Caste Background of Health Professionals in India

It is well known that there is inequitable distribution of healthcare professionals across social groups, especially for physicians. The census publishes this data every ten years and the NSSO also collects data on occupations (but does not publish disaggregated data listing various health professionals) but a literature search shows that this subject of caste background of health professionals is inadequately researched and discussed. Humanpower statistics published by the Institute for Applied Manpower Research provides information only for those in public services but does not disaggregate by caste. The SC and ST Commissions who should have a keen interest in such a profile too do not collate and provide any data/statistics about SC / ST occupational data. So generally there is very little information about caste and professions/occupations and this lack of information is indeed surprising given that there exists education and job quotas / reservations for the SC and ST, and now also for OBCs and Muslims.

In 2003 the World Health Survey by WHO and IIPS (2006) on Health Systems Performance Assessment provided an excellent profile of the health system in India but failed to record caste. However they classified households into income quintiles and this data shows some interesting patterns of health human resources. Bottom THREE quintiles did not have a single physician whereas the top quintile accounted for 83 percent of all physicians – not unexpected as doctors have a clear class character and generally class and caste go together so we can deduce that most physicians would also be from the upper caste groups. The 2001 census data in the Table below provides the evidence of the caste character of physicians.

With regard to nursing and midwifery too there was some concentration in the top 2 quintiles in the WHO survey – 61 percent of nurses. The bottom two quintiles had only 19 percent nurses. But for the support health staff the contribution of the bottom quintile was as much as 37 percent.

The 2001 census data in the following table gives a snapshot of the caste character of various healthcare professionals and the distribution patterns are not very dissimilar to what we see in the class distribution from the WHS 2003. The last three columns in the table tell the real story for each social group, Scheduled Caste (SC), Scheduled Tribe (ST) and Others. For the health professional groups the variances from the proportion in the population (non-agricultural workers as universe) for each social group is highly negatively skewed for the SCs and STs, the deficits being between 50 and 80 percent, but for the “others” group it is in excess between 10 to 15 percent. As we move down the hierarchy to nurses and paramedics the variances become narrower and one sees a few excess ratios for SC and ST, notably for the category of sanitarians and nursing/midwifery. For the ST the nursing and midwifery categories surprisingly show a huge excess of over 100 percent. Thus despite affirmative action policies the SC and ST have been unable to break the glass ceiling of upper caste control over the health professions, especially physicians of all types.

Further, the “others “ is a very varied group and includes a number of underprivileged categories like OBCs and Muslims. If further disaggregation for this category was available the upper caste domination, similar to upper class (top quintile) would have come out more sharply. Historical evidence from Gazetteers, Indian Medical Service Reports and writings on colonial medicine suggest that the Brahmins, Parsis and Christians were the first to take advantage of modern medical education and hence they got a head start. Their domination continued in early Independent India but soon other upper caste Hindus, initially Kshatriyas and later baniyas entered the medical profession in large numbers. With reservations for dalits and adivasis they too got an opportunity to enter medical schools. As medicine got commodified, especially post 1980s, and private medical education and

Table 1: Caste Profile of Health Professionals and paramedics for all non-agricultural workforce 2001 Census India Economic Tables B-25, B-25SC and B-25ST           

