|The poorer health indices for girls and women mandate a social revolution which not only provides equal opportunities but also focusses on achieving equal outcomes. |
There has been significant improvement in the health, education and employment status of women in India over time. Yet, health indices for girls and women compare much less favourably with those for boys and men. Successive governments have recognised the inequalities in health indices and have implemented many schemes to improve women’s health. Many programmes, including the National Rural Health Mission, provide care for women, especially during pregnancy and deliv ery and after childbirth. Family planning programmes offer services related to contraception for women, improving their health. Many programmes aimed at the general population also impact women’s health.
Nevertheless, community programmes have contended and shown that economic development results in greater improvement in women’s health than direct medical interventions alone. Consequently, education and employment for women became core features of such programmes. The national campaigns on education (Sarva Shiksha Abhiyan) and employment (National Rural Employment Guarantee Scheme) have a specific focus on girls and women. Self-help groups and micro-credit initiatives also increase skill levels, provide alternative livelihoods and generate income and assets for women.
Indicators of the status of women: A detailed analysis of national data shows some reduction in maternal deaths and an improvement in many indices related to infant health. However, there are gender differentials in many indices, with data disaggregated by gender, showing far greater improvement for males than for females. The perinatal mortality rate, infant mortality rate and under-5 mortality rate are poorer for girls. There is evidence of foeticide and infanticide of girls. They are often malnourished and brought to hospital later in their course of illnesses than boys. The birth of a girl and failure to conceive a boy are significant risk factors for post-partum depression. The suicide rate among young women is about three times that seen for young men. Violence against women and girls is common.
Women and girls have lower adult literacy rates, school enrolment and attendance figures. The long walk to school with its associated fear for physical safety, lack of toilets at schools, the small number of women teachers and the second class status of the girl child contribute to these lower rates.
Women’s work at home, because of its invisibility, is rarely recognised, although they work for roughly twice as many hours as men. Technological progress in agriculture and the shift from subsistence to a market economy have had a dramatic negative impact on women, cutting them out of employment as many women are unskilled and lack education. Child labour among girls and unequal wages for women for similar work are common. Working women of all segments of society face various forms of discrimination, including sexual harassment. Women’s work is also socially devalued and autonomy in decision-making related to their life rarely exists for the majority of women.
While gender equality and justice are among the United Nations Millennium Development Goals, their implementation in India has been slow and patchy. Issues related to gender equality are not adequately mainstreamed for India. Discussion of gender is usually confined to Goals 3 and 5, which are gender equality and maternal mortality. Women are cast only in the role of victims, rather than as equal partners in development. The social, economic and cultural contexts, the most significant predictors of women’s health, are barely mentioned.
Health justification for gender justice: Gender injustice is often viewed in the socio-cultural context and usually in terms of social outcomes. However, analysis of health data clearly documents the importance of gender and its impact on women’s health. Women are the largest discriminated group in India. This results not just in adverse social outcomes but also unfavourable health outcomes.
Social determinants have a significant impact on the health of girls and women. Viewing the health of women in general as an individual or medical issue and suggesting individual medical interventions reflects a poor understanding of issues. Reducing public health related to women to a biomedical perspective is a major error of the public health movement. Social interventions should form the core of all health and prevention programmes as individual medical interventions have little impact on population indices which require population interventions.
Barriers to scaling up interventions for women: The major barrier to mainstreaming gender justice and to scaling up effective interventions is gender inequality based on socio-cultural issues. The systematic discrimination of girls and women based on culture and tradition needs to be tackled if interventions have to work. Although the short time-lag between the (absence of) medical intervention and the health outcomes stand out as causal, it is the longer latent period and the more hazy but ubiquitous and dominant relationship between gender and culture which have a major impact on the outcome. Failure to recognise this relationship and refusal to tackle these issues result in poorer health standards of women. Tradition and culture maintain their stranglehold on gender inequality. Debates on gender equality are often reduced to talking about culture, tradition and religion. The prevalent patriarchal framework places an ideological bar on the discussion of alternative approaches to achieve gender justice for girls and women.
The way forward
While the Constitution guarantees equality for women, legal protection has little effect in the face of the prevailing culture. Many researchers and activists are no longer convinced that we can succeed in improving women’s health or status unless society attempts to confront its gender bias openly. For too long we have been refusing to discuss women’s issues explicitly with society. It would appear that nothing short of a social revolution would bring about an improvement in the health of Indian women.
Many approaches have been suggested. They will all need to include approaches which examine, understand and confront gender discrimination in social, cultural and religious spheres. Legal solutions enforcing gender justice are equally necessary, and monitoring the implementation of legislation is mandatory.
The right to health is a fundamental right and the poorer health indices of half the population is a cause for concern. There is an urgent need for a detailed re-examination of public health statistics for India, disaggregated by gender and region. There is an equally vital need to set up policies and programmes to counter adverse trends. The evidence from such disaggregated data should be used to set targets for action. Progress has to be visible and benchmarks have to be set high.
The magnitude of the inequality related to health is often downplayed even within medical circles. The second-class status of women in Indian society persists and women’s perspectives continue to be missing, marginalised or ignored. There is a definite need to engage communities and the population as a whole in a debate to challenge traditional stereotypes and accepted social norms. Programmes to achieve gender equality should not only focus on the provision of equal or greater opportunities for women. They should also concentrate on achieving equality in gender outcomes within a reasonable time frame. Outcomes in general, and health outcomes in particular, are measurable with a much greater degree of accuracy than opportunities.
All plans and projects within community programmes should be assessed using the “gender lens” in order to achieve gender justice for women. These programmes will have to cover the social context of home, school, workplace, law and politics in order to improve women’s health. There is a need to challenge the normalisation of gender discrimination in India. The focus should be on public health approaches to change social and cultural perspectives with the aim of primary prevention of discrimination while continuing medical interventions for early diagnosis and management of the medical consequences. There is a need for aggressive gender justice in order that women in India achieve equal health and social status in the foreseeable future.
(Professor K.S. Jacob is on the faculty of the Christian Medical College, Vellore.)