The third Sustainable Development Goal (SDG) about “Good Health and Well-being” targets universal health coverage, access to sexual and reproductive health, including family planning, reduction in maternal, neonatal, and child mortality, and reduction in Non-Communicable diseases through Health promotion, disease prevention, treatment and focus on mental health and wellbeing. At our centre we are aligned with this goal and the underlying targets.  

Our centre, through evidence-based activities and appropriate use of technology will aim to improve the health of the rural women in a group of villages in North Solapur Taluka. It is a relatively accessible population that may benefit from our interventions. 

In this section, we have detailed the situation analysis of rural women in India with focus on access and common health problems encountered by them.

Access to healthcare for rural women in India

The definition of access is the ability to receive services of a certain quality at a specific cost and convenience. The rural healthcare system of India is still struggling in three factors related to access to healthcare: provision, utilisation, and attainment. Provision of healthcare facilities is essential since only then it can lead to utilisation, and finally attainment of good health.

Public healthcare is free for every Indian resident. The Indian public health sector encompasses 18% of total outpatient care and 44% of total inpatient care and was originally developed to provide a means to healthcare access regardless of socioeconomic status or caste. However, due to several reasons the citizen relies on the private rather than public sector.  More than 57% of households point the main reason at the national level to be poor quality of care in the public sector. Much of the public healthcare sector caters to the rural areas, and the poor quality arises from the reluctance of experienced healthcare providers to visit the rural areas. Consequently, most of the public healthcare system catering to the rural and remote areas relies on underpaid, contractual and unmotivated staff. Other major reasons are long distances between public hospitals and residential areas, long wait times, and inconvenient hours of operation.

The private sector health care is unregulated pushing the cost of health care up and making it unaffordable for the rural poor. Out-of-pocket private payments make up 75% of the total expenditure on healthcare.

In terms of non-medical costs, distance can also prevent access to healthcare. Costs of transportation prevent people from going to health centers. According to scholars, outreach programs are necessary to reach marginalized and isolated groups. Without outreach, services cannot be spread to distant locations. Without financial ability, those in distant locations cannot afford to access healthcare. Both issues are tied together and are pitfalls of the current healthcare system.

Gender- a social determinant of Health

Gender is one of the main social determinants of health which include social, economic, and political factors—that play a major role in the health outcomes of women in India and access to healthcare in India. Therefore, the high level of gender inequality in India negatively impacts the health of women.

Gender discrimination begins before birth; females are the most aborted sex in India. If a female fetus is not aborted, the mother’s pregnancy can be a stressful experience, due to her family’s preference for a sonOnce born, daughters are prone to being fed less than sons, especially when there are multiple girls already in the household. As women mature into adulthood, many of the barriers preventing them from achieving equitable levels of health stem from the low status of women and girls in Indian society, particularly in the rural and poverty-affected areas. Women are also seen as less valuable to a family due to marriage obligations.

Numerous studies have found that the rates of admission to hospitals vary dramatically with gender, with men visiting hospitals more frequently than women. Differential access to healthcare occurs because women typically are entitled to a lower share of household resources and thus utilize healthcare resources to a lesser degree than men. Furthermore, it has been found that Indian women frequently underreport illnesses. The underreporting of illness may be contributed to these cultural norms and gender expectations within the household. Gender also dramatically influences the use of antenatal care and utilization of immunization.

Health challenges of rural women in India

1. Malnutrition and morbidity

Mental and physical health status is often dramatically impacted by the presence of malnutrition. India currently has one of the highest rates of malnourished women among developing countries. A study in 2000 found that nearly 70 percent of non-pregnant women and 75 percent of pregnant women were anemic in terms of iron-deficiency. One of the main drivers of malnutrition is gender specific selection of the distribution of food resources.

A 2012 study by Tarozzi found the nutritional intake and the rate of malnutrition increases for women as they enter adulthood. Furthermore, Jose et al. found that malnutrition increased for ever-married women compared to non-married women. Maternal malnutrition has been associated with an increased risk of maternal mortality and childbirth defects. Addressing the problem of malnutrition would lead to beneficial outcomes for women and children.

2. Maternal health

As a nation, India contributed nearly 20 percent of all maternal deaths worldwide between 1992 and 2006. Factors contributing to high maternal mortality rates are often associated with non-utilization of antenatal care (ANC) prior to and during childbirth. Barriers to seeking care include delays in the decision to seek care, arrival at a medical institution, and provision of quality care. Poor maternal health often affects a child’s health in adverse ways.

Our project intents to assist the existing ante natal care health system.


