Social Determinants of Health in India: Reimagining of Dr. B.R. Ambedkar’s Vision in the Light of Marginalized Communities

Abstract

The ongoing existence of health disparities in marginalized communities in India can be attributed to social health determinants such as poverty, caste, gender, and limited access to education and healthcare. Dr. B.R. Ambedkar, an iconic figure in Indian social reform and the driving force behind the Indian Constitution, acknowledged the significance of the social determinants of health influencing health outcomes. This paper explores Dr. Ambedkar’s vision of addressing health disparities, with a focus on his contributions to public health policy and the promotion of social justice. Additionally, it analyses the ongoing perpetuation of inequality through the examination of social determinants of health and explores how Ambedkar’s vision can provide guidance for present public health strategies. The analysis highlights the importance of strong primary healthcare systems, recognizing universal healthcare as an essential human right through the vision of Dr. Ambedkar. It also advocates for greater government funding and policy coordination to effectively tackle health disparities.

1. Introduction

Scheduled Castes (SCs), Scheduled Tribes (STs), women, and children are among India’s marginalized communities, experiencing severe social marginalization and lower social status. Healthcare disparities are caused by social determinants such as caste, gender, and poverty. These determinants contribute to the complex web of healthcare issues. According to the Inequality Report (2021), health disparities disproportionately affect socioeconomically marginalized communities. In recent years, the public healthcare sector has prioritized understanding the complex determinants that influence health outcomes outside of traditional healthcare settings. These determinants are strongly influenced by social policies, which can also have a significant impact on overall well-being (Braveman and Gottlieb 2014, pp. 19–31).

2. Social Determinants of Health

The World Health Organization (WHO) Commission on Social Determinants of Health (SDH) offers a comprehensive definition of SDH as the various conditions and environments that shape individuals’ lives from birth to death. The well-being, quality of life, and overall health of individuals are greatly influenced by various factors, such as caste, class, education, income, and access to fundamental resources such as clean water, nutritious food, and sanitary facilities. The health outcomes of individuals are influenced by these factors’, known as SDH, impact on public health (World Health Organization n.d.).

Patel and Chauhan (2020, pp. 526–30) conducted a study that identified several determinants that the Indian marginalized communities and women used to encounter, such as geographical locations, cultural norms, and socioeconomic status, while seeking healthcare. Baru et al. (2010, pp. 49–58) reveals that the intersection of caste and socioeconomic status amplifies healthcare inequalities, particularly impacting marginalized communities in India.

Dr. Bhimrao Ramji Ambedkar emphasized the significance of tackling socioeconomic determinants of health to enhance healthcare services for marginalized groups and eradicate health disparities (Ambade 2022). In Meka (2022, pp. 1026–40), similarities were identified between Dr. Ambedkar’s vision and the Sustainable Development Goals (SDGs). The study emphasized the importance of empowering marginalized communities and tackling systemic injustices. Bhat (2023, pp. 730–36) elucidated Ambedkar’s stance on maternity benefits contributing to the advancement of women’s empowerment.

Despite numerous studies exploring Ambedkar’s contributions, there remains a lack of comprehensive evaluation regarding the impact of Ambedkar’s vision on SDH, social security policies, and health insurance, despite several studies that have been conducted based on his ideas. This paper seeks to fill this gap by examining the relevance of Ambedkar’s vision of social democracy and human rights in addressing contemporary global inequalities within marginalized communities in modern India.

3. Methodology

This study analyzes the writings, policies, and influence of Dr. Bhimrao Ramji Ambedkar on public health, with a specific focus on healthcare challenges experienced by marginalized communities in India. Dr. Bhimrao Ramji Ambedkar, born on 14 April 1891, was a multitalented personality—an intellectual giant, economist by training, anthropologist, sociologist, and chief architect of the Indian Constitution. Throughout his life, he worked tirelessly for the emancipation of marginalized communities, which he regarded as his life’s mission. Known as the father of the Indian Constitution, Dr. Ambedkar himself came from a marginalized community and personally experienced the discrimination and struggles that those communities faced. While his vision is often understood through the lens of caste and his contributions to the Indian Constitution, his perspective was far broader. Dr. Ambedkar was not only recognized nationally but also internationally for his advocacy for social justice (Meka 2022, pp. 1026–40). For example, United Nations Development Programme (UNDP) (2018) Administrator Achim Steiner has highlighted the relevance of Dr. Ambedkar’s vision in achieving the 2030 Agenda for Sustainable Development. Steiner noted, Sustainable development was at the core of Dr. Ambedkar’s egalitarian ethos. Equality of opportunity and of access—critical to Dr. Ambedkar’s vision of development for all—are at the heart of the 2030 Agenda for Sustainable Development. He stated, “If we invest in the future, we can together realize the vision of the 2030 Agenda for all, so that no one is left behind—a vision that was shared by Dr. Ambedkar” (United Nations Development Programme (UNDP) 2018).

