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From the Field to the Judge’s Bench


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From the Field to the Judge’s Bench …

From the Field to the Judge’s Bench

Published by Human Rights Law Network(HRLN), a division of Socio Legal Information Centre(SLIC). For more details about our works, visit us at

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  • 1.   From  the  Field  to  the  Judge’s  Bench:     Developing  Litigation  Strategies  to  Improve  the  Lives  of  Women     24th  –  25th  November  2012   Assam  Association   A-­‐14  B  Qutab  Institutional  Area,  New  Delhi                                 IN  COLLABORATION  WITH       HEALTHWATCH  FORUM  –  BIHAR   INITIATIVE  FOR  HEALTH  AND  EQUITY  IN  SOCIETY   WOMEN’S  ASSOCIATION  MARCHING  AHEAD   MANASI  SWASTHYA  SANSTHAN   ALL  INDIA  DRUG  ACTIONNETWORK   JANADHIKAR  MANCH  -­‐  BIHAR                              
  • 2.                   From  the  Field  to  the  Judge’s  Bench:     Developing  Litigation  Strategies  to  Improve  the  Lives  of  Women                         IN  COLLABORATION  WITH       HEALTHWATCH  FORUM  –  BIHAR   INITIATIVE  FOR  HEALTH  AND  EQUITY  IN  SOCIETY   WOMEN’S  ASSOCIATION  MARCHING  AHEAD   MANASI  SWASTHYA  SANSTHAN   ALL  INDIA  DRUG  ACTIONNETWORK   JANADHIKAR  MANCH  -­‐  BIHAR                                                  
  • 3. Human  Rights  Law  Network’s  Vision     • To  protect  fundamental  human  rights,  increase  access  to  basic  resources  for  marginalized   communities,  and  eliminate  discrimination.     • To  create  a  justice  delivery  system  that  is  accessible,  accountable,  transparent,  efficient,   affordable,  and  works  for  the  underprivileged.     • To  raise  the  level  of  pro-­‐bono  legal  experience  for  the  poor  to  make  the  work  uniformly   competent  as  well  as  compassionate.     • To  professionally  train  a  new  generation  of  public  interest  lawyers  and  paralegals  to  be   comfortable  in  the  world  of  law  as  well  as  in  social  movements  and  to  learn  from  such   movements  to  refine  legal  concepts  and  strategies.           FROM  THE  FIELD  TO  THE  JUDGE’S  BENCH:  DEVELOPING  LITIGATION  STRATEGIES  TO   IMPROVE  THE  LIVES  OF  WOMEN   January  2013     ©  Socio  Legal  Information  Centre*         Editor:  Kerry  McBroom     Coordinator:  Karla  Torres       Printed  at:  Rudra  Printers,  181,  First  Floor,  Bapu  Park,  Kotla  Mubarakpur,  New  Delhi  –  110003.       Published  by:       Human  Rights  Law  Network  (HRLN)     A  division  of  Socio  Legal  Information  Centre     576  Masjid  Road,  Jangpura,  New  Delhi  –  110014,  India   Ph:  +91-­‐11-­‐24379855/56     E-­‐mail:     Website:         Disclaimer:       The  views  and  opinions  expressed  in  this  publication  are  not  necessarily  the  views  of  HRLN.  Every   effort  has  been  made  to  avoid  errors,  omissions,  and  inaccuracies.  HRLN  takes  sole  responsibility   for  any  remaining  errors,  omissions  or  inaccuracies  that  may  remain.       *Any  section  of  this  volume  may  be  reproduced  for  public  interest  purposes  with  appropriate   acknowledgement  without  prior  permission  of  Human  Rights  Law  Network.        
  • 4. Table  of  Contents       Introduction……………………………………………………………………………………………………………………………...1     Welcome  Address……………………………………………………………………………………………………………………...2     Access  to  Sexual  Health  Education:  Helping  Youth  Exercise  their  Rights………………………………………3     National  Entitlements:  There  is  No  Benefit  if  There  is  No  Implementation…………………………………...6     Access  to  Contraception:  Supporting  Women  to  Achieve  the  Highest  Standard  of  Sexual  and   Reproductive  Health………………………………………………………………………………………………………………..11     Skilled  Birth  Attendants  in  the  Field:  How  a  Shortage  in  Human  Resources  and  Training   Jeopardizes  Women’s  Maternal  Health……………………………………………………………………………………..16     Child  Marriage:  Protecting  the  Rights  and  Lives  of  India’s  Children……………………………………………18     Hysterectomies:  Insurance  Fraud  and  Reproductive  Rights………………………………………………………23     Status  of  Family  Planning  in  India………………………………………..........................................................................27     Experiences  from  the  Field:  Francis  Elliot’s  Personal  Recount………………………………………………......29     Devika  Biswas  vs.  Union  of  India  and  Ors.:  Female  Sterilization  in  India………………………………………30     Female  Sterilization  in  India:  A  State  by  State  Recount  from  Uttar  Pradesh,  Rajsathan,  Odisha,   Madhya  Pradesh,  and  New  Delhi…………………………….………………………………………………………………..34     List  of  Participants………………………………………………………………………………………………………………......47      
  • 5. Introduction     Over  two  days,  activists  and  advocates  gathered  to  discuss  some  of  the  most  pressing  reproductive   rights  issues  in  India.  Activist  presented  on  a  wide  range  of  topics  ranging  from  child  marriage  to   sexual   health   education   to   female   sterilization   all   with   the   aim   to   determine   how   these   reproductive  rights  violations  can  be  advanced  through  public  interest  interventions.  Our  purpose   was   to   bring   grassroots   level   activists,   policy   experts,   and   advocates   together   to   bridge   the   gap   between   activists   in   the   field   and   advocates   in   the   courtroom.   In   this   way,   together,   we   can   promote  reproductive  rights  as  human  rights.       Reproductive  rights  violations  in  India  are  fomented  and  compounded  by  cultural,  religious,  and   societal   contexts.   Any   approach   to   address   reproductive   rights   violations   in   India   must   be   committed,  crosscutting,  and  collaborative.  There  is  no  silver  bullet  to  right  these  wrongs,  just  like   there  is  also  no  panacean,  hierarchical,  or  methodical  method  of  bringing  an  end  to  them  either.     Instead,   a   comprehensive,   multi-­‐faceted   approach   to   advocacy   is   necessary.   This   approach   must   embrace   field   level   activism   and   litigation,   policy   advocacy   and   demonstrations;   all   efforts   undertaken   as   pieces   of   a   bigger,   cohesive,   picture   to   eradicate   the   ills   of   rampant   reproductive   rights  violations.         Reproductive  Rights  in  India       The   1994   Cairo   International   Conference   on   Population   and   Development   (ICPD)   defines   reproductive  rights  as  follows:     Reproductive   Rights   rest   on   the   recognition   of   the   basic   right   of   all   couples   and   individuals   to   decide   freely   and  responsibly   the   number,   spacing   and   timing   of   their   children   and   to   have   the   information   and   means   to   do   so,   and   the   right   to   attain   the   highest  standard  of  sexual  and  reproductive  health.  They  also  include  the  right  of  all   to   make   decisions   concerning   reproduction   free   of   discrimination,   coercion   and   violence.1     In   India   today,   women   young   and   old   are   victims   of   one   of   the   highest   maternal   mortality   rates   in   the  world,  coercive  population  control  policies,  forced  sterilization,  a  lack  of  comprehensive  sexual   health   education,   limited   information   regarding   contraception,   inadequate   access   to   contraception,   and   persistent   child   marriages.   All   of   these   issues   continue   compromising   the   lives   of   millions   of   women,   female   adolescents,   and   girl   children   in   violation   of   their   reproductive   rights.     The  following  paragraphs  provide  a  short  background  on  each  reproductive  rights  issue  discussed   during  our  National  Consultation.  Following  each  issue  is  a  summary  of  the  information  presented   and  the  recommended  ways  forward.                                                                                                                           1  Chapter  VII,  Reproductive  Rights  and  Reproductive  Health,  International  Conference  on  Population  and   1  
  • 6. Welcome  Address     Sonali  Regmi,  Center  for  Reproductive  Rights  (CRR)     Ms.  Regmi  presented  on  the  work  of  her  organization,  the  CRR.  The  CRR  is  an  international  NGO   based   in   the   United   States,   which   has   been   working   on   reproductive   rights   for   20   years.   The   organization  recently  opened  regional  offices  in  Latin  America,  Africa,  Europe,  and  Asia.  Ms.  Regmi   is   based   at   the   Asian   regional   office,   which   is   based   in   Kathmandu.   Ms.   Regmi   began   her   presentation  by  stating  that  as  reproductive  rights  are  not  fully  recognized  as  human  rights,  the   CRR   works   to   connect   reproductive   rights   to   the   larger   human   rights   framework.   She   told   the   participants   that   there   is   a   clear   link   to   the   right   to   life   and   the   right   to   health   but   that   reproductive  rights  also  engage  a  myriad  of  other  rights.  She  also  stated  that  reproductive  rights   are  inherently  connected  to  women’s  rights  and  that  the  CRR  uses  international  standards  such  as   the  ICPD  and  the  Beijing  Declaration  to  promote  women’s  rights  in  the  area  of  reproductive  health   law.     Ms.  Regmi  told  the  participants  that  the  CRR  focuses  on  reducing  maternal  mortality,  increasing   access   to   contraception,   improving   access   to   safe   and   affordable   abortions,   and,   more   recently,   preventing  harmful  traditional  practices  including  child  marriage.  Ms  Regmi  shared  that  the  CRR   is   now   focusing   on   child   marriage,   as   there   is   a   link   between   this   practice   and   maternal   deaths.   She   told   the   participants   that   CRR   felt   it   was   essential   to   begin   working   against   child  marriage,   as   when   people   are   married   at   a   young   age,   they   generally   do   not   know   their   rights.   This   means   that   young  married  people  often  have  limited  access  to  contraception  and  are  unaware  of  their  right  to   decide  on  number  and  spacing  of  children  which  in  turn  leads  to  greater  maternal  mortality.       The  strategies  employed  by  the  CRR  include  litigation,  amicus  briefs,  and  advocacy  before  treaty   committees.   The   CRR   focuses   on   advocacy   at   both   a   national   and   international   level   by   taking   litigation   to   national   courts   but   also   appalling   to   international   treaty   monitoring   bodies   which   offer   an   extra   forum   if   domestic   remedies   fail   to   create   change.   Ms.   Regmi   told   the   participants   that   the   CRR   also   works   on   policy   reforms   and   initiatives   where   lacunas   exist   in   reproductive   rights.       Finally,  Ms.  Regmi  shared  that  the  CRR  also  conducts  training  for  lawyers  and  judges  to  sensitize   them  to  reproductive  rights  issues  and  the  human  rights  framework.  She  told  the  participants  that   training  helps  ensure  more  comprehensive  and  supportive  orders  from  the  courts.  She  stated  that   they  have  spent  ten  years  working  with  judges  in  Nepal,  which  has  led  to  good  judgments,  such  as   the   2009   Lakshmi   judgment.   This   case   concerned   a   women   who   was   pregnant   for   the   fifth   time   and  who  wanted  an  abortion.  Abortion  is  legal  in  Nepal  but  the  women  and  her  husband  could  not   afford   the   1,200   rupees   that   they   were   quoted   at   the   public   hospital   for   the   procedure.   She   therefore   had   to   continue   her   pregnancy   against   her   will.   In   their   judgment,   the   court   utilized   a   reproductive   rights   framework   and   held   that   access   to   abortion   was   a   constitutional   right   and   directed   that   the   government   formulate   a   separate,   rights   based   law   for   abortion.   Ms.   Regmi   highlighted  that  this  was  a  very  good  judgment,  but  stated  that  implementation  was  poor  and  that   no   law   had   so   far   been   created.   In   order   to   combat   this,   the   CRR   had   begun   working   with   national   human  rights  institutions  in  order  to  ensure  implementation  of  judgments.  In  this  case  Ms.    Regmi   stated  that  the  CRR  was  working  with  the  National  Women’s  Commission  in  Nepal  to  produce  a   draft   bill.   She   shared   that   working   with   such   groups   can   often   make   it   easier   to   get   the   legislation   through  for  enactment.     2  
  • 7. Access  to  Sexual  Health  Education     Background  Information     In   its   report   on   adolescent   and   youth   development   for   the   formulation   of   India’s   12th   Five   Year   Plan,   the   Working   Group   on   Adolescents   and   Youth   Development   listed   the   following   as   one   of   its   objectives:   “g)   Facilitate   access   to   all   sections   of   youth   to   basic   nutrition   and   health   especially   related  to  reproductive  and  sexual  health  information  and  facilities  and  services  …”2  This  is  a  not  a   new   sentiment.   The   Working   Group   for   the   11th   Five   Year   Plan   made   a   similar   recommendation   and   stressed   that   a   lack   of   information   on   sexual   and   reproductive   health   leads   to   early   and   unwanted   pregnancies,   the   spread   of   HIV,   sexually   transmitted   infections   (STIs),   and   Reproductive  Tract  Infections  (RTIs).  The  Working  Group  noted  that  although  “adolescents  want   sexuality   education,”   there   is   “resistance   from   adults   in   the   family   and   community,”   adding   that   even  teachers  “feel  inhibited  to  discuss  issues  related  to  sexuality  and  reproductive  health.”3       The   Ministry   of   Human   Resource   Development   in   collaboration   with   the   National   AIDS   Control   Organization   developed   the   Adolescent   Education   Programme   (AEP),   a   sexual   health   education   curriculum.   Although   the   drafters   envisioned   AEP   as   a   nation-­‐wide   curriculum,   several   states   including   Rajasthan,   Chhattisgarh,   Madhya   Pradesh,   and   Uttar   Pradesh   have   rejected   the   AEP   curriculum   arguing   that   it   leads   to   devious   and   harmful   sexual   activities.   In   addition   to   being   banned  in  several  states,  several  important  NGOs  criticized  the  AEP  for  being  out  of  touch  with  the   youth   of   today.   The   AEP   suffered   from   serious   flaws   and   focused   on   “abstinence   only   until   marriage,”  as  a  means  of  avoiding  unplanned/early  pregnancies,  HIV,  RTIs,  and  STIs.     An  improved,  comprehensive,  sexual  health  education  is  essential  to  preventing  early/unplanned   pregnancies,   the   spread   of   HIV,   RTIs,   STDs,   and   to   ensuring   that   women   achieve   the   highest   standard   of   sexual   and   reproductive   health.   Legal   advocacy   to   pressure   the   Government   to   a)   work   with   NGOs   on   developing   a   new   and   improved   curriculum   and   b)   implementing   it   on   a   national  scale  can  be  effective  and  will  improve  the  lives  of  women  in  India.       Information  Presented     Gopika  Bashi,  The  YP  Foundation  (TYPF)     Representing  TYPF,  Projects  Manager  Ms.  Gopika  Bashi  presented  on  TYPF’s  work  and  aims.  TYPF   is  a  youth-­‐run  and  led  organization  with  partnerships  in  18  Indian  states.  TYPF  works  to  promote,   protect,   and   advance   young   people’s   health   and   human   rights   through   youth-­‐led   leadership   building,  strengthening,  and  initiatives.  Their  target  age  groups  are  5-­‐9,  10-­‐14,  15-­‐19,  and  20-­‐25   (following   the   United   Nations   definition   of   youth).   TYPF   focuses   on   working   with   young   people   both  in  and  out  of  school  and  collaborates  with  young  people  from  lower  income  communities  and   youth   from   the   disabled,   LGBT,   children   of   sex   workers,   living   with   HIV,   and   who   have   been   orphaned,  abandoned  or  live  in  government  care.                                                                                                                     2  Report  of  Working  Group  on  Adolescents  and  Youth  Development,  Dept.  Of  Youth  Affairs,  M/o  YA&S  for  Formulation   of  the  12th  Five  Year  Plan  (2012-­‐2017),  Ministry  of  Youth  Affairs  &  Sports,  2011,  p.  68.   3  Draft  Final  Report  of  the  Working  Group  on  Youth  Affairs  and  Adolescents’  Development  for  Formulation  of  11th  Five   Year  Plan  (2007-­‐2012),  p.  12.   3  
  • 8. Promoting Artist Rights & Livelihood Opportunities Mental Health and Substance Abuse prevention. Digital Media, IT and Learning Young People working with their Communities Education Sexual and Reproductive Health and Rights (Life Schools & Formal Education) & Health (Hygiene & Sanitation) Governance & Democracy (RTE & RTI)     Ms.   Bashi   noted   the   lack   of   knowledge   on   how   to   involve   young   people   in   policy   making   and   national   programmes   and   sees   a   need   to   create   safe   spaces   for   young   people   to   communicate   directly  with  decision  makers.  To  strengthen  youth  leadership,  TYPF  engages  youth  in  a  constant   dialogue   on   issues   including   child   marriage,   unsafe   abortion,   gender   discrimination,   HIV/AIDS,   and   a   lack   of   youth-­‐friendly   health   services.   TYPF’s   programme   objectives   between   2011-­‐2013   include   increasing   young   people’s   understanding   and   awareness   of   their   Sexual   and   Reproductive   Health   Rights   (SRHR),   advocating   for   the   implementation   of   comprehensive   sexual   education   (CSE)  in  Uttar  Pradesh,  National  Capital  Region,  and  Maharashtra,  and  mentoring  50  youth  leaders   to   enable   the   implementation   of   CSE   at   the   district   level.   To   this   end,   partnership   is   vital   to   the   campaign’s  successful  implementation.     Ms.  Bashi’s  presentation  also  highlighted  the  youth  friendly  monitoring  and  evaluation  framework   that   TYPF   employs.   Additionally,   Ms.   Bashi   shared   several   complimentary   policy   responses   to   TYPF’s  approach  to  CSE  promotion.  These  have  included  structuring  the  HIV  Prevention  for  Youth   and   Adolescents   Programme,   serving   on   UNESCOs   Global   Advisory   Group   for   Sexuality   Education,   producing  data  that  is  being  used  in  a  pilot  to  strengthen  school  mechanisms  and  train  teachers  in   12   zones   of   Delhi,   and   creating   adolescent   strategies   to   ensure   CSE   for   out   of   school   youth   in   UNFPA’s  Country  Programme  8.       TYPF   has   faced   several   challenges   in   implementing   its   organizational   objectives.   These   include   that   a)   it   has   multiple   partners,   which   can   make   forward   movement   time   consuming,   b)   its   monitoring   and   evaluation   process   needs   to   work   for   young   people   and   also   create   credible   evidence  from  the  field,  c)  its  approach  is  a  novel  process  for  government  agencies,  which  can  take   time   to   build   trust,   and   d)   its   entry   points   for   advocacy   change   constantly,   requiring   consistent   monitoring  and  constant  building  of  new  relationships.       Dipa  Nag  Chowdhury,  MacArthur  Foundation     Ms.  Nag  Chowdhury  spoke  on  the  reality  of  policy  and  policy  making  in  New  Delhi.  For  example,   policy   makers   in   the   capitol   are   unwilling   to   deal   with   child   marriage.   In   states   where   child   marriage  is  endemic,  Ms.  Nag  Chowdhury  stressed  that  advocacy  is  as  important  as  law.  As  girls   get  married,  they  need  specialized  services  that  do  not  necessarily  or  always  fall  under  women’s   services.  This  is  especially  detrimental  to  women  who  depend  on  comprehensive  health  services   in  their  teen  and  mature  ages.  Ensuring  sexual  health  education  is  an  important  way  of  providing   4  
