Indian Journal of Public Health

: 2013  |  Volume : 57  |  Issue : 4  |  Page : 242--247

Universal health care: Pathways from access to utilization among vulnerable populations

Sanghmitra S Acharya 
 Associate Professor, Centre of Social Medicine, Jawaharlal Nehru University, New Delhi, India

Correspondence Address:
Sanghmitra S Acharya
Associate Professor, Centre of Social Medicine, Jawaharlal Nehru University, New Delhi - 110 067


The present paper discusses universal access to health-care in the light of the barriers faced by some vulnerable individuals and groups due to caste based identities. Factors such as perception of self, availability of services, sensitivity of the providers determine access and consequently affect utilization among vulnerable populations. The paper examines the inter-linkages between these factors. Efforts, which create enabling environment have been discussed to highlight impeding and enhancing factors, Field based research has been used to reflect on some of these factors and possible best practices.

How to cite this article:
Acharya SS. Universal health care: Pathways from access to utilization among vulnerable populations.Indian J Public Health 2013;57:242-247

How to cite this URL:
Acharya SS. Universal health care: Pathways from access to utilization among vulnerable populations. Indian J Public Health [serial online] 2013 [cited 2021 Sep 21 ];57:242-247
Available from:

Full Text


The notion of universal health coverage is endowed with the benevolence of ensuring health and wellbeing for all. Universal health-care refers to "organized health-care systems, which are based on the principle of universal coverage for all members of society, including health financing and service provisioning." [1] However, the translation of these ideas into tangible measures is a path fraught with many barriers. Although on the one hand, the State with its limited resources, attempts to provide for people's health, on the other, the particular nature of social institutions that make up the fabric of societies in South Asia, particularly India, make access to these resources difficult for some people more than the others. Thus large sections stand deprived of or are denied access to health-care resources owing to their social identities. Although there is much evidence in existing literature of the role played by gender and economic factors in this exclusion, caste based determinants and the consequences of deprivation that they contribute to have not found adequate representation. The discussion on caste in the context of health-care resources has largely been as associated with the lens of gender [2],[3],[4],[5] and social and economic indicators. [6] There is evidence of the role that caste based identities play in accentuatingdeprivation. [7],[8],[9],[10],[11],[12] The existing vulnerabilities of poor access to education, skills, lack of awareness stand worsened or mitigated depending on the caste that people belong to. Therefore, it is imperative to examine the social heterogeneity of the people for whom the health care needs to be universalized; and to understand the barriers, which impede the pathways toward utilization of care. Access leads to utilization in consonance with availability of services. Utilization is also dependent on perception of self. The present paper, therefore, examines pathways from access to utilization of resources and services. It aims to understand discrimination as a barrier in universal access to health-care and plausible means of creating enabling environments for inclusion of those socially excluded.

 From Access to Utilization through Availability and Perception of Self

Access and final utilization results from awareness, information, knowledge and conducive environment to use the services and resources. It also hinges on the capability to overcome inhibitions and obstructions for interactions with providers and providing institutions. Inhibitions largely arise due to no or few opportunities for education and income generating activities leading to poor living conditions, housing, nutrition, life-style and health and social environment. Availability of resources is governed by the procurement chain- from the place of generating the resource, through the market to the providing agencies or individual providers to the users. The policy regime, market, media, advertisement, motivation and buying capacity of the user collectively influence availability of resources. Perception of the self too is both collective and individual. It has elements of the image created by others. Positive images enhance confidence by limiting inhibitions, and are cherished, while negative images, particularly when emanating from biases and stereotypes, are resented and continuous efforts are made to counter them.

Enabling environment for vulnerable populations * can be created through institutions by ways of policies and programs and the sensitivity of the providers and co-users of the resources and services. Enhancing factors include the positive self-image consequent of propensity which allows access in contract to the negative self-image. Thus, a matrix of five factors juxtapose themselves to transcend from access to utilization [Figure 1].{Figure 1}

Utilization is affected by the availability of resources, services and personnel as much as it is by exclusion and discrimination. [10],[13],[14] Utilization is lower among the vulnerable populations as compared to others. [14],[15],[16],[17],[18],[19],[20]

 Social Inclusion from the Lens of Access

Social inclusion of vulnerable populations who have been historically excluded has been the focus of the governments, sympathizers; and of affected communities, groups and individuals. Public goods, which should be available to all are limited to a few. [21] Understanding the elements and processes, which create a social divide has been a continuous intellectual pursuit because subordination and marginalization of this group is fairly well-recognized. Identifying and addressing these elements and processes is crucial in creating the enabling environment for inclusion. Participation in social, economic and political activities and processes at various levels and in various capacities is considered synonymous with social inclusion [22] and enables access to resources. Denial of participation results in oppression leading toward social exclusion.

