Framing Women's Health Issues In 21st Century India

Women suffer more, are treated lessand have poorer health outcomes.Challenges Despite the well-documented health transition leadingto a situation where deaths and disabilities in women dueto NCDs, such as cardiovascular and respiratory diseases,cancers, injuries and mental disorders, including suicide,are on the rise, little attention is being paid to addressingthese issues. Funding agencies, donor organizations and academicbodies are yet to embrace the life-course agenda towomen’s health, leading to neglect of health of womenbeyond childbearing years. Women provide the bulk of healthcare worldwide, bothin the formal healthcare setting as well as in the informalsector and in the home. Yet women’s own needs forhealthcare are poorly addressed, especially among ruraland poor communities.6Framing Women’s Health Issues in 21st Century India - A Policy ReportThe George Institute for Global Health India, May 2016. Gender inequality, in both biological, environmental andsocial terms, makes women more vulnerable to certainrisks, leading to poorer outcomes. These issues needspecial attention through independent programs thatwill be distinct from men’s health. Extrapolation of health data taken from men leadsto under-recognition of the manifestations, severityand consequences of disease, differential access toinformation and health services. Women’s household roles impact their health -- such asexposure to smoke and women’s limited engagementin physical work. These challenges do not have theirsolutions rooted in medical health but a holistic approachto public health and inter- departmental partnerships.

44%THE INCREASED RISKOF DIABETIC WOMENHAVING A STROKEOVER DIABETIC MENTHE INCREASED RISKOF DIABETIC WOMENHAVING A HEART ATTACKOVER DIABETIC MEN27%The Goals of ReformThe main goals of reform in women’s healthcare reflectthe principles behind universal human rights and the UNSDGs. These include: Getting a better understanding of issues around thebarriers to delivering quality healthcare to women. Sensitizing academic organizations, policymakers,funding bodies, and NGOs to developing anindependent women’s health research andimplementation agenda. Optimizing healthcare to women through highquality care. Optimizing the experience of women in encounters withthe healthcare system through development of a lifecourse approach. Ensuring equity and achieving value for money. Providing incentives for behavior change to promoteachievement of these goals.The Indian healthcare system requires discussions,advocacy and research to underscore women’s health asone of the focus areas in research and implementation.Such a process can be informed by similar work doneelsewhere. For example, sex-disaggregated analysesof data have shown that women with diabetes have a44% higher risk of heart attack than men with diabetes.8Similarly, women with diabetes have a 27% increased riskof stroke compared to men with diabetes. Given the factthat South Asians are at increased risk of CVD, especiallyat a younger age, such sex-disaggregated studies aremuch needed in India. All sections of the society, includingmen, need to be involved in promoting the women’shealth agenda.7Framing Women’s Health Issues in 21st Century India - A Policy ReportThe George Institute for Global Health India, May 2016.An example of the type of evidence requiredto show the benefits of integrating a focus onSRH and NCDs to improve health outcomes forwomen in South Asia.In August 2015, an award was made by the Global Alliancefor Chronic Diseases, with funding from the Indian Councilof Medical Research and the National Health and MedicalResearch Council of Australia, to support a lifestyleintervention program for the prevention of type 2 diabetesmellitus amongst South Asian women with gestationaldiabetes mellitus.Primary research aim: To determine whether a resourceand culturally appropriate lifestyle intervention programin South Asian countries (Bangladesh, India and Sri Lanka),provided to women with gestational diabetes mellitus(GDM) after delivery, will reduce the incidence of type 2diabetes mellitus (T2DM), in a manner that is affordable,acceptable and scalable.Research methodology: A new lifestyle interventionprogram is being developed that will be delivered byauxiliary nurse midwives or their equivalent in eachparticipating hospital, representing a strategy of withinsystem task-shifting. The intervention will be evaluated ina randomized controlled trial (1414 women from 24 centres)to determine whether it will reduce the incidence of T2DMat a median of 20 months follow-up. This project focuseson generating new knowledge around implementationof a preventive strategy embedded within existing healthsystems, using mixed-methods evaluation to inform oncost-effectiveness, acceptability and scalability.

