The world has never been as rich as it is today. Yet substantial proportions of the global population live short
and brutal lives, haunted by hunger, ill-health and disease. The average life expectancy in Sweden countries
in 2015 was 82.4 years; that in Swaziland was 58.9 (WHO, 2017). Over the last 30-odd years, as the world
entered a neo-liberal turn to economic growth, along with a growing wealth gap between rich countries
and poor countries, and between the rich and poor within countries, there is also a growing health gap. For
example, the maternal mortality rate in the black population in the United States is three times higher than
that in the white and is increasing. In India itself, a person born in Kerala can expect to live 18 years longer
than one born in Bihar or Jharkhand.
This paper explores the realities and complexities experienced by women in marginalised communities in
accessing safe abortion services. It specifically explores the experiences that shape the perceptions and
behaviour of Narikuruvar women towards accessing both public and private reproductive healthcare facilities.
This is illustrated by the case of a married Narikuravar woman who had undergone self-induced abortion in
Kumbakonam, a town in Tamil Nadu. In addition, the paper examines the circumstances that force women
in the margins to adopt unsafe, self-induced abortion and discusses the strategies used by the Narikuravar
woman for self-induced abortion. This is a qualitative research study and has used a phenomenological lens
to capture the individual experiences of the woman across diverse life events associated with pregnancy,
motherhood and abortion. The paper describes how contextual factors such as lack of access to resources
and decision-making structures intersect with other cultural and gender identities of women. The principal
argument here is that the needs, aspirations, interests, knowledge and agency of women from marginalised
communities are not recognised in public and private decision-making spaces, and this impacts on women’s
sexual and reproductive rights.
Globally, stroke leads to 21.7 per cent of deaths among women in the geriatric age-group. For those who have
survived it, it demands prolonged care-giving. A relatively longer life expectancy adds to the higher stroke
burden among women compared to men. In a country like India with an aging population, a non-functional
healthcare system, and a large number of people living in poverty, the burden of post-stroke care, in entirety,
gets shifted to households. Within Indian households, women are seen as the primary caregivers, putting them
at risk of physical and psychological stress. Patriarchal social norms also place women stroke survivors in
severe disadvantage in many ways.
Timely postpartum screening for diabetes following a pregnancy with gestational diabetes mellitus (GDM) is
crucial to reduce the future risk of incidence of diabetes. This study explored barriers to timely postpartum
screening for diabetes mellitus after a pregnancy with GDM, by assessing the concerned women’s views and
Data for this study pertains to fifteen respondents from among participants in a larger cross-sectional survey
conducted in Malappuram District of Kerala among women affected with GDM during a recent pregnancy.
The selection was based on detailed responses to open-ended questions asked in the quantitative study. The
responses were transcribed and deductively coded. The findings were organized around major themes.
We identified five main areas of barriers in the management of diabetes during pregnancy. These were a)
inadequate instructions from the healthcare provider who attended the pregnancy and delivery; health services
related barriers; perceived difficulties of the oral-glucose-tolerance-test; lack of time owing to multiple roles
as mothers and home-maker; and postponing the screening but unable to specify a reason for it. Of these,
health-provider and services -related barriers and lack of time owing to multiple responsibilities were the
most often- stated barriers. Participants had a general awareness of possible complications following GDM
in pregnancy but often could not name specific effects on the woman or child during and after the GDM
pregnancy. A majority of the participants were unaware of their elevated risk of developing Type 2 Diabetes
The barriers to postpartum screening identified in this study could help planning programmes to assist women
in achieving timely postnatal screening for Type-2 Diabetes Mellitus.
Universal Health Coverage (UHC) has emerged as a major health policy discourse across the world. Its
proponents claimed it as the third grand transition in health after demographic and epidemiological
transitions, whereas others have called it “old wine in a new bottle.” UHC aims that everyone irrespective
of their socio-economic status or gender should have access to essential healthcare facilities without facing
any financial hardships. Equity is considered to be the central epithet in any UHC model, and in the Indian
context, gender equity is a critical factor in the quest for achieving UHC.
This study aims to explore progress towards UHC in the dimensions of access and financial protection in
India, and differentials in these by sex.
The current study is based on India’s recently released data from the 71st Round of the National Sample Survey
(NSS), 2014. The survey covered 65932 households (rural: 36480, urban: 29452) in India which included
3,33,104 individuals (men: 1,68,697 women: 1,64,407). Healthcare utilization, hospitalization rate, the
proportion of the ailing population (PAP), insurance coverage, out of pocket expenditure (OOPE), catastrophic
health expenditure (CHE) and impoverishment were calculated from the data set. By disaggregating the data
set by sex, all the above indicators were analyzed through a gender lens. Various other equity dimensions
(geographical location, caste, and economic category) were also analyzed in the sex-disaggregated data set.
Descriptive statistics were used as the main data analysis technique.
