This was a presentation on SAHAJ's work amongst the urban poor women in Vadodara India, (2013 Bangladesh)

1. Mobilizing in slum communities for
change: A rights-based approach to
women’s health in slums
Renu Khanna, SAHAJ, India
Urban Space: Integrated action on health, rights and
poverty reduction
Symposium Organized by BRAC and Mailman School of
Public Health, Columbia University
19-20 April 2013

2. About SAHAJ…
• Registered as a Society and Trust in 1984
• Focus on marginalized and deprived
communities, aiming to make a practical
difference in people’s lives and social processes
• Programmes in urban Vadodara on children’s
rights, right to shelter, health rights, adolescents’
rights, accountability for maternal health, relief
and rehabilitation
• Over the years has worked in between 20 and 30
bastis (slums)

3. Gujarat: The Context 1
• Gujarat most urbanised state - the urban
population 42.6 % (Census 2011), 37.4 % in
2001.
• Migration, overpopulation, lack of basic
amenities
• Worsening situation for the urban poor.
• Women’s health status in urban Gujarat is not
compatible with claims of development!

4. Vadodara - the Context 2
• Vadodara is the third largest city in Gujarat
• 20 % Vadodara population in 336 slums
• DLHS 3 for Vadodara District also shows
worsening situation

5. SAHAJ’s Urban Health Programme
2003- 2013
• Situational analysis – Social exclusion and gender
issues affected women’s health
• Baseline studies – home deliveries, low uptake of
ANC, PNC, FP, weak family including husbands’
support, low awareness of entitlements
• Led to defining our Perspective

6. Perspective
• Comprehensive Women’s Health
• Reproductive and Sexual Rights integral
• Urban Poverty is multidimensional
• Social health
• Living in a society that is free of conflict, has peace,
harmony, respect for all members, where a person is not
discriminated against because of his/her gender, caste,
religion, economic or social status, presence of a disease
(e.g. TB, HIV/AIDS) or condition (e.g. infertility) or non-
conformation with cultural norms, can live without any
fear, can live his/her life as s/he wishes to / needs to and
enjoys all human rights.

7. Comprehensive Women’s Health...
• ....acknowledges the crucial linkages between
physical-mental and social health and addresses
mental and social health issues related to
maternal and reproductive health.
• works on all determinants that influence the
women’s physical, mental and social health; e.g.
poverty, lack of information, cultural practices,
illiteracy, gender discrimination, other types of
discrimination and men’s involvement.

8. Strategies
• Various cadres of Change Agents from the community
– health workers, peer educators, child rights
animators,
• Basti level Committees with representation from men,
women, youth – Matru Mandals, Health Committees,
Community Development Committees, Education
Committees.
• Awareness generation
• Facilitating access to services
• Providing counselling services at basti level
• Creating a ‘voice’ – Generating demand, Monitoring
services, Jan Samvaads

9. Lessons learnt – at various levels
• Body literacy and literacy around maternal
health entitlements is first step to increasing
utilisation of maternal health services
• Carefully selected, well trained and supported
local women can play a key role as a bridge
between women and the health system
• Woman centred, rights based perspective will
lead to improved health system indicators –
family planning, ANC utilisation etc.

10. • It is possible to develop strategies to address
both determinants of health as well maternal
health needs.
• Even in urban situations, it is possible to
organise people’s committees
All these have an implication for the National
Urban Health Mission

11. What Urban Poor Women want from
the Health System
• Services at the primary level
– Quality and regular health services at the Anganwadi.
– Proper follow up of maternal health at the basti level on Mamta Divas.
– Competent Link Workers/USHAs which implies appropriate training to link
workers on follow up and documentation of a wide range of reproductive health
conditions.
– Not being ‘chased’ repeatedly for permanent contraception. (Emphasis on
temporary contraception rather than permanent contraception.)
• Improvement in Ward level services.
– Appointment of lady gynecologist and Paediatrician in all the Ward clinics for 8
hours, all working days.
– Deliveries, Ante Natal Care and Post Natal Care checkups (with Hb test,
sonography, urine tests etc.), abortions and all contraceptive care including
tubectomies at Ward level.
– Availability of all medicines, pregnancy confirmation strips, reproductive tract
and sexually transmitted diseases.
– Availability of treatment for child health at Ward level including incubators.

