importance of system analysis in education

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Education sector analysis

An education sector analysis (ESA) is an in-depth, holistic diagnosis of an education system. It assists with understanding how an education system (and its subsectors) works, why it works that way, and how to improve it. An ESA provides the evidence base for decision-making and is the first step in preparing an education sector plan.

An ESA is a nationally driven process, involving collaboration and dialogue among different actors and institutions in a system. Empowering and consulting the different stakeholders throughout the process are essential, as ‘sustainable changes that lead to improved learning outcomes cannot be brought about in the absence of involvement of the individuals and groups who will implement the change’ (Faul and Martinez, 2019: 31).

The ESA process must therefore be participative and aim to create an understanding of the key stakeholders in the education system, their incentives, relationships and accountability, as well as how these dynamics shape education systems (IIEP-UNESCO et al., 2021).

What does an ESA cover?

An ESA includes context analysis, existing policy analysis, cost and finance analysis, education performance analysis, and system capacity analysis, including stakeholder analysis (IIEP-UNESCO and GPE, 2015). Any challenges identified through the ESA should be analysed through the lens of Sustainable Development Goal 4 (UNESCO, 2016). Quality of learning is one factor analysed in the performance of the education system along with issues related to access and coverage, equity and inclusion, and internal and external efficiency of the system. Quality of learning involves analysing the range of inputs and processes including teachers, learning and teaching materials, school facilities, and learning outcomes (IIEP-UNESCO and GPE, 2015; IIEP-UNESCO, World Bank, and UNICEF, 2014).

Teachers play a decisive role in ensuring learning quality. Teacher management features – ranging from recruitment and deployment to pre- and in-service training, career pathways, motivation and job satisfaction, absenteeism and effective teaching time – also need to be analysed. Typical indicators include (IIEP-UNESCO, World Bank, and UNICEF, 2014):

• Pupil/teacher ratio by level for primary education
• Pupil/trained teacher ratio
• Teacher utilization rate
• The consistency in teacher allocation (R2 coefficient)
• Theoretical teaching time in relation to theoretical instruction time for secondary teachers
• The percentage of pre- and in-service teachers trained by level
• The number of teachers disaggregated by status (civil servants, contract, or community teachers)
• Qualifications and teaching experience

Learning and teaching materials

An ESA should analyse the equitable allocation of learning and teaching materials and other inputs among different schools and regions. An ESA should include indicators such as the proportion of teachers with teacher guides, pupil/textbook ratios, and the notion of useful pupil/textbook ratio (IIEP-UNESCO, World Bank, and UNICEF, 2014). Qualitative information gathered through teacher interviews, for example, can also be integrated into the analysis to complement quantitative data. For instance, in crisis-affected areas, quantitative data may be weak regarding the actual distribution and use of textbooks throughout the country (IIEP UNESCO and GPE, 2016).

School facilities

School facilities (school buildings and infrastructure such as electricity or school landscaping) can have a significant impact on students’ learning achievements. Proper water, sanitation and hygiene (WASH) facilities in schools can improve access to education and learning outcomes, particularly for girls (UNICEF and WHO, 2018). Relevant indicators include classroom utilization rate and, when applicable, type of classroom (such as temporary, open air, permanent, or home-based classrooms); the percentage of schools with functioning WASH facilities; the percentage of schools with electricity; the percentage of schools with boundary walls for security reasons; and the percentage of classrooms that need to be rehabilitated (IIEP-UNESCO, World Bank, and UNICEF, 2014).

Learning outcomes

Student assessments include national examinations and admission tests, national large-scale learning assessments, regional or international standardized assessments, citizen-led assessments, and household surveys. The analysis of learning assessments enables education planners and decision makers to understand whether the education system is transferring knowledge to students as expected, as well as whether this transfer is equitable or is leaving certain population groups or geographic areas behind. Learning assessments can further help countries track the progress of learning achievements over time, compare results with comparable countries, and identify plausible causes for weak learning outcomes (IIEP UNESCO, World Bank, and UNICEF, 2014).

However, there are several risks when using learning data, such as the accuracy of data and their interpretation; the use of a single test score for decision-making; the use of learning assessment data to legitimize predefined agendas; and narrowing educational measurements to simplified indicators (Raudonyte, 2019).

Changes in learning assessment results over time should be interpreted with caution and cross-checked with other evidence. For instance, a sharp increase in enrolments may affect learning outcomes (IIEP-UNESCO, World Bank, and UNICEF, 2014).

ESA data sources

An effective ESA relies on both qualitative and quantitative rigorous data. Relevant data sources include (IIEP-UNESCO and GPE, 2015; IIEP-UNESCO et al., 2021; IIEP-UNESCO, World Bank, and UNICEF, 2014):

• National, regional and international learning assessments: provide information on whether the education system is transferring knowledge as expected; track progress on learning achievements over time; allow comparisons with comparable countries; and identify plausible reasons behind weak learning outcomes.
• School data on students, textbooks, teachers, and subsidies: provide information on resource distribution and learning time, among others.
• Administrative manuals: provide information on teacher management, teaching time, and other resources.
• Teacher training institute data: provide information on whether the capacities of teacher training institutes meet current and projected needs.
• Human resources data: provide information about teacher recruitment, deployment and utilization, among others.
• Sample surveys: can be used to assess teaching and learning time.
• Household surveys: provide information on the relationship between the level of literacy and the number of years of schooling.
• Specific research exercises: provide valuable information on relevant issues faced by education systems.
• Interviews and questionnaires of stakeholders: provide relevant qualitative information, for instance related to institutional capacity.

An ESA should further assess information gaps and whether primary data collection will need to be undertaken to obtain missing information (IIEP-UNESCO and GPE, 2015).  

Plans and policies

• Liberia: Education Sector Analysis
• Somalia:  Education Sector Analysis
• IIEP-UNESCO; Global Partnership for Education. 2015. Guidelines for Education Sector Plan Preparation
• IIEP-UNESCO; Global Partnership for Education; UNICEF; Foreign, Commonwealth and Development Office. 2021. Education Sector Analysis Methodological Guidelines: Vol. 3: Thematic Analyses
• IIEP-UNESCO; World Bank; UNICEF. 2014. Education Sector Analysis Methodological Guidelines: Vol 1: Sector-wide Analysis, With Emphasis on Primary and Secondary Education
• IIEP-UNESCO; World Bank; UNICEF. 2014. Education Sector Analysis Methodological Guidelines: Vol. 2: Sub-sector Specific Analysis
• UNESCO-UIS. 2009. Education Indicators: Technical Guidelines

Faul, M.; Martinez, R. 2019. Education System Diagnostics. What is an 'Education System Diagnostic', Why Might it be Useful, and What Currently Exists?

IIEP-UNESCO; GPE (Global Partnership for Education). 2015. Guidelines for Education Sector Plan Preparation. Paris: IIEP-UNESCO.

––––. 2016. Guidelines for Transitional Education Plan Preparation. Washington, DC: GPE.

IIEP-UNESCO; GPE (Global Partnership for Education); UNICEF; FCDO (Foreign, Commonwealth and Development Office). 2021. Education Sector Analysis Methodological Guidelines: Vol. 3: Thematic Analyses .  Dakar: IIEP-UNESCO.

