M.A.3rd Sem, KU-Women's Studies, Paper-4, Unit-II (Govt.Intiative Health Facilities) Class Notes

 By Dr. Farzeen

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Unit II: Government Initiatives in Women’s Health

1. Constitutional and Legal Framework

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A. Constitutional Provisions and Women’s Health

1. Fundamental Rights

• Article 21: Right to Life and Personal Liberty

  • The Supreme Court of India has interpreted “right to life” as including the right to health, medical care, and a dignified life.

  • Landmark judgment: Paschim Banga Khet Mazdoor Samity vs. State of West Bengal (1996) – held that the government is obligated to provide adequate medical facilities.

  • For women, this right covers:

    • Safe maternal health services.

    • Access to reproductive health facilities.

    • Protection from unsafe sterilizations, abortions, and medical negligence.

• Article 14: Right to Equality & Article 15: Prohibition of Discrimination

  • Women cannot be discriminated against in accessing healthcare facilities.

  • Article 15(3) allows the state to make special provisions for women and children, including in healthcare.

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2. Directive Principles of State Policy (DPSPs)

Though not justiciable, these guide the state in framing laws and policies:

• Article 39 (a) & (e)

  • Ensure that women are not forced into work unsuitable to their health and strength.

  • Provide adequate means of livelihood, with equal access to nutrition and health.

• Article 42

  • Directs the state to make provisions for just and humane conditions of work and maternity relief.

  • Forms the constitutional basis for maternity benefits and workplace support for women.

• Article 47

  • Duty of the state to improve public health, nutrition, and standard of living.

  • Covers maternal and child health programs, immunization, nutrition schemes like ICDS and POSHAN Abhiyaan.

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3. Fundamental Duties (Article 51A)

• Citizens, including women, have a duty to protect and improve public health and safeguard the environment.

• Emphasizes community participation in women’s health awareness and preventive healthcare.

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B. Legal Framework and Women’s Health

1. The Maternity Benefit Act, 1961 (Amended in 2017)

• Key Provisions:

  • Paid maternity leave increased from 12 weeks to 26 weeks (for the first two children).

  • For the third child onwards → 12 weeks maternity leave.

  • Adoptive and commissioning mothers are entitled to 12 weeks leave.

  • Mandatory crèche facility in establishments with 50+ employees.

  • Prohibition on dismissal during maternity leave.

• Impact on Women’s Health:

  • Encourages institutional deliveries, postnatal care, and breastfeeding.

  • Reduces maternal mortality by ensuring adequate rest and healthcare.

• Challenges:

  • Benefits often limited to formal sector workers (less than 10% women in India’s workforce).

  • Informal sector women workers lack maternity protection.

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2. The Employees State Insurance Act, 1948

• Provides medical benefits, including maternity benefits (confinement, miscarriage, sickness).

• Focused on insured women workers in organized sectors.

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3. The Medical Termination of Pregnancy (MTP) Act, 1971 (Amended 2021)

• Legalizes abortion under specific conditions:

  • Danger to life or health of mother.

  • Risk of child suffering serious abnormalities.

  • Pregnancies caused by rape or contraceptive failure (especially for unmarried women after 2021 amendment).

• Amendment 2021:

  • Increases upper gestation limit from 20 weeks to 24 weeks for certain categories (rape survivors, minors).

  • Removes marital status as a condition for access.

• Impact: Strengthens women’s reproductive rights, ensures safe abortions, reduces maternal deaths due to unsafe procedures.

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4. The Pre-Conception and Pre-Natal Diagnostic Techniques (PCPNDT) Act, 1994

• Prohibits sex-selective abortions and misuse of technology.

• Safeguards women from forced abortions and protects the right to life of girl child.

• Aims to address declining sex ratio (important for women’s health and dignity).

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5. The National Food Security Act, 2013

• Provides nutritional support to pregnant women and lactating mothers:

  • Free meals during pregnancy and 6 months after childbirth.

  • Maternity benefit of at least ₹6,000 under Pradhan Mantri Matru Vandana Yojana (PMMVY).

• Direct impact on reducing maternal undernutrition, anemia, and infant mortality.

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6. Sexual Harassment of Women at Workplace (Prevention, Prohibition & Redressal) Act, 2013

• Indirectly impacts women’s health by ensuring a safe and stress-free work environment.

