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Relooking at providing equitable healthcare to all on World Health Day 2019

Over the past decades, India has made great strides in closing the gap in various health indicators such as maternal and neonatal mortality, and under-five mortality, and has also successfully eradicated polio. In keeping with the the Sustainable Development Goals ratified by India, Goal 3 of which seeks to ensure health and wellbeing for all citizens, India charted the National Health Policy of 2017 which aspires to deliver universal health coverage to its entire population; universal health coverage is also the theme for World Health Day being celebrated on 19th April, 2019. Despite the promising health statistics, it is worthwhile to ask how close India is to achieving universal health coverage. India is marred by vast health inequities. The lower socioeconomic strata of the Indian society have historically been underserved with regard to quality health services.

CEHAT has been working closely with the public health system since the year 1994. It engages in intervention as well as research in the domain of health and related fields, and advocates for equitable access to healthcare for all. Through its analysis of Rajiv Gandhi Jeevandayee Arogya Yojana, a publically-funded health insurance scheme of 2012, CEHAT found that the majority of hospitals empanelled were from the private sector. Furthermore, there were few hospitals empanelled from the least urbanized areas of the country, leading to great out-of-pocket expenditures for individuals residing in these areas, apart from creating barriers in accessing healthcare. This problem is exacerbated by the fact that there is scant regulation of the private health sector in India, creating great hurdles in accessing healthcare by the socioeconomically disadvantaged.

Moreover, owing to inherent gender biases prevalent in the country, the issue of lack of access of quality healthcare is compounded for women belonging to marginalized communities. CEHAT realized the need for providing dedicated services to women facing violence, and recognized violence against women as a public health issue; women who face violence generally approach the hospital to avail of treatment for the adverse health impacts of violence, healthcare providers being their first point of contact. It established the first crisis intervention centre called Dilaasa for women facing violence in a public hospital in Mumbai in the year 2000. Healthcare providers are trained to identify the signs of violence among their patients and refer them to the Dilaasa centre wherein they receive psychosocial support. Since 2000, Dilaasa has been replicated in 11 other government hospitals in Mumbai, and is being scaled up in other states of India. CEHAT is also currently collaborating with the World Health Organization to develop a health system response towards gender-based violence. This approach differs from developing individual capacities, and aims to equip the entire medical staff of hospitals to first identify survivors of violence, and then refer them to appropriate services.

Engagement with the public health system also reveals the poor treatment provided to survivors of sexual violence, and to women and girls availing of abortion services. Sexual violence survivors are often subjected to unnecessary medical procedures such as the two-finger test for the sake of evidence collection, and ‘no evidence’ is often interpreted as ‘no violence having occurred’. Women seeking abortion are often asked for consent of their partners or family members. This problem multiplies manifold for pregnant girls below the age of 18 seeking abortions. They are forced to file a case against their partners with whom they have engaged in consensual sexual relations; this mandatory reporting many a time drives girls to access unsafe abortions, and in some cases, also deliver the child. CEHAT is addressing these issues in healthcare by orienting healthcare providers to the gender perspective in medicine. Its project Gender in Medical Education aims to plug the gap with regard to gender-related content in the medical syllabus, so that medical students are equipped to provide gender-sensitive care from the undergraduate level.

Through its work in Dilaasa, CEHAT also learnt of the phenomenon of disrespect and abuse of women during childbirth, an issue gaining global importance in the present day. Women have confided to counsellors at Dilaasa about the mistreatment in the form of physical and verbal abuse they faced when they were in labour; a study carried out by CEHAT in 2013 exploring discrimination against religious minorities in healthcare facilities also brought to light this phenomenon of labour room violence. While national and international policies and schemes stress upon improving maternity mortality indicators, and hence maternal health, this issue of labour room violence remains unrecognized as a human rights violation – violating the woman’s rights to bodily integrity and the right to be free from harm and ill treatment. Such mistreatment meted out to women is a reflection of the wider gender-based violence prevalent in the society, and severely compromises women’s physical and mental wellbeing. CEHAT is currently working towards equipping healthcare providers with skills to provide respectful treatment in labour rooms, as well as adopt a gender-based lens in the treatment of its patients.

In order to realize the dream of universal health coverage, it is imperative to ensure equity of access to healthcare, which includes taking into account the unique impediments and needs of these populations; India must close this gap of inequity in healthcare to truly achieve universal health coverage.