Exclusion from health: withheld citizenship of indigenous people in South India

Social exclusion is an important yet long under--‐recognised determinant of health and of health coverage. It finally came to the fore though the work of the Commission of Social Determinants of Health (CSDH)1. The Commission’s Social Exclusion Knowledge Network (SEKN) defines social exclusion as consisting of “dynamic, multidimensional processes driven by unequal power relationships interacting across four main dimensions – economic, political, social and cultural – and at different levels including individual, household, group, community and global levels”2. Lister describes social exclusion as “a variety of ways in which people may be denied full participation in society and full effective rights of citizenship in the civil, political and social spheres”3. While the SEKN’s definition is essential in pointing at all possible dimensions of social exclusion, Lister’s description appropriately reminds us of the wider framing within a human rights framework and, specifically, citizenship. As recognised by Lister and contrary to popular belief, citizenship extends beyond the political sphere. As highlighted earlier by Fraser, the linked ideal of social justice requires redistribution and recognition4, both having important implications down to the personal level. From 2011 onward, in the Indian states of Karnataka and Maharashtra, we explored the dynamics of social exclusion from RSBY – a welfare scheme offering health insurance – within the EC--‐funded Health Inc project5. In doing so, we responded to the SEKN’s call for research on the relationships between the process of exclusion and the creation and maintenance of health inequities6. Analysing who, why and how people were excluded from social health protection schemes that were designed to include them, in the Health Inc project we confirmed that social exclusion is indeed an important cause of the limited success of a range of recent health--‐financing reforms. The project coming to an end, we were able to formulate practical recommendations for the health protection programmes under study to become more inclusive. The Health Inc project successfully did so based on a mixed--‐methods explanatory sequential research design7. The Health Inc project however, due to the inherent complexities of multi--‐stakeholder research and a restrictive focus on programmes more than people, was limited in its ability to identify generative mechanisms of exclusion. In the Health Inc Karnataka case study, we were able to identify withheld citizenship, defined as “a combination of a lack of political networks, and a lack of a political voice in the existing climate of political neglect, cultural discrimination and social segregation”8 as an umbrella mechanism that could explain the exclusion of particularly indigenous people, but the evidence base still needs consolidation. Indigenous people9 – besides being under--‐studied in South India – were also more affected by exclusion from social health protection than any other social category. This leaves us with a double evidence gap: more in--‐depth knowledge on withheld citizenship as a generative mechanism of social exclusion from health, and its articulation with the observed excessive exclusion of indigenous people. We posit that further exploration of the already collected qualitative Health Inc data, plus a modest additional round of data collection, can contribute to fill this gap.