  • 9. young  people,  especially  young  girls,  with  the  skills  and  tools  to  protect  themselves  and  give  them   a  happier,  safer,  and  healthier  life,  particularly  as  regards  to  HIV/AIDS.     Shocking   instances   of   gang   rape   of   children   can   be   used   to   highlight   the   need   for   and   push   for   greater   sexual   health   education.   To   this   end,   government   services   and   education   must   complement   each   other.   Ms.   Nag   Chowdhury   also   noted   that   even   in   states   where   sexual   health   education  is  being  taught,  it  is  not  being  taught  well.       Senior  Advocate  Colin  Gonsalves     Acting   as   facilitator   and   moderator,   Mr.   Gonsalves   asked   who   amongst   our   participants   saw   the   potential   for   a   PIL   in   the   presentation   on   access   to   sexual   health   education.   One   woman   recognized   that   a   PIL   could   be   filed   to   make   CSE   compulsory   in   school.   Another   woman   shared   that   often   teachers   feel   uncomfortable   teaching   sexual   health   education   to   their   students.   She   recommended   a   PIL   that   includes   a   request   for   a   centre   where   students   can   speak   to   social   workers  and  psychologists  that  offer  sexual  health  counselling  for  children  and  parents.  One  man   noted   that   developing   a   PIL   first   requires   significant   ‘homework’.   He   shared   that   female   biology   teachers  are  uncomfortable  teaching  male  students  about  their  reproductive  systems  and  instead   avoid  the  subject.  Therefore,  before  a  PIL  can  be  filed,  CSE  and  CSE  instructors  must  be  sensitised.   Judges   in   particular   must   be   sensitised.   Another   woman   was   of   the   opinion   that   sexual   health   education  needs  to  happen  within  the  sphere  of  the  family:  if  parents  are  given  the  resources  to   teach  their  children  about  sexual  health,  there  is  no  need  for  it  to  be  taught  outside  of  the  home.   Finally,   one   woman   shared   about   the   need   for   counselling   of   children   who   have   suffered   sexual   violence.         Recommended  Ways  Forward     The  ban  on  sexual  health  education  is  the  starting  point  for  a  PIL.  While  it  is  in  place,  it  is  arbitrary,   discriminatory,  and  unconstitutional  because  it  deprives  the  young  people  of  India  with  education   necessary   for   them   to   lead   a   healthy   life.   (Constitution   of   India:   Right   to   life,   Article   21).   Mr.   Gonsalves   agreed   that   the   ‘backward   cultural   angle’   must   be   handled   sensitively.   Mr.   Gonsalves   also  suggested  that  to  start  a  PIL,  we  must  develop  a  sample  to  show  what  sexual  health  education   means   and   what   it   comprises.   In   order   to   do   so,   Mr.   Gonsalves   counselled,   we   must   look   at   successful   international   examples.   He   also   stressed   that   there   must   be   a   coalition   of   groups   backing   the   PIL.   He   agreed   that   caution   must   be   taken   to   avoid   filing   a   PIL   that   reaches   farther   than  judges  are  willing  to  go  sharing  that  perhaps  there  should  be  an  attempt  to  reach  out  to  and   educate  judges  before  a  PIL  is  filed.     Issue   Sexual  Health   Education   PIL  Status   • •   • Background   gathering   Coalition   building   Drafting   Complimentary   Advocacy  Partners   Strategies     • Sensitization   • HRLN   workshops   • The  YP   • Youth  Awareness   Foundation   Raising   • MacArthur   workshops   Foundation   5  
  • 10. National  Entitlements     Background  Information     As   last   recorded,   India’s   Maternal   Mortality   Rate   (MMR)   is   212   deaths   for   every   100,000   live   births.   According   to   the   United   Nations   Population   Fund,   as   of   2010,   one   third   of   all   maternal   deaths  in  the  world  take  place  in  India  and  Nigeria  alone,  14%  and  20%  respectively.  In  order  to   address   its   high   MMR,   the   Indian   government   developed   several   national   benefit   and   incentive   schemes  to  promote  maternal  health  vis  a  vis  institutional  deliveries  and  ante-­‐  and  post-­‐natal  care.   Notwithstanding,   these   schemes   have   had   moderate   success   due   in   large   part   to   their   lack   of   implementation.  The  following  is  a  short  description  of  some  of  the  national  entitlements  available   to  pregnant  and  lactating  women  in  India.     National  Rural  Health  Mission  (NRHM)     The  National  Rural  Health  Mission  (NRHM)  was  launched  to  strengthen  public  health  systems  in   rural   areas.   NRHM’s   aim   is   to   provide   effective   health   care   to   India’s   rural   population   with   a   special  focus  on  states  that  have  poor  public  health  indicators  and/or  weak  infrastructure.       Through   NRHM,   state   governments   are   provided   central   government   funds   to   improve   the   state’s   public   healthcare   systems.   In   this   way,   states   bear   the   responsibility   of   identifying   and   assisting   their  most  broken  district  public  healthcare  systems.     Janani  Shishu  Suraksha  Karyakram  (JSSK)     JSSK  is  a  scheme  developed  under  NRHM.  The  scheme  ensures  free  services  to  pregnant  women   including  cashless  delivery  at  a  government  centre,  caesarean  section  if  needed,  medicines,  drugs   and   consumables,   diagnostics   facilities   including   ultrasound,   provision   of   blood   units   without   payment  of  testing  charges,  exemption  from  all  user  charges  and  free  diet  during  the  stay  at  the   facility  (three  days  in  case  of  normal  delivery  and  seven  days  in  case  of  a  caesarean  section)  and   free  transportation  home.     Janani  Suraksha  Yojana  (JSY)     NRHM   launched   the   JSY   scheme   to   promote   institutional   delivery   and   to   reduce   neo-­‐natal   mortality.  The  JSY  scheme  entails  specific  guidelines  for  health  care  during  pregnancy:     The  scheme  provides  financial  assistance  to  Below  Poverty  Line  (BPL),  Scheduled  Caste  (SC),  and   Scheduled   Tribe   (ST)   pregnant   women   who   obtain   antenatal   care,   undergo   institutionalized   delivery,  and  seek  postpartum  care.         Under  the  JSY  scheme,  ASHAs  are  assigned  to  every  village  to  serve  as  a  link  between  the  pregnant   woman  and  governmetn  schemes  and  facilities.  The  ASHA’s  responsibilities  include:     • Identifying   pregnant   women   as   a   beneficiaries   of   the   schemes   and   reporting   or   facilitating  registration  for  ante-­‐natal  care  (ANC);   • Providing   and/or   helping   women   receive   at   least   three   ANC   checkups   including   Tetanus  injections  and  Iron  Folic  Acid  tablets;   6  
  • 11. • • • • • • • • Preparing  a  micro  birth  plan;   Identifying   a   functional   government   health   center   or   an   accredited   private   health   institution  for  referral  and  delivery,  immediately  upon  registration;   Counseling  women  for  institutional  delivery;   Escorting   the   beneficiary   woman   to   the   pre-­‐determined   health   center   and   staying   with  her  until  she  is  discharged;   Arranging  to  immunize  the  newborn  until  the  age  of  14  weeks;   Informing  the  Auxilary  Nurse  Midwife  (ANM)/Medical  Officer  (MO)  about  the  birth   or  death  of  the  child  or  mother;   Performing  a  post-­‐natal  visit  within  7  days  of  delivery  to  track  the  mother’s  health;   Counseling   for   initiation   of   breast-­‐feeding   to   the   newborn   within   one-­‐month   of   delivery  and  its  continuance  until  3-­‐6  months  and  promoting  family  planning;  and   Facilitating  the  payment  of  financial  assistance  immediately  following  the  delivery.   •   Additionally,  the  JSY  scheme  ensures  that  BPL  women  receive  Rs.  500  for  home  delivery.       National  Maternity  Benefit  Scheme  (NMBS)     NMBS  is  a  social  assistance  scheme  meant  to  provide  financial  assistance  to  pregnant  BPL  women.   The  beneficiary  woman  must  be  a  permanent  resident  of  a  village  and  the  entitlement  is  valid  up   to  any  number  of  births.  NMBS  is  the  result  of  a  2001  Supreme  Court  order  in  PUCL  vs.  Union  of   India  and  Ors.,  (Writ  (Civil)  Petition  No.  196  of  2001).  Under  NMBS:       • All  BPL  pregnant  women  should  be  paid  Rs.  500,  8–12  weeks  prior  to  delivery  for   each  of  the  first  two  births;  and   • The  benefit  under  NMBS  must  be  paid  irrespective  of  place  of  delivery  and  age.     The  Supreme  Court  has  said  that  the  JSY  and  NMBS  schemes  are  distinct  and  that  women  should   have  access  to  benefits  under  both  schemes.  In  reality,  unfortunately,  they  are  interpreted  as  the   same  scheme  and  women  usually  only  receive  money  under  JSY.         Information  Presented     Javid  Chowdhury,  Former  Secretary  of  Health,  Ministry  of  Health  and  Family  Welfare     Mr.  Chowdhury  began  by  saying  that  there  is  no  explicit  right  to  health  and  no  statutory  right  for   anyone  who  wishes  to  access  health  rights  in  India.  The  Constitution  covers  the  Right  to  Equality,   Right  to  Public  Discrimination,  and  Right  to  Life,  but  there  is  no  explicit  right  to  health.     Mr.   Chowdhury   shared   that   the   Indian   government   had   recently   introduced   a   draft   National   Health   Act,   which   sought   to   reduce   the   requirements   for   approaching   the   Appeals   Courts   through   PILs.   However,   this   effort   proved   ineffective   because   the   Act   tried   to   a)   provide   everything   to   everyone,  which  achieves  nothing,  and  b)  centralize  the  powers,  which  are  state-­‐bound.  Therefore,   a   reasonable   National   Health   Act   should   be   formed   through   which   citizens   can   approach   subordinate  authorities  for  implementation.     7  
  • 12. Mr.   Chowdhury   also   suggested   several   issues   to   file   a   PIL   on   that   could   have   far-­‐reaching   impacts.   These  included:   • Great  Deficiency  of  Statistical  Data:     o As   Health   Minister,   when   malaria   cases   were   on   the   increase,   Mr.   Chowdhury   struggled  to  ensure  that  the  Ministry  reported  the  true  number  of  malaria  cases.  The   clerk  in  the  Ministry  insisted  that  there  be  no  variation  in  the  figures  for  the  same,   so  the  official  data  indicated  that  deaths  due  to  malaria  were  less  than  1,000  even   though  the  actual  figure  had  gone  up  to  several  thousands.  The  honest  thing  for  the   Indian   government   to   do   in   such   cases   is   to   accept   that   it   does   not   have   the   appropriate  and  accurate  statistics.     o One   great   service   NGOs   have   accomplished   is   that   they   have   pushed   for   better   statistics   and   demographic   information   via   PILs.   For   example,   if   a   PIL   were   raised   on  this  issue  to  higher  courts,  these  would  in  turn  raise  the  issue  to  the  government.   There  is  no  statistical  base  in  the  country  and  it  is  important  to  insist  on  one.  Our   national   statistical   organizations   are   some   of   the   best   in   the   world   but   unfortunately,  this  is  not  true  where  public  health  records  are  concerned.   • Dismal  Infrastructure  in  Health  Care:     o The  underlying  reason  for  this  issue  is  a  lack  of  resources,  which  is  substantial  and   extremely   damaging.   Mr.   Chowdhury   called   for   PILs   to   be   filed   asking   the   government  to  allocate  more  resources  in  public  health  facilities.   o Resources  per  capita  for  primary  health  care  are  approximated  at  Rs.  204  per  health   care  facility.  Under  the  current  situation,  it  is  impossible  to  ensure  a  person’s  right   to  life  through  accessible,  adequate  health  care.     The  recent  Supreme  Court  intervention  in  the  Mid-­‐Day  Meal  Scheme  was  important  and  helpful,   but  Mr.  Chowdhury  stressed  that  it  is  also  important  to  interact  and  provide  health  education  in   rural   areas.   NRHM   has   been   moderately   successful,   he   admitted,   because   it   has   attempted   to   interact   with   villager   and   because,   when   NRHM   provisions   have   not   been   implemented,   PILs   have   been   filed   to   ensure   they   are   implemented.   Unfortunately,   through   the   years,   important   suggestions  have  not  been  implemented.  The  Planning  Commission  recently  convened  and  issued   an   important   report   on   the   subject.   For   example,   the   Planning   Commission   recommended   that   70%   of   health   care   resources   be   allocated   for   primary   health   care.   This   would   ensure   that   90%   of   health   problems   are   dealt   with   at   the   primary   level.   Mr.   Chowdhury   urged   legal   activists   to   support  the  report.     NRHM   called   for   a   reduction   in   the   gap   between   strong   and   weak   states,   but   a   review   after   six   years   of   implementation   shows   that   this   has   not   been   effective.   Mr.   Chowdhury   suggested   that   PILs  be  filed  to  redirect  more  money  to  weaker  areas.     Mr.   Chowdhury   noted   that   there   is   a   tendency   in   the   Indian   government   to   demarcate   NGO   activities  from  government  activities  and  stressed  that  it  is  time  to  do  away  with  that.       Finally,  Mr.  Chowdhury  re-­‐focused  on  public  health  stating  that  although  diseases  like  malaria  can   be  treated  symptomatically,  this  approach  is  not  taken.  Moreover,  drugs  should  be  made  available   free  of  cost  to  poorer  sections  of  the  society  in  order  to  increase  the  outreach  of  health  services.   Mr.   Chowdhury   stressed   the   necessity   of   public   health   access   and   proper   implementation   of   corresponding  schemes.     8  
  • 13.   Jashodhara  Das  Gupta,  SAHAYOG     Mrs.   Das   Gupta   began   by   referring   to   a   chapter   in   the   Planning   Commission   Committee   Report,   which   dealt   with   citizen   engagement.   In   the   past   7-­‐8   years,   she   reported,   many   laws   have   been   framed   for   uplifting   the   poor,   including   those   targeting   health,   education,   employment,   and   women’s  rights.  These  laws  have  only  been  possible  due  to  Jan  Andolan  i.e.,  People’s  Movements.     The  Movement  for  Food  has  been  growing  strong  and  many  schemes  including  JSY  and  JSSK  have   been  created  to  give  entitlements  to  the  poor.  Had  their  intended  beneficiaries  actually  accessed   these   entitlements,   the   Right   to   Food   Commission,   for   example,   would   have   proved   more   successful   in   its   last   11   years   of   implementation.   In   many   cases,   complimentary   successful   judgments   have   also   been   issued.   Nevertheless,   the   challenge   of   implementation   still   remains.   According  to  Mrs.  Das  Gupta,  there  are  two  elements  of  implementation:     1. Making  a  facility  available  to  the  court:  This  would  require  infrastructure,  resources,   manpower,   etc.   Most   recently,   in   the   Planning   Commission,   a   budget   was   created   for   providing  universal  health  in  the  next  few  years.   2.  Accountability:   Even   after   obtaining   judgments   that   are   in   favour   of   the   public,   if   there  is  no  accountability,  judgments  are  ineffective.     Mrs.  Das  Gupta  explored  the  meaning  of  accountability  saying  that  it  has  two  essential  elements.   The   first   is   a   hierarchical   system   for   managerial   accountability.   Here,   reporting   to   a   higher   authority  is  necessary.  It  is  mandatory  that  a  budget  be  made  to  account  for  expenses.  However,   this   is   not   the   kind   of   accountability   Mrs.   Das   Gupta   referred   to.   Instead,   she   wanted   to   talk   about   social   accountability,   which   has   more   to   do   with   the   relationship   between   the   implementers   of   these  schemes  and  their  intended  beneficiaries.   Mrs.  Das  Gupta  shared  that  her  last  26  years  of  experience  in  Uttar  Pradesh  with  adivasis,  Dalits,   and   other   marginalized   communities   made   her   realize   that   India’s   schemes   system   shows   an   unequal   power   struggle   between   the   implementers   and   the   beneficiaries.   For   example,   remote   areas  do  not  benefit  from  these  schemes  because  there  is  no  parity  in  their  implementation.  Poor   villagers  do  not  know  whom  to  approach  if  they  want  to  obtain  a  BPL  card  or  a  Dalit  certificate.   Under  JSY,  pregnant  women  are  told  they  will  receive  Rs.  2,400  if  they  deliver  in  public  hospitals.   Yet,  once  they  go  to  public  hospitals,  they  are  treated  roughly  and  rudely  turned  away.       Mrs.   Das   Gupta   stressed   that   to   file   a   PIL,   we   must   make   sure   that   we   have   the   support   of   the   People’s  Movement.  It  is  of  no  use  to  press  for  a  change  through  litigation  without  their  support.   Women   in   poorer   areas   are   not   satisfied   with   the   family   planning   schemes.   Entitlements   are   available,  but  they  do  not  reach  the  poor.  Under  JSSK,  everything  from  transport,  treatment,  and   post-­‐operative  checks  are  meant  to  be  free  of  cost.  Additionally,  women  are  meant  to  receive  Rs.   2,400   for   institutional   delivery   under   JSY.   Instead,   a   recent   survey   reveals   that   women   end   up   spending  around  Rs.  1,277  during  their  pregnancy  and  delivery.  It  is  necessary,  then,  for  people  to   claim   the   benefits   to   which   they   are   entitled.   If   people   remain   unaware   of   these   schemes,   they   are   of  no  use.  Mrs.  Das  Gupta  noted  that  lawyers  must  form  relationships  with  villagers  with  the  help   of  the  People’s  Movement  and  NGOs  working  on  these  issues.     9  
  • 14. Mrs.  Das  Gupta  concluded  her  remarks  stating  that  judgments  are  of  no  use  if  they  are  limited  to   paper.   Instead,   we   must   all   work   together   to   ensure   that   these   judgments   reach   their   intended   beneficiaries.       Advocate  Shamik  Naraian:     Mr.  Naraian  stressed  that  we  need  to  be  vigilant  and  make  sure  that  the  implementation  of  these   schemes  is  being  continuously  measured.  Advocates  and  NGOs  should  also  work  collaboratively  to   make  sure  positive  judgments  are  implemented.       Recommended  Ways  Forward     Issue   PIL  Status   Non-­‐Implementation   • Background   of  National   gathering   Entitlements   • Coalition  building   • Fact  Finding   • Drafting   Complimentary   Strategies     • Monitoring   Committees  to   oversee   implementation   • Impose  fines  on   non-­‐participating   public  health   facilities                                                   10   Advocacy  Partners   • SAHAYOG  
  • 15. Access  to  Contraception     Background  Information     Access   to   contraception   in   India   is   an   essential   element   to   improving   women’s   health.   Nevertheless,   Frederika   Meijer,   India’s   representative   to   the   United   Nations   Population   Fund,   recently  revealed  that  the  estimated  number  of  women  without  access  to  contraceptives  in  India   sits  at  28  million,  which  accounts  for  10%  of  the  world’s  unmet  need.  If  access  to  contraceptives   was   provided   to   Indian   women,   Ms.   Meijer   noted,   “unintended   pregnancies   would   drop   by   two   third[s]   and…[it]   would   save   [the]   lives   of   thousands   of   women   and   newborns.”   Nevertheless,   according  to  the  Annual  Health  Survey,  “at  least  one-­‐fifth  of  CMW  [currently  married  women]  are   yet  to  meet  their  family  planning  requirement…”       Young  women  are  also  implicated  in  India’s  unmet  need.  UNICEF  recently  reported  that  with  243   million   adolescents,   India   has   the   highest   number   of   adolescents   in   the   world.4  A   2011   report   revealed   that   condom   use   is   staggeringly   low   among   adolescents   who   engage   in   premarital   sex;   only   an   alarming   27%   of   young   men   have   ever   used   a   condom   and   just   7%   of   young   women   have   used  a  condom.5       Information  Presented     Dipika   Jain,   Professor   Jindal   School   of   Law,   Centre   for   Health   Law,   Ethics   and   Technology   (CHLET)     Ms.  Jain  shared  that  her  organization,  Centre  for  Health  Law,  Ethics  and  Technology  (CHLET)  has   recently   undertaken   an   evidence-­‐based   research   project   because   she   “   wanted   to   know   what's   going  on  in  the  field  rather  than  depend  entirely  on  theoretical  data."  CHLET  began  collecting  data   for  its  study  in  September  2012  by  visiting  5  districts  in  Haryana  to  investigate  women’s  access  to   contraceptives.  The  study’s  findings  could  then  be  used  to  gauge  the  availability  of  and  access  to   contraceptives  in  Haryana  districts  and  for  a  possible  PIL  on  the  issue.     Ms.  Jain  shared  the  following  background  information  to  provide  context  to  the  issue.  There  are  14   different   varieties   of   contraceptives   available   in   India,   of   which   10   have   been   scientifically   declared   'effective'.   The   national   list   of   essential   medicines   includes   hormonal   contraceptives,   condoms,  and  copper-­‐T.  CHLET’s  study  was  concerned  with  whether  or  not  the  medicines  listed   on  the  national  list  of  effective  medicines  are  readily  available  in  hospitals  and  whether  married   women  are  aware  of  them.  If  they  are,  CHLET  questioned  why  women  do  not  avail  themselves  of   them  or  know  to  avail  themselves  of  them,  CHLET  wondered  whether  women  failed  to  seek  access   to  contraceptives  because  of  socio-­‐cultural  barriers  or  whether  there  are  other  reasons.     Ms.   Jain   reported   that   29%   of   India’s   MMR   could   be   prevented   if   women   had   access   to   safe,   effective   contraceptives.   Unfortunately,   of   the   budget   assigned   to   procurement   and   dissemination   of   contraceptives   in   India   for   2012,   about   68.75%   was   left   unused.   This   led   CHLET   to   conclude                                                                                                                   4  UNICEF  defines  adolescents  as  those  who  are  between  the  ages  of  10  and  19.     5  K.G.  Santhya,  et.  Al.,  Condom  Use  Before  Marriage  and  Its  Correlates:  Evidence  from  India,  International  Perspectives   on  Sexual  and  Reproductive  Health  Vol.  37,  No.  4,  Guttmacher  Institute,  2011.     11  
