Social Work Education and Health Equity in India: A Critical Review

Ngaopunii Trichao Thomas, University of Delhi

Abstract & Keywords: Considering the persistence of significant health inequities in India, exploring the interface between health equity and social work education is a critical research priority. This article attempts to present a systematic analysis of the present status of health equity and social work training in India, elaborating on healthcare discrepancies among various populations in India, examining reasons for elevated morbidity and mortality rates among marginalized communities, and approaches to social work education at present. Consequently, curriculum revision should be all-inclusive and focus on highlighting fairness in health provision as well as cultural competency with an emphasis on social justice. It also calls for a paradigm shift towards contextualized knowledge, critical pedagogy and community engagement to prioritize health equity by suggesting that future training should focus on a holistic approach to dealing with preventable illnesses emanating from these determinants. In conclusion, this article points out the significance of giving more attention towards health equity within Indian schools of social work while providing some directions for possible research lines.

Keywords: Marginalised populations; health equity; social work education; curriculum development; community engagement; cultural competence

Introduction

Social work education and health equity intersections need to be understood in India, where the disparities in health still persist. Health equity is a basic human right of all persons, entailing equal access to resources, opportunities, and outcomes for all. It challenges us all to ponder the basic nature of health-and of society-and, ultimately, of human rights (McKay & Taket, 2020).Nevertheless, poor sections of Indian society are faced with numerous hurdles in accessing healthcare services, thus resulting in negative health conditions as well as a high disease burden (Prasad & Jesani, 2018). Social work education is an important field that helps in tackling social determinants of health, thereby ensuring equitable health through practice, policy, and research (Friedman & Merrick, 2015). The purpose of this article is to provide an overview of the current situation regarding the issue of health equity and social work education in India by looking at issues such as the social determinants of health within marginalized populations, how they shape health outcomes among these communities and programs being run by schools that offer social work courses. This research points to gaps and challenges in integrating health equity concepts into social work education. The paper, therefore, seeks to catalyse contributions to developing an equitable and fair society where everybody can access quality healthcare services and optimal health possibilities.

Current Landscape of Health Equity in India

Factors such as enhancing revenue, health consciousness, decreased bureaucracy, price liberalization and support from private healthcare are rapidly changing India’s healthcare system. Although India has achieved the recommended ratio of doctors per WHO population, it still faces challenges like escalating costs, lack of sufficient nursing and long-term care facilities for the elderly or infirm, exorbitant medical expenditure on the poor population, surge in new diseases and insufficient public health finance (Mehta et al., 2010).

India is a country where social disparities exist in access to healthcare services and health outcomes among marginalized groups. The distribution of resources in India’s healthcare system remains lopsided, with significant differences between rural areas that have few healthcare providers and urban ones with enough capacity. This contributes to unfavourable health consequences for vulnerable populations like higher rates of infant deaths, a shorter lifespan as well as more cases of communicable diseases (Dabla-Norris et al., 2015).

The socio-demographic factors for health in India are diverse, and they include poverty, education, and gender. Inequality in service delivery is evident where, for example, low-income persons cannot afford to pay for healthcare services; education level correlates with health status and parity shows the inequalities wherein women, particularly marginalised populations, have been discriminated out of health care services and products and the ranked last whereby they have no access to health care information (Ramesh & Bali, 2021). The above-mentioned challenges are critical in enhancing healthcare delivery in India.

Current Efforts to Address Health Inequities in India

The government of India identified the need to address health inequity and has launched Health reform strategies such as the National Health Mission (NHM) and the Ayushman Bharat. The NHM aims to enhance and expand health care for the disadvantaged group, whereas the Ayushman Bharat targets health insurance to the vulnerable group of society. These efforts are important to eliminate the problems of health disparity in India (Hooda, 2022). Nevertheless, non-government organizations or NGOs are also significant in addressing India's health inequalities (Asher, 2010). Thus, the NGOs are trying to eliminate the factors contributing to health inequalities through the Health Access, Health Education and Empowerment programs. For instance, some NGOs are involved in offering quality health care services to marginalized populations, while others are involved in the promotion of health by disseminating information on various diseases to the community.