IIEP-UNESCO; World Bank; UNICEF. 2014.  Education Sector Analysis Methodological Guidelines: Vol 1: Sector-wide Analysis, with Emphasis on Primary and Secondary Education.  Dakar: IIEP-UNESCO.

Raudonyte, I. 2019. Use of Learning Assessment Data in Education Policy-making. Paris: IIEP UNESCO.

UNESCO. 2016. Mainstreaming SDG4-Education 2030 in Sector-wide Policy and Planning: Technical Guidelines for UNESCO Field Offices. Paris: UNESCO.

UNICEF; WHO (World Health Organization). 2018. Drinking Water, Sanitation and Hygiene in Schools: Global Baseline Report 2018. New York, NY: UNICEF and WHO.

Related information

• Supporting education sector analyses [IIEP-UNESCO Dakar]

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Constructing Scientific Explanations: a System of Analysis for Students’ Explanations

• Published: 14 August 2017
• Volume 49 , pages 787–807, ( 2019 )

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• Vanessa de Andrade 1 ,
• Sofia Freire 1 &
• Mónica Baptista 1  

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This article describes a system of analysis aimed at characterizing students’ scientific explanations. Science education literature and reform documents have been highlighting the importance of scientific explanations for students’ conceptual understanding and for their understanding of the nature of scientific knowledge. Nevertheless, and despite general agreement regarding the potential of having students construct their own explanations, a consensual notion of scientific explanation has still not been reached. As a result, within science education literature, there are several frameworks defining scientific explanations, with different foci as well as different notions of what accounts as a good explanation. Considering this, and based on a more ample project, we developed a system of analysis to characterize students’ explanations. It was conceptualized and developed based on theories and models of scientific explanations, science education literature, and from examples of students’ explanations collected by an open-ended questionnaire. With this paper, it is our goal to present the system of analysis, illustrating it with specific examples of students’ collected explanations. In addition, we expect to point out its adequacy and utility for analyzing and characterizing students’ scientific explanations as well as for tracing their progression.

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Acknowledgements

This study is supported by the Portuguese National Foundation for Science and Technology (SFRH/BD/119701/2016). The authors are grateful to the teachers and students who participated in this study.

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de Andrade, V., Freire, S. & Baptista, M. Constructing Scientific Explanations: a System of Analysis for Students’ Explanations. Res Sci Educ 49 , 787–807 (2019). https://doi.org/10.1007/s11165-017-9648-9

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Published : 14 August 2017

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DOI : https://doi.org/10.1007/s11165-017-9648-9

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What is Situational Analysis in Education: What You Should Know

Table of Contents

Situational analysis in education is a critical process that plays a vital role in shaping learning strategies and aiding educational advancements. It involves conducting needs analysis and situation analysis, which are essential in designing a successful curriculum plan.

Needs analysis is the initial step in situational analysis, where information is gathered about students’ abilities, needs, and purposes for learning. It helps categorize these needs into necessities, lacks, and wants, providing valuable insights for instructional design.

Situation analysis, on the other hand, goes beyond students’ needs and focuses on identifying key factors that may influence the implementation of the curriculum plan. These factors can be social, economic, political, educational, or institutional in nature. Examining classroom factors such as class size, teacher availability, time, and learner motivation is equally important in this process.

By conducting a thorough situational analysis, educators can ensure that the course is suitable, practical, and realistic. It enables them to tailor learning experiences based on the unique characteristics and challenges present in the educational context.

Key Takeaways:

• Situational analysis in education involves needs analysis and situation analysis.
• Needs analysis focuses on gathering information about students’ abilities, needs, and purposes for learning.
• Situation analysis identifies key factors that may impact the implementation of the curriculum plan.
• Factors considered in situation analysis include social, economic, political, educational, and institutional aspects.
• Classroom factors such as class size, teacher availability, time, and learner motivation are also taken into account.

For more information on situational analysis in education and other educational strategies, visit Exquisitive Education .

The Importance of Situational Analysis in Education

Situational analysis is crucial in education as it provides valuable insights into the current educational environment and helps identify areas for improvement. By conducting a thorough analysis, educators can gain a comprehensive understanding of the factors that affect the implementation of the curriculum plan. This includes social, economic, political, educational, and institutional factors, as well as classroom-specific variables such as class size, teacher availability, time constraints, and learner motivation. Taking all these factors into account is essential to ensure that the course design is suitable, practical, and realistic.

One of the major benefits of situational analysis in education is its ability to inform the decision-making process. By gathering and analyzing relevant data, educators can make informed choices about curriculum design, resource allocation, teaching strategies, and assessment methods. This helps to create a learning environment that meets the needs of students and promotes their overall success.

Moreover, situational analysis in education is not only limited to the planning phase but also extends to the ongoing evaluation of educational programs. By regularly assessing the current state of education, educators can identify any gaps or areas that require improvement and implement necessary changes. This continuous analysis ensures that the educational system remains adaptive and responsive to the evolving needs of students.

Uses of Situational Analysis in Education

Situational analysis in education has versatile uses that extend beyond the planning and evaluation of educational programs. It can also aid in the identification of best practices, the development of targeted interventions, and the understanding of student outcomes. By analyzing the existing educational landscape, educators can identify successful models and strategies that can be replicated to improve learning outcomes. Additionally, situational analysis helps identify challenges and barriers that students may face, allowing for the development of targeted interventions to address these issues effectively.

In conclusion, situational analysis plays a vital role in education by providing valuable insights into the current educational environment and helping educators identify areas for improvement. By conducting a thorough analysis, educators can make informed decisions, create practical learning experiences, and ensure that education remains relevant and adaptive to the needs of students.

Steps of Situational Analysis in Education

Conducting a situational analysis in education involves specific steps and techniques to ensure accurate data collection and analysis. This process allows educators to gain a comprehensive understanding of the current educational landscape and make informed decisions for course design.

The first step is to identify the objectives of the analysis and establish the scope of the study. This includes defining the target audience, such as students, teachers, or administrators, and determining the specific aspects of education to be examined.

Next, data collection methods are selected and implemented. These can include surveys, interviews, observations, and document analysis. By gathering data from multiple sources, educators can obtain a holistic view of the educational environment and identify any gaps or areas for improvement.

Once the data has been collected, it must be analyzed and interpreted. This involves organizing the information, identifying patterns and trends, and drawing meaningful insights. Data visualization techniques, such as tables and charts, can be used to present the findings in a clear and concise manner.

In conclusion, conducting a situational analysis in education is a crucial step in course design. By following the steps outlined above, educators can gather relevant data, analyze it effectively, and make informed decisions to create practical and realistic learning experiences. To learn more about situational analysis in education, visit Exquisitive Education .

Factors Involved in Situational Analysis

Situational analysis in education involves addressing challenges and utilizing appropriate tools to effectively understand the educational landscape. It is essential to examine various factors that can impact the implementation of the curriculum plan. These factors can be classified as social, economic, political, educational, or institutional in nature. By thoroughly analyzing these elements, educators can ensure that the course design is tailored to meet the specific needs and requirements of the learners.

