There are several ongoing discourses on the benefits of improving women’s health and gender equality at international and national levels. Women’s health can be taken as a key indicator of gender equality in a country. The Gender Inequality Index (GII) is calculated with measurements of reproductive health, empowerment and economic status among women.
Sri Lanka is ranked 87nd out of 159 countries on the GII (UNDP, 2016, cited by Aturupane, Shojo, and Ebenezer, 2018). Very low political participation and high unemployment among women are contributing factors to this low ranking. The reproductive health measurements in Sri Lanka are comparatively more positive. Women’s reproductive health indicators include the maternal mortality ratio and average life expectancy. Maternal mortality ratio in Sri Lanka, as of 2020, was 36 per 100,000 live births and life expectancy was at 79 years (UNFPA, 2022). These indicators are quite good in comparison to the rest of the region. Universal healthcare and education are argued to be contributing factors to these indicators. However, it is doubtful whether these indicators can be taken as proof of quality living and health among Sri Lankan women. This article will provoke thought on improvements that could promote the health and wellbeing of Sri Lankan women.
Equal or Unequal? And Intersectional Inequalities
The Sri Lankan Constitution guarantees gender equality among men and women. However, in certain instances, even the law is discriminatory against women. For example the law asserts the father’s superiority as the legal guardian of children under marriage. The mother however, is the sole guardian of children outside of marriage (UNDP, 2016, cited by Aturupane, Shojo, and Ebenezer, 2018). The legislation denies women equal rights regarding marriage and land ownership. Women are also not allowed legal and safe abortion, because abortion is yet criminalised. This is very detrimental to women’s rights, disallowing women having full autonomy over their own bodies. These laws reiterate the fact that Sri Lankan society is quite systematically patriarchal.
Women in different communities are also marginalised by state policies, violence, injustice and apathy. For example the end of the ethnic conflict has left many Tamil women-headed households in the North and East. These women may face insecure work situations due to governance apathy about their conditions and social stigma. Many war or conflict affected women carry underline trauma due to injustices that they have faced and are facing. Trauma can cause intense psychological ill-health. However, there is a lack of psychosocial services to help women overcome this suffering (Brounéus et al., 2024).
Many women from marginalised and disempowered socio-economic backgrounds, such as the Malaiyaha Tamil women, have no alternative than to work as caregivers, plantation workers, garment workers or to migrate for labour (Bjarnegård, Håkansson, and Zetterberg, 2022). Working conditions in these environments are often exploitative and workers often experience high rates of wear and tear. However, there is no health insurance that covers this wear and tear and any other illness or disability these women may face.
The low political participation of women of only 5.8 percent in the Parliament and 4.1 percent in Provincial Councils (Asian Development Bank (ADB) and Deutsche Gesellschaft fur Internationale Zusammenarbeit (GIZ), 2015, cited by Aturupane, Shojo, and Ebenezer, 2018), and unemployment can be a influencing factor for inequalities for women across other sectors, including economic empowerment, good health, social life, participation in STEM education, and safety from Sexual and Gender based Violence (SGBV). The labour force participation rate of women is 35.9 percent, compared to 74.7 among men (UNDP, 2016, cited by Aturupane, Shojo, and Ebenezer, 2018) and there is a major gap in gross national income per capita for women (Department of Census and Statistics, 2020). The disparity in income inequality could also be a reason women face difficulties in accessing good healthcare, including private screenings and regular health checks. Even with a limited income, women play the major role of caretakers, sacrificing their health and wealth for the interest of their family and children’s interests over their own. Aligning policy to provide women with necessary healthcare services should be a priority in the social transformation to a gender inclusive and equal society.
Correlation between Violence and Health
SGBV rates faced by women are high, with 1 out of 3 women in Sri Lanka having experienced GBV (UNFPA, 2023). Women who face SGBV also experience high rates of depression, anxiety and suicidal thoughts (Department of Census and Statistics, 2020). An outstanding number of women 14.6% who faced sexual violence have attempted suicide (Department of Census and Statistics, 2020). Sri Lanka ratified the Convention on the Elimination of All forms of Discrimination against Women (CEDAW) in 1981, the Women’s Charter was adopted in 1993, and the Prevention of Domestic Violence Bill was passed in 2005. Domestic violence is a prevalent issue with 28.9% of women sustaining injuries due to physical or sexual violence by a partner (Department of Census and Statistics, 2020). Child marriage is also an existing problem that undervalues gender equality, wellbeing and empowerment. Child marriage rate by the age of 18 was 10 percent (UNFPA. 2023). Adolescent birth rate is 15.7 births per 1,000 women of ages between 15-19 (UNFPA Sri Lanka, 2022). Child marriage and adolescent can deter full development of girls and women as they are burdened with family at an early age. The issue of child marriages exacerbated due to the economic crisis, with many families having to marry off their girl children early due to the inability to support them financially.
LGBTQI+ community also faces considerable amounts of SGBV in society. Some of the surgeries needed by transgender population are not available in the Sri Lankan healthcare system. The community also faces discrimination from healthcare professionals due to existing socio-cultural biases.
Limiting Access to Health and Nutrition
Sri Lanka is also lagging behind in terms of nutritional status of women and children. 16.7 percent of the pregnant women and 22.2 percent of non-pregnant women are anaemic, while 18.4 percent of pregnant women and 18.2 percent of non-pregnant women are undernourished (UNDP, 2016, cited by Aturupane, Shojo, and Ebenezer, 2018). Findings published in the British medical journal, The Lancet, covering the years from 1990-2022, revealed that Sri Lanka had the second highest prevalence of underweight girls ( between the age group of 5 to 19 years) (Bandara. 2024). Cultural biases may also be a reason behind the nutritional deficiencies among women, as the food requirements of the male figures are often prioritised within family settings. These conditions would have been exacerbated after the economic crisis which caused many households to experience food insecurity. With additional families going under the poverty line, many could not access the proper number of meals and proper nutrition.