This study emphasizes the significance of Dr. Ambedkar’s ideas in present-day India, particularly concerning the accessibility and quality of healthcare for marginalized communities. In order to explore these issues, the authors gathered pertinent information on SDH and Dr. Ambedkar’s vision using resources, such as Scopus, PubMed, JSTOR, Elsevier, and Google Scholar. The study seeks to offer a detailed understanding of SDH and Dr. Ambedkar’s vision, with a specific focus on addressing health disparities and gaining a comprehensive understanding of the complex dynamics of SDH in India.

To ensure a thorough examination, the selected databases were searched using specific keywords, including “social determinants of health”, “marginalized communities”, “health disparities”, “public health policy”, and “Dr. Ambedkar’s vision”. The integration of these varied sources enabled a comprehensive analysis of the primary discussions and engagements, which were subsequently classified into several subthemes. These subthemes were thoroughly deliberated in the results section, offering a nuanced understanding of SDH and Dr. Ambedkar’s vision in the context of existing health disparities.

4. Marginalized Communities in India: Overview and Challenge

Marginalization is one of the major challenges in India, stemming from both structural inequality and social structures. Women, children, STs, and SCs are the most affected groups in India. Historically, marginalized communities have faced exclusion from social, political, and economic spheres and have been subject to marginalization (Vijayalakshmi et al. 2023, pp. 46–49). Identifying these issues is the initial stage in guaranteeing that individuals from all backgrounds have equal access to healthcare. Below is an overview of the significant challenges and factors that hinder marginalized communities’ access to healthcare services.

4.1. Economic Factors: Poverty and Access to Healthcare

Acharya (2022, pp. 211–22) defines economic challenges as the inability to acquire goods and services due to insufficient income and social status, which includes factors such as caste, race, gender and others. The 2030 Agenda for SDGs addresses the economic, environmental, and social aspects of societal well-being, with a specific focus on the important concept of inclusivity for all individuals and groups. The objective of SDG1 is to eradicate poverty in all its forms and dimensions by implementing a variety of measures that extend beyond socioeconomic status (United Nations n.d.). India’s economy has experienced rapid growth in recent years, making it one of the world’s fastest-growing major economies. Nevertheless, a significant portion of its population, including marginalized such as SCs, STs, women, children, and others, still has been encountering such complicated challenges associated with SDHs.

Poverty is one of the major important SDHs. The examination of the Global Multidimensional Poverty Index (GMPI) highlighted the notable disparities in poverty rates among various regions and social strata in India. The data suggested that a significant proportion of individuals belonging to STs and SCs are experiencing severe poverty. The Multidimensional Poverty Index (MPI) developed by the National Institute for Transforming India (NITI Ayog) offers valuable insights into the economic challenges faced by Indian states, with a significant number of people living below the poverty line. The percentage stands at 42.16% in Jharkhand and 37.79% in Uttar Pradesh. The percentages for Meghalaya and Madhya Pradesh are 32.67% and 36.65%, respectively (Behera 2023).

Healthcare expenditure in India further highlighted the economic challenges. Based on the World Development Indicators, India’s current healthcare expenditure accounts for only 3% of its gross domestic product (GDP). This figure is lower than that of neighbouring countries such as Bhutan (4.4), China (5.6), and Sri Lanka (4.1). India ranks below average in health spending according to the 2022 Commitment to Reduce Inequality Index (CRII). Currently, it is positioned as one of these countries with the lowest rankings globally, having dropped two places to 157th.

Due to India’s insufficient investment in public healthcare, the underprivileged population is confronted with a challenging choice: either settle for substandard public healthcare or incur expenses for expensive private healthcare alternatives (Sriram and Khan 2020, pp. 1–21). One of the main objectives in India has been to safeguard households from financial risks associated with healthcare costs. Despite these efforts, out-of-pocket (OOP) expenses in India make up a significant portion of total household spending, leading to a reduction in spending on other essential needs and overall household welfare. According to the WHO, India ranks third in South and Southeast Asia for the highest OOP health expenditures. In India, these expenses represent approximately 62.6% of the total healthcare spending, which is among the highest globally (Sriram and Albadrani 2022, pp. 7120–28).

Furthermore, there are economic and social inequalities within the informal sector workforce, which includes gig workers, taxi drivers, and others. According to a study’s survey of over 10,000 Indian cab drivers, gig workers, and platform workers, a significant number of individuals work more than 14 hours per day. In addition, a significant percentage of drivers work for more than 12 hours per day, making up a substantial majority of those who work more than 10 hours. The challenging circumstances are exacerbated by the unfair social environment, given that the majority of drivers belong to marginalized communities and are obligated to work for over 14 hours daily due to their economic situation. The research findings indicate that more than 43% of the participants have a monthly income of Rs. 15,000 (approx. USD 200) and a daily income of Rs. 500 (approx. USD 6.60). A thorough survey consisting of 50 questions was conducted, incorporating feedback from 5028 delivery persons and 5302 cab drivers originating from eight distinct cities: Indore, Hyderabad, Bengaluru, Mumbai, Lucknow, Kolkata, and Delhi. Due to their demanding work schedules, these drivers suffer from physical fatigue and are more likely to be involved in car accidents; the need to meet 10-minute delivery deadlines worsens this situation. The report highlights the income disparities among workers from different castes, emphasizing how these inequalities perpetuate social disparities and maintain the cycle of poverty and suffering in these communities (Jigeesh 2024).

