Inequality Report 2021: India’s Unequal Healthcare Story


Published in July 2021, Oxfam India’s Inequality Report 2021 presents a comprehensive analysis of the status of health across different socioeconomic groups in India. It aims to gauge the level of ‘health inequality’ in the country. The report examines the structural inequalities in government interventions – made worse due to the Covid-19 pandemic – and presents recommendations to the Union and state governments.

The report presents results of a primary survey undertaken in the states of Andhra Pradesh, Maharashtra, Uttar Pradesh, Delhi, Kerala, Bihar and Odisha. The objective of the survey is to determine the impact of Covid-19, particularly on people from Scheduled Caste (SC), Scheduled Tribe (ST) and Muslim communities. As many as 768 respondents were surveyed through a structured questionnaire, all of whom were or had been infected with Covid-19 between March and September 2020.

This 128-page report is divided into six chapters: The Need to Examine Health Inequalities (Chapter 1); Determinants of Health: Analysing the Contributing Factors (Chapter 2); Impact of Health Interventions in India (Chapter 3); Inequalities in Outcomes of Health (Chapter 4); The Efficacy of Government Intervention–A Review (Chapter 5); and Inequality Amidst a Health Emergency (Chapter 6).


  1. The report notes the average household size in India to be 4.45 people. At the same time, 59.6 per cent of the country’s population lives in one room or less. This makes it difficult for households to adhere to safety protocols during Covid-19.

  2. In India, the report states, there is one government-employed allopathic doctor for every 10,189 people, and a State-run hospital for every 90,343 people. This is from the National Health Profile of 2017, published by the Central Bureau of Health Intelligence, Ministry of Health and Family Welfare. In terms of hospital beds per thousand population, India ranks lower than countries such as Bangladesh, Chile and Mexico, as per data from the Organisation for Economic Co-operation and Development (OECD).

  3. According to an Oxfam report titled Commitment to Reducing Inequality Report 2020, India ranks 154th worldwide in health spending. Only around 50,069 health and wellness centres (HWCs) are functional in the country due to a lack of investment in health infrastructure.

  4. Women's education has a direct impact on improving health in households as it enables them to make informed healthcare decisions such as the use of contraceptives. The report notes that the literacy rate among general category women in India is 18.6 per cent higher than that of women from SCs and 27.9 per cent higher than women from STs.

  5. In 2015, poor water, sanitation and hygiene conditions in India caused the deaths of 100,000 children under the age of five due to diarrhoeal illnesses. Over the last decade, urban areas in the country have witnessed a 3.9 per cent reduction in access to improved water sources. This is primarily due to rising pollution levels in surface and groundwater sources, resulting in poor water quality.

  6. The average health expenditure of the poorest 40 per cent of households in India – the report notes – is 30 per cent less than that of the richest 20 per cent of households. As per National Sample Survey data on health from 2017-18, 81 per cent of the total hospitalisation expenditure was paid through household savings.

  7. The infant mortality rate (IMR) in India – defined as deaths per 1,000 live births of children under the age of one – has dropped from 57 per thousand live births in 2005-06 to 40.7 in 2015-16. Despite this reduction, India continues to lag behind the United Nation’s Sustainable Development Goal 3, which prescribes the IMR target for 2020 as eight per thousand live births. Additionally, the IMR among SCs is 13.1 deaths higher than the general category, and among STs it is 12.3 deaths higher.

  8. As per the report, public expenditure on health was as low as 0.32 per cent of the gross domestic product in 2019-20. The report recommends that health spending in India be increased to 2.5 per cent of the GDP for a more equitable healthcare system.

  9. The report states that India’s inadequate public healthcare system, combined with the increasing push towards privatisation, has resulted in an increase in private healthcare institutions. The private health sector – which includes corporate hospitals, independent practitioners and ‘faith healers’ – provided only 5-10 per cent of total patient care in India during the time of independence. As of 2021, the private sector accounted for 66 per cent of hospitalisation and non-hospitalisation cases, and 33 per cent of institutional births.

  10. Over half of the survey’s respondents from SC and ST communities faced difficulties in accessing medical facilities unrelated to Covid-19 in the first few months of the 2020 lockdown, compared to 18.2 per cent of those belonging to the general category.

  11. According to the primary survey, 35.1 per cent of the respondents belonging to households with a monthly income of Rs. 30,000 or less faced discrimination from their neighbours or community after testing positive for Covid-19.

  12. About 14.8 per cent of the respondents with monthly household incomes of Rs. 30,000 or less reported facing issues of ‘slow response from the government’ when they were hospitalised for Covid-19. About 22.2 per cent of these respondents faced issues relating to the quality of food served at hospitals. On the other hand, among respondents belonging to the highest income range, no issues relating to slow responses emerged while only 4.8 per cent expressed concern over the quality of food served.

    Focus and factoids by Khushi Agrawal.

    PARI Library's health archive project is part of an initiative supported by the Azim Premji University to develop a free-access repository of health-related reports relevant to rural India.


Oxfam India, New Delhi


Oxfam India, New Delhi


Jul, 2022