Abstract: Social determinant of health (SDH) has become a fashionable term to refer to factors beyond the conventional biomedical and behavioural risk factor approach to health. This commentary examines critically the SDH discourse and practice in India, at what it emphasizes and what it ignores, and the implications for health. While this idea of the influence of non-medical, social factors on health is not entirely a new one, the current discourse obfuscates the meaning of social determinants in various ways, emphasizing some proximal social factors, while obscuring and diverting attention away from some others. For instance: the increasing informalisation of work that affects more than 90 per cent of the working population in India, including bulk of working women, finds no place in the discourse on social determinants of health.
Keywords: work as SDH, informal sector, women workers, social security, Alma Ata Declaration (on primary health care), working conditions, access to healthcare, macro-social determinants of health, unemployment, National Commission on Enterprises in the Unorganised Sector (NCEUS)
Since around the 1990s it has become commonplace to talk of social determinants of health(SDH), as a convenient term to refer to factors beyond the conventional biomedical and behavioural risk factor approach to health. Towards the end of the 20th century when questions and doubts began to be raised about the possibilities of attaining the goal set in 1978 of Health for All by 2000, and when it was no longer possible to ignore the large number of reports linking health to non-medical factors too, SDH started to gain currency, especially among the numerous international agencies and institutions in health. In 2005 the WHO appointed a Commission on SDH to generate evidence on social causes of poor health and to suggest action, which put out its report in 2008 (CSDH 2008).
According to this Commission, “mal-distribution of health care – not delivering care to those who most need it – is one of the social determinants of health. But the high burden of illness responsible for appalling premature loss of life arises in large part because of the conditions in which people are born, grow, live, work, and age. In their turn, poor and unequal living conditions are the consequence of poor social policies and programmes, unfair economic arrangements, and bad politics. Action on the social determinants of health must involve the whole of government, civil society and local communities, business, global fora, and international agencies. Policies and programmes must embrace all the key sectors of society not just the health sector. That said, the minister of health and the supporting ministry are critical to global change. They can champion a social determinants of health approach at the highest level of society, they can demonstrate effectiveness through good practice, and they can support other ministries in creating policies that promote health equity. The World Health Organisation (WHO), as the global body for health, must do the same on the world stage”.
This short commentary examines critically the SDH discourse and practice in India, at what it emphasizes and what it ignores, and the implications for health of the public.
SDH as a re-invention of older ideas
The increased attention in the closing decades of the twentieth century to influence of non-medical, social factors on health, does not mean that this idea is entirely new. What is however new is the manner in which the discourse obfuscates the meaning of social determinants in various ways, by which it emphasizes some social factors, while obscuring and diverting attention away from some others. Since the rise of industrial capitalism from the mid-18th century onwards and the accompanying urbanisation and rise of social and medical problems, there has been a stream in medicine and public health that has pointed to the shaping of health and disease by social factors, including political and economic structures – in general to the structural determinants of health. However, they have been marginalised to a large extent through the twentieth century, except in some parts of the world.
Even in the 20th century the discourse preceding the 1978 Alma Ata Declaration on Primary Health Care focussed on non-medical factors affecting health and the need to address them, and not rely on solely medical/technical measures. The Alma Ata Declaration included among other things, promotion of food supply and proper nutrition; adequate supply of safe water and basic sanitation. It also placed health within a global and political context by calling for peace, reduced military expenditure and a ‘New International Economic Order’ to reduce the health status gap between developing and developed countries.
