One year into Pradhan Mantri Jan Arogya Yojana (PMJAY), heart surgery data from the tertiary care arm of Ayushman Bharat show a gender skew, with women comprising just 29 per cent of total hospital admissions in the country for cardiothoracic and vascular surgery (CTVS) procedures. The National Health Authority (NHA) is looking at incentives such as paying for transportation cost of women patients to close the gap.
Of the 15,168 hospital admissions under PMJAY across India, 10,744 were men and 4,421 women. States such as Tripura (13.33%) and Karnataka (23.45%) are lower than the national average, while the best figure is from matrilineal Meghalaya, where 65% of the total 35 heart surgeries under PMJAY were done on women.
Launched by Prime Minister Narendra Modi on September 23 last year, PMJAY is the largest government-funded health insurance scheme in the world, under which the target is to provide 10.74 crore families with annual health insurance of Rs 5 lakh. With a fifth of the intended beneficiaries reached so far, more than 50 lakh secondary and tertiary level treatments worth Rs 7,901 crore have already been funded under PMJAY. More than 60 per cent of the amount spent has been on tertiary care, with cardiology, orthopaedics, radiation oncology, CTVS and urology having emerged as the top tertiary specialities.
While there is a difference in the pattern of heart disease in men and women — it develops 7-10 years later in women than in men, though in women above 65 years it remains a major cause of death — cardiologists say this alone does not explain the dramatic gap in hospitalisation figures. Traditional wisdom is that because women are less likely to be breadwinners, especially in families of limited means (who are primarily the targeted PMJAY beneficiaries), families are more reluctant to pay for their treatment. However, PMJAY is cashless for beneficiaries.
NHA CEO Dr Indu Bhushan told The Indian Express, “We are thinking of introducing incentives for better gender balance for provision of services. The gender gap is not just about money spent on treatment, there are other expenses such as transportation or livelihood loss for the person accompanying the patient to the hospital. All of these may deter people from bringing women to the hospital. Maybe we can pay for transportation of women patients, and look at incentives for the state or state health agencies to correct the gender balance.” He added that the programme would undertake extensive public awareness campaigns to address the skew.
Awareness required among patients, physicians
Addressing the gender skew requires awareness not just among people but also physicians, experts say. Beyond societal issues, classic medical textbook symptoms may not always relate to women. For example, women with heart attack/angina more often present breathlessness and fatigue rather than typical chest pain. This come from systemic bias in medical studies where women are often highly underrepresented, according to experts.
There is a gender gap in the incidence of cardiovascular diseases. A 2018 paper by researchers from Public Health Foundation of India, Harvard T H Chan School of Public Health and others in PLOS Medicine, estimated: “Overall, the mean 10-year risk of a CVD event in the (not age-standardized) population aged 30-74 years was 12.7% among females and 21.4% among males.” However, published literature warns that the risk of cardiovascular diseases in women is often underestimated, leading to higher mortality and treatment gaps.
According to a 2017 paper in BMJ Global Health, “Cardiovascular disease (CVD) is still the leading cause of death worldwide. In 2013, 32% of deaths in men and 35% of deaths in women were due to CVD. Despite the higher percentage of CVD deaths in women, CVD is still widely considered as a man’s disease. This assumption stems from the historical misperception that the manifestation of CVD among women is uncommon or is not characterised by the same symptoms as it is in men. Men generally develop CVD at a younger age and have a higher propensity of developing coronary heart disease (CHD) than women. Women, in contrast, are at a higher risk of stroke, which often occurs at older age.”
Health-seeking behaviour of female patients — or the lack of it — has been a concern in many low-income countries. An analysis by experts at AIIMS, ISI Harvard T H Chan School of Public Health and PM’s Economic Advisory Council had concluded that in 2016, of OPD patients from Delhi, Haryana, UP and Bihar who visited AIIMS Delhi, there were 4,02,722 “missing” female patients.
Dr Ambuj Roy, professor of cardiology at AIIMS and one of the authors of that study, said, “There is a gender gap in heart disease incidence but these PMJAY figures do not seem to reflect just that…. The bias clearly goes beyond monetary reasons. As a society we need to reflect on why women are not getting the care they deserve. Maybe we should a line to Beti Bachao Beti Padhao — Beti Ka Ilaj Karao.”