Gendering health policy

Poverty, malnutrition and gender inequality have implications for maternal and infant survival. In adopting steps to tackle infanticide and improve the nutritional status of girls, the cue lies in powerful social movements that have addressed these issues, say VENKATESH ATHREYA and SHEELA RANI CHUNKATH.

IT is now almost universally accepted, except perhaps among 'free market' fundamentalists, that economic growth by itself will not ensure positive outcomes for vulnerable sections of society such as the poor, the dalits and women. The implication of such acceptance is that government policies should be informed by a specific focus on each of the dimensions of inequality, including class, caste and gender.

Let us explore, in this context, some of the implications of gender for health policy. The strongly patriarchal nature of our society has specific consequences for the survival and health of women. A summary indicator of the relative well-being of the female gender is a society in the sex ratio, defined as the number of females per 1000 males in the population. The sex ratio for India has been declining through successive censuses since 1901 - it was 927 in 1991. Tamil Nadu's sex ratio has also declined sharply over the period 1901-1991, from 1044 to 974, the second largest absolute decline among all major states, next only to Bihar. The decline in sex ratio is a clear indicator of the relative survival disadvantage of females in our patriarchal society. In the case of Tamil Nadu, districts such as Salem (including Namakkal), Dharmapuri and Madurai (including Theni) have shown an especially rapid decline in the ratio of female to male children in the age group of six years or less, since 1971.

Underlying this rapid decline in sex ratio is the phenomenon of female infanticide. It is estimated that around 3,000 female infants are put to death in the State every year, accounting in 1998 for as much as 19 per cent of all female infant deaths in rural areas. In the districts of Dharmapuri, Salem (including Namakkal and Madurai (including Theni), the proportions were much higher, being 47 per cent, 52 per cent and 25 per cent respectively. State policy needs to address the issue of female infanticide - a social issue with enormous significance for female survival - urgently. A good beginning has been made by the State Government in this regard in Dharmapuri district, first through using kalaipayanams (itinerant street theatre troupes composed of local volunteers) to motivate and mobilise the community and health service providers against infanticide, and then through involving leaders of panchayats in the campaign. Following the success of the campaign in Dharmapuri district, it has been extended to Theni.

While female infanticide accounts for a large part of excess female infant mortality in the districts where it is widespread, survival disadvantage of females in general and female infants in particular stem from other factors as well, including neglect of the female in the family throughout her life cycle. Both poverty and malnutrition in general, and intra household gender inequality in the distribution of food and health care in particular, contribute to malnutrition of adolescent girls as well as mothers. This is turn has serious implications for maternal and infant survival, key concerns of health policy in any society.

An analysis of a large sample of infant deaths in Tamil Nadu in 1998 shows that 60 per cent of such deaths occur in the first seven days after birth. Infanticide in some districts and inadequacies in newborn care facilities as well as in training of personnel generally account for a large proportion of such deaths. However, as much as 15 per cent of infant deaths are caused by low birth weight almost all of which is directly attributable to maternal malnutrition. Strategies to reduce infant mortality in Tamil Nadu thus need to address the issue of gender inequality, both in order to eliminate the heinous social practice of female infanticide, and in order to improve the nutritional status of females from infancy onwards.

Malnutrition among girls and women in the child bearing age groups also has important implications for maternal survival. Poor nutritional status results from both inadequate intake of nutritious food (caused by both poverty and patriarchy) and low biological utilisation of food (caused by infestations arising from inadequate sanitation facilities and hygiene, and non- availability of safe drinking water, again correlated with both poverty and gender division of labour). Also relevant is the enormous burden of work, within and outside the household, borne by women. Poor nutrition, in turn, is a basic cause for maternal anaemia, which accounts directly for over six per cent of all maternal deaths, and contributes in equal or greater measure indirectly.

Maternal survival chances can be enhanced by improved maternal nutrition and appropriate ante-natal care, including immunisation, iron and vitamin supplementation and early identification of high risk pregnancies. However, ante-natal care by itself cannot prevent maternal death. Provision of reliable, emergency obstetric care is crucial to reduction of maternal deaths.

Between 1,800 and 2,000 maternal deaths occur in Tamil Nadu in a year. Patriarchal attitudes which put a low value on a woman's life, the enormous burden of hard toil and poor nutrition, the lacunae in transport and communication facilities, delay in accessing needed health facilities, and the lack or poor quality of essential and emergency obstetric services - all these contribute to maternal mortality. Among the medical causes, heamorrhage, both ante-partum and post-partum, accounted for nearly 40 per cent of all maternal deaths in rural Tamil Nadu in 1996. A key to reducing maternal mortality therefore lies in availability of adequate quantities of blood in time. All the government hospitals in the State need to be equipped with blood banks.

An important cause of maternal mortality and morbidity is unsafe abortion. No firm estimates are available either of the number of abortions or of maternal deaths due to abortion. But the evidence available - based on estimated number of abortions and actually reported cases of medical termination of pregnancy - strongly suggests that safe abortion services remain inaccessible to a sizable proportion of women who need them. Data also suggest that rural women are particularly vulnerable. The policy implications of this scenario are two fold. On the one hand, provision of safe abortion services must be given greater attention and not be made conditional on or linked to permanent sterilisation. Health system personnel must be sensitised to the woman's right to reproductive choice. On the other hand, the need to ensure that abortion is not used as a method of contraception has to be addressed through health education, aimed especially at the male so as to enhance male contraceptive use which is at present minimal.

The hold of partriatchal structures and value systems find clear reflection in population policies in our country. Even in Tamil Nadu, the remarkable decline in birth and fertility rates have come primarily through female sterilisation. It is now increasingly recognised that a sound and sustainable population policy must be based on gender equality. Currently, the number of vasectomies done per year in the state is negligible, and the use of condoms by males is largely confined to urban areas. A recent survey has reported that only 15 per cent were using modern methods of contraception. Family welfare efforts need to be reoriented to emphasise and ensure male participation in contraception and family limitation.

Finally, in this brief and selective overview of gender issues in health policy, let us take a look at the practice of female foeticide. This practice, widespread in some parts of the country such as Punjab, Haryana, Delhi and Maharashtra for a decade or more, has recently spread to Tamil Nadu. Media reports suggest that the practice is thriving in districts like Madurai and Salem in the name of "genetic counselling". Urgent action is needed to ensure strict implementation of the Prenatal Diagnostic Techniques (Regulation and Prevention of Misuse) Act, 1994 forbidding sex determination tests. It is also imperative that the community is motivated and mobilised against the practice of female foeticide. Strategies to tackle foeticide (and infanticide) must also address the larger issue of weakening patriarchy and empowering women.

Over the decades, thanks to powerful social movements led by Periyar and other progressive forces, gender issues have received attention from successive governments in Tamil Nadu. But there is still much to be done. With enlightened state policy, and the alert and active involvement of the community and various movements for gender equality, Tamil Nadu can emerge as a trend setter in gender-sensitive health policy.

Venkatesh Athreya, Professor and Head, Department of Economics, Bharathidasan University, Tiruchirapalli.

Sheela Rani Chunkath, Commissioner for Maternal, Child Health and Welfare and Project Director, DANIDA Tamil Nadu Area Health Care Project.

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