Whither women’s health
RECENT trends in public and policy awareness about women’s health needs and concerns, and actual access by women to the means and services to address those concerns show complex and contradictory tendencies. This paper identifies these tendencies and argues that a critical absence of focused attention to their implications underlies the weak progress made in improving women’s health in the country.
The decade of the 1990s highlighted a number of policy shifts and changes with direct and indirect implications for women’s health. These include (i) the overarching economic reforms agenda with its emphasis on liberalizing controls in different industries, and controlling the fiscal deficit through real expenditure cuts; (ii) a contested paradigm shift in national population policy in line with the new ICPD ethos of meeting the reproductive and sexual health needs of individuals and couples; (iii) growing concern over HIV/Aids and its increasing ‘feminisation’ as it spreads from high-risk groups into the general population; and (iv) growing recognition after the 1993 Vienna Conference on Human Rights and the Fourth World Conference on Women of Beijing (1995) of violence against women as a major health and human rights problem.
These tendencies have had differing and at times quite contradictory implications for awareness about women’s health and women’s access to health services. To understand why this is so, it is necessary to have a panoramic view of awareness and access prior to the 1990s.
Were women’s health needs taken seriously prior to the 1990s? Although women became central targets of the family planning programme from the late 1960s on, it is well known that their reproductive health needs were neither acknowledged as a policy concern nor set within an overall integrated approach to their health. The field of women’s health in India was full of resounding policy and research silences, misdirected and partial approaches, and insufficient attention to critical issues such as co-morbidity1 or the reversal of the traditional gender paradox in health.2 In many ways these problems in India mirrored a global lack of attention to gender equity in health. But the acute nature of gender bias and son preference in the country made their consequences even more severe.
In a country that had the first modern public family planning programme, and in which targeted programmes for female sterilization had grown rapidly, the lack of awareness of the range and intensity of women’s reproductive health problems was all the more ironic. The prevalence of reproductive tract infections, unmet contraceptive needs, infertility, uterine prolapse and fistulae were practically unacknowledged prior to the 1990s. Women’s own stated discomfort with IUDs was ignored or dismissed as psychosomatic.
Problems of irregular bleeding and amenorrhea were left unaddressed despite growing evidence of the pre-valence of under- and mal-nutrition and iron-deficiency anemia among girls and women. The cross-linkages between anemia and vulnerability to malaria continued to be ignored by policy and programme. So also did the prevalence of violence against women and its connections to sexual health and rights. In a country where abortion had been legal since the early 1970s, it continued to be unsafe for an overwhelming majority of those who needed the service.
It is true that awareness of the problem of declining sex-ratios and gender bias within households in favour of boys’ and men’s nutrition and health care had grown. But many other problems, such as those above, were only weakly recognized. And if the field of reproductive health was weak during this period, this was even more true of areas such as occupational, environmental or mental health. Nor was much attention given to gender concerns in the handling of infectious diseases.
Undoubtedly the weak policy and funding support that bedevilled public health infrastructure and services in this period was experienced most seriously by the poor and by women especially among the poor. Official statistics on illness in the latter half of the 1980s shows very similar rates for women and men (with the caveat that women in India tend to underreport illness), but higher untreated illness rates for women. Poor household members were less likely to get their illness treated, and these differences by household economic class status (as measured by household consumption expenditure) were more acute among women than among men. That is, the access gap for poor women was greater than for poor men.
Overall, because of the continuing weaknesses of the public sector health services, and relatively low cost differentials between public and private health providers, over 70 per cent of outpatient care was provided by the private sector. However, partly because of greater cost differentials, only 40 per cent of inpatient care was handled by the private sector.3
Major changes in awareness regarding women’s health among researchers, policy-makers, and funding agencies occurred during the 1990s. Although many women’s health groups had been critiquing the narrow, sterilization-focused and target-driven approach of the family planning programme and had challenged the conditions under which new reproductive technologies were being introduced in the country, it wasn’t until the conferences of the 1990s (Vienna, Cairo, and Beijing) that major changes in policy thinking occurred. The recognition in Vienna of women’s rights as human rights and of violence against women as a violation of those rights, the paradigm shift of ICPD from top-down demographic control to population policies focused on meeting reproductive and sexual health and reproductive rights, and the reinforcement of these forward shifts at the Beijing conference had a major impact on policy thinking.