With the announcement of the National Health Protection Scheme in February 2018 by the Indian
Government, the policy direction based on an insurance-based model of health financing as a panacea for
all ill-health has become even more evident than in the past. This is surprising, given that the evidence on
the positive impact of a publicly funded health insurance scheme (PFHIS) is equivocal. There are only a
handful of reviews of studies on national and state level PFHIS on equity dimensions, and none of them have
applied a gender lens.
The current paper aims to provide a systematic as well as an interpretive review of available literature on
PFHIS in India by employing a gender and health equity lens. It aims to understand the evidence on gender
dimensions in process indicators (awareness, enrolment, and utilization) and impact indicators (health
expenditures and coping mechanisms) of PFHIS. It also aims to answer why we do not know enough about
the gendered aspects of PFHIS given their existence for more than a decade.
Using PRISMA techniques, a total of 80 papers covering 17 specific states in India were reviewed to
aggregate the evidence on gender differences. For the interpretive review, the same studies were critically
reviewed to understand the nature of gender analysis and to uncover the reasons for the thin evidence
emerging on gender equity in PFHIS.
Estimates by academicians have pointed out that salaries appropriate as much as 70 – 80per cent of state
budgets, leaving a minuscule share for health infrastructure and other inputs. A solution to the problem has
been offered through reforms which have propagated alternative mechanisms of recruiting workforce. These
include hiring staff on short-term renewable contracts and outsourcing tasks to a contracting agency. The
following paper is a case-study of a tertiary-care hospital which has adopted such hiring practices.
This study on contract-hired and outsourced workers aims at documenting the dynamics and implications of
reforms in recruitment on the conditions of work of those recruited on such work arrangements, and on the
quality of healthcare.
This paper draws on a larger qualitative study which examined the implications of health reforms for
services provisioning within a tertiary -level government hospital. Between September 2016 and June 2017,
in-depth interviews were conducted with 85 health workers including both permanent and casual staff. Prior
consent from the Delhi Health Department was solicited for conducting the study.
Reforms in recruitment have advocated outsourcing for the lowest rung of employees, while for technical,
nursing staff and physicians, the system of contracts has been introduced. Both groups of workers were paid
lower than regular employees carrying out the same tasks and had to contend with long-term job insecurity.
However, the experiences of outsourced workers revealed a more humiliating working environment. The
process of ‘casualization’ of workforce showed a class dimension, further marginalising the already
vulnerable sections of society. Also, it was women from the groups who were concentrated in the lowest
There appears to be class, caste and gender-based discrimination of employees in the health sector through
contracting and outsourcing.
Medicine, as a field, has been critiqued for being gender biased and not accounting for social determinants
that shape health conditions, access to healthcare, and health outcomes. Gender bias permeates many aspects
of medicine in India: clinical practice, research, health program delivery, and medical education. In 2007 the
World health organization (WHO) acknowledged the imperative of systematic integration of gender in the
curricula of undergraduate medical students.
This paper is a case study describing the process of implementing the ‘Gender in Medical Education (GME)’
project in Maharashtra by the Centre for Enquiry into Health and Allied Themes (CEHAT), the Department of
Medical Education and Research, Maharashtra (DMER) and the Maharashtra University of Health Sciences
(MUHS). The paper aims to illustrate the complex steps involved in integrating gender concerns into an
undergraduate medical curriculum.
The GME project consisted of five components, some implemented sequentially and others taking place
simultaneously. Three of the components are relevant to this paper. The first component involved ascertaining
interest and support for the project from the concerned authorities. The second component consisted of
identifying from among medical educators in the state, a core group of champions for the integration of
gender into the undergraduate medical curriculum and building their capacity for gender-analysis of health
issues. A third component involved the core-group of-medical-educators working with experts to revise the
UG medical curriculum and make it gender-sensitive.
In recent times, a significant proportion of the global population lives in an urban context, as cities offer
unparalleled opportunities for livelihood. In an urban setting, when a majority of programmes, data, and
services focus on urban averages, the intra-urban differences are often missed, rendering urban health
inequities invisible. The objective of this paper is to examine the unmet health care needs of the urban-poor
population, through examining the many steps involved in having one’s health care need to be met, from
finding a suitable health provider through to having the health problem resolved. After providing an overall
picture of unmet needs and associated barriers, we delve deeper into the pathways to unmet need for care for
acute morbidity conditions.
A cross-sectional epidemiological survey was conducted to assess the health care needs of the urban- poor
population and a series of case profiles to identify those people who get left behind within the poor urban
section. The study population comprised the urban-poor population of Thiruvananthapuram Municipal
Corporation. Households enlisted in the ‘Below Poverty Line’ (BPL) list ward-wise for urban Kerala were
the study universe, and the sample was selected using multi-stage cluster sampling. The most recent episode
of illness or health care need in the sample household within the reference period was documented, and five
categories of health care needs were captured. We examined the outcome variable ‘unmet health care needs’
through a sequential five-step process: Sought health care; Consulted health provider; Started treatment;
Completed/ On-going treatment; Health problem resolved.
