indicators can further amplify vulnerability. Based on this rationale, our findings indicate that Boniyar, situated near the Line of Control (LoC), exhibits heightened vulnerability. This vulnerability serves as a hotspot according to the analysis and underscores the importance of ensuring health equity in immunization. The paper will conclude by presenting a framework to ensure health equity in similar areas, with a focus on localizing the framework to suit specific contexts.

References:

Piketty, T. (2017). Capital in the Twenty-First Century. USA: Harvard University Press.

Sai Ma, S. A. (2023). Distinguishing Health Equity and Health Care Equity: A Framework for Measurement . Massachusetts: NEJM Catalyst.

Sen, A. (2000). Development As Freedom. New Delhi: Oxford University Press.

Sen, A. (1999). Inequality reexamined. New Delhi: OXFORD University Press.

Sen, A. (1985). Well-Being, Agency and Freedom: The Dewey Lectures 1984. The Journal of Philosophy, 82, 169-221.