October 14, 2022
By Devanshi Singh and Roshni Sekhar
India presently is on its way towards fulfilling the Sustainable Agenda Goals (SDGs) to achieve a homogeneous socio, political and economic growth in the future. At this time of development, it becomes imperative for the Nation to progressively overcome its existing gender stereotypes, gaps in health, nutrition and workforce as well provide its infant and adolescents with adequate care. Hence the agenda of rolling out a comprehensive macro policy on Women and Child Development tops the chart in terms of the policy discourse for India. As observed in the last few years, India has made some strides to empower the women and children of the country. In spite of this progress, we have to prioritize, invest and strengthen the public service delivery mechanisms of the government to reduce the disease burden, empower women, enhance labour participation and to capture the demographic advantage. Given the centrality of women’s health and participation in enabling an inclusive economic development, a paradigm shift is needed at this crossroad.
The following note attempts to describe the most critical policy bottlenecks to implementation of core schemes and programs related to overall quality of health and well-being outcomes for women. Additionally, the note also lays out twelve-point action agenda that might be adopted by the government to bring about new measures for policy changes women care.
Women are the strong pillars of any vibrant society; whose empowerment is crucial to achieve an inclusive economic growth for the nation. Maternal and child health is an important aspect for the development of any country in terms of increasing empowerment, equity and reducing poverty. The survival and wellbeing of mothers is not only important in their own right but are also central to solving large broader, economic, social and developmental challenges. At this juncture, India has slipped to rank 112 in 2019 (from 108th last year) on the World Economic Forum’s Global Gender Gap Index 2019. Moreover, as per the annual survey, India now ranks in the bottomfive in terms of women’s health and survival and economic participation. However, growingly it has been observed that many of the India’s neighbor like Srilanka has made commendable progress in healthcare, with its IMR and MMR much below the global and regional average. Easy physical access to health services close to households was ensured in Sri Lanka by 1970s and this along with 95% of the inpatient care under the public sector has ensured that people do not generally fall prey to catastrophic medical expenditure. Other South Asian countries like Thailand, and Bangladesh have achieved impressive progress on different healthcare indicators and health care financing leaving India behind which is evident from the country’s slow progress in ensuring good quality healthcare, especially to the most vulnerable like women and children.
India has a high maternal mortality rate, with over 100,000 women dying in childbirth every year. India also struggles with child mortality: the country represents about one quarter of the global burden of infant and under five deaths. Access to health and nutrition services for mothers and children during pre and postnatal care stages have been poor adding to higher mortality rates. One out of every five children under the age of 5 years is wasted and 43% are underweight for their age, outcomes which are closely related to the nutritional status of their mothers. Children whose mothers are underweight (with a body mass index less than 18.5 kg/m2) are much more likely than other children to be stunted, wasted and underweight.
To break the cycle of malnutrition in mothers and children, the government has taken key interventions such as the Indradhanush, Janani Surakhsha Yojana, Janani Shishu Suraksha Karyakram scheme which encompasses free maternity services for women and children, a nationwide scale-up of emergency referral systems and maternal death audits, and improvements in the governance and management of health services at all levels. Strategic investments have also been made under the National Health Mission for improvement of maternal and child health. However, adolescent and illiterate mothers living in inaccessible places have a much higher chance of dying during or after childbirth. Adolescent girls outside Indian cities are especially vulnerable as teenage marriage and pregnancies are very high in rural and remote areas of the country.
As described in the previous paragraph, despite substantial attempts by the Government to improve the health outcomes for women in India, several of them still face challenge in accessing high quality healthcare due to legislative biases in health policy and gender discrimination. Through the review on the research and evidence regarding quality of health care in India, below are the critical policy gaps that needs to be addressed for making the health systems more robust.
There is a system of accrediting health facilities or evaluating functionality of health facilities under NABH and private agencies like CRISIL. However, an accreditation by NABH takes over 6-8 months, while it’s rejected for smaller hospitals due to added costs. There is a lack of a standard accreditation system, and program and organizational challenges faced by the system directly impacts the quality of healthcare.
