Reforming Women’s Healthcare in India
By Arunima Rajan
Technology and changes in consent could be the answer.
The doctor made the diagnosis without so much as blinking: “You have adenomyosis and PCOS.”
The patient (let’s call her Sana) thought she heard wrong. She asked the doctor to repeat herself, and the diagnosis remained the same. As horrible as it was, the next moment was almost worse– when instead of explaining the details of Sana’s conditions and how the treatment would work, the doctor just handed her a prescription.
It was December. Sana had been planning a family trip, before her worst fears came true right there in that doctor’s office. Now what?
Sana isn’t alone. There are many more women in India looking for a judgement-free gynaecologist who will actually take the time to explain what’s going on with their bodies. The recent mushrooming of women’s health startups and women’s health clinics prove that the demand for better women’s healthcare services in the country is there– but is it being met?
Do women-run healthcare organisations understand women better?
Priyanka Idicula is the director and senior midwife of the women’s birth centre Birthvillage, based in Cochin, Kerala. She says it’s undeniable that women from middle-income or low-income backgrounds have inadequate access to information, resources, or even decision-making capabilities concerning their reproductive health.
“To change this scenario, one must have health information that is simple [and] available in the vernacular language; [plus] simplified access for services (virtual as well as in-person) without the need for an additional consent form.” Consent from male family members is often necessary for a woman to receive healthcare services. Says Idicula, “We need to place the woman right at the centre of decision-making in maternal healthcare.”
According to Idicula, Birthvillage was created from the necessity for space where any woman could give birth with full autonomy. “It's crucial for us that women's voices were heard, and her right to access resources to achieve health, happiness, and personal growth according to her needs, perceptions and goals was always upheld.”
She says that the countries with the lowest mortality and morbidity rates for mothers and infants are those in which midwifery is a valued and integral pillar of the maternity care system. “The midwifery model is a low-tech, high-caring model that produces excellent outcomes for low-risk clients and for vulnerable and at-risk people.”
The midwifery model of care, whether practised in clinics, private homes, hospitals or birth centres, is characterised by the midwife listening, offering advice, and helping clients make decisions. Every appointment at Birthvillage lasts anywhere from 45 - 90 minutes.
When the founder pioneered a birth centre led by midwives in the country, it meant engaging not just with new parents, but with extended family members. Some traditional views surrounding childbirth do not easily mesh with the beliefs and experiences of the midwives at the clinic.
“We have had to build collaborative relationships with varied practitioners amidst a climate of scepticism; though this model has immense popularity and acceptance worldwide, anything new is often fraught with its share of challenges in God's own country. We are also a woman-run organisation from top to bottom, which meant another higher glass ceiling altogether. It has taken us over a decade to reach where we are today,” explains Idicula.
Do health startups focus too much on PCOS?
Achitha Jacob, CEO and founder of Proactive for Her, a digital health platform for women, seconds the views of Priyanka Idicula. She says, “the gendered nature of access to healthcare in India is undeniable and that is something that we at Proactive For Her are striving to change.
“During our research, we spoke to hundreds of modern, liberal-thinking women who are dissatisfied with their previous healthcare experiences. I have also previously worked with Fortune 500 healthcare companies and startups where I noticed that even with gender-neutral issues such as kidney diseases and dialysis, women tend to de-prioritize their health to save for their families instead. This type of behaviour exists across the board and is something I observed even while I was studying at Harvard Business School.
“The stigma attached to women’s menstrual, sexual and reproductive health issues, coupled with inaccessibility to non-judgemental support, have long prevented many women from addressing their healthcare needs. Further, there also seems to exist a hyper-focus on PCOS in the market currently, and we at Proactive For Her recognized the pressing need for a full-stack and holistic approach when it comes to women’s healthcare.
“Proactive For Her bridges this gap through our solution-specific digital health clinics, health coaching by handpicked experts, curated diagnostic panels, and long-term support programs across various areas of concern,” says Jacob.
