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Gender in the HLEG Report

Apart from referring to gender concerns in its chapters addressing critical areas of the healthcare system, the High Level Expert Group's report on Universal Health Coverage for India has a separate chapter on gender and health. While the report as a whole and this chapter make several sound suggestions, what comes through is that much more could have been done. In the absence of a gender and health analysis framework, the report tends to address gender issues in an ad hoc and uneven fashion.

UNIVERSAL HEALTH COVERAGE

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between them will affect the extent to

Gender in the HLEG Report

which they will benefit from the recommendations towards achieving UHC.1 We

Missed Opportunity

then focus on the chapter on gender and health, commenting on its content and recommendations.

T K Sundari Ravindran, Manju R Nair

Apart from referring to gender concerns in its chapters addressing critical areas of the healthcare system, the High Level Expert Group’s report on Universal Health Coverage for India has a separate chapter on gender and health. While the report as a whole and this chapter make several sound suggestions, what comes through is that much more could have been done. In the absence of a gender and health analysis framework, the report tends to address gender issues in an ad hoc and uneven fashion.

The opinions expressed in this paper draw on research done by one of the authors for the WHO’s “Gender, Women and Primary Health Care Renewal: A Discussion Paper” (2010).

T K Sundari Ravindran (ravindrans@usa.net) and Manju R Nair are with the Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram.

T
he report of the High Level Expert Group (HLEG) on Universal Health Coverage (UHC) for India deserves to be commended for putting gender firmly on the agenda of healthcare. In its definition of UHC, the report includes gender alongside income level, social status, caste and religion as attributes that could individually and in combination constitute barriers to equitable access to healthcare. Gender is recognised as a social determinant of health, but also receives special emphasis because “gender discrimination and gender insensitivity, if left unaddressed, will threaten the very framework and guiding principles of UHC for India” (HLEG 2011: 48). Accordingly, the report dedicates an entire chapter to gender and health besides referring to gender concerns in the other chapters. In addition, many of the report’s excellent recommendations, aimed at inclusiveness, have been developed within an equity and rights framework and they also benefit those at a disadvantage because of gender.

Despite these and other strengths, there are crucial gaps in the gender issues related to UHC identified and highlighted in the HLEG report. In this paper, we first examine the recommendations made in the chapters addressing critical areas of the healthcare system from a gender perspective. That is, we examine whether and how the different roles of women and men and the unequal power relations

february 25, 2012

Gender Issues in Critical Areas

The HLEG report opens with a chapter on the overall vision for UHC and is followed by six chapters, each of which is devoted to a critical area for action to enable India’s health system to deliver care in an equitable manner to all. Detailed recommendations are made for each of the following areas.

  • Health financing and financial protection;
  • Health service norms;
  • Human resources for health;
  • Community participation and citizen engagement;
  • Access to medicines, vaccines and technology;
  • Management and institutional reforms.
  • The recommendations on health financing and financial protection focus on reducing out-of-pocket expenses while relying on tax-based revenue as the principal source of financing. If implemented, they will lower the financial barriers in the way of women-seeking healthcare. For instance, the availability of essential drugs free of cost will take a major financial burden off older women who suffer from chronic conditions. In general, such conditions affect more women than men. Though they have a higher life expectancy than men, most women are less likely to be covered by health insurance because of not having worked in the formal sector. Likewise, more investment in healthcare at the primary level will bring services closer

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    to women (and others) who find it difficult to travel or are unable to afford the costs of transportation.

    An important factor that will influence the expenses that will still have to be borne by patients is the content of the National Health Package (NHP) because services not included in it will have to be paid for. The report says the NHP should “cover all common conditions and highimpact, cost-effective healthcare interventions for reducing health-related mortality and disability” (2011) but if it ultimately does not cover services that a significant proportion of women or men will need at different points in their life, they will remain beyond the reach of those who cannot pay for them. Much will depend on the extent to which the public and private health sectors actually make available the services listed in the NHP, failing which the population will once again have no recourse but to pay for them from other private-sector providers, formal or informal.