As of July 2005, women represent approximately 40 percent of the HIV/AIDS cases in India. The number of infections is rising in many locations in India; the rise can be attributed to cultural norms, lack of education, and lack of access to contraceptives such as condoms. Cultural aspects also increase the prevalence of HIV infection. The insistence of a woman for a man to use a condom could imply promiscuity on her part, and thus may hamper the usage of protective barriers during sex. Furthermore, one of the primary methods of contraception among women has historically been sterilization, which does not protect against the transmission of HIV. The current mortality rate of HIV/AIDS is higher for women than it is for men. Integrating HIV screening in the broader Rural Health mission (like during ante natal care) is a promising opportunity.

Our project would like to cooperate with the existing National AIDS Control Program and other NGO associations to increase awareness and testing for HIV as a routine screening during antenatal care or for high-risk groups.

5. Reproductive rights, Family planning and right to choose abortion

About 10 % of women in rural India have an unmet need for Family planning. India legalized abortion through legislation in the early 1970s. However, access remains limited to cities. Less than 20 percent of health care centers can provide the necessary services for an abortion. The current lack of access is attributed to a shortage of physicians and lack of equipment to perform the procedure.

Well informed and guided protocols for safe and clinically monitored early medical abortions would strengthen the health care of the common women closer to their homes instead of seeking late gestational age surgical and more complicated procedures in the urban/ hospital setup.

6. Infertility

Infertility is “a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse. Sexually transmitted infections (STIs) are the leading preventable cause of infertility by causing 70% of pelvic inflammatory diseases responsible for tubal damage. According to World Health Organization estimate the overall prevalence of primary infertility in India is between 3.9 to 16.8%. The inability to have children affects couples and causes emotional and psychological distress in both men and women. Despite the various social, psychological, economic, and physical implications, infertility prevention and care often remain neglected public health issues, or at least they rank low on the priority list, especially for low-income countries that are already under population pressure.

Investigating and providing simple ovulation monitoring ultrasound and inseminations procedures can help many couples to achieve pregnancy instead of sophisticated IVF procedures in an urban setup. Our project aims to provide outpatient procedures like tubal patency testing, ovulation monitoring and minimally invasive treatment possibilities in the rural setup.

7. Screening for precancerous conditions like cervical dysplasia and HPV (Human papilloma virus)

Cervical cancer is the fourth most common cancer found in women worldwide. The incidence rate per 100.000 women population in Maharashtra is 16.7 % (2019, ref Singh et al BMC cancer) and mortality 9.26% in Maharashtra.  In Maharashtra barely 2% of rural women go to screening for cervical cancer.

Systematic and routine nationalized cervical cancer screening program and inclusion of HPV vaccination in the National immunization program in countries like Denmark, Australia, UK have had a big impact in reducing the Global and National burden of the disease. Accessibility to treat with minimally invasive methods like conization as an OPD procedure would prevent major surgery like hysterectomy. 

Our project would include this as a core activity.

8. Excessive menstrual bleeding and fibroids and uterine cancer

 Premalignant conditions like uterine hyperplasia can be detected and treated with minimally invasive procedures like hysteroscopy or medically with hormonal intrauterine devices instead of major operations like hysterectomy. Availability of these diagnostic and treatment modalities at the rural location is most relevant since delay to reach the urban hospital due to socioeconomical restrictions can lead to advancement of the disease and hence need for major operations.

Our project includes routine ultrasound examination and provision of on-site office hysteroscopy with possibility of treatment of minor abnormalities in the uterus.

9. Urine incontinence (UI):

UI is defined as “the complaint of any involuntary leakage of urine.” Stress UI is “complaint of involuntary loss of urine with effort or physical exertion, or on sneezing or coughing.” Urgency UI is “complaint of involuntary loss of urine associated with urgency.” Mixed UI is “complaint of involuntary loss of urine with urgency and also with effort or physical exertion or on sneezing or coughing.”

Studies show a prevalence of 10%–42% with stress UI being the most common type. Age-adjusted prevalence progressively increased from the 3rd to 7thdecade (5.6%, 14.2%, 27.3%, 34.3%, and 39.0%, respectively). This finding has important implications for health planning since the population of Indians older than 60 years is set to double from 117 million in 2015 to 246 million by 2040. Two noteworthy risk factors were delivery at home and pregnancy at young age. Social embarrassment (about 25%) was possibly more important than financial constraint (3%–14%) in determining help-seeking behavior. Several women silently suffer and socially isolate themselves due to lack of accessibility to find help.

