Healthcare Concepts for Women in India. Problems of the System and Ways to Solve Them

Academic Paper, 2021

26 Pages, Grade: 1,0


Table of Contents

1. Introduction

2. The most important data about India

3. Indian Health System
3.1 The General structure of the Indian healthcare system
3.2 National Health Plan
3.2.1 SubCenters(SC)
3.2.2 PrimaryHealthCenters (PHC)
3.2.3 Community Health Center (CHC)
3.2.4 FirstReferralUnits(FRU)
3.3 National Rural Health Mission

4. The role of women in India
4.1 Cultural role
4.2 Problems for women in the health sector
4.2.2 A lack of maternal healthcare
4.2.3 Other problems that arise for women in health care system

5. Health Care Concepts
5.1 Governmental health concepts for women
5.2 NonGovernmental concepts for women
5.3 Concept evaluation

6. Conclusion

7. References

Table of Figures


Figure 2: Time Line for NRHM Activities

Figure 3: Charged Cases & Conviction Rate

Figure 4: Factors which make India the most dangerous countryforwomen in

1. Introduction

“OverTwoLakhYoungGirlsDieEveryYearinIndiaBecauseofTheirGender”1.Theseare only figures concerning abortions and the death of girls under the age of 5. Far more women and girls die because of poor access to medical care or hygiene problems. Not to mention deathsduetodomesticandsexualviolence. Inequality is a very present issueinIndia.Not only is the woman disadvantaged in social and legal matters, but also in health aspects, the woman receives less attention for her concerns. Why is a lack of health care far more dangerous for women than it isformen?

This paper focusses on the issue of cultural misogyny and how this effects the health of women's' inIndia. It mainly analysis the structural and cultural problems, that directly affect the women's health. Therefore, the second chapter outlines the most important facts and figures of the subcontinent. In the third chapter the structure of the health system is discussed in further precision. The National Health Plan (NHP) is examined in more detail, and the structure and role of the healthcare centers is explained. The chapter ends with information about the National Rural Health Mission (NRHM) that was created to accompany theNationalHealthPlan,whichthereforefocusesmoreintensivelyontheconditionsofrural areas. In more bucolic regions and hardtoreach places, the access to medicine is difficult. Women and girls in particular are dependent on male members of the family, as they are usually never educated or do not have the opportunity and permission to travel alone. These problems and many others that women have to endure are addressed in the following chapter. Women are immensely disadvantaged because of their gender. This relates both to the cultural aspect and the role of women and runs through the health sector. Hygiene, violence and pregnancy are dangerous factors for Indian women due to lack of education and the patriarchal society.

In this regard, both some state programs and private organizations have been trying to educate and support women in their position. For this purpose, numerous concepts have been developed to support women in the respective problem areas. Concepts, which go beyond the healthrelated, are to enlighten women and to help to overcome misogyny in this area retroactively and futureoriented.

The concepts are evaluated in the last chapter with regard to their effect, achievement of objectives and acceptance. It will be attempted to clarify whether the individual concepts are useful andtowhat extent they could perhaps even be improved.

This topic has a personal significance for every woman in the world and even more so for Indian women who have grown up in better circumstances outside India. Writing this paper is a way of understanding the contexts better it is about openly addressing the issue in the hope of being another voice demanding change in order to make India safer for women in every way. The following lines are an attempt to draw attention to terrible conditions and to change them. The paper is about thoroughly understanding the issue and lying out a base for further studies. Those may help implementing new local projects bycombiningthe most effective aspectsof theanalyzed concepts.

2. The most important data about India

India is the seventhlargest country in the world in terms of area, but second in terms of population. The total area is 3.287.263 km2, which is composed of 2.973.193 km2 land area and 314.070 km2 water surface.2T ie population in India is higher than ever before, with around 1.403 billion3 people currently living on the subcontinent. Around 77,000 babies are born every day, but at the same time only 28,000 people die each one day. So the population is still growing. One big reason for this is the demographic change.

But it isgrowing into a certain direction, there are lot moreman than women. The sex ratio of Indiaissoalarming, that itisranked189thout of201 countries.

