Women and health in India

This International Women’s Day, I4I Editorial Advisor Nalini Gulati presents a curation of economic research on women’s health in India, encompassing aspects of maternal and child health, gendered access to healthcare, intimate-partner violence, and mental health concerns – and considers the role of resources, gender attitudes, and information in addressing inequalities.

The longstanding problem of gender inequality in India pervades most economic and social outcomes, including health. Traditionally, the intersection of gender and health in the country has been dominated by maternal and child health (MCH). However, improvements in this area, combined with trends such as the increasing burden of non-communicable diseases (NCDs), make it imperative to take a broader view of ‘women’s health’ in policy and research.

This post brings together a curation of economic research on women’s health in India – tracing studies that examine policy efforts to make motherhood safer, recognise gendered differences in healthcare access more broadly, analyse intimate partner violence (IPV), highlight mental health concerns, and explore the efficacy of potential solutions around resources, gender attitudes, and information access.

Maternal and child health: Policy and research

In the 1990s and through the 2000s, the discourse on women’s health in India centred on MCH. This was motivated by the country’s exceptionally high Maternal Mortality Ratio (MMR)¹, which stood at 556 in 1990 against a global average of 385 (Ministry of Women and Child Development (MWCD), 2022). Timebound targets were laid down under the National Health Policy, 2017 as well as the Millennium Development Goals (2000-2015).²

A key response by the government was the flagship safe motherhood programme, Janani Suraksha Yojana (JSY). Launched in 2004, JSY provides poor women a financial incentive to deliver births at health centres and seek antenatal and postnatal care. Accredited Social Health Activists (ASHAs) are also given cash incentives for connecting these women to MCH services.

Overall, India experienced an increase in the utilisation of MCH services between 2004-2006 and 2014-2016 (Paul 2018) and a reduction in MMR at an annual rate of 5% over this period (Jose 2018) – reaching a figure of 97 in 2018-2020 (MWCD, 2022). Paul (2018) also noted that while there was a decline in inequality in the utilisation of MCH services by household wealth status, rich-poor gaps did persist. In the same vein, Mishra and Syamala (2021) documented the existence of inter-state and rural-urban disparities behind the headline numbers.

Over the years, researchers studied different aspects of JSY. For instance, Dansereau, Kumar and Murray (2013) found that distance to health facility was a significant barrier to institutional deliveries – with household ownership of vehicles and better road connectivity acting as mitigating factors. Joshi and Sivaram (2014) observed that while the targeting of JSY was effective for some vulnerable women (rural, with no formal education) it failed to reach the poorest women – likely because there were problems in the identification and monitoring of beneficiaries, and the mobility patterns of pregnant women were not fully accounted for. Chatterjee and Poddar (2023) highlighted a change in fertility preferences among JSY beneficiaries – without bias towards son preference – consistent with the idea that the cash transfer may have enhanced women’s bargaining power and empowerment.

Given the link between high fertility rates and poor MCH, a segment of the literature has focused on family planning. Assessing the impact of Mission Parivar Vikas³, Agarwal, Chatterjee and Dey (2023) found that government interventions led to a decline in the number of births, changed fertility preferences among women and men, and increased adoption of contraceptives and sterilisation. Exploring the role of social norms and family constraints, a survey in Uttar Pradesh (Anukriti, Herrera-Almanza and Karra 2020) revealed that a young, married woman co-residing with her mother-in-law (MIL) had fewer close peers outside the home, which in turn reduced her access to and utilisation of reproductive health services. This is explained by misalignment between women and their MIL vis-à-vis fertility preferences (that is, ideal number of children and sons). Similarly, fieldwork in Bihar by Dutta, Ghosh and Hussain (2021) showed that the MIL serves as a mediator in the interaction between ASHAs and reproductive-age women.

In a follow-up study in Uttar Pradesh, (Anukriti et al. 2023) observed that if women were offered subsidised family planning services at a local clinic, they were more likely to initiate related discussions with the MIL, and there was a greater chance of the MIL approving of family planning. Further, if women were accompanied to the clinic by a peer, their probability of availing family planning services went up (Anukriti et al. 2023).

This evidence indicates that the country has indeed made strides in tackling maternal mortality and promoting family planning, although more can be done to reduce inequalities across regions and socioeconomic groups. There also appears to be scope for creative approaches to navigate the underlying context of social and cultural norms and interpersonal relationships.

Changing healthcare needs, disparities in access

Bhan and Shukla (2023) noted that along with the decline in MMR, there has been an epidemiological transition from infectious diseases to NCDs – causing a change in the healthcare needs of women in India. NCDs such as cardiovascular diseases, cancers, diabetes, etc., accounted for 53.5% deaths among women in 2018 – a rise from 33% in 2000. Previously, Anderson and Ray (2013) attributed excess female mortality at older ages mainly to NCDs. This work opened up a broad area of research that goes beyond skewed sex ratios at birth, mistreatment of young girls, and maternal mortality as explanations for “missing women” (Sen 1990). While this paper did not delve into the mechanisms, one suggested explanation was that women seek or receive medical care less often than men.