There is a growing need to ensure better care for women with both common and severe mental health problems. Awareness on mental health issues as well as availability of services at the community level is lacking as highlighted in the Common Review Mission 12th report. The Committee on Empowerment of Women 2018 recommends that Obstetricians, gynaecologists and paediatricians need to be trained in the identification, early treatment and referral for women with mental health issues associated with gynaecological problems like postpartum depression. India also suffers from wide treatment gaps in mental health care due to the inadequate infrastructure and scarcity of health care professionals in India. Further, services for special groups like older women, adolescent girls and women with conditions such as HIV and Cancer need to be developed in govt. Institutions.
At the national level, there are two major divisions within the Ministry of Health and Family Welfare: The Department of Family Welfare (DFW) and the Department of Health Research (DH). MCH, reproductive health, rural health, primary healthcare, and family planning come under the DFW while medical colleges, national institutes, and disease-control programmes come under the DHR. The Maternal Health Division within the DFW looks after all technical and administrative aspects of maternal health activities throughout India. Maternal Health Division should be equipped with a high level of technical and managerial capacity. Further, an inter department convergence becomes important for an effective functioning and management of maternal health services.
There are various schemes that work towards improving the maternal and child health. However, the schemes towards similar outcomes lack convergence. Convergence between schemes like MDM (under Ministry of Women and Child Development) and ICDS (under Ministry of Human Resource Development), both working towards improving nutritional needs of the children can be achieved for better outcomes. This points to another issue of lack of inter ministry convergence to achieve better coordination and implementation
Establishing a reliable vital registration system is a must to achieve low rates of maternal mortality; without it, the impact of safe motherhood programmes remains unknown. Sweden, Sri Lanka, and Malaysia have established a robust vital registration system at early stages of their battle against maternal mortality. Information on the levels, causes, and patterns of maternal mortality in India is, at best, incomplete and unsatisfactory compared to infant mortality for which estimates are available from the Registrar General of India. The Maternal Death Review which works towards providing detailed information on various factors at facility, district, community, regional and national level that are needed to be addressed to reduce maternal deaths. However, states have instituted the Maternal Death Review process with varying degree of reporting, review and action planning. An analysis of the progress till date brings forward key gaps – first that less than 50% of the estimated maternal deaths in India get reported under the health management information systems and second that while the institutional mechanisms for reviews have been established, the capacity to undertake quality review at various levels are weak and thirdly, the translation of key findings into action, in other words the ‘mechanism for response’ lags behind.
The large rural health infrastructure consists of over 5 lakh trained doctors working under plural systems of medicine and a vast frontline force of over 7 lakh ANMs, MPWS and Anganwadi workers besides community volunteers. They form the strongest link to public health system and key community resources but faces several challenges. The need to improve the quality of skills of ASHAs and ANMs related to nutrition, counselling for family planning, recognition of danger signs of pregnancy, and first contact care for sick new-born and children are some of the issues as highlighted by the 10th Common Review Mission Report. Further, there is a need to incentivise Asha and ANM workers who form the backbone of the rural healthcare service delivery and meet the unmet demands of women and children.
At present, the government has moved towards gender-based budgeting. However, it still doesn’t follow gender-based auditing assessing the impact of schemes on outcome. A gender-based auditing system shall be developed to improve health outcomes.
The increasing burden of Non-Communicable Diseases (NCDs) even when communicable disease burden already exist on account of communicable diseases and Maternal and Child Health care (MCH) creates a double whammy. Government has taken initiatives to address the increasing burden of NCDs, but the implementation on the ground has been poor.
The neglected tribal health conditions were highlighted in the ‘Tribal Health in India- Bridging the Gap and a Roadmap for the Future’ report published by an expert committee headed by Dr Abhay Bang. It has identified 10 major health issues that affect the tribals disproportionately including Malaria, malnutrition, child mortality, maternal health problems, family planning and infertility, addiction and mental health issues, sickle cell disease, animal bites and accidents, low health literacy, and poor health of tribal children in Ashramsalas. The committee also addressed the dearth of data on tribal related indicators and recommended major principles that should underpin the research in the tribal health field.
