It is a well-known fact that women form half the population of the world, but they remain discriminated against where distribution of power, resources, and access is concerned. The more patriarchal a society, the more evident this is. While the relative lack of power exhibits itself in all domains of life, health and access to healthcare stand out as matters of urgent concern since the consequences are grave not only for the women themselves but also their families and all of society.
The sex ratio at birth is one of the strongest summary indicators of the ecosystem of patriarchy in the country. The female-to-male sex ratio at birth remains at 917 girls to 1,000 boys (with Chhattisgarh at 974 and Uttarakhand at 868, according to the latest Sample Registration System data), while it should be about 950 by genetic predisposition. This is testament to a persistent male child preference and the continuance of sex-selective abortion in Indian society that is recalcitrant to laws prohibiting sex-selection during pregnancy.
Gender as a determinant of health and access to health has been well recognised in public health theory and action for decades: a gendered lens is formally employed in most public policies, schemes, programmes, and budgets running in India as part of a “whole of government” approach that is signified by “gender mainstreaming” and “gender budgeting”. Nonetheless, gender equity in the distribution of health and access to healthcare services remains a distant dream.
Concerns relating to poor nutrition among women stand out in terms of severity and spread. About 60 per cent of women of reproductive age suffer from anaemia and about 40 per cent have basic metabolic indices that are not optimal, reflecting both excess and inadequate weight. Inadequate weight and anaemia predispose women to various diseases, vulnerability to infections, and mortality from complications of pregnancy and childbirth. Excess weight predisposes them to higher risk of chronic diseases like diabetes and conditions like high blood pressure.
Gujarat leads in gender inequality in health parameters
A recent study titled “An analysis of inequality in physical health status of women in India: 2015–2021” uses National Family Health Survey (NFHS) data to expose some significant negative trends in women’s health and access to healthcare. Looking at inequality as measured by the distribution of anaemia, nutritional imbalance, high blood pressure, and diabetes, the study found the highest inequality in Gujarat, Odisha, Chhattisgarh, and Bihar, with Gujarat leading in inequality, and the lowest in Kerala, Punjab, Tamil Nadu, and Uttarakhand. Notably, the State-level average is large enough to create a negative trend for India on the whole.
Correlating this gender inequality with health infrastructure, public health amenities, and social development, the study came to the expected conclusion that socio-economic factors such as poverty, lack of education, and access to public health amenities like water, sanitation, and clean cooking fuel are key social determinants of health.
Where access to healthcare is concerned, health policies and programmes for women have typically focussed on their reproductive roles. This undoubtedly reflects the patriarchal understanding of women’s roles as mothers and child-carers as central to their existence. Yet, it is also correctly anchored in the understanding that maternal mortality is almost entirely preventable and represents a partially true mirror of healthcare services available to women for all purposes.
Thus, the reduction of maternal mortality is a stated national goal, corresponding to the WHO’s Sustainable Development Goal target of fewer than 70 deaths for every 1,00,000 live births by 2030. This focus has resulted in major improvements in the percentage of institutional deliveries (nearly 90 per cent), antenatal care services (60–70 per cent), and reduction of maternal mortality from 130 per 1,00,000 live births in 2014–16 to 97 in 2018–20.
Some examples underscore how women fare even in terms of key concerns of the healthcare system, maternal health being primary among them.
In India, 23 per cent of all women aged between 20 and 24 are married before turning 18. Early marriages are nearly always followed by early pregnancies, with NFHS-5 finding nearly 7 per cent of the women in the reproductive age group experiencing pregnancy between the ages of 15 and 19. These pregnancies are prone to more complications for both the mother and the newborn. There is also the related problem of teenaged mothers being burdened with child rearing and losing out on their childhood.
The Prohibition of Child Marriage Act, 2006, and the Protection of Children from Sexual Offences (POCSO) Act, 2012, carry punitive provisions that should have acted as deterrents against the practice of child marriages and teenage pregnancies. POCSO also makes it mandatory for healthcare staff who encounter such cases to report them.
Sociocultural factors and socio-economic pressures
The problem, however, is complicated by sociocultural factors and socio-economic pressures. These often result in such cases not being reported and data being falsified in the relevant documents. Correct reporting comes with its own risks for under-age mothers. The Pradhan Mantri Matru Vandana Yojana (PMMVY), for instance, requires the mother to be aged above 19 in order to access benefits under the scheme.
Consequently, teenage mothers do not get the support they require if their age is correctly recorded. Benefits under the PMMVY are also unavailable beyond the first two children, with only the girl child being covered for the second birth.
Inadequate as the scheme appears in comprehensively meeting maternal health requirements, even the benefits it does offer do not reach about half the eligible group. Some estimates using birth rates suggest that only about 50 per cent of eligible first-time mothers received the meagre cash benefits under the PMMVY in 2021–22; about a quarter of the eligible group received the full amount of Rs.5,000.
This amount, in any case, does not compensate for pregnancy-induced wage loss and is hardly enough to support a breastfeeding mother’s recovery in the postpartum period. All these system-related issues combine to marginalise the poorest of the poor and contribute to maternal and infant mortality.