Providing financial risk protection (FRP) to the poor and vulnerable population by preventing the incurrence
of Catastrophic Health Expenditure (CHE) is critical to achieving Universal Health Coverage in any country.
The World Health Organization has endorsed the ability of pre-payment financing mechanisms such as Social
Health Insurance (SHI) to provide FRP and to improve access to healthcare for the poor. The state of Tamil
Nadu in India introduced one of the early state- sponsored health insurance programmes in 2009, known since
2012 as the Chief Minister’s Comprehensive Health Insurance scheme (CMCHIS). The scheme covers lowincome
households for hospitalizations. In this paper we examine the extent to which CMCHIS has enabled
urban poor households to meet all their healthcare needs without the risk of incurring CHE.
We conducted a ten-month longitudinal study of 600 urban- poor households, selected using multi-stage
random sampling, in the Kanyakumari district of Tamil Nadu. We categorized the poor households into four,
based on their socioeconomic status: very poor, poor, marginal and vulnerable. Four waves of data were
collected at zero, one, six and ten months, from six wards of two municipalities. Healthcare needs of the
household were defined as any household member having chronic disease, seeking out-patient care (acute
morbidity) or in-patient care (hospitalization).
The relationship between social exclusion and health is a complex one. Social exclusion predisposes affected
communities to a variety of social and economic vulnerabilities with the potential to jeopardize their health.
These result in the community being ‘left out’ deliberately, discouraging social participation or even actively
denying them services. The institutional structures that perpetuate social exclusion differ by gender, class,
sexual orientation, race, ethnicity and other similar structures. In India, religious identity is one such structure,
and Muslims (a religious minority) is one such socially excluded group.
This paper examines the health status of Muslims in the State of Maharashtra. It describes the socioeconomic
context of Muslims and explores how this influences the health of the community. Using secondary data, it
also seeks to compare how Muslims fare on key health indicators versus other socio-religious groups in India.
This paper is based on analysis of the National Family Health Surveys, District Level Household Surveys,
and the National Sample Survey Organizations data sets. It also draws upon published literature, particularly
primary studies commissioned by the Maharashtra State Minority Commission in 2013.
Traditional medicine refers to different forms of medicines and therapeutic practices, both popular and
scholarly. This paper draws on the field data collected from two villages of Nepal to reflect on whether popular
traditional medicine is becoming unpopular among the rural communities. The article looks into community
perceptions, changing practices and therapeutic choices among the local people. Inequalities and differences
were observed in the use of popular traditional medicine (PTM) and scholarly traditional medicine (STM).
We found that the overall popularity of PTM has declined over the past few decades. Field narratives and
treatment- seeking data show the falling use of PTM. It appears that the present trajectory of healthcare
development has had a damaging effect on PTM.
STM, which has been recognized as part of national health care system, gets some support for its growth and
development but PTM, on which still a large number of people rely, lacks such support. We argue that the
damages to PTM will have a serious implication from a health equity perspective. Rising inequities in health
cannot be addressed without taking PTM on board. Furthermore, the damages to PTM will have a damaging
effect on the growth and development of STM as well. We question the policy rhetoric of “promoting Ayurveda
and other alternative systems” and “making health care services accessible to all.” We conclude that
promotion of positive aspects of PTM can contribute to the advancement of STM. Making healthcare services
more accessible and affordable lies not in the growth of an unregulated private sector and pushing towards
biomedicine- based- government- healthcare provisioning. It depends on the promotion and strengthening of
the public sector with a balanced role for traditional medicine, both popular and scholarly.
SAHAJ (Society for Health Alternatives), a non-government organization (NGO) and two other partner
NGOs have been working since 2012 with tribal and marginalized communities in three districts of Gujarat
to strengthen social accountability for maternal health. This paper discusses the results of an evaluation
conducted during April 2016-March 2017 to assess the changes in community leaders’ knowledge, attitudes
and understanding towards maternal health.
The evaluation was conducted in 45 control and 43 project villages. This evaluation assessed the effectiveness
of the NGOs’ interventions (from a gender and rights perspective) wherein the organizations’ staff disseminated
focused messages about maternal health, government entitlements, and strategies for improving accountability
among community members. The evaluation consisted of three components: a baseline quantitative survey
(April 2016), longitudinal qualitative research consisting of participant observation of periodic review
meetings and field activities (April 2016-March 2017), and an end-line survey (March 2017).
Significant improvements were seen in knowledge levels of antenatal care (ANC) services available, highrisk
symptoms, handling emergency obstetric situations, maternal-health entitlements, and maternal death
reviews. Significant improvements were also seen in views and understanding towards maternal health as a
Gram Sabha (village council) issue and on the responsibilities of the Panchayat (village government) towards
maternal health. There was also an increase in the number and variety of maternal health issues discussed
in Gram Sabha meetings and increased participation of community members and local health system-actors.
In a setting with community organizations and strong NGO support, systematic multi-method dissemination
of key maternal health messages, along with discussions and actions through the Panchayat, can succeed in
making maternal health a community issue.
Note to Reviewers