India bears the burden of having the largest number of anaemic women in the world accounting for 51%, as per the Global Nutrition Report 2019. Low awareness, illiteracy, poor hygiene and the practice of putting the family before oneself are some of the factors responsible for high rate of anaemia among women of reproductive age. Mothers who consumed iron folic acid for 100 days or more when they were pregnant
(%) s per NFHS-4 was 30% viz-a-viz 15% as per NFHS3. Non-pregnant women age 15-49 years who are anaemic (<12.0 g/dl) (%) is 53.2 according to NFHS-4 (viz 55.2 in NFHS-3) and pregnant women who are anaemic (<11.0 g/dl) are 50.4.
The 2015 study on Medical Termination of Pregnancy Bill 2014, in the Indian journal of Medical Ethics stated that 10-13 percent of maternal deaths in India are due to unsafe abortions. The Committee on Empowerment of Women report 2018 noted that the poor and downtrodden women and girls are not only deprived of basic sexual and reproductive health in general but also, they have very poor access to safe abortion services. Moreover, the Committee also acknowledged that around 80 percent of women do not know the legality around abortion coupled with instances of slow judicial process which makes abortions complicated and difficult.
In order to address the aforementioned policy gaps a 12-point action plan has been charted below. The following suggestions for consideration, caters to the holistic development of women centric policies focusing on health, governance and legislation.
Access to sustainable energy is critical to alleviate poverty and empower women and children. Calorific mapping and biofortification of food according to the World Health Organisation’s standards enhance better nutritional based outcomes. This further enables access to energy and better labour participation.
We need to shift towards performance-based monitoring of medical professionals, certified nurses and officers of allied health services in order to improve the quality of healthcare services rendered to women and children.
ASHA workers who form the backbone of India’s rural health infrastructure need to be skilled and equipped through various medical skilling service centres. It can be done by convergence through PMKVY. Moreover, ASHA and ANM workers should be covered under some social security benefits.
Develop mechanisms integrating technology to address leakages of nutritional prenatal care supplies and to ensure that it reaches the last mile beneficiaries.
A standard accreditation along with dynamic metrics (changing with changing needs) shall be developed to gauge the quality of healthcare. A standard accreditation system becomes important to improve the quality of healthcare given to the people, especially mother and child. Further, it shall also be developed for smaller hospitals at a reduced cost.
A Nodal Cell shall be made to establish convergence between schemes and departments. The nodal cell shall consist of experts from key ministries like MoHWF, MoWCD, and they can further map schemes to determine similar objectives and establish a convergence with the help of the nodal cells.
The operational efficiency enhancement of the Nutritional Rehabilitation Centre (NRC) set up under the National Rural Health Mission will ensure better rehabilitation, treatment and stabilisation of children facing Severely Acute Malnourishment (SAM). Further regular periodic review should be conducted to accelerate the quality of service rendered by these NRCs.
Schemes that aims to improve health for tribal children and women shall be made inclusive and sensitive to their needs. The nodal cell can work towards seeking convergence with Ministry of Tribal Affairs to make the policies sensitive and inclusive to the needs of the tribals.
Besides gender-based budgeting, we need to shift the focus to gender based auditing and devise various metrics to assess the impact of gender-based schemes. We need to also include gender-based auditing besides gender-based budgeting.
The program has to be strengthened further to improve the health infrastructure related to labour. Moreover, we can move towards a PPP execution, whereby the government can incentivise the private sector to look into improving the infrastructure of the labor rooms. Further, LaQshya needs to seek convergence with JSY to improve outcomes on institutional deliveries.
The Lucky Iron Fish experiment of Cambodia is a simple and effective cooking tool that adds extra iron to daily foods or drinks. It is an alternative to pills, especially for those with iron deficiency anemia. India needs to come up with simple yet effective low-cost alternative to combat anemia among women of reproductive age.
A composite indicator to measure health care coverage in India for efficient monitoring of health performance benchmarking the goals and targets.