In an inspiring example of Germany’s feminist development policy in action, the Indo-German Universal Health Coverage (IGUHC) project is supporting the Government of India to extend social health insurance to the transgender community, upholding their rights to free, quality health services.

‘In public health facilities, people like us are regularly discriminated against by staff members and by other patients, too. They force us to wait in long queues designated for males or females, and then we have to register our gender as ‘other’’, says Ms Nisha Kinnar, founder of the New India Help Foundation Trust and a transgender activist. She thinks that this is why many individuals from the community are forced to seek quicker, more expensive care in the private sector, despite being among India’s most marginalised groups (Rhude, K, 2018).

The recent extension of India’s social health insurance scheme to cover the transgender community is therefore an exciting and important development in the Indian health landscape. Understanding the relevance and need for this inclusive step for her community, Ms Nisha is aiding the initiative by helping her friends and colleagues to register for the scheme via the government’s online portal.

Laying the foundations for better healthcare access

Recognising transgender as a third gender in 2014, India’s Supreme Court took an important first step towards realising the social, economic and political rights of the country’s transgender community. Some years later, in early 2020, the Indian Government then introduced the Transgender Person’s Act 2019. 

Although the Act was highly contested by sections of the transgender community for being ill-timed during the COVID-19 lockdown, and insufficiently consulted upon, it ushered in important changes related to accessing healthcare. According to the Act, medical facilities are now mandated to provide care to transgender people, including for gender-affirmative procedures, and discrimination against them during health service delivery is prohibited. The Act also calls for a review of medical training curricula to ensure the explicit incorporation of transgender people’s health needs. 

However, despite these important legal changes, access to quality health care for transgender and gender-variant people has remained worryingly low when compared with their cisgender counterparts (Ming, Hadi, & Khan 2016).

Addressing the barriers to accessing services

Although the Indian subcontinent has a long history of Hijras, a contested term used to refer to individuals who identify as transgender or intersex, transphobic and homophobic attitudes permeate society at every level. Discrimination at health facilities, the high cost of certain medical procedures, the lack of trained health staff and tailored treatment protocols, and low health literacy are among the major barriers to accessing health services for the transgender community. Additionally, the community also struggles to engage in health promotion and disease prevention efforts, particularly those related to sexual health, placing them at higher risk of sexually transmitted infections, including HIV (ibidem).

Fully implementing the Transgender Act will consequently take time and require far-reaching changes, both to the structure and quality of health services. A significant development is the signing of an agreement in August 2022 between the National Health Authority under the Ministry of Health and Family Welfare and the Department of Social Justice and Empowerment, to extend India’s social health protection scheme – Ayushman Bharat Yojana – to transgender people throughout India.

Once rolled out to the different states – a process that is already underway in Uttar Pradesh – individuals from the transgender community will be able to access a package of health services free of charge, including gender-affirmative procedures, at empanelled public and private health facilities.

Extending financial protection for health services

Launched in 2018, the Ayushman Bharat scheme has continued and expanded the work of the earlier RSBY and is the Government of India’s flagship health scheme, designed to help the country achieve Universal Health Coverage (UHC) by moving towards a comprehensive, needs-based health care service. It comprises two synergistic components: a network of Health and Wellness Centres that aim to provide comprehensive primary health care closer to people’s homes; and, Pradhan Mantri – Jan Arogya Yojana (PM-JAY) which provides financial protection, covering the costs of an essential package of health services for some of India’s most vulnerable people.

The IGUHC project, financed by Germany’s Federal Ministry for Economic Cooperation and Development (BMZ), supports the Ministry of Health and Family Welfare and the National and State Health Agencies on the implementation of PM-JAY. A team of technical specialists from Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) support all aspects of the scheme, from the policy through to the community level, using a gender equity and social inclusion approach to their work.

Today, PM-JAY is the world’s largest government-funded health insurance scheme, covering nearly 100 million vulnerable families – some 500 million individuals. And while transgender people make up less than one percent of the scheme’s beneficiaries, their explicit inclusion sends a powerful signal about their importance in society.

India’s most populous state is blazing a trail…

Uttar Pradesh – India’s most populous state – is the first state to kickstart activities to extend health insurance to transgender people. With support from GIZ, the State Health Agency aims to fully introduce the scheme within a couple of months, using digital media to facilitate implementation. As CEO of the State Health Agency in UP, Ms Sangeeta Singh said,

‘This is a huge, huge step towards gender sensitisation and gender equity. We have to cater to everyone in a society and this is a population that has traditionally not been allotted parity, and that has been overlooked’.

Ms Sangeeta Singh, CEO of the State Health Agency in UP

Funded by central government, coverage of the transgender community differs from the wider PM-JAY scheme where 60% of funding is from the national government and 40% from state governments. Each individual who registers via the online portal will be issued with an Ayushman Bharat card and will be allocated the same financial package as a family – that is, they can access health services up to the value of 5 lakh rupees per annum (= approx. five and a half thousand Euros). 

This recognises the higher costs of the health services that transgender people may need, and the fact that they often live in separate communities rather than traditional family units. As the IGUHC Gender Focal Point, Shakeel Ahmad points out, 

This sends a strong signal from central government about the importance of improving access to health services for the transgender community. It will help to address discrimination towards them among health service providers.

Shakeel Ahmad, IGUHC Gender Focal Point

It’s early days but progress is being made

Some 10 million people in Uttar Pradesh are covered by PM-JAY and 3,400 hospitals have been empanelled. Although concrete initiatives are yet to start, more than 3,000 transgender beneficiaries identified on the basis of their socio-economic and cast census data (SECC 2011) had already used the health services at the end of February 2023.

Activities in Uttar Pradesh will focus on a twin strategy of reaching out to the transgender community to make them aware of their rights and inform them about the scheme, and strengthening the delivery of services by, for example, sensitising healthcare providers around the needs of the community and expanding the number of empanelled hospitals that can provide services to them, including for gender realignment.

A highly focused communications strategy aims to keep costs low

The IGUHC is helping the State Health Agency to develop a highly focused communications strategy that will utilise social media and other digital technologies, such as WhatsApp and SMS messaging, to reach the maximum number of beneficiaries while keeping costs down. The programme will also work with non-government and civil society groups that are already working closely with transgender people, and piggy-back on other government programmes, such as the State AIDS Prevention and Control Societies (SACS), where there is a high degree of trust in the activities from within the transgender community.

One such civil society organisation is the aforementioned New India Help Foundation Trust, founded by Ms Nisha, which is active in fund-raising and advocacy for transgender rights. As a transgender person and well-known activist in Uttar Pradesh, Nisha is a trusted and well-known figure among the community, and is using her knowledge of PM-JAY and other social protection schemes to support the community to uphold their rights to free, quality healthcare.

Looking to the future – the benefits of research

As the changes to PM-JAY are rolled out at state level, and more transgender people start to access the health services they need, IGUHC Project Director, Amit Paliwal would love to have the necessary resources to conduct more operational research, and even one day, an impact assessment, saying, 

the government of India is trying to integrate transgenders into the economic and social mainstream, so I would love to look at the wider societal impact of incorporating transgenders into the health insurance, and at how these changes have impacted on their daily lives.

Amit Paliwal, IGUHC Project Director

As Ms Nisha notes, ‘this scheme has come like a ray of hope in our lives’. Given the ground-breaking nature of these changes for India’s transgender community, a well-designed impact assessment would make a critical contribution to the evidence base for extending UHC to highly vulnerable groups and would help to identify lessons for other contexts and countries.

Corinne Grainger,
April 2023