There are 108,176 men for every 100 women. This makes a gender difference of 48.04% female to 51.96% male population.4 This discrepancy derives from a strong cultural inequality and discrimination of women. Especially in rural areas, the gap is much bigger, thebirthof a woman is considered negative in the culture of most Indians.

India's geography has 2,980,489 km2 of rural land.5 This accounts for nearly 90% of the total area. For this purpose, a rural area is defined by the Reserve Bank of India (RBI) as, an area with less than 49,000 inhabitants.6 This means that around 66% of the people in India live in rural regions.7 In most cases, they include villages that have the following characteristics: Most often, they have a population density of fewer than 400 people per km2. The villages have clearly measured boundaries but usually have their small community council, also called “Panchayat”. Most often, more than 75% of the men work in agriculture or other manual labor, such as pottery, tailoring, or sewing.

These small manual labor jobs and family businesses unfortunately do not bring much salary.Indiaisoneofthe40poorestcountriesintheworld.Intermsofthenumberofpeople earning below the poverty line, India ranks first. About 270 million people live on less than $1.90perday,andasmanyas1.1billionpeoplelivebelow$5.5perday.Thatmakesalmost 80%ofthetotalpopulation.8 The poverty line that is set, is barely enough for all three meals foroneperson,nottomentionotheressentials.Thissalaryisofcoursefartoolow,especially for women, considering that they usually take care of children. So there is often no budget for any hygiene items thatwomenwouldbe needing.

Not only is there a lack of money, in Indian culture women struggle immensely and are oppressed in manyways. Thetopicoftheir health, for example, isnot given much attention and evolves around many topics that are still considered taboo today. Women are seen inferiortomen,whichisalargehumanrightsissue.InWesternculturethisinequalityisless severe.ManytopicsthataretabooinIndia areaddressed as early as school age, whereas sexeducationin Indiaishardlytalkedabout.

3. Indian Health System

In the following section, the structure of the Indian health care system is roughly explained. The pronounced goal of the Indian government is to strengthen its health care system in the country and to provide access to medical facilities throughout India. For this purpose special concepts have been established to enable a more systematic development of the medical infrastructure. In the following the most important aspects of the National Health Plan and the National Rural Health Mission are discussed.

3.1 The General structure of the Indian healthcare system

Just like the German health care system, the Indian system is officially committed to the right to life and health. Health is considered a public good and is one of the basic human rights that should be accessible to everyone. The government's proclaimed goal is to provide basic health care to the people of India regardless of class, wealth, or location, and to make essential medical services available to everyone without financial hardship.

The organization of the health system is divided between the central government and the 29 federal states with the seven additional union territories. The federal states are independently responsible for the provision of health services. The state, on the other hand, regulates international contracts, medical education, food prevention, national disease control, and family planning programs.

The idea that health insurance should serve to cover the general population in the event of illness is such a huge task and by far not yet fulfilled. In 201 71.6% of expenditures in the health sector were financed by private funds. Therefore only 26.7% were due to the taxpaying population. However, the problem is that about 80% of the population lives below the poverty line, meaning they live on less than 6 U.S. dollars per day. In numbers, this means that only 36 million, or 27% of the people, are registered in a health insurance system at all. Private health insurance is also available, but only a small number of the urban, affluent population can afford and take advantage of it. Besides, there are some free programs for the entire population. These are intended to contain widespread diseases such as HIV, dengue fever, and malaria. Mothers and children are immunized against these and other common diseases. However, the availability of medical personnel, equipment, and medicines varies enormously within the different districts.

The only safety net for the population living in poverty is a series of governmentfunded centers that provide partial or total health care for some patients.

The government's current goals are to provide nationwide funding for medical supplies and to provide even greater security for health care in rural areas. Besides, there should be a reform of the health insurance system that entails a stronger social approach and prevents the already poor rural population from plunging into everhigher costs just to be able to obtain basic health care. Some of the options introduced to provide universal health care are described in rudimentary form below.9

3.2 National Health Plan

To look at the issue as a whole and, one needs to look at how the healthcare system is set up there. To do this, we look at the infrastructure of the healthcare system and take a closer look at NHRM.

