How Marginalisation Drives Health Inequalities: An In-Depth Look

Health is rarely just a matter of biology. Where a person is born, the caste or community they belong to, the income their family earns, and the social respect they receive often decide whether they live a long, healthy life or die from preventable causes. Marginalisation, the process by which certain groups are pushed to the social, economic, and political edges, sits at the heart of this story. It explains why two children born on the same day in the same district can have completely different chances of surviving past the age of five.

What marginalisation really means in a health context 🔗

Marginalisation is not just about poverty. It is a long-term process where specific groups are excluded from full participation in society because of their caste, tribe, gender, religion, sexual orientation, disability, occupation, or geography. The World Health Organization notes that health follows a social gradient, where more deprived living conditions translate directly into lower income, fewer years of education, and worse health outcomes. In India, this gradient maps closely onto historically excluded groups such as Scheduled Castes (SCs), Scheduled Tribes (STs), religious minorities, sexual minorities, persons with disabilities, sex workers, manual scavengers, migrant workers, and the urban poor.

These groups together form a significant share of the population. Scheduled Castes and Scheduled Tribes alone constitute roughly 16.6% and 8.6% of the total population according to the 2011 Census. When you add other marginalised groups, the picture becomes even larger and more diverse.

The link between marginalisation and health 🔗

Marginalisation affects health through multiple, overlapping channels. The clearest of these is the unequal distribution of what public health scholars call the social determinants of health, the non-medical conditions in which people are born, grow, live, work, and age.

Limited access to healthcare 🔗

For tribal communities living in forested or hilly regions, the nearest functional health facility may be several hours away on poor roads. The National Family Health Survey (NFHS-4) data analysed across India showed that Scheduled Tribes had the lowest institutional delivery rates at 68% against a national average of 80%, the lowest full immunisation rates at 56% against the national average of 62%, and the highest levels of child stunting and wasting. These are not small gaps. They translate into thousands of preventable deaths every year.

Poverty and the cost of falling ill 🔗

Even where facilities exist, the cost of treatment, transport, and lost wages can be catastrophic. Out-of-pocket expenditure on health continues to push 50 to 60 million Indians into poverty every year due to medical-related expenditure. For a family that already lives on the edge, a single hospitalisation can wipe out years of savings, force the sale of land, or pull children out of school.

Education and health literacy 🔗

Low literacy levels among marginalised groups mean information about nutrition, vaccination, family planning, and disease prevention often does not reach them in a form they can use. A mother who has not been to school may not recognise the early signs of pneumonia in her child or understand why an antibiotic course must be completed. This is not a failure of intelligence but a failure of the system that denied her education in the first place.

Occupational and environmental risks 🔗

Marginalised communities also face the dirtiest, most dangerous work. Manual scavengers, sanitation workers, brick-kiln labourers, and waste pickers are exposed to toxic substances, infectious agents, and physical injury every day, usually without protective gear or insurance. Their bodies wear out early, and they often die a decade or more before the national average life expectancy.

Inequitable health access: how discrimination shapes outcomes 🔗

Even when marginalised people manage to reach a hospital, discrimination can shape what happens next. Studies have documented how Dalit and Adivasi patients are sometimes made to wait longer, spoken to rudely, examined less thoroughly, or denied beds in wards. Pregnant tribal women have reported being refused admission or being subjected to humiliating comments about their hygiene or dress.

Discrimination is not merely an interpersonal problem. As public health researchers increasingly argue, discrimination is itself a social determinant of health, acting as a chronic stressor that gets under the skin and produces measurable physiological harm. Repeated experiences of being insulted, ignored, or treated as inferior raise stress hormones, disturb sleep, and over time contribute to hypertension, depression, and cardiovascular disease.

Intersecting identities make it worse 🔗

The harms multiply when several axes of marginalisation overlap. A Dalit woman in a poor rural household faces caste discrimination, gender discrimination, and economic exclusion all at once. Research from Maharashtra has shown that SC and ST women from low-income households face the highest levels of poor health outcomes, with gender norms and income constraints together restricting their healthcare utilisation. A transgender Adivasi person, or a Muslim woman with a disability, faces an even denser web of barriers.

Geographical exclusion 🔗

Geography compounds social exclusion. The Odisha Tribal Family Health Survey, conducted across 14 tribal-dominated districts, found that indigenous tribal communities in Odisha face persistent health disparities driven by socio-economic marginalisation, geographical isolation, and limited healthcare access. Roads that wash away in the monsoon, ambulances that cannot reach interior villages, and Primary Health Centres without doctors or medicines mean that even universal schemes often stop short of the people they are designed to help.

