Health inequalities are a growing concern across the world, with many problems originating from unequal access to healthcare services.  This is especially so in countries where private companies provide healthcare, which inevitably makes it accessible only to those who can afford it.

New research from King’s College London aims to explore how the introduction of the National Health Insurance Scheme in India back in 2007 has affected health inequality in the country, especially among the poorest 40% of the population for whom access to healthcare was subsidized.  Despite this, enrollment rates have been low, especially among the poorest who need it the most.

The paper argues that a lack of awareness is at the heart of this, and explores how information has failed to reach the neediest communities.  It also suggests that the social caste system may also have been a substantial barrier.

Social barriers

The caste system was officially banned in 1948, but the centuries old social classification system still endures to this day.  The authors believe that appropriate financial incentives can be an effective way to overcome some of the barriers introduced by the caste system in terms of access to healthcare.

The researchers employed local women from the state of Karnataka to visit families and raise awareness of the National Health Insurance Scheme among these disadvantaged groups.  Each village was assigned an agent, with some agents given additional financial incentives that were dependent upon the success of their dissemination of the information.  This was measured via follow up knowledge tests about the healthcare scheme in the communities.

The results suggest that this incentivization did have an impact, with communities served by these agents having higher awareness of the health scheme than communities served by agents on a standard wage.  Indeed, in interviews with communities, it emerged that incentivized agents actually spent far more time with people of a different caste to themselves, which suggests it could be an effective way at breaking down some of the social barriers to access.

“It appears that this incentive payment pushed the agents to engage with people of all castes and encourage them to enroll in the healthcare scheme,” the researchers say.  “If the agent wasn’t incentivized, but was from different caste than the beneficiary, enrollment rates were lower.  This suggests that, without a financial incentive, people may simply prefer not to interact with people from different castes. This is the common ‘preference’ story that is cited in literature, but we now want to test this.”

The team now plan to further explore this apparent ‘caste cost’ to see whether it’s the result of entrenched prejudice or more a case of communication barriers, such as the differing dialects used between castes.  The aim is for both projects to better inform policy makers so that health inequalities in India can be addressed more effectively.