The challenges faced by these communities are worsened by the lack of social and occupational stability, leading to potential health complications. Addressing these challenges is essential to achieve health equity among the marginalized communities.

4.2. Infrastructure and Environment Factors: Sanitation, Water, and Health

Universal, adequate, and equitable access to water, sanitation, and hygiene (WASH) is essential for the promotion of global health. The WHO defines WASH as the provision of sanitation facilities, water, and soap for handwashing to prevent the transmission of infection and disease, as well as the protection of marginalized and vulnerable populations (Ghosh et al. 2022, pp. 396–417). SDG 6 is crucial in this context as it aims to ensure that all individuals have access to safe, affordable drinking water by 2030. Furthermore, it endeavours to ensure that all individuals have access to sanitation and hygiene as well as to prevent open defection (United Nations n.d.). The susceptibility of an Indian household to disease is influenced by a variety of essentials, such as modern cooking fuel, drainage, potable water, and latrines. These vulnerabilities are exacerbated by the presence of influential socioeconomic factors (Selvaraj et al. 2022a, pp. 216–43). The Indian populace’s unhygienic practices and inadequate access to WASH facilities resulted in an excessive number of health hazards, including dysentery, malaria, and diarrhoea, as well as detrimental effects on social dynamics (Ghosh et al. 2022, pp. 396–417).

Several initiatives were announced by the Government of India (GOI) (2021) to provide and improve water and sanitation conditions, with a particular focus on the SDG6 targets. The Swachh Bharat Mission of 2014, the National Rural Drinking Water Programme (NRDWP), the National Urban Sanitation Policy (NUSP), and the Jal Jeevan Mission of 2019 were among the initiatives. Despite significant initiatives disparities in access to WASH facilities persist among marginalized. In 2017, for instance, the upper-class households had access to latrines at a rate of 98%, while the marginalized households had access to only 66%. According to Selvaraj et al. (2022b, pp. 191–15), a substantial number of tribal households, 7 out of 10, used traditional cooking methods, such as firewood and cow dung, which endangered the health of the residents and exposed them to environmental contamination. The 11.5% and 2.8% of SC and ST families, respectively, have access to safe drinking water, well below the national average (Aneesh 2021, pp. 138–52).

The Swachh Bharat Abhiyan, one of the primary programs implemented by the Indian government, was characterized by its ambitious objectives of attaining open defecation-free status for India by 2019. Since 2014, the Department of Drinking Water and Sanitation has documented an extraordinary increase in the construction of toilets in India, with an estimated 9 crores (a unit of measurement in India, equivalent to 10 million) being accomplished. Nevertheless, a notable inequity has existed regarding the distribution of households lacking access to latrine facilities among different states in India.

The states like Orrisa, Jharkhand, Uttar Pradesh, and Bihar have comparatively low levels of latrine facilities. The GOI has constructed 10.28 crore toilets throughout the nation. Nevertheless, the available data shows that despite the availability of these facilities, their optimum utilization has not been made due to various structural issues, e.g., water supply issues, the lack of a suitable structure, and others. Despite numerous efforts undertaken by the central and state governments, the scarcity of potable water continues to be a major concern. Access to this fundamental necessity varies considerably between social groups, impeding the progress toward inclusive development. Addressing these disparities is essential for achieving SDG6 and ensuring equitable health outcomes (Aneesh 2021, pp. 138–52).

4.3. Women and Children Health: Current Status and Health Outcomes

In order to achieve the best possible health outcomes for the entire population of a country, it is imperative to prioritize the well-being of children and women. The health of women and children is acknowledged and emphasized in the precise targets of Goal 3 of the SDGs. The aforementioned objectives encompass the prevention of premature deaths among infants and children under the age of five, the lack of skilled personnel during childbirth, and the reduction of maternal mortality (Bustreo and Doebbler 2019, pp. 229–34). According to Press Information Bureau (2019), the GOI has implemented numerous initiatives under the National Health Mission (NHM), such as the National Programme for Family Planning, Janani Shishu Suraksha Karyakaram, Rashtriya Kishor Swasthay Karyakram, Universal Immunisation Programme, Mission Indradhanush, Janani Suraksha Yojna, and Pradhan Mantri Surakshit Matritva Abhiyan (Press Information Bureau 2019).