• Mental health protection is also recognized as part of women’s health rights.

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C. Judicial Interventions Strengthening Women’s Health Rights

• Laxmi Mandal v. Deen Dayal Harinagar Hospital (2010): Court recognized maternal health as a fundamental right under Article 21.

• Suchita Srivastava v. Chandigarh Administration (2009): Affirmed reproductive autonomy as part of personal liberty.

• Devika Biswas v. Union of India (2016): Supreme Court highlighted unsafe sterilization practices as violations of women’s health rights.

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D. Contemporary Challenges

• Despite constitutional safeguards, gaps remain:

  • Rural–urban disparity in healthcare access.

  • Underfunding of women’s health schemes.

  • Low coverage of maternity benefits in informal sector.

  • Socio-cultural barriers to reproductive rights (stigma, gender norms).

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✅ Summary for Students (MA 3rd Semester Level):

• Constitutional base → Right to health under Articles 21, 14, 15, DPSPs (39, 42, 47).

• Legal framework → Maternity Benefit Act, MTP Act, PCPNDT Act, ESI Act, NFSA 2013.

• Judicial interpretations → Expanded scope of Article 21 for women’s reproductive and maternal health.

• Policy implication → India recognizes health as both a right and a duty of the state, yet implementation gaps persist, especially for marginalized women.

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Unit II: Policies and Programmes for Women’s Health in India

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1. National Health Mission (NHM), 2013

Background

• Launched in 2013 by merging National Rural Health Mission (2005) and National Urban Health Mission (2013).

• Objective: To provide universal access to equitable, affordable, and quality healthcare services with emphasis on reproductive, maternal, newborn, child, and adolescent health (RMNCH+A).

Key Features

• Strengthening primary healthcare infrastructure through Sub-Centres, PHCs, CHCs.

• Accredited Social Health Activists (ASHAs) as community health workers.

• Emphasis on maternal and child health – safe deliveries, immunization, reduction of maternal mortality ratio (MMR) and infant mortality rate (IMR).

• Janani Suraksha Yojana (JSY) and Janani Shishu Suraksha Karyakram (JSSK) implemented under NHM.

• Special programmes for tribal and hilly regions.

Impact

• Institutional deliveries increased significantly (NFHS-5: 88.6% nationally, 87% in Uttarakhand).

• Reduced MMR (from 556 in 1990 to 97 in 2020).

• Increased immunization coverage.

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2. Janani Suraksha Yojana (JSY), 2005

Background

• Launched under NHM in 2005.

• Aimed to reduce maternal and neonatal mortality by encouraging institutional deliveries.

Key Provisions

• Cash incentives to pregnant women for institutional delivery.

• Special focus on low-performing states with high maternal mortality.

• Incentives also for ASHA workers who facilitate delivery.

Impact

• Institutional births rose from 39% (NFHS-3, 2005-06) to 88.6% (NFHS-5, 2019–21).

• Contributed to decline in maternal mortality ratio (MMR).

• Empowered ASHA workers as community health mobilizers.

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3. Janani Shishu Suraksha Karyakram (JSSK), 2011

Objective

• To eliminate out-of-pocket expenditure for pregnant women and infants.

Entitlements

• Free and cashless delivery in government health facilities.

• Free C-sections, drugs, diagnostics, and blood transfusions.

• Free transport: home to health facility, referral transport, drop back home.

• Free diet for 3 days (normal delivery) and 7 days (C-section).

• Similar benefits for sick newborns up to 1 year of age.

Impact

• Reduced financial burden on poor families.

• Increased utilization of public health facilities by pregnant women.

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4. Pradhan Mantri Matru Vandana Yojana (PMMVY), 2017

Background

• Implemented under the National Food Security Act (2013).

• Aimed at providing partial wage compensation to pregnant and lactating women.

Provisions

• ₹5,000 cash incentive in three installments for the first living child.

• Additional ₹1,000 under Janani Suraksha Yojana in many states.

• Promotes safe delivery, breastfeeding, immunization, and nutrition.

Limitations

• Restricted to first child only (criticism from activists).

• Coverage gaps in informal sector women.

