Introduction
The 2008 publication of the Commission on Social Determinants of Health (CSDH) report focused attention on the crucial role of living conditions for preventing morbidity and mortality, improving health status, and dictating inequalities in health outcomes and utilization of health services [
1]. One of three overarching recommendations of the report was to “measure the problem, evaluate action, [and] expand the knowledge base”[
1]. However, since the’s publication, a regional-level assessment for the European region is published [
2], but detailed assessments of social determinants of health (SDH) at the country level are not available. As the relative importance of different social determinants of health, the availability of data for tracking progress, and the history of relevant government actions vary by country, it is important to extend this discussion to the country level for national policy relevance.
To guide this review, we used the CSDH framework, which defines SDH as the impacts of conditions “in which people are born, grow, live, work, and age” on health status. Inequalities are inextricably linked to this framework as it is often socially constructed inequities in access and exposure to key determinants that make them significant for health. A large and growing literature links these determinants to health outcomes; these determinants vary from more upstream factors, such as inclusion in political processes, to more downstream factors, such as access to clean water and sanitation [
3],[
4]. Studies finding associations between SDH and health are further strengthened by research demonstrating causality, such as recent reports finding improved flooring led to decreases in the incidence of childhood infections [
5] and that households given stoves producing less indoor air pollution had less severe pneumonia cases [
6]. The broad definition of SDH employed by the CSDH encompasses a web of factors that interact in multiple and complex ways; as a result most analyses are not able to include all underlying factors or do a full analysis of the ways determinants affect one another. With this limitation, this review includes major SDH in India for which there are available data, examined for important inequities when possible. Key SDH not included in this review due to the absence of data are described in the discussion.
The recent High Level Expert Group Report on Universal Health Coverage for India discussed the importance of synergistic action on SDH to ongoing efforts to achieve universal health coverage [
7]. As a basis for identifying and setting SDH priorities in India, there is no compilation of the levels, trends, and inequities in these indicators. Inequalities by location are common in all countries; in India, where many states’ populations are equivalent to those of the world’s most populous countries, this is especially significant. In this report, we focus on subnational variations, presenting analyses of the available data for measuring key SDH in India over the past two decades. We assess inequities by geography, caste, and gender, and identify priorities for public policy.
Discussion
From these analyses of trends in SDH in India over the past two decades, five issues emerge as the most urgent to address: air pollution (both indoor and outdoor), child undernutrition, unimproved sanitation, employment conditions, and gender inequality. These priorities coincide with the major risk factors contributing to lost years of healthy life in India, as identified in disease burden analyses. We discuss trends in each of these priority areas in the context of relevant national policies over the past two decades, which are summarized in Additional file
3: “Major national SDH policies.”
Household surveys reveal the striking proportion of the Indian population exposed to indoor air pollution, which is particularly significant for women and young children who typically spend more time inside near stoves. Data from air quality monitoring stations nationwide indicate dangerous levels of particulate matter in most of the country. Both household air pollution and ambient particulate matter were among the top 10 risk factors contributing disability adjusted life years (DALYs) lost in India in 1990 and in 2010 [
28]. This persistence of outdoor air pollution has occurred during a period of over twenty years with no major new environmental legislation and reducing indoor air pollution has not been the focus of any national schemes. As of 2013, half of the twenty most polluted cities in the world, including the worst four, are in India [
29]. Policies that provide access to cleaner fuels or improved stoves have been identified as cost-effective across a variety of national contexts [
30]; and China recently demonstrated health improvements achievable through policies to reduce ambient air pollution [
31], indicating possible policy approaches for India to address its indoor and outdoor air hazards.
Child undernutrition continues to affect a significant proportion of households in more and less developed states alike, and has failed to significantly decline despite national economic growth [
32],[
33]. This is crucial in terms of the large number of children affected as well as the life-long implications for cognitive development and adult health [
34]. Childhood underweight was a top five risk factor for the disease burden in India in both 1990 and 2010 [
28]. Data from the 2011 national HUNGaMA Survey confirm a continued lack of progress in child undernutrition in the most recent years [
35], despite this being the focus of two of the longest-running national schemes. In 1965, the Public Distribution System began to provide subsidized food to poor families [
36]; and the Integrated Child Development Services Scheme started in 1975 with a focus on early childhood health and nutrition [
37]. India’s continuing challenge of child undernutrition, with a high prevalence and the greatest number of undernourished children in the world [
38], suggest these national programs should be evaluated and improved. A variety of effective interventions exist to address child undernutrition [
39], which should be considered and, if feasible, be implemented effectively in India.