One of the main challenges in situational analysis is identifying and overcoming obstacles that may hinder the success of the educational program. These challenges could include limited resources, lack of funding, or time constraints. By acknowledging and addressing these challenges, educators can develop strategies to mitigate their impact and create a more conducive learning environment.

Furthermore, situational analysis in education involves the use of various tools to gather and analyze relevant information. These tools can include surveys, interviews, observations, and data analysis techniques. By employing such tools, educators can gain valuable insights into the current state of education and make informed decisions about the course design.

In conclusion, situational analysis plays a crucial role in education by considering the challenges involved and utilizing the appropriate tools to understand the educational landscape. By conducting a thorough analysis, educators can ensure that the course design is practical, suitable, and realistic. It empowers them to address challenges, overcome obstacles, and create effective learning experiences for students.

Examples of Situational Analysis in Education

To illustrate the effectiveness of situational analysis in education, here are some examples showcasing how it has been implemented in various educational settings.

Example 1: In a primary school located in a low-income community, a situational analysis was conducted to identify the specific needs and challenges faced by the students. Through surveys and interviews with the students, teachers, and parents, it was revealed that many students lacked access to basic learning resources and struggled with language barriers. Based on these findings, the school implemented targeted interventions such as providing additional reading materials and offering language support programs. As a result, the academic performance of the students improved, and their overall engagement in learning increased.

Example 2: A university planning to launch a new online course conducted a situational analysis to understand the existing online learning landscape. The analysis involved reviewing competitor programs, analyzing market trends, and collecting feedback from potential students. The findings revealed a demand for flexible, self-paced learning options and a need for more comprehensive course materials. With this information, the university was able to design a course that aligned with the needs and preferences of the target audience, leading to high enrollment rates and positive student feedback.

Example 3: Contextual Keyword Term

Situational analysis plays a crucial role in ensuring that educational institutions and courses are tailored to the specific needs and contexts of learners. By understanding the challenges, opportunities, and unique circumstances of each educational setting, educators can design effective learning experiences that meet the expectations of students and deliver measurable outcomes.

For more information on situational analysis in education and its practical applications, visit Exquisitive Education .

Understanding Different Analysis Methods

Situational analysis employs a range of analysis methods such as needs assessment, SWOT analysis, and benchmarking to gather comprehensive data. These methods are crucial in understanding the current state of education and identifying areas for improvement.

Needs assessment: This method involves gathering information about students’ abilities, needs, and purposes for learning. By categorizing needs into necessities, lacks, and wants, educators can tailor their teaching strategies to meet students’ individual requirements.

SWOT analysis: This analysis examines the strengths, weaknesses, opportunities, and threats within the educational landscape. By identifying these factors, educators can make informed decisions about curriculum development, resource allocation, and strategic planning.

Benchmarking: This method involves comparing educational performance against predetermined standards or other institutions. By benchmarking against high-performing schools or districts, educators can gain valuable insights and set realistic goals for improvement.

Examples of Situational Analysis Methods

Other analysis methods used in situational analysis include context analysis, environmental scan, readiness assessment, gap analysis, problem analysis, root cause analysis, current state assessment, landscape review, background research, analytics, and diagnostics. These methods provide different perspectives and data points that contribute to a holistic understanding of the educational context.

By utilizing these analysis methods, educators can gain deep insights into the educational context, enabling them to develop targeted strategies and interventions. Understanding the current state of education is essential for creating meaningful and impactful learning experiences for students.

The Role of Situational Analysis in Course Design

Situational analysis plays a pivotal role in course design, ensuring that educational programs are tailored to meet the needs and preferences of the learners. By conducting a thorough situational analysis, educators can gather valuable information about their students, the learning environment, and the broader context in which the course will be delivered. This analysis allows for a comprehensive understanding of the factors that may influence the successful implementation of the curriculum plan.

Gathering Data through Needs Analysis

One key aspect of situational analysis is needs analysis, which involves gathering information about students’ abilities, needs, and purposes for learning. By categorizing needs into necessities, lacks, and wants, educators can prioritize the content and activities that are most relevant and meaningful for the learners. This data-driven approach ensures that the course design aligns with the specific requirements and goals of the target audience.

Identifying Key Factors through Situation Analysis

In addition to needs analysis, situation analysis helps identify key factors that may positively or negatively impact the implementation of the curriculum plan. This analysis takes into account various dimensions such as social, economic, political, educational, and institutional factors. Classroom-specific factors like class size, teacher availability, time constraints, and learner motivation are also considered. By understanding these factors, educators can make informed decisions about instructional strategies, resources, and assessment methods to create a course that is suitable, practical, and realistic.

Overall, situational analysis is an essential step in course design, allowing educators to create effective and engaging learning experiences. By taking into consideration the unique characteristics of the learners, the learning environment, and the broader context, educators can design courses that are not only academically rigorous but also relevant and applicable to the real world.

Assessing the Current State in Education

Assessing the current state in education involves evaluating the existing educational landscape and identifying areas for improvement and innovation. It is a crucial step in situational analysis, as it provides valuable insights into the strengths and weaknesses of the educational system. By closely examining the current state, educators can better understand the challenges they face and develop strategies to address them.

One aspect of assessing the current state in education is analyzing the educational advancements that have taken place. This involves examining the use of technology in classrooms, the implementation of new teaching methodologies, and the incorporation of innovative learning tools. By staying abreast of these advancements, educators can adapt their teaching approaches to provide students with a more engaging and impactful learning experience.

In addition to analyzing educational advancements, assessing the current state also involves examining the education landscape as a whole. This includes studying social, economic, political, and institutional factors that may influence the effectiveness of the curriculum plan. By considering these external factors, educators can make informed decisions and implement changes that align with the needs and realities of the educational environment.

Table 1: Factors Influencing the Current State in Education

By conducting a comprehensive situational analysis that includes an assessment of the current state in education, educators can make informed decisions and design courses that are relevant, practical, and tailored to the needs of students. This analysis not only facilitates effective course design but also enables educators to stay ahead of the curve and embrace innovation in education, creating an environment that fosters optimal learning outcomes.

In conclusion, situational analysis plays a crucial role in education, enabling educators to make informed decisions and create impactful learning experiences. Through needs analysis, educators gather essential information about students’ abilities, needs, and purposes for learning. This helps categorize students’ needs into necessities, lacks, and wants, allowing educators to tailor the curriculum accordingly.

Situation analysis, on the other hand, identifies key factors that may positively or negatively affect the implementation of the curriculum plan. This includes social, economic, political, educational, and institutional factors. Equally important are classroom factors such as class size, teacher availability, time, and learner motivation. By considering all these factors, educators can ensure that the course is suitable, practical, and realistic.

By conducting a thorough situational analysis, educators are equipped with the necessary insights to design and deliver courses that meet the specific needs of their students. It helps them understand the context in which education takes place, and adapt their teaching methods accordingly. With the knowledge gained from situational analysis, educators can create a stimulating and effective learning environment, fostering optimal student engagement and achievement.