Amnesty International reported that the nutrition level of pregnant and breastfeeding were critical among women, especially those who were unemployed and whose husbands did not have a regular income during the economic crisis. The supply of Thriposha was not regular, and government food vouchers, offered to pregnant and breastfeeding women could not be redeemed due to a lack of state funds (Amnesty International, 2023).
There is also the issue of inadequate basic health infrastructure in Well Woman Clinics. The Well Woman Clinics were established to screen nutritional status of women, hypertension, diabetes, breast abnormalities, thyroid gland abnormalities, cervical abnormalities, family planning status, menstrual disorders, reproductive tract infections, and perimenopausal and menopausal problems. This is a great initiative as issues in above health areas are the cause for high rates of morbidity and mortality. But these clinics are located in unsuitable and poorly maintained buildings which lack amenities such as water and seating. The referral system is also weak, with lack of follow up on patients referred to other hospitals. In addition, many women from disempowered socio-economic backgrounds do not have the money to cover the necessary transport and additional medicine costs (Family Health Bureau, 2019).
These screenings are crucial, especially for early diagnosis of cancers. Breast cancer, which is the most common cancer among women, accounts for 26% of all cancers affecting women (National Cancer Control Programme, 2020). Mammography, clinical breast examination (CBE) and self-examination of the breast (SBE) are the methods of screening for this particular cancer. People who do not have the necessary awareness to self-examine must be encouraged to attend clinics regularly to get the screening done by healthcare professionals.
Cervical cancer, which is the second-most common type of cancer among women, can be caused due to poor menstrual hygiene. 1721 women are diagnosed with cervical cancer and 690 succumb to it annually (HPV Information Center, n.d., as cited in Arudpragasam, 2018). The economic crisis also exacerbated the issue of lack of access among women to menstrual hygiene products in the market. Only 30% of menstruating women use disposable sanitary napkins (Arudpragasam, 2018). A majority of women resort to the use of clothes which have a higher chance of leading to infections. Poor menstrual health can lead to urogenital infections and cervical cancer, Bacterial Vaginosis (BV) and urinary tract infection (UTI). UTIs, when left untreated, can spread up the urinary tract and permanently damage the kidneys. BV carries many risks and may cause early or preterm birth, loss of pregnancy, pelvic inflammatory disease and the acquisition of sexually transmitted infections (Arudpragasam, 2018). Period poverty or the lack of access to period products have caused school absenteeism, poor concentration and engagement among girls in school and impacted women’s participation in the labour force. Period poverty can cause mental distress and anxiety among women, as feelings like shame, insecurity, anxiety and fear of stigma are attached to menstruation (Arudpragasam, 2018).
Menstrual health problems can also include conditions like Endometriosis, Polycystic Ovary Syndrome (PCOS), Pelvic Inflammatory Disease and Fibroids. These conditions need medical attention, but the stigma regarding menstruation can prevent women from seeking necessary healthcare. Women sometimes may prefer to consult women doctors for gynaecology related ailments and may forgo medical attention if a female doctor is unavailable. There are many cultural biases and myths regarding menstruation among women in Sri Lanka (Hemachandra and Manderson, 2009) that could also prevent consulting medical views. Although such myths are being overcome with awareness, more awareness, facilities, research and care is necessary for women’s menstrual wellbeing.
Healthy Women is Good Economics
In terms of positive news, according to data from 2016, 74.3% of women of reproductive age (15-49 years) had their family planning needs satisfied with modern methods (UNWomen. n.d.). However, legal inequalities, lack of representation, agency and recognition, limitations in resources, violence with a structural basis and cultural burdens can have negative impacts upon women’s physical and psychological well being.
Scholars have written how healthier women and their children contribute to productivity and education in their societies (Onarheim, Iversen and Bloom, 2016). Family planning awareness and methods help women’s empowerment, by opening up more opportunities to explore higher education and employment. Family planning programs can also improve the Gross Domestic Product (GDP) of a country through the improvement of household finances. Studies find that children conceived in areas with greater awareness and access to family planning were more likely to attain higher education. Poor maternal health is associated with issues like low birth weight, neonatal survival, cognitive development, educational performances, and higher rates of behaviour problems among children (Onarheim, Iversen and Bloom, 2016).
Many of the discourses on the benefits of improving women’s health are centred on the economic benefits to the state and society. Yet, we must recognise that women face multiple barriers when trying to fulfil their healthcare needs. The Sri Lankan women also have different healthcare needs across different intersections. Psychosocial and disability aid for war affected women, elderly women and women from marginalised backgrounds are examples of such needs. These needs may not necessarily align directly with the mainstream developmental goals and narratives of the state, but are necessary to ensure the wellbeing of these women and their communities. Bridging barriers across intersections such as gender, ethnicity, class and caste, ensures that everyone has equal quality care and ensures social justice. Paying attention to mostly maternal health is an underestimation of women’s needs and their capabilities to merely the reproductive component of the society. Women’s healthcare and wellbeing must be equal to men in any society as it is a matter of life and justice.
Article by Chamika Wijesuriya (Content Specialist, Hashtag Generation)
References
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