Unimproved sanitation facilities also remain too common in India, most significantly in rural areas. The prevalence of unimproved sanitation in the less developed states during the 2010-11 Annual Health Survey does not show dramatic improvement from the 2007-09 DLHS findings presented here [
40]. Unimproved sanitation contributes to the spread of many infectious diseases, of which India still has a substantial burden [
41]. This is in spite of almost three decades of national policies addressing this issue: the Central Rural Sanitation Programme was implemented in 1986 and most recently reconfigured as Nirmal Bharat Abhiyan in 2012 [
42]. These policies should be examined for their effectiveness and potentially reconfigured using successful programs in other countries as models; much of east and southeast Asia have achieved larger gains in the percentages of their populations with access to improved sanitation over the past twenty years [
43].
India has made progress in reducing child labor, but many other aspects of employment conditions continue to be problematic a lack of job security, insufficient safety measures, and inadequate compensation. Occupational health and safety are covered in piecemeal fashion by schemes for specific sectors, but until the 2009 National Policy on Safety, Health, and Environment at Work Places, no comprehensive national policy existed, and this has yet to be fully implemented [
44]. The 1987 National Child Labor Policy preceded the observed declines in child labor [
45]. The ongoing implementation of the National Policy on Safety, Health and Environment at Work Places should be evaluated to assess whether it leads to improvements in occupational health and safety.
Finally, gender-based inequities persist in employment and governance, limiting women’s power in households, businesses, and private and public decision-making. At the national level, the percentage of women representatives in the
Lok Sabha, the larger national parliament body, remained low over the past decade, from 9% in 2000 to 11% in 2012 [
46]. Two recent national policies specifically target gender inequality: the Dhanalakshmi Scheme, started in 2008, offers cash payments for female births as well as for their immunizations and school enrollments [
47], and the 2010 Rajiv Gandhi Scheme for Empowerment of Adolescent Girls provides skills training, supplemental food, and facilitates school enrollment for adolescent girls [
48]. These policies have coincided with continued reductions in gender inequalities in education, but substantially more progress is needed to improve overall gender equality in India. In the World Economic Forum’s 2013 ranking of countries for gender equality in economics, health, education, and politics, India fell in the bottom third of 135 countries [
49].
The availability of data was an important limitation of this review and influenced the priorities that could be identified; the limited information available to assess certain determinants highlight priorities for additional data collection. Strikingly high levels of dangerous air and water pollutants indicate an urgent need for better monitoring of environmental conditions. More detailed employment-related statistics, such as occupational hazards and the incidence of job-related injuries, should be routinely compiled [
50]. For other important SDH not discussed here, there is a notable absence of data. Urban housing shortages are currently crudely estimated and more reliable projections are needed, particularly given the rapid pace of urbanization [
51]. Transportation injuries and deaths are on the rise, but systematic data on road conditions and the enforcement of road safety laws do not exist [
52]. No detailed estimates of the proportion of households without income security in case of unemployment, death, disability, or old age have been compiled. Finally, the impacts of transnational factors on the prices of health-related goods and services, climate change-related natural disasters, and agricultural yields should be assessed.
The persistence of these identified challenges in spite of relevant, and in some cases long-term, public policies, indicate that analytical studies are needed to understand the impact of interventions related to a variety of social determinants of health. A recent analysis of public expenditure in the Indian states over the past fifteen years found that increases in overall social sector expenditure, but not specifically health expenditures, were significantly associated with reductions in child mortality [
53]. Another recent study indicated that a national employment scheme in India has the potential to reduce inequities in food consumption if implemented on an adequate scale [
54]. More analytical studies of this kind can help to identify successful policies for improving SDH in India.
The current momentum for achieving universal health coverage in India is an important initiative, but sustained improvements in health outcomes require substantial actions on SDH in addition to expanding access to health services. Such preventive approaches are essential to controlling costs as health care coverage expands to a larger population and for reducing health inequalities and increasing healthy life expectancy for everyone in India.
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Competing interests
The authors declare that they have no competing interests.