Access to healthcare is constrained by three key factors – physical access to healthcare facilities, ability to pay, and quality of care. In this note, Udayan Rathore discusses how within poor households, women and children suffer disproportionately more on account of these constraints.
This is the third post of a five-part series
In light of the evidence on India’s achievements and its commitment to healthcare, the new National Health Policy (NHP), 2017 is being envisaged as a game changer. The stated objective of the NHP (2017) is “to achieve the highest possible level of good health and well-being …and to achieve universal access to good quality health care services without anyone having to face financial hardship as a consequence.” To guard against the penchant for setting lofty yet unattainable goals, it is critical that we evaluate the constraints associated with access to healthcare. This note examines the realities of rural life in Odisha and Bihar that limit healthcare access of many poor individuals, especially women.
There are three intertwined factors that complicate access to healthcare. First, distance to healthcare facility and presence of all-weather roads often shape the coping strategies of households. Second, and relatedly, constraints on the ability to pay for healthcare often force households to be selective about who in the family seeks treatment, for what illnesses, and where. Third, the quality of healthcare is highly variable, and households expressed frustration with poor services available to them, more so if they are not well off. For all these factors, gender dynamics interact with poverty creating situations where women are less likely to access good-quality healthcare – if at all they access care – relative to their male partners.
Physical access to healthcare facilities
In Kandhamal, Odisha, a mother of three daughters explained that they often have to travel long distances, to either Phulbani (district administration headquarters of Kandhamal) or D. Berhampur in Ganjam, Odisha, to seek medical attention. Poor households try to save money wherever possible, including walking rather than taking rickshaws. A mother of a young child from Nayagarh, Odisha shared, “Once my son had fever and we walked 3-4 kms. The doctor was shocked to hear that he walked in such a condition. What can we do? We are bound by poverty.”
Roads are in a bad state for parts of the year, making it difficult to reach health facilities
Photo credit: Sudha Narayanan
However, we found that in many cases, such cost-saving measures are more likely to be employed when seeking treatment for children and women than for men. For example, a woman in Nayagarh, Odisha reported that when men are sick, they usually opt for the costly option of hiring an auto rickshaw to the nearest health facility, whereas women and children are made to walk, even under dire circumstances.
Ability to pay
Given the impediments to access and cost of healthcare, households self-diagnose and rely on a mix of herbal medicines, local quacks, or exorcists for what they consider to be minor ailments. But, for serious ailments they often take loans and go to health facilities at the panchayat level and subsequently to the block and district levels. Further, the burden of these loans often falls disproportionately on women. We found that most of the men migrate away for work and are therefore not in regular contact with local moneylenders. They therefore rely on women to raise loans, especially for medical purposes. These loans are often secured by depositing valuables as collateral. Some women respondents from Kandhamal and Ganjam in Odisha reported selling gold ornaments for medical treatment of their husbands.
Though local moneylenders continue to be the dominant source of finance, particularly in Bihar, Self Help Groups (SHGs) have gained some traction in Odisha, where moneylenders are considered usurious and restrictive in terms of the use of money by borrowers and choice of crops to cultivate. In the words of a woman from Kandhamal, Odisha, “If I borrow from a local moneylender, we have to pay a heavy amount of interest, which is very difficult for us. Now, they give loans only if you grow turmeric. I instead borrow from SHG, where I pay interest when I get money.” Thus, the presence of SHGs gives more latitude to women to decide what to cultivate, and when and to whom to sell the produce. Directly, it also brings down the borrowing costs and aids seeking of healthcare. However, given seasonal vulnerability across the community and bunching of epidemiological risks, SHGs are only able to have a limited impact on facilitating access to healthcare. Hence, there is a need to look beyond SHGs and other community credit mechanisms to facilitate greater access to healthcare.
Men seem to have priority in accessing healthcare. Some women claim that men undertake more physical labour and hence, such a choice is only natural. Not only are patriarchal norms at work, but also this difference could be stemming from the fact that men (at least in Araria, Bihar) engage in paid work whereas females are usually involved in unpaid work.
