There is a large gap in the use of public services in the country. The “2018 Gender Gap Index” of the World Economic Forum and its sub-index, “Health and Survival” — India ranks 108 in the overall index and 147th out of 149 in the sub-index — shine a light on this challenge.
Girl children face discrimination even before they are born and continue to experience bias during their life, including in the provision of nutrition and use of health services. Faced with limited resources, families, in general, prioritise the healthcare, nutrition and other needs of men at the cost of women. Some cultural factors, such as the reluctance of women in some regions to consult male doctors, also constrain their access to healthcare services.
The National Family Health Survey (4th round) shows that the main reasons women do not seek healthcare services are because these services are unaffordable, they are not easily available and there aren’t enough women healthcare providers.
Ayushman Bharat PM-JAY seeks to bridge the gender gap in the use of healthcare services by addressing a key constraint — healthcare costs. Cashless services through PM-JAY are helping to narrow the gender gap in availing healthcare. Learning from the experience of earlier schemes like the Rashtriya Swasthya Bima Yojana, PM-JAY’s design incorporates several features that will improve the use of healthcare services by women and girls.
First, families with no adult male members is one of the deprivation criteria for identifying target beneficiaries, which will help a large number of women. Second, there is no cap on the size of families. A cap of five beneficiaries from a family in earlier schemes worked against women. It was observed that large families preferred that their male members be beneficiaries.
Finally, the packages include a large number of health conditions that exclusively, or primarily, affect women. Of the 1,393 health benefit packages under PM-JAY, 116 are women centric, 64 are for only men while 1,213 are common to both.
The initial data for utilisation of services under PM-JAY shows that the use of services is more or less evenly balanced among men and women. Of all hospital admission requests, 52 per cent were for men and 48 per cent were for women. In fact, the gender gap starts to show up at only above 50 years. In the age groups from 0 to 50 years, use of services by women is either equal to or greater than that by men.
It is important to note that some health conditions are prevalent either only among women or men. Looking at conditions that are likely to affect both men and women equally provides better insights. The disaggregation of data on utilisation of major specialty services shows mixed patterns. Use by women patients is higher in 10 specialties — OPD diagnostics, radiation oncology, follow-ups, palliative care, burns management, ophthalmology, pediatric cancer, PHC and surgical oncology. However, in others like pediatric surgery, general medicine, urology and cardiology utilisation by male patients is higher.
There are variations across states as well. For example, at the national level, 66 per cent of all treatment in orthopedics were received by men. However, in Kerala, the proportion is 53 per cent while it is much greater in UP and Maharashtra — 70 per cent.
There are variations at the level of procedures. For example, within orthopedics, women are the majority users of packages such as total knee replacement — 57 per cent. There are state-level variations in this respect as well — with 83 per cent utilisation by women in Kerala, and only 40 per cent in Jharkhand and Punjab.
Among the three major specialty services provided by PM-JAY— oncology, cardiology and nephrology — a majority of the users of oncology services are women. However, there are large gender gaps in the use of cardiology and nephrology-related services. PM-JAY will need to analyse the reasons for this.
Some of the variation may be explained by the gender-wise difference in the prevalence of various diseases. Men and women may also have varying incidence of certain diseases because of the degree of exposure to the proximate cause or an individual’s biological disposition. An analysis of these factors will need to be undertaken to effectively assess the potential gender gap in the use of services.
The overall message from the analysis of initial PM-JAY data is that the scheme seems to be on the right track, even though more effort is needed to achieve total gender parity. There is no gender-gap when it comes to people seeking several specialty services in many states. Up-to-date data available with PM-JAY will help in continuously assessing the gender pattern of health-service use, analysing the reasons for any gender-based discrimination and providing cues for corrective action.
Monitoring the disaggregated service utilisation data will help sensitise implementing agencies and district authorities about possible gender gaps. Gaps, if any, can be addressed by more informed and gender-sensitive planning, including targeted IEC (information, education and communication) campaigns. Women might need to be informed about their eligibility for the scheme so that they can get their e-cards made and seek treatment in time. In addition, tele-consultations with women healthcare providers might be required in case there are cultural barriers in consulting with male doctors.
PMJAY has a strong potential to empower women to take decisions on their health and wipe out the gender gap in use of health services. Within the deprived and vulnerable population that PMJAY seeks to serve, women constitute a particularly marginalised section. The scheme will be successful only when it can ensure that women and girls receive their due in the use of healthcare services.
This article first appeared in the print edition on December 12, 2019 under the title ‘More equal care’. The writer is CEO, PM-JAY.
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