A few months ago, in an unannounced visit to a government community health centre in rural Tamil Nadu, I found four doctors, several nurses and technicians, and a functional pharmacy attending to more than fifty patients, a majority of whom were women. As someone who works primarily in rural Bihar and Madhya Pradesh, I usually encounter closed government health centres, absent doctors, uncooperative staff, or struggling patients. Why are these States so different in the indicators and delivery of health? This is the central question that Dipa Sinha’s book,Women, Health and Public Services in India tries to answer.
Are the States different because of their economic performances? Sinha makes an excellent presentation of evidence from national and international studies as well as primary data analysis to effectively argue that differences in economic conditions do not adequately explain the inter-State inequalities in health outcomes. While economic well-being has positive impact on health at the individual level, such as lesser chances of an infant dying in a richer household, the same does not hold true when comparing two districts or States. For instance, even though Haryana was at the top among eighteen States for its economic performance on per capita National State Domestic Product in 2009-10, it ranked eleventh for its performance on infant mortality rates. On the other hand, Tamil Nadu, whose per capita National State Domestic Product in 2009-10 was less than sixty percent than that of Haryana, was the second-best performing State in terms of infant mortality rates.
What, then, explains the variations in human development and health across States? The key, as Sinha puts it, is women’s status. Acknowledging that ‘status’ is difficult to conceptualize and measure, the book proceeds to analyse how certain aspects of women’s status such as education, work, autonomy and kinship systems, and women’s exposure to media influence health outcomes. The data analysis shows that education has the most significant positive relationship with a State’s performance in health. The States with higher female literacy (such as Kerala, Tamil Nadu, Himachal Pradesh, and Maharashtra) show a clear pattern of lower rates of infant mortality, under-five mortality, and stunting. In fact, female literacy emerges as a stronger factor in determining health outcomes than indicators of economic well-being. Further, women’s higher exposure to media and lower gender gap in access to media are also shown to have a positive correlation with health outcomes.