    The financing recommendations do not make any reference to social protection health schemes targeting vulnerable groups of the population, which, according to the World Health Organisation (WHO), “would be needed in order to bridge the gaps in health status resulting from social and gender inequities” during the transition to UHC (2008: 33). In other words, social protection health schemes are needed as immediate measures in the short run to begin the process of closing the gender and social divides in health status as well as access to care.

    The recommendations related to healthservice norms could have better addressed issues of gender equity. A number of criteria have been outlined for determining the contents of the NHP, but gender-related ones are missing. One commonly used set of criteria for taking into consideration gender differentials in health needs is addressing conditions that occur exclusively in women and men as well as ailments that are more common to women, manifest differently in them and are more severe or have more serious consequences to them. It also includes illnesses that have different risk factors for women and men (PAHO 1997). The same can be extended to include

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    february 25, 2012

    traditionally underserved groups such as transgendered people, those with different sexual orientations, older persons and adolescents. Although presented only as an indicative and illustrative list, a life cycle framework (as suggested in the gender and health chapter) could have been provided and the heavy slant towards a traditional maternal and child health (MCH) package could have been avoided.

    Many non-financial barriers exist in access to health services that are rooted in gender-power inequalities between women and men, such as women’s lack of decision-making power on whether, when, where and for what to seek healthcare and restrictions on their mobility. These barriers can be mitigated to some extent by suitable organisation of health services and this could have been mentioned in the recommendations on healthservice norms. For example, services available closer to home or the workplace and at times suitable to women or men are more likely to be utilised and could make a big difference to identification of morbidity and effective treatment and cure.

    Another dimension is creating exclusive spaces and timings within service delivery settings for women, men and young people of both sexes to make services more “acceptable” to them. Inte gration of some services could enhance privacy and/or reduce stigma as, for example, when services for sexually transmitted infections (STI) or HIV/AIDS, abortions (especially medical ones) or infertility are made available at the primary care level as part of comprehensive sexual and reproductive healthcare. Horizontal integration of services across traditionally vertical programmes will be a further advance, such as, for example, the availability of directly observed treatment, short-course (DOTS) services for tuberculosis in the same facility as MCH care.

    Equity in access to hospital beds for the rural population and the urban poor has been rightly emphasised in one recommendation. A similar emphasis is needed on beds for women (excluding maternity beds). According to anecdotal evidence, many hospitals have fewer beds for women than men when maternity beds are not considered.

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    The recommendation on quality assurance standards within health-service norms could have gone beyond Indian Public Health Standards (IPHS) to include a rights-based perspective on patientprovider interactions. The following are a few essential quality norms from a gender and rights perspective.

  • No physical or verbal abuse of any patient by any member of the health team;
  • Informed (and “understood”) consent for all procedures obtained from adult patients;
  • No requirement for husband’s permission for procedures carried out on adult married women;
  • No conditionalities imposed for provision of any services (for example, acceptance of contraception made a condition for providing abortion services);
  • Visual and auditory privacy;
  • Confidentiality;
  • Non-discrimination on the basis of class, caste, gender, sexual orientation; and
  • Sensitivity to the possibility that any woman examined may be experiencing gender-based violence and adopting a policy of upholding the woman’s safety above all else.
  • Human Resources Chapter

    The chapter on human resources for health recommends the inclusion of social determinants and gender and equity issues in the curricula of medical professionals. It would be equally important to integrate gender and equity issues in the pre-service and in-service training curricula of all health workers such as nurses, auxiliary nurse midwives (ANMs) and the cadre of community health workers proposed by the HLEG. A recognition of gender inequalities within the health workforce is missing from the human resources chapter. These are, however, addressed to some extent in the chapter on gender and health.

    Recommendations related to community participation and citizen engagement call for the inclusion of women’s groups in the proposed community health councils and in running people’s facilitation centres for redressing grievances. Both are welcome measures if implemented and could potentially draw attention to

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    issues involved in unpaid health and care work carried out in households, mostly by women.

