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Field
Abstract
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Before
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 that vary only in 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 case 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. Further, the lower care quality experienced by minority groups (Muslim or Dalit) was abated when the provider was also of a minority group but the difference in healthcare quality between the minority and Hindu SP types increased. 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 – especially by providers of a different religious or caste identity. The results suggest that interventions such as implicit-bias trainings or assigning underserved communities with healthcare providers from the same communities could help improve outcomes for these groups.
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After
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.
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