Mending the fracture: India’s healthcare gender gap

Bengaluru: It had been months of regular outpatient appointments at a hospital in Mumbai for Sana (name changed), but the mystery of her ailment remained at large. The issue began with a tingling sensation behind her ear which soon developed into a throbbing pain. Since the 28-year-old was already diagnosed with an autoimmune condition, she decided to seek medical intervention immediately. 

“You are overthinking. Take a break, go shopping, eat good food and get a boyfriend. Your issues will go away,” the doctor said on one such visit. Considering his 30 years of experience, Sana joined a yoga class and even practised mindfulness. 

It was when she began to lose mobility and was affected by paralysis on the right side of her body, that she realised that her symptom was serious and that medical attention was paramount. A year later, the underlying issue was finally diagnosed — Sana had diabetes and had gone into hyperglycemia, resulting in permanent nerve damage and paralysis. 

Despite having access to hospitals and being proactive in seeking out treatment, Sana's concerns were dismissed as unfounded fears. “This kind of ‘medical gaslighting’ also impacted my mental and economic well-being,” she says. It took another year to treat the resulting nerve damage. 

In many cases, symptoms dismissed by doctors have turned out to be serious medical conditions. For instance, Preethi (name changed), a 20-year-old resident of Indore, Madhya Pradesh, went to see a doctor when she started experiencing shooting pains in her chest. “The doctor kept insisting that it was nothing more than stress and prescribed painkillers even though I went back to her three times,” says Preethi.

The pain continued, compelling her to approach a cardiologist. “After an ECG, the cardiologist told me that there is a small tear near my heart's wall along with general cardiac fatigue,” she says. 

These stories are among many that evidence the long-standing history of medical bias based on gender, which commonly manifests in the dismissal of women’s symptoms and pain. The diagnosis of health issues in women takes much longer than in men. Heart disease is diagnosed seven to 10 years later in women than in men, according to a US-based study. 

According to a 2019 Danish study, on average, women are found to have diabetes 4.5 years later than men.

While narratives and studies about the gender gap in diagnosis, treatment and research have come to the fore globally, there is little research or even acknowledgement of these gaps in the Indian context.  

According to a 2022 study based in Delhi, for every two boys diagnosed with cancer, only one girl receives a diagnosis. For women across age groups, fewer hospital visits can mean reduced instances of identification of medical conditions. A 2018 study found that 49% of expected female outpatient visits were missing from Delhi, Haryana, UP and Bihar.   

The gendered nature of clinical trials and research compounds the problem. According to the US Centers for Disease Control and Prevention (CDC), around 70% of chronic pain sufferers are women. However, 80% of pain studies are conducted on either male mice or men. 

Dr Sylvia Karpagam, a public health expert based out of Bengaluru, adds that most drug trials are conducted on men and extrapolated to women. “There is very little data on how women respond to drugs and variations related to nutritional status, hormonal status, pregnancy or postpartum status etc. Women are just viewed as miniature versions of men who require smaller doses,”  she says. 

Globally, a 2022 study found that only 1% of funding is invested in researching female-specific conditions. This is particularly concerning in the Indian context, where 50 million women suffer from reproductive health problems. 

The resulting gap has high economic and social costs too. A study by McKinsey Health Institute and the World Economic Forum (WEF) revealed that closing the women’s health gap could boost the global economy by $1 trillion annually by 2040. The health gap currently leads to the loss of 75 million years of life due to poor health or early death per year. This is the equivalent of seven days per woman per year. 

The shocking proportions stem from the high number of women suffering from chronic illnesses and pain. Chances are, within your own group of friends and family, several women would attest to facing symptoms connected with Polycystic ovary syndrome, endometriosis, thyroid or hormonal conditions, with little support from medical professionals.  