Yet, there are still several key issues that have to be tackled for achieving health equity in India. The distribution of the healthcare system is still imbalanced for the deprived population as they face challenges in using quality healthcare services. Also, social factors, including poverty, education, and gender, remain dominant influences that affect the health of individuals. The topic of health equity in India is rather elaborate and is faced with many issues in the present. This has persisted despite considerable efforts in the solution of health disparity, as minorities still experience prejudice in the reception of health services and health status (Nambiar & Muralidharan, 2017). In order to build on current work and make further progress, in particular towards Indian health equity, the existing work should be maintained going onward; in addition, the relation to social causes and effects of health inequity should also be taken into consideration. This needs a long-term focus on healthcare, promotion of health and creation of empowered versions of health literacy, and recognition of global social preconditions of health (Grover & Singh, 2019). Thus, it is pertinent to build over the current efforts and resolve the issues of structural determinants of health inequity to transform the current inequitable healthcare system in India into a fair system that offers a chance for better health among disadvantaged communities.

Social Work Education in India: Overview of Social Work Education in India

The formation process of social work education in India can be traced back to the early twentieth century. The development of the institutional base for the discipline was determined by the Western models; establishments like the Tata Institute of Social Sciences (TISS), the Delhi School of Social Work (DSSW), and the Madras School of Social Work also contributed a lot to the development of the discipline under the Indian contexts. These institutions emphasized learning through exposure to practical situations, practical attachment, and community involvement as concepts that form the foundations of their learning models (Adaikalam, 2014). From then on, social work education has grown exponentially with many universities and colleges now offering social work programs at both the undergraduate as well as postgraduate levels. In the following decades, a number of changes occurred in the context of the provision of social work education in the Indian scenario, with some of them being historical landmarks (Baikady et al., 2021). The processes of the professionalization of social work, the launching of the Global Agenda for Social Work and Social Development, and collaborations with universities and organizations from other countries have all impacted or propelled the course and evolution of social work education in the country (Truell, n.d.).

Contemporary Social Work Education in India: An Overview

Social work education has rather been witnessing gradual growth and developments across India and to some extent, there are different courses that are offered at different levels. These programs address the demands for higher qualified social workers in a wide range of areas, including but not limited to health, education, and welfare (Dash et al., 2020).

At the undergraduate level, a Bachelor of Social Work (BSW) prepares students with a basic understanding and practice in social work. Such courses normally take between three and four years of study and are offered across a number of areas, such as social work theories, research and social work field practice, among others. At the postgraduate level, Master of Social Work (MSW) programs expand on the fundamentals taught at the undergraduate level. They take two years to complete and offer options in clinical social work, community organizing and social policy. The most common scholarly degrees in social work are doctoral degrees, including Ph. D. in Social Work, provided by different universities in India different universities in India. Such programs are intended for the postgraduate level in social work practice and usually take three to five years to complete.

A majority of educational programs in social work are built under universities across the country and aim at catering increasing need for professionally trained social workers in respective sectors. Due to the practical nature of these appliances, these programs are mostly formulated with the assistance of different stakeholders, starting with government agencies, NGOs, and other organizations that are involved in the practice of the mentioned professions. Apart from the academic curriculum, there are many institutions in India that offer certificate courses, diplomas, and continuing education in social work. These programs meet the continuing education requirements of social workers and other professionals practising in the related field. Thus, the social work education system in India is diverse and focuses on preparing students for practice in the changing social work context. The future prospects show that due to the increase in demand for qualified social workers, it could be expected that social work education in India is also a prospect for further development and expansion.

Curriculum and Pedagogy in Social Work Education in India: A Critical Analysis

The content taught in the social work courses in India purposely prepares students with the knowledge, skills, and/or attitudes required by social workers. Health equity, cultural competency, and social justice are the major philosophies that guide the curriculum addressing SDOH and the effect of poverty, inequality, and discrimination on health (Singh & Srivastava, 2003). The courses are classified to cover as many aspects of health inequalities in India as possible, emphasizing social and economic models. The subject specifier enables the students to analyse how aspects such as poverty, inequality, and discrimination continue to exacerbate health inequalities and enable them to learn effective ways of eradicating such inequalities through social work practice.

