Despite health being one of the most fundamental issues for survival, it faces continued neglect from the Indian State. The most glaring neglect comes in the form of lack of governmental spending in all aspects of healthcare. India, shamefully, continues to have one of the lowest public healthcare budgets in the world. Additionally, important health and wellbeing concerns continue to be ignored in the spending.

The pandemic has laid bare a deep crisis within India’s healthcare system. A significant side to it is related to exploitation of workers, especially ASHA and ANM workers, nurses, and cleaners, many of whom constitute a ‘feminized’ workforce. On the one hand they are publicly praised for their work, and on the other they are made to overwork without adequate pays, benefits and occupational safeguards.

The lockdown and pandemic exposed and exacerbated the reality of difficulties in accessing public healthcare in India. At least 79 people are reported to have died during the initial months of the lockdown due to lack of timely health care. These deaths were not because of COVID-19 per se, but because they faced difficulties such as lack of transport, unjustified demands for documents, or simply refusal to be admitted by hospitals. Most of these deaths took place within oppressed communities, with a callous lack of tracking and measures taken to address them.

With or without the pandemic, medical and health care system is largely inaccessible, insensitive and violent towards the needs and lives of marginalized people. This includes the informal workforce, which employs 93% of the working population and women in a major way. It is also the case with reproductive healthcare, maternal well-being and sexual health, which are very important especially when it comes to marginalized women, Dalit and Adivasi. The causes for inadequate medical services are also linked to the weak public infrastructure, the increase in privatization, lack of qualified personnel, lab facilities etc.

There have been multiple studies showing that domestic violence has only increased during the pandemic and this implies a need to ensure physical and psycho-social support to survivors, as per the Domestic Violence Act, 2005. However, with weak mechanisms in many states and resource crunch, women have largely not been able to access support. In instances of sexual violence where women and gender non-conforming people are able to report the incidents, the medical and psychological support needed are often absent, and survivors are subjected to traumatic experiences in the medical institutions.

Lack of sensitization and appropriate changes in medical curriculum around gender and sexuality mean that transgender and queer-identifying persons are pathologized while accessing healthcare, including mental health. The lack of medical insurance schemes makes access to essential healthcare impossible for many in the informal sector and especially for trans* persons and sex workers surviving on informal and unrecognized work. Further, people living with HIV face additional stigma and suffer the severe impact of crises like the current pandemic-triggered one. Budgetary resource allocation for all these vulnerable populations is barely sufficient.

Additionally, numerous voices from across movements and lived experience have pointed out the violence of mental healthcare, which does not acknowledge and address trauma and distress caused by structural violence like caste or gender oppressions, embedded in a capitalist and extractive political economy, both in terms of people’s resources and people’s labour. State-sponsored mental health services are unavailable to the working classes, and where they are they fail to respond to the needs of the most marginalized. Lack of representation of Dalit, Adivasi, Vimukta, trans* and queer persons among mental health practitioners is another issue that contributes to denial of empowering healthcare.

As with other struggles, voices from the disability movement point out to the inordinate power that medical professionals assert over those accessing healthcare, and towards the same kind of lack of recognition of bodily autonomy and pathologization. There is also continued lack of funding on disability-related healthcare. The budget for disability has been cut down from 1325 Cr (2020) to 1171 Cr (2021), with some schemes disappearing completely. While there is a need to improve healthcare in rural areas, addressing specific illnesses, and making provisions for gender and disability, the budget conveniently ignores this. In doing so, the Govt of India is actually violating the statutory provisions of the Rights of Persons with Disabilities Act, 2016.

The move towards privatization and the Public Private Partnerships further alienate marginalized people from access to basic healthcare. In addition to the fundamental lack in health infrastructure and personnel, shifts in education such as the centralized emphasis placed on NEET also alienate students from marginalized communities from becoming health professionals and participating in making medical practice and the healthcare system more egalitarian and empowering.

Education is intended to function as a tool for empowerment and emancipation as envisaged by our constitution-makers as well. However, since the 90s in particular, we have witnessed a steep model of privatization, corporatization and in the last decade, centralization, that has effectively commodified the entire sector. The advent of the BJP-RSS has also ushered in a phase of saffronization of education, which is patriarchal, manuvadi and unscientific at multiple levels.