Q: What is situational analysis in education?

A: Situational analysis in education involves conducting needs analysis and situation analysis to gather information about students’ abilities, needs, and purposes for learning, as well as identifying key factors that may affect the implementation of the curriculum plan.

Q: Why is situational analysis important in education?

A: Situational analysis is important in education because it ensures that the course design is suitable, practical, and realistic. It helps educators understand students’ needs and tailor the curriculum to meet those needs. It also takes into account various factors that can impact the successful implementation of the curriculum.

Q: What are the steps involved in conducting situational analysis in education?

A: The steps involved in conducting situational analysis in education include gathering information about students’ abilities, needs, and purposes for learning (needs analysis), as well as identifying social, economic, political, educational, and institutional factors that may affect curriculum implementation (situation analysis).

Q: What factors are considered in situational analysis?

A: Situational analysis takes into account various factors, including social, economic, political, educational, and institutional factors. It also considers classroom factors such as class size, teacher availability, time, and learner motivation.

Q: Can you provide examples of situational analysis in education?

A: Examples of situational analysis in education could include conducting a needs analysis survey to determine students’ prior knowledge and skills, analyzing the economic factors that may affect the availability of resources for teaching, or assessing the institutional support and infrastructure for implementing a new curriculum.

Q: What are some analysis methods used in situational analysis?

A: Analysis methods used in situational analysis include needs assessment, context analysis, environmental scan, readiness assessment, gap analysis, SWOT analysis, problem analysis, root cause analysis, current state assessment, benchmarking, landscape review, background research, analytics, and diagnostics.

Q: How does situational analysis contribute to course design?

A: Situational analysis plays a crucial role in course design by providing essential information about students’ needs and the contextual factors that may influence the implementation of the curriculum. It ensures that the course is practical, relevant, and effective in meeting the desired learning outcomes.

Q: How is the current state in education assessed?

A: Assessing the current state in education involves analyzing the educational landscape, including advancements, challenges, and trends. It requires conducting research, gathering data, and evaluating the existing educational systems and practices.

About The Author

Ethan Emerson

Ethan Emerson is a passionate author and dedicated advocate for the transformative power of education. With a background in teaching and a love for writing, Ethan brings a unique blend of expertise and creativity to his contributions on ExquisitiveEducation.com .His articles are a delightful mix of insightful knowledge and engaging storytelling, aiming to inspire and empower learners of all ages. Ethan's mission is to ignite the spark of curiosity and foster a love for learning in every reader.Ethan Emerson, is your companion in the realm of general education exploration. With a passion for knowledge, He delves into the intricate world of Education Expenses & Discounts , uncovering financial insights for your educational journey. From the vitality of Physical Education to the synergy of Education & Technology , Ethan's here to bridge the gap between traditional and innovative learning methods. Discover the art of crafting impressive Resume & Personal Documentation in Education , as well as insights into diverse Career Paths, Degrees & Educational Requirements . Join Ethan in navigating through a sea of Educational Courses & Classes , exploring the nuances of various Education Systems , and understanding the empowering realm of Special Education . With an eye on Teaching & Teachers , He offers a glimpse into the world of educators who shape minds. Let's unlock Studying Tips & Learning Methods that turn education into a delightful journey of growth with Exquisitive Education .

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The Importance of School Systems: Evidence from International Differences in Student Achievement

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Guidelines for data classification.

The purpose of this guideline is to establish a framework for classifying institutional data based on its level of sensitivity, value, and criticality to the university as required by the university's Information Security Policy. Classification of data will aid in determining baseline security controls for the protection of data.

This policy applies to all faculty, staff, students, and third-party agents of the university and any other university affiliate authorized to access institutional data. In particular, this guideline applies to those who are responsible for classifying and protecting institutional data, as defined by Information Security Roles and Responsibilities .

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The definitions below are for use within the Guidelines for Data Classification. An affiliate is anyone associated with the university, including students, staff, faculty, emeritus faculty, and any sponsored guests. Most individuals affiliated with the university have an Andrew userID.

Confidential data is a generalized term typically representing data classified as restricted according to the data classification scheme defined in this guideline. This term is often used interchangeably with sensitive data.

A data steward is a senior-level employee of the university who oversees the lifecycle of one or more sets of institutional data. See the   Information Security Roles and Responsibilities   for more information.

Institutional data is defined as all data owned or licensed by the university. 

Non-public information is defined as any information that is classified as private or restricted information according to the data classification scheme defined in this guideline.

Sensitive data is a generalized term typically representing data classified as restricted according to the data classification scheme defined in this guideline. This term is often used interchangeably with confidential data.

Data Classification

Data classification, in the context of information security, is the classification of data based on its level of sensitivity and the impact to the university should that data be disclosed, altered, or destroyed without authorization. Data classification helps determine what baseline security controls are appropriate for safeguarding that data. All institutional data should be classified into one of four sensitivity levels or classifications:

Classification of data should be performed by an appropriate data steward. Data stewards are senior-level university employees who govern the lifecycle of one or more sets of institutional data. See Information Security Roles and Responsibilities for more information on the data steward role and associated responsibilities.

Visit the Data Classification Workflow for a process on how to classify data.

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Data stewards may wish to assign a single classification to a collection of data that is common in purpose or function. When classifying a data collection, the most restrictive classification of any of the individual data elements should be used. For example, if a data collection consists of a student's name, CMU email address, and social security number, the data collection should be classified as restricted even though the student's name and CMU email address may be considered public information.

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Periodically, it is important to reevaluate the classification of institutional data to ensure the assigned classification is still appropriate based on changes to legal and contractual obligations as well as changes in the use of the data or its value to the university. This evaluation should be conducted by the appropriate data steward. Conducting an evaluation on an annual basis is encouraged; however, the data steward should determine what frequency is most appropriate based on available resources. If a data steward determines that the classification of a certain data set has changed, an analysis of security controls should be performed to determine whether existing controls are consistent with the new classification. If gaps are found in existing security controls, they should be corrected in a timely manner, commensurate with the level of risk presented by the gaps.

Calculating Classification

The goal of information security, as stated in the university's Information Security Policy, is to protect the confidentiality, integrity, and availability of institutional data. Data classification reflects the level of impact to the university if confidentiality, integrity, or availability is compromised.

Unfortunately, there is no perfect quantitative system for calculating the classification of a particular data element. In some situations, the appropriate classification may be more obvious, such as when federal laws require the university to protect certain types of data (e.g., personally identifiable information). If the appropriate classification is not inherently obvious, consider each security objective using the following table as a guide. It is an excerpt from  Federal Information Processing Standards (FIPS) publication 199 , published by the National Institute of Standards and Technology, which discusses the categorization of information and information systems.

As the total potential impact on the university increases from low to high, data classification should become more restrictive, moving from public to restricted . If an appropriate classification is still unclear after considering these points, contact the Information Security Office for assistance.

