GENDERED VULNERABILITIES: WOMEN’S HEALTH AND ACCESS TO HEALTHCARE IN INDIA

MANASEE MISHRA, Ph.d

The Centre for Enquiry into Health and Allied Themes (CEHAT), Mumbai

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By Centre for Enquiry into Health and Allied Themes Survey No. 2804 & 2805 Aaram Society Road Vakola, Santacruz (East) Mumbai - 400 055 Tel. : 91-22-26673571 / 26673154 Fax : 22-26673156 E-mail : [email protected] Website : www.cehat.org

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Health and Human rights has explicit The Background Series is a collection of intrinsic connections and has emerged as papers on various issues related to right to powerful concepts within the rights based health, i.e., the vulnerable groups,health approach especially so in the backdrop of systems, health policies, affecting weakening public health system, unregulated accessibility and provisions of healthcare in growth of the private sector and restricted India. In this series, there are papers on access to healthcare systems leading to a women, elderly, migrants, disabled, near-total eclipse of availability and adolescents and homosexuals. The papers are accessibility of universal and comprehensive well researched and provide evidence based healthcare. A rights-based approach to health recommendations for improving access and uses International Human Rights treaties and reducing barriers to health and healthcare norms to hold governments accountable for alongside addressing discrmination. their obligations under the treaties. It We would like to use this space to express recognises the fact that the right to health is our gratitude towards the authors who have a fundamental right of every human being and contributed to the project by sharing their it implies the enjoyment of the highest ideas and knowledge through their respective attainable standard of health and that it is papers in the Background Series. We would one of the fundamental rights of every human like to thank the Programme Development being and that governments have a Committee (PDC) of CEHAT, for playing such responsibility for the health of their people a significant role in providing valuable inputs which can be fulfilled only through the to each paper. We appreciate and recognise provision of adequate health and social the efforts of the project team members who measures. It gets integrated into research, have worked tirelessly towards the success advocacy strategies and tools, including of the project ; the Coordinator, Ms. Padma monitoring; community education and Deosthali for her support and the Ford mobilisation; litigation and policy formulation. Foundation, Oxfam- Novib and Rangoonwala Right to the highest attainable standard is Trust for supporting such an initiative. We encapsulated in Article 12 of the International are also grateful to several others who have Covenant on Economic, Social and Cultural offered us technical support, Ms Sudha Rights. It covers the underlying preconditions Raghavendran for editing and Satyam necessary for health and also the provisions Printers for printing the publication. We hope of medical care. The critical component that through this series we are able to within the right to health philosophy is its present the health issues and concerns of the realisation. CEHAT’s main objective of the vulnerable groups in India and that the series project, Establishing Health as a Human Right would be useful for those directly working on is to propel within the civil society and the the rights issues related to health and other public domain, the movement towards areas. realisation of the right to healthcare as a fundamental right through research and documentation, advocacy, lobbying, Chandrima B.Chatterjee, Ph.D campaigns, awareness and education Project In Charge (Research) activities. Establishing Health As A Human Right

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Gendered Vulnerabilities: Women’s Health And Access To Healthcare In India

Dr. Manasee Mishra has an M.A and Ph.D in Sociology and is currently a Research Consultant in the Child in Need Institute (CINI) in Kolkata. She previously worked with the Tata Institute of Social Sciences (TISS) and the Centre for Enquiry into Health and Allied Themes (CEHAT), both at Mumbai. Here career highlights include National Talent Search scholarship awarded by the NCERT, New Delhi, University Merit Scholarship and the University Medal awarded by the University of Hyderabad, and Junior Research Fellowship of the UGC, New Delhi.

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PDF created with pdfFactory Pro trial version www.pdffactory.com CONTENTS

I.Introduction...... 1 Introduction...... 1 Risk factors in women’s lives...... 2

II.Women’s health in India...... 5 Nutrition...... 5 Women’s morbidity...... 9 Reproductive Health...... 11 Women and Disability...... 21 Women and Mental Health...... 23 Women and Work...... 24

III.Access to healthcare...... 26 Household as a site of discrimination...... 26 Formal healthcare...... 32 Disability and access to healthcare...... 34 Women and access to mental healthcare...... 35 Occupational health...... 36 Reproductive health services...... 37 Informal healthcare...... 46

IV.Key concerns and Recommendations for Policy...... 47 References ...... 49 Annexures ...... i

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PDF created with pdfFactory Pro trial version www.pdffactory.com LIST OF TABLES

1.Nutritional status by sex of the child...... 6 2.Body mass index (BMI) and anaemia in Indian women...... 8 3.Proportion of persons reporting ailment, NSSO 52nd round...... 10 4.Morbidity rates in different rounds of the NSS...... 11 5.Prevalence of RTI/ STI and treatment sought...... 14 6.Pregnancy outcomes in India...... 18 7.Distribution of the disabled by type of disability, sex and residence...... 22 8.Sex differentials in child immunization and treatment of childhood ailments...... 29 9.Treatment of ailments and hospitalization, NSS (42nd and 52nd rounds)...... 30 10.Proportion of persons hospitalized by MPCE fractile group, NSS 52nd round...... 31 11.Average total expenditure incurred per ailment for non-hospitalised and hospitalized treatment, NSS 52nd round...... 31 12.Fertility and unmet need for family planning among select groups...... 38 13.Antenatal care services in the states of the country...... 40 14.Place of delivery and post natal care in India...... 42 15.Adequacy and select reproductive health services at public health facilities...... 46

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PDF created with pdfFactory Pro trial version www.pdffactory.com LIST OF ANNEXURES

1.Child sex ratio in states and union territories of India...... i 2.Infant mortality rate by sex and residence...... ii 3.Sex wise age specific death rates...... iii 4.Women’s experience of and attitude towards domestic violence...... iv 5.Body Mass Index (BMI) and anaemia among women of select groups...... vi 6.Morbidity levels according to different NFHS rounds...... vii 7.Point prevalence of morbidity NSSO 52nd round...... vii 8.Prevalence (per 1000 aged persons) of chronic ailments by sex and residence...... viii 9.Maternal mortality ratio in select states of India...... viii 10.Menopause among currently married women by age and state...... ix 11.Women with types of disabilities in states and union territories of India...... x 12.Prevalence of disability among the elderly...... xi 13.Male and female workers in India...... xi 14.Establishment of CHCs, PHCs and SCs in India...... xii 15.CHCs, PHCs and SCs in tribal areas of India...... xiii 16.Knowledge of contraceptive methods...... xiv 17.Antenatal care received by select social groups in the country...... xv

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PDF created with pdfFactory Pro trial version www.pdffactory.com GENDERED VULNERABILITIES: WOMEN’S HEALTH AND ACCESS TO HEALTHCARE IN INDIA

I. INTRODUCTION threat. In recent decades, there has been an alarming decrease in the child sex ratio Like most cultures across the world, Indian (0-4 years) in the country. Access to society has deeply entrenched patriarchal technological advances of ultra sonography norms and values. Patriarchy manifests and India’s relatively liberal laws on itself in both the public and private spheres abortion have been misused to eliminate of women’s lives in the country, female foetuses. From 958 girls to every determining their ‘life chances’ and 1000 boys in 1991, the ratio has declined resulting in their qualitatively inferior to 934 girls to 1000 boys in 2001. In some status in the various socio-economic states in western and north western India, spheres. It permeates institutions and there are less than 900 girls to 1000 boys. organisations and works in many insidious The sex ratio is at its worst in the states of ways to undermine women’s right to Punjab, Haryana, Himachal Pradesh and dignified lives. There are similarities in Gujarat, where severe practices of seclusion women’s lived experiences due to such and deprivation prevail. Often in gendered existences. However, in a vast contiguous areas in these states, the ratio and socio-culturally heterogeneous dips distressingly below 800 girls to every country like India, women’s multiple and 1000 boys (RGI, MOHFW, UNFPA, 2003). often special needs are played out on a Annexure I gives the child sex ratio in variegated terrain of age, caste, class and different states and union territories of region resulting in a complexity of India as per the 2001 census. experiences. Traditional bases of social stratification such as caste and class The discrimination against the girl child reproduce themselves in women’s lived is systematic and pervasive enough to experiences as also do rural-urban and manifest in many demographic measures regional disparities. New needs emerge as for the country. For the country as a whole women progress through the life cycle. as well as its rural areas, the infant Talking about women’s health and access mortality rate is higher for females in to healthcare in such a complex setup thus comparison to that for males (Annexure II). poses a challenge. Usually, though not exclusively, it is in the northern and western states that the female If health is defined ‘as a state of complete infant mortality rates are higher, a physical, mental and social well-being and difference of ten points between the two sex not merely the absence of disease or specific rates not being uncommon. The infirmity’, it follows that existence is a infant mortality rate is slightly in favour of necessary condition for aspiring for health. females in the urban areas of the country The girl child in India is increasingly under (as a whole) But then, urban India is

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PDF created with pdfFactory Pro trial version www.pdffactory.com marked by greater access to abortion pain and injuries; weakness, fever, services and unwanted girl children often respiratory problems; problems in the gastro get eliminated before birth. intestinal tract; skin, eye and ear problems and a residual category of ‘other’ problems. It has been commented in the context of The study also found, quite significantly, women’s health that sustainable well-being that degraded living environment, as in a can be brought about if strategic slum, has deleterious effects on people’s interventions are made at critical stages. health and that the morbidity rates were The life cycle approach thus advocates highest for those adult women with strategic interventions in periods of early children who were living in slums and childhood, adolescence and pregnancy, were engaged in paid work (ibid). Another with programmes ranging from nutrition study of working and non working women supplements to life skills education. Such in the slums of Baroda found that though interventions attempt to break the vicious working women contributed significantly intergenerational cycle of ill health. The to the household income, yet they had to vulnerability of females in India in the face a burden of household work and crucial periods of childhood, adolescence childcare (in addition to their paid work). and childbearing is underscored by the Such women put in more hours of work to country’s sex wise age specific mortality fulfill their numerous responsibilities and rates. From childhood till the mid twenties, had less leisure time. Women in both the higher proportions of women than men die categories had lower nutritional intake in the country. In rural India, higher than what is recommended, with the proportions of women die under thirty. The working women faring worse than the sex wise age specific mortality rates are housewives. Similarly, in the case of given in Annexure III. nutritional deficiencies such as anaemia, mottled enamel, etc, both the categories of Risk factors in women’s lives women fared poorly, with the working Health is socially determined to a women being worse off. The mean number considerable extent. Access to healthcare, of clinical signs of nutritional deficiency is almost fully so. This being so, the ‘lived was 2.8 for the working women in experiences’ of women in India are replete comparison to 2.2 for housewives. with potential risk factors that have Interestingly, the study showed that implications for their lives and well-being. working women had greater access and The multiple roles of household work, child higher utilisation of antenatal care services rearing and paid work that women carry (Khan, Tamang and Patel, 1990). out has implications for their physical and mental health. A study on the impact of There may be gendered risks to women’s work and environment on women’s lives in the home environment. In India, a morbidity in a sample population in vast majority of the households rely on bio- Mumbai found that cohabiting women with fuels (wood, dung, etc) for cooking. Cooking children engaged in paid work had the being a female preserve in the household highest morbidity rates (Madhiwalla and domain, the pollutants arising from the Jesani, 1997), higher than that of either burning of such bio-fuels affect women single women or housewives. The types of (and young children) disproportionately, morbidity experienced by the women with consequences on their health - included reproductive problems, aches, respiratory tract infections, blindness and

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PDF created with pdfFactory Pro trial version www.pdffactory.com asthma being some of the diseases that INCLEN’s multicentric study of urban and affect them (Parikh, Smith and Laxmi, 1999; rural areas across seven sites of India found also Gopalan and Saksena, 1999). that 40.3% of the women reported at least one episode of physically abusive behaviour In recent years, studies on domestic (INCLEN, 2000). Not only is domestic violence in the country have systematically violence a violation of women’s human debunked the myth of the home as a safe rights, it can also have severe health haven. Violence against women in India consequences. A study of the casualty cuts across caste, class and other divides. records of a large, multispeciality hospital Nationally it is estimated that 21 % of in Mumbai, revealed that a fifth of all cases women have experienced beatings or (22.4%) were ‘definitely domestic violence’ physical mistreatment ‘by husband, in- and another 44% of the cases pertaining laws, or other persons’ since the age of to women were ‘possibly domestic fifteen (IIPS and ORC Macro, 2000). The violence’(Daga, Jejeebhoy and percentage of women having experienced Rajgopal,1999). (By rough estimates two- such violence in the past one year is 11%. thirds of the cases pertaining to women in Women of all socio-demographic the casualty department of the hospital backgrounds experience domestic could be related to domestic violence).The violence (Annexure IV). In fact, given the form of assault experienced by the women sensitive nature of the topic, it would not ranged from kicks and beatings (with be erroneous to say that the low levels of instruments or otherwise) to strangulation violence reported by women of high and burning. Attempted suicide by the standard of living or those having ingestion of various substances was completed at least high school may be prominent in the cases of ‘possible because of deliberate underreporting of domestic violence’. Serious injuries were violence rather than genuine differentials sustained in considerable percentages of in levels of violence experienced. Such is the cases - comprising 13% of the cases of the internalisation of gendered roles and ‘definitely domestic violence’ and 60% of the acceptance of violence that high the cases of ‘accidental stove bursts’ percentages of women of varied (ibid).Another study that analysed records backgrounds justify violence for different in healthcare facilities across the tiers also ‘reasons’, namely, the husband’s suspicion found evidence of violence in many cases of the wife’s faithfulness; non giving of of women accessing such facilities money or other items by the wife’s natal (Jaswal,1999). family; wife’s disrespect of the in-laws; wife’s going out without telling the Intimate relationships may be fraught with husband; wife’s neglect of the house or other dangers. Sexual relationships with children, and; wife’s not cooking food one’s spouse are not without risks, its properly. acuteness heightened in this age of HIV/ AIDS. Across the country, sex within Findings of smaller studies usually put marriage is viewed as the man’s right. violence faced by women at higher levels. Women may have some leverage in Visaria’s study of married women in five temporarily stalling off sex but to ‘deprive’ villages in rural Gujarat revealed that 66% their husbands of it ‘for too long’ would percent of women were subject to either invite social censure (George, 1997). If the physical or verbal abuse (Visaria, 2000). man has been straying, then it puts the

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PDF created with pdfFactory Pro trial version www.pdffactory.com woman at risk, inspite of her being in a cultural value placed on the son(s), dowry monogamous relationship. In fact one of (and its consequences on the family’s the tragic aspects of the HIV/AIDS epidemic economic security), the girl child faces a in the country today is that it has spread to battle even before her birth. An undesirable monogamous women in the rural interiors fallout of the declining fertility in India has of the country, the infection having been been that lives of girl children have been contracted from the husband who has compromised to restrict the family size of migrated to urban centres often in search many middle and upper class families - a of a livelihood. Transmission of the human case of demographics and gender equity immunodeficiency virus (HIV) in the being at odds. country is overwhelmingly through sexual contacts, with other modes like perinatal The discrimination against the girl child transmission, blood and blood products, continues during adolescence and the injection of drugs, etc together accounting lack of preparedness in meeting life for less than 15 percent of the total infection situations underscores her vulnerability. (CBHI,2003). Though, in the conventional sense adolescence is understood to be a period In general, women in India are restricted relatively free from morbidities that mark in matters of decision making, freedom of childhood and old age, the insularity of mobility and access to money, though wide adolescence from morbidity is getting variations exist depending on the socio- undermined in recent years owing to the demographic context (IIPS and ORC Macro, risks associated with unsafe sex and the 2000).Certain periods in a woman’s life like attendant dangers of contracting HIV/ early childhood, adolescence and old age AIDS and RTIs/STIs. Late adolescence may may be especially vulnerable to mark initiation into sex that is usually ill discrimination and neglect. The informed and unprotected. In the Indian discrimination/neglect faced by women in context, initiation into sex by adolescent such ages is elucidated in the relevant girls is usually in the context of marriage, sections of this monograph. The current though premarital sex among girls is not section draws from socio-anthropological unknown (Abraham, 2003; FPAI, 1994).The literature to understand the reasons for median age at first marriage for girls in such vulnerability. The status of women in India is only 16.4 years (IIPS and ORC India is depressed on many socio-economic Macro, 2000).In most states of the country, indices with low literacy rates, poor half the girls marry by the time they participation in political processes, complete their teens; in states like Bihar concentration in low skilled and low and Rajasthan, the median age at first paying economic activities and a culture marriage being only 15 years. However, life that values motherhood and care giving skills that could enable them to respond roles in women. Born in such a milieu, the preparedly to their life situations are found girl child (especially one born higher in the to be sorely lacking among adolescent girls birth order to a family having older girls) (and boys). It has been reported how is, in many ways, unwanted and adolescent girls are taken unawares by the disadvantaged. For varying reasons such onset of menstruation (Garg, Sharma and as the safeguarding of the physical security Sahay, 2001) and have little or no and ‘modesty’ of the girl, the deeply knowledge about contraception and embedded notions of patriliny and the childcare (ANSWERS, 2001).

