Socio-Political and Economic Determinants of Women’s Health in Kerala

Abstract: Despite evoking wider approbation in the field of women’s health and ranking highest in gender development index among the Indian states, beyond the relatively better conventional indicators, Kerala face a deteriorating status in women’s health in the 21st century. The historical legacy of gender discriminatory ideology and translation of values of subjugation in contemporary neoliberal Kerala is more deepened, along with the class and caste inequities as women’s lives are ensnared in subservience, low work participation, economic marginalisation, relatively low enrolment in technical education and professional/technical employment seeking, constraints in politics, curtailed freedoms and mounting atrocities. Since health is a social construct deeply rooted in the socio-political milieu, these failings are often intertwined with the persisting women’s health issues including mental distress and rising violence, and accumulated disadvantages and health vulnerabilities of the aged women. Getting deeply entrenched in patriarchal domination, the state, political parties in the state and public policies often display a greater disregard for women’s issues. Kerala needs resolute political intervention and public policies in creating social and gender justice across all dimensions of women’s lives for achieving better women’s health.

Keywords: women’s health, gender discrimination education, morbidity, distress, non-communicable diseases (NCDs), economic marginalisation, gender/castes segmentation, patriarchal domination, social determinants, Kerala health, politics and health, Private and Out-of-Pocket (OOP), public policies.

Introduction

Kerala has been projected as the archetype of gender equality and women’s development in India and in South Asia, a region well renowned for its low status of women. The impressive progress in women’s socio- demographic indicators in the state has a long history- stretching over a hundred years. And the state apparently stands out in the country with relatively better education, higher female life expectancy, reduced fertility, favourable female sex ratio, and a declining maternal mortality. Kerala beckoned wider approbation in the global public health discourses following the publication of the UN sponsored document, Poverty, Unemployment and Developmental Policy: A Case Study of Selected Issues with Reference to Kerala, in the mid 1970s which emphasised the states’ momentous achievements in health and demographic transition, despite its poor economy (CDS 1975). This was also a period international development agencies and policy circles trying to justify ignoring the need for transfer of funds from the developed world to the developing nations for substantial transformations in the economic and production basis (Mencher 1982).

However, given the low economic performance of the state and wider gender constraints prevalent in the Indian subcontinent, the improvements in Kerala women’s health indicators were remarkable and the state has been projected as a “less expensive” “model” for low income nations where centuries old colonialism and decades of western- sponsored development initiatives created new inequalities and higher levels of miseries (Franke and Chasin 1991; Derez and Sen 1996). More recent studies emphasize that, the policies of the state (and Sri Lanka’s too) on social equity and gender, i.e., on health and education, are the hope for the desperate state of maternal and child health in the rest of South Asia ensnared in the despair arising out of maladies such as preventable child death, unjustifiable disregard for girl children and women, and deepening miseries of millions entrapped in poverty (Bhutta et al. 2004). Nevertheless, issues in Kerala health in general, and women’s health in particular has been highlighted by a variety of studies since the 1980s (Mencher 1980; Kannan et al. 1991; Saradamony 1994; Thresia 2001;Thresia and Mohindra 2011). And looking into the history of women, politics, and well-being in the state, Jeffery (2001) argues that, there is no Kerala model neither in the sense of consistent policies which resulted in explicit outcomes nor a desirable goal that other parts of the country or the world might wish to realise. Thus, Kerala evoked and continues to evoke wider attention in the national and international health and development debates as well as in women’s health discourses.

Indeed, the state rank highest in gender development index in the country (HDR 2005) and Kerala’s unique experience in women’s health and social development has important lessons to offer the world. Nonetheless, an uncritical acceptance of the projected image of the high social standing of women in the state based on selected indicators- maternal mortality, fertility, and education, albeit its importance, is problematic. Such a fragmented approach carries limitations in unraveling the historical continuities and ruptures in women’s health, and the complex intersections of socio-political processes, economic parameters and cultural ideologies shaping it. Globally, biomedical perspectives and quantitative analysis dominate the discourses on women’s health (Doyal 1995). Such reductionisms pervasive in the scientific analytical discourses often masks the role of women’s own experiences of unequal gender power relations in the household and social spaces which shapes their health. As Qadeer (2006) argues, patriarchal domination prevails in each level of socio-economic hierarchy, induce gender inequality around work, sexuality, entitlement, inheritance, access to opportunities and freedom of choice which relegate women to inferior roles and shift power equations favourable for of men; and these unequal power relations legitimise a range of gender differentials across class and caste combinations.