    The recommendations related to medicines, vaccines and technology are comprehensive and informed by equity considerations. The control of drug prices and the manufacture of vaccines and drugs within the country will benefit women for several reasons. For example, many have less access to or feel less entitled to financial resources but have to buy medicines for several years. Examples would be users of reversible contraceptive methods such as the oral pill and older women afflicted by chronic diseases. However, special attention must be paid to the different health needs of women and men across the life cycle when defining “essentiality” for the purpose of drug price control. An example is the female condom, which has the potential for saving women’s lives by preventing heterosexual transmission of HIV as well as preventing pregnancies, but is currently beyond the reach of most women because of its high cost.

    The chapter on managerial and institutional reforms makes excellent recommendations on ensuring professional advancement, with a special focus on opportunities for ANMs and nurses. Yet, more could have been said on promoting the gender balance in leadership in academic medicine, public health and nursing through specific initiatives to nurture and mentor leadership capabilities. Further, specific recommendations could have been made for institutional changes in the health sector that would have supported the system-wide integration of a gender perspective. For instance, health officials could be made accountable for attention to gender equity in all policies and programmes.

    It is disappointing to note that the recommendation on developing national health information technology makes no reference to the production of essential information for gender-sensitive policymaking and programming. The issue of data for addressing gender concerns is, however, brought up in the separate chapter on gender and health.

    In short, the recommendations across different chapters of the HLEG report address gender issues sporadically, without a systematic gender analysis framework that would have drawn attention to the many ways in which gender-based differences and inequalities affect specific aspects of the health system.2

    Focus on Gender and Health

    Ideally, the chapter on gender and health would have provided the background information necessary to understand the need for paying attention to the gender-based differences and inequalities that pose a challenge to achieving UHC. It would have consolidated and filled the gaps in the recommendations made in all the other chapters and added recommendations to cover the areas of gender-based disadvantages in healthcare not addressed in them. In its present format, the chapter stands unrelated to the other chapters. It does not effectively make the case for integrating gender issues across all dimensions of UHC and does not bridge the gender divide (some of which have been pointed out above) in the recommendations made in the other chapters. Nor is it an effective stand-alone chapter that comprehensively addresses all gender issues related to UHC.

    In our view, one of the fundamental problems with the chapter is the absence of a gender and health analysis framework informing the conclusions presented. Attention to gender issues seems to be often reduced to addressing the differential needs of different genders, arising out of biological as well as social differences. Even when political, economic, social and health system barriers are identified, these are not related to the unequal gender-power relations in society and in its various institutions.

    The chapter begins with an inclusive definition of gender, going beyond the male-female binary to include other genders, which is admirable. However, given that there is very limited published “evidence” currently available on the different health needs, barriers to health-seeking and discriminatory treatment of other genders as well as the social and economic consequences of ill health among them, this addition remains a token gesture. The other genders also do not find a substantive place in any of the recommendations made in this or other chapters. Rather than make a token inclusion, it may have been better to acknowledge the limitations in data and at least examine gender inequalities across the male-female binary and the consequences of its intersections with other axes of structural inequalities such as caste, class and sexual orientation.

    There is also a conflation of gender and sexual identities in the definition of gender. “A gendered perspective would thus take into account the health needs of all categories of sexual identity;

