Why is women's utilization of a publicly funded health insurance low?: a qualitative study in Tamil Nadu, India.

BACKGROUND: The continuing impetus for universal health coverage has given rise to publicly funded health insurance schemes in lower-middle income countries. However, there is insufficient understanding of how universal health coverage schemes impact gender equality and equity. This paper attempts to understand why utilization of a publicly funded health insurance scheme has been found to be lower among women compared to men in a southern Indian state. It aims to identify the gender barriers across various social institutions that thwart the policy objectives of providing financial protection and improved access to inpatient care for women. METHODS: A qualitative study on the Chief Minister's Comprehensive Health Insurance Scheme was carried out in urban and rural impoverished localities in Tamil Nadu, a southern state in India. Thirty-three women and 16 men who had a recent history of hospitalization and 14 stakeholders were purposefully interviewed. Transcribed interviews were content analyzed based on Naila Kabeer's Social Relations Framework using gender as an analytical category. RESULTS: While unpacking the navigation pathways of women to utilize publicly funded health insurance to access inpatient care, gender barriers are found operating at the household, community, and programmatic levels. Unpaid care work, financial dependence, mobility constraints, and gender norms emerged as the major gender-specific barriers arising from the household. Exclusions from insurance enrollment activities at the community level were mediated by a variety of social inequities. Market ideologies in insurance and health, combined with poor governance by State, resulted in out-of-pocket health expenditures, acute information asymmetry, selective availability of care, and poor acceptability. These gender barriers were found to be mediated by all four institutions-household, community, market, and State-resulting in lower utilization of the scheme by women. CONCLUSIONS: Health policies which aim to provide financial protection and improve access to healthcare services need to address gender as a crucial social determinant. A gender-blind health insurance can not only leave many pre-existing gender barriers unaddressed but also accentuate others. This paper stresses that universal health coverage policy and programs need to have an explicit focus on gender and other social determinants to promote access and equity.

Age of consent: challenges and contradictions of sexual violence laws in India.

India enacted a new child sexual abuse law in 2012 and made important changes to the rape law in 2013 to expand the definition of rape and sexual assault, introduce several reforms and improve gender sensitivity in rape trials. However, the child sexual abuse law with its definition of who is a child has increased the age of consent for sex from 16 years to 18 years, echoed by similar changes in the rape law. This paper revisits the debates on the age of consent in India in the late nineteenth century. It reviews them in the light of the new legislative changes, adjudication of cases of sexual assault, and examines the implications of the new laws on adolescents and their sexuality. We contend that the changes in the law have resulted in several challenges: for adolescents exploring their sexuality on the one hand, and for courts to adjudicate on love, romance, and elopement, on the other. Further, in conjunction with raising the age of consent, other changes such as mandatory reporting of sexual activity among adolescents, especially by hospitals, have increased family control on adolescents' sexuality and strengthened regressive social norms linked to marriages. One of the most troubling developments is the resulting barriers to adolescents' access to reproductive and sexual health care. This paper explores how laws devised to address harm and extend protection to children play into dominant social norms and are in the service of protectionist and patriarchal control on young people and their sexuality.

Five years post Nirbhaya: Critical insights into the status of response to sexual assault.

It is five years since the fatal gang rape of Jyothi Singh (Nirbhaya), a physiotherapy student, on December 16, 2012, in New Delhi, the capital of India. The legal and policy reforms triggered by the Nirbhaya case will remain a watershed moment in the history of efforts towards seeking justice for survivors of gender-based violence in India. The Criminal Law (Amendment) Act, 2013 and the "Guidelines and protocols: Medico-legal care for survivors/victims of sexual violence" issued by the Ministry of Health and Family Welfare in March 2014 are two landmark reforms. March 2018 marks four years since the issuance of these Guidelines and five years since the Criminal Law (Amendment) Act, 2013. Any reasonable tribute to Nirbhaya would constitute fair implementation of legal reforms, efforts to strengthen multi-sectoral response and sincere attempts to reduce crimes against women, gender and sexual minorities, and children. This paper reviews the issue, through a close study of recent cases of rape, police responses, court judgements, studies, news reporting and field-based observations. It brings forth the gaps in implementation that persist, and constitute a major obstacle in making these progressive policies and reforms effective. Given the fact that the reforms are intersectoral in nature, implementation has been particularly challenging. Lack of efficient implementation of such policies and reforms amounts to denying survivors their right to justice.

Gendered pattern of burn injuries in India: a neglected health issue.

There are an estimated 7 million burn injuries in India annually, of which 700,000 require hospital admission and 140,000 are fatal. According to the National Burns Programme, 91,000 of these deaths are women; a figure higher than that for maternal mortality. Women of child bearing age are on average three times more likely than men to die of burn injuries. This paper reviews the existing literature on burn injuries in India and raises pertinent issues about prevalence, causes and gaps in recognising the gendered factors leading to a high number of women dying due to burns. The work of various women's groups and health researchers with burns victims raises several questions about the categorisation of burn deaths as accident, suicide and homicide and the failure of the health system to recognise underlying violence. Despite compelling evidence, the health system has not recognised this as a priority. Considering the substantial cost of burns care, prevention is the key which requires health systems to recognise the linkages between burn injuries and domestic violence. Health systems need to integrate awareness programmes about domestic violence and train health professionals to identify signs and symptoms of violence. This would contribute to early identification of abuse so that survivors are able to access support services at an early stage.

Unintentional injuries among children in resource poor settings: where do the fingers point?

Every year, over 875,000 children between 0 and 18 years of age die as a result of unintentional injuries (UIs), with a higher proportion occurring in low- and middle-income countries (LMICs): the WHO 2008 World Report on Child Injury Prevention shows a child UI death rate 3.4 times greater in LMICs than in high income countries (HICs) (41.7 per million vs 12.2 per million, respectively). Deaths due to injuries from drowning, burns and falls are significantly higher among LMICs at 7.8, 4.3 and 2.1 per million, respectively, as compared to HICs with 1.2, 0.4 and 0.4 per million, respectively. The authors present a review of childhood UIs in LMICs undertaken to determine demographic and socioeconomic risk factors. As in industrialised settings, age, gender and social deprivation are significant factors in determining UI-related vulnerability among children. However, certain patterns are unique to LMICs, including road traffic injuries among child pedestrians, drowning and accidental paraffin poisoning. These demand contextual understanding and the implementation of appropriate injury control measures, which are currently inadequate.