Therefore, the approach to learning adopted by institutions of social work education in India is learner-centered and based on concepts of Analysis, Reflection, and Skill acquisition. For instance, through case studies and group discussions, the students are trained to critically analyse and solve problems. Cultural sensitivity also receives a lot of attention in the curriculum because students are likely to possess different cultural prejudices and presuppositions. In response to this, students are trained on culturally and socially appropriate intervention skills through acquiring, for example, field practice. But, it is important not to overlook the models' and curriculum's difficulties in implementing this sort of pedagogy, especially regarding its resources. For instance, featuring limited resources and structures may put a constraint on the achievable personal attachment exercises. However, it also may seem that curriculum must be changed according to the student’s needs and their contexts as well. Nonetheless, keeping health equity, cultural competence and social justice in the curriculum and teaching-learning paradigm of social work education in India is immensely relevant given the marginalized populations' existing and emerging healthcare needs. Therefore, it is possible to conclude that understanding and overcoming these challenges may help the educators of social work in India to further enhance the paradigm and curricular framework, which would remain sensitive and adaptive to the students and the populations that they work with.

Fieldwork and Practical Training in Social Work Education in India: A Critical Component

The field and practical training are the significant components of social work education in India, where students are exposed to applying theoretical knowledge and gaining the required experience to effectively perform the social work practice. By engaging in practical placement, students are exposed to healthcare facilities such as hospitals and community centers and non-government organizations dealing with clients and the population with the aim of acquiring hands-on experience and practicing what they have learned (Nair et al., 2019). The fieldwork dimension of the BSW, as well as the MSW programs of social work education in India aims at enabling students to get practical experience in social work practice so as to be able to assess, intervene and evaluate. Clients and communities directly engage the students; through practice, the students solve several problems pertaining to practical experiences and existence. It also facilitates a broader view of the profession and expands students’ perception of what the real world of social work looks like and how culturally competent interventions should be carried out (Subhedar, 2001). As for practical training, the classrooms in India must train the students to learn skills in specific areas of practice, such as counseling, case management, and community organization. By so doing, the student is able to implement or put into practice the knowledge gained and the theories learnt in class in real-life scenario, thus acquiring the important skills needed in practising social work Nair, 2014). The issues of fieldwork and practicum components in the social work and education in India are particularly significant in preparing students for efficient social work.

Health Equity Curriculum in India: A Critical Examination of Arguments and Counterarguments

The integration of health equity into social work education has spawned an important discourse in India. Supporters hold the belief that an education in health equity would orient social workers with knowledge and capabilities that are more appropriate for working on social determinants, access to health care, and health inequity issues. However, counterarguments posit that the existing curriculum is already saturated, and the implementation of new content would be hindered by resource constraints. Moreover, critics argue that a more focused approach is necessary to address India's unique health challenges. Sanjeev Kelkar contends that leveraging existing resources can achieve a comprehensive and effective solution. Nevertheless, this requires a radical re-evaluation of certain entrenched ideas and a willingness to discard outdated concepts, particularly in the realm of Primary Care and its structural organization. Such a re-evaluation can be accomplished without compromising the quality of care for the most vulnerable populations (Kelkar, 2021). Critical analysis of arguments puts one in a position calling for nuance. Whereas it has the potential to enhance social work education with a health equity curriculum, it also belongs to the domain of practicality in such a way that any such integration is done thoughtfully, well-resourced, and contextually relevant. The present state of social work education in India is very inadequate to be based on the archaic West-driven models that have no insight into the present complicated health and social inequities in Indian society as a system. The lacuna in the curriculum about marginalised populations, system-induced barriers, and critical areas like mental health, community health, and poverty is absent (Dash et al., 2020).

This can only be addressed by including Health Equity, cultural competency, and Social Determinants of Health in the educational curricula for social workers in India. Contextual knowledge sharing, critical pedagogy, and community engagement will aid students in the acquisition of some skills necessary for advocacy and community empowerment. There is a need to transform education by embracing a more nuanced and collaborative model that integrates contextualized learning, critical pedagogy, and community involvement. It then becomes incumbent upon the field of social work education in India to take a proactive role in addressing the social determinants of health and promoting health equity. The comprehensive revamping of curriculum and pedagogy will be required to achieve this objective. Anything less will be a dereliction of its responsibility toward advancing social justice and human rights.