Appendix A: Predefined Types of Restricted Information

The Information Security Office and the Office of General Counsel have defined several types of Restricted data based on state and federal regulatory requirements. This list does not encompass all types of restricted data. Predefined types of restricted information are defined as follows:

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Revision History

• Open access
• Published: 26 August 2024

Health care needs and barriers to care among the transgender population: a study from western Rajasthan

• Tanvi Kaur Ahuja 1 ,
• Akhil Dhanesh Goel 1 , 2 ,
• Manoj Kumar Gupta 1 , 2 ,
• Nitin Joshi 1 ,
• Annu Choudhary 1 ,
• Swati Suman 1 ,
• Kajal Taluja 1 ,
• Madhukar Mittal 3 ,
• Navdeep Kaur Ghuman 4 ,
• Navratan Suthar 5 &
• Pankaj Bhardwaj 1 , 2  

BMC Health Services Research volume  24 , Article number:  989 ( 2024 ) Cite this article

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Transgender people comprise an estimated 0.3–0.5% (25 million) of the global population. The public health agenda focuses on understanding and improving the health and well-being of gender minorities. Transgender (TG) persons often have complex healthcare needs and suffer significant health disparities in multiple arenas. The international literature suggests that this community is at a higher risk of depression, and other mental health problems, including HIV. Many transgender people experience gender dysphoria and seek specific medical needs such as sex reassignment surgeries, implants, hormonal therapies, etc., but are unable to access these services due to financial or social reasons. The objective of this study was to assess the healthcare needs and associated barriers experienced by transgender people in Western Rajasthan. Methodology: A qualitative study was carried out in which multilevel stakeholder interviews were conducted using interview and focus group discussion guides. Data was analyzed using the qualitative thematic analysis technique. Results: Findings reveal that transgender people have expressed their need to access health services for general health needs, including but not limited to mental health, non-communicable diseases, and infectious diseases. Barriers to healthcare services were identified on 3 levels: health system, social and personal. Health system barriers include policy, accessibility, affordability, and acceptability issues. Social factors such as inadequate housing, education, and job opportunities also play an important role in affecting the individual’s health-seeking behavior. The knowledge of healthcare providers in this context was also limited in context of health insurance schemes, package of services available for transgenders and the importance of gender sensitive healthcare. Conclusion: Transgender people expressed the need for mental health services, programs targeting nutritional improvement, gender-affirmation procedures besides regular screening of non-communicable diseases as operational for males and females. Levels of barriers have been identified at various levels ranging from absence of targeted policies to individual behavior.

Peer Review reports

Introduction

Universal Health Coverage (UHC) means that all people have access to quality healthcare services (service coverage) without any financial hardships (catastrophic health expenditure) [ 1 ]. To achieve UHC, National Health Policy 2017 projects to increase the government’s health expenditure to 2.5% of GDP by 2025 [ 2 ]. In alignment with this objective, the budgeted health sector spending has increased from 1.3% (2019-20) to 2.1% of GDP (2021–2022). According to National Health Accounts 2018-19, Out of Pocket Expenditure per capita (in Rupees) is 2155 [ 3 ].

Incidence of catastrophic health spending is felt at a higher rate by vulnerable communities due to gender, socio-economic position, disability status, or sexual orientation, besides other characteristics. The Transgender (TG) community is one such community whose gender expression (masculine, feminine, other) differs from their assigned sex (male, female) at birth. They can be identified as trans-man or trans-woman [ 4 ]. In the Indian context, transgender individuals identify themselves differently including Hijras, Aravanis, Kothis, Jogtas/Jogappas, and Shiv-Shakthis. For the first time, this population was included in India’s 2011 census. Reports suggest that 4.8 million Indians identified themselves in the ‘other’ category.

Recent legal and policy changes in India have significantly affected gender-diverse communities. The Transgender Persons (Protection of Rights) Bill formulated in 2014 went through changes over a period of 5 years and was finally declared an Act in 2019. The Act highlighted the need to prohibit discrimination including denial of service or unfair treatment in relation to healthcare [ 5 ]. With respect to UHC, there are evident disparities in service coverage across the transgender population [ 6 ]. Transgender persons face a disproportionate burden of certain diseases, including HIV, viral hepatitis, and other sexually transmitted infections. They also pose a higher risk for mental health issues or substance abuse. Literature also suggests that transgenders may seek gender-affirming health services apart from general healthcare services. This might involve counseling support for themselves and their family related to gender id entity or undergoing gender transitioning procedures and surgeries. Transition-related treatment may include cross-sex hormonal therapy, hair removal, and gender-affirming surgeries.

In India, there are significant disparities in the availability and accessibility of healthcare. Existing research has identified various challenges and barriers encountered by transgenders in accessing and navigating the healthcare system. These include a lack of provider expertise in transgender care, the gap in health systems delivery mechanisms, lack of culturally sensitive healthcare training, inadequate financial coverage or low socio-economic condition, and poor community health-seeking behavior [ 7 ]. Rajasthan is one of the high focus states under the National Health Mission [ 8 ]. Since Western Rajasthan is a desert area, healthcare becomes even more challenging [ 9 ]. It further causes adverse impact on the desire and ability of transgender people to access healthcare. Poor healthcare access and health outcomes among the transgender population can also be attributed to lower levels of health literacy [ 10 ]. Rajasthan is one of the states with the lowest literacy rates among the transgender population [ 11 ].

In order to improve the health of transgenders and address the barriers to healthcare, it is crucial to identify the health priorities. A growing body of research regarding the healthcare experiences of transgenders exists worldwide, but there is still a paucity of research in the Indian context. This study has been conducted with the aim of reviewing the health issues and challenges faced by them in the existing healthcare system in Western Rajasthan. Although behavioral and social factors play a pivotal role in transgender health, this research focused on health needs and healthcare system-related barriers and challenges.

Research questions:

What are the basic health needs of the transgender community?

What are the barriers they encounter in the process of obtaining healthcare services?

How are the experiences of transgender persons in healthcare facilities?

What is the level of knowledge among healthcare providers regarding health of transgender persons?

How can healthcare services be enhanced for the transgender population?

Methodology

The study was conducted in the state of Rajasthan during the year 2022.

Research Design: This study utilizes a descriptive qualitative research design to allow in-depth insight into the existing health-related needs of transgender persons, their experiences in healthcare facilities and the barriers they encounter in meeting their needs. The study was approved by the Institutional Review Board of All India Institute of Medical Sciences, Jodhpur in July 2022.

Setting: The study was conducted in a community-based organization.

Sampling and sample size: Purposive sampling was utilized for this research. Transgender people above or equal to 18 years of age residing in different geographical region of western Rajasthan were approached with the help of established Civil Service Organizations (CSO). People who responded back were included in the study.

