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Women suffer more, get treated less

By Neha Madhiwalla

Morbidity amongst women is higher than amongst men. But women are less likely to access healthcare for several reasons: they cannot afford treatment, they can't get time off work, they have little status within the family, and they're intimidated by a public healthcare system that does not cater to the needs of the illiterate

 Lack of resources fundamentally changes the way illness is viewed. While for the average middle class person sickness is a period where one can legitimately expect care, concern and opportunity for rest, for the poor, illness constitutes a crisis, especially if it affects those who provide for the family.

Within the Indian family structure, which is based on filial obligations, able-bodied adults are the last to receive healthcare because they are obliged to keep working and earning as long as they can. Women, whose work is seen as less important and less strenuous, receive even less attention. Medical treatment means taking time off work, admitting to yourself and the family that you cannot work, getting others to look after you. It means that instead of providing, you have to be provided for. All of these are conditions that adults in poor families cannot accept.

Specifically for women, whose status and authority derive from their contribution to the family, accepting the above would be extremely difficult; it would make them vulnerable within the family.

Poverty also implicitly means that levels of education are low, lower still among women. In the rural setting, where public life is premised on the assumption that people cannot read and write, health functionaries are expected to reach out to and 'compensate' for people's illiteracy. But in the city, where literacy is taken for granted, people are expected to function in a literate, 'educated' way. This puts migrant women, who have never had any education, at a big disadvantage. Not being able to read, travel alone, communicate effectively with doctors, nurses, etc, limits women's mobility and increases their dependence on others to access primary healthcare services.

Women's lack of education has not only a functional aspect but a social aspect as well. Such people are looked down upon and treated with disrespect within the health system. They are much less likely to be consulted about treatment choices or given information. They are also much less likely to obtain redressal than more educated, better-off patients.

Poor urban women are often invisibly employed. They work as home-based workers or part-time casual workers, with no documented employment. Such work is very un-remunerative and affords no sense of a collective, because they never come into contact with each other. Thus women spend long hours doing paid work, but do not get the status or identity of workers. They do not get the opportunity to meet other people, form relationships outside their family circle, learn from the experiences of other women and come into contact with the larger world outside the home. A larger social network is very important for women because it gives them opportunities for self-development, skills to negotiate with outsiders (whether they are employers, officials, colleagues or customers) and a safety net during times of crisis (for example, domestic violence, accidents and catastrophic illnesses, death, etc).

This is the background against which we must understand what happens when women seek healthcare. When such women seek services in the public sector they face problems at every level. Firstly, these relate to poverty. Not being able to afford healthcare is still one of the primary reasons for not seeking treatment. The costs of healthcare may be direct -- in the form of doctors' fees, hospital charges, medicines, tests and so on. Then there are the indirect costs, such as the cost of transportation, food and bribes, 'rewards' that need to be paid to various functionaries. Often in public hospital nowadays, only the fees are waived and everything else has to be paid for. Moreover, most government centres are crowded, extremely bureaucratic and rigid. So one has to spend the whole day, even several days, to get simple tests done or get medicines. For the poor, who have no paid leave, this is a big indirect cost. For women, who either have no leave (from housework and childcare) or get paid only when they work (as in home-based work), it becomes very difficult to take so much time off. Inevitably, they go to the public hospital only when they become so sick that they cannot work in any case.

These pressures inevitably push the poor to the private sector, where the costs may be a little higher but the timings, terms of payment and location of services are more convenient. The private sector is also very varied and has all kinds of practitioners -- ranging from completely unqualified quacks to specialists. The lower-end practitioners are the ones who cater to the large proportion of the poor's health needs, for obvious reasons. For women, who must make do with as little as possible, these quacks seem the ideal solution. Therefore it is not uncommon for people to drift from one quack to another, then to general practitioners before finally ending up at the government hospital as the problem worsens. This is one of the reasons why health problems become chronic and needlessly long-term. The more time is wasted on incomplete cures or neglect, the more difficult the problem becomes to treat.

