From the Field to the Judge’s Bench


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From the Field to the Judge’s Bench

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From the Field to the Judge’s Bench

  1. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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