Notably, contemporary evidence reveal Kerala face an increasing patriarchal domination and deteriorating status in the women’s health in the 21st century on several fronts. Important disjunctures and differentials in women’s health gains across class/caste and ethnic groups in the state have been observed where the low social classes and tribal groups were the worst victims (Thresia 2001, 2006; Mohindra et al. 2006). While the claims of birth control itself has been critiqued from a feminist perspective that it did not secure the interests of women, compared to the interests of the state and family, either in asserting control over their own bodies or increasing their life choices (Devika 2005).

Furthermore, despite the state’s rich heritage of social reform movements, radical political traditions and matrilineal inheritance, the historical legacy of gender discriminatory ideology and translation of values of subjugation in contemporary Kerala is more apparent in several tangible and intangible arenas of women’s economic, political, and cultural life ensnared in subservience (Jeffrey 2001; Osella and Osella 2000; Lindberg 2005). Such inferior status may be linked to the rising violence against women in the state and women’s higher levels of morbidities including mental distress. While politics in the state echoes a kind of, depoliticisation of the citizenry characteristic of neoliberal era marked by an array of market oriented principles promoting private profits by controlling the social interests (Bourdieu 2010), ignoring the deprived populations in general (Rammohan 2008; Devika 2010) and women in particular (Thresia 2014), despite the land’s vibrant political culture.

Given this context, locating health in a broader socio-political and gender relations perspective, this article attempts to provide a critical analysis of women’s health and its determinants in the state based on the review of secondary data sources. The paper starts with a brief overview of the history of improvements in women’s health in Kerala, and then illustrates the glaring distortions, particularly in the context of Kerala’s changing socio-political milieu and shifting epidemiological patterns. In the final section, we investigate the gendered nature of vulnerabilities in the social, economic and political arenas and its linkages to women’s health.

Women’s Health Improvements: A Historical Overview

Unlike other parts of India or South Asia except Sri Lanka, Kerala’s development trajectories indicate striking social sector gains especially in women’s health and education. Indeed, historically, the educational attainments were higher even in colonial Kerala where the princely regions of Thiruvithamcore and Kochi were much ahead in education compared to many other enlightened states such as Baroda and Bombay (Aiya 1906). By the 1990s, the state became fully literate, and in 2011 female literacy accounted 92% compared to 65% for whole India. The relatively better health gains began during the early decades of the 20th century (Ramachandran 1996), despite the nascent stage of western medicine. The female advantages in the state’s unique achievements including in fertility, sex ratio and longevity were ahead of the Indian averages even in the early 1900s. In 1911-20, women’s life expectancy was 27.4 years compared to 25.5 years for the males while the respective figures for India as a whole were 23.3 and 22.6. Over a century, by 2001, especially with a sharp rise during the 1960s and the 1980s, these figures turned out to be even more impressive accounting 76 years for females and 71 years for males, while India still lags behind the state with 63 years for females and 61 years for males (RGI 2005). Apart from the increased longevity 5 years higher than Kerala men and nearly 10 years higher than other Indian women, in 2007-09, Kerala women were 14 times less likely to die from pregnancy related causes compared to the women in Uttar Pradesh (RGI 2011).

