Caste-based healthcare inequality in Dalit communities in Makwanpur, Nepal: A mixed-methods study.

Abstract

Introduction The caste system is a three-millennium-old social stratification system. Caste discrimination is common in Nepal despite being illegal since 1962. Dalits (known as untouchables) rank at the bottom of the caste hierarchy and often experience discrimination due to notions of untouchability resulting in poor health outcomes. Caste-based inequality has an impact on the wellbeing of individuals, experiences of violence, and opportunities to access education, employment, and healthcare. This research will help to understand discrimination by caste through exploring experiences and challenges that Dalit minorities face in accessing and utilising health services. Methods A cross-sectional mixed-methods study was conducted in Makwanpur district, Nepal in 2019. Qualitative study included six focus group discussions, six key stakeholders’ interviews and five exit interviews. The quantitative survey included 202 health workers. Qualitative data were organised using NVivo 12 software and thematically analysed, and quantitative data were analysed using SPSS 26 descriptive analysis. Findings The qualitative findings identified, caste discrimination affects health (physical and psychological), impacts wider health determinates (gender, education, employment, and poverty) and positive attitudes of health workers towards Dalits. Research presented that Dalits do not prioritise medical healthcare thus, resulted poor health. Nearly all (98.5%) health workers stated that no discrimination in health services towards Dalits, however, 53% reported that no discrimination and promoting equal opportunity will contribute to better health outcomes within Dalit communities. Conclusion Caste-based discrimination is still prevalent in Nepali society and influence individual’s health. The services that actively promote, and address health inequality experienced by Dalits are lacking. The outcomes of this thesis can help to identify gaps in Dalit healthcare, leading to better training and education and benefitting policy makers, health workers and researchers alike.