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PDF created with pdfFactory Pro trial version www.pdffactory.com As the country undergoes demographic existing evidence on the topic. Different transition, people live longer, typically aspects of women’s health are thematically women outliving men. The National Sample presented as a matter of presentation and Survey, for example, estimates that the the themes are not to be construed as share of the aged females is higher than that mutually exclusive and water tight of males in both rural and urban areas of compartments. The conditions of women’s the country (NSSO, 1998a). But, old age is lives shape their health in more ways than a period associated with morbidities one. (especially chronic ailments). It also signals a change in social status. With the active Nutrition productive life of a person being over and Nutrition is a determinant of health. A well the second filial generation having made balanced diet increases the body’s its entry in the family, the position of the resistance to infection, thus warding off a individual undergoes a change. host of infections as well as helping the Vulnerability during old age sets in due to body fight existing infection. Depending on physical, economic and psychological the nutrient in question, nutritional dependence, more so for elderly women deficiency can manifest in an array of among whom higher proportions are disorders like protein energy malnutrition, dependent on others ‘for day to day night blindness, iodine deficiency maintenance’ in comparison to elderly disorders, anaemia, stunting, low Body males (NSSO, 1998a).This is especially true Mass Index and low birth weight. Improper if a woman has been widowed with little nutritional intake is also responsible for property against her name. Her status in diseases like coronary heart disease, the family is considerably reduced from the hypertension, non-insulin-dependent time when she was in her middle age, with diabetes mellitus and cancer, among telling implications for her health and well- others (Shetty,2004). Nutritional deficiency being. disorders of different types are widely prevalent in the countries of south east Asia, with some pockets showing II. WOMEN’S HEALTH IN INDIA endemicity in certain types of disorders. Iodine deficiency disorder is endemic to Health is complex and dependent on a host the Himalayan and several tribal areas and of factors. The dynamic interplay of social anaemia is a pervasive problem across most and environmental factors have profound socio-economic groups of the country. and multifaceted implications on health. Economic prosperity alone cannot be a Women’s lived experiences as gendered sufficient condition for good nutritional beings result in multiple and, status of a population, the state of significantly, interrelated health needs. Maharashtra in western India being a prime But gender identities are played out from example in this regard. Maharashtra has various locational positions like caste and one of the highest per capita incomes class. The multiple burdens of ‘production among states in the country, but is marked and reproduction’ borne from a position of by poor nutritional profile of its people. disadvantage has telling consequences on More than half the households in both the women’s well-being. The present section rural and urban areas of the state receive on women’s health in India systematizes less than the prescribed adequate amount

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PDF created with pdfFactory Pro trial version www.pdffactory.com of calorific intake and the situation has predominantly non-tribal district while worsened in the rural areas of the state in Yawatmal has a mixed tribal-nontribal the past twenty years (Duggal, 2002). population. The district of Nandurbar has a predominantly tribal population.) The nutritional status of children and women in India has attracted the attention National level estimates from the NFHS-2 of academics and policy planners for some also show that girls are more likely to be decades now. Despite the interest, these undernourished or even severely population subgroups continue to suffer undernourished for the indicators of from poor nutritional status. The girl child, weight for age and height (Table 1). More disadvantaged from birth (or even before it) girls than boys are thus underweight and due to her sex, is systematically denied or stunted. Boys are slightly more likely to has limited access to the often paltry food show undernourishment and severe resources within the household. A recent undernourishment in the case of weight for study of three backward districts of height, that is, they are more likely to be Maharashtra shows that in the project areas thin than the girls. of the ICDS (the Integrated Child Development Services-the state run Women’s physiological makeup calls for programme designed to ameliorate the special nutritional supplements. nutritional status of children and pregnant Menstruation and childbirth are iron and nursing women with the help of depleting physiological processes. Calcium supplementary nutrition), the girl needs to be continually supplemented beneficiaries consistently showed poorer during a woman’s life cycle as a bulwark weight for age results, compared to the boy against osteoporosis in later life. The beneficiaries (Mishra, Duggal and Raymus, predominantly vegetarian diet of Indians 2004). This was true for all the three project does not fulfill many of their nutritional defined age groups of children below one requirements. Further, cultural practices year; between one and three years and disadvantage women in many ways and between three and six years. All the three add to their poor nutritional status. It is districts of Jalna, Yawatmal and Nandurbar customary in many households across the displayed such a consistency. (The three country that the women should eat last and districts encompass considerable socio- eat the leftovers after the men folk have had cultural heterogeneity, Jalna being a their food (Dube, 1988). The choice of

Table 1: Nutritional status by sex of the child

Weight for age Height for age Weight for height Sex of% below -3%below -2% below -3% below -2% below -3% below -2 the childSDSD•SDSD•SDSD• Male16.945.321.844.12.915.7 Female19.148.924.447.02.715.2 Source: NFHS-2 Note: The indices are expressed in standard deviation units (SD) from the median of the International Reference Population. • Includes children who are -3 SD below the median of the International Reference Population.

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PDF created with pdfFactory Pro trial version www.pdffactory.com dishes prepared is often in keeping with inequities in Indian society and the the preference of the male members of the deprivation caused by the market economy household. The NFHS-2 estimates that that disadvantaged social groups suffer 35.8% of women in the country suffer from from poor nutritional status. As free access chronic energy deficiency, with a body to natural resources gets curtailed and mass index (BMI) of less than 18.5 kg/m2. purchasing power increasingly determines The proportion of such women is highest one’s well-being, tribals and poor rural in Orissa (48.0 %), followed by West Bengal communities (among others) inhabit the (43.7%). On the whole, the eastern and margins of the economy with telling effects central states of the country fare worse on their health (and livelihood). Higher than the others in this measure. However proportions of rural women have a BMI less barring a few small states, in the rest, a than 18.5 kg/m2 than urban women quarter or more of the women have a body 2 (Annexure V). Women belonging to the mass index below 18.5 kg/m (Table 2). The Scheduled Castes and the Scheduled NFHS-2 also shows that, at the national Tribes are more likely to suffer from level, more than half (51.8%) of the women moderate and severe anaemia. At the same in the reproductive age group suffer from time, considerable proportions of women some form of anaemia. With the exception of Kerala (22.7%) and Manipur (28.9%), of socio-economically advantaged levels of anaemia are consistently high for backgrounds (that is, those belonging to the other states, the proportion of women high standard of living; high education) are suffering from some form of anaemia often obese. Thus, the nutrition profile of the being more than 40.0%. Assam leads with country is not only indicative of the 69.7% of its women anaemic. Bihar deprivation that disadvantaged social (63.4%), Meghalaya (63.3%) and Orissa groups suffer from but also provides a vivid (63.0%) follow (Table 2). picture of the double burden of nutritional disorders that differentially affect social It is a sad observation on the enduring groups in the country.

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PDF created with pdfFactory Pro trial version www.pdffactory.com Table 2: Body mass index (BMI) and anaemia in Indian women

Weight for height% of women with % with% with% withMildModerateSevere BMIBMI ofBMI ofanaemiaanaemiaanaemia below25.030.0 18.5kg/m2 kg/m2 kg/m2 or moreor more North India Delhi1233.89.240.529.69.61.3 Haryana25.916.63.94730.914.51.6 Himachal Pradesh29.713.12.340.531.48.40.7 Jammu & Kashmir26.413.8358.739.317.61.9 Punjab16.930.29.141.428.412.30.7 Rajasthan36.17.11.648.532.314.12.1 Central India Madhya Pradesh38.26.11.254.337.615.61 Uttar Pradesh35.87.51.548.733.513.71.5 East India Bihar39.33.70.563.442.9191.5 Orissa484.40.66345.116.41.6 West Bengal43.78.61.362.745.315.91.5 North east India Arunachal Pradesh10.75.10.662.550.611.30.6 Assam27.14.20.769.743.225.60.9 Manipur18.810.81.228.921.76.30.8 Meghalaya25.85.81.263.333.427.52.4 Mizoram22.65.30.54835.212.10.7 Nagaland18.48.20.738.427.89.61 Sikkim11.215.72.561.137.321.42.4 West India Goa27.121.24.336.427.38.11 Gujarat3715.84.446.329.514.42.5 Maharashtra39.711.72.948.531.514.12.9 South India Andhra Pradesh37.4122.249.832.514.92.4 Karnataka38.813.62.942.426.713.42.3 Kerala18.720.63.822.719.52.70.5 Tamil Nadu2914.72.756.536.715.93.9 India TOTAL35.810.62.251.83514.81.9 Source: NFHS-2

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PDF created with pdfFactory Pro trial version www.pdffactory.com Women’s morbidity prevalence rates of (reported) morbidities Evidence on different morbidities in India for the four ailments were lower for females suffers from a problem common to many in comparison to that for males (Annexure developing countries. Levels and types of VI). Similarly in NFHS-1, for the country as morbidities experienced by different a whole, barring (partial and complete) population subgroups in these countries blindness, morbidity rates for the ailments are often not systematically documented of tuberculosis, leprosy, physical leading to huge gaps in information that impairment of limbs and malaria are lower impair research and policy making. In for females. The pattern replicates itself in India, for the better part of the post the rural and urban areas of the country, independence era, women’s reproductive except in the case of malaria in urban India, health (more specifically, contraception where the incidence was higher among and maternity related events) were common females. subjects of enquiry with the topic of women’s general morbidity receiving One of the signal contributions of the comparatively little academic attention. feminist movement worldwide has been the integration of gender concerns in theory Further, there are inherent methodological and practice of research. In India, studies problems in exploring morbidity in low adopting gender sensitive methodology literate, third world societies. Household indicate higher levels of morbidity among level studies mostly rely on self reported women. For example, a study on women’s morbidity status – a task fraught with morbidity in the Nasik district of dangers. Self reported morbidity data are Maharashtra exclusively employed trained often a reflection of people’s perceptions of and sensitsed female investigators, built their health status and their levels of health rapport with the community and used a consciousness. It is for this reason that probe list to elicit greater information on people belonging to the higher socio- women’s health (Madhiwalla, Nandraj and economic classes often report higher levels Sinha, 2000). In a sample of more than 3,500 of morbidity. Morever, proxy reporting may women, the morbidity levels reported were misrepresent morbidity related data. It has very high, with half the women reporting been seen, for instance, that in the NSSO ill in the month prior to the survey. A large surveys, members of a household may proportion of such illnesses were chronic answer questions directed at other and non-infectious in nature. Morbidity members. rates were higher among adult women in comparison to that of girls and the authors Data on morbidity (for certain ailments) has say that ‘the pattern of morbidity among also been collected in the two rounds of the women showed linkages to their living NFHS. In NFHS-2, information was sought environment (air, water, food), work and on asthma, tuberculosis, jaundice and childbearing and contraception’ (ibid:120). malaria. Questions on morbidities afflicting different members in a household were From time to time, different rounds of the addressed to the household head or ‘other National Sample Survey Organisation knowledgeable adult in the household’. (NSSO) have collected information on the (The overwhelming proportion of heads of morbidity and health seeking behaviour of households in both rural and urban areas people in India. In the survey, pregnancy of India is male). Almost consistently, and child birth related events are not

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PDF created with pdfFactory Pro trial version www.pdffactory.com considered as morbidities though morbidity data reported in the different complications arising out of pregnancy and rounds. Roughly speaking then, the data childbirth are. The 52nd round of the NSSO from various rounds of the NSSO show that (conducted in the mid 1990s) reports that morbidity rates have increased for the in rural and urban areas of India, for the people of India since the 1970s (Table 4). 15 day reference period, greater The early sixties, when the NSSO 17th proportions of women than men report round was carried out, show very high acute as well as chronic ailments rates of proportions of people reporting (NSSO,1998b). The gender differences in ailments, across both the genders in rural reported morbidities for both acute and and urban areas of the country. The chronic ailments are slightly higher in morbidity rates declined in the 1970s (28th urban areas (Table 3). In the survey, point round), after which they showed an prevalence of morbidities is estimated in increase. This is true for both males and two ways - morbidity on the day prior to the females in rural as well as in urban areas survey and on the 15th day preceding the of the country. In fact, the increase in survey. The point prevalence of morbidities morbidity rates is higher for women in is higher for women on both the reference comparison to that of men in both the dates in rural as well as urban areas of settings. India, the gender differentials (again) being sharper in urban areas (Annexure VII). Gender differentials in morbidities are also evident among specific population sub Strictly speaking, morbidity data in the groups. The elderly as a group (expectedly) various rounds of the NSSO are not reports very high prevalence of chronic comparable. This is owing to differences in ailments (NSSO, 1998a). Elderly females the reference period taken for different may be afflicted by certain ailments more rounds of the survey, the adoption of (for instance, joint problems) in urban as prevalence rates (PR) in an earlier survey well as in rural India. Apart from it, instead of the proportion of ailing persons curiously, for urban India, greater (PAP) calculated now. The survey report proportions of elderly females suffer from carries out adjustments to make indicative chronic ailments with the prevalence rates comparisons possible between the of certain chronic diseases like cancer,

Table 3: Proportion of persons (number per 1000) reporting ailment (PAP) in the 15 day reference period, NSSO 52nd round

AreaAilmentMaleFemaleIndia RuralAcute414442 Chronic131413 Any ailment545755 UrbanAcute394341 Chronic131514 Any ailment515854 Source: NSSO Report no.441, 1998.

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PDF created with pdfFactory Pro trial version www.pdffactory.com Table 4: Morbidity rates in different rounds of the NSS

1995-96 (52nd round)1986-871973-741961-62 (42nd round)(28th round)(17th round) PAPDerivedDerivedPAPPRPAP (estimated)PAPPR (15 days)(30 days)(15 days)(30 days)(15 days)(30 days) Rural Male5484546447139 Female5789586340123 Person5586566443132 Urban Male5181523043133 Female5889583341128 Person5484553142131 Source: NSSO Report no.441,1998. Note: 1PAP: Proportion of ailing persons (number per 1000); PR: Prevalence rate 2The recall period is given in parentheses.

blood pressure problems (and the staple in policy parlance a ‘life span approach’. joint problems) being higher for them Reproductive health continues to enjoy the (Annexure VIII). preeminent position on expositions on women’s health in India, however, the Reproductive health connotations have widened implying a The terms of the discourse on reproductive wider range of reproductive health health of women in India have changed conditions that women experience. considerably in the last decade, largely owing to changed political expression post For example, the issue of gynaecological the International Conference on morbidities in women in India gained Population and Development (ICPD) at attention in the late 1980s. The Cairo in 1994. Prior to it, engagements with pathbreaking study by Bang, et.al (1989) the issue of women’s reproductive health which highlighted the high prevalence of were limited. Topics like levels and trends gynaecological or sexual diseases among in contraceptive prevalence, reasons for rural Indian women opened the proverbial non acceptance of contraception and the Pandora’s box. The study carried out like were the mainstay in the literature that among 650 women in two villages of the ensued. The corpus of literature on backward Gadchiroli district of women’s reproductive health has triggered Maharashtra found an astonishing 92.2 new areas of enquiry (and concerns), percent of all women having one or more evidence on reproductive tract infections gynaecological or sexual diseases, with an and abortions being two prominent ones. average of 3.6 diseases per woman (Bang, In the wake of the Cairo conference, et.al.,1989). The surreptitious nature of women’s reproductive health has assumed, such diseases can be gauged by the fact

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PDF created with pdfFactory Pro trial version www.pdffactory.com that only 55.38% of the women had one or the lack of available female controlled more gynaecological or sexual complaints barrier methods and because the power (apart from complaints of ‘non-specific but dynamic in sexual relationships related symptoms’ of low backache and frequently limits their ability to negotiate lower abdominal pain) and that even the conditions under which intercourse women without any symptoms were ‘very occurs. For anatomic reasons, likely’ to have diseases of the reproductive transmission of HIV or discharge tract. Such diseases were also more syndromes (e.g. gonorrhea, chlamydia, frequent among women who had used trichomoniasis) following exposure appears contraception (especially tubectomy). to be more efficient from male to female Quite notably also, only 7.8% of the women than from female to male. When had sought gynaecological care in the past transmission occurs, women are far more for their problems. Another study likely than men to be asymptomatically employing multiple methods on 385 infected, and as a result, not seek care. If women in rural and urban areas of a woman is “lucky” enough to develop Karnataka found that major gynaecological symptoms, it is frequently socially complaints (to a social worker) were bad unacceptable for her to seek care for a odour/itching/irritation during vaginal genital problem, particularly in an STD discharge, lower abdominal pain or vaginal clinic’ (Wasserheit and Holmes,1992:13). discharge with fever and menstrual problems (Bhatia, et.al., 1997). Subsequent The authors further say that the diagnosis history taking by a female gynaecologist of a number of STIs is more difficult in the reported higher levels of menstrual case of women than men and that the problems with 62.3% of the women spread of infection to the upper genital reporting one or more menstrual problems. tract is greater in women. For such reasons, Further, it was seen that women with women are more likely to experience from clinically diagnosed RTIs or Pelvic severity of complications of RTIs and seek Inflammatory Disease are ‘three times delayed treatment (if at all, one may add). more likely’ to report menstrual problems The host of medical conditions that RTIs than those not so diagnosed (ibid). engender include infertility, ectopic pregnancy, cervical cancer, facilitation of Reproductive Tract Infections(RTIs)/ HIV transmission and several adverse Sexually Transmitted Infections(STIs) outcomes of pregnancy (namely, Recent literature on Reproductive Tract spontaneous abortion or still birth; low Infections(RTIs) point to the enormity of the birth weight babies; congenital or perinatal problem afflicting women in India. infections) (ibid). Women’s physiological getup and social vulnerability make them susceptible to Bang, et.al (1989), found that infections RTIs. In an evocative piece, Wasserheit constituted a major proportion of and Holmes say that: gynaecological morbidities among women. High prevalence of RTIs was found in a ‘RTIs, and particularly STDs, study in Karnataka (Bhatia, et.al.,1997). disproportionately compromise the health Thirty-six percent of the women were of women. Women are less able to prevent clinically diagnosed as having RTIs and the exposure to an STD than men, because of figures went upto 56 percent when