Kerala is the only state with a favourable female sex ratio since the late 19th century (1006 in the southern and 1014 in the northern Kerala in 1881) which continued over the last and present century reporting 1084 in 2011 compared to 943 for all India, although the state’s female advantage in sex ratio is questioned in a recent study (Rajan and Sreerupa 2007). Interestingly, Kerala’s birth rate (39.8) which was almost similar to all India figure (39.9) during the period of 1941-50, started declining by the middle of the 1950s had gained momentum since the late 1960s much faster than the country, achieving 14.9 by 2012, significantly less than the rate for India’s 21.6 for the same period. Despite a paucity of reliable data on fertility, the state shows a low fertility rate (5.6) than Indian average (6.3) even during 1951-61 and it continued through the more sharp declines of the 1970s than the previous decade, and the1980s (Bhat and Rajan 1990), reached below replacement level by the 1990s which further dropped to 1.7 by 2009 (RGI 2011). In spite of the fragmentary statistics on levels and trends, the states’ performance in maternal mortality has been impressive with significant reductions, although the 1990s showed stagnation in the progress in its fall. Since the 1950s, maternal mortality in India is steadily declining; and during 2007-09 Kerala reported the lowest maternal mortality (81per 100,000 live births) in the country which is less than half of the national average (212) (RGI 2011).

Thus, some of the indicators of women’s health in the state, historically, are far ahead of the Indian figures indicating better survival for women. However, beyond the better averages and the conventional statistics, inequalities and discrimination in Kerala health across gender as well as different sections in the social hierarchy, necessitate a critical exploration of the women’s health, which we focus in the next section.

Distortions in Women’s Health

Historically, improvements in women’s health indicators in Kerala are outstanding. Perhaps, this is only partially true primarily due to the differentials and inequalities in the health gains across, class, caste and ethnic groups, as the health outcomes are poor among the deprived, lower castes and tribal women whose lives are mired in poverty and misery (Thresia 2006; Mohindra et al. 2006). Further, the improvements largely in the realm of conventional reproductive health indicators are often conflated as women’s health, leaving several other critical arenas of women’s health and its social determinants unidentified. While recognising the achievements, a noncognisense of a range of issues in health and its determinants including morbidity burdens, rising anaemias, greater mental distress, rising violence against women and girl children, health issues of the aged women and gender constraints in employment opportunities and in medical care access in contemporary Kerala (IIPS 2008; Kerala Police 2013; Navaneetham, et al. 2009; Thresia and Mohindra 2011) will be misleading and often delegitimising the world of women’s experience of health and illness.

Kerala has been termed as an area with ‘high morbidity and low mortality’ since the mid 1980s (Panikar and Soman 1984; Kannan et al. 1991). Often, morbidity loads are higher for the women in the state (261) compared to the men (240), as for the country, which is nearly three times higher than the national average for women (97) and men (85) (NSSO 2006). Apart from the burden of emerging and newly emerging diseases (Government of Kerala 2011), community based studies indicate that, in conformity with the fast pace of epidemiological transition, noncommunicable diseases (NCDs) including diabetes and hypertension are on the rise in the state, and women clearly bear a higher burden compared to men (Soman et al. 2009 a; Thankappan et al. 2006), along with the poor and Scheduled castes (Navaneetham et al. 2009). However, recent studies indicate that, the health system failures add to the challenges faced by the state (Thresia 2013; Jagadeesan 2013).

Interestingly, world over evidence suggest a social gradient in the distribution of NCDs as the poor bear a heavy burden, and economic deprivation, sub optimal use of health services, and psychological stress can help explain it (Greenhalg 1997; Middlekoop 1999; Marmot et al. 2008). In Kerala, a lack of economic and social opportunities, and resultant stress coupled with inadequate health care may associate with a rise in NCDs, particularly for women who tend to suffer from greater levels of mental stress, low economic autonomy as well as limited decision making power compared to men of similar economic and social status (Thresia and Mohindra 2011).

