It was nearly four decades ago that economist Michael Lipton brought to the fore the concept of an urban bias in the process of development, noting ‘the spatial differences or inequalities in poverty between urban and rural areas’.
He also highlighted that although domination of the urban class could be seen along many dimensions, it was perhaps most importantly manifested in the form of state health resource allocation that favoured urban priorities at the expense of national equity and efficiency (Lipton, 1977, ‘Why Poor People Stay Poor: Urban Bias in World Development’, Cambridge).
Even poverty is now being defined in multidimensional ways including health status, which is today a key factor and critical dimension of human development (Amartya Sen, 1981, ‘Poverty and Famines: An Essay on Entitlements and Deprivations’, Oxford University Press).
Millennium Development Goals (MDGs) have also placed considerable emphasis on the health indices considering that three out of its eight goals relate to health.
When it comes to health status and health care, Indians are split into two groups – the first comprising of the middle and upper classes of urban India with access to quality medical care. However, the second and larger group comprise of those that live below the poverty line in rural areas and have limited access to medical care.
The successive rounds of National Family Health Survey (NFHS 1-3) revealed huge rural-urban differences in key maternal and child health indicators. The latest NFHS results show that the rural-urban differences in mortality are especially large for children in the age interval of 1-4 years. In both, the neonatal and post neonatal periods, mortality in rural areas is about 50 per cent higher than mortality in urban areas.
Although India has initiated policies to bring down the gap between poverty and the health status, it appears that the inclusive growth policy of the Indian government is not benefiting the rural and urban areas equally. The undergoing programmes such as National Rural Health Mission (NRHM), initiated in 2005 are proving to be insufficient in ushering in equity as there is still a huge deficit in health outcomes in India.
The National Sample Survey (NSS, 2009-10) results clearly indicate an 88 per cent rural-urban difference in average monthly per capita expenditure. Rural people also spend less on health care as compared to their urban counterparts. The majority of the rural population are smallholders, artisans and labourers, with limited resources that they spend chiefly on food and necessities such as clothing and shelter.
The evidence for rural-urban health divide based on recent health statistics provided by Sample Registration System (SRS), Statistical Report 2012, Office of the Registrar General of India, New Delhi is presented in the figures below. The inequalities in distribution of selected sensitive measures of health status: infant mortality rate (IMR), under five mortality rate and life expectancy at birth (LEB) have been interpolated. It is evident from Fig 1. that the infant mortality rates are highly skewed towards rural areas as all the states fall below the line of equity. Madhya Pradesh, Maharashtra, Rajasthan, Gujarat, Andhra Pradesh, Odisha and Uttar Pradesh show a huge rural-urban divide. On the other hand, states such as Kerala, Tamil Nadu and West Bengal stand closer to the line of equity.
Fig. 2 likewise shows that the rural-urban gap of under-five mortality rates is greater in the states of Assam, Jharkhand, Rajasthan, Odisha, Madhya Pradesh, Gujarat and Jammu & Kashmir. Kerala and Tamil Nadu, however, stands near equity.
The rural-urban gap is also large in the under-five mortality rates across the major states of India. The interpolation places all states above the line of equity indicating that people living in urban areas are in an advantageous position in terms of LEB. The gap is greater in Assam, Madhya Pradesh, Odisha, Karnataka, Bihar and Maharashtra as compared to the other states. Only the state of Kerala stands near the line of equity.
India is still predominately rural in terms of its population concentration. The results of the Provisional Census – 2011, points out that of a total of 1210.2 million the size of the rural population is 833.1 million or 68.84 per cent. However, National Commission on Macroeconomics and Health (NCMH) report that about 80 per cent of health infrastructure, medical manpower and other health resources are concentrated in urban areas where only 31 per cent of the population live.
Then again, rural healthcare in India is characterised by a huge gap between supply and demand. Currently, rural healthcare needs are met either by limited government facilities and private nursing homes, which in most cases are unable to keep pace with the increasing demand and specialised services. The quality of infrastructure is usually poor and people access nearby large cities to seek high-quality care.
It is a well documented fact that many of the maternal and infant deaths occur due to the lack of emergency and timely health care at the rural health care centres. It is envisaged that providing essential and specialised maternal and child health services including emergency services in rural areas will reduce 60 to 70 per cent of maternal and child mortality.
Additionally, rural populations, are the prime victims of unhealthy living environments, and are often the first victim of epidemics. The 2011 Census in fact reveals that more than 70 per cent of the households of rural India do not have toilet facilities. Unsafe and unhygienic birth practices, unclean water, poor nutrition, poor habitats, and unsanitary environments are challenges to the public health system. India therefore urgently needs to strengthen its rural health care infrastructure and manpower manifold in order to serve the nation in true sense of the term.