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

Abstract

Background
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.
Methods
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) dataset.
Findings
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 disadvantages.
Conclusion
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 Award	2021
Original language	English
Supervisor	Itismita MOHANTY (Supervisor), Rachel DAVEY (Supervisor), Penney UPTON (Supervisor), Theo NIYONSENGA (Supervisor) & Rakhal Gaitonde (Supervisor)