The authors who work on a gendered overview of the public health sector in India, wonder what impact would the move to rename the public health centres in India as Ayushman Arogya Mandir or AAM bear on women’s health issues? Will women from rural India dare to go in a place called ‘Mandir’ to consult freely, for instance, on menstrual health related issues given the age-old taboos attached with menstrual cycles and places of worship?
Modi Government rebrands Public Health Centres Across India
The Government of India (GOI) recently renamed the existing Ayushman Bharat Health and Wellness Centres (AB-HWCs) (erstwhile ‘sub-centres’), as ‘Ayushman Arogya Mandir’. The AB-HWCs have been invested with a new cadre of workforce. A trained non-physician health worker with BSc Nursing/BAMS qualification, designated as Community Health Officer (CHO), is now further renamed Ayushman Arogya Mandir as primary care team of health workers to support ANM and ASHA’ .
Taking the term, ‘Mandir’ (Temple) to another level
Indian politicians have a penchant to refer to the term ‘temple’ in their socio-political discourses. It was during the laying of the Bhakra Nangal Dam that India’s first Prime Minister Jawahar Lal Nehru urged the nation to think of dams as, “temples of modern India”. In a symbolic way, Nehru used the reference to describe the scientific and academic research facilities, steel mills, and power plants that were being built in India after independence to spur economic and scientific development. Together the country would embark upon the trail towards a free spirited progressive temper and enact a politics of welfare.
An Overkill on the institution of ‘Mandir’?
Mandir’ in its original meaning, viz, ‘temple’ returned to Indian politics with a vengeance and has haunted it ever since beginning of 1990s. In the past few years post -2014, we have seen a culmination of the ‘mandir rhetoric’ looming large over Indian politics and dictating its course in ways more than one. However, the most recent expansion in the significance of the term ‘Mandir’ is seen in the political vocabulary of the health sector in India. The question is Will India’s Arogya Mandirs/ Wellness Temples break the silence on Menstruation in India or foreclose any more voice on the issue and hinder it further?
National Health Mission 2012 and the 12th Five Year plan (FYP): What Changed?
The National Health Mission (NHM) in India is a government initiative aimed at addressing health sector challenges. In its Framework of Implementation 2012, NHM recommended – “strengthening of the Sub Centre/Urban Primary Health Centre to deliver a larger range of preventive, promotive and curative care services, so full range of primary care services”.
Earlier, from 1990 to 2015, the principle focus of the public health system was on the attainment of the Millennium Development Goals (MDGs). A heavy emphasis was laid on the expansion of maternal and childcare services to check the daunting prevalence of mother and infant/new born mortality in India. Besides that, the primary care services, at the time, were largely focused on prevention of a few communicable diseases such as malaria, leprosy and TB, etc.
Newer Conceptions and Commitments of GOI with respect to AB-HWCs
The framework for the NHM underwent significant changes in 2013, under the 12th Five Year Plan (2012-2017). The Government of India (GOI) launched the National Health Mission in 2013 by merging two existing programs: the National Rural Health Mission (NRHM) and the National Urban Health Mission (NUHM).
In December 2014, the Ministry of Health and Family Welfare (MoHFW) constituted a Task Force for the roll out of Comprehensive Primary Health Care (CPHC). The country made a commitment to ensure that the 1,50,000 Sub Health Centres (SHCs) and Primary Health Centres (PHCs) in rural and urban areas that serve our 135-crore people, will be transformed to Ayushman Bharat – Health and Wellness Centres. Conceived to shift the energy from illness to wellness AB-HWCs aim to be able to offer universal access to Comprehensive Primary Health Care (CPHC) services by 2022.
Coverage and the New Plan: Community Ownership of Health under the AAMs
The AB-HWC team is supposed to work closely with people to enable empowerment of individuals, families and communities with knowledge and skills to take responsibility for their own health. The AB-HWCs also focus on improving health literacy through Inter Personal Communication, and media including social media, for promotion of healthy lifestyles – diet, yoga, exercise, tobacco cessation, and self-care for those with chronic disease conditions.
Institutional structures such as Jan Arogya Samitis, with representation from the local bodies and Panchayats, Self Help Groups and patients, have been envisaged to enable community ownership and accountability of AB-HWC teams. Under the Ayushman Bharat Program, by 2018 there were more than 1.6 lakh centres across India.
These centres extend their services beyond maternal and child healthcare, encompassing non-communicable diseases, palliative and rehabilitative care, oral, eye, and ENT care, mental health services, and first-level care for emergencies and
| Total Functional Ayushman Arogya Mandir | 163964 |
| SHC (Sub Health Centres) To have Community Health Officers & Male cum Female ASHAs | 122665 |
| PHC (Primary Health Centres) To serve as first point of Referrals in rural areas | 23629 |
| UPHC (Urban Primary Health Centres) To serve as first point of Referrals in urban areas | 5012 |
| AYUSH Ayurveda, yoga and naturopathy, Unani, Siddha and Homoeopathy | 8270 |
| UHWC (Urban Health Wellness Centres) | 4388 |
Source: Official Website Ayushman Arogya Mandir (nhp.gov.in): Table adapted from data as on 11.01.2024.
