About the author:
Navya is a 12th grade student currently enrolled in Singapore American School. Having been brought up in an international school in Singapore, Navya is passionate about understanding different cultures and backgrounds, sparking her interest in the field of international relations and public policy. She will be attending Tufts University in the fall of 2024 to further her studies in this field.
Abstract
Caste, class, and gender not only influence the availability of healthcare services but also affect the quality of care received by different groups. In India, higher social strata are found to have better access to healthcare facilities, more options in choosing healthcare providers, and receive more attentive care. In contrast, lower social strata face significant barriers, including financial constraints, limited healthcare infrastructure, and systemic discrimination. This study examines the profound impact of social stratification on healthcare access and quality in India. The paper discusses how these disparities contribute to varying health outcomes and proposes policy interventions aimed at reducing inequity in healthcare provision. Recommendations include strengthening public healthcare systems, implementing anti-discrimination policies in healthcare settings, and promoting community-based health programs that are sensitive to the nuances of India’s complex social hierarchy. By addressing these key issues, the paper argues for a more equitable healthcare system that can improve overall health outcomes in India.
Introduction
Caste, class, and gender not only influence the availability of healthcare services but also affect the quality of care received by different groups. In India, higher social strata are found to have better access to healthcare facilities, more options in choosing healthcare providers, and receive more attentive care. In contrast, lower social strata face significant barriers, including financial constraints, limited healthcare infrastructure, and systemic discrimination. This study examines the profound impact of social stratification on healthcare access and quality in India. The paper discusses how these disparities contribute to varying health outcomes and proposes policy interventions aimed at reducing inequity in healthcare provision. Recommendations include strengthening public healthcare systems, implementing anti-discrimination policies in healthcare settings, and promoting community-based health programs that are sensitive to the nuances of India’s complex social hierarchy. By addressing these key issues, the paper argues for a more equitable healthcare system that can improve overall health outcomes in India.
Influence of Social Strata on Access to Healthcare Services in India
As aforementioned in the introduction section, the caste system is a prominent social structure in India and yields extensive implications on the population. While socioeconomic factors also encompass the principles from the caste system, this subsection will specifically outline the impact of socioeconomic disparities and overall affordability on access to healthcare (Malhotra, 2013). Further, it will also detail how the caste structure amplifies social inequality, and thus, the Indian population’s access to healthcare.
The caste system promotes a culture of social exclusion, particularly towards those in the lower castes. This is because being viewed as an ‘inferior’ class not only instills a subordinate mindset among individuals, but also reduces their opportunities for education, employment, and income. As a result, higher caste statuses have more advantages in the healthcare sector because they not only have more capacity to afford healthcare costs, but also more elaborate education abilities. This is where the intersection between caste and socioeconomic factors is evident. A survey presented by India’s National Sample Survey (2017-2018) emphasizes that 12% of respondents reported unmet healthcare needs, which they mainly accredited to the lack of affordable healthcare in various sections of the population. Further, there exists a slight disparity of the unmet healthcare needs between poorer and wealthier economic classes, the underlying pattern was that the burden of unmet was higher among illiterate respondents, regardless of the class disparities.
Another form of social stratification or discrimination can occur with regard to gender, specifically known as gender stratification. While gender roles in India is linked with the caste system and socioeconomic structures, the patriarchy also has other, exclusive, negative impacts on healthcare access in India (Ali, 2021).
India has long been notorious for its patriarchal structured society. In fact, substantiating this claim is a survey by Pew Research Center, where roughly 23% of Indians say there is a lot of discrimination against women, and a further 16% of Indian women reporting that they have personally faced discrimination. In this case, discrimination is exemplified in many different manners. From disadvantages in the employment sector to unequal representation in the political field, the implications of these existing gender barriers play a role in their access to healthcare in India.
Because the patriarchy plays a substantial role in governing the attitudes of people towards female empowerment, women are more likely to experience unequal access to resources and services such as healthcare. Within the context of India, the patriarchal ideals could be explanatory as to why girls have less access to hospital treatment and the lower rates of immunization. Moreover, in patriarchal societies, there is an emphasis on the notion that women are ‘less than men’ or subordinate in comparison to males, thus, reducing their objective value in society. As a result, a study analyzed in a PubMed article articulates that parents consult healthcare professionals more often for their sons over their daughters. Additionally, households with female newborns have also been evidenced to utilize cheaper healthcare options, whereas those with male newborns prefer private providers as they are perceived to be more effective in healthcare. Essentially, this data identifies the disparity of healthcare services households utilize to cater for their female versus male children.