Jacob points out that the first step towards making women's health more equitable is improved awareness about available solutions–especially for the varied healthcare issues women tend to deal with silence. “Through educational initiatives, we are working towards informing women about health services ranging from a holistic PCOS program and sex-positive STI testing services to mental health consults and trauma-informed vaginismus therapy.
“Through our digital health clinics, we offer ‘solution-specific’ support wherein women can consult an array of specialists about their area(s) of concern such as sexual health, hair & skin, PCOS, menstrual health, etc. Furthermore, creating an unbiased, collaborative and evidence-based environment where women feel comfortable to address their concerns and find recourse is equally important.
“The start up’s clinical team of gynaecologists, endocrinologists, dermatologists, psychotherapists, psychologists, and nutritionists have over 150 years of cumulative healthcare experience, and they are committed to offering holistic care and cross-functional support to their patients. The team is specially trained to offer non-judgmental, body-positive, queer-affirmative and trauma-informed support to all customers.”
Femtech still nascent in India?
“Femtech is still nascent in India on account of multiple reasons. Some of them are due to our cultural reasons where, for women, openly talking about their problems is considered taboo. When there is very low focus on calling out and subsequently acknowledging the problem, there is obviously going to be less people working on addressing those problems and therefore also a lower number and lower maturity of the technologies that do exist. The second reason, which is more commercial in nature, has also been the lower ability of this constitution to pay for solutions that address their problems. This, again, has the chilling effect on newer innovations in the femtech space.
“We also had the same kind of economic headwinds that we initially faced with CervAstra. Coupled with a novel innovation that required concept selling, the journey was difficult, to say the least. We then had to tweak the business model to make it appropriate and attractive to the segments,” says Adarsh Natarajan, CEO and founder of AINDRA Systems.
Mental Health and Women
Vasanth Kattalai Kailasam, Founder & Chief Medical Officer of CareMe Health, agrees that there are multiple cultural and social barriers to discussing women’s health, especially in rural India.
“We started CareMe Health with the prime goal to create a safe, non-judgemental space. Trust and ethics are the foundation for any healthcare organisation. As a physician-led organisation, we hold it at high standards.
“Operating a digital healthcare organisation is entirely different from a traditional tech company. Lack of clear understanding of these concepts could potentially create a high-risk industry, which could harm the public and eventually kill technology as the healthcare delivery tool,” he says.
Rural women opt for online therapy in local languages
Kailasam believes his startup focuses on providing a good patient experience for women. “The majority of our therapists are women and we offer services in 8 native languages. We provide the choice to our patients to pick and choose who they want to consult with and arrange sessions accordingly.
“In addition to the traditional talk therapy, we also offer chat therapy, self-therapy and therapy groups. We also use social media for outreach/educational activities, and engage the public in conversations. Our primary goal is to build trust with our patients at every touch point in their therapy journey at CareMe.
“We have built an empathetic care team, of which the majority are trained in psychology. They work with the mission to help our patients overcome their inhibition and reach out for help. I would confidently say that our therapist has helped more women than men at CareMe since the beginning of our platform. This digital platform has empowered them to make decisions for themselves. It is not only specific to the urban population; we are pleasantly surprised by the number of women who reach out to us from remote Indian villages. Covid has changed the perception about online therapy,” he adds.
Evelyn Immanuel is the CEO and founder of MyAva.in, and she agrees with Kailasam's views. “Solutions for urban women are very different from solutions that will work for rural women. A technology-first product (apps, etc.) will require more education/training on the use of technology for rural women.
“Solutions for healthcare need to be built after careful research on the geography, economy and sociography of the target audience. What technology companies can do is make their products modular enough to reach a wider audience, catering to vernacular languages, for example.
“Case in point, promoting usage of pads instead of cloth required awareness and education camps by NGOs and ASHA workers. Building for rural India requires a different model of operations to ensure adaptability,” she adds.
