1. TK Sundari Ravindran, Professor, Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum Researching health inequities

2. OUTLINE Why research health inequities? The current state of research in health inequities – some reflections Some thoughts on how to move forward and what it entails

3. WHY RESEARCH HEALTH INEQUITIES? “If you don’t ask, you don’t know And if you don’t know, you cannot act” (Kreiger, 1992) Urgent need to problematize the routinely described differences in health status across social groups as well as the complete absence of information about other social groups. The resounding silence about health inequities in India’s health policies and programmes; the focus on “poor”,, “women”, “tribal” etc. rather than on inequities

4. THE CURRENT STATE OF RESEARCH ON HEALTH INEQUITIES -1 Focus on measuring and describing ; mainly quantitative. Important first step. But need for recognition of limitations. Caution to be exercised to prevent this from becoming “Blame- the-victim” research, and to not locate the key factors producing a health disparity within the individual, neglecting underlying structural and historical factors that are responsible

5. THE CURRENT STATE OF RESEARCH ON HEALTH INEQUITIES -2 Results should not be interpreted in terms of “how to bring “those” people up-to-speed so that they do not pull down state/national averages?” – i.e. “Deficit-oriented” health equity research. Reliance predominantly on large scale data -limits what can be researched and what cannot. (e.g. “class” reduced to income levels) Fails to guide action for changing the status-quo and may convey a sense of inevitability

6. THE CURRENT STATE OF RESEARCH ON HEALTH INEQUITIES -3 No explicit philosophical approach; interpretations influenced by one’s own implicit biases. While multi-level factors are acknowledged, focus is most often on individual level factors and not on larger structural factors. Consequently, micro-macro linkages are not explored. That which does not lend itself to measurement e.g. alienation, power dynamics – seldom studied. “WHY” questions not addressed for the most part. We have limited understanding on the pathways and mechanisms through which health inequities are created and sustained (discrimination, prejudice, stigma, humiliation, social exclusion).

7. THE CURRENT STATE OF RESEARCH ON HEALTH INEQUITIES -4 The dynamic and context specific nature of health inequities not often visible in the research. Focus on “down stream” determinants of health in intervention research, perhaps because these are amenable to be studied through experimental and quasi-experimental designs – perpetuating the myth that health inequities may be effectively addressed without challenging the status-quo. TRYING TO MAKE OMLETTES WITHOUT BREAKING EGGS? Most importantly – intersections of multiple axes of disadvantages or oppression – ignored for the most part.

8. WHERE TO FROM HERE? “Health inequities” occupies a multidimensional space and does not lend itself to simplistic approaches. Described as the result of inequalities in the distribution of “power, money and resources”. Need to develop approaches that can capture the pathways through which this happens.

9. WHERE TO FROM HERE? -2 Adopt an “intersectionality” approach View from lived experiences and lay knowledge needs to be given its due place, as do participatory and bottom-up approaches to knowledge construction. Key to understanding the relationship between individual agency and structural forces. Need to move beyond narrowly defined interventions research and “start to articulate explicit alternative future scenarios in which greater health equity could be achieved” (Scott-Samuel 2015)

10. Need of the hour: transformational research for social change Approaches that begin to unpack the social forces driving inequities and their everyday manifestations Methodological innovations drawing on multiple disciplines Purposeful research’ of a transformational nature – in terms of how and for what and with whom we do research.