In the 75 years of its journey as an independent nation, India has made quantum leaps in improving the delivery of healthcare services for its people. Despite the progress, inequity continues to hamper health outcomes for many population groups, closely tied to their socio-economic status, identity, and community. Inclusion, in principle, is at the heart of the global goals for universal health coverage. Gender equity in the design and implementation of health policies is, therefore, integral to ensuring equitable access to healthcare services.

The recent decision of the government, taken by the National Health Authority and the Department of Social Justice and Empowerment, to provide an inclusive and composite health package for transgender persons under Ayushman Bharat-PMJAY is a welcome move and a step in the right direction toward inclusive policymaking. Given the stigma and exclusion faced by the transgender community, the provisioning of healthcare services under AB- PMJAY is a significant step towards ensuring that the community is able to overcome physical and social barriers in accessing healthcare.

Social determinants of health are much discussed and debated in research and policymaking. Simply put, these are the non-medical factors that influence health outcomes. They are the conditions in which people are born, grow, work, and live, and the larger systemic forces shaping the conditions of their daily life. In the Indian context, the groups that have traditionally faced exclusion are scheduled castes and scheduled tribes, people with disabilities, and sexual and gender minorities among others.

Transgender persons are a part of the broader LGBTQIA+ community that has historically faced exclusion from healthcare, education, and formal employment in India. LGBTIQA+ is an evolving acronym that stands for lesbian, gay, bisexual, transgender, intersex, queer/questioning, and asexual. The lack of public data on the exact number of gender and sexual minorities in the country continues to be a challenge to responsive policymaking. Not too long ago, the community was denied visibility in official data, hindering their access to social benefits. Collecting gender-based information correctly can help in the inclusion of marginalized genders and identities in society.

In 2009, the Election Commission of India took the first step by allowing transgenders to choose their gender as “other” on ballot forms. India’s 2011 Census was the first census in its history to incorporate the number of the transgender population of the country. The report estimated that 4.8 million Indians identified as transgender, though social activists claim the actual count to be at least five times higher. Later, in a landmark ruling in 2014, India’s Supreme Court recognized transgender people as a third gender. It ordered the government to provide transgender people with quotas in jobs and education in line with other minorities, as well as key amenities.

According to a study conducted by the National Human Rights Commission in 2018, 96 percent transgenders are denied jobs and are forced to take low-paying or undignified work for livelihood like sex work and begging. The study also revealed that about 92 percent of transgenders are deprived of the right to participate in any form of economic activity in the country, with even qualified persons being refused jobs. The report further revealed that around 23 percent are compelled to engage in sex work which has high health-related risks, which results in transgender people being 49 times more at risk of living with HIV compared to the general population.

Beyond sexual and reproductive health services, data on the health of this community is scarce. However, evidence from smaller studies is suggestive of the exclusion of gender and sexual minorities from mainstream healthcare on multiple counts. Scientific studies have shown that the prevalence of mental health issues is higher within the LGBTQIA+ community and their access to mental healthcare, is much lower. In the ongoing COVID-19 vaccination drive, LGBTQIA+ people are facing additional barriers to access, as many of them do not have acceptable documentation, which takes into account the sex assigned to them at birth, instead of their gender. Another study suggests that discrimination from healthcare providers affects health-seeking behaviour among the group.

Inclusive policymaking is still at a nascent stage in India but the fact that it has begun is encouraging. Going forward, it will be important for policymakers to introduce inclusivity right at the beginning, at the stage of policy design. To do this effectively, it will be important to identify and understand the barriers to inclusion and to collect and analyze relevant population-level data. An important part of doing this is to ensure the participation of representatives of the community while drawing up the blueprint of a program. Sensible policymaking also takes into account adequate risk mitigation strategies to ensure no harm is caused to any particular community as an undesired outcome of a policy. Training and sensitizing administrators and ground staff of programs are equally pertinent to their successful implementation. Lastly, ensuring robust monitoring and evaluation practices to understand and analyze the impact on the intended beneficiary groups will set us up for future success.

Homosexuality was decriminalized in India four years ago. But we are yet to put in place a robust legal framework that prevents discrimination in health or other aspects of life for gender and sexual minorities. While discrimination in the access to healthcare is systemic and requires policy-level interventions, there is much that civil society and the public at large can do. Organizations working in healthcare especially can intentionally ensure that their programs are inclusive. Symbolism should not be dismissed as mere tokenism. Effective public health messaging will play a key role in de-stigmatizing sexual and gender minorities.

Krishna Reddy Nallamalla
President, InOrder – The Health Systems Institute

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