The analysis of infant and child mortality revealed disturbing trends, as evidenced by the National Family Health Survey-5 (NFHS-5), which was conducted from 2019 to 2021. The age of under five years, the mortality rate, neonatal mortality rate, and infant mortality rate are reported as 42/1000, 25/1000, and 35/1000, respectively in NFHS-5, as compared to 50/1000, 30/1000, and 41/1000 in NFHS-4. The remarkable advancements in postnatal checkups for newborns within two days of birth can be attributed to the substantial improvement in mortality rates. The rate of these checkups has increased significantly, with a reported rate of 82% in NFHS-5 compared to 27% in NFHS-4. This positive change of 55% is one of the most promising indicators of newborn health in NFHS-5 (Tripathi et al. 2023, pp. 1759–63). When comparing NFHS-4 and 5, there has been a slight improvement in the health and nutrition of children; however, the disparity is not significant. The frequency of sexual and physical abuse of women is identical in both NFHS-4 and NFHS-5. Furthermore, the fact that NFHS-5 reports a significantly higher percentage of ever-married women who have experienced sexual violence (14%) than NFHS-4 is concerning. The prevalence of anaemia among women has increased from 53% to 57%, while children under the age of five now account for 67% of anaemia cases, a notable increase compared to the previous 59% (Tripathi et al. 2023, pp. 1759–63). India maintains the second-highest rate of stunted children among the South Asian countries, despite substantial progress in reducing childhood stunting. Uttar Pradesh, Jharkhand, Bihar, and West Bengal have been identified as the primary regions with high rates of childhood stunting in the results of NFHS-4 and 5 (Pooja and Guddattu 2022, pp. 1–10). Tripathi et al. (2023, pp. 1759–63) argued that the NFHS-5 trends suggest that there are specific health sector areas of concern that require more comprehensive actions to be addressed, including childhood stunning, anaemia, and women’s violence issues. These issues highlight the need for integrated health sector reforms to achieve sustainable health outcomes for women across India.

4.4. Caste: As a Major Social Determinant of Health

Among the other determinants of health, caste prejudice has significant impacts on marginalized communities concerning their work, education, income, and housing. Additionally, caste is a significant factor in determining the healthcare facilities and perpetuation of social exclusion in India (Thapa et al. 2021, pp. 828–38). The term ’Dalits’ is used to describe the people who are historically marginalized. Dr. Ambedkar popularized this term during the struggle for independence (Majumdar and Banerjee 2022, pp. 45–58).

According to the 2011 census, the total ST population in India is 8.6%, which varies across regions in India. In the northern region, there is Himachal Pradesh (5.7%) and Uttarakhand (2.9%). In the southern region, there is Karnataka (6.6%), Kerala (1.5%), and Tamil Nadu (1.1%). Lakshadweep leads among UTs with 94.8%. In the eastern region, there is Jharkhand (26.3%), Odisha (22.9%), and West Bengal (5.8%). In the western region, there is Gujarat (14.8%), Rajasthan (13.5%), and Maharashtra (9.4%). In the northeastern region, there is Mizoram (94.4%), Nagaland (86.5%), and Meghalaya (86.2%), and in Central India, there is Madhya Pradesh (21.1%) (National Commission for Scheduled Tribes n.d.).

The total SC population in India is 16.6%. In the north, Punjab has the highest SC population at 31.94, followed by Punjab at 25.2% and Haryana at 20.17%. Chandigarh, a union territory, has 18.86%. In the south, Telangana leads with SC at 38.8%, followed by Tamil Nadu at 20.01% and Karnataka at 17.15%. Puducherry has an SC population of 15.75%. In East India, West Bengal stood at 23.51%, Odisha (17.13%), and Bihar (15.91%). Rajasthan has 17.83% in the west, with Maharashtra at 11.81%. Dadra and Nagar Haveli, a union territory, has 1.80%. In the northeast, Assam tops at 7.15%, followed by Sikkim at 4.63% and Manipur at 3.78%. Central India has Madhya Pradesh, with a 15.62% SC population (National Commission for Scheduled Castes n.d.).

The lowest rung in the social order is occupied by these social classes. These individuals engage in wide arrays of menial occupations and pursuits, such as marginal farming, scavenging, and sweeping (Sivakumar 2013).

The accessibility of healthcare between members of marginalized communities and the general public was previously characterized by significant disparities. Caste and gender are critical SDH in India, where their intersection compounds marginalization, particularly for women from Dalit and lower caste groups. While all Indian women face health challenges due to patriarchal norms, those from marginalized castes experience even greater disadvantages, leading to severe health disparities compared to Dalit men and upper-caste women (Mal and Saikia 2024, pp. 1–11).

The marginalization experienced by Dalit women during the pandemic has serious implications for their well-being and livelihoods. However, this is influenced by societal and political pressures from multiple dimensions, and Dalit women face this because of their caste. Dalit women usually clean dry toilets, gutters, and drains, and this manual carrying of human faeces is not a form of employment but an injustice akin to slavery as it is the most prominent form of discrimination against Dalit women and violation of their human rights (Aarthimeena and Subbulakshmi 2024).

