a. Centre for Study of Social Change and Development, Institute for Social and Economic Change (ISEC), Bengaluru, Karnataka, India
The paper examines whether the present health service system in India is equipped to check the prevailing discrimination against dalits and cultural isolation of adivasi that explained a great deal of their health deficit. Drawing from official data sources, the paper shows an overall domination of non- Scheduled Caste/ Scheduled Tribes (SC/STs) in key positions of rural healthcare services, which creates an environment favourable for discrimination. The paper also explores the possible relationships between higher intergroup differences in health access between dalits and non-dalits and lower share of dalits in the significant positions of rural health services in various Indian states. The continuing poor state of health infrastructure in tribal India with substantial shortfalls in sub-centres, Primary Health Centres (PHCs), Community Health Centres (CHCs) and significant healthcare personnel is another serious challenge for inclusion. The paper concludes that the Indian health service system present is not equipped to address these issues of exclusion, which calls for urgent policy attention.
Health inequalities across various socio, economic and cultural markers continue in India despite the overall improvements in population health. This paper begins by noting the continuing disparities in health outcomes of dalits and adivasi as compared to other social groups,1-4 the caste based discrimination in health services that often leads to the lower access for dalits5-8 and the systemic isolation of adivasi from health services.9-12 These scholarships have also highlighted the need to have innovative and inclusive practices to check the supply side problems of delivering fair, adequate and discrimination-free healthcare services to people. Among others one of the major proposals emerged was to recruit health personnel from discriminated groups in significant positions of rural health services in order to prevent caste based discrimination and overcome the deficit in health infrastructure in tribal areas to prevent unavoidable exclusions. The paper, in this context aims to examine whether the discriminated groups are adequately represented in the significant positions of rural health services and whether there is an improvement in the provisioning of health services in tribal India. The social profile of healthcare personnel presented in the paper is drawn from the 68th round data of National Sample Survey Organisation (NSSO) on employment and unemployment (2011-12)13 and the status of health infrastructure in tribal areas from the data of the rural health statistics of Ministry of Health and Family Welfare (MoHFW).14
Marginalities and Health Inequity
While health inequality is common in any society, health inequity is specific to some societies, where there is an environment existing for an unfair disparity in health. This can be better understood by the definition offered by Arcarya et al on health inequality and health inequity in the context of avoidable and unavoidable health inequalities. They note that “any measurable aspects of health that varies across individuals or socially relevant groupings can be called a health inequality….in contrast a health inequity…..is a specific type of health inequality that denotes an unjust difference in health”.15 One can easily locate the prevailing caste practices against dalits and cultural isolation of tribals, in India in this definition of inequity since these are the unfavourable, but avoidable social contexts that create and reproduce unjust differences for these group of people. The linkages of caste practices and deprivation of dalits in various spheres are well discussed by the Indian academia7,16-22 and hence does not require any elaboration here. It is, however, important to highlight the studies that brought out the dimensions of health inequities for two major marginalised social groups in India-the dalit and adivasi to contextualise the terrains of discrimination and isolation, which the present paper engages with.
There are mainly two sets of studies that have informed the health inequalities across social groups with regard to their group specific markers of marginalities in India. The first is those which brought out the intergroup differences in access to health services and health outcomes using large data sets. Barik and Kulkarni highlighted the significant intergroup differentials in nutritional status of dalits and adivasi as compared to other social groups.23 The study showed that children from dalit and adivasi populations faced relatively higher risks of mortality as well. Some studies highlighted the lower level of utilisation of health services among the dalits as compared to the non-dalits.1,6,24 Thorat brought out the disparities in health status and healthcare access of dalit and adivasi children as compared to other social groups.25 Dasgupta and Thorat2 reiterated the persisting trend of inequalities in health status access of dalits and adivasi that was reported by Kulkarni and Barik.1 Their study noted that malnutrition and child mortality remained the highest and immunization the lowest for adivasi followed by dalits. The data of National Family Health Survey-3 (NFHS-3) showed that access to Antenatal Care (ANC) was the lowest among adivasi and dalit women. Similarly, institutional delivery was found to be the lowest among adivasi followed by dalits and adivasi remained the most deprived group pertaining to access to skilled personnel for attending birth in 1992, 1999 and 2006 followed by dalits.26