The direct impact was the repudiation of targets in the family planning programme, and the attempt to introduce an approach to service delivery based on community needs assessment. A new programme on Reproductive and Child Health (RCH 1) was introduced with major donor funding and with significant new programme elements included. Although neither the target-free approach nor RCH 1 were as effective as the intention behind them, the policy direction appeared definitely to be changing. However, the RCH programme depends for its effectiveness on the public health infrastructure of subcentres, PHCs and hospitals, as well as staffing, logistics and management inputs from the public health system. This system went through major negative changes during this period. Thus the change in the policy paradigm was undermined by opposite changes in the public health system.
During this entire period, the health sector was undergoing the direct and indirect effects of structural reforms in the overall economy. Real expenditures on public health stagnated, accompanied by infrastructural decline and rising user charges. Perhaps the most significant increases in health costs came from the rapid liberalization of the pharmaceutical industry resulting in sharp increases in drug costs. Spiralling costs have had a significant impact on access. According to the NSS surveys, the importance of ‘financial reasons’ for not treating illness has gone up sharply.4
Recent detailed micro studies of poverty in 12 villages of Rajasthan and 20 villages of Gujarat show health costs as the single most important reason for households falling into poverty in the last 25 years.5 Barring PHC use, the use of public and private hospitals, nursing homes and health facilities run by charitable institutions are all now tilted strongly towards the better-off economic groups.6 This is true for both women and men. This means that not only the private sector health services, but even public health services are more utilized by the better off.
Against this composite picture of heightened inequality in health access, the attempts by donors to promote health sector reforms through SWAPs have had little if any impact. Why SWAPs have not been able to take off in the health sector is a larger question. For our purposes, the main point is that as a policy initiative, it did not function to counteract the decline in access to public health services, reduce costs, or provide a firm basis for the paradigm changes contained in RCH 1. How and whether this changes under RCH 2 remains to be seen.
While the paradigm shift towards the ICPD approach appeared to be gaining ground during the 1990s, this seems to have become more shaky recently. The implementation of the paradigm change was opposed by traditional population controllers even in the early phase. However, the opposition came largely from sections of academics and field staff, some of whom at least have since modified their stance. But politicians in some states and more worryingly, at the Centre, have begun jumping on the population control bandwagon.
One of the fallouts of the forced sterilizations during the Sanjay Gandhi period was that no politician wanted to be associated with the family planning programme which was, as a result, left in the hands of the bureaucrats. The renewed debates set off by ICPD have made population once more a ‘touchable’ issue for the political class. Unfortunately, they are significantly under-informed about the proximate causes of continuing population growth in the country. They are unaware that high fertility desires are projected to make a very small contribution to the anticipated growth of Indian population in this century. The momentum of past population growth (due to a young age-structure) and unwanted fertility will account for over three-quarters of the increase.
Thus, focusing on incentives or disincentives on family size will have very little impact on the growth of population. If we are indeed concerned to bring down the growth rate of population, we would do better by improving the quality of family planning services, empowering women to make reproductive decisions, and lowering the effect of population momentum by raising the effective age at marriage (through keeping girls in school longer, providing them with income earning opportunities).7
Although a number of influential stakeholders including retired senior bureaucrats and donor agencies, not to mention women’s organizations, have been arguing against them, a number of state governments have introduced electoral and other disincentives.8 Currently similar sounds are being heard among key central actors as well. Other than winning imaginary brownie points in an election year, these acts will have little positive impact, and may only serve to further undermine the hard-won change in the population paradigm away from its long association with coercive methods.