Data collection: All recruitment and data collection procedures were completed by public health scholars trained in research under the supervision of a community medicine professor. Multi-stakeholder interviews were conducted. It includes identification of relevant stakeholders to understand facilitators and barriers of the topic of interest. The identified stakeholders included specialist healthcare providers, representatives of civil service organizations and transgender persons (target population). All the individuals who agreed to participate in the study were approached by the interviewer. They were explained the purpose of the study and an appropriate time was decided to ensure active participation. This was also done keeping in view the sensitivity of the subject matter. All the interviews and the focus group discussion were conducted face-to-face in English and translated to Hindi for participants who did not understand English. Key informant interviews ( n  = 7) of specialist healthcare providers central to providing transgender care were conducted. The specialists included of a psychiatrist, plastic surgeon, endocrinologist, gynecologist, and community medicine experts. All interviews with specialist healthcare providers had a duration of 20–30 min. Transgenders residing in different geographical region of western Rajasthan were invited for a focus group discussion (FGD). Informed consent was taken from all the study participants who agreed to participate in the study. Audio and video recordings were done for focus group discussion as well as key informant interviews. The focus group discussion lasted for 2 h. Apart from this, CSO representatives were also interviewed ( n  = 3) i.e., a nurse, social worker and the administrative head of the organization. Data was collected over a period of 2 months.

Before the focus group, socio-demographic data was recorded, including age, gender, education, and income. An FGD guide and interview schedules were prepared and used for focus group and key informant interviews, respectively. They were designed to cover information about:

Knowledge and experience on transgender issues.

Challenges in providing transgender care.

Methods for improvement of the healthcare system.

Analytic approach: Audio-recorded focus group data and key informant interviews were transcribed and translated into English by four researchers. The data obtained through key informant interviews were also transcribed. The data was analyzed manually using thematic analysis. The available data was actively and repeatedly read to familiarize and valuably orient towards the available raw data. Subsequently, codes were identified using an inductive approach i.e., they were reflective of the issues that were apparent in the data and were not dependent or guided by any existing theoretical frameworks. In the next step, themes were constructed by analyzing, combining, and comparing codes. The developed themes were such that they reflected the significance of the entire dataset. Lastly, the themes were reviewed, defined, and named, along with the identification of narratives that justify and explain all the mentioned themes. In the final stage of analysis, the identified themes from the coded data were used to construct a framework using grounded theory approach such that it accurately represents a concise picture of the data.

Ethical considerations: Confidentiality emerged as an ethical concern in this study. All transgender individuals were provided with detailed information about the purpose, procedures, potential risks, and benefits of research. Participants were ensured that their participation was voluntary, and they had the right to withdraw at any time without consequence. All data and identifying information collected during the discussion was restricted to the research team and anonymized to prevent identification of individual participants.

A total of 12 transgenders participated in the FGD. Their socio-demographic characteristics are summarized in Table  1 . All Participants in the study belonged to Rajasthan, India. Eleven out of the total 12 participants self-identified themselves as transgender woman. The mean age of transgender individuals who participated in the study was 23.8 ± 3.6. The selected cohort represented a range of educational qualifications from secondary school to post-graduation. The majority of the participants were employed, but none was employed in the government sector. More than half of the participating individuals had an income of less than INR 10,000 (66.7%) (Table  1 ).

Health needs of the transgender community

The need for regular screening of non-communicable diseases at peripheral healthcare centers was expressed by the transgender participants. Lack of accessible and/or affordable health services and social barriers contribute to anxiety and depression among them, which further leads to their inability to control the use of tobacco and alcohol. This indicates the need for mental health support tailored specifically for this population.

Healthcare provider 1 (HCP-1) “ Gender dysphoria is diagnosed in later stages of life, late adolescence, or early adulthood because individuals are not able to seek help due to a lack of knowledge on available medical options and familial pressure.”

Specifically, they expressed the need for public healthcare facilities to provide gender transitioning procedures ranging from hormone replacement therapies to sex reassignment surgeries.

Figure  1 illustrates coding tree for health needs of transgender participants.

Coding tree for health needs of transgender participants

Barriers enumerated by transgenders in accessing healthcare services were segregated into personal, healthcare system and social barriers (Table  2 ).

Personal barriers

Transgender participants revealed a lack of awareness regarding the provision of transgender identity cards being issued by the Ministry of Social Justice and Empowerment. Moreover, the growing need was identified to educate them regarding their entitlements which may have implications on health. These include but are not limited to recognition of their gender identity, provision of medical facilities for their surgical and hormonal needs, and facilitation of access in hospitals and other healthcare facilities. (Transgender Act 2019)

During a key informant interview, one of the medical practitioners highlighted the need to introduce and explain the range of medical options available to transgenders for their transition.

HCP-2 “ Internationally, I have worked in fertility clinics. Before undergoing hormonal therapies or surgeries, transgender patients usually preserve oocytes and sperms to bear children in the future. The basket of available options must be known to the community. This also improves their quality of life.”

The health outcomes of an individual are dependent on their timely health-seeking behaviors. An interview revealed that many transgenders prefer the traditional removal method of male genitals rather than conventional gender affirming surgery. This reflects multiple dimensions such as lack of awareness regarding appropriate health practitioners and discrimination by the qualified professionals. Other underlying reasons for this include the lack of public hospitals providing these services and the unaffordable costs of surgeries. A study participant has also revealed being comfortable getting the surgery done by the ‘guru’ . Moreover, the distance between their households and healthcare facility makes it inaccessible for them.

Health system barriers

Both transgender persons and healthcare providers reported a lack of knowledge of any insurance schemes specifically for transgenders or insurance coverage for the minority population under the available schemes. Their awareness regarding the inclusion of gender-specific needs such as sexual reassignment surgeries or hormonal therapies in the existing insurance schemes was limited.

The study participants also addressed the need for the inclusion of a third gender column in the patient information / outpatient cards across all the hospitals. This is in alignment with the Transgender Persons (Protection of Rights) Bill, 2019, which prohibits discrimination against them in healthcare [ 5 ]. It would also lead to a transgender-inclusive environment in the hospital and greater acceptance by other people.

TG participant 7 “ Whenever we go to the hospital, we are asked whether to write male or female. There is no option of transgender in the OPD cards.”

In India, nationally recognized identity cards are being provided by the Ministry of Social Justice and Empowerment as a step towards mainstreaming their identity. One participant revealed that recently when she visited a hospital, the authorities denied accepting the TG identity card. This incident reflects the need of generating awareness across all sectors, including healthcare, to prevent the exclusion of transgender people in society.

TG participant 8 I had fever for a few days, I went to a hospital for treatment. I gave my transgender ID card issued by the ministry. They said this is not valid.

Accessibility

Majority of the participants revealed having negative experiences in healthcare settings. They reported that they had to wait very long to access health services.

One participant complained about the long counselling procedure and time to access hormone replacement therapy. Furthermore, many qualified practitioners discourage and demotivate the use of hormones. This reluctance among medical practitioners to prescribe hormones often compels transgenders to refer to the unfiltered content on the internet, resulting in the self-administration of hormones. Since transgenders are unaware of the side effects of unregulated dosages of hormones, it can result in adverse health outcomes.

Sometimes, the health facilities with available resources are situated far away from the residence of transgenders leading to difficulty in access. In one of the key informant interviews, a medical practitioner shared her experience with a transgender patient whose vaginal canal got stenosed as a complication of post Sex Reassignment Surgery (SRS). Since the health facility was around 500 km from her hometown, she could not reach the hospital on time.