To sum, these disparities are clear indicators that the patriarchy has played a substantial role in dictating the quality of healthcare required based on gender. Thus, this demonstrates how social strata can influence the decisions people in India make with regard to quality of healthcare service, and how it serves as a barrier for certain minority, which in this case is women (Borooah, 2022). Along with gender and socio-economic strata, a less direct, yet pressing form of social strata that promotes unequal access to healthcare in India is geographical disparities. This subsection will outline the urban-rural divide in India, as well as other geographical factors within specific areas that have caused obstacles in healthcare access.
It is, without a doubt, that the wealth distribution throughout India is unequal. Considering that the per capita income of the five richest states in India was 145% higher than that of the five bottom states in the early 2000s, a disparity that eventually even grew to 338% in 2017-2018, the wealth distribution is evidently unequal (Siddiqi and Nguyen, 2010). This inequity definitely arises due to differences in state budget allocations towards healthcare, disparities in private sector healthcare availability, and political priorities that are not always consistent or predictable. Therefore, the lack of investment in healthcare in lower income per capita states tend to not have as much investment directed towards healthcare, and thus, diminishing the overall quality or effectiveness of the services provided within these states.
Given the imbalance of healthcare resource allocation and supply of medical facilities across the states of India, one consequential difficulty that arises is that of transportation (Nayar, 2007). As individuals that reside in states with lower quality of healthcare are also those that earn a lower income per capita, they face both explicit and implicit costs associated with traveling out-of-state for higher quality healthcare. Solely due to this geographic limitation, lower-income individuals are faced with inability to access the necessary healthcare, thus, amplifying their existing inequality.
Current Policy Framework
With regard to social strata and healthcare, India is making some progress towards lessening the harsh impact on certain groups through specifically governmental initiatives and plans. This subsection will detail both these areas of policy and identify their effectiveness as well as missing gaps.
Firstly, the Indian government revised their initial National Health Policy (NHP) from 2002 with the goal of attaining the highest possible level of health and well-being for all age cohorts. Essentially, through incentivizing local manufacturing in rural areas, as well as reducing the costs of healthcare services, targeting a wide-range of income status individuals (Selvaraj et al, 2021). Despite these ambitious goals, the implementation of this plan, thus, negating the original goals of the plan. One of the key reasons as to why it didn’t implement as effectively as the Indian government had hoped, inadequate funding that led to lack of quality medical infrastructure didn’t allow the policy to reach its full potential. Further, the disparity of quality infrastructure between areas further amplified the difficulties faced by individuals already trivialized with geographical barriers.
Secondly, the government of India had launched the National Rural Health Mission NRHM in 2005 in 18 different states across India. The act placed an emphasis on bolstering the healthcare quality, particularly infrastructure, services, and human resources in specific rural areas. Therefore, this plan was put out with the goal of reducing disparities of healthcare access between rural and urban populations in India. In order to attain their goal, the NRHM implemented a committee focused on village health and sanitation, as well as partnered with non-governmental organizations in the private sector to provide more hands on deck and quicken their results. However, like the earlier mentioned policy, the NRHM has also lacked proper community engagement and efficient monitoring to successfully implement their plan.
Additionally, in 2018, the Indian government had announced the creation of hundreds of health and wellness, implemented with the goal of delivering primary healthcare closer to people in need. The Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY) of 2018 plan was essentially a benefit cover, health insurance scheme, in order to mitigate extreme expenditure on medical treatment which leads to a mass amount of Indian into poverty. However, reaching this goal requires proper implementation and focused emphasis on groups more prone to becoming impoverished (Siddiqi and Nguyen, 2010). Not only did the plan surmount controversy for facing challenges in relation to abuse and fraud, but also there was a lack of awareness or community engagement for citizens to be able to reap the benefits of this plan’s actions. Despite the plan encompassing costs of medical treatments, transportation and other non-covered service costs are not included, therefore initiating existing inequity.
To sum up, while there are a variety of actions aimed towards this problem made by the government, the necessary steps have not been met. Specifically, transportation costs and lack of community engagement are underlying patterns throughout the above-mentioned initiatives that have not been properly taken into account (Nayar, 2007). Therefore, should the Indian government put more priority and care into their programs as well as adequate funding, they would likely yield more effective and beneficial outcomes for the targeted population and lessen disparities and inequities.
Policy Recommendations
Based on the above gaps identified in existing policy and the root problems outlined above, the purpose of this paper is to bridge these gaps through proposed policy recommendations. This subsection will highlight potential recommendations for improvement.
The underlying issue remains that of stigmatization. Therefore, in order to destigmatize and reduce the marginalization of some groups in India, an extremely effective long-term measure would be to increase the population’s awareness of this problem. The continuation of patriarchal ideals and the caste structure both root from lack of proper education, thus, it is paramount to introduce community engagement educational campaigns in regions in India that most promote these harmful norms (Arun, 2023). This is comparable to the work of ASHA (Accredited Social Health Activists) workers, and can make substantial progress towards gauging communities and reducing the spread of detrimental misconceptions that restrict certain people’s access to healthcare services.
