Comments from Vrishali Shekhar and Anuradha Katyal of ACCESS Health International on Health and Nutrition
India ranks second to last of one hundred thirty four countries in gender equality in health (World Economic Forum, 2010). This highlights the opportunity to improve gender sensitization toward framing health policies in India. From a gender perspective framework, the 2016 Draft National Policy for Women integrates the key features of gender equality by putting equal importance of good health for both men and women, gender equity by incorporating different health needs based on gender, and finally, gender mainstreaming by integrating gender health needs in the design, implementation, monitoring, and evaluation of health policies and programs in its proposed design of health policies.
The policy draft importantly extends beyond the reproductive role of women to encompass the health of women at every stage and aspect of their lives. The health of women is now being viewed holistically as a continuum of care that begins before birth and progresses through childhood and adolescence to adulthood and old age.
This document presents the comments and recommendations of ACCESS Health International, a not for profit think tank, on the National Policy for Women 2016.
Improving Access to Healthcare
Access to healthcare for women is contingent on their access to key resources. This includes income, education, employment, social status, safety and security, and freedom from violence. Equity in accessibility of healthcare services to all women is a product of empowerment and the consequent social awareness about gender parity in demand for good health. Traditionally, women in India have been disadvantaged because of the preferential treatment given to the health of men over the health of women, demonstrated by a relatively lower immunization rate among girls and a focus on the nutrition of the male child.
The policy draft importantly highlights the need to go beyond economic empowerment and stress on social empowerment. However, changing the attitudes of both men and women is critical to transforming societal prejudices against women as a whole and against the various demographic sections that they belong to. There is a need for a paradigm shift in perspectives that focus on gender dimension in the health of women. We recommend that gender sensitization must begin at an early age. A systematic introduction of syllabi based on gender sensitization in schools will go a long way in addressing gender norms and breaking stereotypes among the younger population, which is the largest demographic group in the county. The Government of Telangana became the first state to introduce a compulsory course focused on gender education at the graduate level. Health policies must also focus on recognizing the role that men can play in the demand for health services for women. Active participation of men and boys in community based health programs with special emphasis on women centric issues must also be encouraged.
Evidence suggests that the presence of local self help groups in rural areas is positively associated with the social empowerment of women, improving their decision making capacity, and subsequently resulting in a change to their health seeking behavior. Women engaged in self help group activities develop a sense of ownership and feel responsible to voice their opinion and advocate best practices on matters concerning their health and that of their children.
The health sector also employs women as Accredited Social Health Activists, Auxiliary Nurse Midwives, Lady Health Visitors, and Angadwadi Workers and Nurses. This can be regarded as a twin blessing. On one hand, the employment of a large female workforce in the health sector leads to improvement in their livelihoods and an enhancement in their societal status. On the other hand, representation of women as frontline caregivers helps them identify and safeguard women specific health concerns that arise at various stages of their lives. Few of the health issues pertaining to women that are underrepresented in health policies are the mental health of women, geriatric care, post delivery nutrition, menstrual hygiene, nutritional anemia and other nutritional disorders, and sexual and reproductive health. Sexual and reproductive health includes safe abortions, contraceptive care, and pregnancy related problems. The frontline workers can be responsible for integrating the screening and care of the above mentioned health issues at the primary level.
Integration of Health Systems
The policy draft focuses on improving and strengthening the different levels of healthcare to improve health outcomes among women and children. We recommend that healthcare should ideally be designed with the framework of integrating and centralizing programs for primary, secondary, and tertiary care for greater efficiency and improvement in the health of the population.
An inclusive and holistic approach toward health would require a shift away from the existing vertical disease programs management. In parallel, it would mean that we make concerted efforts toward strengthening the existing healthcare service delivery system. The development of a comprehensive health system would lay special emphasis on preventive and primary care and integrate secondary and tertiary care alongside disease management into the system. An approach to primary healthcare should look to converge various programs that relate to the wider determinants of the health of women and children such as access to drinking water, sanitation, improved nutrition, school education, non communicable disease management, which are all implemented by different ministries through a coordinated network of well trained health workers, and both private and public health providers.
There is also considerable scope for India to consider alternative revenue streams for health, to gradually expand revenue pools by consolidating funding sources, and to integrate supply and demand side programming. Another important lesson is that horizontal integration of multiple government programs can rationalize limited resources and improve the efficiency and reach of service delivery. We propose the integration of services of various national health programs under one umbrella. These include the Employee State Insurance Corporation, Central Government Health Scheme, Rashtriya Swasthya Bima Yojana, and the National Health Mission, including the insurance program provided by the Ministry of Women and Child Development, Anganwadi Karyakartri Bima Yojana. These programs belong to different ministries and maintain little or no coordination in their design and implementation. We propose the establishment of an autonomous entity at the national level that is responsible for expanding risk pooling and redistribution, and enable strategic purchasing with health providers.