Availability

One of the most significant barriers to healthcare reported by transgenders was a dearth of healthcare providers trained to address their specific health problems. Healthcare providers also emphasized the need for training to understand the best practices for their care. Some parts of clinical training should also include the importance and impact of physician-patient communication. The use of correct pronouns should be taught to collect sufficient and accurate information on their gender identity and thus, making the hospital settings friendly for them. Additionally, awareness sessions should also be conducted for medical professionals to make them comfortable and culturally competent while dealing with this section of society.

Some participants also shared that there is a need for designated facilities in healthcare, such as separate queues in OPDs and dedicated wards or beds in hospitals. It was felt that these facilities’ absence contributed to their fear and delay in access and utilization of desired appropriate care. Due to contributory social factors, such as real or perceived stigma, it is challenging for them to accommodate within the general ward. Medical providers had contrasting views in lieu of the unavailability of designated facilities. While most believed that providing separate queues and beds for them in hospitals was essential, one of the doctors felt this would promote social exclusion.

TG participant 1 Where should we stand in hospitals? Queues made for males or females? Separate beds shall be assigned for us so that we can access the services without hesitancy or fear of discrimination . HCP-3 Providing them separate facilities for all services cannot be the ultimate solution. Will this promote equity or rather advance social exclusion? We should think about it.

Moreover, there is a lack of specialist care in hospitals that are accessible to them. There is no provision to address transgender-specific health problems at the primary healthcare level. Lack of robust referral mechanisms leading to delayed or denied care was also reported.

Affordability

Transgenders are not registered and do not have access to benefits under the insurance schemes functioning in the country. All hospitals in the country do not provide gender transition services. Those services provided by the private sector often have charges beyond their paying capacity. As a result, accessing and affording healthcare becomes a challenge for them. This is one reason that urges them to go to unqualified traditional medical practitioners for gender transitioning surgeries or ‘Dai Nirwan.’

Breast augmentation is another common procedure utilized by transgenders. One participant discussed the availability of various implant materials and how their costs vary depending on the quality. Additionally, due to financial reasons and lack of awareness, low-quality implant materials are utilized in surgeries, which increases their risk for breast cancer.

Social barriers

The non-medical factors play a crucial role in impacting health outcomes. Addressing social determinants is central to reducing existing health inequities. In this study, all the participants reported stigma and discrimination while sharing their experiences in healthcare settings. They further added that this discouraged them from utilizing available health services.

The participants reported that even the healthcare providers were uncomfortable with their presence and did not treat them like other patients.

Poor housing conditions and lack of job opportunities further push them into this vicious cycle of stigma and sickness. Transgenders have also reported experiencing psychological distress due to a lack of social support. Positive attitude and gender-supportive relationships in society can promote their well-being. The need for their inclusion in society through awareness generation by government initiatives was emphasized.

TG participant 3 We can promote family planning through condom advertisements, so why not involve transgender figures in government health awareness advertisements and campaigns .

Healthcare provider expertise in TG health

All the healthcare providers felt the need for training to improve physician-patient communication and transgender persons care. A culturally competent healthcare perspective is fundamental for treating the transgender population. Those providers who had experience with such patients were more likely to provide perspectives on their care and barriers than those who had never encountered such cases. They highlighted that very few transgender patients are registered in the hospitals of Rajasthan. This can be attributed to the stigma associated with their presence rather than assuming they do not wish to seek healthcare services.

This study sought to investigate and fill the gap in the domain of transgender healthcare. The purpose of the research was to characterize the health needs and barriers faced by transgender individuals in navigating through the health system. Previous international and Indian studies have reported a lack of transgender-sensitive care. The findings of this research corroborate this premise. There is a wide and serious gap between the population’s needs and the healthcare system’s ability to respond to these needs.

The socio-demographic profile of the participants in this study revealed that the income of the majority of the participants was below INR 10,000. This finding is in alignment with the results (70%) of a study conducted among transgenders in Vadodara, Gujarat, India [ 12 ].

The FGD gave an opportunity to the study participants to express their general and gender-specific health needs. The health needs of the participants in this study included available medical services common to the general population and certain specific transgender needs, particularly psychiatric support, hormonal therapies, and sex-reassignment surgeries. This is in accordance with the previous studies, which also identified general health problems that need to be addressed, including the high prevalence of diabetes and hypertension, substance abuse, anxiety, and depression [ 13 ].

Transgender individuals discussed a range of experiences and barriers encountered in the healthcare system in accessing the available services. The barriers were categorized at the healthcare system, social and individual levels. The system-level barriers ranged from policy issues to hospital or organizational problems. It included a lack of coverage for the transgender population in government health insurance schemes. The introduction of a comprehensive package master in the Ayushman Bharat scheme has now addressed the lack of coverage for transgenders in the existing insurance schemes. It includes the existing packages as well as specific packages for transgenders [ 14 ]. This paves the way for a new chapter in their care. The unavailability of trained healthcare providers is another major problem. In 2019, National Medical Commission (NMC) updated the medical education curriculum and added a new module on Attitude, Ethics, and Communication (AETCOM) competencies [ 15 ]. It could be used as an opportunity to introduce culturally sensitive communication training for medical professionals, especially focusing on LGBTQ + community, to advance our aim to achieve equity. In addition to the unavailability of trained doctors, the inaccessibility of healthcare facilities and unaffordability also negatively impact the people’s health. All these underlying factors contribute to their practice of getting surgeries done by traditional and untrained medical practitioners. These findings are consistent with another study conducted in India to assess the health-seeking behavior of transgender people. They also reported long waiting times in hospitals affecting their health behaviors and are confirmed to have undergone medical procedures performed by gurus or technicians [ 16 ].

The finding of concern that emerged in our study sample was the use of unprescribed hormone therapy. This finding is similar to a study conducted in Maharashtra to assess the practices related to hormonal therapy [ 17 ]. It states that participants reported going for unsupervised hormone replacement therapy due to unaffordability, lack of trained healthcare providers and prior experiences in healthcare settings [ 17 ]. In order to avail the hormonal therapy, transgender patients require to undergo psychological counseling’s for confirmation of gender dysphoria. In our study, transgender individuals felt that the psychotherapy sessions are too long, leading to a delay in the initiation of hormone replacement therapy. World Professional Association for Transgender Health (WPATH) mentioned in their Standards of Care (SOC) that any minimum number of sessions cannot be fixed and is an individualistic approach. It depends whether someone wishes to avail psychological support before, during, or throughout the transition process [ 18 ]. Gender transitioning may involve but not be limited to procedures such as hormonal therapy and sex reassignment surgeries. Moreover, there are only a few public health facilities providing gender-transition services and there is no government support in the form of subsidies to avail these services from a private hospital. The government, is however, working on extending and empaneling public and private hospitals in order to make these services accessible to the population.

This need assessment study also attempted to address the social determinants barring healthcare access. Stigma, discrimination, support from family and friends, and difficulty in seeking housing determine health and healthcare accessibility. These factors have also been highlighted by the study conducted in Vadodara, India [ 12 ]. It re-emphasizes the findings from our study that social determinants such as lack of economic and educational opportunities, rejection, and isolation from society have an impact beyond gender identity issues, rather, they pose a risk to the psychological status of the transgender population.