Gaps and Challenges in Integrating Health Equity into Social Work Education

Despite efforts to integrate health equity into social work education, several gaps and challenges must be addressed. First, most social work programs lack standardized curricula and pedagogies, which can result in inconsistent training and preparation of social workers. This inconsistency may render the approach towards health equity quite incoherent among social workers and eventually affect the practice's efficiency. Any training for social workers should be relevant, especially in identifying and responding to the unique needs of diverse populations, particularly those that overlap across multiple dimensions on which marginalized groups are often categorized. Moreover, more focus has to be put on the social determinants of health and how these factors affect health outcomes. It is important that social workers be taught to recognize how social and economic factors—conditions such as poverty, housing, and education—affect general health (Crisp & Beddoe, 2013). However, current curriculum and pedagogy markers indicate a lack of concentration on these topics that adequately equip a social worker for today. Additionally, there is minor emphasis placed on policy and advocacy in social work schools. Social workers must be educated to become health promotion policy and social determinants of health advocates (Jabir & Choolayil, 2024). However, training for policy and advocacy work might not actually be covered by the current curriculum and pedagogy. A few efforts have emphasized the integration of issues related to health equity into social work education, but much remains to be done. These gaps and challenges can only be effectively addressed if the social workers are well prepared to act for health equity. It calls upon addressing the unique needs of diverse populations.

Enhancing Health Equity in Social Work Education: Innovations and Recommendations for India

There are ample opportunities for innovation and enhancement of creative solutions to remedy the gaps and challenges in delivering social work education.

The Role of the Teacher in Health Equity and Social Work Education in India

The role of a teacher in health equity and social work education in India encompasses multi-dimensional responsibilities. Notable among these would be developing an inclusive classroom composed of diverse pupils with diverse needs and acknowledging them. This may call for culturally responsive instructional strategies and materials that recognize students from diverse backgrounds. It should, therefore, be imperative for teachers to emphasize health equity and social justice in social work practice by teaching students the social determinants of health, health disparities, and the roles social workers play in addressing these issues. Teachers have to give students opportunities to develop practical skills in health equity and social work practice through activities such as case studies, role-plays, and fieldwork. Lastly, teachers must model behaviours and attitudes expected of students by referring to the practice of health equity and social justice and prompting students to do the same (Ahmad & Masih, 2023).

An ideal teacher of health equity and social work in India would need to provide an inclusive learning environment, emphasize health equity and social justice, enable skill development with practice opportunities, and model desired behaviours and attitudes. Through these, teachers can equip students with the requisite knowledge, skills, and attitudes toward promoting health equity and reducing social determinants of health. The teacher's role in preparing social work students to deal with these issues has never been more critical in view of the tremendous health disparities and social inequities that India still faces today.

Community Laboratory as a Pedagogical Bridge

In the pedagogy of social work, the integration of theoretical and hands-on knowledge holds immense importance since it prepares students to tackle the intricate issues related to health equity and social justice. This is especially important in the context of India, where both disparities in health and social inequity are very deeply embedded. This paper posits the concept of a "Community Laboratory" as a pedagogic bridge between theoretical knowledge and skill activities in health equity and social work education in India. Specifically, a Community Laboratory adopts an experiential learning, critical pedagogy, and community-based education approach. Experiential learning assumes that with direct experience and reflection in the learning process, one can develop practice (Loftus & Kinsella, 2022). Critical pedagogy by Freire brings out the aspect of power dynamics and social structures that have to be critically looked at in causing health inequities (Freire, 2013). Through community involvement and participation in the learning process, a community-based education pedagogy is assumed to draw (Strand et al., 2003).

The Community Laboratory approach, by the definition of its constructs, is the method of forming relationships between academic institutions and community organizations in the direction of producing a platform for joint learning. Students have experienced community service in activities such as community-based research, advocacy, and service delivery in practice. Such learning is facilitated under the leadership of experienced educators and community practitioners, with the critical aspect being that community members are engaged in critical reflection and social action. Students can, through the Community Laboratory approach, develop their critical thinking, cultural competence, and advocacy for social justice. By grappling with a variety of communities around solving real-world problems, students can be empowered to develop knowledge and skills relevant to the ongoing struggles for equity in health and social justice. It enhances the community capacity-building and social change approach while community involvement and participation levels are paramount. The Community Laboratory approach promises to serve as a pedagogical bridge between theoretical knowledge and practical skills in health equity and social work education in India. The innovative use of this approach, through the blending of experiential learning, critical pedagogy, and student community-based learning, is further seen to set the stage for critical thinking, cultural competence, and social justice advocacy for students learning social work. The Community Laboratory approach is an added element of valuable strategy in preparing social work students to effectively address the pack of complex issues that India seems to be tackling now.