During the 19thcentury, Rudolf Virchow and Friedrich Engels outlined the political, economic, and social forces that affected the health of workers in urban areas and caused disease and early death. Many medical practitioners of that period too wrote about the poor working and living conditions as causing much ill-health and disease. Subsequently, in the 20th century, practitioners of Social Medicine, a lesser known stream of thinking in public health prevalent in parts of Latin America, sections of sociologists and social epidemiologists working in the historical materialist tradition showed how the organisation of capitalist societies influenced the distribution of economic, social, and political resources within the population, which in turn affected living and working conditions, access to healthcare, and thereby influenced their overall health status. For instance, the relationship between income and health – persons with lower income have greater disease morbidity and higher age-adjusted mortality than persons with higher income – may well be one of the best documented relationships in public health and epidemiology (Putnam and Galea 2008). In the Indian context too there have been efforts to analyse public health policies and systems within the political and socio-economic developments that shaped the politics of the region and influenced the conditions that determine health, such as the colonial past and the reformist present (Qadeer 2011.
However, these analyses of the structural determinants of health were ignored through much of the 20th century and even now remain marginalised by the mainstream discourse on determinants of health among policymakers and health researchers in most parts of the world. According to Raphael health researchers fail to “acknowledge that the quality of the social determinants of health is influenced by the organisation of societies and how these societies distribute material resources among their members”. Further, even fewer bring into their analysis the political, economic, and social forces that shape the organisation al and distributional practices of societies (Raphael 2006).
An attenuated concept of SDH
While this renewed interest in mainstream forums for SDH has been welcomed, it has also been pointed out that SDH is being conceptualised and approached in different ways (Raphael 2006), and that the discourse is not as complete and comprehensive as it should be for effective action, which then affects the kind of action that is taken. For instance: the WHO CSDH itself does not discuss issues such as pharmaceutical policy, presence of pressure groups that operate upon SDH, and war, an important social determinant that kills, maims and displaces large populations (Escudero 2009). Yet others have observed that much of the attention in the SDH arena has a narrow focus on micro- social factors, at the level of individual behaviours and interactions, and there is limited attention to macro-social factors, such as impact of economic priorities and policies, tax regulations, of corporate practices, of gender-race, on factors such as incomes, which in turn impacts health (Putnam and Galea 2008). In other words the current focus on SDH is more on the proximal, immediately visible determinants, rather than on upstream, distal factors that affect health through multiple mechanisms and are not disease-specific.
As rightly pointed out,
Limited epidemiologic attention to macro-social determinants of health is ironic given that macro-social factors such as the rapid industrialisation and urbanisation in the 19th century contributed to the organisation of public health practice and, tangentially, to academic public health research (Putnam and Galea 2008).
Work as SDH
Work itself has long been recognised as an important social determinant of health and health inequalities. The quality and type of employment are important in terms of income and social status. It has been observed that the nature of work has altered considerably over the past two decades in the advanced industrialised countries with a decrease in industrial employment and an increase in the size of the service sector. This has also been accompanied by a decline in the number of standard, full-time, permanent jobs and a rise in flexible, precarious, employment: increasing numbers of people are working on either temporary contracts or no contracts, with limited or no employment or welfare rights. The increased use of shift work in the name of 24X7 work has public health implications due to abnormal working hours.
There is a significant body of medical, epidemiological and social science work on impact of unemployment. Unemployment is associated with an increased likelihood of morbidity and mortality. There are clear relationships between unemployment and increased risk of poor mental health and para suicide, higher rates of all cause and specific causes of mortality, self-reported health and limiting long-term illness and, in some studies, a higher prevalence of risky health behaviours (particularly among young men), including problematic alcohol use and smoking. The negative health experiences of unemployment also extend to families and the wider community and are not limited to the unemployed persons (Bambra 2010; Bambra and Eikemo 2009). Further, there is a negative relationship between precarious, insecure employment and health (Bartley 2005).
What is the relevance, what are the implications of such findings for the Indian context?
Work in India
Changes in the pattern of employment, both quantitative and qualitative, are seen as signifying better work conditions, and are important indicators of standard of living. Let us examine the employment situation in India that emerges from perusal of government data since 2000 (Mehrotra et al 2012).