Health policy underwent a small revolution in 1964 when for the first time in India a real system emerged from the "Health Survey and Development Committee". In this committee, it was proposed to create a threetier system, with prevention and cure playing an important role in both urban and rural areas. It was planned to decrease the number of private doctors in favor of public ones, whereas the topic of health was supposed to be a lot more in political and social hands. This was to ensure that everyone received primary care regardless of individual socioeconomic conditions. The problem that arose, however, was that the capacities of public health care facilities were not sufficient and thus the gap was filled by private clinics. In 1983, a National Health Plan (NHP) was developed based on these goals. It was aimed that through referral systems and simple technologies, with the help of voluntary medical staff, everyone was supposed tobeable to receive medical treatment by the year 2000. In 2003, a renewed form of the NHP was established to operate based on the NHP of 1983. This plan took advantage of the private sector and favored a decentralized form of decisionmaking, establishing more Western medicine.

Today, the health care system is multilayered. The private sector has established itself primarily in urban areas and provides secondary and tertiary care. In rural areas, a three tier system has been vested, which is adapted to the respective regional population norms. They are adjusted to the environment and cultural conditions.

Some centers that maintain the medical infrastructure in India have been established to provide primary health care to the smallest possible areas in India. These are listed and briefly explained below.10

3.2.1 SubCenters (SC)

SubCenters are set up where there is a population of only 5000 people or in mountainous areas of up to 3000 or areas that are difficult to reach. They provide a bridge to primary care, giving many a chance to survive until they reach a proper hospital where they can finally be treated. These centers offer the first possible contact with medicine for most people. The requirements for such a center are to have at least one male and one female health worker. Either the female health worker is already trained as a midwife or one must always be available at short notice. In the "Indian Public Health Standards (IPHS) Guidelines for Sub­Centers Revised 2012"11 you can even find a complete list, from staff to equipment, of what is needed to set up such a center. “All “Minimum Assured Services” or Essential Services as envisaged in the Subcenter should be available, which include preventive, promotive, few curative and referral services [,..]”.12

3.2.2 Primary Health Centers (PHC)

The next level inthe healthsystemisthe Primary Health Center. Theseare established for every 30,000 inhabitants orfor 20,000 inhabitants in areas that are difficult to access. They must have a medical officer who can perform minor procedures and initiate both curative and diagnostic procedures. In addition, he*she takes the leading role in the primariy health center. Also, he*she takes the leading role in the primary health center. In addition to the doctor, there are usually up to 14 medical staff on site. There must be at least 56 beds for patient treatment and aplace to stay for aftercare. The PHCis the link between the SB and thenextlevelof healthcare.

3.2.3 Community Health Center (CHC)

Community health Centers are built at a population density of 120,000 inhabitants and in hardtoreach areas for up to 80,000 inhabitants. Requirements for the staff are to have a team of 4 medical specialists on site. This includes a pediatrician, obstetrician or gynecologist,aphysician, and a surgeon. Also, about 21 assistants have to be available as support. Facilities such as a delivery room, operating room, laboratories, and xray equipmentmustbeattheCHC,alongwithanadditional30bedsforpatientintake.Patients from PHC can be admitted, receive specialist consultations and obstetric care at this center. A significant positive increase can be seen in this regard. Since 2010, the number of CHCs under state management has increased from 91.6% to 99.3% in 2019, which were 5.335 centers in rural areas.13

3.2.4 First Referral Units (FRU)

A first referral unit has to provide a 24/7 emergency service in order to be considered an FRU. This includes first aid for newborns and other emergency cares. In addition, an FRU must be able to handle the usual hospital activities that come with an emergency. Three important points that such a unit must fulfill is to ensure emergency surgery for births, such as a cesarean section. In addition, the care and followup of newborns and thirdly, a blood reserve supply 24/7.14 It must offer over 30 beds. Fresh drinking water and electricity must be available throughout, which is not a given everywhere in India. There must also be an ambulance facility. First referral units can usually provide adequate treatments to meet the needs of patients without being unnecessarily expensive.

