The Systemic Exploitation of Women in India's Healthcare System
India ranks 112th out of 153 countries in the Global Gender Gap Index as per the Global Gender Gap Report 2020 that was published by the World Economic Forum. In 2006, in the first report, India was placed 98th and in 2019, her rank was 108. The fall in rank is attributed to widening gender disparity on the parameters of health and survival (ranked 150), and economic participation (ranked 149). The health and survival parameter takes into account sex ratio at birth and healthy life expectancy. This article explores the scope of women’s access to healthcare in India.
Accessibility has five key elements, namely, geographic or physical accessibility, economic accessibility, administrative accessibility, cognitive accessibility, and psychosocial accessibility.
A study conducted by researchers at the All India Institute of Medical Sciences, Prime Minister’s Economic Advisory Council, Indian Statistical Institute and Harvard University reveals an inverse relationship between geographical distance and gender bias in access to healthcare. The cost incurred on travel has a negative impact on access. This can be attributed to the social reality in which household becomes the primary site of discrimination. Only over a half of Indian women (51.6 percent) have autonomy in decisions on healthcare as per the IIPS data. 73 percent of Indian women are not engaged in activities that yield direct economic benefit. In the trade-off between the breadwinner and the caregiver, women’s health gets neglected. Restrictions on mobility imposed by deep-rooted and institutionalized patriarchy further deny access.
The female literacy rate in India as per Census 2011 is 65.5 percent.
Low levels of literacy translate into institutionalisation of incapacity. The adult literacy rate for females in rural areas is 50.6 percent. Illiteracy limits access to health-related information. Rural women face obstacles in availing of emergency health services such as calling an ambulance. Lack of awareness on mental, sexual and menstrual health remains an alarming concern. Women are even more vulnerable during pandemics such as COVID-19. It is estimated that at least 1,400 to 2000 maternal deaths will occur during lockdown owing to lack of access to family planning services, contraceptives and reproductive health services. In a country where marital rape is still not an offence, women continue to have little say on their sexual health.
Accredited Social Health Activists (ASHAs) are the prime health educators and promoters in rural India. There is a direct correlation between the quality of service delivered by the ASHAs and accessibility. In a TISS fieldwork, of which the author was a part of, that was conducted at Ramchodavaram, it was found that the ASHAs are underpaid and overworked. For instance, in Rampa village, they were paid Rs 300 for catering to pregnant women, Rs 75 for taking them to the hospital, Rs 5 per collection of blood samples.
They held regular dharna-s before the Integrated Tribal Development Agency’s (ITDA) office for permanent work and minimum salaries. We found in the fieldwork that they earn Rs 400 per month on an average but had not been receiving salaries for three months in a year. Most ASHAs had other jobs like tailoring and tea stalls. Women pointed out that they were reluctant to avail of the services of an ASHA since they often demanded additional pay. The lack of respect and pay for the ASHAs translate into poor quality of service delivered by them. There is also a shortage of healthcare staff, for example, in Rampa village, one ASHA was expected to cater to 1000 people. While ASHAs play a pivotal role in rural areas, there are no parallel means of information dissemination in urban areas, especially in urban slums.
As per the Economic Survey 2020, in terms of GDP, the government spending on healthcare is 1.6 percent, a small rise from 1.5 percent in 2019. The National Health Policy 2017 had recommended that the government spend on health should be 2.5 percent of GDP by 2025. It is worth noting that the global average expenditure on healthcare is 6 percent. USA spends 17 percent of the GDP on healthcare. In Sweden, the figure is 11 percent with a primary focus on preventive rather than curative care. Out of pocket expenditure on health is one of the prime reasons people fall into poverty in India. Ayushman Bharat Pradhan Mantri Jan Arogya Yojana aims at providing free secondary and tertiary healthcare to the bottom 40 percent of the poor and vulnerable population. Initial analysis of PMJAY reveals an anti-women bias, with male patients getting more coverage.
Social conditioning through gender roles also deters women from demanding access to healthcare. They are trained to have a high threshold of patience and endurance. They choose to be silent over their health issues while attending to the needs of the rest of the family. Their low self-esteem resulting from neglect at particularly vulnerable stages of life - childhood, adolescence and old age - come in the way of demanding access to health services.
The multiple roles women play in a household ranging from childcare to chores result in deterioration of mental and physical health. Working women who despite contributing to the household income also find themselves burdened with the so-called household ‘duties’. They fare far worse in nutritional intake. Practices, such as women having to eat the leftovers after the whole family has dined also deprive women of their nutritional intake.
Around 2/3rd of the women in India are victims of domestic violence. Domestic violence and the burden of unpaid labour make women more susceptible to mental health issues. The stigma associated with psychological disorders and lack of resources stops them from seeking care. They are often ostracized and rejected by their families. Research shows that women suffer from more internalizing disorders as compared to men.
It is found that gender disparity continues even after free access to healthcare with men accessing free facilities more than their female counterparts for sex-neutral diseases. Universal Healthcare Coverage is one of the targets of Sustainable Development Goals. India needs to focus on external barriers such as families not prioritizing the healthcare of women. Economic upliftment of women through education along with encouraging their participation in labour market will assist in gradual de-commodification of women in Indian society.
Increasing incentives to ASHA workers for visiting homes shall ensure the visits actually happen. Paying their salaries on time is equally important to ensure their availability for quality service. In Rampa village, ASHAs had played a major role in the eradication of Polio. Recruiting more ASHA workers shall enable more face time of ASHA per woman and better information dissemination. It is also important to develop primary care facilities for the 17 percent of the population living in urban slums.
Increasing government spending on healthcare and ensuring it does not remain flat is necessary. Reducing out of pocket expenditure was the aim of PMJAY. Reducing it even further by increasing the government spend on healthcare will dilute the trade-off in healthcare where households choose between the breadwinner and the caregiver.
There is a need for concrete planning for effective government spending in the healthcare sector. Research shows that a developed country is likely to have more non-communicable diseases while a developing country is likely to have more communicable diseases. 55 percent of the illnesses in India are due to non-communicable diseases. 33 percent are due to communicable diseases. Rest 12 percent are due to injury-related diseases. India in the arena of health is more than a developing country but less than a developed country. This leads to confusion on where to invest the money in due to the double burden of communicable and non-communicable diseases.
Health is an inter expertise as well as an inter-agency sector. Health education is in the Concurrent list while health welfare schemes, insurance schemes are in the State List. Conflict of interest between the Centre and the State must be minimized in essential services like healthcare.
Cooperative federalism is pivotal for the effective and integrated delivery of healthcare services. Ensuring the availability of quality health services is the first step before moving onto the next step of accessibility. Government spending is more on curative care rather than on preventive care. Health awareness centres and immunization centres are underdogs without sufficient official attention. Mental health needs to be prioritized as much as physical health.
Kofi Annan once said, “It is my aspiration that health finally will be seen not as a blessing to be wished for, but as a human right to be fought for.” Multilevel interventions to improve the social determinants of health such as education, nutrition, safe drinking water and sanitation, employment, community welfare and housing; institutional interventions to address investment gaps, shortage of healthcare staff, augmentation of healthcare infrastructure; and social interventions to address gender bias, shall enable Indian women to access their long denied human right of healthcare.
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Views expressed are solely those of the author. The post has been updated to reflect current happenings.
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