While there is lipservice paid to the need to ensure education for girls (through campaigns like Beti Padhao-Beti Bachao) and children from marginalized background, the measures taken are often insufficient, especially for students who belong to working class, migrant communities, and children with disabilities, transgender children etc for whom access to schools is in itself fraught. However, the trends over the past two decades do show a growing emphasis that Dalit, Adivasi, Muslim, and especially OBC communities place on education (especially in the English medium) as aspirational, with the latter being ‘new entrants’ whose relative percentage has been growing consistently.

Changes taking place over the past few years have restricted access of students from marginalized communities, especially from entry into higher education institutions through ‘competitive’ examinations. The changes in science syllabus at school level, for instance, have put significant pressures especially on rural schools; the gaps, compensated for by the mushrooming tuition industry, remain glaring for the students who cannot afford these coaching classes. Digitalization of education, it became clear during the pandemic, is an unequal terrain especially for girls and marginalized children, which will also end in exclusion.

The policy shifts brought in during the pandemic itself by the National Education Policy (NEP) make its agenda clear: provide ‘skill’ to people from marginalized communities to in turn provide cheap labour for corporates, rather than allowing education to become a tool for empowerment. Even the limited guarantees brought in after considerable efforts, with the Right to Education Act, now stand challenged. The intention behind introducing multiple exit options at all levels of education is clearly malafide, since the students likely to ‘opt’ to leave programmes early, with only diplomas or certificates are likely to do so under financial or other pressures. Along with the emphasis on distance education, these policy shifts will make it seem as if the dropout rates are lower, when in fact marginalized students’ presence in schools and ability to benefit from access to education will diminish. In all likelihood, children, and especially girls and gender-nonconforming children from marginalized communities, who are compelled to earn for their livelihoods will be out of the education system.

These policy shifts are tied to the increasing saffronisation of education in India, which has been taking place for a long time especially in rural and adivasi areas. The fact that the most significant allocation in the Union Budget 2021 for education within the ST subplan is for Eklavya Model schools, rather than providing for Pre- and Post-Matric scholarships or for making schools safe learning spaces for oppressed communities, is an indication of the attempt to appropriate socially marginalized identities within the hindutva framework.

The growing opposition to reservations, prohibitive fees in private institutions and the likelihood of numerous government schools and colleges being compelled by the NEP to fold up, will mean that students from historically oppressed communities and working classes as well as children who are compelled to leave home for fear of violence, will have less and less access to basic education and will face increasing levels of discrimination in educational institutions.

As it is, there has been an increasing number of instances of discrimination, leading up to institutional murder of Dalit, Adivasi, gender non-conforming and other marginalized students in educational institutions. There has also been significant backlash from students and staff of privileged communities against reservations that ensure opportunity to access education for all students, even as the reservations for transgender students, for instance, have not even been brought into effect as yet. The opposition is more so at the level of teaching staff appointments, leading to a continuous reinforcement of caste and gender hierarchies in academia.

At the same time, within primary education, Anganwadi teachers, poorly paid and rarely acknowledged, are now expected to also take on the burden of foundational education, while in parallel updating their own skills through programmes to be conducted both in online and offline modes. This in a context in which their demands for adequate remuneration have gone unheard.

The NEP also prescribes the addition of breakfast to the mid-day meal the schools are meant to already provide. This of course sounds ideal, if it wasn’t for the reality of the Budget 2021 not allocating more funds for nutrition in schools. Budget cuts in nutrition are a recent blow in the overall failure to ensure mid-day meals and nutrition to children during the lockdown. These failures will have far-reaching effects on attendance, development, and health and nutrition of children.

Just like education and health, access to adequate food and nutrition is also restricted by caste, class and gender determinants. The historic Right to Food Campaign over the past two decades, which involved a protracted legal battle led the Supreme Court to acknowledge that the right to food is an integral component of the right to life under Article 21 of the Constitution. The campaign itself drew attention to how marginalization along the lines of caste, gender and social location adversely affects access to food. While the efforts of the campaign and the intervention of the Supreme Court led to the enactment of the National Food Security Act, (NFSA) 2013, the Act in itself fell short on two serious counts: it did not guarantee universalization of food schemes, and it made a severe compromise in terms of addressing the full-fledged nutritional requirements of every person, in a country where millions are under-nourished.