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PDF created with pdfFactory Pro trial version www.pdffactory.com subjected to laboratory tests. About one- the NFHS-2 estimates for reproductive tenth of the women suffered from sexually health problems are considerably higher for transmitted infections. Another the country and the states.) When it comes community based study among 451 young to seeking treatment, the RCH-RHS reports married women in rural Tamil Nadu found that for the country as a whole, 55.1 that 45 percent of the women reporting percent of the males with symptoms of the symptoms and 30 percent of the women not diseases sought treatment in contrast to reporting any symptoms (initially) had 37.6 percent of the females who had laboratory diagnosed RTIs. About two- symptoms. Treatment seeking is usually thirds (65%) of the symptomatic women higher among males across the states of the had not taken any treatment. The majority country. Gender differentials in awareness among those not seeking treatment thought of the diseases presented a mixed picture. that the symptoms were ‘not alarming’, Higher percentages of women reported hence not necessitating treatment. Other awareness of RTIs compared to men, the reasons for not seeking treatment included figures being 45.4 percent for women and absence of a female healthcare provider at 37.2 percent for men, for the country as a the nearby facility, lack of privacy and whole. However, for both STIs and HIV/ distance of the facility from home (Prasad, AIDS, higher percentages of men reported et.al,2005). awareness of the diseases. Nationally, 36.4 percent of the males reported awareness At the national level, the Reproductive and about STIs as against 28.8 percent of the Child Health-Rapid Household Survey females. For HIV/AIDS, the figures were (RCH-RHS) estimates that 29.7 percent of 60.3 percent for males and 41.9 percent the eligible women in the country had at for the females (IIPS, 2001a). The sample least one symptom of RTI/STI (IIPS, design of the RCH-RHS makes it possible 2001a).The percentage of males having any to arrive at district level estimates. There such symptom was considerably less at are wide variations in the percentages of 12.3%. (It may be reiterated here that RTIs/ men and women reporting RTI/STI STIs are often asymptomatic. Further, as the symptoms and awareness of AIDS across RCH-RHS report points out, ‘the culture of the districts of a state and across the states silence’ (often) prevents people from as well. This has implications for designing admitting such ailments. Hence these programmes for communication strategies figures are indicative at best). The levels of to increase awareness of the diseases and RTIs/STIs differ widely from state to state service delivery for the diseases. Table 5 in the country, but consistently, with the gives state-wise estimates with regards to exceptions of Orissa and (very marginally) symptoms reported for RTI/STI according Jammu and Kashmir, the prevalence rates to the RCH-RHS, (it is a reproductive health are (considerably) higher among women in problem according to the NFHS-2) and comparison to that in men.(Interestingly, treatment sought.

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PDF created with pdfFactory Pro trial version www.pdffactory.com Table 5: Prevalence of RTI/STI and Treatment sought

% having at least oneAmong those having at least symptom of RTI/STI†one symptom of RTIs/STIs, % treatment sought † MalesFemalesMalesFemales State Andhra Pradesh7.618.848.56546.5 Arunachal Pradesh13.320.642.13335.3 Assam15.128.550.640.938.3 Bihar17.737.744.259.137 Goa5.216.440.263.252 Gujarat15.33228.651.336.1 Haryana9.832.338.25438.2 Himachal Pradesh219.133.756.349.2 Jammu & Kashmir3.8360.587.489.5 Karnataka4.416.318.858.653.8 Kerala4.927.742.458.650.8 Madhya Pradesh10.226.144.954.643.7 Maharashtra8.925.44069.247.9 Manipur12.723.65646.146.1 Meghalaya8.526.666.965.231.2 Mizoram10.236.452.540.756.1 Nagaland14.316.545.651.935.7 Orissa17.315.627.552.438.1 Punjab5.43028.36142.4 Rajasthan12.54543.25122.6 Sikkim8.711.348.66049.8 Tamil Nadu10.736.527.825.931.5 Tripura15.139.8*51.645.4 Uttar Pradesh1836.438.15535.8 West Bengal18.130.445.353.430.2 Union Territory Andaman & Nicobar islands2.113.7*3650.5 Chandigarh3.45.4*7549 Dadra / Nagar Haveli1028.5*82.638.7 Daman & Diu1722.4*55.951 Delhi6.314.536.573.378 Lakshadweep3.814.2*68.254.8 Pondicherry0.336*80.933.5 INDIA Total12.329.739.255.137.6 Source: † according to RCH-RHS; • according to NFHS-2 (The symptoms for which information was sought are similar for the NFHS-2 and the RCH-RHS.) Note: * not given in NFHS-2 report.

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PDF created with pdfFactory Pro trial version www.pdffactory.com Maternal mortality and morbidity services also contribute to high rates of Maternal morbidity and mortality are major maternal deaths (WHO,1998). The NFHS-2 public health problems in almost the entire estimates the maternal mortality ratio in south-east Asian region, signifying not the country to be 540 per 1,00,000 live only the poor status of women in the region births for the two year period before the but also the often appalling standards in survey. The ratio is more severe for rural basic healthcare. Maternal mortality has India, being 619, in comparison to urban been defined as ‘the death of woman while India which records 267 during the same pregnant or within 42 days of the period (IIPS and ORC Macro, 2000). termination of pregnancy, irrespective of Maternal mortality ratio in the country has the duration and the site of the pregnancy, been ‘steadily falling’ during the past from any cause related to or aggravated by decades. In the late 1950s, it stood at the pregnancy or its management but not around 1,300, but was between 800-900 from accidental or incidental causes’ deaths in the 1970s, 500-600 deaths in the (WHO,1977). About 40 percent of all 1980s and 400-500 deaths in the 1990s maternal deaths in the world occur in the (Bhat, 2002). Using the sisterhood method south-east Asia region (WHO, 1998) with to estimate levels of maternal mortality India alone accounting for half of all such indirectly in rural India, the ratio was deaths. The number of maternal deaths in found to be comparatively higher for certain the country is estimated at 1,12,000 per social groups (for example, Scheduled year (UNFPA,2000). It is estimated that Tribes, Scheduled Castes, less developed maternal deaths account for a tenth of all villages and illiterate women and Hindus). female deaths in the reproductive age group State level estimates of maternal mortality in the country (CBHI, 2003). The survey of ratio have also been indirectly estimated causes of death estimates bleeding during from sex differentials in adult mortality pregnancy and childbirth, and anaemia to (Bhat, 2002). Assam has the highest be the leading specific causes of maternal maternal mortality ratio in the country, mortality (reported in CBHI, 2003). It has followed by Uttar Pradesh and Madhya also been commented (Shiva, 1992) in this Pradesh. Maternal mortality in Punjab and context that widespread anaemia in Kerala is very low, because of which pregnant women, low height of many estimating it from sex differentials in adult Indian women that puts them at risk of mortality of a sample population is obstructed labour, poor weight gain during difficult. Among the states for which pregnancy among women of the low socio- estimates could be arrived at, Tamil Nadu economic groups and dietary deficiency has the lowest maternal mortality ratio during pregnancy are ‘major causes of (Annexure IX). maternal deaths’ in the country. Further, unsafe abortions are a ‘leading cause of Further, it is estimated that, for every maternal mortality and contribute maternal death, there are thirty other significantly to the maternal morbidity’ in women who suffer from ‘chronic, the country (UNFPA, 2000). debilitating conditions, which seriously affect the quality of life’ (UNFPA, 2000). Glaring shortcomings in the healthcare Despite their stated limitations, various services like poor coverage and quality of community based studies in different sites antenatal care, unsafe deliveries, lack of of India point to substantial levels of emergency obstetric care and poor referral maternal morbidities. Bhatia and Cleland

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PDF created with pdfFactory Pro trial version www.pdffactory.com (1996) report from their study of 3600 proportions in rural India (IIPS and ORC women near Bangalore in Karnataka that Macro,2000). about 40 percent of all women suffered from at least one morbid condition during their Further, there is considerable abortion antenatal, delivery or post natal period. related morbidity. In a recent community About 18 percent of the women reported based study in Maharashtra, post abortion one morbid condition during their morbidities were reported in more than 60 antenatal period, 8 percent experienced a percent of the cases of spontaneous as well problem (especially prolonged labour) as induced abortions (Saha, Duggal and during delivery and (quite notably), 23 Mishra, 2004). Excessive bleeding, pains percent had a problem during their post and aches together accounted for almost natal period. An average of 1.6 episodes per half the reported morbidities. High blood person was estimated for those reporting pressure, breathlessness, vomiting, no at least one morbid condition (Bhatia and control over urination, together formed a Cleland, 1996). Another study by Bang, substantial percentage of the responses. et.al located in Gadchiroli district of Other complaints included early Maharashtra prospectively followed 772 infections, menstrual irregularities and pregnant women from the third trimester vaginal discharge. Complaints were more onwards to 28 days postpartum. The frequent in rural areas and marginally incidence of maternal morbidity was found higher for cases of induced abortions. to be 52.6 percent. It was observed that labour complications (17.7%) were more Abortions serious in nature while post partum The issue of abortion thus merits attention morbidities were more frequent (42.9%). not only for itself but also for the range of Prolonged labour and prolonged rupture reproductive health problems that it can of membranes were the most common engender. Unsafe abortions can lead to intrapartum morbidities while breast infertility, maternal morbidity and problems and secondary postpartum mortality, among other undesirable haemorrhage formed the two most common outcomes. For a long period, since the early post partum morbidities. The authors 1970s, the proportionate share of abortions estimate that almost 15 percnet of the to maternal mortality remained almost women who deliver at rural homes unchanged, accounting for about one in potentially need emergency obstetric care ten maternal deaths in rural India (Soman, and 34.7 percent are in need of medical 1994). Despite its manifold implications attention (emergency or non emergency). and protracted engagements with it at the They also highlight the need of home based policy level, it is only in recent years that post partum care (Bang, et.al, 2004). At the abortion related data has been forthcoming. national level, possible post natal National level estimates of abortion complications are indicated by the NFHS- (especially those related to induced 2 which reports that 11 percent of the abortions) are admittedly underestimates women giving birth in the preceding three (IIPS and ORC Macro, 2000). The NFHS-2 years reported massive vaginal bleeding estimates that for every 100 pregnancies and 12.6 percent reported very high fever in the country, there are 4.4 spontaneous within two months of the birth - both abortions and 1.7 induced abortions. The complications registering higher rates for both types of abortion are higher

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PDF created with pdfFactory Pro trial version www.pdffactory.com in urban India. State wise data shows that some states like Manipur (6.3%), Tamil there are considerable variations across Nadu (5.2%) and Delhi (4.7%) record high states in the rates for spontaneous rates of induced abortion. Table 6 contains abortions- the rates ranging from 2.1 estimates of different pregnancy outcomes percent in Sikkim to 7.1 percent in Goa. (spontaneous abortions, induced abortions, Induced abortion rates are usually low still births and live births) for the states of (rates of less than 1 percent of pregnancy the country, as well as for rural India, urban outcomes not being uncommon). However, India and the country as a whole.

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PDF created with pdfFactory Pro trial version www.pdffactory.com Table 6: Pregnancy outcomes in India (for every 100 pregnancies)

SpontaneousInducedStill birthsLive births abortionsabortions North India Delhi5.84.71.388.2 Haryana5.71.4390 Himachal Pradesh4.51.62.691.3 Jammu & Kashmir5.12.61.890.5 Punjab4.132.990 Rajasthan50.92.191.9 Central India Madhya Pradesh3.811.893.4 Uttar Pradesh4.51.41.892.4 East India Bihar3.20.32.194.4 Orissa5.41.62.190.9 West Bengal42.21.891.9 Northeast India Arunachal Pradesh2.60.73.193.5 Assam6.13.33.287.4 Manipur6.66.31.285.8 Meghalaya5.20.73.390.9 Mizoram5.30.62.391.8 Nagaland5.82.32.389.5 Sikkim2.10.92.994 West India Goa7.13.91.187.9 Gujarat4.92.11.491.6 Maharashtra3.81.91.592.8 South India Andhra Pradesh40.82.392.9 Karnataka40.92.392.8 Kerala5.71.91.291.2 Tamil Nadu6.25.22.586.2

India (rural)4.21.12.192.6 India (urban)5.23.41.589.9 India TOTAL4.41.7291.9 Source: NFHS-2.

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PDF created with pdfFactory Pro trial version www.pdffactory.com Exclusive studies on abortion report an a sharp decline in urban areas of the increasing trend in abortions- a disturbing country. Quite notably also, adverse female fact considering the country’s long to male sex ratios in the 0-6 age group are running family welfare programme. In a now being observed in areas other than the recent community based study in northern and western parts of India Maharashtra, for every 100 pregnancy (Agnihotri, 2003). outcomes for the reference period 1996- 2000, spontaneous abortion stood at 5.1 Infertility and induced abortion at 4.5 (Saha, Duggal Infertility-‘a diminished (or absent) and Mishra, 2004). The rates for both types capacity to produce offspring where the of abortions were higher in urban possibility of achieving conception is not Maharashtra. Both spontaneous and completely ruled out’ (UNFPA, 2000) is at induced abortions registered increased once a biological and a socio-psychological proportions in comparison to the mid problem in India. The centrality of 1970s. While this may be partly owing to motherhood in women’s lives in the recall lapse for the earlier time periods, it country makes infertility an emotionally is also indicative of greater access to difficult experience for them, stigma and abortion services and greater demand for blame often being directed at infertile/ a smaller family with the preferred sex of childless women. Infertility may impair the children. As the study showed, the social relationships, threaten the marital percentage of induced abortions increased relationship, lower the woman’s self-esteem with the order of pregnancy. The and make her feel powerless (Widge,2004; widespread resort to curettage among Unisa,1999; Jejeebhoy,1998). It can be providers can also engender post abortion caused by anatomical, genetic, morbidities apart from escalating costs endocrinological and immunological (Duggal and Ramachandran, 2004). problems (UNFPA,2000; WHO,1991). Qualitative field insights show that women However, it is understood that such factors may view abortion as a ‘safer’ option in are responsible for a miniscule of about 5 comparison to spacing methods like IUDs, percent of infertility cases world wide, a quite obviously oblivious of the serious vast majority of the cases being caused by health consequences that abortions can avoidable reproductive morbidities like bring about (ibid). sexually transmitted diseases and post partum and post abortion complications Another worrying aspect of abortions in (WHO,1991). Thus, common reproductive India is the widespread extent of sex morbidities in India like high levels of selective abortions. The child sex ratio has asymptomatic and untreated RTIs, declined (quite alarmingly) in the country. tuberculosis of genital organs and post It is estimated that as many as ten million abortion and post delivery morbidities are female foetuses were aborted in India in also responsible for bringing about the final two decades of the last century, infertility among women in India the phenomenon being present in major (UNFPA,2000). religious groups and states of the country (Jha, et.al, 2006). A girl child is clearly less Globally, infertility remains a little wanted especially if a family already has a understood phenomenon and may get daughter. In the 1990s, the female to male obscured in high fertility settings (WHO, sex ratio in the 0-6 age group has witnessed 1991). It has been observed that ‘multiple

