The Dalit (formerly "Untouchable) community of India, and the Scheduled Castes and Scheduled Tribes, are subject to many disadvantages in health care access. As of 2008, there are 166.6 million Dalits in India. 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.
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Health care utilisation
Among individuals belonging to scheduled castes, health care utilisation tends to be lower and mortality rates tend to be higher than among members of higher castes. According to a study on health care-seeking behaviour 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.
In a study on utilisation 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.
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. 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.
Current programs
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 programme is to protect BPL households from financial liabilities that often result from major health catastrophes that involve costly hospitalisation. 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.
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 behaviours; among other features.