The health disparities and barriers to care faced by transgenders should be addressed to promote health equity and justice. Comprehensive approaches to improve access, utilization, and quality of healthcare services are currently lacking. These challenges can also be addressed at the following levels:

Individual Level.

Healthcare system Level.

Community Level.

Garima Greh facilities have been introduced as shelter homes for transgender individuals where basic amenities are being provided to them [ 19 ]. They can be utilized as launchpad sites to improve their awareness of their rights and available entitlements and medical interventions. IEC materials can be displayed at Garima Greh facilities for health promotion and modification of their health-seeking behaviors. Similar to ASHA workers who are community members working for their healthcare, volunteers can be appointed from their community. Training of these volunteers can be done (Training of Trainers) so that they can improve their health-seeking behavior, increase awareness, and aid in the overall empowerment of the community.

All hospitals and clinical settings shall provide a safe and welcoming environment for gender-diverse people [ 20 ]. The fact that their physical, mental, and cultural differences affect their behaviors must be known but, more importantly, understand these differences and assigning them value is the key. Actions can be taken to promote transgender identity across healthcare settings by displaying Information, Education and Communication (IEC) material regarding their health needs and promoting their acceptance in society – ‘This hospital is LGBTQIA + friendly.’ Transgenders can also be part of the healthcare system, whereby; they can act as resource persons and promote the inclusivity of gender-diverse individuals. Medical students shall be trained to communicate sensitively to the needs of transgenders, and doctors shall be trained in a culturally competent way to treat their gender-specific needs. To promote access and utilization of health services, specific transgender clinics are being set up across the country. All participants in the study felt this would help them to access available services without hesitancy. Separate general health camps for regular and dental check-ups can also aid in health promotion and equity. Another potential solution to promote transgender health is through digital solutions. Tele-consultation can be an effective way to address their needs as well as to protect them from social stigma and discrimination that hinder their access and utilization of available services.

According to World Health Organization (WHO), social determinants account for 30–55% of health outcomes [ 21 ]. The most effective way to address SDH is by action at the community level. General campaigns and community awareness sessions are essential to promote acceptance by the general population. Moreover, the study suggests that there is a need for awareness and sensitization of transgenders regarding the basket of medical options available for them such as techniques for fertility preservation.

In summary, the study demonstrates the health issues of transgenders and reflects upon the various factors influencing health and access to care. It urges the stakeholders to contemplate the need to safeguard the rights of transgenders by providing equitable access to the available resources.

This study is an attempt to explore health needs from beneficiary as well as service provider perspectives. Our findings are consistent with the previous literature. Findings from this study provide evidence base for future research and a helpful tool for the policymakers and advocates to better address the needs of transgender people.

The study’s major limitation was that only one focus group discussion was undertaken due to limited time and difficulty in accessing the desired population. However, one FGD allowed for exploration of issues related to transgender experiences and healthcare needs. It allowed the researchers to gather detailed narratives that might not emerge from individual interviews. Given the paucity of literature in the Western Indian context, a single focus group discussion can be valuable for informing advocacy efforts and policy reforms. Participants in the study were recruited through purposive sampling and did not differentiate between cultural identities of transgender persons; therefore, the results might vary geographically and according to the social context, thus, limiting the external validity. The health needs might vary between transgender male and female populations, but there was only one transgender male participant in our study. Additionally, the service providers’ knowledge was not directly assessed by explicitly questioning the standards of care.

Proposed framework

Based on study findings, a Gender Responsive Healthcare System Framework is designed. (Fig.  2 ) This framework illustrates and emphasizes on the need for planning, interventions, and actions at 3 levels – policy (a), health system (b), social, and individual (c) in alignment with the identified themes represented in Table  1 . The framework describes how the barriers can be addressed at these 3 levels to have a robust and gender-responsive healthcare delivery system in India.

The concept of healthcare is multi-dimensional. Combined action is required at the administrative, service provider and beneficiary level for a gender responsive healthcare system. Inclusion of the transgender population in existing health insurance schemes is central to reducing their out-of-pocket expenditure and helping them gain recognition in the society through the treatments that they wish to access. Outpatient cards in hospitals should include options of male, female and transgenders/others (gender diverse) creating a safe and welcoming environment. Existing health programs shall also target transgender population for reducing the burden of infectious diseases such as tuberculosis and non-communicable diseases. At the healthcare system level, medical professionals competent to provide transgender specific care and availability of specialists shall be ensured. A robust referral mechanism from primary healthcare centers to higher levels could ensure uninterrupted care for the transgender population. Moreover, hospitals have distinct queues, for men and women. There is a need to understand that gender is not a visibly readable or unchanging phenomenon, rather it is a social construct. Proper queue management can address not only the issues of stigma, but also make healthcare accessible to them. At an individual level, good health seeking behavior and familial support can aid in improving health outcomes. Altogether, these efforts at the policy, health system and individual level can lead to improvement in accessibility, availability, affordability and acceptability of services by the transgender people.

Gender Responsive Healthcare System Framework

This study has explored experiences of transgender people navigating through the healthcare system. These accounts have highlighted their health needs and the barriers they face in accessing care. They expressed the need for mental health services, programs targeting nutritional improvement, gender-affirmation procedures besides regular screening of non-communicable diseases as operational for males and females. Levels of barriers have been identified ranging from absence of targeted policies to individual behavior. Targeted efforts and intersectoral collaboration are required for effective establishment and delivery of healthcare services.

Data availability

The data generated and reviewed are fully available in this article and its supplementary files. For any further data, Dr. Tanvi Kaur Ahuja ([email protected] could be contacted).

All relevant data analyzed during this study are included in this published article and its Supplementary Information files.

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Acknowledgements

The authors would like to acknowledge the contribution of Sambhali trust, Jodhpur and Nai Bhor Sanstha, Jaipur for helping us to get in touch with the transgender participants.

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Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, Jodhpur, India

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Contributions

T.A., A.G. Conceptualized the research study done, A.G., M.G., N.J., P.B. framed the Methodology was framed, T.A., N.K., M.M., N.S., N.G., A.C. contributed in collection of data; T.A., A.G. prepared the Original draft; T.A., A.G., S.S., K.T. Reviewed and edited the manuscript; P.B. M.G., N.J. Supervised the research study, All authors have read and agreed to the published version of the manuscript.

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Correspondence to Tanvi Kaur Ahuja or Akhil Dhanesh Goel .

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The study was approved by the Institutional Review Board in July 2022. The certificate reference number granted by the Institutional Ethics Committee is AIIMS/IEC/2022/4023. Informed consent was taken from all participants who agreed to participate in the study. Participants were informed that they could withdraw consent to participate at any time during the interview. All methods were performed in accordance with the relevant guidelines and regulations.

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Ahuja, T.K., Goel, A.D., Gupta, M.K. et al. Health care needs and barriers to care among the transgender population: a study from western Rajasthan. BMC Health Serv Res 24 , 989 (2024). https://doi.org/10.1186/s12913-024-11010-2

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Received : 29 May 2023

Accepted : 18 April 2024

Published : 26 August 2024

DOI : https://doi.org/10.1186/s12913-024-11010-2

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