In the following figure (refer to figure 1), the pyramid shows how the levels of the Indian healthcare system are structured. According to the number of centers and their equipment and size, the pyramid goes from the base of many but small subcenters to the large but few district hospitals and medical colleges. In 2016, the number of facilities was 722 district hospitals, 4,833 CHCs, 24049 PHCs, and 148,366 SCs in India.15 Lakhs is an Indian unit for 100,000.

Abbildung in dieser Leseprobe nicht enthalten

3.3 National Rural Health Mission

To reduce neonatal mortality and birth complications for mothers and their children, the National Rural Health Plan was launched in 2005. It was targeted for 7 years, up to 2012. The achievement of the goals should be furthered by involving the communities, creating jobs, and making health accessible to everyone as quickly as possible. Hereby minimizing inequality through status, money, and gender. At the same time, this plan was intended to provide communities with access to drinking water, education, nutrition and also sanitation. Particular attention was paid to 18 states that tend to have weaker access to health care or lack adequate infrastructure, for example, due to poverty or inaccessibility. Public spending of the health system should be increased from 0.9% to 23% of GDP. In addition to hiring new medical staff under government salaries, not only new jobs should be created, but also new study places. Old centers were renovated and new ones built, so that medical sites were expanded and made accessible to more people. Smaller health committees in villages should be empowered to be accessible at the local level for health needs and to make decentralized decisions. In addition, patient advocacy committees at the village level are supposed to support health systems. IT systems support is supposed to enabled tracking of service delivery by and for mothers and children.

Thus, the NRHM had to fulfill the following tasks:

Ease access to health facilities and utilization of quality health services.

Create a collaboration between the central government, states, and local governments.

Establish a forum for the involvement of Panchayati Raj Institutions and the community in the management of primary health programs and infrastructure.

Promote equity and social justice.

Establish a process that provides flexibility to states and the community to promote local initiatives.

Develop a framework to promote intersectoral convergence for promotive and preventive health care.16

Therefore, about $17 billion US dollars were spent on this over a period from 2005 to 2013.17 The government also plans to invest the equivalent of about 161 billion euros in rural development. The new health plan is intended to provide better health care for around half a million of India's poorest citizens. In the future, they will have up to 7,294 € per year at their disposal for hospital visits, promised Finance Minister Arun Jaitley in 2018. 18 Previously, the maximum was 377€. In 2018, 3.6% of GDP19 was spent on healthcare in India. In 2019, it was as high as 3.89%. However, only 1% of this was actually invested from the government coffers, with the rest coming from private sources.20

In this table you can see the requirements that were to be fulfilled in the first 4 years by individual states and by the country itself. A proper schedule was drawn up, which the government felt was appropriate and achievable at the time.

Figure 2: Time Line for NRHM Activities

Abbildung in dieser Leseprobe nicht enthalten

Source 2: Ministry of Health and Family Welfare

To encourage state goals, the NRHM rewarded states for achieving goals. This was intended to encourage and empower individual states to invest even more time and money in their health care devices. Values from 2005 were compared to the actual states at that time in 2010. This resulted in a disadvantage for the states that had already made a good start at the beginning. Therefore, the states were subdivided in their initial values to start with comparable values in 2005. The subdivision took place as follows:

High Focus States under NRHM, i.e., the eight former EAG states and two other states belonged to the first category (Bihar, UP, MP, Chhattisgarh, Orissa, Jharkhand, Uttarakhand, Rajasthan, J&K, Himachal Pradesh). This excludes the NorthEastern states.

In the second category, the eight High Focus states in the NorthEastern region were evaluated.

The nonHigh Focus states were awarded in the third category.

Scores were given on four quantifiable criteria and corresponded to importance.

Macro health sector indicators

Physical capacity and service delivery outcomes in rural service centers

Results in improving human resources in the health system

Governance outcomes

The idea behind this NRHM assessment and award was to promote health systems and drive individual states to link their rural areas more closely to their health system or strengthen it locally. This was to provide easier access to medical centers for more rural areas. In this way, the overall health system in the country should perform better.16

4. The role of women in India

Women make up 48% of the Indian population. Women take on the role of daughter, wife and many other positions in the family. Being a woman has a very different meaning in India than in some other Western countries. These differences are culturally very apparent and they subsequently have a strong impact on women's health. In the field of medicine gender differences disadvantage women in many ways. Some of the problems, both cultural and health wise, that women have to face are explained below.