“The most common thing I have been told is that I need to lose weight for all my problems — period cramps, adult acne, intense fatigue and nutritional deficiencies — to be solved. I have heard several female friends share the same experience,” says 26-year-old Kriti T S. “The other usual script involves ‘avoiding stress’ and waiting until you have children, when symptoms are supposed to subside. Imagine saying this as a solution to a teenage girl with debilitating monthly cramps,” she adds.

The general attitude of dismissal and low awareness and research on these health conditions feed into each other. Such is also the case with autoimmune conditions, which are found to be twice as prevalent in women compared to men. “I still do not know what my diagnosis is,” says Meera (name changed), a 30-year-old resident of Delhi. She explains how investigating the presence of the CCL17 antibody was challenging in her case, across Delhi, Mumbai and Vellore, because doctors would often tell her that, “it is all in your head. You need to relax.” 

With autoimmune conditions, Meera recognises that both patients and doctors are dealing with a black box — with little research on symptoms, causes and treatments. “In this kind of a grey area, medical professionals still provide black-and-white answers,” she says. 

Especially in the case of diseases that are found to occur more in women than in men, “doctors need to take the time to understand and examine their responses because there is an increased incidence [of auto-immune conditions] in women,” says Meera. 

While medical professionals are much more likely to view men’s symptoms as physical and clinical, they are more likely to write off the same symptoms as psychosomatic in women. 

“There was a lot of disbelief in community health circles, when women came in, complaining of pain. The general assumption is that women want a break from caregiving and fall ill due to psychosomatic issues,” says Dr Tanya Seshadri, a community health practitioner and researcher, who works with the Soliga community in Karnataka and Tamil Nadu. 

When screening for metabolic conditions became routine, many were diagnosed with diabetes mellitus. “This instance demonstrated why community health practitioners had to pay more attention to listening, believing and evaluating routine complaints that women come to hospitals with rather than dismissing their issues,” she adds.

Social norms

Beyond biases within the medical community, social norms also dictate when and how women reach out for health support. “Since women bear the maximum burden of unpaid care work, they rarely have time for their own health. In my experience, women with serious illnesses come in at a later stage for diagnosis and treatment. For instance, cancer is generally detected only at the third stage among women,” says Dr Shaibya Saldanha, a gynaecologist based in Bengaluru. 

The gender gap persists across social groups and ages – with fewer outpatient visits being recorded among young women and elderly women when compared to men in the same age groups.

Even among children and infants, experts say, rates of hospital visits are significantly lower among girl children. “In a study on the reasons for admission into an ICU, a hospital found that the most common reason for admission was ‘only male child’ and that the frequency of health-seeking behaviour by the parents was higher for boy babies than girl babies,” Dr Shaibya says.

Travel and organisation contribute to hesitancy in approaching hospitals, adds Madevi K, a leader of the Soliga community, based in the Biligiri Rangana Hills, Karnataka. “Women have to think about making food, catching a bus and coming back before dark. Many have to ask their husbands for ‘permission’,” she says. According to the National Family Health Survey 5, only 10% of women could make independent decisions about their health compared to 33% of men. 

Madevi, who was diagnosed with a reproductive health issue, was forced to operate under similar circumstances as well. Such constraints provide women with a small window and a large time deficit, which become obstacles in seeking healthcare.

Women are also reluctant to take the time to pursue doctors or travel to hospitals as they think their tasks as caregiving duties cannot be transferred, Madevi adds. In most cases, families prioritise the health of the primary ‘breadwinner’.

The fear of adding to already stretched household budgets also keeps women from seeking treatment when they notice a symptom or pain, relates an Anganwadi worker based in Anekal district in Karnataka. 

Further, a third of women expressed apprehensions about seeking care due to the non-availability of female health providers in the primary health centres they visited. The Bharat Health Index 2023 found that only 25% of semi-rural and rural populations in India have access to modern healthcare within their localities.

 “While community outreach centres and taluk-level hospitals are primarily accessed by women, district, speciality and private hospitals are mostly frequented by men because of geographical barriers and economic and social norms,” Dr Tanya says. 

