Authors: Rayandev Sen, Anindyo Kamal Sen, Marisha Ghosh
Source: Trinity Care Foundation
Introduction
Bengal has had a rich history of promoting the empowerment of women. The state was home to activists and freedom fighters such as Begum Rokeya Hossain, Basanti Devi and Sarojini Naidu and has produced eminent historical figures such as Sarada Devi and Pritilata Waddedar. The idea of women’s education and empowerment was ingrained into Bengali society relatively early, the fruits of which can be seen in its high female enrolment rates at various education levels. Seeing these results, it stands to reason, to also ask how women have done when it comes to their health. How well have they done when compared to men? What holds them back?
At first glance, they seem to be doing well. The maternal mortality rate is well below the national average, health insurance access rates between the genders is more or less equal and government health schemes cover the genders equally. But we mustn't jump to conclusions. Healthcare ultimately depends on two factors: whether it is available to a community and whether individuals from the community can afford it. With this background, this article analyses the challenges and disparities faced by women in West Bengal to access healthcare resources.
Availability - Women & Public Health
The public health system in India is a stratified system composed of various units designed to serve different healthcare needs. Primary Healthcare Centers (PHCs) and Community Healthcare Centers (CHCs) form the basic stratum. These are of the greatest importance when it comes to the health of women, particularly poorer women who cannot afford private care. PHCs and CHCs are specialised to deliver prenatal and postnatal care, gynaecological examinations, counselling on sexual and reproductive health and serve as dispensaries which provide supplements and sanitary products.
That is the ideal they are supposed to achieve. In reality, health infrastructure in Bengal is severely lacking. From above we see that Bengal displays an uneven distribution of public health infrastructure, with a lower absolute value towards the north and a higher concentration in the central regions. It also has one of the lowest public health infrastructure-to-population ratios in the country. Apart from the distribution, there is a massive shortfall of trained staff in these healthcare centres, particularly in rural and tribal areas, where women are the most marginalised. This is reflected in the Rural Health Statistics Report (2022) according to which, between 2005 and 2021 the number of OB GYN specialists in CHCs in rural West Bengal fell by over 49.62%. As of 31st March 2021, the shortfall of OB GYN specialists in CHCs in rural West Bengal is one of the highest when compared to states with similar levels of development.
Furthermore, while enumerating the number of OB GYN specialists at CHCs in tribal areas, it is observed that West Bengal has significantly fewer human resources in these regions as well when compared to states with similar levels of development, as shown above (Rural Health Statistics Report, 2022). The lack of human resources, especially for women, in rural and tribal West Bengal emanates from a low state-capacity to provide for the people and a general consensus amongst doctors against working in rural and tribal locations (Sharma, 2015) which makes hiring difficult. The healthcare system suffers from a high attrition rate, such that doctors who are supposed to staff these centres are often not present there (Gautham et. al, 2011).
Even when public health centres are staffed they lack the equipment and the infrastructure to provide adequate assistance to patients (Dreze & Sen, 2012). Some of these centres don’t even have running water or electricity. The fact that 71% (NFHS-5, 2020) of women in West Bengal suffer from anaemia serves as evidence of the failure of these institutions to serve as dispensaries to deliver supplements to the community.
The result of such widespread unavailability of reliable public health care has led to a dependency on the private sector which has terrible implications for those who cannot afford their services - particularly women belonging to backward castes and marginalised sections.
Affordability - A Gendered Perspective
Dreze & Sen point out that the dependency on private-sector healthcare arises from the ill performance of the public sector. This is especially true for West Bengal. The dependency on private healthcare increases catastrophic health expenditure (CHS), which is health expenditure which proves to significantly deplete the savings of a family. This affects women the hardest. With low bargaining power in the family, health expenditure on women is often forgone for expenditure elsewhere. This is reflected in the inequality between out-of-pocket (OOP) expenditure on men and women for CHS in the state. As per an empirical study conducted by Das (2020) expenditure on healthcare for CHS for men is significantly higher than for women in more than half the districts in the state.
One way to bridge the affordability gap is through subsidies and government schemes. Even then, women remain at a disadvantage. Even though they may be literate, women have difficulty understanding and availing these schemes independently, without the permission of a patriarch. Although both genders have similar subscription rates to subsidy schemes for health expenditure from the government, the actual benefits differ drastically across genders (Bose & Dutta, 2015).
This widespread inequality in terms of expenditure and affordability cannot be remedied by simply funnelling subsidies and schemes down to the public. Most women do not receive a subsidy in the first place as most of the beneficiaries tend to be from the affording class rather than the deserving class (Bose & Dutta, 2015). Those who do receive these benefits cannot utilise them as well as their male counterparts; often because of their male counterparts.
Gender Inclusive Healthcare- A Path Forward
The focus of the government, therefore, should be twofold. Firstly, reduce the dependency on the private sector for women by establishing robust public health care. This will automatically provide women with the healthcare they need but do not receive when approaching the private sector due to the funnelling out of OOP expenditures towards males. This can be achieved by increasing public health expenditure over time and with public-private partnerships. Expenditure needs to be focused on building infrastructure in rural and tribal areas with sufficient incentives to attract qualified doctors to those places. Secondly, attention must be paid to teaching women to register for and avail government subsidies and health schemes, particularly for women in rural and tribal areas. This can be achieved through the state’s robust network of self help groups. The state can partner with SHGs at a village level to disseminate information on healthcare, insurance schemes and subsidies and teach women how to avail them, at the time of need.
Thus, it can be observed a lack of support from the state and pre-existing inequalities within the household prevents women in Bengal from availing the same benefits in healthcare as men do. It is only a matter of providing opportunity to these women to take their health into their own hands which will lead to true equity.
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