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PDF created with pdfFactory Pro trial version www.pdffactory.com definitions’ of infertility make it difficult half of the currently married women aged to compare between different studies on 48-49 have experienced menopause. infertility and measure levels of infertility Andhra Pradesh, on the other hand, is a in the population (Widge,2004; state where 82.2 percent of the currently Jejeebhoy,1998).There are 8-10 million married women of that age group have infertile couples in the country, the already attained menopause. There are prevalence of primary infertility being 3% some states in the country where and that of secondary infertility at 5% menopause sets in early (before the age of (UNFPA,2000). The NFHS-1 estimates that 40) for a considerable proportion of women. for the country as a whole, 2.2% of the Andhra Pradesh is by far the front runner currently married women aged 40-44 years in this regard, with menopause being and 2.4% of such women aged 45-49 have reported by 22.1 percent of the currently never had a live birth. The rates for primary married women aged 35-39 years and infertility are almost similar for rural and another 12.8 percent of the currently urban India (IIPS,1995).The prevalence married women aged 30-34 years. Early rate of infertility may be high in some menopause is also seen in Gujarat and states- a study in Andhra Pradesh showing Karnataka, where more than 10 percent of that 5 percent of the currently married the currently married women below the age women suffer from (majorly primary) of 40 have experienced menopause. infertility (Unisa,1999). Annexure X gives information on menopause among currently married Menopause women by age and state. Early menopause Menopause marks the cessation of the may be related to the poor health status of reproductive life of a woman. Owing to women. A study in rural Andhra Pradesh hormonal changes that signal the end of a found that low haemoglobin and protein woman’s childbearing phase (with the levels, high parity and infections (bacterial, connotations of loss of youth and fecundity fungal and viral) are ‘major determinants’ and allusions to being an old hag ‘sadeli of early menopause in women (Mahadevan, buddhi’), menopause may be a mentally et.al, 1982). A more recent study based on and physically unsettling process. NFHS-2 data shows that women belonging Successful resolution may involve, among to the disadvantaged social groups of the other things, a redefinition of self. However, country (rural, illiterates, low standard of despite the universality of menopause, living, among others) are more likely to social science literature on the subject is experience the early onset of menopause remarkably scanty in India. The problem (Syamala and Sivakami, 2005). remains largely hidden, the socio- psychological consequences as Women and Disability experienced by women in the country The disabled (the differently abled) in India being little understood. represent diversities in their composition ranging from those with relatively According to the NFHS-2, by the age of 48- inconspicuous and non-hindering 49, two-thirds of Indian women have disabilities (for example, minor attained menopause. There are, however, orthopaedic handicaps) to those with more considerable interstate variations in this substantive ones. The social gaze that regard. In West Bengal (48.4%), Madhya stigmatizes and discriminates the disabled Pradesh (51.9%) and Kerala (53.0%), about is articulated from the vantage point of

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PDF created with pdfFactory Pro trial version www.pdffactory.com those more ‘privileged’ in terms of fullness marginalisation and discrimination in of limbs and organs. The very word society. disabled, for example, conjures up an image of one incapacitated in the carrying The census of 2001 puts the number of out of activities related to work and persons with disabilities in the country at personal life. The disabled are also victims 21,906,769. Of these, almost three-quarters of stereotyping, the word being used in a are in rural areas, slightly more than the monolithic sense without acknowledging rural share in the country’s population the differences in the various categories of (Table 7). In some forms of disabilities the disabled and their differing needs. (especially hearing disabilities), the Widespread exclusionary social practices proportion of the disabled in the rural areas characterise societal attitudes towards the is considerably higher than that in urban disabled in the country, many of them areas. Gender differentials in disabilities stemming from sheer oversight of the needs indicate that more than half the disabled of this group. An oft quoted example in this (across the various categories of regard being the flight of steps that mark disabilities) are men. This is especially the entrance of many buildings in the true in the case of those with movement country- a sight that would be formidable disabilities, where almost 64 percent are and a deterrent to people with orthopaedic men. This may be owing to the fact that and/or visual handicaps. Affirmative action motor accidents, which are a major cause on the part of the state and a more sensitive of limb impairment, are mainly societal disposition are thus very much in experienced by men. order in order to help the disabled fight

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PDF created with pdfFactory Pro trial version www.pdffactory.com Table 7: The Distribution of the Disabled by type of Disability, Sex and Residence, India 2001

TotalRuralUrban% rural Total disabled population 21,906,76916,388,3825,518,38774.81 %male57.5457.4257.91 %female42.4642.5842.09 No. of people with visual disabilities 10,634,8817,873,3832,761,49874.03 %male53.953.6354.66 %female46.146.3745.34 No. of people with speech disabilities 1,640,8681,243,854397,01475.8 %male57.4157.457.46 %female42.5942.642.54 No. of people with hearing disabilities 1,261,7221,022,816238,90681.07 %male53.453.6852.24 %female46.646.3247.76 No. of people with movement disabilities 6,105,4774,654,5521,450,92576.24 %male63.9263.9263.93 %female36.0836.0836.07 No. of people with mental disabilities 2,263,8211,593,777670,04470.4 %male59.8459.5760.49 %female40.1640.4339.51

Note: Computed from Census 2001 figures.

Women with disabilities constitute a disabilities come a distant second at 23.68 substantial population subgroup in the percent. The proportionate share of country, totaling 9,301,134 (RGI, 2005c). mentally retarded women is 9.77 percent The proportion of women with different followed by those with speech (7.51%) and disabilities to the total disabled women in hearing disabilities (6.32%). State wise India closely replicates the gender breakup usually follow the national pattern aggregated national pattern. Women with in the proportionate distribution of visual disabilities account for more than different types of disabilities. Visual half (52.71%) of the total disabled women disabilities constitute the single largest in the country (Annexure XI). The category of disabilities in women across all proportion of women with movement states and union territories of the country.

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PDF created with pdfFactory Pro trial version www.pdffactory.com In some states like Jammu and Kashmir either the feminist movement or the (70.83%) and Tamil Nadu (66.62%), the disability movement. Disabled women are proportionate share of the visually impaired more vulnerable to neglect and abuse women is very high to the total population because of their disability. They are more of disabled women. Women with movement likely to be ‘physically, sexually and disabilities usually constitute the second emotionally abused’; subject to forced largest category of disabled in the states sterilisation, contraception and abortion; and union territories. However, the north- and more likely to be malnourished than eastern states of Arunachal Pradesh, disabled males. In many countries, the Mizoram, Nagaland and Sikkim have higher mortality rates are higher for disabled proportions of women with speech/hearing females when compared to that of disabled disabilities than movement disabilities. males (Mobility International USA, 2003). The third largest category of disabled It has also been observed in the Indian women in the different states of the country context that disabled women are deemed may be either those with mental retardation asexual- socially, biologically and or speech/hearing disability, the pattern psychologically- resulting in the denial of differing from state to state. their sexuality. This has telling implications on growing up, disabled girls In contrast to the age aggregated data, being confused about processes like breast among the elderly, higher proportions of the development, menstruation and sex and women are disabled in comparison to the their being under constant danger of men (NSSO, 1998a). (Higher proportions of sexual abuse (Limaye, 2003). Disability in the disabled women have been reported in women may make them susceptible to the NSS 47th round (1991) as well as in the certain types of abuse that ‘normal’ women 52nd round (1995-96)). The pattern of may not be subject to, for instance, being disability found among elderly women and abused by caregivers or forcefully being men is also slightly at variance from that shifted to another place (Depoy, Gilson and found in the general population. Visual Cramer,2003). disabilities continue to account for the largest share among the elderly women and Women and Mental Health men, but hearing disabilities constitute the The Tenth Revision of the International second highest type of disability (Annexure Classification of Diseases (ICD-10) XII). categorises mental and behavioural disorders into eleven broad categories, The experiences of disabled women are encompassing the wide variety of mental complex. Disabled women constitute a and behavioural disorders that are ‘neglected minority of women and disabled experienced by people in the world. The in a majoritarian world of men and of the categories are: organic, including non-disabled’ (Hans, 2003). Asha Hans symptomatic, mental disorders; mental also observes that such women face ‘triple and behavioural disorders due to discrimination’, the discrimination being psychoactive substance use; experienced on multiple fronts-as women, schizophrenia, schizotypal and delusional as disabled and as women with disabilities disorders; mood (affective) disorders; (ibid). However, despite their special (and neurotic, stress-related and somatoform gendered) needs, the concerns of disabled disorders; behavioural syndromes women have not been taken up actively by associated with physiological disturbances

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PDF created with pdfFactory Pro trial version www.pdffactory.com and physical factors; disorders of adult patterns. Reviewing a number of studies in personality and behaviour; mental India, Davar observes that while gender retardation; disorders of psychological differentials in severe mental illnesses are development; behavioural and emotional not significant, women are more likely to disorders with the onset usually occurring suffer from common mental illnesses, the in childhood and adolescence; and prevalence rates of such illnesses being unspecified mental disorder. Though an often almost double in women in estimated 450 million people in the world comparison to that in men (Davar,1999). suffer from a mental or behavioural Such gender differentials have been disorder, however, such problems are noticed in rural and urban India. A study ‘largely ignored or neglected’ in many parts of more than 11,000 patients from two of the world (WHO,2001). The 2001 World hospitals in south India found that Health Report observes that ‘advances in depression and somatoform and neurosciences and behavioural medicine dissociative disorders were more prevalent show that, like many physical illnesses, in women (Vindhya, Kiranmayi and mental and behavioural disorders are the Vijayalakshmi, 2001). Such disorders are result of a complex interaction between manifestations of the multiple burdens in biological, psychological and social women’s lives and the role strain and role factors’(ibid:1). This being so, the mental conflict that they experience. The resultant health of a people/ population subgroup stress is compounded by women’s depends on the social environment and powerlessness and their inferior social the individual’s response to it. World wide, status. Interestingly, the study found five the levels of mental illness suffered by men groups of women to be most affected by and women are similar. However, both in mental disorders. These are: married the developed as well as the developing women; women in the reproductive age world, there are consistent patterns in the group; unskilled labourers; women with types of disorders that are likely to be found little education; and women who were in the two sexes. Anxiety and depressive ‘principally housewives’. disorders are more likely to be found in women and substance use disorders and Women and Work antisocial personality disorders in men The multiple burdens of paid work, (ibid). The higher prevalence of anxiety and childcare and household responsibilities depressive disorders among women has that women shoulder and the manifold been attributed to hormonal changes at effects (health and otherwise) it engenders certain times of their lives (for example has been a leitmotif in feminist literature postpartum depression); psychological and on women and work. However, as an area social factors (like the possibility of actual of enquiry in health research, the field of and perceived stressors); and domestic and occupational health occupies an enclave sexual violence that they face. Comorbidity of its own, with limited dialogue with other (especially the presence of depressive, areas. Historically, much of the body of anxiety and somatoform disorders evidence focuses on the (male) worker in together) is also more common among an industrial setting. Sex differentials in women (ibid). occupational injuries and deaths may be obscured because of non-presentation of Studies on the mental health of women in such data. For example, labour statistics India show consistent gender wise do not carry sex disaggregated data on fatal

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PDF created with pdfFactory Pro trial version www.pdffactory.com and non fatal injuries in factories, mines, workplace can also be a site where women railways and ports (Government of India, are subject to sexual violence and gender 2003). Further in India, within the body of discrimination. In addition, the specific work on occupational health of women, a situational contexts of their employment disproportionate share is claimed by may engender numerous health risks in enquiries into women’s occupational women. As Kaila writes, ‘research evidence health in low paying, low skilled (and often indicates that women face certain work- unorganised) sector. It is a truism that related health problems such as women in India concentrate in such jobs, psychosomatic symptoms, general health often with no fixity of employment and little and women specific health problems, or no social security benefits. The 2001 including menstrual disorder, anxiety, census, for example, shows that backache, anaemia, depression, abortion, considerably higher percentages of females miscarriage and other gynaecological than males are marginal workers for the problems’ (Kaila, 2004a: iii). country as a whole as well as its rural and urban areas (Annexure XIII). In such Emerging evidence on occupational health settings, out of pocket expenses typically point to a host of job specific occupational mark any expenses incurred for health health hazards along with the role conflict related events. Traditionally and role strain that women experience. disadvantaged with respect to education Nurses may suffer from workload, role and acquisition of skills, women’s entry ambiguity, problems in interpersonal into the labour market is also hindered by relationships and death and dying childbearing and childcare. They concerns, as also emotional distress, constitute, what has been called in Marxist burnout and psychological morbidity theory, a ‘reserve army of labour’. However, (Parikh, Taukari and Bhattacharya, 2004). women (especially those belonging to the In a study of women working in a small upper castes/classes in urban areas) have scale industry whose work entailed sitting also gained from education and cross legged on the floor for six to eight employment opportunities in independent hours in a day, it was found that the India, constituting a not so negligible prevalence of pain and discomfort among population subgroup of female salaried such women was higher than that in the professionals in the country. control group of housewives. The pain experienced in the working women was A gendered analysis of the occupational more enduring and less amenable to health of women is necessitated due to the amelioration from rest and it was inferred contexts of women’s lives. As we have seen that work posture led to such pain among earlier, the multiple roles that women them (Desai and Gaur, 2004). For women discharge can have deleterious effects on managers, ‘major stressors’ include getting their health. Paid work coupled with the work done, clashes with superiors, childcare and household responsibilities, competition, dual responsibilities of result in role strains and little leisure for household and job, meeting deadlines, and women. For women, the ‘spillover’ of family so on (Kaila, 2004b). A study of women related stress on work related stress is construction workers revealed often long higher than it is in the case of men (10-12) hours of work in a noisy, dusty (Narayan, et.al, 1999 cited in Parikh, environment full of pollutants like tar and Taukari and Bhattacharya, 2004). The glass. Respiratory, eye and skin disorders

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PDF created with pdfFactory Pro trial version www.pdffactory.com as well as noise induced hearing loss were Hospitals and clinics are common. More than half the women (56%) disproportionately concentrated in urban reported of injuries that led to work loss. centres to the literal neglect of rural areas. About three-fourthsof the women reported On the face of weakening public healthcare gendered stressors like sex discrimination in the country and increasing and balancing work and family demands, privatisation, it is usually the urban elite apart from ‘general’ stressors like excessive which gets timely and competent care. workload and underutilisation of skills Apart from such dimensions of access, (Lakhani, 2004). Occupations like women’s access to healthcare is ‘mediated agricultural labour have been seen to be a by gendered experiences’ (Mishra, 2004). ‘significant factor’ in risk of sexually Attitudes towards health and general well- transmitted infections (STIs) (Prasad, et.al, being of girls and women, submissive 2005). gendered roles that translate into limited control over household resources and restricted involvement in decision III. ACCESS TO HEALTHCARE making, and housework and care giving The concept of access, ‘use of healthcare roles that consume much of women’s time by those who need it’ (Makinen et.al (2000) and energies reflect in their inferior health cited in Dilip, 2005), is multilayered in its status and access to healthcare. meaning. In the context of family planning services, access has been synonymously The household as a site of discrimination used with accessibility and defined as ‘the Women’s empowerment is hindered by degree to which family planning services limited autonomy in many areas that has and supplies may be obtained at a level of a strong bearing on development. Their effort and cost that is both acceptable to and institutionalised incapacity owing to low within the means of a large majority of the levels of literacy, limited exposure to mass population’ (Bertrand, et.al., 1995:65). As media and access to money and restricted the authors note, it is assumed in this mobility results in limited areas of definition that potential clients are competence and control (for instance, interested in obtaining the services. Access cooking). The family is the primary, if not has ‘five key elements’, namely, geographic the only locus for them. However, even in or physical accessibility; economic the household domain, women’s accessibility; administrative accessibility; participation is highly gendered. cognitive accessibility, and psychosocial Nationally, about half the women (51.6%) accessibility (ibid). The term, ‘access’, thus are involved in decision making on their not only connotes physical access (physical healthcare (IIPS and ORC Macro, 2000). proximity, transportational mobility, etc) Women’s widespread ignorance about but also refers to dimensions of social matters related to their health poses a access. In the Indian context, typically serious impediment to their well-being. caste and class advantages play it out. The NFHS-2, for example, reports that out Access being a function of many of the total births where no antenatal care determinants, peculiarities in healthcare was sought during pregnancy, in 60 provisioning in India undoubtedly percent of the cases women felt it was ‘not influence access to healthcare in the necessary’(IIPS and ORC Macro,2000). country. There is an urban bias in the And, at a time when AIDS is believed to country’s healthcare infrastructure. have assumed pandemic proportions in the