Small towns and women's health
While one might think that hospitals in small towns don't focus on technology and women’s specific health and wellness needs, hospitals like Mitera in Kottayam prove otherwise.
Dr. M Jaipal Johnson is the CEO and Chief Gynaecologist at Mitera Hospital. He says, “Mitera was conceived with the primary focus to cater to women and children, and we strive to prioritise individual and personal attention and a friendly atmosphere. All of our processes have been made patient friendly right from when a patient walks in for admission to when they leave the hospital.
“Every one of our 100 patient rooms, including the birthing rooms, have large 5x8-foot windows that let in natural light. Even our operation theatres have natural light coming in. The hospital is painted in pastel shades, and all the patient rooms/care areas are painted white. All of our patient rooms also have at least a small part of a wall done in a bright and cheerful wallpaper (though it gets torn down surprisingly often by the guests or their children.)
“Even though it is a nightmare in terms of maintenance and upkeep, it makes a world of difference when it comes to uplifting moods, and consequently quickening a patient’s recovery time,” adds Johnson.
He also says that having an OBYGN available in the hospital 24/7 is something management believes is crucial. "Moreover, over 95% of the staff at Mitera (save for a few admin personnel and MEP staff) are women, which puts our patients at ease during any interactions they may have with the staff during their stay here.
“We also insist on the husband/partner being present during the birth. We conduct all our births in individual, private birthing suites. We are also proud to say we have a comparatively shorter average duration of stay for our patients. Our normal delivery patients are usually discharged on day two, and C-section patients on day three. We also try to avoid C-sections unless it becomes medically unavoidable, and over 70% of our births are normal deliveries. We also encourage VBAC for mothers who have had their C-sections,” he adds.
Nikhil Jaipal, COO of Mitera Hospital, points out that there are different kinds of challenges to offer patient-centric healthcare in small towns. He notes that in small towns, the purchasing power of patients is less, so the services that the hospitals can offer also depend on that. “In big cities like Cochin, specialty hospitals charge two times more. We offer the same services at a much affordable rate.
“The hospital does a hundred deliveries in a month, but not even 10% of the patients opt for additional services like yoga," he adds.
Distance and health care: A balancing act
The higher the distance of the female patient’s home from the hospital, the lesser the probability of women turning to healthcare, points out Garima Sawhney, co-founder of Pristyn Care.
“Pristyn Care has differentiated itself by keeping patient-centricity at the core and ensuring that a 24/7 Personal Care Coordinator is allotted to all of its patients. The Personal Care Coordinator provides end-to-end support to patients during their surgery journey. Right from booking doctor appointments to diagnostic tests, remote insurance claim processing, digital admission and discharge formalities, complementary cab pick-up and drop-off, meals, financing (EMI) and free post-surgery follow-up consultation. This ensures patients and their family members focus on recovery rather than running around,” she concludes.
Solution=Universal health coverage?
David Boucher, Group Chief of Service Excellence with Aster DM Healthcare, points out that to simplify women’s health, universal health coverage for key health interventions would be helpful.
“Improving inequities to access might include steps to enhance coverage (physical, social, geographic, linguistic, financial) and the removal of barriers to access, including legal and policy barriers, criminalization, third party authorization, and overly broad conscientious objection.
“The improvement of the quality of care, including supplies, would simplify healthcare for women. Notably, updating evidence-based norms, standards, and policies, as well as ensuring that there are adequate supplies for key women’s health problems. Further, the development and distribution of the health workforce for women’s health problems, including midwives, is key… and then the provision of incentives to enhance quality, retention, etc.
“I think that our investments in strengthening the overall governance of the health system to ensure better accountability for results and for realisation of rights. And finally, the adoption of innovations that enhance quality, coverage, efficiency, and/or completeness of health interventions to women. Of course, this includes the use of digital technologies,” he concludes.