Exclusion through inclusion: Using ‘Passive inclusion’ to explain the Dalit equity paradox within Kerala’s Primary Health Care landscape
1
Centre for Commercial Determinants of Health, Institute of Public Health Bengaluru, Bengaluru, India
Popul. Med. 2026;8(Supplement Supplement 1):
ABSTRACT
BACKGROUND:
The study highlights paradoxes of equity within the acclaimed public health model of Kerala in India, often veiling the marginalisation faced by Dalit communities. The study, using Heek’s ‘ladder of inclusive innovation’ framework, critically examines two Primary Health Care (PHC) innovations by two different Local Self Governments (LSGs) in Kerala.
METHODS:
Qualitative explanatory case studies through 90 in-depth interviews with elected LSG representatives, health officials, and community members, participants and non-participant observations of LSG processes, 4 Focus Group Discussions and analysis of project-related documents were conducted. The findings were analysed using the ‘ladder of inclusivity’ inclusion levels (intention, consumption, impact, process, structure) for innovations.
RESULTS:
While the socio-economic disadvantages faced by Dalit communities ensured them accessing services, the specific health needs of Dalit communities were never problematised within either innovations. Exclusion of Dalits was further observed within the decision-making in terms of planning for the PHC innovation modalities. Furthermore, despite Dalits occupying formal leadership roles in both LSGs, they were sidelined within decision-making spaces by non-Dalits, leading to PHC innovations that failed to cater to the real health needs of Dalit communities.
CONCLUSIONS:
The study proposes the idea of ‘Passive inclusion’ to signify the paradox of simultaneous inclusion-exclusion endured by Dalits. Passive inclusion highlights the pitfalls in understanding Dalit equity only through the lens of their formal inclusion within democratic spaces and their access to available health services. It points to the pathways of Dalit exclusion legitimised through their namesake inclusion as office bearers of LSG and consumption of PHC services, but devoid of an agentic role within decision-making processes. Such nominal inclusion legitimises power capture by non-Dalit elites within decentralised spaces. This necessitates looking beyond the conventional inclusion-exclusion binaries within mechanisms like PHC and decentralisation to address caste-driven health inequities.
The study highlights paradoxes of equity within the acclaimed public health model of Kerala in India, often veiling the marginalisation faced by Dalit communities. The study, using Heek’s ‘ladder of inclusive innovation’ framework, critically examines two Primary Health Care (PHC) innovations by two different Local Self Governments (LSGs) in Kerala.
METHODS:
Qualitative explanatory case studies through 90 in-depth interviews with elected LSG representatives, health officials, and community members, participants and non-participant observations of LSG processes, 4 Focus Group Discussions and analysis of project-related documents were conducted. The findings were analysed using the ‘ladder of inclusivity’ inclusion levels (intention, consumption, impact, process, structure) for innovations.
RESULTS:
While the socio-economic disadvantages faced by Dalit communities ensured them accessing services, the specific health needs of Dalit communities were never problematised within either innovations. Exclusion of Dalits was further observed within the decision-making in terms of planning for the PHC innovation modalities. Furthermore, despite Dalits occupying formal leadership roles in both LSGs, they were sidelined within decision-making spaces by non-Dalits, leading to PHC innovations that failed to cater to the real health needs of Dalit communities.
CONCLUSIONS:
The study proposes the idea of ‘Passive inclusion’ to signify the paradox of simultaneous inclusion-exclusion endured by Dalits. Passive inclusion highlights the pitfalls in understanding Dalit equity only through the lens of their formal inclusion within democratic spaces and their access to available health services. It points to the pathways of Dalit exclusion legitimised through their namesake inclusion as office bearers of LSG and consumption of PHC services, but devoid of an agentic role within decision-making processes. Such nominal inclusion legitimises power capture by non-Dalit elites within decentralised spaces. This necessitates looking beyond the conventional inclusion-exclusion binaries within mechanisms like PHC and decentralisation to address caste-driven health inequities.
| eISSN: | 2654-1459 |
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