When women are ill, they conceal health-related problems and usually wait for a few days before even voicing their discomfort. They also resort to measures like exclusively seeking local remedies and refrain from buying medicines, especially when they are expensive and/or unavailable at public health centres. A mother of two from Kandhamal, Odisha reported, “Now I am weaker than before because I have not been taking medicines since the last three months. How much expense would my husband bear for me − so I do not tell him at all.” A woman from Ganjam, Odisha, whose husband is an alcoholic expressed, “I suffered from fever for 15 days. We had no money to go to a doctor. I suffered silently as I am a woman.” Similarly, a woman from Nayagarh, Odisha who went hungry the previous night reasoned, “We give priority to the male members of the household to be taken to hospital because if they stay free from disease, they can look after us. When female members are ill, they mostly stay at home and take home remedies or procure medicines locally.” Thus, women’s’ health seems to be the first casualty under financial duress, and each of these quotes point to inequitable access to healthcare based on gender, where women are less likely to access healthcare services.
Quality of healthcare
Poor quality of healthcare can be another potential source of impediment to access. In Araria, Bihar, for example, we found that public facilities often turned patients away, citing unavailability of medicines or/and staff. Private clinics in the region often demand huge cash payment upfront without divulging details on the nature of ailment. Moreover, despite the provisions of the Clinical Establishments (Registration and Regulation) Act, 2010, law enforcement regarding medical practices remains inadequate. Private clinics in the region were often reported to be extractive and would milk patients for relatively minor ailments. This was particularly evident in Araria where ailments required multiple visits, and medical tests, and in some cases multiple surgeries were undertaken for ‘curing’ commonplace illnesses. Sometimes, public health centres were complicit with such private clinics in ethical breaches by not extending basic medicines and life-saving drugs like anti-venom, despite availability. A female community worker in Araria who is an active member of a workers’ union explained, “My husband was bitten by a poisonous snake and wanted to be taken to a quack for treatment but I protested. I was adamant that we should quickly go to the district hospital. At the hospital, staff reported that they did not have anti-venom. In rage, I threatened the doctor with a court case and somehow, anti-venom was magically arranged. This is a regular practice at public health centres here to push patients to private clinics.” These experiences illustrate the ability of some women to make demands on the State to secure access to healthcare. In contrast, a woman whose sibling passed away lamented, “My brother suffered for two years before succumbing to tuberculosis. I took him to Purnia for treatment. The doctor charged me Rs. 5,000 multiple times just for the tests, and this did not include any medicines. Then, he demanded Rs. 15,000 and said that he would cure him if I brought the money.
Addressing the barriers
A roadmap for alleviating adverse health outcomes in India has been a long time coming and NHP, 2017, despite having stopped short of making healthcare a fundamental right is a step in the right direction. The NHP has the opportunity to address the barriers to access faced by many poor, remote households, particularly by women and children within these households. Though the planned outlay of 2.5% of the Gross Domestic Product (GDP) on healthcare has invited a lot of attention and is necessary, without adequate understanding of issues surrounding access, and policy measures that explicitly support women’s empowerment, these lofty goals of ensuring universal access to quality healthcare at affordable rates would remain unattainable.
This note is based on qualitative fieldwork undertaken in May-July 2016 in Araria in Bihar, and Ganjam, Rayagada, Kandhmal, and Nayagarh in Odisha, as part of a project titled Women’s Empowerment in Nutrition Index (WENI), funded by a Competitive Research Grant to develop ‘Innovative Methods and Metrics for Agriculture and Nutrition Actions’ (IMMANA Grants). IMMANA is funded by UK aid from the UK government. Twenty five trained researchers from within the community recorded oral testimonies of 255 respondents on voice recorders, covering a range of issues around women’s empowerment, agriculture and nutrition.
The project is a collaborative initiative between Collaborative Research and Dissemination (CORD), Indira Gandhi Institute of Development Research (IGIDR), University of Texas at Austin, and the National Institute of Nutrition (Hyderabad). We are grateful to JJSS, Agragamee, Sambhav, PRADAN and Anwesha for partnering with us, and to the many community researchers in implementing this research. Thanks are also due to Sudha Narayanan, Anuradha De, Marzia Fontana, Bharati Kulkarni, and Erin Lentz for discussions and comments.
Views expressed in the note do not necessarily reflect the views of the institutions to which the author belongs.