Women with type 1 diabetes have a 37 per cent greaterrisk of dying of any cause compared to men.Key Recommendations Governments, inter-governmental agencies, nongovernment organizations, donor organizations andcorporate bodies need to broaden their focus onwomen’s health to include NCDs.Seven of the top 10 causes of death in women in India areNCDs, led by heart attacks, stroke and respiratory diseases.Despite these data, widespread perception persists that heartdisease and stroke are mainly diseases of men, and that if awoman develops CVD, it will not be as serious as in a man.Moreover, even women do not see it as an important threatto their health. Data also show that women and men whohave high blood pressure or who smoke have an equal risk ofgetting heart attack and stroke, whereas women with diabeteshave a higher risk of IHD and stroke compared to men.8Women with type 1 diabetes have a 37% greater risk dyingof any cause compared to men with type 1 diabetes. Incontrast, women are less likely to receive drug therapy for themanagement of these risk factors, and are less likely to bereferred for diagnostic and therapeutic procedures.8Spurred by these data, a number of organizations anddocuments have highlighted the need to develop a holistic,life-course agenda for women’s health that does not abandonthem once the childbearing age is passed. These includethe Every Woman Every Child movement (2010), WHO’srecognition of women’s health beyond reproduction as anew agenda (2013), the Lancet Commission on Women andHealth (2015), the Global Strategy for Women’s, Children’s andAdolescents’ Health (2015), and the Global Leader’s Meetingon Gender Equality and Women’s Empowerment by the UN(2015), leading to commitments by the UN member states.Major disparities are evident in the provision of care, all to thedisadvantage of women in India. It is time that all stakeholdersrecognize and adopt a life-course approach while advocatingthe women’s health agenda, if genuine progress in women’shealth is to be realized and the 2030 SDG targets are to be8Framing Women’s Health Issues in 21st Century India - A Policy ReportThe George Institute for Global Health India, May 2016.realized. Else, the ongoing health investments will lead todiminishing returns and will not benefit a majority of women.The life-course approach extends beyond women’sreproductive aspects to encompass women’s health at everystage and in every aspect of their lives. It highlights genderas a key determinant of women’s health and well-being,and focuses on the fact that women’s health needs differaccording to their life stages. There is a need to target womenin the lower socio-economic strata. As the approach relies ondata disaggregated by sex and other important variables suchas age and environmental settings, the sex-disaggregateddatabases at all levels need to be strengthened. Such anapproach has the potential to lead to reductions in deathsand disabilities due to NCDs as well as SRH issues.This agenda cannot be achieved without significantinvestment, which must come from all stakeholders –both government as well as private sector. Large donororganizations have played an important role in shapinghealthcare reforms and agendas in India, and it is imperativethat they pivot towards taking a life-course approach towomen’s health. Similarly, large corporates in India continueto provide admirable support to several aspects of women’sempowerment and well-being, including healthcare relatedissues. It is time that they allocate funds from their CSR budgetto support an integrated women’s health agenda. This muststart by supporting gendered analyses of existing health data- without such analyses reform packages cannot be developedand implemented. The Central and State Ministries and Departmentsof Health should promote and support the 2015Global Strategy.The governments have set up an excellent framework forprovision of care for SRH related conditions, which consists ofat least 3 levels of workers. This model has already shown thatinvolvement of non-physician healthcare workers is effective