The NFHS-5 (2019-21) data reveals significant health disparities among women from marginalized social groups like SC and ST. ST women rely heavily on cloth for menstrual hygiene (60.8%) and have the lowest usage of sanitary napkins (52.9%), with only 65.6% using hygienic methods—below the national average of 77.6% (MHFW GOI 2021). Nutritionally, 25.5% of ST women are classified as thin (BMI < 18.5), compared to 20.2% of SC. Anaemia rates are notably high: 64.6% in ST and 59.2% in SC women, with ST women experiencing a 35.2% prevalence of moderate anaemia. Furthermore, marginalized women face higher rates of physical violence during pregnancy, with 3.7% of SC and 3.6% of ST women reporting such incidents, compared to 2.5% in others. These findings highlight the urgent need for targeted health and safety interventions for marginalized women (MHFW GOI 2021).

The anaemia rates of Dalit children are significantly higher than the national average. Data from the seventy-fifth round of the National Sample Survey Organization (NSSO) indicates that inpatient care in private facilities is significantly more expensive than in public facilities, which becomes a challenging determinant for STs and SCs due to the cost. Health expenditure is one of the reasons for poverty; hence, 45.9% of Adivasi individuals and 26.6% of Dalit individuals have been in the lowest hierarchal order of society (Patel 2023). There are two factors that contribute to the low nutritional status: an insufficient food distribution system and lower agricultural production. Additionally, the poor health of these individuals was exacerbated by their low literacy rates and ignorance, which resulted in a low nutritional intake (Majumdar and Banerjee 2022, pp. 45–58). These statistics highlight the urgent need for targeted health and safety interventions for marginalized women.

Despite the fact that India has implemented numerous public health policies and programs, healthcare disparities continue to exist for marginalized communities due to social exclusion and caste discrimination. It is essential to establish a well-organized orientation program in order to combat these healthcare disparities and progress toward the SDGs and universal healthcare (Thapa et al. 2021, pp. 828–38).

4.5. Regional Health Disparities

Health disparities among SCs in India vary significantly by region. In the northern region, Uttar Pradesh has the highest anaemia rates among SC children at 68.4% and substantial malnutrition, with 22.4% of SC women and 14.3% of SC men underweight. Despite this, 68.3% of SC women use hygienic menstrual protection. Punjab has a lower anaemia rate (24.7%) but faces malnutrition issues, alongside a high menstrual hygiene usage of 90.6%. In the western region, Rajasthan shows severe disparities with 72.1% anaemia in SC children and high malnutrition (22.8% women, 18.3% men underweight). Maharashtra has a slightly lower anaemia rate (30%) but significant malnutrition as well, with 21.1% of SC women underweight. In the southern region, Telangana reports a moderate anaemia rate (23.6%), but nutritional issues persist, while Tamil Nadu has high SC anaemia (61.9%) and excellent menstrual hygiene usage at 98%. In the eastern region, West Bengal has a 70.1% anaemia rate among SC children, and Assam also suffers from 67.6% anaemia, but only 67.4% of SC women use hygienic menstrual protection. Overall, the northern and eastern regions exhibit more severe health disparities, especially in anaemia and malnutrition, while the southern and western regions show better outcomes in menstrual hygiene and lower anaemia rates (International Institute for Population Sciences (IIPS) 2021).

As per NFHS-5, there are health disparities among the STs as well. In Himachal Pradesh, the prevalence of anaemia in children is high (61%), and there is a dual burden of undernutrition (13.7% women, 5.9% men) and overweight (26.7% women, 18.9% men). Karnataka has lower child anaemia rates (29.7%) and underweight adults (21.4% women, 20.1% men), with higher menstrual hygiene usage (78.5%). Jharkhand faces significant undernutrition (28% women, 17.9% men) but lower child anaemia (24.7%). Gujarat’s child anaemia rate is 27.6%, with a notable underweight population (35.1% women, 25.1% men) and lower menstrual hygiene usage (53.8%). Rajasthan has high anaemia rates (32%) and severe anaemia in children (77%), with 72.3% menstrual hygiene usage. The northeast, particularly Mizoram, shows better outcomes with high hygiene usage (91.6%) and lower underweight rates but significant child anaemia (46%). In Central India, Madhya Pradesh exhibits moderate anaemia (29.4%) and substantial undernutrition (27.4% women, 19.6% men), accompanied by low hygiene usage (41.2%). Overall, in the northern region, Himachal Pradesh, and the western region, Gujarat, reveal significant disparities, while the northeast and southern regions show better health outcomes, especially in hygiene practices and malnutrition rates (International Institute for Population Sciences (IIPS) 2021).

5. Government Policies and Health Equity: Assessing Effectiveness

The primary objective of India’s health policy has been to enhance the capacity of marginalized and disadvantaged communities to access quality medical services by achieving healthcare equity (Ghosh et al. 2022, pp. 396–417). The Bhore Committee Report 1946, which is also known as the Report on the Health Survey and Development Committee, has had a significant impact on the current health system and policy. The primary goal of the initial National Health Policy (NHP) 1983 was to ensure that all individuals had access to primary healthcare services by the year 2000. NHP 2002 expanded healthcare services to the general public by implementing decentralization, increasing public funding for healthcare, and involving the private sector, building on the foundation established by NHP 1983.