  • 16. that   although   the   Indian   government   has   sufficient   resources   to   provide   better   access   to   contraception,  these  resources  are  being  wasted.     Of   CHLET’s   findings,   Ms.   Jain   presented   only   a   “microcosm”   of   the   study   that   is   indicative   of   the   study’s  overall  findings.  The  study  focused  on  women,  doctors,  and  ASHA  workers.  In  the  District   of   Sonipat,   for   example,   Ms.   Jain   found   that   the   civil   hospitals   she   visited   open   and   close   erratically,  at  times  only  staying  open  for  2  hours  at  a  time.  Moreover,  ASHA  workers  do  not  work   in   the   reproductive   or   obstetric   departments   but   instead   confine   their   work   to   the   hospital’s   pharmacies.  Moreover,  the  counseling  on  'reproductive  health'  these  hospitals  provide  rarely  goes   beyond  HIV  prevention.  When  the  study  group  attempted  to  access  medicines  from  the  hospital’s   pharmacies,   the   team   was   told   that   that   contraceptive   pills   and   medicines   meant   for   free   distribution  were  actually  being  sold.  Moreover,  the  contraceptives  were  past  their  expiry  date.     The  team  found  a  general  shyness  about  contraception  and  reproductive  health.  No  one  the  group   spoke   with   knew   about   female   condoms   though   most   had   an   idea   about   male   condoms   and   copper-­‐Ts,  which  were  the  most  common  method  of  contraception  used.  The  team  also  found  that   many   people   were   reluctant   to   go   to   government   hospitals   because   they   were   “mistreated”   or   kicked  out.  Instead,  people  preferred  going  to  private  clinics.       The  group  next  visited  colleges  in  the  district  to  talk  to  unmarried  women.  The  group  found  that   78%   of   them   think   that   contraception   is   an   issue   of   health   rather   than   of   sexuality.   Although   over   78%   of   them   had   some   knowledge   about   contraceptives,   most   of   them   knew   nothing   about   government   entitlements   in   this   regard.   Of   note,   98%   of   the   girls   the   group   spoke   to   said   that   there   are   some   cultural   or   social   barriers   that   prevent   them   from   being   upfront   or   frank   about   reproductive  health  or  from  approaching  people  for  guidance  or  assistance  in  matters  pertaining   to  the  same.  When  asked  how  the  girls  knew  of  contraception  methods,  they  responded:  44%  from   TV  programs,  22%  through  friends  and/or  peers,  and  5.5%  (one  girl)  through  books.       The   group   asked   each   hospital   it   visited   what   forms   of   contraception   it   made   available.   The   study   revealed   that   87%   of   the   hospitals   had   copper-­‐Ts   while   only   a   few   had   birth   control   pills.   None   of   the   hospitals   in   the   study   gave   birth   control   pills   on   prescription.   Instead,   they   provided   them   over  the  counter.  The  group  also  found  that  none  of  the  staff  the  group  spoke  to  knew  of  injectable   contraceptives.   CHLET   noted   that   this   was   especially   surprising   since,   as   observed   in   Nepal,   Thailand,  and  other  countries,  injectable  contraceptives  are  one  of  the  most  effective  and  hassle-­‐ free  methods  of  contraception.     On  speaking  with  healthcare  workers,  most  stated  that  sterilization  is  the  most  effective  method  of   contraception.   They   noted   that   it   is   widely   recommended   and   extensively   administered.   When   asked  if  they  provided  family  counseling,  the  replies  were  mixed.  Many  healthcare  staff  workers   do   offer   family   planning   counseling.   Some,   however,   expressed   that   they   are   too   shy   to   counsel   patients  and  only  give  family  counseling  to  fellow  women.  The  staff  asserted  that  they  always  take   a   woman’s   consent   before   administering   female   sterilization.   However,   some   personal   accounts   testify  to  the  contrary.  Female  sterilization  is  the  most  common  method  of  contraception  in  India   and   very   few   people   know   about   female   condoms   as   an   alternative   although   they   are   non-­‐ permanent   and   inexpensive.   Ms.   Jain   commented   that   most   women   prefer   not   to   use   contraceptives  until  they  have  had  a  son.  Nevertheless,  most  women  claimed  they  wanted  to  space   their  deliveries  illustrating  that  there  is  a  certain  level  of  awareness  about  family  planning.     12  
  • 17.   Kalpana  Mehta,  Manasi  Swasthya  Sansthan     Ms.   Mehta   shared   that   in   India,   contraceptives   were   intended   neither   for   health   purposes   nor   sexual   reasons,   but   simply   for   population   control.   The   singular   reason   behind   the   whole   initiative   was   to   curb   births.   Since   their   introduction   in   India,   drastic   population   control   measures   have   been  adopted  including  having  men  aged  16  to  60  forcefully  sterilized.     Ms.   Mehta   questioned   how   a   health   mission,   referring   to   NRHM,   is   expected   to   succeed   when   many   people   still   lack   basic   food,   nutrition,   and   sanitation   provisions.   So   that   distributing   contraceptives  to  people  without  improving  their  standards  of  health  is  tantamount  to  spreading   morbidity.     Ms.  Mehta  spoke  of  a  memo,  released  in  1969,  that  revealed  how  given  the  current  mortality  rates,   a  couple  needs  to  have  at  least  six  children  to  be  sure  that  a  single  surviving  son  will  survive  into   adulthood.   Around   this   same   time,   technology   for   detecting   the   gender   of   the   fetus,   also   known   as   amneocentisis,  was  developed.  The  government  endorsed  the  practice,  the  idea  being  that  it  would   give  people  the  option  of  having  a  son  and  therefore  limit  reproduction.  This  would  in  turn  reduce   India’s   birth   rate   and   reign   in   India's   population   explosion.   In   other   words,   “[couples   would   have]   a  son  without  the  unecessary  reproduction  of  females.”  According  to  Ms.  Mehta,  in  the  year  after   amniocentesis   was   introduced,   800   abortions   were   performed.   She   reported   that   of   these,   799   were  of  female  fetusus;  one  of  the  fetusus  was  actually  a  male  fetus  that  was  mistaken  for  a  female   fetus.       Ms.  Mehta  recalls  that  birth  rates  did  initially  decline.  However,  the  sex  ratio  also  declined.  The  sex   ratio,   she   noted,   is   now   so   disturbingly   skewed   that   in   certain   villages   of   Haryana,   girls   are   kidnapped   and   brought   from   states   like   Kerala   to   become   brides   of   Haryana   men   because   there   simply   are   not   enough   females   left   Haryana.   Nevertheless,   it   took   10   years   for   the   Indian   government  to  develop  any  kind  of  law  to  address  the  issue  of  sex-­‐selective  abortion.  Even  today,   with  a  law  on  the  books,  implementation  remains  a  distant  dream.  Ms.  Mehta  shared  that  in  her   hometown,  where  sex-­‐selection  is  a  prolific  trade,  there  has  only  been  one  case  in  which  the  Pre-­‐ Conception  Pre-­‐Natal  Diagnotic  Technologies  Act  (PCPNDT)    has  been  implemented.  In  the  case,   six   doctors   who   had   been   running   an   illicit   ultrasound   clinic   were   each   fined   Rs.   1,000   for   violating  the  law.     Ms.  Mehta  spoke  of  how  women  who  were  provided  with  oral  birth  control  pills  as  part  of  family   planning   in   India   would   throw   them   into   their   fields   because   apparently   the   hormones   in   them   facilitate  robust  plant  growth.  Ms.  Mehta  shared  that  birth  control  pills  have  been  shown  to  slow   down   the   libido,   drastically   increase   the   chances   of   all   forms   of   cancer,   cause   blood   pressure   issues,   and   give   rise   to   potentially   lethal   blood   clots.   Dependence   on   pills,   she   commented,   encourages   the   spread   of   STDs   and   HIV/AIDS.   She   questioned:   “why   would   men   use   condoms   when   a   woman   is   already   on   the   pill?   What   couple   in   their   right   mind   would   go   for   double   contraception?”     Birth   control   pills   market   themselves   as   being   98%   effective.   Condoms   hover   around   80%   effective.   Although   birth   control   pills   are   more   effective   than   other   forms   of   non-­‐permanent   contraception,   because   they   are   taken   continously   over   a   long   period   of   time,   sometimes   from   the   onset   of   puberty   to   menopause,   their   adverse   effects   ought   to   be   researched   and   taken   very   13  
  • 18. seriously.   In   fact,   some   research   has   already   been   done.   Ironically,   however,   this   research   is   usually   carried   out   by   the   very   same   drug   manufactures   that   manufacture   and   market   birth   control  pills.     Recently,  the  drug  industry  discovered  that  estrogen  is  the  root  cause  of  many  of  the  side-­‐effects   associated   with   birth   control   pills.   In   2002,   the   government   of   India   assured   the   public   that   it   would   cease   to   allow   the   sale   of   birth   control   pills   with   such   damaging   hormones   under   the   National  Family  Planning  Scheme.  Instead,  the  government  began  using  contraceptive  injections.   These   injectible   contraceptives,   however,   carry   more   than   10   times   as   many   hormones   as   contraceptive  pills.       Ms.  Mehta  noted  that  injectible  contraceptives  are  by  and  large  provider-­‐controlled.  For  example,   a   doctor   may   inject   a   woman   who   visits   a   hospital   for   other,   non-­‐reproductive   health   purposes.   With  birth  control  pills,  however,  a  woman  always  has  the  option  to  throw  them  away  if  she  would   rather   not   take   them.   Injecting   women   with   contraceptives   means   that   reproducitve   rights   are   being  curtailed  instead  of  being  safeguarded.     Ms.  Mehta  noted  that  there  is  a  certain  level  of  coercion  in  the  government's  vehement  patronage   of   drug   companies   and   their   products.   The   American   government,   together   with   the   American   corporate   sector,   is   interested   in   maintaining   a   wide   market   for   its   products   to   ensure   a   hefty   accumulation  of  profit.    It  is  because  of  this  push  for  profit  that  American  drugs  are  so  conspicuous   in  the  market.  What  is  more,  the  Indian  government  tries  to  hide  the  drugs’  negative  side  effects  to   keep   women   in   the   dark   about   the   risks.   Ms.   Mehta   recalls   once   comparing   an   Indian   and   American  brand  of  the  same  generic  birth  control  pill  and  finding  that  the  Indian  packaging  had  19   listed  side-­‐effects  where  the  American  packaging  listed  47  side-­‐effects.     Ms.  Mehta  stressed  that  we  need  to  understand  the  entity  we  are  locking  horns  with  because  the   authorities  we  need  to  fight  in  our  battle  for  the  protection  and  promotion  of  reproductive  rights   do  not  just  include  the  Indian  government.     On  a  personal  note,  Ms.  Mehta  shared  that  she  found  it  “absurdly  anticlimactic”  when  people  talk   of   India’s   “unmet   needs   of   contraception.”   She   asked   “What   do   we   understand   as   'needs'?”   Especially   in   light   of   millions   of   people   who   lack   access   to   food   and   potable   water.   She   questioned   how  we  can  expect  these  same  people  to  use  government  grants  for  contraceptive  injections  that   cost   upwards   of  Rs.   1,500.   Ms.   Mehta   also   shared   that   she  resents   the   popular   correlation   made   between  contraception  use  and  maternal  mortality  rates.  Ms.  Mehta  commented,  “women  who  die   during  childbirth,  who  go  into  labor  in  pithy  environs  outside  of  proper  clinics,  who  do  not  receive   proper  aid  and  support  during  the  process  of  child  birth,  they  do  not  die  for  unwanted  children.   These   women   nearly   always   wanted   the   child   they   died   delivering.   Having   handed   them   contraceptives  would  not  have  necessarily  saved  their  life,  when  they  after  all,  wanted  to  have  a   child.”  Maternal  mortality,  Ms.  Mehta  suggested,  is  to  be  addressed  using  greater,  more  systematic   measures   and   safeguards.   To   link   it   to   access   to   contraception   is   tantamount   to   trivilalizing   the   whole  issue.             14  
  • 19. Senior  Advocate  Colin  Gonsalves,  HRLN     Mr.   Gonsalves   began   by   outlining   the   issues   needing   the   most   attention   saying,   “firstly   we   need   to   talk   about   unmet   needs,”   stressing   that   in   many   areas   poor   men   and   women   are   seeking   contraceptives   but   cannot   access   them.   Next,   Mr.   Gonsalves   underscored   the   need   to   discuss   dangerous  forms  of  contraception  and  the  availability  of  contraception  over  the  counter  without   the  need  of  a  prescription.     Mr.   Gonsalves   shared   that   only   recently,   HRLN   had   a   case   on   drug   prices   in   which   the   Supreme   Court   said   that   the   government   has   to   bring   348   essential   medicines   under   price   control   ordering   it   to   follow   the   1995   cost-­‐based   method   of   price   control.   Currently,   the   drug   market   in   India   produces  anywhere  between  a  200%  and  800%  profit.         Recommended  Ways  Forward     Issue   Access  to   Contraception   PIL  Status   • Background   gathering   • Coalition  building   • Fact  Finding   • Drafting   Complimentary   Strategies     • Regulating  the   dispensing  of   birth  control  pills   (i.e.,  only   available  with   prescription)   • Research  and   highlight   negative  side-­‐ effects  of   contraceptives                                           15   Advocacy  Partners   • • • • HRLN   Dipika  Jain  -­‐   Jindal  Global   University   Centre  for  Health   Law,  Ethics  and   Technology   Kalpana  Mehta  –   Manasi  Swasthya   Sansthan  
  • 20. Skilled  Birth  Attendants  in  the  Field     Background  Information     The  status  of  skilled  birth  attendants  in  India  is  illustrative  of  the  government’s  disservice  to  the   women  of  this  country.  A  lack  of  human  resources,  training,  and  compensation  leaves  skilled  birth   attendants  disenfranchised  and  ill-­‐equipped  to  handle  the  medical  needs  of  pregnant  women  the   country  over.  A  skilled  birth  attendant  without  proper  training  or  compensation  is  a  skilled  birth   attendant  without  agency  or  accountability.  This  is  a  dangerous  combination,  especially  where  the   health   of   women   and   children   are   at   stake.   If   India   is   to   achieve   its   Millennium   Development   Goal   on   maternal   mortality,   it   must   invest   in   the   proper   sourcing,   training,   and   compensation   of   skilled   birth  attendants.       Information  Presented     Dr.  Prakasamma,  ANSWERS     Dr.  Prakasamma  presented  on  how  an  acute  shortage  and  lack  of  patronage  affect  the  quality  of   care   women   and   their   children   receive.   Dr.   Prakasamma   began   by   highlighting   the   recent   governmental   push   for   institutional   delivery   and   explaining   that   of   all   pregnancies,   only   15%   result   in   complications.   The   push   for   institutional   delivery   was   based   on   evidence   showing   that   the  presence  of  skilled  birth  attendants  at  the  time  of  delivery  reduced  maternal  mortality  as  did   the   availability   of   essential   obstetric   services   provided   to   women   near   their   home.   Skilled   birth   attendants   are   accredited   health   professionals   (e.g.,   midwives,   doctors,   nurses,   and   ANMS)   who   have   been   educated   and   trained   to   proficiency   in   skills   necessary   to   manage   uncomplicated   pregnancies,   deliveries,   and   post-­‐natal   care   as   well   as   in   the   identification,   management,   and   referral   of   complications   in   women   and   newborns.   This   categorization   does   not   include   dais   or   ASHAs.     The   current   situation   in   the   field   sees   an   acute   shortage   at   all   levels   of   staffing,   extremely   unhygienic   facilities,   evidence   of   harmful   practices,   and   anecdotal   evidence   of   abuse.   At   the   community  level,  a  single  ANM  can  optimally  cater  to  100  births  per  year.  In  practice,  this  number   is  so  great  that  a  single  ANM  is  unable  meet  the  needs  of  the  women  in  her  community.  Moreover,   even  when  a  majority  of  women  access  institutions  for  health  care,  continuity  of  care  requires  a   full  time  and  dedicated  provider.  A  continuity  of  care  requires  7-­‐10  antenatal  check-­‐ups,  education   on  and  preparation  for  delivery,  at  least  one  interaction  with  an  obstetrician,  and  coordination  for   delivery.   Moreover,   comprehensive   care   requires   coordinating   with   an   ASHA,   arranging   for   transport,  receiving  the  required  JSY  payment,  postnatal  care  and  follow-­‐up  checkups  at  home.  In   the   months   following   delivery,   a   mother   and   child   also   require   panoply   of   services   including   immunizations,  growth  monitoring,  infant  illness  treatment,  contraceptive  support  for  the  mother,   and  infant  and  maternal  nutrition  and  vitamin  supplements.     According  to  a  recent  survey,  India  has  more  than  200,000  ANMS  in  the  public  health  system,  with   most   ANMs   posted   in   sub-­‐centres.   However,   there   has   been   a   steady   decline   in   the   number   of   facilities  and  the  skill  level  and  readiness  of  ANMs.  In  fact,  ANMs  are  now  becoming  a  rare  sight  in   far-­‐flung   villages.   In   order   to   properly   care   for   pregnant   women   and   newborn   children,   India   needs   a   minimum   of   250,000   skilled   ANMs   providing   services,   following   up   with   patients,   and   16  