4.1 Cultural role

Women are not considered equal to men in Indian culture. Even though already many improvements have been made in terms of equal rights, it is clear that centuries of cultural thinking cannot be easily removed from people's minds through enlightenment and modernization. The costs associated with a woman, whether born into the family or later as a married wife, makes her a burden in those kinds of societies, where women are economically strongly dependent. Even today, the Indian woman is raised to be a good wife and to play her role in the future household appropriately, i.e. she is supposed be able to do household chores and be obedient. Only in rare cases, time or money is invested into a girl, so that women often are neither educated, nor able to can pursue individual dreams and happiness.

In fact, with the birth, the dowry of the daughter is started to be accumulated, which is usually required for the wedding. In the past, this dowry served as a security reserve for herself, but since the British colonial period, it has been paid to the groom's family itself, increasing her economical dependencies. Until today thousands of women and girls are disowned, beaten, harassed, or even burned to death every year because of dowry disputes.17 Even abortions in the womb result in India currently "missing" 63 million women.18 The imbalance of men and women is huge and hard to decrease. For this reason, the practice of dowry has been prohibited by law in India since 1961. Despite this, 2 million girls are still killed each year.19 The fact that women do not receive any education means that, in most cases, they are tied to the inlaws for the rest of their lives and are dependent on their husbands and society. Around 64.37% of Indian women aged 15+ are recorded as illiterate in 2018.

But even after birth, a being daughter is difficult and has loads of disadvantages today. Around 64.37% of Indian women aged 15+ years are recorded as illiterate in 2018.20 Due to the fact that women do not receive any education, they are in most cases bound to the inlaws for the rest of their lives and dependent on the husband and society. If a family manages to marry off a girl despite her dowry, she usually becomes a helper in the house of her husband's family. She serves to perform marital duties and has the duty to perform tasks such as cooking and cleaning in the household. But even in wealthier families, where a housekeeper is usually hired, a woman is often not allowed to have her own professions, because she has to fulfill the role of a mother and wife in its entirety. A woman must surrender to this burden, however, because they are usually not educated differently or have hardly any other perspectives. A divorced woman is usually an outcast or seen as the source of discord herself. To escape these humiliations, the majority of the female population endures violence, rape, and degradation. Shockingly, in 2016, 46.6% of women still thought it was okay to be beaten by their husband, no matter what reason he may have.21


1 Khullar. 23.05.2018

2 Cf. Länderdaten

3 Cf. Department for Global and Social Contacts of Religious Nations, Status: 30.11.2020

4 Cf. Ministry of Statistics and Programme Implementation & UN. 18.03.2020

5 Cf. World Bank. Status: 2010

6 Cf. Dhanlaxmi Bank Limited. 01.12.2010

7 Cf. World Bank. Status: 2019

8 Cf. Afus199620. 25.06.2020

9 Cf. Herter. 2018. P. 3

10 Cf. Chokshi et al. 07.12.2016. P. 9ff

11 Cf. Azad et al. 2012

12 Azad et al. 2012. P. 1

13 Cf.

14 Ebd.

15 Ebd.

16 Cf. Ministry of Health and Family Welfare. 30.10.2010

17 Cf. Dominguez. 17.09.2013

18 Cf. Booth. 30.01.2018

19 Cf. SOS Kinderdörfer Weltweit. 27.02.2018

20 Cf. World Bank. Status: 2018

21 Cf. World Bank. Status: 2016l

Excerpt out of 26 pages


Healthcare Concepts for Women in India. Problems of the System and Ways to Solve Them
University of Applied Sciences Lübeck
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ISBN (eBook)
ISBN (Book)
Indien, Gesundheit Indien, Frauen Indien, Healthcare India, Misogynie, Concepts India, Medicine India, Rural India
Quote paper
Navrup Kaur (Author), 2021, Healthcare Concepts for Women in India. Problems of the System and Ways to Solve Them, Munich, GRIN Verlag,


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