Gender inequality permeates every aspect of life; it is visible in the countless surveys conducted across the world. These numbers — sex ratios, gender development indices and more — silently tell us a far more haunting story of “inequality and neglect leading to the excess mortality of women”, as economist Amartya Sen puts it. It leads to the inevitable problem of ‘missing women’ — the falling number of females reflected in sex ratios, women missing in schools and jobs, and the abysmally low number of women patients in healthcare. Studies on gender inequality have only now begun to gain momentum, but an examination of gender inequality in access to healthcare remains relatively unexplored, both globally and in India.
A new public health study, conducted by a diverse group of researchers, including doctors and economists, seeks to better explain the skewed gender ratio in healthcare. The team studied women’s access to healthcare to understand how it is related to a patient’s age and the patient’s distance from a healthcare facility.
“There is a shortage of literature on missing women in healthcare. This experiment was carried out because we wanted to see if gender discrimination extends into health access for women,” says Dr Ambuj Roy on the motivation behind this study. He is an author of the study and a cardiologist at the All India Institute of Medical Sciences (AIIMS), New Delhi.
The researchers wanted to collect reliable data for an in-depth examination of the different facets of gender discrimination.
The researchers analysed an enormous dataset of more than 2 lakh outpatients from the All India Institute of Medical Sciences (AIIMS), New Delhi, for the year 2016. They systematically placed the patients into five age group — below 18 years, 19–30 years, 31–44 years, 45 -59 years, and 60 and above. For each patient within these groups, they collected the age, gender, state of residence and the hospital department they visited. They then selected the data of patients visiting from Bihar, Uttar Pradesh, Haryana and Delhi. The researchers performed statistical analysis on this data to find how the age, gender, state of residence and the visiting hospital departments influenced female patient visits.
The researchers compared the total number of male patient visits to the hospital in each age and state category to the sex ratio in 2011 to estimate what ought to be the female patient visitation. They then subtracted the total female patient visits recorded in that same state and age group from this quantity to arrive at the number of missing female patient visits. Since census data is available only every ten years, researchers had to make use of the most recent data, which was the census of 2011.
The study found that male outpatients visited 1.69 times more than female outpatients. This ratio is notably different from the census-calculated population sex ratio of 1.09. The relationship between outpatient sex ratio and age showed that middle-aged women were more likely to receive some healthcare than those from other age groups.
“This is perhaps because women in their reproductive ages would be less discriminated against,” explains Dr Roy. “Furthermore, elderly women and young children may need another family member to travel along to a healthcare centre, making it less likely that they would even visit,” he adds.
Comparisons between states also yielded several differences. Bihar had the highest number of missing female patients, followed by Uttar Pradesh, Haryana and New Delhi, with vast differences in the ratio between them. For example, the sex ratio in Bihar, according to the 2011 census, was 1.09, but the male to female patient ratio was at a high 2.37. The researchers argue that this vast difference in patient visits stems from several social factors, including the number of healthcare facilities per unit area. Besides, there could be bias in the data, say the researchers, since it is collected from one hospital in New Delhi. For example, Bihar, which has the highest number of missing female patients, could be so because it is the farthest from Delhi compared to the other states studied.
The researchers also examined the number of missing female patients within departments of a healthcare facility. They found that, among the women patients who did visit the hospital, most tended to visit general departments like the department of medicine or orthopaedics. However, there was an extremely skewed male to female visitation rates in specialised departments such as cardiology. Male visits were almost twice as that of females.
“The frequency of department visitation could be a representation of disease susceptibility and epidemiology in general,'' explains Dr Roy. “But, it is likely that more expensive, specialised treatments and departments are not offered to women patients. Some of our earlier studies show that girl children are less likely to be offered cardiac surgery for congenital heart diseases compared to boys," he remarks.
The findings of the study show how gender discrimination manifests in less obvious ways in our everyday lives. The study analysed the scientific as well as social aspects of the issue, which is vital to any research.
"More of these kinds of linkages should be encouraged, especially in India, because they strengthen the quality and breadth of research that can be conducted," concludes Dr Roy.