The Indian economy had been the second fastest growing large economy in the 2000. However, according to government’s own reports:
We have clearly deviated from the ideal of generating productive employment. The more productive sectors of the economy (manufacturing and services) have not generated enough employment, despite India experiencing the fastest GDP growth ever in its post-independence economic history (Mehrotra et al 2012).
Employment in total and in non-agricultural sectors has not been growing. Further, this jobless growth in recent years has been accompanied by growth in casualisation and informalisation of available employment.
Joblessness and Informalisation
Agriculture continues to be the mainstay of livelihood in the country, although the share of agriculture in total employment had fallen from 57 per cent in 2005 to 53 per cent in 2010. This was accompanied by an absolute shift in workers from agriculture of 15 million to services and industry. However, employment in ‘allied agricultural’ activities (horticulture, animal husbandry, fishing, and forestry) has declined. Male migration out of rural areas has continued unabated, increasing the feminisation of crop agriculture, leaving women with less time to rear poultry or livestock.
There was an absolute increase in employment in manufacturing in the first half of the decade (2000-2010) from 44 million to nearly 56 million in 2004-05. This increase of nearly 12 million in manufacturing in the first half of the decade was, however, off-set by a decline by 5 million in the second half of the decade, when most of the manufacturing subsectors witnessed a decline in employment. Several major sectors which account for about 10 per cent of the total employment in manufacturing saw no increase in employment or an actual decline.
Non-manufacturing employment increased by 9 million between 2000 and 2005, while during the second half (2005-10) the increase was by 18 million with a remarkable growth rate of nearly 132 per cent. Construction was the prime mover in this rapid increase in employment. The pull of the construction growth in both rural and urban areas led to worker’s moving out of agriculture (15 million moved outbetween 2005 and 2010).
Trends in non-agricultural employment – industry and services – by organised and unorganised sectors, and formal and informal employment
Since independence, the relative importance of secondary and tertiary sectors in terms of both output and employment has been growing. A shift in employment from agriculture (which is almost entirely unorganised) to the organised segment of non-agriculture is considered most desirable from the perspective of productivity and decent work. Organised sector employment is supposed to constitute an improvement in the scale of decent work over unorganised sector employment.
The shift in the share of output and employment from primary sector to secondary and tertiary sectors is a phenomenon which has been witnessed in most parts of the developing world, including in India. However, what makes India different is that the share of informal workers in the total work-force is well above the other emerging market economies – 93 per cent of all workers compared to 55 per cent in Brazil.
However, organised employment does not always ensure decent work. In India, when it comes to conditions of work in the wake of the structural shift that is taking place, the story that emerges is not a very pleasant one. Conditions of work have different dimensions – duration of work, physical conditions of work, wages, nature of work contract, applicability of legislative protection, and occupational hazards. Broadly speaking, these different dimensions of conditions of work can be categorised under two main headings – formal and informal nature of employment. While the informal nature of employment is predominant in the unorganised sector of the economy, its prevalence is increasing even within the organised segment as well. There has been a phenomenon of informalisation of workforce within the organised sector during the first decade which has witnessed the fastest output growth since independence. Informal employment is defined as that form of employment where the employee is not eligible for any kind of social security benefit like provident fund, gratuity, pension, health care, maternity benefit etc. (Mehrotra et al 2012).
Overall, the share of employment in the organised segment in the economy in 2009-10 was 16 per cent, which was an improvement from 2000. However, the share of organised employment is only around one- third of the total in each of manufacturing, non-manufacturing, and services sectors. Secondly, despite the increase in organised employment over the years, a large chunk of those employed in the organised sector are informally employed and are deprived of any form of social security benefit. Thirdly, unorganised sector employment is almost entirely informal in nature. So, over the decade of rapid economic growth there has been no overall improvement with respect to decent work and to standards of living for a large section of the Indian population.