In India, the federal structure has resulted in the division of the health system’s governance and operation between the union and state governments (Chokshi et al. 2016, pp. 9–12). As part of a significant health system reform initiative pursued by the government, the National Rural Health Mission (NRHM) 2005 was established. The objectives of the same were to guarantee that healthcare services in rural areas were accessible, affordable, and of high quality. The GOI initiated the National Urban Health Mission (NUHM) in 2013 with the objective of addressing the health concerns of the urban poor. The objective of this mission was to expand the NRHM’s current focus on rural regions by addressing the basic healthcare needs of the urban population (Selvaraj et al. 2022b, pp. 191–15).

In 2008, the Rashtriya Swasthay Bima Yojna (RSBY) was implemented by the GOI to safeguard economically disadvantaged families from the financial consequences of illness. With a particular emphasis on families that are below the poverty line, this national health insurance program targets 65 million marginalized households (Devadasan et al. 2013, pp. 1–8).

The introduction of NHP 2017 has been a significant step in the pursuit of universality, equity, affordability, accountability, and decentralization of public healthcare services. The primary goal of this policy is to ensure that all individuals have free access to primary healthcare services. The Ministry of Health and Family Welfare (MHFW) also aims to increase health expenditures as a percentage of GDP from 1.15% to 2.5% by 2025 and to simplify the integration of private and public healthcare.

In 2018, GOI implemented the Ayushman Bharat Programme with the goal of achieving universal health coverage and providing comprehensive healthcare. The Pradhan Mantri Jan Arogya Yojna (AB-PMJAY) has been implemented by the government as a component of this initiative. Its goal is to provide health insurance coverage to 500 million economically disadvantaged individuals. Additionally, its goal is to offer comprehensive and cost-free healthcare services through health and wellness centres (AB-HWCs). The AB-PMJAY’s eligibility criteria are determined in accordance with the socioeconomic caste census. A diverse array of vulnerable groups, such as slum-dwelling households, families involved in manual scavenging (the practice of manually cleaning, carrying, or disposing of human waste, often done under exploitative and dangerous conditions), primitive tribal communities, rag pickers (individuals who collect and recycle waste materials, often in informal and marginalized settings), domestic workers, sanitation workers, and others, are included in this census (Press Information Bureau 2018).

A significant disparity in the accessibility of healthcare services for marginalized and disadvantaged communities continues to exist, despite the government’s initiatives. Individuals with incomes below the poverty line are the primary beneficiaries of health insurance programs, such as RSBY. Nevertheless, a significant portion of the population, including migrant labourers and individuals employed in the informal sector, earns incomes that exceed the official poverty threshold despite remaining uninsured. Consequently, these communities are not provided with any form of insurance coverage (Bhat et al. 2018, pp. 125–35).

Many state governments, including those of Karnataka, Tamil Nadu, and Andhra Pradesh, have implemented their own health insurance programs using the funds generated from these initiatives. Nevertheless, there is a dearth of evidence regarding the effectiveness of state-sponsored programs in guaranteeing equitable access to financial protection and healthcare. For instance, the “Rajiv Arogya Sri” initiative, which was implemented in Andhra Pradesh, led to a decrease in OOP expenses. Nevertheless, it was insufficiently beneficial to marginalized communities, such as SCs and STs (Fan et al. 2012, pp. 189–15).

The health sector continues to be severely underfunded, despite the substantial financial allocations that have been made to government-funded health insurance. As a result, the impoverished and vulnerable populations have been relegated to the margins of society as a result of prolonged treatment delays, increased personal financial obligations, inadequate literacy rates, and general destitution (Bhat et al. 2018, pp. 125–35).

The Ayushman Bharat Yojana, RSBY, and NHM aim to improve healthcare access in India but struggle to support marginalized groups effectively. Nearly 60 million people fall into poverty annually due to high OOP costs, despite these programs’ intentions to reduce them (Bhanot 2021). About 54% of hospitals under the Ayushman Bharat scheme are private, responsible for 75% of claims, highlighting reliance on private facilities due to inadequate public infrastructure, particularly in rural areas. This dependence increases costs and perpetuates the perception of better private care, disadvantaging low-income families.

Operational inefficiencies in schemes like RSBY, along with low public health spending, further hinder access and quality of care (Gopichandran 2019, pp. 69–80; Kumar 2021, pp. 155–65). To achieve universal health coverage, a comprehensive strategy is needed, including increased public health spending to over 3% of GDP, enhanced healthcare workforce training, and public-private partnerships (PPPs) to improve access while maintaining equity. Continuous investment and targeted approaches are essential for improving healthcare access for marginalized communities (Kumar 2021, pp. 155–65).