Pedagogical Approaches and Integration of Technology in Professional Practice: A Critical Examination

Technology integration in professional practice is one thing that has completely changed the whole landscape relating to social work education. Individualization of teaching is possible with modern technologies but it also gives rise to concerns about students' well-being and the changing role of a teacher. Key organizations, such as the National Association of Social Workers, Council on Social Work Education, Association of Social Work Boards, and Clinical Social Work Association, now have standards guiding the use of technology in social work practice that can serve to facilitate meaningful integration into professional practice (Lawless & Pellegrino, 2007). In particular, social work educators are called upon to understand and become competent users of technology in order to enhance study time efficiency, better individualization, and student mobility (Harvey & Broyles, 2010). Modern technologies of gaming, case studies, design, integrative, and information technologies ensure that children acquire skills through a dynamic learning environment, encouraging creativity and fostering independence in students. However, traditional education that focuses on the content may remain incomplete if not merged with experience and process-oriented learning experiences (Vigilante et al., 2016).

Placements in underserved communities in experiential learning bring real-life experiences with systemic barriers, enhancing the appreciation of social determinants of health and preparing a student to advocate for system change. Instructing, one considers variables that affect learning: learning style, thought processes, past learning encounters, and motivational factors. These roles can be recognized to navigate through the complexities of educational responsibilities in placement within the broader context of social work education (Goldstein, 2001). There needs to be a fine balance between technology and human interaction in the teaching methods in order to engage diverse learners and bridge the gap created via theoretical knowledge into practical application, as pointed out by Smith. A student-centered learning environment in which pedagogical approaches are significant and the integration of technology is core to one's practice would, therefore, be created by turning attention to such issues by social work educators (Smith et al., 2005).

Sensitivity Training in Social Work Education: Bridging Experiential and Theoretical Learning

Sensitivity training is a significant method or factor of professional social work education that acts between experience and theoretical knowledge to bridge the gap. This kind of training enhances personal insight and enlightenment about various conditions leading to change within an individual, personally and professionally (Papell, 1972). Sensitivity training is thus an important portion of social work education, and its demand is increasing among students. The educator embraces sensitivity training thoughtfully, with eyes somewhat open to its potential for encouraging inclusivity and effective engagement with diverse populations. However, the educator is also conversant with the pitfalls that might ensue, such as programmed behaviour, keeping a fine balance between support and tyranny, avoiding over-intellectualization of areas, and monitoring the self-screening process. By being able to acknowledge and move on from these challenges, social workers can take part in sensitivity training in a professional way, which will help them gain an increased understanding of the many diverse perspectives they will come across. This training allows social workers to work through problems while creating an inclusive atmosphere. Sensitivity training is ultimately a part of the education for a social worker, so it would be of great assistance if the attitude toward its presentation and reception were constructive and professional.

Overcoming Traditional Assessment Limitations

Far and wide, the traditional methods of assessment are criticized for being limited, jeopardizing the actual measurement of the student's learning outcomes. Traditional assessments are revealed to be constrained by simply memorizing facts rather than critical thinking and creativity. There are quite a few traditional means, such as standardized tests, written exams, and individual assignments, that are limited in scope. Critical thinking, creativity, and problem-solving skills are often overlooked in favour of memorization. Additionally, traditional assessments can perpetuate biases toward students with greater access to resources and support, exacerbating existing power dynamics and inequalities (Goldstein, 2001).