Why ST health outcomes lag despite affirmative action 🔗

One of the puzzles in Indian public health is why Scheduled Tribes continue to record some of the worst health indicators even after decades of affirmative action. The Indian Journal of Medical Research observes that the ST category has access to affirmative action and yet has the poorest health and other development indicators among major social groups. The reasons include historical displacement from forest lands, loss of traditional livelihoods, weak implementation of welfare schemes in remote areas, cultural distance between government health staff and tribal patients, and a chronic shortage of healthcare workers willing to serve in these regions.

Mental health and stigma 🔗

Marginalisation also breeds stigma, which has a quiet but powerful effect on mental health. People living with HIV, persons with mental illness, sex workers, drug users, and sexual minorities frequently delay seeking care because they fear being judged or outed. The result is late diagnosis, poorer treatment outcomes, and higher mortality. Crucially, stigma feeds back into structural exclusion by making it harder for these groups to find work, housing, or supportive relationships.

Policy implications: building a more equitable health system 🔗

The good news is that health inequalities are not inevitable. They are produced by policy choices and can be reduced by better ones. Several directions are worth highlighting.

Universal health coverage with a pro-poor design 🔗

India’s flagship insurance scheme, Ayushman Bharat Pradhan Mantri Jan Arogya Yojana, aims to provide health cover of ₹5 lakh per family per year for secondary and tertiary hospitalisation to roughly 55 crore beneficiaries forming the bottom 40% of the population. If implemented well, schemes like PM-JAY can sharply reduce the financial shock of illness for marginalised families. But coverage on paper must be matched by quality of care, awareness among eligible beneficiaries, and empanelled hospitals that are actually within reach.

Strengthening primary healthcare 🔗

Hospital insurance alone cannot fix health inequities. Strong, well-staffed primary care that focuses on prevention, maternal and child health, nutrition, and chronic disease management is what makes the biggest difference for marginalised populations. The Health and Wellness Centres component of Ayushman Bharat is intended to do exactly this, but it needs sustained funding, trained personnel, and accountability mechanisms to live up to its promise.

Tackling structural discrimination 🔗

The WHO’s recent World Report on Social Determinants of Health Equity calls on governments to overcome structural discrimination, address economic inequality, invest in universal public services, and devolve money, power and resources to local governments and communities. For India, this means going beyond targeted welfare to confront caste-based, gender-based, and religion-based discrimination in the health workforce, in medical education, and in everyday clinical practice.

Community participation 🔗

Lasting change requires the people most affected to have a voice in designing the systems meant to serve them. Village Health, Sanitation and Nutrition Committees, tribal health councils, peer educator programmes, and community monitoring of health facilities all help shift power closer to the ground. When marginalised communities are treated as partners rather than passive recipients, both trust and outcomes improve.

Data that makes marginalisation visible 🔗

You cannot fix what you do not measure. Disaggregated health data by caste, tribe, gender, disability, and location is essential for identifying gaps and holding the system accountable. Strengthening surveys like the NFHS, conducting more community-based studies in underserved regions, and publishing district-level dashboards on key indicators are concrete steps in this direction.

The road ahead 🔗

Marginalisation and health inequality form a stubborn loop. Poor health keeps families poor, poverty deepens exclusion, and exclusion further damages health. Breaking this loop requires more than medical interventions. It calls for an honest reckoning with the social structures of caste, gender, class, and geography that decide who gets to be healthy. The constitutional promise of equality, the global commitment to universal health coverage, and the simple ethical principle that no one should die for want of basic care all point in the same direction: a health system that is judged by how well it serves those at the very bottom.

What do you think? Which form of marginalisation, in your view, has the deepest impact on health outcomes in your own region, and what is one concrete change in policy or practice that could begin to address it?

References

1. https://www.who.int/news-room/fact-sheets/detail/social-determinants-of-health
2. https://www.epw.in/journal/2024/10/special-articles/state-enumeration-and-marginalised-communities.html
3. https://pmc.ncbi.nlm.nih.gov/articles/PMC7116252/
4. https://pmc.ncbi.nlm.nih.gov/articles/PMC6405049/
5. https://www.healthaffairs.org/do/10.1377/forefront.20200220.518458/
6. https://scientifictemper.com/index.php/tst/article/view/2330
7. https://www.sciencedirect.com/science/article/pii/S2772368225000824
8. https://pmc.ncbi.nlm.nih.gov/articles/PMC10057357/
9. https://nha.gov.in/PM-JAY
10. https://www.who.int/teams/social-determinants-of-health/equity-and-health/world-report-on-social-determinants-of-health-equity