Health care access among Dalits in India
Who are the Dalits?
Dalits, also known as the “untouchables,” make up the lowest of the five castes in the traditional Hindu caste system.[1] According to the Hindu caste system, one’s caste affiliation is inherited and passed down from generation to generation. Thus, no matter how much money one made in one’s lifetime or how much education one attained, a person who born as a Dalit would remain classified as a Dalit throughout his or her lifetime and would pass on this caste affiliation to his or her children and so on. The Indian Constitution also recognizes Dalits as a “scheduled caste” because they are listed as being a part of a schedule of the lowest castes in need of affirmative action. As of 2008, there are 166.6 million Dalits in India.[2]
Why are the Dalits a vulnerable population?
Before caste discrimination was prohibited with the enactment of the Indian Constitution in 1949, Dalits were forbidden to participate in religious and social activities and were often restricted to occupations that required strenuous and “polluting” tasks, such as being an animal slaughterer or being a leather worker. As a result of their “polluting” nature, Dalits also faced and continue to face stigma from their “untouchability” by higher caste members. Even though the Indian Constitution outlaws “untouchability”and other discriminatory acts against Dalits, implementation and enforcement of this law has been difficult. Women who are Dalits are especially vulnerable in India and face disparities when it comes to health care access, education, housing, employment, and political participation and representation.[2]
In addition to social discrimination, many Dalits also face persistent economic difficulties. Many Dalits are in debt and often work off their debts through bonded labor even though bonded labor has been illegal in India since 1976. Any unpaid debt is then often inherited by the next generation, which then creates a continuous cycle of bondage. Additionally, many Dalit families that leave rural areas to find work in larger cities end up living in the slums of these cities. In the cities, Dalits often take up jobs with poor working conditions for some of the lowest wages.,[2][3] As a result, scheduled indigenous tribes and scheduled castes have been and continue to be the most socially disadvantaged groups in India that continue to be identified as needing affirmative action in terms of employment and education, for example, by the Indian government.[4]
Health Status and Utilization Patterns among Dalits
Among individuals belonging to scheduled castes, health care utilization tend to be lower and mortality rates tend to be higher than among members of higher castes. According to a study on health care-seeking behavior and health care spending by young mothers in India, women from lower castes spent less on public sector practitioners than higher caste women. Additionally, lower caste women also spent less on private practitioners and self-medication than higher caste women and non-Hindu women, yet experienced more self-reported morbidities than women from higher castes.[5]
In a study on utilization of antenatal care among women in southern India, women belonging to scheduled castes or scheduled tribes were 30% less likely than women from higher castes to have received antenatal care in the state of Andhra Pradesh even when potential confounding factors, such as age, birth order, and education level, were held constant. Also, while controlling for other factors, women belonging to scheduled castes or scheduled tribes in the state of Karnataka were about 40% less likely to have had antenatal care during the first trimester of pregnancy than women from higher castes. The study also found that women belonging to scheduled casts or scheduled tribes were less likely to give birth at hospitals and to be assisted by a health professional during delivery than women from higher castes.[6]
In terms of mortality, it has also been found that lower caste members face higher mortality rates during the earliest and latest part of life, especially among children and adolescents (i.e., 6 to 18 years of age) and the elderly.[7] In terms of health expenditure, the burden of health care spending is greatest among those living in rural and economically poor areas, with members of scheduled tribes and scheduled castes being the most affected by health care spending.[8]
Current programs and policies that have been implemented to improve health care access among Dalits
One of the most recent government-sponsored initiatives to improve health care access among Dalits includes a state-government-funded health insurance scheme called the Rashtriya Swasthiya Bima Yojana (RSBY), which translates into English as “Health Insurance for the Poor.” It works by sharing the risk of a major health catastrophe by pooling the risks across many households. This health insurance scheme was first implemented on April 1, 2008 by the Ministry of Labour and Employment of the Government of India in order to provide health insurance coverage to families living below the poverty line (BPL). One of the main objectives of the program is to protect BPL households from financial liabilities that often result from major health catastrophes that involve costly hospitalization. Additionally, pre-existing conditions are covered from the first day of coverage, there is no age limit for coverage, and coverage can be extended to five members of the family. However, beneficiaries are required to pay 30 rupees as a registration fee when enrolling in the program. RSBY is not the first attempt by the Indian government to provide health insurance to low-income families. Compared to other past initiatives, though, RSBY allows beneficiaries to choose between public and private hospitals and makes hospitals compete for their clients/patients, follows a business model with built-in incentives for all stakeholders; allows for the portability of coverage from one district to the next through the use of a Smart Card; employs cashless and paperless transactions; among other factors.[9]
Some of the key features of NRHM include: the scaling up of public spending to 2-3% of the gross domestic product by 2012 for vulnerable populations in key geographic areas; an increased flexibility of central and state funds, especially among health facilities that involve local governing bodies; a focus on primary health care, especially in rural areas, with increased opportunity for referrals and improvement in secondary and tertiary referral facilities; the formation of public-private partnerships to improve service delivery; more strategies for reaching distant and isolated populations, such as through the use of mobile health clinics, e-health, and/or telemedicine; the implementation of a conditional cash transfer scheme to encourage facility-based births as a means of reducing infant and maternal mortality rates; an increased role of the community through an investment in community-based health workers and activists; the integration of traditional and alternative methods of healing and wellness; the integration of inter- and multi-sectoral responses to addressing social determinants of health education, knowledge, and health-seeking behaviors; among other features.[10]
References
- ^ Pruthi, R.K. Indian Caste System. New Delhi: Discovery Publishing House, 2004. Print.
- ^ a b c Minority Rights Group International, World Directory of Minorities and Indigenous Peoples - India : Dalits, 2008. Available at: http://www.unhcr.org/refworld/docid/49749d13c.html. Accessed on May 28, 2012.
- ^ Appasamy, P., Guhan, S., Hema, R., ManbiMajumdar, and Vaidyanathan, A. Social exclusion from a welfare rights perspective: the case of India. India: Madras Institute of Development Studies, 1995.
- ^ National Family Health Survey 1998–99. Mumbai, India: International Institute of Population Sciences; 2000.
- ^ Bhatia, J. and Cleland, J. “Health-care seeking and expenditure by young Indian mothers in the public and private sectors.” Health Policy and Planning. 2001;16(1): 55-61.
- ^ Navaneetham, K. and Dharmalingam, A. “Utilization of maternal health care services in Southern India.” Social Science & Medicine. 2002;55: 1849-1869.
- ^ Subramanian, S.V., Smith, G.D., and Subramanyam, M. “Indigenous health and socioeconomic status in India.” PLoS Medicine. 2006;3(10): 1794-1804.
- ^ Balarajan, Y., Selvaraj, S., and Subramanian, S.V. “Health care and equity in India.” Lancet. 2011;377: 505-515.
- ^ Rashtriya Swasthya Bima Yojna. “Health Insurance for the Poor.” Available at: www.rsby.gov.in. Accessed on: May 28, 2012.
- ^ Ministry of Health and Family Welfare, Government of India. “National Rural Health Mission.” Available at: www.mohfw.nic.in/NRHM.htm. Accessed on: May 28, 2012.