The initial discourse on access was mostly on physical disability. [23] Structural factors affect participation, personal characteristics and limit performing activities for the disabled. [24] Similarly, social discrimination disables persons, groups and communities so as to obstruct participation, leading to oppression and exclusion. In the Indian context, socially excluded people are handicapped by the social divide created by caste based differentials in addition to those created by differentials in literacy levels and economic capabilities. This notion was extended to understand processes through which individuals or groups are wholly or partially excluded from full participation in the society within which they live. [6] "Enabling justice" [23] equips people with social disadvantages for building economic capabilities - social position, political participation and inclusion. The two attributes of exclusion are - (a) multiple aspects of discrimination and the related societal processes; and (b) the institutional structures that are involved in deprivation. In both the situations, some people are kept out (unfair exclusion) and some are included on unfavorable terms (unfair inclusion). Unfair inclusion with unequal treatment is likely to have the same adverse effect as unfair exclusion. [25]

Therefore, the typology of social exclusion affecting universal access to health can be visualized as complete, partial and forced (forms); in specific spheres; and related indicators and consequences [Table 1].{Table 1}

In a situation of institutional exclusion and discrimination when policy, organizational structures and the service providers are not sensitive to the concerns of vulnerable populations, utilization is jeopardized. In the service delivery system, there is a minimal effort to involve providers from vulnerable communities at different levels. Why is it that social facilities- school, health center, post office, Panchayat Ghar, for instance, are located proximate to or within residential areas of dominant castes of the village? Why is it that the piped water supply stops before it reaches the living quarters of vulnerable populations in most villages? Why it is that most settlements of the vulnerable populations in the village do not have electricity or are predominantly connected by kuccha roads? Canthose belonging to vulnerable communities reach service delivery centers as freely as others, without fear, verbal abuse, teasing, intimidation, insult, or without physical violence? [13],[26],[27] [Figure 2] {Figure 2}

 Conceptualizing Pathways to Utilization

Access is an important concept in understanding decision making, participation and inclusion [22] leading to utilization of resources and services. Health-care access can be understood through the concepts of "potential" and "realized" access. Potential access focuses on person and service characteristics related to structures and processes. Realized access comprises of measurable indicators such as time and type of services, and subjective indicators related to users' satisfaction. [28]

Utilization has two broad paths, which function through potential and realized access. In the health care delivery system, refusal to observe certain norms, which are mandatory in care giving, but are often violated while providing care to the dalits are evidence of discrimination. These may be manifested in the form of refusal to touch; enter the house; share the seat, food, water and transportation. The spheres in which discrimination is likely to be visible are care delivery centers. It may also be evident in the care delivery at home, source of water supply, role in local self-governing bodies; anganwadi centers; and health camps for immunization and medical checkups. Availing facilities provided through government programs also affects utilization. [13],[26],[29] It is important to understand whether the vulnerable populations know about these schemes or have ever been discriminated against in being informed about these schemes? Is there a likelihood that they will be informed about such events? How many beneficiaries of such schemes have been from among them? What was the experience of those who were eventually recipients of these benefits? There could also be evidence of unfavorable inclusion where persons from these population groups may have been made part of a health or immunization camp, for instance, to ensure the completion of certain target numbers.

 Service Providers and Universal Access to Health Care (UAHC)

Public health includes services and resources that go beyond health-care and affect health indirectly such as safe drinking water; sanitation and drainage; hygiene; housing and basic infrastructure. Prevalence of discrimination in these spheres in various forms impedes UAHC. Most of the basic infrastructural facilities such as electricity, drinking water, road-do not reach or are dysfunctional in residential areas of the vulnerable populations. [13] Utilization is jeopardized if the policy, organizational structures and service providers are not sensitive to the concerns of vulnerable populations.

