Caste and religion based discrimination in healthcare delivery: A standardized patient study with random assignment in Bihar, India

India has seen general improvements in public health, but substantial disparities persist in health outcomes based on caste and religious affiliations. While there is substantial evidence that inequitable access to healthcare contributes to these disparities, the same cannot be said for discrimination in healthcare delivery. This study used the novel unannounced male standardized patients (SPs) method with random assignment of patient identity to measure the discrimination faced by patients at 596 private health care providers in Bihar, India. Unannounced SPs seeking care for asthma are used and their religious and caste presentation was randomly varied to measure their causal effect on technical and interpersonal quality of care. SPs presenting as Muslims with visible religious indicators reported technical quality of care scores that were 0.21 standard deviations lower than upper-caste Hindu SPs and interpersonal quality of care scores that were 0.19 standard deviations lower than Hindu SPs. SPs presenting as Muslims without any visible religious indicators (only a Muslim name) or as Dalit (individuals of a lower-caste or without a caste) did not report significantly lower technical and interpersonal quality of care scores than upper-caste Hindu SPs. These results are driven primarily by informal providers where patients typically seek care. Lastly, the results indicate that although minority (all non-upper-caste Hindu) providers provided better care to all SP types compared to Hindu providers, the difference in healthcare quality experienced by minority (Muslim and Dalit) SPs was larger at minority providers. These findings suggest that differences in health outcomes among underserved male minorities such as Muslims and Dalits are driven, at least in part, by discrimination at the point of care – sometimes by providers of the same religious or caste identity.