Besides morbidity, there are issues in the relatively better survival indicators such as maternal mortality and female sex ratio. The progress of decline in maternal mortality is not as impressive as the rate stagnated during the 1990s (9.2 in 1997-98 and 9.3 in 1999-2001), although it further declined to 4. 1 in 2007-09 which is only a quarter of the all India figure (16.3) (RGI 2011). Despite a scarcity of reliable data on maternal mortality, a recent hospital based statistics indicate that obstetric haemorrage and hypertensive disorders are the main reasons for maternal mortality and the state lack active and systematic approach in managing such issues (Paily 2012).Indeed, these are preventable causes which impair the progress in mortality reductions. Further, the increasing anaemia among the women in the reproductive age group (from 22.7 to 32.3 between 1993-94 and 1998-99), particularly among the pregnant women (from

20.3 to 33.1) (IIPS 2000, 2008) may be a warning sign as it predisposes obstetric haemorrage and other complications. The female sex ratio has been questioned based on the statistics of Kerala Migration Study which argued that, had there been no migration from Kerala, the number of males would have outnumber females, as elsewhere in India (Zachariah et al. 2003). While the reductions in the juvenile female sex ratio during the past few decades (since 1961 from 972 to 959 in 2011, despite a little increase during 1971 and 2001 compared to the previous decades) were highlighted as a likely indication of either excess female child mortality, postnatal discrimination, prenatal discrimination, sex selective abortion or some combination of some of these factors (Rajan and Sreerupa 2007).

Further, the increasing medicalisation of the female body reflecting in rising rate of caesarean sections in the state with a current estimate of 30, three times higher than the national average (IIPS 2008) and double than the WHO suggested rate, is another issue faced by the state. Unfortunately, unethical practices flourishing in the medical care arena including caesareans for non medical reasons such as profits and medical professionals’ personal interests (Ghosh and James 2010; Hindu 2011) raises serious threats to health of women in the state. Moreover, although the exemplary performance of the state in adopting contraception- largely sterilisation- which was instrumental in achieving fertility control was hailed by national and international agencies and academia, there was only limited enquiry in to how the women benefitted, rather, suffered from the low quality services as well as from the sterilisation itself at a younger age or how democratically it was executed.

The state also has the irony of indisputable evidence on mounting violence against women (and children) and greater mental distress and suicide attempts higher than men, despite better gender development index. Between 2007 and 2012, the crimes such as rape has increased more than double from 500 to 1019 while cruelty by husband and relatives rose from 3976 to 5216 incidents (Kerala Police 2013). Not surprisingly, the government and judiciary are abnormally slow in providing justice to the rape survivors and notably, often political nexus is reported in illegal trafficking of women and girl children (Hindu 2013). Perhaps, this may be an attempt to create a kind of perpetual fear among the women of the state which act as powerful deterrent discouraging women/girls breaking newer grounds, in search of freedom and a dignified private and public space, crossing the cultural boundaries of gender norms. The increasing domestic violence may also be linked to the soaring rates of mental stress and depression among women, reported in the hospital (Eapen 2002) and community based studies (Mukhopadyay et al. 2007) which was worse than the national and international figures, although there was a paucity of epidemiological studies on mental health of women in Kerala. Notably, literacy by itself did not result in a reduction of stress levels among the women as it did for the men and unemployed women were more stressed than unemployed men (Mukhopadyay et al. 2007). And Kerala ranks one among the highest in suicide rates worldwide, ranking 4th highest (24.3) in 2012 in the country just below Tamil Nadu (24.9),which was only a little less compared to the rate in 2010 (24.6), but more than double than that of the Indian average (11.2) (NCRB 2012). Further, community based data reveal suicides contribute to the highest share of deaths among young women aged 15 to 24 years which decreases then followed with an increase after 54 years with a peak in 75 years or above (Soman et al. 2009 b). According to the NCRB data, nearly half (44.1%) of the suicides were caused by family problems in which women outnumber men both in the country and in the state. Notably, in micro level studies on suicide attempts in the state which was higher for the women than men, familial problems including marital discords and domestic violence figured as the main causal factors, whereas unemployment and financial problems largely contribute to men’s attempted suicide (Jayasree 1997). All these illustrate the unequal and oppressive gender relations in the family often endangering women’s life and the accentuated vulnerability of the young and aged women to suicide. The rising domestic violence, along with the despair arising out of mismatch between higher levels of expectations and dreams of an educated women population and the lower levels of recognition in the personal and public life is likely to contribute to greater mental distress, and often high levels of suicides in the state.

