Comment

Gender equity and universal health coverage in India In this Series in The Lancet, Srinath Reddy and colleagues1 call for universal health-care coverage in India, and outline why the development of national health provision is both timely and necessary. Without question, India has reached the right point in time to undertake universal health-care coverage, a move that is likely to improve national development. However, as outlined in several papers in this Series, issues of gender inequity remain in India and impede the nation’s public health and development. Any effort toward universal health care in India must at inception be aligned with the broader goals of improving the status of women and girls in the country, or be destined to fail. Although India is presently ranked by the UN as a middle-income country,2 recent findings from the World Economic Forum place the country among the lowest ranked nations in terms of gender equity.3 Women are less likely to be literate, continue in their education, participate in the labour force, receive equal pay for similar work, and hold a political position than are men (figure).3 Although such concerns are not unique to India, they are linked to some gender-specific health vulnerabilities in the country, such as the marriage of young girls and non-use of modern contraception.3–5 As drawn attention to in this series, pregnancy at young age and successive pregnancies cause high rates of maternal morbidity and mortality in India.6 These factors contribute to the World Economic Forum’s ranking of the country as 132nd of 134 nations in terms of gender equity in health and survival.3 The findings presented on health-care coverage in India emphasise that maternal health concerns, such as fertility and maternal mortality, continue to affect large numbers of women and girls in India. Although these concerns are diminishing, present trends indicate that India is not on target to reach national and Millennium Development Goals.6 Impediments to maternal health in India (eg, young marriage, and inadequate access to and control over use of family planning, contraceptives, and abortion services)6 are directly attributable to the low status of women and girls in society. Furthermore, young, rural, and poverty-affected women are most vulnerable.5,6 Improvement of this situation, in conjunction with improved delivery of health services, will be needed to change maternal health in the country.

Studies presented in this Series also show that gender-related health inequities are being carried into the next generation; India currently has lower health-care use for women than for men, infants, and young children, and sex-based disparities exist in fetal, infant, and child mortality.6,7 Although issues of gender-based violence against women (including spousal abuse and sexual violence) were not covered in this Series, they remain a major concern in India,4 and intersection of gender-based violence with other gender inequities affects both maternal and child health. For example, physical and sexual abuse by husbands affects more than a third of wives in India, is more common in women who marry at a young age,8 and is linked with child mortality in girls but not boys.9 Too many Indian women and girls are unnecessarily affected by gender-based violence and inequities in health-care access and use. There is also inadequate female knowledge and autonomy to maintain good health and reproductive control. Universal health-care coverage, in the absence of gender empowerment to address these issues, will be of no use to millions of women and girls in India, leaving poor and rural women, and adolescent wives and mothers, who are in greatest need, without assistance. Reddy and colleagues’ call to action offers clear and feasible guidance about how to undertake the necessary and important effort of developing an Indian national health system. However, as this call becomes a national objective, my hope is that the authors’ recommended strategies will prioritise women and girls’ health and empowerment to ensure public health effectiveness. It is beyond the jurisdiction of this programme to

Published Online January 12, 2011 DOI:10.1016/S01406736(10)62112-5 See Online/Series DOI:10.1016/S01406736(10)61265-2, DOI:10.1016/S01406736(10)61492-4, DOI:10.1016/S01406736(10)61188-9, DOI:10.1016/S01406736(10)61894-6, DOI:10.1016/S01406736(10)61888-0, DOI:10.1016/S01406736(10)61884-3, and DOI:10.1016/S01406736(10)61960-5

In ministerial position In parliament Wages for similar work In labour force Literacy Secondary education Primary education 0

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Figure: Female to male ratios in education and literacy, labour participation and wages for similar work, and political positioning in India (2006–10)3

www.thelancet.com Published online January 12, 2011 DOI:10.1016/S0140-6736(10)62112-5

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address gender inequities in education, employment, or even marital age. However, the system can and should be designed to improve health-care access and use with an emphasis on vulnerable women and girls’ lack of health knowledge, reproductive control, access to health services, and financial means to obtain services for themselves or their children. The approaches chosen will need to consider and address gender-based violence, and must be inclusive of gender-equity promotion that targets men and boys, women and girls, and families. Development of the Indian national health system is an important next step in the country’s role as a global leader. Consideration and reductions in gender inequity are fundamental components of good health, and hopefully improvement in these areas will, within the decade, help to move India up the gender-equity health rankings.

I declare that I have no conflicts of interest. 1

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Anita Raj

Reddy KS, Patel V, Jha P, Paul VK, Shiva Kumar AK, Dandona L, for The Lancet India Group for Universal Healthcare. Towards achievement of universal health care in India by 2020: a call to action. Lancet 2011; published online Jan 12. DOI:10.1016/S0140-6736(10)61960-5. UN Development Programme. Human development report 2010—20th anniversary edition. The real wealth of nations: pathways to human development. October, 2010. http://hdr.undp.org/en/media/HDR_2010_ EN_Complete.pdf (accessed Nov 10, 2010). Hausmann R, Tyson LD, Zahidi S. The global gender gap report 2010. World Economic Forum. 2010. http://www.weforum.org/pdf/gendergap/ report2010.pdf (accessed Nov 10, 2010). International Institute for Population Sciences and Macro International. National Family Health Survey (NFHS-3), 2005–06: India: vol I. 2007. http://www.measuredhs.com/pubs/pdf/FRIND3 (accessed Nov 3, 2009). Raj A, Saggurti N, Balaiah D, Silverman JG. Prevalence of child marriage and its impact on the fertility and fertility control behaviours of young women in India. Lancet 2009; 373: 1883–89. Paul VK, Sachdev HS, Mavalankar D, et al. Reproductive health, and child health and nutrition in India: meeting the challenge. Lancet 2011; published online Jan 12. DOI:10.1016/S0140-6736(10)61492-4. Balarajan Y, Selvaraj S, Subramanian SV. Health care and equity in India. Lancet 2011; published online Jan 12. DOI:10.1016/S0140-6736(10)61894-6. Raj A, Lawrence D, Saggurti N, Donta B, Silverman JG. Association between adolescent marriage and marital violence in young adulthood in India. Int J Gynecol Obstet 2010; 110: 35–39. Silverman JG, Decker MR, Cheng DM, et al. Gender-based disparities in infant and child mortality based on maternal exposure to husband violence: the heavy burden borne by Indian girls. Arch Pediatr Adolesc Med (in press).

Department of Social and Behavioral Sciences, Boston University School of Public Health, Boston, MA 02118, USA [email protected]

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www.thelancet.com Published online January 12, 2011 DOI:10.1016/S0140-6736(10)62112-5