Providers may withhold information about schemes launched for vulnerable groups or may engage in other forms of discrimination. For instance providers and other personnel have been known to not touch dalit users, not enter their houses and not share information. However sensitivity in providers often arises out of their orientation towards biases and stereotypes related to vulnerable populations.

 Voices from the Field

The experience of discrimination in accessing health-care services is the outcome of the interplay between various forces operating in the society, in health-care provisioning, and perception of the self. As children from the vulnerable population groups grow, their experiences acquaint them with this inexplicable practice of discrimination of the religion, which is claimed to be all embracing. It puzzles the young questioning minds who are often "taught" "god is one and we all are his children…!"†. The experience of discrimination while accessing health-care services varies. Verbal communication and non-verbal gestures of providers are indicative of the inferior status that many dalits were thought to have in their eyes. These could include the choice of words, the manner of speech, the ways in which medicine is dispensed; the space to sit, whether they are offered a place to sit, availability of and access to common sources of drinking water in the health-care facility, the amount of time spent waiting when compared to users from other castes, are some of the markers that users employ to judge discriminatory behavior‡ . Some observations from the field § examining spheres and forms of discrimination suggest that utilization is restricted due to discriminatory practices of providers and co-users of health-care services. From among the spheres of discrimination studied, dispensing of medicine was ranked as the most discriminating; while consulting the care providers and seeking referral was least discriminating. Conduct of the pathological test was second most discriminating hence affected utilization in that order. Non-verbal gestures and ways of, physical interaction-touch (touch roughly/do not touch) and conversation (speak gently) were other areas of most discrimination. Use of demeaning words, providers spending "less time" with the users, was also limiting utilization [Table 2].{Table 2}

Perception of self through others behavior or attitude towards them also affect utilization. Thus the dominants castes' attitude toward or opinions of lifestyle and living conditions of the dalits may act as deterrents to the use of health-care facilities¶ . Occupations of dalit users were also seen to be associated with perceptions of poor hygiene and led to discriminatory behavior on the part of the providers, for instance rearing of pigs [Table 3].{Table 3}

Living conditions as perceived by the "others" were reflective of inadequacies, which Dalits often suffer from. For instance, "half-clad children" could be more due to poverty than choice. Similarly, "children with runny noses" is more likely the outcome of inaccessible health-care services than the deliberate health condition. Nevertheless, such children and those who "lived with their animals in the same jhopa **" experienced discrimination.


Discrimination is evident in different forms and spheres and practiced by various personnel. Emerging from the foregoing understanding, caste-based exclusion is related to lack of access to services and goods offered by societies. Utilization can happen when there are adequate resources available and sensitive providers dedicated to providing enabling environments; and can be reached and communicated with. Access translates into utilization through the web of adequate resources, conducive policy regime and providers sensitive to social heterogeneity and differential access; and perception of self. Differentials in these factors cause disparity in utilization and are relevant in addressing social inclusion of vulnerable populations.


* Refers to Scheduled Castes, Scheduled Tribes and Other Backward Castes.

† FGD with Children on their understanding of discrimination. Acharya 2010a, 2012 [13],[30]

‡ Content Analysis of the FGDs with children and women on 'visit to the health centre'; and 'visit of care providers'. Acharya 2010b, 2012 [14],[30]

§ Access to Health Care and Pattern of Discrimination - A Study of Dalit Children in Selected Villages ofGujarat and Rajasthan. Children, Social Exclusion and Development.Working Paper Series. Volume 01, Number 02. Indian Institute of Dalit Studies and UNICEF (India), New Delhi 2010a

¶ Based on individual interviews with non-dalits.