	Category of Worker	ALL	Caste  Category			Variance from Population proportion*
Occup. Code	A. Health Professionals	Persons	%SC	%ST	%Other	SC	ST	Others
2220	Health Professionals (except nursing)	947433	7.49	1.87	90.63	-42.65	-53.20	9.29
2221	Physicians and Surgeons, Allopathic	617619	7.49	1.50	91.01	-42.68	-62.46	9.74
2222	Physicians and Surgeons, Ayurvedic	107346	5.49	1.23	93.28	-58.01	-69.19	12.48
2223	Physicians and Surgeons, Homeopathic	64567	5.42	0.54	94.03	-58.50	-86.42	13.39
2224	Physicians and Surgeons, Unani	10020	3.96	0.49	95.55	-69.67	-87.78	15.21
2225	Dental Specialists	21261	6.00	1.17	92.83	-54.06	-70.86	11.94
2226	Veterinarians	81584	11.25	5.66	83.09	-13.86	41.27	0.19
2229	Health Professionals (Except Nursing), n.e.c.	45036	9.98	4.18	85.84	-23.59	4.38	3.50
2230	Nursing Professionals	14343	14.03	8.40	77.56	7.43	109.86	-6.47
2230	Nursing Professionals	14343	14.03	8.40	77.56	7.43	109.86	-6.47
	B. Paramedic/Associate professionals
3220	Modern Health Associate Professionals (Except Nursing)	545579	11.62	4.11	84.27	-11.06	2.66	1.61
3221	Medical Assistants	91676	8.78	3.64	87.58	-32.78	-9.16	5.61
3222	Sanitarians	164955	14.43	4.84	80.73	10.49	20.87	-2.66
3223	Dieticians and Nutritionists	3321	10.42	2.68	86.90	-20.25	-33.06	4.79
3224	Optometrists and Opticians	12665	6.52	0.81	92.66	-50.08	-79.69	11.74
3225	Dental Assistants	2461	7.07	1.67	91.26	-45.88	-58.39	10.05
3226	Physiotherapists and Related Associate Professionals	6727	7.63	1.14	91.23	-41.63	-71.41	10.00
3227	Veterinary Assistants	27966	10.55	4.16	85.29	-19.26	3.97	2.84
3228	Pharmaceutical Assistants	221552	11.24	3.24	85.52	-13.95	-19.09	3.12
3229	Modern Health Associate Professionals (except Nursing) n.e.c.	14256	12.71	17.23	70.06	-2.71	330.33	-15.52
3230	Nursing and Midwifery Associate Professionals	583284	12.90	5.87	81.23	-1.28	46.67	-2.05
3231	Nursing Associate Professionals	491151	11.54	5.13	83.33	-11.69	28.20	0.48
3232	Midwifery Associate Professionals	92133	20.15	9.81	70.04	54.23	145.15	-15.55
3240	Traditional Medicine Practitioners and Faith Healers	11488	9.48	2.99	87.53	-27.44	-25.42	5.55
3241	Traditional Medicine Practitioners	10885	9.55	3.01	87.44	-26.94	-24.73	5.44
3242	Faith Healers	603	8.29	2.49	89.22	-36.53	-37.86	7.58
0000	TOTAL Non Agricultural WORKERS	145509200	13.06	4.00	82.93

Note: The variance has been calculated using the total non-agricultural workers, and within that the proportion of respective social group as the universe.  *Negative figure means that the proportion is lower by that much percentage as per their population proportion for the concerned social group and a positive figure reflects that it is that much higher

private health insurance entered the scene upper caste domination (being coterminous with upper and middle classes), especially of baniyas got consolidated further.

While the above data is only for a single year, the trend over time would show similar adversity for SCs and STs if not worse, assuming that the affirmative action policy has had some impact in accessing jobs and education enrolment by them in atleast public institutions. In Table 2 an abstract profile of health professionals for Maharashtra for 1991 is compiled. This shows that even in a developed state like Maharashtra which has seen many reform movements and has a politically strong dalit  movement the deficit among SCs and STs as health professionals is very high – similar to the 2001 India average. So it is clear that the impact of affirmative action for becoming a health professional is very limited and the predominance in this profession of upper castes continues to rule.

Table 2: Caste Profile of Health Professionals and paramedics in Maharashtra for all non-agricultural workforce - Maharashtra Census 1991 Economic Tables B-21 and SC & ST Special Tables

Maharashtra 1991 Census					Variance from population proportion
Occupation	Persons	%SC	%ST	% Other	SC	ST	Other
Physician & Surgeons*	92419	5.27	1.59	93.14	-49.57	-62.75	9.21
Nurses, Midwives &Paramedics	131178	14.32	3.33	82.35	37.11	-22.06	-3.44
Medical Scientists	8535	4.93	1.58	93.48	-52.77	-62.93	9.61

* Includes pharmacists and nutritionists, which in 2001 census are part of paramedics

To conclude the adverse experience of dalit and adivasi doctors, nurses and other health workers is reported regularly by the media. An excellent documentation of the personal experience of a dalit cardiac surgeon from Maharashtra reveals how difficult it is for dalits to get into the profession and when they get in, to survive. (Dr. Ashok Bhoyar – My Encounter with Dronacharya, Sugava Prakashan, Pune 2001). The dalits and adivasis suffer a double adversity of their social disadvantage as well as their class position and unless there is radical transformation in the structure of medical education and the healthcare system on one hand and the social discrimination based on caste on the other we will not witness any progressive change.