Framing gynaecological health: A landscaping of health policy and services in India

Globally, women’s health beyond maternal health has yet to be addressed in a comprehensive approach ( Gao et al., 2025 ; Wijeratne et al., 2024 ; Brubaker and Bibbins-Domingo, 2025 ; Cheng, 2025 ). For example, a 2025 global review reports that only 19 of 194 World Health Organization (WHO) member countries have national action plans for women’s health ( Gibbons et al., 2025 ). In many countries, especially lower resource settings, women’s health services primarily focus on family planning and pregnancy, with more recent expansion to non-communicable diseases ( Desai et al., 2025a ). Moreover, gynaecological health – defined broadly by WHO as any condition, disease or dysfunction of the reproductive system not related to pregnancy, abortion or childbirth but may be related to sexual behaviour – is yet to emerge as a priority area within women’s health ( Wijeratne et al., 2024 ; Jejeebhoy et al., 2003 ; RCOG, 2025 ). Gynaecological conditions pose a substantial burden of disease, especially in low-resource settings, with well-documented – and high – costs for women, health systems and society ( Wijeratne et al., 2024 ; Narasimhan et al., 2025 ). Yet there are promising developments. Philanthropists, global organisations and research institutions have committed to closing longstanding gaps in women’s health through improved technology, evidence and advocacy ( Clark, 2025 ). Gynaecology finds an important place in these efforts, such as investments in innovations to treat reproductive tract infections (RTIs) or to understand the yet-unknown causes of endometriosis ( Jarvis ). However, health systems must be equipped to absorb such innovations and technological advancements ( Nassiri-Ansari et al., 2025 ). For gynaecological care, service delivery is required through the life course – from menarche to menopause and beyond ( Hirst et al., 2024 ). Thus far, research and service guidelines regarding gynaecological health have focused on specific conditions, such as the response to cervical cancer or endometriosis ( Gibbons et al., 2025 ; Parkhurst and Vulimiri, 2013 ; Hyatt et al., 2025 ; Akanda et al., 2022 ; Binagwaho et al., 2013 ; Vale et al., 2021 ). However, women experience similar symptoms for different gynaecological conditions: heavy menstrual bleeding or pelvic pain for example, can be signs of endometriosis, fibroids or polycystic ovary syndrome (PCOS) which, in turn, can be linked to infertility ( Yen et al., 2023 ). Accordingly, health services must be equipped to address overlapping symptoms collectively rather than as siloed individual conditions; a systems lens to gynaecological health is essential ( RCOG, 2025 ). Moreover, a substantial body of evidence now links gynaecological conditions and reproductive life events to risk of non-communicable disease, underscoring the need for both a health systems and life course approach to women’s health ( Hardy et al., 2023 ). India presents an important case on how to assess the status of gynaecological health services within the health system. Investment in health systems strengthening towards achieving comprehensive primary health care and universal health coverage has resulted in overall improvements in infrastructure and access, particularly major gains in improving maternal and reproductive health over the past two decades ( Meh et al., 2022 ). Interest in gynaecological health is growing, as reflected by a national strategy on cervical cancer, government guidelines on preventing unnecessary hysterectomies and pilot programmes for endometriosis. Gynaecological care has also reached political discourse: menstrual hygiene, infertility, gynaecological cancers and menopause policy have been addressed as official questions in Parliament ( Lok Sabha Questions, 2025 ). Unnecessary hysterectomy in particular has been raised in Parliament on several occasions, along with a Supreme Court Public Interest Litigation in 2013 and widespread news coverage ( Supreme Court of India, 2023 ). This paper examines the status of how the public health system in India addresses gynaecological health, as reflected by health policy, service guidelines and data collected by national surveys and administrative data. We assess which conditions are addressed in policy guidelines, at what level of the health system and for whom – and how progress is measured through data. We aim to inform ongoing policy and political commitments to women’s health and to highlight priority areas for further action and investment. India’s health system is diverse, reaching a population of 1.4 billion though a mix of public and private services that varies across the country ( Mukherji et al., 2024 ). Health is constitutionally designated as a State subject in India’s federal architecture. National policy and guidelines establish broad priorities, such as the National Health Mission (NHM), India’s flagship public health and health systems strengthening programme towards achieving universal access to equitable, affordable and quality health services, alongside vertical, domain-specific programmes like the National AIDS Control Programme or Anaemia Mukt Bharat (Anaemia-Free India). The public health system is organised into three tiers ( MOHFW, 2022a ). (See Fig. 1 ) Primary health care is delivered through trained frontline workers, community outreach and health facilities (Ayushman Arogya Mandirs/AAMs) that serve a population of 3000–5000 at the sub-health centre level and through primary health centres (PHCs), led by a Medical Officer, that cover 20,000–30,000 people. Community health centres (CHCs) provide basic secondary care for a population between 80,000–120,000, supported by sub-district and district hospitals. Tertiary care is provided through specialised hospitals at the district level or beyond, including medical colleges. Facility norms regarding human resources and minimum service availability are governed by the Indian Public Health Standards at four levels: Ayushman Arogya Mandir; primary health centre; community health centre; and sub-district/district hospital. The Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) is a publicly funded national health insurance scheme that is intended to cover nearly 40% of the Indian population, based on income and vulnerability criteria, through cashless access for secondary and tertiary care hospitalization across public and private empanelled hospitals in India. Benefits under the AB-PMJAY, up to the limit of annual coverage, include hospitalisation expenses, selected outpatient treatment, follow-up care, and pre- and post-hospitalisation care ( Dubey et al., 2023 ). Reproductive health has been a focal area of health policy in India for over three decades. Alongside major improvements in maternal health, family planning programmes have expanded substantially. However, female sterilization continues to comprise 67% of modern contraceptive use ( Singh et al., 2021 ; Sivaram et al., 2022 ). The average reproductive period for Indian women spans seven years, from the age of 21 at first childbirth to 28 years at last ( Singh et al., 2023 ). The most recent national survey (National Family Health Survey-5, 2019–21) found that 10% of adult women reported symptoms of RTI/sexually transmitted infections (STIs), 42% of whom reported seeking care. Cervical cancer screening was reported by less than 2% amongst women ( International Institute for Population Sciences IIPS and, 2021 ). A recent systematic review reported low treatment-seeking for gynaecological morbidities, with pooled estimates ranging from 31% to 54% of women seeking treatment, with the exception of 93% for infertility ( Karthikeyan et al., 2026 ).

We first developed a working definition of gynaecological morbidity for this paper through reviewing global definitions, in consultation with four gynaecologists on our team. We used the following definition of gynaecological health, drawing from WHO definitions: Any condition, disease or dysfunction of the reproductive system that is not related to pregnancy, abortion or childbirth, AND a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity ( Jejeebhoy et al., 2003 ) . We then adapted the categories of gynaecological morbidity, building on categories utilised in a WHO publication on reproductive tract infections and gynaecological disorders ( Jejeebhoy et al., 2003 ) and resources from the International Federation of Gynaecology and Obstetrics (FIGO). The main adaptations were first to create a category of menstrual disorders using the PALM-COEIN, ( Munro et al., 2011 ) a FIGO classification system for the causes of abnormal uterine bleeding in non-pregnant women (see Box 1 ), which were earlier classified as other conditions in the WHO resource. We added health and well-being regarding sexual dysfunction and menopause and included congenital malformations in other conditions. We chose not to include endocrinal disorders as a separate category, as they are included in the PALM-COEIN guidelines. We conducted a narrative review of policies, services and data that Other gynaecological morbidities [congenital disorders, non-inflammatory and inflammatory diseases of the pelvic organs not attributable to address gynaecological health in India, adapting the READ approach to document analysis ( Dalglish et al., 2020 ). READ offers guidance on how to: ready materials [search criteria, indicative places to search and dates of inclusion]; extract [approach to extraction, including software and coding method]; analyse [synthesis of findings, aligned with research question and target audience]; and distil findings [analytic synthesis and write-up]. In India, policy directives are covered in a range of documents, including: (i) policy documents, e.g. National Health Policy; (ii) Indian Public Health Standards (IPHS), which provide norms and benchmarks for infrastructure, human resources and services for four levels of public health facilities, across service areas; (iii) guidelines for programme implementation, such as Operational Guidelines for Comprehensive Primary Health Care or service benefit packages for the national health insurance programme; (iv) Training Manuals for public health cadres, such as for ASHAs (accredited social health activists/community health workers); (v) Standard Treatment Workflows published by the Indian Council of Medical Research (ICMR), developed by experts to be relevant to the Indian context and health system; and (vi) disease or condition-specific guidelines such as the National Guidelines to Prevent Unnecessary Hysterectomy. We initially searched for documents that were: (i) issued by a government institution relevant to public health policy and guidelines for services and treatment, which include: Ministry of Health & Family Welfare (MoHFW), National Health Systems Resource Centre (NHSRC), ICMR and National Health Authority (NHA); (ii) directives regarding services and treatment, including clinical guidelines, within the public health system for gynaecological health. We searched the websites of MoHFW, NHSRC, ICMR and NHA along with google searches on policy for each condition. Inclusion criteria were documents that covered any aspect of gynaecological health, as defined in Box 1 , and