With respect to formal and informal employment, construction deserves special mention. As mentioned earlier, this sector experienced phenomenal increase in employment, particularly during 2005-10. There was a very sharp increase in employment in its unorganised segment throughout the decade. However, the organised segment of construction also witnessed an increase in employment. In the year 2009-10, out of 44 million employed in the construction sector, 31 million were in unorganised and the remaining 13 million were unorganised enterprises. Out of 13 million organised employment, 11.3 million (87 per cent) is informal employment. Therefore, out of 44 million total employment in construction, 42 million (31 million unorganised sector + 11 million informal employment in organised sector) hardly have any kind of social security benefit attached with it. In other words, 95 per cent of workers in the construction sector hardly have any kind of social security coverage.
As mentioned earlier, organised employment accounted for only 16 per cent of the overall employment in the economy. Even within this small organised manufacturing segment, informal form of employment is the predominant form – at least sixty percent of the organised manufacturing employment is in the nature of informal contract. This could be even more – such as in automobile manufacturer Maruti Suzuki India Limited less than 25 % workers were permanent in July 2012. Similarly, in cement manufacturing which is now dominated by multinationals, 80% of the work-force is contractual (informal). Whereas, eighty per cent of the organised non-manufacturing employment is in the nature of informal contract. It is only in the services sector that majority (70 per cent) of the organised employment takes the form of formal job contract between the employer and the employee. Most of formal service sector employment is in Public Administration and Defence, where 87 per cent of all employment in the organised sector is in the nature of formal employment.
Therefore, in addition to the overwhelming presence in India of the unorganised sector in agricultural and non-agricultural employment, we also have the vast problem of informal employment within the organised sector. The government itself concedes that “This issue of informalisation of employment poses a serious challenge in achieving decent work and thereby achieving more inclusive growth and sustainable development during the 12th Plan period”. The government admits that ‘ensuring decent employment for those moving out of agriculture remains a big challenge for policy makers during the 12th Five Year Plan period’.
Not Minimum Wage, but minimal and sub-minimal wages
With the government conceding to the problem of lack of decent employment, it would be instructive to look at how indecent the conditions of employment are for workers in this vast unorganised sector where informal employment is the pre-dominant form of employment. This section gives an idea of the most important condition of employment
– wages, which in turn determines family incomes. It is common-sense knowledge that income is an important determinant of living conditions and of health.
For a long time now, workers’ organisations (maligned and dismissed as trade unions) have been pointing out to the large differences between the wages and benefits provided to the permanent workforce and the contract workers, even though they may be employed for as long as regular workers, in the same department, and doing same or similar work. This is a gross violation of the rights guaranteed to them under various labour laws. In the cement factories of Associated Cement Companies (ACC) the contract workers are paid between Rs 169 to Rs 210 per day (around the minimum wage set by the state government), depending upon their skill and experience. This usually leads to a monthly income of Rs. 3,000 – Rs 4,000! In comparison, permanent workers and casual workers are paid Rs 13,000 to 15,000 per month. However it is seen that many contract workers do not even receive this legally mandated minimum wages, which is not a very decent amount to begin with: contract workers in the mines are paid only Rs. 120-130 per day. In the car manufacturer Maruti Suzuki India Limited, located on the outskirts of Delhi, permanent workers get about Rs.29,000-Rs 30,000 per month while contract workers (helpers) get about Rs.8000 and another category of ‘casual’ workers are paid around Rs. 12,000. It has been pointed out that in terms of work on the shop-floor, the only difference between regular workers and the contract workers are their uniforms and the pay that they get.
In general it has been shown that the real wages in the motor vehicle industry (wages after adjusting for inflation) have come down sharply during the decade 2000-01 to 2009-10. It has also been shown that wages as percentage of net value added has been declining in the automobile industry. For example, while profits of the company have been increasing, real wages of Maruti workers rose by just 5.5% between 2007 and 2011, while the consumer price index rose by 50% during this period. In contrast, the annual remuneration of MSIL’s CEO increased from Rs. 4.73 million in 2007-08 to Rs. 24.5 million in 2010-11, an increase of 419%. In general, in automobile manufacturing expenditure on employee salaries and benefits ranges between 4-5%, and Maruti Suzuki spends lesser than most other companies, a paltry 2.4% of net sales.
