Mother holds child while health worker administers an immunisation shot

Women and health in India

Blog Women's Economic Empowerment, Inclusive Growth and COVID-19

For our 2024 International Women’s Day campaign, Ideas for India’s Editorial Advisor, Nalini Gulati reviews economic research on women’s health in India, encompassing aspects of maternal and child health, gendered access to healthcare, and mental health– and considers the role of resources, gender attitudes, and information in addressing health inequalities.

The longstanding problem of gender inequality in India pervades most economic and social outcomes, including health. Traditionally, the intersection of gender and health has been dominated by maternal and child health (MCH). However, improvements in this area combined with the increasing burden of non-communicable diseases (NCDs) and mental health challenges, makes it imperative to take a wider view of women’s health in policy and research.

This article curates insights from economic research on women’s health in India – tracing studies that examine policy efforts to make motherhood safer, recognise gendered differences in healthcare access, highlight mental health concerns, and explore the efficacy of potential solutions around resources, information access, and gender attitudes.

Maternal and child health

Motivated by high Maternal Mortality Rates (MMR), the discourse on women’s health in India centred on MCH through the 1990s and 2000s. A key policy response was the flagship safe motherhood programme, Janani Suraksha Yojana (JSY) – providing cash transfers to women conditional on delivering births at health centres, and incentivising Accredited Social Health Activists (ASHAs) to connect women with MCH services.

There was an annual 5% reduction in MMR between 2004-06 and 2014-16  – although rich-poor gaps in MCH services utilisation and inter-state and rural-urban disparities remained. Dansereau, Kumar and Murray (2013) found that distance to a health facility was a significant impediment to institutional deliveries. Joshi and Sivaram (2014) observed that while JSY effectively targeted some vulnerable women, it missed the poorest women. Chatterjee and Podar (2023) highlighted a change in fertility preferences among the beneficiaries, suggesting greater women’s empowerment and bargaining power. 

Given the link between high fertility rates and poor MCH, a segment of the literature has focused on family planning. Agarwal, Chatterjee and Dey (2023) found that government interventions led to a decline in the number of births, changed fertility preferences, and increased adoption of birth control. Exploring the role of norms, a survey in Uttar Pradesh (Anukriti, Herrera-Almanza, and Karra 2020) revealed that young, married women co-residing with mothers-in-law (MIL) had fewer close peers, which reduced their utilisation of reproductive health services. This is explained by misalignment of fertility preferences between women and MIL. Similarly, an IGC Bihar study (Dutta, Ghosh, and Hussain 2021) showed that MIL serve as mediators in the interaction between ASHAs and reproductive-age women.

The evidence indicates that India has made strides in tackling maternal mortality and promoting family planning, although more can be done to reduce inequalities across socioeconomic groups and regions. Besides, there is scope for creative approaches to navigate the context of norms and interpersonal relationships, within which MCH is situated.

Changing healthcare needs and disparities in access

Bhan and Shukla (2023) noted that falling MMR has been accompanied by an epidemiological transition from infectious diseases to NCDs – changing women’s healthcare needs. NCDs (such as cardiovascular diseases, cancers, diabetes) accounted for 53.5% of female deaths in 2018 – up from 33% in 2000.

Anderson and Ray (2013) attributed excess female mortality at older ages mainly to NCDs. This opened a broad area of research, beyond skewed sex ratios at birth, mistreatment of young girls, and maternal mortality as explanations for “missing women”. One suggested mechanism was that women seek healthcare less often than men. Pursuing this line of thought, an IGC project (Jayaraman, Ray, and Wang 2014) found that women have worse diagnoses than men with regard to symptomatic eye illnesses – indicating that men (or their parents) are more responsive to their perceptions of ill-health.

Kapoor et al. (2019) uncovered that the sex ratio of clinical appointments (excluding obstetrics and gynaecology) at a prominent tertiary, public hospital in Delhi was worse than the relevant population sex ratio. This likely reflects gender bias rather than gender-differentiated disease infliction, as the analysis included multiple medical specialties and adjusted for department-specific effects. 

In terms of policy effort to expand secondary and tertiary healthcare, the key instrument in India has been public health insurance for the poor. Rashtriya Swasthya Bima Yojana (RSBY) was initiated in 2008, providing health insurance for inpatient care. In 2018, Ayushman Bharat subsumed RSBY, expanding population coverage and the insurance amount. One or all members of a family can use the insurance cover, and official information states that there are no ‘restrictions on gender’.