Pursuing this line of thought, Jayaraman, Ray and Wang (2014) examined gender differences in care-seeking and treatment at a major eye hospital in South India. They found that, at the time of presentation, women have worse diagnoses than men with regard to symptomatic illnesses – indicating that males (or their parents) are more responsive to their perceptions of ill-health. However, there was no systematic evidence that women and men receive differential medical treatment at the facility. In terms of asymptomatic disease, there was no discernible gender difference, implying that either both genders go for preventive health check-ups at similar intervals, or – more likely – they do not go for such check-ups at all.

Kapoor et al. (2019) applied a gender lens to clinical appointments at a prominent tertiary care public hospital in Delhi that has a large referral base in the study region. Excluding obstetrics and gynaecology, the sex ratio (male outpatient visits for every female visit) was higher than the relevant population sex ratio. This was worse in the younger and older age groups, and with increase in distance from the hospital. The researchers interpreted the findings as reflecting gender bias rather than gender-differentiated disease infliction, as the analysis involved multiple medical specialties and adjusted for hospital department-specific effects.

In terms of policy effort to expand healthcare access at the secondary and tertiary levels, the most prominent instrument in India in recent years, has been State-provided health insurance for poor families. At the national level⁴, Rashtriya Swasthya Bima Yojana (RSBY) was initiated in 2008, providing health insurance coverage of Rs. 30,000 annually to below-poverty-line (BPL) families for inpatient care at public and (empanelled) private hospitals. In 2018, a new programme Ayushman Bharat subsumed RSBY, raising the amount to Rs. 500,000 per family per year, and extending cover to the bottom 40% of the population. Benefits are provided on a ‘family-floater’ basis⁵, and official information states that there are no ‘restrictions on gender’.

Analysing data from Rajasthan during 2015-2019, Dupas and Jain (2021) found substantial gender gaps in the utilisation of subsidised hospital care under the state’s health insurance progamme, especially among younger and older age groups – disparities that cannot be explained by the population’s gender composition or sex-specific illness prevalence estimates. Rather, these appeared to be driven by households placing more value on and being willing to allocate greater resources towards the healthcare of male members relative to female members. Female share of visits for a service decreased with increase in out-of-pocket (OOP)⁶ expenses associated with the service. Also, conditional on getting care, the distance travelled for hospital care for males was significantly greater than for females – even when controlling for varying household resources.

In sum, these studies establish the presence of gender gaps in secondary and tertiary healthcare utilisation in India. Yet, little is known about the underlying drivers that are manifesting as gender disparities in accessing healthcare at the medical facility level.

Intimate partner violence

A major public health problem that impacts women in India and globally is IPV, and the health sector has an important role to play (World Health Organization (WHO), 2021). This type of violence against women within homes exhibited an increase during the Covid-19 pandemic, with attitudes towards domestic violence influencing its incidence and reporting in times of lockdown (Ravindran and Shah 2020). A study by Seetha Menon (2023) established a causal link between IPV and hypertension among women – suggesting that “the hidden health burden of domestic violence is likely to be higher than previously thought.”

Several research studies have examined the factors influencing the probability of IPV. For example, Dhamija and Roychowdhury (2018) found a strong negative impact of women’s age at marriage on both less severe and severe forms of IPV.⁷ In a 2022 study, the two researchers also demonstrated that the violation of hypergamy (that is, the wife’s economic status being equal or higher than that of the husband’s) increases the chances of IPV. A chunk of the IPV research has investigated the links with alcohol consumption among male partners. For example, leveraging the case of the state of Bihar, where there was a complete ban on the sale and consumption of alcohol in 2016, Debnath, Paul and Sareen (2023) observed a reduced probability of married women experiencing violence at home.

Recognising men as key players in any effort to address IPV, experts have emphasised imparting gender-transformative life skills to young males. Regular exposure to such interventions at the early adolescence stage can plausibly change attitudes and consequently impact the incidence of violence against women. An example is the ‘Do Kadam Barabari Ki Ore’ (Two Steps Towards Equality) initiative in Bihar (Santhya and Zavier 2021).

Mental health

The Covid-19 pandemic also drew attention to the matter of women’s mental health. The disproportionate impact of a crisis such as the pandemic on women’s mental health may be on account of factors such as increased risk of IPV and greater care responsibilities.

