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  • Jyotsna Singh—India

How caste is a major barrier to health equity in India

India’s Dalit and tribal communities continue to face discrimination, exploitation, and social exclusion. Improving health outcomes, especially among women, requires a coordinated national effort.

Dalit women (left to right) Neha Kumari, Pushpa Bairwa and Asha have experienced caste discrimination in healthcare facilities in India.

Photo: Jyotsna Singh

Seated on a bedstead in an anganwadi (government-run child-care centre) at the Mazdoor Kalyan Camp slum in Delhi, Pushpa Bairwa recalls a painful memory from her childhood, 17 years ago, in Sawai Madhopur district of Rajasthan.

“My aunt was about to give birth and we took her to a government hospital in the main town. Despite seeing that she was in labour pain and our repeated pleas, the doctors refused to admit her and asked us to wait. Finally, she gave birth in the car in front of the hospital. Luckily, a midwife who had accompanied us from our village helped with the delivery.”

The hospital staff did not cut the umbilical cord or provide any other support to the new mother and baby. “This was a distressing experience. Even today, my family does not prefer to go to hospitals for childbirth,” Bairwa says.

Her surname denotes she is a member of the Bairwa community, which is classified as a Scheduled Caste under the Indian Constitution.

[Dalits] are assigned the lowest status in society, and their access to resources, opportunities, and basic rights are severely restricted.

The Scheduled Castes and Scheduled Tribes are among the most disadvantaged socioeconomic groups in India.

Known as Dalits today, the Scheduled Castes were for centuries deemed ‘untouchables’ and assigned the lowest status in society under Hinduism, outside the four birth-determined caste groups with pre-designated occupations and privileges: brahmins (priests and scholars), kshatriyas (warriors and rulers), vaishyas (merchants and farmers), and shudras (labourers).

Dalits—who comprise 17% of India’s population—have historically faced discrimination, exploitation, and social exclusion, including restricted access to resources, opportunities, and basic rights.

While the practice of ‘untouchability’ has been abolished under law, Dalits frequently face exclusion across the country. They are mostly ghettoised in areas that are shunned by the other castes, who consider even their shadow as “impure” and “polluting”.

This explains why the hospital staff in Sawai Madhopur did not come forward, even to cut the baby’s umbilical cord. The family named the baby Gahalod. “Most kids are named after a deity or a word with positive association such as light or music, but ‘Gahalod’ has no meaning whatsoever… the parents chose it merely as a reminder that he was born on the road,” Bairwa explains.

Pervasive caste-based discrimination

Caste affects many aspects of life across India, including education, employment, housing, and social interactions. All this, in turn, impacts access to healthcare institutions and health policies, as these have typically been the preserve of upper castes.

"Once the health staff realises that we are from the Dalit community, they ask us to stand at the end of the queue, making us wait for much longer."

“While in rural areas it is more obvious, in urban settings caste discrimination plays out in a more subtle fashion,” says Asha, a community worker for the National Campaign on Dalit Human Rights who uses a single name. “Most Dalit families are dependent on government health facilities as private hospitals charge exorbitantly. But what they face there is disheartening. For example, even the top government hospitals in Delhi have a separate line for the Scheduled Castes. This separates them from the general crowd, contributing to their stigma.”

Bairwa says the discrimination is as pronounced in the smaller clinics, too. “Once the health staff realise that we are from the Dalit community, they ask us to stand at the end of the queue, making us wait much longer,” she says. “At times we have to visit more than once for the first appointment.”

The resulting disparity in key health indicators includes a wide gap in the nutritional status of young children and their mothers, and overall access to healthcare. According to the fifth National Family Health Survey of India (NFHS-5), which was conducted from 2019-21, the neonatal mortality rate—the percentage of children dying within one month — is much higher among Dalit babies (29%) compared with the general castes (20%). Similarly, for under-five mortality—namely, out of every 1,000 live births, the number of children who die before turning five—it is 48 among Dalits and 33 for the general castes.

So ingrained is the inequity at an institutional level that Sampurna Kundu, a research scholar at Delhi-based Jawaharlal Nehru University, says the NFHS-5 is one of the few data sets to account for the stark differences in health outcomes between Dalits and general castes.

“In most studies, Scheduled Castes, Scheduled Tribes and other backward classes (OBC) are lumped together to observe inequalities in health. In the NFHS, you see caste-based differences, which allow us to look for nuances.” Scheduled Tribes are the indigenous people in India who fall outside the predominant Indian social hierarchy. OBC is a term used to classify castes which are educationally or socially backward.

Role of gender in health outcomes

While Dalits face discrimination at the hands of upper castes, irrespective of gender, the intersection of caste and gender further exacerbates the challenges faced by Dalit women. But the manner in which it is playing out across India is somewhat surprising.