** Thatched hut.


1WHO. World Health Organization, 2008. Available from: [Last accessed on 2011 Dec 23].
2Divakaran S. Gender based wage and job discrimiantion in urban India. Indian J Labour Econ 1996;39:235-56.
3Anker R. Gender and Jobs: Sex Segregation of Occupations in the World. Geneva: ILO; 1981.
4Unni J. Gender in informality in labour market in South Asia. Econ Polit Wkly 2001;36:2360-77.
5Rodger YM, Menon N. Trade policy liberalization and gender equality in the labor market: New evidence for India. Rutgers Univ World Aff Rev 2008;1:1-25.
6Arjan H. Poverty and Social Exclusion: A Comparison of Debates on Deprivation. Working Paper No. 2 Poverty Research Unit. Brighton: Sussex University; 1997.
7Vijayendra R. Does Prestige Matter? Compensating Differentials for Social Mobility in the Indian Caste System. Chicago: University of Chicago, Population Research Center 92-6; 1992.
8Saagar M, Pan I. Scheduled castes and scheduled tribes in eastern India: inequality and poverty estimates. Econ Polit Wkly 1992;29:56-74.
9Borooah V, Iyer S. Vidya, veda and varna - Influence of religion and caste on education in rural India. J Dev Stud 2005;41:1369-404.
10Hoff K, Pandey P. Discrimination social identity and durable inequalities. Am Econ Rev 2006;96:206-21.
11Majumder R. Earnings differentials across social groups-evidence from India. Indian J Labour Econ 2007;50:943-54.
12Madheswaran S, Attewell P. Caste discrimination in the urban labour market-evidence from the national sample survey. Econ Polit Wkly 2009;42:2314-35.
13Acharya Sanghmitra S. Access to health care and pattern of discrimination - A study of dalit children in selected villages of Gujarat and Rajasthan. Children, Social Exclusion and Development. Working Paper Series 01(02). New Delhi: Indian Institute of Dalit Studies and UNICEF (India); 2010.
14Acharya Sanghmitra S. Caste and patterns of discrimination in rural public health care services in blocked by Caste - Economic Discrimination and Social Exclusion in Modern India (eds.) Delhi Oxford University Press. 2010b;208-29.
15Acharya Sanghmitra S., Kanitkar T. Maternal and Child Health - Utilisation of Health Services in Nirpura, District Meerut. Research Series 95. Mumbai: IIPS; 1995.
16International Institute of Population Sciences and Macro International. National Family Health Survey-2 (1998-99), India. Vol. 1. Mumbai: IIPS; 1999.
17International Institute of Population Sciences and Macro International. National Family Health Survey-3 (2005-06), India. Vol. 1. Mumbai: IIPS; 2007.
18Ram F, Pathak KB, Annamma KI. Utilisation of health care services by the underprivileged section of population in India - Results from NFHS. IASSIST Q 1998;16:128-47.
19Acharya Sanghmitra S. Health care Utilisation in Rural North India - A case of Nirpura, District Meerut. MHSP, CSMCH-EU Project. Centre of Social Medicine and Community Health, School of Social Sciences. New Delhi: Jawaharlal Nehru University; Forthcoming 2002.
20Kulkarni PM, Baraik. Utilisation of Health Care Services by Scheduled Castes in India. Working Paper IIDS, New Delhi; 2003.
21Thorat S, Mahamalik M, Panth AS. Caste, Occupation and Labour Market Discrimination - A Study of Forms, Nature and Consequences in Rural India. New Delhi: Indian Institute of Dalit Studies, Study Sponsored by ILO; 2006.
22Galvin R. Can welfare reform make disability disappear? Aust J Soc Issues 2004;39:343-55.
23Finkelstein V. Disability - A social challenge or and administrative responsibility? In: J Swain, V Finkelstein, S French and M Oliver (eds.) Disabling Barriers Enabling Environments, London: Sage; 1993.
24WHO, World Health Organization, 2002. Available from: [Last accessed on 2011 Jul 13].
25Sen A. Social Exclusion: Concept Application and Scrunity. Asian Development Bank Working Paper, 2000.
26Geetha BN. Exclusion and Discrimination in School - Experiences of Dalit Children. Children, Social Exclusion and Development. Working Paper Series 01(01). New Delhi: Indian Institute of Dalit Studies and UNICEF (India), UNICEF-IIDS; 2009.
27Thorat SK. Dalits in India: Search for a Common Destiny. New Delhi: Sage; 2009.
28Aday LA, Andersen RM. Equity of access to medical care: A conceptual and empirical overview. Med Care 1981;19:4-27.
29Kumar K. Health of Dalit Women - Issues of Development and Deprivation in Ambedkar Villages of Sonbhadra District, UP [Dissertation]. New Delhi: Centre of Social Medicine and Community Health, School of Social Sciences, Jawaharlal Nehru University; 2010.
30Acharya Sanghmitra S. Social Discrimination in Health Care Access among Dalit Children - Exploring Inclusive Environment. New Delhi: Academic Publication; 2012.