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PDF created with pdfFactory Pro trial version www.pdffactory.com country, 60 percent of the ever married in many ways. In such a setup, the new women have never heard of the disease bride, already ignorant about health (ibid). Women’s inferior status thus has processes, may be in a difficult position to deleterious effects on their health and seek healthcare. Barua and Kurz report limits their access to healthcare. from their study on married adolescent girls in Maharashtra that ‘girls had neither That the family provides care for the ill and decision making power nor influence’ in is a resource in times of crisis is well- matters relating to seeking healthcare for recognised in social literature. However, their problems (Basu and Kurz, 2001). the receiving of care as well as access to These illnesses that incapacitated girls familial resources can be highly gendered, from discharging their household favouring the males. The family has often responsibilities were treated quickly. The been described in many feminist writings culture of silence prevented care seeking as the ‘the primary site of oppression’, an in problems related to sexual health. Some institution where differential access to reproductive health problems went healthcare is played out. Miller cites untreated because they were considered numerous ethnographic evidence to show ‘normal’. In the Nasik study by Madhiwalla, how son preference shapes practices of et.al, 45% of the episodes of ill health in feeding, medical care and (suggestively) women went untreated (Madhiwalla, ‘love and warmth’ in families in north India Nandraj and Sinha, 2000). In most cases it (Miller,1997).Weaning diarrhoea (a was financial incapacity that precluded condition triggered by weaning and women from seeking treatment. But, quite exacerbated by nutritionally poor food and notably, in almost a quarter of the cases, improper medical attention) is more women thought that the illness did not common among girls than boys. Boys in require medical attention. Treatment was north India may be favoured when it comes also not sought for reasons like to extra helpings of food and savouries. inaccessibility /inadequacy of the health Notably such differentials are not as facilities. pronounced in south India and may favour the females there in certain circumstances In a study carried out in Mumbai and (for instance, during menstruation) (Miller, Bangalore on discrimination, stigmatization 1997). Almost without any dissenting and denial (DSD) experienced by HIV/AIDS evidence, medical care is seen to be delayed people in a variety of contexts-healthcare, and less expensive for girls. There may also home and the community, workplace, be greater readiness to seek medical care schools, etc., - the authors observe that for boys (ibid; also Khan et.al., 1987). discrimination is a ‘gendered phenomenon’ (Bharat, Aggleton and Tyrer, The household has been seen to be a 2001). Such gendered discrimination may prominent site for gender based be experienced in a number of familial discrimination in matters of healthcare in settings and is most prominent in the a number of other studies too. Marriage in marital household. Both the son and the India is predominantly patrilocal with the daughter-in-law may have been afflicted by new bride relocating to her marital house HIV/AIDS, yet it is the woman who was most after marriage. Early marriage usually follows likely to be subject to discriminatory a truncated education, disadvantaging girls practices like refusal of shelter, denial of

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PDF created with pdfFactory Pro trial version www.pdffactory.com household property, denial of access to the of the old women in the household were children, being blamed for the husband’s usually ignored, though blatant HIV positive status (that she could not keep discrimination with respect to food intake him ‘under control’; that she was may not take place (Khan, et.al.,1987). responsible for his state, the latter Sudden and serious sickness may merit especially being true if the husband’s HIV attention from members of the family but positive status came to light soon after recurrent/chronic illness is often marriage). The authors note that neglected, with old people usually being ‘discrimination against daughters-in-law seen as a burden on the family (ibid). was blatant even when sons received good familial care’. Being denied access to That gender differentials in access to treatment and care and the unwillingness healthcare are pan Indian in nature is of the family to expend money towards the discernible from nationally representative daughter-in-law’s treatment formed a surveys like the NFHS and the NSS. recurrent theme in such discrimination. Discrimination against girls in the As Bharat puts it succintly, it is a case of household spills over to public spaces and ‘shared fate: gendered experiences’ may militate against programmes aimed at (Bharat, 1996). ameliorating the community’s health. Gender differentials are present in child Old age usually signals a period of immunisation. The NFHS-1 data shows dependency for most women (and men). that, with the sole exception of the polio The period is one of loneliness (the vaccine given at birth, higher proportions husband usually having predeceased the of boys are vaccinated than girls (Table 8) woman) and reduced power within and and are more likely to be fully vaccinated without the household. In such a setting, than girls. The survey also shows that for the woman may be subject to common childhood ailments like acute discrimination/neglect or even abuse. respiratory infection, fever and diarrhoea, Khan, et.al report from a study in Uttar boys are more likely to be taken to a Pradesh that the special nutritional needs healthcare provider/facility than girls.

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PDF created with pdfFactory Pro trial version www.pdffactory.com Table 8: Sex differentials in Child Immunisation and Treatment of Childhood Ailments

Child ImmunisationTreatment of (% vaccinated)ailments (% taken to a healthcare facility/ provider) DPTPolio 123123 Male 644.668.261.353.569.163.45543.736.770.870.163 Female 60.34.664.457.149.864.858.951.740.634.160.863.159.2 Source:NFHS-1. Note: ± Refers to children who are fully vaccinated i.e. those who have received BCG, measles, three doses each of DPT and Polio vaccine (excepting Polio 0).

In both the 42nd (1986-87) and 52nd (1995- is indicated by the rounds of the NSS. 96) rounds of the NSS, the percentage of ailing males treated was higher than that As an event in healthcare, hospitalisation of ailing females in both rural and urban usually marks an extreme step requiring areas (Table 9). The differences in closer monitoring of and attendance to the percentage of males and females treated is patient’s health through inpatient narrow (the differences being one to three admission. Quite naturally, it is an event percentage points) in both the rounds and that entails considerable expenditure of hence it is argued in the survey report that money and time on the part of the patients ‘the reported rates of treatment of the sick and their relatives. For the working class, do not indicate any perceptible gender bias hospitalisation would mean foregoing work in either of the surveys’ ( NSSO,1998b: 20). days. Thus, in many ways hospitalisation However, given the admission of proxy marks a distinct event in the health reporting in various rounds of the survey seeking behaviour of people and its and the limitations of NSS survey data that reporting is believed to be free from errors. are considered ‘incomplete’ with respect to For the country as a whole, gender economic class and gender (Sen, et.al, differentials are not evident in 2002), the actual differentials in treatment hospitalisation rates for males and females between the sexes may be higher than what in either rural or urban areas (Table 9).

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PDF created with pdfFactory Pro trial version www.pdffactory.com Table 9: Treatment of Ailments and Hospitalisation, NSS (42nd and 52nd rounds)

% of ailing persons treatedNumber (per 1000) of persons during 15 days hospitalised in 1995-96 and 1986-87 1995-961986-871995-961986-87 (52nd round)(42nd round)(52nd round)(42nd round) Rural Male 848314* Female 828013* Person 83821328 Urban Male 919020* Female 908820* Person 91892017 Source: NSSO Report no 441. Note: * estimates not available

However, if hospitalisation data is (almost progressively) with the increase in disaggregated to fractile groups according MPCE indicating that factors other than the to monthly per capita consumption purchasing power of the household expenditure (MPCE)-a proxy for the level of influence women’s hospitalisation rates in living of the household- valuable insights the higher fractile groups. Further, the into access issues within and outside the disparity in healthcare provisioning in the household can be gleaned (Table10). rural and urban areas of the country is Gender differentials are present, though amply demonstrated by the lower not very discernible, in the lower fractile hospitalisation rates in rural areas groups but become prominent in the two compared to the urban areas across all the higher fractile groups. Further, in both fractile groups, even though rural India has rural and urban areas, rates of poor health indices on many counts hospitalisation increase progressively with (including infant mortality rate often the increase in MPCE. It may be argued considered to be a robust indicator of a here that hospitalisation being a costly community’s health). Considering that event both in terms of time and money, poor morbidity rates were lower and people may avoid/delay hospitalisation hospitalisation rates higher during the mid and do so for both the sexes. That the lowest 1980s in the rural areas of the country (as fractile group usually reports a slightly reported by the NSS 42nd round), the higher hospitalisation rate for females may decline in hospitalisation rates in the mid be suggestive of the fact that it must be in 1990s indicates not only deteriorating cases of extreme and incapacitating ill conditions in rural healthcare but also health that women of this fractile group get increasing inability of people to afford hospitalised. The gap in hospitalisation healthcare. rates between the two sexes increases

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PDF created with pdfFactory Pro trial version www.pdffactory.com Table 10: Proportion of persons hospitalised (number per 1000) in the last one year by MPCE fractile group, NSS 52nd round

MPCE fractile group 0-1020-Oct20-4040-6060-8080-9090-100 Rural Male 3681016223914 Female 458915213413 Person 4681015213713 Urban Male 1213171920263920 Female 1313152022283620 Person 1213161921273820

Source: NSSO Report no 441,1998.

The unwillingness of families to expend for females do not show very distinct towards healthcare of female members has differences (patterns can be read into them been reported in a number of micro studies. nevertheless), cost differentials between The NSS data confirm the same for the the sexes in accessing treatment show that country as a whole. For non-hospitalised services that are accessed for females are as well as hospitalised treatment, the total usually the ones that are convenient and expenditure incurred for males is cheap than those accessed for the males considerably higher than that for females in a household. Typically such facilities in both rural and urban India (Table 11). are those that are cheaper and/or closer to Though, as has been seen earlier, the place of residence. treatment for ailments and hospitalisation

Table 11: Average Total Expenditure (in Rs.) incurred per ailment for Non-hospitalised and Hospitalised Treatment, NSS 52nd round

Non-hospitalised TreatmentHospitalised Treatment RuralUrbanRuralUrban Male 1511873,7784,185 Female 1371642,5103,625 Person 1441753,2023,921 Source: NSSO Report no 441,1998.

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PDF created with pdfFactory Pro trial version www.pdffactory.com Formal healthcare The private health sector in the country is The formal healthcare setup in India is large and amorphous, and chiefly engaged huge and diverse. Sectoral plurality and in curative care. The not-for-profit sector functional diversities mark the (including services by non governmental provisioning of healthcare in the country. organisations) is also present in many The privileging of the biomedical model in urban and rural areas of the country. There medical colleges across the country is remarkable diversity in the private sector reflects in various ways, ranging from in terms of the systems of medicine textbooks that are often gender blind/ practised, the type of ownership (ranging insensitive to providers’ attitudes that may from sole proprietorship to partnerships display lack of understanding of socio- and corporate entities), and the services economic causes underlying ill health. The provided. The private sector has a presence public sector has a considerable and in most medium to big villages as well as diverse physical presence, largely owing to in towns and cities. However, facilities with the gains made prior to the 1990s. The technologically advanced equipment and public healthcare infrastructure ranges offering varied specialisations are almost from a subcentre in a village to always in the big urban areas. In terms of multispecialty, multibedded hospitals in sheer numbers as well, the private sector urban areas. Primary Health Centres, is disproportionately concentrated in the Rural Hospitals, Civil Hospitals as well as urban areas. For example, in 2004, Jalna a host of facilities like municipal hospitals district of Maharashtra had nine private and clinics are some of the other public facilities for every public facility for the healthcare facilities. The state may also district as a whole. The ratio is higher in run health facilities dedicated to specific talukas having greater urban populations. diseases (for example, leprosy clinics) or Jalna taluka, where the administrative specific population sub groups (for headquarters is located, had twelve private instance, Central Government Health facilities to every public facility (Mishra and Scheme). The structure of the public health Raymus, 2004). sector is thus fairly well defined. In the 1990s, there has been uneven growth in Large scale national surveys like the NSS the number of Community Health Centres and the NFHS, as well as numerous smaller (CHCs), Primary Health Centres (PHCs) and studies report that the private sector is the Subcentres (SCs) in the different states and dominant sector in healthcare. The 52nd union territories of India. While some round of the NSSO (carried out in the mid states have witnessed considerable 1990s) estimates that the private sector increase in such facilities, the progress has accounts for nearly 80% of non- been very slow or stagnant in others hospitalised treatments in both rural and (Annexure XIV). For the country as a whole, urban areas, up by 7-8 percentage points tribal areas are deficient in the three types from the estimates of the 42nd NSSO round of public facilities set up for providing in the mid 1980s (NSSO, 1998b). For primary healthcare, the deficiency being hospitalised treatment, the public sector severe for Community Health Centres. has lost out to the private sector in the Barring a few states and union territories, 1990s, in contrast to the 1980s when the the others have deficiencies in the three public sector accounted for the majority of types of public facilities (Annexure XV). the hospitalised treatments in both rural

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PDF created with pdfFactory Pro trial version www.pdffactory.com and urban areas of the country (ibid). Client operates nutritional and educational satisfaction is higher in the private sector programmes for adolescent girls. along indices like behaviour of the staff, privacy accorded, amount of time spent, Given its reach and the machinery, the etc (IIPS and ORC Macro, 2000). Despite ICDS has tremendous potential in realising its ubiquity and appeal, the private its goals. However, it has often been healthcare sector in India is poorly criticised for being a tremendous drain on regulated and operates with little state resources with little benefits accruing accountability with respect to its actions thereof, widespread malnutrition related (Nandraj,1994).Allegations of irrational deaths of children in tribal areas being a practices and even malpractices are not case in point. The programme suffers from uncommon against the private sector in severe limitations. It rarely nets in all India. A large number of studies (micro as eligible children and women as well as large scale macro studies) have beneficiaries. In the state of Maharashtra, pointed out the high cost of treatment in for example not more than three quarters the private health sector of the country, the of eligible children and women are costs being many a time more than double enrolled in the programme (the figures of that incurred in the public sector. being lower for women). A little more than half the eligible women benefit from The Integrated Child Development Services supplementary nutrition. In the case of (ICDS) is a centrally sponsored programme children, the proportion stands a bit higher of the Government of India, operational being a little above 60 percent (Duggal, since 1975. The programme, the largest of 2002). Further, inspite of delivering its kind in the world, provides a host of services to pregnant and nursing women services,aimed at ameliorating the and to some extent, adolescent girls, the nutritional and health status of children programme is child centric in design, its and women. The programme operates on stated objectives focussing on child health the premise that children below six years and well-being. The inclusion of pregnant and pregnant and nursing women of the and nursing women as beneficiaries is ‘poorest of the poor families and living in owing to their maternal status. The focus disadvantaged areas including backward on child health is deserving and merits the rural areas, tribal areas, and urban slums’ attention. However, it dilutes the other constitute the ‘most vulnerable groups’. components of the programme. Among Currently the scheme is operational in ICDS functionaries, pregnant and nursing 4200 projects in the country with the women are seen as incidental to the number of stated beneficiaries being 2.77 programme. In one study, such women crores. The scheme has ‘universal/near were never seen during random visits to universal coverage’ in the states and union anganwadis and programme functionaries territories of Arunachal Pradesh, Goa, admitted that the supplementary nutrition Haryana, Himachal Pradesh, Karnataka, meant for women is often collected and Manipur, Meghalaya, Mizoram, Sikkim, supposedly consumed by the women at Tamil Nadu, Tripura, Andaman and home (Mishra, Duggal and Raymus,2004). Nicobar islands, Chandigarh, Delhi, Dadra and Nagar Haveli, Daman and Diu, Disability and access to healthcare Lakshadweep and Pondicherry. In some of Many disabilities are preventable and by the blocks in the country, the scheme also one account, over 70 percent of the

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PDF created with pdfFactory Pro trial version www.pdffactory.com disabilities can be prevented (Mullick the world, disabled girls and women are Alkazi, 1992). Disabilities owing to motor disadvantaged in many ways that limit accidents, polio induced handicaps, minor their participation in development. Denial speech and hearing problems, are (or limited) access to education, vocational avoidable and could be effectively training, employment, and rehabilitative circumvented where timely and competent services as well as limited mobility both on care is readily available. In a more account of their disability as well as equitable society, where access to restrictive practices make disabled women healthcare is not as skewed as it is in India, lead secluded and isolated lives (Mobility the burden of disabilities would not be as International USA, 2003). It has also been much. observed that access to reproductive health services are denied to disabled women by Addressing the various needs of the a host of factors working in tandem, disabled requires a multipronged strategy. namely, ‘cultural attitudes, physical As Mullick Alkazi points out, rehabilitation barriers, financial constraints and of the disabled includes physical unenlightened medical personnel and management of disabilities (that includes healthcare providers’(ibid). the training of the disabled in the use of appropriate aids and appliances), ‘early and Another indicator of the lopsided pattern adequate education’ and vocational in addressing disability based needs of the rehabilitation. It is estimated that only 0.2 country can be gauged from the percent of the disabled in India have geographical distribution of medical access to rehabilitative services (ibid), there specialists in the country. Personnel being many reasons for it. Typically class, trained in the specialities of eye, ENT (ear, geographical location and gender factors nose and throat), orthopaedics and intersect resulting in poor rehabilitative psychiatry as also those trained in different services for the disabled. Physiotherapy therapies would be indispensable in centres are few and limited to big hospitals, addressing the needs of the different types usually in the private sector. There are very of the disabled. However, such specialised few training institutes for physiotherapy in doctors are minimally present in the public the country. The reliance on expensive healthcare system of the country. Four equipment and shortage of trained human types of specialists (gynaecologists, power along with deficiencies in the paediatricians, physicians and courses (like the ‘misplaced emphasis on anaesthetists) are recruited to service the electrophysiology’) have resulted in gross network of rural/cottage hospitals that form shortcomings. Further, aids and the backbone of the public healthcare appliances ( for instance, hearing aids) are network in the country, virtually leaving usually western in their design, which the vast ranks of the disabled in rural India make them inappropriate in the Indian to seek services from the private sector. On context resulting in a ‘very high rate of its part, the facilities in the private sector rejection’ by the disabled person (ibid). One offering services to such a ‘niche clientele’ may add that in a context where disability as the disabled (to borrow a not so has attracted such little and lopsided inappropriate term from Management attention, addressing gendered needs Theory) are few and present in big urban within disability takes a backseat. Across areas.