  • 21. documenting   their   services.   More   importantly,   India   needs   ANMs   that   are   dedicated   and   skilled   maternal  and  child  health  providers,  not  multi-­‐purpose  providers.     A   lack   of   ANMs   and   skilled   birth   attendants   means   that   the   health   of   pregnant   women   and   newborn   children   is   unnecessarily   placed   at   risk.   A   low   availability   of   facilities   and   providers   means  that  infection  prevention  measures  are  ignored,  facilities  are  poorly  organized  for  routine   deliveries   and   unprepared   for   complicated   deliveries,   and   that   patients   are   victimized   by   unsensitized   staff.   On   a   micro-­‐level,   this   also   means   that   many   facilities   operate   under   very   unhygienic   circumstances   without   disinfection   practices,   sterile   labor   sets,   gloves   or   even   hand-­‐ washing   protocols.   Dr.   Prakasamma   stressed   that   labour   rooms,   especially,   should   be   as   emergency-­‐prepared  as  intensive  care  units  (ICUs)  stocked  with  adequate  supplies  of  emergency   drugs  and  equipment,  blood  supplies  and  blood  storage  units,  and  staffed  with  skilled  personnel   who  are  able  to  handle  emergency  situations.       The  Indian  government  recently  implemented  a  training  program.  However,  the  program,  which   lasted  only  two  weeks,  has  been  slow  moving,  ad  hoc,  and  ineffective.  Notably,  the  program  did  not   incorporate   a   sensitization   element.   It   is   a   lack   of   sensitization   that   spurs   the   neglect   and   physical   and  emotional  abuse  of  women  at  public  health  facilities.         Advocate  Sandhya  Raju,  HRLN     Advocate   Raju   stressed   that   there   needs   to   be   a   strengthening   of   ASHAs   in   the   field   through   training,   skills   building,   and   capacity   building.   Most   importantly,   skilled   birth   attendants   must   learn  to  be  accountable  for  their  training  and  the  services  they  provide.  Government  hospitals,  too,   must   ensure   basic   hygienic   environments   for   their   patients.   To   provide   anything   less   gives   rise   to   a   strong   PIL.   Infrastructure   must   be   bolstered   in   India’s   public   health   facilities   so   that   facilities   adhere   to   NRHM   and   Indian   Public   Health   Standards   (IPHS)   and   provide   all   of   the   essential   mandated   services.   Advocate   Raju   also   stressed   that   public   health   facilities   need   to   be   held   accountable  for  all  of  the  funds  and  resources  they  receive,  especially  in  light  of  the  services  they   fail  to  provide.       Recommended  Ways  Forward     Issue   Shortage  of  Skilled   Birth  Attendants  in   the  Field/Poor   Labour  Rooms   PIL  Status   • Background   gathering   • Coalition  building   • Fact  Finding   • Drafting   Complimentary   Advocacy  Partners   Strategies     • Sensitization   • HRLN   training  of  public   • Dr.  Prakasamma  -­‐   health  facility   ANSWERS   staff   • Auditing  of   public  health   facility  labour   rooms         17  
  • 22. Child  Marriage     Background  Information     According   to   UNICEF,   47%   of   girls   in   India   are   married   by   age   18   and   18%   of   girls   are   married   by   age   15.6     Experts   agree   that   child   marriage  contributes  to  poor  health  indicators,  lower   levels  of   education,   high   rates   of   maternal   and   infant   mortality,   and   increased   HIV   infection   rates.     Data   shows  that  girls  between  the  ages  of  15  and  19  are  twice  as  likely  as  girls  between  the  ages  of  20   and  24  to  die  of  pregnancy  related  complications.7       Child   marriage   persists   in   the   face   of   the   Prohibition   of   Child   Marriage   Act   (2006).   Tradition,   honor,   gender   inequality,   security,   and   socio   economic   instability   perpetuate   child   marriage.   Moreover,   the   government   has   done   little   to   ensure   implementation   of   the   Prohibition   of   Child   Marriage   Act,   including   posting   Child   Marriage   Prohibition   Officers.   In   fact,   tracking   data   between   the   first   National   Family   Health   Survey   and   its   most   recent   iteration,   there   has   been   little   difference  in  the  percentage  of  women,  age  20-­‐24  who  were  married  between  the  ages  of  15  and   20  (NFHS-­‐1,  45%,  NFHS-­‐2,  44%,  and  NFHS-­‐3,  46%).8       Child  marriage  affects  all  women  in  India  and  especially  those  who  are  too  young  to  advocate  for   their  rights.         Information  Presented     Dinesh   Sharma,   Rural   Development   Society   and   Vocational   Training   Organization   (RUDSOVOT)     Mr.   Sharma   shared   the   experiences   of   his   organization,   the   Rural   Development   Society   and   Vocational   Training   Organization   (RUDSOVOT),   during   a   three-­‐year   project   in   Sawai   Madhopur,   Rajasthan.   RUDSOVOT   conducted   research   on   child   marriage   in   five   districts   and   31   villages.   RUDSOVOT   selected   the   Sawai   Madhopur   area   as   Rajasthan   has   the   second   highest   rate   of   child   marriage   in   India;   82%   of   women   in   the   State   are   married   before   they   reach   18.   In   Sawai   Madhopur,  the  average  ages  of  marriage  are  18.3  for  men  and  14.9  for  women.       RUDSOVOT   conducted   their   research   through   household   surveys   and   through   focus   group   discussions.   Mr.   Sharma   also   stressed   the   importance   of   advocacy   and   awareness   campaigning   during  the  project.  In  this  vein,  RUDSOVOT  held  meetings  with  key  decision  makers  in  children’s   lives  including  parents,  village  heads,  and  schoolteachers.  RUDSOVOT  also  held  advocacy  meetings   and  workshops  and  reached  out  to  five  local  NGOs  and  several  government  departments  to  further   spread  awareness  of  the  project.  Furthermore,  RUDSOVOT  opened  Youth  Information  Centres  and   Youth   Groups   to   educate   adolescents   on   child   marriage.   They   also   initiated   a   peer   education   programme   where   they   trained   selected   girls   and   boys   in   the   district   so   that   they   in   turn   could   educate   their   peers.   The   project   also   led   to   the   creation   of   immunization   camps   to   vaccinate   children   with   DT   and   TT   injections.   Finally,   RUDSOVOT   released   a   magazine   called   Yuva   Ankur,   which  incorporated  personal  stories  of  problems  faced  by  young  adults.                                                                                                                     6  UNICEF  Statistics,  India,  2010.   7  Pregnant  Adolescents:  Delivering  on  Global  Promises  of  Hope,  The  World  Health  Organization,  2006.   8  National  Family  Health  Survey  (NFHS-­‐3)  2005-­‐2006,  Ministry  of  Health  and  Family  Welfare,  p.  35.   18  
  • 23.   Mr.  Sharma  shared  the  information  gathered  using  social  mapping  in  the  project  area.  The  social   map   showed   that   girls   living   the   districts   covered   were   rarely   educated.     Although   there   are   accessible   government   schools   in   the   area,   girls   are   not   being   sent   to   school.   When   local   people   were   asked   about   this,   they   said   there   was   no   point   in   educating   their   girls   because,   after   marriage,  the  girls  will  be  unable  to  financially  help  their  parents.  RUDSOVOT  also  spoke  to  girls  in   the  region  who  were  working  in  traditional  roles  including  cattle  or  sheepherders  or  as  helpers  on   their   parent’s   fields.   When   asked   why   they   were   not   attending   school,   the   girls   answered   that   their   parents   tell   them   that   they   should   take   on   the   role   of   looking   after   the   animals   to   allow   their   brothers  to  attend  school.  Soon  after  this  investigation,  RUDSOVOT  opened  night  schools  to  allow   girls  who  work  during  the  day  to  attend  school.       Mr.  Sharma  then  shared  his  views  on  how  to  help  eradicate  child  marriage.  First,  the  government   must   promote   a   delay   in   the   age   of   marriage.   Second,   we   must   create   an   environment   that   encourages   a   delay   the   age   of   a   woman’s   first   pregnancy.   Third,   we   must   ensure   that   there   is   interactive   and   effective   policy   analysis   and   review   of   child   marriage.   Fourth,   documentation   of   appropriate   intervention   designs   must   be   guaranteed.   Fifth,   there   must   be   education   for   young   people  on  family,  sexual,  and  reproductive  health.  Finally,  Mr.  Sharma  stressed  the  importance  of   ensuring  and  enhancing  youth  participation  in  these  projects.       Mr.   Sharma   shared   some   thoughts   on   the   situation   in   the   field   as   well   as   photos   of   recent   child   marriages.   When   asked   about   child   marriage,   he   reported,   people   often   say   that   since   child   marriages   have   been   taking   place   for   generations,   the   tradition   cannot   be   stopped   now.   They   also   stress  that  generally,  the  bride  remains  with  her  family  after  marriage  until  she  has  matured.  He   also   highlighted   some   new   problems   where   the   number   of   girls   has   decreased   so   much   due   to   families   choosing   to   have   male   children   that   parents   in   other   areas   have   begun   to   take   lakhs   of   money  to  send  their  daughters  far  away  to  be  married.  In  some  villages,  all  the  brothers  in  a  family   will  marry  a  single  girl,  sometimes  with  the  proviso  that  the  girl  need  not  do  any  housework.     Mr.   Sharma   closed   by   sharing   his   sadness   when   he   receives   records   from   the   peer   educators   trained   by   RUDSOVOT’s   project   of   the   children   who   are   still   getting   married   in   the   villages.   Despite  the  District  Collectors  efforts,  and  due  in  part  to  the  corruption  of  the  police,  not  a  single   marriage  in  the  area  has  been  officially  prevented.       Govind  Beniwal,  Member  of  Rajasthan  Commission  for  Protection  of  Child  Rights     Mr.  Beniwal  focused  his  presentation  on  the  structural  issues  of  child  marriages,  He  said,  “I  feel  it   is   important   to   look   at   it   from   the   child   rights   perspective   as   well   as   the   domestic   rights   perspective.   I   feel   that   most   people   think   of   domestic   rights   as   limited   to   marital   discords   but   this   is   not   true.   Domestic   rights   also   include   the   treatment   of   children   in   a   family.”   As   such,   Mr.   Beniwal  explained,  child  marriage  is  an  issue  that  falls  under  domestic  rights.       To  address  this  issue,  the  Indian  Government  passed  the  Prohibition  of  Child  Marriage  Act,  2006   (PCM).  The  law  has  four  distinct  aspects:  Prevention,  Protection,  Rehabilitation,  and  Prosecution   of   offenders.   In   India,   Mr.   Beniwal   explained,   the   Prevention   aspect   is   the   one   that   receives   the   most  attention.  Mr.  Beniwal  stressed  that  we  must  realize  that  the  children  who  have  already  been   married  off  also  need  care.  Especially  as  many  married  children  seek  to  annul  their  marriages.  The   19  
  • 24. PCM   Act   has   a   provision   that   addresses   this   issue,   Mr.   Beniwal   explained,   but   because   of   inadequate  implementation,  activists  are  not  able  to  work  on  it.  A  second  issue  with  the  PCM  Act  is   the   lack   of   clarity   in   the   role   of   stakeholders.   The   Act   gives   power   to   SGMs   as   stakeholders   and   mandates   the   appointment   of   Child   Marriage   Prevention   Officers   (CMPOs),   but   this   power   is   frustratingly   vague.   Mr.   Beniwal   noted   that   India   already   has   an   Integrated   Child   Protection   Scheme   (ICPS),   and   stressed   that   officers   appointed   under   that   scheme   should   also   be   given   agency  under  the  PCM.  Additionally,  rehabilitation  is  unfortunately  not  given  much  importance.       Although   India   may   sometimes   be   successful   in   preventing   child   marriages,   the   aftermath   of   existing   child   marriage   also   needs   attention.   As   India   does   not   ensure   protection   of   married   children   under   its   Domestic   Violence   Act,   2005,   Mr.   Beniwal   urged   India   to   link   India’s   Protection   of   Children   from   Sexual   Offence   Act   with   the   PCM   Act   to   better   protect   children   from   child   marriage,  especially  female  children  whose  consent  is  not  required  under  the  age  of  18.       Turning   to   what   states   can   do   to   curb   child   marriages,   Mr.   Beniwal   underscored   that   states   provide   no   legal   support   to   child   marriage   victims   who   wish   to   annul   their   marriage   or   receive   counseling.   Most   girls   want   to   get   out   of   their   marriages   but   do   not   know   how   to   legally   do   so.   Once  a  child  marriage  occurs,  the  child’s  rights  are  consecutively  violated  and  the  child  is  deprived   of   many   rights   including   his   or   her   right   to   education.   After   marriage,   children   remain   unaware   of   how  to  protect  themselves  from  sexually  transmitted  diseases  and  infections  (STDs  and  STIs)  so   that   their   right   to   health   is   also   made   vulnerable.   Because   many   child   marriages   are   never   registered,  it  is  difficult  to  really  tackle  the  issue.       Mr.   Beniwal   shared   that   in   Bundi   District,   Rajasthan,   which   sees   a   high   number   of   child   marriages   every  year,  the  infant  mortality  rate  (IMR)  is  similarly  very  high.  Mr.  Beniwal  urged  that  we  focus   on  human  trafficking,  which  has   been  on  the  rise  in  the  current  year.  Most  cases  involve  men  over   50   years   of   age   paying   families   an   undisclosed   figure   to   marry   their   minor   daughters.   This   has   been  happening  more  frequently  in  the  past  few  decades,  a  result  of  extreme  poverty.  Mr.  Beniwal   shared   that   only   the   previous   day   he   had   heard   of   a   case   where   seven   child   marriages   were   scheduled  to  take  place.     Mr.  Beniwal  pointed  to  the  well-­‐known  case  of  Bhanwari  Devi,  who  was  gang  raped  by  five  men   after  she   stopped  the  marriage  of  a  child.  This  fear  of  retribution  is  another  reason  why  people  do   not   come   forward   to   stop   child   marriages.   To   support   whistle-­‐blowers   and   child   marriage   activists,  the  Indian  Government  should  declare  monetary  awards  to  whoever  comes  forward  with   a   complaint   of   an   impending   child   marriage.   Additionally,   we   must   focus   on   the   prosecution   of   those  who  violate  the  PCM  Act.  In  Rajasthan,  only  four  offenders  have  been  prosecuted  since  the   Act  was  passed  and  all  four  cases  have  occurred  only  this  year.       In   response   to   criticism,   supporters   of   child   marriage   claim   that   children   consent   to   being   married.   This   consent,   however,   is   obtained   illegally   and   under   duress   rendering   the   marriage   invalid.  Mr.  Beniwal  stressed  that  until  we  look  at  this  issue  from  the  child  rights  perspective,  we   will   be   unable   to   successfully   implement   the   PCM   Act.   We   need   to   develop   appropriate   mechanisms,   monitoring   systems,   and   rehabilitation   systems   in   order   to   improve   the   condition   of   young  child  brides.         20  
  • 25. Advocate  Anant  Kumar  Asthana,  New  Delhi     Mr.   Asthana   discussed   the   conflict   between   the   rights   of   children   and   young   people’s   right   to   choose,   particularly   in   light   of   the   enactment   of   the   new   Protection   of   Children   from   Sexual   Harassment   Act.   The   age   of   consent   has   been   rendered   immaterial   and   this   has   caused   a   crisis   because  courts  have  been  very  consistent  in  acknowledging  16  years  of  age  as  the  age  of  consent.   Accordingly,  if  there  is  an  allegation  of  rape  due  to  sexual  relations  between  young  people  below   the   age   of   18   and   if   the   girl   states   that   she   consented,   state   high   courts   can   quash   any   First   Instance   report   (FIR)  filed   against   the   accused.   Due   to   this  recent   legislation,   any   sexual   activity   between  people  below  the  age  of  18  is  heavily  punished  and  the  accused  can  be  booked  under  any   of  the  Act’s  five  offences.     The   issue,   however,   is   much   more   complicated.   The   Delhi   High   Court   has   recently   issued   a   comprehensive  three-­‐bench  judgment  based  on  the  judgments  of  four  previous  cases:  Lajja  Devi   (2008),   Mahadev   (2008),   Devender   (2010)   and   Laxmi   Devi   (2011).   These   cases   each   involved   a   minor   girl   who   exercised   her   right   to   choice   and   married   a   man   who   was   an   adult.   The   consequences  of  these  cases  are  very  complicated.  Under  Hindu  Law,  the  husband  is  the  guardian.   Therefore,   if   the   marriage   is   lawful,   how   must   one   deal   with   the   question   of   custody?   The   Delhi   High   Court   judgments   give   a   clue   as   to   how   Parliament   has   created   contradictory   laws.   For   example,  a  husband  can  rape  his  own  wife  without  any  legal  consequence  if  the  wife  is  above  the   age   of   16.   It   is   only   if  the   wife   is   15   years   or   younger   that   Section   375   of   the   Indian   Penal   Code   (IPC)  is  enacted.       The  Delhi  High  Court  judgment  also  mentions  that  there  is  a  lack  of  sexual  education  provided  to   young   people,   which   means   that   young   brides   lack   adequate   knowledge   about   sexual   relations,   their   bodies,   and   their   reproductive   systems.   This   denies   girls   the   ability   to   make   informed   decisions   about   their   sexual   relations,   family   planning   choices,   and   their   health.   This   ultimately   results  in  the  girl  leading  a  life  over  which  she  has  no  control.     Mr.  Asthana  explained  that  when  we  deal  with  child  marriage,  important  human  rights  principles   we   uphold   are   pitted   against   each   other.   How,   then,   can   we   link   the   principles   of   reproductive   rights  with  those  of  children’s  rights?       Mr.  Asthana  next  discussed  India’s  personal  law.  The  Delhi  High  Court  has  recently  declared  that  if   a  Muslim  girl  below  the  age  of  15  decides  to  exercise  her  right  to  be  with  a  man  who  is  an  adult,   she   may   do   so.   “What   then   is   the   scope   of   secular   law?”   Mr.   Asthana   stressed.   “Which   law   will   prevail?”   Mr.   Asthana   shared   that   there   is   no   consistency   in   the   application   of   these   laws;   sometimes  it  is  secular  law  that  prevails,  while  other  times  personal  law  prevails.       Mr.   Asthana   urged   audience   members   to   read   the   Criminal   Miscellaneous   Application   No.   11101001   of   2011,   saying,   “on   the   second   page,   you   will   find   Writ   Petition   Criminal   No.   338   of   2008,”   a   62-­‐page   long   judgment   that   includes   the   four   cases   he   had   previously   cited.   The   cases   reveal  that  the  High  Court  suggests  that  an  Amendment  of  Section  375  of  the  IPC  is  required.  In   fact,   the   High   Court   has   asked   Parliament   to   amend   that   section   and   to   examine   several   acts   including   the   PMC   Act   and   the   Hindu   Marriage   Act   to   reach   a   clear   position   on   the   law.   Mr.   Asthana  stressed  that  this  must  be  done  so  that  individuals  know  which  options  they  can  exercise.   Moreover,  a  person  should  know  if  he/she  will  be  prosecuted  for  opting  to  exercise  or  not  exercise   a  given  option.  For  example,  the  PMC  Act  does  not  say  that  marriage  between  minors  is  illegal.  Yet   21  
  • 26. it   simultaneously   provides   punishment   for   the   same.   Thus,   we   need   to   have   in-­‐depth   dialogues   about  the  glaring  contradictions  in  these  important  laws  and  provisions.       Recommended  Ways  Forward     Issue   Child  Marriage   PIL  Status   • Background   gathering   • Coalition  building   • Drafting   Complimentary   Strategies     • Sensitization   training   • Comprehensive   rehabilitation   services  to  youth   • Incentive/   Support   programmes  for   families  with   unmarried   girls/boys                                                             22   Advocacy  Partners   • • • • HRLN   RUDSOVOT   Rajasthan   Commission  for   Protection  of   Child  Rights   Advocate  Anant   Asthana  