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    heterosexual, homosexual, lesbian, gay, to be achieved through a package of health indicators (distinct from sex-dis
    bisexual, ‘queer’, transgendered, trans services that covers broad sexual and aggregated indicators) and how one
    sexual, and asexual,” says the report reproductive health services, critical men would go about identifying a core set of
    (2011: 297). We believe that the issue of tal health services, services to address indicators for a country that could be
    discrimination on the basis of sexual ori gender-based violence and work-related taken advantage of.3
    entation or identity merits independent health issues. There is also mention of The fourth recommendation calls for
    examination as an axis of inequality that locating health services in locations con the empowerment of women, girls and
    would be a barrier to UHC. Combining it venient to women and operating them at other vulnerable genders, an essential
    with gender-based inequalities does not times suitable for them. Training health condition for realising health rights.
    do justice to either – inequalities bet workers to be sensitive to the issues Empowerment is a complex process
    ween women and men, and discrimina women and girls, and poor and margin requiring changes on many fronts and
    tion and disadvantages based on sexual alised communities face also find men the two rather disparate strategies out
    orientation. tion. The last presumably includes “other lined under this recommendation – sen-
    The core of the UHC scheme rightly genders” and “diverse sexual identities” sitising young people on health, gender
    sees health as a human right and the sys though it is not spelt out. One would power equations and their health conse
    tem as such is envisioned from a rights have expected this recommendation to quences; and removing conditionalities
    perspective. However, it is not clear be tied to those on the contents of the from all health programmes – are not
    whether sexual and reproductive rights NHP, which is to be available to all per particularly useful.
    are assumed to be an integral component sons free of cost at the point of delivery. In conclusion, although brilliant in
    of such a framework. The first section of The second recommendation is about parts, gender issues have been ad
    the chapter, on the burden of disease, recognising and strengthening the cen dressed in an ad hoc and uneven fashion
    makes no link between the violation of tral role of women in healthcare provi in the HLEG report on UHC. The recom
    sexual and/or reproductive rights of sion in the formal and informal sectors. mendations do not in most instances
    women, men, other genders and sexual It calls for creating safe and secure provide specific and clear guidelines for
    minorities and disease burden. Vulner working environments free of gender correcting gender-based inequalities in
    able groups such as sex workers and bias, while meeting the housing and access to healthcare. This is unfortunate
    people living with HIV/AIDs tend to childcare needs of women health workers. and a major missed opportunity. It is
    disappear from the discussion in the Ensuring that there is scope for re-entry also unexpected given that there was
    absence of a sexual and reproductive to the workforce after a break for child considerable expertise on gender among
    rights framework. bearing, and accountability and redress the HLEG members. The only plausible
    After a sketchy section on the burden mechanisms against sexual harassment in explanation for this is that the report is
    of disease that contains little information the workplace also figure under this rec the result of a negotiated consensus
    on other genders or diverse sexualities, ommendation. Improving the prospects among disparate positions, which may
    the chapter moves on to establish the for expanding career opportunities and have neutralised the significant repre
    rationale for a gender perspective in representation in management positions sentation of gender experts in the group.
    UHC. It presents evidence on gender dif is a sensible suggestion. A major propos
    ferentials in healthcare in no particular al to ease the burden of home-based car- Notes
    logical sequence. It would have been ers is creating community-based care pro 1 We acknowledge the importance of going beyond
    really useful if it had systematically addressed gender issues in the six criti grammes such as day care centres and facilities for palliative care, domiciliary the binary categorisation of male and female in gender analysis but do not have the expertise to bring in the concerns of other vulnerable
    cal areas discussed in the report and illustrated the imperative to incorporate care and ambulatory care. These are important and welcome measures that genders into this analysis. 2 For example, the WHO gender and health Analysis framework calls attention to differentials in
    a gender perspec ive, for ed by a genperspec
    tt
    ive,
    ii
    nn
    for
    mm
    ed by a gender and health analysis framework. As
    will definitely ease the burden of women health workers, formal and informal. health needs in terms of incidence, prevalence, risk factors, severity and prognosis of health conditions; in health-seeking behaviour; in
    such, it is not clear why some issues have been highlighted in the recommenda- Building the capacity of the health system to recognise, measure, monitor health system responsiveness; and in the social and economic consequences of ill-health. 3 See, for example, papers in the supplement on
    tions while others have not been. and address gender concerns is addressed in the third recommendation. gender-sensitive indicators in the International Journal of Public Health (2007), Vol 52.
    Recommendations Information is vital for the formulation of
    The gender and health chapter makes four recommendations. The first is appropriate policies and programmes, but the collection of sex and age disaggregated References HLEG (2011): High Level Expert Group Report on Universal Health Coverage for India, Planning
    improving access to health services for women, girls and “other vulnerable gen health data by all concerned, as outlined in the recommendation, will not be ade- Commission of India, New Delhi. PAHO (Pan American Health Organisation) (1997): Workshop on Women, Health and Development,
    ders”. There is no mention of sexual quate to “address gender concerns”. A Washington, DC, PAHO.
    identity or sexuality or the different health needs of men. Improved access is reasonable amount of work is available on what constitutes gender-sensitive World Health Organisation (2008): The World Health Report 2008 – Primary Health Care (Now More Than Ever), Geneva, WHO.
    Economic & Political Weekly february 25, 2012 vol xlviI no 8 73
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