Besides these woes, Kerala’s rapid transition into an aging population (12.6% in 2011) which is faster than the growth of general population, despite increased longevity, especially for the women, creates new challenges in women’s health and health care (Rajan and Gulati 1999; Bose 2006). This increases the proportion of aged women likely to have higher morbidity levels, as well as widows (58% in 2001), a socially discriminated and economically marginalised group in the Indian and Kerala cultural context. Indeed, old age increases illnesses (Kerala stands highest among Indian states in old age people reporting illness in 2004 (537 per 1000), and dependencies in which economic dependency among the females was much higher than the males. In 2004, 70% of rural and 64% of urban women in the state were fully dependent on others, and not surprisingly, a high proportion of men (85%) were supported by their children than the women (83%) (NSSO 2006). While the state schemes that support the aged and widows in Kerala is covering only a small proportion of these populations (Rajan and Gulati 1999). Indeed, several of these distortions which dismay the promises and hopes in Kerala women’s health achievements are reflective of the increasing magnitude of unequal gender power relations resulting from the deeply entrenched patriarchal dominations pervasive in several arenas of women’s personal, private and social life, as health is largely a sociopolitical construct. This necessitates an exploration of the social roots of women’s health and ill health.

Socio-Economic Determinants

The social, political and economic forces and policies have a determining impact on women’s health and a decisive role in shaping the conditions in which they live and die (Doyal 2002; CSDH 2008). The forms of social inequality/discrimination including poverty, gender, class, caste and ethnicity/race have a differential impact on health and health determinants such as education, employment and income levels of different populations (Banerji 1982; Qadeer 1985, 2009; Krieger 1999). Indeed, in Kerala the poor and Scheduled caste women bear higher levels of poverty, illiteracy, fertility and morbidity (Thresia 2001, 2006) while tribal women are even more disadvantaged in health and health care access (Mohindra et al.2006). Similarly, despite Kerala’s better standing in education, the socio-cultural patterning- preponderance of women in courses such as general science, arts, nursing, etc. which suits the feminine compared to technical education or management studies- indicate subtle gender constraints more in conformity with women’s gender roles, although Kerala has a greater gender equality in access to school education, in stark contrast with the Indian situation. This increases the marriagability of women as better home makers but it less equip the women to enhance economic autonomy, enjoy decision making power, evade negative trends in property rights and dowry practices, and eliminate violence against them (Kodoth and Eapen 2005).

The women’s economic marginalisation and lack of autonomy is also linked to the glaring gender difference emerges in their work participation rates and employment patterns. The work participation rate of Kerala women has been one among the lowest in the country, and their unemployment becomes the highest, especially among the educated. Since the early 20th century, the census data generally indicate a consistent decline in both female (32.7 in 1901 to 15.3 in 2001) and male (56.3 to 50.

4) work participation. While the decline for females were sharper than males increasing the gender gap to 35.7% in 2001, despite the rise in educational attainments (Rajan and Sreerurpa 2007). According to the NSSO, in 1999-2000 female educated unemployment (rural 36.7%, urban 34.2%) was double than that of the Indian averages (rural 14.6%, urban 14.3%). The NSSO 68th round (2011-2012) indicate female unemployment (27.4%) in Kerala is more than double than that of male unemployment (11.9%). This is despite 2/3rd jobseekers are women (in 2013, 23.85 lakhs women compared to 15.92 lakhs men), although the female technical jobseekers (59108) are only just above half of the male employment seekers (100231) (Economic Review 2013). This shows women’s search for economic security, and perhaps improved self esteem, although the gender constraints impairs their opportunities for technical education and hence better choice of employment and income earnings.