In another state, Karnataka, the daily minimum wage for garment workers has been set between Rs 252-262, which translates to less than Rs 10,000 a month, even if the workers get work for 30 days in a month. A recent government notification has stipulated that a helper in a garment unit cannot now be paid less than Rs. 5,720 per month (which would go up to Rs. 6,450 when costs for inflation are included as DA)(see http:// www.thehindu.com/news/national/karnataka/highest-onetime-hike-in-minimum wages/article5963173.ece?ref=sliderNews). In Delhi the minimum wages revised in April 2014 for skilled work, the highest paid, was Rs 10, 374 a month and Rs 399 a day.
This brings us to another important finding – that in the first place the minimum wage itself set by the government is often not more than Rs 10,000 a month and is not exactly a decent, living wage that can take care of the minimum needs of a person in a city when price inflations, especially of food items are taken into account. Minimum wages especially for agriculture are so low that even if workers find employment everyday in a year and are paid the minimum wage, they will not be able to fulfill the basic needs of their family, as specified by various labour committees and courts (see http://ntui.org.in/what-we-do/minimum-wage/a-just- minimum-wage/). Secondly, in the vast informal sector even these wages are not paid and workers have to wage an incessant struggle to get even the legal minimum wages implemented. For instance, recently mid-day meal workers from Punjab took up a struggle demanding that their wages be increased from Rs 1200 a month to between 6500-7000, and even that was not being conceded by the government!
The National Commission on Enterprises in the Unorganised Sector (NCEUS) created in 2004 had published several detailed reports that provide accurate measures of the size of the unorganised sector and had highlighted the abysmal conditions prevailing there. It highlighted the complete lack of growth of organised employment during the phase of rapid growth in India since the early 1990s. Virtually all the growth in employment since 1991 has been informal employment. The NCEUS defined informal sector workers as those who lacked employment security, work security and social security. It highlighted the low wages/ earnings and bargaining power of informal workers, which not only kept them poor but also made them vulnerable. For instance, the large overlap between the poor and the group of informal workers was brought into public discourse by one of the early NCEUS reports which came out with the much-cited figure that 77 percent of the population spent less than Rs 20 per day in 2004-05. The NCEUS made several important recommendations, including some relevant legislation. Most of these have been ignored by the government and the NCEUS itself was quietly wound up.
Gender aspects of informal employment
In most developing countries including India women are reported to make up more than 50 per cent of the informal sector. In India nearly 94 % of the total women workers are engaged in the informal sector, of which ~ 20 per cent work in urban centres. Majority of these women belonged to those section which need work at any cost, nearly 50 percent of these women workers were reported to be sole income earners for their families (Singh and Gupta 2011).
Women in the informal sector are engaged in the following kinds of work:
- Construction labour: Women labour have to work always as unskilled labour carrying construction material on their heads to the construction site, while the skilled/ semi-skilled work is done by men. The informal nature of employment often means that women do not get equal wages as men, there would be no crèche facilities, no maternity benefits, etc.
- Domestic workers: This category of employment goes mainly to women, especially young girls. In 1997-98, there were some 1.68 million female domestic workers, while the number of maleworkers was only 0.62 million (Singh and Gupta 2011). The household workers include part-time and full- time workers. Wages in this category are negotiable and far below minimum wages, and there never is any social security, paid leave, etc. for these workers.
