Gender Bias in Utilisation of Health Care Facilities in Rural Haryana

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1 Gender Bias in Utilisation of Health Care Facilities in Rural Haryana Rajeshwari Haryana as a whole is one of the developed states of India whereas, socially and demographically, i e, in terms of sex ratio; sex differences in child mortality, and female literacy rates, etc, the state is one among the lowest category in India. Secondly, in the provision of public health care infrastructure, the state ranks among the better provided states of India. However, there are inter-district variations in the provision of public health care facilities. This paper examines the gender bias and levels in women 's health care by taking such districts in the state which are the representative of low provision of health care infrastructure and high level of economic development on one side, and on the other, districts which are economically backward but the provision of public health care infrastructure is maximum. IMPROVEMENT in female health status critically depends upon a number of factors. Studies have shown that poverty [Batliwala 1982, Chatteijee 1985], low level of female participation in economic activity [Bardhan 1982], education [Cochrane 1980, Nag J 983J, empowerment, kinship system and autonomy, and culture [Dyson 1983, Das Gupta 1987], determine not only the health status ot women but also affect the selective bias against them. Other studies have argued that it is the poor availability of health care facilities which adversely affect the gender bias and health status of women [GOI 1975, Ramalingaswamy 1987]. The present article focuses on levels in women's health care and gender bias in use of HCFs in rural areas in Haryana, which is one of the more advanced or agriculturally developed states in India. However, not all the districts of the state are equally developed. The western districts of the state adjoining the state of Rajasthan, Bhiwani and Mahendragarh are relatively agriculturally backward due to the non-availability of assured water supply [Bhalla 1989]. Similarly, in terms of public health care infrastructure, the state of Haryana on an average, provide one primary health centre for every 35,000 persons ( ) in its rural area. (This is very close to the norm of National Health Policy, 1983). One may witness the inter district disparities in this field also. The western districts of the state are being better provided with all kinds of public health care facilities (HCFS). Paradoxically, it is the agriculturally developed districts of the state which are being least provided with all kinds of health care infrastructure, whereas the less developed ones have the major share [Rajeshwari 1993]. Secondly, socially and demographically, Haryana as a whole, figures in the less developed category in India. For instance, sex ratio, sex differences in child mortality, and rural female literacy rates are found to be quite low [Visharia, 1969, Dasgupta 1989]. The adverse sex ratio and excessive mortality of females is commonly hypothesised to be due to discrimination against females in the allocation of food and health care within the household. The objective of the present paper is to examine the spatial variations in gender bias in use of public health care facilities. This is done at two levels. First, in relation to the availability of public HCFs at the place of residence, and another, in relation to the economic development of an area (since there is inter-district disparity in economic development). A number of studies have presented quantitative evidence of sex bias in patterns of child nutrition and health care. Amartya Sen (1983) in a study on West Bengal has shown that girls continue to have poor nutritional status in all socioeconomic strata. Hence, the economic development in itself is not helping much in reducing gender bias. The present paper however, hypothesises that economic development reduces gender bias. This assumption is based on the logic that better economic development will lead to belter education, exposure, awareness, opportunities and ultimately will get reflected in better understanding and reduced selective discrimination against women. The second hypothesis examined here is that the availability of public health care facilities at the place of habitation also helps in reducing gender bias in preventive and curative aspects of health care. DATA AND METHOD The results of the present paper are based on a primary survey carried out during March to September 1991 in rural Haryana. About 389 households spread over eight villages were studied. The sample villages belong to Bhiwani and Kurukshetra districts of the state. The selection of the districts are based on the provision of public health care infrastructure. Bhiwani district of the state comes out to be the better provided district whereas, Kurukshetra district figured as the least provided in terms of public HCFs. Likewise, two TABLE 2: PROPORTION OF TREATED AILMENTS (PER LAKH) TO TOTAL AILMENTS BY SEX AND FRACTILE GROUP: ALL INDIA RURAL ( ) Economic and Political Weekly February 24,