In terms of patterns of employment among the women, there are greater gender and caste segmentation of the labour market. For instance, there is a preponderance of women, especially scheduled caste women in the traditional labour intensive sectors such as agriculture and cashew characterised by limited technology, poor wages, and less welfare protection than capital intensive sectors. Further, women dominate in the service sectors such as nursing, and teaching whereas only limited female representation can be seen in the more sophisticated specialisations in medical fields such as surgery and orthopaedics. In Kerala’s development process with increasing privatisation and informalisation of jobs, in the traditional industries and other several newer job avenues such as textile shops, petrol pumps, medical care institutions, teaching institutions, small scale information technology ventures etc., the work organisation itself is organised in a way to maximize female labour exploitation in several ways including distorted wage structures, debilitating physical conditions of work, evasion of welfare amenities and inculcation of job insecurities (Thresia 2001; Lindberg 2005). Thus, the gendered existence of women with poor chances for technical knowledge expansion, limited choice of better job opportunities, higher levels of informalisation of employment and eroding status of customary property rights weakens women’s individual freedoms and economic autonomy. This is likely to reflect in their ill health, rising violence against them and mental distress. Notably, women owning land or house face a relatively lower risk of marital violence compared to propertyless women (Panda and Agarwal 2005; ICRW 2006).

Politics as Health Determinant

Another important determinant in the social historiography of women’s health development is politics, and translation of state (government) policies in the wider social, economic and cultural spheres has a bearing on health outcomes (Navarro 2006). Kerala has an enlightened history of political discourses and greater politicisation of the masses including women, through unique social reform initiatives from the bottom of the social hierarchy, nationalist traditions, and radical political and trade union contributions which began during the mid 19th century (Desai 2007). And Kerala’s health has been superior to its counterparts in India even during the colonial and princely past, which continues to the post-independent period; and welfare contributions especially healthcare and educational endeavours of the princely rulers and later state governments were emphasised for such a development (Panikar and Soman 1984). However, a recent analytical study on the state’s public health service system using a systems approach, indicate that Kerala’s health services are no different from the country’s health care, rather, the state is a keen follower of the centre’s health care policies while the health improvements in the state is the result of the intersection of a variety of factors including politicisation of the masses than medical technology or education alone (Jagadeesan 2013). Notably, several scholars argue that, various 19th century princely proclamations and initiatives including that in the arenas of education, health and land entitlements were the consequence of colonial impetus towards commercialisation and capitalist penetration and compulsions of missionaries (Kusuman 1973; Desai 2007). The democratisation process and pressures and compulsion for people’s rights began since the mid 19th century might have forced the princely rulers as well as the governments after the state formation to initiate welfare inputs rather than specific public policies aimed to achieve better health. As Jeffrey (2001) argues, Kerala’s achievements were more related to social conditions than public policy.

Unfortunately, despite the increasing politicisation and democratisation of the polity, the pertinent role of women in politics and trade union movement since the 1920s, was less recognised. Considering politics as an exclusive male domain, the patriarchal domination made women in the state submissive, and gender constraints for women’s political participation in Kerala is like in any other states in India (Jeffery 2001). Several of the senior women union workers aired their disappointment in the union politics where the women were relegated to the status of subordinates rather than equal partners or leaders, irrespective of the ideological affiliation of the political parties (Thresia 2001). Even today, women’s representation in the legislative assembly, and parliament including in the ongoing election, is abysmally low, although there is a better representation in the local self government institutions. Thus, women get very limited chances to politically represent their causes while the political parties displayed little concern in women’s issues.

The contemporary politics, and neoliberal policies over the past three decades characterised by reduced public responsibility for the health of populations, increased choice of markets and transformation of national health services into insurance-based health care system, increased personal responsibility for health improvements and rising emphasis on health promotion as behavioural change (Navarro 2007) hasten women’s health and social issues including morbidity burdens, violence, health system failures and changes in labour market accentuating rise in informal jobs (Thresia 2014). These policy reforms are reflected in the reductions in public spending on health, as Kerala’s health expenditure as a percentage of total expenditure declined from