A classic example of this would be uterine prolapse. This problem affects a large number of women, mainly after delivery. While women who have had many children seem to be more prone to this, even those who have had just one child are known to suffer from uterine prolapse. In this condition, the muscles of the pelvic floor become weak and the uterus protrudes from the vagina. As time passes, the prolapse becomes worse. Women find it distressing because it causes incontinence, problems during future deliveries as well as frequent infections. Treatment for this condition ranges from exercise to surgery, depending on the severity of the problem. Invariably, women ignore the problem initially out of embarrassment. A large majority of practitioners in slums are men who will not do vaginal examinations. Even if they are women, there is no privacy in which to do an internal examination. So women are given tonics and antibiotics (if they complain of vaginal discharge). After several years, they may land up at a government hospital, when the problem has become quite severe. At this point they may be told that there is no alternative to surgery (to remove the uterus), and they return because they are unable to afford the cost of surgery or because they are daunted by the idea of possible danger and disruption to their daily lives.

Thus, clearly, the problem of access to healthcare for poor urban women is rooted in poverty, but not explained entirely by poverty. While making free healthcare available to all would solve many women's problems, there will be other hurdles to cross. Changing power relations in the family, making social support available (childcare, housekeeping, nursing), creating opportunities for women to come together, interact, learn from each other and form a sense of community, gainful and satisfying work that allows women to develop confidence and self-reliance, and, finally, a healthcare system which treats them seriously, with respect and sympathy are all important elements in improving women's access to healthcare.

45% of illness episodes among women go untreated

Two studies suggest that women have less access to healthcare than men do, though they may need it more

Sunil Nandraj, Neha Madhiwalla, Roopashri Sinha and Amar Jesani interviewed 3,581 women in 1,193 urban and rural households in Maharashtra . The district was selected for its 'average' development index and substantial tribal population. (Health, Households and Women's Lives: A Study of Illness and Childbearing Among Women in Nasik District, Maharashtra, CEHAT 1999).

  • Women reported a higher morbidity than men did (506 per 1,000 women vs 307/1,000 men reported illness within the given reference period). Their illnesses tended to be chronic and linked to their work, childbearing and contraception.
  • Yet, women's utilisation of healthcare was relatively low -- they did not seek formal or informal treatment for 45% of the illness episodes they reported. In 40% of these episodes, the reason for not seeking treatment was that it cost too much.
  • Women were more likely to use home remedies and informal services.
  • Certain types of illnesses, such as aches/pains, injury and weakness, were mostly treated in the informal sector. Long-term illnesses were not treated as frequently as short-term infectious illnesses.
  • Women did use public health services, but this was mostly restricted to contraception.
  • More than 12% of women's illness episodes were not treated at all, because health facilities were not accessible or adequate.
  • In general, women from deprived groups -- women from remote villages, scheduled castes and urban minority communities -- did not receive healthcare for a large proportion of their illnesses.

The same researchers did a similar study in Mumbai ( Women and healthcare in Mumbai -- A study of morbidity, utilisation and expenditure on healthcare in the households of the metropolis CEHAT, Mumbai , 1998). Women in 430 households in slums, chawls and an apartment block in the city were interviewed in detail. Some findings:

  • Again, women reported much higher morbidity than men did, with health problems linked to their household work. But men were more likely to receive treatment.
  • The average private per capita expenditure on healthcare was Rs 415.68 per year. In contrast, the state government spent Rs 250 per person in Mumbai; the national per capita public expenditure was Rs 90.
  • In both slum and non-slum areas, households spent less on women's health -- Rs 148.56 per illness episode for men and boys, and Rs 78.59 per illness episode for women and girls.
  • More than 32% of illness episodes were not treated. Almost two in five reproductive illnesses were not treated, apparently because women did not have access to female doctors or other health services.
  • Fifty-seven per cent of pregnant women who used some type of health facility went to the private sector; only 32% utilised public facilities.
  • Twenty per cent of deliveries were conducted at home. Forty-three pregnant women did not utilise any healthcare facilitie

(Neha Madhiwalla is managing trustee of CHEHAK which runs a community health programme for women. Contact: This email address is being protected from spambots. You need JavaScript enabled to view it.)

InfoChange News & Features, June 2005