Majority of these women can be helped with non-operative methods on an OPD basis.

10. Ovarian cancer

 In India, during the period 2004-2005, proportion of ovarian cancer varied from 1.7% to 8.7% of all female cancers in various population-based registries of Indian Council of Medical Research. The Age Specific Incidence Rate (ASIR) for ovarian cancer revealed that the disease increases from 35 years of age and reaches a peak between the ages 55-64.

But due to detection in late stages of disease the recurrence is common and eventually death follows. With increasing life expectancy, there is increase in incidence of ovarian cancer. Efforts should be made to detect the disease at early stage. Routine ultrasound could be one of the ways of detecting earlier stage cancer.

11. Breast cancer:

A study on breast cancer conducted by Indus Health Plus Preventive Health Services found that 40 percentage of women in Maharashtra have a higher risk of breast cancer. Awareness and emphasizing mammography as an important test to detect the possibility of breast cancer at an early stage for those above 40 years of age and adopting the habit of regular and timely checkups can be of great value.

12. Mental health:

Mental health is more than the absence of mental illness and is defined by the World Health Organisation (WHO) as a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to contribute to his or her community. About one-quarter of patients using primary health care (PHC) services in India have a mental illness. Despite this substantial burden of disease and the possibility of effective and affordable treatments, mental health care remains a neglected issue, especially in developing countries 

Depressed women in India often present with somatic rather than emotional symptoms. Consequently, when they attend busy primary care settings with somatic complaints, the diagnosis of depression is often overlooked and families incur unnecessary costs for healthcare consultations, investigations and treatments, and psychosocial interventions are not initiated. Depressed women in India attribute their condition to a range of factors including poverty, traditional expectations of women’s role, lack of affection and conflict with their husbands, widowhood and divorce, and difficulties providing dowries for their daughters. Post-natal depression in India affects 11–23% of women, and is linked to poverty, antenatal psychiatric morbidity, poor marital and family relationships, lack of support, marital violence, and birth of a girl child.

Women subjected to violence have a higher risk of mental illness including depression, anxiety, and psychosomatic symptoms. Violence against women in India is a common social problem. A household survey of 500 women in rural Maharashtra reported 23% had been beaten in the last six months. The husbands of 12% of these women had explicitly threatened to pour kerosene on them and set them alight. The National Mental Health Program, launched in 1982 and reviewed in 1995, sought to integrate mental health care with PHC. It has had mixed success in achieving this goal and 90% of the rural population remain without access to mental health services. Most care for people with mental illness is provided by the family. Many people remain untreated, and those families who do seek treatment will often turn to non-allopathic providers including practitioners of traditional medicine, religious healers, faith healers and astrologers.

Mental health and empowerment are closely aligned concepts, and that their realization potentially has shared and mutually reinforcing pathways. 

Even though effective mental health promotion is a useful strategy for minimizing the impact of mental illness, it remains essential that affordable, accessible, appropriate treatments are available and that reliable systems of referral are established for people with serious mental illness that cannot be managed at the PHC level. Increasing community awareness in relation to detection of and response to mental illness by providing relevant training at the PHC level (e.g., to the VHWs at CRHP) is a feasible and potentially beneficial intervention.

The National Rural Health Mission (NRHM) in India:

NRHM seeks to provide equitable, affordable, and quality health care to the rural population, especially the vulnerable groups like women and children. However, non-availability of diagnostic tools and increasing reluctance of qualified and experienced healthcare professionals to practice in rural, under-equipped and financially less lucrative rural areas is a big challenge. Rural areas in India have a shortage of medical professionals. 74% of doctors are in urban areas that serve the other 28% of the population. This is a major issue for rural access to healthcare. The lack of human resources causes citizens to resort to fraudulent or ignorant providers. Doctors tend not to work in rural areas due to insufficient housing, healthcare, education for children, drinking water, electricity, roads, and transportation. Additionally, there exists a shortage of infrastructure for health services in rural areas. 

Women’s Health in Maharashtra

Maharashtra is the third largest state in India. The state has addressed women health issues with policies like – two child family norm, prevention of child marriage, prevention of misuse of pre- natal sex determination Act, implementation of birth, death and marriage registration Act, empowerment of Gram panchayats, recognition to Health Institutions doing quality work. From the 5th National Family Health Survey Literacy (2019-2020) the literacy rate of rural women in Maharashtra is 76.9 % and about 43.1% women have a mobile phone that they themselves use. 93% rural women undergo institutional deliveries and 96% have a mother and Child protection card (MPC).