Globalization, Distance and Disease:
Spatial Health Disparities in Rural India
Anirudh Krishna
Professor of Public Policy and Political Science
Duke University
212 Sanford School
Durham, NC 27708-0245, USA
(919) 613-7337
and
Kripa Ananthpur
Assistant Professor
Madras Institute of Development Studies
79, 2nd Main Road,Gandhinagar, Adyar
Chennai – 600020, India
+91 44 2441 1574(Ext 329)
Abstract
More than 50 percent of the Indian population lives in villages that are located more than five kilometers from the nearest town. This half of India is more likely to experience illnesses of different kinds and simultaneously less likely to get qualified medical treatment. The incidence of premature deaths, infant and child mortality, and malnutrition are all significantly higher within villages located further from towns. In consequence, such villagers are more susceptible than others to being overcome by the medical poverty trap. Poverty has increased within villages located more than five kilometers from towns, even as the national economy was surging ahead. Globalization privileges cities, disadvantaging locations at greater distances from towns. Public policy is required to compensate. Efforts to limit spatial inequalities must take precedence in future health policies.
Keywords: spatial health disparities, globalization, rural India, distance from town
1. Introduction: Investigating Spatial Inequality
Spatial inequalities have widened during the period of post-liberalization economic growth in India. Globalization produces effects that privilege cities. Prior analyses have shown how spatial inequalities in India have become more pronounced in relation to per capita incomes and household assets. Cities, together with a small group of villages located close to cities, have acquired greater economic potential, moving further ahead. Villages located at greater distances from towns have fallen further behind.[1]
This article examines spatial inequalities in the realm of health. It is not clear that disparities in income will automatically find reflection in similar inequalities in health. At least insofar as government-run medical services and incentives are concerned, the effects of public policy should be to minimize, rather than reinforce, inequalities of different kinds; that is, after all, a guiding objective of public provision. And yet, as the evidence advanced below demonstrates, as you go deeper into rural areas, health outcomes become progressively worse. Simultaneously, qualified care becomes harder to access.
A vast majority of Indians continues to live in rural areas, with this share falling only marginally, from 71 to 69 percent, over the decade prior to the Indian census of 2011. It would be foolhardy to expect that this share will fall to Western proportions at any time within the foreseeable future.
Policies intended to serve rural India will be required for a long time – and such policies need to be designed bearing in mind the growing importance of different degrees of “rural-ness.” Villages in India can be segmented according to their distance from the nearest town: 22 percent of the rural population lives within 5 kilometers from the nearest town, constituting an inner belt of villagers; 28 percent are situated between 5 and 10 kilometers of a town; while the remaining 50 percent of the rural population lives more than 10 kilometers from the nearest town.[2] Thus, a total of 78 percent of the rural population – amounting to more than 50 percent of all Indians – lives in settlements that are located 5 or more kilometers from the nearest town.
The results presented below show that it is among this half of the Indian population that multiple health disparities are clearly visible. In general, the more rustic one’s existence – the further one lives from towns – the greater are the odds of disease, malnourishment, weakness, and premature death.
Section 2 reviews the general proposition concerning how spatial disparities within nations have arisen together with advancing globalization. Section 3 interrogates the available national data, uncovering evidence of significant spatial inequalities in relation to a variety of health outcomes. In an effort to understand better the processes giving rise to such inequalities and how these effects are experienced among different households, Section 4 probes primary data collected by the authors in one rural part of India. Section 5 concludes by bringing together supply-driven and demand-based explanations for rising spatial inequalities, offering suggestions for policy reform.