6. Revisiting Dr. Ambedkar’s Vision for Health Equity in India

The gaps and challenges faced by marginalized communities in India as discussed earlier, highlighted the need for a comprehensive framework that prioritizes equity and inclusivity. Dr. Ambedkar’s vision for health equity provides a pathway to address these gaps. Dr. Bhimrao Ramji Ambedkar, a prominent figure in India’s progress, played a crucial role in moulding the nation’s contemporary as an egalitarian society (Meka 2022, pp. 1026–40). His concepts regarding poverty eradication, inclusivity promotion, hunger elimination, and provision of safe potable water were pivotal in the formulation of the SDGs. Ambedkar devoted his life to the establishment of a society that promotes equality and the implementation of proactive measures to achieve social justice (Ambade 2022). While a written account cannot comprehensively encapsulate the entirety of Dr. Ambedkar’s policies and vision, the following will scrutinize his viewpoints: intersectionality, socio-ecological approach, sanitation, water, health literacy, the health of women, food security, the responsibility of the government, social security for the marginalized, and health equity.

6.1. Understanding Intersectionality in Ambedkar’s Vision

Intersectionality, a theoretical framework developed by Kimberle Crenshaw, addresses how people’s experiences are shaped by intersecting social identities (e.g., race/ethnicity, gender, class, age, etc.) (Crenshaw 2013, pp. 23–51). This perspective emphasizes the significance of understanding power, privilege, and social frameworks concerning individuals’ access to resources, experiences of discrimination, and their interactions with others. The authors contended that social determinants are experienced collectively rather than in isolation; an individual’s distinct and overlapping positions within social categories and structures, along with their identities, shape their conditions.

This modern concept of intersectionality aligns with the vision of Dr. Ambedkar. He recognized that the marginalization of Dalits and other oppressed communities was closely tied to their limited access to essential services, including healthcare, sanitation, and safe drinking water. He understood that sanitation and public health issues were not only about infrastructure; they were also connected to deep-rooted social hierarchies. For example, his struggle for Dalits’ rights to access public water during the Mahad Satyagraha in 1927 was about more than just access to water; it was aimed at dismantling the caste-based systems of exclusion (Akhilesh 2021; Alves 2022).

This perspective relates directly to the essence of intersectionality, acknowledging that marginalized communities’ health is being influenced by various intersectionality factors such as caste, class, gender, poverty, etc., which need to be addressed together to achieve healthcare equity. Ambedkar’s broader framework for social justice highlights the necessity of tackling power dynamics—like caste discrimination and economic inequality—that intensify health disparities. His contributions helped establish the understanding that health should not be viewed as a separate medical concern, but rather as fundamentally linked to social justice, equity, and human rights protection.

6.2. Socio-Ecological Model of Health in Ambedkar’s Thought

The socio-ecological model of health offers an extensive framework for interpreting health inequity as the outcome of various intersectionality of factors, which encompass individual, community, and societal influences (Golden and Earp 2012, pp. 364–72). This model views health in a broad context and emphasizes the many elements that can impact health. It recognizes that health is shaped by the interactions among the individual, community, and surrounding physical, social, and political environments (Reupert 2017, pp. 105–7).

Dr. Ambedkar’s approach to public health aligns with this model, as he championed the rights of marginalized communities and emphasized the government’s duty to guarantee fair access to healthcare by ensuring the eradicating caste untouchability, conducive working environment in working places, and health facilities such as clean drinking water, food security, health insurance, social justice, etc. by arguing that it is the government’s responsibility to take an active role in providing all citizens with essential resources such as food, water, and education (Jadhav 2016, pp. 1–124; Meka 2022, pp. 1026–40).

In Ambedkar’s work, we see the integration of both individual-level health concerns (like sanitation and clean water) and structural-level solutions (like government policies, social security measures, and legal protections) (Akhilesh 2021; Alves 2022; Masuki 2022, pp. 21–46). This mirrors the socio-ecological model’s emphasis on the importance of addressing both individual needs and the broader environmental, cultural, and political systems that influence health. For instance, Ambedkar’s advocacy for the rights of sanitation workers and his efforts to improve water resources and irrigation demonstrate how public health can be improved by confronting systemic inequalities at both community and governmental levels.

6.3. Sanitation and Water

A crucial component of Ambedkar’s vision was his focus on foundational public health necessities like sanitation and access to water. Recognizing these basics for health equity, Ambedkar’s initiatives aimed to remove caste-based barriers to essential resources, highlighting the role of infrastructure in achieving social justice. In India, basic sanitation encompasses sewage and water infrastructure, solid waste administration, and rainwater drainage systems. Manual scavenging, the practice of cleaning latrines and septic tanks, is a crucial component of sanitation procedures. The caste system in India still has a significant influence on sanitation practices, particularly affecting manual scavengers who are derogatorily referred to as “Harijans”, causing them distress (Alves 2022).

Dr. Ambedkar, a visionary leader, identified issues and enacted concrete measures to legally protect them. In the Legislative Assembly Debates, he voiced his apprehension and pledged to enhance housing and sanitary management for marginalized communities (Akhilesh 2021). Ambedkar’s vision for the upliftment of marginalized communities and their social status in India aligns with the present obstacles faced in public health (Masuki 2022, pp. 21–46).