Diabetes-related excess risk of stroke in women is due toundetected and therefore untreated higher cardiovascular riskprofiles in pre-diabetic conditions.Key Recommendations Continuedin democratizing care delivery and improving outcomes. Thesame framework can be mobilized to develop a life- courseapproach to women’s care. Such a recommendation isconsistent with the National Program for Prevention andControl of Cancer, Diabetes, CVD and Stroke.The program must make provisions for collecting andreporting gendered-analyses of health data at all levels. Sexdisaggregated data collection will lead to better planning andimplementation of women-centric health interventions.Government and health department officials must ensure thatany proposed interventions have been analyzed separatelyfor women and men before making decisions. This would becrucial to attainment of the SDGs.As these programs are implemented, plans should be put inplace for promotion of disaggregated analyses and inequalitymonitoring as recommended in the WHO Roadmap for Action2104-19.8 Professional and academic organizations, especiallythe Indian Council of Medical Research, obstetricsand gynecology societies, academic institutions, anduniversities and journals, should recognize, promote andaddress a broader, integrated women’s health agenda.The implementation of any change can be realized only whenthere is systematic engagement with, and monitoring of, allhealthcare providers, including both government and privatesector. Such a task requires involvement of independentprofessional and research organizations.All professional organizations interested in aspects of women’shealth should develop, irrespective of the primary area ofspecialization, an integrated women’s health agenda.Societies need to carry out comprehensive and independentevaluation of all new and existing programs, so as todetermine how investment in gendered research can providenew knowledge and lead to improved outcomes.9Framing Women’s Health Issues in 21st Century India - A Policy ReportThe George Institute for Global Health India, May 2016.Academic institutes and universities should develop programsfor gendered analyses, on the lines of the Advice Paper ofthe League of European Research Universities (LERU), thatprovides case studies showing how a gendered approach toscience has contributed to increased excellence in scienceand the production of new knowledge.9 These organizationsshould engage with governments and funding agencies tohighlight the importance of gendered analyses, and allocationof funds for this purpose. All new research should be designed to facilitate inclusionof gendered analyses. Such a step will be crucial toformulating gender-specific strategies when needed.Effective and collaborative research, data collection,monitoring, evaluation and knowledge transfer to advancethe evidence base on women’s health is necessary for framingbetter policies. Social research and clinical studies shouldmake it a point to include as many representative womenas men.All government and private organizations, NGOs, foundations,etc. engaged in the provision of healthcare should promote,produce and report gendered analyses of healthcare statistics.This recommendation particularly applies to agencies thathold large insurance datasets, both in the government and innon-government sector. Resources should be allocated to:- Continuous monitoring of gendered analyses ofhealthcare statistics.- Examine pathways and quality of care for women at alllevels of the health system.- For gender-neutral conditions, determine whether thesepathways differ for men and women.- Identify evidence-based strategies that could beimplemented to ensure women receive the bestavailable care.

Mental health needs to be made an integral part of thewomen’s health agenda in India.Key Recommendations ContinuedFunding bodies, such as the ICMR, the Department of HealthResearch and the donor bodies should recognize the needto promote such research and bring out specific calls forproposal. In particular, funds should be allocated within theICMR to develop a program of research in this area.In order to develop evidence that is directly applicableto women, research projects should include women inappropriate numbers - whether in the study of biology orenvironmental factors, examination of variations in access tocare and its reasons, or implementation research aimed atproviding the best care to women. Empower and educate women to take charge of their own– and their families’ health.There needs to be impetus on educating women to bringfundamental behavioral change and awareness of innovativeapproaches to improve healthcare of themselves and theirfamilies. Women should be sensitized by the primary-levelhealth systems about the importance of having a healthylifestyle and inculcating it in their family.Women in uninsured households should be taught the virtuesof using microfinance and insurance to access healthcare. Theyshould be taught about the importance of filing claims andparticipating in decision making around healthcare delivery inthe family.Socio-behavioral researchers should develop interventions toraise overall attention to women’s health among communities,emphasizing the life-course agenda and including NCDs,mental and respiratory disorders and de-addictions. Suchinterventions should be culturally sensitive.Mental health needs to be made an integral part of thewomen’s health agenda in India, and conversations shouldfocus on removing the element of stigma around it. Thisrequires behavioral change communication in the healthsystem to primary-level health workers and through them tothe communities.10Framing Women’s Health Issues in 21st Century India - A Policy ReportThe George Institute for Global Health India, May 2016.A woman empowered with knowledge about the disease andrisk factor burden, can be transformative to the health of entirefamilies. Such empowerment is required early - the existingAdolescent Reproductive and Sexual Health (ARSH) clinics canserve as the ideal vehicle for such initiatives. Moving from conversations to action needs carefulplanning, extensive discussion and consultation, and astaged approach.Increasing broader public awareness that there is scope forimproving our healthcare system through modifying fundingapproaches is an immediate priority. The concept of patientsas partners in care must also be acknowledged in this context.Political buy-in and commitment to reform is also essential. Abroad constituency is needed to reach agreement and drivechange that outlasts the political cycle. Community and nonhealth agencies should be given a voice in health pathwaysand in the bundling of services.An important opportunity exists to learn from other schemeswithin and outside the health sector and from overseas. Forexample, the NDIS (National Disability Insurance Scheme)is a useful case study for patient-driven service deliverypolicy reform.Evaluation and staged implementation of programs areneeded to generate the evidence base to ensure effectiveroll-out of reforms. Consideration should be given to forminga reform ‘statutory body’ with a permanent secretariat tocontinue the reform process and monitor progress.