The system also needs to take into account the fact that women live full human lives beyond their reproductive roles and suffer their full share of all disease burdens afflicting humankind. There is a vast amount of literature pointing to the constraints that women face in accessing healthcare for themselves and their children for all kinds of health issues, not just ones relating to reproductive health. These constraints are linked to a variety of factors that interact with each other. Poor literacy and inability to take financial or health-related decisions independently are problems that get compounded by geographical distances and lack of safe, affordable transport.
At the end of the road, if the facility that needs to be accessed is not known to be easily available with regularly attending staff, and if the assurance of empathetic behaviour is absent, the struggle to get there often seems pointless. There are also the opportunity costs of unattended housework, agricultural work, childcare, and care of the sick and the elderly. All these considerations further inhibit health-seeking behaviour in women. These inhibitors get highly exaggerated when women migrate, especially for recent migrants who have left all their social capital behind and are often in extremely dire financial straits.
A doctor engaging with women to impart health education in an area that has limited access to healthcare facilities.
| Photo Credit:
Mayur Kakade/GETTY IMAGES
A recent study, titled “Women’s healthcare access: assessing the household, logistic and facility-level barriers in India”, uses NFHS-5 data to show that as many as 84 per cent of the surveyed women perceived at least one obstacle to accessing healthcare. Significantly, the facility-level obstacles topped the list, with lack of availability of drugs being the most frequently reported problem followed by unavailability of healthcare providers, particularly women healthcare providers. These factors are related to the functioning of the healthcare system.
The logistical and household-level constraints were related to issues of distance, transport, decision-making, and finances. Lack of formal education was found to be a major problem, along with lack of mobile phones, exposure to social media, and bank accounts. Unsurprisingly, poverty, lack of formal employment, SC/ST/OBC status, and being Muslim showed strong correlations with perceived barriers.
State-level differentials
Again, State-level differentials were marked, with States occupying different places in the hierarchy for each set of factors. For instance, Chhattisgarh topped the list for facility-level and household-level barriers, whereas Arunachal Pradesh showed the maximum logistical barriers. The lowest barriers were found for Kerala in all three categories. Among the richer States, Gujarat fared worse than the national average in all three categories.
Although this study did not allude to it, the absence of decent toilets for women is one of the commonest reasons for a poor experience of public healthcare services, with one UNICEF study reporting only about 19 per cent of labour rooms having decent functional toilets.
Disrespectful and even abusive treatment often marks women’s experience of the public healthcare system, along with a lack of privacy: women are often examined without their privacy being protected by screens or curtains.
Women are also healthcare providers
No analysis of women in the health sector is comprehensive if they are considered only as users of healthcare. Women play a crucial role as a human resource in the health sector. How they are perceived and treated as healthcare workers also reflects their relative status in any society.
Currently, there are about 10 lakh community healthcare workers who are women: the Accredited Social and Health Activists (ASHAs), who form the “front line”, link village communities to the entire spectrum of healthcare services, with a small number serving urban slums. They are supported by 28 lakh anganwadi workers and helpers who enable most of the healthcare programmes related to pregnant and lactating women and adolescent girls, as well as children under 6.
This enormous all-female cadre of nearly four million workers are labelled as “honorary workers” and denied decent wages and working conditions, despite decades of protests.
There are about 2 lakh Auxiliary Nurse Midwives in the country and 50,000 nurses at the primary health centre level. There are the paramedical technical staff and doctors, too. Women form a high proportion of the cadre of nurses. It is beyond the scope of this article to go into the details, but working conditions of women providing services in the health sector are far from satisfactory.
Perhaps none of these structural and systemic failures can be set right if women are not able to participate effectively in health sector governance and decision-making.
A quick examination of the Ministry of Health & Family Welfare (MoHFW) web page, which lists senior officers and advisers, as of January 2026, revealed a preponderance of men with only a few women in senior positions: 6 officers and 21 advisers. At the other end, there are no participatory processes at the community level that promote the participation of women in local health planning or decision-making.
The panchayati raj structure does have reservation for women for the posts of sarpanches and panchayat members. However, this is subverted by what is known as the “panch pati” system wherein husbands of elected representatives often perform the actual functions of the statutory bodies.
ASHA workers, midday-meal workers, and anganwadi workers from various States protesting against low wages, precarity of employment, and gender discrimination, in New Delhi in 2021.
| Photo Credit:
SHIV KUMAR PUSHPAKAR
In any case, the entire concept of decentralised health planning promoted by the National Rural Health Mission 2005 as a “core strategy” has seen a comprehensive decline with increasing centralisation of all policies, schemes, and programmes.
Community-based monitoring processes and social audits do offer some space for women to voice their needs and demands, but these are hardly in evidence across the country and are just about absent in the public health system. In the system of private health care, patients’ rights are at a very preliminary stage of acknowledgement and existence, though the National Human Rights Commission recommended a patients’ rights charter to the MoHFW in 2019. It was shared with all States and Union Territories for adoption, and elements were also included in the Clinical Establishments Act, 2010, and further updated in 2022.
Given these conditions, a transformational improvement in the health status of women requires radical change that will allow for decentralisation of power with the specific intent of ensuring an equitable, reserved space for women as users, workers, and decision-makers. For this, the necessary first step will be to have strategies that can re-establish participatory processes and community monitoring for all health programmes, with specific reservation in the decision-making aspects of the health system.
Vandana Prasad is a public health professional who has been engaged in community policy-level interventions for three decades.
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