In Indian culture, it is the man who is the bread winner, and his life is precious as the entire family hangs from the financial thread which he weaves. On the other hand, a woman can be easily replaced by another, with no difference to anyone around, except her children. The inequality in healthcare stems from the status of the woman in her family.

The United Nations regards gender equality as a human right, yet for a country making strides as an emerging economic power, gender inequality remains an area where it compares poorly with the rest of the world. India is placed 129th among 146 countries in terms of gender inequality index (GII), far behind neighbouring Sri Lanka at 74 and lagging behind most other countries in the region. The GII is calculated using indicators from three broad dimensions – health, empowerment and the labour market. The health indicators used are Maternal Mortality Ratio and Adolescent (age 15 to 19) Fertility Rate. [1] The indicators for empowerment are Secondary Education and Representation in Parliament. From the labour, the proportion of the female population employed is the indicator for the Labour Market.[1]

Discrimination against women and girls remains the most prominent form of inequality. Gender based violence, economic discrimination, reproductive health inequities and harmful socio-cultural practices are the various ways in which women are relegated to a status much below that of the men in their homes, may it be their fathers, their husbands or their sons!

Gender inequality affects the health of women, for example it may prevent a woman from accessing health care because norms in her community prevent her from travelling alone to the clinic. Gender inequality may also prevent a married woman from contracting HIV through her HIV positive husband only because she cannot prevent her husband from promiscuity nor can she insist that he uses condoms.[2]

Unicef has estimated that 50 million girls and women are “missing” from India’s population either because the female fetus was terminated or due to high mortality of the girl child due to lack of nutrition and care .[3]   Gender inequality is closely correlated to the problem of the adverse sex ratio in India. Most explicitly, girls are not wanted, so they are aborted. The child sex ratio has dropped from 945 females per 1000 males in 1991 to 927 females per 1000 males in 2001.[4]  Census 2011 published the results for the sex ratio of children 0-6 years a few months back. This ratio showed a decline from a level of 927 in 1999- 2000 to 916 in 2009- 2010. On the face of it, this declining 0-6 Sex Ratio would suggest that the gender bias is getting worse. But the Sex Ratio at Birth (SRB) in the 2009-10 survey of the educated class showed a stunning level of 978- which meant that sex selection is on a downward trend. And we can thank the education of the middle class for this turnaround. And maybe the next time the UN, and others discuss gender inequality in India, they will recognize the India of the present and the future, and not of the past.

The Twin Process of “elimination of daughters” and the “slow killing” through neglect and discrimination of those who are already born, has become a matter of grave concern. Realizing the future impact of lower female to male sex ratios, the PCPNDT Act of India was passed in 1996.[5]  which prohibited determination of sex of the fetus, with penalties ranging from imprisonment for 7 years to 14 yrs for all the persons involved in the crime. Lack of empowerment of women prevents them from protesting against such repeated abortions which they undergo under male pressure, coercion and domination. Thus unwillingly, they become party to a crime which they do not wish to commit, but cannot prevent it as they have no control over their bodies. The rich and those who have the means, use cross border assistance in determining the sex of their future children. Depending on their financial status they undergo sex selected embryo transfer, chorion villus sampling, amniocentesis or simply an ultra sound at 16 weeks. A study published in the Canadian Medical Association Journal on April 16th 2012 looked at 76,7000 births in Ontario Province from 2002 – 2007 .[6]    and checked them against their mother of origin. Indian mothers gave birth to 1883 sons and 1385 daughters, a hugely distorted ratio of 136 to 100 which can never be explained as being a natural event!

 

 

 

The demographic crises of more boys as compared to girls will lead to increasing sexual violence, trafficking of women, a higher number of child marriages, and even more maternal deaths due to related illegal abortions. In States like Kerala and the North Eastern States of India, where women are educated and are aware of their rights, sex ratios are similar as in the rest of the developed world. [5]

Gender violence is not limited to female feticide or infanticide, Every single day, 138 women are sexually abused or harassed, 60 raped per day, 80 minor girls are kidnapped, 7 women forced into becoming commercial sex workers, 23 women burnt for dowry and 257 women suffer domestic violence!

Girls are married young, even though the Indian law does not permit marriage for girls before 18 years of age and educating them is not high priority for families with limited resources. Close to 245 million Indian women lack the basic capability to read and write, hence are not empowered enough to make any decisions regarding their own health. 300 women die every single day due to child birth and unsafe abortion, even though India was one of the first countries in the world to legalize abortion! A much larger number suffer from chronic morbidity, such as fistulae following obstructed labour and pelvic sepsis following unsafe abortion. Access to abortions and childbirth in rural areas is limited and even though the infrastructure exists, skilled birth attendants are rare. [7]   

The average nutritional deficit in women is 500-600 calories per day, [8]    seriously affecting their nutritional status, hence low birth weight babies and child malnutrition are seen extensively in this group. Long term in utero problems have been neglected, whilst diseases such as TB, Malaria and HIV are receiving attention. Low public health spending, lack of emphasis on prevention, lack of accountability in health care, are some of the key problems of poor health.

Various legislations have been enacted in the Indian Parliament which are pro women and legally protect them against any form of violence. They are intended to bring about women’s economic and social empowerment to the maximum and to equip women to exercise their rights. Even though the law is a powerful instrument of change, yet the law alone cannot get rid of the social problems of treating women as second class citizens. Besides the economic factor, there are other factors which devalue women. Cultural traditions allow only the son to light the funeral pyre of his parents when they die, and it is the son who can extend the family lineage. This is because most of Indian Society is patriarchal, where girls drop their own family names and adopt their husbands’ family names. Such practices and traditions are hard to change, and need a change of thought process. Such change can only be achieved through cumulative sensitization of Society by religious and social leaders, responsible media, the medical profession, and the political will in the country. India is a good example of a country with a huge gap between policy and practice!

Even though India’s health sector is growing at a fast pace, the Government contributes to only one third of the spending as compared to the private sector. The Government spends only 2.5% of GDP on the health sector much below the WHO Recommendation of 5%, inspite of the fact that 36 % of India’s population survives on less than $ 1 per day.[4]  70% of the money for medical treatment comes from personal contribution. The limited financial resources of a family are utilized mainly for the health of the bread winners of the family. [9]  

In India, women’s health is directly related to her status in Society. When she acquires an equal status, only then will her health matter. Women’s education and empowerment is the necessary change.