  • 27. Hysterectomies     Background  Information     Although   technically,   a   hysterectomy   refers   to   the   removal   of   a   woman’s   uterus,   doctors   also   perform   the   surgery   to   remove   any   portion   of   a   woman’s   reproductive   organs.   A   hysterectomy   requires  invasive  surgery  under  general  anesthesia.  Methods  of  hysterectomy  include:  abdominal;   vaginal;  werthium  (a  radical  hysterectomy  that  includes  the  removal  of  a  woman’s  womb,  uterus,   cervix,   upper   part   of   the   vagina,   lymph   nodes,   fallopian   tubes,   peritoneium,   and   ovaries);   oorphoractomy  (removal  of  one  or  both  ovaries);  salpingotomy  (removal  of  the  fallopian  tubes);   and   caesarian.   Each   of   these   methods   involves   varying   post-­‐surgical   symptoms   as   well   as   post-­‐ surgical  health  risks  ranging  from  fatigue  and  bleeding  to  developing  cancer.       The   reasons   most   commonly   cited   for   a   hysterectomy   include   fibroids,   uterine   health   problems,   uterus   prolapse,   pervasive   infections,   and   cancer.   It   is   often   after   a   woman   complains   of   abdominal  pain,  brought  on  by  multiple  pregnancies,  early  childbearing,  and  malnutrition,  that  a   doctor   recommends   a   hysterectomy   to   alleviate   the   pain.   Like   any   invasive   surgery,   hysterectomies  require  extensive  pre-­‐surgery  counseling,  testing,  and  care.         Most   recently,   media   reported   an   unnatural   spike   in   hysterectomies   performed   at   Rashtriya   Swasthya   Bima   Yojna   (RSBY)   empaneled   health   facilities   in   Chhattisgarh.   According   to   records,   over   the   last   two   and   a   half   years,   doctors   performed   more   than   7,000   hysterectomies   in   Chhattisgarh.   Other   sources   quote   a   number   closer   to   50,000.   More   often   than   not,   doctors   and   private  hospitals  target  SC,  ST,  and  BPL  women.       Private   hospitals   in   Chhattisgarh   have   reaped   as   much   as   2   crore   rupees   performing   hysterectomies  under  the  RSBY  scheme,  which  provides  heavily  subsidized  health  care  coverage   to   BPLs.   The   scheme’s   schedule   of   fees   reimburses   doctors   depending   on   the   method   of   hysterectomy.   Data   from   journalists   and   activists   indicates   that   a   few   private   hospitals   near   Raipur  District  performed  the  bulk  of  hysterectomies  in  the  state.     Dorpradi,  who  lives  in  Dongatarai   Village,  Raipur  District  and  had  a   hysterectomy  in  2011  at  a  private   facility  empanelled  under   Chhattisgarh’s  RSBY  scheme         23  
  • 28.   The  situation  of  women  in  Chhattisgarh  is  not  unique,  as  large-­‐scale  unnecessary  hysterectomies   have   also   been   reported   in   Odisha   and   Rajasthan.   It   is   important   that   we   appreciate   the   unchallenged  and  continued  violation  of  these  women’s  basic  human  rights.         Information  Presented     Dr.  Narendra  Gupta,  PRAYAS       Dr.   Gupta   presented   a   joint   study   between   PRAYAS   and   JSA   on   women’s   experiences   with   hysterectomies   in   Dausa   District,   Rajasthan.   A   hysterectomy   requires   the   surgical   removal   of   a   woman’s   uterus   and   prevents   the   women   from   conceiving   in   the   future.     There   are   several   methods  to  perform  a  hysterectomy  and  these  include  vaginal  and  abdominal.  A  woman  may  seek   a   hysterectomy   for   several   reasons   including   uterine   prolapse,   cancer   of   the   uterus,   cervix   or   ovaries,  abdominal  vaginal  bleeding,  chronic  pelvic  pain,  and  endometriosis.     In  April  2011,  several  national  and  regional  newspapers  reported  that  around  226  women  from   Dausa  District  had  had  their  uteruses  removed  at  private  nursing  homes/hospitals  after  seeking   treatment   for   severe   abdominal   pain   and   menstrual   irregularities.   Several   civil   society   groups   conducted   an   investigative   mission   shortly   after   these   figures   were   reported.   These   groups   filed   a   Right  to  Information  (RTI)  application  to  get  a  list  of  all  of  the  women  in  the  Dousa  District  who   had  received  a  hysterectomy.  The  groups  then  met  with  16  of  these  women  and  documented  their   accounts.  Dr.  Gupta  presented  these  accounts,  some  of  which  are  shared  below:     • Gulab  w/o  Ram  Avtar,  age  unknown,  mother  of  three:     o Had  her  fallopian  tubes  litigated  at  a  sterilization  camp  10  years  before;   o Has  experienced  abdominal  and  general  body  pain  the  past  6  years;   o Initially  sought  treatment  at  government  hospital  in  Jaipur;   o After  she  was  referred  to  Manhur  Hospital,  a  private  hospital  in  Banikui,  the  doctor   advised   a   sonography   and   informed   Gulab   that   her   uterus   had   to   be   removed   because  “it  had  swollen  and  there  was  danger  of  cancer  happening  later  on.”  Gulab   underwent  a  hysterectomy  a  few  days  later;   o Gulab  stayed  in  the  hospital  7  days  and  was  charged  Rs.  20,000.   • Sunita  w/o  Ram  Khiladii,  mother  of  three:   o Was  sterilized  after  the  birth  of  her  third  child;   o Has   experienced   abdominal   pain   and   an   irregular   menstrual   cycle   since   she   was   sterilized;   o In   2011,   sought   the   services   of   a   doctor   at   Madan   Hospital   in   Banikui.   The   doctor   advised   her   to   get   a   sonography   and   later   told   Sunita   that   her   “uterus   has   been   decaying   and   required   to   be   removed.”   Dr.   Madan   urged   her   to   have   the   surgery   immediately   and   “didn’t   give   [Sunita]   any   time   to   think.”   Sunita   underwent   her   hysterectomy  that  same  day;     o Was   discharged   7   days   later,   charged   Rs.   20,000,   and   told   to   get   medicine   costing   between  Rs.  1,000  and  1,500  for  post-­‐operative  care;   o To  this  day,  she  suffers  from  abdominal  pain  and  general  weakness.     24  
  • 29. Dr.   Gupta   stressed   that   a   hysterectomy   is   usually   considered   only   after   all   other   treatment   approaches  have  been  tried  without  success.  However,  in  all  of  the  cases  he  documented,  no  pre-­‐ surgery   treatment   was   given   and   women   were   not   given   either   enough   information   or   time   to   make   an   informed   decision   regarding   their   reproductive   rights.   The   testimonies   of   most   of   the   women  interviewed  revealed  that  most  hysterectomies  were  performed  in  private  hospitals.  The   pattern  of  events  usually  involved  a  visit  to  a  private  hospital,  a  sonography,  and  a  doctor’s  strong   medical   advice   to   have   a   hysterectomy   citing   emergency   circumstances.   Neither   the   pain   these   women  complained  of  nor  their  irregular  cycles  were  ever  investigated.       Bhupendra  Pareek,  Independent  Health  Activist     Dr.   Pareek   presented   on   a   RTI   he   filed   on   hysterectomies   in   Dausa   District,   Rajasthan   and   subsequent  investigations  into  their  prevalence  there.  He  began  by  sharing  that  the  entire  process   began   when   it   was   reported   that   in   one   village   in   Dausa,   almost   every   women   had   had   her   uterus   surgically   removed.   These   women   reportedly   suffered   from   many   problems   including   vomiting,   dizziness,  and  other  similar  grievances.       As   a   result   of   this   report,   Dr.   Pareek   filed   an   RTI   application   to   find   out   how   many   operations   had   been  performed  in  the  district’s  five  hospitals  and  how  many  of  these  operations  had  been  related   to   any   problem   with   the   uterus.   The   RTI   revealed   that   90%   of   the   women   who   had   undergone   operations   in   the   district   had   had   their   uteruses   removed.   Moreover,   doctors   justified   these   hysterectomies  by  citing  their  worries  about  the  women’s  health.       Dr.   Pareek   shared   that   the   RTI   revealed   that   even   where   women   reported   to   the   hospitals   with   simple   cases   of   stomach   ache   or   back   pains,   doctors   claimed   that   the   women   could   have   cancer   and   that,   if   not   operated   on   immediately,   they   could   be   in   danger   of   dying.   In   these   cases   a   thumbprint  was  taken  for  consent  and  the  women  were  rushed  into  surgery.  He  highlighted  that   women  were  charged  between  Rs.  5,000  and  15,000  for  the  operation.  Dr.  Pareek  also  shared  that   three   private   hospitals   had   particularly   high   numbers   of   hysterectomies.   In   one   example,   data   revealed   that   of   the   30   operations   performed   at   the   private   institution   Vijay   Hospital   in   April   2012,  27  of  them  had  been  hysterectomies.       As   a   result   of   this   information,   a   fact-­‐finding   team,   which   included   HRLN   activists,   travelled   to   Dausa   district   to   look   into   the   matter.   The   team   found   that   even   women   who   had   not   yet   had   children  reported  having  had  their  uteruses   removed.   Dr.   Pareek  told  that  the   team   approached   the   District   Collector   and   asked   him   to   organize   an   investigation   into   why   everyone   went   to   private  hospitals  and  whether  the  doctors  at  these  hospitals  had  the  training  and  skills  to  perform   hysterectomies.   This   request   led   to   the   creation   of   a   district   level   committee   committed   to   monitoring  the  situation.     Dr.  Pareek  stated  that  he  was  not  happy  with  the  committee  and  its  findings.  While  the  committee   report   revealed   that   there   was   only   one   government   anaesthetist   who   covered   all   the   private   hospitals,   Dr.   Pareek   claimed   that   the   committee   was   subject   to   outside   influence   and   failed   to   admit   to   any   wrongly   performed   operations.   In   addition,   the   report   erroneously   concluded   that   the  government  did  not  have  control  over  the  functioning  of  private  hospitals.     25  
  • 30. Dr.  Pareek  then  turned  to  the  status  of  the  Clinical  Establishment  Act,  which  has  been  approved  in   draft  form  but  has  not  yet  been  implemented.  No  enquiries  have  been  made  about  the  activities  of   private   hospitals   and   the   government   will   not   cancel   their   registration.   A   PIL   regarding   this   is   currently  being  filed.     Dr.   Pareek   also   discussed   the   need   for   a   finished   version   of   the   Clinical   Establishment   Act.   The   fact-­‐finding  team  found  that  government  hospitals  lack  sufficient  medical  officers.  In  particular,  a   lack  of  anaesthetists  leads  to  people  going  to  private  hospitals  for  treatment.    There  is  also  a  lack   of   female   doctors   at   every   hospital   level.   This   information   has   been   published   in   newspapers   nationwide  and  on  television  in  Rajasthan,  but  nothing  has  been  done  to  improve  the  situation.  Dr.   Pareek   highlighted   again   that   the   committee’s   report   was   subject   to   outside   influence   and   that,   therefore,  its  claims  that  the  doctors  had  not  performed  any  unnecessary  procedures  and  that  52   out   of   58   women   were   satisfied   with   their   operation   cannot   be   taken   at   face   value.   He   also   shared   that  the  six  women  who  reported  dissatisfaction  had  complained  that  they  still  suffered  from  the   original   symptoms   that   had   led   them   to   seek   medical   advice   in   the   first   place.   Moreover,   they   reported   that   they   only   agreed   to   the   operation   after   their   doctors   had   scared   them   by   telling   them  they  were  at  risk  of  dying  from  cancer  if  they  did  not  opt  for  surgical  intervention.     Dr.   Pareek   shared   that   despite   meetings   with   both   the   Chief   Minister   and   the   State   Minister   for   Health   and   public   assurances   that   a   committee   would   be   formed   to   look   into   why   such   unnecessary   operations   were   being   carried   out   over   one   year   ago,   no   such   committee   has   been   formed.   He   said   that   activists’   attempts   to   raise   the   issue   in   the   media   led   to   district   doctors   claiming  that  there  was  a  conspiracy  against  them  and  subsequently  going  on  a  two-­‐day  strike.       Dr.   Pareek   then   drew   attention   to   the   PCPNDT   Act,   which   is   effective   against   private   practitioners   because  it  allows  for  charges  against  individual  doctors.  If  a  charge  is  brought  under  the  PCPNDT   Act,   the   State   Medical   Council   will   suspend   the   doctor’s   license   to   practice   within   30   days.   Dr.   Pareek   argued   that   this   shows   that   government   legislation   can   be   effective   against   private   practitioners  who  commit  medical/ethical  violations.  Dr.  Pareek  stressed  that  there  is  an  urgent   need  for  a  functioning  Clinical  Establishment  Act  in  order  to  hold  private  hospitals  accountable  for   their  actions.         Recommended  Ways  Forward     Issue   Unnecessary   Hysterectomies   PIL  Status   • Will  be  filed  in   January  2012   • Coalition  building   Complimentary   Strategies     • Monitoring  of   RSBY  scheme   hysterectomy   claims   Advocacy  Partners   • • •             26   HRLN   Dr.  Narendra   Gupta  –  PRAYAS   Dr.  Bhupendra   Pareek  
  • 31. Family  Planning  in  India     Dr.  Abhijit  Das,  Centre  for  Health  and  Social  Justice     Before  delving  into  the  subject  of  family  planning  and  female  sterilization  in  India,  Dr.  Das  asked   the  audience  how  many  believed  that  population  is  a  pressing  concern  in  India.  After  fewer  than   10   hands   were   raised,   Dr.   Das   noted   that   if   he   polled   the   general   public   he   would   likely   find   thousands,  if  not  lakhs,  of  people  who  believe  that  population  is  a  genuine  concern  in  India.       Before  acknowledging  population  as  a  problem,  Dr.  Das  probed,  “we  first  need  to  analyze  why  we   consider   it   one.   Do   we   believe   that   population   in   our   country   has   started   touching   explosive   magnitudes?  Do  we  believe  that  the  population  of  our  country  has  risen  so  much  that  it  poses  a   mortal   threat   to   the   environment,   and   that   the   news   about   global   warming   that   we   encounter   every  now  and  then-­‐  that  population  explosion  has  a  direct  bearing  on  that?  Is  it  the  infrastructure   in   our   cities   that   makes   us   think   so?”   Dr.   Das   pointed   to   the   roads   in   Delhi   that   are   so   overburdened  it  takes  an  unnaturally  long  amount  of  time  to  traverse  relatively  short  distances.     Dr.   Das   pointed   to   myriad   worries   centered   on   the   issue   of   population   and   stressed   that   it   is   important  to  put  them  to  rest.  If  we  look  at  the  statistics,  Dr.  Das  cautioned,  we  get  a  different  take   on  the  population  “explosion.”  Population  growth  has  been  decreasing  over  the  past  few  decades.   India’s   population   has   been   growing   at   progressively   slower   and   slower   rates.  Why   then   does   the   number  of  people  only  seem  to  be  growing?  Dr.  Das  offered  that  the  reason  the  overall  population   is  expanding  in  number  is  because  the  number  of  childbearing  women  is  rising.     In  previous  generations,  Dr.  Das  explained,  the  population  grew  because  the  number  of  children   per   household   was   higher.   That   same   group   of   children   is   today   reaching   its   childbearing   age.   Looking   at   current   statistics,   the   number   of   childbearing   women   is   “colossal.”   If   in   previous   generations   there   were   100   childbearing   women   for   each   1,000   people   in   India,   today   that   number  is  closer  to  200.     Changing   Demographics 2010 1990     27  
  • 32. Dr.   Das   next   turned   to   a   frequently   quoted   adage   that   India   adds   the   equivalent   of   Australia’s   population  to  itself  each  year.  The  majority  of  population  explosion  related  issues  are  due  in  part   to  the  fact  that  this  “explosion”  is  happening  among  the  poor.  That  is,  the  number  of  children  born   to   India’s   poor   population   is   growing   disproportionately   as   compared   to   birthrates   amongst   middle  and  upper  class  Indians.     Dr.   Das   drew   attention   to   the   fact   that   if   we   look   at   a   graph   of   annual   increase,   the   overall   production  of  edibles  and  economic  turnout  in  India  is  increasing  at  a  much  faster  pace  than  its   population.   However,   the   number   of   destitute   people   in   India   is   also   expanding   at   a   rapid   rate.   This,   Dr.   Das   underscored,   points   to   the   increasing   disparity   between   the   rich   and   the   poor   in   India.   Even   if   the   total   amount   of   resources   is   increasing,   these   are   all   being   concentrated   in   India’s  upper-­‐class  population.     Dr.  Das  next  addressed  the  advocates  present  saying  “it  is  important  to  understand  what  the  issue   actually  is…  we  need  to  be  clear  as  to  what  the  issue  is  that  we  seek  to  address.”    Dr.  Das  pointed  to   the   landmark   case   of   Jahada  vs.  Union  of  India,   where   the   Supreme   Court   could   not   ascertain   what   the  ‘greatest  issue  in  contemporary  India´  is  –  whether  population  or  poverty.     It   was   Paul   Lenning’s   who   first   proposed   the   idea   of   a   moribund   population  bomb   in   the   1960s   after   he   landed   in   Delhi   and   drove   through   Connaught   Place.   He   commented   on   how   he   could   ‘see   nothing   but   a   deluge   of   people   in   each   direction’   -­‐   a   great   mass   of   humanity,   a   great   mass   of   poverty.   Dr.   Das   stressed   that   Mr.   Lenning’s   issue   seemed   to   be   more   with   the   poverty   he   witnessed   than   with   population   explosion   per   se.   At   any   point   in   time   there   is   much   more   of   a   crowd   in   New   York’s   Time   Square   than   at   the   New   Delhi   Railway   Station.   However,   the   Times   Square  crowd  would  not  leave  Mr.  Lenning  very  unsettled.       Dr.   Das   offered   that   the   obvious   answer   to   why   India   has   a   population   explosion   is   that   people   do   not  have  any  economic  facility  –  there  is  no  occasion  for  them  to  earn  a  livelihood  in  the  villages   and  they  are  therefore  drawn  to  the  cities.  These  same  cities,  however,  have  no  infrastructure  to   accommodate   the   masses   of   people   who   migrate   there   –   there   is   no   sanitation,   housing   or   transportation  system  that  can  adequately  accommodate  them.       Dr.   Das   explained   that   population   explosion   has   become   shorthand   for   describing   a   much   more   complex   and   multifaceted   issue.   If   a   person   produces   more   resources   and   contributes   more   to   the   world  than  what  he  or  she  consumes,  then  his  existence  cannot  be  a  burden  on  the  world.  If  we   contribute  to  the  world  more  than  we  consume  –  be  it  by  intellectual,  physical  or  other  means  -­‐   then  we,  Dr.  Das  asserted,  are  an  asset  to  the  world,  not  a  burden.       Dr.  Das  highlighted  that  the  problem  originates  with  a  general  lack  of  education  saying,    “in  order   to   bring   our   productivity   to   the   prime,   a   crucial   required   investment   is   education.   It   is   the   government’s  responsibility  to  provide  education.  Unfortunately,  it  has  slowly  been  veering  away   from   this   crucial   responsibility   and   instead   placing   a   greater   priority   on   healthcare.   We,   as   Indians,  Dr.  Das  explained,  have  gotten  into  the  habit  of  viewing  the  poor  as  an  issue,  a  problem,   rather   than   working   productively   towards   their   benefit.   The   problem   really   is,   Dr.   Das   underscored,  India’s  inequity  of  distribution;  some  people  in  our  nation  have  far  too  much  while   others  have  too  little.  This  is  especially  egregious  in  Bihar,  Rajasthan,  Madhya  Pradesh,  and  Uttar   Pradesh.   Dr.   Das   concluded   by   expressing   that   litigation   should   be   used   as   a   method   of   last   resort   after  policy  initiatives  and  grassroots  level  advocacy  have  failed  to  create  positive  change.   28  