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5. POSHAN Abhiyaan (National Nutrition Mission), 2018

Objective

• To reduce stunting, undernutrition, anemia, and low birth weight in children, adolescents, and women.

• Part of the “New India @ 2022” vision.

Targets

• Reduce stunting among children (0–6 years) to 25% by 2022 (not fully achieved).

• Reduce anemia in women (15–49 years) from 53% (NFHS-4) to 40% by 2022.

Key Strategies

• Use of technology (mobile apps, ICDS-CAS).

• Community-based events for nutrition awareness.

• Convergence of ministries (health, women & child development, rural development).

Current Scenario (NFHS-5, 2019–21)

• Stunting: 35.5% (India); 33.5% (Uttarakhand).

• Anemia among women (15–49 years): 57% (India); 45% (Uttarakhand).

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6. Reproductive and Child Health Programme (RCH-II), 2005–2010

Background

• Successor to RCH-I (1997–2004).

• Integrated into NHM in 2013.

Components

• Family Planning Services (contraceptives, sterilization, counseling).

• Maternal Health: Skilled birth attendance, emergency obstetric care, safe abortion services under MTP Act.

• Child Health: Immunization, management of childhood illnesses, neonatal care.

• Adolescent Health: Sexual and reproductive health education, menstrual hygiene.

Impact

• Fertility decline (India’s TFR: 2.0 in 2021, Uttarakhand: 1.9).

• Increase in contraceptive prevalence.

• Improvement in safe abortion access.

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7. Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (PM-JAY), 2018

Objective

• Provide financial protection for secondary and tertiary healthcare to economically vulnerable families.

Provisions

• Coverage up to ₹5 lakh per family per year.

• Target beneficiaries: ~50 crore Indians (poor and vulnerable households).

• Covers maternal and child healthcare services, cancer treatment, surgeries, etc.

• Strengthening Health and Wellness Centres (HWCs) for primary care, including women’s reproductive health services.

Impact

• Reduced catastrophic health expenditure.

• Increased access to hospitalization for poor women.

• However, challenges in coverage for maternal health (since most services fall under primary health, not hospitalization).

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Critical Analysis of Policies and Programmes

• Successes:

  • Decline in MMR (from 212 in 2007–09 to 97 in 2020).

  • Increased institutional deliveries and skilled birth attendance.

  • Expanding role of ASHA and ANM workers in rural healthcare.

  • Integration of nutrition with health via POSHAN Abhiyaan.

• Challenges:

  • Gaps in implementation at the grassroots.

  • Exclusion of women in the informal workforce from maternity benefits.

  • Persistent high anemia and malnutrition rates despite POSHAN.

  • Rural-urban disparities and shortage of specialists in government hospitals.

  • Overdependence on ASHAs with low honorarium.

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✅ Summary for MA 3rd Semester:

• NHM provides the overarching umbrella for women’s health programmes.

• JSY & JSSK: Promote institutional, cashless deliveries.

• PMMVY: Maternity benefits, wage compensation for first child.

• POSHAN Abhiyaan: Nutrition mission targeting anemia and malnutrition.

• RCH-II: Family planning, safe abortion, adolescent health.

• Ayushman Bharat – PMJAY: Financial protection for hospitalization.

• These programmes collectively aim to reduce maternal mortality, ensure safe motherhood, improve nutrition, and promote reproductive health, though issues of coverage, equity, and sustainability remain.

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Unit II: Challenges in Implementation of Women’s Health Policies and Programmes

Despite progressive constitutional guarantees, laws, and health programmes, India continues to face significant implementation challenges in ensuring women’s health and well-being. These challenges arise due to structural, social, economic, and cultural barriers.

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1. Urban–Rural Disparity in Access

• Healthcare facilities are concentrated in urban areas, while rural and remote regions face shortage of hospitals, doctors, and specialists.

• NFHS-5 (2019–21) data highlights disparities:

  • Institutional births: Urban – 94.7%, Rural – 86.7%.

  • Antenatal care (4+ visits): Urban – 70%, Rural – 58%.

  • Anemia among women (15–49 years): Urban – 50.3%, Rural – 59.5%.

• Uttarakhand example: Hilly districts (e.g., Chamoli, Pithoragarh) face delays in emergency obstetric care due to difficult terrain and lack of 24x7 facilities.