2 Economic and Political Weekly February 24,1996

3 tahsils in each of these districts were selected. In each of these tahsils, two villages were selected. One village was such where any kind of public HCFs (invariably PHC) was located, whereas the other was about 5 to 10 km away from such facility. In all, eight villages were selected out of which four were PHC villages and four were non-phc villages. (It would be pertinent to highlight that the two districts, namely, Bhiwani and Kurukshetra are at two different levels of socio-economic development. It is intriguing to note that in provision of public HCFs Bhiwani ranks first, while in terms of economic development Kurukshetra district belongs to one among the advanced districts of the state.) Utilisation of HCFs has been considered with reference to preventive and curative care. In case of preventive care, the utilisation of HCFs has been measured as: (i) levels of infant'simmunisation,(ii)levelsof ante-natal care for expecting mothers, and (iii) care during childbirth or say institutional deliveries, etc. The curative aspect of health care and their utilisation has been observed on the basis of levels of medical intervention in case of any ailment. The paper is divided into three sections. The first section deals with levels of health care and use of HCFs vis-a-vis availability of these facilities. The second section describes the utilisation pattern with reference to the main occupation of the head of the household. The main occupation of the household is in terms of categories, e g, cultivators, business, service and others. Cultivators are being further divided into various sub-categories on the basis of size of landholding. Occupational categories, thus arrived have been taken as a proxy of economic status of the households. The third section of the paper presents levels of HCFs used by women vis-a-vis the educational status of the head of the household. An attempt has also been made to find out which factors are showing positive impact in determining better care for them. I Availability of Public HCFs and Utilisation The availability of HCFs and their better utilisation is well known. Data from the survey of infant and child mortality show that infant mortality is highest where medical facilities are unavailable and trained birth attendance is low. The availability of services stimulates their use by mothers for the purpose of child health care. The results of the sample study area have been presented in Table 1. It shows that immunisation levels of girl infants are somewhat better in the villages where public HCFs are present within the place of habitation, whereas, in non-phc villages, the level of immunisation is remarkably low. Similarly, in the case of ante-natal care at aggregative level, one may obtain that availability of public HCFs has a positive impact in its utilisation. However, in the case of institutional deliveries, one may not find variations in the PHC and non-phc villages, thereby indicating less impact in utilisation of HCFs due to its availability. At the disaggregative level, i e, in PHC and non-phc villages of Bhiwani and Kurukshetra districts, the table shows that here also levels in utilisation of HCFs are better in the PHC villages as compared to the non-phc villages. The only exception seems to be in case of ante-natal care in Kurukshetra district where the levels of care is more frequent in non-phc villages as compared to the PHC villages. The above situation raises further questions as the non-phc villages here constitute only those villages which are up to eight kms from the existing PHC village. Hence, it may be pertinent to say that the villages which are more than 10 km away from the PHC village would be having much lower levels of utilisation of HCFs in preventive and curative care, meaning thereby that the nonavailability of public HCFs have a compound adverse effect on the health status of women in terms of immunisation, etc. Table 1 is testimony to this observation which shows that gender disparity is higher in non-phc Economic and Political Weekly February 24,

4 villages of both the districts in preventive as well as in curative care. The availability of HCFs at the place of residence, thus, is an important factor which contributes significantly in reducing the male-female disparity in its utilisation. One may, however, discover from the table that the levels of utilisation are higher in the PHC and non-phc villages of Kurukshetra district than those of Bhiwani district. It must be remembered that the provision of public HCFs is better in Bhiwani district as compared to Kurukshetra. The higher levels of care for females in utilisation of HCFs in Kurukshetra district may be associated with the better economic development of the district which has been stated earlier. On the basis of this, one may say that the levels of female health care is positively affected by the economic development and gender disparity gets reduced with the overall economic development of an area (Ds is.08 in PHC villages of Kurukshetra district). Although it is argued that in such situations Punjab and Haryana should have low malefemale disparity in terms of immunisation and other health care parameters, the truth however, does not correspond with it. In Kerala, for instance, the gender disparity is lowest in India despite being not so economically developed as are the states of Punjab and Haryana. This is in contradiction with the popular belief that economic realities shape the gender bias. This brings in the clement of literacy and educational levels as the contributing factor in determining the women* s health status. Hence, an attempt has been made to examine the factors shaping these variations in the state of Haryana. II Occupational/Economic Background and Utilisation of HCFs One may obtain from Table 2 that there is a positive association between expenditure/ income group and proportion of females treated with ailments. Among upper fractile groups, the care is more in favour of women as compared to male counterparts, it reflects that better income has a compound positive impact on women's health status. One may hypothesise that higher income leads to better exposure and opportunities which ultimately leads to better understanding of health and 492 Economic and Political Weekly February 24, 1996