12. What Urban Poor Women want from the Health
System
• Tertiary level services
– Protocol for emergency care to be followed in the Government
hospitals.
– Doctors should use I-cards or have name plates on their coats
so that they can be identified.
– Interns should not be given complicated cases without constant
supervision of experts because majority of cases fail due to
inability of handling them properly. The ICU Ward for the
neonates should not have interns without experts.
– Availability of all medicines at all times free of cost (nowadays
medicines are prescribed from outside).
– Cost of caesarean delivery at the tertiary level hospitals should
be minimized.
• Private health care
– Protocol of quality health care for private practitioners
including Chiranjeevi doctors.
– Standard cost of care at private hospitals (because hospitals
are charging any amount, not the same everywhere).

13. Some achievements
• Improvement in Maternal Health indicators
– increase in early registrations of pregnant women,
– increase in women availing antenatal care,
– increase in institutional deliveries,
– awareness of post natal care,
– complete vaccination in children,
– awareness of and an increase in medical abortions,
– increase in use of temporary contraceptives
– increased treatment seeking for reproductive tract infections.
• increased support of husbands and mothers in law.
– Condom use increasing,
– accompanying wives for ANC checkups or delivery,
– joint decisions on use of contraceptives or abortions
• Women coming to the basti level counseling centers - health workers
addressing mental and social aspects of maternal health problems.
• Increased community action on determinants of health – Public
Distribution System campaign, Anganwadi centres, quality of health
services

14. Outcomes
• Increasing realisation of Reproductive Rights
• Strong cadre of dynamic local health workers and
peer educators
• Effective Health Committees and Community
Development Committees
• Creation of Role Models of Husbands and
Mothers in Law in bastis
Social norms around women’s health are changing

15. Issues emerging

16. Issues emerging (contd)
• Frequent demolition of bastis, resulting in invisiblisation of the poor
• Lack of basic amenities- electricity, toilets, water: adverse consequences
particularly for women and girls.
• Inaccessible public health facilities - distance, require repeated visits and
lengthy procedures .
• Out of pocket expenditure even in Government facilities, so people prefer
private services. People feel lost in hospitals - no directions, and
information on entitlements at various levels.
• Absence of public sector maternity services at the primary level, lack of
attention to adolescents’ reproductive and sexual health (RSH).
• Schemes like Chiranjeevi and JSY available for Below Poverty Line families
However, many eligible families do not have BPL card , general lack of
awareness of various schemes for poor women
• Non compliance of private providers with requirements of government
schemes.

17. ‘Citizenship’
• Slum dwellers and informal settlers face
stigma and social exclusion by living in
settlements for which there are no official
addresses. They may have no identity
documents because they live in ‘illegal’
colonies.
• ‘Citizenship’ being redefined - those who pay
taxes, user charges, own property are
legitimate citizens, all others are encroachers!

18. Systems or processes for regulation
and accountability
• do not seem to be many models for
promoting participation of urban
‘communities’
• local governance structure proposed by 74th
Amendment and Ward Committees, also
mandated under JN National Urban Renewal
Mission have not been operationalised, at
least in Vadodara city

19. Training Health Workers to address young
women’s issues

20. “This is how you use the pills”

21. Family counseling on who is responsible for sex of the
baby

22. Theater Group’s performance in Basti

23. Working in the basti on women’s health rights

24. Right to Info Workshop

25. Society for Health Alternatives-SAHAJ, India 25
“Public Hearing” - A link between Government and Community
Committees (community representatives)
articulating their health issues with medical
officer

26. Acknowledgements
This presentation is based on a paper that has been
compiled from several reports and presentations made
by SAHAJ colleagues
Support from Population Foundation of India and Sir
Dorabji Tata Trust - thanks
Thank you, and feedback is welcome!
Renu Khanna – sahajbrc@yahoo.com