Caste And Religion Based Discrimination In Healthcare Delivery: Evidence From India

Last registered on June 23, 2023
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Pre-Trial

Trial Information

General Information

Title
Caste And Religion Based Discrimination In Healthcare Delivery: Evidence From India
RCT ID
AEARCTR-0011070
Initial registration date
March 09, 2023

Initial registration date is when the trial was registered.

It corresponds to when the registration was submitted to the Registry to be reviewed for publication.

First published
March 13, 2023, 3:11 PM EDT

First published corresponds to when the trial was first made public on the Registry after being reviewed.

Last updated
June 23, 2023, 3:04 PM EDT

Last updated is the most recent time when changes to the trial's registration were published.

Locations

Country
India
Region
Bihar

Primary Investigator

Name
Rushil Zutshi
Affiliation
RAND Corporation
Contact Primary Investigator

Other Primary Investigator(s)

Additional Trial Information

Status
On going
Start date
2022-06-01
End date
2023-08-31
Keywords
Health
Additional Keywords
JEL code(s)
Health and Economic Development
Secondary IDs
Prior work
This trial does not extend or rely on any prior RCTs.
Abstract
Despite overall improvements in population health in India, there remain significant differences in health outcomes along caste and religious lines. Due to the lack of rigorous evidence, it is unclear if these differences stem from a lack of access to healthcare or discrimination at point of care. I use a randomized controlled trial to measure the discrimination faced by patients at point of care by private health care providers in Bihar, India. I use standardized patients (SPs) seeking care for asthma and randomly vary their religious and caste presentation to measure the causal effect of caste and religion on technical and interpersonal quality of care. SPs presenting as Muslims with religious indicators (such as eyeliner, a beard, and skullcap) received technical quality of care scores that were 0.29 standard deviations lower than upper-caste Hindu SPs and interpersonal quality of care scores that were 0.19 standard deviations lower than Hindu SPs. SPs presenting as Muslims without any religious indicators (only a Muslim name) or as Dalit (individuals of a lower-caste or without a caste) also received lower technical quality of care scores than upper-caste Hindu SPs but did not experience significantly worse interpersonal quality of care. I also find that, although minority providers provide better care to all patient types compared to Hindu providers, the disparity in healthcare quality experienced by minority patients was larger at minority providers. These finds suggest that differences in health outcomes among underserved minorities such as Muslims and Dalits are driven, in part, by discrimination at the point of care – often by providers of the same religious or caste identity. The results suggest that interventions such as implicit-bias training could help improve outcomes for these groups.
External Link(s)

Registration Citation

Citation
Zutshi, Rushil. 2023. "Caste And Religion Based Discrimination In Healthcare Delivery: Evidence From India." AEA RCT Registry. June 23. https://doi.org/10.1257/rct.11070-1.1
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Experimental Details

Interventions

Intervention(s)
Intervention Start Date
2022-07-01
Intervention End Date
2022-09-30

Primary Outcomes

Primary Outcomes (end points)
Technical quality of care, Interpersonal quality of care
Primary Outcomes (explanation)
The outcomes are broadly categorized as outcomes concerned with the technical quality of care and those concerned with the interpersonal quality of care. The former includes outcomes such as diagnosis given, key questions asked, physical tests performed, and correct treatment. The outcomes concerning interpersonal quality care are part of a standardized scale developed to measure patient perceptions of quality in India (Rao, 2006). Questions cover the information that the doctor gave the patient about their illness and treatment, the doctor's behavior, and the doctor's interpersonal skills.

In order to present multiple outcomes in these two separate domains, we also collapse these outcomes into two separate technical quality of care and interpersonal quality of care indices. In order to do this, we implement the mean effects approach (Kling, 2007) which uses the mean of the variables within each index after they have been standardized to the control group (Type-1 SPs).

Secondary Outcomes

Secondary Outcomes (end points)
Secondary Outcomes (explanation)

Experimental Design

Experimental Design
The primary aim of this study is to identify the discrimination faced by individuals based on their caste and religion. In India, caste and religion are usually gleaned by one's name and when applicable, by the way in which one presents oneself. As such, we designed an intervention that induces random variation in these attributes. We randomly vary SP roles across providers to estimate the effect of caste and religion of the patient on the healthcare they receive.

Each provider received a visit from one of four different SP types. Each SP type introduced themselves by name before the visit begins in order to signal their religion or caste. Type-1 SPs had an upper-caste Hindu name and were dressed in a well-ironed shirt and trousers. They introduced themselves by saying "Namaste" (the Hindi salutation most commonly used by Hindus in India). Type-2 SPs had a Muslim name and were also dressed in a well ironed shirt and trousers. Type-3 SPs also had a Muslim name (the same as Type-2) but they presented with certain religious indicators such as skull cap, a beard, and were wearing a kurta-pyjama. Both Type-2 and Type-3 SPs introduced themselves by saying Salaam (the Urdu salutation most commonly used by Muslims in India) Type-4 SPs had a Dalit name and were dressed in a more unkempt manner than the other SPs. This was only because, in the Indian context, caste is often (but not always) very closely correlated with class. Instead, caste is usually only displayed by physical religious indicators by those of the upper-castes (and even then, it is uncommon in most cities). Type-4 SPs also introduce themselves by saying Namaste.


Ten unique enumerators were selected from a larger pool of 16 actors to play the SP roles. Of the ten enumerators, five were Muslims and five were Hindu. The Muslim enumerators played both muslim roles while the Hindu enumerators played both Hindu roles but the Muslim enumerators did not play either Hindu role and vice versa. This was done to ensure the safety of the enumerators since religion and caste are very sensitive issues in India and if an enumerator was caught pretending to be someone of a different caste or religion, they may be mistreated. All the SPs presented with an identical case of asthma. This case of asthma was adapted from the cases developed by ISERDD in New Delhi (Institute for Socio-Economic Research on Development and Democracy) for the Quality of Tuberculosis Care (Qutub) Project. They were trained extensively over the week long training period. so that each role
was portrayed consistently across actors. This included memorizing answers to common questions
(e.g., “when did you last feel breathless?”, ”how long does an episode of breathlessness last?”, or “what were you doing when you last felt breathless?”) so that each
actor responds similarly for the respective role. We randomly assigned the SP role the providers receive (stratified by town) and further, randomly assigned the actors to play each role (within the Muslim and Hindu pools of enumerators). All SPs completed the visit and pay any fees required by the doctor. The standardized nature of the cases presented to the providers helps isolate the effect of the caste and religion (and visibility of religion) on healthcare delivery.
Experimental Design Details
Randomization Method
Office by computer
Randomization Unit
Provider
Was the treatment clustered?
No

Experiment Characteristics

Sample size: planned number of clusters
604
Sample size: planned number of observations
604
Sample size (or number of clusters) by treatment arms
159 Hindu, 150 Dalit, 149 Muslims without religious indicators, 146 Muslims with religious indicators
Minimum detectable effect size for main outcomes (accounting for sample design and clustering)
Supporting Documents and Materials
IRB

Institutional Review Boards (IRBs)

IRB Name
RAND Human Subjects Protection Committee
IRB Approval Date
2022-07-05
IRB Approval Number
HSPC: 2020-0387-AM03
Analysis Plan

Post-Trial

Post Trial Information

Study Withdrawal

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Intervention

Is the intervention completed?
No
Data Collection Complete
Data Publication

Data Publication

Is public data available?
No

Program Files

Program Files
Reports, Papers & Other Materials

Relevant Paper(s)

Reports & Other Materials