5 allied issues, and thereby the levels of female health care would be higher and the gender disparity would be lower in such categories. In the sample study area, occupational background, however, does not correspond with the levels of immunisation in PHC villages. In non-phc villages it is high among large and very large farmers (80 per cent). In PHC villages it is least among business category households (0 per cent), followed by medium farmers. In non-phc villages it is the small, marginal and medium farmers which are worst affected in terms of levels of infant's immunisation. Hence, it implies that where a health care facility is available, gender disparity does not show any correspondence with the economic/ occupational categories, while in villages where HCFs are available at certain distance, disparity is less only among the well-off households. One may also discover that gender disparity is lower among almost all the occupational categories in Kurukshetra district against that of Bhiwani district. Itissurprising to note thatinnon-phcvillagesof Kurukshetra district, gender disparity is almost absent among landless agricultural labour households. The disparity value is negative among marginal and small farmers and service II category households. It indicates that increased income of rural family in itself is not an adequate explanation in reducing gender disparity. There may be some other factors which are interacting and must be looked into while dealing with the discrimination against girl child. In case of ante-natal care, women's utilisation of HCFs may be obtained from Tabic 5. One may find that at aggregative level such care is highest among large and very large fanners, followed by service II category households. It is found to be minimum among landless agriculture labourers (27.3 per cent), and small and marginal farmers (28 per cent). At disaggregative level, taking both the districts separately, one finds a remarkable difference. In Bhiwani district, about 12 per cent of expecting mothers had received such care, the corresponding percentages were about 70 per cent for Kurukshetra. It is intriguing to note that in Bhiwani, utilisation of HCFs in antenatal care seems to be indifferent vis-a-vis occupational characteristics of the households. In Kurukshetra district one finds that it was 100 per cent among large and very large farmers, medium farmers, and service II category households. It also shows little intercategory variations. One may observe that in PHC villages of both the districts, ante-natal care was taken in almost all the occupational categories of households though the proportion varied across the occupational categories. In Bhiwani PHC villages it shows correspondence with the occupational characteristics which reflect the economic status of the households. In comparison to this, the non- PHC villages of Kurukshetra district showed a positive result. Here, the recipient of antenatal care were about 90 per cent women which is even higher than the PHC villages of the same district. The analysis hence shows that the occupational characteristics and access to health services are interlinked in case of Bhiwani villages whereas the association is not so in the villages of Kurukshetra districts. Utilisation of health services in case of maternity care, vis-a-vis occupational characteristics is presented in Table 6. One may discover from the table that at the aggregative level, institutional deliveries were maximum (66.7) among large and very large farmers. It was almost absent among landless agricultural labourer households. As stated earlier, Kurukshetra district of the state has been characterised by a much higher level of economic and social development in comparison to Bhiwani district. The table shows that in Kurukshetra district, it is only among large and very large cultivators where the maternity care is found to be highest. In Bhiwani district, it seems to be more in service I category, followed by medium and small farmers. One may thereby argue that occupational categories which are considered a proxy for economic prosperity, in itself does not present a sufficient explanation in detennining the health status and use of HCFs by women. Levels of curative vis-a-vis main occupation of the households show that it is lowest in service I category in PHC villages. In case of non-phc villages, the tabic shows that among marginal and small farmers about a half of illness cases were left without any medical treatment during ailment. The situation is equally worse in medium farmer households where about one-third of cases were left unattended. One may say that the non-availability of public health care facilities at the place of habitation adversely affects the women's health during ailment more specificto those which belong to lower economic stratum of society. Levels of sex disparity in curative care, as presented in Table 8, shows that in case of non-phc villages, it is high among marginal and small farmers, medium farmers and among landless agricultural labourer households. In PHC villages, one may find that it is much lower in those categories as compared to the non-phc villages. In PHC villages of both the districts, gender disparity vis-a-vis occupational characteristics of households does not show large variations. However, in case of non-phc villages, it shows a correspondence with the occupational oharacteristics of the households. It shows much larger disparity (Ds=.30 and.45) among landless agricultural labourer households and, marginal and small farmers category. One may also note that the disparity reduces as one moves up, for instance, Ds value is 0.0 among large and very large farmers category. Hence, the analysis on levels of curative care reveals that non-availability of public HCFs at the place of habitation adversely affects the health status of women especially those which belong to lower economic categories. The availability of public HCFs not only reduces sex disparity but it also helps in improving the medical intervention during ailment for those which are at the bottom economic stratum of society. A cross district analysis, however, shows that inter category variations are less in the economically better developed areas coupled with location of HCFs at the place of habitation. Economic and Political Weekly February 24,