  • 33. Experiences  from  the  Field:  Francis  Elliot’s  Personal  Recount     Francis  Elliot,  The  Times  UK     Mr.  Elliott  began  with  the  story  of  how  he  came  to  be  newsgathering  in  a  village  in  Bihar.  He  had   read  an  article  in  The  Hindu  written  by  Mr.  Shoumojit  Banerjee,  that  to  him,  seemed  to  establish   beyond   a   doubt   that   something   extraordinarily   ghastly,   but   well   documented,   had   happened   in   this   village.   Mr.   Elliot   explained   that,   generally,   journalists   often   have   problems   finding   the   evidence  for  such  stories.  This  story,  however,  seemed  to  him  to  be  solid  and  well  founded.     He  explained  that  he  first  met  Ms.  Devika  Biswas  after  Ms.  Leena  Uppal  from  the  National  Coalition   Against   Two   Child   Norm   and   Population   Control   Policies   put   him   in   touch   with   her.   Ms.   Biswas   volunteered  to  help  him  visit  the  female  sterilization  camp,  which  had  happened  in  her  home  area   of  Araria.  Mr.  Elliot  recalled  that  there  was  some  resistance  to  having  a  journalist  along  with  a  fact-­‐ finding  team  and  that  at  one  point  he  was  told  he  could  not  go.       Once   reaching   Patna,   Mr.   Elliot   met   with   Ms.   Biswas   who   introduced   him   to   Mr.   Lande,   the   Superintendent   of   Police   at   Patna.   Mr.   Elliot   noted   that   the   story   would   not   have   been   possible   without   the   involvement   of   Mr.   Lande   because   it   was   the   people’s   confidence   in   Mr.   Lande   that   lead  them  to  share  details  of  the  camp  with  him.       After  meeting  with  Mr.  Lande,  Mr.  Elliot  and  Ms.  Devika  visited  the  village  where  all  the  women   from   the   sterilization   camp   and   locals   showed   them   the   school   and   classrooms   where   the   camp   took   place.   A   total   of   150   local   people   met   with   Mr.   Elliot   and   Ms.   Biswas.   Of   these,   they   were   able   to   interview   15   women   who   had   been   sterilized.   Although   none   of   the   women   said   they   had   been   coerced  into  the  surgery,  none  of  them  had  been  offered  pre-­‐operative  counseling.  The  only  thing   the  women  had  been  offered  before  their  surgery  was  painkillers,  which,  Mr.  Elliot  and  Ms.  Devika   discovered,  had  all  been  out  of  date.       Mr.  Elliot  shared  the  story  of  Jitni  Devi  who  was  told  she  was  pregnant  while  she  was  undergoing   her   surgery   and   subsequently   miscarried.   After   the   PIL   was   filed,   the   state   denied   that   she   had   been   pregnant   and   claimed   that   she   had   made   it   up   in   return   for   incentives   offered   by   the   fact-­‐ finding  team.  In  fact,  Jitni  Devi  had  shared  her  story  of  her  own  volition  and  had  been  offered  no   incentives.   The   state   also   claimed   that   because   its   own   investigative   team   could   not   find   Jitni   Devi   to   corroborate   her   story,   her   story   was   invalid.   Mr.   Elliot   stressed   that   he   would   be   happy   to   testify  as  to  the  voluntariness  of  the  information  Jitni  Devi  and  the  other  women  shared  with  the   fact-­‐finding  team.  He  also  shared  that  there  were  other  women  with  terrible  stories  including  that   some  of  them  had  actually  woken  up  during  their  procedure.     The  fact-­‐finding  team  next  visited  the  nearby  medical  office  of  a  doctor  who  had  issued  a  report  on   the  camp  saying  that  it  was  properly  conducted.  When  asked  why  she  had  issued  such  a  patently   false   report,   Mr.   Elliot   noted   that   the   doctor   lacked   any   control   over   the   their   meeting.   In   fact,   there  were  many  men  in  senior  positions  responding  to  his  questions  without  the  doctor’s  input.   Mr.  Elliot  had  previously  learned  that  these  same  senior  officials  were  under  severe  pressure  to   meet   their   female   sterilization   targets.   This   information   was   especially   important,   Mr.   Elliot   stressed,   because   Bihar   claimed   that   this   had   been   a   “one-­‐off”   incident.   Mr.   Elliot,   however,   was   wary  of  this  claim.       29  
  • 34. The   state   of   Bihar   has   been,   and   is   still   being,   praised   by   international   organizations   including   the   World   Health   Organization   (WHO)   for   its   use   of   Public   Private   Partnerships   (PPPs)   in   the   healthcare  sector.  This  situation,  accordingly,  was  very  embarrassing  for  the  state  as  it  showed  the   failings   of   the   very   policy   for   which   it   was   being   praised.   The   evidence   collected   by   the   superintendent   included   CDs   of   previous   camps   that   had   been   conducted   by   the   same   NGO   that   conducted   the   one   Mr.   Elliot   investigated.   Records   also   showed   that   the   NGO   was   claiming   payment  for  sterilizations  that  were  never  carried  out.     Mr.   Elliot   also   shared   information   that   he   was   not   able   to   corroborate   and,   therefore,   could   not   print.   One   such   allegation   was   that   that   there   was   some   link   between   the   NGOs   that   had   had   approval  to  carry  out  such  camps  and  senior  Bihar  politicians.  Additionally,  there  were  allegations   that   NGOs   were   lying   about   the   number   of   operations   they   conducted.   Mr.   Elliot   noted   the   allegation’s   probable   truth   since   NGOs   claimed   twice   as   many   female   sterilizations   than   had   the   state  government.     Finally,  Mr.  Elliot  urged  that  journalists  and  field  workers  should  be  more  organized  and  focused   in  collecting  evidence  for  the  courts  alongside  promoting  their  news  gathering/activist  activities.   Moreover,   there   should   be   more   use   of   smartphones   to   record   statements   and   footage   –   video   footage  was  key  in  this  case  as  it  provides  both  immediate  coverage  and  strong  evidence  in  a  legal   case.                                                           30  
  • 35. Female  Sterilization     Background  Information     In  India,  ‘family  planning’  is  used  as  a  euphemism  for  female  sterilization.  According  to  the  most   recent   District   Household   Survey   of   2008,   only   54%   of   the   population   surveyed   used   contraceptives.   Female   sterilization   accounted   for   a   shocking   34%   of   the   contraceptive   methods   used. 9  Data   from   the   2005-­‐2006   National   Family   Health   Survey   of   2005-­‐2006   revealed   that   permanent   birth   control   through   female   sterilization   comprises   about   75%   of   all   modern   sterilization   use   for   married   women   age   15-­‐49. 10     In   fact,   the   three   modern   spacing   methods   (birth   control   pills,   intra-­‐uterine   devices,   condoms)   only   account   for   10%   of   all   contraceptives.   Although  governments  deny  a  sterilization  target,  the  number  of  women  participating  in  daily  or   weekly  family  planning  camps  remains  high  and  a  spike  in  numbers  is  most  evident  in  February   and   March   when   sterilization   targets   are   due.   Moreover,   both   field   workers   who   recruit   women   for   sterilization   and   women   who   undergo   sterilization   receive   cash   incentive   payments   for   agreeing  to  the  surgery.     Female  Sterilisation  in  India 120 5000000 Total  No  of  Cases 6000000 100 4000000 80 3000000 60 %  Ster 2000000 40 1000000 F  Ster 20 0 0     Robbing  women  of  their  right  to  decide  the  number  and  spacing  of  their  children  and  to  protect   their  body  is  indicative  of  the  poor  state  of  reproductive  rights  in  India  and  underscores  the  need   for  stronger  civil  society  engagement,  innovative  legal  advocacy,  and  ultimately  sweeping  change.                                                                                                                     9  District  Level  Household  and  Facility  Survey  (DLHS-­‐3)  2007-­‐2008,  Ministry  of  Health  and  Family  Welfare  Government   of  India,  p.  v.   10  National  Family  Health  Survey  (NFHS-­‐3)  2005-­‐2006,  Ministry  of  Health  and  Family  Welfare,  p.  8.   31  
  • 36.     Information  Presented     Devika  Biswas,  HealthWatch  Forum,  Bihar  and  Advocate  Jayshree  Satpute,  HRLN     Ms.  Biswas  and  Ms.  Satpute  presented  on  a  case  before  the  Supreme  Court  on  female  sterilization   in  Bihar  and  throughout  India.  The  facts  of  the  case  are  reported  below.     On   the   night   of   7th   of   January   2012,   in   the   space   of   two   hours,   the   Government   of   India   sponsored   the  sterilization  of  fifty-­‐three  women  in  a  Government  Middle  School  building  in  the  state  of  Bihar.   All   of   the   women   come   from   marginalised   groups   (Below   the   Poverty   Line   (BPL),   scheduled   castes,  or  other  backward  castes.)  A  single  surgeon  carried  out  all  fifty-­‐three  sterilisations  in  just   two  hours  with  the  help  of  only  a  handful  of  medically  unqualified  NGO  staff.  The  operations  were   carried   out   at   night,   with   only   one   generator-­‐powered   lamp   and   a   few   torches   to   illuminate   the   classroom  cum  operating  theatre.  The  doctor  used  classroom  desks  as  operating  tables  and  after   each   surgery;   the   untrained   NGO   workers   laid   the   women   on   straw   strewn   on   the   ground.     The   women   did   not   receive   medical   assistance   or   post-­‐operative   care.   Meanwhile,   the   surgeon,   Dr.   Chowdhary,  immediately  left  the  premises.       While  she  was  lying  on  the  operating  table  in  semi-­‐consciousness,  Dr.  Chowdhary  told  Jitni  Devi   that  she  was  three  months  pregnant.  He  told  her  that  her  current  pregnancy  would  be  her  last,  but   Jitni  Devi  subsequently  miscarried  18  days  after  the  procedure.  Another  woman,  Rehka  Devi,  was   operated  on  despite  the  fact  that  she  was  conscious  and  suffering  from  severe  pain.  As  a  result  of   these  sterilisations,  three  women  were  left  bleeding  profusely  and  one  woman,  Saraswati  Devi  had   to  be  admitted  to  a  hospital  for  8  days  following  the  procedure.       In   2005,   in   the   case   of  Ramakant  Rai  vs.  Union  of  India  and  Ors.  (Writ   Petition   (Civil)   209   of   2003),   the   Supreme   Court   directed   States   to   follow   minimum   standards   when   conducting   sterilisation   procedures.  The  Court  also  directed  states  to  set  up  Quality  Assurance  Committees  to  ensure  the   implementation   of   these   guidelines.   To   comply   with   these   directives,   the   Central   Government   of   India   issued   standards   for   sterilisation   services   in   2006.   The   standards   mandate   pre-­‐operative   counselling,   the   informed   consent   of   the   patient,   certain   pre-­‐operative   instructions   including   a   pre-­‐operation   health   assessment,   a   review   of   the   surgical   procedure,   and   the   requirements   for   post   operative   care.   Furthermore,   the   standards   detail   the   equipment   and   facilities   deemed   necessary  to  carry  out  a  sterilisation  procedure.       The   sterilisation   procedures   that   were   carried   out   on   the   women   in   Bihar   fell   far   below   the   standards  mandated  by  both  the  Supreme  Court  and  the  government  standards.  The  women  did   not   receive   any   pre-­‐operative   counselling   or   medical   examination.   Moreover,   the   doctor   did   not   seek  any  of  the  female  patients’  informed  consent.  The  women,  who  were  left  without  any  medical   help   or   information   about   post-­‐operative   care,   had   to   have   their   stitches   removed   by   private   facilities  at  their  own  expense.             32  
  • 37.       Women  waiting  to  be  sterilized  at  family  planning  camp  in  Barwani  District,  MP       The  PIL  Ms.  Biswas  subsequently  filed  argues  that  the  NGO,  surgeon,  and  government  violated  the   women’s  reproductive  rights,  their  right  to  health,  and  their  right  to  be  free  from  inhuman,  cruel   and  degrading  treatment.  Furthermore,  the  petition  argues  that  the  government  failed  to  provide   the   women   with   adequate   health   services   in   a   non-­‐discriminatory   manner   as   the   majority   of   female   sterilisation   camps   take   place   in   rural   areas.   The   shocking   conditions   in   these   camps   amounts  to  discrimination  against  rural,  poor,  and  marginalised  women.     The   petition   seeks   compensation   for   the   women   in   Bihar   and   for   an   order   directing   the   respondent  states  to  file  status  reports  on  the  implementation  of  the  Supreme  Court’s  directions  in   the  case  of   Ramakant  Rai  as  well  as  the  Guidelines  for  Female  and  Male  Sterilisation  in  order  to   ensure  that  these  guidelines  are  adhered  to  throughout  India.                                     33  
  • 38. State  Presentations  on  Sterilization     Information  Presented     Rajdev  Chaturvedi,  GPS,  Azamgarh  (Uttar  Pradesh)     Mr.   Chaturvedi   shared   that   his   investigations   revealed   11   female   sterilization   camps   in   Uttar   Pradesh.  These  camps  had  no  oxygen  cylinders,  no  provision  of  rooms  for  changing  clothes,  and  no   provision  of  separate  operation  coats  for  the  doctors  to  wear  in  the  Operation  Theatre.  Only  two   camps   had   clean   clothes   for   the   staff   and   only   six   camps   enforced   changing   clothes   and   medical   instruments   after   each   surgery.   Additionally,   there   was   no   provision   of   toilets   in   any   of   the   camps   Mr.  Chaturvedi  visited.     It  is  a  medical  norm  to  carry  out  a  check-­‐up  before  operating,  but  this  norm  was  violated  in  the   camps.  When  check-­‐ups  were  enforced,  they  were  only  done  for  blood  pressure.  While  some  of  the   doctors   were   competent   to   perform   the   surgeries,   most   had   no   expertise   in   the   matter.   Additionally,  counseling  ought  to  be  provided  to  patients  regarding  the  usage  of  and  the  various   types   of   contraception   options   before   sterilization   surgeries.   This   mandate   was   also   commonly   ignored.   Mr.   Chaturvedi   noted   that   most   women   are   forcibly   sterilized   and   that   screaming   and   yelling  can  often  be  heard  from  the  operating  theatre  during  sterilization  surgeries.     In   reference   to   the   Standards   for   Sterilization   set   out   in   Ramakant  Rai,   Mr.   Chaturvedi   stressed   that  they  are  not  being  implemented.       After  their  operation,  women  should  be  kept  under  care  by  the  medical  staff  in  the  hospitals,  but   they  are  generally  sent  home  immediately  after  their  surgery.  Doctors  rarely  conduct  follow-­‐ups   with   the   women   after   their   operation.   In   12   out   of   18   cases,   women   suffered   from   various   problems   after   their   operation,   including   dizziness,   body   ache,   and   low   haemoglobin   levels.   Women   have   complained   that   there   is   a   lack   of   good   hospitals   in   nearby   areas   and   they   cannot   approach  hospital  staff  with  their  post-­‐operative  problems.  Patients  also  complain  about  having  to   pay  for  their  surgery  and  post-­‐operative  care  when  they  suffer  from  complications.  Other  issues   include   the   ill   treatment   the   women   receive   at   the   hands   of   the   doctors,   the   impolite   and   rude   behavior  of  the  staff,  and  the  lack  of  contraceptives  available  in  the  hospitals.       Mr.  Chaturvedi  reported  that  women  prefer  going  to  private  hospitals  because  they  are  nearer  to   their   homes   -­‐   government   doctors   in   Uttar   Pradesh   can   sometimes   only   be   found   25   km   away   from  the  women’s  homes.       Today,   women   are   still   being   forcefully   sterilized   and   left   to   suffer   from   various   post-­‐operative   complications.   All   of   this   without   any   compensation,   contrary   to   the   government’s   incentive   programme.   Doctors   are   usually   unaware   that   their   patients   are   entitled   to   compensation   and   even  when  they  are,  they  do  not  act  on  it  because  they  think  that  giving  women  compensation  is   tantamount  to  admitting  that  they  performed  the  operation  inefficiently.       Mr.  Chaturvedi  cautioned  that  a  target-­‐free  approach  should  be  employed.  Recently,  the  arrival  of   the  Rashtriya  Gramin  Swasthiya  Mission  has  meant  that  no  incentives  are  provided  to  doctors  or   medical   staff   for   performing   sterilization   operations.   However,   targets   are   still   created   and   34  
  • 39. adhered  to.  In  the  Azamgarh  District  of  Uttar  Pradesh,  the  target  has  been  kept  at  30,777  female   sterilization  surgeries  per  year.         Swarup  Pal,  Manjari,  Bundi  (Rajasthan)     Mr.   Pal   presented   on   a   female   sterilization   study   his   organization,   Manjari   Bundi,   carried   out   in   Rajasthan  in  2009  -­‐  2010.  The  organization  spoke  to  749  women  who  had  undergone  sterilization   that  year.  Mr.  Pal  stated  that  in  Rajasthan,  prior  to  a  woman  undergoing  sterilization,  some  care  is   taken   of   her,   but   that   after   the   operation   has   been   carried   out,   no   one   cares   for   the   woman.   He   stated   that   his   organization   undertook   the   study   in   order   to   find   out   the   levels   of   care   provided   to   women  before  and  after  their  operation.  The  women  involved  in  the  study  had  an  average  age  of   29  and  were  mainly  illiterate  and  belonged  to  other  backward  classes.  Mr.  Pal  stated  that  of  the   women  surveyed,  almost  all  of  them  had  only  consented  to  sterilization  if  they  had  two  or  more   sons   regardless   of   how   many   daughters   they   had.   Only   one   woman   reported   having   undergone   sterilization  with  only  one  son.     Mr.  Pal  shared  some  of  the  data  gathered  by  the  study.  The  study  found  that  only  20%  of  women   had   received   checkups   prior   to   their   operation   and   that,   of   the   prescribed   pre-­‐procedure   checkups,   only   three   were   carried   out;   blood   pressure   tests,   haemoglobin   levels,   and   pregnancy   tests.   The   study   also   showed   that   counseling   was   either   not   provided   to   the   women   or   where   it   was  provided,  government  health  workers  gave  misleading  information  about  the  alternatives  to   sterilization  and  aftercare.  Mr.  Pal  shared  that  around  90%  of  the  women  were  discharged  from   the   hospital   within   30   minutes   of   their   operation   and   that   8%   of   the   women   were   still   unconscious  when  they  were  sent  home.     Mr.   Pal   discussed   the   problems   that   women   often   face   after   their   sterilization   procedures   and   shared   that   around   60%   of   the   women   interviewed   reported   complications   after   their   operations.   Complications  ranged  from  abdominal  pain  to  back  pain  or  pain  while  walking  to  irregularities  in   their   menstrual   cycle.   Furthermore,   the   study   found   17   cases   of   failed   sterilization   –   meaning   that   the  failure  rate  in  the  surveyed  are  was  five  times  higher  than  the  international  standard.  Mr.  Pal   stated  these  women  whose  sterilizations  failed,  had  suffered  mental  trauma,  physical  distress  and,   in  some  cases,  had  been  ostracized  by  their  community  or  family.       Mr.   Pal   then   highlighted   the   main   problems   the   study   uncovered.   First,   there   is   no   proper   reporting   of   failed   sterilizations   or   post-­‐surgery   complications.   Second,   although   there   are   compensation  schemes  for  women  whose  sterilizations  fail,  women  often  do  not  know  about  the   schemes  and  the  medical  staff  generally  do  not  inform  them.  Third,  the  data  maintenance  system   is   faulty.   In   this   case,   faulty   recording   resulted   in   the   records   of   about   200   women   who   had   undergone   sterilization   going   missing.   Therefore,   these   women   could   not   be   traced.   Finally,   Mr.   Pal   talked   about   the   target   system   for   sterilizations.   He   shared   that   officials   set   targets   for   the   numbers   of   sterilizations   they   will   perform   each   year.   Reports   on   the   number   of   sterilizations   carried   out   are   given   to   the   government   in   mid-­‐July,   which   results   in   a   larger   number   of   female   sterilizations  in  the  months  leading  up  to  the  deadline.  He  shared  that  the  women  in  the  area  are   so  used  to  this  that  they  sometimes  take  advantage  of  the  targets  and  wait  until  the  last  push  to   meet  targets  before  asking  for  higher  monetary  incentives  to  undergo  sterilization.       35  