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PDF created with pdfFactory Pro trial version www.pdffactory.com Women and access to mental healthcare fuzzy, less accepted concept of ‘distress’ The development of mental healthcare in than ‘illness’ and reflective of the socio- the country has a chequered history. The political context of their lives- is more pre-independence era was characterised suited to psycho-social research than to the by the establishment of mental hospitals, medical discipline of psychiatry. But the facilities like the hospitals at Ranchi, mental health sciences (and the hierarchy Thana, Yerwada, etc, being embedded in operative therein with psychiatry being the collective imagination of the people of privileged) have been virtually blind to the country. Mental health has attracted women’s mental health vis-a vis the socio- varying degrees of attention in the various political context of their lives. As the author health committees constituted by the puts it, there is a ‘perceptual blackout’ in Government of India. The first steps towards the mental health sciences about the making mental healthcare more accessible woman question. to the communities came in the form of establishment of General Hospital Access to mental healthcare is gendered Psychiatric Units (GHPUs). District in various other ways. Male patients Psychiatric Units (DPU) have also been set outnumbered females in both the hospitals up, though barring some southern states, from where data was collected for the study the DPUs are very rare in the rest of the by Vindhya, Kiranmayi and Vijayalakshmi country. The Alma Ata Declaration of 1978 (op.cit, 2001). (Davar’s review also indicates recommended mental healthcare as an such gender differentials in the utilisation essential part of primary healthcare. of facilities.) More than 50 percent of the However, mental healthcare continues to patients in both the facilities were male, be not only an underserved area in the gender gap being wider for the public healthcare in the country, both in terms of hospital. (Out of a total bed strength of 300 emphasis and human power, but also the in the public hospital, 225 were for men orientation of the discipline betrays bias and the remaining 75 for women). Further, towards psychiatry. The mental health as the authors point out, the mental health curriculum in undergraduate medical services in the country, with their emphasis courses is deficient in terms of the hours on electrotherapy and chemotherapy, are of training and is biased towards the geared to handle severe mental disorders biomedical perspective to the virtual (conditions that usually affect men). The absence of socio-psychological orientation common mental disorders that usually to mental health. afflict women require different lines of treatment like counselling and support Bhargavi Davar observes that the mental structures. The present mental healthcare health sciences, at least traditionally, have system in the country, with its emphasis been individual in their orientation on psychiatric services, thus is (Davar,1999). One should take cognizance inappropriate to meet the needs of women’s of women’s ‘lived experiences’ while mental health problems. As has been addressing their mental health problems. observed earlier, not only is there a deficit Marriage, multiple work burdens, violence, in mental health personnel in the country, membership in marginalised groups, are but also there is marginalisation of clinical stressors that women are (more) subject to, psychologists, psychiatric social workers that lead to somatisation and depression. and psychiatric nurses in the dominant Their experiences, more symptomatic of the discourse on mental healthcare. The

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PDF created with pdfFactory Pro trial version www.pdffactory.com services of the latter are critical to the programmes of the WHO addressing women successful integration of mental workers in the informal sector are yet to be healthcare into primary care as also to in place in the developing countries (ibid). make it responsive to the needs of women. Perchance in the context of a labour Further, the National Mental Health surplus economy like India’s, Programme (NMHP) of 1982 betrays and occupational health is one of the perpetuates the psychiatric bias in mental expendable luxuries for employers. In fact, healthcare. The programme singles out the in a recent study, discrimination in severe disorders of epilepsy, mental financial and career matters were retardation and the psychoses for associated with recurrent physical and intervention and is heavily informed by the psychological symptoms of the workers biomedical model. It has been commented (Lakhani, 2004). As the author also notes, that, ‘(the NMHP) does not have a women’s women may receive less on job safety mental health agenda’ (Vindhya, monitoring than men, making them less Kiranmayi and Vijayalakshmi, 2001). The trained to carry out their tasks. This leads programme is gender blind as well, to a ‘potentially dangerous cycle in which planning only for ‘illness’ and not for tradeswomen are asked to do jobs for which ‘distress’ as Davar comments. She also they are not properly trained, then are observes in this context that the promotion injured when they do them or are seen as of the ‘community’ paradigm in the incompetent when they are unable to do national mental health policy is premature them’ (ibid:191). Further, across the world, since there is as yet little acceptance or there is little recognition of health risks in understanding of mental illnesses, with the occupational setting and the manifold care being highly gendered even within the consequences they can engender. It has familial and community setting been observed, for instance, that excepting (Davar,1999). The community is also not a small minority of cases, very rarely do being equipped, financially or otherwise, doctors enquire about work or work to address such issues (ibid). patterns of women coming with gynaecological or other complaints. Being Occupational health multifactorial and having bearing on the Women’s access to occupational health worker’s working capacity, occupational services is limited for various reasons. diseases are but a subset of occupational Access to occupational health services is health. They are, as we have seen, limited for workers around the world. It is determined by ‘a complex set of social, estimated that only 5-6 percent of the cultural, economic, physical, and workers in the developing countries and biological factors’, necessitating preventive 20-50 percnet in the industrialised world and promotive strategies to forestall disease have access to adequate occupational and ensure health. It has therefore been health services (WHO,2002 cited in articulated that occupational health be Kaila,2004a). Gendered vulnerabilities integrated in the primary health care may further exacerbate the situation. For system (Jeyaratnam,1992). one, a substantial proportion of women in India work in the unorganised sector, Reproductive health services where social security benefits are rare and Decades of policy engagements with routine job entitlements virtually population control has spawned a genre of nonexistent. Occupational health writings on the subject. Literature has

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PDF created with pdfFactory Pro trial version www.pdffactory.com however been restricted to topics like comparison to those for the traditional contraceptive acceptance among women. methods. The public sector is the dominant Such writings on areas like programme provider of contraceptive related services impact and access that mainly flowed in the country as a whole, though its share under the broad rubric of operations has come down from 79 percent in NFHS- research were indispensable to the goals 1 to 76 percent in NFHS-2 (IIPS and ORC and objectives of the female specific Family Macro, 2000). However, inspite of nearly Planning Programme in India. In the past universal knowledge levels of any method decade or thereabouts, there has been a of contraception, there is still a marked shift in the studies on reproductive considerable unmet need for the same. It health services in the country. Areas of is estimated that if all women desirous of enquiry broadly coincide with the spacing or limiting their families were to (emerging evidence on) different use contraception, then the contraceptive reproductive health problems of women. In prevalence rate would increase from the the wake of the adoption of the current levels of 48% to 64% (IIPS and ORC Reproductive and Child Health Programme Macro, 2000). Interestingly, higher unmet by the Indian state, a series of studies needs of family planning are generally seen (namely the RCH Facility Studies) have among groups that have higher fertility been undertaken to gauge the levels (e.g. rural India; women belonging preparedness of the public sector in to lower SLI; Muslims - groups often responding to the demands of the assailed by vested interests to be programme. impediments in the realisation of the country’s population goal) (Table 12) thus Knowledge and use of contraception in indicating programmatic shortcomings. In India have been, understandably, abiding fact, NFHS-2 reports that 42.6% of the themes for academicians and policy current users of a modern method of family planners in the country. Over the span of planning reported that they were not fifty odd years, there has been increase in motivated by anyone, instead they have the levels of knowledge of contraceptive adopted the method on their own. Further, methods. The NFHS-2 reports that 99.0 imparting information on alternate percent of the currently married women in methods of family planning and on the the country are aware of any contraceptive possible side effects of methods is also very method (Annexure XVI). Even rural India infrequent (ibid). Keeping in mind the reports very high levels of knowledge of guiding principles of ‘reproductive rights’ any contraceptive method. The knowledge and ‘informed choice’ emerging from the levels are higher for the programme driven ICPD, such programmatic shortcomings modern methods of contraception in need to be addressed as a policy mandate.

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PDF created with pdfFactory Pro trial version www.pdffactory.com Table 12: Fertility and unmet need for Family Planning among select groups

Unmet need for family planning For spacingFor limitingTotal Residence Urban2.276.76.713.4 Rural3.078.97.816.7 Education Illiterate3.477.88.516.2 Literate (less than middle school)2.648.46.114.4 Literate (middle school complete)2.2611.16.117.1 Literate (high school complete and above)1.998.86.315.1 Religion Hindu2.7887.115.1 Muslim3.59111122 Christian2.448.76.114.8 Sikh2.263.65.18.6 Jain1.95.93.69.5 Buddhist/neo-Buddhist2.137.45.312.7 Other2.336.95.412.3 No religion3.9114.211.425.6 Caste/Tribe Scheduled Castes3.158.68.216.8 Scheduled Tribes3.068.8715.9 Other Backward Classes2.838.67.115.7 Others2.667.77.515.2 Standard of Living Index Low3.3798.817.9 Medium2.858.57.215.6 High2.16.76.112.8 Total2.858.37.515.8 Source: NFHS-2.

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PDF created with pdfFactory Pro trial version www.pdffactory.com A characteristic feature of access to southern states and some others in the rest healthcare in the Indian context is the of the country may have more than 75% unevenness in the physical and functional coverage. In ten of the twenty five states of provisioning of facilities across the the country (for which the NFHS provides country. The uneven access to antenatal the figures), less than 60% of the births have care can, for example, be gauged from the received two or more tetanus toxoid fact that India is classified in the Class B injections. Meghalaya (30.8%), Mizoram category of nations in the world where (37.8%) and Arunachal Pradesh (45.6%) between 11% to 50% of the districts are at bring up the rear (Table 13).Other ‘high risk’ of neonatal and maternal tetanus indicators of antenatal care services are (UNICEF,WHO,UNFPA,2000). Neonatal and as discouraging. Only 43.8 percent of the maternal tetanus can be prevented by births in the preceding three years of the universal coverage of antenatal services survey had received three or more and safe delivery practices. The tetanus antenatal checkups, there being large toxoid injections which form part of routine interstate variations in this regard, too. antenatal care in the country would help While states like Kerala (98.3%) and Goa in countering the problem to a large extent. (95.7%) are the leaders, Uttar Pradesh However, given the poor coverage in (14.9%) and Bihar (17.8%) are the antenatal care services in the country, the tailenders. Similarly, less than half elimination of neonatal and maternal (47.5%) of the births received the supply of tetanus remains an unrealised goal. iron or folic acid tablets or syrup for three months and more. Further, women of NFHS-2 indicates that nationally about certain backgrounds (tribals, illiterates, two-thirds (66.8%) of the births in the three poor) are less likely to receive antenatal years preceding the survey had received care during their pregnancy. For example, two or more tetanus toxoid injections almost half of the births among illiterate during the pregnancies (IIPS and ORC women (48.4%) and poor women (45.1%) Macro, 2000). In no state is there universal are not preceded by any antenatal coverage of such a service, though the checkups (Annexure XVII).

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PDF created with pdfFactory Pro trial version www.pdffactory.com Table 13: Antenatal care services in the states of the country

% recd at% recd 3% recd 2% given any% recd least one ANCor more ANCor more TTiron or folicsupply of iron checkup checkupsinjectionsacid tabletsand folic acid or syruptablets or syrup for 3+ months North India Delhi83.568.284.977.869.5 Haryana58.137.479.76753.3 Himachal Pradesh86.860.966.285.670.9 Jammu & Kashmir83.26677.770.855.8 Punjab745789.979.664.2 Rajasthan47.522.952.139.330.6 Central India Madhya Pradesh6128.15548.938.4 Uttar Pradesh34.614.951.432.420.6 East India Bihar36.317.857.824.119.8 Orissa79.547.374.367.662.2 West Bengal905782.471.656.4 North east India Arunachal Pradesh61.640.545.656.347.6 Assam60.130.851.75545.3 Manipur80.254.464.25038 Meghalaya53.631.330.849.540.6 Mizoram91.875.837.872.762 Nagaland60.423.150.942.526.7 Sikkim69.942.652.762.450.4 West India Goa9995.786.194.787.8 Gujarat86.460.272.77866.6 Maharashtra90.465.474.984.871.6 South India Andhra Pradesh92.780.181.581.270.7 Karnataka86.371.474.97874.2 Kerala98.898.386.495.288.6 Tamil Nadu98.591.495.493.284.1 India TOTAL65.443.866.857.647.5 Source: NFHS-2 Note: Includes information on the two recent births in three years preceding the survey.

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PDF created with pdfFactory Pro trial version www.pdffactory.com Like antenatal care, delivery and post contrast to 64.6% of the births in high SLI natal checkups are limited and skewed group that took place in health facilities, across social groups in the country. (In 18.5% of the births in low SLI took place in more ways than one, seeking of antenatal facilities. While almost two thirds (65.1%) care can be predictive of institutional of the births in urban India took place in delivery as well as post partum checkups. facilities, the figures come down to a The NFHS-2, for example, reports that the quarter (24.6%) for rural India. highest proportion of institutional delivery Considering the high proportion of non- and post partum checkups was among institutional births, especially among the women who had received four or more disadvantaged groups, it is not surprising antenatal checkups, in comparison to (but tragic all the same) that very few those who had had less ANC checkups. receive postnatal care. Considerable Seeking of antenatal care thus sets the proportions of women suffer from possible stage for subsequent care seeking for postpartum complications (as is evidenced delivery and post delivery related from the literature cited in the section on events).Only a third of all births in the maternal morbidity). But, post natal care three years preceding the NFHS-2 took is a neglected area both by service place in institutions (public, private or providers as well as women. Among non- NGO/trust run facilities), while almost the institutional births, only 16.5% were whole of the remainder took place in homes followed by a post partum checkup within (IIPS and ORC Macro,2000). (Deliveries at two months of the delivery. Where post health facilities have registered an partum checkups did take place for non- increase between the two NFHS rounds, the institutional births, few were carried out corresponding figure being 26% for NFHS- within two days of the birth (14%) or the 1). There are large variations across the first week after delivery (31%) (Table 14). socio-economic groups (Table 14). In

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PDF created with pdfFactory Pro trial version www.pdffactory.com Table 14: Place of delivery and post natal care in India

Among those non institutional births Place of deliverywhere postpartum checkup was carried out Health facility/institution‡ PublicNGO/trustPrivate Residence Urban29.11.534.533.919.614.332.3 Rural12.50.511.674.316.114.230.5 Mother’s Education Illiterate10.20.46.881.513.614.531.9 Literate (less than middle school)23.31.11955.72412.828.9 Literate (middle school complete)28.5125.643.923.219.731.1 Literate (high school complete and above)24.21.549.324.327.41026.7 Caste/Tribe Scheduled Castes160.510.372.11715.532.5 Scheduled Tribes10.70.75.781.814.1517 Other Backward Classes16.30.81962.815.611.231.5 Other17.90.921.35918.318.432.9 Standard of Living Index Low11.90.46.280.315.514.430.5 Medium18.10.81664.116.513.629.4 High20.31.143.234.620.515.837.6 Total16.20.716.765.416.514.230.8 Source: NFHS-2. Note:Table is based on the two recent births in the three years preceding the survey. ‡ includes own home and parents’ home

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PDF created with pdfFactory Pro trial version www.pdffactory.com A major public health problem like casualty in the process. The authors say maternal mortality can be tackled by the that, ‘until recently, increasing access to provisioning of emergency obstetric care. MTP services was not an important issue Reduction in maternal mortality ratio can for the Ministry of Health and Family be effected by an equitable access to Welfare’(ibid: 518). Further, certified public emergency obstetric care (as also safe facilities may not carry out abortions for abortion services). Bhat observes, for reasons like lack of equipment, feeling of example, that ‘the level of maternal incompetence among the (trained) doctors mortality is clearly strongly related to and it is estimated that 1.6 million amenities and infrastructure available in abortions in India are handled by informal the village’ (Bhat,2002) (emphasis added). providers (Duggal and Ramachandran, It cannot be said of awomen, however 2004). A recent study carried out in seven normal and uneventful her pregnancy may states (spread across north, west, central be, that she is not in need of obstetric care. and southern India) found that informal The role of antenatal care in preventing or providers were present and provided even predicting obstetric emergencies is services in tribal, rural as well as urban questionable (Maine and Rosenfield,1999; areas of the states. The services of informal McDonagh,1996). Yet, access to providers were varied, ranging from giving emergency obstetric care services is a of oral herbal medicines to invasive privilege usually reserved for the methods like insertion of roots and sticks advantaged groups of urban India. As we into the vagina or resort to ‘modern’ have seen earlier, in the private sector methods like injections. Some injections technologically advanced facilities with given by such providers are actually skilled human power, more often than not, contraindicated during pregnancy operate in urban areas. Very soon in this (Ganatra and Visaria, 2003). section we shall see how considerable proportions of the public health facilities In the Maharashtra community based (like the FRUs, CHCs, PHCs) are not study, only a quarter of the induced adequately equipped in areas of staff, abortions in the period 1976-2000 fell infrastructure, equipment and supply to within the framework of the Medical provide for even outpatient care. With poor Termination of Pregnancy (MTP) Act, the transportation facilities and a poorly majority of the pregnancies being functioning referral system, obstetric terminated for reasons such as unwanted emergency cases from rural India become nature of the pregnancy, economic reasons primary casualties, though urban India is and sex selection. Further, care is not not very far behind either. sought for a considerable percentage (21.6%) of spontaneous abortions with Despite the legalisation of abortion (for telling implications for maternal health. chiefly biological reasons) in India, access The private sector is the overwhelmingly to safe abortion services is neither assured dominant sector in abortion related nor uniform across social groups of the services, often being situated closer than country. There are more number of certified the public facilities. However, among both abortion facilities in urban areas and in the private and the public providers, the developed states of India in comparison treatment (both medical and otherwise) to those in rural India or the less developed varies according to the woman’s states (Khan, et.al), equity being an obvious background, especially the economic class