6 III Women's Health Care vis-a-vis Educational Status Levels of women's health care in preventive and curative care vis-a-vis educational status of the head of the household may be obtained from Tables 9 to 13. In case pf preventive care, i e, percentage of immunised girl infants is better among those households where the headmen are having more years of schooling. The table shows that where public health care facilities are available, the better educated headmen households have a positive attitude towards girls' health care. Similarly, the sex disparity is also low among such households. One also finds the absence of gender disparity (Ds value = 0.00 among better educated households in PHC and non- PHC villages. In the case of ante-natal care and maternity care. Tables 10 and 11 show that it is the illiterate headmen households where such care is least in both kinds of villages. One may thereby say that educational status is a contributing factor coupled with availability of public HCFs in improving women' s health status during and at the time of child birth. Levels of care during ailments vis-a-vis educational status of the head of the household may be obtained from Tables 12 and 13. It again shows that among the households where headmen have obtained educational status above matric, almost all the females who experienced illness were treated medically. Whereas, among illiterate headmen households about a half to one-third of females could not avail any medical treatment during illness. Hence, one may imply that the educational status of the head of the household is an important factor in improving the health care of women in preventive and curative aspects. The present findings can be related to the all-india statistics (Table 13), which shows positive association between adult education standard and proportion of persons treated with ailments. The proportion is found to be appreciably higher among those with higher levels of adult education. One may also witness a decline in sex disparity as one moves up from low education status to high education status. not seem to be an important factor in women's health care or use of HCFs for women. The economic status of the households which is taken in terms of occupational background of the households, shows correspondence with women health care where public health care facilities are not located in the proximity. Educational status of the head of the household emerges as an important factor which has positive effect on women's health care in preventive and curative care in PHC and non-phc villages. Hence it suggests that the provision of public HCFs at the place of habitation coupled with increased educatonal status or awareness towards various health care programmes can certainly reduce the selective bias against women. References Batliwala, S (1982): 'Rural Energy and Scarcity and Nutrition', Economic and Political Weekly, Vol XVIII, February 27. Bardhan, P K (1982): 'Little Girls and Deaths in India*, Economic and Political Weekly, Vol XVII, pp Bhalla, G S and D S Tyagi (1989): Performance of Indian Agriculture: A District Level Study, ISID, New Delhi. Chatterjee, M (1985): 'Competence and Care: Policies-to Develop Health and Nutrition for Women', Asian Regional Conference on Women, 1SI, New Delhi. Cochrane, S H et al (1980): 'The Effects of Education on Health', World Bank Working Paper, No 405, Washington. Das Gupta, M (1987): 'Selective Discrimination against Female Children in Rural Punjab, India 1, Population and Development Review, Vol 13. No l.pp Dyson, T and M Moore (1983): 'On Kinship Structure, Female Autonomy and Demographic Behaviour in India', Population and Development Review, Vol 9, No 1, pp Government of India (1975): Towards Equality, Report of the CSWI, GOI, India. Nag, M (1993): Impact of Socio-Economic Development on Mortality: A Comparative Study of Kerala and West Bengal', Economic and Political Weekly, Vol XVIII, pp National Sample Survey (1992): Sarvekshana, 51 st Issue, Vol XV, No 4, April-June. Ramalingaswamy, P (1987): 'Women's Access to Health Care\ Economic and Political Weekly. Vol XXII, pp Rajeshwari (1993): 'The Spatial Organisation of Health-Care Facility in Rural Haryana: An Inquiry into Its Availability and Utilisation', Unpublished PhD thesis, Centre for the Study of Regional Development, Jawaharlal Nehru University, New Delhi. Sen A and Sen Gupta, (1983): 'Malnutrition of Rural Children and the Sex Bias', Economic and Political Weekly, Vol XVIII, pp Visharia, P M (1987): The Sex Ratio of the Population in India, Census of India 1961, Vol 1, Monograph no 10. SUMMING UP Levels of women's health care vis-a-vis availability of public health care facilities, educational and occupational status of the households in rural Haryana reveal interesting pattern. The availability of public HCFs at the place of residence certainly shows positive impact on women's health status when the comparison is made between the PHC and non-phc villages. However, in economically developed districts, the availability of public HCFs in itself does 494 Economic and Political Weekly February 24, 1996

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