Ambedkar dedicated his efforts to serving marginalized communities, promoting the development of water resources, irrigation, flood control, hydropower generation, and water supply. He stressed the importance of water efficiency and maximizing its use through technology (Abraham 2002, pp. 4772–74). During the 1930s, he organized and motivated Dalits to increase their understanding of their rights in different areas of society. In 1927, he spearheaded the Mahad Satyagraha, a momentous social demonstration with the objective of securing fair and equal access to communal resources, such as water wells (Alves 2022).

Dr. Ambedkar played a crucial role in establishing a sanitation workers union in Delhi in 1944, highlighting the significance of labour organizations in improving the working conditions and social status of the workers. He dedicated his life to overhauling the legal and policy structures of India’s democracy, advocating for the economic and social rights of sanitation workers.

6.4. Social Security Measures for Labor’s and Women’s Health

Beyond sanitation and water, Ambedkar’s vision extended to encompass the social security and welfare of marginalized groups. Dr. Ambedkar, who served as a member of the Viceroy’s Labour Executive Council from 1942 to 1946, enacted legislation aimed at enhancing the well-being of the labour force (Tariq 2015, pp. 51–52). He held the belief that the government should act as a servant and representative of the people in labour affairs and that shared responsibility is crucial for safeguarding labour welfare. He championed the implementation of health insurance for labourers as a key component of the council’s vision. During the sixth meeting of the Standing Labour Committee, Dr. Ambedkar presented a detailed report on the various aspects of financial and healthcare benefits, treatment methods, medical institutions, and government funding. In addition, he addressed topics such as labour welfare, equitable remuneration, social security, cost of living adjustment, Maternity benefits and the establishment of industrial canteens to ensure food accessibility (Jadhav 2016, pp. 180–212).

6.5. Food Security

Ambedkar’s advocacy for labor welfare naturally connected to his emphasis on food security, recognizing that hunger and malnutrition were not just individual issues but systematic failures. His vision included sustainable agriculture and equitable resource distribution as a cornerstone of public health. This vision aligns with the UN SDG2 which seeks to eliminate hunger and malnutrition by 2030, ensuring that every person has access to sufficient and nutritious food.

The food security objectives and goals of SDG2 are derived from the vision of Dr. Ambedkar (Meka 2022, pp. 1026–40). This encompasses the promotion of sustainable agriculture, provision of assistance to small-scale farmers, and guarantee of equitable access to land, technology, and market participation. Dr. Ambedkar’s concept of food security is based on his understanding of the correlation between public health and food security. Despite favourable economic conditions and declining birth rates, a substantial segment of the population is still unable to access nutritious food due to poverty. Dr. Ambedkar stressed the significance of agriculture and the government’s responsibility in owning agricultural land, managing production resources, and ensuring a fair distribution among the population (Mahanand 2020). In 2015, Sharad Pawar, a former Union Minister, acknowledged the profound influence of Ambedkar’s vision on the government’s efforts to achieve food self-sufficiency (Times of India (TOI) 2013).

6.6. Government Role for Ensuring Public Healthcare Accessibility

At the core of Ambedkar’s vision for public health and social security lies the belief in the government’s primary role in addressing societal inequities. He highlighted the government’s obligation to enhance social determinants of health, such as the availability of food, financial resources, and drinkable water. Dr. Ambedkar stressed the significance of directing government tax revenue toward agricultural debts, poverty eradication, and education. The national budget is a manifestation of the government’s responsibility to the citizens, prioritizing the well-being of the public. Since the beginning of the twentieth century, it has been suggested that governments should take on the responsibility of developed nations by guaranteeing access to essential resources for individual progress and advancement. Ambedkar advocated for the Indian government to protect the well-being of workers by establishing guidelines and an internal organization to ensure the enforcement of these guidelines (Jadhav 2016, pp. 1–124).

7. Conclusions

The paper emphasizes the importance of addressing health disparities by advocating for a robust primary healthcare system that ensures affordable access to healthcare for marginalized communities. A significant challenge is the uneven distribution of healthcare services, which highlights the gap between government initiatives and the essential healthcare needs of the marginalized communities. To bridge this gap and tackle these inequalities, it is necessary to prioritize the equitable distribution of healthcare resources and increase government investment to at least 3% of GDP in healthcare services. In this context, the paper highlights Dr. Ambedkar’s vision that universal healthcare access is a fundamental human right. As he famously stated, “What we want is not equality, but equity, for equality does not necessarily mean equity”. This visionary perspective highlights the critical distinction between equality and equity, emphasizing that true justice in healthcare cannot simply rely on providing the same resources to everyone, instead, it requires an approach that addresses the unique needs of the marginalized communities. Aligning with Dr. Ambedkar’s vision, the paper advocates for greater collaboration between Central and state governments to foster conditions that promote economic growth and financial stability for all citizens. Community participation in policymaking, along with data-driven interventions, can create sustainable solutions. Ultimately, embracing Dr. Ambedkar’s vision is crucial to effectively addressing health inequities and ensuring comprehensive healthcare for all in India.