July 29, 2016
New Delhi: Health systems have an important role in contributing to and promoting gender equality and equity. Although committed to providing services indiscriminately, our health system might be failing at the same due to inadequate provisioning and access, which are hindering them from meeting these goals.
It has been well-documented that despite efforts to improve overall health of both women and men, there are large gaps between quality of and access to services available, with women being far more disadvantaged than men. Data in the past three decades has consistently shown a relatively higher level of health disadvantage among women and girls as compared to men and boys.
Social and cultural norms, attitudes, and thus, practices that underpin gender inequalities and inequities in a society greatly determine women’s ability to access appropriate health services: whether women are able to recognize physical or mental health issues; whether they can access appropriate and timely health services (preventative and curative); whether they are provided with good quality of services; and whether they can access those services without being stigmatized or discriminated against either by her family and community members, or by the healthcare providers themselves.
Identifying and addressing gender inequalities as well as ensuring provision of gender equitable services are the cornerstone of a well-functioning health system. This implies addressing concerns in ways that are not instrumentalist, i.e.,designed to ‘meet’ set health outcomes or targets alone;they should be able to address the gaps and issues to achieve outcomes or goals of gender equality and equity.
How gender stereotyped roles and social norms adversely impact women’s access to health services
While women and men may have some common health risks, such as infectious diseases (TB, Malaria), there exist health concerns specific to women due to various biological factors, i.e., maternal and reproductive health issues, cervical cancer, etc. In addition, social stereotypes and prescribed gender roles can further compound risks and thus create greater health differentials, for instance, lung damage among women as a result of smoke from traditional methods of cooking (coal stoves, etc.)
Research on the social determinants of health have shown how class, caste and education among other determinants further interact with gender inequality to adversely impact the health outcomes for women. For instance, we know how deeply-entrenched patriarchal values and the strong son-preference continue to cause greater female mortality as compared to boys in early years of life.
While social determinants are key factors affecting healthcare, it is equally important to remember that health policies, programs and systems across the world have been shown to exacerbate gender inequity because of the manner in which they are conceptualized, implemented and delivered. Ironically, this is true even for those programs that are well-intentioned and claim to improve women’s health.
A classic example of how our health system can and does perpetuate gender inequality despite good intentions is family planning. The programme continues to place emphasis on a single method – female sterilization – notwithstanding recent attempts to promote a method mix. The programme rarely makes proactive attempts to engage with women to assess their reproductive intentions and needs, much less to engage with men. This singular focus on female sterilization has effectively blocked all such communications and messages that encourage wide ranging discussions on women’s preferences and options most suitable to her.
The convenient ways in which the program has operated for many years has often worked to the disadvantage of women and their health. Over time, numerous studies have highlighted the need for services of much higher quality that are gender sensitive and assist women in identifying the best method to suit their needs.
Yet another way in which the health system has perpetuated gender inequality is its singular focus on narrow health outcomes. Over the past few decades, women’s health in India has been discussed and addressed primarily within the framework of reproductive or maternal health. This obsessive focus on narrow outcomes further limits the ability of the health system to address the complex social, economic and cultural drivers that place women and girls at risk for other physical or health issues.
The National Sample Survey 2014 (NSS) data on health spending is revealing in this regard Low gender sensitivity of the public health services drive women into expensive (and unregulated) private maternities, which cost more money and thus perpetuate poverty.
Only half of all pregnant women in this nationally representative sample (N=19,445) had attended three ante-natal checkups (ANC), delivered in a hospital, and attended both ANC andpost-natal checkups. Clearly a large number of pregnant women are still not seeking full maternity care despite the Janani Suraksha Yojana(JSY). Further, the data revealed a very high out of pocket spending on maternity care, particularly catastrophic expenditures (expenses incurred in complicated cases). The average cost of delivery was close to Rs 9,000 and the total maternal spending estimated in this analysis was significantly higher than previous estimates.
One of the reasons for this rise in expenditure is the enormous increase in the use of private healthcare and in the number of caesarean delivery cases. Poor quality public maternal healthcare services either do not detect incidence of pregnancy complications during the ANC check-ups or do not provide services at the time of delivery pushing women into the fold of expensive private healthcare services.
The spending data showed that delivery in a private hospital increased the probability of a much higher spending as compared to delivery in a public hospital. Studies have shown that high out-of-pocket expenses for maternity care among low socio-economic groups, further exacerbates debts and poverty, despite the government promise of free services. While the JSY has made significant progress, covering almost 40 percent of the total deliveries in the country, the NSS data shows that of the total 14,482 deliveries analyzed, the cost of institutional delivery was zero only in 19 deliveries.
How do we ensure that the health system’s intention to provide gender equitable services and address gender inequality generates the desired positive impact?
A review of both global and Indian health programs suggests that there are proven, evidence-based strategies that health systems must adopt to address gender-based barriers to healthcare. A recent systematic review of 146 gender integrated health interventions from around the world, which included 34 Indian health interventions, has brought out a few important lessons.
1. The most critical requirement for the health system is to gather and constantly use gender-disaggregated data for addressing gender equity. The health system, at all levels, must be prepared to routinely produce gender-disaggregated data and use gender-sensitive indicators to inform, monitor and modify the health programs, that is, both quantitative and qualitative information right up to the levels of primary health centers, besides ensuring their ability to use the data for decision-making.
2. It is not enough to make programmes ‘gender aware’. The results of the interventions that address gender barriers to health services were positive, but not as compelling as those that sought to transform gender norms. Transformative programmes and approaches were grounded in the contextual reality, addressed the holistic health needs of the women and girls, were informed by data and evidence, and ensured greater gender sensitivity of the work-force in the manner they were recruited and trained.
3. Establishing strong community linkages is also crucial. Globally, 75 percent of the interventions that built and reinforced links between communities and local health services were far more effective and promising. This means having more link persons, i.e., ANMs, Ashas, etc; and including more community-based programs to address the social and cultural determinants (norms, attitudes). Transformative programs with strong community linkages were significantly more successful in improving outcomes related to safe motherhood, neo-natal and child health and nutrition, and healthy timing and spacing of births. The health system must reinforce the ‘communitization’ process to bring a wider section of stakeholders on board.
4. Engaging men in the program and building their stakes is of great significance. More often than not, reproductive health services, traditionally considered domain of women, have excluded men or tend to exclude them. As part of the transformative strategies, however, successful programs have made serious efforts to engage men in the domain. One of the programs, for instance, had health providers engage with couples, rather than with women and men separately, to ensure that the decision of the family planning is jointly made and owned by couples.
5. Gender budgeting, which is the most powerful tool in gender mainstreaming, needs to be monitored and evaluated for how this is implemented to maximize its impact on promoting gender equality in various sectors including health. It has been argued that there is need to see gender budgeting in consonance with the entire budgetary allocations and regularly evaluate its gender impact.
6. Finally, health programs and health systems must make ‘gender equality’ a goal to be achieved through better health outcomes rather than merely a means to achieve those better health outcomes. This is a much-needed paradigm shift to bring about sustained and long-term change. Health systems must make a proactive commitment to promote gender equality and equity rather than waiting for the social determinants of inequality to change.