Traditional measures highlight the dependence on rote memory, with intellect and creativity being reduced to insipid inventiveness. It is, therefore, necessary that other methods of assessment be developed. Some methods available to educators are student-centred, assessing the student's capacity to acquire and develop various skills and competencies. These methods comprise competency-based assessments and authentic assessments that assess their relevance to the real world. Other features include self-assessment, peer assessment, and conferences, individually or as a group. These help develop critical thinking and communicative skills and better cooperation and collaboration skills. These methods promote professional development, cultural competence, and overall growth among social work students to facilitate the realization of their potential as competent professional social workers (Hamilton & Krase, 2022). An instructor can push assessment practices past the traditional using student-centered approaches that focus on higher-order thinking skills, creativity, and collaboration through competency-based assessment, authentic assessment, self-assessment, peer assessment, and group conferencing. Embracing such innovative practices results in a comprehensive and inclusive approach to the evaluation process and students themselves, making it a student-centered form of learning that promotes essential skills for the future.

Implications for Policy and Practice

 In order to attain substantial changes in policy and practice for integrating health equity into social work education in India, there needs to be a paradigm change from solely managing individual cases to giving comprehensive views that address systemic barriers of health disparities. Social workers need to support and promote policies, programs, and practices that reflect the social determinants of health toward fair access to healthcare, with special reference to rural communities, women, and marginalized groups. This means addressing institutional barriers perpetuating health disparities through factors like poverty, lack of education, and social inequality. Also, culturally informed practice is a subject matter of great relevance which social workers in India must consider while addressing the needs of different populations. This considers the culture and beliefs among diverse communities and the ability to respond to health-specific challenges different communities face. Embedding health equity in social work education will indeed support India in taking a crucial step towards realizing an equitable and just healthcare system where every individual accesses quality care through opportunities created to attain optimal health and well-being. Social work practice shall meaningfully contribute to reducing health inequities and promoting health equity, hence upholding the fundamental human right to health.

Social work to promote health equity in India would, hence, be multidimensional and grounded in advocacy for policies related to poverty and education, increasing healthcare accessibility to rural and marginalized populations, culturally responsive practice that takes into account the needs of diverse populations, addressing system barriers that continue to promote inequities in health, and the priority placed on health equity in curricula preparing social workers to address the health needs of diverse populations. Through such a comprehensive approach, social workers in India can make a valuable contribution to minimizing health inequities and promoting health equity, thereby upholding the universal human right to health.

Future Research Directions

The New Education Policy 2020 has far-reaching and sweeping reforms in health equity and social work education in India, thereby enabling tackling health inequities and promoting health equity. This policy aligns with health equity in the following issues: focus on equity and inclusion, social determinants of health, interdisciplinary education, community engagement, research and innovation, teacher training, technology-enabled learning, and accountability. Future research should rigorously evaluate the integration of health equity into social work education and its effectiveness in healthcare outcomes in India, as well as develop evidence-based interventions for addressing health inequities. Research is also needed to identify any function of social work education in promoting health equity, the best practices within the integration of health equity, and the impact of policy initiatives on health equity. Particular areas of interest at the junction of health equity and social work practice include developing culturally sensitive interventions, the roles of social workers in addressing health inequities, and how health equity impacts social work education. Health equity can be advanced by working collaboratively across disciplines for a just and fair healthcare system that fosters well-being for all persons.

Conclusion

When one considers the intersection of the need for health equity and social work education in India, the details shine forth as a critical area that needs careful treatment. Social work education has the challenge of addressing these health inequities, for which curricular design and pedagogy must ensure that competent graduates are equipped with appropriate knowledge, skills, and attitudes to achieve health equity. Although problematic and lacking elements such as formalized standards on curriculum and pedagogy in areas like intersectionality and cultural competence, current recommendations and innovations include: community laboratory approaches, technology infusion, sensitivity training, and alternative evaluation efforts. The study, therefore, points out the necessity of a paradigmatic shift in practice, which indicates the emphasis on policy advocacy in healthcare, equal access to healthcare, and addressing systemic barriers that fuel health disparities. Future research directions include assessing the incorporation of health equity in social work education, its effect on the healthcare results, the design of interventions that would help overcome health inequity, and the role played by social work education on health equity, including best practices and policy initiatives. A more just and fair healthcare system in India will be realized by prioritizing health equity and working collectively.

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Author´s Address:
Dr. Ngaopunii Trichao Thomas
Department of Social Work, University of Delhi
ntthomas@socialwork.du.ac.in