The Way ForwardThe development of an independent women’s healthprogram that takes a life-course approach to improvingtheir access to healthcare is needed to enable managementof all issues that affect women’s health. This should includeimproved management of sexual and reproductive healthissues, integrated with the management of chronic diseases,including cardiovascular diseases, cancers and mentalhealth. It should also encourage prevention and removebarriers to healthcare utilization. Such an agenda could bedeveloped by the following approach:- Increased focus on the collection and use of datadisaggregated by sex and age, as well as other indicatorsrelevant to women’s health and survival.- Improved partnerships and synergy betweengovernment and non-government (international andlocal) bodies working on women’s health.- Staged implementation of individual programs of reform,building on existing programs such as the primary careSRH program, accompanied from the outset by rigorousevaluation and routine collection of appropriate data.- In the longer term, rolling out of such reforms across theentire geography.- Expansion of existing IT capacities for data collectionand analysis.11Framing Women’s Health Issues in 21st Century India - A Policy ReportThe George Institute for Global Health India, May 2016.- Significant investment in change management processesby government as well as private providers – in particular,the infrastructure costs that might be incurred inimplementation of these programs.- Corporate organizations to recognize the importance ofan integrated women’s health agenda as an importantCorporate Social Responsibility, especially in light ofthe SDG No 3, and allocate funds to support genderedanalyses of health data and improved understanding ofcare pathways for women.- Improved investment in primary care to ensure thatdevelopment of NCDs in women can be prevented.In fabricating these reforms there needs to be broad andongoing consultation and consideration of all perspectives– public and private sectors, insurance companies, and thepatient-consumer.This recent round table meeting representsthe first step in this process and is particularlyrelevant, given its timing alongside theannouncement of the SGDs, and as a naturalfollow up to steps recommended by majorglobal organizations.

Thank youThe George Institute, India is grateful for the participation of the following representatives in the roundtablediscussion that is the basis of this report:Abha Mehndiretta - World Bank/Nice InternationalRahul Kaul - BiovoiceDinesh Sharma - Senior JournalistSimi Khan - MamtaHarinder Sidhu - High Commissioner of Australia to India,Australian High CommissionAmit Khanna - The George Institute for Global Health, IndiaKarthikeyan G - Department of Cardiology, All India Institute ofMedical SciencesRajesh Sagar - Department of Psychiatry, All India Institute ofMedical SciencesAparna Khanna - Lady Irwin College, University of D

Framing Women's Health Issues in 21st Century India - A Policy Report The George Institute for Global Health India, May 2016. The George Institute for Global Health, India 219-221, Splendor Forum, Plot No. 3 Jasola District Centre New Delhi 110025 India Tel: 91 11 4158 8091-93 Fax: 91 11 4158 8090 info@georgeinstitute.org.in