Coffey et al. (2020) discussed findings from a self-reported questionnaire on mental health administered by SARI (Social Attitudes Research, India) in Bihar, Jharkhand and Maharashtra in 2018, highlighting that women who eat last in the households have worse mental health than those who do not – partly on account of the correlation between eating last and decision-making powers. A phone survey by Afridi, Dhillon and Roy (2020) in industrial areas of Delhi during the March-April 2020 lockdown, uncovered that women experienced higher levels of financial and health stress relative to men. In a large-scale phone survey across six Indian states (Bau et al. 2021), a high proportion of the female respondents reported a worsening of their feelings of depression, exhaustion, anxiety and perception of safety, over the course of the pandemic. The adverse effects on well-being were particularly strong among working mothers with young children, women who had daughters, and female household heads. Noting women’s limited access to mental health support in low-resource settings, Ahmed et al. (2021) demonstrated the positive impact of a low-cost, tele-counselling intervention in rural Bangladesh – including modules like health awareness, self-care and relevance of staying connected with loved ones.

Since the Covid-19 pandemic, there has been growing recognition in India of the need to enhance awareness and sensitivity around mental health issues, as well as to strengthen mental healthcare systems. The above evidence suggests the importance of such efforts being gender-responsive.

Possible solutions: Distilling the elements of resources, attitudes, information

One view is that the lack of control over financial resources may be restricting women’s healthcare access. For instance, in the Uttar Pradesh study discussed in this post, providing a subsidy for accessing family planning services proved helpful in altering the dynamic between young women and MIL around the subject. On the other hand, a recent study by Agrawal, Chatterjee and Chatterjee (2023) demonstrated that increase in women’s disposable income does not necessarily lead to greater healthcare spending, and may even cause a decline. This may be attributable to women’s preferences – either inherent or propelled by social, family or peer pressures – to contribute towards household welfare instead.

More generally, the relationship between women’s economic empowerment and health empowerment has not been sufficiently explored. In principle, engaging in paid work outside the home and/or control over resources can serve as an instrument of empowerment and agency. However, women’s expanded economic prospects may trigger backlash within households (Anderson 2023) – as was also noted earlier in this post regarding hypergamy and IPV. While Maxwell and Vaishnav (2021) found a positive association between women’s work status and their agency in household decision-making, there is a need to extend such work to include decisions pertaining to women’s health – reproductive and beyond.

Bhan and Shukla (2023) contended that “women’s willingness to forgo the healthcare they need has not been understood well, and may relate to both their lack of self-awareness as well as low self-value.” They advocated for NCD-related programmes to incorporate elements that seek to enhance self-care among women such that their health may be prioritised within families and health systems. The authors also noted the particular importance for women of “respectful care” in interactions with the health system.

In the context of shaping attitudes, a clutch of studies have explored the role of female leaders. In a cross-country analysis by Bhalotra et al. (2023), it is observed that implementation of gender quotas was followed by a jump in the share of women in politics and a sharp decline in MMR. The authors highlighted mechanisms such as increased skilled birth attendance and prenatal care utilisation, reduction in fertility, and a rise in female schooling. In the Rajasthan study discussed above, the authors found that long-term exposure to local female leaders did make a difference, via greater investments in MCH, and enhanced female agency in the village.

Finally, it is well-known that information plays a crucial role in healthcare utilisation. Analysing cash incentives under JSY, Debnath (2021) found that larger incentives for health workers were more effective in increasing the probability of institutional delivery, as compared to larger incentives for mothers. The strong complementarity between incentives given to mothers and health workers held true especially in the case of poorer or less-informed households.

In a follow-up to the Rajasthan study, Dupas and Jain (2023) recognised that intended beneficiaries of the public health insurance programme had low awareness regarding their entitlements – even when they had been availing of the insurance for several months. Providing phone-based information to patients was seen to cause significant increases in their awareness of the programme – especially among poorer, less educated, and female patients. Armed with information, patients were able to “advocate for themselves at public hospitals and get their due benefits.”

Hence, insights into how resource enhancement, information access, and behaviour change intersect and translate into improved outcomes, can help craft effective interventions.

Gendered approach to health policy

As pointed out by Dupas and Jain (2021), without actions that specifically target females, public spending on healthcare is effectively pro-male. In a setting with entrenched gender biases, gender-neutral policies will not suffice and could potentially aggravate existing disparities. The evidence calls for a gendered approach to public health policies and programmes in India. Deeper, nuanced understanding of the differential healthcare needs of women, and the particular barriers they face in engaging with health systems, can inform the design and implementation of tailored, innovative strategies – with the ultimate objective of achieving good health for all.

Notes:

Number of women dying during childbirth per 100,000 live births.
The MMR target in NHP, 2017 was to reach a figure of 100 by 2020. As per goal 5 of the MDGs, India was expected to reduce its 1990 MMR by three-fourths by 2015.
Launched in 2016, Mission Parivar Vikas adopts “a stratified approach for substantially increasing the access to contraceptives and family planning services in [high-fertility] districts…” (Ministry of Health and Family Welfare, 2016)
Some state governments have their own public health insurance programmes.
Insurance cover can be used by one or all members of the family.
While hospital care is meant to be free for the poor, patients do incur OOP expenses (Economic Survey, 2021) on medicines, diagnostics, travel to hospital, etc.
On the policy side, the minimum legal age for marriage for girls in India was raised from 18 to 21 in the year 2021.