The second set of studies, recognising this relative health deficit of certain social groups, attempted to link the lower access and health outcomes to group specific cultural markers of discrimination, prejudices and isolation to bring in the dimension of health inequity. If not many, there were a few notable scholarly attempts to link it to discrimination and resulting deprivation.3,4,7 Borooah, for instance, showed that the health outcomes of people are significantly affected by their social group attributes.3 Acharya brought out the different levels of discrimination in dalits accessing health services in the state of Gujarat and Rajasthan.7 Saroha et al noted that caste is a significant barrier to maternal healthcare service use among the rural women of Uttar Pradesh.27 Das et al showed that the group identity as ‘adivasi’ was found to be significant “for having higher rates of child deaths even after controlling for wealth” and highlighted that “the highest number of child death in the age group of 1-5 was in the adivasi concentrated districts”.12 One of the major reasons that this study identified for the higher rates of child death in tribal areas is lack of access to health facilities. Barnes highlighted that adivasi women are often subjected to verbal and physical abuse at public health centres and the poor quality public sector facilities multiplied the ill health of adivasi women in Jharkhand.10 In certain cases, discrimination in health services and financial un-affordability determined the decisions of treatment seeking of dalit families. For instance Dilip showed that the proportion of untreated patients among dalits and adivasi living in rural areas was higher as compared to other groups.28 Rani et al based on a primary study conducted in a district of Jharkhand state showed that “maternal healthcare seeking among adivasi women was limited and a substantial proportion of adivasi women did not receive antenatal services; nearly all delivered at home and only a small proportion received a post-partum check-up due to unavailability of services in the locality”.11 Some of the studies also drew linkages of health seeking behavior of adivasi with their geographical isolation and cultural correlates such as belief, practices and customs. Barnes, for instance, argued that the low institutional delivery in tribal areas can be explained with factors such as financial and physical inaccessibility to services and prevailing belief systems.10
The literature shows that health outcomes of dalits are strongly linked with their overall deprivations emanating from the social and economic relations of caste system, which are created and reproduced in all spheres of life. Similarly, remoteness, underdevelopment and isolation continue to have strong bearings on the health outcomes of adivasi communities. These cultural and structural markers of inequity in health outcomes across social and ethnic groups vex when the country claims to have achieved or nearly achieved the millennium development targets of maternal and child health. The official version of overall health improvement thus camouflages the health inequities and allows the system to recreate the environment, which is favourable for exclusion. It is important in this context to understand the social profile of healthcare providers as well as state of availability of healthcare infrastructure in tribal India. There is no direct data available on the social profile of healthcare personnel in India. Nonetheless, the NSSO employment and unemployment data provides information on health and related occupations including doctors, technicians, nurses and assistants as under the National Classification of Occupation (NCO), from where social profile of some of the healthcare personnel could be extracted.13 It should be mentioned that the data does not give information across sub castes, which is a major limitation. The periodical data released by the rural health statistics provides the state of healthcare infrastructure in tribal India.14
Terrains of Discrimination
The social profile of some of the significant healthcare providers in the rural areas enables us to understand whether dalits are represented adequately in significant positions of care giving and whether there is a favourable environment existing for caste based discrimination. The data shows that the share of dalits in the positions of healthcare is less than other social groups and is particularly underrepresented (as a proportion to their total population) in rural India except in the group of nursing and midwifery and associate professionals (see figure 1). Furthermore, among all social groups it is only the group of ‘others’, which includes the middle and upper level castes that has adequate/over representation among health related professionals including general medical practitioners, specialists doctors, trained nurses, technician and associated health staff. It should be noted that while this group constitutes a nearly 24 percent of the rural population, their share is as much as 40 percent in the category of health professionals, 70 percent in nursing professionals, 34 percent in health associate professionals and 26 percent in nursing and midwifery associate professional. On the other hand, dalits and adivasi are underrepresented in such positions. The underrepresentation of SCs is found to be the highest in nursing- one of the most crucial caregivers who need to closely interact with patients in a hospital setting. In short, the data indicates that there is visible overrepresentation of middle and upper caste groups and underrepresentation of lower castes and STs in important positions of healthcare delivery, which creates an environment favourable for discrimination against dalits.
The state level data provides clear pictures on the level of underrepresentation and overrepresentation of social groups. The dalit’s representation in the category of health professionals (including doctors and specialists) except nurses is negligible in the rural areas of Madhya Pradesh and Tamil Nadu, and notably underrepresented in Bihar (1.7%), Orissa (5%), Andhra Pradesh (6.4%), West Bengal (9.6%), Uttar Pradesh (10.7%) and Karnataka (13.9%) (See table 1). The profession on the other hand is overrepresented by OBCs in all states excluding Punjab, Rajasthan, Gujarat and Maharashtra. The overrepresentation of OBCs in the profession is the highest in Bihar with nearly 89 percent followed by Madhya Pradesh (71%), Uttar Pradesh (65%), Karnataka (66%), Kerala (55%) and Andhra Pradesh (51%). Likewise, the upper and middle level caste groups are also visibly overrepresented in all states except Bihar. Their overrepresentation is notable in the rural areas of West Bengal (82.4%), Maharashtra (75.8%), Gujarat (75%) and Rajasthan (56.7%). It must be noted that states including Punjab, Haryana, Kerala, Rajasthan, Gujarat and Maharashtra have representation of dalits more than or equal to their population share. The representation of STs was negligible in all states except Orissa.