• Migration of healthcare workers towards cities further weakens rural health systems.

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2. Lack of Infrastructure in Remote Areas

• Inadequate Health Facilities: Many Sub-Centres (SCs), Primary Health Centres (PHCs), and Community Health Centres (CHCs) lack basic amenities such as operation theatres, blood banks, and emergency transport.

• Shortage of Specialists: According to Rural Health Statistics (2023), India faces 83% shortage of surgeons, 74% shortage of obstetricians & gynecologists at CHCs.

• Poor Transport & Connectivity: Pregnant women in remote areas often cannot reach health facilities in time → leading to home births and higher maternal mortality.

• Technology Gap: Limited availability of telemedicine and digital health services in hilly and tribal areas.

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3. Social Stigma in Discussing Reproductive Health

• Taboos around menstruation, contraception, and sexual health restrict women (especially adolescents) from seeking timely healthcare.

• Cultural silence on reproductive issues leads to unsafe abortions, unplanned pregnancies, and higher maternal risks.

• Adolescent girls often lack access to menstrual hygiene products and proper reproductive education → contributes to school dropouts and infections.

• NFHS-5 (India): Only 55% of married women (15–49 yrs) can make independent decisions on their own healthcare.

• In Uttarakhand, women in rural communities still rely on traditional healers and family elders instead of modern medical facilities.

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4. Gender Bias in Allocation of Family Resources

• Intra-household inequality: Male family members are often prioritized for healthcare, while women’s health needs are neglected.

• Financial dependence: Many women lack independent income, so they cannot afford out-of-pocket healthcare costs.

• Nutrition bias: Women often eat last and least in households → leads to high levels of anemia and undernutrition.

• NFHS-5: 57% women in India are anemic; in Uttarakhand, it is 45%.

• Preference for sons leads to neglect of girl children’s healthcare and nutrition.

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5. Additional Challenges

(a) Human Resource Constraints

• Heavy reliance on ASHA workers, who are often underpaid and overburdened.

• Lack of skilled birth attendants in rural areas.

(b) Policy–Practice Gaps

• Schemes like PMMVY (maternity benefit) and POSHAN Abhiyaan face coverage gaps due to slow fund disbursement and weak monitoring.

• JSY cash incentives sometimes delayed, discouraging beneficiaries.

(c) Fragmented Convergence of Services

• Women’s health programmes are spread across different ministries (Health, WCD, Labour) with weak coordination.

(d) Persistence of Unsafe Practices

• Despite MTP Act (2021), unsafe abortions still contribute to ~8% of maternal deaths in India (MoHFW).

• Sterilization camps continue in some states with poor safety standards.

(e) Socio-Economic Barriers

• Poverty, low literacy, and lack of awareness reduce women’s access to preventive and curative healthcare.

• Marginalized groups (SC/ST, minorities, migrant women) face multiple exclusions.

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Case Illustration: Uttarakhand

• Geographic barrier: Mountainous terrain makes health access difficult.

• Human resource shortage: Rural health facilities have >60% vacancy rates for gynecologists and specialists.

• Nutrition challenge: Stunting in children under 5 (NFHS-5) – 33.5% in Uttarakhand.

• Cultural stigma: Women in hilly rural areas often hide pregnancies until late, limiting antenatal care visits.

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Critical Analysis

• India has robust health policies for women (NHM, JSY, JSSK, POSHAN, PMMVY, Ayushman Bharat), yet implementation is uneven.

• Challenges are multi-dimensional: structural (infrastructure, funding), social (gender norms, stigma), and economic (poverty, inequity).

• Women’s health cannot be improved only by schemes unless accompanied by:

  • Gender-sensitive budgeting.

  • Empowering women with decision-making rights.

  • Community awareness campaigns.

  • Strengthening public health infrastructure in rural/tribal/hilly regions.

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✅ Summary for MA 3rd Semester Students:

• Urban–Rural Divide: Urban women have better access; rural women face barriers.

• Infrastructure Deficit: Shortage of facilities, specialists, and emergency care in remote areas.

• Social Stigma: Taboos restrict women from accessing reproductive health services.

• Gender Bias: Women’s health often neglected within families.

• Overall Challenge: Despite progressive programmes, implementation gaps and socio-cultural barriers hinder women’s right to health.

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