  • 40. Mr.   Pal   stressed   that   currently   in   Rajasthan,   women   are   pressured   into   undergoing   sterilization   yet   as   soon   as   the   procedure   is   over,   even   if   the   women   suffer   from   complications,   they   are   ignored.       Advocate  Rudra  Prasad  Mishra,  HRLN     Chitrakoot  is  the  most  backward  part  of  the  Bundelkhand  area,  and  has  a  high  number  of  Dalits   (backward   classes)   and   financially   crippled   citizens.   The   issue   of   health   has   been   addressed   by   NRHM,  but  it  has  still  not  improved  sufficiently.  Doctors  do  not  wish  to  come  to  this  area  and  those   who   do,   do   not   wish   to   stay   for   long.   This   is   because   there   is   a   staggering   amount   of   corruption   in   the   area.   Nobody   dares   to   speak   out   against   such   corruption   as   goons   usually   punish   complainants.     As   soon   as   a   woman   reaches   the   hospital,   she   must   pay   everyone,   starting   with   the   ASHA   worker,   nurse,   and   finally   the   doctor.   If   she   resists,   she   is   shooed   away   from   the   hospital   with   excuses   ranging  from  the  unavailability  of  blood  to  a  lack  of  medical  equipment  in  the  hospital.  Mr.  Mishra   shared  that  the  previous  week,  a  pregnant  woman  was  refused  treatment  in  a  hospital  after  she   refused   to   pay   the   staff   a   bribe.   In   response,   she   was   told   that   she   had   miscarried   and   that   her   child  had  died.  However,  as  soon  as  she  exited  the  hospital,  she  went  into  labour  and  gave  birth  to   her  child.     If  a  woman  dies  of  hunger,  officials  assign  it  to  disease  and  do  not  investigate  further.  If  a  person   dies  because  she  has  not  had  food  for  7-­‐8  days  and  contracted  a  disease  as  a  result,  health  officials   must   investigate   rampant   malnourishment   and   undernourishment.   In   such   circumstances,   Mr.   Mishra   urged,   we   have   no   other   option   but   to   approach   the   Consumer   Forum,   file   a   case,   and   demonstrate  on  the  issues.     The  hospitals  available  to  many  women  in  rural  areas  are  situated  so  far  away  from  the  settlement   areas   that   women   need   to   walk   20-­‐22   km   before   they   reach   them.   Even   after   travelling   so   far,   women   find   that   only   a   midwife   or   a   staff   without   child   birth   training   is   present.   There   have   even   been  times  when  not  a  single  medical  staff  is  present.       Citizens   who   are   aware   of   the   problems   and   are   willing   to   fight   against   them,   face   consistent   resistance  from  influential  people.  If  PILs  or  cases  are  filed  against  such  doctors,  the  officials  try  to   suppress  the  issue.     Mr.   Mishra   concluded   by   sharing   the   recent   case   of   a   woman   who   visited   her   nearest   government   hospital  seeking  treatment  for  her  son,  who  suffered  from  a  hearing  problem.  The  doctor  they  saw   gave  them  some  medicines  and  additionally  poured  some  medicine  into  the  boy’s  ear.  Two  hours   after  they  returned  home,  the  mother  found  that  her  son  had  lost  his  sight.  When  she  went  back  to   the  doctor,  he  claimed  that  it  was  a  slight  reaction  to  the  medicine  and  gave  her  other  medicines.   When   she   approached   him   again   the   next   day,   she   was   directed   to   another   hospital   –   a   private   hospital,   where   she   received   more   medicine.   After   4-­‐5   days   of   this,   Mr.   Mishra   and   HRLN   approached  the  District  Magistrate  but  the  doctors  refused  to  take  responsibility  for  the  boy’s  loss   of   sight.   Instead,   they   claimed   that   the   boy   had   been   blind   before   his   treatment.   Mr.   Mishra   and   HRLN  then  approached  the  Consumer  Forum.  The  matter  is  still  being  argued  today.  Mr.  Mishra   and   HRLN   also   approached   the   court   meant   for   addressing   the   issues   faced   by   Dalits   but   the   36  
  • 41. matter  was  suppressed  there  as  well.  Meanwhile,  the  woman  was  repeatedly  told  to  accept  money   from  the  doctor  and  drop  the  case  against  him.     Laws   and   forums   exist   in   society   but   they   are   of   no   use   to   the   backward   classes,   or   Dalits,   and   the   downtrodden  poor.  Mr.  Mishra  urged  everyone  that  this  issue  necessitates  our  attention.       Dr.  Manmath  Mohanty,  Human  Development  Foundation  (HDF)  (Odisha)     Dr.  Mohanty  presented  an  evaluation  of  the  Green  Card  Scheme  (GCS)  in  Odisha.  The  scheme  was   started   in   1983   in   order   to   promote   two-­‐child   families.   To   do   this,   the   scheme   offered   six   benefits   to   those   who   had   two   children   or   less.   The   benefits   included   5%   quotas   for   Green   Card   holders   in   housing  and  certain  university  and  college  courses,  land  free  from  certain  taxes,  access  to  certain   loans,  and  a  lottery  with  a  cash  prize  of  Rs.  10,000.  The  lottery  system  was  discontinued  in  1994,   but  due  to  a  demand  for  financial  benefits  the  Health  and  Family  Welfare  Department  was  advised   to  undertake  an  evaluation  of  the  lottery  system  and  reintroduced  it  with  a  greater  cash  prize.       Dr.  Mohanty  presented  an  HDF  study  that  reviewed  GCSs  compatibility  with  the  Reproductive  and   Child   Health   Programme   (RCH).   The   study   assessed   the   influence   of   the   GSC   on   reproductive   rights,   whether   the   GCS   has   influenced   the   prevalence   of   sterilization   in   the   state,   the   level   of   benefits  received  by  Green  Card  holders,  the  importance  of  the  lottery  scheme  to  those  accepting  a   Green  Card,  and  assessed  the  impact  of  the  GCS  on  reducing  the  unmet  need  for  contraception.  The   study   consisted   of   research   and   a   primary   survey   in   two   districts.   Dr.   Mohanty   highlighted   that   due   to   a   lack   of   data   from   the   Department   of   Health   and   Family   Welfare,   it   was   difficult   to   ascertain  the  number  of  cards  issued  under  the  scheme.     Dr.   Mohanty   shared   that   91%   of   those   who   participated   in   the   study   were   female   and   that   only   1.1%  of  respondents  reported  male  sterilization.  The  study  also  showed  a  twofold  increase  in  the   percentage   of   women   who   were   sterilized   when   they   had   two   or   less   children   but   showed   a   decrease  in  the  total  numbers  of  sterilizations  overall.  However,  the  study  showed  there  was  no   definite  correlation  between  sterilization  increase  or  decrease  and  the  GCS.       Dr.   Mohanty   highlighted   that   the   GCS   was   not   in   step   with   international   thinking   on   family   planning.  In  particular,  he  stated  that  it  conflicted  with  the  ICPD  and  its  focus  on  preventing  the   use  of  coercion,  incentives  or  disincentives  to  achieve  family  planning  targets.  Dr.  Mohanty  further   stated   that   a   higher   percentage   of   couples   who   accepted   sterilizations   under   the   scheme   were   unhappy  with  their  decision  compared  to  the  general  percentage.  He  also  highlighted  that  over  a   quarter  of  sterilized  women  under  the  scheme  reported  that  their  husbands  made  the  decision  for   them   and   50%   of   women   felt   pressure   from   outside   their   family   to   undergo   sterilization.     Dr.   Mohanty  stated  that  66.7%  of  respondents  were  influenced  by  the  benefits  under  the  GCS  when   they  were  considering  sterilization.       37  
  • 42. *Source:  Demography and Evaluation Cell of Directorate of Family Welfare, Government of Odisha Trends  in  Sterilization:  A  review  of  last  thirty  years   performances  in  Odisha Financial  Year Total  Sterilization No.  Sterilized  with   Two  or  less  children 1980-­‐81 1981-­‐82 1982-­‐83 Total  upto 1983-­‐84 Total  since  1983-­‐84 92989 110130 146693 349812 3062389 16750 15567 22607 54924 890302 %  of  Sterilization  with   Two  or  less  children   to  total  Sterilization* 18.01 14.14 15.41 15.70 29.07 Twofold  increase  in  %  of  sterilization   with  two  or  less  children   Period  upto 1982-­‐83  (15.70%)  and  1983-­‐ 84  onwards  till  2006-­‐07  (29.07%) Figure-­‐3.5:  %  of  Sterilization   with  Two  or  less  children   to  total  Sterilization 45 40 35 30 25 20 15 10 5 0 Green  card   introduction Lottery   draw   discontinued 1980-­‐81 1981-­‐82 1982-­‐83 1983-­‐84 1984-­‐85 1985-­‐86 1986-­‐87 1987-­‐88 1988-­‐89 1989-­‐90 1990-­‐91 1991-­‐92 1992-­‐93 1993-­‐94 1994-­‐95 1995-­‐96 1996-­‐97 1997-­‐98 1998-­‐99 1999-­‐00 2000-­‐01 2001-­‐02 2002-­‐03 2003-­‐04 2004-­‐05 2005-­‐06 2006-­‐07 Percentage  of  Sterilizations *Source:  Demography  and  Evaluation  Cell  of  DFW,  GOO Financial  years     Dr.  Mohanty  then  turned  to  the  influence  of  the  GCS  among  scheduled  castes  (SC),  scheduled  tribes   (ST),   illiterate   people   and   the   poor.   He   stated   that   there   were   higher   percentages   of   green   card   holders   among   all   these   groups   than   among   the   total   respondents.   He   also   stated   that   people   who   belong  to  these  groups  are  easy  targets  for  health  workers  and  often  will  choose  sterilization  even   without  the  GCS.  However,  despite  the  higher  numbers  of  Green  Card  holders  among  these  groups,   they  are  unlikely  to  be  able  to  fully  access  or  enjoy  the  benefits.  For  example,  Dr.  Mohanty  raised   the   question   of   the   likelihood   of   someone   from   these   groups   having   the   money   to   pay   the   fees   for   their   reserved   university   course.   Furthermore,   some   of   the   benefits,   such   as   access   to   urban   housing,  are  not  useful  to  the  rural  poor  of  Odisha.  Dr.  Mohanty  also  shared  that  only  11%  of  the   Green  Card  holders  in  the  districts  surveyed  had  received  any  benefits  under  the  scheme.  He  also   stated   that   there   was   no   systematic   tracking   of   benefits   distributed   under   the   scheme   and   that   only   16%   of   those   who   were   sterilized   were   aware   of   some   of   the   benefits   available   under   the   GCS,   particularly   the   lottery   scheme.   He   stated   that   until   1994,   only   0.2%   of   those   who   have   undergone  sterilization  under  the  GCS  have  received  any  benefit  under  the  lottery  scheme.       The   study   revealed   that   the   GCS   is   in   conflict   with   ICPD   principles   and   domestic   population   strategies,  that  there  was  no  consistency  in  the  trends  of  increase  or  decrease  in  sterilization  since   its   introduction   until   2007   and   that   SC,   ST,   poor   people   and   those   who   are   illiterate   are   easy   targets  for  the  scheme  but  are  unable  to  realize  the  majority  of  the  benefits  offered  under  it.  These   conclusions   led   the   HDF   to   make   a   number   of   recommendations.   The   provision   of   incentives   or   disincentives   in   family   planning   amounts   to   coercion   and,   thus,   the   HDF   recommended   that   the   government   of   Odisha   refrain   from   using   such   methods.   The   HDF   also   recommended   that   the   greatest   need   in   Odisha   is   for   spacing   methods   to   allow   people   to   choose   when   and   how   many   children   to   have.   Finally,   as   there   was   no   correlation   shown   between   sterilization   numbers   and   the   influence   of   the   GCS,   HDF   recommended   that   the   state   divert   the   resources   used   on   the   scheme  to  strengthen  the  health  system  and  promote  informed  choice  instead.         Dr.   Mohanty   concluded   by   sharing   that   a   presentation   of   the   study   was   made   to   the   Director   of   Family  Welfare  in  Odisha  and  as  a  result,  the  GCS  was  withdrawn  on  the  8th  of  November  2012.   38  
  • 43. Now,  HDF  is  pushing  for  several  other  reforms  including  the  repeal  of  the  law  disqualifying  people   with  more  than  two  children  from  contesting  PRI  elections,  implementation  of  community  based   distribution   of   contraceptives,   ensuring   male   involvement   in   decreasing   the   unmet   need   for   contraception,   and   creating   a   unified   strategy   to   lodge   PILs   for   cases   where   there   is   a   denial   of   health  rights,  particularly  where  such  a  denial  has  resulted  in  death  or  permanent  disability.           Sashi  Bindhani,  SWAVINANEE  (Odisha)     Ms.  Bindhani  began  by  reaffirming  the  right  of  women  to  decide  freely  whether  or  when  to  have   children   and   stating   that   this   includes   the   right   to   information,   education,   and   accessible   and   affordable   services,   all   of   which   are   necessary   for   the   protection   of   reproductive   health,   safe   motherhood,   and   safe   abortion.   With   this   in   mind,   Ms.   Bindhani   turned   to   reflect   on   the   family   planning  policies  in  Odisha.       Ms.   Bindhani   shared   that   the   median   age   at   marriage   for   women   in   Odisha   is   17.9,   a   year   younger   than  the  Indian  average,  and  that  the  total  fertility  rate  (TFR)  of  the  state  is  2.37.  This  is  lower  than   the  national  average,  but  she  highlighted  that  among  the  Scheduled  Tribes  in  Odisha,  the  TFR  rose   to   3.1,   well   above   the   national   average   of   2.7.   Ms.   Bindhani   also   highlighted   that   14%   of   girls   in   Odisha   between   15   and   19   years   old,   were   already   having   children   and   that   the   contraceptive   prevalence  rate  amongst  currently  married  women  is  only  50.4%  which  is  lower  than  the  national   average  of  56.3%.  She  also  stated  that  the  unmet  need  for  family  planning  in  Odisha  at  15%  was   higher  than  the  India-­‐wide  average  of  12.8%.  The  unmet  need  for  family  planning,  particularly  for   the  purposes  of  spacing  births,  was  highest  among  women  aged  15  –  24.       Unmet  need  for  FP  by  age  group  (NFHS-­‐III) Unmet  need  of  Family  Planning    in  Orissa       25 21.8 20 18.3 14.3 15 12.1 10 8.1 11.5 8.7 5 2.2 1.5 0.6 0 15-­‐19 20-­‐24 25-­‐29 Spacing Limiting 30-­‐34 35+     Ms.  Bindhani  stated  that  79%  of  women  access  their  contraceptives  from  the  public  medical  sector   with  15%  going  through  the  private  medical  section  and  5%  gaining  access  through  other  sources.   34.1%   of   people   in   Odisha   use   sterilization   as   their   method   of   family   planning   and   male   sterilization  accounts  for  only  1%  of  contraceptive  use.  Ms.  Bindhani  stated  that  the  other  modern   methods  of  contraception  were  not  as  common  as  only  7%  of  women  used  the  oral  birth  control   pill,  3.2%  used  condoms,  and  0.6%  used  intra-­‐uterine  contraceptive  devices  (IUCDs).  In  addition   39  
  • 44. to   these   modern   forms   of   contraception,   Ms.   Bindhani   stated   that   5.8%   of   people   in   Odisha   still   use  traditional  or  natural  forms  of  family  planning.     Ms.   Bindhani   then   turned   to   discuss   the   challenges   that   Odisha   faces   in   delivering   government   programmes   aimed   at   addressing   the   unmet   need   for   contraception   by   assuring   delivery   of   services,   increasing   male   sterilization,   promoting   the   use   of   IUDs   and   emergency   contraceptive   pills,  and  increasing  contraceptive  choice.  She  highlighted  that  Odisha  has  a  high  rural  population   at  86%,  which  can  create  problems  due  the  difficult  geographical  terrain  of  the  state.  Ms.  Bindhani   also   stated   that   there   is   inadequate   attention   paid   to   family   welfare   programmes   in   the   state,   that   service  provision  for  limiting  methods  of  family  planning  are  seasonal,  and  that  Odisha  does  not   focus   on   offering   spacing   methods   of   contraception.   She   also   highlighted   that   the   state   has   a   large   young  population  that  is  now  entering  reproductive  age.  Furthermore,  low  male  participation  in   contraception   options,   low   age   at   marriage   and   first   child   bearing,   insufficient   spacing   between   pregnancies,   a   strong   preference   for   male   children,   and   low   female   literacy   rates   and   empowerment   all   contribute   to   Odisha’s   family   planning   problem.   However,   Ms.   Bindhani   also   raised   some   encouraging   facts,   which   she   argued   would   create   opportunities   for   better   family   planning  in  Odisha.  She  reported  that  as  66%  of  households  rely  on  the  public  health  system  for   healthcare,  80%  of  contraceptives  are  accessed  through  the  public  system  and  more  than  80%  of   deliveries   are   institutional,   the   state   could   reach   a   lot   of   people   with   their   services   if   they   were   improved.     Finally,   Ms.   Bindhani   turned   to   discuss   the   state   level   family   planning   programme   now   in   place   in   Odisha.  Under  the  programme  the  state  has  six  priorities.  First,  to  strengthen  the  system  through   bolstering   the   State   and   District   Family   Welfare   Bureau   to   improve   management,   strengthening   the   Quality   Assurance   Mechanism   to   improve   the   monitoring   and   feedback   system,   promoting   facility   based   monitoring,   and   institutionalizing   the   review   mechanisms.   Second,   to   increase   the   range   and   reach   of   family   planning   services   by   starting   Fixed   Day   Centres   for   family   planning,   promoting  the  use  of  IUCD,  increasing  the  focus  on  vasectomies,  particularly  in  tribal  districts,  and   by  promoting  post  partum  and  post  abortion  family  planning  services.  Third,  to  address  the  unmet   need   for   contraception   by   promoting   ASHAs   and   staff   nurses   as   family   planning   counselors,   implementing   the   home   delivery   of   contraceptives   by   ASHAs,   and   by   using   MAMTA   Divas   platforms  to  provide  information  and  supplies  for  family  planning.  Fourth,  to  address  the  needs  of   young  couples  by  training  and  capacity  building  with  AHSA  and  staff  nurses  and  by  ensuring  that   other   schemes   also   address   young   couples.   Fifth,   by   promoting   contraceptive   security   by   streamlining  the  supply  management  system  for  contraceptives  in  the  state.  The  final  objective  is   to   create   an   enabling   environment   by   offering   family   planning   trainings   and   capacity   building   sessions   for   medical   staff   and   ensuring   a   supply   of   necessary   instruments,   equipment,   and   consumables.       Ms.  Bindhani  concluded  by  sharing  a  letter  of  appreciation  from  the  Chief  Minister  of  Odisha  to  the   Minister  of  Health  and  Family  Welfare  stating  that  there  had  been  significant  improvements  in  the   provision  of  spacing  methods  in  Odisha  and  asking  him  to  ensure  the  programme  was  continued.         Karla  Torres,  Reproductive  Rights  Initiative,  HRLN  –  Delhi     Ms.  Torres  presented  on  her  fact-­‐finding  mission  to  Barwani  District,  Madhya  Pradesh.  She  visited   the  district  in  late  August  to  gather  evidence  on  the  implementation  of  NRHM  and  IPHS  norms  in   40  
