Key Factors Shaping the Health of Marginalised Communities

Why do some communities in India remain trapped in cycles of poor health, despite decades of policy interventions and rising national prosperity? The answer rarely lies in biology or individual choices. It lies in the layered realities of caste, class, geography, and history that shape who gets to be healthy and who does not. For marginalised groups – Dalits, Adivasis, religious minorities, persons with disabilities, sexual minorities, and the rural and urban poor – health outcomes are determined long before a person ever reaches a clinic. Understanding the forces at play is the first step toward dismantling them.

Socio-economic determinants of health 🔗

The World Health Organization defines social determinants of health as the conditions in which people are born, grow, live, work, and age. For marginalised communities, these conditions are systematically worse – and the consequences are measurable in years of life lost. A study published in the Proceedings of the National Academy of Sciences found that compared to higher-caste Hindus, Adivasi life expectancy is more than four years lower, Dalit life expectancy is over three years lower, and Muslim life expectancy is about one year lower. These are not small statistical gaps; they represent millions of premature deaths shaped by social position alone.

Poverty and access to resources 🔗

Economic deprivation is the most visible determinant. Marginalised groups disproportionately lack access to the underlying foundations of good health – safe drinking water, nutrition, housing, and sanitation. According to data analysed by the Bridgespan Group, only 19 percent of tribal households use clean fuel for cooking compared to 47 percent of non-tribal households. Tribal homes are also significantly less likely to have electricity, improved sanitation, or reliable drinking water. Each of these deficits translates directly into higher rates of respiratory illness, diarrhoeal disease, and maternal complications.

Poverty also shapes how people interact with the health system. When a daily wage is the difference between eating and not eating, taking a day off to visit a primary health centre becomes a luxury. Out-of-pocket health expenditure pushes millions of Indian families below the poverty line every year, and marginalised households absorb this burden most heavily.

Education and health literacy 🔗

Education is one of the strongest predictors of health outcomes, especially for women. A study of rural Indian women published in the Indian Journal of Medical Research found that women with lower education levels were significantly more likely to face barriers in accessing maternal health interventions, often citing lack of family or spousal support. Lower literacy reduces a person’s ability to navigate hospitals, understand prescriptions, recognise warning signs, and demand quality care. It also limits employment options, locking families into intergenerational poverty.

Geographic isolation and infrastructure 🔗

Where a person lives matters enormously. The Council on Foreign Relations notes that more than three-quarters of India’s health infrastructure is concentrated in urban areas, yet nearly 90 percent of Dalits live in rural settings. Rural health centres also report severe shortages – vacancy rates exceeding 80 percent for surgeons and 76 percent for obstetricians and gynaecologists. For Adivasi communities living in forested or hilly terrain across Madhya Pradesh, Odisha, Jharkhand, and Chhattisgarh, the nearest hospital may be hours away by foot, often along roads that become impassable in the monsoon.

Political and historical context 🔗

Health disparities do not arise in a vacuum. They are the contemporary expression of centuries of social stratification, exclusion, and political neglect. To understand why a Dalit child in rural Bihar is more likely to die before age five than an upper-caste child in the same village, we have to look backward as much as forward.

The legacy of caste and untouchability 🔗

The caste system has functioned for centuries as a social hierarchy that determined where people could live, what work they could do, and what services they could access. A critical analysis published in the International Journal of Social Determinants of Health and Health Services argues that the caste system has deprived Dalits and tribal communities of health equity, and that disease-specific health programmes often fail because they ignore the intersecting disadvantages these groups face. Practices of untouchability – though constitutionally abolished – continue to shape interactions in clinics, schools, and labour markets. Studies have documented health workers refusing to enter Dalit homes, or providing perfunctory care that reinforces the message that some lives matter less.

Adivasi displacement and the loss of forest livelihoods 🔗

For India’s 104 million tribal people spread across 705 communities, marginalisation has a different but equally damaging history. As detailed in research published in the Journal of Global Health, tribal populations have faced displacement from forests, mines, and dam projects, severing them from traditional food systems and medicinal knowledge. The shift from subsistence forest economies to wage labour at the margins of the formal economy has created the paradox of “development-induced poverty” – communities pushed out of self-sufficient ways of life into deeper precarity.

Intersecting identities and compounded disadvantage 🔗

Marginalisation rarely operates along a single axis. Research published in SSM – Population Health demonstrates that Dalit Christians and Muslims face a unique double disadvantage because they are excluded from Scheduled Caste constitutional protections that Dalit Hindus, Sikhs, and Buddhists receive. A Dalit Muslim woman with a disability in rural Uttar Pradesh experiences caste, religious, gender, and ability-based discrimination simultaneously – and each layer compounds the others. Public health interventions that treat these identities as separate boxes routinely miss the people who need them most.