were issued in or after 2005, the year that the flagship National Rural Health Mission was introduced. We excluded documents that did not specifically address gynaecological health, were not publicly available or not authored by a government institution (such as professional associations). Selection went through two phases: four authors [SD, SSi, SSu, AS] first searched and screened documents based on the criteria above, followed by a detailed review with gynaecologists and two health policy experts in the team to assess appropriateness of each document and whether documents were missing. After this phase, we chose to include Parliamentary Questions [official government responses to questions posed by legislators] from 2005 to 2025, which serve as an official public record of government activities and policies. We searched publicly available digital catalogues of Parliamentary Questions in the lower (Lok Sabha) and upper (Rajya Sabha) houses for gynaecological health terms, including: women’s health; gynaecological, hysterectomy; menstrual; PCOD/PCOS; gynaecological cancer; cervical cancer; ovarian cancer; endometriosis; infertility; menopause; sexual health; sexual dysfunction; reproductive tract infections and sexually transmitted disease/infection. For data, we included sources that are nationally representative and regularly collected by the government. These data sources included: i) National Family and Health Survey (NFHS), round 4, 2015–16 and round 5, 2019–21, ii) Longitudinal Ageing Survey of India (LASI 2017–18), iii) National Sample Survey, round 75, schedule 25.0 (NSS 2017–18, Household Social Consumption: Health) iv) Health Management Information System (HMIS), published annually by the MoHFW and v) publicly available AB-PMJAY claims analyses. We prepared a matrix for document extraction organised by the eight gynaecological health categories in Box 1 . For each health category (row), we read and extracted from all relevant documents across eight columns: the specific gynaecological conditions addressed in the document; population(s) of focus; and services defined at the primary, secondary and tertiary level. Consistent with the Indian public health system ( Fig. 1 ) and organisation of the IPHS, primary level services were extracted as: community outreach/awareness/screening by frontline workers and services as defined for the sub-health centre and PHC. Secondary included services at the CHC/sub-district facilities, while tertiary covered district facilities, medical colleges and upwards. For data sources, we extracted the following information by gynaecological health category: last conducted survey, frequency, population covered; and the specific variables collected related to prevalence and treatment provided or sought. Four authors [SSi, SSu, AS, RJS] did the first round of extractions, each of which was then reviewed by three authors [SD, RV, DN] and then discussed within the wider author group. We developed a matrix to assess the extent of services, as included in policy documents, across the life course [adolescence, reproductive period, till the average age at menopause (age 47) ( Prasad et al., 2021 ), and beyond age 48]. We adapted this approach from a service assessment and readiness assessment tool (SARA) and a published service landscaping exercise with similar aims ( O’Neill et al., 2013 ; Neupane et al., 2024 ; Girase et al., 2022 ). We examined three aspects of policy and service guidance across gynaecological health categories: (i) is it addressed in national health policy/operational guidelines/service delivery frameworks? (ii) do guidelines include any community-level outreach, such as home visits, group or community-based activities e.g. Village Health and Nutrition Days, awareness-raising through mass media or targeted communication programmes, or community-based screening (iii) are there policy directives for facility-based service delivery at the primary/secondary/tertiary level? Our multi-disciplinary team, including gynaecologists and public health specialists, arrived at these criteria to examine how the public health system approaches gynaecological health, while recognising that policy inclusion does not necessarily translate into effective availability. Further, the three criteria accounted for flexibility based on condition-specific service needs. For example, not all gynaecological conditions require screening at the primary level, while community-based outreach could be inappropriate for others, such as infertility. Along with the three-point gradient, we qualitatively describe the extent of service guidance for each category. In addition, we conducted an in-depth analysis for one specific gynaecological condition to examine services at the primary, secondary and tertiary levels across five of the WHO health system building blocks: service delivery, health workforce, health information, medical products, vaccines, and technologies and health financing. We chose heavy menstrual bleeding as an illustrative example because it is mentioned in both the IPHS and Standard Treatment Workflows. Small surveys estimate that heavy menstrual bleeding affects up to two in five women in India, and thus a significantly large proportion of women require awareness, diagnosis and accessible treatment ( Sinharoy et al., 2023 ). We discussed findings from the analysis within the authors team to assess completeness of the search and type of analysis. We developed a narrative summary for each set of results and identified trends across conditions. Next, we charted services and data availability across the life course, from adolescence to menopause and beyond.

