Why Universal Health Coverage would be meaningless without gender justice

On Universal Health Coverage Day 2023, Martand Kaushik, Senior Specialist-Media and Communications, Population Foundation of India and Sanghamitra Singh, Chief of Programmes, Population Foundation of India highlight that despite significant strides, India’s journey towards UHC is still fraught with challenges. The National Health Policy of 2017 aspires for every individual to maintain their health and access quality medical treatment without prohibitive costs. Initiatives like Ayushman Bharat-Pradhan Mantri Jan Aarogya Yojana (PMJAY) and Health and Wellness Centres (HWCs) represent monumental steps in this direction. However, gaps in healthcare coverage and inequities in health outcomes, especially concerning family planning services, persist

In the mid-nineteenth century, the British government was deeply concerned about their soldiers getting venereal diseases. An 1864 report of the Sanitary Commission noted that a third of the army was affected, with the number at over 50 per cent in some military bases.

The colonial authorities saw local Indian women as the source of the disease. In 1868, the Contagious Diseases Act was passed, solely to protect the soldiers. The policy was designed to curb the spread of venereal diseases among troops, and targeted local women, often labeling them as prostitutes and subjecting them to mandatory health checks. The approach not only reflected the gender biases of the time but also underscored the power imbalances between the colonial rulers and the ruled.

By all accounts, the Act proved ineffective, with no effect on the incidence of diseases. However, it carried a significant social cost by unfairly targeting Indian women. The entire episode serves as a reminder of the complex interplay between health policies and social factors, especially gender inequality.

Over a century later, health outcomes for women are still compromised due to persistent gender inequality. Indian women often lack the agency to make decisions around their reproductive health and face societal pressures of conforming to stereotypes, early marriage, and childbearing. These factors not only restrict their life choices but also significantly affect their health outcomes. It is therefore clear that without enabling women to have the agency to access health services, the mere provision of health services or legislation would not serve the purpose.

According to the fifth round of the National Family Health Survey, one in four Indian girls continues to get married before the age of 18. Young girls are not only denied the right to choose their partners but are also marginalized and subjected to practices that violate their basic human rights. This leads to compromised physical and mental health, increased susceptibility to psychological abuse, domestic violence, and a lack of economic opportunities. Adolescent mothers face higher risks of maternal mortality, unsafe abortions, preterm births, and other complications, contributing to a cycle of poor health outcomes, poverty, and gender inequality. Alarmingly, NFHS-5 data indicates that nearly 7% of girls aged 15-19 were pregnant or mothers, and 59 per cent of adolescent girls in India are anaemic. The problems are widespread and not limited to child marriages, as women of all ages and backgrounds often face similar pressures of varying degrees throughout their lifetime.

Universal Health Coverage, or UHC, is the concept of ensuring that every individual has equitable access to necessary health services without suffering financial hardship. As part of the Sustainable Development Goals, 193 UN member nations, including India, are committed to providing affordable, high-quality healthcare to all communities by 2030. A crucial aspect of UHC is family planning, which entails access to sexual and reproductive health services, information, and quality-assured contraceptive methods.

Despite significant strides, India’s journey towards UHC is still fraught with challenges. The National Health Policy of 2017 aspires for every individual to maintain their health and access quality medical treatment without prohibitive costs. Initiatives like Ayushman Bharat-Pradhan Mantri Jan Aarogya Yojana (PMJAY) and Health and Wellness Centres (HWCs) represent monumental steps in this direction. However, gaps in healthcare coverage and inequities in health outcomes, especially concerning family planning services, persist.

For instance, the National Family Health Survey (2019-21) revealed that 9.4 per cent of married women of reproductive age have an unmet need for family planning, which means that they either lack agency or access to contraceptives even when they need them. In India, access to and use of family planning services vary significantly based on location, identity, wealth, and education, highlighting the deep-rooted inequities within the system.

Addressing the unmet need for family planning is crucial for achieving UHC. This requires not just coverage, but also paving the way for societal changes that allow equitable access to health services. Strengthening primary healthcare, integrating self-care interventions, and engaging with private healthcare providers, who serve over 75% of the population, are essential steps in this direction.

But we also need to go beyond and seek changes at a societal level. Enabling girls to complete their education can delay marriage and foster financial independence. It is essential to address barriers to education, especially for girls in marginalized communities, rural areas, and from the lowest wealth quintiles. Secondly, skill-building for adolescent girls is crucial for their economic empowerment and transition to adulthood.

Challenging and transforming patriarchal norms that exclude girls from marriage-related decision-making is another vital step. This includes ensuring gender equality in legal marriage ages across all religions, castes, classes, and creeds. Furthermore, mandatory registration of all marriages, births, and deaths is essential for tracking and effectively addressing child marriage. These interventions are crucial in moving towards gender equality and improving health outcomes for women in India​.

As we celebrate International Universal Health Coverage Day on December 12, commemorating the United Nations’ unanimous endorsement of UHC in 2012, we must recognise that UHC cannot be achieved without viewing health systems through a gender lens and taking into account power dynamics and women’s access to health services.

Just as the failure of the Contagious Diseases Act taught us the perils of ignoring societal context and gender dynamics in health policy, today’s efforts towards UHC must not repeat these mistakes. In order to be truly inclusive, India’s path towards UHC must prioritise addressing social determinants of health.