By Preeti Sudan, Vandana Gurnani and Dr. Rajani Ved
India’s drive to provide universal, affordable and equitable healthcare reflects the commitment articulated in our national health policy and sustainable development goals. Our aim is to increase equitable access to health care for women and men.
In maternal and reproductive health, we have seen significant advances, including strong declines in maternal mortality and improved gender disparities in infant and child mortality reductions.
The maternal mortality ratio in India has dropped to 122 per 100,000 live births in 2015-17 from 178 per 100,000 in 2010-11. The infant mortality rate has declined from 50 per 100,000 live births in 2011 to 33 per 100,000 in 2019.
This is a higher rate of decline than the global trends.
These achievements reflect the success of policies designed to deliver services close to home, easing access and minimizing economic and cultural barriers for women and children. And yet, we know that there are many structural barriers in women’s access to health care.
In the past two decades, investments in health services were targeted toward maternal, newborn, child health and reproductive health services. Sustained investments in government health systems and public health facilities have enabled equity in access for childbirth-related services, particularly among poorer citizens. Barriers that women face in obtaining care have been reduced and preventive services, such as immunization, have been improved.
Such investments include expansion of infrastructure, additional human resources, strengthened outreach services, provision of entitlements and assured services for maternal newborn and children’s health, involving private practitioners and incentivizing quality improvements.
These initiatives include countrywide implementation of national programs aimed at maternal, newborn and children’s health: Janani Suraksha Yojana, Janani Shishu Suraksha Karyakram (so far, more than 10,000,000 women have delivered children in government health facilities in 2019-20), Pradhan Mantri Surakshit Matritva Abhiyan and others.
The government has recently launched the Surakshit Matritva Aashwasan program with the commitment to provide assured, dignified, respectful and quality healthcare, at no cost and with zero-tolerance for denial of services, for every woman and newborn.
Changing demography and epidemiology across the country mean that preventive, promotive and treatment strategies for chronic care are urgently needed.
The Global Burden of Disease estimates suggest that the leading killers of women worldwide, including in India, are increasingly related to ischaemic heart disease and stroke.
The transition toward a higher burden of chronic diseases with co-morbidities needs a paradigm shift in addressing such diseases among women in the reproductive age group and beyond.
In the endeavor to improve women’s health, Ayushman Bharat (the government’s flagship healthcare program) offers us a ray of hope. Its two components — the Health and Wellness Centers, which offer universal, free, primary healthcare; and the Pradhan Mantri Jan Arogya Yojana (PMJAY), which provide secondary and tertiary hospital care to the vulnerable — have specific design strategies to reduce gender discrimination in health care.
While we know that there is excess mortality among women as compared to men, the extent of gender disparity in access to care-seeking — other than obstetrics and gynecology — is exemplified in several studies.
The gender disparities in access combined with a rise in chronic disease signify the need to reorganize service delivery even while we address other barriers related to women’s health.
Population-based screening, prevention and management — including treatment and referral for common non-communicable diseases such as hypertension, diabetes, oral, cervical and breast cancers — are aimed at improving access for women and men.
Reliable reports from Ayushman Bharat Health and Wellness Centers show that a sub-health center providing services throughout the day — supplemented by intensified outreach, and delivered through a primary health are team, consisting of a community health officer and one or two additional workers — has led to more foot traffic than has been recorded in these facilities. And we have seen this in the relatively short time frame of 24 months.
In addition to 1 million ASHAs (community health workers) and over 800,000 female multipurpose workers across the country, we now have more than 10,000 female community health officers at the sub-health center level Health and Wellness Centers, representing 67 percent of the total.
Increased numbers of female providers at Health and Wellness Centers not only provide increased employment opportunities for women, but also enable increased care-seeking by women.
Evidence from reporting data of nearly 32,300 Health and Wellness Centers highlight that more women than men access the Centers.
Indeed, 55 percent of reported outpatient foot traffic in functional Health and Wellness Centers is made up of women.
These Centers have reportedly done more than 11,000,000 screenings for breast cancer and 7.34 million screenings for cervical cancer.
Making healthcare accessible and affordable for women has also resulted in a fundamental design shift in the PMJAY program. Learning from failure of past insurance programs where a cap on family size had the potential of denying care for women, PMJAY has removed the cap on family size. This minimizes the opportunity for male capture of hospital entitlements. About 48 percent of total authorized hospital admissions receiving benefits of hospital care under PMJAY are women.
Universal health coverage cannot be achieved without making women full beneficiaries of access to information and services and addressing social and environmental determinants of women’s health. Large-scale efforts such as Beti Bachao-Beti Padhao Ujjwala healthcare program for girls, and the Swacch Bharat Mission clean-up program, play a significant role in responding to such determinants.
Ayushman Bharat offers us a significant opportunity to do more and do better for women’s health – we need to do all we can to use this opportunity well.
Preeti Sudan is Secretary, Ministry of Health and Family Welfare. Vandana Gurnani is Additional Secretary and Mission Director, National Health Mission. Dr. Rajani Ved is Executive Director, National Health Systems Research Centre.