The social profile of modern healthcare professionals such as radiologists, lab technicians, pharmacist etc (excluding nurses) shows that dalits are considerably underrepresented as a proportion to their population share in the rural areas of Bihar, Orissa, Kerala, Tamil Nadu, Uttar Pradesh, Madhya Pradesh and Maharashtra (see table 2). Along with the underrepresentation of dalits, there is a visible overrepresentation of OBCs and upper and middle level caste groups in these states, creating an environment favourable for caste based discrimination. While there is a pronounced overrepresentation of OBCs in the states of Tamil Nadu (98%), Uttar Pradesh (87%), Kerala (57%) and Orissa (54%), it is pronounced for upper and middle level caste groups in Punjab (100%), Bihar (85%), Maharashtra (62%) and Kerala (43%). The states where dalits are represented proportionately or more to their share of population in rural areas were West Bengal (70%), Himachal Pradesh (40%), Andhra Pradesh (31%), Karnataka (30%) and Rajasthan (24%).
Another important category of healthcare personnel in rural India is nursing, midwifery and associates health workers like male and female health workers. This group is crucial in the rural healthcare delivery since they interact with people more frequently to deliver everyday personalised healthcare services like administering medicine, dressing wounds, injections, vaccinations, home visits, pre and post natal care services, health education, counselling etc. The presence of dalits in these occupations is surprisingly negligible in rural Himachal Pradesh, Tamil Nadu, Rajasthan, Punjab, Gujarat and Madhya Pradesh (see table 3). While the social group OBC is overrepresented in Bihar, Himachal Pradesh, Andhra Pradesh, Rajasthan and Kerala, the dominance of upper and middle level caste group is pronounced in Gujarat, West Bengal, Maharashtra and Kerala.
The social profile of healthcare personnel clearly shows the states where a favourable environment exists for discrimination with the sweeping presence of OBC communities and the middle and upper level caste groups, which are the dominant social groups in the hierarchy of caste relations in rural India. Dalits are underrepresented in all three categories of occupation in some states including Bihar, Uttar Pradesh and Orissa. Likewise, OBCs, upper and middle level caste groups are considerably overrepresented in all the three categories of occupations in all the states in general and particularly in those states where underrepresentation of dalits is prominent. What is important to note is that some of the states, for instance, Tamil Nadu, Himachal Pradesh, Kerala and Andhra Pradesh, irrespective of their better outcomes in population health do not have health personnel from dalit groups in all significant categories of care givers proportionate to their population share. It should be mentioned here that discrimination is mostly experiential in nature and it is incorrect to argue that dominance of non-dalit/tribal group is an absolute condition for discrimination against dalits. It is contextual and also varies across places and persons. However, one cannot discount the possibility of discrimination if there is visible domination of certain caste groups, taking the adaptive nature of caste system and its continuity in one form or the other into account.29
Although it is difficult to attribute the lower access and adverse health outcomes of dalits to their inadequate representation in significant positions of rural health services, data on intergroup disparities in accessing health services and social profile of care givers together could give us some insights on the possible relationship between the two. The data on birth attended by skilled personnel, which is an access related indicator from the NFHS-3 is presented here (see figure 2). It shows four major patterns of intergroup disparity between SCs and non-SC/STs in various states. First is the group of better performing states where the number of deliveries attended by skilled person is better for all social groups and has negligible intergroup differences. This group includes the southern states of Kerala and Andhra Pradesh. Second is the group of states, which is lower performing with significant (more than 10 percentage points here) intergroup differences. This group includes Bihar, Uttar Pradesh, Orissa and Rajasthan. States in the third group, although are better performers, have significant intergroup differences. This group includes Tamil Nadu and Karnataka. Finally, the states which are not better performers but have only negligible disparities such as the West Bengal. We can draw some observation while looking at this data along with the social profile of the significant health providers in rural areas. First is that the states, which are both poor performers in terms of access to skilled person for delivery and have significant social group disparity unfavourable to dalits, have visible underrepresentation of dalits in all positions of service delivery. Secondly, despite being better performers, states like Tamil Nadu and Karnataka, where health service system is dominated by OBC and others, show significant intergroup disparity. These relationships, however, are to be further empirically verified with suitable methodologies.
