Equitable access to healthcare in the era of universal health coverage : a study of excluded communities in the state of Kerala

Student thesis: Doctoral Thesis


Inequity in health and access to healthcare is a longstanding issue that has serious consequences
for the wellbeing of those who experience it. A disproportionate number of those affected
belong to socially excluded communities who suffer poor access to various resources, including
healthcare. Acknowledging ongoing gaps in achieving health for all, the World Health
Organization (WHO) has proposed universal health coverage (UHC) as a key policy for
enabling equitable access to healthcare. In this thesis, I explore and critique the dominant model
of UHC and discuss its limitations in ensuring equitable access to healthcare.
A mixed methods approach, consisting of an embedded research design (major qualitative stage
nested with a minor quantitative study) was applied. The qualitative stage followed the
grounded theory (GT) tradition of Charmaz, and the principles of GT along with those of
ethnography are used during data collection and analysis to capture both processes and setting.
The setting focused on two excluded communities in the south Indian state of Kerala –
Indigenous communities and widows above the age of 60 living alone. Multiple methods of
data collection, including in-depth interviews, focus group discussions and participant
observations, were carried in two phases between 2018 and 2019 with members of both
communities and key stakeholders in the healthcare system. For the quantitative analysis,
multilevel mixed models were used to understand the differentials in access to treatment
between various social classes in India and the ability of health insurance to improve access to
treatment for major morbidities in two waves of the India Human Development Survey (IHDS)
Efforts to address lack of access to healthcare did not take into account the intersectional nature
of exclusion and inequity, focusing only on clinical measures and insurance coverage. Multiple
factors at the macro, meso and micro levels combine to lead to the othering and exclusion of
participants from various resources, including healthcare. Common threads between the three
levels included power differentials between excluded communities and others and the lack of
intersectionality in addressing exclusionary processes (e.g. Indigeneity framed as cause, social
norms, medicalisation, candidacy). The quantitative findings confirm the role of social class in
differential access to treatment and the limitations of health insurance in overcoming these
This research demonstrates the need to move beyond the notion of a health system divorced
from the broader sociocultural and political contexts if we are to address inequitable access to
healthcare. Cultural safety that foregrounds power differentials and positions healthcare as a
right offers a more comprehensive framework to achieve UHC in an equitable manner. Framing
good health and access to healthcare as a right for all and addressing the power gaps will enable
us to navigate the difficult terrain of inequity and achieve the goal of equitable healthcare
within the context of a just society.
Date of Award2021
Original languageEnglish
Awarding Institution
  • University of Canberra
SupervisorItismita Mohanty (Supervisor), Rachel Davey (Supervisor), Penney Upton (Supervisor), Theo Niyonsenga (Supervisor) & Rakhal Gaitonde (Supervisor)

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