We identified 34 policy documents that contained information on gynaecological services in the health system ( Fig. 2 ). A selection of key documents is presented in Table 1 , with the full list available in Supplementary Table 1 . There is no singular strategy or policy for gynaecological health—or more broadly for women’s health—that defines the landscape of services in India. The National Health Policy, which sets out broad priorities for the health system, notes that services should contain provisions for reproductive morbidities and health needs of women beyond the reproductive age group (40 +) and address gender-based violence (NHP 2017). The National Health Mission, an umbrella health systems strengthening initiative, focuses on reproductive, maternal, newborn, child, adolescent health and nutrition (RMNCAH+N), communicable and non-communicable diseases, including community engagement and decentralisation. Four sources provided the bulk of information on service guidelines for gynaecological health: (i) IPHS revised in 2022 provide detailed standards for a range of gynaecological services at four levels of facilities; (ii) Operational Guidelines for Comprehensive Primary Health Care include guidelines for screening and outreach at the sub-health centre and primary health centre; (iii) Standard Treatment Workflows on heavy menstrual bleeding, hysterectomy for benign conditions, hypothyroidism, infertility, dilatation and curettage (D&C), uterine fibroids/polyps and female infertility; and (iv) specific guidelines such as for adolescent health, cervical cancer and unnecessary hysterectomy. Gynaecological health was raised 126 times in Parliamentary Questions over twenty years ( Table 2 ). The majority of questions focused on cancer, infertility and menstrual health. Questions were a mix of information requests about available services and the disease burden of specific conditions. Although the search term “menstrual” returned several results on menstrual hygiene management and menstrual leave policy, which were excluded, the remaining questions addressing menstrual health were typically answered with information on government programmes for adolescent girls. Amongst gynaecological cancers, a majority were focused on cervical cancer incidence and Human Papillomavirus (HPV) vaccines (prior to the vaccine roll-out in 2026). Questions on infertility highlighted existing guidelines for Assisted Reproductive Technology (ART). On menopause, four questions were raised on whether the government will introduce a menopause policy for women working in the public and private sectors. All categories of gynaecological health are mentioned in a national policy or operational guidelines ( Table 3 ). Only three conditions are comprehensively discussed in policy/guidelines and include community-based outreach and facility-based management: RTIs, gynaecological cancers and gender-based violence (GBV). Menstrual disorders and infertility have guidelines for facility-based services, but not community outreach. Menopause and sexual health do not have guidelines for services or for community awareness/outreach. Guidelines for services for reproductive tract infections are found in the IPHS, the National AIDS Control Policy, adolescent health strategy ( Rashtriya Kishor Swasthya Karyakram /RKSK) and Comprehensive Primary Health Care operational guidelines ( MOHFW, 2014a , 2022a ; NACO, 2022 ; NHSRC, 2018a ). Outreach services include community outreach and awareness through community “talk shows” and counselling on monthly Village Health and Sanitation Nutrition Days for women, as well as through peer educators for adolescents. Facility-based screening and treatment involves syndromic management for common RTIs at designated clinics, with walk-in services for adolescents at weekly clinics. Service descriptions target both adolescents and adults, with additional outreach for populations considered at higher risk of sexually transmitted infections. Select menstrual disorders such as fibroids and heavy menstrual bleeding are mentioned in the IPHS, Standard Treatment Workflows and in the National Guidelines to Prevent Unnecessary Hysterectomies ( MOHFW, 2022a ; DHR/ICMR, 2019 ; MOHFW, 2022b ). At the community level, ASHAs are charged with providing awareness on menstrual hygiene, with specific counselling for adolescents on menstrual disorders at weekly adolescent clinics. Although the national hysterectomy guidelines recommend annual screening for abnormal uterine bleeding and other conditions, screening has not yet been included in either the IPHS or other service guidelines. Standard Treatment Workflows provide clinical protocols for primary, secondary and tertiary level treatment of heavy menstrual bleeding and fibroids, spanning hormonal treatment, intrauterine devices and conservative surgery. The AB-PMJAY (Health Benefits Package 2.2) covers surgeries for many gynaecological conditions, including: myomectomy (removal of uterine fibroids), polypectomy (removal of endometrial polyps), cystectomy, cryosurgery, hysterectomy, laparoscopic surgery for endometriosis, as well as D&C ( NHA/AB-PMJAY, 2021 ). Gynaecological cancers are included in the IPHS and in national plans to control NCDs and common cancers ( MOHFW, 2022a , 2023 ). Each cancer programme has strategies for community-based outreach, through fixed days for information, education and communication, risk factor assessment, community mobilization for screening and population-based screening. Screening programmes are directed to be included at