- Garment workers: Women comprise a major chunk of workers in the garment manufacturing sector that produces designer wear for major global brands. Around 80% of the workers in the garment industry, spread over Bangalore, Chennai, Delhi, Mumbai and Tirupur, were reported to be young women between the ages of 21-25 (Singh 2009). The violations of basic statutory labour rights, including non- payment of even minimum wages and impact of the work conditions on poor health status of women workers in this industry is well- documented (See for example Singh 2009). Women also work with some drapers, boutiques, knitting woolens and stores; here too women work as helpers to male tailors (called as masters).
- Vendors: This is the most scattered category, which includes women engaged in selling different types of commodities, like broomsticks, cane baskets, utensils, petty cosmetics, bangles, vegetables and those running roadside tea stalls, etc. Nearly 40% of total vendors are women and 30% of these women are the sole earning members in their families.
- Sales girls: These workers were further divided in two categories, one, those moving from door to and place to place, and those working in shops.
While conditions for all workers in the informal sector and in informal wage work are appalling, it is worse for women workers. One needs to bear in mind that along with earning wages, these women also have to do their own domestic chores and work at home to take care of their own children and other family members, and may or may not have support of other family members in this household work. The impact on women’s health, of the double burden of poor working conditions as well as of taking care of families with such poor wages, its implications for access to essential goods and services, can only be understated.
Why do work and wages not count as social determinants of health?
What emerges is this: Informalisation of employment has been the norm for nearly two decades now in India. The vast majority of informal sector workers not only has no social security; it does not even get a living wage to get decent calories and to live in decent conditions. The effects of such poor family incomes, of such increasing informalisation are visible everywhere around us, in the urban slums and shanties. Yet it escapes the vision and plans of policy makers and public health researchers and experts as a social determinant of health. This is particularly so for the women who are being pushed either out of formal work spaces or into the informal sector where they have to work harder and get lower wages as compared to men in the name of unskilled work. It also means a poor deal in contracts for cultivating their fields for women farmers due to lack of land titles and deprivation from benefits such as institutional credits and extension services or subsidised inputs that pushes both their cost of cultivation and their vulnerability to crisis situation (Ghosh 2011).
This reality and the acts of commission and omission by the government only cast doubts on the government’s endorsement of the recommendations of the CSDH. Not only are the recommendations of the WHO CSDH regarding role of governments and ministers of health ignored. The recommendations by its own commissions such as the NCEUS are not followed; the government does not allow implementation of its own labour laws enacted to provide minimum protection to workers; in practice it wants to relax further these labour laws to enable more investments and growth; and the government continues to promote India as a source of cheap labour and lax laws.
While the government operates under the structural constraints of its politics and ideology, what is puzzling and paradoxical is the neglect by public health experts and researchers also of these realities when they talk about SDH in India. In several other countries job insecurity and its effect on health is an important area of study in social epidemiology. Several analyses have found continued job insecurity to be a health risk and secure re-employment to actually improve health; public health researchers recommend that reduction in job insecurity should be a part of policy interventions to improve population health (Bartley 2005). However, we find that the increasing Informalisation of work that affects more than 90 per cent of the working population in India, including bulk of working women, finds no place in the discourse on social determinants of health.
Will the current attention, in the Indian context, to only reproductive health needs of women, to sanitation – hygiene-drinkingwater – education – information – governance-community participation as SDH be effective in improving health status, when the larger determinants are actually leading to deterioration of living conditions, to poor nutritional status, to pushing more women into the informal wage sector? Will the public health community stand up and acknowledge the limits of the current concept of SDH in India, and broaden the SDH framework in India, to look beyond the immediate unhygienic living conditions of people, at their work and employment conditions too. Can the public health community broaden its framework to consider the impact of factors such as the abysmal wages and incomes, lack of adequate employment and livelihoods, in shaping living conditions and hence health of populations. Can it highlight and emphasize the status of these critical upstream social factors and the consequences of neglecting them, for the health status, for health policy and for health systems?
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INDIRA CHAKRAVARTI. Is a publichealth researcher and currently a Fellow at Nehru Memorial Museum and Library, Delhi.