Similar to educational measures, empowerment measures can be implemented through health literacy programs. Essentially, these programs would go hand in hand to the campaigns mentioned in the earlier solution, where individuals would learn more about the importance of health and their rights within the healthcare system. Oftentimes the discrimination they face can reduce their desire to receive quality healthcare (Seth et al, 2017). Therefore, these measures will empower them to realize their rights, and thus, promote equitable healthcare. As addressed earlier in the paper, a major component that reduces certain populations’ access to healthcare services is the difficulty of affording transport. Therefore, a plan that could be imposed is to begin implementing community health workers. Through establishing medical educational programs for women and caste members that have been otherwise discriminated in the employment sector, this would grant them a job opportunity as well as promote more accessible healthcare services within communities (Bambra, 2020). Further, another convenience recommendation is to partner with civil society organizations and hospitals to instill efficient medicinal delivery programs. For example, a telephone helpline so that certain individuals to call to make a free delivery request for medicine to avoid them having to travel in and out of state or far distances (Cowling, 2014).
The Path Forward
From this paper, it is clear that some individuals have restricted access to healthcare based on their social strata in India. More specifically, the three key barriers or identifications of social strata in this paper are caste system, the patriarchy, and geographical disparities. Current government interventions around addressing these issues have made little progress for redressing societal norms and discrimination.
Therefore, this paper proposed policy recommendations to bridge the gaps that remain in the existing government schemes. Policymakers can now take into account the major concern of discrimination that exists as a barrier to healthcare services (Borooah, 2022). Especially when realizing the catastrophic revelations that the COVID pandemic revealed, policymakers can take this awareness and be more prepared and put more emphasis on the geographical disparities that marginalize individuals. Still, this paper does come with limitations. The paper generalized India as a whole, and focusing on one specific region or state would have likely yielded more effective policy recommendations. Further, the degrees of social strata playing a role on access to healthcare differ depending on the prevalence of the caste system. However, despite these limitations, the large literature synthesized, and patterns drawn prove the recommendations useful with regard to this topic.
References
- Ali, Istikhar. (2021). Social Stratification among Muslims and its Implications for Access to Health Services: An Exploratory Study in Mirzapur, Uttar Pradesh. Journal of Political Sciences & Public Affairs. 09. 1-5.
- Arun, A., & Prabhu, M. P. (2023). Social Determinants of Health in Rural Indian Women & Effects on Intervention Participation. BMC Public Health, 23(1), 921. https://doi.org/10.1186/s12889-023-15743-3
- Bambra C, Riordan R, Ford J, et al. (2020). The COVID-19 Pandemic and Health Inequalities. Journal of Epidemiol & Community Health;74:964-968.
- Malhotra, C., & Do, Y. K. (2013). Socio-economic disparities in health system responsiveness in India. Health Policy and Planning, 28(2), 197–205. https://doi.org/10.1093/heapol/czs051
- Cowling, K., Dandona, R. & Dandona, L. (2014) Social determinants of health in India: progress and inequities across states. International Journal for Equity in Health 13, 88. https://doi.org/10.1186/s12939-014-0088-0
- Nayar, K Rajasekharan. (2007). Social Exclusion, Caste & Health: A Review Based on the Social Determinants Framework. The Indian Journal of Medical Research. 126. 355-63.
- Selvaraj, S., Karan, A.K., Mao, W. et al. Did the Poor Gain from India’s Health Policy Interventions? Evidence from Benefit-Incidence Analysis, 2004–2018. The Indian Journal of Medical Research 20, 159 (2021). https://doi.org/10.1186/s12939-021-01489-0
- Chauhan V, Dumka N, Hannah E, Ahmed T, Kotwal A. (2022). Recent Initiatives for Transforming Healthcare in India: A Political Economy of Health Framework Analysis. Journal of Global Health Economics and Policy. doi:10.52872/001c.34300
- Borooah, V. K. (2022). Issues in the Provision of Health Care in India: An Overview. Arthaniti: Journal of Economic Theory and Practice, 21(1), 43-64. https://doi.org/10.1177/0976747920945186
- Siddiqi, A., & Nguyen, Q. C. (2010). A cross-national comparative perspective on racial inequities in health: the USA versus Canada. Journal of Epidemiology and Community Health (1979-), 64(1), 29–35. http://www.jstor.org/stable/20721128
- Seth, A., Tomar, S., Singh, K. et al. Differential Effects of Community Health Worker Visits Across Social and Economic Groups in Uttar Pradesh, India: a Link Between Social Inequities and Health Disparities. International Journal for Equity in Health 16, 46 (2017). https://doi.org/10.1186/s12939-017-0538-6