Although the first HIV case in the country was detected only as late as 1986 in Chennai, a decade of silent but deadly spread of the disease now leaves us with approximately four million official cases and perhaps 10 million actual cases. After South Africa, India now has the largest number of HIV-infected persons using the official estimate. Over 85 per cent of transmission is sexual, and a growing proportion is heterosexual. Almost 90 per cent of reported cases are in the age 18-49, i.e., the most sexually active and economically productive population. Women currently account for about a quarter of the infections, but given the rate at which the infection appears to be spreading from the so-called ‘high risk’ groups to the general population, this ratio is very likely to increase in the near future. The window of opportunity for controlling the epidemic in the country may be closing rapidly.9
The most alarming aspect of the current situation is the combination of heterosexual transmission and the weakness of sexual rights for women in the country. The right to say ‘no’ to sex within marriage, and the ability to negotiate condom use with male partners are capacities that very few women have. Family planning practices in even a more socially advanced state such as Kerala see couples typically using no family planning methods after marriage until the desired two children have been had. At this point the woman undergoes sterilization. Spacing and condom use are still relatively rare.
Rising concerns about HIV/Aids have certainly generated greater willingness to tackle awareness about sexuality, adult and adolescent sexual behaviour, and complex issues of medical ethics. However, social awareness changes slowly, and this area has received little by way of political leadership. Furthermore, the spread of HIV/Aids is likely to further stretch the capacity of public health infrastructure to meet women’s health needs.
All the dilemmas faced by women’s health at this time point in the direction of approaches that reinforce women’s rights. The responsibility to ensure these rights lies with families, communities and the government at both state and central level. Ensuring effective and equitable access to affordable health services is the job of the state. An effective public health infrastructure can act as a floor for health access, and is a crucial ingredient of poverty reduction. Providing this on a priority basis will both improve health status and also support the paradigm changes of the 1990s.
But women’s health as we know is not only a matter of access to services; it also requires a change in mindsets and power equations. Without these changes, no real paradigm change is possible.
1. For more discussion of the consequences of not taking gender seriously, see Gita Sen, Asha George and Piroska Ostlin, ‘The case for gender equity in health research’, Journal of Health Management, 4:2 (2002) and Engendering International Health: the Challenge of Equity (eds) Gita Sen, Asha George and Piroska Ostlin, The MIT Press, 2002.
2. The traditional gender paradox in health is defined by the fact that in many countries, women have higher morbidity (sickness) rates than men, but men have higher mortality (death) rates. This does not appear to be true in India – women are both more ill, and die off at a higher rate than men.
3. For more detailed analysis of the National Sample Survey data, see Gita Sen, Aditi Iyer and Asha George, ‘Structural reforms and health equity: a comparison of NSS surveys, 1986-87 and 1995-96’, Economic and Political Weekly 37(14), 6-12 April 2002.
4. Sen, Iyer and George (2002); ibid.
5. Ill health and expenses were stated to be important in 85 per cent of all cases of households falling into poverty in the Gujarat villages. See Anirudh Krishna et al, ‘Falling into poverty in a high-growth state: escaping poverty and becoming poor in Gujarat villages’, Economic and Political Weekly 37(49), 6-12 December 2003.
6. An apparently growing epidemic of unnecessary C-sections and hysterectomies in the private sector compounds this dismal picture.
7. Gita Sen, ‘Population: a new paradigm for old and new concerns,’ in Challenge of Sustainable Development: the Indian Dynamics (eds) Ramprasad Sengupta and Anup K. Sinha, IIM Calcutta (2003); Leela Visaria and Pravin Visaria, An analysis of the long term projections for major states of India, 1991-2101 (revised draft).
8. Gita Sen and Aditi Iyer, ‘Incentives and disincentives: necessary, effective, just?’ Seminar 511, March 2002.
9. See Suresh Mohammed, ‘The Ugandan response to HIV/Aids: some lessons for India’, The National Medical Journal of India 16(5), 2003.