Science Feature

India’s women may be missing tertiary healthcare

Large study suggests that women reach big public health centres much lesser than men.

Alakananda Dasgupta

doi:10.1038/nindia.2020.23 Published online 7 February 2020

Older and younger women, and those living far away from tertiary healthcare centres are more disadvantaged.

© S. Priyadarshini

Women get marginalised when it comes to accessing the highest level of public healthcare in India, according to a study conducted at a large, tertiary hospital, the All India Institute of Medical Sciences (AIIMS) in New Delhi.

Although India has seen steady improvement in tertiary healthcare in the past few years, women are still the last to receive treatment. This apparent skew in healthcare access led Ambuj Roy, a cardiology professor at the AIIMS, to look at the number of women visiting the hospital, which receives more than two million outdoor patients annually. He teamed up with Mudit Kapoor, an associate professor in the Economics and Planning Unit of Indian Statistical Institute in New Delhi, to bring together a multidisciplinary group of economists, doctors and epidemiologists. 

The team analysed records of 2,377,028 outpatients (excluding obstetrics and gynaecology patients) as well as data from the AIIMS hospital information system for the year 2016. The hospital caters to four states — Delhi, Haryana, Uttar Pradesh and Bihar. The researchers computed the 'missing' female patients for each state taking the sex ratio for these states from the 2011 population census as the yardstick.

The difference between the actual number of women who came to AIIMS and the number that should have come vis-a-vis men was not proportionate with the sex ratio of these states — this, they considered as the 'missing' number. They found that the overall sex ratio of the patient visits was 1.69 men to every woman (63% men patients and 37% women), whereas the overall sex ratio of the population of the four states was 1.09. In total, they found 402,722 women missing tertiary healthcare access from this population alone.

Younger and older female patients, they report, were poorly represented as compared with middle-aged women. The figures also pointed to a relation between the women's relative distance from the hospital and their access to healthcare — those living farther away from the facility were less likely to visit the hospital. This ratio of males to females was 1.41 for Delhi, 1.70 for Haryana, 1.98 for Uttar Pradesh and 2.37 for the farthest state Bihar.

The study differs from similar studies conducted earlier in its large dataset and the diversity of patient groups. Roy told Nature India that they hope to create awareness of the gender skew so that more women-specific health programmes beyond just maternal health can be created. “We emphasise that improving local health infrastructure would help women much more,” he says. 

However, fixing infrastructure may not be the solution to gender disparity in healthcare, says Jacob Creswell, head of innovation and grants at the Stop TB Partnership in Geneva, Switzerland. Deeper cultural and societal biases are at play here, he feels. “The next step for India is to address the barriers for women accessing care,” Creswell says.

The authors concede that the study has some limitations. It was conducted only in a single tertiary hospital and there’s need to replicate it in all public hospitals, Kapoor says. “That’s possible as data is increasingly getting digitised,” he says.

Siwan Anderson, a professor at the Vancouver School of Economics in Canada points to another possible limitation. The difference in the number of visits by gender for a certain age group does not necessarily imply discrimination, she says. "For one, there are differences by gender and age in the incidence of different diseases. And two, men and women may make different decisions with regards to going to a hospital," she says. The opportunity cost of being ill is higher for higher income earners, typically the men in the families, Anderson points out.

The concept of ‘missing women’ was earlier proposed by Nobel Prize winning economist Amartya Sen when he reported that in certain developing countries, like India and China, the ratio of women to men getting healthcare is alarmingly low2, 3. Sen attributed this imbalance to inequality and neglect that leads to higher female mortality.

Literacy and economic development, directed only at girls or women, is not enough to address the paradox of missing girls, according to a similar study4. India needs evidence-based multimodal approaches to combat the preference for a boy child and gender-based neglect. Besides community education, introduction of gender-related dialogues between boys and girls in school curricula using new age mobile technology would also help, they say.

A 1996 World Bank report5 on women’s health issues in India noted that lack of knowledge, motivation, ability to pay, social status, and availability and quality of services may be coming in the way of women’s accessing healthcare. The report also delineated the importance of political will in making this happen.


1. Kapoor, M. et al. Missing female patients: an observational analysis of sex ratio among outpatients in a referral tertiary care public hospital in India. BMJ Open 9, e026850 (2019) doi: 10.1136/bmjopen-2018-026850
2. Sen, A. K. Missing women: social inequality outweighs women’s survival advantage in Asia and north Africa. Brit. Med. J. 304, 586–587 (1992)
3. Anderson, S. et al. The age distribution of missing women in India. Econ. Polit. Weekly XLVII, 87–95 (2012)
4. Balan, S. et al. Are we losing the war on missing girls? Lancet Glob. Health 2, e22 (2014) doi: 10.1016/S2214-109X(13)70183-9
5. India-Issues in women's health (English). World Development Sources. Washington, DC: World Bank (1996) Rep. 15328-IN