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PDF created with pdfFactory Pro trial version www.pdffactory.com to which she belongs. Further, on an private sector. Recourse to such services average, services in the private sector cost are often the last resort, after the couples Rs.1300 (being almost eight times costlier have tried out other ‘less intrusive’ options than those in the public sector), a cost that (Widge 2001 cited in Widge, 2004).The may be formidable for many (Saha, Duggal author also notes that there is difficulty in and Mishra,2004). accessing information about ARTs and specialist doctors. Services are usually Treatment for infertility is an expensive carried without imparting adequate and time taking process. In a country information or counselling and there is where concerns of overpopulation have poor observance of informed consent dominated the policy environment, practices. In a poorly regulated infertility is seen as an ‘ancillary environment, accessing services for issue’(Unisa,1999). Further, infertility infertility may also make the couple/ being non fatal, it has not attracted woman vulnerable to unscrupulous and requisite attention from policy and exploitative practices of the providers programme planners (ibid). Health seeking (Widge, 2004). behaviour for infertility may range from seeking allopathic treatment on one hand The Facility Survey conducted under the to trying out other systems of medicine, aegis of the Reproductive and Child Health traditional healers, home remedies, and project indicate adequacies of public visits to religious places and persons. healthcare facilities in categories of staff, Allopathy has been observed to be the laboratories, operation theatres, drugs, preferred system for treatment (Unisa, equipment, training of staff for various 1999).However, the extremely limited services, etc. According to the survey, no presence of the public sector in this regard hospital is fully equipped to discharge the makes the private sector the dominant services, though the District Hospitals (DH) provider of infertility related services in the in the country are found to be better placed country. High costs of treatment are a major in critical inputs than the First Referral deterrent for seeking services for infertility. Units (FRUs) which, in turn, are better Unisa’s study in Andhra Pradesh shows situated than the Community Health that the average cost of first course Centres (CHCs) (IIPS,2001b). As is treatment was about Rs. 2,500 in a private characteristic of facilities and services in sector hospital and about Rs.2000 for the country, there are considerable services availed at a private doctor’s clinic. interstate differences with the indices The cost for similar services availed at a being usually (though neither always nor government hospital was about Rs.1410. exclusively) poorer for the BIMARU states. The protracted and expensive treatment for Among district hospitals, 80 percent or infertility resulted in many case dropouts. more of the facilities have adequately Also, service seekers tried other options in equipped laboratory, generator, separate cases where allopathy did not work (ibid). operation theatre for gynaecology and OPD Further, there are a number of Artificial facilities for gynaecology/obstetrics, but Reproductive Technologies (ARTs) like only 66 percent of the facilities have artificial insemination, in vitro fertilisation, linkages with a blood bank. The proportion gamete intra-fallopian transfer and intra of the FRUs having such facilities falls with cytoplasmic sperm injection, the services about 70 percent having adequately being almost exclusively offered by the equipped laboratory, generator and

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PDF created with pdfFactory Pro trial version www.pdffactory.com separate operation theatre for gynaecology. district hospitals and the FRUs and a OPD services for gynaecology/obstetrics quarter of the CHCs had attended to are available in 63 percent of the FRUs. At referred cases of delivery during the three least 60 percent of the CHCs have months prior to the survey. Among the adequately equipped laboratories and 57 PHCs surveyed, 88 percent had a male percent have separate operation theatre for medical officer and 20 percent had a gynaecology. OPD facilities for female medical officer. Normal delivery kit gynaecology/obstetrics is available in only was available in 46 percent of the PHCs, 43percent of the CHCs. In the area of staff, labour room table/equipment in 53 district hospitals are most likely to have the percent and MTP suction aspirator present medical and paramedical staff required for in only 16 percent of the facilities. Barring reproductive and child health services. In contraceptive services, provision of the FRUs and the CHCs, excepting certain reproductive services is very limited in the categories of paramedical staff (for PHCs. Only 34 percent of the PHCs carry instance, laboratory technician, staff nurse out deliveries and a meagre 3 percent and pharmacist), the others (including conduct MTPs. RTI/STI services are specialist doctors) are more likely to be provided in 16 percent of the PHCs. Indeed, absent. Training of the staff in the fields of a telling comment on the primary sterilisation, IUD insertion, emergency healthcare system in the country, built on contraception, RTI/STI, new born care and an edifice of community location and a emergency obstetric care was inadequate referral chain. Table 15 gives the across the various types of facilities. percentage of adequately equipped Emergency obstetric care kits are available facilities at various levels, percentage of in about 30% of the district hospitals and hospitals attending to referred delivery FRUs and 15% of the CHCs. Normal cases and the proportion of the PHCs delivery kits are available in about half or carrying out specific reproductive health more of such facilities. About a third of the services.

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PDF created with pdfFactory Pro trial version www.pdffactory.com Table 15: Adequacy and select reproductive health services at public health facilities

Hospitals Dist. Hosp.FRUsCHCs -210-760-886 % adequately equipped% adequately equipped% carrying out select reproductive services Infrastructure948466Infrastructure36Delivery34 Staff844625Staff38MTP3 Supply282610Supply31RTI/STI16 Equipments896949Equipments56IUD insertion72 % attending 333425Training12Sterilisation65 to referred delivery cases• Source: RCH Facility Survey Note: Figures in parentheses refer to number of facilities surveyed. • in three months prior to the survey.

Informal healthcare Such facilities were usually present in The formidability of the formal healthcare rural areas, where the formal (public as system may drive women to seek care from well as private) healthcare structure was the informal sector- a prospect riddled with either completely missing or dangers to life and limb. The poor quality dysfunctional. The ‘qualifications’ sported of care (perceived to be) received at the by such providers were often similar public facilities and the sector’s general sounding to formal ones and the provider inaccessibility (in terms of distance, time, usually had some degree of familiarity with and behaviour of staff), and the high costs the formal healthcare, having either worked of the private sector are often the guiding as an assistant to a doctor earlier or in a reasons for women to seek the services of non-technical capacity in a formal the informal sector. Other reasons for healthcare facility. In another study, seeking such care may include the privacy again in Maharashtra, providers with ensured by the informal sector (especially unknown qualifications/unqualified in sensitive matters like abortion and providers constituted 6.0 percent of the sexually transmitted diseases) and total providers in Ahmednagar district, the congeniality of behaviour of the providers. low figures for unqualified practitioners The size of the informal sector in the being understood to be underestimates country is not inconsiderable. In the year (Kavadi, 1999). 2004, in the economically average district of Jalna in Maharashtra, facilities run by Women’s access of services provided by the informal providers constituted about a informal sector has been reported in a seventh of all healthcare facilities in the variety of situations. The study on women’s district (Mishra: personal observation). morbidity in Nasik district of Maharashtra,

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PDF created with pdfFactory Pro trial version www.pdffactory.com revealed that there was ‘extensive use of in rural areas and in health concerns that informal service’ by the women, especially pertain to the intensely private and for chronic and non infectious cases personal (for instance, sexually transmitted (Madhiwalla, Nandraj and Sinha, 2000). diseases). But the vulnerabilities of women Resort to the services of informal providers are many a time, more complex and for abortion has been seen in contexts compelling. To reiterate, women’s resort to where formal providers are difficult to informal care not only indicates the reach, are expensive or ‘do not treat clients failings of the formal healthcare system in with respect or dignity’ (Ganatra and the country but also underscores the Visaria, 2003). As the authors note, ‘their vulnerability of women in India with (informal providers’) personalized services, respect to access to healthcare. ready availability, congenial behaviour and the convenience also appeared important IV. KEY CONCERNS AND reasons for clients to use their services’ RECOMMENDATIONS FOR POLICY (ibid:26) indicating the failure of the formal healthcare system in many respects. High This monograph has attempted to highlight costs for treatment of infertility may result the vulnerability of women in India with in discontinuation of the treatment or respect to their health and access to resort to unqualified providers (Singh, healthcare. Women’s experiences are Dhaliwal and Kaur, 1996 cited in Widge, played out in a variety of contexts, namely, 2004). age, caste, class, etc. That women experience inferior health status and Services of the informal sector may hold restricted access to healthcare vis-a vis appeal to women constrained by limited men similarly placed is perhaps trite yet resources of time and money. Rural areas true. The gendered nature of women’s of the country being especially existences are experientially borne out in disadvantaged in terms of the provisioning diverse contexts to produce consistent of facilities, it is no surprise that informal patterns of vulnerability therein. Women’s service providers are especially present health needs are numerous- nutrition, and active in remote reaches of the country. general morbidity, reproductive health, Some providers in the informal sector may disability, mental health, occupational be practising traditional medicine that may health,—and are interrelated. Moreover, as be efficacious (see, for example, Ganatra women progress through the life stages, and Visaria, 2003). But, the sector is largely unresolved health needs can have replete with practitioners with limited (and cumulative burdens on their health. For often dangerous) knowledge and practices instance, poor nourishment during that can be life threatening. For women to childhood and adolescence can lead to access such services exposes them to unfavourable reproductive health unknown and innumerable hazards. outcomes starting from early adulthood. Or, Women’s multi faceted vulnerability unresolved mental health needs early in (social, cultural, economic, etc) make them life can have lasting consequences on the gullible customers of such a sector physical well-being of women during old operating in the grey areas of the age. Thus, throughout the life cycle, healthcare services. This does not suggest childhood, adolescence, old age and also, that vulnerable men may not be users of quite notably, middle age, (the latter often the informal sector, for they do, especially thought to be a period when women in

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PDF created with pdfFactory Pro trial version www.pdffactory.com India enjoy maximum autonomy), women provider of curative services in the in India are vulnerable in terms of their country, it is indeed surprising that health and healthcare seeking behaviour. it operates with so little accountability. The private sector It is indeed unfortunate that a welfare should be subject to controls with state, founded on the principles of equality, regards to the charges levied, social justice and democracy should minimum acceptable standards for display such inequities in health and practice, geographical dispersal of access to health care. It is the ‘usual services, etc that would make access suspects’- rural India, the poor, the lower to the sector more equitable for castes (especially the Scheduled Castes), groups across this vast country. the Scheduled Tribes, the less developed Equitable distribution of services is states and regions of India, that show poor a non negotiable and will greatly health status and restricted access to facilitate access. healthcare. In fact, with the considerable 4Make the health systems gender weakening of the public healthcare system sensitive. Health systems should be and the gradual entrenchment of the sensitised to the multiple and market economy, differentials among interrelated health needs of women socio-economic groups are widening. and the gendered nature of their existences. A gender sensitive Any programme that aims to address health system will not only women’s health needs should therefore be encourage women to seek care but sensitive to such complexities in women’s will also respond to their needs lives being staged on a social terrain of appropriately. remarkable inequities. The following 5Institute community health policy recommendations are offered to insurance schemes that would be address the situation: bulwarks against catastrophic health events. It is imperative that 1Adopt comprehensive and gender such schemes be need based and sensitive primary healthcare to cover vulnerable groups in the address women’s diverse health country and not be a privilege of a needs and to overcome the many few. In a society where resources limitations that they experience in can be so inequitably distributed accessing healthcare. within and outside the family, it 2Strengthen public healthcare. For needs to be emphasised that the poor and the marginalised, the community health insurance public sector is the only sector that schemes should protect the can potentially provide qualified interests of women. and affordable care. In the rural 6Strengthen civil society interiors of the country, it is usually initiatives that advance women’s the only sector having qualified ‘practical’ and ‘strategic’ interests, personnel. for the two are intricately 3Regulate the private sector. For intertwined in women’s lives. a sector that is the dominant

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PDF created with pdfFactory Pro trial version www.pdffactory.com ANNEXURES

Annexure 1: Child sex ratio in states and union territories of India, 2001

ChildChild Sr.no.StatesexSr.no.Union Territorysex ratioratio 1Andhra Pradesh9651Andaman and Nicobar islands958 2Arunachal Pradesh9752Chandigarh846 3Assam9713Dadar and Nagar Haveli980 4Bihar9574Daman and Diu923 5Chhatisgarh9765Lakshwadeep967 6Delhi8706Pondicherry971 7Goa936 8Gujarat888 INDIA (2001)934 9Haryana817 10Himachal Pradesh889 11Jammu & Kashmir938 12Jharkhand976 13Karnataka948 14Kerala962 15Madhya Pradesh938 16Maharashtra913 17Manipur958 18Meghalaya975 19Mizoram973 20Nagaland978 21Orissa960 22Punjab794 23Rajasthan913 24Sikkim951 25Tamil Nadu946 26Tripura966 27Uttar Pradesh929 28Uttaranchal906 29West Bengal966 Note: Computed from Census 2001figures

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PDF created with pdfFactory Pro trial version www.pdffactory.com Annexure 2: Infant mortality rate by sex and residence, India 2002 (for bigger states, smaller states and union territories)

Bigger states

TotalRuralUrban TotalMaleFemaleTotalMaleFemaleTotalMaleFemale India 636265696772404039 Andhra Pradesh626460716972354723 Assam707071737273383443 Bihar615666625767504753 Gujarat605566686076373934 Haryana625473645675514361 Karnataka555653656762252327 Kerala10912118148114 Madhya Pradesh858188898594566051 Maharashtra454842525449343829 Orissa8795799010180564569 Punjab513866554173352843 Rajasthan787580817983554962 Tamil Nadu444643505149323528 Uttar Pradesh807684837890586647 West Bengal495345525549364525

Smaller states Union territories

Total Total TotalMaleFemale TotalMaleFemale Arunachal Pradesh373836 Andaman & Chhatisgarh737670 Nicobar islands151416 Goa171816 Chandigarh212221 Dadra & Nagar Haveli566151 Jharkhand514756 Daman & Diu425527 Himachal Pradesh525745 Delhi302932 Jammu & Kashmir454941 Lakshadweep252029 Manipur141414 Pondicherry222223 Meghalaya616062 Source: SRS Bulletin, 2004. Mizoram141611 Note:•Due to part receipt of returns, data for Nagaland not given. Consequently the IMR NagalandN.A.N.A.N.A. estimates for India do not include figures for rural Nagaland. Sikkim343433 •The IMR for smaller states and union territories are based on figures for three Tripura343534 years. Due to wide annualfluctuations, the Uttaranchal413846 sex disaggregated IMR is not given for smaller states and union territories.

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PDF created with pdfFactory Pro trial version www.pdffactory.com Annexure 3: Sex wise age specific death rates, India 1999

Age groupIndiaRuralUrban PersonsMaleFemalePersonsMaleFemalePersonsMaleFemale 0-420.419.821.122.921.923.911.712.211.2 9-May1.81.62.12.11.82.410.91.1 14-Oct1.21.21.31.41.31.50.70.70.7 15-191.91.72.12.21.92.41.21.11.3 20-242.62.32.82.92.73.11.81.32.2 25-292.92.92.82.92.932.62.92.4 30-343.13.52.73.33.732.431.9 35-393.84.82.844.833.44.52.3 40-4455.945.36.34.34.153.1 45-4978.55.37.38.85.66.47.94.5 50-5410.212.18.31113.28.88.19.36.8 55-5916.319.41316.819.61414.8199.9 60-6422.92719.124.728.920.817.22113.3 65-6936.840.83337.941.534.433.138.428.1 70-7456.259.553.258.762.455.447.949.946 75-7978.686.371.38392.374.264.466.562.6 80-84103.2109.497.4107.2116.198.990.487.892.7 85+165.8171.8160.5167.4175.8159.6160.9158.2163 All ages8.78.98.29.49.79.16.36.75.7 Source: Central Bureau of Health Intelligence, 2003. Note: Owing to part receipt of returns, estimates exclude Nagaland (rural) and Jammu & Kashmir.