6.4 % to 5.5% between 1993-94 and 2002-03 (HAP 2007). While private spending in the state during 1999-2000 was four times higher than that in Rajasthan and three times than that in Bihar (Garg and Karan 2009). And there has been a soaring rise, fivefold increase between 1987 and 1996, in the household medical care expenditure (Kunhikannan and Aravindan 1996). As a consequence, like India among several countries in the developing world, within India, in 2004, Kerala ranks highest in OOP expenditure for medical care and resultant medical impoverishment in terms of all households falling below poverty line due to health care costs (Bermen et al.2010). Not surprisingly, the decline in public sector expenditure and resultant stagnation/decline in the pace of growth of public sector health care and reductions in the quality of services as well as increase in the private and out-of-pocket (OOP) expenditure for medical care affect women’s health and health care access more than men’s owing to the gender discrimination. This is particularly true for the aged women as their proportion (in 2004, 87.4%) in seeking health care from public sector was higher than aged men (83.3%) (Singh 2013), and widows given their economic and decision making vulnerability (Rajan and Gulati 1999; Bose 2006). Only just over a half of the women population in the state (54.6%) decide upon seeking health care by themselves while even less (42.3%) have the power to decide how to spend the money they earned (NSSO 2006; IIPS 2000). Although there are newer public-private initiatives to address the health needs of the deprived including Rashtriya Swasthya Bhima Yojna and Karunya Benevolent Fund, it needs to be empirically investigated to recognise its utility for the poor and women.

In short, economic marginalisation, political subservience, cultural barriers in technical education, gender segmentation in the labour market, limited social space, poor decision making power, curtailed freedoms and mounting atrocities are some of the social determinants which distort women’s health in contemporary Kerala. This is rather similar to the changes in transitional China and Sri Lanka (having a similar history of ‘good health at low cost’) where economic reform process created gender- differentiated health impacts including newer vulnerabilities in employment market, health status and its access (Chen and Standing 2007; Hancock 2006).

Conclusion

Despite a better standing in the history of women’s health discourses in the developing world, a variety of socio-economic and political deterrents such as poverty, gender, class, cast, ethnicity and other differentials, and discrimination in the arenas of family, education, employment, income, and politics coupled with limited health system response often impair progress in women’s health in Kerala in the 21st century. Achieving better educational gains or well organised medical care services are not sufficient to mitigate the accumulated disadvantages in health and its determinants in the personal and social spaces of women’s lives, in a social order deeply entrenched in patriarchal dominance and structural inequalities, although it is necessary. More precariously, contemporary politics and policies often illustrate a disregard for the women’s (and often men’s) individual and social rights and determinants of health which is more evident in the silence against exploitation in the employment arenas such as traditional sectors and rapidly growing informal sector including medical care, and household realm. Indeed, historically, neither endeavours for meeting women’s strategic needs and economic independence nor efforts to recognise or question gender inequalities were priorities of political parties or trade union sources. Kerala needs resolute political intervention and public policies in creating social and gender justice across all dimensions of women’s lives for achieving better women’s health and there by augmenting gains in Kerala health.

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Contributor:

C.U. THRESIA. Trained in anthropology, and done Ph.D. in gender, work and health from Jawaharlal Nehru University, New Delhi. She was at Achutha Menon Centre for Health Science Studies (public health school), Sree Chitra Tirunal Institute for Medical Sciences and Technology, Kerala, India. Has been published in a few national and international journals including International Journal of Health Services and Monthly Review. Her research interests spans around health inequalities, gender and women’s health, history of medicine and public health and social determinants of health. Currently pursuing research on health inequities and history of medicine.

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C. U. THRESIA
Trained in anthropology, and done Ph.D. in gender, work and health from Jawaharlal Nehru University, New Delhi. She was at Achutha Menon Centre for Health Science Studies (public health school), Sree Chitra Tirunal Institute for Medical Sciences and Technology, Kerala, India. Has been published in a few national and international journals including International Journal of Health Services and Monthly Review. Her research interests spans around health inequalities, gender and women’s health, history of medicine and public health and social determinants of health. Currently pursuing research on health inequities and history of medicine.

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