Achieving Universal Health Care has been a key goal of the Indian Government since the Constitution was drafted. The Government has since launched several programs and policies to realize 'Health for All' in the nation. These measures are in line with the sustainable development goals set by the United Nations. Health disparities generated through the Hindu caste system have been a major roadblock in realizing these goals. The Dalit (untouchables) community occupies the lowest stratum of the Hindu caste system. Historically, they have performed menial jobs like - manual scavenging, skinning animal hide, and sanitation. In pictures: The many lives of India's Dalits. BBC News. December 20, 2023. The Indian constitution officially recognizes the Dalit community as 'Scheduled Castes' and bans caste-based discrimination of any form. However, caste and its far-reaching effects are still prominent in several domains including healthcare. Dalits (Scheduled Caste or SC) and Adivasis (Scheduled Tribes or ST) have the lowest healthcare utilization and outcome percentage. Their living conditions and occupations put them at high risk for disease exposure. This, clubbed with discrimination from healthcare workers and lack of awareness makes them the most disadvantaged groups in society.

Healthcare Utilisation

Historically, Dalits lived on the outskirts of civilization, worked as bonded labourers, and lacked access to basic amenities. They were denied access to water, land, and education. They had limited access to doctors and healers. According to research, socioeconomic discrimination affects health outcomes in three ways- 1) health status, 2) quality of healthcare services, and 3) healthcare access.  The inequalities in health created by the caste system are prominent even today.

Most of the Dalit population resides in rural areas and face challenges in travelling to healthcare centres. In urban areas, Dalit families can be found in urban slums. Most do not avail healthcare subsidies due to a lack of identification documents. Surveys reveal that there is mutual distrust between Dalit communities and healthcare workers. This is a form of institutionalized discrimination. Auxiliary-trained midwives (ANMs) and nurses are less likely to visit Dalit households, often citing sanitation concerns or social norms. Dalits often complain that they receive differential treatment from workers at regional health subcenters. As a result, they prefer to rely on unqualified healers and doctors and end up paying a lot. Increased privatization of the healthcare system has only worsened the problem due to price hikes.

According to data from the National Family Health Survey, life expectancy at birth for the general caste is 68.0 years. The life expectancy of SC and ST is significantly lower at 63.0 and 64.0 years respectively- with the life expectancy of men lower than that of women; this is likely due to the uncertain and unsafe conditions they are exposed to. Dalits are at a higher risk of contracting HIV-AIDS. Most Dalits suffer from skin problems, respiratory disease, parasitic illnesses, and diminishing vision and eyesight. The India Inequality Report of 2021 reports that SC and ST communities have the highest fertility rates yet the infant mortality rate and under-5 mortality rate in these communities are higher than the national average. The percentage of stunted children in SC and ST households is 12.6 and 13.6% higher than that in general castes. A majority of these children are also anaemic. Dalit children also face discrimination through the Midday Meal Scheme, defeating its purpose. Nonetheless, there have been some encouraging results from government programs. Due to an increased push from the government for childhood vaccinations and appropriate antenatal care in mothers, there is an increasing trend in vaccine utilization during infancy and pregnancy, however, the degree of adherence is still low and most individuals do not complete their vaccination schedule. The gap between institutional births between SC & ST and the general category is also decreasing. SC & ST households receive higher food supplements than the national average, indicating improvements in government food programs.

Healthcare indicators have been improving in urban, high-income families; most SC - ST communities are rural and low-income. Although household medical expenditures have improved over the years, an average general category household spent 1.7 times higher than Dalits in 2017-18. Huge out-of-pocket expenses on medication and tests discourage these communities from seeking healthcare. Dalit practitioners in the healthcare workforce are rare, despite measures for affirmative action. All these factors, skew the healthcare experience received by different social groups.