2. Globalization, Geography and Growth
Alongside advancing globalization, economic opportunity has become concentrated within cities, especially larger ones. Sassen (2001: 3) notes how a “combination of spatial dispersion and global integration has created a new strategic role for major cities… [which] now function in four new ways: first, as highly concentrated command points in the organization of the economy; second, as key locations for finance and for specialized service firms, which have replaced manufacturing as the leading economic sectors; third, as sites of production…; and fourth, as markets for the products and innovations produced. These changes in the functioning of cities have had a massive impact… Cities concentrate control over vast resources.”[3] Another commentator has similarly noted how economic activity in the era of globalization has become concentrated within city-based “clusters of highly specialized skills and knowledge, institutions, rivals, related businesses, and sophisticated customers in a particular nation or region. Proximity in geographic, cultural, and institutional terms allows special access, special relationships, better information, powerful incentives, and other advantages in productivity and productivity growth that are difficult to tap from a distance” (Porter 2000: 32; emphasis added).
The effects of living at a distance from a city or town are experienced in terms of differences in economic opportunity. While larger cities advance economically, remote rural communities lag behind.
Remarking upon the “spiky” nature of current-day economic growth, Florida (2008: 19) notes how “the tallest spikes – the cities and regions [concentrated around cities] – are growing ever higher, while the valleys… mostly languish.” Such spatial clustering of economic opportunity has become acute within many parts of the developing world. China’s remarkable economic growth, for example, is “a result of only a handful of…spiky centers such as Shanghai, Shenzhen, and Beijing, each of which is a world apart from its vast impoverished rural areas… In 2006, average household incomes in urban China were two and a half times those in rural areas [where]…17 percent of China’s population lives on less than a dollar a day, almost half lives on less than two dollars a day… The prospects for bridging these gaps are weak… But all that pales in comparison with the growing pains felt by India’s poor. India’s growing economic spikes – city regions such as Bangalore, Hyderabad, Mumbai, and parts of New Delhi – are also pulling away from the rest of that crowded country” (Florida 2008: 35-36).
Analysts examining the rise of inequality in India have noted how income differentials are widening between urban areas (which still account for no more than 30 percent of the country’s population), and the vast rural countryside (Deaton and Dreze 2002; Dev and Ravi 2007; and Sen and Himanshu 2004). The biggest Indian towns have the largest concentrations of assets. In towns with populations of more than five million (home to six percent of the Indian population), 24 percent of all households possessed cars in 2005, 82 percent had color TVs, 64 percent had refrigerators, and 54 percent had mobile phones. The corresponding percentages in towns with fewer than 50,000 people were 7 percent, 51 percent, 26 percent, and 21 percent. In rural India, these percentages were lower still, respectively, 3 percent, 24 percent, 8 percent, and 7 percent – less than half the corresponding proportions within the smallest towns.
The potential for upward mobility is significantly implicated with geography. How well you do depends to a considerable extent upon where you happen to live. A close observer of these trends concludes that “despite all the hype about ‘the death of distance’ and the ‘flat world,’ where you live matters more than ever” (Moretti 2012).
These observations are borne out by recent trends in India. No matter what one’s level of education or training, earnings are higher if one lives within a large town compared to a small town and in a small town compared to a rural village. Individuals who have only a primary education earned up to 68 percent more by living in a metro city (one that has more than five million people) compared to a smaller town (with fewer than 500,000 people). Among people with college degrees, the corresponding income differential is smaller though still substantial: 38 percent (Shukla 2010).
Spatial economic differences have intensified over time in India. During the period 1993-2005, for example, when India’s economy grew rapidly, the largest cities experienced the largest average income gains. Smaller towns also gained but not by as much.
Beyond towns, the benefits from economic growth were radially dissipated: Inflation-adjusted per capita incomes grew in villages located within five kilometers of towns. But outside this inner circle of villages, inflation-adjusted per capita incomes have fallen, with the deepest reductions occurring in villages located at greater distances from towns - which had, to begin with, lower per capita incomes. To make matters worse, the poorest income groups within such, more remote, villages have suffered the largest cuts in purchasing power; evidence of widening income inequalities simultaneously along both spatial and socioeconomic dimensions (Krishna and Bajpai 2011). Concurrently, poverty has grown. In villages located between 5 and 10 kilometers from towns, the percentage of households below the official poverty line increased from 35.8 percent to 41.4 percent, a gain of 5.6 percentage points over this 12-year period, widely regarded as a period of unprecedented high-speed growth. In villages located more than 10 kilometers from towns, the increase in poverty was even larger: 6.2 percentage points.