the sub-health centre level through AAMs, including visual inspection with acetic acid (VIA) and pap smears at the PHC level. In addition, guidelines include HPV vaccination through schools and through health facilities for girls missed through school health programmes. Referrals are indicated in these documents to health facilities with an available gynaecologist and ultrasound machine. Treatment is designated at tertiary cancer centres, with follow-up chemotherapy and palliative care at district hospitals. The AB-PMJAY covers medical oncology and surgical procedures for ovarian, cervical, endometrial and vulvar cancers. The insurance package includes chemotherapy treatment, diagnostic/staging laparoscopy and surgeries ( NHA/AB-PMJAY, 2021 ). The IPHS indicate that infertility counselling should be available at the PHC level ( MOHFW, 2022a ). There is no provision for community-based outreach through frontline workers or community activities in the IPHS or operational guidelines for comprehensive primary health care. Standard Treatment Workflows indicate that clinics designated as Level 1 ART clinics should be equipped to provide preliminary investigations, including diagnosis of the type and cause of infertility as well as intrauterine insemination ( DHR/ICMR, 2019 ). Clinics (private or public) designated as Level 2 with specialist obstetrician and gynaecologists are to be equipped to provide complete diagnostic and therapeutic interventions. Treatment for infertility is covered under the Central Government Health Scheme (CGHS) for government employees but not the national AB-PMJAY ( Lok Sabha, 2024 ). The RKSK Adolescent Health Programme strategy includes counselling on concerns related to sexuality and sexual health for adolescents ( MOHFW, 2014a ). We could not identify any additional documents that outlined services for adults regarding sexual health or sexual dysfunction, outside of prevention and treatment of sexually transmitted infections, as noted above under RTIs. The National Health Policy identifies action against GBV as a priority area, with a call to strengthen access to free and dignified healthcare in the public and private sectors ( MOHFW, 2017 ). Injuries related to GBV, including domestic violence and sexual violence, are discussed in both the IPHS and the adolescent health programme ( MOHFW, 2022a , 2014a ). Designated actions include counselling services on prevention of violence during Village Health and Nutrition Days, awareness during Adolescent Health and Wellness Days and through Adolescent Friendly Health Clinics. First-aid for injuries from GBV are included in guidelines at the primary level, with centres encouraged to disseminate information and organise campaigns. Standards include integrated counselling services at the secondary level, as well as provision for examination of GBV victims in emergency departments. AB-PMJAY includes coverage of a procedure to examine the genital tract under anaesthesia for minor, unmarried abuse victims ( NHA/AB-PMJAY, 2021 ). There are no specific policy documents or guidelines that describe services for women experiencing health problems associated with the menopausal transition. Earlier guidelines (2007) for monthly Village Health, Nutrition and Sanitation days included counselling for peri-menopausal and menopausal women, but the updated 2019 guidelines do not refer to menopause ( MOHFW, 2007 ; MOHFW/WCD, 2019 ). Standard Treatment Workflows for heavy menstrual bleeding and hysterectomy for benign gynaecological conditions have separate treatment guidelines for post-menopausal women ( DHR/ICMR, 2019 ). Menopause policy has been raised in Parliament on at least four occasions. In the most recent question in 2023, the response reported that there is no menopause policy under consideration for women employees in the public or private sector ( Lok Sabha Question, 1071, 2023 ). However, the government has conducted awareness campaigns through media, street plays and workshops ( Woman2024, 2024 ). Fig. 3 illustrates service guidance across the gynaecological life course. We categorised the gynaecological life stages across adolescence, the reproductive period and until and beyond menopause, based on median age for each stage in India. As below, RTIs, gynaecological cancers and GBV have comprehensive guidelines for women across life stages. Menstrual disorders and infertility, however, have service guidelines but no provisions for community awareness. Sexual health is mentioned in guidelines for adolescent health, but nowhere for adult women at any life stage. Lastly, there is no guidance for awareness or services during the menopausal transition. We examined the health system response to heavy menstrual bleeding across the health systems building blocks and three levels of care ( Fig. 4 ). For human resources, the primary level includes ASHAs, auxilary nurse midwives (ANMs) and a Community Health Officer (CHO) or Medical Officer ( NHSRC, 2018a ). Training reading material for ASHAs includes the signs of abnormal and/or heavy menstrual bleeding as a reason for women and girls to seek medical care ( MOHFW, 2006a ). A section on anaemia includes guidance for homeopathic treatment for heavy bleeding ( MOHFW, 2006b ). Available training material for CHOs mentions menstrual hygiene and referral for menstrual irregularities ( NHSRC, 2018b ). For Medical Officers, who are already trained in basic gynaecology as physicians, the only specific training materials we identified included information on menstrual hygiene for adolescents ( MOHFW, 2014b ). For diagnostics at the primary level, Standard Treatment Workflows for heavy menstrual bleeding indicate blood investigations and pelvic and speculum examinations should be offered, with hormonal/medical treatment options ( DHR/ICMR, 2019 ). At the secondary level, further diagnostics – through an ultrasound and endometrial sampling – are recommended if a gynaecologist is available ( DHR/ICMR, 2019 ). Diagnostics require access to an ultrasound, which Standard Treatment Workflows note may not be readily available in secondary facilities. Designated treatment options at the secondary facility include LNG-IUS (Levonorgestrel-releasing intrauterine system), hormonal pills and tranexamic acid. Tertiary facilities are defined to be equipped with gynaecologists with provisions for ultrasounds, endometrial sampling and hysteroscopy as well as ablative techniques and hysterectomy. AB-PMJAY covers a range of surgical procedures, including D&C, fibroid removal and hysterectomy ( NHA/AB-PMJAY, 2021 ). However, LNG-IUS is not available free of cost in the public health system or through publicly-funded insurance. Four sources collect data on the prevalence of gynaecological symptoms or conditions and utilisation of services: NFHS (15–49 years), LASI (women >45 years and spouses of men >45 included in the survey), NSS (all household members, across ages)–and programme data collected through HMIS and National Cancer Registries. ( Table 4 , Appendix A ). Overall, there is no gynaecological condition for which both prevalence and service utilisation are available for women across the life course. Population-based data that estimate the proportion of women reporting gynaecological concerns are available for five issues: symptoms of RTI/STIs amongst women between 15 and 49; intimate partner violence; childlessness (as a proxy for infertility); history of hysterectomy and symptoms of either menopause or menstrual disorders amongst women > 45 years. The NSS combines symptoms of menstrual disorders and infertility in one question. There are no other population-based data on menstrual disorders or sexual health beyond infections. National Cancer Registries provide incidence estimates of gynaecological cancers through data collected from facilities, and history of cancer diagnosis is collected amongst women > 45 years. Data on patterns of women’s service utilisation are patchy. Population-level data on whether women sought treatment services are collected for: RTI symptoms, screening for cervical/breast cancer but not treatment; intimate partner violence; and symptoms of menstrual disorders or menopause amongst women > 45 years. HMIS tracks public provision of services for RTIs and cancer screening. There are no data collected for service provision or utilisation for menstrual disorders, sexual health or infertility. NFHS and LASI collect data on hysterectomy and use of public or private hospitals. HMIS reports on hysterectomy in public hospitals and AB-PMJAY tracks insurance claims in empanelled private or public hospitals, although raw data are not publicly available.

Many components of gynaecological health are addressed in policy guidelines in India. Policy guidelines for RTIs and gynaecological cancers are the most comprehensive, with directives for both community outreach and facility management at different levels of the public health system, from adolescence to menopause and beyond. Similarly, awareness, counselling and services for GBV–identified as a priority area in the National Health Policy–have guidelines for both adolescents and women. However, our analysis also finds many gaps in services for women’s gynaecological health across the life course. Sexual health and menopause have almost no mention in policy or guidelines for community-based outreach or services, while menstrual disorders and infertility do not have comprehensive guidelines that include both community-based awareness/outreach and facility-level management. Lack of priority for sexual health may reflect systems constraints as public health services expand beyond reproductive health, as well as sociocultural barriers and limitations in provider training or resources ( Giritharan, 2020 ). Although private professional associations have issued practice guidelines for sexual dysfunction ( Avasthi et al., 2017 ) as well as menopause, ( Meeta et al., 2026 ) public health policy does not yet address these conditions. The case of heavy menstrual bleeding illustrates the interlinked nature of gynaecological conditions and the need for a comprehensive, system-level response. Heavy menstrual bleeding can be a sign of several conditions, such as endometriosis or fibroids and it is also a major cause of anaemia, a significant burden amongst women in India ( Sinharoy et al., 2023 ). Yet there are critical design gaps that limit service implementation according to the Standard Treatment Workflow. For example, training modules for ASHAs and CHOs do not include symptoms and treatment for heavy menstrual bleeding. While surgical management is covered in the health insurance scheme, financing within the public health delivery system does not offer conservative, hormonal treatment, such as the LNG-IUS, for free. The ramifications of this gap are significant: national surveys consistently find that women report excessive bleeding as the leading reason for undergoing hysterectomy, at an average age of 37 – which in turn renders them vulnerable to considerable consequences linked to early menopause ( Desai et al., 2023 ). Qualitative