Will renaming AB-HWC to Ayushman Arogya Mandir (AAM) deepen or combat the silence on menstruation?
The authors who work on a gendered overview of the public health sector in India, wonder what impact would the move to call the public health centres in India as Ayushman Arogya Mandir or AAM bear on women’s health issues? Will women from rural India dare to go in a place called ‘Mandir’ to consult freely, for instance, on menstrual health related issues?
Will women from rural India dare to go and consult freely on menstrual health related problems and reproductive health? Will tribal women, a tea-leaf picker, a fisher woman or a woman working in the oppressive unorganized labour sector be heard on her sexual and menstrual disorders and woes in the AAMs of her locality? Given that the issues of women’s reproductive and sexual health including Menstrual Hygiene Management (MHM) are either enshrouded in a stigmatized silence or broached hesitatingly, or in situations of emergencies, it is doubtful what the chemistry between combating the silence on women’s health issues and AAMs will be.
Can the Ayushman Arogya Mandirs reconcile to women-centric themes such as Menstruation, Reproductive and Sexual Health?
There could be two possibilities: Either the augmentation of the staff and having a qualified nurse etc., in the AAMs will encourage the women to be spoken or heard or they will feel embarrassed, out of place and once again fall back or be pushed into cycles of silence.
For although, the newly renamed public health centres, namely the AAMs, contain a symbolic reference to something revered by Hindus, ironically Mandirs as places of worship have been a segregated space for women. More so, menstruation and MHM do not go hand in hand with ‘Mandirs’ in Indian society. Visits to mandirs, performing Pooja (worship) and participation in religious rituals and ceremonies during periods are strictly forbidden for menstruating women. More, mixing the two is considered a sin in most parts and cultures of the India. Many women have nurtured and/or been subjected to these feelings and taboos for generations.
Contemplate the other dimension: Public Health Centres in India receive the stock of as well as distribute menstrual absorbents and pads. GOI staff such as ASHAs and now, in the AAMs, officers such as a trained nurses are responsible for making the health centres conducive to discussing menstruation and other reproductive and intimate heath related issues. However, in a society that compartmentalizes a menstruating women’s health and places it outside the precincts of temples, will Ayushman Arogya Mandirs (AAMs) distributing and storing pads, or discussing such issues, not provoke a conflicting image?
GOI must take into account People’s Perspectives when it names and re-names its schemes
Women and girls make half of India’s population (approximately). Around 355 million of them constitute active menstruators. For every menstruator, menarche (onset of periods/menstruation) is a normal biological process, but many girls do not possess complete and accurate understanding or resources to handle the same. Therefore, a majority of the women suffer period poverty in India.
Lack of access to toilets with proper sanitation and hygiene facilities or a total lack of toilets thereof, and the absence of open conversations on the issue already make menstruation a stigmatized, restrictive issue overshadowed with myths, hurdles and immobility for many in rural and remote parts of India. The first basic requirement is to guide women to keep up with her intimate and personal hygiene, clean and change with regularity to avoid infections and other disorders.
However, approximately 70 percent women in India face frequent menstrual health issues out of which 5 to 9 percent have recurrent MHM related issues more than three/ four times in a year. Fungal or bacterial infections occurs at various age groups due to increase in estrogen levels, immunosuppression, diabetes, consumption of antibiotics, ignorance, negligence and inadequate Water, Sanitation and Hygiene (WASH) facilities.
Public Health Centres should be Period-Safe Information Hubs in India
Our society constitutes multiple religions and communities, which include those who do as well as do not profess Hinduism. Mandir is a not only a term in Hindi but signifies a Hindu place of worship. One needs to exercise political caution in imposing such exclusive terms over society. On their own, certain terms have banal and/ or ritualistic, linguistic as well as cultural connotations. Nonetheless, if used to describe institutions that belong and cater to all citizens, these portend a risk of deeply polarization.
In this article, we raise one such aspect: We discuss how the common person would juxtapose or even reconcile the term ‘Mandir’ to MHM and other intimate health issues that women and young girls in India need to broach.
Way Forward
We certainly require innovative health schemes conceived in 2012 and expanded further in 2014, to function for Indian women. It would be a great misfortune if the women shy away from participation in the AAM system, just because of its new name, besides of course the other anomalies that surround MHM in India. Hence, the government must focus on eliciting maximum participation of women as well as help break barriers. For doing so, the GOI needs to demonstrate and walk the path of being culture-sensitive yet at the same time dispel taboos and promote awareness on MHM. Perhaps, it is a good moment to consider that women’s participation in health requires that infrastructural discomforts and social taboos and myths around menstruation be eased.
Author Bio-Notes
Deepali Sudhindra is Researcher in health (data analyst) working in Anusandhan Trust, SATHI, Pune since last 16 years. Also worked as an independent consultant on various research projects.
Dr. Bobby Luthra Sinha is Deputy Director at the Centre for Asian, African and Latin American Studies (CAALAS), Institute of Social Sciences (ISS), Delhi and Head of Research at Un Paso Mas (UPM) LLP, Delhi.