Terrains of Isolation
While there is an overall increase in health infrastructure including availability of sub-centres, PHCs, CHCs and significant medical personnel in all states, except Madhya Pradesh and Gujarat,14 such trend is not found to be visible in most part of tribal India, reinforcing the continuing isolation of tribal communities from health services. Tables 4 and 5 give comparative pictures of improvement in health infrastructure and availability of key health care personnel in tribal India between 2006 and 2014. As the tables show, several states have substantial shortage of sub centres, PHCs and CHCs in the tribal areas. Besides, the data shows that the shortage increased some states over a period of time. For instance, the shortage of sub-centres in tribal areas of Gujarat increased to 685 in 2014 from 79 in 2006. Similarly, it increased to 1850 from 898 in Madhya Pradesh, 945 from 470 in Maharashtra, 400 from 216 in Bihar, 309 from 270 in Orissa, 1324 from 1039 in Rajasthan and 290 from 159 in Meghalaya. Another alarming trend is the huge deficit in some states, which once had adequate number of sub-centres in tribal areas. For instance, the sub-centres were surplus in the tribal areas of Karnataka in 2006 whereas the state reported a shortage of 819 sub-centres in 2014. Though not as pronounced as in Karnataka, Himachal Pradesh also showed the similar trend in the shortage of sub-centres. It raises important questions on allocation of resources and maintenance of already installed infrastructure even after ten years of implementation of the National Rural Health Mission (NRHM). The shortage of PHCs and CHCs also increased considerably in some states including Gujarat, Madhya Pradesh and Bihar between 2006 and 2014. The states, which showed considerable improvements in the number of sub-centres, PHCs and CHCs are states in the north east region except Meghalaya, southern states of Kerala and Tamil Nadu, West Bengal in eastern India and Chhattisgarh in central India.
Tribal areas of several states continue to have shortage of healthcare personnel including qualified doctors and nurses. The shortage in some of the key healthcare personnel in tribal India as of 2014 is available from table 5. Out of a total shortage of 701 doctors in PHCs and CHCs of tribal areas, the highest was in Chhattisgarh (262) followed by Nagaland (205), Assam (83) and Gujarat (52). Similarly, out of a total shortage of 3549 nurses in PHCs and CHCs, the highest was in Nagaland (988), followed by Uttaranchal (821), Chhattisgarh (551), Kerala (501), Madhya Pradesh (289) and Arunachal Pradesh (167). While several states fulfilled the requirement of female health workers, considerable shortage was reported from states including Uttaranchal (998), Nagaland (200), Assam (161), Jharkhand (98), Chhattisgarh (80) and Arunachal Pradesh (55). Lab technician was another group of healthcare personnel where all states showed shortage. Although most of the states reduced the shortage of healthcare personnel in tribal areas between 2006 and 2014, the shortage of doctors and nurses increased, especially in the states of Chhattisgarh, Nagaland and Tripura.
The recent Indian Human Development Survey -2 (IHDS-2) of National Council for Applied Economic Research and the University of Maryland highlighted the continuing practice of untouchability in rural India. As per the survey, despite its legal abolition, 27 percent of the households in India practice untouchability.31 What is interesting here is that the states, which showed both higher level of disparity unfavourable to dalits and underrepresentation of dalits in significant positions of rural healthcare delivery, happen to be the states (for instance, Madhya Pradesh, Uttar Pradesh and Bihar) with the highest prevalence of untouchability. Notwithstanding the ongoing academic debates on the cultural markers of inferior health outcomes, the official discourses of public health in India still tend to sideline the interlocking structural as well as cultural questions of exclusion while examining the gap in the health status among social groups. The most recent example, perhaps, is the Draft National Health Policy,32 which is silent on the exclusion of people from services on cultural markers. While the draft policy, among others, emphasises on issues like governance, community participation and efficient public health delivery, it does not give any indication on how issues of inclusion such as caste based discrimination and cultural isolation would be dealt with. The paper shows that the Indian health service system at present is not equipped for addressing this issue. Ensuring the presence of dalits in sufficient numbers in different levels of care giving in line with the local cultural specifications could be an important option. Although it is questionable whether such measures would strengthen the existing caste hierarchies, it is important to ensure adequate representation of healthcare personnel from excluded communities since it can reduce cultural prejudices and discrimination. Reduced access to services due to cultural and geographical isolations is another critical policy concern, especially in tribal India. As discussed in the paper, health infrastructure was alarmingly inadequate in tribal areas, which could further worsen their already inferior health status. States like Chhattisgarh has already introduced initiatives like Rural Medical Corps, which aims to encourage medical care personnel to work in tribal areas by providing incentives like residential accommodation, life insurance, extra marks for admission for post graduation for doctors and above all financial incentives. Studies show that some of these show positive results.33 It is important for other states as well to learn from such experiences and encourage health personnel with promotive measures to work in tribal areas along with improving the available health infrastructure.
This paper is taken from the ongoing research project of the author on Discrimination and Health Seeking Behaviour of Dalits, Supported by the Indian Council of Social Science Research. The author thanks professor KR Nayar for his useful comments. All usual disclaimers apply.
Conflict of Interest: None declared
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