“There is definitely gender bias across castes and communities, owing to the patriarchal norms of society,” explains Professor Sanghamitra Sheel Acharya from the Centre of Social Medicine and Community Health at Jawaharlal Nehru University. “However, we notice that the gap between Dalit women and men is relatively less compared with upper castes.”

“Acute discrimination and deprivation due to the intersectionality of caste, class and gender cannot be more visible.”

In the case of cancer, nearly 76% of Dalit women seek care for cancer after detection, compared to 80% of Dalit men. Among upper castes, just 78% of women access care, in comparison to 92% of men.

However, the gap between Dalit women and men in access to healthcare is increasing, leading to growing inequity, explains Acharya. “Dalit men are emulating upper caste men as it seems more desirable in society. This process is called ‘Sanskritisation’. Emulating patriarchal norms to impose restrictions on, for instance, decision-making pertaining to accessing healthcare, is likely to adversely affect the health of women.”

Jobs traditionally done by Dalit women also put them at increased risk for health problems. Data from the government’s Sample Registration System (SRS) shows that the average life expectancy for Dalit women is 59 years, compared to 65 for women from upper castes.

During the pandemic, Acharya says, Dalit women were on the front lines. “A majority of the female sanitation workers and cleaners come from the Dalit community. While everyone else was advised to stay home, they were not allowed to do so as cleaning had to be done. But as they were lowest in the hospital hierarchy, they were not given proper protective equipment and faced a disproportionate impact of the pandemic.”

The health of cleaning staff in other industries—again, predominantly Dalit women—is also heavily compromised. “When you are sweeping the roads, you are inhaling a lot of dust and other pollutants. So, you need masks at all times, but they are hardly available for these workers,” Acharya says, explaining that some cleaning tasks require gumboots, but since they are ill-fitting, the women prefer to work without them, leading to health problems.

“Acute discrimination and deprivation due to the intersectionality of caste, class and gender cannot be more visible.”

On the margins of care

There is yet another group of Indian women who suffer acute discrimination from birth—those belonging to Scheduled Tribes, who form 8% of the Indian population, according to the 2011 census. NFHS-5 and SRS data suggest they face worse discrimination than even Dalit women.

“Tribals are among the most marginalised groups in the country,” says Ashwini Jadhav, an independent researcher on tribal health based in Central India. “They look different due to a different sense of dressing. Their language is also different. There is a general perception about lower literacy rates among them. Hence, their neglect.”

The average life expectancy of women from Scheduled Tribes is just 55 years, with poor access to healthcare facilities remaining a central issue. According to NFHS-5, 34% of tribal women say they are unable to visit a health facility owing to the distance, as against 24% of Dalit women and 20% of Indian women generally. As against 36% of Indian women and 39% of Dalit women, as much as 50% of tribal women say they do not have access to health providers in healthcare facilities close to them.

"The government should frame policies that give people the confidence that they can approach a health facility without any disadvantage."

“The data speaks for itself—tribal areas in India are deeply neglected by the health system,” Jadhav says. “First, there are fewer health facilities. Secondly, even where they exist, they are understaffed and lack infrastructure.”

Dalit men emulating upper-caste men in their attitudes toward gender norms affects Dalit women’s access to healthcare.

Photo: Jyotsna Singh

Addressing gaps in accessible, quality services

The Indian National Health Policy, 2017, stipulates universal access to quality healthcare services across the country. “This means that wherever a person is in the social structure, they should be able to access adequate healthcare,” Acharya says.

Training healthcare workers at all levels on the need for cultural awareness and inclusion can improve health equity among Dalits and tribal women, she says.

“Over the years, we have seen that whether it is doctors in hospitals or community health workers at local levels, they do not treat Dalits and tribals with the same diligence as with others,” she says. “[Reversing this] requires training and repeated sensitisation of hospital staff.” A system that requires healthcare providers to be answerable for inappropriate behaviour is another effective approach, she says.

Asha from the National Campaign on Dalit Human Rights calls for training at a government level, with policies that provide clear guidance to healthcare workers on treating marginalised groups fairly and with respect.

“We need community participation and equal opportunities for all marginalised groups,” she says. “The government should frame policies that give people the confidence that they can approach a health facility without any disadvantage. If needed, their privacy should be maintained to guard against biased staff.”

Acharya says there is an opportunity to build on the formal structures already in place at an institutional level. “India’s laws have affirmative action, whereby seats are reserved for Scheduled Castes and Schedules Tribes in education institutions and jobs. However, implementation is poor—that should improve. In addition, such requirements should extend to the private sector, which is also a major provider of health services in India.”

Ultimately, she says, inclusive policies can facilitate social mobility of marginalised groups. “Mingling of people belonging to different groups also helps in removing stigma and biases, which has both short-term and long-term impacts.”


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