Policy gaps and political voice 🔗

Political marginalisation translates into policy invisibility. The National Medical Journal of India has pointed out that the National Health Policy 2017 largely reduced social determinants to ecological and lifestyle factors, sidestepping deeper questions of how caste, religion, and gender determine health. When marginalised voices are absent from legislative bodies, planning commissions, and health councils, their priorities – clean water in Adivasi hamlets, manual scavenging eradication, or culturally sensitive maternal care – slip down the agenda.

Self-determination and participation 🔗

If exclusion is the problem, inclusion is part of the answer – but not inclusion on someone else’s terms. Genuine improvements in marginalised health outcomes happen when communities have meaningful control over how interventions are designed, delivered, and evaluated. This principle, known as self-determination, has emerged as one of the most powerful levers for change.

Community-led interventions in practice 🔗

The work of MAHAN Trust in the Melghat region of Maharashtra offers a concrete example. Operating in remote Korku tribal areas since 1997, MAHAN built its model around respect, trust, and reciprocity rather than top-down delivery. The team uses video consent recorded by trusted village leaders, trains community health workers from within the community, and adapts protocols to local norms. Over more than two decades, this approach has produced significant reductions in severe child malnutrition and infant mortality – outcomes that vertical, externally-imposed programmes had failed to achieve.

Participatory research and indigenous knowledge 🔗

A study of the Paniya tribal population in Kerala used a Participatory Poverty and Health Assessment to let community members themselves define what mattered most to their wellbeing. The findings, published in the International Journal for Equity in Health, revealed “vulnerability traps” that outsiders had failed to see – interconnected cycles of debt, bonded labour, alcoholism, and ill-health that no single intervention could break. Such approaches challenge the older model of treating marginalised communities as passive recipients of health services and instead treat them as experts on their own lives.

Collaborative models and structural change 🔗

The launch of Anamaya, the Tribal Health Collaborative, illustrates how community participation can be embedded into national-scale efforts. As outlined by the Bridgespan Group, Anamaya works with the Ministry of Tribal Affairs, the Health Ministry, philanthropies, and civil society to end preventable deaths in tribal areas. Its strategy explicitly prioritises generating demand through community ownership – Village Health, Sanitation and Nutrition Days, participatory learning, and behaviour change rooted in local culture rather than imposed from above.

True self-determination also requires structural change: representation in panchayats and legislatures, enforcement of constitutional protections like the Prevention of Atrocities Act, recognition of forest rights, and budgetary commitments matched to actual need. Without these foundations, participation can become tokenistic – a meeting attended, a form signed – rather than a genuine redistribution of power.

What this means for the future 🔗

The health of marginalised communities is not simply a medical problem awaiting a medical solution. It is a mirror reflecting how a society distributes its resources, its respect, and its political voice. Improving outcomes requires interventions on three fronts simultaneously: addressing material deprivations through economic and educational investment, confronting historical injustices through policies that name and remedy caste, gender, and religion-based discrimination, and building genuine partnerships in which marginalised communities lead the design of their own health futures.

Public health professionals, policymakers, and citizens all have roles here. Recognising that infant mortality among Scheduled Tribes remains markedly higher than the national average is not a statistic to be filed away – it is a call to ask why, and to act on the answer.

What do you think? Which of these three factors – socio-economic conditions, historical and political marginalisation, or lack of self-determination – do you believe deserves the most urgent attention in current Indian health policy, and why? Can a community-led approach succeed without first dismantling the structural inequalities that shape day-to-day life?

References

1. https://pmc.ncbi.nlm.nih.gov/articles/PMC8915795/
2. https://pmc.ncbi.nlm.nih.gov/articles/PMC4201685/
3. https://www.bridgespan.org/insights/effort-to-solve-india-tribal-health-conundrum
4. https://pmc.ncbi.nlm.nih.gov/articles/PMC10199518/
5. https://www.thinkglobalhealth.org/article/caste-out
6. https://pubmed.ncbi.nlm.nih.gov/39106365/
7. https://jogh.org/2025/jogh-15-03020/
8. https://www.sciencedirect.com/science/article/pii/S2772653324000224
9. https://nmji.in/the-social-determinants-of-health-in-india/
10. https://pmc.ncbi.nlm.nih.gov/articles/PMC2848202/