Dupas and Jain (2021) found substantial gender gaps in utilisation of subsidised hospital care under Rajasthan’s health insurance programme – disparities unexplained by the population’s gender composition or sex-specific illness prevalence. Rather, these may be driven by households’ willingness to allocate greater resources towards male members’ healthcare.

These studies establish the presence of gender gaps in secondary and tertiary healthcare utilisation in India – but the underlying drivers need further investigation.

Mental health

COVID-19 drew attention to the matter of women’s mental health. The gendered impact of such a crisis may be due to increased risk of intimate partner violence, women’s care responsibilities, and so on.

In IGC research, Coffey et al. (2020) highlighted that women who eat last in the household have worse mental health than those who do not – partly on account of the correlation between eating last and less autonomy. A phone survey among urban poor in Delhi during the March-April 2020 lockdown – undertaken as part of an IGC project – showed that women experienced higher levels of financial and health stress relative to men (Afridi, Dhillon, and Roy 2020). In a phone survey across six Indian states Bau et al. (2021) found a high proportion of female respondents reported worsening of depression, exhaustion, anxiety, and perception of safety, through the pandemic. The impact was particularly strong among working mothers with young children, women with daughters, and female household heads. Noting women’s limited access to mental health support in low-resource settings, Ahmed et al. (2021) demonstrated the positive effect of a tele-counselling intervention in Bangladesh – including modules like health awareness, self-care, and relevance of staying connected with loved ones.

There has been growing recognition of the need to enhance awareness and sensitivity around mental health, and to strengthen mental healthcare systems. The evidence emphasises the importance of such endeavours being gender-responsive.

Possible solutions

One view is that lack of control over resources restricts women’s healthcare access. For instance, in a follow-up experiment in Uttar Pradesh, Anukriti et al. (2022) found that subsidising family planning services altered the dynamic between women and their MIL around the subject. On the other hand, Agrawal, Chatterjee, and Chatterjee (2023) demonstrated that increase in women’s disposable income does not necessarily lead to greater healthcare spending, and may even cause a decline. This may be attributable to women’s preferences – inherent or propelled by social, family or peer pressures – to contribute towards household welfare.

The relationship between women’s economic empowerment and health empowerment has not been sufficiently explored. In principle, work or control over resources can serve as an instrument of agency. However, women’s expanded economic prospects may trigger backlash within households (as studied by Anderson 2023). Maxwell and Vaishnav (2021) establish a positive association between women’s work status and their role in household decision-making – but there is a need to also consider decisions pertaining to women’s health.

Bhan and Shukla (2023) contended that “women’s willingness to forgo the healthcare they need has not been understood well, and may relate to both their lack of self-awareness and low self-value.” They advocated for NCD programmes to strive to enhance self-care among women such that their health may be prioritised within families and health systems. The authors also noted the particular importance for women of “respectful care” in interacting with the health system.

With regard to shaping attitudes, a clutch of studies have explored the role of female leaders. In a cross-country analysis, Bhalotra et al. (2023) observed that as the share of women in politics increases, MMR declines. Possible mechanisms include increased female schooling and reduced fertility. In the Rajasthan study, long-term exposure to local female leaders made a difference, via greater MCH investments and female agency.

Information plays a crucial role in healthcare utilisation. Debnath (2021) found strong complementarity between JSY incentives given to mothers and health workers – especially for less-informed, poorer households. In a follow-up to the Rajasthan study, Dupas and Jain (2023) recognised that intended beneficiaries had low awareness of their entitlements. Providing phone-based information enabled patients – especially women, the poorer and less educated – to “advocate for themselves at public hospitals…”.

Insights into how resource enhancement, behaviour change, and information access, intersect and translate into improved outcomes, can help craft effective interventions.

Gendered approach to health policy

As underlined by Dupas and Jain (2021), without actions that specifically target women, public healthcare spending is effectively pro-male. In a setting with entrenched gender biases, gender-neutral policies will not suffice and may aggravate existing disparities. The evidence calls for a gendered approach to public health policy. Deeper, nuanced understanding of the differential healthcare needs of women and their barriers in engaging with health systems, can inform the design and implementation of tailored, innovative strategies – with the ultimate objective of achieving good health for all.

A longer version of this article first appeared on Ideas for India.