It is also important to highlight that the target population for the above programs overlap. This offers tremendous opportunity to improve the operation efficiency of the Auxiliary Nurse Midwife, Accredited Social Health Activist, and Anganwadi cadres operate. The role of the Multi Purpose Worker, the primary grassroots health functionary can be expanded and redesigned to transform them as a single caregiving entity. The proposed list of the responsibilities can include the provision of preventive and curative care, activities around environmental sanitation, control of communicable diseases, addressing nutritional needs of children, adolescents, pregnant women, elderly and sick, child health immunization, providing delivery care and a complete package of reproductive child healthcare, mental health screening and support, and sensitizing families towards healthy aging. The role of the health worker will also be to assess community health needs and engage in necessary communication and counseling activities to improve community health outcomes.
The creation of an integrated health information management system across various government programs mentioned above will promote evidence based decision making. Health Technology Assessments have shown to be instrumental in keeping costs low, strengthening monitoring and evaluation processes, making health services more client centered and accountable, and maintaining the quality of care. The lifecycle and gender approaches to the health of women rely on the use of reliable information and gender disaggregated data that is often difficult to access. The integrated health systems dashboard would enable better oversight and planning for resource allocation.
Importance of Quality of Health Services
Quality of services is a leading indicator of the effectiveness of a government program. For instance, although programs such as Janani Suraksha Yojana have increased the number of institutional deliveries, they have not led to a decline in maternal and neonatal mortality rates, primarily due to the poor quality of services at the institutional level. Ensuring quality of health systems is a crucial area neglected in the policy draft and health policies must treat quality improvement as a priority area. This should include defining systems for accountability and external independent performance monitoring.
We recommend the establishment of a Quality Improvement Cell, an independent entity at the national and state level that is well integrated with the quality assurance structures of the relevant departments of Women and Child Development, National Health Mission, and the Department of Public Health. The Quality Improvement Cell is proposed to improve the service quality in hospitals by encouraging provision of high quality data and support the hospitals to achieve accreditation. The cell would also simplify the approval and decision making process that incentivizes senior medical staff and frontline workers by linking these incentives to process and performance measures. It would also be responsible for capacity building or knowledge and skill enhancement of the frontline caregivers who are the primary grassroots health functionaries targeting women and children. The cell would also be responsible for process reengineering wherein bottlenecks are identified and resolved, leading to improved patient experience and service delivery.
Stressing on quality assurance has demonstrated an improvement in the quality of care provided at public facilities. The Government of Gujarat is a leading example of attempting to improve quality assurance in the public healthcare facilities by establishing an accountable network of community health centers, primary health centers, and district and teaching Hospitals. In 2002, the Government of Gujarat established a District and State Quality Assurance cell for the implementation of this program, with a special focus on reproductive and child health. As a result of this program a large number of public facilities and labs received National Accreditation from the Bureau of Hospitals Accreditation.
The importance of community engagement and voice is another dimension that can be instrumental in improving quality of care. Evidence from Kerala indicates that a substantial improvement in the quality of public health after Panchayati Raj was made a part of the decision making process. This involved the creation of a Hospital Management Committee under the leadership of the elected head of the concerned local government. The committee was responsible for the attendance of health officials, availability of medicines, quality of services, and the quality of infrastructure of public health facilities. They saw considerable improvement in the mentioned indicators.
Summary of the Key Recommendations to Improve Health Outcomes and System Efficiency
In summary, we propose that gender sensitization must begin at an early stage by a systematic introduction of syllabi addressing gender specific needs and concerns.
It is also important to strengthen leadership at national and state insurance programs for improving Quality. Quality Improvement training for hospital and insurance trust staff must be encouraged too. Attempts should be made to integrate the quality improvement methodology into National Health Mission and National Quality Assurance standards. A pay for performance mechanism must be encouraged to improve the service quality.
The use of Health Technology Assessments must be made integral to health policymaking. Creating a health information management system across various government programs and conducting requisite training on the collection and analysis of data to measure the quality of care in hospitals and linking pay for performance in mother and child programs can be treated as a crucial first step towards promoting evidence based decision making.
Finally, we propose creating a single point of caregiving by building capacity of the Multi Purpose Worker to include providing preventive and curative care and other underrepresented women health concerns such as mental health, geriatric care, post delivery nutrition, menstrual hygiene, nutritional anemia and other nutritional disorders, and sexual and reproductive health. Efficient usage of data can help in the formulation of standard treatment protocols and integrated care pathways. These protocols enable the healthcare provider to work on a system that integrates various levels of care and makes access to healthcare seamless for the beneficiary.
 Joseph L Mathew (2012), Inequity in Childhood Immunization in India: A Systematic Review