research finds that the lack of feasible, alternative gynaecological treatments is a primary reason that women undergo hysterectomy for benign conditions ( Sardeshpande, 2014 ; Desai, 2016 ). Building on the adage that ‘what isn’t measured isn’t done’, we also examined the availability of data on the prevalence of, and treatment sought for, gynaecological morbidity. While smaller studies demonstrate the high burden of gynaecological conditions across the life course in India, population-level data to monitor progress remain scarce ( Das and Jungari, 2024 ). Our analysis found comprehensive data for the three conditions for which policy guidelines are in place: RTIs, cancer and GBV, as well as some information on menopause amongst women > 45 years. On the other hand, data are scarce for menstrual disorders, infertility and sexual health, the three conditions that have received limited policy attention – which suggests a correlation between measurement and action. Notably, data on hysterectomy in India – the only low-and-middle-income-country to collect nationally representative data – emerged as part of the government’s response to reports of high prevalence in young women in parts of the country. Our focus on “gynaecological health” rather than a specific condition highlights a broader issue with terminology and policy and programmatic approaches to women’s health. Gynaecological health is not commonly used in public health research, policy guidelines or health departments as a key component of sexual and reproductive health. Instead, menstrual health or specific conditions such as endometriosis have recently gained prominence ( Narasimhan et al., 2025 ; Wilson et al., 2021 ). Yet from the view of health systems, women present with similar symptoms (such as pelvic pain) for different, often interlinked conditions. Providers and services must be equipped to address these through coordinated gynaecological care pathways rather than disease-specific approaches ( RCOG, 2025 ). Without an intentional framing as gynaecological health, opportunities for comprehensive training and primary health care can be missed ( RCOG, 2021 ; Ranjithkumar, 2025 ; Jabeen et al., 2025 ). Moreover, there is no comprehensive women’s health strategy or policy division. As a result, gynaecological health largely falls between divisions of Maternal and Child Health and Non-communicable diseases – neither of which encompass menstrual disorders or menopause. Encouragingly, the ICMR recently renamed its centre for research on reproductive and child health to the National Institute for Research on Women’s Health. Our policy analysis only examined guidelines for services in the public system. However, the private sector is a major provider of care in India. For example, over two-thirds of women who undergo hysterectomy use private services and treatment for infertility is largely sought in the private sector ( Tholeti et al., 2024 ).The ability to utilise private healthcare services is deeply unequal and stratified by caste, class, education and geography. Poorer households, rural populations and scheduled caste/scheduled tribe groups also face considerable barriers within the public health system ( Yadav et al., 2022 ). For gynaecological conditions—for which treatment-seeking is already low ( Karthikeyan et al., 2026 )—the domination of the private sector will render care unaffordable for vulnerable women in particular. Or as the case of hysterectomy illustrates, a lack of affordable options to treat menstrual disorders forces women to consider permanent surgery at a young age, however damaging to long-term health, as a seemingly pragmatic option ( Sardeshpande, 2014 ; Desai, 2016 ). Strengthened policy for gynaecological care in the public health system, therefore, is essential to protect women’s health and well-being through the life course. Our analysis identifies concrete opportunities to improve services for gynaecological health in India and similar settings. As a first step, gynaecological health needs an integrated, life course strategy as a part of women’s health. Gynaecological health could be integrated into Ministry Programme departments and Directorates of Health that oversee menstrual health, anaemia, maternal health, family planning programmes. For example, interventions for menstrual disorders that cause anaemia can be coordinated alongside the national anaemia programme (Anaemia Mukt Bharat). A women’s health strategy requires addressing the interlinked nature of reproductive life events and sex-specific risk factors, such as recurrent miscarriage and the risk of cardiovascular disease, as well as common determinants and outcomes across women’s lives, such as obesity and PCOS ( Hardy et al., 2023 ; Desai et al., 2023 ). Further, the voices of women and experts are essential to shape an India-specific strategy for women’s health, illustrated by initiatives such as the public call for evidence that informed England’s first Women’s Health Strategy in 2022 ( UDoHaS, 2022 ) and global listening exercises on “what women want’ implemented by the White Ribbon Alliance ( White Ribbon Alliance, 2018 ). Participatory processes can help identify social norms and potential barriers to address within policies on sexual health or menopause, which may carry stigma in wider implementation. Second, expanding the capacity of facilities to address common gynaecological conditions, particularly at the primary level, will require investing in training and diagnostics for non-gynaecologists such as front line nurses and