That half of the Indian population which lives more than 5 kilometers from the nearest town is thus faced with a grimmer set of prospects. In the upward direction its movement is restricted; for many, their already bad situations are becoming worse.
One would hope and expect that in the realm of health care, at least, such disparities would be minimal or actively reduced. Bad health and medical expenses can bankrupt families. A slew of recent studies show how the largest numbers of people fall into poverty and remain poor on account of ill health and high health care costs (Krishna 2010; Whitehead, et al. 2001; Xu, et al. 2001). As many as 3.7 percent of the entire Indian population falls below the poverty line each year on account of unaffordable medical expenses, often incurring unbearable burdens of debt (EQUITAP 2005; Garg and Karan 2005).
Spatial disparities in health, therefore, need to be carefully examined. If the burden of disease were higher and access to qualified care simultaneously lower among villagers located more than 5 kilometers from towns, then they would be cumulatively disadvantaged. Coupled with the lower chances that they have, compared to villages located closer to cities, of gaining higher incomes and accumulating assets, the existence of a greater danger of descent, of falling into poverty, would tend to make spatial inequalities wider still, difficult to surmount without sustained external assistance.
Both parts of the analysis presented below help demonstrate that such, indeed, is the case. We look first at the national picture, focusing on the supply side of the explanation. Section 4 considers a micro-level view, helping understand better some demand-related aspects of disparate outcomes and health-seeking behaviors.
3. Spatial Health Disparities in National Context.
Prior examinations of health disparities in India have identified a number of factors, significantly associated with diverse outcomes and behaviors among different population segments. Analysts have examined differences arising on account of caste and wealth, finding significantly poorer outcomes among scheduled castes (SCs) and scheduled tribes (STs)[4] and between richer and poorer Indians (Balarajan, Selvaraj, and Subramanian 2011; Gaudin and Yazbeck 2006; Mohindra, Haddad, and Narayana 2006; Subramanian, et al. 2004). Differences between men and women have also been found to be salient, particularly when seen alongside socioeconomic inequalities (Iyer, Sen and George 2007; Iyer, Sen, and Östlin 2008). Substantial regional differences – across states of India – have been uncovered (Pande and Yazbeck 2003); and gaps between rural and urban areas found to be persistent and large (Baru, et al. 2010; Duggal 2005).
For reasons examined in the previous section, it is important additionally to examine differences arising within rural areas, particularly among villages located close to towns and others situated more remotely. Only one previous study has examined spatial differences of this kind. An examination of data collected in the early 1990s, during the initial phase of globalization-driven economic growth in India, found that “inequality in health indicators is very high… both infant and child mortality rates increase sharply [among villages located at greater distances from the nearest town] … short-term morbidity also shows a positive relationship with distance” (Kundu, Pradhan, and Subramanian 2002: 5042-3).
In the 20 years since these data were collected, this stream of explanation has not been followed up. While scholars have investigated diverse aspects of the relationship between globalization and health care,[5] finding both positive and negative features, the spatial dimension of health disparities has not attracted further examination within India.
In other developing countries, researchers have looked at the effects of distance to nearest health facility, concluding variously how distance, so measured, does or does not correlate with diverse health outcomes and disparate care-seeking behaviors. A study conducted in the late-1980s in Ghana found, for example, that distance was an important deterring factor in seeking institutional health care; the cost of care was less important in comparison to distance (Lavy and Germain 1994). A study undertaken in rural parts of one state of Nigeria came to a similar conclusion (Awoyemi, Obayelu and Opaluwa 2011). Other studies have, however, arrived at the opposite conclusion, finding that distance makes either no or relatively little impact (Acharya and Cleland 2000; Kesterton, et al. 2010; and Moisi, et al. 2010).
It is timely and important, therefore, to examine the recent evidence for India, considering whether and how in the phase of advancing globalization spatial health disparities have become larger or less significant. We present below the results from analyses undertaken using recent nationally-representative data sets.