She cites the example of prenatal check-ups to illustrate how this can contribute to reduced exposure to the healthcare system for women. “While the WHO recommends four visits during pregnancy, most women are only able to go to one or two,” she adds. 

Insurance

Progress has certainly been made – India has climbed up five spots from ranking the lowest on the WEF’s health and survival subindex in their annual Global Gender Gap report. More women have access to community health services, prenatal care, medication and doctors. A Policybazaar study reported a 40% rise in health insurance coverage among women in FY24. 

The Ayushman Bharat Pradhan Mantri Jan Arogya Yojana, India’s public health insurance scheme, was introduced in 2018, aiming to provide coverage to over 12 crore families. As of 2023, ​​​​women accounted for nearly 49% of beneficiaries under the scheme.

While insurance has opened the door for many women to access health services, it is far from a well-rounded solution to gender inequity, says Dr Radhika Jain, assistant professor in health economics, University College of London. Along with researcher Pascaline Dupas, Dr Radhika is working on a study on how insurance reaches women and men in Rajasthan. “...A massive public subsidy is not reaching women as effectively as it is men, and large gender disparities persist even when care is highly subsidised,” they write.

Universal insurance schemes tend to exclude those with complications. As women receive diagnosis and treatment much later, they are more likely to experience these complications. “For instance, the third or fourth stages of cancer, kidney, lung or liver disease may not fall within the health insurance packages. Additionally, chronic medical conditions may get left out, as the scheme tends to cater mostly to surgical procedures,” says Dr Sylvia. Chronic conditions require outpatient care rather than admissions, which insurance schemes do not cover, she adds.  

Most government insurance schemes also require documentation, which already puts women at a disadvantage, as many, especially women from vulnerable groups, rarely have access to this. “When women are required to produce documentation, they are more likely to not avail this service, many do not have IDs at all. Most are forced to depend on their family, who may hold their IDs and documents,” adds Madevi.

Solutions with nuance

Relying on insurance to address women’s health issues might not be a comprehensive solution. “Insurance programmes typically come with many caveats and only a certain percentage of people will be able to access such policies. India should look at other healthcare models for solutions. For example, the United Kingdom, Costa Rica and Australia are among several countries with universal healthcare,” Dr Shaibya says. 

When large-scale insurance policies are implemented by governments, they eat into the total budget allocated to health. “The amount that could be spent on providing free OPD and hospital admissions will go into paying insurance premiums, which in any case, exclude many of the illnesses that women face,” she adds. 

A gender-targeted framework is key, say public health experts. The WEF report identifies five avenues of intervention. “There is an opportunity to close the women’s health gap by (1) investing in women-centric research and development, (2) strengthening the collection and analysis of sex- and gender-disaggregated data, (3) enhancing access to gender-specific care, (4) encouraging investments in women’s health innovation, and (5) examining business policies to support women,”  the report says.

In addition, as research on women’s health expands and picks up pace, gender sensitivity training is essential to ensure women’s concerns are taken seriously in the medical community.

The issue, along with a lack of research into how diseases present in women, Dr Tanya says, is also a lack of trust in women’s accounts of their health problems. 

Addressing the trust deficit and biases requires a better and more diverse representation of women. India still lags on this front, with a recent study showing despite the majority of healthcare workers in the country being female, as of 2021, only 17% of hospital board members were women. Further, only one in four people on health committees are women. To decisively shape inclusive policymaking, equal representation is an essential first step.

Finally, across studies and regions, proximity to hospitals and doctors plays a major role in women accessing timely and effective health services. This is particularly a concern for women from rural regions. 

Gender-specific interventions are critical, as they not only shape the prospects of about half of our population but also largely affect the day-to-day quality of women’s lives. In order to fully address the gender gap, it is also essential to recognise and address gender biases ingrained within the medical system and provide women’s accounts with the trust and dignity they deserve.