Dalit women

Dalit women face the double burden of being lower caste and female. This can be attributed to the lack of safety, sanitation, and exposure to diseases as an occupational hazard. In rural areas, Dalit women perform household chores as well as work as bonded labours with little to no pay. In urban areas, they usually work in households as maids. These women lack any form of social security in society. Most women are married by the age of 20 and are responsible for the care of multiple children. In most households, the men are the primary decision-makers. Studies reveal that healthcare utilisation is higher in households where the woman has the freedom to make decisions of her own. Surveys reveal that Dalit women have to travel long distances on foot to reach the regional healthcare subcentres- which may or may not be functional. Even though the government provides antenatal care medications like- anti-parasitic tablets, folic acid tablets, tetanus shots, and education for pregnancy- very few women can avail these.

According to a study on healthcare-seeking behaviour and healthcare 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. Only 23.7% of Dali households have access to toilets. Girls and women usually travel long distances for sanitation purposes, which poses a serious challenge to reproductive and menstrual health. Another study on the utilisation of antenatal care among women in southern India found that lower-caste women were less likely to have received maternal healthcare than women from higher castes. In the state of Andhra Pradesh, scheduled castes and scheduled tribes were 30 per cent less likely to have received antenatal care than women from higher castes- even when potentially 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. The country witnessed a 45 per cent rise in reported cases of rape in Dalit women between 2015 and 2020. Dalit women are frequently exposed to domestic violence, physical assaults as punishment for being lower castes, human trafficking, and prostitution. Dalit women's literacy has improved their social status, however, the situation remains glum.

The COVID-19 Effect

The COVID-19 pandemic sheds more light on the healthcare disparities in India. The impact of the complete lockdown in India was felt the most by the poorest of the poor who worked as daily wage workers and labour. While the government issued guidelines on home quarantine, the fact that most Dalit households do not have basic amenities like a toilet and food supplies was overlooked.Das, R, "How caste is disproportionately affecting the Dalits of South Asia in COVID-19 pandemics", International Dalit Solidarity Network Approximately 11,000 migrant labourers were stranded away from home due to the lockdown and 96 per cent did not receive any government-sponsored ration during this period. Several migrant workers chose to walk on foot across state borders and were met with severe hostility. This period also saw a spike in hate crimes against Dalits. The guidelines on 'social distancing' reinforced the means of caste-based discrimination. For instance, the Yanadi (SC) community of Vijaywada, Andhra Pradesh was barred from travelling to local markets for buying food and medicine since the lockdown. The municipal corporation is responsible for providing safety equipment like clean clothes, soap, headgear, gloves, rubber boots etc. to manual scavengers. The Ministry of Family Health and Welfare recommended that sanitation workers receive personal protective equipment like N-95 masks, sanitisers, rubber gloves and boots during the pandemic as they dealt with biological waste. This recommendation was barely acted on by the Municipal Corporations. Thus, Dalits were at a higher risk of being exposed to COVID and received little government support during the lockdown.

During the pandemic, the SC-ST groups faced greater difficulty in securing healthcare. 21% of villages did not allow SC families access to public health centres during the pandemic. Most lacked the connections to arrange for transportation, oxygen tanks, or beds in private hospitals. Reports also suggest that these communities faced serious travel accessing non-COVID-related care during this period. During the vaccination drive, high-income, urban dwellers were able to secure vaccine appointments through private hospitals at a higher cost. Poor marginalized communities queued up outside government centres for receiving their vaccination. Vaccine distribution between hospitals was also unequal. In a country with a huge digital literacy gap, schemes to digitize vaccinations only made COVID- care more inaccessible to Dalit families.

Current programs and policies

Led by B.R. Ambedkar, the Dalit Movement gained momentum in 1956. He was also one of the authors of the Indian Constitution which provides guidelines to ensure equality and prevent discrimination in society. Article 17 laid out stipulations for abolishing 'untouchability' of any kind. To create a level playing field, the Constitution laid out guidelines for reservation and affirmative action for members of lower caste communities in employment, education, and political representation. The Prevention of Atrocities Act of 1989, recognized the discrimination and threat to lower caste individuals. Despite these efforts, Dalits receive little benefit that the State promised them- Dalits are still subject to hate crimes, affirmative action provisions have failed to reduce grassroots-level issues in primary education, Dalit students have a high dropout ratio and employees are less trained, and discrimination against Dalits is evident across the health sector.