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PDF created with pdfFactory Pro trial version www.pdffactory.com Annexure 4: Women’s experience of and attitude towards domestic violence

% beaten% agreeing % beatenor physicallywith at or physicallymistreatedleast one Socio-demographicmistreated in the past % agreeing withreason for characteristicsince age 15one yearspecific reasons for violence violence 123456 Age 15-1915.411.537.28.638.741.743.128.861.1 20-2921.112.432.66.83436.640.424.956.3 30-392311.332.86.533.636.14024.156.3 40-4920.37.631.16.532.1353822.954.1 Marital duration Less than 5 years14.49.6316.233.135.3382354.2 Between 5 and 9 years21.212.832.96.633.235.640.124.956.1 More than 10 years22.911.533.76.834.237.140.625.157.2 Not currently married27.46.830.98.635.138.14224.955.3 Residence Urban16.87.724.73.928.22934.117.747.1 Rural22.512.235.67.835.939.242.12759.5 Education Illiterate25.514.138.6937.341.343.729.161.6 Literate- less than middle school19.28.829.8534.436.641.823.656.4 Literate-middle school complete15.2725.33.330.93236.318.651.2 Literate- high school completed or above8.63.617.32.121.119.624.911.137.1 Religion Hindu21.211.132.8734.136.740.325.256.5 Muslim21.211.434.85.933.638.138.723.256.5 Christian21.810.3349.441.942.852.420.765.2 Sikh13.97.118.80.28.26.98.23.927 Jain6.82.8140.724.320.527.816.938.8 Buddhist/ neo-Buddhist20.81036.37.75448.86347.973.7 Others16.811.416.65.826.331.83418.544 No religion26.111.23613.135.451.666.727.275.4 Caste/tribe Scheduled Caste27.415.434.67.334.638.441.12657.9 Scheduled Tribe231340.211.240.141.445.928.762.8 Other Backward Class2311.7347.636.840.344.826.761.7 Others15.77.828.84.929.331.133.920.849.1

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PDF created with pdfFactory Pro trial version www.pdffactory.com % beaten% agreeing % beatenor physicallywith at or physicallymistreatedleast one Socio-demographicmistreated in the past % agreeing withreason for characteristicsince age 15one yearspecific reasons for violence violence 123456 Type of household Nuclear24.512.732.86.833.937.241.124.757.1 Non-nuclear18.19.532.86.833.83639.124.555.5 Cash employment Working for cash2914.534.59.739.242.348.128.962.2 Working but not for cash2412.141.210.342.946.950.935.467.5 Not worked in past 12 months16.99.330.34.729.731.934.320.551.3 Standard of living Low29.216.636.99.138.142.345.129.162 Medium20.110.134.46.835.538.3422658.8 High10.1422.3323.323.127.314.240.9 Total211132.86.833.936.64024.656.3 Source: NFHS-2 Note: Reasons for violence:1: husband suspects of wife’s unfaithfulness 2: wife’s natal family does not give money or other items 3: wife shows disrespect towards in laws 4: wife goes out without telling husband 5: wife neglects house or children 6: wife does not cook properly.

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PDF created with pdfFactory Pro trial version www.pdffactory.com Annexure 5: Body Mass Index (BMI) and anaemia among women of select groups

Weight for height % with BMI% of women with < 18.5> > kg/m2 25.030.0MildModerateSevere kg/m2 kg/m2 anaemia anaemiaanaemia Residence Urban22.122.623.55.845.73212.21.5 Rural19.640.65.90.953.936.115.82 Education Illiterate19.542.65.10.955.836.716.82.3 Literate- less than middle school20.632.612.92.750.134.413.81.9 Literate- middle school complete21.12815.73.2483412.61.3 Literate-high school complete and above22.517.8266.440.329.79.70.9 Caste/tribe Scheduled Caste19.542.15.80.95637.216.52.3 Scheduled Tribe19.146.33.30.564.941.221.42.3 Other Backward Class20.235.89.41.750.734.314.52 Others2130.515.43.747.633.312.91.5 Standard of living index Low18.948.12.60.360.238.918.62.7 Medium20.135.68.61.550.334.514.11.7 High22.717.327.26.841.930.110.71.1 Source: NFHS-2.

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PDF created with pdfFactory Pro trial version www.pdffactory.com Annexure 6: Morbidity levels according to different NFHS rounds

UrbanRuralTotal Morbidity*MaleFemaleMaleFemaleMaleFemale (NFHS-2) Asthma1,9551,9782,7842,5082,5612,369 Tuberculosis#446330690507624460 Jaundice during the past 12 months1,3541,0851,6751,1341,5891,121 Malaria during the past 3 months2,1332,1804,3204,1843,7343,658 (NFHS-1) Blindness (partial)1,9722,6662,4822,9002,3462,839 Blindness (complete)366386411450399433 Tuberculosis397286625393564365 Leprosy104791629514791 Physical impairment of limbs671439814513776494 Malaria during the past 3 months165518103984380433633283 Source: NFHS-1 and NFHS-2. Note:*number of persons per 1,00,000 suffering from the stated ailments. # includes medically treated tuberculosis.

Annexure 7: Point prevalence of morbidity (PPM) on the 15th day preceding and the day before the survey, NSSO 52nd round

AreaReference dayMaleFemalepersons Rural Preceding 15th day 232524 Day before survey 283029 Urban Preceding 15th day 212623 Day before survey 273029 Source: NSSO report no. 441.

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PDF created with pdfFactory Pro trial version www.pdffactory.com Annexure 8: Prevalence (per 1000 aged persons) of chronic ailments by sex and residence

RuralUrban malefemalepersonmalefemaleperson Cough 250195222179142160 Piles 331624321825 Joint problems 363404384285393340 High/low blood pressure 108105106200251226 Heart disease 342730685361 Urinary problem 382331492436 Diabetes 362832856675 Cancer 233243 Any of the above527514520528560545 Source: NSSO Report no.446 Annexure 9: Maternal mortality ratio in select states of India (indirect estimates from sex differentials in adult mortality),1982-86 and 1987-96

Maternal mortality ratio 1982-861987-96 Andhra Pradesh394283 Assam1068984 Bihar813513 Gujarat373596 Haryana494472 Karnataka439480 Kerala247* Madhya Pradesh507700 Maharashtra439380 Orissa844597 Punjab207* Rajasthan627580 Tamil Nadu372195 Uttar Pradesh920737 West Bengal561458 India (rural)638528 India (urban)389311 India (TOTAL)580479 Source: Bhat, 2002. Note: * Maternal mortality being very low, estimating from the sex differentials in adult mortality in the reproductive age group is not possible.

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PDF created with pdfFactory Pro trial version www.pdffactory.com Annexure 10: Menopause among currently married women by age and state (all figures in percentages)

Age in years 30-3435-3940-4142-4344-4546-4748-49 North India Delhi1.53.411.420.931.935.473.4 Haryana1.74.810.723.33743.666.7 Himachal Pradesh0.959.622.432.14672 Jammu & Kashmir2.16.616.731.933.952.462.9 Punjab1.44.420.820.635.452.563.3 Rajasthan2.34.613.519.935.139.361.2 Central India Madhya Pradesh2.97.315.123.532.644.851.9 Uttar Pradesh2.17.320.231.342.358.568.8 East India Bihar2.99.223.635.251.160.775.8 Orissa1.75.319.523.831.750.662.4 West Bengal1.54.312.822.134.946.148.4 Northeast India Arunachal Pradesh13.86.9*-8.2** Assam1.66.222.530.443.655.773.4 Manipur0.84.89.614.421.8-31.8-48.9 Meghalaya1.42.9-4.1-13.9-21.7** Mizoram1.12.37.610.1-8.1-9.2* Nagaland2.91.5-7.6-20.1-39.4** Sikkim2.15.812.27.828.8*-68.9 West India Goa1.74.7151727.640.966.1 Gujarat3.110.72427.542.355.562.7 Maharashtra4.37.816.621.540.562.964.8 South India Andhra Pradesh12.822.137.635.95565.482.2 Karnataka1.610.622.726.645.858.376.1 Kerala1.23.78.212.521.137.453 Tamil Nadu24.512.626.130.549.869.7 India (rural)3.58.520.628.140.955.666.4 India (urban)2.2715.123.135.45067.3 India TOTAL3.181926.539.353.966.6

Source: NFHS-2 Note: Figures in parentheses are based on 25-49 unweighted cases; * less than 25 unweighted cases; percentages not shown.

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PDF created with pdfFactory Pro trial version www.pdffactory.com Annexure 11: Women with types of disabilities in the States and Union Territories of India

Of the women disabled %%%% %speechhearingmovntmental visual dis.dis.dis. dis.dis. 1Andhra Pradesh591,01044.4810.656.3426.9611.58 2Arunachal Pradesh11,14061.019.0612.5912.095.25 3Assam232,78454.9510.8210.4315.298.51 4Bihar756,08559.377.054.0421.897.65 5Chhatisgarh188,11940.447.38.3733.3110.57 6Delhi91,01454.246.684.2724.3810.43 7Goa6,86030.2812.117.7126.6523.25 8Gujarat440,50150.155.867.9227.078.99 9Haryana181,20349.565.126.9229.089.32 10Himachal Pradesh65,50644.738.0110.4226.5210.31 11Jammu & Kashmir130,85470.835.514.9411.27.53 12Jharkhand184,14844.579.326.7827.4311.9 13Karnataka402,91349.59.986.0624.2610.2 14Kerala402,44441.567.4310.7523.716.57 15Madhya Pradesh583,83549.615.186.3231.317.58 16Maharashtra635,71540.977.756.3930.7214.18 17Manipur12,92042.179.8111.4420.6715.91 18Meghalaya13,48646.0612.4613.8916.5711.03 19Mizoram7,24837.9612.7215.3614.619.37 20Nagaland11,95836.317.6720.2916.119.63 21Orissa452,42153.046.868.4921.6110 22Punjab171,66745.265.44.7331.2113.4 23Rajasthan571,32956.64.656.1925.776.78 24Sikkim8,95852.3616.9716.889.674.13 25Tamil Nadu850,81266.626.624.4415.856.47 26Tripura25,47946.618.8211.3521.4811.74 27Uttar Pradesh1,376,86558.817.594.0122.447.16 28Uttaranchal81,56048.18.358.825.599.16 29West Bengal788,48949.869.567.6618.4114.51 Union Territories 1Andaman and Nicobar islands2,83149.959.58.4821.1610.91 2Chandigarh6,00056.355.524.2222.1311.78 3Dadra & Nagar Haveli1,71957.777.59.3718.56.86 4Daman & Diu1,39259.555.965.3919.839.27 5Lakshwadeep77739.6410.39.1425.8715.06 6Pondicherry11,09242.797.5511.0929.638.94 INDIA (2001) 9,301,13452.717.516.3223.689.77 Note: Computed from Census 2001 figures.

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PDF created with pdfFactory Pro trial version www.pdffactory.com Annexure 12: Prevalence of disability (per 1000 persons) among the elderly by type, sex and place of residence (NSS 57th round)

Type of disability visualhearingspeechlocomotorAmnesia/senilityAny disability Rural Male 2491393210796380 Female 29115638115113425 Person 27014835111105402 Urban Male 225111298061333 Female 260132349480367 Person 243122328770350 Source: NSSO Report no. 446

Annexure 13: Male and female workers in India, Census 2001

Proportion to total workers Main workersMarginal workers PersonsMalesFemalesPersonsMalesFemales Total 77.8287.3257.2722.1812.6842.73 Rural 73.9485.0454.0726.0614.9645.93 Urban 90.8393.2779.319.176.7320.69 Source: Census 2001. Note:A ‘main worker’ is one who has been engaged in an economically productive work for six months or more in the past one year. A ‘marginal worker’ is one who has been engaged in an economically productive work for less than six months in the reference period of one year.

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PDF created with pdfFactory Pro trial version www.pdffactory.com Annexure 14: Establishment of Community Health Centres, Primary Health Centres and Sub centres in India

Community HealthPrimary HealthSub centres CentresCentres no. fningno. fning no. fning no. fningno. fningno. fning at the end as on at the end as onat the end as on of 7th plan31 Marchof 7th plan31 Marchof 7th plan31 March (1985-90)2001(1985-90)2001(1985-90) 2001 1Andhra Pradesh4621912831386789410568 2Arunachal Pradesh6202465155273 3Assam6010044961051095109 4Bihar147148200122091479914799 5Chhatisgarh 6Goa551719166172 7Gujarat143242842100168347274 8Haryana416436640122992299 9Himachal Pradesh356519030218512069 10Jammu & Kashmir335326633714601700 11Jharkhand 12Karnataka1562491142167677938143 13Kerala5410590894450945094 14Madhya Pradesh172342118116901191011947 15Maharashtra2903511671176892489725 16Manipur10166469420420 17Meghalaya3135685272413 18Mizoram493558220346 19Nagaland493346244302 20Orissa92157875135259275927 21Punjab7010546048428522852 22Rajasthan1852631048167480009926 23Sikkim222024132147 24Tamil Nadu72721386143686818682 25Tripura8114958506539 26Uttaranchal 27Uttar Pradesh177310300038082015320153 28West Bengal87991250126278738126 29Andaman & Nicobar islands34141884100 30Chandigarh11001213 31Dadra & Nagar Haveli01563436 32Daman & Diu01231421 33Delhi00884242 34Lakshadweep13441414 35Pondicherry3422397380 India191030431867122842130165137311 Source: CBHI,2003 Note: Figures prior to reorganisation of states in the late 1990s.

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PDF created with pdfFactory Pro trial version www.pdffactory.com Annexure 15: Community Health Centres, Primary Health Centres and Sub centres intribal areas of India (as on 31 March 2001

Community HealthPrimary HealthSub centres CentresCentres StatesRequired% in Requiredposition% in Requiredposition% in Required Andhra Pradesh3426.4913782.4891889.76 Arunachal Pradesh2871.437389.0455049.64 Assam31109.68121109.9280454.85 Bihar12215.5748942.54352251.79 Chhatisgarh Delhi• Goa• Gujarat6487.531982.762126103.9 Haryana• Himachal Pradesh220011154.5577128.57 Jammu & KashmirNANANANANANA Jharkhand Karnataka46106.52228156.141520124.74 Kerala103042145.2427990.32 Madhya Pradesh19880.8180782.65599382.75 Maharashtra9169.2336680.33243976.75 Manipur785.714190.2426384.03 MeghalayaNANA81104.9444792.39 Mizoram12756096.67324106.79 Nagaland12756373.0241872.25 Orissa11850.8550790.93263470.8 Punjab• Rajasthan3488.24171107.02114197.81 Sikkim1100215013146.15 Tamil Nadu21005889.666774.63 Tripura1442.863093.3327590.91 Uttar Pradesh333.3321986.3138199.64 Uttaranchal West Bengal3485.29157130.5794678.01 Union Territories Andaman and Nicobar islands25041003488.24 Chandigarh• Dadra & Nagar Haveli2508755466.67 Daman & Diu0011004100 Lakshwadeep3100410014100 Pondicherry• INDIA87067.59399988.522624381.66 Source: CBHI (2003) Note:Figures prior to reorganisation of states. • no notified scheduled tribes. NA - figures not available

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PDF created with pdfFactory Pro trial version www.pdffactory.com Annexure 16: Knowledge of contraceptive methods

MethodUrbanRuralTotal Any method99.798.799 Any modern method99.798.698.9 Pill91.575.279.5 IUD87.864.670.6 Condom8864.971 Female sterilisation99.397.898.2 Male sterilisation93.687.889.3 Any traditional method60.344.948.9 Rhythm/safe period56.74145.1 Withdrawal41.127.731.2 Other method*3.12.62.7 Source: NFHS-2. Note:* includes any other method (modern or traditional) not listed separately.

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PDF created with pdfFactory Pro trial version www.pdffactory.com Annexure 17: Antenatal care received by select social groups in the country

ANC outside home• from DoctorOtherTBA, healthother professional Residence Urban274.88.80.213.681.987.5 Rural6.641.211.50.339.862.580.5 Education Illiterate7.332.111.20.348.454.777.4 Literate- less than middle school4.862.112.90.319.378.483 Literate- middle school complete371.811.20.113.584.286.4 Literate-high school complete and above1.285.47.20.15.891.290.4 Religion Hindu6.247.211.20.234.566.582.5 Muslim3.350.78.50.436.465.680.8 Christian373.47.50.215.47487.9 Sikh1.344.729024.987.580.7 Jain3.184.76.505.787.985.5 Buddhist/Neo-Buddhist1.474.99.2014.565.390.8 Other0.359.915.70.119.75289 No Religion1053.70.7035.643.586.6 Caste/Tribe Scheduled Caste5.941.713.30.238.264.880.7 Scheduled Tribe1034.711.50.343.146.481.6 Other Backward Class5.948.99.60.234.868.484.9 Others456.510.60.227.972.282 Standard of Living Index Low7.335.8110.245.155.479.1 Medium5.150.111.10.332.868.781.8 High2.873.710.50.212.487.588.4 India Total5.648.610.90.23466.882.5 Source: NFHS-2 Note: Information based on two recent births in the three years preceding the survey.

• refers to births in which the women received ANC outside home, even if they might have received ANC at home. Though the woman might have received ANC from different types of providers, provider with the highest qualification shown.

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PDF created with pdfFactory Pro trial version www.pdffactory.com Previous publications

Year of Publication 1Review of Health Care in India: Country Health report ...... 2005

2Health and Health Care in Maharashtra: Health Status Report of Maharashtra (in English and Hindi) ...... 2005

3Health Facilities in Jalna: A study of distribution, capacities and services offered in a district in Maharashtra ...... 2004

4Health and Health Care Situation in Jalna, Yawatmal and Nandurbar ...... 2004

This is one of background papers to the Establishing Health as a Human Right Project. It reflects solely the views of the author. The views, analysis and conclusions are not intended to represent the views of the organisation.

ISBN : 81-89042-45-9

PDF created with pdfFactory Pro trial version www.pdffactory.com