community health officers. RCOG (2021) ; Jabeen et al., (2025) . To illustrate, LNG-IUS, an effective treatment for heavy menstrual bleeding, is currently only available at medical colleges or tertiary hospitals, and costs may render it out of reach for the poorest women. The very low proportion of women who have been screened for cervical cancer suggests that women face barriers – supply and demand-related – that will require wide-scale investment in primary level gynaecological care and outreach. Expanding access to such treatment will require adapting from experience gained through provision in tertiary hospitals to build a referral network from within primary health care facilities. Further, there is potential to build on lessons from a pilot in the state of Rajasthan that demonstrated feasibility in a primary health care setting, with insertion by nurses and a visiting gynaecologist. Wider scale implementation will require training, access to ultrasounds and gynaecological referrals across a continuum of care from community-based outreach, screening, referrals and follow-ups ( Iyengar et al., 2022 ). Training and adapting clinical protocols to local realities where gynaecologists are in short supply can build on lessons from efforts in Bangladesh and Nigeria that focused on front-line providers ( RCOG, 2021 ). Other relevant efforts in South Asia, such as Well Women Clinics in Sri Lanka to reach women over 35 years and through midwife-led outreach, offer insight on how nurses can deliver integrated women’s health services ( Desai et al., 2025a ). Third, community outreach efforts, largely implemented by ASHAs, ANMs and Community Health Officers, do not address awareness on most aspects of gynaecological health care beyond cancer screening. Print and digital media increasingly address menstrual hygiene but have not yet launched large campaigns on women’s overall gynaecological needs. Working with women’s groups is a demonstrated method to disseminate and discuss information on women’s health, aligned with their age and life course needs. For example, the nation-wide network of over 10 million self-help groups (whose members are on average 38 years old) offers a potential space to share information relevant to members’ health needs through mid-life ( Desai et al., 2024 ). While previous programmes have addressed maternal health and nutrition, there is an underutilised opportunity to address issues aligned with women’s mid-life health, such as common gynaecological conditions and the menopausal transition ( Desai et al., 2024 ). Community mobilisation to address social norms or stigma that prevents discussion on sexual health or infertility can be an important strategy. Further, monthly group meetings offer a safe, private space to expand awareness on gynaecological health, if time is available and deemed a priority by members ( Ranjithkumar, 2025 ). Lastly, India’s own experience with national surveys demonstrates the impact of expanded data collection to track women’s gynaecological health. Inclusion of additional questions into the NFHS to address hysterectomy proved critical to developing national policy guidelines ( Kay, 2013 ). Similarily, inclusion of a module on common gynaecological health conditions, building on established scales such as SAMANTA to measure heavy menstrual bleeding and the discontinued module on menstrual disorders in earlier District Level Household Surveys can provide invaluable insight to develop appropriate services ( Sinharoy et al., 2023 ; Hoffman et al., 2021 ; Anand et al., 2018 ). Alongside surveys, improved national monitoring data on gynaecological health is feasible through existing administrative data. Primary research on gynaecological health and treatment-seeking through the life course remains rare, despite well-established need and methodological approaches ( Das and Jungari, 2024 ; Desai et al., 2025b ; Jejeebhoy and Koenig, 2003 ; Amin and Bentley, 2002 ; Koenig et al., 1998 ; Kielmann, 2002 ; Pradhan et al., 2023 ). This assessment, the first to our knowledge in India and other LMICs, intended to be a start to understanding the country’s policy and services context for gynaecological health. By design, we focussed on policy intentions and guidance, rather than utilisation or service provision in practice. While this analysis focussed on the public health system, the private sector requires primary, context-specific research. We did not include guidelines and recommendations from professional associations that include public and private providers, such as the Federation of Obstetrics and Gynaecological Societies of India, Indian Menopause Society and Indian Fertility Society. Lastly, implementation of guidelines will vary widely depending on the strength of state health systems. Assessing state-level policies and programmes alongside women’s utilisation should be part of next steps towards improved gynaecological health. India’s experience demonstrates how policy priority for specific conditions such as RTI/STIs can be translated into population-level programmes with service delivery and community-based outreach. Women’s health deserves national strategies and system-level, sustainable investments in services from menarche to menopause and beyond. Equitable services in India and similar settings will require expanded training and service provision across the health system, community outreach and mobilisation with women, robust data, and, most critically, a commitment to addressing the range of gynaecological health through the life course.