  • 45. support   of   the   ongoing   litigation   Duna  Bai  vs.  State  Madhya  Pradesh  and  Others.   With   the   guidance   of   local   activist   Madhuri   Krishnaswarma,   Ms.   Torres   visited   12   public   health   facilities   in   11   villages  over  a  one-­‐week  period.     Ms.   Torres   found   female   sterilization   was   rampantly   practiced   at   every   facility   visited.   One   doctor   she  spoke  to  at  Rajpur  Community  Health  Centre  (CHC)  confirmed  that  the  district  had  a  female   sterilization   target   equal   to   1%   of   the   district’s   female   population.   At   the   same   CHC,   Ms.   Torres   witnessed  over  50  women  sterilized.  The  women  arrived  at  the  CHC  in  the  early  morning  only  to   be   made   to   wait   for   the   surgeon   until   the   late   afternoon.   When   Ms.   Krishnaswarma   asked   the   women  how  long  they  had  been  waiting,  they  responded  that  they  had  been  waiting  for  over  five   hours.  They  also  complained  that  many  sterilized  women  never  received  their  incentive  payment   as  promised.  ASHAs  present  at  the  CHC  complained  of  the  same.       Generally,  women  are  pressured  to  opt  for  sterilization  after  they  have  had  two  children,  assuming   that   one   of   the   children   is   male.   This   pressure   also   extends   to   ASHAs   and   hospital   staff   in   order   to   meet  their  yearly  target.  Women  are  seldom  counseled  on  alternative  forms  of  contraception  and   lack  access  to  the  same.     All   of   the   facilities   Ms.   Torres   visited   were   egregiously   unhygienic   and   many   lacked   a   medical   officer   on   staff.   All   of   the   PHCs   and   CHCs   visited   only   had   labour   rooms   in   which   sterilizations   were   performed,   sometimes   without   reliable   power.   Because   these   facilities   lacked   a   medical   officer,   a   single   surgeon   from   the   District   Hospital   spends   much   of   each   month   traveling   to   numerous   health   facilities   to   perform   female   sterilizations.   Most   harrowing,   the   average   time   spent  on  sterilizing  50  or  more  women  is  only  two  hours.  This  means  that  each  woman  receives   less  than  two  minutes  worth  of  medical  care.  The  surgeon  usually  uses  local  anesthesia  that  leaves   the   women   unconscious   for  up   to   four   hours.   The   women   Ms.   Torres   spoke   to   at   Rajpur   and   other   facilities   where   family   planning   camps   take   place   expressed   frustration   with   having   to   return   home   without   follow-­‐up   care,   transportation   services,   and   in   some   cases,   without   fully   recovering   consciousness.               41     Women  in  corridor  at  CHC  Rajpur,   Barwani  District,  after  their   sterilization  surgery  
  • 46. Although   family   planning   camps   are   not   isolated   to   Barwani   District,   Madhya   Pradesh,   the   predatory  nature  of  these  camps  is  most  keenly  felt  in  “backward”  districts  like  Barwani.  This  case,   then,  merits  special  attention  and  advocacy.       Kerry  McBroom,  Reproductive  Rights  Initiative,  HRLN  –  Delhi     Ms.   McBroom   presented   on   a   recent   family   planning   camp   fact-­‐finding   in   New   Delhi.   The   team   visited   two   slum   areas,   two   government   hospitals,   a   private   charity   hospital,   and   spoke   with   government   staff   and   community   members   alike.   According   to   the   2007-­‐2008   District   Level   Household  and  Facility  Survey  (DLHS-­‐3),  35%  of  women  between  35-­‐49  years  of  age  in  Delhi  are   sterilized.  Of  these  59.4%  received  their  promised  incentive  payment.  Of  note,  only  22.6%  of  these   women  received  counseling  on  the  potential  side  effects  of  their  sterilization  surgery.     Under   Devika  Biswas  vs.  Union  of  India  and  Ors.,   each   respondent   state   was   ordered   to   submit   a   response  to  the  petition’s  allegations.  In  its  response,  the  National  Capital  Territory  (NCT)  stated   that  the  facts  in  the  case  did  “not  apply”  and  that  Delhi  “fully  complied”  with  the  Supreme  Court’s   previous   Ramakant   Rai   order.   It   further   stated   “no   ‘rights’   of   sterilization   seeking   clients   are   jeopardized  and  health  care  personnel  are  bound  by  professional  ethics  to  treat  their  clients  with   dignity.”  The  fact-­‐finding,  however,  proved  otherwise.       The   fact-­‐finding   team   found   a   severe   shortage   of   facilities,   especially   sub-­‐centers,   and   specialized   medical   officers   including   gynecologists,  pediatricians,  and  pharmacists   at   the   CHC   and   PHC   level.   The   team   visited   Jagiwan   Ram   Memorial   hospital,   a   government  health  facility,  and  found  it  to  be   unclean  and  its  labour  room  to  have  unclean,   old   mattresses   with   multiple   women   for   every   bed.   One   of   the   doctors   the   team   spoke   to   stated,   “women   have   many   children   because  they  are  uneducated.”  Doctors,  then,   bear   the   burden   of   “convincing”   women   to   use   contraception.   However,   the   staff   does   not   encourage   birth   control   pills   or   other   forms   of   temporary   contraceptives   because   woman   “do   not   obey”   their   directions.   The   staff   also   admitted   that   women   are   not   counseled   on   family   planning   because   the   hospital  is  understaffed:  four  doctors  service   about  300  ante-­‐natal  patients  per  day.                     Crowded  ward  in  Jagiwan  Ram  Hospital     42  
  • 47. The   team   next   visited   Jahangir   Puri   K   Block   Hospital,   also   a   government   health   facility,   and   interviewed  23  women  about  their  family  planning  experiences.  Most  of  the  women  said  that  after   their  first  child,  they  received  pressure  to  use  the  Copper-­‐T  contraceptive.  However,  when  any  of   them  suffered  from  complications  or  sought  follow-­‐up  care,  they  were  refused  medical  service  and   had  to  have  the  Copper-­‐T  removed  elsewhere.  Women  also  shared  that  they  were  pressured  to  opt   for  sterilization  after  they  had  had  two  children.  In  fact,  women  with  three  or  more  children  are   often  turned  away  and  never  receive  their  incentive  payment  if  they  opt  for  sterilization.       One   woman   the   team   spoke   to,   Saroj,   said   that   she   had   been   sterilized   in   2009   after   having   her   third   child.   She   told   the   team   that   the   doctor   did   not  carry  out  any  tests  or  provide  any  counseling.   Moreover,   it   was   Saroj’s   husband   who   provided   consent   to   have   Saroj   sterilized.   She   remembered   saying  to  the  doctor,  “I’m  scared.  I  don’t  want  to  do   this.”  A  man  who  was  walking  around  the  room  in   which   she   was   sterilized   told   her   not   to   worry   and   gave   her   a   shot   in   the   arm.   The   next   thing   Saroj   remembered  was  waking  up  in  a  room  on  a  mat  on   top   of   several   other   women   and   feeling   pained,   nauseous,  and  drugged.  The  only  staff  in  the  room   was   a   cleaning   person.   She   later   left   without   any   medicine,   instructions   or   certifications   of   her   sterilization  surgery.  Saroj  later  had  to  remove  her   own   stitches.   When   she   visited   the   hospital   seeking   her   incentive   payment,   she   was   denied   any   payment   and   to   this   day   has   never   received   her  incentive.                   Saroj  with  her  children     Saroj’s   story   is   not   unique.   Many   women   in   Delhi   share   harrowing   stories   where   women   are   operated   on   without   pre-­‐operative   check   ups,   counseling,   or   post-­‐operative   medical   care.   These   women   are   operated   on   under   unhygienic   circumstances   and   are   sometimes   sterilized   in   only   a   matter   of   minutes.   They   are   then   left   to   regain   consciousness   while   lying   on   the   floor   of   a   dirty   room  without  any  medical  attention.  Finally,  they  are  forced  to  leave  the  medical  facility  because   hospital  staff  complains  of  overcrowding.     This  inhumane  and  degrading  treatment  of  women  is  endemic  of  a  society  that  devalues  women   and  denies  their  reproductive  rights  as  human  rights.  The  disregard  for  the  autonomy  of  indigent   women   in   slum   areas   is   especially   shocking.   These   women   place   their   trust   in   medical   professional   who   mislead   them,   take   advantage   of   their   ignorance   about   health   issues,   and   ultimately  place  their  lives  in  jeopardy  in  order  to  meet  a  state  mandated  sterilization  target.                   43  
  • 48. Recommended  Ways  Forward     The  following  are  prayers  participants  suggested:       • “Sterilization  camps  do  not  exist  in  isolation,  so  I  think  we  should  focus  on  health  care  in   general  and  take  a  step  back  from  sterilization,  because  it  does  not  exist  in  a  vacuum.”     • “We   should   discuss   the   Right   to   Privacy   and   Confidentiality,   because   the   women   come   in   for   treatment,   and   everyone   knows   what   you   are   doing.   Many   times,   one   does   not   want   anyone  else  to  know,  so  this  is  a  right  that  should  be  given  to  people.  We  could  connect  it  to   Article  21  of  The  Constitution  and  make  the  Prayer  stronger.”   • “An   independent   body   should   be   formed   in   order   to   provide   women   who   are   having   problems   after   sterilization   operations   with   compensation.   The   body   should   also   have   power  to  act  against  doctors  who  treat  women  negligently.”     • “We   have   to   delete   the   word   ‘compensation’.   We   should   focus   on   ‘medical   after-­‐care’,   as   women  end  up  spending  money  from  their  own  pockets  following  the  procedure.   o Secondly,   laparoscopy,   as   a   method,   was   adopted   to   fool   people   in   order   to   make   them  believe  that  the  woman  will  only  need  4  hours  of  rest.  So  families  are  happy   believing  that  the  woman  will  be  back  at  work  in  the  house  and  doctors  are  happy  as   they  can  discharge  the  women  quickly.  Even  if  women  opt  for  sterilization  because   they   have   finished   their  childbearing,   they   should   be   given   an   option   of   Tubectomy.   Everybody   should   not   rush   to   laparoscopy.   Tubectomy   is   safer   because   the   doctor   can  see  everything,  so  the  doctor  operates  better.  It  requires  hospitalization,  so  it  is   more   expensive   for   the   government,   as   it   requires   hospitalization   for   8   days.   Secondly,  the  doctors  should  also  be  held  responsible  for  the  problems  faced  after   the  operations.   o About   incentives,   we   should   be   very   careful,   as   the   poor   people,   especially   during   times  of  drought,  accept  these  incentives.”     • (Addressing   the   previous   suggestions)   “The   committee   should   be   made   up   of   renowned   persons  who  are  activists  so  that  they  can  interfere,  with  the  consent  of  doctors,  in  order  to   get   a   straight   approach   to   what   the   patient   needs   for   solving   her   problem,   post   her   operation.”     • “In  Bihar,  one  case  of  failure  has  come  to  our  notice,  and  we  find  that  the  government  never   issues  a  certificate  for  compensation.  I  read  in  the  book  that  it  can  be  given  after  a  month.   Secondly,  whenever  anyone  asks  for  the  certificate,  they  are  told  to  come  themselves,  and   are  told  that  the  certificates  are  just  pieces  of  paper  of  no  value.  Therefore,  they  cannot  ask   for  compensation.”       • One  needs  to  file  for  compensation  within  a  month,  but  most  people  don’t  know  they  can   get   compensation   and   even   officials   don’t   know   how   much   compensation   to   give.   The   period   during   which   compensation   can   be   asked   should   be   extended,   as   a   woman   might   start   getting   complications   even   10   months   after   the   operation.   Also,   the   amount   of   compensation   to   be   received   should   be   mentioned   on   the   back   of   the   certificate.   The   44  
  • 49. • Government   should   also   issue   notices   in   the   newspaper.   Regarding   the   informed   choice   given   to   the   patients,   information   should   be   provided   in   the   local   language.   Mostly,   the   women  are  forced  to  make  their  thumb  impressions.  This  needs  to  be  tackled.”     “There   should   be   a   record   with   the   woman,   stating   how   much   she   is   to   receive   for   compensation.  Similarly,  there  should  be  a  public  board  that  declares  that  if  a  woman  gets   pregnant  after  sterilization,  she  can  file  a  complaint  for  compensation.”     • •   • •   •   • • •   “Talking   about   uniform   consent   forms   and   checklists,   we   need   to   realize   that   how   these   forms   will   serve   their   purpose   depends   on   how   these   forms   are   designed.   Instead   of   leaving  it  to  the  government  to  design  the  forms,  the  standard  designs  of  the  forms  should   be  suggested  by  us.”     “I   feel   that   if   we   add   our   suggestions   towards   the   drafting   of   the   forms,   in   the   Annex   of   the   Petition,   we   should   do   this   with   the   consultation   of   the  government   and   National   Human   Rights  Institutions,  in  order  to  add  validity  to  the  drafting  suggestions,  so  the  Court  takes  it   more  seriously.”     “We   should   talk   about   how   pre-­‐sterilization   and   post-­‐sterilization   health   care   should   be   strictly   followed,   and   there   should   be   a   follow-­‐up   of   the   woman   after   3   months,   or   any   particular   period.   Also,   the   woman   should   sign   the   consent   letter   only   after   she   is   made   aware   of   the   operational   procedure   and   the   after-­‐effects   of   the   sterilization.   The   doctor   should   not   perform   continuous   sterilization   operations   (i.e.,   operations   performed   one   after   the   other)   within   a   short   period   of   time.   The   Doctor’s   Panel   should   ensure   the   availability   of   proper   health-­‐care   facilities.   Counseling   should   be   provided   to   the   women.   The  Panel  of  Doctors  should  be  specifically  numbered,  something  that  is  not  mentioned  in   Ramakant  Rai.”     “The   number   of   sterilization   operations,   the   number   of   failure   cases,   and   the   number   of   cases   where   women   are   facing   complications   post-­‐operation   should   be   made   available   in   the  Public  Domain.”     “There  are  a  lot  of  organizations  and  activists  who  are  pushing  for  guidelines  that  look  into   the   human   rights   perspective   of   the   ethical   aspects   of   sterilization,   which   the   Ministry   of   Health  Guidelines  do  not  focus  on.  I  feel  we  should  create  space  to  discuss  these  issues.”     “We  can  discuss  how  sterilization  programs  focus  predominantly  on  females.”     “I  think  that  what  the  speaker  who  spoke  last  wants  to  say  is  that  ultimately,  we  need  to   talk   about   how   this   is   a   practice   that   targets   women,   and   affects   women.   So   we   need   to   recognize  and  announce  that  this  is  a  discriminatory  practice.”     “I  feel  that  there  is  a  different  angle  to  the  problems  faced  due  to  sterilization.  The  failure  of   sterilization   as   an   effective   procedure   is   a   direct   result   of   the   cancellation   of   the   45  
  • 50. registration   of   clinics   and   surgeons.   Because   the   medical   council   of   India   has   set   very   clear   guidelines  about  surgical  medical  procedures.  Once  the  doctor  operates,  he  is  immediately   individually   responsible   for   follow-­‐up   check-­‐ups.   Secondly,   the   organization   under   which   the   entire   process   takes   place   is   also   responsible.   Thirdly,   if   the   person   facing   post-­‐ operative  problems  does  not  report  the  matter  to  the  authorities,  it  also  results  in  various   problems.”       All   of   these   suggestions   were   taken   note   of   and   the   HRLN   legal   team   is   currently   developing   rejoinders   to   all   responding   states,   conducting   fact-­‐findings   to   increase   information   and   awareness,  and  developing  a  more  comprehensive  advocacy  plan.     Issue   Female  Sterilization   PIL  Status   • Filing  response   • Awaiting  further   state  responses   • Using  some  of  the   suggested  prayers     Complimentary   Strategies     • Fact  findings     46   Advocacy  Partners   • • HRLN   Devika  Biswas  
  • 51.     LIST  OF  PARTICIPANTS   Ramatai  Ahire     Navsarjan     Maharashtra     Junaid  Alam     Chapal  Gram  International     Bihar     Adv.  Shadab  Ansari     HRLN     Jharkhand     Afreen  Asrar   Mamta  Health  Institute  for  Mother  and   Child     New  Delhi     Adv.  Anant  Kumar  Asthana     Independent  Advocate     New  Delhi     Raj  Kumar  Awasthi     Bharat  Seva  Sansthan     Gopika  Bashi   The  YP  Foundation  (TYPF)     New  Delhi   Arpita  Choudhary     Proletariats  and  Tinkers  Horde  (PATH)  New   Delhi   Javid  Chowdhury     Former  Secretary,  Ministry  of  Health  and   Family  Welfare   Sushil  Kumar  Das     Prerana  Bharati     Jharkhand   Dr.  Abhijit  Das     Centre  for  Health  and  Social  Justice  (CHSJ)   New  Delhi   Jashodhara  Dasgupta     SAHAYOG     New  Delhi   Aarti  Dhar     The  Hindu   Dr.  Bhaskar  Dwivedi     Chhattisgarh  Voluntary  Health  Association   (CARDS)     Chhattisgarh     Govind  Beniwal     Francis  Elliot     Rajasthan  Commission  for  the  Protection  of   The  Times     Child  Rights     London,  UK   Rajasthan     B  Bhattacherya       Pushplata  Ganvir     The  Academy  of  Nursing  Studies  and   Navsarjan     Women’s  Empowerment  and  Research   Chhattisgarh   Studies  (ANSWERS)     Andra  Pradesh     Ajit  Sunder  Bilung     Katy  Gilmour   Chhattisgarh  Voluntary  Health  Association   HRLN  (Intern)   (CARDS)     New  Delhi   Chhattisgarh     47  
  • 52.   Sashiprava  Bindhani     SODA     Odisha     Devika  Biswas     HealthWatch  Forum  -­‐  Bihar   Rajdev  Chaturvedi     GPS   Uttar  Pradesh     Kalpana  Indu     Manasi  Swasthya  Sansthan   New  Delhi     Dipika  Jain     Centre  for  Health  Law,  Ethics  and   Technology  (CHLET)     New  Delhi     Shafiq  ur-­‐Rhman  Khan     Empower  People   Haryana  and  Assam     Adv.  Shanno  Shagufta  Khan     HRLN   Madhya  Pradesh     Radhey  Krishna     Samarpan  Jan  Kaylan  Samiti   Uttar  Pradesh     Manoj  Kumar     LAKSHYA     Bihar     Tarun  Kumar     AANSVA     Bihar   Swapna  Majunbar   Freelance  Journalist   Senior  Adv.  Colin  Gonsalves   HRLN     New  Delhi   Dr.  Narendra  Gupta     PRAYAS     Rajasthan     Jashodhara  Das  Gupta     SAHAYOG     New  Delhi   Adv.  Kishore  Narayan     HRLN     Chhattisgarh   Dr.  Manmath  Mohanty     Human  Development  Foundation     Odisha   Swarup  Pal     Manjari   Rajasthan   Bhupendra  Pareek     Akhil  Bhariya  Gisiahak  Panchayat     Rajasthan   Phillip  Perl     Centre  for  Health  and  Social  Justice  (CHSJ)   New  Delhi   Manjula  Pradeep     Navsarjan     Gujarat   Dr.  M.  Prakasamma     The  Academy  of  Nursing  Studies  and   Women’s  Empowerment  and  Research   Studies  (ANSWERS)     Andra  Pradesh     Sudipta  Purkayastha   HRLN  (Intern)   New  Delhi     48  
  • 53. Sunita  Malviya     Betul  DLN  Society  (BTNP)     Madhya  Pradesh   Kerry  McBroom   HRLN     New  Delhi         Lavanya  Mehra     Centre  for  Health  and  Social  Justice  (CHSJ)   New  Delhi   Smriti  Minocha     HRLN   New  Delhi   S  N  Misra     Brij  Bal  Vikas  Kendra   Uttar  Pradesh   Rudra  Prasad  Mishra     Pragati  Sheel  Manch   Mazhar  Rashidi     Association  of  Minorities  Action  for  Nation   (AMAN)   Uttar  Pradesh     Ankita  Rawat     The  YP  Foundation  (TYPF)   New  Delhi   Adv.  Ahmed  Raza     HRLN   Jharkhand   Sonali  Regmi     Center  for  Reproductive  Rights  –  Asia   Nepal             Dr.  Shakeel  Ur  Rahman     Centre  for  Health  and  Resource  Management   (CHARM)   Bihar     Ashutosh  Rai     Satya  Nonayam  Seva  Sansthan  (SNSS)   Uttar  Pradesh   Narendra  Kumar  Rai     Ashok  Sansthan   Uttar  Pradesh     Dinesh  Kumar  Rai   Satya  Narayan  Sewa  Sansthan  (SNSS)   Uttar  Pradesh     Adv.  Sandhya  Raju     HRLN     Kerala     Adv.  Manas  Ranjan     HRLN     Odisha     Manish  Sharma     Ujjain     Madhya  Pradesh   Sanjai  Sharma     HRLN   New  Delhi     Sona  Sharma     Population  Foundation  of  India  (PFI)   New  Delhi     Vishwa  Vaibhav  Sharma     SAFE  Society         49  
  • 54. Natassia  Rosario     Fulbright  Scholar   Adv.  KK  Roy   HRLN   Gujarat   Kundan  Lal  Sah     CHARM     Bihar   YK  Sandhya     SAHAYOG   New  Delhi   Adv.  Jayshree  Satpute   HRLN     Delhi   Rajkumari  Sen     Sagar  Network  Sagar  DLN   Madhya  Pradesh   Disha  Sethi     The  YP  Foundation    (TYPF)   New  Delhi   Neetu  Singh     Gramya   Uttar  Pradesh   Rakesh  Kumar  Sinha     BREAD   Dinesh  Sharma     Rural  Development  Society  and  Vocational   Training  Organization  (RUDSOVOT)   Rajasthan     Parmendra  Sisodiy     Ratlam  Jila  Network  of  People  Living  with   HIV/AIDS  Society  (RNPPLUS)   Madhya  Pradesh     Dr.  Raju  SMG     HRLN  (Volunteer)   New  Delhi     Aditi  Sood     SAHAYOG   New  Delhi   Dr.  Prasanth  Subrahmanian     NHSRC   New  Delhi       Adv.  Rohit  Thakur     HRLN   Jharkhand     Adv.  Namrita  Tiwari   HRLN   Uttar  Pradesh     Adv.  Alban  Toppo     HRLN   Chhattisgarh     Karla  Torres   HRLN     New  Delhi     Kartik  Tripathi   HRLN  (Intern)   New  Delhi     Leena  Uppal     Centre  for  Health  and  Social  Justice  (CHSJ)   (Delhi)  and  National  Coalition  against  the   Two  Child  Norm  and  Coercive  Population   Policies     New  Delhi     50