The pandemic and lockdown have shown the urgent need for universalization of PDS beyond the limited guarantees included in the Food Security Act (2013). However, instead of expanding the Public Distribution System (PDS) net, the Central Government has actually passed three farm laws which can potentially lead to a dismantling of the PDS, a lifeline against hunger and malnutrition in India. The ongoing farmers’ movement, equally led by women farmers as well as working people’s opposition to the farm laws has sharply brought into focus these concerns. A lot of analysis is available on how the implementation of the farm laws would adversely affect the economic and food security of women, many of whom are small, marginal cultivators, single women, informal workers etc and do not have access to land and other resources.

In the context of wide-scale, rapid privatization and displacement of rural, adivasi and forest dwelling people to make way for large-scale projects, the issue of food insecurity and increasingly limited access of adivasis to forests also needs to be acknowledged and addressed. Here as well, women who are primarily dependent on forest resources for survival would be adversely affected.

The recent findings on the increase of child undernutrition in India are alarming, to say the least. The recently released national family and health survey 2015-16 shows a jump in child malnutrition: in 7 out of 10 states for which data are released, proportion of children who are underweight has increased and in 6 out of 10 states, stunting among children increased. These are numbers before the pandemic, and therefore, there is a strong likelihood that undernutrition, especially among children, would have risen even further.

Despite the alarming rise in undernutrition, the budget for nutrition schemes has been further slashed this year. For the Saksham scheme, which includes both anganwadi services and the National Nutrition Mission, a budget of 20,105 crore is allotted, which is even lower than last year’s Rs 20,532 for anganwadi services. Similarly, the Pradhan Mantri Matru Vandana Yojana, a scheme for nutrition and maternity needs for pregnant and nursing women, has also faced a budget cut.

It is rather ironic that with unacceptably high levels of undernutrition in India, the focus continues to be on politicizing food and building a narrative of the brahminical ‘vegetarian India’. Such a narrative, by design, excludes religious minorities as well as caste-oppressed communities whose food cultures have evolved as a result of deprivation, and then subjects them to state-condoned violence as a result. Several large states continue to refuse to provide eggs, in anganwadis and schools. There is also no commitment to include millets and other locally available grains in the PDS and MDM basket. This would adversely impact nutrition outcomes and the health of India’s current and future populations.

Legal provisions to ensure access to food through the PDS system also continue to fall prey to casteist practices across different states of India. In conditions of crisis, such as floods or ‘natural’ disasters, the Dalit and Adivasi communities are the first to bear the brunt and the last to receive whatever measly relief and rehabilitation measures set in place. Various struggles have also pointed that there needs to be targeted support for persons marginalized on grounds of gender and disabilities.

With an overwhelming informal working-class population, India needs a comprehensive system for social security, starting from livelihood and wage security. There has been a running demand for a higher number of days of employment guarantee under NREGA, higher wages, and better working conditions. But these fail to materialize because of the neo-liberal agenda, as the State continues to withdraw from its responsibilities. However, the pandemic has highlighted that without a comprehensive social security system, many lives get further pushed into further precarious living conditions at times leading even to death. Women and gender non-conforming people are worst affected without a social security net.

There are several ways in which such a social security system would need to be strengthened. Employment guarantee through NREGA, another lifeline in general but especially during the pandemic, needs a boost with 200 work days in a year. Clearing pending arrears, providing cash-transfers, eliminating aadhaar-based payment system and reverting to NEFT payments, and providing work guarantee for NREGA workers for later are some of the necessary steps that should be taken.

Instead of diluting the legal guarantees through labour codes, the Government should effectively implement the Building and Construction Workers Act, 1996, the Unorganized Sector Workers’ Act, 2008, the Street Vendors’ Act 2014, and such legislation which provides a framework for social security to large working populations. Millions of women continue to be employed as domestic workers, construction workers, NREGA workers, garment workers, hawkers, etc, and the social security net needs to respond to the particularity of their circumstances.

Insurance and pension schemes continue to need strengthening in most states. While some states do have provisions for pensions for persons with disability, widows and senior citizens, pensions for transgender persons don’t exist in most states. Furthermore, the pensions which do exist, in many states are abysmally low (as low as 200 rupees a month). Not only do the social security pensions need to be universalized, they also need to be increased to a dignified amount which allows the recipient to meet their basic necessities.

The right to housing also needs to be seen as integral to social security entitlements. Not only is housing not guaranteed, but Governments have continued their eviction sprees in spite of the pandemic, with severe effects on working populations and women who already suffered loss of livelihoods. While in many places women have organized and resisted against this, their core demand of secure shelter with a legal guarantee is yet to materialize.